13906	----	CONCEPTION CONTROL AND ITS EFFECTS ON THE INDIVIDUAL AND THE NATION by FLORENCE E. BARRETT, C.B.E., M.D., M.S., B.Sc. Consulting Obstetric and Gynæcological Surgeon to the Royal Free Hospital. President of the Federation of Medical Women. With a Foreword by His Grace the Archbishop of Canterbury. 1922 PREFACE This small book has been written in response to many requests for some statement regarding the individual and national effects of the widespread practice of conception control. It is not intended to give medical advice on the subject for, in my judgment, that is best given to the individual by his or her medical adviser, and will vary in different circumstances. The question as to whether control of conception shall or shall not be practised is a decision ethical and not medical in character when husband and wife are healthy, and in the last resort will be decided by the individual pair for themselves; but they will be wise to discuss the question with their medical attendant in order to realise all that is involved in their decision. Space forbids anything like a full discussion of the national issues, but that aspect of the subject demands quite as careful study as personal needs or desires. F.E.B. 31, DEVONSHIRE PLACE, W.1. September, 1922. FOREWORD The Archbishop of Canterbury allows me to use the following letter as a Foreword to this little book. DEAR LADY BARRETT, I have read with great interest the manuscript of your pamphlet. Very many of us who have daily to do with the problems and perplexities of our social life and to give counsel to the anxious or the penitent or the perturbed will thank you for these clear and cogent chapters. To arguments based on moral and religious principle you add the weight of ripe experience and of technical scientific knowledge. Your words will gain access to the commonsense of many who would perhaps regard the opinions of clergy as likely to be prejudiced or uninformed. I am of course not qualified to express an independent judgment upon the medical or physiological aspects of this delicate problem, but I desire on moral and religious as well as on social and national grounds to support your general conclusions, and to express the hope that your paper may have wide circulation among those who are giving attention to what is becoming an urgent question in thousands of English homes. I am, Yours very truly, RANDALL CANTUAR. LAMBETH PALACE, S.E. 3rd August, 1922. CONTENTS CHAPTER I THE PROBLEM OF TO-DAY CHAPTER II THE DEMAND FOR KNOWLEDGE AND FROM WHOM TO OBTAIN IT CHAPTER III METHODS CHAPTER IV THE EFFECT OF WIDESPREAD CONCEPTION CONTROL ON NATIONAL EFFICIENCY SUMMARY OF CONCLUSIONS CHAPTER I THE PROBLEM OF TO-DAY In the late seventies of last century a pamphlet entitled _The Fruits of Philosophy_ was republished by Mrs. Annie Besant and Mr. Charles Bradlaugh, in their desire to mitigate the suffering of poor women who were overburdened by work and further weakened by frequent child-bearing. They resolved to face public obloquy and even legal prosecution in order to bring to these women knowledge of how to prevent conception, which, in their opinion, would give the relief they so sorely needed. As is well known, the later pamphlet on the same subject written by themselves was withdrawn from publication by Mrs. Besant in 1886 on religious grounds. During the last few years the idea of the need for conception control has again become prominent, partly as a revolt against the bondage of women in child-bearing, partly accentuated by the difficulties and uncertainties of an adequate livelihood, and the desire to have a few children well educated and cared for rather than many who shift more or less for themselves. But also the claim is made that marriage exists at least as much for the fulfilment of happiness in union with the beloved as for the procreation of children; and that it should be possible for a married pair to have the fullest gratification without fear of children unless they desire them. Others, but these are extremists, go so far as to claim that apart altogether from marriage vows, sexual intercourse should be the experience of all, and that knowledge of how to avoid the birth of illegitimate children should be given to all. The discussion of this subject has taken place under the title of Birth Control, but the control or regulation of births is not really the point under discussion. A very big factor in the diminution of births comes under the heading of abortions, whether voluntary or through conditions which might be remedied. That subject is not touched upon in this paper, but only methods which avoid conception, which is, of course, a very different subject from the larger one of avoiding births. At first sight it might seem a comparatively simple thing, in view of the knowledge which already exists of the physiological processes involved in conception, to advise a method which shall prevent conception at will without harmful effect upon man or woman and yet leave intercourse unimpaired. But even at first sight it is obvious that whatever knowledge may be available, and whatever methods may be devised, it would not be easy to convey this knowledge rightly to the individual it is hoped to benefit without doing harm to others. Further thought shows that the national problems involved are so important and far reaching in effects that they might well arrest the attention of the most careless advocate of indiscriminate conception control. This is a subject, therefore, which requires careful consideration from the point of view of the individual, of public morality, and of national welfare--and the more closely it is studied the more apparent are the far reaching issues involved. It is improbable that the practice of using contraceptives will continue for even a generation without revealing the harmful effects which must to some extent ensue. In the whole discussion of this subject it is important to keep in mind that the physical is only one aspect of the sex relation. In the evolution which sex has shared with all else, the psychic side appears even in the higher animals. In them the desire is not for mere indiscriminate physical satisfaction, but the element of choice comes in, a factor which sometimes upsets the plans of breeders. In man this aspect of the relation is all important. The higher side of sex, or what we may call the psychical secondary sex characters, seem to extend through the whole range of mental and spiritual activities. Because of this there is freshness of contact in mental and spiritual intercourse between men and women which differs somewhat from that between individuals of the same sex, and very much of the joy of life springs from the impact of these differing yet completing selves the one upon the other. Where the whole being enters into the union of the sexes the complete joy of marriage is realised, the characteristic of which is that it does not fade, but becomes ever deeper and more fully realised, a sure indication that the highest pleasure of sex union is only attained when it consummates a love which involves mutual sympathy and consideration. Physical union alone produces dissatisfaction the more quickly in proportion as it is physical only; on the other hand, when all parts of the nature find their counterpart in another, the joy of such intercourse pervades the whole life, and frequent repetition of physical intercourse is not essential to its highest development. This is well known to all true lovers who have for varied reasons exercised some voluntary self-control in regard to the physical side of sex in marriage, either in deference of the one to the desire of the other, or to avoid too frequent child-bearing, or in special seasons such as Lent. On the other hand it has been observed by most people that many marriages which seem to promise well, quickly lose even to the eye of the outsider all the romance of the days of courtship. Is not too frequent physical indulgence sometimes the cause? Even the time of courtship is spoiled by unrestrained demonstration of affection, and the beauty of the higher side of love is apt to lose its delicate bloom by over accentuation of the physical in marriage; husband and wife sadly admit to themselves that disillusionment has come--the real truth being that in seeking only physical satisfaction in each other, their eyes have become blinded to those higher qualities which each glimpsed in the other during the happier days of courtship, and the "road of the loving hearts," which they hoped to tread through life, has been missed because they have forgotten that "man is a spirit and doth not live by bread alone." To many the introduction of this aspect of the question may seem beside the mark. For them the practical question in a world of sense is how to avoid having children when for any reason they are not wanted, and yet leave unimpaired facilities for married life. It is true the problem is not always stated so bluntly. The uses of contraceptives are explained, together with a recommendation for moderation in physical intercourse; but as will be shewn below, if such moderation is really practised, it is possible to live a natural married life such as renders unnecessary the use of artificial contraceptives with all their attendant evils and yet limit the size of the family. But it is necessary to consider more carefully the claim made to-day that contraceptives are both necessary and harmless, and that public propaganda on the subject is desirable. There are several different groups for whom relief is claimed:-- 1. Women who are suffering from chronic or from temporary ill-health are frequently not in a condition to bear the strain of child-bearing, and indeed it may become a real danger to their future health, either mental or physical. 2. There are cases of inherited disease, mental or physical, which ought to prohibit child-bearing. 3. There are over-worked women whose daily work, added to child-bearing, destroys their health and vitality. These people are found not only among the so-called working classes; the same conditions with somewhat different types of strain are found in wives of professional men with very slender incomes. 4. Some parents wish to "space" their children, that greater attention may be given to each, or they wish to limit the number of their family on account of financial and other difficulties. With these and other considerations in view, the widespread teaching of methods of preventing conception is advocated because it is claimed:-- (a) That except for general propaganda, the greatest sufferers, viz., poor women with constantly recurring pregnancies, would otherwise never learn of any method of relief. (b) That many young people who for various reasons, such as housing or financial difficulties or inherited disease, feel themselves unable to have a family, would if such knowledge were available marry much earlier, and their natural desires would be satisfied, while apart from marriage they might resort to promiscuous intercourse. (c) That homes where the growing difficulties and strain of a continually increasing family are leading to estrangement between husband and wife, are restored to happiness when saved from the difficult choice between continence, which they have never trained themselves to practice, or many children with which they cannot cope. There are, however, serious fallacies in these contentions. The propagandists of conception control appear to take it for granted that after preventive measures in early youth, children may be conceived at will whenever they are desired; and, moreover, it is assumed that apart from such precautions every woman will conceive annually and will continue to do so until 10-12 children have been born. Neither of these suppositions is supported by facts. On the contrary, there are large numbers of married couples who would give anything to have children, but have postponed it until circumstances should seem quite desirable, and then, to their grief, no children are given to them. It is very unfair to teach people that they may safely postpone the natural tendency to bear children in youth and rely upon having them later in life. Probably gynæcologists are consulted more often by women who desire children but do not have them, than by those who wish to avoid having them--the truth being that the tendency among people in comfortable surroundings is towards relative sterility rather than towards excessive fertility. Those who are interested in this aspect of the question will find the facts admirably set forth in Mr. Pell's book on _The Law of Births and Deaths_, being a study of the variation in the degree of animal fertility under the influence of environment. He finds that the all-important factor which determines fertility is the amount of nervous energy of the organism, and that nervous energy is produced or modified by three specially influential factors, viz., Food, both quantity and quality; Climate, hot or cold--moist or dry; and, lastly, all those varied conditions which make for greater or lesser mental and physical activity. Fertility, broadly speaking, varies in inverse proportion to the degree of nervous energy or what we may call vitality. Conditions, therefore, which lower the general vitality below the normal produce abnormal fertility. This excessive child-bearing under present conditions still further lowers the standard of life and the health of the mother, hence a vicious circle is set up, the only escape from which will come by such consideration of the laws of health relating to work, housing, food and recreation as shall ensure the maximum of vitality to the workers. This is the true method of conception control. There comes a point in the development of nervous energy which is productive of sterility. It is true that principles based on so many varying factors will necessarily appear to fail in individual cases. Environment with its influence on the nervous energy of the individual will be modified by the inherited tendency of that individual towards fertility or the reverse. We find, therefore, isolated cases of large families among the well-to-do and small families among those whose vitality is below the normal, but if the general principle is true we should expect to find a larger number of _sterile_ marriages among the well-to-do than among those whose lives are more full of hardship, and this undoubtedly is the case. This aspect of the problem is deserving of careful study. The desire for children in so many homes where every advantage could be given, may be gratified when more knowledge of how wisely to modify the environment of the rich is within our grasp. It may be that the more simple life among those who have much will give to them the prize of children which they covet more than things which wealth can buy. But let us return for a moment to the false expectation that children will come to all unless prevented. The results of this assumption are really serious. They involve the training of large numbers of people in unnatural practices, which in many cases are unnecessary, even if they were desirable. They rob many families of the children who would have been the delight of their parents through middle and later life. Moreover, it is obvious that advice which may be quite necessary in cases of ill-health or special conditions, may be fundamentally wrong to give broadcast to all individuals, for apart from the fact that when given to all it is largely unnecessary, there are other serious objections, as follows:-- 1. A public opinion at the present time is being gradually produced which takes it for granted that as a matter of good form young people should not have children for a few years after marriage, and it is becoming a common practice to start married life with sordid and unnatural preparations for a natural act; yet many of these young people, men and women alike, are most anxious to have children, and only seek to know how to prevent them because they believe it to be "the thing to do." One or two illustrations which have come to my personal knowledge will perhaps show the kind of idea which is conveyed to the mind of young people by books and speeches on this subject, though such results may not have been desired by the authors or speakers. A young bride came to her mother on returning from her honeymoon and said, "Mother, how long must we wait before having children--is it really necessary to prevent them for a year or two? We are both dying to have babies." A young couple on the eve of marriage consulted a gynæcologist regarding the question of using the cap pessary to prevent the possibility of having children for a few years. The bride, who was greatly distressed, produced the pessary which she had purchased, and said she could not possibly use it; her fiancé, however, had been advised that she could, and ought to do so, hence the first serious dispute had arisen between them, clouding the future. She was told by her doctor that it was quite impossible for her, and this fully satisfied the future husband. The next point was if this method were impossible what should be used. They were a splendid young couple, with ample means to support a family, and the doctor naturally asked--"But for what purpose do you need any methods to prevent children at all?" They hesitated and looked at each other, and then said--"I don't know, but we thought it was the thing to do." They left with the whole nightmare put aside, determined not to spoil the perfect consummation of their happiness. Many similar cases might be quoted where young people, without any considered motive, are acting in accordance with the vogue of the moment. 2. The use of contraceptives does not encourage self-control, yet the cultivation of self-control is a far higher gain to the individual and the nation than any apparent advantages obtained by its abandonment. By no means unimportant is the influence that wide diffusion of the knowledge of how to prevent conception would have in causing more irregular unions and greater promiscuity in sex relations. The effect of this would not only loosen, rather than strengthen, the marriage tie, but would inevitably lead to an extension of venereal disease. Many people seem to think that contraceptives prevent venereal disease at the same time that they prevent conception. But this is not so. The use of methods of prevention by women is no protection to them from infection. 3. We have, moreover, to take a wider view, and consider who will receive and act upon the advice given, and hence what the result will be on the differential birth-rate of the community. It is quite obvious that the educated classes can most easily follow instructions which result in protection from conception, and since such knowledge most easily circulates among the more highly endowed classes, it has been claimed that it is important to make efforts to let the knowledge be so widespread that it may reach all. The result, however, could only be that the practice of conception control would spread throughout the upper, middle and more intelligent of the working classes, and this would involve a very serious reduction in the births of those who furnish the leaders and efficient workers in all branches of life, and in those only. For the birth-rate amongst the least intelligent, least efficient and the mentally deficient will be unaffected. It must be apparent that after a very few generations of such weeding out of the best, with the continuous multiplication of the worst type of citizen, the general standard of efficiency, enterprise and executive skill of the nation would be seriously impaired. Such, briefly stated, is the problem before the public at the present time. CHAPTER II THE DEMAND FOR KNOWLEDGE AND FROM WHOM TO OBTAIN IT Even the brief survey given in the first chapter will have suggested to the reader that the people who ask for knowledge seek it for various reasons. Indeed, the first thing that strikes anyone who gives consideration to the subject is the difference in type and circumstance of the people for whom relief is claimed. We begin to realise at once that the subject of conception control is an intimate and individual one, and can only really be dealt with by advice which is given to the individual and not to the public at large. This is perhaps most obvious in the first group mentioned on page 17, where the woman is suffering from chronic or acute disease, and the necessity for preventing conception is clear to her medical adviser. If disease renders child-bearing a danger to the life and health of the mother, it becomes a positive duty of her doctor to prevent such a catastrophe--but the method advised will differ according to the special nature of the case. Again, where in the case of husband or wife there is a serious inheritance of mental or physical disease, and especially when the same weakness exists in both families, it is justly regarded as a duty by the married pair not to bring children into the world. It may be contended that men and women with such an inheritance should not marry, but that is a matter for the decision of the individuals concerned. It not infrequently happens that marriage has taken place before they know of the inherited tendency. In such cases clearly the advice of the family doctor should be given as to the best course to pursue in order to avoid conception. The case of the overworked and burdened mother with a large and increasing family is nearly allied to that of a woman with disease, though in her case the causes for ill-health are more complicated. While it is true that ill-health and premature ageing in working women are the result of many causes, yet where child-bearing still further injures health it is essential that she should consult her medical adviser on this point, for she not only needs treatment to restore her health, but also advice specially suitable to her own case, as to the best method to avoid conception for the time being, and such advice will vary according as the disability is temporary or permanent. It is, happily, as possible for the poor woman to obtain advice in all matters of health as it is for the rich. The mothers of the country are in touch everywhere with maternity clinics, where doctors advise them on all questions of health relating to pregnancy, and treat each woman as a separate individual. But the case of the poor working woman overburdened with work which she cannot accomplish--yet with the added burden of bearing more children than her more fortunate sisters, deserves some further consideration. What is it that prematurely ages so many of these women of the slums--is it child-bearing alone? The answer to that is immediately in the negative, for women in comfortable circumstances may have large families, with no sign of weariness and dejection. No, the causes of ill-health and debility are diverse, and to pretend to solve the question by conception control is a mockery, for it salves the conscience of the community without really dealing with the question of the disabilities of the working woman, or the true cause of her excessive fertility. Ill-health in working-class mothers often has its origin in inherited weakness and lack of care in childhood. It is further accentuated by overwork, with no labour-saving devices; lack of suitable food; too few, if any, hours of recreation, and hence very little out-door exercise. Badly ventilated homes deprive the mother of necessary supplies of oxygen, and insufficient sleep is often the last straw which breaks down the patient burden bearer. A true and haunting picture is given in a recently published book called _The Woman in the Little House_ (which first appeared in a series of articles in the journal "Time and Tide"), describing the anxiety of a working woman at night to keep her baby quiet that the husband may sleep. Now it is quite true that a small family instead of a large one will diminish the work and anxieties of such a mother, but it will not give her the remedies which she needs, nor will it diminish the excessive sexual demands made upon her. Everyone who knows these women intimately realises what an exhausting feature is this habit of excess due to lack of knowledge or self-restraint on the part of the husband. I believe if facilities were provided whereby the woman could do her laundry with modern appliances outside her own home, if family meals were arranged in service rooms equivalent to the arrangements in service flats, and if there were crêche rooms where children might be left for an hour or two in safety while necessary work was done--we should find a greatly increased standard of comfort even in existing homes, and a great improvement in dietary for the whole family. Such relief, added to teaching both to husband and wife as to the times of conception, would revolutionise the life of women more than any teaching of artificial birth control, and would lift it up to a higher level instead of degrading it to the grossly physical. We come to very different considerations in group 4, p. 18, where choice rather than necessity impels the parents to limitation of the family. The teaching now being advocated by certain books and pamphlets advises deliberate delay in child-bearing for a period after marriage, and the spacing of certain periods between the births of such children as are allowed to come into the world, with limitation of the number in each family. Teaching on these lines, if followed, would involve an artificial mode of sex life always--natural spontaneous union would find no place. Already young wives are seeking advice for some relief from methods of preparation which they say have destroyed in them all spontaneous desire. The tragedy of it all is that even to attain the end in view--moderation in the size of families--such methods are to a large extent unnecessary. Not to every young married couple does a child arrive at the end of a year. Some, using no artificial checks, wait two or three years before the first baby comes. Even if it does come, however, at the end of a year, there are many advantages to counterbalance the small means and perhaps hard living of the young pair. For when people are young they can put up with small means, because they are strong enough to work hard and help each other; indeed, the demand for little work and many luxuries in youth is not a healthy one, it is a sign of decadence in the race. Moreover, even though an early family involve real hardship for awhile, it has the great advantage that parents and children later on are still young together, and that means far more to the child in understanding friendship and helpfulness during the most critical period of life than extra comforts or pleasures would have meant to the parents, and if young parents realised this, would they not put the child first? The so-called advantages of a few years between one child and the next so that the parents may give fuller care and attention to each, are far outweighed from the child's point of view by the advantages of playmates in the nursery of nearly its own age, who are a source of education in the give and take of life such as no adult can supply. If parents wish to have only three or four children, it is to the advantage of the mother as well as of the children, to have the little family early in life--they are then all in the nursery together, and later all at school, and her life work is in this way so arranged that she may give most service to the world in addition to carrying on the race. Our conclusion is that for mothers and children it is very desirable that no contraceptives should be used in the early years of married life. In the vast majority of families where no restrictions or unnatural means are used and where mothers nurse their children for eight or nine months, children only come every two years. Even if a young couple decide that they cannot afford to bring up more than four children, they have first to prove that four children will be given them--in many cases they will not have so many, and as years go by the fertility of the mother becomes progressively less, so that if child-bearing is postponed till after thirty, in a certain number of families no children are born. There are many men and women who bitterly regret having let the years go by in which children might have been born to them, and it is only fair that young couples of to-day should fully understand this risk. CHAPTER III METHODS There are certain points in regard to methods of preventing conception which should be made clear. It is, of course, obvious that conception can be voluntarily controlled by abstention from intercourse except when children are desired. This has been called a counsel of perfection. It could only rightly be so described where such a method of life was both desired and approved by both husband and wife. It would not be a fair thing for either to enforce a practically celibate life on the other without the fullest understanding and consent before the marriage vows were taken. But conception can also be controlled by avoidance of those parts of the monthly cycle in which conception most commonly takes place. That in the great majority of women there is a time in the monthly cycle when no conception occurs has been noted for a long time. The rough-and-ready method of reckoning the date of birth in relations to the last menstrual period is an example of the assumption that conception will probably have taken place a week later, and the frequency with which such reckoning is justified shows that it is not altogether unfounded. During the war it was possible to make some more exact observations owing to the short leave granted to soldiers to visit their homes. Seigel has published a paper in the "Münchener Medizinische Wochenschrift," 1916, in which he gives information regarding the conception of between two and three hundred children born during the war. He finds that the likelihood of fertilisation increases from the first day of menstruation, reaching the highest point six days later, the fertile period remains almost at the same height till the 12th or 13th day, and then declines gradually until the 22nd day, after which there is absolute sterility. This suggests that conception control can be attained without artificial methods if intercourse is confined to one week in the month. Such control of conception, though natural, does not make it any more desirable to space the births unduly so that the children are brought up in separate units instead of in a happy family group in which they can share games and interests--but it does avoid the risks which are associated with artificial methods of conception control. It is not proposed to discuss in detail artificial methods in this pamphlet, because no advice can be wisely given on this subject in a general way. Those who after careful consideration choose to use artificial means to prevent child-bearing will be wise if they consult their medical attendant as to those methods which are least harmful for their individual case, and ask for careful instruction in their use. Most of the methods so widely advertised are productive of diseased conditions, whether from the nature of the method itself or from the way in which it is used, and all of those recommended to women interfere with normal physiological processes. The object aimed at in methods recommended to women, is either to produce, by drugs or otherwise, conditions in the vagina inimical to the life of the male cell, or to prevent by mechanical means the reception of the semen into the uterus. Owing to the uncertainty in the results of either of the above methods of prevention, the later editions of books which teach conception control now advocate the use of both methods at the same time in order to approximate more closely to certainty of result. All these artificial preparations for intercourse demand from the woman an investigation of and interference with her own internal organs, which is revolting to all decent women, and such teaching is directly opposed to the advocacy of cleanliness and non-interference with the genital organs, which is the natural habit of healthy-minded women. The effects, however, go further than this. Nature has provided in the healthy vaginal secretions an antidote to infection which quickly destroys harmful germs. If the natural secretions are altered it is difficult to restore them to their natural quality. Professor Arthur Thomson, F.R.C.S., has shewn ("British Medical Journal," January 7th, 1922) from observations of the lining of the womb in animals and in women that "the weight of evidence goes to prove that its function is more likely to be absorbent than excretive, and that as such it plays an important part in the animal economy." After describing at length the evidence that the male secretion consists largely of the secretions from special glands as well as the sex cells, he refers to the fact that these are all largely received into and absorbed by the glands of the womb, and he discusses the probability that such absorption profoundly and beneficially affects the physiological reaction in the woman. He points out that the use of artificial checks "while preventing fertilisation may also be the means of depriving the female of certain secretions which may exercise a far reaching influence on her economy"; and he concludes, "As a rule we cannot interfere with the normal course of nature without some consequent evil result. May this not be an instance in which for some apparent gain in one direction, the woman pays the penalty?" CHAPTER IV THE EFFECT OF WIDESPREAD CONCEPTION CONTROL ON NATIONAL EFFICIENCY In every nation individual capacity varies within wide limits. We have men and women of brilliant attainments, and of all grades of intelligence ranging downwards to the mentally defective. There is no doubt that all grades of intelligence can be improved by education, but there appears to be a limit to the capacity of development of each individual. Lower intelligence, therefore, is not only due to lack of opportunity, but to an inborn constitutional defect. Further study has shewn this defect to be hereditary--the parents or grandparents of such people shew defective intelligence, and their offspring are likely to do the same; indeed, if two mentally defective people marry it is fairly certain that their children will all be mentally defective. There are, however, no sharply defined classes of intelligence; just as the mentally defective are in many grades, so ordinary men and women vary from low or average intelligence up to outstanding cases of genius or capacity. By the newer methods of mental testing it has been shewn that children of various classes of the community, as well as men and women of different races, can be grouped according to their intellectual capacity, and that no educational facilities will develop that capacity beyond a certain point. Professor W. McDougall, F.R.S., in his most useful and interesting book on _National Welfare and National Decay_, reaches the important conclusion "that innate capacity for intellectual growth is the predominant factor in determining the distribution of intelligence in adults, and that the amount and kind of education is a factor of subordinate importance." He claims that the evidence is overwhelming as to the validity of the results obtained by mental testing. A few examples of experimental work given in Professor McDougall's book will suffice to show the trend of these results. Tests of intelligence were carried out on recruits for the American Army, white and coloured, and they shewed marked superiority of the white race. A special test was carried out in Oxford by Mr. H.B. English, who compared the capacity of boys in a school attended by children of the intellectual classes with that of boys in a very good primary school, whose fathers were shop-keepers, skilled artisans, etc., coming from homes which were good, with no sort of privation. The result showed marked superiority of the sons of intellectual parents. Mr. English concludes that the children of the professional classes, between 12 and 14 years of age, exhibit very marked intelligence, and he is convinced that the hereditary factor plays an altogether predominant part. In another experiment, Miss Arlitt, of Bryn Mawr College, tested 342 children from primary schools in one district, who were divided into four groups:-- Group 1. Professional. Group 2. Semi-professional and higher business. Group 3. Skilled labour. Group 4. Semi-and unskilled labour. Marked differences between the groups were shewn. The intellectual capacity was represented by figures as follows:-- Group 1 125 Group 2 118 Group 3 107 Group 4 92 A further research of 548 children, grouped according to the occupation of their father, gave its results in terms of the percentage of children in each group who scored a mark higher than the median for the whole 548. They are as follows:-- Professional group 85% Executive group 68% Artisan group 41% Labour group 39% In the "Journal of Educational Psychology," Vol. IX, 1916, Mr. A.W. Kornhauser gives evidence from the examination of 1,000 children drawn from five schools in Pittsburgh. Schools A and B were attended by children of unskilled manual workers. Schools C and D by children of skilled artisans and small shopkeepers. School E by children of parents in very comfortable circumstances. The results are tabulated as-- Retarded, _i.e._, below average. Normal, _i.e._, average. Advanced, _i.e._, above average. | Retarded. | Normal. | Advanced. A } Manual workers {| 45.2 | 47.1 | 7.7 B } {| 36.7 | 55.9 | 7.4 | | | C } Artisans, etc. {| 29.4 | 50.2 | 20.7 D } {| 28.8 | 50.2 | 19.5 | | | E Most comfortable | 12.7 | 62.7 | 24.6[A] [Footnote A: I am indebted to Professor McDougall's book for information here given.] These experiments all shew the trend of intelligence (and with it will power or power of concentration, and what we may call general capacity) to be more concentrated in the so-called higher grades of society, and to be less and less evident as we descend in the scale from skilled to unskilled workers. It would, of course, be clear to all that the children of mentally deficient parents can only be a burden on the State or can rarely contribute anything of value to the common weal. Now the teaching and advocacy of methods of conception control is most easily assimilated and practised by the intelligent classes; indeed, we may say with certainty that such methods can only be used effectively by the intelligent members of the community, such as leisured, professional and mercantile classes, skilled artisans and better class workers, whereas the lowest type of casual labourers whose home conditions render the use of preventive methods difficult or impossible, and the mentally deficient and criminal classes, are unaffected by such teaching. The result in a few generations must be a marked decrease in the numbers of the intellectual and efficient workers, while the hopelessly unfit continue to produce their kind at the same rate as before. The figures given do not suggest that individuals with marked ability are to be found in the upper classes only, but they do indicate that there is a larger proportion of boys and girls in the more comfortable classes whose inherited ability is above the average, though this may be partly due to the more intellectual atmosphere in which their early childhood has been passed. The provision of education for all, with facilities for children of every class to pass on to higher grades of work, is essential if the latent powers in all, whatever they may be, are to be developed to the utmost. The point for our consideration at the moment, however, is that if the production of all capable workers, whether mental or manual, is to be curtailed and the numbers of the population maintained in greater proportion from the mentally deficient or criminal classes, the result must be national disaster. For in a very short time there will not be enough leaders of real capacity to occupy positions of initiative and responsibility in the various activities of the country at home and abroad, nor will there be an adequate supply of good practical work: a lowered standard of efficiency must result. From a national point of view, therefore, we regard the propaganda in favour of conception control to be a real and increasing danger. The problem of the mentally deficient is of another order. In this case another kind of control is urgently needed, but it is one which can only be undertaken by the State, and not by the individual. It is to put in force such a method of compulsory segregation as would ensure the comfort and contentment of the mentally deficient, and safeguard them and the nation from the reproduction of their kind. The problem also of the insane and criminal classes in relation to heredity is one which demands careful consideration by those competent to give it. SUMMARY OF CONCLUSIONS 1. There are certain women who for medical reasons should be prevented from bearing children. 2. There are couples with undesirable inheritance who rightly decline to bear children. 3. There are many women of the poorer classes in whom child-bearing is sometimes the last straw in circumstances all of which tend to destroy health and vitality. 4. Public teaching on contraceptives, like medical advice advertised in newspapers, is generally applied to cases for which it is unsuitable and applied in the wrong way. It is therefore detrimental to public health as well as being detrimental to public morality. 5. A public opinion in favour of small spaced families does not serve the best interests of the children or of their mother. 6. Married love should express itself at once in the usual way without the use of artificial contraceptives. 7. The diminishing fertility of the more capable classes is a national peril. To counteract this tendency every encouragement should be given to the intelligent and efficient classes of the community to bear healthy children. The study of problems which give rise periodically to a propaganda in favour of the practice of conception control reveal the fact that excessive child-bearing is found in those classes who suffer the greatest privation, and in whom large families are a real hardship, while many couples among the well-to-do are childless though greatly desiring children. Such facts suggest that the true remedy for the general problem lies in raising the standard of living among working-class mothers and advising a more simple life to the more richly endowed. 8. It is desirable that the Government should make provision for methods which will arrest the propagation of the mentally deficient, insane and criminal classes. 
26923	----	U EMERGENCY CHILDBIRTH A REFERENCE GUIDE FOR STUDENTS OF THE MEDICAL SELF-HELP TRAINING COURSE LESSON NO. 11 ACKNOWLEDGMENT We wish to acknowledge with grateful appreciation the many services provided by the American Medical Association, through the Committee on Disaster Medical Care, Council on National Security, Board of Trustees and staff, in the preparation of this handbook. From the inception of studies to determine emergency health techniques and procedures, the Association gave valuable assistance and support. The Committee on Disaster Medical Care of the Council on National Security, AMA, reviewed the material in its various stages of production, and made significant contributions to the content of the handbook. A joint publication of the U.S. DEPARTMENT OF DEFENSE Office of Civil Defense and the U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Division of Emergency Health Services 5600 Fishers Lane, Rockville, Maryland 20852 Reprinted December 1970 EMERGENCY CHILDBIRTH What To Do 1. Let nature be your best helper. Childbirth is a very natural act. 2. At first signs of labor assign the best qualified person to remain with mother. 3. Be calm; reassure mother. 4. Place mother and attendant in the most protected place in the shelter. 5. Keep children and others away. 6. Have hands as clean as possible. 7. Keep hands away from birth canal. 8. See that baby breathes well. 9. Place baby face down across mother's abdomen. 10. Keep baby warm. 11. Wrap afterbirth with baby. 12. Keep baby with mother constantly. 13. Make mother as comfortable as possible. 14. Identify baby. What Not To Do 1. DO NOT hurry. 2. DO NOT pull on baby, let baby be born naturally. 3. DO NOT pull on cord, let the placenta (afterbirth) come naturally. 4. DO NOT cut and tie the cord until baby _AND_ afterbirth have been delivered. 5. DO NOT give medication. DO NOT HURRY--LET NATURE TAKE HER COURSE. If it becomes necessary for families to take refuge in fallout shelters there will undoubtedly be a number of babies born under difficult conditions and without medical assistance. Every expectant mother and the members of her family should do all they can to prepare for emergency births. They will need to know what to do and what to have ready. (See "Expectant Mother's Emergency Kit.") SPECIAL SAFEGUARDS A pregnant woman should be especially careful to protect herself from radiation exposure. She should have the most protected corner of the shelter and not be allowed to risk outside exposure. She should not lift heavy objects or push heavy furniture. If food shortages exist, she should be given some preference. Fear and possible exertion involved during an atomic attack will probably increase the number of premature births and of miscarriages. PREPARATIONS Usually there is plenty of time after the beginning of first labor pains to get ready for the delivery. Signs of labor are low backache, bloody-tinged mucous strings passing from the birth canal, or a gush of water from the birth canal. The mother will need a clean surface to lie on. Her bed should be so arranged that the mattress is well protected by waterproof sheeting or pads made from several thicknesses of paper covered with cloth. Cover these protective materials with a regular bedsheet. A warm bed should be made ready in advance for the baby. It may be a clothes basket, a box lined with a blanket, or a bureau drawer placed on firm chairs or on a table. If possible, warm the baby's blanket, shirt, and diapers with a hot water bottle. Warm bricks or a bag of table salt that has been heated can be used if a hot water bottle is not available. A knife, a pair of scissors, or a razor should be thoroughly cleansed and sterilized in preparation for cutting the umbilical cord. If there is no way to boil water to sterilize them (the preferred method of sterilization), sterilize them by submersion in 70 percent isopropyl alcohol solution for at least 20 minutes or up to 3 hours, if possible. Sterile tapes for tying the umbilical cord will be needed. (Do not remove them from their sterile wrappings until you are ready to use them.) If no tapes are available, a clean shoestring or a strip of sheeting (folded into a narrow tie) can be boiled and used wet as a cord tie substitute. STAGES OF LABOR Labor is the term used to describe the process of childbirth. It consists of the contractions of the wall of the womb (uterus) which force the baby and, later, the afterbirth (placenta) into the outside world. Labor is divided into three stages. Its duration varies greatly in different persons and under different circumstances. During the first and longest stage, the small opening at the lower end of the womb gradually stretches until it is large enough to let the baby pass through. The contractions (tightening) of the uterus, which bring about this stretching and move the baby along into the birth canal, cause pains known as labor pains. These pains, usually beginning as an aching sensation in the small of the back, turn in a short time into regularly recurring cramplike pains in the lower abdomen. By placing your hand on the mother's abdomen just above the navel, you can feel each tightening of the uterus as an increasing firmness or hardness. It lasts for 30 to 60 seconds. The pains disappear each time the uterus relaxes. At first these pains occur from 10 to 20 minutes apart and are not very severe. They may even stop completely for a while and then start up again. The mother should rest when she is tired but need not be lying down continuously. She may sleep between tightenings if she can. She can take a little water or perhaps tea during the entire labor process. She should urinate frequently during labor so the bladder will be as empty as possible at the time of birth. The skin in the vaginal area of the mother should be sponged occasionally with soapy water. Special attention should be given to cleaning the inner sides of the thighs and the rectal area with heavy lather. Soap or water should not be allowed to enter the vagina. A slight, watery, bloodstained discharge from the vagina normally accompanies labor pains or occurs before the pains begin. For first babies, this stage of labor may continue for as long as 18 hours or more. For women who have had a previous baby, it may last only 2 or 3 hours. The end of this first stage is usually signaled by the sudden pressing of a large gush of water (a pint or so), caused by the normal breaking of the bag of waters which surrounds the baby in the mother's womb. For some women, the bag of waters breaks before labor begins or perhaps as the first sign of its beginning. This should not cause the mother or those helping her any concerns. It usually does not seriously affect the birth. Through this first stage of labor, the mother does not have to work to help the baby be born. She should not try to push the baby down, but should try to relax her muscles. She can help do this by taking deep breaths with her mouth open during each tightening. [Illustration: A. At full term, or after 40 weeks of pregnancy, the baby is ready to be born. The cervix through which baby must leave the uterus is shown clearly here, still closed. The contractions of the muscles of the uterus will open the cervix, and force the baby down through the vagina, or birth canal, to the outside.] [Illustration: B. At the end of the first stage of labor the cervix is completely open and the baby's head is beginning to come down through the vagina. Contractions begin in the lower back and later are felt in the lower abdomen. At the time shown here contractions are probably coming every 2 minutes, lasting 40-60 seconds and very strong.] [Illustration: C. The first stage of labor usually lasts several hours and is hard work. The mother needs to relax, rest, and be reassured. Give her water and fruit juices. In this picture the second stage of labor is well along. It is shorter than the first stage and the mother will now be pushing down with each contraction, helping to force the baby into the world. ] [Illustration: D. The head of the baby has been partially born. This shows the usual position with the face down and the back of the head up. The bag of waters in which the baby is enclosed throughout the pregnancy may have broken at the beginning of labor, before or during the first stage. It may break now, or have to be torn with the fingers.] [Illustration: E. Here you see the baby's head turned to the right as is usual. The shoulders are about to be born. The head must turn so that the baby's body can fit into the birth canal and come through more easily. After the birth of the baby there will be further uterine contractions and the placenta will be separated from the uterine wall and expelled.] CHANGE OF FEELING Gradually the time between the labour pains grows shorter and the pains increase in severity until they are coming every 2 to 3 minutes. It will not be long now before the baby is born. At this stage the mother will notice a change. Instead of the tightness in the lower abdomen and pain across the back, she will feel a bearing down sensation almost as if she were having a bowel movement. This means the baby is moving down. When this happens, she should lie down and get ready for the birth of the child. The tightening and bearing down feelings will come more frequently and be harder. She will have an uncontrollable urge to push down, which she may do. But she should not work too hard at it because the baby will be brought down without her straining too hard. There will probably be more blood showing at this point. _The person attending the delivery should thoroughly scrub hands with soap and water. Never touch the vagina or put fingers inside for any reason. The mother also should keep her hands away from the vagina._ As soon as a bulge begins to appear in the vaginal area and part of the baby is visible, the mother should stop pushing down. She should try to breathe like a panting dog with her mouth open in order not to push the baby out too rapidly with consequent tearing of her tissue. She should keep her knees up and legs separated so that the person helping her can get at the baby more easily. MOMENT OF BIRTH _The person helping the mother should always let the baby be born by itself. No attempt should be made to pull the baby out in any way._ Usually the baby's head appears first, the top of the head presenting and the face downward. Infrequently the baby will be born in a different position, sometimes buttocks first, occasionally foot or arm first. In these infrequent situations, patience without interference in the birth process is most important. The natural process of delivery, although sometimes slower, will give the child and the mother the best chance of a safe and successful birth. The baby does not need to be born in a hurry, but usually about a minute after the head appears the mother will have another bearing down feeling and push the shoulders and the rest of the baby out. As the baby is being expelled, the person helping the mother should support the baby on her hands and arms so that the baby will avoid contact with any blood or waste material on the bed. If there is still a membrane from the water sac over the baby's head and face at delivery, it should immediately be taken between the fingers and torn so that the water inside will run out and the baby can breathe. If, as sometimes happens, the cord, which attaches the child from its navel to the placenta in the mother's womb, should be wrapped around the baby's neck when his head and neck appear, try to slip it quickly over his head so that he will not strangle. After the baby is born, wrap a fold of towel around his ankles to prevent slipping and hold him up by the heels with one hand, taking care that the cord is slack. To get a good safe grip, insert one finger between the baby's ankles. Do not swing or spank the baby. Hold him over the bed so that he cannot fall far if he should slip from your grasp. The baby's body will be very slippery. Place your other hand under the baby's forehead and bend its head back slightly so that the fluid and mucus can run out of its mouth. When the baby begins to cry, lay him on his side on the bed close enough to the mother to keep the cord slack. The baby will usually cry within the first minute. If he does not cry or breathe within 2 or 3 minutes, use mouth-to-mouth artificial respiration. _Very little force should be used in blowing air into the baby's mouth_. A short puff of breath about every 5 seconds is enough. As soon as the baby starts to breathe or cry, mouth-to-mouth breathing should be stopped. CUTTING THE CORD There should be no hurry to cut the cord. Take as much time as necessary to prepare the ties and sharp instruments. You will need two pieces of sterile white cotton tape or two pieces of 1-inch-wide sterile gauze bandage about 9 inches long to use to tie the cord. (If you do not have sterile material for tying the cord but do have facilities for boiling water, strips of sheeting--boiled for 15 to 20 minutes to make them sterile--can be used.) Tie the umbilical cord with the sterile tape in two places, one about 4 inches from the baby and the other 2 inches farther along the cord toward the mother, making two or more simple knots at each place. Cut the cord between these two ties with a clean sharp instrument such as a knife, razor blade, or scissors. A sterile dressing about 4 inches square should be placed over the cut end of the cord at the baby's navel and should be held in place by wrapping a "bellyband" or folded diaper around the baby. If a sterile dressing is not available, no dressing or bellyband should be used. Regardless of whether a dressing is applied or not, no powder, solution, or disinfectant of any kind should be put on the cord or navel. If the afterbirth has not yet been expelled, cover the end of the umbilical cord attached to it (and now protruding from the vagina) with a sterile dressing and tie it in place. [Illustration: Cut between the square knot by bringing the left tape over right tape for first loop and right tape over left for second loop. Tighten each loop firmly as tied. Use scissors or a razor blade to cut cord.] THIRD STAGE OF LABOR Usually a few minutes after the baby is born (although sometimes an hour or more will elapse) the mother will feel a brief return of the labor pains which had ceased with the birth. These are due to contractions of the uterus as it seeks to expel the afterbirth. _Do not pull on the cord to hurry this process_. Some bleeding is to be expected at this stage. If there is a lot of bleeding before the afterbirth is expelled, the attendant should gently massage the mother's abdomen, just above the navel. This will help the uterus to tighten, help the afterbirth come out, and reduce bleeding. It may be desirable to put the baby almost immediately to the mother's breast for a minute or two on each side even though the mother will have no milk as yet. This helps the uterus contract, and reduces the bleeding. Someone should stand by the mother and occasionally massage her abdomen gently for about an hour after the afterbirth is expelled. After that the mother should feel the rounded surface of the uterus through the abdomen and squeeze firmly but gently with her fingers. The bedding should be cleansed and the mother sponged. Washing and wiping of the vaginal area should always be done from the front to the back in order to avoid contamination. A sanitary napkin should be applied. Keep the mother warm with blankets. She may have a slight chill. Give her a warm (not hot) drink of sweetened tea, milk, or boullion. Wipe her hands and face with a damp towel. She may drop off to sleep. The mother's diet after delivery may include any available foods she wishes. She may eat or drink as soon as she wants to, and she should be encouraged to drink plenty of fluids, especially milk. Canned milk can be used and made more palatable by diluting with equal parts of water and adding sugar, eggs, chocolate, or other flavoring. For the first 24 or 48 hours after delivery, the mother will continue to have some cramping pains in the lower abdomen which may cause a great deal of discomfort. Aspirin may help relieve these afterpains. She should empty her bladder every few hours for 2 days following the birth. If her bowels do not move within 3 days after delivery she should be given an enema. MISCARRIAGE If a pregnant woman shows evidence of bleeding, she should restrict her activities and rest in bed in an effort to prevent possible loss of the baby. If a miscarriage does occur, keep the patient flat with the foot of the bed elevated from 12 to 18 inches to retard vaginal bleeding. Keep her warm and quiet, and give her fluids. EXPECTANT MOTHER'S EMERGENCY CHILDBIRTH KIT The public health and civil defense agencies of one State have planned a 1 1/2-pound emergency childbirth kit made up of basic supplies that can be carried in a 1-yard-square receiving blanket. The kit consists of the following: One-yard square of outing flannel, hemmed (receiving blanket). Plastic (polyethylene flexible film) for outer wrapping of the kit if desired. (_Do not_ wrap the baby in this plastic film.) One or two diapers. Four sanitary napkins (wrapped). Adhesive tape identification strips for mother and baby. Short pencil. Soap. Sterile package containing: Small pair of blunt-end scissors (cheapest scissors will do), or a safety razor blade with a guard on one side. Four pieces of white cotton tape, 1/2 inch wide and 9 inches long.[1] Four cotton balls. Roll of 3-inch gauze bandage. Six 4-inch squares of gauze.[1] Two or more safety pins. [1] You will actually use only two tapes for tying the umbilical cord. The two extras are included as a safeguard in case one or two should be dropped or soiled. Extra 4-inch squares of gauze also are included. [Illustration: Emergency childbirth kit] Instructions such as those contained in this chapter also should be considered a part of the emergency childbirth kit. To make the kit ready to carry, lay the plastic (if used) out flat, and lay receiving blanket out flat on top of the plastic. Place the diapers, sterile package, soap, sanitary napkins, identification tapes, pencil and instructions in the center. Pull two opposite corners of the receiving blanket and plastic together and tie. Do the same with the other opposite corners, pulling each side together well so that nothing will fall out. Then tightly knot the loose ends together in the same way, leaving an opening so that the kit can be slipped over the arm for carrying the kit while leaving the hands free. Such an emergency delivery kit will weigh about 1 1/2 pounds. The contents suggested are basic essentials only, for extreme emergency. Much more could be added, but the extra weight might mean leaving behind some other items needed for survival. Additional supplies could be stored in your home shelter to be ready in the event the birth takes place there. In the case there is no need for an emergency delivery, either in the home, shelter or in some evacuation situation, the supplies in the kit can be used in home care of the baby. IDENTIFICATION TAPES In emergency situations, identification will be particularly important, especially if the birth should take place in a group shelter rather than a family shelter, or in an evacuation situation. Two wide strips of adhesive tape will be needed--one long enough to go around the mother's wrist, and the other long enough to go around the baby's ankle. Information should be written on these strips as shown below. [Illustration: For mother--Write parents' names, blood types, and mother's Rh factor, street address, and whether it is a first or later child.] [Illustration: For baby--Write date and hour of birth and parents' names and address.] 
34029	----	generously made available by The Internet Archive/American Libraries.) PARTURITION WITHOUT PAIN OR Loss of Consciousness. BY JAMES TOWNLEY, Member of the Royal College of Physicians of Edinburgh, Fellow of the Royal College of Surgeons of England, Fellow and Councillor of the Medical Society of London, F.L.S., Etc. Etc. _SECOND EDITION._ LONDON: JOHN W. DAVIES, 54, PRINCES STREET, LEICESTER SQUARE. EDINBURGH: MACLACHLAN AND STEWART. DUBLIN: FANNIN AND CO. MDCCCLXII. LONDON: SAVILL AND EDWARDS, PRINTERS, CHANDOS STREET, COVENT GARDEN. PREFACE TO THE SECOND EDITION. A second edition of my little work being required at the expiration of only a few months is gratifying to me, as evidence that my views regarding the use of an Anodyne in Parturition have attracted considerable attention. I may take this opportunity of stating, that I have never had any intention of undervaluing the merits of others who have laboured in the field of anæsthetics, my only claim to attention consisting in the novelty of my mode of applying the agent, by which its effects are so remarkably modified. When chloroform is administered in the usual way it is given slowly, and "goes the round of the circulation" before it relieves the pain or produces anæsthesia. Whereas, in my plan of using the "anodyne," the rapidly repeated but interrupted impressions made on the nervous system produce the anodyne without the anæsthetic effect--before, indeed, the mass of the blood has become affected. In this consists all the originality to which I lay claim. I have used the word "anodyne," instead of "modified chloroform," in consequence of this peculiarity of its effects. I cannot but regard this as an improvement on the old plan of using chloroform--which relieved pain, it is true, but it produced loss of consciousness also, and was not unattended with danger. _2, Harleyford Place, Kennington, S., October, 1862._ ADVERTISEMENT TO THE FIRST EDITION. The following remarks on the administration of an anæsthetic agent during parturition are reprinted from the _Lancet_. I have appended a series of Letters, illustrative of the efficacy of the mode of proceeding I adopt. _2, Harleyford Place, Kennington, S., June, 1862._ PARTURITION WITHOUT PAIN. For some time past, my attention has been directed to the use of anæsthetics in parturition. I had often been requested by patients to administer chloroform to them during labour, but I had seen the ill effects of this drug in one instance so strongly and almost fatally developed, that I shrank from its use. After considerable reflection on the subject, I thought that if a plan could be devised by which the anæsthetic agent should act only in deadening sensation, and not interfere with consciousness, it would be a boon to the accoucheur as well as to the patient. How was this to be effected? Two conditions appeared necessary for its accomplishment,--namely, a modification of the Inhaler at present in use; and certain additions to the chloroform--additions which would reduce its strength, and give it a certain flavour. These two conditions I had not much difficulty in fulfilling. But there arose an obstacle of more serious moment: How, when, and for what time, was the inhalation to be made? I will now give an account, _seriatim_, of my inhaler, the anodyne fluid which I employ, and the mode in which I direct the inhalation to be made. _The Inhaler_[A] is similar to one very commonly used in administering chloroform. It has, however, in addition, two tubes, an inch and a quarter long and a quarter of an inch in diameter, running parallel to the floor of the inhaler. These tubes, being placed above and to the sides of the inspiring valve, admit two small streams of fresh air, which to a great extent are inspired unmixed with the vapour of the anodyne. In the place of the grating there is a curved prong for retaining the sponge under the right tube and opposite the hole in the right side connected with the cup which receives the mixture to be inhaled. The object of this cup is--first, to receive the mixture, and direct it to the centre of the sponge. It has, in the second place, the advantage of helping to keep the Inhaler cool by the patient making use of it to rest her thumb upon when she is inhaling. It will therefore be gathered from this that the patient herself always holds the inhaler. [Footnote A: Manufactured by Messrs. Weiss and Son.] [Illustration: A, cup; B, external opening of tubes; C, internal opening of tubes; D, sponge.] _The anodyne mixture_ which I have found to be the most manageable is composed as follows: Alcohol, two ounces; one drachm of aromatic tincture; with sufficient chloroform added, short of the production of a turbid state of the fluid. The object of adding the tincture is to make it pleasanter to inhale; the spice also appears to prevent the sickness which would otherwise sometimes arise from long-continued inhalation. By giving a little colour to the mixture, also, it prevents any accident that might arise by putting in by mistake pure for the modified chloroform. I prepare the aromatic tincture as follows: One drachm of nutmegs; two drachms of cloves; pterocarp chips, a drachm and a half; water, four ounces; alcohol, five ounces: mix. _Mode of administering the anodyne vapour._--The great object to be attained is to so far influence the nerves of sensation as to prevent pain, and yet not carry the anæsthetic agent to the extent of producing unconsciousness. This can be effected in the following manner:--The woman, in the upright or recumbent position, as the case may be, holds the Inhaler in her right hand. She is directed to take a full inspiration, and then to apply the Inhaler to the mouth and nose. She is then to breathe rapidly for six, eight, or more inspirations (the inspirations and expirations being equal) only with the diaphragm and abdominal muscles, the chest being kept a fixture all the time. The Inhaler should then be removed immediately, and one or two full, deep, quick chest-inspirations taken. This will be found sufficient to relieve all pain, and there will be no loss of consciousness. During the entire process it is desirable to have a full light upon the face, to watch the countenance and feel the pulse occasionally, and observe the pupils. These, in some cases, are very quickly affected, and then the inhalation requires to be suspended for a time. During the time the process is going on, I am in the habit of giving a teaspoonful of brandy in a cup of weak tea with plenty of milk, and something to eat; or, instead, a glass of wine and a little cake or bread-and-butter, from time to time, to keep up the strength and prevent that sudden pallor of the face which sometimes occurs. I may add, as only a portion of the alcohol is taken up in vapour, it accumulates in the sponge, so that it is necessary occasionally to squeeze it out before adding a fresh quantity. I can hardly attempt to explain clearly the _modus operandi_ of the agent. Practically, however, it answers the purpose intended. The great point is, of course, to arrest its action before it produces unconsciousness. This is effected by using it as I have described. It is requisite that the patient be carefully watched, so that the moment for administering the agent may be seized. From the experience I have now had of its use, I can estimate pretty accurately the exact time the inhalation should be resumed or discontinued. After a little practice this knowledge can be obtained by any competent observer. I have now given my anodyne mixture in 216 cases, and without in any one instance seeing a bad result _quoad_ the administration of the mixture. Of these cases many have come to me in consequence of the severity of their former labours, their extreme nervousness, and other causes. I select a few instances from my notebook in which the anodyne was employed with complete and satisfactory effects: 1. The patient was in her twenty-ninth year, by no means robust, of a nervous temperament, and looking forward to her first labour with great apprehension. 2. Was in her thirty-third year, and looked forward to her first labour with great dread. 3. Her sixth labour; all her previous labours had been very severe. 4. Her tenth labour; her previous labours very severe, and each time followed by a great deal of after-pain. 5. Her eighth labour; had suffered intensely in every previous labour, in some of which she had been delivered with instruments; had had a protracted recovery after each labour. 6. Her seventh labour; inflammation had followed each of her former labours. 7. Her fifth and sixth labours; her former labours had been very severe. 8. Her third and fourth labours; her former labours having been very severe. 9. Her first labour; very strong expulsive pains; soft parts at first being very rigid, then gradually giving way after six hours' use of the inhaler. 10. Her third labour; child's head very large and firm; much exhaustion; delivered with the short forceps, very great force requiring to be used before the head could be extracted. 11. Her first labour; very nervous and timid; with difficulty could I get her to use the Inhaler rightly, but she became much more composed towards the end, and inhaled very well. I have rarely seen stronger expulsive pains than she had towards the last; the arch of the pubes being rather contracted, and the child full-sized. 12. Her fourth labour; breech presentation; used the Inhaler for three hours. 13. Her first labour; in her thirty-ninth year; very severe expulsive pains for nine hours; the last hour, owing to the size of the head and the contracted outlet, no progress was made; and beginning to get exhausted, it was decided to apply the forceps, which were accordingly sent for, but a few minutes before they arrived, nature had overcome the difficulty; the child was born alive, but with a large caput succedaneum, showing how firmly it had been retained the last hour. 14. Had always had great suffering in her former labours; used the Inhaler about three hours; breech presentation; placenta was adherent, and required great force to peel it off. I have thus given the results of my experience with an agent calculated, under proper management, I venture to think, to be of great service in the practice of midwifery. I believe my experience with it has proved that-- 1st. It is possible for a woman to be delivered with less pain from the beginning to the end of her labour than a rhubarb draught would occasion. 2nd. It is possible to afford that relief without interfering with the regular and natural action of the heart or brain. 3rd. It is possible for the child to be born without the mother experiencing any pain whatever, while at the same time she retains her consciousness and power to bear down when told to do so; and her first knowledge of the birth of her child shall be from hearing it cry. 4th. That when a woman is delivered without suffering pain, although she shall have had inflammation after each of six previous labours, the prevention of the suffering will have the effect of preventing the usual inflammation. 5th. That by preventing the suffering of labour, the woman does not lose her strength, and always has a speedy recovery. CASES. _Of the following Letters from Patients which I have selected for publication, six relate to cases of first labour._ It is generally admitted that the suffering of first labours equals, if not surpasses, that of subsequent ones. In three of these six labours there was the additional drawback of age, the youngest being more than twenty-eight years old. In one of these cases also there was a contracted outlet, which retained the head for one hour. It follows, therefore, that if in the severer cases of labour, with obstacles to impede delivery, women can be so fully relieved as not to suffer pain, the more ordinary and milder cases will also have the same relief. I, therefore, think it unnecessary to give any larger number of cases. I will only add, that in all these cases the patient deserved as much credit as the accoucheur, as it was by her quickly altering and exactly following his directions in the manner of inhaling that enabled her to go through the labour without pain. Some patients, with the best intentions of doing what you wish, find it difficult, and then they have a little pain at times, but so little that I am within bounds when I say it is not one-twentieth of what they would otherwise have suffered. * * * * * Providence Place. My dear Sir, Having always had a great dread of the pains of labour, I was exceedingly pleased when you told me that you had it in your power almost entirely to prevent their being felt, though I must confess I was at the time rather sceptical as to the amount of alleviation you could effect without producing unconsciousness; but having been so happy as to be under your care during my confinement, I can truly say that the result fully realized all you had said. I suffered very much before you arrived, part of the time lying on the floor in great agony, perfectly unable to rise; but from the time I took the Inhaler in my hand, and used it under your directions, I had no more pain, lying quite still on the bed, and giving orders to the attendants to get all that was required (as you are aware, I was confined quite unexpectedly). I was perfectly conscious all the time, and remembered where everything was that was wanted. I was quite free from pain, excepting when you took the Inhaler from me to replenish it, when the pains came on rapidly, and I was delighted to get it back again. When the child was born, there was a feeling of great forcing, but scarcely any pain; indeed, I did not think it was born until you said "There, Mamma, you have a nice little girl." Again thanking you, dear Sir, for your kindness, and the immense relief I experienced under your most beautiful method, I remain, Yours very truly, * * * Dr. Townley. * * * * * Oxford Terrace. My dear Sir, Having heard of the great relief many ladies had received from your plan of treatment in their confinements, and having a great dread and fear of the pain and suffering, it somewhat relieved my mind to know that you had the means of very much mitigating them; but it is impossible for me to express a tithe of the benefit and relief I obtained while using your Inhaler. I had been suffering more or less pain for thirty-six hours before sending to you; but you had not been with me five minutes before I was perfectly free from all pain, and continued so for the six hours that my labour lasted, and the first knowledge of baby being born was my hearing it cry. I held the Inhaler myself the whole time, and was not the least unconscious for a single moment. I was laughing and talking with my aunt and nurse the greater part of the time. No one who has not experienced or seen it can have the least idea of the marvellous effect of your process. I will only add, that I had no after pains, and felt well, and quite strong enough to get up the next day, if I had been allowed. No words can sufficiently convey my thanks to you for this inestimable boon in my hour of need. I remain, My dear Sir, Yours very sincerely, * * * Dr. Townley. * * * * * Roupell Park. Dear Sir, It is with great pleasure I testify to the wonderful efficacy of your method of treatment during the agony and peril of childbirth. Having had the benefit of your professional services in my former confinements, you are well aware how greatly I suffered on those occasions. After a lapse of four years I was anticipating my sixth confinement with feelings of dread and apprehension, until assured by you that you had a means of greatly easing suffering women at these times; but I can truly say, that unless I had myself experienced the marvellous effects of your beautiful method, I could not have believed it possible that aught in medical science could have been so perfect in application and result. At the time of your arrival, I was in great agony; five minutes after you entered my room I was entirely free from pain, and unless I had occasionally removed the Inhaler, I should not have believed I was in labour: the intensity of pain then felt made me hastily replace it. During the whole time--about an hour and a half--I was perfectly conscious, able to ask and answer questions. I did not know when my baby was born. I had not the slightest feeling of pain or distension; and even when twice assured by yourself, and also by my sister, who was present, that baby was born, I could not believe, until I saw the child with my own eyes, that my trial was over. I had no after-pains or inconvenience of any kind as hitherto, but regained my strength quickly and comfortably. I can only say, in conclusion, that it is impossible to speak sufficiently in praise of your marvellous process, or for me to offer you thanks at all in proportion to the great blessing you have been the means of bestowing on suffering women. I remain, Dear Sir, Yours very sincerely, * * * To Dr. Townley. * * * * * Clapham. My dear Sir, It gives me great pleasure to have this opportunity of stating the very great relief I received in my late confinement from your most beautiful plan of treatment. Having had a large family, and, as you know, always suffering so much in my previous confinements, I could scarcely believe I was in labour when using the Inhaler under your direction, as I had not the least particle of pain, and only when I took it away to have it refilled was I aware that labour was going on. My husband, mamma, and nurse, who were in the room at the time, were quite astonished to see me without the least pain or suffering during the five hours my trouble lasted. I never lost my consciousness, but knew all that passed, holding the Inhaler myself the whole time; and, more wonderful still, when baby was born I did not feel any pain or inconvenience whatever, and only when told it was over, did I know the child was in the world. I had no after-pains, from which I generally suffer so much; felt perfectly well the next day, and continued so the whole time, which was a perfect contrast to my former confinements, as I have always been many weeks before I regained my strength. In conclusion, I must say I cannot sufficiently speak in praise of your beautiful process, which not only relieves all pain at the time, but prevents loss of strength afterwards. Allow me, with my husband, to offer you my most sincere thanks; and rejoiced are we to think that at any future time I can be relieved from such agonizing pain by your invaluable method. I am, my dear Sir, Yours very sincerely, * * * To Dr. Townley. * * * * * Kennington Lane. Dear Sir, It was with no ordinary apprehensions that I looked forward to my hour of peril. My previous labours had been seasons of the most prolonged and intense suffering, at times rising to intolerable agony. My medical attendants in the country have been compelled to remain, with slight intervals of absence, from twelve to twenty-four hours, yet utterly unable to afford aught but momentary relief. My anxiety was somewhat abated by the statements I received from ladies whom you had attended, by hearing the great relief they had received from your plan of treatment; and I am happy to have it in my power to corroborate their testimony. No one but those who have experienced it can conceive or describe the immense alleviation of suffering it produces, without in the least taking away the power of consciousness; and when baby was born I did not feel the least pain or inconvenience, and did not know that it was born till you assured me it was. My recovery, too, was marked by the absence of pains and other inconveniences, which sometimes awakened the greatest apprehensions on the part of my family. Very grateful am I to you for your attention; and sincerely do I thank God, who has enabled you to mitigate to a most wonderful degree the pains and agony of child-bearing. I will only add, that after you came I can conscientiously say that I had no pain at all. I am, Sir, Yours most respectfully, * * * Dr. Townley. * * * * * Epsom. Dear Sir, With pleasure I write to tell you of my safe return home and continued good health. My rapid restoration and early return is a subject of wonder and astonishment to my friends, who have been accustomed to see me at the end of six and eight weeks in a precarious and suffering condition. My six former confinements being very severe, the time of labour varying from twenty to thirty-six hours, followed by violent inflammation, leaving me much exhausted. I was looking forward to my seventh with great fear and dread, when I heard of the wonderful efficacy of your system from two of my sisters, who had received such great relief from the liquid they inhaled. I came to town doubting I should derive the same benefit, when I considered the agony I had endured on every previous occasion, both during and after. I feel I cannot sufficiently express on paper the astonishing fact, that for six hours, using the Inhaler myself the whole time, I was perfectly free from pain, and without one moment's loss of consciousness, occasionally talking and laughing with those around me; and when told by yourself that my trouble was nearly over, it appeared to me impossible; and so great was my joy, that I did not replace the Inhaler the last few moments, consequently felt a pain with distension. I quite believe, had I attended, and replaced the Inhaler in time, I should not have felt the slightest pain. I was suffering much when you came to me, but you were not in my room more than three minutes before I was perfectly easy, and remained so the whole time until the birth of my babe, when I experienced the pain I have named. The after effects of your skilful process are equal, and even surpass, the time of labour; not one adverse symptom attended or followed on the present occasion to retard my recovery. I was better at the end of a fortnight than I had previously been at two months. I assure you that I cannot realize that I have been in so short a time reprieved from pain, and feel most grateful under Providence to your skill and kind attention from not being, as hitherto, not hours or weeks, but months, in a state of suffering in mind and body. Earnestly do I wish every such patient could receive the boon of your assistance in their hour of anguish. Accept my own and my husband's best thanks; and should I again require assistance, our chief anxiety would be to secure the inestimable benefit to be derived from the use of your Inhaler. I remain, Yours very truly, * * * To Dr. Townley. * * * * * Camberwell New Road. Dear Sir, Allow me to express my gratitude for the benefit I received under your care during my two last confinements. I had had four children when I first heard of your treatment in alleviating the pains of childbirth; and having a great dread from severe suffering in my former labours, I determined to place myself under your care. The first time you attended me, when you came I was in much agony; immediately upon inhaling the vapour you gave me, I felt as if it ran down my back to the exact spot where the pain was, which it immediately relieved, and a sense of forcing, with a trifling uneasiness, was all I experienced during the birth of my babe; and I can truly say that its benefit during my labour this last time surpassed the first. Having had chloroform three times previously, I can testify that the effects of your treatment are quite different, and infinitely superior; for while in the one case I lost my senses and power of action, under you my senses were as acute as at any time in my life, and my bodily powers the same. No one can imagine the relief obtained under your process: it must be felt to be believed. With deep gratitude to God as the first cause of every blessing, and with sincere thanks to yourself for the very great relief you gave me, Believe me to remain, Dear Sir, Yours respectfully, * * * To Dr. Townley. * * * * * Kennington. Dear Dr. Townley, Having been so fortunate as to procure your professional services during my accouchement, and receiving so much benefit thereby, I cannot allow it to pass without expressing my admiration at the skill and success with which you relieved me from all pain, whilst at the same time I remained perfectly sensible. Before you arrived I was suffering great agony, but you immediately relieved it. The labour went on regularly for nearly five hours without my feeling the _slightest_ particle of pain. I can conscientiously state that I did not know the child was born till I heard it cry, at the same time being perfectly sensible and able to converse cheerfully with a friend I had with me. I did not suffer from headache, fever, or any other bad symptom which sometimes follows childbirth. I consider the process you use in midwifery cases to be, without any exception, the greatest boon which has been, or ever can be, given to woman, and will, I trust, be appreciated as such. I have received the wonderful benefit of it myself, as well as witnessing it in two other cases; one an extremely difficult one, where I am fully convinced that the patient must, in all human probability, have lost her life, had it not been for your beautiful process, whereby she was totally relieved from pain, which must in her case have exhausted nature. I could add much more in favour of this great boon, but will not trouble you with a tedious letter. In conclusion, let me offer my sincere thanks to you for devoting your time and talents to the discovery of so wonderful and useful a practice in the most important branch of your profession; and you will, I am sure, be fully repaid by knowing the amount of suffering you have prevented, and, I may also add, the lives you have saved. You are at liberty to show this letter to any one, or to refer them personally to me. It is my opinion that too much cannot be said in praise of your beautiful process. I remain, Dear Dr. Townley, Yours most sincerely, * * * * * * * * Stockwell. My dear Sir, Allow me to express my gratitude for your kind care and attention to me during my two last confinements, and the great benefit I derived from your mode of relieving the dreadful pains of childbirth. When consulting you in the year 1859 relative to my approaching confinement, which I very much dreaded, having upon two previous occasions suffered intensely the pains of labour for the space of nearly two days each time, I gladly accepted the proffered relief you offered me, though I was somewhat sceptical it would afford me all the relief you considered it was calculated to convey. I now beg to state, for the information of any who may never have participated in its inestimable benefit, that both in 1859 and in the last month (March, 1861), I am perfectly convinced it has been under Providence the means of saving my life; that its marvellous effects are such that pain is scarcely felt or known; and while inhaling the vapour there is not the slightest degree of unconsciousness. I was able to converse and give directions with the same ability and readiness of perception as a person in the most perfect health would do; in addition, I may also state, that whereas in my previous labours I had always suffered much pain from distension and soreness afterwards, in the two last there was a total absence of both these inconveniences. I cannot but express my fervent thankfulness for your skill and watchfulness during my hour of need, and should only be too happy to testify personally to any one expecting to take it, that they need be under no apprehension whatever from ill effects, at the time or afterwards, either to themselves or their infant. So beautiful is it, that I told my nurse, as far as the pain at the time of labour went, I should not mind going through the same every week. Incredible as these results may appear to those who have never felt nor witnessed your mode of alleviating the pains of labour, the earnest desire of both myself and husband is, that by God's blessing your valuable life may long be spared, and that you may enjoy the happiness and privilege of being, to a constantly-increasing number of ladies, the means of proving that what has hitherto been considered an impossibility can be done--namely, the birth of a child without any pain or any loss of consciousness to the mother throughout the whole of her labour. I remain, Dear Sir, Yours very sincerely, * * * Dr. Townley. * * * * * Camberwell. Dear Dr. Townley, I had great dread of going through my first confinement, and accordingly, when a friend of mine, on whose experience of your aid I could place the greatest reliance, recommended me to try your anodyne treatment, I was very glad to avail myself of your scientific services. I had expected that all you could do would be to relieve me of a little of the usual pain of a confinement, but I can now confidently declare that I did not feel any pain at all during my labour. For I knew very well when every pain was approaching, and by using the Inhaler under your direction, I was enabled to bear the labour without experiencing any pain at all. What I really did feel was an unpleasant sensation of extreme forcing, to which it would be wrong of me to give the name of pain; that sensation is easily accounted for, since it was the opinion of a medical friend who was present, that my child could not be born without the use of the instruments; but I thank God, that with the help of your anodyne, and with your own attentive encouragement, my child was born alive, and without the use of the instruments. On the following day I felt neither pain, nor stiffness, nor discomfort of any kind. With many thanks for your kind attention, I am, Yours truly, * * * * * * * * Vassall Road. Dear Sir, It is with mingled feelings of pleasure and gratitude that I take up my pen to testify to the extraordinary results of your wonderful process for alleviating and lessening the pains and perils of childbirth. I have, as you are aware, thrice passed through this ordeal; the first without the aid of your invaluable process, and well do I recollect the agony I then endured; the second time I was induced to submit myself to your new mode of treatment, and although it was a tedious and protracted labour, I passed through it with little or none of the suffering I experienced on the first occasion. In my third and last confinement I cannot speak too highly of this inestimable boon. I was in great agony on your arrival; but as soon as I used the Inhaler, which I held in my own hand, I felt no more pain. I was perfectly sensible the whole of the time, conversing freely with those in the room. But what I consider most extraordinary was, when you were obliged at the last, owing to the great size of the baby's head, to have recourse to instruments; even at that trying time, I experienced little or no pain or distension, to the utter astonishment and delight of my mother and the nurse, who were present. As to myself, I could hardly believe it possible that my trouble was over. My speedy recovery is well known to you, being enabled to rise from my bed on the fifth day after my confinement, quite strong, and to leave my room within the fortnight, neither myself nor babe ever having since experienced the least unpleasant effects from the astonishing relief afforded. In conclusion, I beg you to accept the sincere thanks of myself and husband for your great kindness and unremitting attention to me in the hour of need, and trust you may long be spared to witness the marvellous results of your arduous exertions for relieving suffering women. I remain, Dear Sir, Yours very sincerely, * * * To Dr. Townley. * * * * * 18th Feb., 1862. Dear Sir, When I was at Clapham last week, I heard that my confinement had been hit upon by some persons (who are much prejudiced against your splendid discovery) as an example of its _failure_; and as I do not think it should be looked upon in that light, I am writing to say you are at liberty to send any one to me, and I will tell them that, although I cannot say (as I _know_ some of your ladies can) that I never felt a pain, yet that the anodyne gave me such relief that I shall be thankful to get the same alleviation another time. You will recollect you found me in great pain, but that instantly subsided when I used the Inhaler as you told me; and for an hour or two, strictly following your directions, I could not believe that the labour was going on, as I felt nothing, though perfectly conscious the whole time. But once allowing the pains to get ahead, I seemed as if I could not listen to you. It being my first confinement, I suppose I was frightened and nervous, consequently, then, not being able to do as you told me, I suffered intensely for a time, but towards the end I must have used the Inhaler better, for I certainly did not feel my _great baby_ being born. You yourself called it a _terrific bout_; but I recovered very rapidly, which must be a proof that I did actually derive much benefit from the anodyne, notwithstanding my having that interval of suffering when I did not use the Inhaler properly, for I walked downstairs to dinner on the fifth day, and was home at three weeks, and thirty miles down in the country three days after. I speak of you and your wonderful discovery whenever I get the opportunity, and sincerely hope I may have your valuable assistance again, if I should be in a condition to need it. Believe me, Dear Sir, Yours very truly, * * * To Dr. Townley. * * * * * April 12th, 1862. My dear Dr. Townley, I cannot allow the benefits that I have personally received from the application of your valuable discovery in alleviating the pains and anguish in the hour of childbirth to pass unacknowledged. I have delayed writing earlier, being anxious to confirm the lasting benefits conferred at the time. It is now five months since you attended me, and I unhesitatingly affirm that on the three previous occasions of my confinements, I have never been so fully recovered at the end of one month, as I was on the last occasion at the end of a fortnight, as was instanced by the fact, as you know, of my being obliged to closely watch and nurse, night and day, my youngest boy, in a severe and critical illness. Apart from the general and speedy restoration to health and strength, I can safely state that while under the influence of the anodyne, which I applied myself, retaining consciousness the whole period, and when strictly following your directions, experienced no pain whatever, although you are aware the difficulty in my case was increased by being what is termed a cross-birth, and which I feel sure, under the ordinary treatment, would have left me utterly prostrated through severe and protracted suffering. I willingly, and unsolicited, render you this simple tribute of my sincere and best thanks, that under divine Providence, you have been enabled to introduce so marvellous a relief in the hour of such momentous maternal anxiety and suffering; and I shall be most happy to satisfy any one who may wish for a reference as to the beneficial effects of your wonderful discovery, so far as I have individually experienced it, and readily accord you full liberty to make use of this communication as may be most satisfactory to you; and with best wishes for your continued success, Believe me, My dear Dr. Townley, Yours very truly, * * * To Dr. Townley. * * * * * 13th May, 1862. Dear Sir, It is with great pleasure I testify to the wonderful effects of your beautiful method of treatment during the agony of childbirth. Being my first confinement, I was naturally nervous and fearful. I had been suffering great pain more or less for five hours before I sent for you, but had no sooner taken your Inhaler in my hand than all my nervousness, fears, and pain vanished, and for the next six hours that my labour lasted felt perfectly easy. The only pain I felt was when I removed the Inhaler to have it replenished, my great anxiety being to get it back again. I did not in the least lose my consciousness, but was laughing and talking with my mamma and nurse the whole time. When my baby was born, the feeling I experienced was just as if the parts had been india-rubber--a gentle expanding, but not the least pain. I had no after-pains, and there was no inconvenience afterwards, either to myself or child, and I felt perfectly well, and strong enough to get up the next day had I been allowed. Thanking you, dear Sir, for all your care and watchfulness over me during my hour of need, I remain, Yours most respectfully, * * * To Dr. Townley. * * * * * May 15th, 1862. Dear Sir, I cannot help expressing on paper, for the benefit of others who might be as incredulous as I was myself, the perfect success of your treatment. In a previous confinement, five years ago, I was obliged, after a most protracted labour and much suffering, to be delivered by instruments. This time, although it was a cross-birth from the time you came, I suffered no pain; and after three hours using the Inhaler under your direction, when you assured me the baby would soon be born, I could not believe it, having no forcing or sensation of any kind. I was perfectly sensible, and able to talk cheerfully with those around me. Though some time under your hands whilst removing the after-birth, which adhered, I had not the slightest pain. In all my previous confinements I had been much troubled afterwards, in consequence of the protracted and forcing nature of my labour, from piles and other inconveniences, none of which I experienced under your care; consequently, I felt better on the second day than I ever had before at the end of a fortnight. All who have used your Inhaler must be thankful that you have been directed by a gracious God to a means of mitigating such severe suffering. Believe me, Dear Sir, Yours truly, * * * * * * * * May 20th, 1862. Dear Sir, With much pleasure I acknowledge the benefit I derived from inhaling your anodyne during my recent confinement. I confess it was with some fear and reluctance I yielded to the persuasions of two of my friends (who themselves had experienced its benefit) to try it. I could not forget how much I suffered some time since from the use of chloroform administered to me for the extraction of a tooth. On that occasion, after the tooth was out, they were obliged to open the windows and deluge me with cold water. It was an hour and a half before any signs of consciousness returned, and then the ringing in my ears and distress in my head were dreadful. It was a full week before I could bear any light or noise in my room, and even now a little camphorated chloroform for toothache quite upsets me. In taking your anodyne, however, I felt nothing of the kind. I was perfectly conscious all the time, and whilst inhaling it suffered no pain. I have been stronger and better since than in any of my four previous confinements. This time I was dressed and sat up to dinner before baby was five days old, without feeling the slightest inconvenience of any sort, and the earliest time I have sat up to dinner before has been two weeks. I am sure that ladies who suffer much at these times, or from debility afterwards, will find it a very great boon. I am, Dear Sir, Yours sincerely, * * * To Dr. Townley. THE END. 
29612	----	This Treatise on the Diseases of Women Is Dedicated to the Women of the World. Yours for Health Lydia E. Pinkham This entire book copyrighted in 1901 and 1904 by the Lydia E. Pinkham Medicine Co., of Lynn, Mass., U. S. A. All rights reserved and will be protected by law. List of Lydia E. Pinkham's Remedies. +Illustration of Products+ LYDIA E. PINKHAM'S VEGETABLE COMPOUND. Put up in three forms: Liquid, Lozenge, and Pills Price, $1.00 LYDIA E. PINKHAM'S LIVER PILLS, per Box " .25 LYDIA E. PINKHAM'S BLOOD PURIFIER " 1.00 LYDIA E. PINKHAM'S SANATIVE WASH, per Packet " .25 ALL THE ABOVE, EXCEPTING THE LIQUIDS, CAN BE SENT BY MAIL ON RECEIPT OF PRICE. ALL DRUGGISTS SELL MRS. PINKHAM'S REMEDIES. CHAPTER I. A WOMAN BEST UNDERSTANDS A WOMAN. =Experience a Perfect Teacher.=--Do you know what it is to suffer pain? Have you had your body racked and torn with intense suffering? Have you ever experienced that indescribable agony which comes from overworked nerves? Have you ever felt the sharp, stinging pain, the dull, heavy pain, the throbbing, jumping pain, the cramping, tearing pain, the sickening, nauseating pain? Then you know all about them. Nobody can tell you anything more. Experience is a perfect teacher. =Book-Learning Alone Not Sufficient.=--Suppose you had never experienced pain, but had just read about it in a book, do you think you would have any kind of an idea of what genuine suffering was? Most certainly not. Book knowledge is valuable. It teaches the location of countries, the use of figures, and the history of nations; but there are some things books cannot do, and the greatest of these is, they cannot describe physical and mental suffering. These are things that must be experienced. =Personal Experience Necessary.=--After you have once suffered, how ready you are to sympathize with those who are going through the same severe trials. If a member of your own home or a friend is passing through the trying ordeal of motherhood, and you have suffered the same, how you can advise, suggest, comfort, guide! If you have had a personal experience of intense agony once every month, do you not think you are in a far better position to talk with one who is suffering in the same way than you would be if you had never gone through all this? =You Best Understand Yourself.=--But let us go a little farther in this study. When you listen to an eminent orator, you have but little idea whether he is nervous or not, but little idea whether he is undergoing a severe strain or not; for you have never been in his place, cannot understand just that condition. Men become greatly interested in political matters; perhaps it often seems to you that they become too much disturbed; and yet how can you judge, for you have never been in their place? And so we might go on, giving illustration after illustration as additional proof to this one great fact. IT TAKES A WOMAN TO UNDERSTAND A WOMAN. =Man Cannot Know Woman's Suffering.=--What does a man know about the thousand and one aches and pains peculiar to a woman? He may have seen manifestations of suffering, he may have read something about these things in books, but that is all. Even though he might be exceedingly learned in the medical profession, yet what more can he know aside from that which the books teach? Did a man ever have a backache like the dragging, pulling, tearing ache of a woman? No. It is impossible. =Even Medical Men Cannot Understand These Things.=--To a man, all pain must be of his kind; it must be a man-pain, not a woman-pain. Take, for instance, the long list of diseases and discomforts which come directly from some derangement of the female generative organs; as, for instance, the bearing-down pains, excessive flowing, uterine cramps, and leucorrhoea. Do you think it possible for a man to understand these things? Granting that he may be the most learned man in the medical profession, how can he know anything about them only in a general way? You know, we know, everybody knows that he cannot. A WOMAN CAN BEST PRESCRIBE FOR A WOMAN. =Relief First Offered in 1873.=--Away back in '73 these thoughts came to Lydia E. Pinkham. She saw the most intense suffering about her on every hand, and yet no one seemed able to give relief. Her thorough education enabled her to understand that nearly all the suffering of womankind was due to diseases and affections peculiar to her sex. The whole question resolved itself into just this: If a remedy could be made that would relieve all inflammations and congestions of the ovaries, Fallopian tubes, uterus, and other female organs, the days of suffering for women would be largely over. =First Made on a Kitchen Stove.=--Could this be done? Mrs. Pinkham believed with all her heart that it was possible. So on a kitchen stove she began the great work which has made her name a household word wherever civilization exists. Without money, but with a hopeful heart, she made up little batches of this remedy to give to neighbors and friends whom she felt could be relieved by it. The story soon spread from house to house, from village to village, from city to city. Now it looked as if a business might be established upon a permanent basis, a basis resting upon the wonderful curative properties of the medicine itself. ="We Can Trust Her."=--By judicious advertising the merits of this remarkable remedy were set forth; and before she was hardly aware of it, she found herself at the head of one of the largest enterprises ever established in this country. That face so full of character and sympathy, soon after it was first published, years ago, began to attract marked attention wherever it was seen. Women said, "Here is one to whom we can tell our misery, one who will listen to our story of pain, one whom we can fully trust." And so the letters began to arrive from every quarter. Now hundreds of these letters are received every day. More than a hundred thousand were written in a single year. Everyone is opened by a woman, read by a woman, sacredly regarded as written strictly in confidence by one woman to another. Men do not see these letters. =Men Never See Your Letters.=--Do you want a strange man to hear all about your particular disease? Would you feel like sitting down by the side of a stranger and telling him all those sacred things which should be known only by women? It isn't natural for a woman to do this; it isn't like her, isn't in keeping with her finer sense of refinement. =No Boys Around.=--And then, how would it be when some boy opens the letters, steals time to read a few before they are handed to some other boy clerk to distribute (and probably read) around the office to the various departments? It makes one almost indignant to think how light and trivial these serious matters are so often regarded. =You Write to a Woman.=--But when you know your letter is going to be seen only by a woman, one who sympathizes with you, feels sorry for you, knows all about you, how different all this seems. =Confidence Never Violated.=--Although there are preserved in the secret files of Lydia E. Pinkham's laboratory many hundreds of thousands of letters from women from all parts of the world, yet in not a single instance has the writer accused Mrs. Pinkham of violating her confidence. =The Largest Experience in the World.=--The one thing that qualifies a person to give advice on any subject is experience--experience creates knowledge. No person can speak from a greater experience with female ills nor a greater record of success than Mrs. Pinkham. Thousands of cases come each month, some personally, others by mail; and this has been going on thirty years, day after day, and day after day, thirty years of constant success--think of the knowledge thus gained. Surely women are wise in seeking advice from a woman with such an experience--especially when it is free. If you are ill get a bottle of Lydia E. Pinkham's Vegetable Compound at once--then write Mrs. Pinkham, Lynn, Mass. What medical man has ever lived who has prescribed for so many women? What whole corps of physicians in any hospital or medical college has answered so many letters, or treated in any way so many patients? =She Helps Everyone.=--No woman ever writes to her for advice without getting help. No matter how rare you think your case may be, she is almost certain to find letters on file asking advice for other cases of the same kind. By special permission of the writers I print a few of the letters showing what cures have been effected. But if the reader could go through these secret files which are never shown, she might hour after hour, day after day, week after week, spend her whole time reading letters, each one telling some special story of rescue from serious illness, intense suffering, or impending death. =The Largest Record of Cures.=--The writers of these letters are found in every clime and there is hardly a country in the world without its multitude of grateful women cured by Lydia E. Pinkham's medicines. They have the largest record of absolute cures from female ills known to have been effected by any physician or his medicines. CHAPTER II. WHAT SHALL THE FUTURE GENERATION BE? =Important to the Nation.=--It is impossible to fully comprehend how important to us as a nation is the health of the young women of to-day. We fail to realize that these women are to be the mothers of the next generation, and that in their hands will lie, in large measure, the power to form the characters and direct the destinies of the boys and girls of the future. =Woman Must Be Strong.=--We may educate our young men all we wish, yet we cannot have national power through their strength alone. The women of the country must have this physical education if we are to have a people that is strong and hearty. Upon the sound health and vigor of the young women of to-day will depend, to a large extent, the health and capacity of the future generations. =What are Girls Worth?=--It is estimated that there are about twelve million young women in the United States between fourteen and twenty-eight years of age. What are these young women worth to the home, to the State, to the nation, to the human race? This is largely a question of physical health. It is the stern duty of the mother to make this clear to her daughter, and it is the solemn duty of every young woman to thoroughly study the subject herself. =Not Prepared for Motherhood.=--But largely through ignorance, often through indifference, these young girls become mothers when little prepared to do so, and they find not only their own health shattered thereby, but also that they are the mothers of weak, delicate, and perhaps deformed children. =Women Desire Children.=--We read a great deal in the newspapers about how American women are doing everything they possibly can to prevent having children. This is not in accord with our experience. It is a slander on American womanhood,--it is an outrageous falsehood. In not one letter in a thousand which we receive do wives ask how childbearing may be prevented, while every day brings us many, many letters asking if something cannot be done in order that there may be a baby in the house. =A Healthy Mother and Child.=--If you desire a child, you wish a healthy child; and you certainly desire to be a strong mother, one capable of caring for her infant in every way, and able to direct it all through its young life. Then let us give you some advice. =Why Some Women Do Not Have Children.=--The reason why some wives do not have children may be entirely the fault of the husband; but if this is not the case, then in all probability there is some inflammation of the generative organs. This may be of recent or of old standing. It must be thoroughly removed before the impregnated egg from the ovary can become attached. =The Cure for this Condition.=--That these changes can be brought about in a vast number of cases I have the most positive testimony. I have advised such wives to continually use Lydia E. Pinkham's Vegetable Compound; and, with this treatment alone, such a healthy condition of the generative organs has been brought about that pregnancy has very soon followed. This is precisely according to nature's laws, as I have indicated before. Therefore, I say to every wife who desires a child, "Give Lydia E. Pinkham's Vegetable Compound a thorough trial. If the fault is yours, the Compound will surely remove it, and the longing of your heart will be satisfied." CHAPTER III. REPRODUCTION. =The Reproductive Instinct Strong.=--The reproductive instinct is very strong in the human race, as is indicated by the large amount of energy the woman expends in the bearing of children, and by both sexes in the care and education of their young. As we know, it is only by the production of new individuals that the continuance of the race is assured. =Problems of Reproduction.=--The problems of reproduction are extremely broad, involving not only the immediate questions of individual reproduction, but also those broader and deeper ones which relate to heredity. =A New Life, By Chance.=--It is a most astonishing fact that nearly all persons born into the world are given life as the result of chance rather than by careful design. "If my parents had only known!" is the frightful wail of many a wretched life. =To Create is Divine.=--At no time does man come so near being omnipotent as when, by the tremendous powers given him, a new life is called into existence. And yet, whether strong or weak, refreshed or exhausted, healthy or diseased, sober or intoxicated, sweet or ill-tempered, yielding or resisting, a new life is begun which may be either of two extremes. How great are such questions! The human mind seems appalled when asked to consider them. =Education on These Subjects Necessary.=--It is not the purpose of this book to moralize upon these themes, or to say what should and should not be done; but knowing something of the wretchedness of womankind, and the fearful slavery she often has to endure, I can only hope, with all my heart, that the coming generation may be better educated on these most important topics. It is with a thought or two of this kind in mind that I append the following brief outline of this subject:-- =Two Sexes Necessary.=--In the higher animals two sexes are necessary for the reproduction of the race, the male and the female. Each contributes some particular element toward the beginning of a new life; this is known as the germ-cell. =The Germ-Cells.=--The germ-cells of the male are called spermatozoa, and those of the female, ova. The reproductive process is simply a fusion, or union of these male and female germ-cells. =The Male Elements.=--The spermatozoa are exceedingly delicate and minute; they constitute the greatest part of the semen, or sperm. They are peculiar shaped bodies, having a head, body, and tail, as illustrated in the accompanying figure, and they can only be seen by powerful magnifying glasses. (Fig. 1.) ~FIG. 1. At the left are six spermatozoa, or male-elements, male germ-cells. At the right is an ovum, egg, female germ-cell. All highly magnified.~ They have the remarkable property of moving about with considerable activity, and their number is almost beyond computation. =Only One Male Element Necessary.=--Although this number is so vast, yet only a single one is required to endow the female cell, or egg, with life. It is another illustration of how nature does everything possible to increase the chances of perpetuating the race, for without such immense numbers, the chances of the female egg being fertilized would be much less. =May Live for Days.=--Although these male elements can live but a few hours outside of the body, even when especial precautions are taken to make every thing favorable to their existence, yet they have been known to maintain their full life in the vaginal canal for more than eight days after their discharge; another remarkable provision of nature, for the prolonged existence of these cells increases the probability of the fertilization of an egg, and thus increases the chances of producing a new life. =The Female Element.=--As I have already said, the female germ-cell is also known as the ovum, or egg. A single ovum is shown in Fig. 1. If not fertilized by the male elements, the egg passes off into the outside world; if fertilized, it stops in the cavity of the uterus, where it forms an attachment. Here it remains until perfectly developed, when, at the end of nine months, it is brought forth to the outside world as a perfect infant. =One Female Element; Many Male Elements.=--The human ovum is often said to be a miniature of the egg of the common fowl, although there are some quite marked differences between the two. It is a very interesting fact to note that there is only one egg given off at a time; while there are many thousands of the male elements. This is in harmony with the larger size of the egg, and the fact that while this egg awaits fertilization it is most carefully protected within the body of the mother. =Where is Life First Made?=--Where the wonderful union of the male and female elements takes place is not definitely known, although it is generally believed that it is upon the surface of the ovary, itself. If this be true, then it is necessary for the male element to traverse the whole length of the uterine cavity, out along the course of the Fallopian tube, and there be deposited on the surface of the ovary. =The Fertilized Egg.=--When a fertilized or impregnated egg is set free from the surface of the ovary, it follows the same course that the unimpregnated egg does until it reaches the uterus. Here some most remarkable changes immediately take place whereby the egg is held firmly to the inner wall of the uterine cavity; while the unimpregnated egg, as I have said, passes down the uterine cavity into the vagina, and thus out of the body. In other words, the fertilized egg is retained within the body, while the unfertilized one is cast off. =One Egg Discharged Each Month.=--An ovum, or egg, is discharged during each menstrual period. It cannot be seen because of its minute size, a magnifying glass being necessary to detect it, even under favorable conditions. At just what time during this period the ovum is cast from the body is not definitely known, but it is generally thought to be toward the latter part. =Time When Fertilization is Most Probable.=--From this it is seen that but one egg fully develops and ripens ready to be fertilized each month. As it is the ripened egg which is thrown off at each menstrual period, therefore it follows that the fertilization of this egg would be most probable at about the time of menstruation. =Times When Ova Do Not Ripen.=--As a rule, these ova do not ripen, or develop, either during pregnancy, or during the nursing of the child, although there are certain exceptions to this rule; for menstruation occasionally takes place during lactation and pregnancy, and pregnancy itself may occur while the mother is nursing her child. CHAPTER IV. THE REMEDY THAT CURES. =A Vegetable Compound.=--I hardly think it necessary to mention in detail the separate ingredients of Lydia E. Pinkham's Vegetable Compound. We wish to call your attention, however, to that word "Vegetable." I do not believe in mercury, arsenic, and the host of mineral poisons which are found in so many remedies. When taken into the system they disturb every function, interfere with the most vital processes, and produce the most disastrous consequences. =The Purest and Best.=--Knowing these things, Mrs. Pinkham was exceedingly careful to put only the purest and choicest of products of the vegetable kingdom into her Compound. Each of the roots and herbs is selected with the most extreme care, and all are prepared under the personal supervision of the most thoroughly trained specialists. =One Secret.=--One great secret of the success of Lydia E. Pinkham's Vegetable Compound is that each vegetable is so treated that all useful elements are retained, and all useless discarded. =Highly Concentrated.=--For instance, it is possible for the expert workmen in our laboratory to condense all the medicinal power that exists in a pound of the coarse root into a mass no larger than could be held on the point of a knife. In this way it is possible for a teaspoonful of the Vegetable Compound to represent all the curative properties usually found in eight or ten times that quantity; in other words, it is highly concentrated. =Acts Upon Female Organs.=--Mrs. Pinkham knew from the very first that she was on the right track. She knew that her Vegetable Compound contained medicines which act directly and naturally upon the female organs. She knew that one ingredient produced certain effects on the uterus, while other ingredients tended to relieve pain in the ovaries. She knew that one remedy would heal an inflamed uterine cavity, while another ingredient would cause better circulation in the blood-vessels of this part of the body. Having the theory all worked out most carefully, she awaited the practical test, feeling confident as to the result. =Success Was Immediate.=--But she did not have to wait long. Immediately the cures began, and her neighbors and friends told each other what had been done for them. Soon letters came by the hundreds from all parts of the world. Thousands upon thousands have written to Mrs. Pinkham telling her their story, and giving to her, also, full permission to use their testimonials. =It Bridges the Gulf.=--I am sure you would be delighted, as well as surprised, if you could see the immense difference between the first and last letters received from women. The first is the story of suffering, of extreme agony with prolonged misery and abandoned hope. The last is a song of gratitude, of great love, of joy and peace. The first tells of disease, the last of health. But what an immense gulf between these two!--a gulf, however, I am glad to say, that can be bridged with Lydia E. Pinkham's Vegetable Compound. =You Cannot Possibly Doubt.=--I do not believe you can possibly doubt for one moment the power of this marvelous remedy to cure the diseases of women. How can you doubt it? For a quarter of a century it has gone into every city, village, and hamlet in our land, and into almost every country home. Across the water it is finding its way among the rich and the poor. No remedy was ever known that was so generally used. Wherever there are women, there are suffering women; and wherever there are suffering women you are sure to find Lydia E. Pinkham's Vegetable Compound. =The Testimonials Are True.=--Do you think there are hundreds of thousands of your own sex who would wilfully falsify? Do you think that any could be found who would deliberately do this, and without hope of gain or reward? Yet I could point you to hundreds of thousands of letters received from women who write from the fulness of the heart to thank us for what we have done for them. =We Speak Strongly.=--Then am I not justified in speaking strongly to you? Don't you think we feel sure of our position? I certainly know what we have done for others, and that makes us feel sure we can do the same for you. =We Can Cure You.=--I believe our Vegetable Compound will cure you. I believe it will cure every case where a cure is among the possibilities. You need not be particular whether the soreness in the lower part of your body is in the right side or the left side; whether the pain is sharp, or dull and heavy; whether you suffer terrible agony each month with local pain, or whether it is mental depression; whether the flow is too scant or too profuse. =It Corrects the Wrong.=--You need not be particular about these things, for they all show that something is wrong, and Lydia E. Pinkham's Vegetable Compound corrects this wrong. That is what it was made for; that is precisely the work it does. =Have Faith in Us.=--Don't purchase a bottle thinking you will "see what it will do," having made up your mind that you will "try the experiment." Don't come in this spirit, for there is no need of it. Come with the feeling that has inspired so many thousands of your sisters,--come believing that you have at last found a remedy that will relieve you from this terrible slavery to suffering. I am anxious to have you enjoy all the robust health that is your right. I am anxious to make you happy, hopeful, healthy. Put your confidence in Lydia E. Pinkham's Vegetable Compound. You will never be disappointed. CHAPTER V. THE FEMALE PELVIS AND ITS CONTENTS. =The Pelvis.=--The pelvis is the bony framework which forms the lower part of the body. On each side it forms a union with the hip bone to make the hip joint. The female pelvis contains the reproductive organs (uterus, vagina, and ovaries), and also the bladder and lower bowel. Fig. 2 gives a very good idea of the shape and general structure of this bony framework; while a careful study of Fig. 3 will enable one to form a very correct idea of the relative size and position of the various parts contained in this framework. ~FIG. 2. The female pelvis. The flanging sides form the hips. The union of the bones in front forms the pubic arch which is felt at the front of the lower part of the body. The lower end of the spinal column, or backbone, is seen at the back of the figure.~ =The Vagina.=--The vagina is a membranous canal extending from the surface of the body to the uterus, or womb. Its posterior wall is about 3-1/2 inches long, and its anterior about 3 inches. A careful study should be made of our illustration, in order that the relation of the vagina and uterus to the rectum behind and the bladder in front may be thoroughly understood; also the angle which is formed by the vagina and the uterus. Notice should be taken, also, of the opening of the uterus into the upper part of the vagina; as inflammation of the uterus often causes a discharge which passes into the upper part of the vagina and finally out of the body. This gives rise to the belief that the only trouble is in the vagina itself, whereas the real seat of the disease may be high up in the uterus. ~FIG. 3. A lateral view of the contents of the female pelvis. 1. the vagina; 2. uterus; 3. bladder; 4. lower bowel; 5. bone forming the pubic arch; 6. the spinal cord, with bone in front and back of it.~ =The Uterus.=--The uterus, or womb, is a hollow organ formed of muscular tissue, and lined with a delicate mucous membrane. The bladder is in front, the rectum behind, and the vagina below. =Three Parts.=--Physicians divide this important organ into three parts,--the fundus, body, and neck. The fundus is all the upper rounded portion; the body all that portion between the fundus and the neck; and the neck all the rounded lower part. =The Cavity of the Uterus.=--This is divided into the cavity of the body and the cavity of the neck. By consulting our illustration it is seen that these cavities differ greatly in shape; that of the body being triangular, while that of the neck is barrel-shaped. By referring again to Fig. 4 it will be seen that the cavity of the body has three openings, one on either side at the top going to the Fallopian tubes, and an opening at the bottom passing into the cavity of the neck. A constriction exists between these two cavities; but after childbirth this is largely done away with, and there is not that marked difference which existed formerly. =Glands in Uterus.=--In the mucous membrane lining the uterus are vast numbers of minute glands which secrete mucus. It has been asserted that in the cavity of the neck alone there are from ten to twelve thousand of these glands. It is in this mucous membrane that such remarkable changes occur each month during menstruation, and still more wonderful changes during pregnancy. =The Ligaments of the Uterus.=--By referring to Fig. 5 it will be seen that there are on each side of the uterus flat bands of tissue known as "broad ligaments." These ligaments are attached to the sides of the pelvic cavity, and aid greatly in holding the uterus firmly in place. There are also other ligaments concerned in this same work, although the broad ligaments are most important. The illustration also shows the walls of the vagina cut open, in order that the position of the mouth of the uterus may be easily seen. ~FIG. 4. This illustration shows the cavities in a uterus which has been pregnant. 1, the vagina; 2, cavity of the neck of the uterus; 3, cavity of the body, above which is the fundus of the uterus; 4, Fallopian tubes, extending to the ovaries.~ ~FIG. 5. The female generative organs. 1, the vagina; 2, uterus; 3, broad ligament of left side; 4, a smaller ligament; 5, Fallopian tube; 6, ovary; 7, fringed end of Fallopian tube.~ =Blood-Vessels Surrounding Uterus.=--The uterus is well supplied with blood-vessels, as Fig. 6 shows. Indeed, there is all over the walls of the uterus and through its tissue a vast network of these vessels. Whenever, for any reason, the circulation of the blood through the pelvis is disturbed, these blood-vessels are likely to become engorged, over-filled, producing congestion and inflammation. ~FIG. 6. The blood-vessels of the right side of the uterus. 1, blood vessels; 2, end of the Fallopian tube; 3, ovary; 4, right edge of uterus.~ =All Parts Closely Related.=--The close relation of these blood-vessels to the blood-supply of the bowels, liver, etc., makes it possible for most serious disturbances to take place even from slight causes. =Study the Illustrations.=--By studying these illustrations it can be readily seen how an over-distended rectum may produce such an impediment to the circulation that there will be congestion of all the neighboring parts. Or, the intestines themselves may become over-distended with fæcal matter, or gas, from dyspepsia, and the pressure induced thereby may be sufficient to interfere with the free circulation of these parts, and thus uterine congestion produced. It is also seen how improper dress may compress the organs about these parts, and thus interfere with the circulation. Again, it is easily understood, simply from studying the illustrations alone, how any of these causes might produce dislocation of the uterus itself. =Object of Uterus.=--The uterus is the source of the menstrual discharge, a place for the foetus during its development, and the source of the nutritive supply of this foetus. It is the uterus which contracts at full term and expels the child. =Uterus Not Rigidly Fixed.=--In a perfectly normal condition there is considerable mobility to the uterus; in other words, it is not fixed firmly by the ligaments already mentioned. It is rather simply suspended, or hung in the pelvic cavity, by these broad flat bands of tissue. A full bladder will push it backward, while a distended rectum will move it forward; as the body changes its posture, so will the uterus change its position by force of gravity. =Cannot Be Bent Upon Itself.=--The uterus cannot be bent upon itself without producing injury; neither can it be pushed too far forward or backward, nor crowded down too far without causing great distress and actual disease. =Fallopian Tube.=--Figs. 4 and 5 show that there is given off from each side of the upper part of the uterus a tube. This is called the Fallopian tube. Each tube is about four inches long. Near the uterus its cavity will just admit an ordinary bristle; but near its free end, at the ovary, it is as large as a goose-quill. It is a peculiar tube in that it terminates in a number of fringe-like processes, one of which is always attached to the ovary itself. ~FIG. 7. Part of an ovary, showing a ripe ovum, or egg, about to be cast off, as occurs at each menstrual period. It is here this egg may be fertilized or impregnated by the male elements.~ =Object of This Tube.=--The Fallopian tube conveys the sperm of the male from the uterus to the ovary, and also takes the germ-cell (or ovule, or egg) from the ovary to the uterus. When a ripe egg is about to be discharged from the ovary, one of these fringe-like processes of the Fallopian tube grasps it and receives it into the mouth of the tube, whence it is conveyed directly into the uterine canal. =Ovary.=--On each side of the uterus and in each side of the pelvic cavity is an ovary. It is about one and a half inches in length, three-fourths of an inch in width, and one-third of an inch in thickness. It weighs from one to two drachms, and is an elongated, oval-shaped body. ~FIG. 8. This figure illustrates the course followed by an ovum. The ripened egg leaves the ovary (1), passes down the Fallopian tube (2), and thence into the uterine cavity (3).~ ~FIG. 9. An exceedingly minute piece of an ovary, highly magnified. It shows eight ova or eggs.~ =Object of Ovaries.=--The ovaries are the essential organs of generation in the female. In each ovary are large numbers of cells, ovules, or eggs, one of which, at least, is supposed to pass into the uterine cavity with each menstruation. Anatomists tell us that each human ovary contains as many as 30,000 of these ovules, or eggs. LOCAL TREATMENT.--FAST PASSING AWAY. =It Makes One Indignant.=--When I recall the terrible and almost horrible treatment which women have had to undergo in the past, I cannot help but become deeply indignant. It seems as if all medical study had gone for naught, as if the teachings of nature had been forgotten, and most of all, as if no such thing as delicacy and modesty existed. =This Makes Confirmed Invalids.=--It is only necessary for a woman to complain of discomfort in the back, a bearing-down pain, or some unnatural discharge, when some physician says that local treatment, and local treatment only, must be taken. Women so thoroughly understand what their physician is going to say that they do not consult him, but go on suffering more and more until they become almost confirmed invalids. Others, after they are told what must be done, return home and become gloomy and melancholy over the outlook. =Specialists Are Crazy for Work.=--The specialists are so crazy for this kind of work that it seems as though they would gladly scrape and burn the inside of the stomach for dyspepsia, if they could do so! Or, they would take a long probe and go down into the interior of the lungs and apply strong caustics, if such a thing were possible! =The Patient Is Deceived.=--If the ache, or the pain, or the discharge was on the back of the hand where it could be seen, and where these "treatments" could be watched, the specialists would have a hard showing indeed, for the patient herself would then see that little good came from these local applications. But being situated within the body, so that only the physician himself can examine the parts, the patient has to rest content, not knowing whether a little pure water is applied (and the fee collected), or whether the strongest acids which burn deep into the tissues are used (and the fee collected). =Local Treatment Unnecessary.=--Now all of this is almost invariably unnecessary. It is not showing ordinary common-sense, not in accord with nature, and not in keeping with the best medical science of to-day. Yet thousands upon thousands of women are undergoing the worst kind of mental and physical torture in taking these local treatments, while all the savings of the household have to go toward paying the enormous bills of the specialist. =The True Doctor Not Blamed.=--_Do not misunderstand me, please. I am not talking against doctors, not against the real, true, genuine, noble physicians and surgeons._ There is no nobler profession than that of the physician, none practiced more faithfully than the good old family physician of this country practice theirs. The best of them are glad to help their patients in any way they can, and in spite of professional prejudice, many have tried Lydia E. Pinkham's Vegetable Compound upon their patients and have been delighted at the wonderful success of the trial. =Nature the Best Teacher.=--The trouble with so many of these physicians who call themselves "Specialists on Diseases of Women" is that they get it into their head that they know more than nature. They map out a course of their own, and pay no attention whatever to the laws of health. Just as if a dog barking at the moon would make it shine less brightly! Now any one who has given any thought to the preservation of the health can readily understand how impossible it would be to cure an inflammation of the uterus or ovaries, or check an unnatural discharge from the vagina, by applying strong acids, nitrate of silver, pure carbolic acid, strong tincture of iodine, or other destroying, caustic, irritating, and dangerous drugs. All of these must be injurious, must postpone recovery, and if their use be continued for any great length of time must make a cure quite impossible. =A Good Medicine Needed.=--Of course what is needed in these cases is something that will restore the natural circulation of the blood through the tissues of the uterus, something that will relieve congestion and cure inflammation. When the swelling and irritation have subsided, then the nerves are no longer irritated, and all pain disappears. =What This Will Do.=--Then all these parts become better nourished, the weakened and diseased tissues take on new strength, and all unnatural discharges cease. When the relaxed ligaments are properly fed and toned up, then they hold the uterus in its natural position, and all bearing-down pains and other symptoms of displacement quickly disappear. Of course this constitutional treatment with Lydia E. Pinkham's Vegetable Compound is hastened by keeping the parts perfectly clean, which can be easily done with Lydia E. Pinkham's Sanative Wash. =A Hearty Welcome to the Perfect Cure.=--A hearty welcome to the most scientific treatment; a hearty welcome to the most natural, the most easy, and the most perfect method of cure; a hearty welcome to Lydia E. Pinkham's Vegetable Compound; a hearty welcome to the remedy that never fails to restore the uterus to perfect health and natural position. CHAPTER VI. MENSTRUATION. =Occurs Monthly.=--Once every twenty-eight days very remarkable changes occur in the uterus, giving rise to that peculiar monthly periodicity called menstruation, monthly sickness, monthlies, or being unwell. Although this usually occurs once in about four weeks, yet it may be a week less or a week longer; or, indeed, the variation may be even greater than this. =Symptoms of its Approach.=--As a perfectly natural menstrual period approaches, there is a certain degree of discomfort and lassitude, a sense of weight in the lower part of the body, and more or less disinclination to enter society. These symptoms may be slightly pronounced or very prominent, for it is quite unusual to find a person who does not have at least some general discomfort at this time. =Its Appearance.=--First there is a slight discharge of mucus which soon becomes of a rusty brown or yellow color from the mixture of a small quantity of blood. By the second or third day the discharge has the appearance of pure blood. The unpleasant sensations which were so marked at first now gradually subside, and the discharge, after continuing for a certain number of days, grows more and more scanty. The color changes from a pure red to a rusty tinge, and finally disappears altogether. Then the ordinary duties are resumed. =The Age of Puberty.=--Menstruation begins at about fourteen or fifteen years of age, this period being known as "the age of puberty." It is preceded and attended by peculiar signs. The whole figure becomes more plump and round, the hips increase in breadth, and the breasts rapidly develop. The more striking changes, however, occur in the inclinations and emotional susceptibilities. =Age Modified.=--A great many circumstances modify the age at which the first menstruation takes place. In hot climates this takes place earlier, the difference between hot and cold countries being as great as three years; yet heredity has more to do with this than anything else. "As was the mother so is the child" is a common saying among women. =Continues About Thirty Years.=--The menstrual function continues active from this age until about the forty-fifth year, although this may be extended even ten years later. During all these years the woman is capable of bearing children, because at each month there has been a fully developed ovum, or egg, ready to be fertilized. =The Change of Life.=--When the menstrual function ceases, then the period of childbearing is over. The time of its disappearance is known as "the change of life, or menopause." =Amount of Monthly Loss.=--The amount of blood lost during menstruation varies greatly with different individuals, and it would be quite impossible to give anything like an accurate rule. It varies, normally, from one to eight ounces, the average being probably about five ounces. =Duration of Period.=--The duration of the period is from one to eight days, the average being five days. Hence it will be seen that the average loss of fluid per day would be about one ounce. =Loss Should Be Small.=--It should be stated here that, as a rule, those enjoy the best health who lose but a small quantity of blood at this time. Some persons seem to think that a very free discharge is necessary, and that they feel better at such times; but there is no possible reason why this should be the case. =The First Menstruation.=--The appearance of the first menstruation is a most critical time in the life of every young girl, and the mother should be prepared to give her daughter the best of advice. Some slight inattention, some undue exposure, some thoughtlessness due entirely to ignorance on these great subjects, may change the whole future from a life of comfort and good health to prolonged days of misery and intense suffering. =Menstruation and Childbearing.=--It is the belief at the present time, among all who have studied this subject, that menstruation is closely connected with the function of childbearing. The changes which take place each month within the uterine cavity are of precisely the proper character to prepare this tissue for the reception of the fertilized egg. =Rules to be Observed.=--A few rules should be carefully followed during each menstruation, in order that future trouble may be prevented. First of all, it is necessary to avoid taking cold; yet a person should not stay in the house by the side of a fire, or in a warm room all the time, for this would increase the susceptibility to cold. Care should be taken to avoid undue exposure, for nothing will disturb the menstrual process quicker than the sudden chilling of the body, especially when moist with perspiration. Intense mental excitement should be avoided, also. If the young girl is at school, she should be told to study more lightly at this time; while any great excitement of any kind, as giving way to anger, or extreme merriment, should be avoided. The feeling of debility and depression which usually accompanies this time is a gentle warning by nature that the body should remain quiet and at rest. It is natural for many persons to be especially depressed at this time; an effort should be made by those who understand the situation to make everything as agreeable and pleasant as possible to the sufferer. =Danger to School Girls.=--Without the slightest doubt, many women are suffering intensely to-day who might be enjoying the best of health had they not been obliged to study so intensely while in school. A moderate amount of study does no harm at this time, but the dread of examinations, with our modern system of cramming at certain times of the school year, has, without doubt, so worked upon the nervous system that many a life has been made miserable as a result. =Danger to Office Girls.=--It is astonishing, when one fully understands the processes of menstruation, how so many girls and young women can remain all day behind the counter in the store, or at the work-table, during these few trying days, and even escape without serious illness. Employers never think of the subject, and there is a natural delicacy on the part of those most concerned to mention the subject. There should be in all such establishments some woman to whom these girls could confide their condition. This woman, or overseer, could easily be made responsible for the apparent neglect of duties by these girls at such times. =Criminal Carelessness.=--How often is it true that young ladies attend balls, skate, and otherwise recklessly expose themselves at this most critical time. One is almost inclined to call such exposures really criminal, because of the terrible consequences so sure to follow. A simple wetting of the feet, or resting quietly in a draught after exercise, during menstruation may impose upon the person a life-long injury. How carefully, then, should mothers watch their daughters at these periods, and how strongly should they impress upon them the necessity of special care. =Condition of Bowels Important.=--The condition of the bowels should also be carefully looked after at these times. Indeed, this is so important that it should never be neglected. There should be at least one good movement of the bowels each day. Nothing can more certainly derange the menstrual function than persistent constipation. =Regularity Important.=--Every mother should make careful inquiry into the exact frequency of the menstrual period with her young daughter, at least during the first two years of the menstrual function. If there is pain at this time, then something is certainly wrong, and treatment should be taken at once. If there is irregularity, this also requires most prompt attention, as it will surely develop into something serious sooner or later. If the flow is too free, or not free enough, or if there is any deviation from the standard of health, the mother should be acquainted with it, and should proceed at once to correct the difficulty. =First Two Years Very Important.=--If a girl can get through the first two years of her menstrual life without serious disease, she stands a very good chance of enjoying good health during the rest of her life; while a slight mistake at this time may produce the most serious disease in later life. If you do not understand your ailments write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful. CHAPTER VII. DISORDERS OF MENSTRUATION. =Amenorrhoea.=--This is a condition in which the monthly flow is suspended. It can hardly be called a disease, as it is rather a symptom of some disorder of the uterus, or of some constitutional defect. This may occur at the time when menstruation should normally appear, namely, from fourteen to fifteen years of age. =Danger of a Decline.=--If the young girl does not menstruate at sixteen, seventeen, or eighteen, something is certainly wrong, and treatment should be taken at once in order to correct the difficulty before the girl goes into a decline. It is not wise to trust too much to nature in these cases. Such girls are generally thin and pale, with a peculiar sallow, or yellowish-green color to the skin which has given rise to the term "green-sickness," or "Chlorosis." They fall easy victims to scrofula, consumption, nervous prostration, insomnia, and other diseases. =Treatment.=--When the time for menstruation arrives, and the flow does not appear, the mother should give her daughter regular doses of Lydia E. Pinkham's Vegetable Compound. This remedy acts strictly according to the laws of nature, and simply brings about natural conditions. For some reason nature may not succeed in beginning this important change in the girl's life, but with the help that comes from the Vegetable Compound, this is sure to come to pass. =How Lydia E. Pinkham's Vegetable Compound Acts.=--A better circulation is established, the condition of the blood is improved, the nervous system is greatly invigorated, and, as a result, the menstrual flow is established. This should set at rest a great deal of worry on the part of the mother, and it means a great deal to the daughter, as well. Now, the mother can be assured that one great danger is passed, and, with proper care and attention, there need be no more trouble. Lydia E. Pinkham's Vegetable Compound, however, should be taken for some weeks or months until the habit is well established and menstruation appears regularly every twenty-eight days. =Delicate Girls.=--If the young girl menstruates, and yet is not in good health, then she should certainly take the Vegetable Compound for a week before the time when menstruation is expected; the great object being to establish regularity in the menstrual function. =Keep the Bowels Regular.=--In all these cases attention should be given to the condition of the bowels, which are usually constipated. To correct this, the girl should take laxative doses of Lydia E. Pinkham's Liver Pills, just enough each night so that there may be one good, natural movement the day following. =Look Well to the Diet.=--A great deal can be done, also, in the way of diet. Girls, especially at this time, have a most perverted appetite, preferring pickles, olives, rich pies and cakes, and other indigestible foods. These are all bad, of course, as they disturb the digestion and keep the blood thin. Let the diet consist principally of rich milk, eggs, lamb chops, beefsteak, chicken, and good bread and butter. If the milk rests heavy on the stomach, then add a tablespoonful of lime water to each glass of milk. Daily exercise in the open air is also of value, and the sleeping-room should be well ventilated, especially at night. =Menstruation Suspended During Pregnancy.=--During pregnancy menstruation is usually suspended, although the regular monthly flow may continue for two or three months. Of course, suspension at this time is natural, and nothing should be done to bring on the flow. If menstruation appears when there is a strong probability that pregnancy exists, then the person should remain quietly in bed and eat only light food, and every precaution should be taken lest a miscarriage be brought on. =Should a Mother Nurse Her Child While Menstruating?=--Menstruation is also usually suspended during nursing, although not infrequently this function is resumed again three or four months after childbirth. The question here arises whether the mother should continue to nurse her child while menstruating. If the child remains healthy, keeps steadily gaining in weight, and seems to be well nourished, and if the mother is not losing ground in any way, then there is no reason why the mother should not keep on nursing her child. If, however, the mother's health fails, or if there is evidence that the child is not prospering, then weaning should take place. As a rule, a menstruating mother does not have good milk for her child; it is usually thin and watery; although, as I have said, under certain conditions nursing may continue. =Sudden Suppression.=--Sudden suppression of menstruation is most generally due to a cold, mental shock, or undue exposure of some kind. It is always accompanied with pain in the back, headache, more or less fever, and other unpleasant symptoms. It should generally be considered as a dangerous condition, and every effort should be made to restore the menstrual function. Sometimes when menstruation is suddenly suppressed in this way, a so-called "vicarious" menstruation occurs, and there is hemorrhage from the lungs, the nose, the gums, the bowels, or from some other source. =Treatment of Suppression.=--The treatment of sudden suppression consists of a hot foot-bath, or sitting in a tub of hot water. At the same time the person should drink a bowl of hot ginger tea, or hot lemonade, be covered well with blankets, and every effort be made to bring about a profuse sweating. Then have the person go to bed, and apply hot cloths across the lower part of the bowels. Place at the feet bottles of hot water, or hot bricks, and keep up the perspiration in this way for an hour or two. This is all that need be done in the great majority of cases. =Only One Medicine to be Taken.=--As the shock to the system tends to disturb the menstrual function for some time to come, the person should begin at once with Lydia E. Pinkham's Vegetable Compound, and should continue it through the coming month, in order to insure that the next menstruation may be normal in every way. =Scanty Menstruation.=--Often menstruation appears with perfect regularity and yet is greatly deficient in amount. As we have stated elsewhere, there is no rule about this, and yet when the menstrual function is scanty, it is almost invariably a symptom of anæmia, or poverty of the blood. =Anæmic Girls.=--Such girls are listless, easily tired, nervous, with little appetite, poor digestion, and with no resistive power. By taking Lydia E. Pinkham's Blood Purifier regularly a most remarkable change is brought about; and by the use of an easily digested and very nourishing diet, as just given in this chapter, together with plenty of outdoor exercise, this condition can be corrected before serious trouble ensues. =Dysmenorrhoea.=--This is better known as "painful menstruation." It is due to a large number of causes, and yet can almost invariably be relieved by proper treatment. =Two Great Causes.=--In the great majority of cases the cause is two-fold: Weakness of the nerves and congestion of the uterus. These are so closely allied that it is often quite impossible to tell which is the ruling factor; indeed, one seems to be largely dependent upon the other. It is certainly true that congestion of the uterus almost invariably produces neuralgia of different parts of the body; while nervous exhaustion, nervous prostration, neuralgia, and general nervousness often show themselves by this increased pain at the menstrual period. =Symptoms of Dysmenorrhoea.=--Usually the most marked pain is before the flow is well established. The person has a heavy pain in the lower part of the bowels, with sharp, darting pains extending down the back of the limbs. Then the pain becomes more concentrated in the uterus itself, or sometimes in an ovary at the side. The pain may begin as a dull, heavy ache, which gradually changes into a sharp, darting pain, and which culminates at last in distinct and positive attacks of uterine colic, or cramps. The person suffers such intense pain that a chill may be produced which is followed by a high fever. Often the pains are of a bearing-down character, and are not unlike those in the last stages of ordinary labor. =Often Make a Complete Wreck.=--These attacks of uterine cramps tell severely on the general health of the person, and if they are allowed to continue without treatment, they almost invariably make a complete wreck of the constitution. =Can Be Cured.=--This most distressing and most agonizing complaint may be quickly and entirely cured by a thorough course of treatment with Lydia E. Pinkham's Vegetable Compound. This remedy should be taken continuously; not a day should pass without the regular dose. =Old Cases Cured.=--If the disease has existed for some time, it must not be expected that it can be cured in a month, but by perseverance the cure will certainly come and will be perfectly satisfactory. =A Valuable Aid.=--In the meantime, the person who suffers from painful menstruation, a day or two before menstruation is expected, should take Lydia E. Pinkham's Vegetable Compound, being careful to keep the bowels in good condition. =Additional Treatment.=--If possible, the person had better remain in bed, or recline upon a sofa, for at least a day before the expected menstruation, certainly as soon as the first uncomfortable symptoms appear. Then have her take a hot foot-bath, get into bed and cover with warm blankets, with bags or bottles of hot water, or hot bricks at the feet and back, and with warm cloths over the lower part of the abdomen. =Temporary Relief.=--If the pain is exceedingly severe, and is not relieved by these simple measures, then wring out flannel cloths from as hot water as can be borne and place these over the lower part of the bowels, directly over the uterus, covering them with dry flannels. As soon as these become cool, change for hot cloths again, using care, of course, that the cloths be not hot enough to burn. It is often surprising what instant relief from pain this simple procedure will produce. =Do Not Take Opium.=--No one should think for a moment of taking opium in any form at these times, as the opium habit is very easily contracted and is almost impossible to break up. This is also true of other anodyne remedies. By carrying out the suggestions given above, it will be found that their use will not be necessary. =Thousands of Grateful Letters.=--If the readers of this book could only see the thousands of letters from grateful women the world over telling how this Vegetable Compound relieved them from the fearful torture which they had been enduring for years once a month, they would use every endeavor possible to spread the good news to every suffering friend that at last there is a perfect and absolute cure for this most distressing and most frightful complaint. =Reasons for these Startling Cures.=--The reason why Lydia E. Pinkham's Vegetable Compound works so admirably in these cases is easily understood when we call to mind the fact that some of its ingredients are the strongest of nerve tonics, building up, strengthening, and giving tone to the whole nervous system; while other ingredients have the remarkable property of relieving congestion of all the female generative organs. =To Illustrate "Congestion."=--If a string be tied around the base of the finger snugly, but not too tightly, the finger soon becomes darkened from the obstructed circulation. We say the finger is "congested." All that has to be done, in this case, is to cut the string and the congestion is promptly relieved. =Cures Congestion.=--In cases of congestion of the uterus, Lydia E. Pinkham's Vegetable Compound removes obstruction to the circulation as effectually as cutting the string relieves the congestion of the finger. When the circulation is perfectly natural through these parts, then the congestion and inflammation must disappear and the uterus itself must again resume its natural position. =Menorrhagia.=--This is better known as "profuse menstruation." Just what constitutes an unnatural loss of blood cannot be stated, as each woman is a rule to herself. From experience she knows just about what is the normal amount she should lose each month and retain her health and strength. When this amount is more than natural, especially when sufficient to produce weakness and prostration, then it becomes "profuse." =Occurs in the Full-Blooded.=--Profuse menstruation may occur in those who are very full-blooded, or in those who are extremely weak and pale. When occurring in the former, the person usually complains of a dull, heavy, throbbing headache, pain in the back, and other symptoms of fever. Such persons recover from an excessive flow of blood quite promptly, and do not suffer severely from it. =Occurs in the Pale.=--On the other hand, when this condition occurs in those who are very weak, pale, and thin, there is usually great prostration, which may even become most alarming. =Treatment for the Former.=--When profuse menstruation occurs in those who are full-blooded, the diet should be quite simple and plain. Indeed, it would be better if the person should take but two meals a day and should eat but little or no meat. Immediately upon the appearance of menstruation she should go to bed and remain there as quiet as possible, for in this way the pain and fever will be less and the amount of the flow greatly diminished. =Treatment When Pale and Debilitated.=--It is a much more serious matter when this excessive loss occurs in those who are pale and debilitated. Often the most energetic measures are necessary even to preserve life itself. The following rule should be observed when possible:--Just as soon as menstruation appears, the person should go to bed and remain there quietly until the flow is nearly over. Of course it is an easy matter to give these directions, and exceedingly hard, often quite impossible, for them to be carried out. Many women have work that must be done, or children who must be cared for during these days just as well as any other time, and it is almost out of the question for them to remain quiet. Yet the question seems to be whether they will remain in bed two or three days at this time, and then have far better health for the rest of the month, or whether they will drag along through all the month. We would certainly urge that this suggestion be carried out as often as possible, and that for one or two days the person keep as quietly in bed as possible. =When Very Excessive.=--If the flow is very free, then the foot of the bed may be raised three or four inches by placing blocks of wood under each lower corner. This will tend to check the flow. =Wonderful Cures Possible.=--Lydia E. Pinkham's Vegetable Compound has made some most startling and almost miraculous cures in just these conditions. An immense number of letters are on file from women who have despaired of relief, given up all hope, and who were confirmed invalids until after taking this famous remedy. Its continued use heals the inflammation in the cavity of the uterus, causes a better circulation through that organ, makes the blood richer, strengthens the digestion, and thus greatly improves the general health. =Relief is Prompt.=--The very next month after beginning its use the flow is diminished, the next month it is still less, and so on, until soon there is only a regular, natural menstruation. =A Happy Change.=--And what a change this means to suffering women! It means new life, new hope, new ambition, new courage. It means work better done, children better cared for, and all social and domestic duties better performed. I am indeed most happy in being able to tell suffering women what prompt relief Lydia E. Pinkham's Vegetable Compound is sure to bring them. In these cases I always recommend the use of the Vegetable Compound in the form of Lozenges, or Pills. =Metrorrhagia.=--When there is great loss of blood at other times than during the menstrual period, it is given the technical name of metrorrhagia. It means "uterine hemorrhage." Keep the person quietly in bed, and have the foot of the bed raised as suggested above. If the hemorrhage is at all severe, a physician should be summoned in order that a careful examination may be made and the cause of this unusual occurrence thoroughly understood. =If you do not understand your ailments write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful.= All such letters are strictly confidential; only women assist her in answering them. CHAPTER VIII. DISEASES OF THE UTERUS AND OVARIES. =Inflammation of the Uterus.=--Inflammation of the uterus may be either acute or chronic. When acute, as following an abortion, taking cold during menstruation, etc., there is considerable fever, pain in the lower part of the bowels, nausea, and sometimes vomiting, tenderness on pressure over the uterus, pain when passing the urine and general discomfort. =Treatment of the Acute Form.=--The treatment consists in having the person remain quietly in bed, applying bottles of hot water to the feet, if they are cold, and keeping cool cloths over the head if hot from the fever. In this way the circulation may be better balanced, and the tendency to congestion relieved. Then take a flannel cloth about six inches square, dip it in hot water, and wring as dry as possible with the hands; now sprinkle ordinary spirits of turpentine freely over one side, and place this side directly over the centre of the lower part of the bowels, that is, just over the uterus. Cover this flannel with another warm, dry flannel, and allow it to remain on until the smarting is quite pronounced, or the skin red. Then remove this, and apply hot cloths wrung from hot water. Use the turpentine cloth again in four or six hours, if the tenderness and pain still persist. =Only One Medicine Needed.=--Begin at once with Lydia E. Pinkham's Vegetable Compound, in order that the attack may be cut short. This the Compound will certainly do if taken faithfully according to directions. After the acute attack is over, if there is any constipation, this should be relieved by Lydia E. Pinkham's Liver Pills; and if there is any discharge from the uterus, Lydia E. Pinkham's Sanative Wash should be used once or twice each day, in order to hasten recovery all that is possible. =Chronic Inflammation.=--It is not exaggerating in the least to say that probably 75 out of every 100 women in the world have more or less chronic inflammation of the uterus. =Causes.=--The causes of this are many, as improper dress, which constricts the waist, and presses down upon the delicate organs in the pelvis; improper attention to the health at each menstruation; over-work; anxiety; miscarriages; unskillful treatment at childbirth, etc. =Lives of Suffering and Sorrow.=--What miserable lives women have to endure who go about from day to day with a chronic inflammation of the uterus. Each hour there is that dragging, pulling, bearing-down pain; that heavy weight; that terrible depression; and that feeling of abandoned hope. Yet hundreds of thousands, I might say millions of women have had all this suffering and sadness turned to joy and comfort, simply by taking Lydia E. Pinkham's Vegetable Compound. =Stories Almost Beyond Belief.=--The stories received from our friends seem almost beyond belief. The most striking of them cannot be printed because I fear my readers would think such cures were quite impossible. The letters tell as terrible stories, as frightful conditions as could possibly exist, and yet all this has quickly and promptly changed to robust health by the use of Lydia E. Pinkham's Vegetable Compound. So often has this been reported that there is not the least room for doubt. =I Speak Positively.=--I am not guessing in this matter; it is altogether too serious; there is too much at stake. So I urge upon you to give Lydia E. Pinkham's Vegetable Compound a thorough trial, feeling positive, without the slightest question of a doubt, that you will be quickly and permanently cured. =Leucorrhoea.=--This is also known as "the whites, or the female weakness." It is a symptom of inflammation of the uterus; and that this disease is so prevalent is again proved by this almost universal ailment among women. It is characterized by a white discharge from the vagina which often becomes very irritating, and is especially bad just before or after menstruation. It is a symptom that should not be allowed to go untreated, for it shows that there is serious trouble which may bring about an incurable condition. Yet when properly treated, it may be quickly remedied, and all danger removed. =Treatment.=--First of all, it is necessary to remove the inflammation that exists in the uterus itself. This is done by the persistent use of Lydia E. Pinkham's Vegetable Compound. As I have described elsewhere, this will remove all congestion, heal the inflammation, and bring about a healthy circulation. For this I strongly recommend that Lydia E. Pinkham's Sanative Wash be also used with a syringe for local treatment.[1] This should be used each night as a vaginal injection, according to directions, thus thoroughly cleansing the parts, and entirely relieving all irritation which these acrid secretions are sure to set up. If this discharge has been irritating enough to cause any chafing, eruption, itching, or uncomfortable sensation of any kind about the external parts, then the Sanative Wash should be used for bathing the parts; the relief will be immediate, and the cure very prompt. =May Be Quickly Cured.=--I speak with great positiveness here, because of vast experience and because of the universal success of this treatment. I do not believe there is a case of leucorrhoea which cannot be relieved and soon permanently cured by this treatment. There is no delay; relief comes at once. A great improvement in all the symptoms is very marked, even after the second or third day of treatment. =Neglect Causes Ulceration.=--I would add a word of caution here to women who are afflicted in this way, as the retention of these discharges is likely to produce an irritation about the mouth of the uterus which will result in serious ulceration, and even be the means of producing the most serious and most incurable diseases. =Ulcers on the Uterus.=--Because of the low condition of the system, thin blood, and the local inflammation in the uterus itself, ulcers may form about the mouth of the uterus. These are accompanied by more or less pain, a sense of heaviness and weight in the lower part of the bowels, and a whitish discharge similar to that of leucorrhoea only frequently streaked, or tinted, with blood. The discharge continues about the same all through the month between the days of menstruation. This condition should have the same treatment as that mentioned above for leucorrhoea, and the recovery will be equally prompt. =Early Treatment Necessary.=--If women only understood better how easy a matter it is for these ulcerations to widen and deepen until some incurable and terrible disease results, they would be more prompt in taking treatment, especially when this is sure to be followed by a perfect cure. When the blood is thin and poor, and when the weight is reduced, Lydia E. Pinkham's Blood Purifier should be used regularly. The Blood Purifier, the Vegetable Compound, and the Sanative Wash, have done as great work in preventing serious disease as in curing it. =Displacement of the Uterus Forward.=--The uterus may be displaced either forward, backward, or downward. By referring to the illustration in the first part of this book, it will be noticed that the uterus naturally tips slightly forward, so that when it is displaced forward, the condition is simply an exaggeration of its natural state. =Causes Bladder Trouble.=--By referring to this illustration again, it is at once apparent that this tipping forward must bring about some difficulty with the bladder, and such is the case. The most marked symptom is painful and frequent passing of the urine, with a dull and heavy pain across the lower part of the bowels. Often this weight is so increased by walking that the person can be upon the feet only a short time without causing discomfort and pain. This condition may be brought about by some unusual effort at lifting, jumping, or straining, or especially by wearing too tight clothing about the waist, tight lacing being probably the most frequent cause of all. =The Cure.=--The general treatment here consists in taking a thorough course of treatment with Lydia E. Pinkham's Vegetable Compound, in order to strengthen the ligaments of the uterus which hold this organ in place. When the condition of the system is improved, the nerves strengthened, and the blood made more rich by the use of this Compound, then these ligaments partake of this general improvement, and by becoming more tense, bring the uterus back into position. =Displacement Backwards.=--The uterus may be tipped backward, in which case it will rest against the lower bowel. The principal symptom here is pain in the lower part of the back, as if a movement of the bowels were necessary. There is great discomfort in walking, because of this sense of pressure. The pain is always increased when the bowels move, and is associated with a sense of obstruction, and painful menstruation is very common. =The Treatment.=--Here the same treatment should be followed as mentioned for the opposite condition above. In the first place, the bowels should be kept in good condition by the use of Lydia E. Pinkham's Liver Pills, taking these in just sufficient amount to cause a free movement of the bowels daily. Then thorough and prolonged treatment with Mrs. Pinkham's Vegetable Compound will give such strength and tone to the ligaments about the uterus that they will again bring back this organ to its proper position. =Falling of the Womb.=--The most distressing of all these displacements is that known as "prolapsus, or falling of the womb." The most frequent cause of this condition is complete relaxation of the ligaments which naturally support this organ. When the ligaments become weak, they easily stretch, and thus allow the uterus to fall down into the vaginal canal, even nearly to the surface of the body. =Symptoms.=--This displacement causes irritation of the bladder and lower bowel, discomfort in walking, painful menstruation, leucorrhoea, a dragging pain in the back, and most marked bearing-down pain in the lower part of the body. =The Cure Is Certain.=--The treatment of this most distressing affection is usually followed by prompt and permanent results. Lydia E. Pinkham's Vegetable Compound should always be taken, because of its great power to relieve all inflammation and give strength and tone to the ligaments which hold up the uterus. Lydia E. Pinkham's Sanative Wash should be used, also, for its cleansing and strengthening properties, on the local parts. If a sitz bath-tub is in the house it may be used to great advantage in these cases. A single pail of water will be sufficient, and should be as hot as can be comfortably borne. If a tub of this kind is not at hand, then an ordinary bath-tub may be used, having in it sufficient water to come well over the hips when the person sits in it. =The One Permanent Cure.=--By taking Lydia E. Pinkham's Vegetable Compound, these relaxed ligaments are given strength and tone so that they assume their former power. As they gain strength they contract, pulling the uterus up into its natural position, and holding it there permanently. I can most positively assure every woman who is suffering from all the discomfort and terrible distress which always accompany falling of the womb, that she may be promptly and most perfectly cured if she will only follow my advice. =An Abundance of Proof.=--So many letters have come from women who have suffered and have been cured that it is not possible for a reasonable person to doubt what they say. I can only urge all affected with these complaints to give Lydia F. Pinkham's Vegetable Compound a good trial, feeling perfectly assured that they will be abundantly satisfied in every way. If you do not understand your ailments write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful. Such letters are strictly confidential communications from one woman to another who will never betray the confidence. Footnote: [1] Every woman suffering from uterine or vaginal troubles should own and use a syringe. I would recommend the use of Ruth Paxton's Improved Fountain Syringe. I believe it is the only one that will convey the solution to every part of the vaginal cavity. The ordinary syringe is inadequate. It can be obtained by sending to The R. Paxton Company, 221 Columbus Ave., Boston, Mass. Price $1.75, postpaid--registered letter or postal note. It will repay you a thousand times to take the trouble to send for it, as the recoveries from disease are quicker when it is used. Anyway, send two-cent stamp for her little book of information. You will see by the letters it contains how the syringe is regarded by those who are using it. CHAPTER IX. DISEASES OF UTERUS AND OVARIES (Continued). =Ovaries, Congestion of.=--This disease usually comes from taking cold during menstruation, from some injury, extra strain during lifting, or from some slow inflammatory process. The symptoms are pain and tenderness in one or both sides of the lower part of the body. There is more or less continuous pain, which is always worse in standing or walking. The tenderness in the sides is increased during menstruation, especially if pressure be made over the part. Sometimes the pain is quite severe when the bowels move. There is always a feeling of distress, frequently associated with nausea, and often more or less fever. =Treatment.=--For treatment the person should have as good surroundings as possible, and should take complete rest during menstruation. In order to relieve the congestion in these parts and thoroughly control the pain, Lydia E. Pinkham's Vegetable Compound should be taken at once. =Removal of Ovaries.=--This condition of the ovaries gave rise to the practice of removing these organs. Just as soon as a woman consulted a physician and complained of tenderness over the ovaries, he was sure to advise her to have these organs removed. =Less Operating Than Formerly.=--But this practice is rapidly passing away, and the very surgeons who were so anxious to operate a few years ago are now found advising against it. This is because of the serious results which follow this operation. While the pain and tenderness in these parts would be relieved, yet the profound and overwhelming impression made upon the nervous system, by producing such a remarkable change in the life of the woman, was even worse than the disease itself. =Results of Removal of Ovaries.=--Women who have had their ovaries removed are frequently the victims of hysteria, melancholia, extreme nervous prostration, insomnia, and other distressing and dangerous complaints. =Surgical Operations Unnecessary.=--Then, again, it is becoming well known over the whole country that Lydia E. Pinkham's Vegetable Compound can relieve congestion and pain so thoroughly that the surgeon's knife is unnecessary. I am so confident in this belief that it hardly seems possible that any woman would continue to suffer in this way, when it is so useless. I know we can make every woman perfectly comfortable and at rest, no matter how long she may have suffered, if she will only follow our simple directions. =The One Certain Cure.=--All she has to do is to keep her bowels in good condition by taking Lydia E. Pinkham's Liver Pills, and at the same time take a thorough course of treatment with the Vegetable Compound. If you have any friends or neighbors who are suffering from this disease, and who fear that it will lead to ovarian tumors, which must ultimately necessitate a dangerous surgical operation, I urge upon you to tell them the story of this Vegetable Compound. =Always Brings Good Cheer.=--It has brought happiness to so many homes, has relieved so much suffering, and has cheered and comforted so many thousands of women, that I am sure you will be doing a great deed of charity if you will only aid in spreading this glad news. =Tumors of the Uterus.=--The uterus is subject to tumors, or growths, the symptoms of which are much like those of chronic inflammation. As a rule, the person suffering from these tumors knows nothing whatever of their existence until some competent physician has told her such is the case. =Fibroid Tumors.=--The most common tumors are known as fibroids. They are often small, and yet sometimes attain a considerable size. Until within a few years surgeons were always anxious to operate upon these tumors; but this is now largely done away with, for they are not fatal in themselves, and only become serious when they attain an exceedingly large size, or, what is more frequently the case, cause excessive flowing during or between the menstrual periods. =Tumors Cured Without the Knife.=--In these cases Lydia E. Pinkham's Vegetable Compound shows its remarkable power to great advantage. By establishing a better circulation through the uterus, and relieving the congestion in the surrounding parts, and by giving strength and tone to the smaller blood-vessels, the hemorrhage is controlled and the inflammation is reduced. The tumors cease to grow, diminish in size, and disappear altogether under its influence. =Vagina, Inflammation of.=--Occasionally there is an acute and most intense inflammation of the vagina caused by exposure to cold, irritating discharges from the womb, the use of pessaries, supporters, or some contagious disease. Many women suffer from this complaint towards the close of menstruation, when the discharges are acrid and most irritating. =Promptly Cured.=--This inflammation can be promptly cured by the frequent use of Lydia E. Pinkham's Sanative Wash. Prepare this strictly according to the directions on each package, and use it as a vaginal injection two or three times a day. The cure will be hastened by employing a sitz-bath (sitting in a tub of hot water, or in a bath-tub). =To Prevent Extension of Disease.=--In order to prevent the inflammation from extending into the uterus, it is always wise to take Lydia E. Pinkham's Vegetable Compound for a few days after an attack of this kind. =Pruritus, Itching.=--Pruritus, or itching of the external parts, is a most annoying affection, which often renders life itself almost unendurable. Its most frequent cause is due to irritating discharges from the uterus or vagina. Quite a large per cent of the women who are passing through the "change of life" are troubled in this way. It is also a marked symptom of diabetes, or "sugar in the urine;" and if the itching is associated with an unusually large flow of urine, together with dryness of the mouth and extreme thirst, there is a probability that the person is suffering from diabetes. In such a case a specimen of the urine should be taken to a competent physician, and he should be asked to make a thorough examination of it in order to definitely determine this point. =Treatment.=--The treatment of pruritus consists in keeping the parts thoroughly cleansed by frequent vaginal injections of Lydia E. Pinkham's Sanative Wash, even three or four injections daily; and also bathing the external parts with the same solution. =Can Be Promptly Controlled.=--Although medical writers so generally claim that this disease is almost impossible to relieve, and although they recommend the application of severe caustics, yet I have never found any difficulty in promptly controlling and curing this affection by the faithful and persistent use of Lydia E. Pinkham's Sanative Wash as a local application and the Vegetable Compound for its constitutional effects. =Constitutional Treatment Necessary.=--Although this disease shows itself in only one place, yet the difficulty is in the whole system, and can only be thoroughly removed by the internal use of Lydia E. Pinkham's Vegetable Compound. Thousands of letters from women tell that their life of agony, distress, and sleeplessness was changed to one of perfect comfort almost immediately upon the use of these remedies. =Bladder, Inflammation of.=--Sometimes the inflammation of the vagina and uterus is so severe that it involves the bladder; or an irritable condition of the bladder may be produced by a pregnant uterus pressing forward against it; or the uterus may be tipped forward a trifle more than natural, and thus press against the bladder sufficient to cause irritation. =Symptoms.=--The principal symptom of congestion or inflammation of the bladder is a frequent desire to pass the urine. This act is almost always painful, and is sometimes accompanied with spasmodic contractions of the walls of the bladder, causing severe straining. =May Become Chronic.=--If treatment be neglected, this condition easily becomes chronic, when it is very difficult to cure. Prompt treatment in these cases is strongly urged because it can be cured in every instance, and thus an immense amount of suffering avoided. =Treatment.=--If possible, the person should remain in bed or recline on a couch. The diet should consist largely of liquids, nothing being better than good milk. Meats, rich soups, and all pastries should be avoided. Mrs. Pinkham's Vegetable Compound should be taken at once, because of its most happy effect in relieving congestion and inflammation of all the pelvic organs. Indeed, here is one instance where the Vegetable Compound is alike useful to both sexes. The most flattering testimonials have come from men who have tried this remedy "because it was in the house," and who were most happily surprised to find that the relief was prompt and the cure speedy. For all irritable conditions of the bladder, whether of recent or old standing, I do not believe there is a remedy in the world that holds out such great promises of complete relief equal to Lydia E. Pinkham's Vegetable Compound. =The Menopause, or "Change of Life."=--This is a cessation of menstruation. It usually occurs between the ages of forty and fifty years, although frequently before and even after this time. =Symptoms.=--The person first notices that although menstruation had previously been regular, yet now it has become irregular, not appearing more frequently than once every six weeks or two months; or possibly passing over a month, and then appearing regularly again for the following two or three months; or the flow may be less and less month after month, until gradually it disappears altogether; or, not infrequently, menstruation ceases abruptly, without any warning whatever. =A Natural Condition.=--The change of life should be a perfectly natural condition, not associated with any unpleasant symptom whatever. Yet this is rarely the case, while often the suffering at this time is most intense in every way. =Affects Nervous System.=--The most severe effects are frequently produced on the nervous system. These are known as "heat flashes." It is a marked symptom with a great many women, and is described as a sensation of waves of heat passing over the body. Sometimes these are very severe, causing the face to become very red, producing dizziness and intense headache. Often there is melancholia, great depression, and not infrequently complete prostration of the nervous system. The digestion may be disturbed, producing constipation, diarrhoea, dyspepsia, loss of appetite, offensive breath, biliousness, etc. Most marked changes are certainly taking place in the whole system, and it is but natural that every part of the body should be profoundly impressed. =Not Expensive Treatment.=--I cannot urge too strongly upon my readers the necessity of their taking Lydia E. Pinkham's Vegetable Compound all through these remarkable changes. It is not a great expense to take this Vegetable Compound in moderate doses four times a day for weeks, or even months, during these changes. =A Critical Time.=--If this period of life be passed over in safety, then there may be years and years of robust health remaining; while if it be not attended to properly, the remainder of the life may be one prolonged day of agony. Even when persons have suffered during all their menstrual life, they can now have perhaps a score or more of years of complete relief if they properly care for themselves during this change. =Keep Under Its Influence.=--Lydia E. Pinkham's Vegetable Compound is a great tonic in itself, bracing up the whole nervous system, aiding digestion, and causing all the forces of the body to act more in accord with nature. Then it has a special influence over the uterus and ovaries; indeed, so marked is its power to correct disease that all the trying days of the "change of life" may be passed over in perfect safety, if only the system be continuously kept under its influence. =May Be Made Easy and Natural.=--Women who have been dreading this change, and who have been made to look upon it as something horrible to pass through, may now lay all such anxiety aside, for Mrs. Pinkham long ago solved the problem of making this time of life as healthy and natural as any other. It is not claiming too much to say that if women everywhere will only take Lydia E. Pinkham's Vegetable Compound through this trying time, they will come out of it feeling better in every way than they have felt for many years. =If you do not understand your ailments, write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful. Such letters are strictly confidential and answered with the help of women only.= CHAPTER X. PREGNANCY, ITS SYMPTOMS, DISEASES, ETC. =Sometimes Difficult to Tell.=--Even the most skilled physicians sometimes make mistakes in stating that pregnancy exists when it does not. =The First Sign.=--The most valuable and striking sign of pregnancy is the cessation of the monthly periods; yet even this is not always reliable. Sometimes menstruation continues for three or four months, especially during the first pregnancy, although this is exceedingly rare. As a rule, to which there is hardly an exception, if menstruation ceases in a married woman who has previously been regular, she is, in all probability, pregnant. =Other Signs.=--Another important sign is the enlargement of the abdomen, although this cannot be detected much before the fourth month. A valuable sign, also, is the enlargement of the breasts, with a widening and browning of the pink ring around the nipples. Enlargement of the breasts often begins as early as the second month, and is quite marked by the fourth or fifth month. =Morning Sickness.=--Morning sickness is a symptom present in the majority of cases. It usually consists of a marked nausea upon rising, and perhaps vomiting. This may last only a few hours in the early morning, or continue through the greater part of the day. It generally appears in the second month and lasts only through the third month, although, in bad cases, it may continue through the whole period, and very seriously affect the health. =Treatment.=--There are any number of remedies recommended for the treatment of this morning sickness. What will cure one case seems to be perfectly useless in another. It has been my experience that the best way to manage these cases is as follows: Have the person take a slice of toasted bread, or a toasted cracker, with a little coffee if desired, while in bed, remaining there at least half an hour after eating. Or, the person may take a glass of milk to which two tablespoonfuls of lime water have been added. Then, by rising slowly and moving about carefully, it is often possible to go through the day without any sickness whatever. I have known many cases to be entirely relieved by eating a little ordinary pop-corn. =The Morning Meal.=--The morning meal may consist of milk to which a little lime water has been added; or a poached or soft-boiled egg. Sometimes scarped beef, lean and rare, salted and spread on very thin bread, quiets the stomach at once, while it is highly nourishing. =Only One Medicine Needed.=--It is surprising what happy changes Lydia E. Pinkham's Vegetable Compound brings about in this condition. The irritability subsides, the digestion is greatly improved, the nervous system is strengthened, and all these uncomfortable and disagreeable symptoms pass away. The Compound should be taken in small doses three times a day, after meals. =A Bandage May Relieve Nausea.=--An abdominal bandage will sometimes relieve the morning sickness, if placed snugly, but not too tightly, about the body. It need be worn only a week or two, for a trial, and should always be taken off at night. If the nausea persists during the day, then let the food be light and taken in small amounts, at frequent intervals. ="Quickening."=--This is another sign of pregnancy. The word refers to the detection by the mother of the movements of the child. Although, without doubt, the child moves within the mother at a much earlier period, yet these movements are too feeble to be noticed until pregnancy has advanced four or four and a half months. =Other Symptoms of Pregnancy.=--Other symptoms are morbid longings for unusual articles of food, as sour apples, vinegar, charcoal, clay, slate pencils, etc. These longings, however, should not be satisfied, as they do not represent the demand of nature for these substances. They belong to the same class of changes which are shown by a marked difference in the disposition of a person whereby the lively and cheerful woman becomes melancholy, gloomy, and irritable. =Diet During Pregnancy.=--The diet during the whole of pregnancy should be generous, yet easily digestible. A great many women do not change their diet at all, and if the person is in good health and does not suffer in any way, there is no reason whatever why the diet should be changed, unless the evening meal be made somewhat lighter. =Eat Sparingly of Meat.=--It is always wise not to eat meat more than once a day. This is because a meat diet throws more work upon the kidneys, and any failure of the kidneys increases the probability of serious trouble at childbirth. So far as is known, there is no foundation for the belief that any special article of diet has any particular effect upon the development of the child. =Care of the Breasts.=--The care of the breasts during pregnancy must be commenced early. All pressure of the clothing should be removed, in order to give them full opportunity to develop. They should be kept warm, however, and well supported, if the size renders them uncomfortable. =Mothers Should Nurse Their Children.=--Statistics show that the summer diarrhoeas and dysenteries, which carry off such immense numbers of children each year, are almost unknown among babies that nurse. It is the artificially fed child which suffers from wasting diseases and disturbances of the digestion which are so fatal to life. Therefore, every prospective mother should do everything in her power to prepare for the proper nursing of her child. =Care of the Nipples.=--If the nipples are flat, they can be pulled out gently each day with the fingers, and thus the difficulty entirely remedied. At the beginning of the last month of pregnancy, the nipples should be hardened in order that nursing may be painless, and that all fissures, or cracks, may be avoided. Every morning and night apply the following solution to the nipples with a piece of absorbent cotton:-- Glycerite of Tannin, 1 fluid ounce. Water, 1 fluid ounce. Allow this to remain on the nipple. This cannot be used after confinement, for the bitter taste would be objectionable to the child. =Can Sex Be Foretold?=--Mothers often wish to know if it is possible to determine the sex of the child before it is born. Although a great deal has been written on this subject, and a number of so-called rules have been made, yet it is absolutely impossible to tell whether the child will be a boy or a girl; and it is also equally impossible to do anything that could in any way exert an influence in producing a child of the desired sex. =To Tell Time of Confinement.=--For two hundred and eighty days, or forty weeks, the prospective mother has been conducting herself in the best way she thought possible, that all good might be exerted upon the new life. The question now comes, When may the day of confinement be expected? I give here a table for calculating this day, which I am sure will be found very convenient. OBSTETRICAL TABLE. --------+---------------------------------------------- January | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Oct'r | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- Feb'y | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Nov'r | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- March | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Dec'r | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 --------+---------------------------------------------- April | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Jan'y | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 --------+---------------------------------------------- May | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Feb'y | 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 --------+---------------------------------------------- June | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 March | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- July | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 April | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 --------+---------------------------------------------- August | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 May | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- Sept'r | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 June | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- October | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 July | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- Nov'r | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Aug | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 --------+---------------------------------------------- Dec'r | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Sept'r | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 --------+---------------------------------------------- ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 |Nov. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 | 24 25 26 27 28 29 30 1 2 3 4 5 |Dec. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 |Jan. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 20 27 28 29 30 | 22 23 24 25 26 27 28 20 30 31 1 2 3 4 |Feb. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 |Mar. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |April. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |May. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 |June. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |July. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |Aug. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |Sept. ---------------------------------------------+------ 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |Oct. ---------------------------------------------+------ As labor occurs in the larger proportion of cases between 270 and 290 days from the first day of the last menstruation, 280 days is the average. The table presents at a glance the beginning and end of 280 days for every day in the year. Find the date of menstruation in the upper line of the horizontal column, and the figure below, with the corresponding month, will indicate 280 days. =To Avoid Miscarriage.=--The pregnant woman must be very careful as the usual time for menstruation approaches. It is then that any undue effort, unusual lifting, excessive grief, or shock to the system, may bring on a miscarriage. This is especially true if such a misfortune has previously occurred. =A Great Preventive.=--The most abundant testimony shows that Lydia E. Pinkham's Vegetable Compound is an almost certain preventive to miscarriage or abortion. It gives strength to the uterine walls, quiets the first approach of pain, controls any spasmodic contractions, and brings about such a healthy condition that all danger is averted. I cannot speak too strongly of this Vegetable Compound for these cases. So many mothers have written us that they are now happy in the possession of a child, when, for time and time again, they would have a miscarriage at the third or fourth month. =Keep it in the House.=--Every pregnant woman should always keep in the house a bottle of Lydia E. Pinkham's Vegetable Compound. She does not know the day when she will need it, and when that day comes she will require it promptly. At any time when there is soreness, tenderness, unusual pain, any unnatural discharge, or any symptom whatever that shows pregnancy is not pursuing a perfectly natural course, she should begin to use the Vegetable Compound at once. It should be taken in small doses two or three times a day, just enough to produce its strengthening, quieting, and healing effects. If she finds she has been overdoing, has strained herself in any way, or fears that some unfortunate result will follow an extra hard day's labor, let her take a few doses of Lydia E. Pinkham's Vegetable Compound as a certain preventive to future trouble. =The One Universal Cure.=--In other words, I repeat what I have already said so many times, that whenever there is trouble of any kind with any part of the female generative organs, whenever these do not act in a perfectly natural manner, then the Lydia E. Pinkham Vegetable Compound is indicated; for it is the one great, universal and never-failing cure for all the affections which fall to the lot of womankind. =Makes Mother and Child Strong.=--Many thousands of wives owe the fact that they are mothers to-day to this grand remedy, and thousands upon thousands of children are happy, strong and robust because their mothers were wise enough to use it. Keep it in the house. Do not be a day without it. Have it where you can reach it at any time. Put your confidence in it. 'Twill prove a never-failing friend to you in time of need. =Mothers' Marks.=--There is a wide belief among women that any strong impression made at a certain time during pregnancy will exert a powerful influence in producing some defect or deformity in the child. The opposite is also held, to the effect that beautiful objects, delightful music, and everything elevating and ennobling will have a favorable effect upon the body or mind of the child. An immense amount of testimony can be produced on both sides of this question. The weight of evidence, however, is rather in favor of these so-called "maternal impressions." In other words, it seems possible that under very unusual conditions the mother may affect her unborn child because of some powerful impression made upon the system. Yet hundreds of thousands of mothers become frightened and undergo the most terrible experiences without having the slightest unfavorable effect upon the child; while other mothers give birth to deformed children when they have been surrounded with every comfort and have not been disturbed in any way. No one understands this subject, and but little can truly be said about it. =Hereditary Influences Are Strong.=--On the other hand, we all know how strong is heredity. Therefore it is only acting the part of ordinary wisdom for every pregnant woman to avoid all disagreeable things possible and cultivate everything that is good and true. =Early Training Necessary.=--When we come to study the theory of heredity, we see that it is impossible for any mother to completely change her course of life simply during pregnancy and have a corresponding effect upon her child. To produce the best results on the offspring it is necessary that the mother should have cultivated her own mind and body through many years of training. =Were Cured Early in Life.=--Lydia E. Pinkham's Vegetable Compound has done untold good to the present generation. There are hundreds of thousands of children living to-day who are healthy and happy because years before they were born their mothers, when young girls, took this grand household medicine. They were restored to health, a great load was lifted, and things again looked cheerful and bright, and in this condition a happy baby was born into the world. =If you do not understand your ailments write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful. Such letters are strictly confidential and answered with the help of women only.= CHAPTER XI. PROBLEMS IN NURSING. =Diet During Nursing.=--Many mothers believe that it is necessary to eat only certain articles of diet while nursing their baby, for fear the child may be given the colic. While this may be true in certain cases, yet it is the exception. As a rule, mothers may eat nearly everything digestible without fear of affecting the baby. =Exceptions.=--Sometimes raw fruits or acid substances may change the milk in some way so that it will disagree with the baby, but as I have said, this is not the rule. Occasionally, however, when such articles of diet as onions, cauliflower, and cabbage have been eaten, these will impart such an odor and taste to the milk that the child will refuse to nurse. =Must Be Guided By Experience.=--The only precaution the mother need take is that if she finds some article of diet disagrees with her, or if she knows a certain article always causes pain or discomfort in the child, then these should be avoided. It is true that certain medicines, especially purgatives, may be taken by the mother which will affect the child very quickly. Here the same rule should be the guide as should always govern one, namely, no article of diet should be used which is known to disturb the digestion. =Insufficient Supply of Milk.=--When a mother knows that the chances of her child's life are greatly increased if it has its natural food, she will certainly make unusual efforts to supply all the food necessary. Mothers are too likely to think that an increase in the quantity of the milk answers every purpose; but this is of no use unless the quality is increased as well. The free use of soups and some malt extracts may increase the quantity, but this does the child no good. It too much resembles the example of the milk-man who uses the well-pump to increase his supply of milk. =How Increased.=--However, the supply of milk can easily be increased in quantity and correspondingly improved in quality if the mother will drink freely of cow's milk, and use other substantial foods at the same time. If the milk is constipating, or rests heavy on the stomach, then a little lime water may be added to it in the proportion of one or two tablespoonfuls to a glass of milk. Regular exercise in the open air is also necessary in order that the general health may be kept in the best possible condition. =Anger May Poison Milk.=--It is a fact that if the child nurses after the mother has had a severe fright, or has become violently angry, the milk will sometimes act as an intense poison. In such cases the mother had better empty the breasts with a breast-pump, and not nurse the child for ten or twelve hours afterward, substituting some artificially prepared food. =Extra Supply of Milk.=--Sometimes the secretion of milk is so great that even a strong child cannot take it all. This produces a distention of the breasts, causing what is known as "caked breasts," or "milk cake." This should be promptly attended to, as there is great danger of an abscess forming. =To Prevent Caked Breasts.=--The way to relieve this condition is to gently but firmly rub the breasts with warm sweet-oil, continuing this for fifteen or twenty minutes at a time. An occasional use of the breast-pump is necessary also. =How to Diminish Supply.=--When weaning-time comes, the question arises how the secretion of milk may be diminished. This is best done by having the mother take as little liquid as possible, whether of water, tea, milk, soup, or anything of this kind. She should also take a gentle laxative each day, as a little Hunyadi Water, or laxative mineral water of any kind. Then support the breasts by passing a broad band beneath them, and carrying it over the shoulders, compressing the breasts slightly, but not too greatly. The breast-pump should be used as soon as any distention becomes painful, and the breasts should be diligently rubbed with warm sweet-oil. =If you do not understand your ailments write to Mrs. Pinkham, Lynn, Mass. Her advice is free and always helpful. Such letters are strictly confidential and answered with the help of women only.= CHAPTER XII. TO PREVENT CONVULSIONS AT CHILDBIRTH. =Work of the Kidneys Most Important.=--The kidneys are constantly engaged in removing from the body certain poisonous substances which are held in solution in the urine. If they should fail to do this work, or if no urine should be secreted for even a few hours, most serious consequences would follow. =Cause of Convulsions.=--When these poisons are retained in the system to a sufficient degree they cause convulsions and unconsciousness, and are frequently fatal. The convulsions which some women have at childbirth are caused by this imperfect action of the kidneys. =To Tell If Danger Is Present.=--An examination of the urine at any time will tell whether the kidneys are acting well or not, and thus it is possible to determine whether there is danger of having these convulsions during confinement. Therefore I urge upon all pregnant women the necessity of having their urine examined once or twice during the course of pregnancy, and certainly during the eighth or ninth month. =Albumen in the Urine.=--Imperfect action of the kidneys is shown by the appearance of albumen in the urine. Any competent physician can easily determine whether this albumen is in the urine or not, and if present he can take such prompt measures as to remedy the evil before any serious danger occurs. Of course I know that hundreds of thousands of women pass safely through childbirth and have no unfavorable symptom at all; yet I also know that now and then a most valuable life is lost when it might just as well have been spared as not, if these simple suggestions had been carried out. It is the teaching of all the best medical authorities in the world that this precaution should be taken by every expectant mother. =Symptoms of Kidney Trouble.=--When the kidneys are not performing their work properly, the mother may know it, herself. If she finds her feet and ankles swelling at night, if she has a puffy look under the eyes, and especially if the amount of urine passed in twenty-four hours is not so great as formerly, then there is probably albumen in the urine. In this case she should stop eating meat of all kinds, and live largely upon milk, keeping the bowels in laxative condition by using Lydia E. Pinkham's Liver Pills, and bathing the skin well once or twice a day. She should also begin at once the use of Lydia E. Pinkham's Vegetable Compound, resting assured that this will remove the congestion in the kidneys, and will cause a more free secretion of the urine. =Self-abuse (Masturbation).=--This is a cause of many of the diseases of women, also men. Small girls learn the practice from larger ones, and through ignorance continue it often to maturity without knowing that it is bringing upon them a physical and moral injury. _If mothers instructed their daughters on this subject there would be fewer broken lives._ SYMPTOMS.--The main symptoms are wakefulness, restless nights, headache, indolence, melancholy, indisposition to study, forgetfulness, despondency, weakness in the back and private organs, no confidence in one's own abilities, a desire for seclusion from society; whites, hysterics, and inability to look any one in the face. Sometimes the muscles are relaxed, limbs tremble, the skin is sallow and dry, with pain in the womb. =REMARKS. Write to Mrs. Pinkham in perfect confidence, and she will tell you exactly what to do. Delay is dangerous in this matter.= CHAPTER XIII. DYSPEPSIA, CONSTIPATION, GENERAL DEBILITY, SLEEPLESSNESS. =Dyspepsia, Acute.=--Acute dyspepsia is usually caused by some improper diet, as the eating of an unusual article of food or of a larger amount than necessary. Such articles of diet as cucumbers, unripe or overripe fruit, an excessive amount of sweets, rich salads, heavy puddings, etc., may so irritate the stomach that an acute attack of dyspepsia follows. =Nature Often Cures.=--Nature often makes a prompt cure in these cases by causing a sharp attack of vomiting or diarrhoea. If a cure is not made in this way, then we can imitate nature by giving an emetic, or by taking a laxative, in order to rid the body of the indigestible material as soon as possible. =Treatment.=--If there is much pain in the stomach, a mustard plaster should be placed directly over the pit of the stomach, or cloths wrung out in hot water. For the next day following the attack the diet should be restricted to milk, or poached eggs on toast, or something of this kind. =Chronic Dyspepsia.=--It is chronic dyspepsia, however, which is so annoying because of its persistence. It has been called "The American Disease" because so many people are troubled with it. =Symptoms.=--Persons suffering from chronic dyspepsia complain of a bad taste in the mouth, dry throat, nausea, and a feeling of great weight in the stomach for an hour or two after each meal. Frequently there is no appetite whatever, or it may be even more ravenous than natural because of the irritation and inflammation in the stomach. When the latter is the case, food does not satisfy, and it becomes necessary to eat every two or three hours in order to quiet the gnawing and empty feeling in the stomach. The chronic dyspeptic suffers greatly from nervousness and depression of spirits; indeed, it seems almost impossible to maintain the usual cheerfulness. =Thought to be the Heart.=--Many persons go to their family physician thinking they have a serious form of heart disease, when the whole trouble is with the stomach, the violent beating of the heart being simply a nervous manifestation caused by the irritable condition of the stomach. =Two Diseases Closely Associated.=--Chronic dyspepsia is almost invariably associated with the diseases of women. Indeed, the two seem almost inseparable, for whenever you find a woman complaining of soreness across the lower part of the bowels, irregular menstruation, ovarian irritation, inflammation of the bladder, leucorrhoea, etc., you will find a confirmed dyspeptic. The blood is thin and watery, the bowels are constipated, and the whole nervous system seems to be upset. =Which Disease Is the Cause?=--The question comes whether the disease in the pelvis causes the difficulty with the stomach, or whether the stomach produces the inflammation in the uterus and surrounding parts. Probably one is true at one time and another at another time. The fact is that both conditions need correcting, and there is one remedy which answers perfectly in each case. =Both Must Be Cured.=--The digestion certainly cannot be perfect while there is this inflammation in the pelvic organs; while the latter can hardly maintain a healthy condition if the stomach fails to do its work. =Both May Be Cured.=--By paying attention to a few rules of diet, and by taking Lydia E. Pinkham's Vegetable Compound for a short time, I believe every case will promptly yield to treatment. =Cures Dyspepsia of Men.=--Indeed, strange as it may seem, a great many men who have taken Lydia E. Pinkham's Compound because they have seen its good action on the stomach in cases of other members of the family have written reporting good results. It certainly has a most soothing and strengthening power on this organ, while its gently stimulating effect on the whole alimentary canal brings about the most desirable changes. =Regular Action of the Bowels.=--I would recommend that Lydia E. Pinkham's Liver Pills be taken each night in just sufficient doses to cause a regular action of the bowels each day. Then if Lydia E. Pinkham's Vegetable Compound be taken, it will not only allay all inflammation in the stomach and impart great strength, but it will at the same time remove the soreness and pain in the pelvic organs. =A Simple but Valuable Aid.=--All such persons will obtain relief by drinking a cupful of hot water at least half an hour before breakfast each morning; and if the case is very bad, then the hot water may be repeated before each meal. The water should be as hot as can be comfortably taken. =Useful Hints.=--I would strongly urge the necessity of thoroughly chewing the food and eating slowly. If this rule alone were observed there would be far less dyspeptics in the country. Drink should be used sparingly at meal-time, also, for while the body requires a great deal of liquid during the day, yet this should be taken between meals rather than during meals. The stomach should certainly have time to rest from its work of digesting the food, hence nothing should be eaten between meals. The habit so many girls have of eating before retiring is very injurious to the health, and should be corrected at once. Meals should be taken at regular intervals and not at any time when most convenient. =Diet for Dyspeptics.=--The chronic dyspeptic should use soups sparingly, for, as a rule, they are quite difficult of digestion, while they do not contain much nourishment. Plain mutton and beef soup without much fat are the least harmful. Such fish as pickerel, trout, shad, and white fish may be used moderately; while oysters, especially when raw, are easily digested. The best kinds of meat are roasted or broiled beef, lamb chops, and some fowl, as chicken. Eggs are easily digested, and are exceedingly valuable as an article of diet for the dyspeptic. They may be cooked in almost any form except hard-boiled. They are highly nourishing, can be prepared in many delicate ways, and are, as I have said, as valuable an article of diet as the dyspeptic can have. Persons with chronic dyspepsia do not digest vegetables well, as a rule, although such green vegetables as lettuce, green peas, asparagus, celery, and spinach may be used. Potatoes often ferment in the stomach, producing gases, and should be used sparingly. Toast is always well borne, but should never be buttered while hot. Bread should not be used until it is at least a day old. Rolled oats, cracked wheat, etc., may be taken, although with many they cause fermentation. Nearly all cooked fruits are well borne by the stomach, and so are nearly all ripe fruits. Puddings made from rice and custard are easily digested. Milk is valuable at all times, and if the chronic dyspeptic bears it well, this diet alone will frequently make a marked cure. If it rests heavy on the stomach, a little lime water may be added to it in the proportion of a tablespoonful of lime water to a cupful of milk. =Forbidden Diet.=--There are certain articles of diet which the dyspeptic should not use under any circumstances. Among such are fried foods of all kinds, pork, liver, veal, rich soups, turkey, goose, duck, mackerel, lobster, cucumbers, cabbage, turnips, parsnips, string beans, pies and cakes, cheese and nuts. =Constipation.=--As we have already stated, constipation is productive of the most serious evils. When the lower bowel is distended, pressure is made upon the surrounding blood-vessels, and thus the circulation seriously interfered with. =Causes Inflammation of Uterus.=--As a result, there is congestion in the blood-vessels of the ovaries and uterus, and inflammation of these organs is likely to follow with its long train of ailments. Constipation also seriously interferes with the general health, producing nausea, indigestion, headache, backache, nervousness, general debility, etc. =Daily Movements Necessary.=--Nature intended that the alimentary canal should be relieved of its contents at least once every twenty-four hours, and if this is not done, then certain poisons are absorbed into the blood which produce the most undesirable effects. =To Cure Constipation.=--For constipation I strongly recommend Lydia E. Pinkham's Liver Pills. I know they give the most prompt and satisfactory relief. I have received letters from hundreds of women who have been cured of the most distressing ailments of the uterus and bladder simply by using these Liver Pills, and all because constipation was cured and in this way the cause of the suffering removed. =Diarrhoea.=--Diarrhoea, as a rule, is an effort of nature to get rid of some offensive material. While this may be the first reason for its existence, yet if it is allowed to go on, it produces such an irritation in the bowels that serious results may easily follow. =Treatment.=--If the person is conscious of having eaten something indigestible, as unripe or overripe fruit, then it is best to aid nature by taking some gentle laxative, as a laxative dose of Lydia E. Pinkham's Liver Pills, thus hastening the removal of the indigestible substance. If, however, there have been a number of movements of the bowels, until the offending material is probably all removed, then the following plan is all that will be necessary to make a cure: Let the person rest at full length upon a couch or bed, remaining as quiet as possible. For the diet nothing should be taken but hot milk. A glass of hot milk can be slowly sipped once every three hours, and nothing else whatever should be taken into the stomach for a day, at least, or until the diarrhoea is checked. If the pain is quite severe in the stomach or bowels, then a mustard plaster may be placed over the most painful part, or cloths wrung from hot water; or a poultice of linseed meal or slippery elm may be applied. I have seen the good results of this treatment of "rest and hot milk" in so many cases, and it is so exceedingly simple, that I earnestly recommend its trial. =General Debility, Exhaustion, Anæmia.=--Many women go about suffering from great debility, being hardly able to drag themselves through the day. When night comes they are too tired to sleep, and when morning comes it seems they are more tired than they were at night. All parts of the body partake of this general weakness. There are great discomfort and suffering through the lower part of the body, difficulty in passing the urine, constipation of the bowels, leucorrhoea, and all other affections which naturally come from an impoverished condition of the blood. =May Be Promptly Cured.=--To all women who are suffering from this general debility, exhaustion, and nervous prostration I earnestly recommend Lydia E. Pinkham's Blood Purifier. If the inflammation in the uterus and surrounding organs is quite marked at the same time, then the Blood Purifier may be taken before meals and the Vegetable Compound after. If the female generative organs are not much involved, then the Blood Purifier may be used alone. =A Grand Medicine.=--This grand medicine has done great good, and I am confident it will build up the system, purify the blood, and greatly improve the general health. Persons suffering from general debility of this kind do not prosper well on a milk diet alone. They need more hearty food, such as rare beefsteak, rare roast beef, lamb chops, and eggs. =Sleeplessness.=--Sleeplessness is frequently the result of a too liberal use of tea or coffee. Many persons cannot take a cup of coffee at any time during the evening without lying awake many hours to pay for it. It is a strong stimulant to those who have a sensitive nervous system, and should be used only sparingly at all times and never after the midday meal. Strong tea acts in this way upon a great many, and if any of my readers are troubled with sleeplessness, and yet at the same time use tea and coffee freely, I would suggest that they try, first of all, to do without these drinks and note the effect. =Treatment.=--A warm (not hot) foot-bath taken just before retiring will often cause a good night's rest, as it draws the blood from the head, makes the circulation more evenly distributed, and in this way induces sleep. Frequently a baby or young child may be made to sleep all through the night if a warm bath be given just before retiring. When the sleeplessness is due to nerve exhaustion, as is frequently the case, the very best results will follow the use of Lydia E. Pinkham's Vegetable Compound, because of its great nerve tonic properties. =A Hard Cold.=--Whenever any one has taken a hard cold, it can often be speedily and completely broken up in the following manner: Take a hot foot-bath for at least half an hour. While the feet are still in the hot water throw a blanket completely about the limbs and body, in order to retain all the heat possible. At the same time drink one or two cupfuls of hot lemonade, or hot ginger tea. Then retire to bed, having the bed previously well warmed, if during the wintertime. Put on plenty of covering, keeping a hot flat-iron or a hot water-bottle at the feet, and in every way try to induce free perspiration. After an hour or two, gradually remove the extra clothing. Be careful about going out the next morning, for the body will be especially susceptible to the cold. In this way it is possible to break up a hard cold at once. If there is any tendency to cough, or any tightness or soreness in the chest, place a mustard plaster directly over the chest, and allow it to remain on until the skin is quite red. =Sore Throat.=--An old-fashioned remedy for sore throat, and a very good one, too, is to bind on each side of the throat a piece of salt pork. The surface of the pork may be slightly covered with black pepper, in order to increase its drawing power. This is allowed to remain on all night, but should be taken off in the morning. During the day a flannel is worn about the neck. A gargle for sore throat may be made by dissolving half a teaspoonful of chlorate of potash in a cupful of warm water. Gargle the throat with this every hour or two during the day, but do not swallow the mixture. After this has been used for a day or two, then a solution may be made by adding a teaspoonful of pulverized alum to a cupful of warm water; this is applied to the inflamed sides of the throat by means of a swab. Gargling the throat with a solution of ordinary extract of witch hazel, one part, and water two parts, also very useful. =Croup.=--As a rule, croup may be quickly cured by the use of either hot or cold water. Immediately the child begins to breathe hard and cough with a dry, hollow, barking cough, wring out a towel from cold water and apply around the throat, covering this with a dry towel. The wet towel should be changed in a few minutes, just as soon as it becomes a little warm. Often before the second cloth is removed the spasm will be broken, and the danger passed. _Cool_ water will not answer; it must be _cold_. If the spasm does not break, and the breathing does not become easy within fifteen or twenty minutes, then change to hot water. Wring out the cloth from water as hot as can be borne and apply about the neck, changing in a few moments, and so on. =How to Lose Flesh.=--I have often been asked whether it were possible to have the flesh reduced without in any way affecting the general health. If the person be only slightly heavier than usual, and is in the best of health, it certainly seems wrong to experiment in any way to reduce the weight, especially when this is done only to better follow the dictates of fashion. If, however, the excess of flesh is becoming so great as to be uncomfortable, to interfere with the regular work, or to cause weak action of the heart, etc., then something should be done. There are a few rules which a person may follow to advantage in such cases, although the change should be made gradually. So long as a person continues to gain in flesh, it is positive evidence that more food is being taken than necessary. Therefore the first rule is that the quantity of food should be gradually diminished. The second rule is that exercise should be taken regularly. This will keep up the general health, while it will cause the fat to be more evenly distributed over the body. Another rule is to keep the bowels well open, so that there may be at least two movements daily. For this special purpose the mineral laxative waters are best. =Diet for Reducing the Flesh.=--Fatty foods should be avoided, and so should all drinks in excess. Foods containing sugar or starch should be taken sparingly, as oatmeal, potatoes, rice, cakes, sweetened tea and coffee. Milk is very fattening to many, hence should not be used. The eminent Dr. Mitchell, of Philadelphia, instituted a course of treatment for reducing the weight, which is quite rigid, but nevertheless effective. The regular diet should be changed gradually until it meets Dr. Mitchell's demands. He prescribes outdoor exercise, and a diet of one cupful of milk and one egg every three hours when awake. No other food or drink is allowed for twenty days, when the list of foods is gradually extended. There are a number of anti-fat remedies upon the market, but many of them depend for a cure upon their power to disturb digestion, and thus interfere with the general health. =How to Gain Flesh.=--When it is natural for persons to be thin, it is quite impossible for them to gain in weight under any kind of diet or treatment. Many persons, however, are thin simply because some of the digestive organs do not perform their work properly; or because the diet is not the right kind. Thin persons need good meats and some vegetables. If the digestion is all right, then such meats as mutton, chicken, broiled bacon, broiled ham, etc., may be used; also rare broiled steak, rare roast beef, etc. Eggs may be used in any way except hard-boiled. Good bread, oatmeal, cracked wheat, hominy, etc., are good. Such indigestible foods as pork and veal, thin soups, cabbage, turnips, pickles, pies, and pastries of all kinds should not be used. Often a good preparation of cod-liver oil will increase the weight; and this is also true of many of the extracts of malt. It is useless, however, to try to increase the weight by using a generous diet, unless the digestion is in good order. When the digestion is weak, the person should take Lydia E. Pinkham's Vegetable Compound because of its power to strengthen the digestion and enable the system to obtain all the good possible from the food. =Pimples, Rashes, Eruptions.=--Many persons, especially young girls, are afflicted with pimples on the face, rashes, blackheads, etc. To cure this condition it is necessary that the bowels be made to act regularly each day, which is easily done by the use of Lydia E. Pinkham's Liver Pills. Then a good course of treatment should be taken with Lydia E. Pinkham's Blood Purifier in order to make the blood perfectly pure in every way. Attention should also be paid to the diet, and such indigestible articles as pork, pickles, rich pies and cakes, and rich sauces, sweetmeats and nuts should be avoided. For local treatment, the face should be washed each day in warm, soapy water, using the best Castile soap. Then with a sponge or wash cloth wash off this water with as hot water as can be borne. It is best to keep up this sponging with the hot water for at least five minutes in order that the face may become thoroughly steamed. The face should then be wiped dry and rubbed briskly for a few minutes. =Burns.=--Burns are likely to occur at any time in the household, and one should always know what to do promptly. The best treatment is to add a teaspoonful of ordinary baking-soda to a cupful of water. Saturate some cloths in this solution and lay them over or loosely bind them about the burned part. This will take out the pain and sting at once. As the cloths become dry, more of the solution should be poured over them, and they should not be removed from the burned parts. After a few hours, these wet cloths may be replaced by cloths well covered with vaseline. =If you do not understand your ailments write to Mrs Pinkham. Her advice is free and always helpful. Such letters are strictly confidential; they are never shown without the writer's express permission; women only assist in answering them.= Free Medical Advice to Women ALL CORRESPONDENCE STRICTLY CONFIDENTIAL +Lady with Raised Hand+ In addressing Mrs. Pinkham you are confiding your private ills to a woman--a woman who speaks from a greater experience in treating women's diseases than can any living physician--male or female. You can talk freely to a woman when it is revolting to relate your private troubles to a man--besides, a man does not understand--simply because he is a man. Many women suffer in silence and drift along from bad to worse, knowing full well that they ought to have immediate assistance, but a natural modesty impels them to shrink from exposing themselves to the questions and probably examinations of even their family physician. It is unnecessary. Without money or price you can consult a woman, who can speak from a greater actual experience than can any local physician in the world. Every one will agree that there are the strongest of all reasons why, if we are ill, we should appeal to the person who knows the most about the kind of illness with which we are afflicted--one who has had the greatest experience in treating just such cases and meeting just the symptoms that are manifest in our particular case. What confidence does one gain by consulting one who has occasionally met a case just like ours, but has had no great experience? None whatever. All treatment under such a person must of necessity be experimental. But in writing Mrs. Pinkham you consult one who has, actually filed in her office for ready reference, an immense correspondence with patients suffering from female ills which has been constantly going on for more than twenty-five years; and it is safe to say there is not a case or complication of female derangements with which she is not familiar. It is a positive fact, easily verified, that within the last few months she, with her corps of trained women assistants, has advised in over one hundred thousand cases, and that a vast number of the women of this country owe the restoration of their health to her advice and Lydia E. Pinkham's Vegetable Compound. Now, if a woman is ill and miserable, it seems to us only simple justice to herself that she should avail herself of the help of a woman of such enormous experience. MRS. PINKHAM'S STANDING INVITATION. Women suffering from any form of female weakness are invited to promptly communicate with Mrs. Pinkham, at Lynn, Mass. She asks nothing in return, except their good will, and her advice has relieved thousands. Surely any woman, rich or poor, is very foolish if she does not take advantage of this generous offer of assistance. =Address simply Mrs. Pinkham, Lynn, Mass., U. S. A.= El Compuesto Vegetal de Lydia E. Pinkham es un remedio seguro para todas las enfermedades de las mujeres, incluyendo la caída del útero, leucorrea, menstruaciones irregulares y dolorosas, inflamaciones y ulceraciones de la matriz y del ovario, para toda clase de afecciones de los órganos de la generación, así como también para las enfermedades de los riñones de ambos sexos. Este remedio está compuesto de las raíces y yerbas mas puras y escogidas, que se encuentran en la naturaleza para las enfermedades de las mujeres. =Menstruación.=--Las menstruaciones tempranas no son deseables, aunque muchas menstruaciones aparecen de los trece á los quince años; sin embargo mucho depende de la constitución de la muchacha. Si habiendo llegado á esta edad no ha menstruado todavía, la madre deberá prestar singular cuidado á la hija; esta probablemente crecerá delgada y pálida con una complexión lívida, que hará de ella una víctima fácil y segura de la tisis y de la nevrastenia. Nada hay comparable para estos casos al Compuesto Vegetal de Lydia E. Pinkham. Ayuda y promueve los cambios importantes que han de verificarse en la vida de la muchacha en esa edad previniendo largos años de padecimientos los cuales son resaltados seguros de la negligencia. El Compuesto deberá tomarse siguiendo estrictamente las direcciones hasta que la menstruación ocurra regularmente cada veinte y ocho días. Si hay propensión á estreñimiento, las Píldoras de Hígado de Lydia E. Pinkham deberán tomarse juntamente con el Compuesto Vegetal. Estas píldoras han sido hechas especialmente para mujeres y obran in perfecta harmonía con el Compuesto Vegetal. =Supresión de las Reglas= es la suspensión de la menstruación. Si la supresión de las reglas ocurriese, excepto en los casos de preñez ó de amamantamiento, el Compuesto Vegetal de Lydia E. Pinkham deberá tomarse hasta que la menstruación vuelva á producirse regularmente. Curará todas las irregularidades. =Menstruaciones dolorosas.=--Muchas mujeres sufren dolores terribles durante la menstruación. El Compuesto Vegetal de Lydia E. Pinkham curará esos martirizantes dolores. Nada importa que el caso sea reciente ó que haya existido durante muchos meses, si el Compuesto Vegetal se toma regularmente y siguiendo las instrucciones, la cura será un hecho cierto. =Menstruaciones abundantes= ocurren á menudo en las personas sanguíneas y en las pálidas y linfáticas. El Compuesto Vegetal de Lydia Pinkham ha hecho algunas de las curas más asombrosas precisamente en esas condiciones. Para las menstruaciones abundantes avisamos que se tome el Compuesto Vegetal de Lydia E. Pinkham en forma seca, es decir en píldoras ó pastillas. =La inflamación y la ulceración del útero= es la causa de casi todas las enfermedades de las mujeres. El Compuesto Vegetal de Lydia E. Pinkham ha curado más de un millón de casos de enfermedades uterinas. El número de relaciones recibidos de mujeres que han estado enfermas á punto de morir y han sido curadas por este remedio es casi increíble. Una mujer puede conocer perfectamente si padece de alguna enfermedad del útero, porque estas enfermedades vienen acompañadas de terribles dolores en el abdomen, espalda etc., desmayos, pesadez en las extremidades, y de toda clase de otros dolores. Una cura segura se encuentra en el Compuesto Vegetal de Lydia E. Pinkham. =Leucorrea (ó Flores Blancos).=--Uno de los primeros síntomas de la inflamacíon del útero es la leucorrea, familiarmente conocida bajo el nombre de Flores Blancos, la cual consiste en una secreción blancusca de la vagina la cual debilita muchísimo el sistema y produce una irritación de la membrana mucosa que reviste el canal vaginal. El uso regular del Compuesto Vegetal, por sus efectos en la constitución, y la Loción Sanativa de Lydia E. Pinkham usada en inyecciones curará positivamente los casos más graves de leucorrea. La negligencia de esta dolorosa enfermedad originará úlceras, flujos excesivos, estableciendo los cimientos para la más terrible de todas las enfermedades--el Cancer. =Caída del Utero.=--Existen muchos desplazamientos del útero, pero el más principal es él conocido generalmente con el nombre de la Caída del Utero. Esto es debido muchas veces á la flojedad de los ligamentos que soportan este órgano. El Compuesto Vegetal de Lydia E. Pinkham fortalece lás ligamentos, alivia todas las inflamaciones y gradualmente restaura los órganos á su propia condición. El Compuesto Vegetal de Lydia E. Pinkham removerá los tumores del útero en su temprano desenvolvimiento tan seguro como el sol brilla. =La Inflamación de los ovarios= es una de las enfermedades más desesperantes que atacan á las mujeres de 20 á 40 años. Esta enfermedad va siempre acompañada de algunos dolores de la región de los ovarios y de una sensación de pesadez especialmente durante la menstruación. A menudo el dolor extiéndese por el costado y la espalda, especialmente en el lado izquierdo produciendo continuos deseos de orinar. A menos que esta enfermedad se ataque prontamente nada curará á la paciente que no sea la cuchilla del cirujano. El Compuesto Vegetal de Lydia E. Pinkham a curado miles de mujeres que sufrían enfermedades del ovario, salvándolas de los riesgos de una seria operación. =La Esterilidad= es á menudo debida á la extrema debilidad e inflamación crónica del útero; frecuentemente el uso regular del compuesto Vegetal de Lydia E. Pinkham ha restaurado los órganos reproductivos de la mujer á sus condiciones normales quitándolas la idea de que su esterilidad era imposible de curarse. =Cambio de Vida= es el período peligroso por el cual pasan todas las mujeres que han cumplido 45 años; durante este período las mujeres sufren toda clase de dolores y enfermedades, pero si el Compuesto Vegetal de Lydia E. Pinkham se toma regularmente este cambio importante puede ser pasado sin peligro de enfermedades ó muerte. =Las Enfermedades de los Riñones y de la Vejiga= son comunes en ambos sexos, generalmente de difícil curación, pero pueden curarse si se atienden á tiempo; nada sin embargo es tan fatal como el no atenderlos debidamente á su tiempo, siendo la muerte el resultado inevitable. El Compuesto Vegetal de Lydia E. Pinkham no reconoce rival entre los remedios que para estas enfermedades han sido descubiertos. Es digno de absoluta confianza tanto por hombre como por mujer. =Los Dolores de la Espalda= no son una enfermedad pero son uno de los principales síntomas; cuando existe una enfermedad de los órganos de la generación, ésta es telegrafiada, como si dijeramos, al gran nervio simpático que tiene uno de sus principales centros en la parte mas baja de la espalda. El Compuesto Vegetal de Lydia E. Pinkham curando las enfermedades del útero y de los riñones hará desaparecer los dolores de la espalda. =Dispepsia é Indigestión.=--Nada en el mundo será descubierto que pueda compararse al Compuesto Vegetal de Lydia E. Pinkham, para las enfermadedes del estómago. =Preñez.=--Muchos dolores y sufrimientos que ocurren al dar á luz á un niño podrían evitarse enteramente, si la madre fortificase su sistema durante dos meses antes del nacimiento con el Compuesto Vegetal de Lydia E. Pinkham. DIRECCIONES GENERALES. Una cucharada del Compuesto Vegetal de Lydia E. Pinkham deberá tomarse cada 4 horas al día para cualquiera de las enfermedades arriba mencionadas. * * * * * Empápese un cuarto del paquete le la Loción Sanativa de Lydia E. Pinkham en cantidad suficiente de agua para hacer una pinta después de haberse filtrado; cuando los flujos son profusos, úsese la mitad de esta cantidad, añadiendo una pinta de agua caliente. * * * * * Para estreñimiento, dolores de cabeza, biliosidades tómense tres Píldoras de Hígado de Lydia E. Pinkham la primera noche, dos la segunda y una la tercera, y á menos que se obtenga una saludable flojedad de los intestinos deberá seguirse tomando una cada noche, hasta concluir la caja. * * * * * Cuando la sangre es pobre y el paciente se sienta débil y cansado, y desganado, nada en el mundo es tan bueno como el "Purificador de la Sangre" de Lydia E. Pinkham. Una cucharada tres veces al día curará el reumatismo, scrófula, erupciones de la piel, etc. etc. * * * * * De venta por todos los farmaceúticos y droguistas. Preparado por The Lydia E. Pinkham Medicine Company, Lynn, Mass., E. U. de A. LYDIA E. PINKHAM'S �RT-MEDICIN ar ett säkert botemedel för alla qvinnosjukdomar, såsom lifmoderns nedfallande, hvitsot, oregelbunden och smärtsam rening, inflammation och sårnad på lifmodern och äggstockarne, samt alla andra svagheter uti de qvinliga skaporganen, äfvensom njurlidande hos båda könen. Det är sammansatt af utvalda och renaste slag af rötter och örter, såsom naturen sjelf fråmställt dem för botandet af qvinnans lidanden. =Rening.=--För tidig rening är icke önskvärd, ehuru densamma vanligen börjar vid omkring tretton intill femton års ålder; emellertid beror dervid mycket på flickans kroppsbyggnad. Om hon nått denna ålder och ännu icke haft rening, bör modren fästa särskild uppmärksamhet dervid; hennes dotter blir antagligen mager och blek, med en egendomlig gulblek hy och hon blir ett säkert och lätt offer för lungsot och nervös nedslagenhet. Ingenting i verlden när upp till Lydia E. Pinkhams Vegetable Compound i dylika fall. Det bidragar att åstadkomma den vigtiga förändring uti en flickas lif, som bör ega rum vid omkring denna ålder och förebygger sålunda åratal af elände, som är en säker följd af uraktlåtenhet. Medicinen måste tagas bestämdt enligt föreskrift, intill reningen inträffar regelbundet hvarje tjuguåttonde dag. Om inelfvorna äro benägna att hoptränga sig, borde Lefver-Piller (Lydia E. Pinkhams Liver-Pills) begagnas, hvilka blifvit särskildt sammansatta för qvinnans bruk och verka i fullkomlig harmoni med Vegetable Compound. =Förhindrande af Flytningen= är ett uppharonde sedan reningen vederbörligen börjat. Om ett upphörande eger rum, så framt det icke är en följd af hafvandeskap eller gifvande af di, är det ett allvarligt fall och Lydia E. Pinkhams Vegetable Compound bör tagas tills reningen åter blir regelbunden. Den förbättrar säkert alla oregelbundenheter. =Smärtsam Rening.=--Många qvinnor lida marterande smärta under reningen. Lydia E. Pinkhams Vegetable Compound botar säkert denna smärtande känsla. Det inverkar ej om detta förhållande nyligen inträdt eller om det egt rum under många månader; om Lydia E. Pinkhams Vegetable Compound tages regelbundet och enligt föreskrift är ett botande säkert. =För Ymnig Rening= förekommer ofta hos dem, som äro blodfulla, liksom hos dem som äro bleka och svaga. Lydia E. Pinkhams Vegetable Compound har åtstadkommit åtskilliga af de mest förvånansvärda botaden i just dylika fall. För för ymnig rening eller flytning rekommendera vi alltid Lydia E. Pinkhams Vegetable Compound i torr form, antingen som piller eller kakor. =Inflammation och Sårnad på Lifmodern= är orsaken till nästan alla qvinnosjukdomar. Lydia E. Pinkhams Vegetable Compound har botat mera än en million fall af Lifmoderfel. De skildringer, som erhållits från qvinnor, hvilka varit dödsjuka och som botats genom Lydia E. Pinkhams Vegetable Compound äro nästan otroliga. En qvinna vet säkerligen om hon har något slags lifmoderfel, enär dylikt nästan alltid åtföljes af en nedtyngande känsla uti underlifvet, ryggvärk, svimmingsanfall, styfhet i lederna och all annan tänkbar värk och smärta. Ett aldrig svikande botemedel är Lydia E. Pinkhams Vegetable Compound. =Leucorrhea eller Hvitflytning.=--En af de första symptomerna af lifmoderns inflammation är leucorrhea, vanligen kallad "hvitt," hvilken består af en hvit flytning från moderslidan och som är mycket kraftnedsättande för systemet och retande för moderslidans känsliga slemhinna. Ett regelbundet begagnande af Lydia E. Pinkhams Vegetable Compound på grund af dess inverkanpå kroppsbeskaffenheten och Lydia E. Pinkhams Läkande Medel för insprutning uti moderslidan, botar säkert de allvarligaste fall af hvitflytning. Försummande af denna ledsamma sjukdom förorsakar sårnader, öfverdrifven flytning och lägger grunde för den forskräckligaste af alla sjukdomar nemligen Kräfta. =Lifmoderns Nedfallande.=--Det finnes många olika rubbningar hos lifmodern, den vanligaste känd under namn af lifmoderns nedfallande. Detta beror hufvudsakligast på förslappning af de band som uppbara detta organ eller hålla det på sin plats. Lydia E. Pinkhams Vegetable Compound starker dessa band, lindrar inflammation och återställer så småningen delarne uti deras behöriga läge. Lydia E. Pinkhams Vegetable Compound borttager svullnad uti lifmodern i dess tidigare stadium lika säkert som solen skiner. =Inflammation uti �ggstockarne= är en särdeles allvarlig sjukdom, som angriper qvinnan mellan 20 och 40 års ålder. Den åtföljes alltid af ömhet och hårda smärtor i trakten af äggstockarne och en känsla af uppfyllnad isynnerhet under reningen. Ofta utstracka sig smartorna till sidan och ryggen, isynnerhet till venstra sidan, med ett ständigt begår att urinera. Sä framt icke denna sjukdom genast häfvas, kan ingenting rädda patienter från operationsknifven. Lydia E. Pinkhams Vegetable Compound har emellertid botat tusentals qvinnor för sjukdomar uti äggstockarne och räddat mångfaldiga från hospitalet och en allvarlig operation. =Ofruktbarhet= har often sin orsak uti ytterlig svaghet och kroniskt inflammeradt tillstånd af lifmodern. Regelbundet begagnande af Lydia E. Pinkhams medicin har ofta återställt lifmoderns fruktbara organer till deras normala tillstånd och lindrat från den bekymrande tanken att ofruktbarheten var obotlig. =Förändring I Lifvet= ar en farlig period för alla qvinnor, som hunnit till 45 års ålder. Under denna tid har qvinnan all slags sjukdom och smärta, men om Lydia E. Pinkhams Vegetable Compound tages regelbundet, kan denna vigtiga förändring i en qvinnas lif passeras utan fara för sjugdom eller död. =Njurlidande och Blåskatarr= hos båda könen aro vanliga och svåra sjukdomar, men de kunna botas om de tagas itu med i rätt tid. Ingenting ar emellertid så olycksbringande som symptomerna till dessa sjukdomar om de ej gifvas akt på i tid och döden är oundviklig. Lydia E. Pinkhams Vegetable Compound öfverträffas ej af något annat botemedel, som någonsin uppståckts för botande af alla sjugdomar i njurarne och blåsan. Det är fullt tillförlitligt både för män och qvinnor. =Ryggvark= är icke en sjukdom utan en tydlig symptom da sjukdom förefinnes uti skaporganen och ger sig tillkänna som om det vore uti den stora sympatiska nerv, som har ett af sina förnämsta lägen i lägre delen af ryggen. Lydia E. Pinkhams Vegetable Compound, som häfver lifmoders-, äggstocks-, och njurlidanden, botar tryckande ryggvärk. =Magsyra och Dålig Matsmåltning.=--Ingenting verlden har någonsin uppstäckts, som uppnår Lydia E. Pinkhams Vegetable Compound for magsjukdomar. =Hafvande Tillstand.=--Vid barnsbörd intraffer mycken smärta och lidande, som kunde helt och hållet undvikas om den blifvande modern stärkte sitt system genom regelbunden behandling med Lydia E. Pinkhams Vegetable Compound under en period af två månader före barnsbörden. ALLM�N ORDINATION. En matsked af Lydia E. Pinkhams Vegetable Compound hvarje fjerde timma under dagens lopp för hvilken som helst af förutnmände sjukdomar. Lägg ett fjerdedels paket af Lydia E. Pinkhams Läkande Medel i tillräckligt med vatten för att utgöra en pint sedan det silats. Då flytningen är för riklig, tag hälften deraf och tillsätt en pint varmt vatten. Begagna dagligen för insprutning i moderslidan. För föstoppning, hufvudvärk och gallsjukdom tages tre Lydia E. Pinkhams Lefverpiller första natten, två den andra och en den tredje och såvida ej en regelbunden och helsosåm förändring inträdt uti underlifvet, fortsätt att taga ett hvarje afton så länge de räcka. När blodet är fattigt och patienten är svag samt alltid känner sig trött, är mager och ej har appetit, så är intet i verlden så välgörande som Lydia E. Pinkhams Blodrenare. En matsked tre gånger dagligen botar rheumatism, skrofler, hudsjukdomar m. m. Säljes hos Apotekare, prepareradt af Lydia E. Pinkham Medicine Company, Lynn, Mass., Förenta Staterna. LE REM�DE V�G�TAL DE LYDIA E. PINKHAM. =Le Remède Végétal de Lydia E. Pinkham= est un remède absolument sûr pour toutes les maladies de femme telles que le prolapsus de la matrice, la leucorrhée, les menstrues irregulières et douloureuses, l'inflammation et l'ulcération de la matrice et des ovaires, ainsi que pour toutes les autres affections des organes génitaux de la femme, et les maladies des reins et du foie des deux sexes. Il se compose des herbes et racines les plus pures, telles que les pourvoit la nature elle même. =Menstrues.=--Il n'est pas à désirer que les règles aient lieu a un âge trop jeune, quoiqu'en général les menstrues commencent entre la 13e et la 15e année, la constitution de la jeune fille y jouant un certain rôle. Si la fille a atteint cet âge et qu'elle n'ait pas encore ses règles, la mère ne saurait être trop soigneuse; il est probable que la fille est pâle et maigre, et que son teint montre cette couleur livide qui nous fait craindre qu'elle ne devienne sous peu la victime de la phthisie et qu'elle ne devienne fortement neurasthénique. Pour empêcher un tel malheur rien n'égale "Lydia E. Pinkham's Vegetable Compound." Il produit d'une manière salutaire et prompte le changement qui devrait alors avoir lieu, en prévenant ainsi de longues années de souffrances, résultat inévitable de tout manque de précaution. Lydia E. Pinkham's Vegetable Compound doit être pris strictement selon les instructions, jusqu'à ce que les règles aient lieu tous les 28 jours. Si, de plus, il y a de la constipation, on se servira des Pilules de Foie de Lydia E. Pinkham, faites exprès pour l'usage des femmes et opérant entièrement d'accord avec le remède. =L'Absence des Règles= après qu'elles ont commencé une fois, à moins qu'elle ne soit due à la grossesse ou à l'allaitement, est une affaire de la plus grande importance et personne ne devrait manquer de se servir de Lydia E. Pinkham's Vegetable Compound jusqu'à ce que de nouveau les menstrues se montrent regulièrement. =Règles Douloureuses.=--Il y a bien des femmes qui, pendant le temps de leurs règles, souffrent des douleurs tout à fait terribles. Notre remède guérira d'une maniere sûre cette affection n'importe si c'est un cas récent ou vieux de plusieurs mois. On peut s'attendre à une guérison sûre et efficace pourvu que le remède soit pris regulièrement et suivant les instructions. =Les Règles Excessives= se montrent d'abord chez des personnes sanguines et chez les personnes affaiblies et pales. Notre remède, Lydia E. Pinkham's Vegetable Compound, a obtenu des résultats tout à fait merveilleux dans ces cas. Pour guérir l'excès ou l'hémorrhagie des règles nous conseillons l'emploi du remède dans sa forme sèche, c'est à dire en pilules ou en pastilles. =L'Inflammation ainsi que L'Ulcération de la Matrice= peuvent être regardées comme cause de presque toutes les maladies de la femme. Cependant Lydia E. Pinkham's Vegetable Compound a guéri plus d'un million de maladies de la matrice. Les rapports que nous recevons des femmes qui ont failli en mourir et qui ensuite ont été gueries, sont presque incroyables. La femme peut s'assurer assez facilement, si elle est atteinte ou non d'une affection de la matrice, vu le fait qu'ordinairement elle est sujette à des tiraillements d'estomac, à des peines dans les reins, à des évanouissements, à l'engourdissement des membres et à une foule d'autres douleurs. Le seul remède infaillible pour guérir toutes ces affections est Lydia E. Pinkham's Vegetable Compound. =La Leucorrhée= que nous connaissons plus familièrement sous le nom de "Fleurs Blanches," représente un des premiers symptômes de l'inflammation de la matrice. Le mal se montre sous la forme d'une secrétion blanchâtre du vagin, enfaiblissant le système et exerçant un irritation très sérieuse sur la muqueuse du vagin. L'emploi régulier de Lydia E. Pinkham's Vegetable Compound, grâce à son effet sur le système, ainsi que de la Lotion Sanitaire de Lydia E. Pinkham (Lydia E. Pinkham's Sanative Wash) appliquée sous forme d'injections dans le vagin, ne tardera guère de guérir les cas les plus obstinés de leucorrhée. En négligeant cette maladie désastreuse on est sûr de donner lieu à des secrétions excessives, à des ulcères ainsi qu'a la plus dangereuse de toutes les maladies--le Cancer. =Prolapsus de la Matrice.=--Il y a un grand nombre de déplacements dont le plus important est appelé "le prolapsus de la matrice." Celui-ci est produit d'abord par une relaxation des ligaments qui, dans leur état normal, maintiennent cet organe à sa place. Lydia E. Pinkham's Vegetable Compound fortifiera ces ligaments, l'inflammation disparaîtra et peu à peu l'organe sera remis dans sa condition normale. Notre remède aura de plus un succès indiscutable pour guérir toutes les tumeurs de la matrice pourvu qu'on commence à s'en servir dès leurs première phases. =L'Inflammation des Ovaires= est une des maladies les plus désastreuses atteignant les femmes entre la vingtième et la quarantième année. Les personnes qui en souffrent s'aperçevront vite d'une sensibilité extraordinaire dans la région des ovaires, de plus des sensations d'enflements désagréables, surtout dans la période des règles. Souvent la douleur s'étend aux flancs et au dos, surtout au flanc gauche, et il se fait sentir un désir incessant d'uriner. A moins que cette affection ne soit arrêtée promptement rien ne pourra sauver la malade d'une opération. Lydia E. Pinkham's Vegetable Compound, cependant, a guéri les maladies d'ovaires de milliers de femmes et bien de femmes ont été assez heureuses, par conséquent, pour échapper à un long traitement à l'hôpital ainsi qu'à une opération des plus sérieuses. =La Stérilité= est très souvent une conséquence directe d'une inflammation chronique de la matrice et d'une faiblesse extrême. L'emploi régulier de Lydia E. Pinkham's Vegetable Compound a souvent rétabli les fonctions normales de l'organe générateur, et a ainsi détruit cette idée fatale que la stérilité etait incurable. =La Période Climatérique ou Changement de Vie= est une période très importante et assez dangereuse pour toute femme qui a passé l'âge de 45 ans. Pendant cette période les femmes sont atteintes de toute espèce de maladies et de peines; l'emploi régulier de Lydia E. Pinkham's Vegetable Compound cependant va leur garantir une immunité parfaite contre tout accident dangereux qui pourrait leur survenir dans cette période. =Les Maladies des Reins et de la Vessie=, chez les deux sexes, sont très frequentes et très obstinées. Aussi peuvent-elles devenir très dangereuses et même fatales, si l'on manque de s'en occuper dès l'apparence des premiers symptômes. Lydia E. Pinkham's Vegetable Compound, que nous conseillons d'employer le plus tôt possible, est la =médicine par excellence= qui dans tous les cas de maladies du foie et de la vessie produira un résultat simplement merveilleux chez l'homme et chez la femme, et qui ne manquera guère de sauver une vie trop souvent menacée fatalement. =Le Mal de Dos=, quelque fréquent qu'il soit, n'est guère une maladie proprement dite, mais plutôt un symptôme de la plus haute importance, comme il indique par le centre dorsal du grand nerf sympathique, qu'il y a une affection des organes générateurs qu'on fera bien de ne point négliger. Aussitôt que ces affections ou utérines, ou ovariennes ou rénales sont guéries par l'emploi de Lydia Pinkham's Vegetable Compound, ce mal de dos tourmentant va cesser tout seul. =Dyspepsie et Indigestion.=--Rien au monde n'égale la force guérissante de notre remède pour toutes les maladies de l'estomac. =Grossesse.=--Une grande partie des douleurs et des souffrances qu'en général les femmes doivent endurer en accouchant pourraient être evitées, si elles se préparaient convenablement en fortifiant leur système par l'emploi de Lydia E. Pinkham's Vegetable Compound, à peu près deux mois avant l'accouchement. MODE D'EMPLOI. Prenez une cuillerée de Lydia E. Pinkham's Vegetable Compound toutes les 4 heures pendant la journée pour guérir chacune des maladies décrites ci-dessus. Trempez le quart d'un paquet de Lydia E. Pinkham's Sanative Wash (Lotion Sanitaire) dans assez d'eau pour obtenir une pinte après la filtration; la secrétion étant très forte on doit employer la moitié de cette quantité à laquelle on ajoutera une pinte d'eau chaude. Employez la lotion chaque jour en l'injectant dans le vagin. Pour guérir la constipation, la migraine, les attaques bilieuses, prenez trois pilules la première nuit, deux la suivante et une la troisième et continuez jusqu'à ce que la boîte soit vide, à moins qu'il n'y ait pas une évacuation regulière plus tôt. Quand le sang est appauvri et que le malade est toujours fatigué, bien amaigri et sans appétit, rien au monde ne lui fera autant de bien que le remède purificateur Lydia E. Pinkham's Blood Purifier. Une cuillerée trois fois par jour guérira les rhumatismes, la scrofule et toutes sortes d'éruptions de la peau. Vendu chez tous les pharmaciens. Préparé par Lydia E. Pinkham Medicine Company, Lynn, Mass., E. U. Lydia E. Pinkham's Kräutermittel, unter dem Namen "Vegetable Compound" auf den Markt gebracht, ist ein absolut zuverlässiges Heilmittel für sämmtliche Frauenkrankheiten, einschlie�lich Vorfall der Gebärmutter, Leukorrhoe, unregelmä�ige und schmerzhafte Menstruation, Entzündung und Geschwürbildung in der Gebärmutter und den Eierstöcken, ferner für alle sonstigen Schwächezustände in den weiblichen Geschlechtsorganen und für Nierenkrankheiten bei beiden Geschlechtern. Das Mittel ist aus den reinsten und erlesensten Wurzeln und Kräutern, wie sie Mutter Natur zur Heilung aller Frauenleiden selbst geschaffen hat, zusammengestellt. =Menstruation.= Eine übermä�ig frühe Menstruation ist keineswegs wünschenswerth; obwohl die Monatsregel oder Menstruation im Allgemeinen in der Zeit vom dreizehnten bis zum fünfzehnten Jahre aufzutreten pflegt, wobei jedoch viel von der Constitution des betreffenden Mädchens abhängt. Hat sie jedoch dieses Alter erreicht, und sollte sich die Menstruation noch nicht eingestellt haben, so mu� die Mutter sich um die Sache bekümmern. Wahrscheinlich ist das junge Mädchen mager und bla�, wobei der Teint ein besonders, gelbliches Aussehen hat, so da� es nur zu leicht ein Opfer der Auszehrung und allgemeiner Nervenschwäche wird. Für solche Fälle ist Lydia E. Pinkham's Vegetable Compound geradezu unvergleichlich. Es trägt vor allem dazu bei, da� der Wechsel im Mädchenleben, der um diese Zeit eintreten sollte, auch richtig stattfindet, und es verhindert somit jahrelanges Leiden, das in der Regel eine sichere Folge einer Vernachlässigung in diesem Sinne bildet. Lydia E. Pinkham's Vegetable Compound sollte genau nach Vorschrift eingenommen werden, bis die Regeln regelmä�ig sich alle 28 Tage einstellen. Zeigt sich Anlage zu Verstopfung, so mu� man auch Lydia E. Pinkham's Leberpillen brauchen, die speciell für den Gebrauch von Frauen zusammengestellt worden sind und in jeder Beziehung harmonisch mit dem "Compound" zusammenwirken. =Ausbleiben der Regeln.= Mit diesem Ausdruck bezeichnet man das Nichterscheinen der Menstruation, nachdem dieselbe einmal zu erscheinen angefangen hat. Ein derartiges Ausbleiben, sofern es nicht der Schwangerschaft oder dem Stillen zuzuschreiben ist, ist eine ernsthafte Angelegenheit, und Lydia E. Pinkham's Vegetable Compound mu� eingenommen werden, bis die Menstruation wieder regelmä�ig eintritt. Durch den Gebrauch dieses Mittels kann man zuverlässig alle Unregelmä�igkeiten beseitigen. =Schmerzhafter Monatsflu�.= Bei vielen Frauen verursacht der Monatsflu� überaus gro�e Schmerzen, und alle, die daran leiden, sollten ja nicht verfehlen, sich durch den Gebrauch von Lydia E. Pinkham's Vegetable Compound von dieser wahrhaften Gei�el zu retten. Dabei ist es gleichgültig, ob der Fall ein akuter ist oder ob er schon viele Monate gedauert hat. Vorausgesetzt, da� das Vegetable Compound regelmä�ig und genau nach Vorschrift genommen wird, darf man zuverlässig eine Heilung erwarten. =Zu starker Monatsflu�.= Sowohl vollblütige als auch besonders bleichsüchtige und schwächliche Personen leiden häufig unter zu starker Menstruation. Gerade mit Bezug auf derartige Zustände vermag Lydia E. Pinkham's Vegetable Compound au�erordentlich günstige Resultate aufzuweisen. Doch empfehlen wir bei zu reichlich auftretender Blutung Lydia E. Pinkham's Vegetable Compound in seiner trockenen Form, d. h. in der Form von Pillen oder Pastillen einzunehmen. Beinahe alle Frauenkrankheiten haben ihren Ursprung in =Entzündung und Geschwürbildung in der Gebärmutter=, und es ist daher nicht genug hervorzuheben, da� Lydia E. Pinkham's Vegetable Compound schon mehr als eine Million Fälle von Gebärmutteraffektionen glücklich geheilt hat. Fast unglaublich klingen die Berichte vieler Frauen, die todtkrank waren, und die dem Vegetable Compound ihre Rettung verdanken. Es ist nicht schwer für eine Frau zu erkennen, ob sie an einer Affektion der Gebärmutter leidet, da eine derartige Erkrankung fast stets von ziehenden, äu�erst empfindlichen Schmerzen im Unterleib, Rückenschmerzen, Ohnmachtsanfällen, Erstarrung »Einschlafen« der Gliedma�en, sowie von einer Reihe anderer Schmerzen begleitet ist. Lydia E. Pinkham's Vegetable Compound ist ein unfehlbares Mittel gegen alle derartigen Erkrankungen. =Die Leukorrhoe oder der wei�e Flu�.= Eines der allerersten Symptome, die eine Entzündung der Gebärmutter anzeigen, ist die Leukorrhoe, oder wie man sich gewöhnlich ausdrückt: Der wei�e Flu�. Derselbe zeigt sich als eine wei�liche Absonderung aus der Vagina oder Mutterscheide, die den Körper auffallend angreift und schwächt und besonders die empfindliche Schleimhaut des Scheidekanals irritiert. Aber selbst die hartnäckigsten Fälle von wei�em Flu� lassen sich positiv kurieren durch den Gebrauch von Lydia E. Pinkham's Vegetable Compound in Verbindung mit Lydia E. Pinkham's "Sanative Wash" oder »hygienischem Waschwasser.« Das erstere stärkt das System und das zweite heilt die lokalen Erscheinungen, da es direct in die Scheide eingespritzt wird. Man hüte sich ja, diese Art von Krankheit zu vernachlässigen, da sich sonst leicht Geschwüre und übermä�ige Absonderung einstellen können, die oftmals den ersten Grund zu der schrecklichsten aller Krankheiten -- dem Krebs legen. =Gebärmuttervorfall.= Es giebt eine Reihe von Fällen, wo die Gebärmutter eine Veränderung ihrer normalen Lage erleidet; von diesen ist der wichtigste der sogenannte Gebärmuttervorfall. Derselbe kommt hauptsächlich von einer Erschlaffung der Bänder her, die dieses Organ stützen und in seiner richtigen Lage erhalten sollen. Lydia E. Pinkham's Vegetable Compound stärkt diese Bänder, vermindert die Entzündung und verleiht nach und nach den erkrankten Theilen ihren früheren, normalen Zustand wieder. Die =Entzündung der Eierstöcke= ist eine äu�erst schwere Erkrankung, die Frauen im Alter von 20 bis 40 Jahren befällt. Sie ist stets von gro�er Empfindlichkeit und scharfen Schmerzen in der Gegend der Eierstöcke begleitet, wozu sich ein Gefühl der Völle, besonders zur Zeit der Menstruation, gesellt. Die Schmerzen erstrecken sich auch häufig auf die Seite und den Rücken, mit Vorliebe aber auf die linke Seite, in Verbindung mit fortwährendem Verlangen das Wasser abzuschlagen. Wird nicht prompt gegen diese Erkrankung eingeschritten, so vermag nichts den Kranken vom Messer des Chirurgen zu retten. Lydia E. Pinkham's Vegetable Compound hat aber tausende von Fällen von Eierstockerkrankungen geheilt und hat viele Frauen der Nothwendigkeit enthoben, sich im Hospital einer gefährlichen Operation auszusetzen. =Unfruchtbarkeit= ist oft weiter nichts als der Folgezustand ausnehmender Schwäche, sowie einer chronischen Entzündung der Gebärmutter. Der regelmä�ige Gebrauch von Lydia E. Pinkham's Vegetable Compound hat schon in vielen Fällen die weiblichen Zeugungsorgane wiederum ihrer normalen Thätigkeit zurückgegeben und eine anscheinend gänzliche Unfruchtbarkeit glücklich gehoben. Die sogenannten =Wechseljahre= oder die =Menopause= sind eine Zeit wirklicher Gefahr für alle diejenigen Frauen, die das 45. Jahr überschritten haben. Während dieser Zeit sind die Frauen allen möglichen Beschwerden und Erkrankungen ausgesetzt, die sich aber alle vermeiden lassen, ohne ernstliche Krankheit oder sogar den Tod fürchten zu müssen, wenn man während dieser sehr wichtigen Periode des Frauenlebens regelmä�ig Lydia E. Pinkham's Vegetable Compound einnimmt. =Nieren- und Blasenbeschwerden= sind häufige und hartnäckige Leiden beider Geschlechter. Sie sind alle heilbar, vorausgesetzt, da� man sich bei Zeiten um sie kümmert; werden sie aber vernachlässigt, so können sie leicht verhängnisvoll werden und sogar den Tod nach sich ziehen. Sicher ist aber, da� Lydia E. Pinkham's Vegetable Compound als ausgezeichnetes Mittel zur Heilung aller Nieren- und Blasenkrankheiten von keinem anderen bisher erfundenen Mittel übertroffen wird. Männer und Frauen können volles Vertrauen in dasselbe setzen. =Rückenschmerzen= sind nicht eine Krankheit, sondern sind vielmehr nur ein, gewisse Krankheiten anzeigendes, Symptom. Bei Krankheiten der Geschlechtsorgane wird der gro�e sympathische Nerv, dessen Hauptcentrum im unteren Theil des Rückens liegt, in Mitleidenschaft gezogen und verkündet sozusagen das Vorhandensein einer derartigen Krankheit. Dadurch, da� Lydia E. Pinkham's Vegetable Compound alle Affektionen der Gebärmutter, der Eierstöcke und der Nieren heilt, heilt es auch das so sehr peinigende Rückenweh. =Verdauungsbeschwerden.= Es giebt in der ganzen Welt kein besseres Mittel gegen alle Störungen der Magenthätigkeit als gerade Lydia E. Pinkham's Vegetable Compound. =Schwangerschaft.= Oftmals ist die Geburt eines Kindes mit vielen Schmerzen und Beschwerden für die Mutter verbunden, und doch könnten alle diese zum gro�en Theil vermieden werden, wollte nur die Mutter ungefähr zwei Monate vor der Entbindung anfangen, ihren Körper durch den regelmä�igen Gebrauch von Lydia E. Pinkham's Vegetable Compound zu kräftigen. Gebrauchsanweisung. Für sämmtliche oben erwähnte Beschwerden nehme man alle vier Stunden während des Tages je einen E�löffel voll von Lydia E. Pinkham's Vegetable Compound ein. * * * * * Man weiche ein Viertel Packet von Lydia E. Pinkham's Sanative Wash in genügend Wasser, um nach dem Durchseihen ein Pint zu haben. Ist die Absonderung sehr bedeutend, so brauche man die Hälfte der so erhaltenen Flüssigkeit, füge noch ein Pint warmen Wassers dazu und benütze diese Flüssigkeit, um täglich Einspritzungen in die Scheide zu machen. * * * * * Gegen Verstopfung, Migräne, sowie Gallendrang nehme man drei von Lydia E. Pinkham's Leberpillen die erste Nacht, zwei die zweite Nacht und eine die dritte Nacht; tritt auch dann noch kein regelmä�iger Stuhlgang ein, so nehme man eine Pille jede Nacht soweit der Vorrath reicht. * * * * * Befindet sich das Blut in schlechtem Zustande und ist der Patient immer müde, abgemagert und angegriffen, und leidet er dazu noch an Appetitmangel, so benütze er Lydia E. Pinkham's Blood Purifier (Blut-Reiniger), das beste Mittel auf der Welt für diesen Zweck. Dreimal im Tage ein E�löffel voll heilt zuverlässig alle Fälle von Rheumatismus, Skropheln, Hautausschläge, &c. &c. In allen Apotheken zu haben. Hergestellt von der LYDIA E. PINKHAM MEDICINE COMPANY, =Lynn, Mass., V. S. von A.= Read the following TESTIMONIALS. Dear Mrs. Pinkham: I wish all women suffering from female troubles might know what you have done for me. A year ago last June I was very sick, and on examination my physician said I had Polypus of the womb and that I would not stop flowing until I had an operation. I always had a horror of operations and could not bear the thoughts of having one, as I am a nervous person. I wrote to you and followed all your directions faithfully, and all the while I prayed that I might not have to have one. At that time I could hardly walk across the floor and I was pale and thin. Now I weigh one hundred and thirty-five pounds, do all my work, and my husband and children say that I am growing young. I am still taking your medicine and will do so until after the turn of life. MRS. NELSON BAVIER, West Hartford, Conn. Dear Mrs. Pinkham: I suffered for over three years with female weakness brought on by falling on an icy pavement. I had frequent backache and fearful headaches, blinding me with pain. I also had intense pains at the menstrual period. My family physician prescribed several remedies, but although he was considered an excellent physician, he was unable to relieve me. A cousin who visited me had a bottle of Lydia E. Pinkham's Vegetable Compound with her and spoke so highly of its efficacy that I took a few doses of it. I was pleased and surprised to find that it seemed to relieve my pains in twenty-four hours. I took it regularly, and within twenty-four hours more I felt like a different woman, and two weeks continued use of it restored me to health and strength such as I had not known in years. I consider Lydia E. Pinkham's Vegetable Compound the only medicine on the market which is reliable for the ills of the sex. MISS MAUD BELL, 408 Lanwee West, Lansing, Mich. Grand Recorder, Daughters of American Independence. September 22, 1902. I would like to have your advice as I am a married woman and would be pleased to have children. I cannot tell what is the trouble, but I lose them and I am as careful as I can be. It happens just when I am on the fourth month. I have just had my third miscarriage and been flowing over two weeks and have much pain in back and womb. My menstruation is very painful and some months I have it twice. My stomach bothers me. I suffer with indigestion and dyspepsia. MRS. FRANK WILCOX. August 25, 1903. I will let you know that I have a son, and if it had not been for Lydia E. Pinkham's Vegetable Compound I would not have my baby. Your medicine kept me well until the last minute. I did not know what an ache was. I used fourteen bottles of the Compound and three boxes of your Liver Pills. I cannot thank your medicine too much as it has done me more good than the doctors. MRS. FRANK WILCOX. 43 Orange St., Bloomfield, N. J. June 26, 1903. I have been a sufferer for seven years with womb trouble, ever since my child was born. My doctor says my ovaries are affected also and will have to be taken out. I suffer with pains in my back and left side and at times cannot rest day or night. I have leucorrhoea and menstruation is very irregular and very free with a good deal of pain. I was told to write you for advice. MRS. J. D. CURTIS. September 25, 1903. I am still taking Lydia E. Pinkham's Vegetable Compound and have improved wonderfully, have gained ten pounds and feel like a new woman. I will recommend your medicine to all women suffering from female trouble for it has done me more good than the doctors have for three years. You are perfectly welcome to use my name and statement for the good of others for everyone ought to know of your wonderful medicine. MRS. J. D. CURTIS, Box 262, Monaca, Pa. January 15, 1901. I was reading to-day in a paper of the recovery of a lady after writing to you and as her case seemed to be very much the same as mine, I was impressed with the desire to write to you to see if I could not get relief. I am the mother of two children and have never had any weakness of any kind until the past year. I am pregnant at present, my back pains me nearly all the time and left side of abdomen. My back pains so sometimes I cannot stand on my feet or straighten up. My appetite is poor and my friends tell me I look badly. I hope that you will be able to give me some advice. MRS. D. D. EDDY. June 27, 1903. About one year and a half ago, I wrote you in regard to my taking your medicine. I was pregnant at the time and in perfect misery. I suffered everything. You very kindly wrote to me advising your Lydia E. Pinkham's Vegetable Compound which I began to take at once and when my baby was born, I was sick only half an hour and the sixth day I was upon my feet and felt as well and strong as I ever felt in my life. My baby is a strong healthy boy. I wish to thank you from the bottom of my heart for your kind letter to me. Lydia E. Pinkham's Vegetable Compound is the grandest medicine in the world for women. I shall recommend it as long as I live. MRS. D. D. EDDY, 243 East Ave., Saratoga Springs, N.Y. Dear Mrs. Pinkham: I am very grateful for the good Lydia Pinkham's Vegetable Compound did for me. I began using it when I thought there was no help for me and that I would be an invalid for life. The doctor said that I would not get well unless I underwent an operation for ovarian and female difficulties. I was afraid that my health would not stand the strain and so when a friend who was similarly afflicted told me of the good Lydia Pinkham's Vegetable Compound did her, I immediately began to use it and I am glad that I did so, for in less than four months I could report as she did a perfect cure. Words fail to express my thankfulness. Very truly yours, MARGRITE RYAN, Hotel English, Indianapolis, Ind. Treasurer St. Andrews Society. Dear Mrs. Pinkham: Last Spring my health seemed gradually to decline, until I finally felt so weak I thought I would have to give up entirely. I lost my appetite, had headaches, and bearing down pains with cramps so that I was in perfect misery. I became wakeful and extremely nervous. Reading of the value of Lydia E. Pinkham's Vegetable Compound in our paper here, I decided to try it, and am pleased to state that I derived immediate benefit, and soon enjoyed permanent relief. Within eight weeks I was restored to normal health, and felt refreshed and strengthened as though I had enjoyed a lengthy vacation. Since that time I have recommended your Compound to a number of my lady friends suffering with female irregularities, and those who have used it report great benefit from its use. MRS. E. E. VAN DINTER, 965 College Ave., Appleton, Wis. Vice-President Social Economic Club. +Lady on sofa with head obscured by pillows; child sitting on floor crying+ ~Don't~ Don't wait until your suffering have driven you to despair, with your nerves all shattered and your courage gone. Help and happiness surely await you if you accept Mrs. Pinkham's advice. Disease makes women nervous, irritable, and easily annoyed by children and household duties; such women need the counsel and help of a woman who understands the peculiar troubles of her sex; that woman is Mrs. Pinkham, who with that famous medicine, =Lydia E. Pinkham's Vegetable Compound=, has restored thousands upon thousands of sick and discouraged women to health and happiness. Her address is Lynn, Mass., and her advice is free. Write to-day, do not wait. =Will not the volumes of letters from women who have been made strong by Lydia E. Pinkham's Vegetable Compound convince others of the virtues of this great medicine?= =When a medicine has been successful in more than a million cases, is it justice to yourself to say, without trying it, "I do not believe it would help me?"= =Surely you cannot wish to remain weak and sick and discouraged, exhausted with each day's work. If you have some derangement of the feminine organism try Lydia E. Pinkham's Vegetable Compound. It will surely help you.= I am firmly persuaded after eight years experience with Lydia E. Pinkham's Vegetable Compound that it is the safest and best medicine for any suffering woman to use. Immediately after my marriage I found that my health began to fail me. I became weak and pale with severe bearing down pains, fearful headaches and frequent dizzy spells. The doctors prescribed for me and yet I did not improve. I would at times bloat after eating and have frequent vomiting. I had acrid discharge and pains down through my limbs so I could hardly walk. It was as bad a case of female trouble as I have ever known. Lydia E. Pinkham's Vegetable Compound cured me within four months and since that time I have had occasion to recommend it to a number of patients suffering with all forms of female difficulties and I found that while it is considered unprofessional to recommend patent medicines, I could honestly recommend your Vegetable Compound for I have found it cures where other medicines fail. My mother and two sisters have used it also and their health has been restored and their strength renewed. It is a grand medicine for sick women. MRS. MARTHA POHLMAN, 55 Chester Ave., Newark, N. J. Graduate nurse from Blockley Training School at Philadelphia and for 6-1/2 years the chief clinic nurse at the Philadelphia Hospital. March 31, 1902. Lydia E. Pinkham's Vegetable Compound has done me a great deal of good. When I first had my monthly period I suffered very much. I would have such headaches, also pain in abdomen and side. Was not able to go to school. After taking several bottles of your medicine I was relieved of my trouble and I am now well and enjoying good health. MISS MARY E. ROGERS, Kipton, Ohio. October 8, 1901. It gives me great pleasure to tell what your Vegetable Compound has done for me for the benefit of other suffering women. I would have been a total wreck and probably not living to-day had I not taken your medicine. My legs were so stiff and my back so sore that I could not be on my feet and at times I would have the sick headache so bad that I did not know what I was doing. I also had leucorrhoea all the time which caused me to feel very weak. I lost in flesh until I weighed only ninety-eight pounds. I was unable to carry babe to maturity. My first child being born in seven months. Since taking your medicine I have had two little girls which are pictures of health and which I owe to Lydia E. Pinkham's Vegetable Compound. I have taken twelve bottles of the Vegetable Compound, used one box of Liver Pills which I found excellent to regulate the bowels. I am now in good health and weigh one hundred and twenty-five pounds. I cannot praise your medicine enough for the benefit I have derived from its use. What a blessing it is that women can consult with a lady and if every woman feels as I do, they would all consult you far and near. MRS. NELSON F. SPANGLER, Center Oak, Pa. April 18, 1901 I will now write you a letter of gratitude for what your medicine has done for me. I suffered with very painful menstruation and could not become pregnant which was my great desire. I began the use of your medicine and after taking sixteen bottles I found myself pregnant. I continued the use of your Vegetable Compound and felt well all the time. Last October my baby was born, it was a girl and weighed eleven and one-half pounds. It is my belief that I would never have had my baby if I had not used your medicine. I recommend Lydia E. Pinkham's Vegetable Compound to all, believing there is no better medicine for women. MRS. CHAS. ROHDE, 621 Vine Street, Peoria, Ill. I have intended for some time to write to you and tell you what Lydia E. Pinkham's Vegetable Compound has done for me. I had been feeling weak and nervous, very easily tired and had much backache. I took two bottles of your Compound and felt so much better that I enjoyed, instead of dreading my household duties. I can and do gladly recommend your medicines to anyone suffering from female troubles. MRS. M. E. SHEPLER, 17 Amesbury Place, Cleveland, Ohio. Household Cares +Top right: Lady sitting in chair with large broom in the backgroud; Bottom left: Lady standing with forefinger on cheek+ A Sick Woman's Devotion to Duty is a Heroism which a Well Person Cannot Understand. How distressing to see a woman struggling with her daily round of household duties, when her back and head are aching, and every movement brings out a new pain. One day the poor woman is wretched and utterly miserable; in a day or two she is better, and laughs at her fears, thinking there is nothing much the matter after all; but before night the deadly backache reappears, the limbs tremble, the lips twitch--it seems as though all the imps of Satan were clutching her vitals; she "goes to pieces" and is flat on her back. No woman ought to arrive at this terrible state of misery, because these symptoms are a sure forerunner of womb troubles. She must remember that =Lydia E. Pinkham's Vegetable Compound= is almost an infallible cure for all female ills, such as irregularity of periods, which cause weak stomach, sick headache, etc., displacements and inflammation of the womb, or any of the multitude of illnesses which beset the female organism. Read how Mrs. Frake wrote to Mrs. Pinkham when she was in great trouble. Her letter tells the result, and how a cure was effected by the use of Lydia E. Pinkham's Vegetable Compound. _READ THESE LETTERS FROM MRS. FRAKE._ "DEAR MRS. PINKHAM:--I have read of your medicine making so many cures, and have been advised to write to you, but I feel that it is of no use. The doctor says that I have womb trouble, but he does not seem to help me a great deal. I have such a weakness across me most of the time--have backache, am very nervous, and am troubled with leucorrhoea. I am very weak, cannot walk any distance or stand long unless I ache all over. I would like to know it you think your medicine would do me any good."--MRS. SAMUEL FRAKE, Prospect Plains, N.J. "DEAR MRS. PINKHAM:--I cannot thank you enough for what =Lydia E. Pinkham's Vegetable Compound= has done for me. When I first wrote to you I had suffered for years. The doctor said I had congestion of the womb, was troubled with my kidneys and bladder, my back ached dreadfully all the time, and I suffered with bearing-down feeling, could scarcely walk about to do my own housework. I stopped doctoring with the physician and took your medicine, and am now able to do my own work, have no more backache or weakness across me, and can do all my own work. I cannot praise your medicine enough, and would advise all suffering women to try it."--MRS. SAMUEL FRAKE, Prospect Plains, N.J. The Medicine that has Restored a Million Women to Health is Lydia E. Pinkham's Vegetable Compound. June 10, 1901. My daughter sixteen years old, has been in very poor health ever since the change to womanhood a year ago. She had the best of doctors but they did her little good. She complained of feeling tired all the time, did not care for anything, pain in her back, very nervous, poor in flesh and so pale. It made her tired to ride or walk any distance, could not go to school. Some thought she could not live long. Through the use of Lydia E. Pinkham's Vegetable Compound she is now in the best of health. I feel that your medicine saved her life. MRS. ANNA HUGHES, Altmar, N. Y. December 12, 1902. About a month ago I took a very bad cold and it was at time of menstruation and it stopped my menses. I began to have pains in my ovaries and at last I had inflammation of the ovaries and pain in my kidneys and bladder. I got over that but did not flow hardly any. The last time I came around I began to have that pain in my right ovary and it lasted a week and I have been flowing for a week. I would like some advice as I do not know what to think of my case. MISS RUBY MUSHRUSH. July 22, 1903. About three months ago the doctor turned the X-ray on me to see what was the matter and found that I had an abscess near my ovary and in a place that if it had broken would have killed me right away. The doctor's medicine did me no good, so Mama went to the store and got me a bottle of Lydia E. Pinkham's Vegetable Compound. I am now so well that I can work, thanks to your medicine. It has saved me from an operation. MISS RUBY MUSHRUSH, East Chicago, Ind. February 10, 1902. As I have heard and read so much about your medicine, I have decided to write you and tell you my trouble and ask your advice. I am completely run down, am a widow, twenty-five years old, and have one boy five years old. I have never been strong since the birth of my child. Menstruation is irregular and scanty and am always in such distress, pain in lower abdomen and limbs, pain and dizziness in head, cold hands and feet, poor appetite, sick headache, nervous, have leucorrhoea badly, bearing down pains in small of back, pain in both sides, also have catarrh of head and throat. I have had different doctors but they do not help me and I am discouraged. I will be glad to hear from you. Would like to feel well once more. MRS. ANNIE M. WAHL. June 1, 1902. I think it is my duty to let everyone know what Lydia E. Pinkham's Vegetable Compound has done for me. It has made me well and happy. Five months ago I could hardly walk across the room, I was so full of pain. I could scarcely step. I now feel like a new woman. I sleep well and have a good appetite. I used to get such awful sick headache spells, but now I have them no more. Also would be troubled with awful bearing down pain at time of menstruation but have also been relieved of this. I cannot praise your medicine enough. I think it is the best thing made for women. I advise, everyone who suffers with female trouble to try Lydia E. Pinkham's Vegetable Compound. MRS. ANNIE M. WAHL, Bellwood, Blair Co., Pa. October 10, 1901. I think it is my duty to let you know the good that Lydia E. Pinkham's Vegetable Compound has done for me. I think it is the best medicine in the world. I was well until I weaned my baby and then I began to bloat and had bearing down pains. I took to filling up with water in my abdomen. I had the doctor and he said it was abdominal dropsy and that not having menstruation was the cause of it. He said I would have to be tapped. He tapped me once and took eleven quarts of water from me and in a week I began to fill up again and he was waiting to tap me again. I wrote to Mrs. Pinkham and began to take the Vegetable Compound and the water began to leave me. When I had taken two bottles it had all left me and menses appeared. I now feel as well as I ever did and am able to do all my work. I feel very thankful to you. MRS. HATTIE RILEY, Waterford, Ohio. Backache ~MISS PEARL ACKERS.~ The ordinary every-day life of most of our women is a ceaseless treadmill of work. How much harder the daily tasks become when some derangement of the female organs makes every movement painful and keeps the nervous system all unstrung. One day she is wretched and utterly miserable; in a day or two she is better and laughs at her fears, thinking there is nothing much the matter after all; but before night the deadly backache reappears, the limbs tremble, the lips twitch--it seems as though all the imps of Satan were clutching her vitals, she "goes to pieces" and is flat on her back. No woman ought to arrive at this terrible state of misery, because these symptoms are a sure indication of womb diseases, and backache is merely a symptom of more serious trouble. Women should remember that an almost infallible cure for all female ills, such as irregularity of periods, which cause weak stomach, sick headache, etc., displacements and inflammation of the womb, or any of the multitudes of illnesses which beset the female organism may be found in Lydia E. Pinkham's Vegetable Compound =When a medicine has been successful in more than a million cases, why should you say, "I do not believe it will help me?" If you have some derangement of the feminine organism try Lydia E. Pinkham's Vegetable Compound. It will surely help you. If there is anything in your case about which you would like special advice, write freely to Mrs. Pinkham, Lynn, Mass.; her advice is given free and will greatly help you.= "DEAR MRS. PINKHAM:--About two years ago I consulted a physician about my health, which had become so wretched that I was no longer able to be about. I had severe backache, bearing-down pains, pains across the abdomen, was very nervous and irritable, and this trouble grew worse each month. "The physician prescribed for me, but I soon discovered he was unable to help me, and I then decided to try =Lydia E. Pinkham's Vegetable Compound=, and soon found that it was doing me good. My appetite was returning, the pains disappearing, and the general benefits were well marked. "You cannot realize how pleased I was, and after taking the medicine for only three months, I found I was completely cured of my trouble, and have been well and hearty ever since and no more fear of the monthly period, as it now passes without pain to me. Yours very truly, MISS PEARL ACKERS, 327 North Summer St., Nashville, Tenn." March 10, 1902. I now write to tell you what your medicine has done for me. After my first child was born, my womb came down so far that the doctor had to replace it and it was always weak and would never stay in place. A friend told me about Lydia E. Pinkham's Vegetable Compound. I got one bottle of it without any faith at all for I was so bad, I did not think it would do as much good as she said. Well, I took seven bottles and now I am entirely well. I have used the Vegetable Compound right along when pregnant and found it a great help, child-birth being almost painless. I have had four children and have always been able to do my work even the washing until the child was born. It certainly is a wonderful medicine for pregnant women and I would not be without it at that time. MRS. GEORGE GOODCHILD, Port Kennedy, Pa. June 9, 1901. I had falling of the womb and such an aching across my pelvis bone could hardly walk as the least jar hurt so. I was better before I had finished the second bottle and after taking six bottles was entirely cured. I can recommend Lydia E. Pinkham's Vegetable Compound to any one. MRS. ROSA G. BURTON, 1006 Brandywine St., Phila., Pa. August 19, 1902. I take great pleasure in writing to thank you for what Lydia E. Pinkham's Vegetable Compound has done for me. I suffered for years with painful menstruation, pains in the back, leucorrhoea, dizziness and nervous prostration. Since taking your medicine, I feel like a new woman. I never will be without your Vegetable Compound and will recommend it as long as I live. Hoping my testimonial may be of benefit to others, I remain, Yours truly, MRS. MARY BRADY, 1929 Dumaine St., nr. Prieur, New Orleans, La. July 16, 1901 I have been taking Lydia E. Pinkham's Vegetable Compound for the past eight months and it has done me a great deal of good. Before taking it, I suffered with my head and pains in my back and when I had my changes I suffered agony, could hardly stand on my feet. I have taken twelve bottles of the Compound and to-day I am a well woman. I weighed one hundred and twenty pounds before taking it and now I weigh one hundred and forty-five. I keep a laundry and recommend your medicine to my customers. AUGUSTA BLISS, 530 E. 84th St., New York, N. Y. April 29, 1902. I write this letter so that all suffering women may know what your wonderful medicine has done for me. Before I began taking your medicine I was very weak and not able to do anything. I had had a miscarriage and a bad flooding spell and my husband had given up all hopes of my ever getting strong again. Some of my friends told me to try Lydia E. Pinkham's Vegetable Compound. I was in bed at the time. After taking a few doses I began to feel better. I have taken now three bottles and am telling my friends what it has done for me. My husband would not have me do without the medicine. MRS. GEORGE PERRY, Box 52, Fort Gibson, Ind. Ter. June 14, 1901. When I wrote to you for advice a year and a half ago, I was confined to my bed and had just about given up hopes of ever being well again. I had heard so much about Lydia E. Pinkham's Vegetable Compound I told my husband I would like to try it. He got me a bottle and after taking two bottles I was able to get up and walk a little. My trouble was enlargement of the womb, also had ovarian trouble. I had spells of flooding nearly losing my life at monthly periods. Altogether I was sick and discouraged. The pains and aches I suffered I cannot explain. I took seventeen bottles of your Vegetable Compound and was cured. In due time I gave birth to a nice baby girl. My baby is now six months old and so fat and healthy and I am so well, no more female trouble or pain in back. MRS. MAY M. MORGAREIDGE, Mayoworth, Wyo. Fibroid Tumors Cured. A distressing case of Fibroid Tumor, which baffled the skill of Boston doctors. Mrs. Hayes, of Boston, Mass., in the following letter tells how she was cured, after everything else failed, by =Lydia E. Pinkham's Vegetable Compound=. =Mrs. Hayes' First Letter Appealing to Mrs. Pinkham for Help:= "DEAR MRS. PINKHAM--I have been under Boston doctors' treatment for a long time without any relief. They tell me I have a fibroid tumor. I cannot sit down without great pain, and the soreness extends up my spine. I have bearing-down pains both back and front. My abdomen is swollen, and I have had flowing spells for three years. My appetite is not good. I cannot walk or be on my feet for any length of time. "The symptoms of Fibroid Tumor given in your little book accurately describe my case, so I write to you for advice."--(Signed) MRS. E. F. HAYES, 22 Ruggles St., (Roxbury) Boston, Mass. =Note the result of Mrs. Pinkham's advice--although she advised Mrs. Hayes, of Boston, to take her medicine--which she knew would help her--her letter contained a mass of additional instructions as to treatment, all of which helped to bring about the happy result.= "DEAR MRS. PINKHAM--Sometime ago I wrote to you describing my symptoms and asked your advice. You replied, and I followed all your directions carefully, and to-day I am a well woman. "The use of =Lydia E. Pinkham's Vegetable Compound= entirely expelled the tumor and strengthened my whole system. I can walk miles now. "=Lydia E. Pinkham's Vegetable Compound= is worth five dollars a drop. I advise all women who are afflicted with tumors or female trouble of any kind to give it a faithful trial."--(Signed) MRS. E. F. HAYES, 99 Ziegler St., (Roxbury) Boston, Mass. =Mountains of gold could not purchase such testimony--or take the place of the health and happiness which Lydia E. Pinkham's Vegetable Compound brought to Mrs. Hayes.= Woman's Kidney Troubles. Lydia E. Pinkham's Vegetable Compound is Especially Successful in Curing this Fatal Woman's Disease. Of all the diseases known with which the female organism is afflicted, kidney disease is the most fatal. In fact, unless early and correct treatment is applied, the weary patient seldom survives. Being fully aware of this, Mrs. Pinkham, early in her career, gave exhaustive study to the subject, and in producing her great remedy for woman's ills--Lydia E. Pinkham's Vegetable Compound--was careful to see that it contained the correct combination of herbs which was sure to control that fatal disease, woman's kidney troubles. The Vegetable Compound acts in harmony with the laws that govern the entire female system, and while there are many so-called remedies for kidney troubles, Lydia E. Pinkham's Vegetable Compound is the only one especially prepared for women. The following letters will show how marvellously successful it is. Oct. 17, 1901. I have noticed your advertisement in the papers of your wonderful medicine, and I wish to consult you in regard to my sickness. I have been a sufferer of female weakness for the past six months; have doctored a great deal, but it has done me no good. I have _kidney_ and _bladder_ trouble, backache, constipation, headache, terrible pains in my left side, have leucorrhoea, painful menstruation, which compels me to take my bed for two and three days; also have falling of the womb. Blood is very thin. I hope to hear from you soon. MRS. W. N. MATTHEWS, 548 W. Jefferson St., Springfield, Ill. April 15, 1902. I am almost ashamed to acknowledge the receipt of your letter received last Fall. After I had doctored for a year without receiving any relief, I then wrote you for advice in regard to my sickness and began the use of your medicine. I am happy to say that I never felt better in my life than I do now. I can eat hearty, sleep well, and feel like a new woman. Many thanks for your kind and highly appreciated letter. I wish every suffering woman would try Lydia E. Pinkham's Vegetable Compound. MRS. W. N. MATTHEWS, 548 W. Jefferson St., Springfield, Ill. June 15, 1901. It affords me great pleasure to give you my testimony in regard to the value of Lydia E. Pinkham's valuable remedies. I suffered for some time with internal trouble, being at times unable to walk across the floor. I had weakness of the bladder and was very nervous. After taking one bottle Vegetable Compound I felt better. I continued its use, and after taking five bottles could walk two miles without difficulty. My health is now good and I am sixty years old. I think your Vegetable Compound the best medicine I have ever taken. MRS. HENRY GITTELMAN, 1004 N. 6th St., Reading, Pa. June 26, 1901. I will write and let you know how much good Lydia E. Pinkham's Vegetable Compound has done me. I cannot express the terrible suffering I have had to endure. I was taken last May with nervous prostration; also had female trouble, liver, stomach, _kidney_ and _bladder_ trouble. I was in a terrible condition. The doctor attended me for a year, but I kept getting worse. I got so I was not able to do any work. Was confined to my bed most of the time, and thought I would never be able to do anything. People thought I would not live. I decided to try your medicine. I have taken twelve bottles Vegetable Compound and cannot praise it too highly, for I know it will do all and even more than it is recommended to do. I tell every suffering woman about your medicine and urge them to try it. MRS. EMMA SAWYER, Conyers, Ga. ~Change of Life~ A Danger Period Through Which Every Woman Must Pass. Owing to modern methods of living, not one woman in a thousand approaches this perfectly natural change without experiencing a train of very annoying and sometimes painful symptoms. At this period a woman indicates a tendency towards obesity or tumorous growths. Those dreadful hot flashes, sending the blood surging to the heart until it seems ready to burst, and the faint feeling that follows, sometimes with chills, as if the heart were going to stop forever, are only a few of the symptoms of a dangerous nervous trouble. The nerves are crying out for assistance. The cry should be heeded in time. =Lydia E. Pinkham's Vegetable Compound= was prepared to meet the needs of woman's system at this trying period of her life, and all women who use it pass through this trying period with comfort and safety. August 6, 1902. My trouble was Change of Life and cramping. No human tongue can describe what I suffered with the cramp. I dreaded from one time to another so much that I almost wanted to die. Our family physician did everything he could for me, but I got no relief. He said if I lived to get through with the other trouble it would wear away after a time, but I had it six years, and could not walk or exercise in any way without bringing on an attack of the cramp, and I would suffer untold misery until I would be perfectly exhausted and helpless. I read in one of your little books about Lydia E. Pinkham's Vegetable Compound being good for female trouble and Change of Life, and thought there was no harm in trying it. So I did, and it helped me, and I was able to take walks and work some. I am very thankful for the relief your medicine has been to me. MRS. V. M. BLAKE, Deep Water, W. Va. Dear Mrs. Pinkham: I began to dread the approach of Change of Life some years ago, as so many of my friends had been miserable for five or six years during that period and as I was not very strong and being subject to headaches and weakness, I felt that I did not have the strength to carry me through this dangerous period and had it not been for Lydia E. Pinkham's Vegetable Compound, I feel that I would not have been alive to-day. I began to take it about three years ago when I felt the change coming on and continued taking it for three months, then I did not take any for a couple of months, and began to feel so badly that I started to use it again, and then continued to take it for about six months out of every year for three years and am pleased to state that it has kept me free from sickness. Very truly yours, MRS. GEORGE SHEPHERD, Berlin, Wis. Vice-President Mothers' Club. June 28, 1902. I thought I would write and state my condition to you and ask if you think you can do me any good. I am fifty-five years old, never had any children. I came here from Brooklyn for my husband's health, he having consumption. I have always had good health, never any trouble with my menses, always regular until two or three months before my husband died, which was March 25, 1901. As soon as he died, I commenced and flowed constantly ever since. I know it must be the Change of Life. I did not worry about it for four or five months, then I had a doctor but he did me no good. I had another with the same result. Last May I had to go to New York and traveling I think was too much for me as I have been worse. I saw a doctor there and he wanted me to go to the hospital and have my womb curetted, but I did not feel like having that done. I never have any pain only once in a while a little backache. Please let me know if you think you can do me any good. MRS. J. J. REARDON. January 18, 1903. I feel that I must write and thank you for the good you have done me. I wrote to you my case last summer. I flowed constantly for sixteen months so badly that I dared not go any where and the doctors all said an operation. Nothing did me any good. As a last resort I appealed to you. I had no faith in your medicine, but thought I would try it and if it did me no good I would go to the hospital. I took two boxes of the Lydia E. Pinkham's Compound Pills and started on the third and now I am all right. I was run down, nervous, could not sleep, no appetite, but Lydia E. Pinkham's Compound has cured me entirely. I am very grateful to you and wish that everyone afflicted as I was would try it. MRS. J. J. REARDON, Milford, Pa. November 20, 1901. Lydia E. Pinkham's Vegetable Compound did wonders for me during the _Change of Life_. I was troubled with backache and headache, hot flashes and cold chills, pains in my hips, and at times would have such pains under my shoulder blades that I could hardly move for a while. I hope that other suffering women will take your medicine. Many thanks for what you have done for me. MRS. SARAH DERFER, Dundee, Ohio. +Ladies in Profile+ TIRED MOTHERS =A nervous, irritable mother, often on the verge of hysterics, is unfit to care for children; it ruins a child's disposition and reacts upon herself. The trouble between children and= their mothers too often is due to the fact that the mother has some female weakness, and she is entirely unfit to bear the strain upon her nerves that governing a child involves; it is impossible for her to do anything calmly. She cannot help it, as her condition is due to suffering and shattered nerves caused by some derangement of the uterine system with backache, headache, and all kinds of pain, and she is on the verge of nervous prostration. When a mother finds that she cannot be calm and quiet with her children, she may be sure that her condition needs attention, and she cannot do better than to take Lydia E. Pinkham's Vegetable Compound It builds up her system, strengthens her nerves, and enables her to calmly handle a disobedient child without a scene. The children will soon realize the difference, and seeing their mother quiet, will themselves become quiet. _=Read what the Vice-Pres. of the Mothers' Club, at Hot Springs, Ark., says:=_ "DEAR MRS. PINKHAM--=Lydia E. Pinkham's Vegetable Compound= will make every mother well, strong, healthy and happy. I dragged through nine years of miserable existence, worn out with pain and weariness. I then noticed a statement of a woman troubled as I was, and the wonderful results she had obtained from your Compound, and decided to try what it would do for me, and used it for three months. At the end of that time I was a different woman, and the neighbors remarked it, and my husband fell in love with me all over again. It seemed like a new existence. I had been suffering with inflammation and falling of the womb, but your medicine cured that, and built up my entire system, till I was indeed like a new woman."--Sincerely yours, MRS. CHAS. F. BROWN, Vice-Pres. Mothers' Club, Hot Springs, Ark. FREE MEDICAL ADVICE TO WOMEN. =From a vast experience in treating female ills, extending over 20 years, Mrs. Pinkham has gained a knowledge which is of untold value.= =If there is anything in your case about which you would like special advice, write freely to Mrs. Pinkham. Address is Lynn, Mass. Her advice is free, always confidential and helpful.= LYDIA E. PINKHAM'S VEGETABLE COMPOUND +Lady Gazing Upwards+ =Has Cured More Women Than Any Other Medicine in the World.= Its annual sales are greater than those of any other medicine exclusively for women. It holds the record for the greatest number of actual cures of woman's ills. This fact is attested by hundreds of thousands of letters from grateful women which are on file in the Pinkham laboratory, and which are constantly being published. Merit alone can produce such results. Good advertising serves to call attention for a time, but merit alone can stand the test of time. The ablest specialists now agree that Lydia E. Pinkham's Vegetable Compound is the most universally successful remedy for woman's ills known to medicine. All sick women should note these facts, and placing all possible prejudices aside, should realize the truthfulness of these statements, and that a cure for their troubles actually exists. Wise is the woman who has faith in Lydia E. Pinkham's Vegetable Compound, for health and happiness is sure to follow its use. =YOU CAN GET HELPFUL ADVICE FREE.--If there is anything about your illness you do not understand, Mrs. Pinkham, at Lynn, Mass., will be glad to receive a letter from you telling her all the details. She will send you promptly a reply which may save you years of suffering and pain. She has helped thousands of women. For all this she will not charge you a cent; besides, she will keep your letter strictly confidential. Write her to-day.= October 14, 1902. I suffer something terrible with flooding every month and pass large clots of blood. The pains are excruciating. I can hardly stand them. The doctor says my ovaries are decayed and my womb needs to be scraped. I do not wish to go under the operation if I can possibly avoid it. I hope you can relieve me. MRS. MARY DIMMICK. September 16, 1903. After giving Lydia E. Pinkham's wonderful remedies a thorough trial, I am very anxious to send in my testimonial that others may learn of their great value. I have been a great sufferer for the last eight years, the trouble first originating from painful menstruation, and I also had inflammation and ulceration of the womb. The doctor told me I must have an operation or I could not live. I then wrote you telling all my ailments. I followed your advice very carefully and am now entirely well. I can walk miles without an ache or pain and can safely say I owe my life and health to Lydia E. Pinkham's Vegetable Compound. I cannot speak too highly of its merits. My friends all look at me in astonishment, for my case was very serious and it seems almost a miracle that I am cured. I wish suffering women could read this testimonial and realize the value of your remedy. I shall take much pleasure in recommending it to all. MRS. MARY DIMMICK, 59th and E. Capitol St., Benning P. O., Washington, D. C. July 14, 1901. Words cannot express the gratitude I feel towards you for what Lydia E. Pinkham's Vegetable Compound has done for me. My trouble was misplacement of the womb, also womb was lacerated, and had inflammation of the ovaries. I went away for treatment to a specialist on female diseases and passed through twelve operations. Was gone from home eight weeks and gradually grew worse and returned home to die, having given up all hope of ever getting well. My heart would stop beating at times and I became very weak, could not sit up in bed. A friend of mine brought me a bottle of the Vegetable Compound and I began its use and by the time I had taken half a bottle I could see that I had improved. I used in all twelve bottles of the Compound and am now able to do all my house work and enjoy better health than I have in six years. I owe my life to you, for I believe I would have been in my grave to-day had it not been for the Vegetable Compound. Your medicine is a God-send to suffering women. MRS. J. A. JORDAN, Canoe Station, Ga. March 3, 1901. Dear Mrs. Pinkham: I would like some advice from you as I have such very bad pains in ovaries, falling of the womb, and every time I have my monthlys I have the cramps very bad, and seem to be getting worse. I always have it a week and I am so very nervous. I don't want an operation. Every time I become pregnant I carry the child only seven months, and then it is born and lives only a week or two. I have lost four children this way and hope you will tell me what to take as I know you have helped others. MRS. FRED SEYDEL. August 26, 1902. Dear Mrs. Pinkham: Over a year ago I wrote you a letter asking for advice how to carry my babes to full time as I had lost four children between five and seven months. I took Lydia E. Pinkham's Vegetable Compound and did as you instructed me, and now I have a beautiful baby girl about six months old and we are both healthy. I advise all suffering women to call on you for help and I tell every one of the good you have done me. MRS. FRED SEYDEL, 412 N. 54th St., West Phila., Pa. June 13, 1901. Last summer I had terrible pains in my back and head. I went to the doctor and he told me I had a touch of Bright's disease and gave me some medicine but it did me no good. My mother advised me to take some of your medicine, and after taking eight bottles of Lydia E. Pinkham's Vegetable Compound I can say that I am feeling well. MRS. ANNIE DAMBACK. 263 Grand Street, Rahway, N. J. +Ladies with Children+ DYSPEPSIA OF WOMEN =Requires Treatment which acts in Harmony with the Female System.= A great many women suffer with a form of indigestion or dyspepsia which does not seem to yield to ordinary medical treatment. While the symptoms seem to be similar to those of ordinary indigestion, yet the medicines universally prescribed do not seem to restore the patient's normal condition. =Mrs. Pinkham= claims that there is a kind of dyspepsia that is caused by derangement of the female organism, and which while it causes disturbance similar to ordinary indigestion cannot be relieved without a medicine which not only acts as a stomach tonic, but has peculiar utero-tonic effects as well; in other words, a derangement of the female organs may have such a disturbing effect upon a woman's whole system as to cause serious indigestion and dyspepsia, and it cannot be relieved without curing the original cause of the trouble, which seems to find its source in the pelvic organs. As proof of this theory, we call attention to the letter from Mrs. Maggie Wright, who was completely cured by the use of Lydia E. Pinkham's Vegetable Compound. "MY DEAR MRS. PINKHAM--For two years I suffered more or less with dyspepsia, which so degenerated my entire system that I was unfit to properly attend to my daily duties. I felt weak and nervous, and nothing I ate tasted good or felt comfortable in my stomach. I tried several dyspeptic cures, but nothing seemed to help me permanently. I decided to give =Lydia E. Pinkham's Vegetable Compound= a trial, and was happily surprised to find that it acted like a fine tonic, and in a few days I began to enjoy and properly digest my food. My recovery was rapid, and in five weeks I was a different woman. Seven bottles completely cured me, and a dozen or more of my friends have used it since."--MRS. MAGGIE WRIGHT, 12 Van Voorhis St., Brooklyn, New York. =Many women were utterly discouraged, and life lacked all joy to them when they wrote Mrs. Pinkham, Lynn, Mass. They received advice which made them strong women again.= +Lady sitting in chair with elbow on table and hand propped on chin+ THE BLUES =Don't Wait Until Your Sufferings Have Driven You To Despair, With Your Nerves All Shattered and Your Courage Gone.= When a cheerful, brave, light-hearted woman is suddenly plunged into that perfection of misery, the BLUES, it is a sad picture. It is usually this way: She has been feeling "out of sorts" for some time; head has ached, and back also; has slept poorly, been quite nervous, and nearly fainted once or twice; head dizzy, and heart beats very fast; then that bearing-down feeling. Her doctor says: "Cheer up; you have dyspepsia; you will be all right soon." But she does not get "all right." She grows worse day by day, till all at once she realizes that a distressing female complaint is established. Her doctor has made a mistake. She has lost faith in him; hope vanishes; then comes the brooding, morbid, melancholy, everlasting BLUES. =Lydia E. Pinkham's Vegetable Compound= instantly asserts its curative powers in all those peculiar ailments of women, and the story recited above is the true experience of hundreds of American women, whose letters of gratitude we constantly publish. =Surely you cannot wish to remain weak, and sick and discouraged, exhausted with each day's work. If you have some derangement of the female organism try the remedy that has restored a million women to health=, Lydia E. Pinkham's Vegetable Compound. "DEAR MRS. PINKHAM--I cheerfully recommended =Lydia E. Pinkham's Vegetable Compound= to my suffering sisters as a perfect medicine for all female derangements. I was troubled with displacement of the womb and other female weakness. Had headache, backache, and such bearing-down pains I could hardly walk across the floor, and was very nervous. A friend advised me to try your medicine, which I did, and after using the first bottle I began to improve. I took in all twelve bottles of Vegetable Compound, one box of Liver Pills, also used the Sanative Wash and was cured, and have no return of my troubles. I am as well now as I ever was. I am more thankful every day for my cure. I know that your medicine will do everything that it is recommended to do for suffering women."--MRS. DORA ANDERSON, North Muskegon, Mich. "DEAR MRS. PINKHAM--I want to tell you what your remedies have done for me. Before taking them I used to have a continuous headache, would be very dizzy, would have spells when everything seemed strange, and I would not know where I was. I went to our local doctor. He gave me some medicine, but it did not seem to do me any good, but after taking =Lydia E. Pinkham's Vegetable Compound=, I began to improve at once. I can honestly recommend your remedies to all suffering women and advise all to give it a trial."--MRS. HENRY SELL, Van Wyck, Wash. FREE MEDICAL ADVICE TO WOMEN. =If there is anything in your case about which you would like special advice, write freely to Mrs Pinkham. She will hold your letter in strict confidence.= IN THE TREATMENT OF FEMALE TROUBLES Such as Leucorrhoea, and all Inflammation of the Vaginal Passage by local application, experience has proven that nothing excels LYDIA E. PINKHAM'S SANATIVE WASH FOR VAGINAL INJECTIONS. Every woman will find this a most valuable assistant whenever a =Vaginal Injection= is desirable. It is soothing, cleansing and healing. In connection with the VEGETABLE COMPOUND it hastens the cure. We are permitted to publish on this page several testimonials which demonstrate the virtue of the SANATIVE WASH, and should convince every woman that she should place complete reliance on any statement made by Mrs. Pinkham in regard to the virtue and reliability of any of these medicines. DIRECTIONS FOR USING THE SANATIVE WASH. Steep one-fourth of the package in sufficent water to make one pint after it is strained. When the discharge is very profuse, use one-half of this, adding to it one pint of warm water, daily, as a VAGINAL INJECTION. =25 Cents per Package. Sold by Druggists Everywhere.= Sanative Wash. I feel that I neglect a duty in not writing you that others may know what your Vegetable Compound has done for me. Before taking it I was almost an invalid, could not walk any distance and suffered pain all the time. After taking nine bottles I was very much better, and can now do my house work and ride a wheel. It would take too much space to tell you all of its merits but I must not forget to speak of the Sanative Wash for it simply acts like magic. Trusting that this may help some other sufferer, I remain. Yours truly, MRS. A. C. SAXTON, Port Jefferson, N. Y. Sanative Wash. It affords me great pleasure to tell you of the benefit I have derived from taking your Vegetable Compound and Sanative Wash. I can hardly find words to express my gratitude to you for the boon which you have offered suffering women in your excellent remedies. Before taking your Compound I was thin, sallow and nervous. I was troubled with leucorrhoea, and my menstrual periods were very irregular. I tried three physicians and gradually grew worse. About a year ago I was advised by a friend to try your Sanative Wash and Vegetable Compound, which I did. After using your Vegetable Compound and Sanative Wash I am now enjoying better health than I ever did, and attribute the same to your wonderful remedies. I cannot find words to express What a godsend your remedies have been to me. Whenever I begin to feel nervous and ill, I know I have a never failing physician at hand. It would afford me pleasure to know that my words have directed my suffering sisters to the road to health and strength through your most excellent remedies. I thank you again for what your remedies have done for me. MISS MARY SACHNER, 205 E. Town St., Columbus, Ohio. Sanative Wash. I am glad to state that through the use of your Vegetable Compound and Sanative Wash, etc., I am cured from the worst form of female weakness. I was troubled very much with leucorrhoea, bearingdown pains and backache. It seemed that I had no strength at all. I was in pain all over. I began to feel better after taking the first dose of Vegetable Compound, and am now like a new woman. I know if other suffering women would only try it, it would help them. MRS. GEORGE. W. SHEPARD, Box 127, Boonville, N. Y. LYDIA E. PINKHAM'S BLOOD PURIFIER Is far superior to any other known Remedy for the Cure of all Diseases arising from Impurities of the Blood, such as Scrofula, Cancerous Humor, Erysipelas, Rheumatism, Canker, Salt Rheum and Skin Diseases. IMPURE BLOOD CAN BE MADE RICH AND PURE. There is no condition of the human system so uncertain or so deceptive as the condition of the blood. Other disease makes itself known by aches or appearance, but the blood courses on with no sign of vitiation, carrying its poison to every nerve and fibre of the body. Suddenly comes the awakening; pains that were never thought of before, ulcers or eruptions where never a pimple existed, make you ask in wonder, if not in agony, the cause. This effect may come in various ways, but the cause is always impure blood. This impurity or blood poisoning produces _Rheumatism_, _Debility_, _Neuralgia_, _Scrofula_, _Mercurial or Syphilitic Ulcers_, _Fistula_, _Eruptions_, _Consumption_, _Scurvy_, _&c._ INDIGESTION AND BILIOUSNESS. These two complaints are closely akin and generally exist together. _Dyspepsia, or Chronic Indigestion_, is more prevalent in this country than anywhere else on the face of the earth, the chief reason being that we eat with intemperate haste, and consequently do not, as a rule, properly masticate our food. The work that should be done by the dental mill we remit to the stomach; and, as it cannot accomplish the task, the _food-grist_ is not properly ground up and applied, and the whole body--aye, every fibre and tissue of it--suffers. We need not here describe the pains and penalties of _Dyspepsia_. They are within the personal experience of two-thirds of the adult population of the United States. _Biliousness_ is a somewhat indefinite term, but it means, in its common acceptation, an _unnatural determination of bile to the channels of circulation_. The yellow tinge of the skin and of the white of the eyes in bilious cases is caused by the undue presence of bile in the superficial blood-vessels. A proper course of Lydia E. Pinkham's Blood Purifier, together with her celebrated Liver Pills, will purify the blood and drive off the bile, making you happy and pleasant, instead of grouty and disagreeable. LYDIA E. PINKHAM'S BLOOD PURIFIER Is as great a success as her celebrated Vegetable Compound, and may be used with great benefit in all diseases caused by impurities of the blood. Do not class it with bitters of any kind. It is not a drink or an appetizer, but a _strictly medicinal preparation_. It is a powerful alterative, but a purely vegetable preparation, and may be taken without fear by any invalid. The dose is small and with good nutritious diet of any kind, avoiding highly seasoned or greasy food, you will be free from the tortures of rheumatism, clear of scrofulous sores or ulcers, and eradicate every taint, whether inherited or contracted. You will have a beautiful complexion and a soft, smooth skin, and rejoice in a healthy body and pure blood. =For Sale by your Druggist, $1.00 per bottle.= Sept. 15, 1902. I feel it my duty to send you a testimonial and tell you how much good Lydia E. Pinkham's Vegetable Compound and Blood Purifier has done my daughter. She feels like a different person. Her menstruation was irregular; did not come around for two months. She took some medicine from the doctor which did not help her, and he thought she would have to take treatments. She took some of your Vegetable Compound and now her menses are regular again and she rests well nights, which she had not been able to do for about a year. Her friends all wonder at her improved looks as well as health. I never fail to recommend your medicine when I know of any woman who has female troubles. MRS. MAGDALENA SCHICK, Washington, Ill. Jan. 21, 1902. I will tell you what your remedy has done for me. I was in a very bad condition with scrofula swellings around my neck. It started with a bunch on the side of my neck, and it kept growing until the whole side of my face was swollen. I had tried everything in the shape of patent medicines for five years. I had gone under an operation in one of the hospitals in Boston and had them cut out. I had thirty little tubular glands taken from back of my ear down my shoulder. They looked like a bunch of grapes, and about the same size. After the cuts healed over they started to come again worse than before. After suffering so much I thought I would try Lydia E. Pinkham's Blood Purifier, and before I had taken two bottles there was a great change in the swellings. I continued its use and to-day I am a well woman. Every word of this is true. I cannot speak too highly in praise of your Blood Purifier. MRS. W. H. HAYNES, 38 Adams Ave., Everett, Mass. Lydia E. Pinkham's Liver Pills Are especially adapted to the needs of the stomach and liver, the derangement of which they prevent and cure. They are purely vegetable and perfectly harmless. They do not purge, gripe or weaken, but are a gentle effective laxative which stimulates the natural action of the bowels. They are excellent in conjunction with the Vegetable Compound; especially in those cases when the complaints that are peculiar to women are attended with constipation and sluggishness of the liver. In such cases these Pills enable the Vegetable Compound to do its work more speedily and effectively. The enormous sale of Lydia E. Pinkham's Liver Pills has been attained purely on their merit. During the last 25 years, we have found nothing to excel them. One box contains more than three times the number of pills ordinarily sold for 25 cents and we therefor justly claim superiority both in quantity and quality. January 12, 1901. I write you these few lines to see if you can suggest some means to cure me. A little more than a year ago, I was sick with menstruation for the first time and since then I am sick all the time in some way or other. I have painful and irregular menstruation. I went to summer resorts for my health and was doctored all summer, but to no effect. I have not flowed for two months and thought I would see if you could do me any good. MARION BARBER. May 25, 1903. About two years ago I wrote to you for advice, being troubled with irregular menstruation and womb disease. I began taking Lydia E. Pinkham's Vegetable Compound and Liver Pills and using the Sanative Wash and I am glad to say I am completely cured and have not had any sickness since. I wish to thank you for your kind advice and shall recommend your medicine to my lady friends. MARION BARBER, 101 Bracewell Ave., North Adams, Mass. I am passing through the Change of Life, am suffering from extreme nervousness and depression of spirits, am very constipated and blood impoverished. I have heard so much about Lydia E. Pinkham's Medicine I wish to give it a trial. Please advise me. MRS. ALICE PICKERING, 14 George Street, Providence, R. I. June 29, 1900. Six months ago I wrote to you stating my case. You advised me to take Lydia E. Pinkham's Vegetable Compound, Blood Purifier and Liver Pills. I followed your instructions. I never used anything in my life that benefited me so much. They are wonderful medicines. I cannot say enough in their praise. I know I should have been insane if I had not taken them. MRS. ALICE PICKERING, 14 George Street, Providence, R. I. IMPORTANT When writing to Mrs. Pinkham for advice and counsel, it is highly important that you should answer the following questions: =Is your menstruation regular?= =Is your menstruation profuse?= =Is your menstruation scanty?= =Is your menstruation painful?= =Are you married or single?= =If married, have you borne children?= =Have you any discharge from the vagina other than the courses?= =Have you a free movement of the bowels daily?= =Are you constipated?= =Is your blood in good condition?= Write out plainly all symptoms you do not understand. Be sure of the strictest confidence. Mrs. Pinkham never betrays a trust. You can rely on her help implicitly. Address your letters to "Mrs. Pinkham, Lynn, Mass." A Word of Warning. No other medicine in the world has received such widespread and unqualified endorsement as has Lydia E. Pinkham's Vegetable Compound. No other medicine has such a record of cures of female troubles or such hosts of grateful friends. Do not be persuaded that any other medicine is just as good. Any dealer who asks you to buy something else when you go into his store purposely to buy Lydia E. Pinkham's Vegetable Compound, has no interest in your case. He is merely trying to sell you something on which he can make a larger profit. He does not care whether you get well or not, so long as he can make a little more money out of your sickness. If he wished you well he would, without hesitation, hand you the medicine you ask for, and which he knows is the best woman's medicine in the world. Follow the record of this medicine, and remember that these thousands of cures of women whose letters are constantly printed in this paper were not brought about by "something else," but by =Lydia E. Pinkham's Vegetable Compound, The Great Woman's Remedy for Woman's Ills=. Those women who refuse to accept anything else are rewarded a hundred thousand times, for they get what they want--a cure. Moral--Stick to the medicine that you =know= is Best. =When a medicine has been successful in restoring to health more than a million women, you cannot well say without trying it, "I do not believe it will help me." If you are ill, do not hesitate to get a bottle of Lydia E. Pinkham's Vegetable Compound at once, and write Mrs. Pinkham, Lynn, Mass, U. S. A., for special advice. It is free and helpful, and will cost you nothing.= This entire book copyrighted in 1901 and 1904 by the Lydia E. Pinkham Medicine Co., of Lynn, Mass., U. S. A. All rights reserved and will be protected by law. ~THE HOME OF LYDIA E. PINKHAM'S REMEDIES LYNN, MASS., U. S. A.~ Transcriber's Notes: Passages in italics are indicated by _underscore_. Passages in bold are indicated by =bold=. Illustration captions are indicated by ~caption~. Illustration descriptions added by the transcriber are indicated by +description+. The obstetrical table on page 26 was split in half for this text file. Misprints corrected: "grea" corrected to "great" (page 16) "ryggväkr" corrected to "ryggvärk" (page 38) missing "to" added (page 60) 
34436	----	generously made available by The Internet Archive.) HINTS TO HUSBANDS: A Revelation of THE MAN-MIDWIFE'S MYSTERIES. BY GEORGE MORANT, LATE GRENADIER GUARDS. "Sit you down, And let me wring your heart, for so I shall, If it be made of penetrable stuff; If damned custom have not brazed it so, That it be proof and bulwark against sense." Third Edition, REVISED AND ENLARGED. LONDON: SIMPKIN, MARSHALL, & CO., 4, STATIONERS' HALL COURT. 1857. TO THE HUSBANDS & FATHERS OF THE UNITED KINGDOM, AND TO THOSE HONOURABLE MEN OF THE MEDICAL PROFESSION, WHO REPROBATE AND CONDEMN THE UNNATURAL CUSTOM OF MAN-MIDWIFERY, AS AN OUTRAGE ON THE MODESTY OF WOMEN, AND DEROGATORY TO THEIR OWN VOCATION; AND TO ALL WHO HAVE HEARTS TO FEEL AND COURAGE TO COPE WITH THIS ENORMOUS WRONG, THESE PAGES ARE INSCRIBED BY THE AUTHOR. PREFACE. The two-fold object which we desire to attain in the following pages, and to which we earnestly entreat the attention of our readers, is the exposure and amendment of a vast social evil, which we have reason to believe has, to most reflecting men, become well nigh intolerable. It will be obvious that to bring this evil, with effect, to the bar of public opinion, we must probe it to the very core, and fearlessly unveil and drag into the light its indecent mysteries. In so doing we shall doubtless incur the censures of those easy-going people who agree with the poet that-- "Where ignorance is bliss 'tis folly to be wise;" who, like the bird of the desert, by hiding their heads deem their bodies out of danger; who, dead to all the generous sympathies which elevate man above the brute, would reduce the minds of others to their own dull and dreary level of stolid inanity; of those prudent persons who, closing their eyes to the lightning flash and their ears to the vollied thunder, sneak through the world by any side-path sooner than encounter a difficulty foot to foot and hand to hand; and, without pretending to any extraordinary knowledge of the human heart, we fear, of the majority of those women who have already sacrificed their modesty at the altar of custom; and, above all, of that class whose presumptuous charlatanism we desire to lay bare. But for all this we care not one jot, provided the mists of imposture be dispelled, and our countrywomen rescued from the disgrace and degradation of an odious system, which, originating in a dissolute age, has since been promoted and encouraged by self-interested empirics, and sanctioned by indifference, credulity, and error. HINTS TO HUSBANDS, &c. &c. CHAPTER I. "There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy." The practice of _man_-midwifery is one among the noxious weeds which the rank luxuriance of civilization has produced, and since its introduction it has thriven with unrestrained vitality and ever-increasing strength, until at length it spreads its Upas shadow far and wide over our land, and treacherously, mysteriously, and silently distils the poison of its presence deep into the sanctuaries of domestic life. Reader, we will make plain to you the nature and polluting influence of this redundant growth of luxury and vice; and then, with God's help, may you, and tens of thousands of your fellow-men, swear by all things holy, just, and good, that the hallowed purity of home shall never more be blighted by its deadly shade. We are accustomed to speak of ourselves as of a highly moral people; and of our manners, habits, and customs as superior to those of other nations; and of our capital as the most civilized city in the world; "But these are the days of advance, the works of the men of mind, When who but a fool would have faith in a tradesman's ware or his word? When the poor are hovell'd and hustled together, each sex like swine, When only the ledger lives, and when only not all men lie; When chalk, and alum, and plaster are sold to the poor for bread, And the spirit of murder works in the very means of life. And sleep must lie down armed, for the villanous centre-bits Grind on the wakeful ear in the hush of the moonless nights. While another is cheating the sick of a few last gasps as he sits, To pestle a poison'd poison behind his crimsoned lights." Oh, but, say you, these are not flaws in the crystal, but mere specks upon the mirror, which a little careful polishing may remove with ease. See the propriety, order, and decency of our households; our noble sense of justice, right, and honour; our strict observance of religious duties; the chaste and modest demeanour of our women; and beholding these things, who shall say that we are not a moral people? To the unreflecting and casual observer, mere outward semblance would appear to justify and confirm this character of our society. Nevertheless there is, beneath the surface of this seeming health, a loathsome canker, eating into the very vitals of home life![1] and we ourselves are sapping the very foundations of morality, and insulting and outraging the most precious feelings of those whom we should love best and cherish most upon earth, by subjecting them to a usage which first robs them of their birthright, modesty, and then deadens, and finally destroys, all perception of their loss; while "moral England," under the delusion of a falsely termed necessity, endures, and even fosters a pollution, which France, to her honour, now repudiates and abhors! Believing it to be a fact that ninety-nine men in every hundred are ignorant of the extent of the outrages to which their wives submit, when "attended" by a _man_-midwife in their "confinements," we shall, in this essay, endeavour to clear up the mystery which envelopes the proceedings of this class of practitioners, showing by extracts from their own treatises what their "process" is; and having afterwards placed before our readers the opinions and arguments of able and scientific men against such an utter subversion of propriety, we shall, with confidence in the result, leave the question to be decided by the strong voice of public opinion whether this pernicious custom, indecent and degrading as all will admit it to be, shall longer disgrace our country. The spirit of evil, though not, as in Eden, "Squat like a toad, close at the ear of Eve, Assaying by his devilish art to reach The organs of her fancy," yet, under another shape, was still at his old work at the time when,[2] instead of the ordinary midwife, whose presence would have given rise to scandal, a surgeon[3] was summoned to attend the delivery of Mademoiselle de la Valiere, mistress of Louis XIV., for so powerful was the effect of fashion in these dissolute times, that, soon after the first examples had been given by persons whose rank and condition enabled them to brave public opinion, the Parisian ladies of fashion, throwing aside the veil of modesty, which had from the earliest ages, and in all countries, enjoined female attendance, followed the precedent of this abandoned woman, and the practice of _man_-midwifery soon became general in the French capital. The historian well and truly describes the state of society in those evil days, and how the manners of the age became, year by year, more lost to virtue, dignity, and honour, until at length all the better feelings of human nature, even religion itself, became a by-word and a mockery amidst the chaos of the Revolution. "The ante-chambers of Versailles were daily besieged by crowds of titled, yet needy supplicants, who eagerly sought employment, favour, or distinction from the king's ministers or his mistresses, and mandates issued from them were obeyed without a murmur from Calais to the Pyrenees. What, then, was it which, in a country so profusely endowed with the riches of nature, and inhabited by a race of men so brave, so active, and so enterprising, has led to a convulsion attended with the unspeakable horrors of the French Revolution? The answer is to be found in the previous state of the country, and the general perversion of the national mind; in the oppressions to which the people were subjected, the vices by which the nobles alienated them; the corruptions by which morals were contaminated; the errors with which religion was disfigured; the extent to which infidelity had spread."[4] "Corruption, in its worst form, had long tainted the manners of the court as well as the nobility, and poisoned the sources of influence. The favour of royal mistresses, or the intrigues of the court, openly disposed of the highest appointments, both in the army, the church, and the civil service. Since the reign of the Roman emperors, profligacy had never been conducted in so open and undisguised a manner as under Louis XV. and the Regent Orleans. From the secret memoirs of the period, which have now been published, it is manifest that the licentious novels, which at that time disgraced French literature, conveyed a faithful picture of the manners of the age."[5] "It is difficult to treat of this subject (times of Louis XV.) without disclosing particulars at which purity may blush, or on which licentiousness may gloat; but general observations make little impression on the mind even of the most reflecting reader, if not attended with a detail of facts which proves that it is well founded; and one authentic example of the manner of the court and aristocratic circles in Paris, anterior to the Revolution, will produce a stronger conviction than whole chapters of assertion. All that we read in ancient historians, veiled in the decent obscurity of a learned language, of the orgies of the ancient Babylon, was equalled, if not exceeded, by the nocturnal revels of the Regent Orleans, the Cardinal Dubois, and his other licentious associates."[6] Such is a faithful picture of the manners and vices of the age and country in which the custom of man-midwifery took its rise. Here and there a bright star shone out, the brighter for the blackness of that hideous night: men of the highest order of mind did all that great eloquence and vigorous thought could do to stay the strong and turbid current of pollution which threatened to overwhelm the human race, and amongst these great spirits of the past, the physician Roussel, in a work remarkable for the delicacy of its sentiments, the force of its satire, and the strength and power of its language, endeavoured to turn the attention of his countrymen to the indecency of the practice which was first adopted in the harlot De la Valiere's chamber.[7] In some measure he succeeded; but who can wonder if, in that vicious age, his eloquence had passed unheeded, and the delicacy of his sentiments had been scoffed at and derided by the charlatans of the day, in a city where adultery was the fashion, and marriage but a cloak for vice. The causes which then prevented the writings and counsels of these eminent men from taking full effect upon the public mind, no longer exist; and, accordingly, in that very Paris, where, in former times, amidst such scenes of vice and profligacy as the historian describes, the immodest practice originated, has since sprung up an agitation against it, which is increasing day by day. Colleges, both metropolitan and provincial, have long been established for the instruction of _females_ in the obstetric "art," and many of those women, who have been educated in them, possessed such talents and intelligence that the treatises written by them have become the acknowledged text books of the French medical world. Madame Boivin[8] in the dedication of her "Mémorial de l'Art des Accouchements," 4me ed., says:--"Moved and affected by the painful cries which mothers, victims of barbarity and ignorance, caused to be heard from far, the Government hastened to reply to them by establishing a practical School of Midwifery within the Lying-in Hospital: from all parts were summoned, _not men but women_, to come and assist at the lectures of the most eminent professors of surgery and medicine.... Already a great number have, from this fertile source of instruction, derived the knowledge and the qualities necessary for the exercise of an art so important in its results to the population of the kingdom and the happiness of families." In the preface to the above treatise, 4me ed., p. 10, we read the following allusion to the practice on this side the channel; "Thus you will find in this edition some novel remarks ... on certain cases of difficult labour, and on the operative process practised in these cases, so brutally treated by practitioners beyond sea, and in a manner so simple and so happily different by us, especially at the School of Midwifery in Paris." And what are we about in "moral England," all this time? Where are our colleges of instruction, to which we have summoned "_not men but women_"--our _Hospices de la Maternité_,[9] wherein and whereby we may preserve the modesty of our women? Where is the voice to cry shame upon the custom which introduces men into the sacred precincts of the marriage chamber to perform offices which are, by nature, the duty of women alone?[10] Shall it be said that two thousand years ago the Romans possessed a higher sense of moral feeling than we do now? Roussel says, "The principal reason which, among the ancients, forbade the belief that the duty of aiding delivery could be proper to any but women--excepting in cases of very rare occurrence, where every consideration might necessarily yield to a pressing danger--was the grand interest of manners. This was an object to which ancient Governments had always special regard. They knew morality to be the foundation of all legislation, and that good laws would be made in vain unless good morals insured their execution. The cruelty of Archagathus' surgical operations drove the doctors from Rome. She banished also from her bosom the Greek philosophers and orators who were accused of having introduced and cultivated the taste for the arts and vices of Greece. She would surely not have permitted, for any length of time, the existence of an art, which, practised by men, would, under the specious pretence of utility, threaten the sanctuary of marriage, and which, striking a blow at the chief safeguard of families, would next attack the mainsprings of the state; an art which, with power to alarm the modesty of women, would soon leave them without a blush,[11] and cause them to lose even the recollection of that severe virtue which had merited the respect and veneration of the Romans, and which of old had been the principle of the grandest revolutions. Cato, always careful to protect the hearts of the citizens from corruption, would never have permitted their wives, when presenting children to the republic, to tarnish the boon by a forgetfulness of the first of all decencies."[12] "The Greeks," says Dr. Stevens, "invariably employed women; Phanarete, the mother of that distinguished man, Socrates, was a midwife. Hippocrates makes mention of them; and Plato speaks somewhat extensively of midwives, and explains their duties." "We have reason to believe," says Dr. Denman, "that the obstetric art was altogether in the hands of women, _the natural delicacy of females having reluctant recourse to the professional aid of the other sex_." Hecquet says, "The Greeks, moreover, had their female physicians, as we perceive by the words [Greek: akestrides] and [Greek: eatrinai], which have been preserved to us." "Such was the chasteness of the times, that lithotomy on the female subject was practised by one of their own sex. At Athens the positive enactments of the land were inefficient to overcome their scrupulous modesty. It is said the Athenian doctors procured a legal enactment transferring the practice of midwifery to themselves; but at the very attempt the women rose _en masse_, and declared _they would die rather than submit to such an outrage_ upon common decency.... The Romans[13] also employed women only. Pliny, in his _Natural History_, speaks of midwives,[14] explains their duties, and mentions some of great reputation. According to Roman law, midwives were recognized as a distinct class in society, and enjoyed certain rights and immunities in common with the medical profession."[15] We have shown, on the testimony of medical writers, that the practice of _man_-midwifery was introduced in France, or rather in Paris, for it was never generally adopted in the provinces,[16] so early as the end of the seventeenth century; but more than a hundred years elapsed before the unnatural and debasing custom became fashionable in England: and we find that late in the eighteenth century it was considered so objectionable, that few persons, excepting in those rare cases where danger was imminent, ever permitted "a medical man" to usurp the duties of the midwife: and it is only within the last fifty years that _man_-midwifery has prevailed in these kingdoms. Indeed Dr. Ramsbotham, in 1845, in the preface to his work on obstetric medicine and surgery, alludes to the difficulty which it would appear had not even then been entirely got rid of, in overcoming the very natural aversion of women to the regulations of midwifery practice as laid down in the many swollen and prurient treatises on the "pretended art." Nothing appears more extraordinary, or more opposed to all our preconceived notions of propriety, than that this _man_ should bustle into the marriage chamber, our holy of holies, with so much privileged assurance, and that the world should look upon the affair with such perfect indifference. But we suppose that his presence is a necessary evil, and the whole proceeding quite a matter of course, in which "sensible people" see no harm whatever; _honi soit qui mal y pense_. Some such train of ideas may have been suggested by the arrival of Dr. A. B. or C., M.D. and accoucheur, whom you, perhaps, still young in the world's ways, have summoned, you know not why, but that you had been told, it may be by your wife's mother, that it was absolutely necessary to engage a fashionable "ladies' doctor" to "attend" your first born's introduction into the world; in fact, you began to have grave doubts whether it would be possible for the child to arrive without the doctor; (you may have since ascertained, much to the chagrin of A. B. or C., M.D. and accoucheur, that such an event is not altogether beyond the circle of probabilities.) You have also hired a "month nurse," _recommended by the doctor_ as an experienced and skilful woman, in every way fitted for her office. The critical moment approaches; in a state of nervous excitement and anxiety you are advised to retire to the drawing-room, which, like a fool, you do. From time to time you are assured that all is going on as well as possible, and at length you are gratified by the intelligence that you are a father. You are, of course, utterly ignorant of all that has been done, what the nurse's share of duty may have been, and what the doctor's, although you have perchance a sort of vague and undefined suspicion that you were wrong in leaving all that you held dearest in the hands of a stranger, and that stranger a _man_, at a moment when she, the loved one, required your presence to comfort, console, and strengthen her in the hour of trial. Nor would your ignorance be enlightened, unless, as we did after years of credulity and miserable evasion, you catechise the doctor. Then will break upon you, in all their horrible reality, the indignities to which you have subjected her for whom you would have given life itself, the purest of the pure, the idol of your love, the very essence of your being, your heart of hearts! Then, indeed, will you repent, when it is all too late, your folly in trusting to the candour of Dr. A. B. or C., M.D., and the actual crime which you have committed in not acquainting yourself, _while there was yet time to prevent it_, with the "process" by which the _man_-midwife pretends to improve upon the all-powerful machinery of nature, and the infinite wisdom of nature's God. In the bitterness of your thoughts you may, perhaps, venture to question the doctor's mode of proceeding, upon the supposition that the nurse, having been recommended by him as a skilful and competent person, should alone have _actively_[17] interfered, when you may be truculently told that he was not there "only to stand by and make reports;" or that "an accoucheur is not necessarily an old woman;" that "there are no feelings;"[18] that "the first thing he always does, when he comes to the bed-side, is to make _an examination per vaginam_!" with other observations equally harrowing to the sensibilities of a husband. What shock so terrible to a man who, rejoicing in the delightful sentiment of a wife's purity, discovers that all he held dearest and most sacred, all which he would shield from profanation with the last drop of his life's blood, has been invaded by the presence, and _violated by the actual contact_ of the _man_-midwife? The doctor may be a sober, discreet, oily man, of staid appearance, and a very pattern of propriety; or he may be a vulgar, low-bred person, in his leisure consorting with those of a similar bent; or "Yonder a vile physician, blabbing The case of his patient...;" or he may be a tippling, jovial fellow, who at some roystering party is always called on for "a good song," sure to have as its theme wine, love, and woman,--for accoucheurs are mortals like other men; or he may be some tyro in "the art," just let loose from his course of walking the hospitals, strong in syphilitic cases, and with all the recollections of a young surgeon's life fresh upon him: nevertheless, whatever he be, _the very inmost secrets of your wife's person_ are known to him,[19] the veil of modesty has been rudely torn aside, and the sanctity of marriage exists but in the name. ----"Such an act, That blurs the grace and blush of modesty; Calls virtue hypocrite; takes off the rose From the fair forehead of an innocent love, And sets a blister there; makes marriage vows As false as dicer's oaths: oh, such a deed, As from the body of contraction plucks The very soul, and sweet religion makes A rhapsody of words: heaven's face doth glow; Yea this solidity and compound mass, With tristful visage as against the doom, Is thought-sick at the act." CHAPTER II. "O shame! where is thy blush?" It now becomes our most painful but necessary task to explain what that "process" is to which we have alluded, by giving some extracts from one of the principal works on midwifery, and in the very words of the treatise, to prove the gross outrages to which women are obliged to submit when "attended" by these male practitioners. Nothing but a sense of the enormity of this monster evil would induce us to contaminate our pages by the introduction of such garbage; but we are well aware that "general observations make little impression on the mind even of the most reflecting reader, if not attended with a detail of facts which proves that it is well founded; and one authentic example will produce a stronger conviction than whole chapters of assertion." EXTRACTS FROM DR. RAMSBOTHAM'S OBSTETRIC MEDICINE AND SURGERY. "_Duties of the Medical Attendant under Natural Labour._ "From the knowledge which the foregoing pages will afford of the beneficence displayed by nature throughout the processes of utero-gestation and labour, and of the admirable contrivances adopted by her to overcome difficulties and avert dangers, it will be evident that, in a very large proportion of cases, the duties of the obstetrician must be few and simple. Generally, indeed, no _active_ assistance is necessary, until after the birth of the child; all that is required of the attendant being, that he should remain an observant, though unofficious spectator of the process, ready to exert himself with promptitude and energy on the first accession of any alarming symptoms, but equally or more ready to allow the changes necessary for the completion of nature's object to proceed, uninterrupted by any meddlesome interference; for no maxim in obstetric science is of more universal application than that unnecessary 'assistance,' rendered with a view of expediting the termination of the case, or shortening the sufferings of the patient, is not only useless, but in the highest degree injurious, and directly calculated to defeat its own end. "Let it not be supposed this declaration includes the admission, that a partial acquaintance with the obstetric branch of medicine is sufficient for the safe practice of the profession; for although, in thirty-nine cases out of forty, little is required to be done beyond protecting the extended structures from injury, separating the child, and extracting the placenta from the vagina after its total exclusion from the uterine cavity; still, in the fortieth danger may occur, only to be arrested by the promptest, the most decisive, and most judiciously directed help. "Much knowledge[20] is necessary to discriminate the kind of cases in which assistance is proper, and determine the time at which that assistance ought to be employed, as well as the mode of its application. It is this which distinguishes the scientific from the ignorant obstetrician; it is this important knowledge on which the life, the future health and comfort of many a parturient woman must depend; which, nevertheless, has been held in such low estimation by some members of the profession, as to be thought unworthy of cultivation by the scientific and literary mind; unfit to be possessed by men of respectable station in society; and the adaptation of which knowledge to practice has been characterized, in an official document under the seal of the highest of our medical corporate associations, as 'an art foreign to the habits of gentlemen of enlarged academical education.'[21] In the same communication it is asserted, 'that the most successful practice of midwifery requires no such laborious preliminary study as is necessary for the practice of medicine, else discreet matrons, and plain uneducated men in the country, who frequently arrive at great notoriety in this calling, would not acquire that credit which they often attain.'... nor, perhaps, are we generally expected to regulate the number of individuals to be present, though we may be called upon occasionally to exercise our authority in this respect. The only persons whom I would willingly admit are the nurse and some female married friend, the mother, or other near relation, or an intimate acquaintance, to act as _confidante_ to the sufferer, into whose sympathizing ear she may whisper all her apprehensions and distresses, and from whom she may receive those numberless comforts and sustaining consolations of which she stands so eminently in need. Unmarried females are neither the most fit companions for the patient, nor the most useful assistants to the practitioner.[22] "On being ushered into her chamber, we may engage her in some general conversation, which will give us an opportunity of observing the frequency, duration, strength, and character of the pains; and our conduct must be framed according. Should they be of trifling importance, we may content ourselves with giving some ordinary directions and retire from the apartment. But if they are returning with frequency and activity, we must not allow much time to elapse before we require to make an examination PER VAGINAM.[23] An objection may be raised by the patient to the necessary examination being then instituted, under the idea that _no assistance_ can be rendered her so early in the labour. As I would regard the feelings of a parturient woman in a degree only secondary to her safety, I would by no means insist on putting her to this inconvenience, unless I thought it quite indispensable. But as much valuable information may be gained by this first examination, and as it is highly desirable to obtain that information during the progress of the first stage, it is right firmly, but gently, to urge its propriety. It is seldom, indeed, that she will not accede to the recommendation of her medical attendant, provided he possesses her confidence, and conveys his request with becoming delicacy.[24] "Much knowledge must be acquired during the first vaginal examination. It is, first, whether the woman be pregnant;[25] secondly, if she be in labour; thirdly, whether the membranes have ruptured, or are still entire; fourthly, how the child is presenting; fifthly, how far the labour is advanced; and, sixthly, the state of the os uteri, vagina, and perineum, in regard to their distensibility.... She should be also covered by a light counterpane, or a blanket and a sheet. In this position (lying on her left side, with the nates brought to the edge of the bed) _the vaginal examination_ is to be conducted in the following manner:--The attendant, sitting rather behind her, and having anointed the two first fingers of his _right_ hand, with some unctuous substance, mostly in readiness, is to place them on the labia externa; then gently separating these organs, he must introduce the first finger into the vagina,[26] in the direction of its entrance, which is backwards and upwards: or he may take the perineum as his guide, and insinuate his finger within the genital fissure posteriorly, close to the fourchette. Having introduced it as high as he conveniently can, he must pronate his wrist, so that the junction of the first and second finger shall fit in under the symphysis pubis. In this way he will be able usually to reach the os uteri without difficulty. Should that organ, however, be situated so high that he cannot perfectly command it, rather than remain in ignorance of its condition, and of the presentation of the child, he may introduce the first two fingers of his left hand, and as these may be passed higher within the pelvis, they will give a greater facility for inquiry. "These examinations are commonly made during the urgency of pain; and this has given rise to the phrase of 'trying a pain.' It is, however, desirable, on many accounts, that we should not introduce our finger up to the os uteri at the time when the uterus is acting strongly, because then the membranes are protruded into the vagina, and if we press against them at that moment, we may, probably, rupture the cyst, and lose its influence in the after progress of the labour. Besides, it is impossible, under such protrusion, to ascertain the presenting part of the foetus with precision, because of the quantity of water which is then interposed between our finger and its person. "Nevertheless, as it is expected that we should examine while the uterus is in action--and, indeed, as in many cases the patient would not allow us to pass our finger at all, were it not for the belief that we can 'assist' her--and that only in the time of pain, it is necessary that we should request her to inform us when there is a return, and take that opportunity of introducing our finger within the external parts. Having gained this advantage, we must allow it to remain inactive in the vagina while the pain continues; and upon its cessation, which we have seldom any difficulty in ascertaining, we may direct it up to the os uteri. "_Frequent examinations should not be made during the first stage of labour._ "We can do no good by such a practice after we have once gained the information we require. We cannot facilitate the descent of the child; we cannot dilate the parts; but we may do a great deal of injury, for we denude the vagina of that soft relaxing mucus which is designed by nature to protect it; and we, moreover, run the risk of destroying the integrity of the membranous cyst. We may, therefore, predispose the parts to inflammation, and retard the dilatation of the os uteri itself. As, however, it is a common idea among women that, under each examination, material assistance is rendered,[27] we shall frequently be urged, during the first stage, especially if the labour be rather slower than usual, to remain in close attendance on the patient's person; and these solicitations are generally advanced with a degree of fervency, that it appears the extreme of cruelty not to accede to. "Should this be the case, the finger may be introduced from time to time, with the greatest care and gentleness; more to pacify the patient's mind, and assure her she is not neglected, than with any other view beyond that, and also watching the progress of dilatation. The more rigid the parts are, the more do they require the softening influence of the natural secretion, and the more careful must we be to preserve it.... In about an hour ... we may see her again, and we may then, if we think it right, make another examination, to ascertain that the labour is proceeding satisfactorily. _Duties during the Second Stage._ "The second stage of labour having commenced, we are summoned to the patient's room, if we have been absent, and told that 'the waters have broken.' She is most likely found reclining on the bed, and, probably, the pains are more urgent than they were before; or, perhaps, they are somewhat suspended. We now require to make another examination, because it is possible that the head may have fully entered the cavity, and may be soon expelled. Finding it low in the pelvis, finding the os uteri almost entirely dilated, the membranes broken, and the pains strong and coming on frequently, it is right not to leave the room; but unless the perineum is somewhat on the stretch, we need not yet take our post exactly by the bed-side. But as soon as the head has come to press upon the external parts--particularly when it has made its turn, and is beginning to extend the structures at the outlet of the pelvis, it becomes our duty to take our seat by the bed-side, and never to move from our position till the child has passed. This we do to protect the perineum, in order to prevent laceration.[28] "_For the purpose of supporting the perineum_ we sit rather behind the patient, and apply the palm of the left hand--guarded, for the sake of delicacy, cleanliness, and convenience, with a soft napkin--steadily and firmly against the perineal tumour. I have already mentioned that the thighs must be drawn up towards the abdomen, and the legs bent a little back upon the thighs, and the whole person lying on the left side; and the patient is usually placed so that her feet may rest against the bed-post.[29] "We render the shoulders also another fixed point, so as to steady the upper part of the body, by tying a long napkin, or a round towel, to the same bed-post, and desiring her to hold it in her hand. We tell her, when the pain comes on to press with her feet against the bed-post, and pull gently at the towel, cautioning her against straining violently. The consequence is she so fixes her person as to render it almost impossible for her to jump away suddenly, or to recede to any distance from us. Independently of this little manoeuvring, when the head is in any degree extending the vulva the nurse must be required to raise the right knee to some distance from the other, by which means the thighs are separated, and an increased facility given to the exit of the head through the external parts, as well as some control exerted over the patient's movements.... After having examined the uterus through the parietes of the abdomen, we must make an internal examination, more perfectly to assure ourselves in what way the placenta is disposed of. Twisting the funis umbilicalis around the first two fingers of the left hand, and bringing it to its bearing, we pass the first finger of the right hand, previously anointed, into the vagina, as in a common examination. If the placenta be entirely _in utero_, which, as just remarked, is most commonly the case immediately after the child's expulsion, we shall either not be able to touch it at all, or if it be within reach, we shall only detect a very small portion of it; we may just feel it offering itself at the os uteri; but we cannot surround its volume, nor can we probably discover the insertion of the funis. "_Removal of the Placenta._--There is no part of natural labour which requires so much judgment as the conduct of the third stage; for the slightest mismanagement of the placenta may be productive of most serious mischief, by converting a perfectly natural into a most dangerous and complicated case. As long, then, as the placenta remains _in utero_, so long we must wait, within a certain limit--provided there be no flooding--for those contractions which are to expel it from the uterus into the vaginal cavity, &c.; while we are thus watching, we shall most likely be informed of the return of uterine action, by the woman complaining of two or three comparatively trifling pains affecting the back and loins. As it is probable that under these pains the placenta may have somewhat descended, another examination may then be made _per vaginam_ to satisfy ourselves on this point, &c. "The removal of the placenta from the vagina is easily effected. Twisting the funis umbilicalis two or three times around the first and second finger of the right hand, we draw it down in a line tending towards the coccyx, and receive it in the left, placed under the perineum; or we may introduce the two first fingers and the thumb of the left into the vagina, embrace the mass between them, squeeze it as we would a sponge, and slowly extract it.... "Having perfectly satisfied ourselves on this point, we may a second time take away the napkins soiled with the accumulated discharges, and envelope the lower part of the patient's person in others that are warm and dry. Three will be sufficient: one must be partially slid under the left hip; another may be placed over and around the right hip; and the third carried between the thighs, directly on the vulva, &c.... "Some practitioners adapt the bandage themselves, and apply it immediately after the placenta has been removed. I think it preferable, in common cases, to leave this duty to the nurse; and that it should not be put on until the body linen of the patient is shifted; because, in the first place, it appears to me more desirable that perfect quietness should be preserved until the first changes in the uterus consequent upon labour are effected, that no disturbance may interrupt their progress; and, in the second, I cannot help thinking that there is something highly indelicate in its being applied by a man--much more so, indeed, than any of the duties we are ordinarily called upon to perform under natural labour. It is of most service when next the skin. It must be sufficiently broad to reach from the pubes almost to the ensiform cartilage; and it cannot be properly adapted unless the abdomen be quite uncovered. In addition, I would remark that the nurse must know very little of her duties, if she cannot draw a properly contrived bandage round the person, and give it the due degree of tightness without incurring danger." The reader of the preceding extracts will have observed that they begin with a panegyric on the extraordinary powers of nature in adapting means to an end; which, nevertheless, the author forthwith proceeds to qualify, as if he had admitted too much, in giving nature credit for the due execution of her own work, and her capability for enforcing her own laws, by enlarging on the profound and scientific knowledge required in the man-midwife, the opinion expressed by the Royal College of Physicians to the contrary notwithstanding; and in effect impiously detracting the infinite power and wisdom of God, "who created man in his own image, in the image of God created He him; male and female created He them. And God blessed them, and God said unto them, be fruitful and multiply." "And God saw everything that He had made, and behold, it was very good." After descanting on the inutility, and even positively detrimental effects of _active_ interference in natural labour, he warms with his subject, and, in the course of the three stages by which he limits and defines the operations of nature in introducing man into the world, enjoins, in language horribly disgusting from its technical obscenity, an amount of grossly indecent interference, only to be measured by the credulity and endurance of his miserable patient. If the maxim of non-interference which he inculcates holds good, he deceives and wrongs his patient to a most shameful extent, by permitting and encouraging the delusion that by these vaginal examinations he can render her "assistance," or mitigate the sufferings which nature has ordained; and we assert, without fear of contradiction, that the man who should dare to practise upon the weakness of women in such a manner, and at a moment when they are least able to resist his solicitations, deserves the severest condemnation. In all this foul tissue of verbiage descriptive of the practice in natural labour there is nothing which a _female_ attendant of the most ordinary intelligence could not accomplish with the greatest ease, and yet the nurse, who is generally a well instructed midwife, is scarcely mentioned at all, and her duties appear to be confined to a trivial and unimportant after-operation, which the conscientious and sensitive doctor deems an act of far greater indelicacy than those eight times repeated _examinations per vaginam_, and other contact with the patient's person, so sedulously prescribed, and which, in truth, appear to constitute the whole "art," so far as the treatment of natural labour is concerned. One more extract will more than suffice to show the nature of this abuse, which we fear is, from its daily increasing power and influence upon the female mind, becoming more and more difficult of cure; but which, when considered in all its hideous bearings, should arouse even the most callous and indifferent to a sense of its criminality, and cause the hearts of all who reverence modesty in woman to swell with righteous indignation at the insults which a vile custom has mercilessly heaped upon the sex:-- "She now, at length, submitted to an examination _per vaginam_, which I made from behind, as she stood erect by the bed. The finger failed at first to reach the os and cervix uteri, until, on pressing upwards, as far as possible, I found the uterus lying transversely, the os higher than the body, pointing to the right side, and the body of the uterus lodged in the left side of the pelvis, near the groin, where it seemed to be firmly fixed. I now made her kneel on the bed, with the head low, so as to elevate the nates, and cautiously tried through the rectum, as well as _per vaginam_, to raise the uterus from its position into the median line, but without success. An attempt on the following day was with no better result.... After the interval of a month, I made another examination _per vaginam_, also of the nipples, and found no change in either. After the interval of another month I found the nipples and areolæ precisely as at first; but, to my great satisfaction, the uterus had nearly righted itself in position, and the body of it was rounded and plainly enlarged. The lady also hinted a suspicion that she had quickened."... "In this instance my suspicion of pregnancy (which at first was very slight) rested on the interruption of menstruation alone. The health improved from the time of quickening, and the pregnancy went on. I may add that I have no doubt the latero-version of the womb occurred at the period of the miscarriage;... and that its righting itself, at length, was the consequence of its increasing bulk."[30] Such is the practice of man-midwifery! We observe that, in this revolting case, the disgrace, the shame, the infamy of the poor patient was endured in vain, and that after all the tentatives, and "manipulations," and experiments, so perseveringly repeated by the accoucheur, without any beneficial result whatsoever, nature alone was the true physician. We will conclude this chapter of horrors in the strong and earnest language of the late Sir Anthony Carlisle, with the conviction that his burning words will go right home to the hearts of those who may not hitherto have given a thought to this fearful violation of the rights of nature. "The woman who sacrifices her modesty to fashion, her person to indignity, and her husband's honour to the sneers and contempt of her male midwife, is below contempt. She is a disgrace to her sex! "It is my firm opinion that the practice of man-midwifery compromises the character and morality of our country. It is demoralizing to society, an insult to virtuous women, and a foolscap to men. If not checked and abolished, the pretensions to female modesty, and a respect for the decorums of society, will eventually be altogether excluded from the female character." CHAPTER III. "Such devils would pull angels out of heaven, Provided they could reach them; 'tis their pride; And that's the odds 'twixt soul and body-plague! The veriest slave who drops in Cairo's street, Cries, 'Stand off from me,' to the passengers; While these blotched souls are eager to infect, And blow their bad breath in a sister's face, As if they got some ease by it." If the reader views with disgust and horror the above rules of ordinary practice in _man_-midwifery--and what man is base enough (save an accoucheur) not so to regard them?--these feelings will be intensified a thousand-fold by the contemplation of the latest invention[31] of "obstetric art." We allude to the SPECULUM. The adoption of this instrument, as we are informed, is now becoming general; and its employment plunges its wretched victim, woman, down into the lowest deep of infamy and degradation. We will not pollute our pages by describing its method of action; suffice it to say, that, to the sense of _touch_, common to all midwifery practice, is added, in its application, that of _sight_; exposure the most complete of all which modesty, even in the most abject of races, invariably conceals. [Illustration: G. Morant. Inc. THE SPECULUM] In confirmation of our own view of this most villanous invention, we will convict its advocates by the testimony of distinguished members of their own profession. The denunciations of the speculum, by these morally-courageous men, addressed, for the most part, solely to their fellow-practitioners, shall now go forth to be read and pondered on by every reflecting Englishman who may chance to open these pages. "We have already exposed, with our utmost vigour, the improper practice which Drs. Ashwell and Lee so strongly condemned. All we said on that occasion we repeat now.... To employ it (the speculum), as it is rumoured certain persons in London have employed it, to attract notice, and place themselves prominently before the public--to use it merely as a means of personal advancement--in fact, _to gain practice_--is a crime against the laws of morality, and treason against professional honour. "The erroneous and one-sided opinions, which the advocates for the indiscriminate use of the speculum hold, prove how little they have presented to themselves the true facts of the case. Dr. Locock, who made the startling assertion that delicacy ought not to be considered in matters of disease, and was both for and against the speculum, said, that he looked into the vagina as he would into the throat. True enough, so far as _he_ simply is concerned. He would look into the vagina as an ordinary matter of business, and think _only_ of what, in the course of business, it might be necessary to do there. But would the _woman_ regard it in this philosophical light? Is it the same to _her_ whether her tongue is pressed down with a spatula, or her vagina distended with a speculum? Is _her_ moral state to be left out of account altogether, and are we to treat the most sensitive organ in her frame as if it was so much inert matter, whose great use was to be cauterized? "We do not hesitate to say, that no man, who regards properly his science and himself, can ever use this instrument without feeling that he is _driven_ to it; that other means have failed, and that it has become necessary to adopt additional modes of investigation and of cure. And if it appear from the inquiries which will, doubtless, now be made--that the necessities for its employment have been knowingly exaggerated by its advocates, no condemnation can be too severe for so great a breach of scientific honour."--_Medical Times_, 8th June, 1850. "Dr. Marshall Hall describes in the _Lancet_ a new form of hysteria, connected with and caused by the abuse of the speculum. In his preliminary remarks, alluding to the manner in which the charge of indecency was received by one of the speakers at the late meeting of the Medico-Chirurgical Society, on the ground of the non-necessity of the exposure of the person, he says, 'But if there be no exposure of the person, is there, at first, no wounding of the feeling, and is there afterwards no deterioration and blunting of those feelings by the repeated daily or weekly use of the speculum vaginæ in the virgin, and in the very young, even amongst the married?' He declares that there is such deterioration, and that the female who has been subjected to such treatment is not the same person, in delicacy and purity, she was before. Dr. Marshall Hall's declaration on this point is fully confirmed by the results of experience. The consequences of the abuse of this practice are, indeed, lamentable. Dr. Hall says he has known cases of the most revolting attachment on the part of the patients to the practice and the practitioner. The current of the ideas becomes hypochondriacally directed to the organs of generation. The very mind is poisoned. A new and lamentable form of hysteria is induced. The patients become reserved, and moody, and perverse, and speak unintelligibly in broken sentences; the peace and happiness of the family are broken up; subjects are discussed on the domestic hearth which ought never to be mentioned except in the sick room--words which wound are spoken, and thoughts which are derogatory are expressed by others, perhaps by the male, members of the family. Dr. Hall mentions cases in which the speculum has been repeatedly employed, and had induced this sad, wretched state, and yet no uterine disease existed. He believes the cases in which the young, and especially the unmarried, are afflicted, so as really to justify the use of the speculum, to be rare, and the cases in which the injection of a solution of nitrate of silver, by the patient herself, may not take the place of the application of this valuable remedy in substance by the hand of the practitioner, to be rare indeed. We heartily thank Dr. Marshall Hall for this additional blow at 'the pollution.' It is greatly to his credit."--_Medical Times_, 15th June, 1850. "I have no doubt that I was one of a considerable number, who, at the last meeting of the Royal Medical and Chirurgical Society (a meeting which will long be memorable in its annals), wished to express their sentiments on the subject of the use of the speculum vaginæ, without having what they deemed a perfect opportunity. I regret that the discussion was not adjourned to another evening. "I think the profession deeply indebted to Dr. Robert Lee for bringing this question forward for discussion. It is not one of mere medical or surgical treatment, but of medical and public ethics; and I confess myself astonished at the light manner in which a vaginal examination was spoken of by one of the gentlemen present at the Society. I think the challenge of Dr. Bennet should have been accepted at once, and that a committee should have been, and should now be, appointed to test the existence, or the non-existence, of the thousand and one 'ulcers,' or 'abrasions,' of which so much has been said of late. "The gentleman to whom I have alluded above, huffed the idea of indecency in making a vaginal examination. There need be no exposure of the person of the patient. Surgeons make no scruple about an examination of the rectum (as if the two examinations could, morally speaking, be compared). But, if there be no exposure of the person, and if the examination of the rectum be frequently made, is there, at first, no wounding of the feelings? and is there afterwards no deterioration and blunting of those feelings by the repeated daily or weekly use of the speculum vaginæ in the virgin, and in the very young, even amongst the married? I loudly proclaim that there is such deterioration, and that the female who has been subjected to such treatment is not the same person, in delicacy and purity, that she was before. "I have known cases of the most revolting attachment, on the part of such patients, to the practice and to the practitioner. I have known them to speak of the 'womb' and of the 'uterine organs' with a familiarity which was formerly unknown, and which, I trust, will, ere long, be obsolete. The current of the ideas becomes hypochondriacally directed to these organs. The very mind is poisoned. A new and lamentable form of _hysteria_--I had almost said of _furor uterinus_--is induced, with this aggravation, that the subject of distress is either concealed by the greatest effort, or explained at the expense of virgin or female modesty. "There is a case of 'poisoned mind' in the male sex, induced by the quack doings of the day, relative to the existence of impotency, which all of us must have treated and deplored. A similar case of 'mental poisoning' is now being induced in the other sex, by the frequent, constant, and undue reference, on the part of the profession, to the condition of the 'uterine organs.'"... "One poor, miserable patient comes to me weekly, thus afflicted. She has been treated by the speculum and the caustic for months, as an out-patient at University College Hospital. I sent her to Dr. Robert Lee twice. Twice that gentleman examined, and declared that there was _no_ uterine or vaginal disease. Meanwhile the miserable patient's mind is absorbed by this ideal malady, and the peace of her husband's home is destroyed. "I sent another patient to Dr. Robert Lee a few days ago (whom I had never seen) under similar circumstances, but moving in a different rank of life. The same opinion was given, the miserable patient suffering dire disappointment! "I recently attended a poor curate's wife, who had come to London for medical aid, at, as I suppose, great inconvenience. During my short attendance, this patient was constantly urged by a friend, a titled lady (the aristocracy always take the lead in quackery), to send for her physician, who is a strong abettor of the speculum. The course which followed may be imagined, and need not be described. A case of more complicated misery for a husband cannot well be conceived. A sickly wife, afflicted with uterine hypochondriasis, set upon by a titled advocate of the uterine quackery, with straitened resources. "The advocates of the speculum speak of cases which had resisted the efficacy of the usual general and local treatment, and which yielded to the use of the speculum and the caustic. I have seen cases in which, the speculum and caustic having been employed--and unduly employed, as I believe--the patient remained more miserably afflicted in mind and body than ever, and this the effect of that treatment. Whether the former supposition be as well founded as the latter, I will not presume to determine; but I believe the cases in which the young, and especially the unmarried, are afflicted, so as really to justify the use of the speculum, to be rare, and the cases in which the injection of a solution of nitrate of silver, by her own hands, may not take the place of the application of this valuable remedy in substance, by the hand of the practitioner, to be rare indeed. "I will not advert even to the epithets which have been applied to the frequent use of the speculum by our French neighbours, who are so skilled in these matters; but I will ask, WHAT FATHER AMONGST US, AFTER THE DETAILS WHICH I HAVE GIVEN, WOULD ALLOW HIS VIRGIN DAUGHTER TO BE SUBJECTED TO THIS 'POLLUTION'? Let us, then, maintain the spotless dignity of our profession, with its well-deserved character for purity of morals, and throw aside this injurious practice with indignant scorn, remembering that it is not mere exposure of the person, but the dulling of the edge of the virgin modesty, and the degradation of the pure minds of the daughters of England, which are to be avoided." _Dr Marshall Hall in the 'Lancet.'_ Dr. Dickson, an eminent medical reformer, and accomplished surgeon and physician, formerly on the staff, and now, and for many years past, in extensive practice in London, says:-- "But of all the medical quackeries that have sprung up in these times, none can compare with the infamous _speculum_ treatment of certain members of the faculty, who confine their practice principally to females. No matter what may be the woman's real complaint--a cough, pain of the side, or anything else--she is at once assured that it proceeds from 'disease of the womb.' A pretended examination must, forsooth, be gone through, which, in every case, is made to confirm the dishonest assurance given in the first instance. The patient is forthwith victimized, week after week, and month after month, with a host of operations, for a disease which, in the beginning, at least, never existed at all, but which is very soon brought on artificially by the horrible appliances of men, who ride in their carriages, by this daily and hourly outrage to the constitutions and the decency of our women."--_The Forbidden Book_, vol. ii. page 195. Again, in the same work, appears the following letter, under the head of "Obstetric Quackery in Edinburgh:"--"SIR,--The members of the Town Council of Edinburgh are the patrons of the University. Most of them are known to be conscientious men, and keenly alive to all that can affect the honour and the usefulness of the institution over which they preside. It appears extraordinary that they should have remained so long unacquainted with the leprosy which has infected some of the professors; or that they should not have summarily driven these persons from the chairs they were polluting, when the fact was discovered.... It is to him (Dr. Simpson) that we chiefly owe the infinitely more dangerous and disgusting quackery in midwifery, which rages like a pestilence in London, and in every town and village throughout the empire, and in some of our most distant colonies. On the present occasion, it may be sufficient to enumerate the proceedings to which I allude: To Dr. Simpson we owe the invention of the dangerous weapon called the uterine-sound or poker--pessaries which have justly been designated infernal and impaling uterine machines, to cure retroversions which never existed; instruments for pumping the uterus, to excite menstruation; and the proposal to rub its inner surface with lunar caustic, for the same purpose. To him we owe the hysterotome, for slitting open the os uteri, to cure sterility; and to his efforts, more than any other individual, we are indebted for the profligate use of the speculum which has prevailed, and the practice of destroying the os and cervix uteri with caustic potash. To Dr. Simpson we owe the attempt to revive the brutal practice of turning in cases of distortion of the pelvis; of attempting to substitute the Cæsarian operation for the induction of premature labour; to him we owe the attempt to subvert the established practice in placental presentation, by extraordinary statistic tables; and, lastly, we owe to the genius of the Professor of Midwifery in the University of Edinburgh, the baby-sucker! Are these specimens of what the _Edinburgh Monthly Journal_ for this month calls 'the simple treatment taught and practised in Edinburgh, and which, if adopted in London, would reduce many practitioners from comfort to starvation?' We may well excuse the members of the Town Council if they are not so dexterous in _harliquinade_ as the University Professor.--I am, Sir, your obedient Servant, ISAAC IRONS, M.D. Sept., 1851." We now proceed to quote the words of "a Fellow of the Royal College of Surgeons," which appear in a pamphlet entitled, "The Speculum: its Moral Tendencies." We believe the author to be very well known, both as a writer in the medical periodicals, and as a skilful and accomplished surgeon. He says--"Were fame and fortune, however, the only results, were the public simply gulled, there would be nothing in its consequences to take this imposition out of the ordinary category. But, unfortunately, this is not the case. The practices of these men leave results of a far more serious and lasting character, not to be sought for amongst material things, but in the lowered and loosened state to which it is rapidly bringing the morality of the country. "This is a strong assertion, but not stronger than the facts that support it. The profession is well aware of the baleful tendency of the proceedings of these men, whilst they deplore their inability to prevent or to expose them. Scarcely a member of it whom you meet but has a tale to tell of their practices, which, if made public, would bring the mighty from their seats; but there is too much indecency involved in the disclosure to allow of its publicity. Thus are they doubly hedged; _their diploma checks suspicion, whilst the nature of their performances secures them secrecy_. "To believe in the necessity for this constant and general use of the speculum, is to admit a sad deterioration in nature itself. Either this, or that anterior generations were great sufferers without being aware of it. Perhaps, like the Spartan boy they endured in silence, rather than betray a want of courage, or, what was more laudable, a want of delicacy. "But I do not believe in this. I believe the workmanship of the Creator to be as perfect now as of yore, and that the modern and multitudinous disorders attributed to the uterine system are wicked inventions put forth to sanction unnecessary interference. Why, if we are to believe these men, there is scarcely a patient who applies to them that is not suffering from one or the other of these numerous affections. The womb, with them, is so invariably out of order or out of position, that disease and dislocation are more constant than its normal conditions. Young or old, married or single, whatever their age, whatever their condition, the same opinion, the same treatment, varied only in the selection of the instrument. No matter what the complaint, or what the ailment, the _fons et origo mali_ is declared to be the uterus.... "Nor are these practices confined to the high priests in these temples of immorality; faith in their professions now pervades a large portion of female society; like the flame in a stubble field the mania has spread, the convert quickly becomes the proselyte, and the consequence is, that some men, in the general practice of our profession, are induced to shape their treatment less by the nature of the complaints, than the suggestions of their patients.... "The result of this can be easily imagined; unskilfulness is associated with fraud. The Speculum is brought into play, and startling are the revelations made by its glittering wall. Alarmed or amused, no matter which, the patient is secured, and remains long enough under treatment to familiarize her with indecency, and to enable the practical hand of the neophyte to attain the _tour de maitre_, both in handling the instrument and the fee.... "Then again, these uterine complaints, contrary to the laws that govern local affections, are made to assume an almost epidemic character, for it is by no means uncommon to hear that several members of the same household are under treatment, as they call it, at the same time.... "But besides those whom I have mentioned as abusing the Speculum, there are others, who, more honest, yet not less dangerous, are, unconsciously perhaps, contributing their share to this work of demoralization; I mean that portion of the profession who, unable to form opinions for themselves, are ready at all times _jurare in verba magistri_, adopting any practice, provided the example be set in high places.... with these men one would like to deal charitably; but the best of motives must not be allowed to compensate the consequences of dangerous acts; THEY MUST NOT BE ALLOWED TO JEOPARDISE THE MODESTY OF THE SEX, SO LONG THE PRIDE AND THE PROPERTY OF ENGLAND. "That an instrument, capable in its application of such wide-spreading mischief, should possess some compensating good, some power whereby diseases, hitherto obscure and intractable, should be compelled to render up the morbid secrets on which they rest, and to take their place amongst curable disorders, was to have been expected, and had this been so, the case would stand far differently.... "But unfortunately this is not the case; the diseases here alluded to, though obnoxious to its application, instead of being benefited are materially aggravated by its use; take, for instance, the scirrhous affections, in these cases its use is not only inefficacious, but positively injurious--it only adds torture to torment.... "Driven, then, from the field of real disease, these advocates of the Speculum are obliged to invest with a false character ailments that the profession has hitherto regarded as too trifling to admit of any save the simplest treatment.... The Speculum has been greatly extolled as the means of conveying appliances immediately to the parts affected. But it must not be forgotten that the effects of local remedies in constitutional affections are short-lived in the extreme, or that those can hardly be called remedies, that are notoriously so slow in their operation, as to leave it doubtful whether they have not, after all, been robbing time of the merit of the recovery. "That the profession is silent on these abuses is, in my opinion, to be deplored. Such silence may arise from the fear that the denunciation of them would tend to lower it in the estimation of the public, more than the continuance of the abuses themselves. Yielding to none in the desire to uphold the dignity of my order, I must say that I share in no such apprehensions. The public in return for the confidence they repose in us, have a right to such protection, and if they find that it has been withheld, that, in a mistaken solicitude for our own interests, we have neglected theirs, they will bind us all up in one common withe together, and the diploma, though it may still indicate the man of science, will cease to insure us the position of gentlemen."[32] The last extract which we shall give appears in the _Lancet_, a periodical whose very title is behind the age, indicative of professional bigotry, a record of antiquated fallacy and prejudice. The tide must surely be on the turn, or the exposure of these speculumizing villainies would never have been permitted to grace its columns:-- "On the use of the speculum in the diagnosis and treatment of uterine diseases, by Dr. Robert Lee, the author referred to the tabular statement of 220 cases of real and imaginary disease of the uterus, published in the 38th volume of the Medico-Chirurgical Transactions, and presented in a similar tabular form the details (of) eighty additional cases, which had since come under his observation. Of the 300 patients forty-seven were unmarried, one had barely completed her eighteenth year, several were under twenty, and the majority under thirty years of age, and were suffering from hysteria, leucorrhoea, dysmenorrhoea, or some nervous affection of the uterus, without inflammation, ulceration, or any structural disease or displacement of the organ. In Case 256 the patient had been told that the womb was prolapsed and much ulcerated, and an instrument had been introduced for six weeks, with an aggravation of all the symptoms. The hymen was found so perfect on examination that it was impossible to reach the os uteri without using an unjustifiable degree of violence. On the ground of morality, and on every other ground, he could see no defence for the employment of the speculum in these forty-seven cases. Of the 300 patients seventy were barren, and the sterility was not removed, nor the other symptoms relieved in a single instance. SEVERAL OF THESE INDIVIDUALS SPOKE WITH HORROR AND SHAME OF THE TREATMENT TO WHICH THEY HAD BEEN SUBMITTED. A considerable number of the cases were suffering from cancerous disease, in all of which the symptoms seemed to have been aggravated by the treatment. In Case 236 the character of the disease was unmistakable, but after an examination with the speculum a favourable prognosis had been given, and the actual cautery employed for months, and hopes of recovery held out to the last. The author expressed his conviction that neither in the living nor in the dead body had he ever seen a case of simple ulceration from chronic inflammation of the os or cervix uteri; and to apply the term to states of the os uteri in which the mucous membrane or, as it is termed by some, the basement membrane, is not destroyed by ulceration, was an abuse of terms calculated only to deceive and mislead the members of the medical profession, from whom the truth has been carefully concealed. The speculum emanates from the syphilitic wards of the hospitals at Paris, and _it would have been better for the women of England had its use been confined to those institutions_."--The _Lancet_, July 25, 1857. Such is the language of earnest, honourable men, who have dared to dispel, by the light of true philosophy, the fog of "scientific" rascaldom--that empiric haze so desolating, so destructive to the inwrapped and blinded public. Few will deny that there are, in the foregoing extracts, sentiments which do honour to their authors, and revelations for which society should feel the deepest gratitude. Were we to relate the numbers of weak and deluded creatures who, upon the slightest pretext, submit to this accursed rite, it would appear incredible. We know that one fashionable pretender to peculiar skill in the diagnostics of uterine affections, has boasted of five such examinations in one family in a single day! and that another has spoken of the exposure of _fifty_ women to his professional gaze in the same space of time. These are facts--horrible, but undeniable, facts! "O shame! where is thy blush?" O woman! where is thy vaunted modesty, in a country tainted by such unspeakable and hideous mysteries, permitted--nay, tacitly encouraged--as they are, under the hypocritical guise of scientific discovery, and the pretended mitigation of human ills? Is it possible that in this age, and in this our land, men should be found so utterly insensate, so beggared of all feeling, so lost to all the chivalry of manhood, that, with this libidinous iniquity made patent, they would not arise, and, in one mighty and overwhelming surge of execration, crush its perpetrators, and abolish this obscene invasion of marital rights. No! perish the thought! The azure blood, which throbbed and pulsated in the British heart in those far off days of the second Richard, when the indecent outrages of the poll-tax gatherers lashed the people into fury at their daughters' wrongs, still runs in the veins of Englishmen; and we will not believe that the halo of purity, which made the homes of "merrie England" the watchword of our sires, can have departed for ever from those of their descendants. CHAPTER IV. "The chariest maid is prodigal enough, If she unmask her beauty to the moon; Virtue itself 'scapes not calumnious strokes; The canker galls the infants of the spring, Too oft before their buttons be disclosed; And in the morn and liquid dew of youth, Contagious blastments are most imminent. Be wary, then, best safety lies in fear." We have already, in the foregoing pages, quoted the words of Roussel, a celebrated French physician of the last century, whose delicate and sensitive mind revolted at the indecency of the practice which had then but lately been adopted in his country; and before we proceed to quote more largely from the same author, we think it proper that our readers should be made acquainted with the character of the man who so lovingly exerted his great talents to release his countrywomen from the gross thraldom of designing charlatans and empirical impostors. Dr. Cerise, in the account of Roussel prefixed to the edition of the Physical and Moral System of Women, published in Paris, 1855, says: "Among the celebrated physicians that France has produced, a great number have distinguished themselves not only by their erudition, but still more by the elegance of their language, by the elevation of their sentiments, by the profundity of their conceptions; their names belong to letters and philosophy, as much as to medicine. Roussel is a member of that glorious family of Petits, Bordeus, Vicq-d'Azyrs, Cabanis, Aliberts, which, at the present day, is honourably represented by two writers, Pariset and Reveillè-Parise. Through them medicine is not only a useful, but it is also an agreeable science. "Let us hope, that so illustrious a family will not become extinct, and that descendants worthy of it will faithfully keep alive the sacred fire, perpetually threatened by the freezing breath of scientific materialism. "Roussel was born at Ax, in the department of Ariége, in 1742. His education, commenced in that town, was finished at Toulouse. His taste for medical study manifested itself early. He betook himself to Montpellier, where he profited by the scientific lectures of Lamure, Venel, and Barthez. These medical studies completed, he was desirous of further instruction, and came to Paris. He closely allied himself with Bordeu. This physician, according to the expression of Alibert, was too illustrious to be happy; the friendship of Roussel consoled his vexations; but Bordeu soon died, and Roussel had the melancholy commission to pronounce his funeral elogy. We are assured that love was the genius of Roussel. "He was still very young," says his biographer, "when this sentiment was awakened in his soul; it was then that his inspired imagination began to meditate on the tastes, the manners, the passions, and the habits of women, and that he made a constant study of their physical constitution, and of the moral attributes which they derived from it. He soon arranged the fruits which he had collected, and composed a body of science interesting as its subject. "Thus was written _the Physical and Moral System of Woman_. This treatise, which agreed in its development with a title so imposing, has remained superior to all those which have been written upon woman, without excepting the remarkable work of M. Virey, which failed, perhaps, in eclipsing that of Roussel, solely from its severer method and more scientific manner of treatment. He soon undertook another treatise, intended to serve as a pendant to the former. This new treatise, entitled the _Physical and Moral System of Man_, was not completed, which, judging from what he had published, is much to be regretted. He caused to be inserted in the journals of the day, _An Essay on Sensibility_; _An Account of Madame Helvetius_; a short dissertation, entitled, _Historic Doubts on Sappho_; some remarks '_On the Sympathies_.' He had commenced a lengthened work on Stahl, the celebrated head of the medical college, called _Animist_, but this work remained unpublished; he reviewed the work of Madame de Staël, upon the Affinities of Literature with Social Institutions; he applied himself to combat the doctrine of the indefinite perfectibility of the human spirit, developed by Condorcet, in one of his most remarkable writings. The problem was then proposed in terms such as could not afford any satisfactory conclusion--as yet the science of history did not exist. He wrote upon the right of making a will, which he regarded as inviolable and imprescriptible; he addressed public exhortations to political electors, to remind them of their duties and of their rights; he admired the institutions of Lycurgus, and published a dissertation on the government of Sparta. It is thus that the empire of circumstances under which France at present exists dominates over all minds. Roussel, yet meditating with a tender partiality upon the physical and moral constitution of woman, could not resist descending into the arena of political discussion. Thanks to the moderation of his character, his voice, in the midst of revolutionary storms, was hardly understood, and his existence was not disturbed. "Roussel loved retirement and unaffected manners. Traits of a charming simplicity are related of him. Alibert congratulating him one day on the marriage of one of his brothers, suggested that he should follow his example and marry. 'I assure you,' replied the irresolute bachelor, 'that this idea often occurs to me, but one must go before the priest, before the magistrate--there is no end to the affair.' There are persons for whom pleasing and indefinite fantasies have a charm which they love to prolong; they seem to dread a real happiness which might deprive imagination of its most smiling visions. Roussel was one of these persons. He was smitten with a violent passion for a young and beautiful person whom he had restored to health. Happy, doubtless, in secretly bearing a cherished image in his heart, he refrained from giving utterance to his thoughts. One day it was announced that this person was going to be married. 'Ah,' cried he, '_I am so grieved; I could not have believed it_;' and he shed abundant tears of regret. He was often sorrowful; in one of these fits of melancholy, he ran at midnight to a physician of his acquaintance--'My head turns,' said he; 'I feel myself very ill. I am come to you to implore your attention.' Imbert reassured him, and calmed his alarmed imagination. The two friends engaged in conversation, and Roussel forgot his malady. "Roussel was good; benevolence, a quality so precious to a physician, was in him lovely and expansive. When he suffered, study was an asylum for his grief, a refuge for his afflicted spirit. He found in the joys of the mind a defence against the sorrows of the heart. His internal agitations dissipated themselves thus without gall and without bitterness. His excellence was proof even against evil days. He lived poor, but the affectionate and delicate hospitality of a respectable family never allowed him to perceive it. He could, thanks to the care of M. Falaize, neglect, quite at his ease, both his affairs and his fortune, exercise his profession with the confident and noble freedom so agreeable to elevated minds; meditate without interruption upon Plato, Plutarch, and Rabelais, and withdraw himself, without peril, from those petty torments which impose themselves under the name of social proprieties. A perfect courtesy with him was marvellously allied to good nature a little rough, and which was not without a dash of mischief. Roussel no more sought honours than fortune. He refused the offer of an honourable employment, made to him by the Great Frederic. He failed, however, to be called to the legislative body. He wanted only two votes. Powerful friends had designed him for the Tribuneship. He declined that honour, urging the weakness of his voice, and his timidity. Roussel was timid through excess of modesty. "Roussel was endowed with a delicate constitution. He had been suffering more than usual for many days, when he quitted Paris to retire into the country, to M. Falaize, near Chateaudun. Enfeebled by prolonged sufferings, he soon yielded to the attack of a fever which raged epidemically in the neighbourhood. He sank under it the second complementary day of the year X. (1802), aged about sixty years. Roussel had possessed devoted friends; those who survived him remained faithful to his memory. Alibert recorded his life with touching eloquence. He did more; he collected his principal writings, of which some were disseminated in the journals, and published an edition of his works." This account of Roussel, brief as it is, will suffice to inform our readers that he was no ordinary man, and that, from his learning, and long experience as a physician, his opinions and reflections upon "the pretended art" of man-midwifery are entitled to the greatest respect. Those who would ridicule his sentiments, and treat his arguments as false and visionary, and his ideas as antiquated and unsuited to the taste and advancement of the present day, are those who, from mean and despicable motives of self-interest, would confirm the vicious system which Roussel has denounced, and, while destroying woman's modesty, would erect their own fortune on its ruins. Towards the end of the preface to the Physical and Moral System of Woman, will be found the following sentences, which we would commend to the serious consideration of every man whose sense of decency has not been altogether obliterated, and whose mind still retains any of those finer feelings, which God, when he made man in his own image, implanted in the human breast. "It is not the same, perhaps, with the abuses introduced by that art, almost unknown among the ancients, which, under the pretence of assisting nature in producing man, itself sometimes prevents his seeing the light, in attempting to do that which she unaided could more effectually perform; which enervates in woman, by effeminacy and the needless lengthening out of precautions, the instinct, which alone puts them in a condition to do without it. In fine, which, by a usage, as indecently as unreasonably repeated in men's attendance upon women, enfeebles, and at length annihilates the sentiment which most adorns the sex. I have made some reflections upon this pretended art in the chapter which treats of natural labour." Again, in the chapter on pregnancy, Roussel speaks trumpet-tongued, not only against the indelicacy, but of the absolute inutility of those digital examinations _per vaginam_ now in vogue, and so dogmatically prescribed in the text books of midwifery. "As the instant when a woman conceives does not manifest itself in her by any well characterized expression, and the consequences of this act remain for some time concealed by a thick veil, that spirit of unrest which ordains that man, dissatisfied with the present which he may enjoy, should ever press on towards that future, which he perhaps shall never see, induces him to seek with eagerness the as yet hidden signs of pregnancy, and to question nature long before she deigns to speak. Men might, in this respect, spare themselves the torments of needless impatience, since it can neither accelerate nor retard its object. It would be much more in order to wait patiently until the natural signs themselves announce pregnancy, than that the tentatives by which it is pretended they are anticipated should annoy women weak enough to submit to them, without throwing any more light on the motive which suggests a recourse to them. "These tentatives are the work of a shameless charlatanism, which solicits them, and which disports itself with chastity and decency, to establish its empire upon the ruins of a virtue to which the sex owes its own most solid foundations. "We here feel ourselves compelled to inform women, that those whom they employ at this kind of trials deceive them, in affecting a knowledge which they do not possess. All information derived from _the touch_ is very uncertain. The concurrence of external and obvious signs can alone be reckoned on; such as the increased size of the abdomen, the swelling of the bosom, preceded by qualms, nausea, and suppression of the menses. But the most decisive of all, by the actual avowal of all men-midwives, the sole indubitable proof consists in the movements of the infant, which make themselves felt towards the fourth month of pregnancy. Thus women can inform themselves better than any one whether they are with child, and the men-midwives, who are forced themselves to acknowledge this, ought to erase from their treatises on midwifery the nonsensical rules which they give upon _the touch_.[33] To give an idea of the solidity and wisdom of these rules, I need cite but one, taken from a work of one of the most celebrated men-midwives. 'When one is called on,' says he, 'to examine a girl by _the touch_ for some suspicion of pregnancy,[34] one ought at first to introduce the finger with caution, for fear of deflowering her, if she was not so.' Is not this the very climax of absurdity to be willing, upon the simple suspicion of an evil which, perhaps, is imaginary, to produce a real injury, to expose one's self, for the sake of knowing whether a girl had committed a fault, to the rendering more easy to her all those which she might commit in future, by destroying the prime bulwark which in her opposes itself to vice; in fine, to deflower a girl in order to discover whether she had lost her virginity?[35] And unhappily again for the rule, the means which it points out are insufficient to attain the desired information. It is from time alone that this revelation may be expected. Three or four months of patience will enlighten you more than can this dangerous practice, the disgraceful essays of which are worse than the doubts that they would dissipate. Although the inconveniences of this practice are not so considerable for women as for girls, we would never do them the injustice to suppose, that it would not be painful for them to consent to an examination which ought to humiliate them in their own eyes, and which must sometimes render them contemptible in the eyes of others: they should free themselves from this torturing ceremony, though there was no other reason for it than its inutility for the object which induces them to submit to it."[36] Again, in the chapter on natural labour, Roussel says:-- "Final causes, which some philosophers would banish as a barren principle (which is perhaps true in natural philosophy), are in medicine the foundation of the most solid truths, which the ancients, and above all, Hippocrates, have transmitted to us. They have perhaps supposed that it was too trite and too commonplace to think that the Creator, who presided at the formation of our bodies, had made the mouth to eat, the eyes to see, and the ears to hear. We know not if it required much effort and subtle reasoning to divest them of the first ideas of common sense, but it seems to us, that they who reject altogether final causes discard perhaps as much truth as those who have most misused them, for it must be owned, that certain writers have made a strange use of them. Not to travel out of the subject which occupies us, we may quote M. Astruc,[37] who alleges that the coverings of the foetus, in engaging themselves at the same time with it in the orifice of the womb, serve to line that passage, and to defend it against the bruisings of the foetus, and _the fingers of the midwife_. To suppose that nature, in arranging the objects which should assist delivery, had contemplated the awkwardness of male and female midwives, is to impute to her a foresight which unhappily would be only too necessary, but that she had little for the errors that we are able to commit. She has done all for the best in our favour, so much the worse for us if we mar her work. _It must be_, said the same author, _that its face (of the foetus) was turned from the side of the os sacrum, to prevent its nose from being crushed by the bones of the pubes, and that it might not be suffocated by the waters of the amnios_. A child that had been living nine months in water to be suffocated, when passing out of it, by a few drops! O Astruc! have you well considered this? "Without, then, ascribing to nature frivolous fears, or confining her to details which she disdains, we may reasonably believe that after having alloted to different organs destined to aid in generation, the modifications most suitable to the conception of the child, and its preservation during pregnancy, she would afford those also which should, with the least inconvenience, effect its exit from the maternal bosom."[38] After describing the process of nature in parturition, Roussel goes on to say:--"O Rubens! I leave to your pencil the care of expressing that touching state in which the last impressions of abated pain still tinge the serenity of purest joy; where the melancholy, caused by sufferings now terminating, is not yet effaced by the most delightful sentiments which can animate the soul; where the dread of losing life, natural enough in suffering, gives place to the delicious pleasure of having presented it to a new being. But wherefore must it be, that this state is the price of a train of inconveniences, and a gradation of suffering often insupportable; and why are we here compelled to envy the kinds of animals amongst which pregnancy is without embarrassment, and delivery almost without a pang, or at least exempt from the sad or fatal consequences which so often follow it in the human species? It would, nevertheless, be wrong to tax nature with injustice.[39] We yet find races in whom her primitive impress has never been effaced by the abuses of a refined society, and amongst whom women enjoy nearly the same privileges as the females of animals. "The women of the Ostiaks, it is said,[40] never have any uneasiness about the time of their delivery, and take none of those precautions which European effeminacy renders almost indispensable. They are delivered wherever they may happen to be without any inconvenience; they, or the persons who assist them, plunge the new-born infant into water or snow, and the mother returns immediately to her ordinary occupations, or continues her march, if on a journey.[41] As these people dwell in the vicinity of the Samöides,[42] between the fifty-ninth and sixtieth degree of north latitude, they do not fail to attribute this vigorous constitution to the severity of the climate. "Meanwhile, in the same history, we read that the wives of the dwellers in the island of Amboina, towards the third degree of south latitude, are in the same category; and the author or compiler of that history, in reporting the fact, discovers the cause of it in the heat of the climate, which renders women's members supple and capable of accommodating themselves with ease to the labours of parturition. One may perceive from this how versatile are the explanations obtained from _cold_ and _heat_, and how, in the jargon of mechanicians, causes altogether opposite can serve with more vraisemblance than actual truth for proof of the same effect. We repeat again, the effect of manners and custom is not often enough considered. In all climates nature has given both to man and brute the faculties necessary for fulfilling the functions of life with ease. The former has very often perverted their use, believing that luxuriousness, precautions, and an abundance of all things could supply their place. "Without seeking for examples beyond those to which we shall refer, we might disabuse ourselves of so dangerous an error, if we would compare, without prejudice, even in our own climate, the women in the rural districts with those resident in towns. The former, having their attention continually diverted by their necessary occupations, often find themselves in the middle of their pregnancy almost without perceiving it, and this is already a great deal gained. This novel state, without changing anything in the course of their health, or in their way of living, obliges only some preparations more necessary for the infant than for themselves. Arrived at the end of the ninth month (as they are never in a hurry to lie in) they do not aggravate the troubles which accompany this function by the anxieties of vexatious expectation. Nature sometimes surprises them in the midst of the rustic employments in which they are occupied during their pregnancy, and which only prepare them the better to support those of labour. Finding in them healthy organs and a calm mind, she operates without obstruction, and, in consequence, delivers them with less suffering and more celerity.[43] The consequences of labour, which are, to the majority of women in towns, in part a real malady, and partly a kind of etiquette and convention, which subjects them, during a fixed period, to the regimen of sick persons, when they have ceased to be so, are almost nothing to women in the country. Nature, having neither caprice nor excess to combat in them, only occupies herself for their re-establishment; and as they yield nothing to custom or opinion, they enjoy as much as possible the favours of nature. They have not time to crawl methodically, during many weeks, from their bed to a sofa; they have almost always that courage which increases their powers, and which necessity sometimes gives even to women resident in towns. Among these even it is by no means rare to see the wives of poor workmen, who walk to a midwife at the moment of parturition, and who return the next day free and exempt from accidents, which the woman of higher rank does not always escape, in the midst of the studied precautions which are taken on her account; their condition in life does not permit them to be inconvenienced for more than three or four days. It seems that nature gives us powers in proportion to the necessity that we have to make use of them. We have known a young girl who found the means to conceal from her parents the humiliating signs of her weakness, and the operation which relieved her from it. As her pregnancy was not legitimate, she had not the right to be an invalid.[44] "As for most women in towns, and above all those of the upper classes, instead of courage capable of annihilating the sentiment of evil, all concurs to nourish a pusillanimity in them, which renders it more vivid. The eager curiosity with which they endeavour to find out whether they are pregnant, the new regimen to which they submit themselves when they are declared to be so, the preparations, the anxieties, the alarms, real or feigned, which reign around them, the number of persons who besiege them, the inaction to which they are condemned, should give them a frightful idea of their state, and would seem to deprive them of the ability to make use of their proper powers, and so to render them of no effect. The feebleness and inertia of their minds, passing to their organs, cannot but dispose them to a stormy pregnancy, and prepare them for a painful and sometimes fatal labour. The instinct which watches for the preservation of our lives, which knows so well how to manage its resources in the most serious evils, must weaken and lose itself amidst the throng of succours with which the patients are sometimes overwhelmed. What could it have to do when so many are acting for it? "Delivery is an animal function which, in all likelihood, nature had no desire to render a disease. This function exercises itself almost without pain and without danger in the brute. In all places where the means of assisting it have never been reduced to art, women have ordinarily labours less severe and more fortunate than in those localities which swarm with accoucheurs and midwives. Whence comes this distinction, if it is not from the difference of manners and methods of treatment in the one and the other, or from the abuse which, in the latter places, is made of a pretended science? "If the delicacy which results from a luxurious and inactive life renders the movements of the womb more painful, we should attribute the irregularity which renders them sometimes fatal to the mother and the child, to a disordered sensibility, which is excited by attempts almost always ill-directed, and almost always executed by mischance. It is in this disturbance that the infant assumes those disadvantageous positions of which the accoucheurs and midwives unquestionably exaggerate the danger, to put a higher value on their 'manipulations;'[45] but which, in effect, render the delivery longer and more laborious: disturbance maintained and augmented by the embarrassment which the presence of a number of persons, some dear, others odious, some unknown, who in general fill the chamber of a woman in labour, must naturally produce, BY THE TORMENTS OF A MODESTY TOO LITTLE REGARDED, by an air of importance too much affected, which the assistants, and others who are to operate, throw over the affair in which they are engaged. All these objects must excite a variety of sentiments in the woman, which, by distracting her mind, necessarily disturb the organic action of the parts which should perform the delivery. Happy is it, if too presumptuous accoucheurs and midwives do not, by their precocious tentatives, solicit in her a nature which is not yet prepared to engage itself, precipitate its movements, and consequently abort the fruit which they ought to await, weary the parts already too much irritated, and rendered too sensible by the orgasm and tension which they have suffered, and hurry both mother and child into inevitable ruin. "Women who have the good fortune not to be annoyed by numerous attendants, and in whom nothing discomposes nature, are seldom subject to those catastrophes which, very far from bringing discredit on the operator, who is often the cause of them, only make him appear the more necessary. Nature, when she works alone, knows so well how to combine and graduate her action that she does that only which she ought to do. Ah! why should she not with ease accomplish an operation for which she has foreseen, and well prepared everything? Why should she not succeed in extracting with facility from the centre of the womb, from an active, flexible, and very vigorous organ, a body which is familiar to it, and which, from its form and consistence, cannot much injure the parts which it touches? Why should she be embarrassed in bringing to light an infant whose situation is so near the outlet through which it is to issue, she whom we have sometimes seen conducting, without accident, pointed or sharp-edged bodies through the windings of the urinary ducts, and the tortuous folds of the long passage of the intestines? There are, besides, operations which she loves to execute in silence and in secret. This delicate instinct manifests itself even in some species of animals, which never fulfil certain functions in presence of witnesses, and fly from the gaze of man to perform them. Delivery, from its nature, and from all the circumstances which characterize this function, is one of those which, in the human species, requires most especially to be covered with a veil. It cannot be doubted that they would assist her in a way the most efficacious, if the number of persons in attendance on a woman in labour was limited to two or three of her most intimate friends, who, by a gay and lively manner, should divert her from her sufferings, or by their confident appearance pacify her apprehensions; and to a midwife, whose presence of mind, patience, reserve, and protection should be a guarantee for her tranquillity. It is not to be doubted, I say, that a woman would be by those means more effectually succoured than by the tumultuous assistance of a number of persons, sorrowful, aghast, impatient, whose multiplied and often mis-directed attentions magnify in her imagination the evil which she must endure, and the danger which she fears, and above all by the awful appearance of a man ever ready to operate, always armed with suspicious instruments, and to be dreaded from his sex. "It must be owned that although the midwife's function belongs to the healing art, it was not intended to be exercised by men.[46] The character of this function, the small amount of knowledge which it requires, the entire and absolute confidence which persons of the same sex must naturally have in each other, in fine, everything demands for it the agency of women; this employment seems their proper existence; they possess all the advantages necessary to fulfil it with success. We know with what address and with what dexterity their hands, small and supple, glide and insinuate themselves everywhere without annoyance, capable of penetrating to the very source of the evil without augmenting it, and conveying the remedy to the part diseased, without awakening, by the act, pangs which had been allayed. "It is these precious talents, as well as that delicate attention capable of divining the wants which there is not strength to express, and that enlightened sensibility which knows how to regard the very caprices of the complaint, which gave rise to the proverb, honourable to the sex, that wheresoever there is a suffering being, his sighs summon woman to console him.[47] "They will tell us that long and serious studies, to wit, physics, mechanics, and even mathematics, are necessary to insure skill in the art of midwifery. Eh! where is it that they have not introduced, especially of late, physics and mathematics? All that which is material; all that which is within the jurisdiction of the senses, belongs, without doubt, to physics and to mechanics: one could not move a step, one could not lift a straw, without its being done by the laws of physics; but every one performs these mechanical operations, as the Bourgeois gentleman did prose, that is to say, without suspecting it. There are natural mechanics with which not only all men, but even all animals are acquainted without having studied them. All perform actions, without having been trained to them, wherein sparkle the most subtle mechanics; all know of themselves, and without previous practice, how to assume the most convenient postures which their different wants demand. Those who compose treatises on midwifery describe at great length the position which a woman ought to take during labour, and that which is proper for the accoucheur. The legs of this latter, say they, ought to describe an angle of _forty-five degrees_. An operator, to give lustre to his art, may well appeal to that of mechanics and geometry; but he ought not to say that it is above the capacity of women. The sole difference which exists, perhaps, between them is, that a woman, in abandoning herself to her natural dexterity, in liberating herself from the constraint of a fixed position, and in effecting the movements which circumstances require, rather than those which the rule demands, will go about the work better than the man-midwife gravely moored (_affourché_) at his _angle of forty-five degrees_. "The art of midwifery, stripped of regulations, useless or of little moment, and of the frivolous finery wherein it has been arrayed, reduces itself to a very small number of simple principles,[48] easy to attain, and most suitable to the capacity of women. They soon learn what are those faulty positions which the infant may take in the womb: what are those which they may rectify; and those which, not being remediable, leave nothing to the address of the operator but the wise resolution to diminish, as much as possible, their inconveniences. "Again, it must be considered, that those principles are not to be applied, excepting in cases wherein nature, insufficient in herself, demands the assistance of another's hand; for, by the avowal of accoucheurs themselves, natural labour, which is and ought to be the most common, can conduct itself without the intervention of art. We may then conclude, with certainty, that accoucheurs who 'manipulate,' who instrumentalize us much as they can, most frequently do it without necessity, and from this cause are prejudicial to the success of the operation. We may also, in that way, reduce to their just value the exaggerated details which they give of pretended obstacles which they have had to overcome, of the address and dexterity which was necessary to surmount them; details which seem intended to show that the delivery had been their work, or that, at least, much of it was theirs, and very little nature's own.[49] "Either, in the time of the Greeks, women were delivered with greater ease than now, or they judged better than us of the true degree of influence that the midwife or the accoucheur possesses in this function. By the appellation which they gave to their midwives, it appears that they limited them to the duty of cutting the umbilical cord; they called them [Greek: omphalotomoi], umbilical cord-cutters. The females of animals perform this operation with their teeth; and as the umbilical cord can in their case do without a ligature, there are authors who doubt whether it is as essential in man as many persons pretend. There are observations for and against it. This is not the place to discuss this question; but we believe that they may much deceive themselves if they look upon the umbilical cord as a simple continuation of the vessels of the child or of the mother, and not as a fragment of affinity which only serves, for a certain time, as a point of communication established between the mother and the infant, that nature retains so long as she requires it, but which she leaves to decay, and fall away, when it is no longer useful to her. After the delivery she contracts, compresses, and closes up the part of the infant to which it adheres; and by intercepting the blood and the life which gives it subsistence, she soon causes it to wither and dry up, without any prejudice to the child. "Although the easiness of the art of midwifery might have been, among the ancients, a motive for intrusting it to women, they also doubtless had a regard for natural propriety, which suggested that the infant, on coming into the world, should be received into the hands of a midwife, to pass into those of a nurse, and from the hands of the nurse into those of a governess, who should prepare him to receive from men a masculine education. A repository so weak and so delicate would perhaps have found, in the rough and unbending kindness of the latter, aid less adapted to its state; it required a gentle and yielding support, knowing how to be pliant as itself, the better to defend it. In fine, the care of infancy is the destination of women; it is a task which nature has assigned them. It is woman who must bear the infant during nine months in her womb; _it is woman who ought to facilitate the means of its exit_; it is woman who should furnish the first nourishment which it requires; in fine, it is woman who should keep watch over the first developments of its organs and of its mind, and prepare it for the lessons which should elevate it to the condition of man. But the principal reason which, among the ancients, forbade the belief that the duty of aiding delivery could be proper to any but women, excepting in cases of very rare occurrence, where every consideration might necessarily yield to a pressing danger, was the grand interest of manners.[50] This was an object to which ancient governments had always special regard.[51] They knew morality to be the foundation of all legislation, and that good laws would be made in vain, unless good morals insured their execution. The cruelty of Archagathus' surgical operations drove the medical men from Rome. She banished also from her bosom the Greek philosophers and orators, who were accused of having introduced and cultivated the taste for the arts and vices of Greece. She would surely not have permitted, for any length of time, the existence of _an art which, practised by men, would, under the specious pretence of utility, threaten the sanctuary of marriage_, and which, striking a blow at the chief safeguard of families, would next attack the mainsprings of the state; an art which, _with power to alarm the modesty of women, would soon leave them without a blush_, and cause them to lose even the recollection of that severe virtue which had merited the respect and veneration of the Romans, and which of old had been the principle of the grandest revolutions. Cato, always careful to protect the hearts of the citizens from corruption, would never have permitted their wives, when presenting children to the republic, to tarnish the favour by a forgetfulness of the first of all decencies. All nations were sufficiently agreed, up to the middle of the last century, never to admit the agency of men in delivery. M. Astruc[52] alleges that it was not until 1663 that they began at court to make use of a man-midwife, and this was, say they, on one of those occasions when honour in danger takes counsel but from the perplexity which misleads it, and violates one part of its rules to save the other. Who would believe it? It was shame which compelled recourse, for the first time, to men. A king, who knew the force of example on the throne, and who wished to conceal his weaknesses, and to be tender of the delicacy of her who shared them, believed that he could not place in better hands an interest so dear. It is thus that Jupiter sometimes confided to the inferior gods, rather than to the goddesses, his embarrassments, and the care of concealing from the eyes of Juno the fruits of his infidelities. Whatever it might be, _unquestionably it was not in a tranquil moment that a woman could, for the first time, make up her mind to abandon herself to the mercy of a man to deliver her_. The first examples having been given by those persons whose rank and condition carried opinion with them, the usage of men-midwives is since extended and spread with that rapidity which is common to all inventions of luxury, although even physicians[53] are themselves forced to expose its inconveniences."[54] CHAPTER V. "----Mine honour's such a ring: My chastity's the jewel of our house, Bequeathed down from many ancestors; Which were the greatest obloquy i' the world In me to lose." Mrs. Jameson, in her admirable essay, "The Communion of Labour," most truly observes--"That some departments of medicine are peculiarly suited to women, is beginning to strike the public mind." Again, in her "Sisters of Charity," she quotes the following words of the late Dr. Gooch:--"Many will think that it is impossible to impart a useful knowledge of medicine to women who are ignorant of anatomy, physiology, and pathology. A profound knowledge, of course, would not, but a very useful degree of it might--a degree which, combined with kindness and assiduity, would be far superior to that which the country poor receive at present. I have known matrons and sisters of hospitals with more practical tact in the detection and treatment of disease than half the young surgeons by whom the country poor are commonly attended."[55] "Perhaps," says the author of "Women and Work," "there is no profession which so calls for women as that of medicine. Much suffering would be saved to young women if they had doctors of their own sex, who, with friendly counsel and open speaking, would often prevent many forms of severe disease by attending to first symptoms." Elizabeth Blackwell,[56] one of those noble women who, braving the servile conventionalisms of the world, with right and reason, morality and religion on their side, have triumphed over prejudice and bigotry, by firmly establishing themselves as female physicians[57]--in "an appeal on behalf of the medical education of women," after referring to the establishment and opening of medical schools for women in Philadelphia, Boston, and other towns of the United States, in the nine years since "the first woman was admitted as a regular student to a medical college, and graduated with the usual honours," says:--"In all these places public opinion has expressed itself heartily in favour of the action of the colleges. The majority of the female graduates have entered upon the practice of their profession, and many of them have already formed a large and highly respectable practice. The intense prejudice which at first met the idea of a female doctor, is rapidly melting away. If further evidence were needed of the vitality of the new idea, and its adaptation to a real want in the community, it might be found in the character of the practice which has come to those physicians now most firmly established. Intelligent, thoughtful women, of calm good sense, who appreciate the wide bearing of this reform, and foresee its important practical influence, have been the first to employ the new class of physicians in their families, and encourage them with their cordial approbation." Dr. Dickson says, in "The Destructive Art of Healing:"--"One of the greatest obstacles to the progress of medical truth in England, is the employment of surgeon-apothecaries as midwives--almost entirely monopolizing the practice of medicine by the influence which they have gained over the minds of our women; these people will countenance no physician who does not prescribe large quantities of useless, and too frequently deleterious medicine. "The ladies of this country should take a lesson from the American ladies, who not only prefer midwives of their own sex, but actually employ female physicians. Female modesty and morality alike require that the diseases of women should be attended to solely by women; and all through the United States you now meet with regularly-bred female physicians, most of them having the degree of M.D. from a university, and many of them being in the enjoyment of large and lucrative practice. "We have the pleasure of an acquaintance with Mrs. Dr. Longshore--she is a lady possessing a strong and original mind, close powers of perception and reasoning, and a thorough medical education. As a practical anatomist she has few superiors, even among practitioners of the 'sterner mould.' Mrs. Dr. Longshore is 'a Friend,' and her whole character is marked by the excellencies of the 'Friends,' or Quakers, as they are called. Placid, thoughtful, observant, full of sympathy, and governed by an active benevolence, she delights in doing good. Her practice is large, rapidly increasing, and generally successful, and she is devoutly attached to her noble profession.... "Medicine and midwifery are both domestic arts; woman is all but born a doctor. Ladies of England, think of this. Hitherto you have left the field of 'labour' to men who would be better employed with your distaffs and spindles. Mothers of England, you have a mission--fulfil it; proclaim to your daughters that the birth of a child is not a surgical operation, but a natural process; and that there is no case of parturition so difficult that may not be better managed by a well instructed woman than by a man, whose very presence in the sick chamber disturbs the uterine action, and causes the greater number of difficulties that occur in such cases." "In a country like England, to clear away a given folly is too often, unfortunately, only to make room for some other folly equally egregious. This, in our day, has been the case with medicine. Just as a considerable number of physicians had come to adopt my own view of the true constitutional origin of diseases, up sprung a class of people who will have it, that in the majority of female complaints, at least, there must ever be more or less of _local wrong_, which no possible constitutional treatment can cure! Whispering mysteriously the words 'engorgement,' 'tumour,' 'inflammation,' 'ulceration of the _os_,' 'version,' and 'retroversion'--phrases for the most part invented for the mere purpose of striking panic into the hearts of families who must ever be in the dark _here_--these men straightway confine the patient to her couch--in which unnatural position they keep her for months, and, if possible, for years together--during which they subject her to the most odious treatment; performing, with speculum, caustic, and other dangerous appliances, the most daring and indecent operations.... "By the people to whose practices I have just alluded a woman is told all possible and impossible things--things the most frightful that imagination can conceive--to cure which, forsooth, she must lie on her back for months. And if this oracular sentence be enforced by two or more of their number, acting in consultation--anglicè in _collusion_--the weak creature believes accordingly. From that moment she is the dupe and the victim of the most unprincipled scoundrels, many of whom, by mixing up religion with their medical cant, contrive to bring some of the richer class of women to such a state, that they become annuities to those impostors throughout the greater part of their most unnatural and most miserable lives.... "If, in common with these medicines, then, every medicinal force will produce its own peculiar _local_ effect, _when swallowed by the mouth_, why, in the case of 'uterine disease,' of all others, should any woman submit to the local application of any remedy that cannot be used thus without the odious manipulations of the persons whose conduct every right mind, when properly instructed, must deprecate? "But, as a matter of fact, these manipulations, so far from curing any disease of the womb or its appendages, have actually set up in the sound structure a very large share of the possible diseases for which these people pretend to apply them; and some of the disorders thus set up too frequently cease only with the life of the victim. Men of England! if you only knew what your wives and daughters needlessly--mark that word!--_needlessly_ experience at the hands of those ruthless cheats, your brows would burn with shame and indignation. How such brutality as these creatures practise ever came to pollute our shores, is one of the miracles of the times. A proper feeling in the minds of our women should have preserved them from the humiliation and torture to which they have been subjected; while Englishmen of all ranks should have united, long ere this, to expel from the land the sordid wretches who first introduced the grossness and indecency of the hospitals of Paris to the houses and hearths of a too-confiding nation!" Again, the Author of "Physic and its Phases" brands these counterfeit professors with infamy in racy and vigorous verse:-- "Men, are you men--who lead such hybrid lives, Who, being surgeons, sink into midwives? If with the sex you seriously would vie, Why not the distaff and the spindle try? Throughout the Orient, Arab, Turk, and Jew On such occasions, never send for you; Not even the Nubian, by the harem door, Dare show his face, until the birth is o'er. Talk of the sanctity of married life-- Nation of fools! who thus degrade the wife! At such a moment, when the feminine mind Shrinks from the succour of her nearest kind, Could you do worse, were she a courtezan, Than to her chamber introduce a man? No longer left to woman's gentle care, Travail is now her terror everywhere. * * * * Once in the sick room, with an eye to fees,[58] Tales they get up of uterine disease; Disease, the realms of Physic never knew, Till 'speculating Simpson' gave the cue; And, working thus on woman's weaker nerves, They raise whatever ghost their purpose serves. Then, not the young alone, but graver dames, Fooled by mere phantoms with un-English names, Endure 'examinations'--Ladies, speak! Do these not shock the soul and blanch the cheek? Surprise comes first--next horror, ill disguised, But soon to worse some get familiarized! For what will trusting woman not believe And bear, when 'scientific men' deceive? With no suspicion of the game these play, Their tales of terror haunt her night and day. Now she dreads 'tumour,' now 'occlusion,' now 'Version' she talks of, with a 'why' and 'how.' Reasons, of course, and numberless occasions, Have these quick rogues for their 'manipulations.' But who--immortal truth!--can justify The frightful means they locally apply? Caustics, that keep their patients always ill, Yet ever ready to indorse their skill; While abscess, ulcer, hæmorrhage itself, Attest what men may CAUSE for love of pelf. Note the result--whatever the pretext, In soul, at least, the woman is unsexed; Words that of yore would make her forehead flush, She now blurts out to men without a blush! Heavens! how can husbands, fathers, brothers lend Their countenance to such an odious end! In all the _animal_ kingdom, where or when Were such things needed--tell us, Englishmen! Of 'base chirurgery' let the world take heed, For this is base chirurgery indeed!" Dr. Ewell, in the introduction to his _Letters to Ladies_, says:-- "The serious object of my present solicitude is to wrest the practice of midwifery from the hands of men, and transfer it to women, as it was in the beginning, and ever should be. I have seldom felt a more ardent desire to succeed in any undertaking, because I view the present practice of calling on men, in ordinary births, as a source of serious evils in child-bearing; as an imposition upon the credulity of women, and upon the fears of their husbands; as a means of sacrificing delicacy, and consequently virtue; and as a robbery of many good women of their proper employment and support. "Several observing moralists have remarked that the practice of employing men-midwives has increased the corruption among married women. Even among the French, so prone to set aside the ceremonies between the sexes, the immorality of such exposures has been noticed. In an anecdote of Voltaire, it is related, that when a gentleman boasted to him of the birth of a son, he asked who assisted at the delivery; to the answer, 'a man-midwife,' he replied, Then you are travelling the road to cuckoldom! The acutely observing historian of nature, Count Buffon, observes, virginity is a moral quality which cannot exist but with purity of heart. In the submission of women to the unnecessary examinations of physicians, exposing the secrets of nature, it is forgotten that every indecency of this kind is a violent attack against chastity; that every situation which causes an internal blush is a real prostitution.... "But the opposition, the detestation of this practice cannot be so great in any husband as among some women. The idea of it has driven some to convulsions and derangement; and every one of the least delicacy feels deeply humiliated at the exposure. Many of them, while in labour, have been so shocked at the entrance of a man into their apartment, as to have all their pains banished; others, to the very last of their senses, suffering the severest torments, have rejected the assistance of men. To be instrumental in relieving one of this truly interesting class, will be a heavenly consolation to all who can be alive to the pleasures of serving the virtuous." Dr. Beach, in his work on Midwifery, has the following:-- "Who shall officiate in parturition? In consequence of the practice which prevails in the present day, this has become a grave question. The physician contends, with much zeal, that it is his province to officiate. Females, he alleges, are incompetent; and these assertions of physicians have influenced the minds of females to such an extent, that they are forcibly impressed with the belief that there are no others competent; and when it is proposed to many women to employ a midwife, they appear to shrink with horror, and many even suppose that in trusting themselves to the most accomplished female accoucheur, they jeopardize their lives.... "The physician takes it for granted, and even boasts, that if he can attend one single case of midwifery in a family, he has _for ever after_ secured their patronage; so that both interest and prejudice operate as obstacles and barriers to any improvement or change in the practice; and although the most fearful consequences have (occurred), and are still daily occurring, modern females cling to this unnatural practice. "Notwithstanding, however, the existence of the above obstacles, we are well assured that females, if rightly qualified, are not only as fully capable as men, but are even more so; and, therefore, the most valid and conclusive reasons may be assigned why a reformation should take place in this department of the practice. What more conclusive than the fact of the actual attendance of women in child-birth in all nations, previous to the sixteenth century; and the attestation of competent persons during the first century of man-midwifery to the fact, that not half so many fatal cases occurred before as after the innovation. And, in the first settlement of this country (America), when females[59] attended exclusively on such occasions, it was as rare a fact to hear of a woman perishing in child-birth, as it is now to hear of an Indian or an animal perishing in labour, who are delivered by the unaided powers of nature." A letter, addressed by Sir Anthony Carlisle, late President of the College of Surgeons, to the late Sir Robert Peel, on the attempt by some members of the medical profession to legalize man-midwifery, is well worthy of the perusal and consideration of our readers. The letter appeared in the _Times_ newspaper, and raised a ferocious howl from the men-midwives; but the ever gullible British public looked upon the affair as a mere medical question in which it had no concern, and the howl carried the day against reason, morality, and truth:-- "SIR,--The high ministerial station which you deservedly occupy, must often expose you to the various kinds of applications respecting the condition and management of our national institutions, and also to personal or partial interference about their several real or pretended interests. In all such instances you must perceive the fairness and the ultimate advantage of preferring direct information from the respective constituted authorities, of requiring advice from rival institutions upon doubtful measures, and of regarding with jealousy the private communications of interested individuals. It is, however, reported that you are, at this time, beset upon the subject of introducing an ordeal for licensing men-midwives, by certain members of the London College of Surgeons, and that you are urged by popular men (whose wisdom and disinterestedness may be questioned) to favour their scheme with your powerful influence. "As the prevalent vice of avarice may have some share in this professional movement, it is fit that you and the public should be acquainted with the probably concealed effects of granting the solicited privileges; and, for the reasons already given, I am induced to address you through the press. "Man-midwifery has only been practised in England during the last hundred years, and it was introduced as a French fashion. From the beginning it has been strongly opposed on the score of its indecency, by many distinguished and scientific medical men; and also, because the birth of mankind appears to them to be a purely natural process, so wisely ordered, that it very rarely demands any other aid than experienced mothers can safely give. Even so late as the illustrious mother of his present majesty, that exemplary Queen was personally attended by good Mrs. Draper, without difficulties or misadventures; whereas the contrary result, under male management, in the fatal affair of the Princess Charlotte and her infant, will be long remembered. "If it should be asked why so many professional men addict themselves to a degrading vocation, it may be answered, that the practice of man-midwifery leads to unlimited power in every family, and thence to lucrative ends. Women, naturally timid, and ignorant of their own structure, are peculiarly exposed, during the most important office of their existence, to the persuasions or menaces of more knowing persons, and they are thence easily made to believe, that the natural and wholesome delays and pains of childbed are within the controul of medical or surgical art--an assumption which is too generally acted upon, and with unvarying evil consequences; because it is a violation of the ways of nature. Men-midwives have continually alleged that ignorant women practitioners commit many fatal mistakes, and now they present similar objections against unlicensed men. If, as I believe, the safeguards of child-bed are amply provided for by nature, and that not one instance in a thousand calls for any other help beyond what any moderately experienced woman can give, why are we to license adventurers, who may seek notoriety by desperate acts, often involving manslaughter--operative acts, the moral propriety of which is very doubtful, and the time and the methods for performing them still subjects for rancorous disputes? But the present affair is not respecting the utility of men-midwives, but the impropriety of empowering any special corporate medical body to coerce the rest; to further impede female-midwives in a becoming duty, and to deprive delicate women of that great resource of self-respect. Already the prevalence of man-midwifery has driven country surgeons and apothecaries to adopt this humiliating office, and the number of women practitioners has been thence so reduced, that paupers are in many places delivered by apprentice boys under sixteen years of age. The Royal College of Physicians in London, who rank the highest for learning and decorum, have lately rescinded their admission of licentiates in midwifery, whether for considering the practice as derogatory to a physician, or as an overweening privilege towards females and children, is not avowed; but it seems that no London physician, educated at Oxford or Cambridge, has yet condescended to be a man-midwife. The Royal Colleges of Surgeons in London, in Dublin, and in Edinburgh, have likewise hitherto renounced every connexion with man-midwifery. "The teachers of midwifery are indiscriminately doctors and surgeons; but at this moment the majority of lecturers and superintendents of lying-in charities are physicians, while a multitude of legally appointed sub-physicians (styled apothecaries) are equally entitled, with the other classes of the faculty, to establish tribunals for examining and licensing candidates for man-midwifery, if they should deem it expedient. Finally, it may be noted, that the different classes of men-midwives have never yet agreed among themselves to adopt a common ordeal for certifying the qualifications of their calling, and you may be assured, Sir, that many worldly interests will rage against the establishment of any monopoly of this kind in any single institution, because man-midwifery is the covert way to medical fortunes. If, however, the greediness of a few individuals should expose this subject to free discussion, and the judgment of married men and modest women should be copiously awakened, perhaps the general custom of employing women may be again resorted to, and their competent instruction publicly enforced. "It is said, that our changeable neighbours at Paris are already tired of their fashionable freak; and when our countrywomen reflect, that not one in ten thousand of their sex throughout the globe allow of the presence of a man during the rites of child-bed, they may acquire courage, and unite their efforts to replace the routine of midwifery among themselves. I will not offend you and the public by any observations upon the outrageous stories collected on this occasion, to prove the violent and fatal injuries committed by unlicensed men-midwives, because I think the privilege sought for would increase those evils. "With the greatest respect, I have the honour to be, your very obedient Servant, "ANTHONY CARLISLE. "_Langham-place_, Feb. 19." "In a recent number of the _North British Review_ appeared an excellent article on 'The Employment of Women;' under the head of women doctors, the writer says: 'But the something practical--where is it?' We believe that a great deal, which is very practical, is scattered over this article. But we have still some further suggestions to offer. Not very long ago, a statement 'went the round of the papers,' to the effect that there were already eight diplomatized female physicians practising in Boston (U. S.), and that there were thirty-eight students in the Female Medical College. 'Whenever,' says an American writer, 'there are sufficient data to establish the truth (now little if at all disputed in America), that child-birth is freed from its worst difficulties and dangers when the unnatural presence of men is dispensed with, the medical and surgical care of women and children will pass into the hands for which nature designed it.' There would appear to be nothing very unreasonable in this, but, on the contrary, something extremely rational and hopeful. But see how the facts stated above are received by the faculty in England. The leading medical journal of this country thus comments upon them:-- "'Female physic thrives apace in America. At Boston, where Columbia gave birth to the young Constitution, which is now sowing its wild oats broadcast, there is a female medical college, numbering thirty-eight students. A grant of government money has also been voted towards establishing a similar institution at New York. This is to be under the immediate superintendence of Elizabeth Blackwell, M.D., late of St. Bartholomew's, with a bevy of those spinsters mentioned by Shakespeare as free "maids who weave their threads with bones" for anatomical demonstrators. "'At Boston, moreover, there are eight doctoresses with diplomas in full practice. We suppose some of these female physicians are married, and this involves a great social mystery of which we have as yet received no account. When the Mrs. M.D.'s are attending to patients in their boudoirs of consultation, or pointing out pathological nicknacks in their anatomical drawing-rooms, or going their rounds with stethoscopes in their bonnets, what are their husbands doing? Do they superintend the perambulators, or are these hitched on to the professional broughams of their mammas? Is it a part of the husband's marital duty to manage the nursery--in short, to attend to the domestic affairs generally? Perhaps matrimony is ignored altogether. Indeed, we do not well see how a conscientious doctoress could promise to love, honour, and obey a husband who might order her to give her patients a dose of strychnia all round.' "Surely this is not the way to deal with so grave a question. Argument must be wanting, or the sneer would not be resorted to by so distinguished an authority. The same questions as are here put might be employed also to write down any description of independent female labour. When women go out to teach drawing or music, or when they attend to shops, or make caps and bonnets, gowns or mantles, what, it may be asked, are their husbands doing? Attending to their own business, if they have any, or living on their wives' earnings, Mantalini-like, if they have not. We do not mean to say that there are no practical difficulties in the way of the effectual working of this scheme. Objections will readily suggest themselves; but they are not insuperable objections. All women may not be fit for such work. But all men are not fit for it. Many women will lack the necessary amount of nerve; but many men lack it also. In difficulty and danger women have great presence of mind. They are often calm and collected where men are unhinged and unbalanced, and incapable of exertion. Women have more tenderness and more patience, and they must necessarily understand many female ailments better than men. They will always have one great advantage over male practitioners--female patients will be more unreserved in their communications to them. Many women have been sacrificed to their delicacy--to their repugnance to state fully their ailments to men-doctors; perhaps even to call them in until it is too late. Let such objections as these be fairly balanced against those which may be adduced against female practitioners, and let us calmly consider the average result. "We do not pretend to know, under the existing order of things in Great Britain, what proportion of children are annually brought into the world without the assistance of any male practitioner. But we know that in humble life it is very common to employ only a nurse or midwife. And we do not believe that, under such circumstances, more dangerous cases of parturition occur than where men are professionally employed. But if such were the case, if the number of deaths or injuries were proportionately greater, no argument could be derived from the fact against the employment of educated and diplomatized women. If, in the present state of things, accidents arise from the absence of men, it is not on account of the sex, but on account of the ignorance of the practitioner. The same amount of knowledge, as indicated by the diploma, existing in both cases, we cannot help thinking that the advantage, in most cases, will be on the side of the female attendant. "We might pursue this subject much further; but time and space have alike narrowed to a small compass, and we have by no means exhausted our notes. In the early part of this paper we have touched on the subject of nurses, but rather in connexion with amateur than with professional labour. Many women of a better kind might find profitable employment in this path of life; and if licenses, or diplomas of an inferior class, indicating a certain amount of medical and physiological knowledge, were granted to them, the business would not be beneath the adoption of women of birth and education. _But here again, perhaps, the jealousy and selfishness of men would step in and thwart our efforts; for the presence of such educated nurses would often render it wholly unnecessary to call in a regular practitioner at all."--North British Review_, No. LII. page 333. "Among the highly civilized and numberless ladies and women of China[60] and the East," says Sir Anthony Carlisle, "ordinary matrons are universally employed in the sanctuary of child-birth: and they would revolt with horror from any proposal to admit the presence of a man." This statement, coming, as it does, from such a high authority, when inveighing against the needless outrage upon the modesty of women, which we commit by the employment of men-midwives, cuts from under them the argument of the interested professors of "the art," who would have us believe, that British women, from the peculiarities of the climate, and a high state of civilization, are more liable to accident and danger in the parturient state, than the women of those countries in which the _fashion_ of man-midwifery is unknown. Even Roberton, one of themselves, is compelled to admit, that any argument based upon climatic influence is fallacious, and easily capable of disproof, for he says, in his apology for the study of midwifery as a science:--"In reply to such a statement as this (Sir Anthony Carlisle's), it has been common to argue that, in warm countries, the parts concerned in admitting the passage of the child are so relaxed, that labour becomes comparatively easy; and that hence we are to account for the nonemployment of accoucheurs. This is a very false view of the subject. In warm countries, whose inhabitants live after the same manner as ourselves, parturition is in no degree easier than it is here. In the town of Sierra Leone, so near the equator as latitude 8° north, we are assured by Dr. Winterbottom, who resided there, that having been present at a number of labours, they in every respect resemble those of women in the same situation of life in England. "I have met," says he, "with instances in England where the foetus was expelled with more ease than I ever knew it to be at Sierra Leone."... "The prophetical writings of the Old Testament furnish many allusions to painful parturition. The Jews inhabited a warm climate; and yet, were we to judge of parturition among them from the frequent reference the prophets make to it in figures and similes, when predicting the sufferings to be produced by impending judgments, we should conclude that in no people was nature's sorrow more severe. Thus, Jeremiah, the coming miseries of Judah passing before his vision, exclaims:--'I have heard a voice as of a woman in travail, and the _anguish_ as of her that bringeth forth her first child, the voice of the daughter of Zion that bewaileth herself, that spreadeth her hands.' A multitude of passages containing a similar allusion might be cited. In the historical part of the Scriptures, too, there is incidental mention of several cases in which parturition proved fatal. So much for the relaxing influence of a warm climate! a notion which, like various others respecting the influence of climate on the human system, is at variance with facts." Among the myriad peoples inhabiting the vast Continent which, in the aggregate, we term India, men-midwives are unknown. There have been, no doubt, attempts made by Europeans to introduce the abominable custom, but we believe, excepting in some of the towns most frequented by them, without any considerable success. As the inhabitants of Tahiti, and the isles of the Pacific, once the abode and very Paradise of nature in her glorious perfection, have found to their cost, so we fear in all other portions of the world's surface, where our boasted civilization has set its foot, the evils which accompany its progress invariably take precedence, and largely preponderate over its advantages. Wherefore should we add to the primal curse fulminated against woman, irrespective of locality or race, "in sorrow shalt thou bring forth children," a far greater one in the ruin of her modesty, by the introduction of man into the sanctuary hallowed by his absence from the beginning of the world. O ye fine ladies of England, who talk so glibly of all the virtues, and blazon your moral excellencies before the nations! if ye will not take example from the highly civilized and numberless ladies and women of China and the East, learn from the poor savage, in whom, though doomed to the lowest grade of earth's inhabitants, there yet glows fresh from Heaven, like a pure star gleaming through the night of heathenism, that loveliest attribute of woman--modesty. Over that mysterious rite which God has confided to the female sex, the rude, wild, cruel, ignorant, uncivilized, naked, idol-worshipping natives of New Holland, throw a veil impenetrable to man. Roberton says, page 480, "Among them (the New Hollanders) a man is not permitted to approach where parturition is going on." There are, however, rare and beautiful exceptions to that accursed fashion which now so debases the women of this country; for we have undoubted authority for stating that "there are ladies, and ladies of rank, titled ladies, who would not let a man near them." In these bright examples propriety still finds a refuge; in their chaste minds the light of reason and refinement shines with a fair and unsullied ray amidst the gloom of apathetic indecency, which shrouds in its cold and clammy cerements so many of their sex. All honour to those true-hearted women who so proudly uphold their native modesty, their sex's loveliest charm, above the rank pollution which, in these sensuous and degenerate days, infects the sanctuary of marriage.[61] Among the Jews, the peculiar people, guarded and preserved so wondrously by the Providence of God, from the day that Israel went down into Egypt with three score and ten souls, until they had multiplied "as the stars of the heaven, and as the sand which is upon the sea shore," no such violation of decency was permitted or required to insure the fulfilment of God's promise to Abraham. We learn that females were regularly authorized and appointed as midwives, for the Sacred writings give us the names of two of them: "And the King of Egypt spake to the Hebrew midwives, of which the name of the one was Shiphah, and the name of the other Puah: and he said, When ye do the office of a midwife to the Hebrew women, and see them upon the stools: if it be a son, then ye shall kill him; but if it be a daughter, then she shall live. But the midwives feared God, and did not as the King of Egypt commanded them, but saved the men-children alive. And the King of Egypt called for the midwives, and said unto them, Why have ye done this thing, and have saved the men-children alive? And the midwives said unto Pharoah, Because the Hebrew women are not as the Egyptian women; for they are lively, and are delivered ere the midwives come in unto them. Therefore God dealt well with the midwives: and the people multiplied and waxed very mighty. And it came to pass, because the midwives feared God, that He made them houses." We know also that there were physicians in those days, for "Joseph commanded his servants the physicians to embalm his father, and the physicians embalmed Israel." Now, it is most certain that if the great protecting power of the Jews--the father of his people, had deemed it necessary or proper, for the safety of mothers or of offspring, to afford any assistance beyond that which nature and the midwife supplied, it would have been so ordained, and as surely mentioned by the great historian and leader of the Israelites, or by some other of the sacred writers; but of this there is no sign whatever, and we must, therefore, infer that this innovation was not so much as thought of by the Jews, highly civilized and vicious people as they were, and that it was reserved for us, in the nineteenth century of the Christian era, to permit such a scandalous breach of decorum as the prostitution of our wives to the impure touch of a _man_-midwife. Roberton says, in his Apology--"But an objector will ask, cannot a matron practise these expedients? and if so, where is the use or propriety of such a class as men-midwives? I reply, doubtless a matron may practise many of the expedients referred to, if they have been taught her. It is of the value of midwifery as a science, originating with and practised by men, compared with matron or uncultivated midwifery, of which I have been speaking. A certain proportion of instructed female midwives in a community may, for aught I know, be a benefit." Let the reader mark, learn, and inwardly digest these words! Here is the admission of an accoucheur of the present day, confirming the words of Roussel, and the many other authorities whom we have quoted, as to the fitness of women for the practice of the expedients necessary in midwifery, and, further, a most important acknowledgment, as coming from one of his class, that females, properly instructed as midwives, would be a benefit to society. To be sure they would! Who doubts it? And is there not enough of wealth, and energy, and right feeling in England to say--We will that there shall be in every community properly instructed midwives; we will that there shall be organized, in all our great towns, schools of midwifery for the instruction of women,[62] who shall go forth from them fully competent in "nine hundred and ninety-nine cases out of every thousand," to perform that office which is now, from their sex, so indecently performed by men. The instruction of midwives has nothing of novelty in it: women are so instructed in the Dublin Lying-in Hospital, at this day, and we believe[63] that they are so instructed at Manchester and in London; they "walk the hospital," as the term is, for six months, and at the end of that time they receive a "diploma;" but there is a jealousy on the part of the accoucheurs, who fear, naturally enough, that their trade (a very lucrative one[64]) might be injured if these women should assume too much responsibility, and the consequences of this jealousy[65] are injurious to the full and complete instruction and competency of the "nurses."[66] These nurses are very much in the power of the accoucheurs, for it is principally through the latter's recommendation that they obtain employment, at least among the upper classes, and the evils which arise from this state of things are fatal to the interests of morality. _The nurse is afraid to act without the man-midwife_, not because she is incompetent, for she has walked the hospital and has her diploma of efficiency, but because it essentially concerns the _man_-midwife to play the principal part, in order that the belief in the necessity for his presence and _assistance_ should not, by any act of hers, be shaken; such is their jealousy on this head, that we have known the man-midwife, on arriving too late to be present at the birth, roundly rate the nurse of his own appointment for not having sent for him sooner, although the case was of the most ordinary description, and great additional ease of mind and general comfort were experienced by the patient, through the absence of the doctor.[67] The nurses in their six months' training at the hospital learn much, however, that is useful to them in their own after-practice, for many of them are employed by the humbler classes from motives of economy, and we would fain believe of delicacy also. Through one of these nurses we have learnt the frightful indignities to which the poor hospital patients are sometimes subjected. A difficult case of labour, as it is termed, occurs, the wretched victim is stripped naked, candles are placed around the bed, and the students assemble in crowds, perched on ladders and benches, to watch the progress of the labour, and the manipulations of the operator. O God! that in a Christian land, in our boasted Britain, priding herself on her civilization and proprieties, such orgies, which would raise a blush amidst the rites of devils, should disgrace the name of science! We have said that women are admitted as pupils at the Lying-in Hospital in Dublin, and that after a six months' probation they obtain a diploma: but, as they are never permitted to operate in any but ordinary cases, it cannot be intended that their education should obviate the necessity for the employment of accoucheurs. Now we would suggest, that instead of this partial instruction they should be afforded ample opportunity for acquiring a perfect knowledge of the expedients necessary for overcoming the difficulties of their profession; that, instead of dismissing them at the end of six months, they should be retained until they are sufficiently instructed to be able with confidence and facility to undertake those extreme cases which are now reserved to men. No man of intelligence, who reflects on this subject, will for a moment doubt that where nicety of touch and delicacy of handling are required, the female organization is more perfectly adapted for them than that of men; and when we consider the delicate duties to be performed in midwifery, we cannot but think (and the thought will find an echo in the minds of thousands) that woman, and woman alone, is both morally and physically fitted for the office.[68] It may possibly be urged by the men-midwives, that, if they were to be deprived of their ordinary practice, and to be superseded by women, in all cases of labour in which no extraordinary difficulty presented itself, they would not be so well prepared to operate when accident might call for their interference. We may in all justice reply, what is that to us? see ye to that; are we to prostitute our wives to your impure touchings, "manipulations," tentatives, and experiments, in nine hundred and ninety-nine needless cases, in order to afford you the requisite experience for the thousandth? We trow not; and the science of surgery must indeed be at a low ebb if, when occasion requires, there are not to be found men of that noble profession who could undertake with success any needful operation. In former times the difficulties in certain cases of parturition, which are now trumpeted forth by the writers on man-midwifery "with all the pomp and state of academic learning," were easily overcome by discreet and experienced women, who, although innocent of physical, classical, or mathematical science, knew full well how to operate when necessity called for their intervention. We find the following passage in Albertus Magnus:--"Whence it is to be known that in some women there is greater suffering than in others, because in some it happens that the foetus sometimes presents a hand, and sometimes a foot, all which are hurtful. Then the midwives carefully thrust back the foetus, and hence great pain is produced, so that many women, unless very robust, are weakened even to death," &c. Then, after describing the effect of an accident which sometimes occurred even with the more appropriate assistance of the female hand, but which[69] _if the truth was known_, since the invention of instruments has probably been of much greater frequency, he continues: "Then discreet midwives use a certain ointment, anointing the vulva, because the womb is often injured and wounded in the vulva, and therefore it is necessary that discreet women and experienced in this operation should be employed in delivery.[70] But this I have learnt from some women, that when the foetus presents its head in the outlet, then the business fares well, because then the other members follow without difficulty, and an easy labour is the result."[71] To the casual reader who has the curiosity to wade through the filthy and disgusting details of the ponderous tomes on obstetricity, for the most part garnished with engravings at which "purity must blush and licentiousness may gloat," and who incontinently pins his faith upon the dogmas thereof, it will seem absolutely incomprehensible how unit after unit, of millions on millions numberless, who have peopled earth, contrived to see the light, from the days of our general mother Eve, until that happy hour when first "obstetric science" flashed upon the world, and by its magic touch scattering the dreams of a primeval curse, vouchsafed its "art" to teach poor feeble ineffectual nature how to act. One result of the frightful tissue of imaginable and unimaginable horrors contained in these books, is that almost every woman in the upper and middle classes believes that the chances are ten to one in favour of a "cross birth;" the nurse, instead of relieving her fears, rather confirms them, and on the strength of that understanding which always prevails between the nurse and the _man_-midwife, she takes care to impress upon the sufferer, wrought up to a pitiable state of nervous excitement, that nothing but the beastly manipulations of the "doctor" can render the labour successful. Women, while suffering under the severe pangs of parturition, most frequently lose much of that natural delicacy belonging to the sex, and at the moment when terror and anxiety overrule every other feeling, the _man_-midwife approaches, and offers to the trembling victim that disgusting insult, the examination _per vaginam_; an inquest both morally and physically injurious to the patient, and utterly needless, from the information previously obtained by the female attendant. Furthermore, these men well know that "one fool makes many," and that the more they are able to convince the public of the dangers and difficulties of child-birth, the more sure are they of an unfailing trade in the practice of _man_-midwifery. _Ce n'est que le premier pas qui coute_, and when they had successfully achieved one generation of patients, the rest was easy; all henceforward was plain sailing; the mothers, despite the qualms of outraged delicacy, once convinced that their safety had been dependent on the skill of the _man_-midwife, the daughters, as a matter of course, followed in their wake; the idea, if perchance it occurred, of the indecency of the act, being promptly set at rest by the recollection that their mothers had done the same. Thus a kind of freemasonry is established between the _men_-midwives and women, which, from its very nature, cannot be free from gross impropriety, and is sometimes attended with most pernicious consequences, of which the husband is kept in entire ignorance.[72] It is a common occurrence in ordinary life to see the _man_-midwife seated as a guest at your dinner-table, or as a morning visitor in your wife's drawing-room, who perhaps but a few weeks before may have informed himself both by _touch_ and _sight_ of all the inmost secrets of her person, who knows as well as you do yourself every hidden charm which she possesses. Faugh! the very thought is gall and wormwood, and outraged delicacy demands instant and eternal redress. Sir Anthony Carlisle, late President of the Royal College of Surgeons, assures us that child-birth, like parturition in the lower animals, is purely a natural process, the safety of which Divine Providence has most wisely secured; and consequently that it is always mischievous to tamper with pregnant women, under the pretence of hastening, easing, or retarding their delivery. Roberton, in allusion to the above, says--"If this be correct, it follows of course that midwifery is no science, but a presumptuous fraud."[73] Again he says, "Admitting, as I do, not that ninety-nine in a hundred, but that a large proportion of labours, say nineteen out of twenty, would terminate well under the eye of an intelligent nurse, were they left _solely_ to the energies of nature,"[74] &c.; and again, "I have admitted that a considerable proportion of labours would do well, unaided, under the eye of a nurse," &c.[75] Dr. Johnson says--"The ordinary treatment of women in child-bed is irrational, indefensible, and most preposterously foolish. Nothing can be more absurd. Childbirth is not a disease! It is simply the performance of a natural function, like eating, drinking, &c., yet we treat it as though it were some formidable and dangerous malady. Dr. Conquest, a London accoucheur of repute, says--'Child-birth is that natural process by which the womb expels its contents, and returns to the condition in which it was previously. I call it a natural process; and in my opinion no sentiment is more pregnant with mischief, than the opinion which almost universally prevails, that this process is inevitably one of difficulty and danger. I am well aware that some degree of suffering is connected with child-birth; and this applies equally to the whole animal creation, whether human or brute, though the former suffer more than the latter, _because the habits of brutes are less unnatural_. That the suffering of women during child-birth is referrible, in a great degree, to their artificial habits of life, and not to their form and make, is evident from a variety of circumstances. History, in all ages of the world, establishes this position. What made the striking difference between the ancient Hebrews and Egyptians, of whom it is said: "The Hebrew women are not as the Egyptian women; for they are lively, and are delivered ere the midwives come in unto them?" What, I would ask, made the marked difference in the labours of these two classes of women, but the plain, simple, and industrious habits of the Hebrews, as contrasted with the effeminacy, and luxurious living of the Egyptians? Look into more modern history, and you will see the same fact established again and again. I could mention innumerable proofs, but a few must suffice. "'The celebrated traveller, Bruce, says, that the Abyssinian women retire by themselves, and go through the process of child-birth with so much ease and expedition, that they do not confine themselves a day after labour, but return to their usual occupations immediately. "'The same simplicity, expedition, and freedom from danger, attend this natural process amongst the natives in most parts of Asia, Africa, the West Indies, and America, where the mode of living among the natives is more simple and abstemious, and their occupations and general habits more laborious, than in more civilized countries. "'The Moorish women have no midwives, but are usually alone at the time of delivery, lying on the ground under an indifferent tent. They will even travel, on the same day, a distance of fifteen or twenty miles. "'In Morocco the women suffer so little, that they frequently go through the duties of the house on the day after their delivery, with the child on their back. "'One respectable traveller assures us, that with the native Africans labour is so easy, and trusted so entirely to nature, that no one knows of its existence till the woman appears at the door of the hut with the child. "'Another, equally respectable, tells us, that as soon as an American Indian woman bears a child, she _goes into the water and immerses it and herself_.[76] One evening he asked an Indian where his wife was: he replied: "I suppose she has gone into the woods to set a trap for birds." In about an hour she returned with a new-born infant in her arms, and holding it up exclaimed: "Here, Englishman, here is a young warrior!" Were it necessary, many more instances might be brought forward. But it has been said, this occurs only in warm climates, where the heat relaxes the parts concerned in parturition. This objection is not consistent with truth, for the natives of Livonia, and the savages of North America, retire to some private place, and return immediately after their delivery to their customary work; and the Greenlanders do all their common business just before, and very soon after their labour, and a still-born or deformed child is seldom seen or heard of among them. Still further to establish the assertion that human parturition is not necessarily a process of danger, we know that in this country servant girls, who become illegitimately pregnant, very often absent themselves for an hour or two, and, after giving birth to a child, return to the discharge of their household duties immediately.[77] It is, therefore, obvious that the difficulty and danger that so often attend child-bearing in civilized society,[78] are attributable, principally, to _unnatural customs and habits of living_, in which, women, in this and other countries, indulge from their infancy,[79] and which operate by preventing the constitution from acquiring its proper firmness and vigour, and by producing a weak, feeble, and irritable state of body, &c.'" Dr. Johnson adds: "This is the language of Dr. Conquest--a metropolitan accoucheur physician of much eminence--a man who, from the long and successful practice of his profession, has deservedly acquired wealth and distinction--a man, therefore, who can afford to be honest--a man who, unlike Archdeacon Paley, can afford to keep a conscience. With those, therefore, who put their trust in authority rather than in the light of their own reason--that is to say, with nine hundred and ninety-nine persons out of every thousand--the opinions of such a man as Dr. Conquest cannot fail to have more than ordinary weight."[80] In the foregoing pages we have sought to place before our readers, in the clearest light, the opinions of Roussel and other eminent men, touching the practice of man-midwifery; opinions the force and truth of which, based as they are upon principles of the purest morality, and the sound doctrines of physical science, cannot be controverted or denied. We have shown that the Royal College of Physicians, so lately as the year 1827, designated the practice of _man_-midwifery as "an art foreign to the habits of gentlemen of enlarged academical education," and one which might safely be entrusted to discreet matrons. We have, in confirmation of these opinions, quoted the sentiments expressed by Sir Anthony Carlisle, late President of the College of Surgeons, who styles the boasted "art" "a pretence," and accoucheurs "mere nurses." We have proved, by the admission of men-midwives themselves, that the great majority of cases of midwifery would do well under the eye of a nurse, and that skilled midwives would be a benefit in every community. We have before our eyes the example of France with her schools of midwifery; and against the arguments and dispassionate opinions of men of the highest rank in the medical profession, mooted as they have been at various times, and in different countries, yet all tending to the same conclusion, we find absolutely nothing but the self-interested doctrine of an anomalous class[81] of medical men, whose policy it is, for the furtherance of their own selfish views, to decry the powers of nature, and to abrogate the employment of females in the sanctuary of child-birth; a doctrine which suffers its disciples, regardless of all delicacy, and in defiance of the contempt of their professional brethren, to prey upon the weakness and natural timidity of the sex, and with presumptuous indecency to arrogate to themselves duties proper only to women; a doctrine which, while it deals an irreparable blow[82] at the very heart of every family, threatens with destruction virtue, modesty, and honour. Husbands, fathers, countrymen, THINK OF THESE THINGS! We do most heartily believe that if, unbiassed by the self-interested and fraudulent assertions of quackery and empiricism, you would exert your own reasoning powers on the question, the doom of this abuse would soon be sealed. But as, in many another usage which men individually admit to be blots in that high state of civilization to which we have advanced, our apathy overcomes our desire for their correction, and we let them pass; so, because this wrong has forced its prostituting influence through the length and breadth of the land, magnified and sustained as it is by the terrorism of treatises, and the artistic display of its abettors, despite the warnings of our consciences, we yield ourselves to its guidance, we dare not lift up the veil which conceals its abominations, and even fear, cowards that we are, to question its privileges, privileges which a "damned custom" has accorded; privileges the very thought of which should make the blood curdle in our veins with disgust and horror! For if we for a moment reflect upon the precepts laid down in the indecent farragos of "obstetric science," and further upon the fact, that these precepts are invariably carried into effect, whenever the "patient" can be induced to submit to the outrages therein enjoined, we must acknowledge that in all such cases purity itself can oppose no effectual barrier to these insidious assaults, and that modesty must fly from the chamber when the _man_-midwife crosses its threshold. O hateful, horrible thought! that the young bride, radiant with joyous innocence, and love's glowing fantasies, "beautiful exceedingly," and pure as fair, must in a few short months, in blind obedience to a spurious custom, yield herself to the pollution of a stranger's _touch_, and banish for ever from her husband's soul that dear delicious dream, entirety of possession! This is no exaggerated picture, no overstrained description of that mortal stain which rends into very shreds the charm of delicacy; but a simple truth, a terrible reality, not to be glozed over by the fallacious reasonings of frigid philosophy. O men! if you have the souls of men, if one drop of the old chivalrous blood of your ancestors yet palpitates in your veins, if you have not irrecoverably bowed down to the idol custom, if mammon, lust of gain and power, with all the fell catalogue of vicious inclinations, have left but one cell unoccupied in your heart's mansion, if you yet hold woman to be the fairest, purest, best of the Creator's works; oh! let the cry of "out damned spot," rise heavenward from every home in the United Kingdom; let sacred purity once more assert her rights, let nature's illimitable powers do their work unaided, undefiled by the sordid infamy of charlatanism, and future generations shall gratefully invoke unnumbered blessings on the memory of those who saved the daughters of England from the curse of a cruel degradation. THE END. Footnotes: [1] "In the midst of our apparent material prosperity, let some curious or courageous hand lift up but a corner of that embroidered pall, which the superficial refinement of our privileged and prosperous classes has thrown over society, and how we recoil from the revelation of what lies seething and festering beneath!" _Mrs. Jameson's_ "_Communion of Labour_," pag. 20. [2] Anno 1663. Vide Roussel, Systeme Moral et Physique de la Femme, ed. 1855, p. 224, and Astruc, Maladies des Femmes, t. vii. [3] This surgeon was most probably a person named Chison, of whom Count Bussi Rabutin relates the following anecdote:--"Meanwhile Madame de Crequi went to seek Madame on the day which she had appointed for their party to St. Cloud. She there met Chison, who had come to see one of Madame's girls who was ill; he is La Valiere's medical man, and is facetious and witty; after he had learned the complaint of the young lady, Cheer up, said he to her, I have remedies for all, even for lovers' hearts. Ho! G---- G----! replied Madame, teach me them directly, for ten or a dozen that I have, whom I should like to cure, provided it costs me only a few garden herbs. Ha, Madame, replied he, it costs me much less than herbs, it costs me nothing but words. In fine, Chison, who sacrificed everything for the entertainment of Madame, related to her how the king had sent to him to inquire, and that he had demanded, with extreme emotion, whether Mademoiselle de la Valiere could really survive, and if her leanness was not a bad symptom. And what was your answer? replied Madame. What, said he, can your highness be in doubt? I assure you that I promised him, with as much boldness, the prolongation of her years, as if I had a letter from Heaven. I spoke as a philosopher of life, and death, and destinies; it needed nothing (when I saw the joy of the king) but to have promised him an immortality for the girl. True, G----, cried Madame; what secret charms has the creature to inspire so great a passion? I assure you, replied Chison, that it is not her body which supplies them."--_Hist. Am. des Gaules. Amours de la Valiere_, page 430. The "witty and facetious" Chison spoke with a certainty which experience alone could give; he had doubtless attended La Valiere in her "confinement." Do such conversations ever occur now? There is nothing new under the sun; what has been will be, and the laureate, not without reason, sings in Maud:-- "Yonder a vile physician blabbing The case of his patient." [4] Alison's History, page 111, vol. i. [5] Ibid. page 180, vol. i. [6] Alison's History, page 217, vol. i. [7] Astruc, des Maladies des Femmes. [8] Ex-Maitresse Sage-Femme, Surveillante-en-chef de l'Hospice de la Maternité et de la Maison Royale de Santé et de l'Administration Generale des Hôpitaux et Hospices Civils de Paris; Docteur en Médecine de l'Université de Marbourg, &c. &c. &c. [9] Since this was written we have ascertained that a Charity, called the "Royal Maternity Charity," has existed for a century in London. "It was instituted, 1757, for the gratuitous delivery of poor _married_ women at their _own habitations_. The patients are attended in their lying-in by skilful and well-taught midwives, (of whom there are now thirty-five), under the watchful superintendence of appointed physicians, by one of whom the midwives are first carefully instructed at the charge, and expressly for the service of this charity; and, being located in various parts of the metropolis, and not restricted, in the exercise of their profession, to the patients of the Charity solely, though such patients are, at all times and without exception, to have the preference, their services are available to any other persons, who, either from choice or necessity, may be desirous of employing a midwife instead of a medical man; and as these occasions are not rare, some of the midwives having from fifteen to twenty _private_ patients per month, it is not among the least of the advantages incident to the establishment of the ROYAL MATERNITY CHARITY that it is the means of keeping up a class of respectable, intelligent midwives for such emergencies."--_Prospectus of the Royal Maternity Charity, office 17, Little Knight Rider-street, Doctors' Commons, London._ [10] "It must be acknowledged that, although the function of midwife belongs to the healing art, it was never intended to be exercised by men."--_Roussel_, page 217. "It is incompatible with the general infirmities of human nature to expect that the medical profession, exercised as it is for the daily means of maintenance, can be filled with men of science, with philosophers, or even with honourable gentlemen, while the greatest number are remunerated according to the quantity of drugs they craftily sell at random, as pretended antidotes, and others follow the business of mere nurses, with all the pomp and state of academic learning."--_"On Health," by Sir Anthony Carlisle, F.R.S., late President of the Royal College of Surgeons, and Surgeon of the Westminster Hospital._ 1841. [11] "Others, many others, less industrious, have been amusing and facetious. It is not long since I stood by the bed of a lady, who, between every pain, was making merry in talking with the nurse; and, the moment after the head and no more was born, commenced giving me an amusing account of one of my patients, a relative of hers, whose ailments, she assured me, arose from inattention to my rules of diet." (!!)--_Roberton, Physiology_, &c., page 459. Oh, Roussel, how prophetic were your words! [12] Roussel, p. 222. [13] Female physicians were still known at Rome in the time of the Emperors, according to this verse of Martial, "Protinus accedunt medici medicæque recedunt."--_Hecquet._ [14] Olympias, Sotira, Salpe, Laïs, all cited by Pliny, and many others of whom distinguished authors make mention.--_Hecquet._ [15] _Stevens' Man-Midwifery Exposed._ [16] Hecquet says: "The provinces at a little distance from Paris still find this custom very revolting."--_De l'Indecence aux Hommes d'accoucher les Femmes_, page 8. [17] "In labours strictly natural, terminating after a few hours of moderate suffering, scientific midwifery is passive; its interference extending only to the division of the funis."--_Roberton._ [18] Lives there a man who would believe that the strongest passion which nature has implanted in the human heart is altogether dead in the _man_-midwife, that he is in fact emasculated by his profession, although "not necessarily an old woman?" It is far otherwise, and many of these gentry have the organ of philoprogenitiveness strongly developed. [19] By "_le toucher indiscret_," as the French term this hateful indecency. [20] We are informed that in the Dublin Lying-in Hospital neither nurses in training as midwives, nor male students, are permitted to operate in any case of difficulty. We are not aware if this remark applies to the London hospitals and similar institutions in other parts of the kingdom, but we have little doubt that in this respect the practice is the same in all. It is not easy to understand how, under these circumstances, either nurses or students can acquire much, or indeed any, knowledge for discrimination. It is most painful to reflect that any experience which these persons may ever possess, must of necessity be gained after they are let loose upon the world, at the sacrifice, it may be, of life, or at least of moral and physical suffering, and injury to those patients who are the unfortunate objects of their first essays. [21] Letter from the Royal College of Physicians to the Secretary of State for the Home Department, dated May 2nd, 1827, in reply to a memorial from the Obstetric Society. [22] No; because "unmarried females" have not themselves endured these outrages, and still retain a modesty which is born in every woman, and, therefore, might possibly re-animate in the patient feelings which, howsoever natural, beautiful, and holy, would mar "the doctor's process." [23] "Generally, indeed, no _active_ assistance is necessary until after the birth of the child," &c. _See ante, Ramsbotham ipse._ "And another reason is, that such patients have been spared the ill effects arising from vaginal examinations," &c.--_Treatise on Midwifery._ Hardy and M'Clintock. Page 9. "We here feel ourselves obliged to inform women that those persons whom they employ in this kind of examination deceive them by affecting a knowledge which they do not possess. All information derived from 'touch' is very uncertain."--_Roussel Systeme Moral et Physique de la Femme. Chap. sur la Grossesse._ [24] Has the doctor first informed the husband of the necessity for this _vaginal examination_? Has he, before entering the patient's chamber, or at least before he dared to make such "a request" to her, gained the husband's confidence by candidly and honestly explaining the indelicate nature of the usages which his "art" permits him to adopt? [25] See Roussel, _ante_. [26] There is a maxim prevalent with accoucheurs, and the hellish aphorism is treated as a jest among them, that a woman will usually desire to patronise, upon all subsequent occasions, the man-midwife who has once introduced his finger _per vaginam_. [27] A foul delusion, promoted and encouraged by the doctor, and the midwife, at his instigation, well knowing, that in nine hundred and ninety-nine cases out of a thousand, nothing else would induce a woman to submit to so gross an indecency. [28] "It has been said that women delivered under circumstances where they had no assistance, generally escape laceration; now this is not universally true; but supposing that it were, it admits of this easy explanation: namely, that inasmuch as these females are almost always involuntarily subjected to the deprivation we have mentioned, they naturally use their utmost endeavours to retard the birth of the child when they feel the head in the vagina, in the hope of aid reaching them before the critical moment of delivery; and another reason is, that such patients have been spared the ill effects arising from vaginal examinations, &c."--_Extract from Treatise on Midwifery, by Drs. Hardy and M'Clintock_, page 9. Let the reader compare these observations with those of Dr. Ramsbotham--"look on this picture and on that,"--and then he will be astonished, not at the difference of opinion between the men-midwives, but at the fact that women do so frequently escape the terrible consequences of all this interference with the laws of nature. [29] As if nature would not of herself direct the position most likely to facilitate delivery. "Who ever found the eagle dead upon her eyrie, or the she-wolf in her lair?" and would the doctor have us believe that while giving to man dominion over every living thing, thus recognizing his physical as well as mental superiority, and greatly multiplying the conception of woman, God had forgotten to instruct her in a faculty which he gave in perfection to all the lower animals? [30] Roberton, Physiology, &c., page 425. [31] An instrument called the speculum matricis was, however, in use at the beginning of the last century, and is mentioned in the Bibliotheca Anatomica, 1712. [32] The Speculum; its moral Tendencies. By a Fellow of the Royal College of Surgeons. London: Bosworth & Harrison. [33] Vide Ramsbotham, _anté_. [34] "It was to the midwives that they applied, in the first ages of the Church, to be assured of that fidelity which Christian virgins had vowed to their state of chastity. But, if the Fathers found fault from the time when Christian females were thus exposed to the judgment of their own sex; if they discovered in this practice something shameful and infamous, of what criminality would they not have taxed the attempt of men at the present day, who, in like cases, are not ashamed to deprive the midwives of this employment."--_Hecquet, De l'Indecence aux Hommes d'accoucher les Femmes_, page 7. [35] O ye adepts in chloroform, take heed to your ways, and O ye fools, who submit to be made _dead-drunk_ under its influence, beware lest a worse thing happen unto you! "It would be absurd to suppose that the cases of sudden death from chloroform constitute the full measure of the mortality. How few even of these are generally known or reported. Hardly any in private practice; and now, even in hospitals, they are concealed. It is well known to the frequenters of the London hospitals, that, in the same week in which the recent death from chloroform at St. Thomas's occurred, another took place in another hospital, but which did not become the subject of judicial inquiry. Humanity, and the character of the profession, demand that the whole subject should be investigated anew."--_Medical Times and Gazette._ [36] Roussel, page 177, de la Grossesse. [37] Maladies des Femmes, t. v., p. 375. [38] Roussel, de l'Accouchement Naturel, page 208. [39] "It is a common notion, that the brute enjoys great advantages, compared with woman, in the act of parturition, from the position and configuration of its pelvis. Is not this groundless? In the first place it is said that the oblique axis of the brim, in woman, is less favourable to the descent of the foetal head than the axis of the brim in the brute, which is parallel with the spine. But the physiologist knows, that ordinarily in woman, just before the commencement of the labour pains, the uterus slowly, and without pain, descends by a mechanism, which Sir C. Bell has so beautifully described in his memoir on the muscularity of that organ; and that thus a small segment of the foetal head becomes engaged in the brim, and in the position most favourable for passing, before the uterine pains commence. The truth is, the obliquity of the axis of the brim is, in general, _no disadvantage or impediment whatever_. In the second place, it is urged, that the great size of the human foetal head occasions incomparably more difficulty than the sharp-pointed, small head of the brute foetus. For this there is equally no foundation. The size and figure of the human brim are as well fitted to give passage to the large head of the child, as the brim of the brute pelvis to allow the entrance of the comparatively smaller head of the foetal brute, &c., &c. Still looking at the figure of the human foetus, and comparing it with that of the foetal brute, some may be inclined to imagine, notwithstanding what has been said, that the brute will pass with far greater facility than the child; such was my own opinion till I subjected the point to the test of experiment. We are not to think, but to try, as John Hunter advises," &c.--_Roberton, Physiology, &c._, p. 247. [40] _L'Histoire General des Voyages._ [41] "During pregnancy the squaw continues her usual avocations, and, even in its most advanced state, she neither bears a lighter burthen on her back, nor walks a shorter distance in a day, than she otherwise would. If on a march she feels the pains of parturition, she retires to the bushes, throws her burthen from her back, and, without any aid, brings the infant into the world. After washing in water, if at hand, or in melted snow, both herself and the infant, she immediately replaces the burthen upon her back (weighing, perhaps, between sixty and one hundred pounds), secures her child upon the top of it, protected from the cold by an envelope of bison robe, and thus hurries on to overtake her companions."--_James' Narrative of Expedition from Pittsburgh to the Rocky Mountains._ [42] "The Samöides are a tawny, squat, miserable race of pagan savages, subjects of the Russian empire. They are found along the Frozen Sea, on the European side of the Jugorian Mountains, east of these on the River Oby, and elsewhere on the vast shores of Siberia. According to Tooke, they are mature at a very early age," &c.--_Roberton_, quoting _Tooke's Russian Empire_, vol. ii. p. 286. [43] "The truth is, that when the pregnant will submit to prepare themselves for what is before them, will be temperate in their eating, regular in their hours for sleep, and for exercise daily in the open air, a considerable proportion may secure benign labours. It is the sedentary and luxurious who oftenest suffer severely in parturition," &c. &c.--_Roberton's Notes on Pregnancy_, p. 460. [44] Roberton has a remark to the same effect. [45] "The beasts ca't manipulated."--_Shepherd on the Phrenologists, Noctes Ambrosianiæ_, vol. ii. p. 21. [46] "The calling of 'accoucheur' does not appertain to men. It is with them nothing but a usurpation, or a rash experiment, founded upon the timidity of women, who believe that, by this unworthy submission, they insure their lives; and upon the credulity of husbands, who, by this dangerous condescension, imagine that they more surely preserve their wives."--_Hecquet, De l'Indecence aux Hommes d'accoucher les Femmes_, page 9. [47] "Ubi non est mulier, ibi ingemiscit æger." Where woman is not, there the sick man groans. [48] "At the time when this work was published, there had appeared a catechism, in which M. Dufot, a physician, who was the author of it, proposed to himself to instruct the midwives in the country, and he set forth in a manner clear, exact, and perspicuous, the principles of the art of midwifery. It would be desirable that these ideas, which are sufficient for their purpose, should be disseminated; they would prepare the public to do without the help of men in an office where their agency seems necessarily to compromise morals. This object, to which some men only gave the attention which it deserved, is doubtless the one which has urged some intendants to occupy themselves in the instruction of midwives. We learn from the _Gazette de France_, of 25th September, 1776, that the dame Ducoudrai, commissioned and pensioned by his Majesty, had, by the care of M. Fontette, chief magistrate (intendant) of Caen, organized more than a hundred and fifty midwives in two public courts which she had held. That example, without doubt, will not be lost on the provinces; whatever the price of knowledge may be, it is in such close contiguity to the temptation to abuse it, that I dare hardly put up any prayers for my country. In all the County of Foix, where I was born, deliveries are intrusted to women of the lower order, who never have the least idea of anatomy, and with whom the whole art is reduced to some practical and traditionary customs. But they display zeal, patience, and uprightness, while the others apply themselves to nothing but the glitter of a scientific phantom, and the former cannot but succeed the best. I remember to have seen but one woman perish, in my little town, from the consequences of labour. It is true that, contrary to custom, she had been delivered by a man. The event was so distressing, that they had every cause to believe that nature reprobated such a fatal innovation." [49] Here let us illustrate the truth of Roussel's observations, by a statement of facts which have occurred in our own day:--The _Portafoglio Maltese_ (October, 1856), in describing the frightful effects of a late earthquake in Candia, gives the following:--"In one case a woman was discovered alive under the fallen ruins. She had been miraculously preserved by a beam falling in such a manner as to leave a small space, where she remained eight days without food before being discovered. During this time she gave birth to a child, which was also alive. Another woman was being delivered when the earthquake commenced; the husband and three women who were attending her fled. On the husband returning after the panic was over, on removing the ruins of his house, he found his wife with her child in her arms alive in a corner of one of the rooms, which had only partly fallen in. During the awful moment she had been safely delivered." [50] "While such are the prominent vices and defects of the poor, vices and defects of a different kind, but no less offensive to morality, are found among the rich. Sensuality and excess, selfishness, evil speaking, want of charity and kindness abound. All these are obstacles to moral and philosophical progress. Upon what can we rely to counteract them? Upon the force of civilization? Twice have its powers been tried and found wanting. In the days of Augustus Cæsar, when order had been established and prosperity revived, when Virgil and Horace flourished at Rome, and the vast provinces of the Roman Empire were blest with peace and tranquillity, everything seemed to promise a long duration of happiness. But the Christian Apostle and the Pagan Satirist alike prove all was hollow and delusive. Vice increased, knowledge decayed, power vanished, and soon everything portended the decline and fall of the Roman Empire. Again, in the eighteenth century of our era, civilization had reached a very high point. That century, enlightened above all its predecessors, which enjoyed the literature of the age of Louis XIV. in France, and of Queen Anne in England, when Racine, Moliere, Boileau, La Fontaine, Dryden, Pope, Addison, and Swift were read and admired; when Newton's philosophy was established; when La Voisier, and Black, and Cavendish had advanced chemistry to a science, and Watt had, by his improvement of the steam engine, rivalled the invention of the printing press, seemed, in its course, tending to the happiness of nations. But before that century ended, revolutions tearing up the foundations of society, wars desolating all the nations of Europe, bore sad testimony to the mistake that had been made. What was that mistake? The nature of man is so prone to evil that a strong restraint is required to keep down his bad passions, and subdue his vicious inclinations. He requires, likewise, some special incentive to good. The legislators of antiquity sought that restraint upon evil, and that incentive to good, in powerful institutions guarded by sanctity of manners. It was thus that Sparta and Rome were led to virtue. But these institutions perished when manners no longer supported them."--_Lord John Russell._ Lecture delivered at Exeter Hall, on the Obstacles which have retarded Moral and Political Progress, November, 1855. [51] "I know that our philosophy, always abounding in singular maxims, pretends, contrary to the experience of all ages, that luxury forms the glory of states; but after having forgotten the necessity of sumptuary laws, will she yet dare to deny that good manners are essential to the duration of empires, and that luxury is diametrically opposed to good manners?"--_Rousseau Discours_, p. 67. [52] "It was (says M. Astruc) at the first delivery of Mademoiselle de la Valliere, and for the safer keeping of the secret. It was feared that the presence of a midwife in the palace, where suspicion reigned already, would furnish fresh food for the malign curiosity of the courtiers; to impose on them they made use of a surgeon whose practice attached him to the court. For the rest, it cannot be denied that there have been, in every age, men who studied or taught the art of midwifery. We have treatises on midwifery of very ancient date, written by physicians. Surgeons, while exercising themselves in other surgical operations, did not neglect that of midwifery. But the habitual and daily custom of delivery was never established as it is at present; they interfered only in difficult cases, where it was believed that an experienced operator was required." [53] There is a work of M. Hecquet, entitled _De l' Indecence qu'il y a aux Hommes d'accoucher les Femmes_. [54] "There are, nevertheless, women, even now, whom it would be impossible to induce to be delivered by men. We speak not of those localities where this employment is confided to women, but in towns, where men-midwives are more in vogue. There is, it is said, a great Queen in Europe who has an accoucheur of whom she never makes use. Women deliver her, and the _man-midwife_ is in the ante-chamber, as a witness of the tribute yet paid to a custom which had been renounced." We fear that, in these "days of advance," even Majesty itself has succumbed to the prevailing fashion. [55] "Sisters of Charity," page 75. [56] "While Miss Nightingale is showing the world the great good to be achieved by ladies devoting themselves to the sick and suffering in hospitals, there is a lady in Paris who has actually worked her way to the title of M.D. The lady in question is Dr. Emily Blackwell, daughter of the late Mr. Samuel Blackwell, of Bristol, and has, it appears, a sister practising in New York, as a regular physician, armed with the authority of a diploma. Dr. Elizabeth, like Dr. Emily, completed her medical studies in Paris. To the latter lady the Paris hospitals have been freely opened, and Dr. Emily Blackwell has followed the clinical lectures of Jobert de Lamballe, Huguier, Casenove, Guersaint, and Blanche; and on the Register of the great hospital of the Hotel Dieu may be seen the first woman's name ever entered, as a medical student, on its books. The intense earnestness with which the lady doctor labours to make herself perfect mistress of those branches of the art which chiefly concern women and children, has not only overcome prejudice, but made her a favourite with her able instructors, who have been brought to say, that there can be no more objection to the presence of ladies in hospitals, practising as physicians, than to nurses. Baron Sentin, one of the Physicians in Ordinary to the King of the Belgians, has invited Dr. Emily Blackwell to visit the great women's hospital at Brussels."--_Daily News._ [57] A respected correspondent has communicated to us the following extract from a recent paper:--"There are not far from twenty of them, and several of them are in excellent business. They confine themselves generally to midwifery, and the diseases of their own sex. Their success in the former branch tends to establish them firmly in families. The number will probably be gradually on the increase, since they are beginning to be employed in the neighbouring cities of Charlestown, Cambridge, Roxbury, and adjacent towns, much more than formerly." Among these female physicians the Misses Emily and Elizabeth Blackwell, natives of Bristol, are justly celebrated. See an interesting sketch of the life of Miss Emily Blackwell in the _Englishwoman's Review_, June, 1857. [58] A correspondent has kindly communicated to us the following "ower true" tale of humble life:--"A poor girl, married, at the age of sixteen, to a youth not much older than, and equally poor with, herself (so impoverished are they), fell in labour of her first child. She was living with her father and mother, and he with his, for they were too poor to keep house, and her father was an old man and paralyzed, and both generations, on both sides, were as poor as was possible, consistently with living at all. Nevertheless, the wife's mother, having known better days, was ambitious of having her daughter attended by a doctor, and, during her pregnancy, had, by one device or another, scraped together the sum of half a guinea--the doctor's fee--which was laid up in store--an uneasy possession, in the meantime, for the poor mother, whose pressing occasions often tempted her to break in upon it. Labour, at length, coming on, late at night, as usual, the chosen doctor was sent or rather gone for, and came. The girl was in considerable pain, but the doctor, after the usual examination, declared his services to be, for the present, unnecessary. The doctor, however, was not so occupied with his patient but that he was observed, by her mother, to cast sundry glances around the forlorn and desolate apartment, as if doubtful of his fee. It is but justice to the apartment to state that it fully warranted the doctor's suspicions. The doctor, however, not being wanted, as he said, went home, leaving it to be understood that he would come again. Not coming, a long time having elapsed, and the labour becoming urgent, the mother went to the doctor's house (this was the third time that, full of trouble, she traversed a mile of windy streets at midnight). Her application to the knocker was answered from the window by the doctor's wife, who stated that her husband was in bed, and meant to stay there unless his fee was paid down. In vain the poor woman urged that the fee was ready, pleading besides her daughter's extremity. 'No,' was the reply, 'if not paid then and there the doctor would not stir.' This being simply impossible, the poor woman again sought her home, which, by this time, was a scene of pain, terror, and confusion. And now, instead of the 'usurper,' the 'true prince' was first thought of in the person of an old woman in a neighbouring court, who was well spoken of, and, by her timely aid, the long protracted labour was at length terminated for the moderate fee of five shillings. So the girl did well, the mother saved five shillings and sixpence, and the doctor remains a _respectable man_!!" [59] Dr. Stevens mentions, that Dr. Gregory took from a gravestone in "the old burying ground" in Charlestown the following inscription:-- "Here lyes interred the body of Mrs. Elizabeth Phillips, wife to Mr. John Phillips, who was born in _Westminster_, in Great Britain, and commissioned by John, Lord Bishop of _London_, in the year 1718, to the office of a midwife, and came to this country in the year 1719, and, by the blessing of God, has brought into this world above 3,000 children." An obituary notice in the _Boston Liberator_ of 1845, runs thus:-- "Mrs. Janet Alexander died in Boston, September 15, 1845, after an illness of nearly four months, aged 61 years. She was a native of Scotland, and was instructed in the theory and practice of midwifery by Dr. James Hamilton, the celebrated professor of Midwifery in the University of Edinburgh. She received her diploma from him in 1817. She arrived in Boston in November, 1819, and commenced the exercise of her profession on the ensuing Christmas day; and for a period of more than twenty-five years' practice among the most intelligent and respectable portion of the community, was most singularly successful, having NEVER, IN ANY INSTANCE, LOST A PATIENT." [60] "We may, with tolerable safety, estimate the present population of the Chinese Empire as between 350,000,000, and 400,000,000 of human beings. The constant flow of emigration from China, contrasted with the complete absence of immigration into China, is striking evidence of the redundancy of the population; for though that emigration is almost wholly confined to two provinces, namely, Kwangtung and Fookein, representing together a population of probably from 34,000,000, to 35,000,000, I am disposed to think, that a number nearer 3,000,000 than 2,000,000 from these provinces alone, is located in foreign countries. In the kingdom of Siam it is estimated that there are at least 1,500,000 Chinese, of which 200,000 are in the capital (Bankok). They crowd all the islands of the Indian Archipelago. In Java, we know by a correct census, there are 136,000. Cochin China teems with Chinese. In this colony we are seldom without one, two, or three vessels taking Chinese emigrants to California and other places. Multitudes go to Australia, to the Philippines, to the Sandwich Islands, to the Western Coast of Central and Southern America, some have made their way to British India. The emigration to the British West Indies has been considerable; to the Havannah greater still. The annual arrivals in Singapore are estimated at an average of 10,000, and 20,000 is the number that are said annually to return to China."--_Sir John Bowring._ [61] "Notwithstanding all our affectation of superior delicacy, and our reprehension of the coarse manners of our ancestors, we suspect that they would have been shocked at the idea of the _indelicate_ and _unnecessary_ presence of a man in the sanctuary of the lying-in room."--_Plea for Physicians, Fraser's Magazine_, March, 1848. [62] "An institution such as I have in my mind, should be a place where women could obtain a sort of professional education under professors of the other sex,--for men are the best instructors of women;--where they might be trained as hospital and village nurses, visitors of the poor, and teachers in the elementary and reformatory schools," &c.--_Mrs. Jameson's_ "_Sisters of Charity_," page 116. [63] Roberton says, "In speaking of the small mortality in child-bed among the poor, I limit my remark to those of this community (Manchester), who have long had the advantage of being attended chiefly by midwives carefully trained and educated in connexion with our Lying-in Charity."--_Pag._ 437. [64] We have heard that the almost incredible sum of five hundred guineas has been paid as a fee to one of the fashionable "ladies' doctors:" and that another caused it to be understood that he would not take a less fee than fifty guineas, whereupon the number of patients soliciting his attendance increased a hundred fold. [65] We know a case in point, where a lady was anxious to engage a midwife who had been recommended to her as perfectly competent to perform her office without the intervention of the _man_-midwife, but the latter would not hear of this, and insisted on the substitution of one of his "own nurses." It is easy to perceive the reason of this manoeuvre. Had the original midwife attended, she would have undertaken the operation, and the importance of the _man_-midwife would have been materially lessened. The lady's delicacy and comfort were not of sufficient weight to counterbalance this consideration. _Ex uno disce omnes._ [66] "In 1848 sixty-one mothers died to every 10,000 children born alive. Since that year the mortality has progressively declined, as follows:--58, 55, 53, 52, 50, down to 47 in 1854. This is a gratifying result, and there can be no doubt that by further care and skill, especially by training up a class of educated nurses, the deaths in child-birth may be largely reduced from their present high number, 3009."--_Medical Times and Gazette._ [67] So far from the presence of a _man_-midwife being a source of consolation or assurance to the sufferer, as Dr. Ramsbotham alleges, we have it on the authority of a lady, the mother of many children, that on three occasions, when the "doctor" _was not present_, her labours were much easier, and in all respects more thoroughly natural and happy in their results; than on those in which the _man_-midwife officiated; and further, _that the very ring of the bell announcing the arrival of the hated accoucheur has frequently "put back" the pains of labour_. [68] Before we laugh at this short-sighted folly and cruelty, which supposes that the interests of the two sexes can possibly be antagonistic, instead of being inseparably bound up together, we must recollect that we have had some specimens of the same feeling in our own country, as, for instance, the opposition to the female school at Marlborough House, and the steady opposition of the inferior part of the medical profession to all female practitioners. That some departments of medicine are peculiarly suited to women, is beginning to strike the public mind. I know that there are enlightened and distinguished physicians both here and in France who take this view of the subject, though the medical profession as a body entertain a peculiar dread of all innovation, which they resist with as much passive pertinacity as Boards of Guardians and London Corporations."--_Mrs. Jameson's_ "_Communion of Labour_," p. 40. "When educated gentlemen set an example of selfishness and exclusiveness, it is only to be expected that the working classes should follow it, and so the greed of man is the degradation of woman."--_North British Review_, No. 52, p. 837. [69] "According to Osborne's testimony, instruments are used _dangerously_ in parturition, _one thousand one hundred and seventy-six times_ in every twelve hundred cases; and the same author, in his reprobation of Denman's culpable and inconsiderate introduction of them into practice, makes this memorable remark: 'I must believe that he must have forgotten THE MANY UNHAPPY EFFECTS which have come from their use to our mutual knowledge, even when they had been in the hands of very experienced and skilful men.'"--_The Author of_ "_The Death-blow to Man-midwifery_," quoting _Osborne's_ "_Essays_." [70] "The conduct of medical men in all former ages proves still farther that which we would establish (that the profession of man-midwife is repugnant to nature). If they required information on the state of their female patients, it was to the midwives they applied. The midwife, therefore, passed for the eye of the doctor, because it was through her ministration that he assured himself of what he neither committed to his own examination or to that of another man."--_Hecquet_ "_De l'Indecence aux Hommes d'accoucher les Femmes_," page 6. [71] Albertus Magnus de Secretis Mulierum. _Ed. Amst._ 1662, p. 85. [72] The _man_-midwife usually intimates his wish to make the examination _per vaginam_, through the medium of the nurse of his own recommendation, and should the patient, struck with the daring impropriety of his request, desire to inform her husband of the infamous proposal, the nurse dissuades her by saying, that "husbands are not supposed to understand these things," and that she will probably destroy both her own life, and that of her child, by refusing to submit to it! After this the accoucheur soon triumphs, the examination is effected without further remonstrance, and the victim is irretrievably entangled in his insidious toils. [73] Roberton, Apology, page 470. [74] Roberton, page 486. [75] Ibid. page 489. [76] "The moon had gathered oft her monthly store Of light, and oft in darkness left the sky, Since Monnema a growing burthen bore Of life and hope. The appointed weeks go by, And now her hour is come, and none is nigh To help; but human help she needed none. A few short throes, endured with scarce a cry, Upon the bank she laid her new-born son, Then slid into the stream, and bathed, and all was done." _Southey's Tale of Paraguay._ [77] See Roussel, _ante_. [78] What will the men-midwives, with all their precautionary humbug, say to this? "On the 3rd of June, 1857, at Moradabad, amid the terrors of mutiny, the wife of Captain M. B. W----, Bengal Native Infantry, gave birth to a son, and on the same day, with all the officers and their families, escaped to Nynee Tal, a hill station distant about sixty-five miles, which they reached in safety on the 5th instant at 11 a.m. They fled with only the clothes on their backs, having been plundered of everything."--_Correspondent of the Times._ Well might this English lady exclaim with the Indian mother, "Here, Englishmen, here is a young warrior!" [79] There cannot be a doubt that the habit of wearing stays is as injurious to the internal organization of women as it is to their external form. Physiologists are well aware of this, yet European women are so enslaved by custom, that we see them tightening up their daughters, from very infancy, in a framework of iron and bone, until their bodies assume the shape which the corset-maker chooses, instead of that which nature, in the perfection of her knowledge, would bestow. [80] Diseases of Women, by E. Johnson, M.D. [81] "The most natural proof that, in the first ages of the world, the _man_-midwife (accoucheur) was unknown, is, that there is no word whatsoever in the mother or original tongues to signify this profession in a man, whereas that which signifies a midwife (accoucheuse) is found in all languages."--_Hecquet de l'Indecence aux Hommes d'accoucher les Femmes_, p. 1. [82] Let any man who disputes this position peruse the case of D----against D----, in Robertson's Reports of Cases in the Ecclesiastical Courts, a terrible picture of conjugal contention and wretchedness in high life, all clearly attributable to the accoucheur, who insisted upon the husband leaving the lying-in chamber, and influenced the wife, fatally for her husband's peace and her own, to concur in his exclusion. A more flagrant instance of medical presumption and insolence could not readily be found. "Here then," says Sir Herbert Jenner Fust, in his judgment, "is the clue to everything that subsequently took place--an end of all that happiness and comfort which might have been expected to attend the union between these parties." The archives of the law would afford the inquirer many a fearful example of similar evils consequent on the unnatural and sinful practice of man-midwifery. Transcriber's Notes: Passages in italics are indicated by _italics_. The original text includes Greek characters. For this text version these letters have been replaced with transliterations. Punctuation has been corrected without note. The following misprints have been corrected: missing "be" added (page 24) transposed lines correced (pg 62) "instrustrument" corrected to "instrument" (page 63) "aros" corrected to "arose" (Footnote 11) "Pitsburgh" corrected to "Pittsburgh" (Footnote 41) "surgica" corrected to "surgical" (Footnote 52) The mismatched quotation mark in footnote 68 is presented as in the original text. Hyphenation inconsistencies have been retained from the original. 
4986	----	This eBook was produced by Jim Weiler, xooqi.com THE FOUR EPOCHS OF WOMAN'S LIFE A Study in Hygiene BY ANNA M. GALBRAITH, M.D. Author of "Hygiene and Physical Culture for Women"; Fellow of the New York Academy of Medicine ; Ex-President of the Alumnae Association, Woman's Medical College of Pennsylvania; Attending Physician, Neorological Department, New York Orthopedic Hospstal and Dispensary. _________________________________________________________________ WITH AN INTRODUCTORY NOTE by JOHN H. MUSSER, M.D. Late Professor of Clinical Medicine, University of Pennsylvania. "As in a building Stone rests on stone, and wanting the foundation All would be wanting, so in human life Each action rests on the foregoing event That made it possible, but is forgotten And buried in the earth." -- LONGFELLOW. _________________________________________________________________ INTRODUCTORY NOTE _________________ IT has been well said that the bulwarks of a nation are the mothers. Any contribution to the physical, and hence the mental, perfection of woman should be welcomed alike by her own sex, by the thoughtful citizen, by the political economist, and by the hygienist. Observation of the truths, expressed in a modest, pleasing, and conclusive manner, in the essay of Dr. Galbraith contribute to this end. These truths should be known by every woman, and I gladly commend the essay to their thoughtful consideration. JOHN H. MUSSER, M.D., Late Professer of Clinical Medicine in the University of Pennsylvania. _________________________________________________________________ PREFACE TO THE SECOND EDITION. _________________ THE author takes this opportunity to thank the medical profession and the laity for the very cordial reception which has been tendered the first edition of this small volume. The necessity for the use of technical expressions in a book written expressly for the laity must always be a matter of regret. And only those who have attempted to write a similar work can fully appreciate the truth of Herbert Spencer's remark, that "Nothing is so difficult as to write an elementary book on scientific subjects." The author has added to this edition a section on "The Hygiene of Puberty," one on "Hemorrhage at the Menopause a Significant Symptom of Cancer," and one on "The Hygiene of the Menopause." ANNA M. GALBRAITH. 15 WEST NINETY-FIRST STREET, NEW YORK. _________________________________________________________________ PREFACE. _________________ "Ignorance is the curse of God; Knowledge, the wings wherewith we fly to heaven." -- "Henry VI." PERFECT health is essential to perfect happiness. The greater the knowledge of the laws of nature, and the more closely these laws are lived up to, so much nearer "ideal" will be the health and happiness of the individual. Hence the necessity that these same laws should be as familiar to the adult man and woman as the alphabet. Further, with our present knowledge of the certain suffering, disease, and death that are bred by ignorance of all these subjects, it is little less than criminal to allow girls to reach the age of puberty without the slightest knowledge of the menstrual function; young women to be married in total ignorance of the ethics of married life; women to become mothers without any conception of the duties of motherhood; other women, as the time approaches, to live in dread apprehension of "the change of life;" and many women unnecessarily to succumb to disease at this time. The masses of women have at last awakened to a sense of the awful penalties which they have paid for their ignorance of all those laws of nature which govern their physical being, and to feel keenly the necessity for instruction at least in the fundamental principles which underlie the various epochs of their lives; and it is in response to a widespread demand that this small volume has been written. This is preeminently the day of preventive medicine; and the physician who can prevent the origin of disease is a greater benefactor than the one who can lessen the mortality or suffering after the disease has occurred. ANNA M. GALBRAITH. 15 WEST NINETY-FIRST STREET, NEW YORK. _________________________________________________________________ CONTENTS _________________ INTRODUCTION EDUCATION AS THE CONTROLLING FACTOR IN THE PHYSICAL LIFE OF WOMAN Huxley's Definition of Education; the Correlation of Mind and Body; the Emotional Nature; Age for Going to School; the Effect of the Study of the Scientific Branches; Industrial Education _________________ PART I.-- MAIDENHOOD _________________________________________________________________ CHAPTER I. PUBERTY Sexual Development; Age of Puberty; Physical Changes at Puberty; First Onset of Menstruation; Psychic Changes at Puberty _________________________________________________________________ CHAPTER II. HYGIENE OF PUBERTY Home Life; Corsets; Shoes; Underwear; Nutrition; Diet; Water; Constipation; School Life; Spinal Curvature; Exercise; Walking; Running _________________________________________________________________ CHAPTER III. ANATOMY OF THE FEMALE GENERATIVE ORGANS The Vulva; the Hymen; Condition of the Hymen as a Proof of Virginity; the Bladder; Vagina; Uterus; Respiratory Movements of the Uterus; Fallopian Tubes; Ovaries _________________________________________________________________ CHAPTER IV. PHYSIOLOGY OF THE FEMALE GENERATIVE ORGANS Ovulation; Etiology of Menstruation; Uterine Nerve-supply; the Function of the Uterus; Stages of the Menstrual Cycle; Average Duration of the Menstrual Flow; Character of the Flow; Relation of Ovulation to Menstruation; the Menstrual Wave; Definition of Menstruation; Premonitory Symptoms of the Flow; Hygiene of Menstruation _________________________________________________________________ CHAPTER V. THE ANOMALIES OF MENSTRUATION Menorrhagia and Metrorrhagia; Dysmenorrhea; Amenorrhea; Leucorrhea; Pruritus Vulva _________________________________________________________________ CHAPTER VI. THE MARRIAGE QUESTION Herbert Spencer's Definition of Love; What Constitutes a Suitable Husband; Best Age for Marriage; Shall Cousins Marry? Contraindications to Marriage; Do Reformed Profligates Make Good Husbands? the Proper Length of Time for the Engagement; the Right Time of the Year to Marry; the Selection of the Wedding Day _________________ PART II.-- MARRIAGE _________________________________________________________________ CHAPTER VII. THE ETHICS OF MARRIED LIFE The Wedding Journey; the Ethics of Married Life; Shall Husband and Wife Occupy the Same Bed? the Consummation of Marriage; the Marital Relation; Times when Marital Relations Should be Suspended _________________________________________________________________ CHAPTER VIII. SEXUAL INSTINCT IN WOMEN Sexual Instinct in Women; Excessive Coitus; Causes of Sexual Excitability _________________________________________________________________ CHAPTER IX. STERILITY Sterility; the Prevention of Conception and the Limitation of Offspring; the Crime of Abortion; Infidelity in Women _________________ PART III.-- MATERNITY _________________________________________________________________ CHAPTER X. PREGNANCY Nature of Conception; Pregnancy Defined; Duration of Pregnancy; the Signs of Pregnancy; Quickening; the Determination of Sex at Will; the Influence of the Male Sexual Element on the Fernale Organism; Heredity; Hygiene of Pregnancy; Causes of Miscarriage _________________________________________________________________ CHAPTER XI. THE CONFINMENT Preparation for the Confinement; Signs of Approaching Labor; Symptoms of Actual Labor; The Confinement-bed; the Process of Labor _________________________________________________________________ CHAPTER XII. THE LYING-IN Management of the Lying-in; Lactation; Nursing _________________________________________________________________ CHAPTER XIII. THE NEW-BORN INFANT The Infant's Toilet; the Crib; Feeding of Infants; the Wet-nurse; Artificial Feeding; Characteristics of Healthy Infants; the Stools; Constipation; Urination; Teething _________________ PART IV.-- THE MENOPAUSE _________________________________________________________________ CHAPTER XIV. THE MENOPAUSE Average Duration of the Menstrual Function; Duration of Menopause; the Menopause; General Phenomena of the Menopause; Prominent Symptoms of Menopause; Pathologic Conditions of Menopause; Hemorrhage at the Menopause a Significant Symptom of Cancer; Causes of Suffering at Menopause _________________________________________________________________ CHAPTER XV. HYGIENE OF THE MENOPAUSE Diet; Constipation; Stimulants; the Kidneys; Skin; Turkish Baths; Massage; Exercise; Profuse Menstruation; Hemorrhage; Mental Therapeutics _________________________________________________________________ CHAPTER XVI. HINTS FOR HOME TREATMENT Indigestion; Constipation; Enemas; Diarrhea; Vaginal Douché, Baths; Headache; Fainting; Hemorrhage _________________ GLOSSARY _________________ THE FOUR EPOCHS OF WOMAN'S LIFE _________________ INTRODUCTION. _________________ EDUCATION AS THE CONTROLLING FACTOR IN THE PHYSICAL LIFE OF WOMAN. Huxley's Definition of Education; the Correlation of Mind and Body; the Emotional Nature; Age for Going to School; the Effect of the Study of tuse Scientific Branches; Industrial Education. "What is man, If his chief good, and market of his time, Be but to sleep and feed? A beast; no more. Sure, He that made us with such large discourse, Looking before and after, gave us not That capability and godlike reason To fust in us unused." -- "Hamlet." THE word education is here used in its broadest sense, and is meant to include the physical, mental, intellectual, and industrial. Huxley's definition is as follows: "Education is the instruction of the intellect in the laws of nature, under which I include not only things and their forces, but men and their ways; and the fashioning of their affections and of the will into an earnest and living desire to move in harmony with these laws. That man, I think, has had a liberal education who has been so trained in his youth that his body is the ready servant of his will, and does with ease and pleasure all the work that, as a mechanism, it is capable of; whose intellect is a clear, cold, logic engine, to be turned to any kind of work, to spin the gossamers as well as to forge the anchors of the mind; whose mind is stored with the great and fundamental truths of nature and the laws of her operations; one whose passions are trained to come to heel by a vigorous will, the servant of a tender conscience; one who has learned to love all beauty, whether of nature or of art, to hate all vileness, and to respect others as himself." The Correlation of Mind and Body.-- It is of the utmost importance that the mutual reaction of mind and body upon each other should be thoroughly understood. This reaction is so constant, so intricate, and so complex that it is at times difficult to say which is cause and which effect. Does the depressed state of the mind cause the indigestion, or is a torpid liver the real seat of the melancholia? The brain is the most delicately constructed organ in the entire body. In the lower animals the brain is simply the great nerve-center which, with its prolongation the spinal cord, presides over all the functions of life which differentiate the animal from the vegetable. In the human being the brain is much more highly developed and complicated; and is, in addition, the seat of the mind, the intellect, and the affections. Like all the other tissues of the body, the brain receives its nourishment from the blood-vessels which pass through it, and its healthy maintenance is in a direct ratio to the condition of its blood-supply. A most interesting psychologic study is found in the case of cerebral paralysis of young children, where there is mental defect amounting to stupidity or imbecility, accompanied by extensive paralysis of the body, so that the child is not able to sit up. With the gradual improvement of the physical condition, so that the muscles become firm and the child can sit, stand, and even walk, there is a corresponding mental development; from being stupid and dull, the expression of the face brightens and becomes intelligent; the child talks quite as well as other children of its age, and sometimes becomes really intellectually precocious. Here we see the development of the brain as a direct result of the improved physical condition. In certain cases of insanity, on the contrary, we find that the wasting away of the body results from the disease of the brain, i. e., the disease of the brain has wrought the wreck of the body. From these pathologic studies, or studies of how the diseased state of the brain and body may be overcome by physical development, on the one hand, and, on the other hand, how the healthy body may be wrecked by disease of the brain, we will turn to a consideration of the effect of the development of the mind and intellect upon the physical health. On a girl's entering Vassar College an exact and detailed physical examination is made by the resident physician, a health record is kept during her stay there, and at the time of her graduation a final physical examination is made. As a result of these statistics Dr. Thelberg says: "These statistics, now covering a number of years, show that not only can girls profitably take a college education, that is accomplished; but will prove that grave physical imperfections can be corrected in the period between eighteen and twenty-two years of age, coincidently with the development of the mind along the lines of college work; the college work, if not excessive in amount, being a real and most important factor in the physical development." But a still more striking proof can be cited of the beneficial result of mental and intellectual occupation upon the bodily health. At Vassar a great deal of attention is very properly paid to general hygiene and the physical development, in addition to the natural advantages of outdoor life in the country. Take, for example, a woman's medical college located in the city: the four years' course places the greatest strain on both mind and body; practically no time is left for recreation, and very much too little time is spent in sleep; the amount of exercise taken is the minimum. Yet in spite of all these disadvantages under which the young women labor, a great many of them who enter far below par in health, or, indeed, on the fair road to become chronic invalids, graduate very greatly improved in health. The Emotional Nature.-- Formerly much more than now, owing to the defective methods of her education and mode of life, the emotional nature of woman was allowed to run riot. The child was coddled; the girl was allowed to grow up without any of the discipline which young men receive in their college and business life, and little or no attention was paid to her physical development. The woman naturally became a bundle of nerves, highly irritable, unreasonable, and hysterical. All this reacted in the most detrimental manner upon her physical health. The seed for much of this emotional hyperesthesia is sown in childhood. From birth until the end of the eighth year should be one grand holiday. During this time the child develops very rapidly, especially during the first two years of life. And at the end of the eighth year the brain has attained to within a few ounces of its full weight. The muscular system has been developed together with the coordination of motion. The child has learned to use a language fairly well; she has developed an excellent memory and is most inquisitive and acquisitive. Another method for undermining the healthy tone of the nervous system is the intricate dances taught very young children and then placing them on public exhibition, where they are wrought up to the highest pitch. From a purely medical standpoint, children under eight years of age should not be allowed to take dancing lessons. After this age a moderate amount of dancing in a well-ventilated room is good exercise. Children's parties belong in the same category, and, on account of the injurious effects on the nervous system, should be tabooed. They are too exciting, and cause an overstimulation of the nervous system and a precocious childhood and puberty. Instead of rearing an oversensitive hot - house plant that must be fragile in the extreme, strive to rear a sturdy plant that can hold its own amid the storms. The child should spend as much of its life as possible in the open air, and in the warm months live out-of-doors. City children should be taken to the seashore or country to spend several months every summer. Together with outdoor sports, gymnastics adapted to the age of the child should be begun early and continued throughout life. Good muscular development is attended with good digestion and a well-balanced nervous system. Until after the twelfth year there should be absolutely no difference between the physical, mental, or industrial education of girls and boys. And, still further, they should be encouraged to have their sports together; this will improve the girls physically and broaden them mentally, and will do a great deal to take the rough edges off the boys. After this age it will be wise to allow slight barriers to grow up, without calling the attention of any one to the fact, that will cause the companionship to be less free and unrestrained. Age for Going to School.-- Although the child may be allowed to go to kindergarten long before this time, it should not be allowed to enter the school-room before eight years of age. And from eight to twelve years, not more than four hours a day should be spent in study. After this time it may be put down more closely to intellectual work; but no more mental work should be required than will enable the girl to enter college at eighteen. And eighteen years of age is as young as any girl should be allowed to go to college; after this age the mind is more matured and acquires knowledge more easily than before, while the development of the body is less rapid. The physical system has become more stable. The literature indulged in by girls under eighteen years of age should be most carefully selected. The Effect of the Study of the Scientific Branches.-- A knowledge of the laws of nature is essential to health; hence the necessity for the study of the natural sciences-- anatomy, physiology, chemistry, physics, and zoology. Aside from the intrinsic value of this knowledge, it is almost universally conceded that these studies develop the judgment; and no one will have the temerity to deny that a lack of judgment must undermine the health as well as the success and happiness of the individual. Industrial Education.-- When it is considered how intimate are the relations between the physical and the psychic states, and how often the psychic condition leads to actual disease, and that often of the most incurable type, it needs no demonstration that a mental occupation which will take the woman out of herself is a physical necessity. Therefore when the girl has reached the subjective limit of her intellectual education,-- that is, when she has reached the limit of her capacity or taste,-- it is essential to her physical well-being that she should turn her attention to some industrial occupation. This may be housekeeping or any other occupation for which she has taste or talent. A healthy mental occupation is an absolute necessity to prevent the individual from becoming self-centered. And to become self-centered is the first step on the certain road to chronic invalidism. A most important part of an education is the knowledge of how to procure the most perfect development of the body possible, and how to maintain the health. This has not been touched upon here, since the outlines for the general physical education have already been given in "Hygiene and Physical Culture for Women,"* and the present volume concerns itself only with the four critical epochs of woman's life. * By Anna M. Galbraith, M. D.; published by Dodd, Mead & Co. With this broad view of an education, as a means to procure the best physique possible; a mind disciplined to meet to the greatest advantage all the vicissitudes of life; an intellect developed along the lines of its greatest possibilities; and an occupation chosen in accordance with the tastes and talents of the individual; it becomes an incontrovertible fact that the education is the controlling factor in the physical life of every woman. _________________________________________________________________ "Be not simply good; be good for something." THOREAU. _________________ PART I.-- MAIDENHOOD. _________________ CHAPTER I. PUBERTY. Sexual Development; Age of Puberty; Physical Changes at Puberty; First Onset of Menstruation; Psychic Changes at Puberty. "Self-reverence, self-knowledge, self-control, These three alone lead life to sovereign power." -- "OEnone." Sexual Development.-- Sexual development goes on during all the years of childhood, but is not complete in the female sex until between the twenty-second and the twenty-fifth year. If the child has no inherited taint, and has been properly educated morally, physically, and intellectually, it must follow that the structural development of the pelvic organs has been normal; and normal organs always perform their functions perfectly. The commencement of the ovarian function does not cause any more profound change in the system and habits than does dentition. The various epochs of life are generally spoken of as if they were paroxysmal-- as though they were separated by some tremendous chasm, which had to be leapt over or fallen into. Nature makes no such egregious blunders; preparations for every change in life have been going on for a very long time before the evidences of such change become manifest. In a healthy girl the psychic and physical changes incident to puberty occur so gradually as to escape the girl's own notice. The first and, if the girl has not been properly prepared for it, always startling change is the appearance of the menstrual flow. The mother who has not told her daughter of this coming change in her life before it is due has committed a serious error; it is no uncommon occurrence for girls who know nothing of this function to get into a tub of cold water to stop the flow; and if they stay in long enough, it generally does stop, and the girl's health may be ruined for life. The opinion of Dr. Ely van de Warker is that "if healthy ovulation is the outcome of healthy childhood, the function will obey the law of periodicity year by year, and all this time the young woman will be able to sustain uninterrupted physical and intellectual work as well as the young man. Not that the laws of health may be violated with impunity at puberty or any other time of a woman's life; but a law of health is no more binding upon a young woman than it is upon a young man; and there really is no such thing as one law for women and another for men." Age of Puberty.-- In the temperate regions the age of puberty is reached between the ages of twelve and fourteen years. The girl is then said to be nubile; that is, as soon as menstruation appears it is possible for her to bear children; but she is by no means sufficiently developed to do so, as she herself will not be completely developed physically or mentally before the age of twenty-two or twenty-five years. Physical Changes at Puberty.-- The physical changes that gradually take place, beginning at the time of puberty, are: the breasts, pelvis, and neck enlarge; hair develops over the pubis and in the arm-pits; the voice alters. As a rule, women continue to grow in stature until the twenty-fifth year. It is said that brunettes develop sooner than blondes, and that large women develop more slowly than women of small stature; city girls develop younger than girls brought up in the country. Whatever stimulates the emotions causes a premature development of the sexual organs; as children's parties, late hours, sensational novels, loose stories, the drama and the ball-room, talk of beaux, of love and marriage, and children being surrounded with the atmosphere of riper years. It is generally believed that early stimulation of the sexual instincts leads to the premature establishment of puberty, as do also spiced foods and alcoholic beverages. First Onset of Menstruation.-- Sometimes the first menstrual discharge appears suddenly, lasts for a few days, and then stops; it may appear after an interval of two or three weeks, or not for several months. If for several months the flow appears at the regular time, and the quantity is about the same as the first, the menstrual habit may be said to be established. The mode of onset varies considerably within the limits of health. So long as the general health remains good, no anxiety need be felt in regard to the establishment of the menstrual function. In other cases there may be a discharge of blood at the first period, and none afterward for several months; in other words, menstruation may be established suddenly, intermittently, or gradually. It must be remembered that certain pathologic conditions cause many disturbances connected with the onset of puberty. Psychic Changes at Puberty.-- The angular, gawky feeling gradually disappears; the girl becomes self-conscious; new impulses arise, and she gives up many of the hoydenish ways of childhood. The girl's imagination is more lively, and just at this time mathematics form an excellent subject for mental occupation. The girl now begins to question the whys and wherefores, and demands reasons for the course that is laid out for her, and is full of ideas of her own; so that while as a child she had accepted almost unquestioningly the commands of her parents, she can be managed now only through the power of reason. And this is just as it should be, for the girl has reached the years of discretion, and now is the time when her reason and judgment are capable of rapid cultivation. CHAPTER II. HYGIENE OF PUBERTY. Home Life; Corsets; Shoes; Underwear; Nutrition; Diet; Water; Constipation; School Life; Spinal Curvature; Exercise; Walking; Running. "Every man is the architect of his own fortune." PSEUDO-SALLUST. Home Life.-- With beginning menstruation the equilibrium of the body is very easily disturbed, so that even in the case of the healthy girl some precautions should be taken and a rational regime should be adhered to; while in the case of the delicate girl a still more careful attention will have to be directed toward her weak points, in order that she may develop into a healthy woman. For every girl at this time of life home is preeminently the place; so that she may not only have the benefit of a mother's watchful care, but also lead a life as free from conventionalities and as much in the open air as possible. No girl should be sent away to school at this period of rapid growth and development; nor should girls of the working classes, when it can possibly be avoided, be sent out to fill positions as clerks in illy ventilated stores, in factories, or as domestics. If a girl can be kept at home until she is eighteen years old, she will be a much stronger, healthier woman than would otherwise be possible. Corsets.-- At this period of life it is particularly necessary that the clothing should be warm and at the same time sufficiently loose to prevent the constriction of any part of the body. And whatever the adult woman may elect to do in the matter of wearing corsets herself, she does her young daughter an irreparable injury by constricting and moulding her growing body in these corset-splints. Corsets placed on the young girl interfere with the functions of circulation, respiration, digestion, and of the pelvic organs, also with muscular development. In addition to all this, the girl is handicapped in taking all outdoor exercises and athletic sports. The lungs, heart, and great blood-vessels are placed in and completely fill an air-tight, distensiblecage, which is most distensible at its base. The least chest girth of the adult woman-- that is, the under-arm girth around the chest-- that is consistent with health is twenty-eight inches; and this girth must be enlarged three inches in forced inspiration. In ordinary respiration the waist expansion should be one-half to one inch, while during great muscular activity it should be from one and a half to three or four inches. One-third of the lungs lie below the point of beginning corset pressure, so that with tight corsets this amount of lung substance must be more or less useless. It is self-evident that any restriction placed about the waist, by preventing the full expansion of the ribs and the descent of the diaphragm, will further embarrass the heart's action by diminishing the amount of room it has to work in, at the same time that it diminishes the amount of oxygen which is inspired. Fresh air is by far the most important part of the daily food. It is in the lungs that the blood throws off its carbonic acid and other impurities; but it is able to do this only when the lungs are supplied with an abundance of oxygen. Every inch which a woman adds to her chest measure adds to the measure of her days. Great physical injury has followed women playing lawn-tennis while tightly corseted. And although dancing is a much milder exercise, since it frequently takes place in an overheated and poorly ventilated room, fatal results occasionally occur from the same cause. Standing erect calls into action almost all the muscles of the trunk, neck, and lower extremities. So long as the line of gravity falls within the area of the feet, the muscular effort required is so slight that it is little more than the tonicity contained in all living muscle. The greater the displacement of the line of gravity, the greater the muscular effort required to maintain the equilibrium of the body. Up to a certain extent, exercising the muscle develops the strength and size of the muscle. On the other hand, when a muscle within the body is unused, it wastes; when used within certain limits, it grows. But when the corset splint is applied to the body of the young girl, it supplants the functions of the abdominal and back muscles, which is to hold the trunk erect, and these muscles gradually grow weak and waste. And so the liability to the various spinal curvatures is increased. The original object of the corset was to give greater prominence to the hips and abdomen. But fashions change! In "the French figure" or straight-front corset now in vogue the pelvis is tilted forward, producing a sinking in of the abdomen and a marked prominence of the hips and sacrum, necessitating a compensatory curve of the spine which increases the curvature forward at the small of the back-- a deformity which, a few years ago, women were going to orthopedic surgeons to have corrected. In this attitude the line passing through the centre of gravity strikes the heels, the knees are hyper-extended, and the muscles of the calves and thighs are rendered tense. By interfering with the muscular development and digestion, the girl is very apt to become angular, flat-chested, anemic, and to have a muddy complexion. And so the corset really defeats the object for which it was put on-- that of giving the girl a good figure and enhancing her beauty. There is no objection to girls wearing any of the various forms of hygienic waists now on the market. Shoes.-- The feet are the part of the body to come in contact with the greatest degree of cold, whether on the floor of the house or the pavement of the street. Hence it is a matter of prime importance to the entire body that the feet should be properly clad. The thick-soled, flat-heeled shoes which became popular with bicycling and golf are most hygienic, and it is highly desirable that this style of shoe should be adhered to for outdoor exercise. Underwear.-- In our cold and changeable climate the most suitable undergarment is the "combination" woolen undersuit, which reaches from neck to ankles and has long sleeves. Much greater warmth is afforded when the undersuit is moderately tight fitting. Such a suit should be worn the entire year, the grade of weight being adapted to the season. Nutrition.-- The nutrition of the body is dependent on the food supply, digestion and excretion. The growing girl should eat more than the adult woman, because of her more active life and of the fact that the food which she takes must not only replace the worn-out material of the body, but also provide new material needed for growth. Insufficient food and food of defective quality and composition work proportionately for more harm during the growing age. The full adult weight is not attained before the twenty-fifth year. When the final growth of the body and development of the vital organs is completed, the function of food is simply to replace waste with new material and to furnish material for the development of force. Diet.-- The diet should be a mixed one, consisting of the various kinds of fresh meats, fish, milk, eggs, poultry, vegetables, fruit, and fat in the shape of cream, butter, and the fat of beef and mutton. Animal food improves the condition of the muscles, which are made firmer than they would be through a vegetable diet. Meat in general has a more stimulating effect upon the system and is more strengthening than vegetable food, and it gives rise to a sensation of energy and activity. The common estimate is that meat should occupy one-fourth and vegetable food three-fourths of a mixed diet. Common salt in moderate quantity is essential, but all highly spiced or seasoned foods should be avoided, also pickles and vinegar. All "sweets" are harmful, because they destroy the appetite for other things and upset the digestion. Tea and coffee should be tabooed, as well as all alcoholic beverages. Good digestion depends for the most part on serving the meals at the same hour every day, eating leisurely, and masticating the food well. There is a great tendency on the part of the school girl to sleep late in the morning, then "bolt" her breakfast in order to get to school in time. Nothing could be more pernicious to the digestion, unless it is the eternal nibbling of candy. A healthy girl needs nothing between meals. A delicate girl will be the better for a glass of milk in the middle of the morning and at bed-time; or pure beef juice may be given instead. Water.-- Water is needed to keep the kidneys properly flushed. The amount of urine secreted during the twenty-four hours should be three pints. Of course it will be less than this if the quantity of water is insufficient. In addition to the urine about ten ounces of water are lost from the surface of the lungs, and eighteen ounces from the skin, making a total of about five pints; and this quantity of water must be taken daily in order to maintain the equilibrium of the body. The solid food of a mixed diet contains from fifty to sixty per cent. of water, so that about twenty-five ounces of water are taken into the system daily as an integral part of the food. In addition, three pints more should be taken as plain water. The bladder acts as a reservoir for the urine, and should be emptied at least three or four times a day. Constipation.-- In order to keep the digestive system in good condition, the refuse matter which collects in the lower bowel must be evacuated every day. And in order to secure this regular bowel movement, regularity in the time of going to the toilet is a prime necessity. And now is the time when the habits of a lifetime are being formed. If a tendency to constipation exists, it can almost always be overcome by increasing the amount of fruit and vegetables eaten, also by eating cracked wheat, oatmeal, corn and graham bread; all of which increase the peristaltic action of the intestines. The small amount of water taken by girls and women is another fertile source of constipation. School Life.-- When it is considered that fully one-half of the girl's waking hours are spent in school or in study preparing for school, it becomes evident that the girl's attitude at her desk should be the correct one. The malpositions at the desk are the most frequent cause of lateral curvatures, round shoulders, and flat chests. And these deformities are more common in girls than they are in boys. The common faults of the desk and seat leading to these malpositions are unsuitable shape of the back of the seat, too great a distance between the seat and the desk, and the incorrect slope of the desk. The edge of the desk should slightly project over the edge of the chair. The top of the desk should incline downward about ten degrees toward the student, and be low enough to allow the forearm to rest on it without raising the shoulder. The seat should be sufficiently deep to support almost the entire thigh, and close enough to the floor to allow the soles of the feet to rest firmly on it. The back of the chair should be arched so as to support the hollow of the back, and should reach just above the lower part of the shoulder-blades, and so make it easy and comfortable for even a weakly child to sit upright. If the seat is too high, the feet do not rest on the floor, and so the girl does not get the proper aid from the legs and feet to maintain an erect position. If the desk is too high, the elbow can rest on it only by curving the spine and raising the shoulder. The work is brought too close to the eyes and causes extra strain. If the desk is too low, the child stoops over it and becomes round-shouldered, and there is a tendency to become short-sighted. The pupil should sit erect with the weight equally borne by both buttocks; the legs should be straight before the trunk, and the feet firmly resting on the floor. The book should be held about twelve inches from the eyes. Spinal Curvatures.-- It should be distinctly borne in mind that lateral curvature of the spine is a distortion of growth. The deformity appears and is developed during the growing years. It is more common in girls than in boys, for two reasons: that at the age when lateral curvature is first seen, girls grow more rapidly than boys; and their muscular system is less well developed. In most early cases the faulty attitudes are clearly the result of muscular weakness. The growth in size has not been accompanied by a corresponding development of the muscles. This condition is most frequently met with in rapidly growing girls, and it is one of the most common causes of lateral curvature. In these cases proper gymnastics are indicated, but they should be prescribed and carried out with much care. It is upon the erectness, suppleness, and strength of the spinal column that most of the power and grace of the body depend. Lack of ventilation is a fertile cause of headache, anemia (or an impoverished condition of the blood in iron and oxygen), and dyspepsia. All these are rare before but common after twelve years of age. Exercise.-- In physical culture the object aimed at should be the symmetrical development of all the muscles of the body. Hence the necessity for bringing every individual muscle into play, at first for its development, and later for its maintenance. The tendency of almost all forms of exercise is to develop some portion of the body at the expense of the rest. The most perfect form of exercise is therefore that one which will most nearly call into play all the muscles of the body. Walking.-- Walking is the only form of exercise which may be said to be universal. In walking the muscles of the chest get little exercise, and those of the spine and abdomen even less. In walking the arms should swing easily at the sides, both from a physiological and an esthetic point of view. If the girl is weak or is unaccustomed to take any exercise, the guide for the amount of exercise taken at any one time must be this: At the first sense of fatigue, stop at once and rest, otherwise positive harm instead of good may be accomplished. The girl who depends on walking for her outdoor exercise should walk at least three miles every day, and walk at the rate of three miles an hour. After acquiring as great a walking speed as is consistent with a graceful and easy carriage, the running exercise should be begun, gradually increasing the distance, but not the rate of speed. In exercising, all tight clothing about the neck, chest, and waist must be removed. Pure air and full breathing are required during and after exercise. Full breathing not only promotes the change of air in the lungs, but also quickens the functions of the circulation and digestion. Eating must be avoided shortly before or shortly after any considerable exercise, as it impairs digestion. Running.-- Running is the best exercise for developing the breathing capacity. While brisk walking is allowable, fast running is not. The rule for running is to begin slowly, run moderately for perhaps fifty feet, then increase the speed gradually; but in running for exercise, never speed to the utmost. A five-mile gait is quite sufficient. The run should be closed with the same moderation with which it was begun, and the girl should never stop short, as this sudden arrest of action gives a most undesirable shock to the heart. In beginning to take any form of exercise the intensity and duration of the movements practiced must be increased very gradually, or positive harm instead of good will be done. As soon as fatigue is appreciable, the exercise should be discontinued and at once be followed by complete rest. Rapid respiration, palpitation or dizziness, headache, the face becoming pale or pinched or flushing suddenly, a feeling of great heat or excessive perspiration, are all danger signals showing that the exercise has already been carried too far and should cease at once. Continued over-exertion carried to a point of exhaustion leads to an obstinate irritability of the heart as well as to organic lesions. Mountain-climbing, rowing, and bicycling call into play almost all the muscles of the body. Of all the outdoor exercises for girls, swimming is one of the most perfect. It not only calls into vigorous action most of the muscles of the body, but spares many of those muscles that are so commonly overworked, the most of the work being performed by muscles that are so little used as to have become flabby and weak. Swimming and sea-bathing must be avoided by girls who have weak hearts and in whom the reaction after a plunge into cold water is never established; also by girls with heart disease or kidney disease. The principal outdoor games are croquet, archery, golf, tennis, cricket, foot-ball, and base-ball. Of these, croquet is the mildest, and is for that reason a good beginning exercise. Croquet, archery, golf, and tennis are all defective in that they cause a greater development of the right than of the left side of the body. As the greater majority of these outdoor exercises can only be indulged in for seven months of the year, they should be supplemented by exercises in the gymnasium for the remaining five winter months. There should be the greatest variety possible in the kinds of exercise taken, not only to develop the body symmetrically, so as to obtain strength, vigor, grace, celerity, and accuracy of movement, but also because there is no such potent cause of fatigue as monotonous repetition of the same act, whether physical or mental. It has been repeatedly proven that physical deterioration can be overcome by exercise, and that by so doing the mental capacity is greatly increased. CHAPTER III. ANATOMY OF THE GENERATIVE ORGANS. The Vulva; the Hymen; Condition, of the Hymen as a Proof of Virginity; the Bladder; Vagina; Uterus; Respiratory Movements of the Uterus; Fallopian Tubes; Ovaries. "He that respects himself is safe from others; He wears a coat of mail that none can pierce." -- LONGFELLOW. The Vulva.-- The female generative organs consist of three groups-- the external, the intermediate, and the internal. The vulva, or external generative organs, comprises all those organs which are external to the body. The vulva is pierced by two openings, the smallest and most anterior of which is the external opening of the urethra, or excretory duct of the bladder. This opening is surrounded by a slight eminence and has a somewhat puckered aspect. The larger opening is the vaginal orifice. In the virgin this is partially closed by the hymen. About one inch back of this is the anus, or the external orifice of the large bowel. This part of the bowel is known as the rectum. The Hymen.-- The hymen consists of a thin duplicature of mucous membrane strengthened by fibrous tissue, and is stretched across the posterior part of the vaginal orifice, which it partly occludes. Rupture of the hymen usually, but not always, occurs during the first sexual intercourse. In rare cases it is found intact at the time of the birth of the first child. In women who have borne children the vaginal orifice is surrounded by small irregular elevations; these are the remains of the ruptured hymen, but are usually present only after labor has taken place, since the torn hymen is converted into eminences as the result of the pressure incident to child-bearing, and not to coitus. The Condition of the Hymen as a Proof of Virginity.-- Formerly much stress was laid on the condition of the hymen as a proof of virginity. The hymen tightly closed, barely admitting the tip of a small index-finger, is positive evidence of virginity. But the hymen may lose its tone by a local catarrhal condition or by a general muscular relaxation; it may then become so relaxed that the only positive evidence rendered by the intact hymen is that the woman has not borne a child. In a paper on the preservation of the hymen, Dr. Hannah M. Thompson writes: "Further, if the hymen was intended as a guarantee of moral character, and for moral protection, either of man or woman, would we not have some reason for reflecting on the wisdom and righteousness of a Creator who has failed to make equal provision, and to give a like guarantee of an uncorrupted manhood? As physicians, we know too well that where one woman enters the marriage relation tainted in body there are thousands of men reeking with disease; and there is no demonstrable test to distinguish these, no proof for the young woman of the virginity or virtue of the young man." The Bladder.-- The female bladder is relatively broad and capacious, and is also highly distensible. When the bladder is allowed to become overdistended, it is carried backward and tends to cause a backward displacement of the uterus. The urethra, or excretory duct of the bladder, is about an inch and a half long, and lies firmly imbedded in the anterior vaginal wall. The Vagina.-- The intermediate organ is the vagina. This is a musculo-membranous canal which connects the external with the internal organs of generation. The vagina lies in relation with the bladder and the urethra in front, and with the rectum behind. The vagina is sufficiently distensible to allow of the passage of so large a body as the child. The Uterus.-- The internal organs of generation are the uterus, the ovaries, and the Fallopian tubes. Of these, the ovaries and the uterus are the essential female organs of generation. The virgin uterus is a small, hollow, muscular organ, somewhat pear-shaped, whose cavity is about one and a half inches deep. The uterus is divided by a natural constriction into a body and a neck. The neck, or cervix, is somewhat spindle-shaped, and has a canal running through its center which opens by a small aperture-- the so-called external orifice,-- into the vagina. In the virgin uterus the apposition of the anterior and posterior walls reduces the cavity to little more than a longitudinal cleft. With the advent of old age the whole organ suffers marked atrophy. The uterus is situated in the middle of the pelvic cavity, between the bladder and the lower bowel. It is held in place by broad elastic bands which go to different sides of the pelvis; it is also in part supported by the structures below and above it. But so loosely is the uterus held that it is easily pushed about-- as, for instance, by a full bladder or a packed bowel. And persistently allowing the bladder to become overfull, and failure to have a daily evacuation of the bowels, are prolific sources of displacements of the womb. Respiratory Movements of the Uterus.-- When no constrictions are placed about the waist, the uterus moves freely up and down with every respiration. So distinctly and with such regularity do these movements take place that an operator by watching the movements of the uterus can tell the effect that the anesthetic is having on the patient's breathing. These so-called respiratory movements play a very important role in the circulation of the uterus, and in the return of the venous blood to the heart. Anything which interferes with these movements, as the use of corsets, or of tight bands around the waist, prevents the free return of the venous blood. The uterus becomes congested, and through the constant abnormal weight of the organ itself, as well as the pressing down upon it from above of the superincumbent organs, the uterus is pushed down below its normal position, the ligaments whose duty it is to hold it up become relaxed, and the unhappy woman suffers all the agonies that are attendant on the "falling of the womb." For this reason the disorder is frequently met with in women who have never borne children as well as in those who have. The Fallopian Tubes.-- The Fallopian tubes extend from the upper, rounded angles of the uterus, within and along the free margin of the broad ligaments, for a distance of about two inches, to the vicinity of the ovaries, where each one terminates in a funnel-shaped orifice surrounded by a series of fringed processes. The lumen of the tube is narrowest at its inner end, where it opens into the cavity of the uterus by a minute orifice which scarcely admits a bristle; the diameter of the canal gradually increases until it reaches its ovarian extremity. The mucous lining of the tube is clothed by a single layer of hair-like epithelium, whose current sweeps from the ovarian toward the uterine end of the tube; and it is these movements which propel the ovum from the ovary to the uterus. The Ovaries.-- The ovaries are two small bodies of an almond shape, and lie on either side of the uterus. The bulk of the entire organ consists of connective tissue, in which lie imbedded the Graafian follicles or ovisacs, in which the ova are contained. These follicles or ovisacs are minute cells which are packed immediately beneath the surface, where they occur in all stages of development. With the increase in size which accompanies their development the follicles pass toward the surface, where they form a distinct projection, and at this point will occur the final rupture of the sac and the escape of the ovum. It is supposed that the ovum is grasped by the fringe-like extremity of the Fallopian tube and is carried through it by the movements of the ciliary epithelium to the uterus. The formation of new follicles continues only for a short time after birth, when the Graafian follicles are the most numerous; the entire number contained within the ovaries of the child being estimated at over 70,000. In view of the unquestionably large number of follicles in very young ovaries, and the relatively small number of ova which reach maturity, the degeneration of many follicles after reaching a certain degree of development seems certain. CHAPTER IV. PHYSIOLOGY OF THE FEMALE GENERATIVE ORGANS. Ovulation; Etiology of Menstruation; Uterine Nerve-supply; the Function of the Uterus; Stages of the Menstrual Cycle; Average Duration of the Menstrual Flow; Character of tahe Flow; Relation of Ovulation to Menstruation; the Menstrual Wave; Definition of Menstruation; Premomitory Symptoms of the Flow; Hygiene of Menstruution. "Toil and grow strong; by toil the flaccid nerves Grow firm, and gain a more compacted tone." -- ARMSTRONG. Ovulation.-- At birth the formation of the ova is nearly completed; the production of' new cells probably ceases after the second year. The ovaries of the child of two years contain, therefore, the full quota of ova, although the vast majority of these cells always remain immature and undeveloped. While it is probable that a variable number of the immature ova undergo partial development before puberty, yet the advent of sexual maturity at that time marks the establishment of the regular development of the Graafian follicles and their contained ova, accompanied by the attendant phenomena of menstruation. During the entire child-bearing period, or from about the age of fifteen to forty-five years, the development of the Graafian follicles and the discharge of the ova are continually taking place. The liberation of the ova usually takes place at definite times, which in general coincide with the menstrual epochs, one or more ova being set free at each period; but this is by no means invariable. The ripe human ovum or germ cell is a spheric cell, about 0.2 mm. in diameter, consisting of granular protoplasm, in which lies a nucleus which contains the germinal spot. The proper cell-wall is a structure of great delicacy, outside of which is a secondary envelope. Menstruation.-- The etiology of menstruation has been variously explained at different epochs. The chief theories have been that of plethora, and the ovulation, the tubal, and the nerve theories. First, the Theory of Plethora.-- From the time of Hippocrates to 1835 the theory prevailed that in the female body the formation of blood is sufficiently rich to provide every four weeks for an overflow of the same, the evacuation of which becomes a necessity. It was believed that this excess of blood depended on an excess of formative power in the woman. Second, the Ovulation Theory.-- This was distinctly formulated about 1845. It construed the menstrual hemorrhage as a subsidiary phenomenon, entirely dependent on the periodic dehiscence of ovules. The changes supposed to take place in the Graafian follicles at each menstrual period were believed to involve a peculiar expenditure of nerve force, which was so much dead loss to the individual life of the woman. The growth of the Graafian vesicle and its contained ovum was supposed to cause an irritation of the nerves of the ovary, which was reflected to the entire nervous system. The gradual accumulation of this irritation finally caused a reflex action which determined an afflux of blood to the uterus and ovaries, which constitutes the catamenial flow. The ovulation theory was refuted by the following facts: Ovulation may and does occur without menstruation; women who have never menstruated may conceive; conception may occur during lactation, without the menses having returned since the last parturition; children at birth have many ovules contained within the ovaries; ovulation may persist for a time after the menopause, and even pregnancy has occurred, although very rarely after this time; the menses may continue regularly after the removal of the ovaries and Fallopian tubes; this is exceptional, and, as a rule, the periods only continue for two or three years at longest. Third, the Tubal Theory.-- Lawson Tait thought that thorough removal of the tubes was far more essential in determining the menopause, and that cases of periodically recurring hemorrhage after the removal of the ovaries were to be explained by the fact that the tubes had not been sufficiently removed. As an anatomic and surgical fact, the tubes can never be wholly excised unless the upper part of the uterus is also amputated. Fourth, the Nerve Theory of Menstruation.-- This is based upon the following views: 1. That menstruation is a process directly controlled by a nerve-center situated in the lumbar region of the spinal cord. 2. That the menstrual impulses reach the uterus through two sets of nerves. 3. That menstruation is the result of nerve irritation, vascular congestion, and the subsequent relief of these by hemorrhagic discharges. 4. That hemorrhage from the uterus is the result either of a local uterine condition, or of influences outside of the uterus acting directly on the center. 5. That the removal of the appendages arrests menstruation by preventing the propagation of uterine influences to the center. Uterine Nerve Supply.-- One set of nerves causes contraction of the muscular fibers of the uterus, while the other set transmits impulses which bring about its vascular engorgement; and they are probably concerned in bringing about the determination of blood to the uterus and its appendages, which is so marked a feature of the menstrual process. As the result of long-continued investigation, Johnstone has come to the conclusion that the lining membrane of the uterus belongs to that class of organs whose function it is to replace organic waste. "Menstruation is a periodic wasting away of those corpuscles that are too old to make a placenta." He has further found that, as compared with the uteri of very many of the lower animals, the human uterus is very scantily supplied with lymphatics, and the only way to rid the uterus of the overripe, and therefore consequently useless, tissue is to wash it out through the vagina by a blood-stream. The tough wall of the human uterus and the increased blood-pressure caused by the erect position cause the difference between menstruation in the human female and rut in the lower animals. The strong light of recent investigations has necessitated the laying aside of many time-honored theories; and as the close of the nineteenth century has seen the emancipation of the uterus from the thralldom of the ovary, so we may believe that the twentieth century will find women of such fine physique as to prove the error of the popular fallacy that the cause of woman's weakness lies in the performance of her functions. The Function of the Uterus.-- The function of the uterus is to provide a favorable place for the reception of the product of conception, where it may be protected and nourished during the period of its development. The purpose of menstruation is to keep the uterus in suitable condition for the reception of this product of conception at any time. It is now known that the menstrual flow is not the whole of menstruation, and that the changes going on in the uterus are almost as continuous as the process of digestion. The whole of the reproductive life of woman has been divided into cycles of twenty-eight days each; these cycles have been divided into four stages. Stages of the Menstrual Cycle.-- The first or constructive stage is one of preparation for the reception of the ovum. During this stage the preparing of a decidua takes place, or building a nest for the expected egg; there is a swelling of the mucous membrane, an enlargement of the uterine glands, and an increase in the connective tissue. It is thought that this stage lasts for one week; when pregnancy does not occur, it is followed by degenerative changes. The second or destructive stage is marked by destructive changes which give rise to the usual phenomena of the menstrual period; there is a discharge of blood, mucus, and disintegrated mucous membrane. The actively growing cells of the uterine lining membrane undergo rapid destructive changes, the fabric of the half-formed decidua tumbles to pieces, the turgid capillaries burst and pour out the menstrual flow, which sweeps away all the useless debris. The irritation sets up reflex uterine contractions, and so the blood is squeezed out of the distended capillaries and washes away the degenerated cells. The third or reparative stage, as its name indicates, is one of repair, in which by constructive changes the epithelial lining which was thrown off is replaced by new, which is formed in from three to four days. The fourth or quiescent stage includes the remaining twelve or fourteen days of the menstrual cycle, and represents the quiescent period prior to the initiative changes which mark the beginning of the next period. Average Duration of the Menstrual Flow.-- The average duration of the menstrual flow is five days, although the variations are considerable in healthy women. A flow lasting any place from two to six days is perfectly consistent with health; but a flow continuing less than two or more than six days generally indicates local or general disease. Character of the Menstrual Flow.-- For the first few hours, or perhaps for the first day, the flow is usually slight in quantity and light in color; on the second and third days the flow reaches its height, and is profuse and dark, but it should never be clotted; after this it gradually ceases. The amount of the flow varies from five to ten ounces. If less than five or six or more than eighteen napkins are pretty well saturated through, the amount may be considered abnormal. Relation of Ovulation to Menstruation.-- It has not yet been decided just in what relation the processes of ovulation and menstruation stand to each other. It is supposed that the transit of the ovum to the uterus occupies at least one week. It has been thought that the decidua of a particular menstrual period is related, not to the ovum discharged at that period, but to the ovum discharged at the preceding period. The menstrual wave, or the wave of "supplementary nutrition,"[*] upon which the menstrual process ultimately depends, was first established by Dr. Mary Putnam Jacobi in the Boylston prize essay for 1876; showing that menstrual life is associated with a wave of well-marked vital energy, which manifests itself in a monthly fluctuation of the tempera ture of the body, in the daily amount of the excretion of urea and of carbonic acid, and of the rate and tension of the pulse. The wave attains its maximum during the week preceding menstruation, and slowly falls to its minimum, which is reached the week after menstruation. * Dr. Goodman and Dr. Stephenson have since written on this subject, and the "wave" is often known as the Stephenson wave. This wave indicates a periodic variation in the bodily metabolism, and is probably directly influenced by the rhythmic activity of the menstrual center. This observation would seem to be nullified by the fact that the phenomena referred to have been found to occur in men as well as in women; and that the lower animals also seem to show the same periodic variations. "It is therefore evident that the phenomena belong not to the function of menstruation, but to a general law of vital energy." Definition of Menstruation.-- Menstruation may, then, be defined as the periodic discharge of blood from the uterus, accompanied by the shedding of the epithelium of the body, as well as that of the uterine glands near their orifices. The sanguineous discharge is due partly to the oozing of blood from the surfaces denuded of epithelium, and partly to active congestion. The discharge from the uterus is largely augmented by mucus secreted in increased quantity at this period from the enlarged uterine glands. The tubes take some part in the process of menstruation; their mucous membrane is swollen, the epithelium is shed in places, and they are filled with a thin bloody fiuid, containing blood-corpuscles and cast-off epithelium cells. The menstrual wave continues from puberty to the menopause; it is a nervous phenomenon. Ovulation is a progressive, non-periodic process; it begins before birth and continues till the ovarian tissue is atrophied or worn out. Premonitory Symptoms of the Flow.-- The premonitory symptoms of the monthly flow should not be so marked as to cause the individual any discomfort. The first indication of the return of the period should be the appearance of the flow. There is generally a feeling of abdominal fulness with some lassitude, and sometimes slight headache. The temperature is lower and the pulse is slower than at other times. This lowered tone of the system is an additional reason for increased care against exposure in wet or cold weather. Hygiene of Menstruation.-- During the menstrual periods all cold baths must be strictly prohibited, whether tub-baths or cold sponges. The reason of this is that the application of cold to the surface causes a driving in of the blood from the exterior of the body to the internal organs; and at the menstrual periods there is already a congested condition of the pelvic organs, and it must be remembered that congestion is the first stage of inflammation. Hot or warm sponge-baths may be taken throughout the period; and the vulva should be bathed with warm water twice a day through the entire period of the flow, as this not only removes the clotted blood before it decomposes and becomes the source of irritation, but also removes other irritating matters, and prevents the nervousness that is caused by a local irritation. It is strange how women who are scrupulously neat in all other respects will allow the smegma to collect in and about the vulva; as a matter of fact, for the purpose of cleanliness it is much more necessary that the external genitals should be washed twice a day with soap and water all through life than that the face should be washed that often. Another question which is still sub judice is the necessity for and the frequency with which vaginal douches should be taken; all physicians are agreed that a vaginal douche taken immediately after the menstrual period is beneficial, as it removes all the debris of the flow, which is sometimes very irritating. Exercise.-- A moderate amount of exercise should be taken every day; this is needed now quite as much as at any other time, and only good can result from it. And no harm comes of a woman going out in the rain or in cold weather; as has been shown, the menstrual process is going on for a large part of the time, and the flow is only the external appearance, but during the time of the flow the woman must be unusually careful not to get her feet wet or to sit down with damp clothing on. Violent exercise of all kinds is to be prohibited at this time, as dancing, rides on the bicycle, gymnastics, and walks of over three miles. The reason for this is very obvious; the uterus has now reached the height of its turgescence, and is heavier than at any other time, hence the danger that displacements or a very profuse flow would be caused by any kind of violent exercise. Treatment.-- If the woman has been so unfortunate as to get caught out in a heavy rain so that her clothes have been wet through, or if in the cold weather she should come into the house thoroughly chilled, the best thing to do is to take off her wet things as quickly as possible, be well rubbed down with hot, rough towels, drink a cup of hot tea, go to bed at once and place a hot-water bag over the abdomen. She should remain in bed until the next morning, to the end that the circulation may regain its equilibrium as quickly as possible by the immediate relief of the pelvic congestion. If this exposure should have caused the sudden cessation of the flow, a hot mustard foot-bath should be taken. One tablespoonful of mustard is used to a gallon of water as hot as can be borne; the pail should be made as full as can be without running over, and a blanket wrapped around the pail and woman, so as to cause a profuse perspiration; this should be kept up for ten minutes; if the water cools off, hot water may be added. CHAPTER V. THE ANOMALIES OF MENSTRUATION. Menorrhagia and Metrorrhagia; Dysmenorrhea; Amenorrhea; Leuchorrhea; Pruritus Vulvae. "Defer not till to-morrow to be wise, To-morrow's sun on thee may never rise." -- CONGREVE Menorrhagia and Metrorrhagia.-- By menorrhagia is meant an excessive or too profuse menstrual flow; by metrorrhagia, a flow of blood between the menstrual periods. Neither one constitutes a disease by itself, but is a symptom of some pathologic condition. It has already been stated that the excretory organs, by constantly eliminating from the system the worn-out material, keep the machine healthy and in good working order. Kept within natural limits, this elimination is the source of strength and health; beyond these limits, the menstrual flow becomes an actual hemorrhage that, by draining away the life, becomes the source of weakness and disease. No physician would dare to bleed a man or woman once a month, year in and year out for thirty years; but, through ignorance or folly, this is what many girls do for themselves. This excessive flow, aside from actual local disease, is brought about by excessive muscular exercise during menstruation; by the use of all stimulants, whether alcoholic beverages or quinin; as well as by the thinness of the blood. When the flow is excessive, it must be considered a pathologic condition, which needs the physician's attention. Rest in the recumbent position is the first essential; the diet must be plain and unstimulating, and attention must be paid to the condition of the blood. The general diseases which generally cause this condition are anemia, Bright's disease, malaria, the early stages of tuberculosis, and heart disease. The local causes may be reflex, as powerful emotions; or due to local disease of the uterus and its appendages, as the various inflammations and displacements of the uterus, fibroid tumors, polypi, and cancer. Dysmenorrhea is painful menstruation. The most frequent forms are due to uterine congestion; to mechanical causes, as a narrowing of the cervical canal, particularly at its internal opening, or to a constriction caused by the bending over of the uterus at the junction of the body and the neck; or to ovarian irritation. The pain varies in intensity from slight discomfort to the most intense uterine colic, which is experienced in the lower part of the abdomen. In severe cases the general health becomes undermined, the nervous system gives way, and hysteria and other disorders of the nervous system result. The congestive variety usually occurs in patients who have previously menstruated painlessly. The pain comes on suddenly with the flow and ceases when the flow stops; it is very severe and is generally accompanied by a diminution or a cessation of the flow. There is severe headache, marked diminution in the secretion of the kidneys, and general restlessness. The patient frequently experiences pain in walking, is easily fatigued, has leucorrhea and an irritable bladder. In ovarian dysmenorrhea the pain precedes the flow for several days and ceases when a free flow is established. The pain is of a dull aching character, and may be felt on one or both sides of the abdomen, according as one or both ovaries are involved. Amenorrhea.-- In amenorrhea the menstrual flow may not appear for some years after it is normally due; or the flow may cease after some months or years of continuance; or the flow may be abnormally scanty or even absent. The menstrual flow is much later in appearing in some families than in others, so that this may be considered as a family idiosyncrasy; and if the girl's health is good, it need cause no anxiety. If, on the contrary, the girl has severe headaches, or suffers in any way, the physician should be summoned at once, as the absence of menstruation may be indicative of some serious pathologic condition, A scanty flow is often indicative of thinness of the blood; on the other hand, serious anemias often lead to profuse menorrhagias or metrorrhagias, as has already been stated. The cause of the profound anemia itself may be insufficient nutrition, overwork, or lack of exercise. Scanty menstruation is often seen to occur in fevers, in the later stages of consumption, in advanced Bright's disease, in malaria, or in any other very serious disease. In these cases it seems to be a conservative process on the part of nature in the run-down state of the system. As consumption progresses menstruation generally ceases absolutely, never to return again; and in this case nothing should be done to try to induce a return of the flow. Great shock sometimes causes a sudden cessation of the flow; and sometimes a sea-voyage, followed by the change of habitat, will cause an obstinate form of amenorrhea. But it cannot be too well understood that, after the menstrual flow has been regularly established, it continues with the greatest regularity throughout the child-bearing period, unless the exposure to wet or cold has been sufficiently severe to cause great indisposition on the part of the woman. In this case it is possible that, if the exposure took place just previous to the time of the expected flow, one period may remain out. But except in case of serious illness,-- as for example, typhoid fever,-- two or more periods do not fail to appear except in the case of pregnancy. Leucorrhea.-- Leuchorrhea, or "whites," is a mucous or mucopurulent discharge from the vagina; it may be a symptom of uterine or vaginal disease. Immediately after the menstrual flow there is a well-marked vaginal secretion which is whitish in appearance; it may be transparent or of a milky color, and is sometimes very acrid. This secretion may also precede the flow, and there is nothing abnormal in this. But any discharge occurring between the periods sufficient to stain the clothing-- the so-called whites or leucorrhea-- is abnormal, and is caused by an inflammation of the vagina or the neighboring parts. In addition to the discharge there is heat and swelling of the parts, more or less local distress, and generally intense nervousness. If the disease is not cured, it may become chronic. The pain, heat, and scalding disappear, but a copious discharge continues, and in this stage the disease may be very obstinate and greatly reduces the strength. The constant drain breaks down the system, producing pallor, debility, pain in the back, palpitation, indigestion, and so forth. The character of the discharge in leucorrhea varies considerably, from a whitish or mucous secretion, to a yellowish or mucopurulent secretion, and is debilitating in proportion as it is profuse. It is to be remembered that this is not in itself a disease, but indicates a disease of some of the pelvic organs; and that all such inflammations left to themselves incline to grow worse. A severe leucorrhea is generally attended with frequent and finally painful micturition; pain in walking in the lower part of the abdomen, which may become so severe as to compel the patient to go to bed. Pruritus Vulva.-- This is an intense and persistent itching of the vulva, and is a symptom rather than a disease. It is not an infrequent result of leucorrhea, the acrid discharge of the latter leading to an irritation of the parts; this causes rubbing of the parts until a veritable inflammation is produced. Other causes of pruritus vulvae are: The local congestion, such as occurs at the menstrual period, or in certain cases of pelvic inflammations, or in early pregnancy; constipation; sedentary habits; congestion of the liver; incontinence of urine, and diabetes. When dependent on the latter, the malady is most obstinate in yielding to treatment. Indigestible foods or drinks, the rubbing of the clothes, the friction of walking, and the heat of the bed act as exciting causes in those predisposed to it. The essential treatment here is to at once ascertain and remove the cause; aids in the treatment are vaginal douches and cooling lotions. CHAPTER VI. THE MARRIAGE QUESTION. Herbert Spencer's Definition of Love; What Constitutes a Suitable Husband; Best Age for Marriage; Shall Cousins Marry? Contraindications to Marriage; Do Reformed Profligates Make Good Husbands? the Proper Length of Time for the Engagement; the Right Time of the Year to Marry; the Selection of the Wedding Day. "Well, Brutus, thou art noble; yet, I see, Thy honourable mettle may be wrought From that it is disposed: Therefore, 'tis meet That noble minds keep ever with their likes. For who so firm that cannot be seduced?" -- "Julius Caesar." Herbert Spencer's Definition of Love.-- "Love is habitually spoken of as though it were a simple feeling, whereas it is the most compound, and therefore the most powerful, of all the feelings. Added to the purely physical elements of it, are first to be noticed those highly complex impressions produced by physical beauty; around which are aggregated a variety of pleasurable ideas, not themselves amatory, but which have an organized relation to the amatory feelings. With this there is united the complex sentiment we term affection-- a sentiment which, as it can exist between those of the same sex, must be regarded as an independent sentiment, but one which is here greatly exalted. Then there is the sentiment of admiration, respect, reverence, in itself one of considerable power, and which in this relation becomes in a high degree active. There comes next the feeling called the love of approbation. To be preferred above all the world, and that by the one admired above all others, is to have the love of approbation gratified in a degree passing every other experience, especially as there is added that indirect gratification of it which results from the preference being witnessed by others. Further, the allied emotion of self-esteem comes into play. To have succeeded in gaining such attachment from and sway over another is a proof of power which cannot fail to agreeably excite amour propre. Yet again, the proprietary feeling has its share in the general activity. There is the pleasure of possession, the two belonging to each other. Once more, the relation allows of an extended liberty of action. Toward each other a strained behavior is requisite. Around each there is a suitable boundary that may not be crossed; an individuality on which none may trespass. But in this case the barriers are thrown down, and the love of unrestrained activity is gratified. Finally, there is an exaltation of sympathies, egotistic pleasures of all kinds are doubled by another's sympathetic participation, and the pleasures of another are added to the egotistic pleasures. Thus around the physical feeling forming the nucleus of the whole, are gathered the feelings produced by personal beauty that constitutes simple attachments, of self-esteem, of property, of love of freedom, of sympathy. These, all greatly exalted and severally tending to reflect their excitements on one another, unite to form the mental state we call love. And as each of them is comprehensive of multidinous states of consciousness, we may say that this passion fans into immense aggregate most of the elementary excitations of which we are capable; and that hence results its irresistible power." What Constitutes a Suitable Husband.-- It is desirable that the husband shall be a few years older than the wife. Man is later in coming to maturity, and also retains his sexual powers considerably longer than woman; so that for these functions to cease about the same time, the wife must be younger than the husband. A difference of from two to five years is best; if the parties are young, it is not essential that the husband should be much the wife's senior, as it is later in life. The husband may be ten years older, but a greater disparity of age than this is rarely compatible with congeniality of tastes and dispositions, so essential to a happy married life. The woman who risks her happiness with a man many years younger than herself violates a precept of nature. The average stature of the man is about three inches greater than that of the woman, and in the physiologic marriage any great deviation from this should be avoided. The essentials for a happy marriage may be summed up as follows: that the parties shall be of suitable age; that they shall be physically well mated and in full sympathy with each other's views of life, of the same social position, and of equal education. The Best Age for Marriage.-- The reproductive life begins with puberty, but maturity is not reached before the age of twenty-one. It is only then that the standard of development is reached that is most compatible with the successful bearing of the grave responsibilities of wifehood and motherhood. The too early exercise of the reproductive functions leads to increased suffering on the part of the mother, depresses her vitality, and increases her liability to disease. Statistics show that the mortality is very much greater where girls marry under twenty years of age. The offspring are apt to be small and ill developed, and die in large numbers in early life; only a small percentage live long and robust lives. In France it has been observed that where the fear of conscription has caused many young people to marry the offspring were lacking in vigor. Among the offspring of immature parents there is a larger proportion of idiots, cripples, criminals, scrofulous, insane, and tubercular than among the children of nubile parents. In our climate women are best fitted to become wives and mothers between the ages of twenty-four and twenty-eight years. Before this age neither their self-knowledge, their knowledge of the world, nor their experience is sufficiently mature to fit them to wisely make the choice of a companion for life, or to become mothers. After forty, most women cannot hope for children. Men had better wait until between the ages of twenty-seven and thirty years, before they undertake the responsibilities of parenthood. Shall Cousins Marry?-- They might if both families were perfectly healthy; but as few families are without some lurking predisposition to disease, it is not well, as a rule, to run the risk of developing this by too repeated unions. Contraindications to Marriage.-- Young women in whose family there is a distinct history of such hereditary diseases as cancer, tuberculosis, or insanity for two generations back, should not marry at all. Not only is this a fearful legacy to hand down to their children, but pregnancy and child-bearing very decidedly favor the development of these diseases. Syphilis in either sex is a distinct bar to marriage; first, the party married is sure to contract the disease, even though it may have been supposed to have been cured. Fortunately, the children of such marriages are generally still-born; still, they do sometimes live, and are most pitiable and sickly objects. For any one to marry under these conditions is a crime against society, against the State, and against posterity. Women who have serious forms of heart disease, tuberculosis, or Bright's disease would, by becoming pregnant, run a serious risk of losing their lives toward the close of the pregnancy or at the time of their confinement. In case of heart disease, the pulmonary congestion that accompanies pregnancy, together with the encroachment of the pregnant uterus on the cavity of the chest, would greatly add to the embarrassment of the heart's action. In normal pregnancy there is some congestion of the kidneys; where there is actual disease of the kidneys prior to the pregnancy, this congestion is apt to become so severe as to threaten the woman's life. These organic diseases are not to be confounded with functional diseases which are dependent on some other cause; as palpitation of the heart due to indigestion, or heart murmurs dependent on the thin state of the blood, or congestion of the kidneys due to exposure to cold;-- all of which may be cured by proper treatment. Should a woman with a fibroid tumor marry, she would run a great risk to her life; she should have the tumor removed, or, if this is not possible, she should give up all thoughts of marriage, since the increased irritation and congestion consequent upon the marital relations would tend to favor its growth. Should pregnancy ensue, delivery might be attended with serious complications, as very difficult labor, postpartum hemorrhage, or, as these tumors have but little vitality, and the pressure to which they are subjected during labor is liable to cause their death, disorganization, sloughing, and, as a result, puerperal septicemia. Sometimes there is such a lack of development of the genital organs as to prevent the woman from having children. Two persons with even a slight tendency to the same disease, either inherited or acquired, should not intermarry, even if they are in comparatively good health at the time. Their offspring would be quite sure to inherit their diseased tendencies. Persons whose constitutions have been somewhat injured, but who are not tainted with actual disease, may rear children much healthier than themselves, provided their own lives are wisely regulated. If they are growing better all the time, and are not too much broken in constitution, it may be safe for them to marry. Among the Jews the physician is frequently consulted before matrimonial alliances are contracted. This custom could not but be of universal benefit; many local or general diseases would be eradicated before marriage, and in this way much suffering and unhappiness would be spared; or, in other cases, the patient would be advised of the inadvisability of marriage. Do Reformed Profligates Make Good Husbands?-- The manner of life that has been led by this class of men is such as to undermine their health, if not to have rendered them physical wrecks. There is the overindulgence in alcoholic beverages, and perhaps, added to this, some drug habit. In addition to this, these men early in their career are apt to become infected with some of the venereal diseases, or perhaps with all of them-- gonorrhea, syphilis, and so forth; and these diseases have the horrible characteristics of becoming latent. A man who contracts this kind of a disease can never be really sure that he is cured. All venereal diseases are highly contagious. It is now a well-established fact that gonnorrheal infection is not only one of the most common causes of pelvic inflammations in women, but that these same inflammations are of the most virulent types, unless they are recognized and treated in the early stages. It is also a well-known fact that a large percentage of married women suffer from this disease. Sterility almost always results. In the case of a syphilitic parent, one or two children may be born, but the offspring is generally sickly and diseased. Inebriety as well as sexual excesses are both well recognized as distinct forms of disease accompanied by degeneracy of brain tissue. It is nothing less than criminal for such men to have children, since these children would at least inherit the tendency to the same diseases, if they did not actually have them; there is also a strong probability of such children being born idiots or imbeciles. It is therefore self-evident that, instead of a reformed profligate making a good husband, he must make a very diseased one. It has therefore been suggested that the parents of the prospective bride should demand from the intended groom a certificate of freedom from all venereal diseases by a physician of their own selection. Also that there should be legislation upon the subject, and that before a man is granted a license of marriage, he should have a certificate from the health officer of freedom from syphilis, gonorrhea, and tuberculosis. The Proper Length of Time for the Engagement.-- A period not shorter than three months, nor longer than one year, should elapse between the engagement and the marriage. There are strong physiologic reasons against long engagements: they keep the affections and the passions in an excited and unnatural condition, which after a time tends to weaken the nervous system and undermine the health. These evil consequences are common to both sexes. It is far better that the subject of marriage should not be entertained at all unless the circumstances are such that the union might with propriety be effected at once. The Right Time of the Year to Marry.-- When woman marries she enters upon a new life, and a very trying one. Extreme heat and extreme cold are both very taxing to the human economy. Midsummer and midwinter are therefore both objectionable, but especially the former. The Selection of the Wedding-day.-- This is by common consent left to the bride. She should select a time about ten or fifteen days after the end of one of her menstrual periods, as this is the time of comparative sterility, and it is most desirable that the first sexual relations should be fruitless. _________________ PART II.-- MARRIAGE. _________________ CHAPTER VII. THE ETHICS OF MARRIED LIFE. The Wedding Journey; the Ethics of Married Life; Shall Husband and Wife Occupy the Same Bed? the Comsummation of Marriage; the Marital Relation; Times when Marital Relations Should be Suspended. "If it is possible to perfect mankind, the means of doing so will be found in the medical sciences."-- DESCARTES. The Wedding-journey.-- The wedding-journey, which was formerly the cause of so much discomfort to both husband and wife, has fortunately gone out of vogue; and in its place has come the retirement to a quiet country or seaside spot, away from the prying eyes of friends. Thus the nervous strain incident to sight-seeing and travel is avoided. The Ethics of Married Life.-- It has been said that God set men and women in pairs in order that they might perfect each other and complete each other's happiness. The secret of all true happiness in life lies in the spirit of altruism; one must be able to wholly forget herself and to find her happiness in the welfare of others. The woman who exhausts herself physically and financially on the preparation of her trousseau and her wedding does her husband a wrong by bringing him a wife who is on the verge of nervous prostration. The secret of a happy married life depends to no small extent on the very beginning: the relation is so entirely new, and much lies hidden in the character of each that was never suspected by the other. Between husband and wife there must always be mutual concessions, forbearance, and sympathy; a mutual helpfulness to attain all that is best. This, of course, implies that the life of each is an open book for the other to read; that there is an unreserved exchange of thought; and that no privilege is claimed by the one that would not willingly be accorded to the other. "How many men," says Balzac, "proceed with women as the monkey of Cassan with the violin; they have broken the heart without knowing it, as they have tarnished and disdained the jewel whose secret they never understood. Almost all men are married in ignorance of women and of love. They have commenced by forcing open the doors of a strange house and have wished to be well received in its salon. But the most ordinary artist knows that there exists between him and his instrument-- his instrument which is made of wood or ivory-- a sort of indefinable friendship. He knows by experience that it has taken years to establish this mysterious rapport between an inert material and himself. He could not have divined at the first stroke all its resources and caprices, its faults and its virtues. His instrument only became a soul for him and a source of melody after long study; he only came to understand it as two friends after the most learned interrogation. "So the world is full of young women who grow pale and feeble, sick and suffering. The ones are a prey to inflammations more or less severe; the others remain under the dominion of nervous attacks more or less violent. All these husbands have caused their own unhappiness and ruin. Never begin married life with a rape. To demand of a young girl whom one has seen forty times in fifteen days to love you because of the law, the king, and justice is an absurdity. "Love is the union of necessity and of sentiment. Happiness in marriage is the result of perfect understanding between the spirits of husband and wife. From this it happens that in order to be happy, a man is obliged to bind himself to certain rules of delicacy and honor. After taking advantage of the social laws which consecrate the necessity, it is necessary to obey the secret laws of nature, in order to make the sentiments flourish. If a man places his happiness on being loved, it is necessary that he should love sincerely; nothing resists a veritable passion." Shall Husband and Wife Occupy the Same Bed?-- Among civilized nations custom differs in this regard; in Germany, for instance, the husband and wife occupy separate beds in the same room; formerly in this country it was almost the universal custom for husband and wife to occupy the same bed. The current of opinion has changed in this respect, and it is now considered in the highest interests of both that they shall occupy not only separate beds, but separate rooms; these rooms communicating through a door which connects their respective dressing-rooms. This is unquestionably the best arrangement from the hygienic as well as from the ethical point of view. Health requires that one-third of the time shall be spent in sleep; the bed was made for sleep; and the most refreshing sleep can only be obtained by occupying the bed alone. If two persons occupy the same bed and one is restless, the sleep of the other is necessarily disturbed. Again, two persons occupying the same bed necessitates the same hour for rising and retiring, which is not always convenient or agreeable. Balzac writes on this subject: "To put the system of separate bed-rooms into practice is to attain to the highest degree of intellectual power and of virility. By what syllogism man arrived at establishing as a custom that of man and wife sleeping together, a practice so fatal to happiness, to health, to pleasure, and even to self-love, would be curious to seek out." If for financial reasons it is not possible to have separate bed-rooms, the German custom of having separate beds should be adopted. The Consummation of Marriage.-- The consummation of marriage is often attended with difficulty owing to the rigidity of the hymen; this, if present, must usually be ruptured before connection takes place. Great gentleness and care must be exercised by the husband if it does not readily yield, the use of hot vaginal injections should be kept up for several weeks before the trial is repeated. These usually relax the parts very considerably; but if coitus is still found impossible, it is better to consult a physician at once, when a simple operation will generally remove the trouble and the woman is spared much suffering. In no case is any violence on the part of the husband allowable, as it might produce irreparable injuries. There is always more or less suffering on the part of the wife at first, partly due to the rupture of the hymen, and partly to the forcible dilatation of the vagina and she should be allowed a sufficient time for nature to repair these injuries. By so doing, the constitutional disturbances and the nervous disorders which are so very prevalent may be prevented. Too frequent indulgence at this period is a prolific source of inflammatory diseases, and often occasions sterility and ill-health. The first nuptial relations should be fruitless, in order that any indisposition arising therefrom should have had time to disappear before the woman becomes pregnant. The Marital Relation.-- It is most important for the interest of both parties that there should be chastity in the marriage relation as well as out of it. Many young couples have had their lives ruined by excessive sexual indulgence. The effect is usually most severe upon the husband, yet the wife becomes weak, nervous, and excitable. Sexual excess is also the grave of domestic affection. The general rule given is that coitus should never take place oftener than every seven or ten days. When coitus is succeeded by langour, depression, or malaise, it has been indulged in too frequently. Among civilized people there are three widely diferent views as to the proper course to be pursued: First, those who maintain that sexual intercourse should not take place except for the propagation of the species. Second, those who believe that the act is a love relation, mutually demanded and enjoyed by both sexes, and serving other purposes besides that of procreation. Third, those who hold that sexual intercourse is a physical necessity for the man, but not for the woman. The first theory, "that the sexual relations should never be sustained save for the purpose of procreation," has many advocates. They teach that there are other uses for the procreative element than the generation of offspring, and far better uses than its waste in pleasures. They claim that a life of total chastity increases the physical and mental vigor; and there will result a procreation on the mental and spiritual planes, instead of on the physical ones. They also claim that to woman belongs the creative power; that she must choose when a new life shall be evolved; and that only by adhering to this law can she be protected in the highest function of her being-- the function of maternity. The adherents of the second theory, "that the act is a love relation, mutually demanded and enjoyed by both sexes, and that it serves other purposes besides that of procreation," claim that the female sexual life indicates that the healthy woman is neither indifferent nor passive in the generative act. It has much the same effect as in man-- a powerful increase in her sensations, whole groups of muscles are set in motion, and the uterus as well as the entire nervous system are in an excited condition and activity. And that it is the province of the mother to decide when a new life should begin. The third theory, "that sexual intercourse is a physical necessity for the man, but not for the woman," is by far the most widely accepted. We will consider, first, the practical results of this last theory; and, second, the scientific basis on which it rests. It is generally acknowledged that this practice has done more to cause domestic misery, sickness, and death than that dreadful scourge of the human race, tuberculosis. This man, accustomed all his life to gratify his sexual passions promisculously, marries a virtuous young girl. In her menstrual periods she has had to do only with the secondary phenomena; with the expulsion of the ova not at all. She has had no instruction in the corresponding physiologic life of the man, and is astonished at the male sexual indications, and is led to believe in their physiologic necessities. The result is that she not only suffers physically, but feels outraged and disgraced. She is liable to the chance of maternity at any time; and such offspring will probably be sickly. Passion is presented to the young wife in so hideous a guise that it will take the utmost consideration of her husband afterward to enable her to completely overcome her repugnance. If she be worn and weary of excesses in the early days of her married life, the husband will have only himself to blame if he is bound all his life to an apathetic and irresponsive wife. Husbands place great strains upon the affections of their wives, and lower themselves almost past reinstatement in their respect and esteem. Lastly, on what scientific basis does this "physilogic necessity" for sexual gratification on the part of the male rest? Analogy with the lower animals does not bear it out. Among animals, except in rare instances under domestication, the female admits the male in sexual embrace only for procreation. Among many savage tribes this same rule has but few exceptions. The analogies between the male and the female sexual organs; between seminal emissions and menstruation; between the sexual life of the male and of the female, only go to accentuate the fact that this so-called physiologic necessity on the part of the male has arisen chiefly through the difference of education; so that it has come to be that the woman is chaste and the man is degraded; that the woman is too sentimental and the man too passionate. From a purely medical standpoint, the most eminent physicians and physiologists of the day all unite in advocating a chaste and continent life, simply for the sake of the man's own health, independently of all other considerations. Times when Marital Relations Should be Suspended.-- The marital relations should always be suspended during the menstrual period. During pregnancy intercourse should never, or at least very rarely, be indulged in. At this time the mother needs to conserve all her strength and energies for herself and child; and any sexual relations during this time increase the sufferings of the mother and impair the vitality of the child. It has been even suggested that much of the pain during parturition would be avoided by entire continence during pregnancy. Intercourse during the early months of pregnancy is a frequent cause of abortion. Women who have supposed that they have never been pregnant have in reality been having abortions every second or third month. A woman should never be subjected to coitus until three months after delivery. During lactation intercourse should never, or at least very rarely, be indulged in; as the function of lactation makes a heavy drain on the strength of the mother, and anything which would further weaken her would tend to impoverish the quality of the milk and thus the child would suffer. CHAPTER VIII. SEXUAL INSINCT IN WOMEN. Sexual Instinct in Women; Excessive Coitus; Causes of Sexual Excitability. "Virtue, the strength and beauty of the soul, Is the best gift of heaven." -- ARMSTRONG. Sexual Instinct in Women.-- After careful observation of the sexes in the married state, it is found that the sexual appetence is less in women than it is in men. Much of this difference in sexual appetence is doubtless due to the chastity of their lives, coupled with and resulting from the difference of education. The girl is taught repression, and the boy expression; that girls must be chaste; that chastity for boys is impossible. According to the intensity of the sexual instinct women have been divided into three classes: A larger number than is supposed have little or no sexual feeling. Second, those who are subject to strong passion; this class is larger than the first, but small as compared with the whole of their sex. Third, those in whom the sexual appetite is moderate; this class comprises the vast majority of women. And, even granting to woman more pleasure in sexual indulgence than usually comes to her by largest allowance, it is safe to say that in nine cases out of ten maternity, with its early pains and later cares, greatly lessens her power of enjoyment; and that for the larger part of her married life she is either positively distressed by the apparently necessary demands of her husband upon her, and irresponsive to them, or kept to a cheerful response by a self-abnegation and regard for his comfort, not to say fear of his moral aberration, which is a positive drain upon her health and strength. Excessive Coitus.-- Those who are most frequently found to suffer from venereal excesses are the newly married; especially if they have weak constitutions and excitable temperaments. A great deal of mischief is done by two persons of unequal constitutions being matched together; the husband may exhaust the wife or vice versa, the weaker party being constantly tempted to exceed their strength. In all sexual matters there must be a consideration for others. It is not so much from selfishness as from ignorance that such a mistake is made. The ignorance comes from a lamentable morbid delicacy which prevails on all sexual matters, and which prevents all open and rational conversation on them, even between those who have the most intimate knowledge of each other. When the conjugal act is repeated too often, the man will become gradually conscious of diminished strength, diminished nerve force, and diminished mental powers. Excess weakens a man's energies, and enervates and effeminates him. Moreover, it renders him liable to an infinity of diseases and a readier victim to death. Not only is the strength of the constitution lowered by the excessive expenditure of force and matter requisite for the perpetuation of the species, but this lowered standard of vitality is transmitted to children. There can be but little doubt that this is one of the reasons why so many healthy parents beget sickly children, who die early. They have exhausted themselves of the material from which a new life is created, and so it is not properly started at the beginning and never reaches its highest development. To the truth of this statement attests the mental imbecility, the pallid and attenuated forms, of the children who are the earlier products of marriage. The effect of excessive coitus in women is seen by the confirmed ill health of so many women after marriage and repeated child-bearing. A large number of these cases are dependent upon alteration and diseases of the genitalia; but a considerable number are unconnected with local disease, and in many other cases the health is never regained after all local phenomena have disappeared. Sexual excitement in the woman causes certain congestion of the genital organs; and at the time of the orgasm there is a reflex movement which corresponds to erection, and which consists of a peristaltic movement of the tubes and uterus; to the uterus also is ascribed an act of suction by which the spermatozoa are drawn up into its interior. Even when pregnancy does not follow, the too frequent excitation and activity of the uterus in weak constitutions causes illness, first of the genital organs and then of the nervous system. Local diseases caused in women by excessive coitus are: vaginal catarrh, acute catarrh of the vulva, acute inflammation of the lining membrane of the uterus as well as of the uterus itself, inflammation of the ovaries, and even peritonitis. It is also known to be an important factor in the origin of blood-tumors and of cancer of the uterus. Especially is coitus at a time of great physical fatigue liable to be provocative of uterine inflammations. Aside from ethical considerations, coitus during the menstrual period may be the cause of rupture of the impaired blood-vessels, thus causing blood-tumors. Excessive coitus is a well-known cause of chronic inflammation of the uterus; that is, a habitual congestion of the uterus is induced by excessive sexual intercourse. This has been frequently mentioned by authors as leading to enlargement of the uterus in the non-pregnant condition; and it is a still more potent factor in the recently impregnated organ, whose tissues are succulent and the vessels enlarged, a condition inviting congestion and enhancing the susceptibility to engorgement. The general manifestations of impaired health in women due to excessive coitus are: chronic anemia, with malnutrition; impaired and altered functions in all the organs, especially those of the nervous system. Menorrhagia is apt to be induced by overstimulation of the ovaries, together with exhaustion and sexual apathy. The source of so much misery is the increasing physical weakness of the female and the increasing nervous weakness of the male, with an increasing sexual excitability, two factors of tragic effect for the wife. Here is seen the unfortunate result of teaching two kinds of morals, one for men and another for women. Causes of Sexual Excitability.-- Too frequent genital irritation, onanism, too frequent intercourse, alcohol, too rich and too highly seasoned foods, lack of exercise. Treatment of Sexual Excitability.-- Avoid alcohol and precocious puberty. Strictest attention must be paid to the diet; everything is to be avoided which is difficult of digestion or which retards it. The following articles of diet must all be avoided: cheese, foods seasoned with pepper and curry, highly salted and acid foods, and all rich foods; and meat must be eaten only in moderate quantities. Constipation irritates the genitalia directly and increases the inflammation. The close relation of Venus and Bacchus is known not only in mythology. Carbonated waters are to be especially avoided, such as soda, seltzers, Preblauer, Geisshubler, and acid waters; also champagne and beer, heavy Italian, Spanish, and English wines. All alcoholic drinks must be forbidden. As heavy gymnastics as the strength of the individual will admit, and plenty of exercise out-of-doors must be taken. There must also be constant mental and physical employment. In women sexual excitability is often caused by local diseases, and passes off with their cure; if not, she must use her will-power, and take the various forms of cold baths. Sexual intercourse not oftener than once in two or three weeks, and avoid all intimate approaches; if this is not sufficient, she will have to leave her husband for a few months. CHAPTER IX. STERILITY. Sterility; the Prevention of Conception and the Limitation of Offspring; the Crime of Abortion; Infidelity in Women. "Never let yourselves do evil that good may come. If you do, you hinder the coming of the real, the perfect good in its due time." -- PHILLIPS BROOKS. Sterility.-- Conception is least apt to take place from the tenth day after one period until the third day before the next; but there is practically no time during a woman's sexual life when she may not be impregnated; in this connection it must be remembered that the spermatozoa stay alive in her for more than a week. During lactation women are generally sterile, especially in the first months which follow the accouchement, because the vital forces are then concentrated on the secretion of milk. The age of the wife at the time of marriage has much to do with the expectation of children. As the age increases over twenty-five years the interval between the marriage and the birth of the first child is lengthened. For it has been ascertained that not only are women most fecund between twenty and twenty-five years, but that they begin their career of child-bearing sooner after marriage than either their younger or older sisters. A wife who has had children and ceases to conceive for three years will probably bear no more. When marriages are fruitless, the wife is almost always blamed; but it is by no means the wife that is always at fault; many husbands are absolutely sterile. Every man is not prolific who enjoys good health and is vigorous. Gross states that in one case out of six the sterility was due to the male. Kehrer, after a series of carefully conducted experiments, has arrived at the conclusion that in at least a third of the cases of sterile marriages the husband was the party at fault, and that gonorrhea was the cause of the barrenness. Venereal diseases have their share of influence, and the gonorrheal infection is a potent cause of sterility. It is by no means proved that syphilis has any unfavorable influence on conception, though abortions due to this are frequent. Gonorrhea often prevents conception by the inflammation traveling up the womb, and along the Fallopian tubes to the ovaries, whose covering is rendered thick and dense, so that the ovum cannot escape, or if it does, the fimbriated end of the tube is so agglutinated that it cannot grasp the ovum. Alcoholism is considered a cause of sterility. It evidently does diminish the sexual potency in the male, and for this the female is often blamed. It does not follow because a woman has not given birth to a child that she has not conceived. The life of an infant for a long time after birth is a frail one, and before birth its existence is extremely precarious; it often perishes a few days after conception. A period coming on a few days late, and at the same time one which is unusually profuse, is the only evidence which the young wife may have of an abortion. Among prostitutes, the frequent delay of menstruation, then abundant hemorrhage, is in many cases only habitual abortion, and leads to changes in the generative organs which must result in sterility. A tendency to miscarriage may therefore be all that stands in the way of having a family; this can frequently be remedied. Sexual incompatibility is well known to exist; prominent examples being Augustus and Livia; Napoleon and Josephine. It is also a well-known fact that frigidity is a cause of barrenness. A short separation of husband and wife is often salutary in its influence upon fertility. It is a well-established fact that the time immediately before the period, but still more that immediately following the period, are the most favorable times for conception to take place; the remaining quiet in bed of the woman after the generative act is also favorable to conception. The most frequent causes of sterility in women are inflammation of the lining membrane of the uterus, or of the neck of the uterus, or of both. The source of this condition in women who have had children is most frequently due to parturition or abortion. In the newly married it may be due to a previously existing slight uterine catarrh in a displaced uterus, or it may be a manifestation of a run-down state of the system. In a majority of the newly married, however, the inflammation of the endometrium is probably due to the first efforts at conjugal approach. Many young women as the result of the preparation of the trosseau, augmented by a round of gaities at the time of marriage, enter the married state in a condition bordering on physical and nervous exhaustion; and then begin engorgements and inflammations which lead to future suffering and to sterility. Displacements and flexions of the uterus also cause sterility. Such displacements of the neck of the uterus may occur that, instead of lying in a pool of semen, as it should, it is above, in front of, or away from it, and this may prevent conception. Vulvar and vaginal hyperesthesia, inflammations of the vulva, undue shortness of the vagina, unless great care is exercised by the husband, will induce painful coitus, and may bring about sterility by favoring the formation of a copulation sac outside of the axis of the uterine canal, and consequently misdirection of the semen. Scrofula, probably by its effects on the general condition, leading to deficient development of the whole body, the genital organs included, may be productive of sterility. The female being less passionate than the male, the orgasm comes on later with her, or the male orgasm occurs so soon that she may not reach that stage at all. If both were simultaneous, it is reasonable to suppose that conception would be more likely to occur. Ovulation is doubtless more frequently performed in some women than in others. Some women conceive with more or less regularity every fifteen or eighteen months, and others at intervals of several years. The effect of repeated coition, provided that impregnation does not take place at once, is to engorge the uterine vessels, to alter the nature of the glandular secretions, to cause profound reflex disturbances, and thus to produce such changes in the endometrium as to lead to local inflammation and to general nervous exhaustion. Backache, leucorrhea, and irritable bladder are the first symptoms of this disorder; but frequently there are added to these, headache, indigestion, rectal tenesmus, painful and profuse menstruation. In many cases the disease continues in a mild catarrhal form, giving the woman little inconvenience besides the slight leucorrheal discharge which stains her clothing; but often this is indicative of such a change of the lining membrane of the uterus as to render it unfit for the fixation and development of the ovum, even should impregnation take place. Under normal conditions, during the intermenstrual period, a plug of clear viscid mucus, which is secreted by the glands of the cervical canal, blocks up that passage, but is washed away each month by the menstrual discharge. Under ordinary conditions this obstruction must seriously interfere with the entrance of the spermatozoa into the cavity of the uterus, and renders the former theory, recently revived by Bossi, quite tenable, that impregnation is most likely to occur just after the menstrual epoch. The vaginal secretion under certain pathologic conditions may become so acid that it induces sterility. Women who suffer m severe vaginal catarrh are frequently sterile, the spermatozoa being found dead in the vagina some hours after copulation, although an examination a shorter time afterward revealed them still alive. In cases where conception takes place in spite of a very acid condition of the vaginal secretion, it is probable that some of the spermatozoa enter the uterus before the secretion has had time to act on them, or possibly the spermatozoa being injected in a mass, the acid secretion is unable to penetrate and kill them all. The reaction of the normal vaginal mucus is always acid, that of the cervix alkaline; but as the result of the inflammatory condition, the reaction of each is often intensified, especially that of the vagina, which has an exceedingly sour and penetrating odor. This acid discharge, bathing the neck of the uterus, penetrates more or less into the cervical plug and causes coagulation of the alkaline mucus. The chief constituent of the semen is albumin; agents which affect albuminous substances influence the functional activity of the spermatozoa-- heat, concentrated acids, and probably concentrated alkalies. In normal conditions the alkalinity of the seminal fiuid seems to be sufficient to neutralize the acidity of the vaginal secretions, so that the spermatozoa may remain seventeen days or more (Bossi) within the vaginal canal, even during a menstrual period, without having their vitality destroyed. When hyperacidity of the vaginal secretion is present, it is probable that the fertilizing element is at once rendered inert; but should some of the spermatozoa succeed in reaching the interior of the cervical canal, the increased alkalinity of the secretion there would in all probability put an end to all further progress. The conditions, then, which appear to prevent fecundation are: First, the absence of the proper nidus for the ovum; second, the obstruction of the cervical canal by a mucus plug; third, increased alkalinity of the cervical secretion, often accompanied by the increased acidity of the vaginal secretion. Three conditions must, then, be determined: First, are there spermatozoa in the semen? Second, do they get into the uterocervical canal? Third, do the secretions in the canal poison the spermatozoa? "For those who are very anxious for offspring," wrote Marion Sims, "I usually order sexual intercourse on the third, fifth, and seventh days after the flow has ceased; and on the fifth and third days before its return. For the most obvious reasons this would always be before going to bed at night, instead of just before rising in the morning. The horizontal position favors the retention of semen; the erect its expulsion. I am satisfied that too frequent sexual indulgence is fraught with mischief to both parties. It weakens the semen; in other words, that this is not so rich in spermatozoa after too frequent indulgence; and when carried to the extent of a debauch, the fiuid ejaculated may be wholly destitute of spermatozoa. Thus it will be seen that it will be much better to husband the resources of both man and wife." The Prevention of Conception and the Limitation of Offspring.-- Some of the contraindications to procreation are when either parent suffers from a disease which is transmissible, and such diseases frequently manifest themselves only after marriage; when the pregnancy would endanger the mother's life, or even where the pregnancy is a nine months' torture to her; where either parent is suffering from ill health; or where for economical reasons no more children are desired. If there exists no condition in either parent or in their circumstances why they should not have children, the next consideration due to their children, is how the same may be procreated under the most favorable conditions possible; this condition can only be secured by making the circumtsances such that the mother shall be able to choose the time for their conception when both parents are in the best physical condition. That children should be brought into the world haphazard, as the result of accident, is to degrade the human race below that of the lower animals, where the female admits the male only at the time of the rut, which in the majority of cases occurs only once a year. Another requisite to bearing healthy children is that the pregnancies shall not follow each other too rapidly. Aside from the consideration for the health of the mother herself, she must be in good physical condition to bear the healthiest children she is capable of giving birth to; and for this there must be from two and a half to three years between the successive pregnancies. The results of overproduction on the children are frequently, that they are sickly, short-lived, or suffer from rickets, cerebral paralysis, idiocy, or imbecility. And last, but certainly not least, many women become chronic invalids, or are hastened to premature graves, by having children as fast as they possibly can. The most natural and moral way for the artificial prevention of conception, when on account of ill health or for economic reasons no more children are desired, is to abstain from sexual intercourse. But in the majority of cases the husband will not agree to this, and so the greatest number of methods have come to be used to prevent conception. Perhaps the most frequent method use to prevent conception is withdrawal before the ejaculation of semen. While this is most injurious to the husband-- debility, nervous prostration, and even paralysis are said to ensue-- the health of the wife also suffers. If, this interrupted sexual congress is continued for years, there develop gradual nervous disturbances on both sides, and a serious disease of the uterus makes itself felt. The generative organs become engorged with blood, but are not permitted to enjoy relaxation consequent upon the full completion of the act. This engorgement may lead to undue local nutrition, and diffuse growth and proliferation of the connective tissue may take place. Hence the uterine walls become dense and thickened and the nerves compressed. Of course, pain and tenderness and a sense of bearing down will be the result. Flexions and versions may be consequent upon the engorgement. The nerves become shattered, and the woman will be fortunate if she contracts no serious womb trouble. "It is strange," says John Stuart Mill, "that intemperance in drink or any other appetite, should be condemned so readily, but that incontinence in this respect should always meet not only with indulgence, but with praise. Little improvement can be expected in morality until the producing of too large families is regarded with the same feeling as drunkenness, or any other physical excess." Sismondi writes: "When our true duties toward those whom we give life are not obscured in the name of a sacred authority, no man will have more children than he can properly bring up. If a woman has a right to decide any question it is how many children she should bear. Whenever it becomes unwise that the family should be increased, justice and humanity require that the husband should impose on himself the same restraint which is submitted to by the unmarried." In the opinion of Dr. Edward Reich, it is very much to be wished that the function of conception should be placed under the domain of the will. But the strongest appeal has been made for the sake of morality itself; namely, to prevent the crime of abortion. Dr. Raciborski, of Paris, took the position that the prevention of offspring to a certain extent is not only legitimate, but it is to be recommended as a means of public good. Continence, self-control, and a willingness to deny himself-- that is what is required of the husband. But suffering women assure us that this will not suffice; that men refuse to restrain themselves; that it leads to loss of domestic happiness, to illegitimate amours; or that it is injurious physically and mentally; that, in short, such advice is useless because it is impracticable. Dr. Napheys writes: "Is it amiss to hope that science will find resources, simple and certain, which will enable a woman to let reason and sound judgment, not blind passions, control the increase of her family?" The Crime of Abortion.-- From the moment of conception a new life begins, a new individual exists; another child is added to the family. The mother who deliberately sets about to destroy this life by want of care, or by taking drugs, or by the use of instruments, commits a great crime, and is just as guilty as if she strangled her new-born infant. The crime she commits is child-murder. Women in their frenzy at finding themselves in this condition, and with no slightest idea of the sin that they are committing, are constantly guilty of committing abortions on themselves, or going to professional abortionists to have this crime of child-murder committed. This is another of the sins due to the ignorance of the sex in all matters pertaining to reproduction; and it is a fearfully prevalent one. Infidelity in Women.-- "We have now reached the last infernal circle of the divine comedy of marriage; we are at the depths of the inferno. There is something, I do not know what, terrible in the situation in which a married woman finds herself when an illegitimate love has ruined her for the duties of a wife and mother. As has been so well and strongly expressed by Diderot, infidelity in woman is like incredulity in a priest; it is the last step in human forfeitures; it is for her the great social crime, for it implies all the others. "Weigh the sufferings of the future, the agonies of years by the ecstasy of half an hour. If this conservative sentiment of the creature, the fear of death, does not stop her, what could be expected of laws? Oh, sublime infamy!"-- (Balzac). _________________ PART III.-- MATERNITY. _________________ CHAPTER X. PREGNANCY. Nature of Conception; Pregnancy Defined; Duration of Pregnancy; the Signs of Pregnancy; Quickening; the Determination of Sex at Will; the Influence of the Male Sexual Element on the Female Organism; Heredity; Hygiene of Pregnancy; Causes of Miscarriage. "Happy he With such a mother, faith in womankind Beats with his bood, and trust in all things high Comes easy to him, and though he trip and fall, He shall not bind his soul with clay." -- TENNYSON. Nature of Conception.-- Conception, or impregnation, is the union of the germ and the sperm cell, the result of which is a new being. On coition, the semen being received into the female organs, which are at that time in a state of turgescence, the spermatozoa, by means of their own vibratile activity, find their way into the Fallopian tubes, and here come in contact with the ovule. The ovule is a minute cell with a transparent membrane, within which is the yolk containing the germinal vesicle. The spermatozoon penetrates into the ovule and becomes fused with it. The processes of development begin at once to occur. There is congestion of the uterine mucous membrane out of proportion to the rest of the uterus; the ovum finds lodging here, and becomes surrounded by a membrane which incloses it in a separate sac. Pregnancy Defined.-- Pregnancy begins with conception and ends with parturition; it provides for the nutrition and the expulsion of the embryo and for its nutrition for a short time after birth. The average duration of pregnancy is ten lunar months, or two hundred and eighty days. The date of the confinement is calculated by reckoning from the date of the last menstrual flow; count backward three months from the date of the first appearance of the last menses; to this add twelve months and seven days, five days being for the average menstrual duration and two days for the possibility of fecundation. Duration of Pregnancy.-- Many difficulties are experienced in determining the date of the expected confinement. As most pregnancies occur in married women, we cannot base any calculations on a single act of coitus. And even if there was but one, all physiologists agree that there is a variable period in different women, and in the same woman at different times, between insemination and the fertilization of the ovum. It is the moment of fecundation, or the union of the germ and sperm cells, which marks the beginning of pregnancy. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. While it is not certainly known, it is probable that the ovum is capable of impregnation any time during its sojourn within the oviduct and before reaching the uterus, or probably for a period of about one week from the time of its escape from the Graafian follicle. The remarkable vitality of the spermatozoa even under less favorable circumstances-- direct observation shows that these elements retain their movements for over nine days outside of the body-- renders it almost certain that their powers of fertilization are maintained for a long time after they are deposited within the healthy female genital tract; it is believed that the spermatozoa are capable of fertilization after a sojourn of three or more weeks within the oviduct. Consideration of these facts renders apparent the impossibility of fixing with certainty the date of the beginning of pregnancy, since conception may result from the union of the ovum liberated at the beginning of the period with the spermatozoon introduced at the end of that time; or it may result from the meeting of the male elements already within the oviduct with an ovum discharged a day or two before the occurrence of the menstrual period. The Signs of Pregnancy.-- The cessation of the menstrual period is the sign of the greatest value in women who have been regular; but it must always be remembered that there may be an irregularity of menstruation for the first few months after marriage. The appetite is capricious; morning sickness or nausea in the morning on first getting up is a very common symptom in the early months of pregnancy; enlargement of the abdomen; in the first two months of pregnancy the abdomen is flattened and the umbilicus is depressed; after this the abdomen begins to enlarge. There is also an increase in the size of the breasts, with a deepened color of their areolae and later a watery secretion. The external genitals become swollen and of a bluish color. Feeling of the fetal movements-- that is, the movements of the small parts of the child in the womb-- by the mother is not always reliable, since gas in the intestines has sometimes been mistaken for this. These signs are more valuable when several exist together. The nausea and vomiting of pregnancy, the so-called morning sickness, consists of nausea accompanied often by vomiting or retching of a glairy fiuid, showing itself most frequently on rising in the morning, but sometimes appearing after breakfast. It is aggravated by the assumption of the erect position. It may begin within a few days, but as a rule it does not show itself until the fourth week of pregnancy; and it generally ceases about the fourth month, rarely persisting throughout the entire time. In the majority of cases it does not sensibly impair the health. It is a sympathetic disorder reflected from the uterus; it is aggravated by indigestible food, by sexual excitement, and by emotional disturbances; it is most marked in first pregnancies and in women of highly emotional natures. It is not infrequently due to some inflammation of the uterus or erosion about the external orifice, and disappears on the removal of the cause. Mammary Changes.-- During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the pelvis; consequently a genuine physiologic enlargement commences in these organs from the beginning of gestation. Their glandular structure becomes larger, fuller, and firmer; a sensation of weight or pricking is felt by the patient; the veins become more prominent. The nipples also become enlarged, more elongated, and somewhat erect. Surrounding the nipple is the areola; this becomes darker in color. In most women a drop of watery fiuid, the so-called colostrum, may be squeezed out from the nipple at the end of the third month of pregnancy. The signs of pregnancy are divided into the presumptive, the probable, and the positive. The presumptive signs are: menstrual suppression, morning sickness, irritable bladder, mental and emotional phenomena. The probable signs are: mammary changes, abdominal enlargement, changes in the neck of the womb, and certain changes which are felt on bimanual examination. The positive signs are: feeling the various parts of the fetus, active movements of the fetus, and hearing the fetal heart sounds. Functional disturbances of the bladder are quite often noticeable in the early part of the pregnancy. In the first part of the pregnancy the bladder is dragged upon, and later it is pressed upon by the enlarged uterus so that the bladder capacity is lessened and frequency of urination is the result. In the fourth month, when the uterus ascends into the abdominal cavity, these bladder symptoms subside, until the very close of the pregnancy, when by the descent of the now greatly enlarged uterus there may be even incontinence of urine. Changes in the Abdomen.-- During the first two months of the pregnancy there is a flattening of the abdominal surface, due to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and drawing the umbilicus inward. In the latter part of the fourth month there is noticeable a slight abdominal enlargement, and the umbilicus is no longer sunken. By the end of the fourth month the base of the uterus has risen two inches above the symphysis, and at the end of the thirty-eighth week it touches the lower extremity of the breast-bone; the umbilicus has been for many weeks protruding; during the last two weeks of pregnancy the uterus again descends and the woman feels more comfortable. On the inspection of the abdomen of a pregnant woman there will be noticed a brown line which extends from the umbilicus to the pubes, and all over the surface the presence of striae, or long purple grooves, due to the distention of the abdomen; on the sides of the abdomen and down the thighs, red, blue, or white markings, like cicatrices, may be seen. Quickening.-- Quickening is the sensation experienced by the mother as the result of the active fetal movements of the child in the womb. These movements are first felt between the eighteenth and the twentieth week; the common rule is that quickening occurs at the middle of pregnancy; that is, at four and a half months. As pregnancy advances these active motions increase in frequency and become more marked. When felt or seen by the physician, as can be done in the sixth month, fetal movements constitute a positive sign of pregnancy. The Determination of Sex at Will.-- Although this has always been a question of great interest, and the subject of much experimentation, no rule can as yet be given by which the parents can know in advance of the birth of the child what the sex will be. Dr. Schenck's theory is that the ruling factor in determining the sex is the food partaken of by the mother. Furst believes that the differentiation may occur before, during, and a little while after the impregnation; that the chances of the development of one or another sex in one and the same woman may vary before final differentiation occurs. It is impossible to determine the sex of the embryo before the tenth week of fetal life. The cause of the differentiation, he believes, lies largely in the good or bad state of the health of the parents; in the first instance there being an excess of females, and in the latter an excess of males, relatively speaking. He believes that there is an excess of male children when conception takes place during the post-menstrual anemia. He has investigated one hundred and ninety-three cases carefully in regard to the probable date of conception after menstruation, and there is a notable increase of male births over female in the cases where conception occurred in the first five days after menstruation; that is to say, where the woman is not so well nourished as later. Dr. J. Griffith Davis gives as the result of her experiments in this direction, that when conception takes place three days before the menstrual period or within forty-eight hours afterward, the child will be a girl; when conception takes place ten days after the period, the child will be a boy. Although there are a greater number of the female than the male sex in all parts of the world where reliable statistics have been taken, in all civilized countries the proportion of male births is greater than that of females. There is a greater tendency of the male offspring to die earlier, and this is seen even before birth, in the proportion of three to two. For this reason the stronger sex as applied to men has been regarded by some authors as a misnomer. They are physically weaker in early life and succumb more readily to noxious influences. The relative age of the parents is said to be another factor in determining the sex of the children. Seniority on the father's side gives an excess of male children; equality in the age of the parents gives a slight preponderance of females; seniority on the mother's side gives an excess of females. Men, and especially scholars, who pass a sedentary life and who exhaust their nervous force to a great extent, beget more girls than boys; so, also, a very advanced age on the part of the man diminishes the number of male offspring. The Influence of the Male Sexual Element on the Female Organism.-- Dr. Alexander Harvey, of Aberdeen, has adopted the theory of fetal inoculation. He believes that the effect is first due to the influence of the male element upon the ovum, which, in consequence of the subsequent close attachment and freely inter-communicating blood-vessels between the modified embryo and the mother, inoculates the condition of the mother with the qualities of the male; and so, on the subsequent impregnation by another male, the offspring resembles the first male and not its real parent. He even goes further, and says that it is conceivable, by successive impregnations effected by him, that the influence may be increased, and if so the younger children begotten by him, rather than the elder, might be expected, ceteris paribus, to bear their father's image. And as regards the mother, he suggests the question, whether there is not something in the popular notion that in the course of years the wife comes to resemble the husband; and that not merely in respect of temper, disposition, or habits of thought, but in bodily appearance, which may be referable to this influence exerted by the husband on her constitution, through the medium of the fetuses in utero. "Yet it shall be; thou shalt lower to his level day by day, What is fine within thee growing coarse to sympathize with clay. As the husband is the wife is; thou art mated with a clown, And the grossness of his nature will have weight to drag thee down. He will hold thee, when his passion shall have spent its novel force, Something better than his dog, a little dearer than his horse." Darwin, on the other hand, considers it a most improbable hypothesis that the mere blood of one individual should affect the reproductive organs of another individual in such a manner as to affect the subsequent offspring. The analogy, he says, from the direct action of the foreign pollen on the ovaries and seed coats of the mother plant strongly supports the belief that the male element acts directly on the reproductive organs of the female, and not through the intervention of the crossed embryo. Dr. John Brown, in reviewing the subject, says it must be conceded that the male element has an influence on the female, over and above its fertilizing influence upon the ovum. The limit of this influence is at present unknown. Heredity.-- Girls are more apt to resemble their fathers in mental traits, disposition, and constitution; while boys take after their mothers. Boys procreated by intelligent mothers will be intelligent; while it does not always follow that the sons of intelligent fathers are intelligent. The poets Burns, Ben Johnson, Goethe, Walter Scott, Byron, and Lamartine were all born of women remarkable for vivacity and brilliance of language. Hygiene of Pregnancy.-- The health and perfection of the child depend largely upon the health and perfection of the parents at the time of its conception, as well as upon the condition of the mother during the pregnancy. Even when both parents possess a strong constitution, but one or both of them is suffering from a temporary exhaustion or malaise, the child will be born below the standard of health it ought to possess. Children born during the first year of married life seldom equal in health the children born of the same parents later; they are not only apt to be sickly, but the liability to premature death is greatly increased. For this reason it is better that the first year of married life should be allowed to pass without conception taking place. A child begotten in an intoxicated or depraved condition of a parent may be depraved itself in the same way, and is apt to be feeble-minded or idiotic. It must be borne in mind that prenatal culture of some sort begins at the time of conception; and that on the mental as well as on the physical state of the mother, the health as well as the disposition of the child will depend to no slight extent. The prospective mother who constantly gives way to her feelings does a wrong to her unborn child. The mother is at this time more impressionable, more nervous, and more irritable than is natural to her; and while her family should make a certain allowance for her condition, she, on her part, should not allow herself to give way to her morbid feelings. The prospective mother should not lead a life of self-indulgence, on the one hand, or, on the other, should not be weighed down with cares; she should interest herself in her usual duties, and be relieved of all anxiety possible. Dress.-- The clothing must be loose, and all compression about the waist and abdomen must be especially avoided. If the woman wears corsets, she must take them off at once, and substitute a Ferris or some similar hygienic waist. The corset prevents the proper development of the abdominal muscles, which play so important a role in the expulsion of the child from the womb, as well as in the proper growth and development of the fetus itself. If the woman has already borne children, and toward the end of the pregnancy the abdomen becomes pendulous, she will very materially add to her comfort by swearing a muslin abdominal bandage. A woolen undersuit, or undervest and drawers, with high neck and long sleeves, must be worn winter and summer; the grade of the wool to be adapted to the season of the year. The especial necessity for wearing wool next the skin during the pregnancy is because of the intimate relation between the skin and the kidneys. Any chilling of the body at this time is apt to lead to the congestion of the kidneys. If there is already any congestion of the kidneys present, or any abdominal pain, in addition to the undersuit an abdominal bandage should be worn. These bandages come woven in ribbed woolen, and fit the body snugly. This bandage is to be constantly worn, and, of course, changed at night. During the cold weather the stockings should also be of wool. Under no circumstances are garters allowed to be worn, as they form a constriction around the leg and interfere with the return of the venous blood to the heart, and so increase the tendency to the formation of the varicose veins. It is better not to use any means to hold the stockings up; they will be kept sufficiently well in place by the under-drawers. Low shoes should never be worn except in the hottest weather. It is of the greatest importance that the woman should be impressed with the necessity of the avoidance of taking cold, since any lung or kidney trouble is a serious complication of pregnancy. Diet.-- The diet is the same as that at any other time, only it is more necessary to guard against anything which is likely to cause indigestion. In other words, the diet should be plain, simple, and easy of digestion; nutritious and partaken of at regular intervals. In the latter part of pregnancy owing to the pressure of the enlarged uterus on the stomach, the food may have to be partaken of in smaller quantities and at shorter intervals. At this time also the appetite is abnormally large. Where it does not disagree with the patient, milk is the best adjuvant possible to the diet. Constipation.-- Constipation is the rule of pregnancy. This is due to the great pressure that the enlarged uterus makes on the bowel; and as important as it is at all times to keep the bowels regular, it is at this time more necessary than ever that the woman should have the bowels well evacuated every day. A retention of fecal matter in the body causes the reabsorption into the blood of the toxic matters, with the resulting headaches, dizziness, loss of appetite, and intense nervousness. To obviate this tendency to constipation, plenty of fruit and vegetables should be eaten, as well as cereals if the woman is taking a good deal of outdoor exercise, otherwise the latter had better be omitted. The woman should drink plenty of water-- at least three pints a day; this acts as a laxative as well as to flush out the kidneys. If, in spite of all these measures, constipation still persists, as it probably will, a seidlitz powder can be taken the first thing on rising in the morning; or from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda in a glass of water, also to be taken on rising in the morning; or one-half grain of the solid extract of cascara sagrada night and morning. The object of these is to keep the bowels open, but purgation must always be avoided. Bladder Symptoms.-- If there is any irritability of the bladder, any scalding on urination, or a very great frequency of emptying the bladder in the early months of pregnancy, a physician should be consulted at once; in the last months of pregnancy there is a desire to evacuate the bladder frequently, and sometimes at the last there is an incontinence of urine, which is due to the descent of the uterus and the great pressure on the bladder; this condition disappears with the confinement. Leucorrhea.-- If this is present to any marked degree, the vaginal douche should be continued throughout the pregnancy; the temperature of the douche should be from 110° to 112° F.; it must never be taken very hot or very cold. The fountain syringe should be used, and the bag should not be hung more than three feet above the bed, so that there shall not be too much force to the stream of water. Baths.-- Warm tub-baths may be taken throughout the pregnancy, but never oftener than twice a week, and the woman should never stay in the tub longer than is absolutely necessary for the bath, as otherwise the bath is too enervating. A daily sponge-bath of cool or cold salt water at a temperature of from 80° to 70° F., and in the proportion of a pint of rock or sea salt to a gallon of water is most invigorating, and counteracts many of the nervous symptoms and promotes sleep and good digestion. The temperature of the room in which this bath is taken should be 72° F. Shower-baths cause too great a shock to the nervous system, and they as well as foot-baths must be prohibited. Sitz-baths at a temperature from 110° to 90° F. may be taken just before retiring throughout the pregnancy. The frequency and duration of the bath as well as the temperature should be regulated by the attending physician. In cases of intense nervousness and insomnia these baths have an excellent sedative effect. A pregnant woman must never under any circumstances take ocean baths, since there is always great danger that the shock of the waves will cause an abortion. Sea-voyages should be avoided because of the severe nausea and vomiting, as well as the danger that the lurching of the vessel may cause miscarriage. The sewing-machine is a tabooed thing for the pregnant woman, because of the jarring of the pelvis which it produces. Sweeping of heavy carpets is also injurious. There must be no lifting of heavy pieces of furniture, and especially no lifting from the floor, as it interferes with the circulation in the uterus and is apt to produce miscarriage. Driving in an easy carriage over smooth roads is permissible; dogcarts, or any conveyance which produces much jolting, must be avoided; and while driving is good, the woman should not do her own driving, on account of the danger of the jars that would be caused by the sudden pulling of the horse upon the lines. Horseback-riding and bicycling are, of course, forbidden, as are also golf, tennis, and dancing. Exercise.-- Exercise in the open air should be taken every day, when the weather is suitable, and walking is the best form of exercise. The amount will be regulated to some extent by what the woman has been accustomed to taking, and it should always stop short of fatigue. The woman should live as much as possible in the open air, and she should attend to her ordinary duties about the house. Long railway journeys are always objectionable. Hemorrhoids or piles are very often troublesome toward the close of the pregnancy. To overcome this, the patient should lie down immediately after the bowel movement, and remain in the recumbent position for ten or fifteen minutes. In addition, care should be taken to secure a loose movement of the bowels. Should the piles come down, applications of cloths wrung out of hot water, and held well pressed against the bowel, should be made; the piles should then be pressed back until the finger feels that the mass has been pushed above the second constriction of the bowel, which is felt to exist at about two inches above the sphincter ani muscle. Should these means not suffice, the physician must be consulted at once. Swelling and pain of the external genitals and of the lower limbs are best relieved by the recumbent position. Should the veins of the legs be much enlarged or the feet swollen, the patient should have compression made by the wearing of elastic stockings. Or in some cases a bandage is sufficient; in this case the bandage may be made of muslin; it should be three inches wide, and, beginning at the toes, should extend up as high as the enlargement of the veins continues. This bandage should be freshly applied every morning before rising. Pain caused by the stretching of the skin may be relieved by the inunction of the skin with cottonseed or cocoanut oil. For severe pain in the small of the back, rubbing with soap liniment or alcohol will be found useful. Mental Occupation.-- Important as this always is, it is doubly so now. The mind should be constantly and pleasantly occupied, but no severe study should be indulged in. The emotional susceptibility is generally somewhat increased. The pregnant woman, quite excitable and irritable, readily responds to influences by which in the non-gravid condition she could not be affected. Sometimes she feels unusually well, is intellectually brightened and more active, and says she is positively happier. At other times she is despondent and morose. Physiologists admit and observation proves that maternal emotions do affect the development and the exterior of the fetus; likewise the mental organization of the fetus may be affected. All unpleasant news, frights, and physical shocks, also scenes of suffering and distress, must be avoided, as the mind is particularly impressionable at this time. Around the patient should be thrown a gentle and protective care, and she should be treated with the considerate kindness which her condition demands. Theatres and all places where there will be a large assemblage of people should be avoided, as the close air and general bad ventilation are apt to produce vertigo and sometimes attacks of fainting. Sleep.-- During pregnancy a large amount of sleep is required; there should be eight hours spent in sleep at night, and one hour every afternoon. Pregnant women should never do any night watching. There is unusual necessity for good ventilation during sleep at this time. The Marital Relation.-- Coitus is, as a rule, distasteful to pregnant women. It is for the best interest of the wife as well as for that of the child that all marital relation should be suspended at this time. Even uncivilized nations have condemned the privilege of sexual intercourse during pregnancy, and have visited punishment on the offender. If these relations are not wholly suspended, they must at least be at those periods which correspond to the time at which the woman would have been unwell had she not been pregnant. To the continuance of these relations throughout the pregnancy is due much of the suffering of the wife, not only then, but at the time of the labor as well; and the nourishment of the child is interfered with. Causes of Miscarriage.-- Hemorrhoids; straining at stool; excessive intercourse in the newly married; nursing; ocean-bathing; overexertion; overexcitement; a fall; any violent emotion; anger; sudden or excessive joy; a fright; running; dancing; horseback-riding; riding in a heavily built carriage over rough roads; great fatigue; lifting heavy weights; the abuse of purgative medicines; disease or displacements of the womb; and a general condition of ill health. The danger of miscarriage is greatest during the first three months of pregnancy. Miscarriage is a fruitful source of disease and often of danger to wives; it is said that thirty-seven out of every hundred pregnant women miscarry. Miscarriage is most apt to occur during the first pregnancy; and great care should be taken to prevent this, as the habit is easily established, and after one miscarriage has occurred, another is likely to follow, so that it is sometimes with the greatest difficulty that the woman can be made to carry the fetus to full term. Artificially produced abortions are not an infrequent cause of sterility; the young wife becomes pregnant, and has an abortion produced because she is not yet ready to give up all her pleasures; and eventually when she does become very anxious to have a child such an extent of uterine disease has been produced by the abortions that she cannot conceive. To Prevent Miscarriage.-- The life must be free from all excitement, and must be as quiet as possible without becoming monotonous; especial care must be exercised at the return of the dates for the menstrual periods. The symptoms of miscarriage are a show of blood, more or less profuse, with intense abdominal pain; on the slightest show of blood the patient should go to bed at once and the physician should be sent for. CHAPTER XI. THE CONFINEMENT. Preparation for the Confinement; Signs of Approaching Labor; Symptoms of Actual Labor; the Confinement-bed; the Process of Labor. "To my conception one generation of educated mothers would do more for the regeneration of the race than all other human agencies combined; and it is an instruction of the head they need, and not of the heart. The doctrine of responsibility has been ground into Christian mothers above what they are able to bear." -- ISABELLE BEECHER HOOKER. Preparations for the Confinement.-- The right time to engage the physician who is to take charge of the woman at her confinement is just so soon as the woman knows that she is pregnant. It used to be argued that, since giving birth to children was a physiologic process, there was no necessity for the woman to consult the physician until he was sent for when the labor pains began. Take the case of the woman who is for the first time pregnant; she is absolutely at sea; she has not the least idea how she ought to feel, what she ought to do or to leave undone; the result is that she often has a miscarriage which is the source of the greatest disappointment to her husband and herself, or she suffers very unnecessarily throughout the entire pregnancy, has a difficult labor, and perhaps gives birth to a sickly child. The educated physician will explain to her what symptoms are normal and what are pathologic, and often he will be able to entirely cure the latter. It is now a well-established fact that the most serious complications of the pregnancy, and of the labor itself are caused by severe congestion or disease of the kidneys. The condition of the kidneys can only be determined by frequent examinations of the urine; during the early months of pregnancy these examinations are made once a month, and during the last month they are made every week. The amount of urine passed in the normal condition is three pints a day. Nowhere, perhaps, is the constant vigilance of the physician so well rewarded as in the careful oversight of the pregnant woman. She goes through her entire pregnancy feeling well, and often the greatest discomfort that she suffers is due to her size; her labor and her lying-in are normal, and she gives birth to a healthy child. Engagement of the Nurse.-- This is generally left to the physician in charge of the case, since he is responsible for the safe delivery of the woman; but if the patient has any decided choice in the matter, it is acceded to unless there should be some very valid objections, and the physician always sends the nurse in view for that case to see the patient in order to ascertain if she is personally agreeable to the patient. Choice of Room for the Confinement and Lying-in.-- The room should be light, sunny, and well ventilated; it should not be too near a water-closet. In the city as quiet a room as possible should be selected, and one that is well removed from the rest of the house, so that if necessary perfect quiet can be maintained. The room should be as cheery as possible. The dress of the mother during the lying-in consists of a merino undervest, with high neck and long sleeves, and a nightgown, which shall be open all the way down the front. The gowns should be made of light muslin or of cambric; and there should be a sufficient number so that they may be changed every day. Six abdominal bandages should be provided. These are made of light muslin, and they should be eighteen inches wide and long enough to go once and a third around the patient's hips at the sixth month of pregnancy, or about one yard and a quarter long; they may be made straight or to fit the patient at the sixth month. This bandage is fastened down the front; it is applied directly after the labor, and adds greatly to the patient's comfort during the lying-in. The vulvar pads used during the lying-in are the antiseptic absorbent pads which can be obtained at any place where surgical dressings are sold; they are made of absorbent cotton, covered with cheesecloth, and sterilized. There must be a sufficiently generous supply of sheets so that they can be changed every day, and the drawsheet as often as may be required. Nothing is so important to a good lying-in as to have a clean, well-ventilated room, and plenty of fresh bed-linen. Cleanliness is the first requisite to antisepsis, and this is the secret of avoiding puerperal fever. Articles to be provided for the confinement are: 1. An oblong douche-pan of agate-ware. 2. An agate bed-pan. 3. A bath thermometer. 4. Two pieces of rubber sheeting; one, one yard square, and the other two yards square. 5. Two sterilized bed-pads, 30 inches square by 3 to 4 inches thick. 6. Three dozen antiseptic absorbent pads. 7. One pound of sterilized absorbent cotton; twelve yards of cheese-cloth. 8. Six abdominal bandages, eighteen inches wide, preferably made to fit the figure at the sixth month of gestation. 9. Two hand-scrubs. 10. Four ounces of the tincture of green soap. 11. Bottle of corrosive sublimate tablets. 12. Four ounces of powdered boric acid. 13. Half a pint of good whisky. 14. Two ounces of aromatic spirits of ammonia. 15. Two ounces of aqua ammonia. 16. One pint of alcohol. 17. Two tubes sterilized white vaselin. 18. Plenty of large and small safety-pins. 19. Hot-water bag. 20. New fountain syringe, to hold four quarts; with glass nozle. 21. One small basin for vomited matter. 22. Two very large agate basins or wash-bowls for washing doctor's hands and for antiseptic solutions. 23. Vessel for after-birth. 24. Three large pitchers; one for boiling water, one for cold boiled water, and one for antiseptic solution. 25. Tumbler for boric acid solution for washing baby's eyes, with fine old linen sterilized. 26. One dozen freshly laundered sheets, and two dozen towels. 27. Stocking-drawers, muslin. 28. Change of night-clothing warmed for the mother. 29. A warm blanket to receive the baby. 30. An infant bath-tub. 31. A large piece of oil-cloth to protect the floor.* * Van Horn & Co., Park Avenue and 41st Street, New York, keep an obstetric outfit, containing many of the above articles, cleansed, sterilized, and packed in a box ready for use, so that they remain intact until needed. The price of this outfit is $16.50. Baby's Outfit.-- Four flannel bandages, to be made of fine, soft flannel, four inches wide, to go once and a third around the body. The edges may be pinked or whipped, but should never be hemmed; a tape is sewed on double, the ends passing around the body, and so the bandage is fastened without pinning. Six merino shirts, with high neck and long sleeves, made to button down the front. Cotton diaper napkins, not too large; old soft ones are preferable. Long merino stockings which can be pinned to the napkin. Flannel petticoats, not too long; these may be made on muslin bands, which are held up on the shoulders by means of straps. The essential in all the clothing is that it should be sufficiently loose. Dress-slips should not be so elaborate that they cannot be washed and changed with sufficient frequency; and not so long that the baby's feet will be hampered in their movements by them. All of baby's clothes but the dress should be fastened by safety-pins. Baby's basket should contain: 1. One outfit of clothes. 2. One tube of sterilized tape. 3. A pair of blunt-pointed scissors. 4. Large and small safety-pins. 5. Pieces of fine old linen; old handkerchiefs are the best. 6. A soft hair-brush. 7. A powder box and puff, with talcum powder. 8. Two tubes of sterilized white vaselin. 9. Two soft towels. 10. Castile soap. 11. Single-bulb syringe; so-called "eye and ear syringe." 12. A woolen shawl or wrap. If there is no nurse available before the labor sets in, and it is necessary for the patient to see to the sterilizing of the above articles, she should first scrub off all pitchers, basins, and other utensils, as well as the douche-pan, fountain syringe, and rubber sheeting, with a brush and hot soap-suds; the hand-scrubs are to be well washed; then each article should be pinned separately in coarse towels, and put to boil for half an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing the towels, put away, and not opened till the time of the labor. The abdominal bandages must be laundried and pinned up in separate towels until they are needed. The cheese-cloth must be laundried and then sterilized. The vulvar pads should be pinned in an old napkin, in packages of half a dozen each; and one package is sterilized at a time by placing it in the oven until the outer covering is scorched. The linen for the baby's eyes and the cheese-cloth are treated in the same way; they are to be cut up into small pieces and sterilized as needed. Signs of Approaching Labor.-- About two weeks before labor there is a sinking of the womb. At the beginning of the ninth lunar month this was at the end of the breast-bone; it now descends to a point midway between this and the navel; the abdomen becomes smaller, the pressure on the lungs is relieved, and the woman breathes more freely. But at the same time that the woman is relieved of the pressure on the chest, she experiences increase of the troubles in the lower extremities. There is an increase of the bladder symptoms, with a desire for frequent unrination. Constipation becomes more troublesome, and there may be hemorrhoids; the veins of the lower extremities may become greatly enlarged. There is an increased fullness of the external genitals and a greatly augmented amount of mucous discharge. There is a feeling of anxiety and nervousness, with depression of spirits. During the last two weeks of pregnancy patients are apt to have cramp-like pains in the lower part of the abdomen. These are often mistaken for labor pains. True labor pains are characterized by starting in the back, extending around the abdomen and toward the pubes and down the thighs; they come at more or less regular intervals of half to three-quarters of an hour, and increase in intensity with a decrease in the intervals. A strong pain is apt to be followed by two weaker ones. The so-called false pains are irregular in their occurrence. Symptoms of Actual Labor.-- First is generally the show; this is a discharge of mucous tinged with blood; at the same time the true labor pains set in. When the patient or nurse is in any doubt as to the character of the pains, or when the show appears, the physician should be summoned at once. Other symptoms are frequent desire to empty the bladder and bowels, and a sensation of shivering. The Confinement-Bed.-- A single bed is much more convenient, but it is rarely found in a private house. The double bed is arranged as follows: The hair mattress is covered with a large rubber sheet, which is pinned with safety-pins at the corners and tucked well under the mattress; the rubber sheet must not be drawn too tightly for fear of tearing. Over this comes the sheet, and over the upper half of the bed, the draw-sheet; this is a sheet folded four double, which goes across the bed so as to come under the hips of the patient, and is tucked under the mattress at both sides. The object of this is so that it may be frequently and easily changed without disturbing the patient. The sheet, blanket, and spread which are to serve as a covering after delivery are folded back and placed on the left side of the bed. The lower right-hand corner of the bed-- the right side of the bed is that side which is toward the right hand as one stands facing the foot-board-- is arranged for the confinement; on this is fastened the smaller rubber sheet, and over this the sheet is folded, and both are fastened down with safety-pins. The pillow for the patient should be placed at the upper and inner corner of the square. After the delivery the patient is lifted to the upper part of the bed and the temporary dressing is removed. A sheet and blanket are used for a covering during the confinement. Before the labor begins it is well to fasten up the vest and gown, so that they will not be soiled, as it is important that the patient shall be moved as little as possible after the labor, as all movements tend to increase the bleeding. The floor oilcloth must be spread at the side of the bed which is made up for the confinement, and should extend slightly under the bed. A bureau in the room should contain the mother's and baby's clothing, bed-linen, towels, and any other articles which will be needed, all properly arranged. The clothing for the mother and baby will be placed where it will keep warm, and the infant bathtub will be in readiness in case of sudden need for it. All water used about the confinement must have been carefully sterilized in advance. The best way to sterilize the water is by boiling it in a large wash-boiler; whatever vessel is used must be scrupulously clean, and ought to be new. The vessel is covered over, and the water is allowed to boil for half an hour; it is then, still covered, set aside to cool. There should be three gallons each of sterilized hot and cold water; since in case of an emergency there must be plenty of water ready for use. The various articles ordered in the confinement outfit will be at hand ready for use. It is the duty of the nurse to have everything ready for the doctor before his arrival. The patient should have a full warm tub-bath, fresh night-clothes put on, and an enema should be at once given to unload the bowels, and this even though there may have been a bowel movement only a few hours previously. The patient should remain in bed until the arrival of the doctor. After an examination has assured the latter that all is right, she may be allowed to go around the room, with a wrapper thrown on over the night-gown. Conveniently near the bed should be a small table, covered with one or two freshly laundried towels. This table should have on it a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable aseptic lubricant for the hands. The Process of Labor.-- The process of labor is divided into three stages. The first stage is that of dilatation; by which is meant the stretching of the mouth of the womb so that the child may pass through. At the first confinement this stage lasts about fifteen hours; at subsequent labors the length of this stage is much shorter, the average time being eight hours. The pains during this stage are sharp and cutting, and they are accompanied by a slight show of blood. The patient is fretful and nervous The second stage of labor is called that of expulsion, because in this stage the uterus contracts down together with the abdominal muscles to expel the child from the womb and the vagina into the world. The duration of this stage in the first confinement is about an hour and a half. The third stage of labor includes the time from the expulsion of the child till the coming away of the after-birth; the average length of this stage is from twenty minutes to half an hour. The average length of time for the first labor is seventeen hours; and for subsequent labors from eight to eleven hours. The bag of waters is the sac of membranes in which the child is inclosed. It contains a liquid in which the child floats; the object of the water is to protect the child from sudden shocks or any kind of injury during pregnancy. During labor this membrane with its contained water serves as a dilating wedge to assist in the opening of the womb, and it also protects the child from the direct contraction of the uterus upon it. When the waters break prematurely, the labor is much longer and more tedious; normally this should not occur before the mouth of the womb is fully dilated. The pains of the second stage of labor are of a bearing down character, and constantly increase in force and frequency; the climax being reached as the head passes through the vulvar orifice. A child usually lies in the womb with the head downward; the reason of this is that there is more room in the upper part of the uterus, and as the small parts of the child as it is folded upon itself take up the most space, they occupy this position, while the head lies just above the pubes. The normal position of the child is: the head is flexed on the chest, the legs on the thighs and the thighs on the abdomen, and the hands are folded across the chest. And so the child is usually born head first. During the stage of expulsion the head of the child is forced down slightly during each pain, to recede a little during the intervals between the pains; in this way the vagina and its external orifice are gradually stretched so that the head of the child may pass through without tearing the parts. If the head is allowed to pass through suddenly, or where the labors are rapid, as in the case of women who have given birth to several children, much mischief may be done by tearing the soft parts. After the birth of the head there is a short interval of rest, when the shoulders are born; the rest of the body easily slips out; and with the expulsion of the after-birth the labor is over. At the very beginning of labor the patient should be given a full warm tub-bath, and make an entire change of linen. She will usually prefer to be dressed in her night-clothing, over which during the first stage she may wear a loose wrapper; a sterilized napkin should be worn over the vulva during this stage. During the first stage, as a rule, the patient should not be confined to bed until the dilatation is well advanced; she is generally more comfortable if she is allowed to move around the room, and the pains are thereby advanced. The only way in which the physician can determine whether labor has begun is by making an internal examination; and this will enable him to decide as to whether it is necessary to remain or not. The nurse should always wear a wash dress in the confinement and lying-in room. If the labor is long, nourishment in the form of beef-tea, broths, and milk may be given. No stimulants should be given without the direction of the physician. The frequent taking of cold water is permissible. At the beginning of the labor the family and friends must be excluded from the room, and it must be kept as quiet and as cheerful as possible. Toilet of the Patient.-- The newly born child is received in a small blanket, is well wrapped, and laid in a warm place. The nurse then turns her attention to the mother; the external genitals and soiled parts of the body are cleansed with sterilized cheese-cloth wrung out of an antiseptic solution; if the body-linen has become soiled, it is also changed, and all blood-stained articles are removed from the bed. The patient is then carefully lifted up on the permanent bed, and the vulvar pad and the abdominal bandage are applied; after which the patient is allowed to rest. CHAPTER XII. LYING-IN. Management of the Lying-in; Lactation; Nursing. "'Tis is ourselves that we are thus or thus. Our bodies are our gardens; to the which, our wills are gardeners."-- "Othello." Management of the Lying-in.-- Immediately after the delivery the first essential for the patient is absolute quiet and rest; the room must be kept quiet and darkened, and ordinarily the patient is allowed to fall into a light sleep. During the first few hours after labor the best position for the mother is flat on the back, with only a small pillow under the head. After the first twenty-four hours the patient may be allowed to turn on the side as she prefers. Since absolute rest is the first requisite for the patient, she must be left alone with the nurse, who must see that she does not fall into too deep a sleep. If the child's cries disturb the mother, it must be taken into another room. The lying-in room must be kept free from all odors, all soiled clothing must be at once removed from the room, and good ventilation must be insured, being careful to prevent any drafts. While the patient is asleep, and after the baby has been attended to, the nurse should place all blood-stained articles in cold water to soak. If in the city, the after-birth may be burned in the furnace or range; it should be well covered with coal. In the country the after-birth can be buried in a deep hole. During the first two or three days the vulvar dressings should be changed from every three to six hours, and at all times as often as they are soiled. Each time that the dressing is renewed the external genitals and their immediate surroundings are to be carefully cleansed with sterilized water, and finally washed with a solution of boric acid, in the proportion of one tablespoonful of boric acid to one quart of water. It is convenient to keep this solution mixed and on hand, as it takes some little time to prepare it; it should be kept in a strength double that which is desired, so that it may be diluted with warm water to give the desired temperature. This solution may be poured over the parts from a small pitcher, the douche-pan having been placed under the patient before the washing began. After labor the vulva is very sensitive, so that while the greatest care must be used to remove all clots of blood and the discharge, there must be no brisk rubbing of the parts. No blood-stained linen should be permitted to remain about the patient or the bed. Since the lying-in woman perspires freely, her skin ought to be frequently cleansed by sponging with a weak solution of alcohol in tepid water; this should be followed by friction with a towel until the skin is in a glow. Cleanliness of the bed is promoted by the use of a draw-sheet, which is a sheet folded to four thicknesses and placed beneath the patient's hips in such a way that the upper edge of the sheet shall come under the lower part of the pillows. Air and light must be freely admitted at all times in order that the room may be bright and cheerful. For the first few weeks the eyes of the new-born infant should be shielded from all strong light. Visitors.-- For the first week after the confinement the patient should see no visitors. Even the husband or mother should not remain in the room long at a time. Nothing of a disagreeable nature should be told to the patient; and whoever goes into the sick-room should always carry the most cheerful manner, as it is highly necessary that the patient should be kept mentally as well as physically quiet at this time. Diet.-- For the first twenty-four hours the diet must be restricted to liquids, and in most cases nothing is given until the patient has had a few hours' rest. The first thing that is given to the patient should be a cup of warm milk or tea. Milk is the best diet; this may be varied with beef-tea, bouillon, mutton or chicken broth; any of these broths may be made with rice or barley to vary the flavor, but these must not be given to the patient. The patient should have six ounces of the liquid every two hours during the day and every three hours during the night. On the second day bread well toasted through may be added to any of the liquids. On the third day stewed or baked apples should be added to the diet. On the fourth day, and from this on, the patient will have regular meals, but the diet must be a plain one. For breakfast, stale bread, a soft-boiled egg, fruit, and a cup of tea, not too strong. For dinner, which should always be given in the middle of the day, an oyster-stew or clam broth, a lamb chop, or a very small piece of beefsteak or chicken; but with these there must be no gravies or dressings; a potato baked in the skin; raw tomatoes, if in season; apple sauce or cranberry; celery; junket, plain corn-starch, lemon jelly, plain cup-custard. From this list the diet must be arranged so as to give as much variety as possible from day to day. Midway between breakfast and dinner, and again in the middle of the afternoon, the patient should have a glass of milk. The diet should be generous, but simple. Urination.-- The feeble condition of the bladder in the first few hours after delivery frequently leads to the retention of urine. Owing to the copious secretion of urine which is so common at this time, painful and injurious distention of the bladder may result. The patient should therefore endeavor to pass her urine in at least six hours after labor, whether she feels any inclination to do so or not; the sound of running water or warm fomentations over the bladder, warm water in the douche-pan, and moderate pressure applied by the hand over the suprapubic region, are often effective in accomplishing the desired result. If all these means fail, the catheter must be used as the last resort. During the entire lying-in the bladder should be emptied every six hours. Evacuation of the Bowels.-- There should be an evacuation of the bowels in from twenty-four to thirty-six hours after the labor. For this purpose a seidlitz powder may be given, or the liquid citrate of magnesia. If this does not suffice, an enema of warm water, to which a little soap or two teaspoonfuls of glycerin have been added, may be given. Two pints of water should be prepared; the patient will retain as much as she comfortably can, and as long as she can. The bowels should be opened daily after the first day. After-pains are caused by the same physiologic process that causes labor pains-- namely, by the contractions of the uterus. After the first confinement the after-pains are, as a rule, not severe; attention to the regular emptying of the bladder and bowels also lessens the severity of the after-pains; these pains seldom last after the second day. The Lochia.-- The discharges of the mother continue for about two weeks, and are called lochia. For the first twenty-four hours they are pure blood; the second and the third day they are of the character of bloody water; from the fourth to the sixth day they have a, greenish-yellow color, and from the tenth to the twelfth day they become pure white. Soiled napkins and dressings should never be allowed to remain in the patient's room. Duration of the Lying-in.-- This lasts for six weeks. During this time the organs of generation are returning to their normal size and condition. In order that the woman may be in the best condition possible at the end of this time, it is essential that for the first two weeks she should remain in bed; and so long as there is any blood in the discharge the woman should not be allowed to sit up. The first sitting up should be in bed, the patient being supported by a bed-rest. During the second two weeks the patient may be allowed to divide her time between the bed and the couch; in the latter part of this time she may be allowed to go around her room a very little; and for two weeks more she should remain on the same floor. The first sitting up should not last more than half an hour. Getting up and going around too soon after the confinement, "being too smart," is one of the most prolific sources of falling of the womb, and all manner of uterine trouble, by which the general health of the woman is greatly impaired. Lactation.-- If it is at all possible, every mother should nurse her own child; in the interests of both the mother and the child. So far as the mother is concerned, the process of lactation is beneficial because it hastens the return of the uterus to its normal size. Wet-nurses are known tyrants, and if the quality of the milk has anything to do with the disposition of the child, as is believed to be the case, the idea is distasteful of having a woman who belongs to the lower classes provide nourishment for your child; and artificial feeding is one unmitigated trouble. A deficiency of the quantity or the quality of the mother's milk can generally be remedied by the diet and attention to the health of the mother; if the deficiency in quantity persists, the mother's milk can be supplemented by artificial feeding. There may exist certain conditions of the mother in which nursing her own infant would be inadvisable or even impossible. Syphilis contracted late in the pregnancy, and tuberculosis, are contraindications, owing to the danger of the mother infecting the child. Inversion of the nipples, their excoriation, or persistent sensitiveness may make it impossible. In marked general debility of the mother from any cause whatever, it would be injurious to the mother and the child. After the mother and the new-born infant have had some hours of rest and sleep, it is advisable to apply the child to the breast, to receive by this first effort the small quantity of milk which is an especial provision to act as a natural purge and to start the bowels of the child into a healthy activity; this also excites the milk glands to secretion. The mother's milk in full supply may be expected in from forty to sixty hours after delivery. Nursing.-- When the mother's nipples are of the normal size and well formed, the healthy infant instinctively suckles at once when placed at the breast, but sometimes it has to be taught; by squeezing out a few drops of milk to wet the nipple, the child will usually take hold, or a little sugar and water may be put on the nipple; a little patience and tact are all that is necessary to insure success. But the infant must be taught to nurse at once before the breasts become engorged with milk. Under ordinary circumstances the child is to be kept at the breast for one year. But if within this time the menstrual period should recur and be profuse, or should the woman again become pregnant, the quality of the milk becomes poor, and necessitates the immediate weaning of the child; the character of the milk is also altered, and even its secretion may be checked. Nervous agitation may so alter the quality of the milk as to make it poisonous. A fretful temper, fits of anger, grief, and sudden terror not only lessen the quantity of the milk, but render it thin and unhealthful, inducing disturbances of the child's bowels, diarrhea, and so forth. Position of the Mother When Nursing.-- When in bed in the recumbent position, the mother should lie on that side from which the infant is going to nurse; when up, the mother should sit erect. Care of the Nipples.-- Immediately after each nursing the nipples should be washed off in a saturated solution of boric acid in cold water, and dried with a soft cloth. If they are disposed to crack, anoint them with cocoa-butter immediately after each cleansing. If the skin of the nipple is very sensitive, a nipple-shield should be used for the first few days; or should the nipple become sore at any time, the shield can be resorted to. The nipple-shield must fit tightly; the best ones are made of glass with a rubber tip. In the intervals of nursing the nipple-shield should be kept in cold water after it has been thoroughly cleansed by being brushed on both sides. The breasts are sometimes distended from an over-secretion of milk; this is relieved by saline cathartics, by abstinence from liquids, and by the use of a compression breast bandage. This is made of a straight piece of muslin, with a shallow notch cut in one edge for the neck, and, a deep one for each arm; the bandage is closely applied over the breasts, and the ends pinned in front; it is also pinned over the shoulders. In debilitated women the supply of milk may be insufficient; the most reliable evidence of this is the fact that the infant ceases to gain in weight. CHAPTER XIII. THE NEW-BORN INFANT. The Infant's Toilet; the Crib; Feeding of Infants; Artificial Feeding; the Wet-nurse; Characteristics of Healthy Infants; the Stools; Constipation; Urination; Dentition. "O thou child of many prayers, Life hath quicksands; life hath snares." -- LONGFELLOW. The Infant's Toilet.-- So soon as the mother has been made comfortable, the toilet of the infant is attended to. This should be made near the register or stove; and the lap of the nurse should be covered with a small flannel blanket. The baby's body will be found to be covered over with a white, greasy, somewhat cheesy substance; some sort of grease is needed for its removal; rendered lard, sweet oil, and lanolin are the best; vaselin is less effective. All of this cheesy substance must be at once removed; the most difficult parts will be in the folds and creases. The nurse should grease the palms of her hands, then take the head of the child between them, and thoroughly grease it; particular attention must be given to the ears; then come the neck, shoulders, arms, chest and back, groins, external genital organs, and lower extremities. After the child has been thoroughly gone over, the grease should be rubbed off with a soft towel. A rectal injection of one tablespoonful of warm water is given at once to unload the bowels of the meconium; this generally acts before the baby's toilet is completed. The meconium is the first discharge from the infant's bowels after birth, and that which had collected in the intestines during the pregnancy. The Baby's Bath.-- The baby's bath-tub is filled about one-third full of water at a temperature of 100° F., tested by the thermometer. The baby is then gradually immersed in the water, with the exception of the head; this is supported on the left wrist of the nurse, which passes under the infant's neck, while her hand grasps the left shoulder; with the right hand the nurse quickly rubs over the child's head and body; the entire bath should not occupy over five minutes. The infant is then lifted out into the lap of the nurse, on which is spread a soft, warm towel, with which it is carefully dried. One of the important points in giving the infant its bath is to be sure that the groins, arm-pits, and genitals are thoroughly well dried; otherwise excoriation at these parts is sure to occur. After this a daily tub-bath is given in the same way; soap is rarely needed; when it is, castile soap should be used; its constant use is not necessary and would only irritate the skin. These daily baths strengthen the nervous system and prevent coughs and colds. The bath should be given during the morning, one hour after feeding, and should not last more than five minutes. The mother herself, just as soon as she is able to go around, should superintend the bath; in this way she is assured that if properly given, and will also recognize any incipient affection of the child. These daily baths should be continued till the child is four years old. Powder is not essential; but if it is desired, a plain talcum powder may be used. The Dressing of the Cord.-- After the bath the ligature which was tied around the cord at the birth of the child will be found slightly loosened; this should first be made tight, and then the cord, doubled back on itself, should be tied by the ends of the same ligature. A square of soft sterilized linen or gauze is slit up to its center; the cord is allowed to pass through this slit, which looks toward the child's right; the stump of cord is laid on the left and the ends of gauze are folded over this; the whole is kept in place by the abdominal bandage. As there is some exudation from the cord, it is necessary to change these dressings twice a day; as this exudation is of a somewhat gluey nature, it will be found that the dressings stick to the cord. In removing the gauze great care must be used not to make any traction on the cord; when the infant is placed in the bath, the water loosens the dressing and it falls off in the water; at other times it must be removed with the greatest care. There should never be any odor about the cord; it usually drops off about the fifth day. The process of ulceration by which the cord falls off leaves an open surface on the child's body which offers an avenue for septic infection. Great care must therefore be taken that the nurse's hands or anything which comes in contact with this surface should be perfectly clean. The dressings used must be thoroughly antiseptic. Care should be used not to fasten the abdominal bandage too tightly; the bath is given on an empty stomach, and allowance should be made for this; the binder should be loose enough to allow two or three fingers to easily slip under it. The Meconium.-- The First discharge that comes from the bowels is of a dark, greenish color, and should come away during the first twenty-four hours; if it does not, the baby may suffer a good deal of pain, and an enema of warm water must be given. As this substance is very difficult to be washed out of napkins, the first ones used should be old and afterward be burned. Cleansing.-- Every time the napkin needs to be changed, even if it is only wet, the baby should be washed with warm water. A napkin should never be used twice without washing; it chafes the child, and it is an unsafe as well as a filthy practice; the napkin must always be removed as soon as it is wet. The Infant's Toilet.-- After the application of the binder and napkin, comes the undervest; the fingers of the nurse are passed up through the sleeve to seize the infant's hand and pull it through; as soon as it gets a little older the child will grasp a finger laid in its palm, which greatly facilitates this part of the toilet. The stockings are next put on and pinned with safety-pins to the napkin; then comes the petticoat, the band of which is also loosely fastened with safety-pins, and with the slip the toilet is complete. All the clothing should be changed night and morning. The eyes and mouth should be washed out with separate pieces of gauze or old linen. For the mouth, a small piece of cloth wet in warm water is wrapped around the little finger of the right hand, going into the left angle of the baby's mouth and coming out at the right, going between the gums and cheeks as well as over the tongue. This procedure should be gone through with every time preceding and following the nursing, and in this way the milk is prevented from souring in the mouth, and the digestion is kept in good condition. A sore mouth in a baby indicates carelessness on the part of the nurse. A soft hair-brush may be used, but the scalp is too tender to permit the use of a comb. After the toilet has been completed, the baby is laid in its crib, on the right side of the body, and warmly covered. The weaker the baby, the more attention must be paid to the external warmth. It may be necessary to place a warm-water bottle in the crib, but this must never touch the infant. The Crib.-- The infant must have its own crib, without rockers, and it must on no account be put to sleep in the same bed with its mother. In its early life it should never be taken out of its crib except to be fed, to have its clothing changed, or to be bathed. There should be no holding on the lap, no dangling, no carrying or fussing over the new-born infant; and the more the baby is let alone, the better and healthier it will be. If baby cries, look at once to see if it needs a fresh napkin; if not, if any pins are sticking into it, if the clothing is possibly too tight; if none of these things are wrong, give it a sup of water and turn it over on the other side. The baby often becomes restless by sleeping for several hours in the same position. But on no account take the infant up out of its crib simply because it cries. Cheerfulness and good nature on the part of the infant are dependent on its general good health. A healthy infant should not have colic, but if such is the case, there is a peculiar look of distress on the face, which indicates that the child is in pain; what is needed is warmth or medication according to the severity of the case, but never floor walking. Begin the latter procedure, and you may hope to keep it up for several years. Ventilation.-- The air is sometimes vitiated for children's uses in various ways; their nervous susceptibilities are greater than those of older people. A very little odor of tobacco may cause nausea and discomfort to an infant in arms. The atmosphere of the room should be sweet and pure and unscented. All scents and perfumes affect the nervous system, and by constant excitation do it damage. A bouquet of flowers renders the air of a closed room too heavy. Feeding of Infants.-- During the day the infant should be put to the breast once every two hours, and once every three hours during the night. This interval of time between the feeding is necessary in order that there may be sufficient time given for digestion to take place. Regurgitation of milk soon after feeding is a sign that the stomach has been overfilled. As the infant usually falls asleep after nursing, it is necessary to waken it up at the time for the next nursing, as good digestion depends upon regularity of feeding. For the first nursing the infant may be put to the breast in from two to six hours after the labor if the mother is sufficiently rested; from ten to twenty minutes is long enough for each nursing. Before each nursing the nipples should be carefully washed off with a solution of boric acid. The first secretion of the breasts is laxative; that is, it acts on the bowels, and makes is unnecessary to give the infant anything to take for this purpose. The breasts should be used alternately in feeding the infant, as this allows a longer time for the accumulation of the milk. For the first few days the infant needs very little food, and the mother's milk is generally sufficient. The infant should be given a teaspoonful of cool water to drink two or three times a day, as the milk does not quench the thirst. The water should be sterilized by boiling, and be kept in an air-tight flask. At the end of the third month the intervals of nursing for the daytime should be three hours, and the last nursing at night should be at eleven o'clock, and the first nursing in the morning at five o'clock; thus allowing the mother an interval of six hours of unbroken sleep. The best evidence of the proper nutrition of the child is a progressive gain in weight. The child should be weighed every week. A loss of a few ounces usually takes place during the first few days after birth, so that the child does well if at the end of the first week it weighs as much as it did at birth. After the first week the weekly gain should not fall below five ounces. The Wet-nurse.-- When the mother for any reason whatever is not able to nurse her child, the best substitute is a wet-nurse. Before she is employed the wet-nurse should always be carefully examined by a physician to insure her freedom from disease. The best age is between twenty and thirty years, and the age of the child of the nurse should be at least within a month of that of the child to be nursed. The best sign of the good health of the nurse and of the condition of her milk is furnished by the health of her own child. The breasts should be well formed and the nipple of good shape. It is well, if possible, to get a woman who has borne several children, as she will understand the care of the child better. No woman who is not perfectly healthy is fit to be a wet-nurse; and even after she has been engaged her health and her habits must be watched over. Artificia1 Feeding.-- The first requisite in artificial feeding is that the milk shall be made to correspond as nearly as possible to that of the mother. For this purpose the following formula, prepared by Rotch, of modified cow's milk is considered the best: Milk 2 ounces Cream 3 ounces Water 10 drams Milk-sugar 6 3/4 drams Lime-water 1 ounce To make one pint of the mixture for use in the twenty-four hours, take the milk and cream as soon as it comes in the morning, and mix as above directed. No less important than the correct proportions of the ingredients, is freedom from disease germs and bacteria of putrefaction. Complete sterilization is possible by prolonged boiling; but experience has proved that under prolonged exposure to a temperature near the boiling-point certain changes take place in the albuminoids of the milk which greatly impair its digestibility. Full sterilization of milk for infant feeding has therefore practically been abandoned. It has been found that milk heated to 167° F. for twenty minutes, and promptly chilled by placing on ice, remains practically sterile for twenty-four hours, and it is spared the injurious changes which take place at a higher temperature. This process is known as Pasteurization. The Arnold steam sterilizer affords a convenient method of sterilizing; if used with the cover removed, the steam chamber being open, the temperature of the steam chamber does not exceed 170° F. It is claimed that in the Arnold steam sterilizer, with the use of a suitable gas stove, the water begins to boil at the end of two minutes after the gas is lighted. A four-ounce bottle of milk at an initial temperature of 70° F. in the open steam chamber attains a temperature of 170° in just one hour. An exposure of about one hour and twenty minutes in the steam chamber is therefore necessary for the Pasteurization. The rules for sterilizing are as follows: First, clean the bottles thoroughly; then place them in cold water, which is allowed to come to boil and boiled for ten minutes. Second, fill each with the milk you wish to use; put in the rubber cork without the glass plug; this leaves a small opening in the rubber cork; set the bottle in the basket, then in the boiler. Third, set in the refrigerator until needed for use. Fourth, when wanted for use, place a bottle of the milk so prepared in the tin mug which accompanies the sterilizer; fill the mug with hot water to the height of the milk in the bottle, heat the milk to the temperature of 99° F., remove the rubber cork and put on the nipple, when it is ready for use. Fifth, cleanse the bottle immediately after using; throw away any milk that has not been used. Sixth, if the steaming process is preferred, place the basket without the bottles in the boiler, fill the water up to, but not above, the bottom of the basket, place the bottles in the basket, and proceed as before. It is important that the milk should be sterilized or Pasteurized as soon as it is served in the morning. Each bottle must be thoroughly washed as soon as it is emptied. Milk sterilized in this way will keep for days without spoiling, as it is hermetically sealed and all the unhealthy germs have been removed. The most exact method for the artificial feeding of infants, and that which most nearly approaches the mother's milk, is that used by the "Walker-Gordon Laboratory," branches of which are to be found in many of the large cities. Not only is the greatest care taken that the milk used shall be pure and sterilized ready for use, but these laboratories are equipped by special machinery which separates the important elements of the milk-- namely, the fat, the milk-sugar, and the proteids. So that the physician can modify the proportions of these various ingredients of the milk to meet the necessity of the age and requirements of the infant. When the milk contains too little sugar, the infant does not gain as rapidly in weight as it would otherwise do. Too much sugar in the milk is indicated by colic, thin, green, or acid stools, or eructations of gas from the stomach. An excess of fat in the milk is indicated by vomiting; too little fat causes constipation with dry hard stools. Proteids in excess are a prolific cause of colic and also of diarrhea. Prescription blanks are furnished the physician, who fills out the percentages of fat, milk-sugar, proteids, and alkalinity, to suit the age, weight, and general condition of the child. He orders also the amount to be given at each feeding, and the number of feedings to be given in the twenty-four hours. Each bottle contains just the amount to be given at one feeding. All that the mother needs to do is to place the bottle in a receptacle containing warm water, until the milk has attained a temperature of 99° F., remove the cotton stopper, and put on the nipple, when it is ready for use. The Nursing Bottle.-- This should be of clear glass, with a rounded bottom, and of such a shape as is easy to clean; so that no particles will cling around a corner which cannot be reached. The graduated bottle is the most convenient, as it enables the quantities of each of the materials used in the preparation of the feeding to be mixed in the bottle, doing away with the trouble of measuring before putting into the bottle. Rubber Nipples.-- Two nipples should be kept for alternate use, and no nipple should be used longer than two weeks. A soft rubber of conical shape is best, with an opening at the top which is not too large, so that the milk will not flow through, as it is desirable that the child should obtain the milk by suction. So soon as the feeding is over, the nipple should be removed from the bottle, and brushed on both sides with a stiff brush. It should then be put in cold water, where it is kept until it is again wanted. The baby should be fed slowly, from ten to twenty minutes being taken for each feeding. Sucking from an empty bottle or with a nipple in the mouth should never be permitted, as in this way the baby draws air into its stomach, which will result in colic. Each flask should contain only enough for one feeding. In lieu of the regular sterilizing apparatus, milk may be similarly prepared by placing the milk in an ordinary glass fruit-jar with a screw lid. This is placed in a colander over a pot of boiling water; the milk should be allowed to boil in the open jar for two minutes; the jar-lid is then screwed on, and it should steam for twenty minutes longer. The capacity of the infant stomach at birth is about one ounce, which is the average quantity of food that should be taken at one meal. The average rate of increase in the amount of food is one and a half drams a week for the first six months; subsequently somewhat less. The intervals of feeding should be two hours at birth, and increased to three hours at the end of the third month. The food should be given at a temperature of 99° F. and fed directly from the sterilizing bottle. Fresh Air.-- In warm weather the baby is taken out-of-doors in from three to four weeks after birth; in cold weather not before two to three months. In the latter case it is prepared for the change by being first dressed as for the street, with wrap and cap; the windows of the room are then opened, and the infant is carried about here. In the winter months when the baby is first taken out, it is better to carry it in the arms, as it will be kept warmer in this way, and if it does become chilled it will be more quickly noticed. Characteristics of the Healthy Infant.-- The average weight of an infant at birth is about seven pounds, and its length is about twenty inches; the extremes are four pounds or a little less up to eleven pounds. The head and trunk of the child are developed out of proportion to the limbs. The skin of the new-born infant varies from pinkish to red; about the fourth day the color becomes somewhat yellowish; this tinge should disappear about the end of the second week, and at the same time the skin begins to peel off.This process lasts about two weeks longer, when the baby's skin takes on its normal color. The shape of the head varies greatly, much being due to the amount of pressure during labor; but this disappears in a few days. As a rule, the large bones of the head are felt to be separated by membranous ridges called sutures; there is one on the median line on the top of the head, and at either end of the suture is a large open space, called a fontanel. The largest one is at the front of the head, and is called the anterior fontanel; it is about large enough to be covered by the tips of two fingers, and is of a lozenge shape; this opening does not close till the child is about eighteen months old. In a healthy baby this fontanel should be on a level with the bones of the head; a slight pulsation may be noticed in it, due to the pulsations of the vessels of the brain. There is a much smaller three-cornered fontanel at the back of the suture, and one behind either ear; these soon close up with bone. A new-born baby cannot probably do any more than distinguish light from darkness. Up to the sixth week there is an inability at coordination of the ocular muscles; after this time the eyes begin to move in an orderly manner, and they will follow a bright object moved slowly in front of them. At about the end of the second month rapid movements are perceived, as is evinced by the child's closing its eyes quickly on an object suddenly approaching it. At three months the child begins to recognize colors; the first recognized are yellow, red, pure white, gray, and black. But the faculty of distinguishing between colors is not perfected till the third year. The mother is recognized about the third month. Hearing and a sense of smell develop rapidly after birth; loud noises in its vicinity will cause a child to start during the first day after birth. By the time the child has reached three months of age it shows signs of having a mind of its own, and is capable of exercising thought. It grasps for objects, and indicates its likes and dislikes. At from eight to ten months it can utter several syllables, and at the age of one year should be able to say mama and papa; at two years it should be able to frame short sentences. Weight of the Baby.-- By the end of the sixth month the child's weight should be double what it was at birth; that is, about fourteen pounds; at the end of the twelfth month be three times as much as at birth, or about twenty pounds. Muscular Action.-- Muscular action in the new-born infant is entirely involuntary, there being no voluntary acts until about the end of the third month. Sucking and licking are largely instinctive. The movements of the arms and legs are impulsive acts, and occur during sleep, just as they did in the intra-uterine life. The act of raising the head, which is attempted about the fourth month in healthy children, is volitional, requiring not so much added strength of muscle as power of coordination. As volition develops the power of coordination gradually increases, and the child learns to perform voluntary or purposeful acts. Voluntary grasping is done after the fourth month. As the child learns to balance its head, it attempts to sit up. This act is not successfully accomplished until about the fortieth week; the child sits firmly alone when ten or eleven months old. Before this time it is necessary to support the head and spine of the child with the hand. By the third or fourth month the infant should be able to grasp things. The child begins to creep about the ninth month. The clothing should be so arranged as to allow entire freedom of motion. It should be able to stand up by a chair by the tenth month, and be able to walk alone at the end of the first year. It is important that parents should know this, since not knowing what a normal baby ought to be able to do, cases of birth palsy, or even an attack of paralysis due to teething, are not infrequently overlooked, not only by the mother, but even by the doctor, who attributes the inability of the child to do what other children can do at this age simply to weakness, which the child will outgrow; and thus the time passes in which the most could be done to cure the child and to prevent the subsequent deformity. A baby should not be forced to stand or walk; a very stout baby, on account of its weight, will stand up and walk much later than a slight one, the two being equally healthy. Or if a baby has been sick, it will feel no inclination to stand up. Naturally, a child creeps before it walks, and this develops the muscles of the lower limbs, so that they will support the weight of the child in standing. By prematurely forcing a child to stand up and walk, there is danger of causing bow-legs, as the bones of the legs are still weak; the child should be discouraged from standing up too much rather than encouraged to stand up more. Sleep.-- A large proportion of the time of early infancy is spent in sleep; for the first few weeks the infant only wakens up to be fed. During sleep the eyelids should be tightly closed; a partial opening of the lids, showing the whites of the eyes, is an indication of ill health. Up to the age of six, children require twelve hours of sleep at night, besides an hour or more in the middle of the day; the child should be permitted to sleep as long in the morning as it will. Respiration.-- The healthy infant breathes on an average forty-four times a minute; the only time the respirations can be satisfactorily counted is during sleep. When the child is awake, the respirations are hurried by slight movements of the body, crying, and so forth. The average pulse of a newborn baby is one hundred and forty; this is hurried by the same causes that hastens respirations; the pulse is most easily counted at the anterior fontanel. The average temperature of the infant is 99° F. When the tip of the nose and the extremities are cold, it indicates a lowered vitality. The nature of the child's cry indicates, variously, hunger, temper, or pain; the mother will soon learn to distinguish these varieties. If the child cries because it is hungry, the cry ceases so soon as it is fed. But a child is never to be fed simply because it cries; it must be fed on the hour by the clock. If this rule is not strictly adhered to, it will suffer all the forms of indigestion and colic that babies are heir to. If it cries because of colic, there is a drawn look on the face, and at the same time the legs are sharply flexed on the thighs and the thighs on the abdomen. If the cries are due to earache, the head will be rolled about from one side to the other. In either case nothing will stop the cries until the pain is relieved. A baby does not shed tears until the third month. The Stools.-- The stools of a very young baby fed on breast-milk should be of a yellow or orange color. There should be three or four evacuations daily; they should contain no curds. Stools of bottle-fed babies are lighter in color and more offensive. Constipation.-- Constipation is not uncommon in infancy; it may be overcome by the use of a soap suppository, or by an injection of warm soap-suds into the bowel, or by an injection of oil and water, or by gentle friction over the bowel, following the course of the large intestine. To make the soap suppository, take a piece of castile soap about an inch long, give it the shape of a cone not any larger than the end of the little finger, and make it perfectly smooth. This is inserted to about half of its length into the rectum and held there until it causes the bowels to move. The bowel injection is best given by means of the single-bulb syringe, known as the eye and ear syringe; the bulb holds about two tablespoonfuls of liquid. This may be warm cotton-seed oil, sweet oil, or glycerin one teaspoonful to warm water two tablespoonfuls. The nozle should be small, smooth, and well oiled. It should be very carefully introduced into the bowel, being directed a little to the left side, and the bulb gently squeezed to force the contents into the bowel. The injection is more effective if it is retained for a little while; this is accomplished by making slight pressure on the anus with a towel. Rubbing the abdomen for about ten minutes in the direction of the large bowel is sometimes very effective in overcoming constipation; begin in the right groin and rub up as far as the border of the ribs, then across to the left, then down on the left side. Vomiting.-- Vomiting means often only that the stomach has been overfilled, and may be relieved by withholding all food for a few hours. Urination.-- The frequency of urination in a newborn baby will vary greatly with the weather and other conditions; in cool weather it is not unusual for the napkin to need changing almost every hour. Healthy urine should not stain the napkin. The new-born infant secretes very little urine until it begins to take nourishment freely. The bladder is usually emptied during birth, and very often the bowels also, so that if the child seems well and there is no malformation of the parts, the family may be assured that the apparent retention of urine is only temporary. The use of hot fomentations over the kidneys and bladder will often hasten the evacuation of urine if it has been unduly delayed. If the secretion seems highly concentrated, a drop of sweet spirits of niter in a teaspoonful of water may be given every two hours. Teething.-- The first tooth generally appears about the end of the fourth month; in delicate children they come later. As a rule, the lower front teeth come first, coming in pairs, one tooth coming on each side of the mouth; followed in about a month by the corresponding teeth in the upper jaw. Preceding their appearance the gums become swollen, hot, and painful, and the saliva forms in excess and runs from the mouth. The child is irritable, flushed and restless; and there usually occurs some disturbance of the bowels, commonly diarrhea. This all indicates a nervous derangement, and calls for a judicious diet and general careful oversight. The symptoms subside when the teeth are through. During teething the child manifests a desire to bite on something, and a soft rubber ring will give it great comfort. The first set of teeth are twenty in number, and are usually cut in groups, starting about the fourth month and continuing until between the twentieth and thirtieth month, when the first dentition should be complete. As a rule there is an interval of rest between the eruption of the various groups. During dentition children are generally more peevish and fretful than usual, but there should be no general constitutional disturbance. During dentition it is of especial importance to keep the bowels well opened; it is better to have them too loose than costive; constipation at this time greatly increases the tendency to convulsions. Bottle-fed babies are apt to cut their teeth later than those nursed at the breast. The lack of appearance of any teeth before the end of the first year indicates that the nutrition of the child is below par, or, in other words, that the child has rickets. The permanent teeth begin to appear about the sixth or seventh year. _________________ PART IV.-- THE MENOPAUSE. _________________ CHAPTER XIV. THE MENOPAUSE. Average Duration of the Menstrual Function; Duration of Menopause; the Menopause; General Phenomena of the Menopause; Prominent Symptoms of Menopause; Pathologic Conditions of the Menopause; Hemorrhage at the Menopause a Significant Symptom of Cancer; Causes of Suffering at Menopause. "Yet I doubt not through the ages one increasing purpose runs, And the thoughts of men are widened with the process of the suns. Knowledge comes, but wisdom lingers, and I linger on the shore, And the individual withers, and the world is more and more. Knowledge comes, but wisdom lingers, and he bears a laden breast, Full of sad experience, moving toward the stillness of his rest." -- "Locksley Hall." Average Duration of Menstrual Function.-- The average duration of the menstrual function is from thirty to thirty-two years. Raciborski estimated the duration of menstrual life at about thirty-one years and nine months. According to him, the mean age of puberty at Paris was fourteen years and seven months; therefore, the average age of the menopause was forty-six and one-half years. Tilt gives the average age of the cessation of menstruation in 1082 cases as forty-five years and nine months. The average age is between forty-five and fifty years. It has been shown by Krieger, Kisch, and others, that the earlier the menses appear, the later they cease, and vice versa. However, when the first period is unusually early or late, the menopause comes very early. Also that the sexual function is usually abolished earlier in the laboring classes, who are compelled to work hard and who have many cares, than in the well-to-do and rich. Race does unquestionably influence the duration, but given a sound healthy race, which is not too much enervated with civilization, and the menstrual process will, equally with the total physical vigor and the vitality, be increased. At the present day there is an increased sexual vitality, which shows itself in the fact that the duration of menstrual life has been increased three to four years during the past generation. The inference can be fairly deduced that vigorous vitality causes prolongation of the menstrual process and the actual age. Duration of Menopause.-- By the menopause or climacteric is understood the whole period from the beginning irregularities in the time of appearance of the menstrual flow until its actual cessation. The average duration of the menopause is from two and a half to three years. The Menopause.-- The menopause is a physiologic and conservative process. It occurs at a time of life when all the tissues are most stable and the nutrition of the body is at its best. Other physiologic changes which occur at the same time are decrease in the size of the spleen and lymphatic glands, the muscular coats of the intestine atrophy, and lessened peristalsis ensues; hence the increased tendency to constipation. These are not the degenerations of age, but the blood-supplying, blood-making, and blood-elaborating organs of the body have completed the growth of the organism, done their work, and are striking a balance with the needs of the economy. The object of each metamorphic or developmental epoch is a critical readjustment of the organism, in order to insure the greatest possible amount of health for each subsequent period of life. In the vast majority of cases this object is quietly effected, but sometimes the constitution only rallies after having been severely shaken for a varying period. General Phenomena of the Menopause.-- Borner states that while many women pass this period without noting any change in their former condition, and are conscious of the occurrence of the change of life only by reason of the absence of the menstrual flow, others suffer for years with a host of troubles. One of the most essential changes is that of the woman s psychic condition-- from slight vagaries, loss of interest in the daily affairs of life, to melancholia and insanity. "Two factors are generally taken into account: first, the sudden cessation of the menses; second, the reflections of the patient caused by her condition, meditations on the loss of youth and sexual power, and anxiety in view of the dangers of the climacteric. It cannot be denied that there is some truth in the supposed sad thoughts about the beginning of old age, and the depression caused by them can scarcely be considered abnormal" (Borner). Napier believes that it is extremely rare for the cessation to occur without some physical discomfort or some disturbance of the nervous system, but adds that: "Some women, however, cease menstruating with very slight inconvenience." As a rule, the woman misses one, two, or more periods, then a menstruation of almost normal quantity and duration; and this is again repeated at gradually longer intervals, and with a diminished flow, until actual cessation occurs. The periods cease owing to the degeneration and disappearance of the glandular tissues of the uterus, and secondarily to similar changes in the ovaries and other glands. This is followed by an atrophy of all the structures of the genitalia. An increase in the size of the uterus, from increase in the amount of blood, is frequently noticed at the beginning of the menopause; later it becomes smaller in all its dimensions. The wall becomes thinner; the cervix becomes shorter and thinner, sometimes hard, sometimes flabby as a membrane. But the distinguishing feature of the menopastic uterus is atrophy of its lining membrane. The changes in the uterus and Fallopian tubes are earlier than those in the ovaries, so that ovulation, though lessened in activity, may persist for a considerable time after menstruation has ceased. Ovarian atrophy has been referred to senile rather than menopastic changes. Atrophy of the ovaries occurs very gradually. Peuch found that in one case the ovaries were of normal size three years after the establishment of the menopause. Kiwisch describes the structural change in this gland as consisting, on the one hand, of an increase of the connective-tissue stroma; and, on the other hand, the Graafian vesicles themselves undergo retrograde change. In consequence of these microscopic changes, which take place very slowly, the entire organ becomes harder and smaller. Napier believes that the ovaries secrete specialized substances which aid in determining menstruation; and that in a less degree the utricular glands and the glands of the Fallopian tubes share in this action. He considers that this is probably secondary to the chain of peripheral irritation from the uterine glands, but that this secretion is none the less an essential feature of the menstrual process. In support of this view he calls attention to the pigmentation of the skin which occurs during pregnancy and chlorosis, showing that the absence of the catamenia results in the retention in the blood of some substance which would normally be excreted at this time. Other atrophic changes in the genitalia are shriveling of the vulva, with prolapse of the vagina or uterus from relaxation of the ligaments and loss of the natural support afforded by the changed perineal body. Uterine catarrh occurs almost invariably, and only ceases in advanced years. Displacements of all kinds are frequent, but on account of the now greatly diminished weight of the uterus, these are insignificant. The vagina is at first almost always hyperemic, but this disappears as the vessels successively atrophy. The vagina gradually becomes narrower and shorter. The mucous membrane loses its rugae and presents a pale, grayish, blanched hue. The researches of Byron Robinson, made by the dissection of a number of old women, show that after the menopause not only is there an atrophy of the genital organs, but that the hypogastric plexus of the great sympathetic nervous system also shrinks away. "It becomes smaller and firmer, and no doubt some strands disappear. On this fact must he based the pathologic symptoms accompanying the cessation of the menstrual function." The importance of the genital organs is shown by the vast nerve-supply sent to them. When this great nerve-tract becomes atrophic, so that it can no longer transmit the higher physiologic orders, all parts of the sympathetic system must be unbalanced, until a new line, the next line of least resistance is established. And Robinson believes that this is the explanation of the many pathologic manifestations of every viscus at the menopause; that is, "the irritation which arises by trying to pass more nervous impulses over plexuses than normal gives origin to what is unfortunately known as functional disease. It is just as organic as any disease, only we are unable to detect it." Chemical changes in the blood and tissues are constant vital phenomena; increased oxidation causes increased activity of the circulation, increase of temperature, increase of urea and carbonic acid in the economy from retrograde changes, and, finally, during menstrual life the flow of blood from the uterus carried off the effete materials from the highly charged system. The elimination of albuminoids, as shown by the altered condition of the blood after menstruation, is greater than can be accounted for by the blood discharged. When the menopause is attained suddenly, the retention of such albuminoid substances must act toxically. Hence the resulting clinical fact that sudden cessation of the menses is, in the majority of cases, attended with pronounced symptoms of discomfort, and it is in these cases that untoward results are most likely. James Oliver believes that the catamenial flow eliminates from the body substances whose presence in the blood would exert a deleterious influence on the animal economy. The Prominent Symptoms of the Menopause.-- Christopher Martin holds that the symptoms of the change of life are produced largely by a condition of instability and increased excitability of certain other cerebrospinal centers directly brought about by failure of the menstrual center, and adds: "It is probable that the ovaries, like the liver and thyroid gland, modify the blood circulating through them, and add to the blood some peculiar product of their metabolism. It may be that some of the climacteric symptoms are due to the loss of this substance from the system." Arthur Johnstone's theory of the symptoms of the menopause is that the lining membrane of the uterus atrophies and becomes old cicatricial tissue, and sinks into quiet decay. The nervous system begins to readjust itself; but no longer having free outlet through the soft, lymphoid tissues of the uterus, the wave pressure meets with resistance and a choppy sea results. Vertigos, bilious attacks, and so forth are nothing more than reflex waves. The weakest organ of the individual is the one that generally suffers. And that the kidneys, which all along have borne the brunt of life, should now show positive signs of disease is natural. The etiology and pathology of the menopause lie in the sympathetic nervous system. And it is by the breaking up of the harmony of previous processes that nervous disturbances are produced. After the cessation of the flow, over 8% of women suffer from "flashes"; this symptom is caused by irritation of the heart and vasomotor centers. The blood-vessels of the head and neck seem to be most affected, yet the skin of the whole body shares in the disturbance. Besides the vasomotor and heat center being disturbed, the sweat center is irritated. The flushes and flashes are followed by various degrees of sweating, which varies from a slight moisture to great drops. Nervous irritability is a prominent symptom in 8% of women at the time of the menopause. Most of the pain arises around the stomach; that is, the solar plexus. Digestive disturbances are very common at this time; they may be in the shape of fermentation, diarrhea, or constipation, accompanied by congestion of the liver. Tilt holds the very plausible view that the too strong reaction of the sexual organs on the central ganglia of the sympathetic nervous system is their principal cause of disease. Puberty, menstruation, pregnancy, lactation, or the menopause almost always entail some derangement of this system which is sometimes sufficiently severe to lead to insanity and suicide. Debility underlies all affections of the sympathetic nervous system, in the same way as nervous irritability underlies all cerebral diseases. Sometimes there is an overpowering sense of exhaustion pervading the whole system. Forms of climacteric insanity are delirium, mania, hypochondriasis, melancholia, irresponsible impulses, and the perversion of moral instincts. "If the reproductive apparatus does not act on the brain by the instrumentality of the circulating organs of the blood, it must do so by means of the nerves. The genital apparatus is richly endowed with nerves from the sympathetic system, and I have shown how frequently evident signs of disturbance in these centers coincided or alternated with headaches, nervousness, hysteria, and epilepsy. What wonder, then, if the same powerful influence of the sexual organs, through the instrumentality of the sympathetic system, should at times produce a permanent derangement of the mental and moral faculties. I am thus led to look on the sympathetic nervous center as a source of vital power producing reflex morbid phenomena, in accordance with variable cerebral predisposition" (Tilt). Another very frequent symptom of the menopause is distress in the region of the heart, with palpitation and shortness of breath. It may be caused by the condition of the blood, whether it be impoverished-- anemia-- or too rich in red globules; by reflex irritation of the pneumogastric or sympathetic nerves; by overexertion; or by alcoholism. It may also be due to general debility; the woman resists fatigue less easily, and she experiences a general malaise. To the palpitations are rapidly added faintness and shortness of breath. The sleep is troubled with distress in the region of the heart. It is said that women in whom the menopause occurs early are more liable to tachycardia than those who menstruate later in life; and that it occurs with especial frequency when the menopause has been prematurely induced by surgical operation or by disease. It is believed that this functional heart trouble is caused by the increased connective-tissue fibers of the sexual organs acting in some unknown way on the terminal fibers of the sympathetic; and it is not infrequently due to the formation of scar tissue at the seat of a cervical laceration, and has often been promptly and permanently relieved by removing the cicatricial tissue and suturing the wound. The cause acts by producing a transitory paralysis of the inhibitory fibers of the pneumogastric nerve. Pathologic Conditions of the Menopause.-- Perhaps the most alarming symptom of the menopause is hemorrhage. It may be due to general or local causes. Among the general causes are diseases of the heart, lungs, spleen, and kidneys. Local causes of hemorrhage are: inflammation of the lining membrane of the uterus, chronic pelvic inflammations, faulty uterine positions, erosions and ulcerations of the mouth of the uterus, fibroid tumors, and cancer. All competent observers agree that cancer in women is much commoner from forty to fifty years than at any other age. Hemorrhages occupy the foremost place among the pathologic phenomena of the genital tract during the menopause. Hemorrhage has been attributed in many instances to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure which is brought to bear on their walls; there is also softening and relaxation of the uterine tissue. Additional causes are found in the circulatory disturbances in the pelvic organs, whereby the outflow of blood from the pelvic vessels is hindered a chronic congestion in the uterine vessels is produced. It has also been attributed to early and profuse menstruation, frequent and difficult labors, frequent abortions, and excess in drinking. The third and last variety includes those cases which may be referred to some disease of the pelvic organs themselves. Anatomic changes may lead up to pathologic conditions. A chief feature characteristic of uterine disease is malnutrition from atrophy-- a sudden curtailing of the blood-supply from the degeneration of the genital-nerve apparatus and consequent impaired vitality of tissue from defective nourishment. The anatomic changes in the glands and substance of the uterus also favor the irritation, and the development of new growths, which may be malignant or benign-- as cancers, fibroid growths, and so forth. Hemorrhage at the Menopause a Significant Symptom of Cancer.-- Not only should any excessive and prolonged bleeding at the time of the menopause be a source of great anxiety to the woman, but even the irregular appearance of a slight show of blood just sufficient to keep the clothing stained, or a slight bleeding following coition; since all of these are symptoms of very great gravity, and demand an immediate local examination and appropriate treatment. The widespread belief among the laity that hemorrhage at the time of the menopause is a normal condition, and that if left alone it will stop in the course of a few years, is most erroneous and fatal. On this altar of ignorance thousands of women sacrifice their lives every year. The case-book of any gynecologist will testify to the truth of this statement. The following three cases will serve to illustrate different types of hemorrhage in cancer patients, in no one of which did the patient even suspect that she was suffering from anything more serious than the "vagaries of the menopause." Case I.-- Woman aged seventy years; came on account of incontinence of urine, which had been troublesome for two years. The menopause occurred at fifty. She stated that three or four years previous to her visit, she had had a return of the flow of blood, perhaps twice in the first year, and that during the past year there had been a flow every month-- about the same that there used to be. This she took to be a return of the menstrual period. She said, further, that there was a constant bleeding-- enough to necessitate the wearing of a napkin-- and an occasional severe hemorrhage; that she could not take long walks or drives because of the excessive flow which followed. The case was one of cancer of the uterus which had spread to all the pelvic viscera; and in addition to this, the patient's general condition was such that any operation was out of the question. Yet the patient had never thought of the possibility of any uterine trouble sufficiently serious to make a local examination necessary. It was only the loss of control over the bladder that drove her to seek a physician's advice. Case II.-- Woman aged fifty-three years came to consult me because of pain, hemorrhage, and loss of weight. There had never been any cessation of the menstrual period. She said that she began to have irregular hemorrhages three years previously, and that they were constantly becoming more frequent and more alarming, and that, in addition to this, there was a constant discharge of blood, which necessitated her wearing a napkin all the time. She also stated that for the preceding six months the pain had been so severe that she had not had one solid night's sleep, and that in that time she had lost forty pounds in weight. This patient was in the very last stages of cancer of the uterus, and all that could be done for her was to make her comfortable. She had given birth to one child which caused a deep tear of the neck of the womb; and it is probable that this neglected tear was the primary cause of the cancer, which began in the neck of the womb. Case III.-- Woman aged forty-five years; married, but had never had any children. She said that the periods were normal as to duration and amount, but that for the past two years they had two days ahead of time, and that for the past four months she had been having just enough irregular bleeding between the periods to keep her clothing stained. On examination a diagnosis of cancer of the uterus was made. The pathological examination proved this to be a most malignant type of cancer of the neck of the womb. The entire uterus and appendages were at once removed. And although the patient made an excellent recovery from the operation, she succumbed to the disease one year after the operation was performed. These cases have been cited at length because they are all typical and because of the variety of symptoms and the great difference of age. Only in one of the cases was there any very severe pain, and it was really the pain, which had become unendurable, which caused the patient to seek relief. It is the concensus of opinion of the medical profession that cancer of the uterus is one of the common causes of death among women; that the cancer rate of mortality has increased during the last four decades; that it is most common near the time of the menopause; and that there is a direct causal relation between cancer of the neck of the womb and the traumatisms which occur during childbirth. The symptoms of cancer of the uterus are hemorrhage, a more or less offensive discharge, and pain. The quantity of blood may vary from a slight amount which occasionally stains the clothing to a profuse hemorrhage. In the married, bleeding following coition is always a suggestive symptom. During the menopause any irregular or profuse bleeding should excite suspicion. After the cessation of the menopause any bleeding whatsoever, whether slight or profuse, should always be regarded as a danger signal which demands an immediate and thorough local examination. The same is true of any offensive vaginal discharge. Pain is frequently so late a symptom that to wait for its appearance means that the favorable time to perform an operation has passed by. Emaciation is also a symptom of advanced disease. Cancer is chiefly a disease of the climacteric; when there is a diminished power on the part of the tissues to resist adverse influence. It affects the debilitated and overworked, but it is also found in the well nourished and in the comparatively young. Cancer always begins as a local disease, and when it occurs in the uterus, it is easily accessible and eradicable in its earliest stages; that is, if the disease is discovered in its incipiency, an operation will remove all the diseased tissue. If, on the contrary, the disease is left to nature, the growth spreads out into the surrounding viscera like the roots of a tree in the earth, and the cancer may be literally said to eat into the tissues which it invades. At the same time the germs of the disease begin to be carried all through the body, and the entire constitution is affected. Prophylaxis, or the Prevention of Cancer.-- All pelvic inflammations should be promptly treated, and not allowed to become chronic. Leucorrhea is a symptom of inflammation, the true cause of which can be determined only by local examination. Women who have given birth to children-- and this is more especially necessary as they near the age of forty years-- should be carefully examined for tears of the neck of the womb. If these tears are extensive they should be repaired, as it is certain that malignant growths frequently do follow local injuries and traumatisms. Any irregular or profuse bleeding demands an immediate investigation by means of a local examination. A stormy, irregular, or delayed menopause should excite in the woman a suspicion of some abnormal condition. The importance of women being carefully watched by gynecologists at this period of their lives cannot be too emphatically stated, for upon the early recognition of cancer depends the only hope of radical cure of the disease. It is estimated that at the present time not less than 95 per cent. of all cases of cancer of the uterus come under the observation of the profession at a stage of the disease when all prospect of permanent relief is out of the question. It is a deplorable state of affairs that women, not knowing what a normal climacteric is, attribute all hemorrhages, no matter how severe, to the change of life. Therefore, regarding the hemorrhage as a necessary evil, they fail to consult a specialist until the favorable time for eradicating the disease by means of an operation has passed. And whatever knowledge science may bring in the future as to the cure of cancer, at present it is a fact universally agreed upon that early operation, while the cancer is still local, is the only radical cure for the disease. Pruritus Vulvae. Perhaps one of the most annoying and obstinate symptoms of the menopause is pruritus vulvae. This is sometimes caused by sugar in the urine; there is a congestion of the liver which results in sugar being thrown into the system and this is eliminated by the kidneys. It is quite possible that this is due to the altered circulatory conditions of the menopause. Kidney Disease.-- The last pathologic condition which we will mention is kidney disease. Le Gendre believes that the menopause exerts a deleterious effect on the kidneys, whether this be a congestion, followed by a diminution in the quantity of urine, or a sort of auto-intoxication due to the retention of a poison in the system that has been prevented from leaving by the ordinary path. Armstrong says that in almost all cases at the time of the menopause the amount of urine passed is below normal, the specific gravity is increased, and that the urine contains urates and almost always uric acid in excess. Further, that the functions of digestion and assimilation and the various metabolic changes are so largely under the control of the nerve-centers that nothing seems more likely than that so great a disturbance of that system as takes place at the menopause should cause secondary derangements of these most important functions. That being so, the blood becomes loaded with waste products, and the usual symptoms follow-- gout and so forth. It has been a grave question in the mind of the medical profession whether the dangers that certainly do attend the menopause are natural or acquired; that is, could these dangers be averted by any precautions or hygienic measures on the part of women, or are these dangers a necessary accompaniment of this period of life? Tilt has reached the conclusion that: "The best way to avoid the dangers of this critical time is to meet its approach with a healthy constitution. A marked want of strength prevents the regular succession of the vital phenomena by which all critical periods are carried on. And as the change of life is marked by debility, when this is grafted on constitutional weakness, loss of power will be of long duration. All complaints remain chronic because there is not stamina enough to carry them through their stages." Causes of Suffering at Menopause.-- Dusourd, whose practice lay in an agricultural district in the south of France, as well as Tilt, believes that peasant women suffer little at this time. Their health is generally good when the menopause comes on and they are little liable to nervous disorders. The poor of large towns suffer much at this epoch-- the necessity of working hard, the anxieties of poverty and their unhygienic surroundings. But by a fortunate compensation the necessity for working hard prevents or cures the nervous affections which so often assail the rich at this period. Tilt's cases showed that women who suffered much at the menopause had previously suffered at puberty and at the menstrual periods. And among thirty-nine cases where there was no suffering at the menopause, there was the same immunity from suffering at puberty and at the menstrual epochs. Tilt's statistics were, or course, taken from English women. In forty-four cases of my own, all women past the menopause, the average age of the first menstruation was fourteen years and four months; and the average age of the actual cessation of the menstrual flow was forty-eight years and five and two-thirds months. Subtracting from this the average age of the first menstruation, we have as the mean age of menstrual life thirty-four years one and two-thirds months; that is, the average duration of the menstrual function was from two to four years longer than that usually given. A further investigation in order to ascertain any possible relation between the age of marriage and the number of pregnancies and the sufferings of the menopause elicited the following statistics. The average age of marriage was twenty-five years and ten months. Of the four women who were married after thirty-eight years, all were sterile; among the remaining there was an average of slightly above three children each. Forty per cent. of all these cases had one or more miscarriages. Nine had habitually suffered from severe dysmenorrhea, eleven had slight dysmenorrhea, and twenty-two had never felt the slightest inconvenience. In a list of fifty-two cases, eight were added to the list already given, all of whom had passed the menopause. Five were perfectly healthy and had never suffered the slightest inconvenience. Of these, one was single and only one had one miscarriage. Ten had suffered at the time of the menopause from slight malaise, but not sufficiently to call in a medical attendant. Thirty-seven were more or less seriously ill; thirty of these needed local as well as constitutional treatment, and seven constitutional treatment only. The prominent symptoms of the climacteric were as follows: Marked debility, 24; intense nervousness, 31; nervous prostration, 9; melancholia, 10; headache, 14; neuralgia, 6; hysteria, 7; irritable heart, 11; tachycardia, 8; insomnia, 19; indigestion, 32; constipation, 28; diarrhea, 3; leucorrhea, 38; rheumatism, 21; gout, 1; Bright's disease, 12; hemorrhage, 6; alcoholism, 2; corpulency, 2. As a result of the study of these cases, the most striking feature was the relation of miscarriages to the sufferings and ill health at the time of the menopause. Of the nineteen women who had miscarriages, only one did not suffer in some way at the time of the menopause. Four suffered only slightly, and fourteen suffered extremely, not only during the menopause, but in the post-climacteric period as well. And the next most striking feature was that the prominent symptoms of the menopause are preeminently reflex or the functional diseases of the nervous system. Tilt believes that single women suffer less than other women at the time of the menopause. He further writes: "As at puberty, from the ignorance in which it is still thought right to leave young women, so at the change of life, women often suffer from ignorance of what may occur, or from exaggerated notions of the perils which await them. It would be well if they were made to understand that if in tolerable health, provided that they will conform to judicious rules, they have only blessings to expect from the change of life. Most unfortunately, the individual not cognizant of the invisible changes going on in the economy does not adapt the mode of life to the new conditions of the organism, and the weakened and lessened amount of the digestive fluids is unable to master the large quantities of food. The absorbents refuse to take more than is needed to repair the tissues. The atrophying muscles of the digestive tube, unable to hurry on the mixed products of indigestion; fermentation; and micro-organisms inciting fermentations and elaborating toxic alkaloids, poison and disorder the functions of life. Man's outdoor life enables him to escape many of these evils. "Woman's enervating mode of life, the continued introspection, coupled with the peculiar changes in the nutrition of the body at this time, render the nervous system peculiarly impressionable and liable to the manifold forms of diseases. 'The woman is told that she must be calm and patient, and in time the tomb-builder will alleviate all her sufferings.' This critical period may be dangerous to those who are always ailing, for habitiual sufferers at the menstrual periods, and for those affected with uterine diseases. If, on the first indication of the change of life, women who are in fair health carefully followed a regimen and pursued a line of life in harmony with the physiologic processes on which this change depends, disease would be prevented. But as the change concerns a natural function, it is left to nature; no additional precautions are taken, and advice is sought only when the mischief is done." It is not wise to marry during this period. On the first appearance of the irregularities of the menopause the amount of food and stimulants to which women have been accustomed should be curtailed rather than augmented. The system requires supporting by medicine and regimen-- as, baths, mental and moral hygiene, and occupation-- rather than stimulating by spirits. We have seen that, in accordance with the plethric theory, which prevailed until 1835, and with the nerve theory, which is based on the latest anatomic and physiologic researches, menstruation is a physiologic process to get rid of effete material, and is therefore an excretion. At the end of perhaps thirty years, by a conservative process of nature, the child-bearing period ceases and the organism is readjusted to the end that the woman's vitality may all be conserved for her own individual life. Each metamorphic or developmental period of life-- dentition, puberty, and the menopause-- throws a special strain on the nervous system, and the recent studies of the sympathetic nervous system at the time of the menopause show that very extensive anatomic changes occur at this time. That being the case, the woman must lead such a life as will insure her having on hand a large reserve force necessary to meet these heavy demands. Tilt's observations show that women who have experienced no suffering at puberty or, at the menstrual periods do not suffer at the menopause. It is therefore evident that the time to begin this preparation is in childhood. That single women suffer less than married women would suggest that excessive coitus and the occurrence of abortions, frequent child-bearing, and lesions as the result of pregnancies, many of which lesions could have been prevented or cured by the timely aid of the physician, are the combined sources of much of the suffering at the time of the menopause. That the most frequent and serious disturbances are those of the nervous system, and that from their mode of life and habits of introspection the rich suffer more from these ailments than the poor, must cause serious consideration of the physiologic necessity for a definite occupation for the daughters as well as for the sons of the rich. The frequency with which Bright's disease is found at the time of the menopause is dependent not so much on the local physiologic changes which are taking place as on the time of life. Loomis says that it was not until life-insurance examinations became so common that the frequency with which kidney disease existed in persons who believed themselves well was even imagined. And as a result of his observations in these cases, and of a large number of autopsies conducted at the Bellevue, he stated that it was his belief that 90% of men and women over forty years of age suffer from some form of Bright's disease. That being the case, it would seem that after this period of life at least as much attention should be directed to the kidneys as to the teeth, and that a semi-annual examination of the urine should be made. Although the menopause is a physiologic occurrence, yet, owing to the many pathologic changes which are liable to take place at this time, the woman should be as carefully watched during the menopause by the gynecologist as the pregnant woman now is by the obstetrician. If the same care were taken, in the majority of cases, the dangers attending the menopause would be avoided, and the woman would be prepared to enjoy a healthy and useful post-climacteric period of life. CHAPTER XV. HYGIENE OF THE MENOPAUSE. Diet; Constipation; Stimulants; the Kidneys; the Skin; Turkish Baths; Massage; Exercise; Profuse Menstruation; Hemorrhage; Mental Therapeutics. "'Tis the breathing time of day." -- "Hamlet." Hygiene of the Menopause.-- The changes which occur in all the organs of the body at the time of the menopause are retrograde, and therefore just the opposite of those which occur at the time of puberty. This fact should be borne in mind in the matter of alimentation. All that is now needed is to make the repair equal to the waste. Diet.-- Unless the woman is taking a great deal of active exercise, it is better to diminish the amount of meat eaten, and to increase the vegetable food and take more fluids. Unless the effect of the meat eaten is counterbalanced by active outdoor exercise, it produces an excess of waste matter, which accumulates and causes biliousness, and sometimes rheumatism and gout. A vegetable diet is less taxing to the excretory organs than an animal diet. Indigestion is at this time of life apt to appear in the form of fermentation, which may assume the gastric or intestinal type. The chief causes of the formation of gases are the lessened peristaltic action of the intestines, the increased tendency to congestion of the liver and to obstinate constipation. All dishes rich in sugar, as cake, candy, preserves, and jelly, should be indulged in with moderation; or where there is a tendency to fermentative indigestion, they should be wholly avoided. All dishes known to be difficult of digestion, as hot breads, pastry, cheese, fried dishes, and rich salads, should be cut off the menu, since these readily overtax an already weakened digestive system. If there is a hereditary tendency to rheumatism or gout, the disease is most apt to take on an active form at this time. In either case the manifestation of the disease indicates an excess of uric acid in the system, and a diet becomes a necessity. Pickles, all highly spiced articles of food, and vinegar must be omitted from the bill of fare. The vinegar may be replaced in salad-dressings by lemon juice. Tomatoes, rhubarb, strawberries and grapefruit are contra-indicated; also all articles of food rich in sugar. In chronic cases animal food cannot, as a rule, be excluded from the dietary, but must be limited in quantity. Fish, eggs, and fowl may be eaten, also a moderate amount of lean meat in the form of beef, lamb, and mutton. Milk may be indulged in freely. The diet should consist principally of easily digested fresh green vegetables. The amount of tea and coffee should be limited. All malt liquors, sweet wines, and champagne must be absolutely prohibited. Constipation.-- A daily free evacuation of the bowels is essential to good health. Where constipation exists, and the woman is full-blooded, with a tendency to a rush of blood to the head, saline laxatives are indicated. But if the woman is constipated and anemic, cascara sagrada is a better laxative; while cod-liver oil acts as a laxative and at the same time improves the quality of the blood. Stimulants.-- Women resort to alcoholic stimulants as an analgesic to relieve pain, whether physical or mental; as a narcotic to produce sleep; and as a spur to a failing appetite or bodily powers. The majority of women patients say that they first used alcohol in the shape of whisky, brandy or gin to relieve pain at the time of the menstrual period. The pain that is caused at this time by a chilling of the body would be as effectually relieved by drinking a cup of hot tea; while if the pain is intense and constant, recurring every month, it is doubtless caused by some local inflammation, and the use of alcohol only veils the real trouble, and the woman loses valuable time by not consulting a physician at once. As to the use of alcohol to blunt the nervous sensibility due to mental suffering, it is the testimony of the entire medical profession that this is the greatest cause of inebriety or drunkenness among women of all classes of society. Sleeplessness generally arises from some well-defined physical cause-- very frequently from inaction of the liver-- and the proper remedial agents should be used to remove the cause. While at first the use of alcoholic beverages increases the appetite, as the amount taken is increased, distaste for food is created, the system languishes under an insufficient food-supply, and the original aim of increasing the appetite is defeated. As to taking stimulants to do more work than one could otherwise accomplish, it is by means of stimulants that woman can accomplish her physiological ruin more quickly than is possible in any other way. And the early symptoms of chronic alcoholism show themselves in the form of neuralgia, insomnia, palpitation of the heart, and muscular tremors. The Kidneys.-- On account of the prevalence of some form of Bright's disease after forty years of life, the kidneys should be carefully watched at this time. And in order to keep them in good condition they must be well flushed with water every day. Three pints of urine should be excreted daily, and three pints of water as such must be taken into the system daily. The urine should be examined by the physician every six months. In this way kidney disease is often discovered in its incipiency, which otherwise might run into a serious form of Bright's disease. The Skin.-- It must be remembered that the skin is one of the excretory organs of the body, and the pores should be kept well open by the various forms of baths. The Turkish bath or some modification of it will often be found to be particularly useful. Massage with alcohol after the bath lessens the tendency to take cold. For a woman who is anemic or run down, it is well to follow the Turkish with the Roman bath, which is an inunction with almond oil or cocoa-butter. A much more thorough massage is given with the Roman bath than with the "alcohol rub." It is often necessary to modify the Turkish bath by omitting the steam-room and shortening the time spent in the hot dry air. In ordinary cases the time spent in the hot dry-room should be only that necessary for producing a free perspiration. This time varies in different individuals from ten to twenty minutes. No woman should go to a Turkish bath without first consulting her physician, since if the woman has a weak heart, the bath may be the source of positive danger. Comparatively few women are strong enough to take the cold plunge. Massage.-- Massage, well given by a skilful masseuse twice a week, will greatly tone up the nervous and circulatory systems. Women who are very stout and who have sluggish livers with obstinate constipation will find massage particularly beneficial. Exercise.-- Daily exercise in the open air is absolutely essential to every woman's good health. The minimum amount of outdoor exercise compatible with health is an hour's walk, at the rate of three miles an hour. If the woman has never taken any exercise, she must begin with a very short walk and stop on the first sign of fatigue. Gradually increase the distance and the speed until the three miles is reached. Profuse Menstruation.-- If the menstrual flow is unusually profuse or lasts beyond the regular time, the woman should stay quietly in bed until the flow ceases. All exercise increases the flow. The flow now becomes less in quantity, and the periods more infrequent than formerly. Hemorrhage must always be regarded as a danger-signal the significance of which can scarcely be overestimated. To immediately consult a specialist on the appearance of any irregularities of the flow would, in the opinion of the most eminent gynecologists of the day, be the means of saving thousands of women's lives every year. Mental Therapeutics.-- It is particularly necessary at this time of life that the mind should be pleasantly occupied. Her children have passed the age when they need her constant supervision, and the mother must take some relaxation from her home cares, in the form of social diversions, amusements, outdoor life, and change of scene. Any mental occupation that will take the woman out of herself is the best possible safeguard against a state of introspection which conjures up a host of evil fantasies, and which is the first step in the downward road to a fixed and permanent melancholia. "Hang sorrow, care will kill a cat; And therefore let 's be merry." CHAPTER XVI. HINTS FOR HOME TREATMENT Indigestion; Constipation; Diarrhea; Enemas; Vaginal Douche; Baths; Headache; Fainting; Hemorrhage. "Woman is woman's natural ally." -- EURIPIDES. Indigestion.-- The chief causes of indigestion are: eating rapidly, eating at irregular hours, eating indigestible foods, constipation, and lack of exercise. No one who values her good health will allow herself to be hurried through a meal, nor will she allow the perplexities of life to be thrust upon her at the table for solution. The first requisite for the digestion of foods is that they should be well masticated, so that the digestive fluids may act on the finely divided particles to the greatest possible advantage. And while digestion is going on all mental labor should be held in abeyance, in order to avoid drawing the blood away from the stomach to the brain. Furthermore, it is a well-known fact that digestion is best performed when the meals are served at regular hours. Constipation leads to the formation of gases in the intestines, to fermentation, and to the absorption of toxic materials by the blood. Through lack of exercise, the appetite fails, the liver becomes torpid, and the muscular and nervous systems lose their tone. The exercise which the housekeeper gets in going around her house is not sufficient. Daily exercise in the open air is essential to health; as this is to supplement the indoor exercise, the amount taken will vary in proportion to the former. For teachers or those who have a sedentary occupation an hour's active exercise in the open air-- a three-mile walk-- should be supplemented by active gymnastic exercise. For people in good health, a mixed diet-- that is to say, a diet consisting of meat, vegetables, and fruit-- is the best. If the individual is not well, then the diet must be adapted to meet the needs of that particular case. Hot breads, all articles of food fried in fats, salads, and pastry are difficult to digest. Tea is very constipating, and when taken in excessive quantities renders the individual nervous. An excess of coffee leads to congestion of the liver. Where indigestion exists, the simplest and most sensible remedies are to regulate the diet, and avoid eating between meals. By drinking a glass of water as hot as it can be sipped one hour before each meal, the mucus is washed out of the stomach, the stomach is empty on coming to the table, and in the best possible condition for the gastric juice to act on the food-stuffs. Constipation.-- Constipation is the rule with the average American woman; the causes are their corsets, the tight bands of their clothing, lack of exercise, and the fact that they drink too little water and too much tea. The most rational means to overcome it is to drink more water; at least three pints a day should be taken, in addition to soups, tea and coffee, and so forth; the water must be taken into the system as such. Then attention must be given to the diet; plenty of fruit should be eaten, vegetables, and coarse bread. Regularity in this, as in all other habits of life, is most essential, and the individual should go to the toilet at the same hour every day, even if there is no inclination to have a bowel movement, and thus the habit will be established; the most convenient time is directly after breakfast. Medical Treatment.-- But if all these means have failed, medicines must be resorted to. Cold water is a better laxative than hot; to a glassful of cold water add from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda, and take this the first thing on rising in the morning. This preparation of soda is particularly useful because it acts slightly on the liver. Other laxatives are: a seidlitz powder dissolved in a glass of cold water on rising; a wineglass or more of Hunyadi Janos, also taken on rising. Any of these may be taken with safety by pregnant women. For children the simplest laxative is one teaspoonful of Husband's milk of magnesia, to be taken in one glass of water on rising. Enemas.-- Perhaps one of the most common methods used by the laity for the relief of constipation is the rectal injection, or enema. Enemas habitually given to unload the bowels are productive of much harm by overdistending the rectum, so that in time the rectum fails to react to the normal stimulus-- namely, the presence of the feces-- as it otherwise would. But by some means or other the bowels must be well moved once every twenty-four hours. And it is much better to use an enema than to go to bed without a bowel movement. If the woman is going around, so that she can give the enema to herself, the most effective way to take it is in the knee-chest position or an approximation to this. Either a fountain or bulb syringe may be used for this purpose; a quart of water at a temperature of 110° F. should be prepared by making it into a suds with castile soap, or one tablespoonful of glycerin may be added to one pint of water. The nozle to be used is the smallest one that comes with the syringe, the so-called infant's nozle; this is quite large enough, and its insertion is not nearly so painful as the larger ones; the nozle must be well greased with vaselin. When everything is ready, the patient gets down on her knees with the shoulders near the floor, having first loosened all of her bands and taken off her corsets; the nozle is introduced as far as it will go into the rectum, and if a bulb syringe is used the water must be very gradually squeezed into the rectum, otherwise it will not retain so much; or if the fountain syringe is used, it must not be hung too high. So soon as the patient feels that she has taken all that she can retain, she should lie down on the left side, and retain the water as long as possible, as it is thus rendered more effective. An enema so taken will be very much more effective than one taken in the ordinary manner of sitting on the toilet. In the method just described more water can be used and it will be longer retained; it can be felt to go up along the course of the large bowel, and it will often be found very effective when the ordinary enema fails. This enema will often be found to be a very valuable aid in curing an obstinate chronic diarrhea, which is kept up by particles of feces remaining in the folds of the large intestine. If the patient is confined to bed, she should lie on the left side, with a heavy towel folded under her to prevent the bed from becoming wet; when the nurse withdraws the nozle she should make pressure on the anus with the towel, to help the patient to retain the water as long as possible. But should the patient have gone so long without a bowel movement that all these means fail, it will be necessary to precede the water enema with one of oil; or still more effective is the following combination: take one teaspoonful of the spirits of turpentine, the yolk of one egg, and two tablespoonfuls of olive oil, and beat well together, and add to these one pint of water at a temperature of 110° F. Constipation, however, of so obstinate a character as this demands a physician's attention. Diarrhea.-- A diarrhea may be acute or chronic; the treatment is essentially different. For an acute attack accompanied by frequent stools and severe abdominal pain the first thing to do is to go to bed. If there is nausea, drink a glass of water as hot as can be taken, at once; for the diet, a glass of scalded milk, not boiled but just allowed to come to the boiling-point, every two hours; and nothing else should be taken until the diarrhea is well in check. If the pain is severe, a spice plaster over the abdomen will be found to be very comforting. It is made as follows: take of powdered allspice, cinnamon, cloves, and ginger each two tablespoonfuls, and two teaspoonfuls of cayenne pepper; mix well together in a bowl; then quilt in a piece of flannel large enough to cover the abdomen; when ready for use, dip in hot whisky and apply as hot as the patient can bear; cover over with a large napkin, as the plaster produces a deep stain which does not wash out; keep on as long as necessary. If the rest in bed and the milk diet kept up for twenty-four hours do not suffice to cure the diarrhea, it is not wise to take any risks, but send for your doctor at once. Or if there should be any blood in the stools, do not wait for anything, but send for the doctor without delay. For a chronic diarrhea an enema given in the knee-chest position, as already described, will often be found a most efficient remedy. In diarrheas the use of fruits and vegetables should be avoided; the best diet after the milk is bread well toasted through, toast-water, soft-boiled eggs, beefsteak, oyster stew, and clam broth. Vaginal Douche.-- To be of service except for mere cleansing purposes the douche must be taken in the horizontal position, either on a couch or, if it is not cold, on the floor. Of course, this position necessitates the use of a douche-pan. The douche-pan is best of agate-ware, oblong in shape, and with a broad strip which comes under the nates. On lying down to take the douche the nates must come down well over the pan and the clothing must be pushed well up to prevent the water from seeping up the back. To make the woman more comfortable there should be a pillow under the head, and she must have a shawl or some light woolen material to throw over her while taking the douche to prevent chilling; thus doing more harm than good. There are two forms of syringes on the market: the bag or fountain syringe, which is hung up sufficiently high-- about three feet above the patient-- to cause the water to flow; and the bulb syringe, in which the bulb has to be constantly squeezed by the hand, which is tiresome to many women, but this is a much more convenient form to have in traveling. During pregnancy the fountain syringe only should be used, and it should be hung as low as will enable the water to flow. For a woman who has never taken douches it is well to begin with a temperature of 110° F., gradually increasing the temperature to 118° or 120°; this is as high as the woman should attempt to go, for a higher temperature would burn her, leaving the vulva so sensitive that she would only be able to take cool douches for a long time after this; a bath thermometer should be used in all cases to test the temperature, so that the woman knows exactly what she is doing. In cases of inflammation of the uterus or its adnexa four quarts of water should be used, and the douche should be taken in the horizontal position. The water thus acts as a hot poultice about the uterus, and the woman will find on rising that some water flows out from the vagina. Ordinarily plain hot water is all that is necessary to use, but where the discharge is acrid and scalding, the plain hot-water douche should be followed by a warm douche containing one teaspoonful of borax to a pint of water. The best time for taking a douche is at night just before retiring; there is also less danger of taking cold when the douche is taken at this time. The scalding sensations at the vulva may be due to the acidity of the urine, in which case it will be increased just after urination; or it may be due to an acrid discharge from the vagina. A little observation on the part of the patient will enable her to distinguish which is the real cause. If there is any trouble with the urine, it should be carefully examined at once, as some congestion or inflammation of the kidneys is not infrequently present, which if attended to might be cured, and which if allowed to run on unattended to, may develop into a serious form of Bright's disease. The genitals should be washed with soap and water night and morning. Women who do not suffer from leuchorrhea need not take a vaginal douche more than once a week; after the menstrual flow the vaginal injection is advised to remove the detritus of the flow. Baths.-- The most ordinary forms of baths used may be classified under sponge-, shower-, sitz-, and tub-baths. The sponge-bath as ordinarily taken is of service for cleansing purposes, and if the water be cold it tones up the system to some extent, and is so a preventive against taking cold. The effect of this bath will be found to be vastly more beneficial if salt is added to the bath in the proportion of a pint of salt to a gallon of water; either sea-salt may be used or the ordinary coarse salt. It is most advantageously taken sitting in a bath or hat-tub, so that the entire surface of the body will be wet at the same time, and the water can be allowed to run down the back and over the chest. It is well to begin these baths at a temperature of 80° F. and to gradually decrease this until the bath is taken at 70°, which is about the temperature of running water, and the bath should be kept up at this. For most people the best time to take the bath is just before retiring; this bath is not only very strengthening, but also is excellent in cases of insomnia and nervousness. Shower-baths.-- These may be taken after a hot bath, or taken alone after violent muscular exercise. The body should be quickly scrubbed off and the shower should be warm at the beginning and gradually allowed to become cold, stooping over so as to get the full force of the shower on the spine and over the region of the stomach and heart. They will be found to be most refreshing after great muscular fatigue, and, when taken after the hot tub-bath, greatly lessen the susceptibility of the individual to taking cold. Sitz-baths.-- These are given for their local effect in cases of inflammation; whether this inflammation be of the kidneys, bladder, or of the uterus and its adnexa. A sitz-tub is necessary to properly take this form of bath. The water should be used as hot as is comfortable to the patient, from 105° to 110° F., hot water being added as the first cools off; a pint of salt should be added to the gallon of water, and the patient should remain in this from five to eight minutes. A blanket should be wrapped about the patient so that she will be thrown into a perspiration; it is almost needless to say that the only time for taking this bath is just before retiring, and that this bath does make the woman more susceptible to taking cold, so that it is necessary to wear an abdominal woolen bandage day and night. Tub-baths.-- The tub-bath ought not, as a rule, be taken more than twice a week, unless the cold plunge is used, which may be taken every day. If the tub-bath is taken hot, the woman should remain in it not much longer than is necessary to scrub off with a flesh-brush; this bath should be followed either with a cold shower-bath, or the water in the tub be gradually allowed to cool off until it is down to 70° F. Headaches.-- Headaches, aside from those of acute illness, may be roughly divided into three classes: first, those which are due to indigestion; second, neuralgic headaches; and, third, those due to pelvic inflammations. The headaches due to indigestion are usually located over the eyes and all over the forehead; they are more or less constant and are accompanied by other symptoms of indigestion, and very often by constipation. The feces are allowed to remain in the bowels overlong, the toxic matters are taken up by the blood, and headaches and vertigo result. Neuralgic headaches are of an entirely different character; the pains are here of a lancinating character, and are not confined to any one region of the head. As a rule, they are accompanied by neuralgic pains in other parts of the body. Neuralgia generally means a rundown state of the system from overwork, worry, or malaria, and tonics and cod-deliver oil are indicated. A constant dull pain on the top of the head or in the back of the neck generally indicates some uterine inflammation, and can only be cured by removing the cause. In any case it is very evident that taking the various "headache powders" with which the market is flooded will never cure the woman of her headaches; and many of these powders are very dangerous, especially where the heart is weak, as most of them are heart-depressants. Fainting.-- Fainting may be due to a weak heart, to heart disease, or to sudden shock, as on receiving a bad piece of news; during pregnancy the close air of a room may cause a woman to faint. The first thing to be done is to lay the woman down on the floor or bed with nothing under her head; loosen all her clothes about the neck and waist, and throw the windows open so that she will get plenty of fresh air. If she is able to drink, give her one teaspoonful of aromatic spirits of ammonia in four tablespoonfuls of cold water. If the feet are cold, place hot-water bottles to them to improve the circulation. And if at the end of fifteen minutes she does not show signs of decided improvement, give her two tablespoonfuls of whisky in an equal quantity of hot water. In the meantime the physician will have been summoned. These attacks of fainting often occur in a crowded ball-room, and are due to tight lacing and the poor ventilation of the room. Hemorrhage.-- A profuse hemorrhage is the most alarming as well as the most dangerous thing which can befall a woman, and the very nearest doctor should be summoned until the family physician can be gotten there. The woman should be made to lie down wherever she may happen to be, her clothes loosened, the windows thrown open, so that she will not only have plenty of fresh air, but that the air shall be cool. If the blood is coming from the mouth, give her pieces of ice to hold in it; if she coughs up the blood, it would be well to put a bag of ice-cold water or cloths wrung out of ice-water on the chest. If the woman is suffering from a uterine hemorrhage, have her take at once a hot vaginal douche, from 118° to 120° F., and have the foot of the bed raised. The head should always be kept low. Women hold their health in their own hands to a far greater extent than they have ever dreamed of; and if the majority of women suffer, it is very often their own fault, either because they have disregarded nearly every law of health, or have allowed trivial ailments to go on until they were almost incurable. _______ "The broad mountain-top, with its sunlight and free air, is possible to all of us, if we choose to struggle on and reach it." -- Phillips Brooks. _________________ GLOSSARY. _________________ Abortion. The expulsion of the fetus before the end of the third lunar month. Afferent Nerves. Those nerves which convey the impressions to the nerve-centers. After-pains. The pains which follow labor and which are caused by the contractions of the uterus. Amenorrhea. Absence of the menstrual flow. Anemia. The so-called thinness of the blood, due to a deficiency of red blood-corpuscles. Antisepsis. The use of chemical substances which have the power of destroying germs. Anus. The external circular outlet of the rectum or distal part of the large intestine. Appendages, Uterine. The Fallopian tubes, the ligaments of the uterus, and the ovaries. Atrophy. A progressive diminution in the bulk of an organ or tissue. Automatic. Involuntary, mechanical. Bulbi Vestibuli. A plexus of veins on each side of the vestibule. Capillaries. The terminal and very finest branches of the blood-vessels. Catamenial Flow. See Menstruation. Cellular Tissue. A loose, transparent tissue which surrounds the muscles and organs of the body. Cerebrum. The upper and larger portion of the brain. Chlorosis. Anemia of young women about the time of puberty. Climacteric. See Menopause. Clitoris. A small, elongated, erectile organ situated at the upper part of the vulva. Cohabitation. See Coitus. Coition. See Coitus. Coitus. Syn., coition, copulation, cohabitation, sexual congress, sexual intercourse. The carnal union of the sexes. Colostrum. A thin albuminous fluid which appears in the breasts at the fourth month of pregnancy. Conception, or impregnation, is the union of the germ and sperm cell which results in a new being. Confinement. Childbed, the expulsion of the child from the womb. Congestion. The abnormal accumulation of blood in a part. Constipation. Costiveness; a state in which there is not a free daily evacuation of the bowels, or where the evacuations are hard or expelled with difficulty. Continence. Abstinence from or moderation in sexual indulgence. Copulation. See Coitus. Cord, Umbilical. The cord which connects the fetus with the mother. Through the blood-vessels contained in this cord the child receives nourishment. Corpuscle. A very small particle. Decidua. A membranous sac formed in the uterus during gestation, and thrown off after parturition. Defecation. The act by which the contents of the bowel are expelled from the body. Dehiscence. The splitting open of an organ. Dentition. The cutting of the teeth. Dysmenorrhea. Painful and difficult menstruation. Dystocia. A difficult labor. Embryo. The name applied to the very earliest stages of the child in utero; that is, up to about the time of quickening. Endometrium. The lining membrane of the uterus. Epithelium. A layer of minute cells which forms the covering of many membranes. Erection. The state of a part which, having been soft, becomes rigid and elevated by the accumulation of blood within its tissues. Fallopian Tubes. Two very small tubes extending from the upper angles of the uterus to the ovaries and serving to convey the ova from the ovaries to the uterus. Feces. Stools; the normal discharge from the bowels. Fetus. The child in utero from the time of quickening to that of birth. Fomentations. The application of cloths which have previously been dipped in hot water. Function. An action of an organ which could be performed only by that organ, and which is necessary to the well-being of the individual. Generative Organs. Syn., genital, reproductive, sexual; those organs in the male and female by means of which a new being is created. Genital. See Generative. Gestation. See pregnancy. Gonorrhea. A highly contagious venereal disease, characterized by an inflammatory discharge of mucus from the urethra and prepuce in the male, and from the urethra and the vagina in the female. Graafian Follicles. Minute ovarian vesicles which contain the ova. Hemorrhoids. Piles or tumors at or within the anus, and consisting of enlarged veins. Hymen. The semilunar fold situated at the outer orifice of the vagina in the virgin. Hypertrophy. The increased activity of a part which leads to an increase in its bulk. Hypochondriasis. Morbid feelings concerning the health and simulating disease. Impregnation. See Conception. Infectious. See Contagious. Katabolic Nerves are those nerves which stimulate the breaking down of tissue. Labia Majora. Two thick folds of skin which extend backward from the mons veneris. Labia Minora. Nymphae; two very delicate folds of skin which are inside of and protected by the labia majora. Labor. See Parturition. Lactation. The secretion of milk; nursing, suckling the child. Lactiferous Ducts. The milk ducts. Leucorrhea. Whites; a whitish or yellowish discharge from the vagina. Lochia. A discharge which follows labor and which lasts for about two weeks. Lying-in. The period which follows childbed. Lymphatics. The vessels in which the lymph is carried. Mammae. The mammary glands; the breasts. Marital Relations. See Coitus. Massage. A systematic kneading of the muscles. Meatus Urinarius. The external orifice of the urethra. Meconium. The first discharge from the infant's bowel after birth, and which had collected in the intestines during the pregnancy. Medulla. The base of the brain at its junction with the spinal cord. Menopause. Climacteric, change of life, the time of the natural cessation of the monthly sickness. Menorrhagia. An excessive menstrual flow. Menstruation. Menstrual period, menstrual flow, menses, monthly sickness, the monthly discharge of blood from the uterus, which, with certain exceptions, recurs monthly from about the age of thirteen to forty-six years. Metabolism. Transformation changes. Metamorphoses. Changes of shape or structure. Metrorrhagia. A flow of blood between the menstrual periods. Micturition. The act of passing water. Miscarriage. The expulsion of the fetus between the twelfth and twenty-eighth weeks. Molecular. Belonging to the molecules, or the minutest portion of anything. Mons Veneris. The uppermost part of the vulva, which is a fatty cushion covered with hair. Nerve-center. A nerve station from which orders are transmitted and where orders are received. Nubile. Puberty, that period of life in which young people of both sexes are capable of procreating children. Nymphae. See Labia minora. Ovaries. Two small ovoid bodies, one on each side of the uterus, in which the ova are formed. Oviduct. See Fallopian tobe. Ovulation. The formation of the ova in the ovary, and the discharge of the same. Ovule. See Ovum. Ovum. Germ cell, a small, round vesicle situated in the ovaries, and which, when fecundated, constitutes the rudiments of the embryo. Parturition. Labor, delivery, child-birth, the expulsion of the child from the womb. Pathologic. Relating to the diseased condition of tie body. Pelvis. The bony cavity situated at the lower end of the spinal column and supported by the thighs. Periodicity. The recurrence of physiologic phenomena at regular intervals. Periphery. The circumference of an organ. Peristaltic Action. An alternate contraction, making small, and enlargement of the bowel; it is by this means that foods, etc., are forced along its passage. Peritoneum. A serous membrane which lines the abdominal cavity, and wholly or in part envelopes the organs contained in it; it also partly covers the organs contained in the pelvic cavity. Phenomena. Remarkable appearances. Physical. Pertaining to the body. Placenta. After-birth, a soft, spongy, vascular body adherent to the uterus, and which is connected with the embryo through the umbilical cord. Plethora. A condition marked by a superabundance of blood. Postpartum Hemorrhage. Hemorrhage following labor. Pregnant. Enceinte, gravid; the state of a woman who is with child. Premature Labor. The expulsion of the fetus between the end of the twenty-eighth week and the time that labor ought to have occurred. Propagation. The spreading or extension of a thing. Pruritus Vulva. An intense itching of the privates, or vulva. Psychic. Pertaining or belonging to the mind. Puberty. Sexual maturity; nubility; that period of life in which young people of both sexes are capable of procreating children. Pubes or Pubis. The lowest and middle part of the pelvis in its anterior surface. Puerperium. The lying-in after child-birth. Quickening. The sensation experienced by the mother as the result of active fetal movements in the womb. Rectum. The lower extremity of the large intestine. Reflex. The reflection of an impulse from a nerve-center which has been received from elsewhere by that center. Reproduction. See Generative. Respiration. Breathing. Rugs. Wrinkles. Rut. The copulation of animals. Septicemia, Puerperal. Childbed fever. Sexual. That which relates to sex. See Generative. Smegma. A cheesy substance which may collect about the vulva. Spermatozoa. The essential male fertilizing elements. Sympathetic Nervous System. Presides over involuntary acts; as digestion, breathing, etc. Syphilis. A venereal disease which is highly contagious by coition, contact with the lips, etc. Tachycardia. Distress in the region of the heart, with palpitation and shortness of breath. Umbilicus. Navel. Urea. The most important of the solid constituents of the urine. Ureters. The ducts leading from the kidneys to the bladder. Urethra. The excretory duct from the bladder for the escape of the urine. Urination. The act of passing water. Uterosacral Ligaments. Ligaments which pass from the uterus to the sacrum, and assist in holding the uterus in position. Uterus. Womb; the hollow, pear-shaped pelvic organ which is destined to retain the child from the moment of its conception until the time of its expulsion at birth. Utricular Glands. Glands of the uterus. Vagina. The canal which connects the female internal and external organs of generation. Vascular. Pertaining to the blood-vessels. Vasomotor Nervous System. Comprises the brain, spinal cord, and the nerves given off from the cord: this system presides over voluntary acts, that is, those acts which are under the control of the will. Vestibule. A smooth cavity that exists in the female between the perineum and the nymphae. Viscera. The contents of the large cavities of the body. Vulva. The external genitals, private parts, the female external organs of generation. Vulvitis. Inflammation of the vulva. 
7129	----	THE PROSPECTIVE MOTHER A Handbook for Women During Pregnancy by J. MORRIS SLEMONS Associate Professor of Obstetrics, The Johns Hopkins University. * * * * * PREFACE This book, written for women who have no special knowledge of medicine, aims to answer the questions which occur to them in the course of pregnancy. Directions for safeguarding their health have been given in detail, and emphasis has been placed upon such measures as may serve to prevent serious complications. Treatment of such conditions has not been discussed, as it can be judiciously carried out only by a physician who has the opportunity to observe and study the individual patient. Furthermore, if there is to be notable improvement in the management of cases of childbirth, the appearance of untoward symptoms should not be awaited before consulting a physician; on the contrary, prospective mothers must be taught that they should be under competent medical supervision throughout pregnancy. At present intelligent women demand some knowledge of the anatomical and physiological changes incident to the development of the embryo and the birth of the child. These subjects do not readily lend themselves to popular description, but I have told the story as simply as possible, following in a general way the text-book of my teacher and friend, Professor J. Whitridge Williams; indeed, my main purpose has been to reproduce his book "in words of one syllable." The use of a number of technical words has been unavoidable, and, though their meaning has been given in the context, it has not been feasible to repeat the definition every time an unfamiliar term was used. On that account a glossary has been provided. It is with pleasure that I avail myself of this opportunity to acknowledge the cheerfully given assistance of many friends. In particular I wish to thank Doctor Henry M. Hurd, until recently Superintendent of the Johns Hopkins Hospital, for his interest and advice. I am also under deep obligation to my friend John C. French, of the English Department of the Johns Hopkins University, for helpful criticism of the manuscript, and to my colleagues, Doctors Rupert Norton and Thomas R. Boggs, for valuable assistance. To many others--doctors, nurses, and patients--I am indebted for numerous suggestions which have been made either consciously or unconsciously. J. MORRIS SLEMONS. * * * * * INTRODUCTION In all branches of medicine the master word is _prophylaxis_, or prevention, and its benefits are nowhere more strikingly illustrated than in the practice of obstetrics. In former times every woman who gave birth to a child or passed through a miscarriage was exposed to grave danger of infection or child-bed fever; but at present--thanks to the recognition of the bacterial origin of the disease and of its identity with wound infection--this danger can be practically eliminated by the rigid observance of surgical cleanliness and aseptic technique. Physicians have also learned that the most effective method of coping with other serious complications of pregnancy and labor is by preventing their occurrence, or at least by subjecting them to treatment in their earliest stages; for, if they be allowed to go on to full development, the results are little better than in times past. Furthermore, a careful examination some weeks before the expected date of confinement enables us to recognize the existence of abnormal presentations and of disproportion between the size of the mother's pelvis and that of the child's head. Timely recognition of such conditions makes appropriate treatment possible and practically insures a successful outcome; while tardy recognition is frequently followed by disastrous results. These few examples give some idea of the benefits of prophylaxis in the practice of obstetrics. Prospective mothers should understand not only that there is an advantage in taking such precautions, but that they may be risking their lives, or at least their future well-being, unless they insist upon competent medical attention. It is true, of course, that pregnancy and childbirth are generally normal processes, but they are not always so. Fortunately, most of the abnormalities give timely warning of their occurrence, and in most instances may be relieved by comparatively simple measures; or, if not, they afford indications for treatment which should lead to a happy termination. The recognition of the existence of such conditions, however, is not always easy, and their ideal treatment requires careful training and sometimes the utmost nicety of judgment. Consequently, if prospective mothers wish to be assured of the best care, they should be cautious in the choice of their medical attendant. As the ordinary layman has no means of determining the real qualifications of a physician, the choice should not be made upon the advice of casual acquaintances; but, instead, the family physician should be consulted, who, should he feel unwilling to assume the responsibility of the case, will be able to recommend a thoroughly competent substitute. From my own experience as a teacher and consultant, I state without hesitation that in no other branch of medicine or surgery are graver emergencies encountered than in certain obstetrical complications whose treatment involves the greatest responsibility and requires the highest order of ability to insure a successful outcome for the mother and her child. For these reasons a physician should be chosen only after mature deliberation, and his services should be esteemed much more highly than is usually the case. In order that the principles of prevention may receive their fullest application during pregnancy, labor, and the lying-in period, it is also advisable that intelligent women should possess some knowledge of the Reproductive Process in human beings. This information is imparted by Doctor Slemons' book, which I can thoroughly recommend to prospective mothers. The subject matter has been carefully chosen, and the author has wisely refrained from giving advice with regard to treatment which can be satisfactorily directed only after careful study by a physician. At the same time he has given a clear account of the physiology of pregnancy and labor, and has laid down sound rules for the guidance of the patient. One of the most important facts emphasized by Doctor Slemons is the value of medical supervision for several weeks after the child is born; this precaution contributes greatly toward a rapid and complete convalescence. During the lying-in period the physician should supervise the care of the mother and the child, should insist upon the necessity for maternal nursing, and should keep the mother under observation until perfectly normal conditions are regained. If the latter duty is conscientiously fulfilled many years of invalidism may be saved and thousands of operations rendered unnecessary. Although there have been notable advances in the science and in the art of obstetrics since the middle of the eighteenth century, a great many fundamental facts must yet be learned. For example, we are almost totally ignorant of the stimulus which causes the mother to fall into labor approximately 280 days after the last normal menstruation. There are two points which I desire to impress especially upon the readers of this book. Firstly, that the advance of the science of obstetrics, and consequently improvements in its practice, must depend greatly upon the cooperation of intelligent women. They must come to realize that they will secure the best treatment only as they demand the highest standard of excellence from their attendants; and they can aid in securing this for their poorer sisters and their children by interesting themselves in obstetrical charities. Secondly, they must realize that real progress in the science of obstetrics can be expected to proceed only from well equipped clinics connected with strong universities, and in charge of thoroughly trained and broad-minded men. As yet such institutions scarcely exist in this country. Women who are anxious to promote the welfare of their sex can find no better way of doing so than by bringing this need to the attention of wealthy men interested in philanthropy and education. Furthermore, they should bear in mind that most of our important discoveries would not have been made had animal experimentation not been available, as it is solely by this means that modern surgical and obstetrical technique has been brought to its present degree of perfection; and further progress can scarcely be expected without its aid. They should remember also that whenever they take such a well-known drug as ergot for the control of bleeding, or make use of many other apparently simple measures, they are unconsciously rendering tribute to this type of investigation. J. WHITRIDGE WILLIAMS. Johns Hopkins University, September, 1912. * * * * * CONTENTS I. THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT II. THE DEVELOPMENT OF THE OVUM III. THE EMBRYO IV. THE FOOD REQUIREMENTS DURING PREGNANCY V. THE CARE OF THE BODY VI. GENERAL HYGIENIC MEASURES VII. THE AILMENTS OF PREGNANCY VIII. MISCARRIAGE IX. THE PREPARATIONS FOR CONFINEMENT X. THE BIRTH OF THE CHILD XI. THE LYING-IN PERIOD XII. THE NURSING MOTHER GLOSSARY * * * * * The Prospective Mother CHAPTER I THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT The Positive Signs--The Probable Signs--The Presumptive Signs: The Cessation of Menstruation; Changes in the Breasts; Morning Sickness; Disturbances in Urination--The Duration of Pregnancy--The Estimation of the Date of Confinement--Prolonged Pregnancy. Many puzzling questions occur to the woman who is about to become a mother. Most of these questions are reasonable and natural, and should be frankly answered; but a false conventionality has--until recently, at least--forbidden any open discussion of facts connected with childbirth. The inevitable result has been that, without experience of their own to guide them, prospective mothers have sought advice from older women, whose experience was at best very narrow, and whose views were often biased by tradition. Or, distrusting such sources of information, they have consulted technical medical works which they could not understand. Either of these methods is very likely to result in misinformation and to cause unnecessary anxiety. Yet no one need be alarmed by a plain, accurate account of Nature's plan to provide successive generations of human beings. Some trustworthy knowledge of a process so fundamental should be part of every person's education; it is especially helpful to women who are pregnant because it affords a rational basis for hygienic measures which they should adopt. A popular work, however, no matter how frank and helpful it may be, will not enable one to dispense with professional advice. For the prospective mother no counsel is more important than this: _Put yourself at once under the care of a physician_. Insistence on the importance of medical advice should not be taken to imply that pregnancy is to be regarded as other than a normal process. Its dangers are comparatively slight, as we should expect, since the property of all living matter to reproduce its kind is both fundamental and essential; the continuance of living creatures in this world, plants as well as animals, depends upon the Reproductive Process. And yet, natural as it is, pregnancy may be attended by complications. Such complications, though happily rare, are to be guarded against in every case, and that may be most effectually done if patients are taught to remain under competent medical supervision from the time of conception until several weeks after the child is born. This precaution greatly reduces the frequency of annoyances during pregnancy and also assists materially toward conducting a birth to a safe conclusion. Moreover, if this advice is followed, when complications do arise they will be recognized and dealt with promptly; they will not be permitted to grow more serious until, perhaps, they may jeopardize the life of the mother or the child or both. The initial symptoms of pregnancy are so widely known that in most instances the prospective mother herself makes the diagnosis shortly after conception has taken place; but now and then pregnancy advances for several months unrecognized and is then detected by a physician who has been consulted on account of symptoms which the patient has incorrectly attributed to some other condition. On the other hand, women sometimes suspect that they are pregnant when they are not; and such mistakes occur because certain symptoms which are implicitly trusted by the laity as manifestations of pregnancy are occasionally associated with conditions quite foreign to it. It is clear that one interested in the matter must know not only what the manifestations of pregnancy are and when they appear, but also how far the evidence that they give is reliable. The signs of pregnancy may be classified, according to their reliability, as presumptive, probable, and positive. The doubtful evidence appears first and the infallible proof last. No one need be surprised, therefore, if, when her suspicion is first aroused, she is unable to decide positively whether she is pregnant. Physicians of broad experience, possessed of facilities for observation which their patients cannot employ, may find it necessary to make more than one examination before they commit themselves to a definite opinion; in some cases, though very rarely, they must wait for two or three months to be able to do this. THE POSITIVE SIGNS.--The earliest absolutely trustworthy manifestation of pregnancy is the motion of the fetus. The perception by the mother of these movements, which is spoken of as "quickening," generally occurs toward the eighteenth week, if she has been told to watch for them; otherwise they may pass unnoticed until the twentieth week or later. At first the motion, felt in the lower part of the abdomen, is very gentle; it has been variously likened to tapping, or to quivering, or to the fluttering of a bird's wings. As time goes on the movements grow stronger and occur more frequently; they are, however, perceived but rarely throughout the day and seldom interfere with sleep. Occasionally women are annoyed by the sensation and complain that the child is hardly ever quiet. Even these troublesome movements are never a cause for anxiety; but prolonged failure to feel motion after it is once well established should be reported to the doctor. In the first pregnancy the passage of gas through the intestines may be mistaken for quickening long before the movements of the child are really perceptible; but those who have once experienced quickening will not be deceived. Whenever women who have borne children are in doubt the sensation is almost surely not quickening. Furthermore, in any doubtful case, the motion should be observed by a physician before being accounted a positive sign of pregnancy. This precaution will scarcely delay an absolutely positive diagnosis, since the proper method of examination reveals these movements to the physician almost as early as the patient feels them. About the time these movements become perceptible another positive sign is available. The physician whose ear has been trained to catch such sounds when he listens over the lower part of the mother's abdomen will hear the fetal heart-beat. Other sounds may be audible there, but the character and the rate of the heart-sounds are distinctive. Since the child's heart beats almost twice as fast as the mother's, under ordinary conditions it is impossible to confuse one with the other. The mother never feels the beating of the child's heart, but occasionally she will mistake for it the throbbing of her own blood vessels. Ability to hear the fetal heart not only provides a means of confirming the existence of pregnancy in doubtful cases, but also enables the physician to reassure his patient if she fails temporarily to feel the child move. Sometimes the presence of twins is recognized in this way. Toward the end of pregnancy the heart sounds are also of material assistance in determining what position the child has permanently assumed. There is a third positive sign of pregnancy to which the physician has recourse, but generally it is inapplicable as early as those already mentioned. In the latter months of pregnancy it is possible to outline the child through the mother's abdominal wall. Although this procedure adds little or nothing to our resources for making an early diagnosis, the information it ultimately affords proves one of the greatest aids in the practice of obstetrics. THE PROBABLE SIGNS.--Obviously, phenomena for which the child is responsible--such as have just been described--supply the most trustworthy evidence of pregnancy; and these phenomena alone are accepted as positive signs. But there are earlier manifestations which intimate very strongly that conception has taken place. Shortly after pregnancy has become established changes begin in the uterus, as physicians call the womb, and soon reach the point where they may be recognized by a simple examination which enables the physician to express an opinion little less than positive. As one result of pregnancy, for example, the supply of blood is increased to all the organs concerned with the reproductive process. Partly on account of this congestion and partly on account of embryonic development, the uterus becomes altered in a number of ways. Although these changes occur regularly in pregnancy, they may also occur when the womb is enlarged from other causes; therefore, if a physician should make the diagnosis of pregnancy whenever they were found, he would make it somewhat too frequently. With a little patience, however, he excludes the chance of being misled; a second examination, approximately four weeks after the first, will generally place the existence of pregnancy beyond question, for under normal conditions the degree of enlargement which takes place in a pregnant womb during a given interval is absolutely characteristic. THE PRESUMPTIVE SIGNS.--Although women are most often led to suspect that they are pregnant by symptoms which are of such doubtful significance that they must be regarded as merely presumptive evidence, the practical value of these symptoms is attested by the fact that subsequent developments rarely fail to confirm the suspicion. Perhaps they prove misleading once or twice in a hundred cases; the number of mistakes is small, because the diagnosis is commonly made not from only one of these doubtful signs but from a group of them. In order of importance the doubtful or presumptive signs of pregnancy are these: (1) cessation of menstruation, (2) changes in the breasts, (3) morning sickness, (4) disturbances in urination. _The Cessation of Menstruation_.--The failure of menstruation to appear when it is expected is nearly always the first symptom of pregnancy to attract attention, and, as a rule, when this happens to healthy women during the child-bearing period--which usually extends from the fifteenth to the forty-fifth year--it may be taken to indicate that conception has occurred. But there are exceptions to this very good rule. Besides pregnancy we are acquainted with several conditions that cause temporary suppression of menstruation; and to understand its significance we must learn something of the menstrual process itself. Menstruation is a function of the womb and in all probability is brought about through the influence of the ovaries. The bleeding, popularly regarded as the entire menstrual process, is, in fact, indicative of only one of its stages; the others give rise to no symptoms whatever. What the stages in the menstrual process are, what relation they bear to each other, and what the significance of the whole process is, are problems that have been solved with the aid of the microscope. In this way the mucous membrane lining the womb has been studied both at the time of the periods and in the interval between them, and we have learned that it is constantly undergoing changes intended to facilitate the reception and the maintenance of an embryo. Anticipating these duties the mucous membrane receives a more abundant supply of blood; it also increases in thickness and all the structures which enter into its composition become more active. Unless conception takes place these preparations, which represent the most important phase in the menstrual process, are without value; and therefore failure to conceive means that the mucous membrane will return to the same condition as existed before the preparations were begun. The congestion is relieved by rupture of the smallest blood vessels, and there follow other retrogressive steps which completely restore the various structures to their former state. Then there is a pause, though it is not long, until preparatory changes are again initiated, or, as we say, another Menstrual Cycle is begun. Each cycle lasts twenty-eight days, and includes four stages, namely, a stage of preparation, of bleeding, of restoration, and of rest. Although pregnancy may become established at any time during the interval between the periods of bleeding, it is more likely to be established just before a period is expected or shortly after it has ceased. Furthermore, whenever conception does take place, the preliminary preparations for the reception of the embryo are followed by much more elaborate arrangements for its protection and nutrition. Under these circumstances the hemorrhagic discharge does not appear. Were there no other condition to bring about the cessation of menstruation, the diagnosis of pregnancy would be greatly simplified. But any one can appreciate the fact that diseases of the womb may interfere with the menstrual process. Menstruation is influenced, also, by the ovaries. As a result of age, for example, the ovaries undergo changes which invariably bring about the permanent cessation of menstruation, called the menopause. This event occurs prematurely if both the ovaries are removed by operation. In view of these facts it is not surprising that sometimes ovarian disorders abolish menstruation. An impoverished state of the blood, or nervous shock and strain, or constitutional debility may also interrupt the regular appearance of the menstrual discharge. The value of menstrual suppression as an evidence of pregnancy is not, however, to be discounted to the extent that we might expect. This is true because the ailments which lead to confusion are relatively infrequent, and also because they exhibit characteristic symptoms which are foreign to pregnancy. Often these symptoms are obvious to the patient herself; if not to her, they will be obvious to her physician. It is about the doubtful cases, naturally, that a professional opinion is sought, and on that account physicians are perhaps inclined to overestimate the difficulty women have in learning for themselves whether or not they are pregnant. As a matter of fact, it is unusual for a prospective mother to fail to reach a correct decision--a decision for which she relies chiefly upon the suppression of her menstrual periods. It is doubtful whether menstruation ever continues after conception has taken place. Instances in which the menstrual function is believed to persist are not uncommon, and yet in all probability the discharge regarded as menstrual has a different origin. In most cases it should be interpreted as meaning that there is some danger of miscarriage. Since miscarriage often occurs about the time a menstrual period would ordinarily be expected, there is unusual opportunity for confusing the symptoms. At all events women err much more frequently in suspecting that they are pregnant than in overlooking the condition. Indeed, pregnancy is not likely to be overlooked unless menstruation has been irregular or suppressed for a month or more previous to conception. Thus, in the case of nursing mothers in whom menstruation is already suppressed and who are, moreover, deprived of certain evidence that the breasts give, pregnancy may sometimes advance several months before it is recognized. _The Changes in the Breasts_.--Various sensations in the breasts are accepted by women as a reliable sign of pregnancy; thus throbbing, tingling, pricking, or a feeling of fullness will be mentioned by one mother or another as having given her the first intimation that she was pregnant. A few women also find their breasts become tender immediately after they have conceived; this may be so marked that they cannot bear pressure. But unless such symptoms are accompanied by definite, visible changes, they have no value as signs of pregnancy. About the end of the second month the nipples become larger and more erectile, and deepen in color. The pigmented, circular area of skin which surrounds the nipple, called the areola, also darkens. The shade that the areola assumes will vary according to the complexion of the individual, growing darker in brunettes than in blondes. Ultimately, within this pigmented circle a number of elevated spots appear about the size of a large shot. These spots betray the presence of tiny glands always located there which, on account of the better state of nutrition during pregnancy, grow larger, and generally become visible. Usually, after two menstrual periods have been missed the breasts increase in size and firmness, and often the veins which run just beneath the skin stand out conspicuously. Before very long it is possible to squeeze from the breasts a fluid which many persons believe to be milk, though it is really colostrum, a substance that resembles milk but very slightly. At first colostrum is a clear, white fluid, but in the later months of pregnancy it becomes yellow and cloudy. None of the changes in the breasts are absolutely characteristic of pregnancy; even the secretion of colostrum has been noted in association with various other conditions. Furthermore, as a sign of pregnancy the presence of colostrum is totally deprived of value in the case of a woman who has recently nursed an infant, for a small quantity of milk or colostrum often remains in the breasts for months after the infant is weaned. In general, however, women who have not been pregnant before should assume that they have conceived if, after missing a menstrual period, they note the characteristic changes in the breasts. _Morning Sickness_.--Soon after conception many women suffer from nausea and vomiting, especially on rising in the morning. "Morning sickness" usually passes off in a few hours, although it may be more persistent. Perhaps this manifestation occurs more frequently in the first than in subsequent pregnancies, but certainly one-half, and probably two-thirds, of all prospective mothers suffer from it. Usually the nausea begins just after a menstrual period has been missed, and ceases about the third month or a little later. But morning sickness is never counted an indication of pregnancy unless taken in conjunction with other symptoms, for individuals who are not pregnant may also suffer from nausea in the morning. On the other hand, a number of prospective mothers escape morning sickness altogether, and a few experience nausea at other times of day. _Disturbances in Urination_.--It is not an uncommon belief that some characteristic change occurs in the urine shortly after conception. But this is not true; at least no change is revealed by any method of analysis known at present. Yet there are symptoms associated with the passage of the urine which appear very promptly and prevail for several weeks. Chief among these is the desire to empty the bladder frequently; some patients also have difficulty in urination, and a few experience discomfort with it. All the bladder symptoms gradually disappear about the fourth month, but become prominent again toward the end of pregnancy. Since the inclination to empty the bladder more often than usual may be due merely to nervousness or to many other conditions, this symptom taken alone cannot be regarded as a definite sign of pregnancy. Indeed, it is mentioned, not because of its importance, but to point out that it is in no way connected with the kidneys, as patients are sometimes led to believe. It is a direct and natural result of pregnancy. Since the womb enlarges and tilts forward at a more acute angle than formerly, it presses against the bladder, giving the same sensation as when the bladder is distended with urine. Although the presumptive signs which we have considered by no means exhaust the list, all the others are totally untrustworthy. Each of the more reliable symptoms, as we have seen, must be accepted cautiously; but taken altogether, except in very unusual cases, they may be relied upon. _If, for example, menstruation has previously been regular and then a period is missed, the patient has good reason to suspect she is pregnant; if the next period is also missed and meanwhile the breasts have enlarged, the nipples darkened, and the secretion of colostrum has begun, it is nearly certain that she is pregnant; whether morning sickness and the desire to pass the urine frequently are present is of no importance._ But the most characteristic evidence, we must remember, is not available until the eighteenth or twentieth week; then the signs of pregnancy are unmistakable. THE DURATION OF PREGNANCY.--After the existence of pregnancy has become assured, perhaps the greatest interest centers about the date upon which the birth may be expected. Even to approach accuracy in this prediction the prospective mother must be familiar with certain facts which she will always observe, but which, unless she appreciates their importance early in pregnancy, she may fail to record or to remember. In a few cases, however, such exceptional information as knowing the date of conception does not lead to an absolutely accurate prediction. But the deviation from the rule will be understood only after we understand the rule itself, which is based upon what we accept as the average duration of human pregnancy, technically called the period of gestation. In a broad sense, the period of gestation for each variety of mammal is determined by the time required for embryonic development to reach the point where the young may live independently of the mother. This point is reached more quickly with small animals than with large. The mouse, for example, generally brings forth its young in three weeks, whereas the pregnancy of the elephant lasts two years. In human beings, counting from the time of conception to the time of delivery, pregnancy continues approximately 273 days. This number is merely an estimate calculated from hundreds of cases in which there was no question as to the underlying facts. Individual cases vary notably, and indicate that two women may become pregnant on the same day and yet not necessarily be delivered at the same date. Irregularities in the duration of pregnancy are not limited to man. Thus, while the mean period of gestation in the rabbit is thirty-one days, it may be either shorter or longer by as many as eight days. Similar variations occur in the pregnancies of all animals, and are, moreover, notably greater among larger animals, since for such animals the period of gestation is relatively long. For instance, the accurate observations of veterinarians indicate that the mean period of pregnancy in the cow is 285 days from the time of conception. This fact notwithstanding, a competent observer found that, of 160 cows, 67 were delivered before the 280th day; 68 between the 280th and the 290th day; and 25 after the 290th day. Although nothing unnatural was observed in any instance, the first animal was delivered 67 days before the last, and in 5 instances gestation continued 308 days. In ancient times it was believed that the duration of pregnancy was of even more uncertain length in man than in the lower animals; but since the eighteenth century thirty-nine weeks have been accepted as the average duration of the human pregnancy when reckoned from the day of conception. As this date is seldom known, it is most convenient to reckon from the first day of the last menstrual period. Estimated in this way its average duration is 280 days. As this period corresponds to ten menstrual cycles, physicians prefer to describe pregnancy as lasting 10 lunar months of four weeks each. This is equivalent to 9 calendar months, in terms of which its duration is popularly stated. THE ESTIMATION OF THE DATE OF CONFINEMENT.--Since pregnancy is not an absolutely fixed period, we possess no reliable means of predicting the exact day when it will end. The most satisfactory method of prediction consists in counting forward 280 days from the beginning of the last menstruation or, what gives the same result, counting backward eighty-five days from this date. _To make the calculation in the simplest way we count back three months and add seven days_; this addition is made because seven days generally represents the difference between three months and eighty-five days. If the last menstruation, for example, began on October 30th, we count back three months to July 30th and add seven days, which gives August 6th as the probable date of confinement. A prospective mother should remember that this prediction is no more than approximate. The calculation does not give the exact date of delivery more than four or five times in a hundred cases. It is accurate within a week in half the cases and within two weeks in four-fifths. We also know that delivery is somewhat more likely to occur after the expected date than before it. But perhaps we shall get the clearest idea of the accuracy of the rule, or better still of its inaccuracy, if we imagine twenty patients to have the same predicted date, all of them giving birth to mature infants. The chances are that only one of these patients will be confined upon the day predicted; nine will be confined before and ten after it. In all probability five of those who pass the predicted day will be delivered within a week and four others within the second week, while the twentieth patient will not be delivered until three weeks or more have elapsed. Such results clearly indicate our inability to make accurate predictions even though pregnancy is normal in every way. Whenever patients pass their expected date uneventfully, if they will bear in mind that the fault lies with the method of prediction and not with the pregnancy, they will often be saved anxiety. Frequently such discrepancies are attributable to a false assumption, for our rule always assumes that the conception took place immediately after a menstrual period. While this is generally true, the number of cases in which it occurs just before the period to be missed is by no means inconsiderable, and in these we should not expect pregnancy to end until two or three weeks after the day predicted by the rule. Occasionally patients know the precise day upon which conception took place, and prefer to estimate the day of confinement from that rather than from the beginning of the last menstruation. They may do so by counting back thirteen weeks from the day of conception; but this method also is subject to error for, as we have noted, the duration of pregnancy reckoned in this more exact manner is not constant. Such a calculation rarely offers any advantage over that made from the menstrual record. Another method of estimating the date of confinement is based upon the assumption that fetal movements are first perceived by the mother toward the eighteenth week of pregnancy; and in consequence twenty- two weeks generally elapse between quickening and the day of delivery. Although such a calculation is far from certain in its prediction, there are instances in which no other calculation can be made. A nursing mother, for example, may become pregnant before menstruation has been reestablished. Under these circumstances, obviously, the date of confinement cannot be estimated in the ordinary way, and it is then especially important to know the first day on which the fetal movements were felt. Furthermore, it is helpful to note this date in every case, since it serves, if for nothing more, to confirm the prediction made from the menstrual record. Besides the two methods just described, which are alike in that they require the patient herself to make the necessary observations, there is a third method of estimating how far pregnancy has advanced, by which the physician is enabled to draw his own conclusions. This method is based upon the fact that the womb enlarges from month to month during pregnancy at a constant rate. Up to the end of the third lunar month it cannot be felt through the abdominal wall; but in the course of the fourth month, on account of its size, it must rise into the abdominal cavity. At the beginning of the sixth month the top of the womb is at the level of the navel, and at the ninth reaches the ribs. The diaphragm then prevents the womb from going higher; and two or three weeks before the end of pregnancy it drops several inches, causing a change in the figure which is noticeable to the patient, since her skirts hang somewhat lower than before. From this time on she is more comfortable, because the lungs are not crowded, and there is less interference with breathing. These alterations in the position of the womb indicate very satisfactorily the month to which pregnancy has advanced, but not the week and much less the day. They do not afford a more accurate means of predicting the date of confinement than does quickening. The evidence gained from the position of the womb, like that afforded by the beginning of quickening, generally confirms the prediction made from the menstrual history; it serves only occasionally to correct it. PROLONGED PREGNANCY.--Since birth does not occur in many cases until the predicted date has been passed, it will be helpful even at the cost of repetition to sum up what we know in explanation of such unfulfilled predictions. They are to be explained sometimes by uncertainty as to the beginning of pregnancy, as for example by the supposition that conception took place shortly after the last menstrual period, whereas it actually occurred two or three weeks later. In a few instances, however, errors of observation or of calculation will not account for false predictions. It is generally admitted that second pregnancies average somewhat longer than first pregnancies; one series of statistics indicates that the duration increases slightly with each pregnancy up to the ninth and decreases after that. Pregnancy is protracted more frequently in healthy women than in those who are not, and again more frequently in those who are inactive than in those who work. With twins, contrary to the popular belief, pregnancy is apt to end before, not after, the expected date. The sex of the child, in all probability, has no influence upon the duration of pregnancy. As we might expect, individuality is also a factor in this problem. Thus, the period of gestation with some women is regularly longer, with others habitually shorter than the accepted average. Until experience has demonstrated their existence, generally, such peculiarities are overlooked. But occasionally they may be detected from knowledge of the interval between the menstrual periods; an unusually long interval between them, for example, would lead us to anticipate a protracted pregnancy. Any delay after the expected date of birth has arrived taxes the patience of the prospective mother. The fact, however, that more than 280 days have passed since the last menstruation, does not necessarily mean that a patient has gone "over time." Such a question can be decided solely from the weight and length of the child. Judged in this way, comprehensive statistics indicate that once in several hundred cases pregnancy may be fairly called prolonged. Even in these rare instances an examination about the time of the predicted date makes it clear whether pregnancy should be artificially ended or be allowed to proceed to its natural conclusion. CHAPTER II THE DEVELOPMENT OF THE OVUM The Germinal Cells--Fertilization--The First Steps in Development-- The Reaction of the Uterus--The Amniotic Fluid--The Placenta--The Umbilical Cord. Pregnancy, besides changing the external form of the body, causes sensations--as for example those due to fetal movements--which are so distinctive that they cannot escape notice. These obvious evidences of approaching motherhood naturally lead thoughtful women to wonder about the hidden mechanism of development, a mechanism which, of itself, causes no sensation whatever. It is for this reason, perhaps, that a prospective mother's imagination is so apt to be unusually active, often picturing absurd conditions as responsible for one symptom or another. Those who give free play to the imagination in regard to the formation and progress of the embryo are pretty certain to arrive at erroneous if not grotesque conclusions; for example, they may attribute a protracted pregnancy to the child's having grown fast to the mother, a situation that cannot arise. Of course it is not essential that a prospective mother should understand what is happening within the womb. And upon those who prefer to be ignorant of the mechanism of development I would not urge another point of view, for not ignorance but the unchallenged acceptance of "half-truths" and of totally incorrect explanations is the chief source of harm. On the other hand, my own experience has taught me that women who wish to know about development should be told the truth. In accord with this is the fact that I never have more satisfactory patients than those who have previously been trained nurses and who, in preparing for that profession, received instruction concerning the reproductive function of human beings. A description of development, in order to be perfectly clear, must begin with a word about the fundamental structure of the adult body. Everyone knows that the various parts of the body perform different functions; but not everyone, perhaps, realizes that, in spite of their different functions, all the organs of the body are composed of similar structural units, known as cells. Of course, cells are definitely arranged according to the use for which the tissue that they chance to compose may be designed; they have, moreover, distinctive individual peculiarities which can be easily recognized under the microscope; but the essential features of the cells remain the same, wherever they may be located. That is to say, each cell is a minute portion of living matter, or protoplasm, separated from its neighbors by a partition, the cell-membrane; each has its own seat of government, the nucleus, located near its center; and each, to all intents and purposes, leads an individual existence. THE GERMINAL CELLS.--Many of the cells in the human body are able to produce others of their kind. This they do virtually by growing and splitting in half; cell-division, as this splitting is called, really represents reproduction reduced to the simplest terms. Most cells can do no more than produce units like themselves. The bodies of women contain, however, a type of cell which possesses a far more wonderful power. Provided the requisite conditions for such development are met, these cells are capable of developing into human beings. Each of these remarkable units is called an Ovum, or egg-cell, and represents one variety of the germinal cells. But the other variety, represented by the Spermatozoon and developed only in the male sex, is also required for the production of a human being. Every ovum originates in the ovaries. These are organs peculiar to women, having the size and shape of large almonds, and placed in the lower part of the abdominal cavity. Though the ovaries are two in number, one alone is sufficient for every requirement of health. It has been estimated that the ovaries together contain at the time of birth about 40,000 ova, distributed equally between them. Since less than 500 ova are required to insure regularity in the menstrual function, it is clear that, if the surgeon finds it necessary to remove one of the ovaries, the other will provide abundantly for menstruation and for the bearing of children. Although every ovum that will be produced as long as a woman lives has already sprung into existence by the time she is born, not a single one ripens for from twelve to fifteen years. The ripening process begins about the time of puberty, and, unless suspended through the occurrence of pregnancy, continues until the menopause. During this period, which is also characterized by the periodical appearance of menstruation, one ovum ripens each month; sometimes, though rarely, several ripen at once, and this tendency is partly responsible for twins. The human ovum is a tiny structure, measuring about 1/125 of an inch in diameter. With the naked eye it can barely be seen; magnified by the microscope it appears as a little round bag made of a transparent membrane. Briefly described, the ovum is a single cell. That is, it belongs to the simplest class of anatomical structures, and is one of the millions upon millions of units that make up the body. It contains a nucleus surrounded by nutritive material, the yolk. Yet the quantity of yolk is exceedingly small. In this particular the human ovum differs notably from the egg of birds, as it does also in that it lacks a shell. Obviously, a shell would not only be useless to an embryo developing within the body of its parent, but would shut off the nourishment, which, since the ovum contains so little, must necessarily be provided by the mother. When the ovum has ripened, it becomes detached from the ovary, and enters a fleshy tube about the size of a lead pencil, known as the oviduct. There are two of these tubes, one running from the neighborhood of each ovary; both enter the uterus, but on opposite sides. The ovum travels down the tube which corresponds to the ovary where it originated. The journey is fraught with momentous consequences, for it is during this passage through the oviduct that the fate of the ovum is determined. If it is to develop into a living creature, a great many conditions must sooner or later be fulfilled; but there is one which must be promptly satisfied. Shortly after leaving the ovary the ovum must receive the stimulus to live and grow; otherwise it will quickly wither and die. This vital stimulus can be imparted only by the spermatozoon. The male germinal cell is like the female cell in the possession of a nucleus; in other respects it is very different. Longer but much narrower than the ovum, the tiny arrow-shaped spermatozoon is particularly distinguished by its active motility, for it has a tail that propels it. The human male cell must travel some distance to reach the point where it can meet a ripe and vigorous ovum; and since the journey is not without danger to its life, Nature has provided that exceedingly large numbers of the male cells shall be deposited in the vagina at the time of the marital relation. In this way, it is made sure that some of them will travel up through the uterus and oviducts, arriving in the neighborhood of the ovaries. FERTILIZATION.--Convincing observations upon the lower forms of life, especially upon fishes, have shown that when the germinal cells come near to each other, the ovum attracts the spermatozoon. The power of attraction which the ovum exerts may be likened, most simply, to the influence of a magnet upon iron-filings. While there has been no opportunity to observe such attraction between the parent cells of human beings, its existence is not open to doubt. And it is practically certain that these cells meet in the oviduct, even in that portion of it which receives the ovum just as it leaves the ovary. Thither a number of the male cells have traveled by their own activity; several come in contact with the ovum and one, but only one, actually enters it. Almost at the moment when they touch, the two cells unite so intimately that all trace of the spermatozoon is lost. Fertilization of the ovum, as this event is scientifically termed, has as its main purpose the uniting of the nucleus of a male germinal cell with the nucleus of the female germinal cell. This detail has been carefully studied; we know that the nuclei quickly blend into one, and that the particles of living matter contributed by the male animate the female cell with a new and wonderful activity. In our every-day way of speaking, fertilization means conception; it is the instant in which a living being begins its existence. There is no longer the slightest excuse for confusion regarding the period at which the life of the unborn child begins. Before the significance of fertilization was understood, it was perhaps not unreasonable to believe that life began with quickening or about the time the fetal heart-sounds could be heard. But now we must acknowledge that both these ideas were incorrect. The animation of the ovum at the moment of conception marks the beginning of growth and development which constitutes its right to be considered as a human being. Individuality, hereditary traits, sex--all these, we may be sure--are unalterably determined from the moment of conception. The germinal cell forms the total contribution of the male parent to pregnancy; therefore no other opportunity for him to influence his progeny presents itself, and the substance which enters the ovum at the time of fertilization must be the basis of inheritance from the father. It is equally true, as we shall see in the next chapter, that the nucleus of the ovum and the nucleus alone transmits maternal qualities. The material which conveys inheritable characters can be seen and has been identified in both germinal cells; from each of them the fertilized ovum derives equal amounts. As the parental nuclei unite, the material which they contain intermingles and establishes a new being; to attain full development, it requires nothing further from the father, and nothing save nourishment from the mother. THE FIRST STEPS IN DEVELOPMENT.--Although the identity of the spermatozoon is lost at the moment of fertilization, its influence just then begins to be asserted. In the fertilized ovum the dawn of development is shown at first by unusual activity within and later by alterations upon the surface. Before very long the circumference of the cell becomes indented as if a knife had been drawn around it, and shortly two cells appear in place of one. These two cells in turn divide, yielding four cells which grow and divide into eight. In this manner division follows division until a multitude of cells have sprung into existence, all of which cling together in the shape of a ball. Development always proceeds in the same orderly way; evidently it is governed by fixed laws which decree that the mass shall remain for a while in the form of a ball, though the ball, at first solid, soon becomes hollow. While these changes are taking place the growing ovum is carried down the oviduct a distance of four to six inches and finally comes to rest in the uterus, where it is to dwell during the months necessary to its complete development. The time consumed by this journey cannot be measured accurately; it may be as short as a few hours or as long as several days, but in all probability it is never longer than a week. Although the element of time is uncertain the method of transmission is well understood. Of its own accord the ovum can move after fertilization no better than before; it is never capable of moving itself. The active agent of transportation is the oviduct, which has been fitted for this purpose with millions of short, hair- like structures that project into its interior. These are closely set upon the inner surface of the oviduct; their outer ends are free and continually sway to and fro like a wheat field on a windy day; and by their motion they create a current in the direction in which the ovum should move, namely, toward the uterus. While passing through the oviduct, the ovum has no attachment whatever to the mother, yet development is going on all the time. It is thus made perfectly clear that development is not directed by the parent. This independence of the parent, though it continues to be one of the characteristic features of the development of the ovum, shortly becomes less evident, for communication is set up between the mother and the ovum as soon as it reaches the uterus. Unless we were warned, we might easily misinterpret the significance of this attachment to the parent. It does not permit the mother, for instance, to influence the mind or character which the child will have. The purpose of the attachment is twofold, namely, to anchor the ovum, and to arrange channels by which, on the one hand, nutriment may reach the embryo, and, on the other, its waste products may return to the mother. The mother may influence the nutrition of the fetus; but she cannot determine the kind of brain or liver her child will have; neither for that matter can she alter the development of any portion of the embryo. After its entrance into the cavity of the uterus prepared to receive and protect it, the mass of cells sinks into the soft, velvety lining of the organ. Here it is entirely surrounded by tissue which belongs to the mother. But just before implantation takes place the architecture of the ovum is modified in such a way as to indicate the trend of its subsequent development. We left it, a hollow ball passing down the oviduct; had we examined the sphere more closely we should have found its wall composed of a single layer of cells. At one spot, however, the wall soon thickens. The thickening is due to a specialized group of cells which gradually grows toward the hollow center of the ball. A little later, if we study the structure as a whole, we find it a small, distended sac, from the inner surface of which hangs a tiny clump of tissue. The clump of cells within and the inclosing sac as well are both requisite to the ultimate object of pregnancy; yet they fulfill very different purposes. The clump within will mold itself into the embryo; the inclosing sac will make possible the continued existence and growth of the embryo by securing and conveying to it nourishment according to its needs. These two structures, which from now on constitute the ovum, can best be considered separately and in the order of their development. We shall therefore first study the sac and in the next chapter the embryo. For a time after this sac, or ball, as you may choose to think of it, becomes implanted in the uterus, every part of its wall shares in the responsibility of procuring nourishment for the embryo. On this account the wall, or capsule, is for several weeks the most conspicuous part of the ovum. Its position is naturally advantageous, for, since it forms the outermost region of the structure and comes into immediate contact with the tissues of the mother, it has the first opportunity to seize and appropriate nutriment. Consequently, while there is still relatively little development in the embryo, the capsule of the ovum gives evidence of rapid extension; the wall becomes thicker, and the circumference of the sac increases. The significant thing about this growth, however, is the fact that it does not progress evenly. At some points cell-division is more active than at others, with the result that the surface of the ovum speedily loses its smooth, regular outline. Projections from the capsule appear; they increase in number and in length; and by the end of four weeks the ovum, as yet less than an inch in diameter, resembles a miniature chestnut-burr. To make the comparison more accurate, we must imagine such a burr covered with limp threads instead of rigid spines. These projections, the so-called Villi, push their way into the mucous membrane of the uterus and serve a two-fold purpose. One of their functions is to fix the ovum in its new abode; and, though the attachment is not at first very secure, it becomes stronger in the course of time and is capable of withstanding whatever tendency the activity of daily life may have to loosen it. The other, and equally important, task of the villi, the majority of which dip into the mother's blood, is to transmit substances to and from the embryo. We have traced thus far the earliest steps in the development of the ovum. One portion, we observed, was promptly set apart for the construction of the future child; this favored portion became inclosed by all the rest of the ovum, which has a more or less spherical form and is technically called the fetal sac. The first duty of the sac is to take root in the womb, and the second, no less vital, is to draw nourishment from the mother. But neither of these functions can be performed without the participation of the uterine mucous membrane, the soil, as it were, in which the ovum is planted. We must now learn how the maternal tissues assume the responsibility placed upon them. THE REACTION OF THE UTERUS.--The womb, which is small before marriage, is converted by pregnancy into the largest organ of the body. The virginal uterus, shaped somewhat like a pear, and placed with apex downward, is carefully protected within the bony basin between the hips, which is commonly called the Pelvis. The upper and larger part of the organ, known as the body, lies at the bottom of the abdominal cavity; the lower part, the neck, projects into the vagina. The cavity inside the womb communicates above with the two oviducts and terminates below in a canal which runs through the neck and opens into the vagina by an orifice known as the mouth of the womb. Pregnancy modifies every portion of the womb in one way or another; but the most profound alterations occur in the body, in the cavity of which the ovum has come to rest. During the forty weeks of gestation the organ grows in weight from two ounces to as many pounds; from three inches in length it increases to fifteen inches; and its capacity is multiplied 500 times. The mucous membrane which lines the cavity of the uterus responds to the stimulus of pregnancy in a characteristic manner and with a single purpose, namely, to promote the development of the ovum. In connection with menstruation we noted that this membrane periodically prepares for the reception of an ovum. And if the expected ovum has been fertilized, its arrival is followed by arrangements for its protection and nutrition which are far more elaborate than the preparations for its reception. Within a few weeks the mucous membrane becomes half an inch thick, that is, about ten times thicker than it was; and all the elements entering into its composition, become unusually active. The blood-vessels are congested; the glands pour out a more elaborate secretion; and certain cells lay up a bountiful store of material to be drawn upon in the formation of the embryo and the building up of the structures that promote its development. The ovum is as likely to find a resting place at one spot as another upon the surface of the uterine mucous membrane. The whole of that surface has been made ready to receive it; yet the area actually required to imbed the tiny object is extremely small. As the ovum escapes from the oviduct and enters the womb, it is smaller, in all probability, than the head of a pin. For at least a week after its coming, diligent search is necessary to find the site of implantation. Insignificant as it is at first, however, the region of implantation later becomes very prominent, for it undergoes a transformation that the rest of the mucous membrane does not share. That is to say, it becomes the point of attachment of the Placenta, an organ that has the very important function of drawing upon the resources of the mother's blood. As the ovum sinks into this especially prepared bed, the villi are formed. They break open the adjacent capillaries of the mother, thus diverting her blood from its accustomed course. The blood collects in microscopic lakes in contact with the capsule of the ovum, and from them flows back into the mother's veins. Through the veins it returns to her heart, by which it is distributed through the arteries to the various regions of the body. The tiny lakes, in which the villi hang, are thus made a part of the mother's circulation and as such are regularly replenished with purified blood. By this means the ovum receives a rich supply of nutriment, and as a natural consequence its growth is rapid. Before very long the diameter of the ovum is greater than the depth of the mucous membrane which surrounds it. Consequently that part of the membrane which covers it is pushed into the uterine cavity, as the ground is raised by a sprouting seed. Growth continues, the bulging increases, and extensive alterations are wrought both in the womb and in the capsule of the ovum. One of these alterations will be more easily understood if we still think of the ovum as a seed, for it grows away from its roots just as plants do. Most of the capsule, therefore, is removed step by step farther from its source of nourishment, for the maternal blood-vessels do not follow the expanding sac but retain their original position at its base. Partly on account of the lack of nutriment thus occasioned and partly on account of the distention caused by the contents of the sac, atrophy occurs in the distant portions of the sac's wall. As a final result of these two factors, the maternal tissue which covers the ovum becomes thinned and stretched; it is pushed entirely across the uterine cavity; and by about the twentieth week meets the opposite side of the cavity, to which it becomes adherent. Subsequently, the sac which incloses the embryo becomes everywhere fastened to the inner surface of the uterus and completely fills the uterine cavity. THE AMNIOTIC FLUID.--The great enlargement of the uterus which is so marked a characteristic of the latter part of pregnancy is due in a measure to the luxuriant blood-supply, for better nutrition always causes growth. In a far larger measure, however, it is due to distention for which the product of conception is responsible. Beside the fetus the inclosing sac also contains a considerable quantity of fluid. This fluid, called "The Waters" by those who have no special knowledge of anatomy, is technically designated as the Amniotic Fluid. In the earlier months of pregnancy the amniotic fluid is not abundant; later it increases rapidly, so that by the end of the period it measures about a quart, and frequently even more. The slightly yellow amniotic fluid is itself clear, but small particles of dead skin and other material cast off from the surface of the child's body are floating in it, and may cause turbidity. The absence of odor supports the view that this fluid is not the child's urine. The evidence thus far adduced, though not absolutely conclusive, gives good reason to believe that "the waters" are secreted by the inner side of the sac which incloses the fetus. Very early in pregnancy this sac becomes a double-walled structure; and, though its layers are intimately blended, and together measure not more than 1/16 of an inch in thickness, with a little care they can be separated. The outer layer, which comes in contact with the inner surface of the uterus and has to do with the matter of nutrition, is called the Chorionic Membrane; the inner, the so-called Amniotic Membrane, is much the stronger and is devoted to the protection of the embryo, which it completely surrounds with fluid, at the same time retaining the fluid within set bounds. The amniotic fluid performs many important duties. Perhaps the first, in point of time, is to provide sufficient room for the embryo to grow in. Later, as the fluid increases, it permits the fetus to move freely, and yet renders the movements less noticeable to the mother. Again, the amniotic fluid prevents injuries that might otherwise befall the child in case the mother wears her clothing too tight. Harmful as the practice of tight-lacing during pregnancy is, it does not, thanks to the presence of the amniotic fluid, result in the disfigurement of the child. For the same reason a blow struck upon the abdomen, as in a fall forward, is not so serious as might be thought, since the fluid, not the child, receives the force of the impact. Some physicians believe that the fetus swallows the amniotic fluid and thus secures nourishment. The fluid also serves to keep the fetus warm; or, to be more exact, protects it from sudden changes in the temperature of the mother's environment. Normally the temperature of the fetus is thus kept nearly one degree higher than the temperature of the parent. Ultimately, the amniotic fluid assists in dilating the mouth of the womb, which remains closed until the beginning of the process that terminates with birth. The uterine contractions at the onset of labor compress the fluid; in turn the fluid attempts to escape but is held in check by the amniotic membrane, which it drives into the canal leading from the uterine cavity to the vagina. Acting like a wedge, the fluid gradually pushes the mouth of the womb wider and wider open, until it is large enough for the child to pass. The sac usually ruptures when that point is reached, the fluid escapes, and in due time the child is born. This is followed within half an hour by the extrusion of a mass of tissue--in reality the collapsed fetal sac-- which in every language, so far as I know, is named the After-Birth. An examination of this tissue at the time of delivery repays the physician, for it is important to ascertain that none of it has been left in the uterus. Our interest at present, however, is to learn how the after-birth has assisted toward the growth of the child. THE PLACENTA.--The after-birth has puzzled scientists as well as the laity, and not until comparatively recent times have its origin, structure, and use been satisfactorily explained. Its meaning profoundly interested primitive men and stimulated their imagination scarcely less than the mystery of conception. Some uncivilized tribes believed that the after-birth was animated like the child; consequently they spoke of it as "the other half," and often saved it to give to the child in case of sickness. But generally the after- birth was buried with religious ceremony, and was occasionally unearthed later to discover whether the woman would have other children; the prophecy was made according to the manner of disintegration or some other equally absurd circumstance. The after-birth consists of a round, fleshy cake, the placenta, to which two very essential structures are attached. One of these, running from one surface of the cake, is a rope-like appendage, the umbilical cord, which links the placenta with the fetus. The other, attached to the circular edge of the cake, is a thin veil of tissue, in some part of which a rent will be found. Now, if we lift the margin of the rent, we shall see that the veil and the cake together form a sac which we are holding by the opening. This aperture through which the fetus passed, and it was really made for that purpose, was formerly placed over the mouth of the womb; the sac itself, distended by the fetus and the amniotic fluid, was fastened everywhere to the inner surface of the womb. It is plain that we have now in our hands the fetal sac, the development of which we have already traced from the beginning. The wall of the sac, it will be recalled, was originally of the same formation throughout; but when the ovum became imbedded in the womb, that part of its capsule which remained in permanent contact with the mother's blood underwent special development, whereas the rest of the capsule gradually pushed away from its primary position and, becoming stunted in its growth, even lost to some degree the development it had attained. This latter portion, the veil that passes from the edge of the placenta, is formed of the two membranes we have mentioned, namely, the chorion and the amnion. The placenta is, for the most part, a highly developed portion of the chorionic membrane, which became specialized simply because it happened to receive the best supply of blood. At the time of birth the placenta measures nearly an inch in thickness, is as large around as a breakfast-plate, and generally weighs a pound and a quarter, that is, approximately one-sixth of the weight of the child. This relation between the weight of the placenta and of the child is regularly maintained; therefore, the larger the child the larger the placenta associated with it. The placenta has two surfaces, easily distinguished from each other. The raw maternal surface was formerly attached to the inside of the uterus; the fetal surface, covered by the amniotic membrane, was in contact with the amniotic fluid. Across the fetal surface run a number of blood-vessels containing the child's blood, converging toward a central point at which the umbilical cord is inserted. The point at which the cord is attached affords the simplest means of distinguishing the two surfaces of the placenta. Our knowledge as to how the exchange of food and excretory products between mother and child is carried on by the placenta has been gained chiefly through the microscope. The oldest medical writings, as we might suppose, express very fanciful ideas regarding the nature of embryonic development and the means by which it is made possible; no rational view of these matters could exist until the circulation of the blood was described by William Harvey in 1628. After this epoch-making revelation, it was accepted as true that the mother's blood entered the unborn child and returned to her own system. But that view eventually became untenable, for it was proved conclusively that there is no communicating channel between the two. For years after that, it was believed that before birth the womb manufactured milk to sustain the child, just as the breasts do afterwards; but this theory also was disproved; and, as I have said, only by the use of the microscope have we learned the truth about fetal nutrition. When thin slices of the placenta are magnified they are found to contain countless numbers of tiny, finger-like processes; these are the villi, and they constitute the major portion of the organ. The villi seen in a mature placenta are the same as those which projected from the capsule of the young ovum, but not these alone, for many branches have sprouted from the original projections. The primary trunks with all their branches hang from the capsule of the ovum and extract nutriment from the mother's blood which surrounds them, just as the roots of a tree extract it from the soil. The interchange of material between mother and child as carried on in the placenta can, perhaps, be made clearer if we compare one of the trunks and its branching villi to a human forearm, hand, and fingers. The hand, we will imagine, is held in a basin of water, in which, by turning on a spigot and leaving the outflow unstopped, we have arranged that the water changes constantly. In terms of this illustration, the water corresponds to the mother's blood, rich in oxygen, mineral matter, and all other kinds of essential nutriment; and the fingers are the villi. The blood-vessels in the fingers, to go a step farther, represent the blood-vessels which exist within the villi, connecting with the umbilical cord, and passing by that route to the body of the child. The blood which thus circulates through the villi, it is important to emphasize, is the child's blood; it cannot escape through the coating of the villi, just as our blood cannot escape through the skin of the fingers. Similarly, the mother's blood cannot enter the child; the two circulations are absolutely separate and distinct. It must be noticed, moreover, that the maternal blood not only brings to the surface of the villi everything the child needs, but it also takes away the waste products of fetal life. Let us select one of the foodstuffs necessary for the unborn child, and follow its course so far as it relates to fetal nutrition. The mother's blood brings sugar, for example, from her intestinal tract to the surface of the villi; through the coating of the villi the sugar passes into the fetal blood, is carried to the fetal heart, and distributed to the various fetal organs. They burn it, deriving heat and energy, and in return give off waste products, namely, carbonic acid gas and water, which are taken up by the fetal blood, borne back to the placenta, and pass again through the coating of the villi into the mother's circulation. These waste products are then transported to the mother's lungs and to her kidneys, and are finally thrown off from her body. Before the child is born, therefore, the placenta, which is an aggregation of villi, acts as its stomach, intestines, lungs, and kidneys. In every pregnancy the placenta serves in this way as an organ of nutrition, arranging for the passage of food from the mother's blood to the fetal circulation. Occasionally, it is interesting to observe, the placenta performs a very different function, namely, the protection of the unborn child from diseases that may attack the mother. It is able to afford such protection, because the coating of the villi is not permeable to all sorts of substances. In order to pass through their walls, material must be in solution; solid bodies, therefore, are denied admission to the fetal circulation. The most significant result of this restriction is, perhaps, that so long as the coating of the villi remains intact and healthful, bacteria cannot gain access to the unborn child. Since in health there are no bacteria in the mother's blood, this fact has no bearing upon the average pregnancy; but in those exceptional cases in which typhoid fever or some other infectious disease appears during pregnancy, it is gratifying to know that Nature has provided an unusual defense against infection of the unborn child. That we do not know all about the interchange of substances between mother and child must be admitted; but the essential facts, and they alone are of interest here, have been established beyond contention. There is no doubt whatever that the mother's blood surrounds the placental villi but never enters the child. The fetal blood, on the other hand, is first in the child's body, then in the villi, and then returns to the child again. It never enters the blood-vessels of the mother but passes to and from the placenta as long as pregnancy lasts. THE UMBILICAL CORD.--This rope-like structure, familiarly known as the navel-string, which connects the placenta and the fetus, is approximately twenty inches long; its length, therefore, is sufficient to permit the newly born child to lie between the mother's knees while the placenta remains attached to the womb. The cord is about the thickness of the thumb and contains three blood-vessels, all filled with fetal blood; in two of them the current is directed toward the placenta, the third carries the blood back to the fetus after it has circulated through the placental villi. In the cord the vessels lie near together and are encased in a jelly-like substance that protects them from injury. So far as is known; the umbilical cord performs no service other than to link the blood-vessels in the placenta with those in the fetus. Simple as this may seem, it is of paramount importance in maintaining the life of the fetus, for compression of the vessels in the cord would shut off its nutriment. Against such accident, however, perfect provisions have been made; both the amniotic fluid and the jelly-like substance which surrounds the vessels are safeguards which effectually protect the circulation from pressure that might interrupt it. Frequently, prospective mothers are told they must not "reach up" for fear the cord will become entangled. Such a precaution is quite unnecessary. No matter what the mother does, or does not, the cord will be found around the child's neck at the time of birth in one of every three cases. It is not difficult to understand how this happens. The cord is longer than the uterine cavity and must fall in coils toward the bottom of it. Now, since the fetus is free to move it enters and withdraws from these loops, many times, in the course of pregnancy. Finally, when it takes up a position head downward, as it nearly always does, the head is the part of the fetus which passes through the coil, should one happen to lie in its path. After the head is delivered the physician always feels about the neck to discover whether a loop of cord is there. If it is, he can release it easily. This condition, since it occurs so frequently and since it so rarely produces harmful consequences, should not be considered unnatural. After the child is born, the physician cuts the cord, and in due time the after-birth is expelled through the same passage as was the child. The expulsion of the after-birth frees the mother of all the tissue derived from the growth of the ovum, for the intricate mechanism that served to nourish and protect the embryo was almost entirely developed from the ovum itself. It is a remarkable provision of Nature that very little of the mother's tissue is cast off at the end of pregnancy; and even this small portion is promptly replaced. By about the sixth week after delivery, the wound which was made by the separation of the fetal sac has completely healed. Meanwhile the mucous membrane that underwent elaborate preparations to receive the ovum, the cavity that was adjusted to its growth, and the muscle fibers that were strengthened to insure its safe entry into the world have all regained their original state. Except for the activity of the breasts, the mother is left in the same physical condition as before she became pregnant. CHAPTER III THE EMBRYO The Development of Form--The Determination of Sex--Twins--The Rate of Growth--The Newborn Infant--Heredity--Maternal Impressions. The new human being begins existence, as I have shown, as soon as the ovum is fertilized, though at that moment it consists merely of a solitary cell formed by the union of the two parental cells. From a beginning relatively simple the human body develops into the most complex of living structures; and, startling as it may appear to be, it is demonstrably true that every one of the millions of cells which compose an adult has descended from the ovum. Furthermore, the individual himself is not the entire progeny of the ovum; the placenta and the membranes dealt with in the preceding chapter, we saw, were also derived from that same source. They possess only a transitory importance, to be sure, and to most persons they are less interesting than the embryo, yet we gave them consideration before discussing its growth because the manner in which the ovum becomes attached to the womb and draws nutriment from the mother primarily determines the fate of a pregnancy. Now that we have become familiar with the arrangements for the protection of the embryo, we are prepared to learn how it develops, and may accept the phrase, embryonic development, to cover the whole period of existence within the womb. In a more technical sense, however, the use of the term _embryo_ is limited to the first six weeks of pregnancy and designates the condition of the young creature before it has acquired the form and the organs of the infant; after that time the unborn child is called a _fetus_. Embryonic development, therefore, in the strictest sense of the term, chiefly involves the shifting of various groups of cells and the bestowal upon them of different kinds of activity. During this period comparatively slight growth takes place. By about the twentieth week, the house, it may be said, is set in order; and there follows a period marked by the rapid growth of the fetus. THE DEVELOPMENT OF FORM.--A very old explanation of embryonic development was that the process consisted altogether in growth. According to that view the embryo lay curled up in the egg; at the outset it was equipped with organs, limbs, features, and all the other bodily structures found in an adult. In order that the ovum might be transformed into a mature infant, only unfolding and growth were required. After the microscope came into use, however, so simple an explanation could no longer be accepted. Scientists soon realized that the embryo did not exist "ready made" in the ovum, which, even when magnified, failed to bear the faintest likeness to a human being. Although the microscope made impossible this very simple explanation, it gave in return a truer, if more complex, account of the transformation from egg to offspring. By this means it has been definitely proved that the ovum multiplies rapidly after it has been fertilized, and becomes, as was explained in the preceding chapter, a sac-like structure within which hangs a tiny clump of tissue. This inner mass of cells forms the embryo. It has proved a difficult task to secure very young human embryos, and many of the ideas we hold relative to the initial stages in the development of man are based upon what has been found true in certain mammals, the class of animals to which we belong. The youngest human ovum known at present has already undergone about two weeks' development, and there the embryo is represented by a flat disk. From this stage to the stage of complete development a satisfactory series of embryos has now been collected, but it is impossible to give here, even in outline, a description of the evolution of the human embryo. No one can understand this intricate subject without the aid of diagrams, models, and other material beyond the reach of all save laboratory workers. By the end of the second month the development of the embryo has advanced so far that anyone could recognize its human shape. About that time, too, the external sexual organs make their appearance. At first these are quite similar in both sexes; and, if they are used as the criterion, it is possible only toward the end of the third month to say whether the embryo is a male or female. THE DETERMINATION OF SEX.--The fact that a number of months pass before the sex can be distinguished by an external examination of the fetus has led to the erroneous belief that it can be influenced during the early part of pregnancy or actually determined at will. Various means to accomplish this have been suggested; many of them depend upon modifying the mother's mode of living according as a boy or girl is desired. The most widely known of these doctrines, that of Schenck, was to the effect that the sex of the offspring is always that of the weaker parent. He suggested, therefore, that increasing the vigor of the mother by an appropriate diet would produce a male child, whereas a decrease in her strength would lead to the opposite result. His views, however, were incorrect. After studying extensive statistics Newcomb came to the conclusion that "it is in the highest degree unlikely that there is any way by which a parent can affect the sex of his or her offspring." Moreover, the results of experimental research clearly indicate that we shall never possess the means by which a mother may control the sex of her child. In the main laboratory investigations have sought to answer two questions. First, at what time is the sex of the offspring determined? and, second, what accounts for the origin of a male in one instance and of a female in another? The study of these problems has been carried on chiefly in connection with insects, worms, and fowl; but as yet insurmountable difficulties have prevented similar investigations in higher animals. For this reason, it is not without the greatest caution that results thus far obtained may be assumed to apply to man. Sufficient facts, however, have been collected to admit no doubt regarding the answer to the first question. In most animals it is definitely known that the sex of the offspring has been fixed when the male cell enters the female cell, in other words, at the instant the ovum is fertilized. Excellent reasons exist for believing that human beings conform to this rule, and that the sex of the child is unalterably determined at the moment conception occurs. Consequently, any attempt to influence it after that event must prove futile. For the present, the second question cannot be answered with equal assurance. More than five hundred theories have been offered to explain the relation of sex; nearly all of them have no reasonable foundation and are only of historical interest. The view that girls are derived from the right ovary, boys from the left, has long since been disproven, and deserves mention merely because the laity still believe it. Happily, during the last few years, observations and experiments have been made which greatly advance our knowledge of the subject and give promise of an early solution of the problem. The controlling factor in sex determination has been narrowed down to three possibilities; it is inherited either from the single cell contributed by the father or from the single cell contributed by the mother, or it is determined by the effect these two cells have upon each other at the moment when they unite. In most animal species the weight of authority distinctly favors placing the whole responsibility upon the male cell. According to recent evidence, there are two kinds of male germinal cells; one kind giving rise to female offspring and the other to male. In all probability, at the time of the marital relation, these varieties are deposited in the vagina in equal numbers; and, moreover, the mode of their production is such as to place absolutely beyond human control the possibility of changing this ratio. Since only one spermatozoon enters the ovum, whether or not the child will be a boy or a girl depends entirely upon which type gains entrance. If this explanation is correct, and it is in accord with careful biological observations, it removes from the mother all responsibility for the sex of her child. Furthermore, since the facts indicate that male-producing and female-producing spermatozoa are present in equal numbers, it follows that practically there is an even chance that an embryo will develop into a boy or a girl. Birth statistics bear out this conclusion, as data gathered from many countries indicate that when long periods of time are studied 105 boys are born with a surprising regularity for every 100 girls. Thus, the records of Berlin, Germany, for a hundred years show that the maximum difference occurred in 1820, when the males outnumbered the females by 4.79 per cent.; the minimum difference, which was noted in 1835, was .64 per cent. in favor of boys. No inquiry is more often submitted to the physician by prospective mothers than this, "Can you tell me if my baby will be a boy or a girl?" He cannot. Many rules, to be sure, have been advocated as safe guides toward reaching the correct answer; every midwife possesses her individual formula which she has "never known to fail." But the boastful success depends upon the application of some such method as the following, which I have heard my teacher, Dr. J. Whitridge Williams, expose to his classes. The patient is asked if a boy or girl is desired. She confesses, and is then informed that the sex of her child will be the opposite of her wish. When this guess proves to be correct, there is no doubt of the prophet's wisdom; when it is not, his honor is protected, for the parents have had their hope fulfilled. Their happiness makes them forgetful that the guess was wrong, or, for that matter, that it was ever made. It was once believed that the sexes might be distinguished before birth by the number of heart beats occurring within a minute. In a general way, the action of this organ in females is somewhat more rapid than in males; and so it was thought that a rate of 144 or more indicated the female and a rate of 124 or less the male sex. But experience has taught that this rule leads to accurate prophecy in no more than half of the cases. As a matter of fact, no means of definitely foretelling the sex of the child has been discovered, and I doubt if it ever can be. TWINS.--As every one knows, pregnancy commonly terminates with the birth of a single child. Twins appear in approximately only one of ninety pregnancies, while triplets are extremely rare. It is true that even quintuplets may occur, though up to 1904 only 29 authentic instances could be collected from the whole range of medical literature. Twins are most frequently born to parents whose ancestors have established this tendency; the trait is usually inherited from the mother's family, though occasionally it is passed on through the father. Of course, that does not explain the cause of twins, which in reality may result from either of two circumstances. More commonly their genesis depends upon the ripening of two eggs at about the same time and the fertilization of both by two different spermatozoa. The children, in this instance known as double ovum twins, may be of the same sex or not. On the other hand, single ovum, or identical, twins are always of the same sex; this follows, since but one egg and but one spermatozoon are here concerned. The incident permitting twins to develop from a solitary ovum must occur soon after conception has taken place. It will be remembered that the first step in the development of the fertilized ovum consists in its dividing into two cells. Ordinarily, both these take part in the development of one embryo, but occasionally they separate and give rise to two. Frequently, the presence of twins can be recognized during the latter months of pregnancy, and accurate means are known of determining after they are born to which variety any given pair belongs. THE RATE OF GROWTH.--When we recall the definite and often marked differences in the physical character of women, such as weight and height, it is surprising to learn that the prenatal development of their children proceeds with uniform speed. One very practical result is that the physician is thus enabled, at the birth of a premature infant, to estimate accurately the period of its development. Various criteria, some of which are easy of application, aid in this determination. For example, the length of the child is practically constant for each of the ten lunar months into which the whole gestation period is divided; if, therefore, the length of the newborn infant is known, the stage of its development can always be inferred. From the fifth month the calculation is especially simple, since the length measured in centimeters divided by the figure 5 gives the month to which pregnancy has advanced. Similarly, we can infer the period of development from the weight, though the calculation is more intricate and the method less reliable, inasmuch as the size of the child in the latter months varies somewhat according to the weight of its mother. At the end of the fifth month, the weight of the fetus is from nine to ten ounces; whereas an average infant when born at the expiration of the full term of pregnancy, that is, with the completion of the tenth month, weighs about seven pounds. The fetus, therefore, acquires roundly ninety per cent, of its weight during the second half of pregnancy, which clearly indicates that Nature reserves this period of gestation for the fetus to increase in size, a phenomenon less mysterious but no less important than the evolution of the embryo. Nothing is more valuable than the weight in affording an indication as to whether a prematurely born infant may be reared. It is unusual to raise a child weighing less than four pounds, which corresponds approximately to the end of the eighth lunar month of development (a trifle more than the seventh calendar month). After this time, the prospect of living becomes greater in proportion to the nearness with which the infant has approached maturity. No truth exists in the widespread belief that the seventh-month child is favored above that born later but before the natural end of pregnancy. Experience has taught that the probability of success in rearing the child increases rapidly after the seventh month. This is reasonable on the following somewhat theoretical grounds. The digestive organs later attain a higher state of perfection, and are better prepared to carry on their work satisfactorily. Moreover, the gradual deposition of fat beneath the skin during the last two months of pregnancy materially assists in fitting the child for the conditions met with in the external world, since the fat affords a barrier against the escape of heat generated within the body, making it much easier to keep the child's temperature at the normal point. Even other more technical reasons could be given to demonstrate the error of the superstition regarding the seventh-month child--a conviction endorsed by medical men hundreds of years ago and as yet not discarded by the laity. When pregnancy has reached "term," the child, having completed its prenatal development, is ready to cope with conditions as they exist in the external world. At term the average child is twenty inches long and weighs 7 1/7 pounds (3,250 grams). The length is remarkably constant; but the weight, as is well known, is often somewhat above or below the average figure. In a general way, smaller children occur in the first than in subsequent pregnancies, and, moreover, may be expected when the mother is a small woman, or poorly nourished, or has worked hard during her pregnancy. On the other hand, a tendency to bear large children is present when the opposite conditions prevail. It is not unusual to see infants weighing eight or nine pounds at birth, but babies of more than ten pounds are rare, and the fabulous, though not infrequent, reports of fifteen and twenty-pound infants are probably not based upon actual weighings, but upon the impression of someone who has merely seen the child or perhaps guessed the weight from lifting it. Although the fetus frequently changes its position during the earlier months of pregnancy, generally by the beginning of the tenth lunar month it has assumed a permanent posture. It has then reached such a size that it can best be accommodated in the cavity of the uterus if its various parts are folded together so as to give the fetus an ovoid shape. To secure this form its back is arched forward, and its head bent so that its chin touches its chest; its arms are crossed just below the head, its legs raised in front of the abdomen, and its knees doubled up. In this form the fetus occupies the smallest possible space. With relation to the mother the position of the child, for several weeks before birth, is one in which its long axis is parallel to the long axis of her body. This remains true no matter whether the head or the buttocks are to precede at the time of birth. In ninety-seven out of a hundred cases, however, the head lies lowermost and consequently is the first portion of the child to be born. The opposite position, in which the head is the last portion born, is, even with the most skillful treatment, somewhat more serious for the infant, though not for the mother. THE NEWBORN INFANT.--The baby at birth is not a miniature man. As compared with an adult its head and abdomen are relatively large, its chest relatively small; its limbs are short in proportion to the body; and at first glance it appears to have no neck at all. The middle point of a baby's length is situated about the level of the navel, whereas in a man the legs alone represent approximately half his height. The changes after birth consist chiefly in growth; but not altogether, since at least one organ, the thymus gland, becomes smaller and completely disappears during childhood, and other organs, especially the liver, are proportionately smaller in the adult than in the infant. The body of the infant also differs from that of the man in possessing greater softness and flexibility. These qualities depend upon the nature of its skeleton, which is composed of more bones than later in life, when several have fused together to form one to give the mature body a more rigid frame. Furthermore, the individual bones are not so firm, consisting of an elastic material called cartilage, so that some movements which in an adult would cause such serious injuries as fractures and dislocations are perfectly harmless to a newborn child. The legs are not only short in proportion to the body but are always curved, and the feet are held with the soles directed toward one another, a position clearly abnormal in the adult. But every mother should know that these are natural conditions in the infant, and are the result of the posture of the child before birth. They soon straighten out. The bowed legs of an adult are of an entirely different origin, resulting from a disturbance of nutrition in infancy called rickets. A small amount of short wooly hair is usually found over the back of a newborn infant. More conspicuous, however, is the presence there of a gray, fatty substance which, though always more abundant over the back, is at times distributed over the whole body; rarely is it entirely absent. The material, technically named the vernix, is the product of the glands in the skin and is a perfectly normal secretion. After its removal, which is readily accomplished by greasing the infant with lard or vaselin before giving the initial bath, it never reappears. A varying amount of hair covers the head of the infant. No significance should be attached to the quantity, for the conviction that exists, especially among negroes, that a heavy suit of hair for the child occasions "heart-burn" in the mother during pregnancy is without foundation. The color of the hair at birth does not indicate its ultimate shade; changes are often noted during infancy. Similarly the permanent color of the eyes is not assumed until later; at the time of birth the eyes are generally, if not always, blue in color. A baby's head is a matter of great concern to the family. Occasionally, the skull is round and well shaped from the moment of birth, but more often it is long and narrow; sometimes the form is even startling to the inexperienced. The peculiar shape of the head results, of course, from its passage through the birth-canal and is not a sign of any disease. In a few weeks, or even less, the strange appearance passes away. It is unwise to attempt to alter the shape of the head by bandaging or massaging since the growth of the brain will spontaneously accomplish what is desired; interference can do no good, and may do serious harm. Nature facilitates an appropriate molding of the head during birth so as to permit its easy passage through the bony pelvic cavity of the mother, and gains that end in two ways. The bones of the head remain pliable until after the infant is born, and, further, their edges are not welded together as in an adult, but are separated from one another by an appreciable distance. During the act of birth the edges are brought into contact or even overlap, materially reducing the size of the head. Within a few hours after birth the bones again spread apart, and some months elapse before they begin to unite; the union is not completed until some time during the second year of infancy. Many mothers are anxious to know how far the senses of the infant have developed when it enters the world. This problem has stimulated some scientific investigation, though hardly so much as its interest would justify. Two lines of inquiry have been pursued toward its solution. The objective point of one of these has been to determine how nearly the sense organs of the newborn correspond anatomically to those of an adult; that is how perfectly has their organization been completed. The other has been to learn how the infant reacts when the various senses are stimulated; the interpretation of these reactions is, however, particularly liable to error and sometimes amounts only to guesswork. The organization of the nerves and muscles in the eye is far from perfect at the time of birth. The muscles act irregularly; indeed, the lack of muscular adjustment is such that movements of the eye likely to alarm the parents are regularly observed in very young infants. Furthermore they cannot focus images which fall upon their eyes. The retina, which receives visual impressions, has reached such development at birth, however, that sensations of light can be perceived. For example, if a lamp is suddenly flashed before the face of a newly born baby it cries. From this and similar evidence, indicating that strong light irritates the delicate structures of the eye, we have learned that a nursery should not be illuminated, during the day or night, so brightly as the rooms adults occupy. Certainly several weeks, and probably several months, pass before an infant can see anything save as blurs of light and darkness. Objects, such as a hand, probably appear as shadows, which are not correctly interpreted until late in infancy. In regard to color vision we have as yet no reliable information concerning children under two years of age. Infants of less than a year have been known to distinguish certain colored papers. But such discrimination is probably due to a difference in brightness of the colors. Although the organ of hearing is well developed at birth, the drum of the ear in very young infants cannot transmit sounds, as in the adult. For the latter kind of transmission it is necessary that the pressure on both sides of the drum-membrane should be equal, and this is arranged by the admission of air to the middle ear through a passage from the throat. At the time of birth, on account of the swollen condition of the mucous membrane which lines this passage, it is blocked, and the middle ear is filled with fluid; these conditions interfere with the transmission of sound, and consequently its perception is dulled. But even in the absence of a drum-membrane an adult can hear; the vibrations in such cases are transmitted through the bones of the skull, and this very likely also occurs in newly born infants. In most instances, at least, they react to a disagreeable noise within the first twenty-four hours, and their sensitiveness in this direction explains why the nursery should be kept quiet. Investigators have not come to uniform conclusions concerning the sense of smell and of taste. In all likelihood, smell is not acute at the time of birth. Taste probably is better perceived, yet some newborn babies are said to suck a two per cent solution of quinin as eagerly as milk, though stronger solutions are distasteful. According to the best available information a young infant can detect the difference between a sweet, bitter, sour, or salty taste only when the tests are made with a solution possessing the quality in question to a marked degree. It is common knowledge that babies cheerfully suck the most tasteless objects, and it is not improbable that at first the reaction depends upon the temperature of the object and the feeling it creates in the mouth. The moment it is born, a baby perceives pressure if its skin is touched. To this sensation, however, some parts of the body are much more sensitive than others; the tongue and lips are most sensitive of all. Heat and cold are probably perceived more acutely by infants than by adults; to pain, on the other hand, babies are less sensitive. An infant is aware of the movements of its own muscles, and also appreciates a change from one position to another, as experienced nurses know very well, and on that account carefully avoid keeping a baby on one side continuously. The vast majority of movements performed by young infants are reflex acts, that is, the cerebrum, the part of the brain with which thinking is done, is not concerned with their performance. Of these reflexes the most notable are sucking and swallowing, but sneezing, coughing, choking, and hiccoughing may also be observed; stretching and yawning have been recorded in several instances, even during the first days of infant life. None of these movements, we must remember, are produced consciously; the baby cannot reason and does not recognize anyone, even its mother. HEREDITY.--The transmission of bodily resemblance and of traits of character from parent to child is a broad and complicated subject, whose fundamental principles biologists are just beginning to grasp. The facts thus far established regarding heredity relate chiefly to plants and to the lower animals. There is no doubt whatever that the meager knowledge we possess of heredity in man will be amplified and will ultimately indicate on the one hand the marriages which are advisable and, on the other hand, those which are not. Indeed, the foundations for a science called Eugenics, which purposes to improve the human race in this way, have already been laid. It is barely a decade, however, since our knowledge of heredity has approached that order and system which entitle it to be ranked as a science; and in this brief period great strides could hardly be expected in its most intricate field, that of human inheritance. The modern teachings of heredity are of interest to us, nevertheless, since they intimate the time when a child's inheritance is fixed and the means by which hereditary characters are conveyed. To understand these fundamental points we must recall that at the moment of conception a male germinal cell combines with a female cell, and that this act, which is named fertilization, brings together vital elements from the two parents. We have seen that the spermatozoon represents the solitary contribution of the father toward the development of the child, and the spermatozoon, therefore, must convey the material basis of paternal inheritance. Similarly we might expect the ovum to be the bearer of the maternal qualities inherited by the child. This is actually true; but much of the evidence is of a technical character and must be omitted. Yet an experiment successfully conducted by Castle and Phillips will indicate, even to those who have no special knowledge of the mechanism of heredity, the important role the ovum plays. These investigators removed the ovaries from an albino guinea-pig, and in their place substituted the ovaries of a black guinea-pig. "From numerous experiments it may be emphatically stated that normal albinos mated together produce only albinos." But in this experiment the result was otherwise, for the albino into which the ovaries of a black guinea-pig were grafted produced only black offspring. The color-coat of her young, therefore, was not influenced by her own white hair, but was determined by the eggs really belonging to the black animal from which the ovaries were taken; in no other way can the result be interpreted. It is certain, moreover, that the mode of transmission of material qualities here exemplified is not exceptional; on the contrary there is no doubt that the ovum always conveys the sum total of the qualities the offspring inherits from the mother. The germinal cells then contain the material basis of inheritance, and in all probability the substance is located within the nucleus of the cells. This substance had been seen and studied long before its relation to the problem of heredity was suspected. Because it takes a deeper stain than the rest of the nucleus, it stands out prominently when the cell is treated with certain dyes, and this property accounts for its name--chromatin. Under such conditions as prevail just before a cell divides, the chromatic substance is broken up and reassembled in the form of rods called chromosomes. Curiously enough the number of rods is uniform for each species of animal, though different numbers are characteristic of different species; the characteristic number for man is twenty-four. Unless some arrangement was made to prevent it, the act of fertilization would cause the number of chromosomes in the fertilized ovum to be double the number characteristic of the species. In man, for example, the addition of twenty-four chromosomes from the spermatozoon to an ovum that already contained twenty-four chromosomes of its own would mean that after fertilization the ovum contained forty-eight. Such a result is prevented through the process to which we have referred in the preceding chapter as the ripening of the ovum, and also through a similar process in the case of the spermatozoon. These two processes lead to a reduction in the number of chromosomes, so that finally every human germinal cell contains twelve, and therefore when the ovum is fertilized the characteristic number twenty-four is restored. While we know nothing of the forces which determine, on the one hand, what elements shall be discarded by the germinal cells and, on the other hand, what elements shall remain, it is definitely proved that a selective process always takes place. This fact admirably explains the variation in the characteristics inherited by children of the same family. So far as is known, the traits which will be passed on from either parent are a matter of chance. Whatever these hereditary traits happen to be, the best evidence we have indicates that the problem of a child's inheritance is settled once for all the moment conception takes place. MATERNAL IMPRESSIONS.--Contrary to all that we know of heredity, the conviction prevails among the laity that the character of a child depends greatly upon the mother's surroundings during pregnancy: this is the doctrine of maternal impressions. As is usual with superstitions, this one emphasizes the unfavorable possibilities and holds that the unborn child may be affected by the mother's unhappy thoughts or maimed by her mental distress if she is exposed to unpleasant sights. For this belief there is no foundation; the cases often cited in its support may be fully explained on the grounds of coincidence. With the possible exception of such individuals as are spending their lives in solitary confinement, there is scarcely a human being who has not in the course of nine consecutive months some untoward physical or mental experience which engraves itself upon the memory. Prospective mothers are not apt to be exempt from a rule so general in its application, but if by good chance one happens so to be she will hardly fail to hear of the misfortune of others, which, according to the doctrine of maternal impressions, may be equally effective in interfering with the proper development of the child. We should then rightly expect most, if not all, babies to be "marked"-- clearly a situation which does not prevail. In order to learn how frequently prospective mothers may have disagreeable experiences which they fear will affect the formation of the child, I have lately asked the patients whom I have attended, "Was there any incident during your pregnancy to which you could have attributed the infant's condition, had it been marked?" The babies of all those to whom the question was submitted were normal; yet without exception those whose pregnancies just completed were their first answered in the affirmative. It is also pertinent that one of these patients had lost her brother by a violent and accidental death when she was four months pregnant; a similar bereavement was suffered by another at the eighth month; each was, however, delivered of a perfectly healthy child. Among those with whom the recently ended pregnancy was not the first I found some who could remember incidents popularly believed to have an influence over the development of the embryo; most of them, however, had given the matter so little thought that they could not definitely recall whether such incidents had occurred or not. From a similar series of observations covering two thousand cases, William Hunter came to the conclusion, nearly two hundred years ago, that there was no support for the belief in maternal impressions. Whenever a child does happen to develop abnormally, it must be clear that, from the very nature of our existence, some incident can be recalled which will satisfactorily, yet unjustly, bear the blame. It may be confidently said, however, that, for every mother whose fears are realized, hundreds are agreeably disappointed in finding their babies perfectly normal. In the face of so many negative instances it is amazing that any person, even though ignorant of medical teaching, should be inclined to attribute abnormal development to something the mother has seen or heard, thought or dreamt, or otherwise experienced while she was pregnant. Yet unfortunately many do believe this. It is worth while, therefore, to supply further evidence, and thus escape any suspicion of unfairness in argument, to prove that maternal impressions are unable to affect the formation of the embryo. It is found, as a matter of experience, that the superstition regarding maternal impressions generally begins to cause anxiety during the second half of pregnancy; and then such an influence is entirely out of the question. By the end of the second month the form of the embryo has been definitely determined, and subsequently cannot be altered. It is even true that errors in development are most apt to occur within the two or three weeks that immediately follow conception, and therefore occur at a time when pregnancy is not often clearly recognized. Thus it happens that women begin to worry about the influence their minds will have upon the formation of the child long after its form has been established. Incidents in the life of a prospective mother are in point of fact equally inert so far as their influence upon development is concerned, no matter whether they occur during the earlier or later part of pregnancy. There is never any anatomical means by which maternal impressions could be conveyed to the embryo. Such an influence would have to be exerted through the placenta; and that is impossible. There are no nerves in the placenta to carry impulses from the mother to the child. Even the blood streams of the two beings are kept apart; and though it is unheard of that the blood should carry nerve impulses, if that happened to be the case, it could not prove effective here, for the blood of the mother does not enter the child. It is nourished by food which passes from the mother's blood, to be sure, but there is no more reason to expect this nutriment to exert an hereditary influence than there is to expect an infant to grow to resemble the cow with the milk of which it is fed. With these two possibilities eliminated, no path can be imagined by which impulses might travel from the mother to the embryo. Scientific investigation has brought to light these facts, as it has also taught the real causation of the disfigurement once attributed to the mother's mind. Departures from the usual form of the body occur during the earliest days of pregnancy and arise in consequence of some irregularity in the process which molds the body-form from a simple spherical mass of cells. Why irregularities sometimes occur is not altogether clear; except in so far as it has been determined that the fault lies within the embryo itself. Whenever these defects are associated with events which have disturbed the mother's mind, it cannot be other than a simple coincidence. CHAPTER IV THE FOOD REQUIREMENTS DURING PREGNANCY The Food-stuffs: Water; Mineral Material; Protein; Carbohydrate; Fat-- What We Do to Our Food--How Much Food Is Needed During Pregnancy?-- The Importance of Liquid Nourishment--The Choice of Food--Cravings-- The Relation Between the Mother's Diet and the Size of the Child. There is a gain in weight during pregnancy amounting finally to about thirty pounds; exceptionally, it is as little as ten or fifteen pounds, and, at the other extreme, as much as forty or fifty. With individuals inclined to be stout the increase is greater, and it is relatively greater in later pregnancies than in the first. During the early months of pregnancy the weight generally remains stationary or suffers a slight loss; even in those rare instances in which the weight begins to increase shortly after conception the gain is less marked in the earlier months than later. For the last three months the average monthly gain has been found to be between three and a half and five and a half pounds. The weight gained during pregnancy is not, as can be readily understood, permanently retained. At the time of birth, in consequence of the expulsion of the child, the after-birth, the amniotic fluid, and a varying amount of blood, there is necessarily a loss of from ten to fifteen pounds. Later, as the maternal tissues, whose growth has been stimulated during pregnancy, return to their original condition, a further loss in weight takes place. It is not unusual, however, for women to remain permanently better nourished than before they became pregnant. Under ordinary conditions the food of the prospective mother provides not only for her own wants but also for those of the embryo. Between the two organisms there exists a relation which resembles that existing between a house in course of construction and the contractor who supplies the building material. The mother furnishes what is needed to construct the "living edifice," as Huxley called the growing embryo, but she is not responsible for the lines of the building. The embryo is both architect and mechanic, designing the structure and arranging the "organic bricks" in their proper places. The work of construction necessitates the expenditure of an appreciable amount of energy and the creation of waste products that must be removed, lest they accumulate and interfere with the growing structure. These waste products leave the embryo by way of the umbilical cord and the placenta and return thus into the mother's circulation; ultimately they leave the mother through the same channels that carry off her own waste. First and last, then, the nutrition of the mother and of the child are so bound together that it has been impossible to study them separately. Our knowledge of food requirements during pregnancy has been obtained by measuring the food requirements of the mother alone; and as nutrition during gestation is fundamentally the same as nutrition at other times, it is necessary for us first to consider in general the food needed by the human body. THE FOOD-STUFFS.--The waste products we throw off indicate that the substances which compose our bodies are being constantly broken down and reduced to a condition such that they are useless to us. In normal persons hunger signifies that they need material to replace what has been used up. The substances thus required, if the wants of the body are to be satisfied correctly, are called the food-stuffs; and they are the same during pregnancy as at other times. The foodstuffs are usually classified according to their chemical properties; on this basis they are placed in five groups: (1) Water, (2) Mineral Materials, (3) Proteins, (4) Carbohydrates, (5) Fats. In view of the different purposes which the foodstuffs serve, it is convenient to group them in another way. Thus, the carbohydrates and the fats may be placed together because they are the body fuel; their value consists in the heat and energy which they yield when acted upon in the tissues. Water and mineral matter, on the other hand, are never a source of energy; they assist in building new tissue or in repairing tissue that already exists. The proteins are unique, in that they may serve either purpose. Primarily the proteins are tissue-builders, but in the absence of sufficient fat or carbohydrate the body burns protein to secure heat and energy. Each food-stuff, therefore, serves a distinct purpose, and some of them render services which the others cannot perform. A man will die if either water or mineral matter or protein is completely withdrawn from his diet. Fat or carbohydrate, on the other hand, or even both of them, may be excluded for some time without causing serious inconvenience. It is true, nevertheless, that each food-stuff performs some task better than any of the others can perform it, and for that reason all of them should be included in the diet of an healthy individual. Some of the food-stuffs, such as water and table salt, come to the body separate from the others; but generally the different types reach us intimately mingled in the various articles of food in common use. Foods vary greatly, however, in the amount of the different food-stuffs they contain. The meats, for example, have a relatively large protein content; in the vegetables starch, which is one of the carbohydrates, predominates. As to the choice of food and the amount that is necessary for the average person, generally the appetite is a safe guide; but the accurate observations of physiologists have gone so far as to determine the exact requirements of the body. Not the least important principle taught by these investigations is to avoid dietary fads, for in arranging a satisfactory diet the problem to be solved is not, What is it possible to live on? but, What serves best as nourishment? The experience of countless generations has taught us that we thrive best on a diet which includes all five food-stuffs. _Water_ constitutes nearly two-thirds of the weight of the body. As water is constantly being given up in the life process, health demands an abundant supply of liquids to replace the waste. The average daily loss has been found to be between two and three quarts. Of this amount the urine constitutes nearly two-thirds; and the remaining third is eliminated through the skin, the lungs, and the bowels. Although the deficiency thus created is met in part by the water in our solid food, the greater part of the loss is made up by the liquids we drink, and we are warned, in a measure, by the sensation of thirst that they are needed. _Mineral material_ is of the greatest importance as a constituent of our food. It contributes to the welfare of the body in at least three ways; (1) it gives rigidity to the bones, (2) it supplies an essential ingredient of the living substance in all the tissues, (3) it is present in the blood and in the other body fluids, where it is of service in such vital processes as the beating of the heart, the transportation of oxygen to every portion of the body, and the maintenance of an acid or alkaline condition of the digestive juices according as the one or the other is necessary for the assimilation of the food. An animal deprived of mineral food will die as surely as one deprived of water. In arranging our diets, however, we are not compelled to take the minerals into account, for, with the exception of table salt (sodium chlorid), the meat and vegetables that we eat provide the mineral material the body requires. Iron, for example, which imparts to the blood one of its most essential qualities, occurs in relatively large amounts in apples, spinach, lettuce, potatoes, peas, carrots, and meats. Only now and then does it become advisable to add iron deliberately to the diet. Similarly lime (calcium) the material that makes the bones hard, is present in quantities ample for the needs of the body in the bread, milk, eggs and vegetables that we eat. The remaining mineral constituents of the body, among which the most conspicuous are magnesium, potassium, sulphur, and phosphorus, occur in foods which we are naturally inclined to take, so that we secure an abundance of them unconsciously. _Protein_, the third food-stuff which we must eat to keep alive, contains the chemical element nitrogen in such form that it can be incorporated in our tissues. Although most persons derive their protein in part from meat, milk, and eggs, it is possible to satisfy the requirements of the body on a purely vegetarian diet. Experience has shown, however, that it is both natural and advantageous that we employ a mixed diet. The property of protein to build living tissue and replace tissue waste probably depends upon several factors; but certainly one of them is the presence of nitrogen. So intimately associated are the consumption of the tissue substance and the elimination of nitrogen that we have no better way of judging the amount of tissue substance used in the body than by determining the quantity of nitrogen that appears in its various waste products. From such investigations it has been found that the quantity of protein required to repair the breaking down of the tissues is not great. The average man consumes approximately a quarter of a pound (100 to 120 grams) of protein daily; but this quantity is in excess of his real needs. Indeed, Chittenden has shown that for various classes of individuals, namely, students, athletes and soldiers, half as much is sufficient. Other physiologists, though admitting that this is true, contend that it is inadvisable to regulate one's diet on such a slender basis. Very good reasons are assigned for the view that more protein is needed than just enough to counterbalance the tissue waste. Thus, in the case of animals, it has been found that a diet low in protein finally causes digestive disturbances and other ailments. Although it does not seem advisable to practise rigid economy in arranging the protein content of the diet, it is equally important that we should not go to the other extreme. The consumption of over- large quantities of protein, as would be the case if we lived exclusively upon meat, increases putrefaction in the intestines and throws unnecessary work upon the kidneys, which are the organs chiefly concerned in getting rid of the waste products of protein. _Carbohydrate_ is the name given the group of foodstuffs to which the sugars belong. The food value of cane sugar, the most familiar member of the group, was recognized even in prehistoric days by the natives of India. By boiling the plant we call sugar-cane they obtained a substance to which they gave the name Sakkara, and from this our word sugar evidently originated. The roots of this plant were carried into Europe and cultivated during the Middle Ages. Obviously, its value was and is appreciated, since the cultivation of the sugar-cane and the sugar-beet has become the foundation of a great modern industry. There are some persons, perhaps, who do not realize that beside cane sugar many kinds of carbohydrate occur in our food. Glucose or grape sugar, for example, occurs not only in the fruit indicated by its name, but also in other fruits, in corn, in onions, and in the common vegetables. Glucose is especially suited to act as nourishing food. In keeping with that fact our digestive juices convert most of the sugars we eat, if not all of them, into glucose, which is regularly present in our blood. It is unnecessary to enumerate all or even the more important compounds included in the carbohydrate group; but everyone should know that starch is its chief member, and that after being thoroughly digested starch enters the body as glucose and therefore serves the same purpose as sugar. The value of carbohydrates as a source of heat and energy may be accurately measured, and is technically expressed in terms of a unit, called the calorie. As the energy which our bodies require may be estimated in the same terms, it is possible to determine whether or not our food is equal to our wants. Very naturally the energy requirements of any individual are influenced by his weight and by the work he does. But we may take as a standard the results of an extensive study of American families which indicate that women require four-fifths as much energy-yielding food as men. It also seems safe to conclude that a woman weighing 130 pounds who does her own housework requires food every day having an energy-value of 2,500 calories; smaller women and those who do no work require somewhat less. In a mixed diet the chief source of this energy--and the source from which it is most economically obtained--is the carbohydrates. _Fat_ yields more energy and heat than does carbohydrate, bulk for bulk; but fat is burned by our tissues less readily. We instinctively avoid eating a great deal of this food-stuff; in the course of a day the average person consumes no more than one or two ounces. The natural aversion which many feel toward fat may possibly depend upon the difficulty with which they assimilate it. In colder climates, however, we know fat to be a staple article of diet; and it is not unlikely that the very conditions which make it necessary there explain the unusual tolerance for it. Fat is more than fuel. Deposited in our bodies, beneath the skin for example, it prevents the escape of heat that we generate and protects us against the penetration of cold. This food-stuff, therefore, contributes in several ways toward maintaining the temperature of the body at a constant level. Our source of fat is chiefly animal food and in a smaller measure vegetables; but the fat our food contains is not altogether responsible for the fat in our bodies. Carbohydrates, if in excess of momentary needs, are partly converted into fat and stored as such. A reserve supply of nourishment is thus provided, and is drawn upon only when the food that we consume does not contain as much energy as we expend. WHAT WE DO TO OUR FOOD.--With the exception of water and mineral substances, the food-stuffs must undergo chemical alterations before they are capable of being absorbed into the body; this is the work of digestion. The digestive processes, the main purpose of which is to break up the carbohydrates, proteins, and fats into substances of much simpler chemical structure, begin in the mouth and are not completed until some time after the food has entered the intestine. As the food moves through the alimentary canal, it is mixed with the various digestive juices containing ferments, such as pepsin, which are the active agents of digestion. Although digestive processes go on automatically, they are, in a degree that is far from negligible, influenced by the mind. Thus, cheerfulness promotes digestion, and not infrequently mental depression may be the direct cause of indigestion. Indeed, it is chiefly in regard to the state of the mind of the prospective mother that the existence of pregnancy may be said to have a bearing, whether favorable or unfavorable, upon her digestion. The digestive juices are prepared in glands which lie either within the lining of the alimentary canal or adjacent to it. In the latter event the glands are connected with the canal by means of tubes. These glands must be warned when to pour out their secretion, and their very first warning usually comes from the agreeable sensations experienced when we see, smell, or taste inviting food. If we are hungry, our viands attractive, and our surroundings congenial, the stimulus excites a plentiful secretion of the digestive juices; conversely, the opposite conditions, to some extent, check their flow. The sight of attractive food, as we all know, "makes the mouth water," that is, it calls forth the saliva which contains one of the digestive ferments. Thus, at the beginning of a meal, favorable conditions for digestion are established. The saliva, however, acts only upon starch; and, moreover, its action upon this carbohydrate is weak unless the food is thoroughly chewed and mixed in the mouth. Most of us, perhaps, overlook the importance of mastication, which not only crushes all the food-stuffs, preparing them for efficient digestion, but also stimulates the flow of the digestive juices. Furthermore, by thoroughly masticating our food, we know intuitively when we have had enough, and thus avoid overeating. In the stomach the digestion of starch is continued for a time, but the chief work of gastric digestion concerns the proteins. They alone are attacked by pepsin, a ferment secreted by the mucous membrane of the stomach. Moreover, since pepsin is able to act only when an acid is present, the gastric mucous membrane also secretes hydrochloric acid. Just as the digestive glands in the neighborhood of the mouth become more active when we are conscious that desirable food is at hand, so do the glands in the stomach. Mastication also stimulates the flow of the gastric juice, and this flow is greater if we enjoy what we eat. Furthermore, it has been shown that, after entrance into the stomach, the food itself increases the flow of the digestive juices. All articles of food are not, however, equally efficient in producing this effect: thus meat requires more pepsin for satisfactory digestion than bread, and consequently meat calls forth a larger quantity of gastric juice. Fat in all probability is not digested in the stomach; even starch and protein are not broken down sufficiently by the time gastric digestion is complete to permit them to be absorbed into the body. "The value of digestion in the stomach," as Howell says, "is not so much in its own action as in its combined action with that which takes place in the intestine." It is even possible for satisfactory digestion to take place without the assistance of the stomach. This fact has been substantiated by several cases in which men have lived for years after the stomach was removed to eradicate a disease. It is true, nevertheless, that intestinal digestion can be performed more economically if it begins where gastric digestion normally leaves off. Of the changes wrought in the food by the various digestive processes, those which are the most profound take place in the intestine. While the food is being moved through this organ--some thirty feet in length--it is reduced to simple chemical fragments, which are absorbed by the intestinal wall. Digestion in the intestine is carried on through the agency of a number of ferments, the more important of which are supplied in the juice manufactured by the pancreas. The pancreatic secretion contains three separate and distinct ferments, which act respectively upon carbohydrate, protein, and fat. The absorption of fat, however, is materially assisted also by the action of the bile. A part of what we eat always escapes digestion; the unused portion, it has been estimated, is somewhat less than one-tenth of an ordinary mixed diet. The residue from vegetables is notably larger than the residue from meat. The _undigested_ portions of all the food- stuffs collect in the lowermost portion of the intestine and form a part of the feces. Here also are gathered the _indigestible_ material we have eaten, the products of bacterial decomposition in the intestine, and other waste substances that the body should throw off. HOW MUCH FOOD IS NEEDED DURING PREGNANCY?--In connection with the development of the child we have already referred to the difference in the purpose of the constructive processes which go on in the earlier months of gestation and those which take place in the later months. In a general way the first half of pregnancy is occupied with the formation of the embryo from relatively simple structural elements, the second half with its growth into an infant, which acquires ninety per cent. of its substance and weight at birth after the fifth month of embryonic development. A similar contrast may be observed in the nutritional processes of the mother. Often, at the beginning of pregnancy, the appetite is poor and there is indisposition of one kind or another, with the natural result that there is slight if any change in the mother's weight; whereas later a period ensues when her appetite increases, her health improves, and she gains in weight. Since it is natural that the weight of the mother should remain practically stationary during the early months of pregnancy, it is clear that a diet which has previously been ample will likewise be sufficient for some time after conception has taken place. To most persons, however, it is not clear that the quantity of food ordinarily eaten will suffice also during the later months of pregnancy. On the contrary, popular opinion holds that the prospective mother "should eat for two." It is not unimportant to point out the erroneous character of this superstition, because overeating during pregnancy is much more likely to provoke discomfort than insufficient nourishment. In order to comprehend the nutritional needs of the prospective mother, one must keep in mind the fact that our food always serves two purposes. These are, as we have seen, to build or to repair tissue and to furnish heat and energy. Since these needs of the body during pregnancy--as at all other times--are best understood when considered in their relation to the food-stuffs which supply them, we shall take up these various ingredients separately. Protein, which repairs tissue and also furnishes the substance from which new tissue is made, is used more economically during pregnancy than when the maternal functions are inactive. As a result of this economy the same allowance of protein which is sufficient before conception is sufficient also during pregnancy. This fact has been put in the clearest light by extensive observations made upon animals. Dogs which were not pregnant, for example, have been carefully fed so that their food should contain just enough protein to cover the needs of the body and keep their weight constant. Subsequently, when these animals became pregnant precisely the same amount of protein was fed to them. The result was that they gained in weight, and at the same time the waste products of protein they threw off were notably diminished. Such observations, of which there have been a large number yielding concordant results, may be safely taken to mean that an amount of protein previously satisfactory for the animal is also sufficient for her during pregnancy. We are forced to conclude that protein was used more sparingly in the latter condition--a view which has been repeatedly confirmed with regard to human beings as well as animals. It is found, for example, that an amount of protein competent to meet the needs of a man of a given weight will not only provide for the wants of a woman of equal weight while she is pregnant, but will also leave a surplus sufficient for the growth of the fetus. With regard to the mineral substances, likewise investigations indicate that the "housekeeping" of the body during pregnancy proceeds along unusually economic lines. It is not advisable, therefore, to make any change in the diet with regard to these substances. Attempts have been made to cut down the amount of minerals in the food for the purpose of softening the fetal skeleton. The success sometimes attributed to these efforts is, however, very doubtful, for we know that the mother's tissues will be robbed of minerals for the embryo whenever her food fails to contain them in sufficient amount for her own needs and those of the child. Practically speaking, the mineral content of diet during pregnancy requires no thought, for so long as meat and vegetables are eaten in satisfactory quantity the mineral nutrition will take care of itself. The food-stuffs which supply heat and energy, since the amount of energy utilized by the body during the latter months of pregnancy is somewhat in excess of that previously required, do not follow the same rule as the protein and the mineral matter. It has been found that just before the fetus becomes mature the energy requirements of the mother are approximately one-fifth greater than in the non- pregnant condition. It is certain, however, that no extra demand for energy exists until the fifth or sixth month of pregnancy, and that the excessive requirement is extremely small until the last three or four weeks. Even then the prospective mother requires less energy- giving food than the average man. Since the body handles carbohydrate more readily than fat, it is preferable that whatever additional energy pregnancy necessitates should be supplied by carbohydrates. An increase in the daily consumption of fatty food, over and above that previously found agreeable, is not only unnecessary but undesirable. Every-day experience teaches that less fat taken with the meals promotes the comfort of the prospective mother. A glass of rich milk a little before meal time, however, not only makes up for this omission but also prevents "heart-burn," a very common ailment of pregnancy. Although there is an appreciable increase in the quantity of starch and sugar utilized toward the end of pregnancy, it is generally quite unnecessary to increase these materials correspondingly in the diet. Nearly everyone eats more of all the food-stuffs than the body needs. In the case of the prospective mother the surplus ordinarily taken meets every need incident to her additional energy requirements. Because we eat more than we need, someone has said, with as much truth as humor, that prospective mothers "neither want nor need to eat for two. The fact is more likely that enough for one is too much for two." For the average woman it is wiser to take less during pregnancy rather than more, for over-indulgence is apt to lead to indigestion. The moment when the appetite is satisfied should be accepted as the stopping point, and that will be instinctively recognized if one eats deliberately, and thoroughly masticates the food. Regularity in the hour of eating is always healthful, and for some prospective mothers three meals a day prove quite satisfactory. Not a few, however, who adhere to this habit make the mistake of eating more than is wise; and large meals are particularly inappropriate to pregnancy. On this account most prospective mothers will be more comfortable if they take some simple and wholesome nourishment at fixed times between meals. Such an arrangement modifies a ravenous appetite, and it is, at the same time, beneficial to those who are not inclined to eat enough at the regular meals. If small amounts of food are taken five or six times a day, a tendency to be nauseated, which is not uncommon in the early months of pregnancy, can often be averted. In the latter months, too, because the capacity of the stomach is diminished through the encroachment of the enlarged womb, frequent meals generally contribute toward comfort and health. While the inevitable consequences of overloading the stomach are to be avoided at all times of the day, it is especially important to remember the disagreeable results of a hearty meal at night. The evening meal should be a light one and should be eaten three or four hours before going to bed. THE IMPORTANCE OF LIQUID NOURISHMENT.--Every prospective mother should have brought to her attention the great importance of drinking water at regular times and in larger quantities than was formerly her custom. Since water constitutes two-thirds of the substance of our bodies, it is necessary, of course, for everyone; but during pregnancy it is especially necessary for the building of new tissue and for safeguarding the mother's kidneys. Prospective mothers would protect themselves against a number of ailments if they were more careful to drink a sufficient amount of liquids. They may easily determine whether they are doing so, for whenever the urine passed during twenty-four hours measures less than a quart, they are not drinking enough. Generally the daily elimination of urine fluctuates between two and three pints; a larger amount, however, is rather a favorable indication than the reverse. The variations in the quantity of liquids that healthy persons drink make it impossible to say just how much anyone should take. It may be said with confidence, however, that women who are pregnant should consume at least three quarts of fluid every day, and by far the greater portion of this should be water. The rest may be taken in the form of milk, soup, cocoa, and chocolate. Against the moderate use of tea and coffee no valid objection can be raised; the tradition that they may cause miscarriage is incorrect. For well-known reasons the habitual use of strong tea or coffee is always harmful, and it is, therefore, equally as objectionable during pregnancy as at other times. Beverages which contain a small percentage of alcohol, such as malt and beer, may or may not be helpful; they should be regarded as medicine, not to be taken without consulting a physician. THE CHOICE OF FOOD.--There is no diet specifically adapted to the state of pregnancy; the prospective mother may usually exercise the same freedom as anyone else in the selection of food. She should, however, choose what will agree with her and avoid that which she cannot digest and assimilate. Personal experience in the main must guide everyone as to what to eat, and most women may follow the dictates of appetite after they become pregnant as safely as they did before. It is true, of course, that careful scientific observations have taught not only what the nutritional requirements of the body are, but also how the diet may be arranged to satisfy these requirements most conscientiously and economically. "Caloric Feeding" is the name given the method which aims to furnish an individual the exact amount of food, and usually to furnish it at a minimum cost. Its principles are of great practical importance to the commissary of an army or to the purveyor of an institution which provides for large numbers of people; but it is neither necessary nor advisable that the diet of any healthy individual be regulated solely with a view to satisfying the actual requirements of his or her body. Food should possess other qualities than fuel value: first of all it must be appetizing, for appetizing food receives the most thorough digestion. We all know how variable are our appetites. What appeals to one will not appeal to another, and frequently the same person has no appetite to-day for food that she will eat with relish to-morrow. Precise rules, therefore, to guide healthy persons in the selection of their food are not obtainable; neither are they desirable, for the exercise of individual preference possesses notable advantages. In order, however, that there may not also be disadvantages, the prospective mother, like anyone else, must be content to choose food that is simple, wholesome, and of such a character that it will not throw an undue burden upon the digestive organs. During pregnancy some uncooked food should be eaten every day. Ripe fruit answers the purpose admirably. At all seasons of the year fruit of one variety or another, such as apples, peaches, apricots, pears, oranges, figs, cherries, pineapples, grapes, plums, strawberries, raspberries, and blackberries may be obtained and should have a place in the diet. In making a choice personal taste alone need be consulted. Fruit contains a large proportion of water as compared with other articles of diet; and, therefore, is especially capable of quenching thirst. Fruit also lessens the desire for sweets, acts as a laxative, and furnishes mineral material which the body needs. Its laxative effect is most pronounced when it is eaten alone, as, for example, in the morning before breakfast or at night upon going to bed; cooked fruit taken with the meals acts much less effectively. Fruit and vegetable salads are wholesome, but cannot be recommended indiscriminately during pregnancy, for not infrequently the dressing used with them causes discomfort. Under these circumstances it is obvious that one should do without salads. The cereals wheat, corn, rye, oats, and barley are the most prominent source of starch in an ordinary diet. Breakfast foods manufactured from grain are not only nutritious in themselves, but their value is increased by the milk or cream used with them. Bread is the staple starch-containing food in this country, and starch is our main source of energy, but it is necessary to eat only a small quantity of bread, if the diet includes a relatively large amount of vegetables. It is advantageous to use bread made from unbolted flour (Graham bread) or from corn meal, because the coarse undigested residue which they leave stimulates the movements of the intestine and assists in overcoming the constipation which is generally associated with pregnancy. Pastry must be avoided by those who suffer from indigestion; and every prospective mother should eat pastry only occasionally, and not very much of it at any time. The best desserts are raw and freshly cooked fruit, preserves, gelatin, custard, ice cream, and light puddings, such as rice and tapioca. Vegetables should be abundant in the diet of every prospective mother. Some of them, however, are digested with difficulty, and on this account cabbage, cauliflower, corn, egg-plant, cucumbers, and radishes should be eaten sparingly. Occasionally it will be necessary to exclude them from the diet altogether. Other vegetables produce flatulence, and for that reason parsnips and beans may cause discomfort. The prejudice, however, which exists against onions, asparagus, and celery should not be heeded; all of them are harmless, and celery thoroughly cooked with milk is very wholesome. Besides these, moreover, there are many highly nutritious and easily digestible vegetables which can be freely recommended, such as both sweet and white potatoes, rice, peas, lima beans, tomatoes, beets, carrots, string beans, spinach, Brussels sprouts, and lettuce. Vegetable food contains all the material necessary to sustain life, and some persons prefer to adhere strictly to a vegetarian diet. Most prospective mothers, however, find a mixed diet more agreeable, and this is sufficient reason for using it. Furthermore, no fair objection can be raised against the use of animal food, provided the pregnancy is normal. It is important, nevertheless, to remember that meat contains protein in concentrated amounts, and that meat once a day answers every need not only of the mother but also of the growing fetus. The ideal animal foods are milk and eggs; they contain every ingredient necessary to repair old and to form new tissues. But usually the prospective mother may have any animal food she wishes: beef, veal, lamb, poultry, game, fish, oysters, and clams. The relatively large fat-content of pork, goose, and duck renders them indigestible for some persons, who, of course, should not eat them. From what we have learned about foods in general and their relation to pregnancy it is clear that the question so often asked by prospective mothers, "Are there any special directions regarding my diet?" may be briefly answered as follows: Under no circumstances is the need of food increased in the first half of pregnancy. During the last two or three months, while the most notable growth of the fetus is in progress, there is a perceptible increase in the amount of energy expended by the mother, and this may be readily supplied by a glass of milk or some equally simple nourishment between meals. Furthermore, throughout pregnancy, most women are made most comfortable by frequent small meals; they will almost certainly suffer discomfort if heavy meals are eaten three times a day. The most nearly ideal diet consists of very little meat and a comparatively rich allowance of vegetables and fruit. The food should be chosen with regard to individual appetite and should be varied frequently. Thorough mastication always increases the efficiency of a diet. Thus the food will be most perfectly mixed with saliva and broken into fragments which can be readily attacked by the digestive juices of the stomach and the intestines. CRAVINGS.--There is a well-known tradition that women who are pregnant are subject to longings for one article of diet or another, and that unless the desire be promptly gratified the child will be "marked." In the light of what has already been said regarding maternal impressions, this evidently is nonsense. A prospective mother, like anyone else, does frequently desire one article of food more than another. So long as the object of her wish is not obviously harmful, it should be granted; but if it is not granted no harm will come to the child. Remarkable instances in which disgusting substances have been craved and eaten are often talked about and have even found their way into popular novels. The unfortunate victims of these unnatural cravings are not of sound mind. With reference to them a physician of unusually broad experience wrote fifty years ago, "I have never met with any example of this sort; which leads me to infer that these longings are more frequent in books than in the practice of our art." This conclusion is even more fully justified to-day than when originally expressed. THE RELATION BETWEEN THE MOTHER'S DIET AND THE SIZE OF THE CHILD.-- With the beginning of careful, scientific study of the nutritional problems of pregnancy, investigators were interested to learn the source of the material which was used to build up the child's body. Two possibilities suggested themselves: one that the material came from the mother's food and the other that it was derived from her own flesh. In order to determine which of these methods was the natural one, animal experimentation was resorted to and gave identical results in the hands of independent observers. It was found, as I have already stated, that the same diet which had previously kept an animal's weight constant was sufficient to meet her requirements during pregnancy and also to provide for the growth of her offspring. The mother animal was actually found somewhat heavier at the termination of pregnancy than at the beginning. It seemed fair to conclude, therefore, that nutrition had proceeded along more economic lines, and that under these conditions the customary diet had furnished the material for the formation of the young. Still other observations indicated that, if the food is not sufficient for both mother and offspring, it is Nature's plan to protect the young and leave the mother's wants incompletely satisfied. On the other hand, when an unnecessarily large amount of nourishment is taken, the excess is stored partly in the young, and partly in the mother's body. There can be no doubt that the results of such observations upon animals are applicable to human beings. Everyone familiar with the practice of obstetrics knows that women who gratify enormous appetites during pregnancy, especially if they also fail to take exercise, give birth to large children. On the other hand, it is said that children born during times of famine are frequently delivered prematurely, or, if mature, they are small and puny. A similar though much less marked contrast exists between the babies of the working classes and the well-to-do, and clearly indicates that the weight of the baby varies directly with the food of the mother. The quantity of the food is more influential than its quality, though the latter is also a factor in determining the size of the child. An excessive amount of starch or sugar in the mother's diet is stored as fat in the child. On this account it is reasonable to eat sparingly of candy, cake, and other sweets; but further attempts to reduce the weight of the fetus by discrimination against different articles of food are not advisable. The various theories that have been advanced with a view to reducing the size of the child are impracticable; some of them, rigidly carried out, would actually jeopardize the health of both beings. All of them are designed to make the infant's bones soft and to diminish the fat in its body. To this end, generally about two months before the expected date of birth, the mother's diet is arranged to consist chiefly of meat; and as far as possible she is denied candy, sweet desserts, soup, bread, cereals, vegetables, and water. Such a diet overlooks, among other things, the tremendous importance of liquids to the woman who is pregnant. Certainly its indiscriminate use would result in far more harm than good; and no one should adopt it without minute directions from a physician. Attempts to make the infant's bones soft by limiting the mother to food containing extremely small amounts of lime and other minerals are also unnatural, for we have learned that whenever the mother's food fails to contain the material the fetus requires the mother's tissues are called upon to supply it. Under these conditions, therefore, her bones will give up their lime. It is of the very first importance that the mother's nourishment be correct from the standpoint of her own requirements, and such treatment will also redound most beneficially to the child. She should never fall, however, into the error of over-eating, which will not benefit her and will cause unnecessary growth of the fetus. On the other hand, there can be no justification for measures that tend to weaken her. She may be careful, in other words, to avoid over- growth of the fetus, but should not adopt a diet so restricted as to interfere with normal development. So long as her health is successfully maintained, she may give herself no concern as to what the size of the child is likely to be. That is a detail which concerns her physician, and which will be observed by him several weeks before the expected date of birth. CHAPTER V THE CARE OF THE BODY The Bowels--The Kidneys--The Skin--Bathing--Douches--Clothing-- Corsets--The Breasts. If we stop to think it is only too apparent that the human body is a machine. We seize energy in one form and convert it into another, just as truly as do the windmill, the locomotive, and the dynamo. In the case of the human machine, the latent energy of the food is turned into the various activities of everyday life. Our bodies utilize their fuel more perfectly than any machine that man has invented; but they fail, nevertheless, to do so completely. And just as the efficiency of an engine cannot be maintained unless the smoke escapes and the ashes are raked away, so no human being can enjoy health unless his waste products are promptly removed. The task of removal, as most of us know, is assumed by our excretory organs, which include the bowels, the kidneys, the skin, and the lungs. During pregnancy the mother must get rid not only of her own waste products, but also of those of the child. The waste products of the child, if weighed, would not amount to a great deal; but they are by no means negligible. So far as we can tell, it is chiefly on account of their peculiar character that they increase the work of the mother's excretory organs. Whatever the cause, they do increase it, and experience has taught us that these organs must always be kept in a healthful condition to protect both the mother and the child from harm. Consequently a prospective mother who wishes to take proper care of her body must, in the first place, direct her attention toward keeping up the normal activity of all the excretory functions. THE BOWELS.--While pregnant, nine out of ten women suffer from mild constipation. Those who have been previously troubled with this complaint may find it aggravated from the outset, but in most instances it does not appear until after several months have passed. Constipation is explained by the fact that the enlarged womb presses against the intestines; and, as the enlargement increases, constipation generally becomes more pronounced. No doubt there was a time when women, perhaps unconsciously, counteracted this natural result of pregnancy by the use of a diet consisting largely of fruit and vegetables and also by outdoor exercise. Such measures, indeed, still afford the simplest means of overcoming constipation. Throughout pregnancy the bowels should move at least once every day. When they do not, some of the waste material that should be removed is absorbed by the body and seeks to leave it through the organs that are already doing their full share of work. For example, under such conditions, the kidneys, instead of exerting themselves more vigorously, may become less active than they were. It is everyone's duty to form the habit of having the bowels move regularly. Now the most favorable opportunity for assisting the intestines to empty themselves occurs shortly after meal-time, since the involuntary movements of the intestines are most active while digestion is in progress. It should be regarded as an imperative duty, therefore, to grant Nature such an opportunity every morning just after breakfast. This should be done at a definite hour, day after day, even though the inclination is absent; and in many instances the desired habit will be formed. A glass of water on going to bed or on getting up has a laxative effect; and there are other dietary measures which may be employed with advantage. Thus, coarseness of the food, as we know, stimulates intestinal activity, and this fact explains the peculiar value of Graham bread, bran bread, and corn bread. Fresh fruit and vegetables counteract constipation for two reasons, namely, because they leave in the bowels a relatively large amount of undigested substance, and because they contain ingredients that have a specific purgative action. Such ingredients are especially noteworthy in rhubarb, tomatoes, apples, peaches, pears, figs, prunes, and berries. Enemas used as a routine measure are mischievous. They interfere with the "tone" of the bowel-muscle so that it acts sluggishly and bring about a condition in which the bowels will not move without artificial stimulation. At best these irrigations remove no more than the contents of the lower bowel, and should be employed only when there is acute and urgent need of clearing out the rectum. Obstinate constipation is uncommon, and strong purgatives are seldom needed. If they become necessary, a physician should be consulted as to what to take. Whenever dietary measures and exercise, which is discussed in the next chapter, fail to counteract the natural tendency toward constipation, the prospective mother may generally resort to "senna prunes" or some equally simple and harmless household remedy. Senna prunes are prepared as follows: Place an ounce of dried senna leaves in a jar and pour a quart of boiling water on them. Allow to stand two or three hours; strain off the leaves and throw them away. To the liquor add a pound of prunes. Cover and place on the back of the stove, allowing to simmer until half the liquor has boiled away. Add a pint of water and sweeten to taste, preferably with brown sugar. The prunes should be eaten with the evening meal. The number required must be learned from experience. Begin with half a dozen, and increase or decrease the number, as required. The syrup is an even stronger laxative than the prunes. THE KIDNEYS.--Any one may judge for herself whether or not the bowels are doing their work satisfactorily, but not so with the kidneys. For this purpose the urine must be examined by a physician. In spite of this fact, considerable responsibility rests upon the prospective mother, whose duty it is to collect the specimens properly--a detail that is apt to be neglected. It is impossible to urge too strongly the importance of saving, at regular intervals, all the urine passed in twenty-four hours, of protecting it from decomposition, and of sending a sample to the physician. The intervals may be longer at first, for the kidneys have very little extra work to do until the sixth month. Usually, therefore, it is a satisfactory plan to send a sample for analysis the first of each month during the early half of pregnancy; but during the latter half one should be sent the first and the fifteenth of each month. To estimate the exact amount of urine passed in twenty-four hours and to protect it properly, in the first place, the vessel in which it will be collected should be carefully scalded out. As a further precaution against decomposition, add a teaspoonful of chloroform to the vessel, which should be kept covered, and not allowed to stand in a warm room. Unless these details are conscientiously observed, putrefaction may take place and vitiate the analysis the physician wishes to make. The precise amount of urine which the kidneys excrete in twenty-four hours will be determined as follows: At a convenient time, for example at 8 A.M., empty the bladder and throw the urine away; this marks the beginning of the observation. Subsequently, save all the urine passed during the day and night, and finally at 8 o'clock the next morning empty the bladder and add this urine to that previously collected. The total amount, thus collected, should be measured. It is unnecessary to send all the urine to the physician; six ounces, somewhat less than half a pint, will be enough. But the physician should know what the total amount was found to be; therefore, a record of the measurement, the date, and the patient's name should accompany the sample. If limited to a single fact about the urine, it would be most helpful to know the amount passed during the twenty- four hours. In this way, as I have already pointed out, the patient herself may derive valuable information, for if the urine is scanty in amount--that is, less than a quart--she should drink more water. Unscrupulous newspaper advertisements alarm people through incorrect statements about trouble with the kidneys. For example, they declare that a sediment in the urine is a sign of disease; but that is false. The mere act of cooling sometimes causes substances to crystallize out of perfectly normal urine. Or, putrefactive changes which frequently take place after the urine has stood for a time may cause some of its normal constituents to be precipitated. A sediment, either white, pink, or yellow, may indicate that the urine is too concentrated, and consequently means that the individual should drink water more freely; but it generally means nothing more serious. The really important abnormal constituents of the urine, namely, albumin and sugar, never form a sediment. "Pain in the back" is a complaint frequently used to defraud the public. This symptom does not indicate Bright's disease. It is generally due to the muscles far away from the kidneys, with which, usually, the pain has nothing whatever to do. Similarly a desire to pass the urine frequently does not indicate any disturbance of kidney function, but is explained by the pressure of the enlarged womb against the bladder; it is a very annoying, yet a natural, result of pregnancy. THE SKIN.--The functions of the skin are at the very foundation of health. It protects the delicate structures which it covers, assists in the regulation of the temperature of the body, and excretes waste products. The excretory function of the skin is always active, but we are unconscious of this activity except on warm days and at times when we perspire freely. In the coldest weather, however, the body throws off what physiologists call the "insensible perspiration." The most important measures for the care of the skin are those intended to insure the activity of the sweat glands, namely, bathing and proper clothing. But before considering these measures, we will describe certain alterations in the skin which cannot escape the notice of the prospective mother, and which she is likely to misinterpret. On account of the growth of the uterus the abdominal wall is stretched during pregnancy. To a certain degree the skin yields to the distention, but it finally cracks, and lines appear which are commonly called "pregnancy streaks." At first they are delicate and pink or blue in color; later they become white and more extensive. The streaks indicate the situation of small breaks in the deeper layer of the skin, which is less elastic than the upper layer. They are not painful, and should never cause anxiety. Their size and number vary with the degree of abdominal distention, which in turn depends upon various factors, such as the size of the child and the quantity of amniotic fluid. Although these streaks are most frequently located upon the lower part of the abdomen, they may extend to the outer sides of the thighs; and occasionally appear over the breasts, since they too enlarge during pregnancy. Stretching of the skin, of course, is not confined to pregnancy; consequently, the same kind of streaks often appear in people who are growing stout. Attempts to prevent or limit the pregnancy streaks prove futile. There is a common belief that they may be prevented by the use of vaselin, goose-grease, mutton-fat, or some one of a variety of lotions; but this teaching is not borne out by experience. None of these applications, however, are harmful, and there can be no objection to using them except that they cause needless soiling of the clothing. After the child is born the streaks fade of their own accord, though they rarely disappear entirely. In certain localities the skin grows darker during pregnancy. We have already referred to the deepening of the color around the nipple as one of the signs of pregnancy; a similar but much less pronounced discoloration occurs about the navel, which also becomes shallow and may begin to pout in the latter months of pregnancy. About this time, with very few exceptions, there appears a more or less intense brown line which runs downward from the navel in the middle of the abdomen. Sometimes, though not very often, small dark areas, which have been called "liver spots," appear elsewhere over the body. The name is unfortunate, for the spots do not indicate a disorder of the liver. At present it is generally admitted that alterations in the color of the skin during pregnancy are due to deposits of iron. This mineral substance, among others, as we have learned, is required for the development of the embryo. The child is born with a supply of iron calculated to meet its needs for about a year. Such a reserve is necessary, as Bunge has pointed out, because human milk does not contain enough iron to satisfy the infant's requirements. During pregnancy, therefore, the mother's blood transports iron to the placenta, where it can be absorbed into the child's system; and while being thus transported some of it is deposited in the maternal tissues. The deposits are especially frequent, as I have mentioned, in the middle line of the abdomen, on account of the arrangement of the blood vessels there. Deposits elsewhere may depend upon other conditions; but whatever their cause the pigmentation vanishes a short time after the birth. Alterations in the color of the skin have no effect upon its excretory function, which, indeed, generally becomes more active during pregnancy. According to one estimate, the average person possesses twenty-eight miles of sweat glands. If these figures are not sufficient to demonstrate the importance of the skin as an excretory organ, surely no one will fail to be impressed by the tragic result which in one case followed throwing all the sweat glands out of action. This was brought about in the case of a young boy whose body was covered with gold leaf to provide entertainment at a Parisian festival. The living statue was not exhibited, however, for shortly after the youth was gilded he became ill and died. In health more than a pint of water is eliminated through the skin every day, and along with it waste products are removed from the body. Exercise, hot drinks, warm weather, and heavy clothing promote the activity of the sweat glands. Under certain circumstances physicians endeavor to relieve the kidneys by stimulating their patients to perspire freely. It should be clear, therefore, that when a prospective mother naturally perspires it is a good indication. Attempts to stop the perspiration are always ill advised; rather should this function be encouraged by keeping the skin in good condition with baths and warm clothing. BATHING.--The accumulation of dead skin, grease, dust, and dried perspiration on the surface of the body hinders the actions of the sweat glands. Some of this material is wiped off by the clothing, and more of it is removed by washing with plain water; but the most effectual cleansing results from a liberal use of warm water and soap. Since the prospective mother must throw off the waste products of the embryo as well as those of her own body, it is obvious that cleanliness is never more important than during pregnancy. For this reason she should take a tepid tub bath or shower every day. It is not necessary that the temperature of the bath be determined with accuracy or that it be always the same; but generally a temperature between 80 and 90 degrees F. is found most agreeable. At this temperature a bath is termed "indifferent," because it is neither stimulating nor depressing; it is employed purely for cleansing the body. Every part of the body should be well soaped, and from ten to fifteen minutes should be given to washing all the exposed surfaces. The best time for such a bath is just before going to bed, though there is no objection to taking it during the day, provided that two hours have passed since the last meal, and that another hour is permitted to elapse before one goes out of doors or undertakes anything that requires exertion. Prolonged hot baths are fatiguing. They draw the blood from the interior to the surface of the body; and during pregnancy they are particularly depressing. Vapor and steam baths have a similar action and should never be taken without the consent of a physician. They serve admirably for the treatment of rare complications of pregnancy; but, like medicine, their use should be limited to cases in which they are clearly indicated. Unless disagreeable results are noticed, those who have become accustomed to cold baths may continue to take them during pregnancy, but others should not. If, however, the temperature of the water is modified so that it will not produce a shock, no one need omit the morning plunge or shower which most persons find invigorating. Sponging answers the same purpose, for the intent of the morning bath is not to cleanse the body but to arouse the circulation. A thorough rub-down assists in bringing the blood to the surface of the body. Bath and massage together thus constitute a kind of skin gymnastics especially beneficial throughout pregnancy. Although hot foot-baths have sometimes been thought to cause miscarriage, there is no good reason for believing they ever do. Sea- bathing, on the contrary, may be directly responsible for such a mishap. It is true that pregnant women sometimes indulge in surf- bathing without harmful results; nevertheless the danger of miscarriage they assume is not slight. The shock of the low temperature, the exertion required to keep a firm footing, and the pounding of the surf against the abdomen are all unfavorable influences which more than counterbalance any advantage of such a bath. On the other hand, there is slight risk if any in bathing in a quiet stream or lake. DOUCHES.--A great many women have the conviction that the vagina is not clean and should, therefore, be regularly cleansed by means of irrigations. This assumption is false and the treatment based upon it is unnecessary. In structure the walls of the vagina closely resemble the skin, but unlike the skin they do not contain glands; the vagina, therefore, has nothing to do with the elimination of waste products from the body. The secretion which issues from the vagina really originates in the glands around the mouth of the womb, and serves to protect the birth-canal against infection from harmful bacteria. Careful examinations have shown that under normal conditions, which of course include pregnancy, disease-producing bacteria are absent from the vagina; in this respect the vagina is even cleaner than the skin, for disease-producing bacteria are present on the surface of the body. The vaginal secretion becomes more abundant during pregnancy, and the increase is interpreted as an additional guarantee against infection at the time of labor. So far as possible, therefore, this natural antiseptic should not be disturbed. The advice to abstain from douches will not be adopted by every prospective mother without protest, for, as I have said, many women regard them as necessary to cleanliness. Others who have delicate skins are occasionally annoyed by the irritation of the vaginal secretion, which is not only increased during pregnancy but has a more pronouncedly acid character. Under extraordinary circumstances, it may be permissible to use douches in the early part of pregnancy, but it is practically never advisable to do so during the month preceding the expected date of confinement. Furthermore, at no time should the use of douches be begun without consulting a physician. A more rational hygienic measure for the relief of itching and smarting about the vaginal orifice consists in removing the secretion as soon as it appears. In other words, the external parts should be kept clean and dry. Great comfort is often derived from the use of a "sitz-bath," which may be easily prepared by placing a small tub upon a low stool and pouring in warm water (about 90 degrees F.) until it is five or six inches deep. Cold sitz-baths are useful in the treatment of hemorrhoids. Whether the bath be hot or cold, the treatment should continue from ten to fifteen minutes, and after it the skin should be thoroughly dried. A special form of tub, called a "bidet," has been devised to facilitate bathing the parts in question. The device is convenient but expensive, and is certainly not essential. Every purpose will be served by the small tub, provided the desired temperature of the bath is properly maintained by changing the water as may be necessary. CLOTHING.--In these days at least it is not idle to remark that the first use of clothes is to keep the body warm; all other services they are made to perform are secondary and relatively unimportant. There are very good reasons, to be sure, for dressing neatly and even for dressing in accord with the fashion, so long as the prevailing styles are not harmful. Odd as it may seem, these are matters which are not without significance for the physical well-being of a prospective mother. Neat and comfortable clothing will help her to overcome a natural inclination to become a "stay-at-home," and on this account an inconspicuous way of dressing is often more valuable than medicine. So long as they do not attract attention, most prospective mothers go out in the day time, mingle with their acquaintances, and attend public places of amusement. Deference to fashion, therefore, may contribute substantially to good health. Yet no prospective mother can afford to forget that first of all her clothing must keep the body warm. Our clothing confines a cushion of air which prevents the escape of the heat that we generate. Now, since dry air conducts heat poorly and moist air conducts it readily, the underclothes should be made of material that absorbs the perspiration; otherwise the heat that the body generates is quickly lost. Woolen garments effectually absorb the perspiration and should be given the preference. Most persons who cannot wear wool next the skin must choose cotton, since silk and linen are much more expensive; there is not in this, however, a serious deprivation. Cotton undergarments are perfectly hygienic; adapting their weight to the season of the year, one will find them equally satisfactory in summer and winter. Except in summer every inch of the body should be covered with the underclothing; this means that high-neck and long-sleeve shirts and long drawers should be worn, for healthful activity of the skin can thus be best preserved. It is well known to physicians who practice obstetrics that the kidneys fail in their work more frequently during the winter than the summer. To my mind, this is chiefly explained by the way women dress. Even with light clothing the sweat glands respond actively to the heat of summer and thus relieve the kidneys, but in cold weather the sweat glands will not remove their share of the waste products unless the clothing is warm. Nature generally indicates that the body should be kept warm during pregnancy. Many prospective mothers complain of perspiring freely; others, if reproached because they are not clad warmly enough, reply that they must wear light clothing to keep from perspiring. Thus they discount or render absolutely ineffective a most important natural safeguard against serious complications. It cannot be too strongly emphasized that warm clothing helps to maintain healthful activity of the kidneys quite as much as a proper amount of exercise and the drinking of a suitable quantity of water. The texture of the outer garments should take into account this same quality of warmth; in other respects in selecting them personal taste is an excellent guide. Outfitters carry a variety of maternity garments; patterns for such garments are also sold by dealers, so that those who cannot afford the ready-made clothes will find it easy to have them made at home. Alterations in the clothing are compulsory as pregnancy advances, and should be timely, made in anticipation of inevitable development rather than in response to it. No prospective mother need go to the extreme of "Reform Clothes"; her apparel should illustrate both her good sense and her personal pride. It is obviously even more harmful during pregnancy than at other times to cramp the body by the clothing; the chest and the abdomen, the parts most likely to be compressed, are at such times most in need of freedom. To a slight degree natural causes always compress the chest from below upward; and on this account nothing should be allowed to hamper the expansion of the lungs from side to side. On the other hand, if the waist is constricted, not the breathing movements alone but also the growth of the womb will be interfered with. In order to avoid such disagreeable consequences, and at the same time to limit the extent of the maternity wardrobe, skirts may be fitted with practical devices which permit letting out the waistband as occasion demands. So far as possible, however, all the clothing should be hung from the shoulders, and under no circumstances should heavy skirts be worn. Shoes contribute toward health, or the lack of it, more significantly than the average person realizes. It is particularly advisable that prospective mothers should select foot-wear with care, because their bodies are heavier than usual. The feet are apt to become swollen in the latter months of pregnancy, and consequently the shoes should be roomy, but should always fit. To escape the discomfort of tight shoes, it is generally advisable to wear a shoe an inch longer and broader than the foot at rest. High heels have been proved a frequent cause of back-ache; half of such cases, in all probability, may be thus explained. High heels tilt the body forward in such a way that the erect posture can be maintained only by an unnatural tenseness of the back-muscles. Some strain of this kind is inevitable during the latter months of pregnancy on account of the enlargement and the position of the womb; it is reasonable, therefore, to minimize it by wearing low, broad heels. Besides being responsible for many cases of backache, high heels add greatly to the danger of tripping and falling; for this reason alone they should not be worn. Improper foot-gear and not the joints themselves deserve the blame for weak ankles. To prevent "turning the ankle," it is not necessary to restrict oneself to high shoes, but merely to see that the shoes that are worn have low heels and broad soles. Such shoes provide a sure, firm footing, and this the prospective mother particularly needs. CORSETS.--No question connected with women's dress has provoked so much discussion as the use of corsets. "Are corsets necessary to health?" has been differently answered by those who would appear to be equally competent authorities. In the time of our savage ancestors we may safely conclude that they were not used; and, therefore, it is really a question as to whether their continued use for generation after generation has finally made some support of this kind indispensable to the average woman. While that matter has not as yet been settled, it is obvious that custom is really responsible for the conviction of many women that they appear slovenly without corsets. On the other hand, not a few women, unmindful of fashion, never wear them; they testify that they are healthier for doing so. Whether this be true or not, no one can honestly believe that corsets will soon be banished; and the practical problem is to distinguish between those that may do good and those certain to do harm. During pregnancy the abdomen tends to fall forward and slightly downward, and though it is in pregnancies after the first that this tendency is most marked, every prospective mother will be more comfortable if she wears some sort of support to counteract what physicians term a "pendulous abdomen." Such a condition can be prevented by the use of several appliances, and the device best suited to the case should be chosen. Those who have never become accustomed to corsets will probably find a corset-waist or an abdominal supporter the most comfortable and useful. But the average young woman who has previously employed a sensible, well made, and loosely fitting corset need make no change until the third or fourth month of pregnancy. From then on she should wear a corset especially designed to conform with the changes that naturally occur in the figure. There is a plan, wrong in principle, which many adopt. Reasoning that it will be necessary to change the corset from time to time, and desiring to practice economy, a number of women purchase the cheapest corset at hand. This they replace with a larger one of the same style from time to time. The result is that an improperly fitting garment is worn continuously; and, in the end, this plan proves almost as expensive as, and far less suitable than, a proper corset, which would remain serviceable throughout pregnancy, or at least until a few weeks before confinement. Most, and probably all, of the injuries for which corsets are responsible result from their misuse. Naturally serious consequences may be expected if they are worn with the design of compressing the abdomen so as to render pregnancy less noticeable or perhaps to conceal it altogether. Thus worn, the corset becomes not only an instrument of torture but a source of danger both to the mother and to the child. Fortunately there are very few women who fail to appreciate the risk of thus striving to disguise their condition; and generally it is the needless discomfort, the trifling ills thoughtlessly inflicted upon themselves, that prospective mothers must be taught to avoid. At present there are manufactured a number of excellent maternity corsets; but there are also worthless types, and some likely to do harm. To judge them fairly they must be examined with regard to several requirements. In the first place the corset should not be stiff and should always be capable of easy adjustment; it must never interfere with the activity of any organ. As _enceinte_, the French word meaning pregnant, signifies, the prospective mother should be unbound. Tight clothing, as we have already remarked, hinders the breathing movements; it also interferes with the action of the heart, and occasionally causes the child to assume an unfavorable position within the uterus. The adjustment of the maternity corset to the progressive development of the body is generally provided for by means of extra lacings down the sides, and by the insertion of elastic material. The maternity corset, in the next place, must support the enlarged uterus. Correctly shaped and worn, it extends well down in front, fits snugly around the hips, and arches forward so as to conform to the curve of the abdomen. In place of the arching, or "cupping" as manufacturers call it, some maternity corsets have attached to their lower edge limp flaps of a strong fabric which lace together. The maternity corset-waist also should extend well under the abdomen and fit snugly around the hips. Finally, the corset should support the bust; the unpleasant sensations due to congestion of the breasts can be relieved most successfully by elevating them. It is exceedingly important, however, that the upper part of the corset should fit loosely, for otherwise the development of the breasts may be hindered, and the nipples depressed. As a further precaution against pressure above and also to secure the proper amount of support below, it is generally advisable to begin putting on the corset while lying down. In every case the corset should be laced from below upward; if laced in the opposite direction it fails to lift the womb and tends to push all the abdominal organs downward. Any kind of corset is likely to become uncomfortable toward the end of pregnancy; and of course should then be discarded. An abdominal supporter made of woven linen or rubber is frequently used to advantage during the last three or four weeks. With the first pregnancy the supporter is rarely necessary, but with subsequent ones it is frequently useful as early as the sixth month and is indispensable later. A substitute for the manufactured supporter can be made at home. Some such device often facilitates turning in bed, and on that account may be found even more useful at night than during the day. THE BREASTS.--Personal hygiene during pregnancy includes the preparation of the breasts with a view to success in nursing. All measures which promote the health of a prospective mother also serve to equip her for the nursing period; and in that sense the directions just given for the care of the body, as well as the rules to follow in the next chapter regarding a wholesome way of living, bear directly upon lactation. But there are also local measures to be adopted, some of which, such as supporting the breasts and avoiding constriction by the clothing, have already been mentioned. Finally, the nipples must be toughened and, if short or flat, they must be drawn out, for the best supply of milk will count for nothing if the infant cannot nurse comfortably. Some approved method of toughening the nipples so that they will not be injured by the sucking efforts of the infant, no matter how vigorous, should be begun eight weeks before the expected date of confinement; to start earlier will do no harm, but it is quite unnecessary. A number of procedures have been advocated, but in my own experience the following simple method is the best. The nipples are scrubbed for five minutes, night and morning, with soap and warm water. Generally, a soft brush, such as a complexion-brush, is satisfactory; but if this is too harsh, at first a wash cloth may be used. After having been thoroughly scrubbed the nipples are anointed with lanolin and covered with a small square of clean, old linen to prevent soiling of the clothing. Another method widely used, but somewhat less trustworthy, consists in bathing the nipples and applying a dilute solution of alcohol. Formerly brandy, whiskey, or cologne were recommended, but at present the following solution is commonly used. A tablespoonful of powdered boric acid is added to three ounces of water and thoroughly mixed. This is poured into a six-ounce bottle, which is then filled with grain alcohol (95 per cent). The solution is applied twice a day with a small piece of absorbent cotton. Well-formed nipples need only be toughened, but depressed nipples require additional treatment; and this should be begun about the middle of pregnancy. The old-fashioned way of making the nipple more prominent was to cover it with the mouth of a bottle which had previously been warmed. The vacuum created, as the bottle cooled, drew the nipple out. Similarly, the bowl of a clay pipe was sometimes placed over the nipple; the patient sucked the stem, the nipple was drawn into the bowl, and with persistence day after day success was often attained. A similar and somewhat more aesthetic procedure is now employed. The nipple is seized between the thumb and finger and alternately pulled out and allowed to retract. These manipulations, if faithfully practiced for several months, generally make the nipple prominent enough for the infant to grasp. Occasionally patients need to wear a contrivance sold at instrument stores which consists of a circular piece of wood modeled to fit the breast and perforated in the middle to accommodate the nipple. The appliance should not be used unless a physician thinks it necessary. Directions regarding the care of the breasts are sometimes taken lightly, yet such care is not a minor duty. Now and then a patient will pass through pregnancy uneventfully, will be delivered without difficulty, and will enter upon what promises to be a rapid convalescence when her recovery is interrupted by the development of inflammation of the breast. Because such a complication may be prevented, its appearance is the more to be regretted. Furthermore, the responsibility for its prevention usually rests with the patient herself. If she has been conscientious in preparing the nipples and continues to watch them throughout the nursing period, the annoyance of an abscess will almost certainly be prevented. CHAPTER VI GENERAL HYGIENIC MEASURES The Need of Fresh Air--Outdoor Exercise--Massage and Gymnastics--The Influence of Work upon Pregnancy--Relaxation and Rest--Is Traveling Harmful?--Mental Diversion. Besides the hygienic measures described in the preceding chapter, whose observance should be recognized as more or less obligatory, there are more general questions of conduct, such as exercise, relaxation, mental occupation, and amusement, which are also important. These measures, although frequently determined merely by personal inclination or by the force of circumstances, nevertheless exert a tremendous influence upon health. This fact a prospective mother is likely to realize, for she is certain to consider not only her own welfare but also that of the expected child; and she is consequently concerned about details of conduct that most persons would regard as trivial. She may, indeed, be too conscientious. Well- meaning friends, sometimes in reply to her questions and sometimes without solicitation, offer her a great deal of advice. Their counsel, aside from the fact that some of it may be misleading, may have the effect of prescribing so many rules that, if she followed them all, she would never lose sight of the fact that she is pregnant. Such a degree of self-consciousness is certain to make her unduly apprehensive. The proper attitude of mind is quite the opposite; so far as possible the prospective mother should forget that she is pregnant. This state of mind is really the more rational, for if a woman's daily life has previously been in accord with such simple rules of health as everyone should adopt, the existence of pregnancy calls for very slight changes. It does not, for example, condemn her to inactivity and seclusion, for it is advisable to lead a moderately active life during pregnancy. Of course, such obvious indiscretions as prolonged exertion, violent exercise, and fatiguing journeys should be avoided, for transgression of the laws of health brings its own punishment, generally in the form of discomfort, more quickly, and often more severely, during pregnancy than at other times. Yet, on the whole, it is more frequently necessary to emphasize to prospective mothers what they should do than what they should avoid. This happens to be the case because, as a rule, they are inclined to become recluses. For fear of attracting attention they often wish to give up outdoor exercise during the day; they stay away from public places of amusement, and deny themselves other pleasures to which they have been accustomed. Against this tendency they must be warned, for if they yield to it they will surely be the worse off both physically and mentally. Every prospective mother should make up her mind to enjoy recreation out of doors regardless of comments. THE NEED OF PURE AIR.--Outdoor life has been so urgently advocated of late that the public has come to appreciate its benefits almost as fully as do physicians. The existence of pregnancy does not lessen, but rather enhances, the value of fresh air; in order to enjoy the best health during this period one should spend at least two hours out of doors every day. Neither the season of the year nor the state of weather should modify this obligation. If the sun is shining the "airing" is more delightful, but it should be taken in bad weather also, on a protected porch or in a room with the windows wide open. Even when the injunction to be regularly out of doors is observed women are accustomed to spend the greater portion of the day in the house, and on that account special attention must be given to keeping the air of the house pure. Ventilation takes care of itself in summer, when the windows are open, but in cold weather, when in our anxiety to keep the temperature comfortable we may overlook the need of fresh air, it demands close attention. The necessity of ventilation at all times is due, of course, to the composition of the atmosphere and to the changes produced in it as we breathe. The air about us is a mixture of gases, of which oxygen and nitrogen are the most important. Although nitrogen, which constitutes four- fifths of the atmosphere, is taken into our lungs in breathing, we make no use of it, but breathe it out in precisely the same condition as we take it in. As chemically combined in the food-stuff known as protein, nitrogen is indispensable to animal life; but our bodies make no use of the gaseous form of nitrogen. Oxygen, on the other hand, supports life; and though it forms less than one-fifth of the atmospheric air, it is present in ample amount for our needs. After we draw air into our lungs, the oxygen it contains is absorbed by the blood and used by the tissues. In return our tissues give up a waste product, carbonic acid gas, which is thrown off by the lungs. It is interesting to observe that the carbonic acid gas which animals exhale supports the life of plants, and that the plants, under the influence of sunlight, give back pure oxygen to the atmosphere. Obviously, the complementary relation exhibited here is of mutual benefit. The average person uses about four bushels of air a minute. Consequently, rooms that are occupied must be constantly replenished with fresh air; otherwise the point is quickly reached where the occupants are breathing an atmosphere that is not only poor in oxygen but saturated with carbonic acid gas and other impurities conveyed by the breath. Foul air such as this causes headache, dizziness, faintness, nausea, and occasionally even more serious disturbances. Those who live in "close" rooms day after day grow pale and languid; their appetite fails and some of their natural power of resistance against illness is lost. Many people are unhealthy simply because they neglect to supply their living quarters with a steady stream of air from the outside. While it is impossible to keep the air in any room as pure as the outside atmosphere, perfectly satisfactory ventilation can be easily arranged. Some of the impure air in a house is always escaping of its own accord and its place is taken by air from the outside. Thus, the cracks around the windows and doors let bad air out and good air in; and, besides, most building materials are porous. These natural paths, however, must be supplemented. The simplest device for ventilation, which is also the best, consists in opening a window at the top and bottom. The width of the opening may be regulated so as to permit the air in the room to change without occasioning disagreeable drafts; if necessary the current may be broken by a screen of some pervious material placed in the opening. The bed-room should always be supplied with plenty, of fresh air, which "quiets the nerves" and helps one to sleep soundly. Furthermore, the temperature of the bed-room should be lower than the temperature of rooms occupied during the day. Both these requisites will be properly met by leaving a window open at night, which may be done throughout the year in most climates, if one puts on enough covering. There is no danger of catching cold from sleeping with the window open; on the contrary, breathing fresh air day and night is one of the best ways to prevent colds. OUTDOOR EXERCISE.--Outdoor exercise is indispensable to good health. It benefits not only the muscles, but the whole body. By this means the action of the heart is strengthened, and consequently all the tissues receive a rich supply of oxygen. Exercise also promotes the digestion and the assimilation of the food. It stimulates the sweat glands to become more active; and, for that matter, the other excretory organs as well. It invigorates the muscles, strengthens the nerves, and clears the brain. There is, indeed, no part of the human machine that does not run more smoothly if its owner exercises systematically in the open air; and during normal pregnancy there is no exception to this rule. Only in extremely rare cases--those, namely, in which extraordinary precautions must be taken to prevent miscarriage--will physicians prohibit outdoor recreation and, perhaps, every other kind of exertion. Under such circumstances the good effects that most persons secure from exercise should be sought from the use of massage. The amount of exercise which the prospective mother should take cannot be stated precisely, but what can be definitely said is this-- she should stop the moment she begins to feel tired. Fatigue is only one step short of exhaustion--and, since exhaustion must always be carefully guarded against, the safest rule will be to leave off exercising at a point where one still feels capable of doing more without becoming tired. Women who have laborious household duties to perform do not require as much exercise as those who lead sedentary lives; but they do require just as much fresh air, and should make it a rule to sit quietly out of doors two or three hours every day. It will be found, furthermore, that the limit of endurance is reached more quickly toward the end of pregnancy than at the beginning; a few patients will find it necessary to stop exercise altogether for a week or two before they are delivered. Walking is the best kind of exercise, but long tramps are inadvisable during pregnancy, except for those who have previously been accustomed to them. Most women who are pregnant find that a two or three-mile walk daily is all they enjoy, and very few are inclined to indulge in six miles, which is generally accepted as the upper limit. Perhaps the best way to measure a walk is by the length of time it consumes. Accordingly, a very sensible plan is to begin with a walk just long enough not to be fatiguing and to increase it by five minutes each day until able to walk an hour without becoming overtired. It is always advisable not to crowd the exercise of a day into a single period but rather to take it in several installments, for example, an hour in the morning, and another in the afternoon. Under all circumstances, it must never be forgotten that the feeling of fatigue is a peremptory signal to stop, no matter how short the walk has been. Very few outdoor sports can be unconditionally recommended to a prospective mother. Because athletic exercise is either too violent or else jolts or jars the body a great deal, it is especially dangerous in the early months of pregnancy--the only time when it is likely to be at all attractive. Croquet, alone, perhaps, is free from these objections. Although golf and tennis are by no means certain to bring on miscarriage, they involve a risk which, slight though it may perhaps be, will not be assumed by cautious women. Horseback riding during pregnancy is injurious. We occasionally hear of women who have ridden horseback without immediate harmful consequences, but they have nevertheless exposed themselves to danger unnecessarily. It is better to give up skating and dancing also than to run the risk of accident, especially since these diversions are attended with some danger of falling. In a general way, whenever the question of entering into any kind of recreation must be decided, it is wise to err on the conservative side rather than risk overstepping the limit of endurance and having to pay a penalty more or less severe. Carriage riding cannot take the place of walking and can scarcely be classed as exercise; it is wholesome, nevertheless, because it takes the participant out of doors and provides a change of scene. Certain details, however, should be carefully observed; thus, a safe horse, a carriage that rides easily, and smooth roads should be selected. Similar advice pertains to motoring; with smooth roads, a cautious driver, and a comfortable machine, short rides in an automobile are not harmful. Carriage riding and motoring are particularly serviceable as a means of getting outdoor diversion during the last few weeks of pregnancy. MASSAGE AND GYMNASTICS.--If a prospective mother is obliged to stay in bed several weeks, massage may be useful; otherwise there is no necessity for this treatment. Whenever required, massage should if possible be given by an experienced masseuse. If this is out of the question and the patient must rely upon one of her friends, it should be understood that "general massage" is needed; in other words, one part of the body after another should be gone over systematically. With an inexperienced masseuse, however, it will be safer not to massage the abdomen, since awkward, vigorous, or prolonged manipulations in that locality may provoke painful uterine contractions. Rubbing the breasts also can do no good; on the contrary, it may do harm by bruising them. The best time of day to have massage is in the morning, at least an hour after breakfast. The duration of the treatment will depend upon the patient; it should always cease as soon as she begins to feel tired. After one has become accustomed to it, massage may generally be continued for an hour. The room in which it is given should be cool, and after the treatment has been completed the patient should be wrapped warmly and left undisturbed for half an hour. Gymnastics, like massage, are useless to those who can enjoy outdoor exercise. Walking more perfectly strengthens the muscles which take part in the act of birth than any system of "home calisthenics" that has been suggested. In some conditions which make walking inadvisable the use of calisthenics will be helpful. These exercises generally consist in breathing movements and in movements of the extremities, especially the legs, which bring into play the same abdominal muscles that are used at the time of delivery. A detailed description of the exercises is here purposely omitted, since gymnastics should not be used unless advised by a physician, who should watch their effect and thus be guided as to whether the patient should continue them. THE INFLUENCE OF WORK UPON PREGNANCY.--No single influence is more unfavorable to comfort and health during pregnancy than is idleness, so that every prospective should occupy herself with congenial work and fitting diversions. The kind of occupation makes no essential difference, so long as it does not overtire either the body or the mind. Since most women are absorbed in the affairs of the home, it may be well to begin by saying that the existence of pregnancy by no means requires the abandonment of domestic duties. On the contrary, when it is convenient, the prospective mother should have a share in the housework. She should not undertake everything that is to be done about the house, for no matter how small the household there are certain duties too laborious for her to attempt; these will be easily recognized and turned over to someone else. Even with regard to those tasks which lie within her strength she should use a little forethought to prevent unnecessary steps. All kinds of violent exertion should be avoided--a rule which at once excludes sweeping, scrubbing, laundry work, lifting anything that is heavy, and going up and down stairs hurriedly or frequently. The use of a sewing machine is also emphatically forbidden. Treadle work is known to be one cause of swollen feet, of varicose veins, and of aches and pains in the legs or the abdomen. If a prospective mother has to do her own sewing, the machine should be fitted with a hand attachment or motor. Except for the possibility of straining the eyes, there is no objection to sewing by hand. Besides the activities that should be excluded because they may be harmful, every housekeeper will find enough to keep her busy. It is generally not a small task to suggest what others shall do and to see that orders are properly carried out; consequently those who take no part in the actual work may retain an absorbing interest in their domestic affairs by directing them. Such direction, indeed, should, toward the end of pregnancy, constitute the mother's sole participation in the housework. In a general way the amount and the kind of work that a woman may be permitted to undertake during pregnancy depend upon what she has been used to. It is not unlikely that anyone who is unaccustomed to manual labor may injure her health and cause the pregnancy to end prematurely if she undertakes hard work. On the other hand, women of the working classes sometimes continue at their occupations to the natural end of pregnancy without harmful consequences. It is undeniable, however, that among this class miscarriages are more frequent than among the well-to-do. Furthermore, the average birth- weight of mature infants whose mothers have remained at work during the last three months of pregnancy is ten per cent. less than the average birth-weight of infants among the leisure class. This matter of the baby's weight is not always serious in itself, but indicates in the case of working women who are pregnant the existence of a strain that sometimes leads to serious accidents. The employment of women during pregnancy and immediately thereafter is regulated by law in many countries. For example, the laws of Holland, Belgium, England, Portugal, and Austria prohibit the employment of women in factories during the last four weeks of pregnancy or the four weeks following childbirth. Such employment is unlawful in Switzerland for two weeks before and six weeks after childbirth. There is no legal regulation of the employment of pregnant women in either Germany or Norway, but the laws of both countries forbid them to return to work until six weeks after they have been delivered. Among civilized nations Turkey, Russia, Spain, Italy, France, and the United States make no attempt to regulate employment either before or after childbirth. Of course there are strong sentimental reasons for relieving prospective mothers of the necessity of earning a living, but there are also excellent hygienic reasons against many kinds of employment. For example, it should be unlawful to employ them in chemical industries where, owing to their condition, they are especially liable to be injured by the materials which they handle. Jacobi states that the worst occupation for pregnant women is working with metals, in particular lead; more than half of them suffer miscarriage or premature confinement. Furthermore, the health of the child may be endangered if the prospective mother does hard work of any kind. This is true chiefly because she does not have appropriate intervals of relaxation, for it is a firmly established principle that a prospective mother must be free to rest the moment she begins to feel tired. The least, therefore, that can be done to better prevalent conditions among women who must work during pregnancy is to require by law a reduction in the number of their working hours, and to protect them from the necessity of earning a living for two months after they have been delivered. RELAXATION AND REST.--During the early months of pregnancy many women complain that they feel enervated, and tire quickly even when they do things which were formerly done with ease; this experience is so common that it can scarcely be considered other than natural. Curiously enough this is also the period during which the attachment of the ovum to the womb is relatively insecure, and therefore the inclination to be quiet is justified by the prevailing anatomical conditions. No prospective mother should struggle against the inclination to rest; she should yield to it in spite of the advice to the contrary which older women are apt to give. Furthermore, it is especially important about the time when a menstrual period would ordinarily be expected to be guided by this impulse not to be active, since overexertion then, more than at other times, is apt to be followed by miscarriage. Except in rare cases the observance of this precaution is less urgent after the fourth month, when the ovum has become more securely attached to the womb. But again, toward the end of pregnancy the development of the mother's body necessitates a comparatively large amount of rest; patients who continue to exert themselves may expect to suffer from shortness of breath and a number of other annoyances. In order to save needless steps and to avoid confusion and worry, it is always helpful to map out beforehand what must be done in the course of the day. Ideally, such a schedule should set apart intervals for relaxation and rest. In the morning, for example, while the housework is in progress, it is important to stop occasionally, if only for a few moments, and lie down on a couch. After the midday meal it is advisable to undress and go to bed. Even though one does not fall asleep, an hour or two of complete relaxation will be beneficial. A nap in the afternoon does not interfere with sleeping at night provided plenty of exercise has been taken during the day. In this way walking in the late afternoon or early evening helps to secure a good night's rest. During the first six or seven months, pregnancy, in itself, does not cause sleeplessness, but later, as a natural result of the enlargement of the womb, there are several disagreeable symptoms which may cause broken rest at night. In the later months the weight of the womb requires women to sleep on the side, and for some of them this position is awkward at first. Frequently the pressure makes it necessary to get up several times during the night to empty the bladder. In a few cases also the compression of the chest interferes somewhat with breathing. When insomnia is due to the pressure of the womb against neighboring parts of the body, it can be partially counteracted by getting into a comfortable position; but it is also necessary to have the surroundings as conducive to sleep as possible. Thus anyone will be much more likely to rest well if the bed-room is large and well ventilated, if the mattress is comfortable, and if the coverings are warm without being heavy. Finally, not the least important detail is to occupy a single bed, so that it is possible to turn over without fear of disturbing someone else. In most instances, however, the inability to sleep during pregnancy-- and indeed at any time--is due to a faulty frame of mind. With reference to the average man or woman, in his very helpful book "Why Worry," Walton says, "it is futile to expect that a fretful, impatient, and overanxious frame of mind, continuing through the day and every day, will be suddenly replaced at night by the placid and comfortable mental state which shall insure a restful sleep." Like everyone else, the prospective mother must stop thinking when she retires, otherwise the blood will not be diverted from the brain as it must be to fall asleep. To aid in bringing about this condition a number of expedients may be employed. For example, a warm bath, warm sheets, or a hot-water bottle placed against the feet all help to draw the blood from the brain to other parts of the body. Similarly, a warm glass of milk or a small portion of easily digestible solid food taken just before retiring will help to make one drowsy; on the other hand, over-eating at the evening meal or later is not an infrequent cause of wakefulness. The use of narcotics is rarely necessary in the early months of pregnancy, and the simple measures just mentioned will also generally be found sufficient in the later months. But these procedures, or any other except the use of strong drugs, will be ineffective unless the individual knows how to get into the proper state of mind. This means not only that she must be able to banish worries, regrets, and forebodings; she must also have acquired confidence in whatever method she employs. She must convince herself that she can sleep, or at least that _it makes no difference if she cannot_. This independent spirit, which is very essential, can be confidently assumed, for if she does not sleep well it can be made up during the next day or at least the next night. Having adopted this attitude, and having assumed a comfortable position, which should be retained as long as possible, the attention should be concentrated upon the thought, "I am getting sleepy, I am going to sleep." Under these circumstances she can hypnotize herself and "produce the desired result more often than by watching the proverbial sheep follow one another over the wall." IS TRAVELING HARMFUL?--Traveling has been made so easy and alluring that nowadays long journeys are undertaken with scarcely more concern than was once felt when the people of neighboring towns exchanged visits. Thus modern facilities have introduced a new factor into the problem of the way to live during pregnancy. It is a well-known fact that traveling is sometimes attended with risk to the prospective mother, though the danger is exaggerated in the popular estimation. For this the newspapers are chiefly to blame. They inform the public of the cases in which embarrassing situations have arisen, but there is no record of the thousands of pregnant women who travel without any mishap. What the effect of traveling is likely to be is very difficult to predict under any circumstances, and the question cannot be answered at all unless the specific conditions presented by each case are taken into account. In a general way the points to be considered are the vigor of the patient, the period of pregnancy at which she has arrived, and the character of the journey she wishes to undertake. Prudent women will never attempt to decide this question for themselves, but will always obtain professional advice. The disapproval of the physician, no doubt, will sometimes cause keen disappointment; but conservative advice is the best and should always be followed. To be on the safe side a prospective mother who has previously had a miscarriage should not travel at any time during pregnancy; others are not obliged to follow this stringent rule except during the first sixteen and the last four weeks of pregnancy. In the former period there is some danger of miscarriage because traveling may cause separation of the relatively loose attachment of the ovum. In the latter period the muscle-fibers of the womb are usually irritable and therefore the rolling of a ship or the jolting of a car may set up painful contractions which in some instances expel the fetus. Generally there is the least risk of accident between the eighteenth and the thirty-second weeks, though patients should be careful even during this interval not to travel at the time when a menstrual period would ordinarily be expected. The length of the journey and the ease with which it can be made are also important features to be considered. Obviously there will be less danger of mishap from a short trip than from a long one; if possible, therefore, long journeys by rail should be broken so as to afford opportunity for rest. Railroad trips which do not exceed two or three hours are generally not so fatiguing that they must be prohibited, provided the individual is perfectly well. Traveling by boat is less tiresome than traveling by rail and, if equally convenient, the boat should be given the preference. Long automobile tours are attended with considerable risk of miscarriage and, therefore, are forbidden. MENTAL DIVERSION.--As a rule good health prevails throughout pregnancy; it would be enjoyed even more frequently if many prospective mothers did not think so much about the fact that they are pregnant. For this deplorable self-consciousness the spirit of the age is in part to blame; there never was a time, in all probability, when people took such a keen interest in all matters pertaining to health. It is also true, however, that fuller instruction is needed now because the temptations to depart from a regular, temperate way of living have notably increased. At all events the point has now been reached where the average man or woman knows something of anatomy, physiology, and the laws of hygiene. Such knowledge should be helpful, and generally is, but if it causes anyone to think incessantly about the workings of the body, to that person it is detrimental. We all know such individuals. They are made miserable because they scrutinize functions, like the beating of the heart, that go on automatically and should be left unobserved, or they minutely analyze their feelings and misinterpret normal sensations as the evidence of disease. The tendency to be introspective is especially pronounced in women who are pregnant, and this is readily explained by the reciprocal relations between the mind and the body. If the prospective mother correctly interpreted the changes which occur in her body, as well as the sensations for which these changes are responsible, she would escape the uneasiness of mind that causes many sorts of discomfort. It is unfortunately true, however, that her lack of familiarity with the facts about pregnancy and her belief in unfounded traditions frequently lead to the misinterpretation of natural conditions. An anxious frame of mind also causes real ailments to assume an importance out of all proportion to their actual significance. Patients who have followed my advice to place themselves in the care of a physician as soon as they clearly recognize the existence of pregnancy will receive his assistance in properly estimating the significance of what they notice. This service is by no means the least the obstetrician renders his patients. His opinion should always be sought when symptoms are not understood; but it is not unusual for patients to bring to the doctor's attention many complaints that would pass unnoticed if they taught themselves to restrain the imagination, to refrain from pessimistic reflections, and to divert their thoughts from themselves to outside affairs. Generally it is during the early months of pregnancy that patients are most likely to be self-centered, and consequently suffer from many annoyances that either proceed from or are exaggerated by this faulty frame of mind. During this period a prospective mother is not fully aware of the meaning of pregnancy. Toward the twentieth week, however, she perceives the movements of the child and her thoughts are turned to it instinctively. About this time many of the discomforts of pregnancy disappear and there ensues a period of unusually good health. Perhaps it would be going too far to give this more wholesome altruistic mental attitude the entire credit for the relatively better health of the second half of pregnancy, but without doubt it is a most important factor. Such then is the influence of the mind over the body that anyone who wishes to cultivate good health must correct the faulty habit of always thinking of herself. The most suitable form of diversion will depend upon personal taste. Domestic duties absorb the attention of most prospective mothers, but domestic duties should not occupy them exclusively. Outdoor recreation is necessary and serves the double purpose of strengthening mind and body. Public amusements should also be patronized; no prospective mother has the right to sacrifice herself to pride. Music, the various arts, a systematic course of reading, the acquisition of a foreign language--all these are commendable forms of diversion, and others will occur to anyone. Obviously the avocation will be most happily chosen if it directs the attention into channels likely to lead to the greatest pleasure. CHAPTER VII THE AILMENTS OF PREGNANCY Nausea and Vomiting--Heartburn--Flatulence--Defective Teeth--Pressure Symptoms: Swelling of the Feet; Varicose Veins; Hemorrhoids; Shortness of Breath--Leucorrhea--Toxemias. Most of the ailments to which prospective mothers are liable are merely the natural manifestations of pregnancy, exaggerated to such an extent as to cause inconvenience and discomfort. In the early months, for example, persistent nausea and vomiting may become the source of great annoyance, and later the pressure of the womb against neighboring structures may cause a variety of symptoms. It does not follow, however, that any of these ailments will necessarily appear. On the contrary, many women are more healthy during pregnancy than at any other time. Occasionally illness is charged to pregnancy with which in reality pregnancy has nothing to do. While awaiting the birth of a child, just as at other times, women may suffer from coughs or colds, from aches or pains, from malaria, pneumonia, typhoid fever, or in fact from any disease. It is evident that such complications are accidental; and, though pregnancy confers no immunity against them, it does not, on the other hand, render women more susceptible to all kinds of ailment. And yet there are diseases for which pregnancy is directly responsible. These are, to a very large extent, preventable; and, though they occur rarely, precautions for their prevention should be taken in every case of pregnancy. By far the most important members of this group are the toxemias of pregnancy. These, as will be explained later, cause symptoms which the patient herself may recognize, and her physician may often detect their presence still earlier by alterations in the composition of the urine. For this reason routine examination of the urine during pregnancy is a means of prevention indispensable for safeguarding the health of the prospective mother. A number of ailments of which prospective mothers may complain do not require treatment with medicine. This, however, will not be taken to imply that there is no need to consult a physician. On the contrary, and it cannot be emphasized too strongly, the prospective mother should _seek professional service whenever there is anything about her condition she does not understand_. Sometimes, when she thus consults the physician, he will explain to her that what she has noticed is merely one of the natural manifestations of pregnancy and that she can have no control over it; at other times he will suggest changes in her mode of life which will very likely afford her relief. The frequency with which physicians find that ailments may be corrected by the adoption of hygienic measures indicates that such ailments are more often due to ignorance or carelessness than to the existence of disease. NAUSEA AND VOMITING.--We have already learned that nausea, especially in the morning on rising from bed, frequently corroborates the suspicion of a woman that she has become pregnant. So commonly, indeed, is this symptom expected that most women take no account of it other than as an evidence that they have conceived, and consequently do not complain of it. A few who have heard the old adage, "a sick pregnancy means a safe one," which incidentally is not correct, actually accept nausea as a favorable sign. In other cases the nausea is not to be dismissed so lightly; and a relatively small group of patients suffer from persistent vomiting. When prospective mothers are questioned systematically, it appears that at least one- half and perhaps two-thirds of them experience more or less discomfort from sick stomach. Generally this begins shortly after a menstrual period has been missed and ceases six or eight weeks later; it persists occasionally until the movements of the child have been perceived. Nausea and vomiting are limited, in the vast majority of cases, to the early morning, but some patients are annoyed only after meals, and a few at irregular intervals during the day. The fact that the attacks do not always appear at the same time, and that they differ in severity, indicates that different causes may be concerned in their production. And it is true that there are several kinds of vomiting that occur during pregnancy, although the classification interests only physicians. The laity, however, should understand that the treatment of any given case will vary according to the class to which it belongs, and therefore the occurrence of troublesome vomiting should be promptly reported to the physician. Most frequently it will be found that there is nothing serious the matter. The vomiting ceases or, at least, it becomes less troublesome as soon as the diet has been more carefully arranged, constipation has been corrected, or other hygienic details, such as outdoor recreation and mental diversion, have received the attention requisite for good health. In a much smaller group of cases the restoration of the womb to a proper position or the treatment of some other local condition, which can generally be remedied without difficulty, is all that is necessary. But finally, in extremely rare instances, the vomiting of pregnancy is due to a definite disease whose existence may be recognized by special methods of analyzing the urine. In any case, if the physician is given an opportunity to make the necessary observations and thus determine the variety of the vomiting, no time will be lost in beginning effective treatment. In an overwhelming majority of the cases, as I have said, nothing serious will be found; and then the control of the vomiting will lie within the power of the patient herself. Since nausea is usually experienced in the morning on rising from the recumbent to the upright posture, measures to prevent an attack should be begun even before the patient raises her head from the pillow. In the first place something to eat should be taken as soon as she awakens. The most satisfactory results follow eating two or three pieces of crisp toast or a Bent's cracker (sold by grocers), either of which should be thoroughly chewed and swallowed without taking anything to drink. Good results are also obtained, though less uniformly, from eating other food, such as fruit, oatmeal, or eggs. The benefit secured from this procedure is explained, perhaps, by the activity of the digestive organs and the effect of that activity upon the circulation of the blood. The food eaten before rising is not intended to take the place of breakfast, which ordinarily will be eaten later. Furthermore, it is essential to remain in bed until half an hour after the food was taken; and not to rise then unless perfectly comfortable. Anyone who is inclined to be nauseated should get up slowly and dress leisurely, sitting down as much as possible while putting on the clothes. If breakfast is not desired at once, it should not be forced, but some food should be eaten between early morning and noon. It is an exceedingly good rule to bend every effort toward escaping the initial attack of nausea, for in this way one soon gains confidence, and overcomes the depressing habit of being continually on the watch for the symptom, lest she be taken unawares. Exceptionally, however, patients feel more comfortable if they vomit in the morning; this may be helpful, for example, if a large meal has been eaten just before retiring the previous night. Next to morning sickness in point of frequency comes the disposition to be nauseated about meal time. Those who vomit after the meal is finished are frequently inclined to eat soon again; and there is no reason why they should not. Sick stomach after meals may be due to several causes, such as eating hurriedly, eating too much, or selecting food that is difficult to digest. If a meal is bolted the stomach may be overloaded before the appetite is appeased; and consequently those who eat too much are fortunate when the stomach rejects the excess. Eating slowly and masticating the food thoroughly, we know, is the proper way to insure taking no more than is needed. One of the most valuable precautions against persistent nausea consists in taking small amounts of food five or six times during the day. Directions regarding the frequency of meals and the choice of food have been given in Chapter IV, to which the reader may refer. It may be repeated, however, that a prospective mother should naturally avoid anything which she knows is likely not to agree with her. On the other hand, she is almost certain not to be nauseated by any article of food for which she has an appetite. Lying down for a short while after meals frequently serves to prevent an attack of vomiting. It is a good rule, furthermore, at whatever time of day the sensation of nausea may occur, to lie down immediately. An ice bag or cloths wrung out of cold water, if applied to the abdomen, often give relief; warm applications occasionally serve the same purpose better. Some patients prevent nausea by constantly wearing a flannel bandage about the abdomen. Many instances of the vomiting of pregnancy cannot be explained by errors in diet, for the attacks come on repeatedly whether the stomach contains food or not. Under these circumstances mental influences frequently have to be reckoned with. Indeed, in most cases of vomiting of pregnancy dietetic and other hygienic measures are of no avail unless the patient learns to divert her attention from troublesome thoughts. That the brain can exert an influence over the stomach is a fact well substantiated both by physiological experiment and by medical observation. In all probability there is a definite spot in the brain, called the "vomiting center," the irritation of which causes retching and the upheaval of the contents of the stomach. As this nervous mechanism is possessed by everyone, it is not called into existence by the advent of pregnancy. Nevertheless, it seems likely that pregnancy renders it more sensitive, and it is certain that pregnancy establishes new means by which the center may be stimulated. This admission does not imply, however, that the prospective mother must submit to inevitable discomfort, for she can and should muster the strength to resist it. Time and again an unhappy frame of mind exaggerates or prolongs the vomiting of pregnancy. Thus, disappointment, anxiety, grief, fright, and other types of mental uneasiness not only magnify the discomfort but sometimes are its sole cause. The curious cases in which the husband suffers from nausea while his wife is pregnant are explained by mental influences. As a result of the same kind of influence, women who imagine themselves to be pregnant often suffer from violent vomiting, which ceases as soon as they discover their error. On the other hand, women who for several months remain ignorant of the fact that they are pregnant rarely suffer from sick stomach. Any kind of worry may be and often is the direct cause of the vomiting of pregnancy, though patients are often unwilling to confess it; and occasionally do not seem to know what it is that troubles them. In any event, having received the assurance of her physician that there is nothing serious the matter, the prospective mother who is annoyed by nausea should make every effort not to become self- centered. She should have congenial companionship and should interest herself in pursuits outside of, as well as within, her home. Of all the measures that may be employed to overcome this manifestation of pregnancy the most fundamental and essential is mental diversion. HEARTBURN.--Obviously, it would not be fair to consider indigestion as one of the ailments peculiar to pregnancy, for anyone is liable to suffer from indigestion. Yet dyspeptic symptoms, more especially heartburn and flatulence, occur so frequently at this time that something should be said regarding their causation and treatment. A burning sensation rising from the stomach into the throat, familiarly called heartburn, is generally due to an overabundant secretion of hydrochloric acid, which is, as we have learned, a normal constituent of the gastric juice. Of late, the conditions which influence its secretion have been the subject of laboratory investigation, which has disclosed, among other interesting facts, the way to _prevent_ heartburn. These experiments have taught that the introduction of fat into the stomach shortly before a meal decreases the amount of acid secreted during digestion. Consequently, anyone who is troubled by heartburn and wishes to avoid it _should take a tablespoonful of olive oil, a cup of cream, or a glass of rich milk fifteen or twenty minutes before meal-time_. On the other hand, fatty food eaten with the meals prolongs the stay of food in the stomach and causes an increase in the secretion of hydrochloric acid. An excess of the acid, as we have just learned, is favorable to the development of heartburn. Therefore, as a further precaution against this source of discomfort, it is advisable not to use a large amount of butter or of salad oil, and to refrain from fried food, rich desserts, or any other article of diet known to contain a relatively large amount of fat. Once it has developed, heartburn will be aggravated by taking cream or olive oil. The most rational _curative measures_ then consist in diluting the acid by drinking a couple of glasses of water and in counteracting (neutralizing) the acid by taking a teaspoonful of baking soda (bicarbonate of soda) or a tablespoonful of limewater; and, if necessary, either of these doses may be repeated. Patients often adopt the very sensible habit of carrying with them a block of magnesium carbonate, which they nibble whenever the symptom appears. FLATULENCE.--The distention of stomach and intestines with gas, technically called flatulence, may be associated with heartburn or appear independently. The gas arises from the action of bacteria upon the food. There can be little doubt that flatulence occurs so regularly during pregnancy because the pressure of the enlarged womb prevents the contents of the intestine from moving along as rapidly as they have done previously. To be relieved from this source of discomfort, it is necessary, in the first place, that the bowels should be regularly evacuated; very often nothing further is required than to overcome the habit of constipation. Occasionally, however, the diet must be arranged so as to exclude food which is likely to form gas. For example, parsnips, beans, corn, fried food, candy, cake, and sweet desserts, all of which are known to cause flatulence, should be avoided; in aggravated cases the allowance of starchy food of every kind should be cut down to small portions. Since the production of gas in the intestine is due to the action of bacteria sometimes relief from flatulence is secured only after the administration of intestinal antiseptics. Drugs, however, will be prescribed by the physician, and will not be employed until the simpler hygienic measures have failed. Similarly, the physician should decide whether it is advisable for the patient to drink milk inoculated with harmless bacteria (The Bulgarian Bacillus) which has lately been placed on the market. The bacteria thus administered in the milk are antagonistic to the intestinal bacteria that produce gas, and consequently have been recommended for the treatment of flatulence. If this commercial product cannot be conveniently obtained, one may use instead tablets containing the bacteria, which can be supplied by druggists. DEFECTIVE TEETH.--Unless suitable precautions are observed, the digestive disturbances of pregnancy have a tendency to injure the teeth. The regurgitation of the acid contents of the stomach, for example, may cause cavities to develop or may enlarge those that already exist. In all probability the damage done in this way--and not the removal of lime from the teeth for the formation of the child's skeleton, as some have thought--is responsible for the origin of the saying that "every child costs a tooth." This notion is of course absurd, yet it is quite true that toothache and the decay or loosening of the teeth are not infrequently associated with pregnancy. On this account, throughout the period of pregnancy particular care should be given the teeth. One of the very first duties of a prospective mother, after she knows that conception has taken place, is to visit her dentist. This step is very important as a means of insuring the teeth against such harmful influence as pregnancy may have upon them. If the dentist finds the teeth in poor condition, the patient should consent to have them treated immediately. That this is the reasonable course seems sufficiently obvious, yet the majority of women have been slow to adopt such a view. For a long time dental work of every description was incorrectly believed to have an untoward effect upon the development of the child; and the extraction of a tooth, it was thought, would surely be followed by miscarriage. Although the extraction of teeth is not frequently undertaken nowadays, I have known several prospective mothers who required the operation, and who had it performed without experiencing a single untoward symptom. Very naturally dental work should be restricted during pregnancy to that which is absolutely necessary, and temporary fillings generally suffice; but whatever is needed should be done without delay. Brushing the teeth after meals and removing particles of food that may have been caught between them--important enough at all times--are of even greater importance during pregnancy. If the gums are sore and the teeth show a tendency to loosen, the best tooth-paste is one containing potassium chlorate. An alkaline mouth-wash should be used several times a day; after an attack of vomiting it is always advisable to rinse the mouth with such a solution. As a wash either lime water or milk of magnesia, or a solution of bicarbonate of soda may be used; they are equally good. Lime water may be prepared at home inexpensively in the following way: Place a teacupful of builders' lime in a large bowl and add two quarts of water; thoroughly mix and allow to settle. Pour off and throw the water away, since it often contains impurities. Add two quarts of water again and allow the mixture to stand three or four hours, stirring occasionally. Strain through a piece of muslin into bottles and keep well corked. One tablespoonful of this solution should be added to a glass of water to obtain the proper strength for a mouth-wash. PRESSURE SYMPTOMS.--Because human beings walk erect, and not on all fours, they are liable to suffer from various ailments of pregnancy that quadrupeds escape. Thus the upright posture is the chief factor, at least, in causing such complaints as swollen feet, varicose veins, hemorrhoids, and cramps in the legs. The attention of patients should be called to the source of these troubles, for in most instances they can be prevented by forethought and prudence. During the last two or three months of pregnancy every prospective mother should carefully avoid being too much on her feet; she should lie down, as has already been emphasized, at regular times of day and frequently sit down to rest. Proper support for the abdomen, such as is afforded by a correct corset or a maternity supporter, lifts the pregnant uterus, and to a notable extent relieves of pressure the structures beneath it. On the other hand, incorrectly made corsets, the use of circular garters, and running a sewing machine by foot- power all aggravate the pressure symptoms of pregnancy. _Swelling of the Feet_.--So long as the swelling is confined to the feet and legs it does not mean that there is trouble with the kidneys; the swelling is satisfactorily explained by the pressure of the enlarged uterus upon the veins which pass through the lower part of the abdomen and conduct the blood from the legs on its way back to the heart. The womb is rarely heavy enough during the first half of pregnancy to interfere with the flow of blood through these vessels, but in the last few months such interference is very common. Generally the limbs are equally affected, yet occasionally the swelling is more marked on one side or the other. The characteristic changes begin in the feet. The skin covering the back of the foot becomes tense and has a waxen appearance; it is easily indented, bearing for a moment the imprint of anything that is pressed against it. Often the swelling extends no higher than the ankles, but it may involve the calves, the thighs, or even the vulva, which is the region between the thighs. If the swelling remains slight, no attention need be paid to it. But if it becomes extensive or painful, nothing will give relief except going to bed. Patients observe for themselves that the swelling lessens during the night, and from this usually learn that the proper treatment is rest. When it is absolutely impossible to remain in bed long enough for the swelling to disappear, the next best plan is to accept every opportunity, during the day, to sit down and prop up the feet. _Varicose Veins_.--The distention of the surface veins of the legs, the condition known as varicose veins, is not a peculiarity of pregnancy. Anyone who must be on his feet a great deal is liable to suffer from this ailment. It is true, nevertheless, that pregnancy increases the likelihood of the development of varicose veins. The walls of the vessel are generally able to withstand whatever strain is placed upon them during the first pregnancy, and usually the varicosed condition does not develop until after there have been several pregnancies. As a rule, both legs are similarly affected, but if only one, it is more likely to be the right. This is explained by the fact that the position of the child within the womb is ordinarily such as to cause greater pressure on the vessels of the right side. For the same reason when the legs are unequally affected, generally the veins of the right side are the larger. In any case, however, the birth of the child removes the source of the interference, and during the lying-in period, provided that the patient remains quiet for a sufficient length of time, the vessels regain their normal caliber. Once they have been distended, however, the veins remain more susceptible to engorgement. Consequently, in order not to increase the strain these vessels naturally bear during the latter months of pregnancy, the precautions just mentioned for the avoidance of all the pressure symptoms should be strictly observed. Upon the first intimation that the veins are becoming dilated, a patient should be unusually careful to keep off her feet all that she can. Only in extreme cases will it be compulsory to go to bed. But, if the veins are large and painful, she should stay in bed until material improvement has taken place. Subsequently she should wear a flannel bandage, snugly applied, about the leg from the toes to a point somewhat above the knee; the bandage should extend higher whenever the veins of the thigh also are dilated. In putting on the bandage the heel may be left uncovered; after leaving the foot a turn of the bandage will be taken around the ankle and thence applied upward. A flannel bandage may be easily made at home. Bias strips are cut about three inches in width and sewed together end to end so that the joining will lie flat. Unless the bandage must extend far above the knee, eight yards will be a sufficient length. Elastic stockings, which may be purchased from a druggist, serve the same purpose as the bandage, but are very much less durable. Even if worn during the day they should be taken off at night; and when protection of the veins is required after going to bed, the bandage is the most sanitary way of securing it. The danger that one of the vessels will break may be disregarded, if they are constantly protected by the measures that have been mentioned. In the event of accident, however, make firm pressure over the bleeding point with a freshly laundered handkerchief, and apply an ice bag outside the dressing until the doctor arrives. _Hemorrhoids_.--Hemorrhoids are caused in the same way as varicose veins of the legs. The two conditions differ merely in point of location; but hemorrhoids, on account of their location, are much more exposed to irritation. Although the development of hemorrhoids cannot always be prevented, it is a well-known fact that constipation renders the chance of their appearance much greater. In a measure, therefore, regular, daily evacuation of the bowels serves to prevent the ailment, and also to cure it, once it has developed. But walking and even standing aggravate hemorrhoids. The recumbent posture, as might be expected, is of itself frequently enough to give relief. It is much more likely to do so, however, if the hips are elevated by placing a pillow under them. In severe cases it is helpful to restrict the diet for a few days until the congestion and acute suffering have subsided. If the hemorrhoids protrude, they should be replaced (which the patient may generally do for herself), and an ice bag should be applied to the seat of pain. Various ointments and suppositories of different composition are valuable in the treatment of this ailment, but, as not all cases are relieved by the same medicine, a physician should be consulted to learn what is most suitable in any given instance. Hemorrhoids often grow progressively worse as pregnancy advances, and are frequently aggravated immediately after the birth of the child; but they generally disappear within a few weeks. Whenever a natural cure is not thus effected, it may become necessary to resort to surgical treatment. Operative procedures, however, should not be undertaken during pregnancy, since the condition is likely to reappear before the child is born. _Cramps in the Legs_.--There are nerves as well as blood vessels that the pregnant uterus may press upon, and pressure of this kind may cause pain. At times the pain is definitely localized at the point where the nerve is pressed upon; under these circumstances the discomfort is felt in the lower part of the back. On the other hand, the pain may be referred to the point where the nerve ends. In this way is explained not only pain in the leg but also those sensations of numbness and tingling which prospective mothers not infrequently complain of. The presence of these pressure symptoms is usually limited to the last few weeks of pregnancy. They often begin about the time the child's head enters the bony canal through which it is ultimately born; engagement of the head, as this is called, occurs simultaneously with the dropping of the waist-line, that is, about two or three weeks before delivery. From the time the head is engaged all the pressure symptoms become somewhat more intense. From the very nature of their causation, it is clear that cramps in the legs are difficult to treat. The recumbent posture lessens the discomfort, and, if in addition the hips are elevated, absolute comfort will occasionally be secured. Whether or not the administration of medicine is advisable must be determined by the physician who has the opportunity to see the patient. The birth of the child, of course, removes the cause of the pressure and permanently relieves this discomfort. _Shortness of Breath_.--Besides the ailments caused by the downward pressure of the pregnant uterus, there are also symptoms due to its upward growth. Thus shortness of breath is regularly noted toward the end of pregnancy, and, as has already been mentioned, it is one of the reasons for exercising leisurely. Unlike the other pressure symptoms, shortness of breath is ordinarily aggravated by the recumbent posture, for lying flat on the back increases the compression of the chest. At night, which is frequently the time when difficulty in breathing is most pronounced, the patient may, if necessary, sleep propped up in bed. For this purpose an appliance called a back-rest may be used, but an extra pillow under the head and shoulders is usually sufficient. LEUCORRHEA.--The meaning of the white discharge from the vagina known as leucorrhea is variable: at times it indicates the existence of an ailment requiring treatment, and at other times it does not. To be on the safe side, therefore, anyone who is troubled by leucorrhea should obtain her physician's opinion as to its significance. Normally, as we learned in Chapter V, there is an increase in the vaginal secretion during pregnancy; but this fact is rarely noticeable until the latter months. Usually it is pronounced only during the last few weeks. At that time, owing to its antiseptic qualities, this pale white fluid should not be disturbed by the use of douches. In the early months of pregnancy, however, leucorrhea may cause such inconvenience as to demand medical treatment. While itching is the most disagreeable effect of such a vaginal discharge, it should be known that itching is not always due to leucorrhea. Thus it may be caused by a highly concentrated urine, and in that event will be relieved by drinking a larger amount of water; or it may be due to the presence of unusual constituents in the urine. Skin diseases also cause itching; and light haired people, since they have more delicate skins that brunettes, are especially susceptible to these ailments. To such skin affections soap and water may be very irritating; so that when they exist it is often advisable to cleanse the parts with olive oil. In other cases, ointments are required and will be prescribed by the physician. Itching of the skin over the extremities or over the whole body, it is clear, cannot be attributed to leucorrhea, but in these very rare cases the irritation would seem to be caused by some waste product which is being eliminated through the sweat glands. We do not know what the substance is, but, as the symptom appears so seldom, it must be due to an unusual kind of waste product or else to one whose elimination normally occurs through other channels. The affection of the skin thus brought about is really a very mild kind of poisoning, and since the offending substance arises in the body of the patient herself the condition is called an autointoxication. Effective treatment consists in drinking water freely and taking a cathartic, for the one stimulates the kidneys and the other the bowels to assist in getting rid of the cause of the trouble. TOXEMIAS.--In order to understand what are known as the toxemias of pregnancy, we must remember that the nutrition of our bodies involves three separate and distinct sets of processes. What we eat is, in the first place, digested and absorbed into the body; secondly, the products of digestion are utilized by the tissues; and, finally, the waste material is thrown off from the body. Any one of these processes may be carried out in a way that is not consistent with health. Most of us realize that disturbances may occur in the course of digestion, and we are also aware that the excretory organs occasionally fail to do their work in a satisfactory way. But what laymen, perhaps, do not appreciate is that the intermediary steps-- between the time when the food is absorbed and the time when the waste material is finally eliminated--may not be taken precisely as health requires. Of course, any person may be the subject of one or another of these nutritional disorders, but unquestionably such disorders are somewhat more frequent during pregnancy than at other times. Nor is this difficult to understand, for the nutritional processes of two beings are here linked together. They generally proceed harmoniously, but if they do not there results an autointoxication of the mother which is called a toxemia. Such toxemias, with extremely rare exceptions, do not occur in the early months, but are associated with the period of the active growth of the fetus, namely, the second half of pregnancy. For this reason, and for some others which do not concern us here, it seems probable that the nutritional processes of the child are primarily responsible for these ailments. This view, however, must be somewhat modified, for experience has clearly taught that the efficiency with which the maternal excretory organs do their work has a great deal to do with the effect that the fetal waste products have upon the mother. On this account she has been urged to pay attention to personal hygiene. It is also necessary, however, that she should become acquainted with the symptoms which give warning that the excretory organs are acting imperfectly. Autointoxication can almost always be prevented. The means of prevention are neither mysterious nor difficult to carry out; they lie within the power of every prospective mother, for they consist merely of what has already been discussed, namely, the intelligent regulation of the diet, the care of the body, and a correct ordering of the daily life. To the chapters dealing with these subjects reference should be made and particular attention should be paid to what has been said concerning: (1) Wearing suitably warm clothes, (2) Bathing regularly, (3) Taking a proper amount of exercise, (4) Drinking water liberally, (5) Avoiding an excessive quantity of meat, (6) Guarding against constipation. At present the value of prevention in the treatment of the toxemias of pregnancy is so clearly recognized that charitable organizations employ nurses to visit women of the poorer classes during pregnancy in order to instruct them about the measures that I have just indicated. Remarkable results have already been obtained. In one clinic where this method has been adopted the frequency of all kinds of toxemia, I am told, has notably diminished, and serious types are not permitted to develop. Similar results should be obtained in private practice when patients place themselves under medical supervision at the beginning of pregnancy. Under these favorable circumstances symptoms of autointoxication probably occur not oftener than once in every hundred pregnancies, but nine out of ten of them, being promptly recognized, yield readily to relatively simple treatment. The early detection of such complications depends largely upon the patient herself. As has been emphasized--and it cannot be said too frequently--she should not fail to submit, at appropriate intervals, a specimen of urine for examination. It is by such an examination generally that the development of a toxemia is first detected. Occasionally, however, significant signs will attract the patient's attention before there is any change in the urine. For that reason, it is important to notify the physician if any of the following symptoms appear: (1) Serious vomiting. (2) Persistent headache. (3) Dizziness. (4) Puffiness about the face. (5) Blurring of vision, or the appearance of black spots before the eyes. (6) Neuralgic pains, especially in the pit of the stomach. It must be clearly understood, however, that any of these symptoms may be present without indicating that a toxemia is developing. Nevertheless, they should be brought to the physician's attention without delay, and, at the same time, a specimen of urine should be given him for examination. Although the kidneys are not responsible for all the toxemias of pregnancy, an analysis of the urine affords the most definite means of determining whether or not such a condition is present. When thus detected, prompt treatment will guarantee to the patient almost certain relief. On the other hand if, as usually happens, the analysis shows conclusively that there is nothing serious the matter, this reassurance fully justifies the trouble taken to secure it. CHAPTER VIII MISCARRIAGE Frequency--Causes and Prevention--Habitual Miscarriage--Warning Symptoms--After-effects--Criminal Abortion--Therapeutic Abortion-- Premature Delivery. We have learned that forty weeks are required for the full development of the human embryo, but this fact carries no assurance that pregnancy will last so long; in reality, it may end abruptly at any time. If growth is interrupted before the twenty-eighth week (the seventh lunar month), the infant will be too immature to live. Even when born alive, it will usually perish within a few hours, or a few days at most. Children born during the seventh month have occasionally survived; but the prevalent belief that they are more likely to do so than if born a month later is erroneous. That superstition originated at a time when great virtue was ascribed to numbers. Since seven was a sacred number, it was considered more auspicious to be born in the seventh month than in the eighth. Universal experience, however, teaches us that the likelihood of rearing a premature child is, by a rapidly increasing proportion, the greater for every week that it remains within the uterus. This is precisely what we should expect, for the period of its existence there measures the perfection of its development; and that, under ordinary conditions, determines how strong and hardy the child will be. Although during the first six months the outlook for the infant will be equally unfavorable at whatever time pregnancy may be interrupted, physicians prefer to distinguish cases which terminate in the earlier part of this period from those which terminate in the latter part. For technical reasons, the sixteenth week represents a natural point of division. A birth which takes place before that time is called an abortion; one which takes place between the sixteenth and the twenty- eighth week is called a miscarriage. The anatomical reasons which justify such a distinction do not concern us here, and the matter deserves mention merely because the same terms are often employed in a very different sense by the laity. As most of us know, the interruption of pregnancy results sometimes from purely natural causes, and sometimes from the employment of artificial means. As a rule, persons who are unacquainted with medical terminology call a birth of the former kind a miscarriage, and reserve the term abortion for an interruption of pregnancy that is deliberately provoked. Physicians, however, make no such distinction. They use these words, as I have said, simply to indicate how far development has progressed before the termination of pregnancy. Since the term abortion is apt to carry with it the implication of a criminal act, confusion will be avoided if we agree for the time to depart from strictly medical usage and designate as miscarriage the spontaneous termination of pregnancy prior to the twenty-eighth week. FREQUENCY.--Early interruption of pregnancy is extremely common. Some sociologists declare that it is becoming more and more frequent, and see in it a grave national danger. French statesmen attribute the alarming decline of the birth-rate in their country, in great part, to a rapid increase in the number of pregnancies which end prematurely. Reliable English and German statistics indicate that of the pregnancies which come under the observation of physicians approximately twenty per cent, end in miscarriage. In our own country, though extensive and complete data are not available, it is likely that the incidence is equally high. The actual frequency of miscarriage is generally underestimated. Patients themselves often do not know what has really happened. When the accident occurs a few days after conception, bleeding may be its only evidence, which will almost certainly be misinterpreted as an irregularity of menstruation; and professional advice will not often be thought necessary. Moreover, in other cases in which the true situation is appreciated the patient does not feel sick enough to seek medical assistance. If it were possible to include in the statistics all these cases as well as those which are concealed because intentionally provoked, the frequency with which pregnancy is interrupted during the early months would be found somewhat greater than is usually supposed. If we omit the miscarriages which occur within the first few weeks of pregnancy, and which consequently often escape detection, the majority of cases fall within the second and third months. After the fourth month has passed, the probability of such an accident, though not excluded, is greatly diminished. Some statistics recently published by Taussig make this clear. In a series of several hundred cases of miscarriage, one hundred and fifty-seven instances occurred in the second month, two hundred and twenty-two in the third month, seventy-three in the fourth month, thirty-seven in the fifth month, and five in the sixth month. This order of frequency might be anticipated from the anatomical conditions which prevail during the early months of pregnancy, since the attachment of the embryo to the mother is at first relatively insecure, but gradually grows firmer, and becomes as secure as it ever will be by about the fifth month. It is noteworthy that miscarriage occurs much less commonly in the first than in subsequent pregnancies. Indeed, a somewhat greater liability to the accident with each succeeding pregnancy goes far toward explaining the greater frequency of miscarriage among women who have passed the thirty-fifth year than among those who are younger. CAUSES AND PREVENTION.--We have seen that the proportion of pregnancies which end in miscarriage is quite formidable. But this should not be true, as the accident is frequently preventable, and many of these accidents could be avoided by the cooperation of patients. As self-denial and personal inconvenience are often essential, it is only fair to explain their value. Furthermore, the, patient who appreciates the reason for certain directions the physician gives becomes responsible to herself, and is much more likely to carry them out than is one who is cautioned without receiving a satisfactory explanation. At best, however, the advice which the physician is able to offer will be imperfect, for it must not be imagined that everything is known concerning the causation and prevention of miscarriage. While our knowledge is so imperfect we must be content to make the most of what we possess. It must be added that no suggestion such as can be given here will enable anyone to dispense with her own medical adviser. On the contrary, if there is reason to fear miscarriage, the prospective mother should be encouraged to seek his counsel as early as possible. Aside from the hygienic measures which she may learn to carry out for herself, various drugs are often of great value in preventing miscarriage. Since these are not applicable to all cases, they should be employed only upon medical advice. Very early miscarriages may be explained by the loose attachment of the ovum during the first six weeks of pregnancy. This tiny, living sphere, it will be recalled, reaches the womb a few days after conception, and adheres to the uterine mucous membrane. At first, however, its roots are short and delicate, and not so capable of anchoring the ovum as they become later. It is only toward the end of the eighteenth week that the union between the womb and its contents becomes firm. From what we have learned in Chapter II regarding the anatomical conditions in the early days of pregnancy it is obvious that we need not be greatly surprised at the frequency of miscarriage. On the other hand, it must not be forgotten that there are many natural safeguards against accident: to mention only one, the uterus is ingeniously swung in the abdominal cavity so as to afford a large measure of protection against mechanical shock. Usually, the provisions nature has made are sufficient to resist forces from without which tend to dislodge the ovum. Now and then it happens that the most irrational acts will not interrupt pregnancy; indeed, they often seem particularly inert when practised intentionally. Fear of loosening the ovum from its uterine attachment prompts experienced women to caution prospective mothers against any kind of sudden or violent effort. Their advice, however, is often needlessly alarming; a great many traditional precautions lack a reasonable basis. Thus, no harm can possibly result from sleeping with the arms above the head; nor from "over-reaching," as when hanging a picture, though a fall under such circumstances might be dangerous. Patients who have been warned by one experience should always be on their guard if they would avoid repeated miscarriages; others need only lead a sensible, hygienic life, a matter we have already discussed in the chapters dealing with the care of the body and the way to live. For the sake of emphasis, I may here repeat that no prospective mother should become fatigued from any cause; sweeping, moving heavy furniture, lifting heavy articles, and running a sewing machine are not to be attempted. But household duties which do not require strong muscular effort are better assumed than not. Amusements which may cause jolting, or expose one to the danger of falling, involve some risk of miscarriage. Short rides in a carriage or an automobile over smooth roads are free from objection. Railway- travel and sea-voyages are not advisable in the early months; after the eighteenth week they may be undertaken with a greater degree of safety, provided comfortable accommodations are assured, and the patient has never had a miscarriage. A few physicians, even at present, attribute the interruption of pregnancy to strong emotions, including intense joy or sorrow, anger, fright, or even jealousy. Without denying altogether the possibility of such an influence, we may be sure that its importance is greatly exaggerated. It is not unusual to see patients who are able to recall a mental shock of some kind shortly before the miscarriage occurred; nevertheless, in such cases diligent search will usually reveal a physical cause for the accident. Another popular fallacy relates to the effect of drugs upon pregnancy. The use of castor oil and other strong purgatives do not interrupt it. Should the administration of any cathartic be followed by miscarriage, some fault inherent preexisted in the pregnancy, and no amount of precaution would have enabled the patient to reach full term successfully. Quinin in tonic doses may be taken with impunity, and even larger quantities are being constantly used for the cure of malaria without doing the pregnancy any harm. Many other drugs are reputed to have great efficacy in causing the expulsion of the product of conception; unfortunately, they are too well known to require enumeration. They are usually unreliable, and are absolutely inefficient in doses small enough not to endanger the mother's life, provided the pregnancy is a healthy one. Instances in which miscarriage is attributed to the use of some drug are quite common, and we cannot dismiss them without a word of explanation. Such cases generally fall into one of two classes. Often a drug is given credit for efficiency where conception has been erroneously suspected. Shortly after the menstrual date passes, some medicine is resorted to, and the subsequent phenomenon, regarded as the interruption of pregnancy, is really no more than normal menstruation. In another group of cases miscarriage does actually occur, although the medicine employed plays only a minor role in its production. In such instances the irritation which the drug occasions is the last link in a chain of events leading up to the miscarriage, but the main factor lies in some fundamental imperfection in the pregnancy. Physicians recognize a variety of these imperfections, and know that they may be located in the womb, in the embryo, or in the tissues which unite the one with the other. As an intimate knowledge of pathology is often necessary to recognize the underlying, and therefore the actual, cause of the miscarriage, it is not at all surprising that patients frequently err in their interpretations of such accidents, and emphasize unimportant matters. It would lead us too far afield to attempt to discuss every cause of miscarriage. Nevertheless, there are some very important ones, not yet mentioned, which should be understood by the laity, as appreciation of their significance may avert trouble. In some instances, on the other hand, the accident is unavoidable; to know this should afford the patient a large measure of comfort. Irregularities in the position of the womb are often responsible for miscarriage. Such a condition may exist in women who have not borne children, but it is far more likely to occur as a result of childbirth. After delivery, the enlarged womb becomes the seat of intricate changes, the purpose of which is the restoration of the organ to the condition which existed before conception. It dwindles in size, and gradually drops to its accustomed location within the pelvic cavity. Six weeks are usually required for these changes. At the time of birth it is impossible to predict whether the womb will finally resume a satisfactory position. Accordingly, an examination two to four weeks later is essential. In four out of five patients the organ will be found in its proper location, but, even though it is not, suitable measures adopted at once will generally serve to replace and hold it in good position. On the other hand, if the malposition is not recognized until months or years later, simple procedures will prove inefficient, and a surgical operation will become necessary. Were there no other reason for a careful examination at the end of the lying-in period, it would be amply justified by the information which it gives relative to the position of the uterus. Although there can be no doubt that the routine correction of uterine displacements shortly after labor would go far toward restricting the occurrence of subsequent miscarriage, it would be incorrect to leave the impression that miscarriage will always occur if the uterus is out of its normal position. Not infrequently the changes wrought by pregnancy will cause the uterus to right itself spontaneously. Another important cause of miscarriage consists in abnormalities in the lining of the uterus. Through inherent defect or acquired disease this tissue may become unsuited for anchoring or nourishing an ovum. In either event, a surgical procedure, known as curettage, affords the most likely means of restoring it to a healthful state. The operation removes the old lining; and a new one quickly develops, which is often more capable of fulfilling the purpose for which it is intended. An appreciable number of miscarriages depend upon conditions over which medical skill has no control. Under such circumstances, though the accident may be regretted, there is no room for remorse or censure. Often the embryo should bear the blame; if its development is imperfect or if it dies, miscarriage usually occurs very promptly. We are familiar also with a few maternal conditions which seriously affect the embryo, often seriously enough to cause its expulsion, alive or dead. In this respect, certain constitutional disorders are preeminent. Bright's disease and diabetes are prejudicial to the development of the embryo; women suffering from either of them must be watched with great care. Occasionally, such pregnancies come to a premature end in spite of every precaution. Various infectious diseases, as typhoid fever and pneumonia, also are fatal to the embryo if the causative bacteria pass into it. Fortunately this rarely happens, since the placenta generally affords an effectual barrier to their entrance into the embryo. Organic diseases of the mother's heart also may bring about miscarriage. A patient thus affected should place herself under the supervision of a physician as soon as conception is suspected. Now and then physicians are completely at a loss to explain cases of miscarriage. Our ignorance is unfortunate, particularly when repeated miscarriages have occurred and their causation cannot be detected. HABITUAL MISCARRIAGE.--Experience teaches that women who have had one miscarriage must be more careful than other prospective mothers if they would escape a repetition of the accident. Persons who know themselves to be subject to miscarriage should regard no precaution as too burdensome. Not only should they avoid motoring, driving, railroad journeys, sea voyages, and every kind of strenuous exertion, they must accept every opportunity to be quiet and rest. Often such hygienic care yields sufficient protection; but occasionally medicine is also necessary. A number of causes are at hand to explain habitual miscarriage, but, in fairness, it must be acknowledged that physicians are not able to interpret all cases. With one class of patients the muscle fibers of the womb are peculiarly irritable, whereas in another its lining proves incapable of firmly anchoring the ovum. Moreover, derangements of organs which do not belong to the reproductive group may be responsible for the habit. It is a curious fact that the accident is most likely to occur when menstruation would be expected were the individual not pregnant. Obviously, extraordinary precaution is advisable at such times, and if the patient would avoid even the slightest risk, she should not leave her bed. The same purpose will not be served by sitting quietly in a chair, nor by reclining on a couch; complete relaxation and composure are secured only when one lies flat on the back, loosely attired in sleeping garments. I have known several persons with a tendency toward miscarriage who overcame it in this way. Recently one of them who had been delivered prematurely on two former occasions, and who was anxious for a successful issue to her third pregnancy, was willing to remain in bed practically the whole period of gestation. She had her reward; a well-developed infant was born at full term, and has continued to thrive. Prolonged rest in bed, some will say, is debilitating. While that may be true to a degree, untoward effects can always be avoided by systematic massage of the extremities. The abdomen should not be subjected to such manipulations, for they will occasionally provoke painful contractions of the uterus and defeat the purpose of staying in bed. Patients who are not disposed to undergo a long period of enforced rest, no matter what profit may be promised, should at least consent to keep in bed during that period of pregnancy at which a previous miscarriage took place. We know that the event is particularly apt to recur at such a time. Specifically, it is important to remain in bed one week before and one week after the date in question. When pregnancies follow one another in rapid succession, the liability to miscarriage is notably increased. A natural interval between births has been provided, an interval which depends upon the mother nursing her child. Ideally, menstruation, and with it the ripening of the ova (egg-cells), does not occur while the breasts are active; but when the infant does not suckle, the ovaries regularly resume their function in a very short time. Since the circumstances attending miscarriage always deprive the mother of the opportunity of nursing, another pregnancy may quickly ensue unless these facts are appreciated. Those who anticipate the possibility of a premature interruption of pregnancy should realize that the marital relation is inadvisable after conception has taken place. For others, who have no reason to expect irregularity in the course of pregnancy, such a precaution is unnecessary. None the less, women who marry late in life or who first conceive toward the time of the menopause will do well to follow the same rule. The risk of accident may be very slight, but conservative persons will not assume it when the likelihood of subsequent conception is doubtful. Not infrequently the fundamental reason for habitual miscarriage lies in some anatomical abnormality which a surgical operation alone can correct. As the necessity for interference can be determined only after a careful examination, recommendations of wide application are not possible. Nothing short of painstaking study of each case will afford a basis for advice and action. SYMPTOMS.--Very definite warning usually precedes a miscarriage, but the threatening symptoms vary greatly in severity and duration. If appropriate measures are taken promptly, these symptoms may disappear with no harmful result Everyone concedes that bleeding and pain are the chief indications of impending miscarriage, although an occasional patient, profiting by former experience, may find other signs prophetic in her own case. Mature women, accustomed to the regular monthly function of their sex, are prone to treat with indifference a slight discharge of blood occurring during pregnancy. Indeed, it is widely believed that menstruation frequently continues after conception. In point of fact, however, it is very unusual in early pregnancy, and becomes entirely impossible after the fourth month. Accordingly, whenever vaginal bleeding is noticed, some other explanation should be sought; and the patient who would adopt the wisest plan should assume that she is threatened with miscarriage. There are other possibilities, but these are for her doctor to consider. It is true that small hemorrhages are not necessarily followed by miscarriage. One may even experience slight loss of blood repeatedly, and yet give birth to a healthy child at the natural end of pregnancy. None the less, bleeding, however moderate, should always excite suspicion, as we know it usually denotes the breaking to some degree of the connection between mother and child. The extent of the separation usually determines the degree of the hemorrhage, which in turn indicates the seriousness of the accident. The fate of the fetus will depend upon the area of placenta, which has been incapacitated. Flooding, however, always imperils the fetus, and generally warrants the inference that so much of the placenta has been separated as to render further development impossible. On the other hand, so long as the hemorrhage does not exceed the customary flow at the monthly periods, the life of the child is rarely endangered; while a chocolate-colored discharge, and even the loss of small clots, may continue indefinitely without doing serious harm. Under such circumstances, however, the patient should communicate with her medical adviser, and should save for his inspection whatever may be expelled. Pain, the other conspicuous symptom of threatened miscarriage, has not a uniform significance. Since it frequently occurs during the course of pregnancy in association with a number of conditions, it is not a reliable sign of danger. Moreover, the susceptibility to pain varies; thus, of two patients in the same stage of threatened miscarriage one may suffer intensely, while the other remains comparatively comfortable. Typically, the onset of miscarriage is attended by discomfort in the small of the back, which may be continuous, but more often is intermittent. If preventive measures are instituted at the outset, there is hope of relieving the discomfort and averting the miscarriage; but if the warning goes unheeded, the pain will gradually shift to the lower part of the abdomen and become more severe. It often happens that the cramp-like abdominal pain of threatened miscarriage is confused with that associated with intestinal indigestion. A simple test will sometimes decide the question. If due to the latter cause, the discomfort will usually yield to a teaspoonful of paregoric, whereas it will be without effect if miscarriage is imminent. Exceptions to this rule are not uncommon, yet a better one cannot be given; as a physician, even after considering the technical evidence, may find it impossible to decide at once whether or not miscarriage is threatened. No confidence can be placed in many so-called signs of miscarriage, though implicitly trusted by the laity. Lassitude, depression of spirits, and general bodily ill-feeling may forecast the interruption of pregnancy; but more frequently they have no such significance. The same estimate holds true of other symptoms, including diarrhea and a persistent inclination to empty the bladder. Nor does fever always lead to the termination of pregnancy. A moderate rise of temperature is without significance; but high fever, persisting for several days, may result in the death of the fetus and subsequent miscarriage. Nevertheless, prolonged febrile affections, such as typhoid fever, frequently leave pregnancy unharmed. So long as the symptoms are confined to slight bleeding and mild attacks of pain, physicians regard miscarriage merely as threatened. If the bleeding increases, the outlook becomes less favorable, and, as I have said, miscarriage is inevitable when it amounts to flooding. Likewise, rupture of the sack containing the fetus, with escape of the amniotic fluid, indicates that the culmination of events will not long be delayed. The most favorable outcome is when the entire contents of the womb are spontaneously expelled, which unfortunately does not always occur. There is, to be sure, rarely any difficulty in the natural birth of the fetus, for its meager development prevents serious complications. The separation and extrusion of the placenta, on the contrary, are apt to be imperfect when pregnancy ends in the early months, and medical attention is necessary to determine whether the uterus has been emptied completely. This is particularly important, because the retention of placental tissue affords opportunity for several unpleasant complications; and neglect in this regard accounts in part for the belief that miscarriage is certain to leave women irreparably broken in health. AFTER-EFFECTS.--No one will deny that invalidism follows the untimely interruption of pregnancy more often than the birth of children at full term. This is not due, as is sometimes said, to the fact that a miscarriage differs from a normal birth in that it is unnatural, for other reasons are apparent. One of them, the retention of placental tissue, has just been mentioned, but serious consequences resulting from it are almost inexcusable, for, although the placenta may separate less readily and be cast off less thoroughly after miscarriage, modern medical skill can successfully cope with such conditions. Another fruitful source of unfortunate after-effects is the imprudence of the patient. Women should remain in bed fully as long after a miscarriage as after the birth of a mature infant; if they would consent to do so, many ill-effects would be averted. But physicians frequently encounter strong opposition to precautionary measures such as this. Many patients argue, illogically, that less precaution is necessary since pregnancy failed to attain its natural conclusion, and infer that the earlier that it ends the more quickly one may leave the bed. In point of fact, even greater precaution is required than if all had gone normally. Still a third cause for ill- health may be found in physical ailments which antedated the miscarriage but were not recognized until after its occurrence. Invalidism which follows pregnancy and which may be fairly regarded as chargeable to it depends, in most instances, upon an infection acquired at the time of delivery. Infection occurs more frequently when pregnancy ends during the early months, because in this category is included the great majority of criminal abortions, which are usually induced without regard for surgical cleanliness. Fatal complications, or serious consequences which narrowly escape a fatal ending, are common among women who attempt to rid themselves of an unwelcome pregnancy. As they are ignorant of aseptic precautions, their manipulations must necessarily contaminate the site of operation; for this reason and others as well women who attempt to perform an abortion upon themselves imperil their lives. The danger is scarcely less when abortion is induced unlawfully by incompetent operators; for lack of skill, the need of secrecy, and the desire of haste all interfere with necessary aseptic technique. Everyone knows that sad accidents befall those who submit to such operations; but it is not generally recognized that these cases are largely responsible for the ill-repute borne by miscarriage in general. On the other hand, properly supervised miscarriages are attended by no greater danger and probably less than delivery at full term. CRIMINAL ABORTION.--The destruction of a pregnancy, except when its continuance threatens the life of the patient, is forbidden by law. The important ethical and religious aspects of the act which the law thus stigmatizes as criminal we may properly neglect. Although various religions present a diversity of teaching relative to its moral nature, all agree in regarding it as sinful. Equally important, however, is the fact that no matter what opinion anyone may hold as to the morality of the act he is bound to obey the law. This is apparently not clearly understood by the laity, for many persons think that a physician may terminate pregnancy whenever he is so inclined. If the liability to criminal prosecution which a physician would assume should he comply with a request for the means of destroying pregnancy were clearly realized, patients would not beseech him to incur the risk of heavy find and long imprisonment merely to gratify their own convenience or to save them from disgrace. The Common Law, an inheritance from England, enriched with authoritative decisions by our own courts, is the groundwork of the law in all the States, and its principles are binding in the absence of express statutes. At Common Law, abortion is punishable as _homicide_ when the woman dies or when the operation results fatally to the infant after it has been born alive. If performed for the purpose of killing the child, the crime is _murder_; in the absence of such intent, it is _manslaughter_. _The woman who commits an abortion upon herself is likewise guilty of the crime._ The great majority of those who desire the interruption of pregnancy feel they have not assumed an illegal position so long as they avoid instrumental procedures. That is not correct, for even at Common Law it is a misdemeanor to bring about the death of an unborn child _by the use of drugs or by any other means_. At Common Law there was a difference of opinion as to whether all induced abortions were illegal. Many courts formerly held that quickening was a necessary prerequisite; but under the modern statutes, practically without exception, the law disregards the period of pregnancy at which the abortion is provoked. Since the time of conception determines the beginning of embryonic development, to prove that the act was committed before fetal movements were perceived is no longer a valid defense. This has been emphatically stated by Judge Coulter, of Pennsylvania, who said: "_It is not the murder of a living child which constitutes the offense, but the destruction of gestation by wicked means and against nature. The moment the womb is instinct with embryonic life and gestation has begun, the crime may be perpetrated._" Each commonwealth has enacted its own statutes for the regulation of abortion. In many states, simply _to seek the means for destroying pregnancy is a criminal act_. Thus, Indiana, perhaps the most progressive of the States in reconstructing its criminal code to accord with modern sociological teaching, has enacted a law which I quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page 1029. "Every woman who shall solicit of any person any medicine, drug or substance, or thing whatever and shall take the same, or shall submit to any operation or other means whatever with intent thereby to procure a miscarriage, except when done by a physician for the purpose of saving the life of the mother or child, shall, on conviction, be fined not less than ten dollars, and be imprisoned in the county jail not less than thirty days nor more than one year." To include the woman as a party to the crime is a signal mark of progress toward bringing abortion under effective legal control. Heretofore, the perpetrator alone has been responsible, and in most States he remains so, while the woman is regarded as a victim. Clearly, that is unjust, for criminal abortions are rarely, if ever, performed without application by the subject of the operation. According to most of the statutes no distinction is made between the attempt at abortion and its accomplishment. Irrespective of the outcome, those who supply drugs or employ instruments purposing the destruction of pregnancy are guilty of the offense. An extensive analysis of the various State laws is unnecessary; the mention of a few statutes, selected from different sections of the country, will suffice to indicate the character of prevalent legislation. Massachusetts imprisons those found guilty of abortion for a period of three years or less, and permits a fine of one thousand dollars. In Pennsylvania the same prison sentence is imposed, though the fine may not exceed five hundred dollars. Three years is the minimum imprisonment in Virginia, and a maximum of ten years is allowed. Colorado's law duplicates that of Massachusetts. California imposes no fine, and prescribes a sentence of from two to five years in the State prison. All the statutes make the offense much graver when the woman dies as a result of the practice. Under these circumstances, the crime never takes lower rank than manslaughter; and generally it is murder. Evidently we possess sufficiently stringent laws regarding criminal abortion; yet, as everyone knows, they do not prevent perpetration of the crime. On good authority, we are informed that eighty thousand unlawful abortions are performed annually in New York, in spite of a possible penalty of four years in the State prison. This is due in part to difficulty in securing evidence and failure to prosecute when evidence could be gathered, but more particularly to the fact that the general public does not appreciate the gravity of the offense. The same feeling is illustrated in the advertising of abortifacients. Newspapers and magazines unhesitatingly carry, under the guise of remedies to regulate the health of women, notices of drugs and equipment intended to destroy pregnancy. This is expressly forbidden by many statutes. [Footnote: Thus, the Maryland law provides that "any person who shall knowingly advertise, print, publish, distribute or circulate any pamphlet, printed paper, book, newspaper notice, advertisement or reference containing words or language or conveying any notice, hint, or reference to any person or to the name of any person, real or fictitious, from whom, or to any place, house, shop, or office, where any poison, drug, mixture, preparation, medicine, or noxious thing or any instrument or means whatever; or from whom advice, direction, information or knowledge may be obtained for the purpose of causing the miscarriage or abortion of any woman pregnant with child, at any period of pregnancy, shall be punished by imprisonment in the penitentiary for not less than three years, by a fine of not less than five hundred dollars, nor more than one thousand dollars, or by both, in the discretion of the court."] The knowledge that prohibitory laws exist is sufficient to deter reputable physicians from illegal practice; whereas known laxity in the enforcement of the law continually tempts unscrupulous persons to provoke abortion. Among the poorer classes the procedure is undertaken by ignorant women, while persons in more comfortable circumstances avail themselves of the services of medical men who are usually incompetent and value money above professional honor. The net result is an unpardonable death-rate and a large proportion of invalids. Aside from the legal aspect of the act, the element of personal danger would seem a warning to be heeded by women who contemplate becoming a party to this crime. THERAPEUTIC ABORTION.--If a woman is suffering from tuberculosis or some organic affection, pregnancy may add a serious strain upon the already crippled machinery of her body. Occasionally gestation itself may cause changes which threaten life. In either event the duty of the physician is plain. The law is acquainted with such emergencies, and explicitly permits the termination of pregnancy when undertaken to relieve or cure such conditions. When performed to restore health the operation is called therapeutic abortion. The Maryland law, for example, grants the right to induce abortion whenever two or more physicians see the patient and agree that "no other method will secure the safety of the mother." Similar rules are prescribed by the statutes of other States, but none concedes the right of abortion as a means of keeping the woman from suicide. Since therapeutic abortions are legal, they may be done openly; hence the operation is performed in appropriate surroundings and with every refinement of surgical technique. These fortunate conditions materially alter the outlook; serious consequences of the operation itself need not be feared. Competent surgeons, employing modern methods, may perform hundreds of abortions without the loss of a single patient. Moreover, pregnancy may be terminated safely and expeditiously at any time; the lay view which regards abortion as more serious after the second month than before it is a relic of days gone by. PREMATURE DELIVERY.--In the introduction to this chapter we noted that the infant becomes viable after the twenty-eighth week, which marks in a practical sense, the transition of the fetus from an immature to a premature stage of development. In point of frequency, premature delivery ranks far below either abortion or miscarriage. Unlawful interference with pregnancy generally proceeds from a desire to avoid offspring, and lacks incentive after the infant becomes capable of living independently. Criminal operations, therefore, are not a conspicuous cause of premature delivery. Occasionally physicians resort to artificial means to end gestation during the later months in order that organic complications may be relieved; but most premature births occur spontaneously. Sometimes they are due to ill-health, while in other instances no evidence of disease is found in either mother or child. Careful study of the individual patient, however, is generally helpful toward the prevention of repeated premature delivery. The course of premature labor closely resembles delivery at full term. But it is shorter because the infant is small; and the subsequent loss of blood is not so great. The recovery of the mother is never retarded by the fact of earlier delivery, though the conditions which caused it may prevent rapid convalescence. The outlook for the infant depends upon a great many factors. Most important among them is the perfection of its development, which may be estimated most satisfactorily from its weight and length. Occasionally children have been reared when they weighed as little as three pounds, but hope that they will survive should not be entertained unless they weigh four pounds or more. This is attained about eight weeks before maturity, and corresponds to a length of forty centimeters (16 inches), measured from the crown of the head to the heel. Premature children perish, most frequently, either from incomplete development of their heat-regulating apparatus, which predisposes them to pneumonia, or from imperfections in the digestive functions, which increase the liability to malnutrition. To overcome the first danger, incubators have been devised and have become familiar to everyone through public exhibitions. A basket or box supplied with hot-water bottles answers the same purpose, and has the advantage of better ventilation. The second danger can be overcome only by proper feeding. Breast-milk provides the most reliable nourishment for premature infants. If the mother cannot supply it, a wet-nurse should be procured, and, if the infant has not the strength to suckle, the milk should be drawn from the breast and fed with a medicine-dropper or a spoon. In addition to providing proper food and maintaining an even body- temperature, care must also be taken to protect these infants from various harmful influences such as too much handling, strong light, and loud noises. Although every precaution be observed, frequently all counts for nothing; but if the child does thrive, there is no reason for worry about its ultimate development. When a premature infant lives, the same chances for adult health await it as it would have had if born in its due time. CHAPTER IX THE PREPARATIONS FOR CONFINEMENT Engaging the Nurse--Desirable Qualities in the Nurse--Preliminary Visits of the Nurse--The Necessary Supplies for Confinement--The Baby's Outfit--Sterilization--The Choice and Arrangement of a Room-- The Bed--The Preliminary Visit of the Doctor--When to Call the Doctor--Personal Preparations--The Care of Obstetrical Patients at the Hospital. Prospective mothers are anxious to learn how they shall prepare for the approaching confinement. They desire their preparations to be thorough, reliable, and in accord with the most approved methods of treatment, for they realize that preparations along these lines will not only prevent haste and confusion at the time of birth, but will also promote a satisfactory convalescence. Apparently trivial details often safeguard confinement against serious accident. Indeed, measures which aim at the prevention of illness form the chief asset of modern obstetrics, and of these none takes higher rank than the maintenance of strict cleanliness during and after childbirth. This fact fortunately is widely appreciated at present, and not a few women inquire voluntarily the means of observing the proper precautions. It is true, of course, that even today many women are delivered in filthy rooms and upon dirty beds, and that in spite of such surroundings some of them make a good recovery. Yet grave complications develop much more frequently among those who have not paid attention to the preparations for confinement. The surgical dressings and other supplies do not require attention in the early months of pregnancy. A number of articles, invaluable when delivery occurs at full term, are useless if the fetus is immature and cannot live, and therefore it is unnecessary to provide them until two or three months before the confinement is expected. In the event of a miscarriage what is needed can be procured upon very short notice. But, on the other hand, delivery subsequent to the twenty- eighth week may require all the equipment useful at full term so that everything should be in readiness by that time. ENGAGING THE NURSE.--As soon as the existence of pregnancy is clearly recognized the patient should select the doctor and the nurse who will attend her. Prompt selection of a nurse will assure the widest choice, for proficient nurses are in demand and book engagements far in advance of the date they will be needed. Furthermore, it is a relief to the patient to have her attendants selected. The possibility of premature delivery never interferes with engaging the nurse very early in pregnancy, for that accident releases both patient and nurse from their contract. Nurses demand that the date be specified upon which an engagement shall begin, as, unless their calendar is definitely arranged, they are unable to earn a livelihood. This leads to a question which is difficult to answer, for the precise day of delivery is uncertain; consequently to fix the beginning of the engagement may prove a troublesome matter. On the one hand, there is risk of having to pay the nurse for a time before her services are actually needed; on the other, a false economy may result in the absence of the chosen nurse at the critical moment. In finding a way out of this dilemma a patient must be guided by her means and the location of her home. Those who can afford it will not hesitate to employ a nurse from one to two weeks in advance of the expected date of confinement; and for those who live where nurses cannot be procured quickly, a similar course is recommended. But persons of only moderate resources, living in a city where, in an emergency, a substitute can be gotten from the local "Nurses' Directory," will find it convenient to engage the nurse from the calculated date. The substitute will remain with the patient until the arrival of the nurse originally engaged. Occasionally, it may happen that a patient will prefer to keep the substitute. Such a course, however, would be unjust to the nurse who was first selected, unless she could immediately secure other work. She has reserved a definite period of her time for the patient, and probably has declined work which seemed likely to conflict with the engagement already made. She is fairly entitled, therefore, to assume charge of the case, and the patient who refuses to make the change is obligated to pay her according to the terms of the agreement. How long will a nurse be needed after the child is born? The answer to this question may be altered by so many circumstances that a hard and fast rule cannot be given. Before the advent of "Trained Nurses," obstetrical patients were cared for by "Monthly Nurses," so called because they remained one month with their patients. It is, likewise, customary to keep the trained nurse four weeks after the birth; but whenever possible it would be well to retain her six weeks, since this period elapses before the mother has entirely regained her normal physical condition. Those who can afford to keep a trained nurse six months or a year are exceptional, but very fortunate. Someone may feel that the suggestions I have made are not suitable to her case. Very likely they may not be; to cover all the possibilities could scarcely be expected, for every case has its problems and peculiarities. After consultation with her physician each patient will decide what is particularly advisable for her. Nevertheless, I would emphasize the importance of securing a competent nurse and retaining her for at least four weeks. Even with those who must guard their expense account the truest economy will lie in such a course. Whenever lack of resources seems likely to prevent this arrangement, the patient who is looking to her best interests should enter a hospital where excellent care can be provided at a cost within her means. DESIRABLE QUALITIES IN THE NURSE.--It is rarely advisable to select as nurse a member of the family or an intimate friend. Some of the motives governing such a course--sentiment, mutual devotion, and the desire to be humored--are inconsistent with the best kind of nursing. If the nurse knows the patient intimately, undue anxiety may interfere with her judgment; thoroughness in routine duties may be hindered by mistaken consideration for the patient; and in an emergency sympathy rather than reason may guide her. A successful nurse must satisfy at least two requirements; she must be capable professionally and also personally agreeable to her patient. Some regard advanced years as essential to the first of these qualifications, but this does not necessarily hold good. The personal qualities generally welcome in a nurse are neatness, thoughtfulness, a sympathetic nature, an even disposition, and a cheerful view of life. Since a short interview is insufficient for taking the measure of a nurse, patients usually rely upon the opinion of someone else in selecting her. The judgment of her former patients is frequently prejudiced in one direction or the other, and such an estimate must always be accepted with caution. Much the most trustworthy method is to allow the physician to select her. He will know nurses who possess the requisite qualities, and certainly he is most competent to judge their professional attainments. If the choice of a nurse be left to the doctor, the two are sure to work harmoniously, and the patient will benefit by their cooperation. Otherwise she may suffer because of their dissensions, for, if the doctor is accustomed to one procedure and the nurse to another, misunderstandings may occur, although both methods yield equally good results. Whenever he does not select her, she should be asked to confer with him long before the case is due. Obviously, a physician cannot be held responsible for a nurse's ability unless he is acquainted with her training and methods of work. In an effort to economize, many are inclined to employ "half-trained" or "practical nurses." When the confinement is not the first and there is no reason to anticipate any irregularity during labor or thereafter, I can see no vital objection to such an arrangement. It is of the first importance, however, to be assured that the "practical nurse" is neat and appreciates the necessity of keeping everything about the patient scrupulously clean. But competent nurses who charge less than the customary fee will be hard to find. The recommendations which these women receive are apt to be even more misleading than in the case of trained nurses, because more is expected of the latter. My experience has taught me that patients form particularly unreliable opinions of practical nurses, and I have frequently witnessed incompetence in such women which was overlooked by the patient. A low-priced nurse is seldom a cheap one, as her shortcomings may be reflected in the health of the mother or the infant long after she has left the case. Especially when the baby is the first, the mother will depend upon the nurse for instruction which should be both sound and thorough. The principles taught her will be put into practice and utilized for many months, playing a vital part in the training of the infant. It becomes essential, therefore, to secure a nurse who will give the baby a good start, and instruct the mother along right lines. Perhaps this is less needful if the mother has learned her lesson from previous experiences. But even then a good nurse relieves her of responsibility and materially assists her to a quick and lasting convalescence. In the end the most proficient nurses are the least expensive. THE PRELIMINARY VISITS OF THE NURSE.--Many of the precautions which safeguard a confinement should be considered by the patient and the nurse together. The character and quantity of the supplies, the choice of a room for delivery and subsequent convalescence, the proper clothing for the infant--all these are problems which may be solved most satisfactorily in the light of the nurse's experience and the resources at hand. Two visits are usually sufficient to arrange these details. An interview early in pregnancy, soon after the nurse has been selected, provides an opportunity to lay plans and especially to review the list of articles needed at delivery. Such articles as are already in the house may be checked off; the others may be procured at leisure. Eight to ten weeks before the expected date of the confinement the nurse should pay a second visit and should inspect the supplies to see that they are complete. Certain articles which I shall indicate must be sterilized. As this procedure is more reliable when carried out by an experienced person it will be convenient to have all the dressings finished by the time of the nurse's second visit, in order that she may sterilize them. The question may arise as to whether the nurse shall come to the patient upon the date for which she has been engaged or shall wait until summoned. From the physician's standpoint it is often more acceptable to have the nurse in the house a few days before the confinement, though some patients strongly object to this. Provided the nurse may be got quickly at any time of day or night, there can be no objection to leaving the decision to the patient herself. THE NECESSARY SUPPLIES FOR CONFINEMENT.--As to just what a confinement outfit should contain physicians differ to some extent; but this disagreement pertains rather to luxuries than essentials. In the lists here suggested nothing essential has been omitted, although economy, as far as is consistent with good judgment, has been kept in mind. Any article not included in my list which the doctor or nurse in attendance recommends may be noted in the space for memoranda. Some patients prefer to take no part in preparing the supplies for confinement. Indeed, the demand for a ready-made confinement outfit has become large enough to lead several firms to put them upon the market. These outfits differ in completeness and vary in price from a few dollars up to fifty. The majority of patients, however, still attend to such details themselves, and will find a list of the needful supplies convenient. _Make-up and Sterilize_: 7 Dozen Sanitary Pads. 2 Sanitary Belts. 2 Delivery Pads. 5 Dozen Gauze Sponges. 2 Dozen Gauze Squares. 4 Dozen Cotton Pledgets. 2 Sheets. Bobbin for tying the Cord. A Pair of Obstetrical Leggins. A Dozen and a Half Towels (Diapers). _Obtain from the Druggist_: 100 Bichlorid of Mercury Tablets. 100 grams Chloroform. 4 ounces Powdered Boric Acid. 4 ounces Tincture Green Soap. 1 pint Grain Alcohol. A small jar of White Vaselin. A cake of Castile Soap. A two-ounce Medicine Glass. A Medicine Dropper. A bent glass Drinking Tube. _The following articles should be in the house, ready for use._ An ample supply of Towels, Sheets, and Gowns. A new Hand-Brush; the cheap variety with wooden back and stiff bristles is preferable. Two slop Jars or enamel Buckets with Covers. A two-quart Fountain Syringe; an old one may be substituted provided it has been thoroughly boiled. Three Basins and a one-quart Pitcher of agate or enamel-ware. A Douche-Pan; the "perfection Bed-Pan" is preferable. Two pieces of Rubber-Sheeting are required, one large enough to cover the mattress of a single bed (2 x 1-1/2 yds.), the other smaller (1 x 3/4 yd.). Should this be too expensive, the best substitute is white table oil-cloth. The nurse will explain how the various surgical dressings are made, but, as the patient may forget some of the directions, all the details will be given here. At least three to four pounds of absorbent cotton will be used in the dressings. To make the pads entirely of absorbent cotton is very expensive. The cheaper cotton- batting is therefore employed to give them body, and they are faced only upon one side with the absorbent material. Furthermore, the rolls of absorbent cotton, as purchased, may be separated into three or four layers, one of which is thick enough for the facing. About six rolls of the batting should be purchased. Surgical gauze, which tradespeople sometimes call dairy-cloth, is the most suitable material for covering the pads. Bleached cheese cloth will answer the same purpose, but it is more expensive and rather heavy. Approximately thirty-five yards of the gauze, which comes in a thirty-six-inch width, will be needed. When the supplies are finished, they are wrapped in separate bundles and sterilized. Old muslin or some of the diapers are generally used for covers. _The sanitary pads_, also called vulval or perineal pads, absorb the discharge which always occurs after delivery. They are made of absorbent cotton and cotton-batting covered with gauze; a convenient size is ten inches long and three to four inches wide. Their thickness is approximately an inch, one-third of which is composed of absorbent cotton. _The sanitary belt_ is used to hold these pads in place. Very satisfactory ones are made of two strips of unbleached muslin, three inches wide. The first of these must be long enough to reach around the waist; the second, which passes over the pad, is somewhat shorter and has two parallel slits in one end; through which the waist-band passes at the back; the three free ends are pinned together in front. _The delivery pads_ are made of the same materials as the sanitary pads; preferably a yard square and four inches thick. A rather heavy top-layer of absorbent cotton must be used in them, and they should be quilted or tacked at several points to prevent slipping. A rubber pad is ill adapted for use during delivery. Some absorbent material made into proper shape proves much more satisfactory since it can be thoroughly sterilized and can be thrown away after it has been used. I am told that cotton-waste is a good substitute for absorbent cotton in the delivery pads. It is inexpensive, and will be rendered capable of absorbing fluids after it has been boiled in washing soda and dried in the sun. Each delivery pad should be separately wrapped and sterilized. _Gauze sponges_ will be needed by the doctor; about five dozen should be prepared. The gauze is cut in eighteen-inch squares. Opposite edges are folded toward one another, about two inches being lapped each time; this finally yields a seven or eight-ply strip, which is wrapped into appropriate shape about two fingers. The ravelled ends are then tucked into the roll. It is most satisfactory to divide the sponges and sterilize them in two bundles. Small pieces of gauze about two inches square will also be needed in caring for the baby's eyes and mouth. Several dozen should be cut, and they may all be sterilized together. _Cotton pledgets_ are simply bits of absorbent cotton the size of a hen's egg, the rough edges of which have been twisted together. A small pillow-case full of them ought to be made up and sterilized. _Obstetrical leggins_ are preferably made of canton flannel; they are cut to fit loosely and should reach the hip. If they are prepared so as to extend to the waist at the sides, they may be held in place by a waistband, and in this way will prevent unnecessary exposure without interfering with the doctor. They should be sterilized. _Towels_, if used at all, should be without fringe. It is economical not to employ them, but to use diapers in their place. Three packages, each containing six diapers, should be sterilized. _Sterilized sheets_ are often useful at the delivery; more than two are never needed. They should be wrapped separately for the sterilization. _Sterilized bobbin_ is generally used for tying the cord. Several pieces are cut in nine-inch lengths and sterilized in a single package. _A dressing for the cord_ will be required, but there is no necessity for preparing a special one. It is generally satisfactory to wrap the cord in one of the sterile gauze sponges which has been previously soaked in alcohol. Several methods of drying up the cord give equally good results, and it is usually a good plan to allow the nurse to dress it as she wishes, since the employment of a method with which she is familiar will more likely insure a satisfactory result in her hands. A dressing popular with many nurses is prepared as follows: In a piece of muslin four inches square cut a small circular opening; double the linen and dust boric acid between the folds. If this method is preferred, several of the dressings should be prepared and sterilized together. THE BABY'S OUTFIT.--Preparations for the infant may be thorough without being elaborate. Instinctively, the prospective mother leans toward extravagance in fitting out her baby's wardrobe, and easily slips into the error of providing too much. Time and energy are frequently devoted to an extensive wardrobe which the infant quickly outgrows; in consequence many articles must be made over before they are used. Even with modest resources a prospective mother can acquire everything the baby really needs. A very sensible plan, in my judgment, is to prepare what will be wanted during the first two months; subsequently, articles may be made or bought as they are needed. Accordingly, the quantity of wearing apparel and the nursery supplies I have suggested pertain only to the early weeks of infant life. Although no essential has been omitted, the outline is plain and economical. At present, outfitters supply a variety of ready-made, garments for the infant and conveniences for the nursery; in many of them notable ingenuity is displayed which aims at the child's comfort or the saving of labor to the mother. Catalogs of these articles, which are often expensive, are furnished by dealers. In preparing clothing for the new-born, several principles must be kept in mind. The first is that the garments must be warm without being unduly heavy; and another that they should be roomy, permitting perfect freedom of motion. A third no less important principle is simplicity. Adornment of the clothing gratifies the mother, but does not serve a single useful purpose. The lists which follow include all that is necessary for the young infant; they will also serve as a basis for elaboration if a more lavish outfit is desired. _Necessary Clothing_. 4 Abdominal Flannel Bands. 3 Undershirts. 4 flannel Skirts. 4 Night Gowns. 12 White Slips. 3 Knit Bands. 4 Dozen Diapers. Cloak and Cap. _Nursery Equipment_. An old Blanket. Assorted Safety Pins. Soft Damask Towels. Wash Cloths. Hot-Water Bag with Canton Flannel Covers. Talcum Powder. Olive Oil. Bassinet. _Additional Articles; Convenient but Not Essential_. Rubber Bathtub. Rubber Bath-Apron. Flannel Apron. Bath Thermometer. Bath Hamper. Quilted Mattress Covering. Baby Scales. Screen. Low Chair without Arms. Drying Frames. STERILIZATION.--Now and again, those who follow very rigid rules to avoid infection during childbirth are criticized for their pains. The general public has not yet grasped the true relation of bacteria to this condition; a relation which, indeed, first became clear to medical men within comparatively recent years. The development of our knowledge of the nature of infection forms one of the most entertaining chapters in obstetrics, and provides a simple way of showing the genuine need of preventive measures. Several observant physicians had previously suspected the character of "child-bed fever" (as infection of the mother was once called), but convincing proof of its contagious nature was not forthcoming until the middle of the nineteenth century, when signal facts were pointed out by three men, each working independently, though all came to similar conclusions. The evidence they gathered should have left no one doubtful that the disease is contagious, and largely preventable. On the contrary, bitter opposition was encountered for the time, and only within the last two decades has their teaching found wide practical application. In 1843 Oliver Wendell Holmes published the paper on "The Contagiousness of Puerperal Fever," which is now preserved in his volume of "Medical Essays." Physicians were startled to be frankly told the responsibility they assumed if they neglected the truth taught by epidemics of this disease. "The dark obituary calendar" which marked the progress of these epidemics clearly indicated that "the disease is so far contagious as to be frequently carried from patient to patient by physicians and nurses." A violent controversy followed this arraignment, and, consequently, the preventive measures which Holmes so convincingly urged were not adopted as promptly as they should have been. The full justice of his conclusions has since been universally admitted, and medical men now find it difficult to understand how anyone could have taken issue with the sentiment which he expressed. "For my part," Holmes said, "I had rather rescue one mother from being poisoned by her attendant than claim to have saved forty out of fifty patients to whom I had carried the disease." But the most important early observations upon child-bed fever were made in 1847 by a young Hungarian, Semmelweiss, while he was an assistant in the large Lying-in Hospital in Vienna. In thoroughness, power of conviction, and practical value his work was masterful. It is no exaggeration to regard his observations as the rock upon which antiseptic surgery, the glory of the nineteenth century, was built. Semmelweiss had been seeking an explanation of the dreadful scourge, and his mind was ready for the reception of the truth when it was revealed through the death of one of his colleagues. This physician injured his finger accidentally in performing an autopsy upon a patient who had died from child-bed fever. And the condition disclosed by examination of his body after death was identical with that found in cases of child-bed fever. Here then was the clew; the disease was contagious. Semmelweiss was ignorant of Holmes' views; what had happened before his eyes suggested to him that the disease was due to a poison which could be conveyed from one person to another. Moreover, his interest and his power of insight led to further comparison. Clearly, the open wound on the physician's finger had been the portal through which the poison entered; but where was there a similar portal in obstetrical patients? The answer was plain. The birth-canal at the time of delivery is always an open wound. There the poison entered, and child-bed fever was a wound infection! Several years later Tarnier, who was to become an eminent obstetrician, but was then a student in Paris, chose the diseases of the lying-in period as the subject for his graduating thesis. He was unacquainted with the work either of Holmes or of Semmelweiss, and approached the problem from still another standpoint, drawing attention to the much higher deathrate among women delivered amid unsanitary surroundings. Tarnier also considered that the disease was a form of poisoning, that it was contagious, and that measures should be instituted to protect patients against it. Of these pioneers, by far the greatest credit is due Semmelweiss, who devoted his life to the problem, although his opinions continually met with scepticism and even ridicule. More convincing proof than he could furnish was demanded before his contemporaries would believe that child-bed fever was due to lack of precaution. Fortunately the evidence was soon produced. In 1880, Pasteur obtained bacteria from the organs which had been infected, and was able to grow the bacteria in his laboratory; thus the ultimate cause of the disease became firmly established. With the harmful agents in their hands, Pasteur and his followers were enabled to study their characteristics and to recommend means of destroying them. Much as we must regret that the warnings of Holmes and of Tarnier passed unheeded; lamentable as may be the blindness of the generation of Semmelweiss to the truths revealed by his research, it is not surprising that such radical teaching met with a hostile reception. As we measure time in retrospect from the vantage ground of to-day, the three to four decades required for full acceptance of their revolutionary doctrines seem a brief span. Antiseptic methods would not have prevailed so quickly as they did, had not the same epoch which gave us a Pasteur also given a surgeon with a receptive mind, ready to seize and apply the discoveries of the French genius. This was the great service of Joseph Lister. Impressed with Pasteur's studies on fermentation, Lister saw an analogy between this process and the putrefaction of wounds, a condition which he was eager to prevent. He had reason to believe that carbolic acid would check decomposition, and he employed a weak solution of it in the treatment of wounds; later he devised a "carbolic spray," by means of which when his operations were performed the atmosphere round about might be sterilized. It is but a short step from antiseptic operations to our own era of aseptic surgery, and that a step in the direction of simplicity. Now we know that the sterilization of the air is rarely necessary and have dispensed with Lister's elaborate apparatus. Furthermore, and of far greater moment, experience has taught that the destruction of bacteria before they have opportunity to come in contact with the wound is more effective than efforts to kill them as they approach or after they have invaded the tissues. Initial freedom from bacteria is the ideal of asepsis; to secure it, the modern surgeon is ever watchful of the cleanliness of his hands, his instruments, his dressings, and of the site of operation or whatever may come near it. The importance of the changes wrought by the adoption of aseptic methods requires no emphasis, for the marvels of modern surgery are even more impressive to laymen than to the medical profession. Everybody now understands that strict cleanliness is indispensable to the success of a surgical operation. But the general public has not fully awakened to the same profound necessity in connection with childbirth, although it was child-bed fever that called forth the observations and experiments upon which modern surgical technique rests. Although most obstetrical patients appreciate the fact that there is an advantage in sterilized dressings and sanitary surroundings, few realize the risk they run without them. One must know the mournful history of the past to be adequately impressed with that danger, for we no longer see the epidemics of childbed fever which formerly swept over communities, sacrificing ten of every hundred women as they became mothers. Precaution is no less necessary on that account; the scourge would be rampant again if the reins were loosened. Most instances of puerperal infection are, it is true, referable to lack of care. Nevertheless, the complication develops now and then where all precautions have been conscientiously observed. Under such conditions the infection will in all likelihood be a mild one, and a tedious convalescence usually proves its most disagreeable feature. Such stringent preventive measures as are now practiced in many hospitals have reduced the frequency of infections to the point where only one fatal case, or even less, occurs in a thousand deliveries. These rare cases remind us that vigilance must never be relaxed, and that patients who are confined at home require just as much care as those in hospitals, where conditions are the best to prevent infection and the complications, which follow. The first essential toward the avoidance of infection in obstetrical cases is clean dressings. Naturally, these should be clean to the sight, but it is in invisible dirt that serious danger lurks; bacteria are the causative agents of this disease. Experiments have taught the bacteriologist that disease-producing organisms are killed in half an hour when subjected to a high atmospheric pressure and the temperature of steam. Special apparatus has been constructed for carrying out the procedure. It is unnecessary for our purposes, however, since the essential conditions may be secured, though with less convenience, in any kitchen. If a prospective mother finds it awkward to do the sterilizing at home, and her nurse is unable to take charge of the matter, she may arrange with a local hospital or the nearest nurses' directory to sterilize her dressings. Yet a very little ingenuity suffices to do the work at home with perfect satisfaction. Installments of the smaller bundles may be sterilized in a galvanized bucket. To do this place an inverted bowl, with a depth of three to four inches, at the bottom, and pour in water until the bowl is almost covered. A breakfast plate rests on the bowl, and upon this the dressings are stacked; a second larger plate which fits the top of the bucket is utilized as a lid to close in the sterilizing chamber. This will not accommodate the larger packages; a more satisfactory method for all of them is to use a wash-boiler in which has been swung a muslin hammock. To arrange the latter form of home sterilizer, cut an oblong piece of unbleached muslin large enough to sink far down into the boiler and run a drawing-string of stout cord about the edge. Cover the bottom of the boiler with several inches of water; tie the hammock in place, passing the cord beneath the handles of the boiler to hold the muslin securely. Pack in the dressings, which have been wrapped in appropriate bundles; put the lid in place, thus closing the sterilizing chamber, and leave the dressings exposed to the steam for at least half an hour. After the operation has been completed, the bundles are taken out of the boiler and allowed to dry in the air. They must not be opened until the occasion for which the supplies were prepared arrives; awaiting this event, they are laid away in a convenient closet or drawer. A word of caution may be added concerning a method of sterilization employed at home more frequently, perhaps, than any other. According to this procedure, the supplies are wrapped in paper, thrust into a hot oven, and left there until the paper is scorched. From the standpoint of economy as well as of thoroughness, this method is likely to prove unsatisfactory. Frequently, the dressings themselves are scorched; I have known patients to ruin several installments of their supplies in this way. Moreover, dry heat is not so trustworthy as steam for sterilizing purposes. Judicious management means the preparation of the supplies necessary for confinement before turning to the selection of the infant's outfit. Ordinarily, both these tasks should be finished by the end of the eighth month, and final arrangements for the approaching delivery will then claim attention. If the patient expects to remain at home, she must decide which is the best room to occupy; she will wonder how it ought to be equipped, and she will be anxious to learn what personal preparations are advisable at the beginning of labor. Intelligent answers to these questions are important. A patient should request the physician to criticize her plans when he pays the preliminary visit four to five weeks prior to the expected date of confinement. If she has acted unwisely in any respect, he will point it out, and may suggest changes which will enable her to employ to the best advantage the resources at hand. THE CHOICE AND ARRANGEMENT OF A ROOM.--An old-fashioned custom, which relegated obstetrical patients to the most secluded part of the house, with little regard for comfort and still less for hygiene, has now few, if any, adherents. There is an advantage, to be sure, in having a quiet room; but this qualification may be secured in a room well located with regard to other essentials. Selection of a suitable room is not a trivial point. In most cases, since patients ordinarily remain for convalescence in the same room in which the infant is born, the chamber must serve a two-fold purpose. A number of requirements, therefore, must be met, and they must all be kept in mind when the room is chosen. We have seen that the act of birth, natural as it is, may have a very unnatural sequel if precautions against infection are treated lightly. It is proper, therefore, that the delivery-room should be as clean as care can make it. Such radical measures as may be employed in sterilizing the dressings are here out of the question; if possible, they would be absurd. Infection usually develops because harmful bacteria come in contact with the patient. For that reason, an infection is more likely to be communicated by the dressings than by articles about the room, which only become a source of danger when the dirt upon them is transferred by an attendant. An acceptable delivery-room may be arranged in any home; it is by no means necessary to duplicate the equipment of a modern hospital. To choose a room convenient to the bathroom will be found advantageous not only at the time of birth but throughout the lying-in period. The furnishing should be simple and scrupulously clean; indeed, it is improbable that one of these good points can be secured without the other. Furthermore, the preparation of the room should be completed well in advance of the date of confinement. A large collection of furniture interferes with the nursing, and also increases the difficulty of keeping the room free of dust. It is sound advice, therefore, to remove everything which will not serve some good purpose during the delivery. Should any article be wanted later, it can be brought back to its accustomed place. The furniture may be conveniently limited to a bed, a bureau, a washstand, a table, and several chairs, one of them a large, comfortable rocker, which will prove invaluable during the early part of labor. To approach perfect conditions, bric-a-brac, needless hangings, and everything that might collect dust should be temporarily removed. A profusion of pictures does not accord with the best sanitation of a room devoted to the treatment of obstetrical patients; those which are to be left upon the wall ought to be taken down and wiped carefully with a damp cloth. Other desirable preparations would be instinctively undertaken by the modern housekeeper, and it may seem presumption to mention that the room itself ought to be subjected to most thorough cleaning. It is well to leave the floor bare or merely covered with freshly cleaned rugs. Carpeting is difficult to protect against soiling and is not sanitary. If left down, the carpet should be covered with some suitable material, firmly stretched and tacked in place. We know that the air in most households does not contain disease- producing bacteria; but the presence of any contagious disease materially alters the situation, and may imperil the convalescence of an obstetrical patient. Preferably, one should never select a room in which there has lately been sickness, and under no circumstances may such a room be used until carefully fumigated. The more conspicuous diseases which for at least several months absolutely disqualify an apartment for obstetrical purposes are diphtheria, pneumonia, pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of all varieties, and every sort of discharging sore. When possible, two adjoining rooms should be given over to the mother and the infant; if this is impracticable, the single room should be large, easily ventilated, well lighted, and heated in such a way as to permit a change of temperature without difficulty. All these features help to make convalescence comfortable and free from petty annoyances. A room which has a southern or eastern exposure proves grateful for those who must remain indoors; frequently, this will be beyond reach, but a room getting the sun's rays directly during part of the day will always be available, and the selection should be made with that requirement in mind. At the time of birth and for the first few days which follow, a patient may not appreciate this feature; ultimately she will understand the need of sunlight better than the need for the more technical, and therefore the more impressive, preparations. THE BED.--Now that housekeepers recognize how easily such furniture can be kept clean, few homes are without a brass or an iron bedstead; they are equally sanitary. Undoubtedly, this kind of bedstead fulfills the needs of an obstetrical patient much better than any other; and, if at hand, it should be used. The single bedstead is the most acceptable, and the mattress ought to be at least twenty inches above the floor. A low, wide bed interferes with proper management of the delivery and later handicaps the nurse in taking care of the patient. Wooden blocks may be used to raise a bed which otherwise would be too low. It is well worth while to provide them if one desires good nursing, for no attendant can do her best when she must continuously bend over a very low bed. The location of the bed at the time of delivery is not an unimportant matter; it must always be placed so that the brightest possible light will shine over the foot. Since birth often occurs at night, one should make certain that the artificial lighting of the room is good, and place the bed most advantageously in reference to it; at the same time the necessity of a good light from the windows, when delivery occurs during the day, should not be forgotten. The head of the bed may be placed against the wall, but both sides must remain freely accessible not only at the time of delivery but also throughout the lying-in period. A smooth, firm mattress, made in one piece, should be provided. One which has been used several years and possibly worn in a hollow will require renovation to be made comfortable. A feather bed should not be used under any circumstances. The mattress must be protected; and protection is best secured by means of a large piece of rubber sheeting. The regulation household sheet covering the rubber should be tucked well under the mattress at the ends and sides; in that way the rubber sheeting will be held firmly. Since the part of the bed where the hips rest will be most exposed to soiling, the protection of this area is usually reinforced by a "draw sheet." To arrange this, a cotton sheet is doubled so as to make a strip about one yard wide and two yards long; the smaller piece of rubber sheeting is laid between the folds. The draw sheet will reach from the middle of the back to the knees; its ends should be tucked under the sides of the mattress, to which it is fastened by means of large safety pins. After delivery, the draw sheet may be removed without disturbing the mother, who will thus be assured a clean, dry, and comfortable bed. The bed-clothes covering the patient during labor will vary with the season of the year, but should always be light; in summer a single sheet will suffice, and in winter a blanket will likely be needed. For sanitary reasons, a freshly laundered sheet should also be placed outside the blanket until the delivery has been completed; later, it may be replaced with a light spread. Two pillows will be needed, and it is very convenient to have one of hair, the other of feathers. While there is no necessity for sterilizing the bed-clothes, it is advisable to use linen which has been recently laundered and kept well protected from dust. Among the poor, infection from soiled bed- linen is not uncommon. THE PRELIMINARY VISIT OF THE DOCTOR.--No teaching of medical science has been given greater prominence of late than the principle of prevention. In obstetrics it finds a particularly wide field of application, and its practice is responsible for removing many of the former terrors of childbirth. We have just learned that preventive measures effectually reduce the frequency of puerperal infection, and in an earlier chapter we saw the value of routine examination of the urine as a means of anticipating other complications. Moreover, the benefit of promptly reporting to the physician anything that does not seem to be as it should has been urged constantly, for in this way is afforded the earliest opportunity to treat complications. Similarly a visit from the doctor about four weeks before the expected date of confinement is indispensable to skillful management of the delivery; neglect of this precaution is sometimes responsible for bad results. At this visit the physician not only becomes familiar with the general health of his patient, but he also notes certain facts which will have a direct bearing upon the course of labor. By means of a few simple measurements he may accurately determine the character of the pelvis, the bony structure through which the fetus passes. When they are compared with what we know as the normal measurements, a very good idea is gained as to whether the birth-canal will present any obstacle to the passage of the child; and, if it will, there is opportunity to deliberate what treatment may be necessary. Since another factor in the problem, namely, the size of the child, cannot be accurately predicted, occasionally the physician may hesitate to express as definite an opinion as the patient may wish. Nevertheless, though it may be impossible to learn every detail, the available information well repays the time and trouble expended. In nine out of ten cases nothing whatever is found out of the way; the result is an assurance which always justifies the examination. During this examination the position of the child is also ascertained. By means of a series of painless manipulations through the abdominal wall of the mother, the head, the body, and the extremities of the child may be mapped out, and the conclusions verified by locating the fetal heart-sounds. In this regard, also, the physician usually finds normal conditions. The most favorable presentation, that in which the head is the part to be born first, occurs in ninety-seven of every hundred cases. When less favorable conditions are recognized, they may frequently be corrected at once; but should that prove impossible, with foreknowledge of the presentation, the physician will be more competent to conduct the delivery. With a clear understanding of the character and value of the information gathered at the preliminary examination, patients are not likely to refuse it. If they do, the risks should be fully explained to them. Some physicians decline to assume the responsibility of a patient who will not permit these observations. Such a decision is rarely necessary, for in my experience the patient's consent has never been difficult to obtain. Many women now regard the visit as part of the routine attention, and inquire when it will be made. The appropriate time for this examination, as I have indicated, is approximately one month prior to the calculated date of confinement. Before this period, we have no assurance that the presentation which is found will continue until the time of birth. The fetus frequently alters its position as long as it is not large enough to fill out the cavity of the womb, consequently it is only during the last month of pregnancy that the final presentation can be determined. But to defer the examination after the period I have specified is unsafe since we lack an exact method of fixing the day of confinement, and too long a delay might render a preliminary examination impossible. Aside from its relation to the observations just outlined, the preliminary visit provides an opportunity for the physician to criticize the preparations which have been made, and for the patient to inquire about the personal preparation advisable at the beginning of labor. She will also learn the signs which indicate that labor has begun and will be told what to do when they appear. Although physicians may not agree in all these directions, there can be no difference of opinion relative to the essential points. At least, the rules given here will serve to bring the patient and the doctor to a definite understanding as to the course he desires her to follow. WHEN TO CALL THE DOCTOR.--During the last two or three weeks of pregnancy not a few patients are more comfortable than they have been for several months. About this time the womb usually drops somewhat and relieves the pressure which has interfered with breathing. These changes, however, do not promote comfort in every direction; more freedom for the organs of the chest means compression of the structures below the womb; consequently, the inclination to empty the bladder and for the bowels to move becomes more frequent. Patients complain also of cramps in the legs and experience difficulty on walking. This order of events enables some women to recognize the approach of delivery. Of course there is other evidence when labor actually begins. Its onset may be indicated in one of three ways, namely, by periodic pains, by a gush of water from the vagina, or by a discharge of blood as though the patient were taken unwell. Each of these unmistakable signs is a sufficient reason for notifying the doctor. At the onset of labor, dragging pains are usually felt at the back, but sometimes in the lower part of the abdomen. The rhythm with which they come and go identifies them more certainly than any other feature, though this indication is not entirely reliable, for intestinal colic also causes rhythmical pain. At first the uterine contractions which occasion the discomfort are weak and appear at long intervals. Gradually they become stronger and closer together. When the interval between them has been shortened to half an hour or less their significance is fairly certain, provided the abdomen becomes tense and hard with each pain, remaining comparatively soft between them. When contractions begin during the day or early evening, the physician will be glad to have immediate notification in order that he may arrange his appointments and thus be free to attend the patient when she needs his services. On the other hand, if they begin between 11 P.M. and 7 A.M. the nurse, who will always be summoned with the very first warning, should be allowed to decide when the doctor is to be called. Unless other instructions have been given, she will usually wait until the interval between the contractions is five to ten minutes. Usually the symptoms make it clear that labor has begun, but occasionally the greatest difficulty will be experienced in deciding whether the discomfort has not some other origin. Uncertainty may prevail not only because of the similar effects of colic, but also from the fact that uterine contractions do not always have the same value. Preliminary pains may appear several days, or even weeks, before the actual onset of labor. Now and then the "false" pains cease, and after a period of comfort efficient contractions are established. There is never difficulty in recognizing the latter; doubt always relates to the preliminary pains, which may subside or may pass into the efficient type. We lack a method of foretelling which turn they will take; developments may be calmly awaited, with the assurance that ample warning will precede the birth. A slight mucous discharge from the vagina is frequently seen toward the end of pregnancy and may be disregarded, but a gush of watery fluid always means that the sac which contains the fetus has ruptured. Uterine contractions generally follow within a few hours, though in a few instances they will not appear for a number of days. Under any circumstances the event ought to be promptly reported to the doctor. Similarly, he should be notified whenever bleeding from the vagina occurs, since it is important to have him determine its significance. Anyone who supposes that patients are more likely to be infected when delivery occurs so quickly that there is not time for the doctor to arrive overlooks the leading factor in the production of this complication. Unless harmful bacteria are introduced into the birth- canal and lodge there, infection is impossible. Bacteria never enter of their own accord; they are usually carried into the vagina by means of an examining finger or some other foreign body. Accordingly, with the exception of those instances in which local inflammation already exists, there is no reason to fear infection when delivery proceeds so rapidly that internal examinations are not required. PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in the house, she will arrive in time to assist the patient in making the final arrangements for delivery. Should the nurse be delayed, the patient herself may make certain preparations to insure personal cleanliness, another very important factor in the prevention of infection. The presence of hair and the folding of the skin about the outlet to the birth-canal render the disinfection of this area somewhat difficult. It is advisable, therefore, to clip the hair as short as possible and, while bathing the whole body, to scrub the region in question with especial thoroughness. Before the bath an enema of soap-suds should be taken to clear the rectum of material which otherwise might be expelled during the birth and contaminate the field of delivery. The bath-towels and the gown which are used should have been freshly laundered. Other especial preparation of the delivery-field will be made later by the nurse. But whenever labor progresses so rapidly that neither the nurse nor the doctor arrives before the child is born, such preparations as I have indicated will be sufficient, for more minute precautions are unnecessary unless an internal examination must be made. THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of obstetrical patients are attended at home, and there is no reason why this should not be. Generally it is unfair to urge a woman to go to a hospital if she has already passed through a normal confinement and there is no reason to anticipate trouble in the approaching one; on the other hand, if any complication whatever is anticipated, the patient should certainly enter a hospital. Furthermore, it frequently proves advantageous to do so where the pregnancy is the first, though no complication is expected and none develops. The average labor with the first child lasts somewhat longer than with subsequent ones, and in consequence there is greater opportunity for the patient's family or friends to interfere with the management of the case, which never benefits a patient, and is sometimes a serious handicap. Then again, the cramped apartments, so common in these days, are poorly adapted to the treatment of sickness of any sort and should induce many obstetrical patients to choose the hospital. There are, besides, other features which favor this course, such as economy, convenience, and safety. From my own experience, which includes the care of patients both at home and at the hospital, I am convinced that, as a rule, the latter is much more satisfactory. Most cities now have institutions which provide a room and all the essential care, exclusive of the doctor's services, at approximately the cost of a trained nurse at home; luxuries will naturally add to the expense in hospitals as quickly as elsewhere. If one considers the various items connected with attention at home, such as the maintenance of the nurse and of the patient, the cost of the equipment necessary for confinement, the additional household laundry, and the sundry other details, it is clear that hospital treatment becomes distinctly economical. Moreover, the uncertainty of the date of confinement may necessitate paying a nurse for a longer or shorter period before the birth. Expense at the hospital, on the contrary, usually begins when the patient enters; and if she lives in the city it is rarely advisable for her to leave home until the beginning of labor. Even aside from the matter of expense some women prefer the hospital, since in this way they avoid the technical preparations for the birth. Much more vital, however, is the care patients receive in the hospital, for rigid adherence to surgical cleanliness is exemplified in the hospital as it can be nowhere else. Infections rarely develop there. Formerly these accidents were more common in the hospital than in the home, but conditions are now reversed and fatalities predominate among those delivered in private houses. The modern theory of asepsis has, to be sure, been widely accepted and is practiced so far as possible wherever obstetrical patients are attended, but only in the hospital can the underlying principles be applied with complete thoroughness and persistence. The hospital is constantly alert, whereas in private houses carelessness or ignorance, or both, often lead to lax technique. As a result, statistical evidence indicates that two to three infections occur among those delivered at home for one at the hospital. In the event of an emergency during labor, the hospital affords another distinct advantage in its staff of trained attendants. Of course they may be brought to one's home, yet not without some delay and extra expense; whereas in the hospital their assistance is instantly available. In institutions charity patients are often delivered under more favorable auspices than are the wealthy at their homes. Convalescence likewise is favored at the hospital, since the rules which control the admission of visitors guard the mother from exhaustion and annoyance. Moreover, isolation such as can only be secured in a hospital is conducive to a well-trained baby. Patients debating what course to follow often ask when they must leave home, what they should take with them, and how long they ought to remain at the hospital. The attending circumstances will alter the answers to these questions, but in a general way the following directions will serve as a guide. Ordinarily, the patient may remain at home until the first warning of labor. Departure from this rule is justified if the patient becomes unduly anxious about reaching the hospital in time, especially when she lives some distance from the institution, or if there is any doubt of securing accommodations. In either event, she should go to the hospital at least one week before the confinement is expected. There is no danger in riding to the hospital after labor has begun; frequently, the ride exerts a helpful influence and shortens the labor. Whatever is to be taken to the hospital should be packed in a bag several weeks before the predicted date of confinement and put in a convenient place so that one may be spared the trouble of gathering it at the last minute. Beside her usual toilet articles, the mother will require several gowns, a dressing-robe, and bedroom slippers. Clothing for the child will also be needed since most institutions stipulate that the infant use its own wearing apparel. If impracticable to transport the entire wardrobe when the mother enters the hospital, so much may be taken as will be needed during the first few days, and other articles may be brought as the need of them arises. The personal laundry of both mother and infant is usually done outside the institution. Surgical dressings of every description are provided by the hospital. Those who intend to enter a hospital, therefore, may disregard the list of articles necessary for confinement. Similarly, the sterilization, the preparations of the room and of the bed, and personal preparations will be of interest only to the patient who intends to stay at home. It is not always possible for the physician to say how long a patient should remain at the hospital; the rapidity of the mother's convalescence and the progress of the child, both important factors, cannot be accurately foretold. Frequently, it is a good plan to remain until the infant is four weeks old, but the majority of patients are dismissed at a somewhat earlier date. In no instance, however, should the mother be allowed to leave before the infant is two weeks old. Even when given the privilege of leaving so early she will always understand that competent assistance must be provided at home, for the mother should not resume her routine duties until six weeks after the birth. CHAPTER X THE BIRTH OF THE CHILD The Cause of Labor--The Course of Labor--The Stage of Dilatation--The Stage of Expulsion--The Placental Stage--The Effect of Labor upon the Child--Meddling--Justifiable Intervention--Management of Birth without the Doctor--Methods of Reviving the Child. The birth of a child is an act of nature, an act generally performed as satisfactorily as any other bodily function. Birth has, however, so deep a meaning for the mother, as well as for her family and her friends, and is, above all, so vital to the future of the race, that it has naturally become the subject of many impressive superstitions. Primitive peoples have invariably embodied in their religion their views of the origin of life and the phenomena of its inception. With these mysteries Greek and Roman mythology dealt extensively, as did also the myths of the Phoenicians, the Egyptians, the Chinese, and the people of ancient India. No race, indeed, has lacked its own interpretation of childbirth, and no phase of the process has failed to have attributed to it a supernatural significance. A number of these superstitions still distress women on the eve of motherhood. To correct exaggerations and to deny many utterly false impressions of childbirth there is no better way than to give a frank account of what does actually occur. I shall adhere to a purely physiological description of the event, for, although I appreciate fully the fact that its sociological and sentimental aspects are perhaps equally important, these are not, in my opinion, pertinent to a medical discussion. In a scientific sense the act of birth may be described as a series of muscular contractions which widen the birth-canal and expel the contents of the pregnant womb. Since the process requires an expenditure of energy, it has come to be called labor. Intrinsically, labor does not differ from many other physiological acts. The heart drives blood into the arteries; the bladder empties itself; the intestine moves its contents and finally expels the undigested residue. All these acts strongly resemble that of birth; but they also differ from it, for the head of the fetus is a hard body which resists being molded to the shape of the passageway through which it enters the world. To this resistance the pain which accompanies delivery is largely due. And yet even in this respect the act of birth is not unique; certain circumstances lead to painful contractions of the muscle fibers in the intestine and less frequently of those in other organs. It is natural to ask what purpose is served by the pain associated with labor; and a moment's reflection will make it clear that one reason for the discomfort is the warning which it gives of the approach of birth. If the mother were not thus cautioned, she might be delivered under very awkward circumstances, and even under such conditions that occasionally the infant would perish the instant it was born. All mammals suffer in giving birth to their young, though with quadrupeds the period of suffering is shorter, for the upright posture of man has changed the shape of the pelvis, rendering birth somewhat more difficult. Anyone who observes the lower animals preparing for delivery will be convinced that they also are responding to pain, the most compelling call of nature. That the suffering is at all essential to the mother's love for her child I cannot believe. Under certain circumstances, as for example when the Cesarean operation is performed before the onset of labor, the delivery is painless; yet I have never known a mother less devoted to her child on that account. Biology throws no light upon the relation of the "curse of Eve" to present-day confinements. THE CAUSE OF LABOR.--It is evident that, in a general way, the muscular contractions of the womb cause the birth of the child; but before we thoroughly understand the act, science must discover what stimulates the muscle to contract. Although careful research has thus far failed to disclose the source and character of the stimulus, it has taught many properties of the contractions themselves. Their force has been measured and found to increase as the end of labor is approached; the pressure they exert varies between nine and twenty- seven pounds. We also know that the patient can neither hasten nor delay the contractions voluntarily. Strong emotions are believed to accelerate them at times, and we find a very extraordinary illustration of this effect recorded in I Samuel, IV, 19, where we read: "Phineas' wife was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father-in-law and her husband were dead, she bowed herself and travailed; for her pains came upon her." On the other hand, and much more familiarly, excitement checks the contractions after they have begun. Every obstetrician has heard patients say that with his arrival the pains died down. Yet such an influence is never permanent; the contractions soon reappear, and labor advances as though no interruption had occurred. For the artificial induction of labor, the physician has at his disposal means that resemble the method sometimes employed by nature. Suitable appliances introduced into the womb provoke contractions, and labor proceeds step by step as if the stimulus were a normal one. Nature does not, however, ordinarily employ mechanical irritation to start the uterine contractions. The initial factor is more remote and, as I have said, is not yet well understood. Since, as everyone admits, delivery occurs with conspicuous regularity about the end of the fortieth week of pregnancy, and pregnancy corresponds, therefore, to ten menstrual cycles, some have been led to believe that labor and menstruation have a common basis. The truth of this supposition, however, must be doubtful until we know the cause of menstruation. Yet it is a matter of common observation that the uterus becomes unusually irritable about the time when the tenth menstrual period would be due. Strong purgatives administered with other drugs on or after the calculated date frequently bring about delivery, whereas previous attempts of this kind prove unsuccessful. To account for this peculiar irritability of the uterus about the fortieth-week of pregnancy, microscopical changes in its tissues have been suggested but sought in vain. Nor will the distention of the organ explain it. A great many theories have been offered to explain the causation of labor, but they have now only an historical interest. To-day we are just beginning to learn the correct methods of studying the problem. The experience of ages has firmly established the fact that the fetus is expelled when ready to enter the world, or as we say, when it has become mature. But how does the fetus assert its maturity? There is the kernel of the matter; that is the real problem, a problem for the solution of which, happily, we possess better facilities than have heretofore existed. One solution that has been suggested assumes that the fetus loses ultimately its power to assimilate the nourishment provided through the mother's blood. In consequence, it is argued, the material which previously enabled the fetus to grow now collects-- in the maternal circulation, stimulating the womb to contract. A part of this explanation, namely, that the material which stimulates the muscle fibers, whatever it may be, is a chemical substance and that it circulates in the mother's blood, is almost certainly true. There are, however, very weighty reasons for believing that this substance has not the character of food. A more plausible supposition is that the fetus produces this material in the course of its natural living processes, and the substance would accordingly be a waste-product. THE COURSE OF LABOR.--The current view that labor begins in the early evening and generally ends during the night is incorrect. This impression has grown out of the fact that the whole process frequently consumes twelve hours and must in such an event include some part of the night. Statistical evidence indicates that almost as many births occur at one hour of the twenty-four as another; to be precise, only five per cent. more children are born between 6 P.M. and 6 A.M. than between 6 A.M. and 6 P.M. As already pointed out, labor commonly begins with transient discomfort in the lower part of the back. At first the uterine contractions are far apart; they last but a moment and cause only twinges of pain. Gradually, the preliminary contractions give place to others of more definite character, which appear at intervals of five to ten minutes. Estimates of the total length of labor will vary according as one counts from the first warning or from the advent of typical contractions which we hear called "pains of the right kind." These generally continue for about four hours, and this period represents the average length of time the physician remains constantly with his patient. Estimates which include the initial symptoms are longer, varying from ten to eighteen hours. Prolonged labors are rare; and extremely short labors are also infrequent, though now and again it will be only an hour or two from the very first pain until the child is born. To predict absolutely the length of labor for any particular patient is impossible. The averages calculated from large groups of cases have no more than a broad scientific interest; when applied to any individual they are apt to be very misleading. Thus, from statistics we should expect the first labor to be longer than subsequent ones, but we are often surprised by an unusually rapid delivery. To facilitate description, labor is divided into stages which are conveniently designated the first, the second, and the third. During the first stage the way is prepared for the expulsion of the child; at the end of the second stage the child is born; the third stage is occupied with the separation and the expulsion of the after-birth. The progress of labor may be ascertained from time to time by means of suitable examinations. Whereas formerly vaginal examination was the only method which served this purpose, we are now acquainted with several. For example much of the information necessary for the proper management of delivery may be gained from examination of the patient's abdomen; and this may be supplemented by observations too technical to consider here. Occasionally I have heard doctors accused of negligence because they failed to make numerous vaginal examinations. Censure of this kind generally is unjust, for discretion in limiting the number of vaginal examinations provides against infection a guarantee which cannot be overestimated. In many cases, of course, they are still invaluable toward determining what treatment should be pursued, yet they are never employed to the extent once customary. Moreover, physicians have learned to take extraordinary precautions whenever vaginal examinations must be made. Anyone who practices obstetrics in these days appreciates how careful he must be, especially of the cleanliness of his hands. Energetic scrubbing with soap and water and the free use of antiseptics, as physicians now employ both these measures, appear ridiculous to some women who have witnessed deliveries under a less stringent regime. They may be bold enough to express their disapproval. They may remind us that many women have been successfully delivered without such care. And in this they are correct; we know that nine of every ten mothers passed through childbirth uneventfully before modern precautions were dreamed of. Such precautions as are now taken, however, are necessary to secure the safety of the tenth patient. And it is because they are anxious that all their patients shall enjoy the greatest possible security that physicians dare not omit any precaution. Disinfection of the physician's hands does not entirely exclude the danger of infection through vaginal examinations. Although he may have been most conscientious, there is some risk of carrying contaminating material into the birth-canal from the region about the opening of the vagina. Unless that region has been satisfactorily disinfected, sterilizing the dressings and cleansing the hands may become a waste of time. Sensible patients, therefore, will never object to the preparations which the nurse is instructed to make. THE STAGE OF DILATATION.--For reasons which are sufficiently clear, the womb must remain closed while fetal development is in progress; but under normal conditions, when this development is complete, the mouth of the womb dilates and the infant is expelled. The infant never takes an active part in its birth, although physicians once thought it did and attributed tedious labors to stubbornness on its part. The error has been corrected in medical teaching, but many persons unacquainted with the facts cling to the idea that the infant forces its own way out of the womb. At the end of pregnancy the mouth of the womb is small, too small, often, to admit an instrument as broad as a lead pencil. It is obvious, therefore, that very radical changes must be wrought before the infant can pass. The door, as it were, must be widely opened. This phenomenon, which we call dilatation of the womb, is brought about by involuntary contractions of the muscle fibers in its wall, every point of which they draw upward. Now, the top of the womb is directly opposite its mouth, consequently the contractions inevitably pull its lips wider and wider apart. Ordinarily another factor is concerned in this mechanism. To understand the whole process we must recall that a fluid surrounds the fetus, and that this fluid is contained within elastic membranes. The uterine contractions compress the fluid, drive the membranes, like a wedge, into the mouth of the womb and spread its lips apart. Thus, to the pulling effect just mentioned, a pushing force is added. After full dilatation has been accomplished and the membranes can serve no further purpose, they rupture; as the midwife puts it, "the bag of waters breaks." The quantity of fluid which escapes will vary. Occasionally, a huge gush will drench the patient's clothing; but more often what is lost at first amounts to only a few teaspoonfuls, though small quantities of fluid often dribble away with subsequent contractions. Although not the rule, it is by no means unusual for the membrane to rupture at the onset of labor, or at least before the mouth of the womb is fully dilated. Exceptionally, rupture occurs a few days before labor begins; and still longer intervals, though extremely rare, have been recorded. Whenever the membranes rupture prematurely, the pushing force of the uterine contractions becomes less effective, though the pulling force is never impaired. Under these circumstances, which occasion what is called a "dry labor," delivery is apt to proceed slowly, yet that does not follow necessarily, for the part of the fetus which happens to lie over the mouth of the womb may act as efficiently as the unruptured membrane would. During the first stage, the longest of the three, the patient is comfortable between the contractions and generally interests herself in some diverting occupation. The presence of the physician can be of no assistance then, and patients rarely demand it. Usually, they are satisfied to know he is ready to come when called. It is wrong to deceive patients with various recommendations from which they will vainly expect help during this stage; their welfare is best served when they are left alone. Generally the advice of well-meaning friends will be as harmless as it is futile, yet I must emphasize that during the first stage straining to expel the fetus is ill advised. Such effort will surely be ineffective then and may exhaust the patient; in that event it becomes harmful, for she will be fatigued when she most needs strength. Since, during the first stage, the progress of delivery is not influenced by what the patient may choose to do, she may follow her own inclinations. The average patient will be restless and will keep on her feet most of the time; alternately she will walk or stand still as one or the other happens to make her more comfortable. As a contraction begins she often seeks support, leaning upon a chair or bending over the foot of the bed, and presses with her hands against the lower part of her back. Patients may sit down or lie down whenever they wish; if so inclined they may even go to sleep. Most patients take no food during the whole course of labor, but, if nourishment is desired, there is no reason for abstaining from it. They may always drink water as freely as they like, and may also have milk, weak tea or coffee, or broth; but alcoholic beverages should never be taken without the specific consent of the physician. This same caution applies to strong coffee and tea. If desired, crackers or toast and rice or other cereals may be eaten in reasonable quantity. For fear of vomiting a patient will occasionally be told not to partake of any food. This advice is given, not because the symptom is alarming, but to save her needless annoyance. Indeed, vomiting frequently indicates that dilatation is well advanced, and, therefore, may generally be regarded as an encouraging sign. Ordinarily a persistent inclination to have the bowels move has the same significance. On the other hand, a constant desire to empty the bladder is more prominent at the onset of labor than later. To know the moment which marks the transition from the first to the second stage of labor can be of no benefit to the patient; but for the medical attendant the greatest interest centers about this point. Casual observation sometimes enables the physician to recognize it, for characteristically at the close of the first stage the whole picture changes. In a typical case the membranes will rupture at this instant, expulsive efforts will begin, and, as we have just learned, there may be symptoms referable to pressure. Moreover, a blood-tinged discharge, spoken of as the "show," usually makes its appearance about the same time. Since slight bleeding frequently occurs at the beginning of labor, or a little later, this manifestation, like all others, may not be implicitly trusted to indicate the end of the first stage. Such uncertainty, however, is a matter of no great consequence, for in the absence of all these symptoms the physician may, if necessary, accurately determine the degree of dilatation by an internal examination. THE STAGE OF EXPULSION.--The term delivery has been broadly applied to include the whole of labor. More strictly, its use should be limited to the second stage, for this period alone is concerned with the actual birth of the child. Although dilatation has been completed, the uterine contractions continue, devoting their force to emptying the womb. In this they now receive assistance from the voluntary contractions of the abdominal muscles. The second stage is very much shorter than the first; for this reason and others, too, it proves much less trying. As the child is moved downward through the birth-canal, the mother usually appreciates for herself that she is making headway; whereas in the first stage she may know of progress only through what she is told. Moreover, it is possible in this stage for the physician, by means of inhalations of chloroform, to relieve her of the pain attending the expulsion of the child. Since the anesthetic properties of chloroform were discovered by an obstetrician who was searching for a drug with which to lessen the pain of childbirth, the facts connected with the discovery have a peculiar interest for mothers. Sir James Y. Simpson had always been anxious for some means to prevent the suffering endured during surgical operations "without interfering with the free and healthy play of the natural functions." He, therefore, welcomed the introduction of ether anesthesia from America; and in January, 1847, at the Edinburgh Medical School, administered ether to an obstetrical patient. This was the first instance in which an anesthetic was employed at the time of childbirth. Since ether, to his mind, had certain shortcomings, Simpson set about finding another anesthetic, and devoted all his spare time to testing the effect of numerous drugs upon himself. How he came to try chloroform has been vividly told by one of his neighbors. [Footnote: "Late one evening, it was the 4th of November, 1847, Dr. Simpson, with his two friends and assistants, Drs. Keith and Duncan, sat down to their somewhat hazardous work in Dr. Simpson's dining room. Having inhaled several substances, but without much effect, it occurred to Dr. Simpson to try a ponderous material which he had formerly set aside on a lumber- table, and which, on account of its great weight, he had hitherto regarded as of no likelihood whatever; that happened to be a small bottle of chloroform. It was searched for and recovered from beneath a heap of waste paper. And with each tumbler newly changed, the inhalers resumed their vocation. Immediately an unwonted hilarity seized the party--they became bright-eyed, very happy, and very loquacious--expatiating upon the delicious aroma of the new fluid. But suddenly there was talk of sounds being heard like those of a cotton mill, louder and louder; a moment more, and then all was quiet--and then a crash! On awakening, Dr. Simpson's first perception was mental--'This is far stronger and better than ether,' said he to himself. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair, quite unconscious, and snoring in a most determined manner. More noise still and much motion. And then his eyes overtook Dr. Keith's feet and legs making valorous attempts to overturn the supper table. By and by Dr. Simpson having regained his seat, Dr. Duncan having finished his uncomfortable and unrefreshing slumber, Dr. Keith having come to an arrangement with the table and its contents, the _sederunt_ was resumed. Each expressed himself delighted with this new agent, and its inhalation was repeated many times that night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place and turn at the table, and fell asleep, crying: 'I'm an angel! Oh, I'm an angel!'"--Quoted from "The Life of Sir James Young Simpson," by H. Laing Gordon; Masters of Medicine Series.] The introduction of chloroform met with violent opposition, not upon medical grounds alone, but also for moral and religious reasons. "To check the sensation of pain in connection with the visitations of God," zealous theologians announced, "was to contravene the decrees of an all-wise Creator." Simpson reminded them "that the Creator, during the process of extracting the rib from Adam, must necessarily have adopted a somewhat similar artifice--for did not God throw Adam in a deep sleep?" Nevertheless, a number of years passed before the prejudice against artificial sleep was overcome. Chloroform only became popular after Queen Victoria consented to its use at the birth of her seventh child, Prince Leopold, in 1853. There is still some difference of opinion regarding the routine employment of chloroform in obstetrical practice, though the weight of authority favors its use during the contractions at the end of the second stage, providing always that no preexisting organic derangement renders the drug dangerous. Under no circumstances, however, should chloroform be given in the first stage, and seldom at the beginning of the second. Prolonged administration will exert an injurious influence upon both mother and child; under these conditions it ultimately weakens the uterine contractions and delays the delivery. Such an effect must be avoided, since it would endanger the life of the child by asphyxiation as well as exhaust the mother. On the other hand, a few drops of chloroform inhaled with each pain toward the end of the second stage will dull sensibility, although consciousness remains unaffected. When the drug is thus administered, the uterine contractions are scarcely, if at all, altered, and the assistance which the patient is willing to give herself generally becomes more powerful. Should the anesthetic have the opposite effect, it must be withheld; but that is seldom necessary. As the head advances the anesthesia is deepened, and the mother sleeps soundly while the child is being born. As long as dilatation is in progress, the patient may sit up or walk about; but with the advent of the second stage she should go to bed, for there she will be able to make the best use of the expulsive pains. The appropriate posture for delivery is still the subject of dispute, though modern views in no instance advocate the unnatural absurdities formerly supported by custom or superstition. Students of ethnology relate that among savage tribes almost every conceivable position was advocated for women in labor. Subsequently it became customary to have delivery take place in specially constructed chairs which are still used in semi-enlightened countries. With civilized nations at present women are always delivered in bed; yet national peculiarities still prevail. Some physicians favor what is known as the English position, in which the patient lies on her left side with her face inclined toward the chest, the trunk bent toward the knees, and the legs drawn up toward the abdomen. The majority of obstetricians, however, prefer that the patient should lie flat on her back. With the average case, and from the standpoint of facility in delivery, which of these postures happens to be chosen is a matter of indifference. But it is so much less awkward for the physician when the patient is on her back that this position has been widely adopted in America. During the expulsion of the child the mother intuitively desires to help herself; generally she cannot resist straining, and rarely needs encouragement. Assisting the uterine contractions with voluntary muscular effort, the act commonly described as "bearing down," may be performed most effectively when the patient is lying on her back. The knees are drawn up and spread apart; the feet are braced against some firm object; the hands grasp straps fastened at the foot of the bed; and the head is slightly raised so as to bring the chin near the chest. When the contraction begins the patient takes a deep breath and holds it while she strains vigorously, as if to make her bowels move. All voluntary effort should cease as the contraction wears away, for straining between the contractions can accomplish nothing. Her own inclination to "bear down" will clearly indicate to the patient when she ought to act. In the second stage patients regularly experience a feeling of pressure against the rectum, and this sensation, since it depends upon a low position of the child's head, is a welcome sign. Cramps in the legs also indicate progress, for they result from similar pressure against nerves adjacent to the lower part of the birth- canal. The cramps disappear immediately after the child is born, and are consequently never dangerous. Straightening out the legs or rubbing them usually gives relief. Most women, however, complain during the expulsive period only of pain in the back, and find nothing so grateful as firm pressure over this region. Energetic efforts quickly bring the head to the outlet of the birth- canal, where it may be seen, at first only during the contractions, but later during the pauses as well. The crown of the child's head is generally directed upward and becomes fixed against the pubic bones of the mother, which lie just in front of the bladder. Around this firm pivot the child's head rotates upward, and, as a result of the movement, forehead, eyes, nose, mouth, and chin successively emerge from the birth-canal. Following the birth of the head, natural forces turn the body upon one side, the better to accommodate the shoulders to the passageway. After these are born, the rest of the body slips easily into the world, and the second stage ends. THE PLACENTAL STAGE.--Although the third stage is chiefly concerned with the separation and the delivery of the after-birth, on which account it is known as the placental period, the description of other no less remarkable events belongs here. Even after the infant is born the umbilical cord extends from its navel to the placenta, just as it has done throughout pregnancy. Among larger mammals separation of the new-born from the mother is brought about in one of two ways; sometimes the activity of the young breaks the navel-string, though more frequently the mother bites it in two. Both these methods, we are told, have been employed by savages; but at the beginning of civilization it became customary to sever the cord with a cutting tool, and the tie thrown round it represents the first attempt of man to ligate blood-vessels. Ordinarily there is no need for haste in this operation. On the contrary, some delay is often of advantage, since an appreciable quantity of blood that otherwise would remain in the placenta is thus given opportunity to enter the infant's body. According to present ideas, as long as the heart-beat can be felt in the cord it should not be tied. The sleep induced toward the close of the previous stage lasts for a few minutes, so that most patients are unconscious through the greater part of the brief placental stage. Before the influence of the anesthetic has worn off, the physician has an excellent opportunity to sew up any laceration which may have occurred in the course of delivery. Slight injuries are not uncommon, especially if the confinement be the first, for the most skillful treatment often fails to prevent them. Since superficial tears are never serious if promptly closed, it is not their occurrence, but the failure to recognize them, or to sew them up when they are recognized, that deserves condemnation. After the birth of the child the womb becomes smaller, its walls grow thicker, and the cavity within is narrowed. This series of changes partly detaches the placenta, but the separation depends chiefly upon the uterine contractions. These contractions also force the after- birth into the vagina, whence it may ultimately be dislodged by the patient if she bears down again. Usually, however, it is preferable to save her further efforts of this kind, and, as a routine, the physician places one hand upon the abdominal wall, grasps the womb, and, during the contraction, makes firm pressure downward. The maneuver expels the after-birth, which consists of the placenta, the membranes, and the umbilical cord. Then the empty womb will form a hard, spherical mass about the size of the child's head, lying just above or to one side of the bladder. Slight bleeding also occurs during the third stage, and further loss of blood follows the removal of the after-birth. The total loss varies between a half pint and a pint, though larger amounts may be noted occasionally without appreciable effect upon the mother. Naturally, large, robust women can spare much more blood than those who are anemic. And yet pregnancy invariably prepares the mother for a loss of blood that would alarm anyone unfamiliar with obstetrical practice. Often the woman just delivered is not harmed by a hemorrhage that would endanger the life of a healthy man. This may seem paradoxical, but it is not; for the surplus blood, which formerly performed important duties in connection with the nutrition of the fetus, must now be removed to readjust the mother's circulation. In a very small number of cases an unduly large loss of blood follows the expulsion of the placenta. Fortunately, by treatment which consists usually in spurring Nature to more vigorous action we are well equipped to deal with this emergency. A wonderful mechanism has been provided by Nature to control excessive bleeding after delivery. If the forces upon which this mechanism depends are sluggish, the physician stimulates them. As in the preceding stages, the muscle fibers of the uterus supply the power in question, and because of this role an observant obstetrician once called them, "living ligatures." Certain of these fibers encircle the mouths of the blood- vessels which have been left open through the detachment of the placenta. When they contract the vessels are squeezed, impeding the escape of blood. The necessity of this action explains the contractions which continue even after the placenta has been expelled, when they are vigorous enough to cause discomfort they are spoken of as "after-pains." After-pains seldom follow the birth of the first child, but they regularly follow later confinements. In any case, such contractions do not persist very long, for tiny clots form within the blood vessels and effectually close them. As soon as the lining of the womb has been restored the clots are absorbed, leaving the organ in much the same condition as before conception took place. THE EFFECT OF LABOR UPON THE CHILD.--Unless the experience of countless generations had taught us otherwise, we should fear the child would be injured by its passage through the birth-canal. Immediately after the birth evidence of the journey is seldom wanting, but it quickly disappears. The unusual size of the infant's brain requires the head to be large, and bestows upon it a contour which differs from that of the mother's pelvic cavity. Since the bones of the pelvis are rigid, while those of the fetal skull are malleable, the head is molded as it descends into the pelvic cavity, so that its passage may be made the easier. As the result of this process of accommodation the skull becomes relatively longer from crown to chin than in adults. Within a few weeks, however, the modification vanishes. If an infant is born with the buttocks first, the head does not linger in the birth-canal, a fact which in such cases explains the pleasing shape of the skull, which emerges with the contour determined by fetal growth. Whenever a soft swelling appears over that portion of the scalp which was foremost during the birth, the curiosity of the family is aroused; but the swelling is harmless and subsides quickly. It originates for the same reason that a finger swells if too tight a ring is worn, which, as everyone knows, is because of interference with the circulation. Just as the swelling of the finger disappears when the constriction is removed, so the swelling of the scalp subsides shortly after the child is born. Usually no trace of it can be found the next day; but even when more persistent it will always vanish after a short time. For the child the most notable result of labor relates to the revolutionary changes in its mode of existence. Up to the time of birth the fetus received nourishment by way of the placenta, but after separation from the mother another source of food must be found. The health of the tissues, perpetually in need of oxygen, requires that the lungs act very promptly. Contact with the air, which is cooler than the previous environment of the child, irritates the nerve-endings in the skin; in response to the sensation thus produced breathing is established automatically. Whenever the temperature stimulus proves insufficient, physicians employ a stronger one, spanking the child until it cries lustily. Crying not only expands the lungs, but also has a favorable influence upon needful alterations in the fetal circulation. The lungs, since they must from this time on provide oxygen for the infant, need to receive more blood than formerly. The vessels leading toward them must be widely opened, and structures which previously diverted the blood-stream to the navel must be closed. The intricate shifting of forces which produces the change cannot be understood without a knowledge of anatomy; it will suffice for us to know that the blood is drawn into the vessels of the lungs with each inspiration. Other changes also occur. On account of some of these, namely, certain alterations in the blood current through the heart, physicians once taught that newly born infants should always be laid upon the right side. Except in very unusual cases, that precaution is now regarded as unnecessary. Of all the elements essential to nutrition, oxygen is the only one required immediately after birth; as the child enters the world well stocked with all the others. Babies are not born hungry, as many people seem to think. Neither is their crying a proof of it, for, as we have observed, they have other very good reasons for crying; nor is their readiness to suck anything that comes in contact with the mouth, for they will behave in the same way while they are receiving an abundance of nourishment through the umbilical cord. Many hours pass before a newly born infant can possibly need food. Indeed, it could survive a week or longer without taking anything, by mouth, except water. The ability to suckle at birth merely indicates that the infant is prepared to utilize the mechanism which nature will now employ to sustain it. After the umbilical cord has been severed the blood vessels within it can serve no further purpose. Consequently the remnant of this structure attached to the child's abdomen begins to shrivel. Formerly the care of the stump was considered a trivial matter; when cleanliness was neglected decomposition caused more rapid separation than takes place under the treatment which it now receives. No annoyance should be felt because the cord hangs on a long time; indeed, such an experience means it has been given exceptionally good care. Separation rarely occurs before the end of a week. It may be deferred for two weeks, or even longer, if the stump has been kept perfectly clean. After the shriveled cord drops off, the skin around the navel contracts, leaving a small raw area which discharges a yellow fluid for two or three days before the healing is complete. MEDDLING.--In selecting a physician the patient will almost certainly have been guided by her confidence in his ability. It may seem strange, therefore, to insist that he be allowed to conduct the delivery as he thinks best. Nevertheless, suggestions from outsiders are so common, especially if the labor be at all prolonged, that it seems appropriate to warn patients to pay no attention to such advice. In the heat of excitement well-meaning relatives are sometimes inclined to interfere, and women who are not members of the family occasionally wish to discuss their experiences, irrelevant as they may be. The patient's intimate friends, quite naturally, have the keenest personal interest in the event, an interest that of itself disqualifies them from reasoning calmly at the time. Their influence may be positively harmful if they persuade the physician to undertake procedures which his judgment convinces him are inadvisable. Should he turn a deaf ear, they will think him lacking in sympathy; but should he adopt their suggestions he would assume the full responsibility, and would perhaps be censured later by the very persons whom he sought to please. There can be no question of the proper course for him to pursue. Any influence which such entreaties may have will always be in the direction of too early interference, which is fraught with danger to mother and child alike. The master- word is patience, and it applies alike to the mother herself, to the doctor, and to her friends. Almost always the whole duty of the doctor consists in watching the progress of labor, so that he may be ready to render assistance should it be needed. Until the second stage begins there is no real necessity for him to remain in the room. Indeed, it is better for him not to do so after he has made sure that satisfactory conditions prevail, for his judgment will be less biased if the patient is not continuously under his observation. JUSTIFIABLE INTERVENTION.--It is quite true that in the progress of the birth difficulties now and then arise; yet they are far less common than rumor would lead us to believe. The unusual always attracts attention, often receiving greater emphasis than it merits. The particulars of confinement provide no exception to this rule; a delivery which requires artificial aid will be talked about, while hundreds that terminate naturally pass without comment. In this way the public gets an exaggerated notion of the frequency of difficult labors. Moreover, the nature of the trouble is usually distorted, for reports of medical events are apt to be incorrect, and errors multiply with each rehearsal. Obstetrical patients who wish, so far as possible, to escape the depressing influence of such inaccurate reports will be most likely to succeed if they follow the advice to select a physician at the beginning of pregnancy. When this is done the physician will have opportunity to explain or discredit alarming rumors, a task which it is usually necessary for him to perform, for there are always some persons who feel that a prospective mother should listen to everything that they have heard of childbirth. The most frequent cause for intervention during labor is insufficiency of the muscular contractions to overcome the resistance of the birth-canal. Unusual resistance of this kind explains the longer labors of women who have passed middle life before becoming pregnant. They may need to exercise more patience than younger women, though they have no greater reason to apprehend serious difficulties. Whenever rigidity of the muscles adjacent to the birth-canal arrests delivery the physician may employ the obstetrical forceps, which have been in use since the seventeenth century. Although it is widely known that physicians sometimes terminate labor in this way, the public estimate of the merits and of the limitations of the instrument is so inexact that the truth about it should be understood. Obstetrical forceps were devised by one of the Chamberlens, a family of French Huguenots who fled to England in 1569. The invention was long kept a secret; therefore its date cannot be fixed, nor even the inventor clearly identified, though everyone agrees that he was a member of this family. Clearly the instrument had been in use for some generations prior to Hugh Chamberlen, who translated from French into English the foremost obstetrical textbook of his time. The book, published in 1672, does not contain a description of the forceps, but in his preface Hugh Chamberlen refers to delay in delivery, saying, "My father, my brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women without prejudice to them or their infants in this case." It is not questioned that the forceps was the secret that his ancestors and he himself employed so long and so profitably. About a century ago what are probably the original models of the instrument were discovered in a country home of Essex which once belonged to the Chamberlens; there they had been hidden in a trunk in the garret. The box in which they were concealed contained four pairs of forceps, representing different stages in their development, besides other instruments and a number of letters which established their ownership. After an unsuccessful attempt to sell the family secret in Paris, Hugh Chamberlen found a purchaser in Amsterdam. The privilege of using it in Holland was then granted physicians for a monetary consideration, and that practice continued until two philanthropists purchased the secret to make it public. It was ultimately learned, however, that the sale was a swindle, for the device which the purchasers obtained consisted of only half the genuine instrument. The real secret was revealed by a son of Hugh Chamberlen, who bore the same name as his father; but probably the first accurate printed description of the forceps was made by Samuel Chapman, in his treatise on obstetrics which appeared in 1733. Subsequently they came into general use, and, with many modifications, remain the most important instrument in the obstetrician's equipment. There can be no exaggeration in the claim that the instrument has done more to save human life than any other surgical appliance. The obstetrical forceps have been of such great service in diminishing the number of still-born infants that they were once called the child's instrument. The need of its employment in behalf of the child may be determined by careful observation of the fetal heart-sounds, which are heard over the mother's abdomen, and by means of which one may learn the condition of the child. Signs of danger are extremely uncommon so long as dilatation of the womb is not complete, for any strain which labor may impose upon the child will usually occur during its passage through the pelvis. Most often, therefore, the head has reached the outermost part of the birth canal before extraction becomes advisable. The forceps are used also on behalf of the mother, if the continuation of labor seems likely to throw undue stress upon her. On this account the physician frequently resorts to them if his patient is suffering from pneumonia, typhoid fever, or any acute illness at the time of labor. Other maternal indications for their use include various chronic derangements, well exemplified by certain diseases of the heart. Furthermore, even when there are no preexisting complications forceps are employed on account of exhaustion or other conditions which may develop during the course of labor. It must be clearly understood, however, that the physician alone can determine when intervention is justified, as well as what operative procedure is most appropriate; for even though good reasons for terminating labor exist, forceps cannot be properly used unless nature has already fulfilled very definite requirements. By no chance can the patient, much less her friends, decide this matter. And besides, none but a trained observer can detect the symptoms which clearly indicate Nature's incompetence to effect delivery. Disregard of these truths by the family with consequent urging that something be done must be held partly responsible for the reckless use of the instrument. It will be a step in the right direction, therefore, when the laity comes to understand that the value of the instrument generally pertains to the welfare of the child, and that, in any event, its use will be harmful if employed before the womb has been completely dilated. Although forceps can be employed only in cases of head presentation, intervention may be warranted when some part of the fetus other than the head will be born first. Two or three times in every hundred patients we meet with breech presentations, that is, cases in which the buttocks precede; after their expulsion, the body, the arms, and the head follow. Breech presentations occur more frequently among women delivered prematurely, as might be expected since an examination eight to ten weeks before the calculated date reveals a larger percentage of breech presentations than a similar examination about the normal end of pregnancy. In explanation of these results we accept the view that the size of the fetus at the earlier date does not require nicety of adaptation to the cavity of the womb, whereas at term, unless the child is small, the best accommodation is secured when the head lies downward. Most breech cases are delivered spontaneously; if not, the outlook for the mother is no less favorable on that account. Assistance, when undertaken, is usually prompted in the interest of the child, which will be seized by the legs and extracted if there are indications to terminate labor. Purely as a precautionary measure, a second physician will often be called about the time the stage of expulsion begins. Foresight of this kind must give the patient confidence rather than alarm her. Indeed, should operative intervention of any kind become necessary in the practice of obstetrics, the inclination of the doctor to call an assistant must be regarded as an evidence of superior judgment. MANAGEMENT OF BIRTH WITHOUT A DOCTOR.--A prospective mother should not be left alone during the four weeks prior to the expected date of delivery, for it is important that during this period aid may be quickly summoned in the event of an emergency. However, if the confinement be the first, ample warning of delivery will always be given. Even in a later confinement several hours will probably elapse between the preliminary signs and the birth itself. It is extremely rare to have labor progress so rapidly that the child is born before the doctor arrives. Under such circumstances, if the nurse be present she will be master of the situation; whenever she has been unable to reach the patient, someone near by should be called to render what assistance may be needed. A labor which advances so rapidly that skilled assistance cannot be procured is proof in itself that everything is going in an ideal manner, and that interference is not necessary. Although the doctor may not arrive until after the child is born, he frequently renders valuable service in expelling the placenta or in sewing up lacerations. No one should presume then that there is never need for a physician after the second stage is over. If the suggestions made in the preceding chapter are heeded, immediately after labor begins the room will be set in order and the bed will be properly protected; the patient will take a tub-bath and will put on a freshly laundered nightgown. The sterilized dressings are then placed where they can be easily reached, but are not opened until needed. Antiseptic tablets have been procured, and, following the directions on the bottle, it will be simple to make up a solution of bichlorid of mercury of a strength of 1-1,000. After the contractions become strong and return at intervals of five minutes, or if the waters have broken, the patient should go to bed; the knees should be drawn up and spread apart, but bearing down with the pains should not begin until the inclination is irresistible, since this forbearance will make the delivery slower and thus afford protection against lacerations which physicians ordinarily seek to prevent by the use of chloroform. In the absence of a doctor it is never permissible to administer this or any other anesthetic. As long as a physician familiar with its action gives the chloroform untoward results need not be feared in obstetrical cases; but the risk would be too great to allow anyone to give it who was unacquainted with the early signs of an over-dose. Again, fear of accident should prevent patients from using the closet when labor is progressing rapidly, for an inclination to empty the bladder or the rectum often signifies that birth is about to take place. Even though this is true, if there is need, patients may try to use the bed-pan. About the time when the patient goes to bed the attendant prepares to render such assistance as may be required. First she should scrub her hands thoroughly with soap and water and subsequently soak them in the bichlorid solution for five minutes, or longer if there be no need for haste. A large delivery-pad is then placed under the patient, the leggins put on, and, from this moment, the outlet of the birth-canal should be exposed to view. After the scalp of the child comes into sight, the attendant is not to leave the bed-side, though she must keep "hands off" until the head has been completely expelled. A pause occurs between the birth of the head and of the rest of the body. It is usually safe to await further expulsive contractions, but should the child's face turn a dusky blue, which indicates that it needs to breathe, the patient is to be advised to strain vigorously and to make firm pressure over the womb with both her hands. At the same time the attendant must pull the child downward, having seized its chin with one hand and the back of its head with the other. The straining of the mother combined with traction by the attendant will be certain to effect delivery quickly. As soon as the child is born, it should take a breath and begin to cry. If it does not cry of its own accord, it can usually be made to do so by holding it up by the feet and slapping it on the back several times. Subsequently the child is placed between the patient's legs in such a way as to prevent stretching of the cord. Usually the nurse will leave it in this position and turn her attention to the mother. After the birth of the child it is easy to feel through the mother's abdominal wall, which has now become lax and flabby, the organs which lie beneath it. The top of the womb, once just below the edge of the ribs, may now be found about the level of the uppermost part of the hip bones, a position which it keeps until detachment of the after- birth begins. As the after-birth peels off, the firmly contracted womb gradually rises in the abdominal cavity, and by the time when the separation has been completed reaches the region of the navel. While these changes, which naturally require from ten to thirty minutes and occasionally longer, are taking place, the attendant must wait patiently; attempts to hurry the separation of the placenta are never wise, for they may lead to excessive bleeding. No effort should be made to bring away the after-birth by pulling upon the cord. It is equally unwise for inexperienced persons to press upon the womb in the hope of pushing out the placenta. To encourage the mother to strain just as she did in assisting the birth of the child would always be a safer plan. And if that is ineffective, further delay is necessary; in several instances a natural separation of the placenta has repaid me for waiting as long as two hours. Prolonged delay may be annoying, yet, provided that the doctor arrives within a reasonable time, it can scarcely lead to anything more serious than annoyance. Rather than authorize frantic efforts to remove the afterbirth, I should much prefer to have a patient of my own call another doctor. If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly. The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement. One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors. Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed. This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut. So long as the child is in good condition there is no urgent need of this operation. If the child is breathing satisfactorily it may generally be deferred until the doctor arrives. When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable. The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution. Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed. A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed. All the dressings must be saved so that the doctor may see how much blood has been lost. As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature. If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten. Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding. What to do in this event must therefore be made plain. First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine. The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb. When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel. With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ. The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading. Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases. Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation. Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions. There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good. Very often a slight chill follows labor. It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable. On the other hand, excitement of any kind aggravates this condition. In general, recently delivered patients must be kept quiet no matter how well they feel. A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it. METHODS OF REVIVING THE CHILD.--Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor. Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants. Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration. Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue. In most cases nothing else will be necessary. But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other. Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body. With very rare exceptions these procedures make the child cry. One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough. In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta. As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial. Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub. This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries. One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful. Indeed, the necessity for keeping it warm must be constantly borne in mind. With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable. Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge. Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side. This maneuver is repeated fourteen times to the minute, but not more frequently. When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant. Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer. One method after another should be tried in the order which I have indicated. A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives. CHAPTER XI THE LYING-IN PERIOD The Changes in the Uterus--The Lochia--The Return of Menstruation-- Other Restorative Changes: The Loss in Weight; The Abdominal Wall; The Pelvic Floor--The Care of the Patient: The Elimination of Waste Material; Cleanliness; The Diet; The Environment; The Time for Getting up--The Final Examination. A generation ago physicians were accustomed to see their obstetrical patients only at the time of labor. No preliminary examination was thought necessary, and after the delivery visits were not made unless the family became alarmed and requested them. When thus asked to come back the physician sometimes found that an infection had developed; occasionally the breasts were giving trouble, or some other difficulty in the care of the mother or of the infant was baffling the nurse. It is now recognized that the medical attendant should not wait for the appearance of untoward symptoms. Although the strict observance of the various precautions which I have already emphasized should lead and usually do lead to an uneventful convalescence, it is none the less true that the danger of infection and of other immediate complication has not passed until several weeks after delivery. For this reason and also because skillful guidance of the mother at this time will prevent unwelcome sequels in the later years of life, physicians now extend their watchfulness beyond the hour of birth. The number of visits ordinarily required is not large. In each case, to be sure, the circumstances will determine the number; but, as a rule, ten visits, if properly distributed, will be sufficient. During the month succeeding delivery these visits should be made in about this order: a daily visit for the first five days, subsequently one upon the seventh, the tenth, the fourteenth, the twenty-first, and the twenty-eighth day. At the conclusion of labor there begins a series of changes which are the reverse of those incident to pregnancy, and which restore the body to its original condition. Six weeks are generally required for these alterations. They should leave the mother in _perfect_ health, but traces of pregnancy are not entirely effaced; even in the absence of outward evidence, if a woman has ever given birth to a child a thorough internal examination will disclose the fact. The initial steps in these restorative processes are taken most promptly and effectively when patients remain in bed. The traditional custom of doing so has given to the first few weeks following delivery the popular name, "the Lying-in Period." To these weeks physicians usually apply the technical term _puerperium_, the child's period, a designation which brings to mind the secretion of milk which, though not a retrogressive change, is, nevertheless, one of the most distinctive results of childbirth. Radical as the bodily changes in progress at this time are, the lying-in period is not a period of illness. But there is, perhaps, no other time in a woman's life when she may cross the boundary between sickness and health so easily; for here nature tolerates no trifling. Not infrequently puerperal patients who are feeling well attempt too much, and suffer a more or less serious set-back; it is an all- important duty of the obstetrician, therefore, to restrain them from harmful activity. In my experience patients yield to restraint most readily, and secure the best results, if I explain to them the anatomical facts which should guide the management of the lying-in period. THE CHANGES IN THE UTERUS.--Since of all the organs the uterus undergoes during pregnancy the most extensive development, it also holds the place of prominence during the lying-in period. Immediately after delivery the womb weighs two pounds and measures some eight inches in height, five in breadth, and four in thickness. In the course of a few days it begins to dwindle in size, gradually sinking in the abdomen until it lies entirely within the pelvic cavity. Toward the end of five or six weeks it resumes the position occupied before conception, regains approximately its original dimensions, and weighs two ounces. We speak of the process which leads to these results as the _involution_ of the uterus. Since a great deal depends upon the rapidity with which involution progresses, we must understand just what it is and how it may be influenced. The muscle of the womb, to which this property of involution belongs, is an aggregation of thousands of individual fibers. In response to excellent nutrition during pregnancy, these fibers have grown thick and strong, in order that they may furnish the power needed at the time of labor. When this purpose has been fulfilled each fiber becomes smaller and gradually passes into a resting stage the better to preserve its vigor. It is the shrivelling of the individual fibers, therefore, which accounts for the total reduction in the size of the womb. Although the source of the stimulus which causes the muscle-fibers to atrophy is not so clear as we should like it, we are acquainted with certain influences to which involution is susceptible. Of these none merits so much attention as the influence of the breasts. The intimate relation between the breasts and the uterus manifests itself in such a variety of ways and with such force that no one doubts its existence. Thus, if a nursing mother becomes pregnant her infant is usually deprived of sufficient nourishment or suffers some digestive disturbance; if not, and the mother, ignorant of her condition, continues with the breast feeding, she may jeopardize the newly begun pregnancy. Very likely she will be warned of the fact by the signs of threatened miscarriage. More frequently, but in quite the same way, we find that nursing causes uterine contractions in the early part of the lying-in period, when they are called after-pains. Women who experience them tell us they are more severe while the infant nurses; and they also say that the discomfort disappears after several days, a fact which indicates that involution has made notable headway. The physician is not dependent on such evidence, however; for a simple examination reveals at any time how far involution has progressed. By this means we have learned that nursing facilitates the involution process. On the other hand, it is found to be true, as we should naturally expect, that women who decline to suckle the infant recover from childbirth somewhat less rapidly than those who follow nature's plan. In this fact, therefore, is found a selfish motive, yet a very good one, which should impel mothers to perform this exceedingly important duty. Aside from the change in the mass of the uterus, notable results of involution relate to its mouth and to its ligaments, for these structures are also chiefly muscle. The mouth of the womb, lately stretched to permit the exit of the child, gapes widely for a time; but ultimately its lips are drawn together, the tissues which compose them stiffen, and the canal which they enclose is narrowed to almost microscopical dimensions. When involution is complete, the uterus has so far regained its virginal character that no trace of childbirth remains other than a few small fissures in the margin of its mouth. It is the office of the ligaments to hold the uterus in proper position. In consequence of pregnancy they have been stretched, and, as we might anticipate, after the contents of the womb are expelled the ligaments hang loosely from its sides, very much as sails hang when a breeze dies down. Immediately after delivery, therefore, the ligaments give the womb little or no support; eventually they shorten and tighten, readily accommodating themselves to the existing conditions. Until the accommodation is perfected, it is especially desirable to permit no pressure which might push the womb backward. It is for this reason that many obstetricians object to the time- honored custom of applying a tight bandage about the abdomen at the conclusion of labor; for, though bandaging is not always harmful, it has a distinct tendency to misplace the womb. A friend who has served as an assistant in one clinic where patients were bandaged regularly and in another where they were not, tells me that displacements of the womb were much more common among women treated by the former method. While the process of involution is altering the shape and size of the womb, other forces are at work within the organ to provide its cavity with a new mucous membrane. In character and in extent the inner surface of the womb, left raw and bleeding at the conclusion of labor, is comparable to the wound which would result if some accident removed the skin from the palms of both hands. No one would question the wisdom of guarding such an injury to the hands; but cleanliness is even more necessary to the prompt and healthful restoration of the uterine mucous membrane. However, the wound within the uterus is so far from the surface of the body that it need not be directly covered with a surgical dressing; sterile pads are kept over the vulva to exclude contaminating material until the healing is completed. Since bleeding ceases after that point is reached, we have no difficulty in knowing when the mucous membrane has been restored. THE LOCHIA.--The vaginal discharge which regularly follows the termination of pregnancy gets its name from the Greek word _lochia_. At first the discharge is pure blood, because it issues exclusively from the vessels left open by the removal of the after-birth. The greater part of the blood flows out of the birth canal, but frequently some of it collects in the cavity of the uterus or of the vagina; there it coagulates, and the clots may not be expelled until several days later. In that event, as whatever effect the bleeding may have had has long since passed, the appearance of the clots is usually no occasion for alarm. The amount of lochia varies, and will likely fall below the average in small or anemic women and rise above it in those who are large or robust. Then again, the discharge is less profuse if considerable blood has been lost immediately after the labor. For the first ten days the total quantity seldom exceeds eight or ten ounces; after that time it is so small that it cannot be accurately estimated. Formerly much larger amounts were considered normal, and, therefore, it is probable that modern aseptic treatment of child-birth has lessened the subsequent loss of blood. Toward the end of a week the lochia changes from a bright red to a brownish color, because the discharge now includes certain products of disintegration. Somewhat later the lochia consists almost entirely of mucus, being only streaked with blood; but there will be an increase in the bleeding when the patient gets up; and injudicious activity may cause flooding. A slight bloody discharge may be expected to continue until five or six weeks after the child was born. A faint but characteristic odor to the lochia proves very disagreeable to some patients, and on that account it was formerly customary to give them a daily douche throughout the lying-in period. This was before the characteristics of the puerperal uterus and the nature of infection were thoroughly understood. Most physicians are now convinced that the early use of douches is rarely beneficial; and since there is danger of washing infectious material from the lower part of the vagina into the uterus, they may, if given prior to the second week after delivery, actually do harm. Consequently douches are not now used in a routine way. Whenever irrigations are indicated the doctor will prescribe them. Late in the puerperium vaginal douches are unobjectionable, and patients may take them unassisted, for then the fluid will not penetrate the womb so long as it has a free escape from the outlet of the vagina. Moreover, it is immaterial if some of the fluid should pass into the womb, for its lining will have been largely restored by this time, and at points where restoration is incomplete defenses have been thrown up against infection. THE RETURN OF MENSTRUATION.--On account of the dilatation at the time of labor women who have previously suffered with menstruation may look forward to relief after child-birth. Menstruation generally becomes as painless as the flow of the lochia; and so far as a patient can tell the two phenomena are identical. Actually, however, they bear no relation to each other. The fact that the cavity of the uterus has been deprived of its lining is responsible for the lochia, whereas the menstrual discharge occurs in spite of the lining, through which it breaks at regular intervals in response to a stimulus that is absent for a longer or shorter period after the birth of a child. In the latter part of the puerperium there may be doubt as to whether a discharge is menstrual or lochial; though, if necessary, an examination of the interior of the womb would always settle the question, for structural changes in the uterine mucous membrane form the most characteristic feature of menstruation. If, therefore, small bits of this tissue are removed and studied under the microscope, a definite conclusion can be reached. Physicians may resort to such an examination when the significance of a discharge is not clear without it; but other evidence usually enables them to decide the matter. The secretion of milk often exerts an influence upon the reestablishment of menstruation. Under ideal circumstances the mother does not menstruate while she nurses her infant; whereas, if the breasts are not in use, the menstrual function returns six to eight weeks after delivery. Other pertinent clinical facts also lend weight to the opinion that the activity of the breasts, more technically called lactation, should not only prevent menstruation but also hinder the ripening of egg-cells in the ovary. Thus, the nursing infant has a potent influence upon the reproductive function of its mother, enabling it to preserve its food supply; for in the event of conception the milk usually decreases in amount or becomes of an inferior quality. To secure this protective influence should prove a strong incentive for the mother to nurse her child; in barely half the cases, however, is it effective throughout a year. One-third of nursing mothers, statistics indicate, begin to menstruate about two months after delivery, and month by month the proportion gradually increases. Since menstruation appears so frequently during lactation, it cannot be considered abnormal. It does not follow that the function will become permanently reestablished after a patient has menstruated once; in many instances several months elapse before there is another period, and in a few cases there will be only one period during the year the child suckles. Nevertheless, when the function has once made its appearance extraordinary precaution should be exercised to avert a return, and about the time its reappearance would be expected the woman should go to bed for several days. Although this measure may prove futile, we know of no other so likely to prove successful. Menstruation is more apt to return prematurely after the birth of the first child than of later ones. This may be due in part to a kind of accommodation of the maternal organism to the reproductive process as one pregnancy follows another; but I am convinced that it is also due in part to the greater physical and mental composure of experienced mothers. Until a woman has learned the unwelcome consequences she is apt to take over household duties before she is equal to the task, or she may engage in too strenuous amusements; and most mothers err in a too energetic care of the baby. OTHER RESTORATIVE CHANGES.--Many of the restorative changes in the mother's body are either so intricate or so devoid of practical significance that we may pass them by; though all of them have great interest for the specialist, and some have occasioned bitter controversy. The alterations in the heart, for instance, have been the subject of a prolonged dispute between French and German scientists. The former still assert that this organ regularly enlarges during pregnancy and subsequently returns to its normal size. The Germans deny both these contentions. Certainly the alterations are insignificant from a practical standpoint; otherwise competent observers would not disagree. The really important changes in the body, other than those pertaining to the uterus, are familiar to women who have passed through pregnancy; but other prospective mothers may not understand that they will regain the bodily condition which existed before conception. _Loss in Weight_.--While the weight lost during the lying-in period is not so vital as some other alterations, many have a keen interest in it. In addition to the loss of ten to fifteen pounds at the time of birth, a further loss occurs in the course of a few weeks. Diminution in the size of the uterus is responsible for the loss of nearly two pounds, and the lochial discharge for at least another; but the chief factor concerned is the removal of water from the tissues, many of which have become dropsical toward the end of pregnancy. Altogether patients do not lose less than ten pounds during the lying-in period, and often lose a great deal more. The average loss for the first week alone is said to equal one-twelfth of the patient's weight at the conclusion of labor; the total loss for the whole of the puerperium corresponds to one-tenth of her weight at the beginning of it. Variations from the rule are attributed to individual peculiarities of nutrition. In general, stout women lose more than slender ones, but with all types the loss is greater if the mother nurses her infant. On the other hand, a generous diet tends to counteract any loss in weight whatever. _The Abdominal Wall_.--Much more important than the question of weight is the recovery of the abdominal wall from the strain imposed by the enlargement of the womb. In normal cases, to be sure, there is very slight disproportion between the size of the pregnant uterus at term and the capacity of the abdomen, yet the abdominal wall invariably suffers a little stretching and unless it retains its elasticity, the viscera are deprived of essential support, and cause more or less discomfort. The restorative changes in the abdominal wall involve the skin, the fatty tissues, and the muscles. As soon as the distention has been relieved the skin falls into folds, less noticeable if the pregnancy was the first; and the muscles become so flabby that one has no difficulty in pushing the wall backward until it touches the tissues which cover the spinal column. Within a few weeks, if all goes well, the muscles regain their "tone." Coincidently, the excessive fat over the abdomen is absorbed. The skin becomes smooth, and its pigmentation fades completely; but the pregnancy streaks rarely vanish entirely, although they always become very much less noticeable. Whether or not the abdominal wall will recover from the distention of pregnancy depends entirely upon the muscles. As the lying-in period advances each fiber should gradually shorten until the whole muscular structure becomes as firm and tight as it ever was. But this takes time, and no artifice can hasten the repair. Perfect recovery is most likely with the body in a recumbent position, which relieves the muscles from any strain. These facts are better appreciated than formerly, hence most physicians encourage their obstetrical patients to remain in bed somewhat longer than their mothers did. Generally nothing else will be required, and only under extraordinary circumstances will nature need assistance. Thus, if there has been unusual distention, as, for example, that due to twins, the muscular impairment may be extreme; or if pregnancies follow one another in quick succession the strain becomes so nearly continuous that there is not sufficient time for adequate repair. Whenever nature does need encouragement calisthenics of some kind are advisable. These systematic exercises, which the patient practices in bed and flat on her back, are usually begun about a week after delivery, though there may be some reason for beginning them earlier or later than this. The physician will always select the proper calisthenics, but the following "movements" generally prove satisfactory. To exercise the muscles at the front of the abdomen one leg after the other is raised and lowered; as this is being done the knee will be bent (flexed) at first, but later the leg may be held straight (extended). Other muscles come into play when the feet are alternately brought together and separated as widely as possible. A third movement which exercises the muscles at the side of the abdomen consists in raising the shoulders from the bed and twisting the trunk so that the weight of the chest rests now on the right, now on the left elbow. When these movements can be performed fifteen or twenty minutes without fatigue more vigorous exercises may be adopted. For example, the buttocks, together with the lower part of the back, are raised off the bed, while the shoulders, elbows, and the heels remain stationary. A day or so before getting up the patient should practice alternately raising herself from the recumbent to the sitting posture and returning to the above position without assistance from the arms. The value of bandaging the abdomen immediately after delivery as a means of strengthening the abdominal muscles is questionable; though physicians agree to the advantages of a supporter after patients are out of bed. We constantly see perfect restoration of these muscles without the early use of a binder; in fact, women who have employed it throughout the lying-in period do not secure an efficient abdominal wall more frequently than others who began its use two weeks after they were delivered. Even those physicians who advocate an early application of the binder concede that it works harm in certain cases and do not recommend it indiscriminately. Those who postpone for a fortnight the use of the binder will escape the tendency it has to cause displacements. By this time the involution will have advanced so far that the womb lies within the pelvic cavity, where it is surrounded by the hip bones, which protect it from external forces that otherwise would influence its position. When permitted to get up patients ought to use a binder, because it counteracts the feeling of "falling to pieces" of which some complain when the abdominal walls are not comfortably supported. But there is no evidence to show that a binder plays any part in restoring the figure. When, in spite of ample rest, the abdominal muscles fail to recover completely, we have no better way of strengthening them than by use of calisthenics or massage. _The Pelvic Floor_.--Second only in importance to having the womb restored to its original position is the necessity of restoration of the pelvic floor. This structure, also called the _perineum_, we should know, lies between the thighs, shuts in the bottom of the abdomen, and prevents prolapse of the viscera. In women it forms the lower portion of the birth-canal, enclosing the aperture through which the child enters the world. Although intelligent management of labor is of the greatest value for the protection of the pelvic floor, under certain circumstances it may be impossible to preserve it intact; injury to it is the rule when the first child is born, and not unusual in later births. There can be no doubt regarding the advisability of uniting the edges of a tear; indeed, to do so immediately is the very first essential toward restoring the pelvic floor to its wonted integrity. But even though tears are sewn up successfully, there is invariably some relaxation of the perineum until the restorative process, which here again chiefly concerns the muscles, has been given opportunity to become effective. As with all the restorative changes in the lying-in period, to rest calmly in bed favors the perfect recovery of the pelvic floor more than anything else. Keeping the thighs together during the first few days undoubtedly assists tears in healing, but that precaution is not always necessary, and when it is the physician will call attention to the fact. The really important matter, as I have said, is that the upright position should not be resumed until the pelvic floor has become firm. THE CARE OF THE PATIENT.--Now we have learned enough of the manifold changes in the lying-in period to appreciate the fact that patients require medical direction even though they are feeling perfectly well. The view held by former generations that women can get along without a doctor and with any sort of nursing is partly responsible for the existence of gynecology, the branch of medicine which deals with the diseases of women. Recently delivered women should be treated as surgical patients, not because they are ill, but to keep them from becoming so. If the patient desires the highest degree of protection an experienced nurse is indispensable, for she will make systematic observations which would consume too much of the doctor's time for his personal attention, yet without which he would not be sufficiently conversant with his patient's condition to guide her properly. The temperature, the rate of the pulse, and of the respiration should be recorded at regular intervals during the day and night. An elevation of temperature at the conclusion of labor need give no uneasiness, for experience has shown that it generally subsides within a few hours. Moreover, slight elevations in the course of the following week are so frequent that obstetricians have agreed to regard as a normal temperature for this period 100.4 degrees instead of the usual normal of 98.4 degrees. The pulse-rate most frequently does not depart from what is characteristic for the individual, though about one-fifth of puerperal women have a slowing of the pulse, a phenomenon of favorable significance. Any difficulty in breathing that may have existed in the latter part of pregnancy disappears when the abdominal distention is relieved, and the respiratory rate becomes normal. So long as the body is getting rid of the tissue-substance essential to pregnancy, but now without any purpose, more than the usual amount of waste material is present in the expired air. _The Elimination of Waste Material_.--As we might expect from the loss in body weight, the excretory organs are particularly active during the lying-in period. In quantity the loss of water exceeds all the other waste-products together; and pronounced activity of the kidneys or of the sweat glands may become a source of annoyance. Since it is undesirable to interfere with these functions, whatever inconvenience either may cause will be borne with less complaint if the patient understands that a large loss of water at this time indicates a healthful condition of the body. Shortly after delivery there may be difficulty in emptying the bladder; and, under such circumstances, the doctor or nurse used to catheterize the patient immediately; this habit once begun, it was often necessary to repeat the operation day after day, or, for that matter, several times a day. But as physicians came to know more of the relations of bacteria to inflammation of the bladder, they grew more cautious, and preferred to wait a long time before resorting to the catheter. The reward of this patience was to find that, with remarkably few exceptions, puerperal women ultimately void of their own accord. Accordingly catheterization after child-birth is now postponed, and is never performed until a number of devices to get the patient to void spontaneously have been tried without success. Often urination follows putting a hot-water bottle over the bladder; or pouring warm water over the vulva; or placing the patient upon a bed-pan from which steam is rising. When these and other devices well known to every nurse are not effective, catheterization becomes necessary. With the elaborate precautions taken to avoid infection of the bladder, catheterization is now performed with very slight risk. Constipation, for various reasons, becomes a regular feature of the lying-in period. The confinement in bed, restricted diet, relaxation of the abdominal wall, and sensitiveness about the region of the rectum, all have a tendency to prevent spontaneous movements of the bowels. As one of these influences after another is removed the bowels begin to act naturally. Childbirth may cause chronic constipation, but this sequel would occur much less often if a little care were taken to prevent it. The routine use of enemas deserves to be condemned. I see no objection to an occasional enema if purgative medicine has been taken without effect, but constant use of them, more than likely, will result in the enema habit. Similarly, long-continued administration of strong purgatives tends to make them a permanent necessity. While in bed if medicine is taken every other day the bowels will have opportunity on the intervening days to move spontaneously, though we do not really expect them to move naturally until six or eight weeks after the delivery, when the patient is able to take as much exercise as she likes. Toward the end of the second week, however, mild laxatives generally prove effective, and it is important to select one the dose of which may be gradually decreased. Senna prunes, which were described in Chapter V, fill the purpose very well. Six or eight of them may be needed at first, but the number may be gradually reduced, until finally none are necessary. _Cleanliness_.--In view of the excessive elimination of waste products from the body, the maintenance of cleanliness during the lying-in period may require the use of a large amount of linen. Occasionally patients perspire so freely that the night clothes have to be changed several times in twenty-four hours, and the bed linen only a little less frequently. But at any cost it is imperative not to hinder but rather to promote this function and to keep the skin in a healthful condition through bathing and massage. Nurses are taught, on this account, to give a warm soap and water bed-bath in the morning and an alcohol rub at night. Patients are usually allowed to take tub-baths after the third week. Local cleanliness, which is a matter of the very first importance, can only be attained through bathing the vulva with an antiseptic solution and the use of sterile pads. At first the pads are changed very frequently, but after the discharge becomes less profuse they are renewed at intervals of four to six hours. _The Diet_.--For the first week of the lying-in period not all patients are given the same diet, and the physician always leaves specific directions regarding it. Generally the diet consists of liquids, such as milk and broths, for a couple of days; under some circumstances liquid nourishment is continued longer. As the appetite increases easily digestible but nutritious food is added, and before long the patient resumes her ordinary diet. The modern tendency is to give solid food and to give it in substantial amounts much earlier than was once customary; restrictions, none the less, are still observed so long as the patient remains in bed. With the body at rest, its food requirements are diminished and hearty meals are unnecessary. If convalescence proceeds satisfactorily such wide latitude in the choice of food is permissible that the nurse may regulate the diet, consulting the physician whenever necessary. _The Environment_.--A large, bright room that can be quickly heated and easily ventilated adds notably to the comfort of the lying-in period. The windows may be opened through the greater part of the day and at night should always be left so. To make thorough airing of the apartment more feasible and to protect the mother from annoyance when the baby cries, it is more satisfactory to have the baby occupy an adjoining room where the nurse sleeps within call. Under any circumstances some arrangement must be made so that the mother's rest at night will not be broken needlessly. No pains should be spared to keep the patient quiet for at least ten days. Household cares and petty worries materially delay convalescence. During this period only a limited number of the immediate members of her family ought to see her, and their visits should be brief. Unfortunately, if too many relatives and friends visit her a number of questions will be repeatedly asked which are decidedly wearing on any patient. _The Time for Getting Up_.--How long a woman should stay in bed after the birth of a child is a question which has given rise to prolonged discussion. The majority of obstetricians adhere to the traditional ten days; but there are advocates of a longer period and advocates of a shorter one. The generalizations of many writers upon this subject are too sweeping, for exceptions may be found to any rule. Each patient is best counselled when the advice given is based upon her own condition and particularly upon the progress made in the involution of the uterus, which does not advance with the same rapidity in all cases. More or less in imitation of the custom among savages, Charles White, in 1776, recommended that women should not remain in bed longer than a day or two after child-birth. Very likely the inadaptability of the method to civilized women soon became apparent; at any rate his suggestion was not widely adopted, and had been completely forgotten until a few years ago, when the custom was revived in one of the German clinics. The innovation met with violent opposition in Europe, and, so far as I know, has found but scant favor in America. Generally patients are allowed to sit up in bed toward the end of the first week, but if there are stitches, sitting up is deferred until ten days or later, when the stitches have been removed. Under the most favorable circumstances, however, sitting up in bed becomes wearisome, for the weight of the body does not fall upon the spine, as it should; and besides the extended position of the legs is fatiguing. No one should force herself to keep this posture, for at best it does no more than relieve monotony. The exercises previously suggested prepare her much more effectually for getting upon her feet. Between the tenth and the fifteenth day patients may leave the bed and sit quietly in a chair. The condition of the uterus, the character of the lochia, and the firmness of the pelvic floor will determine the day, but usually it proves wiser to defer it until fully two weeks have lapsed. As a rule, the patient remains out of bed an hour the first day, two the second, three the third, and so on until she is up all day. She should not attempt to walk until the second or third day. At first she should take only a few steps, but gradually she may increase the number and finally walk with freedom and ease. Several reasons make it advisable for patients to remain four weeks on the floor where they have been confined; going up and down stairs is especially tiresome, and, of still greater importance, patients pass from the doctor's control as soon as they go down stairs. For fear of overtaxing the strength none of the household cares should be assumed before the fourth week, and not all of them then, for women are not capable of resuming their accustomed duties fully until the sixth week; and some are not strong enough to do so until a somewhat later date. Since patients generally feel well during the lying-in period they are apt to object to remaining in bed two weeks. Most of them acquiesce as soon as they understand the organic changes in progress and appreciate the lasting benefits of a temporary forbearance, but a few must be made to realize that very serious penalties may be attached to undue haste. For the latter it might be better if the alarming consequences of getting up too early--discomfort, hemorrhage, and collapse--occurred more frequently than they do. As it happens, the ill-effects of such indiscretion are not usually felt immediately; when too late the lesson is learned that many of the operations upon women in the later years of life are dependent on imprudent conduct just after the first child was born. THE FINAL EXAMINATION.--Looking to complete restoration of the woman's health, the modern management of obstetrical cases breaks decisively with tradition at three points. An utter disregard of precaution has given way to very careful preparations before and at the time of labor; definite rules for the management of the lying-in period are carried out under the supervision of the physician; and finally, prompted by the same impulse, the physician examines his obstetrical patients before discharging them. Satisfactory conditions are generally found; if they are, it is a great comfort to be assured of the fact; and if not, timely treatment of the abnormality may readily correct it; with delay, on the other hand, treatment often becomes more formidable. The end of the fourth week of the lying-in period proves a convenient time for this examination. As yet the restorative changes in the reproductive organs have not been completed, but one may definitely say by this time whether or not they will culminate in a satisfactory manner. Besides, making the examination while the changes are in progress sometimes enables the physician to treat approaching complications before they actually develop. Thus, when the pelvic floor has not regained its strength sufficiently, the patient will be advised to forego the liberty in moving about ordinarily granted at this time. When the womb inclines to an improper position, a temporary support may be introduced to hold it where it belongs; later, upon removing the device, the womb usually retains a good position. Again, there are conditions which a douche will relieve, and still others benefited by medicinal treatment. If an abnormality is recognized which cannot at once be treated to the best advantage, arrangements will be made for such prompt treatment that the woman will not become an invalid. Instead of placing obstacles in the way, patients should rather insist upon this examination, for it is important in guarding their future health. Now and then patients are kept under observation for a longer period, but, as a rule, they are discharged as well as examined at the end of four weeks. They may also discard the abdominal binder about this time and put on corsets, which, however, should not be tightly worn. Although thrown upon her own resources from this moment, the patient will clearly understand that she must continue to exercise sound discrimination in what she does. And here, of course, we encounter the greatest difficulty in offering practical advice, for what one may do easily will overtax another. Generally speaking, going up and down stairs more than once a day is inadvisable until another two weeks have passed. Likewise the mother who would adopt a conservative policy will not take full charge of her baby before it is six weeks old, though there can be no objection if she wishes to direct its care. The same advice applies to running the household. Over- exertion, no matter what the source, delays convalescence from child- birth to such an extent that the safe plan is always to err on the side of doing too little, rather than to run the risk of doing too much. CHAPTER XII THE NURSING MOTHER The Breasts--Human Milk--The Technique of Nursing--Hygiene of the Mother: Diet; Psychic Influence; Recreation and Rest--The Supplementary Bottle--Weaning. When the obstetrician pays his final visit the mother usually has ready a number of questions, most of which anticipate difficulties in the care of the baby. At that time, however, minute and far-reaching directions cannot always be given. Unforeseen peculiarities in the development of the child may modify such general principles for the management of infants as could be laid down in advance. With a few exceptions, therefore, mothers require during the early years of a baby's life skilled advice as to his upbringing--advice for which neither instinct nor haphazard counsel is a safe substitute. It is an excellent plan, and one which is becoming more and more popular, to have a physician supervise the care of the baby through the period of most active growth. According to this plan, the mother, even though her baby is well and developing as it should, consults the physician at regular intervals, once a month for example, and upon these occasions secures help in solving problems which are certain to present themselves. Such an arrangement shows a merited appreciation of the proverbial "ounce of prevention," and when serious difficulties do arise materially counteracts the tendency to panic which is exhibited by so many young mothers. Among the problems which the mother must solve, that of nutrition outranks all others in importance; and unless the infant is nourished with human milk, it also exceeds them in perplexity. For, although great advances have been made in artificial feeding, science has not yet removed all the intricacies and dangers involved in the use of the bottle. On the other hand, mothers who nurse their babies rarely meet with difficulty. Human milk is perfectly adapted to the wants of the infant; and all substitutes, though carefully designed to duplicate it, are only partially successful. We have learned how to modify cow's milk so that in chemical constituents, at least, it is a very close imitation of human milk; but human milk possesses, in addition to its chemical properties, other desirable qualities which cannot be instilled into an artificial food. We must agree, therefore, that attempts to disseminate a wider knowledge of the correct principles of bottle-feeding do not have the highest aim. Our real need is a vastly greater proportion of women who nurse their children. THE BREASTS.--For success in nursing the first essential is healthful breasts. With this the largeness or smallness of a breast has nothing to do, for size is no more an index of its capacity for producing milk than is the weight of a woman an index of her energy. The breast is not a warehouse, but a factory, with very limited storage capacity for its product. Differences of size are generally to be explained by the variable amount of fatty-tissue the breast contains. And so far as the secretion of milk is concerned the fat is entirely passive; it fills in the space between the glandular elements; and a layer of fat just beneath the skin protects the glands against external influences that otherwise might disturb their activity. Stripped of their fatty envelope the structures which actually secrete the milk and convey it to the nipple resemble a miniature cluster of grapes. Each tiny, spherical gland corresponds to one of the grapes and contains a cavity lined with cells which manufacture the milk. From this cavity the milk flows through a microscopic tube which unites with similar tubes to form a larger one; this in turn joins others of its kind; and so on, until ultimately the milk enters a relatively large duct-- the figurative stem of the cluster--which conducts the milk to its destination. There are from ten to fifteen of these terminal ducts; each drains a separate group of glands, but all end in the nipple. Shortly after conception the breasts become congested; in consequence they enlarge, become tender, and begin to show swollen veins beneath the skin. The most significant alteration, however, occurs in the cells which line the glands; these increase in size at first; and then, by a process of cell division, their number multiplies. After pregnancy has advanced six to eight weeks these cells begin to elaborate the thin, watery fluid called colostrum. Contrary to popular belief, the quantity of colostrum is not prophetic of the character of the milk; there is no ill-omen, to be sure, in a plentiful secretion, but a meager one is quite as likely to be followed by successful lactation. At present we are unable to predict by any means either the quantity or the quality of the milk which a prospective mother will produce. Some writers contend that influences which come into play during girlhood ultimately affect the capacity of the breast for making milk; for example, irregular habits in youth and the wearing of improper styles of clothing are said to be particularly detrimental influences. Of course, a healthful mode of life at the time when a girl is approaching maturity reacts favorably upon her development in every way, and naturally enough the breasts share this benefit; but the relation between unhygienic habits at about the time of puberty and a subsequent deficiency in lactation has been exaggerated by many writers. It is impracticable, certainly, to institute special measures to prepare the breasts for their function until the need of such measures is clearly evident. Throughout pregnancy clothing about the breasts should be loosely worn. If the nipples are not already prominent they should be drawn out; and about six or eight weeks before confinement is expected they should be given the treatment described in Chapter V. For the first day or so after the infant begins to nurse its efforts have a tendency to injure the skin which covers the nipple; and unless measures to render the nipple resistant have been previously adopted, nursing may cause the mother considerable discomfort. Moreover, it is extremely important throughout lactation to keep the skin covering the nipple free from abrasions, for if it cracks bacteria have thus an opportunity to enter the glands and set up an acute inflammation which may result in the formation of an abscess. This complication is to be avoided, not only because of the unpleasant symptoms which attend it, but also because for the time it brings the usefulness of the breast to an end. Fortunately an abscess seldom impairs the breast permanently. At any period of lactation there may be an overproduction of milk. In this event the breasts are likely to become distended, hard, and very tender. Most frequently "caked breasts," as this condition is called, develop a few days after delivery, when the secretion of milk is just beginning, for at first the secretion is more plentiful than need be. Generally twenty-four hours later there is an adjustment between the supply of nourishment and the natural demands of the infant. Occasionally a longer interval elapses before the breast is completely emptied at each nursing. Formerly it was customary, whenever the breasts became tense and uncomfortable, to express an excess of milk by means of massage; but this mode of treatment lost favor as soon as physicians realized that massage stimulated the glands to greater activity. Drawing the milk with a breast-pump has a somewhat similar though less potent influence, and, because pumping often affords relief when the breasts are distended, there is rarely any objection to it. In the light of modern experience, however, most physicians prefer to avoid manipulation of the breast so far as possible, and generally resort to other measures to relieve the mother's discomfort. Thus most patients are made comfortable if an appropriate bandage is used to transfer the weight of the breasts from the arm-pits and the front of the chest to the bones of the shoulder-girdle. It may be necessary also in some cases to swathe the breasts in warm cloths; in others cold applications are more acceptable; the choice between these methods will vary with the time of year, and usually may be left to the patient herself. Now and then medicine will be employed to relieve the pain, but the administration of drugs to diminish the production of milk is inadvisable. It is never very long before the amount of milk becomes adjusted to the infant's wants, and then distention disappears spontaneously. No artifice can bring about the adjustment as ideally as nature does. During the later months of lactation the liability of the breasts to over-filling is slight, provided the infant empties them regularly and completely. Nevertheless, so long as a mother is nursing her child she must be careful to keep the breasts in a healthful condition. They require support, yet must not be compressed. And they should be covered with clothing which will adequately protect them from sudden changes of temperature. This latter precaution, perhaps, requires more emphasis than formerly, on account of the present popularity of motoring; for the chill which one experiences when driving fast may have a very unpleasant effect upon a nursing mother unless her breasts are carefully protected. Occasionally fever and neuralgic pains in the breasts are caused by motoring, or by exposure to the air-current from an electric fan playing directly upon them. But even under these circumstances an abscess need not be feared unless the nipples are sore. _Human Milk_.--Between the time of birth and the beginning of lactation there is always an interval during which the breasts secrete colostrum, just as they do throughout pregnancy. Although the nutritional value of this fluid is not great, it is doubtful if colostrum serves any other essential purpose than as nourishment. Possibly it also stimulates the intestines to expel the material which has collected within, them during fetal development, yet we know the bowels will move without a purgative; and often do so long before the infant is placed at the breast. Typically, the secretion of milk begins the third day after delivery; yet in perfectly normal patients it may appear as early as the second or as late as the fifth, and occasionally lactation does not begin until the baby is more than a week old. As to what starts the secretion of milk we have only a vague idea; but we know that when the flow is once established its continuation depends primarily upon the sucking efforts of the infant. If nursing is discontinued the secretion dwindles and the breasts dry up. On the other hand, the strong, persistent stimulus of the infant's suckling gradually brings the secretion to a high degree of efficiency. Within the first two weeks, therefore, the daily secretion increases from a few ounces to a pint or more. Subsequently the output fluctuates between one and two quarts daily, according to the demands made upon the breasts; the secretion is larger, consequently, if there are twins. Astounding yields of milk have been recorded, as in the case of a wet-nurse in a German institution who nursed a number of infants and became capable of supplying three to four quarts daily. That newborn infants thrive better on human milk than on any other nourishment is a conviction that must come home to every one who has had even a limited experience. It keeps the babies in health, serves to make them grow, and promotes the development of all their organs as nothing else will. Because there are present in this fluid all the elements necessary for nutrition, physiologists have called it a perfect food. Quantitatively its most important ingredient is water, which constitutes about 86 per cent. of its weight. It also contains about 7 per cent. of milk-sugar, 4 per cent. of butter fat, 2 per cent. of protein, and 0.2 per cent. of mineral matter. The milk of all animals contains a relatively small quantity of mineral matter; judged from this standpoint, the mineral matter would seem of minor importance, but it is actually as vital as any other constituent. Without it the bones would hot harden properly; and other services which it performs are absolutely essential to life. As we should expect, human milk contains all the mineral ingredients necessary for the development of the infant; indeed, with the single exception of iron, they are present in the precise amounts in which they are needed. In this omission, however, nature is guilty of no oversight, since the infant has already been provided by the time of birth with a rich supply of iron. THE TECHNIQUE OF NURSING.--Since the mother should have opportunity to recuperate from the fatigue of labor, physicians generally recommend that an interval of at least twelve hours elapse between the birth of the infant and the time it is first put to the breast. Moreover, the best interests of the infant demand that it be kept warm and left undisturbed while becoming accustomed to its new environment. There is no immediate need of food; and if there were, nature does not fit the mother to supply it, for at this time the breasts contain merely small quantities of colostrum. Some babies nurse vigorously at the outset, but later, discouraged because they get so little, become indifferent and restless, or even decline to take the breast. And the mother, who is handicapped by inexperience and by the awkwardness of nursing in a recumbent position, often feels desperate. Fortunately technical difficulties are confined to the first few days, and, trying as they sometimes are, no one should be discouraged or imagine that she is incapable of nursing; for practically every woman who persists will succeed. For a week or ten days the mother will nurse in the recumbent posture. She turns to one side or the other, according as the right or left breast is used, and holds the corresponding arm to receive and support the baby, which will lie beside her. Then with the opposite hand she holds the breast, placing her thumb above and her fingers below so as to keep it from the baby's face, for only in this way can the infant breathe freely. One must also remember that the infant draws the milk into the terminal ducts chiefly with the back of its mouth, and drains the ducts by compressing the base of the nipple with its jaws; the infant therefore should take into its mouth not only the nipple, but also the areola, the area of deeply colored skin round about it. Mothers frequently disregard these directions, and the failure of their infants to nurse properly may be thus explained, for it is impossible to secure undisturbed nursing unless they are obeyed. Generally the breasts are employed alternately, but both may be used at each nursing if one is insufficient. To fix the duration of the nursings arbitrarily is impossible; from ten to fifteen minutes generally proves satisfactory, but in each case systematic observations of the change in the baby's weight, of the character of its stools, and of its general condition must determine how long to leave it at the breast. The common error, unfortunately, is to be over-indulgent, and, as a result, infants are more frequently ill because the nursings are too long, than too short. Furthermore, the duration of the feedings can never be gauged accurately if the infant is allowed to nap while nursing. The successful training of a baby begins with the development of regular habits of nursing. The old-fashioned custom of allowing the baby to nurse whenever it cried, tacitly--and incorrectly--assumed that it could have no other sensation than hunger. As a matter of fact an infant may have pain from overfeeding. Again, it may be thirsty, or uncomfortable from the pricking of a pin, from the monotony of one position, from a soiled napkin, or from neglect of many simple details in its care. Any of these things make a baby cry, for it has no other means by which it can express disapproval. So long as the breasts contain colostrum the nursings should be at least three hours apart during the day; at night it is preferable not to disturb the mother at all. As soon as milk appears the interval is usually shortened to two hours during the day. In many cases, however, the three-hour interval will be retained even after the milk appears, for otherwise the infant may not become hungry and will fail to nurse as strongly as it should. The following schedule is adapted to the average infant: Age Interval During Total Number the Day of Feedings From 1st to 4th week 2 hours 9 " 4th " 8th " 2-1/2 " 8 " 2nd " 4th month 3 " 7 " 4th " 10th " 3 " 6 " 10th " 12th " 4 " 5 After the first few days most young infants require one feeding in the middle of the night, which is usually given about 2 A.M. The day feedings then begin at 6 A.M., and are repeated at regular intervals until 9 or 10 P.M. The daily bath should be scheduled so that a feeding will be due just after the bath has been completed. If asleep when the next succeeding feeding falls due, the infant should not be waked, but at other times nothing should interfere with the regularity of the schedule. Occasionally there may be difficulty in getting the child to nurse during the day, but it must be taught to do so; otherwise it will want to nurse throughout the night. At no time should an infant remain in the bed with its mother after it has finished nursing; at night this rule must be rigidly enforced, for mothers have been known to fall asleep and smother the baby, an accident known as over-lying. Infants can frequently be trained to go without feeding in the middle of the night even when a month old; and such training is always advisable, since it affords the mother opportunity for six or eight hours' continuous sleep. Before and after each nursing the mothers' nipple should be cleansed with a solution of boric acid made by placing a tablespoonful of the powder in a tumbler which is then filled with water. Such cleansing protects the breasts against infection, a complication which the nursing mother must spare no pains to prevent. Now and then, in spite of conscientious efforts to harden them, the nipples become sore. If they crack, the baby's mouth must not come in direct contact with them, since nursing with a cracked nipple is a common source of a gathered breast. Fortunately when a nipple cracks we may employ a shield, obtainable at any drug-store, which enables the infant to nurse without any danger to the mother. Most babies will take the shield as well as the breast itself; nevertheless, its use should be discontinued as soon as the nipple heals, for while the shield is used the secretion of milk is not stimulated as vigorously as when the infant nurses directly from the breast. In the rare cases in which the shield cannot be used satisfactorily the infant must be taken from the breast temporarily and given a bottle. Radical as this advice may appear, the mother must consent to follow it, for, as I have pointed out, to permit an infant to nurse a cracked nipple is extremely hazardous. When treatment is begun promptly the cracks will generally heal within twenty-four hours. HYGIENE OF THE MOTHER.--Since the mammary glands manufacture their product from the constituents of the mother's blood and their activity is controlled by her nerves, it is clear that her physical condition and her state of mind will influence the secretion of milk. Intelligent women who understand this desire to know how they should live that they may best insure an ample supply of good milk. Fortunately the first important step toward success has been taken when a mother wishes to nurse her baby; but there are also necessary wholesome food, habits conducive to health, and a mind free from worry. It is unfortunate that current beliefs throw many restrictions about nursing-mothers which are unreasonable and unsupported by scientific investigation. There was a time when mothers did not question their ability to nurse, they assumed this duty as a matter of course. Indeed, they were compelled to do so, since refined methods of artificial feeding had not as yet been devised. Among the agricultural class, even to-day, it is exceptional for mothers to fail to nurse their children, if they are provided with the ordinary comforts of life. But women who live at the higher tension of city life are frequently unsuccessful, because they are more inclined to be nervous or because they disregard, among other things, the need of fresh air, plain food, or regular habits. It is wrong to suppose that elaborate rules of conduct are necessary for nursing mothers; the instruction they require is simple and scarcely different from that to be given anyone who desires good health. If she lead a wholesome existence a woman will not only nurse her child successfully but will gain in strength. _Diet_.--In manufacturing centers, where a large proportion of the women are employed in confining work, the percentage of mothers who are able to nurse their children is exceedingly small; consequently the infant mortality is very high. Better nourishment for the mother, it has seemed, would render her more capable of successful lactation, and would decrease or even eliminate badly executed artificial feeding, and would therefore reduce the death rate among the babies. In a few foreign cities the idea has been put into practice. Free restaurants have been established for working mothers, and they have thus been enabled to perform their maternal duties much more successfully. Incidentally it has been shown that nourishment may be supplied mother and infant at a smaller cost than proper artificial food for the infant alone. The quantity of nourishment required by nursing mothers is not so large as might be expected, and in many instances it is over-feeding rather than under-feeding that must be guarded against. Very accurate observations have been made which indicate that during the early weeks of nursing no more food is needed than at other times; in all probability this remains true throughout the whole period of lactation. Over-eating, as many of us know, is a frequent cause of indigestion. It is of the first importance, therefore, that nursing mothers should not take more food than they can assimilate, for indigestion will provoke disturbances in the milk which in turn will make the baby uncomfortable. For a similar reason mothers should have their meals at regular intervals. As a rule the appetite is a reliable guide not only as to how much to eat, but also as to the choice of food, for without exception what is good for the mother is good also for the child. Generally the diet should be a mixed one, consisting of milk, gruels, soups, vegetables, bread, and meat. In order that monotony may not dull the appetite, no one article of food should be employed continuously. With this exception food should be selected with regard only for its wholesomeness and digestibility. All food is milk-making food; no sharp distinctions between the various kinds can be recognized. Milk, because it contains all the elements necessary for perfect nutrition, is particularly wholesome. Water also, since it forms such a large proportion of their milk, should be taken freely by nursing mothers. Generally it proves advantageous to take milk or some other nutritious drink between meals and again before retiring at night, but the danger of ruining in this way the appetite for solid food must not be overlooked. It ought to be unnecessary to say that a nursing mother should deny herself any article of food, no matter how much she may want it, if she knows it will disagree with her; but she must remember also that the same article of food will not necessarily disagree with other mothers. Generalizations of this kind are largely responsible for the wrongful tendency to reject from the dietary many altogether harmless articles. There would be little left for a nursing mother to eat if she avoided every article of food which one person or another assures her will damage her milk. No belief regarding what a nursing mother should eat is held more widely, I suppose, than that she should abstain from salads, tomatoes, and fruits which contain acid. This view is erroneous. The very idea upon which it is based is incorrect, since acids are neutralized as soon as they pass from the stomach to the intestines and cannot enter the milk. With certain persons some varieties of fruit invariably cause indigestion. Lactation does not correct such an individual peculiarity, and a nursing mother who knows she possesses it will act accordingly. Occasionally those who have no such idiosyncrasy worry after they have eaten something which contains an acid because they have heard it will do harm. In such cases it is the mental state of the woman which disturbs her milk and upsets the baby. With the exception of those who have such an idiosyncrasy and those inclined to worry, nursing mothers may partake of fruits and salads with impunity. There are vegetables, of which the onion and turnip are good examples, that contain ingredients that find their way unaltered into the milk. So long as these do not disturb the mother their presence has no unfavorable influence upon the child. Similarly a number of substances appear in the milk when administered as medicine to the mother. In one way this is fortunate, for under certain circumstances it provides a very satisfactory method of treating unhealthy children without giving the medicine directly. In another respect, however, it is a disadvantage, for it sometimes interferes with giving the mother purgatives, which she may need. So far as possible, therefore, the taking of medicine should be limited during lactation, and certainly no drug should be employed without the advice of a physician. Time and again some drug, some beverage, usually one that contains alcohol, or some special article of food has been recommended as a means of increasing an inadequate secretion of milk, but thus far all attempts in this direction have failed of general application. There are at present on the market widely advertised preparations for which astounding efficiency is claimed. None of them, however, has a definite or consistent value; and it is unfortunately true that no substance has yet been discovered that has the specific action of increasing the production of milk. _Psychic Influence_.--Although the nerves of the breast which regulate the secretion of milk do their work whether the mother wills it or not, her state of mind has an influence over the process, just as it has over digestion. No one doubts that our minds influence our digestions as has been so clearly proved by the skillful experiments of Pawlow, an eminent Russian physiologist. Cheerfulness promotes perfect assimilation of the food, whereas mental depression decreases the secretion of the digestive juices or checks them altogether. In a similar way, perhaps, we shall some day have explained to us the unquestioned fact that mothers who maintain a happy disposition nurse their babies efficiently, while those who are inclined to worry often experience real or imaginary troubles with lactation. The most striking manifestations of such psychic influences are those in which, as a result of some strong passion or deep sorrow, the secretion of milk suddenly ceases altogether. Fortunately such effects occur rarely and are never permanent. After a few hours at most the secretion is reestablished; and if there are alterations in the quality of the milk, these will correct themselves just as quickly. More common, and therefore much more important, are cases in which, because the mother allows herself day after day to worry over one thing or another, the secretion of milk suffers permanent disturbance in quantity or in quality. Sometimes worrying lest the milk will be unsatisfactory causes it to become so. Generally, however, unnecessary anxiety for the baby is to blame. Again and again, when there is really nothing out of the way, inexperienced mothers make themselves miserable because they fear something may go wrong. Such a state of mind always invites trouble; not infrequently it is the direct cause of insufficient or unwholesome milk. The self-assurance gained through taking care of the first baby is responsible more than anything else for the greater success mothers have in nursing subsequent children. The mother who is nursing her first baby should take success for granted, and never mistrust her ability to succeed. If the physician has been asked to visit the baby regularly, as was suggested at the beginning of this chapter, he will quickly detect the evidence of failure should failure be imminent. His opinions should be accepted and his directions followed, for by so doing the mother will most readily acquire the assurance which is so necessary to success. The habit, easily fallen into, of paying attention to promiscuous advice is unwholesome, for such advice is injudiciously given and is usually incorrect. More often than not the counsel of well-meaning friends only serves to perplex and distress the mother. _Recreation and Rest_.--Next to worry no influence upon lactation is more detrimental than neglect of recreation and rest. Both are very necessary to a nursing mother, for without them she will soon begin to exaggerate minor troubles and even to worry though nothing is wrong. A mother who has the care of a baby added to other responsibilities may have extraordinary difficulty in finding time for outdoor exercise, for congenial companionship, or for diversion of any kind. Occasionally it may seem almost impossible even to get time for sleep, a necessity so fundamental to health that, as we should expect, a mother deprived of it would fail utterly in nursing her infant. Difficult as it may seem, however, the mother must find time for recreation, for if she does not there will follow disturbances, generally in the quantity, or sometimes in the quality, of her milk. Keeping in mind that whatever benefits the mother will react favorably upon the infant, one should regulate exercise during lactation with regard to the kind and the amount of exercise to which she has been previously accustomed. Walking usually fulfils all the requirements satisfactorily, and there is ordinarily no reason why nursing mothers should not participate in sports that are unattended by violent exertion. Exhausting sports, however, must be shunned, because fatigue has the same injurious effect upon the secretion of milk as lack of exercise. As might be expected, women who are frail are most susceptible to the strain of nursing, especially if they fail to get sufficient rest. All nursing mothers ought to have at least eight hours of sleep in the twenty-four. The night-feeding, generally advisable for the first six to eight weeks, does not break the mother's rest longer than half an hour if the baby is well trained. But if a baby that has not been properly trained turns night into day and keeps the mother awake for long intervals, the milk will quickly deteriorate. Under such circumstances someone must relieve the mother of the care of the infant during the night; she should not be disturbed even to nurse it. The night-feeding will then be supplied artificially; as will also one feeding during the day in order that the mother may have opportunity for exercise and diversion. THE SUPPLEMENTARY BOTTLE.--At first glance it may seem that in the suggestion that the infant be given one artificial feeding each day the mother's comfort alone has been considered. As a matter of fact, however, the adoption of the plan benefits mother and infant alike. The diversion and recreation which the mother, thus relieved of her maternal duties for from four to six hours, has time to secure becomes a direct benefit to the infant. Not infrequently by pursuing this plan, mothers who would otherwise be incapable of nursing are assured successful lactation. The child, moreover, having thus become accustomed to the bottle, is much more easily denied the breast when the time for weaning comes. Objections have been raised to giving the baby even one bottle when the mother has an ample supply of milk, but none of them are valid. Since cow's milk is acknowledged to be less easy of digestion than is human milk, it will occur to someone that there is danger of upsetting the baby by giving it a bottle. But this need not be feared; extensive experience has shown that if an infant is getting human milk of satisfactory quality at all its feedings during the twenty-four hours, save one or two, at these times it will digest properly modified cow's milk without the least inconvenience. Nor is it true that if once a day cow's milk is substituted for that of the mother, the infant will come to prefer the bottle to the breast. There is no danger, on the other hand, that the mother's milk will dry up. Very thorough investigation of these objections has failed to substantiate them in the least. Of course, it will be necessary in preparing the supplementary feeding to take the same precautions as if the infant were on the bottle exclusively. To avoid contamination of the milk care must be exercised to have everything perfectly clean that comes in contact with it. And it will be necessary also to vary from time to time both the strength and the amount of the feeding. These alterations will be made most successfully if left to the judgment of a physician who is familiar with the development of the infant and who may be guided accordingly. WEANING.--Occasionally, even before they are delivered, women express the conviction that they will be incapable of nursing. A few mothers who take this attitude, which it would seem is becoming more and more common, make no attempt at nursing, and others give it up after a very short trial. Premature weaning is practiced among the women of two widely different classes: those who are unwilling to deny themselves social pleasures, and those who, because they must earn a living, cannot be encumbered with maternal duties. A still larger class, however, are those mothers who wean the baby for neither of these reasons, but rather because they become discouraged and conclude that there is something wrong with their milk. In this way many infants are weaned without sufficient reason. Before giving up nursing her child a mother should submit several samples of the milk for analysis. If it is unfit for the infant, reliable evidence of the fact will often be secured in this way. With the exception of tuberculosis, physicians recognize no condition that necessarily unfits a mother for nursing. As we have already seen, pregnancy is generally incompatible with lactation; in the event of conception the mother's milk almost always takes on qualities which render it unsatisfactory for the infant, and yet occasionally pregnancy advances several months before these changes in the milk occur. Meanwhile the infant suffers no inconvenience, and often in these cases the symptoms of threatened miscarriage give the first intimation of the mother's condition. Under all circumstances, however, nursing should cease as soon as the mother recognizes that she is pregnant, for probably no woman is strong enough to provide nourishment for her infant and for the development of the embryo simultaneously. Menstruation, on the other hand, rarely if ever provides a good and sufficient reason for weaning. In the great majority of instances this function is re-established before lactation ends. There may be a reduction in the amount of milk during menstruation, but if the infant has been given the breast as usual, the supply increases as soon as the period ends. Qualitative disturbances which would render the milk unfit for use are practically never a consequence of menstruation. It may happen as the infant grows older that the flow of milk will diminish; then the breast feedings will of necessity be more frequently replaced by the bottle, and the question of weaning will settle itself. But if the time of weaning is a matter of choice, it should be approximately coincident with certain notable developments in the infant's digestive functions, which occur toward the end of the first year. The fact that the infant is prepared to take other food is outwardly shown by the appearance of teeth, of which there are usually six or eight at the end of the year. If the suggestion regarding the daily substitution of one bottle for the mother's milk has been adopted, there will be no difficulty in discontinuing breast-feeding whenever it is desirable; otherwise an infant may raise strong objection to the change. The mother, on the other hand, will not be seriously inconvenienced by the weaning, provided she leaves her breasts alone. Until recently mothers were advised to employ a very elaborate treatment for drying up the breasts. The diet was restricted, and as far as possible liquids of every kind were forbidden; strong purgatives were administered daily; and, in addition, the breasts were covered with some ointment, swathed in cotton, and tightly compressed with a bandage. Fortunately, we now realize that none of these measures are required. When nursing is discontinued the breasts are apt to become distended and uncomfortable. They require support while the distention lasts, which is never very long, and if they become painful, medicine may be employed to give relief. But other measures, some of which occasionally do harm, are absolutely unnecessary, for, at whatever period of lactation the breasts cease to be used, they dry up spontaneously. GLOSSARY [Footnote: The Century Dictionary has been freely used for these definitions.] ABNORMAL.--Irregular; deviating from the natural or standard type. ABORTIFACIENT.--Whatever is used to produce an abortion. ABORTION.--The expulsion of the embryo during the first four months of pregnancy. AFTER-BIRTH.--The mass of tissue expelled from the uterus at the end of labor. It includes the placenta, the umbilical cord, and the membranes of the ovum. ALIMENTARY CANAL.--The digestive tract. It begins with the mouth, includes the stomach and the intestines, and ends with the rectum. AMNIOTIC FLUID.--The liquid inclosed within the amniotic membrane. AMNIOTIC MEMBRANE.--The innermost of the two membranes which envelop the embryo; the lining membrane of the closed sac familiarly called "the bag of waters." ANEMIA.--A deficiency of some of the constituents of the blood. ANATOMY.--The science which deals with the structure of the body. ANTISEPTIC.--Anything which destroys bacteria. AREOLA.--The colored, circular area about the nipple. ARTERY.--A vessel through which the blood flows away from the heart. ASEPSIS.--The exclusion of disease-producing bacteria. ASEPTIC.--Free from injurious bacteria. ASPHYXIA.--The extreme condition caused by lack of oxygen in the blood, brought about by interrupted breathing. ASSIMILATION.--The process by which living creatures digest and absorb nutriment so that it becomes part of the substance composing them. ATROPHY.--To waste away. AUTO-INTOXICATION.--Poisoning by material formed within one's body. BACTERIA (the plural of bacterium).--Exceedingly minute, spherical, oblong, or cylindrical cells which are concerned in putrefactive processes. Some varieties cause disease. BACTERIAL DECOMPOSITION.--Putrefaction brought about by the action of bacteria. BIOLOGY.--The science which deals with the phenomena of life. BIRTH-CANAL.--The passage through which the child enters the world. It is composed of the uterus and the vagina, and is surrounded by the pelvic bones. BLADDER.--A thin, distensible sack acting as a reservoir for the urine between the time it is secreted by the kidneys and leaves the body. BREECH.--The buttocks. CESAREAN OPERATION.--The operation by which the child is taken out of the uterus by an incision through the abdominal wall. CALORIE.--The unit ordinarily employed by scientists to measure heat. CAPILLARIES.--The minute blood vessels which form a network between the terminations of the arteries and the beginnings of the veins. CARBOHYDRATE.--Any one of a group of chemical substances of which starch and sugar are the most familiar members. CARBONIC ACID GAS.--An animal waste product eliminated in the breath. In daylight plants absorb it energetically from the atmosphere through their leaves, and decompose it, assimilating the carbon, and returning the oxygen to the air. CARTILAGE.--A firm, elastic tissue; gristle. From this material many of the bones develop. CATHETERIZE.--To empty the bladder by means of a tube-like instrument which is introduced into the passage through which the urine normally leaves the bladder. CELL.--One of the microscopical structural units which make up our bodies. CELL-DIVISION.--The process by which a single cell becomes two cells. CEREBRUM.--The portion of the brain which is the seat of mental activity. CHORIONIC MEMBRANE.--The outermost of the two membranes which surround the embryo. CHROMATIN.--A substance within the nucleus of a cell which has a special affinity for certain staining agents. CHROMOSOMES.--One of the pieces into which the chromatin is broken during the act of cell-division. CLINICAL.--Pertaining to the sick-bed. COLOSTRUM.--The fluid secreted by the breasts during pregnancy and for two or three days after the birth of the child. CONTRACTION.--The act by which the muscle fibers of the uterus become shorter and press upon its contents. CURETTAGE.--Scraping out the lining of the uterus. DELIVERY.--The birth of the child. DIAGNOSIS.--The determination of either normal or abnormal states of the body. DIAPHRAGM.--The muscular partition between the chest and the abdomen. DIETETIC.--Pertaining to the diet. DUCT.--A tube which conveys the secretion from a gland. EMBRYO.--The offspring before it has assumed the distinctive form and structure of the parent. ENEMA.--A quantity of fluid injected into the rectum. ENGAGEMENT.--The entrance of the fetus into the birth-canal. ETHNOLOGY.--The science which deals with the character, customs, and institutions of races of men. EUGENICS.--The science which deals with the improvement of the human race by better breeding. (Davenport.) EXCRETION.--Waste substance thrown off from the body. FEBRILE.--Attended with fever. FETUS.--The unborn child after the third month of development. FOOD-STUFF.--Anything used for the sustenance of man. FUNCTION.--The discharge of its duty by any organ of the body. GASTRIC JUICE.--The digestive fluid secreted by the wall of the stomach. GERMINAL CELLS.--The structural units from which a new individual takes origin. The cell contributed by the mother is called an egg- cell or ovum; that contributed by the father, a spermatozoon. GESTATION.--Same as pregnancy. GLAND.--An organ which separates certain substances from the blood, and pours out a material, usually fluid, peculiar to itself. HYGIENE.--That department of medical knowledge which relates to the preservation of health; sanitary science. INANITION.--The condition which results from insufficient nourishment. INFECTION.--A disease due to bacteria. INTESTINE.--The bowels; the long membranous tube extending from the stomach to the rectum. INVOLUTION.--The process by which the uterus returns after child- birth to its former size and position. LACTATION.--The secretion of milk. LIGAMENT.--A band of tissue serving to bind one part of the body to another. LIGATURE.--Anything that serves for tying a blood-vessel. LOCHIA.--The discharge continuing for several weeks after the birth of a child. LOTION.--Any liquid holding in solution medicinal substances intended for application to the skin. LUNAR MONTH.--A month of twenty-eight days. MAMMAL.--The highest order of animal, namely, one which suckles its young. MAMMARY.--Relating to the breast. MASTICATION.--The act of chewing. MENOPAUSE.--The permanent abolishment of the menstrual process, which generally occurs between the 45th and the 50th years. MICRO-ORGANISMS.--Bacteria and other living agents of disease which are visible only with the aid of the microscope. MISCARRIAGE.--The termination of pregnancy prior to the seventh month. MUCOUS MEMBRANE.--The lining of certain cavities of the body, such as the mouth, stomach, intestine, uterus, etc. MUCUS.--The material manufactured by the glands in a mucous membrane. MUSCLE-FIBERS.--The muscle-cells. NARCOTICS.--Drugs which produce sleep. NITROGEN.--One of the chemical elements. NUCLEUS.--A clearly defined area found in every cell which seems to be its seat of government. OBSTETRICS.--The branch of medicine which deals with the treatment and care of women during pregnancy and child-birth. OVARY.--The organ which contains the egg-cells or ova. OVIDUCTS.--Two tubes, each of which leads from the neighborhood of one of the ovaries; both terminate in the uterus. OVUM.--An egg: the cell contributed by the mother to her offspring. OXYGEN.--One of the chemical elements. PATHOLOGY.--The branch of medicine which deals with the altered structure and activity of diseased organs. PEPSIN.--A ferment found in the digestive juice secreted by the stomach. PELVIC FLOOR.--The muscles, ligaments, and other tissues which form the bottom of the basin inclosed between the hips. PELVIS.--The bony ring formed chiefly by the hip bones. Posteriorly the ring is completed by the sacrum. PERINEUM.--The region extending backward from the outlet of the vagina to the rectum; it is the most essential part of the pelvic floor. PHYSIOLOGY.--Scientific knowledge of the manner in which the various parts of the body perform their duties. PIGMENT.--Any coloring matter. PLACENTA.--The organ through which the communication between the mother and the offspring is established. One of its surfaces is attached to the wall of the uterus; at about the middle point of the other surface the umbilical cord takes its origin. PRENATAL.--Pertaining to the period before birth. PROTEIN.--A food-stuff which is distinguished by the fact that it contains nitrogen and is a tissue builder. PROTOPLASM.--The living substance in the cells which compose our bodies. PUBERTY.--Sexual maturity in human beings. PUBIC BONES.--The part of the pelvis which forms an arch in front of the bladder. PUERPERIUM.--The same as the lying-in period. RETINA.--The innermost coat of the eye-ball and the one which receives visual impressions. RICKETS.--A disease of infancy characterized by softening of the bones. SECRETION.--The product of the activity of a gland. SEDIMENT.--The material which settles to the bottom of any liquid. SPERMATOZOON (plural spermatozoa).--The microscopic cell contributed by the male parent, which stimulates the ovum to begin its development. SUPPOSITORY.--A medicinal substance made into the form of a cone to be introduced into the rectum. TERM.--The time of expected delivery. THERAPEUTIC.--Concerned with the treatment of disease. THYMUS GLAND.--A structure located behind the breast bone near the root of the neck. Only traces of it are found in adult life. TISSUE.--An aggregation of similar cells in a definite fabric, as muscle, nerve, gland, etc. TUBES.--The oviducts. UMBILICAL CORD.--The structure carrying the blood vessels which pass between the placenta and the child's navel. UTERUS.--The womb: a hollow muscular organ designed to receive, protect, nourish, and expel the product of conception. VAGINA.--The canal through which the child passes from the uterus into the world. VEIN.--A vessel through which the blood flows back to the heart. VERNIX.--The fatty substance deposited over the skin of the newly born infant. VIABLE.--Capable of living. VILLI (singular villus).--The microscopic, finger-like processes which hang from one of the surfaces of the placenta and are surrounded by the mother's blood. VISCERA.--The internal organs which occupy the cavities of the chest and the abdomen. VULVA.--The folds of tissue which surround the outlet of the vagina. 
40654	----	Transcriber's note: The original text includes various symbols that are represented as [Symbol: description] in this text version. A SYSTEM OF MIDWIFERY. by EDWARD RIGBY, M. D., Physician To the General Lying-In Hospital, Lecturer on Midwifery, at St. Bartholomew's Hospital, etc. etc. * * * * * * _Lea & Blanchard have lately published._ NEW REMEDIES, _The Method of Preparing and Administering them_; THEIR EFFECTS UPON THE HEALTHY AND DISEASED ECONOMY, &c. &c. BY ROBLEY DUNGLISON, M. D. _Professor of the Institutes of Medicine and Materia Medica in Jefferson Medical College of Philadelphia; Attending Physician to the Philadelphia Hospital_, &c. THIRD EDITION BROUGHT UP TO 1841. IN ONE VOLUME. A NEW EDITION Completely Revised, with Numerous Additions and Improvements, OF DUNGLISON'S DICTIONARY OF MEDICAL SCIENCE AND LITERATURE: CONTAINING A concise account of the various Subjects and Terms, with a vocabulary of Synonymes in different languages, and formulæ for various officinal and empirical preparations, &c. IN ONE ROYAL 8vo. VOLUME. _A Fourth Edition Improved and Modified, of_ DUNGLISON'S HUMAN PHYSIOLOGY: ILLUSTRATED WITH NUMEROUS ENGRAVINGS. IN TWO VOLUMES, OCTAVO. _Brought up to the present day._ A PRACTICAL TREATISE ON THE HUMAN TEETH: Showing the causes of their destruction and the means of their preservation. By Wm. Robertson: with plates. First American, from the second London edition. In one volume. OUTLINES OF A COURSE OF LECTURES, ON MEDICAL JURISPRUDENCE. BY THOMAS STEWART TRAILL, M. D. _From the Second Edinburgh Edition_, WITH AMERICAN NOTES AND ADDITIONS. ARNOTT'S ELEMENTS OF PHYSICS. _Complete in One Volume._ A new edition of Elements of Physics, or Natural Philosophy, general and medical, written for universal use, in plain or non-technical language, and containing New Disquisitions and Practical Suggestions, comprised in five parts: 1st. Somatology, Statics and Dynamics. 2d. Mechanics. 3d. Pneumatics, Hydraulics, and Acoustics. 4th. Heat and Light. 5th. Animal and Medical Physics. Complete in one volume. By Neil Arnott, M. D., of the Royal College of Physicians. A new edition, revised and corrected from the last English edition, with additions, by Isaac Hays, M. D. THE NINTH BRIDGEWATER TREATISE. A FRAGMENT, BY CHARLES BABBAGE, ESQ. From the Second London Edition. IN ONE VOLUME, 8vo. A New Edition with Supplementary Notes, and Additional Plates; of BUCKLAND'S GEOLOGY AND MINERALOGY, considered with reference to Natural Theology; from the last London Edition with nearly one hundred Maps and Plates. PROFESSOR GIBSON'S RAMBLES IN EUROPE, in 1839:--Containing Sketches of Prominent Surgeons, Physicians, Medical Schools, Hospitals, &c. &c. In One Volume. AN ATLAS OF PLATES, illustrative of the Principles and Practice of Obstetric Medicine and Surgery, with descriptive Letter Press, by Francis H. Ramsbotham. This will form a large super royal volume, with over One Hundred lithographic plates--to be ready in November. THE PRINCIPLES AND PRACTICE of MEDICINE, By Professor Dunglison in 2 vols. 8vo. This work will be ready the approaching fall. THE LIBRARY OF PRACTICAL MEDICINE. Edited by Tweedie, is now complete in five volumes, royal octavo, handsomely bound in leather, to match. The different volumes may be had separate, bound in extra cloth. * * * * * * A SYSTEM OF MIDWIFERY. With Numerous Wood Cuts. by EDWARD RIGBY, M. D., Physician to the General Lying-In Hospital, Lecturer on Midwifery, at St. Bartholomew's Hospital, etc. etc. With Notes and Additional Illustrations. Philadelphia: Lea & Blanchard. 1841. Entered, according to the Act of Congress, in the year 1841, by Lea & Blanchard, in the District Court for the Eastern District of Pennsylvania. Griggs & Co., Printers. THE EDITOR'S PREFACE. This System of Midwifery, complete in itself, was published in London, as a part of Dr. Tweedie's "_Library of Medicine_." The first series of the Library, that on "_Practical Medicine_," recently completed, has been received with extraordinary favour on both sides of the Atlantic, and the character of the publication is fully sustained in the present contribution by Dr. Rigby, and will secure for it additional patronage. The late Professor Dewees, into whose hands this volume was placed, a few weeks before his death, in returning it, expressed the most favourable opinion of its merits; and the judgment of such high authority renders it supererogatory to add a word farther of commendation. It is only necessary for the editor to say that the production of the author is so complete as to have rendered his labour a light one. He has restricted himself mainly to such additions and references as he conceived would render the work more useful to American practitioners. The object of the publication being to present the most condensed view of each subject, he believed it to be inexpedient to depart from the plan by making extensive additions, and entering into the discussion of controversial points, most of which are of minor practical importance. CONTENTS. INTRODUCTION, Page 13 PART I. THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION. CHAPTER I. THE PELVIS. Ossa innominata.--Sacrum.--Coccyx.--Distinction between the male and female pelvis.--Diameters of the pelvis.--Pelvis before puberty.--Axes.--Inclination, 15 CHAPTER II. FEMALE ORGANS OF GENERATION. Internal and external.--Ovaria.--Ovum.--Corpus luteum.-- Fallopian tubes.--Uterus.--Vagina.--Hymen.--Clitoris.-- Nymphæ.--Labia, 22 CHAPTER III. DEVELOPMENT OF THE OVUM. Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical cord.--Embryo.--Foetal circulation, 48 PART II. NATURAL PREGNANCY AND ITS DEVIATIONS. CHAPTER I. SIGNS OF PREGNANCY. Difficulty and importance of the subject.--Diagnosis in the early months.--Auscultation.--Changes in the vascular and nervous systems.--Morning sickness.--Changes in the appearance of the skin.--Cessation of the menses.--Areola.--Sensation of the child's movements.--"Quickening."--Auscultation.--Uterine souffle.--Sound of the foetal heart.--Funic souffle.--Sound produced by the movements of the foetus.--Ballottement.--State of the urine.--Violet appearance of the mucous membrane of the vagina.--Cases of doubtful pregnancy.--Diagnosis of twin pregnancy, 80 CHAPTER II. TREATMENT OF PREGNANCY. Sympathetic affections of the stomach during pregnancy.-- Morning sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.--Spasmodic cough.--Palpitation.--Toothach.-- Diarrhoea.--Pruritus pupendi.--Salivation, 101 CHAPTER III. SIGNS OF THE DEATH OF THE FOETUS. Difficulty of the subject.--Signs before labour.--Motion of the foetus.--Sound of the foetal heart.--Uterine souffle.-- Signs during labour where the head presents--where the face, the nates, the arm, or the cord, present.--Fetid liquor amnii.--Discharge of meconium, 107 CHAPTER IV. MOLE PREGNANCY. Nature and origin.--Varieties.--Diagnostic symptoms.-- Treatment, 112 CHAPTER V. EXTRA-UTERINE PREGNANCY. Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance of the uterus, 117 CHAPTER VI. RETROVERSION OF THE UTERUS. History.--Causes.--Symptoms.--Diagnosis.--Treatment.-- Spontaneous terminations, 126 CHAPTER VII. DURATION OF PREGNANCY, 136 CHAPTER VIII. PREMATURE EXPULSION OF THE FOETUS. Abortion.--Miscarriage.--Premature labour.--Causes.-- Symptoms.--Prophylactic measures.--Effects of repeated abortion.--Treatment, 141 PART III. EUTOCIA, OR NATURAL PARTURITION. CHAPTER I. STAGES OF LABOUR. Preparatory stage.--Precursory symptoms.--First contractions.--Action of the pains.--Auscultation during the pains.--Effect of the pains upon the pulse.--Symptoms to be observed during and between the pains.--Character of a true pain.--Formation of the bag of liquor amnii.--Rigour at the end of the first stage.--Show.--Duration of the first stage.-- Description of the second stage.--Straining pains.--Dilatation of the perineum.--Expulsion of the child.--Third stage.-- Expulsion of the placenta.--Twins, 156 CHAPTER II. TREATMENT OF NATURAL LABOUR. State of the bowels.--Form and size of the uterus.--True and spurious pains.--Treatment of spurious pains.--Management of the first stage.--Examination.--Position of the patient during labour.--Prognosis as to the duration of labour.--Diet during labour.--Supporting the perineum.--Treatment of perineal laceration.--Cord round the child's neck.--Birth of the child, and ligature of the cord.--Importance of ascertaining that the uterus is contracted after labour.--Management of the placenta.--Twins.--Treatment after labour.--Lactation.--Milk fever and abscess.--Excoriated nipples.--Diet during lactation.--Management of lochia.--After-pains, 169 CHAPTER III. MECHANISM OF PARTURITION. Cranial presentations--first and second position.--Face presentations--first and second positions.--Nates presentations, 199 PART IV. MIDWIFERY OPERATIONS. CHAPTER I. THE FORCEPS. Description of the straight and curved forceps.--Mode of action.--Indications.--Rules for applying the forceps.-- History of the forceps, 216 CHAPTER II. TURNING. Turning.--Indications.--Circumstances most favourable for this operation.--Rules for finding the feet.--Extraction with the feet foremost.--Turning with the nates foremost.--Turning with the head foremost.--History of turning, 230 CHAPTER III. CÆSAREAN OPERATION. Indications,--Different modes of performing the operation.-- History of the Cæsarean operation, 243 CHAPTER IV. ARTIFICIAL PREMATURE LABOUR. History of the operation.--Period of pregnancy most favourable for performing it.--Description of the operation, 250 CHAPTER V. PERFORATION. Variety of perforators.--Indications.--Mode of operating.-- Extraction.--Crotchet.--Embryulcia, 256 PART V. DYSTOCIA, OR ABNORMAL PARTURITION. CHAPTER I. FIRST SPECIES OF DYSTOCIA. Malposition of the child.--Arm or shoulder the only faulty position of a full-grown living foetus.--Causes of malposition.--Diagnosis before and during labour.--Results where no assistance is rendered.--Spontaneous expulsion.-- Malposition complicated with deformed pelvis or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm not to be put back or amputated.--Presentation of the arm and head.-- Presentation of the hand and feet.--Presentation of the head and feet.--Rupture of the uterus.--Usual seat of laceration.-- Causes.--Premonitory symptoms.--Symptoms.--Treatment.-- Gastrotomy.--Rupture in the early months of pregnancy, 264 CHAPTER II. SECOND SPECIES OF DYSTOCIA. Size and form of the child.--Hydrocephalus.--Cerebral tumours.--Accumulation of fluid and tumours in the chest or abdomen.--Monsters.--Anchylosis of the joints of the foetus, 281 CHAPTER III. THIRD SPECIES OF DYSTOCIA. Difficult labour from faulty condition of the parts which belong to the child.--The membranes.--Premature rupture of the membranes.--Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta, 286 CHAPTER IV. FOURTH SPECIES OF DYSTOCIA. Abnormal state of the pelvis.--Equally contracted pelvis.-- Unequally contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.--Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.--Effects of difficult labour from deformed pelvis.--Fracture of the parietal bone.--Treatment.--Prognosis, 292 CHAPTER V. FIFTH SPECIES OF DYSTOCIA. _Obstructed Labour from a Faulty Condition of the Soft Passages._ Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.-- Edges of the os uteri adherent.--Cicatrices and callosities.-- Agglutination of the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in the vagina.--Hymen.--Fibrous bands.-- Perineum.--Varicose and oedematous swellings of the labia and nymphæ.--Tumours.--Distended or prolapsed bladder.--Stone in the bladder, 308 CHAPTER VI. SIXTH SPECIES OF DYSTOCIA. _Faulty Labour from a Faulty Condition of the expelling Powers._ I. Where the uterine activity is at fault--functionally or mechanically--from debility--derangement of the digestive organs--mental affections--the age and temperament of the patient--plethora--rheumatism of the uterus--inflammation of the uterus--stricture of the uterus.--Treatment. II. Where the action of the abdominal and other muscles is at fault.--Faulty state of the expelling powers after the birth of the child.-- Hæmorrhage.--Treatment, 324 CHAPTER VII. INVERSION OF THE UTERUS. Partial and complete.--Causes.--Diagnosis and symptoms.-- Treatment.--Chronic inversion.--Extirpation of the uterus, 345 CHAPTER VIII. ENCYSTED PLACENTA. Situation in the uterus.--Adherent placenta.--Prognosis and treatment.--Placenta left in the uterus.--Absorption of retained placenta, 354 CHAPTER IX. PRECIPITATE LABOUR. Violent uterine action.--Causes.--Deficient resistance.-- Effects of precipitate labour.--Rupture of the cord.-- Treatment.--Connexion of precipitate labour with mania, 361 CHAPTER X. PROLAPSUS OF THE UMBILICAL CORD. Diagnosis.--Causes.--Treatment.--Reposition of the cord, 368 CHAPTER XI. PUERPERAL CONVULSIONS. Epileptic convulsions with cerebral congestion.--Causes.-- Symptoms.--Tetanic species.--Diagnosis of labour during convulsions.--Prophylactic treatment.--Treatment--Bleeding.-- Purgatives.--Apoplectic species.--Anæmic convulsions.-- Symptoms.--Treatment.--Hysterical convulsions.--Symptoms, 376 CHAPTER XII. PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA. History.--Dr. Rigby's division of hæmorrhages before labour into accidental and unavoidable.--Causes.--Symptoms.-- Treatment.--Plug.--Turning.--Partial presentation of the placenta.--Treatment, 393 CHAPTER XIII. PUERPERAL FEVERS. Nature and varieties of puerperal fever.--Vitiation of the blood.--Different species of puerperal fever.--Puerperal peritonitis.--Symptoms.--Appearances after death.-- Treatment.--Uterine phlebitis.--Symptoms.--Appearances after death.--Treatment.--Indications.--False peritonitis.-- Treatment.--Gastro-bilious puerperal fevers.--Symptoms.-- Appearances after death.--Treatment.--Contagious or adynamic puerperal fevers.--Symptoms.--Appearances after death.-- Treatment, 415 CHAPTER XIV. PHLEGMATIA DOLENS. Nature of the disease.--Definition of phlegmatia dolens.-- Symptoms.--Duration of the disease.--Connexion with crural phlebitis.--Causes.--Connexion between the phlegmatia dolens of lying-in women and puerperal fever.--Anatomical characters.--Treatment.--Phlegmatia dolens in the unimpregnated state, 463 CHAPTER XV. PUERPERAL MANIA. Inflammatory or phrenitic form.--Treatment.--Gastro-enteric form.--Treatment.--Adynamic form.--Causes and symptoms.-- Treatment, 473 INDEX, 483 A SYSTEM OF MIDWIFERY. INTRODUCTION. By the term Midwifery is understood the knowledge and art of treating a woman and her child during her pregnancy, labour, and the puerperal state. We employ it in this extended sense, because most systematic writers of later times have adopted this arrangement. The terms, _Art des Accouchemens_ of the French, the _Ostetricia_, and _Arte della Parteria_, of the Italians and Spaniards, and the _Geburtshülfe_ of the Germans, are restricted to the process of parturition, although they have been and continue to be, used in the same extended sense as that in which we propose to use the term Midwifery. Although pregnancy and parturition, strictly speaking, are perfectly natural functions, yet they involve such a complication and variety of other processes, and also changes of such extent, that the whole system is rendered more or less subservient to them during the periods of their existence: hence, therefore, their number and variety must ever render them more or less liable to deviations and irregularities of action, which will necessarily be aggravated by the effects of civilized life, and in many instances are productive of derangement in the general economy of the system. Under such circumstances the irritability of the system increases at the expense of its strength and vigour, and not only increases its liability to these derangements, but diminishes its power of resisting their effects. In order that we may render the nature and treatment of the changes and phenomena, which take place in the human system during the periods above alluded to, more intelligible, we shall take a short anatomico-physiological view of the structure, form, arrangement, and function of the parts and organs which are more or less directly concerned in these important processes. This will embrace the subject of embryology, a department of physiological knowledge, which, though it has lately been much enriched by valuable discoveries, still affords a rich field of investigation and research. The diagnosis and course of healthy pregnancy, and its various diseases, terminating with the subject of healthy parturition and its treatment will form the subject of the succeeding part. Parturition properly speaking, will come under two separate heads _eutocia_ and _dystocia_; the one signifying natural or favourable labour, the other, unnatural, faulty, or unfavourable labour. The concluding part will contain a short account of some of the more important diseases which occur to the female during the first month after parturition. PART I. THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION. CHAPTER I. THE PELVIS. _Ossa innominata.--Sacrum.--Coccyx.--Distinction between the male and female pelvis.--Diameters of the pelvis.--Pelvis before puberty.-- Axes.--Inclination._ The Pelvis, as the frame-work which, in great measure, contains, supports, and protects, the complicated apparatus of the generative organs, first claims our attention; since an accurate knowledge of the form, size, and uses, of its different parts is indispensably necessary, not only to understand the situation of the viscera it contains, but also to form a correct view of the mechanism upon which the process of parturition depends. This osseous canal or circular archway, consists essentially of three bones, the right and left os innominatum, which form the sides of the arch, with the sacrum between them, acting as a keystone, and supporting the whole weight of the trunk above. _Ossa innominata._ The ossa innominata in early life consists of three distinct bones, the _iliac_ or _hip bones_ at the sides, the _ischia_ or lower portion upon which we sit, and the _ossa pubis_ which meet each other anteriorly to form the front part of the pelvis. In the adult these are consolidated into one bone, merely leaving irregular lines and ridges here and there to mark their previous existence. These bones present several striking points of resemblance with those which belong to the upper extremities, viz. the scapula and clavicle; and in the early stages of development, this similarity is much more distinctly seen: it is remarkable, that although the ischia and ossa pubis are formed later than the ilia, yet they unite with each other much sooner than with the ilia, so that the two consolidated bones bear the same relation to the ilium which is separated from them, that the clavicle does to the scapula: many other points of resemblance between the bones of the shoulder and pelvis might be noticed if necessary. (Meckel, _Anat._ vol. ii. p. 239.) The ossa innominata meet each other in front, forming the _symphysis pubis_, having layers of fibro-cartilage interposed between their extremities, and bound together by ligamentous fibres constituting the _ligamentum arcuatum_, or _annulare ossium pubis_, and by which a more rounded appearance is given to the pubic arch. They are united to the sacrum posteriorly, one on each side of it, forming the _right and left sacro-iliac symphysis_ or _synchondrosis_; this differs in many respects from the symphysis pubis, the cartilaginous coverings of the opposing bones being much thinner, especially those of the ossa innominata; the surfaces are extremely uneven from the deep indentations which each bone presents at this part, locking, as it were, into each other, and thus contributing greatly to increase the firmness of the joint, which is also still farther strengthened by the support of powerful ligaments. Between the ligamento-and cartilaginous layers which cover the surfaces of the bones at the pubic and sacro-iliac symphyses, a minute collection of synovial fluid may be detected, like that found in the fibro-cartilages between the vertebræ; it serves to lubricate their surfaces, and separates them more or less, thereby increasing the thickness of the intervening cartilaginous structure; and separating also the edges of the bones, to a certain extent, more especially at the symphysis pubis. (Portal, _Anat. Méd._) These laminæ of intervening fibro-cartilage are thicker in the female than in the male, although of smaller extent; and this is still more remarkable during pregnancy, this ligamento-cartilaginous structure becoming now more cushiony and elastic, while in the latter months we can easily distinguish blood-vessels ramifying through it, which are branches of the pudic arteries and veins. _Sacrum._ The sacrum, which forms the upper and posterior portion of the pelvis, contributes greatly to the general solidity of the whole bony circle. From its wedge-like shape, it is admirably adapted to support the entire weight of the trunk, and acts, as we have before observed, as a kind of keystone to the arch which is formed by the ossa innominata. It is of a triangular shape, being concave before and convex behind. In the foetus it consists of five distinct pieces of bone separated by intervening layers of cartilage, like the vertebræ of the spinal column, and from their resemblance to those bones they have been called false vertebræ. These cartilages, after a time, gradually disappear; bony matter is deposited in their place; so that by the period of puberty the five sacral vertebræ become united into one solid bone, although they may be distinguished, until an advanced period of life, by the ridges which their edges form. The upper surface of the sacrum, having to sustain the whole weight of the spinal column, is broad and flat, and corresponds to the lower surface of the last lumbar vertebra. Its anterior surface forms with that of the other mentioned bone a considerable angle, which projects forwards and more or less downwards towards the symphysis pubis, and is called the _promontory of the sacrum_. Beneath this point, the sacrum takes a considerable sweep backwards as it descends, gradually advancing again forwards, as we approach its inferior extremity, forming an extensive concavity upon its anterior surface: this is termed _the hollow of the sacrum_. _Coccyx._ The lower end is prolonged by a small bone, called _Coccyx_ or _os Coccygis_, from its supposed resemblance to a cuckoo's beak. It usually consists of four, and sometimes (especially in women) of five portions; they are much smaller than the bones of the sacrum, and are very imperfect rudiments of vertebral formation; like these, they are at an early period little else than cartilage, and even when the bones are fully formed, they are united by intermediate cartilage, and thus retain so much mobility upon each other, as well as upon the lower end of the sacrum, as to admit of being forced backwards to the extent of a full inch, thus contributing greatly to increase the capacity of the outlet. The sacrum not only serves to form the posterior parietes of the pelvis, but by the curve which its lower portion takes forwards, together with the coccyx, it gives a powerful support to the pelvic viscera. When we take a general view of the bones which collectively form the pelvis, we find that it is evidently divided into two portions--an upper and a lower one. On the Continent these have been called the large and the small pelvis; in Britain we merely speak of the pelvis above or below the _brim_, the line of demarcation being the linea ilio-pectinea at the sides, the crista of the os pubis in front, and the promontory of the sacrum behind. The alæ of the ilia form a prominent feature in the upper pelvis, and not only afford an attachment for numerous muscles, but furnish a powerful and ample means of protection and support to the pelvic and lower abdominal viscera. In the female pelvis this is remarkably the case, the cavitas iliaca being well expanded and of greater extent than in the male, the crista of the ilium thrown more outwards; hence the distance between the antero-superior processes is much more considerable. _Distinction between the male and female pelvis._ At the brim, the female pelvis presents several well-marked points of distinction from that of the male. The male pelvis has a contracted brim of a rounded or rather triangular form, with the promontory of the sacrum considerably projecting; whereas, that of the female is spacious, of an oval shape, and with a slightly prominent sacrum, thus affording more room for the passage of the child through the brim. The cavity of the male pelvis is deep, while in the female pelvis it is shallow, a circumstance which is very strikingly seen in comparing the length of the symphysis pubis in each, that of the male pelvis being nearly double the length of the female. This is an important point of difference as regards parturition, because in a shallow pelvis, the extent of surface exposed to the pressure of the head will be much less than where it is deep, and hence the resistance to the passage of the child will be proportionably diminished: in confirmation of this, we find that tall women, in whom the pelvis is usually deep, do not, on the whole, bear children so easily as women of middling stature in whom the pelvis is more shallow. The capacious hollow of the sacrum in the female pelvis adds also greatly to the extent of its cavity, and peculiarly adapts it for parturition, the injurious pressure of the head upon the soft linings of the pelvis being thus prevented, and every facility afforded for its quick and easy transit through the cavity. This applies especially to the neck of the bladder, which would almost inevitably suffer in every labour, were it not for the ample hollow of the sacrum relieving the pressure of the head against the anterior portions of the pelvis. The bones of the female pelvis being more slender and delicately formed, the foramina ovalia and sacro-ischiatic notches are wider, and thus add still farther to the capacity of the cavity. In no part of the pelvis is the difference between the sexes more strongly marked than at the outlet. The spacious and well-rounded arch of the pubes in the female of the slender rami, is a striking contrast to the contracted angular arch of the male pelvis; and the tuberosities of the ischium being much wider apart, the head is enabled to pass under the arch with greater facility, and thus still farther to relieve the anterior of the pelvis from its pressure. The length of the sacro-sciatic ligaments, and the mobility of the coccyx upon the sacrum, by which it can be forced backwards to the extent of an inch by the pressure of the head during labour, not merely serve to distinguish it from the male pelvis, but afford a beautiful instance of design and adaptation. The greater width of the pubic arch in the female pelvis is seen by comparing its angle with that of the arch in the male pelvis. In the female it has been estimated to form an angle varying between 90° and 100°, whereas in the male it is not more than between 70° and 80°. (Osiander, _Handbuch der Embindungs-kunst_, cap. iv. p. 58.) From the greater width of the female pelvis, the acetubula are farther apart, and the great trochanters of the thigh-bones more projecting; hence the greater motion of the hips in the female when she walks, which is still more visible when she runs, for the motion is communicated to the whole trunk, so that each shoulder is turned more or less forwards as the corresponding foot is advanced. The thigh-bones, which are so far apart at their upper extremities, approach each other at the knees, contributing to produce that unsteady gait which is peculiar to the sex. "The woman," says Mr. John Bell, "even of the most beautiful form, walks with a delicacy and feebleness which we come to acknowledge as a beauty in the weaker sex." (_Bell's Anat._ vol. i.) These characteristic marks of the female figure, upon which its beauty in great measure depends, are well seen in all great works of art, whether of sculpture or painting. "The ancients," as Mr. Abernethy has observed, "who had a clear and strong perception of whatever is beautiful or useful in the human figure, and who, perhaps, delicately exaggerated beauty to render it more striking, have represented Venus as measuring one-third more across the hips than the shoulders, whilst, in Apollo, they have reversed these measurements." (_Physiological Lectures._) _Diameters of the pelvis._ It is of the utmost importance to the obstetrician, that he should be thoroughly acquainted with the various dimensions of the female pelvis, for, without this, he can form no correct idea of the manner in which the presenting part of the child passes through its brim, cavity and outlet during labour; indeed, unless he be thoroughly versed in this necessary point of obstetric knowledge, he will remain in almost total ignorance of the whole mechanism of parturition, which must, in great measure, be looked upon as the basis of practical midwifery. The dimensions of the brim cavity and outlet of the pelvis may be given with sufficient correctness for all practical purposes, by measuring three of their diameters,--1. the _straight_, _antero-posterior_, or _conjugate_; 2. the _transverse_; and 3. the _oblique_. At the brim they are as follow:--the straight diameter, drawn from the middle of the promontorium sacri to the upper edge of the symphisis pubis, 4·3 inches; the transverse diameter, from the middle of the linea-ilio-pectinea of one ilium to that of the other, 5·4 inches; and the oblique diameter, from one sacro-iliac synchondrosis to the opposite acetabulum, 4·8 inches. The oblique diameters are called right and left, according to the sacro-iliac symphysis from which they are drawn. [Illustration: _Fig. 1. Fig. 2._ In the annexed representations of the superior and inferior aspects of the female pelvis are shown the three diameters of its brim and outlet; those of the former in _fig. 1._, and those of the latter in _fig. 2._ The same letters of reference are used in each figure to indicate the several diameters; thus _a p_ refers to the antero-posterior, _t t_ to the transverse, _o o_ to the right oblique, and _o' o'_ to the left oblique diameters. In _fig. 2._ the coccyx is represented in situ.] In the cavity these dimensions vary more or less. The straight diameter, measured from the centre of the hollow of the sacrum to that of the symphysis pubis, is 4·8 inches; the transverse, from the point corresponding to the lower margin of the acetabulum on one side to that of the other, 4·3; and the oblique, drawn from the centre of the free space formed by the sacro-ischiatic notch and ligaments on one side of the foramen ovale of the other, 5·2. At the inferior aperture or outlet the alteration is still more remarkable. The straight diameter, from the point of the coccyx to the lower edge of the symphysis pubis, measures only 3·8 inches; but from the mobility of the coccyx enabling it to be pushed back during labour to the extent of a whole inch, it is capable of being extended to 4·8 inches. The transverse diameter from one tuberosity of the ischium to the other, measures 4·3 inches: and the oblique, from the middle of the lower edge of the sacro-sciatic ligament of one side, to the point of union between the ischium and descending ramus of the pubes on the other 4·8 inches. Although these are the proportions of the brim cavity and outlet of the female pelvis in the skeleton state, their real dimensions during life, when the pelvis is thickly lined with muscular and other structures, are very different. The large masses of the psoas magnus and iliacus internus, besides other muscles of inferior size, contribute to alter materially the relations of the pelvic diameters to each other; hence we find that, so far from being the longest, the transverse diameter is one of the shortest, being little more than the antero-posterior. This holds good, especially during labour, because these muscles being thrown into powerful contraction, their bellies swell, and thus tend still farther to diminish its length. The oblique diameters are, in fact, the longest during life, because not only are the parietes of the pelvis at the brim covered by a very thin layer of soft tissues in these directions; but as the extremities of these diameters, in the cavity and outlet, correspond to free spaces which are merely filled up with soft yielding structure, it follows that their length can be somewhat increased when pressure is applied in these directions; the antero-posterior diameter of the outlet can alone be compared with the oblique diameters in this respect, and then only when the coccyx is forced backwards to its full extent by the pressure of the head. _Pelvis before puberty._ The proportions of the adult female pelvis are no longer what they were during childhood; before the age of puberty they resemble those of the male pelvis, the brim being contracted and more or less triangular, and the antero-posterior diameter equalling or even exceeding the transverse. Indeed, at a still earlier period, it presents many points of resemblance even to the pelvis of animals; as, however, growth and development advance, and the various changes which constitute puberty take place, the transverse diameters of the brim, cavity, and outlet increase at the expense of the antero-posterior, until at length, it has assumed the proper proportions of the adult female pelvis. _Axes._ Of not less importance is it that the obstetrician should be thoroughly acquainted with the direction which the central line or axis of the entrance and outlet of the pelvis takes. The axis of the superior aperture has been considered to form with the horizon an angle varying between 50° and 60°; this was noticed long ago by Dr. Smellie: "when the body of a woman," says this valuable author, "is reclined backwards, or half sitting half lying, the brim of the pelvis is horizontal; and an imaginary straight line, descending from the navel, would pass through the middle of the cavity; but in the last month of pregnancy such a line must take its rise from the middle space between the navel and scrobiculus cordis in order to pass through the same point of the pelvis." (_Treatise of Midwifery_, book i. chap. i. sect. 2.) _Inclination of the pelvis._ The angle which the axis of the superior aperture of the pelvis forms with the horizon, when a woman is in the upright posture, necessarily marks what has been called _the inclination of her pelvis_, and varies, of course, in proportion to the angle which the above mentioned axis forms. In a tall woman of slender figure, where the different curves of the spinal columns are slight, the inclination of the pelvis is much less than in a short thick set woman, where the spine is much more strongly curved. Where the inclination is slight, the hollow of the sacrum is generally small, and the vulva directed more forwards; where, on the other hand, the pelvis is much inclined, the hollow of the sacrum is generally observed to be deep, and the vulva directed more or less backwards. The axis of the lower aperture or outlet appears to depend, in great measure, on the curve which the lower part of the sacrum takes downwards and forwards; but, as a general rule, we think it will be found to form, more or less, a right angle with the axis of the brim. The greater the angle which the axis of the brim forms with the horizon, the less will be that which the axis of the outlet forms, and _vice versâ_; or, in other words, the angle with the horizon which the axis of the one forms is inversely to that of the other. The consideration of the various deviations, as to size and form, from the natural proportions which the female pelvis occasionally presents, belongs, more strictly speaking, to that species of faulty labour which arises from these conditions. We, therefore, refer to the fourth species of dystocia, viz. _Dystocia Pelvica_, where the different pelvic anormalities are described. CHAPTER II. FEMALE ORGANS OF GENERATION. _Internal and external.--Ovaria.--Ovum.--Corpus luteum.--Fallopian tubes.--Uterus.--Vagina.--Hymen.--Clitoris.--Nymphæ.--Labia._ The female organs of generation have been usually classed by the English authors under the two heads of _internal_ and _external_; a similar arrangement has also been followed by the Continental writers, but with the advantage of using distinctive terms which are more expressive of their peculiar functions, viz. the _formative_ and _copulative_ organs. Under the first are included the ovaria, Fallopian tubes, and uterus: under the second, the vagina and external parts. We propose to give a short description of these in the unimpregnated state, and then to describe the changes which they present during pregnancy, labour, and the puerperal condition. In point of situation and arrangement they bear a considerable resemblance to the generative organs in the male, being situated at the lower portion of the trunk, and arranged in symmetrical order, so that they either occur in pairs, one on each side the median line of the body, or singly, being equally divided by it throughout their whole length. Although there is in many points considerable difference between the male and female organs, still there is sufficient resemblance to entitle them to be considered as being formed upon the same fundamental type, a resemblance which is seen still more strikingly in the early periods of foetal life. They differ essentially from all the other organs of the system, being in activity during a portion of a woman's life only, and then only at intervals. _Ovaria._ The ovaries are situated in the upper part of the cavity of the pelvis, one on each side, near to the uterus, to which they are merely attached by a ligament (the _ligamentum ovarii_) which is a portion of that duplicature of the peritoneum which connects the uterus to the pelvis, and is known by the name of ligamentum latum, or broad ligament. They are of an oval figure; their anterior and posterior surface is convex, the superior margin is also convex, while their lower edge is straight or somewhat concave: towards their inner and outer extremities they become thinner. Their external surface in the virgin state is usually smooth, but in advanced age they become uneven and shrivelled; when fully developed they are about an inch and a half in length: their greatest breadth, which is at that portion of the ovary which is farthest from the uterus, is half an inch; their thickness is somewhat less. [Illustration: Convoluted arteries of the ovary, crossing it in nearly parallel lines.] The ovaries are supplied with blood by the spermatic arteries, which are of course considerably shorter in the female; they pass between the two layers of the broad ligament to the ovarium, assuming there a beautifully convoluted arrangement, very similar to the convoluted arteries of the testis. These vessels traverse the ovary nearly in parallel lines, forming numerous minute twigs, which have an irregular knotty appearance from their tortuous condition, and appear to be chiefly distributed to the Graafian vesicles. The external covering of the ovaries is formed by peritoneum, which here receives the name of _Inducium_; it envelopes the parenchymatous tissue of the gland called _stroma_, which is a dense laminar cellular tissue of a reddish colour; its external portion which is in contact with and firmly adherent to the indusium, is condensed into a species of covering of a firm structure and whitish colour, and is called the _tunica albuginea of the ovary_. In the substance of the stroma are embedded a number of vesicles of various sizes, which, although previously described by Vesalius and Fallopius, have been called Graafian vesicles, after De Graaf. These do not commonly become visible until the seventh year, from which period they gradually enlarge until puberty, when the ovaries increase in size, become softer and more vascular, and one or two of these vesicles may be observed to be larger, more developed, and projecting considerably from the surface of the gland. The proper capsule of the Graafian vesicle is composed of two layers. The outer is formed of dense cellular tissue, in which are ramified many blood vessels; the inner layer is thicker, softer, and more opaque than the preceding, to which it is closely united, and from which it receives vascular twigs. _Ovum._ The contained part or nucleus of the vesicle of De Graaf consists of, first, a granulary membrane, enclosing, secondly, a coagulable granular fluid; thirdly, connected with the granulary membrane on one side is a circular mass or disc of granulary matter, in the centre of which is embedded, fourthly, the ovum. This disc, called by Baer the _proligerous disc_, presents in its centre on the side towards the interior of the vesicle, a small rounded prominence, called the _cumulus_, and on the opposite side a small cup-like cavity hollowed out in the cumulus. The cavity is for the reception of the ovum.[1] [Illustration: _Diagram of a section of the Graafian Vesicle and its contents, showing the situation of the Ovum._ _a_ The granulary membrane. _b_ The proligerous disc. _c_ Ovum. _d_ The inner and outer walls of the Graafian vesicle. _e_ Indusium of the ovary. _From T. W. Jones._] From the very minute size of the human ovum, and the difficulty of detecting it, the existence of this little corpuscule was not satisfactorily ascertained until modern times. Although De Graaf had observed ova in the Fallopian tube so early as 1668, which fact had been confirmed by the researches of Dr. Haighton and Mr. Cruickshank, still, as no traces of such ova had been discovered in the Graafian vesicle, and as it was evident that the Graafian vesicle, from its size, &c. could not pass along the Fallopian tube, it was concluded that the inner surface of the vesicle was a species of glandular structure which secreted the fluid with which it was filled, and which was analogous to the semen of the male testicle; hence, in former times, the ovaries were known by the name of _testes muliebres_. The celebrated anatomist Steno[2] first pointed out the analogy between these organs and the ovaries of the fish tribe: this view was afterwards supported by De Graaf,[3] and they have since continued to retain the name of ovaries. To Professor von Baer, now of St. Petersburg, is due the merit of having first pointed out the distance of the ovum in the Graafian vesicle, and of thus putting beyond all doubt the accuracy of De Graaf's observations, as well as those of Dr. Haighton and Mr. Cruickshank. _Corpus luteum._ Upon impregnation taking place, one or more of the most prominent Graafian vesicles begins to show marks of considerable vascularity, both in its external capsule and in the surrounding stroma of the ovary. The vesicle swells, and at length bursts, discharging its contents into the funnel-shaped extremity of the Fallopian tube, which firmly grasps the ovary at this point by means of its fimbriæ. These changes begin to take place immediately after impregnation; the inner lining of the vesicle, which Professor von Baer considers to be a mucous membrane, appears to undergo a rapid development, much more so than the external capsule which contains it. It is, therefore, thrown into a number of corrugations by which the cavity of the vesicle is greatly diminished; it becomes much thicker, and assumes a yellow colour. As its growth proceeds, the cavity of the vesicle becomes still farther contracted, until being unable longer to retain its contents, it bursts and discharges them as above described. [Illustration: Corrugation of the lining membrane of the Graafian capsule after impregnation. _From Baer._] The remains of the ruptured vesicle form a round glandular yellow coloured body, called _corpus luteum_: it projects considerably from the surface of the ovary, attaining the size of a small mulberry. In the middle of this projection there is a little irregular and generally triangular depression or indentation, which is the opening through which the ovum was discharged from the Graafian vesicle: this after a short time closes, forming a little cicatrix on the surface of the ovary. [Illustration: Corpus luteum in the third month. _From Dr. Montgomery._] "Upon slitting the ovarium at this part, the corpus luteum appears a round body, of a very distinct nature from the rest of the ovarium. Sometimes it is oblong or oval, but more generally round. Its centre is white, with some degree of transparency; the rest of its substance has a yellowish cast, is very vascular, tender and friable, like glandular flesh. Its larger vessels cling round its circumference, and these send their smaller branches inwards through its substance: a few of these larger vessels are situated at the cicatrix or indentation on the outer surface of the ovarium, and are there so little covered as to give that part the appearance of being bloody when seen at a little distance."[4] Upon making a section of a corpus luteum, we observe that its cavity has an angular form, from which, as from a centre, white lines radiate to the circumference of the vesicle; an appearance which is evidently produced by the corrugation of the inner membrane of the vesicle, as above alluded to. To a similar cause we may also attribute the lobular appearance, which the structure of the corpus luteum presents when a section is made of it. The number of these corpora lutea corresponds exactly with the number of newly formed ova. Meckel, after having examined no less than two hundred pregnant animals of the class mammalia, found that the number of corpora lutea corresponded exactly with that of the young produced. "When there is only one child," says Dr. W. Hunter, "there is only one corpus luteum, and two in the case of twins. I have had opportunities of examining the ovaria with care in several cases of twins, and always found two corpora lutea. In some of these cases there were two distinct corpora lutea in one ovarium, in others there was a distinct corpus luteum in each ovarium." A Graafian vesicle cannot be converted into a corpus luteum except by actual and effective sexual intercourse; and the strange and discrepant accounts which have every now and then been published, even by authors of considerable repute, of corpora lutea having been found in the ovaries of virgin and even newly-born animals merely prove that the true characteristics of the corpus luteum were not sufficiently known. The irregular cysts, cavities, or deposites of whitish or yellowish structure which are frequently found in the ovary, independent of impregnation, and which have been improperly enough called virgin corpora lutea, present points of difference so marked that they can scarcely be mistaken by an experienced eye. The angular cavity opening externally, the stellated, radiated, cicatrix-like appearance, which a section of the corpus luteum presents, its soft and delicate structure as described by Dr. Hunter, and above all its vascularity, and the facility with which its vessels can be injected from the general tissue of the ovary, are characters only found in a true corpus luteum. Virgin corpora lutea frequently occur under circumstances of disease, especially those of a tubercular character. They frequently appear as distinct cysts, the walls of which are semi-cartilagenous; at other times they seem to be nothing more than a coagulum of blood: they seldom project much from the ovary, and in no instance have they the peculiar structure of the corpus luteum, nor the external cicatrix, nor are they capable of being injected. After awhile the cavity of the corpus luteum contracts, and the opening into it closes. The surrounding stroma loses its vascularity, the prominence at this part of the ovary gradually subsides, and the ovary returns to its former size. The periods at which these changes take place vary, but with the exception of those first mentioned they proceed slowly whilst pregnancy lasts, after which time, now that the increased activity of the pelvic circulation peculiar to that period has ceased, they advance more rapidly. [Illustration: Corpus luteum at the end of the ninth month. _From Dr. Montgomery._] "If an examination be made within the first three or four months after conception, we shall, I believe, always find the cavity still existing, and of such a size as to be capable of containing a grain of wheat at least, and very often of much greater dimensions: this cavity is surrounded by a strong white cyst (the inner coat of the Graafian vesicle,) and as gestation proceeds the opposite parts of this approximate, and at length close together, by which the cavity is completely obliterated, and in its place there remains an irregular white line, whose form is best expressed by calling it radiated or stelliform."[5] Dr. Montgomery adds, "I am unable to state exactly at what period the central cavity disappears, or closes up to form the stellated line. I think I have invariably found it existing up to the end of the fourth month. I have one specimen in which it was closed in the fifth month, and another in which it was open in the sixth: later than this I never found it." When pregnancy is over, the corpus luteum gradually diminishes and disappears. Dr. Montgomery states that "the exact period of its total disappearance I am unable to state, but I have found it distinctly visible so late as at the end of five months after delivery at the full time, but not beyond this period." Hence it will be seen that in a few months after the termination of pregnancy, all traces of the corpus luteum are lost, and that, therefore, it will be impossible to decide as to how frequently impregnation has taken place, merely by examining the ovaries, as has been supposed. There is also another point to which Dr. Montgomery has alluded, which is well worthy of notice: in mentioning the fact that a vesicle may contain two ova, and thus a woman be delivered of twins, and yet there be but one corpus luteum, he observes that "the presence of a corpus luteum does not prove that a woman has _borne a child_, although it would be a decided proof that she has been impregnated, and had conceived, because it is quite obvious that the ovum, after its vivification, may be, from a great variety of causes, blighted and destroyed, long before the foetus has acquired any distinct form. It may have been converted into a mole or hydatids: thus, however paradoxical it may at first sight appear, it is nevertheless obviously true, that a woman may conceive and yet not become truly with child, a fact already alluded to, as noticed by Harvey; but the converse will not hold good. I believe no one ever found a foetus in utero without a corpus luteum in the ovary; and that the truth of Haller's carollary, 'nullus unquam conceptus est absque corpore luteo' remains undisputed." During childhood, the ovaries present a perfectly smooth surface, and their structure appears to be homogeneous, consisting of a dense cellular tissue. About the seventh year, the first traces of the Graafian vesicles make their appearance; as the period of puberty approaches, the whole gland enlarges, becomes softer and more vascular; the Graafian vesicles are more numerous, and generally one or two will be found larger and more prominent than the rest. After repeated impregnations, and especially towards that time of life when the catamenia are about to disappear, the ovary becomes more or less flabby and corrugated, and at a still more advanced age presents a shrivelled appearance. The ovaries are liable to inflammation and its consequences, more especially abscess, general enlargement, and induration: the malignant changes of structure, viz. cephaloma, hæmatoma, and cancer, rarely have their origin in the ovaries, but extend to these organs from the adjacent parts. Lipomatous or fatty tumours are occasionally met with, containing hair, rudiments of teeth, &c. Cysts not unfrequently occur in the ovaries, and attain a very considerable size; they are simple or compound, sometimes consisting of several cysts one within the other, and distended with fluids, which vary considerably in their character. These tumours come under the general head of OVARIAN DROPSY. The ovaries are also liable to many remarkable morbid changes in the puerperal state, such as softening and complete disorganization, the natural structure of the organ being entirely broken down and converted into a bloody pulpy mass; in some cases the whole gland is apparently dissolved away, so as scarcely to leave a trace of its previous existence. _Fallopian tubes._ The Fallopian tubes, which act as excretory ducts to the ovaries, take their course through the upper portion of the broad ligaments, running from without inwards, towards the superior margin of the uterus, the ovaries being situated behind and somewhat above them. They are somewhat contorted, and are considerably more dilated at their abdominal extremity where they are unattached, than where they are connected to the uterus, being as much as from three to four lines at the former point; whereas, at the latter, they are not more than half a line. Their abdominal extremity, which is like the mouth of a funnel, has its edge strongly fimbriated, and has hence been called the _morsus diaboli_. Their other extremity opens into the cavity of the uterus at the angle which the fundus forms with its sides, and the whole of the tube is about five inches. The Fallopian tubes receive their external covering from the peritoneum, which becomes connected at their open extremity with the membrane which lines them. Between the external and internal membrane is the proper tissue of the tubes, and which, except in very muscular subjects, seldom display the fibrous structure; still, nevertheless, two layers of fibres have been observed--an outer or longitudinal, and an inner or circular layer. The Fallopian tubes are lined with mucous membrane, forming numerous longitudinal rugæ. The canal is not pervious during the early months of foetal life, the abdominal extremity being closed and rounded; this appears to open about the fourth month. The canal is relatively larger, the younger the embryo is, and may, therefore, be easily demonstrated at this time. At the period of impregnation, the Fallopian tubes implant themselves by means of their fimbriated extremity upon that part of the ovary where the Graafian vesicle is about to burst; they become remarkably engorged with blood, assuming a deep purple colour, and are now much thicker; the canal enlarges, so that a tolerably-sized probe can be introduced, whereas, at other periods it will scarcely admit a large bristle. The uterine extremity of the tube is closed by a continuation of that pulpy coagulable lymph-like secretion which now lines the cavity of the uterus, forming the membrana decidua of Hunter, and which, especially on the side where the corpus luteum is found, extends into the tube to nearly the distance of an inch. The tubes are now observed to be in a state of distinct peristaltic motion, "like writhing worms," as Mr. Cruickshank has well expressed it; "the fimbriæ were also black and embraced the ovaria (like fingers laying hold of an object) so closely and so firmly, as to require some force and even slight laceration to disengage them."[6] From the great degree of vascularity which is observed in the Fallopian tubes at this period, some anatomists have been induced to consider that their proper tissue was vascular, analogous to the corpora cavernosa penis. Besides the peristaltic motion already mentioned, other movements called ciliary have been observed in the Fallopian tubes at this period, consisting of minute portions of mucous membrane moving briskly and whirling round their axis, apparently for the purpose of propelling the ovum.[7] As pregnancy advances, the Fallopian tubes undergo other changes as respects their situation, which are worthy of notice. The broad ligaments, in the upper parts of which the Fallopian tubes take their course, are well known to be merely expansions of peritoneum from each side of the uterus, and therefore become gradually unfolded and shorter as the uterus increases in size. "In proportion as the fundus uteri rises upwards and increases in size, the upper part of the broad ligament is so stretched that it clings close to the side of the uterus, so that in reality the broad ligament disappears, no more of it remaining than its very root, viz. its upper and outer corner, where the group of spermatic vessels pass over the iliacs immediately to the side of the uterus. In this state, though the small end of the tube opens in the same part of the uterus as before impregnation, yet the tube has a very different direction. Instead of running outwards in the horizontal direction, it runs downwards, clinging to the side of the uterus. And behind the fimbriæ lies the ovarium, for the same reason clinging close to the side of the uterus."[8] _Uterus._ The uterus is a hollow fibrous viscus situated in the hypogastric region between the bladder and the rectum, below the intestinum ileum and above the vagina, and is by far the largest of the generative organs. It is of a pyriform figure: its upper portion which is the largest is triangular, becoming gradually smaller inferiorly; that portion of it which is above the spot where the Fallopian tubes enter is called the _fundus uteri_; the lower and cylindrical portion receives the name of _cervix_; that between the cervix and fundus is called the _body of the uterus_. The parietes of the adult uterus are nearly half an inch in their greatest thickness, which is about the middle of the body, the body being slightly thicker than the cervix, which is of a somewhat harder structure. Near the point at which the Fallopian tubes enter the uterus the parietes become thinner, gradually diminishing from four or five to only one line in thickness. The cavity of the uterus is triangular, its base being directed upwards, the superior angles corresponding to the points where the Fallopian tubes enter it. The cavity of the uterus is so small, owing to the thickness of its parietes, that they are nearly in contact: it is only four lines in breadth; the fundus, which forms the base of the triangle, is convex both internally as well as externally; whereas, the sides which form the body are convex internally, but somewhat concave externally. The cavity of the uterus is most contracted at the point where the cervix is united to the body, which here forms the _os uteri internum_; from this point the cervix gradually dilates as far as its middle portion, when it again contracts; its lower extremity terminates in the upper part of the vagina by an anterior and posterior cushion-like projection, of which the posterior is usually the longest, although from the direction of the uterine axis the anterior is commonly felt lowest in the pelvis. Between these there is a transverse fissure known by the name of _os tincæ_ or _os uteri externum_, the lips or labia of which are formed by the two above-mentioned prominences. The internal surface of the body of the uterus is smooth, whereas that of the cervix is uneven, forming upon its anterior and posterior wall a number of delicate rugæ diverging obliquely in an arborescent form, and hence called the _arbor vitæ_. The lips of the os uteri are smooth, except when slight lacerations have taken place during labour. In the virgin state the uterus is about two inches long, of which the cervix occupies the smaller half: the greatest breadth of the body is sixteen lines; that of the cervix from nine to ten. The uterus which has been impregnated, especially when this has been frequently the case, scarcely ever regains its original dimensions, and the fissure which the os tincæ forms becomes broader from before backwards. The weight of an adult virgin uterus is from seven to eight drachms, but the uterus which has been once impregnated is seldom less than an ounce and a half. It lies between the bladder and rectum, its upper half being covered by peritoneum, which closely adheres to it. In the adult state it is situated entirely in the cavity of the pelvis; the fundus, which is below the upper edge of the symphysis pubis, is turned forwards and upwards, while its mouth is directed downwards and backwards, so that its long axis is nearly parallel to the axis of the superior aperture of the pelvis. The uterus is connected to the neighbouring parts by several duplicatures of peritoneum, which are continuous with that portion of it which covers the fundus. The most considerable are the _broad_ or _lateral ligaments_: these arise from the sides of the uterus, which is enclosed between their anterior and posterior layers or laminæ; they proceed transversely outwards towards the sides of the pelvic cavity, which is thus divided into two portions, and are then continued into that portion of the peritoneum which lines the cavity. The _round ligaments_ arise from the sides of the uterus close beneath and a little anterior to the uterine extremity of the Fallopian tubes. They pass between the two layers of the broad ligaments, behind the umbilical arteries, and before the iliac vessels, in a direction upwards and outwards to the external opening of the inguinal canal; they then make a turn round the epigastric artery downwards, inwards, and forwards, and pass through the abdominal ring, and dividing into numerous fasciculi and fibres are gradually lost in the cellular substance of the mons Veneris and upper portion of the labia. Besides consisting of cellular substance and blood-vessels, the round ligaments contain some very distinct bundles of muscular fibres, of which the upper arise from the external layer of uterine fibres, and the lower from the inferior edge of the internal oblique muscle, and pass upwards. Upon a superficial examination, the structure of the uterus would almost seem to be homogeneous, nevertheless a number of reddish yellow strata interspersed with whitish streaks running from behind forwards may be perceived even in the unimpregnated state; between these strata the vessels of the uterus take their course, forming numerous anastomoses. There is much difference of opinion among anatomists as to the fibrous structure of the uterus. The majority however agree as to the presence of muscular fibres,[9] some considering that they always exist, while others, and by far the greater number, consider them as appearances peculiar to pregnancy: they are, it is true, extremely indistinct in the unimpregnated state, but they are far from being peculiar to pregnancy, as they are frequently developed by any circumstances by which the formative powers of the uterus are excited. Thus in cases where the uterus has been much distended by some anormal growth, its fibres become much developed and distinctly fasciculated. Lobstein observed them very distinctly in a uterus which had been distended to the size of a seven months' pregnancy by a fatty tumour. The uterine fibres have been usually considered as fleshy, but they differ from the red fibres of voluntary muscles, in being of a paler colour, flatter, and remarkably interwoven with each other: nevertheless they appear to be really muscular fibres from the powerful contraction with which they expel the foetus and placenta, and nearly obliterate the cavity of the uterus. In the unimpregnated state they resemble the fibrous coat of an artery, whereas, those of the gravid uterus are more like the fibres of muscle. Most anatomists agree in describing two sets of fibres, viz. longitudinal and transverse. The external layer of fibres appears to form the round ligaments, which seem to have the same relation with them as tendon and muscle. "The fibres arise from the round ligaments, and regularly diverging spread over the fundus until they unite and form the outmost stratum of the muscular substance of the uterus. The round ligaments of the womb have been considered as useful in directing the ascent of the uterus during gestation, so as to throw it before the floating viscera of the abdomen: but in truth it could not ascend differently; and on looking to the connexion of this cord with the fibres of the uterus, we may be led to consider it as performing rather the office of a tendon than that of a ligament."[10] "On the outer surface and lateral part of the womb, the muscular fibres run with an appearance of irregularity among the larger blood-vessels, but they are well calculated to constringe the vessels, whenever they are excited to contraction. The substance of the gravid uterus is powerfully and distinctly muscular, but the course of the fibres is less easily described than might be imagined: this is owing to the intricate interweaving of the fibres with each other--an intermixture however which greatly increases the extent of their power in diminishing the cavity of the uterus. After making sections of the substance of the womb in different directions, we have no hesitation in stating that towards the fundus the circular fibres prevail, that towards the orifice the longitudinal fibres are most apparent, and that on the whole, the most general course of the fibres is from the fundus towards the orifice. "This prevalence of longitudinal fibres is undoubtedly a provision for diminishing the length of the organ, or for drawing the fundus towards the orifice. At the same time these longitudinal fibres must dilate the orifice and draw the lower part of the uterus over the head of the child. "In making sections of the uterus while it retained its natural muscular contraction, I have been much struck in observing how entirely the blood-vessels were closed and invisible, and how open and distinct the mouths of the cut blood-vessels became when the same portions of the uterus were distended or relaxed. This fact of the natural contraction of the substance of the uterus closing the smallest pore of the vessels, so that no vessels are to be seen, where we nevertheless know that they are large and numerous, demonstrates that a very principal effect of the muscular action of the womb is the constringing of the numerous vessels which supply the placenta, and which must be ruptured when the placenta is separated from the womb." "Upon inverting the uterus, and brushing off the decidua, the muscular structure is very distinctly seen: the inner surface of the fundus consists of two sets of fibres, running in concentric circles round the orifices of the Fallopian tubes; these circles at their circumference unite and mingle, making an intricate tissue. Ruysch, I am inclined to believe, saw the circular fibres of one side only; and not adverting to the circumstance of the Fallopian tube opening in the centre of these fibres, which would have proved their lateral position, he described the muscle as seated in the centre of the fundus uteri. This structure of the inner surface of the fundus of the uterus is still adapted to the explanation of Ruysch, which was that they produced contraction and corrugation of the surface of the uterus, which, the placenta, not partaking of, the cohesion of the surface was necessarily broken. Farther, I have observed a set of fibres on the inner surface of the uterus, which are not described: they commence at the centre of the last described muscle, and having a course in some degree vortiginous, they descend in a broad irregular band towards the orifice of the uterus: these fibres co-operating with the external muscle of the uterus, and with the general mass of fibres in the substance of it, must tend to draw down the fundus in the expulsion of the foetus, and to draw the orifice and lower segment of the uterus over the child's head." (C. Bell, _op. cit._) There are other circumstances which prove the muscularity of the uterus, beyond the mere evidence of its fibres, as seen during pregnancy. "In the quadruped," as Dr. Hunter observes, "the cat particularly and the rabbit, the muscular action or peristaltic motion of the uterus is as evidently seen as that of the intestines, when the animal is opened immediately after death." It is also proved by the powerful contraction which it exerts during labour, and "by the thickness of the fibres corresponding with their degree of contraction." (_Ibid._) The inner surface of the uterus is lined by a smooth or somewhat flocculent membrane of a reddish colour, which is continued superiorly into the Fallopian tubes; inferiorly it becomes the lining membrane of the vagina. Mucous follicles are only found in the cervix, especially at its lower part: when by chance these become inflamed, the orifice closes, and the follicle becomes more or less distended by a collection of thin fluid. The mucous casts of these follicles have been known by the name of _ovula Nabothi_, having been mistaken by an old anatomist for Graafian vesicles, which had been detached from the ovary, and conveyed into the cavity of the uterus. The mucous membrane which lines the cervix uteri is corrugated into a number of rugæ, between which the mucous follicles are chiefly found. [Illustration: Uterus duplex.] Before quitting this subject, it will be necessary to point out the changes which the uterus presents at different periods of foetal life, and the great resemblance it has at these periods to the uterus, as it appears in the lower classes of the mammalia. We may, however, observe in the first place, that the uterus is not found to exist as a separate organ until we come to the class mammalia; and even in the lower genera of this class it bears a strong resemblance to the tubular character of the generative organs in the inferior classes of animal life. The nearest to the tubular uterus, and where the transition from the oviduct in birds, &c. to the uterus in mammalia is least distinctly marked, is in the _uterus duplex_. Although the uterus is double, there is but one vagina into which the two ora uteri open; its low grade of development is marked by the resemblance which each uterus bears to an intestinal tube: there are as yet no traces of a cervix, each os uteri merely forming a simple opening at the lower end of what is little more than a cylindrical canal. We do not find that thickening at the lower extremity of the uterus which distinguishes the cervix in the higher mammalia. This species of uterus is found among a large portion of the rodentia, and is also occasionally met with as an abnormal formation in the human subject. The next grade of uterine development appears under the form of the _uterus bicollis_. The double os uteri here ceases to exist, and the division begins a little higher up, so that the two cavities of the uterus communicate for a short space: the ova, however, do not reach the common cavity, but remain each in its separate cornu. In this form of uterus, the os uteri is not only single, but the lower portion is thickened, although it has not yet formed a distinct neck or cervix; it is met with among some of the rodentia, and also certain carnivora. [Illustration: Uterus bicollis.] [Illustration: Uterus bicorporeus.] In the _uterus bicorporeus_, the union of the cornua is higher up, so that the lower portion is single, while the upper part alone is double, consisting of two strongly curved cornua. This conformation is peculiar to ruminating animals. If two ova be present they are separate from each other, each being contained in its own distinct body or cornu, but a portion of the membranes extends along the common cervix, from one body to the other. [Illustration: Uterus bifundalis.] A still higher grade is the _uterus bifundalis_, where the fundus alone is double, the cornu being formed only by this portion. This formation is observed in the horse, ass, &c.: the common cavity is here the receptacle of the ovum, so that in the unimpregnated state, the cornua appear only as appendices, into which a portion of the membranes extend. In the _uterus biangularis_, the double formation has nearly disappeared, except at the fundus, where the uterus imperceptibly passes into the tubes: this is the case among the edentata, and some of the monkey tribes. The highest grade is the _uterus simplex_: every trace here of the double form is lost; the fundus no longer forms an acute angle, where it bifurcates into two cornua; but is convex. We now for the first time see the divisions of the uterus into body and cervix distinctly marked. [Illustration: Uterus biangularis.] The human uterus presents a similar variety of forms, as it gradually rises in the scale of development during the different periods of utero-gestation. It is at first divided into two cornua, and usually continues so to the end of the third month, or even later; the younger the embryo the longer are the cornua, and the more acute the angle which they form; but even after this angle has disappeared, the cornua continue for some time longer. [Illustration: Uterus simplex.] The uterus is at first of an equal width throughout; it is perfectly smooth and not distinguished from the vagina either internally or externally by any prominence whatever. This change is first observed when the cornua disappear and leave the uterus with a simple cavity. The upper portion is proportionably smaller, the younger the embryo is. The body of the uterus gradually increases, until at the period of puberty it is no longer cylindrical, but pyriform: even in the full-grown foetus the length of the body is not more than a fourth part of the whole uterus; from the seventh even to the thirteenth year it has only a third, nor does it reach a half until puberty has been fully attained. The os tincæ or os uteri externum first appears as a scarcely perceptible prominence projecting into the vagina; it increases gradually, in size until the latter months of gestation, when the portio vaginalis is relatively much larger than afterwards. The parietes of the uterus are thin in proportion to the age of the embryo. They are of an equal thickness throughout at first: at the fifth month, the cervix becomes thicker than the upper parts; between five or six years of age, the uterine parietes are nearly of an equal thickness, and remain so until the period of puberty, when the body becomes somewhat thicker than the cervix. As the function of menstruation with its various derangements will be considered among the diseases of the unimpregnated state, we proceed to consider these changes which the uterus undergoes during pregnancy as well as during and after labour: these are very remarkable both as regards its structure, form, and size. Shortly after conception, and before we can perceive any traces of the embryo, the uterus becomes softer and somewhat larger, its blood-vessels increased in size, and the fibrous layers of which its parietes are composed looser and more or less separated. The internal surface when minutely examined has a flocculent appearance, and very quickly after conception becomes covered with a whitish paste-like substance, which is secreted from the vessels opening upon it; this pulpy effusion soon becomes firmer and more dense; it bears a strong analogy to coagulable lymph, and forms a membrane which lines the whole cavity of the uterus, and which in the course of a few weeks (from changes to be mentioned hereafter) crosses the os uteri and thus closes it. The uterine cavity in a short time becomes still farther closed by the canal of the cervix being completely sealed, as it were, by a tough plug of gelatinous matter which is secreted by the glandules of that part. The structure of the uterus becomes remarkably altered; its fibrous structure is much more apparent; in fact, it is only during pregnancy, or when the uterus has been distended by some anormal growth, that we are able to detect the uterine fibres with any degree of certainty. This has led some anatomists to consider that they are only formed at such periods, a supposition which is not very probable; at any rate they now become very distinct: hence the uterus does not owe its increasing size to mere extension, but it evidently acquires a considerable increase of substance, a fact which is not only proved by examining the contracted uterus after labour at the full period, but also by comparing its weight with that of the unimpregnated organ. The adult virgin uterus weighs about one ounce, whereas the gravid uterus at the full term of pregnancy, when emptied of its contents, weighs at least twenty-four ounces, showing that there has been an actual increment of substance in the proportion of one to twenty-four. Having ascertained this point, it next becomes a question, whether the parietes of the gravid uterus increase in thickness during pregnancy, or whether they become thinner. Meckel, who is one of the greatest modern authorities on these subjects, states that from careful admeasurement of sixteen gravid uteri at different periods of gestation, he finds the parietes become thicker during the first, second, or third months, but after this period they become gradually thinner up to the full time: they are thicker in the upper parts of the uterus, whereas inferiorly they are a third or nearly a half less. Nothing proves the actual increase of bulk and substance in the uterus more than its appearance when contracted immediately after labour at the full term; it forms a fleshy mass as large as the head of a new-born child, the parietes of which are at least an inch in thickness. "The spongy or cellular tissue (says M. Leroux) becomes considerably developed during pregnancy, and its porous cells increase in proportion as the uterus dilates, more especially at the fundus and the spot where the placenta is attached, where they become so large as to admit a goosequill. The internal membrane is pierced with numerous orifices, of which some are the mouths of arteries, and others communicate with the cells already mentioned. This membrane also during pregnancy forms those irregular tufted rugæ, which serve to give a more intimate connexion between the uterus and the placenta. In the unimpregnated uterus and in the intervals between the menstrual periods the little orifices which are observed in the lining membrane of the uterus contain only a transparent lymph, which lubricates the interior of the uterus; during the appearance of the menses they contain blood, and during pregnancy they are connected with the vessels of the placenta and chorion."[11] There is no circumstance in which the gravid uterus differs more from the unimpregnated than in the size and termination of its blood-vessels. The arteries, both spermatic and hypogastric, are very much enlarged. The hypogastric is commonly considerably larger than the spermatic, and we very often find them of unequal sizes in the different sides. They form a large trunk of communication all along the side of the uterus, and from this the branches are sent across the body of the uterus both before and behind. The cervix uteri has branches only from the hypogastrics, and the fundus only from the spermatics; or, in other words, the hypogastric artery gives a number of branches to the cervix, besides sending up the great anastomosing branch, and the spermatic artery supplies the tube and fundus uteri before it gives down the anastomosing branch on the lateral parts of the uterus. All through the substance of the uterus there are infinite numbers of arteries large and small, so that the whole arterial system makes a general network, and the arteries are convoluted or serpentine in their course.[12] Hardly any of the larger arteries are seen for any length of way upon the outside of the uterus. As they branch from the sides where they first approach the uterus, they disappear by plunging deeper and deeper into its substance. The arterial branches which are most enlarged are those which run towards the placenta, so that wherever the placenta adheres, that part appears evidently to receive by much the greatest quantity of blood, and the greatest number both of the large and small arteries at that part pass through to the placenta, and are necessarily always torn through upon its separation. The veins of the uterus would appear to be still more enlarged in proportion than the arteries. The spermatic and hypogastric veins in general follow the course of the arteries, and like them anastomose on the side of the uterus. From thence they ramify through the substance of the uterus, running deeper and deeper as they go on, and without following precisely the course of the arterial branches. They form a plexus of the largest and most frequent communications which we know of in the vessels of the human body, and this they have in common with the arteries that their larger branches go to, or rather come from, that part of the uterus to which the placenta adheres: so that when the venous system of the uterus is well injected, it is evident that that part is the chief source of returning blood. Here, too, both the large and small veins are continued from the placenta to the uterus, and are always necessarily broken, upon the separation of these two parts. As I know no reason for calling the veins of the uterus sinuses, and as that expression has probably occasioned much confusion among the writers upon this subject, I have industriously avoided it.[13] The form of the uterus changes considerably during pregnancy: the upper part appears to increase in greater proportion than the lower, a fact which appears to be proved from the alteration which takes place in the relative position of the Fallopian tubes, which are situated much lower down the sides of the uterus at full term than in the unimpregnated state, nor do they entirely regain their former position after labour, until the female has attained an advanced age; hence as the cervix diminishes in length during the latter half of pregnancy, it follows that the difference in point of size between the fundus and the body of the uterus, and this part will be continually increasing. As the uterus increases, the fundus of course rises and can be felt through the distended abdominal parietes: its anterior surface, especially in the latter month of pregnancy, lies immediately behind the anterior wall of the abdominal cavity, and pushes the small intestines upwards, backwards, and to the sides. The form of the gravid uterus differs also from that in the unimpregnated state in other respects, and this difference appears to depend in great measure upon its increase of size, and upon the form of the cavities which it occupies. Thus in the unimpregnated state when it occupies the cavity of the pelvis, its anterior surface which corresponds to the bladder is flattened; whereas its posterior surface, which is turned towards the hollow of the sacrum, is convex; it is however the reverse during the latter half of pregnancy. The anterior surface is now strongly convex, being merely covered by the yielding anterior wall of the abdomen; whereas posteriorly the uterus is nearly concave, corresponding to the solid convexity of the lumbar vertebræ, a fact which may be easily ascertained by examining the abdomen of a patient in the last month of pregnancy while lying down. The situation and position of the uterus are also changed in the unimpregnated state; the fundus is inclined somewhat backwards, the os uteri being nearly in the centre of the pelvic cavity, but the gravid uterus during the latter half of pregnancy has its fundus strongly inclined forwards and the os uteri directed backwards towards the upper part of the hollow of the sacrum.[14] A minute and intimate knowledge of the changes and appearances which the uterus presents at every period of pregnancy, is essential to the diagnosis and treatment of the various derangements to which this process is subject. The numerous and important questions in medical jurisprudence connected with pregnancy can alone be determined by its means; and it is only by more close and attentive observation of every step in the gradual development of the uterus up to the full term of gestation, that we can expect to increase our means of forming a correct and certain diagnosis in those cases of doubtful pregnancy, where not merely professional reputation is more or less at stake, but the character, happiness, and even life of the individual upon whose case we are required to decide. During the first month of pregnancy the changes are not very appreciable upon examination during life. The uterus has become larger, softer, and more vascular, much as it does during a menstrual period. The portio vaginalis of the cervix, which in the unimpregnated state is hard and almost cartilaginous to the feel, becomes softer and larger:[15] the transverse fissure which the os uteri forms is more oval. In the second month, the abdomen becomes somewhat flat: the portio vaginalis can be now reached by the finger with greater ease than at any time of pregnancy, which is not from the uterus itself being lower in the pelvis, but from not yet having altered its position; any increase of its size therefore will cause its inferior extremity to be felt lower down and nearer to the os externum. The os uteri has undergone a considerable change, inasmuch as its edges have lost their lip-like figure; they now form a ring or rather dimple-like concavity at the lower end of the cervix, its canal being closed by the gelatinous plug already mentioned. In primiparæ, or women pregnant for the first time, the margin of the os uteri thus closed is not only circular but perfectly smooth; whereas in multiparæ, not only is the cervix usually larger in every direction, but the os uteri itself is larger, thicker, and of an irregular shape; it is also knotty here and there from little callous cicatrices, where its edge has been torn in former labours. In the third month of pregnancy the uterus rises above the brim of the pelvis. A slight protrusion of the abdomen may be sometimes observed above the pubes; the os uteri is not reached so easily as in the preceding month. The alteration which takes place in the situation of the uterus during the third month appears to result from gradual shortening of the broad ligament as it increases in size. As the uterus rises it pushes up that portion of the small intestines which rests upon it; these however being confined by the mesentery to the spine, and therefore prevented ascending before the uterus, at length slip down behind it, and the fundus being freed from the superincumbent pressure rises in a direction upwards and forwards into the cavity of the abdomen. The direction of the uterus becomes much altered; the os uteri is no longer in the middle of the pelvic cavity, but inclines towards the upper part of the hollow of the sacrum, whereas the fundus approaches more and more to the anterior parietes of the abdomen. In the fourth month, the fundus uteri has risen about two or three fingers' breadth above the symphysis pubis; this is not very easily ascertained even in a thin person, still less where the patient is stout and the parietes of the abdomen therefore thick. The directions which the celebrated Roederer has given for making an examination of the abdomen during the early months of pregnancy, are well worthy of notice. Having evacuated the bladder and rectum, the patient should be placed in a half-sitting posture with the knees drawn up, so as to relax the abdominal parietes as much as possible: she must then breathe slowly and deeply; and if the hand be suddenly pressed against the abdomen a little above the symphysis pubis, at the moment of her making a full expiration, we shall in all probability feel the hard globe of the uterus. In the fifth month, the fundus will be felt half way, or a little more, between the symphysis pubis and umbilicus. The increased size of the abdomen cannot be concealed by the dress; the portio vaginalis has become distinctly shorter, and the os uteri is situated higher in the pelvis and more posteriorly. In the sixth month, the fundus has risen as high as the umbilicus; the irregular folds of the skin which form the fovia umbilici or navel depression begin to disappear; the first perceptible movements of the child may occasionally be felt; the portio vaginalis has lost half its length, being scarcely half an inch in length. [Illustration: Cervix uteri about the sixth or seventh month.] In the seventh month, the fundus rises an inch or so above the umbilicus, the folds of which have nearly disappeared. In some cases it begins to protrude, forming a species of umbilical hernia: this varies a good deal in different individuals, being more marked in primiparæ; whereas in women, whose abdomen has been distended in previous pregnancies, little or no convexity of the navel is produced until a later period, and not always even then, the umbilical depression being merely diminished in point of depth, and its folds not so strongly marked. The movements of the child are now perfectly distinct; the portio vaginalis is still shorter, and approaches more and more to the upper part of the hollow of the sacrum. The anterior portion of the inferior segment of the uterus, or that part which extends from the os uteri towards the symphysis pubis, is now considerably developed and convex, and on pressing the point of the finger against it, the presenting part of the child will be felt. When this is the head as is usually the case, it will feel like a light ball which rises when pushed by the finger, but which, if the finger be held still, in a few moments descends and may again be felt. [Illustration: Cervix uteri in the eighth month.] In the eighth month, the fundus has risen half way between the umbilicus and the scrobiculus cordis. The abdomen has increased considerably in size, and has become more convex; the umbilical depression in primiparæ has entirely disappeared. The portio vaginalis is still shorter, being barely a quarter of an inch in length. The os uteri is so high up as not to be reached without difficulty; the presenting part of the child can be distinctly felt. [Illustration: Cervix uteri in the ninth month.] In the ninth month, the fundus has reached nearly to the scrobiculus cordis, and by the end of the month is quite in it; this is more especially the case with primiparæ: the anterior parietes of the abdomen not allowing the fundis to incline so strongly forwards, the oppression of breathing is therefore more marked in them than in multiparæ, for the fundus uteri rising so high prevents in great measure the action of the diaphragm, so that the chest is expanded by other muscles; hence the shortness of breath and inability of moving, so frequently complained of at this period of utero-gestation. The portio vaginalis is still shorter, and in the primipara forms little more than a soft cushiony ring which marks the os uteri. The inferior part of the uterus is becoming more spherical, and is usually occupied by the presenting part of the child: this latter is no longer so moveable as before, its size as also its weight being evidently increased. That portion of the uterus which extends between the symphysis pubis and os uteri is now not only more convex but lower in the pelvis than the os uteri itself. During the last four weeks of pregnancy a considerable change is observed. The fundus is now lower than it was in the preceding month, being about half way between the scrobiculus cordis and umbilicus; the abdomen has, as it is called, _fallen_; and from the diaphragm being now able to resume its functions the breathing becomes more easy, and the female feels more comfortable and capable of moving about. On examination per vaginam the anterior portion of the inferior segment of the uterus will be felt still deeper in the pelvis: if the head presents it distends this part of the uterus, so that, in many cases, we have to pass the finger round it before we can reach the os uteri, which is now in the upper part of the hollow of the sacrum. All traces of the cervix have now disappeared, it having been required to complete the full development of the uterus; the situation of the os uteri itself is marked merely by a small depression or dimple; there is no longer any distinction between the os uteri internum and externum; the edges of the opening are so thin as to be nearly membranous, but remain closed in primiparæ until the commencement of labour.[16] In women who have had several children, a considerable difference is observed as regards the state of the cervix and os uteri: the cervix does not undergo that shortening during the latter half of pregnancy, which is the case in a primipara, a portion of it at least remaining up to the full term of utero-gestation: in many cases, especially where the female has had a large family, it is nearly an inch long at this period; nor is the lower portion of the uterus so spherical as in the primipara; to this circumstance may probably be attributed the fact of the head not descending so deep into the pelvis just before labour. In multiparæ the os uteri is also very different: instead of being perfectly round with its edges smooth, it is irregular and uneven, and seldom loses altogether the lip-like shape of the unimpregnated state in consequence of the greater thickness and elongation of its lips from former labours; its edges here and there is uneven and knotty, from little callous cicatrices, where it has been torn; moreover it does not remain closed till the commencement of labour, but the os uteri externum (commonly called os tincæ,) and sometimes even the os uteri internum will be more or less open during the last three or four weeks of pregnancy. These peculiarities are of great importance in coming to a conclusion as to whether a patient be in her first pregnancy or not: although not invariable in the utmost sense of the word, still their occurrence, even after a single labour, is sufficiently frequent to make them worthy of careful observation. Indeed, on more than one occasion, we have known them occur even after a miscarriage, a circumstance on the strength of which the patient had ventured to deny that she was pregnant. On the other hand, we sometimes meet with the os uteri in a second pregnancy so little altered by the effects of the previous labour, that it would be extremely difficult to come to a decision. When labour is over, the uterus contracts very considerably, and, in a few days after, its parietes will be found at least an inch in thickness. It now gradually diminishes in size, and continues to do so for some weeks; the blood-vessels contract, and losing the peculiarly loose spongy structure of pregnancy it becomes harder, firmer, and more compact. It nevertheless remains softer and larger than in the virgin state, and does not attain its original size and hardness until an advanced period of life. The os uteri, which in the latter months of pregnancy had formed a circular opening, resumes its former shape, except that its lips, especially the posterior one, which are more or less irregular and uneven, are thicker and longer than in the virgin state. For the first weeks after labour, the os uteri is high in the pelvis, soft, and easily admits the tip of the finger; at the end of the second week it is much lower in the pelvis, and no longer permits the finger to pass. Immediately after labour, the contracted uterus forms a hard solid ball, the size of a new-born child's head; this state of contraction is not, however, of long continuance: in the course of half an hour, or even less, it begins to increase in size, becoming softer and larger, and continuing to increase slowly for some hours, when it again gradually diminishes, until, as before observed, it approaches its original size in the unimpregnated state. The state of powerful contraction in which the uterus is felt immediately after labour, after a time gradually relaxes; its spongy texture, from which the blood had been forcibly expelled by the violent action of its fibres, becomes again filled with blood; the organ swells and becomes softer and more bulky, and the orifices of the vessels which open into the cavity of the uterus are again partly pervious, and emit a sanious fluid called the _lochia_. This state lasts for two or more days after delivery, when the vessels begin to recover their former caliber, and lose that degree of dilatation peculiar to the gravid state. The lochia become less and less coloured, and now, and not before the uterus undergoes that gradual diminution of size and bulk which we have just alluded to. The copulative or external organs of generation are the _vagina_, _hymen_, _clitoris_, _nymphæ_, and _labia_, the three last being known by the term _vulva_. _Vagina._ The vagina is a canal of about four inches in length and one in breadth, broader above than below; its parietes are thin and are immediately connected with the uterus. It envelopes the portio vaginalis of the uterus at its upper or blind extremity (fundus vaginæ,) and is continuous with its substance; inferiorly, where it is narrowest, it passes into the vulva. It is situated between the bladder and rectum, and attached to each by loose cellular tissue. Its direction differs from that of the uterus, for its axis corresponds very nearly with that of the pelvic outlet, running downwards and forwards. Posteriorly it is somewhat convex, anteriorly concave. The vagina consists of two layers; the external, which is very thin, firm, of a reddish-white colour, and continuous with the fibrous tissue of the uterus; and a lining mucous membrane which is closely united to it. This latter is much corrugated, especially in the virgin state, the rugæ running transversely in an oblique direction, and gathered together on its anterior and posterior surface, forming the _columna rugarum anterior and posterior_, which appear to be a continuation of the corrugations which form the arbor vitæ of the cervix. In the upper part of the vagina there are considerable mucous follicles, which moisten the canal with their secretion, and which during sexual intercourse, and particularly during the first stage of labour, pour forth an abundant supply of colourless mucus for the purpose of lubricating the vagina, and rendering it more dilatable. Near its orifice, especially at the upper part, the veins of the vagina form the _plexus retiformis_, a congeries of vessels which has almost a cellular appearance, and from this reason has been called the _corpus cavernosum_ of the vagina; it appears to be capable of considerable swelling from distension with blood, like the corpus cavernosum penis, and by this means serves to contract still farther the os externum during the presence of venereal excitement. A similar disposition to form plexuses of vessels is seen in the venous circulation of the nymphæ, bladder, and rectum. _Hymen._ The lining membrane of the vagina is of a reddish-gray colour, interspersed here and there, especially at its upper part, with livid spots like extravasation. At the os externum it forms a fold or duplicature called _hymen_, running across the sides of the posterior part of the opening, and usually of a crescentic figure, the cavity looking upwards. The duplicatures of membrane are united by cellular tissue. In some instances, the hymen arises from the whole circumference of the os externum, having a small orifice in the centre for the escape of the menses and vaginal secretions: in some rare cases it is cribriform; and in others it completely closes the vaginal entrance. When torn in the act of sexual intercourse, it generally forms three or four little triangular appendages, called _carunculæ myrtiformes_, arising from the posterior and lateral portions of the os externum. From the identity of its fibrous coat with that of the uterus, the vagina possesses considerable powers of contraction, when excited by the presence of any body which distends it; hence it is a valuable assistance to the uterus during labour: it also stands in the same relation to the abdominal muscles that the rectum does, so that as soon as it is distended by the head, &c. it calls them into the strong involuntary action, which characterizes the bearing down pains of the second stage of labour. The orifice of the vagina (os externum) is surrounded by a thin layer of muscular fibres, which arise from the anterior edge of the sphincter ani; they enclose the outer margin of the vagina, cover its corpus cavernosum, and are inserted into the crura clitoridis at their union. It has been called the sphincter or constrictor vaginæ, and assists the corpus cavernosum still farther in contracting the os externum. _Clitoris._ The clitoris is an oblong cylindrical body, situated beneath the symphysis pubis, arising from the upper and inner surface of the ascending rami of the ischium, by means of two crura of about an inch long, and uniting with each other at an obtuse angle. It terminates anteriorly in a slight enlargement, called the _glans clitoridis_, which is covered with a thin membrane or a loose fold of skin, viz. the _preputium clitoridis_. It is a highly nervous and vascular organ, and like the penis of the male, is composed of two crura and corpora cavernosa, which are capable of being distended with blood; they are contained in a ligamentous sheath, and have a septum between them. The clitoris is also provided with a suspensory ligament, by which it is connected to the ossa pubis. Like that of the penis, the glans clitoridis is extremely sensible, but has no perforation. Upon minute examination, it will be found that the gland is not a continuation of the posterior portion of the clitoris, but merely connected with it by cellular tissue, vessels, and nerves; the posterior portion terminates on its anterior surface in a concavity which receives the glans. In the glans itself there is no trace of the septum, which separates the corpora cavernosa. On the dorsum of the clitoris several large vessels and nerves take their course, and are distributed upon the glans, and upon its prepuce are situated a number of mucus and sebaceous follicles. The crura clitoridis at their lower portion are surrounded by two considerable muscles, called the erectores clitoridis, arising by short tendons close beneath them from the inner surface of the ascending ramus of the ischium, and extending nearly to their extremity. _Nymphæ._ The _nymphæ_ or _labia pudendi interna_, are two long corrugated folds, resembling somewhat the comb of a cock, arising from the prepuce and glans clitoridis, and remaining obliquely downwards and outwards along the inner edge of the labia, increasing in breadth, but suddenly diminishing in size. At their lower extremity they consist of a spongy tissue, which is more delicate than that of the clitoris, but resembles considerably that of the glans, of which it appears to be a direct continuation. It has been called the _corpus cavernosum nympharum_, and is capable of considerable increase in size when distended with blood. The two crura of the prepuce terminate in their upper and anterior extremities; they are of a florid colour, and in their natural state they are contiguous to, and cover the orifice of the urethra. The skin which covers them is very thin and delicate, bearing a considerable resemblance to mucous membrane, especially on their inner surface, where it is continuous with the vagina; externally it passes into the labia. The space between the nymphæ and edge of the hymen is smooth, without corrugation, and is called _vestibulum_. Close behind the clitoris, and a little below it, is the orifice of the urethra, lying between the two nymphæ: it is surrounded by several lacunæ or follicles of considerable depth, secreting a viscid mucus; its lower or posterior edge is, like the lower portion of the urethra, covered by a thick layer of cellular tissue, and a plexus of veins, which occasionally become dilated and produce much inconvenience; it is this which gives the urethra the feel of a soft cylindrical roll at the upper part of the vagina; and in employing the catheter, by tracing the finger along it, the orifice will be easily found. _Labia._ The labia extend from the pubes to within an inch of the anus, the space between the vulva and anus receiving the name of _perineum_. The opening between the labia is called the _fossa magna_: it increases a little in size and depth, as it descends, forming a scaphoid or boat-like cavity, viz. the _fossa navicularis_. The labia are thicker above, becoming thinner below, and terminate in a transverse fold of skin, called the _frænulum perinei_, or _fourchette_, the edge of which is almost always slightly lacerated in first labours. They are composed of skin cushioned out by cellular and fatty substance, and lined by a very vascular membrane, which is thin, tender, and red, like the inside of the lips; they are also provided with numerous sebaceous follicles, by which the parts are kept smooth and moist. CHAPTER III. DEVELOPMENT OF THE OVUM. _Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical cord.--Embryo.--Foetal circulation._ _Membrana decidua._ The earliest trace of impregnation which is to be observed in the cavity of the uterus, and even before the ovum has reached it, is the presence of a soft humid paste-like secretion, with which the cavity of the uterus is covered, and which is furnished by the secreting vessels of its lining membrane. This is the _membrana decidua_ of Hunter: properly speaking, it should be called the _maternal membrane_, in contra-distinction to the chorion and amnion, which, as belonging peculiarly to the foetus, are called the _foetal_ membranes.[17] Although at first in a semi-liquid state, it soon becomes firmer and more compact, assuming the character of a membrane: it appears to be nothing else than an effusion of coagulable lymph on the internal surface of the uterus, having "scarcely a more firm consistence than curd of milk or coagulum of blood." (Hunter, _op. cit._ p. 54.) Hence, although much thicker than the other membranes, it is weaker; it is also much less transparent. It is not of an equal thickness, being considerably thicker in the neighbourhood of the placenta than elsewhere; inferiorily, and especially near the os uteri, it becomes thinner: during the first weeks of pregnancy it is much thicker than afterwards, becoming gradually thinner as pregnancy advances, until it is not half a line in thickness. In the earlier months its external surface is rough and flocculent, but afterwards it becomes smoother as its inner surface was at an earlier period. It is much more loosely connected with the uterus during the first months of pregnancy than afterwards, and this is one reason why premature expulsion of the ovum is more liable to take place at this period than during the middle and latter part of utero-gestation. It is more firmly attached to the uterus in the vicinity of the placenta than any where else, which is owing to the greater number of blood-vessels it receives from the uterus at this point; whereas commonly "it has no perceptible blood-vessels at that part which is situated near the cervix uteri," (_Ibid._,) this portion being much more loosely connected with the uterus. The course which the decidual vessels take on coming from the inner surface of the uterus is admirably adapted to render the attachment of this membrane to it as firm as possible. [Illustration: Vascularity of the decidua. _From Baer._] Upon examining the lining membrane of the uterus at a very early period, when the decidua was still in a pulpy state, Professor v. Baer observed[18] that its villi, which in an unimpregnated state are very short, were remarkably elongated: between these villi, and passing over them, was a substance, not organized but merely effused, and evidently the membrana decidua at an extremely early age. The uterine vessels were continued into this substance, and formed a number of little loops round the villi, thus anastomosing with each other. On account of this reticular distribution it was impossible to distinguish arteries from veins; there is evidently the same relation between the uterus and the decidua as between an inflamed surface and the coagulable lymph effused upon it. [Illustration: Decidual cotyledons. _From Dr. Montgomery._] Professor v. Baer considers that at a later period the connexion between the decidua and mucous membrane becomes so intimate, that it is impossible to separate the former without also separating the latter from the fibrous tissue of the uterus. This, we apprehend, is the stratum which, as Dr. Hunter observes, "is always left upon the uterus after delivery, most of which dissolves and comes away with the lochia." He does not appear to have been fully aware of the close connexion between the decidua and lining membrane of the uterus, although he evidently observed the fact from the following sentence: "in separating the membranes from the uterus we observe that the adhesion of the decidua to the chorion, and likewise its adhesion to the _muscular fibres of the uterus_, is rather stronger than the adhesion between its external and internal stratum, which, we may presume, is the reason that in labour it so commonly leaves a stratum upon the inside of the uterus." According to the observations of Dr. Montgomery, a great number of small cup-like elevations may be seen upon the external surface of the decidua vera, "having the appearance of little bags, the bottoms of which are attached to, or embedded in, its substance; they then expand or belly out a little, and again grow smaller towards their outer or uterine end, which, in by far the greater number of them, is an open mouth when separated from the uterus: how it may be while they are adherent, I cannot at present say. Some of them which I have found more deeply embedded in the decidua were completely closed sacs. They are best seen about the second or third month, and are not to be found at the advanced periods of gestation."[19] [Illustration: _a_ Uterus. _d_ Decidua reflexa. _b_ Fallopian tube. _e_ Ovum. _c_ Decidua.] The membrana decidua does not envelope the ovum with a single covering, but forms a double membrane upon it, somewhat like a serous membrane; in fact, the descent of the ovum through the Fallopian tube is very similar to that of the testicle through the inguinal canal into the scrotum. The ovum pushes before it that portion of the decidua which covers the uterine extremity of the Fallopian tube, and enters the cavity of the uterus, which is already lined with decidua, covered by the protruded portion which forms the _decidua reflexa_. It must not be supposed that this reflexion of the decidua is completed as soon as the ovum enters the uterine cavity; the ovum usually remains at the mouth of the Fallopian tube, from which it has emerged, covered by the plastic mass of soft decidua, and the reflexion of this membrane will take place in proportion as the ovum gradually increases in size. The external layer of decidua is called _decidua vera_; the internal or reflected portion is called the _decidua reflexa_, having received this appellation from its discoverer, Dr. Hunter. These membranes would, as Dr. Baillie has correctly observed, be more correctly named the _decidua uteri_ and _decidua chorii_: the decidua chorii or reflexa is reflected inwardly from above downwards; it is connected on its inner surface with the chorion: externally it is unattached, whereas, the decidua uteri or vera is unconnected on its inner surface, but attached to the uterus externally. The membrana decidua differs in its arrangement from that of a serous membrane, inasmuch, as it is not only reflected so as to cover the chorion, but at the point of reflexion it is continued over the chorion externally, where it forms the placenta, so that the chorion is enclosed in all directions by the decidua: this latter portion, however, is not formed till about the middle of pregnancy. The decidua uteri or vera does not extend farther than the os uteri internum, which is filled up by the plug of tough gelatinous substance above described; the decidua chorii or reflexa, from its forming the outer covering of the chorion, of course passes over the os uteri. [Illustration: _Membrana decidua._ The lower orifice corresponds to the os uteri, the two upper ones to the Fallopian tubes. _From Dr. Hunter._] According to Mr. John Hunter, the decidua vera is continued some little way into the Fallopian tubes, more especially, on that side where the corpus luteum has been formed; it is perforated at the points where the Fallopian tubes enter, as well as at the os uteri, a fact which is beautifully shown in Dr. Hunter's last plate: but this does not continue long, for, as Mr. John Hunter observes, the inferiour opening becomes closed in the first month, and, according to Lobstein's observations, the openings of the Fallopian tubes are closed after the second month. "Where the decidua reflexa is beginning to pass over the chorion, there is, at an early period of pregnancy, an angle formed between it and the decidua, which lines the uterus; and here the decidua is often extremely thin and perforated with small openings so as to look like a piece of lace. "In proportion as pregnancy advances, the decidua reflexa becomes gradually thinner and thinner, so that at the fourth month it forms an extremely fine layer covering the chorion; it comes at the same time more and more closely in contact with the decidua, which lines that part of the uterus to which the placenta is not fixed, till at length they adhere together."[20] That portion of the decidua which passes between the placenta and uterus during the latter half of gestation, is called the _placental decidua_, the description of which will be given with that of the placenta. To Dr. W. Hunter are we indebted for the first correct description of the decidua; indeed, so excellent is it, that the membrane has been called after him, the _decidua of Hunter_. Although he was the undoubted discoverer of the reflexa, the existence of the decidua was distinctly noticed by Burton, in 1751. In stating the _post mortem_ examination of a woman, who died undelivered at the full time of pregnancy, he says, "Upon wiping the inside of the uterus very gently with a sponge, there seemed to be pieces of a very tender thin transparent membrane adhering to it in such parts of the uterus where the placenta did not stick to it; but as the womb was somewhat corrupted, and the membrane so very tender, we could not raise any bulk of it so as to be certain what it was." (Burton's _Midwifery_.) The decidua seems chiefly intended to form the maternal part of the placenta: (see _Placenta_:) hence in all those quadrupeds when the maternal part of the placenta is permanently appended to the internal surface of the uterus, no decidua is found. Having described the maternal membranes of the ovum, we come now to the membranes which form the parietes of the ovum. These are called the _foetal membranes_, for they are essentially connected with the origin of the foetus itself. They are the _chorion_ and the _amnion_; besides which, there are two others that require notice, viz. the _vesicula umbilicalis_ and _allantois_. _Chorion._ The chorion is the proper covering of the ovum, and corresponds to the membrane lining the shell of an egg, in oviparous animals. It is a thin and transparent membrane, and presents on its external surface a ragged tufted appearance, being covered externally with groups of arborescent villous processes, which after a time unite into trunks to form the umbilical vessels, which, according to Lobstein's observations, are merely veins during the early period of gestation. These loose tufts of venous radicles appear to absorb nourishment for the ovum, much in the same manner as the roots of a plant. Although the chorion is so thin and transparent, it consists nevertheless of two laminæ or layers, between which the villi, which produce this shaggy appearance, take their course. Although the chorion on its external surface is nothing but a net-work of villi, which in process of time become vascular, anatomists have been unable to detect blood-vessels in the structure of the membrane itself. Its vascularity, however, has been asserted chiefly on the ground of the known vascularity of the decidua, it being supposed that the vessels of the decidua penetrate into the chorion. The chorion, however, belongs so essentially and exclusively to the foetus, that it appears extremely improbable that any maternal vessels should ramify in its structure for the purposes of its nourishment and growth, and the more so when we reflect that the nutrition of the foetus itself at this early period is obtained in so different a manner. It is, moreover, extremely difficult to distinguish between the venous absorbing radicles of the chorion, which form the early rudiments of the umbilical vessels, and any vessels which may take their course in the structure of the membrane itself; and the more we consider the relation between the chorion and the decidua, the less are we inclined to accept Meckel's explanation of the vascularity of the chorion, viz. that the vessels of the decidua have the same relation to those of the chorion as the blood-vessels of the maternal part of the placenta have to those of the foetal part. Neither nerves nor lymphatics have been discovered in the structure of the chorion, unless, indeed, those white filaments, which are observed here and there about the edge of the placenta, perform the office of lymphatics. This has been hinted at by Dr. Hunter, where he says, "these are the remains of those shaggy vessels which shoot out from the chorion in a young conception, and give the appearance of the ovum being altogether surrounded by the placenta at that time. With a magnifying glass, they appear to be transparent ramifying vessels, which run in corresponding furrows upon the internal surface of the decidua, and a good deal resemble lymphatics." (W. Hunter, _op. cit._ p. 53.) The chorion undergoes various changes during the different periods of pregnancy, and forms a very important part of the physiology of utero-gestation. Its thickness, which in the earlier months of pregnancy is more considerable than afterwards, at this period is uniform in every part of the ovum: its external surface covered with those villous prolongations which have already been alluded to. In the second month of pregnancy these become larger, and much more arborescent; after the third month a considerable portion of them gradually disappears, generally from below upwards, so that the greater part of its external surface becomes nearly smooth, except at that point where the umbilical cord has its origin, at which spot the villous prolongations become more developed, and unite to form the umbilical vessels. This part of the chorion, together with the corresponding portion of the membrana decidua, forms a flat circular mass, which at the end of pregnancy covers nearly one-third of the surface of the ovum, and constitutes the placenta or after-birth. At this point the chorion, which forms its inner surface, is considerably thicker than elsewhere. At the commencement of pregnancy the chorion is but loosely connected with the decidua, but by degrees it becomes so closely connected by fibres, which are the remains of the little vascular prolongations, especially where these two membranes combine to form the placenta, that in the latter months of pregnancy, they can scarcely, if at all, be separated. For the more minute consideration of the formation, development, and functions of the chorion, we must refer to the description of the placenta and foetus. _Amnion._ The amnion is the inner membrane of the ovum. It is transparent, and of great tenuity, "yet its texture is firm, so as to resist laceration much more than the other membranes." (W. Hunter, _op. cit._ p. 50.) It is loosely connected with the chorion on its external surface, except when this membrane unites with the decidua to form the placenta at which spot it adheres to the chorion much more firmly. Its inner surface, which is in immediate contact with the liquor amnii, is very smooth; whereas externally, from being connected with the chorion by an exceedingly fine layer of cellular tissue, its surface is not so smooth. Dr. W. Hunter considers that this intervening tissue, is a gelatinous substance: it seems, however, to possess too much elasticity for such a structure; and, from the reticular appearance which it generally presents upon the membranes to which it adheres, we are inclined to adopt the opinion of Meckel in considering it cellular. "In the very early state of an ovum the amnium forms a bag, which is a good deal smaller than the chorion, and, therefore, is not in contact with it." (_Ibid._ p. 75:) hence, therefore, a space is formed between the two membranes which is filled with a fluid called the _liquor amnii spurius_, or more correctly the _liquor allantoidis_. "In the course of some weeks, however, it comes nearly into contact with the chorion, and through the greater part of pregnancy the two membranes are pretty closely applied to each other." (_Ibid._) Lobstein, in his admirable _Essai sur la Nutrition du Foetus_, observes, that the membranes continues separate from each other so late as the third and fourth month. Cases every now and then occur where a considerable quantity of fluid is found between the chorion and amnion in labour at the full period of pregnancy. We shall defer the minute description of the amnion and its relations, during the very early periods of utero-gestation, until we describe the embryo. The amnion is reflected upon the umbilical cord at its insertion into the placenta, envelopes the umbilical vessels, the external covering of which it forms, and is continued to the anterior surface of the child's abdomen, passing into that projecting portion of the skin which forms the future navel. Blood-vessels and nerves have not as yet been discovered in the structure of the amnion, but Meckel considers it extremely probable that the fine layer of cellular tissue by which it is connected with the chorion contains vessels for its nutrition. _Liquor amnii._ The amnion contains a fluid known by the name of liquor amnii. In the earlier months of pregnancy it is nearly, if not quite transparent; as pregnancy advances it becomes turbid, containing more or less of what appears to resemble mucus: it has a distinctly saline taste; its specific gravity is rather more than that of water. Its relative and absolute quantity vary considerably at different periods of pregnancy: thus the relative weight of liquor amnii to that of the foetus is very considerable at the beginning of pregnancy, at the middle they are nearly equal, but towards the end, the weight of fluid to that of the child, diminishes considerably, so that during the last weeks of pregnancy it scarcely equals a pound, and seldom more than eight ounces, whereas the medium weight of the child is usually between six and seven pounds: the quantity, however, varies considerably, sometimes amounting to several quarts. In the early months the absolute quantity increases, so that between the third and fourth months it sometimes equals as much as thirty-six ounces. Chemically it consists chiefly of water, a small quantity of albumen and gelatine, a peculiar acid called amniotic, with a little muriate of soda and ammonia, and a trace of phosphate of lime. The source of the liquor amnii is still unknown. Dr. Burns asserts that "it is secreted from the inner surface of the membrane by pellucid vessels," but as he confesses that "these have never been injected or traced to their source (_Principles of Midwifery_, by J. Burns, M. D. p. 222.,) little weight can be attached to such a view." Meckel considers (_Handbuch der Menschlichen Anatomie_, vol. iv. p. 707,) that the greater part of it, especially in the early months, is a secretion from the maternal vessels, but that afterwards, as pregnancy advances, it becomes mingled with the excretions of the foetus. It appears to be a means of nourishment to the foetus during the first part of pregnancy, from the fact that it contains more nutritious matter in the early than in the latter months, since at that time a considerable coagulation is produced by alcohol, &c. The disappearance of this coagulable matter of the liquor amnii, towards the end of pregnancy, may be attributed to its having been absorbed at an earlier period, and to the process of nutrition being now carried on by other means. Besides being a source of nourishment to the foetus, it serves many useful purposes; it secures the foetus against external pressure or violence, and supports the regular distension of the uterus; on the other hand it diminishes and equalises the pressure of the foetus upon the uterus; during labour by distending the membranes into an elastic cone, it materially assists to dilate the os uteri; it also serves to lubricate and moisten the external passages. _Placenta._ The placenta is formed essentially by the chorion and decidua; it is a flat, circular, or more or less oval mass, soft, but becoming firmer towards its edge. It is the most vascular part of the ovum, and by which it is connected most intimately with the uterus. Its longest diameter is generally about eight, its shortest about six inches; its greatest thickness is at that spot where the umbilical cord is inserted, which is usually about the middle of the placenta, although it occasionally varies considerably in this respect, the cord coming off sometimes at the edge. The placenta, as ordinarily seen after labour, is barely an inch in its thickest part, but when filled with blood or injection it swells very considerably, and is then little short of two inches. It is generally attached to the upper part of the uterus in the neighbourhood of one of the Fallopian tubes, and more frequently on the left side than on the right; its inner or foetal surface is smooth, being covered by the chorion, which at this part is much thicker. The placenta cannot be distinguished from the other parts of the ovum until the end of the second month, at which period it covers nearly half the surface of the ovum, gradually diminishing in relative size, but increasing in thickness and absolute bulk up to the full period of utero-gestation. It forms a spongy vascular mass, its uterine surface being divided unequally into irregular lobes called _cotyledons_. The uterine surface of a full-grown placenta is covered by a pulpy membrane, resembling in structure the decidua which covers the chorion, and of which it seems to be a continuation. This is always found present at the end of pregnancy: it covers the lobes of the uterine surface of the placenta, descending into the sulci which runs between them: in some parts it is thicker than in others, especially where it is connected with, or in fact becomes, the decidua of the chorion or decidua reflexa. This membrane, which has been called the _placenta decidua_, is pretty firmly attached to the vessels of the placenta, so as not to be separated without rupture; but by maceration, its texture is more or less destroyed, so that we may easily distinguish the extremities of these vessels. "This decidua, or uterine portion of the placenta," says Dr. Hunter, "is not a simple thin membrane expanded over the surface of the part: it produces a thousand irregular processes, which pervade the substance of the placenta as deep as the chorion or inner surface; and are every where so blended and entangled with the ramifications of the umbilical system, that no anatomist will perhaps be able to discover the nature of their union. While these two parts are combined, the placenta makes a pretty firm mass, no part of it is loose or floating; but when they are carefully separated, the umbilical system is evidently nothing but loose floating ramifications of the umbilical vessels, like that vascular portion of the chorion, which makes part of the placentula in a calf; and the uterine part is seen shooting out into innumerable floating processes and rugæ, with the most irregular and minutely subdivided cavities between them that can be conceived. This part answers to the uterine fungus in the quadrupeds: it receives no vessels demonstrable by the finest injection from those of the navel string; yet it is full of both large and small arteries and veins: these are all branches of the uterine vessels, and are readily filled by injecting the arteries and veins of the uterus, and they all break through in separating the placenta from the uterus, leaving corresponding orifices on the two parted surfaces." (Hunter, _op. cit._ p. 42.) According to Lobstein's observations, although this membrane appears to be a continuation of the decidua which covers the chorion, it nevertheless does not exist during the earlier months. During the first months of pregnancy the placenta does not present a solid mass, with its uterine surface covered with projecting lobuli, as it does at the full term of pregnancy; but the vessels of which it is composed (foetal) are loose and floating, as if it had been subjected to maceration. It has been supposed, that this irregular lobulated appearance of the uterine surface of the placenta was produced at the moment of its separation from the uterus during labour; this, however, is not the case, for Lobstein having opened the uterus of a woman who died in the fifth month of pregnancy, and separated the placenta with great care, found these lobular prominences, although not yet covered by the membrane of which we have just spoken. Wrisberg, professor of anatomy at Göttingen, considered that this membrane was distinct from the decidua reflexa, since with care the two membranes can be easily separated. [Illustration: _Uterine surface of the Placenta._] In examining the uterine surface of a full grown placenta it is necessary to place it upon something convex, in order that it may resemble, as nearly as possible, the form which it had when attached to the concave surface of the uterus; the cotyledons are thus rendered prominent and separated from each other; the sulci, which run between them, are wide and gaping: whereas, when the placenta is laid upon a flat surface, its cotyledons are closely pressed together, and the sulci more or less completely concealed. On minute examination of these sulci a number of openings may be observed, varying in size and shape, but usually more or less oval, their edges distinct, smooth, and thin; on directing a strong light into some of the larger ones a number of smaller apertures may be observed opening into them, in much the same way as is observed when looking down a large vein. Some of these canals do not immediately lead to smaller orifices as above described, but open at once into an irregular-shaped cell or cavity, in the parietes of which numerous small apertures may be observed, through which blood oozes when the adjacent parts of the placenta are slightly pressed upon. Besides these openings at the bottom of the interlobular sulci, others may be seen here and there upon the cotyledons; these are generally smaller, their edges thicker, and in most instances they are round; but they are not so invariably met with as the openings between the cotyledons, these lobular projections being sometimes very thickly covered with placental decidua. The openings observed on the uterine surface of the placenta correspond to the mouths of the uterine veins and arteries, which, in the unimpregnated state, open into the cavity of the uterus, but which now, by means of the decidua, convey maternal blood to and from the placenta. "Any anatomist," says Dr. W. Hunter, "who has once seen and understood them, can readily discover them upon the surface of any fresh placenta; the veins, indeed, he will find have an indistinct appearance from their tenderness and frequent anastomoses, so as to look a good deal like irregular interstitial void spaces: the arteries which generally make a snake-like convolution or two, on the surface of the placenta, and give off no anastomosing branches, are more distinct." (Hunter, _op. cit._ p. 46.) From the observations of Messrs. Mayo and Stanley, and from their examination of the original preparations in the Hunterian museum at the College of Surgeons, London, illustrating this subject, it appears that, in all probability, most of the large thin-edged apertures at the bottom of the interlobular sulci are connected with the uterine veins; whereas, the smaller orifices, the margins of which are thicker, and which are chiefly observed upon the cotyledons, are continuations of the uterine arteries. These openings were also pointed out by the late Dr. Hugh Ley, in describing the _post mortem_ examination of a woman who had died at the full term undelivered (_Med. Gaz._ June 1, 1833:) "The uterine surface (of the placenta) thus detached from the uterus, exhibited its lobules with their intersecting sulci, even more distinctly than they are seen in the uninjected placenta; and in several parts there could be perceived, with the naked eye, small apertures of an oval form, with edges perfectly smooth, regularly defined, and thicker, as well as more opaque, than the contiguous parts which they penetrated." The communication between the openings of the placental cells, and the mouths of the uterine veins and arteries, which convey their blood to the placenta, as before observed, is effected by means of the placental decidua. The connecting portion of canal is of a flattened shape, runs obliquely between the uterus and placenta, and appears to be formed entirely of decidua. The manner in which the arteries pass to the placenta is very different to that of the veins: "the arteries," as Dr. W. Hunter observes, "are all much convoluted and serpentine; the larger, when injected, are almost of the size of crow-quills: the veins have frequent anastomoses." Mr. J. Hunter has described this point more minutely, and gives still more precise notions of the manner in which the arteries pass to the placenta. "The arteries of the uterus which are not immediately employed in conveying nourishment to it, go on towards the placenta, and, proceeding obliquely between it and the uterus, pass through the decidua without ramifying: just before they enter the placenta, making two or three close spiral turns upon themselves, they open at once into its spongy substance, without any diminution of size, and without passing beyond the surface as above described. The intention of these spiral turns would appear to be that of diminishing the force of the circulation as it approaches the spongy substance of the placenta, and is a structure which must lessen the quick motion of the blood in a part where a quick motion of this fluid was not wanted. The size of these curling arteries at this termination is about that of a crow's quill. The veins of the uterus appropriated to bring back the blood from the placenta, commence from this spongy substance by such wide beginnings as are more than equal to the size of the veins themselves. These veins pass obliquely through the decidua to the uterus, enter its substance obliquely, and immediately communicate with the proper veins of the uterus; the area of those veins bear no proportion to their circumference, the veins being very much flattened."[21] On examining these vessels in an injected uterus to which the placenta is attached, we shall therefore find that all traces of a regular canal or tube are suddenly lost upon their entering the placenta; each vessel (whether artery or vein) abruptly terminating in a spongy cellular tissue. If a blow-pipe be introduced into a piece of sponge, we shall have a very simple but correct illustration of the manner in which the uterine blood circulates through the placenta. The cell into which each vessel immediately opens is usually much larger than the rest, so that when the cellular structure of the placenta is filled with wax, a number of irregular nodules[22] are found continuous with these vessels and passing into an infinity of minute granules, which are merely so many casts of smaller cells. That this cellular tissue pervades the whole mass of the placenta, and communicates freely with the uterine vessels by which it is filled with blood, is proved by repeating a very simple experiment of Dr. Hunter, viz. "if a blow-pipe be thrust into the substance of the placenta any where, the air which is blown into the cellular part opens, and rushes out readily by, the open mouths both of the arteries and veins." (Hunter, _op. cit._ p. 46.) That it also envelopes the umbilical vessels of the cord is shown by the fact, that if a pipe be inserted beneath the outer covering of the cord near to its insertion into the placenta, we shall be able to "fill the whole placenta uniformly in its cellular part, and likewise all the venous system of the uterus and decidua, as readily and fully as if we had fixed the pipe in the spermatic or hypogastric vein; so ready a passage is there reciprocally between the cells of the placenta and the uterine vessels." (_Ibid._ p. 47.) The maternal portion of the placenta therefore consists of a spongy cellular tissue, which is filled by the uterine vessels, and also of those trunks which pass through the decidua, and which form the communication between these vessels and the placental cells. [Illustration: _Foetal surface of the placenta._] The foetal surface of the placenta is smooth and glossy, being covered by the amnion and chorion; it is much harder than the uterine surface, and is streaked over by the larger branches of the umbilical vein and arteries, which radiate irregularly from the point where the cord is inserted; and which pass beneath the amnion, and between the two layers of which the chorion is composed, to which they are intimately connected. These vessels supply the various lobuli of which the placenta is composed, so that each lobulus receives at least one of these branches; for, although the umbilical cord consists of two arteries and one vein, this arrangement does not continue into the body of the placenta. "Every branch of an artery," as Dr. Hunter observes, "is attended with a branch of a vein: these cling to one another, and frequently in the substance of the placenta entwine round one another, as in the navel string." (_Ibid._ p. 40.) Each cotyledon receives its own vessels, so that the vessels of one cotyledon have no direct communication with those of the adjacent ones, as proved by Wrisberg's examinations; for if we inject the vessel or vessels of one of these lobuli, the injection will not pass into those of the others. When the vessels have reached the cotyledons, they are divided and subdivided _ad infinitum_; they are connected together by a fine cellular membrane, which may be very easily removed by maceration, and then they may be seen ramifying in the most beautiful and delicate manner possible; the main branches having no communication or anastomosis with each other. The umbilical arteries anastomose freely with each other upon the foetal surface of the placenta, before dividing into the branches above-mentioned; hence, if an injection be thrown into one umbilical artery it will return almost immediately by the other; but if this be tied also, the injection, after a time, will return by the umbilical vein, but not until all the vessels of the placenta have been filled, proving that there is a free passage of blood from the arteries into the veins. From these remarks, founded chiefly on the admirable observations of the Hunters, and repeated examinations of the placenta, which we have made with the greatest care and impartiality, it may be stated with confidence, that the placenta consists of two portions--a maternal and a foetal. The maternal portion consists, as we have before observed, of a spongy cellular tissue; and also of those trunks which pass through the decidua, and which form the communication between the uterine vessels and the placental cells. The foetal part is formed by the ramifications of the umbilical vessels: "that each of those parts has its peculiar system of arteries and veins, and its peculiar circulation, receiving blood by its arteries, and returning it by its veins; that the circulation through these parts of the placenta differs in the following manner: in the umbilical portion the arteries terminate in the veins by a continuity of canal; whereas, in the uterine portion there are intermediate cells into which the arteries terminate, and from which the veins begin." (Hunter, _op. cit._ p. 48.) Although various observations and anatomical injections show that to a certain degree, there is a communication between the uterus and the placenta, inasmuch as the blood of the former is received into the sinuses or cells of the latter, we possess no proof that the blood can pass from these sinuses into the umbilical vessels: on the contrary, every thing combines to prove that the circulation of the foetus is altogether independent of that of the mother. We know from daily experience that in labour at the full term of pregnancy, the placenta is easily expelled from the uterus: that, upon examining the surface which had been attached to the uterus we find no laceration, and that a discharge of more or less blood takes place for some days afterwards. We know, also, that when the placenta becomes detached from the uterus during the progress of gestation, it is followed by a considerable hemorrhage, which greatly endangers the life of the mother. These facts prove that there is a circulation of uterine blood in the placenta, which is destroyed upon its being separated from the uterus. That this uterine circulation in the placenta is unconnected with the circulation of foetal vessels in the placenta is proved by the fact first pointed out by Wrisberg, viz. that, where the mother has died from loss of blood, and the maternal vessels therefore drained of their contents, those of the foetus have been full of blood. Still farther to illustrate this fact, he killed several cows big with calf, by a large wound through the heart or great vessels, so as to ensure the most profuse and sudden loss of blood possible, and never found that the vessels of the calf were deprived of blood, although those of the mother were perfectly empty; moreover, no anatomist has ever yet succeeded in making injections pass from the foetal into the uterine vessels, or _vice versâ_. Lobstein has mentioned a mode of illustrating this fact (_Essai sur la Nutrition du Foetus_,) which is both simple and striking. Upon examining the uterine surface of a placenta which has been expelled at the full term, it presents the appearance of a spongy mass gorged with blood, which may be removed by washing or maceration, and if a placenta thus prepared be injected, the fluids will pass with the greatest facility from the umbilical arteries into the umbilical vein, but not one drop into its cellular structure; it is evident, therefore, that the blood which had filled the intervals between the vessels, and which had been removed by washing and maceration, could not have belonged to the foetus, but must have come from the mother; for if any of the vessels had been ruptured the injection would not have succeeded. In concluding these observations upon the placenta, we may briefly state, that there is the same relation between the umbilical vessels and the maternal blood, which fills the placental cells, as there is between the branches of the pulmonary artery, and the air which fills the bronchial cell.[23] _Umbilical cord._ The umbilical cord, funis, or navel string, is a vascular rope extending between the foetus and placenta, by which they are connected together. It usually arises, as we have before observed, from about the middle of the placenta, and terminates at the umbilical ring of the foetus; it consists of two umbilical arteries and one umbilical vein; the former conveying the blood from the common iliac arteries of the foetus to the cotyledons of the placenta; the latter formed by the union of the collected umbilical veins, on the inner surface of the placenta, and returning this blood to the foetus. In the early periods of pregnancy it also consists of the duct and vessels of the vesicula umbilicalis, the urachus, and more or less of the intestinal canal. The umbilical cord does not present the same form or appearance at every period of gestation; the younger the embryo, the shorter and thicker is the cord; in fact, there are no traces whatever of a cord at first, the embryo adhering, by its lower or caudal extremity, directly to the membranes. By the fifth or sixth week it becomes visible; at this early period the vessels of which it is composed pass from the foetus in a straight direction, but as pregnancy advances they become more or less spiral, winding round each other, and usually from left to right: according to Meckel, they take the opposite direction much less frequently, viz. in the proportion of one to nine. The vessels of the umbilical cord are imbedded in a thick viscid substance; upon minute examination, it will be found to consist of a very fine cellular tissue, containing an albuminous matter which slowly exudes, when pressed between the fingers. This cellular tissue itself may be demonstrated by the inflation of air or injection with mercury: it seems to accompany the umbilical vessels as far as the posterior surface of the peritoneum; and Lobstein is of opinion that it is a continuation of the cellular tissue, which covers this membrane. (Lobstein, _sur la Nutrition du Foetus_. § 75.) Externally, the umbilical cord is covered by a continuation of the amnion, which, although it be the inner membrane of the ovum, is the outer covering of the cord: in some places it is very thick and strong, and not easily ruptured. From repeated observations, the weakest part of the cord seems to be at about three or four inches distant from the umbilicus, this being the spot where it has invariably given way in every case we have seen, where the cord has been broken at the moment of the child's birth. From the time of the commencement to the full time of utero-gestation, the cord becomes gradually longer, so that it attains an average length of from eighteen to twenty inches; this, however, varies remarkably. We have known the cord exceed forty inches; and a case is described by Baudelocque, where it was actually fifty-seven inches long: on the other hand, it is sometimes not more than four or five inches in length. It is remarkable that the cord, which at the end of pregnancy is usually of about the same length as the foetus, is relatively much longer during the sixth month; hence we may conclude, that in those cases where knots have been found upon the cord, the knot must have been formed at this period when the foetus was small enough to pass through a coil of it. Neither blood-vessels nor lymphatics have as yet been found in the structure of the cord itself. A filament of nerve from the solar plexus has been occasionally seen passing through the umbilical ring, and extending to a distance down the cord. The vesicula umbilicalis and allantois, being essentially connected with the earliest grades of foetal development, will be considered under that head. _Embryo._ There is, perhaps, no department of physiology which has been so remarkably enriched by recent discoveries, as that which relates to the primitive development of the ovum and its embryo. The researches of Baer, Rathke, Purkinje, Valentin, &c. in Germany; of Dutrochet, Prevost, Dumas, and Coste, &c. in France; and of Owen, Sharpey, Allen Thomson, Jones, and Martin Barry in England, but more especially those of the celebrated Baer, have greatly advanced our knowledge of these subjects, and led us deeply into those mysterious processes of Nature which relate to our first origin and formation. These researches have all tended to establish one great law, connected with the early development of the human embryo, and that of other mammiferous animals, viz, that it at first possesses a structure and arrangement analogous to that of animals in a much lower scale of formation: this observation also applies of course to the ovum itself, since a variety of changes take place in it after impregnation, before a trace of the embryo can be detected. At the earliest periods, the human ovum bears a perfect analogy to the eggs of fishes, amphibia, and birds; and it is only by carefully examining the changes produced by impregnation in the ova of these lower classes of animals, that we have been enabled to discover them in the mammalia and human subject. As the bird's egg, from its size, best affords us the means of investigating these changes, and as in all essential respects they are the same in the human ovum, it will be necessary for us to lay before our readers a short account of its structure and contents, and also of the changes which they undergo, after impregnation. In doing this we shall merely confine ourselves to the description of what is applicable to the human ovum. [Illustration: _Section of a hen's egg within the ovary._ _a_ The granulary membrane forming the periphery of the yelk. _b_ Vesicle of Purkinje imbedded in the cumulus. _c_ Vitellary membrane. _d_ Inner and outer layers of the capsule of the ovum. _e_ Indusium of the ovary.] The egg is known to consist of two distinct parts, the vitellus or yelk surrounded by its albumen or white; to the former of these we now more particularly refer. The yelk is a granular albuminous fluid, contained in a granular membranous sac (the _blastodermic membrane_) which is covered by an investing membrane called the _vitelline membrane_ or _yelk-bag_. The impregnated vitellus is retained in its capsule in the ovary, precisely as the ovum of the mammifera is in the Graafian vesicle. The whole ovary in this case has a clustered appearance, like a bunch of grapes, each capsule being suspended by a short pedicle of indusium. [Illustration: _a_ Vitelline membrane _b_ Blastoderma. _From T. W. Jones._] In those ova which are considerably developed before impregnation, the granular blastermodic membrane is observed to be thicker, and the granules more aggregated at that part which corresponds to the pedicle, forming a slight elevation with a depression in its centre, like the cumulus in the proligerous disc of a Graafian vesicle. This little disc is the blastoderma, germinial membrane or cicatricula; in the central depression just mentioned is an exceedingly minute vesicle first noticed by Professor Purkinje of Breslau, and named after him: in more correct language it is the _germinal vesicle_. According to Wagner, the germinal vesicle is not surrounded by a disc before impregnation; and it is only after this process that the above-mentioned disc of granules is formed. By the time the ovum is about to quit the ovary the vesicle itself has disappeared, so that an ovum has never been found in the oviduct containing a germinal vesicle, nothing remaining of it beyond the little depression in the cumulus of the cicatricula. The rupture of the Purkinjean or germinal vesicle has been supposed by Mr. T. W. Jones to take place before impregnation; but the observations of Professor Valentin seem to lead to the inference that it is a result of that process, and must be therefore looked upon as one of the earliest changes which take place in the ovum or yelk-bag upon quitting the ovary.[24] During its passing through the oviduct (what in mammalia is called the Fallopian tube,) the ovum receives a thick covering of albumen, and as it descends still farther along the canal the membrane of the shell is formed. On examining the appearance of the ovum in mammiferous animals, and especially the human ovum, it will be found that it presents a form and structure very analogous to the ova just described, more especially those of birds. It is a minute spherical sac, filled with an albuminous fluid, lined with its blastodermic or germinal membrane, in which is seated the germinal vesicle or vesicle of Purkinje. When the ovum has quitted the ovary the germinal vesicle disappears, and on its entering the Fallopian tube it becomes covered with a gelatinous, or rather albuminous covering. This was inferred by Valentin, who considered that "the enormous swelling of the ova, and their passage through the Fallopian tubes," tended to prove the circumstance. (_Edin. Med. and Surg. Journ._ April, 1836.) It has since been demonstrated by Mr. T. W. Jones in a rabbit seven days after impregnation. The vitellary membrane seems, at this time, to give way, leaving the vitellus of the ovum merely covered by its spherical blastoderma, and encased by the layer of albuminous matter which surrounds it. From what we have now stated, a close analogy will appear between the ova of the mammalia and those of the lower classes, more especially birds, which from their size afford us the best opportunities of investigating this difficult subject. In birds, the covering of the vitellus is called _yelk-bag_; whereas, in mammalia and man it receives the name of _vesicula umbilicalis_. Its albuminous covering, which corresponds to the white and membrane of the shell in birds, is called _chorion_: by the time that the ovum has reached the uterus, this outer membrane has undergone a considerable change; it becomes covered with a complete down of little absorbing fibrillæ, which rapidly increase in size as development advances, until it presents that tufted vascular appearance, which we have already mentioned when describing this membrane. The first or primitive trace of the embryo is in the cicatricula or germinal membrane, which contained the germinal vesicle before its disappearance. In the centre of this, upon its upper surface, may be discovered a small dark line;[25] "this line or primitive trace is swollen at one extremity, and is placed in the direction of the transverse axis of the egg." [Illustration: _a_ Transparent area. _b_ Primitive trace.] As development advances, the cicatricula expands. "We are indebted to Pander,"[26] says Dr. Allen Thomson in his admirable essay above quoted, "for the important discovery, that towards the twelfth or fourteenth hour, in the hen's egg the germinal membrane becomes divided into two layers of granules, the serous and mucous layers of the cicatricula; and that the rudimentary trace of the embryo, which has at this time become evident, is placed in the substance of the upper-most or serous layer." "According to this observer, and according to Baer, the part of this layer which surrounds the primitive trace soon becomes thicker; and on examining this part with care, towards the eighteenth hour, we observe that a long furrow has been formed in it, in the bottom of which the primitive trace is situated; about the twentieth hour this furrow is converted into a canal open at both ends, by the junction of its margins (the _plicæ primitivæ_ of Pander, the _laminæ dorsales_ of Baer:) the canal soon becomes closed at the cephalic or swollen extremity of the primitive trace, at which part it is of a pyriform shape, being wider here than at any other part. According to Baer and Serres, some time after the canal begins to close, a semi-fluid matter is deposited in it, which on its acquiring greater consistence, becomes the rudiment of the spinal cord; the pyriform extremity or head is soon after this seen to be partially subdivided into three vesicles, which being also filled with a semi-fluid matter, gives rise to the rudimentary state of the encephalon." "As the formation of the spinal canal proceeds, the parts of the serous layer which surrounds it, especially towards the head, become thicker and more solid, and before the twenty-fourth hour we observe on each side of this canal four or five small round opaque bodies, these bodies indicate the first formation of the dorsal vertebræ. [Illustration: _a_ Transparent area. _b_ Laminæ dorsales. _c_ Cephalic end. _d_ Rudiments of dorsal vertebræ. _e_ Serous layer. _f_ Lateral portion of the primitive trace. _g_ Mucous layer. _h_ Vascular layer. _k_ Laminæ dorsales united to form the spinal canal.] "About the same time, or from the twentieth to the twenty-fourth hour, the inner layer of the germinal membrane undergoes a farther division, and by a peculiar change is converted into the vascular mucous layers." (A. Thomson, _op. cit._) It will thus be seen, that the germinal membrane is that part of the ovum in which the first changes produced by impregnation are observed. The rudiments of the osseous and nervous systems are formed by the outer or serous layers; the outer covering of the foetus or integuments, including the amnois, are also furnished by it. "The layer next in order has been called _vascular_, because in it the development of the principal parts of the vascular system appears to take place. The third, called the _mucous_ layer, situated next the substance of the yelk, is generally in intimate connexion with the vascular layer, and it is to the changes which these combined layers undergo, that the intestinal, the respiratory, and probably also the glandular systems owe their origin." (A. Thomson, _op. cit._ p. 298.) [Illustration: _a_ Serous layer. _b c_ Vascular layer. _d_ Mucous layer. _e_ Heart.] The embryo is therefore formed in the layers of the germinal membrane, and becomes, as it were, spread out upon the surface of the ovum: the changes which the ovum of mammalia undergoes appear from actual observation, to be precisely analogous to those in the inferior animals. (_Baer_, _Prevost_ and _Dumas_.) From the primitive trace, which was at first merely a line crossing the cicatricula, and which now begins rapidly to exhibit the characters of the spinal column, the parietes of the head and trunk gradually approach farther and farther towards the anterior surface of the abdomen and head until they unite; in this way the sides of the jaws close in the median line of the face, occasionally leaving the union incomplete, and thus appearing to produce in some cases the congenital defects of hare-lip and cleft palate. In some way the ribs meet at the sternum; and it may be supposed that sometimes this bone is left deficient, and thus may become one of the causes of those rare cases of malformation, where the child has been born with the heart external to the parietes of the thorax. In like manner the parietes of the abdomen and pelvis close in the linea alba and symphysis pubis, occasionally leaving the integuments of the navel deficient, or, in other words, producing congenital umbilical hernia, or at the pubes a non-union of its symphysis with a species of inversion of the bladder, the anterior wall of that viscus being nearly or entirely wanting. The cavity of the abdomen is therefore at first open to the vesicula umbilicalis or yelk, but this changes as the abdominal parietes begin to close in; in man and the mammalia merely a part of it, as above mentioned, forms the intestinal canal, whereas, in oviparous animals the whole of the yelk-bag enters the abdominal cavity, and serves for an early nutriment to the young animal. Another change connected with the serous or outer layer of the germinal membrane is the formation of the _amnion_. The foetal rudiment which from its shape has been called _carina_, now begins to be enveloped by a membrane of exceeding tenuity, forming a double covering upon it; the one which immediately invests the foetus is considered to form the future epidermis; the other, or outer fold, forms a loose sac around it, containing the liquor amnii. Whilst these changes are taking place in the serous layer of the germinal membrane, and whilst the intestinal canal, &c. are forming on the anterior surface of the embryo, which is turned towards the ovum, by means of the inner or mucous layer, equally important changes are now observed in the middle or vascular layer. "In forming this fold," says Dr. A. Thomson, "the mucous layer is reflected farthest inwards; the serous layer advances least, and the space between them, occupied by the vascular layer, is filled up by a dilated part of this layer, the rudiment of the heart." (_Op. cit._ p. 301.) Whilst this rudimentary trace of the vascular system is making its appearance, minute vessels are seen ramifying over the vesicula umbilicalis, forming, according to Baer's observations, a reticular anastomosis, which unites into two vessels the vasa omphalo-meseraica. (_British and Foreign Med. Rev._ No. 1.) These may be demonstrated with great ease in the chick: the cicatricula increases in extent; it becomes vascular, and at length forms a heart-shaped net-work of delicate vessels, which unite into two trunks, terminating one on each side of the abdomen. [Illustration: _b_ Is a portion of the convexity of the amnion, upon which, at _a_ is the fundus of the diminutive human allantois. _c_ The duct of the vesicula umbilicalis, dividing into two intestinal portions; and besides this duct are two vessels which are distributed upon the vesicula umbilicalis, and form a reticular anastomosis with each other. _From Baer._] The umbilical vesicle now begins to separate itself more and more from the abdomen of the foetus, merely a duct of communication passing to that portion of it which forms the intestinal canal. The first rudiment of the cord will be found at this separation; its foetal extremity remains for a long time funnel-shaped, containing, besides a portion of intestine, the duct of the vesicula umbilicalis, the vasa omphalo-meseraica (the future vena portæ,) the umbilical vein from the collected venous radicles of the chorion, and the early trace of the umbilical arteries. These last-named vessels ramify on a delicate membranous sac of an elongated form which rises from the inferior or caudal extremity of the embryo, viz. the _allantois_; whether this is formed by a portion of the mucous layer of the germinal vesicle, in common with the other abdominal viscera, appears to be still uncertain: in birds this may be very easily demonstrated as a vascular vesicle, arising from the extremity of the intestinal canal; and in mammalia, connected with the bladder by means of a canal called _urachus_: from its sausage-like shape, it has received the name of _allantois_. The existence of an allantois in the human embryo has been long inferred from the presence of a ligamentous cord extending from the fundus of the bladder to the umbilicus, like the urachus in animals. But from the extreme delicacy of the allantois, and from its function ceasing at a very early period, it had defied all research, until lately when it has been satisfactorily demonstrated in the human embryo by Baer and Rathke. It occupies the space between the chorion and amnion, and gives rise occasionally to a collection of fluid between these membranes, familiarly known by the name of the liquor amnii spurius, which, strictly speaking is the liquor allantoidis. The function of the allantois is still in a great measure unknown. In animals it evidently acts as a species of receptaculum urinæ during the latter periods of gestation; but it is very doubtful if this be its use during the earlier periods. It does not seem directly connected with the process of nutrition, which at this time is proceeding so rapidly, first by means of the albuminous contents of the vitellus, or vesicula umbilicalis, and afterwards by the absorbing radicles of the chorion; but, from analogy with the structure of the lower classes of animals, it would appear that it is intended to produce certain changes in the rudimentary circulation of the embryo, similar to those which, at a later period of pregnancy, are effected by means of the placenta, and after birth by the lungs, constituting the great functions of respiration. In many of the lower classes of animals, respiration (or at least the functions analogous to it) is performed by organs situated at the inferior or caudal extremity of the animal: thus for instance, certain insect tribes, as in hymenoptera, or insects with a sting, as wasps, bees, &c.; in diptera, or insects with two wings, as the common fly; and also the spider tribe, have their respiratory organs situated in the lower part of the abdomen. In some of the crustacea, as, for instance, the shrimp, the organs of respiration lie under the tail between the fins, and floating loosely in the water. Again, some of the molusca, viz. the cuttle-fish, have the respiratory organs in the abdomen. We also know that many animals, during the first periods of their lives, respire by a different set of organs to what they do in the adult state: the most familiar illustration of this is the frog, which, during its tadpole state, lives entirely in the water. [Illustration: _a_ Bronchial processes. _b_ Vesicula umbilicalis. _c_ Vitellus. _d_ Allantois. _e_ Amnion. _From Baer._] As the growth of the embryo advances, other organs whose function is as temporary as that of the allantois, make their appearance: these also correspond to the respiratory organs of a lower class of animals, although higher than those to which we have just alluded,--we mean bronchial processes or gills. It is to Professor Rathke (_Acta Naturæ Curios._ vol. xiv,) that we are indebted for pointing out the interesting fact, that several transverse slit-like apertures may be detected on each side the neck of the embryo, at a very early stage of development. In the chick, in which he first observed it, it takes place about the fourth day of incubation: at this period the neck is remarkably thick, and contains a cavity which communicates inferiorly with the oesophagus and stomach, and opens externally on each side by means of the above-mentioned apertures, precisely as is observed in fishes, more especially the shark tribe; these apertures are separated from each other by lobular septa, of exceedingly soft and delicate structure. Rathke observed the same structure in the embryo of the pig and other mammalia; and Baer has since shown it distinctly in the human embryo. It is curious to see how the vascular system corresponds to the grade of development then present: the heart is single, consisting of one auricle and one ventricle; the aorta gives off four delicate, but perfectly simple branches, two of which go to the right, and two to the left side; each of these little arteries passes to one of the lobules or septa at the side of the neck, which correspond to gills, and having again united with the three others, close to what is the first rudiment of the vertebral column, they form a single trunk which afterwards becomes the abdominal aorta. In a short time these slit-like openings begin to close; the bronchial processes or septa become obliterated, and indistinguishable from the adjacent parts; the heart loses the form of a single heart; a crescentic fold begins to mark the future division into two ventricles, and gradually extends until the septum between them is completed. It is also continued along the bulb of the aorta, dividing it into two trunks, the aorta proper and pulmonary artery; at the upper part the division is left incomplete, so that there is an opening from one vessel to the other, which forms the ductus arteriosus.[27] A similar process takes place in the auricles, the foramen ovale being apparently formed in the same manner as the ductus arteriosus; these changes commence in the human embryo about the fourth week, and are completed about the seventh. At first the body of the embryo has a more elongated form than afterwards, and the part which is first developed is the trunk, at the upper extremity of which a small prominence less thick than the middle part, and separated from the rest of the body by an indentation, distinguishes the head. There are as yet no traces whatever of extremities, or of any other prominent parts; it is straight, or nearly so, the posterior surface slightly convex, the anterior slightly concave, and rests with its inferior extremity directly upon the membranes, or by means of an extremely short umbilical cord. The head now increases considerably in proportion to the rest of the body, so much so, that at the beginning of the second month, it equals nearly half the size of the whole body: previous to, and after this period, it is usually smaller. The body of the embryo becomes considerably curved, both at its upper as well as its lower extremity, although the trunk itself still continues straight. The head joins the body at a right angle, so that the part of it which corresponds to the chin is fixed directly upon the upper part of the breast; nor can any traces of neck be discerned, until nearly the end of the second month. The inferior extremity of the vertical column, which at first resembles the rudiment of a tail becomes shorter towards the middle of the third month, and takes a curviture forwards under the rectum, in the fifth week the extremities become visible, the upper usually somewhat sooner than the lower, in the form of small blunt prominences. The upper close under the head, the lower near the caudal extremity of the vertebral column. Both are turned somewhat outwards, on account of the size of the abdomen; the upper are usually directed somewhat downwards, the lower ones somewhat upwards. [Illustration: _Diagram of the foetus and membranes about the fourth week._ _a_ Vesicula umbilicalis already passing into the ventricular and rectum intestine at _g_. _b_ Vena and arteria omphalo-meseraica. _c_ Allantois springing from the pelvis with the umbilical arteries. _d_ Embryo. _e_ Amnion. _f_ Chorion. _From Carus._] The vesicula umbilicalis may still be distinguished in the second month as a small vesicle, not larger than a pea, near the insertion of the cord, at the navel, and external to the amnion. From the trunk, which is almost entirely occupied by the abdominal cavity, arises a short thick umbilical cord, in which some of the convolutions of the intestines may still be traced. Besides these it usually contains, as already observed, the two umbilical arteries and the umbilical vein, the urachus, the vasa omphalo-meseraica, or vein and artery of the vesicula umbilicalis, and perhaps, even at this period, the duct of communication between the intestinal canal and vesicula umbilicalis, the foetal extremity of which, according to Professor Oken's views, forms the processus vermiformis. [Illustration: _Diagram of the foetus and membranes about the sixth week._ _a_ Chorion. _b_ The larger absorbent extremities, the site of the placenta. _c_ Allantois. _d_ Amnion. _e_ Urachus. _é_ Bladder. _f_ Vesicula umbilicalis. _g_ Communicating canal between the vesicula umbilicalis and intestine. _h_ Vena umbilicalis. _i i_ Arteriæ umbilicales. _l_ Vena omphalo-meseraica. _k_ Arteria omphalo-meseraica. _n_ Heart. _o_ Rudiment of superior extremity. _p_ Rudiment of lower extremity. _From Carus._] The hands seem to be fixed to the shoulders without arms, and the feet to adhere to the ossa illi; the liver seems to fill the whole abdomen; the ossa innominata, the ribs, and scapulæ are cartilaginous. In a short time the little stump-like prominences of the extremities become longer, and are now divided into two parts, the superior into the hand and the fore arm, the inferior into the foot and leg; in one or two weeks later, the arms and thighs are visible. These parts of the extremities which are formed later than the others, are at first smaller, but as they are gradually developed they become larger. When the limbs begin to separate into an upper and lower part, their extremities become rounder and broader, and divided into the fingers and toes, which at first are disproportionately thick, and until the end of the third month are connected by a membranous substance analogous to the webbed feet of water birds; this membrane gradually disappears, beginning at the extremities of the fingers and toes, and continuing the division up to their insertion. The external parts of generation, the nose, ears, and mouth appear after the development of the extremities. The insertion of the umbilical cord changes its situation to a certain degree; instead of being nearly at the inferior extremity of the foetus as at first, it is now situated higher up on the anterior surface of the abdomen. The comparative distance between the umbilicus and pubis continues to increase, not only to the full period of gestation, when it occupies the middle point of the length of the child's body, as pointed out by Chaussier, but even to the age of puberty, from the relative size of the liver becoming smaller. Though the head appears large at first, and for a long time continues so, yet its contents are tardy in their development, and until the sixth month the parietes of the skull are in great measure membranous or cartilaginous. Ossification commences in the base of the cranium, and the bones under the scalp are those in which this process is last completed. The contents of the scull are at first gelatinous, and no distinct traces of the natural structure of the brain can be identified until the close of the second month; even then it requires to have been sometimes previously immersed in alcohol to harden its texture. There are many parts of it not properly developed until the seventh month. In the medulla spinalis no fibres can be distinguished until the fourth month. The thalami nervorum opticorum, the corpora striata, and tubercula quadrigemina, are seen in the second month; in the third, the lateral and longitudinal sinuses can be traced, and contain blood. In the fifth we can distinguish the corpus callosum; but the cerebral mass has yet acquired very little solidity, for until the sixth month it is almost semi-fluid. (Campbell's _System of Midwifery_.) About the end of the third, during the fourth, and the beginning of the fifth months, the mother begins to be sensible of the movements of the foetus. These motions are felt sooner or later, according to the bulk of the child, the size and shape of the pelvis, and the quantity of fluid contained in the amnion, the waters being in larger proportionate quantity the younger the foetus. The secretion of bile, like that of the fat, seems to begin towards the middle of pregnancy, and tinges the meconium, a mucous secretion of the intestinal tube which had hitherto been colourless, of a yellow colour. Shortly after this the hair begins to grow, and the nails are formed about the sixth or seventh month. A very delicate membrane (membrana pupillaris,) by which the pupil has been hitherto closed, now ruptures, and the pupil becomes visible. The kidneys, which at first were composed of numerous glandular lobules (seventeen or eighteen in number,) now unite, and form a separate viscus on each side of the spine; sometimes they unite into one large mass, an intermediate portion extending across the spine, forming the horse-shoe kidney. Lastly, the testes, which at first were placed on each of the lumbar vertebræ, near the origin of the spermatic vessels, now descend along the iliac vessels towards the inguinal rings, directed by a cellular cord, which Hunter has called _Gubernaculum testis_: they then pass through the openings carrying before them that portion of the peritoneum which is to form their tunica vaginalis. The length of a full-grown foetus is generally about eighteen or nineteen inches; its weight between six and seven pounds. The different parts are well developed and rounded; the body is generally covered with the vernix caseosa;[28] the nails are horny, and project beyond the tips of the fingers, which is not the case with the toes; the head has attained its proper size and hardness; the ears have the firmness of cartilage; the scrotum is rugous, not peculiarly red, and usually containing the testes. In female children the nymphæ are generally covered entirely by the labia, the breasts project, and in both sexes frequently contain a milky fluid. As soon as a child is born, which has been carried the full time, it usually cries loudly, opens its eyes, and moves its arms and legs briskly; it soon passes urine and fæces, and greedily takes the nipple. (Naegelé's _Hebammenbuch_.) Thus, then, in the space of forty weeks, or ten lunar months, from an inappreciable point, the foetus attains a medium length of about eighteen or nineteen inches, and a medium weight of between six and seven pounds. As these observations on the development of the ovum show that the structural arrangement of the embryo undergoes a succession of changes, by which it gradually rises from the lowest to the highest scale of formation, so we shall find it furnished with a succession of means for its nutrition, each corresponding more or less to the particular grade of development which it may have attained. Its earliest source of nourishment is doubtless the vitellus, or albuminous contents of the vesicula umbilicalis. The radicle or primitive trace, in this respect, bears a strong analogy to the seed of a plant; it brings with it its own supply of nourishment for its first stage of growth; in the latter, the cotyledons afford nourishment to the little plumula, until, by the formation of roots and absorption of moisture from the surrounding soil, it is enabled to support the early rudiment of the future plant. The early function of the chorion is very analogous to that of roots; it is an absorbing apparatus, collecting nourishment by means of its numerous absorbing fibrillæ: hence, according to Lobstein, the umbilical vein exists for some time previous to the umbilical arteries, and seems to perform an office in the foetus similar to that of the thoracic duct at a later period; its radicles or absorbing extremities seem to absorb a milky fluid, which after the first two months is found in the placenta, and which must be looked upon as a means of nourishment which does not exist in the latter months. This milky fluid was noticed by Leroux, who even then expressed his doubts, whether the radicles of the umbilical vein receive blood from the mother, or whether they only serve to absorb a white fluid which resembles chyle. In some manuscript notes of Dr. Young's lectures, which were taken by the late Dr. Parry, of Bath, when a student at Edinburgh, we find the following observation: "There is evidently in the placenta, besides blood-vessels, some other substance, which serves to absorb juices from the uterus, and to convert these into a chylous matter proper to nourish the foetus, and this matter is absorbed by the umbilical veins. This seems to be proved from the consideration of the placenta of animals which have cotyledons; for, on squeezing these glandular substances, we force out a sort of chylous liquor, and these are surrounded by the placenta, which absorb their liquor and convey it to the foetus." The absorbing power of the umbilical vein continues till the fifth month; during the second or third, the foetus receives a good deal of nourishment from the liquor amnii, which at this period contains a considerable quantity of albuminous matter; this diminishes in the latter months of pregnancy. Moreover the body of the foetus begins to be covered with the vernix caseosa towards the seventh month, so that in the eighth and ninth months the absorption of liquor amnii by the skin is considerably impeded. How far the full formed placenta, as seen after the fifth month, serves as a means of nutrition to the foetus, may still be a matter of doubt; its chief use after this period is, as we have already shown, for the purpose of producing certain changes in the blood of the foetus analogous to those of respiration;[29] still, however, it would seem that its function of nutrition is not entirely at an end, even at a late period of pregnancy. The numerous little granules of phosphate of lime, which are frequently found on the uterine surface of a full-grown placenta at a time when ossification is rapidly advancing in the foetal skeleton, would surely lead us to infer that the placenta in some way or other supplies the materials for this process. _Foetal circulation._ We have already shown, that, in the early stages of development, the heart of the embryo is single, consisting of one auricle and one ventricle; that a septum gradually divides these into two parts until the double heart is formed, leaving two openings of communication between the right and left sides, the one between the auricles called the _foramen ovale_, the other between the pulmonary artery and aorta, viz. the _ductus arteriosus_. From these and other peculiarities it will be seen that the foetal circulation differs essentially from that of a child after birth; and, in order to comprehend the nature and mechanism of the changes which take place in it when respiration first commences, it will be necessary that these peculiarities should be thoroughly understood. The condition of the foetus must also be remembered: surrounded by the liquor amnii, the foetus does not respire; its lungs have as yet been unemployed; they are therefore small and collapsed, and present a firm solid mass, nearly resembling liver in appearance. In this state but little blood from the pulmonary arteries can circulate through them; for, as the extreme ramifications of these vessels are distributed upon the mucous membrane lining the bronchi and air-cells, the free passage of blood through them will in great measure depend upon a previous condition of the air-cells. The pulmonary arteries in the foetal state are therefore small, and transmit but a small quantity of blood into their numerous ramifications, just sufficient to keep pervious these vessels which after birth are to be so greatly distended: in this state the lungs when thrown into water sink. Hence, as the pulmonary arteries do not afford a sufficiently free exit to the contents of the right side of the foetal heart, nature has provided it with a peculiar means for carrying off the overplus quantity of blood, which is poured into the right auricle from the vena cava. This is attained first by the _foramen ovale_, an oval-shaped opening in the septum between the right and left auricles, and furnished with a semilunar valvular flap, so constructed, as to allow a free passage for the blood from the right to the left auricle, but none in the contrary direction. By this means a considerable quantity of blood is transmitted at once from the right to the left auricle, and, consequently, much less into the right ventricle and pulmonary artery. Still, however, more blood passes into the right ventricle than the pulmonary artery, in the collapsed state of the foetal lungs, is capable of conveying away. The pulmonary artery is therefore continued beyond its bifurcation into the aorta at its curvature, by means of the _ductus arteriosus_, which, in the full-grown foetus, forms a short thick passage between these two vessels; and in this manner is the right ventricle enabled to get rid of its surplus quantity of blood. Thus we see that the foetal heart although consisting of two auricles and two ventricles, continues to perform the functions only of a single heart, both ventricles assisting simultaneously to propel the same column of blood, viz. that of the aorta, and thus enabling the heart to act with considerable power. The chief part of the blood, which flows through the iliac arteries, instead of being sent to the inferior extremities, is carried into the umbilical arteries, which passing up along the sides of the bladder meet the umbilical vein at the navel, and thus form the vessels of the umbilical cord. These arteries convey the blood of the foetus to the placenta, where, having undergone changes to which we have already alluded, it is returned by the umbilical vein. This vessel, which afterwards forms the round ligament of the liver, passes through the umbilicus along the anterior edge of the suspensory ligament; it supplies the left lobe with blood, and having given off a communicating branch to the vena portæ, which supplies the right lobe, it passes at once by a short passage, called _canalis venosus_, into the vena cava. Thus, then, the peculiarities of the foetal circulation may be considered as four, viz. the _foramen ovale_, or passage from the right to the left auricle; the _ductus arteriosus_, or communication from the bifurcation of the pulmonary artery into the arch of the aorta; the _umbilical arteries_ arising from the iliac arteries, and carrying the blood along the cord into the placenta; and, lastly, the _canalis venosus_, or passage between the umbilical vein and vena cava. Let us now examine the changes which take place in the foetal circulation at the moment of the child's birth. The child, which had hitherto been immersed in the bland and warm medium of the liquor amnii, is at once exposed to the action of the external air. By means of the sympathy existing between the skin and respiratory muscles, sudden and convulsive efforts at inspiration take place; the air-cells of the lungs become partially inflated, and, after a short time as the respiration increases in power and activity, become distended throughout their whole extent. The thorax rises; the flaccid diaphragm, which hitherto had been pushed up by the large foetal liver, now contracts, pressing down the liver into its natural situation. The lungs, from being a hard solid heavy substance, resembling liver, at once become inflated, elastic, and crepitous, light and permeable to air in every part. The capillary terminations of the pulmonary artery, which ramify in the mucous membrane, forming the parietes of the air-cells, and which hitherto had been firmly compressed by the collapsed state of the foetal lungs, are suddenly rendered pervious throughout their whole extent. By this means, a vacuum, as it were, is formed in the ramifications of the pulmonary artery; each inspiration is accompanied by a rush of blood from the right ventricle into the newly-inflated structure. The pulmonary artery, at its bifurcation, swells and becomes turgid: the blood is carried off into its numerous ramifications as fast as the right ventricle can supply it; this may be easily understood from the law, in anatomy, viz. that the area of two arteries is greater than that of the trunk from which they bifurcate. From this state of distension, the distance between the pulmonary artery and the aorta is increased; the ductus arteriosus, which has now become empty, is stretched, and thus partially closed; the right auricle, which, but for the foramen ovale, could not have cleared itself of the whole quantity of blood which was poured into it from the vena cava, is now enabled to transmit its entire contents into the right ventricle; the left auricle, which before birth was supplied only by the foramen ovale from the right auricle, is now rapidly filled by the blood brought into it by the four pulmonary veins;--the equilibrium between the two auricles becomes altered;--the right, which hitherto had been somewhat gorged with blood, is now able to clear itself with facility; whereas, the left, which was but partially supplied, is now distended with a much greater quantity: there is now rather a disposition for the blood to regurgitate from the left to the right auricle; this, however, is prevented by the semilunar fold of the foramen ovale, which now acts as a valve, and generally becomes firmly attached to the septum. The obliteration of the canalis venosus at the posterior margin of the liver, and of the umbilical vein at the anterior edge, may, we think, be explained by the changes which necessarily follow the inflation of the lungs: the diaphragm, when it contracts, pulls down the liver into its natural situation; the distance, therefore, between the liver and the heart is increased, and the canalis venosus is consequently stretched, and considerably pressed upon, and precisely the same results follow with the umbilical vein. PART II NATURAL PREGNANCY AND ITS DEVIATIONS. CHAPTER I. SIGNS OF PREGNANCY. _Difficulty and importance of the subject.--Diagnosis in the early months.--Auscultation.--Changes in the vascular and nervous systems.--Morning sickness.--Changes in the appearance of the skin.--Cessation of the menses.--Areola.--Sensation of the child's movements.--"Quickening."--Ausculation.--Uterine souffle.--Sound of the foetal heart.--Funic souffle.--Sound produced by the movements of the foetus.--Ballottement.--State of the uterine.--Violet appearance of the mucous membrane of the vagina.--Cases of doubtful pregnancy.--Diagnosis of twin pregnancy._ There is, perhaps, no subject connected with midwifery, which is of such importance, or which, from its difficulty and the serious questions it involves, demands such attentive consideration, and requires so familiar an acquaintance with every part of it, as the diagnosis of pregnancy. The responsibility which a medical man incurs in deciding cases of doubtful pregnancy, and in thus giving an opinion which may not only affect the fortune, happiness, character, but even life itself of the individual concerned, is rendered more painful by the perplexing obscurity of the circumstances under which these cases sometimes occur, being not unfrequently complicated with diseases which add still farther to the difficulty of coming at the truth, and occasionally rendered peculiarly obscure by wilful and determined falsehood and duplicity. To render this subject more intelligible to our readers, we propose first to consider the general effects which pregnancy produces upon the system, and then to describe those changes and phenomena which are _peculiar_ to this state, and which may therefore be taken as so many means of diagnosis. Under all circumstances, the diagnosis of pregnancy must ever be difficult and obscure during the early months; the development of the uterus is still inconsiderable, and the effects which it may have produced upon the system, although appreciable and even distinct, are nevertheless too capable of being also produced by other causes, to warrant our drawing any decided conclusion from them. The effects over the whole animal economy, which result from the presence and advance of this great process, are very remarkable, and show themselves in every portion of it. The vascular system undergoes a considerable change; the actual quantity of blood in the circulation appears to be increased; the pulse is harder, stronger, and more full; in many instances the blood, when drawn, exhibits the buffy coat, as in cases of inflammation; the vagina is more vascular, it is warmer, and the secretion of mucus considerably increased; there is a disposition to headach, and occasional flushing of the face; the animal heat over the whole body is increased. In the nervous system we also observe distinct evidences of a change having taken place: the irritability is increased; there is weariness, lassitude, and a peculiar alteration of taste and disposition; women, who otherwise are of a cheerful disposition, are now gloomy and reserved, and _vice versâ_; in some the temper becomes fretful and hasty, and in those who are naturally so, a most agreeable change for the better is sometimes observed.[30] Some are liable to spasmodic affections, palpitations, spasmodic cough, vomiting, fainting, headach, toothach, &c.: under this head will come the "morning sickness," which is so commonly observed during the first weeks; the nature and treatment of which will be considered under the DISEASES OF PREGNANCY; on the other hand, women who are constantly suffering from spasmodic affections, for instance, asthma, &c. are now entirely free from them, and appear to be insensible to causes which, in the unimpregnated state, would induce an attack. To changes in the nervous system must we, in great measure, attribute not only the sickness just mentioned, but also those extraordinary longings or antipathies for certain articles of food or drink, and in some cases, as in chlorosis, for substances which, under other circumstances, would excite disgust. In many, the changes in the function of the digestive apparatus does not amount to actual disease, the stomach merely refusing to digest articles of food which before had agreed with it: but in others, producing severe cardialgia, acidity, or even vomiting. Hence, we not unfrequently observe that women who had hitherto enjoyed a good digestion, now suffer from dyspepsia, and are obliged to be exceedingly careful in their diet; whereas those, in whom the digestion had been previously weak, are now able to digest almost any thing. The secretions of the whole alimentary canal are altered both in quality and quantity; the saliva frequently becomes tenacious, white, and frothy (_Dewees_,) and at times is so much increased in quantity as to amount to actual salivation; the secretions of the stomach are remarkably altered, as shown by the copious formation of acid in some cases during pregnancy; the mucus is ropy, and frequently vomited up in considerable quantities. The bowels are in some cases much relaxed; in others, constipated. This latter condition, however, may in part be attributed to the pressure of the gravid uterus obstructing the peristaltic motion. The changes in the appearance of the skin during pregnancy are also worthy of notice. Women, who are naturally pale and of a delicate complexion, have frequently a high colour, and _vice versâ_; in some the skin assumes a sallow or cadaverous hue; copper-coloured blotches appear on the face and forehead: in others the skin appears loose and wrinkled, giving the patient an aged haggard expression, and destroying her good looks. Mole spots become darker and larger, and these, with a dark ring beneath the eyes and the changes already mentioned, combine to alter the whole appearance of the face. In some women a considerable quantity of hair appears in those parts of the face where the beard is seen in the other sex; it disappears after labour, when the skin resumes its natural functions, but returns on every succeeding pregnancy. In others a similar appearance takes place upon the breasts. The secretions of the skin are more or less altered; women who perspire freely have now a dry, rough skin; whereas those who at other times have seldom or never a moist skin, have copious perspiration, which is not unfrequently of a peculiarly strong odour. Cutaneous affections, also, which have been very obstinate, or had even become habitual, sometimes disappear, or at least are suspended during the period of utero-gestation. Similarly favourable changes are observed for a time in severe structural diseases of certain organs: the fact of well-marked phthisis apparently disappearing whilst pregnancy lasts, is well known. The breasts become larger, blue veins are seen ramifying beneath the skin, and the circular disc of rose-coloured skin which surrounds the nipples becomes remarkably changed in colour, &c.; appearances, the description of which we shall defer until we come to the consideration of those phenomena produced by pregnancy, which may be looked upon as diagnostic. The urine undergoes various changes; it is sometimes considerably increased, at others it is very high-coloured, or shows a peculiar milky sediment. A case has been quoted by Dr. Montgomery from Professor Osann's _Clin. Rep._ for 1833, p. 27., where the patient in three successive pregnancies was affected with diabetus mellitus, which each time completely ceased on delivery, and again returned when she became pregnant. None of the changes above enumerated excepting of those of the breasts, whether taken separately or conjointly, will enable us to form a correct diagnosis as to the existence of pregnancy. The appearance and feel of the abdomen during the early months afford no sure data: in fact, there is not a single symptom of pregnancy at this period, upon which we can rely with any degree of certainty. _Cessation of the menses._ One of the most remarkable changes produced by pregnancy, and one which most constantly appears, is the cessation of the menstrual discharge. From its occurring so uniformly and so soon after conception, it is generally used by women as the best means of reckoning the duration of their pregnancy: still, however, it is very far from being a certain sign, and never can be depended upon by itself in forming our diagnosis. It is well known how many causes produce suppression of the catamenia, independent of pregnancy; and, on the other hand, ample experience has shown that suppressed catamenia are by no means a necessary consequence of pregnancy. Although the fact has been contradicted by men of experience, still the regular appearance of the menses for the first few months of pregnancy is of such frequent occurrence as to place the matter beyond all doubt: in stating this, we do not allude to occasional discharges of blood from the vagina, but to regular periodical appearances of fluid distinctly bearing all the characters and peculiarities of the catamenia. This fact has been noticed so long ago, as by Mauriceau, who says, "I know a woman who had four or five living children, and who had with every child her menses from month to month, as at other times, only in a little less quantity, and was so till the sixth month, yet notwithstanding she was always brought to bed at her full time."[31] It is rare, however, to meet with the catamenia at so late a period, although cases do now and then occur where it lasts throughout pregnancy; more frequently it does not continue beyond the third or fourth month. The source of this discharge appears to be from the vessels of the upper part of the vagina[32] and from the cervix uteri;[33] the gradually shortening of the latter as pregnancy advances may be considered as the reason why, in the majority of instances, the discharge diminishes after the second or third month, and usually ceases by the fifth or sixth. Dr. Dewees supports the same opinion with some excellent observations which are worthy of attention. "We are" says he "acquainted with a number of women who habitually menstruate during pregnancy until a certain period, but when that time arrives it ceases: several of these menstruated until the second or third months, others longer, and two until the seventh month; the last two were mother and daughter. We are certain there was no mistake in all the cases to which we now make reference. First, they (the menses) were regular in their returns, not suffering the slightest derangement from the impregnated condition of the uterus; 2. they employ from two to five days for their completion; 3. that the evacuation differed in no respect from the discharge in ordinary, except that they did not think it so abundant; 4. there were no coagula in any one of these discharges, consequently it could not be common blood of hæmorrhage; 5. in the two protracted cases, the quantity discharged regularly diminished after the fourth month, a circumstance perhaps not difficult of explanation." (_Compendious System of Midwifery_, § 235.) It occasionally happens that the first appearance of the catamenia after conception is more abundant than usual, a circumstance which had been noticed by Dr. W. Johnson in 1769, and confirmed by Dr. Montgomery in his admirable work on the signs of pregnancy, who also confirms the general fact of the menses occasionally appearing during pregnancy by his own experience, and by very ample references. (_Op. cit._ p. 46.) The rarest and most extraordinary deviation of this kind from the usual course of things is the appearance of the menses _only during pregnancy_. Cases of this sort have been recorded by authors of the highest respectability, so that there can be no doubt as to the correctness of their statements. Thus, for instance, Baudelocque says, "I have met with several women, who assured me that they had not had their menses periodically except during their pregnancies; their testimony appeared to me to deserve more credit, because they only applied for an explanation of this extraordinary phenomenon."[34] By far the most interesting and detailed case of this nature is one described by Dr. Dewees. "A woman applied for advice for a long standing suppression of the menses; indeed she never had menstruated but twice. She had been married a number of months, and complained of a good deal of derangement of stomach, &c. We prescribed some rhubarb and steel pills; about six months after this she called to say that the medicine had brought down her courses, but that she was more unwell than before. The sickness and vomiting had increased, besides swelling very much in her belly; we saw this pretty much distended and immediately examined it, as we suspected dropsy; but from the feel of the abdomen, the want of fluctuation and the solidity of the tumour, we began to think it might be pregnancy, and told the woman our opinion. On mentioning our impression she submitted to an examination per vaginam; this proved her to be six months advanced in pregnancy. After this she had the regular returns of the catamenial period, until the full time had expired; during suckling she was free from the discharge. She was a nurse for more than twelve months; she weaned her child, and shortly after was again surprised by an eruption of the menses, which as on a former occasion proved to be a sign of pregnancy." (_Op. cit._ § 237.) There are other circumstances also connected with the catamenia, which warn us against placing too much confidence in its disappearance as a sign of pregnancy: a woman may become pregnant who has never menstruated, a fact which has been noticed by several authors, and which has been explained as well as confirmed by Levret in his _Art des Accouchemens_, § 230:--"A woman," says he, "may conceive, although she has not yet menstruated, provided menstruation would otherwise have made its appearance shortly."[35] Another circumstance, of much more frequent occurrence, is the fact that a woman may become pregnant without having had a return of the menses since her last confinement; hence we occasionally meet with cases where, from a rapid succession of pregnancies, the menstruation has not appeared for several years. From what has now been said, it will be seen, beyond all doubt, that the non-appearance of the menses cannot be looked upon by itself as a diagnostic of pregnancy, or _vice versâ_: this is more particularly the case when any morbid condition of the system is also present; under such circumstances, little or no confidence can be placed upon it as a guide in forming our diagnosis. In cases where it is an object to conceal pregnancy, the appearance of the menstrual fluid upon the clothes has been imitated in order to deceive. (Montgomery, _op. cit._ p. 50.) Although, therefore, the cessation of the menses, when taken in connexion with other symptoms, will prove useful in assisting us to a correct opinion, nevertheless, when taken by itself, it will scarcely ever enable us to decide with certainty. _Areola._ Among the earliest of those symptoms which must be considered as diagnostic are the changes observed in the appearance of the breasts; "they increase, become full; they are occasionally painful and grow hard: the veins in them are rendered conspicuous from their blue colour; the nipple becomes more bulky and appears inflated, its colour becomes darker, the surrounding disc undergoes a similar change, increases in extent, and is covered with little prominences like so many diminutive nipples."[36] "The several circumstances (says Dr. Montgomery, p. 59,) here enumerated at least ought in all cases to form distinct subjects of consideration, when we propose to avail ourselves of this part as an indication of the existence or absence of pregnancy. One other, also, equally constant and deserving of particular notice, is a soft and moist state of the integument, which appears raised and in a state of turgescence, giving one the idea that if touched by the point of the finger it would be found emphysematous. This state appears, however, to be caused by infiltration of the subjacent cellular tissue, which together with its altered colour, gives us the idea of a part in which a greater degree of vital action is going forward than is in operation round it, and we not unfrequently find that the little glandular follicles, or tubercles, as they are called by Morgagni, are bedewed with a secretion sufficient to damp and colour the woman's inner dress. These changes do not take place immediately after conception, but occur in different persons after uncertain intervals. We must therefore consider, in the first place, the period of pregnancy at which we may expect to gain any useful information from the condition of the areola. I cannot say positively what may be the earliest period at which this change can be observed, but I have recognised it fully at the end of the second month, at which time the alteration in colour is by no means the circumstance most observable; but the puffy turgescence, though as yet slight, not alone of the nipple, but of the whole surrounding disc, and the development of the little glandular follicles, are the objects to which we should principally direct our attention, the colour at this period being in general little more than a deeper shade of rose or flesh colour, slightly tinged occasionally with a yellowish or light brownish hue. During the progress of the next two months the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion.[37] The extent of this circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of the colour."[38] "In the centre of the coloured circle the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part of it which lies more immediately around the base of the nipple, is studded over, and rendered unequal by the prominence of the glandular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and lastly the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed at this period, especially in women of dark hair and eyes, numerous round spots, or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all round, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part. I have not seen this appearance earlier than the fifth month, but towards the end of pregnancy it is very remarkable, and constitutes a strikingly distinctive character exclusively resulting from pregnancy. The breasts themselves are at the same time generally full and firm, at least more so than was natural to the person previously, and venous trunks of considerable size are perceived ramifying over their surface, and sending branches towards the disc of the areola, which several of them traverse along with these vessels. The breasts not unfrequently exhibit about the sixth month, and afterwards, a number of shining, whitish, almost silvery lines like cracks; these are most perceptible in women, who, having had before conception very little mammary development, have the breasts much and quickly enlarged after becoming pregnant." In enumerating these various changes which are observed in the breasts, we fully agree with Dr. Montgomery in saying, that the alteration in the colour of the areola is by no means that upon which we can depend with most certainty: in the first place, we frequently meet with so little discolouration during the earlier months as to be altogether inappreciable; we have also already shown that if the patient be a brunette, and has already had children, the colour of the areola cannot be trusted to, as it never entirely disappears after her first pregnancy. On the other hand, we occasionally meet with a considerable change of colour in the unimpregnated state, arising from uterine irritation, as in dysmenorrhoea, &c. Where, however, this is accompanied by the other changes above enumerated, there can be, we apprehend, no doubt as to the existence of the pregnancy. Dr. Smellie, and also Dr. W. Hunter both considered the areola as proof positive of pregnancy. The latter one decided upon a case of pregnancy under very extraordinary circumstances; the body of a young female was brought into the dissecting room, which at the first glance he pronounced to be pregnant, but the accuracy of his diagnosis was not a little doubted when it was ascertained that a perfect hymen was present: to decide the point he had the abdomen opened when the uterus was found to contain a small foetus. _Movements of the foetus._ The sensation to the mother of the child moving in the uterus, cannot be looked upon as a certain sign of pregnancy, for even women who have had large families of children are frequently deceived in this respect by the movement of flatus in the intestines, by occasional spasmodic twitchings of the abdominal muscles, &c.; but when the motion of the child can be distinctly felt by the hand of an experienced practitioner, it will no longer admit of any doubt: this, however, is a symptom which can seldom be made use of before the middle of the sixth or seventh month. _Quickening._ This leads us to the subject of quickening as a symptom of pregnancy. The very vagueness of the term _quickening_ is of itself a sufficient objection to its use as a source of information on these points. Strictly speaking, it refers to that moment of pregnancy when the woman is supposed to have become _quick with child_, or in other words, when the foetus becomes endued with life, "an error," as Dr. Montgomery observes, "which the continued use of the term was obviously calculated to foster and to prolong" (p. 75.) As far as we can understand, the word "quickening" at the present day refers to two different events during pregnancy: the one is when the motion of the child first becomes perceptible to the mother; the other consists of those effects which are frequently observed when the uterus quits the pelvis, and rises into the abdominal cavity, viz. fainting, sickness, &c.; in either case it will be evident that no correct conclusion can be formed by this means. It may safely be asserted that until the last twenty years we possessed only three diagnostic marks of pregnancy, viz. the appearance of the areola, a series of changes but little understood; the being able to feel the movements of the child through the abdominal parietes, and the head of it per vaginam. Hence Dr. W. Hunter in describing the uncertainty of the signs of pregnancy says, "I find I cannot determine at four months, I am afraid of myself at five months, but when six or seven months are over, I urge an examination." In the primipara, the changes which pregnancy produces upon the os and cervix uteri are generally sufficient to lead to an accurate conclusion. The round dimple-like depression which the os uteri forms, the soft cushiony state of the cervix, are changes which we consider as peculiarly the effects of pregnancy, but their distinctness and certainty ceases when the patient has had several children; the irregular shape of the os uteri, its thickened edges, hard here and there, and the os tincæ, itself more or less open, the cervix scarcely, if at all, shortened, even at a late period of gestation, tend not a little to perplex the diagnosis furnished by this mode of examination; and where disease is complicated with pregnancy, the difficulty is greatly increased, and not unfrequently so much, that scarcely a single satisfactory point will be obtained. _Auscultation._ Of late years, an immense advance has been made in the diagnosis of pregnancy, by means of the stethoscope. M. Major of Geneva,[39] in 1819, observed the interesting fact that he could hear the pulsations of the foetal heart through the parietes of the mother's uterus and abdomen: he appears, however, to have carried his researches no farther; and little attention was excited to the circumstance until three years afterwards, when a masterly essay on the subject was read before the Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.[40] In this interesting memoir, the author has described two sounds, which are perfectly distinct from each other in point of character. One of them consists of single pulsations, synchronous with those of the mother's heart, accompanied with the deep whizzing rushing sound, which may be heard over a large portion of the uterus at once; the other of sharp, distinct, double pulsations, producing a ticking sound, and following a rythm, which is not synchronous with that of the maternal circulation. Kergaradec supposed that the former sound was produced by the circulation of the blood in the spongy structure of the placenta, and hence called it the _souffle placentaire_; later observations[41] have, however, shown that it is not connected with the placenta, but depends upon the increased vascularity and peculiar arrangement of the uterine vessels during the gravid state. The other sound is produced by the pulsations of the foetal heart. _Uterine souffle._ The uterine sound, or _souffle_, may invariably be heard in one or other of the inguinal regions, and usually over a considerable portion of the uterus, extending anteriorly or along the sides of the organ; and according to the observations of Professor Naegelé jun.,[42] there is no part of the uterus, capable of being osculted, in which this sound may not be heard. He considers that the souffle, which is so uniformly heard in the lower parts of the uterus, especially in the inguinal regions, seems to be produced by the uterine arteries before they enter the uterus; these vessels, as soon as they arrive at the broad ligament, assume a different character, become larger than they were on branching off from their original trunk, and are much contorted before entering the parietes of the uterus. Dubois first pointed out the similarity which exists between the sound heard in the gravid uterus, and that of aneurismal varix, where there is a direct passage of blood from an artery into a vein: the sound in this latter condition is produced by the current of blood rapidly issuing from the dilated artery, and mixing with the slower flowing stream of the dilated vein. The circulation of blood in the dilated arteries of the uterus present a considerable resemblance, in many respects, to that of the above-mentioned disease. That the uterine sound is not confined to that part of the uterus where the placenta is attached, as was supposed by Professor Hohl,[43] is proved by the fact that we can frequently hear it in two different and sometimes opposite parts of the uterus at the same time, which, if his opinion be correct, would indicate the presence of twins; and yet the result of labour has proved that the uterus has contained but one child, and that the placenta had neither been attached in the one or other of these situations. The very circumstance which we have already mentioned, of this sound being invariably heard in one, if not in both, of the inguinal regions, shows that it is independent of the vicinity of the placenta; nevertheless, it must be allowed, that as the uterine vessels undergo the greatest degree of development at this part, the sound will usually be at least as distinct here as in any other portion of the uterus. The uterine souffle is the first sound which auscultation detects during pregnancy; it may be heard as early as the fifteenth or sixteenth week, but cases now and then occur where it has been even distinguished in the thirteenth or fourteenth week, and Dr. Evory Kennedy, has given some very interesting examples where he was able to hear it with certainty at the twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy, _op. cit._ p. 80.) During these earlier periods, the sound is weaker, but extends over the whole uterus, from the diminutive size of which it can be heard most readily immediately above the symphysis pubis; in fact, there is every reason to suppose, that the uterine souffle might be detected at a still earlier period, if the uterus were at this time within reach of the stethoscope. As pregnancy advances, it becomes more distinct and powerful, and is occasionally so to a remarkably degree. During the latter periods of pregnancy, it frequently presents considerable modifications of tone, especially where there is general or local vascular excitement, as in cases of fever, or dispositions to hæmorrhage, where the vessels are usually distended, or where (Naegelé, _op. cit._ p. 86,) the placenta is situated near the os uteri, it assumes a piping, twanging sound of considerable resonance: the same is also observed where, either from the weight of the gravid uterus or any other cause, pressure has been exerted on any of the main arterial trunks: hence, as we shall show more fully when speaking of labour, a remarkable change is produced in the tone of the uterine souffle by the first contractions of that process. The causes of these modifications are not always very easily explained; we sometimes observe the souffle on the same side of the uterus vary rapidly in its degree of intensity, and occasionally even disappear for awhile without our being able to assign any satisfactory reason for such changes. The uterine souffle taken by itself, although a very valuable sign of pregnancy, can scarcely be looked upon as one which is perfectly certain and diagnostic, since a similar sound may be produced by aneurism of the abdominal aorta and its large branches: there is much reason to think that the uterus, enlarged from other causes than that of pregnancy, and pressing upon the iliac arteries, will produce a similar sound. Professor Naegelé, jun., has also shown that the sounds of the patient's heart may sometimes be heard very low in the abdomen, even as far as the ossa ilii, a circumstance which seems to have depended upon the sound being transmitted through the intestines distended with flatus. Where any of these causes of abdominal souffle have existed in connexion with suppressed catamenia, swelling of the breasts, &c., we might be liable to be deceived if we allowed ourselves to be entirely guided by this sound. With regard to the foetal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the foetus appears to have no effect upon their rapidity, for even at the earliest periods at which we can detect these sounds the rate of the pulsation is the same as at the full term of pregnancy. Although Dr. Kennedy has in a few cases detected this sound even before the expiration of the fourth month, it will not in the majority be possible until a later period. "At the fourth month it frequently requires not only close attention, but considerable perseverence to detect the foetal heart; and at this period it has occurred to us to examine patients whom there was strong reason to suppose pregnant, and after spending a considerable time in endeavouring to detect this sound, we have been on the point of giving up the search as hopeless, when it has been suddenly discovered in the identical spot that had before perhaps been explored without success." (Kennedy, _op. cit._ p. 101.) The sound of the foetal heart is usually heard at about the middle point between the scrobiculus cordis and symphysis pubis, usually to one side, and that, generally speaking, the left. The extent of surface over which the sound may be heard varies a good deal, and depends, in great measure, on the distance which intervenes between the foetus and stethoscope; hence, when the uterus is distended with a large quantity of liquor amnii, or when the uterine and abdominal parietes are very thick, it is heard over a much larger space, although with diminished intensity; on the other hand, when there is but little liquor amnii in the uterus, it is audible over a small portion only, but is remarkably distinct: this is peculiarly the case during labour after rupture of the membranes. The rapidity and strength of the foetal pulsations appear to be entirely independent of the mother's circulation; violent exercise, spirituous liquors, &c., which will raise her pulse to a considerable degree, have no influence whatever on the foetal pulse. In cases of fever, where the mother's pulse has ranged between 110° and 120°, and even higher, not the slightest change was observable in the sound of the foetal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnoea, and also in tubercular phthisis; in cases where the patient has been bled; in cases of menstruation during pregnancy; and even in severe flooding, and when the mother's pulse has been greatly reduced, no perceptible change has been observed in that of the foetus. (Naegelé, _op. cit._ p. 39.) Dr. Kennedy has observed some remarkable cases where the foetal pulse appeared to vary in accordance with that of the mother (_op. cit._ p. 91;) but when we bear in mind the frequent changes in point of rapidity, &c., to which the foetal heart is subject, independent of any thing of the kind in the mother's pulse, and that similar changes are constantly observed in the child shortly after birth; and, moreover, that very considerable acceleration of the maternal pulse has decidedly no effect upon that of the foetus in many well-marked instances, we cannot agree with him in supposing that a connexion of the sort to which he has alluded exists. The double pulsations of the foetal heart can only be heard at one point of the uterus at a time, provided there be but one child; but if there be twins, then the sound is heard in two places at once. It has been supposed by some authors (_Dubois_) that the heart of the second child could not be distinctly heard until labour, when the membranes of the first child had ruptured. Generally speaking, both sounds can be heard pretty distinctly during the last weeks of pregnancy, one of them being low down on one side, and the other high up in an opposite direction. Although in some twin cases there is an evident difference of rhythm between the two foetal hearts, still in many others they are so nearly synchronous as to be scarcely if at all distinguishable in this respect. Hence, therefore, from the known variable character of the foetal pulse, it will be necessary that the sound of each heart should be ausculted at the same moment, minute for minute, by two observers, and thus the slightest appreciable difference between them determined. _Funic souffle._ Dr. Kennedy has shown that, where a portion of the umbilical cord passes between the child's body and the anterior wall of the uterus, or crosses any of its limbs or other projections, pulsations are heard synchronous with those of the foetal heart; although not possessing the same characters. "In some cases where the uterus and parietes of the abdomen were extremely thin, I have been able," says Dr. K., "to distinguish the funis by the touch externally, and felt it rolling distinctly under my finger, and then, on applying the stethoscope, its pulsations have been discoverable remarkably strong; and, on making pressure with the finger for a moment on that part of the funis which passed towards the umbilicus of the child, I have been able to render the pulsations less and less distinct, and even, on making the pressure sufficiently strong, to stop it altogether." (_Op. cit._ p. 121.) In many cases where the umbilical arteries, by their convolutions round a limb, or by any other cause, are subjected to slight pressure, a distinct whizzing sound is produced, which is called by Dr. Kennedy the _funic souffle_. The sound of the foetal heart must be looked upon as a sign of the highest value in the diagnosis of pregnancy, since, however complicated and obscure the other symptoms may be, whether from co-existing disease, wilful deception, &c. if this sound be once heard unequivocally, the real nature of the case is satisfactorily established beyond all possibility of doubt. Another sound in the gravid uterus has been lately noticed by Professor Naegelé, junior, which promises to equal that of the foetal heart, as a certain diagnostic of pregnancy, and must be looked upon as a valuable addition to our means of ascertaining the truth in cases of this sort. The movements of the foetus may be distinguished by the stethoscope at a very early period of pregnancy, long before they are perceptible to the hand of the accoucheur, and in many cases before the patient has been aware of them herself. According to Professor Naegelé's observations, these sounds may usually be heard some little time before the foetal heart is audible, and are sounds which can neither be feigned nor concealed: they can only be heard in the gravid uterus, and under no other circumstances. Although the sounds of the heart and movements of the foetus are unequivocal proofs of pregnancy, which may be heard at a very early period, still it must, in some degree, remain uncertain at this time, how far their absence can be looked upon as a proof of its non-existence. Under such circumstances, the examinations require to be conducted with the greatest possible care, and to be repeated at favourable opportunities, until no doubt as to the correctness of their results can any longer exist. The soft cushiony feel of the cervix uteri is a change produced by pregnancy, which, in our opinion, has not received that attention which it deserves; as far as we are able to judge, this condition of the cervix is peculiar to pregnancy, and exists very shortly after conception. We occasionally meet with a soft flaccid state of the os and cervix uteri in certain diseases; but the feel which this communicates to the finger is very different to that above-mentioned, which resembles more the elastic inflated condition of the nipple during pregnancy, than any thing to which we can compare it. _Ballottement._ At the beginning of the seventh month we shall be able to feel the head of the foetus upon examination per vaginam. If we direct our finger against the uterus, midway between the os uteri and symphysis pubis, and suddenly exert a slight degree of pressure, we shall become sensible of having struck against something hard within the cavity of the uterus; upon repeating the experiment immediately, we shall probably not feel it, the foetus having risen in the liquor amnii to the upper parts of the uterus; but if hold our finger still for a few moments, it will, by this time, have again descended, and we shall again feel it; at other times, when the foetus is larger and heavier, the head will rest like a light ball, on the tip of the finger, from which circumstance it has received the name of _ballottement_ by the French authors. _Motion of the child._ The sensation of the child's movements to the mother is a symptom of very little value, and is liable to mislead the practitioner if he place much reliance upon it; for the passage of the flatus along the bowels, or little spasmodic flickerings of the abdominal muscles, will produce a very similar sensation, and will even completely deceive a patient who has been the mother of several children; but when they become perceptible to the experienced hand of the practitioner, this may also be looked upon as a certain indication that pregnancy exists. The foetal movements can seldom be felt distinctly until the beginning of the seventh month, and even then it requires some caution before we can venture upon a positive opinion. Their activity varies considerably in different cases; in some their nature is almost immediately evident; whereas, in others they are so few and feeble, as to make it very difficult to decide. It has been recommended to put the head in cold water previous to applying it upon the abdomen, as, by this means, a considerable shock is produced which excites these movements more distinctly. We cannot say that we have found this proceeding of any use, since, by this means, the abdominal muscles are rendered so irritable as frequently to obstruct the examination considerably: it is rather desirable to have them in as perfect a state of repose as possible, in order that no movement of the foetus, however slight, should escape our notice. It is in cases of abdominal enlargement from disease; that this means of diagnosis is occasionally very difficult, and where men, even of great experience, have been led to form a very erroneous opinion. The celebrated Peter Franck has related a case of this sort which occurred to himself, where the patient was supposed pregnant, and where he imagined that he had felt the motions of the child: she died shortly afterwards, and the examination of the body showed it to have been a case of ascites complicated with hydatids. Dr. Dewees has given a still more remarkable case of a similar error having occurred to himself. A young lady had her menses suppressed for several months; the abdomen swelled very much, the breasts became enlarged, she had nausea and vomiting in the morning, and other indications of pregnancy; "examining the abdomen carefully, I found it," says Dr. Dewees, "considerably distended; there was a circumscribed tumour within it, which I was very certain was an enlarged uterus. While conducting this examination I thought I distinctly perceived the motions of a foetus. The case proved to be one of accumulation of menstrual fluid in the uterus." (Dewees's _Essays on several Subjects connected with Midwifery_, p. 337-8.) In reviewing what has now been stated respecting the diagnosis of pregnancy, it will be observed that we have enumerated four symptoms, which must be looked upon as perfectly diagnostic of this condition, and in the accuracy and certainty of which we may place the fullest confidence: two may be recognised at an early period by means of auscultation, viz. the sounds produced by the movements of the foetus and by the pulsations of its heart; the two others are not appreciable until a later period, and are afforded by manual examination, viz. the being able to feel the head of the foetus per vaginam, and its movements through the abdominal parietes. The next in point of value after these are the changes in the os and cervix uteri, those connected with the formation of the areola in the breasts, and, at a somewhat later period, the sound of the uterine circulation, changes, which, although they cannot separately be entirely depended upon, are nevertheless symptoms of very great importance in the diagnosis of pregnancy. Two other signs of pregnancy have also been mentioned, viz. the appearance of a peculiar deposite in the urine as described by M. Nauche, or rather by Savonarola (Montgomery, _op. cit._ p. 157.,) and the purple or violet appearance of the mucous membrane lining the vagina and os externum, as described by Professor Kluge of the Charité at Berlin, and by M. M. Jacquemin, Parent Duchatelet, &c. of Paris. With regard to the first, which is an old popular symptom of pregnancy, there is too much variety in the appearances of the urine, depending on general health, diet, temperature, &c., to enable us to place much confidence in any change of this sort. "I have myself tried it," says Dr. Montgomery, "in several instances, and the result of my trials has been this:--In some instances no opinion could be formed as to whether the peculiar deposite existed or not, on account of the deep colour and turbid condition of the urine; but in the cases in which the fluid was clear, and pregnancy existing, the peculiar deposite was observed in every instance. Its appearance would be best described by saying that it looks as if a little milk had been thrown into the urine, and having sunk through it had partly reached the bottom, while a part remained suspended and floating through the lower part of the fluid in the form of a whitish semi-transparent filmy cloud." (_Op cit._ p. 157.)[44] The purple colour of the vaginal entrance appears, from the extensive experience of the above-mentioned authors, to be a pretty constant change produced by the state of pregnancy; it probably occurs at a very early period. How far a similar tinge is produced by the state of uterine congestion immediately before a menstrual period, we are unable to say; at any rate, the character of the examination itself must ever be sufficient to preclude its being practised in this country. The diagnosis of pregnancy is a subject well worthy of the student's most serious attention; for he will of course be liable, when in practice, to be called upon to give his evidence before a court of justice under circumstances when the responsibility must ever be of the most serious and not unfrequently of the most fearful nature, the more so as the old custom of impanelling a jury of "twelve discreet matrons" to determine whether the woman be _quick with child_ has fallen deservedly into disrepute. He should lose no opportunity of making himself familiar with the various symptoms of pregnancy above enumerated, and of so practising the different senses of hearing, touch, and sight, as instantly and certainly to detect their presence. Numerous cases are on record, where a false diagnosis in women convicted of capital offences, has led to most lamentable results, and where dissection of the body after death has shown that she was pregnant. Dr. Evory Kennedy has recorded an interesting case of this sort which occurred at Norwich in 1833, when a pregnant woman was on the point of being executed through the ignorance of a female jury. (E. Kennedy's _Observations on Obstetric Auscultation_, &c., p. 197.) We may also mention a dreadful case of this nature which occurred to the celebrated Baudelocque at Paris, during the horrors of the French revolution.[45] A young French countess was imprisoned during the revolution, being suspected of carrying on a treasonable correspondence with her husband, an emigrant. She was condemned, but declared herself pregnant; two of the best midwives in Paris were ordered to examine her, and they declared that she was not pregnant. She was accordingly guillotined, and her body taken to the school of anatomy, where it was opened by Baudelocque, who found twins in the fifth month of pregnancy. Equally important is it (and perhaps in some respects even more so) to determine the absence of pregnancy in cases where it has been supposed to exist. In many instances the character and happiness of the individual must depend upon the judgment which the practitioner pronounces; and, painful as will be the task of communicating an opinion which implies guilt and loss of honour, how infinitely revolting and inexcusable must that step be considered, which turns out to have been founded upon an incorrect diagnosis. Hence the importance of separating those symptoms of pregnancy which may be considered certain, and therefore trustworthy, from the crowd of others, which, although collectively they may warrant a suspicion, yet never can justify a decision that pregnancy exists, more especially in cases where so much is at stake. No two symptoms have led more frequently to this cruel error, and therefore to the most unjust suspicions, than the cessation of the menses with swelling of the abdomen, and yet from how many different causes may they arise besides that of pregnancy? Putting even the impulse of common feeling aside, we would ask how a practitioner can dare recklessly to incur the responsibility of injuring a woman's character by hazarding an opinion which involves so much, and is based upon symptoms which, by themselves, prove so little? Whether he exercise his profession in town or country, cases of doubtful pregnancy will constantly come under his notice. We cannot, therefore, too strongly urge the importance of ascertaining how many of the certain symptoms are present, before we allow ourselves to be influenced by those which are uncertain. In speaking of the enlargement of the abdomen as a sign of pregnancy which is extremely equivocal, Dr. Dewees well observes, "But little reliance can be placed upon this circumstance alone, or even when combined with several others; for I have had the pleasure in several instances of doing away an injurious and cruel suspicion, to which this enlargement had given rise. Within a short time, I relieved an anxious and tender mother from an almost heart-breaking apprehension for the condition of an only and beautiful daughter on whom suspicion had fallen, though not quite fifteen years of age: this case, it must be confessed, combined several circumstances which rendered it one of great doubt, and, without having had recourse to the most careful and minute examination, might readily have embarrassed a young practitioner. This lady's case was submitted to a medical gentleman, who, from its history and the feel of the abdomen, pronounced it to be a case of pregnancy, and advised the sorrow-stricken mother to send her daughter immediately to the country as the best mode of concealing her shame. Not willing to yield to the opinion of her physician (a young man,) and moved by the positive denials of her agonized child, the mother consulted me in this case. The menses had ceased, the abdomen had gradually swelled, the stomach was much affected, especially in the morning, and the breasts were a little enlarged. On examination it proved to be a case of enlarged spleen." (Dewees, _on the Diseases of Females_, p. 178.) We occasionally, also, meet with cases of self-deception, as to the existence of pregnancy, to an extent which would scarcely seem credible. Women who have been the mothers of several children, will, upon some very slight foundation, suppose themselves with child. Knowing from previous experience many of the symptoms of this state, they will frequently enumerate them most accurately to the practitioner, who, if he rest satisfied with general appearances, may easily be led into a wrong diagnosis. A case of this kind we published in our midwifery reports, where the patient, the mother of two children, came into the General Lying-in Hospital, not only under the supposition that she was pregnant, but that labour had actually commenced; the catamenia had ceased about nine months previously, and the abdomen was considerably enlarged. Examination proved that she was not pregnant. (_Med. Gaz._ June, 1834.) In a work solely devoted to cases of doubtful pregnancy by the late W. J. Schmitt, of Vienna, these cases have been very fully discussed. "We occasionally observe certain conditions of the female system, which put on a most striking resemblance to pregnancy, both functionally as well as organically, without at all depending on the actual presence of pregnancy. The abdomen begins to swell from the pubic region exactly in the same gradual manner as in pregnancy; the breasts become painful, swell, and secrete a lymphatic fluid, frequently resembling milk; the digestive organs become disordered; there is irregular appetite, nausea, and inclination to vomit; constipation, muscular debility, change in the colour of the skin, and frequently of the whole condition of the body; the nervous system suffers, and even the mind itself frequently sympathizes; the patient is sensible of movements in the abdomen like those of a living foetus, then bearing down pains running from the loins to the pubes; at last actual labour-pains come on as with a woman in labour, and if by chance her former labours have been attended by any peculiar symptoms, these, as it were, to complete the illusion, appear likewise." (W. J. Schmitt, _Zweifelhafte Schwangerschafts-fälle_.) A most extraordinary case of the self-deception with regard to pregnancy, has been published by the celebrated Klein of Stuttgardt: it has been quoted in the work of W. J. Schmitt above alluded to, and a brief sketch of it has been given by Dr. Montgomery in his _Expositions of the Signs and Symptoms of Pregnancy_, p. 172, to which we must refer the reader for much valuable information on this and all other subjects connected with the diagnosis of pregnancy. _Diagnosis of twin pregnancy._ Before concluding this chapter, we shall offer a few observations on the diagnosis of twins. A variety of symptoms have been enumerated as indicating the presence of two foetuses in utero, such as the great size of the abdomen, its flat square shape, the movements of a child at different parts of it, &c. The size of the abdomen can never be admitted as a diagnostic mark of twin pregnancy; first, because it equally indicates the presence of an unusual quantity of liquor amnii, or of a very large child; and secondly, because women pregnant with twins are not always remarkable for their size: the flatness, &c., of the abdomen is, we presume, a symptom based on the supposition that there is a foetus in each side of the uterus: this is very far from being correct, as it is well known that the children usually lie obliquely, the one being, perhaps, downwards and backwards, while the other is situated upwards and forwards. The sensation of the child's movements in different or opposite parts of the uterus is no proof whatever that there are twins, because it is constantly observed where there is but one child--a circumstance which is very easy of explanation. The stethoscope affords us the only certain diagnosis of twin pregnancy; and even here it is limited to the sounds of the foetal hearts; the increased extent and power of the uterine souffle, as remarked by Hohl, arising, as he supposed, from the large mass of the double placenta, is not a proof which can be depended upon. In cases of suspected twin pregnancy the auscultation must be conducted with the greatest possible care, and, generally speaking, a certain diagnosis can only be obtained by two observers ausculting the two hearts at one and the same moment; for, otherwise, the difference between their rhythm is frequently so small as to be inappreciable. The sounds are seldom or never heard at the same level, one being generally heard high up on one side, the other in a contrary direction. CHAPTER II. TREATMENT OF PREGNANCY. _Sympathetic affections of the stomach during pregnancy.--Morning sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.-- Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--Pruritus pudendi.--Salivation._ In the preceding chapter we have enumerated those changes and phenomena which are observed to take place in the system during pregnancy: many of these amount to actual derangements of function, and will, therefore, as such, demand our attention in a practical point of view, for the purpose of alleviating or removing them. Many of these changes are produced by the altered distribution of blood, as well as by the actual increase of quantity which now exists in the circulation; the nervous and also the vascular system of the uterus are now in a state of high excitement and activity--a condition which must necessarily communicate itself to those organs which are supplied by the same nerves; viz. the sympathetic, and by the same portion of the circulation, viz. the branches of the abdominal aorta. No organ, except the stomach, possesses sympathetic connexions so widely extended over the rest of the system as the uterus; and, we may add, that no two organs are so intimately and reciprocally united as the uterus and the stomach. In the unimpregnated state, we see this manifested in a remarkable degree; if the stomach becomes deranged the uterus sympathizes; thus the states of gastric disturbance, known under the general term of dyspepsia, are frequently followed by leucorrhoea, or some derangement of the menstrual function: on the other hand, uterine disease is invariably accompanied by symptoms of gastric disturbance, and, in many cases, to such an extent as to conceal the real seat of the evil, and mislead the attention of the patient and her medical attendant. In like manner we find that during pregnancy, especially in the early stages of it, the patient is annoyed with a great variety of symptoms more or less indicative of derangement in the functions of the primæ viæ. _Morning sickness._ One of the most troublesome, and by no means the least frequent, is vomiting, which, from coming on usually in the morning, is commonly called morning sickness; in some cases the female merely rejects what food or mucus may be present in the stomach, after which she feels relieved; in others she continues to strain violently and ineffectually for some time. In the former case it resembles the common vomiting from a deranged stomach, and cannot be considered as the direct result of sympathy with the uterus: the tone of the stomach has become impaired, and vomiting has followed as a consequence of its being loaded with undigested food and depraved secretions. Hence, in these cases, it is generally preceded by nausea and the other common precursory symptoms of this act: in the latter, however, it appears to be the immediate result of irritation transmitted from the uterus, and assumes rather a spasmodic character; the patient is suddenly seized with involuntary efforts to vomit, which are not preceded by nausea or oppression, and come on independently of the stomach being full or empty. Morning sickness usually appears during the first few weeks after conception, and continues until the third or fourth month; in some cases it continues throughout pregnancy; in a few it does not begin till much later, and in many it does not appear at all. It scarcely deserves to be called a disease of pregnancy, for it frequently appears as a salutary effort of nature to relieve a cause of much gastric irritation, and, unless it proceeds to a very exhausting degree, must rather be looked upon as a favourable symptom, as it tends to prevent the formation of too much blood, which is so frequent a cause of abortion during the early months. (Hamilton, _on Female Complaints_.) Hence, therefore, experience verifies the correctness of the old proverb, that a "sick pregnancy is a safe one." The ejected matter on these occasions, when there is but little or no food upon the stomach, consists of a glairy ropy mucus, sometimes mixed with a considerable quantity of intensely sour fluid, containing a large proportion of muriatic and acetic acid: in some cases more or less bile is vomited. The treatment of morning sickness will depend in great measure on the severity of the attack: where it is slight, the patient may assist its operation with a little warm water, or chamomile tea: after which the bowels should be briskly opened by a saline laxative, as for instance, a seidlitz powder, sulphate and carbonate of magnesia, &c.: small doses do more harm than good, as, from their slow and ineffective action, they rather tend to increase the irritation and aggravate the symptoms. In severe cases, especially where the pulse is excited, a small bleeding may be used with much advantage, but in most instances the usual treatment of gastric derangement, as it occurs in the unimpregnated state, produces most relief. The bowels should be first opened in the way already mentioned, after which a combination of Pil. Hydrarg. and Extr. Hyosc. or Extr. Humuli, is to be given at night, and a vegetable tonic during the day. Acids, more especially the mineral, have been very judiciously recommended by Dr. Dewees, and, when combined with any bitter infusion, will be found of great service. Where the constant secretion of acid is very distressing, the nitric acid will be found particularly useful; it allays the irritability of the stomach, and produces a healthy state of its secretion. Opiates are by no means desirable remedies, and rather tend to aggravate the disease by still farther injuring the tone of the stomach and producing constipation. We have known them given in considerable doses and in very powerful forms, but without relief. Hydrocyanic acid, creosote, &c., have also been tried, but with no permanent success; in such cases Dr. Burns has found the application of leeches useful, "especially if accompanied with pain or tension in the epigastric region." On the same principle, we presume, have we found a sinapism of great service. Where the vomiting, in spite of all the above modes of treatment, still goes on unabated, there is nothing which, in our experience, is so useful as covering the epigastrium with a hot flannel, upon which a mixture of camphorated spirits of wine and laudanum has been sprinkled. "We have," says Dr. Dewees, "in several instances, confined patients for days together, upon lemon juice and water with the most decided advantage. We have repeatedly found much benefit from the use of the spirit of turpentine three or four times a day, in doses of twenty drops: this medicine is very easily taken, if it be mixed in cold sweetened water. When the system is not excited to febrile action, and where the stomach rejects every thing almost as soon as swallowed, we have often known a table-spoonful of clove-tea act most promptly and successfully." (_Compendious System of Midwifery._) _Heartburn_ is another form of gastric derangement which frequently occurs to a very distressing degree, and must be looked upon as a modification of morning sickness; in many cases it arises from the presence of acid in the stomach, but in others it is merely a sympathetic result of gastric irritation, without any proof of acidity being present. The treatment of heartburn is much the same as that just described for morning sickness, the main object being to restore the stomach and bowels to a healthy condition. Besides the mineral acids, small quantities of iced water will be found very grateful, relieving the sense of burning in the back of the pharynx, and diminishing, in great measure, that gastric irritability of which it is a symptom. The frequent, and sometimes almost unlimited, use of antacid absorbents, viz. magnesia or chalk, in this disease, is a practice much to be deprecated: compounds are thus formed in the stomach which are positively injurious, and, beyond the temporary relief procured by removing the acid, they tend to aggravate these symptoms, by increasing the state of gastric derangement. The only chemical antacid which should be given in these cases is the carbonate of soda; by this means a compound is formed (the common muriate of soda,) which of all others is most grateful to the stomach, and which, from its gently laxative effects, is well adapted to keep up a healthy action of the bowels. It is scarcely credible to what extent the use of antacids may be carried to relieve the cardialgia of pregnancy. Dr. Dewees mentions having attended a lady with several children, "who was in the constant habit of eating chalk during the whole term of pregnancy; she used it in such excessive quantities as almost rendered the bowels useless. We have known her many times not to have an evacuation for ten or twelve days together, and then only procured by enemata, and the stools were literally nothing but chalk. Her calculation, we well remember, was three half pecks for each pregnancy. She became as white nearly as the substance itself, and it eventually destroyed her, by deranging her stomach so much that it would retain nothing whatever upon it." (_System of Midwifery_, § 275.) The _constipation, flatulence, colicky pains, and headach, the spasmodic cough, palpitation, toothach_, &c. are symptoms arising from the same cause, a knowledge of which circumstance will influence our treatment of them more or less. Still, however, the indications are the same, viz. to restore and keep up a healthy action of the stomach and bowels. Thus, we frequently find that a severe headach, obstinate cough, or attacks of palpitation, are relieved by aperient medicines; that toothach may be relieved, or even removed, by occasional doses of carbonate of soda, or by blue pill and aperient tonics. Indeed, it is a question in many cases, whether it is proper to extract a carious tooth under these circumstances, for the shock which it produces is sometimes so great as to run the risk of exciting abortion; and in many instances we might extract every tooth on the painful side, and yet not relieve the suffering which arises from nervous pain induced by gastric irritation, and, if carefully examined, the pain will be found to be not confined to a single tooth but to spread over the whole side of the face, darting from the edge of the ear, and extending even to the forehead. The breath is usually sour, and the acid state of the saliva is indicated by the instantaneous reddening of litmus paper laid upon the tongue; in many cases there is at the same time a considerable deposit of lithic acid observed in the urine. Spasmodic cough, or palpitation, if allowed to continue, may ultimately bring on abortion. The treatment just detailed is equally applicable here, and if the circulation be at all excited blood-letting will prove useful. In bleeding women at this early stage of pregnancy it is not desirable, or even safe, to draw a large quantity suddenly from the system, as it may greatly endanger the life of the foetus, and from the state of the nervous irritability, may even run the risk of bringing on convulsions; syncope is always more or less hazardous to a pregnant woman, and should if possible be avoided. Some caution will be also necessary in our choice of aperient medicines; drastic purgatives, as aloes, colocynth, scammony, &c. are not suited to the state of pregnancy, as they irritate the lower bowels, and thus excite a disposition to uterine contraction; mild, but effectual laxatives, such as castor oil, confectio sennæ, a seidlitz powder, are better adapted; the latter, especially will be found useful, as, from its being taken during effervescence, it is better calculated to quiet the stomach. _Diarrhoea_ is sometimes an exceedingly troublesome symptom during pregnancy. It not only weakens the patient and thus tends indirectly to induce abortion by destroying the life of the foetus, but it acts also in a more direct manner by exciting uterine contractions, particularly when accompanied, as is frequently the case, with tenesmus. The diarrhoea which is met with in pregnant women is not so frequently, as has been supposed, the result of irritation from the uterus, producing simply an increased peristaltic action of the bowels without any considerable derangement of their functions; by far the most usual form is connected with a very deranged state of the alimentary canal; the evacuations are offensive and generally very acrid; the liver is torbid or secretes an unhealthy bile, so that at length a state approaching to dysentery is produced. Even if the patient go to the full term of utero-gestation, she is much reduced, and is ill able to make those exertions which will be required during labour. If the motions, though frequent, are scanty in proportion to the ingesta, or if scybala are occasionally expelled, one or two doses of castor oil will be required; a few drops of Liq. Opii Sedativ. may be added with advantage to allay the irritability of the bowels, after which, equal parts of blue pill, or Hydr. c. Cretâ, and Dover's powder, will excite the liver to a healthier action, and still farther control their inordinate activity. If the disposition to tenesmus be troublesome, a small injection of starch and opium will afford relief. If the stomach will bear it, a rice-milk diet for a day or two is desirable; it is a gentle demulcent to the irritable intestines, and has a slightly constipating effect. _Pruritus pudendi_ to a very distressing degree occasionally comes on during pregnancy, and though in most instances a very manageable form of disease, yet if its nature be not properly understood it proves exceedingly obstinate, and much suffering is the result. It appears to be essentially different from the common prurigo, being an aphthous state of the lining membrane of the vagina and skin which covers the perineum and external organs. There is great heat and redness of the parts, which are more or less swollen, and from the scratching which the intense itching demands, the cuticle, where it has been raised by the pustules, becomes abraided, so that severe excoriations, and, where there has not been sufficient attention to cleanliness, even ulcerations may be produced. The pustules on the external parts frequently attain a considerable size, being more distinct than in the vagina, which is usually incrusted with one confluent mass of aphthæ; whereas, on the perineum and margins of the labia we have seen them as large as peas. These cases for the most part yield to the tepid Goulard lotion, or solution of borax. Where the patient is plethoric, and the system in a state of considerable excitement from the irritation, blood-letting will be necessary, followed by cooling saline laxatives; and if there be much inflammation of the parts, leeches will prove of great service. In every case the bowels ought to be attended to, for constipation will greatly increase the inflammation, and the obstinacy of the disease. It is to Dr. Dewees that we are indebted for first pointing out the real cause and nature of this troublesome affection.[46] Aphthæ of the vagina are not unfrequently met with in cases of uterine disease, where the discharge is extremely acrid, but the prominent symptom, viz. the intense pruritus, is absent. The aphthous vagina of pregnancy is not a common affection. _Salivation_ is another affection which is occasionally, though rarely, met with in pregnancy. It is usually attended with morning sickness, constant nausea, and deranged bowels, and may reduce the patient excessively: attention to the state of the bowels, followed by gentle alteratives and tonics, generally gives relief. CHAPTER III. SIGNS OF THE DEATH OF THE FOETUS. _Difficulty of the subject.--Signs before labour.--Motion of the Foetus.--Sound of the foetal heart.--Uterus souffle.--Signs during labour where the head presents--where the face, the nates, the arm, or the cord, present.--Fetid liquor amnii.--Discharge of meconium._ Well has the celebrated Mauriceau observed, "S'il y a occasion où le chirurgien doive faire plus grande reflexion, et apporter plus de précaution aux choses qui concernent son art, c'est en celle où il s'agit de juger si l'enfant qui est dans la matrice est vivant, ou bien s'il est mort." There are few circumstances more painful to the feelings of an accoucheur, than the uncertainty as to whether the child be alive or dead, in a labour where the passage of the head is rendered unusually difficult or dangerous for the mother, even with the aid of the forceps; whether the difficulty be produced by want of proportion between the head and pelvis, unusual rigidity of the os uteri, &c. Could he assure himself that it was alive, he would feel justified in either trusting still longer to the efforts of nature, or in applying the forceps, even although he knows that the delivery cannot be effected without considerable difficulty and suffering: whereas, if he could once feel satisfied that the child had ceased to exist, he would have recourse to perforation, for the purpose of diminishing the size of the head, and thus releasing the mother from the dangers of her situation. The increasing success which has attended the Cæsarean operation of late years, adds still more to the importance of having the signs of the child's life or death in utero carefully investigated and understood; for, under such circumstances, it becomes a most serious question whether we are always justified in destroying the life of the foetus by perforation, when we might in all probability have saved it by resorting to another means of delivery, which, formidable as it is, is now infinitely less so than it was in former times. It becomes a question whether we ought not, in certain cases to adopt the same indications for performing the Cæsarian operation, as are used upon the Continent, and apply it not only to those cases where the child cannot be delivered _par vias naturales_, but also in those cases of minor pelvic obstruction, where, if we could feel sure of the child's death, we should have recourse to perforation. Under circumstances of this nature, the question becomes one of fearful responsibility, the painfulness of which is not a little increased by the uncertainty as to whether the child be alive or not. Mauriceau was the first author who devoted a chapter expressly to the consideration of this subject, and those few who have done the same since his time, have borrowed largely from his observations. A great number of symptoms have been enumerated as indicating the child's death in utero, but for the most part they are deserving of very little confidence, frequently occurring where the result of labour has shown the child to be alive and strong, or _vice versâ_. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occur _before_ labour, and those which occur _during_ labour. The symptoms of the child's death, which are usually enumerated as occurring _before_ labour, are, cessation of the child's movements; the abdomen undergoes no farther increase of size, but rather diminishes; the uterus has no longer the tense elastic feel of pregnancy, but becomes flaccid and moveable; the patient has a sensation of coldness and weight in the abdomen, so that when she turns from one side to the other, she feels as if a heavy weight rolled over to that part of the abdomen which is lowest; the breasts are flabby, and sometimes there is a fetid slimy discharge from the vagina. These changes are accompanied by some or all of the following symptoms: the patient is seized with a sudden shivering, languor, and debility; she loses her appetite and spirits; the stomach and bowels become disordered; the breath is fetid, and the face pale, sallow, and of a dark leaden colour under the eyes. All these symptoms taken collectively will enable us to decide, with a tolerable degree of certainty, that the child is dead: but scarcely any of them alone can be trusted to. The most trust-worthy is the sensation of a heavy weight rolling about the abdomen: when the female turns in bed, rises from her chair, or in any way alters her position, this weight is felt as it were tumbling down to that side which is lowest. A woman who is pregnant with a living child, feels nothing of the sort; she may even dance or jump, and yet she feels no more of a living foetus than she does of her own liver or spleen. The living foetus obeys the laws of organic life; the dead foetus those of gravity. When once the child has ceased to exist, it acts like any other mass of inanimate matter, and pushes the uterus down to that side which is lowest. In most instances this symptom will be sufficient to make us suspect that the child is dead, but it now and then occurs where the result of labour proves the child to be alive; this must rather be looked upon as an exception to the rule, for it is not of frequent occurrence. We have observed it in two or three cases: it has been also noticed by Dr. E. Kennedy, (_op. cit._;) and, therefore, cannot invariably be looked upon as a certain sign of the child's death. We have observed it frequently in cases threatening abortion at an early period: in many it has been followed by premature expulsion, but in others the symptom has gradually disappeared as the health improves, and the patient has eventually been delivered of a living child at the full period. In these cases, we should rather attribute the source of this symptom to a loss of the firmness and tone peculiar to the uterine parietes during pregnancy, and which depends upon the increased activity of the circulation in them at this period: when this is considerably diminished, the uterine parietes will necessarily become more flaccid, and, therefore, less able to withstand the influence of gravity, or sustain the uterus in its proper situation. The embryo itself during the first two or three months is too small and too light to produce this symptom itself. The sensation (to the mother) of the child's movements is as fallacious an indication of the child's life as it is of pregnancy; nor can the absence of this sensation be looked upon as a proof of its death. Women are very liable to be misled in this respect; so much so, that it will be much safer for the practitioner never to allow his diagnosis to be at all influenced by their statements; the more so, as it applies equally to mothers of large families as to primiparæ. Thus cases every now and then occur where the patient declares her conviction that the child is dead; that she has not felt it move for several days before labour; that she feels altogether differently to what she did in any of her former pregnancies, and yet she is delivered of a healthy living child. On the other hand, we as frequently meet with cases where, up to the very commencement of labour, the patient asserts that she has distinctly felt the motion of the child, and yet she brings forth a child in such a state of decomposition as proves beyond all doubt that it must have been dead some eight, ten, or more days. As the sound of the foetal heart is the surest sign of pregnancy, so it is an equally certain proof of the child's life: but is the absence of this sound, a certain symptom of its death? at the best it is a negative evidence, and the value of it must entirely depend upon the skill of the ausculator and the care with which he makes his examination. If, after repeated and careful auscultation of the abdomen, the well-practised ear can no where detect a trace of the foetal pulsations, it may be asserted on very safe grounds that the foetus has ceased to live. This is more particularly the case during the last weeks of pregnancy, when the pulsations are stronger, and the bulk of the child, in proportion to that of the liquor amnii being absolutely, as well as relatively, greater. The distance between the heart and surface of the abdomen is less during the last weeks of pregnancy also; the child's movements are not so free as at an earlier period; and hence, if the foetal heart is beating, it will be more easily discovered. The uterine souffle affords us little aid in the diagnosis of the child's death: it is frequently very distinct when the child is evidently alive; and where it has been heard previous to its death, it will continue for some hours afterwards, although with diminished strength and over a smaller space. During labour there are a variety of symptoms, by the aid of which we can pronounce, with a very tolerable degree of certainty, whether the child is alive or not; if alive, the foetal heart can invariably be detected; and, for the reasons above stated, will be heard more distinctly than in the earlier months of pregnancy. If, from the violence or duration of the labour, or any other cause, the child is becoming exhausted, the pulsations become weaker and slower until they stop; so that by the aid of auscultation we possess distinct evidence of the child's life being endangered, and of its complete extinction. If the _head_ presents during labour, a firm elastic swelling (caput succedaneum) will rise on that portion of it which first enters the vagina: this is produced by the circulation in the presenting part of the scalp being obstructed by the pressure which the os uteri and vagina exert upon it, an effect which can only be produced upon the head of a living child: where, on the other hand, the child is dead, the scalp will be felt to be soft, flabby, and without swelling. This may be looked upon as a very certain proof of the child's death in primiparæ, where the head is advancing slowly, and where it is tightly encircled by the distended vagina. But in multiparæ, where the soft passages have been dilated by repeated labours, the pressure upon the head is so slight, and its passage through them so rapid, that little or no swelling is produced: even in these cases the finger of the accoucheur will easily distinguish the head of a dead child by the loose yielding flabby feel of its integuments; the cranial bones are more moveable, and overlap each other at the sutures more than usual; their edges feel sharp, as if no longer covered by the scalp; and frequently communicate a grating sensation when they rub against each other. The great fontanelle is flaccid and loose; the bones, which form it, appear falling together, from a want of sufficient contents to keep them asunder, a circumstance which probably arises from the circulation in the brain having ceased; and in those cases where the child has already been dead some time, a crackling or crepitous sensation is communicated to the finger from emphysema, the result of decomposition. The only case in which the swelling of the head is capable of misleading us, is in lingering difficult labours, where the child has been alive at the beginning, the swelling has formed, but from the duration and severity of the labour the child has died: wider such circumstances, a dead child may be born with the usual swelling of the cranial integuments which is observed in a living child. This can only happen where it has been expelled almost immediately after its death, for in two or three hours the swelling loses its former firm tense feel, and becomes so soft and flaccid, as not to be easily mistaken. If the face presents during labour, the flabby state of the lips will instantly lead us to suspect that the child is dead: the tongue is also flaccid and motionless. Whereas, in a living child the lips are firm and full; if the face be approaching the os externum, a considerable swelling will be felt on that side which presents; the tongue is firm, and frequently moves upon the finger. If the nates present, the state of the sphincter ani will be a sure guide in ascertaining whether the child be alive or not. If it be alive, it will be found closed, and will contract distinctly upon the finger; whereas, if dead, it will be relaxed, and insensible to the stimulus of the finger. In an arm presentation, where the child is alive, the arm will swell, and grow livid or nearly black; but if it be dead, no swelling will be observed, the arm will be very flabby, and where it has been dead some time, the epidermis will peel off. In this case, as in head presentations, the date of the child's death will more or less modify these appearances; if it has not taken place until some time after the commencement of labour, a dead child may be born exhibiting the swelling and discolouration above-mentioned. The pulse in the wrist of the prolapsed arm is no guide, as the very degree of pressure, which produces these changes in its appearance, will be generally sufficient to render it imperceptible. In cases where the cord has prolapsed, we have certain evidence with respect to the child's life: if alive the cord is firm, turgid, and distinctly pulsating; if dead, it is flaccid, empty, and without pulsation. Fetid liquor amnii, and the discharge of the meconium, have also been enumerated as signs of the child's death, which occur during labour. The first affords no proof whatever, as cases not unfrequently occur in which the liquor amnii is excessively fetid, and of a thick slimy consistence, and yet the child is born alive and healthy. The appearance of meconium during labour is a suspicious sign where the nates do not present, and will at any rate justify the supposition, that if the child be not actually dead, it is very weakly; in nates presentations, however, this will not hold good, for the meconium is constantly discharged during labour, where the child is in this position, and yet it will be born alive and well. CHAPTER IV. MOLE PREGNANCY. _Nature and origin.--Varieties.--Diagnostic Symptoms.--Treatment._ When any cause has occurred to destroy the life of the embryo during the early weeks of pregnancy, one of two results follows, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and continue to grow for some time longer, until at length they form a fleshy fibrous mass, called _mole_, or _false conception_.[47] It is well known that the venous absorbing radicles of the chorion, which give it that shaggy appearance during the first months of pregnancy are the means by which the embryo is furnished with a due supply of nourishment at this period: if the embryo should die from any cause, and the uterus show no disposition to expel the ovum, the nourishment which has been collected by the absorbing power of the chorion appears now to be directed to the chorion itself, which therefore puts on a fleshy growth and increases very rapidly in size. (Roederer, _Elementa Artis Obstetricæ_, p. 738.) In other instances, the thick fleshy character of the ovum is not produced by a growth of substance, but is the result of hæmorrhage from rupture of some of the vessels which run between the uterus and the ovum. In this case, if the placental cells be already formed, they become distended with the blood of the hæmorrhage which solidifies by coagulation; and not only render the chorion or incipient placenta much thicker and more solid, but give it also a lobulated tuberculated appearance: from the same reason, the little funis, which is probably not an inch long, is greatly distended, being in some cases as thick as the body of the embryo itself, the blood having penetrated from the placental cells into the cellular tissue of the chord. This is by no means an uncommon form of mole; externally it is covered by the decidua, which appears to be in a natural condition, and the inner surface of the cavity is lined by a fine membrane, having all the usual characters of the amnion. The lobulated appearance is chiefly seen from within, the amnion being raised by a number of irregular convexities. "When the blood is poured out from its containing vessels into the substance or cells of the placenta, or between the membranes, gradually coagulates, and assumes a very dark purple, and sometimes almost a melanotic black colour: after a time, however, it begins to lose this tint, the colouring matter gradually becomes removed, and the coagulum successively assumes a chocolate brown, a reddish or brownish yellow hue; and latterly, if time sufficient be allowed, it presents a pale yellowish white or straw-coloured substance, the fibrinous portion of the coagulum being then left alone."[48] This form of mole, as far as our own observation goes, seldom attains any considerable size, rarely exceeding four inches in length, and is usually expelled between the eighth and twelfth week. The size and condition of the foetus varies a good deal; in some cases it appears nearly healthy, although the cord is much thickened and distended; this is probably owing to its having been expelled shortly after its death, or to its having gone on to live a short time after the injury which had caused hæmorrhage: in this way alone can we explain why we occasionally meet with cases where the parietes of the ovum are much thickened and solidified, and yet the embryo is in such a state of integrity as to prove that its death must have been very recent. The extravasation of blood between the ovum and uterus does not appear to be sufficient to annihilate immediately the nutrition of the embryo, so that the blood has had sufficient time to solidify before the ovum was expelled. At other times the embryo exhibits evident marks of having been dead some time: it is much smaller and younger in proportion to the size of the ovum; sometimes it has disappeared entirely, a short rudiment of the funis merely remaining to mark its previous existence. "Should the embryo die (suppose in the first or second month) some days before the ovum is discharged, it will sometimes be entirely dissolved, so that when the secundines are delivered, there is nothing to be seen. In the first month the embryo is so small and tender, that this dissolution will be performed in twelve hours; in the second month, two, three, or four days will suffice for this purpose." (_Smellie._) Where the growth of the ovum proceeds after the destruction of the embryo, it increases very rapidly in size, much more so than would be the case in natural pregnancy, so that the uterus, when filled with a mole of this sort, is as large at the third month as it would be in pregnancy at the fifth. Another form of mole is where the uterus is filled with a large mass of vesicles of irregular size and shape like hydatids, which appear to be the absorbing extremities of the veins of the chorion distended with a serous fluid; it is difficult to distinguish these from real hydatids; the more so, as Bremser asserts that he has occasionally met with real hydatids among them. Perhaps the mode of their attachment will in some degree assist the diagnosis: these vessicles, or _hydatids of the placenta_, as they have been called, are attached over a large portion of the uterus,--an arrangement we believe, not generally seen in real hydatids, which are mostly attached to a single stalk or pedicle. Indeed, it may be doubted if the masses of vesicles which are occasionally expelled from the uterus are ever true acephalocysts, as they are invariably connected with a blighted ovum, and are, therefore, formed as before observed, by a dropsical state of the venous radicles of the chorion. A variety of other molar growths have also been enumerated by authors; in fact, "the term _mole_ has been rather vaguely applied to almost every shapeless mass which issued from the uterus, whether this proved to be coagulated blood, detached tumours, or a blighted conception." (Churchill, _on the Principal Diseases of Females_, p. 153.) Thus a fibrinous cast of the uterus, which has been formed by a coagulum of blood, from which the colouring matter has been drained, has been called a fibrous mole: these, however, may easily be distinguished from real moles, which are invariably the product of conception: from inattention also to this circumstance, fungoid, bony, and calcareous tumours have been described as so many species of moles.[49] _Diagnostic symptoms._ The diagnosis of a mole pregnancy is exceedingly obscure; in fact, for the first eight or ten weeks we know of no symptom by which we can distinguish it from natural pregnancy. As the death of the embryo is intimately connected with the first morbid changes in the condition of the ovum, and in most cases precedes them, the earliest symptoms which can excite our suspicions are those which indicate this event: thus we shall find that the face becomes pale and chlorotic, the digestion deranged, the breasts flaccid, with unusual lassitude, debility, and depression of spirits; many of the sympathetic affections which belong to early pregnancy, such as the morning sickness, nausea, &c. cease suddenly; in some cases, an attack of hæmorrhage comes on, and may be repeated several times, causing much loss of strength and exhaustion, and attended with a good deal of pain, more especially if the uterus be about to throw off its contents. In that form of mole where the parietes of the ovum have been thickened and lobulated by masses of coagulated blood, the uterus undergoes little or no more increase of size, but the mole, especially the hydatic, continues to grow rapidly; and the unusual increase in the size of the abdomen, as already mentioned, will be an additional reason for suspicion. In all cases, hæmorrhage sooner or later makes its appearance, the patient's health still farther declines, leucorrhoea comes on, followed by oedema of the feet, general breaking up of the health, and even incipient cachexia. Occasionally the discharge is excessively putrid and offensive. Where it is of the hydatic species, we can frequently ascertain its character by the expulsion of two or three hydatids which have separated from the main mass, or by the escape of some limpid colourless water resulting from the rupture of one or more of them. The expulsion of the mole itself clears up all doubts. The amount of hæmorrhage will chiefly depend upon the extent of surface by which the mole is attached to the uterus: hence it is observed to be greatest in cases of hydatic mole, from the large size of the mass to be expelled: indeed, under these circumstances, it is frequently more profuse than hæmorrhage from detachment of the placenta. The process of the expulsion itself resembles that of an abortion: pain in the back, groins, and lower part of the abdomen comes on, with more or less discharge of blood; at length bearing down pains succeed, and the mass is expelled. We cannot better describe the symptoms produced by the presence of a hydatic mole, and the mode of its expulsion, than by quoting a case from the work of Dr. Gooch, _on some of the most Important Diseases peculiar to Women_. "I was sent for to ----, a few miles from London, to see a lady, who, having ceased to menstruate for one month, and becoming very sick, concluded that she was pregnant. The next month she had a slow hæmorrhage from the uterus, which had continued incessantly a month when I saw her: she kept nothing on her stomach. On examining the uterus through the vagina, its body felt considerably enlarged, and there was a round circumscribed tumour in the front of the abdomen, reaching from the brim of the pelvis nearly to the umbilicus. I saw her several times at intervals of a fortnight, during which the hæmorrhage and the vomiting continued unrelieved: the peculiarity about the case was the bulk of the uterus, which was greater than it ought to be at this period of pregnancy; it felt also less firm than the pregnant uterus, more like a thick bladder full of fluid. Eleven weeks from the omission of the menstruation, she was seized with profuse hæmorrhage; towards evening there came on strong expelling pains, during which she discharged a vast quantity of something which puzzled her attendants. The next morning I found her quite well--her pain, hæmorrhage, and vomiting, having ceased. I was then taken into her dressing-room, and shown a large wash-hand basin full of what looked like myriads of little white currants floating in red-currant juice. They were hydatids floating in bloody water." _The treatment_ previous to the expulsion of the mole should be gently alterative and tonic; the chylopoietic functions should be kept in regular action, and the strength sustained. When hæmorrhage comes on, we must be guided a good deal by the quantity lost, and by the effect which it has upon the pulse. Generally speaking, when the pulse has been a good deal reduced in strength and volume, we shall find the os uteri relaxed and dilated, and in all probability a portion of the mass protruding into the vagina, which may be hooked down by the fingers, and thus the expulsion of the whole mass facilitated. For farther details regarding the management of such cases, we must refer to the chapter on premature expulsion of the ovum, between the symptoms and treatment of which, and of mole pregnancy, there is a close analogy. The after treatment will always be a matter of considerable importance, and will, in a great measure resemble that in abortion or mis-carriage. Patients who have suffered from a mole pregnancy generally have their strength seriously reduced and their health much broken: hence, they are liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long series of troublesome and even dangerous affections, the recovery from which will be slow and difficult, requiring a long course of tonic medicines, and removal to the sea-coast or some watering-place where there are chalybeate springs. CHAPTER V. EXTRA-UTERINE PREGNANCY. _Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance of the uterus._ The ovum when impregnated does not always quit the ovary and pass along the Fallopian tube into the uterus. It may remain in the ovary and become here developed; it may pass into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this canal, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence, extra-uterine pregnancy has been divided into three species, viz. _graviditas tuberia_, _ovaria_, and _ventralis_, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has called _graviditas in substantia uteri_, a modification probably of tubarian pregnancy. [Illustration: _a_ The uterus, its cavity laid open. _b_ Its parietes thickened, as in natural pregnancy. _c_ A portion of decidua separated from its inner surface. _d_ Bristles to show the direction of the Fallopian tubes. _e_ Right Fallopian tube distended into a sac which has burst, containing the extra-uterine ovum. _f_ The foetus. _g_ The chorion. _h_ The ovaries; in the right one is a well marked corpus luteum. _i_ The round ligament.] This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal hæmorrhage. In ventral pregnancy, the sac is attached to the abdominal viscera, and is usually imbedded among the convolutions of the intestines: hence the duration of extra-uterine pregnancy will depend upon its situation; thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the foetus will not only be carried to the full term, but far beyond that period, amounting to several years.[50] Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These attacks of pain are generally accompanied with very painful forcing and tenesmus, and not unfrequently with a discharge of bloody mucus from the vagina. In tubarian pregnancy, however, the case generally follows a much shorter course: the patient is suddenly seized with an acute pain in the lower part of the abdomen, followed by nausea and vomiting; she becomes faint and weak; the abdomen evidently increases in size (from effusion of blood into the cavity;) the debility becomes more alarming, and death quickly follows. In ovarian pregnancy the fatal termination is merely postponed till a later period, during which the patient has to undergo attacks of most terrible suffering: at length, after a paroxysm more than usually severe, and frequently attended with the sensation of something giving way in the abdomen, faintings come on, speedily followed by death. During the attacks there is obstinate constipation, which is attended with painful and fruitless efforts to evacuate the bladder and rectum; the face is pale, and expressive not only of the most acute suffering, but of great anxiety and mental depression; nevertheless, in the intervals of the attacks she feels easy, and appears well and cheerful. The termination of a ventral pregnancy is very different; after a time the foetus dies, and may either remain enclosed in the cyst for life, or it may be discharged in portions by means of an abscess, either through the intestines, uterus, vagina, or abdominal parietes. Cases have occurred where it has come away by the bladder; in the former case, where it is retained, it diminishes more or less in size, becomes hard and closely packed together, and, in some instances, encrusted with a layer of calcareous matter. It is to our venerable friend, the late Dr. Heim, of Berlin, that we are indebted for much curious and interesting knowledge respecting extra-uterine pregnancy. Although the symptoms in the very early stages are so obscure as to render it nearly impossible to detect its presence, he has nevertheless observed some facts connected with it, which are peculiar, and deserve to be noticed. No morning sickness has been observed in cases of extra-uterine pregnancy, a circumstance which can easily be accounted for, if we bear in mind the causes of morning sickness in natural pregnancy: the patient could only lie on the affected side, and the abdomen was observed to swell irregularly, not in the same manner as in regular pregnancy. In tubarian and ovarian pregnancy, the pain was in the pelvis, but in ventral pregnancy it occupied more or less the whole abdomen, the parietes of which were very tender upon pressure. In cases where the foetus died at an early period, the symptoms gradually disappeared after a time, especially when followed by the bursting of an abscess through the rectum or any other part. One of the most remarkable facts which Dr. Heim observed, was a peculiar whining tone of voice, with which the patient expressed her sufferings during a paroxysm of pain; so peculiar, that when once heard, the sound can never be mistaken. On several occasions Dr. Heim was enabled by means of this symptom alone to decide confidently as to the nature of the case the moment he entered the room, a fact which would appear scarcely credible had not the results of the cases proved the correctness of his assertion. A most interesting case of this sort occurred, which he pronounced to be ventral pregnancy, and when it had gone the full term gastrotomy was performed, a living child was extracted but the unfortunate mother perished: she could not be induced to submit to the operation until inflammation had come on, and she died in two days after. It must always remain a matter of great obscurity as to the immediate _causes_ of extra-uterine pregnancy, more especially of the ovarian and ventral species; and the more so as we are still ignorant of the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary immediately over the impregnated vesicle of de Graaf at the moment of conception. In many cases we are inclined to think that this function of the Fallopian tube is destroyed by adhesions between it and the ovary, a circumstance of not uncommon occurrence; but from the alteration in the shape and size of these parts, as also from the extensive adhesions which are usually found after death, in such cases it will ever be difficult, and perhaps impossible, to prove it. The _treatment_ of extra-uterine pregnancy must be chiefly guided by the prevailing symptoms: where any portion of the abdomen is very tender to the touch, leeches and warm fomentations will be required; the pain during the attacks can only be alleviated by frequently repeated opiates; and constipation must be carefully guarded against by laxatives and enemata between the paroxysms. Where an effort is made by nature to discharge the foetus by means of an abcess, the case will require all our care to sustain the powers of the system through a long protracted struggle. Portions of the foetus come away from time to time, and if the exit afforded them be by way of the intestine, the suffering produced is very great, particularly when any of the larger bones are passing. The presence of such a mass of semi-decomposed animal matter in the abdomen is of itself sufficient to injure the general health materially: hence it is that patients, during the process of expulsion, suffer greatly from severe attacks of fever, which recur from time to time. Where the abscess opens through the abdominal parietes, the whole is completed with much greater ease and safety to the patient: in some instances the tumour has been opened, and a foetus with a large quantity of putrid pus has been removed. (_Medical Obs. and Inquiries_, vol. ii. p. 369.) A case of ventral pregnancy has recently come under our care, a short account of which will enable the reader to understand the subject better than a mere enumeration of symptoms; the more so as we believe it to have been the first case of extra-uterine pregnancy in which the stethoscope has been used. The patient, æt. 32, and the mother of four children, was admitted, May 26, 1837, into St. Bartholomew's Hospital, under Dr. Latham, who kindly consigned her to our charge. She considers herself to be six months advanced in pregnancy; is continually suffering from attacks of acute pain in the lower part of the abdomen, both at the sides and front, causing her to moan from its great severity; this is accompanied with a constant dragging pain on the right side, and in the loins: the attacks of abdominal pain go off at intervals, leaving her comparatively easy. She is pale, with an anxious expression of face. Pulse 120, and firm. Tongue moist. Bowels very constipated. The abdomen is as large as in common pregnancy at the sixth month, but does not present the same uniform distension, being irregularly shaped. At the left hypogastrium is a soft tympanitic prominence of considerable extent, and appears, from its feel and also from auscultation, to consist of a large portion of the intestines pushed over to that side: at the inner edge of this tumour a solid mass, as large as the head of a six months' foetus, can be felt. Between this and the median line of the abdomen, and half way between the pubes and umbilicus, a small hard knob-like and moveable prominence is felt immediately beneath the abdominal parietes, and intensely painful to the touch. From this point, quite to the right side, the abdomen has a solid irregular feel; below this to the symphysis pubis, a very loud souffle is heard, synchronous with the mother's pulse, having all the characters of the uterine souffle in common pregnancy except its extraordinary loudness. Its limits, superiorly, are remarkably defined; below a transverse line, drawn half way between the umbilicus and pubes, it is heard in full strength, whereas, immediately above it the sound ceases: it is also heard some way to the right side. At the upper part of the right iliac region two ridge-like prominences, like the extremities of a child, may be felt close beneath the abdominal parietes. No trace of foetal pulsation can be heard over any part of the abdomen, although it has been carefully ausculted round to the loins: it was however distinctly heard the day before we saw her, by two gentlemen who are proficients in the use of the stethoscope, and whom we consider fully capable of judging in such a case. On examining per vaginam, the os uteri is found high up and backwards, barely within reach. Its edges are thick, soft, and closed; the cervix is short, and seems less than half an inch. The anterior portion of the inferior segment of the uterus feels somewhat firm and full, as if there was something in the uterus. We were confirmed in this respect by our friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country at the time, and who examined the case with us. He was at first induced to suppose that it was the head. We considered that it was the uterus more or less anteverted, the fundus being pressed forwards and downwards, and the os uteri backwards, by the extra-uterine cyst above; farther examinations tended to confirm this view. She states that the catamenia appeared last in November, during the middle of which month she was attacked with inflammation of the bowels, for which she was treated, and soon afterwards began to have the violent attacks of pain of which she now complains. She felt the child move at the usual time; it evidently formed the mass which occupies the lower part of the abdomen, and its movements appeared unusually close to the surface. During the last few days they have ceased altogether. The above-mentioned attacks of pain have continued to recur ever since at short intervals and with increasing severity. As leeches had been applied without relief, and as the pulse was quick and hard, she was ordered to be bled to eight ounces, and to take half a grain of morphia immediately. _June 2._--Has been in constant suffering, in spite of leeches and morphia; bowels obstinately constipated, but moved at length by repeated injections and doses of house medicine. Has not felt the motions of the child since the intestines have become tympanitic: still, however, the mass can be felt lying across the abdomen, half-way between the pubes and umbilicus, commencing from about three inches to the left of the median line, and extending to about four inches on the opposite side. On the left side it feels firm and rounded, and so superficial, that it can almost be grasped through the abdominal integuments. Face very pale and anxious. Pulse 120. _June 10._--Was easy and free from pain when we first saw her: the souffle is heard over a smaller extent; in the centre of the space where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circumference. As she was able to rise we examined her standing: the os uteri is exceedingly high up to the left sacro-iliac symphysis, so that it can scarcely be reached; the cervix is short, the lips somewhat larger than usual, and the whole very firm and immoveable. The anterior portion of the uterus, to be felt through the vaginal parietes, is somewhat firmer and larger than usual: on pressing the tumour in the left hypogastrium, this appeared to lie altogether anterior to the uterus. Little motion is communicated to the os uteri when this is moved. _June 20._--Has been in much suffering since last report; much emaciated; complains of a fetid taste in the mouth; bowels inclined to be purged; stools of a whitish purulent appearance; tongue clean; pulse tolerably natural; has continued to pass portions of fibrinous matter from the vagina, mixed with bloody mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pass round it: it has the precise feeling of the head; the mass which lies across the abdomen is also more distinct: the souffle is heard over a much smaller space and is diminished in strength. _June 27._--Much the same, except that, after severe bearing down and tenesmus, she has passed a considerable quantity of blood from the rectum and vagina. The little prominences on the right side, presumed to be the extremities, are remarkably distinct, like two heels or knees. _July 18._--No material change has taken place since last report; she has suffered from irregular attacks of pain, and has had repeated discharges of blood from the vagina, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular mass on the left side is lower and much nearer to the median line; the little prominences on the right are also lower, and nearer the median line; the whole mass appears much more compressed together and nearer to the pubes; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any trace of souffle to be heard. Shortly after this she left the hospital, and for some time continued to enjoy tolerable health, occasionally suffering from severe paroxysms of abdominal pain; the abdomen diminished considerably in size, and the various prominences became indistinct. In _May, 1839_, she was again admitted in a state of great exhaustion from constant severe pain. The abdomen had diminished still more, and a portion of the mass had descended between the uterus and rectum; the constipated bowels were moved with great difficulty, but with much relief. The symptoms gradually diminished, and she was discharged in the first week of the following _August_. In _January, 1840_, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early in _February_ she passed a quantity of putrid purulent matter from the rectum, after which the abdomen diminished considerably. The pain appeared to be chiefly situated in the upper part of the rectum, accompanied with severe bearing down, and on examining per vaginam the mass was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early in _February_. Our notes of the post mortem examination were as follows:-- Much emaciated, abdomen concave, but on pressing it the tumour can be felt at the brim of the pelvis. On opening the abdominal cavity, the mass was found adhering firmly to the neighbouring intestines, and on the right side to the soft linings of the pelvis: it was of an irregular form, with spots of livid vascularity in different parts: on the upper and left side of it, fetid purulent matter was seen exuding from a small orifice. The uterus was below, its fundus pushed over to the left side. On separating its adhesions, and attempting to raise the sac from the pelvis, the half-softened parietes gave way, and the decomposed putty-like mass of the foetus became visible; the cranial bones were at the left side; the feet were still distinct on the right side; the whole was immersed in a quantity of thick fetid pus, and there were no traces either of umbilical cord or placenta. Cases of ventral pregnancy have been recorded where the child has remained in the mother's abdomen without producing any dangerous symptoms, and where she has again become pregnant in the natural way. The earliest instance of this sort was recorded so long ago as by Albucasis. A very interesting case of this nature is described by Dr. Bard of New York. (_Med. Obs. and Inquiries_, vol. ii. p. 369.) It was the patient's second pregnancy; at the end of nine months she had pains, which after a time went off; the tumour gradually diminished somewhat, and in about five months after she conceived again, and in due time was delivered, after an easy labour, of a healthy child. "Five days after delivery she was seized with a violent fever, a purging, suppression, pain in the tumour, and _profuse fetid sweats_:" an abscess formed in the abdomen, which was opened, and a vast quantity of extremely fetid matter was discharged; the opening was enlarged, and a foetus of the full size was extracted. Dr. Bard "imagined the placenta and funis umbilicalis were dissolved in the pus, of which there was a great quantity." It becomes a question of deep interest whether it be really possible to save the patient and the child in cases of ventral pregnancy, by performing gastrotomy. The separation of the placenta from the walls of the cyst can only be effected with much difficulty and hazard; indeed, we are at a loss to conceive how it can be removed with any degree of safety, where the child has been found alive. The attachment in these cases was more than usually firm, and it has been left to undergo that process of solution which has been described in Dr. Bard's case. In all the cases where gastrotomy has been performed some time after the child's death, little or no trace of the placenta has been found, but in its place a quantity of ill-conditioned purulent matter, which was excessively fetid. The fourth species of extra-uterine pregnancy, which M. Breschet has described as taking place in the substance of the uterus, is of very rare occurrence, four cases only having been recorded by him. (_Med. Chir. Trans._ vol. xiii.) M. Breschet has attempted a variety of explanations of this singular anomaly, but without success; and from the circumstance of the cyst having always been found situated in the fundus to one side, the Fallopian tube of which was closed at its uterine extremity, we think that there can be little doubt of its having been a modification of tubarian pregnancy, where the ovum had been obstructed at that portion of the Fallopian tube where it passes obliquely through the wall of the uterus: in one case the tube appears to have given way at this part, and the ovum to have insinuated itself between the uterus and peritoneum. In these cases the sac ruptured at about the same period as in tubarian pregnancy, except in one instance, where she went five months. A rather inexplicable case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds (_Med. Obs. and Inquiries_, vol. iii.,) where a full grown foetus was found enclosed in a large sac, which filled the abdominal cavity, and which communicated inferiorly with the uterus. On tracing the umbilical cord, "we were led," says Mr. Hay, "to a large aperture in the right side of the inferior globular sac already mentioned, from which that which contained the foetus seemed to have its origin. This inferior sac we now found to be the uterus, containing a very thick placenta, which adhered very firmly to about three-fourths of its internal surface, having the navel string attached to its centre, and this centre corresponded nearly with the centre of the fundus uteri. The placenta filled up the greatest part of the aperture of communication between the uterus and sac. The Fallopian tube on the left side was very small; the place of that on the right was occupied by the beginning or orifice of the sac." (_Op. cit._) This would seem to have been a case of pregnancy in the substance of the uterus, and where a portion of the ovum had burst its way into the cavity of the uterus lined with decidua, to which it adhered; the other portion, containing the embryo, distended the uterine parietes in a contrary direction, and thus formed the large sac which communicated with the cavity of the uterus. CHAPTER VI. RETROVERSION OF THE UTERUS. _History.--Causes.--Symptoms.--Diagnosis.--Treatment.--Spontaneous terminations._ During the earlier months of pregnancy the uterus is liable, although rarely, to a peculiar species of displacement, called _retroversion_, in which the fundus is forced downwards and backwards into the hollow of the sacrum, between the rectum and posterior wall of the vagina, and its os and cervix are carried forwards and upwards behind the symphysis pubis. [Illustration: _a a_ Half the bladder on each side turned over the spine of the os ilium. _b_ Anterior extremity of the vertical incision by which the bladder was opened. _c_ One turn of the rectum, which was seen at the posterior end of the same incision. _W. Hunter._] Retroversion of the uterus appears to have been known to the ancients, as we find it alluded to by Hippocrates (_De Nat. Mulieb._ sect. 5.) and Philumenus (_Histoire de la Chirurg._ par Dujardin and Peyrhille, t. ii. p. 280.) Oetius, who has quoted the works of the celebrated Aspasia, describes this displacement of the uterus very exactly, and gives rules for introducing two fingers into the rectum, in order to remedy it. Rod. a Castro, who wrote in the sixteenth century, in his work on the diseases of women, quotes what Hippocrates had written on the subject of this displacement; and it is astonishing that no farther notice was taken of it until the eighteenth century, when it excited considerable attention among accoucheurs. (_Martin le Jeune_, p. 137.) Gregoire appears to have been the first who gave a good description of it; his pupil, Mr. W. Wall, on his return to England, met with what he considered to be a case of this displacement, and not being able to restore the uterus to its natural position, requested the advice of Dr. W. Hunter. On passing his finger between the os uteri and symphysis pubis, and thus removing, in some degree, the pressure upon the neck of the bladder, a considerable quantity of urine was discharged, but he was unable to return the uterus to its natural situation, and the patient gradually sunk. The bladder was found immensely distended; the lower part of it, "which is united with the vagina and cervix uteri, and into which the ureters are inserted, was raised up as high as the brim of the pelvis by a large round tumour, (viz. the uterus,) which entirely filled up the whole cavity of the pelvis. The os uteri made the summit of the tumour upon which the bladder rested, and the fundus uteri was turned down towards the os coccygis and anus." (_Medical Obs. and Inquiries_, vol. iv. 404.) _Causes._ This displacement may also occur in the unimpregnated state, either from the fundus being pushed into that position by some morbid growth, or where this effect has been produced by the violent pressure of the abdominal muscles in lifting heavy weights, under circumstances where the uterus has been larger and heavier than usual;[51] but it is in the early months of pregnancy that it is most likely to happen, because now the fundus is both larger and heavier than before, and, therefore, more liable to be affected by the pressure of the intestines and abdominal muscles, and has not yet attained a sufficient size to prevent its undergoing this displacement in the pelvis: this period is about the third or fourth month, often before it, but never after it. (Burns's _Anatomy of the Gravid Uterus_, p. 17.) It has been supposed by many authors, especially Dr. Burns, that distension of the bladder is, in many instances, the immediate cause of retroversion, owing to the intimate connexion which exists between the lower part of the uterus and this organ, inasmuch, "that whenever the bladder rises by distension, the uterus must rise also." In the later editions of his work on the principles of midwifery, he has considerably modified this opinion, and from careful examination of the parts in situ, in the third month, is not disposed to consider the distension of the bladder as the cause, but the effect of retroversion. In every case which has come under our own observation, the bladder has not been distended until the retroversion had taken place, in consequence of which the os and cervix uteri had been tilted up behind the symphysis pubis, and having thus compressed its neck had caused the difficulty in passing water.[52] Whenever any force is applied to the fundus uteri at this period of pregnancy, either from external violence, or the action of the abdominal muscles pressing the intestines and bladder against it, it will be pushed against the rectum, in which case the rectum will be flattened at that part against which the fundus rests; and if any mass of fæculent matter be passing along the intestine, its course will be obstructed at this point, and the rectum quickly become distended with an accumulation of fæces above, by which means the fundus will not only be prevented from rising, but in all probability be forced still lower down. If the force which has originally pushed the fundus backwards be of sufficient degree and duration to carry it past the promontory of the sacrum, the increase of space which it will meet with in the hollow of the sacrum, and the straining efforts which are induced by the displacement itself, contribute powerfully to complete the mischief, and to bring the fundus so low into the pelvic cavity as at length to turn it nearly upside down. As soon as the fundus of the uterus is pressed with any degree of force against the posterior parietes of the pelvis, its os and cervix will be directed forwards and upwards against the symphysis pubis, and from the pressure which they exert against the neck of the bladder, the patient either experiences complete retention of urine, or, at any rate, considerable difficulty in passing it; hence, therefore, we find, that where retroversion has come on suddenly, the patient is generally sensible of the pain produced by the displacement, before she has experienced any difficulty in evacuating the bladder. A modern French author of great experience, (_Martin le Jeune_, p. 178,) in enumerating the causes of retroversion, appears to take a similar view of the subject, and places retention of urine very far down in his list. "Sudden and violent contractions of the abdominal muscles and diaphragm in attempting to vomit, to evacuate the bowels or bladder, or to lift heavy weights; the throes during an abortion at an early period of pregnancy; strong mental emotions; retention of urine; tumours in the neighbourhood of the fundus, which by their weight or pressure force it backwards towards the sacrum, are the causes which may produce a retroversion of the uterus." Retroversion may also come on gradually, from "the uterus remaining too long in that situation which is natural to it when unimpregnated, namely, with its fundus inclined backwards. This may depend on various causes; such as too great width of the pelvis, or the pressure of the ileum full of fæces on the fore part of the uterus. In this case the weight of the fundus must gradually produce a retroversion, and she will be sensible of its progress from day to day." (Burns's _Anat. of the Gravid Uterus_. p. 18.) It will thus be seen how peculiarly liable the uterus is to retroversion during the early months of pregnancy. At this time, the fundus is not yet free from the weight of the superincumbent coils of intestine; and if from any cause its ascent out of the pelvis be delayed beyond the usual time, its liability to retroversion is still farther increased; for, not only does the size of the fundus press it still farther backward, but any sudden contractions of the abdominal muscles, or external violence, act upon it with increased effect. The _symptoms_ of this displacement are as follow:--the patient is seized with violent pain, bearing down, and sense of distension about the hollow of the sacrum, with a feeling of dragging and even tearing about the groins, produced by the violent stretching of the broad and round ligaments; the bearing down is sometimes so severe and involuntary as to resemble labour pains, and cases have occurred where it has been mistaken for labour. With all this she finds herself unable to pass fæces or urine, from the pressure of the fundus upon the rectum and of the os uteri upon the neck of the bladder. Upon examination per vaginam, the altered position and form of this canal instantly excite our suspicion: instead of running nearly in a straight direction backwards and somewhat upwards, it now takes a curved direction upwards and forwards behind the symphysis pubis; the hollow of the sacrum is occupied with the globular and nearly solid mass, (the fundus uteri,) which is evidently behind the vagina, the posterior wall of this canal being felt between it and the finger; behind the symphysis pubis, the vagina is more or less flattened, and its anterior wall put violently upon the stretch, so much so that, according to Richter, the orifice of the urethra is sometimes dragged up above the pubic bones, (_Anfangsgründe der Wundarztneikunst_, vol. ii. p. 45:) the os uteri is found high up behind the symphysis pubis, and in most cases can be reached, although with much difficulty; sometimes we shall be able to reach the posterior lip only, which is now the lowest: but "if the retension of urine has been of some duration, it will be impossible to reach the os uteri above the pubic bones with the finger. On examining per rectum, we shall feel the same tumour pressing firmly upon it, and preventing the farther passage of the finger, thus proving that the tumour is situated between the rectum and the vagina; for, in such cases, the bladder forms a considerable swelling below it, and prevents the finger from passing up." (_Op. cit._) "The uterus being situated in the centre of the pelvis, between the rectum and bladder, its retroversion cannot take place without deranging the functions of these organs: the symptoms thus produced come on rapidly when the displacement is sudden, slowly when it is gradual. Their severity is in proportion to the size of the uterus, the degree of retroversion, its duration, and the various circumstances which increase the impaction of the uterus in the cavity of the pelvis: they also determine the degree of inflammation and gangrene of this organ and the neighbouring parts." (_Martin le Jeune_, p. 178.) Hence we frequently observe in the earlier stages of retroversion, before the displacement has become complete, that the patient is able to relieve the bladder to a certain extent, although very imperfectly, and that with some difficulty; a slight dribbling of urine continues to a very advanced stage, when the bladder is enormously distended, and upon the point of bursting: this is not so much the case with the rectum, the passage of fæces being generally completely obstructed at an early period, partly from the pressure of the fundus against it, and partly from the solid nature of its contents. "When such suppressions once begin they aggravate the evil, not merely by causing pain, but by occasioning a load of accumulated fæces in the abdomen above the uterus, which presses it still lower into the cavity of the pelvis, at the same time that the distension of the bladder in this state draws up that part of the vagina and cervix uteri with which it is connected, so as to throw the fundus uteri still more directly downwards." (Dr. W. Hunter, _Med. Obs. and Inquiries_, vol. iv. p. 406.) These conditions of the bladder and rectum, and the retroversion of the uterus, act reciprocally as cause and effect; for the continuance of the distension of the bladder and the descent of the fæces from the part of the intestine above the obstruction, must elevate still more the os uteri, and depress to a still greater degree the fundus. The retroversion, on the other hand, increases the affection of the bladder and rectum, from which the principal danger of the disease arises. (Burns's _Anat. of the Gravid Uterus_.) The _diagnosis_ of retroversion is, generally speaking, not very difficult, the os uteri tilted up behind the symphysis pubis, and the fundus forced downwards and backwards between the vagina and rectum, are sufficiently characteristic of this displacement. We cannot agree with Dr. Dewees that it can easily be mistaken for prolapsus uteri; in cases of sudden prolapsus which has been caused by great violence, there will be, it is true, intense pain in the pelvis, with sensation of forcing and tearing in the direction of the broad and round ligaments; there will also, probably, be inability to evacuate the rectum and bladder; but then the examination, per vaginam, will present such a totally different condition of parts as to preclude all possibility of mistake: the vagina merely shortened, neither altered in direction or form; the os uteri at the lower part of the tumour, which is in the vagina; the mobility of the tumour itself, all conspire to show that the case is one of prolapsus not retroversion. We occasionally meet with cases of retroversion where the os uteri, although carried more or less upwards and forwards, is not forced, to that extreme height behind the symphysis pubis as is usually observed. Instead of looking towards, or rather above, the symphysis, the os uteri itself looks downwards, the neck or lower part of the body of the uterus being bent upon the fundus like the neck of a retort.[53] If, under such circumstances, we cannot satisfy ourselves as to the existence of pregnancy, we might easily be led to form an erroneous diagnosis, and to conclude that some tumour had forced itself down into the hollow of the sacrum, between the rectum and vagina, and had thus pushed the uterus upwards and forwards, above the brim of the pelvis. An extra-uterine ovum of the ventral species may occupy this situation, but its slow and gradual growth, its greater softness and elasticity, and the slight degree of uterine displacement produced in its early stages, would enable us to ascertain its real character. The same would hold good to a certain extent with an ovarian tumour, although in all probability this would produce more or less displacement of the uterus to one side. The danger in retroversion of the uterus chiefly arises from the distension or rupture of the bladder, and from the gangrenous inflammation which may then take place, not only in it, but also in the uterus and neighbouring parts. The very displacement itself is sometimes immediately attended by alarming symptoms, such as faintness, vomiting, cold sweats, weak irregular pulse, as seen in cases of inversion or strangulated hernia. In some cases the suffering at first is but trifling, and only increases in proportion to the degree with which the bladder is distended. Retroversion not reduced may experience a spontaneous termination in two ways, either by abortion being excited, after which the uterus, now diminished in size, returns to its natural situation, or it may go on to increase in this position until a more advanced period of pregnancy, when if it be not capable of being replaced by the action of the pains, sloughing takes place in the fundus, and the foetus is discharged, either by the rectum or vagina, as in a case of ventral pregnancy. In the _treatment_ of retroversion of the uterus, our object should be, first, to remove the accumulated contents of the bladder and rectum, and secondly, to endeavour to restore the uterus to its natural position. The relief of the bladder must be our first aim, for here is the greatest source of danger. The elastic catheter should always be used in these cases, and greatly facilitates the operation of drawing off the water. The altered direction of the urethra must be borne in mind; in many cases we must pass the catheter nearly perpendicularly behind the symphysis pubis: by pressing the uterus backwards, we shall diminish its pressure upon the urethra, and thus enable the catheter to pass with great ease.[54] "The catheter should be employed occasionally, and the bowels emptied daily, either by medicines of a mild kind, or by injections: if this plan do not succeed in restoring the fundus, we should then consider the propriety of mechanically replacing it. To aid us in our judgment, we should consider, first, the period of gestation; secondly, the degree of development the uterus has undergone; thirdly, the nature and severity of existing symptoms. The period of gestation ought almost always to influence our conduct in this complaint, and we may lay it down as a general rule, the nearer that period approaches four months, the greater will be the necessity to act promptly in procuring the restoration of the fundus: the reason for this is obvious, every day after this only increases the difficulty of the restoration from the continually augmenting size of the ovum. The degree of development should also be taken into consideration, as some uteri are much more expanded at three months, than others are at four. The extent or severity of symptoms must ever be kept in view; as, for instance, where the suppression of urine is complete, and not to be relieved by the catheter, in consequence of the extreme difficulty and impossibility to pass it: here we must not temporize too long, lest the bladder become inflamed, gangrenous, or burst; for the bladder, from its very organization, cannot bear distension beyond a certain degree, or beyond a certain time, without suffering serious mischief." (Dewees, _Compend. Syst. of Midwifery, 6th Ed._ § 276.) Our next step should be to relieve the rectum of its contents by emollient enemata; this is not always very practicable, owing to the flattened state of it: hence a glyster pipe of the ordinary sort is too large, and meets with much resistance; in such cases it will be desirable to use a common elastic catheter, or thin elastic tube without an ivory nozzle, which will, therefore, better adapt itself to the form of the bowel. A few doses of a saline laxative should be given to render the contents of the bowels more fluid, and the enemata repeated until a sufficient evacuation has been effected. Where the retroversion is not of long standing, and the patient not far advanced in her pregnancy, these means are generally sufficient; and the uterus, in the course of a few hours, will return to its natural position, either spontaneously or with very slight assistance. Where, however, the uterus is large and firmly impacted, where it has already been displaced more than twenty-four hours, where the suffering from the very beginning has been acute, independently of that produced by the distended bladder, we cannot expect that the spontaneous replacement will follow the mere removal of the accumulated urine and fæces; nor must the uterus be suffered to remain in the state of retroversion, as not only will its pressure on the neighbouring parts produce serious mischief, but from the increasing growth of the ovum, every day will add to the difficulty of moving it out of the pelvis. In determining upon the artificial reposition of the uterus, it must be borne in mind that the chief difficulty is to raise the fundus above the promontory of the sacrum, for if we can once succeed in gaining this point, the rest will follow of itself; our object, therefore, will be to raise the fundus upwards and forwards, in a direction towards the umbilicus of the patient. To effect this purpose various methods have been proposed: some have recommended that, with a finger in the vagina, we should hook down the os uteri, while with one or two fingers of the other hand passed into the rectum, we endeavour to push the fundus out of the hollow of the sacrum. Some object to any attempt being made through the rectum. (Naegelé, _Erfahrungen und Abhandlungen_, p. 346.) We agree with Richter in the utter inutility of attempting to bring down the os uteri; in most instances we can barely reach it with the tip of the finger, and even were we able to lay hold of it, we should run little or no chance of moving it so long as the fundus is impacted in the hollow of the sacrum. The fingers which are in the vagina must endeavour to raise the fundus, and in doing so may be assisted by one or two fingers in the rectum according to circumstances; the very effort to press per vaginam against the fundus, necessarily puts the anterior wall of the vagina upon the stretch, and thus tends of itself to bring the os uteri downward.[55] In all cases where the reposition of the uterus is at all difficult, Professor Naegelé recommends the introduction of the whole hand into the vagina, by which we gain much greater power. Under such circumstances it is desirable to place the patient upon her knees and elbows, as in a difficult case of turning, because now the very weight of the fundus will dispose it to quit the pelvis. The only difficulty which we shall meet with in thus using the whole hand, is the violent straining and efforts to bear down, which the patient is involuntarily compelled to make, from the presence of the hand in the vagina. Dr. Dewees in such cases very judiciously recommends bleeding to fainting, not only to obviate these efforts which would have prevented our raising the fundus, but also to relax the soft parts as much as possible. In our attempts to replace the uterus we must not be discouraged by finding that at first no impression is made upon it; by degrees it will begin to yield, and with a little more perserverance we shall be enabled to push the fundus above the promontory of the sacrum. (See Mr. Hooper's Case, _Med. Obs. and Inquiries_, vol. v. p. 104.) Where the pain in the pelvis indicates considerable pressure of the uterus upon the surrounding parts, arising probably from swelling and engorgement with blood, the result of vascular excitement, a smart bleeding will afford great relief; the size and firmness of the tumour are diminished, the soft parts in which it is imbedded are relaxed, the general turgor and sensibility are alleviated, and if the moment of temporary prostration which it has produced be seized upon by the practitioner, he will find that the reposition of the uterus, which was before nearly impracticable, is now comparatively easy. Where, however, the circumstances of the case are so unfavourable, and the fundus so firmly impacted in the hollow of the sacrum as to resist the above-mentioned means, Dr. Hunter proposed, "Whether it would not be advisable, in such a case, to perforate the uterus with a small trocar or any other proper instrument, in order to discharge the liquor amnii, and thereby render the uterus so small and so lax as to admit of reduction." (_Med. Obs. and Inq._ vol. iv. p. 406.) Dr. Hunter did not live to see this plan carried into execution. In latter years, several cases of otherwise irreducible retroversion have thus been successfully relieved: the remedy, it is true, necessarily brings on premature expulsion of the foetus sooner or later. Under such circumstances, this result cannot be made a ground of objection. In cases of such severity as to require paracentesis uteri, there can be little or no chance of the foetus being alive; and even if it were, of what avail would this be, when almost certain death is staring the mother in the face, unless relieved by this operation?[56] Puncture of the bladder has also been tried where the urine could not be drawn off.[57] Cases have now and then been met with where the retroversion of the uterus has continued to an advanced period of pregnancy without producing serious injury to the patient: Dr. Merriman has even recorded some, where the uterus has continued in this state up to the full term. Some of these had been actually published as cases of ventral pregnancy; but for their history he has shown that they evidently were cases of retroversion: the patient had been subject to occasional suppressions of urine and difficulty in passing fæces; these symptoms had gradually diminished as pregnancy advanced; the os uteri could not be felt, or, if it were capable of being reached, was found high up behind the pubes, the head of the child forming a large hard tumour between the rectum and vagina. The condition of the vagina afforded strong evidences of the nature of the complaint: on introducing the finger in the usual direction, it was stopped, as if in a cul-de-sac: but on passing it forwards, the vagina was found pulled up behind the symphysis pubis. In some of these cases the uterine contractions gradually restored the fundus to its natural position: the os uteri descended from behind the symphysis, and the child was born after long protracted suffering; in others, which have been mistaken for ventral pregnancy, the fundus has inflamed and ulcerated, and the child has been gradually discharged by piecemeal. CHAPTER VII. DURATION OF PREGNANCY. There are few questions of great importance and interest respecting a subject under our daily observation, about which such uncertainty and so much diversity of opinion exists, as the duration of human pregnancy; and yet, as is the case with the diagnosis of pregnancy, upon a correct decision frequently depend happiness, character, legitimacy, and fortune. In like manner it frequently happens, that the data upon which we have to found our opinion are exceedingly doubtful and obscure; and to increase the difficulties of the investigation still farther, we have not uncommonly to contend with wilful deception and determined concealment. The duration of pregnancy must ever remain a question of considerable uncertainty so long as the data and modes of calculation vary so exceedingly. "Some persons date from the time at which the monthly period intermits; others begin to calculate from a fortnight after the intermission; some reckon from the day on which the succeeding appearance ought to have become manifest; some are inclined to include in their calculation the entire last period of being regular; and others only date from the day at which they were first sensible of the motions of the infant."[58] "A good deal of the confusion on this point seems to have arisen from considering forty weeks and nine calendar months as one and the same quantity of time, whereas, in fact, they differ by from five to eight days. Nine calendar months make 275 days, or if February be included, only 272 or 273 days, that is thirty-nine weeks only instead of forty. Yet we constantly find in books on law, and on medical jurisprudence, the expression "nine months or forty weeks." Another source of confusion has evidently had its origin in the indiscriminate use of lunar and solar months, as the basis of computation in certain writings of authority."[59] It is owing to this uncertainty that a considerable latitude has been allowed by the codes of law in different countries for the duration of pregnancy, in order to prevent the risk of deciding where the data are so uncertain. Experience has shown that the ordinary term of human pregnancy, wherever it has been capable of being determined with any degree of accuracy, is 280 days or forty weeks; and this period seems to have been generally allowed even from the remotest ages. As, however, it is so difficult to fix the precise moment of conception, it has been customary in different countries to allow a certain number of days beyond the usual time; thus the Code Napoléon ordains 300 days as the extreme duration of pregnancy, allowing twenty days over to make up for inaccuracy of reckoning. In Prussia it is 301 days, or three weeks beyond the usual time. In this country the limit of gestation is not so accurately determined by law, and therefore gives rise occasionally to much discrepancy of opinion. The grand question which this subject involves, is, whether a woman can really go beyond the common period of gestation. A great number of authors have considered that the _partus serotinus_, or over-term pregnancy, is perfectly possible; but by far the majority use such an uncertain mode of reckoning that little confidence can be placed in them. Two questions here arise, the determining of which will greatly assist us in forming a correct view of this intricate subject, viz. _first_, what has been the duration of those cases of pregnancy where the moment of conception has been satisfactorily ascertained? _secondly_, what are the causes which determine the period at which labour usually comes on? The circumstances under which it happens that we are able to ascertain the precise date of impregnation occur so rarely, that it is nearly impossible to collect any considerable number of such cases. Three have occurred under our own notice, in which there could be little doubt as to the accuracy of the information given, and in each of these the patient went a few days short of the full period. One, a case of rape, was delivered on the 260th day; in the two others, sexual intercourse had only occurred once; in one case she went 264, in the other, 276 days. We could have mentioned several others, but where even the slightest shadow of doubt as to their accuracy has existed, we have rejected them as inconclusive. The mode of calculating the duration of pregnancy, which is ordinarily adopted, viz. by reckoning from the last appearance of the catamenia, although the chief means which is afforded us for so doing, is nevertheless much too vague and uncertain to ensure a decided result; for although it is a well-known fact, that conception very frequently takes place shortly after a menstrual period, there can be no doubt that it is liable to occur at any part of the catamenial interval, and particularly so shortly before the next appearance: hence, by this mode of reckoning, we are not more justified in expecting labour in nine months time from the last appearance of the catamenia, than at any part of the interval between this and what would have been the next appearance. Dr. Merriman, who has devoted much attention to this intricate but important subject, says, "When I have been requested to calculate the time at which the accession of labour might be expected, I have been very exact in ascertaining the _last day_ on which any appearance of the catamenia was distinguishable, and having reckoned 40 weeks from this day, assuming that the _two hundred and eightieth_ day from the last period was to be considered as the legitimate day of parturition" (_Synopsis of Difficult Parturition_, p. xxiii. ed. 1838;) and gives a valuable table of "one hundred and fifty mature children, calculated from, but not including, the day on which the catamenia were last distinguishable." Of these, 5 were born in the 37th week, 16 --- in the 38th, 21 --- in the 39th, 46 --- in the 40th, 28 --- in the 41st, 18 --- in the 42nd, 11 --- in the 43rd; so that about one-third were born three weeks after the 280 days from the last appearance of the catamenia; a circumstance which is perfectly easy of explanation, from what we have just observed, without the pregnancy having overstepped its usual duration: in other words, it would appear that 28 of these cases had conceived one week, 18 two weeks, and 11 three weeks after the last appearance of the catamenia. The question therefore of the _partus serotinus_; as far as these data are concerned, remains still undecided: of 10 cases which have occurred under our own immediate notice, where the patients determined the commencement of their pregnancy from other data than the last appearance of the catamenia, a similar variation was observed, viz. that nearly one-third went beyond 280 days, six of these individuals reckoned from their marriage, and four from peculiar sensations connected with sexual intercourse, which convinced them that impregnation had taken place: of these, seven did not go beyond the 280th day, two having been delivered upon that day, and three went beyond it, viz. to the 285th, 288th, and 291st days: the two former reckoned from their respective marriages; the latter, who went 291 days, from her peculiar sensations. The calculation from the date of marriage is liable to the same objections as that taken from the last appearance of the catamenia; for if it had been solemnized (as is usually the case where it is possible) shortly after a menstrual period, and if conception did not take place until a fortnight or three weeks afterwards, the patient's pregnancy would thus have appeared to have lasted so much longer than the natural term. The case, however, which is stated to have gone 291 days, does not come under this head, for here the pregnancy really appears to have lasted 10 or 11 days beyond the full period, which cannot be accounted for in the way above mentioned: we should not have ventured to quote this, if a similar instance had not been recorded by Dr. Dewees. "The husband of a lady, who was obliged to absent himself many months, in consequence of the embarrassment of his affairs, returned, however, one night clandestinely, and his visit was only known to his wife, her mother, and ourselves. The consequence of this visit was the impregnation of his wife; and she was delivered of a healthy child in 9 months and 13 days after this nocternal visit. The lady was within a week of her menstrual period, which was not interrupted, and which led her to hope she had suffered nothing from her intercourse; but the interruption of the succeeding period gave rise to the suspicion she was not safe, and which was afterwards realized by the birth of a child."[60] Although it is to be regretted that this case has been calculated in the ordinary vague manner of calendar months, yet it is perfectly evident that the pregnancy was longer than the ordinary duration. We shall, therefore, endeavour to investigate the possibility of over-term pregnancy still more closely by a consideration of the second question, viz. what are the causes which determine the period at which labour usually comes on? It is now ten years ago since we first surmised that "the reason why labour usually terminates pregnancy at the 40th week is from the recurrence of a menstrual period at a time during pregnancy when the uterus, from its distension and weight of contents, is no longer able to bear that increase of irritability which accompanies these periods without being excited to throw off the ovum." Under the head of PREMATURE EXPULSION, we shall have occasion to notice the disposition to abortion which the uterus evinces at what, in the unimpregnated state, would have been a menstrual period: for some months after the commencement of pregnancy, a careful observer may distinctly trace the periodical symptoms of uterine excitement coming on at certain intervals, and it may be easily supposed that many causes for abortion act with increased effect at these times. Where the patient has suffered from dysmenorrhoea before pregnancy, these periods continue to be marked with such an increase of uterine irritability as to render them for some time exceedingly dangerous to the safety of the ovum. Even to a late period of gestation, the uterus continues to indicate a slight increase of irritability at these periods, although much more indistinctly; thus, in cases of hæmorrhage before labour, especially where it arises from the attachment of the placenta to the os uteri, it is usually observed to come on, and to return, at what in the unimpregnated state would have been a menstrual period. We mention these facts as illustrating what we presume are the laws on which the duration of pregnancy depends, and also as being capable of affording a satisfactory explanation of those seeming over-term cases which are occasionally met with. From this view of the subject it will be evident, that the period of the menstrual interval at which conception takes place, will in great measure influence the duration of the pregnancy afterwards; that where it has occurred immediately after an appearance of the menses, the uterus will have attained such a dilatation and weight of contents by the time the ninth period has arrived, that it will not be able to pass through this state of catamenial excitement without contraction, or, in other words, labour coming on: hence it is that we find a considerable number of labours fall short of the usual time, so much so that some authors have even considered the natural term of human gestation to be 273 days or 39 weeks: for a somewhat similar reason we can explain why primiparæ seldom go quite to the full term of gestation, the uterus being less capable of undergoing the necessary increase of volume in a first pregnancy than it is in succeeding ones. On the other hand, where impregnation has taken place shortly before a menstrual period, the uterus, especially if the patient has already had several children, will probably not have attained such a volume and development as to prevent its passing the ninth period without expelling its contents, but may even go on to the next before this process takes place: it is in this way that we would explain the cases related by Dr. Dewees and Dr. Montgomery. We are aware that, under such a view of the subject, the duration of time between the catamenial periods of each individual should be taken into account, some women menstruating at very short, and others at very long, intervals; but although this will affect the number of periods during which the pregnancy will last, it will not influence the actual duration of time, as this will more immediately depend upon the size and weight of contents which the uterus has attained. The valuable facts collected by M. Tessier respecting the variable duration of pregnancy in animals, which have been quoted by some authors in proof of the partus serotinus, are scarcely applicable to this question in the human subject; the absence of menstruation, and the different structure of the uterus, prevent our making any close comparison. CHAPTER VIII. PREMATURE EXPULSION OF THE FOETUS. _Abortion.--Miscarriage.--Premature labour.--Causes.--Symptoms.-- Prophylactic measures.--Effects of repeated abortion.--Treatment._ The uterus does not always carry the ovum to the full term of pregnancy, but expels it prematurely. This expulsion of its contents may occur at different periods, and is characterized accordingly: thus, among most of the Continental authors, it has been divided under three heads; those cases which occur during the first sixteen weeks coming under the head of _abortion_; those which occur between this period and the twenty-eighth week are called _miscarriages_; and when they take place at the latter period, until the full term of utero-gestation, they receive the name of _premature labours_. It is perhaps useful to distinguish those cases of premature expulsion which occur before from those which occur after the fourth month, inasmuch as they seldom prove dangerous before that time, from the diminutive size of the ovum and from the slight degree of development which the uterine vessels have undergone; whereas, after this period the hæmorrhage is more severe, and the general disturbance to the system greater. In other respects it will be more simple to divide premature expulsion of the ovum under two heads only; those cases which happen before the twenty-eighth week, or seventh month, being termed _abortions_, and after this period (as before) _premature labours_. This division is highly important in a practical point of view, since it marks the period before which the child has little chance of being born alive; whereas, after this date it may with care be reared.[61] A foetus may be expelled, at a very early stage of pregnancy, not only alive but capable of moving its limbs briskly for a short time afterwards, but it is unable to prolong its existence separate from the mother beyond a few hours. Cases do occur now and then where a child is born in the sixth month, and where it manages to struggle through, but these are rare, and must rather be looked upon as exceptions to the general rule. Abortions usually occur from the eighth to the twelfth week, a period which is decidedly the least dangerous for such accidents. "The liability to abortion is greater in the early than in the later periods of pregnancy; for as the union between the chorion and decidua is not well confirmed, as the attachment of the latter to the internal face of the uterus is proportionably slight, and as the extent of surface which the ovum now presents is very small to that which it offers in the more advanced state of pregnancy, and as it can of course be affected by smaller causes, it will be seen that a separation will be more easily induced, and prove much more injurious to the well-being of the embryo, than a larger one at another stage." (Dewees, _Compendious System of Midwifery_, § 929.) Abortions coming on at a later period, viz. from the sixteenth to the twenty-eighth week, which corresponds to the second division, or _miscarriages_, of the continental authors, are not only more dangerous than abortions at an early stage, for the reasons above-mentioned, but also than premature labours, as in this last division the uterus has attained such a size as to make the process rather resemble that of natural labour at the full term. _Causes._ Premature expulsion may be induced by a great variety of causes, which may be brought under the two following heads: those which act indirectly, by destroying the life of the embryo, and those which act directly on the uterus itself. These various causes may be general or local; the process of nutrition for the growth and development of the embryo may be defective and scanty, from general debility or disease: hence, whatever depresses the tone of the patient's health renders her liable to abortion by causing the death of the embryo. Thus, dyspepsia and derangement of the chylopoietic viscera; debilitating evacuations; depressing passions of the mind; bad or insufficient nourishment; intense pain, as in toothach; severe suffering from existing disease, especially where the health is much broken down by some chronic affection; syphilis, and febrile attacks, all act as indirect causes of abortion.[62] Salivation from mercury not unfrequently has a similar effect; in some instances, however, febrile affections appear to act much more directly, stimulating the uterus to powerful contractions and rapid expulsion of its contents. The symptoms which indicate the death of the child have already been detailed in the chapter upon that subject. The period which may elapse between the death and the expulsion of the embryo varies exceedingly: in the early months the one usually follows the other pretty quickly, owing probably to the slight attachment of the ovum to the uterus; during the middle third of pregnancy the interval may be of considerable duration, and cases every now and then occur where the foetus is retained, not only several weeks, but even some months after its death; whereas, during the latter third of pregnancy, expulsion follows the death of the child after a short interval, seldom exceeding two or three days; for now the weight of the dead foetus speedily irritates the uterus to contraction, and, as has been observed by Smellie, the membranes, running gradually into putrefaction, and being now unable to bear the weight of the liquor amnii, burst, and expulsion soon follows. Among the causes which act locally in inducing premature expulsion by first destroying the child, may be enumerated external violence applied to the abdomen, such as blows, falls, and other violent concussions; these act indirectly by producing separation of the ovum from the uterus, and thus destroying the life of the child. Under the same head may be classed all violent exertions, as lifting heavy weights, straining to reach something high above the head, &c. The mere act of walking, when carried to such an extent as to induce exhaustion, will suffice, in weakly delicate females, to bring on expulsion; sudden and violent action of the abdominal muscles, when excited by a half-involuntary effort to save herself from falling, or receiving any other injury, may produce a similar effect: if the foetus be so young that its movements cannot be felt by the mother, she feels from this moment more or less pain in the pelvis, with a sensation of weight and bearing down; and this, in all probability, will be followed by a discharge of blood from the vagina: where pregnancy has sufficiently advanced for the motions of the foetus to be perceptible, the mother will frequently feel them in an unusually violent degree for a short time immediately after the injury, and then they cease entirely. Premature expulsion may also be induced immediately without the previous death of the child, by causes which directly excite the uterus to action: thus, various violent mental emotions, as rage, joy, horror, may act in this manner, although they may also act more indirectly; sudden exposure to cold, as sudden immersion in cold water, will occasionally produce it instantly. Irritation in the intestinal canal will directly excite uterine contraction; hence an attack of dysentery is frequently a cause of abortion, and we not unfrequently meet with patients who are liable to this affection in every pregnancy: a similar effect may be produced by the improper use of drastic purgatives, which irritate the lower bowels, viz. aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited to contract from the peculiar action of secale cornutum. On the other hand, a loaded state of the bowels equally predisposes to abortion, by impeding the free return of blood from the pelvis. A state of general plethora acts in the same manner; and this is more particularly the case if it takes place at what would, in the unimpregnated state, have been a menstrual period; for, occurring in conjunction with the increased vascular action which prevails at these periods in the uterine system, it produces, as it were, an apoplectic state of the uterine sinuses, which form the maternal portion of the placenta; blood is extravasated between the ovum and uterus; their connexion is more or less destroyed, and the death of the foetus becomes unavoidable: hence, in these cases the expulsion may result either from this latter circumstance, or from the uterus being irritated to contract by the effused blood between itself and the membranes. In patients who have suffered from attacks of dysmenorrhoea in the unimpregnated state, the irritable uterus, when pregnant, is very apt to contract upon its contents and expel them. This usually happens at what would have been a menstrual period, and not unfrequently takes place so soon after impregnation as merely to be looked upon as an unusually severe attack, the little ovum having been imperceptibly expelled among the discharges. Under this head must be brought those cases of spasmodic affection of the uterus, which Dr. Burns has described, and where, from the diminutive size of the ovum, the case has rather resembled one of menorrhagia. Cases of abortion are also mentioned by authors where the uterus is stated to be incapable of undergoing the necessary dilatation and increase of size which pregnancy requires; but we are strongly disposed to refer them to the above head of great uterine irritability, as we neither know of any diagnostic marks which will enable us to detect this condition during life, nor are we aware of any physical condition of the uterus short of actual disease, to be detected after death, which can produce this inability. The uterus may be also excited to expel the foetus, without its previous death by local causes, as acute leucorrhoea, or other inflammatory affections of the vagina, by inflammation and other affections of the bladder, as calculus, &c. Too frequent sexual intercourse during the early months of pregnancy is peculiarly liable to excite abortion: this is especially observed among primiparæ of the better ranks, where, from luxurious living, &c., there is but little physical strength in proportion to the great irritability of the system: hence we find that a fifth, or even a fourth, of these females abort in their first pregnancies. In conclusion we may briefly state that the same circumstances which in the unimpregnated condition produce menstrual derangement and other disorders of the uterine system, now act as so many causes of abortion. The sudden cessation of the breeding symptoms, with sense of weight and coldness in the lower part of the belly, flaccid breasts, pain in the back and loins, and discharge of blood from the uterus, are pretty sure signs of abortion: they are those which are "produced by separation of the ovum and contraction of the uterus," (_Burns_;) the one is attended by hæmorrhage, the other by pain. Although these are two chief symptoms which characterize a case of threatened abortion, and although they must necessarily be present more or less in every instance where premature expulsion actually happens, still neither of them, either separately or conjointly, can be considered as a certain proof that the uterus will carry its contents no longer. Cases not unfrequently happen where patients have repeated attacks of hæmorrhage during the early months of pregnancy, and sometimes to a considerable amount, without any apparent disturbance to the process of gestation, and are delivered of a living healthy child at the full term: on the other hand, we have known instances where the pain of the back was severe, and where, on assuming the erect posture even for a minute, the sense of weight and bearing down in the lower part of the abdomen was so great as to make the patient fear that the ovum was on the point of coming away; still even these threatening symptoms have gradually subsided, and the pregnancy has continued its natural period. Puzos considered that neither pain nor hæmorrhage were necessarily followed by expulsion. (_Mém. de l'Acad. de Chir._ vol. i. p. 203.) When, however, both occur together, and to a considerable extent, the case must be looked upon as one of at least doubtful if not unfavourable termination. Where pain comes on at regular intervals, with hardness of the uterus, and dilatation of its mouth, this is a serious symptom, for it shows that the uterus will no longer retain its contents, but is evidently preparing to expel them. The part of the ovum at which the separation of it from the uterus has taken place, not only determines which of the above symptoms will appear first, but also the probability of expulsion. "When a considerable separation takes place, as must be the case when it commences at the upper parts of the uterus, pain will more likely occur than when it happens near the neck; hence we sometimes have pain before the blood issues externally. The uterus in this instance suffers irritation from partial distension from the blood insinuating itself behind the ovum; contraction ensues; the blood is thus forced downwards, and is made to separate the attachment between the ovum and the uterus in its course, until it finally gains an outlet at the os tincæ. In consequence of the uterus being excited to contraction, the friendly coagula which may have formed from time to time are driven away, and the bleeding each time is renewed and accompanied most probably with increased separation of the ovum, until at last from its extent the ovum becomes almost an extraneous body, and is finally cast off. Hence a separation at or near the os uteri will not be so dangerous, and in all probability there will be hæmorrhage without pain, which is the contrary when it takes place near the fundus." (Dewees, _Compend. System of Midwifery_, § 981, 982.) The pain during the abortion is sometimes exceedingly severe, and not unlike that of dysmenorrhoea: this is probably owing to the violent contractions of the uterus, which are required to dilate the os and cervix before the ovum can pass: they are frequently attended with nausea, vomiting, and fainting, and sometimes with more or less general fever and local inflammatory action; the pain is generally attended with much irritability of the bladder, and frequent desire to pass water; the pulse is mostly quick and small, and where there is arterial excitement, it is sharp and resists the finger. _Treatment._ The treatment of premature expulsion consists in, 1, that which is intended to guard the patient against its occurrence, or _prophylactic_; and 2, in that which is required _during an attack_. A knowledge of the various causes of premature expulsion will materially assist us in the prophylactic treatment; under all circumstances, even where there is not the remotest fear of such an accident coming on, it is nevertheless highly important to pay strict attention to the state of the stomach and bowels, for these are almost always more or less influenced by the presence of pregnancy; the vomiting and sickness must be relieved in the manner already pointed out under the chapter on the TREATMENT OF PREGNANCY; the bowels, if constipated, must be moved by the mildest laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and thus all sources of irritation in the primæ viæ prevented as far as possible. The patient must carefully avoid every thing which may excite the circulation, such as violent affections of the mind, rich indigestible and stimulating food, violent exertion, &c. The diet should be light, nourishing, and moderate; heavy meals must be forbidden, and especially suppers; she should keep early hours, take gentle and regular exercise, and in fact, endeavour by every means in her power to raise her health to a full degree of tone and regularity. In those patients who have already miscarried in their previous pregnancies, these precautions must be enforced with double vigilence; for the system becomes exceedingly irritable, and the uterus soon acquires, as it were, a habit of retaining its contents only to a certain period, and then prematurely expelling them. When this is the case, it becomes exceedingly difficult, and is often actually impossible, to make it carry the ovum to the full term of utero-gestation, and, despite of the greatest care, the symptoms of premature expulsion will come on at about the same time at which they occurred in former pregnancies, and sometimes to the very same week. In the treatment of such cases, where there is so much liability to abortion, we must first examine the precise condition of the circulation, and ascertain whether it be above or below the natural standard of strength; for as abortion may arise from very opposite conditions of the circulation, our treatment must consequently vary. If there be signs of arterial excitement, a small bleeding may be necessary; it unloads the congested vessels, diminishes the force of the circulation, and therefore also the chance of an extravasation of blood between the uterus and ovum; the bowels must be kept open by cooling saline laxatives, and the circulation may be still farther controlled, by the use of nitre two or three times a day. The diet must be spare; she must take regular exercise in the open air, wear light clothing, dress loosely, and sleep upon a hard mattress. In these cases we are often warned that congestion of the uterine vessels is present, by pain and throbbing, and sense of fulness in the groins; leeches applied to these parts give much relief, and frequently render venesection unnecessary. Tight lacing ought to be strictly prohibited in all cases of pregnancy, particularly where there is a disposition to plethora: among other bad effects, it prevents the proper development of the breasts, the nipples are pressed so flat as to be nearly useless, the child being unable to get sufficient hold of them: this may in some degree be avoided, by putting thick ivory rings upon the breasts, and thus shielding the nipples from injurious pressure. It will, however, be much better to have the dress made loosely, to allow for the development of the breasts, which takes place during pregnancy; for there can be little doubt, that irritation of these glands is very liable to be followed by a corresponding state in the uterus. The common but erroneous notion that it is necessary to take an extra quantity of nourishment for the support of the child as well as of the mother must be strenuously opposed. Nature contradicts it in the most striking manner; for, by the nausea and sickness which most women experience during the first half of their pregnancy, she raises an effectual obstacle to any error of this kind. "It certainly cannot be intended for any other purpose, since it is not only almost universal, but highly important when it occurs, as it would seem to add much to the security of the foetus; for it is a remark as familiar as it is well grounded, that _very sick women rarely miscarry_; while on the contrary, women of very full habits are disposed to abortion, if exempt from this severe, but as it would seem, important process." (Dewees, _on Children_, § 45.) Where the case has become one of habitual abortion, the patient's only chance will be by living separate from her husband for twelve or more months: the uterus, not being exposed to any sexual excitement during this period, becomes less irritable, and it gradually loses the disposition which it has acquired of expelling its contents prematurely. In such a case, when pregnancy has again commenced, it requires to be watched most narrowly; every possible source of irritation must be removed by the strictest attention to diet and regimen, and the patient must make up her mind to be entirely subservient to the rules laid down by her medical attendant. Although the chances are against her escaping without premature expulsion, still we are not to despair, experience showing that cases every now and then occur where the patient has gone the full term of pregnancy in safety, in spite of repeated previous abortions. Dr. Young of Edinburgh, in his lectures on midwifery, describes a case where the patient actually miscarried thirteen times, and yet bore a living child the fourteenth time. On the other hand, where the condition of the patient evinces a state of strength considerably below the natural standard, we find a very different set of symptoms to those which have been just described, requiring opposite treatment: the face is pale and even sallow; the pulse is soft, small, and irritable; the tongue pale and flabby; the digestion impaired; the bowels torpid; and the extremities cold: fatigue, or rather a sense of exhaustion, is induced by the slightest exertion, and this is attended with dull, heavy, dragging pain about the pelvis and loins, and a feeling as if the contents of the abdomen required more support, and were disposed to prolapse either by the rectum or vagina, on her maintaining an upright posture for any length of time. Even at a very early period of pregnancy, there is the sensation of a weight in the lower part of the abdomen, falling over to that side which is lowest, as we described among the signs of the death of the foetus at a later period, resulting in all probability from a loss of tone and firmness in the uterus. In this state, if nothing be done to restore the mother's strength, the embryo will inevitably perish, and expulsion follow, sooner or later, as a necessary result. In all cases where pregnancy occurs, in a weakly delicate woman, measures should be taken to increase the general tone of health, in order to fit her for going through this process safely, by removing her to the country, or to the sea-side, or to some watering place, where she will have the opportunity of drinking a mild chalybeate, and enjoying a purer air. Where it is even hazardous to move her, she should be put upon a course of mild chalybeates. The food should be light and nourishing, and a glass or two of wine or mild ale, may generally be taken with advantage. Where she can bear it, tepid salt-water bathing, or sponging, will have the best effects. "For a number of years, (says Mr. White of Manchester,) I have been convinced of the good effects of cold bathing, not only in preventing miscarriages when every other method has been likely to fail, but other disorders which are incident to pregnant women, and generally attendant upon a weak lax fibre. I don't mean the cold bath in the greatest extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing in a tub in the patient's house, with the water a little warmed. I have frequently advised my patients to bathe every other day, at a time when the stomach is not overloaded, and not to stay at all in the water; to begin this process as early as possible, even before they have conceived, as there will be then no danger from the surprise, and continue it during the whole term of pregnancy; and several have bathed till within a few days of their delivery." (White, _on Lying-in Women_, p. 70.) Where exercise can be taken without fear, it should be done regularly but cautiously, so as not to induce fatigue or exhaustion, which is the very effect we must be so careful to avoid; in fact, every means and opportunity should be used of recruiting the powers and the vigour of the system. In proportion as the strength increases, so does the irritability diminish; the uterus becomes less sensitive to external impressions, and can, therefore, bear its gradual development without being excited to contraction; the foetus receives its due supply of nourishment; the feeling of relaxation and deficient support of weight, and bearing down, go off as health returns; and by thus keeping up the powers of the system to the proper standard, it will be enabled to continue the process of pregnancy to the full term. Although some women recover very quickly after an abortion, and appear for the time to suffer but little from its effects, they seldom escape with impunity, more especially if it has been repeated more than once: anæmia, with its varied train of anomalous symptoms and concomitant gastric and cerebral disturbance, profuse leucorrhoea, menorrhagia, and dismenorrhoea, are some of the more direct results of repeated abortion; we may also enumerate prolapsus uteri, inflammation of the cervix, with induration and scirrhus, as the more remote effects. In the treatment of a case where expulsion is threatened, our object will be either to stop that process in time to save the life of the foetus, or if this cannot be attained, to carry it through, in such a manner, as to expose the mother to as little danger and injury as possible.[63] In the first instance, we must be guided nearly by the same rules as in the prophylactic treatment: if there be considerable arterial excitement, and evidence of general plethora, a small bleeding will be useful in restoring a calm to the circulation; the most perfect quiet of body and mind must be insisted upon; the patient should lie upon a hard mattress, and be covered with as little clothing as is consistent with safety; she must refrain from all exertion, and strictly maintaining the horizontal posture for a considerable time. The indications for our treatment will be, 1. to remove every thing which may, in any degree excite the circulation, and, 2. to prevent the contraction of the uterus. Stimulants of every description, and animal food must be forbidden; the bowels must be opened by gentle saline laxatives; and if the pulse still betrays any sharp or resisting feel to the finger, small doses of nitre may be taken as already recommended. When the circulation has become perfectly calm, and every trace of excitement allayed, opiates will prove of inestimable value: they stop any disposition to uterine contraction, and remove the pain in the back and loins which this will cause. The form which we prefer is the Liquor Opii Sedativus, as being more sure in producing a sedative effect than common laudanum, while at the same time, it produces less irritation and derangement in the stomach and bowels. A moderate discharge of blood from the vagina, although showing that a separation has taken place between the ovum and the uterus, cannot be looked upon as an unfavourable sign, for it relieves the pelvic vessels, diminishes the pain in the back, and makes the patient feel more light and comfortable; but if it be at all brisk, and continues so after the employment of the above remedies, if also there be heat and throbbing in the region of the uterus, it will be necessary to apply cloths wrung out of cold water to the lower part of the abdomen and vulva, and to the groins and sacrum; and this treatment must be continued in full force until the symptoms of congestion have abated, and the discharge lessened or stopped. If the hæmorrhage be really profuse, it shows that the separation of the ovum from the uterus must be of considerable extent; and as there will be no chance of preserving the life of the foetus under such circumstances, the expulsion of the ovum is no longer to be avoided, but rather to be promoted; our attention therefore must now be directed to assist the uterus in the evacuation of its contents, with as little injury and danger to the mother as possible. It is, however, no easy matter to decide with certainty when we must give up all hope of preserving the ovum, for a large quantity of blood may be lost without expulsion being a necessary consequence. Uterine contractions may have even taken place, and yet by careful management the mischief may be sometimes averted, and the patient be enabled to go her full time. Even where they have been of sufficient force and duration to dilate the os uteri, we are not justified in discontinuing remedial measures unless the flooding has seriously affected the patient's strength, and the ovum be actually projecting through the os uteri. "We might often prevent abortion (says Baudelocque) if we were perfectly acquainted with its cause, even when the labour is already begun. A very plethoric woman felt the pains of childbirth towards the seventh month of her pregnancy, and the labour was very far advanced when I was called to her assistance, since the os uteri was then larger than half a crown; two little bleedings restored a calm, so much that the next day the orifice in question was closed again, and the woman went the usual time. Food of easy digestion prudently administered quieted a labour not less advanced in another woman, where it was suspected to be the consequence of a total privation of every species of nourishment for several successive days. Delivery did not take place till two months and a half afterwards, and at the full time. Emollient glysters and a very gentle cathartic procured the same advantage to a third woman, in whom labour pains came on between the sixth and seventh months of pregnancy, after a colic of several days' continuance, accompanied with diarrhoea and tenesmus." (_Baudelocque_,) § 2232. Nor is it always easy to decide whether it be the ovum or not which we feel protruding through the os uteri. "When the abortion is in the second or third month, the practitioner must bear in mind that it may have been retention of the menses, and, therefore, what he feels in the os uteri may either be an ovum or a coagulum of blood. To decide this point he must keep his finger in contact with the substance lying in the os uteri, and wait for the accession of a pain (for where clots come away, pains like those of labour are present,) and ascertain whether the presenting mass becomes tense, advances lower, and increases somewhat in size; this will be the case where it is the ovum pressing through the os uteri. On the other hand, if it be a coagulum, which it is well known assumes a fibrous structure, it will neither become tense nor descend lower, but be rather compressed. Generally speaking, the ovum feels like a soft bladder, and at its lower end is rather round than pointed, whereas, a plug of coagulum feels harder, more solid, and less compressible, and is more or less pointed at its lower end, becoming broader higher up, so that we generally find that the coagulum has taken a complete cast of the uterine cavity. If we try to move the uterus by pressing against this part, it will instantly yield to the pressure of the finger, if it be the ovum; whereas, the extremity of a coagulum under these circumstances is so firmly fixed, that when pressed against by the finger the uterus will move also. When abortion happens at a later period of pregnancy, we shall be able to feel the different parts of the child as the os uteri generally dilates, viz. the feet, or perhaps the sharp edges of bones, although we cannot distinguish the form of the head from the cranial bones being so compressed and strongly overlapping each other." (Hohl, _on Obstetric Exploration_.) Although expulsion must be looked upon as the only means of placing the patient in a state of safety, where the symptoms have advanced so far as to preclude all hopes of preserving the life of the foetus, there are so many steps of this process to be gone through before it can be entirely completed, that more or less time must necessarily be required for that purpose. The ovum must be completely separated from its attachments to the uterus, and the contractions of that organ must have been of sufficient strength and duration to produce such a degree of dilatation of its mouth and neck as to allow the ovum to pass; but before this can be effected, such a quantity of blood may have been lost as greatly to endanger the life of the patient. Hence we must use such means as shall enable us to control the hæmorrhage, whilst we give the os uteri time to dilate sufficiently: this object will be gained most effectually by plugging the vagina. The best mode of performing this operation is that recommended by Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to fill the vagina without producing uneasiness, must be wrung out of pretty sharp vinegar, and introduced into the passage up to the os uteri; the blood, in filling the cells of the sponge, coagulates rapidly, and forms a firm clot, which completely seals up the vagina without producing any of those unpleasant effects which are produced by the insertion of a napkin rolled up for the purpose. A hard unyielding mass of this nature frequently produces so much tension, pain of back, and irresistible efforts to bear down, as to render it incapable of being borne for any length of time. The sponge plug may be borne for hours without inconvenience; we may either leave it to be expelled with the ovum, or after awhile remove it for the purpose of ascertaining what progress has been made. If the os uteri be still undilated, and the hæmorrhage going on, the plug must be returned. It is however by no means a remedy to be used in every case of hæmorrhage, for in most instances the treatment already mentioned will be sufficient to keep it within safe bounds. Where, however, the flooding has become very alarming, and the os uteri still remains firm and but little dilated, the plug will prove an invaluable remedy; and so long as the os uteri remains in this condition, and the uterus itself shows no disposition to contract, we may safely trust to perfect rest, cold applications, and the plug. Opium, which in the early stages of the attack is so useful in keeping off contractions of the uterus, will now for this very reason be contra-indicated; it will diminish the power of the uterus, and interfere with the process of expulsion. The acetate of lead has been extolled as a powerful remedy for stopping hæmorrhage, more especially by Dr. Dewees, who states that "in many cases it seems to exert a control over the bleeding vessels as prompt as the ergot of rye does upon the uterine fibre." (_System of Midwifery_, § 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority however of such an author demands respect, the more so as it is known to be a valuable remedy in certain forms of menorrhagia. Where a considerable quantity of blood has been lost, and the patient is much reduced, we must endeavour not only to excite the contractile power of the uterus, but also to assist this organ in the expulsion of its contents: syncope in these cases is a dangerous symptom, because, as the patient is in the horizontal posture, it will seldom be induced except by a serious loss of blood; although we must not therefore allow her to flood until she faints, still, however, when the pulse has become considerably affected, the os uteri dilates more readily, and in this way facilitates the expulsion; we must no longer trust to the plug, for the whole system is beginning to sympathize and grow irritable, the pulse grows quicker and smaller, and the stomach rejects its contents. Although vomiting as well as syncope are symptoms which we cannot safely wait for, they are nevertheless means which nature adopts to relieve herself from the impending danger: by syncope she not only produces greater dilatability of the os uteri, but also, by causing a temporary cessation of the heart's action, she favours the coagulation of blood, and thus checks the discharge; whereas, by the involuntary effort of muscles which she excites by the action of vomiting, the ovum is more speedily separated and expelled. Where it becomes evident that expulsion cannot be prevented, it is our duty to promote this process before nature has had recourse to the means just mentioned. The ergot of rye is here a valuable remedy, for by inducing or increasing the contractions of the uterus we shorten the process and diminish the danger: the powder given in cold water is decidedly the best form in which it can be given; in infusion its powers seem to be injured by the heat of the water, and in tincture by the action of the spirit: the addition of about half its quantity of borax renders its action more powerful and certain. Borax has been long considered in Germany to possess a specific power in exciting uterine contraction, but it was first recommended for that purpose in this country by Dr. Copland. (_Dict. Pract. Med._ art ABORTION.) A scruple or half a drachm of ergot powder with ten grains of borax may be given in cinnamon water, and this repeated every hour for several times. In all cases threatening premature expulsion, wherever there has been much pain and discharge, the napkins which come from the patient should be carefully examined by her medical attendant, for otherwise the ovum may escape among the coagula and not be perceived. Where the separation is nearly complete, a portion of it protrudes at the os uteri; and this we can sometimes hook down with one or two fingers, and bring away: a still better mode is recommended by Levret, viz. of throwing up a pretty powerful stream of warm water by means of a syringe. Dr. Dewees has recommended a wire crotchet, which he has used with very good effect. (_Op. cit._ § 1011.)[64] We ought not, however, to be in a hurry to bring away the ovum, for when the uterine contractions have been of sufficient strength to dilate the os uteri, it will generally come away of itself. One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.[65] This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months' ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the hæmorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the foetus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the size of the uterus is reduced by the escape of liquor amnii, and thus the hæmorrhage checked; and the foetus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes. The treatment after abortion varies considerably: in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhoea and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the sea-side, or, what is still better to a watering place, where there are mineral springs of chalybeate character. For the treatment of anæmia we must refer our readers to the chapter on HÆMORRHAGE. PART III. EUTOCIA, OR NATURAL PARTURITION. CHAPTER I. STAGES OF LABOUR. _Preparatory stage.--Precursory symptoms.--First contractions.--Action of the pains.--Auscultation during the pains.--Effect of the pains upon the pulse.--Symptoms to be observed during and between the pains.--Character of a true pain.--Formation of the bag of liquor amnii.--Rigour at the end of the first stage.--Show.--Duration of the first stage.--Description of the second stage.--Straining pains.-- Dilatation of the perineum.--Expulsion of the child.--Third stage.-- Expulsion of the placenta.--Twins._ Parturition may be divided into two great orders, _Eutocia_ and _Dystocia_, the one signifying natural labour which follows a favourable course both for the mother and her child; the other signifying faulty or irregular labour, the course of which is unfavourable. We may define eutocia to be the safe expulsion of the mature foetus and its secundines by the natural powers destined for that purpose. No function exhibits such infinite varieties, within the limits of health and safety to the mother and her offspring, as that of parturition; no two labours, even in the same individual are exactly alike; still, however, the great objects of the process will be the same, viz. 1st. the preparation of the passages and the foetus for its expulsion; 2dly, the expulsion of the foetus; and 3dly, the expulsion of the placenta and membranes. That we may form a clearer and more comprehensive view of this process, labour has usually been divided into stages or periods, marked by the changes just now alluded to: hence it is generally said to consist of three stages; the first, or preparatory stage, commencing with the first perceptible contractions of the uterus, and terminating in the full dilatation of the os uteri; the second, or stage of expulsion, terminating with the birth of the child; and the third, consisting of the expulsion of the placenta. _Preparatory stage._--_Precursory symptoms._ For some time before the commencement of actual labour, a variety of changes are taking place which must be looked upon as the precursors of this process: during the last weeks of pregnancy, nature appears, as it were, to be preparing for the great change which is at hand, and to be making such arrangements as shall enable it to be completed with the least possible danger both for the mother and her child. One of the earliest warnings which we have of approaching labour is an alteration in the form of the abdominal tumour; the cervix uteri has by this time (especially in primiparæ) entirely disappeared; the presenting part of the child has therefore descended to the lowest part of the uterus; the fundus has sunk lower and more forwards; and from the diaphragm being enabled to act with greater freedom, the respiration is performed with more ease and comfort to the patient; she therefore feels more capable of moving about, and is in better health and spirits than for some time previously. Upon examination per vaginam, the head will be found deep in the cavity of the pelvis, covered by the lower and anterior segment of the uterus; the os uteri is still closed, and situated in the upper part of the hollow of the sacrum, forming merely a small circular depression. In women who have already had children, a portion of the cervix uteri is still remaining; it is thick and bulky; and in some cases, where the uterus has been greatly distended in several successive pregnancies, it is nearly as long as in the unimpregnated state; the os tincæ or os uteri externum is open, its edge irregular from former labours; the upper extremity of the canal of the cervix is contracted, and forms the os uteri internum; it has been closed during the greater part of pregnancy, but usually is now sufficiently open to admit the finger; the os uteri is neither so high up nor so far backwards in the pelvis as in primiparæ, and is reached with greater ease; whereas, the head of the child, instead of being felt in the cavity of the pelvis, generally remains at the brim until labour is more advanced. _First contractions._ The first contractions of the uterus (in a state of health) are so slight as scarcely to be noticed by the patient: they create a sensation of equable pressure and general tightness round the abdomen, and during the contraction the uterus feels somewhat firmer, but they are neither attended with pain, nor do they appear at first to have any effect upon the os uteri; these precursory contractions generally come on a day or two before actual labour commences, and sometimes are felt at intervals for one or two weeks. Where the uterus has been exposed to any source of irritation, and especially where there is a disposition to rheumatic affection of this organ, they may produce much suffering and give rise to one form of what are called _false pains_, hereafter to be described. "The first contractions, says M. Leroux (_Sur les Pertes de Sang_, § 41.,) are feeble, and communicate no sensation to the patient; in order to discover them we must hold our hand upon the abdomen, and if we feel the globe of the uterus raise itself and become hard, this is a true contraction. These contractions gradually increase until they excite pain: but pain is not essential to a contraction; it depends on the distension and compression of the nerves produced by the resistance of the body upon which the uterus acts, and increases in severity in proportion to the degree of resistance and contraction." In proportion as the lower part of the uterus descends into the cavity of the pelvis, so does it exert a degree of pressure on the neighbouring parts; the capacity of the bladder and rectum is diminished; and being therefore unable to contain the usual quantity of urine and fæces, and being probably rendered more irritable by the pressure above-mentioned, the patient experiences frequent calls to pass water and evacuate the bowels, which is sometimes effected with considerable difficulty: in some instances she is obliged to lean forward, or support the abdomen, in order to take the weight of the child off the neck of the bladder before she can empty it: the same cause occasionally requires the use of the catheter, and sometimes renders the introduction of it a matter of considerable difficulty. As these various changes make their appearance, the patient becomes restless and anxious; she cannot remain long in the same posture; the slight precursory contractions which have been just described, are becoming stronger, and begin to produce a sensation of pain; the os uteri (in primiparæ) opens somewhat, its edge at first is exceedingly thin, and feels almost membranous; by degrees however it swells, grows thick and cushiony, and is now more dilatable. _Action of the pains._ The os uteri does not dilate merely by the mechanical stretching which the pressure of the membranes and presenting part exert upon it; it dilates in consequence of its circular fibres being no longer able to maintain that state of contraction which they had preserved during pregnancy; they are overpowered by the longitudinal fibres of the uterus, which, by their contractions, pull open the os uteri equally in every direction. The vagina also swells and grows more cushiony, and this is followed by a copious secretion of colourless and nearly inodorous mucus. "The more albuminous it is the better, and it is always a good sign when lumps of albuminous matter come away from time to time; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete." (Wigand, _Geburt des Menschen_, vol. ii. p. 292.) The thin hard os uteri does not dilate, its fibres are all in close contact, and like a well-twisted cord will not yield; whereas, when they are separated from each other by the swelling of the os uteri, they easily yield to the dilating force which is applied to them. Besides serving the purpose of lubricating the passage, the secretion of mucus is of great importance as a topical depletion, for, by thus unloading the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. "If, on the other hand, the entrance of the vagina is small, the neighbouring parts cool, dry, inelastic, and as if tightly stretched over the bones; if the finger, in spite of being well oiled and carefully introduced, produces pain upon the gentlest attempt to examine, we may expect a tedious and difficult labour." (_Op. cit._ p. 190.) The patient is now no longer able to conceal her pains when they come on. If she be in the act of conversing she stops short, and remains silent until the severity of the pain is over; if she be walking about her room she is obliged to stand still for the time, and rest against or hold by something until the pain has gone off. The true labour pains are situated in the back and loins; they come on at regular intervals, rise gradually up to a certain pitch of intensity, and abate as gradually; it is a dull, heavy, deep sort of pain, producing occasionally a low moan from the patient: not sharp or twinging, which would elicit a very different expression of suffering from her. _Auscultation during the pains._ "If we direct our attention to the changes of tone which the uterine pulsations present during auscultation, we shall find them generally stronger, more distinct and varied in tone during labour; and this is especially the case just before a pain comes on. Even if the patient wished to conceal her pains, this phenomenon, and more especially the rapidity of the beats, would enable us to ascertain the truth. The moment a pain begins, and even before the patient herself is aware of it, we hear a sudden short rushing sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to anticipate the coming on of the contraction: nearly at the same moment all the tones of the uterine pulsations become stronger; other tones, which have not been heard before, and which are of a piping resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter while in the act of vibrating. The whole tone of the uterine circulation rises in point of pitch. Shortly after this, viz. as the pain becomes stronger and more general, the uterine sound seems as it were to become more and more distant, until at length it becomes very dull, or altogether inaudible. But as soon as the pain has reached its height and gradually declines, the sound is again heard as full as at the beginning of the pain, and resumes its former tone, which in the intervals between the pains is as it was during pregnancy, except somewhat louder. This is the course of things if the pain be a true one, and attain its full intensity: where the pains are false or irregular it is very different; the uterine sound either remains unaltered, or increases only for an instant, or its seeming increase of distance, as above mentioned, is not observed." (_Die Geburtshülfliche Exploration_, von Dr. A. T. Hohl, erster theil, s. 105.) _Effect of the pains upon the pulse._ It is curious to observe the effect which a regular pain has upon the rapidity of the mother's pulse; as the former comes on and goes off, so does the other increase or diminish. "The increasing rapidity of the pulse announces the commencement of the pain; it rises and attains its _summum_ with it; and as the pain subsides so does the pulse gradually resume the rate which it had during the intervals; a similar ebb and flow may be heard in the uterine souffle. The more regular the pain is, and the more distinctly it rises to its full extent, the more marked, regular, and distinct, is this change in it. We may also invert the order of things, and say, the more distinctly the rapidity of the pulse comes on and announces the pain, the more regularly it rises and attains a certain height, which it maintains, and then gradually subsides; in like proportion will the pain be more perfect, attain its full extent more completely, and act more efficaciously upon the regular progress of the labour. Where however the rapidity of the beats subsides before it had scarcely begun to increase, the pain is too weak; or where the rapidity rises by sudden starts, the pain is a hurried one; and in either case its effect will be imperfect." (Hohl, _op. cit._ vol. i. p. 108.) In order that we may ascertain these changes correctly, we ought to note the rapidity of the pulse during each successive quarter of a minute as directed by M. Hohl; thus, in a pain which lasts two minutes, the increase and diminution in the rapidity of the pulse may be as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it increases, so that shortly before the birth of the child we shall find that what was the rate of the pulse during the height of the pains at the beginning is now the rate of it during the intervals. _Symptoms to be observed during and between the pains._ When a pain comes on, the uterus grows hard and tense; if the fundus be somewhat to one side, as is not unfrequently the case, it now gradually moves, so that the median line of the uterus corresponds with that of the patient's body; the various prominences of the child are no longer to be felt, the whole is now firm and unyielding; the os uteri is put tightly upon the stretch, the membranes which were loose become tense and are firmly pressed against it, and the presenting part is rendered indistinct: as the pain gradually subsides, the uterus becomes softer, and yields to the pressure of the hand; the different parts of the child which project, as also its movements, can now be felt more distinctly; the patient is free from pain, and feels herself in an agreeable state of tranquillity, which is frequently attended by a short refreshing doze; the os uteri, which has become somewhat more dilated during the last pain, is now soft and loose, so that we can hook the finger into it and move it about; the tight bladder of membranes becomes relaxed and flaccid, and retracts more or less into the uterus, so that we shall now be able to introduce the finger into the os uteri and feel the presenting part through the membranes; while the presenting part of the child, which during the pain was fixed, can be moved somewhat by the finger. _Characters of a true pain._ In examining the course of a true pain we shall find that the contractions of the uterus do not begin in the fundus, but in the os uteri, and pass from the one to the other. (Wigand, _op. cit._ vol. ii. p. 197.) Every pain which commences in the fundus is abnormal, and either arises from some derangement in the uterine action, or is sympathetic with some irritation not immediately connected with the uterus, as from colic, constipation, &c. We very seldom find that a contraction of the uterus, which has commenced in the fundus, passes into the cervix and os uteri, and becomes a genuine effective pain; usually speaking, the contraction is confined to the circumference of the fundus, without detruding the foetus at all. When a genuine pain comes on, so far from the head being pressed against the os uteri, it at first rises upwards, and sometimes gets even out of reach of the finger, whilst the os uteri itself is filled with the bladder of membranes: if it had commenced in the fundus instead of the inferior segment of the uterus, so far from the head being drawn up at the first coming on of the pain, it would have been forcibly pushed down against the os uteri. In the course of a few seconds the contraction gradually spreads over the whole uterus, and is felt especially in the fundus; the head which had been raised somewhat from the os uteri is now again pushed downwards to it, and seems to act as a wedge for the purpose of dilating it; it is not until the whole uterus is beginning to contract that the patient has a sensation of pain. We may, therefore, consider that a genuine uterine contraction consists of certain phenomena which occur in the following order: first, the os uteri grows tight, and the presenting part rises somewhat from it; then the rest of the uterus, especially the fundus, becoming hard, the patient has a sensation of pain, and the presenting part of the child advances. The period of time necessary for all these changes varies not only in different individuals, but in the same individual in different labours, and in different stages of the same labour. "The more completely the os uteri is opposite the fundus, and the more the axis of the uterus corresponds with that of the pelvis, the sooner are the pains, _cæteris paribus_, capable of dilating the os uteri." (_Wigand_, vol. ii. p. 273.) The cushiony state of the vagina and os uteri, and the free secretion of thick albuminous mucus from these parts, as already mentioned, will be of great importance in ensuring their easy dilatation. Where this secretion is either absent, or very scanty, the passages become dry, hot, and tender, from no relief being afforded to the congested vessels by its effusion; and _vice versâ_, where there is a febrile state of the circulation and considerable topical excitement, the secretion is sparing, or, perhaps, stops entirely. This state may arise from a variety of causes, such as from general plethora, too warm clothing, bad ventilation, derangement and irritation of the primæ viæ, and abuse of spirituous and other stimulating liquors: it may arise from constipation, or may be induced by rough and too frequent examination. The patient becomes flushed, excited, and feverish, with a hot skin, dry tongue, thirst, and headach; the uterine contractions become irregular, they produce much suffering, and but very little advance in the progress of the labour; the passages are in a state of inflammation, and more especially the os uteri, which is much swollen and excessively tender. The process of labour is completely interrupted, and can only be restored to a healthy condition by bleeding, warm bath, laxatives, and enemata. _Formation of the bag of the liquor amnii._ When the os uteri has dilated more or less, a quantity of liquor amnii begins to collect between the head and the membranes, so that when a pain comes on they form a tense, elastic, and conical bag, which presses firmly against the os uteri, and protrudes through it into the vagina, and from its form and elastic nature greatly facilitates the speedy dilatation of it. If the edge of the os uteri be still thin, it will become so tense during the pain, and the bag of membranes will press so firmly against it, that we shall have some difficulty for the moment in distinguishing the one from the other. As the labour advances, the intervals between the pains become shorter, whereas the pains themselves are of longer duration and more effective. In this way pain succeeds pain until the os uteri, at length, attains its full degree of dilatation; if the membranes have not yet ruptured, we may now expect them to burst with every succeeding pain. _Rigour at the end of the first stage._ At this moment the patient is occasionally seized with a sudden and violent fit of shivering, so much so as to make the teeth chatter, and even communicate a tremulous motion to the bed itself; this is not the result of cold, nor is it relieved by the application of external warmth; and, in many cases, the patient will express her surprise that she should shiver thus violently, and yet not feel cold. It appears to be a modification of convulsive action, excited by sympathy between the os uteri on its becoming fully dilated, and certain muscles in other parts of the body. _Show._ On examination at this stage of the process, streaks of blood will be found in the mucus which soils the finger, and sometimes it amounts to a slight discharge of blood: this appearance is called by midwives "_a show_," as it usually indicates that the os uteri is nearly or fully dilated. It is produced by a separation of the membranes from the vicinity of the os uteri, and consequent rupture of any little vascular twigs which may have passed from the uterus to them. The full dilatation of the os uteri terminates the _first stage_ of labour. During this stage, the action of the pains does not appear to have been so much for the expulsion of the child, as for preparing it as well as the passages for this purpose, viz. by so arranging and regulating the different forces of the uterus, and at the same time by giving the child such a position (_i. e._ with its long axis parallel to that of the uterus,) and the os uteri such a degree of dilatation, as shall ensure its expulsion with the greatest possible ease and safety. _Duration of the first stage._ The duration of the first stage of labour varies exceedingly, both in primiparæ and those who have had several children; nor is it at all easy to determine with precision the exact moment when labour commences. The sensation of pain to the patient is no guide whatever, for what is attended with much suffering in one patient is scarcely sufficient to excite the notice of another. The dilatation of the os uteri as marking its commencement, must also be taken with some caution: in primiparæ, where it generally remains closed until the contractions are becoming painful, it would obviously be wrong to date the commencement of labour from the moment that the os uteri opens, as regular uterine contractions have been evidently present for some hours previously, although not of sufficient force to produce actual pain. On the other hand, in women who have already had several children, the os uteri is found open some days and even weeks before labour comes on. As a general rule, we may state that regular and genuine contractions of the uterus, sufficiently powerful to produce pain, seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; whereas, in others, the first stage of labour may last for more than quadruple this period before it is completed: in neither can it be considered as abnormal; and we usually find that where the pains of the first stage have been slow and lingering, they become remarkably quick and active during the second stage. This agrees with the experience of Dr. Churchill, in his report of the Western Lying-in Hospital at Dublin, viz. that, "no evil consequences resulted, and they (the labours where the first stage was so protracted) were amongst those in whom the remaining stages of labour were shortest." The first stage terminates with the full dilatation of the os uteri; the rupture of the membranes is a change which is necessarily more or less uncertain, as to the precise period of labour at which it takes place. Thus, in primiparæ, it frequently occurs before the first stage is completed; whereas in other cases the membranes sometimes do not give way until the head approaches or has even passed through the os externum; generally speaking, however, they burst at this period of the labour, and usually effect a remarkable change in the whole process. The pains are now of longer duration and more powerful, the intervals between them are shorter, and yet, although the suffering is actually more severe, it is more tolerable to the patient than that of the first stage. During the first stage they are chiefly confined to one spot in the loins; and as they must necessarily continue for some hours without any distinct evidence of the labour being advanced by them, the patient feels discouraged and gets a little impatient at the endurance of so much apparently useless suffering: but as soon as the gush of liquor amnii takes place, she feels that a great alteration has been produced; the abdomen becomes smaller: the pains assume a very different character, and every thing combines to assure her that she has made progress, and encourages her to patience and resolution. _Description of second stage._ The os uteri has now disappeared entirely, so that the vagina and uterus form one continuous canal, and is thus admirably adapted for the easy passage of the head: the anterior lip, however, dilates much more slowly than the other parts of it, and this is especially the case in primiparæ, for, being pressed between the head and pelvis it becomes oedematous, and swells to a considerable size: if the pains be strong, it is pushed down more or less before the head, and may be frequently felt beneath the symphysis pubis, and occasionally it is detruded so far as to be visible between the labia. According to Wigand, the swelling of the anterior lip sometimes attains such a size as makes it liable to be mistaken for the bladder of the membranes (_op. cit._ vol. ii. p. 308;) it seldom produces much obstacle to the advance of the head, and with a little patience gradually disappears of itself. All attempts to push it up above the head are objectionable, because, in the first place, the finger cannot reach sufficiently high to effect this object, and therefore the swelling descends again to its former situation; and, secondly, the efforts to push it up only tend to inflame it and increase the swelling. Those who imagine that they can push up the anterior lip of the os uteri above the head deceive themselves; and even if they do succeed, it merely shows that had they let it alone, it would have gone up very shortly of itself. _Straining pains._ As the head enters the vagina, not only do the contractions of the uterus become much more powerful, but now another set of forces are called into action, and the half involuntary efforts of the abdominal and other muscles come to aid the uterus in expelling its contents. The sole object of this stage is the expulsion of the child, and even the vagina by its contractions contributes to effect it. The head is therefore subjected to considerable pressure; hence we may now feel the cranial bones overlapping each other at the sutures, and the fontanelles diminished in size; and, from the tightness with which the head is embraced by the vagina, the circulation in the scalp is more or less impeded, and a large oedematous swelling, called _caput succedaneum_, forms on that part of the head which presents. Each pain is attended with a violent and irresistible impulse to bear down, and every muscle which can assist in effecting this object is now brought into play. The tone of the patient's voice, the expression of her face, the hurried breathing and sudden inspiration, stopping short the moment a pain comes on, in order that she may add still greater power to the efforts which she is about to make, all betoken a very different process to that of the first stage, and one which requires a powerful struggle of muscular strength and energy for its completion. Hence it is that the sound of the patient's voice during the pain is frequently of itself sufficient to inform us how far labour is advanced, for "we never see the really powerful straining pains come on (the head may be never so low in the pelvis,) so long as the os uteri is not fully dilated." (Wigand, _op. cit._ vol. ii. p. 310.) This is a wise provision of Nature, for by this means it prevents the danger of laceration to which the os uteri would be otherwise exposed, and shows the importance of not permitting a patient to strain and bear down until the os uteri be fully dilated. In those cases where a patient has been induced to exert herself prematurely, the efforts being voluntary are never so powerful, and soon produce much fatigue. Several reasons have been assigned why the straining pains should come on at this stage. It cannot be owing to the pressure of the head upon the parts of the pelvis, as has been supposed and especially the rectum, thus producing the sensation of a violent desire to evacuate the bowels, because, in almost every case of first labour, the head for several days before the actual commencement of labour is sufficiently deep in the pelvis to produce these effects. It evidently arises from a sympathetic connexion "between the os uteri and vagina on the one hand, and the abdominal and other muscles on the other. We see this connexion most distinctly in those difficult labours where the head is pushed down deeply in the pelvis even to the very outlet, and where the os uteri which is but little dilated is protruded before it. In such cases we never see the really powerful and continued action of the abdominal muscles excited, let the head press never so forcibly upon the rectum; but as soon as the os uteri (perhaps after much suffering) has retracted over the head, the whole auxiliary action of the abdominal muscles commences." (_Ibid._ vol. ii. p. 467.) There is the same relation between these muscles and the vagina, as there is between them and the rectum: the moment the vagina becomes distended, it begins to contract upon the distending body, and like the rectum excites them to strong and involuntary action. The tenesmus of dysentery is a sympathetic action of the same nature; the rectum is highly irritated by the acrid nature of its contents, and excites an irresistible disposition to bear down. The patient wishes for the next pain and yet she dreads it, from the suffering it creates, and the tremendous effort which it compels her to make; the pulse is quicker, and is not only so during the intervals, but undergoes a greater increase of rapidity during the pains themselves than in the first stage; the face becomes red, swollen, and bathed in perspiration; the breath is hurried; the lips are apart; the eyes are wild; every thing betokens a state of the highest excitement. When a pain comes on, she catches hold of whatever she can reach, plants her feet upon any thing which is firm, and, by thus fixing her extremities, she is enabled to bear down with greater power and effect. During the struggle the face often changes its expression surprisingly, so much so, that even her own attendants would scarcely recognise her. _Dilatation of the perineum._ As pain succeeds pain, gradually increasing both in force as well as duration, the head descends along the vagina, and begins to press against the perineum; the rectum becomes flattened; the sphincter ani dilated, and therefore any fæcal matter which may have been lodging there is unavoidably expelled; the anterior wall of the rectum is pressed close against the anus, and where the pressure is very great, even protrudes somewhat through it; the hæmorrhoidal veins are frequently much distended, and form a roll of cushiony swelling around the anus. A small quantity of liquor amnii dribbles away from time to time, but is neither during a pain, nor during the absence of a pain, for in the former case the pressure of the head acts as a plug and prevents its escape, and in the latter there is no uterine contraction present to expel it: the liquor amnii dribbles away only at the moment when a pain is coming on or going off. _Expulsion of the child._ As the head descends farther it begins to press more powerfully on the perineum, and during each pain pushes it out like a large ball; and then, as a contraction goes off, and the resiliency of the soft parts regain their superiority, it retires again. The breadth of the perineum (viz. from the anus to the vulva) increases, whilst it diminishes considerably in thickness, especially towards its anterior margin. Whilst passing through the inferior aperture or outlet of the pelvis, the head advances more or less forwards under the pubic arch, and begins to distend the os externum; during a pain it separates the labia, and protrudes between them, and again retires as the pain goes off; a larger and larger portion of the head gradually forces itself through the os externum as this dilates; the perineum becomes still thinner, so that at length it is scarcely thicker than parchment. When more of the head has passed through, it does not now recede when the pain goes off; the os externum and perineum are at their greatest distension, for the largest diameter of the head, which is presented to the os externum is now encircled by it; the next pain brings the head into the world. This is the moment of greatest pain, and the patient is frequently quite wild and frantic with suffering; it approaches to a species of insanity, and shows itself in the most quiet and gentle dispositions. The laws in Germany have made great allowances for any act of violence committed during these moments of phrenzy, and wisely and mercifully consider that the patient at the time was labouring under a species of temporary insanity. Even the act of child-murder, when satisfactorily proved to have taken place at this moment, is treated with considerable leniency. This state of mind is sometimes manifested in a slighter degree by actions and words so contrary to the general habit and nature of the patient, as to prove that she could not have been under the proper control of her reason at the moment. It is a question how far this state of mind may arise from intense suffering, or how far the circulation of the brain may be affected by the pressure which is exerted upon the abdominal viscera. A short cessation of pain succeeds the birth of the head. The violent distension of the os externum has ceased for a time, and the patient feels comparatively easy; but in the course of a few minutes the pains return as before, although not quite so severe: first, the shoulder, which is turned forwards, passes under the pubic arch, followed by the other which sweeps over the perineum. The rest of the child is expelled with comparative ease, and as soon as its pelvis has passed through the os externum, a gush of the remaining liquor amnii, which had been retained in the upper portions of the uterus, follows; the whole abdomen instantly sinks and becomes flaccid, while the uterus contracts into a firm globe upon the placenta, which is shortly to be expelled. A most delightful and perfect calm succeeds, and the sense of freedom from suffering, and joy for the termination of her trial, are expressed in the liveliest terms of gratitude. _Third stage._--_Expulsion of the placenta._ The period between the birth of the child and expulsion of the placenta varies considerably. Sometimes it follows the child very rapidly, so that, apparently, they are both expelled by the same effort of uterine action; at others, the interval is more considerable. There is generally an interval of ten or fifteen minutes, and then pains of a totally different character make their appearance: these are supposed to denote the separation of the placenta from the uterus, and, from their being usually attended with discharge of more or less blood, have been termed _dolores cruenti_ by many of the foreign writers. The expulsion of the placenta is attended with little or no suffering; it descends into the vagina inverted, _i. e._ with its foetal or amniotic surface turned outwards: whether or not this is produced by pulling at the cord is perhaps a question. _Twins._ If there be twins, the placenta of the first child is seldom expelled until after the birth of the second child. The membranes of the second ovum become distended with liquor amnii, project into the vagina and burst as in a common single labour; the passages have been sufficiently dilated and prepared by the birth of the first child, so that, when the uterus begins to contract, the expulsion of the second will be readily and easily effected. The uterus may resume its efforts for this purpose in twenty minutes after the birth of the first child, or it may remain quiescent for several hours without at all disturbing the regular and natural course of the process which will be precisely the same as in the previous case. The placentæ of twins are usually expelled together, forming one large placentary mass; their vessels, however, are distinct from each other, so that with care one placenta can be peeled away from the other. In other cases, they are separated from each other by an intervening space of membranes; and in one rare instance of triplet placentæ the umbilical arteries of two placentæ anastomosed with each other, before dividing into smaller branches. Upon the expulsion of the placenta, the uterus, being now emptied of its contents, contracts into a firm hard ball, which may be felt behind the symphysis pubes, or sometimes a little to one side, of about the size of a full grown foetal head. This state of hard contraction gradually disappears, and a discharge of blood called lochia follows, which having continued for a few days becomes colourless, and at length ceases altogether. For a description of the changes which the uterus and passages undergo in returning to their former condition as in the unimpregnated state, we refer to the chapter on the FEMALE ORGANS OF GENERATION. CHAPTER II. TREATMENT OF NATURAL LABOUR. _State of the bowels.--Form and size of the uterus.--True and spurious pains.--Treatment of spurious pains.--Management of the first stage.-- Examination.--Position of patient during labour.--Prognosis as to the duration of labour.--Diet during labour.--Supporting the perineum.-- Treatment of perineal laceration.--Cord round the child's neck.--Birth of the child, and ligature of the cord.--Importance of ascertaining that the uterus is contracted after labour.--Management of the placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and abscess.--Excoriated nipples.--Diet during lactation.--Management of lochia.--After-pains._ This is a subject of great extent as well as importance, because it comprehends the whole mass of rules for the management of a woman, not only just previous to and during, but also after, her confinement. On nothing does the course of a natural labour depend so much, as upon the careful removal of every source of irritation which may tend in any way to derange or interrupt the regular progress of that series of changes or phenomena which constitutes the great process of normal parturition. It will be necessary that the reader should have made himself thoroughly master of the subjects discussed in the last chapter, before commencing those of the present one. With each change there mentioned, the state of the system and its functions should be carefully watched, and every slight deviation from the natural course of things checked by appropriate dietetic or medical treatment. Hence, therefore, the more a woman can follow her usual avocations, and take that degree of exercise to which she has been accustomed at other times, the better; for by so doing the circulation is equalized, the digestion is kept in full activity, and the tone and general strength of the system maintained. It would almost seem, by rendering a woman more capable of moving about during the last weeks of pregnancy (which has already been shown to be produced by the sinking of the fundus, enabling the respiration to act more freely,) that Nature intended she should use exercise at this period, and thus prepare her, by increased health and strength, for a process which requires so much suffering and exertion. Her hours should be regular and early, her meals light and moderate, and by agreeable and cheerful occupation she should fit herself, both in body and mind, to meet the coming trial. _State of the bowels._ Attention to the state of the bowels is of first importance, and must never be neglected. It is a subject nevertheless upon which women are remarkably careless, and they will frequently, when not attended to, allow labour to come on with their bowels in a very loaded and highly improper condition. There is, perhaps, no one circumstance which is found to exert such a prejudicial influence on the course of a natural labour, in so many different ways, as deranged and constipated bowels. Where the contents are of an unhealthy character, the irritation which they produce in the intestinal canal is quickly transmitted to the uterus, and tends not a little to pervert and derange the due and healthy action of this organ: hence arises one of the most fertile sources of spurious pains, a subject which will shortly come under our consideration. Where the bowels are loaded, in consequence of the pressure upon the ascending cava, considerable obstruction to the free return of blood from the pelvic viscera is produced, the vessels of which become considerably engorged. No organ feels these effects more than the uterus: from the immensely dilated condition of its veins, a state of local plethora is engendered, which, from the congested state of the uterine parietes, considerably interferes with the free and regular action of its fibres, and not unfrequently predisposes to hæmorrhage. Moreover, the rectum being distended with fæces, diminishes proportionally the capacity of the pelvis, and prevents the ready descent of the head into it; occasionally it forms, at the beginning of labour, a solid cylinder of indurated fæces, so hard, as, at the first touch, almost to induce the suspicion of a projecting sacrum. As a measure of common cleanliness, the bowels ought always to be attended to before labour, for, besides the more serious effects now enumerated, the labour may be rendered exceedingly filthy for the patient, and not less disgusting for the practitioner; for, as the sphincter ani loses all power of contraction when the head advances deeper into the pelvis, it follows that whatever fæcal matter may have been lodging in the rectum will now be unconsciously pressed out. Hence, therefore, for the last few days of pregnancy, the bowels should be regularly opened (unless they are so spontaneously, which is seldom the case) by castor oil or other mild laxatives: and if labour has already commenced before this measure has been taken, and if, therefore, there is not sufficient time for the operation of the medicine, an enema should be given.[66] In Germany it is a rule to throw up some chamomile infusion at the commencement of every labour, by which means the process is rendered more cleanly than is frequently the case in this country; and also, for the reasons already given, the early stage is less apt to be tedious from spurious and ineffective pains. _Form and size of the uterus._ The more regular the first precursory pains are, the more symmetrical and uniform will be the shape of the uterus; and again, on the other hand, the more uniform its shape, the more regularly and effectively will it act. It is these slight but early contractions, which, although they produce little or no effect upon the os uteri, exert a very important influence over the first half of labour; for it is by their action, in great measure, that the form of the uterus is determined, as also the correct position of the child. Hence, therefore, some practitioners lay considerable stress on ascertaining the precise form of the abdomen as a means of determining what sort of labour the patient will have. In a woman pregnant for the first time, and in a state of perfect health, the uterus is of an oval or rather elliptical form at the beginning of labour: when seen in profile, the abdomen presents nearly a uniform degree of convexity. In this state the child lies with its long axis parallel to that of the uterus, that is, with its head or inferior extremity turned towards the brim of the pelvis; and if the fundus has already sunk in the manner above-mentioned, the practitioner may very confidently prognosticate that the head presents, even before making an examination per vaginam. In a perfectly healthy primipara there is scarcely any inclination of the uterus either to one side or forwards, its median line corresponding with that of the abdomen: whereas, in the multipara, the axis of the uterus is seldom straight, inclining more or less to one side, or, from the greater relaxation of the abdominal parietes, being somewhat pendulous. The size of the uterus should also be taken into consideration, especially in first pregnancies; a large uterus shows that either its parietes are gorged with too much blood, or that its cavity is distended with an unusual quantity of liquor amnii, or that the child is very large, or that there are twins. Whatever may be the cause of the distension, it interferes with the regular and effective contractions of the uterus, and tends to make the labour (at least the first part of it) tedious. A moderate sized uterus is much more capable of active exertion, for its fibres not being put so much upon the stretch are enabled to contract better. _True and false pains._ If the patient is already beginning to suffer pains, it is of great importance to ascertain whether they be genuine or spurious; upon the correct diagnosis of which, the favourable or unfavourable course of the labour not unfrequently in great measure depends. A genuine labour pain comes on at tolerably regular intervals, rises gradually to a certain degree of intensity, remains at that point for a few seconds, and then subsides as gradually; the body and the fundus of the uterus increase in hardness, and the os uteri in tenseness, in proportion as the pain rises, and vice versâ; the pain is seated in the back and loins, and is of a dull aching character: but with the spurious pains it is quite the reverse; they come on and go off suddenly and irregularly, the pain is in the abdomen, and produces a sharp twinging sensation, and the hardness of the uterus and tenseness of its mouth bear no proportion to the pain. Spurious labour pains are the early contractions of the uterus perverted and rendered irregular, spasmodic, and painful by irritation, congestion, or inflammatory action; they sometimes come on several days before actual labour commences, and if not recognised and removed, may expose the patient to considerable suffering and exhaustion. Derangement of the stomach and bowels is one of the most frequent causes of spurious pains, for by the irritation which is thus produced, the uterus is almost sure to sympathize, and to have its action more or less disordered. This may arise from unhealthy irritating contents of the bowels producing spasmodic, griping, and colicky pains, or from diarrhoea with tenesmus arising from exposure to cold, or from irritation caused by the pressure of the gravid womb. Spurious labour pains of this character also frequently occur in patients who are accustomed to indulge in the luxuries of the table, or in the lower classes, who are addicted to the use of spirituous liquors. Constipation has been already mentioned as a cause of this condition. The state of plethora, congestion, or inflammation, acting as a cause of spurious pains, may arise from various sources: it is frequently observed in strong healthy young women, especially those pregnant for the first time; the pains do not assume the proper character of genuine labour pains, and exhaust the patient by continued but useless suffering. The os uteri probably dilates somewhat, but its edge remains thin and tense, and the pains appear to have no effect in dilating it any farther. The mucous secretion of the vagina is not of the character described at the beginning of labour in the preceding chapter. The pulse is strong and more or less excited, and the flushed face, and generally increased heat of skin indicate the condition upon which those symptoms depend. The inflammatory form of spurious labour pains is not unfrequently of the rheumatic character, a condition which has not been much noticed in this country, but which is capable of exerting a very considerable influence upon the course and progress of the labour. It is usually produced by exposure to cold and the other common causes of rheumatism in other parts of the body, and is generally accompanied with more or less derangement of the stomach and bowels. In this state each contraction of the uterine fibres is attended with much suffering, although the contraction itself may be so slight as to produce little or no effect upon the os uteri. Most of these conditions, in a severe degree, form that species of dystocia which arises from a faulty state of the expelling powers, for the farther consideration of which we must refer to our chapter upon that subject. In a minor degree they produce these slight derangements of uterine action, which we are now considering under the name of _spurious pains_. _Treatment of spurious pains._ The indications of treatment depend in great measure upon the cause; and we cannot impress it too strongly on the young practitioner, as a rule never to be lost sight of, that, whatever is wrong in the state of the circulation or of the bowels must be first rectified before having recourse to opiates. Where the stomach is much deranged at the beginning of labour, nature frequently induces spontaneous vomiting, with considerable relief to the patient, and mitigation of the pains; if not a gentle emetic may be administered. Where the bowels are loaded, the treatment already mentioned must be put into practice, after which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine in peppermint water, or gr x of Dover's powder may be given. When there is diarrhoea with a good deal of griping and tenesmus, a dose of castor oil with Liquor Opii Sedativus in any aromatic water may be administered; and if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder may be also given at night. If there be a plethoric or even inflammatory condition, the lancet will be of the greatest service; it reduces the temperature of the body, relaxes the soft parts, brings on copious secretion of mucus, and by relieving the congested state of the uterine parietes, enables the fibres to contract with more regularity and effect. In the rheumatic form, laxatives followed by diaphoretics, the warm bath, and even venesection will be necessary. By thus treating the spurious pains according to their cause, they will usually subside readily enough, and be either followed immediately by pains of a more genuine and effective character, or leave the patient perfectly free for several hours, or perhaps even days. It is by inattention to, or ignorance of, these conditions, that patients have been allowed to remain for several days in suffering, during which they have been treated as if they had been in natural labour, until at length they have become so exhausted that, when labour really made its appearance, they were incapable of undergoing the exertions which this process demands. _Management of the first stage._ The preparatory pains of labour, which form the first stage, do not require that the patient should take to her bed at this early period; and this is especially the case in primiparæ, where the first stage is usually somewhat tedious. Until nearly the end of the first stage, she ought rather to be induced to suppose that actual labour has scarcely yet commenced, and that she may still sit up or walk about the room as best suits her feelings, taking care at the same time that every thing is in readiness against the moment when it shall become necessary for her to lie down. A nurse who understands her business will of course duly arrange all these matters, but it behoves the accoucheur, nevertheless, to pay attention to these little details, and to see that every thing is properly prepared: that the bed is ready, and guarded either by several folds of sheeting, or by a leather for the purpose, to prevent the blood and other discharges during labour from soaking into the bedding beneath; this must be done either on the right side or at the foot of the bed, in order that the patient may be better within the reach of the accoucheur: that the patient should be partially undressed, and covered with her dressing-gown: that all the linen should be well aired: that there should be towels, napkins, hot and cold water in readiness, and also a bottle of vinegar, and one of spirit in the room, in case of hemorrhage, suspended animation in the child, &c. &c. These and many other arrangements of less importance are by no means beneath his attention, and require but a moment's glance to assure him that every thing is properly prepared. By encouraging the patient to sit up as long as she can, or even to move about occasionally, the pains are rendered more tolerable as well as more effective; the time passes more agreeably and quickly; and by the time that it has become necessary for her to lie down, the labour has made so much progress that the rest of its course seems to be much quicker than was at first expected. On the contrary, where the practitioner at an early period of the first stage, informs her that she must stay up no longer, that she must go to bed and remain lying on her left side, her mind is solely occupied with her pains, which become wearying and irksome; the time passes heavily away; she becomes impatient and therefore dispirited; and is much disappointed, that, after remaining in this state for some time, the termination of the labour appears to be as far off as ever. Nothing eases the pains of the first stage, or increases their effect, so much as frequent change of position and moving about; when, however, they are severe or of long continuance, and the patient becomes fatigued, she will require rest, and this opportunity, afforded by her lying down, should be seized for the purpose of making an examination. _Examination._ The manner in which this operation should be proposed to the patient cannot be too delicate: it should, as Dr. Dewees has justly observed, always if possible be done by means of a third person, such as the nurse or any elderly female friend who happens to be present. If the accoucheur has proposed it with that degree of gentleness and good feeling which it ought to behove every one to show under such circumstances, he will rarely, if ever, experience the slightest unwillingness to accede to his request: the better the patient's rank in life is, the more docile will she prove at these times, and the more resolute to undergo whatever she is told it is necessary to submit to. The object of an examination is to determine whether the child presents rightly, whether the labour is far advanced, and to form some degree of prognosis as to its course and duration, &c.: these are points which are of such importance as well as interest to ascertain, that the dread which a patient feels at undergoing an operation so repugnant to her feelings is generally merged more or less in the intense anxiety to know if all is right. An examination at an early period of labour is important in many respects. We ascertain the condition of the vagina, whether it be soft, cool, relaxed, and well lubricated with mucus, as described at the beginning of the last chapter; whether the os uteri be dilated; whether its edge be thin and tense, or already becoming soft, cushiony, and yielding; whether the membranes are ruptured; whether the presentation be a natural one, and whether the pelvis be rightly formed. In cases where the umbilical cord is prolapsed, it is particularly desirable to ascertain the existence of this displacement as early in labour as possible. It is usually directed to examine during a pain, because at this moment we feel the os uteri tense, and therefore more distinct to the finger; but it is far better to examine during the interval between the pain: the os uteri being now relaxed, admits the finger more easily; the membranes being loose are not so liable to be ruptured; and, from their not being distended, we shall feel the presenting part more distinctly. Wherever the os uteri is nearly or fully dilated, or from its condition and the effect which the pains have upon it shows a disposition to dilate with rapidity, the patient should go to bed, as we cannot be sure when the membranes may rupture, more especially in primiparæ, in whom this usually takes place early. It is equally desirable, also, in those who have already had children, that the patient should be upon her bed at this moment; because, if the pains be strong, and the os uteri yielding, the head is apt to follow the discharge of the liquor amnii, and sudden expulsion of the child might result at a moment when the patient is unprepared for such an occurrence. The accoucheur should always examine when the membranes give way, because not only will he be able to feel the presenting part now more distinctly, but if the cord has prolapsed, a coil of it will come down into the vagina and cannot escape his notice; in fact, if there is any thing unusual about the presentation, he will be now able to distinguish it with greater certainty. In women who have had large families, the head remains very high in the pelvis until this moment, so that it is frequently extremely difficult to reach it and to ascertain its position: the same is observed with presentations of the nates and of the shoulder, which seldom descend into the pelvis until the liquor amnii escapes. _Position of the patient during labour._ The position which the patient should take during the actual process of labour has been a subject of considerable discussion, and even at the present day varies exceedingly in different countries. In the earliest periods of history, women appear to have been delivered in a sitting posture, as is described in the first chapter of _Exodus_: this mode was revived in comparatively modern times; thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined back, which he preferred to a common bed. Labour chairs were brought into very general use upon the Continent in the beginning of the last century by Hendrick van Deventer of Dort in Holland, and although they have been in great measure discontinued in modern times, there are still some districts of Germany where they continue to be used. It is a species of chaise percée furnished with straps, cushions, &c. by which the patient can fix her extremities, and thus enable the abdominal muscles to act with the greatest power. This is the very reason which renders labour chairs objectionable. The presenting part of the child is forced through the soft passage with great violence, before they have had time to yield and to dilate sufficiently; hence it has been noticed that lacerations of the perineum are of very frequent occurrence in those countries where labour chairs have been in general use. In some remote parts of Ireland, and also of Germany, the patient sits upon the knees of another person, and this office of substitute for a labour chair is usually performed by her husband. Labour chairs, as far as we are acquainted with their history, were never used in this country, nor have they been used for the last century in France, where the patients are usually delivered in the supine posture, on a small bed upon the floor, which has not inaptly been termed _lit de misére_. A modification of the labour chair is the labour cushion first used by Nuger, and afterwards by the late Professor von Siebold of Berlin and Professor Carus of Dresden; it is a species of mattress, with a hollow beneath the nates of the patient for receiving the discharges which take place during the labour. The patient is compelled to lie upon her back during the greater part of labour, and thus maintain the same posture for some time, which must necessarily become irksome and even painful to her. In this country and in Germany the patient is delivered upon a common bed, prepared for the purpose as above mentioned: in England she is placed upon her left side, the nates projecting to the edge of the bed, for the greater convenience of the accoucheur: in Germany, except in Vienna and Heidelberg, where the English midwifery has in great measure been introduced by Boer and Naegelé, the patient is delivered upon her back.[67] In former times the supine posture was also used in this country, but for about a century the position on the left side has been preferred; the patient lies more comfortably to her own feelings; her face is turned from the practitioner who sits behind her, and who, from this posture, is able to examine or to perform any other necessary manipulation without her feelings being annoyed by seeing what is going forward. It is decidedly the easiest position during the last moments of tremendous suffering and exertion; when the presenting part is passing she is not able to exert an undue degree of violence, and from the knees being kept together, there is less danger of the perineum being torn. The left side seems moreover to be the natural position for a woman at the moment of parturition, for if accidental circumstances have occurred, such as sudden labour, &c. by which she is deprived of all assistance at this moment, she will almost invariably be found upon the ground lying on her side supporting herself with one hand. In some cases she will remain during these moments upon her knees, into which posture she has gradually dropped from that of standing: in by far the majority of cases she will take the position upon her side, as above mentioned. So long as the os uteri is not fully dilated, the patient is not involuntarily compelled to strain and bear down: hence it is important to caution patients, more especially primiparæ, not to be induced by an ignorant nurse or friend to exert themselves improperly during the first stage of labour, for not only is the process of dilatation considerably impeded, and much exhaustion produced, but frequently severe febrile or inflammatory action excited, which may lead to serious results after labour. All attempts to accelerate the course of a natural labour, especially the first stage, either on the part of the patient by premature straining, or on the part of the practitioner by attempts to dilate the os uteri and passages, or by giving her stimuli, &c. cannot be too strictly forbidden. It is a mode of practice which has long since been strongly condemned by the highest authorities in midwifery, except in Scotland, and which may very easily lead to most mischievous results. Quick rapid labours are by no means desirable, for they are seldom safe; nor is it possible to limit this or that stage (especially the first) to any given duration of time. No conscientious practitioner, who has clear and enlarged views of the process and mechanism of natural labour, would feel himself justified in interfering with its course, merely because some portion of it has extended beyond a certain fixed period; but would rather guide his conduct by the habit and strength of the individual, and by the effects which the labour has upon her. We have before stated, that no two labours are alike; we may also add, that no two individuals are similarly affected by the same degree and duration of labour, nor indeed are any two labours exactly alike in the same person: hence it will be evident, that what to one patient would prove a protracted and exhausting labour, to another would be nothing more than a perfectly regular labour, natural both in its character and progress. Among other injurious effects which premature efforts on the part of the patient will have, is, that the membranes are liable to give way too soon--this is by all means to be avoided, for nothing is so likely to render the first stage protracted as the occurrence of this accident; the course of the labour frequently undergoes an immediate change; the pains lose their regular and effective character; the os uteri remains thin, tense, and unyielding, and the process of dilatation is greatly retarded. _Prognosis as to the duration of labour._ There are few subjects upon which an accoucheur is so frequently importuned, or about which it is so difficult to give a decided opinion, as the probable duration of labour. It is natural enough that both she and her friends should be anxious to know how long this process of suffering is likely to last: nothing, however, is more hazardous than a prognosis in these cases; and we would warn our junior brethren to be cautious how they commit themselves by venturing an opinion, which the result of the labour may prove to have been founded upon guess-work or ignorance. The character of the labour during the second stage, is frequently very different to that of the first, so that the mode in which the labour commences is by no means a criterion for its latter part. A labour which has commenced briskly and regularly, and with every promise of a rapid progress and termination, frequently becomes exceedingly lingering during the second stage, so that the expelling powers may, perhaps, even fail altogether in making the head pass through the os externum; whereas, on the other hand, a labour, the first stage of which has been slow and protracted, frequently experiences a complete alteration of character, and advances with a degree of quickness and energy, which could scarcely have been anticipated from the manner in which it commenced. In primiparæ, especially, it is particularly difficult to foretell, with any thing like certainty, the duration of labour: hence it is, that unguarded assertions in this respect are not only liable to disappoint the patient, but destroy her confidence in the practitioner. _Wigand's views._ The celebrated Wigand of Hamburgh considered that the form of the vagina would frequently furnish the means of a pretty certain prognosis, as to the duration of labour: thus, if it were wide and yielding throughout its whole length, the labour would be quick, both at its beginning and termination; if, on the other hand, it were small, rigid, and contracted throughout, the labour might be expected to be of a very opposite character. If on examination the vagina is found roomy and well dilated at its upper part, but contracted and rigid near the os externum, the labour will be probably quick and easy during the first half, but slow and difficult afterwards; on the contrary, where the os externum is yielding and wide, but the upper portion of the vagina narrow, the labour may be expected to be slow at first, but to be brisk and active afterwards. We have already stated, that the course of labour varies in every possible way; in some cases the same peculiar character of labour shows itself through two or three successive generations: hence it has been observed, that very tedious or very violent and rapid labours sometimes seems to be hereditary; the mother, daughters, and grand-daughters, being all remarkable for their lingering or rapid labours. _Diet during labour._ The diet of the patient during labour should be simple and unirritating; if every thing is going on naturally and briskly, some gruel or tea, with or without a little biscuit or bread and butter, will be quite sufficient; but if the process is becoming tedious and exhausting, some beef-tea, broth, or any other mild nourishment of this sort will be required to support the strength. During the first stage of labour there is no need for the practitioner to be constantly in the room, nor even during the early part of the second, unless the pains are very violent and protrusive; for, by taking frequent opportunities of quitting the patient for a few minutes, she is left more free from restraint, and the presence of the practitioner becomes less irksome when it is really necessary; whereas, if he continues at the bed-side, she is justified in expecting that the labour must be advancing rapidly to demand so unremitting an attendance, and, therefore, becomes disappointed and impatient to find that his presence has been of so little use to her. The conversation should be light and cheerful, and every means taken to encourage her and keep up her spirits. _Supporting the perineum._ As the head approaches the os externum our attention must be directed to giving the perineum such a degree of support, as shall secure it from any serious degree of laceration during its passage. The greatest danger of ruptured perineum is in primiparæ, for the soft parts never having been subjected to such a degree of dilatation before, do not yield so readily as in multiparæ. The anterior margin of the perineum, called _frænulum_, is, we believe almost invariably ruptured in every first case; but the laceration ought not to extend farther. The more gradual the advance of the head is through the os externum, the better will be the dilatation of the soft parts: hence therefore, when the pains are violent, and the head is thrust with great force against the perineum, it will be desirable to restrain it in some degree, until the parts shall have had sufficient time to yield; on the other hand, where the pains are more gradual, the perineum and os externum may receive the whole dilating force of the head, and every succeeding pain will show that a progressive advance is taking place. The increasing thinness of the perineum itself, and the frænulum becoming tense during the height of a pain, may be looked upon as warnings that the expulsion of the head is not far distant, and now the support of the hand will be needed to prevent laceration; for this purpose the position on the left side is peculiarly convenient, besides having the additional advantage of relaxing the external parts more completely. If the pains be violent, and the impulse to strain very considerable, we must desire the patient to lie as passive as she can, and do her best not to bear down, for otherwise the head is sometimes driven through the os externum with a single effort, and the mischief done in spite of all our care. The support of the perineum has been variously directed by different authors; we prefer using the left hand, because then we have the right at liberty for any manipulations which may be necessary, such as examining if the cord be round the child's neck, &c. &c. It is awkward at first, because it requires the hand to be considerably twisted, and makes the wrist ache a good deal; but a very little practice soon conquers this slight difficulty, and the superiority of the mode will then be apparent. As our object is not merely to support the perineum, but to direct the head as much forwards under the pubic arch as possible, in order that the anterior portions of the os externum should undergo their share of dilatation, and thus in some measure spare the perineum, the chief pressure should be applied near to the sphincter ani, gradually diminishing it up to the frænulum perinei in front: for this purpose the left hand protected by a napkin (partly for the sake of cleanliness and partly for the purpose of having a firmer hold upon the parts, and preventing it slipping) should now be applied with the palm in the vicinity of the sphincter ani, so that the tips of the fingers should project somewhat beyond the frænulum; the whole should be laid as flat and close to the part as possible. In order that we may be sure of the hand being applied exactly along the raphe of the perineum, we should guide it by the examining finger of the right hand, bearing in mind, that when we place this against the posterior margin of the os externum, and bring the middle finger of the left hand in contact with it, we shall hold the left hand in the desired direction. It is desirable also to hold the examining finger of the right hand against the frænulum perinei when a pain comes on, because then we know exactly when the tension of the perineum is becoming such as to endanger its integrity, and when the head is about to pass out. Until this moment the frænulum is seldom on the stretch, although the rest of the perineum is: hence we need not apply our support until now, and thus give the parts the full benefit of the dilating force, which the head exerts upon them, until the very last instant. To relax them still farther, the patient's knees ought not to be separated by a pillow or cushion placed between them, as is usually done, although it must be confessed that in some cases she is relieved by it. In applying the left hand to support the perineum, it should be placed somewhat more backward than the spot which we intend to support: for by this means we are enabled to push the soft parts somewhat forwards, and thus relax them. By this means, also, we not only direct the head against the other parts of the os externum but avoid the danger of its perforating the perineum. When the moment of greatest distension arrives, the process cannot be too slow; we must therefore desire the patient not to bear down, and endeavour, if possible, to make the head remain in the state of _crowning_ until the next pain comes on: the os externum having been held for some moments at its utmost dilatation, permits the head to pass with greater ease and safety. As the globe of the head passes forwards and emerges through the os externum, we feel the posterior portions of the perineum become soft and lax, while the forehead, followed by the face, and lastly the chin glide over the anterior margin of it. The passage of the head is not the only moment of danger to the perineum, for laceration is even still more liable to be produced during the expulsion of the shoulders; any slight rupture of the anterior edge is now apt to be converted into a considerable laceration, unless the support be continued until the thorax be expelled. We have already stated that the frænulum perinei is generally torn through in the first labour; but the laceration ought not, if possible, to extend farther, because serious injury may be produced either to the vagina, or even to the sphincter rectum. To say, however, that laceration of the perineum need never happen, would be preposterous; because cases every now and then occur, where, from the contracted and unyielding state of the os externum, and from the size of the child, it is nearly impossible that the perineum can escape without injury; fortunately, although considerable lacerations are by no means uncommon, they are seldom observed to extend into the sphincter ani, the direction of the rent being usually to one side. Under the ordinary circumstances of perineal laceration, little more than mere attention to cleanliness is required; for the parts contract so astonishingly after labour, that what was a wide rent of an inch and a half long, in a couple of days will be scarcely more than two or three lines in length. Rest, great cleanliness, and gentle-relaxed bowels, constitute the chief treatment. _Treatment of perineal laceration._ Where, however, the laceration extends into the rectum, the case becomes exceedingly troublesome and difficult to cure, and the patient is liable to be rendered a miserable object for life; for the action of the sphincter being entirely destroyed, she is unable to retain fæces or flatus in the rectum; besides which, from the injury to the posterior wall of the vagina, prolapsus uteri is an almost certain consequence. In these cases the slightest movement of the thighs upon each other alters the position of the lips of the wound, and thus tears it open afresh, so that at length the edges of the wound become callous and refuse to heal. A great deal in these cases depends upon the patience and good conduct of the patient herself; for if she have the resolution to lie perfectly still for at least a week, she will have every chance of a perfect cure. If there be much swelling of the edges, and a disposition to slough, a warm poultice of chamomile flowers should be applied, and the bowels kept in a nearly liquid state by gentle and repeated doses of salines, in order to prevent distension of the rectum when the evacuation is passing; she should preserve the supine posture, and have her knees confined together by a piece of tape, as is done with patients after the operation of lithotomy. Straps of adhesive plaster are seldom or never of any use, but if the rent be very severe a suture or two may be required. The great fault in applying these means for bringing the edges of the wound together is the attempting to unite them throughout their whole length; for by so doing the tension of the parts is increased, and therefore there is less disposition to unite; and even if we succeed in effecting complete union of the whole wound, the perineum is so contracted and unyielding from the cicatrisation, that it can scarcely escape a repetition of the injury in succeeding labours. It is, therefore, much better that we should content ourselves with uniting merely the posterior half of the laceration; the parts heal much more readily, and the os externum is left of a sufficient size to escape all danger of laceration on future occasions. Where the edges have become callous and refused to unite, they require to be pared and brought together again; this, however, does not always succeed, and the case becomes very difficult and protracted: under these circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is well worthy of attention. Having pared off the callous edges of the wound, he brings them into the closest opposition by transfixing them with needles in several places, as is done for the operation of hare-lip; and in order to isolate the wound as much as possible from the surrounding parts, and prevent any tension, he makes a free incision through the integuments, parallel with the wound, at a little distance from it, and nearly of the same length; by this means, every cause which might tend to separate the edges is removed; whilst the parallel cuts, being fresh incised wounds, soon close by granulation.[68] It sometimes, although rarely, happens that the perineum, instead of being torn from before backwards, is perforated through its centre by the head, so that the child is not born through the os externum, but through a lacerated opening in the body of the perineum. This accident may arise from a variety of circumstances: the direction of the pelvic outlet may be faulty, or the inclined plane formed by the lower part of the sacrum, by the sacro-sciatic ligaments, &c. may be insufficient to guide the head forwards under the pubic arch; or the perineum may be unusually broad; in which cases the power of the uterus being directed against the centre of it, the head becomes enveloped in a bag of protruded perineum; and if the pains are violent, and the head not properly supported, it at length bursts its way through the centre without even injuring the frænulum. The treatment of this form of ruptured perineum is the same as that of the more common species; the bowels must be kept open, and a fomentation of chamomile flowers applied to the wound, which, from the gradual contraction of the surrounding parts after labour, diminishes remarkably, so that in the course of a short time it will have entirely or nearly closed.[69] Besides the above-mentioned advantages in supporting the perineum, we may mention another which is not generally noticed, and which is sometimes of considerable service. In cases where the head has completely descended upon the perineum, and begins to protrude somewhat through the os externum, the pains occasionally fail at this moment, the labour becomes very lingering, while the advance of the head and state of the parts show that two or three active pains would bring the child into the world; firm pressure applied at the lower end of the sacrum, in a direction forwards, materially adds to the effect of each pain in bringing the head through the os externum, and seems also to excite the patient to make a more powerful effort with the abdominal muscles. On several occasions we have thus assisted the expulsion of the head, when otherwise the labour would have been very protracted, or would have even required the forceps to disengage it. Madame La Chappelle is the only authority in midwifery, as far as we know, that has noticed this fact. _Cord round the child's neck._ As soon as the head is born, we must examine whether the cord be twisted round the child's neck; and here the advantage of supporting the perineum with the left hand becomes evident: it is ready to support the shoulders when they begin to pass, while the right hand is at liberty to perform any manipulations which may be necessary. If it be important to support the head during its passage over the perineum, still more so will it be to support the shoulders; for if a small laceration has already been produced, it is invariably converted into a wide rent at this moment, if great care be not taken: indeed, we are justified in saying that most of the cases of severe perineal rupture are produced by the shoulders, not by the head. _Passage of the shoulders._ If the pains cease for a time, or the child be large, the shoulders do not pass immediately: in this position the face swells and grows purple from the pressure upon the neck, although it does not necessarily result from the cord being round it; if, however, we find that this is the case, we can in most instances loosen it somewhat by the finger, and as the shoulders advance, slip it first over one and then the other: we must recollect that the shoulder, which is forwards, passes out first, and that, therefore, we must slip the cord over it first. It is seldom necessary to assist the shoulders by applying any extractive force to the head, for in the course of a minute or two the uterus generally resumes its activity and expels it: on the other hand, when the shoulders pass through the os externum, the right hand should be in readiness to prevent the body of the child from being born too rapidly: the uterus can scarcely be emptied of its contents too gradually, for by this means it contracts equably, powerfully, and permanently, and throws off the placenta without difficulty; whereas, if suddenly evacuated, it frequently becomes powerless for a time, or if contraction does take place, it is so irregular and incomplete as to endanger partial separation, retention of the placenta, and hæmorrhage.[70] If, however, the cord be twisted exceedingly tight round the child's neck, and imbedded so deeply into the skin, as to render it impossible to push the coil over the shoulder, it may become necessary to divide it in order to let the child pass, in which case the practitioner must seize the divided ends as well as he can, and apply a ligature the instant the child is born. We believe that this is rarely, if ever, necessary; for in proportion as the child advances, so does the fundus descend, and thus relieves, in some measure, the tension to which the cord is exposed. This subject, however, belongs rather to the third species of dystocia, to which we must therefore refer. _Birth of the child and ligature of the cord._ As soon as the child is born, we must place it in such a position as will enable it to breathe with ease. The sudden exposure to the external air is generally sufficient to excite respiration; if not, a gentle pat on the nates, or blowing suddenly in the face, will usually succeed: if, however, the child still remains insensible, recourse must be had to those means which are recommended under the head of _Asphyxia neonatorum_. The cord should not be tied until it has ceased to beat, for unless the circulation be well established in its new course, the breathing is apt to stop, and the child relapse into insensibility: the cord should be tied about three inches distant from the umbilicus; it should be applied tightly, because otherwise it is apt to become loose, as the cord grows flaccid. In tying the ligature, one hand should be supported against the other to prevent giving the cord any jerk in case the ligature breaks; we are able also by this means to tie it more firmly. The cord should be divided at some little distance from the ligature, so as to prevent all chance of its slipping off, and it should be done with a pair of blunt scissors, by which means the vessels of the cord are so bruised as to be rendered nearly impervious. There is no need to apply two ligatures; in fact it is better not, for, as Dr. Dewees justly observes, "the evacuation from the open extremity of the cord will yield two or three ounces of blood, which favours the contraction of the uterus and expulsion of the placenta." It has been recommended, in case of twins, to apply a second ligature, to prevent all chance of the second child bleeding through the cord of the first. There is, however, no connexion between the two placentæ, although they usually form what appears to be one mass. We only know of one case where the umbilical arteries of one cord anastomosed with those of the other, an anormality of very rare occurrence: still, however, it is better to apply a second ligature upon the cord, where we find that twins are present, as a precaution: and also to prevent it being said, in case the second child is still-born, that it had died from no ligature having been applied upon the placental extremity of the cord. It has been questioned whether it was really necessary to tie the cord before separating the child from the mother, from the well known fact that nothing of the sort is required in animals; and that, in cases of rapid labour, where the child has been unexpectedly dashed upon the floor and the cord broken, no hæmorrhage has resulted. This arises from the bruised and lacerated condition of the cord under these circumstances: animals not only bite the cord, but also draw it through their teeth several times, so as to contuse the vessels for a considerable extent; whereas, if it was merely divided with a sharp instrument, there is no doubt but that the new-born animal would quickly bleed to death.[71] _Importance of ascertaining that the uterus is contracted._ As soon as the child is separated from its mother and removed, or even sooner, if this process has gone on slowly, we ascertain if the uterus has contracted: this we shall know by its feeling like a large hard ball behind the symphysis pubis: if there be one rule more important than another, it is this, for without it we cannot be certain of the patient's safety for a single minute: so long as we feel the fundus to be hard, we know that the uterus is contracting, and that it will expel the placenta quickly, and ensure the patient against hæmorrhage; but if it be soft and relaxed, she cannot be considered safe even if their be no hæmorrhage; for the placenta may have been separated, and may be lying across the os uteri, or the os uteri itself may be contracted, or blocked up with coagula, so as to prevent the blood from escaping; it therefore collects in the cavity of the uterus in large quantities, to the imminent danger of the patient. Even where the uterus has contracted, the patient is not permanently safe, for it may again relax and grow soft, and hæmorrhage come on. _Management of the placenta._ The placenta sometimes follows the child immediately, and occasionally is expelled by the same pain; usually, however, a few minutes intervene, during which time the uterus remains more or less in a state of inaction; it then begins to contract, and the dull and peculiar pains which characterize the separation of the placenta are now felt. The interval after the birth of the child varies considerably, and depends in many cases on the degree of rapidity with which the uterus has been emptied: hence in some cases we feel the fundus hard almost immediately, whereas, in others some considerable period elapses before it resumes its state of activity, a period which, if any separation of the placenta has already taken place, will be attended with the greatest danger. The occurrence of pains indicates fresh contractions, and therefore we should now examine to ascertain if the placenta has been detached. As a general rule it may be stated, that if we can reach the insertion of the cord with our finger we may presume that the placenta is ready to be expelled; if not, that it is still partially or wholly attached to the uterus. So long as this latter is the case, the less we meddle with the cord the better, for by pulling at it we only excite the os uteri to contract, and thus seriously impede its removal. Where some time has elapsed without any symptoms of contraction coming on, we may excite the uterus by circular friction of the abdomen, fanning the face, or by sprinkling a little water upon it, &c.: if, however, the uterus is hard and yet the placenta not within reach, we may pull slightly at the cord, pressing it at the same time back with the fore-finger into the hollow of the sacrum; we thus bring it down in the direction of the pelvic axis, and generally succeed in moving it into the vagina. No violent effort should be made, as this would probably tear it off from its insertion into the placenta, but, by keeping a gentle pressure upon it, the placenta will slowly pass through the os uteri, and then come away without farther difficulty. Following the axis of the vagina, we now guide it downwards and forwards; and when it approaches the os externum, it should be seized with the finger and thumb, and rotated several times: the membranes are thus twisted into a rope, and are less liable to be torn in separating from the uterus. The uterus being now completely emptied, contracts into a hard ball of about the size of a child's head. If, however (whether before or after the expulsion of the placenta) the uterus grows soft and swells, if the patient becomes pale and restless, and complains of faintness, sickness, load at the præcordia, darkness before the eyes, &c. we may be sure that hæmorrhage is going on. We refer to the chapter upon uterine hæmorrhage for the measures to be adopted. _Twins._ Where there are twins, the above rules for ensuring the safe expulsion of the placenta require to be still more strictly observed: the uterus has been more distended, the mass of placenta is larger, and is attached to a much greater extent of surface than where there has been only one child: hence there is not only a greater liability to hæmorrhage, but if it does take place, will probably be much more dangerous. We cannot be too cautious how we extract the placentæ of twins: from the size of the mass, the uterus remains larger, and therefore less contracted: hence, if we venture to pull at the cord before being able to reach the placenta with our finger, we shall feel it yield; but this is not from the placentæ being detached and coming away, but from the fundus itself being pulled down with it--a state which would rapidly pass into inversion if the force were continued. In order to detach the mass more equally, we should twist the two cords together; by so doing there is less danger of their giving way. The same rotating movement should be used when the placentæ approach the os externum; the two bags of membranes are thus twisted together, and come away entire: if this be not attended to, the membranes are torn, portions of them are left adherent to the uterus, and come away some days afterwards in a half putrid state producing a fetid discharge, and sometimes considerable fever. _Treatment after labour._ As soon as the placenta is expelled, the soiled and wetted sheet should be removed and a warm napkin applied to the external parts: the patient should remain thus for half an hour or more, and enjoy a little rest, or even a short sleep: by this time the nurse will have washed and dressed the child, and be ready to attend to the mother. The external parts should be sponged with warm water, her linen changed, and a broad bandage pinned firmly round the abdomen to give it the necessary degree of support. Where there has been great abdominal distension and more than one child, it is sometimes advisable to apply the bandage immediately after the birth of the first, in order to assist the uterus in expelling the second, and in contracting afterwards. The bandage, therefore, should be gradually tightened as the abdomen diminishes in size: without this precaution the removal of so much pressure from the abdominal circulation will be sometimes attended with alarming faintings. A similar effect may be produced by the patient incautiously sitting up in bed to take any refreshment which may be offered to her at this moment; she should be warned, more especially if she be a primipara, not to raise herself from the horizontal posture for a few hours after labour; at any rate, not until the bandage has been properly applied: from inattention to this point, cases have occurred where, on the patient's sitting up immediately after labour, she has fallen back in a faint from which she never recovered; in other cases it has been attended by profuse hæmorrhage, which has instantly proved fatal. "The influence of position," says Dr. Meigs, "in determining the momentum of blood in the vessels is well known to the Profession, but there are few cases where it is of more consequence to pay a profound regard to this influence than in the parturient woman. A uterus may be a good deal relaxed or atonic, and yet not bleed, if the woman lie still with the head low; whereas, upon sitting up suddenly, such is the rush of blood down the column of the aorta, the hypogastric and the uterine and spermatic arteries, that the resistance afforded by a feeble contraction is instantly overthrown, and volumes of blood escape with an almost unrestrained impetuosity: the vessels of the brain under such circumstances become rapidly drained, and the patient falls back in a state of syncope, which now and then proves immediately fatal." (_Philadelphia Practice of Midwifery_, by Charles D. Meigs, M. D. p. 192.) Even if all these directions have been strictly obeyed, if every thing has gone well, and the uterus is firmly contracted, we are not sure of its remaining so: after the lapse of many hours it may again relax, and flooding come on, its power of contraction being impaired either by the exhaustion of the previous labour, the warmth of the bed, &c. It will, therefore, be desirable to adopt such measures, as will ensure the patient against this occurrence: in most cases it will be sufficient to keep the room moderately cool, and ensure a due degree of ventilation; but where the uterus has shown a disposition to relax, we know of nothing which guards the patient so effectually against hæmorrhage after labour, and enables us to leave her with so much confidence, as putting the child to her breast. The sympathetic connexion between the breast and the uterus is now well known; nor are there any means so certain of producing permanent uterine contraction as this natural act: it is a duty which nature instinctively prompts the mother to perform, not only for the preservation of her child, but for the safety of herself. We, therefore, make it a rule, whenever the patient intends to suckle her child (a duty which is performed more frequently now than it was a few years ago,) to have it put to the breast before quitting the house: the first excitement of the mother's feelings towards her offspring is a favourable moment for the performance of this act, the erectile tissue of the nipple becomes turgid, the child takes the breast with ease, and the effect upon the uterus is not less certain than complete; even if the child sucks fairly well for only five minutes we feel satisfied, for we cannot call to mind a single case of hæmorrhage after the effects of this operation. _Lactation._ When the wet clothing has been removed, and fresh linen substituted, the patient should be left to enjoy perfect quiet both of body and mind, in order that she may have some sleep, for "the refreshment of sleep seems to be the most powerful natural means of inducing full contraction of the uterus."[72] After this, the child should be placed at her side, in order that it may enjoy the warmth of her body, and make another trial of taking the breast. That new-born animals are not able to maintain a sufficient degree of warmth, is seen by the care with which a bird shelters her young beneath her wings, and by the manner in which kittens, puppies, &c. crawl close to the mother's abdomen to enjoy that degree of heat which of themselves they are unable to produce. Dr. Edwards has shown that the animal heat of a new-born infant is several degrees below that of the adult: the mother's breast is, therefore, the natural place for it, where it can not only enjoy the necessary warmth, but take that nourishment which has been destined for its support at this early period. A child is capable of sucking the moment it is born; indeed, we would say, better at this moment than later, for the power of instinct in it is fully as great as in other animals; whereas, if not put to the breast soon after birth, but fed instead, it quickly loses it. A vigorous healthy child immediately seeks its mother's breast, and if it does not find it, sucks at every thing which touches its mouth, even its own little hand or finger when presented to it: so strong is this instinct, that, on more than one occasion, we have known the child suck at the finger of the medical attendant when the head had only just cleared the os externum. It has been, and even still is, a very general practice not to apply the child to the breast until the second or third day, upon the plea that there is no milk: a more erroneous and mischievous plan of treatment could not be devised, for it is a fruitful source of much injury as well of suffering both to the mother and her child. The child should be put to the breast, "whether there be signs of milk or not." (White, _on Lying-in Women_.) There is always more or less thin watery fluid called _colostrum_ which is admirably adapted to form the first nourishment of the infant; it is slightly purgative, and, therefore, well fitted to unload the bowels of the viscid green mucus, called _meconium_, which fills them. The colostrum has been variously described by authors; some speak of it as a thin watery fluid, others as a thick creamy milk: this difference depends in great measure upon the interval between the birth of the child and its application to the breast: where this has taken place early, as we have just recommended, the colostrum has almost always the thin watery appearance above mentioned; whereas, if some period of time has been allowed to pass before the child is applied, the breast begins to secrete a fluid containing a larger proportion of caseous matter, or, in other words a more perfect milk, which not being drawn off, the watery part of it is absorbed, leaving the thicker portion to be removed by the process of sucking. Instead of giving the child this bland and natural fluid when in a state best fitted for its delicate digestive organs, it is but too frequently the practice to make it swallow some soft sugar, or a tea-spoonful of castor oil, and follow this up with a little gruel. The effects of such treatment upon a stomach which has never yet received food may be easily imagined; the digestive function becomes deranged, pain is excited, acid is secreted, gas is disengaged, flatulence, diarrhoea, &c. are the result, with all those manifestations of gastric irritation, such as strophulus, aphthæ, colic, &c. from which new-born children are made to suffer so severely. Besides the above advantages in applying the child thus early to the breast, there are others of even greater importance which require to be mentioned. The breast is not yet distended; it is soft and conical, and therefore in a most favourable condition for being drawn; the child can seize the nipple and draw it out with ease, and by thus straightening the lactiferous tubes it commands a ready flow of their contents. By the gentle irritation of sucking, an earlier secretion of milk is excited, and being drawn off as fast as it is formed, the breast is never distended by an accumulation of milk. On the other hand, where some time has elapsed before putting the child to the breast, it will have in great measure lost the instinctive desire to suck; the breasts have become distended and painful; instead of being soft and conical, they are now hard and flattened, the nipple is shortened, or even sunken in; and if the child does succeed in drawing it out, it is at the expense of severe suffering to the mother. The process of sucking in this state of the breast is very difficult; a considerable effort is required to elongate the nipple, and the thin delicate skin which covers it is abraded; excoriations and deep fissures round the base of it are produced, and each application of the child is one of absolute torture. In many cases, partly from having been fed, and partly from the difficulty it meets with, the child refuses the breast altogether; in others, the suffering is so severe as to oblige the mother to discontinue the attempt. The breasts now increase in size and hardness, producing great pain from their weight and tension; hard painful knots from the distended tubes and vessels are felt in different parts, and the pain and dragging extends to the axillæ, the glands of which are also swollen and painful. _Milk fever and abscess._ By this time, or even earlier, the patient will in all probability have been attacked with a smart shivering fit followed by a hot and then a sweating stage, and accompanied with headach and febrile excitement of the circulation. This is the _febris lactea_, or _milk fever_, an affection which, at one time, was very generally supposed to be necessary for establishing the secretion of milk: experience, however, has shown that it chiefly results from neglect in not putting the child to the breast sufficiently early; the secreted milk has been in part absorbed into the system, fever has been induced, and the patient has been relieved by the natural crisis of a sweating stage. The febrile excitement will be considerably moderated, and the tension of the breasts relieved, by the action of saline laxatives: the shoulders which are usually kept warm for the purpose of promoting the secretion of milk, should now be clothed more lightly; the relief, however, is but too frequently partial, the breasts still remain large and painful; the process of suckling is just as difficult as before, and the indurated spots increase in hardness, sensibility, and extent; throbbing and darting pain is felt in the part, the skin over it becomes hot and red, and at length presents that shining glazy look which but too surely indicates the formation of matter beneath, a circumstance which is still farther proved by the oedematous feel of the part, or by the presence of actual fluctuation.[73] Where the breast is capable of being drawn, whether by the child or by artificial means, the application of a cold evaporating lotion, and the frequent exhibition of saline laxatives, will generally suffice to check the determination of blood to the breast, and diminish the secretion of milk; but where these means fail to reduce its size and hardness, it should be frequently rubbed with volatile liniment, and then enveloped in a hot linseed-meal poultice: this may be advantageously made with Goulard, and changed every two or three hours, keeping up a brisk action upon the bowels, as before-mentioned.[74] If there be much febrile excitement of the circulation, bleeding may be sometimes required: we have rarely, however, found it necessary, having been almost always able to exert a sufficient effect by means of nitre with small doses of Vin. Antimonii and Sp. Æth. Nitr. Leeches seldom give more that temporary relief, and that only when applied in large quantities; in which case so much irritation and inflammation is produced by their bites as not unfrequently to counteract the benefit arising from the loss of blood. The patient should preserve the horizontal posture, or at least have the breast well supported by a soft handkerchief, as otherwise its weight will produce much painful dragging. It is not always easy to detect the fluctuation, particularly when it is seated deep beneath the fascia, which invests the mammary gland; but wherever it is tolerably distinct, especially in the upper parts of the gland, the abscess should be let out early, otherwise it will burrow through a large extent of the breast, and destroy a considerable portion of the gland; whereas, if it be felt below the nipple, it may be allowed to approach nearer to the surface and point, by which means it will not be necessary to make the incision so large or so deep, a point which is worthy of attention, as otherwise considerable-sized milk tubes and even blood-vessels may be divided. Dr. Burns has mentioned a case of fatal hæmorrhage from this cause. In either case, whether the opening has been made artificially or spontaneously, the breast should be constantly enveloped in a hot poultice of linseed meal: if this be made with boiling water it forms a gelatinous mass, which retains its heat for a very considerable time, and not only acts as a fomentation, but gives great relief by softening the indurated portions and diminishing the tension. If the patient can bear it, the breast ought to be drawn by a glass for that purpose: this is much better than the breast-pump, being simple and easy of application. Where little or no milk comes, it is useless to persevere, as we should only expose the patient to much unnecessary pain, and the breast to a good deal of irritation. It rarely happens that the breast recovers so far as to enable the mother to nurse with it, and she will therefore be obliged to nourish the child entirely from the other, which generally bears the double duty without inconvenience: in some cases, however, there has been so much fever, and the process of inflammation and its consequences has been so long, that it is neither possible nor advisable to keep up or recall the secretions. In succeeding labours great attention must be paid to a breast which has been thus injured, and every disposition to distension and accumulation of milk carefully watched. By the time a mammary abscess has been fairly opened, the strength of the patient is considerably lowered, not only from the quantity of discharge, but also from the nature of the previous symptoms and treatment; her food should now be more nutritious, she should take a little wine or porter; and if the appetite be delicate, two pills, consisting of equal parts of Extr. Gentianæ and Extr. Hyoscyami should be given night and morning; she will thus be enabled to sleep better, and the general irritability arising from her state of weakness will be relieved. If, however, the appetite fail entirely, and she has a pale flabby tongue, or if it is brown and dry in the centre; if the bowels are deranged, and she has a disposition to profuse perspiration, with much pain in the front or summit of the head, and other signs of debility, the Hydr. c. Cretâ and Dover's powder should be given at night followed by a rhubarb and manna draught the next morning, and if these have acted sufficiently, she may be put upon the use of quinine and sulphuric acid with Tinct. of Hyoscyamus two or three times during the day. _Excoriated nipples._ When the nipples are merely excoriated, or there are fissures in them, they should be bathed with tepid Lotio Plumbi or a solution of Zinci Sulph. in rose water, which must be carefully washed off before applying the child to them. If they are too tender to permit being drawn by the child, they should be covered by the shield, to which is attached a cow's udder or some form of artificial nipple, through which the child can draw the milk without pain to the mother; the udder should be kept very clean, and there should be one or two spare ones soaking in water, in order that they may be changed from time to time. Excoriation of the nipples frequently arise from the extreme thinness of the skin which covers them, and from their unnatural softness. Whatever renders the nipples soft and tender, makes the operation of sucking difficult, because the child can draw them out too easily: we should rather be careful to have them firm, and less sensitive of irritation, just as they would be if they had not always been covered by the dress from the earliest childhood, and thus rendered perfectly unfit to perform the office designed them by nature. The best means of attaining this end is to expose them frequently to the air during the latter months of pregnancy, and by dabbing them occasionally with cold water mixed with a little lavender water or eau de Cologne. (_Boer._)[75] It is important that the child should be suckled at regular intervals of about three hours during the day; and if this be done the last thing at night, and the first thing in the morning, there will be no need of giving it the breast during the night. With a little perseverance on the part of the mother, the child soon learns not to require the breast at this time, which ensures her a good night, and spares her much trouble and annoyance. Those mothers who are obliged to suckle their children at all hours of the night to pacify their screaming, have brought the trouble upon their own heads, for if, instead of dosing the children with castor oil, and feeding them for the first day or two after birth, they had put them to the breast at once, the derangement of stomach and bowels which is the cause of this restlessness would have been avoided. _Diet during lactation._ Attention should be also paid to the diet of the mother, for upon this subject much erroneous opinion prevails. If she be strong and healthy, her food should be entirely farinaceous for the first three or four days, using gruel, tapioca, farinaceous powder, arrow root, &c. with a due admixture of milk; if there are no symptoms to forbid it, an egg may now be taken in the morning, and she may gradually proceed from chicken, &c. to the stronger meats, as her general condition and appetite point out. Where she is naturally delicate, or has been weakened by a sickly pregnancy, &c. it will be advisable to allow her chicken broth, and weak beef-tea from an earlier period. "Serious mischief is frequently done by the mother attempting to remedy every temporary diminution of milk, by increasing the quantity of her food, or by imagining that some stimulating drink will answer this valuable end. Owing to some trifling disturbance in the system of a temporary kind, the secretion of milk may be for the moment suspended or diminished. An attempt is made to recall it by an increase of food, by which a slight inconvenience is converted into a permanent derangement of the system, or a fever of even a dangerous character may be generated; or owing to a false theory, or imperfect observation, it has been supposed that certain liquors have a control over the secretion of milk, and hence the too free use of certain combinations, into which ardent or fermented spirits too largely enter. We must not, however, be supposed to deny the influence of certain solid as well as fluid substances upon the secretion of milk, for we well know, that unless the body be properly supported, there must soon be a diminution of milk. We only mean to insist that it is the nutritious, and not the stimulating part of the diet, which is subservient to the plentiful and healthful formation of this fluid. In proof of this we need only observe, that we have often been consulted upon the subject of the failure of milk, where an anxious mother herself, or a hireling nurse, was concerned, and had been informed by them that they had tried every thing with a hope of improving it, such as rich food, porter, ale, beer, &c. without success, or it was followed, perhaps, by a diminution of it. In such cases we have often succeeded in producing a plentiful supply of milk, by adopting the opposite plan of treatment, for it must be borne in mind, as an important truth, that this failure proceeds more frequently from an over, than from an under, quantity of food or of drink. It is a fact well-known to all who have paid attention to the consequences of arterial excitement, that when it amounts to even moderate fever, the milk almost immediately diminishes in quantity; and also when this action is diminished by suitable remedies (provided it has not continued too long,) that the secretion of milk again becomes more abundant. Upon this principle we have frequently prescribed evacuants and abstinence to promote the secretion of milk." (Dewees, _on Children_.) Where the mother does not intend to nurse her child, a different plan of treatment must be adopted: the shoulders should be lightly covered, cold evaporating lotions applied to the breasts, and the bowels freely opened by saline laxatives, her diet must be abstemious until the fulness of the breasts subsides, and she ought not to take much fluid: where there is a disposition to febrile action, an antimonial may be advantageously combined with the salines. In most instances the milk is thus checked without any inconvenience, but every now and then much illness and suffering is produced before this can be effected. Wherever, therefore, it is possible for the patient to suckle, the practitioner should urge the importance of it in the strongest terms. "A very serious evil from a woman neglecting this imperious duty is the probability of her becoming more frequently pregnant than the constitution of most females can sustain without permanent injury. A woman who suckles her children has generally an interval of a year and a half or two years between each confinement; but she who without an adequate cause for the omission does not nurse, must expect to bear a child every twelve months, and must reconcile her mind to a shattered constitution and early old age." (Conquest's _Outlines_.) _Management of the lochia._ The management of the lochia constitutes also an important part of the treatment of a natural labour, for the patient's health will be materially affected by any alteration either in its quantity or quality. The lochia usually continues to be a sanguineous discharge for about three days, becoming paler, thin, watery, and of a brownish hue, and gradually disappears: a free lochial discharge for the first forty-eight hours, at least, is one of the greatest safeguards against the different forms of puerperal fever and inflammation which are so justly dreaded by the practitioner, and nothing tends to ensure this desirable object so much as the early application of the child to the breast. It may seem paradoxical to assert, that what prevents hæmorrhage after labour should promote the lochial discharge: we do not attempt to explain why such is the case, but merely mention it as a fact repeatedly observed. As the lochia is secreted from the internal surface of the uterus, it will continue to accumulate in this cavity and that of the vagina so long as the patient remains in the horizontal posture, the direction of the vagina preventing its spontaneous escape: it will, therefore, be desirable to favour its discharge by occasionally altering the position of the patient, and thus prevent its becoming offensive, which it would readily do from the temperature at which it is kept by the surrounding parts, from being in contact with the external air, and from its muco-sanguineous character. In the same way it frequently happens that small coagula of blood lodge in the uterus and rapidly grow putrid. In either case much irritation and fever are produced by their presence in the passages, and serious symptoms would soon result if they were allowed to continue there. Hence we make it a rule, that whenever the patient requires to evacuate the bladder, she should do it by kneeling: by this means the position of the vagina is altered, and the accumulated discharges and coagula readily drain away and produce the greatest relief. Wherever the patient complains of abdominal pain, and the lochia has become scanty and somewhat offensive, it will be advisable to wash out the vagina with a warm water injection: for the farther treatment of these symptoms, we must refer the reader to the chapter on PUERPERAL FEVER. _After-pains._ When coagula have remained or formed in the uterus after labour, these irritate it by their presence, and excite it to contract: pains therefore of a crampy spasmodic character are produced, which have received the name of _after-pains_. Women who have already borne children are more liable to them than primiparæ. They vary considerably in degree: in some cases they are scarcely sufficient to excite attention; in others they rise to great intensity, and may even be mistaken for inflammation; indeed, they occasionally pass into this condition. During these pains the uterus is evidently in a state of contraction, for the fundus feels hard, and for the moment it is more or less painful to the touch: the patient has also pain in the back like a labour pain. After-pains do not only arise from coagula in the cavity of the uterus irritating it to contraction, but also from little plugs of coagulated blood, which fill the sinuses opening upon the internal surface of the uterus. After awhile they excite contractions, by which they are squeezed out and come away in the discharges: this fact was first pointed out by Dr. Burton in 1751. Having to introduce his hand into the uterus for the purpose of removing a portion of the placenta, he felt several of these little oblong fibrinous masses exuding from the orifices of the uterine sinuses, whenever he at all stretched the uterus by opening his hand; these proved to be so many fibrinous casts of the above vessels, the blood having been retained and coagulated in them, when the uterus contracted after the birth of the child. When the uterus has been slowly emptied during labour, it contracts gradually and uniformly, and forces the blood from its numerous sinuses into the rest of the circulation; but where its contents have been suddenly removed, the contraction is unequal, and a portion of the blood is retained, which coagulates as described. This fact affords an additional argument in favour of putting the child early to the breast: the active contraction of the uterus, which is thereby induced, effectually expels the coagula from its sinuses: hence we see that where a patient suckles shortly after labour, she seldom (_cæteris paribus_) has severe after-pains; but where this has been delayed until the second or third day, the first application of the child to the breast is sure to induce a sharp attack; the truth of the old adage, that "the child brings after-pains," is thus verified. After-pains must be looked upon as an important agent in preventing those attacks of inflammation and fever which arise from the retention of putrid coagula and lochia: they ought not therefore to be checked, unless their severity is such as really demands it: hence the custom of giving an opiate after _every_ labour cannot be too strongly reprobated, for by this means those uterine contractions are suspended, by which nature would have rid herself of the offending cause: nor do we consider ourselves justified in giving an opiate where after-pains are severe, until by change of posture, &c. we are satisfied that no accumulation exists in the passages. "Wherefore," says Burton, "we must not be too forward in giving strong opiates and other internal medicines, which may take them off while this grumous blood is lodged within these sinuses. I doubt not but those patients who die from the eighth to the fourteenth day, whose uterus has been inflamed with the symptoms above-mentioned, have been injured by the too free use of opiates." (_Essay towards a complete new System of Midwifery_, by J. Burton, M. D. p. 342.) We do not deny that a mild sedative is frequently of great benefit after labour: it calms the irritability of the system and procures sleep: these effects will be much better obtained by a little extract of hyoscyamus, lettuce, or hop. Where an opiate is really necessary, twenty minims of Liq. Opii Sed. in any aromatic water will be as good a form as any.[76] CHAPTER III. MECHANISM OF PARTURITION. _Cranial presentations--first and second positions.--Face presentations--first and second positions.--Nates presentations._ If we were asked to point out the basis on which the principles of practical midwifery should be founded, we would answer, on an accurate knowledge of the manner in which the child presents, and passes through the pelvis and soft parts during labour. In confirmation of this remark, we may observe, that almost every great improvement in midwifery practice which has taken place during the last century, has resulted from farther investigation into this difficult field of inquiry, and from the gradual addition of new facts to our knowledge respecting this interesting process. Unless a practitioner be thoroughly acquainted with every step in the mechanism of a natural labour, how can he be expected to understand and detect with certainty any deviation from its usual course, still less make use of those means which may be required under the particular circumstances of the case; and yet, strange to say, there are few subjects which, generally speaking, have excited so little attention, and upon which such incorrect opinions have prevailed even up to the present time. The investigation is confessedly one of considerable difficulty, and as it was more easy to calculate how the head ought to pass in this or that position through the pelvis than to ascertain how it really did pass, ingenuity has been taxed, and theories have been invented, and positions of the child without number have been described, which have never existed in nature, and which have only added to the difficulty and perplexity of the subject. We consider that to form an accurate diagnosis in these cases, requires the highest perfection of the _tactus eruditus_, which can only be acquired by long practice and patient observation: and it is chiefly from this circumstance that we can explain why such gross errors and vague notions should have existed about a process of every day occurrence, and why, with but few exceptions, they should have been transmitted from one author to another even up to the present time. In the last century, when it was so much the fashion to resolve every physiological process into a mathematical problem, it was scarcely deemed necessary to spend much time in actual observation and examination; the proportions between the head and pelvis were ascertained, their angles were measured, and their curves determined, and from these data it was inferred, what must be the course which nature would follow; few attempted the slow but surer method of ascertaining by patient research the real facts connected with the process of parturition. When the long axis of the child's body corresponds with that of the uterus, the child (provided the passages are normal) can be born in that position: it matters little, as far as the labour is concerned, which extremity of the child presents, so long as this is the case; but where the long axis of its body does not correspond with that of the uterus, the child must evidently lie more or less across, and will present with the arm or shoulder, a position in which it cannot be born. In stating this, we wish it to be understood, that we merely refer to the full grown living foetus, and not to one which is premature, or which has been some time dead in the uterus, as these follow no rule whatever, hence the positions of the child at the commencement of labour resolve themselves into two divisions, viz. where the median line of the child's body is parallel with that of the uterus, and where it is not; the first we shall call _natural_, the second _faulty_, presentations of the child. A description of the natural presentations will form the contents of the present chapter. The reader will almost anticipate us when we state, that the natural presentations consist of two classes, those where the cephalic, and those where the pelvic end of the child presents; in the first case, it will be a presentation of the cranium or of the face; in the second, of the nates, knees, or feet.[77] _Cranial presentations._ The presentation of the cranium, (or _vertex_, as it has been improperly called,) is of by far the most frequent occurrence; thus, for instance, of 4042 children which were born in the lying-in hospital, at Heidelberg, 3834 presented with the head; of these the 3795 with the cranium, and 39 with the face: in either case, whether it be a presentation of the cranium or of the face, it will be either with the right or the left side more or less foremost; the former, from its greater frequency, has been called the first position of the cranium or face, the latter the second position. _First cranial position._ It will be recollected we have stated, that the os uteri at the end of pregnancy is turned obliquely backwards, corresponding to the upper part of the hollow of the sacrum. If we examine during the first stage of labour, when it is just dilated sufficiently to allow the finger to pass, we shall feel the sagittal suture of the head running across it, dividing it into two unequal portions, the os uteri itself corresponding nearly to the middle of this suture. If the os uteri be sufficiently dilated to let us trace its course, we shall find that it corresponds more or less to the direction of the right oblique diameter, viz. that it runs from the right and backwards, obliquely forwards, and to the left. If we follow it with our finger in this last-mentioned direction, we come to a spot where it divides into or meets two other sutures; these are the right and left lambdoidal sutures, and beyond them is the hard convex occiput, the point where they meet being the posterior or occipital fontanelle. If we trace our finger along the suture in the other direction, viz. backwards and to the right, we shall come to a four cornered space, where four sutures meet at right angles to each other; these are the sagittal, the frontal, and right and left coronal sutures; the open space itself is the great or anterior fontanelle. That part of the head which lies lowest or deepest in the pelvis, and which the finger first touches upon when introduced along the vagina, is the right parietal protuberance; and if the os uteri be sufficiently dilated, we distinguish it by its hard and conical feel. In primiparæ, where the head usually is deep in the pelvis at the commencement of labour, and where the anterior and inferior segment of the uterus is closely stretched over it, the parietal protuberance may be felt through this part. Hence, then, the first position of the cranium, (or more correctly speaking, parietal bone,) is marked by the following characters: the sagittal suture crosses the os uteri, and runs parallel with the right oblique diameter of the pelvis: the vertex is therefore turned towards the upper part of the hollow of the sacrum, the posterior fontanelle forwards and to the left: the right perietal protuberance, therefore, is necessarily that part which is deepest in the pelvis; and the perpendicular diameter of the head, instead of corresponding to the axis of the pelvic brim, runs in an oblique direction upwards and forwards. If the head at this early stage of labour be high up in the pelvis, viz. has scarcely entered the brim, as is frequently the case in multiparæ, the sagittal suture approaches in its direction to that of the transverse diameter, or to one between the transverse and oblique diameters, the posterior fontanelle corresponding to about the left acetabulum. The higher the head is in the pelvis, the nearer does its greater diameter correspond to the transverse one of the pelvis: the more oblique also is its perpendicular diameter, from which reason the right ear at this time can usually be felt without difficulty behind the pubic bones. Sometimes both fontanelles can be reached with equal ease; most frequently the posterior one is lowest, but occasionally the reverse is the case, and it is the anterior fontanelle, without, however, at all influencing the progress of the labour. As the head advances through the brim and begins to enter the cavity of the pelvis, the sagittal suture corresponds more closely with the right oblique diameter, so that now the posterior fontanelle is turned towards the left foramen ovale, and as it approaches the outlet of the pelvis, the occiput advances still more forwards, although the head entirely quits its oblique position. At this stage of the labour, the fontanelles can usually be again reached with equal facility, and we find the anterior one corresponding to the right sacro-iliac synchondrosis, the occiput is completely behind the left descending ramus of the pubes, the right lambdoidal suture running parallel with it. Owing to this slight change in the position of the head, the occiput having advanced somewhat forwards, we no longer feel the right parietal protuberance to be lowest and in the centre of the pelvis, but the finger now touches upon the posterior and superior quarter of the right parietal bone, for this is the part of the head which first comes under the pubic arch, and first enters the external passages. If there be but little liquor amnii, or the membranes have been ruptured prematurely: if the head be firmly pressed against the os uteri, and we examine when it is not more than two-thirds dilated, we feel a puffy oedematous swelling upon that part of the head which corresponds to the os uteri. This will therefore be found to be situated upon the sagittal suture, nearly equidistant from the anterior and posterior fontanelles; it arises from the circulation in the scalp being obstructed by the pressure of the os uteri upon the head. If the remaining portion of the labour be rapidly completed, this will be the situation of the swelling with which the cranium is born; if, however, it follows a more gradual course, and the head passes slowly through the os uteri into the vagina, as it thus advances deeper into the pelvis, and alters its position more or less, the swelling upon the sagittal suture disappears in part, and forms on that portion of the head which is advancing under the pubic arch, and is now tightly encircled by the external passage: we shall, therefore, find that this second swelling is situated upon the posterior and superior quarter of the right parietal bone, and this is precisely the situation of the swelling of the head, which the child is usually born with. From these facts we may deduce the following simple law respecting the mechanism of parturition, where the head presents: viz. that the head enters, passes through, and emerges from, the pelvis obliquely; and this is the case not only as to its transverse diameter, but also as to the axis of its brim; the side of the head being always lowest or deepest in the pelvis. This shows the beautiful mechanism of the process, for, on account of its oblique position, there is no moment during the whole labour at which the greatest breadth (still less length) of the head is occupying any of the pelvic diameters; even at the last, when the head is passing under the pubic arch, the complete obliquity of its position, in order that it should take up the least possible room, is very remarkable; for the ring of soft parts, by which the head is now encircled, passes obliquely across it, running close behind the left, and before the right parietal protuberance. The head never advances with the occiput, forwards, under the pubic arch, as is stated in works on midwifery, still less with the sagittal suture parallel to the antero-posterior diameter of the pelvis; for the direction of the right lambdoidal suture, as also of the posterior fontanelle, and the position of the cranial swelling, or _caput succedaneum_, as it has been called, completely prove the inaccuracy of such a theory, the sagittal suture crosses the left labium at an acute angle, the right lambdoidal suture being parallel with the left descending ramus of the ischium. Not less incorrect is the theory (for we can call it nothing else) of the head presenting with the vertex, and turning with its long diameter, from the oblique, into the antero-posterior or conjugate diameter, and the face into the hollow of the sacrum, for it is disproved by all the above-mentioned facts, which careful examination during labour puts us in possession of. When the head is born, the face looks backwards and to the right, viz. to the back part of the mother's right thigh, for the shoulders are by this time passing through the pelvis in its left oblique diameter, the right shoulder being forwards and to the right, and lowest in the pelvis: it is also that which is first expelled. Such is the manner in which the head presents in the first or most common position: a slight modification of it is occasionally observed during the early stages of labour, without influencing the favourable character of its progress: the head at first is in the left oblique diameter of the pelvis, the occiput towards the left sacro-iliac synchondrosis, the anterior fontanelle towards the right acetabulum; but as the labour advances, the head turns, so that the occiput corresponds to the left acetabulum, the anterior fontanelle being turned towards the right sacro-iliac synchondrosis, the sagittal suture running parallel with the right oblique diameter of the pelvis. This peculiar commencement of the labour is probably not detected so frequently as it really occurs, owing to its changing into the common position at so early a period. _Second position of the cranium._ The other or second position of the cranium is, where the _left_ side of the head presents. It is, in fact, merely the reverse of the one just described: the sagittal suture crosses the os uteri at the beginning of labour, as in the former case, only now the posterior fontanelle is turned to the right instead of to the left; it is the _left_ parietal protuberance which is deepest in the pelvis, and which the finger first touches upon. As the labour advances, and the head approaches the pelvic outlet, it is the posterior and superior quarter of the _left_ parietal bone which first enters the vagina and protrudes through the os externum, and upon which the swelling of the scalp or _caput succedaneum_ is situated. The chief peculiarity is, that the change, which we noticed in the first position as an occasional occurrence at the beginning of labour, is in this case the regular commencement of it. In the second cranial position, the head at the beginning of labour, with very few exceptions, is always with its long diameter parallel with the right oblique diameter of the pelvis, the posterior fontanelle turned towards the right sacro-iliac synchondrosis, the anterior one towards the left foramen ovale. During the early periods of labour, when the head is passing through the brim, both fontanelles may be reached; and, generally speaking, the posterior one with greater ease, from its being usually somewhat the lower; but as labour advances, and the head has fairly engaged in the pelvic cavity, they may both be reached with equal ease, the anterior fontanelle still corresponding to the left foramen ovale, or rather to the descending ramus of the left pubic bone. "As soon as the head experiences the resistance which the inferior part of the pelvic cavity opposes to it, or, in other words, the oblique surface which is formed by the lower end of the sacrum, the os coccygis, the ischiadic ligaments, &c. by which it is compelled to move from its position backwards in a direction forward, it turns by degrees with its greater diameter into the left oblique diameter of the pelvic cavity, viz. the posterior fontanelle is directed to the right foramen ovale, and as the head approaches nearer and nearer to the inferior aperture, it is the posterior and superior quarter of the left parietal bone which is felt in the cavity of the pelvis opposite to the pubic arch, so that when the point of the finger is introduced under and almost perpendicular to the symphysis pubis, it touches nearly the middle of the posterior and superior quarter of the left parietal bone: and this is precisely the part, as the head advances farther, which first distends the labia, with which the head first enters the external passages, and the spot upon which the swelling of the integuments forms itself." (Naegelé, _Mechanism of Parturition_, transl.) The manner in which this change in the position of the head takes place, varies a good deal in different labours: in primiparæ it usually takes place slowly, and requires several pains before it is completed; as the pain comes on, the posterior fontanelle, which was backwards and to the right, now advances more forward and comes more within reach; the anterior fontanelle, which was towards the left foramen ovale, retreats, so that when the pain has reached its maximum the head will for a moment be felt in the transverse diameter of the pelvis, and again resumes its former position as the pain goes off: with the recurrence of each pain there is a repetition of this screw-like motion, but by degrees the head not only passes from the right oblique into the transverse diameter, but from the transverse into the left oblique, so that at length the anterior fontanelle corresponds to the left sacro-iliac synchondrosis, and the posterior one to the right foramen ovale. In women who have already had children, the whole change is frequently effected during one pain, so that the head, which but a few minutes previously was presenting in what is called the third position of the German schools, will now be found to be in the second. It is to the celebrated Naegelé of Heidelberg that we are indebted for having first pointed out the uniform occurrence of this change in the second position. From his extensive and accurate observations, confirmed since by ourselves, as well as by many others, the head presents with the occiput _originally_ forwards and to the right very rarely, but passes into this position during the course of labour. No one has ever described the mechanism of parturition so minutely and correctly; and the value of his investigations is the more enhanced, when we recollect what erroneous notions have prevailed upon this important subject up to the present time. "In the former part of my practice," says this distinguished obstetrician, "not knowing that the head made this turn, I always concluded that my examinations in the early part of labour were incorrect, and was very uneasy that I did not find it all exactly as the books described, and attributed my want of success in ascertaining the position to my own awkwardness. At length in a private case, in which I was much interested, I again felt what I thought was the anterior fontanelle towards the left foramen ovale; and circumstances occurring which rendered it necessary to apply the forceps and terminate the labour, I found that the head had been actually in the position which I imagined I had felt. Since this time I have, in many cases, sat by the bed-side during the whole labour, with my finger upon the head, and thus come at the truth." (_MS. Lectures._) The very circumstance of this change in the position of the occiput from the sacro-iliac synchondrosis to the foramen ovale of the same side, is of itself quite sufficient to mislead; nor is it to be wondered at that it should have been so long unnoticed, when we recollect how difficult the examination is at this early stage of labour, and how few give themselves the trouble to attain that degree of dexterity and tact, which, even under the most favourable circumstances, is required for this species of investigation. The diagnosis of the sutures and fontanelles may be rendered more difficult by other circumstances: when there is a large quantity of liquor amnii between the head and membranes, it renders the diagnosis exceedingly obscure in the early part of labour. In some cases the cranial bones are remarkably thin and yielding, and communicate a sensation to the finger as if it were touching a fontanelle; in others, the sutures run an irregular course, and form ossa triquetra, &c. which may easily mislead. We may also notice the changes, already mentioned, which are produced by the death of the child, and the various congenital anormalities of hydrocephalus, acephalus, &c. &c. In some cases the sagittal suture is continued backwards through the occipital bone, dividing it into two equal portions, and thus making the posterior fontanelle four cornered, and not to be distinguished from the anterior. Nor is it always easy to distinguish the posterior from the anterior fontanelle under more normal and favourable circumstances; for it would be hazardous to conclude that it is the posterior fontanelle merely because we feel three sutures meeting together, as it may possibly be the anterior one, and we are not able to reach the sagittal suture beyond. In this case we may ascertain which it is by the following rule: if it be the posterior fontanelle in the first position we shall feel a suture running more or less forwards (the right lambdoidal,) but none backwards; but if it be the anterior fontanelle forwards and to the left, we shall also feel a suture (the right coronal) running backwards. Lastly, in the second cranial position the face when born turns to the posterior surface of the mother's left thigh. Such are the two positions in which the head presents during labour, and such is the manner in which it passes through the pelvis and external passages. Slight deviations do occasionally take place, the chief of which is, that the head in the second position does not always make the quarter of a turn as above described, but comes out with the anterior fontanelle forwards and to the left: this is by no means of common occurrence, and, as far as we have observed, increases the difficulty of labour very little. _Face presentations._ The face, like the cranium, may present in two ways, either with its right or left side forwards. The former is the most frequent occurrence, and bears a striking analogy to the first cranial position; indeed, we cannot too strongly impress upon the minds of our readers the advantages of accurately knowing the different features of the two cranial positions just described; for by this means the positions of the face will be rendered much more simple and easy of comprehension. Whether the right or the left side of the face presents (first or second facial position,) the root of the nose crosses the os uteri exactly in the same manner as the sagittal suture does in the two cranial positions; the chin is turned to the right acetabulum, and as the face descends through the pelvis during the progress of the labour, the chin moves somewhat more forwards, as the occiput does in the cranial positions. At an early stage of labour the right eye and zygoma is that part of the face which is lowest in the pelvis, and which the finger first touches upon during examination, precisely as it was the right parietal protuberance in the first cranial position; and as in this case the caput succedaneum was situated upon the posterior and superior quarter of the right parietal bone, so here the livid bruise-like swelling, which the face brings with it into the world, is situated upon the right cheek, this part being the first which presses through the os externum; the chin passes under the right branch of the pubic arch, as the occiput in the first cranial position does under the left, the face during the whole process preserving a strictly oblique position, both as to the transverse diameter and axis of the pelvis.[78] _Second position of the face._ The second position of the face is merely the reverse of the first: it is now the left side which is turned forwards, the left eye and zygomatic process being those parts which are lowest in the pelvis; the chin is turned to the left side and somewhat forward, and advances towards the left foramen ovale during the farther progress of the labour. As the face approaches the inferior aperture of the pelvis, it is the left cheek which first enters the os externum, and upon which the swelling is situated: likewise the chin passes beneath the left branch of the pubic arch. It has been supposed by some authors, and we think correctly that the majority (if not all) of face presentations are originally cranial presentations: if this be the case, we can easily understand why the right side of the face presents more frequently than the left, for if the head in the first cranial position moves round upon its transverse diameter, and thus allows the face to turn downwards, we shall immediately have a first position of the face. We are the more inclined to adopt this opinion, not only from the greater number of cases where the right side of the face presents, but also from our having more than once met with cases where so long as the head of the child was moveable above the brim, the presentation was midway between one of the cranium, and of the face. On one side of the pelvis we could feel the anterior fontanelle; on the other we could, with some difficulty, reach the orbital process of the frontal bone: as the pains increased, and the head advanced lower, the side of the face came more within reach; so that by the time it had fairly entered the cavity of the pelvis, it had become a complete presentation of the face.[79] We distinguish the face by the bridge of the nose, which from its crossing the os uteri may be detected at a very early period of labour: it is far better than the eye, for not only is this liable to mislead us in our examination, but it may also receive injury from the finger. Nor is the malar bone a guide, for this might easily be mistaken for the tuberosity of the ischium, or even for the shoulder. The nose not only tells us that the face is presenting but also in which position, for at one end we shall feel the soft cushiony extremity of it, at the other we shall reach the broad hard expanse of the forehead. It was not until nearly the end of the last century that presentations of the face ceased to be accounted unnatural, and impossible to be terminated by natural means. Although the fact had been pointed out by Portal so early as 1685, that these presentations were very little removed from the usual one, it seems to have excited but little attention until the time of Deleurye in 1770. "I have," says Portal, "delivered several women whose children came with the face foremost, and always without any great difficulty, it being only observed, _that in such cases no violence must be used, but nature be left to its own course; which done, there is no danger either of mother or child_." (Portal's _Midwifery_, transl. obs. 66:) La Motte in 1721, although so accurate an observer, could not divest himself of the general opinion that these were unfavourable positions, even although the face was usually expelled by the natural efforts, after he had fruitlessly endeavoured to rectify it, and although he himself confesses never to have "seen any that had not done well." Giffard has recorded two cases of face presentation (_Cases in Midwifery_, 1734, p. 59, 443.,) both of which he delivered by his extractor, which was one of the early forms of midwifery forceps; and in both, although the labour had lasted some time, the child was alive. He describes the position of the face in the second case, the chin being turned towards the right side. The only practical observation which he makes is, that turning is very difficult where the "waters are gone off, and the uterus closely envelopes the child." This is probably given as an explanation for his deviating from the usual practice of turning in these cases. Deleurye in supporting Portal's views observes, "one daily sees similar labours terminate naturally: it is true they are somewhat longer, but they terminate without the aid of art." (_Traité des Accouchemens_, 1770, § 736.) Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still more decided point of view when he asserted, that "face presentations being merely a rare form of natural labour, should be left to be completed by the natural efforts, since neither the mothers nor their children were exposed to any more danger in this form of labour than they were in the most usual forms of all." Having charge of the great lying-in hospital of Vienna, Boer had ample means of ascertaining the most accurate results on all points of practical midwifery, and his observations on labours where the face presented, are, therefore, peculiarly interesting, and tend strongly to contradict the prevailing opinion respecting the difficulty and danger of these presentations. "Of eighty cases of face presentations which have occurred during a period of some years, and which I have myself observed and noted down, there were three, or at the most four, where the children were born dead. None of the patients suffered in the slightest degree from any of these labours; and, except one case, all were left entirely to nature: in one case only, on account of the weakness of the pains and doubtful character of the symptoms, I deemed it necessary to terminate the labour by the forceps." (Boer's _Natürliche Geburtshülfe_, erstes buch, p. 137.) In spite of this valuable practical fact, supported by experience on so great a scale, the opinion that face presentations were preternatural, continued to prevail upon the Continent, being supported by the authority of Baudelocque and Osiander. A similarly unfavourable opinion was entertained by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures delivered prior to the publication of his plates on the gravid uterus (and, therefore, at an early date,) states, "in this case I do not turn the head round in order to deliver, but nineteen times in twenty leave it to itself to come as it will." (W. Hunter, _MS. Lectures_.) Dr. R. W. Johnson, who dedicated his _New System of Midwifery_, &c. to Dr. W. Hunter and others, in 1769, and probably attended his lectures, expresses a similar opinion, and says, that in these cases "nature herself will do the work." (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks favourably of these presentations. "The head will, however, in most cases, advance in that position by the force of the natural pains, though the delivery will be more slow or painful." (_Outlines of the Theory and Practice of Midwifery._) Farther experience has shown that, so long as the pelvis is of the natural size, the head can be born in this position without peculiar difficulty, the soft parts usually require a little more dilatation than where the cranium presents, and, therefore, this stage of the labour is generally somewhat slower. Although presentations of the face are not so favourable for the child as those of the cranium, they stand next to them in point of safety. Where the cranium presents, a slight misproportion between the head and pelvis produces little or no increase of difficulty to the passage of the child; but under similar circumstances, where the face presents, the difficulty may become very serious, for if the labour is prolonged, "the brain and vessels of the neck," observes Smellie, "will be so much compressed and obstructed as to destroy the child." (Explanation to table 25.) A similar view has been given by Dr. Denman, and still more recently by Professor Chaussier, of Paris, and Professor Naegelé; the two latter authorities examined the brain in several still-born children where the face had presented, and invariably found the cerebral vessels gorged with blood. The presenting side of the face when born is frightfully distorted by the livid swelling above-mentioned; the mouth is pulled to one side and upwards; the angle of the eye is drawn downwards, and the corresponding ala of the nose scarcely discernible amid the purple mass of tumefaction: the less this is meddled with the better, for in the course of a day or two the parts will have returned to their condition; whereas, if friction or hot poultices, &c., be used, ulceration may be the result, and produce considerable disfigurement.[80] _Nates presentations._ "After the presentations of the cranium those of the nates are the most frequent in point of occurrence, and also the most natural," says the celebrated Boer, in the work already quoted. Under the term _nates_ presentations, we include those of the knees and feet, as these latter presentations can only be looked upon as modifications of the former. Professor Naegelé, jun., in his new edition of the admirable essay upon the mechanism of labour, published by his father, in Meckel's _Archiv. für die Physiologie_, has very properly brought these different positions under one head, viz. "positions of the pelvic extremity of the child:" as, however, we possess no word in English to express this, we shall attain the same object by considering knee and footling births as mere modifications of breech presentations. "As regards the relative situation of the limbs to the body of the child, the position is the same as in the two genera of head presentations above described, viz. the knees are usually drawn up to the abdomen, the feet close to the nates, so that not unfrequently they may both be felt together at the beginning of labour, and afterwards descend into the pelvis and are born together. Sometimes the feet (or perhaps only one foot) are felt higher above the brim than the nates; in which case, as the nates descend they rise, and are turned upon the abdomen and breast of the child, and descend with these parts as labour advances. Frequently it is the reverse: the feet are somewhat lower than the nates; they are felt in the os uteri at the beginning of labour, and descend before them as labour advances. It is rare that the knees come down before the nates during the farther progress of labour, and it is not probable that they are ever found alone in the os uteri at the commencement of it." (H. F. Naegelé, _Mechanismus der Geburt_, 1838, p. 57.) The nates may present in two ways, either with the back of the child forwards, or with its abdomen forwards: of these the former occurs most frequently; thus of 161 cases which were accurately ascertained at the lying-in hospital of Heidelburg, 121 were observed with the back of the child forwards, and 40 with it backwards: in either of these positions the transverse diameter of the child's pelvis always corresponds to one or other of the oblique diameters. "Labours with the nates or feet presenting, follow certain laws quite as much as those where the head presents, only that one more frequently sees deviations from them, both with respect to the manner in which the child presents at the time of labour, and its passage through the pelvis; but where, under a proper state of the other requisites for healthy parturition, no prejudicial result occurs." (Naegelé, _on the Mechanism of Parturition_, transl. § 19. p. 128.) "In every case, whether the nates have at first a completely transverse or oblique direction, they will be always found, on pressing lower into the superior aperture of the pelvis, to have taken an oblique position; and that ischium, which is directed anteriorly, to stand lowest. They pass through the entrance cavity and outlet of the pelvis in this position, which is oblique, both as to its transverse diameter as well as to its axis." Thus, if in the first species the left ischium were either originally directed more or less forward, (which is usually the case,) or had taken this direction in passing through the superior aperture, the nates descend in this direction into the pelvic cavity, with the left ischium during the whole time standing lowest; and this is the part, during the farther progress of the nates, which first passes between the labia as the os externum dilates. As they advance, and while the left ischium, which is directed forwards and always somewhat to the right, comes completely under the pubic arch and presses against it, the other ischium, which is situated in the opposite direction, and which has to make a much greater circuit, passes forwards over the strongly distended perineum, so that, when the pelvis is born, the abdomen of the child will be directed to the inner and posterior surface of the mother's right thigh. "The rest of the trunk follows in this position, and as the breast approaches the inferior aperture of the pelvis, the shoulders press through its superior aperture in the direction of the left oblique diameter; and during its passage (viz. the breast) through the pelvic outlet, the arms and elbows which were pressed against it are born at the some moment. But whilst the shoulders are descending in the above-mentioned oblique position, the head, which during the whole progress of the labour rests with its chin upon the breast, presses into the superior aperture in the direction of the right oblique diameter, (viz. with the forehead corresponding to the right sacro-iliac synchondrosis,) and then into the cavity of the pelvis in the same direction, or one more approaching the conjugate diameter. After this, it presses through the external passage and the labia, in such a manner, that whilst the occiput rests against the os pubis, the point of the chin, followed by the rest of the face, sweeps over the perineum as the head turns on its lateral axis from below upwards. "But it is sometimes the right ischium, which, in this chief division, is either originally turned forwards, or in the process of time assumes this direction. In this case the child passes through the pelvis in the same manner as before, only with the difference, that the surface of the body takes of course a different position with respect to the pelvic parietes, viz. its anterior surface, which in the former case corresponded to the right side of the pelvis, will be directed to the left, and the head will press through the superior aperture of the pelvis, in the direction of the left oblique diameter (the forehead passing before the left sacro-iliac synchondrosis.)" "As in positions of the cranium, the swelling of the integuments is chiefly met with on that parietal bone which during the passage of the head, is situated lowest, and on that spot with which it enters the external passage, so in this case the livid coloured swelling appears on that part which, directed forwards, was situated lowest during the passage of the nates, and with which the nates were born. "In the second chief position, viz. with the anterior surface of the child corresponding to the anterior abdominal parietes of the mother, it is chiefly the left ischium which is either originally situated forwards, or takes this direction as the nates sink through the superior aperture of the pelvis, which latter preserve this oblique direction during the farther progress of the labour, both whilst pressing into the pelvic cavity, and when entering the external passages. "If the ischia be already born, the anterior surface of the child turns itself to the right and backwards, either immediately, or as the rest of the trunk advances; but the manner in which the head in this case presses through the entrance cavity and outlet of the pelvis, is the same as has already been described." (Naegelé, _op. cit._ p. 128, 130.) It appears to be a law in nates presentations, that whatever may be the direction of the child (first or second position) at the beginning of labour, it will always, if not interfered with, be found with its anterior surface turned towards one or other of the sacro-iliac synchondroses, when the thorax or the shoulders are beginning to pass through the outlet of the pelvis. When the nates have once passed the os externum, the position of the child frequently varies a good deal, the abdomen turning first to one side and then to the other. This is especially the case in the second position, where it is more or less forwards; nevertheless, as labour advances, it will almost invariably turn obliquely backwards, and be born in this position. Dr. Collins is, as far as we know, the only English author who has distinctly noticed this fact. "It is very desirable," he observes, "the child should be delivered in this position (viz. the back of the child towards the mother's abdomen,) as it renders the getting away of the head much less difficult; yet where there has been no interference by the attendant in the previous part of the labour, he will rarely find it necessary to alter subsequently the child's position, the breech naturally making the turn above alluded to in its passage." (_Practical Treatise on Midwifery_, by Robert Collins, M. D. p. 41.) It sometimes, although rarely, happens in these presentations, that the head does not rest with the chin upon the breast, but the occiput is pressed against the nape of the neck, as in presentations of the face. The passage of the trunk through the pelvis follows, as above-mentioned, as far as the head: this enters the brim with the occiput in advance, and vertex towards one or other ilium. As it advances through the brim into the cavity of the pelvis, it gradually turns more and more backwards, so that when the body is born, the vertex is turned towards the hollow of the sacrum, and the under surface of the lower jaw behind the symphysis pubis. The _diagnosis_ of nates presentations is not difficult. The pointed and more or less moveable coccyx, bounded at its broader end by the hard uneven sacrum, and in the contrary direction by the anus, will scarcely admit of a mistake. The tuberosities of the ischia may easily be mistaken, for the malar bone of a face presentation, or even a shoulder, can scarcely be distinguished from them, and the external organs of generation become too much swollen and pressed together to give any certain diagnosis; nor indeed can they be examined in this state without considerable risk of injury. The direction of the sacrum, like that of the forehead in face cases, points out the exact position of the child. Presentations of the nates, although perfectly natural as far as labour is concerned, are far more dangerous for the child than those of the face, for when the head enters the pelvis, if every thing be not favourable for its passing rapidly through it, the cord is so long compressed that the child is almost certainly lost. The natural position of the foetus in utero is admirably adapted for its safe passage through the pelvis under these circumstances, and is what we ought to maintain, as far as possible, during labour. The legs are turned upon the abdomen, the arms are crossed upon the breast, the chin rests upon it, the head being bent forwards, so that the whole forms an oval mass. So long as the child advances gradually, the fundus presses firmly upon the head, and keeps the chin close upon the breast; the head therefore enters the pelvis in the most favourable position possible, and the uterus, not having been suddenly emptied of a part of its contents, continues to act briskly, and presses the head so rapidly through the pelvis, that the child is born without having suffered from any serious pressure upon the cord. As however the body of the child diminishes from its pelvis up to the axillæ, it is very apt to be rapidly expelled as soon as the nates have passed the os externum; and if not, it is but too frequently _assisted_, as it is called, at the very moment when it ought rather to be supported and prevented from advancing too suddenly. When this is the case, the fundus ceases to press upon the head, the chin quits the breast, and as a space is thus left between them, the arms slip into it, and then turn upwards, so that the head not only enters the pelvis in a most unfavourable position, but, to make matters still worse, it has an arm on each side of it: at this critical moment the uterus, from having been suddenly emptied, ceases to contract, and the head remains so long in the pelvis that the child has no chance of escaping with its life. Where the child has descended gradually, and the arms have advanced with the breast into the pelvis, if the cord be considerably upon the stretch, a portion should be pulled gently down in order to relax it, and we should endeavour as far as possible to guide that part of it which is within reach towards one of the sacro-iliac synchondroses, being less liable there to suffer from pressure. One or two fingers should be introduced to bring down the arms, which are now coming into the lower part of the hollow of the sacrum: they should be hooked down by the bend of the arm, in order to prevent the humeri from sticking across the passage. When this has been effected, the shoulders follow as the head descends through the pelvis. The body of the child should now be wrapped in warm flannel, and two fingers passed up towards the face: the lower jaw must not be trusted to in bringing the head through the pelvic outlet and os externum, for it may easily be broken: the fingers should be applied one on each side the nose, and the chin depressed as much upon the breast as possible, by which means the head will come in a much more favourable direction, and pass readily. In no case is so much mischief done by impatient interference as in presentations of the lower end of the child. This is still more so in footling cases, for here the soft parts are not so well dilated as in nates presentations, where the child comes double: hence the fact, that presentations of the feet are easier to the mother but more dangerous to the child. In either case, the passage of the head through the pelvis must ever be attended with considerable hazard, for if it be delayed beyond a short time, the child's death is certain. "The more gradually the nates and body of the child are expelled, the quicker will its head pass through the pelvis, and the better will be its chance of being born alive." (_Obstet. Memorand._ 2d ed.) Hence, therefore, if the pains are slow at this moment, it will be desirable to rouse them with a dose of ergot; and if the child gives a convulsive twitch, the forceps ought instantly to be applied. The result of Professor Busch's practice in the lying-in hospital at Berlin shows, that by the timely use of the forceps a large majority of children may be saved. For the same purpose, the nurse should be instructed to have a warm bath in readiness, with some spirit, &c. for resuscitating the child the moment it is born. The numbers which we subjoin are taken from the cases in the Dublin Lying-in-Hospital, under the late Dr. Joseph Clark and Dr. Collins, from the private practice quoted in Dr. Merriman's _Synopsis_, and from the General Lying-in-Hospital. Of 71,578 labours, the nates presented once in every 78 cases, and the feet once in every 108-1/2. Of the nates cases the child was born dead in the proportion of 1 to 3·8, and in the footling births 1 to 2·8. PART IV. MIDWIFERY OPERATIONS. CHAPTER I. THE FORCEPS. _Description of the straight and curved forceps.--Mode of action.-- Indications.--Rules for applying the forceps.--History of the forceps._ Before describing the various species of dystocia, or faulty labour, it will be necessary to consider the different means with which the increasing experience of years has furnished us, of giving artificial assistance in such cases. These may be brought under two heads, first, where delivery can be effected with safety to the mother and her child; secondly, where this can only be effected at the expense of the infant's life. Under the first head come the forceps, turning, the Cæsarean operation, and artificial premature labour; under the second are craniotomy or perforation, and embryotomy. Of these the forceps is by far the simplest and safest means of artificial delivery, and is therefore an operation which should always be had recourse to in preference to any of the others wherever it is possible. The forceps is the simplest imitation of nature, for in fact it is nothing more than a pair of artificial hands introduced one on each side the head. It is impossible to define any precise limits of pelvic contraction, within which the forceps can, or beyond which it cannot, be safely applied, for the difference in the size and hardness of the child's head, and in the condition of the soft parts, will greatly modify the degree of resistance to the progress of the labour: hence the attempt to fix the exact degree of contraction beyond which the forceps becomes inapplicable is quite impracticable, as in some cases we might be led to make a trial of it where it would be quite improper, and in others have recourse to the perforator where a cautious application of the forceps would have been attended with success. For the farther consideration of this subject we must refer to the chapter on DYSTOCIA PELVICA. The forceps consists of three parts--the blades, the lock, and the handles. The blades of the present forceps are not solid, but are merely elongated bows of polished metal, by which they are not only rendered much lighter, but allow the most prominent parts of the head to project between them, and thereby take up no additional room when introduced into the pelvis. In the simplest form, viz. the straight forceps, the blades have only one curvature for adapting them to the convexity of the head. The degree of curve varies a good deal in different instruments: the greater the curve the more firmly will the blades hold, because they act more or less as blunt hooks, and do not require much pressure upon the head for the purpose, but on the other hand, they are more difficult to introduce; whereas, blades which are slightly curved can be applied with greater ease, but require much more pressure upon the head in order to hold fast. It has been a general rule with almost every modification of forceps, that the greatest distance between their blades should not be less than two inches and a half, for as this is the breadth of the basis cranii in the foetal head, it would be impossible to compress the head beyond this extent. The form of the head curvature will determine the situation of the point where the blades are most distant from each other: in some forceps it is about one-third the length of the blades from their extremities; in some it is nearly equidistant; whereas, in others it is nearer to the lock; the medium between these extremes is the best. The extremities of the blades ought to be at least half an inch apart: in this country they are usually somewhat more; on the Continent they are much less, being rarely more than one or two lines asunder. The fenestræ, or open spaces in the blades, should be wide and ample, for not only are the projecting parts of the head allowed to protrude between them, but the pressure of the blades is diffused over a larger extent of surface: this is remarkably seen in the forceps of the late Dr. Hopkins and that of Professor Davis, both of which are extensively used. It is also important that the edge at the extremities of the blades should be well rounded and not too thin; it is thus less liable to catch against corrugations either of the vagina or foetal scalp. The greatest breadth of the fenestræ is generally towards the extremities of the blades; in some, their edges are parallel; whereas, in those of Drs. Orme and Lowder the greatest breadth is near the lock: upon the whole, an oval shaped fenestra is the best, for it can be easily introduced, and has the advantages of a wide blade. In 1751 and the following year another curve was given to the blades of the forceps by the celebrated M. Levret of Paris, and by the equally distinguished Dr. Smellie of London, by which the instrument was adapted to the curve formed by the axes of the brim, cavity, and outlet of the pelvis, and by which the head could be seized much higher in the pelvis than by the straight forceps. Each have an equal claim to the merit of having invented this "pelvic curvature," as it has been called: the priority of the invention is perhaps due to Levret; but as he made a secret of it for some years, it is impossible to ascertain the precise fact. The pelvic curve, as it is called,[81] is especially adapted to the long forceps, which thus becomes an instrument of very considerable power. Numerous modifications of these curved forceps have since been made, but they are merely varieties of the original ones invented by Smellie and Levret, which have become the national instruments of their respective countries. Perhaps the greatest improvements in the blades of modern times is seen in the forceps of Dr. Hopkins, above alluded to: the head curvature forms an elongated oval, admirably adapted to the form of the foetal head when considerably compressed during a difficult labour; and from the great breadth of the fenestræ, the pressure of the blades is applied over a large extent of surface; the pelvic curve is but slight, being greater on the posterior edge of fenestræ than on the anterior; the blades themselves are thin, their inner surface flat to ensure a firmer hold, their outer surface slightly rounded in order to be introduced with greater ease; and for a similar reason the edges of their extremities are somewhat thicker and carefully rounded in a peculiar manner. [Illustration: Naegelé's forceps.] The lock of the modern English forceps consists of two deep grooves, into which the shank of each blade mutually fits, so that the two blades are fixed upon each other merely by the pressure exerted upon the handles. In former times the blades were united together by a pivot, which could screw and unscrew at pleasure. This was abandoned by Chapman, who published the first work in English on operative midwifery.[82] He found that the forceps held better without the pivot than with it; and from what we have brought forward elsewhere (_Med. Gaz._ Jan. 8, 1831,) there can be little doubt that he invented the lock which is now generally used in this country. Chapman's forceps was adopted in France prior to this improvement in its lock, especially by Gregoire, and has retained the original pivot lock which now forms one of the most distinguishing marks between the French and English forceps. Although the pivot forms by far the firmest lock, for the blades can never slip from each other, still the difficulty in locking, and also in separating, the blades at a moment's notice, render it much inferior to the English lock. An ingenious modification was invented by the late Professor Von Siebold of Berlin, but the most perfect lock is that of Professor Brüninghausen of Würzburg, first introduced by ourselves into this country, and commonly known among the instrument-makers under the name of Professor Naegelé's forceps. The shank of one blade has a semicircular indentation, which at the moment of locking fits into a fixed pivot in the other: this, therefore, combines the advantages of the French and English locks. We can safely affirm, from extensive experience for many years, that there is even less difficulty in locking it than with the English lock: the blades are capable of instant separation, and yet when locked, the firmness of their union is equal to that of a pivot joint. The handles of the English forceps are pieces of wood or ivory fixed upon each shank below the lock, flat upon the inside, convex externally and furnished with a depression or groove at the lower end for fixing a ligature round them. These handles were probably first introduced by Dr. Smellie, who seems to have borrowed the idea from the forceps of M. Mesnard, for the earlier English forceps, viz. of Giffard and Chapman, terminated in blunt hooks, those of the former being curved inwards, those of the latter outwards, a form of handle which has been retained in the French forceps up to the present time. There are two pieces of forceps, the _long_ and the _short_ forceps; the former for cases where the head is still high in the pelvis, the latter when it is at the pelvic outlet and approaching the os externum; the former with few exceptions being curved, the latter straight.[83] The forceps act in three ways, 1. by mere pulling; 2. as a species of double lever, by moving the handles from side to side; and 3. by compressing the head, thus still farther disposing it to elongate and adapt itself to the passage through which it has to be expelled. The blades should always, if possible, be applied one on each side of the head, the position of which must be determined by the direction of the fontanelles and sutures, not by feeling for the ear, as is usually recommended in this country. The ear can seldom be reached without causing a good deal of pain, even under the most favourable circumstances; in cases, therefore, where the head is so impacted as to be incapable of advancing by the natural powers, it cannot surely be justifiable to force up the finger between the head and the pelvis to ascertain this point, the more so, as the soft parts soon become swollen and more or less inflamed, and, therefore, little able to bear such rude treatment. No operation requires such an intimate acquaintance with the mechanism of parturition as that for applying the forceps: it is simple and generally perfectly easy when the precise position of the head and its relations to the pelvis are accurately known; on the other hand, it is not less injurious and painful to the patient than difficult and unsatisfactory to the practitioner. The most usual circumstances under which the forceps is applied, are where the head is already deep in the pelvis and approaching the os externum; in such cases it is generally required not so much for the purpose of overcoming an unusual degree of resistance, as for assisting the natural powers, which are becoming exhausted: the head is near the os externum, and therefore easily reached; and from there being little or no impaction present, the blades are applied without difficulty. The application of the forceps when the head is at the upper part of the pelvis, and where the greater portion of it has not yet passed the brim, is rarely practised in this country, because as the necessity for performing the operation at this stage arises in most instances from contraction of the brim, the perforator has usually been preferred, wherever the expelling powers have proved incapable of overcoming the resistance to the passage of the head. The circumstance also of this condition requiring the long forceps has been another source of objection, from the much greater power which this instrument is capable of exerting, and from its being therefore more liable than the short forceps to prove mischievous in the hands of the inexperienced. Cases however do occur where there is but a very slight want of proportion between the head and pelvis, where the obstacle is easily overcome, and where, but for the application of the forceps, the labour would either have been protracted to a dangerous degree, or have required the use of the perforator.[84] "On the whole," says Dr. Burns, "I would give it as my opinion that a well instructed practitioner, who has already had some experience in the use of the short forceps, is warranted to make a cautious, steady, but gentle attempt to apply and act with the long forceps in a case where he is not quite decided that the perforator is indispensable, and where the head is higher than admits the application of the short forceps." (_Principles of Midwifery_, 9th ed. p. 493.) In applying the forceps, whether short or long, there are two conditions which, _cæteris paribus_, are requisite in every case; first, that the os uteri shall be fully dilated; secondly, that the pains are within the bounds of what are commonly known as moderate pains. In the first case it will be very difficult and frequently quite impossible to pass the blades between the head and os uteri when only partly dilated; it will be difficult to avoid injuring its edge more or less, and if we do succeed in applying and locking the forceps, on making an extractive effort we shall find that the uterus descends with the head as we draw it down. In the second place we ought never to apply the forceps whilst the pains are violent, for not only do they render its application difficult and even dangerous, but we are adding still farther to the force (already too great) with which the head is pressed against the pelvis. Where the head remains immoveable under violent exertions of the uterus, it is not a case for the forceps but for the perforator; nor does it admit of much delay, for it endangers much injury of the soft parts or even rupture of the uterus. It is exceedingly difficult to assign any precise limits of pelvic contraction, within which the forceps can, and beyond which they cannot be applied, for the size and hardness of the foetal head, the nature of the pains, and the condition of the patient must also be taken into account in every instance; hence, we frequently meet with cases where the pelvis is scarcely if at all contracted, and yet where the labour has been terminated with the greatest difficulty by means of the forceps; whereas, in others where we know the pelvis to be more or less deformed, the child has been delivered by the natural powers. This subject will be still farther considered under DYSTOCIA PELVICA. The _general indications_ for the use of the forceps are two: 1. They are indicated in all labours which are difficult or impossible to complete, either from deficiency in the expelling powers, or from misproportion between the head and pelvis, or from the arm coming down with the head. 2. They are indicated by circumstances or accidental causes, which render labour dangerous for the mother or child, and where the danger can only be removed by hastening labour, as in cases of hæmorrhage, convulsions, syncope, alarming debility, faulty condition of the organs of respiration, danger of suffocation, obstinate vomiting, unusually severe pains in nervous irritable habits, hemorrhoids which have burst, hernia, retention of urine, determination of blood to the head, prolapsus of the cord, (in certain cases,) inflammation of the uterus, &c. (Naegelé, _MS. Lectures_.) We have already stated that an intimate acquaintance with the mechanism of parturition is of the greatest importance in applying the forceps. Knowing that the head always presents in one of the two oblique diameters of the pelvis, and that the blades are applied on each side of the head, it follows that the forceps must always be applied in the contrary oblique diameter of the pelvis to that in which the head is. Before speaking of the operation itself, we must first consider what position of the patient will be the most convenient. In this country no alteration is made in her position, beyond bringing her close to the side of the bed, with the nates projecting as much as possible over the edge, for the greater convenience of the operator; unless this be attended to, it will be difficult to depress the handle of the upper blade sufficiently when introducing it. Upon the continent, and also in America, where the long forceps is more generally used, the patient is usually delivered on her back; she is placed in a half-sitting posture upon the edge of the bed, her back supported by pillows, &c., her feet resting on two chairs, between which the operator stands or sits, and applies the forceps in this position. This, in many respects, is the most convenient posture for him, but the very preparation which it requires cannot but be alarming to the patient, who is obliged to be a witness of all his manipulations; whereas, when she lies upon her left side, she is aware of little or no preparation being made, and if any slight exposure happens to be necessary, viz. at the moment of locking, it can be done without her knowledge.[85] The simplest case for applying the forceps is, where the head has already descended nearly to the os externum, and has begun to press upon the perineum: it is for this that the straight forceps is chiefly intended; and as this is the instrument which is generally used, we shall describe its application first. _Mode of applying the forceps._ Having ascertained that the rectum and bladder are empty, examined the position of the head, and warmed and greased the blades, we proceed to introduce the upper or lower blade first, according as its lock is directed forwards: this precaution is for the purpose of preventing the locks being turned away from each other when brought together after the introduction of the second blade. The trochanter major will guide us as to the precise position of the patient's pelvis, and is especially useful in pointing out the direction of the left oblique diameter, in which the forceps (on account of the first position of the head being in the right oblique diameter) should be most frequently applied: in this case, we pass the upper blade, as it were, beneath the trochanter, and the lower one in the opposite direction.[86] Let us suppose that the head is in the first position, with its sagittal suture parallel with the right oblique diameter of the pelvis, and that in accordance with the above rule, the upper blade is to be introduced first. Having passed one or two fingers up to the head, we guide the blade along them, depressing the handle so as to make the extremity of the blade lie closely upon the head, neither allowing the point alone to impinge upon the head, nor _vice versâ_, to protrude against the vagina. The extremity of the blade, therefore, must be our guide for the direction in which we hold the handle: we must carefully insinuate this by a gentle vibratory motion between the head and passage which surrounds it: the convexity of the head will show the course which it has to take, nor is there any need of passing the finger farther; for when once the extremity of the blade is fairly engaged between the head and passage, it will almost guide itself, and needs little more than to be pushed on gently, the handle gradually rising according to the curve of the blade. The shank or handle should, therefore, be held lightly like a pen, by which means the operator will possess much more feeling with his instrument, than if he grasped it with his whole hand. As the blade advances, he should keep his eye on the general form of the pelvis, the curve of the loins, the situation of the trochanter and symphysis pubis, and thus gain a more accurate idea of the course which the instrument must take. This will, in great measure, depend upon the situation of the head: if it be quite down upon the perineum, the blade should be pointed towards the promontory of the sacrum, and the handle turned downwards and forwards; if it be still in the cavity of the pelvis, and only beginning to engage in the outlet, the blade must be directed upwards towards the centre of the brim, and the handle turned directly downwards. Having passed the blade to its full extent, we must press the handle backwards against the perineum, to allow sufficient room for the introduction of the second blade, and give it to an assistant or the nurse, with the caution to hold it steadily and firmly, especially during the pains, when it is apt to slip into the hollow of the sacrum if held carelessly. As we have passed the upper blade behind the right acetabulum or foramen ovale, so now we must introduce the other in the opposite direction, viz. before the left sacro-iliac synchondrosis: and, as the blades being exactly opposite to each other is essential to the easy locking of the instrument, it will be necessary to guide the course of the second blade, not so much by the form of the pelvis, as by the direction of the first blade. It must, therefore, pass up, so that when introduced to its full extent, the inner surface of its handle shall correspond precisely to that of the first blade. The easy or difficult locking of the blades is a proof of their having been correctly or incorrectly introduced. If, therefore, on bringing the locks together we find that they do not correspond, that the inner surfaces of the handles are not parallel, but form an angle with each other, we must endeavour to rectify this, by withdrawing, to a short extent, that blade which deviates most from the proper direction, and pass it up again more correctly. All attempts to twist the handles so as to correspond with each other, are bad and cannot fail to put the patient to much suffering. When we are about to lock the blades, we cannot be too careful in preventing the soft parts from being pinched between them, for it causes most intolerable pain, and frequently makes the patient give such an involuntary start, as to run the risk of altering the position of the instrument. The whole process of introducing and fixing the forceps should be conducted in as gentle and gradual a manner as possible: no attempt should be made to proceed with the operation during a pain; and in no case is force either necessary or justifiable. Every thing being now prepared for the extraction, we must endeavour to make this resemble as far as possible the natural expulsion. When a pain, therefore, comes on, we should grasp the handle firmly, and pull gently, at the same time giving them a rotatory motion. The direction of the handles, as before said, will depend upon the situation of the head in the pelvis: if it be at the outlet, it will point downwards and forwards; if in the cavity, nearly directly downwards. If the head makes but little or no advance with one or two efforts, it will be advisable to tie the handles firmly together, and thus keep up a continued pressure upon it, and dispose it the more to elongate and adapt itself to the passages. As it advances and begins to press upon the perineum, we must be more than ever cautious not to hurry the expulsion, and give the soft parts time to dilate sufficiently. At this period it is desirable to make the extractive effort not so much forwards as the direction of the handles would seem to indicate: we thus avoid pressing too severely upon the urethra and neck of the bladder, which might otherwise suffer, and assist the dilatation of the perineum. When the head is on the point of passing the os externum, all farther extractive efforts should cease; the perineum must be supported in the usual manner, and the head should be expelled if possible by the patient herself.[87] In applying the curved forceps we must bear in mind another rule in addition to the one above-mentioned for selecting the first blade, viz. the pelvic curvature must correspond with that of the sacrum. As with the straight, so also with the curved forceps, the extremity of the blade will be our best guide as to the direction in which we should hold the handle at the moment of introduction; it must be directed more or less forwards in proportion to the degree of the pelvic curvature of the blade. If, for instance, it be the upper blade which is to be introduced first, we pass it obliquely over the lower thigh or nates of the mother, making it glide closely round the convexity of the head, between it and the pelvis, without impinging either on the one or the other. As the position of the head is still more distinctly oblique at this earlier period of its progress through the pelvis, so will the blades require a more oblique direction, and also (as in the former case) they must be introduced in the contrary oblique diameter to that in which the head is. As the blade passes up between the head and pelvis, so does the handle gradually make a sweep backwards, until at length it approaches to the edge of the perineum. During the process of introduction, one or two fingers should press against the posterior edge of the blade to guide it up to the brim of the pelvis, and prevent its slipping too far backwards towards the hollow of the sacrum. The second blade will be guided in its direction by that of the first: it must be introduced so that the inner surface of its handle corresponds exactly with that of the first. The locking must be performed under the same precautions as with the straight forceps: the more so, as in some cases it has to take place just within the os externum, and therefore requires the most careful attention to prevent the soft parts from being caught and pinched between the blades when they are brought together. In extracting the head we must bear in mind the part of the pelvis in which it is impacted, and make our effort in the direction of its axis; we must also recollect the curved form of the instrument, and that we must not pull in the direction in which the handles point, but rather hold them firmly with one hand, and, by pressing against the middle of the forceps with the other, guide the head downwards and backwards into the cavity of the pelvis. We shall thus make our extractive effort in the direction of the upper portion of the blades, or that part which has the chief hold upon the head: hence, therefore, as it descends, the handles are directed more and more forwards, so that when it has reached the perineum, the handles will not only point forwards, but considerably upwards. Whilst extracting we should, as with the straight forceps, slowly move the handles from side to side, and even make them describe a circle: we thus not only use the forceps as a simple extracting instrument, but make it act as a lever in every direction, and greatly facilitate the advance of the head, even under circumstances of considerable impaction. It is in these cases where keeping up a continued pressure upon the head by tying the handles tightly together, and tightening it after every successive effort, has such excellent effects in diminishing the degree with which it is wedged against the pelvis and soft parts, and in disposing it by gradual elongation to assume a form which is better adapted for advancing through the passages. The slow and gradual pressure of the forceps thus exerted upon the head of a living foetus will have a very different result to that of the experiments by Baudelocque and others, in attempting to compress the head of a dead foetus by the application of a sudden and powerful force. Even if we were capable of effecting no greater diminution of its lateral diameter than a quarter, or at the most, three-eighths of an inch, as stated by Dr. Burns, we should, in most cases of impacted head, where the forceps is justifiable, find it quite sufficient to remove the obstructing causes. The forceps is also occasionally required in presentations of the face and nates. In the first case we must pass up the blades on each side of the face, and along the side of the head, having previously ascertained to which side of the pelvis the chin is turned. In nates cases, the blades should also be passed up along the sides of the child's pelvis, and here the advantages of a broad fenestra will be very evident, for otherwise our hold will not be firm enough without exerting an improper degree of pressure. Cases every now and then occur, where from convulsions, &c., it is desirable to apply the forceps whilst the patient is lying upon her back, as is practised upon the continent. "The patient is placed across the bed, propped up in a half-sitting posture, by pillows, &c., her pelvis resting upon the edge, her feet on two chairs, the knees supported by assistants. Two, and generally three fingers are passed, if possible, up to the os uteri, on the side where the blade is to be introduced: the index finger, is held a little behind the middle finger, so that this last, by projecting somewhat, forms a species of ledge upon which the blade slides, and which acts as a fulcrum to it. The handle is held at first nearly perpendicular; but as the blade advances, it gradually approaches the horizontal direction, being guided by the pelvic curve of the instrument. The middle finger, along the ulnar surface of which the convex edge of the blade slides, prevents its extremity from passing too far backwards, and directs it in the axis of the pelvis. When introduced to the full extent, the handle is inclined obliquely downwards, and is now grasped by an assistant passing his hand below the patient's thigh. The other blade is introduced in the same way on the opposite side of the pelvis; and the locking, extraction, &c., conducted much in the same manner as in England." (_British and Foreign Med. Rev._ vol. iii. April 1837, p. 419.) _History of the forceps._ We have already mentioned some historical points connected with the improvements of the present French and English forceps; it will now be unnecessary to enter more fully into the history of this instrument. The earliest trace of the midwifery forceps which we possess is under the form of a secret in the hands of an English family, named Chamberlen. As to when and by whom it was first invented, this must probably remain for ever unknown; and at any rate there is no more reason to suppose that Dr. Hugh Chamberlen was the inventor than his father or brothers were. He was compelled to quit England on account of being involved in the political troubles of the time, and went to Paris in the beginning of the year 1770, and evidently had then been some time in possession of the secret. He returned to London, in August of the same year, having in vain attempted to sell it to the French government, after having entirely failed in a case of difficult labour which he had asserted he could deliver in a few minutes, although Mauriceau had stated that the Cæsarean operation would be required. Dr. H. Chamberlen published in 1772, a translation of Mauriceau's work, which had appeared four years previously, and in his preface he publicly alludes to this secret, and says, "My father, brothers, and myself (though none else in Europe, as I know) have, by God's blessing and our industry, attained to, and long practised a way to deliver women in this case without any prejudice to them or their infants: though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy, one or both, with hooks." He thus apologizes for not having divulged this secret: "there being my father and two brothers living, that practice this art, I cannot esteem it my own to dispose of, nor publish it without injury to them." Whether a work, entitled _Midwife's Practice_, by Hugh Chamberlen, 1665, was by the translator of Mauriceau's work, or by his father, must now remain a matter of doubt: it was, however, in all probability by the latter, from what the translator says in his preface, viz. "I designed a small manual to that purpose, but meeting some time after in France, with this treatise of Mauriceau, I changed my resolution into that of translating him." On account of his being attached to the party of James II. he was again obliged to quit England, in 1688, and crossed over to Amsterdam, where he settled, and in five years after succeeded in selling his secret to three Dutch practitioners, viz. Roger Roonhuysen, Cornelius Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it generally known. It turned out to be a flat bar of iron, somewhat curved at each end: this lever was stated to have been received from Roonhuysen, one of the original purchasers of the Chamberlen secret; but there is no reason to suppose that any such instrument had been communicated by Chamberlen either to him or the others, as we have distinct evidence that both Ruysch and Bökelman possessed _forceps_, the blades of which united at their lower end by means of a hinge and pin. It is known also that Roonhuysen used a double instrument consisting of two blades. The above-mentioned flat bar of iron, commonly called Roonhuysen's lever, was, without doubt, invented after his time, by Plaatman, who received the Chamberlen secret from him. (_Edin. Med. and Surg. Journal_, Oct., 1833.) [Illustration: Chamberlen's Forceps.] Not many years ago a collection of obstetric instruments were found at Woodham, Mortimer Hall, near Mildon, in Essex, which formerly belonged to Dr. Peter Chamberlen, who, having purchased this estate "some time previous to 1683," was, in all probability, one of the brothers alluded to by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's work. This collection, (now in the possession of the Medico-Chirurgical Society, of London,) contains several forceps, two of which appear to have been used in actual practice: these differ from each other only in size, and present a great improvement upon the instrument possessed by Hugh Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well formed: the locks are the same as of a common pair of scissors, except that in one case the pivot is riveted into one lock, which passes through a hole in the other when the blades are brought together. In the smaller forceps there is merely a hole in each lock through which a cord is passed, and then wound round the shanks of the blades to fasten them together, an improvement in which Dr. Peter Chamberlen had evidently anticipated Chapman, in making the first approach to the present English lock. The earliest professors of the forceps, besides the Chamberlens, were Drinkwater, who commenced practice at Brentford, in 1668, and died in 1728; Giffard, who has given cases where he used his extractor as early as 1726; and Chapman, who possessed a similar instrument about the same time. These forceps correspond very nearly with the above-mentioned ones of Dr. Peter Chamberlen; and as it is well known that from those of Giffard and Chapman, the forceps of the present day are descended, we cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for these instruments, to which his bear so distant a resemblance, as to his relations, who, from living together in England, had doubtless assisted each other by their mutual inventions, and thus brought the instrument to that state of improvement in which it was found as above-mentioned. For more detailed information respecting the history of the forceps we may refer our readers to Mulder's _Historia Forcipum_, &c., particularly, the German translation by Schlegel, to a similar work brought down to the present time, by Professor Edward von Siebold, to our own lectures on this subject, published in the _London Med. and Surg. Journal_, for March 28, 1835, vol. vii., and to the two papers already alluded to in the _London Med. Gazette_, Jan. 8, 1831, and _Edinburgh Med. and Surg. Journal_, October, 1833. [Also, _Researches on Operative Midwifery_, &c. By FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. _Dublin_, 1841.--ED.] CHAPTER II. TURNING. _Turning.--Indications.--Circumstances most favourable for this operation.--Rules for finding the feet.--Extraction with the feet foremost.--Turning with the nates foremost.--Turning with the head foremost.--History of turning._ Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os uteri and vagina, and in this manner the child delivered. (Naegelé, _MS. Lectures_.) Besides turning with the feet foremost as now described it has also been proposed, as being safer for the child, to bring down the nates or the head, but these operations, especially the former, have scarcely ever been practised, and in most cases are impracticable. Turning, in the strict sense of the word, is that operation, by which, without danger to the mother or her child, the position of the latter is changed, either for the purpose of rendering the labour more favourable, or for adapting the position of the child for delivering it artificially. The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the child, it has been very properly recommended by Deleurye, (_Traité des Accouchemens_, 1770,) Boer, (_Naturliche Geburtshülfe_, 1810,) Wigand, (_Geburt des Menschen_, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling powers; hence, therefore, under these circumstances, artificial extraction of the child with the feet foremost can scarcely be said to exist, the operation itself being confined to changing the position of the child. Where, however, the circumstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation. The artificially changing the child's position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty. _Indications._ The artificially delivering the child with the hand alone, or the extraction of it with the feet foremost (which of course presumes that it has presented with the feet, either originally or has been brought into that position by interference of art,) is indicated in all cases where the labour requires to be artificially terminated either on account of insufficiency of the expelling powers, or from the occurrence of dangerous symptoms. Under this head, on the part of the mother, are violent floodings, especially under certain circumstances, convulsions with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;--on the part of the child, prolapsus of the cord under certain circumstances. (Naegelé, _Lehrbuch der Geburtshülfe_, §§ 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the foetus, or which demand a hasty delivery of the child, but which cannot be attained by the application of the forceps. Turning is an operation which is far inferior to that of the forceps, both as regards the safety of the mother and her child, and also the ease with which it is performed. Whenever the circumstances under which it is undertaken are unfavourable, it not only becomes a very difficult operation, but also one of considerable danger: for the child especially is this the case, as the very circumstance of its being born with the feet foremost shows that it is necessarily exposed to the same dangers as those already mentioned in nates presentations, in addition to those of the first part of the operation, viz. the changing its position. The most favourable moment for undertaking the operation of turning is when the os uteri is fully dilated and the membranes are still unruptured. In this state, the vagina and os uteri are most capable of admitting the hand, and the uterus, from being filled with liquor amnii, is prevented contracting upon the child, the position of which is changed with great ease and safety; but when the os uteri is only partially dilated, its edge thin and rigid, the membranes ruptured, and the liquor amnii drained off for some hours, it becomes a matter of great difficulty and danger either to introduce the hand into the uterus under such circumstances, or to attempt changing the child's position: the os uteri tightly encircles the presenting part, and the uterus contracts upon the child itself so as to render it nearly, if not altogether immoveable. The os uteri ought always if possible to be fully dilated: this however is not so essential as with the forceps, for when once it has reached the size of a crown piece, it mostly yields easily to the introduction of the hand. Where turning is indicated in malposition of the child we may safely await its full dilatation so long as the membranes remain unruptured. Where the membranes have been ruptured some hours and the os uteri hard, thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cushiony, and dilatable. In cases which require turning as a means of hastening labour, as for instance in flooding from placenta prævia and other causes, the hæmorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand. Where convulsions indicate turning, the bleeding and other depleting measures, which are necessary to control them, will have a similar effect in preparing the os uteri for this purpose. In ordinary cases of turning there will be no need to change the patient's position, as it will be just as easy to perform it as she lies upon her left side, merely bringing her pelvis nearer to the side of the bed in order to reach her with greater facility. Where, however, from the position of the child or from the state of the uterus, the introduction of the hand and searching for the feet will probably be attended with considerable difficulty, it may be advisable to place her across the bed, sitting upon its edge, her back supported by pillows, her feet resting on two chairs, in the same way as it is used by the Continental practitioners for applying the forceps; or if it be really a case of very unusual difficulty, it will be better to put her upon her knees and elbows, for in this position we gain the upper and anterior parts of the uterus with greater ease. In choosing which is the best hand for performing the operation, the practitioner must not only be guided by the position of the child, but also by the hand with which he possesses most strength and dexterity: many always use the left hand for turning when the patient lies upon her left side; for our own part we have always used the right, and have never failed except in one or two cases of great difficulty, where we judged it more prudent to put the patient on her knees and elbows than risk any injury by using too much force. In introducing the hand into the vagina as the patient lies on her left side, the right is moreover preferable, as we can pass it more completely in the axis of the vagina, than we can the left.[88] The directions which are usually given to introduce one hand or the other according to the child's position, are not practical, because cases occur where it is impossible to ascertain this point without passing the hand into the uterus, as in placenta prævia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repetition of this operation, merely because the position of the child is such as is stated in books to require the left hand instead of the right. Having evacuated the bladder and rectum, and greased the fore-arm and back of the hand, we should gently insinuate the four fingers, one after the other, into the os externum: the whole hand must be contracted into the form of a cone; the thumb will pass up easily along the palm; the passage of the knuckles is the most difficult, for as the os externum is the narrowest part of the vagina, and the hand is widest across the knuckles, it follows that this is the point of the greatest resistance and suffering, and that, when once this is overcome, our hand will advance with greater ease both to ourselves and to our patient. This part of the operation can scarcely be conducted too gradually or gently, for if we give the soft parts sufficient time to yield, it is scarcely credible what an extent of dilatation may be effected by a comparatively moderate degree of pain; the os externum is also the most sensitive part of the vagina, and serious nervous affections may even be provoked by the intolerable agony arising from a rude and hasty attempt to force the hand through it. We must not advance the hand merely by pushing it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the vagina gradually ride over this projecting part as the hand advances. In passing the os uteri the same precautions must be observed, particularly when the os uteri is not fully dilated; at the same time we must fix the uterus itself with the other hand, and rather press the fundus downwards against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand; for we thus not only enable the hand to pass the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the vagina from the uterus, in all cases where the turning is at all difficult. "In those cases (says Professor Naegelé) where artificial dilatation of the os uteri is required to let the hand pass, it should be done in the following manner:--during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and by gently turning them and gradually expanding them we endeavour to dilate it sufficiently to let the hand pass. This must only be done under circumstances of absolute necessity and always with the greatest caution--in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is sufficiently yielding or dilated." (_Lehrbuch der Geburtshülfe_, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the _forcible_ dilatation of the os uteri is justly deprecated by Madame la Chapelle: "I never attempt to produce this forced dilatation, _not even in cases of hæmorrhage_. But we may frequently promote the dilatation of the passages in a remarkable manner by moistening and relaxing them and diminishing their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding." (p. 49.) Her diagnosis of the condition in which the os uteri will yield to the introduction of the hand is well worthy of attention. "If the inactive uterus be unable to expel the child, or to make the head clear its orifice although considerably dilated, if, in this state of affairs, the membranes give way, we can feel the os uteri retract, from being no longer pressed upon. How different is this state of passive contraction to the rigidity of an orifice which has not yet been dilated: in this case, although the os uteri is contracted and even thick, it is soft, supple, and easily dilatable; there is no feeling of tightness or resistance; it is little else than a membranous sac, and the head has not descended sufficiently to press upon it; or if the head does not present, it is some part of the child, as for instance the shoulder, which is unable to advance and act upon the os uteri: in this case operate without fear--in the other wait." (_Pratique des Accouchemens_, p. 86.) If the membranes be not yet ruptured we should use the greatest caution to preserve them uninjured: the hand must be gently insinuated between them and the uterus, and should be passed either until the feet are felt, or at least, until it has gained the upper half of the uterus. Now, and not till now, ought they to be ruptured. As this is done at the side of the uterus little or no liquor amnii escapes, for the torn membranes are pressed closely against the uterine parietes, and the vagina is completely closed by the presence of the arm in it acting as a plug; the uterus is unable to contract upon the child on account of the fluid which surrounds it, and the hand, therefore, passes up with great facility. The uterus is not diminished by the loss of its liquor amnii; its contractile power is, therefore, not increased. When the hand has broken the membranes it can move about in perfect freedom: if the feet have not as yet been reached they will now be easily found, and the position of the child will be changed without difficulty. The importance of passing in the hand without rupturing the membranes was first shown by Peu in 1694.[89] But it excited little or no notice at the time, not even by La Motte, who paid so much attention to improving the operation of turning. Dr. Smellie appears to have been the first after Peu who recommended this mode of practice, although he makes no mention of his name. "Then introducing one hand into the vagina we insinuate it in a flattened form within the os internum, and push up between the membranes and the uterus as far as the middle of the womb: having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them without moving the arm lower down, then turn and deliver as formerly directed." (_Treatise on the Theory and Practice of Midwifery_, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us "introduire la main dans la matrice _sans_ percer la poche des eaux, détacher les membranes des parois de ce viscère, et les percer à l'endroit où l'on juge que les pieds peuvent le plus naturellement se trouver."[90] Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye's mode of practice,[91] and it has still farther been confirmed by Professor Naegelé. Turning under these circumstances is an easy operation, and a very different affair compared with its performance in cases in which the membranes have been some time previously ruptured, and the uterus drained of liquor amnii: the hand is passed up with difficulty, the feet are quickly found, and the child moved round with a degree of facility which is scarcely credible. Where, however, the uterus is irritable and closely contracted upon the child, the liquor amnii having long since escaped, where the os uteri is not more than two-thirds dilated, its edge thin, hard, and tight, as is especially seen in a neglected case of arm or shoulder presentation, every step of the operation is attended with the greatest difficulty, and in fact is neither possible nor justifiable, until by bleeding to fainting, by the warm bath and opiates, we have succeeded in producing such a degree of relaxation as to enable us to introduce the hand. "Blood-letting is the only remedy with which we are acquainted that has any decided control over the contracted uterus. It is one almost certain of rendering turning practicable under such circumstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the practitioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it." (Dewees' _Compendious System of Midwifery_, § 629.) "The vagina is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active hæmorrhage, and this is equally the case in primiparæ as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient's sufferings, under these circumstances delays to introduce his hand until the hæmorrhage shall have ceased. The moment this is the case, the vagina regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state of syncope." (Wigand, _Geburt des Menschen_, vol. ii. p. 428.) When once a powerful impression has been made upon the system by an active bleeding, opiates, which before it, would have only tended to render the patient feverish, are now of great value: they relax the spasmodic action of the uterus, allay the general excitement and irritability, and induce sleep and perspiration. As with bleeding in these cases, they must be given in decided doses: a grain of hydrochlorate of morphia given at once, or in two doses quickly repeated, and at the same time from half a drachm to a drachm of Liquor Opii Sedativus thrown into the rectum with a little thin starch or gruel, will rarely or never fail to produce the desired effect. The opiate by the mouth may be advantageously combined with James's powder, and thus assist its diaphoretic action. The warm bath will also prove a valuable remedy. "If the arm or funis of the child presents and is prolapsed into the vagina, we must not try to push back these parts into the uterus again, but we must endeavour to pass our hand along the inner surface of the presenting arm; or if it be the cord, we must guide it so as to press the cord as little as possible: if however a coil of it has passed out of the vagina and is still beating, we had better carry it upon the hand with which we are about to turn the child." (Boer, _op. cit._ vol. iii. p. 5. 1817.) For farther information on this head we must refer to the observations on _Malposition of the Child_. If the head or nates be occupying the brim of the pelvis it will be necessary to raise them gently and press them to one side: this however is usually effected by the very act of passing up the hand, and seldom produces any difficulty, unless these parts have already advanced deeper into the pelvis; in which case, as turning under these circumstances can only be undertaken with a view to hasten labour, it will become a matter of consideration whether we shall not be able to attain this object better by the aid of the forceps. Although it ought ever to be considered as a rule that turning must not be attempted whilst the pains are violent, the introduction of the hand into the uterus always excites it more or less to contraction: the degree of pressure and impediment which it will produce to the progress of the hand will in a great measure depend upon the quantity of liquor amnii which it contains. Where the uterus has been drained of the fluid, every contraction will be felt in its full force by the operator: his hand is firmly jammed against the child, and if it happens to be caught in a constrained posture at the moment, is liable to be attacked with a severe fit of cramp, which benumbs and renders it powerless. Wherever we find that the hand is tightly squeezed during a pain, we should lay it flat with the palm upon the child, and hold it perfectly still: in this posture it will bear a powerful contraction without inconveniencing ourselves or injuring the uterus; and by letting it be quite flaccid and motionless we shall not provoke the uterus to farther exertions. Attempting to turn during the pain would not only be useless, but we should exhaust the strength of our hand which cannot be spared too much; we should torture the patient unnecessarily, and run no small risk of rupturing the uterus. In letting the pressure of our hand be upon the child during a pain, instead of against the uterus, we must select any part rather than its abdomen, for pressure here seems to act as injuriously as pressure upon the umbilical cord. _Rules for finding the feet._ In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of passing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circumstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman's simple rule, that the hand "must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child." The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction. During all this time the other hand placed externally will be of great service, not only in supporting the uterus, but in fixing the child and rendering the different parts of it more attainable. Where the feet are at some distance, we frequently come first to an arm or thigh, which soon leads us to the elbow or knee; if the introduction of the hand has been attended with some difficulty, it will not be very easy to distinguish these joints from each other, without bearing in mind the following diagnostic points:--the knee present two rounded prominences (condyles of the femur) with a depression between them, whereas, the elbow presents also two rounded prominences, but with a sharp projection (olecranon) between. If the foot is not easily reached, there will be no need of forcing up the hand farther to gain it: it will be much better and safer to hook the finger into the bend of the knee and hold by it for a pain or two: this will generally be sufficient to bring it within reach; or during an interval of the pains, the leg may be gently disengaged and brought down. Not unfrequently we can only feel the toes with the extremities of our fingers, and therefore cannot maintain a sufficient hold upon the foot so as to bring it down: here again the same rule will be applicable, for by keeping but a slight hold upon it during a pain, it will be found to have approached nearer when the pain has gone off; in fact our first attempt to move the child must be done in this cautious manner, and we shall effect our object with greater certainty by merely holding the feet still during the pain, not allowing them to recede from that position in which we had placed them during the intervals, than by using considerable efforts to bring them to the os uteri. By the time we have got one foot fairly within grasp, the other is seldom very distant and should always be brought down if possible: by bringing down both feet we cause the hips of the child to enter the brim of the pelvis more equally; whereas, if one leg only is brought down, the pelvis of the child comes more or less awry, and the ischium of the other side is apt to lodge against the brim of its mother's pelvis.[92] This practice has been recommended on the grounds that, by bring down only one leg, we make the presentation rather resemble a breech case, which is known to be more favourable for reasons already mentioned, and that by having the other leg turned upon the abdomen it will protect the cord from undue pressure. As far as the abdomen is concerned this may possibly be the case, but the pressure of the head upon the cord, which is the real source of danger to the child in turning, can in no wise be influenced by this position. In bringing down the feet it must be done with the articulation, that is, the child must be turned forwards; at the same time the hand upon the abdomen, externally, will be of great service in assisting us to move the child, and in preventing the change of its position from taking place in too sudden and violent a manner, a circumstance which is apt to paralyze the uterus considerably, and even produce alarming symptoms from the shock it occasions. _Extraction._ When once we have brought the feet into the vagina, the first part of the operation, viz. the changing the position of the child, is completed: it has now become a presentation of the feet, and as such ought to be treated, unless some source of danger be present which requires that the delivery should be hastened. The value of this practice in footling cases was first pointed out by Deleurye,[93] and particularly applied to the second act of turning by Wigand. "I have made it," says he, "a strict rule in turning, from the moment that I have brought a foot of the child as far into the vagina as I can without force, to do nothing beyond patiently waiting for the return of the pains, even if this did not take place for many hours, and leaving the rest of the labour entirely to nature. I have found by doing so that when the pains at length began to expel the child, they did it with so much force and activity as was not even seen in the most natural case of head presentation." (_Geburt des Menschen_, vol. ii. p. 130.) As the feet descend towards the os uteri, the presenting part, particularly if the arm has been prolapsed into the vagina, begins to recede, the hand externally will assist in moving the child round, and we should perform this step of the operation so gradually as to be assured that the presenting part has quitted the pelvis before the feet have entered. Without attention to this point, the child may easily be fixed across the upper part of the pelvis, or even the body brought down, while the head is wedged into the cavitas iliaca of the ilium, and produce a serious obstacle to its farther advance. This is a sort of mishap which can rarely happen except to young practitioners. If the process be slowly and carefully conducted, we doubt much if it be ever necessary to disengage the presenting part as has been so frequently recommended: the uterus in fact will move the child round with very little assistance on our part, and we shall find that after every pain the advance of the feet and recession of the part has increased considerably. From our own observations we would say that in all difficult cases, of turning especially, it is desirable for the patient to have several pains between the moment of gaining the feet and bringing them fairly into the vagina: very little force is required to bring them down, and the uterus does not appear to suffer; but where the position of the child has been rapidly changed, its contractile power seems to be injured, and it is ill able to make those exertions during the last stage, which will be required of it in order to save the child's life. Not less necessary is it that we should proceed with the second stage as cautiously as possible: the grand principle is the same, viz. to conduct the expulsion as gradually as possible: there is no use whatever in hurrying this part of the operation, for if the child be alive, we place it in imminent danger of its life; and if it be dead, as will easily be known by the cord not pulsating, we are putting the mother to a great deal of suffering for no reason. Now that it has become a footling case, it must be managed according to rules already given for this species of presentation: the uterus must be emptied as slowly as possible, the anterior part of the child must be directed more or less backward, and the funis guided into the vicinity of one or other sacro-iliac synchondroses. By retarding the advance of the child, we resist the action of the uterus somewhat, and thus excite it to contract more actively, the head enters the pelvis in the most favourable position, and as the pains are still brisk, it passes through so quickly as to subject the child to little or no danger by pressing upon the cord. Where however the passage of the head through the pelvis threatens to be delayed, we would strongly recommend the application of the forceps in order to terminate the delivery before the child has begun to suffer: it is to this mode of practice that Professor Busch, of Berlin, attributes the extraordinary success of turning in his hands; of forty-four cases where turning was deemed necessary only three children are stated to have lost their lives from the effects of the operation, a result which is by far the most favourable known. _Turning with the nates foremost._ It has been proposed by several authors of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (_L'Art des Accouchemens_, § 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,[94] also by some other continental authors; but the difficulty in bringing down a part of the child's body, upon which we can exert so little hold, will always be very considerable, wherever the circumstances under which the operation is undertaken is at all unfavourable. Schmitt recommends that as soon as we reach the nates we should apply the hand flat upon them; while in order to turn the child, active pressure is kept up from without by the other hand: when once we have succeeded in moving the breech somewhat downwards, its farther descent is very easy. A still more recent modification of turning the child in arm and shoulder presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists in raising the presenting part, and at the same time turning the child upon its long axis, as the hand placed in the axilla carries the shoulder to the upper parts of the uterus, after which, as the hand descends, it brings the feet along with it into the vagina. _Turning with the head foremost._ In former times, as the head was considered the only natural presentation of the child, every deviation of its position from this was looked upon as unnatural, and, therefore, the operation of turning only applied to bringing down the head, which had not presented: as, however, the difficulties already mentioned, in turning with the nates, would apply still more forcibly to bringing down the head, it is plain that this mode of turning would rarely be practicable. "Were it practicable at all times," says Dr. Smellie, vol. i. book iii. chap. iv. sect. iv. number v., "to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he, therefore, ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels by the touch that the face, ear, or any of the upper parts present." Still, however, he confesses that the usual method of turning by the feet is the safest. In his first volume of cases, (collection 16, number 6, case 5,) he has given a description of this mode of turning. Dr. Spence also turned with the head foremost, as is shown by his thirty-second case, where the hand and cord were prolapsed into the vagina. "I introduced my hand into the vagina, and in the intervals between the pains reduced both the arm and the cord: but as I found they were like to return again upon my withdrawing my hand, I therefore continued to support them till such time as, by the strength of the pains, the child's head was so far forced down as to prevent any danger of their returning, the happy consequence of which, was, that she was delivered of a live child in about half an hour after: both mother and child did well." (Spence's _System of Midwifery_, p. 465.) Dr. Merriman has recorded a similar case in his own practice: "The arm was returned at two o'clock; there was afterwards no occurrence of pain till six, after which, they became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six." (_Synopsis of Difficult Parturition_, 1838, p. 250.) Still more recently turning with the head foremost has been tried by Dr. Michaelis, of Kiel, (_Neue Zeitschrift für Geburtskunde_, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty. _History of turning._ Turning, as it is generally practised at the present day, viz. changing the position of a living child so that the feet are brought down foremost into the vagina, was unknown to the ancients. There is little doubt, however, that if they could have been induced to have looked upon presentations of the nates and feet as natural labours, they would have been in possession of this valuable means of effecting artificial delivery; as it is, we meet with detached allusions to it in their writings, although applying only to cases where the child is dead. In the writings of Aspasia and Philumenus, which, but for the quotations of Oetius, would have been entirely lost to us, we find directions for turning the child. Thus, Philumenus states, "Si caput foetûs locum obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur." At a still later period, Celsus gave similar directions, but to all appearance they also merely apply to a dead child. "Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est;" and again he says, "Sed in pedes quoque conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas manus commode educitur." (Celsus, _de Medicinâ_, lib. vii. cap. 29.) From this time the whole subject seemed to sink into oblivion, until Pierre Franco, in his work on surgery[95] proposed the extraction of the child with the feet foremost: this was put into practice by the celebrated French surgeon, Ambrose Paré, (Ambr. Paræus, _Opera Chirurgia_, 1594,) who, nevertheless, recommended turning with the head foremost, where it was possible. His work was afterwards translated into Latin by Guillemeau, who, although he still adhered to the old plan of bringing down the head, showed the value of Paré's mode of turning in hæmorrhages and convulsions. To Francis Mauriceau, a man of great learning and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William Manquest de la Motte, in 1721, to whom the merit is due of having pointed out the value of two great laws in turning--the one of not rupturing the membranes as already mentioned, the other of not attempting to push back the arm which presents.[96] CHAPTER III. CÆSAREAN OPERATION. _Indications.--Different modes of performing the operation.--History of the Cæsarean operation._ The next operation in Midwifery for delivering the full-grown foetus alive is that of _Hysterotomy_, commonly called the Cæsarean operation, viz. where the foetus is extracted through an artificial opening made through the parietes of the abdomen and uterus. The _indications_ for performing the operation are so different in this country to what they are elsewhere that they require especial mention: in England the operation is never performed upon the living subject except where the child cannot be delivered by the natural passage; under these circumstances it is scarcely undertaken in this country for the purpose of saving the child's life, but merely that of the mother, it being considered preferable to deliver the child by perforation or embryotomy, even when known to be alive, than to expose the mother to so much suffering and danger. On the Continent and also in America, it has not been considered in so dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother's life, it is performed for the purpose of saving the child's life in cases where, by using the perforator, the child might be brought through the natural passages. The results of the Cæsarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to practitioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. Osborn, &c.) There is no doubt that in England it has been peculiarly unsuccessful. Dr. Merriman has collected the results of 26 cases of Cæsarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90 terminated favourably; and Dr. Hull, in his _Defence of the Cæsarean Operation_, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few women, "some of them having submitted to it three or four times, others five or six, and even as far as seven times, which if they were all true, would superabundantly prove that it is not essentially mortal." (_Baudelocque_, transl. by Heath, § 2095.) During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German practitioners, so that there has been scarcely a journal of late from that part of the Continent which has not contained favourable cases of it. One of the most interesting instances of later years is that recorded by Dr. Michaelis, of Kiel, where the patient, a diminutive and very deformed woman, was operated upon four times:[97] the second operation was performed by the celebrated Wiedemann, and is stated to have been completed in less than five minutes, and without any extraordinary suffering on the part of the patient, who complained most when sutures were made for bringing the lips of the wound together. The uterus became adherent to the anterior wall of the abdomen, so that in the fourth operation the abdominal cavity was not even opened, the incision being made through the common cicatrix into the uterus. There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. "In France and some other nations upon the European Continent," says Dr. Hull, "the Cæsarean Operation has been and continues to be performed where British practitioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repetition of tormenting, though unavailing pains, and before her life is endangered by the accession of inflammation of the abdominal cavity. From this view of the matter we may reasonably expect that recoveries will be more frequent in France than in England and Scotland, where the reverse practice obtains. And it is from such cases as these, in which it is employed in France, that the value of the operation ought to be appreciated. Who could be sanguine in his expectation of a recovery under such circumstances as it has generally been resorted to in this country, namely, where the female has laboured for years under _malacosteon_ (_mollities ossium_,) a disease hitherto in itself incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominal cavity, or been exhausted by labour of a week's continuance or even longer." (Hull's _Defence of the Cæsarean Operation_.)[98] The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than according to that which is followed in this country: the question here is, can the child under any circumstances be made to pass _per vias naturales_ with safety to the mother? The impossibility of effecting this object is the sole guide for our decision. In using the operation as a means for preserving also the life of the child, we must not only feel certain that the child _is_ alive, but that it is also capable of supporting life, before we can conscientiously undertake the operation upon such indications. This uncertainty as to the life or death of the child greatly increases the difficulty of deciding. Under circumstances where there is reason to believe that, although the child may be alive, it is nevertheless unable to prolong its existence for any time, and the pelvis so narrow that it can only be brought through the natural passage piecemeal, we are certainly not authorized in putting an adult and otherwise healthy mother into such imminent danger of her life for the sake of a child which is too weak to support existence. Circumstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural passage: in this case, even if the child be dead, the operation becomes unavoidable. Under the above-mentioned circumstances, it is the duty of the surgeon to perform the operation; and he can do it with the more confidence from the knowledge of many cases upon record where it has succeeded even under very unfavourable circumstances, and where it has been performed very awkwardly: moreover, it seems highly probable that the unfavourable results of this operation cannot often be attributed to the operation itself, but to other circumstances. Not unfrequently the uterus has been so bruised, irritated, and injured by the violent and repeated attempts to deliver by turning or the forceps, and the patient so exhausted, and brought into such a spasmodic and feverish state by the fruitless pains and vehement efforts, together with the anxiety and restlessness which must occur under such circumstances, that it is impossible for the operation to prove successful. Here it is an important rule that we should decide as soon as possible, whether she can be delivered by the natural passages or not: we should allow of no useless or forcible attempts to deliver her; and if these have been made, we should carefully examine whether the passages, &c. have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural passages. (Richter, _Anfangsgründe der Wundarztneikunst_, band vii. chap. 5.) Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has commenced to any extent; for unless the os uteri has undergone a certain degree of dilatation, it will not afford a sufficiently free exit for liquor amnii, blood, lochia, which, by stagnating in the uterus after the operation, would soon become irritating and putrid, in which case they would be apt to drain through the wound into the abdominal cavity and create much mischief.[99] _Different modes of operating._ The incision has been recommended to be made in different ways by different authors; but the highest authorities, as also later experience, combine in favour of that in the linea alba. Richter states, that one great advantage from making it in this direction is, that when the uterus contracts and sinks down into the pelvis, the incision in it still corresponds with that through the abdominal parietes, and therefore admits of a free discharge of pus, &c. through the external wound; whereas, if it have been made to one side, viz. at the outer edge of the rectus abdominis muscle, as recommended by Levret for the purpose of avoiding the placenta, the wound in the uterus when contracted ceases to correspond with it, and the discharge escapes into the abdominal cavity. Besides this the abdomen is usually more distended at the linea alba; the uterus here lies immediately beneath the integuments; the intestines are usually pressed towards each side; and therefore when the incision is made on one side they frequently protrude, a circumstance which rarely happens when it is made in the linea alba, except perhaps towards the end of the operation. In the linea alba we have only to cut through the external integuments in order to reach the uterus, while at the side, we have to cut through considerable layers of muscle. Previous to operating, the rectum and the bladder should be emptied, particularly the latter, because it is desirable to carry the incision of the abdominal integuments, for reasons just given, as near as possible to the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent assistants are necessary, "two to prevent the protrusion of the intestines, and a third to remove the placenta and foetus." (_Neue Zeitschrift für Geburtskunde_, band iii. heft 1. 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air than upon any other cause, for by this means alone can we save the patient from the dangerous peritonitis which is so apt to follow. The two assistants, whose duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to this that the great success of the Cæsarean operation in later years is chiefly owing. The incision in point of length varies from five to six, seven, or more inches, beginning at about two to four inches below the navel, and terminating at rather less than that distance above the symphysis pubis. The peritoneum is usually divided with a bistoury and director, and the wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when passing through the wound, and thus retain it. It is desirable to remove the membranes as far as possible, especially from the os uteri, to allow of a free discharge from the uterus per vaginam. No sutures are needed for the uterine incision: the contractions of the organ not only diminish its length, but generally bring its edges into sufficiently close contact. Some discrepancy of opinion has existed respecting the treatment of the external wound: sutures are of course the most secure means of retaining the edges in apposition, but they produce great suffering, and, from taking up a good deal of time, delay the closing of the abdominal wound more or less; whereas, straps of sticking plaster are applied much quicker and without any suffering to the patient. To do this most effectually it will be advisable to arrange them under the loins previous to the operation: they should be from five to six feet long, and the ends may be rolled up until wanted; the wound can thus be instantly closed and in the most secure manner. Where the operator finds it necessary to use sutures, he must avoid puncturing the peritoneum as far as possible: the lower inch of the wound should be left open to allow any matter to drain out, and the whole dressed according to the common rules of surgery. The patient should be placed upon her side with the knees bent to relax the abdominal parietes. A grain of the hydrochlorate of morphia has been given in these cases with the best effects, having procured sleep and allayed the disposition to spasmodic coughing and vomiting, which so frequently exists after the operation. One of the greatest triumphs of modern surgery is the performance of this dangerous operation four times successively on the same patient. The first operation was performed in June 1826, the woman being then in her twenty-ninth year, the second in January 1830, the third in March 1832, and the fourth on the 27th June, 1836. The second operation was performed by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it appear that the patient's sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.[100] _History._ Although the early records of the Cæsarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed. The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: these were the birth of Bacchus and Æsculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circumstance, however, connected with the birth of Bacchus is curious, viz. that his mother Semele died in the seventh month of her pregnancy. The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, B. C. 508. Scipio Africanus, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius Cæsar was born by this operation, or still less that it derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor Naegelé, viz. that one of the Julian family at Rome had been delivered _ex cæso matris utero_, and had been named Cæsar from this circumstance, so that the name was derived from the operation, not the operation from the name. "The earliest account of it in any medical work is that in the _Chirurgia Guidonis de Cauliaco_, published about the middle of the fourteenth century. Here, however, the practise is only spoken of as proper after the death of the mother." (Cooper's _Surg. Dict._) Among the Jews, however, it appears to have been performed on the _living_ mother at a very early period; a description of it is given in the _Mischnejoth_, "which is the oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In the _Talmud_ of the Jews, also, their next book in point of antiquity, the Cæsarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In the _Mischnejoth_ there is the following passage, 'In the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen, nor the second, can receive the rights of primogeniture, either as regards the office of priest or succession to property.' In a publication called the _Nidda_, an appendix to the _Talmud_, there is the following remarkable direction: 'It is not necessary for women to observe the days of purification after the removal of the child through the parietes of the abdomen.'" (_Introduction to the Study and Practice of Midwifery_, by W. Campbell, M. D. p. 260.) The first authentic operation upon a living woman in later times was the celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, owing to its fatal character and the strong feeling against it, it was performed but rarely: still, however, sufficient evidence existed to mark its occasional success and urge its repetition in similar cases; and from what we have already stated, the history of the last twenty years shows that its results have rapidly become more and more favourable, so that in the present day it can be no longer looked upon as an operation of such extreme danger and almost certain fatality, as it was in former times.[101] CHAPTER IV. ARTIFICIAL PREMATURE LABOUR. _History of the operation.--Period of pregnancy most favourable for performing it.--Description of the operation._ Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circumstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the Cæsarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of passing through the contracted pelvis of its mother. _History._ Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English practitioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute. To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. "A great number of instances," says he, "have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly. He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rectitude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living." (Denman's _Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few practitioners, (_Sue_,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and assign it a totally different object to that which is intended: the very name which they have given to it of _Avortement artificiel_, plainly shows how little they have understood of its real character. Among his objections, Baudelocque states, that "the neck of the uterus at seven months has seldom begun to open; it is still very thick and firm. The pains, or the contractions of that viscus, cannot then be procured but by a mechanical irritation pretty strong and long continued; but those pains, being contrary to the intentions of nature, often cease the instant we leave off exciting them in that manner. If we break the membranes before the orifice of the uterus be sufficiently open for the passage of the child, and the action of that viscus strong enough to expel it, the pains will go off in the same manner for a time, and the labour afterwards will be very long and fatiguing; the child deprived of the waters which protected it from the action of the uterus, being then immediately pressed upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted except in those cases of violent hæmorrhage which leave no chance for the woman's life without delivery; the nature of the accident also disposes the parts properly for it." (_Baudelocque_, transl. by Heath, § 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in fact, his objections do not apply, but to the _accouchement forcé_ of the French practitioners, where, on account of the sudden accession of dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then passed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this country. The celebrated Carl Wenzel, of Frankfort, was the first in Germany who declared himself in favour of the operation. Kraus and Weidemann followed, the former two having performed it with complete success. The favourable results also in the hands of English practitioners and its increasing reputation quickly silenced the virulent abuse which was levelled at it by Stein, jun., and some other German authorities; the celebrated Elias von Siebold, of Berlin, who had first opposed it, candidly confessed his error and became one of its earliest supporters. Increasing experience showed that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases of artificial premature labour. (_Operative Geburtshülfe_, erster band, p. 298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers died after the operation, but of these, 5 were evidently from diseases which had nothing to do with the operation. The most unfavourable circumstances under which the operation can be undertaken are, where the child presents with the arm or shoulder: here it will require turning, which, in many cases, owing to the faulty form and inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminishing the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less dangerous than other species of premature labour, for the hæmorrhages, which are so apt to attend them, are never known to occur here. This mode of delivery has not only been proposed in cases of contracted pelvis: "There is another situation," says Dr. Denman, "in which I have proposed and tried with success the method of bringing on premature labour. Some women who readily conceive, proceed regularly in their pregnancy till they approach the full period, when, without any apparently adequate cause, they have been repeatedly seized with rigour and the child has instantly died, though it may not have been expelled for some weeks afterwards. In two cases of this kind, I have proposed to bring on premature labour, when I was certain the child was living, and have succeeded in preserving the children without hazard to the mothers." (_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 180.) _Period for performing the operation._ Although under the head of PREMATURE EXPULSION we have stated that a foetus is capable of maintaining its existence if born after the twenty-eighth week of pregnancy, we must not be supposed to recommend the artificial induction of premature labour at so early a period as this. "Experience has shown that it was not necessary to induce labour at so early a period as was first imagined, on account of the very great difference which even one or two weeks are found to make in the hardness of the foetal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made sufficient difference." (Naegelé, _MS. Lectures_.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce uterine action, it will be of so much the less consequence: hence, therefore, as a general rule, the most eligible time will be between the thirty-fourth and thirty-sixth week; and if the deformity be very considerable, we may commence operations as early as the thirty-second week or two months before the full term, short of which it will seldom either be justifiable or necessary. On the other hand, where the state of the cervix and the history of her pregnancy combine to make our reckoning nearly a matter of certainty, the later we can safely delay the operation the better, for by so doing the process resembles more a natural labour, and the chances in favour of the child are much increased. _Operation._ The original mode of artificially inducing premature labour was merely by puncturing the membranes and allowing the liquor amnii to escape; the more gradually this is done the better, for by this means the uterus is not entirely drained of its fluid contents, and is, therefore, prevented contracting immediately upon the child; the value of this precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A considerable interval may elapse between puncturing the membranes and the first contractions of the uterus, generally varying from forty to eighty hours: it should be performed while the patient is in the horizontal posture, in order to prevent the escape of too much liquor amnii. A moderately curved male catheter, open at its point and carrying a strong stilet sharpened at the end, is the best and simplest instrument for the purpose: on passing it up to the membranes, the stilet should be protruded, but to a short extent, to avoid injuring the child; and as soon as the liquor amnii runs from the other end, the instrument should be withdrawn, and the patient desired to remain quiet. A dose of opium has been usually given after the operation by the English practitioners, but its utility appears rather questionable: a brisk purge of calomel and jalap, some hours previously, is much more important; uterine action comes on much more regularly and effectively, and there will be much less chance of those rigours occurring which some practitioners, although erroneously, have supposed, were connected with the death of the child. The practice of dilating the os uteri first, as recommended by Brüninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the _accouchement forcé_ of the French authors ever to be permitted. The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by passing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means. The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times. Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;--the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already passed the brim and is now in the cavity of the pelvis; the vagina and os uteri are lubricated with a copious secretion of remarkably pure and albuminous mucus; and in these cases especially, we frequently meet with those little lumps of inspissated mucus which were formerly called the _ovula Nabothi_. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeated exhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr. Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circumstances, from labour having already commenced to a certain extent. A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. "In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid." (Reisinger, _die künstliche Frühgeburt_.) One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103] We have already alluded to this circumstance in the chapter on PREMATURE EXPULSION OF THE FOETUS.[104] CHAPTER V. PERFORATION. _Variety of perforators.--Indications.--Mode of operating.-- Extraction.--Crotchet.--Embryulcia._ The perforation is that operation "where we make an opening into the cranial cavity, and, by allowing the brain to escape, thus diminish the bulk of the head." (_Obstetric Memoranda._) Perforation is one of the most ancient operations in midwifery, for in former times it was the only means of artificially delivering the child when the head presented: hence we find that from the age of Hippocrates down to the last century, midwifery instruments almost entirely consisted of knives or lancets for piercing the foetal head, and blunt or sharp hooks for extracting or dismembering the child. Thus Hippocrates, Celsus, and Albucasis, and others, have described a variety of such instruments and given full directions for their use. _Variety of perforators._ No instrument has been so greatly modified or has appeared under such different forms as the perforator; but it is not our object to enter into any detailed account of its history, for it would not, like that of the forceps, lead to any useful information; we shall, therefore, content ourselves with mentioning those few which have been in general use during the last century. They are chiefly of the scissor kind; the two most commonly known are the perforators of Dr. Smellie and M. Levret: the former are merely strong long-handled scissors, the backs of the blade being neither exactly sharp nor blunt,[105] and furnished each with a projecting shoulder or rest to prevent them from entering too far. Levret's perforator, which is extensively used in this country under the name of Dr. Denman's perforator, and which was originally invented by Bing, of Copenhagen, is also formed like scissors, but has its cutting edges outside; the blades are also furnished with rests or shoulders like the Smellie perforator. [Illustration: Naegelé's perforator.] A useful modification has been invented by Professor Naegelé, which supplies a considerable defect in the two above-mentioned instruments, viz. the necessity of using both hands to open the blades, thereby requiring that the hand which guides the instrument in the vagina should be removed at this moment: for this purpose the blades do not cross at the lock as the others do, by which means the grasp of one hand is sufficient to squeeze the handles together, and thus make the blades diverge in order to dilate the opening. A similar one has been invented by the surgical instrument maker, Mr. Weiss, but it does not appear to be quite so safe. The object of these instruments is not merely to bore through the skull, but to break down the parietal bone to a certain extent, in order to enlarge the opening: a slight curve of the blades is advantageous, because their points thus impinge more directly upon the skull, and enter it at once without running the risk of slipping along the surface. _Indications._ "The perforation is indicated, first, in all cases where the labour is dangerous for the mother, and where the antero-posterior diameter, although more than two inches and a half, is so small that the head which presents, cannot be delivered by the forceps. Secondly, it is indicated where the head is much larger than natural, as in hydrocephalus." (Naegelé, _MS. Lectures_.) For a more detailed and special account of the precise circumstances under which it will be required, we must refer to those different forms of DYSTOCIA, where it is occasionally required, particularly our fourth species, viz. DYSTOCIA PELVICA. Much discrepancy of opinion has existed as to how far the operation itself was justifiable, and has, therefore, given rise to very different results in the practice of different schools. The most obstinately prejudiced against perforation was the late celebrated Benjamin Osiander, of Göttingen, who asserted, that it was never necessary, for, where others were obliged to open the head, he would deliver the patient by means of his forceps, an instrument which, from its great length and the various hooks &c. for applying additional hands, was capable of exerting a degree of force which nothing could justify. In France, the predilection for using exceedingly powerful forceps to a degree, which in this country and the greater part of Germany would be looked upon as very injurious, if not dangerous, has tended to render the perforation a comparatively rare operation: thus out of somewhat more than twenty thousand labours at the Maternité, of Paris, only sixteen were delivered by this means. Of the ninety-six cases in whom the forceps was applied, no mention is made as to the result with respect to the mothers; but, from the description of a forceps case at the Hôtel Dieu which we have received from an eye-witness, the force used must have been carried to a most unwarrantable extent. The English practitioners have frequently been accused by their Continental brethren with being too ready in the use of the perforator; but, with one or two exceptions, the charge is not just, for, as already stated, we are not justified in subjecting an adult and otherwise healthy woman to so much suffering and danger for the sake of a child which, after all, will be probably sacrificed by the severity of the labour.[106] _Operation._ In performing the operation we introduce two or three fingers along the vagina to the presenting part of the foetal head, and carefully guide up the perforator against it: these fingers will not only protect the soft parts from injury, but steady the point so firmly upon the skull, as to enable the other hand to bore through it without difficulty. Having passed the blades up to the shoulders or rests, we dilate the opening, first one way and then the other, to form a crucial incision: we now insert the instrument up to the basis cranii, breaking down the attachments and structure of the brain, and thus enabling it to come away with greater facility. To favour this object still farther, and make the cranial bones collapse more readily, we must pass a long elastic tube through the opening, and by means of a syringe, throw up a powerful stream of water into the cavity of the skull: if this be introduced to the base of it, the water will necessarily drive out the brain before it, so that with every stroke of the piston, a quantity of brain will be expelled nearly equal to that of the water injected. When the perforation has been made, it will be desirable to wait a few hours before making any attempt to extract: we thus give the mother an opportunity of getting a little rest; the attachments of the cranial bones after a short time become more yielding, the head collapses more readily, and adapts itself better to the form of the passages. "In all circumstances," says Dr. Osborn, "which admit and require precision, I would recommend the delaying all attempts to extract the child till the head has been opened at least thirty hours: a period sufficient to complete the putrefaction of the child's body, and yet not sufficient to produce any danger to the mother. From such conduct, the beneficial effects of facilitating the extraction of the child, I am firmly convinced, by frequent experience, will much overbalance any possible injury which may reasonably be expected from the putrid state of the child and secundines in so short a time. The propriety, however, of this delay entirely depends upon the head being opened in the beginning of labour: for if we do not perform the first part of this operation till the labour has been protracted so long as that the woman's strength begins to fail, we must expedite the delivery as speedily as possible, otherwise, the danger which we wish to avoid, will infallibly be incurred: no woman can suffer continued labour beyond a certain period without fever, inflammation, and the most imminent danger, if not death ensuing." (Osborn's _Essays on the Practice of Midwifery_.) It has been recommended to perforate the head at the sutures, on account of the greater facility in passing the instrument through them: but that part of the head which is lowest in the pelvis, or which, in other words, _presents_, must necessarily be the most convenient, not only for the introduction of an instrument, but also for the evacuation of the brain. When the perforation is made at a suture, the edges of the bones gradually overlap as the head diminishes in size, and thus close the opening, a circumstance which cannot occur when it is made through a bone. Splintering the bone in making a crucial opening has been objected to on the ground that the sharp edges and spiculæ are apt to wound the soft parts of the mother: of this, however, there will be but little danger so long as they are covered by the scalp, which we should be somewhat cautious of, and not tear or otherwise destroy the cranial integuments unnecessarily, for it has long since been remarked by the celebrated Peter Frank, that inflammation of the uterus produced by wounds from spiculæ of bone or sharp instruments becoming blunt, &c., usually prove fatal: it is also desirable to disfigure the head as little as possible. Still, however, we are far from recommending the trepan-shaped perforators which have been used by Professors Assalini, Joerg, &c. as they cannot make a sufficiently free opening, nor break down the skull to the necessary extent. _Extraction._ Where sufficient time has been allowed for the cranial bones to collapse, the finger inserted into the opening and acting as a blunt hook will, if assisted by the pains, be enabled to exert a sufficient degree of force to bring the head down to the pelvic outlet; by which time the action of the vagina and abdominal muscles in aid of the uterine efforts will soon succeed in pressing it through the os externum. By using the finger in this way we pull by that part of the head which is already lowest in the pelvis, and, therefore, run no risk of altering the position of the head and bringing it down in an unfavourable direction; this objection (among others) applies to the hook, whether it be fixed internally or externally, and thus frequently renders the passage of the head through the outlet and os externum more tedious, difficult, and painful, than it otherwise would have been. The craniotomy forceps are still more objectionable in all ordinary cases of perforation, for they not only alter the position of the head, but by tearing away portions of bone from time to time are very liable to wound the soft parts. From our own experience, we would recommend the application of the common curved forceps in all cases where the pelvic deformity is not of a very unusual degree, for by this means the hand is equally grasped and compressed, the soft parts to a considerable extent are protected by the blades, and the whole mass brought down exactly in the position in which it presented. On several occasions where the craniotomy forceps and crotchet have failed to move the head, the midwifery forceps has been applied, and the delivery easily and quickly accomplished. Dr. Smellie recommends the crotchet to be applied on the outside of the head, and was evidently aware that its position was liable to be altered by this means. He directs the practitioner to "introduce it along his right hand with the point towards the child's head, and fix it above the chin, in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold. Having fixed the instrument, let him withdraw his right hand, and with it take hold on the end or handle of the crotchet, then introduce his left to seize the bones at the opening of the skull (as above directed) _that the head may be kept steady_, and pull along with both hands." (vol. i. chap. 3. sect. 7. numb. 4.) Where there was considerable difficulty in bringing down the head, Dr. Smellie used to introduce a second crotchet opposite to the first, like the second blade of the forceps, and having locked them together was thus enabled to apply a greater degree of force. _Crotchet._ The usual mode of applying the crotchet at the present day is to pass it into the cranial cavity, and endeavour to fix it upon some portion of the skull, which will afford a sufficiently firm hold for the purpose; the best spot is the petrous portion of one or other of the temporal bones. The plan of passing up the hook on the outside of the head is objectionable, for in most cases where there is much impaction of the head, it will be exceedingly difficult, if not impossible, to push the hook past it without much suffering and probable injury. Not wishing to differ from so great an authority as Dr. Smellie without reason, we have repeatedly tried this mode of using the crotchet, but invariably found that its introduction on the outside of the head was attended with so much difficulty and pain as to make us relinquish the attempt. His objections to passing the hook into the cranial cavity are not valid, for we should never try to fix it upon the "thin bones," nor should we hold it in such a manner that, if it did slip or tear through, it would wound either our hand or the soft parts of the mother. The common form of the crotchet in general use is but ill adapted for taking hold of any part within the skull: it is, in fact, the very instrument left us by Dr. Smellie for applying on the outside of the skull: and, therefore, that which was intended to take hold of a convex surface cannot possibly be also suited for one of the contrary form, viz. a concavity; for this reason, the shank of the hook requires to be straight, so that the point may project at a considerable angle, by which means it will take hold with much greater ease. The point of the hook guarded by the finger should be cautiously introduced up the vagina, and passed into the cranial cavity; having fixed it, as above directed, the finger should be applied externally, so as to correspond with the hook inside: by so doing, if the point slips or tears through the bone, the finger is ready to protect the soft parts from it; the operator is equally safe from injury, for, by grasping the shank of the hook with his thumb and other fingers, his whole hand moves with it and gives him instant warning of its going to slip. Where the deformity of the pelvis is very great, it may be necessary to break down the bones of the head still farther, in order to produce greater comminution; but even here, so long as the bones collapse well together, it will be better not to displace them from their attachments, the whole mass will come down better and with less chance of injuring the soft parts. Where, however, this is admissible, we must give the head sufficient time to undergo that process of softening which is one of the early stages of putrefaction; the cranial parietes may be gradually removed, one after the other, until we have nothing remaining but the base of the skull and the face. Dr. Burns recommends us now to convert it into a face presentation with the root of the nose directed to the pubes: "I have carefully measured, (says he,) these parts placed in different ways, and entirely agree with Dr. Hull, a practitioner of great judgment and ability, that the smallest diameter offered, is that which extends from the root of the nose to the chin." _Embryulcia._ This is merely a degree farther than the perforation: it consists in evacuating the chest and abdomen of their contents, and thus enabling their parietes to collapse. It is chiefly had recourse to in cases of deformed pelvis, where the arm or shoulder has presented, or where the distortion is so great as to prevent the trunk from passing without its bulk being lessened. Dr. Smellie's perforator with its scissor edges is best suited for this object. Having made an opening into the most presenting part of the thorax, we enlarge it by cutting away portions of the ribs and thoracic parietes, and removing the contents of the chest. The abdominal viscera are brought away in a similar way through a perforation in the diaphragm; and if this be not sufficient to let the trunk pass, the crotchet must be inserted into the brim of the child's pelvis, which must be brought down doubled upon the spine, somewhat like the process of spontaneous expulsion. The success of this operation, will, in a great measure, depend not only upon its being undertaken sufficiently early before the patient's strength is exhausted, but upon a sufficient length of time intervening between the removal of the thoracic and abdominal viscera and the extraction of the child. The excellent rule of Dr. Osborn, above quoted, is peculiarly applicable here; for when softened by the effects of incipient decomposition, the body will sometimes even be expelled by the unassisted efforts of the uterus. In a case of this sort, the perforation of the head is the last part of the process to be performed. It will be by all means, desirable not to separate it from the body, but to pass up the curved perforator along the neck, and make an opening behind the ears: this is effected without much difficulty, and the head can be brought away whole, or in portions, according to the nature of the case. PART V. DYSTOCIA, OR ABNORMAL PARTURITION. _Divisions and species._ By the term Dystocia, we understand those labours which either cannot be completed by the natural powers destined for that purpose, or at least, not without injury to the mother or her child.[107] These will, therefore, consist of the two following classes:-- 1. Labours that are difficult or impossible to be completed by the natural powers. 2. Labours which are rendered faulty without obstruction to their progress. The first division of dystocia may either arise from a faulty condition of the expelling powers, or, without any anormality in this respect, it may depend upon the faulty condition either of the child, or of the parts through which it has to pass. As respects the child it may arise from, 1. Malposition. 2. Faulty form and size of the child. 3. Faulty condition of the parts which belong to the child. On the part of the mother this division of dystocia may arise from a faulty condition. 4. Of the pelvis. 5. Of the soft passages. 6. Of the expelling powers. The second condition where labour is rendered dangerous for the mother or her child, without any obstruction to its progress, may arise from, 1. Following too rapid a course. 2. Prolapsus, &c. of the umbilical cord. 3. From accidental circumstances, which render the labour dangerous, viz. convulsion, syncope, dyspnoea, severe and continued vomiting, hæmorrhage, &c. We propose to consider the different species of dystocia in the order above enumerated. CHAPTER I. FIRST SPECIES OF DYSTOCIA. _Malposition of the child.--Arm or shoulder the only faulty position of a full-grown living foetus.--Causes of malposition.--Diagnosis before and during labour.--Results where no assistance is rendered.-- Spontaneous expulsion.--Malposition complicated with deformed pelvis or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm not to be put back or amputated.--Presentation of the arm and head.-- Presentation of the hand and feet.--Presentation of the head and feet.--Rupture of the uterus.--Usual seat of laceration.--Causes.-- Premonitory symptoms.--Symptoms.--Treatment.--Gastrotomy.--Rupture in the early months of pregnancy._ We have already stated that the presentations of the full-grown living foetus may be brought under three classes, viz. those of the head, of the nates or lower extremities, and of the arm or shoulder: the former two have already been considered under the head of eutocia or healthy parturition, and may be distinguished from the latter, by the great peculiarity that in them the long axis of the child's body is parallel with that of the uterus, whereas, in arm or shoulder presentations this cannot be the case, its body lying across the uterus. Although malposition of the child, strictly speaking, refers to one species of presentation only, viz. to that of the arm or shoulder, yet it has been rendered a matter of great perplexity by the speculations and theoretical notions of authors. No one has propagated more serious errors upon this subject than the celebrated Baudelocque, the more so as the great authority of his name has tended to silence all doubts as to the accuracy of his views upon this subject. Almost every author since his time has contented himself with copying more or less from him, without ascertaining by personal observation how far they corresponded with the actual course of nature. By forcing a stuffed figure into a pelvis in every possible direction, he succeeded in making actually ninety-four presentations of the child, all of which he described as if they had really occurred in nature. Few have taken so simple a view of this subject as the late Dr. Denman. "The presentations of children at the time of birth," says this distinguished accoucheur, "may be of three kinds, viz. the head, the breech or inferior extremities, the shoulder or superior extremities; the back, belly, breast or sides, properly speaking, never constitute the presenting part." The two greatest Continental authorities of modern times, viz. Madame La Chapelle and Professor Naegelé, confirm this opinion: the former points out one of the sources of error which has induced practitioners to suppose that they had met with other species of faulty presentation besides those of the arm or shoulder. "In the greater number of shoulder presentations," says this experienced authoress, "I have very distinctly touched the chest, in some positions of the nates I have been able to reach the loins, the hips, or lower part of the abdomen; but it would require no slight bias from prejudice and theoretical systems to find presentations of the chest, the back, the abdomen, or the loins, the neck or the ear."[108] We would, therefore, limit the term malposition of the child merely to presentations of the arm or shoulder: other presentations, it is true, occur, but not of the full-grown living foetus; they are only where the child is premature, or has been dead in utero some time. Under such circumstances it will follow no rule whatever; for in the first case it is too small, and therefore the passages can have no effect in directing its course through them; and, in the second, a child which has been dead some time becomes so softened by gradual decomposition, that it may be squeezed by the pressure of the uterus into almost any shape: it is by this cause that we occasionally see in still-born children parts in close contact, which in a living child could not have been brought together. We do not deny that such presentations may be made by ignorant and awkward attempts to deliver, but it is to be hoped that such cases are daily becoming of rarer occurrence. Malposition of the child is fortunately not of very frequent occurrence: as a general average we would say that it occurs once in 230 cases, as the following results will show:--At the Westminster General Dispensary (1781) it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr. Merriman, once in 155: "calculated from a great number of cases," to Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr. Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle, once in 230. In arm and shoulder presentations the back of the child is turned towards the anterior part of the uterus more than twice as frequently as it is in the contrary direction, from which circumstance Professor Naegelé has called this the first position of the shoulder to distinguish it from the other, which, as being rarer, he calls the second. In investigating the nature of the causes which produce malposition of the child, which, from the above observations, is evidently a circumstance of rare occurrence, the question naturally suggests itself, by what means is the long diameter of the child in so large a majority of cases kept parallel with that of the uterus? This depends in great measure on the form and size of the uterus. Where the uterus is not unduly distended with the liquor amnii, and where it preserves its natural oval figure, it is scarcely possible that the child should present in any other way than with its cephalic or pelvic extremity foremost. There can be no doubt that the first early contractions of the uterus in the commencement of labour have a great effect in regulating the position of the child; for, by the gentle and equable pressure which they exert upon it, they not only maintain it in the proper direction, but tend materially to correct any slight deviations from the right position. Hence, therefore, we find that where any cause has existed to impair or derange the action of these precursory contractions of the uterus, the child is apt to lie across, or, in other words, to present with the arm or shoulder. Thus, for instance, if the uterus be much distended with liquor amnii, the contractions of its parietes can have little influence upon the child's position; this will be particularly the case where the accumulation is very considerable, for here the uterus becomes more or less globular, and presents but little variation as to the length of its diameter in any direction. The form of the uterus is no less worthy of attention as a cause of malposition, and is also in a great measure influenced by the character of its early contractions. Thus in a uterus for the first time pregnant, they generally act equally on all sides: hence it is why in primiparæ the uterus is so exactly oval, and why we so rarely meet with faulty presentations. Sir Fielding Ould, of Dublin, was the first and almost the only practitioner in this country who noticed the influence which the early contractions of the uterus have in determining the position of the child. "The first labour pains, which are very short, continue their repetition for two or three hours, or perhaps for more, before there is the least effect produced upon the os tincæ, which time must certainly be employed in turning the head towards the orifice." (_Treatise of Midwifery_, p. 14.) Wigand, in reasoning upon the physical impossibility of a child presenting wrong, where the uterus is of the natural configuration, says that "the chief cause of faulty position of the child does not depend so much upon the child itself, as upon the deviation of the uterus from its natural elliptical or pyriform shape." (Wigand, vol. ii. p. 107.) The theory at one time so universally entertained, that the obliquity of the uterus was the chief cause of malposition of the child, has long since been disproved, although it continues to find a few adherents to the present day: the uterus, in fact, towards the end of pregnancy, is scarcely ever quite straight; the upright posture of the human female rendering it almost necessary that the fundus should incline somewhat to one side or to the other, or forwards, and yet we find that it has no influence upon the position of the child when labour comes on. The moment a pain commences, the fundus moves towards the median line of the body, so that its axis corresponds nearly with that of the pelvic brim: as the pain goes off, so does it return towards its former oblique position. Even in those cases where it is strongly inclined forwards, and where the abdomen is quite pendulous, the position of the child is unaffected by it. Where, however, the uterus has been altered in point of form, where from irregular contractions of its fibres it has been pulled down unequally to one side, while it is quite relaxed in the opposite direction, the position of the child may be seriously affected, for it will now present obliquely as regards its long axis, and become a case of malposition. We may, therefore, state that the causes of arm or shoulder presentations are of two kinds, viz. where the uterus has been distended by an unusual quantity of liquor amnii; or where, from a faulty condition of the early pains of labour, its form has been altered, and with it the position of the child. It is a well-known fact that cross births, as they have been called, are frequently preceded by severe spasmodic pains in the abdomen, from which the patient suffers for some days or even weeks before labour has commenced: the uterus is more or less the seat of these attacks, which usually come on towards night-time; and, in some instances, it is felt for the time hard and uneven from irregular contraction. It was the circumstance of this symptom having preceded five successive labours of a patient, in all of which the child had presented with the arm or shoulder, which induced Professor Naegelé, when attending her in her sixth pregnancy, to endeavour to allay these cramp-like pains, which had begun to show themselves as severely as on former occasions. Having tried opium by itself, and also in combination with ipecacuanha or valerian without effect, he ordered her a starch injection with twelve drops of Tinct. Opii every night as long as she continued to suffer from these attacks: the spasms soon ceased, nor did they appear again during the remainder of her pregnancy, and he had the satisfaction of delivering her at the proper time of a living child, which presented in the natural manner. Many other causes of malposition have been enumerated by authors, which evidently exist only in theory and not in reality: thus, shortness of the umbilical cord, or its being twisted round the child, insertion of the placenta to one side of the uterus, faulty form or inclination of the pelvis, obliquity of the uterus, as above-mentioned, violent exertions or concussions of the body, plurality of children; of all these, we do not believe that there is one which can exert the slightest influence in determining the position of the child. There is no doubt that several of them will render labour difficult or even dangerous, more especially deformed pelvis; but we constantly meet with it under every degree and variety without at all altering the child's position. Indeed, if malformation of the pelvis were to be a cause of malposition of the child during labour, what difficulties would it not add to the process of delivery under such circumstances? And yet we find, with very rare exceptions, that in every case requiring artificial assistance on account of contracted pelvis, the head is resting upon the brim which is too narrow to allow it to pass. We may also mention another circumstance which has occasionally seemed to produce a faulty position of the child. It sometimes happens that the hand, which is frequently felt lying by the side of the face at the beginning of labour, instead of slipping up out of reach as the head descends, which is usually the case, advances more and more, until it not only prevents the head from engaging farther into the pelvis, but pushes it out, so that the head slips up to one side, and lodges in the cavitas iliaca, allowing the shoulder with the rest of the arm to descend. Where, however, the pelvis is large or the head small, the arm will not always force it to one side, but the two will come down together and be born in this position. (See case in our _Midwifery Reports, Med. Gaz._ April 19, 1834.) Sometimes the two hands present (_La Motte_, book iii. ch. 26.,) or a hand and foot: this, however, does not long continue so, for when the membranes have ruptured, the liquor amnii flowed away, and the uterus contracted upon the child, one shoulder and arm descend before the rest, and remain in this position. The complication of two arms presenting with the head we disbelieve entirely, except where it has been made during some awkward and ignorant attempts at delivery. Although the symptoms of malposition of the child during the last few days before, or at the commencement of labour, are far from being distinct, still, however, when taken collectively, they will be sufficient to excite our suspicion. The abdomen is irregularly distended, and marked with unequal prominences; anteriorly, it is more or less pointed. It is usually much increased in breadth, and this is generally in an oblique direction, forming a globular protuberance at the upper part on one side, and at the lower part on the other: the former is the pelvic extremity of the child; the other, from its size, form, and hardness, may easily be recognised as the head. "The movements of the child feel differently to what they did before; they are no longer exclusively confined either to one side or the other. Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, during which it is more or less distorted with violent movements, apparently of the child, as if it were trying to force its way through the abdominal parietes at this spot." (Naegelé, _Lehrbuch_, p. 223.) Upon examination _per vaginam_, either no presentation is to be reached at all, or only small parts can be indistinctly felt, such as the hand, the arm, or the shoulder. The not being able to feel a presenting part in a primipara shortly before or at the commencement of labour, is an unfavourable symptom; for the head at this time ought to be deep in the cavity of the pelvis; still, however, it does not necessarily prove that the child is presenting wrong, for it may be a presentation of the nates, which, as we have before shown, do not descend so low into the pelvis just before labour, as the head does; or it may arise from the unusual size of the child's head, especially in cases of congenital hydrocephalus. It may arise from a large quantity of liquor amnii, and where the head is nevertheless presenting; it may be a case of twins, or lastly of dystocia pelvica, where the head is presenting, but unable to pass through the contracted brim. In women who have had several children, it is frequently impossible to reach the presentation during the early part of the labour: this arises either from the abdomen in these cases being generally more or less pendulous, or from the circumstance of the uterus having been distended in so many previous pregnancies: its lower part does not become so fully developed as before, but continues more or less funnel-shaped, a considerable portion of the cervix still remaining. Where this is the case, the head will not descend so low as usual at first, but remains out of reach, or nearly so, until the os uteri is fully dilated and the membranes have given way. "If, upon such an examination, it should be ascertained that the os uteri is considerably dilated, and the child cannot be felt, this affords reason to suspect that the presentation is preternatural. Should the liquor amnii be discharged and the child be out of reach of the finger, the probability of a preternatural position is greater. Should the membranes be found hanging down in the vagina not of the usual globular form, but rather conical and small in diameter, this likewise is a presumptive proof of a cross-birth; especially if there be any part presenting through the membranes which is smaller, feels lighter, or gives less resistance when touched than the bulky heavy head."[109] The diagnosis of the shoulder is by no means easy: it offers no distinctive marks, and may readily be mistaken for the nates, or even for the head. It feels round, but is smaller and softer than the head. The scapula and clavicle, the neck, the armpit, the arm itself, and the ribs, assist us in our diagnosis. From the direction of these parts, we shall be able to ascertain the position of the rest of the body, and which shoulder presents. If the hand has prolapsed, the direction of the palm and of the thumb will soon show the position of the child. Labours with malposition are always dangerous; when left without assistance, they are almost always fatal to the child, and generally so to the mother. When a full-grown child has presented with the arm or shoulder, and nothing has been done to assist the delivery of it, the results are usually as follow:--After the membranes have burst, and discharged more liquor amnii than in general where the head or nates presents, the uterus contracts tighter around the child, and the shoulder is gradually pressed deeper into the pelvis, while the pains increased considerably in violence, from the child being unable, from its faulty position, to yield to the expulsive efforts of nature. Drained of its liquor amnii, the uterus remains in a state of contraction even during the intervals of the pains; the consequence of this general and continued pressure is, that the child is destroyed from the circulation in the placenta being interrupted, the mother becomes exhausted, and inflammation or rupture of the uterus or vagina are almost the unavoidable results. Another although much rarer consequence of malposition of the child, is that peculiar mode of expulsion which was first noticed by Dr. Denman in 1772. From the supposition that the shoulder receded and the nates came down into the pelvis, in which position the child was born, he called it "_the spontaneous evolution of the foetus_;" but the term _spontaneous expulsion_, as proposed by Dr. Douglas in 1811, is much better adapted, it having been shown by that gentleman that the explanation of this process as given by Dr. Denman was not correct. (_An Explanation of the real Process of the spontaneous Evolution of the Foetus_, by J. C. Douglas, M. D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the pubes, the side of the thorax and abdomen, followed by the nates, passed in one enormous sweep over the perineum, leaving the head and other arm still to be extricated. The shoulder and thorax thus low and impacted, instead of receding into the uterus, are at each successive pain forced still lower, until the ribs of that side, corresponding with the protruded arm, press on the perineum, and cause it to assume the same form as it would by the pressure of the forehead in a natural labour. At this period, not only the entire of the arm but the shoulder can be perceived externally, with the clavicle lying under the arch of the pubes. By farther uterine contractions the ribs are forced more forwards, appearing at the os externum, as the vertex would in a natural labour, the clavicle having been by degrees forced round on the anterior part of the pubes with the acromion looking towards the mons Veneris. "The arm and shoulder are entirely protruded with one side of the thorax, not only appearing at the os externum, but partly without it: the lower part of the same side of the trunk presses on the perineum, with the breech either in the hollow of the sacrum or at the brim of the pelvis, ready to descend into it, and, by a few farther uterine efforts, the remainder of the trunk, with the lower extremities, is expelled." (Douglas, _op. cit._ p. 28. 2nd ed.) Farther experience has confirmed the correctness of Dr. Douglas's views (_Med. Trans. of the Royal Coll. of Physicians_, vol. vi. 1820;) and, indeed, the original case as related by Dr. Denman himself tends to prove that nothing like an "evolution" of the foetus takes place. I found the arm much swelled, and pushed through the external parts in such a manner that the shoulder nearly reached the perineum. The woman struggled vehemently with her pains, and during their continuance _I perceived the shoulder of the child to descend_. Some years afterwards, the late Dr. Gooch had the opportunity of observing a case of spontaneous expulsion with great accuracy, and came to the same conclusion as Dr. Douglas had done. "Resolved to know what became of the arm, if this (the spontaneous expulsion) should happen, and thus fit myself for a witness on this disputed point, I laid hold of it with a napkin and watched its movements: so far from going up into the uterus when a pain came on, it advanced, as well as the shoulder, still forwarder under the arch of the pubes, the side of the thorax pressing more on the perineum and appearing still more externally; it advanced so rapidly that in two pains, with a good deal of muscular exertion on the part of the patient, but apparently with less suffering than attends the birth of the head in a common first labour, did the side of the chest, of the abdomen, and of the breech, pass one after the other in an enormous sweep over the perineum till the nates and legs were completely expelled." (_Ibid._) The celebrated Boer, has, however, detailed a case where the arm had prolapsed into the vagina, the hand appearing externally; and on introducing his hand for the purpose of turning, he felt the hand distinctly receding, and the breech beginning to occupy the cavity of the pelvis. This is very different to a case of spontaneous expulsion: "the child lay completely across, with its abdomen towards the back of the mother;"[110] it had, in fact, not yet begun to press against the brim, or to assume any definite position, there having been as yet but little uterine contraction, and both rectum and bladder being considerably distended. When these were evacuated the pains increased: the breech being nearest to the brim, descended, and the arm in consequence receded. Dr. Gooch considers it most probable that "it was only a breech presentation, the hand having accidentally slipt down into the vagina." Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child. Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever take place, except where the child has been already dead some time, or where it is premature. "Nor can any event," says Dr. Douglas, "ever be calculated upon than that of a still-born infant. If the arm of the foetus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected." (_Op. cit._ p. 42.) On the other hand, if either from the rigidity, &c. of the child or of the passages, but little material advance is made in the manner above-mentioned, if the soft parts are become swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of PERFORATION, and in this manner the child delivered. _Malposition with deformed pelvis, or rigidity of the uterus._--Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c. as recommended under the head of TURNING. _The prolapsed arm is not to be put back or amputated._--Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the vagina so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience however confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the passages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the passage of the hand. "An arm presenting," says Chapman, "and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hindrance in turning the child." (Chapman's _Midwifery_, p. 46. 2nd. ed., 1735.) In no case is it necessary to separate the arm at the shoulder, "for I have found it," says Dr. Denman, "a great inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child and the parts appertaining to the mother." (_Essay on Preternat. Labours_, p. 32.) Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz. that cases have occurred where the arm had been cut off and where the child was nevertheless born alive. As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon TURNING. The _presentation of the arm with the head_ is of very rare occurrence, so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty. "Independent of the awkwardness of position which the head may assume, from the circumstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its passage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis." (Merriman's _Synopsis_, p. 48, last ed.) It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side. _Presentation of the hand and feet._ We sometimes also meet with cases where the hand presents with one or two feet; but these complications merely exist at the commencement of labour, where the uterus has been greatly distended with liquor amnii, and where its contractions have not yet begun to press the child into the brim. Cases of this nature sooner or later are sure to terminate in presentations of the nates or shoulder, unless the process of labour has been interfered with. _Presentation of the head and feet._ Presentations of the head and one or both feet have also been described: these, however, have only occurred during the operation of turning, when the feet have been brought down into the pelvis before the head had left it, and, therefore, must be considered as having been _made_ by unskilfulness on the part of the practitioner. Where this is the case it may be necessary to premise blood-letting, &c., on account of the inflamed condition of the parts from the previous unsuccessful attempts to turn: after this, a fillet should be passed round the feet in order to secure them, and then the head may be safely pushed out of the pelvis. _Rupture of the uterus._ Of the injurious results arising from protracted or neglected cases of arm or shoulder presentation none can compare in point of danger with those where the uterus has given way or burst. This state may also be produced by deformity of the pelvis, tumours, and other causes of obstruction to the passage of the child, by which the uterus is excited to unusually violent efforts in order to overcome the impediment during which the laceration is effected. It may also arise from injuries to the uterine tissue without undue exertions, as from exostosis of the pelvis, sharp projecting edges of the promontory or brim, and also from organic disease: thus, "when the rent speedily follows the accession of labour, before the pains have become severe, or the uterus has scarcely begun to dilate, its structures will probably be found diseased." (_Facts and Cases in Obstetric Medicine_, by I. T. Ingleby, p. 176.) _Usual seat of the laceration._ The part of the uterus in which laceration is most frequently observed to occur is near to or at the junction of the uterus with the vagina: this happens rather more frequently behind than before, but the difference in this respect is very trifling. Thus in 36 cases which were collected by Mr. Roberton, of Manchester, "in 1 the cervix was separated from the vagina except by a thread: in 11 the laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 anterior-lateral, and in 3 posterior-lateral." (_Edin. Med. and Surg. Journal_, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the Dublin Lying-in Hospital, "in 13 the injury was at the posterior part; in 12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in 6 the particular seat of the laceration was not described." (_A Practical Treatise on Midwifery_, &c., by Robert Collins, M. D., 1835, p. 244.) The nature and extent of the laceration varies a good deal: in the worst cases the uterus is torn completely through, and the child escapes either partly or wholly into the abdominal cavity; whereas, in many, the peritoneum has not given way, the laceration being confined entirely to the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by Dr. Collins, "the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured." In other instances the peritoneum has been cracked or torn in numerous places without any injury to the subjacent tissue. From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the uterus would be more frequently seen among primiparæ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy. Experience also shows that in a large proportion of these cases, the duration of the labour has been very far from being longer than usual; indeed, in a considerable majority, the mischief has taken place very few hours after the commencement of active labour. Thus, the average duration of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of those by Dr. Collins, it was 17 hours: but if we take merely the _majority_ of them we shall have a much smaller average: thus, in 20 of Mr. Roberton's cases it was 9 hours, and in 15 of Dr. Collins's it was only 6 hours. _Causes._ A large proportion of cases where the uterus gives way during labour, are connected with more or less deformity of the pelvis, and where, from previous severe and difficult labours, its structure has been injured, and rendered incapable of bearing that degree of tension, which even the ordinary exertions of the uterine fibres would require. In many others, the impediment produced by the contracted pelvis, or malposition of the child, has roused the uterus to those violent efforts which have produced the laceration. Organic diseases of the uterus, or cicatrisations of the soft passages from extensive injuries in former labours, either render its powers of resistance defective, or, by increasing the resistance, excite it to unusual violence. "The operation of turning is not unfrequently a cause of laceration of the vagina or mouth of the uterus, _particularly_, where it is performed previous to the soft parts being sufficiently dilated to admit the easy passage of the hand, or where great haste is employed. The same consequences may ensue from rash or violent attempts to remove a retained placenta. I have also known the mouth of the womb to be torn by the imprudent use of the forceps when not sufficiently dilated." (Dr. Collins, _op. cit._ p. 242.) "The sex of the infant, it would appear, may also have some share in occasioning this very distressing occurrence." (_Practical Remarks on Lacerations of the Uterus and Vagina_, by Thomas M'Keever, M. D., p. 4.) Thus, of 20 cases reported by Dr. M'Keever, 15 were delivered of boys and 5 of girls; of the 34 cases described by Dr. Collins, "23 of the children were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurement made by Dr. Joseph Clarke." Another circumstance which influences to a certain extent the frequency of rupture of the uterus, is the rank of the patient: in private practice, especially among the better classes of society, it is an extremely rare occurrence; but in the lower grades of life several causes concur to render it more frequent. They are "much more exposed to falls, bruises, and other accidental injuries during pregnancy, in consequence of which the uterus may be either ruptured at the time they have sustained the violence, or may be so weakened in structure at some particular point, as readily to give way during its efforts to accomplish delivery. Lastly, they are more liable to fall into the hands of ignorant inexperienced midwives, who not unfrequently, with a view of expediting the process of delivery, rupture the membranes at an early period of the labour; in consequence of which, the firm unyielding head of the child is prematurely brought in contact with the passages, exciting by its pressure, swelling, inflammation, and an interrupted state of the circulation in the uterus and adjacent parts. In such a case should there unfortunately exist any disproportion between the parts of the mother and the head of the infant, or should proper measures not be employed to obviate distressing symptoms, and that the labour pains continue to recur with extreme violence, there is great risk of the uterus giving way, the laceration being of course most likely to occur at that part where the greatest pressure has been sustained." (M'Keever, _op. cit._ p. 3.) The _premonitory symptoms_ of rupture of the uterus are not always sufficient to warn us of the impending danger, for in many cases nothing unusual has occurred until the actual injury has been produced, and it has then been inferred by the alarming change observed in the patient's appearance. In many cases, especially where the muscular substance only of the uterus was torn, the pains have continued with a sufficient degree of power to expel the child; in others the mischief has been attended with so little suffering at the moment, and for the time with so little constitutional derangement, as to excite no suspicion, either on the part of the patient, or her attendant. "Farther, as on some occasions, the uterus has been known to give way during the very pain which effected the delivery of the child, instances of which may be found in the works of Crantz and Guillimeau." (_Ibid._ p. 15.) _Symptoms._ "When a rupture of the uterus has really happened, it is generally marked by symptoms which are decisive; but it being a case which occurs so very rarely, they do not immediately create suspicions. When labour has continued violent a considerable time, if a pain expressive of peculiar agony is followed by a discharge of blood, and an immediate cessation of the throes, there is reason to apprehend this mischief. If nausea and languor succeed, with a feeble and irregular pulse, cold sweat, retching, a difficulty of breathing, an inability to lie in a horizontal posture, faintness or convulsions, there is still more reason to suspect the nature of the case. But if the presenting part of the child, which was before plainly to be distinguished, has receded and can be no longer felt, and its form and members can be traced through the parietes of the abdomen, there is evidence sufficient, I believe, to determine that the uterus is ruptured. The labour pain, in consequence of which the rupture is supposed to have happened, is often described by the patient, as being similar to cramp, and as if something was tearing and giving way within them. It has been said likewise, to have produced a noise which could be heard by the people present." (_Observations on an extraordinary Case of ruptured Uterus_, by Andr. Douglas, M. D., 1785, p. 48.) Where the peritoneal coat only has been torn, we may have many of the above-mentioned symptoms resulting from laceration of the uterus, without any impediment to the progress of labour. This peculiar species of partial rupture was first noticed by the late Dr. John Clarke, (_Trans. for the Improvement of Med. and Surg. Knowledge_, vol. iii.,) since which cases have been recorded by Mr. Partridge (_Med. Chir. Trans._ vol. xix. p. 72.,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke's case the uterus and vagina "were found to have sustained no injury whatever; but on turning down the fundus uteri over the pubes, between forty and fifty transverse lacerations were discovered in the peritoneal covering of its posterior surface, none of which were in depth above the twentieth of an inch, and many were merely fissures in the membrane itself. The edges of the lacerations were thinly covered with flakes of coagulated blood; and about an ounce of this fluid was found in the fold of the peritoneum, which dips down between the uterus and the rectum." Where the uterus has been torn quite through, a frequent result is, that the child passes either wholly, or in part, through the rent into the abdominal cavity: this occurrence will, in great measure, be influenced by the situation and extent of the laceration, and also by the degree of the uterine contractions. It is easily recognised by the presenting part having receded, and in all probability by the members of the child being felt with unusual distinctness through the abdominal parietes. _Treatment._ Under such an unfortunate complication nothing remains but to effect the delivery in as speedy and gentle a manner as possible. Where the os uteri is fully dilated, the head presenting and but little receded, and the pelvis only slightly contracted, the application of the forceps will be justifiable; but in many instances the circumstances of the case will not warrant it, and the attempt must be made to bring down the feet, which has been most usually had recourse to with success although it occasionally happens that even this is attended with no slight difficulties: the rigid and partially dilated os uteri may be a serious bar to the introduction of the hand; this has been successfully overcome by incisions into its edge;[111] but it is a remedy which no practitioner would use if by any means to be avoided. _Gastrotomy._ Where the whole child has passed into the abdominal cavity, and the uterus has evidently contracted, so as to produce a serious, if not insurmountable obstacle to delivering it through the vagina, or at any rate without the risk of increasing the extent of the laceration, the question then remains as to whether we should perform gastrotomy, or leave the foetus in the abdominal cavity to be gradually discharged, like an extra-uterine pregnancy, by abscess and sloughing. There can be no doubt that the former plan is preferable, nor are there wanting upon record successful cases of gastrotomy after rupture of the uterus; one of which is doubly interesting from the operation having been twice performed with a favourable result in consequence of a repetition of the injury in the patient's succeeding pregnancy.[112] Mr. Ingleby, of Birmingham, gives a similar opinion in favour of the operation: "The result of two cases of Cæsarean operation in which I have been engaged, leads me to view the mere abdominal incision with very different feelings. The operation is not half so dangerous as the Cæsarean, whilst the celerity with which it is done, the absence of hæmorrhage, and the facility with which the intestines are confined within the abdomen, tend to divest it of much of its terror." (_Op. cit._ p. 201.) _Rupture during the early months of pregnancy._ Cases of rupture of the uterus have occasionally been observed at an early period of pregnancy; in many of these the foetus has passed into the abdominal cavity, where it has been enclosed in a species of cyst, and afterwards expelled through the rectum or abdominal parietes by an abscess. It may be doubted whether some of these have not been cases of extra-uterine pregnancy. On the other hand, there is reason to believe that those extraordinary cases of ventral pregnancy, to which we have alluded, where the foetus has been found in a sac in the abdomen, which communicated with the uterus, and to which the placenta was attached, were the results of rupture at an early period of pregnancy, in all probability the result of ulceration or organic degeneration of the uterine parietes. In some instances it has been produced by violence: and it is by no means impossible that it might take place during a miscarriage, when the uterine contractions are occasionally very violent. Mr. Ingleby remarks that in a case of premature expulsion at the fifth month, the violence of the pains seemed quite equal to produce a breech of surface. Dr. Collins has recorded a case of ruptured uterus in about the fifth month. The laceration appears to have taken place imperceptibly: the child was very putrid; and as the os uteri was sufficiently dilated, the head was perforated, and "was brought away almost without any assistance. It was nothing more than a soft mass, being so completely broken down by putrefaction."[113] There was no previous history to explain it; the muscular structure of the uterus at the anterior part of its cervix was torn, leaving the peritoneum entire. Lastly, we may mention a very singular species of laceration of the uterus, of which we know of but two cases, the one recorded by Mr. P. N. Scott, of Norwich, (_Med. Chir. Trans._ vol. xi.) the other which occurred under our own notice, where the whole os uteri separated from the uterus during labour.[114] In both cases, the os uteri presented a degree of unnatural rigidity, which was quite peculiar, and which in one case, defied repeated and active bleeding, as well as opiates. In Mr. Scott's case, the laceration took place during a violent pain, when the patient "felt something snap, the noise of which one of the attendants declared she heard." In the other case, the patient was not aware of any thing peculiar having happened: it was a first labour in the eighth month of pregnancy; the os uteri had dilated to nearly the size of half a crown, but would dilate no farther; the child had evidently been some time dead; the cranial integuments gave way from putrefaction, the brain escaped, the bones of the skull collapsed, and the bag of scalp protruded so far that we could lay hold of it, although the basis cranii had not passed. We were thus enabled to use more extractive force than we could have ventured upon with the crotchet: after a little effort, but without even a complaint from the patient, the head descended and passed through the os externum. "On the bed lay a disc of fibrous matter with a circular hole in the middle; in fact, the os uteri separated from the uterus to the extent of near half an inch, the edge of the laceration being as clean and smooth as if it had been carefully cut off by a knife." In both instances the patient recovered. Whether incisions into the os uteri for the purpose of effecting the necessary degree of dilatation would have been justifiable under circumstances of such unusual rigidity, does not belong to the present subject; for the consideration of this, we must refer to the FIFTH SPECIES OF DYSTOCIA. CHAPTER II. SECOND SPECIES OF DYSTOCIA. _Size and form of the child.--Hydrocephalus.--Cerebral tumours.-- Accumulation of fluid and tumours in the chest or abdomen.-- Monsters.--Anchylosis of the joints of the foetus._ In this case the labour is rendered difficult or impossible to be completed by the natural powers on account of the faulty size, form, or condition of the child. In the first instance, it is merely a case of disproportion between the child and the passages, owing to the unusual size of the former. Where the child is well formed throughout, but larger than usual, it rarely happens that the head experiences any serious degree of difficulty in passing through a well-formed pelvis, the greatest resistance being observed during the dilatation of the external passages. Even when the head is born, the shoulders may produce a considerable obstruction to its farther passage, requiring a good deal of careful manipulation, in order to disengage the foremost shoulder from under the pubic arch, and thus diminish the pressure of the child against the parietes of the pelvic cavity. Where the shoulders have been severely impacted in this position, it has been in great measure owing to the practitioner having endeavoured to bring down the wrong shoulder first, viz. that which is directed more or less backwards. _Size of the child._ We have already stated that the average weight of the full grown foetus is between six and seven pounds, and its length about eighteen inches; but it is frequently found to exceed these proportions very considerably. Children are not uncommonly observed to weigh 10lbs. at birth. Dr. Merriman once delivered a still-born child, which weighed 14lbs., and the late Sir Richard Crofts is said to have delivered one alive which actually weighed 15lbs.; but by far the largest child which we have yet heard of is recorded by Mr. J. D. Owens, surgeon, at Haymoor near Ludlow; it was born dead, and the weight and admeasurements ten hours after birth were as follow:-- The long diameter from the occiput to the root of the nose 7-1/4 inches. The occipito-mental 8-1/2 From one parietal protuberance to the other 5 Circumference of the skull 15-1/4 Circumference of the thorax over the xiphoid cartilage 14-1/2 Breadth of the shoulders 7-1/4 Extreme length of the child 24 Weight of the child 17 lbs. 12 oz. (_Lancet_, Dec. 22. 1838.) We have already pointed out the difficulty of determining the presence of twins merely from the appearance of the mother's abdomen; the same will necessarily hold good with regard to one large child. The size of the patient must rarely have any influence in forming our prognosis: in most cases she will have many symptoms, which arise either from pressure or weight in the pelvis, such as difficulty in passing water, oedema of the feet and legs, varicose veins of the thighs and labia, or from cramps, the result of pressure upon the absorbents, veins, or nerves; considerable expansion of the inferior segment of the uterus: all these will give us reason to suspect the presence of a large child even although the abdomen may not be remarkably distended. Where the head is very large, the bones are seldom much ossified; they therefore yield easily, and the head accommodates itself to the shape of the passage: sometimes, however, it is unusually hard, the bones are well ossified and very unyielding, so that even if it be not larger than common, still, from its hardness, it meets with considerable difficulty in passing through the pelvis. Cases have been described where the cranial bones were completely ossified, and the sutures perfect; but this latter is very doubtful. Perfect mentions an instance where the head was "almost one entire ossification, and where it passed through the pelvis with great difficulty." (Perfect's _Cases in Midwifery_, vol. ii. p. 370.) We have also met with cases requiring perforation on account of deformed pelvis, and where the cranial bones had almost the feel of a hard nut or shell; still, however, as already observed, we seldom see any serious impediment to the passage of a large head, so long as it is naturally formed; and this applies also to the other parts of the child. _Form of the child._ On the other hand, where there is an unnatural form of the child, either from a disproportionate size or anormal configuration of certain parts, labour may be rendered not only very difficult but dangerous: thus one of the three great cavities may be distended with an accumulation of fluid, the most common form of which, is the congenital hydrocephalus. _Hydrocephalus._ In many cases it produces much less resistance than might be expected from the size of the head; this is, in great measure, owing to the unusual width of the sutures and fontanelles, but chiefly to the almost entire want of ossification in the cranial parietes, which are little else than membranous, and so flexible as to allow the head to be squeezed into almost any shape. In some very rare cases the head has burst, a large quantity of fluid has come away suddenly, and this has been followed almost immediately by the birth of the child:[115] but in the majority the labour has been tedious and severe, and in some instances attended with dangerous results to the patient; thus, Dr. Merriman has "known one hydrocephalic foetus pass entire, the circumference of whose head was 17 inches; another passed alive and lived nearly an hour, whose head measured in circumference nearly 22 inches; both the above labours were long and painful." Perfect relates a case of hydrocephalic head, of which he has given engraved delineations; the labour was attended with extreme difficulty, and the woman expired in less than two hours after delivery; the circumference of this head was 24 inches. (_Cases in Midwifery_, vol. ii. p. 525.) An interesting case of hydrocephalus, attended with convulsions and laceration of the vagina, has been recorded by Dr. Collins: "the perforator was used, upon the introduction of which into the head fully three half pints of water gushed out; the bones then collapsed, and the delivery was easily completed." (_Practical Observations_, p. 205.) _Cerebral tumours._ The bulk of the head is sometimes increased by tumours or sacs of fluid, which arise from a suture or fontanelle: they are of the same nature as the spina bifida, being formed by a protrusion of the integuments and cerebral membranes from an accumulation of fluid beneath: these are of very rare occurrence, and appear to have retarded labour but little, even although of considerable size. The largest cases on record are those which have been described by Ruysch, where one was as big as the head itself, and another where it was nearly as large as the child's body.[116] A case of fluctuating tumour upon a child's head has been described by Mauriceau, (Case 544,) but the precise nature of it is not very apparent. _Accumulations of fluid, and tumours in the chest or abdomen._ It is very rare that the chest is distended by any accumulation of fluid or morbid growth, although this is not unfrequently met with in the abdomen. La Motte has given three cases of ascites which, by the distention of the abdomen, produced considerable obstruction to the delivery of the child. (Cases 331, 332, and 333.) In other cases the liver or the kidneys have been enormously enlarged. A case is described by Dr. Hemmer, where the child was born as far as the shoulders, and there stuck; finding it impossible to extract the child, he perforated the abdomen in two places, but could not extract it; in a few minutes after it came away of itself. The abdomen had been distended with small hydatids; these gradually escaped, and thus diminished the size of the abdomen. (_Neue Zeitschrift für Geburtshülfe_, band iv. heft 1, 1836.) Where the child has been dead some time in the uterus, the abdomen is frequently tympanic, and thus retards its expulsion. _Monsters._ Certain cases of monstrous formation may produce very serious obstacles to the progress of labour: the most considerable is of twins united by the breast. It is difficult to conceive how so large a mass can be forced through the pelvis: we can only suppose it possible where the children have been dead some time before birth, or where they were premature: to this latter circumstance only we can attribute the fact of their having been born alive, as in the celebrated case of the Siamese twins. Where the children have been united by one pelvis, &c., the chances here of the foetus being dead before birth would be even still greater. M. Rath, of Zetterfeld, has lately described a case of extremely difficult labour, in consequence of twins united by the breast. "The children (two girls) weighed 15lbs.; they were 17 inches long. The part by which they were united was 9 inches broad and 3 long, and extended from the upper extremity of the sternum to the navel, into which one umbilical cord, which was common to both, entered. The diameter of the two children when laid together was between 7 and 8 inches from one back to the other. One child had two thumbs on the right hand. The cord was 19 inches long, and unusually thick. After suffering some time from peritonitis, &c., the patient recovered." (Siebold's _Journal_, band xvii. heft 2. 1833.) _Anchylosis of the joints of the foetus._ Lastly, we may mention a very rare cause of this species of dystocia, which has been observed by Professor Busch, where the obstruction to the passage of the child arose from anchylosis of its joints. "The head had been delivered by the forceps, but the body would not follow. As no cause of obstruction could be discovered, a gentle and then more powerful traction was used: this was followed by a cracking sound, and the upper part of the trunk passed through the os externum: here again it stopped, but still, as no cause of obstruction could be discovered, and as the child was dead, another traction was made, with a repetition of the cracking sound, and the child was delivered. On examination it was found that all the joints of the extremities were anchylosed in the usual position of the foetus in utero, so that the ossa humeri and then the ossa femoris had given way. The child had been dead some time." (_Neue Zeitschrift für Geburtskunde_, vol. xv. 1837; and _British and Foreign Med. Rev._ April 1838, p. 579.) No precise rules can be given for the treatment of these cases of malformation of the child; it must be modified according to the peculiarities of each individual case. Whenever a part has undergone considerable increase of size from accumulation of fluid, this can be in most cases removed without much difficulty by perforation, whether it be of the head or abdomen. With monstrous growths the accoucheur must depend upon his own resources, ingenuity and knowledge of the mechanism of parturition. The more careful and correct his diagnosis is, the more efficient will be the means he adopts for delivering the child. In such cases the examination can scarcely be made effectually by the finger alone, but the hand will be required for this purpose. CHAPTER III. THIRD SPECIES OF DYSTOCIA. _Difficult labour from faulty condition of the parts which belong to the child.--The membranes.--Premature rupture of the membranes.-- Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta._ In describing this species of dystocia, according to the arrangement of Professor Naegelé, which we have adopted, it will be necessary to observe that serious obstructions to the passage of the child is seldom produced by it, although, at the same time, many slight derangements in the progress of labour are liable to result, which demand the care of the practitioner. The membranes when too thick or tough (Merriman's _Synopsis_, p. 217,) may retard the labour occasionally, especially during the second stage, when instead of bursting and allowing the uterus to contract more powerfully upon the child by the evacuation of the liquor amnii, they are pushed down into the vagina, forming a large conical sac, which may even protrude externally. We doubt much, however, if the non-rupture of the membranes at the proper time during labour is of itself sufficient to retard its progress, for it is frequently observed that the head will, nevertheless, advance rapidly and even be born covered by the protruded membranes. Where labour is rendered tedious by the unusual strength of the membranes, it is generally connected with considerable distention of the uterus from liquor amnii; in which case the bag of waters is so spherical that it will not descend readily into the vagina, even although the os uteri is fully dilated, and, therefore, prevents the advance of the head: to this we shall recur immediately. So long as there is no undue accumulation of liquor amnii, we may safely allow the membranes to descend to the os externum before we rupture them. In former times a variety of instruments were employed for this purpose, many of which were dangerous, and all unnecessary, the finger being in most cases sufficient. The most effectual way of doing this is to press the thumb and middle finger upon the membranes during a pain and thus increase their tension, whilst the point of the fore-finger is pushed against them: scratching them with the nail during a pain will be sufficient when they are higher up the vagina. _Premature rupture of the membranes._ More frequently the membranes rupture too soon, that is, before the os uteri is fully dilated: this may arise from their being too thin, a condition, however, which it is not very easy to prove: in most instances, it is observed where the uterus is but moderately distended, and where it has that oval or pyriform shape which we have already pointed out as being best adapted for acting efficiently upon the os uteri. This, perhaps, is one reason, why too early rupture of the membranes so frequently occurs in primiparæ; and this may be one cause, among many others, why first labours are generally so much more tedious and severe. The membranes may also be prematurely ruptured by violent exertions, coughing, sneezing, vomiting, &c. by straining immoderately and too soon, by rough and awkward examination, &c. Where this is the case, the patient should preserve the horizontal posture, and keep as quiet as she can until the os uteri has dilated sufficiently and allowed the head to advance. _Liquor amnii._ Where the uterus is distended by an unusual quantity of liquor amnii, its contractile power is necessarily much impaired; and until the quantity of its contents be somewhat diminished, the progress of the labour will be more or less retarded. The average quantity of liquor amnii at the full period of pregnancy is about eight ounces; but it frequently exceeds this very considerably, occasionally amounting to several pints or even quarts. The causes of this extraordinary accumulation are still but little known. "M. Mercier has, in some cases, attributed it to an inflammatory condition of the amnion, the foetal surface of this membrane being stated to have been partially coated with false membrane, and the amnion itself crowded with blood-vessels of a rose colour:" in another case "about a quarter of the foetal surface of the amnion was inflamed, being of a deep red colour and double the natural thickness."[117] The results of Dr. R. Lee's observations, after having paid a good deal of attention to the subject, do not tend to confirm this view: he has described six cases of unusual accumulation of the liquor amnii, in one amounting actually to sixteen pints. In five of them "there existed with dropsy of the amnion some malformed or diseased condition of the foetus or its involucra, which rendered it incapable of supporting life subsequent to birth." In two only of the preceding cases was "the formation of an excessive quantity of liquor amnii accompanied with inflammatory and dropsical symptoms in the mother; and in none did the amnion, where an opportunity occurred for making an examination, exhibit those morbid appearances produced by inflammation, which M. Mercier has described, and which led him to infer that inflammation of the amnion is the essential cause of the disease." (Lee, _op. cit._) Dr. Merriman has given a similar opinion, and states, that "when the embryo or foetus is diseased, the liquor amnii is sometimes immense in quantity. I once saw at least two gallons evacuated from the uterus: the child was monstrously formed and much diseased."[118] In these cases the size and globular form of the uterus, the tenseness of its parietes, the more or less distinct feel of fluctuation, the absence of the child's movements and of any prominences arising from the projecting portions of its body, the rapid increase which has been observed in the size of the abdomen, the pain in different parts of the uterus, especially in the groins and pelvis, the oedema or anasarca of the lower extremities, serve to mark this condition. On examination per vaginam we also feel the inferior segment of the uterus much expanded, the cervix probably shorter than might be expected for the period of pregnancy; the ballottement is unusually free and distinct. In some instances the patient has suffered so much, either from the effects of the retarded circulation in the lower extremities, or from the impeded respiration as to require the membranes to be punctured in order to reduce the size of the uterus. The child is usually born dead where the accumulation has gone to so great an extent: in the three cases recorded by La Motte, it was dead before birth in the first two, and died immediately after birth in the third. Many of these cases, which have been complicated with disease or malformation of the foetus, have appeared to arise from a syphilitic taint; but in others, of more common occurrence, where there was merely an unusually large quantity of liquor amnii without any disease either of the mother or her child, the cause must still remain a matter of uncertainty. This latter condition is mostly seen in women who have been frequently pregnant; the os uteri in them is generally yielding, and when once it has attained its full degree of dilatation, we may safely rupture the membranes and thus expedite labour considerably. There being an unusually small quantity of liquor amnii can scarcely operate as an obstruction to labour, except where the membranes have been prematurely ruptured. The _umbilical cord_ may obstruct labour, by either being too short, or rendered so from being twisted round some part of the child. Its length varies very considerably. Although we have stated it to average about eighteen or twenty inches,[119] we have met with extreme deviations both within as well as beyond this medium length. The shortest cord which we know of occurred some years ago at the General Lying-in Hospital, "where, after two or three violent pains, the child was suddenly and forcibly expelled the cord was found ruptured at about two inches from the navel of the child, which cried stoutly. After removing the child the matron sought for the other end of the funis, but could not find it; she examined per vaginam but could not feel it; and on introducing her hand into the uterus, found the placenta with the remains of the cord ruptured at its very insertion; so that in this case the cord could not have been much more than two inches long." (Printed Lectures in Renshaw's _Lond. Med. and Surg. Journ._ May 1835, p. 426.) We quite agree with Professor Naegelé, that unusual shortness of the cord can rarely if ever retard labour; and that where the cord really produces an impediment to its progress, it is from being twisted round the neck, or some other part of the child. (_Lehrbuch_, 2d ed. p. 289.) This generally arises from its unusual length, and from its having formed several coils around the child: we have met with it forty-eight inches long, and twisted four times round the child's neck; but Baudelocque mentions a case where it actually measured fifty-seven inches, "forming seven turns round the child's neck." (Heath's _Transl._ vol. i. § 516.) Mauriceau has given an instance (_Obs._ 401.,) where the cord had "longueur d'une aune et un tiers de notre mesure de Paris:" which, converted into English measure, amounts to somewhat more than sixty-one inches. Although nothing is of more common occurrence than the cord being twisted once or twice round the child, it nevertheless, happens, but very rarely, that its advance is thereby obstructed. In a case of this sort, the labour usually commences quite favourably; the os uteri dilates, and the head advances to a certain extent, beyond which it makes no other farther progress; the uterine contractions are attended with much pain in the fundus, during which the head advances somewhat, but retires again during the intervals. Where the head is already near the os externum, this may be easily attributed to the elasticity of the soft parts, until the delay which takes place to the farther progress of the labour warns the practitioner that something more than ordinary is the cause. But where this takes place, and the head is still in the pelvic cavity; where at the same time, although it refuses to advance, it is quite moveable, and allows the finger to be passed freely round it; where any attempt to extract it with the forceps has not only met with great opposition, but has greatly aggravated the sense of painful dragging in the upper parts of the uterus there will be pretty certain evidence of the cord being either too short, or, what is most probable, of its being twisted round the child. In each of the three cases recorded by La Motte, the head had descended to the os externum; whereas, in two others described by Burton, it was evidently much higher up: he ruptured the cord in both instances; La Motte succeeded in cutting the cord with a pair of scissors in one case, in another he appears to have separated the placenta, and in the other to have delivered by little else than force. Where upon introducing the hand we find it impossible to undo the coil of the funis, we should endeavour to slip it first over one and then the other shoulder, as we have recommended under the more ordinary circumstances: should this fail, we must try to cut it through either by a finger nail slightly notched for the purpose, or by the introduction of a Smellie perforator well guarded. The cord being twisted round the child's neck may not only retard labour, it may destroy the child itself by preventing the free return of blood from the head: this may take place some little time before birth, or during the actual process of labour. That suffocation cannot possibly be the cause of death under these circumstances is sufficiently evident. _Knots upon the cord_ have been mentioned by some authors as a cause of danger to the child shortly before and especially during labour; for the circulation in the umbilical vessels being more or less compressed, the child would either be born dead or in a very weakly state. Experience has, however, shown that these effects have been much over-rated, and that these knots are seldom injurious to the child.[120] Baudelocque has not only met with single, but even triple and very complicated knots tied tightly upon the cord, and yet the child was not only born alive, but remarkably robust and healthy. Circumstances, however, may occur by which the knot is gradually drawn so tight as to destroy the child. Smellie has given a case of this kind; but it is to the late Matthew Saxtorph, of Copenhagen, that we are indebted for an admirable essay on this subject. The result of his observations coincides with those of Baudelocque, viz. that it rarely proves fatal to the child.[121] The manner in which these knots are formed may be easily imagined; when by chance the cord lies in the form of a ring, and the foetus happens to float through it, a noose is made, which, when drawn tight by accident, forms a knot. The most favourable time for the formation of such knots is in the earlier months of pregnancy, when the quantity of liquor amnii, in proportion to the bulk of the foetus, is so much greater than at an after period, and when its movements are consequently less impeded. The circulation in the knot will be obstructed in proportion as the knot is drawn closer: if it be merely somewhat impeded, the vessels on each side of the knot will be distended and varicose, and the cord itself, where it forms the knot, from the constant gradual pressure of one fold against the other, will become more or less flattened.[122] We believe that in every case the cord has been of unusual length. The _placenta_ cannot easily obstruct the birth of the child, although it may render the labour exceedingly dangerous in a great variety of ways: these circumstances will be considered under their respective heads. CHAPTER IV. FOURTH SPECIES OF DYSTOCIA. _Abnormal state of the pelvis.--Equally contracted pelvis.--Unequally contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.-- Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.-- Effects of difficult labour from deformed pelvis.--Fracture of the parietal bone.--Treatment.--Prognosis._ This may arise from there being either too much or too little resistance to the passage of the child; where, in the one case, labour is rendered difficult or impossible to be completed by the natural powers; in the other, it is unnaturally rapid. The latter condition belongs to the second great division of dystocia, where the faulty character of the labour does not depend upon its progress being deranged, but upon other circumstances: we shall, therefore, delay speaking of precipitate or too rapid labour from unusually large pelvis, until then, and devote the present chapter to the consideration of those cases where the labour is more or less obstructed by the faulty condition of the mother's pelvis. The pelvis may obstruct the passage of the child in a variety of ways. 1. It may be merely a diminutive or dwarfish pelvis, viz. well formed but smaller than usual in every direction--the pelvis simpliciter justo minor of Continental authors. 2. It may be distorted and deformed. 3. It may be of the natural form and size, but the passage through it more or less obstructed by exostosis. _Equally contracted pelvis._ The first species of faulty pelvis (_pelvis simpliciter justo minor_,) is not of common occurrence, and has received but little notice in this country. It has been said to resemble the pelvis of a girl in its general appearance; but this only holds good in point of size; for, in the relative proportions of its diameter, it presents all the characters of a well formed adult pelvis. From this circumstance, it can scarcely be said to be an arrest of development, the necessary changes in the form of the pelvis having taken place at the time of puberty, as completely as if it had been of the ordinary size. A pelvis of this sort may be not more than a quarter of an inch too small in every direction, or it may be as much as a whole inch: we do not know of any case where the diminution has exceeded this last degree. The pelvis equaliter justo minor is not accompanied with a corresponding diminutiveness in the rest of the skeleton, most of the patients in whom it has been observed being well formed and of the usual stature. Fortunately, as before stated, it is of rare occurrence, for even a small diminution in the size of the bony passages, which is uniform in _every direction_, presents a most serious obstacle to the passage of the child. Thus, in three cases of the sort, which have been described by Professor Busch in his report of the Berlin Lying-in Hospital, the labour terminated fatally in two. "The first case was a presentation of the breech; the head was delivered by the forceps; the child was dead; the pelvis measured half an inch too small in every direction. In the second case, which was a head presentation, the delivery was effected by the forceps, but not without the greatest efforts; the child was still-born, and the mother died in a day or two after from peritoneal inflammation. The third case required perforation; this also terminated fatally, the forceps having been previously applied, and considerable efforts made without success. On examination after death, every diameter of the pelvis was three quarters of an inch smaller than usual: in appearance it resembled that of a child." (_Neue Zeitschrift für Geburtskunde_, vol. xv. 1837.) _Unequally contracted pelvis._ The unequally contracted pelvis (_pelvis inæqualiter justo minor_) may exist under a variety of forms; the most common is where the antero-posterior diameter is defective, or, in other words, where the distance between its anterior and posterior parietes is less than usual. In a slight degree, it is frequently met with among the poorer classes, and arises from the patient having been compelled to carry heavy burdens in early childhood, or otherwise subjected to severe labour. The practice of entrusting a girl of eight or ten years of age with the care of a heavy infant, which she carries about in her arms for many hours every day, is a fruitful source of this species of pelvic deformity; the young and plastic pelvis is unable to bear the additional pressure which is thrown upon the sacrum by the overloaded trunk, without having the just proportions of its growth materially influenced and perverted, especially at a period of life when the whole form of the pelvis is undergoing considerable changes. The constant pressure and counter-pressure to which the pelvis is subjected by the undue weight which is applied to the sacrum above, and supported by the resistance of the femora against the acetabula below, must necessarily tend at this age, even in an ordinary state of health, to impair its symmetry, more or less, and gradually to diminish the distance between its anterior and posterior parietes. Under no circumstances has this cause of pelvic deformity acted to such an extent as in the English manufactories, where young children are compelled to remain standing for twelve or more hours at the machines: the physical powers are unequal to the endurance of so much unceasing labour, the skeleton of the child soon suffers in its growth, and the pelvis almost certainly becomes contracted. Similar effects may also be produced by undue pressure on the other parts of the pelvis. Thus the outlet may become much contracted by sitting many hours a day on a hard seat, as is frequently the case in schools. The tubera ischii are pressed together, the pubic arch is thereby contracted, and the sacrum becomes strongly curved forwards. Much riding on horseback at an early age is said to be injurious; and it is stated that the females of those American nations who are constantly on horseback bear but few children, and are frequently three or four days in severe labour. _Rickets._ Similar effects, only in a much more aggravated form, are produced by rickets in early life; the pelvic bones having become soft from the loss of their earthy matter, gradually give way under the pressure of the superincumbent trunk, to the support of which they were unequal. In this way the sacrum is forced downwards and forwards towards the symphysis pubis, the acetabula are driven upwards and backwards, the pubic arch becomes distorted; and if the disease continues for a considerable period of time, the whole pelvis becomes so squeezed together as entirely to lose its original proportions. The manner in which the distortion takes place varies exceedingly, and will be more or less influenced by the circumstances under which the child has been placed. The most constant change is the shortening of the antero-posterior diameter at the brim. In severe cases the base of the sacrum has, as it were, sunk down between the illia, so that its promontory occupies the cavity of the pelvis, the fourth, or third, or even the second, lumbar vertebræ occupying its former position. The gradual yielding of the bones seldom takes place with that degree of uniformity as to allow the sacrum to approach the symphysis pubis in a straight line: the more common result of rickets is, that the promontory is, at the same time, wrung more or less to one side. "If the superior strait does not constantly present the same figure in deformed pelvis; if it is sometimes larger on one side than the other; if one of the acetabula is nearer to the sacrum, while the other approaches less; if the symphysis of the pubes is removed in many cases from a line which would divide the body into two equal parts, it is because the rickets has not equally affected all the bones of the pelvis, nor equally hurt all their junctions; and because the attitude which the child takes in walking or sitting may change a little the direction of the compressing power, which I have just mentioned." (_Baudelocque_, translated by Heath, vol. i. p. 60.) Nor is it necessary that the degree with which the disease affects the different parts of the pelvis should vary in order to produce these inequalities of distortion, for there is no reason to suppose that the promontory of the sacrum would approach the symphysis pubis in a straight line, even where the softening of the bones was uniform throughout; the attitude of the child, as above-mentioned, and the manner in which it supports itself, will have no inconsiderable influence in determining the direction in which the distortion takes place. In those instances where the promontory is forced low down into the pelvic cavity, the sacrum becomes bent upon itself, the upper part of it forming a sharp curve backwards, while its lower portion together with the coccyx being confined by their attachments, and more or less compressed by sitting, are directed forwards. This is not seen where the projection of the promontory is but slight; the curve of the sacrum so far from being increased is rather lessened; the sacrum is straighter and flatter than usual, so that, although the brim of the pelvis is contracted, we not unfrequently find the outlet even larger than natural: in other cases, where the softening of the bones has gone to a considerable extent, the outlet is diminished, from the tubera ischii having been forced inwards. The degree to which the promontory projects, of course, varies considerably. The distortion is occasionally so great as not even to leave an inch of antero-posterior diameter. This excessive deformity, however, is more frequently the result of mollities ossium coming on after puberty, for we seldom find children live through this critical period where it has been the result of rickets. The brim of a deformed pelvis varies considerably in shape: "sometimes it has the form of a kidney, or that of the figure eight ([Symbol: infinity]); sometimes it is triangular or heart-shaped, the sides being curved inwards, from the acetabula having been pressed backwards or inwards, the ossa pubis are bent forwards and outwards, and form at their symphysis a sort of beak-like process, which is the apex of the heart: in this species of deformed pelvis, which is usually the result of mollities ossium, the outlet also is usually much distorted: this arises from the tubera ischii being forced nearer to each other, thus contracting the pubic arch." (Naegelé's _Lehrbuch_, 2te Ausgabe, p. 247.) [Illustration: _From_ Naegelé.] [Illustration] _Malacosteon_, or _mollities ossium_. An arthritic, rheumatic, or gouty diathesis is a morbid state, in which softening of the bones may take place at a much later period of life, and to a most extraordinary extent. In almost all the cases of extreme pelvic deformity which have been recorded, the distortion has been owing to this disease, and not to rickets in early life: in a pathological point of view there is a considerable analogy between these two diseases. From a variety of causes there is a superabundant formation of acid in the system, which its excreting organs are unable to throw off. The effects of this condition will vary according to circumstances; among them the softened state of the bones from a deficiency of insoluble bone earth is not the least remarkable. Mollities ossium seldom attacks women who have had no children: sometimes it begins shortly after delivery, and very frequently during pregnancy, during the progress of which it continues to increase. Hence, it occasionally happens, that a woman has given birth to several healthy living children without any unusual difficulty in her labours, and where, after this, the pelvis has gradually become so deformed from mollities ossium, as to render delivery impossible by the natural passages, and, therefore, to require the Cæsarean operation. Pelves of this sort, may be easily distinguished from those which have been deformed in early life by rickets; they have evidently attained their full adult growth before the process of softening had commenced: the ilia, for instance, are of the natural size, but bent across, as if they had been folded like wet pasteboard; whereas, the bones of the ricketty pelvis have not attained their full development, they are stunted in growth as well as distorted in shape, the two processes, viz. of growth and distortion, having evidently, co-existed. The form of the pelvis in mollities ossium necessarily varies with the peculiar circumstances under which the individual is placed: thus, if her strength allows her to sit up, or even to get about, as is generally the case more or less, the promontory and the pubic bones are gradually pressed towards each other, so that the antero-posterior diameter is greatly diminished:[123] if, however, she is confined entirely to bed for a considerable period, the distortion takes a different and much rarer form. From her lying first on one side and then on the other, the pelvis is laterally compressed; the transverse diameter becomes even shorter than the antero-posterior; and if the disease continues long enough, the pelvis is at length so altered and mis-shapen, that nearly all its original configuration is obliterated. The weight of such a pelvis varies considerably: where the disease has ceased some time before death, and bone earth has been again deposited, there will be little difference in this respect from a natural healthy pelvis; but if the patient has died with the disease in full activity, its weight will be greatly diminished, amounting sometimes only to a few ounces. Mollities ossium, to a slight extent, we believe, is not very uncommon, although cases of extreme deformity from this cause are of rare occurrence. Mr. Barlow states, that "eight cases of this species of progressive deformity have fallen under my notice, in one of which the projection of the last lumbar vertebra at its union with the angle of the sacrum was so much bent forwards into the cavity of the pelvis, that on the introduction of the fore-finger up the vagina, a protuberance was presented to the touch very much resembling the head of the foetus pretty far advanced into its cavity. On carrying the finger a little anteriorly past the projection, I could with difficulty ascertain the head of the child: but on moving it around, the distortion appeared so great, that the whole circumference did not exceed that of a half-crown piece. This occurrence was on the 29th of April, 1792, at which time I delivered the woman with the crotchet, and the bones of the pelvis receded considerably to the impulsive efforts during the extraction of the head of the foetus; yet, notwithstanding, the flexibility of the bones of the pelvis, and the debilitated state of her constitution, she recovered speedily and without interruption." On the 2d February, 1794, being in the neighbourhood, and learning that she was still alive, Mr. Barlow visited her and requested an examination. "I found her unable to walk without assistance, and as she sat, her breast and knees were almost in contact with each other. The superior aperture was nearly in the same state as when I delivered her with the crotchet, but the outlet appeared more contracted, the rami of the pubes overreached, leaving a small opening under the symphysis barely sufficient to admit the finger to pass into the vagina by that passage, and another aperture below, but rather larger, and parallel with the junction of the tuberosities of the ossa ischii. From what I learned afterwards respecting this decrepit female, she survived this period about two years, at which time she was become still more distorted in the spine; and after her death it was with difficulty she could be put into her coffin; this woman bore nine children, and died in the thirty-ninth year of her age." (Barlow's _Essays_, p. 329.) Mollities ossium may be feared when, in addition to the general breaking up of the health and strength, the patient suffers from arthritic pains and swellings of the limbs, the urine is generally loaded with lithic secretion: and most of all, where distinct shortening and gradual distortion of the skeleton is taking place. Where the deformity has been the result of rickets in early life, a little careful observation of the patient's external appearance will quickly lead the experienced eye to suspect the nature of the case. _Symptoms of deformed pelvis._ Among the external appearances which would lead us to suspect a deformed pelvis, are "the lower jaw projecting beyond the upper; the chin very prominent; the teeth grooved transversely; unhealthy appearance; pale ashy colour of the face; diminutive statue; unsteady gait; when the woman walks the chest is held back, the abdomen projects, and the arms hang behind; there is deformity of the spine and breast, one hip higher than the other, the joints of the hands and feet are remarkably thick; curvature of the extremities, especially the inferior, even without distortion of the spine is a very important sign; wherever the lower extremities are curved, the pelvis is mostly deformed: it is well to ascertain also if, when a child, it was a long time before she could walk alone; whether she had any fall on the sacrum; whether as a girl she was made to carry heavy weights, or to work in manufactories." (Naegelé's _Lehrbuch_. § 444.) _Funnel-shaped pelvis._ Besides the above-mentioned species of pelvic deformity, others are occasionally met with, the origin of which is but little understood. The funnel-shaped pelvis is of this character, where the brim is perfectly well formed, but where it gradually contracts towards the inferior aperture. There are no evidences of its having been produced by any disease; nor in fact can we assign any satisfactory cause for this peculiar configuration: it appears to have been a congenital formation. [Illustration] _Obliquely distorted pelvis._ A still more remarkable species of pelvic deformity is the _pelvis obliqué ovata_, which, of late years, has been pointed out by Professor Naegelé. In this case the pelvis appears awry, the symphysis pubis being pushed over to one side; and the sacrum to the other; one side of the pelvis is more or less flattened, the other bulges out, so that one oblique diameter is shorter, the other longer than natural; and this applies not only to the brim, but to the cavity and outlet of the pelvis. In most cases the sacro-iliac symphysis on that side which is flattened, and to which the sacrum is inclined, is completely anchylosed, not a trace of the division between the ilium and sacrum to be detected, the two bones being completely united into one. In many, the sacrum on this side is smaller than on the other, as if a portion of it had been removed by absorption during the process of anchylosis, or at least not properly developed. When we consider the form of the pelvis, and the appearances which the sacro-iliac symphysis and the sacrum present, we are almost led to conclude that ulcerative absorption must at one time have existed between the sacrum and ilium at this point, probably at an earlier period, by which means more or less bone had been destroyed before the termination of the disease in anchylosis; indeed, we can to a certain extent imitate this peculiar species of pelvic deformity by sawing off the surfaces of the sacrum and ilium which had formed the symphysis, and then putting the bones together again. Still, however, in the various cases which have been collected by Professor Naegelé, no proofs could be obtained of disease having existed in the pelvis during early life. "In none of the cases, the particulars of which have come to my knowledge, has there been any trace of rachitis; nor have any of the symptoms, appearances, and morbid changes been observed which characterize mollities ossium coming on after puberty. None of these cases have been traced to the effects of external violence, as falls, blows, &c.; nor has there been any complaint of pain in the region of the pelvis, inferior extremities, &c." (_Das Schräg Verengte Becken_, p. 12.) "With respect to the strength, colour, structure, &c. of the bones of this species of deformed pelvis, no difference could be observed between them and the bones of young and perfectly healthy subjects; not a trace either in form or other respects could be detected of those changes which usually result from rachitis or mollities ossium; and but for this distortion and some other slight irregularities, which required close inspection to detect, these pelves would have been looked upon as well-shaped, and of sufficient capacity." (Naegelé, _op. cit._ p. 11.) In some specimens no trace of anchylosis at the sacro-iliac symphysis has been observed; but whether this was the case throughout the union of the two bones we cannot say. Professor Naegelé is inclined to look upon them as modifications of the _pelvis obliqué ovata_, and certainly in the majority of known cases anchylosis has been found present. It is scarcely necessary to do more than enumerate other varieties in the form of the pelvis, which are occasionally met with: it is sometimes round, the transverse and antero-posterior diameters being of the same length; in other cases it possesses many of the characters which distinguish the male pelvis, being more or less triangular, deep, and with a contracted angular pubic arch. _Exostosis._ Lastly, the pelvis may be perfectly well formed, but the passage through it more or less interrupted by the exostosis: this is, perhaps, the rarest species of dystocia pelvica. It may arise from wounds of the periosteum, from fracture of the bones, callus, &c. and may vary in size from a small protuberance to a large mass, which completely fills up the pelvis. _Diagnosis of contracted pelvis._ The difficulty of detecting an abnormal configuration of the pelvis, will depend, in great measure, upon its extent: where it is but slight, it may easily be passed over unobserved by a young practitioner, although it may, nevertheless, be quite sufficient to render labour both difficult and dangerous. In the ordinary form of contracted pelvis, where the antero-posterior diameter is shorter than natural, the being able to reach the projecting promontory of the sacrum with the finger is of itself a sufficient evidence: but the converse of this is not true, for we frequently meet with cases of contracted pelvis, without being able to reach the promontory. The numerous instruments which have been invented at different times for measuring the pelvis are of such doubtful accuracy, as to be nearly useless; the experienced finger is the best pelvimeter; and the power of correctly estimating the dimensions of the pelvis during examination, can only be acquired by constant practice, based on a thorough knowledge of them in the healthy pelvis. The manner in which labour commences is frequently sufficient to make us suspect the presence of a contracted pelvis. Besides, the general appearance of the patient, we frequently find that the uterine contractions are very irregular; that they have but little effect in dilating the os uteri; the head does not descend against it, but remains high up; it shows no disposition to enter the pelvic cavity, and rests upon the symphysis pubis, against which it presses very forcibly, being pushed forwards by the promontory of the sacrum. It is probably from this circumstance that the os uteri, more especially its anterior lip, shows so little disposition to dilate in these cases, for the lower portion of the uterus being jammed between the head and symphysis pubis in front, and promontory behind, the contractions of the longitudinal fibres can have little effect upon the os uteri. Hence we find, that in cases of diminished antero-posterior diameter requiring perforation, and where the os uteri in spite of violent pains, bleeding, &c. has refused to dilate beyond a certain point, on lessening the head, and thus removing its pressure from the symphysis pubis, it has quickly attained its full degree of dilatation. Where the pains have been active, and a portion of the head has forced itself through the brim, and now projects to a certain extent into the cavity of the pelvis, it will be still more difficult to reach the promontory before delivery; and if, as is frequently the case, the sacrum is bent strongly backwards, so as to render the cavity and outlet very spacious, the real cause of impediment to the progress of labour may be entirely overlooked. It is here that the position of the head upon the symphysis pubis will prove a valuable means of diagnosis. The straightness of the sacrum will also be a guide in other cases. In that form of the pelvis which has been called the funnel-shaped pelvis, and where the brim and upper portion of the cavity are of the natural dimensions, but where it gradually diminishes towards the outlet, the appearances are frequently very deceptive, the head advances without impediment, and descends as far as the inferior aperture, with every promise of speedy delivery; but here its progress is arrested, and even in the very last stage may require perforation. It occasionally happens, also, where the deformity is very considerable, that the promonotory projects to such an extent as to be even capable of being mistaken for the head itself; and cases have actually occurred where, under this impression, the bone has been perforated instead of the child's head. So gross an error as this may easily be avoided by care in making the examination; by ascertaining that the projecting mass is immoveable; that the patient is sensible to the pressure of our finger; and that the promontory can be traced to be continuous with the adjacent parts of the pelvis. The effects which may result from labour protracted by pelvic deformity are very various, both as regards the mother and her child. The most common form of injury which is produced by this cause, is the contusion and consequent inflammation and sloughing of the soft tissues which line the pelvis from the long continued pressure of the head against the symphysis pubis in front, and against the promontory of the sacrum behind. Not only may sloughing of the vagina and lower part of the uterus be the result, but the mischief may extend through the posterior wall of the bladder, and thus render the patient incapable of retaining her urine, and an object of great, and, generally speaking, incurable suffering. The danger from rupture of the uterus will chiefly depend on the degree of pressure with which the uterine contractions force the head against the brim. Where the pains are violent, and yet insufficient to overcome the obstacle which the contracted pelvis presents to the advance of the head, there is not safety for a minute, and perforation must be immediately had recourse to. Where the edge of the promontory is very projecting and sharp, the structure of the uterus may be seriously injured by the pressure and contusion. In some cases it has evidently been the cause of ruptures, the fibres having given way first at this spot. The constant severe pressure upon the head will be not less injurious to the child's life; it must inevitably produce a considerable impediment to the cerebral circulation; and where the liquor amnii has escaped, the pressure of the uterus upon the body of the child will scarcely be less prejudicial. The cranial bones frequently become remarkably distorted, so that after a difficult labour a deep furrow is found on that part of the head which corresponded to the projecting promontory. _Fracture of the parietal bone_ may even be produced, a fact of which practitioners, till lately, have not been sufficiently aware; and cases have occurred where children have been born dead, with the head greatly distorted, and one of the bones fractured, from which circumstances the mothers have been suspected of infanticide. Dr. Michaelis, of Kiel, has lately reported an interesting case of this kind, where the fracture seems to have resulted from the great immobility of the coccyx. The head was much disfigured, and on examining it the frontal bones were uninjured, but so flattened that the frontal and parietal portions of the sagittal suture lay nearly in the same place; the fontanelle and anterior two-thirds of the sagittal suture projected high up, and the sagittal borders of the parietal bones were firm and well formed. In the posterior third of the sagittal suture, where the parietal bones were firm and well formed, and the suture only two lines in width, were seen small livid portions of the longitudinal sinus forced between the bones. The occipital bone was flattened and forced deep under the parietal bones, but not otherwise injured. The right parietal bone, which during birth had been turned towards the promontory of the sacrum, was covered anteriorly and superiorly with effused blood, and on removing the periosteum, was found fractured in five places. (_Neue Zeitschrift für Geburtskunde_, vol. iv. part 3. 1836.[124]) Where the action of the uterus is not very violent, and the bones yielding, the head gradually adapts itself to the form of the passage without destroying the foetus; it elongates itself more and more until it is enabled to pass, so that after a tedious labour of this sort, we sometimes find the configuration of the head remarkably altered. Baudelocque, has mentioned a case recorded by Solayres de Renhac, where the head was so elongated that the long diameter measured eight inches all but two lines, the transverse being only two inches and five or six lines. _Treatment._ Where the pelvic deformity is very considerable, there can be little difficulty in deciding upon the line of conduct to be adopted. It is in those cases where the obstruction is but slight that the indications for treatment are less distinctly marked: nor must we be satisfied with merely ascertaining the relative proportions of the head and pelvis; for the hardness or softness of the cranial bones, the disposition which they manifest to yield to the pressure of the uterus and surrounding parts, the state of the cranial integuments, and though last not least, of the soft tissues which line the pelvis, must all be carefully ascertained before a correct opinion as to the precise mode of treatment can be formed. Nor, if the woman has already had children, can we altogether be guided by the history of her previous labours; for where the above-mentioned circumstances have been favourable, a slight diminution of the pelvis will scarcely be attended with any perceptible delay or increase of difficulty beyond the natural degree; whereas, if the head happens this time to be a little larger, its bones more ossified, the fontanelles smaller, the scalp and soft linings of the pelvis more swollen, &c. a serious obstruction to the progress of labour will be the result. Thus it is that we not unfrequently meet with patients in whom the first labour has been tolerably easy, the second has been attended with much difficulty and required the forceps, in the third, the difficulty was so much increased as to require perforation, and the fourth where the labour was, like the first, perfectly easy and natural. It is impossible for the head to remain long in the pelvis (except under unusually favourable circumstances) without more or less obstruction to the circulation, both in the scalp itself and in the surrounding soft tissues. The necessary consequence of this is swelling, by which the head increases while the passage diminishes in size; and this must still be more remarkably the case where the pelvis is at all contracted. It is in these cases that we frequently see such relief produced by venesection; and it is also as a topical depletion to the overloaded vessels, that we can explain why a free secretion of mucus is so favourable a symptom.[125] _Prognosis._ Where the pains are moderate and equable, the os uteri nearly or quite dilated, the head not large, its bones yielding and overlapping at the sutures; where the greater portion of it has evidently passed through the brim, and, although slowly, advances perceptibly with the pains; where the passages are cool and moist, the pulse good, and the patient not exhausted, we may safely wait awhile and trust to the efforts of nature. On the other hand, where the pains are violent, the os uteri thin and undilatable, the head forced forwards upon the symphysis pubis by the projecting serum, if the greater part of its bulk has not yet passed the brim, if the soft parts are much swelled, the vagina hot and dry, the pulse has become irritable, the abdomen tender, the patient exhausted and much depressed both in mind and body, the powers of nature are evidently incompetent to the struggle, and require the assistance of art. Such cases seldom permit the application of the forceps; the head is already pressing too firmly against the brim, and its greatest bulk having not yet passed, a still farther increase of pressure will be required to effect this object, which therefore cannot be attained without producing serious mischief. Where, however, the head has fairly engaged in the cavity of the pelvis, and the case is rather becoming one of deficient power, the forceps will be justifiable, and generally quite sufficient to effect the delivery safely. The young practitioner must be cautious not to mistake an increase in the swelling of the scalp for an actual advance of the head itself--an error which may very easily be committed if he merely touches the middle of the presenting portion: he must carefully examine the circumference of the presenting part, where the head is pressing against the pelvis, and where there is little or no swelling, and he will frequently find to his disappointment, that although the cranial swelling may have even nearly approached the perineum since his last examination, the head itself has remained unmoved. Where the forceps has been determined upon, we should endeavour to render its action as favourable as possible, viz. by bleeding, by the warm bath, and by evacuating the bladder and rectum before proceeding to the operation: we thus improve the condition of the soft parts, and diminish the chances of its acting injuriously. From what has now been stated respecting the various circumstances which may tend to aggravate or alleviate the existing degree of pelvic deformity, it will be seen how incorrect and unpractical must be the attempt to classify the means of treatment merely according to the dimensions of the pelvis. To assert that within certain limits of pelvic contraction the child can be delivered by the natural powers, and that beyond these limits the forceps must be used; and that where it proceeds to a certain extent farther, it can only be delivered by perforation, &c. is evidently objectionable: for there are no two cases alike, even supposing that the degree of pelvic contraction is exactly similar; hence, on the one hand, we might (under such fallacious guidance) be induced to trust to the natural powers when they are wholly incompetent to the task, and on the other, to have recourse to art when the real condition of the case justified no such interference.[126] With regard to the diagnosis and treatment in the case of obliquely distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to enable us to give any decided rules: the immobility of the head, although the antero-posterior diameter appears of its full length, the shortness of one oblique diameter, and consequent undue pressure upon the head in this direction, and the unusual length of the other, are the characteristics which we have observed in the only case of the kind which has come under our notice during life. In all the cases of labour rendered difficult by this condition of the pelvis, which have been collected by Professor Naegelé, the perforation has been strongly indicated; and where the forceps has been used, it has either failed, as with us, or if the delivery has been effected by this means, it has been attended with fatal consequences. In _exostosis_ of the pelvis we must be guided by our knowledge of the healthy pelvis, and by our carefully ascertaining the form and size of the bony growth, and in what degree it is likely to impede the passage of the child. As in cases of simple projection of the promontory, the head may be capable of passing, but in doing so becomes more or less distorted: thus Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the pelvis, the left frontal bone was so greatly sunk in, as to make the eye protrude. Professor Otto, of Breslau, mentions a woman who had pelvic exostosis being the mother of four children, in each of whom a small portion of the cranium was depressed and not ossified. An interesting case has been described by Dr. Kyll, of Cologne, where the patient was the mother of seven children; her former labours had been perfectly natural, except that in the last there had been preternatural adhesion of the placenta, which had required to be removed by the hand; in six days after she was seized with feverish symptoms and violent pain at the spot where the placenta had been attached. The attack yielded to proper treatment, but she continued feverish at night with perspirations, frequently deranged bowels, difficulty in passing water, and severe pain in the abdomen, especially when she tried to stand on the right leg. An abscess formed in the right groin, which was opened and discharged a large quantity of pus, from which her recovery was very slow, and in three years afterwards she became again pregnant. When labour came on, no presenting part could be reached; after a long time the feet came down one after the other, but the nates would not advance. Dr. Kyll found the child resting with the hips on the brim of the pelvis, and completely wedged fast by a hard immoveable tumour as large as a hen's egg, springing from the upper part of the right sacro-iliac symphysis, and apparently having been a result of the pelvic abscess; the child was delivered with great difficulty by embryotomy. [Illustration: Exostosis of the pelvis.] Perhaps the most remarkable case of pelvic exostosis is that which has been described by Dr. Haber of Carlsruhe, and where also the cause was ascertained to have arisen from a violent fall on the ice when carrying a heavy load upon the head; on coming to herself the woman found that she was unable to move, and in this state was conveyed home; she recovered to all appearances in a few weeks, married, and soon became pregnant. When labour came on it was found impossible to deliver her, from the pelvis being entirely filled with a huge exostosis: the Cæsarean section was performed, but she died, and on examination after death an immense mass of bony growth was found springing from the sacrum, which had been apparently fractured, not only filling up the whole cavity of the pelvis, but arising to a considerable extent above the brim. In those cases of funnel-shaped pelvis which we have had the opportunity of observing, perforation has been ultimately required, although the head had passed easily through the brim and entered the cavity; in one of these we have subsequently used the artificial premature labour with success. We have already stated the doubtful utility of arranging cases of deformed pelvis according to their degree of contraction, and of classifying the different modes of treatment by such a scale; still, however, there must be certain limits beyond which it will be impossible to make the child pass, even when diminished by embryotomy. To draw the precise line of demarcation, however, will be nearly if not quite impossible; and, as in cases of slighter deformity, we must take many other circumstances into consideration which we have already mentioned. An inch and a half from pubes to sacrum has been mentioned by many as the extreme degree of contraction through which a full grown child can be delivered by embryulcia; generally, however, in these cases of unusually deformed pelvis, there is much more space on each of the sacrum; and on this, in great measure, will depend the possibility of effecting the delivery. The celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and where he succeeded in delivering the child, although the antero-posterior diameter "could not exceed three-quarters of an inch," has been looked upon as being of doubtful accuracy, and that Dr. Osborn had unintentionally deceived himself. When, however, we learn that on the right side of the sacrum the antero-posterior diameter was an inch and three-quarters, the incredible nature of the case diminishes considerably, the more as the patient was examined by Dr. Denman and others who fully coincided with Dr. Osborn's statements. To assert that in this case the antero-posterior diameter was only three-quarters of an inch, as many have done, is evidently incorrect, and tends to throw doubt upon it: the case was evidently the closest possible approach to the limits requiring the Cæsarean operation; its success was mainly attributable to the gradual manner in which it was performed; the child had become completely soft and flaccid from putrefaction, and was thus more capable of being moulded to the contracted passage. CHAPTER V. FIRST SPECIES OF DYSTOCIA. _Obstructed Labour from a Faulty Condition of the soft Passages._ _Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--Edges of the os uteri adherent.--Cicatrices and collosities.--Agglutination of the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in the vagina.--Hymen.--Fibrous bands.--Perineum.--Varicose and oedematous swellings of the labia and nymphæ.--Tumours.--Distended or prolapsed bladder.--Stone in the bladder._ In speaking of the uterus itself as a cause of this species of dystocia, we only mention it here as one of the soft passages, not as the organ by the contractions of which the child is expelled; we merely refer to those faulty conditions of the uterus which produce an impediment to the child's progress, not to those which interfere with the natural condition of its expelling powers, as this will be considered under the next division of dystocia. We have already stated our disbelief that an oblique position of the uterus can have any influence in producing malposition of the child. With the exception of extreme anterior obliquity, or pendulous belly, we equally doubt that it can have any effect in retarding the labour when the child presents naturally. The highest authorities in midwifery during the last hundred years unite in asserting that this celebrated opinion of Deventer, was a misconception. _Pendulous abdomen._ Where, from great relaxation of the anterior abdominal wall, (a frequent result of repeated child-bearing,) the fundus is inclined so forwards as almost to hang over the symphysis pubis, the child's head does not readily enter the brim of the pelvis, nor can the uterine contractions act so favourably in dilating the mouth of the womb; and in this manner the first part of labour may be considerably retarded. Pendulous abdomen to this great extent is not very common; and in ordinary cases the horizontal posture, especially upon the back, is quite sufficient to allow the head to engage in the pelvis. "We have found more than once," says Dr. Dewees, "in cases of extreme anterior obliquity, that it is not sufficient for the restoration of the fundus that the woman be placed simply upon the back; but we are also obliged to lift up and support by a properly adjusted towel or napkin, the pendulous belly until the head shall occupy the inferior strait. To illustrate this, we will relate one of a number of similar cases in which this plan was successfully employed. Mrs. O., pregnant with her seventh child, was much afflicted after the seventh month with pain and the other inconveniences which almost always accompany this hanging condition of the uterus; was taken with labour pains in the morning of the 10th of October, 1820. We were sent for about noon. The pains were frequent and distressing, and, upon examination per vaginam, the mouth of the uterus was found near the projection of the sacrum, dilated to about the size of a quarter dollar, but pliant and soft. During the pain, the membranes were found tense within the os uteri, but did not protrude beyond it. As this was the first time we had attended this patient, and from the history she gave of her former labours, in which she represented her abdomen being in all equally pendulous, with the exception of the first, we waited several hours (she being placed upon her side) for the accomplishment of the labour. During the whole of this period the head did not advance a single line; nor could it, as the direction of the parturient efforts carried it against the projection of the sacrum. We had several times taken occasion to recommend her being placed upon her back, but to which she constantly objected, until we urged its being absolutely necessary. She at length reluctantly consented to the change of position; when upon her back it was found that it did not advance the os uteri sufficiently towards the centre of the superior strait. The abdomen was therefore raised, and a long towel placed against it, and kept in the position we had carried it by the hands, by its extremities being firmly held by two assistants; at the same time we introduced a finger within the edge of the os uteri, and drew it towards the symphysis pubis, and then waited for the effects of a pain. One soon showed itself, and with such decided efficacy, as to push the head completely into the inferior strait, and three more delivered it." (_Compendious System of Midwifery_, § 224.) This peculiar displacement of the uterus, which has been called by some anteversion of the gravid womb, has occasionally given rise to the suspicion that there was no os uteri, from its being tilted upwards and backwards towards the promontory of the sacrum: it has been said, in some cases, to have even contracted adhesions with the posterior wall of the vagina, from the firmness with which it was pressed against it, and thus tended still farther to increase the deception. "Within our knowledge," says Dr. Dewees in the paragraph preceding the one just quoted, "this case has been mistaken for an occlusion of the os uteri, and where upon consultation it was determined that the uterus should be cut to make an artificial opening for the foetus to pass through. They thought themselves justified in this opinion, first, by no os uteri being discoverable by the most diligent search for it; and, secondly, by the head being about to engage under the arch of the pubes covered by the womb. Accordingly, the labia were separated, and the uterine tumour brought into view. An incision was now made by a scalpel through the whole length of the exposed tumour down to the head of the child, the liquor amnii was evacuated, and in due course of time the artificial opening was dilated sufficiently to give passage to the child. The woman recovered, and, to the disgrace of the accoucheurs who attended her, was delivered per vias naturales of several children afterwards, a damning proof that the operation was most wantonly performed." Where, in addition to the anteversion, strong adhesions have taken place between the os uteri and posterior wall of the vagina, no trace of os uteri will be felt, and the operation above-mentioned does become sometimes necessary. _Rigidity of the os uteri._ The chief way in which the uterus can obstruct the passage of the child, is, by an undilatable state of its mouth: this may arise from a variety of causes, which may be chiefly brought under the two heads of functional and mechanical. Under the first head comes rigidity of the os uteri, either from a spasmodic contraction of its circular fibres, or from irregularity or deficiency in the contractions of the longitudinal fibres of the whole organ. In a slight degree this is frequently met with, especially in first labours, where the patient is young, delicate, and irritable, and where, in all probability, there is some source of irritation in the primæ viæ which tends to disturb and divert the proper and healthy action of the uterus. We see it also in robust plethoric primiparæ; the os uteri dilates to a certain degree, perhaps an inch in diameter, and remains tense and firm, with its edge thin; the contractions of the uterus produce much suffering, and to all appearances are very violent; but they are chiefly in front, and produce little or no effect upon its mouth; the vagina is hot and dry, the patient becomes exhausted with fruitless pains, and fever or inflammation would quickly follow, if nothing be done to relieve this state. As this subject, however, belongs rather to the next species of dystocia, viz. that arising from a faulty condition of the expelling powers, we shall delay the consideration of the treatment. _Belladonna._ It has been recommended, and not very judiciously, to apply belladonna to the os uteri in cases of great rigidity: it was repeatedly tried by the celebrated Chaussier in the Maternité, at Paris, and, according to his observations, it produced a considerable effect upon it. "The knowledge of the extraordinary powers which this drug possesses in causing dilatation of the iris, led to its employment for the object of enlarging the aperture of the uterus; but there is certainly no similarity in the structure and office of the two organs, and no analogy can be drawn between their functions. It is not likely that this means will produce the relaxation we require; and if no good results from its use, it must be injurious; not in consequence of the poisonous quality resident in the drug itself, but in the friction which is necessary for its efficient application. The mucus which naturally lubricates the part must be wiped away, and this irritation must predispose the tender organ to take upon itself inflammatory action." (_Dr. F. H. Ramsbotham's Lectures, in Med. Gaz._ May 3, 1834.) For our own part we must confess, that, although we have seen this application tried repeatedly, it has never produced the desired effects, but has invariably brought on very troublesome and distressing symptoms, such as sickness, faintness, headach, vertigo, &c. There is a condition of the os uteri which is occasionally met with, and which presents a degree of rigidity which we have never seen except where there have been adhesions and callous cicatrices from former injuries. It has nothing of the thin edge put strongly on the stretch during the pains; but it is thick and firm, presenting nothing of the elastic cushiony softness of the os uteri in a favourable state for dilatation; it dilates to about an inch across, tolerably regularly, and without much apparent difficulty, but no efforts of the uterus can dilate it farther. We have already alluded to two extreme cases of this when speaking of ruptured uterus, and where in each instance the os uteri entirely separated from the uterus and came away. Whether there is something peculiar in the structure of the part which renders it thus undilatable, or whether it required even still more powerful measures than those employed, is not very easy to decide. _Edges of the os uteri adherent._--_Cicatrices_, &c. A serious impediment to the passage of the child may be produced by adhesions of the sides of the os uteri to each other; by hard callous cicatrices resulting from ulcerations, lacerations, &c. in former labours; by abnormal bands, or bridles, as they have been called; and by tumours and other morbid growths. Where the structure of the os uteri has been much injured by previous injuries of this character, the resistance will probably be so great as to require artificial dilatation with the knife. Generally speaking, however, the whole circle of the uterine opening is not involved, portions still remaining of natural structure, and, therefore, capable of dilatation. On examination, it feels irregular both in shape and hardness; a part being soft, cushiony, yielding, and forming the segment of a well-defined circle, the rest of it uneven, knobby, and hard, being evidently puckered up by cicatrisation. In many cases, these callous contractions give way more or less when the head begins to press powerfully against them; but even where this is not the case, the healthy portion of the os uteri is so dilatable as to yield sufficiently. It would be difficult to estimate how far an os uteri in this state, with perhaps, not more than half, or even a third, of its circle in a healthy condition is capable of dilating. But from cases which have come under our own observation, and others which have been recorded by authors in whom we place the greatest reliance, we are quite confident that with proper treatment a sufficient degree of dilatation can be effected without resorting to artificial means. Bleeding to fainting, the warm bath, laxatives, and enemata, will assist greatly in promoting our object. Where, however, the contracted portion shows no disposition to yield to this treatment, or to the pressure of powerful pains, but forms a hard resisting bridle or band, which effectually impedes the farther advance of the head, it must be divided by the knife in order to prevent dangerous laceration of the part on the one hand, or protraction of labour on the other. The mode of doing this will be described when these conditions as effecting the vagina are considered. Artificial dilatation of the os uteri by incision has been practised very rarely, the chief of these operations having had reference to the vagina. F. Ould considered that mere contraction of the os uteri from former lacerations did not require this operation; but that where it was in a state of schirrus, there would be "no chance for saving either mother or child but by making an incision through the affected part." We have quoted, on a former occasion, a case of cicatrised os uteri recorded by Moscati, and where, in consequence of injury in a former labour, the opening was nearly closed; fearing the laceration which had occurred in a similar case under his father's care, in consequence of making merely one incision, he made a number of small incisions round the whole of the orifice until a sufficient dilatation was produced. _Agglutination of the os uteri._ Another condition of the os uteri which may produce very considerable impediment to the passage of the child, is that which has been called _agglutination_, where by some adhesive process, apparently that of inflammation, the lips of the opening adhere and completely close it. These species of imperforate os uteri may occur in primiparæ as well as in those who have borne children: the agglutination of its edges takes place during pregnancy, probably shortly after conception. Upon examination we find no traces of hardness, rigidity, or any other morbid condition, either in the os uteri itself, or the parts immediately surrounding it; the os uteri is closed by a superficial cohesion of its edges, and which in some cases seem to adhere by means of an interstitial fibrous substance; this when of a firmer consistence forms a species of false membrane, which in some cases is capable of resisting the most powerful uterine contractions, and in others it appears to cover the os uteri so completely as to conceal it most effectually, and give rise to the erroneous conclusion that the os uteri is altogether wanting. Baudelocque describes this condition (_Op. cit._ § 1961;) but from the brief mention which he makes of it, as also from the treatment recommended, it is plain that he had no very distinct notions about it, for he advises that "in all cases the orifice must be restored to its original state, and be opened with a cutting instrument as soon as the labour shall be certainly begun." In by far the majority of cases which have been recorded, the pains have after a time been sufficient to dilate the os uteri. Dr. Campbell has described two of these cases, where no os uteri could be traced for some time after the commencement of labour: both were first pregnancies: in the former, uterine action continued about twelve hours before the os uteri could be distinguished, when it felt like a minute cicatrix; the other patient had regular pains for two nights and a day before the os uteri could be perceived, and she suffered so much as to require three persons to keep her in bed; both these patients were largely bled, gave birth to living children, and had a good recovery. We may suspect that the protraction of labour arises from agglutinated os uteri, when at an early period of it we can discover no vestige of the opening in the globular mass formed by the inferior segment of the uterus, which is forced down deeply into the pelvis, or at any rate, where we can only detect a small fold or fossa, or merely a concavity, at the bottom of which, is a slight indentation, and which is usually a considerable distance from the median line of the pelvis. The pains come on regularly and powerfully; the lower segment of the uterus is pushed deeper into the cavity of the pelvis, even to its outlet, and becomes so tense as to threaten rupture; at the same time it becomes so thin, that a practitioner who sees such a case for the first time would be induced to suppose the head was presenting merely covered by the membranes. After a time, by the increasing severity of the pains, the os uteri at length opens, or it becomes necessary that this should be effected by art: when once this is attained, the os uteri goes on to dilate, and the labour proceeds naturally, unless the patient is too much exhausted by the severity of her labour. Although the obstacle in some cases is capable of resisting the most powerful efforts of the uterus, a moderate degree of pressure against it whilst in a state of strong distention, either by the tip of the finger, or a female catheter, is quite sufficient to overcome it; little or no pain is produced, and the appearance of a slight discharge of blood will show that the structure has given way. Two interesting cases of this kind have been described by the late W. J. Schmitt, of Vienna, under the title of two cases of closed os uteri which had resisted the efforts of labour, and where it was easily dilated by means of the finger.[127] _Contracted vagina._ The vagina may be naturally very small, or unusually rigid and unyielding: in the first case serious obstruction to the progress of labour is rarely produced, the expelling powers being generally sufficient ultimately to effect the necessary degree of dilatation; the proper precautions must be taken to avoid every species of irritation and excitement of the circulation; the bowels must be duly evacuated; the circulation controlled either by sedatives, or, if necessary, bleeding, and where it is at hand, a warm bath; if this latter cannot be easily procured, a common hip bath, or sitting over the steam of warm water will be of great service; the great object will be to ensure a soft and cool state of the passage with a plentiful supply of that mucous secretion which is so essential to the favourable dilatation of the soft passages. Nauseating remedies, and even tobacco injections, have been tried to a considerable extent for the purpose of relaxing the mouth of the uterus; but they produce little or no good effects, and cause much suffering to the patient. In Dr. Dewees' second case of obstructed labour from the above causes, a sufficient trial of this remedy was used to satisfy all doubts as to its effects. "It produced great sickness, vomiting, and fainting, but the desired relaxation did not take place: we waited some time longer and with no better success. In the course of an hour, or an hour and a half, the more distressing effects of the infusion wore off; and resolving to give the remedy every chance in our power, we prevailed on our patient with some difficulty to consent to another trial of it: its effects were the same as before,--great distress without the smallest benefit, the soft parts remaining as rigid as before its exhibition." Bleeding was now proposed; the patient became faint after losing ten ounces, and the most complete relaxation followed: the forceps were applied, and a living child delivered. _Rigidity from age._ In women pregnant for the first time at an advanced period of life, the vagina and os externum are said to oppose considerable resistance to the passage of the child from their rigid condition, the parts having lost the suppleness and elasticity of youth; the vessels also convey less blood to the mucous membrane and adjacent tissues: hence the secretion of mucus is more sparing; the cellular tissue is more condensed and firm; still nevertheless, although it is constantly mentioned by authors as a cause of this species of dystocia, we cannot help declaring that it exists to a much less degree than has been generally supposed, and that primiparæ at a very early age are much more liable to have tedious and difficult labours than those at an advanced age. Still, however, the circumstance is well worthy of notice; and in such cases we may produce much relief by the warm bath, or hip bath, by sitting over the steam of hot water, by warm water enemata, and great attention to the state of the intestinal canal and of the circulation. Mucilaginous or oleaginous injections into the vagina have been recommended; but we have no experience of their effects: we have frequently used lard, &c. to the edges of the os externum when the head was beginning to distend it, and we think with relief; at any rate it produces a feeling of comfort to the patient, being soft and cooling. _Cicatrices in the vagina._ The most serious impediments to the progress of labour connected with the vagina are the contractions of this canal from callous cicatrices, the results of sloughing and other injuries in former labours. The vagina may be contracted throughout its whole length, its parietes hard, gristly, and uneven, and so small as not to admit even the tip of the little finger; the course of the canal from the irregularity of the contractions and adhesions is frequently much distorted; in other cases it is obstructed in different places by bands or septa, which have been produced by similar causes. Where the condition of the vagina has been ascertained before labour, much may be done to ameliorate the condition of the parts, not only by the treatment already mentioned for rigidity of the vagina under other circumstances, but also by the judicious application of tents, bougies, and other means for dilating the passage. A case of this kind came under our notice some years ago; the patient had been married many years without being pregnant, and was considerably beyond the age of forty. The deranged health and enlargement of the abdomen which took place excited no suspicions of pregnancy either in her mind or that of her medical attendant: the case was suspected to be ovarian dropsy, and a variety of medicines under this supposition were administered, both internally and externally: the commencement of actual labour appears to have been equally mistaken; nor was it until labour had advanced considerably that the real nature of the case was discovered; from its length and severity, violent inflammation and sloughing of the vagina was the result, the canal became much contracted, and was rendered still farther impervious by the formation of strong bands or septa which were stretched across it, and which effectually prevented the os uteri from being reached; sponge tents, and oval gum elastic pessaries of different sizes were introduced, and by degrees such a state of dilatation was produced as not only permitted the os uteri to be reached, but restored the vagina in great measure to its natural size. The action of labour forcing the head of the child against these contractions and adhesions is frequently sufficient ultimately, to effect the necessary degree of dilatation; where, however, this is not the case, they require to be divided by the knife. The proper moment for doing this is during a pain, when the parts are put strongly on the stretch: we can now feel exactly where there is the greatest resistance, and where an incision will produce the most effect. In this state also the incision can be effected with most ease, for the stricture being firmly distended, the knife will more readily divide it than where it is relaxed; the patient also at this moment is not sensible to the cutting of the knife. The lower part of the blade well armed with lint or tow should be cautiously introduced along the side of the finger during an interval of the pains: in this way the necessary number of incisions may be made: this is usually followed by a good deal of bleeding, which tends still farther to relax the parts; and when the head has advanced low enough, a cautious attempt may be made with the forceps to deliver it. In recommending dilatation by means of the knife, it must be distinctly understood, that a sufficient time should be allowed in order to see how much can be effected by the uterine efforts, for in many of these cases the stricture has at length yielded after severe and protracted suffering.[128] In cases of this kind, also, the effects of bleeding are by no means inconsiderable, and must not be neglected. The _unruptured hymen_ has been said to be capable of impeding the progress of the head, but this can only be where the membrane is of unnatural strength and thickness. It has more than once occurred to us at the commencement of labour, to find the hymen uninjured; but it has broken down under the finger, even during examination, and we are convinced would have produced no obstacle whatever to the child. Where its structure is abnormal, and the advance of the labour is evidently retarded by it, division is the simplest and easiest remedy. Bands of firm fibrous or almost ligamentous tissue are sometimes found stretched across the vagina or os externum. We described a remarkable case of this sort in the _Medical Gazette_, Sep. 26, 1835, where it extended from the symphysis pubis backwards to the perineum; it had resisted the pressure of the child's head so powerfully as to produce a deep indentation along the cranial bones; it was divided by a bistouri, and the head was immediately expelled. The _perineum_ can rarely, if ever, prove a serious hindrance to the labour in primiparæ so long as its structure is healthy, even although it may be unusually broad. With patience and due management the necessary degree of dilatation may be obtained by the pressure of the head; and proposals to dilate it artificially, or even to make a slight incision into it, do not deserve a moment's consideration. Where, however, it has been extensively lacerated in a previous labour, and has healed again throughout its entire length (by no means a common occurrence) or when there has been much sloughing, the cicatrix thus formed may render it incapable of relaxation, and thus produce much resistance to the passage of the head. Even here we may do a great deal by warm hip baths, fomentations, and especially by bleeding; an incision through the callous portion is by no means desirable where it can be possibly avoided, as it only endangers a farther laceration during the expulsion of the head. Cases nevertheless, occur where the contracted ring of the os externum is so unyielding and gristly as to make this operation necessary.[129] In all these cases, where, either the adhesion and contractions have given away, or have been divided during labour, great care should be taken to prevent them forming again during the process of healing, by using sponge tents well greased, and other appropriate means. _Varicose and oedematous swellings of the labia and nymphæ_ also deserve mention, although they rarely interfere with the progress of labour to any great extent. Varicose labia seldom annoy the patient during her pregnancy; the veins of the part may have become somewhat dilated and the labium swollen; but it is generally not until the commencement of labour, that they become hard and knotty: at first they feel like a bunch of currants imbedded in the cellular tissue of the labium, and as labour advances, and the return of blood from the part is still more impeded, the swelling continues to increase in size, and frequently obstructs the os externum very considerably. The danger here is not so much from its acting as an obstacle to the passage of the child, as from its bursting during labour and causing loss of blood and other serious consequences. The tumour seldom bursts directly externally, but first gives way beneath the skin, producing extravasation, after which, in consequence of still farther distention, the labium itself ruptures. In some cases the hæmorrhage is not very profuse externally, while the extravasation internally, amounts to some pounds, extending not only to the vagina and perineum, but also to the groin; and instances have occurred where it has spread to a great distance over the glutæus muscles. "The extravasation," says Mr. Ingleby, "usually happens during the pain which expels the child; but sometimes at an early period of labour, as in the example of severe hæmorrhage here annexed. I had just left a patient to whom I had been called, in consequence of the difficult transmission of the child's head through a distorted pelvis, in connexion with an inordinate varicose enlargement of the labia pudendi (especially the left,) when a messenger overtook me urging my immediate return. It appeared that during the violence of the straining, the tumour on the left side had suddenly burst at the edge of the vagina posteriorly. The patient lay in a little lake of blood; and as the bleeding recurred in gushes with the return of every pain, it became essential to complete delivery, and a child weighing fifteen pounds was extracted with the forceps. A large slough separated at the end of the third week." p. 109. Where no laceration has taken place externally, it is seldom that an opening for the purpose of removing the effused blood will be of use; on the contrary, the access of external air cannot but be prejudicial in many cases. The action of the absorbents is generally sufficient for this purpose, and may be increased by friction with stimulating liniments, and most remarkably of all by the application of electricity. Where the extravasation extends beneath the lining membrane of the vagina, so much swelling may be produced as nearly to close the passage; this, however, generally takes place after the birth of the child, the rupture of the varicose vessel having occurred whilst it was passing. On perceiving, at the commencement of a labour, that there are varicose veins in the labium, which are beginning to increase in size and hardness as the head advances, it will be as well to compress them as much as possible during the intervals of the pains, when there is less impediment to the blood returning from them: we can, by thus squeezing out their contents to a certain degree, lessen the size of the swelling, and thus prevent it from gaining that extent which might endanger laceration. We may instantly know when this injury has taken place, by the livid tumefaction of the parts, and our being no longer able to feel the knotty portions of the varix. In order to check the effusion of blood as much as possible, we must apply cold, and thus favour its speedy coagulation beneath the skin. Where the distention is very great, it may become necessary to evacuate the effused fluid; but, generally speaking, it is deeper beneath the surface than might, at first sight, be expected. "It has been proposed," says Mr. Ingleby, "that the swelling should be punctured, provided there has been no delay, and the puncture is made whilst the blood is still liquid. On one occasion I promptly carried this suggestion into effect, but without success; and, considering the structure of the labium, it is probable that the greater part of the blood will coagulate almost as rapidly as it is effused." (Ingleby, _op. cit._ p. 109.) A considerable degree of suffering and annoyance to the patient may arise from oedematous swelling of the labia and nymphæ, both previous to and during her labour. The labia are occasionally so distended as not only to close the os externum, but to require that the legs should be kept as wide asunder as possible, to prevent the swollen parts being crushed: the patient is thus rendered very unwieldy and helpless, if she were not already so previously by an anasarcous state of the lower extremities, which frequently accompanies this condition. Oedema of the labia is of less consequence where the patient has had several children than where she is a primipara, and seldom either retards labour to any serious extent, or is attended with any troublesome consequences afterwards: where, however, it is her first labour, and the swelling is very considerable, laceration may be produced, the results of which may be sloughing and gangrene: a fatal case of this kind has been described by Burton. Where the labia are much swollen, they not only render the patient incapable of moving, but are apt to become inflamed and excoriated, from being in such close contact, and constantly moistened by the trickling of the urine over them. By preserving the horizontal posture, and thus taking off the pressure of the child from the soft parts of the pelvis, by keeping the bowels open by saline laxatives, and by using saturnine and evaporating lotions to the part, a good deal may be done for the patient's relief. Where there is no disposition to inflammation, and the parts appear somewhat flabby, warm and gently stimulating applications will be preferable. Mr. Ingleby remarks that, "if the swollen parts are punctured (and a particularly fine curved needle answers best,) a load of serum is drained off, and relief is rapidly obtained. I have not observed any of the reported bad effects (sloughing and gangrene for instance) succeed this little operation; nor are they likely to occur in an unimpaired constitution." The celebrated Wigand of Hamburgh, who strongly opposed making incisions into the dropsical structure, does not appear to have tried the plan recommended above. He considered that, as these swellings are the result of pressure, the less we do with them the better, merely taking care to keep up the action of the skin. Oedema, or rather dropsy, of the nymphæ, is not of common occurrence, and, when it takes place to a considerable extent, produces a singular alteration in the appearance of the external organs. The nymphæ protrude beyond the labia, and depend so much as to rest upon the bed on which the patient lies, forming a soft membranous bag, fluctuating with the fluid which it contains. If labour has not actually commenced, we would prefer endeavouring to excite the absorbents of the part, and thus remove the effused fluid, to its evacuation by puncture: we have perfectly succeeded, by the use of warm aromatic stimulating fomentations. The "_species aromaticæ_" of the Continental pharmacopeiæ may be used with much advantage in these cases: the mode of its application is, to tie some up in a loose muslin bag, and soak it in hot wine; this forms an excellent warm stimulating application, and appears to excite the absorbents very briskly. A very good imitation of this, is to scald some chamomile flowers, and having squeezed them tolerably dry, to sprinkle some port wine over, and then apply them as a poultice. A swelling of this sort can offer but little obstruction to the passage of the head; and if labour commence before we have been able to reduce its size sufficiently, we may at the last let off the fluid by puncture, should the pressure of the head be such as to threaten laceration. _Tumours_ of different sorts may obstruct the passage of the child, and, in some cases, produce an impediment of the most serious character. Fibrous polypi and hard tubercles of the subcartilaginous character (commonly called the fleshy tubercle) are those which may present the greatest resistance, while fungoid growths of malignant disease, whether cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, rarely oppose much obstruction. Their structure is soft and spongy, they therefore yield to the gradual pressure of the head, become more or less flattened, and thus allow it to pass. But fibrous or chondromatous tumours are of too firm a structure to admit of this, and are capable of rendering the labour not only difficult, but very dangerous. The mass being situated at the lower part of the uterus, or attached to it by means of a pedicle, is perhaps forced down into the cavity of the pelvis, beyond which its attachments do not allow it to advance; if it be a fleshy tubercle imbedded in the structure of the uterus, it will not be able to advance so far, but will obstruct the brim of the pelvis, and thus prevent the head descending into it. In many cases, these tumours are merely covered by the lining membrane of the uterus, which sometimes forms a species of pedicle. In either case, an early diagnosis is of great importance, as we may thus have the opportunity of removing the mass either by the scissors or ligature. Dr. Merriman has recorded an interesting case of this kind, where the polypus which arose from the inner surface of the right lip of the os uteri was tied, and removed rather more than three weeks before labour came on. A fatal case, communicated to him by the late Dr. Gooch, is equally valuable, inasmuch as it shows the results of a contrary practice.[130] "The class of tumours which most frequently obstruct labour comprise follicular enlargements and the prolapsed ovarium. The former disease originates in the vagina, and has been shown by Mr. Heming to consist in a dilated state of one of the mucous follicles, which acquires a cyst, and secretes a fluid of varying colour and consistence, from a dark to a straw-coloured serum, or a deposition purely gelatinous. Owing to the density of its walls, and its general tension, the fluid contents of the tumour are not easily distinguished; but the flaccidity which succeeds a free puncture is very striking." "There are two forms of ovarian tumour which obstruct the passage of the child; in the one, a small cyst in connexion with a very bulky cyst; or else a portion of a large cyst passes into the recto-vaginal septum, and bulges through the posterior part of the vagina: in the other, and that which occurs by far the most frequently, the whole ovary, moderately enlarged, prolapses within the septum. The descent is peculiarly liable to happen at two periods; the first near the end of gestation, the second during labour, the prolapsus being promoted by the relaxation of the soft parts. The changes which the ovary undergoes when long detained in the septum, will chiefly depend upon the capacity and yielding state of the parts. If the woman has not previously borne children, it may remain small, and scarcely retard delivery; but under contrary circumstances, it acquires a large size, and nearly fills the vagina. In rare instances, the bulging is said to have appeared at the anterior part of the pelvis." (Ingleby, _op. cit._ p. 118.) The contents of these tumours vary a good deal; the hard ones are usually lipomatous or fatty tumours, not unfrequently containing hair and rudiments of teeth. Numerous cases have been recorded where ovarian tumours, which had been pushed down before the child, have at length burst, discharging their contents, and thus ceasing to act as an obstacle to the labour. We quite agree with Mr. Ingleby in recommending puncture under such circumstances; for, independent of pregnancy, it is a well-known fact, that there is a much better chance of successfully tapping an ovarian dropsy per vaginam, than through the abdominal parietes. The same holds good in operating through the rectum; and he has described two highly interesting cases where this mode of treatment was completely successful; one in his own practice, the other in that of our friend Mr. W. Birch. _Distended or prolapsed bladder_, &c. Lastly, the urinary bladder may obstruct the passage of the child, from being prolapsed and distended with water, or from containing a calculus which is forced down below the head. In the first case, a prolapsus of the distended bladder can scarcely take place without much inattention on the part of the practitioner, not having ascertained whether the bladder had been lately evacuated. In case we find, upon examination, that there is a disposition to this displacement, the elastic catheter will enable the tumour of the prolapsed bladder to collapse, and thus remove all farther trouble. The examination in these cases must be conducted with care; for an elastic fluctuating tumour of this kind may be mistaken for the distended membranes, or a hydrocephalic head; and Dr. Merriman has given a melancholy case where, in consequence of such an error, the bladder was punctured. _A stone in the bladder_ is sometimes more difficult to manage. If the head is only just beginning to enter the brim, the stone may be pushed up above it; but if it has already engaged completely in the pelvic cavity, it becomes a question whether it will not be necessary to cut down upon it, and thus remove it. These cases are, however, of very rare occurrence, and we must be entirely guided by circumstances, it being impossible to lay down any precise rules for their treatment. CHAPTER VI. SIXTH SPECIES OF DYSTOCIA. _Faulty Labour from a faulty Condition of the expelling Powers._ I. _Where the uterine activity is at fault--functionally or mechanically--from debility--derangement of the digestive organs-- mental affections--the age and temperament of the patient--plethora-- rheumatism of the uterus--inflammation of the uterus--stricture of the uterus.--Treatment._ II. _Where the action of the abdominal and other muscles is at fault.--Faulty state of the expelling powers after the birth of the child.--Hæmorrhage.--Treatment._ Although this species includes that condition of the expelling powers, where their action is excessive, we shall defer this portion of the subject until we treat of _precipitate labour_, with which it is essentially connected. The agency by which the child is expelled during labour is of two kinds: 1st, involuntary action of the uterus, assisted, _secondly_, by the partly voluntary and partly involuntary action of the abdominal muscles. On the approach of labour, the uterus, which hitherto had been merely performing the office of a receptacle and a means of conveying nourishment to the foetus, now assumes a totally different character; from being in a nearly passive state, it assumes an entirely opposite condition, viz. of high irritability and powerful action. We might almost suppose that its connexion with the nervous system was become more close and intimate; for it is now sensible to the influence of impressions which had before produced no effect upon it. Thus, we see, that affections of the mind, even but of moderate intensity, and to which it was, before labour, nearly, if not quite, insensible, are now capable either of rousing its efforts to the utmost violence, or of arresting them in the midst of full activity; and, on the other hand, we see that where its action has been deranged or interrupted, it gives rise to serious affections of the nervous system, or even convulsions. With all this, it now displays peculiarities of function, which strikingly distinguish it from all other organs of the body; in some cases it appears to annihilate or to absorb, by its all-pervading influence, the functional energies of other organs; and, in spite of its increased nervous power and susceptibility to various impressions, it seems to possess the faculty of continuing its efforts uninfluenced by general disease, unimpaired by exhaustion, and, for a time, almost independent of the life itself of the mother. In convulsions and paralysis, in general fever and inflammation of vital organs, its powers appear to be undiminished: on the contrary, where the patient, from whatever cause, is rendered incapable of assisting its efforts by the abdominal muscles, the uterus will take upon itself the whole task of expelling the child, which will be born apparently without a single effort upon the part of the mother. We also observe, that organs, the various conditions and derangements of which have exerted little or no influence upon the uterus in its state of quiescence during pregnancy, now affect it powerfully, and are capable of modifying its action very considerably. The stomach, the intestinal canal, and the skin, are remarkable instances of this, and seldom fail to disturb or pervert the natural efforts of the uterus, whenever these organs deviate from a healthy condition. It will be, therefore, of the highest importance to watch their functions narrowly, in order that we may form a correct estimate of their effects upon the uterus. Derangements in the contractile power of the uterus may arise from a variety of causes, which may be chiefly brought under two heads, viz. _functional_ and _mechanical_. The functional derangements may arise from insufficient activity, the result of general or local debility; from a deranged condition of the digestive organs; from passions or affections of the mind; from hereditary temperament, constitution, or peculiarity; from the patient's age, being either very young or considerably advanced in years, and pregnant for the first time; from plethora, general or local; from rheumatic affection of the uterus; and from uterine inflammation. The contractions of the uterus may be _mechanically_ impeded, by tumours imbedded in its substance; by organic diseases, as schirrus, cephaloma, and hæmatoma; cicatrices from former ulcerations or rupture, or by any other circumstances which interrupt the action of the longitudinal fibres upon the os uteri. _From debility._ Where uterine action is insufficient from debility, the pains are feeble, and do not appear to act in the right direction; they are frequently attended with much greater suffering than might be expected from their inefficiency; the intervals between the pains are unusually long, the pains themselves are very short, or, after a while, cease altogether. This condition, when depending on _general_ debility, may be the result of previous disease, loss of blood, or other debilitating evacuations, poverty, with its attendant miseries, depressing passions of the mind, and health broken down by intemperance. The contractile power of the uterus itself may be injured by previous leucorrhoea or menorrhagia, by abortions, or by attacks of hæmorrhage during the latter part of pregnancy; it may be weakened by over-distention of the uterus, either from plurality of children or too much liquor amnii, by the patient exerting herself improperly at the commencement of labour, straining violently, and endeavouring to bear down before she is involuntarily compelled to do so by the presence of the head in the vagina. It may also be produced by the membranes giving way too soon, as is so frequently observed in first labours. _From derangement of the digestive organs._ We have already described the change which takes place in the relation between the uterus and other organs, as soon as it passes into a state of action. The intestinal canal stands foremost in the influence which it exerts upon the uterus; whether it be from constipation or diarrhoea, irritation from acrid contents, &c., it will greatly modify, and even derange, its contractile power; the pains cease to be genuine uterine contractions, and assume a spasmodic character, producing much painful griping and pinching about the front and lower part of the abdomen, without any of that regularity of interval and duration, and gradual accession and recession, which mark the presence of real labour pains, and, we need scarcely add, with little or no effect upon the progress of the labour itself. These griping colicky pains appear to supersede the true process of parturition, and either to prevent the uterus acting with due regularity and effect so long as they last, or so to pervert its action as to produce a species of metastasis towards other organs. The pains lose their peculiar character as the expelling powers of the uterus; they cease entirely, and the patient is suddenly attacked with dyspnoea, cramps in the extremities, violent shivering, great restlessness, intense headach, delirium, convulsions, or even mania. Wherever the action of the uterus is deranged by gastric or intestinal irritation, the abdomen is generally more or less tender in front, particularly over the symphysis pubis; the os uteri is thin, tense, and rigid; the vagina is hotter than natural; the secretion of mucus is sparing; and both os uteri and vagina are more than usually tender to the touch. _From mental affections._ The mind is capable of influencing the action of the uterus during labour in a remarkable manner, not only where it is suffering from depressing emotions, as grief, great anxiety, or painful anticipations as to the result, but from causes of a much slighter character, which are nevertheless well worthy the attention of the practitioner: his sudden appearance in the room, without the patient having been properly warned of his arrival: the dread of an examination; or annoyances of a much slighter character, as regards his manner, or that of the nurse, &c., will not unfrequently be quite sufficient to stop the progress of the pains. The _age and general temperament of the patient_ will also affect the character of the pains. When pregnancy occurs for the first time, either at a very early age, or considerably advanced in life, labour is apt to be protracted, from defective uterine contraction; in the first case, she has not yet attained that degree of adult strength which is requisite to undergo a process requiring so much exertion; the pains are weak, of short duration, and inefficient, but very exhausting to the patient. From the irritability both of the nervous and vascular systems, so peculiar to youth, arises a long train of troublesome symptoms, such as congestion of blood to the head, spasms, syncope, convulsions, &c. In the other case, the condition of the system is the reverse, the irritability is diminished, the uterus is sluggish in its action, the pains are weak and inefficient, follow each other very slowly, and the course of the labour is much protracted; besides this, the short passages through which the child advances are now less capable of dilatation, from having that elasticity and suppleness peculiar to youth, and therefore oppose a much greater resistance. Where the patient is of a slothful phlegmatic habit, the uterus generally indicates a corresponding state, by the slowness of its action and want of excitability during labour. The same condition is manifested during the catamenial periods in the unimpregnated state, by the absence of pain, weight, throbbing, and other symptoms of local congestion, which are usually observed at these times; so that, but for the discharge, the patient has scarcely any guide to mark their recurrence. On the contrary, where the appearance of the menses is preceded and accompanied by severe pain in the back and loins, throbbing, heat, weight, &c., indicating considerable excitement in the uterine system, we usually observe a similar condition in the uterus during labour, the pains being quick, energetic, and efficient. It is probably from some peculiarity of temperament that we can explain the hereditary disposition which some women show in the unusually lingering or rapid character of their labours. _From plethora._ A congested or overloaded state of the uterine circulation, whether from general plethora or from other causes, is not an uncommon cause of feeble contractions. The spongy tissue of the uterine parietes is so gorged with blood, as to prevent, in a great measure, the free action of the pains, and may thus seriously impede the progress of labour. We have already pointed out, when speaking of the signs of pregnancy, the disposition which the system manifests for forming a larger quantity of blood than before; the pulse is stronger and more full, the animal heat is increased; this is especially observed in the uterus, and continues so during the whole process. Whilst in the state of inaction which belongs to pregnancy, but little inconvenience, comparatively, is felt; but when labour commences, and it contracts, the blood is driven from its engorged veins and sinuses into the general circulation; if, however, it cannot do this, from the general state of plethora, its contractions are rendered very imperfect and inefficient. Besides the appearances of general plethora, we shall easily recognise this condition by the following symptoms: "the patient has much heat of surface and yet but little thirst; the face, eyes, and skin, are red and considerably swollen; we can feel vessels pulsating in every direction; she gets but little sleep, and finds the bed and the bedclothes uncomfortable to her; the uterus is large, thick, tense, and very warm: the os uteri swollen and cushiony, and the vagina also warm and spacious; the foetus is very restless, and causes a good deal of pain by its movements. The pains are short and ineffective, and accompanied with a peculiar sensation of painful stretching or tension, without any symptoms of rheumatism, cramp, or other morbid conditions of the uterus being present." (Wigand, _Geburt des Menschen_, vol. i. p. 138.) This condition is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, constipation, varicose veins of the lower extremities, &c. _Rheumatism of the gravid uterus_ is an affection which, although it has received but little or no notice in this country, has been long known and described by the continental authors. It appears to be a similar condition of the uterine fibres, when developed by pregnancy, to rheumatism in other muscular tissues, arising from the same causes, connected with the same conditions of the system, and producing similar effects; hence, therefore, it must interfere considerably with the healthy action of the uterus, and greatly diminish or entirely destroy, the efficiency of the pains. The whole uterus is unusually tender to the touch; the contractions are excessively painful from their very commencement, the slightest excitement of the uterus producing a sensation of pain; they come on with a sudden twinge or dragging pain about the pelvis and loins, and where the contractions are still powerful, they sometimes rise to an intolerable degree of intensity. This condition is frequently observed to a slight extent at the commencement of labour; the mild precursory pains which, in a healthy state, are merely attended with a sensation of equable pressure and tightness round the abdomen, now produce much suffering and give rise to one form of spurious pains, to which we have already, under that head, alluded. Where the symptoms are of considerable severity and have been aggravated by improper treatment, this state may easily pass into that of actual inflammation. On examining into the history of the case, we shall frequently find that for several days, or even more than a week, the patient has remarked the uterus to be unusually tender to the touch, scarcely bearing the pressure of the clothes; and at night-time the uneasiness has increased to such a degree that she could scarcely remain in bed. There is a frequent desire to pass water, which is highly acid, and deposites much red sediment; and in all probability she complains of rheumatic pains in other parts of her body. The causes of this condition are the same as those of rheumatism under ordinary circumstances: exposure to cold, and alternations of temperature, particularly when heated; derangement of the stomach, with much prevalence of acid, &c.: insufficient clothing, and, upon the Continent, especially in Holland, where it is said to be very frequent, by the use of chauffe-pieds. _Inflammation of the uterus_ is another condition which can not only greatly impair, but entirely suspend, the activity of the uterus. It is usually brought on by improper treatment during labour, where the real cause of the lingering ineffective pains at the commencement has been entirely overlooked, and a state of uterine irritation aggravated into one of actual inflammation by the abuse of stimuli and other heating drinks, given with the view to increase the pains; it may be produced by external violence, improper attempts to dilate the os uteri, rough and too frequent examination, endeavouring to turn the child or to apply the forceps before the soft passages were in a fit condition for that purpose. The whole abdomen becomes extremely tender, and even the slightest contractions of the uterus produce intense suffering; the vagina is hot and dry, and very tender to the touch--its mucous secretion suppressed; the os uteri is swollen, tense, and painful, and the anterior lip is sometimes so distended as to have been actually mistaken for the bladder of membranes; the bowels are confined; the urine is suppressed; the abdomen becomes distended from tympanitis; and general, and probably fatal, inflammation of its contents follows. _Treatment._ The causes of insufficient uterine action are so numerous that the modifications to which they give rise are almost endless, and demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient's health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most frequently in young primiparæ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes much protracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its removal. Change of posture, walking about the room, gentle friction of the abdomen, and occasionally taking some refreshing or mildly nutrient drink, as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully dilated,) an enema will not only clear the rectum of any fæcal matter which may be lodging there, but assist in rousing the uterus to greater activity. Where we can satisfy ourselves that none of the above-mentioned causes are present to protract the labour, we may proceed to the use of those remedies which are considered to have the power of exciting the uterine contractions, such as secale cornutum, borax, cinnamon, and the several diffusible stimulants. This state of uterine inactivity is, however, rare; and we would earnestly warn young practitioners against too readily concluding that it is present. They will find that the more carefully they investigate such cases, the less frequently will they require these remedies. In using the secale cornutum, we give the preference to the powder: it should be carefully kept from moisture, air, or light: from twenty to thirty grains, mixed in cold water, will be the proper dose, and this may be repeated two or three times, at intervals of half an hour, or rather more. Borax is also another remedy which appears to possess a peculiar power in exciting the activity of the uterus: although it is scarcely ever used for such a purpose in this country, its effects upon the uterus have been long known in Germany; and in former times, both it and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:--[Symbol: Recipe] Secalis Cornuti [Symbol: scruple] i--ij; Sodæ Subborat. gr x; Aq. Cinnamomi [Symbol: ounce] jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree. Our own conviction with regard to the use of these remedies is, that they are seldom required _during_ labour, except in nates, or footling presentations, or in cases of turning, where the head is about to enter the pelvis, and where, at this critical moment, the action of the uterus is apt to fail, when it is important to the safety of the child that there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contraction _after_ labour, and thus to promote the safe expulsion of the placenta, where there is a disposition to inertia uteri, and ensure the patient against hæmorrhage. Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive force to the head by means of the forceps, and thus overcome the natural resistance of the soft parts, to using medicines which excite uterine action, and thus stimulate the exhausted organ to still farther efforts. The mere cessation of uterine action, however, where the labour has been tedious and fatiguing, is no proof that the uterus is exhausted, and incapable of farther efforts: so far from its sinking into a state of quiescence, being a symptom of exhaustion, experience shows that, in labours of this character, it indicates a very opposite condition, being nothing more than a state of temporary repose, during which nature affords it an opportunity of recruiting its own powers, as also those of the whole system. The interval of ease which is thus given to the patient is accompanied by refreshing sleep; the skin grows moist; a gentle diaphoresis creeps over her; the circulation becomes calm; and after a time, the uterus awakes again to renewed and astonishing exertions; thus, Wigand has remarked, "the pains during the same labour may cease once, twice, or even oftener, and yet after a little rest will return with renewed strength." (_Geburt des Menschen_, vol. ii. p. 242.) On the other hand, where the pains, in spite of their becoming more and more ineffective, continue to exhaust the patient with fruitless suffering, and prevent her from enjoying that repose which is so desirable under such circumstances; when the uterus, from increasing irritability, scarcely ceases to contract even for a moment, but continues tense and more or less tender during the intervals of the pains, we can have little or no reasonable expectation that such a labour can be terminated by the natural powers. If the head be not far advanced in the pelvis, or the passages fully dilated, if the bowels have been relieved before labour, and there is no febrile excitement of the circulation, a mild diaphoretic sedative, like Dover's powder, will be of great service: it calms the irritability of the system, and induces that state of quiet or actual repose to which we have just alluded. If, on the other hand, the labour be much farther advanced, the head approaching the pelvic outlet, and the soft parts well dilated, a little assistance, by means of the forceps, will quickly terminate the case, and free the mother and her child from farther suffering and danger. Where the uterus is enfeebled by lesion or change of structure, it becomes very difficult to decide as to what course ought to be pursued: in some cases, the soft passages partake in the loss of tone, and offer but little resistance to the advance of the child; in others, however, the uterus is so powerless as to give us no choice but of employing artificial delivery. We have already pointed out the importance of paying the strictest attention to the bowels shortly before and during labour, and how frequently a neglect of this precaution acts as a means of perverting the due action of the pains, and giving them that character, already described under the head of _False Pains_. "After the labour has made much progress, the rectum, if loaded, should be emptied by clysters; indeed, the utility of clysters in almost every stage of labour is so apparent that it is to be lamented they are not more frequently employed." (_Synopsis of difficult Parturition_, p. 19.) We have seen cases where, although the bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the administration of an enema, and removal of a quantity of fæcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short space of time. In like manner, vomiting during the early part of labour produces the best effects; for it not only assists to relax the parts, by the nausea which usually precedes it, but, by emptying the stomach of unhealthy contents, it tends not a little to restore the uterus to its natural activity. Where the bowels are distended with flatus, and loaded with acrid and unhealthy contents; we rarely see the pains become regular and effective until these sources of irritation are removed: the abdomen is painful with spasmodic colicky griping, and excites the uterus to partial and very painful contractions of a cramp-like character, which entirely supersede the regular pains, and thus exhaust the patient with protracted suffering without at all advancing the labour itself. If this condition be allowed to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result. In the management of primiparæ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as possible, and thus enable them to meet the coming trial with safety. Where the patient is very young, we should endeavour, by early hours, regular exercise, good air, and simple nourishing diet, &c., to increase her strength, and the general tone of health, and thus diminish that irritability of the nervous system peculiar to females of this early age. She should lead a country life, be as much as possible in the open air, enjoy the absence of restraint and excitement, which are almost necessary consequences of a residence in town, and, by agreeable occupation and cheerful society, train herself, as it were, to that state of moral as well as bodily health best adapted to ensure a favourable result. It is in cases of this kind where the bodily powers have not yet ripened into adult womanhood, that so much good may be effected by using the tepid or (if the season permit) cold salt water bath; and we would beg to refer our readers to our observations on this subject in the chapter on PREMATURE EXPULSION. In a case which has recently come under our notice, we have had reason to attribute the remarkably healthy and favourable labour of a young and delicate primipara solely to the invigorating effects of regular exercise and the daily use of sea-bathing, which she continued to within a very few days of her confinement. It is commonly supposed that women pregnant for the first time, and advanced in years, always have severe labours: this is not necessarily the case, although, at the same time, the greater rigidity of the soft parts considerably increases the resistance to the expelling powers. It will be equally important in this case, also, to improve her health and strength as far as possible, and, by exercise, warm hip baths, &c., to give the parts a greater degree of suppleness and elasticity. Where the labour is protracted by a state of general plethora or local congestion, the expelling powers are not only enfeebled by the engorged state of the uterine circulation preventing effective pains, but the resistance to the passage of the child is increased by a similar condition of the soft passages, which are swollen and turgid with blood. It is in these cases that bleeding effects such a sudden and complete change; the pulse loses its oppressed character, and rises in point of strength, the uterus loses the thick solid feel which it had before; its contractions become active and powerful, the os uteri dilates, the passages become soft and yielding, and the whole process assumes a different character. By careful observation, this state can easily be discovered before labour has actually commenced; in which case much useless suffering may be prevented by previously reducing the circulation to a proper standard, and thus fitting the uterus for the exertions it has to undergo: besides bleeding, mild saline laxatives, with or without antimonials, will be of great service. The nitrate of potass in these cases has the best effects, either in farthering the effects of the bleeding, or removing the necessity of using so powerful a remedy. In treating rheumatism of the gravid uterus, our practice will differ but little from that in cases of ordinary rheumatism in other parts: this condition, we believe, is rarely excited, until the system had been already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, therefore, it will always be important to unload the primæ viæ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably to the patient's feelings than a smaller dose; there will be less griping and intestinal irritation, but the effect will be more complete and general; not only will the bowels be thoroughly evacuated, but the liver relieved of a large quantity of unhealthy acrid bile, the removal of which cannot but be highly advantageous. We may now proceed to the use of diaphoretics and opiates: of these, Dover's powder stands foremost; and if given in doses of from ten to fifteen grains, accompanied with warm diluent drinks, rarely fails to induce sleep and a pretty active perspiration, which gives great relief. As the abdomen is usually more or less tender on pressure, it should be covered with a piece of soft flannel, or, still farther to ensure the full diaphoretic effect of the remedies, a warm bath may be had recourse to. Where calomel in the above dose has been premised, we seldom fail in procuring a free action of the skin, and, according to our own experience, with far greater relief to the system than where the perspiration has been induced merely by diaphoretics and external warmth. If this condition of the uterus has been neglected, and the contractions are beginning to produce intense suffering; if the abdomen is rapidly becoming more tender to the touch, it should be covered with a hot poultice of linseed meal, made more stimulating by the addition of mustard flour, and this should be continued until the skin is considerably reddened. In the slighter cases of this affection, where the bowels have been opened, friction upon the abdomen frequently produces the happiest effects. We presume it is to these cases that Dr. Power alludes when he says, "in some, the improper action will be removed almost instantly, and, as it were, by a miracle; so that a case which has been protracted for the greater part of a week, under the most intense suffering, without the least progress, has been happily terminated in fifteen or twenty minutes from the first commencement of the friction." (Power's _Midwifery_, 1819.) Where inflammation of the uterus takes place during labour, the case becomes one of the most serious character; for not only is the suffering, which is produced by every contraction, of the most intense description, but the presence of the child aggravates the state of inflammatory action, and excites the uterus to still more violent efforts, while the swollen and unyielding state of the os uteri, &c., precludes the chance of speedy delivery. Under such circumstances, we must trust almost entirely to the lancet in aiding this important object; for, until the circulation has received an effectual check by fainting, the dilatation of the parts cannot proceed, nor can any attempt be made to give artificial assistance. The abdomen should be covered with a hot linseed meal poultice, as above described, in the treatment of rheumatism of the uterus; warm decoction of poppies should be thrown up the vagina, or, if this cannot be procured at the moment, some thin gruel mixed with a little laudanum, or in which a few grains of Extr. Conii or Hyoscyami have been suspended; the bowels should be opened by a simple enema, after which a small opiate injection will be desirable, in order still farther to allay irritation. _Stricture of the uterus._ We have already had occasion to allude more than once to that species of violent and continued contraction which we have denominated stricture of the uterus, but have chiefly considered it where it affects the os uteri; a somewhat similar condition of spastic rigidity is occasionally, though rarely, seen in other parts of this organ, and is capable of producing a most serious obstacle to delivery. The uniform and regular action of the uterus disappears; its contractions become partial, both in extent and effect, one part alone contracts whilst the rest of the uterus is relaxed; its shape thus becomes altered; for, by these partial contractions of its fibres, it may become elongated, shortened, flattened, &c.: the spasmodic action frequently varies its seat, and successively attacks different portions; thus, where it affects the body of the uterus, it becomes contracted almost like an hour-glass, having a transverse circular indentation, as if it had been tied with a cord. Where the contraction affects one side of the organ, it alters the shape of it materially; the fundus is pulled down equally, and the position of the child, as we have shown in the first species of dystocia, may be seriously affected. If the stricture has its seat in the os uteri, this becomes tightly contracted, hard, unyielding, and painful upon pressure: it does not dilate sufficiently, and the inferior segment of the uterus is generally pushed downwards, whilst the os uteri itself is drawn upwards. In cases of this kind, we find that although the uterus contracts, the child does not advance, but rather retracts, during a pain; the contractions are never general, but partial, and even where they are general, the fundus does not attain its due preponderance over the os uteri, so that the one contracts as much as the other does; in severe cases, also, the uterus continues in a state of spasmodic action during the intervals of the pains: this is frequently accompanied with a painful and harassing sensation of tension and stretching, very different to that produced by the action of regular pains upon the os uteri; and in the worst cases we occasionally observe a peculiar state of the brain, which manifests itself by attacks of insensibility, faintings, or even convulsions. Although the head does not advance in spite of the strongest pains, yet, upon examination, we find no want of proportion between it and the pelvis; if the intervals of uterine action be of sufficient duration to allow it, we shall feel the head quite moveable in the pelvis, or, at any rate, with plenty of room for the finger to pass round it, and yet when a pain comes on, the head remains fixed, or if it does descend somewhat, it returns again to its former situation as soon as the pain is over. This state of things is usually seen where the body of the uterus is the seat of the stricture, and is contracted transversely upon that of the child, which it tightly encircles, and renders all farther advance impossible. This state of spasmodic action is produced by whatever tends to irritate the uterus and excite it to irregular action; thus, premature rupture of the membranes, especially when it has been suddenly drained of a large quantity of liquor amnii; the irritation arising from acrid matter in the intestines, or from their being loaded with accumulations of fæces; improper examination, and more especially, attempts to dilate the os uteri by the fingers or hand; endeavouring to strain and bear down during the early part of labour, and when the patient is not involuntarily compelled to do so; attempting to apply the forceps when the os uteri is not fully dilated, or whilst the instrument is very cold: malposition of the child, especially after rupture of the membranes; and lastly, anxiety, fear, and other affections of the mind. The circulation is generally in an irritable state, the patient is of a delicate excitable habit, and is apt to be nervous and hysterical. The treatment in these cases will be precisely on the same general rules as we have above described; the bowels must be relieved by a laxative or by an enema; if necessary, the circulation must be reduced to the proper standard by bleeding, and the irregular uterine action controlled by opiates. Besides these means, the warm bath is of the utmost service, and seldom fails to produce a favourable change. Where the action of the uterus is impeded, or otherwise rendered faulty by organic disease, lesions of its structure, &c., we shall in all probability be compelled to use artificial assistance. II. _Where the action of the abdominal and other muscles is at fault._ Where the faulty character of the labour arises from a faulty state of the partly voluntary, partly involuntary, action of the abdominal muscles which is destined to aid the uterus in expelling the child, this may equally be a result of general debility from previous disease, exhaustion from the long duration of the labour, from the abuse of spirituous liquors, &c. It may also arise from various causes which tend to impede the respiration; such as excessive corpulence, great deformity of the spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm, ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta, dilatation of the heart, &c. Where the size is such as renders the patient very unwieldy, or the spine is much deformed, we must place her in that position in which she can exert herself with greatest effect, and at the same time experience the least possible obstruction to her breathing: with deformed people, this is of great importance; she should be propped up with pillows, &c. into whatever posture she can lie with most comfort, and the practitioner must manage to deliver her in this position. Patients suffering from pluerisy or pneumonia are unable to bear the continued strong inflation of the lungs which is necessary during the second stage: under these circumstances, the pain and inflammation are greatly aggravated; venesection must be used with great promptness, but it does not always bring relief or remove the danger; for the disease is kept up by the presence of labour, which, therefore, in all probability, will require to be terminated by art. In some cases, however, as we have already mentioned, especially where the disease is of an acute character, the uterus appears to take upon itself the whole exertion of the labour, so that the child is born apparently without any effort on the part of the mother. _Faulty state of the expelling powers after the birth of the child._ The last stage of labour, which comprehends the expulsion of the placenta, may also be retarded by a faulty state of the expelling powers. This not only arises from the causes which we have already mentioned, but from those connected with the labour itself; as from premature and immoderate straining during the pains, misuse of medicines given to increase the pains; also, where the uterus has been exhausted by the length and severity of the labour, or where it has been thrown into a state of inertia by the sudden evacuation of its contents, especially when previously much distended. This condition is frequently induced by not supporting the child sufficiently when the shoulders are about to pass through the os externum; the main bulk of the child is therefore suddenly expelled, and the uterus is at once thrown into irregular action by the sudden shock of so great a change, or falls into a state of inertia. The separation and expulsion of the placenta may be also retarded where the labour has required the forceps, turning, or perforation, especially the latter, on account of considerable pelvic deformity; the more so if there has been considerable delay in giving assistance. Irregular and partial action of the uterine fibres, after the expulsion of the child, may easily render the last stage of labour dangerous; for, under such circumstances, the portion of the uterus to which the placenta is attached may be in a state of firm contraction in one part, while the other is quite relaxed, so that incomplete separation of the placenta will be the result, and hæmorrhage follow: hence we cannot be too cautious in avoiding every cause which may at all influence the regular action of the uterus during the last stage of labour, which is far more dangerous than the two others put together. In a case of this kind, we do not feel the uterus contracting into the firm globular mass above the symphysis pubis, as might have been expected; but if inertia uteri be present, it remains soft and large, the peculiar pains of the last stage which indicate the speedy separation and expulsion of the placenta do not make their appearance, or only in a very insufficient degree. If it be contracting irregularly and only in part, we shall feel this distinctly, from the unequal shape and hardness of the uterus, which in some cases will have almost a lobulated feel; in others, it presents a considerable depression either upon the fundus or anterior wall. _Hæmorrhage._ The danger here, chiefly depends upon the occurrence of hæmorrhage: if the placenta be still attached by its whole surface to the uterus, no hæmorrhage can ensue; but if the contractions have been of sufficient power to detach more or less of it from the uterus, large trunks, which have hitherto conveyed maternal blood into the placental cells, are torn through, and a profuse discharge must be the result. The degree of the hæmorrhage will in most instances furnish us with a tolerable estimate of the extent to which the separation has taken place; but it is far from easy to ascertain correctly the quantity of blood which has been lost, and we must rather try to ascertain what are the effects produced upon the system of the patient. The pulse becomes smaller and quicker, the column of blood is evidently diminished, and the heart for a time drives on its contents more rapidly; but as the loss increases, so does it become enfeebled, and although beating with a very frequent stroke, it now becomes so weak as to be scarcely or no longer capable at the wrist of producing such a resistance to the finger as will give the sensation of a pulse; the necessary consequence of this is, that the patient at first complains of great weakness, the face becomes pale, the lips white, the breathing anxious; this is followed by a sense of great prostration, the perspiration breaks out upon the face and forehead, tinnitus aurium, confusion of ideas, and sense of darkness before the eyes succeed; the load at the præcordia, and the oppression of breathing, become more insupportable; she tosses her arms about, and in some instances has a sensation that the room is going round with her, or that she is sinking through the bed; in other cases, the breathing becomes gradually more feeble, until it is almost imperceptible; she every now and then takes a deep sobbing grasp, which seems to rouse her to consciousness for a moment, and then she relapses into a state verging upon insensibility; the pulse is probably now no longer perceptible at the wrist, the face is undergoing a rapid change, the features are contracting, and there is a general expression of death-like collapse which shows too truly the urgency of the danger. The alterations which are taking place in the state of the brain and nervous system, vary in different individuals: in some, there is strabismus; in others, temporary mania, or at least, delirium; and in more unfavourable cases, even convulsions; these last are especially formidable, as they not only show that the system has been severely affected by the loss of blood, but are apt, from their violence, to extinguish the little spark of life which is left, or, in other words, to be followed by sudden death. These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the hæmorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the accumulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from hæmorrhage, perhaps, without any blood having issued externally: this is the _internal uterine hæmorrhage_, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quantity of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh accumulation of blood in its cavity. _Treatment._ So long as the inertia or atony of the uterus continues without any symptoms either of external or internal hæmorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, "in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri." (_Sur les Pertes de Sang_, 1776.) We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a glass of wine may be given with good effect. If, however, hæmorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge. In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p. 330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the hæmorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the hæmorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure. If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the _shock_ which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such _shocks_ may be produced by using another wet napkin to the vulva, and a third to the sacrum and loins; an assistant should remove them in the order in which they have been applied, and dry the skin, for a repetition of the remedy, if necessary. A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen. This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of hæmorrhage:--"Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased--a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock." (_An Account of some of the more important Diseases belonging to women_, by Robert Gooch, M. D.) Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest assistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding. These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel assured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132] It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal hæmorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be passed, to dislodge the clots, and assist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel. Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother's breast. Under no circumstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child. To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents. If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a glass of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circumstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refreshing to the patient; it can also be taken in larger quantities, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, "when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circumstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the hæmorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the constitution has suffered by the hæmorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the constitution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting." When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the vagina, upon the removal of which, the discharge will cease. The application of the child to the breast is not less valuable for preventing any return of the hæmorrhage than for stopping it in the first instance: we are _never_ perfectly secure against hæmorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and hæmorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a practitioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard. There is a form of hæmorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse hæmorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. "I had now witnessed," says Dr. Gooch, "two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse hæmorrhage had nevertheless occurred: let me be understood--after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes hæmorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude hæmorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the hæmorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident." This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen. CHAPTER VII. INVERSION OF THE UTERUS. _Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.-- Chronic inversion.--Extirpation of the uterus._ The uterus is liable, although rarely, to a peculiar displacement called inversion, where the fundus is forced down into the cavity of the uterus, and so through the os uteri into the vagina; or where the whole uterus is turned wrong side outwards, the fundus appearing at the os externum, the former being the _partial_, the latter the _complete_ inversion: in the latter it is not only the entire uterus which is inverted, but it is also the vagina, so that the whole mass which the uterus forms at the os externum is attached to the inverted vagina as by a hollow pedicle, and is encircled by the os uteri close to the labia; the external surface of the mass is the inner surface of the uterus. As it is impossible for the fundus to descend through the os uteri when this is not dilated and open, it is evident that, except in certain cases of polypus, inversion of the uterus can only take place immediately after delivery. If, at this moment, especially when the uterus has been too suddenly emptied of its contents, any force be applied to the fundus, it may be easily pushed down into the cavity, or, by the continued action of that force, the fundus may be carried through the os uteri or even through the os externum. _Causes._ Where this force has been applied externally, it may be produced by violent straining during the last pains, violent efforts, as coughing, vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which the abdominal muscles are put into powerful action. Where, on the other hand, it has been applied from within, it may arise from improper attempts to extract the placenta before the uterus was sufficiently contracted; where the cord has been unusually short, or twisted round the child, or where the patient has been suddenly surprised with violent pains, and the child dashed upon the floor before she could reach her bed, by which means the cord has received a violent jerk, or has been even broken. It has been very much the habit to attribute inversion almost solely to these latter causes, and that, except where it takes place from the shortness of the cord, or the sudden expulsion of the child whilst the mother is in the erect posture, it must almost necessarily be a result of improper pulling at the cord on the part of the practitioner: the cases on record, however, go to prove that, in by far the majority of instances, no force of this sort had been applied to the fundus; and in those instances where the child has been dashed upon the floor and the cord broken (some six or seven of which have at different times occurred under our own notice,) the fundus has not once been pulled down, although the force applied to it must have been very considerable, since the very cord which had thus given way to the weight of the child resisted afterwards, on more than one occasion, a considerable effort which we made to break it. In by far the majority of these cases, the cord has given way nearly at the same spot, viz. about three inches distance from the umbilicus, apparently justifying the inference, that it was weaker here than elsewhere. Another reason why the fundus should not have been pulled down by the weight of the child might be stated, viz. that the placenta being at that moment above the brim of the pelvis, the direction in which the strain was made upon the cord (viz. in that of the outlet, or downwards and forwards,) was not much calculated to affect the fundus. "The practice of pulling too early and violently at the cord," says Dr. Radford, "after the expulsion of the child, before the uterus has contracted, so as to detach and expel the placenta, has been generally considered as the cause of inversion; but we know that the accident happens before any force has been applied to the funis. In case fourth, the descent was so rapid and forcible through the os externum, that it would have been quite impossible to have resisted the unnatural action by which the organ was carried down. It has occurred when the patient was delivered of a dead child, the funis so putrid as to break with a slight effort. It has been found before the cord was separated, and the child given to the nurse. In the practice of Ruysch, this circumstance took place after he had extracted a dead child."[133] Still, however, it is not the less important to recommend caution, especially to young beginners, against pulling at the cord with too much force, in their hurry to bring the placenta away; the condition of the uterus at this moment is highly favourable if in a state of inertia. _Diagnosis and Symptoms._ In cases of _partial_ inversion of the uterus, we distinguish the disease by the absence of the hard spherical tumour of the fundus above the pubes, and by the presence of a globular fleshy body in the os uteri, which is sensible to the touch. This tumour will be found broader at the base than at its extremity; and surrounded by the os and cervix uteri, forming, as it were, a tight ring round it. The patient complains of a sense of dragging amounting to severe pain in the groins and lumbar region, and which compelling her to strain violently, often forces the uterus farther down, and sometimes induces complete inversion; hæmorrhage more or less considerable accompanies it; the pain is more acute in this than in the complete inversion, and the hæmorrhage more violent; the patient suffers under an oppressive sense of sinking, with nausea or vomiting, cold clammy sweats, feeble fluttering or nearly extinct pulse, faintings or even convulsions. In the _complete_ form we have neither the hæmorrhage nor that frightful train of symptoms produced by the strangulated condition of the inverted uterus; for now that it is fairly turned inside out, it is just, or nearly as capable of contracting as in its natural state, which it is prevented from doing when only partially inverted: complete inversion, however, is not the less to be dreaded, for death may suddenly follow from the shock which the nervous system has sustained, or from dangerous fainting in consequence of the sudden evacuation of the abdominal cavity; this latter circumstance will be aggravated by the inversion of the vagina which is apt to accompany the complete form, and thus give rise to considerable displacement of the intestine. _Treatment._ The sooner we endeavour to return the uterus the better, for we shall seldom experience much difficulty in effecting our object, if done immediately upon the occurrence of the accident; indeed, we know of a case where, under these circumstances, it was successfully returned by a midwife. If, on the other hand, some hours are permitted to elapse before the attempt at reduction is made, it will be attended with great difficulty, or even prove entirely abortive; the os uteri contracts powerfully, the uterus swells from the obstructed return of the circulation, inflammation rapidly follows, and diminishes still farther our chances of success. Dr. Denman says, "The impossibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called so early as within four hours, and the difficulty will be increased at the expiration of a longer time." Still, however, we must not despair of success, for numerous cases have been recorded by different authors where the reduction has been effected after a much longer period. There has been a considerable discrepancy of opinion as to the management of those cases where the placenta is still adhering to the uterus, viz. whether it is not safer to reduce the fundus _with_ the placenta, and excite the uterus to throw it off afterwards in the usual way, or whether we ought not to separate the placenta before making the attempt at reduction. Mr. Newnham, the author of almost the only monograph upon this subject, recommends the former mode of practice. "It has been recommended by several respectable authorities to remove first the placenta, in order to diminish the bulk of the inverted fundus, and thus facilitate the reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the hæmorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent _judicious_ treatment as a simply retained placenta will have a good effect in bringing on that regular and natural uterine contraction, which is the hope of the practitioner and the safety of the patient." (_Essay on the Symptoms, Causes, and Treatment of Inversion of the Uterus_, by W. Newnham, Esq. p. 14.) On the other hand, many authorities, especially of modern times, advocate a very opposite practice, and recommend that the placenta should be removed _before_ attempting to reduce the fundus; as by so doing it will pass back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or no danger from hæmorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial inversion, it is generally accompanied with hæmorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed the uterus in a condition in which it is capable of contracting. In Mr. Mann's case, quoted by Dr. Radford (_op. cit._,) the inversion was evidently complete, for the uterus was found to have "passed externally from the vagina, and the placenta attached to it." "I first peeled the placenta from the fundus uteri, and then grasping the extruded part with my hand, I did not find it very difficult to re-introduce it into the vagina, and to carry it through the os uteri. I followed with my hand, or rather pushed it forward, when I observed it suddenly start from me as a piece of India rubber would." Dr. Merriman, who candidly owns that he has altered his opinion on this point, since the last edition of his work on difficult parturition, in favour of removing the placenta, distinctly proves that the presence of this mass was the chief cause of the difficulty. "I tried," says he, "to effect the reduction without removing the placenta, but could, by no possibility, accomplish it till I had first separated the placenta: this being effected, I succeeded to my entire satisfaction in re-inverting the fundus." (_Synopsis of Difficult Parturition._) In reducing the fundus, we must not thrust our fingers collected into a cone against the tumour, as has been recommended by most authors; for, by so doing, we only produce a depression in it, and, as it were, re-invert or double the uterus upon itself, and thus add considerably to the bulk of the mass, and the difficulty of the reduction. We should grasp the tumour firmly, and push it bodily upwards in the direction of the pelvic outlet: at first little or no change is produced, until it has ascended so far, that the vagina which had been dragged down is returned again to its natural situation; the hand must follow the tumour, and now that the lower part of the uterus is fixed, by the vagina being put upon the stretch, the pressure which is applied to the fundus will act with so much greater effect. We should endeavour to "return, first, that portion of the uterus which was expelled last from the os uteri." (Newnham, _op. cit._ p. 616.) As the hand rises into the cavity of the pelvis, and is no longer able to grasp the tumour, so far from contracting the points of our fingers into a cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger space: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (_Sur les Pertes de Sang_, § 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When once the fundus has repassed the os uteri, it usually recedes suddenly from the hand, as already described in Mr. Mann's case: if we feel the uterus through the abdominal parietes well contracted, there will be no need of passing the hand into its cavity; but if it be still flaccid and soft, the hand should be introduced, not only for the purpose of guarding against any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected. Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the passages grow hot and dry, and the chances of reducing the tumour diminish in proportion. "Is it not reasonable," as Mr. Newnham observes, "to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and this very state will in itself be a sufficient obstacle to success." (_Op. cit._ p. 18.) If, under these circumstances, we find that the attempts at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the passages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata as recommended in our treatment of inflammation of the uterus; the operation, which was during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed. Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz. of firmly grasping the tumour until we have succeeded in considerably diminishing its size, and thus removing the chief obstacle to its reduction. "I grasped the body of it in my hand," says Mr. W., "and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish." (White, _on Lying-in Women_, case, 19. Appendix, p. 429, 2d edit.) Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the "pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse," &c. will not only be relieved, but the farther danger from hæmorrhage prevented. "The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; "all reasoning upon the subject" is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper assistants; the hand is to be introduced along the interior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations." (Dewees, _Compendious System of Midwifery_, § 1318.) _Chronic inversion._ Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now passes into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it assumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, "that it is _always difficult_ and _sometimes impossible_, with our present knowledge, to distinguish _partial and chronic inversion of the uterus from polypus_; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be passed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the vagina, so as to allow the finger to pass by the side of the tumour to the extremity of the space remaining between it and the os uteri; and if we find that the finger _soon arrives_ at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the _usual way_, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the _form of polypus_, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty." The periodical hæmorrhages, with profuse leucorrhoea during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate breaking up of the general health, may be as much the result of the one as of the other. The rugged uneven surface of the inverted uterus, the smoothness of a polypus, are distinctions not of long continuance; for, after awhile, the uterus gradually becomes smoother, whereas, a polypus rarely continues long in the vagina without its surface becoming irregular from ulceration. It might be a question whether it would not be possible to detect the menstrual fluid at the catamenial periods oozing from the surface of the inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour pretty high up in the vagina would prevent our ascertaining it, especially when there is more or less hæmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis. "Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation) will be of a mucous kind; but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which in a natural state lined the cavity, to air, as well as to occasional injuries, may induce inflammation and ulceration over a part or the whole of its surface; and the mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all the common symptoms of weakness." (Sir C. M. Clarke, _on the Diseases of Females_, part i. p. 155.) Although such a length of time has elapsed since the inversion, that it has become of the chronic kind, still we are not justified in giving up all hopes as to the possibility of returning it. Dr. Churchill has given an interesting summary of cases where many days, and in one case even twelve weeks, had intervened, and yet, nevertheless, where the reduction was successfully effected. (_On the Principal Diseases of Females_, p. 331.) We may also add two very remarkable cases related by Boyer (quoted by Kilian,) viz. where the uterus had resisted every endeavour to reduce the inversion, which in one case had remained fourteen days, in the other more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently. _Extirpation of the uterus._ Where, however, the powers of the system are rapidly breaking, from the profuse hæmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or in other words, removing the uterus by ligature. Numerous cases are on record where this has succeeded perfectly, although during the process the patient suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation is removed, the hæmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete. CHAPTER VIII. ENCYSTED PLACENTA. _Situation in the uterus.--Adherent placenta.--Prognosis and treatment.--Placenta left in the uterus.--Absorption of retained placenta._ By the term _encysted_ placenta, we mean that state of irregular uterine action after the expulsion of the child, where the lower portion of the uterus, particularly the os uteri internum, is closely contracted, while the fundus contains the placenta enclosed in a species of _cyst_ or cavity formed by itself and the body of the uterus. Upon examination externally, we find the fundus pretty firmly contracted, but probably somewhat higher up the abdomen than usual; the vagina and os uteri externum, or os tincæ, are usually found dilated, the passage gradually tapering like a funnel to the os uteri internum, or upper end of the canal of the cervix. _Situation in the uterus._ This state has been very generally considered to arise from a spasmodic contraction in the circular fibres of the body of the uterus, by which it was as if tightly girded by a cord at its middle, and, from the form it was supposed to take, was called _hour-glass contraction of the uterus_. From the observations of later years there is much reason to suppose that the true hour-glass contraction, as now described, is of very rare occurrence, even if it does take place at all; and that, in by far the majority of cases, the stricture is either produced by the upper part of the cervix, as we have already mentioned, or resides in the os uteri externum or inferior portion of the cervix. Baudelocque was the first who pointed out the neck of the uterus as the real seat of the stricture in these cases: "that circle (says he) of the uterus which is round the child's neck, according to the general laws of its contraction, must narrow itself much quicker after delivery than the other circles which compose that viscus, because it is already narrower, and its forced dilatation at the instant of the expulsion of the child's trunk is only momentary, and because it has naturally more tendency to close than the other circles have, since it is that which constitutes the neck of the uterus in its natural state." (Baudelocque, _Heath's Trans._ vol. ii. § 969.) Dr. Douglas, of Dublin, also investigated this subject, and came to a similar conclusion: he considered that encysted or incarcerated placenta from hour-glass contraction, resulted either from morbid adhesion of the placenta, or from inactivity of the uterus, and does not occur as a primary affection; his observations lead to the conclusion that the stricture in hour-glass contraction "does not form from the middle circumference of the uterus; it is formed by the lowest verge of its thickly muscular substance, at the line of demarcation of its body and cervix." "Thus, then, it would appear that the upper chamber comprises in its formation the entire of the body of the fundus; whilst the lower chamber engages only the cervix uteri and the vagina." (_Medical Transactions of the Col. of Phys._ vol. vi. p. 393.) The late W. J. Schmitt of Vienna considered that the stricture was produced by the os tincæ, or os uteri externum. From our own experience we would say that the seat of the stricture varies considerably in different cases; that in the simplest form it is nothing more than a contracted state of the os uteri externum; that in others it is formed by the upper portion of the cervix uteri, or os uteri internum; but in other instances it appears to be formed by the inferior segment of the uterus itself. The contraction in this part of the uterus, which, according to the observations of Professor Michaelis, comes on when the os uteri is fully developed, and, by closely surrounding the head, is one chief means by which prolapsus of the cord is prevented, may easily produce a state of stricture after the birth of the child, and thus retain the placenta; it may, however, be questioned whether this portion of the uterus, when fully dilated by pregnancy, and which then forms its inferior segment, would not become the os uteri internum when the uterus is empty and contracted. Hour-glass contraction of the uterus is liable to occur where the action of the uterus has been much deranged or exhausted, either by the unusual rapidity or excessive protraction of the labour. In all cases where the child has been rapidly expelled before the uterus has had time to contract regularly and uniformly, the disposition in the os uteri to contract, as pointed out by Baudelocque, will manifest itself. This state may also be induced by great previous distention, as from twins, or too much liquor amnii; by irritation, as by improperly pulling at the cord, by having used too much force in artificially delivering the child, by the introduction of the hand or instruments too cold, &c. The most frequent cause, however, is over anxiety to remove the placenta; the cord is frequently pulled at, and at length the os uteri is excited to contract; in this case we generally find the stricture at the os tincæ, which yields without much difficulty, either by gentle friction with the hand over the fundus, and cautiously pulling the placenta in the axis of the superior aperture, or by introducing the hand and bringing it away. _Adherent placenta._ When the placenta is still attached either wholly or in part, there are generally some preternatural adhesions to the uterus, which, by keeping its upper portion distended, give rise to partial contractions below. This condition of the placenta is observed to attend nearly every severe case of hour-glass contraction; in some instances its whole surface appears as if grown to the uterus, forming an adhesion so close and intimate as to be overcome with the greatest difficulty: we have met with cases where the placenta tore up into shreds which still adhered to the uterus as strongly as before; in others, however, the adhesions are of smaller extent, varying from the size of a shilling to that of a crown piece, sometimes there being only one, sometimes two or three in the same placenta. The nature of these adhesions is but little understood; it is generally considered that they have been produced by some inflammatory process taking place between the uterus and placenta; and certainly the firm feel and lighter colour of the part which has been adherent might, perhaps, justify such a conclusion. Cases have occurred where the inflammatory action has extended in the contrary direction (outwards,) producing mischief in the neighbouring parts, viz. abscess and injury of the pelvic periosteum with subsequent pelvic exostosis. (_Neue Zeitschrift für Geburtskunde_, band v. heft 1.) We may also observe, that these adhesions of the placenta usually occur several times in the same individual. _Prognosis and treatment._ The danger in these cases depends chiefly on the presence or absence of hæmorrhage; in the latter case, we may wait safely, and give the uterus the opportunity of contracting upon the placenta, so as ultimately to dilate the stricture and expel it. In most instances, where the os tincæ is the seat of the contraction, and the placenta (as is usually the case here) already detached, a little patience, aided by gentle friction of the fundus, and carefully abstaining from all irritation of the os uteri, will be sufficient to attain this object; the os uteri will gradually relax and the placenta slowly exude into the vagina. Where, from the feel of the fundus, the uterus appears still unable to exert such a degree of contraction as shall overpower the os uteri, we may follow the plan of Dr. Dewees, in his section "On the enclosed and partially protruded Placenta," and rouse its activity by some doses of ergot: "should this not succeed within an hour, the uterus must be gently entered, by slowly dilating the os uteri, and the placenta removed." One finger after the other must be passed through the os uteri, until it has yielded sufficiently: if the placenta be quite detached, two fingers will generally be sufficient for this purpose, by which means it may be gradually brought down into the palm of the hand, and then removed. Where more or less of it is morbidly adherent, which may be presumed when it continues for some time at the upper part of the uterus without any disposition to descend, we must carefully introduce the whole hand, and endeavour to find the edge of the placenta at which we should begin the process of separation. Where, however, the edge is very thin, and the attachment firm, it is not easy to effect this without risk of injuring the structure of the uterus itself with the nails, nor can we always distinguish the thin and closely adherent edge of the placenta from the uterus itself: in these cases it will be safer to plunge the fingers into the central and thicker portions of the mass, and gradually separate it towards the circumference. Wherever this close adhesion prevails over a considerable extent, it becomes nearly impossible to prevent portions being left adhering to the uterus; thus it not unfrequently happens, where a placenta under these circumstances has been artificially removed, that there are one or more large irregular cavities on its uterine surface, from a portion of its mass having been torn from it, and left adhering. Cases have occurred to us,[134] where the whole central portion has thus remained, the amniotic surface of the placenta having come away entire with the larger umbilical vessels attached to it, and merely a narrow margin of parenchyma at its edge; in others, the whole mass has broken up, the cord, the larger branches of the umbilical vessels, and the membranes have come away, but the greater part of the placenta has remained closely adhering to the uterus. In such a case it becomes a question, whether it be safe to persist in our efforts to remove the remains of the placenta, or whether it will not be better to leave the case to nature: experience shows that the latter plan is the safer, and that a practitioner is not justified in running the risk of severely injuring the uterus by repeated and violent efforts to effect his object. _Placenta left in the uterus._ Where a portion of placenta has been thus left in the uterus, the case may terminate in one of three ways: either it may be expelled in the course of from twelve to twenty-four hours, without any perceptible marks of putrefaction, and with but little or no disturbance to the system; or where, after a longer interval, the discharges have become very offensive, and the placenta has been expelled in a putrid state, with serious disturbance of the health; or lastly, where the lochia has been sparing but natural, and where no trace whatever of the placenta has appeared. In the first mode of termination it may be presumed that the attachment of the placenta has yielded either to the continued contraction of the uterus, or from a slight degree of incipient putrefaction, by which its union with the uterus was weakened; in the second case, from contact with the external air, and being constantly kept at a considerable temperature by the heat of the surrounding parts, the lacerated placenta rapidly putrefies, putrid matter is carried into the system, producing all the effects of a deadly poison, and the patient is placed in a state of the greatest danger; the pulse becomes quick and small, the tongue red and dry, accompanied with great depression of the vital powers, the uterus frequently swells, grows hard, and excessively painful, followed by general peritonitis; it is not, however, the inflammation which necessarily destroys the patient, but the prostrating effects upon the nervous system, produced by the introduction of an animal poison into the circulation. _Absorption of retained placenta._ Where the placenta has not been much lacerated, or at any rate where every portion has been removed which could be separated without violence, where also the uterus has contracted firmly and closely, the part which is retained does _not_ pass into putrefaction, little or no inconvenience is experienced by the patient; the lochia, as we before observed, is sparing but natural, and ceases after the usual time, but not a trace of the placenta comes away. This fact has been repeatedly noticed, especially in later years; but the attention of medical men was first called to the subject by Professor Naegelé, of Heidelberg, in 1828. In 1802, and again in 1811, cases of premature expulsion of the foetus occurred to him where the membranes and placenta did not come away, and where no trace whatever of them appeared afterwards. In 1828[135] his assistance was required in a case of unusually firm adhesion of the placenta, and where, from this as well as other circumstances, the extraction was so difficult that he was compelled to leave considerably more than one-third in the uterus. (_Med. Gaz._ Jan. 10, 1829.) About the same time, a most interesting case was published by Professor Salomon, of Leyden, where the _whole_ placenta of a child only three weeks short of the full time was retained by the firm contraction of the uterus, and, according to Dr. Salomon's view of it, removed by the process of absorption. About the end of the third week, the uterus, which had hitherto been larger than is natural under ordinary circumstances after labour, and more globular, now diminished considerably, and began to assume the usual form as in the unimpregnated state. Besides the cases already alluded to, which we have described in our Midwifery Hospital Reports, we may again refer to one which was mentioned by Dr. Young, formerly professor of Midwifery at Edinburgh: "I could get my hand to the placenta, but no farther, the uterus having formed a kind of pouch for it, so that I at last was obliged to trust to nature; _what was very remarkable, the placenta never came away_, yet the woman recovered." Cases have also occurred where the placenta, after having been retained many days in the uterus, has been expelled quite fresh, the edges worn or rather dissolved away by the process of absorption; thus Dr. Denman mentions one where the whole placenta was retained till the fifteenth day after labour, and was then expelled with little signs of putrefaction except upon the membranes, the whole surface which had adhered exhibiting fresh marks of separation. Cases of abortion have occasionally been observed where the embryo has escaped, but the secundines have never come away, although the discharges, &c., have been watched with the greatest attention; after a time the menses have returned, the patient has again become pregnant, and has passed through her labour at the full term without any thing unusual occurring. The subject has recently been considered very fully, and much interesting knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the fact beyond all doubt, he shows that cases of total adhesion are rarely if ever fatal; and that, where cases have terminated fatally, the placenta has only partially adhered, and the patient has been either destroyed by hæmorrhage, or by the effects arising from the absorption of putrid matter, or from injury of the uterus in attempting to remove the placenta. He considers that a placenta which is not fixed to the uterus by organic and intimate adhesions cannot be absorbed, though it may perhaps be retained for several days without danger, if there is contraction of the uterus. (_Gazette Médicale de Paris_, July 8, 1840.) It may, however, be doubted whether this last observation be correct, as it is a well-established fact that cows which had been supposed with calf, and in which the symptoms of pregnancy had again subsided, have afterwards been killed and nothing but the bones of the calf found in the uterus, the soft parts having been removed by absorption. The same fact has been observed also in sheep and other animals; and knowing how abundantly the human uterus is supplied with absorbents, coupled with what has been already stated, there can be little or no doubt but that the placenta in these cases had been acted upon by a similar process. Although we strongly deprecate repeated attempts to remove the adherent portions of placenta, especially where we have brought away a considerable quantity of its foetal part, still we would warn our readers against leaving any loose ragged pieces in the uterus, for these rapidly pass into putrefaction, and produce the alarming symptoms above-mentioned. The safety of our patient mainly depends on the firm contraction of the uterus preventing the access of air, and on our constantly removing, by means of injections, any putrid discharge which may have collected. The sparing quantity of lochia which has generally been observed, especially where the _whole_ surface of the placenta has adhered, can easily be accounted for, the greater portion of the vessels which ordinarily furnish this discharge being closed up by the adherent mass: from the same reason we can explain why cases of total attachment of the placenta are rarely or never attended with hæmorrhage. Lastly, should any symptoms of fever or abdominal inflammation supervene, they must be treated according to the rules which we have given under these heads.[136] CHAPTER IX. PRECIPITATE LABOUR. _Violent uterine action.--Causes.--Deficient resistance.--Effects of precipitate labour.--Rupture of the cord.--Treatment.--Connexion of precipitate labour with mania._ The second division of Dystocia comprises those species of labour where it becomes dangerous for the mother or child, without obstruction to its progress. Of these we shall first consider precipitate or too rapid labour, not only because it is liable to be followed by a great variety of injurious results, but also because it has received little or no notice by the obstetric authors of this country. Precipitate labour depends on one of two conditions; either the expelling powers exceed their ordinary degree of activity, or the resistance to the passage of the child is less than usual. "Every normal labour has a certain course, which is neither too slow nor too quick. The passages are thus dilated gradually and without excessive suffering; the uterus is felt alternately hard and soft; and the pains have certain and regular intervals, which become very gradually shorter, during which both mother and child are enabled to recover themselves." (Wigand, _Geburt des Menschen_, vol. i. p. 68.) _Violent uterine action._ In the present case the pains are extremely violent from the very commencement of the labour; they produce great suffering; each pain lasts a considerable time, and the intervals between them are very short. During their presence, the patient is irresistibly compelled to bear down and strain with all her force; the whole body partakes of the general excitement: the patient is more restless and less manageable than usual, her manner is altered and becomes strange; the head is hot, the face flushed, and the pulse quick and full. In some cases the intervals between the pains are scarcely perceptible, for one pain has scarcely left off before the next has already commenced; or the uterus falls into a state of continued violent contraction, which does not cease until the child is driven into the world. The abdomen is very hard during the pain, the whole body stiff and rigid; the patient expresses her sufferings very loudly, or actually raves with pain. From the constant and irresistible effort to strain, it seems as if she has scarcely time to get her breath, for she continues to hold it so long that respiration might be almost supposed to have stopped altogether. "As long as consciousness remains, the impulse to lay hold of any object within reach and pull by it is extraordinarily strong, until at length, in the midst of a violent scream, or grinding of the teeth, covered with sweat and with simultaneous evacuation of the rectum and bladder, she is suddenly delivered." (Wigand, _op. cit._ vol. i. p. 71.) _Causes._ This storm of uncontrollable uterine action "appears to depend upon an unusually powerful influence of the nervous system upon the contractile fibres of the uterus or upon a morbid degree of irritability." (_Ibid._) In some cases it appears as an individual peculiarity, every successive labour of the patient being remarkable for its violence and rapidity. Precipitate labours of this kind are frequently observed to be hereditary, and like an opposite and equally faulty condition of the expelling powers, viz. slow and lingering uterine action, are sometimes peculiar to certain families, the mother and the sisters of the patient having had all their labours peculiarly rapid and violent. The character of the catamenial periods before pregnancy is frequently observed to bear a considerable relation to that of the labours in the same individual; thus, if she has always suffered much pain and other symptoms of uterine excitement just before or during these times, so much so as even to require slight medical treatment to allay the periodical suffering, the uterus almost invariably manifests a similar degree of energy and irritability during labour. On the other hand, where the menstrual periods produce so little suffering or derangement that, but for the appearance of the discharge itself, the patient has scarcely any means of determining their recurrence, the uterus betrays a similar want of activity when labour comes on, which may therefore, _cæteris paribus_, be expected to be slow and lingering. Mental affections, which we have already shown to be capable of retarding labour, occasionally have the opposite effect, and rouse the uterus to violent action. It is well known that the dread of the forceps, which the practitioner has declared would be required, has frequently been followed by so much activity of the uterus as to render its application unnecessary. Where the patient is stout, robust, and plethoric, or of a nervous hysterical habit, this state of unruly uterine action is frequently attended with great cerebral excitement; during the pains she raves wildly, and for some time becomes quite unmanageable, or in other cases this state passes into actual convulsions. In febrile diseases, especially of the eruptive kind, the labour is usually of this character; the exertions of the uterus in such cases, especially in scarlet fever, are sometimes quite extraordinary, so that the child seems to be born without any effort on the part of the mother. This is of great importance in inflammation of the lungs, &c. where the patient would be unable to inflate the lungs to that extent which is necessary for any violent efforts. _Deficient resistance._ Where the rapidity of the labour arises from want of that degree of resistance to the expelling powers which is natural, it may depend on circumstances connected with the mother or the child; thus, it may arise from too large a pelvis; the head, covered by the inferior portion of the uterus, is forced down deeper into the pelvis than usual, especially if, as is not unfrequently the case, this state be accompanied with violent and powerful pains; the head may thus be actually forced through the os externum before it has passed the os uteri: cases have been recorded where nearly the whole uterus, has been thus protruded. In an "extraordinary case," as Deventer justly terms it, "the head of the child had passed the os externum as far as the shoulders, and only the summit of it was visible, three-quarters at least of the head being still enclosed in the uterus, although the head and neck had already passed." (_Novum Lumen_, part. ii. chap. 3.) In other cases the sudden expulsion of the child appears to depend merely upon the great dilatability of the soft parts, and may occur quite independently of any disease. We recollect a case of this sort where the patient, a healthy woman, had only two pains--the first awoke her out of a sound sleep and ruptured the membranes, the next drove the child with great violence into the bed. Where the patient is weakened by previous disease, and the soft parts are very relaxed and flaccid, they produce no resistance to the advance of the head: this condition is very unfavourable, "as it implies a greater state of relaxation, or want of tone, than is compatible with the welfare of the patient: hence it is seldom found to take place except when the unfortunate subject is sinking under the last stage of debility, as in phthisis," &c. (Power's _Midwifery_, p. 138.) The want of due resistance to the expelling powers may depend upon the size and hardness of the head; it is either smaller than usual, from the child being premature, or, if of the full size, the cranial bones are imperfectly ossified, the sutures are wide, the fontanelles large, and the whole head very yielding and soft; or it may depend on some congenital defect, in which the brain and cranial coverings are more or less imperfect. In the ordinary cases of precipitate labour the case depends generally on a complication of violent pains, wide pelvis, and small child. _Effects of precipitate labour._ Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration of the vagina, perineum, and hæmorrhage from inertia coming on in consequence of the uterus being so suddenly emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of pressure which the gravid uterus had exerted upon the abdominal circulation during pregnancy. Where the patient has been very unruly, and has exerted herself with great violence, "emphysema of the face and neck (says Dr. Reid) may suddenly occur during labour, and cause great alarm to a young practitioner, as it alters and disfigures the countenance in an extraordinary manner. Great straining or screaming may produce it, and it probably depends on some partial rupture of the lining membrane of the larynx. I have seen two or three cases of this description, and one which occurred to a great extent in the case of an out-patient of the General Lying-in Hospital, in whom this tumefaction spread to the shoulders and chest." (_Manual of Pract. Midwifery_, by James Reid, M. D. p. 231.) The _child_ also may suffer from a precipitate labour, where the pains are excessively violent and run into each other, so that the whole labour is effected during one continued storm of uterine action. If the membranes have given way at an early period, so that the body of the child is exposed to the immediate pressure of the pains, the abdominal circulation suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a recumbent posture upon the floor: in this way it may receive a severe injury upon the head, or the cord may be lacerated, and the child die from hæmorrhage before assistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and vagina is such as to expel the child obliquely downwards and forwards when the mother is in the upright posture, so that the force of the blow is in a great measure broken by this circumstance; the head also, as well as the other parts of the body, are soft and yielding, and nearly preclude the chances of injury taking place; the violence of the fall is generally diminished in some measure by the patient being almost always compelled to drop upon her knees at the moment of great suffering, whilst the child is passing; her clothes also surround it more or less, and thus shield it from any severe injury. _Rupture of the cord._ The cord is liable to be torn in these cases, showing that a considerable jerk had been applied to it, but neither the child nor its mother have suffered from it. Ten or twelve cases of ruptured cord have come to our own immediate knowledge, and in none of them were any unfavourable effects produced. It can scarcely be imagined possible that so much force could be applied to the cord, at the moment when the uterus is so suddenly evacuated, without inversion or prolapsus being the almost unavoidable result, the more so when we recollect that the cord at the moment of birth requires considerable force to break it. This circumstance may be partly attributed to the firmness with which the uterus contracts at the moment that the child is expelled, but chiefly to the fact that the axis of the brim is nearly at right angles with that of the outlet, more especially if the fundus, as is usually the case, is inclined somewhat forwards; the cord passes round the posterior part of the symphysis pubis as upon a pulley, so that a considerable portion of the force which is applied to it, is spent here before reaching the fundus uteri. It is however remarkable, that the umbilicus of the child should receive no injury from a jerk which breaks the cord, when, if we try afterwards to break the remaining pieces of the cord, we find that it will resist very powerful efforts: this fact, and the circumstance that the cord usually ruptures at about two or three inches from the umbilicus, as in some animals, seems to imply that this part is weaker than elsewhere, as if intended by nature to give way with a moderate degree of force. Wigand considers that patients are particularly disposed to have quick labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that such patients are very liable to have adhesion of the placenta after the birth of the child, with hour-glass contraction: the observation, however, has not been confirmed by the experience of others, and certainly not by the cases which have come under our own notice. _Treatment._ Where, from the smallness of the child or unusual size of the pelvis, the pains are forcing the lower portion of the uterus down to, or through, the os externum, it will be necessary to support it carefully, until the os uteri is sufficiently dilated to let the head pass. A case of this kind occurred to Professor Naegelé, of Heidelberg, where, during the patient's former labour, the pains had been so violent, and the uterus had been detruded to such an extent, that actually the lower half of it appeared between the labia: to prevent a similar accident occurring this time, (as the pains were beginning to show the same disposition to violent action as before,) he applied a broad T bandage very firmly upon her, coming over the os externum, so as to prevent the uterus being prolapsed beyond the labia; he cut a hole in it corresponding to the vagina, and the child was born through this with perfect safety to the mother. Where we have sufficient warning, opium in effective doses will probably assist in lulling the irritability of the uterus: if the bowels have been previously well opened, an opiate enema will be desirable; if not, a large emollient enema should be premised. The patient should be made to lie upon her side, and not only strictly forbidden to resist to her very utmost, the urgent impulse which she feels to strain and bear down, but must carefully avoid even holding by or pushing against any fixed body with her hands or feet. Still farther, to quiet the turbulence of the abdominal muscles, a broad bandage should be fastened firmly round the abdomen; it not only gives the patient a comfortable feeling of support, but tends greatly to calm the spasmodic irritability of these muscles. These precautions will be of so much more service if they can be used early, as in cases where we have been already warned by the character of her previous labours: we can thus avoid the premature rupture of the membranes, which is a thing by all means to be avoided; the uterus acts with increased power where its bulk has been diminished by the escape of the liquor amnii, and at the same time becomes still more irritable and unruly from contracting immediately upon the child; and not only is there imminent danger of its giving way in some part, but the child is almost inevitably destroyed by the violence of the pressure to which it is exposed. In cases where the vehemence of the expelling powers appears to be quite beyond our control, Wigand has recommended a copious bleeding to complete syncope as the only means; in which suggestion, he has been followed by Froreip: neither of these authors, however, appear to have had any experience of this mode of treatment, and knowing how much more active the uterus becomes after a smart bleeding in ordinary cases, and how powerfully the state of syncope promotes the dilatability of the soft parts, we should hesitate exceedingly to employ so doubtful a remedy. Wigand also proposes, in cases of this desperate nature, to use effusion with ice-cold water to the abdomen and lower extremities, and by this powerful species of counter-irritation, produce a temporary calm for a few minutes--a measure we should fear of as doubtful a character as bleeding. _Connexion of precipitate labour with mania._ Lastly, we may observe, that the subject of precipitate labour involves a medico-legal question of great importance and interest, which has as yet excited little or no notice in this country, viz. as regards acts of child-murder after labours of this character. The state of mental excitement and frenzy into which a patient is brought, by a labour of such violence and suffering, in many cases falls little short of actual mania. We now and then meet with instances, where, for the first half hour or so after a severe and rapid labour, the patient takes a most insurmountable antipathy to her child, and expresses herself towards it in so unnatural a manner, as to contrast strangely with the tender and affectionate feelings which she had a short time previously expressed for it. Cases have occurred where the patient has been without assistance, during labour, and where, in a state of temporary madness from mental excitement and pain at the moment of the child's birth, she has committed an act of violence upon it, which has proved fatal; a circumstance, which, from obvious reasons, would be more liable to occur with single than with married women. These cases have been very carefully investigated in Germany of late, and in many of them the patient has been, we think, very properly acquitted, on the grounds of temporary insanity, having herself voluntarily confessed the act with the deepest remorse, at the same time declaring her utter incapacity to account for the wild and savage fury which seized her at the moment of delivery. CHAPTER X. PROLAPSUS OF THE UMBILICAL CORD. _Diagnosis.--Causes.--Treatment.--Reposition of the cord._ Although by no means a common occurrence, it every now and then happens that a portion of the umbilical cord falls down between the presenting part of the child and the mother's pelvis either just before or during labour; so that, as the child advances through the passages, its life is placed in imminent danger from the pressure to which the cord is exposed, obstructing the circulation in it. There is probably no disappointment, which the accoucheur has to meet with more annoying than a case of this kind; every thing has seemed to promise a favourable labour; the presentation is natural, the pains are regular, the os uteri is dilating readily, the mother, and, as far as we can ascertain, her child, are in perfect health, and yet because a minute loop of the cord has fallen down by the side of its head, the labour, unless interfered with by art, will almost necessarily prove fatal to it. _Diagnosis._ If the membranes be not yet ruptured, we shall probably be able to feel a small projecting mass like a finger, close to the presenting part, and possessing a distinct pulsation, which, from not being synchronous with the mother's pulse, instantly declares its real nature. When the membranes give way, more of the cord comes within reach, and probably forms a large coil, which passes through the os uteri into the vagina, or even appears at the os externum. _Causes._ The earliest writer that we know of who has given a detailed account of cord presention was Mauriceau; few, even in hospital practice, and certainly none in private practice, have exceeded him in the number of cases described, and very few have surpassed him in the success of his treatment. He mentions chiefly three conditions as being liable to produce prolapsus of the cord, viz. a large quantity of liquor amnii, an unusually long cord, and malposition of the child: later authors have enumerated several other causes, many of which are imaginary; of these, by far the most correct list has been given by Boer, of Vienna, who has justly ridiculed the theoretical views which were maintained by his cotemporaries. "If there be a large quantity of liquor amnii present, and especially, as is not unfrequently the case, the child is at the same time under the usual size; if the head be not firmly pressed against the brim, and does not enter it sufficiently, or when the child's position is faulty, especially if, at the same time, the cord is unusually long; if, under such circumstances, a large bag of membranes has formed, and the brim of the pelvis itself is very spacious; if perchance, the rupture of the membranes takes place at a moment when the patient is moving briskly on in some unfavourable posture, the cord will be very liable to prolapse. Nevertheless, cases are occasionally seen which arise without these predisposing circumstances." (Boer, _von Geburten unter welchen die Nabelschnur vorfällt_.) The uterus is the chief means by which the cord is prevented from falling down between the presenting part of the child and the passages, from the closeness with which its inferior portion encircles it: without this, from the erect posture of the human female, there would be a liability to prolapsus of the arm or cord in every labour. "The contraction of the uterus, which comes on with the rupture of the membranes, and sometimes, where they protrude very much, even before, is of great importance. This contraction takes place in the inferior segment of the uterus; it surrounds the head, and when fully developed extends over the whole head of the child. Thus, for instance, if we attempt to operate at an early stage, it feels more like a hard ring round the head, of about a finger's breadth, and it may be felt to extend itself higher up, in proportion as the stimulus of the hand excites the activity of the uterus." (Michaelis, _Neue Zeiteschrift für Geburtskunde_, band iii. heft. 1.) Hence, therefore, whatever prevents the uterus from contracting with its inferior segment upon the presenting part of the child, deprives the cord of its natural support, and, therefore, renders it liable to prolapse. Many of the causes enumerated by Boer act in this way; thus, where the uterus is distended by an unusual accumulation of liquor amnii; where the contractions at the beginning of labour have been exceedingly irregular; where the arm, or shoulder, or feet present; or where a large bladder of membranes is formed, the lower part of the uterus will either not contract at all upon the head, or so imperfectly as to endanger the descent of the cord. Malposition of the child has been mentioned by many authors as a cause of prolapsus of the cord, and in some cases it may possibly act thus from the inferior segment of the uterus being unable to surround sufficiently close so irregular a mass as the shoulder. In the majority of cases, however, the coincidence of these two circumstances depends upon their being produced by the same causes; thus an unusually large quantity of liquor amnii, or irregular contractions of the uterus, will just as much dispose to the one as the other. The form or size of the pelvis can have, we think, but little effect upon the cord, so long as the uterine action is of the right character and the child alive. Most authors enumerate a large pelvis or small foetal head as a cause, why should we not, therefore, have prolapsus of the cord in every case of precipitate labour which arises from such circumstances? Nor are we at all disposed to consider deformed pelvis as capable of producing it, so long as the uterus is not immoderately distended and acting naturally: we do not deny that the cord is occasionally found prolapsed in cases of dystocia pelvica, but this is chiefly where the child has died from the severity of the labour, and where the flaccid pulseless cord has gradually slipped down during the intervals of the pains. So long as the uterus exerts but a moderate degree of pressure round the head, it is impossible for the cord of a living child to descend, particularly as, according to Dr. Michaelis, the circular contraction of the portio vaginalis commences from below upwards, and would rather push back the cord if a portion of it had descended during the moments of uterine relaxation. The pulsating turgor of the cord when the child is alive will also assist much in preventing its descent, even where the uterus does not surround the presenting part so closely as usual. The unusual length of the cord is also a very doubtful cause of its prolapsus, and will evidently, in great measure, depend upon the causes we have already alluded to. We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it excited the attention of Professor Naegelé, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the placenta, so that if the edge of the placenta touched upon the os uteri, the cord was usually inserted into that part of its edge which corresponded with the os uteri. Although it is certain that the situation of the placenta close to the os uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circumstances we ought to have every case of partial placenta prævia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus. "There is no doubt that the situation of the placenta in the vicinity of the os uteri, may be looked upon as one of the predisposing causes of the cord presenting during labour; an accident which is the more to be feared, the nearer the cord is inserted into the inferior edge of the placenta. If its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way." (_Die Geburtshülfliche Auscultation_, von Dr. H. F. Naegelé, p. 114.) The two cases referred to by Professor Naegelé, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circumstance the more remarkable. The fact was noticed by Giffard as early as in 1728, in a case of flooding from partial placenta prævia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was "in part, if not wholly, separated from the uterus."[137] Prolapsus of the cord is fortunately not a circumstance of frequent occurrence. Dr. Churchill, of Dublin, in a valuable paper, (_Edin. Med. and Surg. Journal_, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282-1/4.[138] That prolapsus of the cord occurs most frequently in foot presentations, as supposed by Professor Naegelé, senior, is disproved by the results of Mauriceau's large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or foot, 1 with the hand and breech, and 1 with the hand and head. In the 16,652 births which have been recorded by Dr. Collins, at the Dublin Lying-in Hospital, the cord prolapsed in 97 instances. "_Twelve_ of the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child. _Nine_ occurred where the feet presented, (not including two met with in twin children,) which was in the proportion of _one_ in every _fourteen_ of such presentations. _Two_ only where the breech presented, which was in the proportion of _one_ in every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which is _one_ in 171-1/2. _Four_ occurred where the shoulder or arm presented: this is in the proportion of _one_ in _nine_ of such presentations. _Seven_ occurred where the hand came down with the head. _Seven_ of the children were born _putrid_; _three_ of the 97 were premature, viz. _two_ at the seventh and _one_ at the eighth month." (Collins's _Practical Treatise on Midwifery_, p. 346.) We may, therefore, conclude with safety, that presentations of the head are by far the most common. _Treatment._ Left to itself prolapsus of the cord is almost certain destruction to the child, for unless the labour comes on very briskly, and the head passes rapidly through the pelvis, the cord is pressed upon so long as to render it impossible for the child to be born alive. Still, however, where the passages are yielding, and the pains active; where the head is of a moderate size, the pelvis spacious, and the cord in a favourable part of it, viz. towards one of the sacro-iliac synchondroses; where also the membranes remain unruptured until the last moment, there will be a very fair chance of the child being born alive. Under no circumstances is it of such paramount importance to avoid rupturing the membranes as in these cases, for the bag of fluid which they form dilates the soft passages and protects the cord from pressure. "Many methods of relief have been recommended, such as turning, delivering with the forceps, pushing up the funis through the os uteri with the hand, and endeavouring to suspend it on some limb of the child, collecting the prolapsed cord into a bag, and then pushing it up beyond the head, pushing up, the funis with instruments of various kinds, endeavouring to keep it secured above the head by means of a piece of sponge introduced; these and many other similar expedients have been resorted to." (Collins, _op. cit._ p. 344.) The first two of these means have been chiefly used in cases of prolapsed funis, the others having, for the most part, been found entirely inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned 19 times: the children were all born alive, except one, which was dead, but required turning as it presented with the arm. In later times, turning or the forceps have been preferred, according to the period of labour at which the prolapsus was discovered or occurred. Thus Madame Boivin has recorded 38 cases, 25 of which occurred at the commencement of, and 13 during labour, the former were all turned; in the latter the forceps was used; 29 children were saved, seven were lost, and the two others were putrid. Our practice must be in great measure guided by the circumstances of the case: where the os uteri is not fully dilated, where the head is still high and not much engaged in the pelvis, the liquor drained away, and the cord beginning to suffer pressure during the pains, we dare not wait until the case be sufficiently advanced to admit the application of the forceps, but must proceed as soon as possible to turn the child. The operation should be performed with the greatest possible caution; the cord should be guided to one of the sacro-iliac symphyses; the expulsion of the trunk must be very gradual; a dose of secale should be given to ensure the requisite activity of the uterus when the head enters the pelvis, and the forceps kept in readiness to apply the instant that its advance is not sufficiently rapid. On the other hand, where the labour has made considerable progress before the membranes give way, and the head has fairly engaged in the cavity of the pelvis, if the os uteri is fully dilated, it will be no longer advisable to attempt turning; the head is within reach of the forceps, which should be immediately applied, taking care that the cord does not get squeezed between the blades and the head. Where the arm or shoulder presents, this will of itself require that the child should be turned. _Reposition of the cord._ Although the reposition of the cord has been recommended from the time of Mauriceau, and by the majority of authors since, it has nevertheless met with so little success as to have fallen into complete disuse until the last few years; one of its strongest opposers was the celebrated La Motte. "The delivery ought to be attempted as soon as we find that the string presents before the head, it being to no purpose to try to reduce it behind the head, which at that time fills up the whole passage, and can only admit you to push it back into the vagina, and it will fall down again at every pain; and if you have done so much as to reduce it into the uterus, what hinders you from finishing the delivery at once, by seeking for the feet? the chief difficulty is then over." (_La Motte_, English translation, p. 304.) This mode of delivery (turning) has been more adopted by practitioners in such cases than any other, especially in former times, when the forceps was either not at all or imperfectly known; by none has it been so with more success than by Mauriceau himself, having saved every living child in which he attempted the operation. Still, however, he recommended that the attempt should be made to return the cord wherever it was possible, and has recorded four cases of this mode of treatment, all of which proved successful, although one of the children was born so feeble as to die shortly afterwards. Giffard seems to have attempted the reposition of the cord only once, and failed, apparently from the unusual size of the child. In later years Sir R. Croft, "has related two cases in which he succeeded, by carrying the prolapsed funis through the os uteri, and suspending it over one of the legs of the child. In both these cases the children were born alive." (Merriman's _Synopsis_, p. 99.) It is to Dr. Michaelis of Kiel that we are indebted for much recent and valuable information on the subject of replacing the prolapsed cord. Having pointed out the fact that it is the uterus alone which prevents the cord from prolapsing, he shows that, in order to replace the cord, we must carry it "above that circular portion of the uterus which is contracted over the presenting part." The reposition of the cord may be effected by the hand, or by means of an elastic catheter and ligature. In replacing the cord by means of the hand alone, Dr. Michaelis remarks that we shall effect this more readily by merely insinuating the hand between the head and the uterus, and gradually passing it farther round the head, pushing the cord before it. In this manner we do not require to rupture the membranes when we have felt the cord before the liquor amnii has escaped; a point of considerable importance. The reposition, by means of the catheter, is effected by passing a silk ligature, doubled, along a stout thick elastic catheter, from twelve to sixteen inches in length, so that the loop comes out at the upper extremity; the catheter is introduced into the vagina, and the ligature is passed through the coil of the umbilical cord, and again brought down to the os externum. A stilet with a wooden handle is introduced into the catheter, the point passed out at its upper orifice, and the loop of the ligature hung upon it; it is then drawn back into the catheter and pushed up to the end. The operator has now only to pull the ends of the ligature, so as to tighten it slightly, passing the catheter up to the cord, which now becomes securely fixed to its extremity. When the reposition has been effected, he has merely to withdraw the stilet; the cord is instantly disengaged.[139] To prevent any injury, the ligature should be brought away first, and then the catheter. "Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where it has been returned by the above means, in nine of which the child was born alive. In three cases the arm presented also, which was replaced, and the head brought down; in two of these the child was born alive." (_British and Foreign Med. Review_, vol. i. p. 588.) A similar plan of replacing the cord by means of an elastic catheter has been tried by Dr. Collins, but he had not tried it sufficiently often at the time of publishing his _Practical Treatise_ to be able to give a decided opinion about it. The plan of introducing a piece of sponge after replacing the cord, in order to prevent its coming down again, is of no use whatever. Dr. Collins tried it in several instances, and considers that "it is quite impossible, however, in the great majority of cases, to succeed in this way in protecting the funis from pressure, as it is no sooner returned, than we find it forced down in another direction." The plan has been recommended by several modern authors, but it is by no means a new invention, having been proposed by Mauriceau; it does not appear, however, that he ever put it in practice. Where no pulsation can be felt in the prolapsed funis, which is flabby and evidently empty, no interference will be required; the child is dead, and therefore the labour may be permitted to take its course. We should, however, be cautious in examining the cord where it is without pulsation, and yet feels tolerably full and turgid, for a slight degree of circulation may go on nevertheless, sufficient to keep life enough in the foetus, even for it to recover if the labour be hastened. We should especially examine the cord during the intervals of the pains, and after we have guided it into a more favourable part of the pelvis, where it will not be exposed to so much pressure, for then the pulsation will become more sensible to our touch, and prove that the child is still alive. The following case by Dr. Evory Kennedy is an excellent illustration of what we have now stated:--"The midwife informed me that there was no pulsation in the funis, which had been protruding for an hour; on examination made during a pain, a fold of the funis was found protruding from the vagina, at its lateral part, and devoid of pulsation. As the pain subsided, I drew the funis backwards towards the sacro-iliac symphysis, and thought I could observe a very indistinct and irregular pulsation; I now applied the stethoscope, and distinguished a slight foetal pulsation over the pubes. Fortunately on learning the nature of the case, I had brought the forceps, which were now instantly applied, and the patient delivered of a still-born child, which, with perseverance, was brought to breathe, and is now a living and healthy boy, four years of age. Had I not in this case ascertained by the means mentioned, that the child still lived, I should not have felt justified in interfering; but, supposing the child dead, would have left the case to nature, and five minutes, in all likelihood, would have decided the child's fate." (Dr. Evory Kennedy, _on Pregnancy and Auscultation_, p. 241.) CHAPTER XI. PUERPERAL CONVULSIONS. _Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.-- Tetanic species.--Diagnosis of labour during convulsions.-- Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.-- Apoplectic species.--Anæmic convulsions.--Symptoms.--Treatment.-- Hysterical convulsions.--Symptoms._ Women are liable, both before, during, and after labour to attacks of convulsions, not only of variable intensity, but differing considerably in point of character. We shall consider them under three separate heads, viz. epileptic convulsions with cerebral congestion; epileptic convulsions from collapse or anæmia; and hysterical convulsions. Other species have been enumerated by authors, but they are either varieties of, or intimately connected with, those of the first species. No author has more distinctly pointed out the fact that epilepsy may arise from diametrically opposite causes than Dr. Cullen; a circumstance which, in a practical point of view, is of the greatest importance. "The occasional causes," says he, "may, I think, be properly referred to two general heads; the first, being those which seem to act by directly stimulating and exciting the energies of the brain, and the second, of those which seem to act by weakening the same." "A certain fulness and tension of the vessels of the brain is necessary to the support of its ordinary and constant energy in the distribution of the nervous power" (_Practice of Physic_;) and hence it may be inferred that, on the one hand, an over-distention, and, on the other, a collapsed state of these vessels, will be liable to be attended with so much cerebral disturbance as to produce epilepsy. _Epileptic convulsions with cerebral congestion._ Epileptic convulsions connected with pregnancy or parturition, and which are preceded and attended with cerebral congestion, alone deserve, strictly speaking, the name of _Eclampsia parturientium_ (which, in fact, signifies nothing more than the epilepsy of parturient females,) being peculiar to this condition; whereas, the anæmic and hysterical convulsions may occur at any other time quite independent of the pregnant or parturient state. The term "puerperal convulsions" is employed in a much more vague and extended sense, and applies generally to every sort of convulsive affection which may occur at this period, and as such, it therefore, forms the title of the present chapter. _Causes._ The exciting cause of eclampsia parturientium is the irritation arising from the presence of the child in the uterus or passages, or from a state of irritation thus produced, continuing to exist after labour. The predisposing causes are, general plethora, the pressure of the gravid uterus upon the abdominal aorta, the contractions of that organ during labour, by which a large quantity of the blood circulating in its spongy parietes is driven into the rest of the system, constipation, deranged bowels, retention of urine, previous injuries of the head or cerebral disease, and much mental excitement, early youth: also "in persons of hereditary predisposition, spare habit, irritable temperament, high mental refinement, and in whom the excitability of the nervous, and subsequently the sanguiferous system is called forth by causes apparently trivial." (_Facts and cases in Obstetric Medicine_, by I. T. Ingleby, p. 5.) _Symptoms._ From the above-mentioned list of causes it will be evident, that these convulsions will be invariably attended and preceded by symptoms of strong determination of blood to the head. Previous to the attack the patient has "drowsiness, a sense of weight in the head, especially in stooping; beating and pain in the head; redness of the conjunctiva; numbness of the hands; flushing of the face, and twitching of its muscles; irregular and slow pulse; ringing in the ears, heat in the scalp, transient but frequent attacks of vertigo, with muscæ volitantes, or temporary blindness; derangement of the auditory nerve; embarrassment of mind and speech; an unsteady gait; constipation and oedematous swellings." (Ingleby, _op. cit._ p. 12.) As the attack approaches, the patient frequently complains of a peculiar dragging pain and sense of oppression about the præcordia, which comes on and again abates at short intervals, and is attended with much restlessness and anxiety: this is followed by intense pain, which usually attacks the back of the head, and upon the accession of which the præcordial affection apparently ceases; the pulse now becomes smaller and more contracted. If the convulsions do not make their appearance by this time, and the headach continues one or more hours, a slight degree of coma supervenes, the patient loses her consciousness more and more, and wanders now and then; after a time she becomes restless and evidently uneasy, the eye becomes fixed and staring, the countenance changes, and the outbreak of convulsive movements follows. Sometimes the premonitory symptoms are much less marked; indeed, in some cases, there is scarcely a sign to warn us of the impending danger; in the midst of a conversation the patient becomes suddenly silent, and, on looking to see the cause, we find the expression altered, the muscles of the face are twitching, the features beginning to be distorted, and the next moment she falls down in general convulsions. Wigand (_Geburt des Menschen_, vol. i. § 102,) considers that the two symptoms which usher in the attack are, the frightful staring followed by rolling of the eyes, with sudden starts from right to left, and twisting of the head to the same side by the same sudden movements; as soon as the convulsions have commenced, the head generally returns to its former position, or rather is pulled more or less backwards; "the eyes are wide open, staring, and very prominent, the eyelids twitch violently, the iris is rapidly convulsed with alternate contractions and dilatations; the face begins to swell and grow purple, the mouth is open and distorted, through which the tongue is protruded, brown, and covered with froth; the lips swell and become purple: in fact, it is the complete picture of one who is strangled." (_Op. cit._) These convulsions, as in common epilepsy under other circumstances, usually if not always commence about the head and face, gradually passing down to the chest and abdomen, and then attacking the extremities. After the above-mentioned changes, they pass into the throat and neck, by which a state of trismus is produced, and the protruded tongue is not unfrequently caught between the teeth and severely wounded. The neck is violently pulled on one side, and from the pressure to which the trachea is subjected, severe dyspnoea is produced. The respiration is nearly suspended, and from the violent rushing of the air as it is forced through the contracted rima glottidis, the breathing is performed with a peculiar hissing sound. The muscles of the chest now become affected, and the thorax is convulsively heaved and depressed with great vehemence; those of the abdomen succeed, and the convulsive efforts are here, if possible, still more violent: such are the contractions of the abdominal muscles, and so powerfully do they compress the contents of the abdomen, that a person who had not previously seen the patient would scarcely believe she was pregnant; the next moment the abdomen is as much protruded as it was before compressed. From the same cause, the contents of the rectum and bladder are expelled unconsciously, the extremities become violently convulsed, and the patient is bedewed with a cold clammy sweat. The duration of such a fit is variable; it seldom lasts more than five minutes, and frequently not more than two, and then a gradual subsidence of the convulsions and other symptoms follow; the swollen and livid face returns to its natural size and colour, the eyes become less prominent, the lips less turgid, the breathing is easier and more calm, the viscid saliva ceases to be blown into foam from the mouth, and the patient is left in a state of comatose insensibility or deep stertorous sleep, from which, in the course of a quarter of an hour or twenty minutes, she suddenly awakes, quite unconscious of what has been the matter; she stares about with a vacant expression of surprise; she feels stiff and sore as if she were bruised: this will be especially the case if it has been attempted to hold her during the fit. The convulsive efforts of the muscles of the body and extremities are not easily resisted, and thus it is that we hear of a delicate woman under these circumstances requiring several strong men to hold her: the result of such treatment is, that her muscles and joints are severely strained, and continue painful for some time after. Patients, on recovering their senses, frequently complain of pain and soreness in the mouth, arising from the tongue having been bitten; in some cases where the tongue has been much protruded, the injury is very severe, the tongue being bitten completely across, and hanging only by a small portion. The woman may suffer but one attack, and have no return of the fit, or in half an hour, an hour, or longer, the convulsions again appear as at first. If this happens several times, she does not recover her consciousness during the intervals, but remains in a continued state of coma from one fit to another. Although it rarely happens, that the patient dies during a fit, still nevertheless, one fit will in some cases be sufficient to throw her into a state of coma from which she does not recover; in others, the patient may lie for even twenty-four hours in strong convulsions and yet recover. The character of these attacks appears to vary a good deal with the cause; thus, where plethora has been the predisposing cause, and the fits frequently repeated, they take on more or less of an apoplectic character, the coma is more profound and of longer duration, and is frequently attended with paralysis; the cerebral affection is more severe, the patient does not recover her senses even where the intervals between the attacks have been of considerable duration; and when the fits have ceased and the coma abated, she is occasionally left in a state of imbecility and blindness, which lasts for several hours or even days. Where it is connected with constipation or deranged bowels, we think that we have seen it more frequently attended with delirium or even temporary mania; the fits are numerous, the convulsions as severe, but the cerebral congestion is not so intense, the coma less profound; instead of being left in a state of torpid stupor, the patient is very restless and at times unmanageable, and when we consider the identity of the causes which produce these convulsions and one form of purerperal mania, it will be easily understood why the symptoms should assume this character. The degree also of determination to the head, will in no slight measure influence the character of the symptoms which attend these attacks. "One circumstance," says Dr. Parry, "of increased impetus deserves to be noticed. The delirium is preceded by a pain in the head, but as the delirium comes on, the pain ceases, though the impetus remains as before, or perhaps increases. Diminish in a slight degree the impetus, and you remove the delirium and renew the pain; diminish the impetus in a greater degree, and the frown on the forehead is relaxed, the features seem to open, and the pain entirely ceases." (_Posthumous Medical Writings_, vol. i. p. 263.) By far the majority of cases of eclampsia parturientium occur in primiparæ: thus in thirty cases which occurred to Dr. Collins, during his mastership at the Dublin Lying-in Hospital, "twenty-nine were in women with their first children, and the other single case was a second pregnancy, but in a woman who had suffered a similar attack with her first child." In two instances, under our own notice, where the disease occurred in multiparæ, the fits did not appear until _after_ delivery; the patients were plethoric, and in one especially, the bowels were excessively deranged; in the other, the attack had much of the apoplectic character, and the coma did not at once abate until the fatal termination. Convulsions usually make their appearance towards evening; and if pains are coming on, they return with every uterine contraction. The patient's danger will, in great measure, depend upon the severity, frequency, and duration of the fits; and although they must ever be looked upon as a disease of the most dangerous character, yet we are justified in saying that in the majority of instances the patient recovers: thus, of the forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of the thirty by Dr. Collins, only five died, "three of which were complicated with laceration of the vagina, one with twins, and one with peritoneal inflammation. It is thus evident that the fatal result in these cases, with the exception of the twin birth, was not immediately connected with the convulsions; and the danger in all twin deliveries, _no matter what the attack may be_, is in every instance greatly increased." (_Practical Treatise_, p. 210.) Although puerperal convulsions usually occur at the commencement of labour, it not unfrequently happens that they do not come on until after the child is born; whereas, in other cases they occur several months before the full period: these varieties depend entirely upon the circumstances under which the attack has appeared. "With respect to their occurrence in the last month of gestation, although the paroxysm mostly appears during the actual dilatation of the os uteri, or on the first approach of labour, still when we recollect that in the last week or two of pregnancy the neck of the uterus is fully developed, the subsequent changes being confined to the os internum (the most sensitive part of the organ,) it cannot be surprising that, in very irritable persons, a serious impression should be made upon the brain at those periods." (Ingleby, _op. cit._ p. 11.) Dr. Merriman has called it _dystocia epileptica_: there is, in fact, no difference between this disease and common epilepsy, beyond that, under ordinary circumstances, epilepsy is a chronic affection, and, generally speaking, not attended with much danger, whereas, in the present case, it is an acute attack, and of a highly dangerous character. Many phenomena connected with uterine irritation, both in the unimpregnated state and during pregnancy, prove the intimate nature of the consent existing between the brain and uterus. Thus it is well known that menstrual irritation is accompanied with a great variety of nervous and hysterical symptoms, which are merely a part of the same series of results to which epilepsy itself belongs: it is occasionally attended with delirium, spasms, and even coma, and preceded by the oppression at the pit of the stomach and pain of head, which we have already noticed among the immediate precursors of puerperal epilepsy; on the other hand, as Dr. Parry has well remarked, "the beginning and end of each epileptic fit, before total insensibility begins and after it ceases, is often delirium, screaming, false impressions, attempt to annoy others under these impressions," &c. (_Op. cit._ vol. i. p. 396. &c.) Thus also during labour, either at the termination of the first stage, when the os uteri has attained its full degree of dilatation, or immediately after the birth of the child, the patient is frequently seized with a sudden convulsive rigour so violent as to make her teeth chatter and agitate the whole bed, and which is nothing more than a harmless modification of convulsive action arising from uterine irritation; the surface is perfectly warm, and the patient frequently expresses her surprise to find herself shivering thus violently and yet not feel cold. It has been a common opinion that epileptic puerperal convulsions are almost certainly fatal to the child, especially if they continue for any length of time: experience, however, proves the contrary, as cases continually occur where the mother has laid for many hours in a constant succession of severe convulsions, and yet has been ultimately delivered of a living child. Still, however, it must be owned, that barely an equal number of the children are born alive under these circumstances. Thus, in Dr. Merriman's 48 cases, as already mentioned, only 17 children were born alive (including the 6 born before the mothers were attacked with convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32 children (two of the women having had twins) were born dead; of these, however, it must be observed, that 8 were delivered with the perforator, and two were born putrid. _Tetanic species._ There is one modification of eclampsia parturientium, which, from the spastic rigidity of the uterus which accompanies it, is peculiarly dangerous to the child's life: it has been called the tetanic form: the convulsions are incessant, without any apparent interval, and the uterus actively participates in the state of general spasms: under such circumstances, the pressure which it exerts upon the body of the foetus will seriously obstruct the abdominal circulation, and produce the same effects as pressure on the cord. In most cases, however, the convulsions have no effect upon the process of labour, which continues its course uninterrupted; so that, where there has been no return of consciousness during the intervals between the fits, and the patient has laid in a continued state of coma for some time, the child may actually be born before there has even been a suspicion that labour was present. It is, therefore, of great importance that the practitioner should be on the watch to detect any symptoms of its coming on, not only for the purpose of giving her the necessary support at the moment of expulsion, but also such assistance as may tend to shorten that process. "By attentively observing what passes in cases of convulsions, we remark that they do not always interrupt the course of the labour pains, whether they had excited those pains, or the pains had preceded them. All authors relate examples of women who have been delivered without help after several fits of strong convulsions; and others while they were actually convulsed, whether there were lucid intervals between, or that the loss of understanding was permanent. The progress of labour in most of these cases seems even more rapid than in others, since we have often found the child between its mother's thighs, though an instant before we could discover no disposition for delivery." (_Baudelocque_, trans. by Heath, § 1109.) _Diagnosis of labour during convulsions._ Where the patient is in a state of insensibility, we may infer the presence of labour by a variety of symptoms; every now and then, from a state of torpor, she becomes restless, and evidently uneasy; she pushes the bed-clothes from the abdomen, and gropes about it as if trying to remove something that is heavy or uncomfortable; she writhes her body, and moans as if in pain; after awhile, she again relapses into her former state of coma. A little attention will soon show us that these exacerbations of restlessness are periodical; and if we examine the abdomen at the moment, we feel the uterus evidently contracting; the os uteri also will be found tense and more or less dilated: if the head has already advanced into the vagina, these contractions will be accompanied by a distinct effort to strain. It is rare to find convulsions complicated with malposition of the child; indeed, so uncommon is the occurrence of it under these circumstances, that we may feel almost certain, on being summoned to a case of convulsions, that there will be little chance of this additional difficulty being superadded. "There was but one case," says Dr. Collins, "of convulsions during my residence in the hospital, where the child presented preternaturally; there was not one case with a preternatural presentation during Dr. Clarke's residence; and Dr. Labatt has stated the same fact in his lectures while master of the hospital. In these three different periods there were 48,379 women delivered, so that from this we may infer, where the presentation is preternatural, there is little cause to dread the attack." (_Practical Treatise_, p. 200.) _Prophylactic treatment._ Under no circumstances is the old saying of "Prevention is better than the cure," so well illustrated as in the prophylactic treatment of puerperal epilepsy: it is only by carefully watching for and recognising those symptoms which we have already enumerated as threatening an attack, that we are able to adopt such measures as shall either keep it off entirely, or at any rate considerably diminish its violence. The treatment which we have recommended during the last weeks of pregnancy, is particularly valuable in keeping off any disposition to these attacks: regular, and for her condition even tolerably active, exercise and strict attention to the bowels, should be required, especially in primiparæ. If any distinct symptoms of cerebral congestion make their appearance, such as flushed face, headach, or slight wandering; if, moreover, the pulse be slow and labouring, we must at once relieve the circulation by bleeding; and by an active dose of calomel and James's powder at night with a warm pediluvium, and a brisk laxative the next morning, endeavour to ward off the dreaded attack. Not unfrequently, however, we have no warning of the danger until the fits burst out, and are thus debarred the opportunity of preparing against them. _Treatment._ During the fit itself little can be done beyond placing the patient in such a situation that she should not injure herself by her exertions. If she happens to be upon a chair when the attack begins, it will be as well to let her sink gently upon the floor, and lie there until the fit is over; if she is in bed when it comes on, we have merely to watch that she does not roll off during her struggles; her movements should be restrained as little as possible, and by so doing we shall spare her the suffering after the fit from strained muscles and half-wrenched joints, which is so severe where the assistants, from mistaken kindness, have endeavoured to hold her. It has been recommended by Dr. Denman to have the patient's face frequently dashed with cold water during the fit, a remedy which, as Dr. Merriman observes, is very effectual in ordinary hysterical paroxysms, and which possibly may have a slight effect in moderating the violence of the epileptic convulsions; but from what we have seen we are not inclined to consider it of much use. _Bleeding._ As soon as the fit is sufficiently over to render the operation possible, the patient ought to be placed in a half-sitting posture, and bled from a large orifice in the arm; the quantity of blood abstracted must be determined by the appearance of the patient, the severity of the cerebral symptoms, and the condition of the pulse; this latter will usually be found labouring, and even small, but will rise considerably in fulness and volume as we gradually relieve the circulation. Syncope is an effect which, under these circumstances, it would neither be easy nor safe to produce; but at the same time it will be highly desirable to produce a powerful effect upon the circulation by so large and speedy an abstraction of blood as shall be certain of alleviating the cerebral congestion: this is not often attained until after a loss of twenty, or five and twenty ounces. She should be supported in the half-sitting posture by means of a chair turned against the head of the bed, so that its back forms an inclined plane, which should be covered with pillows for her to lean upon. _Purgatives._ An active dose of purgative medicine should be given the moment the patient is able to swallow; for in case of the fit returning, it will be sometimes very difficult to make her take any thing. Eight or ten grains of calomel, with fifteen or twenty of jalap, should be mixed into a paste with a little thin gruel and laid upon the back of the tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If this cannot be taken, a few drops of croton oil will seldom fail to produce the necessary effect. It is of the greatest importance to do this as early as possible, not only for the reason we have just assigned, but also because we find that purgative medicines frequently take a longer time to operate in these cases than they do under ordinary circumstances, and require the repetition of even a powerful dose before the bowels can be made to act. Where the convulsions appear to depend in great measure upon the deranged state of the bowels, the indications for the immediate employment of purgatives become still more urgent, for although we may control the cerebral congestion by means of the lancet, we shall not remove the source of irritation; but when once the bowels have been freely evacuated, the chain of morbid actions is broken, and the disease ceases: hence, in some cases, we observe much more striking relief produced by purgatives than even by bleeding. In order, therefore, to ensure a certain and speedy effect upon the bowels, she should take, about two hours after the powder, repeated doses of salts and senna, and if necessary, have their action still farther assisted by a purgative injection. In the mean time, the hair must be closely shaven from the crown and back of the head, leaving the front bands, that she may be disfigured as little as possible, and a large bullock's bladder half filled with pounded ice, applied to the bare scalp; in lieu of which, an evaporating lotion of vinegar spirit and water, may be applied until the ice is procured. Sinapisms to the calves of the legs and soles of the feet will also be required, so that, on coming into a room where a patient is lying in puerperal convulsions, the practitioner may quickly find employment for the numerous friends or assistants, who generally crowd round her on such occasions, and convert their officiousness into real utility. The air of the room must be kept as fresh as possible, and no more people allowed to remain in it than are absolutely necessary. If she be tolerably conscious during the interval, a hot foot bath, rendered still more stimulating by some mustard flour, will be of great service; flannels wrung out of a hot decoction of mustard, and wrapped round the feet and legs, are also useful, and tend still farther to diminish the cerebral congestion. In all cases of convulsions, especially if the patient be near her full time, it will be necessary to ascertain the state of the bladder; for the pressure of the head frequently produces much difficulty in evacuating it, and sometimes causes so much distention and irritation as to be itself quite capable of exciting the convulsions. Lamotte has given two instances where the fits had been evidently brought on by retention of urine, and where relief was immediately given by evacuating the bladder. Where the patient has still some time to go, and no appearance of uterine action has been excited, the probability is, that the above-mentioned treatment, will be sufficient to prevent a return of the attack; and, if we have succeeded in calming the circulation, we may combine a little henbane with her medicine to allay irritability. But if she be near her full time, and labour has distinctly commenced, there will be little chance of the convulsions permanently ceasing until she is delivered, as the contractions of the uterus frequently appear to excite a return of them. The practice in former times of dilating the os uteri, introducing the hand and turning the child, has been long since justly discarded, for the irritation produced by such improper violence would run great risk of aggravating the convulsions to a fatal degree. "No cases require more prudence, attention, and sagacity, than the accident of convulsions in women, with their first children especially. The state of the os uteri is of immense importance, and when it will admit of your delivering the woman without violence, trouble, or irritation, no doubt it ought to be performed with all prudent expedition, as you never can be sure of her being restored without delivery." (M'Kenzie's _Lectures_, MS. 1764, quoted by Dr. Merriman.) Where we are called to a patient, who has been some little time in convulsions, and where bleeding and other necessary measures have been already had recourse to, we may, with a tolerable degree of certainty, expect to find the os uteri fully dilated, and the head in a favourable state for the application of the forceps. The practitioner should be able to apply the forceps whether the patient be lying upon her back or her side, as it is not always possible to choose her position; the former, will generally be the safest, as she will not only lie more quietly upon her back, but can be kept with most facility in this posture. Generally speaking the fits subside immediately after the child is delivered, although not unfrequently they recur during the first twelve or sixteen hours after labour, coming on at increasing intervals. If, however, the state of the os uteri forbids our interfering with art, we must be content to follow out that plan of antiphlogistic treatment which has been just laid down, bearing in mind, that in proportion as we reduce the power of the circulation we increase the disposition of the os uteri to dilate, and, as Baudelocque justly observes, "while we wait the favourable moment for operating, we should only employ those means which we could use after delivery, if the convulsions should continue." (_Op. cit._ § 1110.) By the time that the medicine has begun to operate, a considerable change will usually be observed in all the symptoms--the violence of the convulsions abates, the coma is less profound, and if the child be not yet born, the process of labour much more speedy and favourable; but if we find that the convulsions assume a tetanic character, and that the uterus actively participates in this state of spasmodic rigidity, we must not expect any very favourable change until delivery is effected; and there will be little chance for the child of its being born alive for reasons already mentioned. Under such circumstances, which are fortunately of rare occurrence, it will be our duty to perforate rather than run the risk of losing the mother as well as her child; but before proceeding to this extremity we must satisfy our minds that the state of the os uteri forbids the forceps, and that, from the tetanic action of the uterus, there is little chance of its farther dilatation. "It does not always happen that the convulsions cease upon the termination of the labour; on the contrary, they often continue after the birth of the child, and sometimes increase in violence, and at length produce death. If, however, the intervals between the fits become longer, a more favourable prognosis may be formed, but it will be expedient to continue our exertions in relieving the symptoms." (Merriman's _Synopsis_.) The after treatment will be little more than a continuation of that which has been described during the attack, only in a much milder form: the head must be kept cool by a proper lotion, and the bowels sufficiently open by gentle laxatives; a little gruel, with or without milk, may be given occasionally; and if the child be alive, it should by all means be applied early to the breast, in order to establish a flow of milk as soon as possible. Where the breasts have been very flaccid, and there were little or no signs of milk, we have now and then applied a sinapism over them with very good effect, for the mammary excitement thus produced has been attended with a copious lochial discharge, which has evidently produced much relief. _Apoplectic species._ Dr. Dewees has described a species of convulsions by the term "apoplectic," but it is perhaps questionable how far he is correct in calling them "puerperal convulsions;" for, from the cases which have come under our own notice, the disease has been nothing else than genuine apoplexy occurring in the pregnant, parturient, or puerperal state: he justly observes, that "it may be brought on by causes independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, but is no otherwise accessary to this end, than increasing by its efforts the determination of blood to the head." (_Op. cit._ § 1238.) The treatment will in no respect differ from that of the genuine puerperal convulsions, except that, as the danger is still greater, so, if possible, must the treatment be more prompt; indeed, it can scarcely be said that there is a convulsion, for there is merely loss of motion with insensibility. It is fortunately of rare occurrence, as the patient seldom recovers. _Anæmic convulsions._ The next form of epiplectic puerperal convulsions is the anæmic form, where, in consequence of serious loss of blood or debility otherwise induced, the due balance of the nervous system has been disturbed, and irregular and convulsive actions have been the result. We have already shown that cerebral congestion is favourable to that state of irritability, which, by the help of any exciting cause, may easily pass into a state of epilepsy; an opposite condition, viz. that of exhaustion, is capable of acting in a similar way, and thus confirms Dr. Cullen's assertion, "that there are certain powers of collapse, which, in effect, prove stimulants and produce epilepsy." "That there are such powers which may be termed indirect stimulants, I conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which, we suppose, always to depend upon causes weakening the energy of the brain." "The first to be mentioned, which I suppose to be of this kind, is hæmorrhage, whether spontaneous or artificial. That the same hæmorrhage which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and observations it appears, that hæmorrhages occurring to such a degree as to prove mortal, seldom do so without first producing epilepsy." (_Op. cit._) It is a well-known fact, that when once a state of exhaustion or collapse has been carried beyond a certain point, the irritability of the nervous system increases in proportion: the due balance of its various actions becomes more and more unsteady; their equilibrium is disturbed by the slightest impressions, and losing the state of well-adjusted repose which belongs to health, they continually vibrate between the extremes of excitement or collapse, which seldom fail to produce some serious derangement. "The symptoms of reaction from loss of blood," says Dr. Marshall Hall, "accurately resemble those of power in the system, and of morbidly increased action of the encephalon; and, from these causes, the case is very apt to be mistaken and mistreated by the farther abstraction of blood. The result of this treatment is, in itself, again apt farther to mislead us; for all the previous symptoms are promptly and completely relieved, and this relief, in its turn, again suggests the renewed use of the lancet. In this manner the last blood-letting may prove suddenly and unexpectedly fatal." _Symptoms._ A very little attention, however, will discover the real features of the disease; the pale face, the glazy eye, the shrunken features and colourless lip, the cold moist skin, the heaving chest, the quick, weak, small, and irritable pulse, all betoken a condition of exhaustion and collapse. The history of the case will also show that the patient has suffered from profuse hæmorrhage, or some other debilitating evacuation; and the intense pain on the summit of the head, verging into actual delirium, the rambling thoughts and confused mental associations, the restlessness or absolute insomnia, the tinnitus aurium, disposition to strabismus or other derangements of vision, indicate the defective condition of the cerebral circulation. We have already mentioned, in the congestive form of epilepsy, that where the irritation from gastric derangement is conjoined to a state of body already predisposed to the disease, that this is frequently sufficient to excite it into action; still more will this be the case where the system is rendered irritable by exhaustion; and it will occur under more formidable circumstances, from our means of treatment being confined within still narrower limits. Dr. M. Hall justly observes, that "exhaustion is sooner induced under circumstances of intestinal irritation:" and again, "paralysis has occurred in a state of exhaustion from other causes, as undue lactation; and in various circumstances of debility, as in cases of disorder of the general health, with sallowness and pallor, and a loaded tongue and breath." _Treatment._ Our treatment of these cases will not vary essentially from that of exhaustion from hæmorrhage under the ordinary circumstances; the patient must be placed with her head low, and as soon as she is able to swallow, a little hot brandy and water, or ammonia, should be given to rouse the circulation to a sufficient degree of activity. If the uterus be still flaccid and disinclined to contract effectively, a dose of ergot will be advisable, and the abdomen should be tightly bandaged with a broad towel. When the powers of the circulation have rallied somewhat, a little plain beef-tea will frequently prove very grateful and appear to revive her more powerfully than even the stimulants above-mentioned; and now, as it is of the greatest importance to calm the irritability of the brain and nervous system, we must proceed to the use of sedatives. Of these, opium and hyoscyamus have the preference, the latter especially so, from its not being liable, like opium, to derange the stomach, or contract the bowels. Moreover, where the exhaustion is very alarming, it is not always easy to control the sedative action of opium within due bounds; and in such cases we are sometimes apt to produce so much sopor, as to render it even difficult to rouse the patient. For this reason, the combination with a diffusible stimulant is always desirable: five grains of camphor and of extr. hyosc. in two pills, form, perhaps, the best and safest sedative which can be given; these may be repeated every hour, and then at longer intervals of two or more hours, until sleep has been produced. Sleep, in cases of this kind, is of the greatest importance, and produces the most favourable change in the patient's condition; the intense headach and irritability of the mind, of the sight, and of the hearing, all abate; the circulation becomes calmer, the pulse more full and soft, the heat of the body more equable; in short, the whole nervous system is returning to a more natural and regular state of action, the stomach is more capable of receiving and digesting its food, the bowels are more manageable, and we may now venture to remove a state of constipation, if present, or any morbid intestinal contents without running the risk of bringing on diarrhoea and increasing the debility. We rarely find that the convulsions return when once the patient has enjoyed the calm of a sound and refreshing sleep, and consider the victory as more than half gained when this favourable state has been produced. The laxative should be of the mildest form, such as will merely excite the peristaltic action of the intestines without increasing their secretions; for this purpose a warm draught of rhubarb manna with hyoscyamus, or castor oil guarded by a little liq. opii. sed., will be the safest. Food of the blandest and most nutritious quality should be given in small and frequently repeated doses; it is important not to load the stomach much or suddenly, for vomiting is easily produced, and when once excited, the stomach becomes so irritable as to be scarcely capable of retaining any food whatever. Where, on the other hand, several hours have passed, not only without sleep but without even a temporary state of quiet; where the headach alternates with restless delirium; where the medicines and nourishment have produced little or no effect, or have been rejected by vomiting; where the pulse becomes quicker, and the debility increases, we have not only to dread a return of the fits, but that the stage of actual sinking is at hand. "It would perhaps," says Dr. Marshall Hall, "be difficult to offer any observations on the nature and cause of excessive reaction; but it is plain that the state of sinking involves a greatly impaired state of the functions of all the vital organs, and especially of the brain from defective stimulus. The tendency to dozing, the snoring and stertor, the imperfect respiration, the impaired action of the sphincters, the defective action of the lungs, and the accumulation of the secretions of the bronchia, the feeble and hurried beat of the heart and pulse, the disordered state of the secretions of the stomach and bowels, and the evolution of flatus, all denote an impaired condition of the nervous energy." (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.) _Hysterical convulsions_ scarcely deserve the name of puerperal convulsions, being liable to occur under circumstances quite independent of the puerperal state; they rarely occur during the process of labour itself, but are chiefly observed during the last few weeks of pregnancy, and the first week or so after labour, especially when the milk is coming on. _Symptoms._ The patient is of a nervous hysterical habit; "she is either still very young, or is of a slim and delicate make; the face is pale and interesting; she has full blue eyes and light hair, and was always of a highly sensitive constitution; the pulse is quick, small, and contracted; the temperature of the skin is rather cool than otherwise; her spirits are variable, fretful, and anxious; she starts at the slightest noise, cannot bear much or loud talking, and misunderstands or takes every thing amiss. During her slumbers, which are short, there are slight twitchings of the eyes and mouth, and in her sleep the eyes are in constant restless motion, and she frequently starts. She complains of sickness, and has frequent calls to pass water, which is very pale; slight rigours alternate every now and then with flushing, and she is easily tired, even by trifling pains, and dozes a good deal during the intervals. She is excessively sensitive, even to the most gentle and cautious examination; the os uteri remains thin, hard, tense, and painful to the touch longer than is usually the case. The ordinary tension and stretching of the os uteri at the termination of a regular contraction is attended with much more pain, and with a peculiar feeling of lassitude, although uncomplicated with any rheumatic affection. The pains follow no regular course, being sometimes stronger, at others weaker, and frequently cease entirely for considerable periods. The uterus has a great disposition from the slightest irritation, to partial and spasmodic contractions." (Wigand, _Geburt des Menschen_, vol. i. p. 164.) Before the fit the patient usually passes a large quantity of colourless and limpid urine; she has oppression at the stomach, anxiety, difficulty of breathing and palpitation, with globus, sobbing, and other hysterical symptoms. There are not those precursory symptoms of cerebral congestion as mark genuine epileptic puerperal convulsions; the headach is neither so severe, nor is it in the same place, being usually at the temples and across the forehead; the face is rather pale than flushed, and when the fit begins, we see little or none of the convulsive twitching among the small muscles, as is the case with an epileptic attack; the face is less distorted, but the large muscles of the trunk and extremities are much more violently affected; the patient struggles furiously, and in severe cases has more or less of opisthotonos; she screams, and never appears to lose her senses so entirely as in the epileptic form; her raving may generally be controlled to a certain extent by suddenly dashing cold water in her face, and speaking loudly and sharply to her; at any rate it instantly produces a deep and sudden inspiration, which is frequently attended with a prolonged hooping sound; this is followed by sobbing, gasping, choking, and the ordinary phenomena of an hysteric fit, but the convulsions themselves are usually arrested more or less by this application: we hold the effects of cold water to be one of the best diagnostics of the disease from epilepsy, in which the patient is entirely insensible to such impressions. A similar fact is observed during vaginal examination; the patient seems aware of our intention, and resists in every possible way. "The patient, after the fit, can for the most part be roused to attention or will frequently become coherent so soon as she recovers from the fatigue or exhaustion occasioned by her violent struggles; and though she may lie apparently stupid, she will nevertheless sometimes talk or indistinctly mutter. After the convulsion has passed over, she will often open her eyes and vacantly look about, and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head in the clothes." (Dewees's _Compend. Syst. of Midwifery_, § 1240.) When sufficiently recovered to be capable of swallowing, she should sip some cold water, or what is still better, take a dose of spiritus ammoniæ foetidus in water; this soon produces copious eructations from the stomach, which are followed with much relief. Where there is a disposition to vomiting, and other evidences of a deranged stomach, it should be encouraged by some warm water, chamomile tea, &c. The bowels are almost always in an unhealthy state, which frequently produces much irritation, and in plethoric habits so much tendency to cerebral congestion as to endanger even an attack of the epileptic convulsions. One or two doses of a pretty brisk purgative should, therefore, be given, and if there be still heat or pain of head, a bleeding may be required. Under ordinary circumstances hysterical convulsions are by no means dangerous, and beyond a little fatigue and exhaustion, the patient recovers from them almost immediately. CHAPTER XII. PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA. _History.--Dr. Rigby's division of hæmorrhages before labour into accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.-- Turning.--Partial presentation of the placenta.--Treatment._ There are few dangers connected with the practice of midwifery which are more deservedly dreaded, and which are wont to come more unexpectedly, both to the patient as well as to the practitioner, than that species of hæmorrhage which occurs in cases where the placenta is implanted either _centrally_ or _partially_ over the os uteri. Well has a celebrated teacher observed, that "there is no error in nature to be compared with this, for the very action which she uses to bring the child into the world is that by which she destroys both it and its mother." (Naegelé, _MS. Lectures_.) In other words, where there is this peculiar situation of the placenta it becomes gradually detached, either in proportion as the cervix expands during the latter months of pregnancy, or as the os uteri dilates with commencing labour, and is thus unavoidably attended with a profuse discharge of blood, which generally increases as the dilatation proceeds. The peculiar feature of this species of hæmorrhage, necessarily accompanying the commencement of every labour where the placenta is implanted over the os uteri, was first fully described in this country in 1775, by the late Dr. Rigby, in his classical _Essay on the Uterine Hæmorrhage which precedes the Delivery of the full-grown Foetus_, a work which has been justly looked upon, both in England and the Continent, as the great source to which we are indebted for our practical knowledge in the management of these dangerous cases. _History._ There is abundant evidence to prove the sudden attacks of hæmorrhage during pregnancy, attended with circumstances of great danger to the life of the mother and her child, were known from the earliest times, and especially noticed by Hippocrates where he says, "that the after-burden should come forth after the child, for if it come first, the child cannot live, because he takes his life from it, as a plant doth from the earth." (_De Morbis Mulierum_, lib. i. quoted by Guillemeau.) Hippocrates, therefore, evidently supposed that this presentation of the placenta at the os uteri was owing to its having been separated from its usual situation in the uterus, and fallen down to the lower part of it. This view has been closely adopted by Guillemeau, to whom we are indebted for having called our attention to the above passage. He has devoted his fifteenth chapter[140] to the management of a case where the placenta presents, and shows that "the most certain and expedient method is to deliver the patient promptly, in order that she may not suffer from the hæmorrhage which issues from the uncovered mouths of the uterine veins, to which the placenta had been attached; that, on the other hand, the child being enclosed in the uterus, the orifice of which is plugged up by the placenta, and unable to breathe any more by the arteries of its mother, will be suffocated for want of assistance, and also enveloped in the blood which fills the uterus and escapes from the veins in it which are open." The operation of turning, which had been newly practised by his teacher, Ambrose Paré, and still farther brought into notice by himself, at that time formed a great æra in midwifery, for it furnished practitioners with a new and successful means of delivering the child in cases where urgent danger could only be avoided by hastening labour; hence, therefore, in all cases of profuse hæmorrhage coming on before delivery, it was a general rule, if the case became at all dangerous, to turn the child. Guillemeau's explanation of the nature of placental presentations was still more explicitly adopted by Mauriceau, La Motte, and many others. Mauriceau invariably speaks of the placenta, when at the os uteri, as "entirely detached;" and adds that "even a short delay will always cause the sudden death of the child if it be not quickly delivered; for it cannot remain any time without being suffocated, as it is now obliged to breathe by its mouth, for its blood is no longer vivified by the preparation which it undergoes in the placenta, the function and use of which cease the moment it is detached from the uterine vessels with which it was connected: the result of this is the profuse flooding which is so dangerous for the mother; for if it be not promptly remedied she will quickly loose her life by this unfortunate accident." (Vol. i. p. 332, 6th ed.) He also adds, "it must be observed that the placenta, which presents, is nothing more than a foreign body in the uterus when it is entirely separated," (p. 333,) "for when it comes into the passage before the infant, it is then totally divided from the womb." (_Chamberlen's Transl._ p. 221. 8th ed.) In the sixteen cases which he has detailed, he has distinctly mentioned the fact in thirteen that the placenta was _entirely separated_ from the uterus, and presented at the os uteri. In two of these he has expressly stated his conviction that the placenta had been detached from the uterus, by the mother having been exposed to a violent shock, when the cord was shortened from being twisted round the child. These facts prove that Mauriceau, considered presentations of the placenta to arise solely from its having been separated by some _accident_ from the fundus, and fallen down to the os uteri. Dr. Robert Lee, in his "Historical Account of Uterine Hæmorrhage in the latter Months of Pregnancy," (_Edin. Med. and Surg. Journal_, April 1839,) has omitted all mention of this circumstance, and from the account which he has given of Mauriceau's observations, would infallibly lead his readers to suppose that Mauriceau was fully acquainted with the real nature of these peculiar cases. Thus, he commences with saying, "The symptoms and treatment of cases of placental presentation are here accurately described, and in all cases of hæmorrhage from this cause he recommends immediate delivery;" and again, he observes, "The rules for the treatment of these cases are laid down with the greatest precision. When the placenta was entirely separated, then only did he consider it as a foreign body, and recommend its extraction before the child." The student would be led by such a statement to suppose that Mauriceau did not consider the _entire separation of the placenta_ as the most usual occurrence in these cases, and will therefore naturally infer that in the majority of cases of placental presentation, he recognised the implantation of the placenta upon the os uteri. That such was very far from the case, we have already shown by quotations from various editions of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of placenta prævia from Mauriceau, and has given a short summary of them. Out of the thirteen cases in which Mauriceau has distinctly mentioned that the flooding had been caused by the entire separation of the placenta which presented, Dr. Lee has noticed it in only three; and in one of these he has reversed the expression by saying, "placenta presenting and entirely detached:" thus leading his reader to infer that the placenta had presented at the os uteri, but had become detached from it. Nor is the case (No. 423,) to which Dr. Lee has referred "as a proof that Mauriceau, was aware of the fact, that the placenta had not been wholly detached from the uterus," at all tend to show that he had any idea of the placenta being implanted upon the os uteri. By stating that "Mauriceau has also recorded the histories of thirty-seven cases of uterine hæmorrhage in which the placenta did not present, but had adhered to the upper part of the uterus and been accidentally detached," Dr. Lee has confirmed the erroneous inference that the implantation of the placenta upon the os uteri was known to this valuable author; whereas, we have proved by numerous quotations, that Mauriceau distinctly supposed that in _all_ cases of hæmorrhage before labour, _whether the placenta was found presenting or not_, it had been originally attached "to the upper part of the uterus." Paul Portal was the first, as far as we are acquainted, who describes the placenta as _adhering_ to the os uteri. He has recorded eight cases, "in which," as Dr. Rigby observes, "he was under the necessity of delivering by art, on account of dangerous hæmorrhages, and in all of them he found the placenta at the mouth of the womb." (_Essay on Uterine Hæmorrhage_, p. 22, 6th ed.) In these he distinctly mentions the placenta adhering to the os uteri. In several of these he separated it from the os uteri and brought it away; and in seven he turned the child. In the other (Case 39,) the head burst its way through the placenta. In one case only (51,) does he attempt to make any practical inference whatever, having in all the others contented himself with merely stating the fact of the placenta adhering to the os uteri. In this instance, however, he has described the real nature of the case, and pointed out the cause of the hæmorrhage. On introducing his hand he "found the after-burden placed just before and quite across the whole inner orifice, which had actually been the occasion of the flux of blood; for by the opening of the orifice the said after-burden then being loosed from that part where it adhered to before, and the vessels containing the blood torn and opened, produced this flooding, which sometimes is so excessive as proves fatal to the woman unless it be speedily prevented." (_Portal's Midwifery_, transl. p. 167.) There is no doubt, as Dr. Renton has very justly observed, "that Portal in 1672 (not 1683) knew as much on the subject of uterine hæmorrhage occasioned by the displacement of the placenta from the os uteri, and the practice necessary for its suppression, as we do at the present time." (_Edin. Med. and Surg. Journ._ July, 1837.) But we cannot coincide with him in the passage which follows, viz. "It is to him unquestionably that we are indebted for our knowledge on the subject," because, as Dr. Renton himself has shown, all the authors in midwifery up to the time of Roederer and Levret (1753) were ignorant of Portal's explanation. We do not even except Giffard, as there is sufficient evidence to show that he, for some time, entertained the prevailing erroneous opinions of Mauriceau, until he at last discovered the real nature of the case himself. We attribute the omission solely to the above observation of Portal being so short and isolated, and to its having been entirely unaccompanied by any other practical remarks or inferences which might have been expected from so remarkable a fact. To this reason _alone_ can we attribute the circumstance of its not having been expressly mentioned by Dr. Rigby when alluding to Portal's cases. In a similar way we can explain why Portal has not had the merit of a valuable improvement in the operation of turning which has been attributed to Peu, viz. the passing the hand between the membranes and uterus up to the fundus before rupturing them, solely because he mentions it as a cursory observation, without any farther notice or practical inference. The next author who has at all alluded to the real nature of placenta prævia is Giffard, whose posthumous work was published in 1734. The value of his evidence on this subject is considerably modified by his having made no allusion to the implantation of the placenta upon the os uteri in the first ten cases of flooding, where he found the placenta presenting, but repeatedly describes the placenta as being wholly separated and lying in the passage, and in some, he expressly mentions that the placenta had fallen down to the os uteri. In cases 115, 116. and 224. he gives a perfectly correct explanation of the cause of flooding, but the opinion is expressed with such a degree of hesitation, and so cursorily, that we doubt much if it attracted more notice than the observations of Portal, above alluded to, more especially as in the six cases of placenta prævia, which occur between the last two above-mentioned (viz. 120, 121. 158. 160. 185. and 209.,) he returns again to his former mode of describing them. We, therefore, regret that Dr. Renton has not mentioned this circumstance, and that in quoting from "two of the numerous cases which he relates," he has not stated that these were two out of the only three cases which Giffard had described correctly.[141] It is, therefore, to the above-mentioned circumstances of Giffard having given what is now recognised as the correct explanation, in only three out of nineteen cases, that we can explain why so little notice was taken of the subject at that time; why Dr. Smellie, when speaking of it, makes no allusion to Giffard; and why Dr. Rigby, in his _Essay on Uterine Hæmorrhage_, was led to suppose that he was ignorant of the real nature of these cases: certain it is that his opinion could scarcely be called a decided one. Smellie mentions that "the edge or middle of the placenta sometimes adheres over the inside of the os internum, which frequently begins to open several weeks before the full time; and if this be the case, a flooding begins at the same time, and seldom ceases entirely until the woman is delivered; the discharge may, indeed, be intermitted by coagulums that stop up the passage, but when these are removed it returns with its former violence, and demands the same treatment that is recommended above." His cases contain no observation beyond the recital that a considerable hæmorrhage had occurred, the placenta had been found presenting, and that he had turned the child. In his sixth case (Collect. 33, No. 2.) which is dated 1752, it is evident that he was ignorant of what had been said on the same subject by Giffard and Portal; for he observes, "This case being uncommon, I was uncertain at first how to proceed; but at last considering with myself, if I broke the membranes to evacuate the contained waters, so as to allow the uterus to contract and restrain the flooding, the foetus would be lost by the pressure of the head against the funis (which presented) in the time of delivery. I resolved in order to prevent this misfortune to turn the child, and bring it along in the preternatural way, which would give it a better chance to restrain the one, and save the other, if the operation could be performed in a slow cautious manner." This forms the amount of his observations on this important subject, and, therefore, justifies the observation which Dr. Rigby has made, viz. that there are no practical inferences drawn from the cases; nor in his directions about the management of floodings, are there any rules given relative to this situation of the placenta. Roederer decidedly stands pre-eminent, as being the first author who gave a distinct and complete description of this species of hæmorrhage; he points out the cause of it, and accurately describes its symptoms and mode of attack; he shows that the placenta may be entirely or partially attached to the os uteri; that in the one case the hæmorrhage will be very profuse, and artificial assistance will be required; in the other it will be slighter, and in many cases it may be left to nature.[142] Levret cotemporaneously with the first edition of Roederer's work, published at Paris, a valuable paper on placental presentation, which, with the above-mentioned chapter of Roederer, must be looked upon as the first observations in which this form of hæmorrhage was made a distinct subject of consideration. Although Levret has in no wise claimed the merit of being the first who had noticed the fact of the placenta being implanted upon the os uteri, still there can be no doubt that to him and Roederer we are indebted for having first investigated the subject and called the attention of the profession to its peculiar characters. Levret has reduced his observations under three heads, viz. that the placenta is occasionally implanted over the os uteri, that hæmorrhage under such circumstances is inevitable, and that the safest mode of remedying this accident is the _accouchement forcé_. He has also added a few valuable remarks, but by far the greater part of the essay is occupied with theoretical arguments to prove that it is impossible for the placenta, which had been attached to the fundus, to sink down to the os uteri. Indeed, beyond stating the three above-mentioned positions, which are undeniably of great practical value (although by no means original,) Levret has added but little which is not contained in Giffard, his chief merit being that of making it a subject of distinct consideration, and establishing it as a matter beyond doubt. Levret cannot, however, be looked upon as the first who considered that the flooding, in cases of placenta prævia, was "inevitable," although, from his not having quoted Giffard, we willingly concede to him the merit of originality, as far as he himself was concerned: it was Giffard, however, as far as we know, who first pointed out that hæmorrhage was the necessary consequence of placental presentation, as is shown from what we have already quoted from him, although, to a certain extent, it was hinted at by Portal, in his fifty-first case. Levret's memoir was afterwards reprinted in his large work, entitled _L'Art des Accouchemens_: the third edition, which appeared in 1766, was quoted by Dr. Rigby in the first edition of his _Essay on Uterine Hæmorrhage_, 1775,[143] in farther proof of the placenta being implanted over the os uteri, and being the cause of hæmorrhage. We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine hæmorrhage which precedes the delivery of the full-grown foetus has stood the test of time, and will ever remain, not less remarkable for its practical value, than "for the perspicuity and simplicity of its style." (Renton, _op. cit._) To Dr. Rigby, without doubt, is due the merit of having first distinguished hæmorrhages, which occur before delivery, into _accidental_ and _unavoidable_, a division so truly practical and appropriate, as to have placed this subject in the clearest and simplest possible light. "He was," as Dr. Collins has justly observed, "the first English author who fully established this most important practical distinction in the treatment of uterine hæmorrhages, although Levret had many years before published a somewhat similar statement." Dr. Rigby's arrangement has been adopted by Dr. Merriman, Dewees, and every other modern author of any note; and the medical world have amply testified their sense of its value, as well as of the work itself in general, by the numerous editions which it has undergone in this, and translations and reprints in other countries. We have entered into an historical detail of the literature of this subject, from its having been asserted that Dr. Rigby "published an abstract of the doctrines of Puzos and Levret with the addition of some cases from his own practice," (Burns, _Principles of Midwifery_, 9th ed., 1837, p. 364;) that he availed himself of the discoveries of Dr. Smellie and M. Levret, while he contrived to make the profession believe that his doctrines were original, (Hamilton, _Practical Observations_, &c., 1836, vol. ii. p. 238;) and that "no fact of the slightest importance has since (Smellie) been discovered relating to the causes and treatment of uterine hæmorrhage in the latter months of pregnancy." (Dr. R. Lee, _Edin. Med. and Surg. Journ._, 1839, vol. li. p. 389.) We, therefore, deem it only just to our readers, and also to the author, to lay before them his own account of what, at the time, he supposed to be a discovery, and how far he considered himself justified in laying claim to its originality. "A case of hæmorrhage, in which I found the placenta attached to the os uteri, occurred at a very early period of my practice; but not finding such a circumstance recorded in the lectures which I had attended, or taken notice of in the common elementary treatises on midwifery, I considered it at first merely as a casual and rare deviation from nature. In a few years, however, so many similar instances fell under my notice, as to convince me, that it was a circumstance necessary to be inquired after in every case of hæmorrhage: and this conviction was confirmed by the perusal of cases in midwifery; for I then found that the fact of the placenta being thus situated had been recorded by many writers, though in no instance which had then reached me, had any practical inferences been deduced from it. It appeared to me, indeed, most extraordinary that such a fact, known to so many celebrated practitioners, should not long before have led to its practical application, and in consequence to more fixed principles in the treatment of hæmorrhages from the gravid uterus; and I may, perhaps, be allowed to say, that I congratulated myself, young in years and practice as I was, in being, probably, the first to suggest an important improvement in the treatment of one of the most perplexing and dangerous cases in midwifery; and that I committed my observations on the subject to paper, not only under a conviction of their practical utility, but certainly also under an impression that my suggestions were original. "Not long after the first edition was at press, indeed before the first sheet was printed, Levret's dissertation on this subject fell into my hands, and in a note I referred to it as additional testimony in proof of the placenta, in these cases, being originally attached to the os uteri. "I have been led into this little detail, because it has been suggested that I have borrowed my theory from Levret. After remarking the gross folly I should have been guilty of in quoting Levret, had I furtively adopted his opinions, it will, I trust, be sufficient for me unequivocally to declare that my original ideas on the subject were derived solely from my own personal observation and experience; and that having previously neither read nor heard of the placenta being ever fixed to the os uteri, the knowledge of such a circumstance, derived as before observed, came to me and impressed me as a discovery. "I was, certainly, afterwards struck with the coincidence of the sentiments of Levret and myself on the subject, with the similarity of our practical deductions, and, allowing for the difference of language, even with the sameness of our expressions. I am farther not reluctant to acknowledge, that after reading Levret's dissertation, I felt less entitled to the claim of absolute originality on the subject; and I now rest perfectly satisfied to divide with him the credit arising from the mere circumstance of communicating a new physiological fact. But were I even denied all claim to originality, I should still not be without the satisfaction of having, at least, materially contributed to diffuse the knowledge of an important fact, and of having established its practical utility on the unequivocal testimony of experience; for, had I seen Levret's dissertation sooner, or had even my attention been first directed to the subject by its perusal, ought it to have superseded my publication? Was the practice in this country, at that time, at all influenced by Levret's dissertation? or has it even since been translated into the English language? Was it, at that time, generally known that the attachment of the placenta to the os uteri was a frequent cause of hæmorrhage? and were any directions for our conduct in these cases, founded on the knowledge of the fact, given by those who there lectured on the art of midwifery? "Levret's facts, moreover, though they proved that the placenta might be originally attached to the os uteri, (and a single instance would establish this,) were scarcely sufficient to prove the frequency of its occurrence, from which alone arises the necessity of practically attending to it in every case of hæmorrhage. His observations (perhaps even more creditable to him for being founded on such scanty materials) were derived from four cases only, and of these, but two were under his own immediate cognizance; whereas, in the first edition of this essay my opinions were supported by 36 detailed cases, in 13 of which the placenta was found at the os uteri; and in the fourth edition the number was increased to 106, 43 of which were produced by this peculiar original situation of the placenta." (Preface to the 5th ed.) The _causes_ of this peculiar deviation from the usual situation of the placenta are little if at all known. The condition of the decidua shortly after the entrance of the ovum into the cavity of the uterus, will probably influence the situation of the placenta considerably. Under the ordinary circumstances, this effusion of plastic lymph has already attained such a degree of firmness and coherence as to prevent the ovum from passing beyond the uterine extremity of the Fallopian tube from which it has emerged; but in cases of placental presentation it may be presumed that at this period the decidua was still in a semi-fluid state, had formed little or no attachment to the walls of the uterus, and had, therefore, no effect in preventing the ovum gravitating to the lower part, or even to the mouth of the uterus itself. We state this, of course, as a mere matter of theory, since the difficulty of investigation at such early periods, and the comparative rarity of placental presentations, will probably ever prevent our ascertaining the real cause. _Symptoms._ The first symptom which warns us that the placenta is presenting, is the sudden appearance of hæmorrhage, which is usually more copious than ordinary hæmorrhage, and apparently comes on without any assignable reason: it is usually the more profuse the nearer the patient is to the full term of pregnancy, for not only now are the ruptured vessels larger, but the separation of the placenta is generally greater. If she has still some time to go, the discharge will be probably slight, and with rest and quiet, &c., will cease, to return again in ten days or a fortnight with increased violence: this usually happens at what would have been a catamenial period. The suddenness of its attack, the profuseness of the discharge, and its coming on without any evident cause, are peculiarly suspicious. It has been stated that the abdomen is less distended in these cases than usual, from the placenta not being in the upper parts of the uterus: it is an observation, however, which requires to be confirmed, and certainly our own experience, as yet, has not led us to such a conclusion. On examination, the os uteri is found to be larger and thicker than ordinary: it has a loose spongy feel, for its vessels are now as immensely distended as those of the fundus, when the placenta has its usual situation. If the placenta be partially attached over the os uteri, it is generally upon the anterior lip, which is much thicker. In this case we shall feel the edge of the placenta projecting at one side of the os uteri, and the bladder of membranes, and probably the presenting part of the child at the other. Whereas, if the placenta be centrally attached, we shall find it attached to the whole circumference, except perhaps where the separation is, from which the hæmorrhage proceeds. We shall distinguish the placenta by its spongy mass, by its soft irregular surface, and by the stringy feel which it communicates where it has been torn. The character of the hæmorrhage is also different from that of common hæmorrhage, inasmuch as it increases during a pain, and diminishes or ceases during the intervals, whereas, in hæmorrhage under ordinary circumstances it is the reverse. Where the hæmorrhage takes place at some distance of time from the full period of utero-gestation, it probably arises from the gradual development of the cervix during the latter months of pregnancy: where, on the other hand, it does not appear till just before labour, the separation of the placenta will have been produced by the incipient dilatation of the os uteri itself. It might therefore be supposed, that the period of the attack would, in great measure, depend upon whether the placenta was centrally, or only partially, attached to the os uteri; that in the former case the placenta would be more liable to be separated by the gradual development of the inferior segment of the uterus; and that, therefore, hæmorrhage would come on several weeks before the full term; whereas, if only a portion of it cover the edge of the os uteri, the patient would probably go to the very end of pregnancy before any flooding appeared. Although this view is supported by the high authority of Professor Naegelé, still we can scarcely agree with it, since not only do a considerable majority of recorded cases show that a patient with central presentation of the placenta may go to the full time without an attack of flooding, but also several of those which have come under our own observation lead to a similar conclusion. The most alarming attacks of hæmorrhage are doubtless at the full term, when the os uteri is beginning to dilate from commencing uterine contractions, and the placenta is centrally attached over it: in these cases the discharge experiences little or no abatement beyond an occasional short remission, but returns with the pains, increasing in profuseness as the gradually dilating os uteri produces a still farther separation of the placenta. Such cases, if left to themselves, would almost necessarily prove fatal. The first fainting fit or two would probably produce a temporary cessation of the discharge, and favour the formation of coagula in the upper part of the vagina; but with returning contractions of the uterus, the hæmorrhage would be renewed with increased violence, and quickly reduce the vital powers. In such cases the patient will probably die undelivered, or soon after the birth of a dead child. In some rare instances, the pains have been sufficiently powerful to force the head through the placenta, and thus enable the mother to be delivered by the natural means, although with little chance of the child being born alive, from the injury which the foetal vessels in the placenta have received. Portal's twenty-ninth case terminated in this way. A similar and very interesting case was lately communicated to us by Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have been centrally attached to the os uteri, and where, in consequence of two or three powerful pains, the head was forced _through_, tearing it quite across. The child was born dead, but the mother did well. In a few rare cases the placenta has been entirely separated and expelled before the child, but these have usually been attended with a most alarming loss of blood. In almost all the cases related by Mauriceau, and in the majority of those by Giffard, the placenta is stated to have been entirely detached from the uterus, but this was evidently under the mistaken supposition of the placenta having been originally separated from the fundus. "It is extremely rare to meet with a total separation of the placenta. Dr. Clarke informed me that he met with but one case of total separation; the patient dying before he reached the house." (Collin's _Pract. Treatise_, p. 92.) A still more remarkable instance is recorded by Dr. Collins, where the placenta had been expelled many hours (probably about 18) before the birth of the child. "The membranes had ruptured, and the waters been discharged a fortnight previous to admission, from which time, until the evening before she was brought to the hospital, she had more or less hæmorrhage. It was now ascertained that the placenta had been expelled the evening before her admission, and separated by the midwife in attendance. She left the hospital well on the thirteenth day."[144] (_Op. cit._ p. 103.) In all these cases the child has been born dead, and must ever be so, where any period of time has elapsed between the expulsion of the placenta and that of the child. The only case we know of where a living child was born after the expulsion of the placenta is recorded by F. Ould. "I found this woman in imminent danger, being seized with faintings and hiccough, having her face pale and Hippocratic. Upon examination, I found the placenta presented to the orifice of the womb, which I immediately extracted; and although the head was far advanced in the passage, I put it back into the womb, and taking hold of the feet brought a living though very weakly child into the world. The mother also recovered, though with much difficulty." (_Treatise on Midwifery_, p. 77.) La Motte has described a similar case, but where the child died immediately after birth. (_Obs._ 238.) The irregularity with which cases of placental presentation have appeared at different times, have more than once excited notice: thus it frequently happens to ourselves that several years have elapsed without our meeting with a single case, although connected with a large lying-in hospital; whereas, at other times two or three cases have followed each other at comparatively short intervals. In selecting ten successive years from the period during which Dr. Rigby observed the numerous cases recorded in his essay, we see this irregularity remarkably exemplified. In 1779 three cases. In 1780 four cases. In 1781 none. In 1782 five cases. In 1783 one case. In 1784 five cases. In 1785 two cases. In 1786 two cases. In 1787 one case. In 1788 two cases. A still more remarkable variation has been described by the celebrated Matthias Saxtorph, of Copenhagen. Having stated that placental presentation had occurred only once in 3600 cases, he adds, "the reader will be astonished when I assure him that this case, which is so rare that I had only seen it twice in so many years, and that I had met with it but once out of so many thousand labours at our lying-in hospital, occurred to me in the last six months, _eight times_." (_Collect. Soc. Med._ Havn. 1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his lectures, and states, that in some years placental presentation was so frequent that it seemed as if it were almost epidemic. Experience proves beyond doubt, that, of the serious floodings which occur during the last weeks of pregnancy, the majority arise from the attachment of the placenta to the os uteri. Dr. Rigby also states "that this attachment of the placenta to the os uteri is much oftener a cause of floodings than authors and practitioners are aware of, I am from experience fully satisfied; and so far am I convinced of its frequent occurrence, that I am ready to believe that most, if not all, of those cases which require turning the child, are produced by this unfortunate situation of it." The period of pregnancy at which hæmorrhage may come on from placental presentation, varies very considerably. Although, in by far the majority of these cases, it does not come on until the last four or six weeks, it now and then occurs at a much earlier period, viz. the sixth or even the fifth month, and sometimes even earlier. Where this is the case, it must rather be looked upon as one of "accidental" hæmorrhage or abortion, for it can scarcely be supposed that any changes about the os or cervix uteri could have been sufficient to have produced an "unavoidable" separation of the placenta at this time. Thus, for instance, in Dr. Rigby's seventy-fifth case, the first attack of hæmorrhage had appeared when the patient "was about three months gone with child;" and at that early period could hardly have been attributed to the peculiar situation of the placenta, but to the more common causes of hæmorrhage connected with abortion. In his forty-third case, the hæmorrhage, which came on about the twenty-sixth week, appears at first to have been purely "accidental," although it was afterwards produced by "unavoidable" attachment of the placenta. "We very seldom meet with unavoidable hæmorrhage before the sixth month of pregnancy; it is not until the cervix uteri begins to distend freely, and the changes that take place previous to the approach of labour commence, any suspicions are observed; consequently, it will be in the last three months of utero-gestation that hæmorrhage of this nature is found to occur." (Collins, _op. cit._ p. 93.) The examination of a case where the placenta presents is not always easy; the natural position of the os uteri during the latter months of pregnancy in the upper part of the hollow of the sacrum makes it very difficult for the finger to reach so completely as to afford us the means of ascertaining satisfactorily whether the placenta be attached to it or not. "For this purpose, however, the usual method with one finger will not always suffice, but the hand must be introduced into the vagina, and one finger insinuated into the uterus; for in several of the following cases it will appear, that though the women were frequently examined in the usual way, the placenta was not discovered till the hand was admitted for the purpose of turning the child." (_Essay_, 6th ed. p. 35.) _Treatment._ We have already stated that the earlier the period at which the flooding comes on, the less profuse it will be; the treatment, therefore, where the hæmorrhage is inconsiderable, differs but little from that in an ordinary case of abortion or miscarriage. The indications, in fact, are the same, viz. to stop the discharge, and allay any disposition to uterine contraction. The patient must be placed upon a mattress, and covered as lightly as possible with safety and tolerable comfort to herself. If the circulation be active, the pulse strong, with more or less heat of surface, it may even be desirable to reduce this by means of the lancet. "Under any kind of active hæmorrhage, when the pulse is vigorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by the mere unloading of the vessels, and more especially in diminishing the velocity of blood within them." (Dewees, _Compend. Syst. of Midw._ p. 441.) Cold cloths must be applied to the vulva, loins, and over the symphisis pubis; gentle saline laxatives with nitrate of potass should be given if the bowels are confined; and if there be the slightest appearance of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat. into the rectum will be necessary. This may be given immediately where the bowels are not confined, or, if they are, after the rectum has been washed out by a large domestic enema. If necessary, she should also take an opiate by the mouth. Her food must consist of little else than plain drinks, as tea, milk and water, &c., all of which must be taken cold; and she must preserve the most perfect quiet of body as well as mind. We cannot agree with Dr. Dewees in permitting "our patients, under treatment for uterine hæmorrhage, to be five or six days without a discharge from the bowels;" as a loaded state of the lower bowels cannot fail in our opinion to obstruct seriously the free return of the circulation from the pelvic viscera, and thus greatly increase the disposition to congestion and hæmorrhage. The longer the patient has still to go, the more desirable is it that we should, if possible, control the symptoms, and prevent them from proceeding to such extent as to require artificial delivery. It is of the utmost consequence that we should take such measures as will enable the pregnancy to go on safely, if not to the full time, at least to a later period, for by this means the uterus will have attained such a degree of development as will enable the turning to be undertaken with ease to the practitioner and with safety to the mother; the child also will have so far advanced towards maturity as to give it a better chance of surviving the operation. Wherever hæmorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any assignable reason, we should earnestly warn the patient and her friends to summon the practitioner the moment there are any symptoms of its return; for if it be a case of placental presentation, it assuredly will return, and as certainly much more profusely than at first. Where the patient has gone nearly or quite to her full time, the first attack is much more alarming; the hæmorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quantity of blood is lost; thus a patient whom we had seen but a few hours previously in perfect health, was suddenly seized with profuse flooding as she was standing at the door of her house speaking to a person, and before she could move, a large pool of blood had formed at her feet; in another case, the patient while standing at her tea-table was attacked in a similar manner, and in a moment the floor was deluged with the discharge. Although artificial delivery by turning the child is required in every case of central presentation of the placenta during the latter periods of pregnancy, it is evident that this will not apply during the earlier months, when the uterus from its size will preclude the possibility of such an operation. Dr. Rigby has established a valuable axiom on this point, viz. "that when the uterus is too small for the admission of the hand, the expulsion of the placenta and foetus will happily be timely effected by nature. It is well known that in the early months, instances of fatal termination by floodings have been very rare, as abortion sooner or later puts a stop to the discharge. It has been likewise before observed, that in floodings at any period of pregnancy, women seldom die, at least not in the first instance, unless a considerable quantity of blood has been suddenly lost. Now, as the danger of a great and sudden loss must obviously depend upon the size of the uterine vessels, and as the enlargement of the vessels is in exact proportion to the increased size of the uterus, it becomes probable that when the vessels have acquired such a magnitude, that when detached from the placenta they would bleed largely and suddenly, the uterus itself must have attained to such a capacity as to admit the hand for artificial delivery." (_Op. cit._ p. 48, 6th ed.) He farther observes, "that as the most material increase of the uterus does not take place until the end of the sixth month of pregnancy, a hæmorrhage before that period will seldom require artificial delivery; and after that period, should it become necessary, that it is probable the hand may then be admitted for that purpose." (_Ibid._ p. 51.) In almost every case where the patient is some time short of her full time, the os uteri will be found unyielding and but little dilated; it will, therefore, seldom be possible, and scarcely ever proper, to introduce the hand into the uterus under such circumstances; the os uteri either entirely resists our efforts, or if we do overcome it, the degree of force required to effect this has been so great, as will in all probability have been attended with serious injury to the part itself. In no case is it proper or safe to force delivery by artificially dilating the os uteri, when it is contracted and unyielding (see TURNING;) but where the placenta is presenting, it is peculiarly dangerous, for even slight laceration of the os uteri will be followed by serious consequences. Where the placenta is situated in the upper part of the uterus, it is of very little consequence if the edge of the os uteri has been torn somewhat during labour; but in the present case it is very different; the os uteri now plays the part of the fundus, its vessels are immensely dilated, and large ones are ruptured, which cannot be closed by the firmest contraction of the uterus. "In recommending early delivery, I think it right, however, to express a caution against the premature introduction of the hand, and the too forcible dilatation of the os uteri before it is sufficiently relaxed by pain or discharge; for it is undoubtedly very certain that the turning may be performed too soon as well as too late, and that the consequences of the one may be as destructive to the patient as the other." (Rigby, _op. cit._ p. 37.) Cases have occurred where the os uteri has been artificially dilated, where the child was turned and delivered with perfect safety, and the uterus contracted into a hard ball; in fact, every thing seemed to have passed over favourably; a continued dribbling of blood has remained after labour, which resisted every attempt to check it; friction upon the abdomen and other means for stopping hæmorrhage by inducing firm contraction of the uterus were of no use, for the uterus was already hard and well contracted; the patient has gradually become exhausted, and at last died; on examination after death, Professor Naegelé has invariably found the os uteri more or less torn. "It must be acknowledged, indeed," says Dr. Rigby, "that it may sometimes happen that at the very first coming on of the complaint, if the discharge be small, and more especially, if it be the patient's first child, and the parts be close and unyielding, the admission of the hand into the vagina, as I have directed, will be attended with the utmost difficulty, and, perhaps, be almost impracticable: in this case let us wait (but let it be with the patient) till the discharge increases, and has continued long enough to relax the parts; for certainly, if the woman be able to bear losing a little blood, which at first she may safely do, the examination will be thereby rendered more easy, and the turning of the child, if necessary, be more practicable and safe." (_Op. cit._ p. 36.) We have already shown (see TURNING, p. 236.) that there is no means of rendering a rigid os uteri yielding and capable of admitting the hand equal to the relaxation produced by loss of blood: wherever the powers of the system have already suffered from the effects of hæmorrhage, we may feel almost certain that we shall find the os uteri capable of dilating, even if it be so little open as barely to admit the finger. Where the patient has become faint or fallen into actual syncope, the relaxation of the soft parts is very striking, and frequently to an extent which could scarcely be believed by those who have not felt it; all resistance seems to be at an end for the time, and the hand enters the flaccid passages with scarcely a sensation of pressure from them, but rather (as has been aptly compared, to that of some wet bladder wrapped around it.) "It has been advised (observes Dr. Rigby) never to introduce the hand till nature has shown some disposition to relieve herself by the dilatation of the os uteri to the size of a shilling, or a half-crown; and this rule is certainly founded on a rational principle, for when it is so much dilated, there is no doubt but the turning may be easily and safely effected; but from some of the annexed cases it appears that a dilatation to this degree sometimes does not take place at all; and that even when the woman is dying from the great loss of blood, the uterus is very little open; the reason for which, seems to be, that when the discharge has been considerable, and more particularly when much blood has been suddenly lost, such a faintness is brought on, that though the uterus be totally relaxed, and might, therefore, be opened by the most gentle efforts, yet nature is unable to make use of these efforts; and, moreover, if there be slight pains, the adhesion of the placenta to the internal surface of the mouth of the womb, counteracts their influence, and thereby hinders its giving way to a power, which would otherwise, probably, very easily open it." (_Op. cit._ p. 39.) _Plug._ Where, however, the case is at that doubtful period of early pregnancy, when even under the most favourable circumstances, as above-mentioned, the hand must experience considerable difficulty in entering the os uteri, and yet the expulsion of the child cannot be safely trusted to the natural powers, it becomes necessary, as in certain cases of premature expulsion, to have recourse to such means as shall enable the os uteri to go on dilating without the danger of farther hæmorrhage; in other words, we must plug the vagina. "If, after the commencement of a flooding, we favour the formation of a coagulum by means of a plug, are we not aiding nature? It brings on labour much sooner, and the os uteri has time to dilate without farther loss of blood." (Leroux, _Sur les Pertes de Sang._ § 309.) By means of the plug, we enable the patient to go on with perfect security until the pains have produced a sufficient dilatation of the os uteri to admit the hand; after a time we may withdraw it, and if then not satisfied with the state of the os uteri, it must be again introduced until our object be effected. (For directions as to the use of the plug we must refer to p. 152.) "This remedy should be early employed, as it will, by proper management, save a prodigious expenditure of blood. We gain by its application important time; time that is essential for the successful delivery of the foetus; for, by it, the woman's strength is preserved; pain is permitted to increase; and, eventually, though tardily, the os uteri is dilated, the placenta and foetus thrown off, and the flooding almost immediately controlled. The other means which we have constantly pointed out, should also be tried: they may aid the general intentions, and render the operation of the tampon more certain." (Dewees, _Compend. Syst. of Midw._ § 1142.) Although Dr. Rigby has given a short account of Leroux's views respecting the use of the plug in these cases, we cannot but agree with Dr. Dewees, in regretting that he either did not "put his plan in execution," or that if he did, he has not given us the details of his experience upon it. From what Dr. Gooch, however, has stated in his _Account of some of the more important Diseases peculiar to Women_, there is every reason to suppose that Dr. Rigby was latterly in the frequent habit of using the plug, and that he thought highly of it. The plug is not only useful in keeping the hæmorrhage under due control until the os uteri be sufficiently dilated, but may occasionally prove of the greatest value in cases of extreme exhaustion from loss of blood, where the patient is too much reduced to undergo the act of delivery, without running the risk of dying during the operation; the plug will enable us to wait with safety until the system has had time to rally its powers and be recruited by the administration of proper nourishment. "Mr. Grainger, of Birmingham, on visiting a poor woman with placenta prævia, and apparently in a moribund condition, immediately filled the vagina and os uteri with linen cloths, and waited two days before he durst hazard delivery, which he accomplished with an auspicious result." (Ingleby, _on Uterine Hæmorrhage_, p. 155.) _Turning._ The operation of turning the child will, in no wise, differ from that under more ordinary circumstances, and will require to be conducted according to the rules which we have already given. In no case is it more important to preserve the membranes unruptured until the hand has fairly entered the uterus than here; the hand should be carefully insinuated between the os uteri and placenta; if possible, this should be done at the part where the separation which has caused the flooding has already taken place, in order to avoid all unnecessary detachment of the placenta; the pressure of the hand prevents any great discharge of blood; and as it gradually makes its way between the membranes and the uterus, the arm which now occupies the vagina will effectually act as a plug. Portal, was, probably the first who practised this mode of operation, viz. passing his hand between the os uteri and placenta, and then between the uterus and membranes before rupturing them: in this respect he anticipated Peu, whose work appeared nine years after, (see TURNING, p. 234.) and would have undoubtedly been looked upon as the originator of this improvement in turning, had he given any reasons for this mode of practice, or deduced any inferences from it. Some discrepancy of opinion has existed as to whether it is better to perforate the placenta, or to follow the plan we have just recommended. Dr. Rigby's authority has rather tended to confirm the former opinion, although he afterwards modifies it so much so as to make us almost suppose that he must have preferred the other method. He states, "that by this means, (perforating the placenta,) not more of the placenta may be separated than is necessary for the introduction of the hand, and, consequently, that as little increase of bleeding as possible may be produced by the operation; but if it be impracticable, as I have more than once found it, and it must ever be when the middle of the placenta presents to the hand, from the thickness of it near the funis, it must be carefully separated from the uterus on one side, and the hand passed till it gets to the membranes." (_Op. cit._ p. 61.) To Dr. Dewees are we chiefly indebted for having put the inexpediency of perforating the placenta in the strongest possible light. "We are advised by some," says he, "to pierce the placenta with the hand; but this should never be done, especially as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it. "1. In attempting this, much time is lost that is highly important to the patient, as the flooding unabatingly, if not increasingly, goes on. "2. In this attempt we are obliged to force against the membranes, so as to carry or urge the whole placentary mass towards the fundus of the uterus; by which means the separation of it from the neck is increased, and consequently, the flooding augmented. "3. When the hand has even penetrated the cavity of the uterus, the hole which is made by it is no greater than itself, and consequently much too small for the foetus to pass through without a forced enlargement, and this must be done by the child during its passage. "4. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested; and if force be applied to overcome this resistance, it will almost always separate the whole of the placenta from its connexion with the uterus. "5. That when this is done, it never fails to increase the discharge, besides adding the bulk of the placenta to that of the arms and head of the child. "6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from hæmorrhage. "7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control. "8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance much time is lost that may be very important to the woman." (_Op. cit._ § 1153.) We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri: the less we separate the placenta, the less also will be the hæmorrhage; and even this will be in great measure controlled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case itself is sufficiently dangerous without being increased by other unfavourable causes. To hurry the delivery would be only to increase the danger: the operation must be performed slowly and with caution: every rule which we have given, (see TURNING,) for ensuring its safe and successful termination, must now be adhered to with double vigilence. "Should the woman," says Dr. Dewees, "be very much exhausted before we commence our operations, we should use additional caution in the delivery. It should be very slowly performed, and we should have at each step of the progress assurances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care." (_Op. cit._ p. 463.) When once the os uteri is sufficiently dilated to admit the hand, there will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of hæmorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circumstances. The placenta, which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was effected without difficulty. In this instance, hæmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (_Med. Gaz._ Sep. 2, 1837.) The after treatment should be conducted upon the same principles as in other cases of hæmorrhage. _Partial presentation of the placenta._ Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial delivery by turning. The edge of the placenta frequently projects but a very little over that of the os uteri, feeling, as it were, like a second lip; at other times it covers a third or more of the opening, and is usually attached upon the anterior portion of it. Our own observations have rather led to the conclusion, that where the placenta is but partially attached over the os uteri, the first attack of flooding is rarely delayed until the full term of pregnancy, but makes its appearance some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar reason we may understand why the hæmorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os uteri being prevented dilating by the close adhesion of the placenta--an opinion which is, moreover, approved of by Dr. Dewees as being "both ingenious and probable." Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall seldom find the hæmorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those difficulties connected with a contracted and unyielding state of the os uteri, which we described in cases of central presentation; and if the hand requires to be introduced, which is not often the case, it will seldom experience much opposition. _Treatment._ In our treatment of partial presentation of the placenta, we must be guided, in a great measure, by the strength of the pains and the degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be sufficient to check the hæmorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the membranes will diminish the size of the uterus, and thus excite it to more powerful contraction; if not, a dose of secale cornutum, repeated according to circumstances, will be of great assistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quantities frequently repeated, will rouse the powers; wine or a little brandy, may also be given at intervals; but unless the prostration be very serious, we have not found stimulants so useful as beef-tea, which is usually, also, much more grateful. CHAPTER XIII. PUERPERAL FEVERS. _Nature and varieties of puerperal fever.--Vitiation of the blood.-- Different species of puerperal fever.--Puerperal peritonitis.-- Symptoms.--Appearances after death.--Treatment.--Uterine phlebitis.-- Symptoms.--Appearances after death.--Treatment.--Indications.--False peritonitis.--Treatment.--Gastro-bilious puerperal fevers.-- Symptoms.--Appearances after death.--Treatment.--Contagious, or adynamic, puerperal fevers.--Symptoms.--Appearances after death.-- Treatment._ In enumerating the different species of Dystocia, we have mentioned a long list of causes, by which the process of labour might be rendered one of considerable danger either to the mother or her child; but, for the most part, they are not of very common occurrence, those only which are of trifling import being met with most frequently. Even under the most dangerous forms of dystocia, as for instance, convulsions, and the different forms of hæmorrhage, the danger, although great, is capable of being averted, from the mother at least, in the majority of instances by timely and skilful assistance; the means of treatment which art and experience have supplied us with, being generally capable of affording both certain and effective relief, if used according to the rules which we have given when treating of these subjects; but we now come to a source of danger which follows the most favourable as well as unfavourable labours--which is extremely varied in its nature, fatal in its effects, and (what renders it so peculiarly formidable) by no means uncommon in its occurrence. Of all the dangers to which a lying-in woman is exposed, puerperal fever is by far the most to be dreaded: there are few or no difficulties during parturition which the practitioner has to contend with that can be compared to it; there are none in which he is frequently made to feel so helpless, and his various means of treatment so utterly inefficacious; certain it is that puerperal fever in its worst forms has occasionally committed such ravages among patients of this class as to rival in destructiveness the most malignant pestilences with which the human race has been afflicted. One of the greatest improvements in our knowledge of puerperal fever which has taken place in modern times, is the having ascertained that it is not one specific disease, but occurs under different forms, each of which is subject to a good deal of variety, depending upon individual peculiarity, season of the year, and numberless other circumstances. The chief error into which authors have fallen when treating of this difficult subject, is their having merely described the peculiar form of disease which had come under their own notice, and to which they have exclusively awarded the name of puerperal fever--an error in judgment which has led to still greater errors in practice, and which has certainly tended to prevent the subject being so clearly understood as it might have been. The mode also in which it has been investigated by modern authors has been but of little assistance in disclosing the true features of the disease; they have indeed rather tended to mislead than to guide us, they have directed our attention to certain effects of it, which they have considered to be the disease itself, and thus rather conceal than disclose the real _natura morbi_. In our printed lectures on puerperal fever we have taken a similar view. "I am not sure if the present fashionable morbid anatomy of the day, misnamed pathology, has assisted so much in developing the real nature of the disease as has been supposed: it appears to me rather to have withdrawn the attention of practitioners from a close observation of the phenomena presented during life, to the inspection of those changes which are to be found after death. They have rather sought to examine the _effects_ of the disease at a time when it had attained such an extent as to be incompatible with life, than to investigate upon correct and physiological grounds the series of changes which were taking place during the earlier periods." (_London Med. and Surg. Journ._ June 27, 1835.) Dr. Alison, of Edinburgh, in his dissertation on the state of medical science (_Cyc. Prac. Med._) has taken a similar view of this prevailing mode of investigating the nature of disease; he considers that it is "an important practical error to fix the attention, particularly of students of the profession, too much on those characters of disease which are drawn from changes of structure _already effected_, and to trust too exclusively to these as the diagnostics of different diseases, because in many instances these characters are not clearly perceptible until the latest and least remediable stage of diseases--the very object of the most important practice is to _prevent_ the occurrence of the changes on which they depend. Accordingly, when this department of pathology is too exclusively cultivated, the attention of students is often found to be fixed on the lesions to be expected after death, much more than on the power and application of remedies either to control the diseased actions, or relieve the symptoms during life." "Pathological anatomy (says Dr. Stevens) is but one of the many 'points of view in which we may consider the science of disease,' and notwithstanding all that has been said about 'la médicine eclarireé par les ouvertures des cadavres,' I have a firm belief that morbid anatomy has done little good, particularly in the hands of those who do not understand its real value; for those who are constantly mistaking the effect for the cause, or confounding the immediate cause of death with the cause of the disease, and forming theories on this foundation, not only deceive themselves, but unfortunately, particularly for the inhabitants of hot climates, they have deceived others." (_Obs. on the Healthy and Diseased Properties of the Blood_, p. 182.) We have made our last quotation from one of the most valuable and original works of the present day upon the subject of fevers, and which has tended in great measure to unveil the mysterious nature of these diseases. Dr. Steven's researches have been conducted in the truest spirit of pathological inquiry, and form a striking contrast with the modern morbid anatomy of puerperal fevers. We use the term _puerperal fevers_ precisely with the same meaning as Dr. Locock has done in his valuable essay on this subject (_Library of Pract. Med._ vol i.,) requesting our readers to bear in mind his observation, "that they vary in their nature and treatment as much as other kinds of fevers;" that whether occurring sporadically or in epidemics, they rarely, appear twice alike, but vary with the season of the year and the type of the prevailing fevers of the place; they are influenced by the rank, habits, and constitution of the patient, as well as by the nature and locality of her residence. Although we cannot quite coincide with the views of Dr. Ferguson to their fullest extent, respecting the exclusive cause of the various forms of puerperal fever, viz. the vitiation of the fluids, still, in great measure, we consider them as correct, having not only taught them for many years, but published them in our lectures on this subject in 1835. Much praise is due to the last two mentioned authors for the able manner in which they have handled this difficult subject, they have carefully sifted the mass of jarring opinions, and tested them by their own great experience; and have not only reduced the subject to a simpler form, but have succeeded, we trust, in removing the very erroneous views of some modern authors respecting the supposed identity of certain forms of local inflammation with this disease. Having drawn our information upon puerperal fevers from the same ample source, we willingly bear testimony to the accuracy with which they have described the different forms; and trust that in giving a detail of our own opinions and observations, it will be found that so far from differing from them, we have tended to confirm, reconcile, and carry out their views. _Nature and varieties of puerperal fever._ The history of puerperal fevers at the General Lying-in Hospital, would of itself afford an excellent monograph on this class of diseases in all their varied forms. When we resided at the hospital in 1826, the cases were all of the inflammatory character; they appeared to occur sporadically, among the out as well as the in-patients; and were successfully relieved by bleeding, hot poultices, and a mercurial purge, and occasionally leeches. During the following years, an epidemic of a highly malignant character spread destruction rapidly among the patients, setting at defiance the treatment previously employed. Still more remarkable was the sudden change in the character of the disease noticed by Dr. Locock in 1822. "In the spring of 1822, puerperal fever existed in the lying-in hospital in two very different and well-marked forms, at an interval of about six weeks between the last case of the first epidemic and first case of the second. The early cases were of an active inflammatory character; the peritoneal covering of the uterus and intestines was chiefly affected; the albuminous and serous effusions in the fatal cases showed a sthenic state of the system, that is, the serum was clear, the coagulable lymph firm and white; the patients bore blood-letting, and other active treatment to a great extent, fairly, and with much advantage; the blood drawn was strongly cupped and highly buffed, and the fatal cases were few. Six weeks afterwards a very different epidemic was found to exist. The same remedies which had been so beneficial a few weeks before, were naturally at first tried, but their bad success confirmed the sagacious remark of Gooch, that 'the effects of remedies form not only an essential but an important part of their history.' (Gooch _on Peritoneal Fevers_, p. 35.) The fever was attended with marked oppression and debility; the local pain was comparatively slight; the pulse was extremely rapid from the first, with no force, and easily compressible. In many of the cases, purulent deposites took place in the joints and in the calves of the legs, and in one case there was destructive inflammation of the eye." (Locock, _op. cit._ p. 349.) The various forms and modifications under which puerperal fevers have appeared at different times, have produced an equal variety of arrangement in the classifications of authors. Thus, some who have attributed the disease to inflammation, have merely distinguished its varieties according to the different organs which have exhibited after death appearances of congested or injected vessels, or have been covered and imbedded in effusions of coagulable lymph, &c., or have had their structure more or less broken down and disorganized. Thus, for instance, Dr. R. Lee is of opinion, that "inflammation of the uterus and its appendages must be considered as essentially the cause of all the destructive febrile affections which follow parturition; and that the various forms they assume, inflammatory, congestive, and typhoid, will in great measure be found to depend on whether the serous, the muscular, or the venous, tissue of the organ has become affected." (_Med. Chir. Trans._ vol. xv. part ii. p. 405, 1829.) He accordingly arranges "the principal varieties of inflammation of the uterus in puerperal women under the following heads, viz. 1. Inflammation of the peritoneal covering of the uterus, and of the peritoneal sac; 2. Inflammation of the uterine appendages, ovaria, fallopian tubes, and broad ligaments; 3. Inflammation of the muscular and mucous tissues of the uterus; 4. Inflammation and suppuration of the absorbent vessels and veins of the uterine organs." (_Cyc. Pract. Med._ art. PUERPERAL FEVER.) This arrangement is manifestly incorrect, and by giving so partial a view of puerperal fevers, must, if adopted, necessarily lead to serious errors in practice. "That these forms of inflammation are the proximate cause of the various febrile affections is most completely refuted by the detail of his own (Dr. Lee's) experience, as relates to the varieties occurring under similar circumstances." (Moore, _on Puerp. Fever_.) We may also add, that, according to our own experience, and that of our colleagues at the General Lying-in Hospital, in the worst forms of puerperal fever, the fewest traces of inflammation have been observed; and that in the severest and most rapidly fatal cases it has frequently happened, that not a single vestige of inflammation could be detected. In our review of Mr. Moore's able work in the _Brit. and For. Med. Rev._ Oct. 1836, p. 483, we have made a similar remark, and quoted a striking passage from Dr. Stevens, when speaking of contagious fevers, that "there is not one symptom of inflammation during the fatal progress of the disease, nor one inflammatory spot to be seen after death, to mark its existence, or to induce us to believe that any thing but functional disease had existed in any of the solids; yet these are the very cases of all others which are the most fatal." (_On the blood_, p. 179.) In many of the worst cases which have come under our notice, there has neither been time nor power sufficient to produce either a symptom or a trace of inflammation; the powers of life have from the very commencement sunk under the deadly influence of the disease, without a single effort to establish even a temporary reaction in the system: hence, in most instances, we are led to the necessary conclusion, that inflammation, when it does appear, is the result of disease, not the disease of inflammation. "For," as Dr. Ferguson observes, "if any or more of these (phlebitis, peritonitis, &c.) be assumed as constituting the essence of puerperal fever, abundant examples may be found of puerperal fever, in which the cause fixed on is absent. Thus to believers in the identity of peritonitis and puerperal fever, we can show puerperal fever with a perfect healthy peritoneum. To those who insist on inflammation of the uterine veins, as constituting puerperal fever, we can show the genuine disease without this condition." (_Essays on the most important Diseases of Women_, part i. PUERPERAL FEVER, p. 81.) The _vitiation of the blood_ has long been a subject which has excited our deepest interest, and the admirable researches of Dr. Stevens upon the condition of this fluid under the effects of malignant fevers, have tended to disclose the real nature of the diseases under consideration. We have long been convinced that one of the causes of puerperal fever is the absorption of putrid matters furnished by the coagula and discharges which are apt to be retained in the uterus and passages after parturition,--a view which has been adopted by Kirkland, C. White, and other older authors. It is with sincere pleasure that we now find ourselves supported by the able author, from whom we have just quoted, in this opinion. Dr. Ferguson's three positions respecting "the source and nature of puerperal fever" are highly valuable, for they have been deduced from careful physiological experiments, and not less sound physiological reasoning; they are as follows:-- 1. The phenomena of puerperal fever originate in a vitiation of the fluids. 2. The causes which are capable of vitiating the fluids are particularly rife after childbirth. 3. The various forms of puerperal fever depend on this one cause, and may readily be deduced from it. We do not agree with him in supposing that every form of puerperal inflammation is produced by vitiation of the circulating fluids, because in one species of uterine phlebitis, which occurred sporadically, and prevailed a good deal from 1829 to 1832, it was, in our opinion, evidently produced _directly_ by the absorption of putrid matter into the uterine veins and lymphatics, exciting inflammation in these vessels: the same cause, when only carried to a certain extent, produces a local inflammation, which, when affecting the general circulation, is followed by fever. Thus, then, we may have in the same case uterine phlebitis followed by the typhoid malignant puerperal fever--the local and constitutional disturbance arising from the same cause, imbibition or absorption of putrid matter; the one being the local, the other the general effect, but not the one resulting from the other. The doctrine of the vitiation of the blood from its admixture with pus secreted by the lining membrane of an inflamed vein, though very plausible, still requires farther confirmation, for it is doubtful if the introduction of pure healthy pus into the circulation produces any of those dangerous effects which result from the absorption of putrid matters, whether purulent, sanious, mucous, &c. It is the introduction into the circulation of an animal poison generated by putrefaction, which destroys the vitality of the blood, and renders it unfit for maintaining the vital powers. Few have expressed this opinion more strikingly than Dr. Kirkland, although so long ago as 1774; and it has often created our surprise, that amid all the numerous writings on this subject, which have excited attention during later years, so little notice should have been taken of his observations. We consider that Dr. Kirkland is one of the earliest authors who has shown that puerperal fever is not the result of inflammation, but that it may be produced by the introduction of an animal poison into the circulation. "There are other causes beside inflammation which bring on a puerperal fever; for it sometimes happens that coagulated blood lodges in the uterus after delivery, and putrefying from access of air, forms a most active poison, is in part absorbed, and brings on a putrid fever. In this case the discharge which should immediately follow delivery is not sufficiently large, making allowance for the difference which happens to different women in this respect: small clots of blood make part of the lochia, which are less in quantity than they ought to be; but the patient has not any other sort of complaint for three or four days till the retained blood begins to putrefy. A fever then first makes its appearance, followed by a quick weak pulse, thirst, pain in the head, want of sleep, sighing, load at the præcordia, restlessness, great weakness, dejection of spirits, either wildness or despair in the countenance, and the white of the eyes is often a little inflamed." (_A Treatise on Childbed Fevers_, by Thos. Kirkland, M. D. p. 70.) The late Mr. Charles White, of Manchester, adopted a similar opinion, and in our published lectures we have quoted largely from these two authors in support of the opinions which we have there advanced. Dr. Ferguson's opinion, that the different modes in which the poison infecting the circulation manifests itself, give rise to the different forms of puerperal fever, is highly interesting, and deserves great attention. He conceives that in some instances it spends its virulence upon the peritoneum, producing the inflammatory peritoneal form of puerperal fever. He considers that the gastro-enteric form arises "from the action of the poison being directed to the liver, the organ through which, as the experiments of Gaspard and Fontana, and the admission of all physiologists show, most poisons received into the system endeavour to escape." (_Op. cit._ p. 85.) These views have been proved by injecting putrilage, &c., into the veins of animals, and the effects of which, both as seen in the symptoms during life and the appearances after death, tend strongly to confirm these opinions; still we cannot feel justified in excluding inflammatory forms which have not been indirectly produced by the vitiation of the circulation, but which are the more direct effects of labour itself, or, as we have before observed, from the immediate absorption of putrilage, &c., into the veins and lymphatics, and production of inflammation in them. The production of inflammation in that part of a vein or absorbent, with which putrid matter has come in immediate contact, is an important fact, for it is by this means that nature prevents the poison being carried into the general system, and thus, instead of generating a malignant fever, she limits the injury to a local inflammation, by which farther mischief is confined by the effusion of coaguable lymph, tumefaction, and other means for rendering the vessels impervious. In making these remarks we wish it to be distinctly understood, that we by no means under-value the views brought forward by Dr. Ferguson, that "the introduction of a poison into the circulation is capable of producing local inflammation, varying according to the strength and qualities of the agent," &c. The results of Professor Tiedemann's experiments, of which we have given an abstract in the _Brit. and For. Med. Rev._ vol. i. p. 241, contain some facts which throw much light as to the modus operandi of certain agents when mingled with the circulation, and tend still farther to prove the correctness of Dr. Ferguson's views. In the experiments where musk was injected into the femoral vein of a small bitch, the effects of the poison upon the abdominal viscera were remarkable; the veins of the abdomen were distended with dark coloured blood, the whole intestinal canal was very red, the mucous membrane of the stomach had a reddish tinge; that of the whole intestinal canal was of a dark red, it was swollen, turgid, and in the highest state of engorgement--the canal also contained a quantity of effused dark blood in its lower part; the vessels of the liver and spleen were gorged with dark blood. We are anxious to impress upon the minds of our readers the physiological fact, that most, if not all, vegetable and animal poisons do not act _primarily_ on the nervous system, but indirectly through the medium of the circulation. "The physiological researches (as we have observed elsewhere) especially during the last thirty years, both in this country and the continent, have satisfactorily proved that most, if not all, of the agents which exert such destructive energies on the nervous system, do it through the medium of the circulation: this has been shown by the experiments of Christison and Coindet, of Brodie, Emmert, Viborg, and many others. Those of Sir B. Brodie on the action of the Woorara poison are well known. Emmert showed this to be the case in a still more striking manner, by amputating the leg of an animal, and leaving it connected to the body only by means of the nerves; poisonous substances introduced into the foot produced no effects, not even when applied to the trunk of the nerve; and Viborg even applied one drachm of concentrated prussic acid to the brain of a horse, which had been exposed by trepanning, without producing any effect." (_Brit. and For. Med. Rev._ vol. i. p. 559.) We cannot agree with the opinion, "that the vitiated state of the blood is the secondary and not the primary link in the chain of phenomena," and "that the nervous system is the main instrument by which this change in the blood takes place." (Locock, _op. cit._ p. 353.) "We believe that is _not_ the deficiency of nervous influence which primarily tends to deteriorate this fluid (although it may possibly react in this way afterwards,) but the deteriorated condition of this fluid, which renders it incapable of supplying the brain and nervous system with their due degree of energy." (_Brit. and For. Med. Rev._ vol. ii. p. 483, 1836.) In considering the phenomena of fever, Dr. Stevens has well observed, that we must not look upon them "as the result of either a nervous impression, or local inflammation, for even in the beginning of fever its symptoms are universal and peculiar to itself. It is not, therefore, a local affection; and in all the idiopathic fevers, but particularly in those that are produced by the aerial poisons, there is but one thing which is never absent, namely, the diseased condition of the whole circulating current, and, therefore, this alone can be fairly considered as essential to the disease. This morbid condition of the blood is decidedly the first link in the chain of those phenomena which constitute fever, for even before the attack every drop of the vital currant is changed in its properties; and wherever this deranged blood can circulate, there fever extends its empire: for the cause which produces this disease is not confined to a part, but acts on every fibre, and in every tissue of the living system; it disturbs every function in the body, and deranges every faculty of the mind. All the excretions are in a diseased state, and every one of the secreted fluids is changed both in its quantity and quality. The blood is the medium that conveys the poison, while the impression on the nerves is merely the effect of the diseased condition of its natural stimulus." (_On the Blood_, p. 273.) These observations just quoted, apply strictly to the causes as well as to the phenomena of puerperal fever, more especially of the adynamic kind; and show that, particularly in this form, we must not merely refer the cause to the absorption of putrid matters by the uterine veins and lymphatics, or to the commixture of the blood with pus secreted from the coats of an inflamed vein, but to the still more pervading and truly epidemic and contagious action of miasmata, with which the air that surrounds the patient is charged. The lungs afford a ready and ample means by which effluvia may be conveyed into the circulating current, and enables us to account for the fact adduced by Dr. Stevens, that in situations favourable to the production of fevers, the blood is frequently found in a very unhealthy state, even before the outbreak of the disease itself. Dr. Kirkland has nearly anticipated the discoveries of later years upon this subject; and considering the time at which he wrote, we think that his observations are both interesting as well as valuable. "Seeing then that an absorption of putrid matter will bring on a _puerperal fever_, with common symptoms, may we not conclude that the putrid miasms of lying-in hospitals will produce the same effect? Is it not reasonable to suppose, that the _puerperal fever_ which has been observed in hospitals, is owing to some cause peculiar to hospitals? otherwise, would it not be equally frequent in other places? Dr. Pringle informs us that the foul air occasioned by one mortified limb brought on a malignant fever in the military hospital. Peu also seems to have proved, that the putrid _effluvia_ exhaling from wounded men brought on a fever which killed a great many child-bed women who lay in the same hospital; and are not the putrid _effluvia_ arising from the lochial discharge in lying-in hospitals capable of producing the same disease? I have sometimes been called to women in child-bed, where the offensive _effluvia_ arising from this kind of evacuation, pent up in a small close room, at once evinced to what cause their fever was owing; and though I have not any doubt, but in lying-in hospitals every attempt is made to preserve the air pure and the patient in a state of cleanliness, yet where many women lie in the same ward, it is perhaps impossible to obtain these advantages in the perfection to be wished." (_Op. cit._ p. 73.) Van Swieten compared the state of the inner surface of the uterus with that of a large wound,--"Something of a like nature seems to be affected in the womb, but in a slighter manner, because the injury is here superficial, but on a broad surface." (_Comment. on Boerhaave_, § 1329.) He quotes also an interesting description from Moschion of the changes which are observed in the evacuations after delivery,--"_Primo sanguis, secundo fæculentus et paucus, ultimo purulentus_." "It hence appears," he observes, "that that fever in lying-in women, which is called the milk fever, does not spring solely from the milk brought into the breasts, but also from the purifying of the womb by that gentle and superficial suppuration. But, as even the best pus when retained too long becomes acrid and putrefies, the same thing will hold with regard to the purulent evacuations after delivery, if they should be kept back." "But if that purulent matter does not come out, but being sucked back should be mixed with the humours, it may, being brought to the viscera by a bad metastasis of the morbid matter, give occasion to dangerous disorders." This comparison by Van Swieten and Dr. Kirkland, of the state of the uterus with that of an open wound, has been recently brought into notice by Cruveilhier, and quoted by Dr. Ferguson, in his work. "All the uterine veins and arteries have been torn from the placenta, and they form a part of a large wound, and are, therefore bathed in all the secretions which necessarily take place while this wound is healing. In this respect the uterus presents an exact analogy to the surface of an amputated stump; and it is, therefore, not surprising, that the secondary evils of amputation should be so similar to those of the puerperal state." (_Op. cit._ p. 75.) Professor Schönlein also considers that the contagion of puerperal fever has the greatest similarity with hospital gangrene. The causes of puerperal disease which have been enumerated by Cruveilhier, apply almost solely to those inflammatory affections of the puerperal state which do not depend upon a vitiated state of the circulation, but "are derived from the changes induced by parturition, and are dependent on, "1. The organic changes induced by pregnancy. "2. Those induced by the act of labour. "3. Those consecutive of labour. "1. Pregnancy:--the hyperthrophy of the uterus; the enlargement of the ligamenta lata; the traction on the peritoneum of the neighbouring organs; the extraordinary development of the arteries, veins, and lymphatics. "2. Changes induced by labour:--bruising of all the soft parts--they appear raw. "3. Changes after labour:--the woman presents the faithful picture of one who has undergone a serious surgical operation. The internal surface of the womb may be compared to a vast solution of continuity; the whole of the mucous membrane has been altered by the inflammation, of which it has been the seat; the gaping veins are like the open mouthed vessels of an amputated limb. "Except just at the inner surface of the cervix uteri, there is no mucous membrane at all; but the muscular tissue of the uterus is every where exposed. This, therefore, like the stump, is to be covered by a new membrane. "This process of reparation is accompanied by a traumatic fever, called milk fever. Like the fever from wounds, it has its period of incubation, varying in various individuals: it lasts about twenty-four hours, and vanishes on the third day. "As in amputation, a false membrane covers the stump, and precedes cicatrisation, so the inner surface of the womb is first covered with a false membrane before it is cicatrised. If there be no lochial discharge, there is union by the first intention, as in the stump where there is no discharge: this is the rarest of all cases. "Ordinarily, this false membrane is thrown off with a purulent discharge, which is the lochia. At first it is sanious, _i. e._ mixed with blood, and fetid; then less fetid and more purulent; then thin and serous. The quality and quantity of the discharge are, as in amputations, an index of the state of the wound." (_Cruveilhier_, quoted by Dr. Ferguson, p. 76.) The comparison between the inner surface of the uterus shortly after parturition and that of a stump, does not hold good in every respect: in the one, the open mouths of the vessels are pretty firmly compressed by the contracted state of the surrounding uterine tissue, whereas, in the other they are uncontracted beyond the mere effects of the traumatic inflammation upon their cut extremities, and they are surrounded by the flaccid surface of divided muscles: still, however, it is quite sufficient to show, that the inner surface of the uterus must be for some days bathed in mucous, sanious, and purulent fluids, highly prone to decomposition; and that, in this state, absorption is peculiarly liable to take place. The vehement exertions of the uterus and abdominal muscles during labour, and the violent pressure to which the abdominal circulation has been subjected at this time, are sources of inflammation, which, although not noticed by Cruveilhier, are frequently met with quite independent of puerperal fever, although, from what we have already stated, it will be evident that the disposition to absorption and consequent vitiation of the blood will be still farther increased by the excited state of the circulation. Where blood has been vitiated by the action of aerial poisons, or introduction of putrid matter into its current, changes are quickly produced in its condition, which not only unfit it for the varied functions which it has to perform, especially in maintaining the activity of the brain and nervous system, but which may be perceived, as already shown, before the disease itself appears. It is dark, and of an unhealthy tinge. In severer forms of typhus, "when first drawn, it has a peculiar smell, and coagulates _almost invariably_ without any crust. There are black spots on the surface of the crassamentum; the coagulum is so soft that it can easily be separated with the fingers, and during its formation, a large quantity of the black colouring matter falls to the bottom of the cup. When the serum separates, it has generally a _yellow_, and in some cases even a _deep orange_ colour." (Stevens, _op. cit._ p. 219.) Dr. Tweedie has observed similar conditions of blood in the common typhus of the metropolis, and remarks, "that in this class of fevers, the crassamentum of the blood, instead of forming a firm coagulum, is loose, small in proportion to the quantity of serum, and so soft that it breaks readily on attempting to raise it, resembling in consistence half-boiled currant jelly, and that in some instances, when abstracted late in the disease, it is scarcely coagulated at all." (Tweedie, _Clin. Illust. of Fever_, quoted by Dr. Stephens.) This accords closely with the appearances of blood drawn from patients under puerperal fever, especially of the adynamic form. The blood is of a dark muddy colour, in some cases resembling even thin treacle in consistence: in this state the coagulation is very imperfect, so that after a time it merely forms a homogeneous semi-gelatinous mass, with little or no separation of serum from the crassamentum. After death the blood is found perfectly fluid, readily infiltrating and staining the coats of the vessels which contain it, and resembling thin watery claret, both in colour and consistence. In the other forms, which are of a more inflammatory character, it is highly buffed and cupped; the crassamentum is small, the albuminous layer upon it is of a muddy yellow colour; and the serum, which is frequently large in proportion, is of a similar colour, or even of a slight bilious tinge; in some, there has been occasionally observed a white cloudy appearance, as if from the admixture of milk. The mortality of puerperal fevers depends in great measure upon the form they assume; and, as we have already stated, this will vary in great measure according to the period of the year, the nature of the season, and the type of the prevailing epidemic fevers in the neighbourhood, whether they assume the character of synochus, or low malignant typhus. It varies a good deal according to the class of patients attacked, being more frequently of the inflammatory character among the middling and higher classes, whereas, among the lower orders, who are exposed to the depressing effects of cold, damp, and ill-ventilated dwellings, of insufficient clothing and food, of an atmosphere poisoned with the noxious effluvia arising from a dirty and thickly inhabited suburb, and habitual intemperance, it generally assumes the adynamic or contagious form. This is the reason that puerperal fever is not only seen less frequently among the middling and upper ranks, but even when it does appear, from being usually of the inflammatory form, it is more tractable. It is in lying-in hospitals, where it appears in all its terrors, and occasionally assumes such a degree of malignity as almost to equal the plague or yellow fever, in the frightful rapidity of its course, and in the almost certain fatality of its termination. Few have witnessed it in a more destructive form than the late Dr. W. Hunter at the British Lying-in Hospital. He observes in his lectures that he had seen a great many cases of it in the hospital, "and particularly in one year, when it was so remarkably prevalent there. It was so bad, that not only every gentleman belonging to the hospital, but all our friends in town, had a consultation to think whether we should shut up the house. _In two months thirty-two patients had the fever, and only one of them recovered._" (_MS. Lectures._) Although puerperal fever has never yet attained the frightful degree of mortality at the General Lying-in Hospital, nevertheless, it has appeared repeatedly with such malignity, as to commit fearful ravages among the patients. In these epidemics, the first few cases are generally comparatively mild, being of the peritonitic or gastro-bilious form (_Douglas_:) but as it advances, the malignant adynamic form, which is so destructive, prevails. In some epidemics, as is seen in common fevers, after a short time the disease has become more tractable, it has assumed a milder character, and ultimately has again disappeared. This corresponds with the admirable remarks of Dr. Gooch, to whose graphic pen we are indebted for much valuable information on the subject of puerperal fevers. "Another remarkable circumstance about this disease is, that, when it is most prevalent, it is most dangerous. Each case is more difficult of cure than when it occurs seldomer. The practitioner finds, that, although the group of symptoms resembles what he was formerly accustomed to, he has now to deal with a disease far more obstinate and destructive, and his usual remedies are not so successful as formerly; he loses case after case in spite of his best efforts. When it has been thus raging for a considerable time, it at length subsides; the case becomes less frequent and less severe; the practitioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier, and to treat it better, but probably also because the disease has itself become milder." (Gooch _on Peritoneal Fevers_, p. 3.) The table of the cases at the General Lying-in Hospital and their mortality, which Dr. Ferguson has calculated during the twelve years, from March 1827, to April 1838, is highly important, and points out the period of the year in which puerperal fever, prevails most, and the contrary. The last two and the first seven months of the year are those in which the greatest mortality occurred; whereas, in the month of July, during this whole period, not a single patient died; in August only one; in September two; and again, none in October, although several were attacked. "Puerperal fever was _epidemic_ in the years 1828, 1829, 1835, 1836. 1838; in the other years it was only sporadic. The greatest mortality was in the years 1835 and 1838, in the last of which 20 in 26 died. The malady commenced in January, in which month Dr. Rigby saved only 1 out of 9. The hospital was closed for a month, and opened again in March, when he succeeded in rescuing only 2 in 8. Thinking that another mode of treatment might be more successful, I determined to bleed largely, and to salivate. This plan was fairly tried under the constant attendance of Dr. Cape, and with my supervision, but 3 only in 9 lived. Seeing that no treatment was of avail, the hospital was closed from May till November." (Ferguson, _op. cit._ p. 277.) _Different species of puerperal fever._ Having premised these general observations on puerperal fevers, we now proceed to consider them separately, according to the various forms which they exhibit; and in doing so, shall adopt the arrangement of the subject made by Dr. Douglas, viz. under the three heads of inflammatory gastro-bilious, and the contagious or adynamic form. It is not only one of the earliest, but in our opinion, one of the most correct; nor do the arrangements adopted by Drs. Locock and Ferguson differ essentially from it. We hope by this means to combine the advantages which each affords, while we hold ourselves free to differ or coincide with either, as our opinions lead us, trusting that we shall thus be able to render this complex and difficult subject more complete. Under the inflammatory form we shall not only consider the acute peritonitis, so ably described by Dr. Locock, which is chiefly produced by the effects of labour, to which we have already alluded in the quotation from Cruveilhier, but also that form which, according to Dr. Ferguson, arises from vitiation of the blood, by the introduction of putrid matter into the circulation; a form which has not only a great disposition to assume a typhoid character, but also to become epidemic. Under this head we must also bring the uterine inflammation and phlebitis, which we have described, as resulting from a direct action of putrid matters contained in the uterus, a form which is very liable to pass into uterine, and afterwards general peritonitis; lastly, there remains that species of nervous abdominable pain, which has received the name of false peritonitis. _Puerperal Peritonitis._ _Symptoms._ The acute peritonitis, which has been produced by the effects of labour, generally makes its appearance at an early period after. The labour has probably been either tedious or severe, the efforts of the uterus and abdominal muscles have been violent, especially during the last stage; and from the moment of the child's birth, the patient has complained of considerable soreness over the lower part of the abdomen, amounting to much pain and tenderness when touched. At first she is tolerably easy, so long as she lies still, and keeps the abdominal muscles in complete repose; but, by degrees, fits of pain come on, they become more frequent, and the intervals between them shorter and shorter, until the pain is constant; she now complains of much tension and fulness of the abdomen; the tenderness is greatly increased, both in severity and extent, and is often attended with the painful sense of twisting about the umbilicus, which is observed in ordinary forms of peritonitis. The pain and tension are now so severe that she is constrained to lie wholly upon her back, with the knees drawn up, in order to relax the abdominal muscles, and thus, if possible, alleviate her sufferings. The abdomen itself is evidently fuller to the feel, and is beginning to be tympanitic; the breathing is quick and anxious; the tongue has a thin coating of white fur, which is browner and thicker at the back; the pulse is quick and hard, sometimes small and wiry, occasionally full and strong; the lochia and milk have either never appeared, or only in small quantities, to be quickly suppressed again. As the tympanitis increases, the breathing becomes more anxious and painful; for every effort of the diaphragm in inspiration is followed by severe pain, from the movement which it produces in the abdominal contents. After awhile, the flatulent distention of the intestines, particularly of the stomach, renders the diaphragm irritable, and provokes hiccough, which is excessively painful from the involuntary jerk which it gives to the abdomen; or, what is still worse, retching and efforts to vomit frequently come on, which greatly aggravate her sufferings. She now lies upon her back, perfectly helpless and immoveable, for the slightest attempt to touch her is insupportable; even the jar of a person walking heavily across the room excites pain. The abdomen is now even larger than it was before labour, her anxiety and restlessness increase, and she rapidly becomes exhausted from suffering and want of sleep. The face becomes sallow, the features fallen, the tongue dry and brown, and sordes collect upon the teeth; she falls into an uneasy slumber, during which, the eyelids remain partly open, or she mutters incoherently with low delirium. The abdomen is less painful, but not diminished in size; the pulse is small, hurried, and feeble; subsultus tendinum and picking of the bed-clothes follow, with all the other symptoms of approaching dissolution. Where the attack has risen from the introduction of putrid matter into the circulating current, it usually appears somewhat later, seldom before the third day after labour: it is almost invariably preceded by a severe rigour, followed by intense headach, and darting pain about the lower part of the abdomen, which gradually becomes constant. There is a nearer approach to the adynamic form, or rather, it is frequently attended, or at least followed, by this disease; hence the inflammatory stage is shorter, the pulse is even more rapid, and loses its strength sooner than in the other form; the milk and lochia have usually not only been established, but continue, we think, longer afterwards than in the other case; the pain is perhaps less in many instances, but in other respects, the first part of the attack does not differ essentially from the form above described; but as the disease advances, it gradually assumes the adynamic form; the inflammatory symptoms of the early part of the attack are merged in the general collapse which now exists, the same cause which had produced the peritoneal inflammation now acting on the whole system. Peritonitis occurring by itself, is, as Dr. Ferguson observes, of comparatively rare occurrence in puerperal women, the condition of the system during childbed, disposing it quickly to assume more or less of the adynamic character. _Appearances after death._ On examining cases of fatal puerperal peritonitis, we shall find marks of inflammation, or its consequences, over a large extent of the peritoneum; large portions of it are highly congested, and more or less thickened; considerable effusions of serum or sero-purulent fluid, mixed with flakes of coagulable lymph, into the abdominal cavity: the omentum adhering to the intestines, and also the intestines to each other, by means of coagulable lymph, in which they are occasionally completely imbedded; the broad ligaments and ovaries are frequently much inflamed, covered with lymph, and the latter more or less softened; the Fallopian tubes engorged and adhering to the neighbouring parts; the uterus is covered at its fundus with a coating of coagulable lymph, as if it had been smeared with a quantity of dirty white paint, and this extends more or less in patches over the various reflexions of the peritoneum, in the upper parts of the abdominal cavity. _Treatment._ We may take it as a rule, that the earlier we see the patient in the disease, the less active will be the treatment required. At first, when the pain has not yet assumed its full intensity, and only occurs in paroxysms, when little or no traces of abdominal tension and fulness are to be perceived from incipient tympanitis, we may frequently succeed in cutting short the disease by a full dose of calomel and James's powder, with some morphia or Dover's powder, to allay irritation and assist in producing a general determination to the skin; this must be followed by some castor oil, and if the pain is no longer constant, with the addition of a few drops of Liquor Opii Sedativus. Where the pain has already become severe, a draught of sulphate and carbonate of magnesia in peppermint water, with a little antimonial wine and henbane, will be preferable. We have long since been convinced, that common black draught, or any form of purge which acts violently or gripes, is objectionable, having frequently seen a return of pain brought on by its action. A hot poultice of linseed-meal, large enough to cover the whole abdomen, and as hot as the patient can bear it, must be applied; this, if made properly, will prove a great relief, for it not only allays the pain, but quickly acts as a powerful diaphoretic: there is a little art in making this, and unless it be done properly, it is apt to produce much discomfort, and do more harm than good. The water should be poured boiling hot on the linseed-meal, and the mixture well beaten with a large spoon, until it forms a nearly gelatinous mass; it should then be spread upon a large piece of linen, so as to be between a quarter and half an inch in thickness; there is now only one layer of cloth between the poultice and the patient's abdomen, and it can be applied or removed with perfect facility: without these precautions it is apt to form a pudding-like mass, which greatly annoys the patient from its weight, and from being applied directly to the abdomen, smears about, and is not easily changed. A poultice made in the manner now described, will keep hot for three hours at least, and is by far the most effective form of fomentation which can be employed. Common fomentations of sponges, or flannels wrung out of hot water, are by no means desirable, as from the constant exposure, which is required for their frequent repetition, the patient has little benefit from the temporary heat, and is very liable to catch cold. If the symptoms do not yield to this treatment, but assume a more formidable aspect, or if the attack has not commenced in this gradual manner, but has come on much more suddenly and with greater violence, recourse must be had immediately to the lancet. Leeches are seldom proper as a substitute for bleeding, although they frequently prove of great value afterwards. A certain effect is required to be produced upon the general circulation, before leeches are capable of affording even a temporary relief; and so far from economizing the patient's powers by using leeches instead of the lancet, we shall find that in order to overcome the inflammation by this means, the patient will require to lose a far greater quantity of blood than if it had been suddenly removed from the circulation by bleeding. Upon the same principle, therefore, we must take care, that the blood shall be drawn _pleno rivo_ from an ample orifice: we thus spare the patient an unnecessary loss of power, for the required effect upon the circulation is produced in a much shorter time and with less expenditure of blood, than if the blood had been slowly dribbled from a small opening. "In the treatment of acute inflammation in the vital organs, the customary practice is to consider local bleeding as a milder means of effecting the same object as general bleeding, and to postpone it till the stage for the latter is over. To me it appears that they are calculated to effect two different objects, both of which are necessary at the beginning of the treatment; the one to reduce the violence of the general circulation, the other to empty the distended capillaries of the part. As long as the pulse is quick, full, and hard, it is in vain to take blood from the affected part; if we could completely empty its gorged capillary vessels, they would be instantly gorged again, whilst the heart and large arteries are injecting them with so much violence. On the other hand, after having reduced the force of the general circulation, the capillary vessels of the part often remain preternaturally injected: this, I conclude, from the fact that the patient is often not relieved till local blood-letting has been used, and then is relieved immediately. Hence, as soon as the patient has recovered from the faintness occasioned by bleeding from the arm, leeches ought to be applied without delay." (Gooch, _on Peritoneal Fevers_, p. 47.) It is impossible to fix what quantity of blood is to be drawn; nor is it easy, either from the patient's appearance or the feel of her pulse, to foretell how much she will require to lose: a certain effect is to be produced on the circulation in order to bring it under such control as will moderate the state of inflammation. No two patients are alike in this respect; and it frequently happens, that where, from external appearances, we might have expected to find most strength, faintness is quickly produced, and _vice versâ_: on the whole, we think that where the patient has a small, quick, and oppressed pulse, we may expect she will require to lose a large quantity of blood, for in these cases the pulse rises in volume and strength as the bleeding proceeds; hence, as before observed, we must "carry the bleeding to its proper limits, which is the approach to, or actual state of, syncope." So far from removing the pillows, and letting her lie with the head low, so as to recover from her faintness as quickly as possible, it will be much better to support her in a sitting posture, and thus prolong the state of faintness for some while; the dilated vessels have now time to contract, the heart returns to a more moderate and healthy action, the effects of the bleeding are much more permanent, and the chances of its repetition being required considerably diminished. From this state of relaxation and temporary collapse being prolonged, we find that the secretion of the skin, and particularly the intestinal canal, are more easily re-established, the operation of a purgative being now much quicker and more effective. As soon after the bleeding as possible, a smart dose of calomel and James's powder, followed by an active saline laxative, must be given; and the combination of sulphate and carbonate of magnesia with antimonial wine and Tinct. Hyosc. already recommended, is preferred by us: it is better given in divided doses, as then the effects of the antimonial is prolonged. The action of the bowels may also be assisted by a domestic enema: and if there are no signs of action in the bowels after two hours, the purgative should be repeated. The results of the leeches, fomentation, and purging, will guide us as to the necessity of repeating the bleeding. Dr. Gooch's truly practical remarks on these points are well worthy of attention:--"I waited till the purgatives had operated fully, that I might know what impression the combined operation of general and local blood-letting had produced on the disease, before deliberating on the employment of a second blood-letting. The common effect, of these remedies was this, as long as the faintness lasted in the slightest degree, the pulse remained soft and often slower, and the pain was much less, or ceased altogether; but an hour or two after the bleeding, when the circulation had recovered, the pain returned more or less, and the pulse regained much of its hardness or incompressibility. This state continued till the leeches had bled freely, and the purgatives had acted repeatedly and copiously." (_Op. cit._ p. 48.) If, however, the pain has experienced but little abatement, or has returned as severely as before; if the pulse has quickly reassumed its former condition; if the action of the purgatives has not taken place, or has been at most unsatisfactory, even with a repetition of the saline, we are justified in having recourse to a second bleeding; the faintness this time will probably be more complete; the effect upon the disease more decided; and, in all probability, it will be quickly followed by free evacuations from the bowels, which produce great relief. In some cases the bleeding requires to be repeated again and again before the disease can be subdued: this, however, usually arises not so much from the obstinacy of the attack, as from the first bleedings not having been performed in an effective manner. "The pulse," says Dr. Locock, "is the best guide, for the pain after the first full relief from the bleeding is often of a mixed character, partly inflammatory, partly nervous, to be detected only by watching closely the other symptoms. The tenderness is a less certain guide, for few will bear pressure for a considerable time after the inflammatory symptoms have been entirely relieved. Many patients also from fear shrink from the pressure of the hand, although by drawing off the attention, it will be found that they bear firm and steady pressure very well." (_Op. cit._ p. 355.) Throughout the whole process of treatment, the linseed-meal poultices must be continued, and, if not made too heavy, can be borne when there is a considerable degree of abdominal tenderness. In all cases where the disease has not been completely checked in the very outset, but has shown a disposition to return, the treatment above-mentioned should now be followed by a mild mercurial course. The effects of mercury in allaying inflammation at a certain stage, which does not appear to be fully under the control of mere antiphlogistic remedies, have been amply proved by British practitioners: this applies particularly to inflammation of serous membranes: mercury not only tends to prevent the effusions of serum and coagulable lymph, but, where they have taken place, it is of great value in promoting their absorption. We agree with Dr. Locock, that calomel is by far the best form in which it can be used, where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ, which we have occasionally found useful in the gastro-bilious or enteric form to restore a depraved state of intestinal secretions, has failed us in the other forms where we wished to produce salivation. The purgative dose of calomel, which we have advised to be given after the bleeding, ought not to be less than six to eight grains; but now, as the dose is to be repeated every two or three hours, a smaller quantity will be sufficient: in order to save time we usually begin with five grains of calomel, and an equal quantity of Dover's powder, and repeat this in an hour's time, after which, we proceed with doses of two or three grains every second or third hour according to circumstances. The sooner the system can be brought under the influence of mercury the better, the pulse becomes softer and less frequent, the pain and tension of the abdomen diminish, the tongue becomes moist and natural at the edges, and general improvement follows. Throughout the whole attack the vagina should be occasionally washed out with warm water, more especially if we have reason to suspect that the disease has arisen from the imbibition or absorption of putrid matter. The smell of the patient will frequently guide us in this respect, and point out the condition of the passages and their contents; even if there be no putrid matter lodging there, the application of warm water will always act as a comfortable fomentation to the patient, and assists not a little in favouring a return of the lochia. If the pain and swelling of the abdomen still continue, and the case is evidently becoming more unfavourable, we have occasionally sprinkled the abdomen with spirit of wine or oil of turpentine, and then covered it with a fresh poultice: this has acted as a powerful rubefacient, and has in some cases relieved the patient at a very advanced stage. We have also tried blistering the abdomen, and dressing the vesicated surface with strong mercurial ointment, as recommended by Dr. Locock; but we have not met with the success which he mentions, probably from the disease having already assumed the malignant characters of the adynamic form, and, in some instances, because the patient could not endure the intense smarting which it produced. We have occasionally covered the abdomen with camphorated mercurial ointment without previous blistering, and with good effect. The internal use of turpentine, circular friction upon the abdomen, and enemata of Mist. Assafoetidæ, &c., which we have sometimes found useful in removing the tympanites of the adynamic puerperal fever, and which does not depend on an acute form of inflammation, are scarcely applicable in the present case. When the powers are beginning to fail, as a last hope we must have recourse to stimulants combined with nourishment: the Mist. Spiritus Vini Gallici of the last London pharmacopoeia,--anglice, "egg and brandy,"--has for many years been used at the Lying-in Hospital to support the system at this last stage, and sometimes even under the most unfavourable circumstances with marked success; powerful doses of ammonia will be required at frequent intervals, and an occasional opiate, to procure the still farther refreshment of sleep. Even where the face is assuming a Hippocratic appearance, the pulse so feeble and rapid as scarcely to be counted, where the abdomen is immensely distended, with cessation of pain and cold clammy state of the skin, we ought not to despair; no case, however bad, is entirely hopeless; and although the majority of such cases perish in spite of the greatest care and activity, still we are justified in persevering till the last, knowing from experience that we every now and then succeed even at this late hour in rescuing our patient.[145] _Uterine Phlebitis._ In describing the other species of inflammatory puerperal affection, which we have designated by the title of uterine inflammation or phlebitis, and which we conceive arises in most instances, from the presence and absorption of putrid matter in the uterus, we shall merely confine our description to the early part of the disease, because, as it invariably terminates in peritotinis if not stopped at an early period, it will be unnecessary to go over this part of our subject again. _Symptoms._ This affection generally makes its appearance on the second, third, or fourth day after labour, and varies considerably in its mode of attack. In some cases it will be observed to come on suddenly, with scarcely any premonitory symptoms. The patient is suddenly seized with severe griping pain in the lower part of her abdomen, generally extending more or less to one side, and usually preceded by a smart shivering fit, which is followed by intense headach. On examining the abdomen, the uterus is hard, larger than natural, and excessively painful to the touch; the pulse quick and usually small; the tongue covered with a thin white fur, becoming brown and thicker towards the back part; the countenance anxious. With all this, the abdomen is neither hard nor painful upon moderate pressure; not even over the uterus itself do we produce pain, until we begin to press so hard, that the organ becomes plainly distinguishable to the hand through the soft integuments. The lochia has either not appeared at all, or has been suddenly suppressed; and in all probability, the secretion of milk has followed a similar course. Or the disease may commence in a much more gradual manner. The after-pains are observed to increase in severity and duration, producing a considerable degree of pain over the whole abdomen, but especially the uterus, which, during the paroxysms, is harder than in the intervals. The pains are increased by the slightest pressure, if _suddenly_ applied; but, if gradually increased, the patient will bear a considerable degree of pressure, not only without complaining, but will even remark that the pain is, as it were, benumbed by it; if the hand be now suddenly removed, very severe suffering is produced. The pains become more and more constant, until they assume the uniform character of inflammation of the uterus, as already described, when the disease makes its attack suddenly. If the disease be not checked in its progress, the pain becomes more intense, and gradually extends over the whole surface of the peritoneum; the abdomen swells from tympanitis, and is followed by the other symptoms of acute peritonitis already described. The latter stages of the attack are almost invariably mingled with symptoms of the malignant form of puerperal fever,--a circumstance which, when we consider the probable source of the disease is not to be wondered at. Indeed, we may say, that by the time the peritonitis is fairly established, the introduction of putrid virus into the circulation has been of sufficient duration and extent to render the production of adynamic symptoms almost unavoidable. _Appearances after death._ Examination after death shows that the uterus and its appendages have been the chief seat of the inflammation, its whole peritoneal surface thickly covered with exudations of coagulable lymph; the broad ligaments vascular; the Fallopian tubes livid, swollen, and softened; the ovaries greatly altered in appearance and structure, being generally more or less swollen and much softened,--at times the natural tissue of the gland completely broken down into a pulpy semi-purulent mass, at others the external surface only has been red or gorged with dark-coloured vessels; the whole uterine appendages thickly imbedded in cogulable lymph. The uterus is large and soft, deposites of pus have been found beneath its peritoneal covering, or in the proper muscular tissue of the organ; and in many cases, on cutting into its substance, pus has appeared in numerous little points, oozing from the veins or absorbents which have been divided. In those veins which are large enough to be traced by dissection, their coats have been found vascular, thickened, and in many places lined with lymph, so that the vessel has become completely impervious: in others, they have been filled for a space with pus, and their canal then obliterated, either by swelling, effusion of lymph, or by plugs of fibrine from coagulated blood. These changes in ordinary cases do not extend beyond the substance of the uterus; but where the disease has been of some duration, as well as severity, they become much more extensive, affecting the neighbouring veins to some distance. "Inflammation," says Dr. R. Lee, who has examined this subject with great care, "having once begun, it is liable, as I have before stated, to spread continuously to the veins of the whole uterine system, to those of the ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself does not always escape, the inflammation spreading to it from the iliac, or from the spermatic veins." (_Researches on the Pathology and Treatment of some of the more important Diseases of Women_, p. 54.) The surrounding structures are generally implicated in the inflammation; the muscular tissue of the uterus becomes soft and of a dark red, or even dirty black colour, and, as before stated, the peritoneum which covers the organ is particularly affected. The appearances after death in this species of puerperal fever are those most commonly observed, for puerperal peritonitis is rarely met with in its uncomplicated form, being usually more or less mixed up with it; on the other hand, the majority of cases which belong to the adynamic form of puerperal fever (except the most malignant) are generally preceded to a certain extent and attended by this disease. _Treatment._ In the early stage of the disease, before inflammation (especially peritonitis) has been established, we do not consider that the lancet is required, merely because there is pain with a quick pulse. The uterus may be hard, swollen, and painful, and yet there is not actual inflammation present: we will not deny that inflammation will quickly follow, if nothing be done to remove this state of uterine irritation. The pulse is quick, but seldom hard; and even if it be at all sharp, it produces but little resistance to the pressure of the finger. In these cases we may bleed, but we seldom reduce the quickness of the pulse, although it sinks still farther in point of strength. There is seldom much buffy coat upon the blood when drawn at this stage; and if the pain be relieved for a short time, it returns again as soon as the system has recovered from the immediate effects of the syncope. We do not see that striking relief follows a copious venesection in cases of this sort, which is remarkable in inflammation of the abdominal viscera under other circumstances; and we are more than ever convinced, not only from the fact just mentioned, and from the results of our own experience, but from the unfavourable results of the practice in which bleeding has been uniformly and largely employed, that it is _not_ a remedy which is _always_ to be premised before the employment of other treatment, as in cases of simple inflammation of the viscera or serous membranes. The only circumstances we apprehend, under which venesection ought to be employed in this affection are, where the pain is constant, without intermission, and where, besides its rapidity, the pulse betrays a degree of wiry resistance to the finger, which can never be mistaken. In this case the blood drawn will show all the usual marks of inflammation, and the relief procured will be proportionally great. On the other hand, where the pain, although severe, is not constant, but the patient experiences every now and then a slight abatement in its severity, or a short intermission altogether; where the pulse, although rapid, is soft, and resists the finger but feebly, we shall seldom produce any permanent relief by bleeding; the pulse becomes weaker, but its rapidity, so far from being diminished, is rather increased. The pain may be relieved for a short time, but it almost always returns as severely as before the venesection. Under these circumstances, the pure antiphlogistic treatment seems to have little or no control, either in removing the pain, or diminishing the pulse, or in preventing the disease from running into that state of tympanitic peritonitis, which is so fatal in its effects; and we are not only losing time by employing an inefficacious mode of treatment, but are exhausting the powers of the system, already more or less depressed. "Large hæmorrhages," as Dr. Ferguson correctly observes, "favour absorption," (_op. cit._ p. 108;) and it would seem that by thus reducing the powers of the system, we diminish its capability of ridding itself by the natural outlets of the virus which has been carried into the circulation; nor do we see how this is to be assisted by bleeding. If a state of actual hæmorrhage has been induced, bleeding, of course, must be used with the greatest promptness; but in employing this remedy in the above-mentioned form of puerperal fever, although we relieve the inflammation for a time, the cause is not removed. It still continues to act, and the symptoms return under much more formidable circumstances, from the increased debility of the system confining our means of treatment within still narrower limits. According, therefore, to the views which we have taken of this form of puerperal fever, the indications for treating it will be the following: _first_, to subdue any inflammatory symptoms, if they be present; but it must be remembered, that we have no positive proof of the existence of inflammation, merely from the presence of pain and a rapid pulse, although these two symptoms denote a state of irritation, advancing with rapid strides into actual inflammation. The character of each must be carefully ascertained before we are justified in deciding upon the necessity of bleeding. As this operation is generally performed in the erect posture, to favour a state of syncope, we are following a _second_ indication at the same moment, and perhaps one of the most important, viz. placing the patient in such a posture as will promote the escape of any coagula and discharges which may have been stagnating in the uterus or vagina. To effect this still more completely, a stream of warm water should be thrown up briskly into the uterus, to dislodge any offensive irritating matter which may have collected: the relief thus produced is sometimes quite extraordinary, the pain abates, the uterus becomes less hard, the pulse more natural, and the patient expresses herself greatly relieved. The rule which we have made in our treatment of natural labour, viz. that if possible, the patient should sit up to take her food, and suckle her child, and especially that she should always kneel to pass water, should never be neglected, for in many of these cases it will be found that the patient has not stirred from the horizontal posture, and that the attack had evidently followed the accumulation of stagnant lochia, &c., which from the warmth of the adjacent parts, and free contact with the external air, has rapidly become offensive; and, moreover, from her position, has been prevented from being discharged. To ensure that the uterus has expelled any coagula which may have lodged in it, is a powerful argument in favour of applying the child to the breast as soon as possible after labour; this refers particularly to those long slender coagula, which were first noticed in the uterine veins by Dr. Burton, in 1751, as one of the chief causes of after-pains; for by thus inducing firm uterine contraction, the greater part of these will be generally expelled, and access of air to the venous orifices prevented. "These coagula may be distinctly perceived for several weeks after delivery, and both in their form and colour they differ from those produced by inflammation." (R. Lee, _op. cit._ p. 53.) Our _third_ indication is to increase the action of all the excretory functions, and thus, as far as possible, remove the virus, which may have already entered the system. There is no remedy with which we are acquainted that has such a power of producing a general erethism throughout the whole excretory system, as calomel in large doses. The secretions of the liver, the mucous membrane of the intestinal canal, of the skin, and kidneys, are all very remarkably increased by the action of a large dose of this medicine, and we cannot help attributing the return of healthy lochia, which so frequently follows such a dose of colomel, to a similar action on the vessels of the uterus and vagina. No effort of nature can be so well directed for the removal of any noxious principle from the circulating fluids as a general increased action of the excretory system, and we have seldom or never seen calomel act with such success in this form of puerperal fever, except where it had been given in a sufficient dose to produce this effect. Salivation is by no means a necessary object, nor have we seen it produced even by a scruple dose of calomel. It is, however, seldom necessary to exceed ten grains at a time, although this may occasionally be required to be repeated. It should always be combined with some medicine which will assist its diaphoretic action. For this purpose, in cases where the pain is constant, without any remission, showing that a state of inflammation has been already induced, it will be advisable to combine it with a little of James's or antimonial powder. Where, on the other hand, the patient experiences evident abatement or even remissions of pain, ten grains of calomel with an equal quantity of Dover's powder, made up into pills, will be preferable; the opium acts by relieving the pain, and contributing to induce a copious perspiration. To assist this, and also to relieve pain still more, a hot linseed-meal poultice, as above described, will be of great service; and in a few hours (or the next morning, if the calomel has been given over night,) a saline of sulphate and carbonate of magnesia should be given. The vagina should be well syringed with warm water, and repeated from time to time as occasion requires; in like manner, the poultice must be continued until the pain has entirely ceased. The general result of this treatment is, that in twelve or eighteen hours the uterus loses its tenderness and hardness, the pulse becomes fuller and softer, the tongue cleaner and more moist, the kidneys and bowels have acted copiously, and the lochia and milk have returned. _False Peritonitis._ Under this title, which we believe first originated at the General Lying-in Hospital, and which has been adopted by Dr. Locock in his article upon the subject, we propose to describe that peculiar species of abdominable pain, which Dr. Ferguson has called the _transient_ form of peritonitis. Strictly speaking, neither of these terms are exactly appropriate, for the disease appears to depend upon a state of high nervous irritability, perfectly independent of inflammation, or any other affection of the peritoneum; still, however, as it has been most frequently known and described under the former of these appellations, we shall also continue to use it, merely warning our reader, that the appellation of false peritonitis is more conventional than correct. Properly speaking, it should be called _nervous abdominal pain_; for we have reason to think that its real seat is in the muscular coat of the intestines, and in the abdominal muscles themselves, much more than in any portion of the peritoneum. The disease chiefly attacks women of a delicate frame, and irritable habit of body, with small features, fair complexion, and of a nervous hysterical disposition, whose powers have but ill sustained them through the processes of pregnancy and parturition, and are now beginning to fail under that of lactation. Her mind is anxious and depressed, the sleep is restless, the circulation irritable and feeble; she is pale, forebodes all sorts of evils, and is unusually sensitive; complains inordinately of her sufferings in trying to suckle the child, and of the severity of her after-pains; not unfrequently she has severe headach, of that species which affects the top of the head, and which is generally considered to arise from a state of debility and anæmia. In many cases the pain has evidently been produced by the action of a griping purge. The pain is of the most intense character; indeed, in many cases, it is evidently too severe for the ordinary suffering from abdominal inflammation. So irritable are the abdominal muscles, that the slightest motion, even that of respiration, will throw them into cramp-like contractions to the great agony of the patient. The breathing is short and timid, like that of a person under a severe attack of pleurodyne: the slightest touch of the hand, or of a single finger, produces intolerable suffering, not so much from the pain which its pressure produces, but from the sudden and involuntary contraction to which the irritable muscles are thus excited. The quickened breathing, from a dread of the abdomen being touched, is frequently sufficient to bring on a paroxysm. If by soothing words and promises of cautious proceeding we induce her to let us apply our hand upon the abdomen so gently that it does not even rest with its weight upon it, we shall find that we may now gradually increase the pressure, until by degrees it becomes considerable, not only without her feeling any increase of pain, but with complete relief--the pressure of the hand appearing as it were, to benumb the pain. If we withdraw the hand in the same gradual manner, no pain will be produced; but if we remove it suddenly, a spasm of the muscles, with intense pain, is instantly excited. The pulse is in an equally irritable state; after a few beats it rises in rapidity as soon as the patient's mind is directed to it; in others it is permanently quick. The tongue is sometimes slightly covered with a thin fur; in others it is pale and flabby; and in others disposed to be glazed, red, and dry. The disease rarely exists long uncomplicated with any other form of puerperal affection, but soon passes either into acute peritonitis, or into the typhoid state of the malignant form, the latter transition being almost certain, if the practitioner has considered it as an inflammatory affection, and treated it antiphlogistically. It is to the late Dr. Gooch that we are indebted for having first called the attention of the profession to this disease, and pointed out its true characters by the nature of the remedies which proved successful in relieving it. "The effects of remedies on a disease, if accurately observed, form the most important part of its history; they are like chemical tests, frequently detecting important differences in objects which were previously exactly similar. How many diseases are there in which the symptoms are inadequate guides?" "The local pains and constitutional disturbance which occur in feeble and bloodless persons, and which are aggravated by bleeding and other evacuants, strikingly resemble the local pains and constitutional disturbance which occur in vigorous and plethoric persons, and which the lancet and other evacuants relieve and ultimately cure; yet how many years is it before the young practitioner learns that there are cases apparently so similar, yet really so different, and how to distinguish them; and how many practitioners are there who never learn it at all? Symptoms and dissections can never do more than suggest probabilities about the nature of the disease, and the effects of a remedy on it. A trial of the remedies themselves is the only conclusive proof." (_Op. cit._ p. 37.) In those cases which proved fatal, the post mortem appearances only tended to confirm the nature of the disease. So far from marks of inflammation being found, there was not a single trace to be discovered; in fact, an entirely opposite condition existed; the peritoneum and viscera were pale and bloodless. _Treatment._ It is of the highest importance to distinguish these affections from a state of inflammation; the treatment of the one will be precisely the reverse of the other. The lancet is as little indicated in this case, as it is in puerperal convulsions from anæmia, and the effects produced will be scarcely less mischievous. The fatal cases which Dr. Gooch has recorded, show that it was not the disease so much as the treatment which destroyed the patients, and prove, as we have already stated, that the presence of pain and a quick pulse do not surely indicate a state of inflammation, without being confirmed by the general symptoms of the patient's condition. "These cases taught me a new view of the subject: they taught me that a lying-in woman might have permanent pain and tenderness of the abdomen, with a rapid pulse, independent of acute inflammation of the peritoneum or any other part; that these symptoms may depend on a state which blood-letting does not relieve, and which, if this remedy is carried as far as it requires to be carried in peritonitis, may terminate fatally; and that the most effectual remedies are opiates and fomentations. Most of the patients who were the subjects of these attacks, were women, who, in their ordinary health, were delicate and sensitive; the attack sometimes seems to originate in violent after-pains, gradually passing into permanent pain and tenderness, resembling inflammation, or in the painful operation of an active purgative; but it could sometimes be traced to no satisfactory cause--the patient had had a common labour, and had experienced no unusual cause of debility or irritation. The pulse in all these cases, although quick, was soft and feeble: this, together with the previous constitution of the patient, were my chief guides. When I could trace it to any irritating cause, such as a griping purge, and when blood had been already drawn without relief, and without being buffed, I saw my way still clearer. When I doubted, I applied leeches to the abdomen." (_Op. cit._ p. 72.) In ordinary cases a dose of Liquor Opii Sedativus, or of Dover's powder, repeated according to circumstances, will be sufficient to stop the attack, taking care to clear the bowels of any irritating matter with castor oil in some aromatic water, guarded by a few drops of Battley's solution. In many of these cases, where the circulation is below the natural standard in point of power, and the disease is more or less complicated with hysteria, the opiates should be combined with a gentle stimulant, of which camphor is by far the best. Five grains of powdered camphor with half a grain of hydrochlorate of morphia and a sufficient quantity of extract of henbane, to form two pills, may be repeated at intervals, whenever the pain shows a disposition to return, and constipation prevented by castor oil and Liq. Opii Sedativus as before-mentioned, or a gentle draught of sulphate of potass, rhubarb, and manna. In most cases, when the stomach and bowels are in a proper condition, mild tonics will prove useful, as equal parts of extract of gentian, henbane, with or without a grain or two of quinine or sulphate of iron, at night; and, if necessary, the infusion of some vegetable tonic during the day. The diet should be simple but nutritious, and a certain quantity of malt liquor or wine allowed daily, if the condition of the patient permit it. In some instances the low diet which is usually deemed requisite for the first few days after labour, has appeared to have been the cause of this highly irritable condition, especially in those who have habitually accustomed themselves to pamper the appetite, and to use fermented or spirituous liquors in excess: with spirit drinkers, the loss of their daily stimulus is almost sure to be followed by a low, feeble, irritable state of the system, much gastric and nervous derangement, and the paroxysms of pain just described. It is astonishing how quickly every symptom subsides, and the system returns to a natural condition, by the daily allowance of a small quantity of their favourite beverage. _Gastro-bilious Puerperal Fever._ This is the gastro-enteric species of Dr. Ferguson, and corresponds with the "puerperal intestinal irritation" described by Dr. Locock. In its simple uncomplicated form, this disease cannot be considered as a dangerous affection; it occasionally passes into inflammation, but more frequently it assumes after awhile the typhoid or malignant form, especially where its true characters have not been recognised, and the powers of the system have become much exhausted by its severity and long continuance. Like the false peritonitis it is frequently met with in cases where, from unwholesome or intemperate living, the digestive organs are greatly deranged, or where the bowels have been much neglected for some weeks before labour. We cannot help thinking that the view which Dr. Ferguson has taken of its cause, viz., a vitiated state of the fluids, as with the case of puerperal peritonitis, is far too exclusive, inasmuch as it is evidently produced in many instances by the direct irritation of matters which are contained in the intestinal canal: in others, we fully agree with him, that it is produced indirectly by the introduction of an animal poison into the circulation, which spends its virulence upon the stomach, liver, or intestines, or which, in other words, nature endeavours to remove from the system by these outlets. In the early stage of uterine irritation, or of phlebitis, from the absorption of putrid fluids, we have shown that the cause at first, in most instances, acts directly, and not through the medium of the circulation, otherwise the symptoms would not be so instantly checked by washing out the uterus with warm water, and thus removing the source of mischief; so in the gastro-bilious or enteric form, the symptoms _at first_ are produced in most, if not all cases, by the direct irritation of the unhealthy intestinal contents, upon the removal of which they at once disappear; although at the same time, if the source of irritation be not removed, we have no doubt but absorption will take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland considers that retained fæces during a lying-in are capable of bringing on symptoms which "may, properly enough, be called puerperal fever" (_op. cit._ p. 87;) and Dr. John Clarke, in enumerating the different causes entertained by "writers of good reputation," mentions, where fæces are detained in the intestines, "the thin putrid parts of which are supposed to be taken up into the blood." (_Practical Essay on the Management of Pregnancy and Labour_, by J. Clarke, M. D., 1806, p. 53.) There is, however, no reason to confine the source of the putrilage, which infests the circulating current, in cases of gastro-bilious or intestinal irritation, to unhealthy fæcal matter in the intestines; for in the experiment made by Professor Tiedemann, to which we have already alluded, viz. of injecting musk into the femoral vein of an animal, the poison seemed to concentrate itself upon the mucous membrane of the intestinal canal; and from the diarrhoea which had commenced shortly before death, it is probable, if the dose had been smaller, that nature would have succeeded in ridding the system of it by this means; we may, therefore, conclude, in most of the cases of this affection, which are not the result of direct enteric irritation, but an effort of nature to purify the circulation by expelling the morbid matter, with which it had been vitiated, through the medium of the mucous membrane of the bowels, that the uterus had been the source of its origin, introduction, or absorption, into the system. _Symptoms._ This form of puerperal fever seldom commences so soon after labour as any of the other species, and frequently the symptoms are so trifling, at first, as scarcely to excite attention. There is an indistinct uneasiness about the abdomen; the tongue is never quite natural, being either slightly furred with a few prominent papillæ, or pale and flabby; the appetite is irregular, or fails considerably; the patient complains of weariness and lassitude; there is, perhaps, slight headach across the eyes and forehead; the face has a sallow tinge, and if her complexion be dark, there is a leaden-coloured ring beneath her eyes; the sleep is unrefreshing; the spirits are unequal and anxious; she is chilly at times, and at others, has considerable flushings of heat, with increase of headach. The abdomen becomes full and doughy to the feel; it is somewhat tender to the touch, but not distinctly so, as in peritonitis; the motions are dark, sparing, and excessively offensive; sometimes hard and scybalous; but more usually they assume the character of an irritable diarrhoea, with much acrid slimy mucus, the evacuation of which, is attended with much flatus, and for a time produces great relief, although, at the moment of passing, it is frequently attended with a good deal of forcing. The abdomen becomes more tender, with severe griping flatulent pains at intervals; the diarrhoea assumes somewhat of the characters of dysentery; the pulse becomes quick and irritable; the tongue red and glossy at the tip and edges, with a patch of thin white fur in the middle, or with a red centre between two parallel streaks of creamy fur--the back part yellow, verging into brown; the breath is of a faint disagreeable odour; the attacks of fever, from time to time, are more distinct; and frequently, during the sweating stage, the skin throws out a strong peculiar odour, which taints the air of the whole room. In some cases there is frequent vomiting, either of watery fluid mixed with ropy mucus, or of a greenish colour; the result probably of subacute inflammation of the stomach. As the irritation of the intestinal canal increases, she becomes more exhausted, and rapidly emaciates. The tongue now becomes preternaturally red, its surface glossy smooth, the centre is parched and brown, and sometimes traversed with fissures; the fever assumes a low typhoid character, with delirium at night, and gradual sinking. The appearance of the evacuations varies considerably; at times they appear to consist of minute membranous shreds, floating in dark brown water; in others, they are clay-coloured, slimy, adhesive, excessively offensive, and even pungent; whereas, in others, they seem to consist chiefly of dark unhealthy bile, mixed with water and mucus. This form of disease is frequently met with in patients who have been weakened by hæmorrhage, and necessarily tends to aggravate the state of anæmia which is present. She has the intense pain at the summit of the head, which characterizes this condition; she gets but little sleep, and that is disturbed by restless and uneasy dreams; she lies with the eyelids half closed, and the occasional twitchings of the muscles betray the irritable condition of the system; exhaustion quickly supervenes, and is usually attended either with low delirium, or the anæmic form of puerperal mania. _Appearances after death._ If the dysenteric affection has been very severe, we shall probably find softened or even ulcerated spots in the mucous membrane of the large intestine; but in other cases, there have been no lesions of the kind; the intestines have been found a good deal distended with gas, but pale and bloodless. Where the disease has passed into the typhoid species, other appearances belonging to this form will be observed: coagulable lymph will probably be effused, and those changes in the structure of the uterus, which we shall mention when we come to the consideration of this species. _Treatment._ The treatment will, in great measure, depend upon whether the disease is the result of irritation from loaded bowels, scybalous and unhealthy contents, &c., or from that engorgement of the circulation belonging to the chylopoietic viscera, with more or less fever, which indicates the efforts nature is making to rid the circulation, by this outlet, of any morbid principle with which it may have been infected. In the first case it is simple enough, and, in most instances, the disease is prevented, or, at any rate, checked in its very outset, by the dose of castor oil which is customarily given on the second or third day after labour. If the pulse be quick, the headach severe, with much fulness and uneasiness of the abdomen, and more especially if the bowels have been constipated, or in an unhealthy state before labour, five grains of calomel and carbonate of soda, made up into two pills, with extract of henbane, and followed in a few hours by a dose of castor oil, guarded with some Liquor Opii Sedativus, as before recommended, will be required. We combine a little soda with the calomel, to prevent it griping and acting violently, which it is liable to do where there is much acidity of stomach, from its being converted into the bichloride. We also think that there will be less chance of vomiting, when the calomel is combined with the soda, than with an antimonial, as recommended by Dr. Locock; a common domestic enema of gruel and salt will assist the purgative, and bring away much unhealthy fæculent matter. The medicines will generally require to be repeated in twenty-four hours, to insure the removal of the irritating cause from the bowels; the abdomen becomes softer and more free from uneasiness; the pulse rises in strength and fulness, but diminishes in rapidity, and the patient experiences general relief in her symptoms. She may now take an ammoniated saline, with tincture of hop or henbane during the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and henbane at night, instead of the calomel, and a draught of rhubarb and magnesia with some aromatic confection the next morning, or of rhubarb and manna with sulphate of potash, rendered warm by a little spirit of nutmeg. If diarrhoea has come on spontaneously at an early period, the true nature of the case is more liable to be mistaken; still, however, the evidences of gastric and enteric irritation are quite sufficient to guide the cautious and observant practitioner. The calomel here is not so desirable as where there is constipation; eight or ten grains of Hydrarg. c. Cretâ will produce less irritation, and act as effectually: it will require to be followed by the same treatment as above-mentioned, and to be repeated according to circumstances. The diet should be chiefly farinaceous with milk; rice-milk, when the bowels have been sufficiently cleared, is generally very useful; it is slightly constipating, and soothes the irritable mucous membrane with its bland consistence. Milk and soda-water, as mentioned by Dr. Locock, or with lime-water, is very beneficial, especially where the tongue is disposed to remain red, with a smooth glossy surface; as convalescence proceeds, a tea-spoonful of the concentrated essence or decoction of sarsaparilla may be added with advantage. This form of puerperal affection is never epidemic; it is mere intestinal irritation after labour from scybalous and other unhealthy contents; but this is not the case with the "gastro-enteric form," described by Dr. Ferguson; in the former, the febrile excitement of the circulation is but trifling, and frequently can scarcely be said to exist; whereas, in the latter, the disease rarely appears sporadically, but in conjunction with numerous cases of the same character, or of the malignant adynamic form; it is also, invariably accompanied with much febrile disturbance, and usually of a low form, unless complicated with abdominal inflammation at an early period. "This form of puerperal fever," as Dr. Ferguson observes, "assumes the general characters of a mild typhus, accompanied with intestinal irritation." (_Op. cit._ p. 22.) The object of our treatment here is very different to that of the other form just mentioned; it is to unload the gorged circulation of the stomach, liver, and bowels, of the noxious and excrementitious matters which nature has brought to these emunctories, in order that they may be discharged from the system. It is in these cases where, although little or no food has been taken for some time, and without any evidences of fæcal accumulation, we find the exhibition of certain purgatives, especially calomel, to be followed by such copious fæculent evacuations, which we have every reason to believe have been secreted by the liver and bowels under the action of this powerful remedy. The treatment recommended by Dr. Ferguson, is so in accordance with our own views, and so concisely expressed, that we may be allowed to quote it. "The following," says he, "I have found the most suitable treatment. Get rid of all local inflammations as soon as possible by leeching or by moderate depletion, so as to reduce the malady into simple fever with gastro-enteric irritation. When the skin is early dusky, and there is nausea or vomiting, begin with an emetic. If there be no nausea nor vomiting, but intestinal flux, with a red tongue smeared with suburra, a large dose of calomel, from ten to fifteen grains should be given. Small doses create purging, pain, and irritation, while the full dose produces one to six large pultaceous stools, after which the tongue is cleaned, rendered less red and more moist, and the pulse usually falls. These stools, when examined, appear to contain the fæcal matter suspended in large quantities of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal canal and liver had been freed from their load. In some instances, a repetition only of the same dose is required to efface the main features of the malady, and to leave nothing but debility to support. In others, after a short respite, diarrhoea re-commences, and soon is apt to become colliquative." (_Op. cit._ p. 158, 159.) We have already shown the effects which calomel possesses in large doses of rousing the different excretory organs into full action, and thus assisting to secrete or separate from the circulation any offending principle which may have been carried into it. We are also convinced that where calomel has been promptly given in this manner, the chances of the disease being prolonged or terminating in the adynamic form are considerably diminished. Dr. Hamilton, in speaking of the advantages derived from the use of purgative medicines in typhus fever states, "I am now thoroughly persuaded, that the full and regular evacuation of the bowels relieves the oppression of the stomach, cleans the loaded and parched tongue, and mitigates thirst, restlessness, and heat of surface; and that thus the later and more formidable impression on the nervous system is prevented, recovery more certainly and speedily promoted, and the danger of relapsing into the fever much diminished." (_Observations on the Utility and Administration of Purgative Medicines in several Diseases_, by James Hamilton, M. D. p. 35.) As the gastro-enteric form of puerperal fever which we have just described, is frequently observed in epidemics of the adynamic form, particularly at their commencement and going off, and frequently complicated with it, we would rather consider those local inflammations and deposites of puriform fluid in the muscles, joints, &c., which are occasionally seen after severe cases, to the disease being complicated with, or assuming the nature of, the malignant form. If the symptoms have not yielded to the treatment which we have recommended, the alvine discharge becomes excessively unwholesome and fetid, the skin exhales a strong and unpleasant odour, the strength fails, the tongue is either dry and brown, or smooth and red like raw meat, the fever sometimes assumes the remittent character as described many years ago by Dr. Butter, of Derby; in others, the febrile symptoms subside, leaving the case one of chronic or subacute inflammation of the lining membrane of the bowels, with occasional attacks of irritative fever arising from it. In these cases mercurials, except in mild and guarded doses, appear to aggravate the irritation of the mucous membrane, and increase the disposition of it to ulcerate: five grains of Hydrarg. cum Cretâ and Dover's powder may be given once, or at the utmost, twice, in the twenty-four hours; half a drachm of carbonate of ammonia neutralized by lemon juice, and rendered alkalescent by a little Spirit. Ammon. Arom., may be given in some aromatic water every three or four hours; injections of starch into the rectum with a few drops of Battley are also useful. In some cases, where there was continued flatulence, a small quantity of turpentine in some castor oil has had an excellent effect. Others, where every means had seemed to fail, have yielded under the use of copavia. Dr. Locock has found advantage from the occasional use of very small doses (eight to ten grains) of epsom salts with a few drops of laudanum in some aromatic water. The after treatment, as also, the rules for diet, are the same as in the other form. _The Contagious, or Adynamic, Puerperal Fever._ Although we have classed under the head of "puerperal fevers" a variety of affections connected with, and arising more or less from, the same cause with the dreadful malady which we are now about to describe, and although every form and modification of them is liable to assume its characters, still we must confess that the term _puerperal fever_ belongs _par excellence_ to this form, the adynamic, malignant, and, as we have upon a former occasion called it, the genuine puerperal fever. It is in this form of disease that the vitiated state of the blood is shown with most distinctness, not only from the condition of the blood both during life, and after death, but also from the close connexion which exists between it and the plague, African typhus or yellow fever, and the other malignant fevers, both of the temperate as well as the tropical climates. The interesting and daring researches of M. Bulard upon the pathology of the plague, tend to throw great light upon the nature of this formidable disease, and to confirm the views which we have long entertained of this and other diseases of the same class, that the essence of the disease consists in the vitiated condition of the blood. _Symptoms._ The onset of this disease is almost invariably accompanied with a smart rigour, followed by intense headach, and rapid but generally powerless pulse. It seldom begins before the third day, although in some cases it seems to have commenced from the time of her delivery; whereas, in others the patient has gone on to recover favourably until the tenth or even the fourteenth day before being seized, and had already felt sufficiently well to leave her bed and sit up. The powers of the system seem prostrated at once; the shrunken features and dusky hue of the skin, the leaden colour of the lids, and circumscribed crimson or almost purple patches upon the cheeks, the short imperfect breathing and occasional deep sighing to relieve it, indicate but too surely the nature of the disease, and its depressing effects upon the whole system. "The sensorium," says Dr. Douglas in describing this form, "is seldom in any degree disturbed, whereas, in the others, it is so frequently, and even sometimes it is excited to high delirium. The pulse here is usually from the moment of the attack, soft, weak, and yielding, and in quickness often exceeds 150; whereas, in the first species it is full, bounding, and often incompressible; and in the second, small, hard, and contracted, and in both, moderately quick. The eye, instead of being suffused with a reddish or yellow tint, as in the others, is here generally pellucid with a dilated pupil. The countenance, instead of being flushed, as in the others, is here pale and shrunk with an indescribable expression of anxiety; an expression altogether so peculiar, that the disease could on many occasions be pronounced or inferred from the countenance alone. The surface of the body instead of being, as in others, dry and of pyrexial high heat, is here usually soft and clammy, and the heat not above the natural temperature; and not only is the skin cool with clammy exudation, but the muscles to the impression of the finger feel soft and flaccid, as if deprived of their vis vitæ by the influence of contagion. Indeed, there is such prostration of muscular strength and depression of vital principle from the very outset of the attack, that I must suppose the contagion to act through the medium of the nervous system in a manner analogous to that of the contagion of plague." (_Report on Puerperal Fever._ _Dub. Hosp. Rep._ vol. iii.) Where the powers of the system are not annihilated from the commencement of the attack by the depressing effects of the poison with which the circulation is impregnated, an effort at reaction is frequently made, and for some hours afterwards the surface of the body is hot and dry; but sooner or later, as the stage of collapse comes on, it then assumes the same cold death-like feel, as in the worst cases of malignant cholera. The character of the attack will be in great measure modified by the intensity of the poison, and the extent with which the circulation has been infected by it. The same effort to produce such a state of reaction as will raise the temperature of the skin, will probably assist nature in throwing it off under the form of peritonitic or gastro-enteric species of puerperal fever already described; whereas, where the circulation has been thoroughly impregnated with it in its concentrated form, the vital powers succomb at once, and a state of collapse exists from the very commencement of the disease. The course which the symptoms follow and the duration of the disease, will, therefore, depend not only on the severity of the attack, but also on the power of the particular constitution to resist the deadly effects of the morbid principle upon which the disease depends. When broken down by previous disease, intemperance, poverty, and depressing passions of the mind, the vital powers can make no stand against the powerful enemy by which they are attacked; "the blood is so much vitiated, even early in the disease, that it loses the power of stimulating the heart so as to keep up its healthy action; and, perhaps, also the vascular organs are early affected by the action of the poison, and lose the power of either feeling the stimulus, or reacting with force on the impression, which is communicated to their internal surface by the vitiated blood. In such cases, in place of increased excitement, there is frequently a want of action in the whole system." (Stevens, _op. cit._ p. 188.) The patient sinks without pain or complaint, beyond that of debility, but in such cases with a rapidity which would almost claim for the disease the name of "plague." The tongue becomes dry, red, and brown at the back part, the pulse weaker and more rapid, the debility and exhaustion more overpowering; still, even in this state, her mind usually remains clear, unconscious of the fate which awaits her, and occasionally even cheerful: a peculiar sickly odour exhales from the skin, and in many cases so distinctly, as to warn us the moment we enter the room of the patient's condition. The dusky ashen hue of the skin becomes darker, the fingers are shrivelled, and the nails dark, or of a livid black as in cholera; diarrhoea frequently attends, the fæces are unhealthy, and of the same peculiar odour just noticed; during the first stage the lochia are generally present, although of an unhealthy character; the milk also continues in the milder cases, but as the stage of collapse approaches they both disappear, and the breasts become quite flaccid. In some cases there is vomiting from an early period, with more or less tympanitic distention; but these symptoms rather depend upon the disease being complicated with one of the other modifications. Livid purpurous blotches sometimes appear upon the legs, &c. and in some epidemics it is accompanied with dark or livid eruptions. The surface has now the cold wet feel in its greatest degree, and in some cases even the tongue feels cold to the finger; a drowsy state of insensibility generally follows and continues until death. The symptoms here enumerated present the characteristics of fever under its different degrees of intensity. The peritonitic and gastro-enteric forms may be compared with the ordinary fevers of temperate climates, and which are attended with more or less inflammation of some organ. The malignant adynamic form corresponds closely with the malignant typhus of this, and the pestilential fevers of warm countries, more especially the plague and the African typhus or yellow fever. In all of these diseases, the vitiated state of the blood appears to be the essential condition of their existence, quite independent of any inflammatory action; in fact, in this form, so rapid and overpowering are the effects of the poison which pervades the circulation, and so completely does it paralyze the whole system, that there is neither time nor sufficient vis vitæ to make any effort at reaction. Hence, as Mr. Moore has correctly observed, "when the patient is rapidly destroyed by the violence of the disease, the morbid changes bear no proportion to the severity of the previous symptoms; a dubious trace of inflammation, a little serum, or a few feeble adhesions, are all that dissection under such circumstances displays." (_Inquiry into the Pathology, Causes, and Treatment, of Puerperal Fever_, p. 63.) In many of the most rapidly fatal cases which we have witnessed, there have not been even these questionable evidences of inflammation. The tissues have been pale and bloodless, the uterus softened, its internal surface ragged, and with a dark gangrenous appearance, extending to the os uteri, and dark thin claret-like blood in all the larger vessels. The heart is flabby, soft, and filled with dark blood; the lungs, liver, spleen, and kidneys much softened; the spleen dark, sometimes enlarged and almost pulpy. If we compare these appearances with those observed by M. Bulard in cases of plague, we shall find a striking coincidence between the two diseases. This intrepid pathologist remarks, that "the state of general turgescence and dilatation of the venous system; the presence of inflammable gas in eight cases in the cellular tissue, in the veins of the head, feet, and abdomen; the presence of petechiæ, both internally and externally; the general softening of the tissues; the enlargement, softening, and breaking down of the spleen; the petechial state of the mucous membrane of the stomach; the effusions of blood on the inner surface of that organ; the passive hæmorrhages and boils, are symptoms which result from a change in the condition of the blood. The symptoms connected with the state of the nervous system, viz. the rigours, headach, and confusion of mind, the quick and small pulse, the hurried respiration and vomiting, and also the petechiæ, carbuncles, and buboes, are neither those of vascular nor nervous inflammation. The blood has never shown the buffy coat; it was found just as black in the arteries as in the veins, but in the former, in much smaller quantity; it always had the appearance of being dissolved." M. Bulard observes, that the decomposition of the blood is quite independent of putrefaction being present before death takes place; and he feels convinced that it is not only the sole cause of death, but must also be looked upon as the origin of the various morbid phenomena during the course of the disease. He considers "these phenomena to result from an actual poisoning of the blood, similar appearances being observed in all cases where putrid matter and morbid secretions have been introduced into the system." With regard to the supposed inflammatory nature of the plague, M. Bulard states, that in many cases not the slightest trace of inflammation could be found. The changes in the spleen are of by far the most invariable occurrence. In one hundred autopsies, this organ was found only five times in a healthy state. Where, on the other hand, the powers of the constitution, or the diminished virulence of the disease, have enabled the system to withstand the depressing action of its immediate effects, we find it considerably modified, both in the symptoms which it presents during life, and the appearances after death. Instead of being little else than a state of collapse from the very outset of the disease, under which, not a single attempt is made by the powers of the system to set up even the most feeble effort of reaction, a variety of symptoms attend its commencement and progress, indicating that the vis vitæ has not altogether succumbed beneath the deadly effects of the malady. The very rigour itself, when violent, the headach and flushing of the face, if severe, are rather favourable than otherwise, and show that the system still possesses some power of reaction. It is usually observed, that where the attack commences with these precursory symptoms well marked, it is generally accompanied with peritoneal pain, tympanitis, and other symptoms of inflammatory action; whereas, in the worst cases, we have already stated, that from the very commencement of the disease there is neither a symptom of inflammation during life, nor a trace of it to be found afterwards. Dr. Armstrong rightly observed, that inflammation is not an essential constituent of typhus; and the same holds good in the strictest sense of the word, with the typhoid or adynamic puerperal fever. "Whatever the remote cause of fever may be, it is very evident that this cause must invariably exist, not only at the moment of attack, but even previous to that period. Now in the fevers from poison, the blood is invariably diseased previous to the commencement of the cold stage. During this period there are premonitory symptoms; but these are evidently the effect of the diseased state of the vital fluid: and that these precursors of fever are not the effect of any local inflammatory disease, is evident from the fact, that frequently during this period there is no pain in any of the organs, but a want of action, particularly in the extreme vessels, and consequently a decrease of heat in the whole system. "If inflammation in any of the organs were, in reality, the cause of fever, then the disease ought to be fatal, exactly in proportion to the violence of the local affection; but the very reverse of this is the truth. Mere excitement can easily be reduced, and the inflammatory form of fever is decidedly the most easily cured, though in it the excitement is often so great that the organs are very liable to be injured; while the malignant form of fever is by far the most fatal, though in this the excitement is less, and the organs are seldom affected. This is particularly the case in the worst form of the African typhus, and probably other varieties of malignant fever, where the blood is under the influence of an active poison, and where its vitality is diminished, and its structure is injured even before the attack. "Those who have seen most of the malignant diseases know well that excitement in fever is invariably a good symptom; for this is a sure sign that the blood has not yet undergone any fatal change, and independent of this, mere increase of action is always at the mercy of the lancet. But neither the lancet nor leeches, gum water, vitriolic emetics, calomel, antimony, brandy, opium, or acids, can redden the colour of the black blood, which we invariably meet with in pestilential diseases, or remedy the diseased state of the vital current, so as to cure that fatal form of fever where the malignant symptoms are produced, not by excitement, but by the vitiated state of that mysterious fluid, which in health gives life and nourishment to every solid of the system, and which, when diseased to a certain extent, is by far the most frequent cause of death in all those fevers that are produced by some deleterious poison acting, in the first place, on the vital current, and then on the brain and the whole system through the medium of the blood." (Stevens, _on the Blood_, p. 186.) We have quoted thus largely from the observations of Dr. Stevens and M. Bulard, to whose admirable researches we are so greatly indebted for our present knowledge, respecting the nature of pestilential diseases both of the East and West, for they tend not only to show the true pathology of malignant puerperal fever, but also the class of diseases to which it belongs. _Appearances after death._ Where more or less inflammatory action has accompanied the first part of the disease, the lesions observed after death differ considerably from those of acute peritonitis: the effusions of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with to such an extent where the case has been one of inflammation uncomplicated with the adynamic form of puerperal fever, even although it may have been exceedingly violent; whereas, in the present case, although there has been scarcely sufficient power in the system to set up even a moderate degree of inflammatory action, the intestines and uterine appendages are found glued together, and thickly imbedded in immense effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are engorged with purple vascularity, softened, and, especially the ovaries, quite disorganized, with numerous effusions of sero-purulent matter beneath their peritoneal coverings, or into their parenchymatous tissue. In others, their whole substance has been softened and pulpy, with little cyst-like cavities filled with blood or pus, the remains of the Graafian capsules. During the fatal epidemic which prevailed at the General Lying-in Hospital, in the early part of 1838, we met with several cases where the ovaries had entirely disappeared, their site being only discoverable by an oval thickening of the broad ligament, something like an empty cyst of peritoneum; this contained a small quantity of livid pulpy débris of the ovary, and (on that side where conception had taken place) a remarkably well marked or rather exaggerated corpus luteum. The uterus is larger and its tissue much softer than under ordinary peritonitis, so that, in many instances, the finger can be easily pushed through its whole substance. Where the constitution has borne the brunt of the attack without immediate collapse, and the local mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearances of arthritic or rheumatic inflammation, and also of certain muscles, especially the supinators of the arm, the glutæi, and gastrocnemii. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quantity of greenish coloured pus mixed with blood and serum is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposites of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but if deep beneath the surface it continues to spread in all directions until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent. Inflammation of a similarly arthritic or rheumatic nature occasionally also attacks the eye, and presents all the usual characters of arthritic iritis under ordinary circumstances: there is the same intolerance of light, pain of the eye, dimness of vision, contracted pupil, and peculiar white ring round the edge of the cornea, which distinguishes this affection; but in the present case, the disease runs a far more rapid course, and defies the remedies which in common cases would be sufficient to check it; the inflammation soon extends to the deeper seated structures of the eye, the pain is excrutiating, and, in two or three days, disorganization takes place, followed by suppuration, staphyloma, and bursting of the cornea. So rapid and destructive is its course, that, although five or six cases have come under our notice, in only one instance, with the greatest difficulty, was the eye saved, and, even then, not before it had been considerably injured. These attacks are attended by severe pains of a similar nature in different parts of the body, more especially the joints and limbs; and, from the arthritic character which they assume, tend, in our opinion, still farther to elucidate the real condition of the system. The analogy between gout or rheumatism, and those diseases which arise from a vitiated state of the blood, is exceedingly close, nay, even identical, for in both, a principal pervades the circulating fluids which requires to be removed; and if this be not effected by any of the excretory organs, nature endeavours to throw it off by some process of local inflammation. The connexion between puerperal fever and typhus is very close, for it not only assumes the characters of the typhus epidemics which may chance to be prevailing at the time, but we have distinct evidence that the contagion of typhus will, in a puerperal woman, manifest itself under the form of puerperal fever. Dr. Collins has recorded a very interesting case of this sort:--"A patient was admitted at a late hour at night into one of the wards, labouring under a bad form of typhus fever, with petechial spots over her body; when observed next morning, she was removed into a separate apartment, where she died shortly after. The two females who occupied the beds adjoining hers, while she remained in the large ward, were attacked with puerperal fever, and died." (Collins, _op. cit._ p. 381.) During a typhus epidemic which prevailed a few years ago in the poor districts of the metropolis, a prominent feature of which were petechiæ and a livid rubeoloid eruption, precisely the same appearances were observed among the cases of adynamic puerperal fever at the General Lying-in Hospital. The same has been observed with erysipelas; and, in one short but severe epidemic, the child of every woman who had died of the disease perished also from erysipelas, so severe that it ran its course in a few hours. Dr. Gordon, of Aberdeen, remarks, that "with it and, at the same time, epidemic erysipelas began, progressed with equal pace, arrived at its acmé, and terminated together." He also says, that a very frequent crisis of the disease was an external erysipelas. Mr. Hey remarks, that infectious fevers were common at the time; and he does not recollect ever having seen such malignant cases of erysipelas as then. Dr. Clark also observes, that those inflammatory diseases which occurred were principally erysipelatous. Dr. Armstrong states, "that in 1813 (the year of its greatest prevalence throughout England) low fever, typhus, and acute rheumatism also prevailed to an uncommon degree." (Moore, _on Puerp. Fever_, p. 164.) During the same epidemic, to which we just now alluded, the housemaid of the hospital, a healthy young woman, was suddenly seized with sore-throat and violent erysipelas of the head and face, from which she was saved with great difficulty; her sister came and attended her, as the nurses were too much occupied by the number of patients who were ill; just at the time that she was pronounced out of danger, her sister, not feeling well, went home, sickened, and died, in less than three days, of typhus fever. The contagious nature of puerperal fever has long since ceased to be a matter of doubt, and instances have repeatedly occurred of practitioners and nurses communicating the disease to several patients in succession. Dr. Gooch has recorded some striking instances of the kind, and we could enumerate many others if necessary. Where a practitioner has been engaged in the post mortem examination of a case of puerperal fever, we do not hesitate to declare it highly unsafe for him to attend a case of labour for some days afterwards. The peculiar smelling effluvia which arises from the body of a patient during life is quite, in our opinion, sufficient to infect the clothes; and every one who has made a minute dissection of the abdominal viscera, especially in fatal cases of puerperal fever, knows full well that it is almost impossible to remove the smell from the hands for many hours, even with the aid of repeated washing; it must be, therefore, self-evident, that, under such circumstances, it would be almost criminal to expose a lying-in patient to such a risk. That the discharges from a patient under puerperal fever are in the highest degree contagious, we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge: this fact has been repeatedly proved at the Vienna hospital; but they are equally communicable to women not pregnant; on more than one occasion the women engaged in washing the soiled bed linen of the General Lying-in Hospital have been attacked with abscesses in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue. We have stated that puerperal fever may arise from the effluvia which exhales from the body of the patient, and from the various discharges; it may also be produced by noxious exhalation from sewers, ditches, and other sources of miasmata, the effects of which in producing typhus have been long ascertained. "With regard to the General Lying-in Hospital, its locality rather below the level of the river, and surrounded by a mesh-work of open sewers fifteen hundred feet in extent, receiving the filth of Lambeth, and some not thirty feet from the wards of the institution, may account for its unhealthiness. It is only after repeated remonstrances, that these sources of pollution have in part now begun to be obliterated." (Dr. Ferguson, _op. cit._ p. 104.) The commissioners of sewers refused the application of the hospital, to have the nearest of these nuisances properly bricked over, and assigned this remarkable reason for so doing, viz. that the hospital had come to them, not they to the hospital. Consent was ultimately only obtained by the agreement, that a large portion of the expense should be borne by the institution. On completing the work they afforded us a striking instance of the effects of effluvia on lying-in women; a large quantity of black pestilential mud had been thrown out in making the necessary excavations, this they refused to remove, and actually spread it upon the ground to a considerable extent; the consequence was, that the first two cases of puerperal fever after the re-opening of the hospital occurred within twenty-four hours of this unjustifiable act. _Treatment._ The fatal character of this disease and the varied form of its epidemics will in part explain why so much discrepancy of opinion should have existed among authors and practitioners respecting its treatment. Where its remote cause has been but imperfectly known, it is not to be wondered that practitioners, finding their efforts unsuccessful, should lose their confidence in any one set of remedies or mode of treatment, and try a variety, in the vain hope of hitting upon the right one. But in a great measure this is to be attributed to the difference of the affections which have been described by various authors under the same head; each has described it as it occurred to himself; and in many instances it has been only the description of a single epidemic, and, therefore, has given to the world the treatment which his experience in that particular form has proved successful. Thus, the lancet has been looked upon as the only means of saving the patient by those who have witnessed the inflammatory modification of the disease; whereas, in the hands of those who had to treat it in its adynamic malignant form, bleeding (as but too frequently every thing else) proved utterly inefficacious. A variety of plans have been tried in this last species, and their success described by Dr. W. Hunter in his lectures, gives a fearful view of the nature of the disease we have now to deal with. We continue the quotation which we have already made from him. "In two months thirty-two patients had the fever, and only one of them recovered. We tried various methods. One woman we took from the beginning and bled her, and she died; to another we gave cooling medicines, and she died: to a third we gave warm medicines, such as Confect. Cardiac., cordial julep, Mithridate, &c., and she died. In private practice it was the same, and at least three out of four would die." (_MS. Lectures._) There is no doubt that, wherever the state of the patient will permit it, the lancet should be tried. Where the pulse is quick and small, with little power, it is scarcely more than an experiment to ascertain how the system will bear the bleeding: in the worst cases of the adynamic form, uncomplicated by the slightest effort at reaction, the state of collapse at once forbids such an attempt: but in many instances the circulation is merely oppressed, the pulse rises in volume as the depletion proceeds; and where from its feel before the operation we had little hopes of taking away more than five or six ounces, we are often enabled to continue it until a considerable quantity is lost. In other cases frightful exhaustion is the immediate effect, and warn us instantly to discontinue it. The capability of bearing bleeding may be always looked upon as a favourable prognostic, not only because the patient's strength is better than we had perhaps expected, and also because these are precisely the cases where mercury can be used with decided benefit. Whether it be the bleeding, which, in all probability, renders the system more easily brought under the influence of this medicine, we will not stop to consider; at any rate, its effects are not only more easily obtained, but they exert a more decided control over the progress of the disease, the pain abates, the tympanitic abdomen becomes less tense, the pulse slower, fuller, and softer, the tongue moister, and there is a sense of general improvement in the patient's feelings. But in the adynamic form, when present in its greatest intensity, either there is not sufficient time to impregnate the system, or it is less sensible to its effects; at any rate, even if we succeed in producing salivation, little or no improvement follows. In those cases where the inflammatory symptoms assume a metastatic character, we must act according to the organ implicated. The attacks are frequently of a very sudden nature, the patient being seized, without the slightest warning, with severe pain and heat of head, throbbing of the temples, intolerance of light and sound, and occasionally violent delirium; the face is flushed, the carotids are seen strongly pulsating. These signs denote a dangerous attack of cerebral congestion, which requires the most prompt and active measures for its suppression. In these cases the aberration of mind frequently continues for some time, even after the symptoms of active inflammation have subsided, and form a species of puerperal mania of a very dangerous character, which we shall describe under its proper head. In other cases, effusion rapidly comes on, followed by fatal coma or convulsions. In some instances, the inflammatory action seems to fix itself upon the chest: the patient is suddenly seized with great dyspnoea, oppression, and pain, which latter is much increased by every effort at respiration, and sometimes is so violent as to threaten suffocation, unless promptly relieved by the lancet. These attacks sometimes return two or three times, with the same degree of sudden violence, or change with equal rapidity from one part to another. So long as there are symptoms of local inflammation present, leeches and hot poultices, &c., must be applied, as already mentioned; but it must ever be borne in mind, that the local affection is _not_ the disease, but one of its effects. We must, therefore, direct our energies to ridding the system of the cause upon which it depends. In all cases we think it desirable to begin the calomel in doses of five grains, at intervals of two hours; and if properly guarded with Dover's powder, no disposition to purging will be produced: by this means we not only gain time, but, which is also of great importance, we premise a general increase of the excretions, which tends not a little to relieve the system. After two such doses, the calomel may be given at the ordinary rate of two grains every two hours, with half a grain of opium, or, what is still better, a little Dover's powder, until slight marks of salivation begin to appear. The action should now be kept up by an occasional dose, but never allowed to become at all severe, as considerable exhaustion may be the result. The dark and offensive lochia should be constantly removed by the most scrupulous attention to cleanliness, and by frequently washing out the vagina and uterus with warm water. If diarrhoea has set in to an exhausting degree, the opiates must be increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline draughts of citrate or acetate of ammonia, rendered alkaline in excess by Sp. Ammon. Arom. may be given from time to time; they appear not only to refresh the patient, but also to allay flatulence and vomiting, if present. For her common drink we recommend a solution of carbonate of soda in water, in the proportion of two drachms to a pint, slightly flavoured with orange peel; and whenever she has taken this freely, we have observed a considerable amelioration in her symptoms. Although strongly inclined to advocate Dr. Stevens's views respecting the action of salines in diseases of this character, we must confess that we have been in great measure deterred from carrying them out to the full extent that we could have wished, by the repugnance of the patient to taking a draught so intensely salt as his celebrated mixture. On several occasions we have seen the most beneficial effects from the use of salines; and in two cases, during one of the most malignant epidemics, where every thing seemed to be equally fruitless in arresting the progress of the disease, the exhibition of repeated doses of soda, and encouraging the patient to drink largely of the above-mentioned solution, was followed by the happiest effects. We have again recently tried the common salt, disguised as far as possible in the form of an effervescing draught, and in two cases with very decided results. The acid state of the mouth is a very constant symptom in this disease, and the contents of the stomach after vomiting are frequently intensely sour, so that in most instances the soda drink has been greedily longed for, and by some patients even called lemonade. We have also tried still more recently warm injections into the vagina, of a weak solution of salt and water, but at present, can give no opinion from merely a case or two. Ice has been lately recommended by Professor Michaelis, of Kiel, not only internally but externally, by means of a large bladder. According to his observations it diminished the pain and tympanitis, reduced the quickness of the pulse, and relieved the patient considerably; this was followed by a profuse diarrhoea of light coloured and offensive evacuations, under which the pulse rose in power, followed by general improvement. We tried it on one occasion; it was swallowed with avidity like barley-sugar; it relieved the sense of inward heat and thirst, stopped the hiccough and vomiting which had become very troublesome, and seemed to diminish the tympanitis, but collapse followed as rapidly as in other cases; nor have our subsequent observations been more favourable. It may be given with advantage with other medicines to relieve several distressing symptoms, but does not appear to us to exert any power in arresting the progress of the disease. The patient's diet should be mild but nutritious, much more so than in the other forms of puerperal fever; and if there be symptoms of sinking, wine and ammonia, &c., must be given with a liberal hand. In reviewing what we have said upon the treatment of adynamic puerperal fever, we repeat our conviction, that where the state of collapse has precluded all antiphlogistic measures, and given us but little cause to expect much relief from mercury, we know of no treatment which holds out such rational hopes of success as the saline, based as it is upon the same principles on which it has been employed by Dr. Stevens, in the malignant fevers of warm climates, and by British physicians in the epidemic typhus of this country. CHAPTER XIV. PHLEGMATIA DOLENS. _Nature of the disease.--Definition of phlegmatia dolens.--Symptoms.-- Duration of the disease.--Connexion with crural phlebitis.--Causes.-- Connexion between the phlegmatia dolens of lying-in women and puerperal fever.--Anatomical characters.--Treatment.--Phlegmatia dolens in the unimpregnated state._ _Nature of the disease._ Although we shall not be justified in stating that the disease is one of the sequelæ of puerperal fever, inasmuch, as it is occasionally met with, entirely independent of labour and the puerperal state, still we must recognise a very close relation between these two diseases, especially between it and the uterine phlebitis, since, in a majority of instances, they both arise from the same cause, viz. absorption or imbibition of a morbid poison. At the same time, we can by no means agree with Dr. R. Lee, that "the swelling of the affected limbs in phlegmatia dolens, and all the other local and constitutional symptoms of this affection, invariably depend on inflammation of the iliac and femoral veins;" and, therefore, do not consider his proposition justifiable, "to substitute the term crural phlebitis in place of phlegmatia dolens" (_Researches on the Pathology and Treatment of some of the more important Diseases of Women_, p. 116,) for cases occur where the disease has manifested itself to a very considerable extent without any inflammation of the veins whatever. On the other hand, we willingly allow that in many others it has been preceded by crural phlebitis, although we most distinctly deny that it is ever identical with that disease. _Definition of phlegmatia dolens._ We may define phlegmatia dolens to be tumefaction of a limb from inflammation and obstruction of the main lymphatic trunks leading from it. It is most frequently seen in the puerperal state, attacking one or both extremities, and is then almost always a concomitant or a consequence of puerperal fever. In the unimpregnated state it is usually the result of some organic malignant disease. "Women of all descriptions are liable to be attacked by it during or soon after childbed; but those whose limbs have been pained and anasarcous during pregnancy, and who do not suckle their offspring, are more especially subject to it. It has rarely occurred oftener than once to the same female. It supervenes on easy and natural as well as on difficult and preternatural births. It sometimes makes its appearance in twenty-four or forty-eight hours after delivery, and at other times not till a month or six weeks after; but in general the attack takes place from the tenth to the sixteenth day of the lying-in." (_An Essay on Phlegmatia Dolens_, by John Hull, M. D. p. 132.) _Symptoms._ As the phlegmatia dolens of lying-in women is almost invariably preceded by symptoms of puerperal fever, many of its early symptoms will differ but little from that disease. The patient is usually attacked with rigours, followed by flushing, headach, and generally more or less abdominal pain, with a quick pulse, or the disease has come on when recovering from a severe attack of puerperal fever. "The complaint generally takes place on one side at first, and the part where it commences is various: but it most commonly begins in the lumbar hypogastric or inguinal region on one side, or in the hip, or top of the thigh, or corresponding labium pudendi. In this case the patient first perceives a sense of pain, weight, and stiffness, in some of the above-mentioned parts, which are increased, by every attempt to move the pelvis or lower limb. If the part be carefully examined, it generally is found rather fuller or hotter than natural, and tender to the touch, but not discoloured. The pain increases, always becomes very severe, and in some cases is of the most excruciating kind. It extends along the thigh, and when it has subsisted for some time, longer or shorter in different patients, the top of the thigh and labium pudendi become greatly swelled, and the pain is then sometimes alleviated, but accompanied with a greater sense of distention," (Hull, _op. cit._ p. 184.) The pain next extends down to the knee, and if depending on a state of phlebitis is most severe in the course of the femoral vein, which is felt hard and swollen, and rolling distinctly under the finger when pressed upon: it is precisely in the direction of this vessel that the greatest pain is felt on pressing with the hand: if phlebitis be not present, the pain is diffused more equally over the limb, and is more connected with the state of tension, or otherwise, is confined chiefly to the groin or upper part of the thigh. "When it has continued for some time, the whole of the thigh becomes swelled, and the pain is somewhat relieved;" "the pain then extends down the leg to the foot; after some time the parts last attacked begin to swell, and the pain abates in violence, but is still very considerable, especially on any attempt to move the limb. The extremity being now swelled throughout its whole extent, appears perfectly or nearly uniform, and it is not perceptibly lessened by a horizontal position, as an oedematous limb. It is of the natural colour or even whiter, is hotter than natural, excessively tense, and exquisitely tender when touched; when pressed by the finger in different parts, it is found to be elastic, little if any impression remaining, and that only for a very short time. If a puncture or incision be made into the limb, in some instances no fluid is discharged, in others a small quantity only issues out which coagulates soon after, and in others a larger quantity of fluid escapes which does not coagulate; but the whole of the effused matter cannot be drawn off in this way. The swelling of the limb varies both in degree and in the space of time requisite for its full formation. In most instances, it arrives at double the natural size, and in some cases at a much greater. In lax habits, and in patients whose legs have been very much affected with anasarca during pregnancy, the swelling takes place more rapidly than in those who are differently circumstanced; it sometimes arrives in the former class of patients at its greatest extent in twenty-four hours or less, from the first attack." (Hull, _op. cit._) Phlegmatia dolens rarely or never proves fatal of itself; the patient either dies in consequence of the puerperal fever which has preceded or attended the affection, or from the system gradually sinking under the injury which it has sustained. In those cases where the patient has struggled through, the limb remains for a long time afterwards swollen, stiff, and incapable of motion, from which it slowly and not always very perfectly recovers. _Duration of the disease._ "The duration of the acute local symptoms has been very various in different cases. In the greater number, they have subsided in two or three weeks, and sometimes earlier, and the limb has then been left in a powerless and oedematous state. The swelling of the thigh has first disappeared, and the leg and foot have more slowly resumed their natural form. In one case, after the swelling had subsided several months, large clusters of dilated superficial veins were seen proceeding from the foot along the leg and thigh to the trunk, and numerous veins as large as a finger were observed over the lower part of the abdominal parietes. In some women, the extremity does not return to its natural state for many months, or years, or even during life." (Lee, _op. cit._ p. 119.) _Connexion with crural phlebitis._ We have already stated, that in phlegmatia dolens the lymphatic circulation of the swollen limb has been obstructed by inflammation and obliteration of the main lymphatic trunks leading from it. To call this disease "crural phlebitis," because in a case where the crural vein has been inflamed, the inflammation has spread to the surrounding fascia, or cellular tissue, through which the larger lymphatics of the thigh pass in their way to the abdominal cavity, is manifestly incorrect, and tends to confound two diseases together, which are of a very different character. From the situation of the crural vein as it emerges upon the anterior and upper part of the thigh, and the cribriform appearance of the inner side of the femoral sheath, and of the cellular tissue which fills up the opening in the fascia lata at this part, owing to the numerous lymphatic trunks by which it is perforated, it would be nearly impossible that these structures should escape being inflamed wherever the attack of crural phlebitis is at all severe; and shows that although, as we have stated, phlegmatia dolens may occur without crural phlebitis, it is very questionable if crural phlebitis can exist to any extent without phlegmatia dolens. To MM. Bouillaud and Velpeau, and also to Dr. Davis, are we chiefly indebted for having first pointed out the fact, that the large venous trunks of the thigh and leg are frequently found inflamed in this disease. Great credit is also due to Dr. R. Lee for his indefatigable researches into the history and anatomy of crural phlebitis, for they have taught practitioners to be on the watch for the existence of the one disease whenever the presence of the other has been determined. "The sense of pain, at first experienced in the uterine region, has afterwards been chiefly felt along the brim of the pelvis, in the direction of the iliac veins, and has been succeeded by tension and swelling of the part. After an interval of one or more days, the painful tumefaction of the iliac and inguinal regions has extended along the course of the crural vessels, under Poupart's ligament, to the upper part of the thigh, and has descended from thence in the direction of the great blood-vessels to the ham. Pressure along the course of the iliac and femoral vessels has never failed to aggravate the pain, and in no other part of the limb has pressure produced much uneasiness. There has generally been a sensible fulness perceptible above Poupart's ligament, before any tenderness has been experienced along the course of the femoral vessels; and in every case at the commencement of the attack, I have been able to trace the femoral vein proceeding down the thigh like a hard cord, which rolled under the fingers." (R. Lee, _op. cit._ p. 117.) _Causes._ We consider that the causes of crural phlebitis in the puerperal state are of precisely the same nature as those of uterine phlebitis, already mentioned, viz., the absorption or imbibition of putrid matter contained in the uterus; and from reasons which are self-evident, it will be easily understood why the former affection is so frequently preceded by the latter, or at any rate, by some modification of puerperal fever. Mr. Tyre, of Glouscester, in an essay published 1792, and quoted by Dr. Hull, has taken a somewhat similar view of the subject, although he does not appear to have confirmed it by actual observation. He conceived that "the obstruction to the return of the lymph may commence in the primary inflammation of a trunk or trunks; and, probably, this may be the case more frequently than I have hitherto discovered, or suspected it to be." He considered also that "the remote cause may still be sought for in pressure, in the presence of absorbed acrimonious matter, or in inflammation continued from some absorbent to the trunk or trunks," (_An Essay on the Swelling of the Lower Extremities incident to Lying-in Women_;) but he overlooked the fact, that this inflammation of the lymphatic trunks, when passing through the cribriform portion of the fascia lata, was a result of its having either extended from the inflamed crural vein, or from inflammation of the peritoneum in the pelvis, and of the subperitoneal tissues. _The connexion between the phlegmatia dolens of lying-in women and puerperal fever_ has been demonstrated even still more closely by Dr. Hull, a fact which later experience, and a more intimate knowledge of these two diseases has tended to confirm. "It is, perhaps, in every instance, accompanied by considerable marks of pyrexia, and is very frequently preceded by coldness and rigours, which are succeeded by a hot stage, and during this, the pain, stiffness, heat and other inflammatory symptoms invade the loins, hypogastrium, inguen, or some part of the lower extremity, just as they attack the peritoneum in puerperal fever." We may safely assert, that, whenever this disease attacks a lying-in woman, it is invariably preceded by some form of inflammatory puerperal fever, the inflammation having either been transmitted along the vein, or along the subperitoneal tissues, until it reached the above-mentioned cribriform portion of the fascia lata, so that every lymphatic trunk which passed through it would necessarily be implicated in the inflammatory process, and thus rendered impervious. The opinion, therefore, of the inflammation passing along an absorbent until it reaches the main trunks of the lymphatics, appears to be objectionable, as we find it to have been rather transmitted by communication of adjacent parts, although occasionally it attacks the neighbouring glands, producing enlargement and suppuration of them. _Anatomical characters._ The details of a dissection which Dr. Lee has reported with great minuteness, show marks of severe inflammation to such an extent around the crural vein, that it is evident the greater part, if not all, of the large lymphatic trunks in that neighbourhood had been rendered impervious by it. "The common iliac, with its subdivisions and the upper part of the femoral veins so resembled a ligamentous cord, that on opening the sheath the vessel was not, until dissected out, distinguishable from the cellular substance surrounding it. On laying open the middle portion of the vein, a firm thin layer of ash-coloured lymph was found in some places adhering close to, and uniting its sides, and in others, clogging it up, but not distending it. On tracing upwards the obliterated vein, that portion which lies above Poupart's ligament, was observed to become gradually smaller, so that in the situation of the common iliac, it was lost in the surrounding cellular membrane, and no traces of its entrance into the vena cava were discernible. The vena cava itself was in its natural state. The entrance of the internal iliac was completely closed, and in the small portion of it, which I had an opportunity of examining, the inner surface was coated with an adventitious membrane. The lower end of the removed vein was permeable, but its coats were much more dense than natural, and the inner surface was lined with a strong membrane, which diminished considerably its caliber, and here and there fine bands of the same substance ran from one side of the vessel to the other. The outer coat had formed strong adhesions with the artery and the common sheath: the inguinal glands adhered firmly to the veins, but were otherwise in a healthy condition." (_Op. cit._ p. 123.) In the other case there is also inflammation of the cellular tissue which fills up the femoral ring, but instead of having been a consequence of crural phlebitis, it has extended to this part from puerperal inflammation of the peritoneum and cellular tissue beneath. In our midwifery hospital reports (_Med. Gaz._ Oct. 24. 1835,) we have given the details of an interesting case of this sort which came under our notice during the former year, and which are rendered peculiarly valuable by a most elaborate dissection of the parts after death, by Mr. Nordbald, who was house-surgeon at the time. The patient was single, excessively deformed in her back, and with the peculiarly unhealthy appearance of persons thus afflicted; her labour had been perfectly natural, but on the following day she was seized with rigours, followed by flushings, a quick pulse, and abdominal pain: these symptoms were in great measure relieved, and she appeared to be slowly improving. On the ninth day after labour, she first complained of pain at the outside of the left thigh, extending from the ilium to the knee, very exactly in the course of the inguino-cutaneous nerve: it was tender to the touch, but there was no pain on pressing the femoral vein at the groin. On the following day, the pain and swelling of the thigh had increased, but still no pain was to be detected on pressing the femoral vessels: leeches were ordered, but she sunk immediately after their application, and died early the next morning. Upon examination after death, the body was found "much attenuated; the left thigh one third greater in circumference than the right; abdomen tympanitic, not tense; parietes very thin; the lower part of the ileum, caput coli, and arch of the colon contain air; a streak of inflammation is delineated along the anterior surface of the colon from the centre of the arch, throughout the descending portion of this intestine, to the left iliac region; it is marked by a transverse band of capillary vessels, minutely injected in the thickened peritoneum, along the whole of this course. A few convulsions of the small intestines were smeared with recent lymph, and one fold was found to adhere closely to the left side of the pelvic peritoneum at the point of reflexion of the ligamentum latum uteri. A few small portions of coagulable lymph were also found loose amongst the intestines. At the posterior surface, and left side of the body of the uterus, soft lymph and pus were effused for the space of an inch beneath the peritoneal covering of this viscus, the membrane itself being highly vascular from inflammation, but still showing the effusion through its texture; the fundus of the uterus, where it has the Fallopian tube and round ligament attached, was similarly affected, though in a slighter degree; lymph and pus were effused here also. From these two points, the inflammation appears to have spread to the rest of the serous membrane: from the first indicated point it has progressed along the posterior fold of the broad ligament to the surface of the rectum and colon; from the second situation the round ligament and Fallopian tube have formed the continuous line of its progress. On raising the peritoneum from the iliac fossa, the cellular membrane which envelopes the round ligament, where this cord is about to pass under the epigastric vessels, after quitting the peritoneal cavity, was found infiltrated and condensed with lymph and pus. The whole of the cellular membrane (which it will be borne in mind is the fascia propria of Sir Astley Cooper, and which fills the _femoral_ ring, and moreover forms the medium of transmission for the lymphatics of the thigh) was in the same condition, densely matted by lymph, and containing pus in the interstices.[146] The lymphatic glands in the groin were slightly enlarged, and some serous fluid was effused into the surrounding tissue; the femoral vein and artery were free from disease; the inner coat of the former vessels, as well as the internal and external iliac veins and vena cava, had not the slightest trace of increased vascularity or thickening. The chain of glands from the femoral ring along the course of the iliac vessels and aorta _on the left side_, were enlarged, soft, and vascular; several of these lymphatic bodies contained between the layers of the meso-colon were found enlarged, and to contain soft lymph. The uterus was of the size usually found at this period; its tissue dense; the section shows the sinuses still large; the openings on the internal surface plainly indicated by adherent coagula." We had been led at that time to suppose that phlegmatia dolens and crural phlebitis were identical, and that, therefore, this was not a veritable case of the disease, because no traces of inflammation of the veins were to be found. The history of the disease; its connexion with the puerperal fever which had preceded it, the examination after death, and the inflamed state of the cellular tissue which was perforated by lymphatic trunks on their way from the thigh to the abdominal cavity, plainly show that it was not only a case of phlegmatia dolens, but that the proximate cause of this affection is obliteration of the lymphatics, whether from inflammation of the adjoining vein, or of the layer of cellular tissue through which they pass. _Treatment._ As the earlier part of the disease, when occurring in lying-in women, is invariably accompanied with some form of puerperal fever, the treatment of this stage will be according to the rules we have already laid down in the preceding chapter. It is especially towards the wane of the attack, that any sensation of pain, or even tension about the hip or groin should be regarded with suspicion, and a careful examination of the part immediately instituted. The painful spot should be immediately covered with leeches, and if any pain or swelling be perceptible in the course of the femoral vein, this must be similarly treated in order to allay the inflammation; after this, cold evaporating lotions must be applied; and although we have not yet given it a trial, we would recommend the application of ice over the femoral ring. If she has not taken calomel to such an extent as to affect the system, it may now be given for that purpose; and when the pain has ceased, the part may be covered with a plaster of camphorated mercurial ointment. As the disease, in most instances, is a local affection consequent upon a general one, which has been more or less subdued, by the time that this has appeared, it will frequently be necessary to combine the local depletion and exhibition of mercurials with mild tonics, in order to sustain the powers of the system already somewhat exhausted by the debilitating effects of the puerperal fever. The diet should if possible be nourishing, and we shall frequently find that the general symptoms improve under the use of beef-tea, meat, jellies, &c. When the acute stage of the disease is past, more powerful tonics, as quinine, will be required; and now we may direct our attention to reduce the swelling of the limb; it may be gently rubbed with the compound camphor liniment for the purpose of stimulating the absorbents. Dr. Hull has given a useful formula for the same object:--"[Symbol: Recipe]. Ung. Adipis Suillæ, [Symbol: ounce]jss; Camphoræ, [Symbol: dram]iij; quibus liquefactis admisceantur Ol. Essent. Lavend. gtt xij; Tinct. Opii, [Symbol: dram]ij. Fiat Linimentum, quotide ter quaterve utendum." (_Op. cit._ p. 161.) Phlegmatia dolens occurring in the unimpregnated state, is generally in connexion with some malignant disease of the uterus: it has been chiefly observed in cases of carcinoma uteri, and has evidently been produced by the absorption of the fetid discharges which attend this loathsome disease. In all the instances which have come under our knowledge, the swelling of the leg has been preceded by crural phlebitis; the veins have been felt through the emaciated integuments like a hard cord running along the inside of the leg, acutely painful to the touch. A fact connected with these cases, and for which we are indebted to our late friend and colleague Dr. H. Ley, tends greatly to prove the manner in which the disease is produced. The symptoms of it have never been observed so long as the patient was able to keep up, for by this means a free escape was allowed to the acrid discharges, which are so profuse in the last stages of cancer: but when her strength has been so broken down by loss and suffering that she was obliged to keep her bed, the horizontal position of her body no longer allowed the vagina to drain itself of the fetid secretions with which it was filled, and absorption and venous inflammation have been the result. In our published lectures, we have mentioned two cases of phlegmatia dolens, which had been under our care at St. Thomas's Hospital, and where, in both, the disease had been thus produced during the ulcerative stage of cancer uteri: the interest of them was somewhat increased by their having been admitted at the same time, and by their happening to lie next to each other in the same ward: in one, the attack of crural phlebitis was severe, and the swelling of the limb very considerable; in the other, the affection was less severe: we did not take any notes of the cases, and must, therefore, refer to a similar one which has been recorded by Mr. Lawrence, and in which, the appearances after death were accurately detailed. The patient came under his care, on account of shooting pains in the loins and hypogastric region, which was tender upon pressure; she had incontinence of urine, and a sanious discharge from the vagina. On examination, instead of the os tincæ and cervix uteri, a large irregular ulcerated excavation was found at the posterior end of the vagina. Shortly afterwards, increased uneasiness was experienced in the lower part of the abdomen, the right lower extremity swelled in its whole extent, with pain in the course of the femoral and iliac vessels, and all the other symptoms of phlegmatia dolens. The disease was treated by leeches and other antiphlogistic means, and the pain abated considerably; it, however, returned, and in about three weeks after, she died from a violent attack of uterine hæmorrhage. On dissection, the fundus uteri was found somewhat enlarged and firm, the cervix had been destroyed by that kind of phagedenic ulceration, which is commonly called cancer of the uterus. The hypogastric vein was closed in consequence of previous inflammation of its coats, and the same change had taken place in the internal iliac, the common iliac, the external iliac, the femoral and profunda veins, as well as in the internal saphena, all of which were completely impervious. The affection terminated above at the junction of the common iliac with that of the opposite side, the latter vessel being quite natural. The saphena vein was closed for a length of about four or five inches, beyond which it was natural. The right spermatic vein was closed in its lower half. The coats of the affected vessels, and the surrounding cellular substance were a little thickened, and their cavities were plugged by a closely adherent and tolerably firm substance of a light brown colour; at some parts, the vessels and their contents were of a dark livid hue. (_Med. Chir. Trans._)[147] CHAPTER XV. PUERPERAL MANIA. _Inflammatory or phrenitic form.--Treatment.--Gastro-enteric form.--Treatment.--Adynamic form.--Causes and symptoms.--Treatment._ There are many points of similarity between puerperal convulsions, and the disease which we are now about to consider, so that an acquaintance with the nature of the one, will greatly assist the reader in his study of the other: the same causes which induce the one, will, with trifling modification, induce the other; the different species of puerperal mania, will, therefore, resemble more or less those of puerperal convulsions. Disorder of the mind, which comes under the head of puerperal mania, is rarely met with before labour; for when it occurs during pregnancy it is usually referrible to causes unconnected with that state, as to hysteria; or is, a form of ordinary mania arising from hereditary predisposition, cerebral diseases, &c. It is true these are conditions which will render the patient exceedingly liable to an attack of derangement during labour, and especially during the puerperal state; but the identity of the affections cannot well be carried farther. According to our own experience puerperal mania may occur under one of the three following conditions, viz.-- 1. Where it is attended with, and probably depends upon, cerebral congestion or inflammation. 2. Where it arises from gastro-enteric irritation. 3. Where it is the result of general debility and anæmia. The last two rather deserve the title of melancholia. _Inflammatory or phrenitic form._ We shall divide the inflammatory form into two species: first, where it is wild and furious delirium with phrenitis; secondly, where it is connected with, and is the result of, puerperal fever. The first, usually comes on during labour: the patient is attacked with violent pain, heat, and throbbing of the head, which are greatly increased by her efforts during the throes; the pulse becomes quick and hard; the face flushed and crimson; the eyes wild, and the manner more and more unnatural: if this state be not promptly checked, the cerebral excitement becomes more intense, furious delirium follows, which in its turn is succeeded by coma, effusion and paralysis. On examination after death the ordinary appearances of fatal phrenitis manifest themselves, viz. preternatural fulness of the cerebral vessels, thickening and opacity of the different membranes, softening or even suppuration of the substance of the brain, extravasation of blood, or effusion of serum into the cavities or substance of the brain, or between its membranes. The other form of inflammatory puerperal mania, is only seen _after_ labour, and is invariably connected with, and preceded by, symptoms of puerperal fever. These are the cases of puerperal mania, where the disease comes on with a rigour, a quick pulse, violent headach, and abdominal pain. In some, the attack has appeared from the very commencement to concentrate itself upon the brain; but in others, it more frequently appears in a day or two afterwards, when, from the subsidence of the abdominal pain, we are beginning to hope that the disease has been more or less controlled. The patient is suddenly seized with intense headach, and other symptoms of cerebral congestion, accompanied by disordered mind; but there is not that degree of furious delirium which is seen in the acute phrenitis; there is less excitement, but there is also, less strength; the powers of the system are rapidly giving away, not so much under the effects of the local disease, as under those of the general affection by which the local disease has been produced. The patient is frequently both violent and obstreperous; but we seldom see that state of wild and furious raving which is observed in acute phrenitis. The former of these two species is of very rare occurrence, but from not being complicated with puerperal fever, it is perhaps not so dangerous, if promptly treated, as the other. Dr. Ferguson, has correctly observed, in puerperal fever, that "any cerebral disturbance diminishes the chances of recovery," and that "the presence of delirium in any case is almost always followed by a fatal result." (_Op. cit._ p. 49, 50.) The patient in whom we have chiefly observed phrenitic symptoms during labour were stout, robust, short-necked women, with black oily hair, and a swarthy complexion: from an early stage they had exerted themselves during the pain in a most violent and unnecessary degree, and had gradually worked themselves into that state of excitement, which was followed by the symptoms above-mentioned: in two instances, it was ascertained that the patient had received a violent blow on the head, either during pregnancy, or on some previous occasion. In similar habits the same symptoms have been observed occasionally to accompany the first appearance of the milk, or to follow its sudden suppression when established, or a similar state of the lochia. _Treatment._ The treatment differs but little from that of the congestive epileptic convulsions, already described: she must be bled to fainting, leeches must be applied to the temples, the head shaved and cold applied to it, the feet should be put into hot water, and the bowels opened by an active purge of calomel. If the child be not delivered, and the passages are sufficiently dilated, the forceps should be applied to shorten the labour. In the other case, which is accompanied with puerperal fever, the propriety of bleeding to any considerable extent will be more questionable; it has probably been already employed in the early part of the original disease, and her powers more or less reduced by it: we must here rather trust to leeches and cold to the head, and bringing the system as soon as possible under the influence of calomel and opium. Whether or not the improvement which follows in some cases of puerperal fever has resulted from the use of saline medicines, we will not pretend to determine; but as, on more than one occasion, we have seen calm and refreshing sleep succeed their exhibition, it is not improbable that they might prove useful in this form of the disease. We presume that these are the cases to which Dr. Gooch has referred, when he described them as being "attended by fever, or at least, the most important part of it--a rapid pulse;" and that the majority of them prove fatal: their unfavourable result, however, is not so much from the local affection, as from the puerperal fever under which the patient sinks. Pure phrenitis, which is a rare disease during labour or the puerperal state, is by no means difficult to control by active antiphlogistic treatment, if taken in sufficient time, before the brain has suffered any serious injury; nor is there much danger of her continuing deranged even after the inflammatory symptoms have been reduced. This appears to be also the case in that form which attends puerperal fever; but here the danger to life is so much greater, that we rarely have an opportunity of ascertaining the duration of the mental disorder after the symptoms of cerebral inflammation have been subdued, since most of these cases terminate fatally. _Gastro-enteric form._ In the gastro-enteric form, the cerebral symptoms are of a much milder character: the head is perhaps warmer than natural, and it aches a good deal across the forehead and eyes; the face is seldom flushed, but it is sallow, the eye is yellow, the tongue is foul, the breath offensive, and if any evacuations have been passed, they are excessively unhealthy; the abdomen feels full and loaded, the pulse is irritable, but devoid of strength; the patient is seldom violent, and if so, can usually be restrained by the mildest measures. Her previous history will also assist us in our diagnosis; we shall, probably, find that she has for some time suffered from constipation and deranged bowels, or is known to have greatly neglected them before her confinement. Puerperal mania from this cause is a result of cerebral irritation, not inflammation, and is a state which will generally cease the moment the cause is removed. As is the case with puerperal convulsions from gastro-enteric irritation, so here the moment we break the chain of morbid sympathies, upon which the disease depends, the symptoms disappear, and are instantly followed by a clearing up of the mental disorder. It usually comes on during the first few days after labour, before the patient has taken the laxative medicine which is customary at this time, and seems to be excited to an outbreak by any little source of mental annoyance or irritation. At first, it appears to be little else than giving way to caprice and temper, but by degrees her manner becomes more changed; and ultimately she grows violent and unmanageable. The state of mind, however, is very different to that of the inflammatory form of puerperal mania; there is no raving delirium, and but a slight degree of incoherence; she understands what is said to her, but reasons erroneously under the influence of a false impression. This state rarely proves dangerous either to her life or her reason, if the proper treatment has been promptly had recourse to; but where it has been allowed to run on for some time, or she has been reduced by antiphlogistic treatment under an erroneous fear of cerebral congestion or inflammation, there may be reason to fear that she will ultimately sink, or at any rate, that the derangement will become permanent. _Treatment._ As the pulse scarcely ever betrays a febrile or inflammatory condition of the system, for although quick, it is seldom observed to be full and hard, bleeding is rarely required in this form of puerperal mania, leeches and cold applications being almost sufficient to control any symptoms of determination to the head which may be present: it is upon purgatives that we must place our chief hope in this disease, for until the bowels have been thoroughly and effectively cleared, there will be little chance of the symptoms being alleviated. In some cases it is scarcely credible to what an extent this may be carried; day after day sees the patient relieved of copious, dark, and offensive evacuations, which are evidently not merely the result of enormous accumulations in the bowels, but of excrementitious matters, which are thrown off by the secreting vessels of the liver and alimentary canal. So far from producing debility, the pulse rises with each relief and becomes fuller and slower, the face resumes a healthier aspect, the tongue becomes cleaner, the headach subsides, reason regains its ascendancy, and this favourable change is followed by calm and refreshing sleep. We could quote several cases of our own, in illustration of this form of puerperal mania and its treatment, where the symptoms have quickly yielded, as soon as the source of irritation had been removed from the system; the patient has recovered favourably, although in most instances she has retained a sufficient recollection of what had passed to feel much vexed and even shocked at, what she was aware had been, very strange and unruly conduct; but we prefer selecting Dr. Gooch's thirteenth case, of which the details are given so graphically, as not a little to enhance the value of it. "A lady, twenty-two years of age, clever, susceptible, and given to books, was confined with her first child at ----, -- miles from town: she was anxious to nurse it; but several days passing with little appearance of milk, doubts began to be entertained whether she would be able: _she_ thought she would, her nurse and surgeon thought she would not: this led to irritating discussions; her manner became sharp, quick, and unnatural; and at the end of a few days she was decidedly maniacal. I and another physician were now sent for; we found her in a straight waistcoat, incessantly talking and reciting poetry; her skin was hot, her pulse full, and much above 100; her tongue covered with a dark thick fur; her bowels were confined, and her stools excessively dark and offensive; she took a dose of calomel and jalap, followed by small doses of sulphate of magnesia; these produced a few evacuations, but they were followed by no relief; she talked almost incessantly, scarcely ever slept, and was so violent that it was impossible to keep her in bed without the straight waistcoat. Thus three days passed from our first consultation. The physician who attended with me, thinking the case would be protracted, withdrew, and I was directed to take Dr. Sutherland down with me. As the purgative had operated very moderately, and the tongue and stools were as unnatural as at first, he proposed a more active purge. The next morning, therefore, she took a strong dose of senna and salts, made still more active by the addition of tincture of jalap; after this had been taken about three hours, it procured a very large evacuation, nearly black, and horribly offensive; this was as usual discharged into the bed without any notice on the part of the patient; it acted again an hour or two afterwards; but now the nurse, who was sitting by her bed-side, was surprised to see her turn round, and in a calm and natural manner request to be taken up, as her medicine was going to operate; her waistcoat was immediately loosened, and she was taken out of bed, when she voided a stool of prodigous size, as dark and offensive as the first, and then walked back to her bed calm and collected. We saw her not many hours afterwards; her waistcoat was off, she was lying on her sofa perfectly tranquil, answered questions correctly, manifested no vestige of her complaint, excepting some strangeness in the expression of her countenance, and a timidity and abstinence from conversation which was not natural to her: she recovered rapidly and uninterruptedly." (_Account of some of the most important Diseases peculiar to Women_, by Robert Gooch, M. D. p. 156.) The chances of recovery in puerperal mania, from, gastro-enteric irritation are as great as they are small in the inflammatory form connected with puerperal fever: the danger is more from erroneous practice on the part of the medical attendant, who either prostrates the powers of life by active depletion, under the supposition that he is treating a case of cerebral congestion, or aggravates the disorder of the mind into wild delirium, by the exhibition of opium, to procure sleep. It is in these cases that we occasionally see so much relief procured by the action of emetics, as at one time to have been considered nearly specific in this disease, by some of the French practitioners. If the powers be good, we cannot agree with Dr. Gooch, in objecting to the use of antimony; when in a sufficient dose, and combined with ipecacuanha, it is too speedy in its operation to depress the patient much by nausea, and has the additional advantage of acting as a rapid and effectual purge: when its action is over, she usually falls into a sound sleep, perspires freely, and wakes greatly refreshed. The indiscriminate use of emetics in puerperal mania, is not less mischievous than that of bleeding; they are chiefly indicated in those cases, where, in addition to the symptoms above-mentioned, there are signs of a foul and oppressed stomach, and where the patient either complains of nausea, or has already made several attempts to vomit. As soon as the offending cause is removed, the bowels should be kept open by mild alterative and laxative medicine, as equal parts of blue pill, compound extract of colocynth, and extract of henbane, in two pills at night, and a mineral acid in some bitter infusion during the day. The food should be bland but nutritious, the mind quietly but agreeably occupied, and all excitement carefully avoided. In this form of puerperal mania, it is not only a rare occurrence to find that the disordered state of the mind continues, when the cause which had produced it no longer exists, but it is scarcely ever known to return in the patient's subsequent confinements. In the case which has been so ably recorded by Dr. Gooch, the patient has since had a very large family, her labours have all been perfectly favourable, and without the slightest symptom of her former disease. The _adynamic form of puerperal mania_ is by far the most common species of the disease, and like the adynamic puerperal convulsions, arises from causes which produce exhaustion and collapse in the general powers of the system. It is to Dr. Gooch that we are indebted for a masterly exposition of this disease, and for having been one of the first to point out its real character. _Causes and symptoms._ This form of disordered mind is a disease of true debility, and is closely allied to delirium tremens, and convulsions produced by anæmia. It can scarcely be said to deserve either the terms "puerperal," or "mania," for we frequently see a very near approach to it in females who are much weakened by hæmorrhage, either from menorrhagia, malignant disease of the uterus, or abortion; and from being a disease which arises from great exhaustion, it rather deserves the name of melancholia, than of mania. In lying-in women, "there are two periods at which this is chiefly liable to occur; the one soon after delivery, when the body is sustaining the effects of labour, the other several months afterwards, when the body is sustaining the effects of nursing." (Gooch, _op. cit._ p. 109.) In the one case, it is usually the result of profuse hæmorrhage, in the other, it is produced by suckling her child when she is not strong enough for this purpose. "I have repeatedly seen the commencement of mental derangement in women who had recovered from their confinement and had been suckling several months. Nearly all these cases were instances, not of mania but of melancholia. They occurred in women who had been debilitated by nursing. The disease at this period has been attributed to weaning; but, in all cases, I have seen, the disease has begun before the weaning, and this measure has been resorted to, because the patient had neither milk nor strength to fit her for a nurse. There was a peculiarity about the commencement of the disease which I have seldom or never noticed at the commencement of mania; there was an incipient stage in which the mind was wrong, yet right enough to recognise that it was wrong." (Gooch, _op. cit._ p. 114.) This half-way state of mind between reason and derangement is frequently seen in women who have been exhausted by menorrhagia, leucorrhoea, &c., or who have been drained by nursing. We confess that we can see but little difference in the effects of anæmia upon the brain and nervous system, whether it be in the unimpregnated or puerperal state, beyond that, on account of the great changes which have taken place in the system by the process of labour, by the secretion of milk, &c., the system is probably more irritable, and susceptible than it would otherwise be. Nothing is more common than to see, in cases of menorrhagia, the mind becoming enfeebled, the memory impaired; the patient begins to find that she can no longer control her thoughts in the ordinary manner, but that strange trains of ideas will pass through her mind, the source of which she cannot explain, and frequently so unaccountably, as to cause her serious uneasiness: "If this goes on so, I shall lose my senses," is almost a never failing observation; and the dread that this will be the case, tends to depress the system still more. The sleep is disturbed by frightful dreams, or she passes night after night in wakeful restlessness; she worries herself about trifles, her manner changes, and the mind at length is quite disordered. The same train of symptoms is a frequent result of over-suckling, and as Dr. Gooch has justly observed, is not the result of weaning. "In all the cases which I have seen, months after delivery, the weaning has been the consequence of the disease, not the disease the consequence of the weaning. The patients had been reduced in health by nursing, their memories had become enfeebled, their spirits depressed, and their minds ultimately disordered; they were directed to wean their children, because they had neither milk nor strength to enable them to nurse." (_Op. cit._ p. 130.) A similar state of mind may be induced at an earlier period and more suddenly, by the effects of a profuse hæmorrhage, by serious discharges, which occasionally take place shortly after labour, or even by mental depression; in fact, by whatever lowers the vital powers to a considerable extent. In these cases, the very history and appearance of the patient are sufficient to explain the nature of the disease: her hollow eyes, pale face, and blanched lip, show distinctly how her strength has been reduced. The source and extent of her debilitated state will in great measure determine the degree of danger, and the chances of her recovery. In ordinary cases of this form there is not much to fear, as far as the life of the patient is concerned; and the cases which have come under our own notice confirm the excellent remark of Dr. Gooch, "that mania is a less durable disease than melancholia; it is more dangerous to life, but less dangerous to reason." But if the disordered mind has come on shortly after labour, in consequence of profuse flooding; if the powers of the system have rallied but imperfectly, and from the tinnitus aurium, strabismus, half vision, &c., it is evident that the cerebral functions are greatly impaired; if the nights are passed without sleep, and the days in continued and exhausting excitement; if the pulse be feeble and rapid, the skin cold and clammy, the face covered with perspiration, and there is a disposition to colliquative diarrhoea, we shall have but too much reason to fear an unfavourable issue; every symptom denotes that the powers of the system have received a fatal blow, and she either sinks exhausted, or dies in a state of coma, probably from serous effusion upon the brain. On the contrary, if in addition to a general improvement, she has enjoyed some hours of refreshing sleep, there is every prospect, not only of returning health, but also of reason. A mere gleam of returning reason without a corresponding improvement of health, will afford but little satisfaction to the mind of a discerning practitioner, for it gives no assurance that the danger of fatal sinking is at all diminished. Disordered mind coming on some weeks after delivery from the effects of over-nursing, when the patient has been unable to afford the necessary supply to her child, is seldom attended with so much danger to life, as where suddenly induced immediately after labour by hæmorrhage: the intermediate stage between reason and derangement is more distinctly marked, and is of considerable duration; and the gradually increasing affection of the mind frequently warns even the patient herself to seek medical advice before the symptoms become more serious. We believe that the proportion of patients in whom the mind continues deranged after their health has been restored, is very small, and feel convinced that the results afforded by the practice of lunatic hospitals are far from giving a correct estimate. A large majority of the cases of derangement in lying-in women are of such short duration that they never come even under the notice of those members of the profession whose attention is particularly devoted to this branch of medical practice, still less do they require to be removed into asylums for lunatics. "The records of hospitals contain an account of cases which have been admitted only because they were unusually permanent; they are the picked obstinate cases, and can afford no notion of the average duration of all kinds; the cases of short duration, which last only a few days or a few weeks, which form a large proportion, are totally lost in the estimate of a lunatic hospital." (Gooch, _op. cit._ p. 125.) The results of Dr. Gooch's practice, which is known to have been very extensive, and especially in consultation, shows that out of a considerable number of cases only two of his patients remained disordered in mind, "and of these, one had already been so before her marriage." There are two classes of patients in whom disordered mind is not only much to be apprehended during their lying-in, but in whom there will be some reason to fear that it may become permanent; first, in those who have already been deranged, independent of the puerperal state, or who inherit a strong predisposition to mental disease; and secondly, in those where hysteria has existed in an unusual degree during the latter part of pregnancy. These circumstances justify us in using every precaution in their lying-in to avoid any thing which may excite the disease; but, as already stated, not only is the disorder of the mind rarely of any duration, but it is seldom known to recur on any subsequent occasion. _Treatment._ Our indications of treatment are two-fold, viz., to rouse and support the powers of the patient, and to allay as far as possible the irritability of the brain and nervous system. If the patient has been prostrated by hæmorrhage, not only a nutritious, but even a cordial and stimulant diet will be necessary: the emulsion of egg and brandy, which we have before recommended in anæmic puerperal convulsions, will here prove very useful; and it must be given in small but frequently repeated doses, until an improvement is observed in the pulse and in her general appearance. Under all circumstances, it will scarcely ever be proper or even safe to confine her to low diet: beaf-tea, veal-broth, &c. should be given in considerable quantities during the twenty-four hours; and it is surprising what improvement will even take place merely from the administration of this bland nutriment. If the face be pale and the pulse low, wine may be given according to the circumstances of the case. To calm the cerebral excitement and procure sleep, sedatives will prove of the greatest value, and require to be repeated until the nervous system is fairly under their influence. The intense pain at the vertex, which of itself is sometimes quite sufficient to produce delirium, the tinnitus aurium, &c., all cease; the pulse becomes softer, fuller, and slower; and, even if sleep be not immediately induced, a state of calm tranquillity follows, in which the mind becomes more composed. The Liquor Opii Sedativus may be given in a dose of twenty-five minims, and repeated in an hour or so according to circumstances. The combination of camphor with morphia, or extract of henbane, is an excellent form, and may be given with perfect safety to a considerable extent. The bowels should be opened by the mildest laxatives, such as castor oil, rhubarb and manna, &c., medicines which will neither act violently, nor weaken by producing watery evacuations; and, once in every few days, it will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, with extract of hop or gentian. To assist still farther in restoring her health and strength, she should take an infusion of a vegetable bitter with a mineral acid. As soon as her strength will permit, a change of residence may be recommended, and she should remove to some quiet watering-place, where invigorating air and agreeable scenery and occupations will assist in completing her recovery. "The constant attendants on the patient ought to be those who will control her effectually but mildly, who will not irritate her, and will protect her from self-injury. These tasks are seldom well performed by her own servants and relatives. "If the disease lasts more than a few days, and threatens to be of considerable duration, her monthly nurse and own servants ought to be removed, and a nurse accustomed to the care of deranged persons placed in their stead. Such an attendant will have more control over the patient, and be more likely to protect her from self-injury." "With regard to the removal of her husband and relations, this also will be a question; if the disease threatens to be lasting, it is generally right. Interviews with relations and friends are commonly passed in increased emotion, remonstrance, altercation, and obviously do harm: large experience also is decidedly favourable to separation as a general rule; yet there may be exceptions, which the intelligent practitioner will detect by observing the effect of intercourse." (Gooch, _op. cit._ p. 158.) INDEX. _Abdomen_ of the foetus, labour obstructed by depositions in the, 284. Pendulous, 308. Management of the, 309. _Abdominal_ muscles, faulty action of the, obstructing labour, 336. _Abnormal_ Parturition, divisions and species of, 263. See _Dystocia_. _Abortion_, 141. Explanation of the term, 141. Period at which it is most common, 142. Causes of, 142. Death of the embryo, 142. External violence, 143. Mental emotions, 143. Irritable uterus, 144. Symptoms of, 144. Treatment of, 146. Prophylactic, 146. In the attack, 149. After expulsion, 155. _Abscess_, mammary, 191. Treatment of, 192. _Absorption_ of retained placenta, 358. _Adynamic_ puerperal fever, 450. See _Puerperal Fever_. Mania, 473. See _Puerperal Mania_. _After-pains_, 197. Causes of, 197. Utility of, 198. _Age_, rigidity of the passages from, obstructing labour, 314. Influence of, on the contractile power of the uterus, 327. _Allantoidis_ Liquor, situation of the, 54. _Allantois_, mode of its formation, 70. Its existence in the human embryo, 70. Functions of the, 70. _Amnii_ Liquor spurius, situation of the, 54. Characters of the, 55. Source of the, 55. Use of the, 55. Formation of the bag of the, 162. Excessive quantity of, 287. _Amnion_, description of the, 54. Formation of the, 69. Dropsy of the, 287. _Anatomy_ of utero-gestation, 15. Of the pelvis, 15. Of the sacrum, 16. Of the coccyx, 17. Of the ovaria, 22. Of the Fallopian tubes, 28. Of the uterus, 30. Comparative, of the, 34. Of the external organs of generation in the female, 45. _Anæmic_ puerperal convulsions, 387. _Anchylosis_ of the foetal joints, obstructing labour, 284. _Anteversion_ of the uterus, 309. _Apoplectic_ puerperal convulsions, 387. _Areola_ of the breasts, 86. _Arm_, presentation of the, 272. See _Labour_. With the head, 273. See _Presentation_. _Arthritic_ inflammation supervening upon puerperal fever, 456. _Artificial_ premature labour, 250. _Atony_ of the uterus, 324. Causes of, 325. Debility, 325. Derangement of the digestive organs, 326. Mental affections, 326. Age and temperament, 327. Plethora, 327. Rheumatism of the gravid uterus, 328. Inflammation of the uterus, 329. Treatment of, 339. _Auscultation_ in the diagnosis of pregnancy, 89. Uterine souffle, 90. Funic souffle, 93. Mode of ascertaining twin pregnancy by means of, 100. During the pains, 159. _Axes_ of the pelvis, 21. _Ballottement_, method of performing, 94. _Bladder_, distended or prolapsed, obstructing labour, 322. Stone in the, 323. _Blastodermic_ Membrane, 65. See _Egg_. _Blood-vessels_, uterine, enlargement of, during pregnancy, 38. Their connexion with the placenta, 57, 58. _Breasts_, changes which they undergo during pregnancy, 86. Abscess of the, 191. _Breech_, presentation of the, 210. See _Nates_. _Brim_ of the pelvis, situation of the, 17. _Bronchial_ Processes, description of the, 71. _Cæsarean_ Operation, 243-278. Indications for its performance, 243. Different modes of performing it, 246. History of the, 248. _Canalis_ venosus, situation of the, 78. _Caput_ succedaneum, in what it consists, 165. _Carunculæ_ myrtiformes, how produced, 46. _Cerebral_ tumours in the foetus, obstructing labour, 283. _Chest_, morbid depositions in the foetal, obstructing labour, 284. _Child_, size of, at birth, 281. Its influence on the duration of labour, 282. Unnatural form of the, 282. See _Foetus_. _Chorion_, description of the, 52. Changes which it undergoes during pregnancy, 53. _Cicatrices_ in the vagina obstructing labour, 315. Treatment of, 316. Of the os uteri, 311. _Circulation_, foetal, 77. See _Foetus_. _Clitoris_, anatomical description of the, 46. _Coccyx_, anatomical description of the, 17. _Colic_, occurring during pregnancy, 104. Treatment of, 104. _Colostrum_, nature and use of the, 190. _Conception_, false, 112. See _Mole_. _Constipation_ during pregnancy, 104. Treatment of, 104. _Contagious_ nature of adynamic puerperal fever, 458. _Contracted_ vagina, obstructing labour, 315. _Contractile_ power of the uterus, derangement of the, 324. Causes of, 325. Treatment of, 329. _Contraction_, hour-glass, of the uterus, 354. See _Placenta, encysted_. _Convulsions_, puerperal, 376. Epileptic, 377. Causes of, 377. Symptoms of, 377. Tetanic, 381. Diagnosis of labour during, 382. Prophylactic treatment of, 383. Treatment during the attack of, 383. Apopletic, 387. Anæmic, 387. Symptoms of, 388. Treatment of, 388. Hysterical, 390. Symptoms of, 390. _Copulative_ Organs, 22. _Cord_, umbilical description of the, 63. Vessels of the, 63. Length of the, 63. Round the neck of the child, 183. Ligature of the, 184. Rupture of the, 364. Prolapsus of the, 368. Diagnosis of, 368. Causes of, 368. Treatment of, 372. Reposition of the, 373. Unusual shortness of the, 288. Knots upon the, 290. _Corpus_ Luteum, nature of the, 25. Appearance of, at different periods after conception, 25. _Cotyledons_ of the placenta, situation of the, 56. _Cough_, spasmodic, occuring during pregnancy, 104. Treatment of, 104. _Cranium_, presentation of the, 200. See _Presentation_. _Crotchet_, mode of its application, 260. _Death_ of the foetus, signs of the, 107. See _Foetus_. _Debility_, insufficient uterine action from, 325. _Decidua_ membrana, description of the, 48. Its connexion with the uterus, 49. With the ovum, 50. With the placenta, 51-55. With the Fallopian tubes, 51. Vera, 51. Reflexa, 51. _De Graaf_, vesicles of, 24. _Delirium_ occurring during labour, 167. _Depositions_, morbid, in the foetal cavities, obstructing labour, 284. _Development_ of the ovum. See _Ovum_. _Diagnosis_ of pregnancy, 80. See _Pregnancy, signs of_. Of twin Pregnancy, 100. _Diameters_ of the pelvis, 19. _Diarrhoea_ during pregnancy, 105. Treatment of, 105. _Diet_ during labour, 179. Lactation, 195. _Dilatation_ of the perineum during labour, 166. _Distended_ bladder, obstructing labour, 322. _Dropsy_ of the amnion, 287. _Ductus_ arteriosus, situation of the, 78. _Duration_ of pregnancy, 136. Causes which determine the, 139. Of labour, prognosis as to, 178. Wigand's views, 178. _Dystocia_, 263. Divisions and species of, 263. Malposition, 264. Faulty form and size of the child, 281. Faulty condition of the parts which belong to the child, 282. Abnormal state of the pelvis, 292. Faulty condition of the soft passages, 308. Faulty condition of the expelling powers, 324. Inversion of the uterus, 345. Encysted placenta, 354. Precipitate labour, 361. Prolapsus of the umbilical cord, 368. Puerperal convulsions, 376. Placenta prævia, 393. Puerperal fevers, 415. Phlegmatia dolens, 463. Puerperal mania, 473. _Dystocia_ epileptica, 381. See _Convulsions, puerperal_. _Eclampsia_ parturientia, 376. See _Convulsions, puerperal_. _Egg_, bird's, its analogy with the human ovum, 64. Blastodermic membrane, 65. Vitelline membrane, 65. Yelk bag, 65. Germinal vesicle, 65. _Embryo_, development of the, 64. _Embryulcia_, 261. See _Perforation_. _Encysted_ Placenta, 354. See _Placenta_. _Epileptic_ Convulsions, puerperal, 376. See _Puerperal Convulsions_. _Eutocia_, 156. See _Labour, natural_. _Evolution_, spontaneous, of the foetus, 270. _Examination_ during labour, mode of its performance, 174. _Exostosis_ of the pelvis, 300. Prognosis in, 305. _Expelling_ powers, faulty state of the, after the birth of the child, 337. _Expulsion_, spontaneous, 270. Of the child, 166. Delirium accompanying the, 167. Of the placenta, 167. _External_ organs of generation in the female described, 45. _Extirpation_ of the uterus, 332. See _Inversion_. _Extraction_, method of performing, after turning the child, 239. After perforation, 259. _Extra-uterine_ pregnancy, 117. Varieties of, 117. Tubarian, 118. Ovarian, 118. Ventral, 119. In the substance of the uterus, 117. Symptoms of, 118. Causes of, 119. Treatment of, 120. Case of, 120. _Eye_, rheumatic inflammation of the, after puerperal fever, 456. _Face_ Presentation, 206. See _Presentation_. _Fallopian_ Tubes, description of the, 28. Their agency in impregnation, 29. Changes which they undergo during pregnancy, 29. Pregnancy of the, 117. _Febris_ lactea, 191. See _Milk Fever_. _Feet_, rules for finding the, in the operation of turning, 237. Presentation of the, 273. See _Presentation_. _Female_ Pelvis, distinction between it and the male, 17. Organs of generation described, 22. _Fever_, milk, 192. See _Milk Fever_. Puerperal, 415. See _Puerperal Fever_. _Fibrous_ structure of the uterus described, 32. _Flatulence_ during pregnancy, 104. Treatment of, 104. _Flooding_, 338. See _Hæmorrhage_. _Foetus_, characters of a full-grown, 75. Nutrition of the, 75. Circulation in the, 77. Changes which it undergoes at the moment of birth, 78. Signs of the death of the, 107. Premature expulsion of the, 141. See _Abortion_. Size and form of the, at birth, 281. Morbid depositions in the cavities of the, 284. Anchylosis of the joints of the, 284. Spontaneous evolution of the, 270. _Foramen_ ovale, situation of the, 77. _Forceps_, description of the, 216. Varieties of the, 217. General indications for their use, 221. Mode of applying the, 222. History of the, 227. _Formative_ Organs, 22. _Fracture_ of the parietal bone of the foetus from pelvic deformity, 302. _Funic_ Souffle, 93. See _Auscultation_. _Funis_, 63. See _Cord, umbilical_. _Funnel-shaped_ Pelvis, 298. _Gastro-bilious_ puerperal fever, 444. See _Puerperal Fever_. _Gastrotomy_, 243. See _Cæsarian Operation_. _Generation_, internal organs of, described, 22. External organs of, 45. _Germinal_ Vesicle, 65. See _Egg_. _Graafian_ Vesicles, description of the, 25. _Hæmorrhage_, uterine, after the birth of the child, 338. Treatment of, 339. In placental presentation, 399. Treatment of, 406. _Hand_ and feet, presentation of the, 274. See _Presentation_. _Headach_ during pregnancy, treatment of, 104. _Heartburn_ during pregnancy, 103. Treatment of, 103. _Hour-glass_ Contraction, 354. See _Placenta, encysted_. _Hydrocephalus_, obstructing labour, 282. _Hymen_, description of the, 45. Unruptured, impeding labour, 316. _Hysterical_ puerperal convulsions, 390. See _Convulsions_. _Hysterotomy_, 243. See _Cæsarian Operation_. _Inclination_ of the pelvis, 21. _Indusium_, 23. See _Ovaria_. _Inflammation_ of the uterus, affecting its contraction, 329. _Inversion_ of the uterus, 345. Causes of, 345. Diagnosis of, 346. Symptoms of, 346. Treatment of, 347. Chronic, 351. _Joints_, anchylosis of the foetal, obstructing labour, 284. _Kiesteine_, 96. _Labia_, anatomical description of the, 47. Varicose and oedematous swellings of the, 317. _Labour_, premature. See _Premature Expulsion of the Foetus_. Natural, 156. Preparatory stage of, 157. First contractions, 157. Action of the pains, 158. Auscultation during the pains, 159. Effects of the pains on the pulse, 160. Symptoms during and between the pains, 160. Characters of a true pain, 161. Formation of the bag of liquor amnii, 162. Rigour at the end of the first stage, 162. Show, 163. Duration of the first stage, 163. Second stage of, 164. Straining pains, 165. Dilatation of the perineum, 166. Expulsion of the child, 166. Third stage of, 167. Expulsion of the placenta, 167. Twins, 168. Treatment of, 169. State of the bowels, 170. Management of the first stage, 174. Examination of the patient, 174. Position of the patient, 176. Diet during labour, 179. Supporting the perineum, 179. Perineal laceration, 181, 182. Cord round the child's neck, 183. Ligature of the cord, 184. Passage of the shoulders, 184. Management of the placenta, 186. After treatment, 188. Lactation, 189. Milk fever and abscess, 191. Excoriated nipples, 193. Diet during lactation, 195. Management of the lochia, 196. After-pains, 197. Mechanism of, 199. See _Parturition_. Abnormal, 263. Precipitate, 361. See _Precipitate Labour_. _Laceration_ of the perineum, 181, 182. Of the uterus, 274. See _Rupture_. _Lactation_, management of, 189. Diet during, 195. _Ligaments_ of the uterus, 31. _Ligature_ of the funis, 184. _Liquor Amnii._ See _Amnii Liquor_. _Lochia_, management of the, 196. _Malacosteon._ See _Mollities Ossium_. _Male_ and female pelves, distinction between the, 17. _Malposition_ of the child in utero, 264. Rareness of its occurrence, 265. Causes of the, 266. Symptoms of, 268. With deformed pelvis, 272. With rigidity of the uterus, 272. See _Presentation_. _Mamma._ See _Breasts_. _Mammary_ Abscess, 191. _Mania_ connected with precipitate labour, 366. Puerperal. See _Puerperal Mania_. _Mechanism_ of parturition, 199. See _Parturition_. _Membrana_ decidua, 48. See _Decidua Membrana_. _Membrane_, blastodermic, 65. Vitelline. See _Egg_. _Membranes_, formation of the, 48. Premature rupture of the, 287. _Menses_, cessation of the, in pregnancy, 83. _Mental_ affections, impairing uterine contraction, 326. _Midwifery_, explanation of the term, 13. Operations of, 216. Forceps, 216. Turning, 230. Cæsarian operation, 243. Artificial premature labour, 250. Perforation, 161. _Milk_ Fever, 191. Treatment of, 192. _Miscarriage_, 141. See _Abortion_. _Mole_ pregnancy, 112. Nature and origin of, 112. Diagnostic symptoms of, 114. Treatment of, 116. _Mollities_ Ossium, 295. Causes of, 296. Pelvic deformity from, 296. Varieties of pelvic deformity from, 296. _Monsters_, difficult labour in cases of, 284. _Movements_ of the foetus, value of, as a sign of pregnancy, 88-94. _Nates_, presentation of the, 210. Modifications of, 210. Varieties of, 210. Mechanism of labour in, 211. Diagnosis of, 213. Management of, 213. Comparative frequency of, 215. _Navel-string._ See _Cord, umbilical_. _Nutrition_ of the foetus, 75. See _Foetus_. _Nymphæ_, anatomical description of the, 47. Varicose and oedematous swellings of the, 317. _Nipples_, excoriated, 193. Treatment of, 194. _Oedematous_ swellings of the labia and nymphæ, 317. _Operations_ in midwifery. See _Midwifery_. _Operation_, Cæsarian. See _Cæsarian Operation_. For Inducing premature labour, 253. _Organs_ of generation, internal, in the female, 22. External, 45. _Ossa_ innominata, description of the, 15. _Ossium_, Mollities, 295. See _Mollities_. _Os Uteri_, rigidity of the, 310. Adhesion of the edges of the, 311. Cicatrices of the, 311. Agglutination of the, 312. _Ovaria_, description of the, 22. Situation of the, 22. Arteries of the, 23. Tunica albuginea of the, 23. Graafian vesicle, 24. Appearance of the, during childhood, 28. Diseases to which they are liable, 28. _Ovarian_ Pregnancy, 118. See _Extra-uterine Pregnancy_. _Ovaries._ See _Ovaria_. _Ovum_, development of the, 48. Membrana decidua, 48. Chorion, 52. Amnion, 54. Liquor Amnii, 55. Placenta, 55. Umbilical cord, 63. Analogy between the human, and the bird's egg, 64. Order of development, 66. _Pains_, labour, action of, 158. Auscultation during, 159. Effects of, on the pulse, 160. Symptoms to be observed during and between, 160. Characters of true, 161. Straining, 165. Spurious, 172. Causes of, 172. Diagnosis of, 172. Treatment of, 173. _Palpitation_ during pregnancy, 104. Treatment of, 104. _Parietal_ Bone, fracture of the foetal, from pelvic deformity, 302. _Parturition_, mechanism of, 199. Cranial presentations, 200. Face, 206. Nates, 210. See _Presentation_; _Labour_. _Pelvis_, anatomy of the, 15. Brim of the, 17. Distinction between the male and female, 17. Diameters of the, 19. Before puberty, 20. Axes of the, 21. Inclination of the, 21. Malposition of the child with deformed, 272. Abnormal state of the, 292. Equally contracted, 292. Unequally contracted, 293. Causes of, 293. Symptoms of, 298. Funnel shaped, 298. Obliquely distorted, 299. Exostosis of the, 300. Diagnosis of contracted, 300. Treatment of, 303. Prognosis of, 304. _Pendulous_ Abdomen, obstructing labour, 308. Management of, 308. _Perforation_, 256. History of, 256. Instruments employed in the operation of, 256. Indications for its performance, 257. Extraction after, 259. Embryulcia, 261. _Perforators_, different kinds of, 250. _Perineum_, obstructing labour, 317. Dilatation of the, 166. Mode of supporting the, in labour, 179. Laceration of the, treatment of, 181. _Peritonitis_, puerperal, 420. Symptoms of, 420. Anatomical characters of, 430. Treatment of, 431. False, 441. Symptoms of, 441. Treatment of, 443. _Phlebitis_, uterine, 436. Symptoms of, 436. Anatomical characters of, 437. Treatment of, 438. Crural, connexion of, with phlegmasia dolens, 465. _Phlegmasia_ dolens, 463. Nature of, 463. Definition of, 463. Symptoms of, 464. Duration of, 465. Connexion of, with crural phlebitis, 465. With puerperal fever, 467. Causes of, 466. Anatomical characters, 467. Treatment of, 469. _Physiology_ of utero-gestation, 15. _Placenta_, description of the, 55. Cotyledons of the, 56. _Placenta_, decidua of the, 51-56. Circulation of the uterine blood through the, 57-61. Sulci of the, 57. Foetal surface of the, 60. Expulsion of the, 167. See _Labour_. Management of the, 186. In twin cases, 187. Prævia, 393. History of, 393. Symptoms of, 402. Comparative frequency of, in different years, 405. Treatment, 406. Partial presentation of the, 413. Treatment of, 414. Retention of the, 337. Encysted, 354. Situation of, 354. History of, 354. Adherent, 356. Treatment of, 356. Left in the uterus, 357. Absorption of retained, 358. _Plethora_, effects of, on uterine contraction, 327. _Plug_, utility of the, in restraining hæmorrhage, 410. Best means of applying, 152. _Position_ of the patient during labour, 176. _Precipitate_ labour, 361. From violent uterine action, 361. From deficient resistance, 363. Effects of, 363. Treatment of, 365. Connexion of, with mania, 366. _Pregnancy_, changes induced in the uterus by, 36. Seat and appearance of the uterus in the different stages of, 39. Signs of, 80. General, 81. Cessation of the menses, 83. Areola, 86. Movements of the foetus, 88-94. Auscultatory signs, 89. Ballottement, 94. Urinary deposites, 96. Purple hue of the vaginal entrance, 97. Diagnosis of twin, 100. Treatment of, 101. Morning sickness, 101. Heartburn, 103. Constipation, 104. Flatulence, 104. Colicky pains, 104. Headach, 104. Spasmodic cough, 104. Palpitation, 104. Toothach, 104. Diarrhoea, 105. Pruritis pudendi, 105. Salivation, 106. Mole, 112. See _Mole Pregnancy_. Extra-uterine, 117. See _Extra-uterine Pregnancy_. Duration of, 136. _Premature_ expulsion of the foetus, 141. See _Abortion_. _Premature_ Labour, 141. Artificial, 250. History of, 250. Period for inducing, 253. Mode of operating, 253. Rupture of the membranes in, 287. _Presentation_, cranial, 206. First species of, 200. Second species of, 203. Of the face, 206. Of the nates, 210. See _Nates_. Of the arm, 272. Of the arm with the head, 273. Of the hand and feet, 273. Of the head and feet, 274. Of the placenta, 393. See _Placenta Prævia_. _Prolapsus_ of the umbilical cord, 368. _Pruritis_ pudendi occurring during pregnancy, 105. Treatment of, 106. _Puberty_, state of the pelvis before, 20. _Puerperal_ Convulsions, 376. See _Convulsions_. _Puerperal_ Fevers, 415. Nature of, 418. Varieties of, 418. Pathology of, 418. Peritonitis, 420. See _Peritonitis_. Uterine phlebitis, 436. See _Phlebitis_. Gastro-bilious, 444. Causes of, 444. History of, 444. Symptoms of, 445. Anatomical characters of, 446. Treatment of, 446. Adynamic, 450. Symptoms of, 450. Anatomical characters of, 455. Supervention of arthritic or rheumatic inflammation, 456. Contagious nature of, 458. _Puerperal_ Mania, 473. Inflammatory form of, 473. _Puerperal_ Mania, treatment of, 474. Gastro-enteric form of, 475. Treatment of, 476. Adynamic form of, 478. Causes of, 478. Symptoms of, 478. Treatment of, 481. _Quickening_, 88. _Retained_ Placenta, absorption of the, 358. _Retention_ of the placenta, 337, 356. _Retroversion_ of the uterus, 126. History of, 126. Causes of, 127. Symptoms of, 129. Diagnosis of, 130. Prognosis of, 131. Treatment of, 131. _Rheumatic_ inflammation after puerperal fever, 456. _Rheumatism_ of the gravid uterus, 328. Symptoms of, 328. Treatment of, 333. _Rickets_, a cause of deformity of the pelvis, 294. _Rigidity_ of the uterus, malposition with, 272. Of the os uteri, 310. Treatment of, 310. From age, 314. _Rigour_ after the first stage of labour, 162. _Rupture_ of the uterus, 274. Seat of the laceration, 274. Causes of, 275. Symptoms of, 276. Treatment of, 277. Gastrotomy, 278. During the early months of pregnancy, 278. Premature, of the membranes, 287. Of the umbilical cord, 364. _Sacrum_, anatomical description of the, 16. _Salivation_ during pregnancy, 106. Treatment of, 106. _Show_, 163. See _Labour_. _Sickness_, morning, in pregnancy, 101. Treatment of, 102. _Signs_ of pregnancy, 80. See _Pregnancy_. Of the death of the foetus, 107. _Size_ of a child at birth, 281. _Spasmodic_ cough during pregnancy, 104. Treatment of, 104. _Spontaneous_ evolution, 270. Expulsion, 271. _Stone_ in the bladder, obstructing labour, 323. _Stricture_ of the uterus, 335. Symptoms of, 335. Effects of, on labour, 335. Causes of, 336. Treatment of, 336. _Stroma_, 23. See _Ovaria_. _Structure_, fibrous, of the uterus, 32. _Sulci_ of the placenta, how formed, 57. Their connexion with the uterine vessels, 59. _Tampon_, 410. See _Plug_. _Temperament_, influence of, on uterine contractions, 327. _Tetanic_ puerperal convulsions, 381. See _Convulsions_. _Toothach_ during pregnancy, 104. Treatment of, 104. _Tumours_, obstructing labour, 320. _Turning_, 230. Indications for, 231. Mode of performing the operation of, 232. Rules for finding the feet, 237. Extraction of the child, 239. With the nates foremost, 240. With the head foremost, 241. History of, 242. _Twins_, 168. Management of the placenta of, 168, 187. _Umbilical_ Cord, 63. See _Cord, umbilical_. _Unruptured_ Hymen impeding labour, 316. _Urinary_ deposites in pregnancy, 96. _Uterine_ Souffle, 90. See _Auscultation_. Action, violent, 361. Phlebitis, 436. See _Phlebitis_. _Utero-gestation_, anatomy and physiology of, 15. _Uterus_, description of the, 30. Ligaments of the, 31. Structure of the, 32. Comparative anatomy of the, 34. Changes in the, during gestation, 36. Situations and appearances of the gravid, 39. Condition of the gravid, after delivery, 44. Blood-vessels of the, connected with the placenta, 57, 61. Retroversion of the, 126. See _Retroversion_. influence of the form and size of the, on parturition, 266. Rigidity of the, 272. Anteversion of the, 309. Derangement in the contractile power of the, 224. Rupture of, 274. Rheumatism of the gravid, 328. Effects of uterine inflammation in labour, 329. Stricture of the, 335. Atony of the, 324. Inversion of the, 345. Extirpation of the, 352. Hour-glass contraction of the, 354. _Vagina_, anatomical description of the, 45. _Vagina_, contracted, obstructing labour, 314. Cicatrices in the, 315. _Varicose_ swellings of the labia and nymphæ, 317. _Ventral_ Pregnancy, 119. See _Extra-uterine Pregnancy_. _Vesicle_, germinal, of the egg, 65. See _Egg_. _Violent_ uterine action, precipitate labour from, 361. _Wigand's_ views as to the duration of labour, 178. _Womb_, 30. See _Uterus_. _Yelk-bag_, 65. See _Egg_. THE END. FOOTNOTES: [1] On the Ova of Man and Mamiferous Animals, &c.: by T. Wharton Jones. (_Med. Gaz._) [2] "Inde vero cum viderum viviparorum testes ova in se continere, cum eorundem uterum itidem in abdomen, oviductus instar apertum notarim, non amplius dubito quin mulierum testes ovario analogi sint, quocunque demum modo ex testibus in uterum, sive ipsa ova, sive ovis contenta materia transmittatur, ut alibi ex professo ostendam, si quando dabitur partium genitalium analogiam exponere, et errorem illum tollere quo mulierum genitalia genitalibus virorum analoga creduntur." (_Nicolai Stenonis Elementorum Myologiæ Specimen, &c._ Amst. 8vo. p. 145.) [3] "Ova in omni animalium genere reperiri confidenter asserimus, quandoquidem ea non tantum in avibus, piscibus tam oviparis quam viviparis, sed etiam quadrupedibus ac homini ipso evidentissime conspiciantur." (_Regner de Graaf de Virorum et Mulierum Organis Generationi Inservientibus._ Lugd. B. and Roterod. 1668. 8vo. p. 299.) [4] Anat. Descript. of the Human Gravid Uterus: by W. Hunter, M. D. [5] An Exposition of the Signs and Symptoms of Pregnancy, &c.: by W. F. Montgomery, M. D. p. 226. [6] Phil. Trans. 1797. [7] Purkinje and Valentin, de Phoenomeno generali Motus vibratorii. Wratisl. 1825. [8] W. Hunter, Anatomical Description of the Human Gravid Uterus, &c. p. 13. [9] Vesalius, Malpighi, Morgagni, Diemerbroeck, Vieussens, Ruysch, Monro, Heister, Haller, Roederer, Meckel, Hunter, Wrisberg, Lobstein, C. Bell. (_Meckel's Anat._ vol. iv.) [10] C. Bell, On the Muscularity of the Uterus. (_Med. Chir. Trans._, vol. iv.) [11] Leroux, Sur les Pertes de Sang. [12] The tortuous serpentine course which the arteries of the uterus take, is not, as has been generally supposed, a provision of nature against the increase of size which the uterus has to undergo during pregnancy, but is the result of the structure in which they ramify, having already undergone these changes during a previous pregnancy. [13] Anatomical Description of the Human Gravid Uterus, &c.: by W. Hunter, M. D. [14] The axis of the brim of the pelvis runs in such a direction, that if a line were drawn from its centre, it would pass upwards and forwards through the umbilicus: the gravid uterus has its axis rarely or never inclined less than this, and usually much more, especially in multiparæ in whom the fundus is occasionally inclined so strongly forwards as to receive the name of pendulous belly. [15] We are inclined to think that the soft feel of the portio vaginalis is one of the earliest signs of pregnancy which can be detected by examination. Our attention was first drawn to it in an obscure case of early pregnancy, complicated with extensive disease, which we examined with Mr. Ingleby of Birmingham, and where we gave a wrong diagnosis, not considering the patient to be pregnant. If we had placed as much confidence in this symptom as we are now inclined to do, we should probably have formed a more correct view of the case. Since this we have, on several occasions, found that attending to this circumstance has considerably assisted us in determining cases of doubtful pregnancy at an early period. [16] This description is given according to the lunar not calendar months, of which there are necessarily ten during the forty weeks of pregnancy. [17] We are aware that the plan which we follow, in considering the development of the ovum, is very different to that usually adopted, and will probably be open to some objections on the score of defective arrangement; but it must be remembered that this is a work intended for students, where complete and perfect arrangement must, to a certain extent, be sacrificed in order to place an acknowledged difficult and complicated subject in the clearest and most intelligible light. We have, therefore, preferred describing first the coverings of the ovum during those periods of pregnancy at which they are most frequently seen, and shall delay its minute consideration until we come to the description of the foetus itself, the development of the one being so essentially connected with that of the other, as to render a separate description of them impossible. By this means the reader, by having the general details first brought under his notice, will be enabled to enter with more ease and advantage upon the consideration of those which are obscure and difficult. [18] Siebold's Journal für Geburtshülfe, vol. xiv. heft. 3. 1835. [19] On the Signs and Symptoms of Pregnancy, p. 133.: by W. F. Montgomery, M. D. In a note to the above quotation, the learned author very properly calls them _decidual cotyledons_, "for to that name their form, as well as their situation, appears strictly to entitle them: but from having, on more than one occasion, observed within their cavity a milky or chylous fluid, I am disposed to consider them reservoirs for nutrient fluids, separated from the maternal blood, to be thence absorbed for the support and development of the ovum. This view seems strengthened when we consider that, at the early periods of gestation, the ovum derives its support by imbibition, through the connexion existing between the decidua and the villous processes covering the outer surface of the chorion." [20] Observations by Dr. Baillie, in the posthumous work of Dr. W. Hunter, on the Anatomy of the Gravid Uterus. [21] Observations on Certain Parts of the Animal Economy, p. 134. [22] It has lately been supposed that the irregular nodules of wax in the Hunterian preparations were merely the result of extravasation, a rather hazardous conclusion against the authority of such men as the Hunters. Mr. J. Hunter has, however, expressly met this objection in the following observation:--"this substance of the placenta, now filled with injection, had nothing of a vascular appearance, or that of extravasation; but had a regularity in its form which showed it to be a natural cellular structure, fitted to be a reservoir for blood." (_Observations on Certain Parts of the Animal Economy_, p. 129.) [23] In offering these observations on the placenta, we have purposely quoted, wherever it was possible, from the admirable essays of the Hunter's, on this subject. These works, more especially that of Dr. W. Hunter, are becoming too scarce to be easily attained by the student; and yet it is more peculiarly important to this class of our readers, that they should not only be aware how much we are indebted to these illustrious men for what we know upon the subject; but also that they should be as familiar as possible with their very words and expressions. The essays in question are master-pieces of original observation and correct description, and we may safely assert, that the one by Dr. Hunter is so complete, as to leave us little or nothing more to be wished for on this subject. With such feelings we cannot conceal our surprise, to find that an author like Dr. Burns should have passed over the whole subject of the placenta without once alluding to the name of Hunter; this omission is the more marked in the last editions of his work, where he has furnished the reader with copious references, &c. in the notes. One would have thought that Dr. Burns would have felt pride in acknowledging the merits of his distinguished countrymen. [24] We said, "_one_ of the earliest changes." Mr. Jones considers that "the breaking up of the surface of the yelk into crystalline forms," is the first change which he has observed. [25] Allen Thomson on the Development of the Vascular System in the Foetus of Vertebrated Animal. (_Edin. New Philosop. Journ._ Oct. 1830.) [26] Pander. Beiträge zur Entwickelungs-gesechichte des Hünchens im Eie. Würzburg, 1817. [27] In making these observations upon the formation of the ductus arteriosus, we must request our readers to consider this as still an unsettled question. [28] The vernix caseosa is a viscid fatty matter of a yellowish white colour, adhering to different parts of the child's body, and in some cases in such quantity as to cover the whole surface; it seems to be a substance intermediate between fibrine and fat, having a considerable resemblance to spermaceti. From the known activity of the sebaceous glands in the foetal state, and from this smegma being found in the greatest quantity about the head, arm-pits, and groins, where these glands are most abundant, there is every reason to consider it as the secretion of the sebaceous glands of the skin during the latter months of pregnancy. [29] Fourcroy, it is true, has shown that the foetal blood is not only of a darker colour, but incapable of becoming reddened by the contact of atmospheric air, and that it coagulates very imperfectly. Others have shown that there is no perceptible difference in the colour of the blood of the umbilical arteries from that of the umbilical vein. Still, however, this by no means disproves what we have now stated, and which is now generally allowed to be the office of the placenta during the latter periods of pregnancy. [30] "A gentleman," says Dr. Montgomery, "lately informed me that, being afflicted with a stepmother naturally more disposed to practise the _fortiter in re_ than to adopt the _suaviter in modo_, he and all the household had learned from experience to hail with joyful anticipations the lady's pregnancy, as a period when clouds and storms were immediately changed for sunshine and quietness." (_Exposition of the Signs and Symptoms of Pregnancy_, p. 9.) [31] _Dionis_ says, that "women of a sanguine complexion, who form more blood every month than is necessary for the nourishment of the foetus whilst it is small, discharge the overplus by the vessels which open into the vagina during the first months." [32] The menstrual blood is more pale and sparing: it usually comes from the hæmorrhoidal vessels of the vagina, or at most, from those of the cervix uteri. (Levret, _Art des Accouchemens_, § 233.) [33] Should the vessels of the cervix uteri take upon them the secretion of the menses, this discharge can thus continue through pregnancy. (Carus, _Lehrbuch der Gynakologie_, bd. ii. p. 67.) [34] L'Art d'Accouchemens, § 369. (note;) also Deventer, Novum Lumen Obstet. chap. xv.; Perfect's Cases of Midwifery, vol. ii. p. 71. [Meurer, American Journ. Med. Sc., April 1841, p. 494.] [35] This fact was observed so long ago as by Aristotle, also by Schenk, as quoted by Mauriceau, lib. i. chap. 1. Mauriceau himself mentions having seen several cases, one of which forms the subject of his 393d observation. "Le 8 Juin, 1685. J'ai vu une jeune femme agée seulement de seize ans et demi, marié depuis un an qui était grosse de cinq mois ou environ, quoiqu'elle n'eut jamais eu ses menstrues, à ce qu'elle me dit aussi bien que son marie, qui ne pouvait pas se persuader qu'elle cût pû devenir grosse, n'ayant pas encore eu ce premier signe de fécondité; m'alleguant, pour soutenir son opinion, qu'on ne voyait jamais de fruit d'un arbre qui n'eut été précédé de sa fleur. Mais je lui dis qu'il était certain, comme il reconnut bien par sa propre experience en voyant accoucher sa femme d'un enfant vivant quatre mois ensuite, que les jeunes femmes pouvaient bien quelquefois devenir grosses, ainsi qu'il était arrivé à sa femme, sans avoir jamais eu leur menstrues, si elles usaint du coit dans le temps méme quelles étaient sur le point d'avoir effectivement cette evacuation naturelle pour le premier fois." [36] Roederer, Elm. Art. Obst. p. 46. The original is a masterly specimen of description, not less remarkable for its singular comprehensiveness than the beauty of the style. "Menstruorum suppressionem mammarum tumour insequitur, quocirca mammæ crescunt, replentur, dolent interdum, indurescunt; venæ earum coeruleo colore conspicuæ redduntur; crassescit papilla, inflata videtur, color ejusdem fit obscurior; simili colore distinguitur discus ambiens qui in latitudinem majorem expanditur, parvisque eminentiis quasi totidem papillulis tegitur." [37] "In women with dark eyes and hair, this discolouration is very distinct; in women with light hair and eyes, it is often so slight that it is difficult to tell whether it exists or no."... "In brunettes who have already borne children, the areola remains dark ever afterwards, so that this ceases to be a guide in all subsequent pregnancies." (Gooch, _on some of the more important Diseases of Women_, p. 201 and 203.) [38] We had, at the moment of writing the above, a patient just recovered from her first labour, in whom the discolouration extended nearly over the whole breast: it was darker in some spots than in others, and presented a variety of shades not unlike a large bruise of some days' standing. Dr. Montgomery mentions a case where the areola was almost black, and upwards of three inches in diameter. A similar case occurred not long since. [39] Bibliothèque Universalle, t. ix. p. 248; also in the Isis for 1819, part iv. p. 542. [40] "Mémoir sur l'Auscultation appliquée à l'étude de la Grossesse, ou Recherches sur deux nouveaux Signes propres à faire reconnaïtre plusieurs Circonstances de l'Etat de Gestation; lu à l'Academie Royale de Médecine dans la Séance Générale du 26 December, 1821. Par J. A. Lejumeau de Kergaradec." [41] Dr. Evory Kennedy, Observations on Obstetric Auscultation, &c. 1833. [42] H. F. Naegelé, Die Geburtshülfliche Auscultation, 1838; also Dr. Corrigan, Lancet. [43] Die Geburtshülfliche Exploration, von Dr. A. P. Hohl. [44] This sign of pregnancy has very recently excited some attention, and the researches of M. Tanchou of Paris, (see _American Journ. Med. Sc._ Feb. 1840, p. 483,) Golding Bird, (_Ibid._, Aug. 1840, p. 501,) and Drs. McPheeters and Perry, (_American Medical Intelligencer_, March 15th, 1841, p. 350,) conclusively establish, that taken in connexion with other symptoms, it forms a very valuable aid to diagnosis. The following is the description given by M. Tanchou of the changes which the urine during pregnancy exhibits, and of the characters by which its peculiar ingredient, named by M. Nauche _Kiesteine_, may be recognised. The urine of a pregnant woman, collected in the morning, is usually of a pale yellow colour and slightly milky in appearance; it is not coagulable by heat, or by any of the tests which indicate the presence of albumen. Left to itself and exposed to the air after the first day, there begins to appear suspended in it a cottony-looking cloud, and, at the same time, a flocculent whitish matter is deposited at the bottom of the fluid. These phenomena are not of constant occurrence, and, moreover, healthy urine sometimes exhibits analogous phenomena. From the second to the sixth day, we perceive small opaque bodies rise from the bottom to the top of the fluid; these gradually collect together so as to form a layer which covers the surface: this is the _kiesteine_. It is of a whitish or opaline colour, and may be very aptly compared to the layer of greasy matter which covers the surface of fat broth, when it has been allowed to cool. Examined by the microscope, it exhibits the appearance of a gelatinous mass, which has no determinate form. Sometimes small cubical crystals can be perceived in it, when it has become stale. The _kiesteine_ continues in the state we have now described, for three or four days; the urine then becomes muddy, and minute opaque bodies detach themselves from the surface and settle at the bottom of the vessel: the pellicle thus becomes soon destroyed. The characteristic feature, therefore, of the urine during pregnancy consists in the presence of _kiesteine_. It deserves, however, to be noticed, that the urine, in some cases of extreme phthisis pulmonalis, and also of vesical catarrh, will be found to exhibit on its surface a layer or stratum which is not unlike to that now described as peculiar to the state of pregnancy. But with proper attention we may easily avoid this mistake. The stratum, in the cases alluded to, does not appear so quickly on the surface of the urine as the _kiesteine_ does; and also, instead of disappearing, as it is found to do, in the course of a few days, it (the former) goes on increasing in thickness, and ultimately becomes converted into a mass of mouldiness. Of twenty-five cases, in which M. Tanchou detected the presence of _kiesteine_ in the urine, seventeen occurred in women who were pregnant from four to nine months, four in women who had not quickened, and who considered themselves as labouring under disease of the womb, and the remaining four in patients who had been under treatment for casual complaints--one for sciatica at the Hôtel Dieu, another for ascites in the city, a third for an ulcer in the neck at La Pitié, and the last had been cauterized twice a week for a pretended disease of the uterus. In none of these cases had the existence of pregnancy been suspected, although in every one of them the fact was soon placed beyond doubt.--EDITOR. [45] Baudelocque wrote an account of it to Professor Naegelé of Heidelberg, from whom we received the particulars. [46] See Treatise on the Diseases of Females, 6th ed. p. 46. Ed. [47] Ovum deforme, in quo partes embryonis et secundarum distingui vix possunt, molam vocabimus. (Roederer, _Elementa Artis Obstetricæ_, § 738.) [48] Dr. J. Y. Simpson on the Diseases of the Placenta. (_Edin. Med. and Surg. Journal_, April 1, 1836.) [49] "One must be careful not to mistake these clots of blood, which being washed by the reddish serosities which flow from the womb, harden in the vagina, or womb itself, and look exactly like false conceptions." (_La Motte._) "Every mole is a blighted ovum which has been the product of conception. We are not justified in classing under the head of moles every mass which is produced and lodged within the uterus." (Froriep's _Handbuch der Geburtshülfe_, § 180.) [50] Our friend, Dr. Nebel, of Heidelberg, has a preparation of a foetus which was retained for fifty-four years in the abdomen. This is the longest period on record of a foetus being retained in the cyst of a ventral pregnancy. Many other cases have been described. (See _Burns_, 9th edition, where the notes contain very ample references.) [51] We had lately a case of this kind. The patient had been under our care for inflammation of the cervix uteri. There was that general enlargement of the uterus which attends this condition; and, on endeavouring to lift a heavy weight, she was seized with violent pain in the pelvis, great difficulty in passing fæces and urine, and, on examination, the uterus was found retroverted. The bowels were well opened with castor oil, and in a day or two it recovered its natural position. [52] Dr. W. Hunter has evidently taken the same view of the case, and invariably considers retention of urine as an effect, not the cause, of this displacement. (_Med. Observ. and Inq._ vol. iv.) [53] We were once misled in a case of this description. The os uteri lay close behind the symphysis pubis, and its opening, as well as so much of the neck as we could feel, looked straight downwards. We were unable to pass the finger sufficiently high to trace the continuity between the neck of the uterus and tumour in the hollow of the sacrum formed by the fundus; and the haggard aged appearance of the woman put all suspicion of pregnancy out of our mind. [54] Dr. Burns makes a similar observation. "In most cases the cervix will be found more or less curved; so that the os uteri is not directed so much upwards as it otherwise should be." (_Principles of Midwifery_, p. 281. 9th edit.) [55] "Sometimes it is perhaps better to introduce the fingers into the vagina only, and not into the rectum, not merely because, we can act better and more directly upon the uterus here, but also because if we press the posterior wall of the vagina upward towards the sacrum, and thus stretch the upper part of it which is between the fingers and the os uteri, it will act upon the uterus like a cord upon a pulley, and greatly favour its rotation." (Richter, _op. cit._ vol. vii. sect. 57.) [56] Among others, we may mention an exceedingly interesting case recorded by Mr. Baynham, in the _Edin. Med. and Surg. Journ._ April, 1830. The real nature of the case was not ascertained for six weeks, the catheter only being used night and morning. Even when the bladder was empty, the fundus resisted every attempt to return it. The most prominent part of the tumour in the rectum was punctured with a trocar, and about twelve ounces of liquor amnii, without blood, were drawn off: the reduction followed in about a quarter of an hour. A full opiate was given, and the patient passed a better night than she had done before. Twenty-five hours after the operation, the foetus, was expelled; it was fresh, and about the size of a six months' child. The patient recovered. [57] Dr. Cheston's case, where the child was afterwards carried the full time, and born alive. (_Med. Communications_, vol. ii. p. 6.) [58] Merriman, Med. Chir. Trans. Vol. xiii. p. 338. [59] Exposition of the Signs and Symptoms of Pregnancy: by W. F. Montgomery M. D. p. 253. [60] Dewees, Compendious System of Midwifery, sect. 408. A similar case is recorded by Dr. Montgomery. [61] "Qui inter septimi et noni mensis, à prima conceptione, finem contingit partus, _præmaturus_ vocatur: _abortus_ vero quando ante dictum tempus embryo excidit; id quod circa tertium graviditatis mensem ut plurimum accidit. Vitalem esse præmaturum foetum observatio nos docet, embryonem autem non manere superstitem constat." (Roederer, _Elem. Artis Obst._ cap. xxiii. § 716.) [62] During the great influenza epidemic, abortions were remarkably frequent. [63] This is nearly the same arrangement which has been followed by Dr. Copland, in the article ABORTION, in the Dict. Pract. Med. [64] This crotchet consists of a piece of steel of the thickness of a small quill at its handle, and gradually tapered off to its other extremity which is bent to a hook of small size. (See accompanying figure which represents the instrument one third the natural size.) [Illustration] This instrument is highly useful in cases in which the flooding continues after the ovum has been broken and its contents expelled. A portion of the involucrum sometimes insinuates itself into the neck of the uterus, and prevents the degree of contraction necessary to interrupt farther bleeding. This accident most frequently attends the earlier abortions. As hæmorrhage is maintained by the cause just named it suggests the propriety of never breaking the ovum; especially before the fourth month. When the flooding is maintained by this cause, it will not cease but upon the event of its removal. This condition of the placenta and neck of the uterus is easily ascertained by an examination; it will readily be felt to be embraced by the neck of the uterus; and though a portion may protrude a little distance below the os tincæ, it cannot be extracted by the fingers; for the os uteri or cavity of the uterus will not be sufficiently large to permit the fingers to pass into it, that this mass may be removed; the crotchet should then be substituted; the mode of using it is as follows:--The fore-finger of the right hand is placed within or at the edge of the os tincæ; with the left we conduct the hooked extremity along this finger, until it is within the uterus; it is gently carried up to the fundus, and then slowly drawn downwards, which makes its curved point fix in the placenta; when thus engaged, it is gradually withdrawn, and the placenta with it. Dr. Dewees says, that in every case in which he has used this crotchet, the discharge instantly ceased. See Art. "ABORTION," by Dr. Dewees, in _American Cyclopedia of Pract. Med. and Surg._ Dr. Dewees "from some late experience is induced to believe" that "in cases in which we cannot command the removal of the placenta by the fingers--that is, when this mass continues to occupy the uterine cavity, or but very little protruded through the os tincæ," the administration of ergot, will often supercede the necessity of the crotchet. _Treatise on the Diseases of Females._ Sixth Edition, p. 351.--ED. [65] Dr. Dewees recommends the crotchet only where the flooding continues _after_ the ovum has been broken. See preceding note. ED. [66] "Clysteres injiciantur, quorum irritatione expultrix uteri facultas excitatur, et depleta intestina ampliorem locum utero relinquat." (Riverius, _Prax. Med. de Partu difficili_.) [67] [Dr. Dewees recommends the woman to be placed for labour on her left side at the foot of the bed, in such a manner as will enable her to fix her feet firmly against one of the bed-posts; her hips within ten or twelve inches of the edge of the bed; her knees bent, her body well flexed upon her thighs; her head and shoulders will then be near the centre of the bed, where pillows should be placed to raise them to a comfortable height. This is the position we believe in which the patient is very generally placed in the United States.--ED.] [68] [See an interesting paper "on Laceration of the Perineum during Labour; by Wm. M. Fahnestock, M. D.," in American Journal of the Med. Sc. for Jan. 1841. Editor.] [69] See a case of central perforation of the perineum, _Med. Gaz._ p. 782. Aug. 19, 1837. [70] "The practice of using force to hurry the shoulders and body of the child through the os externum as soon as the head was born, is very generally laid aside. There can be no doubt that this imprudent conduct often brought on a retention of the placenta." (See White, _on Lying-in Women_.) [71] "A ligature upon the navel string is absolutely necessary, otherwise the child will bleed to death; and when tied slovenly, or not properly, it will sometimes bleed to an alarming quantity. As we take such vast care to secure the navel string, you will naturally ask how brutes manage in this particular? I will give you an idea of their method of procedure, by describing what I saw in a little bitch of Dr. Douglas. The pains coming on, the membranes were protruded; in a pain or two more they burst, and the puppy followed. You cannot imagine with what eagerness the mother lapped up the waters, and then, taking hold of the membranes with her teeth, drew out the secundines; these she devoured also, licking the little puppy as dry as she could. As soon as she had done I took it up, and saw the navel string much bruised and lacerated. However, a second labour coming on, I watched more narrowly, and as soon as the little creature was come into the world I cut the navel string, and the arteries immediately spouted out profusely; fearing the poor thing would die, I held it to its mother, who, drawing it several times through her mouth, bruised and lacerated it, after which it bled no more. This, I make no doubt is the practice with other animals." (Dr. W. Hunter's _Lectures, MS. 1752_; from Dr. Merriman's _Synopsis_, p. 21. note.) [72] Carus's Gynakologie, vol. ii. p. 138. This assertion, however, must be qualified, somewhat, as we know of several cases where flooding has come on after labour during sleep. [73] "I have observed," says Dr. Hunter, "in women who do not give suck, and in nurses after they leave off suckling, that the axillary glands become painful, swell, and sometimes suppurate. Is not this owing to the acrimony which the milk has acquired by long stagnation in the breast, and affecting the gland through which it must pass in absorption? I have observed that they are at the same time liable to little fevers of the intermitting kind, which come on with a rigour, and go off with a sweat. Are not such fevers raised by absorption of acrid milk?" (Hunter's _Commentaries_, p. 59.) [74] [The best application we have ever tried, is the vinegar and water as is commended by Dr. Dewees. See his admirable chapter on Milk Abscess. _Treatise on the Principal Diseases of Females._--AM. ED.] [75] [Sore nipples is an affection, of so very frequent occurrence, often so exceedingly obstinate, and sometimes productive of such extreme torture to the patient, that some additional remarks relative to its treatment may be acceptable to the practitioner. The solution of nitrate of silver, two grains to the ounce of water, is highly extolled by MR. ALLARD (_American Journ. Med. Sc._ Feb. 1837,) and DR. CHURCHILL says that he has found it the most effectual application. (Diseases of _Pregnancy and Child-bed_.) This solution should be applied every time the child is taken from the breast, care being taken to wash the nipple previous to the next application of the child. We have frequently found this treatment very efficacious, but in some cases it entirely fails. Dr. Hannay says, that the solution is inferior to the solid nitrate of silver, and asserts that the latter never fails to afford relief and ultimately effect a cure. He uses it as follows. The nipple is to be gently and carefully dried, then freely touched with a sharp pencil of nitrate of silver, care being taken to insinuate the pencil into the chaps or chinks. The nipple is then to be washed with a little warm milk and water. The pain though smart soon subsides, and all that is necessary, according to Mr. H. to heal the sore, is a little simple ointment, or one made with the flowers of zinc. When the pain from the application is very severe, relief should be given by the administration of thirty drops of the solution of morphium. In some cases it is necessary to apply the caustic more than once. (_Am. Journ. Med. Sc._ Feb. 1835, p. 527.) DR. CHOPIN recommends repeated lotions with the solution of Chloride of Soda, which he says will often cure in one or two days. (_Am. Journ. Med. Sc._ May, 1836.) DR. BARD says that simply keeping a linen cloth _constantly_ wet with rum over the nipple is frequently very useful, and as it is one of the easiest remedies, it should be first tried. (_Compendium of the Theory and Practice of Midwifery._) Stimulating ointments, such as ung. hydrarg. rub. diluted with lard, is, according to BURNS, sometimes of service, as is also touching the parts with burnt alum, or dusting them with some mild dry powder. Solutions of sulphate of alumine and of sulphate of copper, of such strength as just to smart a little, are also recommended as occasionally of service by the last named practitioner. (_Principles of Midwifery_, 7th Ed. p. 543.) We have found Kreosote, three to six drops in an ounce of water, very efficacious; in some cases affording more speedy relief than any other application. The mucilage of the slippery elm applied cold is often a most comfortable application, and its efficacy is sometimes increased by dissolving in it some borax. When all these means fail, the mother must give up suckling for a time, when the parts heal rapidly. This last resource will not be often necessary. The great number of remedies which have been employed for the cure of this complaint sufficiently attest its obstinacy. This obstinacy is owing, in some cases, we conceive, to an irritable condition of the patient's system, a fact overlooked so far as we know, by most practitioners. In such cases a mild and nutritious diet, fresh air, keeping the bowels free, &c. will do more towards effecting a cure than local applications; though the latter even here are not to be neglected. Editor.] [76] [Dr. Dewees regards after-pains as an evil of magnitude, and always endeavours to prevent them as quickly as possible. For this purpose he recommends camphor or some preparation of opium. (See his _System of Midwifery_.) We have always adopted this practice to the great relief of the patient, and have never had cause to regret it. Dr. Dewees's observations on this subject should be attentively perused.--ED.] [77] See observations on MALPOSITION OF THE CHILD. [78] We have no words in the English language like the _schrag_ and _schief_ of the German to express these different species of obliquity. [79] On the other hand, Dr. Merriman observes, that he has "twice known the presentation of the face converted by the pains alone into a natural presentation." (_Synopsis_, p. 48.) [80] According to the results of Dr. Collins's experience at the Dublin Lying-in Hospital, the face presented once in about every 504 cases; but as, in several labours, the presentation was not noted on account of their rapidity, the proportion is probably larger. [81] Madame La Chapelle calls this the _courboure des bords_, to distinguish it from the head curvature, _courboure des faces_ (p. 61.) [82] A Treatise on the Improvement of Midwifery, chiefly with regard to the Operation: by Edmund Chapman, 2d edit. 1735. [83] [Dr. Dewees, prefers, in all cases, the long forceps. See the chapters on the Forceps in his _System of Midwifery_. Ed.] [84] See Midwifery Hospital Reports, case of Mrs. Worsley, May 3, 1834, p. 187. [85] Another circumstance is humanely insisted on by Madame la Chapelle with much propriety: "Je ne manque jamais de fair voir le forceps à la femme, et de lui expliquer à-peu près son usage, et sa façon d'agir. Il n'en est aucune que cette démonstration ne tranquillise, et j'en rencontre souvent qui à leur deuxieme accouchement sollicitent l'application du forceps qu'elles ont vu mettre en usage pour les débarasser du premier." (_Pratique des Accouhemens_, p. 64.) [86] Madame la Chapelle confirms this mode of introducing the forceps: "Pour moi, je l'introduis constamment sur le ligament sacro-sciatique." (_Pratique des Accouchemens_, p. 66.) [87] "Quand une fois la tête est hors les parties osseuses, elle ne retrograde plus, je les dêsarticule (the blades) avec la clef placée entre elles en forme de lévier; je les extrais en les inclinant graduellement, car souvent l'extraction un peu brusquée d'une branche produit l'expulsion de la tête." (_La Chapelle._) [88] "Mon avis est que la choix n'est point _nécessaire_ quand l'uterus est encore rempli d'eau, et que la position est douteuse. En pareil cas je conseillerais même plutôt de faire usage de la main droite, quoique, pour mon compte, l'habitude m'ait rendu l'usage aussi familiar que celui de l'autre." (Mad. la Chapelle, _Prat. des Accouch._ p. 88.) [89] "Une chose très importante à observer quand on se trouve contraint par la perte de sang à en venir à l'opération, et que les eaux ne sont point encore ouvertes, c'est de couler la main tantôt à droit, tantôt à gauche le plus haut et le plus doucement qu'il est possible de long les membranes qui contiennent les eaux sans les rompre, jusqu' à ce qu' on ait trouvé les pieds de l'enfant pour s'en saisir. Car s'il arrive qu'elles se rompent avant qu'on ait pris cette précaution, pendant qu'on les cherche, les eaux s'écoulent, les sang se perd, a la matrice se referme en partie, et l'opération devient par-là plus difficile et plus dangereuse." (_Pratique des Accouchemens_, p. 277.) [90] Traité des Accouchemens, 1770. § 691. "Pour moi, j'ai toujours au contraire trouvé un grand advantage à insinuer la main jusqu'aux pieds de l'enfant, et à n'ouvrir les membranes qu'en saisissant ces derniers." (_La Chapelle_ p. 90.) [91] "We must by no means burst the bag of liquor amnii until the hand has passed up between the membranes and the uterus. Every movement is easy whilst there is fluid in the uterus: hence, therefore, we must not withdraw the hand until we have fairly gained the feet and brought them down; for otherwise the waters escape, the uterus contracts, and the rest of the operation is more difficult." (_Boer_, vol. iii. p. 17. note.) [92] "Je suis loin de prétendre, avec Puzos, que la traction sur un seul pied ait les avantages récis." (_La Chapelle_, p. 93.) [93] "Dans tous ces accouchemens je laisse le plus souvent agir la nature, et je le fais avec bien plus de sécurité quand je sçais que la femme a accouché précédemment et fort aisément d'enfans volumineux, quand je reconnois son bassin pour avoir toutes les dimensions requises, quand les contractions de la matrice sont bonnes." &c. (_Traité des Accouchemens_, § 674.) [94] Ueber die künstliche Wendung auf den Steiss, in the Heidelberg Klin. Annalen, vol. ii. part i. p. 142. [95] Traité des Hernies, contenant une ample Déclaration, &c., par Pierre Franco de Turriers en Provence, demeurant à presént à Orange: à Lyon, 1561. [96] See DYSTOCIA FROM MALPOSITION OF THE CHILD. [The student who desires to investigate this subject farther, may consult Dr. Churchill's _Researches on Operative Midwifery_. Essay ii. on Version.--AM. ED.] [97] [Prof. Gibson has operated twice on the same patient, and both times successfully, for mother and children. See _American Journal_, for May 1838.--ED.] [98] [Dr. Churchill has collected the statistics of 409 cases of Cæsarean section, of which number, 228 mothers were saved; and 181 lost, or about 1 in 2-1/4: and out of 224 children, 160 were saved, and 64 lost--or about 1 in 3-1/2. Of the above cases, 40 occurred in the practice of British practitioners, of which, 11 mothers recovered, and 29 died; or nearly three fourths--and 37 cases, in which the result to the child is mentioned, 22 were saved, and 15 lost--or 1 in 2-1/2. Of 369 cases in the practice of Continental practitioners, 217 mothers recovered, and 152 died, or 1 in 2-1/3--and out of 187 cases, where the result to the child is given, 138 were saved, and 49 lost; or nearly 1 in 4. _Researches on Operative Midwifery._ By F. Churchill, M. D., Dublin, 1841. Editor.] [99] [The propriety of an early resort to the Cæsarean section, in cases where it is necessary, has been very properly insisted upon; but the circumstances which render it necessary, are not always readily determined. M. Castel states, that in a case at the _hospice de perfectionnement_, in which the operation was determined on, some delay became necessary in order to find accommodation for the crowd of students who collected to witness it, and before this could be effected the woman was delivered naturally. M. Gimelle says, that at the hospital of M. Dubois, a small woman, who had five times submitted to the Cæsarean section, was delivered naturally the sixth time. _Am. Journ. Med. Sc._ Aug. 1838. Ed.] [100] For the particulars of this interesting case we must refer our readers to the British and Foreign Med. Review, vol. ii. p. 270; and also to vol. iv. p. 521. [Also to _American Journal Med. Sc._, August, 1838, p. 526, and Nov. 1837, p. 244.--ED.] [101] [Those who desire farther information on this subject, may consult, with advantage, Dr. Churchill's Researches, already quoted.--ED.] [102] Dr. Macauley was physician to the British Lying-in Hospital, in Brownlow Street, and colleague of Dr. W. Hunter. [103] Barlow, Medical Facts and Observations, vol. viii. Although we are in great measure indebted to Dr. Denman for having brought this operation into general notice, it is to the late Professor May, the father-in-law of Professor Naegelé, that the merit is due for having first pointed out the advantage of exciting uterine contraction before rupturing the membranes. (_Programma de Necessitate Partûs quandoque præmature, vel solo Instrumentorum adjutorio promovendi._ Heidelberg, 1799.) [104] [The student who desires to investigate this subject farther, is referred to Dr. Churchill's Researches on Operative Midwifery, and a copious analysis of his Essay on Premature Labour, in the _American Journ. Med. Sc._ for Nov. 1838, p. 172, also to the Nos. of the Journal just named, for Feb. 1838, p. 516, November 1839, p. 237, and July 1841, p. 226. Editor.] [105] "The scissors ought to be so sharp at the points as to penetrate the integuments and bones when pushed with moderate force, but not so keen as to cut the operator's fingers or the vagina in introducing them." (_Smellie_, vol. i. chap. 3. sect. 7. numb. 2.) [106] [Dr. Churchill who has collected the statistics of this operation, states, that in 334,258 cases of labour, the crotchet has been used in 343, or 1 in 974-1/2. Of this number, 41,434 cases of labour occurred to British practitioners; in which, there were 181 crotchet cases, or about 1 in 228. Among the French, 36,169 cases of labour; of which there were 30 crotchet cases, or 1 in 1,205-2/3. And among the Germans, 132 crotchet cases, in 256,655 labours, or 1 in 1,944-1/3. Of 251 cases, in which the result to the mother is given, the mortality was 52, or about 1 in 5. (_Op. Cit._) Editor.] [107] The above arrangement is that which is given by Professor Naegelé, in his _Lehrbuch der Geburtschülfe_. [108] _Pratique des Accouchemens_, p. 21. "Je puis assurer n'avoir jamais rencontré aucune position du col, ni du tronc proprement dit." (p. 19.) [109] Merriman's Synopsis of difficult Parturition, last edition, p. 69. The elongated form of the protruded bag of membranes is, however, by no means a constant occurrence, as cases frequently occur where nothing of the kind has appeared. [110] Boer's _Naturliche Geburtshülfe_, b. iii. p. 64. A case of actual evolution has also been described by Mr. Barlow, p. 399. [111] Med. Chir. Trans., case by Dr. Smith, of Maidstone. See also an interesting case by Professor Naegelé, in the British and Foreign Medical Review, where the uterus was ruptured by sudden violence, part of the child was delivered per vaginam, the rest by an abscess through the abdominal parietes. No. x. April, 1838. [112] Lassus, Pathologie Chirurgicale, tom. ii. p. 237, quoted by Dr. M'Keever, _op. cit._ p. 27. [113] Collins, _op. cit._ p. 277. An interesting case of rupture at the sixth month, is recorded by Mr. Ilot, of Bromley, in the seventh volume of the Medical Repository, and quoted by Dr. Merriman, who has also given another at the eighth month by Mr. Glen, p. 268. See also an interesting case in the Brit. and For. Med. Rev. for October, 1838, p. 539. [114] [Another case is recorded by Dr. Carmichael, of Dublin. See _Amer. Journ. Med. Sc._, May 1840, p. 236.--ED.] [115] The late Professor Young, of Edinburg, has described a case of this sort in his lectures: he distinctly "heard the head crack, and a large quantity of fluid came away." [116] Observationes Anatomicæ, 52. A similar case has been recorded by Dr. Wrangel, in the Archiv. der Gesellschaft der Correspondirenden Aerzte zu St. Petersburg. When called to the case, the forceps had been already applied by a colleague, but could not be locked, owing to the enormous tumour of the head. A doughty swelling was felt between the blades of the forceps, of such a size that he could only just reach the cranial bones. He made pretty strong traction twice, when unluckily the instrument slipped off; it seemed, however, to have brought the head so much lower, that the child was delivered in ten minutes afterwards by the natural efforts: it was dead. A sac filled with serous fluid, and as large as the head itself, was attached to the occiput; it was covered by the cranial integuments, and in ten hours afterwards, as the fluid had found its way through the open sutures into the cranial cavity, the tumour had the appearance of a hydrocephalus. [117] Quoted by Dr. Lee in the Med. Gazette, Dec. 25, 1830, from the Journ. Gén. de Méd. tom. xliii. xlv. [118] Merriman's Synopsis, p. 216.; also Dr. J. Y. Simpson's fifth case of fatal peritonitis, in Edin. Med. and Surg. Journ. No. cxxxvii. The patient had suffered under four different attacks of venereal disease. Some interesting cases have been published in the Neue Zeitschrift für Geburtskunde, band vii. heft 1. by Dr. Bunsen of Frankfort and Dr. Kyll of Cologne. In almost every case of great accumulation of liquor amnii, the child was dead, hydrocephalic, or with ascites and in many the placenta was diseased. [119] [Dr. Churchill has given a table of the length of the umbilical cord in 500 cases. In 127 of these, the cord was 18 inches long, in 77 cases 24 inches, and in 45 cases 20 inches long. The extremes were 12 and 54 inches. _Op. Cit._--ED.] [120] In a case of this sort Mauriceau says, "Ce noeud étoit extrémement serré: mais cela ne s'etoit fait seulement que dans la sortie de l'enfant; car s'il eût été long-temps serré de la sorte dans le ventre de la mère, l'enfant auroit certainement peri; à cause que le mouvement du sang que lui étoit nécessaire, auroit été entièrement intercepté dans ce cordon. J'ai encore accouché depuis ce temps la, sept autres femmes, dont les enfans qui étoient tous vivans, avoient pareillement le cordon noüé d'un semblable noeud qui s'étoit fait de la même manière, par l'extraordinaire longueur de leur cordon." (_Obs._ 133.) [121] [Dr. Zollickoffer, of Middleburg, Md., relates two cases, in each of which there was a knot upon the cord without any injury to the children. _American Journal, Med. Sc._ July 1841, p. 109.--ED.] [122] Van Swieten, in his Commentaries on Boerhaave, gives a remarkable instance of its occurring twice in the same patient, so as to destroy the child. "I had occasion to see two instances of the birth of a dead child in one lady of distinction, where every thing was exactly and rightly formed; only the navel string was, towards the middle, twisted into a firm knot, so that all communication between the mother and foetus had been intercepted. The umbilical rope seems to have formed by chance a link, through which the whole body of the foetus passed, and afterwards, by its motion and weight, had drawn the knot, already formed, into such a degree of tightness, that the umbilical vessels were entirely compressed; for when the knot was loosened out, all that part of the navel string which was taken into the knot was quite flattened." (Vol. xiii. § 1306.) [123] One of the most remarkable cases of extreme pelvic deformity from mollities ossium is described by Professor Naegelé in his Erfahrungen und Abhandlungen. The patient was the mother of six living children when she was attacked with the disease: the seventh, after great difficulty, was born dead, and the eighth was delivered by the Cæsarean operation, which proved fatal. The spine was pressed so downwards, that the third lumbar vertebra was opposite to the superior edge of the symphysis pubis; the distance of the left ramus of the pubes from the fourth lumbar vertebra was only 2-1/2 lines; the transverse diameter of the inferior aperture only 1 inch 9 lines. For the farther details of this interesting case we may refer to our published lectures on this subject. A similar and highly interesting case has been recorded by Mr. Cooper, and communicated by Dr. Hunter in the Medical Observations and Inquiries, vol. v. The patient's first three labours were rather easy; in the beginning of her fourth pregnancy she had a violent rheumatic fever, which continued about six weeks; from this time she never enjoyed good health and suffered constantly from rheumatic pains over her whole body: these were followed by laborious respiration, and gradual distortion of spine: her fourth labour was accomplished with much difficulty. During her fifth pregnancy the distortion continued to increase. In her sixth and seventh labours the pelvis was found much contracted, so much so in the last as to require perforation. In her eighth labour the pelvis then appeared to be somewhat less than 2-1/2 inches from the symphysis of the ossa pubis to the superior and projecting part of the os sacrum, and otherwise badly formed. Embryotomy was again performed. She had become much more deformed and helpless, but in three years afterwards she was again pregnant. "She now appeared to be little more than an unwieldy lump of living flesh." The antero-posterior diameter was now only 1-1/4 inch, becoming gradually narrower at each side. The Cæsarean operation was performed with a fatal result. On examination after death, the rami of the ischium were found "little more than half an inch asunder." [124] [A second case has been recorded by Dr. Schultzen, see _American Jour. Med. Sc._ July 1841, p. 238.--Ed.] [125] "Mechanical obstruction to the progress of labour, is sometimes produced by thus fatiguing the woman with continual walking. I have known the whole of the cellular substance lining the pelvis so much distended by oedematous tumefaction, as to make the pelvis greatly narrowed in its capacity, which repose for some hours has diminished, or entirely removed." (Merriman's _Synopsis_, p. 18. last edit.) [126] Mr. Barlow has attempted to form a synoptical table of pelvic distortion. Thus, he says, where the antero-posterior diameter of the brim is from 5 to 4 inches, delivery can be effected by the efforts of nature alone; where from 4 to 3 or 2-3/4 inches, delivery may take place by the efforts of nature, or assisted by the crotchet, or lever; from 2-3/4 to 2-1/2 inches, it requires artificial premature delivery; from 2-1/2 to 1-1/2 inches, embryulcia; and from 1-1/2 inch to the lowest possible degree of distortion, the Cæsarean operation. [127] For many of the above observations we are indebted to an admirable article upon the subject by our friend, Professor Naegelé, jun., in the _Medicenischen Annalen_, band ii. heft 2. [128] Dr. Merriman has detailed two interesting cases, which were terminated by the natural powers. In the first (p. 59,) the patient died afterwards, a small laceration having taken place in the vagina; the other appears to have arisen from an unruptured state of the hymen, which was of unusual thickness; (see Appendix II.) The case did well. [129] For much valuable information on this subject, as also for several interesting cases, we gladly refer to Facts and Cases in Obstetric Medicine, by our friend Mr. Ingleby, of Birmingham; a practical work of great value. [130] [The following very singular case of tumour of the pelvis is recorded by Professor D'OUTREPONT, of Würtzburg. A woman, twenty-six years old and well made, gave birth when twenty-five years of age to her first child without difficulty. Towards the end of her second pregnancy she again applied at the hospital in consequence of experiencing pain in the pelvic region. Vaginal examination discovered a hard and painful tumour, extending from the inner surface of the left ischium nearly to the corresponding point on the opposite side. It was hard, globular, even on its surface, and occupied the ascending ramus of the ischium and the descending ramus of the pubis, and extended over the obturator foramen. It was impossible to reach the lower segment of the uterus, or to feel any part of the child. The size and hardness of the tumour seemed to leave no chance of the birth of a living child, even by the induction of premature labour. Professor D'Outrepont, who doubted whether the tumour was fibro-cartilaginous, or a true bony exostosis, asked the opinion of many eminent men who saw the case. They did not express themselves with certainty as to its nature, and the patient refused to allow an experimental incision to be made into the tumour. A short time before labour began, the tumour was thought to have become slightly compressible. When labour commenced, the professor called a consultation in which it was determined that unless a great change had taken place in the character of the tumour, an attempt should be made to remove it, or to cut away the bone if that should be found to be implicated, and as a last resource, to perform the Cæsarean section. On an examination being made, the right foot of the child was found to present, the cord was prolapsed, and did not pulsate. The tumour, however, was found to be so much softened that it was possible to pass three fingers through the outlet of the pelvis. Professor D'Outrepont brought down the foot, in doing which, he found that the hips had compressed the tumour still more. The chief difficulty was experienced in extracting the head by means of the forceps, which gave the patient considerable pain. The child was still-born, but was speedily recovered. After the birth of the child, the tumour regained its former size, so that the placenta could not be expelled by the natural efforts, and it was necessary to introduce the hand in order to remove it. The patient recovered rapidly, and returned ten weeks after her delivery, in order to have the tumour removed, which operation was performed by Professor Textor. The growth was found to be fibro-cartilaginous, and was connected neither with the bone nor the periosteum. It weighed 11-1/2 ounces, and was so hard that none but they who were present at the patient's delivery, could have believed its previous softening possible. The patient was completely cured.--ED.] [131] A sudden drink of cold fluid will generally excite contractions of the uterus, owing to the close sympathy which exists between it and the stomach. A couple of ounces, at most, will be sufficient for this purpose, if swallowed quickly; a larger quantity not only fails of its effect, by oppressing the stomach, but, by filling it with fluid, renders almost inert any stimuli or medicines which may afterwards be required. [132] "Cold injections," says Dr. Young, "should be thrown into the uterus, and repeated ten or twelve times; as on this the success depends." (_MS. Lectures._) [133] Essay on Inversion of the Uterus. Dublin Journal for September and November, 1837, quoted by Dr. Churchill on Diseases of Females, p. 317. [134] Midwifery Hospital Reports. Med. Gazette, May 31, 1834; also Aug. 26, 1837. [135] "I have reason to believe that a placenta which is entire and uninjured, which is enclosed in the uterus, adherent to it, and shut out from access of air, _never becomes putrid_." (Matthias Saxtorph, _Gesamm. Schriften_.) [136] [An interesting memoir on retained placenta, by Dr. Edward Warren, of Boston, will be found in the _American Journal of Med. Sc._ May, 1840, p. 71.--ED.] [137] Dr. Churchill observes, "I have found, in several cases of prolapse, that the placenta was situated low down on the side of the uterus, and in some few others that the funis was inserted into the lower edge of the placenta." (_Edin. Med. and Surg. Journal_, Oct., 1838.) [138] [Dr. Churchill in his _Researches on Operative Midwifery_, subsequently published, has collected the results of 92,017 deliveries, in which there was prolapse of the cord, in 333 cases, or 1 in every 276-2/3.--ED.] [139] [A figure of this instrument is given in Dewees' Midwifery, Pl. XVIII. and the method of using it fully described.--ED.] [140] In the edition which has been translated into English, A. D. 1612, it is the _twelfth_ chapter. [141] We subjoin the passages to which we have referred in the three above mentioned cases:-- Case 115. "I cannot implicitly accede to the opinion of roost writers in midwifery, which is, that the placenta always adheres to the fundus uteri; for in this, as well as many former instances, I have good reason to believe that it sometimes adheres to or near the os internum, and that the opening of it occasions a separation, and consequently a flooding." Case 116. "The first thing I met with was the placenta, which I found closely adhering round the os internum of the uterus, which, among other things, is a proof that the placenta is not always fixed to the bottom of the uterus, according to the opinion of some writers in midwifery. Its adhering to the os internum was, in my opinion, the occasion of the flooding; for as the os internum was gradually dilated, the placenta at the same time was separated, from whence proceeded the effusion of blood." Case 224. "It is generally believed that the ovum, after its impregnation and separation from the ovarium, and its passing through the tuba Fallopiana, always adheres, and is fixed, after some time, to the fundus uteri; in this case the placenta adhered, and was fixed close to and round about the cervix uteri, as I have found it in many other cases, so that upon a dilatation of the os uteri a separation has always followed, and hence a flooding naturally ensues." [142] The second edition of Roederer's admirable _Elementa Artis Obstetriciæ_, which was published by his distinguished successor, Wrisberg, in 1766, three years after his death, is that which is chiefly known, although it never had an extensive circulation in this country. The means of communication with the Continent at that time were very different to what they are at present; and although none can regret more than ourselves that Roederer's work should have passed unnoticed in Dr. Rigby's _Essay on Uterine Hæmorrhage_, still we feel assured that the liberal portion of the medical world, whether in this or other countries, will not attribute this omission to a disingenuous suppression of his name, but rather to the more probable circumstances that, residing in a provincial town, and actively engaged in the arduous duties of an extensive country practice, Dr. Rigby had not enjoyed an opportunity of consulting the work; at any rate, we have good reasons to know that he never possessed it. [143] Not 1776, as stated by Dr. R. Lee. [144] Dr. Merriman has also recorded three cases of this kind, one of which occurred to himself; in this case "the placenta was expelled many hours before the child was born;" the mother died from puerperal fever. [145] [A very interesting account of puerperal peritonitis, as it prevailed in the Pennsylvania Hospital in 1833, is given by Professor H. L. Hodge, in the _American Journal Med. Sc._, for August, 1833, p. 325, et seq.--ED.] [146] This condition of parts bore the closest analogy to the state of the cellular membrane, so constantly observed in fatal cases of phlegmonoid erysipelas, or diffuse cellular inflammation. [147] [The student may consult, with advantage, Dr. Dewees's chapter on Phlegmasia Dolens, in his "Treatise on the Diseases of Females," also the observations of Dr. Mann, in the "Massachusetts Medical Communications," vol. ii., and the interesting paper, by Professor Walter Channing, in the same work, vol. v. p. 46.--EDITOR.] MEDICAL AND SURGICAL BOOKS. PUBLISHED BY LEA & BLANCHARD, PHILADELPHIA. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, EDITED BY ISAAC HAYS, M. D. SURGEON TO WILLS HOSPITAL, &c. &c. TERMS. 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In proof of this the author need but to remark, that he has found occasion to add several thousand medical terms, which are not to be met with in the only medical lexicon at this time in circulation in the country. The present edition will be found to contain many hundred terms more than the first, and to have experienced numerous additions and modifications. The author's object has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science." "To execute such a work requires great erudition, unwearied industry, and extensive research, and we know no one who could bring to the task higher qualifications of this description than Professor Dunglison."--_American Medical Journal._ "This is an excellent compilation, and one that cannot fail to be very much referred to. It is the best medical lexicon in the English language that has yet appeared. We do not know any volume which contains so much information in a small compass. The Bibliographical notices, though so short, are very important and useful; and altogether we can recommend to every medical man to have this work by him, as the cheapest and best dictionary of reference he can have."--_London Medical and Surgical Journal._ "So far as we have been able to examine this Dictionary, it is exceedingly thorough and correct, not only in matters purely medical, but in whatever can fairly be arranged in the various branches of science, collateral or contributary to Medicine and Surgery."--_Medical Magazine._ "So well known are the merits of this valuable work, that, in noticing a second edition of it, it will suffice to extract the remark of the author in the preface, 'that it will be found to contain many hundred terms more than the first, and to have experienced numerous additions and modifications.' It has been got up by the publishers in very handsome style, and must command, as it deserves, an extended circulation."--_Medical Examiner._ "It is wholly unnecessary, we apprehend, to enter into a long or formal statement of the fact, that Dr. Dunglison's Dictionary, from the first day of its appearance, has been regarded with peculiar favour. And we have now a revised edition, constructed under the immediate eye of the author, who is most favourably circumstanced for adding to the previous edition whatever could give it additional claims on the score of accuracy. Here are eight hundred and twenty-one pages, large octavo, in double colums, distinct type, of which no one ought to complain. Finally, although most of our readers may be owners of the first edition, we cordially and conscientiously recommend to all future purchasers to procure this in preference to any medical lexicon extant. Its true and sterling value as a key to medical science, and its moderate price, are so many common-sense recommendations which should not be forgotten."--_Boston Medical and Surgical Journal._ A NEW AND VALUABLE WORK FOR PHYSICIANS, APOTHECARIES, AND STUDENTS. NEW REMEDIES, _The Method of Preparing & Administering them_; THEIR EFFECTS UPON THE HEALTHY AND DISEASED ECONOMY, &c. &c. BY ROBLEY DUNGLISON, M. D. _Professor of the Institutes of Medicine and Materia Medica in Jefferson Medical College of Philadelphia; Attending Physician to the Philadelphia Hospital, &c._ IN ONE VOLUME, OCTAVO. "The value of this book is hardly to be estimated; to be without it, would be very much like obstinacy, and amount to the same thing as saying, like the Austrians in regard to their government, nothing can be improved, for we already live in a state of perfection. Dr. Dunglison, the author, has done an essential service to all classes of practitioners. It is creditable to the industry and wise discrimination of the author, and quite necessary to the libraries of those who feel the necessity of keeping pace with the improvements and discoveries in the broad but imperfectly exploded domain of medicine."--_Boston Medical and Surgical Journal._ _A Third Edition, Improved and Modified, of_ DUNGLISON'S HUMAN PHYSIOLOGY: _Illustrated With Numerous Engravings_. IN TWO VOLUMES, OCTAVO. "We are happy to believe that the rapid sale of the last edition of this valuable work may be regarded as an indication of the extending taste for sound physiological knowledge in the American schools: and what we then said of its merits, will show that we regarded it as deserving the reception it has experienced. Dr. Dunglison has, we are glad to perceive, anticipated the recommendation which we gave in regard to the addition of references, and has thereby not only added very considerably to the value of his work, but has shown an extent of reading which, we confess, we were not prepared by his former edition to expect. He has also availed himself of the additional materials supplied by the works that have been published in the interval, especially those of Müller and Burdach. So that as a collection of details on human physiology alone, we do not think that it is surpassed by any work in our language: and we can recommend it to students in this country (England) as containing much with which they will not be likely to meet elsewhere."--_British and Foreign Medical Review._ "This work exhibits another admirable specimen of American industry and talent, and contains an account of every discovery in Europe up to the period of a few months prior to its publication. Many of the author's views are original and important."--_Dublin Journal of Medical Sciences._ GENERAL THERAPEUTICS; OR, PRINCIPLES OF MEDICAL PRACTICE. _With Tables of the Chief Remedial Agents and their Preparations, and of the Different Poisons and their Antidotes._ BY ROBERT DUNGLISON, M. D., &c., &c. One Volume, large 8vo. "There being at, present before the public several American works on Therapeutics, written by physicians and teachers of distinction, it might be deemed unjust in us, and would certainly be invidious, to pronounce any of them superior to the others. We shall not, therefore, do so. If there be, however, in the English language, any work of the kind more valuable than that we have been examining, its title is unknown to us. "We hope to be able to give such an account of the work as will strengthen the desire and determination of our readers to seek for a farther acquaintance with it, by a candid perusal of the volume itself. And, in so doing, we offer them an assurance that they will be amply rewarded for their time and labour."--_Transylvania Journal_, Vol. IX, No. 3. THE MEDICAL STUDENT; or, Aids to the Study of Medicine. Including a Glossary of the Terms of the Science, and of the Mode of Prescribing; Bibliographical Notices of Medical Works; the Regulations of the Different Medical Colleges of the Union, &c. By Robley Dunglison, M. D., &c., &c. In one volume, 8vo. ELEMENTS OF HYGIENE; on the Influence of Atmosphere and Locality; Change of Air and Climate, Seasons, Food, Clothing, Bathing, Sleep, Corporeal and Intellectual Pursuits, &c., on Human Health, Constituting Elements of Hygiene. By Robley Dunglison, M. D. &c., &c. In 1 vol. 8vo. MEDICAL ESSAYS. THE CYCLOPEDIA OF PRACTICAL MEDICINE AND SURGERY, _Or Essays on ASTHMA, APHTHÆ, ASPHYXIA, APOPLEXY, ARSENIC, ATROPA, AIR, ABORTION, ANGINA-PECTORIS, and other Subjects Embraced in the Articles from A to Azote, prepared for the Cyclopedia of Practical Medicine by_ Dr. Chapman, Dr. Jackson, Dr. Horner, Dr. Hodge, Dr. Wood, Dr. Dewees, Dr. Hays, Dr. Dunglison, Dr. Mitchell, Dr. Bache, Dr. Coates, Dr. Condie, Dr. Emerson, Dr. Geddings, Dr. Griffith, Dr. Harris, Dr. Warren, Dr. Patterson, Each article is complete within itself, and embraces the practical experience of its author, and as they are only to be had in this collection will be found of great value to the profession. [Symbol: Asterism] The two volumes are now offered at a price so low, as to place them within the reach of every practitioner and student. GIBSON'S SURGERY. A NEW EDITION OF GIBSON'S SURGERY. THE INSTITUTES AND PRACTICE OF SURGERY; being the Outlines of a Course of Lectures. By William Gibson, M. D., Professor of Surgery in the University of Pennsylvania, &c. &c. Fifth edition, greatly enlarged. In 2 vols. 8vo. With thirty plates, several of which are coloured. "The author has endeavoured to make this edition as complete as possible, by adapting it to the present condition of surgery, and to supply the deficiencies of former editions by adding chapters and sections on subjects not hitherto treated of. And, moreover, the arrangement of the work has been altered by transposing parts of the second volume to the first, and by changing entirely the order of the subject in the second volume. This has been done for the purpose of making the surgical course in the university correspond with the anatomical lectures, so that the account of surgical diseases may follow immediately the anatomy of the parts." DEWEES'S WORKS. A PRACTICE OF PHYSIC, comprising most of the diseases not treated of in Diseases of Females and Diseases of Children. By W. P. Dewees, M. D., formerly adjunct professor in the University of Pennsylvania. In one volume, octavo. A COMPENDIOUS SYSTEM OF MIDWIFERY. By DR. DEWEES. Chiefly designed to facilitate the Inquiries of those who may be pursuing this branch of Study. Illustrated by occasional cases and with many plates. The ninth edition, with additions and improvements. In one vol. 8vo. DEWEES ON THE DISEASES OF FEMALES. The seventh edition. Revised and Corrected. With additions, and Numerous plates. In one vol. 8vo. DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. With Corrections and Improvements. The seventh ed. In one volume, 8vo. The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render available a long experience to these objects of our affection when they become diseased. In attempting this, the author has avoided as much as possible, "technicality;" and has given, if he does not flatter himself too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being confounded together, with the best mode of treating them, that either his own experience or that of others has suggested. HORNER'S SPECIAL ANATOMY. A Treatise on Special and General Anatomy. By W. E. Horner, M. D., Professor of Anatomy in the University of Pennsylvania, &c. &c. Fifth edition, Revised, and much improved. In two volumes, 8vo. ELLIS' MEDICAL FORMULARY. The Medical Formulary, being a collection of prescriptions derived from the writings and practice of many of the most eminent Physicians in America and Europe. To which is added an appendix, containing the usual Dietetic preparations and Antidotes for Poisons, the whole accompanied with a few brief Pharmacuetic and Medical observations. By Benjamin Ellis, M. D., Fifth edition, with additions. In one vol. Broussais on Inflammation, 2 vols. 8vo. Broussais' Pathology, 1 vol. 8vo. Colles' Surgical Anatomy, 1 vol. 8vo. Costers' Physiological Practice, 1 vol. 8vo. Greys' Chemistry applied to the Arts, 2 vols. with numerous plates. ELEMENTS OF PHYSICS, OR NATURAL PHILOSOPHY, GENERAL AND MEDICAL, explained independently of TECHNICAL MATHEMATICS, and containing New Disquisitions and Practical Suggestions. By NEIL ARNOTT, M. D. In two volumes, octavo. "Dr. Arnott's work has done for Physics as much as Locke's Essays did for the science of mind."--_London University Magazine._ "We may venture to predict that it will not be surpassed."--_Times._ "Dr. A. has not done less for Physics than Blackstone did for the Law."--_Morning Herald._ "Dr. A. has made Natural Philosophy as attractive as Buffon made Natural History."--_French Critic._ "A work of the highest class among the productions of mind."--_Courier._ ROGET'S PHYSIOLOGY AND PHRENOLOGY. OUTLINES OF PHYSIOLOGY; WITH AN APPENDIX ON PHRENOLOGY; BY P. M. ROGET., M. D. Professor of Physiology in the Royal Institute of Great Britain, &c. &c. FIRST AMERICAN EDITION, Revised, with numerous notes, In one volume, 8vo. From the American Preface.--"Of the Author's qualifications as a physiological writer it is scarcely requisite to speak. The fact of his having been selected to compose the Bridgewater Treatise on Animal and Vegetable Physiology, is sufficient evidence of the reputation which he then enjoyed; and the mode in which he executed the task amply evinces that his reputation rested on a solid basis. "The present volume contains a concise, well-written epitome of the present state of Physiology--human and comparative--not, as a matter to be expected, the copious details and developments to be met with in the larger treatises on the subject; but enough to serve as an accompaniment and guide to the physiological student. "The attention of the American Editor has been directed to the revision and correction of the text; to the supplying, in the form of notes, of omissions; to the rectification of some of the points that appeared to him erroneous or doubtful, and to the furnishing of references to works in which the physiological inquirer might meet with more ample information. "In Phrenology, the Author is a well-known unbeliever, and his published objections to the doctrine have been regarded as too cogent to be permitted to pass unheeded. It will be seen on farther examination in the interval of many years, which has elapsed since the publication of the sixth edition of the Encyclopædia, has not induced him to modify his sentiments on this head. On the contrary, he appears to be as satisfied at this time, of the fallacy of the positions of the Phrenologist, as he was at any former period." [Symbol: Pointing hand] This work will be introduced into many of the Medical Colleges of the union as a Text Book, it being a cheap volume, and well fitted as an introduction to the larger works on Physiology. COATES POPULAR MEDICINE: POPULAR MEDICINE; OR, FAMILY ADVISER. Consisting of outlines of Anatomy, Physiology, and Hygiene, with such Hints on the Practice of Physic, Surgery, and the Diseases of Women and Children, as may prove useful in families when regular Physicians cannot be procured: Being a Companion and Guide for intelligent Principals of Manufactories, Plantations, and Boarding Schools: Heads of Families, Masters of Vessels, Missionaries, or Travellers, and a useful Sketch for Young Men about commencing the Study of Medicine. BY REYNELL COATES, M. D. Fellow of the College of Physicians of Philadelphia--Honorary Member of the Philadelphia Medical Society--Correspondent of the Lyceum of Natural History of New York--Member of the Academy of Natural Sciences of Philadelphia--Formerly Resident Surgeon of the Pennsylvania Hospital, &c. Assisted by several Medical friends. In One Volume. "It is with great satisfaction that we announce this truly valuable compilation, as the most complete and interesting treatise on Popular Medicine ever presented to the public. Simple and unambitious in its language, free from the technicalities, and embracing the most important facts on Anatomy, Physiology and Hygiene, or the art of preserving health; and the treatment of those affections which require immediate attention, or are of an acute character, this should be in the hands of every one, more particularly of those who, by their situations are prevented from resorting to the advice of a physician, nor would the careful perusal of its pages fail to profit the inhabitants of our cities, by giving them a more accurate knowledge of the structure of the human frame, and the laws that govern its various functions; whose perfect integrity is absolutely essential to health, and even to existence; the various systems of medical charlatanry, daily imagined to take advantage of the credulity and ignorance of mankind, would be rendered far less prejudicial to the community than they now are. We would particularly direct attention to the Chapter on Hygiene, a science in itself of the utmost importance, and ably treated in the small space allowed to it in this volume."--_New York American._ DR. CLARK ON CONSUMPTION. A Treatise on Pulmonary Consumption, comprehending an inquiry into the Nature, Causes, Prevention, and Treatment of Tuberculous and Scrofulous Diseases in General. By James Clark, M. D., F. R. S. "As a text-book and guide to the inexperienced practitioner we know none equal to it in general soundness and practical utility--to the general as well as to the professional reader, the work will prove of the deepest interest, and its perusal of unequivocal advantage."--_British and Foreign Medical Review._ "The work of Dr. Clark may be regarded as the most complete and instructive Treatise on Consumption in the English Language."--_Edinburgh Medical and Surgical Journal._ CHITTY'S JURISPRUDENCE. A Practical Treatise on Medical Jurisprudence, with so much of Anatomy, Physiology, Pathology, and the Practice of Medicine and Surgery, as are essential to be known by Members of the Bar and Private Gentlemen; and all the laws relating to Medical Practitioners; with explanatory plates. By J. Chitty, Esq. Second American edition: with Notes and Additions, adapted to American works and Judicial Decisions. 8vo. A TREATISE ON THE PRACTICE OF MEDICINE, or a Systematic Digest of the Principles of General and Special Pathology and Theraputics. By E. Geddings, (now preparing.) SMITH ON FEVER. A Treatise on Fever. By Southwood Smith, M. D., Physician to the London Fever Hospital. Fourth American edition. In 1 volume 8vo. FITCH'S DENTAL SURGERY. A Treatise on Dental Surgery. Second edition, revised, corrected, and improved, with new plates. By S. S. Fitch, M. D. 1 vol. 8vo. ABERCROMBIE ON THE BRAIN. Pathological and Practical Researches on Diseases of the Brain and Spinal Cord. Second American, from the third Edinburgh edition, enlarged. By John Abercrombie, M. D. In 1 volume 8vo. ABERCROMBIE ON STOMACH. Pathological and Practical Researches on Diseases of the Stomach, the Intestinal Canal, the Liver, and other Viscera of the Abdomen. By John Abercrombie M. D., third American from the second London edition enlarged. In 1 vol. 8vo. EWELL'S MEDICAL COMPANION. The Medical Companion or Family Physician: treating of the Diseases of the United States, with their symptoms, causes, cure, and means of prevention. BERTIEN ON THE HEART. A Treatise on Diseases of the Heart and Great Vessels. By J. R. Bertien. Edited by G. Bouillaud. Translated from the French. 8vo. BOISSEAU ON FEVER. Physiological Pyretology; or a Treatise on Fevers, according to the Principles of the New Medical Doctrine. By F. G. Boisseau, Doctor in Medicine of the Faculty of Paris, &c. &c. From the fourth French edition. Translated by J. R. Knox, M. D. 1 vol. 8vo. HUTIN'S MANUAL. Manual of the Physiology of Man; or a concise Description of the Phenomena of his Organization. By P. Hutin. Translated from the French, with notes, by J. Togno. In 12mo. BELL ON THE TEETH. The Anatomy, Physiology, and Diseases of the Teeth. By Thomas Bell, F. R. S., F. L. S. &c., third American edition. In 1 vol. 8vo. With numerous plates. WILLIAMS ON THE LUNGS. A Rational Exposition of the Physical Signs of Diseases of the Lungs and Pleura; Illustrating their Pathology and facilitating their Diagnosis. By Charles J. Williams, M. D. In 8vo. with plates. THE BRIDGE WATER TREATISES, COMPLETE IN SEVEN VOLUMES, OCTAVO. Embracing. I. The Adaptation of External Nature to the Moral and Intellectual Constitution of Man. By the Rev. Thomas Chalmers. II. The Adaptation of External Nature to the Physical Condition of Man. By John Kidd, M. D., F. R. S. III. Astronomy and General Physics, Considered with References to Natural Theology. By the Rev. Wm. Whewell. IV. The Hand: Its Mechanism and Vital Endowments as Evincing Design. By Sir Charles Bell, K. H., F. R. S. With numerous wood cuts. V. Chemistry, Meteorology, and the Function of Digestion. By Wm. Prout, M. D., F. R. S. VI. The History, Habits and Instincts of Animals. By the Rev. Wm. Kirby, M. A., F. R. S. Illustrated by numerous Engravings on Copper. VII. Anatomy and Vegetable Physiology Considered with Reference to Natural Theology. By Peter Mark Roget, M. D. Illustrated with nearly Five Hundred Wood Cuts. VIII. Geology and Mineralogy, Considered with Reference to Natural Theology. By the Rev. Wm. Buckland, D. D. with numerous engravings on copper, and a large coloured map. [Symbol: Asterism] The work of Buckland, Kirby and Rojet may be had separate.