# LIBRARY OF CONGRESS. I 
 
 | jfcfV&ZCX I 
 
 # . I 
 
 I UNITED STATES OF AMERICA. J 
 
t 
 
 OBSTETRIC APHORISMS: 
 
 FOR THE 
 
 USE OF STUDENTS 
 
 COMMENCING 
 
 MIDWIFERY PRACTICE. 
 
 BY 
 JOSEPH GRIFFITHS SWAYNE, M.D., 
 
 PHYSICrAN ACCOCCHEUR TO THE BRISTOL GENERAL HOSPITAL, AND LECTURER 
 ON OBSTETRIC MEDICINE AT THE BRISTOL MEDICAL SCHOOL. 
 
 SECOND AMERICAN 
 
 FROM THE 
 
 FIFTH REVISED ENGLISH EDITION, WITH ADDITIONS. 
 BY 
 
 EDWARD R. HUTCHINS, M.D. 
 
 motf 
 
 PHILADELPHIA: 
 
 HENET C.LEA. 
 
 1813. 
 

 Entered according to Act of Congress, in the year 1872, by 
 
 HENEY C. LEA, 
 
 in the Office of the Librarian of Congress. All rights reserved. 
 
 COLLINS, PRINTER. 
 
TO 
 
 JOHN ALDINGTON SYMOEDS, M.D., F.R.S.E, 
 
 CONSULTING PHYSICIAN TO THE BRISTOL GENERAL HOSPITAL, 
 
 f Ijis Wisxl is Jjriiicatrir, 
 
 AS A MARK OF RESPECT FOR HIS HIGH ATTAINMENTS, 
 
 BOTH PROFESSIONAL AND GENERAL, 
 
 AND OF GRATITUDE FOR MUCH VALUABLE CLINICAL INSTRUCTION 
 
 AND FOR MANY ACTS OF KINDNESS, 
 
 BY HIS FRIEND AND FORMER PUPIL, 
 
 THE AUTHOR. 
 
EDITOR'S NOTICE. 
 
 A little over two years ago the first Ameri- 
 can Edition of this work was given to the pub- 
 lic. The Editor desires to express his sincere 
 thanks to the medical journals and press which 
 have so very kindly noticed his simple but 
 practical suggestions, and to the many young 
 practitioners and students, who have signified 
 their welcome of its issue. His additions to 
 this are inclosed in [ ] brackets, and it is 
 hoped that this little work — so valuable abroad 
 — may be thought none the less of in its second 
 American edition. 
 
 E. E, H. 
 
 Cedab Rapids, Iowa, 
 September, 1872. 
 
 1* 
 
PREFACE. 
 
 The object of this work is to give the student 
 a few brief and practical directions respecting 
 the management of ordinary cases of labor ; 
 and also to point out to him, in extraordinary 
 cases, when and how he may act upon his own 
 responsibility, and when he ought to send for 
 assistance. It has been undertaken by the 
 Author in accordance with a wish often ex- 
 pressed to him by his pupils, and is founded 
 upon his experience of the wants of those who 
 are commencing midwifery practice. The stu- 
 dent is never placed in a more trying situation, 
 nor has to incur a greater amount of responsi- 
 bility, than when he is attending a difficult 
 case of labor in a place remote from medical 
 aid. Should this work serve to keep any, who 
 may be so situated, from the opposite extremes 
 
Vlll PREFACE. 
 
 of temerity or timidity, 1 its end will be fully 
 answered. It is not intended to be used, in any 
 way, as a substitute for a systematic treatise 
 on midwifery, and therefore many details in 
 anatomy, physiology, pathology, and treatment 
 have been purposely omitted. 
 
 It w T ill be observed, that the student is ad- 
 vised to send for assistance whenever it is 
 necessary to use instruments or to introduce 
 the hand into the uterus for the purpose of 
 turning, etc. ; and, indeed, in all cases which 
 are necessarily dangerous, and accompanied 
 with more than ordinary difficulty. The diag- 
 nosis of such cases is, it is hoped, given at suf- 
 ficient length to enable him to know w T hen he 
 ought to send for aid ; but the treatment is in- 
 dicated in as few words as possible, because a 
 fuller account of it would cause this book to 
 exceed the limits of a work which is merely 
 
 1 For instance, the student who undertakes a case of 
 placenta praevia without sending for assistance, is an ex- 
 ample of one extreme ; and the student who sends for 
 help to remove a detached placenta from the vagina, of 
 the other. 
 
PREFACE. IX 
 
 intended to serve the temporary purpose of a 
 guide to beginners in the Obstetric art. 
 
 The Author has only to add, that he feels 
 most grateful for the favorable manner in which 
 the former editions of this work have been re- 
 ceived, especially amongst the junior members 
 of the profession. In the present edition he 
 has done his best to improve on the preceding, 
 although in a manual consisting of short and 
 well-established rules for practice there is not 
 the same room for additions and alterations as 
 in a larger work of more theoretical character. 
 Nevertheless, it will be found that, besides 
 several minor alterations, some important ad- 
 ditions have been made to the text of the pre- 
 sent work, especially in relation to secondary 
 hemorrhage after delivery, the treatment of 
 perineal lacerations, the pathology and treat- 
 ment of pelvic cellulitis, and the use of hydrate 
 of chloral in insomnia, convulsions, and other 
 puerperal affections. 
 
 With respect to the illustrations in this 
 work, it may be mentioned that, with the 
 exception of four, they are taken from the 
 
X PREFACE. 
 
 author's original drawings. For one in par- 
 ticular (ISTo. 8), he is indebted to Dr. Tyler 
 Smith, who most kindly permitted him to use 
 one of the engravings from his own " Manual 
 of Obstetrics." 
 
CONTENTS. 
 
 PART I. 
 
 PAfiE 
 THE MANAGEMENT OF ORDINARY LABOR ... 13 
 
 PART IT. 
 
 CASES WHICH THE STUDENT MAY UNDERTAKE WITH- 
 OUT ASSISTANCE 51 
 
 PART III. 
 
 CASES IN WHICH THE STUDENT OUGHT TO SEND FOR 
 
 ASSISTANCE 118 
 
 PART IY. 
 CHAPTER I. 
 
 DISEASES OF PREGNANCY 158 
 
 CHAPTER II. 
 
 CARE OF THE NEW-BORN INFANT . . . .164 
 
 CHAPTER III. 
 
 ABORTIONS 173 
 
LIST OF ENGRAVINGS. 
 
 PAGE 
 
 Fig. 1. — First stage of labor — Mode of making vagi- 
 nal examinations 21 
 
 Fig. 2. — Normal position of the foetus in utero . 23 
 Fig. 3. — The cavity of the uterus with the parturient 
 
 canal in a state of full dilatation ... 28 
 Fig. 4. — Ordinary position of the foetal head at the 
 
 commencement of the second stage of labor . 30 
 Fig. 5. — Position of the head during the second stage 31 
 Fig. 6. — Position of the head towards the end of the 
 
 second stage 32 
 
 Fig. 7 (1). — Shape of the os uteri in occipito-pos- 
 
 terior position 62 
 
 Fig. 7 (2). — Shape of the os uteri in occipitoanterior 
 
 position 62 
 
 Fig. 8. — Expulsion of the head in occipito-posterior 
 
 position 65 
 
 Fig. 9. — Expulsion of the head in face presentation 66 
 Fig. 10. — Ordinary position of the foetus in breech 
 
 presentations 69 
 
 Fig. 11. — Extraction of the arms in breech presenta- 
 tions 73 
 
 Fig. 12. — Extraction of the head in breech presenta- 
 tions 74 
 
 Eig. 13. — Position of the head in vertex presentation 128 
 Fig. 14. — Position of the head in brow presentation 129 
 Fig. 15. — Position of the head in face presentation. 130 
 Fig. 16.— Presentation of the arm (Churchill) . 132 
 
OBSTETEIO APHOEISMS. 
 
 PART I. 
 
 THE MANAGEMENT OF ORDINARY LABOR. 
 
 Importance of Prompt Attendance. 
 
 1. When sent for to a labor, obey the call imme- 
 diately; for then, if you are too early, you can 
 return home until wanted ; and if you are too late, 
 it is not your fault. 
 
 Delay may occasion, 1, various accidents to both mother 
 and child, from sudden delivery without assistance ; 2, the 
 loss of the best opportunity for rectifying mal-presenta- 
 tion ; 3, the loss of the patient's confidence in you, and 
 the substitution of another practitioner. 
 
 Instruments and Medicines which may be required. 
 
 2. You may take with you a stethoscope, and 
 also a pocket-case containing blunt-pointed scis- 
 sors, a silver or gum-elastic female catheter, curved 
 needles, silver wire or silk for sutures, ergot of 
 rye, laudanum, oil of turpentine, and sal volatile. 
 
 2 
 
14 MANAGEMENT OF ORDINARY LABOR. 
 
 With the exception of scissors, none of these things 
 will be wanted in an ordinary labor; but it is right to 
 be provided with them against emergencies. Cases con- 
 taining them may be procured at any surgical-instrument 
 maker's shop. 
 
 The needles and sutures will be necessary if the peri- 
 neum be lacerated. (See 70, Part II.) 
 
 It is a good plan to carry ergot both in the form of 
 fresh powder and tincture, in case, as often happens, one 
 of these preparations should prove to be inefficient. 
 
 The Extractum Ergotae Liquidum [Extractum Ergotse 
 Fluidum, U.S. P.] of the British Pharmacopoeia can, how- 
 ever, be depended on in most instances. 
 
 Oil of turpentine is not usually carried in a pocket-case; 
 but the author has found it of great efficacy in uterine 
 hemorrhage. 
 
 [The young practitioner never should go to the bedside 
 of one in confinement without the forceps.] 
 
 Preliminary Observations. 
 
 3. On first seeing your patient, do not abruptly 
 question her respecting her symptoms, but con- 
 verse on some ordinary topic, and whilst thus 
 engaged, notice any indications of pain in her 
 countenance, the tone of her voice, or the charac- 
 ter of her respiration. 
 
 A brusque, abrupt manner of putting questions may 
 flurry a patient so as to cause her pains to be suspended 
 for a considerable period. 
 
 In general, the first stage of labor is characterized by 
 low complaints, and an absence of voluntary effort; and 
 the second stage by deep inspirations, a loud outcry, and 
 strong exertions of the voluntary muscles ; and thus an 
 attentive observer may form a rough estimate of the pro- 
 gress of a labor. 
 
MANAGEMENT OF ORDINARY LABOR. 15 
 
 Questions respecting Pregnancy, Previous 
 Labors, etc. 
 
 4. Before making more special inquiries, 3 t ou 
 may ask respecting the patient's constitution and 
 state of health during pregnancy, and (if she be 
 not a primipara) the number and character of her 
 previous labors. 
 
 A knowledge of these circumstances may enable you to 
 calculate the duration of the present labor, or to anticipate 
 the occurrence of difficulties or complications requiring 
 the assistance of art. For instance, if a woman of middle 
 age be in labor for the first time, a lingering labor may in 
 general be expected ; or if it has been necessary in all the 
 previous labors to deliver by instruments, or if post-partum 
 hemorrhage has regularly occurred, you may expect simi- 
 lar untoward events in the present labor. 
 
 [The principal cause for the lingering labor incident to 
 the middle-aged woman (primipara) is the immobility 
 of the sacro-coccygeal joint. After thirty or thirty-five 
 years, if the woman has not given birth to offspring, this 
 joint becomes synarthrodial, the coccyx thus offering a 
 serious impediment to the progress of the labor. Under 
 such circumstances, the ossified uuiou may be fractured, 
 and require subsequent treatment.] 
 
 Questions respecting the Present Labor. 
 
 5. The questions to be asked respecting the pre- 
 sent labor are — when the pains were first felt, and 
 where {e. g., whether in the back or abdomen), 
 their character, duration, and frequency; and, last 
 but not least, whether they have been attended 
 with any " show" or discharge of mucus tinged 
 with blood. 
 
16 MANAGEMENT OF ORDINARY LABOR. 
 
 A consideration of all these particulars will assist you 
 in ascertaining whether the pains are genuine, and whether 
 the labor has actually commenced. 
 
 The show denotes the opening of the os uteri, and is 
 one of the most certain signs of commencing labor; it is, 
 therefore, made of much account by nurses. 
 
 How to propose a Vaginal Examination. 
 
 6. The only certain information, however, re- 
 specting a labor, is derived from a vaginal exa- 
 mination, which should be made as soon as possi- 
 ble, provided the pains are at all regular. You 
 accordingly signify to the patient, either directly 
 or through the nurse, that you wish her to lie 
 down on the bed, so that you may be able to try 
 the next pain, and inform her as to the progress 
 of the labor. 
 
 If your patient shows an unreasonable reluctance to 
 submit to an examination, you may tell her that, for all 
 you know, the labor may be going on very badly, and that 
 you will not be answerable for the result; by thus work- 
 ing upon her fears you will seldom fail to obtain compli- 
 ance with your request. 
 
 How to make a Vaginal Examination. 
 
 1. In order to make a vaginal examination, 
 direct the woman to lie on the right side of the 
 bed, but upon her left side, with the knees drawn 
 up towards the abdomen ; sit down behind her, and 
 pass the forefinger of the right hand (previously 
 anointed with oil or lard) into the genital fissure 
 close to the perineum ; then direct the finger first 
 
MANAGEMENT OF ORDINARY LABOR. 17 
 
 backwards towards the lower part of the sacrum, 
 and then upwards and forwards towards the pubis, 
 so as to reach the os uteri, and presenting part of 
 the child. If the os uteri is high up and far back, 
 the fore and middle fingers of the left hand may 
 be substituted for the right forefinger, because they 
 more readily follow the curve of the sacrum. 
 
 Amongst the lower classes, women Usually wear their 
 ordinary clothes until the labor is over, when they are un- 
 dressed and put to bed. 
 
 Vaginal examinations and other necessary manipula- 
 tions are to be made beneath the clothes of the patient, 
 whose person should be in no way exposed. 
 
 After examining, the fingers should be wiped in a nap- 
 kin, provided for the purpose, and placed beneath the 
 bedclothes. 
 
 It is as well to caution a beginner against passing his 
 finger into the anterior part of the genital fissure, as, by 
 so doing, he may fail to find the entrance of the vagina, 
 puzzle himself very much, and annoy the patient, who 
 may thus discover that she has been intrusted to a very 
 young hand. 
 
 If the fore and middle fingers of the left hand are used., 
 they should be introduced as the forefinger of the right 
 hand is being withdrawn. 
 
 When to Examine. 
 
 8. In general, it is better to examine during a 
 pain; but an examination, to be complete, should 
 be made both during and after a pain ; during a 
 pain (if the labor be in the first stage) it should 
 be strictly limited to the os uteri, vagina, and sur- 
 rounding parts, When the pain is over, and not 
 2* 
 
18 MANAGEMENT OF ORDINARY LABOR. 
 
 until then, the finger may be passed through the 
 os uteri, in order to examine the presentation. 
 
 Any attempt to make out the presentation when the 
 membranes are rendered tense during pain, will in all 
 probability cause their rupture, an accident always to be 
 avoided in the first stage of labor, especially .if the pre- 
 sentation be at all unfavorable— see Part III., 12 and 16. 
 When the pain is over, the membranes and os uteri 
 become flaccid, and the presentation is much more easily 
 distinguished. 
 
 [As a general rule, examinations should be made in the 
 absence of a pain.] 
 
 Information derived from Examination. 
 
 9. The information derived from a vaginal exa- 
 mination is very complete, for by it you learn — 
 i. Whether the passages are in proper condition for 
 labor, ii. Whether labor has actually commenced, 
 iii. Whether it is in the first or second stage, iv. 
 Whether the presentation is natural, v. Whether 
 you can leave your patient for a time with safety. 
 
 State of Passages, etc. 
 
 10. i. When the passages are in a proper con- 
 dition for labor, the pelvis is roomy, with the os 
 uteri in its centre ; both the os and vagina are 
 soft, dilatable, moister than usual, and sometimes 
 plentifully bedewed with mucus ; the canal of the 
 vagina is neither encroached upon by the rectum 
 and its contents behind, nor by the bladder in 
 front ; its walls are rugose in primipara, but much 
 smoother in multipara, especially at its upper 
 
MANAGEMENT OF ORDINARY LABOR. 19 
 
 extremity, where its calibre is also greater ; its 
 temperature is not raised, nor is it tender under 
 an ordinary examination. 
 
 In a pelvis of normal dimensions, the shortest diameter 
 should not be less than four inches, and it should be im- 
 possible to touch the upper part of the sacrum with the 
 finger, in an ordinary examination. 
 
 fit has been found by comparison of a large number of 
 pelves that those of American women are a trifle larger 
 than those of foreign subjects, and the same remark is 
 true of fcetal cranii — those of American being a little 
 larger than those of foreign parentage.] 
 
 In multiparse, the os uteri is usually situated more ante- 
 riorly than in primiparse, in whom it is sometimes so high 
 up and far back, at the commencement of labor, that it is 
 scarcely possible to reach it, unless you examine with two 
 fingers of the left hand. 
 
 With respect to the mucous secretion, Wigand remarks 
 that "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." 
 
 Signs of Commencing Labor. 
 
 11. ii. Labor is known to have actually com- 
 menced by the occurrence of pains, which return 
 at regular intervals, and increase in frequency and 
 force, and which, on making a vaginal examina- 
 tion, are found to be attended with a mucous show, 
 and to have caused more or less dilatation of the 
 os uteri. 
 
 During the ninth month of the pregnancy, the uterus 
 usually sinks somewhat in the abdomen, and this subsi- 
 dence, while it relieves the respiratory organs, causes 
 pressure upon the rectum, bladder, and other contents of 
 the pelvis, occasioning frequent desire to pass water and 
 
20 MANAGEMENT OF ORDINARY LABOR. 
 
 go to stool : these symptoms are so usual, that they have 
 been considered as premonitory signs of labor. 
 
 In multipara;, the os uteri is sometimes so open before 
 the actual commencement of labor as to admit the tip of 
 the index-finger, and even to allow the presentation to be 
 distinguished. 
 
 In primiparse, it is usually closed until labor has actu- 
 ally begun. 
 
 Signs of First Stage. 
 
 12. iii. a. The first stage of labor is occupied 
 in the dilatation of the os uteri. This process is 
 effected solely by the contractions of the uterus, 
 unaided by any of the voluntary muscles. It is 
 characterized by peculiar cutting or grinding pains, 
 first felt in the back, and gradually extending to 
 the front. 
 
 State of Os Uteri, etc., in First Stage. 
 
 b. On making a vaginal examination, you can 
 feel that the upper part of the vagina is occupied 
 by a soft, rounded tumor, formed by the lower 
 portion of the uterus. (Fig. 1.) In the centre of 
 this is the circular aperture of the os tincse, dilated 
 to the size of a sixpence, shilling, half-crown, 
 crown, or even larger; and within the os can be 
 felt the membranous bag of the waters containing 
 the presenting part of the child. When a pain 
 comes on, the os uteri becomes thin and tense; 
 the bag of the waters, which was before flaccid, 
 becomes globular and tense as a drum, and pro- 
 trudes more or less through the os, which is thus 
 
MANAGEMENT OF ORDINARY LABOR. 21 
 
 most effectually dilated. As the pain increases, 
 the presenting part descends and presses upon the 
 os uteri. 
 
 Fig. 1. 
 
 Old nurses often imagine that the pains of the first 
 stage, which they call iJ niggling" pains, are doing no good, 
 and will accordingly direct their patients to hold their 
 breath and to bear down with all their might. This pro- 
 ceeding is not only useless, but injurious, as such exer- 
 tions of the voluntary muscles are premature, and only 
 tend to prod ace exhaustion. 
 
 If the hand be placed upon the abdomen during a pain, 
 the whole uterus will be felt to become very firm and hard 
 under contraction. 
 
 In primiparge, the circle formed by the os uteri during 
 
22 MANAGEMENT OF ORDINARY LABOR. 
 
 dilatation feels much thinner, sharper, and more even than 
 in multipara, in whom it is often irregular, and thickened 
 from the effects of previous labors. 
 
 Sometimes the child's head, covered by the anterior lip 
 of the os uteri, presses down low into the pelvis even before 
 the commencement of labor; and in such a case, a begin- 
 ner, mistaking it for the bare head, may erroneously con- 
 clude that the labor is far advanced in the second stage. 
 A careful vaginal examination will prevent any one from 
 falling into this mistake, for, even if the undilated os uteri 
 is not detected, it will be found that the finger cannot be 
 passed between the presenting body and the pelvis beyond 
 a certain distance, viz., the angle formed by the junction 
 of the vagina and the uterus ; whereas in the second stage 
 of labor the finger may be passed as high between the 
 head and pelvis as it will reach. 
 
 Diagnosis of Presentation. 
 
 13. iv. The presentation should always be made 
 out, if possible, before the membranes are rup- 
 tured. The ordinary and natural presentation is 
 that of the crown of the head, or vertex. This is 
 recognized by being larger, rounder, and harder 
 than any other, but above all, by the divisions or 
 sutures, and spaces or fontanelles between the cra- 
 nial bones. (Fig. 2.) 
 
 If the presentation be not recognized until after the 
 membranes are ruptured, the most favorable opportunity 
 for turning or otherwise rectifying malpositions is lost. 
 
 In multiparas the head is usually much higher during 
 the first stage than in primipara3; and it occasionally lies 
 so much in front and above the pubis, that there is con- 
 siderable difficulty in reaching it before the membranes 
 are ruptured. 
 
 When the sutures and fontanelles can be distinctly felt, 
 it amounts to positive proof of head presentation, as no 
 such structure exists in any other part of the body. 
 
MANAGEMENT OF ORDINARY LABOR. 23 
 Fig. 2. 
 
 When a Patient can be left. 
 
 14. v. A patient in the first stage of labor can 
 be safely left for a short time, under the following 
 circumstances: a. In the ease of a primapara, if 
 
24 MANAGEMENT OF ORDINARY LABOR. 
 
 the presentation be natural, and the os uteri not 
 yet dilated, to the size of a crown-piece. b. In the 
 case of a multipara, if the pains be few and weak, 
 the presentation natural, and the os uteri not yet 
 dilated to the size of a shilling, c. In any case, if 
 there have been very few pains before your arrival, 
 and none for at least an hour afterwards. 
 
 a and h. Dr. Gooch gives the following judicious advice ; 
 "The propriety of absenting yourself from a patient who 
 is in labor will depend upon many circumstances, but 
 principally upon whether or not it is a first labor. If it 
 is a first labor, provided you can be within call, you may 
 visit your other patients, return, ascertain the state of the 
 labor, and perhaps go out again, etc. This you may do 
 until the os uteri is dilated to the size of a crown-piece ; 
 a process which will occupy about two-thirds of the time 
 of labor; afterwards no prudent man would leave his 
 patient until the labor is over. But if it is not the first 
 child, the progress of the labor is very different ; the pa- 
 tient has slight pains, occurring about every ten or fifteen 
 minutes, just sufficient to remind her that she is in labor : 
 the accoucheur is generally apprised of this state of things, 
 in order that he may be in the way. On being sent for, 
 after a notice of this kind, you will find that these trifling 
 pains have been sufficient, perhaps, completely to dilate 
 the os uteri. The pains now become stronger, and the 
 membranes more distended — presently they are ruptured 
 — gush goes the liquor amnii ; and if your arrival has not 
 been pretty expeditious, you may be greeted on entering 
 the room with the squalling of the child under the bed- 
 clothes. If I am called to a labor which is not the first, 
 and find the pains regular though slight, however trifling 
 may be the dilatation of the os uteri, I am exceedingly 
 shy of leaving my patient." 
 
 c. If the pains have ceased in consequence of the pa- 
 tient's nervousness at your sudden appearance, you will, 
 by waiting an hour, have allowed ample time for the effects 
 of this feeling to wear off. 
 
MANAGEMENT OF ORDINARY LABOR. 25 
 
 Prognosis. 
 
 15. After the examination has been made, the 
 patient will probably ask whether all is right, and 
 how long it will be before the labor is over. The 
 first of these questions may be answered in the 
 affirmative, if the head presents and the passages are 
 in proper condition (see 10) ; but to the second you 
 can only reply that it is impossible to tell with cer- 
 taint}', because the duration of the labor will depend 
 upon the strength and frequency of the pains, and 
 other circumstances which are beyond calculation. 
 
 Any attempt to foretell the exact duration, especially 
 of a first labor, would be very likely to end in the expo- 
 sure of the false prophet, and in the disappointment of the 
 patient. 
 
 [It is well especially for the student or the young phy- 
 sician to bear this suggestion in mind. Never 'promise 
 wlien the child vj ill probably be born.] 
 
 Progress. 
 
 16. When the presentation has been made out, 
 the progress of the labor is to be ascertained by sub- 
 sequent examinations ; but the fewer that are made 
 for this purpose, during the first stage, the better. 
 
 Frequent examinations during the first stage cause much 
 discomfort, and tend to render the parts dry and irritable. 
 
 [In the first stage frequent examinations are simply use- 
 less.] 
 
 It is difficult to lay down any precise rule as to the fre- 
 quency of examinations; they should in general be made 
 more frequently when the labor is rapid than when it is 
 slow, but never, perhaps, oftener than once in half an hour 
 during the first stage. 
 
 3 
 
2G MANAGEMENT OF ORDINARY LABOR. 
 
 Position during First Stage. 
 
 17. It is not necessary, during the first stage, 
 to keep the patient on the bed. On the contrary, 
 the pains will be more effectual when she is in the 
 erect posture, either sitting, standing, or walking. 
 
 The question of position at this time is one which may 
 safely be left to the patient, who may be allowed to con- 
 sult her own ease and convenience. 
 
 If, however, the pains become feeble upon lying down, 
 she should be encouraged to get up occasionally and walk 
 about the room. 
 
 [It is well for the patient to keep from the bed as long 
 as possible during the first stage, as under the most favor- 
 able circumstances her condition is most wearisome.] 
 
 Propriety of Occasional Absence from the Boom. 
 
 18. The pressure upon the bladder and rectum 
 during labor is apt to cause frequent desires to 
 pass water and to go to stool ; you should there- 
 fore retire, when you can, into another room, and 
 thus relieve your patient from the restraint occa- 
 sioned by 3 r our constant presence. 
 
 It often happens that amongst the poorest class there 
 is no second room into which the accoucheur can retire ; 
 but when, unfortunately, such is the case, the force of habit 
 has probably done much to blunt any feelings of modesty. 
 
 Diet during Labor. 
 
 19. During the active progress of labor the pa- 
 tient's diet should be very simple. In an ordinary 
 case some tea or gruel, with or without some toast 
 or bread, will be sufficient. 
 
MANAGEMENT OF ORDINARY LABOR. 27 
 
 The process of labor interferes with that of digestion, 
 and therefore a full meal is to be avoided. 
 
 [Oftentimes a simple article of diet affords great relief 
 to the patient.] 
 
 Signs of Second Stage. 
 
 20. The second stage of labor commences with 
 the full dilatation of the os uteri, and terminates 
 with the birth of the child. It is occupied in the 
 expulsion of the child, a process which is effected 
 by the contractions of the uterus, aided by the 
 voluntary muscles, especially those of the abdo- 
 minal parietes and the diaphragm. The pains are 
 of a peculiar, forcing character, and cause the 
 woman to hold her breath, to fix her limbs, and to 
 bear down with all her might. The low complaints 
 of the first stage commonly give place to a loud 
 outcry, both before and after each pain. 
 
 Position during Second Stage. 
 
 21. During the second stage the patient should 
 be kept upon the bed, lying upon her left side. 
 The part of the bed upon which she rests should 
 previously be "guarded," as it is termed, by cover- 
 ing it with a piece of oil-cloth, or sheet India- 
 rubber, so as to protect it from the discharges, etc. 
 Amongst the poorer classes it is customary to 
 turn up the lower half of the bed, so as to uncover 
 the sacking, upon which a folded sheet, blanket, or 
 piece of carpet is then placed. 
 
 [In this country probably the most common position is 
 
28 MANAGEMENT OF ORDINARY LABOR. 
 
 upon the back. The left side seems much more delicate 
 and desirable for the patient.] 
 
 State of Uterus, Vagina, etc., during Second Stage. 
 
 22. Vaginal examinations may be made more fre- 
 quently during the second stage than previously. 
 The os uteri is now fully dilated, so that the uterus 
 Fig. 3. 
 
 Fig. 3 (taken from Dr. Tyler Smith's Manual) represents the 
 uterus and parturient canal in a state of full dilatation. 
 
MANAGEMENT OP ORDINARY LABOR. 29 
 
 and vagina form one continuous canal. (Fig. 3.) 
 At this period the membranes usually rupture, and 
 the waters escape with a gush. 
 
 Vaginal examinations occasion much less annoyance 
 and irritation during the second stage, because the soft 
 parts are well relaxed, and bathed freely, both by liquor 
 amnii and a copious mucous secretion. 
 
 The quantity of liquor amnii is very variable : some- 
 times it is so little that its escape is scarcely apparent ; 
 at other times it is sufficiently great to deluge the bed and 
 to pour down on the floor. 
 
 Diagnosis of Presentation. 
 
 23. As soon as the membranes have ruptured, 
 the exact position of the head should, if possible, 
 be ascertained. The hairy scalp will now be felt 
 distinctly, either loose and wrinkled, or puffy and 
 oedematous; in an ordinary case the posterior 
 superior part of the right parietal bone presents ; 
 the occiput of the child is towards the left aceta- 
 bulum of the mother ; the sagittal suture runs 
 obliquely backwards, and from left to right, and 
 divides the vertex unequally into two parts, of 
 which the anterior is the largest and lowest ; it 
 commences in front with the triangular space of 
 the posterior fontanelle, and terminates behind 
 with the quadrangular anterior fontanelle, which 
 is opposite the right sacro-iliac synchondrosis, and 
 so high as to be almost out of reach. (Fig. 4.) 
 
 The state of the scalp will much depend upon the 
 amount of pressure to which the head is subjected. If 
 the labor be quick and easy, the scalp will be likely to be 
 
 3* 
 
30 MANAGEMENT OF ORDINARY LABOR. 
 Fig. 4. 
 
 loose and wrinkled; if it be slow and difficult, especially 
 if it be a first labor, the presenting part will become tense 
 and cedematous, forming what is called the "caput succe- 
 daneum." 
 
 Descent of the Head. 
 
 24. As the second stage advances, the child's 
 head is felt to press down more and more into the 
 cavity of the pelvis with each pain, and to recede 
 somewhat afterwards. Still, each pain gains upon 
 the advance made by its predecessor, and the head 
 
MANAGEMENT OF ORDINARY LABOR. 31 
 
 gradually fills the hollow of the sacrum, until at 
 last it occupies the outlet of the pelvis, and presses 
 on the perineum. (Fig. 5.) 
 Fig. 5. 
 
 - ■ ■■ 
 
 Management during the Pains. 
 25. During the pains of the second stage, the 
 woman should be encouraged to second the uterine 
 efforts by her own exertions; you maj^, therefore, 
 direct her to hold her breath, to grasp a towel, 
 which is usually fastened round one of the bed- 
 posts for that purpose, and at the same time to 
 press firmly with her feet against the nearest bed- 
 post or the footboard. 
 
32 MANAGEMENT OF ORDINARY LABOR. 
 
 When the extremities are thus fixed, the muscles of the 
 thorax and abdomen will act more advantageously. 
 
 Nurses are in the habit of making firm pressure upon 
 the lower part of the woman's back during each pain, and 
 much relief is often thus afforded. 
 
 Passage of Head through Outlet. 
 
 26. As the head is passing through the outlet of 
 the pelvis, it loses its former oblique position, and 
 makes a slight turn, so as to bring the occiput 
 beneath the arch of the pubis, and the face oppo- 
 site the sacrum. At the same time, whilst the oc- 
 ciput is comparatively fixed, the chin becomes 
 separated from the sternum ; the face descending 
 
 Fig. 6. 
 
MANAGEMENT OP ORDINARY LABOR. 33 
 
 and describing a curve in conformity with the hol- 
 low of the sacrum. The perineum, now greatly 
 distended, and much reduced in thickness, covers 
 the head very closely; the anus is also dilated, 
 and its mucous membrane more or less protruded. 
 (Fig. 6.) 
 
 By the turn just mentioned, which is called the Move- 
 ment of Rotation, the antero-posterior, or long diameters, 
 of the head and pelvic outlet are brought into correspond- 
 ence. 
 
 By the second movement, which is termed Extension, 
 the axes of the head, or occipito-mental diameter, assume 
 the same direction as the axes of the outlet of the pelvis. 
 
 Any feces, which may be contained in the lower part of 
 the rectum, are mechanically expelled by the pressure of 
 the head. This is one of the many inconveniences which 
 may result from a loaded state of the rectum. 
 
 Support of Perineum. 
 
 21. It is generally advised that the distended 
 perineum should be supported. This is usually 
 effected by laying the palm of one hand (previously 
 covered by a napkin) flat upon the perineum, with 
 the wrist toward the coccyx, and the tips of the 
 fingers forwards, and making pressure upon the 
 part, in such a manner as to give the head a proper 
 direction forwards, beneath the pubic arch. 1 
 
 1 The author, being thoroughly convinced of its inutility, 
 has for many years abandoned the practice of supporting the 
 perineum. He would, however, advise the student, before 
 doing the same, to give the practice a fair trial in a certain 
 number of cases, so as to be able to form his own conclu- 
 
34 MANAGEMENT OF ORDINARY LABOR. 
 
 The left hand is usually preferred for the support of the 
 perineum, because the right is then free for any other 
 manipulations which may be required. 
 
 [It is not unfrequent that the patient at this juncture 
 refuses to aid nature by bearing down, on account of the 
 rectum being distended with feces (she dreading an evacu- 
 ation). I have often known labor to be thus retarded no 
 little. Inquiry should be made, and the patient directed 
 to bear down, even if an evacuation of the bowels takes 
 place.] 
 
 Expulsion of Head. 
 
 28. After a variable time, the resistance of the 
 perineum is overcome, and the head, propelled by- 
 two or three long and severe pains, escapes from 
 the vulva. As soon as it is expelled, it resumes 
 its former oblique position, so that the face looks 
 upwards and backwards towards the right hip of 
 the mother. 
 
 The dilatation of the perineum, which in multipara? may 
 be effected in two or three pains, may occasionally in pri- 
 miparae occupy a period of several hours. Young accou- 
 cheurs should, therefore, be cautious not to promise a 
 speedy termination under such circumstances. 
 
 The vertex and back of the head escape first, whilst the 
 border of perineum glides successively over the anterior 
 fontanelle, the forehead, and face. 
 
 The movement of rotation, which is again performed by 
 the head after its expulsion, is termed Restitution [Ex- 
 ternal Rotation] . 
 
 sions respecting its utility. Those who wish to see a full 
 and clear statement of all the reasons that may be adduced 
 against the practice of supporting the perineum, will do 
 well to consult a little work on this subject by Dr. Graily 
 Hewitt. 
 
MANAGEMENT OF ORDINARY LABOR. 35 
 
 During the latter part of the second stage, the accou- 
 cheur should remain sitting at the bedside, making fre- 
 quent examinations, and noting carefully the exact course 
 and progress of the head. 
 
 Interval after Birth of the Head. 
 
 29. In most cases a short interval elapses after 
 the birth of the head, before the uterus resumes 
 its action. During this time the child, if vigorous, 
 ma}^ breathe, or even cry ; but more frequently it 
 is unable to do either, until the body is born and 
 the chest set at liberty. 
 
 When the labor is rapid and the pains very powerful, 
 the head and body are not unfrequently expelled by the 
 same pain. 
 
 30. Whilst waiting for the expulsion of the body, 
 you may support the head of the child with your 
 hand, and remove with your fingers any mucus or 
 portions of membrane which may clog the mouth 
 or fauces. You may also see that everything is 
 ready for the child, and especially that a pair of 
 scissors and a skein or two of stout thread are at 
 hand, for the purpose of tying and dividing the 
 cord. 
 
 The accoucheur should wait patiently for the uterine 
 contractions, and on no account attempt to hasten the 
 delivery by pulling at the child's neck and shoulders — a 
 practice much in favor with old nurses, but very mis- 
 chievous, because it is likely to leave the uterus uncon- 
 tracted, and thus to occasion hemorrhage. (For exception 
 to this rule, see 49, Part II.) 
 
36 MANAGEMENT OF ORDINARY LABOR. 
 
 Expulsion of Body. 
 
 31. After the birth of the head, the uterus speedily 
 renews its efforts, and expels the rest of the body. 
 Whilst the shoulders are clearing the pelvic outlet, 
 a movement of rotation, similar to that performed 
 by the head, causes the right shoulder to pass 
 beneath the pubic arch, and the left in front of the 
 perineum. 
 
 When to separate the Child. 
 
 32. A strong, healthy child, as soon as it is born, 
 will begin to breathe freely, and in most cases to 
 cry vigorously. As soon as it Jias thus given 
 satisfactory proof of its respiratory power, you 
 may at once proceed to separate it from its mother 
 by tying and dividing tfie umbilical cord. 
 
 Ligature and Division of Cord. 
 
 33. Having uncovered the child, so as to see 
 what you are about, place a ligature, consisting 
 of three or four pieces of stout thread, around the 
 cord, about three fingers' breadth from the navel, 
 and tie it tightly with a firm double knot; then 
 place another similar ligature about an inch further 
 from the navel, and divide the cord between the 
 two with a pair of scissors. You then give the 
 child to the nurse, who wraps it up in a piece of 
 flannel called a "receiver, 77 and carries it off to 
 the fireside to be washed and dressed. 
 
MANAGEMENT OF ORDINARY LABOR. 3t 
 
 As soon as the child is born, the accoucheur should see 
 that the air has free access to its face, and that its mouth 
 and nose are not covered by bedclothes, etc. 
 
 In uncovering the child, the clothes should be tucked 
 in round the mother, so as to avoid any exposure of her 
 person. 
 
 If the accoucheur divide the cord carelessly beneath 
 the bedclothes, without seeing what he is about, he may 
 amputate, at the same time, portions of the child's fingers, 
 toes, or even penis, as in cases related by Denman, Merri- 
 man. and others. 
 
 The threads of which the ligatures consist should, before 
 being used, be united together by a knot at each end. The 
 ligature nearest to the umbilicus is necessary to prevent 
 the child from bleeding to death by hemorrhage from the 
 divided umbilical vessels. The other ligature is not abso- 
 lutely necessary, but is used chiefly for the sake of clean- 
 liness, to prevent the blood contained in the rest of the 
 cord from spurting out upon the bed or the clothes of the 
 accoucheur. 
 
 Before the child is given to the nurse, the portion of 
 cord attached to it should be examined, to ascertain that 
 the ligature remains firm, and that there is no oozing of 
 blood from the umbilical vessels. 
 
 As soon as the child is born, the mother may be informed 
 as to its sex; and if the child be healthy and well formed, 
 she may be satisfied upon these points also ; but if there 
 be any defect or malformation, she should not be told of 
 it too soon or abruptly. 
 
 Third Stage of Labor. 
 
 34. The third stage of labor is occupied in the 
 expulsion of the after-birth. The birth of the 
 child is generally followed by a short interval of 
 repose, after which three or four pains set in, 
 which are frequently accompanied with some dis- 
 charge of blood, and resemble those of the first 
 stage in character. By means of these contrac- 
 
 4: 
 
38 MANAGEMENT OF ORDINARY LABOR. 
 
 tions the uterus casts off the after-birth, sometimes 
 completely beyond the vulva, but more often into 
 the upper part of the vagina. 
 
 The period of repose immediately following the birth of 
 the child is generally free from pain, and is a delightful 
 contrast to the preceding suffering. 
 
 It occasionally happens, when uterine action is very 
 energetic, that the child and placenta are expelled together 
 by the same pain. From the flow of blood which accom- 
 panies them, the pains of the third stage have been called 
 the '' dolores cruenti." The blood escapes from the venous 
 orifices which have been laid open by the separation of 
 the placenta from the inner surface of the uterus. In some 
 cases, however, there is apparently no escape whatever. 
 The quantity of blood which escapes with the placenta is 
 very variable; it may be as little as a tablespoonful, or as 
 much as a pint without producing any material effect on 
 the patient ; if it exceeds the latter quantity, it will be 
 likely to produce a marked constitutional effect, as indi- 
 cated by the pulse, etc. ; the case then becomes one of 
 post-partum hemorrhage, and is to be treated accordingly. 
 (See 55, Part II.) 
 
 Necessity of making Abdominal Examination in 
 Third Stage. 
 
 35. As soon as you have given the child to the 
 nurse, you should make it an invariable rule to 
 place your hand upon the patient's abdomen, for 
 the purpose of examining the uterus. In most 
 cases it will be distinctly felt reaching as high as 
 the umbilicus, and becoming perceptibly harder, 
 so that its limits can be easily defined. When it 
 is in this state, it is beginning to contract, but has 
 not yet expelled the placenta. On making an ordi- 
 
MANAGEMENT OF ORDINARY LABOR. 39 
 
 nary vaginal examination, } t ou can feel the cord 
 only, but no portion of the placenta. 
 
 By means of an abdominal examination, you can satisfy 
 yourself, from the greatly reduced bulk of the uterus, not 
 only that that organ is contracting upon the placenta, but 
 that it does not contain a second child. (See 38, Part II.) 
 
 Duration of Third Stage. 
 
 36. The average duration of the third stage, 
 reckoning from the birth of the child to the ex- 
 pulsion of the after-birth, is about a quarter of an 
 hour. During this time } r ou should sit by the 
 bedside, occasionally examining the abdomen, and 
 waiting patiently until the placenta is detached by 
 the natural efforts ; but you should on no account 
 attempt to hasten that process by pulling at the funis. 
 
 The time occupied by the third stage is exceedingly 
 variable : sometimes the placenta follows immediately, or 
 in five minutes after the birth of the child; at other times 
 it is not expelled until twenty minutes, half an hour, or 
 even more, have elapsed. "When it remains more than an 
 hour in the uterus, the case may be considered as one 
 of retained placenta, and treated accordingly. [As a 
 general rule, all circumstances being favorable, the phy- 
 sician may remove the placenta if it is not expelled in 
 half an hour.] (See 31, Part III.) 
 
 Danger of Forcibly Detaching Placenta. 
 
 Traction of the cord when the placenta is still attached, 
 and especially when the uterus is uncontracted, may pro- 
 duce the most disastrous consequences. It may cause — 
 1. Copious hemorrhage from partial detachment of the 
 placenta. 2. Inversion of the uterus. 3. Separation of 
 the cord from the placenta. 4. Irregular or hour-glass 
 contraction of the uterus. 
 
40 MANAGEMENT OF ORDINARY LABOR. 
 
 How to Ascertain if Placenta is Detached. 
 
 3T. In most cases, the placenta, after being de- 
 tached and expelled from the uterine cavity, is 
 found resting on the os tincae, or in the upper part 
 of the vagina. You know that it is in this situa- 
 tion, and may at once proceed to remove it, if, in 
 making an ordinary vaginal examination, you can 
 feel with your finger, not only the insertion of the 
 cord, but also a considerable portion of the body 
 of the placenta. 
 
 If these cases are left to nature, the placenta may re- 
 main several hours before the vagina has regained suffi- 
 cient contractility to expel it. 
 
 In general it is enough to be able to feel the insertion 
 of the cord in order to be assured that the placenta is 
 detached, but it is not always so ; because in what are 
 called " battledore" placentae, the cord may be inserted 
 into the lower edge of the placenta, and this portion may 
 be readily reached, although the chief part of the organ 
 is still attached to the uterus. 
 
 How to Remove a Detached Placenta. 
 
 38. To remove the placenta from the vagina, 
 pass the fore and middle fingers of your left hand 
 up to the insertion of the cord, and using them as 
 a pulley, make steady traction upon the cord with 
 the right hand — first in the direction of the inlet, 
 and then of the outlet of the pelvis. The process 
 will be much facilitated if you can hook down the 
 edge or some portion of the placenta with the two 
 fingers of the left hand. 
 
MANAGEMENT OP ORDINARY LABOR. 41 
 
 To prevent the cord from slipping, it should be grasped 
 with a napkin, or a coil of it twisted round the fingers of 
 the right hand. By meaus of the fingers of the left hand 
 you can readily feel if the cord is beginning to give way 
 near its insertion. Should this be the case, you must at 
 once desist from further traction upon it, and endeavor 
 instead to draw down the placenta itself by the fingers of 
 the left hand. 
 
 ["Such a placenta, buttoned within the orifice, should 
 be dexterously unbuttoned, by bringing its edge to the 
 buttonhole, as you would do with your coat-button."] 
 
 How to Remove Membranes. 
 
 39. In all cases, as soon as the placenta is be- 
 yond the os externum, it should be turned round 
 and round several times before being taken away. 
 By this means the membranes, trailing behind it, 
 are twisted into a rope, in which form they are 
 much less likely to be torn, and are more readily 
 withdrawn from the vagina. 
 
 Any portion of membranes or clots, which may remain 
 behind after the placenta, are to be also taken away. 
 
 The placenta, when removed, is to be put into a chamber 
 utensil, which should be at hand to receive it. It is after- 
 wards taken away by the nurse and burnt, in accordance 
 with a popular custom of long standing. 
 
 State of Uterus after Expulsion of Placenta. 
 
 40. As soon as the placenta has come away, you 
 should again make an abdominal examination. If 
 the uterus be properly contracted, you will feel it 
 through the parietes, somewhere between the um- 
 bilicus and pubis, as a hard, round mass, about 
 the size and firmness of a child's head at birth. 
 
 4* 
 
42 MANAGEMENT OF ORDINARY LABOR. 
 
 Nature guards against hemorrhage from the open venous 
 sinuses by contraction of the uterine fibres. By this means 
 each bleeding vessel is secured as effectually as by a liga- 
 ture. No medical man should feel satisfied in leaving his 
 patient until the uterus has contracted properly. 
 
 The uterus is seldom found to be quite in the middle 
 line, but is more often inclined to one side, especially to 
 the right. 
 
 Rigors after Labor — their Treatment. 
 
 41. The heat and perspiration produced by the 
 violent exertions of the second stage are likely to 
 be followed by chilliness when the labor is over. 
 You may, therefore, remove the soiled sheet from 
 beneath the patient, and substitute a w T arm, dry 
 napkin ; and also apply to the external genitals a 
 similar napkin, which the nurse usually keeps in 
 readiness for the purpose. You may likewise direct 
 the nurse to throw an extra blanket over her, and 
 to give her some warm drink, such as tea or gruel. 
 
 Nurses are very fond of adding some spirits to the tea 
 or gruel ; but, as a general rule, such stimulants should be 
 forbidden, unless the patient appear exhausted, when it 
 will be a good plan to give an egg beaten up with a tea- 
 spoonful or two of brandy. As the ordinary manipula- 
 tions of labor are now concluded, the medical attendant 
 is at liberty to leave the bedside for a short time to wash 
 his hands, etc., but he should not be long away from his 
 patient. 
 
 Hoio to Wrap up the Cord, 
 
 42. Whilst the nurse is dressing the child, 3^011 
 may examine the remnant of cord attached to the 
 abdomen. For the sake of cleanliness, it is usually 
 
MANAGEMENT OF ORDINARY LABOR. 43 
 
 passed through a hole in the centre of a square 
 piece of soft linen rag, in which it is enveloped, 
 and then turned up on the abdomen. To keep it 
 in place, a broad piece of flannel is passed round 
 the child's body and secured by stitches. The por- 
 tion of cord withers, and generally drops off about 
 the end of a week. 
 
 [Generally this occurs from the fourth to the sixth day, 
 and sometimes during the sloughing there is emitted a 
 fetid odor, alarming nurse and mother. It is right to ex- 
 plain the cause.] 
 
 Nurses have a prejudice in favor of scorched rag, which 
 they use under the idea that it promotes in some manner 
 the cicatrization of the umbilicus after the separation of 
 the cord. 
 
 Abdominal Bandage. 
 
 43. A broad bandage should be applied round 
 the abdomen, in order to support that part, and 
 maintain uterine contraction. The bandage should 
 consist of a piece of strong calico about four or 
 five feet long, and twelve or fourteen inches wide. 
 [The word calico has a different meaning in the 
 United States from that in England. Here it 
 signifies "printed cotton cloth having different 
 colors." The common material used for a band- 
 age in our country — and it is the best — is un- 
 bleached muslin, heavy and strong.] It should be 
 drawn firmly round the abdomen, so as to cover 
 it completely, from, the ensiform cartilage to the 
 pubis. The ends of the bandage should then be 
 secured by three or four strong pins. \_A simple 
 
44 MANAGEMENT OF ORDINARY LABOR. 
 
 but an important point. It will always be well for 
 the physician to have with him a few large ^ strong 
 pins.] 
 
 The abdominal bandage is usually applied by the nurse, 
 or other female attendant ; but in all cases, when there is 
 any doubt as to the proper contraction of the uterus, it is 
 far better that the medical attendant should put on the 
 bandage himself. In cases of this kind it should be put 
 on much earlier ; and sometimes it is proper to do so even 
 before the birth of the child. The abdominal bandage 
 should be continued for at least a fortnight. 
 
 [It will occupy but a few minutes, and it is best that the 
 young physician should apply the bandage himself.] 
 
 Necessity of Repose after Labor. 
 
 44. The woman should be allowed to lie quiet 
 for at least an hour after the birth of the child. 
 At the end of this time the attendants may change 
 her dress, bandage her abdomen, and place her 
 comfortably in bed ; taking care, whilst so doing, 
 not to raise her in the least from the recumbent 
 posture. 
 
 [If the uterus has contracted well, and the patient is 
 disposed to sleep, she should be allowed to do so, and not 
 disturbed.] 
 
 Amongst the poor, women are usually confined in their 
 ordinary clothes ; they have, therefore, to undergo the 
 whole process of undressing afterwards. Whilst this is 
 done, they ought to remain passive in the hands of their 
 attendants, and should on no account be allowed to un- 
 dress themselves. 
 
 When the Patient may be left. 
 
 45. You should not leave the patient's house for 
 at least an hour after the termination of the labor. 
 
MANAGEMENT OF ORDINARY LABOR. 45 
 
 During this time, yon may occasionally look at her, 
 feel her pulse, examine her abdomen, etc. Before 
 leaving, you should always make a point of ex- 
 amining the condition of the uterus, to ascertain 
 whether it remains properly contracted. [Always 
 examine the cord before leaving, in order to avoid 
 any risk of hemorrhage.] 
 
 The pulse, which during the second stage was much ele- 
 vated, soon after labor subsides to, or even falls below, the 
 ordinary standard. Hence an unnaturally quick pulse, half 
 an hour or an hour after delivery, is often an unfavorable 
 symptom, and not unfrequently forebodes hemorrhage. 
 (See note 53, Part II.) 
 
 Sometimes the uterus, after contracting, again relaxes, 
 and hemorrhage is the result. The accoucheur should 
 therefore satisfy himself, not only that the uterus is in a 
 state of contraction, but that this condition is likely to 
 be permanent. 
 
 Necessity of Rest after Delivery. 
 
 46. The l}'ing-in chamber should be kept per- 
 fectly quiet, so as to allow the patient to sleep, or 
 at all events to repose for some hours after her 
 fatigues. When she has thus rested, the infant 
 may be put to the breast; and this ought to be 
 done within twelve hours after delivery- [In cases 
 where there is hemorrhagic tendency, the sooner 
 the child is applied to the breast the better. There 
 is that strange, hidden S3 T mpathy between the 
 uterus and mammary glands, that the one responds 
 to the other, as if thus commanded, and a child 
 applied to the breast, by its sucking, contracts the 
 uterus.] 
 
4G MANAGEMENT OF ORDINARY LABOR. 
 
 The room should be darkened by drawing down the 
 blinds, and to insure tranquillity as few persons as possible 
 should be admitted into it. [Most rooms in which the 
 lying-in woman is confined are kept too dark. The old 
 theory that the light " hurts the mother and blinds the 
 child" is erroneous. It is generally conceded now, at least 
 in our own country, that the room should be pleasantly 
 light, for the mutual benefit of mother and child.] The 
 visits of gossiping friends and neighbors should be strictly 
 prohibited. The room should also be well ventilated, and 
 not too warm, as is often the case amongst the poor, who 
 will light up a large fire, in a small close room, in the 
 middle of summer. 
 
 The late Dr. Rigby used to recommend that the child 
 should be applied to the breast immediately after delivery ; 
 in some cases this may be advisable, but in general it is 
 better to allow the woman to rest for some time previously. 
 However, it is always far preferable to apply the child to 
 the breast too soon than too late. [A singularly interest- 
 ing case was recently reported to me by Dr. G. W. Holmes, 
 of this city, in which all means failed to contract the uterus 
 in a primiparous case until the child was applied to the 
 breast.] 
 
 How often the Patient is to be Visited. 
 
 4*7. The frequency of your visits after a labor 
 must be regulated very much by circumstances. 
 As a general rule, you should see your patient 
 twice within the first twenty-four hours, and once 
 every day during the first week; then every second, 
 third, or fourth day during the following week; 
 after which, if all goes on well, you may take your 
 leave. 
 
 Inquiries to be made at First Visit. 
 48. Your first visit should be within tw r elve 
 
MANAGEMENT OF ORDINARY LABOR. 4T 
 
 hours after delivery. After feeling your patient's 
 pulse, and looking at her tongue, you may ask if 
 she has had any sleep, and has been free from pain; 
 if there is any sign of milk ; if there is a plentiful 
 " discharge," and if she has passed water, or had 
 any action of the bowels. Respecting the child, 
 you may ask if it has cried or slept ; if it has been 
 put to the breast ; and if it has passed water or 
 stools. 
 
 TVomen very frequently cannot sleep for some hours 
 after delivery, in consequence of the occurrence of after- 
 pains; these, after some hours, subside of themselves, and 
 as a general rule, require no treatment. (See 59, Part 
 
 ii.) 
 
 The first evacuations from the child's bowels consist 
 of a substance called meconium, which is of a dark- 
 greenish-brown color, somewhat resembling treacle in ap- 
 pearance and consistence. If there be any doubt as to 
 the child's ability to pass urine or feces, an examination 
 should be made to ascertain that there is no malformation, 
 such as imperforate anus, urethra, etc. 
 
 Secretion of Milk. 
 
 49. The secretion of milk commences within 
 twelve hours after delivery, but is seldom fully es- 
 tablished before the end of the third day. As the 
 secretion becomes plentiful, the breasts harden and 
 enlarge, their swelling occasioning feelings of ten- 
 sion, and sometimes even sharp darting pains. 
 The first milk is called colostrum ; it is of a yellow- 
 ish color, and has a purgative effect upon the child. 
 
 The colostrum is the* natural purgative of a newly-born 
 infant. If a child is put to the breast sufficiently early, it 
 
48 MANAGEMENT OF ORDINARY LABOR. 
 
 will require none of the castor oil, sugar and butter, etc., 
 which nurses are so fond of giving for this purpose. 
 
 Newly-born children seldom require any food in addi- 
 tion to the breast. Should, however, the secretion of 
 milk be scanty, or tardy in making its appearance, it may 
 be necessary to give the child some food. The best ordi- 
 nary substitute for the mother's milk is a mixture of two 
 parts of coft'smilk with one part of water, sweetened 
 with a little sugar. The child should suck this from a 
 proper feeding-bottle. 
 
 Excretion of Urine and Feces. 
 
 50. After an ordinary labor there is seldom any 
 difficulty in passing water, but the bowels rarely 
 act without medicine ; on this account, if they 
 have not been previously moved, it is a general 
 rule to give a dose of castor oil on the morning of 
 the third day; one tablespoonful is mostly suf- 
 ficient, which inaj' be repeated after six hours, if 
 necessary. 
 
 It is a good plan to direct that the woman should pass 
 water whilst leaning forward in bed upon her elbows and 
 knees ; because this position readily allows the escape of 
 any retained clots, portions of membranes, etc. [Do not 
 fail to inquire of your patient, whether she has passed 
 water. An overloaded and distended bladder might lead 
 to most serious results. My own experience leads me to 
 the belief that the use of the catheter is far preferable to 
 the exertion consequent upon the position suggested 
 above.] 
 
 Lochial Discharge. 
 
 51. The secretion of the uterus after delivery is 
 called the lochia, or in common language, " the 
 cleansings." It at first bears much resemblance to 
 
MANAGEMENT OF ORDINARY LABOR. 49 
 
 ordinary menstrual discharge, being plentiful, of a 
 red color, and peculiar odor, and frequently con- 
 taining clots, shreds of membrane, etc. In a few 
 days it becomes less abundant and paler in color, 
 changing to brown, yellow, or green (when it is 
 sometimes termed the "green waters"}, until at 
 last it is clear and transparent ; it usually ceases 
 by the end of the third week. 
 
 [It is common for nurses to apply the napkin 
 directly over the month of the vagina, to absorb 
 the lochial discharge. The physician should dis- 
 countenance this, directing the cloth to be placed 
 under the perineum, never over the vulva. Such 
 an application but dams up the lochial discharges 
 against a uterus already excited.] 
 
 During the first week or two after delivery, the whole of 
 the decidual lining of the uterus softens, breaks up, and 
 is discharged with the lochia. 
 
 Diet after Delivery. 
 
 52. The diet of a woman for the first three days 
 &fter delivery should be chiefly farinaceous ; you 
 may allow bread, milk, tea, gruel, arrowroot, sago, 
 etc., with the addition in some cases of broth or 
 beef-tea. On the fourth day some solid animal 
 food may be given. At the end of a week, if all 
 goes on well, the woman may resume her ordinary 
 diet, and take in addition a little wine, beer, or 
 porter. 
 5 
 
50 MANAGEMENT OF ORDINARY LABOR. 
 
 [The latter is not customary among American 
 physicians, unless the exhausted condition of the 
 patient especially demands it.] 
 
 A light, unstimulating diet is proper, until the secretion 
 of milk is fully established, and until any feverishness, 
 which may accompany this process, has quite subsided. 
 As the process of lactation subsequently makes a great 
 demand on the powers of the system, a generous diet be- 
 comes necessary. 
 
 Exercise and General Management. 
 
 53. During the first week after delivery, the 
 woman should remain in bed, and be kept strictly 
 in the recumbent position. During the second 
 week, she may put on a loose dress, and lie on a 
 sofa, or recline in an easy chair, taking care to 
 stand or sit upright as little as possible. During 
 the third week, she may sit up, leave her room, and 
 walk a little about the house. If the weather be 
 warm and favorable, she may go out of doors after 
 the end of the third week ; but in winter it is better 
 to wait until the end of the month at least. 
 
 Displacements, such as prolapsus uteri, are very likely 
 to be caused by getting up too soon after delivery; the 
 frequency of such complaints amongst the poor is thus 
 accounted for. Secondary hemorrhage, also, may be thus 
 produced. 
 
PART II. 
 
 CASES WHICH THE STUDENT MAY UNDER- 
 TAKE WITHOUT ASSISTANCE. 
 
 Cases of supposed Pregnancy. 
 
 1. A woman sends for 3^011 who believes herself 
 to be in labor, but who in reality is not pregnant. 
 You may know that such is the case, and may at 
 once undeceive her, if, on making a vaginal exami- 
 nation, you find that there is no shortening of the 
 neck, and no enlargement of the body, of the 
 uterus. 
 
 The cases which may simulate pregnancy, and even 
 commencing labor, are usually those in which there is 
 suppression of the menses, with enlargement of the abdo- 
 men, from tumors or cysts of various kinds, accompanied 
 with a want of tone and a tympanitic distension of the 
 bowels. Such symptoms are most frequently met with in 
 women approaching the "turn of life," or the age at which 
 the menses cease. In these cases the more conclusive 
 signs of pregnancy, such as the sounds of the foetal heart 
 and ballottement, are of course wanting. 
 
 In the unimpregnated state the cervix uteri forms a 
 conical projection, about three-quarters of an inch or an 
 inch long, into the upper part of the vagina. 
 
 The absence of shortening in the uterine neck denotes 
 either the absence of pregnancy, or, at all events, the non- 
 completion of the first half of utero-gestation. 
 
52 CASES NOT USUALLY 
 
 The absence of any enlargement of the body of the 
 uterus denotes the absence of pregnancy. To ascertain 
 this, the uterus should be poised on the fore-finger of one 
 hand, whilst the other hand is pressed on the hypogastrium. 
 By pressing on its neck, either behind or in front, the 
 uterus may be made to swing backwards or forwards, and 
 thus its weight and mobility may be estimated. By pass- 
 ing the finger as high as possible round the uterine neck, 
 any bulging or increased size of the body may be recog- 
 nized. 
 
 Abortion — Diagnosis. 
 
 2. A woman, in the first four or five months of 
 her pregnane}^ sends for you, because she has ex- 
 perienced periodical pains, like those of the first 
 stage of labor. In all probability, abortion is im- 
 minent ; but 3^011 may feel sure of this, if the pains 
 are followed by hemorrhage from the vagina, and 
 especially if you find that they cause the os uteri 
 to dilate, and the ovum to protrude through it. 
 
 By the terra abortion is implied the expulsion of the 
 fcetus before the period of its legal viability, which has 
 been fixed at six months. Abortion is much more fre- 
 quent during the first two months than at a more advanced 
 period of pregnancy. 
 
 Vaginal examinations, in these cases, should be made 
 with much gentleness and care, lest the tendency to abor- 
 tion should be thereby increased. 
 
 Treatment of Abortion. 
 
 3. If the pains are few, the hemorrhage little or 
 none, and the os uteri not open enough to admit 
 the finger, yon may hope to prevent miscarriage. 
 Accordingly you enjoin perfect rest in the horizon- 
 
REQUIRING A CONSULTATION. 53 
 
 tal posture, in a cool room. You then endeavor 
 to check uterine action by opiates. For instance, 
 you may give a draught containing ttt^xx of liq. 
 opii sedat. immediately, followed every two hours 
 by a mixture containing n^v of liq. opii sedat. and 
 5j of infus. rosse acid, to each dose ; or you may 
 give an enema of n^xx of laudanum in giss of gruel 
 every hour until the pains are checked. 
 
 When the patient is plethoric, general or local bleeding 
 may be required in conjunction with opiates ; but before 
 resorting to this measure, the student had better send for 
 further advice. 
 
 Treatment of Abortion — Premature Labor. 
 
 4. If, however, the pains are frequent and in- 
 creasing in severity, and especially if you can feel 
 the ovum protruding, there is but little hope of 
 checking the miscarriage : the case may then be 
 left to nature. But as various accidents (See Part 
 III., 1 and 2) may occur during and after miscar- 
 riage, it requires quite as much watching as a labor 
 at the full term. 
 
 The clots which come away in the course of an abortion 
 should be carefully inspected, to see if they contain the 
 entire ovum, or any portions of it, such as membranes, etc. 
 
 Miscarriages are called premature labors when they take 
 place during the viability of the foetus ; that is, after the 
 sixth month. They differ from abortions in being accom- 
 panied by little or no hemorrhage, and bear more resem- 
 blance to labors at the full term. The means recommended 
 for the arrest of abortion are to be employed with a view 
 to prevent premature delivery. 
 
 [See Chapter on Abortion.] 
 
 5* 
 
54 CASES NOT USUALLY 
 
 Spurious Pains — Diagnosis. 
 
 5. Women, towards the end of pregnancy, occa- 
 sionally suffer from spurious pains, which simulate 
 those of labor. They are distinguished from true 
 labor-pains by their partial and irregular character; 
 but principally by their being unaccompanied with 
 " show," and causing no dilatation of the os uteri. 
 
 False pains are mostly limited to the fundus uteri, and 
 are felt in the abdomen chiefly, around the umbilicus ; 
 whilst true pains are felt mostly in the back and thighs, 
 and affect the whole uterus, but especially the os tincae. 
 
 Spurious Pains — Treatment. 
 
 6. Spurious pains may arise from colic caused 
 by constipation, errors of diet, etc., or from rheu- 
 matism of the uterus, in consequence of cold. Their 
 treatment should depend very much upon their 
 cause. In general, they may be checked by ape- 
 rients, such as a dose of castor oil, or a warm-water 
 enema followed by sedatives, as n^xx of tinct. opii, 
 or gr. x of Dover's powder. 
 
 Spurious pains should always he checked, as they tend 
 to exhaust the woman, and are productive of no good ; 
 nay, they may even retard labor, if it has already com- 
 menced. 
 
 [Enforce the supine position for a time. Never use 
 opium until the bowels are opened.] 
 
 Vomiting during Labor. 
 
 7. Vomiting is a very frequent occurrence during 
 labor, particularly towards the end of the first 
 
REQUIRING A CONSULTATION. 55 
 
 stage. The matter ejected usually consists of 
 mucus, together with any food or drink that has 
 been last taken. It is by no means an unfavorable 
 occurrence, and very rarely requires any treat- 
 ment. 
 
 The vomiting appears to depend on a kind of sympathy 
 between the stomach and the uterus, and is mostly observed 
 at the time when the os uteri is rapidly giving way to the 
 dilating pains. It is a common saying amongst nurses, 
 that " sick labors are safe ;" but it is far otherwise when 
 vomiting comes on after a prolonged second stage, and is 
 accompanied with great prostration, etc. (See Part III. 
 27.) 
 
 Retarded Labor from Loaded Rectum. 
 
 8. Labor is sometimes retarded by a loaded rec- 
 tum. In such cases an indurated cylinder is felt 
 at the back of the vagina, which might be mistaken 
 by an inexperienced person for a prominent sacrum. 
 By a careful vaginal examination you may distin- 
 guish the scybalous masses, and may partially 
 displace them by pressure. The proper treatment 
 is to empty the rectum by an enema of warm 
 water, or, if this fail, by an enema of a pint of 
 warm gruel containing §ss of ol. terebinth., and the 
 same quantity of ol. ricini mixed up with the yelk 
 of an e^s*. 
 
 A loaded state of the rectum is a fertile source of spu- 
 rious pains, as well as a mechanical obstacle to delivery. 
 The obstacle thus presented is seldom insuperable, for the 
 descending head will at last, after much pain to the patient, 
 and greatly to the annoyance of the practitioner, mechani- 
 cally expel the contents of the rectum. 
 
56 CASES NOT USUALLY 
 
 Should the above-mentioned enema fail, it will be neces- 
 sary to break up the hardened mass of feces with a wooden 
 scoop, or the handle of a spoon ; and then to repeat the 
 enema : but as this proceeding requires some care in man- 
 ipulation, it will be more prudent first to send for further 
 advice. 
 
 Tedious First Stage. 
 
 9. The first stage of labor is sometimes very 
 tedious, from various causes, such as inefficient 
 uterine action, rigidity of the soft parts, etc. ; espe- 
 cially in primiparse, and, above all, in those who 
 are not young. In such cases the first stage may 
 last many days. In general, the only remedy is 
 time and patience. The delay, although fatiguing 
 to all parties, is very rarely dangerous: you should, 
 therefore, do all you can to cheer your patient and 
 keep up her spirits. 
 
 The medical attendant should frequently leave the pa- 
 tient's room, and, above all, should beware of making fre- 
 quent examinations. He should assure her that her labor 
 has barely commenced, and that there is no danger. Dr. 
 Churchill's statistics abundantly prove how little danger 
 attends a prolonged first stage. 
 
 Inefficient Uterine Action — Treatment. 
 
 10. Inefficient uterine action may arise from 
 natural delicacy of constitution, or from any de- 
 bilitating cause, either mental or bodily. If the 
 patient be not a primipara, if she has had good 
 labors previously, if the vertex present, and if, in 
 short, you are sure there is no mechanical obstacle 
 to delivery, you may give ergot of rye to increase 
 
REQUIRING A CONSULTATION. 57 
 
 uterine action ; but you should not venture to do 
 so without a consultation, provided any of these 
 conditions present. 
 
 The ergot may be given in three half-drachm doses at 
 intervals of about a quarter of an hour. The bruised or 
 powdered grains will, if good, answer best. One drachm 
 and a half of the powder should be mixed with half a 
 pint of hot water, and allowed to simmer a few minutes 
 over the fire. One-third of this decoction should be given 
 (grounds and all) every quarter of an hour. Or, instead 
 of the powder, the Extract. Ergotse Liquid, may be given 
 in gss doses. [Occasionally ergot fails to have any effect 
 over the uterus, but this is rare. Dr. Meigs extracts a 
 case from Dr. Lee's Clinical Midwifery, in which the pa- 
 tient took gvij in sixteen days, without sensible effect 
 upon the uterus. On the other hand, very small doses may 
 produce violent uterine contraction. These contractions 
 are not like those of natural labor. They are of greater 
 strength and longer duration, "like a number of violent 
 labor-pains continued into one another without intervals."] 
 
 During the progress of a tedious labor, when there is 
 much debility, beef-tea and wine should be given fre- 
 quently. 
 
 Tedious Labor from want of Sleep — Treatment. 
 
 11. Inefficient uterine action not unfrequently 
 arises from want of sleep, and restlessness caused 
 by a prolonged first stage, and thus tends still 
 further to produce delay. In such cases the ad- 
 ministration of a sedative is attended with the 
 best results. After a sound sleep, the patient 
 awakes refreshed, and the pains set in with renewed 
 vigor. 
 
 Twenty minims of Tinct. Opii or 20 grains of Hydrate of 
 Chloral may be given and repeated after three hours, if 
 
58 CASES NOT USUALLY 
 
 necessary. As a hypnotic, Hydrate of Chloral is, in some 
 respects, superior to opium. It may be conveniently given 
 as follows : H Chloral. Hydrat. gr. xl. ; Syrupi Aurantii 
 3ij. ; Aquam adgiv. M., sumat dimidiam part, statum. 
 
 Rigid Os Uteri — Treatment. 
 
 12. Rigidity of the os uteri is a frequent cause 
 of delay in the first stage of labor. It is most 
 usual in primparse, and chiefly in those who have 
 passed the age of thirty-five or forty. The rigid 
 os will generally give way and the labor termi- 
 nate favorably, provided sufficient time be given. 
 Should the woman be plethoric, bleeding, opium, 
 tartar emetic, chloroform, etc., may be resorted to ; 
 but before employing such measures you had better 
 request further advice. 
 
 [Ether or chloroform, administered simply to 
 that extent that will ease and tranquillize the 
 patient, is by far the best remedy for rigidity of 
 os uteri.] 
 
 Premature Rupture of Membranes. 
 
 13. Premature rupture of the membranes may 
 be a cause of a tedious first stage ; the os uteri 
 being dilated much more slowly and painfully by 
 the child's head than by the bag of the-membranes. 
 This is most likely to happen in first labors. In 
 such cases all that is required is time and patience. 
 If there be unusual difficulty, the remedies for an 
 undilatable os uteri are indicated. 
 
REQUIRING A CONSULTATION. 59 
 
 (Edematous Os Uteri. 
 
 It occasionally happens in such cases that the anterior 
 lip of the os uteri becomes swollen and cedematous from 
 pressure between the head and the os pubis. This state 
 of thiugs will nearly always rectify itself in time; but if 
 it should not, the anterior lip may, in the interval of a 
 pain, be raised by the finger above the crown of the head, 
 and kept there during two or three pains, until it is fully 
 retracted. 
 
 Unusual Toughness of Membranes. 
 
 14. Labor is sometimes retarded by unusual 
 toughness of the membranes. Long after the os 
 uteri is fully- dilated, the membranes may remain 
 entire, and the pains, in consequence, not put on 
 the forcing character of the second stage. To 
 remedy this, you should rupture the membranes 
 by pressing firmly upon them with the forefinger, 
 when they are rendered tense by a pain. Should 
 this fail, you may notch the finger-nail like a saw, 
 and rub it to and fro on the bag of the membranes 
 until it gives way. 
 
 [Both of these means will sometimes fail to 
 rupture the membranes. If so, you should — in the 
 absence of a pain — take up a portion of the flaccid 
 membranes between the forefinger and thumb, and 
 as the contraction of the uterus takes place, slightly 
 twist the fold, and you will thus succeed.] 
 
 The membranes should on no account be ruptured until 
 it is quite certain they have answered their purpose by 
 completely dilating the os uteri. 
 
60 CASES NOT USUALLY 
 
 Anterior Obliquity of Uterus. 
 
 15. In some multipara, the abdominal parietes 
 may be so relaxed as to allow the fundus uteri to 
 fail very much forwards. This anterior obliquity 
 of the uterus is called in common language, " pen- 
 dulous belly," and may be a cause of tedious labor. 
 The os uteri is thrown so much upwards and back- 
 wards towards the sacrum, as to be almost out of 
 reach. The remedy is to support the belly by 
 means of a broad bandage, and to keep the woman 
 lying on her back during the pains. 
 
 In addition to the anterior obliquity just described, the 
 fundus uteri may be inclined to either side, constituting 
 lateral obliquity. This species requires much the same • 
 management as the preceding, viz., to support the abdo- 
 men, and to place the patient on the opposite side to that 
 towards which the fundus uteri is inclined. 
 
 Undilatable Vagina and Perineum- — Treatment. 
 
 16. Delay may be occasioned in the second stage 
 of labor by a rigid, undilatable condition of the 
 vagina and perineum. This state is peculiar to 
 primiparse, especially such as are not young, and 
 in these the dilatation of those parts may occupy 
 several hours. The parts feel dry and tense, and 
 admit the finger with difficulty. To promote their 
 dilatation, you may use warm fomentations and 
 inunctions, or you may direct the woman to sit 
 over a pan of warm water. Should these means 
 
REQUIRING A CONSULTATION. 61 
 
 fail, the remedies for an undilatable os uteri are 
 indicated. (See Part II., 12.) 
 
 Chloroform is sometimes of great use in these cases ; 
 but the student should not administer it without a con- 
 sultation. 
 
 [" In all forms inflammation is apt to supervene. Hence 
 watch to prevent it."] 
 
 Presentations ivith Forehead anteriorly — 
 Diagnosis. 
 
 11. Labor may be retarded in the second stage 
 by unfavorable presentations of various kinds. 
 Thus, in some presentations of the vertex, the 
 forehead may be in the anterior, instead of in the 
 posterior semicircle of the pelvis. You may ascer- 
 tain that the head is in this position, even before 
 the os uteri is fully dilated or the membranes rup- 
 tured, by noticing that the posterior lip of the os 
 uteri is much lower in the pelvis than the anterior 
 lip. (Fig. 7, 1.) After the rupture of the mem- 
 branes, the posterior fontanelle will be found in 
 the posterior half of the pelvis, and the anterior 
 fontanelle in the anterior half, behind one or other 
 groin. 
 
 The depression of the posterior lip of the os uteri de- 
 pends on the following circumstances: In ordinary labor 
 the child's head is, at the commencement of the labor, 
 flexed upon its body ; but during its progress the head 
 becomes still more flexed by the chin approaching still 
 nearer to the sternum. The result of this is, that the 
 posterior half of the child's head is much lower than the 
 anterior. Consequently, in the occipito-anterior presenta- 
 
CASES NOT USUALLY 
 
 tions, the occiput, being in front, presses upon the anterior 
 lip of the os uteri, and depresses it much below the level 
 
 Fig. 7. 
 
 1. Occipito- posterior Presentation, 
 
 2. Occipito- anterior Presentation. 
 
REQUIRING A CONSULTATION. 63 
 
 of the posterior lip. (Fig. 7, 2.) But in occipito-posterior 
 presentations the reverse takes place ; the occiput, being 
 behind, depresses the posterior below the anterior lip. 
 (Fig. 7, 1.) Hence the shape and position of the os, on 
 making a vaginal examination, appear to be very different 
 from that which we ordinarily find. In ordinary cases 
 the finger passes but a slight distance into the angle, or 
 cul-de-sac, formed by the junction of the vagina and the 
 anterior lip of the os (see Fig. 2). But in the occipito- 
 posterior positions the finger passes high up behind the 
 symphysis pubis into the cul-de-sac just mentioned, which 
 in this case forms an acute angle, as in the first it formed 
 an obtuse angle. At the same time the posterior lip, and 
 even the entire os, is unusually low in the pelvis. 1 
 
 Presentations of Forehead anteriorly — How 
 altered by Nature. 
 
 18. Many of these cases will be converted by the 
 natural efforts into ordinary vertex presentation. 
 Thus, as the head descends into the pelvis, it will 
 perform a movement of rotation, the forehead 
 moving backwards from the acetabulum to the 
 sacro-iliac synchondrosis on one side, and the occi- 
 put moving forwards in a similar way on the oppo- 
 site. This movement may be effected artificially, 
 provided the second stage be not too far advanced. 
 
 Dr. Ramsbotham thus describes the mode in which such 
 presentations should be altered : " Presuming that, after a 
 number of tolerably strong expulsive pains, no advance 
 takes place in the situation of the head, it will then be 
 proper to embrace the cranium between the first three 
 fingers and the thumb of one or other hand, and to give 
 the face an inclination to the right or left ilium, accord- 
 
 1 See paper by the author on Varieties of Cranial Presenta- 
 tion, British Medical Journal, Feb. 4th, 1852. 
 
64 CASES NOT USUALLY 
 
 ing as its original direction was to the right or left groin ; 
 and this attempt must be made in the absence of uterine 
 contraction, and before the head has become locked in the 
 pelvic cavity; for if it be delayed till a state of impac- 
 tion has occurred, the mal-position cannot be remedied by 
 the power of the hand alone, and instruments will most 
 likely be required in order to finish the delivery." 
 
 The student will do well not to take upon himself the 
 responsibility of altering one of these presentations, be- 
 cause such a proceeding requires an amount of tact and 
 skill which can only be acquired by experience. 
 
 Labor where Forehead continues in Anterior 
 Semicircle. 
 
 19. But, in many instances, the turn above de- 
 scribed does not take place, and the forehead con- 
 tinues in the anterior semicircle. The labor is 
 thus rendered more tedious, but is nevertheless, 
 with but few exceptions, accomplished by the 
 natural efforts. The head, as it presses clown into 
 the cavity of the pelvis, becomes more and more 
 flexed on the body, until at last the anterior fon- 
 tanelle is placed beneath the pubic arch, and the 
 occiput presses on the perineum, causing more dis- 
 tension of that part than usual. Finally, the occi- 
 put is expelled first, and then the forehead and 
 face. (Pig. 8.) 
 
 In ordinary labor, as the head passes through the outlet 
 of the pelvis, the chin leaves the chest, and the head is 
 extended upon the body; in occipito-anterior presenta- 
 tions the reverse takes place, and hence the long axes of 
 the child's head and body are not so well adapted to the 
 axes of the pelvis ; but there is reason to believe that the 
 difficulties of such presentations have been much over- 
 rated, upon grounds which are more theoretical than 
 
REQUIRING A CONSULTATION. 
 
 65 
 
 practical. Thus it has been stated, that, in consequence 
 of its shape being more square, the forehead does not 
 
 Fig. 8. 
 
 adapt itself so well as the occiput to the arch of the pubis, 
 as the head clears the outlet of the pelvis : without con- 
 sidering how materially that shape may be altered by the 
 overlapping of the frontal bones at their suture. It has 
 been likewise stated that, at the moment of expulsion, the 
 perineum is put much more on the stretch, and is in more 
 danger of rupture, because the occipito-frontal diameter 
 of the child's head (which, in the occipitoanterior pre- 
 sentation, is in relation with the antero-posterior diameter 
 of the pelvic outlet) is much longer than the trachelo- 
 bregmatic, which is in apposition with it in ordinary cases. 
 Here, again, no account is taken of the great capability 
 which the occipito-frontal diameter has of being lessened 
 by the overlapping of the parietal and frontal bones at 
 6* 
 
G6 
 
 CASES NOT USUALLY 
 
 the coronal suture. In fact, in most instances of occipito- 
 posterior presentations, this shortening actually takes 
 place to a great extent, so that the head is at first so 
 much altered in shape as to be nearly round ; whereas in 
 the occipitoanterior presentations the head becomes ma- 
 terially lengthened, especially when the labor is at all 
 protracted. 
 
 Should the head be arrested in the cavity of the pelvis 
 for some hours, or should there be unusual difficulty in 
 any of these cases, the student ought to send for assist- 
 ance, as the forceps will probably be required. 
 
 Face Presentations — Mechanism. 
 20. Face presentations occur about once in 231 
 Fig. 9. 
 
REQUIRING A CONSULTATION. 67 
 
 cases. 1 The right cheek-bone ordinarily presents ; 
 the forehead being towards the left acetabulum, 
 and the chin towards the right sacro-iliac synchon- 
 drosis. (See Part III., Fig. 15.) In all face pre- 
 sentations, as the head passes out of the pelvis, 
 the chin makes a turn from behind forwards, so as 
 to emerge bemeath the arch of the pubis, whilst 
 the forehead and vertex sweep over the perineum. 
 (Fig. 9.) 
 
 The ordinary face presentation is in fact nothing more 
 than the ordinary presentation of the vertex, with the 
 head extended instead of flexed upon the body. 
 
 Diagnosis of Face Presentations. 
 
 21. The face can scarcely be confounded with 
 any other presentation except the breech, and that 
 only when the parts are swollen from protracted 
 labor. You may recognize the face, before the 
 membranes are ruptured, by the hard prominences 
 of the molar bone, forehead, bridge of the nose, 
 and rim of the orbit. After the membranes are 
 ruptured, you can feel the openings of the nostrils 
 and mouth, and you can also feel within the mouth 
 the tongue and gums. By the presence of these 
 organs you at once distinguish the mouth from the 
 ■anus, as well as by the absence of meconial dis- 
 charges, etc. (See 24, Part II.) 
 
 If a face presentation be suspected, the part should be 
 examined with gentleness and care. Instances are related 
 
 1 For these statistics see Dr. Churchill's "Midwifery," 
 
68 CASES NOT USUALLY 
 
 in which cheeks have been flayed, and even eyes " gouged 
 out," by the finger-nails of rough, awkward examiners. 
 
 When the child is born, the face is generally much dis- 
 figured ; for if the second stage be at all protracted, the 
 presenting cheek and eyelids become greatly swollen and 
 discolored from ecchymosis. 
 
 Management of Face Presentations. 
 
 22. As a general rule face presentations require 
 no interference. The labor may be longer and 
 more difficult than with a vertex presentation, but 
 will ultimately be finished by the natural efforts. 
 If the head should be arrested, or if the chin should 
 not come round beneath the pubic arch, the for- 
 ceps or vectis may be required. In such a case 
 you should send for assistance. 
 
 The diameters of the face are not longer than those of 
 the vertex ; but the axes are not so well adapted to those 
 of the pelvis, nor is the face so compressible as the vertex. 
 
 Breech Presentations — Mechanism. 
 
 23. The breech presents about once in 59 cases. 
 The body of the child is placed obliquely in the 
 pelvis, with the back either in front towards the 
 right or left acetabulum, or behind, towards the 
 right or left sacro-iliac synchondrosis. The child 
 is expelled with one side behind the pubic arch, 
 and the other in front of the perineum ; and, in 
 favorable cases, the head turns so as to bring the 
 face into the hollow of the sacrum. 
 
 In its natural position the foetus in utero bears some 
 resemblance in shape to an egg, the head forming the large 
 
REQUIRING A CONSULTATION. 
 
 69 
 
 and the nates the small end. On this account a presenta- 
 tion of the latter at first meets with less resistance than 
 one of the former. In such a case, therefore, the first 
 part of the labor should on no account be hastened, but 
 should rather be retarded, so as to give the soft parts 
 ample time to dilate. 
 
 In a proper breech presentation, the legs are so flexed 
 upon the abdomen that the feet are at first out of reach. 
 
 Fig. 10. 
 
 In the most frequent position of the breech, the left 
 ischium of the child presents, and corresponds to the left 
 acetabulum of the mother; the belly of the child being di- 
 rected forwards and to the right. (Fig. 10.) 
 
70 CASES NOT USUALLY 
 
 Diagnosis of Breech Presentation. 
 
 24. You may recognize a breech presentation 
 before the membranes are ruptured, if you can dis- 
 tinguish the cleft between the buttocks, and one or 
 both tubera ischii, and especially if you can make 
 out the pointed prominence of the coccyx in the 
 centre. If you can reach high enough, you may feel 
 the femur and recognize it by its great length. 
 You may also be able to feel the very characteristic 
 prominence of the anterior superior spinous process 
 of the ilium, and to pass your finger into the angle 
 between it and the femur. After the membranes 
 are ruptured, you can distinguish the parts of 
 generation, and meconium will escape from the 
 anus. If you introduce your finger into the anus, 
 you can feel the sphincter ani contracting, and the 
 finger, when withdrawn, will be soiled with meco- 
 nium. 
 
 [The value of being able to diagnosticate a breech pre- 
 sentation was illustrated not long ago by the following 
 circumstance: A prominent medical gentleman of this 
 city, in attendance upon a lady in her confinement, in 
 which, by examination, he found by anus, tuber ischii, scro- 
 tum and penis, there was to be born a son, notified the 
 father accordingly, and of course a son was born. A few 
 days after, the unlearned but delighted father sent the 
 physician a check for five hundred dollars, remarking 
 that any physician deserved that sum who could tell the 
 sex before the birth.] 
 
 The tuber ischii forms a hard, blunt prejection in the 
 centre of the soft cushion presented by the buttock. 
 
 In male children the scrotum occasionally becomes enor- 
 mously swollen from oedema, produced by compression 
 
REQUIRING A CONSULTATION. Tl 
 
 between the thighs. The tumor thus formed may prove 
 very puzzling to the young accoucheur, if not previously 
 aware of the circumstance. 
 
 Cases in which no Interference is necessary. 
 
 25. Breech cases, although more tedious than 
 those where the vertex presents, are not usually 
 dangerous to the mother. But there is much dan- 
 ger to the child from compression of the cord by 
 the head whilst passing through the pelvis. Still, 
 if the patient be not a primipara, if the labor be 
 rapid, and the child favorably situated (that is, 
 with its back in front, and its head and arms flexed 
 upon its body), such cases may terminate well 
 without any kind of manual interference. 
 
 In no instance, perhaps, is so much mischief produced 
 by meddlesome midwifery as in breech presentations ; and 
 yet these are the very cases in which an ignorant midwife, 
 rejoiced at having something to pull at, would drag down 
 the lower extremities under the idea of forwarding the 
 labor. The result is, that time is not allowed for the soft 
 parts to dilate. If traction be made between the pains, 
 the child's arms, previously flexed across the chest, are 
 carried above the head; the chin hitches upon the brim 
 of the pelvis, and a favorable presentation of the head is 
 thus changed into an extremely unfavorable one ; great 
 delay is thereby produced, and the child's life in all proba- 
 bility is sacrificed. 
 
 Gases for Interference. 
 
 26. In most breech presentations, some inter- 
 ference is necessary, but not until the lower half of 
 the body is expelled. The danger to the child 
 then commences : if, therefore, the upper half do 
 
72 CASES NOT USUALLY 
 
 not speedily follow, the labor must be hastened. 
 As soon as you can reach the umbilicus, you may 
 pull down some of the cord, in order to relax it, 
 and then place the rest in the hollow of the sacrum, 
 where it will be more out of the way of pressure. 
 Then, wrap the child's body in flannel, grasp its 
 hips firmly, and hasten its expulsion by steady 
 traction during the pains. If the child's back be 
 situated posteriorly, you must rotate the trunk be- 
 tween the pains so as to bring that part ronnd to 
 the front. 
 
 A convulsive starting of the child's limbs will sometimes 
 indicate the approach of asphyxia from pressure on the 
 cord. When such a symptom is noticed, there is an urgent 
 necessity for immediate delivery. In breech presentations, 
 the patient's friends 1 should be informed that the child is 
 not presenting rightly, and that in consequence its life 
 will be in danger, but that she herself will not incur any 
 additional risk, nor will there be any necessity for turning 
 the child. 
 
 How to bring down At*ms. 
 
 21. If the arms be raised above the head, they 
 must be brought down ; and it is generally easier 
 to bring down the posterior arm first. For this 
 purpose, pass two fingers over the shoulder from 
 the back, and depress the arm obliquely downwards 
 and forwards across the chest. Then bring down 
 the anterior arm in a similar manner. (Pig. 11.) 
 
 1 It is perhaps better not to inform the patient herself. 
 
REQUIRING A CONSULTATION. ?3 
 
 Fig. 11. 
 
 If attempts are made to bring down the arm in an oppo- 
 site direction to that indicated, the elbow will in all proba- 
 bility hitch upon the brim of the pelvis, and. the force 
 being exerted at right angles with the humerus, that bone 
 will almost iuevitably be fractured. 
 
 How to bring down Head. 
 
 28. If the face be in front, and the chin much 
 
 raised from the chest, the position of the head must 
 
 be changed. Pass the first two fingers of the left 
 
 hand into the mouth, and press the chin backwards 
 
 1 
 
u 
 
 CASES NOT USUALLY 
 
 towards the sacrum, and downwards towards the 
 chest of the child (Pig. 12). Then pass two fingers 
 
 Fig. 12. 
 
 of the other hand behind the occiput, grasp the 
 head between both hands, and extract it first down- 
 wards and backwards in the axis of the brim, and 
 then downwards and forwards in the axis of the 
 outlet of the pelvis. If the child be in a state of 
 suspended animation after birth, the proper means 
 
REQUIRING A CONSULTATION. 75 
 
 for restoring it should be bad recourse to. (See 
 Part II., 51 and 52.) 
 
 "When the chin is much raised, the longest diameter of 
 the head, viz., the occipito-mental, corresponds to one of 
 the diameters of the pelvis. By depressing the chin we 
 substitute a shorter diameter, such as the trachelo-breg- 
 matic, or, at all events, the occipito-frontal. 
 
 When the chin is towards the front of the pelvis, it is 
 very likely to hitch over the pubis, and thus prevent the 
 expulsion of the head. 
 
 Should there be unusual difficulty in extracting the 
 head, that object may sometimes be attained by moving 
 both arms simultaneously in the direction of the dotted 
 line in Figure 12. 
 
 If the nose can be reached, it will be found that by 
 placing the two fingers, one on each side of it, and depress- 
 ing the upper maxilla, the head can be acted upon more 
 powerfully than by passing them into the mouth. 
 
 Presentation of Feet or Knees. 
 
 29. Tbe inferior extremities, tbat is, tbe feet or 
 knees, present about once in 105 cases. Tbe feet 
 may present in two ways, either witb tbe toes 
 turned backwards or forwards, tbe former being 
 tbe most common. Wben tbe feet or knees present, 
 they do not dilate tbe soft parts as well as tbe 
 breech. Tbe first part of tbe labor is consequently 
 likely to be quicker tban in a breecb presentation, 
 but tbe last part more lingering. Hence tbere is a 
 greater clanger to the child ; but, in otber respects, 
 tbe mechanism of tbe labor is similar. 
 
76 CASES NOT USUALLY 
 
 Foot Presentations — Diagnosis. 
 
 30. The foot can scarcety be mistaken for any 
 other part except the hand. If you can only reach 
 the toes, you may distinguish them from the fingers 
 by the following peculiarities : The toes are much 
 shorter, and consequently cannot be doubled up 
 like the fingers. The great toe is close to the 
 others, and of the same length, whereas the thumb 
 is shorter than the fingers, and widely separated 
 from them. If you can reach the ankle, yon feel 
 the heel and malleoli ; you also find that the foot 
 is thicker than the hand, and is articulated at right 
 angles with the leg, whereas the hand is in a direct 
 line with the forearm. If the membranes be rup- 
 tured, and especially if both feet can be felt, a 
 mistake is scarcely possible. 
 
 It is of the greatest consequence in these cases that a 
 correct diagnosis should be formed before the water es- 
 cape. At the same time, too much care cannot be taken 
 lest the membranes be ruptured in making the necessary 
 examination. 
 
 Knee Presentations — Diagnosis. 
 
 31. The knee bears more resemblance to the 
 elbow than to any other part ; but it is larger and 
 rounder than the elbow, and you can feel a depres- 
 sion between the two elevations formed by the 
 cond3 r les of the femur. On the contrary, you re- 
 cognize the elbow by the pointed projection of the 
 olecranon between the condyles of the humerus. 
 
REQUIRING A CONSULTATION. 17 
 
 But all doubt is removed if you can reach the foot 
 or the breech, and especially if both knees present. 
 
 It is scarcely possible that both elbows should present 
 at once, but very likely that both knees should do so. 
 
 Management of Knee or Footling Cases. 
 
 32. Knee or footling cases must be managed in 
 the same way as breech presentations, except that 
 there is still more reason for delaying the first part 
 of the labor. If one foot or one knee present, you 
 should not attempt to bring down the other, be- 
 cause a larger dilating body is presented if you 
 allow the limb to remain flexed upon the trunk. 
 
 Compound Presentations. 
 
 33. It sometimes happens that two different parts 
 of the body present, forming what is called a com- 
 pound presentation ; thus the hand may present 
 with the head, the breech, or the foot. The hand 
 is known by the signs enumerated above. (See 30, 
 Part II.) Great care is necessary in examining ; 
 for the head or breech may be pushed up, or the 
 arm pulled down, through ignorance or inadvert- 
 ence. 
 
 Should the arm become completely engaged in the pel- 
 vis, and should the other presenting part recede, the pre- 
 sentation becomes one of the most unfavorable with which 
 the accoucheur has to deal. 
 7* 
 
78 CASES NOT USUALLY 
 
 Management of Presentations of Hand with Head. 
 
 34. When the hand comes down before the head, 
 there is generally more room in the pelvis than 
 usual, and therefore you need be in no hurry to 
 interfere. When the head is fully engaged in the 
 cavity of the pelvis, you may make a cautious at- 
 tempt to push the hand above it. If there be any 
 difficulty in doing this, you may let it remain ; for, 
 in all probability, it will merely have the effect of 
 somewhat retarding the labor. Should, however, 
 the head become arrested, you had better send for 
 assistance, as the forceps may be required. 
 
 Presentations of the hand with the head are more fre- 
 quent in premature deliveries than in labors at full term. 
 
 Treatment of Presentations of Hand with Breech 
 or Foot. 
 
 35. When the hand presents with the breech, the 
 case should be treated as an ordinary breech pre- 
 sentation. If it present with the foot, the foot 
 should be drawn down, so as to convert the case 
 into a presentation of the inferior extremities. 
 
 In presentations of the hand and foot the cord fre- 
 quently prolapses. The safety of the child then requires 
 that the labor should be terminated without delay. 
 
 Plural Births. 
 
 36. " Plural Births" are those in which more 
 than one foetus is expelled. Twins occur about 
 
REQUIRING A CONSULTATION. 79 
 
 once in 81 cases. Cases of three or more at a birth 
 are exceedingly rare. Twin children are nearly 
 alwaj's below the average size; they are inclosed 
 in separate membranous bags ; the placentae also 
 are distinct, although usually united by their 
 edges. In the majority of cases the heads of both 
 children present, but it is almost as common to 
 find the bead of one and the breech or feet of the 
 other presenting. In some rare cases there is only 
 one common placenta. 
 
 [It is estimated that in about two-thirds of the cases 
 the head of each child presents, and the largest one de- 
 scends first. Malpositions of the foetus are far more com- 
 mon in twin cases than in single pregnancies.] 
 
 The mortality amongst twins, and especially triplets or 
 quadruplets, is greater than amongst other children, from 
 the circumstance that these labors are more often prema- 
 ture than others, and also that the children are smaller 
 and less vigorous. 
 
 Mechanism of Twin Labors, 
 
 37. The delivery of the first child Is usually more 
 tedious than an ordinary labor, but the delivery of 
 the second is much more speedy. In most cases 
 there is an interval of rest between the birth of the 
 first and second child, which ma}' vary from five 
 minutes to half an hour or more. The membranes 
 of the second child do not rupture until after the 
 birth of the first ; the two placentae are expelled 
 after the birth of the second child. 
 
 The delivery of the first child is slow, from the circum- 
 stance that much power is lost, because a considerable 
 
80 CASES NOT USUALLY 
 
 portion of the uterine pressure is transmitted indirectly, 
 through the medium of the second child. The delivery 
 of the second child is speedy, because the soft parts are 
 well dilated by the passage of the first. 
 
 The period of repose between the birth of the first and 
 second child has been known to last for several hours, and 
 even days. Dr. Merriman relates a case in which the 
 second child was retained for six weeks. 
 
 Diagnosis of Twins. 
 
 38. Before labor commences there is no certain 
 sign by which you can ascertain the presence of 
 twins, with the exception, perhaps, of that which 
 is derived from the auscultation of two distinct 
 foetal hearts. After the first child is born, the 
 nature of the case is obvious ; if you place your 
 hand on the abdomen, the uterus feels tense, hard, 
 and but a little diminished in size ; if you examine 
 per vaginam, you at once distinguish the bag con- 
 taining the presenting part of the second child. 
 
 Before labor the size of the abdomen is a very fallacious 
 sign of the presence of twins, for it may depend on other 
 causes, such as excess of liquor amnii, etc. But if two 
 distinct bodies can be felt through the parietes, with a 
 sulcus between them, it is very probable that the uterus 
 contains twins. The evidence amounts almost to certainty, 
 if, on applying the stethoscope to two parts of the ab- 
 domen remote from one another, the sound of the fcetal 
 heart is heard distinctly in each situation. The foetal 
 heart gives a double sound, which very much resembles a 
 muffled ticking, such as is heard when a watch is placed 
 beneath a pillow. The beats of the fcetal heart bear no 
 fixed relation in frequency to those of the mother's, but in 
 general there are at least twice as many in a given time. 
 The discrimination of these sounds requires a quiet room 
 and a practised ear ; the student should therefore take 
 every opportunity of making himself familiar with them. 
 
REQUIRING A CONSULTATION. 81 
 
 [The pulsations of the foetal heart will not be heard be- 
 fore the fifth month, as a general rule, and then, according 
 to Frankenhauser. the heart of the male foetus beats one 
 hundred and twenty-four, and that of the female one hun- 
 dred and forty-five in a minute, on an average.] 
 
 [An experienced ear may, from the number of beats, 
 with a great degree of certainty distinguish the sex of the 
 foetus.] 
 
 Management of TicinCases. 
 
 39. The delivery of the first child is to be man- 
 aged in the same way as an ordinary labor. As 
 soon as it is born and separated from the mother, 
 apply a binder round the abdomen, and wait for 
 the expulsion of the second child. Do not attempt 
 to remove the placenta of the first child until after 
 the birth of the second. When this has taken 
 place, the two placentae will be expelled together. 
 If they remain in the vagina, twist the cords to- 
 gether and remove them in the manner directed in 
 38, Part I. 
 
 An alarming hemorrhage might ensue if the first pla- 
 centa were forcibly separated before the birth of the second 
 child, as a large bleeding surface would be thereby ex- 
 posed, at a time when the uterus would be incapable of 
 close contraction. 
 
 The binder is especially necessary in twin cases, because 
 the bleeding surface, which is exposed by the separation 
 of the placentae, is twice as large as in an ordinary case. 
 Moreover, the uterus, in consequence of previous over- 
 distension, is more likely to fall into a state of inertia when 
 the labor is over. 
 
 [It is always best to mark the first child.] 
 
 Inaction of Uterus after Birth of First Child. 
 
 m 
 
 40. Sometimes the uterus remains in a state of 
 
82 CASES NOT USUALLY 
 
 inaction for a considerable period after the birth 
 of the first child. Should there be no pains within 
 half an hour, you may tighten the bandage, and 
 rupture the membranes. Should there be none 
 within an hour, you may give ergot, as directed in 
 10, Part II., provided the presentation is natural. 
 If the second child be not born within an hour and 
 a half, you had better send for assistance. 
 
 Authors are somewhat divided in opinion as to the 
 treatment of these cases : some recommend immediate 
 interference, whilst others advise that they should be left 
 entirely to nature ; the majority, however, are in favor of 
 a middle course. It is not well to interfere too soon after 
 the birth of the first child, because the woman may be 
 somewhat exhausted, and may need a little repose. At 
 the same time, it is not advisable to delay interference too 
 long, e. g., for several hours, because the soft parts, which 
 have been well dilated by the first child, will have time to 
 contract, and thus any operation (such as turning or the 
 application of the forceps) which may be required will be 
 rendered much more difficult. If there are symptoms of 
 exhaustion after the birth of the second child, a teaspoon- 
 ful of brandy may be given, together with rr^xxx of tinct. 
 opii. 
 
 In all twin cases, the patient should be informed, when 
 the first child is born, that she is likely to give birth to a 
 second. 
 
 This should not be told to her abruptly, and at the same 
 time she should be cheered by the assurance that in all 
 probability she will not have to go through one-tenth part 
 of the suffering which she has already endured. 
 
 Tedious Labor from Disproportion between Head 
 and Pelvis. 
 
 41. The second stage oflabormaybe retarded 
 by a slight disproportion between the size of the 
 head and pelvis : thus, the former may be larger 
 
REQUIRING A CONSULTATION. 83 
 
 than usual, and the latter somewhat contracted, 
 either at its brim, cavity, or outlet. If the dispro- 
 portion be not great, the uterine efforts will proba- 
 bly overcome the resistance, after some hours of 
 additional suffering, without any bad result to 
 either mother or child. 
 
 The pelvis may be too small in all its proportions, or it 
 may be irregular in consequence of disease. (See Note 10, 
 Part III.) 
 
 A very large and firmly ossified fcetal head may be a 
 cause of difficult labor, especially when the pelvis is not 
 roomy ; this cause is more often met with in male than 
 female children. 
 
 WJien such Cases may he left to Nature. 
 
 42. Cases of tedious labor from want of room in 
 the pelvis require much time and patience, and 
 should not be hastily interfered with. You may 
 safely leave them to nature, so long as the general 
 condition of the woman is good, the pains being 
 regular and powerful, and the head advancing ever 
 so little in a given time ; the passages being neither 
 hot nor tender, and the pulse not rising above 100 
 between the pains. 
 
 One of the first lessons which the young accoucheur has 
 to learn is patience. Patience enables the adept, who 
 knows by experience what pangs nature will endure at 
 such times, and yet in the end accomplish her work safely, 
 to quietly await the result, when the tyro, listening to the 
 suggestions of his own timorous imagination, and to the 
 entreaties of the woman and her friends, would rashly re- 
 sort to instruments, and, perhaps, sacrifice the lives of the 
 mother and her helpless offspring. 
 
84 CASES NOT USUALLY 
 
 The student should take care not to mistake the elonga- 
 tion of the cranium and swelling of the scalp, which are 
 so marked in difficult labors, for an advance of the head. 
 
 Retention of Urine daring Labor. 
 
 43. In tedious labors, the pressure of the head 
 upon the bladder may cause retention of urine. If 
 there be any doubt as to the woman's ability to 
 pass water, you should draw it off. For this pur- 
 pose, an elastic male catheter is preferable to the 
 ordinary instrument. The woman lying on her 
 left side, feel for the meatus urinarius with the tip 
 of the left forefinger. You will find it beneath the 
 pubic arch, and just above the vaginal orifice, from 
 which it is separated by a slight projection. Then 
 introduce the catheter (previously oiled), push it 
 on into the bladder, and receive the urine in a small 
 basin. If the child's head resist the catheter, you 
 must repress it a little with your fingers. 
 
 Nurses are very apt to confound the dribbling away of 
 liquor amnii with passing water, and vice versa. Their 
 statements, therefore, must be received with much caution. 
 
 During labor, the urethra becomes elongated, and passes 
 almost straight up behind the symphysis pubis. It is on 
 this account that a long flexible catheter is preferable. 
 
 When the labor is lingering, the parts of generation 
 may become so swollen, that it is difficult to detect the 
 meatus urinarius. When such is the case, the parts must 
 be exposed to view : it is better to do this than to run any 
 risk from long-continued retention of urine. 
 
 The catheter should always be used before turning, or 
 employing instruments. 
 
REQUIRING A CONSULTATION. 85 
 
 Cramps during Labor. 
 
 44. During the second stage of labor, the pres- 
 sure of the head upon the sacral nerves occasionally 
 produces very painful cramps in the thighs and legs. 
 Delivery is the only remedy for these ; but some 
 relief may be afforded by friction of the affected 
 limb. 
 
 Should simple friction be insufficient, the limb may be 
 rubbed with the liniment, chloroform. 
 
 Sometimes the pain arising from cramps is so excru- 
 ciating as to render the inhalation of chloroform advisable. 
 Before adopting this measure, a consultation should be 
 requested. 
 
 Death of Foetus before or during Labor. 
 
 45. The foetus may die either before or during 
 labor. If it die before the full term of pregnancy, 
 it will be retained until it appears to act as a 
 foreign body, and excites the uterus to throw it off. 
 The time during which it thus remains may vary 
 from a few hours to several clays, or even weeks. 
 
 The death of the foetus may be caused by intra-uterine 
 disease, such as syphilis, etc. ; by blows, falls, or other 
 shocks, or it may be a result of difficult labor. According 
 to the time that the foetus has been retained in utero, it 
 may either be slightly decomposed, as shown by some dis- 
 coloration and peeling of the cuticle, or it may be so putrid 
 and rotten that it will scarcely hang together. 
 
 Signs of Death of Foetus. 
 
 46. When the foetus dies before labor, its move- 
 ments cease to be felt, the abdomen subsides, and 
 
86 CASES NOT USUALLY 
 
 there is a feeling of coldness and weight in the 
 uterine region. The breasts become flaccid, and 
 lose the characteristic appearance of pregnancy. 
 The woman's health suffers ; her breath is offen- 
 sive, and her eyes are surrounded by a dark circle. 
 During labor, the cranial bones feel loose and 
 movable beneath the flaccid scalp, and there is 
 no caput succedaneum, however long the labor 
 may have lasted. If there be much decomposition, 
 the scalp becomes emphysematous, and crackles 
 under the linger. The liquor amnii contains me- 
 conium ; the discharges are offensive, and flatus 
 often escapes from the uterus. But auscultation 
 affords the surest sign, both before and during 
 labor. If the foetal heart has been heard distinctly, 
 and if its pulsations, after a time, become quicker 
 and fainter, and cease altogether, you have tolera- 
 bly certain proof of the death of the foetus. 
 
 Many of the signs first enumerated are, when taken by 
 themselves, extremely equivocal, because they depend very 
 much upon sensations which are apt to be fallacious. The 
 diagnosis of the death of the foetus may be a matter of 
 much importance in difficult labor; for it may determine 
 the kind of instrumental interference which is to be em- 
 ployed. The looseness of the cranial bones arises from the 
 pulpy condition of the brain produced by decomposition. 
 The emphysema of the scalp is caused by gas generated 
 during putrefaction. When meconium escapes with the 
 liquor amnii in a head presentation, it is a suspicious cir- 
 cumstance, as it indicates a relaxation of the sphincter 
 ani. 
 
REQUIRING A CONSULTATION. 8T 
 
 Management of Delivery with Stillborn Children. 
 
 47. When the child is dead, the progress of the 
 labor is not materially affected. The uterine action 
 ma}^, perhaps, be somewhat torpid, and a dose of 
 ergot may be necessary. For some days after the 
 labor the vagina should be well syringed with 
 warm water, in order to wash awa}' any putrid 
 matters which may remain behind. This should 
 be done once every day at least. 
 
 The absorption of any kind of putrid matter should be 
 carefully guarded against, as it is a fertile source of puer- 
 peral fever. 
 
 For the purpose of syringing out the vagina, an India- 
 rubber bottle, or an ordinary enema apparatus, will answer 
 very well. 
 
 Coiling of Cord round Neck — Treatment. 
 
 48. When the child's head is born, it often hap- 
 pens that the cord is twisted once or twice round 
 the neck. This is seldom a matter of much con- 
 sequence, because, in these cases, the cord is gene- 
 rally longer than usual. You may draw down a 
 loop of the cord so as to relieve its tension, and, 
 if you can, slip it over the head. If it be too tight 
 for this, you may slip it over the shoulders. When 
 the cord is so unusually tight as to threaten 
 strangulation of the infant, you may divide it, 
 taking care immediately afterwards to secure the 
 cut vessels by ligatures. Such a proceeding, how- 
 ever, is scarcely ever necessary. 
 
88 CASES NOT USUALLY 
 
 The coiling of the cord around the neck or limbs ap- 
 pears to be a provision of nature for disposing of its super- 
 fluous length, and obviating the danger of prolapse. 
 
 If, as very seldom happens, a short cord be tightly 
 twisted around the neck, the child is in danger both of 
 strangulation and compression of the cord. There is also 
 some risk of forcible detachment of the placenta, or even 
 an inversion of the uterus. 
 
 Delay in Expulsion of Body — Treatment. 
 
 49. Sometimes there is a considerable delay after 
 the birth of the child's head. The face becomes 
 livid and much swollen, and the child appears in 
 imminent danger of strangulation or apoplexy. If 
 after ten minutes the body should not be expelled, 
 the delivery may be assisted by making firm pres- 
 sure on the fundus uteri, and using gentle traction 
 upon the neck, or, still better, upon the trunk, by 
 passing up the forefinger along the neck and hook- 
 ing it round the axilla. 
 
 The pressure upon the fundus uteri is made for the pur- 
 pose of inducing uterine contraction, and thus obviating 
 the danger of post-partum hemorrhage. 
 
 Asphyxia of Infant — Causes. 
 
 50. When the child is born, it may be in a state 
 of suspended animation from asphyxia; the heart 
 beats, but there are no respiratory efforts. This 
 condition may arise from various causes, such as 
 pressure on the head during a long labor, flooding 
 from premature detachment of the placenta, com- 
 pression of the cord or neck during birth, etc. 
 
REQUIRING A CONSULTATION. 89 
 
 In some instances, the condition of the child borders 
 closely upon syncope from anaemia; such would be the 
 result of flooding from premature detachment of the pla- 
 centa. In others, there is a state of cerebral congestion 
 approaching apoplexy, and this we should expect to find 
 where there has been a long interval between the birth of 
 the head and the body, and, consequently, much pressure 
 on the neck. 
 
 Treatment of Asphyxia. 
 
 51. If the cord pulsates you should not, as a 
 general rule, tie it for at least a quarter of an hour ; 
 but if the child appears to be in an apoplectic con- 
 dition, as shown by great swelling and lividity of 
 the countenace, you may at once divide the cord, 
 and allow two or three teaspoonsful of blood to 
 escape from it. In all cases you may first attempt 
 to induce respiration by exposing the face freely 
 to the air, and sprinkling it with cold water ; by 
 wetting the trunk and limbs with brandy, and rub- 
 bing them briskly with warm flannels. You may 
 try these means for a minute or two; but if they 
 fail, you must have recourse to artificial respira- 
 tion without delaj r . 
 
 The popular remedy, amongst nurses, of slapping the 
 child's buttocks will sometimes succeed in producing a re- 
 spiratory effort. Galvanism is a powerful means of resus- 
 citation when a proper apparatus is at hand. 
 
 Other means of exciting respiration have been recom- 
 mended, such as holding ammonia or burnt feathers to the 
 nostrils, tickling the fauces with a feather, etc. 
 
 Care should always be taken in these cases to free the 
 mouth or fauces from any mucus which may clog them. 
 
 The contact of cold air with the skin is a powerful 
 8* 
 
90 CASES NOT USUALLY/ 
 
 stimulus to the respiratory act, and therefore the child's 
 face should always be freely uncovered. 
 
 The limbs should be rubbed with gentle pressure up- 
 wards, in order to promote the circulation by propelling 
 the venous blood towards the heart. 
 
 Mode of performing Artificial Respiration. 
 
 52. The most efficient means of resuscitation is 
 undoubtedly artificial respiration. To perform 
 this, first place the infant briskly in the prone 
 position, so as to clear the fauces of mucus or 
 other fluids. Then place it in a sitting posture, 
 and alternately raise it up by the arms and set it 
 down again, about twenty times in a minute. Each 
 time that the child is set down the arms should be 
 pressed gently against the sides and the head in- 
 clined forwards. These movements should be con- 
 tinued until the child breathes with regularity ; and 
 they should not be abandoned as hopeless whilst 
 the least pulsation of the heart is perceptible. 
 
 The mode of performing artificial respiration which has 
 been just mentioned is, with some slight modifications, the 
 same as Dr. Silvester's, whose plan received the approval 
 of the Medico-Chirurgical Society. It has been found to 
 be a more effectual method of inflating the chest than 
 that recommended by the late Dr. Marshall Hall. The 
 latter, however, will in many cases, answer very well, 
 and is thus performed : Place the infant in the prone po- 
 sition, make gentle pressure on the back of the thorax, 
 and then remove that pressure, turn the child on the side 
 and a little beyond. This should be repeated about 
 twenty times in a minute. The child is then to be placed 
 with the face prone, and douched rapidly with hot and 
 cold water alternately. 
 
 The old-fashioned mode of performing artificial respira- 
 
REQUIRING A CONSULTATION. 91 
 
 tion is still preferred by some, and consists in inflation of 
 the lungs by means of a proper tube, or, in default of it, 
 a quill or piece of tobacco pipe. If the tube is used, it 
 should be inserted into the larynx. To do this, the fore- 
 finger of the left hand should be passed over the root of 
 the tongue until it reaches the epiglottis. The end of the 
 tube is then to be passed between the tip of the finger and 
 the posterior surface of the epiglottis, and introduced 
 into the rima glottidis. If a quill or tobacco pipe is used, 
 the child's lips are pressed around the tube and its nostrils 
 closed ; at the same time the larynx is pressed backwards 
 so as to shut the oesophagus. The lungs are then inflated 
 by alternately blowing into the mouth and depressing the 
 ribs with the hand. Care should be taken not to inflate 
 too forcibly, for fear of rupturing some of the pulmonary 
 air-cells. This method, however, is inferior in efficacy to 
 the two others, and especially to the first. It does not 
 imitate the natural respiratory movements so closely, and 
 it may injure the delicate tissue of an infant's lung. But 
 yet, in any case, whenever one plan appears to fail, another 
 may be tried. 
 
 It is sometimes necessary to continue artificial respira- 
 tion for at least an hour and a half. 
 
 The hot and cold water used for sprinkling the child 
 should be respectively of the temperature of about 60° 
 and 100° Fahr. 
 
 [Xo method of resuscitating the asphyxiated is 
 equal to that form of artificial respiration, consist- 
 ing simply of blowing air from your own lungs 
 into the mouth of the infant, and closing the nostrils 
 of the child at the same time. No tube or pipe is 
 needed, the physician placing his mouth in direct 
 contact with that of the child. At the same time 
 the feet are to be kept warm, and a stimulating 
 enema may be thrown into the rectum. By these 
 means resuscitation may be accomplished, even 
 after a long continuance of the asphyxia. 
 
92 CASES NOT USUALLY 
 
 About a year since I attended a case of labor, and the 
 child did not show the slightest signs of life for thirty- 
 three minutes. The above means were used, and after the 
 above time the child gave its first gasp. The attendant, 
 therefore, should never abandon the child as dead until he 
 has used every means towards resuscitation for at least an 
 hour and a half.] 
 
 Post-Partum Hemorrhage, or u Flooding y 
 
 53. The flow of blood which usually accompanies 
 the separation of the placenta may be so excessive 
 as to produce marked constitutional symptoms. It 
 is then called post-partum hemorrhage, because it 
 follows the birth of the child. The hemorrhage is 
 always occasioned by uterine inertia, and, if pro- 
 fuse, may cause pallor of the lips and face, weak, 
 fluttering pulse, faintness, sighing respiration, dim- 
 ness of sight, dysphagia, jactitation, convulsions, 
 and death. 
 
 Post-partum hemorrhage is always a dangerous and 
 alarming accident, requiring prompt and vigorous treat- 
 ment. 
 
 Every student who attends midwifery should know how 
 to meet such cases when they occur. Dr. Gooch has well 
 remarked, "In these cases you would give anything for a 
 consultation, but there is no time for it; the life of the 
 patient depends on the man who is on the spot ; he must 
 stand to his gun, and trust to his own resources. A prac- 
 titioner who is not fully competent to undertake these 
 cases of hemorrhage can never conscientiously cross the 
 threshold of a lying-in chamber." 
 
 In most cases of post-partum hemorrhage an unnatural 
 rapidity and jerking of the pulse may be noticed before 
 the actual occurrence of flooding. Dr. Churchill, in his 
 " Theory and Practice of Midwifery," has made some 
 valuable remarks on this point. He says: "In almost all 
 
REQUIRING A CONSULTATION. 93 
 
 the cases of flooding after labor, when I have had an op- 
 portunity of examining the pulse, up to the time of the 
 occurrence, I have found it remain quick, and perhaps 
 full, instead of sinking after delivery. This has been so 
 marked in several cases that I now never leave a patient 
 so long as this peculiarity remains ; and in more than one 
 instance I believe the patient has owed her safety to this 
 precaution. Three cases occurred within a very short 
 time of each other, in which I noticed this undue quick- 
 ness of the pulse, without any other untoward symptom; 
 at that time there was no excessive discharge, and the 
 uterus was well contracted. In all these, alarming hemor- 
 rhage occurred within an hour, and was with difficulty 
 arrested." 
 
 [" It is in instances like these that promptness, 
 decision, and energy must take the place of sym- 
 patic In 163,138 cases hemorrhage occurred 1338 
 times, or about 1 in 122. Out of 782 cases of 
 hemorrhage, 126 mothers were lost." "Dr. Collins 
 reports 44 cases of hemorrhage after expulsion of 
 the placenta. In 31 of these, the child was of the 
 male, and in 13, or less than one-third, it was of 
 the female sex."] 
 
 Symptoms of Post- Par turn Hemorrhage. 
 
 54. In most cases of post-partum hemorrhage 
 the flooding is sufficiently obvious, both to the 
 woman and her attendants, for the blood will gush 
 forth upon the bed-clothes and mattress until they 
 are saturated, and then run in a full stream on the 
 floor. The uterus will be felt to be in a relaxed 
 and flabby condition, so that you can scarcely de- 
 fine its limits ; or, if it contract and harden for a 
 
94 CASES NOT USUALLY 
 
 few seconds, it will speedily return to its former 
 state. 
 
 In all cases where there is any reason to apprehend 
 hemorrhage, the pulse should be frequently felt, and the 
 uterus examined. The patient should be asked whether 
 she feels any discharge running from her ; and the napkin 
 should be frequently removed and inspected. 
 
 Treatment of Post-Par turn Hemorrhage. 
 
 55. In treating post-partum hemorrhage, the chief 
 indication is to produce uterine contraction. For 
 this purpose, grasp the uterus firmly with one or 
 both hands, and keep up the pressure for a con- 
 siderable period. Apply frequently cold wet cloths, 
 or a bladder containing ice, to the vulva, hj^pogas- 
 trium, and thighs. Keep the woman's head low 
 by taking aw r ay the pillows, and remove all the 
 clothes, except a sheet, from the lower part of 
 her body. Give a full dose of ergot immediately. 
 This may be followed in a quarter of an hour 
 by a tablespoonful of oil of turpentine. If there 
 be much tendency to syncope, give stimulants, 
 such as brandy, ether, or sal volatile. Do not 
 leave the woman for at least three hours after 
 the birth of the child, nor until the uterus remains 
 well contracted. Before leaving, give an opiate 
 to tranquillize the nervous system. Also place a 
 good-sized compress upon the uterus, and apply a 
 binder firmly round the abdomen. [This rule laid 
 down here, of giving opium, seems to me very 
 questionable. A young student or physician may 
 
REQUIRING A CONSULTATION. 95 
 
 attend his first case of post-partum hemorrhage, 
 and having administered the opiate, leave his 
 patient, and under its influence the uterus may be 
 relaxed, and the life lost. Better not leave the house 
 till the uterus is hard like a " cannon ball." If 
 opium is used, let it be as a gentle general seda- 
 tive.] 
 
 3j of the Extractum Ergotse Liquid, may be given at 
 once in these cases. If the woman be a multipara, who 
 has previously suffered from post-partum hemorrhage, it 
 is an excellent plan to give the ergot shortly before the 
 birth of the child. Hemorrhage may be thus entirely 
 prevented. 
 
 The oil of turpentine may be given with an equal pro- 
 portion of milk. 
 
 If the uterus do not contract when grasped, it may be 
 pressed and kneaded by the hands in various ways, or 
 friction may be made on its surface, through the loose 
 abdominal parietes. The cloths may be wetted with vine- 
 gar and water. The more suddenly they are applied the 
 better. 
 
 A tablespoonful of brandy, or a teaspoonful of sal vola- 
 tile, may be given at a time. The sal volatile may be 
 given either in milk or water. 
 
 The dose of opium given should be about "nixxx of the 
 tincture. 
 
 One of the best compresses which can be used in these 
 cases is a large old-fashioned pin-cushion, such as is often 
 seen in lying-in rooms garnished with " Welcome, little 
 stranger," or some other appropriate device, in pins. 
 After carefully ridding it of all pins and needles, the 
 cushion may be turned to good account in the way men- 
 tioned. In default of it, two or three folded napkins, or 
 a small thick book may be used. 
 
 Should the means above recommended be not successful 
 in speedily checking the hemorrhage, the student should 
 send for assistance without delay. 
 
 There are several other methods of inducing uterine 
 contraction, in case the above expedients do not answer. 
 
96 CASES NOT USUALLY 
 
 Some of them, however, require much skill, and would be 
 attended with considerable risk, in the hands of an inex- 
 perienced student. One of the safest and simplest is the 
 cold douche. As Dr. Marshall Hall has shown, it is a 
 very powerful means of exciting reflex uterine contrac- 
 tion. The abdomen being uncovered, a stream of cold 
 water is to be poured upon the hypogastrium from a con- 
 siderable height, by means of a jug. 
 
 Injections of cold water into the rectum will frequently 
 succeed in arresting uterine hemorrhage. The applica- 
 tion of the child to the breast is another safe and simple 
 remedy, and has been strongly recommended by Dr. Rigby. 
 [See p. 46. J A contraction of the uterus is produced 
 from the sympathy between that organ and the mamma, 
 This expedient is well worthy of a trial in all cases of 
 flooding after labor. 
 
 Compression of the abdominal aorta has been frequently 
 successful in post-partum hemorrhage. 
 
 The introduction of the hand into the uterus will some- 
 times excite that organ to contract, when other means 
 fail. 
 
 When the hand is in the uterus, it may be moved about, 
 so as to increase the stimulus occasioned by its presence. 
 The bleeding vessels may also be compressed between the 
 knuckles of that hand, and the palm of the other, placed 
 on the outside of the abdomen. This proceeding should 
 only be adopted when others fail, as it is attended with 
 some risk of uterine inflammation. 
 
 Dr. Tyler Smith speaks very highly of injections of iced 
 water into the uterus as a means of arresting hemorrhage. 
 
 Dr. Robert Barnes strongly recommends injections of 
 perchloride of iron into the uterus. He uses a solution 
 consisting of four ounces of liquor ferri perchloridi fortior 
 of the British Pharmacopaeia, with twelve ounces of water. 
 This should be thrown up by means of a Higginson's 
 syringe, and long elastic tubes. Galvanism has been 
 frequently applied with good effect in cases of uterine in- 
 ertia. 
 
 Lastly, women have been saved when in imminent dan- 
 ger of death from hemorrhage, by the operation of trans- 
 fusion, which consists in abstracting blood from the vein 
 of a healthy person, and injecting it into the vein of the 
 
REQUIRING A CONSULTATION. 97 
 
 patient. But this operation, as well as some of those 
 mentioned just before, should not be attempted without a 
 consultation. 
 
 [If there is any organic disease of the uterus, as fibroid 
 tumors for example, it will be well to compress the aorta.] 
 
 Internal Hemorrhage — Diagnosis. 
 
 56. In some instances, which are not very com- 
 mon, there is no external hemorrhage, but the 
 bleeding takes plaee internally, into the cavity of 
 the uterus. The usual symptoms of hemorrhage 
 appear, but without discharge of blood. The uterus 
 swells, and becomes almost as large as if it con- 
 tained a second child ; but, at the same time, feels 
 soft and doughy, and not firm and hard, like a 
 uterus containing a child. On examining, you find 
 its cavity filled with fluid blood and coagula. 
 
 In internal hemorrhage, the os uteri is closed by the 
 detached placenta, by a coagulum, or by a circular con- 
 striction of its fibres, etc. 
 
 Treatment of Internal Hemorrhage. 
 
 57. In internal hemorrhage, the first indication 
 is to facilitate the flow of blood through the os 
 uteri, and the next to insure uterine contraction. 
 To accomplish the first, introduce your hand into 
 the uterus, and remove the detached placenta, or 
 any large coagula which may obstruct the open- 
 ing of the os. Then use the means for producing 
 uterine contraction, which have been before de- 
 scribed. 
 
 9 
 
98 CASES NOT USUALLY 
 
 In all cases of post-partum hemorrhage, the placenta 
 should be removed when detached, whether it be in the 
 uterus or vagina. 
 
 When the woman is in the ordinary position, the left 
 hand will be found the most convenient for introduction 
 into the uterus, because it is better adapted to the curve 
 of the sacrum. 
 
 Those clots only ought to be removed which are de- 
 tached, and in the lower part of the uterus. The removal 
 of clots which are adherent to the uterine parietcs would 
 be very likely to cause a great increase of flooding. 
 
 After-pains. 
 
 58. Women, after delivery, are liable to painful 
 contractions of the uterus, which are called " after- 
 pains." These are very common in multipara, but 
 comparatively rare in primapara. They come on 
 immediately after the expulsion of the placenta, 
 and may continue for many hours, or even for one 
 or two days. They recur at intervals, like labor 
 pains, and often serve to expel coagula and other 
 matters from the uterus. 
 
 Although after-pains occasion much suffering, they sel- 
 dom give rise to any fever, or abdominal tenderness. The 
 woman feels quite easy between each pain. The suffering 
 produced by them is borne with much impatience, from a 
 belief that they do no good. This idea is not strictly cor- 
 rect, as they are frequently caused by efforts which the 
 uterus makes to get rid of clots, or portions of membrane 
 remaining in its cavity. Nevertheless, it is certain that 
 in some of the worst cases of after-pains, no such cause 
 can be detected. 
 
 Treatment of After-pains. 
 
 59. As a general rule, after-pains should not be 
 checked, in any way, for at least six hours after 
 
REQUIRING A CONSULTATION. 99 
 
 delivery ; if b}^ that time the}' continue with un- 
 abated severity, and seem likely to prevent sleep, 
 you should give an opiate, and this may be re- 
 peated every six hours if necessary. Warm fomen- 
 tations to the abdomen are also of service. 
 
 Should the uterus feel larger and harder than usual, 
 there is in all probability something within its cavity which 
 it is endeavoring to throw off. An examination may there- 
 fore be made, and if any clot or portion of membrane be 
 detected by the finger, it should be removed. Purgative 
 enemata are of much service in promoting the expulsion 
 of clots. 
 
 In order to check after-pains, lUxv of tinct. opii may be 
 given, at a time, in gj mist, cam ph. 
 
 The most convenient kind of warm fomentation is the 
 application of large flannels wrung out of hot water. 
 These should be covered over with dry flannel, or, what is 
 better, a piece of oiled silk or sheet gutta percha. A 
 large piece of spongio piline will answer the same purpose 
 very well. 
 
 [It is best even before giving the sedative to remove 
 clots or membranes in the uterus or vagina, as this may be 
 the cause of the pains. Also examine the rectum and 
 bladder.] 
 
 Nervous shock after Delivery. 
 
 60. Some women, especially those of hysterical 
 temperament, show symptoms of a severe nervous 
 shock after delivery. They appear much exhausted, 
 and are liable to attacks of syncope. There is 
 often severe headache, and much intolerance of 
 light and sound. The pulse is soft and compressi- 
 ble ; sometimes slower, but much more frequently 
 faster than usual. The countenance is pale and 
 
100 CASES NOT USUALLY 
 
 anxious, the tongue moist and tolerably clean, the 
 skin soft and perspirable. 
 
 When the headache depends upon constipation or dis- 
 ordered bowels, the tongue will be coated with fur, and 
 very probably red at its tip and edges. 
 
 Should it depend upon any inflammatory affection of the 
 abdominal organs, the secretions of milk and lochia will 
 be checked. 
 
 Should there be much tendency to syncope, a stetho- 
 scopic examination of the heart should be made, to ascer- 
 tain whether there is any organic disease of that organ. 
 
 Treatment of Nervous Shock. 
 
 61. When there is a severe nervous shock after 
 delivery, the best remedy is an opiate combined 
 with a diffusible stimulant ; and this may be re- 
 peated, if necessary, in smaller doses every four 
 hours. The most perfect repose should be enjoined. 
 The head should be placed rather lower than usual, 
 and the horizontal posture strictly maintained. 
 
 The following draught will answer the purpose very 
 well : — 
 
 R. — Liq. morphise hydrochlor., rn^xxx 1 . 
 
 Spt. ammon. foetid., gss. 2 
 
 Aq. camph. ad ^jss. 
 M. ft. Haustus statim sumend. 
 
 Or this :— 
 
 R. — Liq. morphise acetat., tt^xxx. 
 
 Trse. Sumbnl., rr^xx. 
 
 Spt. Chloroform., ""Ix. 
 
 Aq. camph. ad gjss. 
 M. ft. Haustus statim sumend. 
 
 1 [Sol. morphise muriat.] 
 
 2 [L. E. D. Useless preparation, according to Prof. Carson.] 
 
REQUIRING A CONSULTATION. 101 
 
 Sleeplessness after Delivery. 
 
 62. Women of a nervous excitable temperament 
 are sometimes troubled with insomnia or sleepless- 
 ness after delivery. This requires absolute repose 
 and quiet; tea and coffee should be forbidden, and 
 an opiate or a dose of hydrate of chloral adminis- 
 tered. 
 
 The following will be found to be a good form of opiate : 
 
 R. — Liq. morphias acet, rr^xxx. 
 
 Spt. chloroform, t*\x. 
 
 Aq. camph., §jss. 
 M. ft. Haust. hora somni sumend. 
 
 Hydrate of chloral is often a more effectual remedy for 
 insomnia than opium, and does not leave, like opium, un- 
 pleasant after effects. 
 It may be given thus : — 
 
 R. — Chloral Hydrat., gr. xxx. 
 Syrup. Aurantii, ^ij. 
 Aquam ad giij. 
 M. ft. Haust. hora somni sumend. 
 
 Or two scruple doses may be given as recommended in 
 11, Part II. 
 
 [Great care should be observed in the administration 
 of chloral.] 
 
 Retention of Urine after Delivery — Treatment. 
 
 63. Retention of urine is sometimes a conse- 
 quence of a tedious labor, and arises from swelling 
 of the vaginal orifice and meatus urinarius, to- 
 gether with some loss of power in the bladder. 
 You may first try the application of warm fomen- 
 tations to the vulva; if these do not produce the 
 desired effect, you must use the catheter. If the 
 
 9* 
 
102 CASES NOT USUALLY 
 
 inability to pass water continue, tonics and diu- 
 retics should be given. 
 
 The following mixture may be administered in these 
 cases : — 
 
 R. — Tinct. ferri perchlorid., 
 Spt. aeth. nit,, aa^j. 
 Aquam ad gviij. 
 M. Capt. sextam partem ter die. 
 Sometimes when the patient has been weakened by 
 tedious labor or flooding, there will be inability to pass 
 water so long as she remains in the supine position ; but 
 a slight change of position, such as elevating the shoulders 
 (if not otherwise improper), or turning on the elbows and 
 knees, w T ill suffice to overcome the difficulty. 
 
 Incontinence of Urine after Delivery — its 
 Treatment. 
 
 64. Incontinence of urine is occasionally a result 
 of tedious labor, and is caused by temporary para- 
 lysis of the sphincter vesicae from long-continued 
 pressure. If the power of retaining the urine be 
 not recovered in a few days, preparations of iron 
 or other tonics should be given. 
 
 The following formula is a suitable one : — 
 R. — Tree Cantharides, 
 
 Trae ferri perchlor., aa gj. 
 Syrupi, gij. 
 Aquae, gvijss. 
 M. Sumat. sextam partem ter die. 
 Should this fail, the following mixture may be had re- 
 course to :— 
 
 R. — Liquor Strychnia?, rr^xxx. 
 Syrupi, ^ij. 
 
 Trae. ferri perchlor., gij. 
 Aquae, gvijss. 
 M. Capt. sextam partem ter die. 
 
REQUIRING A CONSULTATION. 103 
 
 The author has found this mixture of the greatest ser- 
 vice both in retention and incontinence of urine, arising 
 from loss of power in the bladder after delivery. 
 
 Incontinence of urine sometimes arises from sloughing 
 of the base of the bladder after very severe labor. Incon- 
 tinence from this cause does not come on immediately after 
 delivery, and is generally preceded by much local pain, 
 tenderness, and fetid discharge, accompanied with conside- 
 rable fever and constitutional irritation. When such symp- 
 toms are present, the student should request a consultation. 
 
 Deficiency of Lochial Discharge — Treatment 
 
 65. The lochial discharge may be deficient in 
 quantity, or may entirely disappear within two or 
 three days after delivery. This is not unusual after 
 the birth of stillborn children, and need occasion 
 no alarm, provided it be unaccompanied with febrile 
 symptoms. The treatment is to apply warm fo- 
 mentations to the vulva, and syringe the vagina 
 daily with warm water. 
 
 Suppression of the lochia is one of the symptoms of puer- 
 peral fever, and is then an effect rather than a cause of 
 constitutional disturbance. 
 
 Excessive Lochial Discharge — Treatment. 
 
 66. In other cases the lochia may be excessive in 
 quantity, or may last beyond the usual time, pro- 
 ducing much debility. The proper treatment is to 
 enjoin rest, and to give tonics, such as quinine and 
 iron. In some cases ergot of rye is of great ser- 
 vice ; in others, astringent injections are of much 
 use. 
 
104 CASES NOT USUALLY 
 
 Sulphate of quinine may be given in two-grain doses 
 with rr^x of acid. Sulph. dil. to each dose. Of the pre- 
 parations of iron, the tincture of the perchloride answers 
 the best, and may be given in ti\x doses twice a day. 
 Weak injections of sulphate of zinc and alum are the most 
 suitable. Decoctions of oak-bark or tormentilla will also 
 answer very well. Too much exercise within the first fort- 
 night or three weeks after delivery may cause the red dis- 
 charge to return, and even put on a hemorrhagic character 
 (See 68, Part II.) after having lost its color and almost 
 disappeared. When this happens, the patient should be 
 kept perfectly quiet in the horizontal posture, and should 
 take five grains of powdered ergot of rye, three times a 
 day. 
 
 Offensive Lochial Discharge — Treatment. 
 
 6T. In other cases the quality of the lochia is 
 altered, the color being dark, and the odor very 
 offensive. This may depend upon the presence of 
 putrid matter in the uterus, such as decomposed 
 portions of placenta, clots, &c. The vagina should 
 be syringed two or three times a day with warm 
 water or with weak disinfectant lotions. 
 
 Putrid and decomposing matters within the uterus are 
 a fertile source of phlegmasia dolens, or even puerperal 
 fever. (See 33 and 34, Part III.) They ought, therefore, 
 to be carefully removed. The patient should be directed 
 to pass water when resting on the elbows and knees ; as 
 clots, &c, will more readily come away in this position, 
 because the vagina and outlet of the pubis are then di- 
 rected downwards. In some cases it may be advisable to 
 wash out the internal surface of the uterus. 
 
 The following disinfectant lotion may be used: — 
 R. — Liq. sodae chloratae. gss. 
 
 Aquae destillat. ad Oj. 
 M. ft. lotio. 
 
REQUIRING A CONSULTATION. 105 
 
 Or what is still better, 
 
 R. — Liq. potass, permanganate., ^iij. 
 
 Aq. destillat. ad Oj. 
 M. ft. lotio. 
 
 Secondary Hemorrhage — Causes. 
 
 68. Secondary Hemorrhage is a sudden loss of 
 blood from the uterus, occurring some hours after 
 delivery, or even at any period within the month. 
 It is most usually caused by the retention of a 
 portion of adherent placenta, or of a large clot in 
 the uterus ; but it may arise from uterine relaxa- 
 tion, disturbance of the circulation, laceration, or 
 disease of the uterus, &c. 
 
 In all these cases a careful investigation should be 
 made to ascertain, if possible, the cause of the hemor- 
 rhage. For instance, the history of the case, and the 
 undue size of the uterus, may lead to suspicion of re- 
 tained portions of the placenta or clots ; to make sure of 
 this a careful vaginal examination should be made. 
 
 Secondary Hemorrhage — Treatment. 
 
 69. The treatment of secondary hemorrhage 
 must depend very much on the cause. Portions 
 of placenta or clots should be removed, if possible ; 
 and the hemorrhage should be restrained by cold 
 applications, cold enemata, ergot of rye, and tur- 
 pentine. 
 
 The ergot of rye may be thus given : — 
 
 R. — Ext. ergot, liquid., ^j. 
 
 Aq. cinnam. ad giij. 
 M. Capt. tertiam partem omni hora. 
 
106 CASES NOT USUALLY 
 
 After this has been taken, turpentine may be adminis- 
 tered~as follows: — 
 
 R._01. Terebinth., gj. 
 
 Mucilag. q.s. 
 
 Syrupi, gj. 
 
 Aquam, ad ^vj. 
 M. Sumat 6tam partem ter die. 
 
 Lacerated Perineum. 
 
 TO. Slight lacerations of the perineum, which 
 merely pass through the thin anterior edge of the 
 mucous membrane or fourchette, are very common, 
 especially in first labors, and give rise to little or 
 no inconvenience. But sometimes the laceration 
 extends further, passing through the whole sub- 
 stance of the perineum, even as far as the sphincter 
 ani. In other cases, happily by no means com- 
 mon, the rent passes through the sphincter ani, 
 and sometimes even the recto-vaginal septum, 
 laying the vagina and rectum open into one pas- 
 sage. 
 
 The fourchette is almost always lacerated in first labors, 
 without any subsequent inconvenience being occasioned. 
 
 A laceration of the perineum, properly so called, seldom 
 heals by the first intention, if unattended to, because the 
 wound is kept open by the constant passage of the dis- 
 charges over it, as well as by the action of the sphincter 
 ani. When the laceration extends through the recto- 
 vaginal septum, the patient loses the power of retaining 
 her faeces, which are liable to come away, at any time, 
 involuntarily. Her after condition is consequently most 
 deplorable. 
 
REQUIRING A CONSULTATION. 107 
 
 Lacerated Perineum — Treatment. 
 
 71. Slight lacerations of the perineum require 
 little or no treatment. It will generally be enough 
 to keep the parts clean, to direct the woman to lie 
 on her side, and to tie the knees together. When 
 more severe they should be treated at once, so as 
 to insure, if possible, union by the first intention. 
 The edges of the wound should be brought to- 
 gether by three or four sutures of silver wire or 
 silk. 
 
 The interrupted suture is the best for ordinary use, and 
 silver wire is, in the opinion of the author, preferable to 
 silk. The best form of needle is the old-fashioned semi- 
 circular one. The needle should pass through the whole 
 thickness of the perineum, and should pierce the skin at 
 a distance of at least a quarter of an inch from the edges 
 of the wound. The sutures may be removed at the end 
 of a week. 
 
 Should the lacerated perineum not unite by the first 
 intention, a surgical operation will, in all probability, be 
 ultimately required to effect reunion. Most of the surgi- 
 cal operations for the cure of lacerated perineum consist 
 in paring the edges of the wound, and bringing them 
 together by sutures of various kinds. 
 
 Mr. I. B. Brown's work on " Diseases of Women" 
 admitting of surgical treatment, gives a full account of 
 these operations. 
 
 Prolapsus Uteri — its Treatment. 
 
 72. Prolapsus uteri, or " falling down of the 
 womb," is a very common complaint amongst the 
 poor. It nearly always arises from getting up too 
 soon after delivery, before the parts have had time 
 
108 CASES NOT USUALLY 
 
 to recover themselves. When it happens within 
 the month, the woman should be kept in bed two 
 or three weeks longer than usual, and (if the 
 lochia have ceased) should use astringent injec- 
 tions. 
 
 There are various degrees of prolapsus uteri, from the 
 slightest subsidence within the pelvis to a complete ap- 
 pearance of the organ externally. 
 
 Prolapsus uteri is usually occasioned by some bearing- 
 down effort within a few days after delivery, when the 
 uterus is large and heavy, and all the parts which surround 
 it and keep it in its place are relaxed and unable to sup- 
 port its weight. It is not at all uncommon to find poor 
 women on the third day after delivery sitting up, and even 
 attending to their household affairs. Hence the fre- 
 quency of prolapsus uteri is not to be wondered at. 
 
 Women who have previously suffered from prolapsus 
 uteri have sometimes been cured by remaining in bed two 
 or three months after their confinement. 
 
 Injections of tannin, oak bark, alum, sulphate of zinc, 
 &c, may be used for the treatment of prolapsus. 
 
 Paralysis of legs after Delivery — Treatment. 
 
 13. Paralysis of one or both legs is sometimes 
 met with after labor, and is caused by pressure on 
 the sacral nerves during the second stage. There 
 is a loss of power, and frequently, also, pain and 
 numbness in the affected limbs. These symptoms 
 usually subside after three or four days, but in 
 some instances last much longer. Warm fomenta- 
 tions to the parts may be used, and also frictions 
 with stimulating liniments. 
 
 The following liniment is a suitable one for such 
 cases: — 
 
REQUIRING A CONSULTATION. 109 
 
 R. — Liq. ammon. fortior., gj. 
 
 01. olivog, §jss. 
 
 01. terebinth., gss. 
 M. ft. liniment., ter die utend. 
 
 This kind of paralysis is a purely local affection, aris- 
 ing from the same cause as cramps during labor. (See 
 44, Part II.) 
 
 How to get rid of Secretion of Milk. 
 
 74. Women who have lost their infants, or who 
 from any cause are prevented from nursing, are 
 apt to suffer much inconvenience from accumula- 
 tion of milk in the breasts. You must, therefore, 
 take means to relieve the distended breasts, and 
 also to get rid of the secretion of milk. For this 
 purpose, a spare, dry diet should be enjoined. 
 The bowels should be moved every other day by 
 laxatives, such as castor oil, etc. Saline diapho- 
 retics and diuretics may also be given. The 
 breasts should be rubbed with warm oil, or covered 
 with soap plasters spread on leather. If they are 
 much distended they should be rubbed with bella- 
 donna ointment, and a little milk should be drawn 
 off by means of a syringe or breast-pump, taking 
 care to abstract only just so much as is necessary 
 to relieve tension. 
 
 The following mixture may be given : — 
 
 R. — Yin. antimonial., 
 
 Spt. agth. nit., aa gij. 
 
 Liq. ammon. acet., £j. 
 
 Aq. cam ph. ad §viij. 
 M. Oapt. sextam part ter die. 
 
 10 
 
110 OASES NOT USUALLY 
 
 Belladonna appears almost to have a specific effect in 
 checking the secretion of milk, and relieving tension of 
 the breast. The extract of belladonna should be mixed 
 with an equal quantity of glycerine, and applied in a circle 
 around the areola every night. 
 
 The breasts should never be completely emptied of milk, 
 as this would only stimulate them to increased secretion. 
 
 [Tea should be avoided, and coffee should be 
 used. The former increases the lacteal secretion, 
 while the latter very decidedly suppresses it.] 
 
 Retracted Nipples — Treatment. 
 
 75. In some women the nipples are retracted, and 
 so short that the child cannot seize them. In con- 
 sequence of this malformation, all its efforts to suck 
 are useless. Retracted nipples should be drawn 
 out by means of an air-pump immediately before 
 putting the child to the breast; which ought to 
 be done before they are much distended. The use 
 of a nipple-shield will sometimes enable the child 
 to get at the milk. 
 
 Retraction of the nipple is produced by various causes, 
 amongst which may be mentioned pressure from articles 
 of dress, such as stays, etc. 
 
 It may be caused also by inflammation set up by the 
 absurd and mischievous practice of pulling and squeezing 
 the nipples of newly-born female children in order to 
 " break the nipple strings," as the phrase is among 
 nurses. 
 
 In the absence of a breast-pump, nurses are in the 
 habit of drawing the nipples by suction with the mouth, 
 or through a tube made for the purpose. 
 
 An older and stronger child will sometimes succeed 
 when a newly-born infant has failed. 
 
 There is a common substitute for an air-pump which 
 
REQUIRING A CONSULTATION. Ill 
 
 will answer well enough in many cases. A decanter or 
 soda-water bottle is filled with hot water ; the bottle is 
 then emptied, and the nipple immediately inserted into 
 its mouth. As the air cools within the bottle, a vacuum 
 is created, which causes the nipple to project into it. 
 
 Sore Nipples. 
 
 76. Sore nipples are a frequent and distressing 
 result of repeated applications of the child to the 
 breasts. The soreness depends upon the presence 
 of excoriations, chaps, fissures, or even deep 
 ulcers upon and around the nipple. These usually 
 appear in a few days after delivery, and, if severe, 
 cause great pain, and sometimes bleed freely 
 during lactation. 
 
 The nipples are more likely to become excoriated when 
 they are retracted, or when, from any other cause, the 
 child has much difficulty in seizing them. 
 
 A thin, tender skin, and a want of sebaceous secretion, 
 will both predispose the nipples to excoriation. 
 
 Soreness of the nipples is sometimes caused by an 
 aphthous condition of the child's mouth. 
 
 Sore Nipples — Treatment. 
 
 77. You may treat simple excoriations of the 
 nipples b}^ painting them with tincture of catechu, 
 or washing them with weak lotions of alum or 
 sulphate of zinc. If the excoriations are limited 
 to the base of the nipple or its areola, you may 
 cover them with a thin layer of collodion. But if 
 there are deep fissures or ulcers, no application is 
 so good as a solution of nitrate of silver. In all 
 
112 CASES NOT USUALLY 
 
 severe cases, the nipple should be protected during 
 suckling b} r means of a proper shield. 
 
 The tincture of catechu should be undiluted ; it may be 
 applied once or twice a day by means of a earners hair 
 brush. 
 
 The lotions of alum and sulphate of zinc may be of the 
 strength of 9j to ,^vj of water; that of the nitrate of 
 silver, gr. x to ^j of rose-water. These may be used 
 twice a day. 
 
 Burnt alum and ung. hydrarg. nitratis may be applied 
 in some cases. 
 
 [If the soreness of the nipples results from an aphthous 
 condition of the child's mouth, a strong solution of chlo- 
 rate of potash will be found most efficacious. Nipples 
 should be washed with warm milk and water before and 
 after nursing.] 
 
 As most of these applications may have an injurious 
 effect upon the child, the nipples should be carefully 
 washed before it is put to the breast. 
 
 Collodion should not be applied over the apex of the 
 nipples so as to obstruct the milk ducts. 
 
 Nipple-shields are of various kinds, and are made of 
 metal, wood, or glass, with a cow's teat adapted to them, 
 or an artificial teat consisting of wash-leather or India- 
 rubber. In women who have suffered from sore nipples 
 after previous confinements, it is a good plan to harden 
 the skin of the nipples beforehand by washing them once 
 a day with brandy and water, or painting them every 
 other day with tincture of catechu. 
 
 Inflammation of Breasts — Symptoms. 
 
 78. The engorgement which accompanies the 
 first flow of milk predisposes the breasts to inflam- 
 mation, and this is easily excited by any sudden 
 exposure to cold, or mental emotion. Inflamma- 
 tion also may extend to the breast from a sore 
 nipple. The inflammation is phlegmonous in its 
 character. There is local pain, soreness, redness. 
 
REQUIRING A CONSULTATION. 113 
 
 and circumscribed hardness. It is accompanied 
 with febrile excitement, and temporaiy suspension 
 of the secretion of milk. It may terminate in 
 resolution or in suppuration. 
 
 The inflammation may involve only one or two lobules, 
 and be comparatively superficial, or it may affect the 
 whole breast and be deep-seated. The axillary glands are 
 then hard and painful. When suppuration sets in, the 
 inflammed part softens in the centre, the skin becomes 
 thin, and the pus, after a few days, escapes. The abscess 
 usually points near the nipple ; but in persons of bad con- 
 stitution the matter may be deep-seated, and may burrow 
 extensively beneath the glandular structure of the breast. 
 After a long time the abscess gives way, and a quantity 
 of matter escapes, together with curdled milk, and sloughs. 
 Such cases, if left to themselves, are extremely tedious ; 
 troublesome sinuses are formed, which occasion great im- 
 pairment of the general health. 
 
 In all cases the discharge of matter is considerable, and 
 is accompanied, for a time, with night-sweats and other 
 hectic symptoms. 
 
 The suppuration not unfrequently occasions so much 
 induration of the breast affected, as to destroy its future 
 use. 
 
 Inflammation of Breasts — Treatment. 
 
 79. Inflammation of the breast should be treated 
 at its commencement by the application of ten or 
 fifteen leeches to the part affected ; or, if there is 
 much fever, by general bleeding. The whole 
 breast should then be covered with a soft linseed- 
 meal poultice. Saline purgatives should be given, 
 together with tartar-emetic diaphoretics. If the 
 inflammation go on to suppuration, 3-ou should 
 let out the matter with the lancet, as soon as } r ou 
 10* 
 
114 CASES NOT USUALLY 
 
 can detect fluctuation. In all these cases, how- 
 ever, you had better request a consultation. 
 
 A draught of sulphate of magnesia and infusion of senna 
 is the best purgative to administer. Tartar emetic may 
 be given in ^-grain doses, with two or three grains of ni- 
 trate of potash. 
 
 When the matter is deep-seated, some tact is required, 
 both to detect it, and let it out. Care should be taken not 
 to cut across the milk ducts in so doing. If sinuses form, 
 they must be laid open : or if they run too deeply, they 
 must be treated by stimulant injections, and pressure 
 with straps of adhesive plaster. To effect this last object 
 properly, the straps of plaster should be so arranged as to 
 make firm and equable pressure over the whole breast, 
 every part of which should be thus covered except the 
 wound by which the matter has been evacuated. 
 
 In all cases of inflammation of the breast there is a 
 troublesome feeling of weight and dragging. This may be 
 much relieved by supporting the breast with a sling 
 placed round the neck. 
 
 Milk Fever — Symptoms. 
 
 80. The congestion and excitement of the mam- 
 mary glands after labor may give rise to a certain 
 amount of sympathetic fever. This is called "milk 
 fever," and generally sets in on the third day, with 
 shivering, pain in the back and limbs, headache, 
 quick full pulse, furred tongue, and feverishness, 
 followed by profuse sweats, after which the febrile 
 excitement subsides. The breasts are swollen, 
 hard, and painful. There is an absence of abdomi- 
 nal tenderness, and a copious secretion of milk ; 
 two features which distinguish this complaint from 
 more dangerous fevers. 
 
 [Headache is always present, rarely noticed in 
 approaching puerperal peritonitis.] 
 
REQUIRING A CONSULTATION. 115 
 
 When the fever is at its height, there is sometimes 
 slight delirium. 
 
 Milk fever is. cceteris paribus, more common in primi- 
 para? than in multipara}, and is much more likely to happen 
 when the application of the child to the breast has been 
 deferred too long. 
 
 Treatment of Milk Fever. 
 
 81. In the treatment of milk fever the patient 
 should be kept on low diet, and should take ape- 
 rients and saline diaphoretics. The ordinary dose 
 of castor oil may be somewhat increased, and re- 
 peated, if necessary- The distended breasts must 
 be relieved by early and frequent applications of 
 the child, or, if necessary, by the breast-pump. 
 
 The following mixture may be given : — ■ 
 
 R. — Yin. ipecac, 
 
 Spt. seth. nit., aa ^j. 
 
 Sodas et potassoe tart., gj. 
 
 Aq. camph. ad 3 viij. 
 M. ft. mist, cujus sumat sex tarn partem ter die. 
 
 [Early attention to the breasts will very frequently ob- 
 viate the necessity of medical interference.] 
 
 Ephemeral Fever. 
 
 82. Women, after delivery, are liable to a transi- 
 tory fever, which has been named ephemeral fever, 
 or (by the Germans) Weid. It may be brought on 
 by fatigue, exposure to cold, or indigestion. Like 
 an intermittent, it has a hot, a cold, and a sweat- 
 ing stage. The first is characterized by shivering, 
 headache, and pains in the back and limbs ; the 
 
11 G CASES NOT USUALLY 
 
 second, by quick pulse, furred tongue, and fever ; 
 and the third, b}^ profuse sweats, and cessation of 
 fever. The whole attack seldom exceeds twenty- 
 four, or at most forty-eight hours. The bowels are 
 usually costive, and the milk and lochia diminished 
 or temporarily suspended. This complaint is dis- 
 tinguished from puerperal fever by its paroxysmal 
 character, and by the absence of marked abdominal 
 tenderness. 
 
 Ephemeral fever most commonly attacks those whose 
 health is somewhat impaired by a residence in low marshy 
 districts. 
 
 Ephemeral Fever — Treatment. 
 
 83. During the cold stage of ephemeral fever, 
 warmth should be applied to the surface, and warm 
 drinks administered. During the hot stage, diapho- 
 retics, such as Dover's powder, are indicated ; and 
 also smart purges of salts and senna. An emetic of 
 gr. v of ipecacuanha, at this stage, will sometimes 
 serve to cut short the attack. After the fever is 
 over, quinine should be given, especially if the 
 attack seems at all likely to recur. 
 
 ["Keep up the perspiratory stage till the head- 
 ache is removed."] 
 
 Miliary Fever. 
 
 84. Miliary fever is another affection occasion- 
 ally met with after delivery. It is characterized 
 by an eruption of very fine vesicles, about the size 
 of a millet seed, and densely crowded together. It 
 
REQUIRING A CONSULTATION. 1 L 7 
 
 comes on two or three days after labor, with rigors, 
 followed by fever and profuse perspiration. There 
 is much headache, and oppression at the praecordia. 
 The tongue is furred, with the papillae red and 
 prominent. The lochial discharge and milk are 
 scanty. After a time the eruption comes out, hav- 
 ing been preceded by tingling of the skin and copi- 
 ous perspirations. It subsides after two or three 
 days. This fever is distinguished from others by 
 the peculiar eruption. 
 
 As the eruption recedes, the vesicles dry up, and the 
 cuticle falls off in branny scales. 
 
 Miliary fever is most frequently met with in patients 
 who have been kept in close, ill-ventilated rooms, with a 
 large fire, and too much bedclothes upon them. 
 
 Miliary Fever — Treatment, 
 
 85. Ventilation is of great importance in the 
 treatment of miliary fever. The room should be 
 kept cool, and some of the bedclothes removed ; at 
 the same time, every care must be taken to avoid 
 sudden exposure to cold. Cooling aperients should 
 be given, and afterwards tonics and astringents. 
 
 The following aperient is a suitable one: — 
 R. — Magnes. sulph., gss. 
 
 Infus. rosse (comp.) §vj.* 
 M. Capt. sext. part, sexta quaque hora. 
 
 As a tonic, the following mixture : — 
 R. — Tiuct. cinchona? co., giij. 
 
 Acid, sulph. arom. gss. 
 
 Aquam ad §vj. 
 M. Capt. sext. part, bis die. 
 
 * [Acid.] 
 
PART III. 
 
 CASES IN WHICH THE STUDENT OUGHT TO 
 SEND FOR ASSISTANCE. 
 
 Abortion — Non-expulsion of the entire Ovum. 
 
 1. When abortion has taken place, and the pla- 
 centa, or any other portion of the ovum, remains 
 behind in the uterus, give ergot, and make cautious 
 attempts to bring it away with the finger. If you 
 do not succeed, send for assistance. 
 
 When the remainder of the ovum cannot be removed in 
 the way just mentioned, the case is one of some difficulty, 
 and requires delicacy of manipulation. The introduction 
 of the hand, or of some instrument for the purpose, will 
 probably be necessary. If the placenta is allowed to re- 
 main in the uterus it may cause secondary hemorrhage 
 (see 68, Part II.), or decompose and produce uterine 
 phlebitis from absorption of putrid matter. 
 
 Abortion with Profuse Hemorrhage. 
 
 2. In cases of abortion accompanied with pro- 
 fuse hemorrhage, before sending, apply cold, as 
 directed in 55, Part II. Give a full dose of ergot, 
 and plug the vagina. 
 
CASES REQUIRING CONSULTATION. 119 
 
 A hemorrhage is profuse when it produces marked con- 
 stitutional symptoms, such as those described in 53, Part 
 II. Cases of miscarriage, under such circumstances, are 
 attended with considerable risk. 
 
 The plug, or " tampon," is a powerful means of arresting 
 hemorrhage in certain conditions of the uterus. By its 
 presence it stimulates that organ to contraction, and also 
 exerts a pressure upon the bleeding vessels. As a general 
 rule, the plug should not be used, under the circumstances 
 above mentioned, after the period of quickening. Before 
 that period the uterus is incapable of containing any large 
 amount of blood ; but after that time there would be con- 
 siderable danger of internal hemorrhage. 
 
 For the purpose of plugging the vagina, tow, lint, or 
 pieces of sponge may be used. These must be gradually 
 introduced with the finger, until the vagina is completely 
 filled. A soft silk or cambric handkerchief makes a very 
 good plug, and should be introduced into the vagina, be- 
 ginning with one of the corners. The plug should not 
 be left in the vagina more than twelve hours, because 
 the retained blood and discharges putrefy and become a 
 source of irritation. 
 
 If a large speculum is at hand, the plug may be intro- 
 duced through it with much more ease and much less dis- 
 comfort to the patient. 
 
 Extra-uterine Foetation — Rupture of the Cyst. 
 
 3. In cases of suspected extra-uterine foetation, 
 when certain symptoms set in which indicate a 
 rupture of the cyst. These are — sudden and acute 
 pain in one iliac region, followed by great exhaus- 
 tion, vomiting, and symptoms of internal hemor- 
 rhage. Before sending, place the patient in the 
 horizontal posture, apply a binder round the ab- 
 domen, and cold to the part. If there is severe 
 collapse, give stimulants. 
 
120 CASES REQUIRING CONSULTATION. 
 
 In extra-uterine foetation the impregnated ovum, from 
 some cause or other, does not reach the uterus, but is de- 
 veloped externally to it, either in the ovary, the Fallopian 
 tube, or in the walls of the uterus. This curious freak of 
 nature is by no means of common occurrence. The diag- 
 nosis is very uncertain; most of the signs of pregnancy 
 are present, but the tumor formed by the impregnated 
 ovum presents itself on one side of the abdomen, usually 
 the iliac fossa. Pain is frequently felt in that region, 
 accompanied with vomiting. The menses, in most cases, 
 continue during extra-uterine gestation. After a variable 
 time the cyst containing the ovum gives way, and the 
 woman dies from the sudden shock to the system, and pro- 
 fuse internal hemorrhage thus occasioned. Such is the 
 usual history of these cases. The cyst is generally rup- 
 tured during the first half of gestation. But there are 
 many instances on record of women who have survived 
 both the shock and subsequent inflammation, and in whom 
 the foetus has been evacuated by abscess, or retained for 
 months and even years. 
 
 Expulsion of Moles, attended with much 
 Hemorrhage. 
 4. In cases of mole pregnancy, when the expul- 
 sion of the mole is attended with much hemorrhage, 
 and when portions of it remain behind in the uterus. 
 In these cases, as in an abortion, you may give 
 ergot, apply cold, and use the plug, before sending 
 for assistance. 
 
 Moles are shapeless masses, which are, properly speak- 
 ing, the result of conception, and consist of various de- 
 generations of the ovum. In many of them scarcely any 
 portion of the ovum can be traced, the mass consisting of 
 semi-organized coagula and layers of fibrine. This is the 
 fleshy mole. In others, the foetal coverings, especially the 
 chorion, have become developed into innumerable vesicles, 
 resembling bunches of grapes or currants. This is the 
 hvdatid mole. When the uterus contains a mole, the 
 
CASES REQUIRING CONSULTATION. 121 
 
 earlier signs of pregnancy present themselves ; but the 
 latter signs, such as the "ballottement," the foetal move- 
 ments, and the sounds of the foetal heart, are wanting. 
 After an uncertain period the uterus expels the mole with 
 all the symptoms of an abortion. The expulsion of the 
 hydatid mole is attended with most risk; it is usually 
 accompanied with much hemorrhage, and the mole fre- 
 quently does not come away entire. "When this happens, 
 the introduction of the hand may become necessary. 
 
 Symptoms of Powerless Labor. 
 
 5. In any case of difficult labor, or otherwise, 
 when symptoms of powerless labor begin to show 
 themselves. These are — diminished frequency and 
 force of the pains, considerable acceleration of the 
 pulse between the pains, severe rigors and vomiting, 
 restlessness, dry, furred tongue, retention of urine, 
 heat and tenderness of the vagina, with brownish 
 and occasionally fetid discharge. 
 
 Powerless labor is always the result of a prolonged 
 second stage, whether it be from obstruction of the head, 
 or from inefficient uterine efforts. There is no precise 
 period at which the unfavorable symptoms set in, but. in 
 general, they are likely to do so after the second stage has 
 lasted twelve hours. Xo prudent practitioner would allow 
 such symptoms to become developed ; but. taking alarm 
 at their first onset, would proceed to assist nature by art. 
 
 [With the above symptoms the labor must be terminated. 
 The forceps will save the mother's life, and probably that 
 of the child.] 
 
 The pains in powerless labor lose the forcing character 
 of the second stage, and bear more resemblance to those 
 of the first. The pulse may range from 100 to 130, or 
 even to 140. between the pains. 
 
 If the above symptoms are allowed to continue unre- 
 lieved, the condition of the patient becomes much worse; 
 the tongue is dry and brown, sordes collect about the 
 11 
 
122 CASES REQUIRING CONSULTATION. 
 
 teeth, the pulse is very rapid and weak ; the matter ejected 
 by vomiting is dark, sometimes consisting of grumous 
 blood ; the abdomen becomes tender, the surface cold and 
 clammy; the restlessness passes on to jactitation, delirium, 
 and death. 
 
 Minute or Imperforate Os Uteri. 
 6. When labor is obstructed by a minute or im- 
 perforate os uteri, which is the result of structural 
 change, and which does not yield to time and the 
 usual remedies for an un dilatable os uteri. (See 
 12, Part II.) 
 
 This condition of the os uteri may be caused by cica- 
 trices resulting from mechanical injuries, by inflammation, 
 or by scirrhus deposit in the part. In some cases there 
 is complete agglutination of the os uteri. The inferior 
 portion of the uterus becomes very tense, and is forced 
 down low into the pelvis with each pain ; but the finger 
 in examining can detect merely a depression, and no 
 opening in the part. In some rare instances, a circular 
 portion of the inferior part of the uterus has yielded to 
 the force of the pains, and separated so as to allow the 
 child to pass. In others, it has been necessary to make a 
 crucial incision in the part before delivery could be accom- 
 plished. 
 
 [Better than the crucial incision is the plan of Moscati, 
 who recommends a number of small incisions around the 
 os, thus securing equable dilatation. Unless the obstruc- 
 tion is removed — the os rendered dilatable — a ruptured 
 uterus would be the result.] 
 
 Strictures of Vagina. 
 
 T. When labor is obstructed by strictures of the 
 vaginal canal, produced by structural alterations, 
 such as cicatrices, callosities, adhesions, etc., which 
 
CASES REQUIRING CONSULTATION. 123 
 
 do not yield to time and the usual remedies for 
 rigidity of the soft parts. (See 16, Fart II.) 
 
 These structural lesions of the vagina are nearly always 
 the result of sloughing, and loss of substance, produced 
 by a previous hard labor. The cicatrices may form rings, 
 •or spirals, around various parts of the vagina, or there 
 may be a partial or complete occlusion of some part of 
 the canal. The cicatrices are sometimes gristly and semi- 
 cartilaginous. It may be necessary to divide them with 
 the knife, or even to lessen the size of the child's head by 
 craniotomy. Such operations of course require a consul- 
 tation. 
 
 [A rigid hymen may obstruct the vaginal canal, im- 
 pregnation being possible without injury to this band.] 
 
 [Since writing the above I have been called to attend a 
 primiparous case, in which the hymen was so tense and 
 rigid that the progress of the foetal head downwards and 
 forwards caused such great pain that I was obliged to cut 
 out the hymen entirely.] 
 
 Obstructed Labor from Pelvic Tumors. 
 
 8. When labor is obstructed by tumors of various 
 
 kinds within the pelvis, and the difficulty appears 
 
 to be insuperable by the natural efforts. 
 
 The tumors may be either within or without the vagina, 
 and may grow from the mucous membrane of the uterus 
 and vagina, or from the exterior of the uterus, its append- 
 ages, or other contents of the pelvis. When these tumors 
 are outside the vagina, they are usually met with in the 
 cul-de-sac of the peritoneum between the vagina and rec- 
 tum, where they produce a bulging of the posterior wall 
 of the vagina. The tumors may be solid growths, such as 
 polypi, fibrous, fatty, sarcomatous, and scirrhous masses, 
 or cysts containing fluid, such as ovarian -tumors, etc. 
 Sometimes a hernia a descends into the vagina during labor. 
 The intestine comes down into the cul-de-sac between the 
 vagina and rectum, and forms a tumor covered by the 
 posterior wall of the vagina. In some rare instances, the 
 
124 CASES REQUIRING CONSULTATION. 
 
 bladder contains a calculus, which descends before the 
 head, during labor. The tumor thus formed is covered by 
 the upper wall of the vagina like a vaginal cystocele, but is 
 firm and hard, and not soft and fluctuating. 
 
 The chief danger from calculus is not so much from the 
 obstacle which it presents, as from the injury which it may 
 inflict upon the bladder, when it becomes compressed be- 
 tween the head and the pubis. In most cases, it is possible 
 to push the calculus above the pelvic brim; but if this 
 should be impracticable, vaginal lithotomy may be neces- 
 sary. In short, in all cases of pelvic tumors, the treat- 
 ment must depend very much on the circumstances of the 
 case ; some tumors are movable, and may be pushed above 
 the head ; others, such as polypi, etc., admit of excision ; 
 others, such as ovarian tumors, may be tapped. All these 
 operations, except the first, are attended with risk, and 
 require much judgment. If any such operation be im- 
 practicable, delivery with the forceps or craniotomy may 
 be required. 
 
 Prolapse of Bladder during Labor. 
 
 9. When there is a prolapse of the bladder during 
 labor. In such cases the bladder descends before 
 the head, and forms a fluctuating tumor, covered 
 by the upper wall of the vagina. The finger readily 
 passes beneath and behind the tumor, until it 
 reaches the head. Before sending, evacuate the 
 bladder, if possible, by passing a gum-elastic cathe- 
 ter with the point directed downwards and back- 
 wards. 
 
 Prolapse of the bladder, or vaginal cystocele, is a rare 
 complaint. It is occasioned by a relaxation of the upper 
 wall of the vagina, and other connections of the bladder. 
 The symptoms are — fulness, tension, and dragging, with 
 a constant desire to pass water, and much difficulty in 
 doing so. If there has been complete retention of urine 
 
CASES REQUIRING CONSULTATION. 125 
 
 for some time, there is considerable risk that the pressure 
 of the head may cause a rapture of the bladder. 
 
 Difficult Labor from Pelvic Deformity — 
 Diagnosis* 
 
 10. When labor is obstructed in the second stage 
 by pelvic deformity. In these cases, the head is 
 arrested in its progress at some particular part of 
 the pelvis (generally the brim), and remains im- 
 movable, notwithstanding there may have been 
 strong forcing pains for some hours. The scalp 
 becomes very tumid, and the bones overlap very 
 much, so as to give the vertex a conical shape. 
 You need not be in a hurry to send for assistance 
 in such cases (see 42, Part II.); but you must do 
 so without delay if there be the least symptom of 
 powerless labor, or if the head become impacted, 
 i. e.j so firmly fixed that it cannot recede between 
 the pains, and can only be displaced with great 
 difficulty. 
 
 Deformities of the pelvis are occasioned by rickets 
 during childhood, mollities ossium in adult age, bony 
 growths, fractures, etc. The deformity may affect the 
 brim, cavity, or outlet of the pelvis. The brim is most 
 usually affected, and the most ordinary kind of deformity 
 is a prominent sacrum, causing a diminution of the antero- 
 posterior diameter of the brim. The pelvis in such cases 
 becomes heart-shaped. 
 
 The degree of deformity may vary very much, but it is 
 most readily estimated by measuring the antero-posterior 
 diameter of the brim. This may be done by introducing 
 the tips of four fingers of one hand in a line, between the 
 sacral promontory and pubis. If they cannot be separated, 
 for instance, there is much deformity; but if they can be 
 11* 
 
196 CASES REQUIRING CONSULTATION. 
 
 separated widely, there is little or none. Again, if the 
 forefinger, during an ordinary examination, impinges on 
 the upper part of the sacrum, we have reason to believe 
 that the deformity is considerable. 
 
 The existence of pelvic deformity may also be ascer- 
 tained by the great difficulty which is experienced in pass- 
 ing up the forefinger between the head and the different 
 parts of the pelvis. Distortions of the cavity and outlet of 
 the pelvis are not so common; they generally depend on 
 unnatural straightness of the sacrum, approximation of 
 the tubera ischii, narrowing of the pubic arch, or anchy- 
 losis of the coccyx, etc. They produce much the same 
 symptoms as distortions of the brim, except that they 
 arise at a later period of the labor. 
 
 The symptoms occasioned by deformity of the brim have 
 been very accurately described by Dr. Rigby. " Besides 
 the general appearance of the patient," he says, " we fre- 
 quently find that the uterine contractions are very irregu- 
 lar; 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." When the deformity is not very consider- 
 able, it often happens that after some hours of severe pain, 
 the difficulty is suddenly overcome, the head passes, and 
 the rest of the labor is speedily accomplished. 
 
 When, however, the deformity is more considerable, the 
 forceps is likely to be required ; when it is still greater, 
 the accoucheur is reduced to the painful necessity of de- 
 stroying the child by craniotomy. Again, where the dis- 
 tortion is extreme, delivery per vias naturales becomes 
 impossible. The Cesarean section is then the last resource 
 of art. 
 
 The forceps is inadmissible when the antero-posterior 
 diameter of the pelvis is less than three inches; because it 
 has been laid down as a rule, that a living child cannot 
 pass through a pelvis of such dimensions. Craniotomy, 
 or the cephalatribe, may be employed when the antero- 
 posterior diameter is not more than three inches, nor less 
 than an inch and a half. When it is less than an inch and 
 a half, delivery per vias naturales is scarcely possible. 
 
CASES REQUIRING CONSULTATION. 127 
 
 Impaction of the bead is always attended with consider- 
 able danger. The constant and severe pressure upon the 
 soft parts lining the pelvis will almost certainly produce 
 inflammation and sloughing of those parts. Hence, there 
 is a necessity for prompt interference. 
 
 Arrest of Head in Cavity of Pelvis. 
 
 11. When the head is arrested, either in the 
 cavity or outlet of the pelvis, in consequence of 
 some want of power in the uterus, and also some 
 slight disproportion between the head and pelvis. 
 The time when you ought to send must depend 
 very much upon the state of the patient; but, as 
 a general rule, you ought to do so before the head 
 has been arrested as long as four hours. 
 
 In the preceding case the use of the short forceps is in- 
 dicated. Ergot of rye is inadmissible, because there is 
 a mechanical Obstacle to delivery, as well as a want of 
 power. 
 
 Unless the condition of the patient be such as to require 
 interference, the forceps should not be used whilst the 
 pains continue regular, and the head advances ever so 
 little. 
 
 Cases in which no Presentation can be felt. 
 
 12. In the first stage of labor, when the os uteri 
 is dilated to the size of a crown-piece, or even 
 larger, and no presentation can be detected, al- 
 though you have made a careful examination with 
 both hands. 
 
 When no presentation can be felt, although the os uteri 
 is widely dilated there is in all probability what nurses 
 call a "cross birth," i. e., the long axis of the child is at 
 
128 CASES REQUIRING CONSULTATION. 
 
 right angles with the axis of the pelvis, the shoulder or 
 arm presenting. 
 
 AVhen the child is in this position, the presentation sel- 
 dom descends sufficiently low to be felt at any early period 
 of the labor. In such cases the greatest care is necessary 
 in examining, lest the membranes be ruptured ; because, as 
 turning will in all probability be required, the escape of 
 the liquor amnii would render that operation very difficult. 
 
 The presentation may also remain out of reach in a 
 similar manner when the pelvis is deformed, or the child's 
 head hydrocephalic. 
 
 Gases of Brow Presentation. 
 
 13. In cases of brow presentation. These unfa- 
 vorable presentations of the head are recognized 
 by the facility with which you can reach the great 
 
 T\s. 13. 
 
 fontanelle and also the upper part of the face, the 
 one being turned towards one side of the pelvis, 
 
CASES REQUIRING CONSULTATION. 129 
 
 and the other towards the opposite side, the pre- 
 senting part being one of the frontal eminences. 
 (Fig. 14.) 
 
 Fig. 14. 
 
 Presentations of the brow are intermediate between 
 those of the vertex and those of the face, approaching, 
 however, more nearly to the latter than the former. When 
 the vertex presents, the head is said to be flexed upon the 
 body, so that the chin is close to the chest (Fig. 13) ; when 
 the face presents, the head is extended completely, and 
 the chin is as far removed from the chest as the neck will 
 admit of (Fig. 15). In a brow presentation the head is par- 
 tially extended, so that one of the frontal bones presents, 
 most commonly either the right or left frontal eminence 
 (Fig. 14) . At the commencement of labor, the presenting 
 part may be included in a circle, the circumference of 
 which touches the root of the nose on one side, and the 
 great fontanelle on the other. On examining at this stage 
 of the labor, the face would be found usually looking to- 
 wards one sacro-iliac synchondrosis, and the great fon- 
 tanelle towards the acetabulum of the opposite side, or 
 vice versa. As the head descends lower, and becomes 
 
130 CASES REQUIRING CONSULTATION. 
 
 more fully engaged in the pelvis, the mento-occipital dia- 
 meter will correspond with one of the oblique diameters of 
 the pelvis, and thus will take a position nearly at right 
 angles to that which it occupies in an ordinary case; for 
 
 Fi<?. 3 5. 
 
 then it is parallel to the axis of the pelvic brim, and is 
 perpendicular to these diameters. In a brow presentation 
 the head is placed in the most unfavorable manner possi- 
 ble for traversing the brim of the pelvis ; for the longest 
 diameter of the head (the occipito-mental, which measures 
 five inches) corresponds with the oblique diameter of the 
 pelvic brim, measuring only four inches and a half. [The 
 occipito-mental diameter of the foetal head, as given by 
 Dr. Meigs, is five and a half inches. Dr. J. K. Yan Pelt, 
 who measured seven hundred foetal heads, places this 
 diameter at 5£$. Dr. Addinell Hewson, who measured 
 one hundred and sixty-six, puts it at 5.25. Thus showing, 
 what I have before remarked, that the foetal heads in this 
 country are larger than those of foreign lands.' Dr. Meigs 
 places the occipitofrontal diameter at 4}| and biparietal 
 3J|-.] It is, therefore, scarcely possible for the head to 
 traverse the pelvis in this position ; and it will be found, 
 as a general rule, that manual interference is necessary in 
 
CASES REQUIRING CONSULTATION. 131 
 
 the treatment of these cases. The forehead may be pushed 
 up, or the chin brought down, so as to convert it into 
 either a vertex or a face presentation. Any attempts to 
 effect the first will probably prove unsuccessful, but the 
 last may readily be accomplished either by the fingers or 
 the vectis. 
 
 Arrest of Child's Body in Breech Presentations. 
 
 14. In breech presentations, when the breech is 
 
 arrested in the cavity of the pelvis, from want of 
 
 room or from insufficient uterine action. 
 
 The rules which are applicable in cases of arrest of the 
 head (see 11, Part III.) respecting the time to send for 
 assistance, will also apply to breech cases. When the 
 breech is arrested, it may be necessary to assist the de- 
 livery. This is usually done by hooking the finger over 
 the groin, and making traction in concert with the pains. 
 Some recommend a blunt hook for this purpose, whilst 
 others advise the use of the forceps. Without much care 
 the first of these instruments would be likely to inflict in- 
 jury on the child; and the same may be said of the se- 
 cond, which is indeed scarcely suitable for breech cases. 
 
 Arrest of Head in Breech Presentations. 
 
 15. In breech presentations, when the head is 
 arrested at the brim of the pelvis, and cannot be 
 brought through by rectifying its position and 
 making cautious and steady traction by the neck. 
 
 In these cases there is generally some want of room in 
 the pelvic brim. The forceps has been recommended, but 
 its utility is very questionable. The child is almost sure 
 to be dead from pressure on the cord, and the best plan 
 then is to lessen the size of the head by opening it behind 
 the ear, and evacuating the brain. 
 
 [If the forceps can be applied, it is best that an attempt 
 to use them should be made before entering upon so ter- 
 rible an operation as craniotomy.] 
 
132 CASES REQUIRING CONSULTATION. 
 
 Presentations of Superior* Extremities — Diagnosis. 
 
 16. In presentations of the superior extremity, 
 i. e., either the shoulder, elbow, or hand. These 
 occur about once in 231 cases. The shoulder is 
 known by its being more pointed than either the 
 head or the breech. You recognize it by feeling 
 the clavicle and spine and acromion process of the 
 
 Fig. 16. 
 
 scapula; and, above all, by the ribs, which will at 
 once distinguish it from any other part of the 
 
CASES REQUIRING CONSULTATION. 133 
 
 body. For characteristics of the elbow, see 31, 
 Part II. ; and of the hand, see 30, Part II. 
 
 When the superior extremities present, the child is 
 placed transversely with regard to the pelvis. Delivery 
 ill this position is almost impossible, but still may take 
 place in rare exceptional instances, by a natural process 
 of expulsion, to which the name " spontaneous evolution" 
 has been given. Such an unusual occurrence should 
 never be depended on in practice. The presentation 
 should be altered by turning the child, and bringing down 
 the feet. 
 
 Assistance should be sent for immediately, as soon as 
 a presentation of the superior extremities is detected. 
 Too much care cannot be taken lest the membranes be 
 ruptured by injudicious examinations. 
 
 In shoulder presentations the hand and arm usually 
 prolapse after the rupture of the membranes, and remove 
 all doubt, if any existed before, as to the nature of the 
 presentation. 
 
 [The membranes unbroken, it is comparatively an easy 
 matter to turn the child, but if the liquor amnii has es- 
 caped, it is sometimes very difficult.] 
 
 Monsters. 
 
 17. When labor is obstructed, in consequence of 
 abnormal development or monstrosity of the foetus. 
 
 Extraordinary size of the foetus, or unusual ossification 
 of its head, may act as a cause of difficult labor, and ren- 
 der the use of the forceps necessary. 
 
 Monsters are of two kinds, viz., monsters by deficiency, 
 and by excess. The former class will be puzzling as re- 
 gards diagnosis, but present no difficulties as to delivery. 
 The latter class, however, may occasion obstacles of a 
 serious kind ; in most cases, various parts of two (or 
 more) children are united together. The treatment 
 must depend very much upon the circumstances of each 
 case. When there is much difficulty, turning, or embry- 
 12 
 
134 CASES REQUIRING CONSULTATION. 
 
 otomy, may be required ; or, perhaps, both these opera- 
 tions. 
 
 Hydrocephalus or Ascites of Foetus — Diagnosis. 
 
 18. When labor is obstructed, in consequence of 
 increased size of the child's head from hydro- 
 cephalus, or of its abdomen from ascites. Hydro- 
 cephalus is distinguished by the very large size of 
 the head, which occupies the entire contour of the 
 superior strait of the pelvis. The head is resist- 
 ing during a contraction, and soft and fluctuating 
 in the intervals of pain. The sutures (especially 
 the sagittal) and fontanelles are unusually open, 
 and the cranial bones are widely separated from 
 one another. Ascites is distinguished by the 
 large size of the abdomen, and the distinct sense 
 of fluctuation which it communicates to the finger. 
 
 In either of these cases, the increased size of the child's 
 head, or body, may occasion a train of symptoms similar 
 to those which arise in the course of a difficult labor, 
 from diminished size of the pelvis. 
 
 When the bones are widely separated, the tips of the 
 fingers may be passed between, and even slightly beneath 
 them. 
 
 Hydrocephalic infants may be expelled by the natural 
 powers, provided the pelvis is roomy; but the labor is 
 usually very tedious and difficult. In most cases assist- 
 ance will be required ; the size of the head must be less- 
 ened by puncturing it with a small trocar, in one of the 
 sutures, and letting out the fluid. The abdomen may be 
 tapped, in a similar way, in ascites. 
 
CASES REQUIRING CONSULTATION. 135 
 
 Prolapse of Umbilical Cord — Diagnosis. 
 
 19. When there is a prolapse of the umbilical 
 cord during labor. In this case (which happens 
 about once in 221 labors), before the membranes 
 rupture, 3^011 may feel through them a small, soft, 
 movable body, which may be readily displaced, 
 and has a rapid pulsation, isochronous with the 
 foetal heart. After the membranes have ruptured, 
 the diagnosis is very easy; for the cord can 
 readily be felt in the vagina. Sometimes it is pro- 
 lapsed beyond the os externum. As soon as you 
 have ascertained the existence of this complication, 
 you must send for assistance without delay, having 
 previously placed the woman on her hands and 
 knees ; but if you find that the cord is quite 
 destitute of pulsation, you may let the labor take 
 its course. 
 
 A prolapse of the funis does not make any difference 
 in the course of a labor as regards the mother ; but it is 
 a complication fraught with the utmost danger to the 
 child. If a prolapsed cord cannot be reduced, the child 
 will almost inevitably die before the termination of the 
 labor, from pressure on the umbilical vessels. There are 
 several causes which may produce this accident, such as 
 unfavorable presentations, irregularity in the shape of the 
 pelvis, sudden escape of a large quantity of liquor amnii, 
 excessive length of cord, 1 low insertion of the cord into 
 the placenta, or attachment of the placenta to the neck 
 of the uterus, etc. 
 
 When the cord can be felt distinctly pulsating, some 
 
 1 In a case occurring in the author's practice, the cord 
 measured five feet in length. 
 
136 CASES REQUIRING CONSULTATION. 
 
 interference is necessary to save the life of the child, pro- 
 vided that the os uteri is sufficiently dilated to allow it. 
 Various means have been devised for reducing the cord 
 and keeping* it up out of the way, until the presenting 
 part has descended and fully occupied the pelvic cavity. 
 One of the best of these is the postural method just 
 mentioned. In this position, on the hands and knees, the 
 cord naturally gravitates towards the fundus uteri. If 
 these devices fail, turning will be necessary. If the labor 
 be too far advanced for turning, the forceps may be used. 
 When the cord is cold and pulseless, the child is dead. 
 There is, therefore, no necessity for interference. 
 
 Accidental Hemorrhage — Diagnosis. 
 
 20. In cases of accidental hemorrhage, i. e. hem- 
 orrhage arising before birth from a casual detach- 
 ment of part of the placenta. This hemorrhage 
 comes on shortly before or at the full term, of 
 pregnancy, and is generally the result of some 
 sudden shock, either mental or bodily. It com- 
 mences with dull pain and aching in the belly and 
 back. The uterus feels firmer, tenser, and percep- 
 tibly larger than before. After a time the usual 
 symptoms of hemorrhage supervene (see 53, Part 
 II.), and, in most cases, fluid blood and coagula 
 escape externally. The os uteri is soft and dilata- 
 ble. If you pass your finger within it, and around 
 its circumference, you feel the smooth bag of the 
 waters presenting. If labor-pains are present, the 
 hemorrhage is arrested during the pains, but re- 
 turns in the interval ; whereas the exact converse 
 takes place in unavoidable hemorrhage. 
 
 The detachment of the placenta is mostly partial ; but 
 
CASES REQUIRING CONSULTATION. 137 
 
 in some exceptional cases the placenta is wholly detached. 
 Again, the hemorrhage may be entirely internal. The 
 hemorrhage may be a result of general plethora, as well 
 as of any sudden shock, such as coughing, sneezing, 
 vomiting, over-exertion, blows, falls, etc. 
 
 When the os uteri is smooth and regular throughout 
 its entire circumference, aud the membranes can be felt 
 presenting, we may be sure that the hemorrhage is not 
 occasioned by placenta previa, especially if it cease 
 during the pains. The hemorrhage is arrested during a 
 pain, because the bleeding vessels are compressed by the 
 contracting fibres of the uterus. 
 
 Treatment of Accidental Hemorrhage. 
 
 21. As soon as you have sent for assistance, you 
 must take some means to check the hemorrhage. 
 If the term of pregnancy has not expired, if the 
 hemorrhage be not profuse, if there be no pains, 
 and little or no dilatation of the os uteri, place the 
 woman in the recumbent posture, and let her be 
 kept cool and quiet. Apply cold compresses to 
 the abdomen and vulva, give cold drinks, and use 
 enemata of cold water. Also administer astrin- 
 gents and sedatives. But, if labor-pains have set 
 in, if the os uteri be dilated, and the hemorrhage 
 severe, you must use, in addition, measures which 
 will increase uterine contraction, such as the ad- 
 ministration of ergot and the application of the 
 binder. If these fail, you may rupture the mem- 
 branes. 
 
 If the term of pregnancy be not completed, we may 
 hope, in some instances, to restrain the hemorrhage, and 
 conduct the woman safely to the full time. 
 
 The following mixture may be given : — 
 12* 
 
138 CASES REQUIRING CONSULTATION. 
 
 R. — Acid sulph. dil., 3j. 
 Tinct. opii, rcixl. 
 Infus. rosae acid, ad ,^vj. 
 M. ft. mistura, cujus sumat sextam partem omni hora. 
 
 Or the following : — 
 
 R. — Plumbi acetat., gr. xviij. 
 
 Acid, acetic, n\xx. 
 
 Morphiae acetat., gr. j. 
 
 Aq. destillat., gvj. 
 M. capt. sextam partem secunda quaque hora. 
 
 A plug has been much recommended in these cases ; 
 but it is a hazardous remedy, especially in the hands of 
 an inexperienced practitioner. 
 
 Rupturing the membranes is one of the surest means 
 both for restraining hemorrhage and forwarding the labor. 
 "When the liquor amnii has escaped, the uterus contracts 
 firmly around the body of the child, at the same time 
 compressing the placenta and closing the bleeding vessels. 
 It should, however, only be adopted by the student as a 
 last resource, because it may possibly fail, and the result 
 would be that the operation of turning, which might be 
 required, would be thus rendered difficult. 
 
 Placenta prssvia — Diagnosis. 
 
 22. In cases of unavoidable hemorrhage. In 
 these, the placenta is attached over the os uteri ; 
 and the necessary result is that, as soon as the os 
 begins to open, the placenta becomes detached, 
 and a copious hemorrhage takes place. The flood- 
 ing usually comes on a few weeks before delivery, 
 and is at first inconsiderable. After a week or 
 two it returns more copiously, until, at last, it be- 
 comes frequent and profuse. The flooding accom- 
 panies each uterine contraction, and ceases in the 
 intervals between them. On examining, you either 
 
CASES REQUIRING CONSULTATION. 139 
 
 find that the entire os uteri is thickened, and occu- 
 pied by the firm, rough, spongy mass of the pla- 
 centa, or 3'on find that the os is partly occupied 
 b}^ the placenta and partly by the membranes. 
 The first is a complete, and the second a partial, 
 presentation of the placenta. 
 
 The hemorrhage from placenta praevia is occasioned, 
 first, by the slight dilatation of the cervix uteri, which 
 takes place some weeks before delivery ; and subsequently, 
 by the still further dilatation which is effected during 
 labor. The opening of the cervix produces a disruption 
 of the connections between the placenta and uterus ; the 
 large venous sinuses of the latter are laid open, and fright- 
 ful hemorrhage ensues, which increases pari passu with 
 the pains. 
 
 Placenta pra^via is the most dangerous of all presen- 
 tations. If labor be permitted to go on under such cir- 
 cumstances without interference, the woman will almost 
 certainly bleed to death before its termination. Still, 
 however, a few exceptional cases occur in which nature 
 effects delivery without a fatal result. In these the ute- 
 rine contractions are very powerful and energetic. The 
 placenta speedily becomes detached and expelled, and the 
 hemorrhage ceases. As soon as the placenta is completely 
 detached the uterine arteries are broken away from it, 
 and the veins are closed by the dilation of the os uteri 
 which effected the separation, as well as by the direct 
 compression of the child's head, which soon descends and 
 occupies the place of the placenta. 
 
 Placenta preevia — Treatment. 
 
 23. In cases of placenta praevia send immediately 
 for assistance, and try to arrest the hemorrhage 
 by placing the woman in the recumbent posture, 
 by cold applications to the abdomen and vulva, 
 by cold drinks and enemata, and by repeated doses 
 
140 CASES REQUIRING CONSULTATION. 
 
 of opium. If the full term has not yet arrived, 
 these means may for a time succeed. If they 
 should fail, you may plug the vagina until assist- 
 ance arrives. If there is a partial placenta presen- 
 tation, you may rupture the membranes, as in ac- 
 cidental hemorrhage. In all cases stimuli are to 
 be given, if necessary. 
 
 In cases of complete placenta presentation, the proper 
 treatment is to turn and deliver as soon as the os uteri is 
 sufficiently dilatable to allow of such a proceeding. In 
 some instances, where the exhaustion from hemorrhage is 
 very great, and when turning would be dangerous, com- 
 plete detachment of the placenta has been recommended, 
 and practised with success. (See Sir J. Simpson's memoirs 
 on this subject.) Should the inferior extremities present 
 with placenta praevia, it is a fortunate circumstance, be- 
 cause there will be no need of turning. 
 
 When the membranes have been ruptured in partial 
 placenta praevia the head descends, compresses the pla- 
 centa and the bleeding vessels of the uterus, and thus 
 stays the hemorrhage. 
 
 Puerperal Convulsions ; Epileptic Form — 
 Symptoms. 
 
 24. In all cases of puerperal convulsions. These 
 usually assume the form of epilepsy, and may su- 
 pervene before, during, or after labor. They are 
 generally preceded by headache, drowsiness, ob- 
 scure vision, and tinnitus aurium. As the fit 
 comes on the woman loses consciousness, the pu- 
 pils become dilated, and the countenance rigid. 
 All the mucles of the body are seized with violent 
 spasmodic contractions; the face is livid and hor- 
 ribly distorted, the respiration hissing, the tongue 
 
CASES REQUIRING CONSULTATION. 141 
 
 is thrust out, and a bloody foam issues from the 
 mouth. After a few minutes the fit passes off, 
 and returns again in half an hour, an hour, or 
 more. According to the severity of the case, con- 
 sciousness may be completely, partially, or not at 
 all, regained during the intervals. 
 
 The muscular contractions during the paroxysms are so 
 violent that the attendants often have the greatest diffi- 
 culty in keeping the patient upon the bed. The tongue 
 being thrust out, it is very liable to be bitten, in conse- 
 quence of the contractions of the muscles of the jaw. 
 Hence it is that the saliva is so apt to be tinged with 
 blood. The urine and feces are often expelled involun- 
 tarily during the convulsions. The progress of labor, 
 although in some degree interfered with, is not arrested 
 by the convulsions. The fits are apt to recur simultane- 
 ously with the pains, and the child may be born during 
 one of these paroxysms. Under such circumstances it is 
 very likely to be dead, or to die soon after its birth. 
 
 In bad cases the breathing remains stertorous, and the 
 patient lies in a comatose state between the fits. 
 
 Epileptic convulsions may occur in very opposite con- 
 ditions of the circulating system. In most cases they 
 appear to be connected with a state of hyperemia. In 
 some few instances they have been noticed in connection 
 with extreme anaemia, from flooding. In by far the greater 
 number, a state of toxaemia has been recognized by the 
 presence of albumen in the urine. It must be obvious 
 that diametrically opposite principles of treatment would 
 apply to the first and second class of cases. 
 
 Hysterical and Apoplectic Convulsions — Diagnosis. 
 
 25. Besides the epileptic form of convulsions, 
 there are the hysterical and apoplectic. These 
 are distinguished from the first bv the following 
 marks : The hysterical convulsions usually come 
 
142 CASES REQUIRING CONSULTATION. 
 
 on during the early months of pregnancy, and re- 
 semble ordinary hysterical paroxysms, being unac- 
 companied with complete loss of consciousness, 
 distortion of the face, or foaming of the mouth. 
 After the attack is over the patient resumes her 
 ordinary condition. Apoplectic convulsions mostly 
 come on during the second stage of labor, and re- 
 semble a severe attack of apoplexy; the convul- 
 sion shows no disposition to return, and is speedily 
 followed by stertorous breathing, and complete 
 loss of thought, sensation, and voluntary motion, 
 until, at last, all muscular action ceases. 
 
 Hysterical convulsions most commonly happen about 
 the time of quickening. They require very different treat- 
 ment from that which is needed in the other two kinds, 
 and are of far less serious import. 
 
 Apoplectic convulsions are almost invariably fatal, and, 
 in general, depend upon a sudden rupture of one of the 
 cerebral vessels. In persons predisposed to apoplexy, the 
 great stress upon the vessels of the brain during the second 
 stage of labor, is very likely to produce such a result. 
 
 Treatment of Convulsions. 
 
 26. In all cases of convulsions, send for assist- 
 ance immediately. In the mean time you should 
 take precautions to prevent the woman from in- 
 juring herself during the paroxysms. You should 
 see that she does not roll off the bed, and insert a 
 cork or pad of some kind between the teeth, to 
 prevent her from biting her tongue. The follow- 
 ing remedies may be used in all cases, viz., cold 
 affusion to the head, and sinapisms to the calves 
 
CASES REQUIRING CONSULTATION. 143 
 
 of the legs, together with purgatives and antir 
 spasmodic enernata. 
 
 The following enema maybe mixed with a pint of warm 
 water or thin gruel, and injected into the rectum : — 
 
 R.— 01. terebinth., 
 
 Trae. assafcetid., aa §ss. 
 
 Ovi vitellum, 
 
 01. ricini, gj. M. 
 
 The student should always request a consultation in all 
 cases of puerperal convulsions, because a widely different 
 treatment is required in the several forms of convulsions ; 
 hence, an error in diagnosis might be attended with dan- 
 gerous or even fatal results. For instance, in the epilep- 
 tic and apoplectic forms, a decidedly antiphlogistic treat- 
 ment is necessary, such as free venesection, leeching, 
 blisters, calomel, etc. Whereas, on the contrary, stimu- 
 lants, anti-spasmodics, and sedatives are indicated in 
 hysterical convulsions. 
 
 Epileptic convulsions, during labor, seem to depend 
 very much upon irritation, caused by the presence of the 
 foetus in utero. Delivery, therefore, becomes an important 
 remedial agent, provided the labor is sufficiently ad- 
 vanced to admit of it. The forceps is preferable to all 
 other means of effecting delivery. In epileptiform con- 
 vulsions, chloroform inhalations have been found of great 
 service in restraining the fits. But, according to the au- 
 thor's experience, a full dose of the hydrate of chloral by 
 enema is still more effectual. 
 
 Bupture of Uterus — Symptoms. 
 
 21. When a rupture of the uterus takes place 
 during labor. The symptoms of this alarming 
 accident are, sudden and acute pain in the abdo- 
 men, followed by a ghastly pallor of the counte- 
 nance, weak thready pulse, syncope, constant 
 vomiting of dark, grumous fluid, resembling coffee- 
 
144 CASES REQUIRING CONSULTATION. 
 
 grounds, and other signs of extreme prostration. 
 There is usually a discharge of blood from the 
 vagina. The presentation recedes out of reach, 
 and, if the rent in the uterus be large, the child 
 escapes through it into the abdominal cavity, 
 where its limbs may be very distinctly felt through 
 the parietes. In these cases, after sending for 
 assistance, you may endeavor to keep up the 
 powers of life by stimuli ; but death nearly always 
 takes place after a few hours. 
 
 Rupture of the uterus is the most dangerous complica- 
 tion of labor to which women are liable : it is fortunately 
 rare, occurring about once in 1331 cases. It may be 
 occasioned by malpresentation, deformity of the pelvis, the 
 abuse of ergot, awkward attempts to turn or to use in- 
 struments, structural degenerations of the uterus, etc. In 
 some instances, the rupture may not extend through the 
 entire thickness of the uterine parietes. When it is of 
 this partial character, it is attended with less imminent 
 danger. 
 
 The vagina may be lacerated during labor at its junc- 
 tion with the uterus. The symptoms produced resemble 
 those of ruptured uterus, but they are not so urgent, nor 
 are they attended with so much danger. 
 
 When the uterus is ruptured, delivery should be accom- 
 plished as soon as possible by turning, by the forceps, or 
 by craniotomy. 
 
 If the child has escaped into the abdominal cavity, the 
 hand must be passed through the rent in the uterus in 
 order to search for the feet. The foetus has been delivered 
 by gastrotomy, when delivery per vices naturales has been 
 found impossible. 
 
 If the woman survive the immediate shock of the rup- 
 ture, she will be likely to be carried off subsequently by 
 peritonitis. Should peritonitis supervene, it must be 
 treated in the usual way. 
 
CASES REQUIRING CONSULTATION. 145 
 
 Inversion of Uterus — Symptoms. 
 
 28. In cases of inversion of the uterus. This 
 dangerous accident is somewhat rare. It usually 
 happens very soon after the birth of the child. It 
 may occur spontaneously, but much more fre- 
 quently is the result of improper traction upon the 
 cord when the placenta is still attached. (See 
 Note 36, Part I.) The inversion may be partial, 
 and limited to the fundus ; or the uterus may be 
 turned completely inside out, and pass beyond the 
 os externum, where it presents as a globular elastic 
 tumor, with a bright-red, rough, bleeding surface. 
 As the uterus descends, the woman experiences a 
 sensation as if a second child were coming into 
 the world, and is immediately afterwards attacked 
 with vomiting, syncope, and alarming prostration, 
 accompanied, not unfrequently, with profuse hem- 
 orrhage. 
 
 In complete inversion the uterus descends through the 
 os uteri, until the whole organ becomes external to the 
 vulva. The inverted organ then contains a cavity com- 
 municating with the abdomen, and lined by peritoneum. 
 Within the cavity are the uterine appendages, and occa- 
 sionally the intestine. In partial inversion, the fundus 
 may be merely depressed into the cavity of the uterus 
 like the bottom of a glass bottle ; or the greater portion 
 of the uterus may be depressed, and form a tumor within 
 the vagina, but not external. When the inversion is com- 
 plete, no uterine tumor whatever can be felt in the hypo- 
 gastric region ; when it is partial, the depression of the 
 fundus can often be felt through the parietes. 
 
 Inversion of the uterus is always attended with much 
 peril. If the displacement be not speedily reduced, the 
 13 
 
146 CASES REQUIRING CONSULTATION. 
 
 woman will in all probability die from the immediate shock 
 of the accident, or from hemorrhage, inflammation, gan- 
 grene of the uterus, etc. 
 
 Inversion in some instances takes place spontaneously, 
 in consequence of the woman making a sudden bearing- 
 down effort immediately after the birth of the child. 
 
 Treatment of Inversion of Uterus. 
 
 29. When the uterus is inverted you should send 
 for assistance, but, at the same time, you should 
 make an immediate attempt to replace it. Accord- 
 ingly, you compress the tumor firmly with both 
 hands, and then push the fundus upwards into the 
 pelvis, in the direction of the vaginal canal, by 
 means of the fingers placed in the form of a cone. 
 Should the placenta adhere to the uterus, it ought 
 to be returned with it ; but should it be impossible 
 to do so, it may be separated. After the uterus is 
 returned, the hand should be kept in its cavity 
 until it is expelled, with the placenta, by the uterine 
 contraction. Should the first attempt at reduction 
 fail, you may try again, after emptying the bladder 
 and rectum. 
 
 The reduction of an inverted uterus is comparatively 
 easy provided it be done immediately after the accident. 
 The chief difficulty is felt in pushing the tumor past the 
 perineum ; as soon as it has passed this point, the uterus 
 flies back into its proper position with a jerk. 
 
 If the uterus has been inverted for four or five hours, 
 the reduction becomes exceedingly difficult, on account of 
 the strangulation and consequent swelling of the inverted 
 organ. 
 
CASES REQUIRING CONSULTATION. 147 
 
 Retention of Placenta — Causes and Symptoms. 
 
 30. In cases of retention of the placenta (see 
 Note 36, Part I.). This may be due to three dif- 
 ferent causes, viz : 1. Torpor of the uterus. 2. 
 Irregular contraction. 3. Morbid adhesion of the 
 placenta to the uterus. The sj-mptoms of the first 
 have already been mentioned (see 54, Part II.). 
 In the second case there is a spasmodic or "hour- 
 glass" contraction of some of the circular fibres, 
 either of the os uteri internum (which is the most 
 frequent), or of the body or fundus of the uterus. 
 The cord may be traced passing through the con- 
 striction. In the third case, the existence of ad- 
 hesion can only be made out when the hand is 
 introduced into the uterus, in order to detach the 
 placenta. In all these cases there will be much 
 hemorrhage, if anj' portion of the placenta be de- 
 tached. 
 
 The name " hour-glass contraction" has been given to 
 irregular contraction of the uterus, because that organ 
 appears to be divided into two chambers, by the circular 
 construction of its fibres. The whole or only a portion of 
 the placenta may be retained in the upper chamber. Ir- 
 regular and spasmodic contraction of the uterus is very 
 likely to ensue if the cord be dragged when the placenta 
 is adherent. (See Note 36, Part I.) 
 
 Retained Placenta — Treatment. 
 
 31. When the placenta is retained, you must en 
 deavor to excite the uterus to proper contractions 
 
148 CASES REQUIRING CONSULTATION. 
 
 by pressure and friction upon its surface. When 
 there is uterine inertia, ergot of rye may also be 
 given, as advised in 55, Part II. When the pla- 
 centa is retained by irregular contraction, you may 
 give a dose of opium, and keep up for some time 
 gentle but steady traction upon the cord. How- 
 ever, in most of these cases, and especially when 
 the placenta is morbidly adherent, the introduction 
 of the hand into the uterus is the only measure 
 which will suffice ; but you had better not under- 
 take this without a consultation. 
 
 When the hand is introduced into the litems, the finders 
 are placed in a conical form, and gradually insinuated 
 into the vagina. If there is hour-glass contraction, the 
 cord serves as a guide along which the tips of the fingers 
 are to be passed, until they reach the constriction. The 
 tips of the fingers are then inserted into the stricture, and 
 the fingers gradually and steadily expanded until they 
 overcome the resistance of the circular uterine fibres. 
 The hand can then be passed on into the uterine cavity, 
 so as to remove the placenta. If the placenta be morbidly 
 adherent, any detached portion of it should be seized, and 
 the remainder gradually and cautiously separated by the 
 fingers from the uterus until the whole can be removed. 
 Whilst this is being done with one hand, the other hand 
 should be placed externally on the abdomen, in order to 
 grasp and steady the fundus uteri. These operations 
 require much tact and delicacy. The introduction of the 
 hand into the uterus is a measure always attended with 
 some risk, but the operation becomes doubly hazardous 
 when the placenta is morbidly adherent. There is then 
 danger of injuring the uterus, as well as of leaving portions 
 of adherent placenta behind. These operations should 
 never be attempted by the student, except in extreme 
 cases ; as, for instance, when there is a profuse hemor- 
 rhage, and no assistance at hand. Should any portions 
 of ihe placenta be left behind, they will be likely to decom- 
 
CASES REQUIRING CONSULTATION. 149 
 
 pose, and occasion much irritation. To obviate these 
 effects, the vagina should be syringed daily with weak 
 disinfectant lotions. (See Note 67, Part II.) 
 
 Puerperal Fever — Symptoms. 
 
 32. In all cases of puerperal fever. These fevers 
 assume various types and degrees, from the acutely 
 inflammatory to the adynamic forms. From the 
 inflammatory lesions, which are present in various 
 cases, they have been called metro-peritonitis, hys- 
 teritis, uterine phlebitis, etc. The usual period of 
 invasion is the third day after delivery. The more 
 prominent symptoms in all cases are rigors, fol- 
 lowed by severe headache, fever, quick and often 
 feeble pulse, suppression of the milk and lochia, 
 pain and tenderness on pressure in the uterine re- 
 gion, extending from thence over the whole abdo- 
 men. The woman loses all interest in her child, 
 and her countenance betokens anxiety and great 
 prostration of strength. Besides these symptoms 
 there are generally delirium, vomiting, tympanites 
 abdominis, and sometimes diarrhoea. The disease 
 nearly always ends in death after a few days. 
 
 There have been very great differences in the classifica- 
 tions of puerperal levers. Dr. Lee referred them all to 
 inflammation of different parts of the uterus and uterine 
 appendages. 
 
 Dr. Ferguson believed them to depend upon a vitiation 
 of the fluids from absorption of putrid matters, etc., by 
 means of the inner surface of the uterus. In some of the 
 worst forms of the disease no inflammatory lesions of any 
 kind can be detected. 
 
 Puerperal fever, in its worst form, is a highly contagious 
 13* 
 
150 CASES REQUIRING CONSULTATION. 
 
 disease, and may be readily communicated from one patient 
 to another, through the medium of the medical man in 
 attendance. Moreover, it has been proved, by numerous 
 cases, that the disease may be produced by a variety of 
 other poisons, and, above all others, by that of phleg- 
 monous erysipelas. Dr. Braxton Hicks, however, refers 
 the greater number to scarlatina. Fevers of different 
 kinds, such as scarlet fever, or typhus, when they occur 
 after delivery, will assume a very malignant form, and bear 
 much resemblance to puerperal fever. It was ascertained 
 in the Vienna lying-in hospital, in 1846, that puerperal 
 fever could frequently be traced to examinations made by 
 students who had, just before, been engaged in opening 
 bodies in the dead house. It cannot, therefore, be too 
 strongly impressed on the minds of students that the 
 greatest caution is necessary in order to avoid communi- 
 cating this disease. No medical man should go to a labor 
 for at least a week after seeing a case of puerperal fever; 
 and when he does go, he should take care that he has on 
 no single article of dress which he wore on that occasion. 
 No student should go to a midwifery case soon after dress- 
 ing an erysipelatous patient, or making a post-mortem ex- 
 amination, especially of a case of abdominal inflammation. 
 In the Vienna Hospital a rule was made, that every stu- 
 dent who had been so engaged, should wash his hands in 
 chlorinated water before examining a lying-in patient. It 
 is better, indeed, that students should not attend mid- 
 wifery cases whilst they are engaged as dressers at hos- 
 pitals ; and as regards post-mortem examinations, Dr. 
 McClintock goes so far as to say that " the man who de- 
 votes himself to obstetrics should abjure the study of 
 pathological anatomy." 
 
 The author is in the habit of using the Turkish Bath 
 after he has been exposed to infection of any kind, and he 
 can confidently recommend it as the best means of cleans- 
 ing the skin and eliminating animal poisons from the 
 system. 
 
 Puerperal fever may commence within twenty-four hours 
 after delivery. The most usual period of invasion, how- 
 ever, is from forty-eight to seventy-two hours. Again, it 
 may not come on until five or six days afterwards. 
 
CASES REQUIRING CONSULTATION. 151 
 
 The pulse averages in most cases 120 to 130 beats in a 
 minute ; it is usually small and feeble, but in the more 
 sthenic forms is hard and wiry. [The pulse quite fre- 
 quently reaches 150 or 160 in a minute.] 
 
 The countenance in puerperal fever is very character- 
 istic, and very soon assumes the Hippocratic character. 
 The complexion is pale and sallow, with a hectic patch in 
 the centre of the cheek. The treatment is nearly always 
 unsatisfactory, and appears to have little effect in delaying 
 the fatal termination. The cases most amenable to treat- 
 ment are the more acute forms of peritonitis, which come 
 on soon after a severe or instrumental labor, for instance. 
 These bear more resemblance to ordinary peritonitis, and 
 require much the same treatment, viz., bleeding, leeches, 
 mercury to affect the system, opiates, and warm fomenta- 
 tions. These are the cases which are most likely to re- 
 cover. 
 
 A somewhat different treatment is required in what is 
 called the gastro-bilious puerperal fever (puerperal in- 
 testinal irritation of Locock). Here free purgation by 
 castor oil, calomel, and enemata is necessary. 
 
 The form called uterine phlebitis is best treated by 
 leeches, cataplasms, Dover's powder, and calomel to affect 
 the system. The vagina should be syringed out daily, as 
 recommended in Note 47, Part II. This is a most useful 
 measure in all cases of puerperal fever. 
 
 The epidemic or adynamic form of puerperal fever is 
 the scourge of lying-in hospitals ; being at the same time 
 the most contagious, and the least amenable to treatment. 
 In this form there are sometimes no morbid appearances 
 to be found after death, in the uterus, or its appendages. 
 In other instances, signs of inflammation are observed, 
 and occasionally purulent deposits are met with in the 
 joints, orbits, etc., as in cases of pyaemia. It appears to 
 make very little difference in the result, whether a stimu- 
 lant or antiphlogistic plan of treatment be adopted. The 
 remedies usually adopted are calomel and opium in re- 
 peated doses ; turpentine both internally and as an exter- 
 nal application to the abdomen ; sometimes leeches ; 
 nourishing broths, wine and other stimuli, are always 
 necessary to sustain the vital powers. 
 
152 OASES REQUIRING CONSULTATION. 
 
 Phlegmasia Dolens — Symptoms. 
 
 33. In cases of phlegmasia dolens. This disease 
 usually comes on about ten days or a fortnight 
 after delivery. It sets in with rigors, headache, 
 quick pulse, restlessness, and general malaise. 
 These are speedily followed by pain and tender- 
 ness in the hypogastrium or groin, extending down 
 the thigh and leg of that side ; the whole limb then 
 becomes greatly enlarged, and at the same time 
 hot, tense, elastic, white, and shining. The femo- 
 ral veins and lymphatics are hard, knotted, and 
 tender to the touch. There is much accompanying 
 constitutional irritation, feverishness, and want of 
 sleep. The tongue is furred, the face is pallid, the 
 milk and lochia usually much diminished. These 
 symptoms commonly pass off in two or three weeks, 
 but the limb ma}' remain stiff and lame for a much 
 longer period. 
 
 There has been much discussion at various times as to 
 the pathology of phlegmasia dolens, or " white leg," as it 
 is vulgarly called. It now seems pretty well established, 
 that the disease consists in an inflammation and obstruc- 
 tion of the principal veins, and also lymphatics, of the 
 limb affected ; and this inflammation, in most instances, is 
 due to the imbibition of poison by the uterine veins. 
 
 The pain and swelling do not always progress from 
 above downwards. The disease sometimes commences in 
 the calf of the leg, which is the seat of a violent cramp- 
 like pain, speedily succeeded by swelling. 
 
 The limb affected may increase to at least double its 
 ordinary size. The swelling is so firm and elastic, that it 
 very seldom pits on pressure, and is scarcely influenced in 
 any way by position. 
 
CASES REQUIRING CONSULTATION. 153 
 
 It occasionly happens, that, as soon as the disease has 
 abated in one leg, the other is attacked, and goes through 
 a similar course, except that the symptoms are scarcely 
 ever so severe. In some rare cases both legs are attacked 
 at once. 
 
 The treatment of this disease consists in the application 
 of leeches, followed by poultices, to the groin, or part first 
 affected. Opiates are generally of great service. After 
 two or three days, turpentine stupes or blisters to the 
 affected parts are very useful. When the acute stage is 
 past, tonics are proper, together with a generous diet. 
 The affected limb may then be painted with iodine or 
 rubbed with various stimulating liniments, and afterwards 
 enveloped in a flannel bandage. 
 
 Phlegmasia dolens rarely goes on to a fatal termination. 
 Should it end thus, the disease in all probability has either 
 accompanied uterine phlebitis, or has resulted in an attack 
 of general phlebitis, followed by deposits of pus in various 
 remote parts of the body. 
 
 Puerperal Thrombosis and Embolia — Symptoms. 
 
 34. In cases of threatened syncope from puer- 
 peral thrombosis. In women who have been lately 
 delivered (especially when there has been hemor- 
 rhage from inefficient uterine contraction after 
 labor), the sudden occurrence of dyspnoea, palpi- 
 tation, and syncope is an alarming symptom, be- 
 cause it usually denotes an altered condition of the 
 blood, which has led to the formation of clots, and 
 consequent obstruction of the pulmonary circula- 
 tion. 
 
 The pathology of puerperal thrombosis and embolia is 
 very well explained by Dr. R. Barnes, in a paper which 
 was published in the " Obstetrical Transactions" for 1863. 
 It is thus described : — 
 
 " 1. There is a dyscrasia of the blood immediately pro- 
 
]54 CASES REQUIRING CONSULTATION. 
 
 ceeding from the puerperal process, which is favorable to 
 the production of clots in the uterine veins and veins of 
 the lower extremities. Imperfect contraction of the uterus, 
 the formation of putrilage in the uterine cavity from the 
 admission of air, which acts upon the blood and serum 
 squeezed out of the vessels, and the remains of adherent 
 placenta or of decidua, are often the immediate antece- 
 dent conditions of peripheral thrombosis 
 
 "2. The next step is that of embolia. Portions of the 
 peripheral thrombi, attended, no doubt, in many cases, by 
 septic matter derived from the uterus, are carried to the 
 right heart. If the solid matters be large enough, or the 
 septic or ichorous matters be irritating enough, to cause 
 a violent perturbation of the heart's action, and to act 
 chemically on the blood-mass, rapid coagulation of blood 
 in the right cavities may ensue, followed by a similar pro- 
 cess in the larger pulmonary arteries. In such cases 
 sudden death occurs. 
 
 " 3. But in those cases in which either minute portions 
 of thrombi are taken up from the peripheral veins, or 
 when the septic or ichorous matter is less virulent, no clot 
 may form in the right heart, but minute emboli may be 
 carried into the finer divisions of the pulmonary artery, 
 causing lobular pneumonia, ending in slower death, or 
 possibly in recovery. 
 
 "4. It has been noticed, that in many of these cases 
 some mental emotion or sudden exertion has immediately 
 preceded (and has seemed to be the exciting cause of) the 
 cardiac and pulmonic distress." 
 
 With respect to the treatment of these cases, Dr. 
 Barnes states : " The point of first importance is to en- 
 courage lactation." " The next points are to enforce the 
 recumbent position, to remove all causes of mental or 
 bodily disturbance ; not to starve the patient, and thus to 
 give activity to the absorption of foul matters, but to 
 supply the circulating fluid with generous materials." 
 
 The remedies adapted to these cases are stimuli and 
 tonics ; wine, bark, iron, and especially ammonia, which, 
 besides being a stimulant, is also believed, in accordance 
 with Dr. Richardson's views, to have a powerful solvent 
 action upon any clots which may have formed in the heart 
 or bloodvessels. 
 
CASES REQUIRING CONSULTATION. 155 
 
 Pelvic Cellulitis and Abscess. 
 
 35. In cases of pelvic cellulitis and abscess. This 
 affection comes on insidiously some two or three 
 weeks after delivery or abortion. It is denoted by 
 fixed pain, swelling, and tenderness, just above the 
 pelvic brim in one iliac region or groin ; by hard- 
 ness and tenderness, on vaginal examination, in 
 the neighborhood of the os uteri, and by painful 
 micturition and defecation. There is much ac- 
 companying general disturbance, quick pulse, 
 hectic fever, and loss of appetite. Suppuration 
 is denoted by rigors and increased severity of the 
 local tenderness and throbbing. The pus may be 
 discharged externally above Poupart's ligament, or 
 into the vagina, rectum, or bladder. This event 
 usually gives relief to all the symptoms. 
 
 In this affection the inflammatory effusion appears to 
 be the result of absorption of irritant matters from the 
 uterine surface. The actual seat of the effusion is usually 
 the meshes of the areolar tissue surrounding the uterus, 
 between the folds of the broad ligament ; but in some 
 cases there is probably pelvic peritonitis present. 
 
 The abscess most frequently bursts into the rectum or 
 bladder, and the case terminates favorably. Sometimes, 
 however, it escapes externally, after burrowing and form- 
 ing troublesome sinuses, which cause the recovery to be 
 very protracted. In som e rare instances it has been known 
 to give way into the peritoueal cavity, and prove rapidly 
 fatal. 
 
 The treatment consists in topical depletion by leeches, 
 warm fomentations, poultices, and turpentine stupes. The 
 pain and restlessness at night should be relieved by opiates 
 and hydrate of chloral, or by opiate enemata and bella- 
 donna pessaries. Tonics and a nutritious diet are required, 
 
156 CASES REQUIRING CONSULTATION. 
 
 especially towards the termination. When distinct fluc- 
 tuation can be perceived either externally or in the vagina, 
 the abscess maybe opened ; but, as this operation requires 
 considerable tact and discrimination, a consultation should 
 be requested. 
 
 Puerperal Mania — Symptoms. 
 
 36. In cases of puerperal mania. This form of 
 insanity may show itself as acute mania, or assume 
 the more chronic form, melancholia. The first 
 kind commences very soon after labor ; the pulse 
 continues very frequent, and the excitement of the 
 second stage, instead of abating, increases to a 
 wild delirium, which, if not relieved, may end in 
 coma, paralysis, and death. The second and more 
 common kind usually commences two or three 
 days after labor, when the flow T of milk sets in, or 
 at a still later period ; and is very apt to assume 
 the form of religious melancholy. The patient is 
 captious, suspicious, and liable to take sudden and 
 unaccountable aversions to those about her. The 
 bowels are usually constipated, and the secretions 
 much vitiated. If fever be present, it is of a low 
 form, and there is a general want of power in the 
 system. 
 
 When the acute form of puerperal mania terminates 
 fatally, the post-mortem appearances usually found are — 
 thickening and opacity of the cerebral membranes, to- 
 gether with vascularity, softening, and effusions of blood 
 or serum in the brain or membranes. This form appears 
 in some instances to be nothing more than a particular 
 kind of puerperal fever. In the chronic form there is 
 usually headache, offensive breath, a sunken appearance 
 
CASES REQUIRING CONSULTATION. 157 
 
 of the eye, and pallor, or sallowness of the countenance. 
 If there is any accompanying fever, it is of a low type. 
 This kind appears to be mostly connected with derange- 
 ment of the digestive organs. In other instances it has 
 been clearly traceable to exhaustion, arising from profuse 
 hemorrhage during labor, or from over-lactation. In the 
 first kind of puerperal mania, an antiphlogistic treatment 
 is proper, such as leeches, and cold to the head, warm 
 pediluvia, and smart purgatives. In the other kind, pur- 
 gatives are necessary; and afterwards great attention 
 should be paid to diet, and to the regulation of the bowels. 
 In both kinds, should sleep be absent, sedatives will be 
 required ; but for this purpose hydrate of chloral is pre- 
 ferable to opium, which often tends to increase the cere- 
 bral excitement. In those cases which appear to be the 
 result of exhausting discharges, the patient should be put 
 on a generous diet, and a course of tonics. Sedatives are 
 also of much service. If over-lactation appear to be the 
 cause, the child must be weaned. 
 
 [The two remedies upon which we are to place 
 our hopes, both in this terrible form of disease 
 (mania) and in that so closely allied to it (puer- 
 peral fever), are opium and the lancet. Leeches 
 do but little good in well-marked cases. The 
 patients should be bled out of the disease, so to 
 speak. From 18 to 28 ounces will show its good 
 result. This should be followed by a large dose 
 of opium. Calomel combined with the opium often 
 proves of great service. 
 
 14 
 
PART IV. 
 
 CHAPTER I. 
 
 DISEASES OF PREGNANCY. 
 
 While there are certain symptoms which a 
 woman is taught to believe to be really necessary 
 signs of pregnancy, and to regard as absolutely es- 
 sential to such a state, yet, perhaps, there is no 
 condition in the life of the female, which needs 
 more the sympathy and care of the physician than 
 this. Realizing this, and that so many circum- 
 stances herein arise, so perplexing to the young 
 physician, I have added this chapter to the few 
 suggestions already given in a former edition. 
 
 Under this head it must be remembered, that 
 the effects of pregnancy are varied. You will find 
 Mrs. A., a delicate frail woman, nervous, anaemic, 
 and weak. She becomes pregnant, her form be- 
 gins to be rounded, her nervous system rallies, her 
 pale, wan features begin to be lighted up, and she 
 steadily improves during the whole period of ges- 
 tation. Mrs. B., on the other hand, a strong robust 
 woman, naturally presenting every evidence of 
 health, under like circumstances gradually or 
 
DISEASES OF PREGNANCY. 159 
 
 rapidly fails in all physical respects, until labor 
 actually sets in. Therefore, while salutary and 
 beneficial results may fall to the pregnant woman 
 in the one case, and most harassing in another, 
 yet there are certain general symptoms largely 
 common to all, and which are discussed in our 
 text books under the head of diseases of preg- 
 nancy. 
 
 One of the first and most common of these is 
 morning sickness. Sometimes this troublesome 
 affection occurs in the early months of pregnane}', 
 ceasing at the period of " quickening ;" again, it 
 may arise for the first time shortly after quicken- 
 ing, and continue until labor sets in, or occasionally 
 it will last throughout the entire pregnancy. It is 
 called morning sickness, from the fact that the 
 woman rarely feels it prior to rising in the morning 
 from her bed, and scarcely ever does it continue 
 more than three or four hours. A slight morning 
 sickness is generally expected, but not unfrequently 
 it becomes exceedingly troublesome, and the physi- 
 cian is summoned to give relief. 
 
 A teaspoonful of nicely prepared charcoal, with 
 a scruple of magnesia, will generally bring ease. 
 If the bowels are constipated, a mild saline cath- 
 artic should be given. Kissengen or Yichy water, 
 or even Epsom salts, will prove serviceable. 
 
 Very often two or three tablespoonfuls of strong 
 coffee, without sugar or milk, will, if taken before 
 rising, bring most happy relief. Prof. Simpson's 
 
160 DISEASES OF PREGNANCY. 
 
 remedy, oxalate of cerium, has lost none of the 
 credit he attributed to it when first he introduced 
 it to our notice. Alone in one grain doses, or 
 combined with Subnit. Bismuth, or even in four or 
 five-grain doses, as has been more recently recom- 
 mended, it proves one of the most efficient reme- 
 dies we have for the treatment of this troublesome 
 affection. 
 
 Heartburn. — This word, commonly used, brings 
 only an idea of temporary trouble, and that, from 
 its common prevalence, of very little moment; but 
 to the obstetrician it means a great deal, and forms 
 one of the most troublesome diseases — for disease 
 it becomes — of pregnancy. It may occur at any 
 part of, or during the entire time of pregnancy. 
 It needs no description, and its relief, not cure, 
 must be brought about by alkalines. Very often, 
 however, when the ordinary alkaline treatment 
 failed, I have given great relief to the patient by 
 two-drachm doses of Hosford's hypophos. lime 
 before meals. 
 
 Costiveness. — Best treated by simple injections 
 of water, repeated at a regular hour of the day. 
 Do not accustom your patient to cathartics. 
 
 Diarrhoea. — This, the direct opposite of the 
 above, is by no means an uncommon complaint of 
 the pregnant woman. A lady, in whose four con- 
 finements I have been the medical attendant, al- 
 
DISEASES OF PREGNANCY. 161 
 
 ways, during her pregnancy, suffered from this 
 complaint, and such cases are not uncommon ; and, 
 while it is best not to suppress it too decidedly, 
 you must be on your guard, lest the patient's 
 strength wanes under its continuance. 
 
 Ipecac, and Dover's powder, combined in small 
 doses of each, answer a good purpose unless con- 
 tra-indicated by obstinate nausea and vomiting. 
 Rhei syrup, in conjunction with a few grains of 
 bicarb, soda, often gives immediate and happy re- 
 lief; or, perhaps, an astringent bitter tonic slightly 
 stimulated will answer the purpose best. Regu- 
 lation of the diet forms an important part in the 
 successful treatment of such disturbances. 
 
 Fainting Fits ; Palpitation of the Heart. — 
 These are common disturbances of the pregnant 
 state. About the period of quickening, the fainting 
 fits are most frequent. Generally these attacks are 
 traceable to some direct cause, such as over- 
 exertion, mental or physical excitement, and the 
 like ; but sometimes the attack is sudden, and 
 no cause is apparent. During the spasm place 
 the patient in a recumbent posture, and manage 
 her as in ordinary faintness, applying ammonia 
 near (not directly to) the nose, giving free air and 
 slight stimulation. 
 
 After the spasm, if it has been traceable to any 
 cause, of course the removal of this will probably 
 prevent a future attack. Direct the patient to 
 14* 
 
162 DISEASES OP PREGNANCY. 
 
 avoid all scenes of excitement, large crowds, and 
 over-heated rooms. A slight stimulant in the early 
 morning answers a good purpose, but, if the patient 
 is of a nervous temperament, use the bromides 
 freely. 
 
 Should she be afflicted with palpitation of the 
 heart, means must be employed to prevent, if pos- 
 sible, future attacks. If these troubles occur 
 during pregnancy for the first time, probably no 
 better remedies can be used than the chalybeates. 
 The disease is here a functional one purely, and 
 brought about by her peculiar condition. Let her 
 strength be built up by a nourishing generous diet, 
 and iron in some form freely administered. It 
 may be well to notice briefly an idiosyncratic con- 
 dition of some women. The ferruginous prepara- 
 tions generally act as astringents, but occasionally 
 the reverse is the case. I have had in my care 
 a patient, to whom if the smallest doses even of 
 any of the irons were given, would be prostrated 
 with diarrhoea. Such cases are not unfrequent, 
 and the young physician should remember this, 
 lest, in the administration of such remedies, a 
 dangerous condition may be produced. 
 
 In the strong and plethoric woman, affected thus 
 with palpitation of the heart, bromide of ammonium 
 or potassium may be used with good success. 
 
 Remember, in all such affections which arise 
 during pregnancy, nothing is more important in 
 bringing comparative comfort to your patient than 
 
DISEASES OF PREGNANCY. 163 
 
 observing the rules of hygiene. As a general plan 
 pure air and regular exercise will bring her 
 comfort when nothing else will. 
 
 These few troubles, which I have necessarily 
 briefly noticed, are those most common to the 
 pregnant state, and to which the physician's atten- 
 tion will be most frequently attracted. 
 
 Many others, e. g. swelling of the limbs, varicose 
 veins, sudden and violent movements of the child, 
 sleeplessness, piles, extreme tension of the abdo- 
 men, etc., will demand the care of the physician at 
 times, but those to which I have called attention 
 are the diseases most frequently requiring the care 
 of the physician. 
 
 Let the young physician always remember this, 
 when you are called to the pregnant woman, realize 
 that you are dealing with a condition demanding 
 your anxious care and warmest sympathy. Let 
 your patient be in the home of wealth and luxury, 
 or in the hovel of poverty and extreme want, the 
 symptoms of suffering and pain may be equal, and 
 will equally demand your kindest care as a physi- 
 cian. 
 
 The simple suggestions offered to you in this 
 and the two subsequent chapters go to you with 
 most earnest desires, that, under your care, pain 
 and suffering may give place to ease and comfort. 
 
1G4 CARE OF THE NEW-BORN INFANT. 
 
 CHAPTER II. 
 
 CARE OF THE NEW-BORN INFANT. 
 
 The few words devoted by the author to this 
 topic, though thoroughly practical in character, 
 seem hardly sufficient for so important a subject. 
 I have, therefore, introduced this chapter to afford 
 some general rules to guide the student, or those 
 just entering the profession, in the management of 
 the new-born child. Too often the physician is 
 utterly ignorant of the duties of the nurse. Too 
 frequently the little stranger, as soon as born, is 
 rolled in flannel and placed by the mother's side, 
 or on the lap of nurse or friend, its loud cries an- 
 nouncing to the household its advent, and here the 
 physician leaves it, without directions to nurse or 
 mother as to its further care or management. 
 
 It is not to be supposed that the physician is to 
 wash and dress it, but he should be familiar with 
 the entire care, and give directions to the nurse 
 accordingly. You will not unfrequently be ques- 
 tioned by the nurse or the mother upon some or 
 all of these points, and with them you must be 
 familiar, if 3^011 would maintain a good name 
 among those who employ your services. 
 
CARE OF THE NEW-BORN INFANT. 165 
 
 Let us suppose the cord has been properly tied 
 and severed, as noticed on page 36, and the nurse 
 is now at liberty to attend to the wants of the 
 child. She should be made familiar, first, as to 
 
 Washing the Infant. — She should be provided 
 with a soft sponge, Castile soap, sweet oil, and an 
 abundance of warm water (96° or 98°). It is best 
 that this first washing should not be protracted, 
 that it may be perfect as to result. The one fol- 
 lowing will prove effectual wherein this one fails. 
 Many infants are covered with a white, cheesy 
 coating (vernix caseosa) — a secretion from the se- 
 baceous follicles — which oftentimes is difficult to 
 remove. Let the child be ivell oiled prior to wash- 
 ing, and the warm water, with soap, will readily 
 remove it. The nurse must remember that the 
 cutaneous surface is very delicate, and must be 
 gently handled, lest abrasion occur. Such result 
 often manifests itself after harsh handling, and is 
 the cause of great discomfort to the little one. 
 The surface should be thoroughly dried with a soft 
 towel gently applied. There are various powders 
 in use among nurses, some of them injurious from 
 the means of scenting used by druggists. Finely 
 levigated white lead has been used — itself a poison 
 — and a case is recorded by Koop, in which death 
 resulted from the use of this powder. Nothing 
 better can be used than finely-powdered starch, and, 
 if there is any excoriation, as there often is about 
 
166 CARE OF THE NEW-BORN INFANT. 
 
 the anus and vnlva and groins, equal parts of pow- 
 dered chalk and calamine (zinci carbonas) may be 
 used with great benefit. Notice should be taken 
 of the cord, that there is no bleeding from it after 
 the child is washed. 1 The nurse should direct her 
 attention now to 
 
 Dressing of the Infant. — They are exceedingly 
 susceptible to the impressions of cold. There is a 
 popular error, which has led to not a few fatal re- 
 sults, that the child, even newly born, has great 
 power of generating heat. Let it be remembered 
 that in all warm-blooded animals there is less power 
 of generating heat and resisting cold at birth, than 
 at any time during life. This principle must be 
 remembered and regarded, and, in a climate so 
 variable as our own, the child should be carefully 
 protected from cold and dampness. A soft flannel 
 binder is placed around the belly of the child, fast- 
 ened comfortably behind by tapes. 
 
 If in winter, the child's neck and arms should 
 be covered. This delicate skin, which fond mothers 
 are so anxious to display uncovered, is particularly 
 sensitive to the action of cold, and you should im- 
 press it upon them, that it is a dangerous prac- 
 tice to allow bare neck and limbs. " A little more 
 common sense, more sleeves, and sacks, and high 
 
 1 A most excellent powder, and one which I have largely 
 used, may be made as follows : I£. — Starch |j ; Zinci Oxid. 
 5j. M. Finely powdered. 
 
CARE OF THE NEW-BORN INFANT. 167 
 
 dresses, arid less vanity and fashion," and mothers 
 will have fewer little graves to weep over. 
 
 If in summer, the child should be kept cool, both 
 by day and night. Inattention to this latter point 
 leads largely to cholera infantum. Remember the 
 simple rule laid down by Churchill : " As regards 
 the dress, the infant requires softness, looseness, 
 and warmth, and as regards handling, gentleness 
 and dexterity." 
 
 The child washed and dressed, you will be asked 
 respecting the 
 
 Physic for the Child. — The beautiful harmony 
 which Providence arranged in the action of the 
 various organs of the body, and the wonderful dis- 
 play of His care and wisdom manifested in the 
 entire construction of beings, is shown no less 
 plainly in the secretion of the breasts, even from 
 the very moment the mother gives birth to her 
 child. In a healthy woman, from the birth of 
 tbe infant, there is a secretion of the mammary 
 glands. Though this secretion is different, during 
 the first forty-eight, or even seventy-two hours, 
 from that subsequent to this time, still it is evi- 
 dently designed for the new-born babe. This pecu- 
 liar secretion (during the first two or three chiys) 
 is known as colostrum, differing from pure milk, 
 from the fact that it contains even a larger amount 
 of solid ingredients, and a large quantity of oily 
 matter — oil globules. It fulfils two purposes. 
 
168 CARE OF THE NEW-BORN INFANT. 
 
 First, it affords, when freely secreted, ample 
 nourishment for the child, and secondly, it acts as 
 a purgative, cleansing the bowels of that dark 
 green matter first passed by the infant, known as 
 meconium. 
 
 Remembering this, it is best not to give any . 
 physic for the child ; but, whenever it is absolutely 
 necessary, from the fact that the colostrum fails to 
 purge, no remedy is equal to fresh castor oil, given 
 a half teaspoonful at a dose. 
 
 Pood for the Child. — How soon shall the infant 
 be put to its mother's breast? You will often have 
 this question asked you, and you have many ex- 
 cellent authorities to guide you. 
 
 I think it is safe to assert, that, provided the 
 mother has passed through her labor without un- 
 toward symptoms, such as unusual pain and great 
 fatigue, consequent upon lingering labor, the child 
 should be given the mother to nurse within three 
 or four hours after labor. Nurses and mothers 
 will generally oppose you in this course, avowing 
 " the child will starve ;" " I have no milk ;" " can- 
 not we give it sugar and water ?" Such remarks 
 will constantly greet you in the lying-in room. 
 The health and comfort of both mother and child 
 lie to a great extent in your hands. Mark out your 
 rules plainly, and see that they are followed, and, 
 under the circumstances already noticed, let the 
 child depend upon the mother's breast for nourish- 
 
CARE OF THE NEW-BORN INFANT. 169 
 
 ment. Should it be necessaiy, under other circum- 
 stances, to feed the child, the best and most con- 
 venient substitute is cow's milk. This should be 
 diluted with an equal quantity of water, and a 
 little sugar should be added, as the milk of the 
 cow possesses less saccharine matter than found 
 in human milk. Care must be taken that the milk 
 is of the proper temperature. It should be 95° or 
 96°. Be sure that sugar and water, molasses and 
 water, catnip tea, etc. — remedies which the nurses 
 are so fond of giving — are avoided. No child 
 should be allowed to nurse oftener than once in 
 two hours. As the mother commences in this 
 regard, so she must continue. 
 
 Cleanliness of the Infant. — In its early life it 
 should be bathed at least once in the twenty-four 
 hours, in water from 96° to 98° Fahrenheit. The 
 surface should be thoroughly dried, especially 
 about the groins, perineum, and axillae. 
 
 The discharges from the bladder and bowels, so 
 frequent in early life, require as frequent change of 
 napkins. This is too often overlooked by the 
 nurse. Not only after each discharge from the 
 bowels, but after every one from the bladder, the 
 child should have applied a clean, dry napkin — not 
 one that has been soiled by urine and then hung be- 
 fore the fire or beneath the sun's rays to dry with- 
 out having been washed ; it is the application of 
 these that causes nearly all the abraded and exco- 
 15 
 
170 CARE OF THE NEW-BORN INFANT. 
 
 riated perineums and vulvae of children, many cases 
 of which are extremely distressing. Should such 
 a case present itself to your notice, inquire into 
 this matter, and you will almost always find its 
 cause. Every napkin should be properly washed 
 prior to use, and in no room in which are confined 
 mother and child, should be hung the soiled cloths. 
 I have noticed this subject somewhat fully, for I 
 have too often seen the evil results from inatten- 
 tion to it. A good nurse will give her attention to 
 these points, but unfortunately we have but few 
 good nurses. 
 
 I have thus, in a familiar and general manner, 
 given you a few directions as to the care of the 
 child during your attendance upon the mother, 
 subsequent to her labor. It is only during these 
 few days that you will be able to give your personal 
 attention to these matters. By observing these 
 few rules, the health and comfort of the child will 
 best attest their value. 
 
 Later Care of the Child. — It is not my inten- 
 tion to enter upon the discussion of the diseases 
 incident to children. Would that I had the power 
 to throw some light upon this dark field. Now, as 
 ever has been, the mortality of infants is the op- 
 probrium of the Divine Art of Healing. The late 
 Dr. Dickson asked in vain, " How shall we prevent 
 the early extinction of half the new-born children 
 of men V] West truthfully asserts the appalling 
 
CARE OF THE NEW-BORN INFANT. 171 
 
 fact that "at least a third of all your patients" will 
 be children ; " and so serious are their diseases, 
 that one child in five dies within a year after birth, 
 and one in three before the completion of the fifth 
 year." May it fall to the lot of some reader of this 
 little volume ere long to solve this startling problem ! 
 I desire, in closing this chapter, to call your 
 attention to two or three points intimately con- 
 nected with early infancy. 
 
 Sleep. — The habits of sleeping or wakefulness 
 will be formed early, and cling closely to the little 
 subject, as it grows older. Without the proper 
 amount of sleep no child can flourish. The more 
 it sleeps the better for the child. It should not be 
 disturbed by nurse or mother, and as is customary 
 to put the child to sleep at noontime in very early 
 life, so should it continue till the child can walk 
 about. It should not be held while sleeping, but 
 laid upon the bed and warmly covered. The natu- 
 ral condition of the infant, in its early life, is sleep, 
 and for no reason should it be disturbed. 
 
 Diet of the Mother. — You will often be ques- 
 tioned respecting this subject. I am satisfied it is 
 best not to stint the mother too rigidly in this re- 
 gard. Let her live upon a generous diet, and not 
 avoid articles containing acid. The child soon be- 
 comes accustomed to the mother's routine of living, 
 and thrives, whereas, if too much restraint is placed 
 
172 CARE OF THE NEW-BORN INFANT. 
 
 upon her, every little digression from her rule af- 
 fects the child. 
 
 Colic. — The names of all the remedies brought 
 into notice by quacks for this affection of infancy 
 would almost fill a volume of this size. Caution 
 your patients to avoid the use of these nostrums 
 for their children. The basis of all is opium, and 
 all tend to harm. Every child will have more or 
 less of colic, and many times will be relieved by 
 the application of a hot flannel to its belly, or the 
 administration of a little fennel water, or a few 
 drops of gin and water. If the colic continues be- 
 yond the age of two or three months, and is ac- 
 companied with green discharges from the bowels, 
 I have found the following prescription to be of 
 great service: — 
 
 R. — Creasoti, gtt. j. 
 
 Tr. opii, gtt. iij. 
 
 Testa prep. 9j. 
 
 Spts. lav. co. gtt. xl. 
 
 Pulv. acacise, gj. 
 
 Aquae destjllat. giss. — M. 
 S. — Shake well. Teaspoonful every 3 hours. 
 
 Infants, even from birth, are liable to constipa- 
 tion. Much harm is done by the early and con- 
 stant administration of purgatives. To obviate 
 the difficulty, an injection of tepid water should 
 be given, and always at the same hour in the day; 
 allowing not more than twenty-four hours to 
 elapse without an evacuation of the bowels. 
 
 The child should be allowed the fresh air as much 
 
ABORTIONS. 173 
 
 as possible, when the weather permits. Much of 
 the health of the child depends upon the simple 
 rules of hygiene, and to enforce these is the duty 
 of the philosophic physician. It is a blessed gift 
 to be able to cure disease, but to prevent it thrice 
 blessed. 
 
 CHAPTER III. 
 
 ABORTIONS. 
 
 It is almost impossible for one to engage in the 
 practice of our profession at the present time, es- 
 pecially in large towns or cities, without noticing 
 to what an alarming extent the crime of induced 
 abortion has reached. Scarcely a tyro enters 
 upon his new work in the field of medicine ere he 
 is asked to produce abortion, and the request is 
 made, perhaps, by those who are little suspected 
 to be guilty of so heinous a crime. Husbands 
 seek it for their wives, libertines ask it for their 
 mistresses, seducers seek it for the unhappy vic- 
 tims of their licentious passion, wives, aye, mothers, 
 even beg it for themselves. The young and old, the 
 rich and poor, the nominal Christian &\\(\ the sinner, 
 alike will seek you out, and with the most ingenious 
 stories plead for this object. You must be pre- 
 pared to meet them, and to follow a noble course. 
 15* 
 
174 ABORTIONS. 
 
 I know too well, that there are those who, even 
 under the garb of a guardian of human life, accept 
 the proffered fee, though " steeped in blood and 
 crimsoned with shame,' 7 and yield to the claims 
 advanced ; but as a class the medical profession 
 nobly stand aloof from such deeds. 
 
 I do not introduce this chapter to afford its 
 readers a moral lesson. I would it were in my 
 power to add something to what has already been 
 said and written, upon this subject, that would 
 show to womankind its dark guilt and its deep 
 crime. I would I could impress upon their minds 
 the absolute truth, that it is quenching immortal 
 existence ; that it is destining what God created 
 in His own image ; that it is bringing to their 
 households dark, gloonry clouds, instead of pure 
 and peaceful sunshine. But this is not my object 
 here. I desire briefly to show to some extent its 
 appalling prevalence, and then, as briefly, to lay 
 down some general rules, to guide you in your 
 treatment of such cases. 
 
 Those who practise in well-settled communities 
 will not unfrequently be summoned to attend those 
 who have been in the hands of an abortionist, and 
 who now rely upon them to relieve them from their 
 sufferings and danger. None of these cases are 
 without peril. The deed has been done, and now 
 you are forced to attend them. Such cases should 
 never fail to receive your care and attention. 
 
 I fear, though I am ashamed to state it, the crime 
 
ABORTIONS. 175 
 
 is more prevalent in our own country than in any 
 other of the world. 
 
 Since I wrote the above words, my intimacy with 
 physicians in cities and towns of small size leads 
 me to state that abortions are proportionally as 
 common there as in large cities. 
 
 The distinguished Prof. Hodge of this city writes: 
 14 We blush while we record the fact, that in this 
 count iy, in our cities and towns, in this city, where 
 literature, science, morality, and Christianity are 
 supposed to have so much influence; where all the 
 domestic and social virtues are reported as being 
 in full and delightful exercise; even here, indi- 
 viduals, male and female, exist, who are continually 
 imbruing their hands and consciences in the blood 
 of unborn infants." 
 
 This is, alas, too true, and the legal authorities 
 not only sanction, but by cognizance encourage 
 this great crime. The Rev. Dr. Todd writes : " I 
 would not advise any one to challenge further dis- 
 closure, else we can show that France, with all her 
 atheism, that Paris, with all her license, is not so 
 guilty in this respect, as is staid Xew England, at 
 the present time." 
 
 Dr. Blatchford, of Troy, X. Y., writes : " A crime 
 which forty years ago, when I was a 3'oung practi- 
 tioner, was of rare and secret occurrence, has be- 
 come frequent and bold. 7 ' 
 
 If we compare Xew York city with Paris, we 
 shall find that " the ratio of foetal deaths to the 
 
176 ABORTIONS. 
 
 population has swollen from 1 in 1633, in 1805, to 
 1 in 340, in 1849, while in France, in 1851, there 
 was only about 1 in 1000 ;" we shall find, secondly, 
 that "the foetal deaths, as compared with the total 
 mortality, had increased from 1 in 37, in 1805, to 
 1 in 10.5, in 1868;" and, thirdly, that " the re- 
 ported early abortions, of which the greater num- 
 ber escaped registry, bear the ratio to the living 
 births, of 1 in 4.04, while elsewhere they are only 
 1 in 18.5 ;" and, lastly, that " early abortion, bear- 
 ing the proportion to the still-births at the full 
 term of 1 in 10.2, in 1846, has increased to 1 in 
 4.02, in 1856." 
 
 " In this description of New York, we have that 
 of the country." 
 
 I have thus led you to view these statistics, to 
 show you the appalling extent this crime of foeti- 
 cide has reached. I write to you at this day with 
 sorrow, stating that this terrible crime is not less- 
 ening, but is steadily, fear fully, rapidly increasing. 
 I trust these facts may excite you to take your 
 stand nobly with those who are battling against 
 a crime, at once so wicked in the eyes of the Crea- 
 tor, and so ruinous to individuals, communities, 
 and to our country. 
 
 Let us suppose you have been summoned to the 
 bedside of one who is pregnant, who tells you she 
 is now aborting or miscarrying, let the case be ac- 
 cidental or intentional. What are the symptoms 
 that will be presented ? (I desire only to speak of 
 
ABORTIONS. 177 
 
 those cases where abortion is conceded, and there 
 is no longer any hope of restraining it.) The two 
 sjnnptoms which are always present, and to w r hich 
 you must direct } T our attention, are pain and hemor- 
 rhage. From the latter symptom, the patient may 
 be apparently moribund when you reach her, and 
 yet your prompt attention and treatment may save 
 her life. If the case be one in which abortion has 
 been purposely produced, boldly take the right 
 stand at the onset, and give the husband or friends 
 to understand that death may occur, and if so you 
 shall insist upon a coroner's inquest. If this stand 
 is taken, it w T ill accomplish much towards checking 
 the crime. Enjoin upon your patient perfect rest. 
 At once make your examination of the uterus. 
 
 You may find the os soft and well dilated, or 
 rigid and undilated. The ovum may be protrud- 
 ing, or still within the uterine cavity. 
 
 Your afrn must be to free the uterus of its con- 
 tents. If the os is sufficiently dilated, you can 
 easily accomplish this with your fingers {the best 
 uterine instrument) or by Bond's placental forceps, 
 Simpson's uterine gouge, or the curette of Recamier, 
 or even by the ordinary uterine forceps. 
 
 But if the os is closed and undilatable, you must 
 bring on rapid and powerful uterine contractions, 
 for upon these alone the arrest of the hemorrhage 
 depends. 
 
 The cold douche on the belly, or ice-water injec- 
 tions, will sometimes accomplish this object, but 
 
IIS ABORTIONS. 
 
 the two remedies upon which you are to place 
 most reliance are the tampon and ergot. The 
 former has already been described on page 119. 
 The entire vaginal passage should be filled, and 
 allowed thus to remain from three to eight hours. 
 At the end of this time the tampon should be re- 
 moved, and, if the os is not sufficiently dilated, 
 another should be inserted, taking care that the 
 bladder is freely emptied of its contents. When- 
 ever the os is dilated sufficiently for your manipu- 
 lations, take care that you remove all of the ovum 
 and placenta, for as long as any fragment is left 
 within the uterus the hemorrhage will continue, 
 and endanger the woman's life. Dr. 0. P. Rex, of 
 this city, recently related to me the history of a 
 case under his care, in which the placenta had been 
 allowed to remain nearly seven months after the ex- 
 pulsion of the ovum, during the whole of which time 
 the woman bled profusely, and was almost in a 
 dying condition when he was first summoned to 
 her relief. Ergot is one of our most efficient reme- 
 dies in these cases. The fluid extract may be given 
 in drachm doses every hour, in cases of profuse 
 hemorrhage. 
 
 With these two remedies at your hands — the 
 tampon and ergot — you will master your case. 
 
 After Abortion. — The treatment after abor- 
 tion is similar to that after labor. Perfect quiet 
 and rest, and the, recumbent posture, should be en- 
 
ABORTIONS. 179 
 
 joined, and 3-011 should, in cases where the hemor- 
 rhage has entirely ceased, employ large doses of 
 opium. The fluid forms are best, as more quickly 
 absorbed. Never give opium unless you are sure 
 the uterus has contracted. The application of cold 
 to the vulva as well as injections of cold water by 
 vagina and rectum, are valuable adjuvants. Upon 
 the first intimation of a return of hemorrhage, 
 have recourse to ergot. 
 
 If by the means mentioned you fail to dilate the 
 os sufficiently, sponge tents or the sea-tangle may 
 be used, a small one being introduced first, and 
 allowed to remain eighteen or twenty hours, and 
 then a large one inserted. In this, as in other af- 
 fections requiring the use of the tent, not more 
 than three should be used consecutively, as more 
 than this number are apt to produce metritis. I 
 have found the sponge tents to be safer and better 
 than the sea-tangle. The offensive odor arising 
 from the use of the tent ma} r be destroyed by using 
 those containing carbolic acid or permanganate of 
 potassa, or by the use of cotton or sponges satu- 
 rated with glycerine. 
 
 It has been a source of very great gratification 
 to me to read the notices of the various journals 
 regarding this brief chapter on Abortions. I ap- 
 preciate it most keenly, and my earnest hope and 
 desire is that such a stand may be taken by the 
 medical profession of America as to crush this vice 
 forever.] 
 
INDEX. 
 
 Abortion, diagnosis of 
 
 induction of .... 
 
 frequency of .... 
 
 treatment of .... 
 
 with retention of part of the ovum 
 
 with profuse hemorrhage 
 
 after-treatment .... 
 Abortions . . . 
 
 After-pains 
 
 Arrest of head in pelvis 
 Artificial respiration .... 
 Ascites of foetus .... 
 
 Asphyxia of infant . 
 treatment of . 
 
 PAGE 
 
 52 
 175 
 175 
 32, 177 
 118 
 118 
 178 
 173 
 
 98 
 127 
 
 90 
 134 
 
 88 
 
 89 
 
 Bandage after labor .... 
 Barnes, Dr. R., on puerperal thrombosis 
 Bed during labor, how to guard . 
 Belladonna, use of, as an anti-lactescent 
 Body, expulsion of . 
 Breasts, inflammation of 
 
 treatment of ... 
 
 Breech presentations, mechanism of . 
 
 diagnosis of . 
 
 evils of early interference in 
 
 management of . . 
 16 
 
 43 
 
 153 
 
 27 
 
 110 
 
 36 
 
 112 
 
 113 
 
 68 
 
 70 
 
 71 
 
 71 
 
182 
 
 INDEX. 
 
 Breech presentations, arrest of body in 
 
 arrest of head in . 
 Brow presentation .... 
 Brown, Mr. I. B., on lacerated perineum 
 
 Calculus in bladder during labor 
 Care of the new-born infant 
 Catheterism during labor 
 Churchill, Dr , statistics of first stage 
 presentations 
 
 on the pulse after labor 
 Cleanliness of the infant 
 Colic of the child 
 Colostrum . 
 Convulsions, epileptic 
 
 hysterical . 
 
 apoplectic 
 
 treatment 
 Cord, umbilical, see Funis 
 Costiveness 
 Cramps during labor . 
 
 Death of foetus . 
 signs of 
 labor after 
 Deformities of pelvis . 
 Diarrhoea . 
 Diet during labor 
 
 after labor . 
 
 of the mother 
 Diseases of pregnancy 
 Dressing the infant 
 
 Ephemeral fever 
 Ergot of rye 
 
INDEX , 
 
 183 
 
 Extension, movement of 
 Extra-uterine pregnancy 
 
 Face presentations, mechanism of 
 diagnosis of . 
 management of 
 Fainting fits 
 Ferguson, Dr., on puerperal fever 
 Fever, puerperal 
 
 treatment of . 
 Flooding, see Hemorrhage 
 Foetus, death of . 
 viability of . 
 Food for the child 
 Foot presentations 
 
 diagnosis of . 
 management of 
 Funis, ligature and division of 
 bandaging of 
 coiling of, round neck . 
 prolapse of . 
 
 Gooch, Dr., rules for leaving during labor 
 on post-partum hemorrhage 
 
 Hall, Dr. M., on the cold douche 
 
 method of performing artificial respiration 
 Head, rotation of 
 
 expulsion of 
 
 interval after birth of . 
 Heartburn .... 
 Hemorrhage after delivery . 
 
 symptoms of 
 
 treatment of 
 
184 
 
 INDEX. 
 
 Hemorrhage, internal . 
 
 secondary .... 
 
 accidental .... 
 
 unavoidable 
 Hewitt, Dr. Graily, on support of the 
 Hydrocephalus .... 
 
 penne 
 
 Imperforate os uteri . 
 Incontinence of urine after delivery 
 Inertia of uterus in twin cases . 
 Infant, care of the new-born 
 
 washing the 
 
 dressing the 
 
 physic for the 
 
 food for the .... 
 
 cleanliness of the 
 
 later care of 
 
 sleep of ... . 
 Instruments, etc., required during labor 
 Inversion of uterus 
 
 treatment of . 
 
 Knee presentations, diagnosis of 
 management of 
 
 Labor, signs of commencing 
 premonitory signs of . 
 first stage of 
 prompt attendance to . 
 preliminary observations of 
 prognosis of 
 second stage of . 
 management of, during pains 
 third stage of 
 
INDEX. 
 
 185 
 
 Labor, diet during .... 
 diet after ..... 
 questions during .... 
 mode of ascertaining progress of . 
 repose after ..... 
 premature ..... 
 tedious, causes of 
 
 from loaded rectum 
 from inefficient uterine action 
 from want of sleep 
 from rigid os uteri 
 from premature rupture of membr 
 from cedematous os uteri 
 from toughness of membranes 
 from rigid soft parts 
 from unfavorable presentations 
 from want of room 
 from anterior obliquity of uteru 
 powerless ..... 
 Laceration of perineum 
 Later care of the child 
 Lee, Dr., on puerperal fever 
 Lochia! discharge .... 
 deficiency of . 
 excessive . . . 
 offensive .... 
 
 Mania, puerperal .... 
 
 Membranes, rupture of 
 
 how to remove .... 
 Merriman, Dr., on twin cases 
 Miliary fever ..... 
 Milk, secretion of ... . 
 
 substitute for .... 
 16* 
 
1SG 
 
 INDEX. 
 
 Milk, how to get rid o 
 fever . 
 
 treatment of 
 Mole pregnancy . 
 Monsters 
 Mother, diet of the 
 
 Nervous shock . 
 
 treatment of 
 Nipples retracted 
 sore 
 
 treatment 
 
 Os uteri, state of, in first stage 
 in second stage 
 in primiparse and in multipara 
 how to distinguish 
 imperforate . 
 
 Pains, spurious, diagnosis of 
 
 treatment of 
 Paralysis of legs after labor 
 Patient, during labor, when to leave 
 
 time for leaving after labor 
 
 visits to, after labor 
 
 inquiries respecting 
 
 management of . 
 Pelvis, deformities of . 
 Pelvic cellulitis and abscess 
 
 tumors 
 Perineum, support of . 
 
 laceration of 
 Phlegmasia dolens 
 Physic for the child . 
 
INDEX. 
 
 187 
 
 Placenta, expulsion of 
 
 danger of forcibly detaching 
 
 how to ascertain detachment of 
 
 battledore . 
 
 how to remove 
 
 retention of . 
 
 retained, treatment of , 
 
 prsevia, diagnosis of 
 treatment of . 
 Position during first stage 
 
 second stage 
 Powerless labor . 
 Pregnancy, diagnosis of 
 
 diseases of . 
 Presentation, diagnosis of 
 
 head, signs of 
 
 ordinary 
 
 forehead anteriorly 
 diagnosis 
 mechanism 
 
 face 
 
 breech 
 
 brow . 
 
 where none can be felt 
 .upper extremity 
 
 placenta 
 
 foot 
 
 knee . 
 
 compound . 
 
 hand with head 
 
 hand with breech or foot 
 Prognosis, in natural labor 
 Prolapse of bladder during labor 
 
 of fundus . 
 Prolapsus uteri . 
 
188 INDEX. 
 
 Puerperal convulsions 
 
 fever . 
 
 treatment of . 
 
 mania . 
 
 thrombosis . 
 Purgative after delivery 
 
 Ramsbotham, Dr., on occipito-posterior presentations 
 Rest after delivery, use of . 
 Restitution, movement of . 
 Retention of urine during labor 
 
 after labor ...... 
 
 of placenta 
 
 treatment of . 
 Rigby, Dr., on post-partum hemorrhage . .# 
 
 on pelvic deformity ..... 
 Rigors after labor ...... 
 
 Rotation, movement of 
 
 Rupture of uterus 
 
 Scalp, tumor of 
 
 Shoulders, rotation of ..... 
 
 presentation of . 
 Simpson, Dr., on detachment of placenta prsevia 
 Sleep of the child . . . . 
 Smith, Dr. Tyler, on treatment of post-partum hemor- 
 rhage ........ 
 
 Stage, first, signs of 
 
 pains during ..... 
 
 position during 
 
 second, signs of 
 
 position during ..... 
 management of 
 third, duration of 
 
INDEX. 
 
 189 
 
 Stillborn children, management of delivery with 
 
 Strictures of vagina . 
 
 Sylvester, Dr., method of performing artificial r 
 
 ration ..... 
 
 Tedious labor from want of room 
 
 Tumors in pelvis 
 
 Twin births, mechanism of 
 
 diagnosis of . 
 
 management of 
 
 Uterus, state of, during third stage 
 
 after expulsion of the placenta 
 
 prolapse of . 
 
 rupture of . 
 
 inversion of 
 
 treatment of . 
 
 Vagina, normal state of 
 strictures of 
 state of, in second stage 
 Vaginal examinations, how to make 
 when to make 
 information derived from 
 frequency of 
 Vienna Hospital, precautions in 
 Vomiting during labor 
 
 Washing the infant . 
 
 Weid 
 
 PAGE 
 
 87 
 122 
 
 spi- 
 
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