,transcriber's ,note3 ,italic text is denoted by underscores and bold text by equal signs4 ,illustration3 ,and ,adam knew ,eve his wife1 and she conceived1 and bare ,cain4 ,chapter ,,iv ,,genesis4 #ast verse ,,the ,,matron',s ,,manual ,,of ,,midwifery1 ,,and ,,the ,,diseases ,,of ,,women ,,during ,,pregnancy ,,and ,,in ,,childbed1 ,,being ,a ,,familiar ,,and ,,practical ,,treatise1 ,,more ,,especially ,,intended ,,for ,,the ,,instruction ,,of ,,females ,,themselves1 ,,but ,,adapted ,,also ,,for ,,popular ,,use ,,among ,,students ,,and ,,practitioners ,,of ,,medicine4 ,by ,,frederick ,,hollick1 ,m4 ,d41 ,,lecturer ,,on ,,physiology ,,and ,,female ,,diseases1--,,and ,,author ,,of ,,the ,,diseases ,,of ,,woman1--,,outlines ,,of ,,anatomy ,,and ,,physiology ,,for ,,popular ,,use1--,,neuropathy1--,,and ,,the ,,origin ,,of ,,life4 ,,illustrated ,,by ,,over #ej ,,splendid ,,engravings4 ,,new ,,york3 ,,published ,,by ,t4 ,w4 ,,strong1 ,,no4 #ih ,,nassau ,,street4 ,,boston3--,,no4 #fd ,,cornhill4 #ahdi4 ,entered according to ,act of ,congress1 in the year #ahdh1 ,by ,,frederick ,,hollick1 ,m4 ,d41 in the ,clerk's office of the ,district ,court of the ,united ,states for the ,southern ,district of ,new ,york4 ,the price of this ,book is ,one ,dollar4--,it may be obtained of all ,booksellers1 or of ,t4 ,w4 ,,strong1 #ih ,nassau-st41 ,n4 ,y41 who will also send it by ,post to any part of the country1 on receiving ,one ,dollar and the ,address4--,n4 ,b4 ,all ,dr4 ,hollick's other ,books will be sent by ,t4 ,w4 ,strong in the same way4 ,,preface4 ,a short time ago ,i published a popular treatise on ,the ,diseases of ,woman1 in the non pregnant state1 and in that work ,i announced my intention of shortly publishing a similar one on ,pregnancy and its diseases4 ,this book is the fulfilment of that promise4 ,being the first popular1 and yet strictly scientific and practical book on ,midwifery ever published1 its preparation has necessarily been a work of great labour and difficulty4 ,everything had to be simplified2 familiar explanations had to be given of complicated processes1 and illustrations had to be designed that could be understood by my readers4 ,little or no assistance could be obtained from other works on the subject1 because they were either designed for professional men2 and therefore too technical1 or else were too general in their explanations1 and too unsystematical1 to be of any practical use4 ,i therefore had to write every part afresh myself1 and plan a new arrangement2 and so difficult was this to do1 satisfactorily1 that ,i have twice before completed the whole work1 and then commenced at the beginning again1 before ,i was satisfied with my own production4 ,as it now stands1 ,i trust this treatise answers the purposes for which it was intended4 ,i have taken care to make it so complete1 and scientific1 that a medical student may take it for his text book2 and at the same time ,i have endeavoured to so simplify it that any female1 of ordinary capacity1 can fully understand both its explanations and practical directions4 ,all purely technical words have been avoided1 or1 when absolutely necessary1 they have been carefully explained4 ,every topic connected with the main subjects has been discussed1 and the latest information given on every point1 and from every source4 ,such a work as this has long been needed4 ,females have been kept in shameful ignorance1 of everything connected with their own systems1 and of the wonderful phenomena in which they play so important a part4 ,that ignorance has led to untold evils1 which can never be corrected till they become more enlightened respecting themselves4 ,fortunately many of them begin to see this1 and they request1 in behalf of themselves and their sisters1 that such knowledge be no longer withheld4 ,i have been now1 for a long time1 engaged in this pleasing task of female instruction1 both by my ,lectures and books1 and in my daily communion with them as patients2 ,i am therefore aware both of their great lack of proper information1 and of their strong desire for it1 and ,i flatter myself ,i also know1 from experience and careful observation1 the best mode of imparting it to them4 ,in fact1 ,i have made it a matter of careful study1 not only to render my subject plain1 but also pleasing and unobjectionable2 so that the most unreflecting shall feel an interest in it1 and the most sensitive be able to study it without pain or repugnance4 ,the object of this book is not to make every woman a professional ,midwife1 nor to induce her to dispense with proper assistance in her hour of difficulty1 but simply to explain to her the nature and manner of child-birth1 and the means by which she is to be assisted4 ,this will disabuse her mind of many pernicious errors--make her more patient under her unavoidable difficulties and pains--more docile to what is required of her1 since she will see the reason for it--and it will also enable her to avoid much positive suffering1 and to render great help1 in many cases1 to her attendant4--,in a case of emergency also1 when other assistance cannot be procured time enough1 or not at all1 it will teach one female how to assist another in delivery1 which every one of them ought to be able to do4 ,very often it happens that a case of this kind occurs1 and the ,females around1 instead of knowing how to help the sufferer1 are utterly useless1 and even make her worse by their evident terror and ignorance4 ,i have known women die in child-bed1 for want of the most trivial assistance1 which even a child could understand how to give1 though there were elderly females1 mothers themselves1 around her2 but they knew not what to do4 ,such a state of things is disgraceful to the boasted intelligence of the age1 and should be remedied as speedily as possible4 ,every ,adult female1 or at least every married one1 should be instructed in these things1 so that she may know how to regulate her own conduct and how to render useful assistance to others in case of need4 ,ill informed women are generally as apprehensive of danger as they are incapable of avoiding it2 and as regardless of proper advice as they are ignorant of the reason for it4 ,the time1 ,i trust1 is fast coming1 when every female will be taught1 as of paramount importance1 everything which concerns her own welfare2 and when ignorance will no longer be considered necessary to propriety and virtue1 nor useful knowledge incompatible with the most refined delicacy and the strictest morality4 ,i consider it my duty to assist in hastening that time1 and ,i feel much pleased that my previous efforts have been so much commended4 ,this book ,i hope will be equally acceptable1 and1 if possible1 more useful1 than those which have preceded it4 ,f4 ,,hollick1 ,m4 ,d41 ,new ,york ,,introduction4 ,parturition1 or the expulsion of the perfectly formed human being from the body of its mother1 is a most wonderful natural function1 for the complete and safe performance of which at the proper time1 every requisite is found to exist4 ,notwithstanding the contrary experience of society1 as it now exists1 it is well known that extreme suffering1 and danger to life1 are not necessary nor even probable accompaniments to child-birth2 for it is invariably found1 when females live under circumstances favourable to their full physical development and health1 that it occurs speedily1 and with little or no difficulty or pain4 ,numerous proofs of this could be given in accounts of the ,indians1 and other uncivilized females1 among whom parturition is regarded as an ordinary occurrence1 for which no preparation need be made1 and about which no apprehension need be felt2 such facts1 however1 are so well known that they only need be referred to here4 ,as the organization and requirements of society changes1 by the adoption of what is called civilization1 the condition of woman becomes very different to what it was originally4 ,in many respects her lot is much meliorated1 and she has great reason to be pleased with the change1 but in other respects she has not been so fortunate4 ,one great evil resulting from her altered position is1 a neglect of proper physical education while young1 and of the various requirements for bodily health in after life4 ,in consequence of which she becomes constitutionally weaker1 and more sensitive to various injurious influences1 which she possesses diminished powers to withstand4 ,this evil increases in proportion as civilization advances1 until at last females become so imperfectly organized1 and so enervated1 that they are utterly unable to fulfil the duties assigned them1 and they either die prematurely1 or pass their whole lives in suffering and complaint4 ,so universally is this the case at the present time1 particularly in cities1 that the exempt are very rare exceptions to a rule most lamentably general4 ,unfortunately1 custom and false notions have given this melancholy state the stamp of propriety1 and thrown around it the charm of fashion4 ,the suffering invalid is called interesting1 and the pale faced debilitated creature1 scarcely able to crawl about1 is styled genteel1 while robust health and physical capability is termed coarseness and vulgarity4 ,so infatuated1 and weak minded1 have females been made on this point1 that ,i have actually known some of them quite chagrined because people could see they were well and strong2 and ,i have known others quite alarmed for fear that they should look so4 ,a short time ago ,i knew a lady who1 by the adoption of a proper course of training and treatment1 passed through her confinement so quickly1 and with so little exhaustion1 that she was up and travelling about in three days after1 not only without inconvenience but with pleasure and advantage4 ,but what was the impression made on her female friends by such a speedy recovery8 did they feel quite pleased at it1 and desirous that all others should be equally fortunate8 ,no2 but quite the contrary6 ,she was actually thought deserving of reprehension1 and was stigmatized as vulgar in the extreme4 ,one person even made the remark1 that she must be a very common person1 and no ,lady6 ,now what a pitiable state of ignorance1 and mental imbecility1 these females must be in1 to be actually proud of their infirmities2 and yet they are but like the majority of their sex4 ,if they were not so unfortunate in not knowing their true interests1 they would be highly culpable1 but as it is they are truly deserving of our pity4 ,it must be admitted1 however1 that though civilization has1 so far1 entailed these evils on women1 it has also done much to alleviate them4 ,many diseases are beneficially modified1 and some are even cured1 by medical treatment2 surgical science has also attained a high point of perfection2 and the difficulties attendant on child birth are overcome to a great extent by obstetrical skill4 ,but notwithstanding all this alleviation1 these evils are still deplorably great4 ,the utmost scientific skill to which society can ever attain1 will do but little towards effectually relieving human suffering1 and removing disease1 so long as it is entirely devoted to the mere art of curing and palliating as it chiefly is now4 ,our knowledge of the human system1 and of the causes which produce in it disease and deterioration1 must be universally disseminated1 so that the whole people may see how these evils arise1 and how they should live1 and conduct themselves1 so as to avoid them altogether6 or1 in other words1 science should teach us how to prevent disease and suffering1 instead of merely how to alleviate them4 ,eventually this will be done1 and our females will then pass through their travail as easily as their savage sisters do now4 ,let us hope that time will soon come2 and let every one esteem it his duty1 who possesses the ability1 to hasten its coming1 by doing all he can to spread the necessary information to those who need it4 ,the happy exemption from difficulty and suffering which females enjoy in more uncultivated states of society1 and which we believe they will ultimately enjoy universally1 does not however obviate the necessity for assistance now1 in our state of society1 and we have therefore to explain how it can best be rendered4 ,it has often been a matter of dispute1 both with medical men and with moralists1 whether ,men or ,women ought to assist in child-birth4 ,the discussion has called forth a great deal of declamation1 but very little has been said to the point on either side4 ,it appears to me1 however1 that the question may be very easily settled1 if it be rightly considered4 ,the first requisite1 and the most indispensable1 in those who are to assist in child birth is1 that they should know how to assist4 ,this is paramount to every thing else4 ,now1 if females really did know what to do in such cases1 and were fully competent to do it1 ,i think there is no question but they would be the best assistants1 to say nothing of their being the most proper4 ,there are many things experienced by females in such situations1 which can never be understood by a man at all1 though they are readily appreciated by one of their own sex1 particularly if she has been a mother herself4 ,with each other also there would be less disposition and less occasion for reserve in delicate communications1 and less repugnance to necessary examination or manipulation1 which could therefore be more efficiently practised4 ,in short1 if women were undoubtedly equally competent with men in this art1 and full confidence was felt in them by their own sex1 ,i think it is evident they would1 in every respect1 be the most fitting practitioners1 and ,i have no doubt but they would be preferred4 ,the question simply arises then1 whether they are so competent8 ,and every one able to judge1 who speaks honestly1 must admit that very few1 if any of them really are so4 ,it has not been possible for them to acquire the requisite information1 nor to pursue the necessary investigations1 and therefore we cannot expect that they can be equal to those who have4 ,there are some women ,i know1 who have been careful observers1 and who have had great experience1 that can render all needful help in most cases1 but even they are apt to meet with difficulties1 which require more skill than they possess to overcome2 therefore very few like to depend upon them altogether4 ,it is naturally argued that1 as a physician may be needed1 it is better to have him at first1 and so be ready for every contingency4 ,that females can make competent ,accoucheurs is proved by numerous well known instances1 among which ,i need only refer to ,,madame ,,boivin1 and ,,madame ,,lachapelle1 both of whom1 as practitioners and as authors1 stand in the very highest rank4 ,these ladies are referred to as authorities1 and their works are quoted by the most eminent ,professors of the day2 in fact1 on many points1 they have surpassed all competitors4 ,further on in our work we shall have occasion to refer to their labours1 the value of which will then be seen4 ,it is therefore evident that females can officiate1 if they are properly instructed1 which ,i think they ought to be1 independent of the reasons already given4 ,that they will eventually be competent ,i have no doubt1 and ,i am proud to throw my mite of instruction in their way to assist in making them so4 ,in regard to the alledged immorality resulting from the present system of men acting as ,midwives1 there is much exaggeration1 and much unnecessary alarm4 ,that it is1 in some respects1 indelicate1 and only to be justified by necessity is true1 but there is no foundation for saying1 as some do1 that it leads to wide spread ,profligacy and ,adultery4 ,i should prefer to see females always able to assist each other2 but ,i cannot nevertheless consider the present system a necessary cause of licentiousness4 ,that females were always depended upon in old times1 and are now in certain rude communities1 is true1 but that is no reason why they should be depended upon under all circumstances4 ,in our present highly artificial state there are numerous causes at work1 and numerous difficulties experienced1 unknown to more primitive times and conditions1 and we therefore require greater skill and more extensive resources4 ,females have in fact become more in want of help1 and less able to assist4 ,at what time1 and in what country1 men first began to assist in cases of labour is not recorded4 ,they have done so however for a long time1 much longer than most people suppose4 ,in the time of ,hippocrates1 called the ,father of ,medicine1 who lived more than four hundred years before ,christ1 it appears that physicians were commonly resorted to4 ,in his writings we find cases described1 which show that he was well acquainted with the process of parturition1 and even with some of the most difficult operations now practised4 ,the ,israelites appear to have employed women1 as most eastern nations in fact do at the present day4 ,midwifery1 however1 did not attract much attention1 nor make much progress1 till about the middle of the sixteenth century1 since when it has been studied and practised by the most eminent ,physicians and ,surgeons1 and has arrived at great perfection4 ,many new discoveries have been made lately1 which enable us to facilitate delivery and ease its pains1 so that it is now robbed of many of its former terrors and dangers4 ,some of these discoveries are of easy application1 and promise much future good2 ,i shall carefully describe them all1 in the following pages4 ,f4 ,h4 ,,illustrations4 ,,frontispiece1 ,eve in the ,garden of ,eden4 ,,plate ,i4--,lateral ,section1 of the ,female ,pelvis1 to show the position of the ,organs in their natural state1 #e4 ,,plate ,,ii4--,front ,view of the ,female ,pelvis1 with the ,external ,walls removed1 #i4 ,,plate ,,iii4--,the ,uterus and its ,appendages1 #ac4 ,,plate ,,iv4--,vertical ,section of the ,womb and ,vagina1 natural size1 #ah4 ,,plate ,v4--,the ,muscular ,fibres of the ,womb1 #bc4 ,,plate ,,vi4--,muscular ,fibres of the ,womb1 #bg4 ,,plate ,,vii4--,bones of the ,pelvis1 #cc4 ,,plate ,,vii4-a4--,male ,pelvis1 to show the difference in structure1 #ce4 ,,plate ,,viii4--,section of the ,pelvis1 #cg4 ,,plate ,,ix4--,diameters of the ,upper ,strait1 #da4 ,,plate ,x4--,the ,bones of the ,pelvis viewed from below1 #de4 ,,plate ,,xi4--,the ,direction of the ,pelvis1 #di4 ,,plate ,,xii4--,section of the ,uterus1 with the ,ovum and appendages1 at about one month1 #fe4 ,,plate ,,xii4-a4--,female ,breast1 #gg4 ,,plate ,,xiii4--,breast about the ,fourth ,month1 #ij4 ,,plate ,,xiv4--,womb1 at about the third1 seventh and ninth months1 #ii4 ,,plate ,,xv4--,primipara1 or the ,first ,pregnancy4--,woman who has borne children before1 #aja4 ,,plate ,,xvi4--,mode of performing the ,ballotment1 to detect ,pregnancy1 #ajg4 ,,plate ,,xvii4--,at the end of the ,fifth ,month1 #aaa4 ,,plate ,,xviii4--,the neck of the ,womb in a first pregnancy1 and in a female who has borne children before1 at the end of the seventh month1 #aaf4 ,,plate ,,xix4--,ftus in the most usual position1 #aba4 ,,plate ,,xx4--,ftus in the next most frequent position1 #abe4 ,,plate ,,xxi4--,presentation of the ,pelvis1 or breech1 #abi4 ,,plate ,,xxii4--,the position of ,twins1 as most usually observed1 #acc4 ,,plate ,,xxiii4--,end of the ,ninth ,month1 #ace4 ,,plate ,,xxiv4--,the ,ftal head1 #adg4 ,,plate ,,xxv4--,diameters of the ,head1 #aea4 ,,plate ,,xxvi4--,attitude of the ,ftus1 #aec4 ,,plate ,,xxvii4--,head just entering the upper strait1 #agc4 ,,plate ,,xxviii4--,head lower in the ,pelvis1 #agg4 ,,plate ,,xxix4--,head beginning to ,rotate1 #aha4 ,,plate ,,xxx4--,rotation of the ,head1 #ahc4 ,,plate ,,xxxi4--,head in the right anterior occipito iliac position1 #ahg4 ,,plate ,,xxxii4--,delivery in a breech presentation1 #aid4 ,,plate ,,xxxiii4--,anterior posterior position of the head1 #aie4 ,,plate ,,xxxiv4--,the chin just passed in presentation of the face1 #bjj4 ,,plate ,,xxxv4--,presentation of right shoulder1 #bje4 ,,plate ,,xxxvi4--,descent of shoulder1 #bjf4 ,,plate ,,xxxvii4--,descent of shoulder1 #bjg4 ,,plate ,,xxxviii4--,trunk descended1 #bjh4 ,,plate ,,xxxviii4-a4--,state of the parts at beginning of labor1 #bae4 ,,plate ,,xxxix4--,manner of supporting the perineum1 #bcc4 ,,plate ,,xl4--,standard form of ,pelvis1 #bga4 ,,plate ,,xli4--,masculine ,pelvis1 #bga4 ,,plates ,,xlii1 ,,xliii1 ,,xliv1 ,,xlv4--,deformed ,pelves1 #bge-bgi4 ,,plate ,,xlvi4--,head fixed in a narrow pelvis1 #bhb4 ,,plate ,,xlvii4--,case of ,tumor1 #bhi4 ,,plate ,,xlviii4--,case of ,polypus1 #bic4 ,,plate ,,xlix4--,limbs cut off by the ,cord1 #cja4 ,,plate ,l4--,forceps1 #cdf4 ,,plate ,,li4--,head extracted by ,forceps1 #cec4 ,,table ,,of ,,contents4 ,,part ,i4--,,midwifery4 ,section ,i4 ,,position ,,and ,,uses ,,of ,,the ,,female ,,organs4 ,page ,,chapter ,i4--,position of the ,organs and ,parts1 #ac ,internal ,organs1 #ad ,external ,organs1 #af ,,chapter ,,ii4--,structure of the ,principal ,organs and ,parts1 #ah ,the ,womb1 #ai ,the ,vagina4--,vulva4--,perineum1 #bi ,the ,pelvis1 #cj ,,chapter ,,iii4--,functions of the ,principal ,female ,organs1 #ej ,the ,womb1 #ej ,the ,ovaries4--,menstruation1 #ea ,conception1 #ed ,,chapter ,,iv4--,ftal ,development1 #eg ,ftal ,nutrition1 #fg ,peculiarities of the ,ftal ,circulation1 #gj ,the ,breast1 #gd ,section ,,ii4 ,,signs ,,of ,,pregnancy1 ,,and ,,the ,,means ,,of ,,detecting ,,it2 ,,its ,,duration1 ,,and ,,the ,,period ,,at ,,which ,,the ,f,,tus ,,can ,,live4 ,,chapter ,v4--,presumptive ,signs1 #hc ,probable ,signs1 #id ,,chapter ,,vi4--,duration of ,pregnancy1 #acg ,,chapter ,,vii4--,period when the ,child can live1 #adb ,section ,,iii4 ,,the ,,form1 ,,size ,,and ,,position ,,of ,,the ,f,,tus1 ,,and ,,its ,,appendages1 ,,at ,,full ,,term4 ,,chapter ,,viii4--,form and ,size of the ,body1 #add ,size and ,form of the ,head1 #add ,attitude of the ,ftus at ,full term1 #aeb ,,chapter ,,ix4--,the ,appendages of the ,ftus at term1 #aee ,,chapter ,,ix4--,the ,membranes1 #aee ,the ,placenta1 #aef ,the ,umbilical ,cord1 #aeg ,section ,,iv4 ,,the ,,mechanism ,,of ,,delivery ,,in ,,all ,,the ,,different ,,presentations ,,and ,,positions ,,of ,,the ,f,,tus4 ,,chapter ,x4--,presentations1 #afj ,positions1 #afa ,mode of ascertaining the ,presentation and ,position1 #afd ,,chapter ,,xi4--,the ,mechanism of ,delivery1 in a ,presentation of the ,head1 #agj ,the ,left ,anterior ,occipito ,iliac ,position1 #agj ,mechanism of ,delivery in all other ,positions of the ,head1 #ahe ,general ,remarks on the ,different ,positions of the ,head1 #ahi ,,chapter ,,xii4--,mechanism of ,delivery in ,presentations of the ,lower ,extremities1 #aia ,delivery in a ,breech ,presentation in the left ,anterior ,sacro-,iliac ,position1 #aib ,delivery by the ,breech in the ,right ,posterior ,sacro ,iliac ,position1 #aif ,delivery by the ,breech in the ,full ,posterior1 or ,sacro ,sacral ,position1 #aif ,general ,remarks on the ,presentation of the ,lower ,extremities1 #aig ,,chapter ,,xiii4--,mechanism of ,delivery in ,presentations of the ,face1 #aii ,delivery in the ,right ,posterior ,mento ,iliac ,position of the ,face1 #aii ,delivery in other positions of the face1 #bjj ,,chapter ,,xiv4--,mechanism of ,delivery in ,presentations of the ,trunk1 #bjc ,mechanism of ,delivery in ,presentations of the ,trunk by ,spontaneous ,evolution1 #bjd ,section ,v4 ,,the ,,physiology ,,of ,,spontaneous ,,delivery1 ,,or ,,childbirth1 ,,and ,,the ,,manner ,,of ,,conducting ,a ,,natural ,,labor4 ,,chapter ,,xv4--,of ,delivery in ,general4--,different ,kinds of ,delivery4--,causes of ,labor1 #baa ,signs of ,delivery1 #bab ,,chapter ,,xvi4--,the ,progress1 ,phenomena1 and ,duration of ,natural ,labor4--,first ,period1 #bad ,second ,period1 #baf ,duration of ,natural ,labor1 #bbj ,,chapter ,,xvii4--,the ,conduct or ,management of a ,natural ,labor4--,preliminary ,requisites1 #bbb ,preliminary ,proceedings1 #bbc ,preparations for the ,delivery1 #bbf ,attendance after the ,preparations are made1 and during the ,delivery1 #bbi ,,chapter ,,xvii4--,delivery of the ,after ,birth1 or ,placenta and ,membranes1 #bci ,attentions to the ,female after the ,delivery of the ,after ,birth1 #bdb ,attentions to the ,child1 #bdc ,accidents which may happen1 #bdf ,subsequent ,attentions to ,mother and ,child1 #bdi ,concluding ,remarks1 #bee ,section ,,vi4 ,,protracted ,,and ,,difficult ,,labors4 ,,chapter ,,xviii4--,the ,causes and ,consequences of ,prolonged ,labor to both ,mother and ,child1 #bei ,the ,consequences of ,prolonged ,labor1 #bei ,,chapter ,,xix4--,causes connected with the ,mother which may impede labor1 or make it difficult1 #bfj ,inertia1 or ,want of sufficiently ,powerful ,contraction in the ,womb1 #bfj ,rigidity of the ,mouth of the ,womb1 ,vagina and ,vulva1 #bfd ,obliquities of the ,womb1 #bff ,prolapsus ,uteri4--,smallness or ,deformity of the ,pelvis1 #bfg ,tumors in the ,pelvis1 #bhf ,tumors externally4--,obstructions in the ,vagina1 #bie ,,chapter ,,xx4--,causes connected with the child1 or children1 which may impede delivery4 #big ,procidentia of the ,umbilical ,cord1 #big ,shortness of the ,cord1 #cjj ,descent of other parts with the head1 #cja ,twins and ,triplets1 #cjb ,excessive size of the ,ftus1 or the diseased development of certain parts1 #cjd ,ossification of the ,head1 #cje ,various presentations and positions of the ,ftus1 #cjf ,presentations of the ,lower ,extremities1 #cjg ,presentations of the ,shoulder1 #caa ,section ,,vii4 ,,accidents ,,during ,,labor ,,which ,,may ,,compromise ,,the ,,mother',s ,,life4 ,,chapter ,,xxi4--,uterine ,hemorrhage1 or ,flooding1 during ,labor1 #cae ,,chapter ,,xxii4--,eclampsia1 or ,convulsions during ,labor1 #ccf ,,chapter ,,xxiii4--,rupture of the ,womb or ,vagina1 #cda ,section ,,viii4 ,,operations ,,with ,,the ,,hand ,,and ,,with ,,instruments4 ,,chapter ,,xxiv4--,operations with ,instruments4--,the ,forceps1 #cde ,other ,instruments1 #cee ,,chapter ,,xxv4--,operations with the ,hand4--,turning1 #ceg ,,part ,,ii4 ,,the ,,diseases ,,of ,,women ,,during ,,pregnancy1 ,,and ,,in ,,childbed4 ,section ,,ix4 ,,the ,,diseases ,,of ,,pregnancy4 ,,chapter ,,xxvi4--,sympathetic ,diseases occurring during ,pregnancy4--,sickness and ,vomiting1 #cff ,ptyalism1 or ,excessive ,salivation1 #cfi ,odontalgia1 or ,toothache1 #cfi ,derangements of the ,appetite1 #cga ,pyrosis4--,dysphagia1 #cgd ,gastralgia1 #cge ,constipation1 #cgg ,dysentery and ,diarrha1 #cgh ,dyspna1 or ,difficulty of ,breathing1 #chj ,cough1 #cha ,palpitation of the ,heart1 #chc ,syncope1 or ,fainting1 #chd ,headache and ,dizziness in the ,head1 #chf ,insomnia1 or ,sleeplessness1 #chh ,temporary ,affection of the ,sight1 ,hearing1 and ,smell1 #chi ,disordered ,judgment1 ,inclinations1 and ,propensities1 #cia ,hmoptysis1 ,hmatemesis and ,epistaxis1 #cic ,varicose ,veins1 #cie ,hmorrhoids1 or ,piles1 #cig dema1 or ,watery ,swellings1 #cii ,hydrorrhea1 or ,profuse ,discharge of ,water1 #djj ,pustules1 and ,mucous ,discharges1 #djj ,derangements of the ,urinary ,organs1 #dja ,cramps4--,pruritus1 or ,itching of the ,external ,parts1 #djc ,,chapter ,,xxvii4--,idiopathic1 or ,primary ,diseases ,incident to ,pregnancy4--,flooding1 #djf ,abortion1 or ,miscarriage1 #dji ,section ,x4 ,,the ,,diseases ,,of ,,women ,,in ,,childbed1 ,,after ,,lying ,,in4 ,,chapter ,,xxviii4--,diseases of ,childbed4--,puerperal ,fever1 or ,childbed ,fever1 #dbj ,affections of the ,breast occurring after ,pregnancy1 #dcj ,bronchocele1 or swelling in the ,throat1 #dch ,phlegmasia ,alba ,dolens1 or ,milk ,leg1 #dci ,trouble with the ,urine1 #dda ,,appendix4 ,,on ,,preventing ,,pain ,,in ,,childbirth1 #ddc ,,part ,i4 ,,midwifery4 ,,plate ,i4 ,lateral ,section1 or side view of the ,female ,pelvis1 to show the position of the ,organs4 ,a4 ,the ,bladder4 ,b4 ,the ,womb4 ,c4 ,the ,vagina4 ,d4 ,the ,rectum4 e4 ,the ,right ,ovary4 f4 ,the ,right ,fallopian ,tube4 g4 ,the ,os ,tinc1 or ,mouth of the ,womb4 h4 ,the ,meatus ,urinarius1 or ,mouth of the ,bladder4 i4 i4 ,the ,small ,intestines4 j4 j4 ,the ,back ,bone4 k4 ,the ,pubic or ,front ,bone4 l4 ,the ,right ,external ,lip1 or ,labium4 m4 ,the ,right ,internal ,lip1 or ,nymph4 n4 ,the ,hymen4 o4 ,the ,opening through the ,hymen4 q4 ,the ,perineum4 p4 ,the ,clitoris4 7,this of course shows the half of all the single ,organs and the right one only of those that are double47 ,illustration3 ,plate ,i4 ,lateral ,section1 or side view of the ,female ,pelvis1 to show the position of the ,organs in their natural state4 ,,plate ,,ii4 ,front ,view of the ,female ,pelvis1 with the ,external ,walls removed4 ,a4 ,the ,bladder4 ,b4 ,the ,womb4 ,d4 ,the ,rectum4 e4 e4 ,the ,ovaries4 f4 f4 ,the ,fallopian ,tubes4 i4 i4 ,the ,small ,intestines4 r4 r4 ,the ,round ,ligaments4 ,illustration3 ,plate ,,ii4 ,front ,view of the ,female ,pelvis1 with the ,external ,walls removed4 ,,midwifery4 ,,section ,i4 ,,position1 ,,structure1 ,,and ,,functions ,,of ,,the ,,organs ,,and ,,parts ,,of ,,the ,,female ,,body ,,concerned ,,in ,,generation ,,and ,,parturition4 ,to understand the subjects treated upon in the present work1 it is necessary to have at least a general acquaintance with the structure1 position1 and special uses of the principal organs and parts of the female system4 ,a complete acquaintance1 so far as our knowledge extends1 would be advisable1 but is not absolutely required1 and could not with convenience be given here4 ,the following explanations therefore1 chiefly taken from my book on the ,diseases of ,woman1 are merely sufficient for the present occasion1 and for reference--full details being reserved for a separate and complete work1 now preparing1 on the ,philosophy and ,physiology of the ,reproductive ,functions4 ,,chapter ,i4 ,,position ,,of ,,the ,,organs ,,and ,,parts4 ,plate ,i1 represents one half of the ,female body1 supposing it to be cut down the middle1 and gives an accurate representation of the relative position of the different organs4 ,plate ,,ii1 represents a front view of the ,female body1 with the external walls removed1 to show the relative position of the organs4 ,plate ,,iii1 represents the uterus and its appendages removed from the body1 so that their connections with each other may be seen4 ,illustration3 ,,plate ,,iii4 ,b4 ,the ,womb4--,c4 ,the ,vagina4--e4 e4 ,the ,ovaries4--f4 f4 ,the ,fallopian ,tubes4--s4 ,the left broad ,ligament1 the right one being removed4--r4 r4 ,the ,round ,ligaments4--g4 ,the ,os ,tinc1 or ,mouth of the ,womb4 ,,internal ,,organs4 ,the ,ovaries4--7e4 e4 ,plates ,i1 ,,ii and ,,iii47--,these are two oval shaped bodies1 about the size of an almond nut1 placed one on each side1 nearly in the groin4 ,they contain a number of small round grains1 or granules1 called the ov1 or eggs1 which are the germs of human beings1 as the eggs of birds are of their particular kind4 ,they are connected with the uterus by two short arms1 or prolongations1 and are enclosed in the folds of the broad ligaments4 ,the ,fallopian ,tubes4--7f4 f4 ,plates ,i and ,,ii47--,these are two ,tubes1 one on each side1 beneath the ,ovaries1 and extending farther4 ,each of them has a small passage which opens into the uterus at one end1 and opposite the ,ovaries at the other4 ,their use is to convey the impregnating principle to the ,ovaries1 at the time of conception1 and to convey the ,ov1 when impregnated1 to the interior of the ,womb4 ,the ,uterus1 or ,womb4--7,b4 ,plates ,i1 ,,ii47--,this is a hollow organ1 placed between the ,bladder1 which is in front1 and the ,rectum1 which is behind4 ,it is connected with the ,vagina1 and opens into it by the small orifice called the mouth of the womb4--7g4 ,plate ,i47--,the ,uterus is the organ which receives the impregnated ovum1 and in which it is developed into the human being4 ,it is connected with the ,ovaries by the ,fallopian ,tubes1 and with the ,vagina by the ,os ,tinc1 and is retained in its situation partly by its connections with other organs1 and partly by the round and broad ligaments4 ,the ,vagina4--7,c4 ,plate ,i47--,this is the passage which leads to the ,womb from the external opening4 ,the ,os ,tinc1 or ,mouth of the ,womb4--7g4 ,plates ,i and ,,ii47--,this is the small orifice1 opening into the ,vagina1 by which communication is established with the ,uterus from without4 ,the ,bladder4--7,a4 ,plates ,i and ,,ii47--,the ,receptacle of the ,urine4 ,it is placed immediately in front1 on the pubic bone1 the ,uterus lying nearly on the top of it4 ,the ,rectum1 or ,termination of the large ,intestine4 7,d4 ,plates ,i and ,,ii47--,this is situated behind the ,vagina1 and between it and the back bone4 ,the ,broad ,ligaments4--7s4 ,plate ,,iii47--,these are two broad folds of membrane1 which serve partly to enclose the ,fallopian ,tubes and ,ovaries1 and partly to sustain the ,womb in its place4 ,they adhere to the ,uterus and to the walls of the ,pelvis4 ,the ,round ,ligaments4--7r4 r4 ,plates ,,ii and ,,iii47 ,these two cords arise from each upper corner of the ,uterus1 and curving downwards are fixed by their other extremities to the pubic bone4 ,they are partly enclosed in the ,broad ,ligaments4 ,they assist in sustaining the ,uterus in its position1 and probably also they strengthen the ,broad ,ligaments and prevent their rupture when the strain upon them is too great4 ,fimbri of the ,fallopian ,tubes4--7t4 t4 ,plate ,,iii47 ,these ,fimbri are like ,tentacul1 or fingers1 springing from the extreme ends of the ,tubes1 and floating loosely in the cavity of the pelvis4 ,their use is to clasp hold of the ovaries at the time of conception1 so that the fecundating principle can reach them1 and also to take up the ov when impregnated1 and convey them into the ,tube1 down which they pass into the ,womb4 ,,external ,,organs4 ,the ,external ,lips4--7l4 ,plate ,i47--,these are commonly termed the ,labi externa4 ,they are two broad folds of membranous and adipose substance1 forming the portals to the ,vulva1 or entrance to the ,vagina4 ,the ,internal ,lips4--7m4 ,plate ,i47--,these are two smaller labi1 sometimes called the ,nymph1 within the first1 the chief use of which appears to be to direct the flow of the urine from the urethra4 ,the ,hymen4--7n4 ,plate ,i47--,this is a membrane generally found in virgins1 which grows over and closes more or less completely the entrance to the ,vagina4 ,use unknown4 ,when it exists there is generally a small orifice through it1 by which the menses escape at each monthly period4--7o4 ,plate ,i47 ,the ,clitoris4--7p4 ,plate ,i47--,this is a small prominent organ1 about the size of a large pea1 placed in the upper part of the opening between the external lips1 and immediately above the ,meatus ,urinarius4 ,it is the principal seat of venereal excitement1 and is subject to many annoying diseases4 ,the ,perineum4--7q4 ,plate ,i47--,the part between the ,vulva1 or entrance to the ,vagina1 and the fundament4 ,it is chiefly composed of the muscles belonging to the neighboring parts1 and assists very much in supporting the womb4 ,the ,meatus ,urinarius1 or ,mouth of the ,bladder1 7h4 ,plate ,i47--,a small opening by which the urine escapes1 placed between the lips1 and immediately above the ,vulva1 or entrance to the ,vagina4 ,these organs are all placed within1 or in contact with1 the lower part of the ,trunk1 called the pelvis4 ,they are all intimately connected with each other1 and some of them have most extensive and strong sympathies with almost every other part of the system4 ,so much so is this the case in fact1 that probably the great majority of diseases to which females are liable arise1 directly or indirectly1 from ,uterine or ,ovarian derangement4 ,very often the heart1 the stomach1 or some other organ1 though perfectly healthy1 is thought to be diseased1 and appears to be so1 merely from its sympathy with the diseased womb4 ,,chapter ,,ii4 ,,structure ,,of ,,the ,,principal ,,organs ,,and ,,parts4 ,illustration3 ,,plate ,,iv4 ,vertical ,section of the ,womb and ,vagina1 natural size4 a4 a4 a4 ,the solid walls of the ,womb cut through4 b4 ,that part of the cavity1 or hollow of the ,womb1 which is in the fundus1 or top4 c4 ,that part of the cavity which is in the lower part1 or neck1 of the ,womb4 d4 ,the ,vagina4 e4 e4 ,the cut edges of the ,vagina4 f4 f4 ,the positions of the ,fallopian ,tubes1 which are cut off1 and down the passages of which two needles are passed4 g4 ,the ,os ,tinc1 or ,mouth of the ,womb4 ,in addition to the general explanation already given1 there are some of the ,female organs whose peculiar structure requires to be more fully noticed1 on account of its important influence on some of the processes hereafter to be described4 ,,the ,,womb4 ,the external appearance of the womb1 viewed in front1 and in connection with its appendages1 is shown in ,plate ,,iii4 ,it is placed in the ,pelvis1 between the bladder and the ,rectum1 and at the top of the ,vagina1 as seen in ,plates ,i and ,,ii4 ,its internal structure is represented in ,plate ,,iv4 ,the length of the ,womb1 after puberty1 is about three inches2 its breadth at the upper part1 or fundus1 about two inches2 and at the cervix1 or neck1 about one inch4 ,the cavity in the interior is small1 owing to the thickness of the walls1 and its form is triangular4 ,the shape of the ,womb resembles a pear1 somewhat flattened1 from before backward4 ,previous to puberty its size is much smaller1 and with those who have had children it often exceeds the dimensions we have given4 ,the ,neck1 or narrow part1 7c4 ,plate ,,iv47 is much changed by pregnancy4 ,in virgins it is long and pointed1 and somewhat enlarged in the middle4 ,in those who have borne children it is considerably shorter1 more obtuse1 and less regular in its form4 ,the cavity in the ,neck is larger in the middle than at either end1 as will be seen in ,plate ,,iv4 ,the ,os ,tinc1 or mouth of the ,womb1 also undergoes considerable change from the same cause4 ,in the young person it is merely like a small slit1 scarcely to be felt1 but after pregnancy it much enlarges1 and remains more or less permanently open4 ,the anterior lip1 or the one in front1 is somewhat larger than the posterior one4 ,the body of the ,uterus is formed of a very dense1 gray colored1 muscular substance1 possessing astonishing contractile power4 ,the interior is lined1 like the ,vagina1 with a mucus membrane1 and the whole organ is plentifully supplied with arteries1 veins1 and nerves4 ,one of the most remarkable properties of the ,womb is that of being able to distend to an extraordinary degree1 and then retract again to nearly its original size4 ,the force which it sometimes exhibits during its contraction is very great1 being sufficient to separate1 and even break1 the bones of the mother's pelvis1 and paralyze the hand of the operator when introduced4 ,the ,muscular ,fibres on which this contractile force depends are most obvious during gestation2 they then appear very numerous1 and very curiously disposed1 some of them ramifying in almost every direction1 as will be seen by ,plates ,v1 ,,vi4 ,it is owing to this that the ,womb contracts in every conceivable direction1 and thus presses1 during labor1 on every part of the child's body4 ,,plate ,v4 ,figures #a and #b4 ,fig4 #a4 ,in this plate represents the ,muscular ,fibres a little exaggerated1 so that they can be more distinctly seen4--a4 a4 are the orifices of the ,fallopian ,tubes4 ,fig4 #b4 ,represents the natural appearance1 the fibres not being quite so distinct1 though sufficiently obvious4--a4 a4 ,the orifices of the ,fallopian ,tubes4 ,in both ,figures the ,womb is supposed to be turned inside out1 its peculiar structure being more readily seen interiorly than exteriorly4 ,illustration3 ,plate ,v4 ,the ,muscular ,fibres of the ,womb4 ,,plate ,,vi4 ,figures #a and #b4 ,fig #a4 ,this represents the appearance of the ,fibres externally1 and shows how they terminate in the round ligament a4 b4 ,fig4 #b4 ,the lines a4 b4 represent the direction of the force of the ,fundul ,fibres2 c4 d4 ,that of the ,circular ,muscles of the body of the ,uterus2 d4 e4 ,the combined force of the ,muscles4 ,the dotted lines represent the force reflected by the liquor amnii4 ,the dotted curved lines the direction of the circular fibres of the body of the ,uterus4 ,illustration3 ,plate ,,vi4 ,the ,muscular ,fibres of the ,womb4 ,,the ,,vagina4 ,the ,vagina 7c4 ,plate ,i47 is a membranous canal1 lined with a mucus membrane like the ,uterus4 ,by its upper part it is attached to the neck of the ,womb1 at about two-thirds of its height--so that two-thirds of the neck hang within the ,vagina4 ,below1 it terminates in the ,vulva1 or external mouth4 ,the upper part of the ,vagina is much larger than the lower part1 particularly in those who have borne children4 ,it is capable of considerable distension1 and after retraction1 to allow of the child passing down it from the ,womb4 ,the external mouth is called the ,vulva1 and is usually partly closed1 in the virgin state1 by the membrane called the ,hymen1 7n4 ,plate ,i47 ,the length of the ,vagina is from three to five inches1 and its diameter from one inch to one and a half1 or even two inches in those who have borne many children4 ,,the ,,vulva4 ,this is the external opening1 or mouth of the ,vagina1 through which the child has to pass at the termination of delivery4 ,the external and internal lips1 with the muscular and membranous tissue surrounding it1 are all capable of great distension1 without injury1 to allow of the passage of the child4 ,,the ,,perineum4 ,this is the part situated between the ,vulva and the ,rectum4 7p4 ,plate ,i47 ,it is composed of a somewhat dense and firm substance1 chiefly muscular1 and1 like all the other parts mentioned1 is capable of great distension4 ,it is important1 in many of the manipulations during labor1 to be well acquainted with it2 and when the child's head is passing the perineum requires supporting1 to prevent its being lacerated or broken through1 an accident which often happens from want of due attention1 and which leads to the most serious consequences4 ,,the ,,pelvis4 ,the ,pelvis is that part of the bony structure1 or skeleton1 of the female1 in which the generative organs are placed1 and through which the process of parturition is effected4 ,an acquaintance with its natural structure1 and with the changes which may be produced in its form and size1 by disease and other accidents1 is indispensable to those who wish to practise or understand midwifery4 ,in early life the ,pelvis is composed of several bones1 many of which1 after puberty1 grow together4 ,in the adult female it is customary to speak of but four bones1 the sacrum1 the coccygis1 and the two innominata1 or hip bones1 7see ,plates ,,vii1 ,,viii47 ,in the young female these are divided into several distinct parts4 ,,plate ,,vii4 ,bones of the ,pelvis4 ,the four principal bones1 as found in ,mature life4--,a4 ,a4 ,the ,ossa ,ilii1 or ,ossa ,innominata1 commonly called the haunch1 or hip bones4--,b4 ,the ,os ,sacrum1 or lower part of the back bone4--,c4 ,the extreme termination of the back bone1 called the ,os ,coccygis4 ,the divisions into parts1 as in ,early life4--,the ,ilium1 ,a1 on each side1 is in three parts2 the ,ilium1 properly so called1 marked a4 a42 the ,pubis1 marked b4 b42 and the ,ischium1 marked c4 c4 ,the ,sacrum is in five parts1 marked #a1 #b1 #c1 #d1 #e4 d4 ,is the last bone of the spine1 which joins the ,sacrum4--e4 e4 ,are the ,sockets in which the upper parts of the thigh bones fit1 forming the hip joints4--g4 g4 ,the two rings1 formed by the bones of the ,pubis and ,ischium1 each called the ,foramen ,magnum4 ,illustration3 ,plate ,,vii4 ,bones of the ,pelvis4 ,illustration3 ,,plate ,,vii4--a4 ,this represents the ,male ,pelvis1 to show the difference in structure4 ,the letters correspond with those in ,plate ,,vii4 ,illustration3 ,,plate ,,viii4 ,section of the ,pelvis1 to show the shape and connection of those parts not distinctly visible in the full view4 ,the section is made down the middle of the back bone1 and through the symphysis pubes1 in front4 ,the letters correspond with those in ,plate ,,vii4 ,a4 ,the right ,ilium4--,b4 ,the ,sacrum4--,c4 ,the ,coccygis4--b4 ,the ,os ,pubis4--c4 ,the ,os ,ischinum4--g4 ,the ,foramen ,magnum4--o4 shows the manner in which the coccygis is bent back through labor4 ,these bones are all firmly bound together by a cartilaginous substance1 which is placed between where they touch1 and is firmly attached to each one4 ,this union is called a symphysis4 ,the one at front which joins the pubic bones is called the symphysis pubis2 the two which join the ,ossa ,illii to the ,sacrum are called the sacro iliac symphyses2 and that which joins the ,coccygis to the ,sacrum1 is called the ,sacro coccygeal symphysis4 ,the two pubic bones are separated a little in ,plate ,,viii1 simply to show them better4 ,the reader will bear in mind that they are naturally connected by the cartilaginous substance which forms the symphysis4 ,these articulations1 or joinings1 become much softened during labor1 and give way a little1 but not to any extent sufficient to assist delivery4 ,it is a mistake to suppose that the bones separate at that time4 ,the only part which gives way is the sacro coccygeal symphysis1 which does relax1 and allows the ,os ,coccygis to be pushed back by the child's head a full inch or more1 thus enlarging the inferior strait4--7,see c4 and o4 ,plate ,,viii47 ,sometimes this little bone will be even broken off1 when there is great disproportion between the head and the strait4 ,i have heard it snap like a stick breaking4 ,there is nothing serious nor alarming in this1 however1 unless it be a first delivery late in life1 though it may cause some pain at the time1 and a little difficulty in sitting for some time after4 ,in young persons the symphysis is soft1 and gives way easily1 so that they have little difficulty during delivery from this cause2 but if a female marry late in life1 after it becomes hardened1 she may suffer considerably4 ,in this case the coccygis is usually curved inwards considerably1 and being firmly fixed the head cannot push it back1 and on that account cannot pass1 without great difficulty1 and with the risk of rupturing some of the soft parts1 or breaking the coccygis completely off4 ,there is in fact great difficulty1 and some danger1 if the first pregnancy takes place late in life4 ,the ,pelvis is usually divided into two parts1--the great pelvis1 or upper part1 enclosed between the wide flanges of the ,ossa illii and the upper part of the sacrum2 and the small pelvis1 or basin1 which is enclosed between the lower part of the sacrum and coccygis behind1 and the ossa ischii and ossa pubes in front4 ,the basin is nearly cylindrical1 larger in the middle1 and curved towards the front4 ,the ,straits of the ,pelvis4--,the bones of the ,pelvis1 it will be seen1 form a kind of broad ring1 or cylinder1 particularly in the basin2 and the straits are two passages1 one by which the child passes into the basin from the upper ,pelvis1 and the other by which it passes out from the basin into the world4 ,in ,plate ,,viii4 the line marked is the antero posterior diameter of the upper strait1 through which the child first passes1 called also the brim1 or entrance to the ,pelvis4 ,the line marked is the diameter of the lower strait1 through which the child passes into the world1 called also the outlet of the ,pelvis4 ,in ,plate ,,vii4 the line marked crosses the upper strait1 or brim of the ,pelvis4 ,the diameters of the ,pelvis are the distances between the prominent points of each strait1 and are four in number for each1 those for the upper strait being represented below4 ,,plate ,,ix4 ,diameters of the ,upper ,strait4 ,a ,b1 which extends from the most prominent point of the ,sacrum1 to the top of the ,symphysis pubes1 is called the antero posterior diameter1 or that from before to behind4--,c ,d1 and ,e ,f1 are called the two oblique diameters2 they extend from each sacro iliac symphysis1 to the most prominent point of the ,os ,ilium on the opposite side4--,g ,h1 is called the ,transverse1 or bis iliac diameter1 it crosses the ,pelvis nearly from one hip joint to the other4 ,the ,sacro ,antero posterior diameter measures four inches4 ,the two oblique diameters four inches and a half each4 ,the bis iliac diameter measures five inches4 7,by comparing this with ,plate ,,vii4 the various points will be still more apparent47 ,the inferior strait has also four diameters1 represented in ,plate ,x4 ,illustration3 ,plate ,,ix4 ,diameters of the ,upper ,strait4 ,,plate ,x4 ,the ,bones of the ,pelvis viewed from below1 looking through the inferior strait1 to show its diameters4 ,a ,b1 which extends from the end of the ,coccygis to the lower part of the ,symphysis ,pubis1 is called the antero posterior diameter2 it measures four inches1 like that of the upper strait1 but is increased a little by the bending back of the ,coccygis4--,c ,d1 and ,e ,f1 are the two oblique diameters1 also corresponding to those in the upper strait2 they measure four inches1 but are increased a little by the giving way of the soft parts4--,g ,h1 is the transverse1 or bis-ischiatic diameter2 it measures four inches4 ,illustration3 ,plate ,x4 ,the ,bones of the ,pelvis viewed from below1 looking through the inferior strait1 to show its diameters4 ,it will thus be seen that the diameters only average from four to five inches1 but it must be remembered that the soft parts1 and even one of the bones1 very readily give way1 and thus they are slightly increased4 ,when we come to describe the form and size of the ftal child's head1 it will be found that its diameters correspond very nearly with those of the pelvic straits through which it has to pass1 so that ordinarily labor presents no serious difficulty4 ,if the head be larger than natural1 from any cause1 or if the ,pelvis be too small1 or deformed1 this mutual adaptation does not exist1 and delivery of course becomes difficult1 or dangerous1 and sometimes impossible4 ,the only obstacle therefore1 which can seriously impede the expulsion of the ftus1 or prevent it altogether1 is this want of conformity1 in size and shape1 between its head and the bones of the ,pelvis4 ,the soft parts may retard labor considerably1 by being contracted or rigid1 but can generally be made to give way1 either by the efforts of nature or by manual assistance2 and the ftal head can be reduced in size if necessary2 but insufficient size1 or faulty form1 in the bones1 is irremediable4 ,the various causes which produce deformity1 or imperfect development1 in the ,pelvis1 and unnatural growth of the child's head1 will be stated in a subsequent section4 ,for the present1 we have only to do with both in the normal state4 ,the importance of an accurate knowledge of the structure of the ,pelvis1 and of the changes which may be induced in it1 will now be obvious2 neither the theory nor the practice of ,midwifery can in fact be understood without such knowledge4 ,it is also frequently of the first importance to know1 previous to marriage1 whether the pelvis of a young person is so formed that delivery can be safely effected6 ,inattention to this has sacrificed the lives of many1 and caused others to live for years suffering and helpless4 ,in another place we shall give some plain rules and directions by which this important point may be determined4 ,the floor of the ,pelvis4--,the soft parts at the bottom of the basin of the ,pelvis1 consisting of the perineum and various muscles1 are called the floor of the ,pelvis--the only passage through which is by the ,vulva1 or mouth of the ,vagina4 ,as the head of the child descends to the bottom of the basin1 it presses upon this floor1 and gradually distends it1 until the ,vulva is sufficiently enlarged4 ,this delay is advantageous1 for if the passage was always large enough1 or increased in size without any difficulty1 the child would pass too suddenly1 and much mischief might often result from its sudden expulsion--such as pulling down of the womb1 flooding1 and the falling of the child upon the ground4 ,direction of the passage of the ,pelvis4--,in most of the lower animals the passage of the ,pelvis is straight1 and on a line with the body1 the two straits being opposite each other1 which makes delivery much more easy with them4 ,even in the negroes1 and other inferior races1 the passage is much straighter than in the whites4 ,the more perfect the organization therefore1 the more difficult is parturition2 and the more imperfect or simple the organization1 the more easy is parturition4 ,the dotted line in ,plate ,,xi4 shows the direction of the passage of the ,pelvis1 in the human female1 to be a curve1 so that the child has to move1 during its passage1 in a circle4 ,illustration3 ,,plate ,,xi4 ,the axis1 or direction1 of the upper strait is denoted by the line ,a1 that of the lower strait by the line ,b1 and that of the ,vulva by the line ,c4 ,the force of expulsion tending to push the child in each direction1 it has to traverse a path intermediate with them all1 or compounded of them all1 not being able to move in either alone4 ,this aggregate direction is denoted by the dotted curved line1 which shows the direction in which the child passes1 and in which the hand must be passed when introduced4 ,i is the ,perineum4--,the dotted line which crosses ,a denotes the upper strait1 and the line ,i the lower strait4 ,,chapter ,,iii4 ,,functions ,,of ,,the ,,principal ,,female ,,organs4 ,the great object for which the whole of the ,female organs perform their several functions is1 that of bringing into existence a new being6 ,for this purpose they act both separately and conjointly1 each one having its specific part to play in the grand phenomenon4 ,as already remarked1 it would not be in place here to give all the details of this wonderful event1 but merely such a description of its principal stages1 as will suffice for an understanding of the main subject of the present treatise4 ,i shall therefore1 first give the uses of the principal organs separately1 and then explain the processes of conception1 and ftal development4 ,,the ,,womb4 ,the ,womb is nothing more than the receptacle in which the impregnated egg is placed1 and in which it undergoes all the wonderful changes by which it eventually is developed into a perfect human being4 ,the womb is not therefore absolutely needed in conception1 and indeed several cases have been known where the new being was formed without the womb altogether1 though not perfectly4 ,its principal use is in ftal development1 which cannot take place perfectly in any other part of the body4 ,,the ,,ovaries4 ,the ,ovaries1 as already remarked1 are two oval-shaped bodies1 placed one on each side of the womb1 and connected with it1 whose use is to form the germ or rudiment1 called the ovum1 or egg1 from which the new being is developed4 ,the structure of the ,ovaries is very simple1 and the manner in which they produce the ovum is not very well understood4 ,it is certain however1 that they are indispensable to conception1 being in fact the most essential parts of the female generative system4 ,,menstruation4 ,menstruation appears to be a process resulting from the development and healthy action of the ,female organs1 and is essential to their well being4 ,the following brief account of its nature and origin is extracted from my ,diseases of ,woman1 page #aeb to #aee3 ,until very recently but little was known1 with any certainty1 respecting this remarkable and important phenomenon of the female system4 ,the most crude and visionary theories have been advanced to explain it1 and our works on medicine and physiology do nothing more than repeat them1 one after the other4 ,the investigations of several distinguished physiologists however1 within the last few years1 have thrown a new light on this hitherto obscure subject1 and explained much that was previously unknown1 or1 at best1 merely conjectured upon4 ,a brief statement of the result of those investigations will not only be highly interesting in itself1 but will materially assist in explaining what we shall afterwards speak upon4 ,it is well known that the female organs are liable1 at regular periods1 to assume a peculiar action1 which results in the discharge of a fluid termed the menses4 ,the secretion and excretion of which are highly essential1 both to the proper performance of many other functions1 and to the maintenance of the general health4 ,whence comes this fluid1 and what causes it to flow8 ,these were questions unanswered1 except by mere supposition1 previous to the discoveries referred to1 which we now proceed to make known4 ,in the first chapter it was stated that the ,ov1 or eggs1 contained the rudiments or germs1 from which1 when impregnated by the male principle1 new human beings were developed4 ,these ov1 however1 are not prepared to undergo this development before the age of puberty1 nor after the change of life1 nor are the whole of them fit for conception even during the prolific period4 ,it appears that they become fit for fecundation in succession1 during the menstrual period1 one ovum1 or more1 being ripened every month6 ,when fully perfected it separates from the ovary and is lost1 unless conception occurs1 in which case it passes along the fallopian tube into the ,womb1 and then develops into the ftus4 ,here then we see the cause of the menses2 the ripening of the ovum causes a local excitement1 and congestion1 in the ovary and womb1 which increases till the period when it is thrown off1 and then the accumulated fluid is discharged1 the excitement subsides1 and a new development commences4 ,this curious process is termed by some physiologists the monthly ponte1 or laying of eggs1 and by others the ,ovarian labor1 or birth6 ,a small scar is left on the ovary at the point where the ovum separates1 which fades away after a time1 but a number of them may always be observed on the ovaries of those who have long menstruated4 ,in those who die during menstruation the ovaries are found very red1 and full of blood1 and sometimes one of the ov will be found swelled1 and just ready to burst through1 or the ruptured opening may be seen through which it has actually escaped4 ,precisely the same phenomenon occurs in the lower animals1 excepting that their periods are more extended2 some of them occurring annually1 and others at still longer intervals4 ,some of the monkeys even have a species of real menstruation4 ,these important facts1 by enabling us to understand what causes menstruation1 give us an insight also into the nature of its derangements1 and the conditions required for their regulation4 ,when we call to mind also the close sympathy between the uterine organs and every other part of the system1 it shows us how important a proper menstruation is to the general health1 because without it those organs must be diseased1 and consequently every other part of the system liable to suffer with them4 ,formerly many absurd notions prevailed respecting menstruation1 which in fact are not quite removed even now4 ,thus some authors asserted that a female1 while unwell1 could cause various diseases1 by merely touching persons6 ,others supposed they would curdle milk1 and nearly all believed that the menstrual fluid itself was highly poisonous1 so that females1 at those times1 were compelled to live apart and approach no one4 ,in the ,old ,testament there are many regulations given1 for females while menstruating1 which show the prevalence of such notions in olden times4 ,it is scarcely necessary to say that there is no foundation whatever for all this1 as the fluid itself differs but little from ordinary blood1 and is equally innocuous4 ,in like manner it was supposed1 that menstruation was influenced by the ,moon1 and only occurred at a certain period of her age4 ,we know1 however1 that females are unwell almost every hour of every day in the year4 ,the due establishment of the menstrual function is absolutely necessary1 to the perfection both of mind and body1 and its regular performance is quite as essential to the continuance of health1 for there is scarcely a single disease that its derangement will not either cause1 or at least seriously aggravate4 ,it is therefore vitally important to attend to this matter1 particularly in young persons approaching puberty6 ,a little care at that time1 properly bestowed1 may prevent years of disease and suffering1 if not untimely death6 ,,conception4 ,conception is the union of the male principle with the female ovum1 or egg1 after that is perfected in the manner described in the article on ,menstruation4 ,the precise manner in which this union is effected is unknown1 though our information in regard to it is much more extensive1 and precise1 than formerly4 ,as nearly as can be stated it occurs in the following way3 ,at the time of a fruitful connection1 which can only occur1 it must be remembered1 when the ovum is ripe1 the male principle is carried into the ,womb1 7,b1 ,plates ,i4 and ,,iii47 and is then supposed1 by some1 to meet with the ovum which has descended down the ,fallopian ,tube 7f1 ,plates ,i4 and ,,iii47 from the ,ovary1 so that the union of the two takes place1 according to this view1 either in the ,fallopian ,tube or in the ,womb4 ,others1 however1 suppose that the ovum does not leave the ,ovary before conception1 but that the male principle passes down the ,fallopian ,tube and meets it there1 and that it is several days after before it reaches the ,womb4 ,there are many facts and arguments brought forward in support of each view1 all of which will be set forth in my forthcoming work on the reproductive functions4 ,all that is known for certain is1 that the two principles must unite in one place or the other1 and that the ovum must pass down the ,tube into the ,womb1 either before impregnation1 or after4 ,the union of the two principles in the ,womb appears so likely an event that it is scarcely possible to avoid thinking that it really does then take place1 but at the same time there are very strong reasons for adopting the opinion that it takes place in the ,ovary4 ,among others may be mentioned the phenomenon of extra uterine conception1 which will be more fully alluded to in another place4 ,in these cases the ftus is found outside of the ,womb1 in the ,tube1 or the ,ovary1 or even in the ,abdomen1 among the intestines4 ,such an occurrence seems to render it almost certain that the ovum must have been fecundated in the ,ovary1 because we cannot well conceive1 if it were not so1 how it could reach the outside of the ,womb4 ,this difficulty is not1 however1 regarded as insuperable1 by the advocates of the opposite theory4 ,possibly conception may occur in both ways4 ,there are many causes which prevent conception1 or1 in other words1 which produce barrenness and sterility4 ,these various causes cannot be all explained1 except in connection with a full explanation of the process of reproduction1 and of the nature of many female diseases4 ,in my work on ,the ,diseases of ,woman1 ,i have given a chapter on this subject1 and have also referred to the present work as one in which it would be more fully treated4 ,this reference1 however1 was made in mistake2 the subject is not needed here1 but will be in the other work1 on the reproductive functions in which it will be discussed at length4 ,,chapter ,,iv4 ,f,,tal ,,development4 ,the last ,chapter brought us up to the point of conception1 or the first commencement of the new being4 ,the next step is to exhibit its various stages of development1 and to show how it is nourished and maintained in its proper position4 ,this is requisite in order to understand the origin of many diseases and accidents which occur during gestation1 and also to explain the various signs by which it is determined whether a female is pregnant or not4 ,f,,tal ,,development4 ,the development of a perfectly formed human being from the egg in which it originates1 is one of the most astonishing phenomena that can come under our observation1 and is eminently deserving the study of every rational being4 ,the present explanation of it must necessarily be brief1 being merely intended to make the main subject more clear4 ,it has already been remarked that it is uncertain whether the ovum is impregnated before it is brought into the ,uterus1 or after it arrives there2 but be that as it may1 nothing has yet been discovered in the ,womb till several days after conception4 ,some physiologists tell us that the rudiment of the new being may be found there about the sixth day2 but others again assure us that it cannot be found before the twelfth1 at which period our explanation of its development will commence4 ,at the twelfth day the ovum is about the size of a large pea1 it is composed of a vesicle containing a thick fluid1 called the germ1 which corresponds to the opaque substance seen in the white of a fecundated bird's egg1 and of a yellowish substance1 in which it floats1 called the vitellus1 which answers to the yelk4 ,the whole being surrounded by two membranous coverings1 the outer one called the chorion1 and the inner one the amnion4 ,between these is a gelatinous substance1 and within the amnion is a fluid1 called the liquor amnii4 ,the two membranes1 the liquor amnii1 and the inclosed ovum1 are called the ovulum6 ,immediately after conception the uterus begins to secrete1 from its inner walls1 another membrane1 very delicate1 called the decidua4 ,this lines the whole cavity1 so that when the ovulum passes out of the tube it is met by this lining which seems to prevent its entrance into the womb4 ,the ovulum1 however1 presses upon it and so makes a depression1 like a nest1 in which it lies4 ,this prevents its moving about1 or falling to the bottom of the womb4 ,the weight of the entire ovulum is about one grain4 ,the embryo commences in the germ1 and may now be seen about the size of a pin's point4 ,the vitellus removes away from it1 but remains connected by a small pedicel or thread-like tube1 down which it is gradually absorbed as nutriment4 ,a small white thread1 scarcely perceptible1 may be seen sometimes as early as this period1 being the commencement of the brain and spinal marrow4 ,the mouth is visible also from the twelfth to the twentieth day1 and frequently the eyes4 ,these are placed at first on the side of the head1 like those of quadrupeds1 and move round to the front afterwards4 ,at twenty-five days1 the embryo is about the size of a large ant1 which it also resembles in form4 ,it begins to have a little more consistence1 and the future bones begin to resemble cartilage1 or gristle4 ,a small groove may be seen denoting the neck1 which thus indicates the separation of the head from the trunk4 ,the weight is three or four grains4 ,the first month1 it is about the size of a ,bee1 and is somewhat like a small worm bent together4 ,the arms may be seen like two little warts4 ,they are first formed under the skin1 and shoot out like buds1 growing straight from the body2 afterwards they become folded together1 in a curious manner1 upon the breast4 ,the head is as large as the rest of the body1 and upon it we can now see distinctly the eyes1 like two black dots1 the mouth1 like a line1 and also the nose4 ,the lower extremity is lengthened out like a tail4 ,weight about ten grains4 ,the second month4 ,every part has now become much more developed1 and the general form is that of a human being4 ,the superior members are much more elongated1 and the inferior ones begin to be distinguished1 forming in the same manner as the others4 ,the fingers are united together by a membrane1 like the web on a ,frog's foot4 ,in the ribs1 clavicles1 and jaw bones1 a few points can be seen ossified1 the cartilage beginning2 to harden into bone4 ,the rudiments of the first teeth are also visible4 ,the weight is about one drachm1 and the length one inch4 ,at about seventy days the eyelids are visible1 the nose becomes prominent1 the mouth enlarges1 and the external ear may be seen4 ,the neck is well defined4 ,the brain is soft and pulpy1 and the heart is perfectly developed4 ,every organ is originally formed without either blood or blood vessels4 ,the circulation which afterwards takes place in them is merely for their subsequent development4 ,the heart is perfect in all its parts1 and even has a slight motion1 before the blood is found in it4 ,three months4 ,all the essential parts are well defined4 ,the eyelids distinct1 but firmly closed4 ,the lips perfect1 but drawn tightly together4 ,the heart beats forcibly1 and in the larger vessels red blood is seen4 ,the fingers and toes are defined1 and the muscles begin to be apparent4 ,the organs of generation are remarkably prominent1 but still it is somewhat difficult1 at first1 to distinguish the sex by these organs1 notwithstanding their development1 as the principal parts in both are nearly identical in form4 ,it can1 however1 be ascertained by other circumstances1 as the form of the head1 dorsal spine1 thorax1 and abdomen4 ,it now weighs about two ounces and a half1 and measures four or five inches in length4 ,four months4 ,the development is remarkably increased4 ,the brain and spinal marrow becomes firmer1 the muscles distinct1 and a little cellular tissue is formed4 ,the abdomen is fully covered in and the intestines are no longer visible4 ,a little of the substance called meconium even collects in the intestines1 the same as is found in at birth4 ,it now weighs seven or eight ounces1 and measures six or seven inches4 ,the bones are ossified in a great part of their extent1 and the rudiments of the second set of teeth are visible1 under the first4 ,the uterus now is so large that it can no longer remain in the lower part of the pelvis1 but is compelled to rise up into the abdomen for more room4 ,this change of position is improperly called quickening6 ,sometimes it takes place very gradually1 so that it is scarcely noticed1 but more frequently it rises suddenly1 disturbing all the internal organs1 and causing in them considerable derangement till they accommodate themselves to the change4 ,this occurrence often causes unnecessary alarm1 though the sickness1 and other unpleasant sensations1 are always sufficiently annoying4 ,this stage corresponds with that in which the young of oviparous animals breaks the shell and escapes4 ,the human being however1 undergoes a remarkable change1 and remains in the womb for a period longer than that already past1 in order to become more perfected4 ,from four to nine months the development is proportionally much more rapid than during the first four months1 owing to the circulation of perfect red blood1 which is now found the same as in the adult1 and is probably derived from the mother's blood vessels4 ,five months4 ,every part is considerably increased in size1 and become more perfect4 ,the lungs enlarge1 and are even capable of being1 to a certain extent1 dilated4 ,the skin becomes much stronger4 ,the situation of the nails can be discerned4 ,the meconium is more abundant1 and lower down in the intestines4 ,the length is now eight or ten inches1 and the weight fifteen or sixteen ounces4 ,six months4 ,the nails are marked4 ,the head becomes downy1 from the first development of the hair4 ,a little fat is formed4 ,length twelve inches1 weight from one and a half to two pounds4 ,no indications of intellectual faculties4 ,seven months4 ,the whole being has rapidly progressed4 ,the nails are formed1 the hair is perfect1 in the male the testicles descend to the scrotum1 and in the female the ovaries reach the brim of the pelvis4 ,the bones are tolerably firm1 and the meconium collects in the large intestines4 ,length fourteen inches1 weight about three pounds4 ,intellectual functions not yet exercised4 ,the two remaining months are merely devoted to further increase in size and weight4 ,no new phenomena present themselves4 ,nine months4 ,every function has become active4 ,the skin becomes colored1 and perspiration occurs4 ,there are no indications of the intellectual functions1 but the animal functions are remarkably active1 particularly that of taste1 which no doubt leads to the act of sucking1 from the natural desire for its gratification4 ,the child can now experience all the ordinary sensations of pain1 hunger1 heat1 and cold1 and is capable of preserving an independent existence if brought into the world4 ,plate ,,xii4 represents a section of the ,uterus at about one month of gestation1 so as to show all the parts in their proper situation4 ,,plate ,,xii4 ,section of the ,uterus1 with the ,ovum and appendages1 at about one month of gestation4--a4 a4 a4 ,the substance of the walls of the ,womb4--b4 b4 ,the ,embryo4--c4 ,the different vessels by which it is connected with the ,placenta4--d4 d4 ,the ,placenta4--e4 ,the ,vitellus4--f4 f4 f4 ,the ,membrane lining the ,uterus1 called the ,decidua2 it is seen to be bent double1 or reflected1 the ,embryo being on the outside of it4--g4 g4 ,the ,chorion1 or ,middle ,membrane1 which is studded over with villosities1 or small blood vessels4--h4 h4 ,the ,amnion1 or inner membrane1 which contains the fluid called the liquor amnii1 in which the ,embryo floats4--i4 i4 ,the blood vessels which connect the ,placenta with the ,womb4--j4 ,is a plug of ,mucus1 by which the mouth of the ,womb is now blocked up4--k4 k4 ,the ends of the ,fallopian ,tubes1 which are cut off2 these are also blocked up with mucus1 the same as the ,os ,tinc4--l4 ,the ,os ,tinc1 or mouth of the ,womb4--m4 ,the ,vagina4 ,illustration3 ,plate ,,xii4 ,section of the ,uterus1 with the ,ovum and appendages1 at about one month of gestation4 ,f,,tal ,,nutrition4 ,the manner in which the new being derives its nutriment1 or the material by which it grows1 is1 in a great measure1 unknown to us1 though we certainly obtain some little information about it by a study of the apparatus employed in the process4 ,for the first fifteen or twenty days the substance called the ,vitellus1 7e4 ,plate ,,xii47 which is analagous to the yelk of the ordinary egg1 appears to supply most1 if not all of the material that is required in the formation of the new being2 and indeed this substance does not totally disappear till after the third month1 though we cannot suppose it to be the sole source of nutriment then4 ,it is also supposed1 by some1 that the amniotic liquor1 in which the ftus floats1 may afford some nutriment1 either by being swallowed1 or by being absorbed through the skin4 ,it is certain that this fluid is nutritive1 and there is nothing impossible in its absorption1 though it is not very likely to occur to a sufficient extent4 ,the idea that it can be swallowed however1 is erroneous1 because the mouth of the ,ftus is firmly closed while in the ,womb2 and besides1 children have been born alive without mouths1 and even without heads1 and of course they could not have swallowed anything4 ,it is now generally conceded by physiologists that the material required by the ,ftus1 for its nutrition1 is obtained from the blood of the mother1 through the medium of the ,placenta1 and the vessels in the ,umbilical cord4 ,it is1 however1 a matter of dispute whether the maternal blood is sent directly1 in its ordinary state1 into the body of the child1 or whether it first undergoes a preparatory process1 which most modern authors suppose it does4 ,from the earliest period of gestation1 the middle membrane1 called the chorion1 7g4 g4 ,p4 ,,xii47 is covered1 on its outer surface1 with a number of small protuberances called villosities1 which subsequently become true blood vessels4 ,about the fourth month these have increased very much in size and number1 and have all become conglomerated into one mass1 in form like a mushroom4 ,this is called the ,placenta4 ,it is almost entirely formed of blood vessels1 which seem to attach themselves at one end1 by open mouths1 to the open mouths of other blood vessels on the inner walls of the uterus 7i4 i4 ,plate ,,xii47 ,at the other end these vessels are drawn together and lengthened out into a long tube1 called the umbilical cord1 or navel string1 which finally enters the body of the child at the navel and so establishes the connexion between it and the mother4--7c4 ,plate ,,xii47 ,the blood vessels in the placenta1 umbilicus1 and ftus1 like those in the maternal body1 are of two kinds1 ,arteries and veins4 ,the arteries1 which come from the left side of the heart1 carry the pure blood1 which contains all the materials for forming and nourishing every part of the system4 ,the veins contain the blood in its impure state1 and take it to the right side of the heart1 from whence it is forced into the lungs to be purified by the act of breathing4 ,the blood is made impure by some of its constituents being absorbed1 to form the different parts of the body1 and by having thrown into it a quantity of waste and poisonous matter no longer needed4 ,the course of the blood1 therefore1 is from the left side of the mother's heart along her arteries till it reaches the arteries of the uterus1 from them it passes into those of the placenta1 and thence into those of the umbilicus which convey it into the body of the child4 ,when there it circulates in its arteries1 supplies the material for its further increase and development1 becomes in consequence impure1 and passes into its veins1 the same as in the maternal body4 ,from these veins it passes into those of the umbilicus and placenta1 and1 apparently1 into those of the mother1 by which it is conveyed to the right side of her heart1 and by its action to her lungs1 to be again purified when she breathes4 ,this explains what was previously stated1 that the child uses the mother's heart1 lungs1 and stomach1 while in the womb1 and has1 therefore1 no occasion to use its own4 ,the diameter of the placenta is about six inches1 and its thickness about one inch and a half4 ,the length of the umbilical cord is from eighteen to twenty-four inches1 its diameter about half an inch4 ,these dimensions are1 however1 subject to great variation4 ,instances are mentioned of the cord being five feet long1 and as thick as the child's arm4 ,i have seen one myself four feet long4 ,sometimes it will be very short1 not more than eight or ten inches4 ,it is composed of one artery and two veins1 twisted together like the strands of a cable1 and of a sheath surrounding them composed of the chorion and amnion4 ,between the sheath and the vessels is a thick gelatinous fluid called the ,gelatine of ,wharton4 ,this explanation1 it must be remembered1 is in fact merely hypothetical4 ,the direct passage of the blood through the ,placenta1 from the mother's vessels into those of the cord1 is denied by many physiologists1 who contend that there is an intermediate set of vessels in the ,placenta1 in which it first undergoes important changes4 ,they also contend that the impure blood does not pass through into the mother's veins at all1 but is purified in the ,placenta1 and immediately returned4 ,some have even averred that the ,placenta is not required at all1 to supply nourishment1 but is merely a purifying organ4 ,it is now known1 however1 that it is not absolutely essential to either process1 for children have been born alive1 and perfectly formed1 which merely floated loosely in the amniotic liquor1 having neither ,placenta nor cord1 nor any other connection with the mother4 ,how they were nourished we cannot tell4 ,these1 however1 must be regarded merely as curious exceptions1 there being little doubt but that ftal nutrition is ordinarily effected through the ,placenta and cord1 by means of the mother's blood1 somewhat in the manner we have described4 ,,peculiarities ,,of ,,the ,f,,tal ,,circulation4 ,from the circumstance of the ftus not using its heart and lungs1 like the adult1 its circulation has several modifications4 ,the engine by which the blood is forced along its vessels is the heart6 ,this is divided into two distinct parts1 each of which has two cavities1 the upper one called the auricle1 and the lower one the ventricle1 which communicate with each other by curious valves4 ,in the adult the whole of the impure blood is poured into the right auricle1 that from the lower part of the body by the inferior vena cava1 and that from the upper part by the superior vena cava4 ,from the right auricle it passes into the right ventricle1 which pumps it into the lungs1 by way of the pulmonary artery2 here it is purified by the act of respiration1 and then brought1 when pure1 by the pulmonary veins1 into the left auricle1 and passes from thence into the left ventricle1 which pumps it into the great aorta1 and from thence into the smaller arteries all over the body4 ,the two sides of the heart1 therefore1 do not communicate directly with each other1 but there is a strong partition between them4 ,in the ftus the arterial blood from the mother1 when it leaves the umbilical artery1 enters first the liver1 runs through its vessels1 gives off the bile found in it1 and then joins the vena cava inferior4 ,by this passage it is taken into the right auricle1 along with the impure blood of the vena cava4 ,from the right auricle it passes through a hole in the partition directly into the left auricle1 instead of taking the indirect route by the lungs as in the adult4 ,from the left auricle it passes into the left ventricle1 and is from thence distributed by the arteries all over the body4 ,this opening in the partition is called the foramen ovale6 ,after birth1 when the blood begins to pass through the lungs1 this passage closes up4 ,by the eighth day it is generally obliterated1 often much sooner1 though occasionally it has remained open longer without inconvenience4 ,in some cases the foramen ovale does not close at all4 ,the child then has what is called the blue disease6 ,the whole body is of a uniform leaden1 or blue color1 and the whole system is generally languid and sluggish4 ,the blue color is caused by the dark blood of the veins mixing with that of the arteries4 ,these children mostly die early1 but some live to be five or six years old1 and one ,i saw twelve1 but this is rare4 ,no remedy can be had for this affliction1 and ,i have never known it to cure spontaneously4 ,some children are so very dark for a few days after birth as to cause great alarm4 ,this is owing to the foramen ovale being very open and closing slowly4 ,no apprehension need be experienced in such cases1 as it soon subsides4 ,the impure blood from the upper part of the ftal body1 which is brought down by the superior vena cava1 also enters the right auricle1 but does not pass from thence through the foramen1 like that from the inferior vena cava4 ,by a peculiar arrangement this blood is made to pass down into the right ventricle1 and from thence along the pulmonary artery1 the same as in the adult state4 ,only a very small portion1 however1 passes into the lungs1 the great part being taken along a tube called the ductus arteriosus into the great artery called the aorta1 where it begins to turn down to the lower part of the body4 ,in consequence of this1 the arterial blood going down to the lower part of the body1 is mixed with this portion of impure1 venous blood1 brought by the ductus arteriosus from the superior vena cava2 while that going to the head1 and upper part of the body remains pure4 ,and this is the reason why the lower part is always so much smaller than the upper part1 previous to birth2 it receives less pure nourishment4 ,the head and chest appear1 at an early period1 almost as large as the rest of the body4 ,this circumstance also explains why1 in the great majority of cases1 the right arm is preferred to the left1 and has more real power4 ,the place where the ductus arteriosus pours the impure blood into the aorta1 is almost immediately opposite to where the artery is given off which feeds the left arm4 ,in consequence of which1 in most cases1 a small portion of this impure blood becomes mixed with the arterial blood1 and the left arm is1 therefore1 in the same situation as the lower limbs1 and like them is comparatively imperfectly developed4 ,the right arm is not liable to any such deprivation4 ,in some cases the insertion of the ductus arteriosus is lower down1 so that no such mixture occurs4 ,both arms are then equal1 and this accounts for the fact that in some persons there appears to be no difference4 ,in some cases1 no doubt1 early habit1 or imitation1 may overcome this natural inferiority1 and even give the preference to the left arm2 but such instances are rare2 the general rule is the contrary1 and for the reason stated4 ,the ductus arteriosus closes up about the same time as the foramen ovale4 ,the two veins which convey the impure blood back to the mother1 to be purified1 originate from the iliac artery1 in the pelvis4 ,they pass up the sides of the bladder towards the navel1 enter the sheath of the cord1 and so reach the placenta4 ,these vessels are obliterated about the third or fourth day after birth1 and remain afterwards in the form of a fibrous cord4 ,the real source of all the blood in the body of the child is a mystery2 it would certainly appear most likely for the whole of it to be derived from the mother's vessels1 but there are many circumstances which make it probable that the child may form some itself1 by digesting the fluid it is supposed to absorb4 ,this view is supported by the fact that there is found in its bowels at birth1 and even before1 a greenish substance like excrement1 called ,meconium4 ,this has every appearance of being the product of digestion1 though some suppose it to be derived from the liver4 ,it occasionally contains hair1 and other anomalous substances4 ,,chapter ,,iv4 ,,the ,,breast4 ,the ,breasts1 or ,mamm1 are not needed in the process of generation1 nor are they absolutely necessary even after birth2 but as they are naturally associated1 in the majority of cases1 with infantile nutrition1 and are besides liable to many derangements and diseases during pregnancy and child-birth1 it is advisable to give some account of them4 ,when one of the breasts is dissected it is found to be composed chiefly of a singular body called the ,mammary ,gland1 which resembles somewhat a very firm piece of fat1 of a yellowish drab color4 ,in the substance of this ,gland are an immense number of little cells1 or vessels1 in which1 by some unexplainable process1 the milk is secreted1 or made from the blood4 ,from these little vessels there proceeds small tubes which gradually unite into larger ones1 and these again into larger ones still1 until at last all the milk is poured into a few tubes1 or canals1 which terminate in the nipple4 ,the outer mouths of these terminal canals are only slightly contracted together1 so that the suction of the child's mouth1 or even the pressure of the milk1 when the breast is full1 will force them open and allow the fluid to flow out4 ,the following plate represents the structure of the ,breast1 and explains1 as far as it can be explained1 the manner in which it performs its functions4 ,,plate ,,xii4--a4 a4 a4 ,the cut edges of the skin4--b4 b4 ,the flaps of the skin thrown back4--c4 c4 c4 ,the fat which covers the breast4--d4 d4 ,the cells of the ,mammary gland4--e4 e4 e4 ,the ,tubes or canals1 which convey the milk from the ,gland to the ,nipple4--f4 ,the ,nipple1 cut down the middle1 to show the ends of the milk tubes terminating in it2 these are usually about fifteen or eighteen in number4--x4 ,shows a bunch of the little cells1 with the tubes proceeding from them1 as they appear when injected4 ,illustration3 ,,the ,,female ,,breast4 ,plate ,,xii4--a4 ,this ,plate represents the structure of the ,breast1 and explains the manner in which it performs its functions4 ,sometimes there has been seen two and even three nipples on one breast1 and in a few cases one of the breasts has had no nipple at all4 ,the two glands are not immediately connected1 but have a very intimate sympathy with each other4 ,the size of the breast depends more upon the thickness of the layer of fatty substance1 than upon the development of the gland1 so that one female1 with a very full bosom1 may have but little milk1 while another1 whose breast is but little prominent1 may have a superabundance4 ,the graceful swell of the fully developed breast is1 however1 a matter of positive utility1 as well as of beauty1 because it better adapts it to the use of the child1 and probably also adds to its pleasure1 as any one may readily conceive who will observe the delight with which an infant1 even when not nursing1 will often caress it4 ,sir ,astley ,cooper says1 ,the natural obliquity of the ,mamella1 or nipple1 forwards and outwards1 with a slight turn of the nipple upwards1 is one of the most beautiful provisions in nature1 both for the mother and the child4 ,to the mother1 because the child rests upon her arm and lap in the most convenient position for sucking2 for if the nipple and breast had projected directly forwards1 the child must have been supported before her1 in the mother's hands1 in a most inconvenient and fatiguing position1 instead of it reclining upon her side and arm4 ,but it is wisely provided by nature1 that when the child reposes upon its mother's arm it has its mouth directly applied to the nipple1 which is turned outwards to receive it1 whilst the lower part of the breast forms a cushion1 upon which the cheek of the infant tranquilly reposes4 ,with the exception of the dark areola1 or circle1 and the little tubercles around the nipple1 the breast is of the most delicate structure and color1 so that it blushes1 or reddens1 like the cheek1 from any sudden emotion1 and goes pale during fainting4 ,as a general rule no milk is secreted in those who have not become pregnant1 nor in those who have passed the turn of life1 but occasionally exceptions are observed to this rule4 ,bandelocque tells us of a girl only eight years of age1 who suckled her little brother more than a month6 ,and ,sir ,hans ,sloane tells us of a lady aged sixty eight1 who nursed several of her grandchildren1 though she had had no child herself for twenty years6 ,dr4 ,francis1 of ,new ,york1 describes the case of a lady who continued to secrete milk regularly for fourteen years after having lost her child1 so that she could always nurse an infant2 and ,dr4 ,kennedy relates an instance of another who continued to suckle children1 uninterruptedly1 for forty-seven years1 and who had milk perfectly sweet and good even when eighty-one years old6 ,dr4 ,clark1 of ,alabama1 informs us that a married lady1 who had never been pregnant1 was requested to take charge of an infant during the night1 and that to quiet it she had put her nipple in its mouth4 ,this was done frequently1 and to the great surprise of all it induced a flow of milk4 ,a singular circumstance connected with this was that the lady soon after became pregnant1 though previously barren6 ,this will not appear so surprising1 however1 to those who know the connection between the breasts and the womb1 and who have observed the mysterious bond of sympathy by which their functions are united4--7,see the articles on ,menstruation1 and on ,sterility1 in my ,diseases of ,woman1 for other instances of this kind47 ,the structure of the male breast is precisely the same as that of the female1 but it is seldom developed4 ,instances have been known1 however1 of the milk being secreted in men1 and of children having been nourished by it6 ,humboldt gives us an instance of this kind1 and ,professor ,hull1 of ,maryland1 exhibited a colored man to his class1 in the year #ahbg1 who had a large full bosom1 like a female1 and who had often officiated as wet nurse in the family of his mistress4 ,the secretion appears to have been established by his putting the children that he had to nurse to the nipple1 to quiet them4 ,when the milk was not needed it was found as difficult to dry it up as it is in some females1 but it was soon made to flow again1 by applying a child to the breast for a few times4 ,this man differed in no other respect from any other man6 ,in the females of some races of the human kind1 the mamm attain a surprising length1 and become very flaccid1 so that they hang down to the hips1 or lower1 and may be thrown over the shoulder for the child to nurse from while carried on the back4 ,some suppose this to constitute a real variety of the human race1 but others suppose it to result merely from habit1 which is probably correct4 ,when the breasts are small sized in young females1 their growth may often be promoted1 but the means need not be pointed out here4 ,,section ,,ii4 ,,signs ,,of ,,pregnancy1 ,,and ,,the ,,means ,,of ,,detecting ,,it2 ,,its ,,duration1 ,,and ,,the ,,period ,,at ,,which ,,the ,f,,tus ,,can ,,live4 ,it is always desirable1 and frequently of the first importance1 to be able to know whether a female is pregnant or not1 both to the accoucheur and to the individual1 or even to be able to judge whether she is probably or possibly so1 or not4 ,sometimes this can be decided positively1 but more frequently it is a matter of great uncertainty4 ,the presumptive and positive signs on which a judgment can be formed are of various kinds1 most of which can be readily observed1 and easily made use of by any person in possession of the information already given in the preceding section4 ,they will be set forth in the following ,chapters1 together with such other matter as appertains to this part of the subject1 in such a manner as will make them available either for professional or for private use4 ,,chapter ,v4 ,,signs ,,of ,,pregnancy1 ,,and ,,the ,,means ,,of ,,detecting ,,it4 ,the signs of ,pregnancy are of three kinds--,presumptive1 ,probable1 and ,certain4 ,,presumptive ,,signs4 ,the presumptive signs of pregnancy are only of value in the first three months4 ,they consist mainly of certain nervous and organic derangements1 and of certain changes in personal appearance4 ,it is scarcely possible to enumerate all these1 nor is it necessary2 we shall therefore only specify those most important1 and most generally met with4 ,colic pains1 and creeping of the skin1 with shuddering and fainting fits1 very frequently follow immediately on conception1 and in many females inform them when that event occurs4 ,some persons speak of other sensations1 of a peculiar nature1 by which they always know1 in their own cases1 when they conceive2 but these sensations are felt by so few1 and are so little capable of being explained or observed1 that they are of no general use4 ,in most cases1 within the first three months1 and sometimes in the first three days1 the face changes remarkably4 ,the eyes are sunk and dull1 and surrounded by a black circle1 the nose seems pinched up1 the skin turns pale1 and red spots1 or freckles1 frequently appear4 ,many females also complain of a husky dry throat1 numbness in the hands and feet1 and a sudden sinking at the heart4 ,these signs1 however1 are very uncertain guides2 very often none of these are felt at all during pregnancy1 and sometimes they are all experienced from other causes4 ,one of the most constant signs1 according to some1 and the most to be relied upon1 is an increase in the size of the neck4 ,this ,i know is often very apparent1 and at a very early period4 ,i am acquainted with females who1 by simply keeping the measure of their necks1 can always tell when they are pregnant4 ,the increase is often considerable in a few days4 ,in young persons of a certain temperament however1 the neck is apt to swell merely from marriage1 though they do not conceive2 and some old nurses1 we are told1 being acquainted with this fact1 judge of the honesty of their unmarried charges by such admeasurements6 ,this singular development is owing1 probably1 to a sympathetic connection between the uterine organs and certain parts of the brain1 and large nerves in the neck4 ,suppression of the ,menses is one of the strongest presumptive signs of pregnancy that can be observed1 but does not always accompany it1 and frequently arises from other causes4 ,in the great majority of cases1 it is true1 the menses cease to flow1 immediately conception occurs2 sometimes they will continue for one or more periods after1 and occasionally during the whole time of gestation1 even up to a few days before delivery4 ,this1 however1 is a very unusual occurrence1 and the stoppage of the menses is by no means so strong a sign that pregnancy has occurred1 as their continuance is that it has not4 ,some females are always irregular1 so that pregnancy makes little difference1 and in them of course these signs are even less to be depended upon than usual4 ,there have cases been known even of women who have conceived without having menstruated1 and of others who never menstruated except when they were pregnant2 and it is not at all unusual to see others who will conceive while nursing1 and never menstruate between the two pregnancies4 ,therefore we can only say that the menses usually stop when conception occurs1 and that their continuance is strong evidence that it has not occurred1 but still both signs may fail4 ,it is also proper to remark that several medical men have advanced the opinion that the discharge which appears during pregnancy is not the menstrual fluid1 but real blood4 ,it has however been accurately examined1 and found in no respect to differ from the usual discharge4 ,in my own opinion there is no doubt but that some females really do menstruate while pregnant4 ,as an instance that the presence of the menses is no proof that pregnancy has not occurred1 ,i give the following case3--,not long since ,i was requested to see a lady who was supposed to labor under a polypus in the womb4 ,she had been married six years1 but had no offspring4 ,on seeing her ,i suggested1 from certain peculiarities in her appearance and manner1 that possibly she might be pregnant4 ,the suggestion was met with a smile1 particularly by the medical attendant who was present1 and ,i was told that there was no sign of such a thing1 and moreover it could not be1 for she had never stopped menstruating1 nor was there the slightest change in the breasts1 nor any disturbance in the stomach1 mind1 or feelings4 ,on making the usual examination however1 ,i felt fully convinced ,i was right1 and told them so1 but my opinion had no other effect than to induce them not to interfere for a time4 ,they had been talking of an operation immediately4 ,she still continued to menstruate for three months after1 but in six weeks from her last period was safely delivered1 without assistance1 of a very fine living child4 ,no part of the body had undergone any material change1 except the abdomen1 though many of the usual changes occurred after delivery4 ,in this case the delay probably saved the lives of both mother and child1 and deeply grateful they all were for the escape4 ,in my work on the ,diseases of ,woman many fatal cases will be found of pregnant females who have been killed from mistakes of this kind1 owing to a blind reliance on such uncertain signs4 ,disturbance of the ,digestive ,functions4--,it is very seldom1 indeed1 that pregnancy does not produce more or less disturbance in these functions1 though it must be remarked that marriage also does the same sometimes1 even without conception4 ,these disturbances are generally manifested by loss of appetite2 sickness1 particularly in the morning2 vomiting1 and depraved taste2 the individual frequently taking a fancy to the most extraordinary articles1 and making herself extremely unhappy if she cannot obtain them4 ,thus some have eaten flies1 spiders1 mice1 and other living things1 and others again have regaled themselves upon charcoal1 chalk1 slate pencils1 and even earth or ashes4 ,such freaks are called longings1 and it is thought highly improper not to indulge them1 which is certainly right when they are for articles not positively injurious2 but ,i have known this notion carried to a very injurious and absurd extent4 ,there is no doubt but these vagaries of the stomach arise1 mainly1 from its sympathy with the uterus1 but it is highly probable that they are often exaggerated1 and frequently even produced1 by a morbid state of the sensibilities1 and by vacuity of mind4 ,the tendency to imitation also1 so strong in most females1 often leads to the same result4 ,a young female who is declared to be1 or who fancies herself1 pregnant1 listens eagerly to all that is said about that interesting state1 by older acquaintances1 and when told that they always longed1 immediately begins to long also4 ,i have known young persons considerably advanced in gestation1 who had never longed at all before1 do so immediately after a conversation of this kind4 ,it must be remembered however1 that the sympathies of the digestive organs with the womb are very strong1 and that the appetite and taste are frequently rendered very capricious at this time1 so that the female really likes or dislikes many things that she did not before2 but still ,i feel convinced that the absurd ways in which this caprice exhibits itself1 are often owing to the causes ,i have stated4 ,the wondering ignorance1 in which most females are kept1 makes them disposed to be led away by a morbid imagination1 and constantly liable to be imposed upon by silly and erroneous statements1 which they of course implicitly believe4 ,these longings are always the strangest1 and most frequently met with1 among the most uninformed and unthinking1 though they are occasionally met with under all circumstances4 ,as a sign of pregnancy this longing is not much to be relied upon alone1 because marriage alone often produces it1 and so do many uterine derangements4 ,usually all these disturbances disappear by the third or fourth month1 the appetite becomes regular1 and sometimes even voracious1 and the digestion improves1 so that the individual may become quite fat1 though previously she was very thin4 ,some suffer from constipation1 and others from diarrha1 but this is more rare4 ,nervous ,derangements4--,the changes produced in the minds and feelings of pregnant females are sometimes of the most extraordinary character4 ,individuals who possess1 ordinarily1 the most agreeable tempers1 and the most amiable dispositions1 will become peevish and fretful1 and often even violently passionate and malicious4 ,some have even been known to have a disposition to commit various crimes1 of which they had the greatest horror in their natural state4 ,others1 on the contrary1 who are usually ill-tempered and unhappy1 attain a charming tenderness of manner1 and a most pleasing serenity of mind4 ,their likings and dislikings also change very much1 so that their most valued friends will become hateful to them1 and those whom they habitually dislike will seem endowed with every loveable quality4 ,some will become perfect misanthropes1 or weep and fret without intermission1 while others will exhibit the most reckless and boisterous gaiety4 ,i have known some much disposed to study while pregnant1 and others who would draw1 or paint1 most excellently1 though at other times they were but indifferent artists4 ,in short1 it is impossible to denote half the singular changes of this kind that are thus produced4 ,suffice it to say that1 when well marked1 they are strong presumptive signs of pregnancy1 especially when coming in connection with other evidences4 ,it must be remembered however1 that hysteria1 and some other uterine diseases1 are often accompanied by similar changes4 ,alteration in the appearance of the ,breast4--,the direct1 and sympathetic connection between the womb and the breast is so great that pregnancy usually causes corresponding changes in both1 though not always4 ,in most cases however1 the breasts swell1 and become painful4 ,the nipple becomes elevated1 and the circle around it assumes a dark brown color1 and is dotted with small tubercles1 from which a thin watery liquor may often be pressed4 ,the nipple will also enlarge1 or become erect on being rubbed1 and1 as gestation advances1 milk may be forced from it4 ,most of these signs however1 may be wanting in pregnancy1 and may arise independent of it4 ,chronic inflammation1 and other diseases of the womb1 will frequently produce them1 as may be seen in my ,diseases of ,woman4 ,marriage alone frequently causes such symptoms1 particularly in certain temperaments1 and deranged menstruation will frequently produce them4 ,the alteration in the color of the areola1 or circle round the nipple1 is a sign much relied upon by some1 but is frequently a deceptive one1 merely from want of close observation4 ,i have known many females1 though frequently mothers1 whose breasts always retained the bright rosy color they had previous to marriage2 and ,i have known young unmarried females with the breasts quite dark4 ,the peculiar hue that arises from pregnancy however1 is different from anything ,i ever saw in non-pregnant females2 and1 though not always to be met with1 is1 in my opinion1 an infallible sign when present4 ,the celebrated ,john ,hunter regarded this sign as an unmistakeable one1 and he gave a remarkable instance of it in his lectures4 ,in making a post mortem examination of the body of a young female1 he observed this peculiar color1 and at once proclaimed her pregnant1 though the hymen was unbroken4 ,on dissection he was found to be correct--she was four months advanced4 ,if this sign were constant1 pregnancy could nearly always be ascertained1 but frequently it does not appear4 ,the peculiar color must be seen to be recognized1 as it cannot be accurately described2 perhaps the nearest approach to it is the shell of a fresh ripe chestnut1 but it is much darker in some than in others4 ,the dark circle is nearly always more elevated than the rest of the breast1 as may be seen by taking a profile view4 ,illustration3 ,,plate ,,xiii4 ,view of the ,breast about the ,fourth ,month4--a4 a4 ,the ,breast4--b4 ,the ,nipple4--c4 ,the ,areola1 or part which becomes brown2 it is elevated above the rest of the ,breast1 as may be seen4--d4 d4 ,the little ,tubercles4 ,most frequently the breasts do not swell1 nor the areola change color1 nor the tubercles appear1 till about the fourth month1 and frequently much later4 ,all these changes in the breast are also liable to become more or less permanent1 after the first pregnancy1 so that they are of much less service1 and less to be depended upon1 in all succeeding ones4 ,they also remain1 with most females1 during nursing1 and are therefore not available in those who conceive while they are nursing4 ,on the whole however1 these signs1 especially in those not previously pregnant1 may be pretty confidently relied upon1 and will seldom deceive an experienced observer4 ,the secretion of milk is1 by most persons1 considered a positive sign of pregnancy1 but it is not so1 for it sometimes takes place in young girls merely from the establishment of puberty1 and in some females it always occurs at each monthly period1 though they have never been pregnant4 ,instances have been known of women nursing other people's children though they had never conceived themselves4 ,miscellaneous signs4--,there are a few other presumptive signs1 not easily classified1 some of which are of value1 while others are so uncertain1 or so little available1 as to be almost worthless4 ,all these however1 it is necessary to point out1 because some of them may be made use of in cases where the more ordinary signs are absent4 ,in the unimpregnated state the mucus membrane1 which lines the ,vagina1 is of a bright rose color1 but in nearly every case of pregnancy it changes to a bluish1 or purplish hue4 ,i do not recollect a single instance1 in the course of my own observation1 in which this change has not occurred1 and the same statement is made by several eminent authors4 ,it is true that in some young females the mucus lining is naturally darker than it is in others1 but1 like the areola round the nipple1 this natural tinge is not like that produced by pregnancy4 ,it is of course impossible to say whether this blue tinge is always produced1 though ,i am inclined to think it is1 and ,i should certainly consider it an almost infallible sign when present4 ,parent ,duchatelet states that he was present when ,m4 ,jacquemin proved this1 without a single failure1 in four thousand five hundred cases4 ,many females are also warned of their condition by pains in various parts of their bodies1 the most frequent of which is one felt at the top of the head4 ,some always have palpitation at the heart1 and others experience a singular kind of fluttering in the womb4 ,many medical men rely altogether on certain peculiarities in the urine1 and as this sign is really a valuable one1 in some cases1 ,i will describe the mode of examination fully4 ,the urine is put in a clean vessel1 and allowed to stand perfectly still4 ,in a short time1 varying from two to six days1 a number of little opaque bodies begin to rise from the bottom1 like flocks of cotton1 which unite together at the top into a thin but firm layer1 or pellicle1 like cream on the top of milk4 ,this layer is frequently so consistent that it can almost be raised out of the vessel1 by taking hold of one edge1 and may be easily drawn out by passing the finger under it4 ,this substance is called kyestein4 ,it is of a whitish color1 semi-transparent1 and looks as if it were partly crystalized4 ,after a few days1 if left undisturbed1 the urine becomes thick and muddy1 and the pellicle of kyestein breaks up and falls to the bottom4 ,according to the experience of many medical men1 and so far as ,i have seen myself1 this peculiar substance is always to be found in the urine of pregnant females1 after the first month1 and frequently even earlier4 ,sometimes a substance similar to it is observed in the urine of those not pregnant1 but there is1 in most of these cases1 sufficient difference between them to enable any one1 who has seen both1 to distinguish one from the other4 ,the only time1 except during gestation1 when real kyestein appears to be formed1 is while the milk is being secreted and not freely discharged4 ,thus it may often be found when the female is weaning1 and1 some writers assure us1 in some cases during the whole period of nursing4 ,on the whole this sign is a very valuable one1 and may be much relied upon4 ,the changes in the pulse1 on which some persons rely1 are of no value whatever as a sign of pregnancy1 since they are no more frequent1 and not at all different1 so far as ,i have seen1 from what ordinarily occur from other causes4 ,the development of the abdomen1 though an invariable accompaniment of pregnancy1 is by no means a certain sign of it1 since it may be produced by other causes2 and besides1 it is sometimes but little to be observed till a late period4 ,the peculiar manner of the development however1 is usually somewhat different from that produced by tumors1 and other diseases4 ,very often the abdomen will be tolerably large by the second month1 and then again become so much smaller that the female will think she is certainly not pregnant4 ,this is owing chiefly to flatulence1 produced by digestive disturbance during the early periods1 but which afterwards subsides4 ,in a short time however1 the uterus not only enlarges more1 but rises1 and the development becomes permanent4 ,this circumstance of there being often two developments has deceived many1 and ,i have known females declared to be not pregnant1 simply because the development of the abdomen went down1 who1 in a short time after1 exhibited unequivocal evidences of being in that condition4 ,the first development1 or swelling1 is merely similar to what often arises from indigestion1 and other causes1 and is therefore no sign of pregnancy2 but the second development is accompanied by other changes1 besides being more permanent4 ,the linea alba1 or white line1 which may be seen extending from the navel to the pubis1 in the ordinary state1 becomes much darker1 the skin of the abdomen wrinkles1 and the umbilicus1 or navel1 becomes prominent4 ,swelling of the eyelids1 and puffing of the face1 are experienced by some females1 but are not very general1 and so frequently result from other causes that they are of little value as evidences in this case4 ,this1 ,i believe1 comprises all the presumptive signs of ,pregnancy that are worthy of notice4 ,some of them are valuable and may be depended upon1 particularly the presence of kyestein in the urine1 which may almost be called a certain sign4 ,others of them are of little value alone1 but are useful in the way of corroboration4 ,the more there are of them observed together1 in any case1 of course the more grounds there are for the presumption that pregnancy exists1 and the reverse4 ,it must be carefully remembered however1 that these presumptive signs are precisely those most likely to be produced by other causes1 particularly by marriage only2 they must therefore be well weighed1 and unless very numerous1 or very distinctly marked1 must not be regarded as conclusive4 ,as already remarked1 it is only during the first three months that most of these presumptive signs are taken much notice of2 after that we have others that can be more depended upon1 and which will be described in the succeeding articles4 ,,probable ,,signs4 ,end of the third month4--,the probable signs now to be described are seldom recognized before this time1 and not generally with distinctness till a still later period4 ,they chiefly consist of certain changes in the form1 development1 and position of different parts of the uterus1 to ascertain which requires an internal examination4 ,these changes are not observable till the end of the third month1 previous to which time we cannot be certain that the womb has really increased beyond its normal size4 ,and even then1 when the increase is obvious1 we cannot tell how it has been produced2 it is not till a much later period1 till five or six1 or even seven months are elapsed1 that pregnancy can be ascertained with anything like certainty4 ,the changes to be noticed are in the form1 and size1 of the neck and body of the womb1 and in its mouth1 and also in the weight of the whole organ4 ,no one1 of course1 can expect to recognize these changes who is not acquainted with the parts in the unimpregnated state1 both in the virgin and in those who have borne children4 ,the mode of conducting the requisite examination is1 by introducing the index finger of the right hand1 covered with oil or mucilage1 into the ,vagina1 and then carrying it upwards till it reaches the ,os ,tinc4 ,by means of this finger the position and length of the neck of the womb are ascertained1 and also the state of its mouth1 whether it is opened or closed1 and to what extent4 ,if it be then placed at the top of the neck1 on the under side1 and the other hand upon the fundus of the womb externally1 and pressing firmly upon it1 the organ is enclosed as it were between the two hands1 so that its size and form may be pretty accurately ascertained1 and also its degree of firmness1 by which a judgment may be formed as to whether it is occupied by any solid body1 or fluid1 or whether it is empty4 ,in addition to this a pretty accurate estimate may be made of its comparative weight1 by balancing1 and raising it up on the finger4 ,this is called by the ,french ,ballotment1 and1 as will be shown further on1 is a valuable means1 at certain stages1 of ascertaining pregnancy4--7,see ,plate ,,xvi47 ,the female may be examined either standing or lying down1 though the recumbent position is best1 except in certain displacements of the womb1 when it is most likely to be thrown into a position in which the neck can easily be reached by the female standing4 ,the position of the neck is very different in many of these displacements1 and during pregnancy1 to what it is in the ordinary state1 and a person not acquainted with these changes might frequently be much puzzled to find it4 ,as we have already remarked1 also1 there are certain differences between those who have had children and those who have not4 ,the following three diagrams represent the changes just spoken of at three different periods3-- ,,plate ,,xiv4 ,figure #a1 represents the form and size of the body1 neck1 and mouth of the ,womb1 at about the third month4 ,figure #b1 the same at about the seventh month4 ,figure #c1 the same at the ninth month4 ,the references are the same in all4 a4 ,the ,neck of the ,womb4--b4 b4 ,the ,body of the ,womb4--c4 ,the ,os ,tinc1 or ,mouth of the ,womb4--d4 d4 ,the cut edges of the ,vagina4 ,illustration3 ,fig4 #a4 ,fig4 #b4 ,fig4 #c4 ,plate ,,xiv4 ,the form and size of the body1 neck1 and mouth of the ,womb1 at about the third1 seventh and ninth months4 ,it will readily be seen by these diagrams that the alterations in the neck and mouth of the womb are very marked1 and of a character easily to be ascertained by the touch4 ,these three should be compared with the section of the womb in ,plate ,,iv1 which represents it in the unimpregnated state4 ,the difference between those who have borne children1 and those who have not1 is well represented in ,plate ,,xv1--the drawings being one-third of the natural size1 and representing the appearance at about three months4 ,illustration3 ,,plate ,,xv4 ,primipara1 or the first ,pregnancy4 ,woman who has borne children before4 a4 a4 ,the neck of the ,womb4--b4 b4 b4 ,the body of the ,womb4--c4 ,the ,os ,tinc1 or mouth of the ,womb4--d4 d4 ,the cut edges of the ,vagina4--e4 ,the ,ftus4--f4 f4 ,the ,fallopian ,tubes1 ,ovaries1 and ,round ,ligaments4--g4 ,the ,placenta4 ,most of the changes produced can be readily distinguished by the finger1 after seeing this representation1 and making a proper comparison between it and the natural state in ,plate ,,iv4 ,the ,neck is not much enlarged at this period1 but its lower part is somewhat soft to the feeling4 ,the ,os ,tinc is more rounded than in the unimpregnated state1 particularly in the ,primipara1 in whom in fact it is nearly circular1 the lips being quite smooth and closed4 ,in the female who has already borne children it is somewhat open1 so that the finger may often be introduced2 and the lips feel rough1 owing to scars and laceration in previous deliveries4 ,it is also larger altogether1 and softer1 than in the primipara4 ,the whole length of the neck at this stage is about two inches4 ,the body of the uterus1 when pressed between the two hands1 will be found much larger than ordinary1 and more round1 and it will feel heavy when pushed up by the finger4 ,in regard to the precise value of these probable signs1 it can only be said1 when they are observed1 that it is certain that the womb is enlarged1 and most probably from pregnancy4 ,but at the same time it must be remembered that several diseases1 and particularly suppressed and irregular menstruation1 or the development of tumors and polypi1 will effect very similar changes1 and that it is not always possible to say whether they arise from these abnormal growths or from pregnancy1 though it can generally be done4 ,but though we cannot1 in every case1 say when these signs exist1 that the female must be pregnant1 we can nearly always say1 when they do not exist1 that she cannot be so1 particularly if the other usual signs are absent4 ,end of the fourth month4--,by this time the neck has become a little shorter still1 and the mouth more open1 but on the whole there is not much change to be felt internally4 ,the body of the womb however1 has now ascended above the superior strait of the ,pelvis1 and begins permanently to enlarge the ,abdomen4 ,it may be distinctly felt between the two hands1 like a firm round ball1 somewhat elastic1 and resisting when pressed4 ,this is the period when the motions of the ftus are usually felt first1 and these motions1 with the ascension of the womb1 are sometimes experienced very suddenly1 so as to alarm the female1 and produce certain curious sensations1 with much nervous derangement4 ,this is called quickening1 and1 with some persons1 is always so well marked as to indicate not only their condition1 but the very period1 with great precision4 ,many however1 never experience anything at all peculiar at this time4 ,it is customary for the medical attendant1 as a means of making the child move1 to put his hand first in cold water1 and then over the fundus of the uterus2 the sensation of cold thus conveyed usually causing it to move immediately4 ,great care must be taken however1 that other motions be not mistaken for those of the child1 an error not at all uncommon4 ,many a female1 and many a medical man also1 has been deceived in this way1 particularly in cases of uterine or ovarian dropsy1 and tumor1 and even in ordinary flatulence and hysteria4 ,females who much desire offspring frequently deceive themselves in this way1 and it is sometimes next to impossible to convince them of their error4 ,some women possess the power of imitating the movements of the child1 with great exactness2 and instances have been known where they have successfully imposed1 both on their friends and medical attendants1 for a long time1 in this way4 ,mr4 ,dubois mentions instances of females who possessed this extraordinary power1 and who1 though not pregnant1 used to present themselves to his class1 for the pupils to ascertain the motions of the child4 ,in short1 this sign must not be too much relied upon1 nor too confidently expected1 for many females observe no ftal motions at all till the sixth or seventh month1 and even then very indistinctly4 ,sometimes also1 after having been distinctly felt1 these motions will altogether stop for a long time1 and then appear again4 ,at this time however1 ,ballotment can begin to be practised1 though it is not quite so certain as at a month later4 ,the manner of performing this important manipulation has already been partly described1 and by examining ,plate ,,xvi1 and attending to the following remarks1 it may be readily understood and practised4 ,,plate ,,xvi4 ,this ,plate represents the mode of performing the ,ballotment1 to detect pregnancy4 ,the outline of the figure is the same as in ,plate ,i1 and most of the organs are lettered the same4 ,the index finger of the right hand is passed into the ,vagina till it touches the body of the ,womb1 the neck being thrown back1 owing to the tilting of the ,fundus forward4 ,the left hand is pressed firmly upon the ,abdomen1 just over the pubic bone4 #a1 ,is the ,ftus4--#b1 ,the ,placenta1 connected with the ,ftus by the cord4--#c1 ,is the index finger of the right hand1 within the ,vagina4--#d1 ,is the left hand4 ,the development of the ,womb1 and the change in its position1 are very well represented in the ,plate1 and so are the alterations in some of the other organs4 ,the manner in which the ,bladder1 ,a1 is pressed out of its usual shape and size1 may be seen by comparing this with ,plate ,i4 ,the shortening of the ,vagina1 and the expansion of its upper part1 are also equally obvious1 and the manner in which the mouth of the ,womb is thrown back against the ,rectum4 ,illustration3 ,plate ,,xvi4 ,this ,plate represents the mode of performing the ,ballotment1 to detect pregnancy4 ,the outline of the figure is the same as in ,plate ,i1 and most of the organs are lettered the same4 ,when the right hand finger 7#a ,plate ,,xvi17 is carried to the top of the ,vagina1 it meets with a round soft tumor1 which is the head of the child felt through the walls of the womb4 ,as soon as this is distinctly felt1 the finger must be withdrawn a little1 and then pushed suddenly against the tumor with a jerk2 this will displace the ftus1 and cause it to rise in the liquor amnii towards the ,fundus1 so that the round tumor will have disappeared4 ,in a few moments it will sink down and may be again felt1 and again displaced in the same manner4 ,this is called the ,ballotment1 or balancing it on the end of the finger4 ,the sensation conveyed on touching the ,ftus1 and when it rises after being pushed1 are so peculiar that they are not likely to be overlooked1 or mistaken for anything else1 after being once experienced4 ,the jerk is not required to be at all violent1 and had better be made at first very slight1 as it can easily be repeated a little more forcibly if the tumor does not rise at first4 ,some practitioners practice the ,ballotment in this way1 using the one hand only2 but others place the left hand also on the ,abdomen1 7#d ,plate ,,xvi17 at the same time1 and immediately after jerking upwards with the right hand1 they suddenly depress the ,abdomen1 just over the pubes1 with the fingers of the left1 so as to send the ,ftus down again more quickly and more forcibly4 ,this is seldom needed1 but if the first way does not succeed the two hands may be tried4 ,a species of ballotment may even be practised externally1 in the following way3--,the fingers of the right hand are placed on the ,abdomen1 just over the fundus of the womb1 like the left hand in ,plate ,,xvi1 and a smart jerk is given downwards and backwards1 several times in quick succession4 ,this also displaces the ,ftus1 which may be distinctly felt to float away1 each time the percussion is made4 ,no one can mistake this peculiar motion who has once felt it4 ,sometimes one of these manuvres will succeed when the other fails1 so that it is well to practise them all4 ,they may be performed with the female either standing or lying down1 and will sometimes succeed one way when they will not the other4 ,it is requisite to remember that in presentations of the breech1 or trunk1 the ballotment may not succeed as well as when the head presents2 or it may even fail altogether1 so that when it is unsuccessful we must not immediately conclude there is no pregnancy4 ,tumors in the womb1 stone in the bladder1 and various uterine displacements1 may also create uncertainty1 or cause failure1 but these accidents are rarely met with1 and only interfere materially at an early stage2 afterwards ballotment can be practised notwithstanding them1 or auscultation may be resorted to4 ,in short1 this mode of detecting pregnancy is one of the most certain1 and the most generally applicable1 that we possess4 ,end of the fifth month4--,at this time the ,uterus has increased considerably in size1 and has ascended so high in the ,abdomen that the ,fundus is level with the umbilicus1 or navel1 in a first pregnancy1 though somewhat lower in those who have borne children before4 ,this rising of the womb makes the ,vagina longer1 and brings the neck of the womb nearer to its centre4 ,in the previous stage the neck was thrown so far back that it was difficult to reach1 but now it is much more favorably situated1 though much higher4 ,its substance is softer than before1 and the two lips are nearly on a level1 and somewhat opened1 particularly in those who have borne children before4 ,indeed1 in them the point of the finger may be introduced1 as seen below3-- ,illustration3 ,,plate ,,xvii4 ,neck of the ,womb in a first ,pregnancy1 very slightly opened4 ,neck of the ,womb in a female who has borne children before1 showing how it admits of the introduction of the finger4 ,this is at the end of the ,fifth ,month1 and the drawings are about one-third of the natural size4 ,ballotment is now much more easily practised1 and is more conclusive4 ,a new sign is also to be distinguished1 by which we are furnished with another valuable means of detecting pregnancy4 ,the child's heart begins to beat so strongly1 and its circulation is so vigorous1 that the sound of it can be heard externally4 ,the same means are taken to ascertain this that are used in sounding the chest of an adult4 ,if the ear be placed on the ,abdomen1 over the womb1 the beating of the ftal heart may be heard quite plainly2 and if the stethoscope be used it will be still more distinct4 ,this practice is called ,auscultation4 ,the signs furnished by it are certainly of the greatest value1 and frequently enable us to detect pregnancy with unerring certainty4 ,indeed1 not only can we tell by them that a child is in the womb1 but often even the very position in which it lies1 and whether there be twins1 or more4 ,this is done by noting where the heart is situated1 by the sound1 and whether the beating is single or double4 ,the nature of these sounds1 and the manner of detecting them1 require to be carefully explained4 ,if the person wishing to notice this sign is not already familiar with the beating of the adult heart1 he had better become so first4 ,the ear should be placed on the left side of a grown up person1 on the skin1 just beneath the breast1 and held very still4 ,the heart will then be heard to beat very distinctly1 there being two sounds1 a long one and a short one1 alternating with each other4 ,when this has been listened to for some time1 the ear will be able to catch any similar sound1 and the auscultation may then be practised to detect pregnancy4 ,the ear must be placed on the ,abdomen1 about midway between the ,pubes and the umbilicus1 and towards the left side4 ,no weight should be borne on the body1 but the ear must be laid sufficiently close to exclude all external sounds1 and no motion should take place1 particularly with the clothes4 ,if the sound be not heard in the position first assumed1 move a little1 in different directions1 till that point is attained where it is most distinct4 ,it can scarcely fail to be heard1 with ordinary care4 ,a practised ear will sometimes distinguish the sound as early as the fourth month1 but generally it cannot be heard before the end of the fifth1 or even till the sixth month4 ,there are several sounds that may either be mistaken for it1 or that may confuse the ear4 ,the beating of the mother's heart will sometimes be very distinct1 as far as the lower part of the ,abdomen1 but it is much slower2 the child's heart throbbing nearly twice as fast4 ,the movements of the ,ftus1 and the rumbling of the intestines1 will also interfere2 but when once the proper sound has been caught it may be kept independently of all these4 ,the manner in which the child lies in the womb will determine where the heart shall be opposite1 and as its position frequently varies1 both in different individuals1 and at different periods1 in the same person1 the sound must be sought for at several points1 till the right one is found4 ,the most usual position will be seen in several of our plates1 and they will give sufficient indication to enable almost any one to practise this mode of detection with success4 ,during the early months the child moves about a good deal1 so that the sound may be heard one day in one place1 and the next in another4 ,about the seventh month however1 it becomes more fixed1 so that the place of the heart can be pretty certainly ascertained1 and thus the position of the whole body is made out1 whether the head is downwards or upward1 and a tolerable idea can be formed even as to the direction of each part4 ,many persons have failed in their attempts to hear the ,ftal pulsation1 but ,i cannot but think it must have been either from inattention1 or from not being acquainted with the sound of the heart at all4 ,i never recollect an instance when ,i could not do so1 at the proper time4 ,m4 ,chailly says he does not hesitate to affirm that in every instance they can be detected2 and ,m4 ,p4 ,dubois distinctly heard them in one hundred and eighty-five females1 out of one hundred and ninety-five1 in the other ten the child being probably dead4 ,indeed1 the absence of this sound is the most certain sign of the death of the ,ftus1 as its existence is of its being alive2 and medical men now tell whether the child is dead or not by these very means4 ,in conducting the auscultation the female must recline1 and keep as still as possible1 breathing low4 ,the ,abdomen may be covered with a single thin garment1 if absolutely insisted upon2 but the judgment will be so much the more uncertain1 owing both to the deadening of the sound and to the friction of the material4 ,the experimenter must also recollect that if the head be held down too long1 the blood will rush to it1 and cause a humming in the ears1 which will confuse him2 it will therefore be better if the bed be high4 ,it is always best to use the stethoscope1 as it covers only a small space1 conveys the sound more directly1 and shuts out external noises more effectually4 ,this instrument is extremely simple1 consisting merely of a tube of wood1 glass1 metal1 gum elastic1 or almost any other material4 ,one end should be expanded a little1 like a bell1 and the other made small1 so as to fit close in the ear--the large end being placed on the ,abdomen4 ,it may be about a foot in length1 though a little shorter or longer will not make much difference4 ,i once used a child's tin trumpet1 having no regular stethoscope with me1 and succeeded with it perfectly4 ,the large end should be pressed on the ,abdomen1 and the smaller one into the ear1 sufficiently close to shut out all other sounds but those coming from the body4 ,this is the same instrument that the lungs are sounded with1 when we want to judge of their action and condition4 ,this is an invaluable means of detecting pregnancy2 in fact1 at the proper time1 and with due care1 it may be said to be certain4 ,end of the sixth month4--,this is the period when1 according to the law1 the child can live4 ,there are no new signs at this time1 but those previously noticed are now more distinct4 ,the neck of the womb is still softer and shorter1 and the finger can penetrate further in the passage than before4 ,the fundus of the womb is now above the umbilicus1 in primipara1 though not so high in those who have borne children2 and the bladder is above the superior strait4 ,ballotment can now be practised with certainty1 the falling and rising of the ,ftus being very distinct4 ,auscultation also becomes more positive1 the sounds being louder and more easily ascertained4 ,end of the seventh month4--,the fundus of the womb has now risen still higher1 and the ,bladder is pushed completely above the upper strait1 so that the whole length of the ,urethra lies behind the pubic bone4 ,it is then much pressed upon and swollen1 and being much longer1 and bent out of its usual course1 the urine is often passed with difficulty1 and the catheter can scarcely be introduced4 ,the upper part of the ,womb now lies over towards the right side of the body1 very evidently4 ,this direction is nearly constant1 in all females1 but the reason for it is not known4 ,there have been many theories to account for the peculiarity1 but none of them are either so plausible1 or so well supported by facts1 as to be generally adopted4 ,the upper part of the ,womb being tilted to the right side1 the neck of course points to the left1 and backwards4 ,it is now very short1 even in primipara1 but in those who have borne children it is scarcely to be distinguished at all4 ,the finger may now be introduced1 even in primipara1 half way up the neck2 and in others it will reach even into the uterine cavity4 ,illustration3 ,,plate ,,xviii4 ,first child4 ,woman who has borne children4 ,the neck of the ,womb in a first pregnancy1 and in a female who has borne children before1 at the end of the seventh month4 ,the part below the lower line here1 shows that part of the neck which is contained in the ,vagina4 ,it will easily be seen how much shorter this part is1 and how much more open the passage is1 in the female who has borne children1 than in a first pregnancy4 ,ballotment and ,auscultation both1 now afford unmistakeable evidences as to the condition of the patient4 ,end of the eighth month4--,by referring to the preceding ,plates1 it will be seen that the part of the neck of the ,womb above the ,vagina1 which is placed between the two dotted cross lines1 remains almost unchanged1 while the part within the ,vagina1 or that below the lowest line1 becomes less and less1 till at this time1 in those who have borne children1 it can scarcely be felt at all2 and even in a primipara it is merely like a small tubercle4 ,about this time however1 the upper part of the neck begins to shorten also1 though that is not so obvious1 and therefore not so useful for our present purpose4 ,on making an examination1 the mouth of the ,womb itself may now be felt1 at the upper part of the ,vagina1 and far back4 ,it is however1 very difficult to reach1 on account of its position4 ,the finger will now pass1 in those who have previously borne children1 into the cavity of the ,womb itself1 but in others it will scarcely reach so far4 ,the linea alba becomes darker at this period1 and so does the areola around the nipple4 ,certain peculiar marks also appear on the ,abdomen1 and upper part of the thighs1 almost like the pits from small pox4 ,they are usually diamond shaped1 slightly depressed1 and dark in color4 ,they appear to be owing to the over stretching of some of the parts under the cuticle1 and which give way in consequence4 ,in first pregnancies1 and in those who enlarge very much1 these marks are sometimes very numerous1 and remain for a long time after delivery1 sometimes even they never disappear4 ,as signs of pregnancy however1 they are but of little value1 because they are often produced by other causes that distend the ,womb4 ,none of these presumptive signs are now needed1 and therefore they are of little consequence1 because there are others more certain4 ,the motions of the child itself can now be generally both felt and seen1 and an experienced observer may even predicate from them1 with tolerable certainty1 the position in which it lies4 ,ballotment1 by one hand on the ,abdomen1 may still be practised with success2 but in the ,vagina it is difficult1 because the ,ftus is both more fixed and heavier4 ,auscultation is now the surest dependence however1 and may be advantageously resorted to also as a means of determining beforehand the position of the child4 ,this may be done even a month earlier1 but not so certainly as now4 ,to understand how this important point is determined1 it is only necessary to recollect1 as will be very evident1 that the pulsation will be heard the loudest immediately over the heart2 and as we know the form and general size of the ,ftus1 and the manner in which it usually lies1 it becomes possible1 when the position of its heart is discovered1 to trace out1 from that1 the position of every other part4 ,this will be evident by referring to ,plates ,,xix1 ,,xx1 and ,,xxi4 ,it will then be seen that1 if a line be drawn across the middle of the ,abdomen1 the heart will be above that line when the breech presents1 and below it when the head presents1 and on the right or left side1 as the case may be1 in each position4 ,in case of twins there will be two pulsations1 and they so much interfere with each other that it is difficult to distinguish either4 ,the two children being generally disposed with the head of one to the heels of the other1 one heart will be above the line1 and the other below1 on opposite sides1 as shown in ,plate ,,xxii4 ,,plate ,,xix4 ,this ,plate represents the ,ftus in the most usual position1 the head downwards1 and the back of it presenting to the left side4 ,the black spot a1 shows the situation of the heart2 usually immediately under that part where the sound is heard the strongest4--,it is below the line4 ,illustration3 ,plate ,,xix4 ,this ,plate represents the ,ftus in the most usual position1 the head downwards1 and the back of it presenting to the left side4 ,,plate ,,xx4 ,this ,plate represents the ,ftus in the next most frequent position1 the head downwards1 but the back of it presenting to the right side4 ,the black spot a1 shows the situation of the heart as in the previous ,plate4 ,it is now below the line1 as before1 but on the opposite side4 ,illustration3 ,plate ,,xx4 ,this ,plate represents the ,ftus in the next most frequent position1 the head downwards1 but the back of it presenting to the right side4 ,,plate ,,xxi4 ,this ,plate shows the position of the ,ftus in a presentation of the ,pelvis1 or breech1 which happens1 comparatively1 but seldom4 ,the black spot a1 denotes the situation of the heart1 which is here above the line1 instead of below4 ,in this case1 as in the others1 the heart may be on either side of the body1 according as the child faces1 but always above the line4 ,illustration3 ,plate ,,xxi4 ,this ,plate shows the position of the ,ftus in a presentation of the ,pelvis1 or breech1 which happens1 comparatively1 but seldom4 ,,plate ,,xxii4 ,this represents the position of ,twins1 as most usually observed1 one having a head presentation1 and the other a breech4 ,the black spot a1 on both1 denotes the position of the heart1 which in one case is above the line1 and in the other below4 ,the head however1 may be on the right side instead of the left1 and so reverse the position of the two hearts1 but this is very seldom the case4 ,when there are more than two1 the confusion and uncertainty becomes still greater4 ,illustration3 ,plate ,,xxii4 ,this represents the position of ,twins1 as most usually observed1 one having a head presentation1 and the other a breech4 ,at this period the signs previously observed become more distinct1 but there are few new ones4 ,the external lips sometimes swell1 and the breathing becomes more difficult1 owing to pressure on the diaphragm4 ,the trouble with the urine is also apt to increase1 and little mucus tubercles1 like pimples1 occasionally form around the ,os ,tinc1 and on the upper part of the ,vagina4 ,end of the ninth month4--,there is but little difference between this and the previous period4 ,the mouth of the ,uterus is more open1 and1 in those who have had children1 the finger will pass directly into the ,womb1 and feel the child1 but in primipara there is still a small portion of the neck left4 ,illustration3 ,,plate ,,xxiii4 ,fig4 #a4 ,the neck of the ,womb1 at near the end of nine months in a primipara4 ,fig4 #b4 ,the neck of the ,womb1 at near the end of nine months1 in a woman who has previously borne children4 ,ballotment is now more obscure than before1 as the ,ftus is very heavy1 and quite low down1 and pretty firmly fixed4 ,auscultation is distinct enough1 but not more so than at the previous period4 ,the swelling of the lips1 and of the veins of the legs1 may increase1 and so may the difficulty with the urine2 but the breathing generally becomes easier1 owing to the ,womb having descended a little1 and so pressing the diaphragm less4 ,these comprise all the signs and indications of pregnancy that possess any real value4 ,some of them1 at certain times1 and under particular circumstances1 may be called positive2 such as those discovered by ,ballotment and ,auscultation1 and also the presence of ,kyestein in the urine4 ,most of the others merely make it probable that pregnancy exists1 or warrant us in presuming as much4 ,they are not to be depended on implicitly alone1 but when many of them are observed together1 and no other cause can be assigned for their production1 the presumption becomes so well supported as almost to be called a moral certainty4 ,a person of experience1 who is familiar with all these signs1 and with the others produced by disease which resemble them1 will seldom find it difficult to decide2 but still there are cases in which pregnancy proceeds1 even to its termination1 with but few unusual symptoms1 so that both patient and attendant are completely at fault4 ,this however is very rare1 and many eminent authors contend that it is always possible to detect pregnancy1 after the sixth month1 and ,i think so myself1 unless the child be dead1 in which case it will soon be evident in another way4 ,,chapter ,,vi4 ,,duration ,,of ,,pregnancy4 ,the duration of pregnancy1 or the precise term of ,utero ,gestation1 is not fixed4 ,it appears1 from accurate observation1 that there is no absolute period determined by natural laws1 and therefore there is none laid down by human enactments4 ,an approximation can be made1 by taking the average of a number of cases1 and the period of limitation may also be determined in the same way4 ,the most usual period is about nine months1 or from thirty-five to forty weeks1 some females going beyond the thirty-six weeks1 and others not so long4 ,first children are frequently born under the nine months1 and more so than those that come after2 this is a fact not generally known1 and ignorance of it has often given rise to unjust suspicions4 ,it is quite possible for a female to be delivered1 with the child at full period1 in a little over eight months after marriage1 without there being any just grounds whatever for suspecting unfaithfulness4 ,dr4 ,r4 ,lee1 in his ,lectures on the ,theory and ,practice of ,midwifery1 gives the best summary that we have in the language1 of our information on this subject2 ,i will therefore quote from his work1 making such comments and additions as ,i may think advisable4 ,the ,roman law fixed the period of gestation at ten lunar months4 ,the civil code of ,prussia ordains that a child born #cjb days after the death of the husband shall be considered legitimate4 ,by the law of ,france1 the legitimacy of a child cannot be called in question who is born #cjj days after the death or departure of the husband4 ,the laws of ,england declare that the usual period of human utero-gestation is nine calendar months1 or forty weeks2 farther than this they do not fix a definite period3 the law is not exact as to a few days4 ,nine calendar months contain only #bge days1 and only #bgc or #bgb if ,february be included4 ,to fix bastardy on a child in ,scotland1 absence must continue till within six months of the birth1 and a child born after the tenth month is accounted illegitimate4 ,the difficulty of determining the precise time when impregnation takes place in the human subject1 renders it almost impossible1 in any case1 to calculate with absolute certainty the duration of pregnancy4 ,we are1 however1 in possession of a sufficient number of observations to establish the fact that the ordinary period is about forty weeks1 or #bhj days2 but it is certain that it does occasionally exceed or fall short of this period by several days4 ,as we can never be certain of the precise day1 between the periods of menstruation1 when conception occurs--whether it takes place immediately after the last period1 or before the expected period1 or midway between these--it is obvious that all calculations founded upon the cessation of the catamenia must be extremely uncertain4 ,the error of the calculation will be still greater if the catamenia should have appeared1 or a discharge like the catamenia should have occurred once or twice after conception4 ,impregnation most frequently takes place soon after menstruation1 but in others it does not happen till a few days before the expected period2 so that two women may have menstruated at the same time1 and one may have reached the full period three weeks before the other2 and to this extent1 or nearly so1 an opinion founded on the disappearance of the catamenia may be erroneous4 ,calculations of the duration of pregnancy1 founded upon what has been observed to occur after casual intercourse1 or perhaps a single act1 in individuals who can have no motive to tell us what is false1 are likely to be much more correct2 and the conclusion to be drawn from these is1 that labor usually1 but not invariably1 comes on about #bhj days after conception1 a mature child being sometimes born before the expiration of forty weeks1 and at other times not until the forty weeks have been exceeded by several days4 ,a case came under my observation very lately1 in which ,i had no doubt the pregnancy existed #bhg days3 the labor did not take place till #bhg days had elapsed from the departure of the husband of this lady for the ,east ,indies4 ,some women are always delivered before the end of the forty weeks1 according to the usual calculation1 and their children are mature4 ,in the evidence given on the ,gardner ,peerage cause1 the period of utero-gestation was limited1 but not strictly1 by some of the witnesses1 to forty weeks1 or #bhj days2 by others it was extended to #caa days4 ,dr4 ,merriman1 whose opinion is always entitled to much respect1 thinks the greatest number of women complete gestation in the #djth week1 and next to that in the #dast4 ,of #aad pregnancies1 calculated by him from the last day of menstruation1 and in which the children appeared to be mature1 #c deliveries took place at the end of the #cgth week2 #ac in the #chth2 #ad in the #cith2 #cc in the #djth2 #bb in the #dast2 #ae in the #db;d2 #aj in the #dc;d2 and #d in the #ddth week4 ,how long before the expiration of the #dj weeks a child may be born with the power of supporting life has not been determined4 ,where ,i have induced premature labor for distortion of the pelvis before the end of the seventh calendar month from the last menstruation1 ,i have never seen a child reared4 ,the lady of the clergyman in ,fife1 whose case has lately given rise to so much discussion1 was delivered #age days after marriage1 and the child lived five months4 ,to what extent gestation may be protracted in some cases beyond the #bhj days it is very difficult to determine1 and the opinions of the most eminent writers differ upon the subject4 ,i should suspect some great error in the calculation where the period of gestation exceeded #cjj days4 ,but the experiments made on the lower animals prove that there exists in them a great variation between the shortest and the longest gestation2 and it is difficult to comprehend why there should be a difference in this respect in the human species4 ,in a trial which took place in this country1 in the county of ,lancaster1 ,pa41 as reported in the ,medical ,examiner for ,june1 #ahdf1 it was decided that ,gestation may be prolonged to three hundred and thirteen days6 ,the female swore that conception must have taken place on the twenty-third of ,march1 #ahde1 and the child was not born till the thirtieth of ,january1 #ahdf1 or over eleven months4 ,the judge directed the jury to return a verdict in her favor1 and ,i suppose this case establishes a precedent for ,america4 ,in a recent number of the ,medical ,gazette1 ,i find a case reported wherein the period was said to be prolonged still farther4 ,a man left his wife in ,new ,south ,wales1 he coming to ,england1 and twelve months after he left she was delivered of a child1 which she claimed to be legitimate4 ,he denied this however1 and the judge in the ,consistory ,court decided1 without hesitation1 in his favor4 ,taking the medium between these two cases therefore1 it appears to be decided that the extreme limits is somewhere between eleven and twelve months6 ,it must be recollected however1 that both were perfectly arbitrary1 and that1 for anything known positively on the subject1 both may be either right or wrong4 ,except when labor is brought on prematurely by violence1 it always commences at what would have been one of the monthly periods2 or in other words1 after a certain number of full months1 and never at any time between6 ,if therefore a female passes over the ninth month1 she will probably go to the tenth4 ,this has been proved by extensive observation1 and is only another proof of the regular method in which nature conducts all her operations4 ,the same law is also observed in abortions1 which generally take place at one of the months1 unless brought on suddenly by violence4 ,,chapter ,,vii4 ,,period ,,when ,,the ,,child ,,can ,,live4 ,the precise period when the child can live1 if brought into the world1 is not determined1 any more than the time it may remain in the ,womb4 ,some children may be able to live a considerable time before the full period of ,gestation1 and others may not till some time after1 there being a great difference in regard to their development4 ,one may be as fully developed at six1 as another at seven months4 ,the common opinion is that the child cannot live if born before seven months4 ,this1 however1 is incorrect4 ,many instances have been known of births at six months1 and even earlier1 in which the child lived1 and became strong and healthy4 ,van ,swieten mentions the case of one ,fortunio ,liceti1 who was born before the sixth month4 ,he was not larger than the hand1 but grew to the average size1 and lived to be seventy-one years old4 ,dr4 ,gunning ,bedford mentions a similar case1 in his translation of ,chailly's ,midwifery4 ,there are even cases mentioned of children living at five months1 but it must be borne in mind that it is seldom possible to determine the exact period4 ,as a general rule however1 the child does not live till after the seventh month1 though there undoubtedly have been cases where it has lived before the end of the sixth month4 ,the law adopts the medium period1 and declares the child capable of living at the end of the sixth month1 and not before4 ,there is no reason whatever for supposing that it is less likely to live at eight months than at seven1 or that it will not live at all at eight months1 as some do4 ,,section ,,iii4 ,,the ,,form1 ,,size1 ,,and ,,position ,,of ,,the ,f,,tus1 ,,and ,,its ,,appendages1 ,,at ,,full ,,term4 ,,chapter ,,viii4 ,,form ,,and ,,size ,,of ,,the ,f,,tus ,,at ,,full ,,term4 ,,size ,,and ,,form ,,of ,,the ,,body4 ,the average length of the ,ftus1 at full term1 is about twelve inches from the head to the breech1 and about eighteen inches from the head to the feet4 ,its weight varies from five to eight pounds1 perhaps averaging about six1 though some have been born weighing only three pounds1 or less1 and some even as high as twelve4 ,the breadth across the shoulders is about four inches1 and the same across the hips1 but both are so easily compressed that during delivery they only measure about three inches1 or three and a half at most4 ,,size ,,and ,,form ,,of ,,the ,,head4 ,the head is the most important part1 because it is the largest1 and usually present first4 ,it is therefore necessary to describe it fully1 and with special reference to its importance1 in the early stages of labor1 as the part by which the position is usually determined4 ,,plate ,,xxiv4 ,the head is generally divided into the ,cranium1 or that part which contains the brain1 and the ,face4 ,the ,bones of the ,cranium4--,these are seven in number1 viz41 two ,frontal ,bones1 or those forming the forehead2 #a1 #a1 ,figs4 #a and #b1 7,plate ,,xxiv47--,two ,parietal bones1 or those forming the sides of the head2 #b1 #b1 ,figs4 #a and #b4--,the ,occipital bone1 or that forming the back of the head2 #c1 #c1 ,figs4 #a and #b4--;,and two ,temporal bones1 which lie over and between the ear and the eye2 #d1 ,fig4 #b4 ,the ,bones of the ,face4--,these are five in number1 viz41 two ,superior ,maxillary1 or upper jaw bones2 #e1 ,fig4 #b4--,two ,malar1 or cheek bones2 #f1 ,fig4 #b4--;,and one ,inferior ,maxillary1 or lower jaw bone2 #g1 ,fig4 #b4 ,illustration3 ,,the ,f,,tal ,,head4 ,plate ,,xxiv4 ,the head is generally divided into the ,cranium1 or that part which contains the brain1 and the ,face4 ,the bones of the cranium are not closed together1 as they are in the adult1 but are separated to a considerable distance1 in certain parts1 and connected by a strong membrane4 ,these membranous spaces are called ,sutures and ,fontanelles1 and a knowledge of them is absolutely necessary1 as a means of ascertaining the position of the head4 ,the ,sutures4--,the first of these spaces1 which extends from the lowest part of the middle of the forehead to the occipital bone1 is called the ,sagittal ,suture1 or antero posterior ,suture3 ,a1 ,b1 ,c1 ,figs4 #a and #b4 ,it separates the two frontal1 and the two parietal bones4 ,the spaces between the two frontal and the two parietal bones are called the ,frontal ,parietal ,sutures1 o4 o4 ,fig4 #a2 and those between the two parietal bones and the occipital1 l4 l4 ,figs4 #a and #b1 are called the ,lambdoidal ,sutures4 ,the ,fontanelles4--,when the different ,sutures meet at a point1 the membranous space is greater than at other parts1 and is called a ,fontanelle4 ,thus when the two ,frontal ,parietal ,sutures meet the ,sagittal ,suture1 at ,b1 ,figs4 #a and #b1 there is quite a large diamond shaped space between the different bones1 filled up with membrane4 ,this is called the ,anterior ,fontanelle1 or bregma4 ,where the ,sagittal ,suture joins the two ,lambdoidal there is another space1 not so large1 and different in shape1 being triangular2 this is called the ,posterior ,fontanelle1 c4 ,figs4 #a and #b4 ,and where each of the temporal bones joins the parietal there are two other spaces1 called the ,temporal ,fontanelles1 t4 ,fig4 #b1 which are also irregularly diamond shaped1 but not nearly so large as the anterior fontanelle4 ,it is evident that if a person can distinguish these ,fontanelles1 when he touches them with his finger1 he can tell what part of the head is presenting1 and hence their use4 ,these spaces allow of the bones lapping over each other1 during delivery1 and thus the head is made smaller4 ,they do not disappear till sometime after birth1 and in very young children the brain may be felt1 and seen to work1 at the anterior fontanelle4 ,eventually however1 the bones come close together1 and are joined by a curious kind of dovetailing4 ,the two frontal bones however1 completely coalesce1 and form but one1 in the adult4 ,sometimes the bones will be very perfectly formed1 and the fontanelles nearly filled up1 before birth1 and then the head cannot be crushed much smaller1 and so the labor becomes both painful and difficult4 ,this is usually called an ossified1 or solid head4 ,diameters of the ,head4--,the diameters of the head are the distances between its most prominent points4 ,they are necessary to be known before we can judge as to the possibility of its passing the straits of the ,pelvis1 in the various positions4 ,generally there are reckoned ten diameters1 and they are represented in the following ,plate3-- ,illustration3 ,,plate ,,xxv4 ,diameters of the ,head4 #a4 ,the ,occipito ,mental1 or from the back of the head to the chin1 ,m1 ,o1 ,fig4 #a1 five inches4 #b4 ,the ,mento ,bregmatic1 or from the chin to the anterior fontanelle at the top of the head1 ,m1 ,o1 ,fig4 #a1 four inches4 #c4 ,the ,occipito ,frontal1 or from the back of the head to the top of the forehead1 ,o1 ,f1 ,fig4 #a1 four inches4 #d4 ,the ,trachelo ,occipital1 or from the throat to the back of the head1 ,t1 ,o1 ,fig4 #a1 four inches4 #e4 ,the ,sub ,occipito ,bregmatic1 or from the nape of the neck to the top of the head1 ,s1 ,b1 ,fig4 #a1 three inches and a half4 #f4 ,the ,trachelo ,bregmatic1 or from the top of the throat to the top of the head1 ,t1 ,b1 ,fig4 #a1 about three inches and a half4 #g4 ,the ,trachelo ,frontal1 or from the top of the throat to the top of the forehead1 ,t1 ,f1 ,fig4 #a1 about three inches4 #h4 ,the ,sub ,occipito ,frontal1 or from the nape of the neck to the top of the forehead1 ,s1 ,f1 ,fig4 #a1 about three inches4 #i4 ,the ,bi ,parietal1 or across the head from one side to the other at the middle of the parietal bones1 the widest part1 ,b1 ,p1 ,fig4 #b1 three inches and a quarter to three and a half4 #aj4 ,the ,bi ,temporal1 or across the head from one temporal bone to the other1 ,b1 ,t1 ,fig4 #b1 about two inches and a half4 ,the necessity for knowing these diameters will be obvious4 ,it is only by being acquainted with them1 and with the straits of the ,pelvis1 already described1 that we can tell whether the child can pass or not in certain positions1 and how we must change its position1 when possible1 to give relief4 ,on comparing the diameters of the head with those of the ,pelvis1 it will be seen that some of them correspond in size while others do not1 so that in one position delivery can take place spontaneously1 while in another it will be difficult1 and in some nearly impossible1 without assistance4 ,thus1 for instance1 if the head should present by the occipito mental diameter1 7,o1 ,m1 ,fig4 #a17 it evidently could not pass while in that position1 because by this diameter it is five inches in width1 and the greatest diameter of the ,pelvis is only about four inches and a half4 ,its position must therefore be changed1 and the accoucheur must know how to change it with advantage4 ,,attitude ,,of ,,the ,f,,tus ,,at ,,full ,,term4 ,the attitude of the ,ftus is represented in the following ,plate3-- ,illustration3 ,,plate ,,xxvi4 ,attitude of the ,ftus4 ,the arms1 it will be seen1 are crossed on the breast1 upon which the chin is also bent2 the thighs are close together1 and brought against the ,abdomen2 the legs are close bent on the ,thighs1 and the feet are turned up against the front of the legs1 the whole body being curved forward4 ,the position in which the ,ftus most usually lies in the ,womb has already been shown1 particularly in ,plate ,,xii1 and in ,plate ,,xvi4 ,the head is downwards1 and the back part of it turned to the mother's left side4 ,what is the cause of this almost universal position is not certainly known4 ,it was formerly thought to depend on the head being heavier than the other parts1 and thus sinking down2 but this supposition has been shown to be entirely without foundation4 ,m4 ,p4 ,dubois has lately advanced the notion that it depends on an instinctive feeling in the ,ftus itself1 which directs it to take that position by which it can most easily make its exit4 ,this opinion appears very reasonable1 and is apparently well founded4 ,it is well known that the ,ftus is susceptible of various impressions while in the ,womb1 and impelled by unerring instinct to take the breast immediately it is born2 nay1 it has even been known to suck the finger of the assistant1 in cases of face presentation1 even before birth6 ,we can readily believe1 therefore1 that it is directed to place itself in the ,womb1 in the best position1 the same as it is directed to take the finger in its mouth4 ,in the young of many of the lower animals this is also strikingly exemplified4 ,the young duck in the shell taps with its little beak against the part that is to be broken1 and rushes into the water even with a part of the shell still on its back4 ,the young oppossums1 who are born imperfect from the ,womb1 shelter themselves1 immediately they come into the world1 in the pouch on the mother's breast1 and fasten themselves to the mamm till they are more perfectly grown4 ,it must be remarked however1 that the head does not always present first1 though it usually does so4 ,occasionally we have the breech present1 and still rarer even other parts2 but these are merely exceptional deviations1 the causes of which are unknown4 ,out of every sixteen children born1 fifteen usually come head first4 ,this however1 will be shown better further on4 ,,chapter ,,ix4 ,,the ,,appendages ,,of ,,the ,f,,tus ,,at ,,term4 ,,the ,,membranes4 ,the uses and arrangements of the membranes surrounding the ,ftus have already been explained1 so that little more is needed to be said here1 because they are not much different at the full term from what they are at an earlier period1 excepting perhaps that the amnion is a little more dense and firm4 ,this membrane appears not only to surround the ,ftus like a bag1 to contain the waters1 but is also reflected close on to its body1 like its skin1 with which in fact it is thought by some to be connected4 ,the child is certainly born with this membrane still on its body1 and does not part with it till some days after birth1 when it peels off like a thin dead skin1 or powder4 ,the waters1 enclosed within the ,amnion1 7see ,plate ,,xii17 have now increased to their greatest quantity2 and there is also1 in most cases1 a second body of fluid between the ,amnion and the ,chorion1 which coming away before the real discharge1 is called the false waters4--7,see ,plate ,,xii47 ,the quantity of the true waters1 at birth1 is about twenty1 or from that to thirty ounces1 but is very variable4 ,it is of a greenish color1 rather muddy1 and heavier than water4 ,it contains albumen1 7white of egg17 sulphate of soda1 and lime4 ,ninety-eight per cent4 of it however1 is pure water4 ,it appears to be excreted1 like perspiration1 from the surface of the membranes1 and most likely is merely the watery portion of the blood exuded through4 ,the uses of this fluid are various4 ,as already stated1 it probably supplies some nutriment to the ftus1 which it also protects1 in a great measure1 from pressure and from concussions4 ,it also prevents the limbs from adhering1 and helps to distend the mouth of the ,womb1 in the earlier stages of labor1 besides affording an abundant slippery fluid for the purpose of lubricating the passages1 thus making the passage of the child more easy4--7,see ,plate ,,xii47 ,the other two membranes1 the ,chorion and ,decidua1 are not of much importance in our present explanation2 and practically1 in fact1 the whole three may be regarded as one envelope1 surrounding the child and the waters in which it floats4 ,,the ,,placenta4 ,at the full term the ,placenta1 7,see ,plate ,,xii17 is about six or seven inches in diameter1 and nearly circular1 though often irregular4 ,its thickness varies from one to two inches1 and is greatest where the cord is inserted4 ,sometimes it is very large1 or very thick1 and may then be difficult to extract1 and even cause serious accidents4 ,as already explained the ,placenta is composed of a mass of blood-vessels1 by means of which the blood of the ftus is1 in some way1 brought into contact1 or commingled with that of the mother4 ,its uterine face is irregular1 being broken into lobes1 or cotyledons1 on which may be seen a vast number of little veins and arteries1 corresponding with others on the inner surface of the ,womb4 ,its outer surface is of a grey red color1 and covered with the ftal membranes1 under which the large blood-vessels can be traced4 ,the ,placenta is usually attached to one side of the ,uterus1 near the fundus1 or at the fundus1 but sometimes it grows wholly1 or in part1 over the mouth of the ,womb2 an occurrence which may cause serious consequences4 ,when there is more than one child each usually has a separate placenta1 and they are all intimately connected4 ,in some rare cases however1 one placenta only exists with twins4 ,each child has also a separate amnion1 and waters2 but there may be only one chorion and decidua for the whole1 or each may have a complete set of membranes itself4 ,instances have been known however1 of two children being enclosed in the same amnion1 and surrounded by the same waters1 having but one placenta between them4 ,these possible diversities show the accoucheur how necessary it is for him1 in any case of multiple pregnancy1 to be sure that he has abstracted all the after birth2 and they also caution him not to proceed to unnecessary manipulations merely because it is not the same as in other cases4 ,,the ,,umbilical ,,cord4 ,this is composed1 as already stated1 of an artery and two veins1 which twist round the artery1 like the strands of a rope4 ,these are all enclosed in a sheath1 and surrounded by a thick kind of mucus1 called the ,gelatine of ,wharton4 ,its thickness is about that of the little finger1 though it may be much larger1 having been seen as thick as the child's body4 ,its usual length is about eighteen or twenty inches1 but it has measured as much as five feet4 ,then again it has been found so small that the vessels in it could not nourish the child4 ,these exceptional variations however1 are very rare4 ,the veins may also be enlarged1 or full of knots1 and the circulation may be so much impeded thereby as to cause abortion4 ,the various accidents which may result from anomalies in the cord will however1 engage our attention in another place4 ,,section ,,iv4 ,,the ,,mechanism ,,of ,,delivery ,,in ,,all ,,the ,,different ,,presentations ,,and ,,positions ,,of ,,the ,f,,tus4 ,,chapter ,x4 ,,presentations ,,and ,,positions ,,of ,,the ,f,,tus4 ,the child may present several different parts of its body1 at the commencement of delivery1 and they may be in different positions relatively to the different parts of the ,pelvis4 ,all these require to be known4 ,different authors have made different classifications of the presentations and positions1 and have differently named them2 but this is of little consequence1 since they are still the same1 no matter how they are named4 ,i shall follow the arrangement of ,m4 ,chailly1 because ,i think it equally perfect1 and much more simple and practical1 than any other yet proposed4 ,,presentations4 ,the ftus may present at the mouth of the ,womb either by the head1 the most usual way--by the lower extremities1 which is the most frequent way after the head--or by various parts of the trunk1 which is the least frequent way of all4 ,in each of these three full presentations there may be certain variations1 which require to be noticed4 ,the head1 for instance1 may present either by the cranium or by the face2 the lower part of the body may present either by the feet1 the knees1 or the breech1 according as the legs and thighs are flexed or extended2 and the trunk may present either on the right or left side1 and inclined towards the back or towards the chest1 though neither the back nor abdomen ever fully present4 ,each of these variations may also have slight variations again4 ,thus the face may present full1 or by one or the other cheek1 and so on4 ,these variations however1 are of little practical consequence1 because we only find them at the very commencement of the labor1 and they always change to the full presentation4 ,practically speaking therefore1 there are five full presentations1 viz41 the ,cranium1 the ,face1 the ,breech1 the ,feet1 or knees1 and the ,trunk1 either by the right or left side4 ,the varieties of these1 as already remarked1 not requiring any special attention from the accoucheur1 providing he is not puzzled or misled by them4 ,,positions4 ,the position means the particular direction in which the presenting part of the ,ftus is placed in relation to the ,pelvic straits4 ,the ,pelvis itself is supposed to be divided into two similar halves1 the right and the left1 and each presenting part has one particular place which is referred to as the indicating point4 ,thus1 for instance1 in the ,cranium the ,occipit1 or behind part of the head1 is the indicating point2 and we therefore say1 in ,cranium presentations1 that it is a right or left ,occipital position1 according as the back of the head is to the right or left side of the ,pelvis4 ,in face presentations1 the chin 7mentor7 is the indicating point1 and we therefore say it is a right or left mento position1 according as the chin is towards the right or left side4 ,in breech presentations1 the child's sacrum is the indicating point1 and we then say it is a right or left sacral position1 according as the ,sacrum is towards the right or left side of the ,pelvis4 ,in trunk presentations1 which are always crosswise1 the head 7cephalo7 is the indicating point1 and we therefore say it is a right or left cephalo position1 according as the head lies towards the right or left side of the mother's body4 ,in ,cranium presentations also1 the back of the head is not merely on the right or left side1 but may be at two different points on each side4 ,it may be either nearest to the ,sacrum 7posterior71 or nearest to the pubes 7anterior71 but still against the ,ilium2 it is therefore called a right or left anterior1 or posterior1 occipito iliac position1 as the case may be4 ,sometimes also1 the occiput lodges immediately on the pubis1 instead of going to either side1 and that is called an occipito pubic position2 at other times1 on the contrary1 it is placed against the ,sacrum1 instead of being on either side1 and that is called an occipito sacral position4 ,in presentations of the head therefore1 we may reckon six positions--the right and left anterior and posterior occipito iliac1 and the pubic and sacral4 ,in presentations of the face the same2 they being mento iliac and so on1 instead of occipito4 ,in presentations of the lower extremities also the same1 excepting that they are sacro iliac and so on1 instead of occipito4 ,in presentations of the trunk we have but two positions for each side1 the right and left cephalo iliac2 according as the head is on the right or left side of the mother's body4 ,the child always lying1 in presentations of the trunk1 crosswise--the feet on one side and the head on the other4 ,most authors enumerate many more presentations and positions1 but they are of little practical utility4 ,when the head presents1 for instance1 the delivery takes place in nearly the same manner1 let it be in what position it may4 ,and in presentations of the face1 or of the lower extremities1 the particular position is of little consequence1 the delivery being usually effected much the same in them all4 ,some of the positions are1 it is true1 much more favorable than others1 but a spontaneous delivery1 generally speaking1 occurs in all of them1 when the head1 face1 or lower extremities presents4 ,very frequently indeed1 the less favorable positions are changed to the more favorable ones1 and the worst seldom do more than impede delivery for a time1 unless there be some malformation1 or loss of power4 ,i therefore refer to them more for convenience in future explanations1 and to enable my readers to know what is meant by them1 when they read other books2 not because they are really necessary to be understood1 or of any great practical use4 ,the celebrated ,baudelocque admitted seventy-four positions1 and twenty-two presentations2 and the number might be made still greater1 if all the variations were to be enumerated4 ,such classifications however1 are more ingenious than useful1 and they are but little noticed even by medical men4 ,i shall merely describe the mechanism of labor in the most frequent positions1 in each presentation1 because the others usually change into these2 and even when they do not1 the process of delivery is essentially the same1 and also the mode of assisting it4 ,,mode ,,of ,,ascertaining ,,the ,,presentation ,,and ,,position4 ,the ,presentation4--,although in general it is not possible to ascertain with certainty1 what part of the ftus presents to the mouth of the ,womb1 until labor commences1 yet a tolerable judgment can frequently be formed before4 ,in head presentations1 on performing ballotment1 the head is felt1 like a firm round tumor1 occupying all the space which the finger can reach1 very differently from any other part4 ,the peculiar cramps in the female's lower limbs1 and frequent inclination to urinate1 mentioned in the signs of labor1 are also strong indications of this presentation1 being seldom experienced in any other4 ,when the labor has actually commenced there can be but little uncertainty in these cases1 for1 immediately the mouth of the ,womb is sufficiently open1 the finger can be introduced1 and the head felt like a smooth1 round1 and elastic bony tumor1 not likely to be mistaken for anything else1 if ordinary care be taken4 ,after the waters have escaped1 it can of course be felt still more distinctly4 ,if even an inexperienced person bears in mind the shape of the head1 and reflects how it must fill up the passage1 and how it must feel1 from being composed of separated thin bony plates1 lying on a soft yielding substance like the brain1 he can scarcely fail to recognize it4 ,the sensation is very much like that of pressing a piece of firm card board on an inflated bladder1 which forms a tolerable representative of the ftal head4 ,sometimes there is a difficulty from a great quantity of water being intruded between the membranes and the head1 which somewhat obscures the touch1 but this only necessitates greater care4 ,the water however1 may be in such quantity as to entirely prevent the touch1 in which case nothing can be done till the membranes break2 the presentation can then be ascertained with certainty1 and it will be quite early enough to render assistance1 if it should be an unfavorable one4 ,i have known some inexperienced persons mistake the bag of water itself for the head1 and commit great errors in consequence4 ,the ,face can seldom be mistaken1 because the nose1 or mouth1 may be felt2 and1 by passing the finger up the side of the head1 the ears also4 ,the trunk is in general easy of recognition4 ,nearly always the right or left shoulder occupies the passage1 or is near to it1 so that the finger may be readily passed under the arm pit4 ,the shoulder joints1 the ribs1 or the shoulder blade bone1 all feel very different to the head1 and are not likely to be taken for it4 ,in presentations of the lower extremities there is still less danger of error4 ,if the feet1 or knees1 occupy the passage1 they can scarcely be mistaken4 ,the breech is certainly something like the head in its form1 but feels different1 and is divided down the middle by the indentation between the two cheeks1 along which the finger can be passed till it enters between the limbs4 ,in irregular presentations1 as of the arms for instance1 or of one leg1 or an arm and leg1 it is only necessary to carefully feel them1 so as to ascertain their form1 and the relation of their parts4 ,thus the fingers can be distinguished from the toes1 and the feet from the hands1 particularly if the ankle can be felt4 ,the accoucheur should ascertain the particular presentation as early as possible1 because he may sometimes be of service in correcting an unfavorable one1 if he is certain of it in time1 and knows what he is about4 ,he should not however1 use any degree of force to ascertain it1 in case he cannot do so without1 but wait till the conditions are more favorable4 ,neither should he1 with the same object1 rupture the membranes too soon1 for he may thereby cause considerable delay and difficulty1 without any good to counterbalance it4 ,all the above-named presentations may1 and usually do1 terminate spontaneously1 except those of the trunk1 and even they do occasionally1 though more frequently they require assistance4 ,relative frequency of the different presentations4--,the most favorable presentations1 and positions also1 are always the most frequent1 while the unfavorable ones are but seldom met with4 ,according to ,madame ,lachapelle1 in fifteen thousand six hundred and fifty-two labors there are about fourteen thousand seven hundred and forty-nine presentations of the head and face2 about five hundred and eighty-six of the breech1 knees1 and feet2 and only about sixty-eight of the trunk1 or shoulders4 ,positions4--,the position is generally of but little consequence1 because in all the favorable presentations spontaneous delivery occurs in every position alike1 and in the unfavorable presentations the same assistance is required in one position as in another4 ,in some cases an unfavorable position of the head may be changed however1 to a better one2 and therefore1 so far as the head is concerned1 the positions are worth ascertaining4 ,the mode of determining the position is by feeling for the sutures and fontanelles1 described in ,chapter ,,viii2 and this cannot be usually done till after the membranes are broken1 when the head can be distinctly touched4 ,by referring to ,plate ,,xxiv1 the shape and position of the ,fontanelles will be seen1 and if the head be supposed placed with the top downwards1 and the back of it to the mother's left side1 they may be readily found with the finger4 ,in the left anterior occipito iliac position1 or that when the back of the child's head is against the left side of the mother's pelvis1 and nearest the pubes1 while its forehead is against the right side1 and nearest the sacrum1--the sagittal suture1 or opening along the top1 will of course run across from right to left4 ,this opening may be distinctly felt with the finger1 which should be passed along it towards the right side1 and it will then reach the anterior fontanelle2 afterwards it should also be passed to the left side1 and then it will reach the posterior fontanelle4 ,the difference between these two openings1 in shape and size1 is shown in ,plate ,,xxiv1 and even if a person has never seen1 or felt1 the head of a newborn child1 they can scarcely be taken for each other1 after noticing that ,plate4 ,if the anterior fontanelle should be felt on the left side instead of the right1 and near the pubes1 while the posterior fontanelles is to the right1 and near the sacrum1 the position must be the right posterior occipito iliac1 or just the reverse of the former4 ,if the sagittal suture should be found to run across from the pubes to the sacrum1 instead of from one side to the other1 it will then indicate either an occipito pubic1 or occipito sacral position1 according as the back of the head is behind or before2 and this can be readily ascertained by finding either of the fontanelles4 ,in short1 if the relative position1 forms1 and directions of these openings in the child's head be clearly understood1 the position of the head can nearly always be determined by feeling them1 as will be evident by referring to our former explanation of them4 ,sometimes however1 the bones overlap a good deal1 from the head being pressed1 and then instead of an opening along the top1 a seam will be felt4 ,and sometimes1 from long continued pressure1 a quantity of blood1 and watery fluid1 will be effused under the scalp1 so as to prevent the bone being distinctly touched4 ,but these accidents seldom happen1 and with ordinary care and perseverance1 need not prevent the position being determined1 after a little delay4 ,the position of other presenting parts is easily ascertained1 by feeling for some known point--as the nose1 or the face1 the depression between the cheeks1 or the breech1 and so on4 ,relative frequency of the different positions4--,the most favorable positions1 like the most favorable presentations1 are also the most frequent4 ,according to ,baudelocque1 in ten thousand three hundred and twenty-two cases1 of head presentation1 there were eight thousand five hundred and twenty-two cases when the back of the child's head was on the mother's left side1 and towards the front1 7or in the left anterior occipito iliac position72 one thousand seven hundred and fifty-four when it was on the right side towards the front1 7right anterior occipito iliac72 twenty-five times to the right side1 but towards the ,sacrum1 7right posterior occipito iliac72 and nineteen times on the left1 but towards the ,sacrum1 7left posterior occipito iliac47 ,being most frequently with the back of the head towards the front on the left side1 as shown in ,plate ,,xxvii2 next towards the front on the right side2 and but seldom towards the ,sacrum1 or back1 on either side4 ,in all these ten thousand cases we do not find a single instance of the head lying from back to front1 in the occipito pubic1 or occipito sacral positions1 commonly called transverse2 neither do we find a single instance in fifteen thousand six hundred and fifty-two cases recorded by ,madame ,lachapelle2 which will show how rare such unfortunate positions must be4 ,what this great frequency of one particular position depends upon we do not know--possibly on that cause1 previously alluded to1 which determines the most frequent presentation4 ,in the next ,chapter1 the mechanism of delivery1 or the manner in which the child escapes out of the body1 as it most frequently occurs1 will be fully explained4 ,,chapter ,,xi4 ,,the ,,mechanism ,,of ,,delivery1 ,,in ,a ,,presentation ,,of ,,the ,,head4 ,,the ,,left ,,anterior ,,occipito ,,iliac ,,position4 ,this is the presentation and position most frequently observed1 perhaps fifteen out of sixteen times4 ,in most ,obstetrical works it is called the first position4 ,by observing the following ,plates1 and referring to the previous explanations of the diameters of the ,pelvis1 and ftal head1 in ,plates ,,ix and ,,xxv1 it will be seen that through all its changes of position1 while making its exit1 the head always presents by one of its shortest diameters to one of the largest diameters of the ,pelvis1 so that the relation between them is invariably the best that could be established2 and many peculiar turnings and revolutions occur1 apparently for the express purpose of bringing this about4 ,before the rupture of the membranes the head presents its occipito frontal diameter1 which measures four inches1 to the right oblique diameter of the ,pelvis1 which measures four inches and a half2 while its bi-parietal diameter1 which measures only about three inches and a half1 is presented to the other oblique diameter1 also measuring four and a half--7,see ,plate ,,xix47 ,even here it will be seen that the passage is larger than the head which has to pass through it1 but a more favorable position still can be obtained1 by a slight movement of the ,ftus1 which nature accordingly accomplishes1 and also follows by others1 to preserve the advantage1 which will next be described4 ,movements of the ,ftal ,head4--,there are three of these peculiar movements1 each of which takes place at a particular period of the labor1 and must be described separately4 ,first movement1 flexion1 and descent4--,immediately after the ,membranes are broken1 the contractions of the ,uterus force the head into the upper strait1 by the occipito frontal diameter of four inches1 as already shown2 but then commences the first movement1 which consists in a bending of the child's chin down upon its breast1 so that the forehead is carried up into the ,womb2 and the most prominent point of the back of the head presents to the middle of the passage1 by the occipito bregmatic diameter1 which is only about three inches instead of four4 ,this of course makes the passage so much easier1 and generally1 immediately after this change1 the head descends into the basin of the ,pelvis4 ,it is not absolutely necessary however1 for this movement to occur1 for in a well formed ,pelvis the head can descend without it1 though not so easily2 and sometimes1 in fact1 it does not take place1 but this is unusual4 ,it must be recollected that this shifting of the head alters the position of the fontanelles--the posterior one being brought more to the centre of the strait1 and the anterior one carried up out of reach1 while previous to the movement they were both on a level4 ,if an examination is not made therefore1 till after this change1 it may be difficult to determine the position1 unless this is borne in mind4 ,the following ,plates show this very well4 ,,plate ,,xxvii4 ,it will be seen here that the neck is straightened out1 and that the two fontanelles are on a line with each other4 ,note4--,the front of the bones are represented in this and the two following ,plates1 as if transparent1 so that the head may be seen through them4 ,illustration3 ,plate ,,xxvii4 ,this ,plate represents the head just entering the upper ,strait4 ,,plate ,,xxviii4 ,at this time the anterior fontanelle can scarcely be reached1 but the posterior one is easily to be reached1 being in the open passage1 on the left side4 ,the head is now fairly within the ,pelvic cavity1 but still lies across from right to left4 ,second ,movement1 ,rotation of the ,head4--,when the ,ftus is thus brought to the bottom of the ,pelvis1 its head turns completely round1 the back of it being brought to the front1 or under the pubes of the mother1 and its forehead turned against her ,sacrum1 as represented in ,plate ,,xxix4 ,illustration3 ,plate ,,xxviii4 ,this ,plate represents the head descended still lower in the ,pelvis4 ,,plate ,,xxix4 ,here the head is seen just beginning to turn--the right side1 and part of the back of it1 just passing under the pubes4 ,as the rotation becomes complete the neck straightens1 so that the two fontanelles are again found on the same level4 ,finally the back of the head fully emerges from under the pubic arch1 and the chin slides gradually out after it beneath1 so that the neck of the child is encircled by the ring of the ,vulva4 ,illustration3 ,plate ,,xxix4 ,this ,plate represents the head still further down1 and beginning to ,rotate4 ,illustration3 ,,plate ,,xxx4 ,in ,fig4 #a1 the back of the head is nearly under the pubic bone1 while the forehead is just passing the external opening below4 ,in ,fig4 #b1 the back of the head is completely extruded1 and also the chin1 so that the whole head is now born4--7p4 is the pubic bone1 in front47 ,in ,fig4 #a it will be seen how the ,os ,coccygis1 or lowest part of the back bone1 7c17 is straitened out1 backward1 while the head is passing1 as ,i explained before2 and in ,fig4 #b it has returned again to its natural position4 ,the reason for this rotation of the head will be obvious on calling to mind the form of the ,pelvis and the external opening4 ,on examining ,plates ,,ix and ,x1 it will be seen that the longest diameter of the ,vulva1 or external opening1 the antero posterior1 is nearly at right angles to the longest diameters of the upper strait1 the oblique4 ,now the longest diameter of the head is adapted to this oblique diameter1 on entering the upper strait1 as already explained1 and it is necessary for it also to be adapted to the longest diameter of the external opening1 the anterior posterior when making its exit2 but as the two are not parallel the head is compelled to turn1 or rotate1 in order to pass from one to the other4 ,to accomplish this however1 the neck has to be twisted considerably4 ,but when the head is fully delivered1 it is immediately straitened again1 by the back of the head turning towards the mother's left side1 so that its proper relations with the trunk is re-established4 ,third ,movement1 ,rotation of the ,shoulders4--,when the head is delivered the shoulders come next1 which also require to turn round a little1 to adjust themselves to the long diameter of the lower strait2 and as they turn within the ,pelvis the head also turns1 to correspond1 and thus the back of it is brought opposite the middle of the mother's left thigh4 ,immediately this movement is effected1 the shoulders rapidly escape through the external opening1 the right one being in front1 a little to the left of the symphysis pubes1 and the left one behind1 a little to the right of the os coccygis4 ,the body then curves upwards1 to accommodate itself to the curved axis of the ,pelvis1 and speedily follows the shoulders4 ,these curious movements cause the child to pass in a spiral direction1 so that each part may pass through the ,pelvis in the most favorable position4 ,sometimes all these movements are not effected1 and yet the delivery may occur1 though not so speedily1 or safely1 as when they are4 ,the shoulders do not always fully rotate1 but may nevertheless pass the opening1 if the parts be large1 and well relaxed4 ,it is questionable however1 if the head can ever pass the lower strait without rotating1 when it enters the ,pelvis diagonally1 the occipit on one side and the forehead on the other2 as it is necessary for either one or the other of these parts to pass under the pubes4 ,,mechanism ,,of ,,delivery ,,in ,,all ,,other ,,positions ,,of ,,the ,,head4 ,the right posterior occipital position4--,this position1 called the second by some authors1 and the fourth by others1 is exactly the reverse of the one just described1 the head lying in the same direction1 but the back of it being behind1 to the right of the ,sacrum1 and the forehead to the left of the pubes4 ,precisely the same movements are gone through in this position as in the other1 excepting that the head has to rotate considerably further4 ,in the former position the back of the head is only a little to the left of the pubis1 and therefore has not far to turn to pass under it2 but in this position the back of the head is behind1 and therefore has to turn very far round to reach the same position4 ,the rotation is therefore more difficult1 not so soon effected1 and sometimes likely to be dangerous to the child4 ,in the other movements there are no difference worthy of notice1 but it must be borne in mind that they all occur the reverse way1 to what they do in the first position1 because the occiput is on the right side instead of the left4 ,the right anterior occipital position4--,this position is precisely the same as the first1 but on the other side4 ,the back of the head is in front1 but to the right of the pubis instead of the left1 while the forehead is behind1 to the left of the ,sacrum4 ,this will be apparent enough by observing ,plate ,,xxxi4 ,,plate ,,xxxi4 ,this is the second most frequent position2 the left anterior occipito iliac being the most frequent4 a4 ,the ,acetabulum1 or socket of the hip joint4 c4 ,the cut edge of the ,womb4 c4 ,the ,foramen ,ovale4 d4 ,the top of the ilium bone1 called the crest4 h4 ,the ,symphysis ,pubes4 i4 ,the ischium4 ,k4 ,k4 ,the pubic bones4 ,illustration3 ,plate ,,xxxi4 ,head in the right anterior occiput iliac position4 ,the mechanism of delivery is precisely the same1 and all the movements occur in the same order and manner1 as in the first position1 but the reverse way4 ,the rotation1 for instance1 being from right to left1 instead of from left to right1 and so of all the others4 ,the left posterior occipital position4--,delivery is effected the same in this as in the left anterior1 or first position1 excepting that the rotation is more extended1 owing to the occiput being behind1 as explained in the right posterior occipital position4 ,,general ,,remarks ,,on ,,the ,,different ,,positions ,,of ,,the ,,head4 ,in all the other positions1 and their varieties1 there is nothing that calls for special notice1 or that is material in practice1 the delivery being nearly the same in them all4 ,no matter what position the head is placed in1 the back of it nearly always comes to the front1 under the pubes1 even though it have to turn half round to do so4 ,the cause of this is supposed to be the peculiar form of the parts1 which give it a screw like motion1 in its descent1 and the shape of the external opening1 which1 being longest from before to behind1 can only allow the long diameter of the head to pass through in the same direction4 ,sometimes1 it is true1 the occiput passes behind1 instead of coming to the front1 and then the chin comes under the pubes1 while the occiput presses on the coccygis4 ,this is very seldom observed1 and when it occurs the labor is more difficult and tedious1 though it may still terminate spontaneously4 ,the resistance of the soft parts1 externally1 appears to be the chief cause of the head turning2 for when they are much relaxed1 and the child's head small1 it will sometimes pass without1 or in the anterior posterior position4 ,and sometimes1 when the head is large1 so that it distends the parts very much1 the shoulders will pass cross wise1 there being room enough for them without turning4 ,in some females1 formed large1 whose organs are excessively relaxed1 and whose children are small1 the delivery takes place without any of the movements being effected1 the child passing straight through in whatever position it may happen to be3 this is rarely seen however4 ,when there are twins they do not usually both present by the head1 but one by the feet2 and frequently the parts are so relaxed by the passage of the first1 that the second is delivered without rotating at all1 though in general it follows precisely the same movements4 ,it sometimes happens however1 that the second birth does not take place till some hours1 or even days1 after the first4 ,it may be said1 in general1 that all positions of the head are favorable to both mother and child1 and may terminate spontaneously4 ,it is seldom that anything more than ordinary assistance is required in any of them1 and they could in general terminate without any at all1 though sometimes with difficulty4 ,the worst cases are those in which the head does not turn round1 but remains across1 or where the back of it turns behind1 instead of coming to the front4 ,in these cases there is great danger of the perineum1 or external lips1 being much lacerated1 or even of an artificial passage being torn through the perineum1 leading to the most serious after results4 ,about one child also1 out of every fifty1 is lost in these unfavorable positions4 ,,chapter ,,xii4 ,,mechanism ,,of ,,delivery ,,in ,,presentations ,,of ,,the ,,lower ,,extremities4 ,this presentation includes the feet1 the knees1 the breech1 and also the hips1 there being no difference in the delivery for all these parts4 ,it is the same also whether there be one foot1 or knee1 or both feet and knees4 ,there are but two positions worthy of notice in this presentation1 and they are determined by the child's sacrum4 ,if the sacrum1 or posteriors1 are to the right of the mother's ,pelvis1 it is called the right sacro iliac position2 but if they are on the left side it is called the left sacro iliac position4 ,the direction in which the child's pelvis is placed1 is analagous to that of the head1 the sacrum answering to the occiput4 ,thus most frequently the sacrum is on the left side1 a little to the left of the pubes1 7left anterior7 while the abdomen faces the right side near the sacrum4 ,when on the right side however1 it is most usually nearest the sacrum1 with the abdomen facing the left side near the pubes4 ,the lower extremities present most frequently next after the head1 but still they are but seldom met with4 ,m4 ,p4 ,dubois tells us that out of twenty thousand labors he only met with eighty-five such cases4 ,in these eighty-five cases the breech presented fifty-four times1 and the feet twenty-six1 the knees being found but once4 ,a presentation of the lower extremities may generally be recognized at an early stage1 by the head being felt at the fundus of the ,uterus1 and by the pulsations of the ftal heart being heard above the umbilicus1 as explained in the section on ,auscultation4 ,after labor has commenced the part felt at the mouth of the ,womb is irregular1 and so different from the head1 that it is not likely to be mistaken for it4 ,if the knees or feet present1 they can always be distinguished2 and if the breech presents it can easily be recognized by its form1 and particularly by the os coccygis1 which can be distinctly felt at the bottom of the depression between the two cheeks4 ,the side on which it is felt of course determines the position1 and the same with the front of the knees1 or the heels4 ,the ,rectum can also be reached with the finger1 when the breech is touched2 but great care must be taken not to intrude it too far1 because with a female child the ,vulva might be mistaken for it1 and thus the hymen be broken1 and other injury committed4 ,the genitals of a male child are more obvious1 so that the sex of the child may be usually ascertained1 along with the position4 ,for want of proper care the breech has been mistaken for the head1 and face1 but this can scarcely happen if the accoucheur is attentive4 ,it is simply necessary to call to mind what must be felt in each presentation1 as the nose and mouth with the face2 the two cheeks of the posteriors1 with the opening between them2 and also the genitals1 with the breech2 and it can be certainly ascertained which of these parts are really at the opening4 ,with the knees or feet there can scarcely be a doubt4 ,,delivery ,,in ,a ,,breech ,,presentation ,,in ,,the ,,left ,,anterior ,,sacro-,,iliac ,,position4 ,in this position the legs and thighs are turned up against the abdomen1 the breech in full occupying the passage1 with the sacrum to the left and in front of the mother's pelvis4 ,the descent of the breech usually takes place without much difficulty1 into the ,pelvis1 it being small and easily compressed4 ,it descends in the same direction in which it first presents--that is diagonally1 like the head--and also rotates1 or turns round1 so that the left buttock comes in front1 just to the right of the pubis1 while the right one goes behind1 to the left of the sacrum4 ,the left buttock reaches the mouth of the ,vulva first1 in this position1 and then remains stationary there while the right one slides along the curve of the sacrum and perineum1 and passes out first at the lower part of the external opening4 ,the left however1 speedily follows1 and when the whole breech is born it rotates again1 one hip coming immediately in front1 and the other going immediately behind4 ,owing to this movement the long diameter of the breech is adapted to the long diameter of the ,pelvis1 as in the case of the head4 ,this will be evident from the following ,plate3-- ,illustration3 ,,plate ,,xxxii4 ,delivery in a breech presentation1 the buttocks having just passed the ,vulva4 c4 ,the ,coccygis1 much straightened4 p4 ,the pubic bone1 in front4 ,the rest of the body then rotates in the same way1 and the arms and shoulders pass through the external opening in the same direction as the hips4 ,the left shoulder first moves to the right of the pubes1 while the left passes behind2 and then1 just when they are both passing out1 one comes immediately in front1 and the other immediately behind1 placing themselves in the long diameter of the ,vulva4 ,the head passes through the superior strait in the left1 anterior occipital position1 and is often delivered in that way2 but sometimes it rotates1 and the forehead passes into the curve of the sacrum1 while the occiput is placed behind the pubes4 ,when this occurs the body also rotates1 to accompany the head4 ,this state of the parts is represented in the following ,plate3-- ,illustration3 ,,plate ,,xxxiii4 ,anterior posterior position of the head1 the occiput being in front1 after the delivery of the body4 c4 ,the ,coccygis4 p4 ,the pubic bone1 in front4 ,at this period the head is passed the uterus1 and there is therefore little or no contraction to expel it1 so that it often remains a long time undelivered4 ,it will be seen that the position is very unfavorable1 the longest diameter of the head1 the occipito frontal1 being the presenting one1 which makes it lie immoveably across4 ,the means of assisting in such a case are plain enough1 the forehead must be brought down while the body is raised1 towards the mother's abdomen2 this will throw the top of the head back1 towards the sacrum1 and change the presenting diameter4 ,the forehead and bregma rapidly escape below1 and the occiput passes out last4 ,this is the way in which nature herself also completes the delivery in such cases1 when she has the power4 ,,delivery ,,by ,,the ,,breech ,,in ,,the ,,right ,,posterior ,,sacro ,,iliac ,,position4 ,this position is the reverse of the preceding one1 the ,sacrum being behind1 and to the right1 while the ,abdomen is to the left in front4 ,the same movements are performed as in the first position1 and the whole process is similar1 only the reverse way4 ,the ,sacrum being behind however1 has to rotate much further to come in front1 precisely the same as with the head when in the posterior position4 ,the head generally follows the ,sacrum1 and the occiput comes under the pubes1 as already explained2 but sometimes only at the moment when being disengaged4 ,,delivery ,,by ,,the ,,breech ,,in ,,the ,,full ,,posterior1 ,,or ,,sacro ,,sacral ,,position4 ,in this position there is no rotation at all1 the back of the child being turned full to the back of the mother1 and the whole body1 and head1 being expelled in that position4 ,in general there is no particular difficulty from this position1 but on the contrary it is thought by some to be rather favorable than otherwise4 ,the longest diameter of the ftal pelvis1 and shoulders1 are adapted to the longest diameter of the mother's pelvis1 at the upper strait1 and easily pass it4 ,they will also generally pass the external opening in the same direction1 unless it be very unyielding1 or the child very large2 and if they pass the head usually follows1 because the parts have been so much dilated by the passage of the body that they offer but little resistance4 ,,general ,,remarks ,,on ,,the ,,presentation ,,of ,,the ,,lower ,,extremities4 ,as a general rule delivery by the breech1 or by any other position of the lower extremities1 is less favorable than by the head4 ,the labor is usually longer1 more painful1 and more exhausting2 still however1 it is generally spontaneous1 and not necessarily dangerous to the mother4 ,to the child1 on the contrary1 it is dangerous1 on many accounts4 ,it appears1 from the observations of ,m4 ,p4 ,dubois1 that in this presentation one child is lost out of every twelve1 while only one out of fifty is lost in head presentations6 ,the chief cause for this greater mortality appears to be the compression of the umbilical cord1 which is greater1 and lasts much longer1 than when the head presents1 as will be evident on examining the circumstances under which delivery is effected in each case4 ,when the head presents it passes1 and also the shoulders1 before the umbilicus is reached2 the mother's organs are therefore much dilated1 and only the smallest parts of the ftus are left1 when the cord is engaged in the passage2 it cannot therefore be much compressed1 nor for any long time1 because the labor is then soon over4 ,when the lower extremities present this is not the case1 the smallest parts then pass before the umbilicus is reached1 so that the cord has to pass along with the head and shoulders1 which are both the largest and the longest in being delivered4 ,this compression of the cord stops the circulation of blood between the ftus and the ,placenta1 as will be evident on referring to the description formerly given of ,ftal nutrition2 and the stopping of this circulation is as fatal1 to it1 as stopping the breath is to an adult4 ,when the breech presents altogether1 there is not so much danger as with the feet1 or knees1 because it is large1 and in its passage dilates the parts so much that the rest of the body1 and the head1 follow more quickly4 ,there is1 of course1 no danger till after the hips have passed1 because the cord is not reached before2 but the delivery should be completed as soon after they are born as possible1 for every minute's delay makes the chances for the child's life so much less4 ,,chapter ,,xiii4 ,,mechanism ,,of ,,delivery ,,in ,,presentations ,,of ,,the ,,face4 ,presentations of the face appear to result from the head being bent backwards1 instead of forwards upon the chest4 ,they are easily recognized1 because the face has so many peculiar parts1 as the nose and mouth1 for instance1 which are altogether unlike what can be felt in any other presentation4 ,in a very early stage the forehead may be taken for the vortex1 unless care be used1 because it feels round and soft like it1 but the mistake cannot last long4 ,the positions in this presentation1 as formerly explained1 are determined by the chin1 and in practice only two are noticed--the right posterior mento iliac1 and the left anterior mento iliac4 ,in the first the chin is on the right side1 near the sacrum1 and in the second it is on the left side1 near the pubes4 ,these answer1 it will be seen1 to the two principal positions of the head itself4 ,it is generally considered that1 though the chin1 like the head1 may assume other positions1 yet it does so in but very few cases1 and these presenting no peculiarities which require special notice4 ,,delivery ,,in ,,the ,,right ,,posterior ,,mento ,,iliac ,,position ,,of ,,the ,,face4 ,the head descends with the forehead and chin nearly on a level1 and the nose occupying the middle of the passage4 ,when fairly in the cavity it rotates1 the chin being brought under the pubes1 while the back of the head passes into the curve of the sacrum4 ,this is nearly always the process2 no matter where the chin may be when the labor commences1 it seldom fails to move under the pubes before it concludes4 ,occasionally it may rotate the other way1 and pass into the hollow of the sacrum1 while the occiput comes in front1 but this is very rare4 ,the chin is born first1 and then follows1 below1 the forehead1 top of the head1 and finally the occiput--the face turning upwards towards the mother's abdomen1 as each part is successively delivered4 ,when the head is fully born1 the body rotates inside the same as in the head presentation1 and the delivery concludes in precisely the same way4 ,illustration3 ,,plate ,,xxxiv4 ,fig4 #a4--,the chin just passed1 in presentation of the face4 ,fig4 #b4--,the head full born in presentation of the face4--p4 ,the ,pubic bone4--c4 ,the ,coccygis4 ,,delivery ,,in ,,other ,,positions ,,of ,,the ,,face4 ,the delivery is precisely the same in all the other positions of the face1 excepting that in some of them the chin has further to rotate before it can pass under the pubes4 ,in all cases however1 it may be safely calculated that it will do so1 there having been so few instances known in which it has rotated the other way1 into the hollow of the sacrum1 which is fortunate1 for there is always more or less difficulty and danger when it does so4 ,sometimes the rotation does not take place at all1 but the face descends diagonally1 as the head occasionally does4 ,on the whole presentations of the face are not particularly to be feared1 as regards the mother4 ,some authors even consider them quite favorable1 and reckon them only as varieties of the head presentation4 ,madame ,lachapelle states as a principle1 that face presentations should always be left to nature4 ,and ,m4 ,chailly says he must admit that1 in all positions of the face1 the labor may terminate spontaneously1 excepting when the chin passes behind1 in which case it will be protracted1 and most likely fatal to the child4 ,the labor is generally a little longer1 and more painful1 owing to the face not being so perfectly adapted to the passage as the head is2 but still it must be regarded as favorable to the mother1 though assistance is oftener required than with the head4 ,there is more or less danger to the child however1 owing to the head being kept under pressure for an unusual time1 which produces congestion4 ,the neck is also forced against the pubic bone1 as will be seen by ,figs4 #a and #b1 ,plate ,,xxxiv1 and thus the jugular veins are compressed4 ,if there be any delay1 it is customary to observe the face closely1 after the chin is born2 and if it appears from any indications that congestion is taking place1 assistance is rendered at once4 ,the face will sometimes become so tumefied1 and engorged with blood1 from this prolonged pressure1 that it will not appear natural till several days after birth4 ,probably about one child is lost in ten or twelve deliveries in these cases2 and if the chin pass behind its death is almost certain4 ,it was formerly the practice to endeavor to turn the face upwards1 when at the superior strait1 and so change the presentation to one of the head4 ,this however1 is now abandoned1 because the attempt is seldom successful1 and does not materially improve the condition of things1 besides being painful to the mother4 ,the only extra danger with the face presenting is to the child1 and this is not removed by the operation2 to the mother the face is nearly as favorable as the cranium4 ,in regard to the frequency of face presentations1 we find that ,madame ,lachapelle met with but seventy-two cases in fifteen thousand six hundred and fifty-two deliveries4 ,,chapter ,,xiv4 ,,mechanism ,,of ,,delivery ,,in ,,presentations ,,of ,,the ,,trunk4 ,it has already been stated that in presentations of the ,trunk it is nearly always the right or left shoulder which occupies the passage4 ,it is stated1 by some authors1 that they have felt the back1 and abdomen1 but others think they were mistaken2 and most certainly such positions are extremely rare1 if they actually do ever exist4 ,there are two presentations of the ,trunk1 determined by the side on which the ftus lies1 and denominated accordingly right or left lateral presentations4 ,each of these presentations has two corresponding positions1 determined by the side on which the child's head lies4 ,if the head be on the mother's right side it is called the right cephalo iliac position1 and if it be on the left side it is denominated the left cephalo iliac position4 ,the mechanism of spontaneous delivery is the same in them both1 and in all their varieties1 and so is the mode of rendering assistance1 so that a description of one will suffice4 ,sometimes1 when the labor has lasted long without assistance1 one arm will be forced down first1 and even appear externally4 ,this used to be considered a separate presentation1 and described as such1 under the name of presentation of the hand and arm4 ,there is no reason for describing it separately however1 and no utility in doing so1 as it differs in no essential particular from ordinary presentation of the shoulders1 and must receive the same assistance4 ,what it is that produces presentations of the ,trunk1 and other unfavorable parts1 is not known1 though they are generally thought to be owing to excessive motion in the child1 or obliquities of the ,womb4 ,m4 ,lachapelle met with sixty-eight cases of ,trunk presentation in fifteen thousand six hundred and fifty-two labors1 which is nearly the same as the face4 ,the right side presents more frequently than the left1 and the head is on the left side oftener than on the right1 as it is in ordinary head presentations4 ,as a general rule assistance is always rendered in presentations of the ,trunk1 and is generally considered absolutely necessary4 ,it is undoubtedly true however1 that nature has effected delivery in such cases unaided1 though rarely1 and such instances are considered as extremely fortunate exceptions to the general rule4 ,m4 ,chailly says that the accoucheur should never leave such cases to nature alone1 but always aid her2 but other authors trust to her a little more4 ,the most usual mode of rendering assistance is to turn the child1 and bring down the feet1 a manuvre which will be fully described hereafter4 ,in some cases the child turns itself1 from the contractions of the ,womb1 before it enters the upper strait2 and in other cases1 when very small1 or long dead1 it will pass folded double4 ,this self-turning however1 cannot take place after the escape of the waters1 so that it seldom occurs when the membranes are broken4 ,,mechanism ,,of ,,delivery ,,in ,,presentations ,,of ,,the ,,trunk ,,by ,,spontaneous ,,evolution4 ,this is the most usual mode for the ftus to escape1 in each presentation1 and in every position4 ,by referring to the following ,plates1 and the accompanying descriptions1 it will be readily understood4 ,illustration3 ,,plate ,,xxxv4 ,position of the ,ftus in a presentation of the right shoulder1 and in the left cephalo iliac position4 ,previous to the rupture of the membranes the child's body lies across1 as formerly explained2 but immediately after the rupture the shoulders descend into the ,pelvis1 as seen in the above ,plate1 while the head remains above the pubes2 the arm frequently1 but not always1 protruding externally4 ,the shoulder then continues to descend1 the body following1 bent up against the face1 as seen in ,plate ,,xxxvi4 ,illustration3 ,,plate ,,xxxvi4 ,descent of the shoulder in a ,trunk presentation1 at a more advanced period4 ,here the shoulder is protruded from the ,vulva1 the back being nearly folded1 and the knees turned up against the face4 ,illustration3 ,,plate ,,xxxvii4 ,descent of the shoulder and trunk at a still later period4 ,the whole ,trunk is now fully delivered1 folded almost double1 and the legs and feet are turned up against the face4 ,they speedily follow however1 and then nothing is left but the head1 and perhaps one or both arms1 placed against the sides of it1 as shown in ,plate ,,xxxviii4 ,illustration3 ,,plate ,,xxxviii4 ,the ,trunk has fully descended1 and only the head is left1 with one arm4 ,the arm is generally very easily brought down1 or it may remain and come with the head4 ,the delivery of the head is effected the same as in presentations of the pelvis1 and is seldom attended with much difficulty1 the parts having been so much distended4 ,the body always rotates so that the back comes in front1 and the chin passes into the curve of the ,sacrum4 ,this is the way in which the delivery is effected by nature in such cases1 and it will readily be conceived how dangerous it is to both mother and child1 and how seldom it can be accomplished4 ,if the ,ftus be of a full size1 and the mother's pelvis no larger than ordinary1 it is almost impossible for this spontaneous evolution to take place2 and even when it does1 it is with the greatest difficulty1 the mother suffering in an extreme degree1 and running great risk1 not only of the most serious after results1 but even of death4 ,to the child the danger is equally great1 owing to the severe and long-continued compression it receives1 and the unnatural position it assumes4 ,m4 ,velpeau tells us that in one hundred and thirty-seven such cases1 one hundred and twenty-five of the children died4 ,the number of the mothers also1 who either died or were made sufferers all their future lives1 was undoubtedly great1 though unknown4 ,it is evident therefore1 that presentations of the ,trunk are the most unfavorable known1 and labor in them is but rarely spontaneous4 ,nature can but very seldom effect the delivery of the ,ftus herself1 and even when she does it is with the greatest risk1 both to it and the mother4 ,the accoucheur should always assist therefore1 if he can1 because even if nature can complete the delivery it is with such danger4 ,the means of assisting1 by turning1 will be described in another ,chapter4 ,if the ftus is not at full term1 and of course is under the full size1 its expulsion may be left to nature safely1 but not otherwise4 ,,section ,v4 ,,the ,,physiology ,,of ,,spontaneous ,,delivery1 ,,or ,,childbirth1 ,,and ,,the ,,manner ,,of ,,conducting ,a ,,natural ,,labor4 ,having now completed the description of the ,mechanism of ,delivery1 in all the various presentations and positions1 it is necessary to explain the physiological phenomena attending a natural labor1 and the duties of the accoucheur when conducting it1 and to show what assistance he can render1 and when he should or should not interfere4 ,,chapter ,,xv4 ,,of ,,delivery ,,in ,,general4 ,,different ,,kinds ,,of ,,delivery4 ,when the child is brought into the world by the unaided efforts of nature1 and without any accident to itself or the mother1 it is called a ,natural ,delivery4 ,when it occurs by the efforts of nature alone1 but not advantageously for both1 it is not called natural1 but simply ,spontaneous ,delivery4 ,and when assistance is required it is called an ,artificial1 or difficult ,delivery4 ,it is also called precocious1 or tardy1 according as it comes before or after the full term4 ,,causes ,,of ,,labor4 ,what it is that causes labor to commence1 and proceed1 is not fully known4 ,at the proper time the ,uterus prepares to cast out the ftus it has so long retained1 in the same manner that the tree casts off its fruit1 and from some efficient cause which we have not yet discovered4 ,it is probable that1 when the ftus attains a certain size1 it presses upon the nerves of the neck of the ,uterus and irritates them1 and they react again upon the muscular fibres of the ,womb and cause them to contract1 and so expel its contents4 ,this is much the same action1 in fact1 as vomiting4 ,when any body very repugnant to the stomach is swallowed1 it irritates the nerves of that organ1 and then they excite its muscular fibres1 which1 by forcible contractions1 expel the offender4 ,it is possible1 also1 that the ftus itself may instinctively assist in bringing about its own delivery1 as was supposed of old by ,hippocrates1 and more lately by ,harvey and others4 ,it is certain that labor is both more difficult1 and more dangerous1 when the child is dead2 though it may take place as usual after the death of the mother1 providing the child be still alive4 ,several instances of this kind have been known1 when the living child was expelled from the ,womb1 by the natural process1 sometime after the mother had ceased to breathe4 ,the contraction of the muscular fibres of the ,womb however1 must be regarded as the immediate or efficient cause of ftal expulsion1 let them be brought on how they may4 ,the muscles of the ,abdomen1 and the diaphragm1 also assist1 in the last stage1 but are not essential4 ,the young of some of the lower animals are observed to perform certain peculiar motions1 during delivery1 by which it is much facilitated2 and this is considered a proof1 by some1 that voluntary movements of the ftus assist in the process4 ,certainly if it be supposed1 as we have shown there is good grounds for doing1 that the child assists in placing itself in the best position1 it is equally probable that it also assists in its own expulsion1 in other ways4 ,,signs ,,of ,,delivery4 ,premonitory ,signs4--,a few days before delivery the ,uterus descends much lower1 so that the diaphragm and stomach are less pressed upon1 and the breathing and digestion becomes easier in consequence4 ,the ease which is thus experienced is sometimes so great that the female becomes unusually animated and cheerful1 and cannot think she is so near her travail4 ,this is not always the case however1 for some on the contrary feel very uncomfortable and melancholy4 ,the lips of the ,vulva are also apt to swell and become painful1 and the lower limbs numbed and cramped1 owing to the child's head pressing on the large nerves4 ,the neck of the bladder is also very liable to be compressed1 so that a constant desire is felt to urinate1 and a similar trouble may also be experienced in the ,rectum4 ,most of these inconveniences1 but particularly the numbness and cramps in the limbs1 are not likely to be experienced except when the head presents1 because no other part is so formed as to be able to descend sufficiently low2 when they are felt therefore1 the female may console herself by the reflection that they indicate1 with tolerable certainty1 that the child is presenting in the best position it can for a safe and speedy delivery4 ,standing1 or walking1 usually become more difficult1 and swelling of the external parts1 or piles1 are apt to occur4 ,with some females also1 a sudden diarrha1 or vomiting1 takes place1 and troubles them up to the period when labor commences4 ,finally the ,uterus begins to contract1 though insensibly at first2 the ,abdomen becomes unusually hard1 and flying pains are experienced1 particularly with first children4 ,this continues with more or less of intermission1 up to the actual period of labor1 which is usually divided into three periods1 each of which must be considered separately4 ,,chapter ,,xvi4 ,,the ,,progress1 ,,phenomena1 ,,and ,,duration ,,of ,,natural ,,labor4 ,,first ,,period4 ,on making an examination the mouth of the ,womb will be found to be dilating1 and a discharge of mucus1 tinged with blood1 issuing from it4 ,the membranes may also be felt protruding into the ,vagina1 and distended1 like a bladder4 ,the female complains of being drawn powerfully together in the inside2 she trembles1 and gasps for breath2 her pulse sinks1 and she often becomes sick and deadly faint2 she complains of great thirst1 and breaks out into profuse perspiration2 frequently she will weep1 and apparently suffer from some terrible apprehension1 while her strength will be completely exhausted4 ,occasionally however1 she will be perfectly passive1 and almost immoveable1 appearing as if in a dream4 ,the pains however1 gradually become more and more acute1 and closer together2 the patient is excited and irritable2 her pulse becomes quicker again1 the thirst increases1 and vomiting frequently ensues4 ,before each pain she frequently experiences a severe chill1 with chattering of the teeth1 and not unfrequently becomes perfectly delirious4 ,with each pain the mouth of the ,womb expands more and more1 till at last it totally disappears1 and the cavity of the ,uterus and the ,vagina form but one uniform passage1 which is completely occupied with the distended membranes1 or bag of waters1 which may be felt like a soft round tumor4 ,this is well represented in the following ,plate3-- ,illustration3 ,,plate ,,xxxviii4--a4 ,fig4 #a4 ,fig4 #b4 ,fig4 #a shows the state of the parts at the beginning of labor4 ,the mouth of the ,womb is considerably dilated1 and the ,membranes1 ,a1 are protruding slightly4 ,fig4 #b shows the state of the parts at the end of the first period4 ,the neck of the ,womb is now so fully dilated that it forms a continuous passage with the ,vagina1 while the bag of waters1 ,a1 projects far down and occupies the whole width of the canal4 ,the first period may be much protracted1 and is generally very exhausting1 though not attended with any danger or special difficulty4 ,,second ,,period4 ,at this stage all the previous symptoms become much exaggerated4 ,the contractions are more powerful1 and the pains more acute1 but with a perfect period of repose between them1 during which the female will feel quite easy1 and even sometimes fall asleep1 but only to be aroused by the pains coming on again4 ,the muscles of the ,abdomen1 and the diaphragm1 are now called into play2 the patient strains1 or violently bears down1 and pants with exertion1 while the perspiration streams from every pore1 the pulse quickens1 and the expression of the countenance betrays the wildest anxiety and excitement4 ,the bag of waters now descends1 and enlarges more and more1 until at last1 being unable any longer to bear the strain to which it is subject1 it bursts1 and the waters flow away in a profuse gush4 ,immediately this takes place the head descends1 and closes up the passage2 the pains cease for a time1 and the patient again has a respite1 while the uterus apparently gains fresh power4 ,very soon the contractions recommence1 more energetically even than before1 the head passes the mouth of the ,womb and enters the ,vagina1 which keeps enlarging as it descends1 till it reaches the lower part1 or floor of the pelvis4 ,the pains now become more violent than ever1 the patient screams with agony1 clutches hold of any object near her1 throws herself back1 draws in her breath1 and bears down with all the force she can command4 ,the fearful cries which most females emit at this time appear to assist the delivery1 by the convulsive efforts at breathing which they necessitate1 and the expulsive straining also does the same4 ,these natural efforts are much assisted by providing a firm support for the patient's feet1 against which she can push1 which she will do with tremendous force4 ,the head now presses1 at each pain1 against the perineum1 which begins to project outwards1 as also does the ,rectum4 ,the ,vulva begins to dilate1 the lips separate wider and wider1 and part of the child's head becomes visible4 ,gradually the lips become thinner and thinner1 and at last disappear nearly altogether1 so that the mouth of the ,vulva is only composed of thin ring1 which seems ready to give way every moment4 ,the head however recedes1 and the parts again assume something like their natural condition for a short time1 when the same process again takes place1 and the distension proceeds still further1 while the head does not retire so far4 ,this alternate action is repeated perhaps many times1 so that the external mouth is opened gradually1 and without the lips or perineum being torn1 which they would be if the head were to pass suddenly1 before they were softened and dilated4 ,after this has been continued for a sufficient period a strong expulsive pain is felt1 the female screams1 the head passes clean through the external opening1 and the lips close round the neck4 ,this however1 is only for an instant1 the rest of the body speedily following the head1 in the manner hereafter to be explained4 ,most usually1 in fact1 the whole body follows the head without any stoppage at all1 but sometimes there is a delay of a few seconds4 ,the ,third period of delivery comprises the delivery of the ,placenta1 which will occupy our attention in another place4 ,differences in the process of ,labor4--,although1 in most cases1 labor proceeds much in the way ,i have just explained1 and is attended with similar phenomena1 yet still we occasionally see marked exceptions4 ,this is particularly the case with regard to pain4 ,most females suffer severely at this time1 and some even the most torturing agony1 while others again experience scarcely anything to complain of1 and some even feel nothing at all4 ,i am acquainted with a lady at the present time1 the mother of several children1 who assures me she never felt any pain at all in her labors1 nor was she in any ways exhausted by them4 ,i have known her rise from her bed in the night1 from feeling indications of the approaching event1 make all her arrangements1 and send for the nurse1 as if it was the most ordinary affair imaginable4 ,on one of these occasions1 before her husband returned with the assistants1 she was delivered while alone1 without any difficulty1 and they found her sitting up in bed nursing the child4 ,she had cut it loose1 and tied up the cord herself1 having heard how to do so at one of my ,lectures1 and actually brought away the ,placenta with her own hand4 ,in two days after she was about as usual4 ,and yet this lady was by no means strong1 nor remarkably healthy2 and what is very singular1 she suffered severe pains at most of her monthly periods2 much more1 as she assured me1 than from all her labors put together4 ,m4 ,chailly also mentions an instance of a young girl of sixteen1 with her first pregnancy1 whose ,vagina was also partly closed by an internal membrane1 whose delivery nevertheless was almost painless4 ,she woke up1 he tells us1 about four o'clock in the morning1 with some very slight pains1 which scarcely disturbed her1 but which continued till about six1 when the child was born suddenly and safely1 without any assistance1 and with scarcely any increase of pain to the mother4 ,i have known many other such cases as these1 and plenty of them can be found recorded2 but what this fortunate exemption from suffering1 in such cases1 depends upon1 is not known4 ,the nature1 and the seat of the pains1 is also very variable4 ,some only feel a dull sort of aching1 with powerful contraction1 or drawing together1 while others call it grinding1 cutting1 and burning pain4 ,some feel it in the back1 and some at front1 while others feel it most in the groins1 and others again experience it in all these parts at once4 ,the peculiar sharp pain which results from the extreme dilatation of the external mouth1 when the head passes1 is perhaps the most constantly felt1 and the most alike in all4 ,the manner in which the mouth of the ,womb opens1 and the time required for its dilatation1 differ much in different cases4 ,in females who have previously borne children1 as before explained1 the mouth is always considerably opened at the full term1 while in a first pregnancy it is nearly closed1 even till some time after the labor actually commences4 ,sometimes the dilatation takes place rapidly1 and at others very slowly2 it is especially liable to be delayed if the ,membranes break too soon1 because then the pressure of the bag of waters is lost1 and that is an important agent in expanding the ,os ,uteri4 ,in some cases the neck of the ,womb is very hard and rigid1 so that a long time is required to make it give way4 ,when any other part than the head presents also1 the opening of the mouth will not take place so soon1 because no other part so completely fills up the passage4 ,the breaking of the bag of waters will sometimes occur very early1 almost as soon as it protrudes2 while at other times it will be delayed till the whole ,vagina is filled up by it1 or even till it appears externally4 ,the quantity of the water discharged at the time of the rupture is also variable2 if the presenting part of the ftus does not completely block up the passage1 the whole may pass away when the rupture takes place2 but if it does1 as is usually the case when the head presents1 only a part flows then1 and the rest comes in gushes1 as the head is raised1 and when the child is born4 ,the too early escape of the waters1 as already explained1 may retard the delivery1 by delaying the expansion of the mouth of the ,womb2 and in this way unskilful accoucheurs have caused lingering labors1 by breaking the membranes too soon4 ,it is important to recollect also1 as ,i explained before1 that a portion of fluid sometimes exists between the amnion and chorion1 which may pass first1 and induce the belief that the true waters have escaped1 when they have not4 ,this is called the false waters1 or shows1 and is not connected with the true waters at all4 ,the general physiological phenomena of a natural delivery having thus been explained1 we have now to state its duration1 and then proceed to its conduct or management4 ,,duration ,,of ,,natural ,,labor4 ,the duration of natural labor is not by any means constantly the same1 nor can it be predicted with anything like certainty in any case2 but still by keeping careful records1 and by duly observing a vast number of cases1 a tolerable approximation can be made4 ,there are various circumstances that tend to lengthen the duration of labor1 some general1 and others belonging to the individual4 ,the mode of life and early habits of the female1 the climate in which she lives1 and the manner in which she has conducted herself during gestation1 all have an important influence4 ,as a general rule1 the period becomes longer in proportion to the civilization of the community in which she lives4 ,the first labor is generally more tedious than the succeeding ones1 owing to the slower dilatation of the parts4 ,it is also thought by some1 that the labor is longer in proportion to the age of the female1 particularly with the first child2 but this opinion is not well founded4 ,the average duration of labor in our country1 is from eight to twelve hours4 ,in some parts it is longer than this1 and in others again it is much shorter4 ,i have good reason also to think1 that it is longer in cities than in the country4 ,an experienced practitioner can sometimes predict with tolerable certainty1 when called to a labor1 how long it will be before it is over2 but this is seldom the case1 and most frequently his success is owing more to chance than to judgment4 ,if the mouth of the womb be well dilated1 the contractions powerful1 and the patient vigorous1 with the presentation natural1 he is of course justified in predicting a speedy delivery2 or the reverse1 if these favorable conditions do not exist4 ,many unforeseen conditions may exist1 however1 and many accidents arise1 that may falsify an apparently safe conclusion4 ,no judicious practitioner1 except in a few rare cases1 will hazard his reputation by fixing any time1 and no well informed patient would ask him to do so1 because she would know that it was out of his power4 ,,chapter ,,xvii4 ,,the ,,conduct ,,or ,,management ,,of ,a ,,natural ,,labor4 ,,preliminary ,,requisites4 ,in most cases of natural labor there is not much assistance needed4 ,the assistant should1 however1 possess a certain tact1 or manner1 calculated to make a favorable impression on the patient4 ,this is especially needed when a man officiates4 ,it must be recollected1 that the situation of the female at such times is a very peculiar one1 and that the presence of one of the other sex1 however necessary1 must be more or less objectionable to her4 ,he should1 therefore1 carefully exhibit in his behavior the most refined delicacy1 combined with a warm sympathy and kind consideration2 thus soothing her scruples and enlisting her gratitude4 ,he must also appear perfectly self-possessed under all circumstances1 and then she will have full confidence in his skill and judgment4 ,it may seem scarcely necessary to state these things1 but ,i have often known men officiate without such qualifications1 and also be perfectly unaware of their deficiencies4 ,such accoucheurs never officiate well2 they may be skillful and attentive1 but yet unsuccessful1 and unappreciated4 ,they are only tolerated1 but not respected1 and are never fully confided in4 ,when requested to see a woman supposed to be in labor1 it is always advisable to be prompt in paying the visit1 because delivery sometimes comes on suddenly and unexpectedly1 and both mother and child may be in great danger if no one is near to assist4 ,some time before the event is expected1 it is advisable to provide certain articles1 which will or may be needed at the time1 and which should not have to be looked for at the last moment4 ,a pair of sharp scissors1 with a piece of strong thread or cord1 are indispensable1 and a female catheter may be needed4 ,a quill with the feather part on1 may also be useful2 and some pure lard or sweet oil is frequently called for4 ,the professional accoucheur will also find it a good precaution to have his stethoscope in his pocket1 and a lancet1 if he ever relies upon bleeding in any contingency4 ,a small box of extract of ,belladonna also1 may often be of great and immediate service4 ,,preliminary ,,proceedings4 ,the first thing required when visiting the patient1 is of course to ascertain positively whether she be pregnant1 and whether labor is really commenced1 and if so how far it has progressed4 ,this necessitates an examination1 the proposal and making of which require the most delicate tact1 particularly if it be with a comparative stranger1 or in a first labor4 ,no allusion to it should be made to the patient herself by the assistant2 he should converse with her about indifferent matters1 or merely upon her health1 and state his wishes to the nurse or female friend1 and then retire4 ,this gives them time to inform her of what is required1 and to make the necessary preparation4 ,on entering the room again1 he should not proceed abruptly1 but resume the conversation1 and make some of the necessary arrangements while carrying it on4 ,he should seat himself by the side of the bed1 with his right hand next her1 and his face opposite hers4 ,then passing his hand under the bed clothes1 after having lubricated it with lard or oil1 he can proceed with the examination as if it were a simple ordinary proceeding4 ,by exhibiting no hurry1 and appearing to think it nothing unusual or in any way strange1 the female herself will cease to think it so1 and will not be flurried or shocked4 ,the hand must be passed under the female's right thigh1 her knees being elevated4 ,she should1 of course1 lie on her back1 and as near to the edge of the bed as convenient4 ,not the slightest exposure is necessary1 nor allowable under ordinary circumstances4 ,the fore-finger being introduced1 ballotment may be practised1 to ascertain if pregnancy really exists2 and if the evidence from this source is not sufficient1 auscultation must be resorted to4 ,after being satisfied on this point1 the mouth of the womb must be carefully examined1 and its degree of dilatation noticed4 ,if the female has pains1 their character and frequency must also be noticed1 and the effects they produce on the parts4 ,it will generally be possible by these means1 to discover how far the labor has progressed1 and even to form an opinion how long it is likely to last4 ,the general form of the parts and their size1 should also be noticed2 particularly of the pelvis1 so that any deformity or deficiency may be discovered4 ,and lastly1 the presentation should be ascertained1 if possible1 so that it may be known in time whether nature will be sufficient herself or will require helping4 ,the position need not be cared for at present1 because it is of little consequence when the presentation is favorable4 ,the time required to make the examination need not be long1 and should always be as short as possible4 ,while conversing with the patient1 much useful information may be gained4 ,the general state of her health1 the nature of her pains1 and the time they first commenced1 should all be known2 and if she has had children before1 it will be highly useful to know what kind of a labor she had2 whether it was long or short1 easy or difficult1 and particularly if attended with any accident likely to occur again4 ,it need scarcely be remarked that great caution is needed in these cases1 many eminent men having been deceived as to the patient's condition1 as already stated in our chapter on the signs of pregnancy4 ,and many times the doctor has been summoned under the supposition that labor had begun1 while it was yet far off4 ,the pains may be false ones1 such as frequently occur towards the end of pregnancy1 and may all pass away4 ,these false pains1 however1 can usually be distinguished1 being continuous and irregular1 while the true ones intermit with periods of almost perfect ease1 and are tolerably regular4 ,the false pains are also felt in various parts1 while the true ones are chiefly fixed in the uterus and vagina4 ,sometimes1 however1 the difficulty in distinguishing them is very great1 and the accoucheur has often waited for several hours and even days2 the labor meanwhile making no progress2 and eventually all has passed off1 and the patient has risen again from her bed4 ,i know one case1 where a gentleman attended nearly three days1 at the end of which time the patient rose and walked down stairs4 ,she was not put to bed till six weeks after4 ,i can scarcely think1 however1 that these mistakes can happen very frequently1 if the examination be properly conducted4 ,,preparations ,,for ,,the ,,delivery4 ,if it appears from the examination that labor has really commenced1 or is about to do so1 everything should be at once prepared4 ,all useless persons should leave the room1 and also those who would be likely to alarm or grieve the patient by uttering cries1 or exhibiting fear2 but no objection should be made to any one being present whom she wishes to see1 unless they cannot be depended upon4 ,thus some females always wish to have their husbands with them1 but others do not1 though they are averse to saying so4 ,in these cases the accoucheur1 if he be an attentive observer1 will soon see what is really desired by his patient1 and will manage matters accordingly4 ,the dress of the female should be perfectly loose1 consisting of a wrapper or night-gown1 but sufficiently complete and warm to allow of her getting up to walk in the chamber1 if she desires it1 as some do4 ,no corsets1 garters1 or other tight bandages1 however1 should be allowed4 ,the bed should be prepared by placing the mattress on the top1 or by removing all from it2 and then placing a thick layer of blankets or quilts1 with a folded sheet over them4 ,this is to provide a firm level surface1 in which the body will not sink1 and also to prevent the fluids soaking through4 ,it is an excellent plan1 if the material can be obtained1 to place a thin oil-skin or ,india-rubber cloth under the folded sheets1 as this keeps all perfectly dry underneath4 ,some persons also place another folded sheet1 or a cushion1 under the pelvis1 to keep it elevated2 but this is not necessary1 unless the bed sinks in very much4 ,it is also advisable to leave a foot-board or other firm body1 against which the female can press her feet when bearing down2 and a long towel folded lengthways should be passed under the back1 so that it can be raised up by a person lifting at each end4 ,this will often be found a better mode of pressing the back1 which nearly all patients call for1 than by merely forcing the hand against it1 which is both tiresome and insufficient4 ,another towel may also be firmly fixed to the bottom of the bed1 so that she can pull by it1 at the same time that she pushes with her feet4 ,some persons are confined on a cot1 but this is not a very good arrangement1 because it sinks in too much in the middle1 and is not sufficiently large and firm4 ,it is advantageous in one respect1 however1 as it can be placed by the side of the bed1 into which the patient can be lifted when all is over1 and be comparatively dry and comfortable4 ,this is the most frequent plan in ,france4 ,if the bed be properly arranged however1 the under sheet can be withdrawn1 and clean warm napkins then passed under the body1 which will be equally as good4 ,the covering should consist of a sheet1 with blanket or coverlid1 according to temperature1 and should1 of course1 never be removed1 except under peculiar circumstances4 ,the chamber itself should be as quiet as possible1 well ventilated1 and not too warm4 ,nothing distresses the patient more than a close1 hot atmosphere4 ,the accoucheur need not1 of course1 be present while these arrangements are being made2 and when he retires he should suggest to the nurse that the female may attend to the bowels and bladder during his absence4 ,this precaution may both facilitate the labor1 and prevent much future annoyance4 ,it would even be advisable to administer an injection if necessary1 of thin starch and a little castor oil1 rather than leave the bowels unmoved4 ,in regard to nourishment1 nothing is needed or proper in the shape of solid food2 because all the energies of the system are concentrated in the uterus1 and as digestion cannot therefore go on1 it would only be an evil4 ,if the labor is much protracted however1 some broth or soup may be taken1 or a little milk4 ,as a general rule1 no spirituous liquors or stimulating drinks of any kind should be taken2 because they impart no real strength1 and may produce inflammation1 or congestion on the brain4 ,some females always prefer tea to drink1 others lemonade1 toast water1 gruel1 or barley water1 and others again simple cold water1 which is perhaps the best of all4 ,in cases of great exhaustion it is sometimes advisable1 and even necessary1 to give a little wine1 or brandy and water1 but it should always be cautiously administered4 ,in some parts it is customary for the female to lie on her side during delivery1 with a pillow between the knees2 some even choose this mode1 and others will desire to stand1 or place themselves on their knees4 ,the most frequent position however1 and certainly the most convenient1 is on the back1 though it may often be changed with advantage under peculiar circumstances4 ,in the early stages of labor she can lie1 or move about1 as she chooses1 or even rise if more agreeable4 ,,attendance ,,after ,,the ,,preparations ,,are ,,made1 ,,and ,,during ,,the ,,delivery4 ,when everything is arranged the assistant should take his seat on the right hand of his patient and repeat the examination4 ,if the head presents1 he need not concern himself much further at present1 but if it be any other part1 he should prepare at once to change it1 or assist1 as the case may be4 ,at this second examination the parties present1 and the female herself are usually anxious to know if the child is coming right1 and how long the labor is likely to last4 ,the answer to these inquiries should be guarded and circumspect in regard to the duration1 because of its uncertainty1 but if the presentation is right1 it is well to say so at once1 because this gives great comfort and encouragement4 ,if it be unfortunately wrong1 it is best not to say so abruptly1 but remark that it is rather obscure1 or cannot yet be fully distinguished1 and so keep up the spirits of the female while you await the proper time1 or make the necessary arrangements1 to interfere2 and then tell her there is a little difficulty which requires to be righted1 but which will not be serious1 nor cause much delay4 ,if the labor steadily progresses it is necessary to remain with the female and attend to it2 but if it be delayed1 and everything remains natural1 she may be left for a time with advantage4 ,when the second stage is fairly commenced however1 and especially after the membranes are broken1 the attention should be unremitting4 ,the state of the parts should be ascertained frequently1 so that the actual progress may be known1 and any necessary assistance rendered4 ,the state of the bladder especially should be observed1 and if it be full and the female unable to urinate1 the catheter should be passed4 ,neglect of this precaution may lead to serious accidents4 ,while making the examinations1 the hand should be introduced with great care1 so as not to bruise or lacerate the parts1 and it should not remain longer than absolutely necessary4 ,many females exhaust themselves unnecessarily by bearing down1 and straining1 with great force1 from the very commencement of labor1 under the mistaken idea that it is necessary to do so1 or will assist4 ,they should be told not to do so however1 till after the membranes are broken1 and not even then unless the neck of the womb begins to dilate4 ,they should also be told not to make any effort except during a pain1 as it will not assist at any other time4 ,no attempt should be made1 under ordinary circumstances1 to rupture the membranes1 or dilate the mouth of the womb1 even though nature may be slow in doing so4 ,patience must be practised1 both by the female and by her assistant1 and sometimes it is severely tried4 ,when the waters have escaped1 and the orifice is opened1 an examination must be made1 to discover whether the cord has descended1 or either of the arms1 as is sometimes the case1 and if so1 they must be returned if possible4 ,as the head descends to the bottom of the pelvis it compresses the rectum1 and produces a feeling as if the bowels must be moved1 or even causes them to be so4 ,this is apt to distress the female1 and make her wish to rise1 which cannot be permitted4 ,if anything of the kind occurs no notice should be taken of it1 or she may even be assured she is mistaken1 while a clean napkin may be interposed4 ,this1 as ,dr4 ,chailly observes1 will soothe her delicacy4 ,such an accident is very apt to occur towards the end of the labor4 ,when the head has rotated1 and presents at the external opening1 or vulva1 and begins to distend it1 the greatest care is required4 ,this is a critical period1 during which the accoucheur can render more real assistance than at almost any other4 ,there is danger at this time1 as formerly explained1 of the head passing through too quickly1 before the parts are sufficiently relaxed1 and so causing them to rupture4 ,this is particularly the case with the perineum1 against which the head presses with great force4 ,it is necessary therefore to support the perineum1 as it is termed1 to prevent this accident4 ,this is done by passing the right arm under the patient's right thigh1 and placing the palm of the hand flat against the perineum1 with the thumb encircling one side of the vulva1 and the forefinger the other4 ,the hand is then gently1 but firmly1 pressed against the part during every pain1 so as to prevent the head passing too quickly1 and also to elevate it1 and thus relieve the perineum of part of the strain1 and throw the occiput under the pubes4 ,some practitioners also pass the left hand over the thigh1 at the same time1 and grasp the back of the head with it1 thus holding the head as it were between the two hands1 so as to direct it at pleasure4 ,the manner of doing this is represented in plate ,,xxxix4 ,,plate ,,xxxix4 ,the manner of supporting the perineum1 during the passage of the head4 ,the right hand is placed underneath1 so as to push the head gently back1 when it presses on the perineum too forcibly1 before it is dilated2 and also to elevate it towards the pubes4 ,the left hand is seen above1 grasping the top of the head1 to assist4 ,this may be done or not1 according to the necessities of the case1 or the custom of the assistant4 ,illustration3 ,plate ,,xxxix4 ,the manner of supporting the perineum1 during the passage of the head4 ,it is also necessary to request the female at this time to moderate her efforts1 and not bear down too strongly4 ,if however she be too excited1 and eager to do so1 more care must be used1 and the head pressed back still more forcibly1 till the parts are fully relaxed4 ,for want of these precautions there is often serious lacerations of the perineum and vulva1 particularly in first labors1 and when the parts are unusually rigid4 ,if proper care be bestowed however1 these accidents ought to occur but seldom1 even in the worst cases1 and nothing can be more hurtful to the reputation of an accoucheur than for them to happen4 ,sometimes it is necessary to support the perineum for hours1 and to bestow constant attention the whole time4 ,it is often useful to keep applying a little simple ointment1 or lard1 in the intervals of the pains1 mixed with the extract of ,belladonna1 which will soften and relax the parts4 ,dr4 ,lee also advises the application of a sponge1 dipped in warm water1 and which would probably do much good in many cases4 ,it will of course be understood that the pressure only needs to be made during the pains2 when the head draws back the ointment or warm sponge may be applied4 ,the knees of the female should be held up by some one1 if she bears down too much1 so as to prevent her from doing so too powerfully4 ,when it is felt that the parts are fully relaxed1 and sufficiently distended1 the head is left at liberty1 during a strong pain1 and it immediately passes the outer ring1 or is born4 ,it should then be held up1 towards the pubes1 and the mucus should be cleaned from the mouth with one of the fingers1 so that the child may breathe4 ,a careful examination should also be made round the neck1 to see if the umbilical cord is around it4 ,if it be so1 but is not tight1 it may be left alone1 or pulled a little over one shoulder1 or even passed clean over the head1 if it can be easily drawn out long enough4 ,when it is very tight1 and cannot be eased1 it must be cut through1 or it will strangle the child4 ,in most cases the shoulders follow immediately after the head1 the uterus resting only a few moments2 but if they do not the head may be slightly drawn upon1 or the fore-finger of the right hand may be linked under the arm1 and a little force employed1 though very carefully4 ,it is better however to wait even two or three minutes1 and only resort to these means when there is evidently a partial suspension of the natural efforts4 ,sometimes also the contractions may be brought on again by merely pressing the hand over the fundus of the uterus1 and this should therefore be tried first4 ,in all cases it being better to let the uterus expel the child than to bring it away by manual force4 ,during the passage of the shoulders the perineum needs as much care as during the passage of the head1 and must be supported in the same way4 ,indeed some authors are of opinion that most cases of laceration are caused by the shoulders4 ,after the shoulders are expelled the limbs and body speedily follow4 ,the child should be received in the hands of the accoucheur1 and laid on its side1 at a little distance from the vulva1 so that it may not be suffocated by the discharged fluids4 ,he should then take a strong ligature and pass it twice round the umbilical cord1 about two inches from the navel1 and also at about four inches1 and then cut the cord through1 between the two bands1 with a pair of sharp scissors4 ,the child may then be handed to the nurse4 ,the tying of the cord is by some deemed unnecessary1 and in most cases probably is so1 but as children have been known to bleed to death1 when it was not done1 it should never be neglected4 ,some practitioners only tie it once1 leaving that part open which is still attached to the placenta1 and they suppose this is advantageous1 inasmuch as it partly empties the placenta of its blood1 and so helps to detach it4 ,there is little or no fear1 as some suppose1 that this bleeding can be extensive enough to hurt the female1 or second child if there be one1 and even if it were likely to be so it could soon be stopped2 it has the inconvenience however of soiling the bed more1 and this is probably one great reason why the second ligature is applied1 which certainly is not necessary4 ,in my directions ,i have said that the cord may be tied about two inches from the abdomen1 and this will be sufficient if the child breathes2 but if not it should be left about four inches long1 so as to give room to cut it again1 which is occasionally needed1 as will be seen further on4 ,the knot should be drawn very tight1 and great care must be taken never to tie it so near as to pinch the skin of the abdomen1 which passes a little distance up it4 ,a small portion of the intestine will enter the cord sometimes1 and swell it out for an inch or more2 this must be pressed back with the thumb and finger1 and carefully avoided by the ligature4 ,some practitioners cut the cord first and tie it after1 but ,i think the other plan is decidedly the safest and the best4 ,after this is accomplished the accoucheur should place his hand again over the fundus of the uterus1 to discover whether it contracts1 and also to judge whether there be another ftus4 ,if the womb is felt drawn up into a hard round ball1 in the middle of the abdomen1 all is right1 and no apprehension need be felt2 but if it remains unaltered in size1 and is soft1 flooding is to be feared1 and the hand should be firmly pressed1 or kneaded1 over the fundus1 to bring on contraction4 ,if there be another ftus1 the womb will remain much the same as before labor1 and the child may also be felt4 ,it is better however to make an examination internally1 and then1 in most cases1 the membranes and presenting part of the second ftus will be found at the upper strait4 ,if there be any doubt after this it is even better to carry the hand a little way into the womb1 than to remain in ignorance on such an important point4 ,the delivery of the second ftus usually follows close upon the first1 though sometimes there will be a delay of some hours1 or even days4 ,and in general there is little or no difficulty with the second1 owing to the parts having been already prepared2 but the longer it is delayed the less easy it becomes4 ,immediately the birth is fully effected the female feels1 as most of them express it1 in heaven2 there is an almost instantaneous change1 from the most agonizing pain to a state of perfect ease4 ,she ceases her cries1 and falls into a quiet and pleasing languor1 strikingly at variance with the state of intense excitement she was in but a few moments before4 ,this repose however1 does not last long2 the ,placenta yet remains1 and a new effort is required to expel that4 ,,delivery ,,of ,,the ,,after ,,birth1 ,,or ,,placenta ,,and ,,membranes4 ,unlike the ,ftus the ,placenta is fast to the walls of the ,womb1 and can only become separated from them by the contraction of their substance1 which usually commences soon after the birth of the child1 and is indicated by new pains1 and a slight discharge of blood4 ,in about a quarter of an hour1 or twenty minutes1 the accoucheur should enquire of the patient whether she has felt any of these pains1 and he should also examine whether the ,placenta has reached the mouth of the ,womb1 or ,vagina1 so that he may remove it4 ,if the pains have not yet come on1 and the ,placenta is not in the passage1 he should press one hand on the fundus of the ,womb1 to promote its contraction still further1 and then gently draw upon the cord with the other1 holding it as high up as possible1 either by a piece of linen around it1 or by looping it around the finger4 ,it should be pulled very gently1 but steadily1 downwards and backwards4 ,if it be snatched1 or drawn too hard1 it may break1 and cause great trouble2 or it may pull down the ,womb1 and either invert it or bring on falling of the ,womb afterwards4 ,the hand placed over the fundus can detect this accident1 and if the uterus be felt to sink down the cord must not be drawn upon any longer4 ,pulling away the ,placenta too soon1 and with rudeness1 has often led to deplorable accidents4 ,in nearly every case it will gradually separate itself1 and be delivered in about half an hour1 and should only be assisted by slight drawing on the cord1 and by pressing the fundus4 ,when the ,placenta is completely detached there is seldom any difficulty in its passing the neck of the ,womb1 and down the ,vagina1 but it usually requires to be drawn through the external opening by the hand4 ,in doing this the membranes may be twisted round the cord1 so as to wind them altogether1 and strengthen the cord4 ,in case the separation does not take place we must wait1 and continue the slight strain on the cord and the friction over the fundus4 ,it is not reckoned safe however1 by most authors1 to wait more than an hour2 and if there is no sign of its coming by that time artificial delivery is resorted to4 ,this is accomplished by carrying the hand carefully up into the ,womb1 and separating the ,placenta from its walls with the fingers1 and then bringing it down at once4 ,when the afterbirth has passed the ,vulva1 a careful examination should be made of it1 to see that no part is left behind2 and for still greater security it is advisable to explore the ,vagina thoroughly1 so that any detached portion may be removed4 ,the membranes are very apt to become broken1 and fragments of them left1 which though ever so small may cause trouble4 ,the finger should also be passed into the mouth of the ,womb1 so as to clear it2 for sometimes a large clot of blood1 or a piece of the membranes1 will remain and keep it open1 and thus cause severe flooding4 ,it is generally considered1 by those who have bestowed attention on the subject1 that assistance should always be rendered1 if the afterbirth does not come very soon4 ,there is danger1 if it be left too long1 of the mouth of the ,womb contracting and retaining it2 in which case it becomes absolutely necessary to abstract it1 but exceedingly difficult1 and even dangerous1 to do so4 ,dr4 ,lee says it should never be left more than an hour at most1 and that it is best never to delay removing it even so long as that4 ,when left purposely1 for observation1 it is found to be expelled spontaneously1 and soon1 only in a few cases2 usually it remains several hours1 and most frequently it requires to be removed by hand4 ,no doubt it is natural for it to be expelled unaided1 but it must be borne in mind that our females are usually too weak1 and deficient in energy1 to perform any unusual natural function without assistance4 ,the accoucheur must use great caution1 so as neither to intrude his help when not required1 nor yet to refuse it when really needed2 and above all he must not substitute violence for skill4 ,when the afterbirth is brought away1 a bandage should be passed round the body of the female1 made of soft linen1 twelve or fourteen inches wide4 ,it should be drawn moderately tight1 and fastened securely4 ,if it pass round twice it will be all the better1 and it should be drawn down as near the pubes as possible4 ,i know many ladies who prefer the ,india ,rubber bands1 recently invented1 as they press more equally and firmly1 and are put on with less trouble1 being all in one piece and drawn over the feet and limbs4 ,some accoucheurs put on the wrapper immediately the child is born1 before the afterbirth passes away2 but ,i think this is not the best plan4 ,when properly adjusted1 the supporting band gives great comfort to the female1 and is very useful4 ,some ladies provide a curious kind of corset to put on1 invented for the purpose1 which however1 as a celebrated author recently remarked1 ,are usually stiff and unyielding1 like the prejudices of their patrons1 and often prove injurious4 ,none of them are equal to the simple contrivances above-mentioned4 ,,attentions ,,to ,,the ,,female ,,after ,,the ,,delivery ,,of ,,the ,,afterbirth4 ,when the afterbirth is removed the patient should be left to repose herself for about a quarter of an hour1 during which time most of the blood escapes1 and then she must be made as comfortable as possible4 ,in ,france1 and with many persons here1 it is customary to cleanse the patient with a sponge dipped in warm water1 pass a clean warm sheet under her1 and then put on clean linen1 after which she is lifted into the clean bed1 previously well warmed2 the accoucheur himself carrying her there4 ,most frequently however1 the sponging is dispensed with till some time after1 and also the changing of beds--the under sheet merely being withdrawn1 and a warm dry one passed in its place1 while the female's limbs are gently wiped4 ,in either case the female should be disturbed as little as possible1 particularly if there be danger of flooding1 and she should be carefully guarded from cold4 ,when the soiled and wet clothes are removed1 as completely as possible1 warm napkins should be placed under the ,pelvis and between the limbs1 to soak up the discharge1 and they should be carefully changed as often as needed1 without uncovering the patient4 ,if she be disposed to sleep however1 and is much exhausted1 these attentions need not be pressed too much till she is recovered a little4 ,many persons here have a dread of using the sponge immediately1 and of being carried to another bed2 but there is no danger from either practice1 in ordinary cases1 when carefully performed2 and it is so productive of comfort1 that ,i never knew one but what was pleased with and benefitted by it1 and desirous of its being done in their subsequent labors4 ,some females will even rise and take a cold bath1 or be wrapped in a wet sheet1 not only without evil effect but with positive advantage4 ,i would not advise any one to do this however1 particularly if they are the least timid at it1 or doubtful of its propriety4 ,without the mental stimulus of faith and hope it may be hazardous4 ,it shows however1 that many of the popular notions1 as to the requirements and susceptibilities of females1 in this state1 are entirely unfounded4 ,the patient may either experience great comfort after being thus attended to1 or she may complain very much4 ,some will even be attacked with a kind of chill4 ,their teeth will chatter1 and their hands and feet grow quite cold4 ,this however usually passes off1 and she falls asleep4 ,the accoucheur ought to remain for an hour or two1 even though she sleeps soundly1 and appears quite well1 because she may become suddenly worse1 or flooding may set in with such violence as to endanger life in a few minutes1 when unchecked4 ,if the patient desires any nourishment she may take a little simple soup1 or gruel1 but nothing stimulating1 unless a little wine be needed from extreme exhaustion4 ,,attentions ,,to ,,the ,,child4 ,inspection when born4--,as soon as the child is born its mouth and nose should be cleared from mucus1 if that has not been done already2 and if it has not breathed1 means should be resorted to immediately to make it do so4 ,sometimes the whole head is covered with a thin membrane1 called the caul1 or veil1 which is most probably only a portion of the ,amnion1 and which may cause suffocation4 ,i remember a case of this kind in my own practice1 in which the caul was unnoticed at first1 and the child came near dying from it4 ,nothing could be seen1 and as it bent before the finger1 when pressed into the mouth1 it was totally unobserved4 ,the nurse however1 called out that the child did not breathe1 and a close examination as to the cause soon revealed why4 ,on passing the finger under the edge of the membrane1 which was round the neck1 it came off like a cap1 and the child cried immediately4 ,washing the child4--,the cleansing of the child may usually be safely committed to the nurse1 or other female attendants1 though some of them have very absurd and injurious practices in this respect4 ,thus ,i have known them rub the whole body over with whiskey1 or raw spirits1 before washing it1 which must cause great coldness from its evaporation1 and also great irritation4 ,the only thing required is perfect cleanliness1 and this should be effected in the quickest and simplest manner4 ,some very mild soap1 and moderately warm water1 is all that is really needed1 though a little sweet oil1 or fresh lard1 or butter1 rubbed on first1 appears to facilitate the operation4 ,the drying should be done as quickly as possible1 after all the mucus is washed off1 and with great care2 the napkin being as soft as it can be1 and never rubbed hard1 for it takes but little force to remove the skin4 ,many persons take great trouble1 and are a long time over this infantile wash without succeeding well with it4 ,they are deceived by the tough mucus slipping under the hand1 but still clinging to the body1 where they leave it even after using the napkin2 it then dries on and forms a hard skin1 very difficult to remove1 and very irritating4 ,this can be avoided with care1 and by using the oil first1 which appears to soften the mucus4 ,some persons use flour1 or ,indian meal1 and others starch1 but none of these are so good as the simple means we have described4 ,dressing the child4--,after the washing and drying is completed the child must be dressed1 and this is a process in which comfort and utility is frequently sacrificed to mere fashion and prejudice1 as it is in adults4 ,the article next the skin should be of soft line linen1 which may be followed by others of warmer material1 according to the temperature4 ,they should all be perfectly loose in their make1 and quite soft to the feel4 ,as far as possible they should all be fastened with strings1 rather than pins4 ,these metallic points are troublesome to fix1 and often injure the child1 in spite of every precaution4 ,they are also apt to be referred to as the cause of the child crying1 and thus prevents other causes being sought for1 which frequently exist4 ,some people put a thick flannel cap on the head1 over a linen one1 but others leave this part altogether uncovered1 which ,i think is the best plan4 ,at most there should only be the linen covering2 the head being better rather cool than otherwise4 ,the dressing of the cord is the next duty1 and this is done by taking several pieces of soft linen1 oiled a little1 and cutting a small round hole in the middle of each1 through which the cord is passed4 ,the linen then lies flat on the abdomen of the child1 and the cord on the top of that1 the holes being just large enough for it to pass easily through4 ,five or six pieces are usually put on1 but very frequently only one is used1 and is found quite sufficient4 ,it should be very fine1 and soft4 ,when this is done another layer is laid over the cord1 and then a bandage of soft linen1 about four or five inches wide1 is passed two or three times over it1 and round the body4 ,this completes the dressing1 and the child may now be wrapped up warmly and laid down to sleep--remembering1 as ,dr4 ,chailly remarks1 that if it be laid on a chair1 or sofa1 it may be accidentally sat upon and killed1 an accident which has happened4 ,,accidents ,,which ,,may ,,happen4 ,before these dressings are needed however1 there are frequently other things of more importance to be attended to4 ,if the labor has been long1 or the presentation unfavorable1 the child may be born apoplectic1 from the pressure it has received4 ,the face will be puffed up1 and of a blue color2 the body will be swollen1 and the limbs without motion1 while the pulsation will scarcely be felt1 either over the child's heart or in the cord4 ,it will feel warm1 and the limbs will be quite flexible1 but still there will be no signs of life4 ,in this case it should be exposed naked to the cool air1 and even blown upon2 and if that does not resuscitate it the cord may be cut through below the ligature1 so as to let out two or three tea-spoonfuls of blood4 ,after this it generally revives1 and begins to move1 while its face assumes a natural color1 and the swelling goes down4 ,the mouth and throat should also be carefully cleaned with a quill feather1 of all mucus4 ,a more frequent accident is ,asphyxia1 or want of breathing1 in which case the surface of the body is cold and pale1 and no breath whatever is drawn1 though the heart beats quite naturally4 ,very weak children1 or those born before their time1 are most likely to become asphyxiated1 or those delivered by instruments4 ,the first thing to be done is to carry the child to the open window1 if it be not exceedingly cold1 and expose its head and chest to the air1 while the rest of the body is wrapped up warm4 ,this will often make it gasp1 but if it does not a little cold water may be dashed on its face and chest1 and the throat may be tickled with a feather4 ,the breech may also be smartly slapped1 and the chest well rubbed with the cold hand4 ,when it begins to breathe a little it may be put into a warm bath up to the middle1 and a warm injection may be given to it4 ,in most cases these means will speedily bring it round1 but if they do not the attendant should place his mouth close over that of the child and breathe into it1 so as to fill the lungs1 and then press down the chest to empty them again1 repeating the process several times4 ,this may be called artificial breathing1 and if it succeed once only there is a probability of its effecting the desired object4 ,the breath however1 must not be blown in too hard1 or it may injure the child's lungs1 nor too rapidly4 ,sometimes a tube is used1 which is passed down into the throat2 but it is troublesome1 and not much better than the mouth1 if any at all4 ,these efforts may be repeated twenty or thirty times if necessary1 or even more4 ,in some cases it is requisite to continue using some1 or all of these means1 for an hour or two without intermission1 before the child begins to breathe freely4 ,i knew an instance even1 where the nurse continued to do so for five hours1 and at last fully recovered the child1 though all present1 including the doctor1 had given it up4 ,she said she did not despair while it continued warm1 though it was doubtful whether the heart beat or not4 ,this may show that the attempt should not be abandoned too soon4 ,in cases of asphyxia no blood should be lost at all1 but on the contrary the cord should be carefully examined to see if it is tied fast2 the bleeding from it frequently aggravating the evil4 ,congenital weakness4--,some children are born extremely weak1 and remain constantly debilitated and cold4 ,this is very apt to be the case when they are born before the full term1 or when the mother is diseased4 ,they should be carefully wrapped in cotton1 or very soft flannel1 and kept warm by bottles of warm water4 ,many instances are on record of these weak children becoming afterwards extremely robust1 so that they need not be regarded with unmixed apprehension1 nor neglected from a supposition that they must die4 ,the child may be deformed4--,the accoucheur should also carefully examine the child1 to see if it be deformed in any way1 or has met with any accident1 because in some of these cases assistance is required immediately1 and may be rendered at once4 ,the child's capability of endurance4--,the capability of the new-born infant to endure extremes of cold is almost as great as that of its mother1 and sometimes even it is benefitted by them4 ,with many persons it is customary to plunge it in cold water1 immediately when born2 and in ,russia1 we are told1 it is even rolled in the snow4 ,in some cases these extremes may be beneficial1 but in others ,i have no doubt they prove fatal4 ,a medium course is best1 in most instances1 leaving the extreme to be resorted to when we wish a sudden stimulus4 ,when all these matters are carefully attended to1 and both mother and child have remained for an hour or two without any unpleasant symptom1 they may be left to the care of the ordinary attendants1 giving them strict orders to send for proper assistance immediately1 if anything unusual transpires4 ,,subsequent ,,attentions ,,to ,,mother ,,and ,,child4 ,the ,bladder4--,one of the most important points to attend to is the urine4 ,a few hours after the delivery is fully effected1 unless the female is reposing1 she should be asked whether she has any desire to urinate2 and1 if she has1 the convenience should be at once afforded to do so4 ,there is always more or less danger of retention of urine1 from the pressure that has been exerted on the bladder2 and if it be allowed to continue too long its removal becomes exceedingly difficult4 ,if on making the attempt the urine does not flow1 the catheter must be used1 and the sooner the better4 ,the pain arising from retention of the urine has often been supposed to arise from inflammation of the womb1 or bowels--neither patient nor physician knowing its real source1 till the passage by the catheter gave relief4 ,there have even been instances of females dying1 merely from an overcharged bladder1 while their attendants were industriously treating them for uterine inflammation4 ,this accident therefore1 should always be suspected1 and a very little attention will prevent any mistake in regard to it4 ,when allowed to become too full the swollen bladder may be felt1 just above the pubes1 hard and tender1 so that the least pressure upon it causes great pain4 ,if not relieved it will at last burst4 ,the ,bowels4--,if the bowels are not opened naturally1 it will be well1 the following day1 to administer an injection of thin starch and water1 or to prescribe a small dose of castor oil1 or a seidlitz powder4 ,this should also be repeated for two or three days1 till the natural power is restored4 ,the ,food4--,but little solid food should be taken1 and nothing stimulating4 ,gruel1 milk1 toast and water1 ,indian meal1 light puddings1 or broth1 should be the chief articles for some time4 ,roast apples are also very good1 being pleasant and relaxing4 ,for refreshing drinks1 if there be any fever1 lemonade or tamarind tea may be taken4 ,the ,after ,pains4--,after the expulsion of the after-birth most females experience1 more or less1 severe pains1 almost like those of labor1 arising apparently from the further contraction of the uterine walls to expel the coagulated blood4 ,these pains are seldom or never felt in first labors1 but afterwards they are often most acute4 ,i have known many patients suffer much more from them than they did during labor4 ,they sometimes last only a few hours1 or a day1 and sometimes even extend to six or eight days4 ,nothing that we know of can prevent them1 though many means are known of mitigating their severity4 ,if there be no tendency to flooding1 a large poultice may be placed over the abdomen1 or it may be fomented1 or covered with cloths wrung out in hot water4 ,an injection may also be used1 either in the ,vagina or ,rectum1 consisting of warm thin starch1 with about twenty drops of laudanum2 or either of the following recipes may be used internally3--,pills of ,gum ,camphor1 two1 about the size of ordinary pills1 to be repeated1 if necessary1 in an hour4--,or1 ,syrup of ,poppies1 two drachms2 ,mucilage of ,gum ,arabic1 two ounces2 and ,solution of ,sulphate of ,morphia1 ten drops2 to be made into a mixture1 one-half of which may be taken at first1 and the remainder in two hours1 if the patient is not relieved4 ,this seldom fails4--,it is necessary to bear in mind that the pains arising from inflammation have been mistaken for ordinary after-pains1 and serious consequences have resulted from the error4 ,the after-pains however1 are concentrated1 and intermittent1 while the sensations from inflammation are more diffused and constant1 and are also usually attended by fever4 ,the ,lochial ,discharge4--,from the time of delivery until the uterus has returned to its ordinary condition1 there is poured from it a discharge1 at first like blood1 and afterwards thin and light colored1 called the ,lochia4 ,the duration of this discharge varies from one week to a month1 and its quantity from one ounce to six or eight ounces1 daily4 ,it gradually diminishes however1 and frequently stops for a few days altogether4 ,in women who do not nurse it is both more abundant1 and lasts longer1 than in those who do4 ,the bloody color usually disappears after the first or second day1 though sometimes it will show itself again1 even when the discharge has nearly ceased1 particularly if the female exert herself too soon4 ,it appears that this discharge is essential to health1 and great attention should therefore be bestowed on the patient1 if it be too small1 or cease too soon1 or too suddenly4 ,in most cases it ceases naturally during the milk fever1 and of course its disappearance then need not excite alarm4 ,sometimes also1 it does not attain its full quantity till some days after its commencement4 ,if however1 it remains small past the third day1 or does not appear when the milk fever is over1 means should be taken for increasing it4 ,the best means for this purpose are warm poultices and fomentations over the abdomen1 and injections in the rectum of simple warm water4 ,some practitioners advise two drachms of powdered ,camphor to be sprinkled on each poultice1 and probably it is an excellent addition4 ,occasionally the lochia is very offensive1 and in that case a simple cleansing injection may be frequently used of thin starch1 or ,chammomile tea4 ,during the whole period of the ,lochia in fact1 even in ordinary cases1 the female will be all the more comfortable1 and better1 for an occasional injection1 and frequent washing4 ,this is very much neglected1 though it never ought to be so4 ,the only care required is not to expose her to cold1 which is quite unnecessary4 ,the ,milk ,fever4--,about the second or third day there usually commences a peculiar temporary excitement in the system1 called the milk fever1 which requires to be described because it may be confounded with something more serious4 ,it is generally ushered in by headache1 flushed face1 and a hot dry skin2 the pulse beats slowly1 and the breasts become hard1 while the veins upon them appear very full4 ,in a short time however1 the pulse becomes quicker1 a perspiration breaks out1 and the breasts become still larger and fuller1 so that the female can scarcely bring her arms to her body4 ,these symptoms last about a day1 or two days at most1 and seldom become much aggravated4 ,occasionally the milk fever is preceded by a slight chill1 or by a furred tongue1 or sick stomach1 but not very frequently4 ,the precise causes of this temporary fever are unknown1 though probably it is connected with the full establishment of the secretion of milk1 and hence its name4 ,it is seldom very severe in those who nurse1 and frequently does not appear at all4 ,during its continuance1 and for some time after1 the female must carefully avoid exposure to cold1 and keep herself quiet2 her diet should also be rather restricted1 and light and unstimulating4 ,an occasional seidlitz powder may also be of service1 or a simple injection4 ,making the ,bed4--,it is not customary to disturb the female1 for the purpose of making her bed1 till the milk fever is passed2 or1 if that does not appear1 till the tenth or twelfth day2 and then it should be done with care1 and so as not to expose her unnecessarily4 ,first sitting up1 and ,going out4--,this must of course be determined more by the condition of the patient1 and the state of the weather1 than by any rules4 ,it may be as well to remark however1 no matter how the patient may feel1 that the first attempt should always be made with care4 ,very frequently she thinks herself stronger1 and more capable1 than she really is1 and premature or undue exertion may do great injury4 ,in most cases the female is allowed to rise within the first week1 and sit for a short time in an arm chair2 after which she begins to walk slowly about the room4 ,the first going out is fixed1 by fashion1 at one month4 ,many females however1 are unfit to leave the house till long after that time1 and others should by no means be confined to it so long4 ,of course these proceedings should depend1 as already remarked1 upon the patient's strength and inclinations1 and upon the state of the weather1 and not upon any fashionable observances4 ,some females are quite able to rise1 and even walk out1 in a few days1 with benefit to themselves2 and it exhibits as great a want of correct feeling1 or common sense1 for any one to make disparaging remarks on them for their early appearance1 as it would if they were to blame the poor invalid for keeping her bed4 ,the apartment should be kept constantly well ventilated1 particularly if the female is confined to it1 and all soiled linen1 or other sources of foul air1 should be removed as quickly as possible4 ,there is reason to believe that inattention to this1 and to properly cleansing the person of the female1 frequently produces child-bed fever4 ,attentions to the ,child4--,if the infant's bowels are not opened by the end of the first day it should have a little sugar1 or molasses and water1 given to it1 and if this does not succeed about half a tea-spoonful of syrup of ,rhubarb may be added4 ,this is however but seldom needed1 if it be put to the breast within a few hours1 as the first secretion of the milk possesses sufficient laxative power itself4 ,it should also be observed whether it has urinated1 and if not it should be placed in a warm bath immediately4 ,some persons prefer to let the child wait till the milk fever is established1 before they let it nurse1 but this is very improper4 ,the early feeding does it no good1 and the purgatives it requires are injurious4 ,as soon as the female is sufficiently reposed1 if there is nothing special to forbid it1 the child should go to the breast4 ,sometimes the child will remain sleepy and dull1 and not seem to require food at all1 for several days1 and even die at last of starvation1 unless aroused4 ,if this lethargy continues it should be put in a warm bath1 and afterwards well rubbed1 while a little sugar and water is poured down its throat4 ,these attentions may be required to be repeated for some time4 ,about the fourth or fifth day the portion of the cord above the knot usually separates and falls off1 if it has not already done so4 ,if the navel is inflamed1 or suppurates1 a little simple ointment may be rubbed on1 and it should be regularly and carefully washed4 ,in some infants it swells out very much1 in which case a pad should be made of soft linen1 and laid upon it1 over which the ordinary bandage may be drawn4 ,the complete healing of the part does not occur till about the twelfth day1 and the bandage must be carefully worn till then at least1 and is better continued a little longer1 particularly if there is any swelling1 or if the child cries much1 or strains4 ,,concluding ,,remarks4 ,from the explanations given above of an ordinary natural labor1 it will be evident that but little manual assistance is required1 either to the mother or the child1 and also what really is called for is of so simple a character as to be easily rendered4 ,it would undoubtedly be improper1 and cruel1 to leave females at such times without aid altogether2 but it is also equally improper and injurious to interfere too much4 ,excepting in cases of disease and deformity1 or of very unfavorable presentations of the ftus1 ,nature herself will nearly always effect the delivery2 and much better1 in most cases1 when left to herself4 ,numerous females and infants have been killed1 and still more have been grievously injured for life1 by rude and uncalled for manipulations2 so that it has been a question with some accoucheurs1 of great experience1 whether as many would die1 or seriously suffer1 from receiving no assistance1 as do now from being improperly handled4 ,without going so far1 it is undoubtedly true that great mischief is done in this way1 which can only be prevented by both accoucheur and patient bearing in mind that ,nature herself is usually competent1 and at most only requires skillful and gentle assistance4 ,some practitioners seem to think that labor is a mere mechanical process1 like the removal of a block of stone1 and hence they depend altogether upon force2 overlooking altogether the wonderful vital powers inherent in the system1 which operate with such certainty1 and yet so safely2 and which frequently succeed of themselves when brute force is completely foiled4 ,the nature of the assistance proper to be given1 in any particular stage of labor1 will be evident on inspecting the structure of those parts1 of both mother and child1 which are brought in connection at the time1 and by considering how their mutual relations require to be changed and modified4 ,if those relations are already such as are required1 and the system retains sufficient force1 nothing can be done with any advantage--we must wait1 and let ,nature operate herself4 ,even many unfavorable conditions may be spontaneously corrected1 and it should always be a matter of consideration1 when the means of assistance are not very obvious1 whether it will not be better to rely upon the natural powers than to interfere4 ,great evil has resulted from teaching females that labor cannot terminate1 safely1 without a great deal of assistance1 which can only be rendered properly by those who possess a vast amount of skill and experience4 ,they are thus led to think themselves totally dependent upon the accoucheur1 and many of them actually seem to believe that he is as necessary to deliver the child as a dentist is to extract a bad tooth4 ,if they were better informed they would feel more confidence in their own natural powers1 and would not be so unnecessarily alarmed when unforeseen difficulties occur1 or when professional aid cannot be immediately procured4 ,in most cases there is more danger after the labor is over1 from puerperal fever1 various local inflammations and other causes1 than there was during its progress4 ,indeed the real danger may be said properly to commence several days after1 and the physician is really needed then more than at the time4 ,,section ,,vi4 ,,protracted ,,and ,,difficult ,,labors4 ,the causes which may impede a labor1 and increase its difficulties1 are numerous1 and they are of several different kinds--some depending upon the mother1 and others upon the child4 ,some of these may be easily removed1 or modified1 but others present more serious difficulty4 ,it is therefore necessary to enumerate and explain them separately4 ,,chapter ,,xviii4 ,,the ,,causes ,,and ,,consequences ,,of ,,prolonged ,,labor ,,to ,,both ,,mother ,,and ,,child4 ,,the ,,consequences ,,of ,,prolonged ,,labor4 ,a labor is usually called protracted or difficult1 if the head presents1 when it is not completed in about twenty-four hours from its actual commencement4 ,there are many labors however1 that last much longer1 and yet terminate quite favorably1 and many that are over much sooner and yet are very difficult4 ,still1 generally speaking1 the danger and difficulty increases as the time progresses1 and it is seldom prolonged beyond twenty-four hours without serious inconvenience4 ,it appears1 from the statistics of the ,dublin ,lying-in ,hospital1 that in seventy-eight thousand deliveries1 one out of every ninety-two of the mothers died1 and one out of every eighteen of the children was stillborn4 ,of those mothers who were in labor with first children1 from thirty to forty hours1 one in every thirty-four died1 and one child in every five was stillborn4 ,of those who were in labor from forty to fifty hours1 one died in every thirteen4 ,of those who were in labor from fifty to sixty hours1 one died in every eleven4 ,and of those who were in labor from sixty to seventy hours1 one died in every eight1 and nearly one-half of the children4 ,it is evident therefore that1 as a general rule1 the danger increases with the length of time4 ,,chapter ,,xix4 ,,causes ,,connected ,,with ,,the ,,mother ,,which ,,may ,,impede ,,labor1 ,,or ,,make ,,it ,,difficult4 ,,inertia1 ,,or ,,want ,,of ,,sufficiently ,,powerful ,,contraction ,,in ,,the ,,womb4 ,this is most likely to occur in delicate females1 and in those who are debilitated by disease4 ,the contractions are very feeble1 and1 as the nurses say do not tell2 the mouth of the womb dilates but slowly1 and the head descends with difficulty into the passage4 ,in many cases in fact the labor is so tedious1 from this cause1 that the female becomes completely worn out1 and finally sinks1 while the child is exposed to the greatest hazard from the delay4 ,it is in these cases that the patient's strength needs supporting1 and that stimulants may be useful4 ,a little wine1 or brandy and water1 will often rouse the failing energies1 and bring on a series of strong contractions that will end the labor at once4 ,the most usual resort however is to the drug called ,ergot1 or ,secale ,cornutum1 a fungus growth which is sometimes found on ears of rye4 ,this possesses the peculiar property of exciting the womb to contract1 the same as an emetic excites the stomach to vomit1 and it seldom fails in its effect2 but still there are many objections to its use4 ,it not unfrequently causes delirium1 great restlessness1 and anxiety1 sickness1 headache1 and convulsions1 or complete prostration1 from which the female may be long in recovering4 ,it is also supposed by some to be not altogether free from danger to the child4 ,if however no other means were known of making the womb contract1 in such cases1 all the probable evils should be risked1 because the labor must be completed at all hazards2 but other means are known1 which succeed even more certainly than ergot1 and without any danger4 ,the application of ,galvanism1 explained in my ,neuropathy1 and ,practical ,facts1 will almost invariably cause the womb to contract1 and speedily bring the labor to a safe termination1 without the slightest risk or inconvenience1 to either mother or child4 ,simple friction over the abdomen will also succeed in many cases1 and gently rubbing the mouth of the womb with the finger in others4 ,these simple means should therefore always be used in preference to the ergot1 but in case they cannot be resorted to1 or fail1 the drug must be administered1 and ,i will therefore explain the manner in which this is done4 ,when gathered the ergot is in large irregular lumps1 and should be so kept4 ,when wanted for use a single drachm should be finely powdered1 and divided into three parts2 one of these parts to be taken first in a glass of sugar and water1 and the others at intervals of ten minutes1 unless the effects of the first are very powerful4 ,it is often thrown from the stomach however even in still smaller quantities1 and is then given1 by some1 as an injection by the rectum1 in which mode it seems more powerful1 so that a smaller dose is sufficient4 ,great caution should always be observed in using this powerful drug1 as it will sometimes act so energetically as to burst the womb2 or expel the child so suddenly as to lacerate the perineum and other parts4 ,the contractions produced by it are different from the natural ones1 being almost constant1 without any interval1 and gradually increasing in force4 ,they usually come on in about ten or fifteen minutes after the last dose1 and continue about an hour and a half4 ,some practitioners depend almost altogether on the ergot1 in every protracted case1 and even use it to bring on premature labor1 when that is required4 ,thus ,m4 ,p4 ,dubois was once called to a dwarf1 whom he delivered with instruments1 the first time1 but with great difficulty and risk4 ,the next time she became pregnant he determined to bring on premature labor1 and accordingly he administered ergot1 when she was about eight months gone4 ,this brought on natural labor1 and she was delivered without difficulty4 ,m4 ,chailly says he believes it will bring on uterine contraction at any time1 and that he has never known it to fail4 ,i consider however that there is always more or less risk in its use1 and ,i should certainly prefer any of the other means1 particularly ,galvanism4 ,it is of the first importance however to be certain1 before using any forcing means whatever1 that there is no physical impediment4 ,if the pelvis should be deformed or small1 if the child's head should be unusually large1 or dropsical1 or if the soft parts of the mother should be undilated and rigid1 the most serious consequences must ensue from violent uterine contractions4 ,in like manner if the presentation be unfavorable1 particularly if it be one of the trunk1 the danger is equally great4 ,in every case the passage of the child must be physically possible1 before it is attempted to force it away4 ,a neglect of this rule has frequently led to fatal results4 ,the ergot has been given and the uterus forced to contract1 while the pelvis was too small for the child to pass through2 and the consequence has been rupture of the uterus1 or complete exhaustion1 with death to both mother and infant4 ,in other cases the delivery has resulted so suddenly1 from the violence of the expulsive efforts1 that the vagina and perineum have been lacerated in the most shocking manner4 ,the ergot is also especially dangerous to very nervous women1 or to those who are disposed to congestion1 apoplexy1 or inflammation4 ,among the special causes which often paralyze the action of the womb1 may be mentioned a full habit of body1 great distention of the uterus from accumulations of fluid1 and extreme thickness of the membranes4 ,in some cases in fact1 the membranes will be so strong that the most violent contractions fail to break them1 and the uterus completely exhausts itself to no purpose4 ,it is in such cases as these1 when the mouth of the womb is fully dilated1 that the accoucheur should rupture the membranes artificially4 ,this is usually done with the finger nail by pinching them4 ,some practitioners however use a pointed instrument1 or a sharp quill2 but there is always more or less danger of injuring the child or the mother by such means4 ,the best time for breaking them is during a strong pain1 when they are fully distended4 ,the mere scratching1 or pushing on them will frequently suffice4 ,i have known cases however in which they were so strong that an instrument was actually necessary to open them4 ,the death of the infant also seems sometimes to check uterine contraction1 though probably not from the mere circumstance of its being dead1 but because the womb suffers from the same morbid cause which produced its death4 ,any strong moral impression may also produce the same state of things4 ,thus in some females the womb will instantly cease its contractions1 and the labor be arrested1 from fright1 or from strong repugnance to somebody1 or something1 in the room4 ,instances have been known of women being so alarmed on first seeing the accoucheur1 or so displeased because he was not the one they wished1 that the uterine efforts immediately ceased1 and could not be again brought on for a long time4 ,the presence of some person who is a subject of dislike may also have a very prejudicial effect1 and if this is known they should be immediately removed4 ,dr4 ,merriman tells us of a female who was seized with a fit1 from which she died1 simply from seeing a strange doctor enter the room4 ,whatever may be the cause which paralyzes the action of the womb we should endeavor1 if possible1 to discover and remove it4 ,if however it be beyond our reach1 the patient's strength must be supported as much as possible1 and the simplest means of exciting the contractions tried first2 if these fail the more powerful ones must be tried1 always preferring the safest4 ,finally1 if all fail1 the hand must be introduced into the womb1 the child turned1 and brought away by the feet2 or the forceps must be used if absolutely necessary4 ,,rigidity ,,of ,,the ,,mouth ,,of ,,the ,,womb1 ,,vagina ,,and ,,vulva4 ,sometimes the mouth of the womb or other soft parts1 will not give way1 but remain obstinately rigid1 so as to render the continued expulsive efforts of the womb of no avail4 ,if this state continues too long the parts become swollen1 hot1 and dry1 and extremely painful1 so that the slightest touch causes acute suffering4 ,the abdomen also becomes exquisitely tender1 fever sets in1 with cold sweats1 the head begins to wander1 the features express great anxiety and suffering1 and the voice alters so that it can scarcely be recognized4 ,these symptoms will sometimes be established1 and become rapidly worse in a remarkably short time1 so that the patient will appear to pass suddenly from a condition of comparative ease and safety to one of extreme peril and suffering4 ,the child also suffers in an equal degree1 the continued pressure upon its head having a most injurious effect4 ,the bones overlap to a great distance1 the scalp is engorged with fluid1 and all its blood-vessels are ready to burst2 the brain is severely compressed2 the circulation in it is suspended1 and apoplexy frequently ensues4 ,even when one of these protracted cases eventually terminates without immediate mischief1 there is much subsequent evil to be feared4 ,the bruised parts frequently slough away1 so that fistulas are formed1 and the whole remain so permanently weak that they can never afterwards retain their places4 ,the most usual resort in these cases of obstinate rigidity is blood-letting4 ,this frequently induces relaxation immediately1 and also checks the tendency to inflammation and fever4 ,in many cases however1 if not in all1 it may be dispensed with1 and should always be so if possible4 ,very frequently it produces as much evil as good1 by alarming the patient1 and by creating a debility which cannot afterwards be removed4 ,simple warm fomentations will often make the rigid parts give way2 and so will lubricating them with soothing ointment1 or better still anointing them with the ,extract of ,belladonna4 ,this frequently acts like a charm1 and opens the rigid os tinc in a few minutes4 ,injections of thin starch and laudanum are also excellent1 and may be advantageously administered before applying the ,belladonna4 ,the ,galvanic ,battery may also be employed1 it having induced relaxation in many cases1 when all other means failed2 as will be seen by the cases quoted in ,practical ,facts4 ,if the labor really does progress though slowly1 it is generally best to have patience and let it take its course4 ,if however the patient is likely to sink before it is completed1 or if it is at a stand still1 and cannot be accelerated1 artificial delivery may be necessary4 ,it is seldom however that all of the above mentioned means fail4 ,,obliquities ,,of ,,the ,,womb4 ,sometimes the womb is so much inclined in a particular direction that its mouth does not present to the middle of the passage4 ,thus it may lean over so much to the right side that the mouth may open against the left wall of the ,pelvis2 or it may lean to the left side1 or to the front4 ,in all these cases the expulsion of the child may be totally prevented1 because it is forced against the walls of the passage instead of down its axis4 ,obliquity is sometimes righted spontaneously1 but more frequently it requires the interference of art4 ,the mode of rendering assistance is to support the womb on the side to which it falls1 particularly during the pains1 so that its mouth may be directed towards the middle of the passage4 ,,prolapsus ,,uteri4 ,falling of the womb may retard labor1 but is not likely to make it more than usually difficult1 nor dangerous4 ,it is requisite1 however to bear in mind that the head of the child may1 by this displacement1 be found in the vagina1 and even at the vulva1 before it has passed through the mouth of the womb1 because the neck itself is already in the passage4 ,the head may therefore be felt low down1 and the accoucheur may think the labor will soon be completed1 when in reality it has scarcely begun4 ,in such cases it merely requires patience and non-interference4 ,in my work on the ,diseases of ,women1 will be found many curious cases of pregnancy and delivery1 occurring during partial or complete prolapsus uteri2 and also much information regarding obliquity1 and other similar derangements4 ,,smallness ,,or ,,deformity ,,of ,,the ,,pelvis4 ,these constitute by far the most serious obstacles to delivery1 and are most to be dreaded4 ,in treating upon them it will be first necessary to explain the chief kinds of deformities1 and the cause from which they arise1 after which it can be shown how they interfere with the progress of labor1 and how they can be best remedied4 ,deformities of the pelvis may either be congenital1 or they may be produced by certain diseases in after life1 and also by bad physical education4 ,the principal causes however are two diseases1 ,rachitis1 or ,rickets1 and ,malacosteon1 called also ,mollites ,ossium1 or softening of the bones4 ,rachitis usually attacks children somewhere between nine months and two years of age1 and produces a variety of well marked symptoms2 such as large head and belly1 protrusion of the breast-bone1 flattening of the ribs1 emaciation of the limbs1 and various deformities of the bones4 ,the patient may recover from the disease1 but the deformity of the bones often remains1 and therefore no female should become pregnant1 who has had rickets1 till the shape and dimensions of her pelvis are known1 or it may cost her life4 ,malacosteon or softening of the bones1 may come on at any period of life1 and frequently occurs without any serious constitutional disturbance4 ,it consists in a gradual absorption from the bones of all their solid matter1 so that they become soft1 and may be bent or twisted like horn4 ,sometimes this state will be reached very soon1 but at other times the disease progresses very slowly4 ,the causes of it are unknown1 and it is incurable4 ,i have seen a patient who could bend the bone of her leg nearly double1 as if it were a piece of rope4 ,in my work on the ,diseases of ,woman1 ,i have spoken upon various other causes which may deform the bones in young females1 such as wearing corsets1 improper attitudes in sitting1 and want of sufficient unconstrained exertion of the body in the open air4 ,the deformities may be of various kinds1 and may either alter the general appearance and the walk1 or may not be discoverable except on examination4 ,sometimes the pelvis is too large1 so that the womb and other parts are continually falling down into its cavity1 but this is very rarely seen2 more frequently it is either too small1 or irregular in its form4 ,in all cases where the irregularity in form1 or diminution in size1 is such as to prevent the passage of the child an operation becomes necessary1 either upon the mother or her infant1 and great danger is consequently incurred by both4 ,it is therefore the duty of every mother1 if she has the slightest suspicion that her daughter is deformed1 though it may not be apparent1 to have her examined before she is allowed to marry4 ,many have lost their lives for want of this precaution4 ,severe blows or falls in early life may also create a pelvic deformity1 and this1 as a possible consequence of such accidents1 should always be borne in mind4 ,the means by which the form and size of the pelvis are ascertained1 as before stated1 are simple1 and such as need not in any way be feared4 ,to enumerate all the varieties of deformed pelvis1 as described by different authors1 is unnecessary1 and would not be useful here4 ,i shall therefore only refer to them generally4 ,sometimes the pelvis is regular enough in its form1 but singularly small altogether1 not larger perhaps than that of a child eight or nine years of age4 ,more frequently1 however one part only is small1 while the others are full sized1 or the different parts are not in a proper position in regard to each other4 ,thus sometimes the pubic bones will be flattened backward1 near to the sacrum1 so as to narrow the antero posterior diameter of the upper strait2 at other times one of the sides will be flattened towards the other1 as if crushed in1 and thus diminish all the diameters2 and at other times one side will sink down lower than the other1 and thus effect similar changes in another way4 ,by referring to the description of the perfect pelvis1 given in the early part of the work1 the nature of these changes will be readily understood1 particularly if the plates given there are compared with those given here4 ,,plate ,,xl4 ,represents the standard form1 with which the rest must be compared4 ,,plate ,,xli4 ,represents a pelvis which resembles that of the male in its form1 and is therefore called masculine4 ,it is deeper1 and less capacious altogether than the standard one4 ,this form is occasionally met with in females of a peculiar general conformation1 and temperament1 approaching that of the other sex4 ,it is not a sufficient deviation from the natural form to create any great difficulty1 though it may cause delay4 ,illustration3 ,plate ,,xl4 ,represents the standard form of the ,pelvis4 ,illustration3 ,plate ,,xli4 ,masculine ,pelvis4 ,,plate ,,xlii4 ,represents the peculiar deformity most frequently produced by ,mollites ,ossium4 ,the different parts are stretched out as it were1 and crushed inwards toward each other4 ,the size of each strait is diminished in nearly every diameter1 and the whole form is very unfavorable to delivery4 ,this is sometimes called a cordiform pelvis4 ,observe the difference between it and the standard one4 ,,plate ,,xliii4 ,this is called an ,ovate ,pelvis4 ,it appears as if it had been crushed by a heavy weight1 from above downward1 the sacrum being depressed below the plane of the pubes4 ,in this case the antero posterior diameter of the upper strait is so much lessened that the two halves appear nearly separated1 and form almost a figure of eight 7#h74 ,illustration3 ,plate ,,xlii4 ,represents the peculiar deformity most frequently produced by ,mollites ,ossium4 ,illustration3 ,plate ,,xliii4 ,this is called an ,ovate ,pelvis4 ,,plate ,,xliv4 ,this is another kind of deformity1 in which one side is sunk down below the other1 while both are twisted as it were round the sacrum4 ,,plate ,,xlv4 ,this is a section of a ,pelvis to show the effect of a corroding disease of another kind4 ,the whole of this is such a mass of disease and deformity as to preclude any particular description4 ,illustration3 ,plate ,,xliv4 ,this is another deformity1 in which one side is sunk below the other1 and both twisted round the sacrum4 ,illustration3 ,plate ,,xlv4 ,the effect of corroding disease4 ,curvature of the spine sometimes affects the pelvis1 when low down1 and therefore if any female is affected with it she should not marry before being examined4 ,several diseases and lesions of the hip-joint1 and of the thigh1 may also do the same1 and should therefore be suspected4 ,in the great majority of cases1 deformities of the pelvis remain unknown1 till the period of delivery1 and all that can be then done is to combat in the best possible way the difficulties they create4 ,it is evident that the amount of difficulty depends entirely on the disproportion between the head of the child1 and the passage through which it has to be born4 ,if the head be large and the passage small the difficulty will be greatest1 but if the head be small it may pass through the pelvis though under its average size4 ,the development of the head cannot be ascertained however1 before birth1 except when it is unusually large from dropsy1 and it is therefore always assumed to be of an average development1 and the pelvis is compared accordingly4 ,the kind of assistance required in these cases depends chiefly on the measure of the pelvic diameters1 though it may be modified somewhat by other considerations4 ,when the smallest diameter of the pelvis measures from three inches and a half to three inches1 it is customary to leave the expulsion of the ftus to nature1 and it is generally effected1 though slowly and with difficulty4 ,if however the patient becomes exhausted1 or the head be unusually large1 the forceps are generally used after waiting five or six hours4 ,in these cases the head often becomes firmly fixed in the upper strait1 so that great force is needed to dislodge it4 ,the upper part passes through1 owing to the overlapping of the bones1 and the scalp then bulges out like a large tumor1 from being engorged with blood and serum1 but the lower being more unyielding remains behind4 ,it is therefore impossible for the head to move either way1 as it is formed like a figure #h1 and held by the narrow part1 as will be seen by the following plate4 ,illustration3 ,,plate ,,xlvi4 ,this ,plate represents the head fixed1 or impacted1 at the upper strait of a narrow pelvis4 ,when the smallest diameter is not more than from three inches to two and a half1 the birth is sometimes effected by nature1 but with extreme difficulty4 ,the accoucheur waits four or five hours1 as in the former case1 and then if no progress is made he applies the forceps1 using great care in doing so4 ,if the extraction is found impossible1 with reasonable force1 the head must be opened and made smaller1 even though the child be living1 because it is more proper to sacrifice it than to risk the life of the mother4 ,in a case like this however1 no one person would like to decide1 unless in a great emergency2 there should always be a consultation if possible4 ,a dwarf1 named ,lepratt1 who used to perform at the theatres1 was delivered with the forceps by ,m4 ,dubois1 though the pelvis only measured three inches4 ,she perfectly recovered1 though the child was born dead3 it was of fair average size4 ,it is contended by some that the delivery may be effected1 under peculiarly favorable circumstances1 when the passage measures only two and a half inches1 and at all events the effort should be made2 but for the sake of the mother such cases should not be left long1 as the chance is so small1 and the risk of delay so great4 ,when the passage is less than two and a half inches1 spontaneous or artificial delivery is allowed to be impossible1 and the only alternatives then are to dismember the child or open the mother4 ,which of these should be done depends on circumstances4 ,whenever the child can be brought away by the natural passages1 though it be piecemeal1 it always is so brought1 unless the danger to the mother be greater than by the cesarian operation1 in which case that operation is resorted to4 ,by means of an instrument called the ,cephalotribe1 which crushes the head1 the child may be brought away1 unless very large1 when the pelvis only measures two inches4 ,when the passage is less than two inches1 the only resort is to the cesarean operation1 which sometimes succeeds1 and saves both mother and child1 though more frequently the mother sinks4 ,the necessity for all these frightful operations is now much less than formerly1 and may be done away with altogether4 ,this important fact should be known universally1 and also the means to be resorted to4 ,in the first place1 every young female should be examined1 before marriage1 by a competent person1 if there be the slightest reason to suspect deformity2 and in case the deformity is found to exist1 the consequences if she becomes pregnant1 must be laid before her4 ,if1 after being told this1 she will marry1 or has already done so1 the means of avoiding conception should be placed at her disposal1 so that she may not be made1 of necessity1 a helpless victim4 ,these means need not be described here1 though ,i have no hesitation in referring to them4 ,when ,i know that the life1 or life-long health1 of a female1 depends on her not becoming pregnant1 ,i consider it my duty to put such means at her disposal1 if she desires it4 ,in many instances ,i have known females suffer1 several times1 the most frightful tortures1 merely to bring into the world the mangled fragments of a dismembered child1 with the greatest risk to their own lives2 and in others ,i have known them in constant dread of becoming pregnant1 because they were conscious it would be their death warrant4 ,in such cases ,i leave it to humanity1 and common sense1 as to whether such information should be withheld8 ,i could not reconcile it with my notions of duty to withhold it4 ,in case pregnancy has occurred before the deformity is discovered1 and it is then found that a full grown child cannot be born1 premature delivery must be brought on2 or1 in other words1 the ,uterus must be made to expel the child before the full term1 while it is yet small enough to pass through the ,pelvis4 ,this operation is of course only allowable when needed to preserve life1 or to escape great suffering and danger4 ,it must always be decided upon by the medical man1 and performed by him1 so that a description of it is uncalled for here4 ,in ,europe it is quite common1 and nothing has tended so much to do away with those disgusting and horrid operations1 on mother and child1 which were formerly absolutely necessary in cases of deformity4 ,if it is found at the first delivery of a female1 or before1 that she cannot bear a living child at full term1 artificial delivery is accomplished at seven or eight months1 thus avoiding all the danger to the mother1 and frequently preserving the child4 ,in the case of the dwarf before referred to1 when she became pregnant the second time1 ,m4 ,dubois brought on premature delivery1 and the child was born alive1 with but little difficulty4 ,according to statistics it appears that1 when artificial premature delivery has been induced1 in one hundred and sixty-one cases only eight mothers have died1 and all but forty-six of the infants were born alive4 ,of the whole number of children seventy-three continued to live2 and of the eight mothers five died from other causes1 leaving but three whose death resulted from the operation4 ,now when the fearful number of deaths from instruments1 and other operations1 necessary at full term1 is recollected1 the advantage of this practice will be evident4 ,in the ,cesarian operation for instance1 which is often the only remaining resort1 but one female out of six recovers4 ,the delivery should be postponed as long as possible1 so as to give the best chance for the child living4 ,this must of course be decided upon after the size of the pelvis is ascertained4 ,seven months is the earliest time at which the ftus is viable1 and it is much better left till eight1 if the size of the parts will allow of its birth then4 ,in case they are so small that it cannot be born even at seven months1 we have our choice1 as ,m4 ,chailly remarks1 between the dreadful ,cesarian operation at full term1 and producing early miscarriage4 ,m4 ,dubois seems to recommend premature delivery in nearly all cases1 if the smallest diameter is under three inches2 because1 as he remarks1 spontaneous delivery at full term is then a very rare exception1 and the danger and suffering to the mother is so great4 ,he also recommends it when there are tumors1 and even when the female is afflicted with any acute disease4 ,of course it is always necessary1 before operating1 to be sure that the child is alive4 ,i knew a lady myself who had given birth1 at full term1 to seven children1 all of which were torn from her with instruments1 dead1 owing to the smallness of the pelvis4 ,when pregnant with the eighth1 premature delivery was brought on1 at my suggestion1 at about seven months and a half4 ,the ftus was born with comparative ease1 and lived4 ,but for this operation she probably would never have been blessed with a living child at all4 ,since then she has avoided conception4 ,,tumors ,,in ,,the ,,pelvis4 ,tumors of various kinds are met with1 both in the bones of the pelvis and attached to the soft parts4 ,they frequently offer the most serious impediments to delivery1 and baffle the skill of the most experienced obstetricians4 ,in fact they differ so much in their structure1 their size1 and their situation1 that but few general directions can be given as to their management4 ,in every case where one exists pregnancy should never occur1 if possible to be prevented1 before it is removed2 for though it may cause no inconvenience at other times1 yet during delivery it may necessitate very serious operations1 or even cause death4 ,some of these tumors are mere vesicles1 or bags1 filled with fluid1 and may be punctured and their contents let out1 so as to make them less4 ,others are more or less solid but moveable1 and may often be supported above the upper strait till after the child is born4 ,when they are so large as to block up the passage1 and are either fixed or cannot be carried up into the ,womb1 there is often no other choice than to either cut them out or open the child's head2 the practice being determined by the circumstances of the case4 ,in some instances the bladder itself1 distended with urine1 has impeded delivery1 and been mistaken for a tumor2 and in other instances stones in the bladder have caused the same error4 ,a specimen of one of these tumors is represented in ,plate ,,xlvii1 and one of a ,polypus in ,plate ,,xlviii4 ,,plate ,,xlvii4 ,this represents an ,ovarian ,tumor1 which has descended before the head of the child1 and completely blocked up the passage4 ,the delivery1 it will be seen1 is utterly impossible in such a case1 unless the ,tumor can either be pushed away1 or reduced in size4 ,illustration3 ,plate ,,xlvii4 ,case of ,tumor4 ,,plate ,,xlviii4 ,this ,plate represents a case which occurred in the practice of ,dr4 ,ramsbotham1 and which terminated favorably4 ,the polypus had a very long neck1 and was forced out of the external opening by the child1 which was then born with ease4 ,i once saw a case myself1 in which the labor was completely arrested by a large hard tumor about the middle of the ,vagina2 it could not be moved1 and delivery was evidently impossible while it remained4 ,in consultation it was decided to cut it out1 as there seemed but little circulation of blood in it1 and its situation was favorable for the operation4 ,this was accordingly done with but little trouble1 and the child was born without difficulty in about twenty minutes after4 ,the mother perfectly recovered4 ,illustration3 ,plate ,,xlviii4 ,case of ,polypus4 ,,tumors ,,externally4 ,sometimes tumors exist externally1 on the lips1 or in the ,vulva1 but as they seldom offer much obstruction1 and are easily detected and managed1 but little need be said about them4 ,they should always however be attended to1 if discovered1 before labor comes on1 or better still before pregnancy4 ,in some instances the veins around the ,vulva become much enlarged1 and resemble tumors1 and sometimes even impede delivery4 ,it is usual then to open them1 and let out the blood1 but not till the head is sufficiently low to press upon it and prevent dangerous bleeding4 ,,obstructions ,,in ,,the ,,vagina1 ,,and ,,narrowness ,,or ,,obstinate ,,resistance ,,of ,,the ,,vulva ,,and ,,perineum4 ,the ,vagina may be partly closed by its sides growing together1 or it may be united by bands and membranes stretching across2 and these obstructions may be sufficient to impede or prevent delivery4 ,most usually they give way1 and are gradually broken down by the pressure of the child's head2 but if they prove too strong1 after waiting a reasonable time1 they must be cut through4 ,cases have even been known in which the hymen has been found perfect at delivery1 and even offered considerable resistance1 so as to necessitate its being cut through before the child could be born4 ,in such cases this membrane is unusually strong1 and conception occurs without its being broken4 ,when the perineum or ,vulva remains rigid and hard1 so that the opening cannot be enlarged sufficiently for the child to pass1 it may also be necessary to operate with the knife4 ,but this should never be done till after every means of relaxation has been tried1 and the head has been kept back as long as prudent4 ,it is however1 always better to open a passage than to let one be torn1 because it may be made in the most favorable place4 ,when the perineum is allowed to be torn1 the most serious consequences often ensue1 and the patient is made a miserable sufferer for life4 ,the ,vagina and ,rectum may be torn into one1 or the power of retaining the contents of the intestine1 or bladder1 may be for ever lost4 ,when an incision is made none of these evils follow2 the wound speedily heals1 and in a little time no trace of it can be seen4 ,it has even been necessary to cut the neck of the ,womb1 when it would not open1 to prevent the organ from being ruptured2 and this has been done with perfect safety4 ,a celebrated practitioner in this city had to perform such an operation very recently1 on a female who had injured herself1 and made the mouth of the ,womb grow together1 by violent attempts to produce abortion4 ,the delivery took place with comparative ease1 and no unpleasant results whatever followed1 either to the mother or the child4 ,,chapter ,,xx4 ,,causes ,,connected ,,with ,,the ,,child1 ,,or ,,children1 ,,which ,,may ,,impede ,,delivery1 ,,or ,,make ,,it ,,difficult ,,and ,,dangerous4 ,,procidentia ,,of ,,the ,,umbilical ,,cord4 ,this means the escape of a portion of the cord before the child itself4 ,it is most frequent in the irregular presentations1 as they do not so fully close up the mouth of the ,womb1 and it is most likely to occur at the commencement of labor1 though not impossible at a later stage4 ,very often the cord descends when the membranes break1 being carried down by the rush of the waters2 and sometimes it is already in the sack1 or bag1 before the rupture takes place4 ,this accident is comparatively frequent1 being found to occur as often as once in about three hundred cases4 ,the causes which produce procidentia of the cord1 are most likely these3--,a large quantity of liquor amnii1 and its sudden discharge1--,unnatural presentations1--,deformities of the superior strait of the ,pelvis1--,a very long cord1--and rupturing the membranes too early4 ,but it may also happen from other causes with which we are unacquainted4 ,there is seldom much difficulty in detecting this accident1 because if the membranes are broken it protrudes into the ,vagina1 and if they remain whole it can be felt within the sack1 and its pulsation will be quite distinct4 ,sometimes1 it is true1 it may be so firmly compressed1 between the ftus and the walls of the pelvis1 that its pulsation may be very indistinct1 or even totally suspended for a time2 but this only necessitates a little extra care4 ,procidentia of the cord may be very serious for the child2 in fact1 it is a frequent cause of its death4 ,the reason of this will be evident when the functions of the cord are borne in mind4 ,the circulation in it is as necessary for the life of the child before birth1 as breathing is after1 and when protruded first it can seldom escape being so pressed upon as to stop its circulation1 and hence the danger4 ,to the mother it makes no difference whatever1 unless it be told and alarm her2 or unless violent efforts are made to correct it4 ,she had therefore better not know if it occurs4 ,if assistance is not rendered in this accident the consequences are almost always fatal to the child1 though in some instances the cord has remained hanging from the ,vulva several inches1 for an hour or more1 and still the infant has been saved4 ,if the fallen cord is detected before the membranes are broken1 it may frequently be put back into the ,womb without much difficulty4 ,the accoucheur must wait till the mouth of the ,womb is fully dilated1 and then watch his opportunity1 in an interval between two contractions1 to push the cord upwards1 between the ftus and the uterine walls4 ,if he succeeds in this1 as is usually the case1 he must then break the membranes during the next pain1 and this will bring the presenting part at once into the upper strait1 and so block up the passage4 ,to effect this manuvre it is requisite to introduce two or three fingers1 and sometimes even the whole hand4 ,it must never be attempted till the mouth is fully dilated1 otherwise the membranes may be ruptured too soon1 and the delivery be delayed1 thus increasing the danger4 ,after the rupture of the membranes the replacing of the cord becomes a much more difficult matter1 and frequently cannot be effected at all2 particularly if the head be descended far down4 ,every effort however must be made1 and if unsuccessful the delivery should be hastened as much as possible4 ,in many such cases the forceps are applied1 and the child brought away at once1 because every moment's delay increases the risk to its life4 ,several different kinds of instruments have been invented to return the cord1 but they are seldom at hand when needed1 and none of them are so good as the hand itself4 ,if the return of the cord cannot be effected1 and the progress of the labor will allow of it1 the hand is introduced and the child turned1 unless the position of the head will allow of the advantageous application of the forceps1 in which case they are mostly resorted to4 ,the only general rule is1 to terminate the labor as speedily as possible1 consistent with the welfare of the mother4 ,in spite of all that can be done the pulsation is often found to cease1 and when the child is born it is either quite dead or breathes but a few times4 ,a very frequent indication that the ftus suffers from compression of the cord1 is a greenish color of the water discharged1 owing to the discharge of ,meconium from the child's bowels4 ,this is brought about1 most probably1 by its straining1 and its efforts to relieve itself4 ,,shortness ,,of ,,the ,,cord4 ,the cord is sometimes too short1 and this may operate very unfavorably in many ways4 ,it may keep the ftus up in the ,womb1 and prevent it from descending to the bottom of the ,vagina1--it may cause the placenta to be torn away too soon1 and so lead to serious flooding1--it may pull down and invert the ,womb1--or it may make the labor very tedious1 and cause the death of the child4 ,unfortunately there are but few signs of this accident1 even after the rupture of the membranes1 and none at all before1 that can be depended upon4 ,if the head has descended properly1 and the parts be fully relaxed1 but still the expulsion is delayed from no obvious cause1 it may reasonably be supposed that shortness of the cord exists2 and if so there is very soon given a proof of it by a discharge of blood4 ,this is owing either to the breaking of the cord1 or to the separation of the placenta1 and is frequently the first intimation the assistant has of the accident4 ,all that can be then done is1 to conclude the delivery as soon as possible1 and in the best way that circumstances will allow4 ,in some cases the cord is not too short absolutely1 but is made so by being twined round the body or limbs of the child1 which are often cut off by it4 ,m4 ,tasil saw a case where the cord round the neck had nearly severed the head2 and ,montgomery gives several instances in which the limbs had been amputated in this way4 ,two of these are represented below3-- ,illustration3 ,,plate ,,xlix4 ,fig4 #a4 ,fig4 #b4 ,limbs cut off by the ,cord4 ,occasionally the cord can be slipped over the head1 or limbs1 when wound round them1 and the strain upon it be thus removed4 ,if this cannot be done however1 and the danger increases1 relief may be obtained by cutting the cord1 particularly if it be absolutely short4 ,but this must not be done till everything indicates that the labor will probably soon terminate2 and the end connected with the child must be carefully held1 or tied4 ,,descent ,,of ,,other ,,parts ,,with ,,the ,,head4 ,one ,arm4--,the descent of one arm along with the head may cause some delay and difficulty1 but ,nature nearly always overcomes the impediment4 ,it is seldom that the arm can be reduced1 and therefore but little can be done at first2 if the delivery be evidently arrested by it the accoucheur must at last assist in the most feasible manner4 ,sometimes even it is necessary for him to apply the forceps4 ,the ,two ,arms4--,even this difficulty is often overcome spontaneously1 though much more rarely than the former one4 ,as soon as it is detected1 the accoucheur must endeavor to return one or both of the limbs1 if the labor has not proceeded too far2 and if he cannot succeed the delivery must be accomplished as soon as possible1 either by turning or with the forceps1 unless there be reasonable ground for delay4 ,the ,feet4--,either one or both of the feet may also descend with the head1 at first1 though they usually recede and allow the head to be born alone4 ,when they are so impacted as to prevent the delivery being completed1 the accoucheur must interfere4 ,in most cases he will find it quite easy to push the feet above the head1 and allow that to descend alone2 but if this is not possible he must introduce one hand1 grasp the feet with it1 and pull them down1 while the other pushes the head up4 ,this will turn the child1 and if it be in no immediate danger1 and the mother is not suffering1 the rest may be left to nature2 but if the contrary is the case1 the delivery must be finished as speedily as possible4 ,when the head is very low down it may be necessary to use the forceps1 but great care must be observed not to grasp the feet along with the head when using them4 ,a ,foot and ,arm4--,the proceeding is the same as with the foot alone4 ,if the limbs cannot be returned the head and arm must be pushed up1 while the foot is brought down4 ,,twins ,,and ,,triplets4 ,in most cases where there are two or more children the delivery is easier than with one1 because they are generally small1 and the first one so prepares the way that the rest are born without difficulty4 ,it is also a fact that twins are nearly always born before full term1 and consequently are not quite grown4 ,the expulsion of the second ftus usually takes place1 immediately after the first1 though sometimes the ,womb stops contracting1 and it is not born for half an hour or more1 and it may even remain for hours or days4 ,it is a question whether1 in such a case1 the second delivery should be left for ,nature to finish1 or whether the accoucheur should terminate it sooner artificially4 ,the most general practice is to wait only about half an hour1 and then1 if the ,womb is still inert1 use friction1 or other necessary means1 to excite it1 and accomplish the second delivery as soon as possible4 ,if there be more than two the proceeding is still the same4 ,some difficulties may arise however with twins1 which it is necessary to be prepared for4 ,thus the two heads may come together1 and mutually impede each other4 ,in this case the one which moves the easiest must be pushed up till the other is descended sufficiently low4 ,one head may also descend with one or two feet2 in which case1 if the feet cannot be returned1 the head must be pushed up1 and they must be brought down4 ,the force exerted however1 must not be very great at first1 because one may belong to each of the children1 and much injury may be done2 a little gentle traction will soon detect this however1 with ordinary care4 ,if two arms1 or one arm and a foot descend1 the same care is also required1 before pulling upon them1 to ascertain that they are not parts of the two children4 ,sometimes when the head of one twin descends along with the feet of the other they may1 if small1 descend together4 ,but if this is impossible1 and interference is needed1 we must first try to push up the head2 and if this cannot be done1 it must be drawn upon1 not the feet2 because if the feet were drawn down the two children would soon occupy the passage together1 body and head1 and would perhaps become firmly wedged4 ,in nearly every case one of the twins presents by the head and the other by the feet1 as formerly shown4 ,,excessive ,,size ,,of ,,the ,f,,tus1 ,,or ,,the ,,diseased ,,development ,,of ,,certain ,,parts4 ,ftus too large4--,it is very rarely the case that the ,ftus is so large as not to pass easily through a well-formed ,pelvis1 though such cases have been known4 ,the mode of proceeding is of course precisely the same as if the pelvis were too small4 ,if no means will succeed in abstracting the ,ftus whole1 it must be made less2 but ,nature should be first allowed full time to act with all her force4 ,hydrocephalus4--,this consists of an accumulation of water in the head of the child1 and is usually termed watery head4 ,the bones of the cranium will sometimes be widely separated by it1 and the head be made so large that it cannot possibly be born till made less4 ,the causes which produce this disease before birth are unknown4 ,in cases of hydrocephalus the head does not descend into the straits1 owing to its size1 and is felt to be full and firm1 during a pain1 but soft and yielding during the intervals1 especially at the fontanelles and sutures1 which are also very large4 ,the bones are usually very wide asunder1 or even totally separated1 as if floating in the fluid4 ,in some cases1 when the quantity of fluid is but small1 the delivery may terminate spontaneously2 the head lengthening1 from being so soft1 and thus adapting itself to the size and form of the strait4 ,most frequently however1 assistance is rendered in such cases1 either by the forceps1 which will sometimes succeed1 or by puncturing the head1 and letting out the fluid4 ,this operation has been performed and the child saved1 though such an occurrence can never be reasonably anticipated4 ,such instances however1 show that great care should be taken not to injure the brain1 as that would destroy the small chance there is4 ,dropsy may also occur in the chest1 or abdomen of the child1 causing similar difficulty with dropsy of the head4 ,if the natural or artificial expulsion of the child cannot be effected without1 the part must be carefully punctured1 and the fluid evacuated4 ,tumors on the ,ftus4--,sometimes various kinds of tumors form on the child's body1 but they are rarely so large as to prevent delivery1 though they may delay it4 ,if they should be too large however1 it will be necessary to remove them1 as in the case of tumors in the ,pelvis4 ,,ossification ,,of ,,the ,,head4 ,occasionally the bones of the head will be so hard1 and so closely united1 that they will not overlap1 in which case the labor may be very difficult1 unless the head is small1 or the pelvis very large4 ,if after waiting a reasonable time1 there be no prospect of the labor terminating naturally1 and the female is exhausted1 it must be terminated artificially1 as if it were a case of deformed pelvis4 ,it is seldom however1 that the head does not eventually give way4 ,,various ,,presentations ,,and ,,positions ,,of ,,the ,f,,tus1 ,,from ,,which ,,the ,,labor ,,may ,,be ,,difficult ,,or ,,protracted4 ,presentations of the ,face4--,these are usually more difficult1 and longer1 than those of the head4 ,they will nearly always however1 terminate spontaneously1 or with ordinary assistance2 but1 if they should not1 artificial delivery must be practised1 either by turning1 if the case be not too far advanced1 or with the forceps4 ,some of the most celebrated authors recommend that all these cases should be treated like cases of natural labor4 ,dr4 ,merriman says that in some very favorable instances turning may be practised with safety and advantage2 but ,dr4 ,lee says1 ,my firm belief is1 that the child1 even under such favorable circumstances1 would have a far better chance to be born alive if the labor were left wholly to ,nature2 or1 if the natural powers were inadequate1 to be extracted with the forceps4 ,in such cases there is often too little patience1 and too much interference4 ,the forehead inclined against the ,pubes4--,in this position the labor may be long delayed1 and difficult1 and most practitioners endeavor to turn the head round1 if they cannot bring down the feet1 or else apply the forceps at once4 ,dr4 ,lee however remarks1 and very properly1 ,from all that ,i have seen of these cases1 ,i am disposed to believe that it is best to leave them to the natural efforts1 and to avoid all interference1 all attempts to change the position1 while the pains continue regular1 and the head advances1 however slowly4 ,if the labor does not progress at all1 or the female becomes exhausted1 of course artificial delivery is necessary4 ,several varieties of head and face presentations may also retard labor considerably1 but ,nature nearly always overcomes the difficulty2 or if she cannot do so mere ordinary assistance is required4 ,,presentations ,,of ,,the ,,lower ,,extremities4 ,it has already been remarked1 in another place1 that breech presentations mostly terminate spontaneously1 and that but few of them require interference4 ,in some of them even1 when the pelvis is large1 or the ftus small1 the delivery is effected quite rapidly4 ,still such presentation occasionally causes delay and difficulty1 and necessitate more or less assistance4 ,as soon as the mouth of the ,womb is opened sufficiently1 unless the labor is rapidly progressing without it1 one of the fingers may be introduced and hooked over the groin1 and a little gentle force exerted upon it4 ,this will assist very much1 and will often be all sufficient4 ,if the pelvis is too small1 or the ftus too large1 and the delivery is evidently arrested1 the breech must be pushed up1 if possible1 and the feet be brought down1 as in turning4 ,the remarks of ,dr4 ,lee on this presentation are so plain and practical1 and marked with such good sense1 that ,i think a better explanation of what should be done in such cases-could hardly be given1 ,i will therefore quote his remarks in full3-- ,having ascertained that the nates present1 whatever the position of the ftus may be1 whether the abdomen look backward or forward1 we cannot alter it with safety1 and no change can be required to be made till the nates and lower extremities are expelled4 ,the os uteri dilates slowly in most cases of nates presentation1 but we cannot employ any means with advantage to accelerate the delivery1 and in most cases1 if we do not interfere1 but wait patiently1 they are gradually pressed lower and lower into the pelvis1 and at last escape from the vagina without any assistance4 ,if the os uteri and vagina are imperfectly dilated1 and the nates are drawn down or pass rapidly through the pelvis1 the child is often lost4 ,the membranes should not be ruptured1 and the expulsion of the nates should be left entirely to the natural efforts1 unless the labor is protracted and exhaustion takes place4 ,except supporting the perineum1 nothing is required in a great proportion of these cases before the nates and lower extremities have been expelled1 when it becomes necessary to ascertain precisely the relative position of the child to the pelvis1 to rectify this if it is unfavorable1 and artificially extract the superior extremities and head1 to prevent the fatal compression of the umbilical cord4 ,if we find1 after the expulsion of the nates and lower extremities1 that the toes are directed forward1 or that the child is in the position represented in the second figure1 with its abdomen applied to the anterior part of the uterus1 and that its back lies along the spine of the mother1 we should wrap the nates and sides in a soft napkin1 and turn the child very gently round during a pain1 observing to which side the feet are inclined to turn1 till its abdomen is to the spine of the mother1 and the toes are directed backward to the hollow of the sacrum1 or to the side of the pelvis4 ,in many cases the nates turn round in the passage spontaneously1 so that it is not required artificially to alter the position4 ,it is necessary always to recollect that it is possible to turn the body of the child round without turning the face round into the hollow of the sacrum1 and that the chin may be over the symphysis pubis when the front of the chest and abdomen are turned backward4 ,after the lower extremities and body of the child have been expelled1 and placed in the most favorable position for the extraction of the superior extremities and head1 it is necessary to proceed without loss of time to draw these through the pelvis1 that the child may not be destroyed by compression of the umbilical cord4 ,as pressure upon the cord for a very short time will in some cases kill the child1 it is proper to watch closely the pulsations of its arteries4 ,draw the body of the child forward as far as the arm-pits1 and place it over the palm of your right hand and fore-arm1 and gently draw the body towards the left thigh of the mother2 then pass the fore and middle fingers of your left hand along the back part of the left arm of the child to the elbow-joint1 and press down the arm with your lingers along the thorax of the child1 and extract it4 ,then transfer the body of the child and left arm to your left hand and fore-arm for support1 and with the fore and middle fingers of your right hand disengage and bring down1 in the same way1 the right arm of the child2 then pass the fore and middle fingers of your left hand into the mouth of the child1 or rather over the lower and upper jaw1 and at the same time place the fore and middle fingers of your right hand over the back part of the neck and occiput1 and with the fingers of the two hands thus applied extract the head1 in the line of the axis of the pelvis4 ,the perineum is very rigid in some cases of nates presentation1 where it is the first child1 and it will be torn if the head is extracted hastily1 and not drawn forward to the symphysis pubis4 ,when you feel the pulsations of the cord beginning to cease1 you may be tempted to employ greater extracting force than the neck of the child and perineum can bear1 and both may be destroyed4 ,the only method of obviating this is to press back the edge of the perineum1 that the air may gain admission into the mouth of the child1 and the respiration go on1 when the circulation in the cord has been arrested1 until the perineum is sufficiently dilated to slide back over the face1 and allow the head to pass4 ,i have seen from twenty minutes to half an hour elapse in some cases1 after the cord had ceased to pulsate1 before the perineum would allow the head to escape1 during which time the respiration was regularly performed4 ,this is not a new practice2 it has been alluded to by some of the older accoucheurs1 and some others2 and the advantages to be derived from it were fully pointed out some years ago by ,dr4 ,bigelow1 in a paper published in the ,american ,journal of the ,medical ,sciences1 ',on the means of affording ,respiration to ,children in ,reversed ,presentations4' ,the object of ,dr4 ,bigelow in this paper is to show that in many cases the life of the child may be saved by forming a communication between the mouth and atmosphere previous to the delivery of the head4 ,if the head be low down1 the fingers alone can give the necessary assistance2 but if it is high in the pelvis1 and is reached with difficulty1 the assistance of a tube may be necessary4 ,he recommends a flat tube1 which is to be guarded1 and kept within the fingers of the inserted hand4 ,where the pelvis of the mother is small or distorted1 and the child large and unfavorably situated1 the efforts of nature may be insufficient to expel the child1 either alive or dead4 ,the nates may become so firmly impacted in the pelvis1 that they cannot advance without artificial assistance4 ,a finger should be passed up to one of the groins1 and when a pain comes on a considerable extracting force may be exerted with it1 without injuring the child2 or a soft handkerchief may be passed between the thigh and abdomen1 and the nates drawn down2 but this cannot be done unless they have descended low into the cavity of the pelvis4 ,where these means fail1 and it is impossible to extract the child alive1 the blunt hook or crotchet must be employed4 ,in cases of nates presentation1 where the pelvis is distorted1 after the extraction of the trunk and extremities1 it is necessary to perforate the back part of the head1 and complete the delivery with the crotchet4 ,in presentations of the feet and knees the treatment does not essentially differ from that required in presentations of the nates4 ,,presentations ,,of ,,the ,,shoulder4 ,these are the most dangerous of all the presentations1 and most frequently require assistance2 in fact the delivery can seldom be terminated naturally when the shoulder presents4 ,sometimes the child will pass doubled up1 as formerly explained1 but this must not be too confidently expected4 ,dr4 ,lee says-- ,it is now a general rule1 established in all countries where midwifery is understood1 that in cases of preternatural labor1 where the shoulder and superior extremities of the child present1 the operation of turning ought to be performed4 ,but the hand must not be forced into the uterus1 if the orifice is rigid and undilatable2 it should be dilated nearly to the size of half-a-dollar piece or more1 or the margin ought to be very thin1 soft1 and yielding1 if it is expanded to a smaller extent than this when turning is attempted4 ,if the os uteri will not admit the extremities of the fingers and thumb in a conical form to be introduced without much force1 if it is thick1 hard1 and unyielding1 some delay is necessary1 that the parts may relax1 death being almost always the consequence of thrusting the hand with violence through the orifice of the uterus in a rigid and undilatable condition1 whether the membranes be ruptured or not4 ,but as soon as it will admit of the safe introduction of the hand1 where you have ascertained that an arm presents1 no time should be lost in completing the delivery1 otherwise the membranes may give way1 the liquor amnii be evacuated1 and a case of little difficulty and danger be suddenly converted into one equally hazardous to the mother and child4 ,in all cases of labor1 where the first stage is far advanced without the nature of the presentation being positively determined1 or a superior extremity is felt through the membranes1 the patient should be kept in the horizontal position1 that they may not be ruptured2 and you should remain in constant attendance upon the patient1 and be prepared to interfere the instant the necessity arises4 ,speaking of the operation of turning in these cases he remarks as follows3-- ,in some favorable cases of shoulder and arm presentation1 the uterus is widely dilated before the membranes are ruptured and the liquor amnii discharged2 and no difficulty is experienced in passing the hand into the uterus1 laying hold of the feet1 and extracting the child by the operation of turning4 ,if the uterus is not contracting strongly and at short intervals1 little resistance is offered to the introduction of the hand1 and the delivery may be speedily accomplished with safety both to the mother and child4 ,but if the membranes have burst1 the liquor amnii escaped1 and the uterus has been contracting firmly upon the child many hours before the operation of turning is attempted1 the child is often destroyed by the pressure1 and the coats of the uterus exposed to great danger from contusion and laceration in passing up the hand and bringing down the feet4 ,the shoulder and thorax become so strongly impacted in the pelvis1 that great force is required to introduce the hand to grasp the feet1 and much exertion necessary before the position can be changed4 ,in other cases of shoulder and arm presentation1 the membranes burst and the liquor amnii escapes at the commencement of labor1 and the os uteri is rigid and undilated1 so that the hand cannot be passed into the uterus after the labor has continued many hours4 ,the difficulty and danger of these cases is greatly increased when the uterus is contracting with violence1 and the pelvis is distorted1 or a disproportion exists between the child and pelvis from any other cause4 ,the greater number of women1 if abandoned to the efforts of nature under these circumstances--the uterus having no power to alter the position of the ftus--would ultimately die undelivered1 from exhaustion or rupture of the uterus and vagina4 ,fortunately these cases are very rare1 and when assistance is rendered early1 the difficulty is readily overcome4 ,this is a strong reason why all women especially should know what to do1 because a little timely help may save much suffering1 or even life4 ,,section ,,vii4 ,,accidents ,,during ,,labor ,,which ,,may ,,compromise ,,the ,,mother',s ,,life4 ,,chapter ,,xxi4 ,,uterine ,,hemorrhage1 ,,or ,,flooding1 ,,during ,,labor4 ,this is always a troublesome1 and frequently a fatal accident4 ,it should be always watched for1 and attended to as early as possible--a few minutes frequently determining the recovery or death of the patient4 ,the chief causes of flooding are1 the too early or violent1 separation of the placenta2 insertion of the placenta over the mouth or on the neck of the womb2 laceration of the womb or vagina2 the bursting of a swelled vein2 rupture of one or more of the blood vessels of the uterus2 and breaking of the cord4 ,probably the most frequent of these causes are the premature or violent separation of the cord1 and the bursting of the blood vessels4 ,the insertion of the placenta over the mouth of the womb1 instead of on the fundus1 occurs very seldom1 but when it does severe flooding is nearly certain to follow1 because the placenta has then to be torn1 by the expansion of the parts1 at the very commencement of the labor1 and probably continues to pour out blood for a long time before the child is delivered1 and it can be expelled4 ,in fact this occurrence1 unless the labor terminates very speedily1 is nearly always fatal to the mother1 and frequently to the child also4 ,in most cases there is more or less hemorrhage from this cause during gestation1 particularly after the sixth month1 when the neck of the uterus begins to enlarge more than the placenta1 and consequently tears away from it4 ,abortion frequently results also1 if the flooding be not stopped4 ,madame ,boivin tells us that in twenty thousand three hundred and fifty-seven deliveries there were but eight cases in which the placenta grew over the mouth of the womb2 which is equal to one case in every two thousand five hundred and fifty-four4 ,dr4 ,churchill has collected the accounts of one hundred and seventy-four cases of this kind1 and he finds that out of these forty-eight terminated fatally2 or nearly one out of every three4 ,the rupture of the blood vessels may occur when they are too much engorged with blood1 or when their coats are weakened and corroded by disease4 ,shortness of the cord may also produce a rupture of the vessels1 by the strain it causes on them and on the membranes4 ,in many cases the flooding comes on suddenly1 without any warning whatever1 though most usually it is preceded by a sensation of weight1 heat1 and fluttering in the pelvis1 pains in the thighs and back1 flushed face1 headache1 and dizziness4 ,the pulse also becomes irregular1 the hands and feet grow cold1 and the ears often ring1 or buzz4 ,the only certain sign that the hemorrhage has really commenced is the appearance of the blood itself1 and this often occurs1 as previously remarked1 without any premonitory sign whatever4 ,the danger from hemorrhage during labor is greatest when it commences the earliest1 because it has then the longest to last4 ,from any of the causes mentioned it is evident that it must continue till delivery is accomplished1 and therefore if it appears at the commencement of the labor it may cause the death of both mother and child1 before the labor can be terminated4 ,the danger is greatest however to the child1 unless the flow be very profuse indeed1 and then it is equally so to both4 ,after delivery the danger is of course only to the mother2 and the rapidity with which it may compromise her life is in some cases fearful4 ,dr4 ,lee thus speaks of such cases4 ,but one of the most dangerous varieties of uterine hemorrhage is that which follows the expulsion of the placenta1 or its removal from the uterus by art4 ,sometimes the blood escapes in great quantities from the uterus immediately after the removal of the placenta1 and the pulse ceases at the wrist1 and consciousness is entirely lost in a few seconds4 ,there is no symptom before labor has commenced1 or during its progress1 to warn you of what is about to take place4 ,the child has been safely delivered1 the placenta has come away in a short time1 and while you are perhaps congratulating yourself on the happy termination of the labor the blood begins to trickle over the bed upon the floor1 or the patient suddenly complains of great faintness4 ,in such cases there may be either a want of uterine contraction1 or the contractions may not be permanent1 but be followed by relaxation and the effusion of a large quantity of blood1 which may either appear externally1 or remain to become coagulated1 and distend the uterus4 ,for several hours after delivery1 in some cases1 this alternate relaxation and contraction goes on1 to the great hazard of the patient1 and if her condition be not clearly ascertained1 and the proper remedies be employed1 death may unexpectedly take place4 ,in regard to the treatment1 he gives such excellent and practical rules1 that ,i cannot do better than quote them4 ,by far the most important remedies in these cases of uterine hemorrhage are constant and powerful pressure over the fundus uteri1 the application of cold around the pelvis1 and the free administration of wine1 brandy1 and other stimulants3 ergot is indicated1 but it most frequently produces no effect4 ,the pressure and cold are always within our reach1 however sudden the attack may be4 ,the hypogastrium should be strongly compressed with the binder1 and a pad of folded napkins placed under it1 and in addition the hand should be firmly applied over the fundus uteri4 ,i do not know who it was that first employed compression of the fundus uteri in cases of flooding after the birth of the child2 but it has been often recommended1 and there are few practitioners in this country who are not fully aware of the importance of the binder and pad1 in exciting permanent and regular uterine contractions4 ,dr4 ,m',keevor states1 that in #ahae it was recommended by ,dr4 ,labatt in his lectures1 and for a number of years before this ,dr4 ,labatt was accustomed to recommend a thick firm pad1 or compress over the pubes1 previous to the application of the ordinary binder1 where1 in former labors1 uterine hemorrhage had taken place4 ,dr4 ,m',keevor states1 that of #fffe women delivered during the years #ahai and #ahbj1 only #be were attacked with hemorrhage after the birth of the child4 ,of these1 #ae occurred before the expulsion of the placenta1 ten afterwards1 and in all the results was favorable4 ,he saw only two fatal cases during the time he was in the ,dublin ,lying-in ,hospital1 and he attributes this small mortality partly to the process of parturition being left entirely to the unassisted gradual efforts of the uterus2 partly to the patient having been kept cool and quiet1 free from all sources of disturbance and irritation2 but1 above all1 to the careful application of the binder immediately after delivery1 by which means the expulsion of the placenta1 and permanent contractions of the uterus1 are most effectually secured1 and whenever any tendency to hemorrhage did occur before the removal of the placenta1 the first point invariably attended to was to tighten the binder1 and in the event of this not succeeding1 a thick firm compress1 made by folding a couple of large coarse napkins into a square form1 was placed over the region of the uterus1 and the binder again adjusted4 ,in the great majority of instances1 these1 with the admission of cool air1 checked the discharge2 if not sufficient1 additional pressure was made with the hands4 ,at the same time that you efficiently compress the fundus uteri with the binder and pad1 cold should be vigorously applied to excite the contractions of the uterus4 ,the best mode of doing this is to plunge a large napkin in a pitcher of cold water1 and dash it suddenly against the external parts1 the nates and thighs2 and this should be repeated till the uterus contracts1 and the violence of the hemorrhage is controlled4 ,i am satisfied that this is the most efficacious method of applying cold to excite uterine contractions2 it is far less formidable than pouring water from a height over the naked abdomen1 but it is not less efficacious1 and it possesses these decided advantages over the other method1 that while the application is made to the external parts1 nates1 and thighs1 the pressure of the binder and pad is not withdrawn from the hypogastrium1 the position of the patient is not changed from the side to the back1 the bed is not inundated with water1 and the application can be repeated as often1 and continued as long1 as the urgency of the symptoms may require4 ,the abdomen may be exposed once1 and cold water poured over it from a height1 and the uterus made to contract1 and the flow of blood be arrested for a time1 but relaxation of the uterus may follow after a short interval1 and the hemorrhage be renewed again with equal violence as at first2 but we cannot with propriety expose the abdomen a second time1 and empty over it from a height the contents of a great decanter or kettle4 ,besides1 by adopting this practice1 we sacrifice the whole of the effects derived from pressure on the fundus uteri4 ,the application of a napkin soaked in vinegar and water to the parts is often sufficient1 along with the binder1 to restrain the hemorrhage where it is not very profuse4 ,i have very seldom introduced a plug of any kind into the vagina in these cases1 but when there has been a draining of blood from the uterus1 after the practice now described has been employed1 a large soft sponge passed into the vagina1 and pressed up against the os uteri1 has appeared in some cases to promote the coagulation of the blood4 ,the sponge1 however1 cannot be employed with safety after the expulsion of the child and placenta1 unless the uterus be firmly compressed above the brim of the pelvis to prevent its becoming distended with blood4 ,more frequently ,i have had recourse with good effect1 to the introduction of several pieces of smooth ice into the upper part of the vagina1 and allowing them to remain there1 in contact with the os uteri1 and be dissolved1 or pieces of ice have been inclosed in a bladder and laid over the pubes4 ,other means besides those now described have been recommended in cases of flooding after the expulsion of the placenta4 ,it has been proposed to inject cold water into the cavity of the uterus by means of the stomach pump1 and favorable reports have been given of the practice4 ,the effect1 ,i think1 would be similar to directing forcibly a stream of cold water against a stump soon after amputation2 the coagula in the cavity of the uterus and in the orifices of the vessels would be all washed away3 nevertheless1 it might perhaps be advantageous in some desperate cases4 ,port wine and water1 as cold as possible1 ,dr4 ,collins says1 injected into the rectum1 has been of service4 ,some of the earlier writers on midwifery1 and many in the present century1 have strongly recommended the introduction of the hand within the uterus for the purpose of removing the coagula accumulated within the cavity1 and to excite the uterus to contract4 ,but it is not necessary to pass the hand into the uterus for the removal of coagula1 because if the binder has been properly applied1 and strong pressure made over the fundus uteri1 clots cannot accumulate within the uterus1 and if they have been permitted to collect in consequence of neglect1 then expulsion will immediately follow the use of proper compression of the hypogastrium1 without the introduction of the hand4 ,nor do ,i consider it necessary1 to excite uterine contractions1 that the hand should ever be introduced into the cavity of the uterus after the removal of the placenta4 ,i am fully convinced1 from repeated observation1 that this practice1 which is so common as to be almost universal in this country at the present time1 is often not only ineffectual for the purpose1 in the worst cases of flooding1 but that it is often followed by the most pernicious effects2 the coagula which nature has formed have been displaced by the hand1 and the uterus has not been excited by the stimulus of it to secure a permanent contraction4 ,in the greater number of fatal cases of uterine hemorrhage after the expulsion of the placenta1 which have come under my observation1 the hand had been introduced into the cavity1 and the closed fist had been pressed for a longer or shorter time round and round against the lining membrane1 to make the uterus contract4 ,i do not recollect a single fatal case1 where the unfortunate result could be fairly attributed to the want of the introduction of the hand into the cavity of the uterus1 and the friction of the knuckles against the lining membrane4 ,i have repeatedly passed the hand into the uterus to produce contraction1 but it has refused to obey the stimulus of the hand2 it has remained like a soft flaccid bag1 more like a piece of intestine than uterus1 and the blood has continued to pour down the arm1 until the hand has been withdrawn1 and more efficient remedies employed4 ,leroux was well aware that the stimulus of the hand would not in all cases excite the uterus to contract1 for he observes1 where the os uteri is contracted1 the means indicated by ,levret are very efficacious1 and remove the hemorrhage as if by a charm4 ,but it is not so in complete inertia of the uterus2 often it is widely dilated1 and offers no resistance to the introduction of the hand4 ,the introduction even of the whole hand excites little sensation1 and the woman will promptly perish from hemorrhage if other means more active and certain are not employed to prevent it4 ,the tampon or plug is the remedy ,leroux recommends in cases of flooding after delivery1 and he affirms that it will often succeed in stopping the flow of blood when all other means fail4 ,dr4 ,dewees observes1 that he has not found it necessary to introduce the hand for the purpose of stopping an hemorrhage after the expulsion of the placenta1 during the last five-and-thirty years1 as he regarded the practice as always frightful1 and oftentimes unnecessary and pernicious4 ,but it is difficult to subvert an established mode of practice1 however unsound1 and probably some of you1 without much reflection1 because you have heard this recommended1 will pass up the hand into the cavity of the uterus after the expulsion of the placenta1 on the very first occasion that you have an opportunity of doing so1 remove all the coagula1 and rub the inner surface with the fist till you are tired1 without effect4 ,i have seen cases repeatedly where this has been diligently performed by those who had neglected to apply the pad and binder1 and all the other means now described4 ,if you pass the hand at all within the parts1 which ,i strongly suspect you will do1 let me entreat you to carry it no farther than the os uteri1 which you may1 with much less risk and with greater effect1 press and rub with the fingers and irritate than the inner surface of the body and fundus of the uterus4 ,mauriceau recommends that women who are subject to flooding after delivery should be bled twice or thrice from the arm during pregnancy1 and once1 or oftener1 after labor has commenced4 ,there are cases of uterine hemorrhage after the delivery of the child and expulsion of the placenta unconnected altogether with the plethora1 or an excited state of the heart and arteries1 and where bleeding and low diet do not prevent the accident4 ,rupturing the membranes at the very commencement of labor is by far the best remedy1 the only thing indeed upon which any dependance can be placed4 ,after attacks of uterine hemorrhage1 the patient should not be raised from the horizontal position for several hours1 and the strength should be supported by wine1 beef-tea1 and light nourishment4 ,brandy in gruel sometimes agrees when wine is rejected4 ,a good large dose of the liquor opii sedativus often produces the most decided benefit after the hemorrhage has ceased2 there are few cases before this in which opium does good1 though it is constantly given in all the varieties of flooding1 even when the great object is to excite uterine action4 ,where recovery is to take place after uterine hemorrhage1 says ,dr4 ,m4 ,hall1 the pallor of the countenance1 the disposition to syncope1 the coldness of the extremities1 the feeble state of the pulse1 and uninterrupted respiration1 pass gradually away4 ,where the case is to terminate fatally1 the symptoms gradually assume a more alarming aspect1 the countenance becomes pale and sunk1 the respiration stertorous1 and the pulse cannot be felt at the wrist4 ,there is great restlessness1 and before death one or more fits of convulsions sometimes occur4 ,where recovery takes place1 in some women it is astonishing how little permanent inconvenience is felt from the great loss of blood which they have sustained4 ,in the course of ten days or a fortnight the effects have entirely disappeared2 and this is the most common result4 ,in some women1 a violent determination of blood takes place to the brain1 marked by heat1 strong pulsations of the carotid and temporal arteries1 intolerance of light1 and all the symptoms of inflammation of the brain or its membranes4 ,a strong febrile attack is also sometimes experienced1 without an increased determination of blood to any particular organ4 ,these affections of the brain and nervous system are aggravated by depletion4 ,the patient should be kept in a cool1 dark room1 and mild cathartics1 anodynes1 and antispasmodics1 occasionally given4 ,where there is much headache and throbbing1 a few leeches should be applied to the temples1 and a cold lotion to the scalp4 ,these remarks of ,dr4 ,lee1 as to bleeding frequently making the after symptoms worse1 should be carefully borne in mind4 ,there is no doubt but that too copious1 or too frequent bleeding1 during pregnancy or labor1 disposes the female to many serious dangers afterwards4 ,i have known some suffer constant headache1 dizziness1 and loss of memory1 for weeks after from it2 and others have even been made light headed4 ,to the above remedies ,i would only append one other1 which has1 on many occasions succeeded1 when all others have failed1 namely ,galvanism4 ,this has1 at the last moment1 when the female was sinking1 brought on uterine contractions1 stopped the flooding1 and saved her life4 ,the application is very simple2 one pole being placed on the back1 immediately between the hips1 and the other over the uterus4 ,or one of the poles may be coated with wax1 all but the end1 and introduced into the vagina1 so that the unwaxed part may touch the mouth of the womb1 while the other is placed over the fundus1 or on the back1 as found most efficient4 ,the power should be sufficiently strong to produce contraction1 and the application must be continued till the contraction remains after the pole is withdrawn4 ,no medical man should give any female up who is flooding1 no matter how severely1 till he has tried ,galvanism4 ,in my ,neuropathy and ,practical ,facts will be found many cases1 with such plain directions that any one could follow them and apply it4 ,the presentation of the placenta1 or its growth over the mouth of the womb1 is the most serious cause of flooding1 and generally makes any attempt to check it of no avail1 except delivery4 ,the discharge however nearly always occurs before the full period1 and either causes miscarriage or necessitates premature delivery4 ,dr4 ,lee remarks3 ,in the greater number of cases of placental presentation the discharge of blood takes place spontaneously in the seventh and eighth months of pregnancy1 and cannot be referred either to bodily exertion1 external violence1 nor to any unusual determination to the uterine organs1 or congestion of their vessels4 ,the hemorrhage generally comes on suddenly1 when the woman is in a state of rest1 and the blood continues to flow until faintness or even syncope takes place4 ,it often ceases entirely1 and the patient resumes her usual occupations1 and has no dread of another attack4 ,but after an interval of several days1 and sometimes not before two or three weeks1 the flooding is renewed1 and perhaps with increased violence1 or a constant profuse discharge takes place1 and a decided effect is produced upon the constitution1--the pulse becomes rapid and feeble1 and the countenance pale4 ,similar attacks return at longer or shorter intervals1 and if delivery be not accomplished by art1 sooner or later death takes place4 ,the first attack of flooding seldom proves fatal1 but it sometimes does so2 for in the second case related in the table1 which occurred in the ,british ,lying-in ,hospital1 the life of the patient was at once extinguished by a single gush of blood from the uterus4 ,i examined the body after death4 ,the centre of the placenta was over the centre of the os uteri4 ,when flooding takes place to an alarming extent in the seventh or eighth months of gestation1 you ought first to ascertain1 by a careful internal examination1 whether or not the placenta be situated at the os uteri4 ,it is impossible1 from the manner in which the discharge of blood takes place1 to be certain of the fact2 for there are some cases of hemorrhage from detachment of the placenta from the upper part of the uterus1 where the flooding occurs spontaneously1 and to as great an extent as in cases where the placenta presents4 ,in some cases ,i have been induced1 from the symptoms1 to believe that the placenta was at the os uteri when it was not4 ,as the treatment and the successful or fatal result of the case will1 in a great measure1 depend on the correctness of the diagnosis1 the examination should be conducted with so much care and circumspection as to leave no room for doubt on the subject4 ,an ordinary examination1 with the fore and middle fingers1 is generally sufficient to enable us to ascertain the true state of the case1 but where the os uteri is very high up1 and directed backwards1 it becomes requisite to introduce the whole hand within the vagina4 ,the finger should then be passed gently through the os uteri1 and1 if the placenta adheres to the cervix1 it will be distinguished from coagulated blood1 the only substance with which it can be confounded1 by its firmer1 fibrous1 vascular structure1 and1 above all1 by its adhering at one part to the uterus1 and being separated at another4 ,if you will take the trouble to pass the finger carefully and repeatedly over the uterine surface of a recently expelled placenta1 you will never1 in actual practice1 mistake a placenta at the os uteri for a clot of blood1 however firm4 ,in all cases it is requisite to proceed at once to determine by an examination1 so carefully conducted as to render a mistake impossible1 whether or not the placenta presents--even though the hemorrhage should be slightly renewed by the displacement of the coagula2 you cannot be too early acquainted with the precise condition of the patient4 ,you ought1 at the same time1 to ascertain whether the placenta adheres partially or completely to the cervix uteri1 and whether the os uteri is in a condition to admit of the operation of turning being performed4 ,the operation of turning1 which is required in all cases of complete placental presentation1 is not necessary in the greater number of cases in which the edge of the placenta passing into the membranes can be distinctly felt through the os uteri4 ,sometimes there is profuse and dangerous hemorrhage where the placenta does not adhere all round to the neck of the uterus1 but only partially4 ,if the os uteri is not much dilated or dilatable1 the best practice in these cases is to rupture the membranes1 to excite the uterus to contract vigorously1 by the binder1 ergot1 and all other means1 and to leave the case to nature3 by adopting this treatment the operation of turning may be avoided with advantage in the greater number of cases of partial placental presentation4 ,but1 if the hemorrhage is profuse1 has returned at different intervals1 and a great quantity has been lost1 and the constitution is really affected1 it is the safest practice at once1 if the orifice of the uterus is in a condition to allow the hand to pass without difficulty1 to deliver by turning the child4 ,where the placental presentation is complete1 the operation of turning should be performed1 in all cases1 as soon as the orifice of the uterus is so much dilated or dilatable as to allow the hand to be introduced without the employment of much force4 ,it is seldom safe to attempt to deliver by turning before the os uteri is so far dilated that you can easily introduce the points of the four fingers and thumb within it3 however soft and relaxed it may be1 until dilatation has commenced1 and proceeded so far1 ,i am convinced there are very few cases in which the operation of turning will be required1 or completed without the risk of inflicting some injury on the os uteri4 ,this is a point of the greatest practical importance1 but ,i do not know in what manner to communicate to you1 in words1 a more clear and definite idea of the grounds upon which you ought to proceed4 ,in every case1 before attempting to turn1 make a most careful examination of the os uteri1 and endeavor1 from the degree of dilatation1 and the thinness and softness of the orifice1 to form a correct judgment upon this point1 before interfering1 for the hemorrhage will be renewed if the attempt is unsuccessful1 and the patient will be placed in a worse condition than she was before4 ,when you have resolved to turn1 let the patient lie on the left side1 with the pelvis close to the edge of the bed1 and introduce the right hand into the vagina as before described1 and then pass the fingers and hand gently and slowly in a conical form through the os uteri1 giving it time to dilate1 and onward into the cavity between the detached portion of the placenta and the uterus3 then force the fingers through the membranes1 grasp both feet1 and bring them down into the vagina1 and slowly extract the child as in the cases of nates presentation1 and do not afterwards be in a hurry to remove the placenta1 unless it is wholly detached and lying in the upper part of the vagina4 ,this operation is easily and speedily performed when the os uteri is widely dilated and dilatable4 ,it is1 however1 a great exaggeration of the facility with which turning may be accomplished in these cases1 to represent it as a very simple process--like putting the hand into the coat-pocket and pulling out your handkerchief4 ,at the best it is a dangerous operation1 and you can never tell with certainty whether or not the patient will recover after its performance1 however easily it may have been effected4 ,but there is not unfrequently most profuse and alarming flooding from complete placental presentation1 where the os uteri is so thick1 rigid1 and undilatable1 that it is impossible to introduce the hand into the uterus without producing certain mischief4 ,in thirteen out of thirty-six recorded cases the os uteri was rigid and undilatable4 ,the tampon or plug has no power to restrain the hemorrhage in such cases1 nor do ,i know of any other means--either cold1 quietness1 or opium--which effectually have1 and it is sometimes absolutely necessary under such circumstances to deliver by turning1 before the hand can possibly be introduced into the uterus without producing fatal contusion or laceration of the part4 ,i have found in several of these cases1 however1 that the delivery may be safely accomplished by merely passing the hand into the vagina1 and afterwards the fore and middle fingers between the uterus and detached portion of the placenta1 grasping with them the feet1 which are generally situated near the os uteri1 and drawing down the inferior extremities into the vagina1 and delivering4 ,i know that the inferior extremities may often be brought down in this way where it is impossible to pass the whole hand through the os uteri4 ,the same state of things may however result from other causes1 and a very different mode of proceeding may then be needed1 as the doctor very clearly shows4 ,flooding may take place in the latter months of pregnancy1 and during labor1 where the placenta does not adhere to the neck of the uterus1 but to the body or the fundus1 and is detached by some external or internal cause4 ,the separation of the placenta from the upper part of the uterus may be produced by violence1 as blows1 falls1 pressure over the hypogastrium1 and shocks of various kinds2 but it arises much more frequently from internal causes1 of which morbid states of the placenta1 and twisting of the umbilical cord once or oftener round the neck of the child1 are the most common and obvious4 ,this variety of hemorrhage1 though usually termed accidental1 can rarely1 however1 be referred to accident4 ,sometimes the flooding occurs to a great extent without any assignable cause2 a large portion of the whole of the placenta1 when in a healthy condition1 being suddenly detached from the uterus1 when the patient has been exposed to no external accident1 or injury of any kind1 and when no symptoms of increased determination of blood to the uterus have preceded the attack4 ,when this happens a large quantity of blood is poured out between the placenta and uterus1 a small portion of which only at the time usually escapes from the vagina1 to indicate what is going on within the uterus4 ,there may be a great internal hemorrhage1 accompanied with the ordinary constitutional effects resulting from loss of blood--as faintness1 sickness1 or vomiting1 coldness of the extremities1 rapid feeble pulse1 hurried breathing2 when there is little or no discharge from the vagina to excite alarm1 or to point out the source of danger1 when it is extreme4 ,it is from the general symptoms of exhaustion1 and by the disagreeable sense of uneasiness1 weight1 or distension of the uterus1 experienced1 and not from the quantity of blood which appears externally in these cases1 that we are led to discover the true state of the patient--to suspect that internal hemorrhage is going on4 ,but much more frequently only a small portion of the placenta is at first detached1 and the greater part of the blood which is extravasated between it and the uterus separates the membranes1 and descends by its weight to the orifice1 and escapes through the vagina4 ,in all cases1 however1 of uterine hemorrhage in the latter months1 the danger cannot be so accurately estimated by the quantity of blood which appears externally1 as by the general symptoms4 ,the portion of placenta which is detached1 never re-unites to the uterus1 but when expelled it is usually seen covered with a dark coagulum adhering to the uterine surface4 ,when the blood escapes in small quantity1 and there are no labor pains present1 and no disposition in the os uteri to dilate1 and the constitutional powers are not impaired1 an attempt should be made to prevent a return of the discharge1 and the occurrence of labor pains4 ,for this purpose1 if the pulse is full and frequent1 some blood may be taken from the arm1 and the patient should be kept in the horizontal position1 surrounded by cool air1 cold applications made over the hypogastrium1 and acetate of lead and opium1 mineral acids1 and other remedies that diminish the force of the circulation and promote the coagulation of the blood1 should be taken internally4 ,the plug is here totally inadmissible2 it can only convert an external into an internal hemorrhage4 ,but where the flooding occurs at first profusely1 and is renewed even in a moderate degree1 in spite of our efforts to check it1 the continuance of pregnancy to the full period cannot be expected2 it will be of no avail to bleed and administer internal remedies1 except for the purpose of checking the discharge1 and thus averting the immediate danger until the uterus is emptied of its contents4 ,the operation of turning1 which is required in all cases of complete placental presentation1 is rarely necessary in uterine hemorrhage where the membranes are felt at the orifice4 ,in a great proportion of these cases1 where1 on making an examination1 you can feel the smooth membranes extending across the neck of the uterus1 the flooding will be arrested1 and the labor safely completed1 if the membranes are ruptured1 the liquor amnii discharged1 and contractions of the uterus excited by gentle dilatation of the orifice1 and other appropriate means4 ,the only cases in which this treatment fails are those in which it has not been had recourse to sufficiently early1 or where the whole or a large portion of the placenta has been suddenly separated from the uterus1 and a great internal hemorrhage has taken place4 ,the uterus will not contract effectually in these cases after the membranes have been ruptured2 the pains1 instead of becoming stronger1 become more and more feeble1 return at longer intervals1 and during these the blood flows more profusely1 and death would take place before delivery1 if the child were not extracted by the forceps1 crotchet1 or by the operation of turning4 ,in all cases1 then1 of uterine hemorrhage in the latter months of pregnancy1 and in the first stage of labor1 where the placenta does not present1 and the quantity of blood discharged is so great as to render delivery necessary1 where it appears improbable that the pregnancy can go on longer with safety1 or to the end of the ninth month1 rupture of the membrane with the nail of the forefinger of the right hand1 evacuate the liquor amnii by holding up the head of the child1 dilate very gently the os uteri with the fore and middle fingers expanded1 and occasionally make pressure with the fingers around the whole orifice2 apply the binder1 give ergot and stimulants1 and the uterus will1 in all probability1 contract upon its contents1 and expel them without further trouble4 ,if the hemorrhage should1 however1 continue after the employment of these means1 delivery must be accomplished by the forceps1 craniotomy1 or by turning1 according to the peculiarities of the case4 ,in women who are liable to attacks of flooding after the expulsion of the child or placenta1 rupture the membranes at the commencement of labor1 even before the os uteri is much dilated1 if the presentation is natural1 and you will often succeed in entirely preventing hemorrhage4 ,the recommendation to bleed may be with good reason objected to1 at least in the great majority of such cases2 and ,i cannot but think that a timely and persevering use of the ordinary remedies1 namely1 keeping quiet1 using acid drinks1 and cold fomentations to the abdomen1 would do away with any necessity for it at all4 ,i question very much if ever bleeding really prevented abortion from flooding1 and ,i cannot but think that it has often brought it on sooner4 ,nevertheless1 if all other means fail to arrest the discharge1 and there are no decided objections to the contrary1 it might be cautiously tried2 though the policy of taking more blood from a person who is already losing too much1 is not very evident4 ,i have often known the most severe flooding stopped1 merely by the female lying on her back1 drinking plentifully of lemonade1 and applying cold wet cloths over the abdomen4 ,a small dose of laudanum occasionally is also useful2 and complete rest and tranquillity of mind is as indispensable as rest of the body4 ,many females flood and miscarry merely from worrying and fretting themselves1 and from passion1 or strong excitement1 particularly of a certain kind4 ,this in short must be carefully avoided1 and the patient must live strictly as if a widow4 ,this accident is likely to occur in subsequent pregnancies1 at nearly the same time1 and should therefore be guarded against by a careful avoidance of all excitement1 or violent bodily exertion1 during the whole time4 ,keeping the bowels gently open1 and practising a regular diet1 are also requisite4 ,a good supporting bandage is also of frequent service4 ,for much more valuable information on this subject however1 ,i refer to my work on ,the ,diseases of ,women1 in which it is fully treated4 ,,chapter ,,xxii4 ,,eclampsia1 ,,or ,,convulsions ,,during ,,labor4 ,convulsions are to be looked upon as very serious indications of derangement1 during either pregnancy or labor1 and are frequently followed by fatal results to both mother and child4 ,they may be of several different kinds1 epileptic1 hysteric1 or cataleptic1 though the epileptic form is most common4 ,they often occur during pregnancy1 but not usually before the seventh month1 though occasionally met with much earlier4 ,according to observations it appears that there is not above one case of convulsions in six hundred deliveries4 ,the principal cause of this disease appears to be the strong sympathy between the womb and other organs1 owing to which they are continually disturbed by the changes it undergoes4 ,certain temperaments also dispose to it1 particularly the lymphatic1 and also dropsy1 rickets1 and other diseases4 ,strong moral impressions may also have a predisposing effect1 such as sudden frights1 joy or anger1 and also acute pain1 or the dread of it4 ,in most cases1 and particularly during pregnancy1 the convulsions are preceded1 and indicated1 by severe headache1 and spasm at the stomach1 with dimness of sight1 bright sparks before the eyes1 buzzing in the ears1 and partial difficulty in speaking4 ,occasionally however the fit comes on quite suddenly1 without any warning whatever4 ,there are few exhibitions of suffering more frightful than one of these attacks1 and none that call for more prompt and decided action4 ,in general females are perfectly helpless when one is attacked in this way1 and instead of being able and disposed to render proper assistance1 they either run away alarmed1 or fall into hysterics themselves4 ,it is however of the utmost consequence that the sufferer should be attended to instantly1 and therefore every female should know what to do in such an emergency1 at least till better aid can arrive4 ,at the first commencement of convulsions the features become gradually fixed1 the eyes are expanded and distorted1 the breath is drawn with difficulty1 and all consciousness appears to cease4 ,the body then begins to twitch1 the mouth opens1 usually on one side1 the tongue protrudes1 the head turns on one side1 and the blood rushes to it and the face in great quantities4 ,in a short time the jaws close again with great force1 and the tongue is bitten if proper care has not been taken to prevent it4 ,at last the eyes began to twinkle1 the mouth moves as if the patient were muttering1 and the nostrils expand2 the arms are thrust straight down by the sides of the body1 with the hands firmly closed2 the legs are stiffened straight out1 and the body is bent back like a bow4 ,in short every muscle is affected with spasms1 which are sometimes fearfully violent1 and may endure for a considerable time4 ,when they subside1 the fit gradually terminates and passes off4 ,during the whole time the breathing is difficult1 the mouth froths very much1 and the heart palpitates quickly1 but irregularly4 ,when the spasm is over the patient falls into a perfect stupor1 during which she remains unconscious1 but with all the limbs soft and moveable1 except the fingers1 which appear to grasp4 ,the jaws generally remain closed1 and so do the eyes1 but they may be easily opened1 and will sometimes remain open2 the breathing becomes powerful and loud1 and the pulse beats with rapidity4 ,at last slight motions are observed1 and consciousness gradually returns1 but the memory is generally gone for some time4 ,this state of stupor usually lasts from ten minutes to half an hour1 but has been known to continue for many hours1 or even a whole day4 ,the spasm seldom continues more than from one to ten minutes1 though it has lasted for an hour or more4 ,these convulsions might be mistaken for ordinary hysteria by those not acquainted with the difference4 ,in hysteria however the female moves about and struggles more2 she also cries out1 and retains both sensibility and consciousness1 so perfectly even sometimes that she requests those around to hold her1 which is never the case in convulsions4 ,during the stupor it might be supposed1 by any one not aware of the previous fit1 that the patient was suffering from apoplexy1 or intoxication1 the appearance being so similar to that exhibited in those states4 ,this shows the necessity for careful inquiries as to what has previously occurred4 ,during pregnancy convulsions generally cause abortion1 either by bringing on uterine contractions or by causing the death of the child4 ,some few patients have suffered from them however1 and yet gone their full time1 but this must never be expected4 ,a gradual extinction of the vital spark1 during the stupor is the ordinary termination1 though sudden death is not unfrequent1 during the fit4 ,gradual recovery is occasionally witnessed1 but seldom without partial loss of memory1 or some other affliction4 ,madame ,lachapelle says that one-half of the females attacked with convulsions die1 and of their children many more4 ,there is no doubt but that the tendency to this fearful affliction may be very much lessened in many females1 by proper attention to diet and regimen4 ,those who are of a full habit1 and disposed to headache1 and rush of blood to the head1 should live low1 and carefully avoid everything of a heating or stimulating character1 and also every kind of excitement or agitation4 ,the bowels should be kept free1 and the skin well rubbed and kept warm1 and the head cool4 ,treatment4--,while the patient is in the fit1 care must be taken that she does not fall off the bed1 or bite her tongue1 to prevent which the jaws must be kept apart1 by putting something between1 as a piece of soft wood1 or the handle of a spoon covered with cloth1 or even a knotted napkin4 ,the face should be sprinkled with cold water1 and the whole body well chafed1 particularly the hands and feet1 which should also be made warm as soon as possible4 ,as soon as the spasm is over it is customary to bleed1 either at the arm1 or by leeches to the temples and behind the ears4 ,mustard poultices should also be applied to the feet1 and inside the thighs1 and an enema should be given of warm water and a table-spoonful of salt4 ,ice1 or cold water1 should be applied to the head constantly1 and if possible the body should be immersed in a hot bath1 which will1 in many instances1 bring the patient round immediately without any other treatment4 ,the bladder should be also looked to1 as well as the bowels1 and if necessary the catheter should be used4 ,as soon as she can swallow a few drops of laudanum may be given1 or a little ether1 but not a full dose by any means4 ,the propriety of bleeding1 even in these cases1 is denied by many1 and ,i am almost inclined to think myself1 that a prompt and persevering use of the other remedies mentioned1 would be fully as successful without it4 ,at all events1 the fearful mortality in spite of it proves that it has not much power1 and may well raise a doubt of its utility4 ,convulsions however are so fearful and violent1 that few practitioners can resist the temptation to bleed1 because it seems so well calculated to give prompt relief2 and besides it has popular prejudice in its favor4 ,some authors however assert that it makes the danger greater of paralysis1 and loss of memory1 afterwards4 ,when convulsions occur during pregnancy they seldom cease entirely till the uterus is emptied of its contents4 ,it is therefore necessary to bring on labor1 and terminate it as soon as possible1 after the parts are in a proper condition4 ,when they occur during labor it must also be finished in the shortest time possible1 to afford the best chance of saving the child1 and also because no treatment will prevent the attack while the patient remains undelivered4 ,all means of bringing on dilatation of the mouth of the womb1 mentioned in the article on ,rigidity1 may be resorted to1 excepting ,ergot1 which should never be used in these cases4 ,m4 ,chailly tells us1 that in thirteen cases of convulsions nine were first pregnancies1 and seven of the females were dropsical4 ,only one was attacked during pregnancy1 ten while in labor1 and two after4 ,only two died1 and ten of the children4 ,it is worthy of remark that where pregnant females have had convulsions1 apparently from living too high1 the children have also had them after delivery4 ,,chapter ,,xxiii4 ,,rupture ,,of ,,the ,,womb ,,or ,,vagina4 ,rupture of the womb arises from various causes1 but most usually from powerful contractions when the pelvis is small1 or the ftus large1 or when it presents unfavorably4 ,it not unfrequently results also from force being used1 particularly with instruments4 ,in fact there is no doubt but that numerous females die from this accident1 brought on by the violence1 haste1 and want of skill of their attendants4 ,few injuries are more serious1 or more beyond the reach of any remedy than this1 though it is sometimes suffered with impunity4 ,the symptoms of rupture of the womb are strongly marked1 and fearfully evident4 ,when it occurs1 which is most usually during a powerful contraction1 the female shrieks1 and instantly complains of an agonizing pain over the seat of the rupture2 her face grows deadly pale1 her pulse falls1 and she faints4 ,in general death is almost instantaneous1 though sometimes life may be preserved for an hour or two1 but very seldom4 ,there have even been cases of recovery1 but they are very few1 and regarded almost as miracles4 ,in most cases1 directly the rupture happens the ftus escapes through the rent into the abdomen1 and most of the fluid with it2 but sometimes it still remains in the womb1 and then if the liquor amnii is discharged there may little or nothing pass through the opening1 and the danger will be much lessened in consequence4 ,in all cases the only proceeding which offers any chance of recovery is1 to deliver as soon as possible1 because when the ftus is expelled the uterus begins to contract1 so as to close the wound1 and when that is effected1 if but little fluid has passed into the cavity of the abdomen1 all may yet go well4 ,it may frequently happen1 when the hand is passed into the womb1 to turn and deliver1 that nothing can be found1 the ftus having passed through the opening into the abdominal cavity1 in which case the hand must be passed through the opening also1 and the ftus be brought back if possible4 ,if however the rent is too much closed1 or the child cannot be reached1 the ,cesarean operation is the only resort4 ,m4 ,p4 ,dubois tells us of a case of this kind which occurred in his own practice4 ,the female had only been in labor about an hour when she uttered a piercing cry1 and sank as if suddenly mortally wounded4 ,the head of the child1 which was previously at the mouth of the womb1 could not be felt1 and on introducing his hand ,m4 ,dubois found its feet were passed through the opening into the mother's abdomen2 he brought them back however1 and effected delivery by turning with comparative ease4 ,strange to say this woman was discharged cured1 in fifteen days after1 though the uterus was so torn that the intestines had forced themselves through the opening into its cavity1 and ,m4 ,d4 put them back with his hand1 which also passed clear into the peritoneal cavity4 ,in all cases1 after the delivery is effected1 the womb should be again explored1 so that if any parts have come through they may be returned before the opening closes1 which it may do very soon4 ,cases are even mentioned where the child passed clear out of the womb into the abdominal cavity1 and remained there till absorbed1 or escaped through a fistulous opening many years after2 while the wound healed up1 and otherwise the patient perfectly recovered4 ,recovery however1 in any way1 is a rare occurrence4 ,some females seem more disposed to this accident than others2 possibly from a peculiar tenderness in the substance of the womb4 ,all are however liable to it1 and this liability should beget a proper caution in all manipulations1 and forbid uncalled for violence in any way4 ,rupture of the vagina is much less serious than rupture of the womb1 unless it occurs at the upper part1 when it may give rise to similar symptoms and results4 ,at the lower part the danger is much less1 though still sufficient to excite apprehension4 ,the treatment is the same as in the former case4 ,delivery must be effected as soon as possible1 and the patient kept still and cool to avoid inflammation4 ,it is generally thought that the greater part of these accidents result from improper treatment1 and particularly from using instruments4 ,,section ,,viii4 ,,operations ,,with ,,the ,,hand ,,and ,,with ,,instruments4 ,,chapter ,,xxiv4 ,,operations ,,with ,,instruments4 ,the use of instruments in effecting delivery is a last resort to save life1 and ought to be intrusted only to persons of skill2 it may therefore be thought unnecessary to treat of them in the present work1 and indeed ,i should not have done so but for the purpose of satisfying the natural curiosity of females themselves4 ,the greater part of the dread they now experience where instruments are needed1 arises from ignorance of their nature and mode of action4 ,at the present time nearly all the instruments used1 in competent hands1 are comparatively safe and harmless1 and if females generally understood how they operated1 much less fear would be excited by their use4 ,years ago1 when cutting and tearing instruments were employed1 in nearly every case of difficulty1 the lamentable results which followed fully justified the fears experienced1 but at the present day such things are seldom seen1 except in medical museums1 the same purpose being much better effected by simpler and more harmless apparatus4 ,i wish therefore simply to give a brief explanation of the structure1 and mode of action1 of the instruments now chiefly employed1 and to show the extent of their application and the results which have followed from it4 ,,the ,,forceps4 ,the forceps are intended to take hold of the ftus1 and assist us to draw it into the world when the natural forces are inadequate1 and no hold can be obtained by the hands4 ,they were first invented about the year #afej1 by an ,english surgeon named ,chamberlin1 who made a secret of his invention and realized a large fortune from it4 ,since that time they have been modified in various ways1 by different practitioners1 but still remain essentially the same as when first used4 ,the most usual form1 and probably the best1 is that represented below3 ,illustration3 ,,plate ,l4 ,fig4 #a4 ,fig4 #b4 ,it consists of two blades articulated by a button1 or screw joint1 so that they can be easily separated and again adjusted1--,fig4 #a4 ,each blade is cut out in the middle1 and curved1 as seen in ,fig4 #b4 ,the only part to which the forceps are intended to be applied is the head1 to the dimensions and form of which they are specially adapted4 ,some practitioners have used them on the breech1 but the practice is not generally sanctioned1 because they seldom retain their hold on this part and are nearly sure to seriously injure the child when so applied4 ,with properly constructed forceps1 rightly applied to the head1 there is but little danger either to the mother or the child2 but in the hands of an unskillful or careless person the consequences of their use may be deplorable to both4 ,it is scarcely necessary to remark that the forceps are neither cutting nor crushing instruments1 but are simply intended to lay hold1 like the hand itself1 and enable us to draw down the head1 or change its position4 ,most usually they are made long and curved1 as shown in the above plate1 but sometimes they are made much shorter and straight4 ,they may be used upon the head when it is either at the upper or the lower straits1 or while it is in the passage2 but on no account should they be applied till the parts are fully dilated1 and everything indicates that the child can pass4 ,thus they should never be used when the head is too large1 or the pelvis too small1 nor when there are tumors in the way4 ,in short no attempt should be made with them to force the ftus through a passage which will not admit it by reasonable efforts4 ,m4 ,dubois says they should never be used when the pelvic diameter is less than three inches1 because with such dimensions the child is nearly certain to be crushed to death1 and the mother can scarcely escape serious bruises and lacerations4 ,in like manner1 if they are thrust into the womb before the mouth of it is naturally dilated they are sure to tear and injure it4 ,it is not necessary here to give directions for using the forceps in every variety of presentation and position1 but simply to show the mode of applying them as they are most frequently required4 ,the two blades are adjusted separately1 one to each side of the head1 and then locked together1 so that the head is firmly inclosed between them1 but not crushed4 ,dr4 ,denman gives perhaps the best and simplest directions on this point1 and ,i therefore quote from his work4 ,the first part of the operation consists in passing the forefinger of the right hand behind the ossa pubis and the head of the child to the ear2 then taking the part of the forceps to be first introduced by the handle in the left hand1 the point of the blade is to be slowly conducted between the head of the child and the finger till the instrument touches the ear3 there can be no difficulty or hazard in carrying the instrument thus far1 because it will be guided1 and in some measure shielded1 by the finger4 ,but the further introduction must be made with a slow semi-rotatory motion1 keeping the point of the blade not rigidly1 yet closely1 to the head of the child1 by raising the handle toward the pubes4 ,in this manner the blade must be carried gently along the head till the lock reaches the external parts near the anterior angle of the pudendum4 ,the point of the blade1 while introducing1 sometimes hitches upon the ear of the child1 and it then requires a little elevation4 ,but when it has passed the ear1 and is beyond the guidance of the finger1 should there be any check to the introduction either of this or the other blade1 it should be withdrawn a little1 to give us an opportunity of discovering the cause of the obstacle1 which we must never strive to overcome by violence1 though we must proceed with firmness4 ,when the first blade is properly introduced1 it must be held steadily in its place by pressing the handle towards the pubes1 and it will be a guide in the introduction and application of the second blade4 ,let the second blade be introduced in this manner4 ,keep the blade first introduced in its place with the two lesser fingers of the left hand1 and carry the fore-finger of the same hand between the perineum and head of the child as high as you can reach4 ,then take the second blade of the forceps by the handle in the right hand1 and1 conveying the point between the finger placed within the perineum and the head of the child1 conduct the instrument1 with the precautions before mentioned1 so far that the lock shall touch the interior part of the perineum1 or even press it a little backwards4 ,in order to fix the two blades thus introduced1 that which was placed towards the pubes must be slowly withdrawn1 and carried so far backwards that it can be locked with the second blade retained in its first position2 and care must be taken that nothing be entangled in the lock1 by passing the finger round it4 ,when the forceps are locked1 it will be convenient to tie the handles together with sufficient firmness to prevent them from sliding or changing their position when they are not held in the hand1 but not in such a manner as to increase the compression upon the head of the child4 ,should the blades of the forceps be introduced so as not to be opposite each other1 they could not be locked2 or if1 when applied1 the handles should come close together1 or be at a great distance from each other1 they would probably slip1 or there would be a failure of some kind in the operation1 as the bulk of the head would not be included1 or they would be fixed on some improper part of the head2 though allowance is to be made for the difference in the size of the heads of children4 ,but if a case be proper for the forceps1 if they be well applied1 and we were to act slowly with them1 there would not be much risk of failure or disappointment4 ,the difficulty of applying the forceps is most frequently occasioned by attempting to apply them too soon1 or by passing them in a wrong direction1 or by entangling the soft parts of the mother between the instrument and the head of the child1 against all which accidents we are to be on our guard4 ,when the forceps are first locked1 they are placed backwards1 with the lock close to1 or just within1 the internal surface of the perineum2 and they can have no support backwards1 except the little which is afforded by the soft parts4 ,the first action with them should therefore be made by bringing the handles1 grasped firmly in one or both hands1 to prevent the instrument from playing upon the head of the child1 slowly towards the pubes till they come to a full rest4 ,having waited a short interval with them in that situation1 the handles must be carried back in the same slow but steady manner to the perineum1 exerting1 as they are carried in the different situations1 a certain degree of extracting force2 and after waiting another interval1 they are again to be carried towards the pubes1 according to the direction of the handles4 ,throughout the operation1 especially the first part1 the action of that blade of the forceps originally applied towards the pubes must be stronger and more extensive than the action with the other blade1 this having no fulcrum to support it1 and chiefly answering the purpose of regulating the action of the other blade4 ,if there were any labor pains when the operation was begun1 or should they come on in the course of it1 the forceps should only be acted with during the continuance of the pains2 the intention being1 not only to supply the want or insufficiency of the pains1 but to follow them1 and imitate also the manner in which they return4 ,by a few repetitions of this alternate action and rest before described1 we shall soon be sensible of the descent of the head2 and it will be proper to examine very frequently1 to know the progress made1 that we may not use more force than needful1 nor go on with more haste than may be expedient or safe4 ,in every case we ought to proceed slowly and circumspectly1 not forgetting that a small degree of force1 continued for a long time1 will in general be equivalent to a greater force hastily exerted1 and with infinitely less detriment to the mother or child4 ,but after some time1 should we not perceive the head to descend1 the force hitherto used must be gradually increased1 till it be sufficient to overcome the obstacles to the delivery of the patient4 ,it was before observed1 as the head of the child descended1 that the face would be accordingly turned towards the hollow of the sacrum1 without any aim or assistance on our part4 ,of course the position of the handles of the forceps1 and the direction in which we ought to act with them1 should alter2 for they becoming first more diagonal or oblique with respect to the pelvis1 and then more and more lateral1 every change in their position will require a differently directed action1 because the handles should ever be antagonists to each other4 ,in proportion also to the descent of the head the handles of the forceps should approach nearer to the pubes2 so that1 in the beginning of the operation1 though we acted in the direction of the cavity of the pelvis1 towards the conclusion we should act in that of the vagina4 ,when we feel that we have the command of the head1 by its being cleared of the pelvis1 and the external parts begin to be distended1 we ought to act yet more slowly1 especially in the case of a first child1 or there would be great danger of a laceration of the soft parts2 and this can only be prevented by acting very deliberately in the direction of the vagina--by giving the parts time to distend--by duly supporting the perineum1 which is the part chiefly in danger1 with the palm of the hand--by soothing and moderating the hurry and efforts of the patient--and1 in some cases1 by absolutely resisting for a certain time the passage of the head through the external parts4 ,illustration3 ,,plate ,,li4 ,the head being drawn through a narrow ,pelvis by the ,forceps4 ,the manner in which the forceps draw the head is well shown in the above plate1 and also the compression of the head itself1 which is seen to be squeezed almost to a point at its presenting part4 ,this compression1 however1 is not likely to do serious injury1 unless it be excessive4 ,the child may be convulsed a little from it1 but usually recovers1 and suffers nothing afterwards4 ,it is merely necessary to remark1 in conclusion1 that the forceps should never be used till it is manifestly impossible for the child to be born without them2 and it should be remembered that nature alone frequently effects delivery under the most unfavorable circumstances1 by giving her time4 ,we should wait therefore as long as the safety of the mother will allow1 but never delay a moment when that safety is compromised4 ,the accidents which have followed from the use of the forceps are numerous and terrible1 and ,i could give a most horrifying account of them if it were necessary4 ,it must be recollected however1 that these accidents have chiefly followed from want of skill in managing the instrument1 or from its being used under improper circumstances4 ,it is true that there is always more or less of pain and injury to be dreaded from the forceps1 even in the most favorable cases1 and with the most competent operators1 but this is no argument against their employment altogether4 ,in every case where they are really called for1 the female would1 most probably1 die undelivered1 or have to be cut open1 so that it is simply a choice of evils1 of which the forceps are the least4 ,the cases in which the forceps are absolutely necessary however1 are ,,very ,,rare1 much more so in fact than many people suppose4 ,patience1 and the persevering use of ordinary assistance1 would probably succeed alone in half the cases where they are now employed4 ,in ,murphy's lectures on difficult ,labors1 he gives us some valuable statistics on this subject4 ,he tells us that in seventy-five thousand nine hundred and eleven labors1 the forceps were used only one hundred and thirty-eight times1 or once in every five hundred and fifty labors4 ,in these one hundred and thirty-eight cases thirty-five of the children died1 and ten of the mothers4 ,dr4 ,murphy however1 thinks that the general results1 to both mother and child1 would be equally favorable if the forceps were not used at all1 and he gives the tables of ,dr4 ,collins to support his opinions4 ,from these tables it really appears that1 when all the difficult labors were left entirely to nature1 the number of deaths was just about the same as when the forceps are used1 in fact rather less1 while the accidents1 and subsequent evils1 were not nearly so great4 ,dr4 ,m4 therefore thinks that the forceps should never be used1 except in a few cases where everything is quite favorable to the passage of the ftus2 and the uterus cannot be made1 in a reasonable time1 to contract and expel it2 and also when immediate delivery is needed to save the mother's life1 as in flooding4 ,in cases of mere ordinary difficulty or delay1 he decries their use entirely2 and he evidently thinks that when the labor is fit to be terminated by the forceps1 nature can and will terminate it herself if left alone4 ,there is no doubt but that they are now used a great deal too much1 either from a desire to operate1 or from want of patience2 and ,i have no hesitation in expressing my opinion that more have been killed than saved by them4 ,,other ,,instruments4 ,respecting other instruments1 such as the ,crotchet1 the ,vectis1 and the ,cephalotribe1 or crushing forceps1 it is not necessary to say anything here1 as their use1 when imperatively needed1 must necessarily be confined to the surgeon2 and fortunately may now be dispensed with altogether4 ,the recently introduced practice of bringing on premature labor1 in all cases of deformity or smallness of the pelvis1 entirely obviates the necessity for any of these dreadful resorts1 if the difficulty be known in time1 which it is sure to be when a sufficient degree of knowledge is disseminated4 ,the ,cesarian operation1 or cutting open the womb externally2 and ,cephalotomy1 or the opening of the child's head1 may also be dismissed with the same observations4 ,they can always be avoided1 if the real condition of the patient is known in time2 and if from neglect nothing else can be done1 they must always be performed by a skillful surgeon4 ,,chapter ,,xxv4 ,,operations ,,with ,,the ,,hand4 ,,turning4 ,this is one of the most useful operations that the accoucheur can perform1 in many cases1 and has the advantage of being altogether accomplished by the hand4 ,its object is to change the presentation1 when unfavorable1 and to facilitate delivery4 ,most usually the hand is introduced into the uterus1 and the feet are brought down4 ,this is called pelvic version2 but sometimes the head is brought to the mouth of the womb1 particularly in shoulder presentations1 and this is called cephalic version4 ,cephalic ,version4--,this can seldom be performed1 and not often attempted with safety4 ,in some cases however1 when it is ascertained that the shoulder presents1 and before the membranes are broken1 an effort may be made to remove it and bring the head in its place4 ,to do this the position of the head must be ascertained externally1 and one hand placed upon it2 then with the two forefingers of the other raise up the shoulder from within1 as in ballotment1 and endeavor to push the head into its place4 ,if the child be very moveable this may sometimes be done1 and will be highly advantageous2 but most frequently the substitution cannot be accomplished1 and the attempt ruptures the membranes1 after which it is still more difficult1 and even becomes dangerous4 ,even if the head be brought down there is always danger of its becoming displaced1 and the shoulder again presented1 owing to the tendency which any presentation has to be reproduced4 ,to prevent this the hand should be firmly pressed on the ftus1 externally1 as soon as the head is brought down1 to fix it2 and the membranes should be ruptured so that it may begin to descend1 after which there is no danger of a change4 ,cephalic version can be so seldom performed however1 and is so difficult1 and sometimes dangerous1 that it is seldom or never attempted2 more particularly as pelvic version can always be substituted1 and is more easy and safe4 ,it is true that presentations of the head are the most favorable1 providing they occur before the rupture of the membranes1 but after that event they may not be so favorable as those of the lower extremities1 and certainly are not so easy or safe to induce4 ,pelvic ,version4--,turning to bring down the feet is performed for various reasons1 and under many different circumstances4 ,as a general principle we may say that it is done either to change the presentation1 when unfavorable1 or to terminate the labor when it is lingering1 or when it is desirable to have it over as quickly as possible4 ,the feet may be drawn through the mouth of the ,womb when it is but little opened1 and when they have once passed1 the limbs and body soon follow1 and the head seldom remains long behind4 ,the ftus may in fact be compared to a wedge1 of which the feet are the point1 and if they enter the passage the rest part is gradually driven after by the uterine contractions4 ,the chief contingencies which call for the operation of turning are1 a protracted labor1 a presentation of the placenta1 causing hemorrhage1 and a wrong presentation1 particularly one of the shoulder4 ,the operation of turning is very clearly explained by ,dr4 ,lee1 and ,i know from experience that his directions can be safely relied upon4 ,it very frequently happens however1 that there will be some peculiar circumstances in a case1 which will necessitate more or less change in the manner of proceeding1 so that the practitioner must after all be guided1 to a great extent1 by the requirements and conditions then existing4 ,dr4 ,lee's directions therefore1 must merely be considered as general ones1 to be modified as occasion may require3-- ,when the operation of turning is required before the membranes are ruptured1 and when the orifice of the uterus is widely dilated1 and there are long intervals between the pains1 it is accompanied with little difficulty and danger4 ,having explained to the patient and her relatives the nature of the case1 let her lie on the left side near the edge of the bed1 with the knees drawn up to the abdomen4 ,sit down by the side of the bed1 and quietly take off your coat2 lay bare your right arm by turning up the shirt above the elbow1 and cover the back of the hand and the whole forearm with cold cream1 lard1 or a solution of soap4 ,introduce one finger after another into the vagina1 and slowly and effectually dilate its orifice4 ,the hand1 in a conical form1 and in a state of half supination1 must then be pressed steadily forward with a semi-rotatory motion against the perineum and sides of the passage1 till it clears the orifice of the vagina4 ,this should always be done very slowly and gently1 as it is accompanied with great pain4 ,let the hand remain some time in the orifice of the vagina1 that it may be fully dilated1 and offer no resistance in the subsequent steps of the operation of turning4 ,when the hand has dilated the vagina sufficiently1 in the absence of pain gently insinuate the points of the fingers and thumb into the os uteri in a conical form2 and if it is not sufficiently open to allow the hand to pass1 you must proceed next to use artificial dilatation here also1 very gently and slowly1 always stopping as soon as a pain comes on1 but not withdrawing the fingers altogether at the time from the os uteri4 ,having succeeded in dilating the part without rupturing the membranes1 slide the hand up between the membranes and the anterior part of the uterus into the cavity1 and grasp the feet when the membranes give way4 ,most frequently the membranes burst as the hand is entering the uterus1 before it reaches the feet1 and the liquor amnii rushes out and is lost1 if it is not prevented by pressing the hand forward firmly into the orifice4 ,never be contented with one foot when it is possible to grasp both2 and this can always be done when the liquor amnii has not escaped1 and the uterus is not closely contracted round the body of the child4 ,seize both feet and legs1 and when there is no pain1 draw them down into the vagina2 and as the nates descend through the os uteri1 the shoulder and arm will gradually recede or be retracted1 and will offer no obstacle to the remaining part of the operation1 which should be completed as if the nates and inferior extremities had originally presented1 and which has already been very fully described4 ,in actual practice1 except in twin cases1 the membranes have been ruptured and the liquor amnii is gone1 in a great proportion of cases--in about ten to one--long before we are called upon to deliver by turning1 and the operation is then a much more serious affair4 ,sometimes1 when the os uteri is half dilated1 there is an interval of freedom from pain for several hours after the rupture of the membranes1 and partial escape of the liquor amnii4 ,here it is advisable to turn without delay2 and the hand can be passed up into the uterus and the feet brought down with little more difficulty than if the membranes had not been ruptured4 ,the operation of turning is however beset with many difficulties1 and unless the conditions for it are very favorable1 and the operator skillful1 it may cause greater mischief than it is intended to remedy4 ,the probability is1 as in the case of other operations1 that it would seldom or never be needed if proper means were used in time1 and perseveringly2 and it is yet a question whether the prospect1 for both mother and child1 would not be more favorable if the delivery was always left to nature1 in those cases where version is now attempted4 ,dr4 ,collins says1 ,as to turning1 the risk to the mother is1 in the majority of cases1 so great as to forbid its employment1 nor do ,i think the practitioner justified by the circumstances in so greatly hazarding his patient's life4 ,,part ,,ii4 ,,the ,,diseases ,,of ,,women ,,during ,,pregnancy1 ,,and ,,in ,,child-,,bed4 ,women are liable during pregnancy1 and after childbirth1 to most of the diseases which afflict them at other times1 and also to many derangements peculiar to those periods4 ,as a general rule either of those conditions somewhat modifies the disease1 and also necessitates certain differences in its treatment4 ,my former work on the ,diseases of ,women having treated on all those affections common to every other period1 ,i shall in this confine myself chiefly to those peculiar to the two conditions referred to2 giving their causes1 symptoms1 and treatment1 with practical hints for their prevention4 ,,section ,,ix4 ,,the ,,diseases ,,of ,,pregnancy4 ,the diseases which are found during pregnancy are of two kinds2 the first kind called ,sympathetic1 or nervous1 consist of various derangements of different parts of the system1 produced chiefly by nervous sympathy with the ,womb4 ,the second kind1 called ,idiopathic1 are real primary derangements of the ,generative ,organs themselves1 or of those intimately connected with them4 ,each of these kinds will be treated of separately4 ,,chapter ,,xxvi4 ,,sympathetic ,,diseases ,,occurring ,,during ,,pregnancy4 ,,sickness ,,and ,,vomiting4 ,nausea1 or sickness1 with or without vomiting1 is one of the most frequent and troublesome accompaniments of pregnancy4 ,it is so general1 in fact1 as to be looked upon as one of the earliest and most reliable signs of that state4 ,it is undoubtedly caused1 in the earlier stages1 simply by the intimate sympathy which exists between the stomach and womb1 and which causes one of those organs to be temporarily deranged whenever the other is in any unusual condition4 ,in the latter months it is also produced by the enlarged womb pressing on the lower part of the stomach1 as it rises in the abdomen4 ,in many diseases of the womb1 particularly in enlargements1 and tumors1 the stomach will become deranged in precisely the same manner as during pregnancy1 and the patient is frequently deceived thereby as to her real condition4 ,in most cases the sickness does not begin till about the second month1 and it seldom lasts beyond the third or fourth4 ,there are some however1 with whom it commences almost immediately after fecundation1 and others with whom it lasts till the very commencement of labor4 ,i have even known persons who always experienced the nausea at the very moment of conception1 and who were thus aware when that event took place4 ,with some persons the trouble occurs only during certain parts of the day1 most usually in the morning1 while with others it comes on irregularly1 or even endures constantly4 ,in most cases it is not very severe1 and causes but little distress2 occasionally however1 it is very serious1 and may even lead to fatal results1 in spite of all that can be done4 ,abortion is frequently brought on by it2 and so are faintings1 and spitting of blood4 ,many women however1 will vomit with violence1 during almost the whole period1 without either accident or evil effect4 ,the treatment must vary according to the cause of the derangement1 its violence1 and the effect it produces4 ,in regard to diet but little can be said that will be found generally applicable4 ,mild and light food is generally recommended1 but is not always the best1 for some females can only keep on their stomachs the most indigestible articles4 ,perhaps nothing more can be said1 with propriety1 than that the patient should take whatever she can retain1 particularly if she has become weak from want of nourishment1 which is often the case4 ,some females can only keep down a little broth1 or tea1 or sweetened water1 while others find solid food the best1 or fruits4 ,i have known many able to take ,gum ,arabic1 either solid or dissolved in water1 and retain it1 when nothing else could be borne4 ,this is nourishing1 and may often keep up the strength till the sickness abates4 ,there are many remedies that will sometimes relieve1 though frequently they are of no use whatever4 ,a little wine or brandy1 or orange flower water2--a few drops of laudanum1 or ether1 or essence of peppermint1 may be tried4 ,one or two ipecac1 or cayenne1 or camphor lozenges1 will sometimes be efficacious1 and so will a little ,port wine and ,peruvian bark1 or a seidlitz powder1 or even common soda water4 ,a tea-spoonful of powdered charcoal succeeds occasionally1 or some very strong bitters1 or a cordial1 such as a wine-glassful of curacoa4 ,a plaster of opium may also be placed over the stomach1 or one of meal wet with laudanum4 ,a mustard poultice over the stomach1 will frequently relieve when everything else fails2--sometimes it is more effective however1 when placed on the spine1 opposite the stomach4 ,as a general rule the bowels should be kept free1 either with injections or with mild purgatives1 as castor oil1 or manna4 ,regular bathing will often act as a complete preventive or cure1 and the vomiting may be frequently stopped by simply dashing cold water over the stomach4 ,some practitioners recommend emetics1 and bleeding if the patient be of a full plethoric habit4 ,leeches and cups have also been used over the stomach1 and sometimes with good effect4 ,ether and chloroform have also been inhaled1 and have operated favorably in a few instances4 ,plentiful draughts of cold water1 or swallowing bits of ice will likewise afford relief to some4 ,in several instances the vomiting has been so violent1 and the patient has suffered so much1 and become so exhausted from want of nourishment1 that it has been absolutely necessary1 after all other means have failed1 to cause miscarriage1 as the only means of saving the patient's life4 ,whenever the trouble can be borne1 ,patience is the grand specific4 ,the sufferer must recollect that it will surely cease with delivery1 and most probably before4 ,,ptyalism1 ,,or ,,excessive ,,salivation4 ,some pregnant females will secrete an immense amount of saliva for weeks and months in succession1 as if they had been salivated4 ,i have never known a case in which this discharge caused any evil1 even when very great1 though it is often troublesome4 ,it would probably not be judicious to stop it1 even if we could do so1 as long as it does no harm1 though it may be advisable at times to moderate it4 ,the only treatment proper to effect this is1 to keep the bowels free and the body well bathed1 and to gargle the mouth with mint or balm teas1 or canella water1 or a little syrup of poppies4 ,this discharge1 like the vomiting1 arises from the sympathetic action of the uterus1 and it generally ceases about the fourth month1 though with some it will last the whole time4 ,,odontalgia1 ,,or ,,toothache4 ,this is also a very general trouble during pregnancy1 and sometimes a very severe one4 ,like several other sympathetic affections it is very irregular as to its first appearance and duration1 some suffering from it most of the time1 almost without intermission1 while others only have it at intervals1 and but slightly4 ,it sometimes depends upon unsound teeth1 but is frequently experienced without any such cause1 and is then a true neuralgia4 ,when it arises from a bad tooth1 the pain is usually confined more or less to the neighborhood of the tooth1 but when it is neuralgic it extends over the greater part or the whole of the jaw and face1 and darts about from one part to another4 ,in true toothache there is also usually more or less inflammation and swelling1 while in the most agonizing neuralgia nothing of the kind can be seen4 ,the treatment must be regulated by circumstances4 ,if the pain appears to be kept up by an unsound tooth1 it should by all means be extracted1 unless the patient be so exceedingly nervous and irritable that abortion is to be feared1 in which case the pain must be alleviated as well as it can be1 though there is almost as much danger in leaving the tooth in such cases as in extracting it4 ,a few leeches to the gums will sometimes relieve1 or a mustard poultice to the cheek1 or a blister behind the ear4 ,the stomach or bowels being out of order may also keep up the irritation1 and regulating them may materially assist in giving relief4 ,some persons are relieved by lotions of camphor1 or laudanum1 and others by washes of cayenne tea1 or alum water4 ,in the neuralgic form1 when no particular tooth can be found in fault1 the treatment must be more general than local4 ,the ,carbonate of ,iron ,pills1 which can be purchased at the druggists ready made1 have frequently an excellent effect2 from two to four may be taken at a dose1 twice a day1 the bowels being kept open1 if necessary1 by a little tincture of rhubarb4 ,if the pain comes at regular intervals1 or intermits1 it may frequently be stopped by quinine4 ,two of the ordinary quinine pills may be taken every five hours1 for two or three days4 ,if the head feels oppressed by their use1 the dose must be lessened to one4 ,m4 ,guillemeau recommends the following to be tried if other means fail1 and ,i have known it to be of decided benefit4 ,take the whites of two eggs1 and two ounces of common black pepper1 in powder1 and beat them well together4 ,spread this on some tow or cotton1 and lay it on the cheek4 ,it may be kept on till it causes considerable irritation1 and sometimes may be used on both sides4 ,some females have been relieved by bathing the face in cold water1 or keeping ice in the mouth1 and others by hot fomentations4 ,it has also been recommended to fill the mouth with cold water1 and bathe the cheek with hot at the same time6 ,occasionally an abscess1 or gum boil will form1 and when there seems a tendency to that it may be promoted by keeping a roasted fig in between the cheek and gum1 over the part where the abscess points2 when full1 it should be lanced1 as the discharge usually gives relief4 ,this pain is however very obstinate sometimes1 and defies all treatment1 but is seldom of such long duration when so severe4 ,,derangements ,,of ,,the ,,appetite4 ,the powerful sympathetic action of the womb on the stomach produces not only nausea and vomiting1 but various derangements of the appetite and taste also4 ,all of these require notice1 and some need attention4 ,anorexia4--,this means a complete distaste1 or even disgust1 for food1 sometimes of particular articles only1 and sometimes for those of every kind4 ,it seldom lasts beyond the fourth month1 but occasionally during the whole period4 ,it is remarkable how some females will be affected in this way1 and how little they will eat1 for several months together4 ,this however is scarcely ever of any consequence1 for the system does not seem to suffer in the slightest degree2 on the contrary1 the mother will remain quite stout1 and the child be born fully developed1 though the quantity of food taken has apparently been scarcely sufficient to sustain life4 ,in many cases there is even a decided benefit from this state of things1 particularly in those who are of a too full habit4 ,as long as the loss of appetite is merely of a sympathetic or nervous character it is not necessary nor advisable to resort to any special treatment4 ,but when it arises from indigestion1 or a foul stomach1 it is necessary to attend to it4 ,a mild emetic of ipecac or warm mustard and water1 may be given1 or a dose of ,epsom ,salts4 ,this state will be recognized by a furred tongue1 unpleasant breath1 and uneasiness at the pit of the stomach2 while in the purely nervous anorexia nothing of the kind is observed4 ,sometimes it may arise merely from debility of the stomach1 and in that case a few of the ,carbonate of ,iron ,pills will be of use4 ,in general the patient is benefited rather than injured by this voluntary fasting4 ,boulimia4--,this state is the reverse of the former1 meaning a ravenous appetite4 ,some females exhibit it in a most extraordinary degree1 and will eat to excess of anything that comes in their way4 ,many injure themselves in this manner1 by causing indigestion1 flatulence1 heartburn1 vomiting1 and even inflammation of the stomach4 ,it is of no use reasoning with them1 for the appetite is so strong that they will eat let them suffer ever so much4 ,all that can be done in such cases is1 to drink freely of various nourishing liquids1 such as soup1 broth1 rice milk1 or chocolate2 and by eating jelly1 arrow-root1 and eggs4 ,these contain much nourishment in a small space1 and satisfy the hunger without overloading the stomach4 ,the appetite may also be deadened considerably by eating figs1 dates1 sugar1 or chocolate2 and by drinking soda water4 ,capricious ,appetite4--,sometimes a female is found to have an inordinate desire for some one particular article of diet1 which she will eat to excess1 but will not touch anything else2 this is called malacia4 ,others will have a craving for some article not proper for food2--this is called ,pica4 ,they will devour chalk1 cinders1 earth1 wood1 flies1 spiders1 charcoal1 and various other things1 sometimes of the most disgusting kind1 though ordinarily they may be quite fastidious in their diet4 ,this unnatural desire is also frequently seen in hysteria and chlorosis1 and in several uterine diseases4 ,it does not appear that a moderate indulgence of these unusual tastes is at all injurious1 unless the article wished for be of a decidedly hurtful character4 ,on the contrary1 it is reasonably conjectured1 by many physiologists1 that they arise from a real want in the system of the very substances longed for4 ,for instance1 there may not be in the mother's blood sufficient lime to form the bones of the child1 and this deficiency is intimated by her desire for chalk or plaster2 nature having no other mode of making her wants known1 or of causing them to be supplied4 ,as a general rule1 so long as the indulgence is not obviously improper1 it should be allowed to a reasonable extent1 both to gratify the patient and to answer to what are probably the demands of nature4 ,it is seldom that interference is needed in these cases1 except when there is danger of the patient doing herself harm2 we may then try to alter the condition of the stomach1 and so change the taste4 ,a gentle emetic will sometimes do this1 or a saline purgative4 ,if these fail use a few of the ,carbonate of ,iron ,pills1 or some good strong bitters1 or teas1 drunk freely1 such as ,cammomile1 ,boneset or ,centaury4 ,,pyrosis4 ,this disease is more frequently called water brash and sometimes heart burn4 ,it is characterized by the raising of a hot acrid fluid into the throat1 causing a sensation of burning from the stomach upward1 even to the mouth4 ,it is a very frequent attendant upon many forms of dyspepsia1 and is generally experienced more or less by most pregnant females1 arising either from improper diet or from mere sympathetic derangement4 ,if it arises only from errors of diet1 a reform in that particular is all that is needed1 but if it is merely sympathetic nothing can be done beyond palliating it1 to give temporary relief4 ,for this purpose the patient must take a spoonful of lime water1 in half a tumbler of milk two or three times a day1 or some carbonate of soda1 or magnesia1 with a few drops of laudanum if there be any pain4 ,in those cases which resist such remedies a little of the compound iron mixture may be of service1 such as can be obtained at the druggists4 ,a nourishing diet should also be observed1 and plenty of exercise should be taken in the open air4 ,,dysphagia4 ,difficulty of swallowing1 which is meant by this term1 is a more troublesome and alarming affection1 frequently attendant on pregnancy4 ,there is however nothing dangerous in it1 except that it frightens the patient4 ,some will gasp and be unable to swallow1 or even speak1 for a considerable time1 and will think they have something in the throat4 ,it is however entirely a nervous symptom1 arising from uterine irritation1 and seldom lasts beyond the third or fourth month4 ,a little cordial1 wine1 or brandy1 will frequently relieve it1 or some spirits of camphor rubbed on the neck4 ,m4 ,colombat d'l',isere recommends the following ointment1 to be rubbed on the neck4 ,extract of ,belladonna forty-seven grains1--,extract of ,strammonium fifteen grains1--white wax one ounce1--oil of lemons twelve drops4--,these must be warmed and well rubbed together4 ,a dash of cold water on the throat and chest will often succeed better than anything else4 ,,gastralgia4 ,this is commonly termed cramp at the stomach1 or nervous colic4 ,it consists of a severe kind of cramp1 with dragging and cutting sensations in the stomach1 as if it were being tied in knots and cut to pieces4 ,sometimes the attack will only last for a few minutes1 and then totally pass away1 at other times it will remain for half an hour or more1 and cause the most intense suffering4 ,the patient will be drawn together1 or doubled up1 with her hands placed on her stomach1 and will groan and exhibit in her features the greatest agony2 sometimes even1 she will faint away with it4 ,this affection may1 like the others1 be merely nervous1 and then it is attended by nothing but the pain4 ,it may also arise from real inflammation of the stomach1 and then it is attended by fever1 excessive soreness and tenderness of the stomach when touched1 and by a hot1 dry mouth4 ,in the nervous spasm the pain is frequently relieved by pressure1 but when inflammation exists the pressure increases it4 ,some females always have these attacks whenever the stomach is empty1 and they pass away immediately anything is taken to eat or drink4 ,with others they are often brought on by overloading the stomach1 or by eating some improper articles4 ,to relieve the spasm1 one of the best things is a tea-spoonful of ,compound ,spirits of ,lavender1 taken without water4 ,this nearly always gives relief in ten minutes at most2 but if necessary a second spoonful may be taken in a quarter of an hour4 ,a little brandy1 or peppermint1 or curacoa cordial will also succeed in many instances1 or simply drinking freely of any hot tea1 or swallowing half a tea-spoonful of common pepper4 ,a mustard plaster put on hot over the stomach will scarcely ever fail1 even without anything being taken internally4 ,m4 ,colombat gives the following recipe as one which he has found efficacious1 and it is certainly a pleasant one4 ,orange and ,linden ,flower waters each two ounces2 ,syrup of ,ether and of ,valerian each one ounce2 ,syrup of ,poppy heads half an ounce4 ,of this mixture a tea-spoonful may be given every quarter of an hour till the pain abates4 ,to prevent the return of the attack1 the patient must carefully avoid everything that disagrees with the stomach1 or creates wind2 she must keep the bowels free1 and accustom herself to regular bathing or rubbing the body4 ,if the stomach appear weak1 which is often the case1 some ,boneset tea1 or ,port wine and bark1 or a few of the ,carbonate of ,iron ,pills may be advantageous4 ,if there be acid on the stomach1 use the means recommended for heartburn4 ,,constipation4 ,this is a very common trouble with pregnant females1 and one that may lead to many others4 ,very frequently it arises merely from the pressure of the expanded uterus upon the large intestine1 but it may also arise from a simple want of power1 the uterine action having apparently weakened the force of all the neighboring organs4 ,it is advisable to correct it as soon as possible1 let it arise how it may1 as it is very apt to cause various derangements of the stomach and intestines1 and even inflammation of the womb itself4 ,as a general rule1 not more than three days should elapse without the bowels being moved1 though some will remain a week or more without any apparent inconvenience2 but there is always danger in such delay4 ,many females do themselves much harm by taking what they call opening medicines1 the action of which is often more injurious than the constipation itself4 ,all drastic purgatives1 such as aloes1 gamboge1 colocynth1 and jalap should be carefully avoided1 as they not only make the costiveness worse after their action is over1 but they also frequently produce inflammation1 and even abortion1 by the violent straining they cause4 ,the best medicines1 when they are really needed1 are manna1 seidlitz powders1 or castor oil4 ,enemas are better however1 as a general rule1 such as those of thin starch1 or molasses and water1 to which may be added a little castor oil4 ,the grand aim should be1 in all such cases1 to stimulate the bowels to an increased action without medicines1 by a properly regulated diet6 ,salads may be eaten when they do not cause derangement of the stomach1 and ripe or stewed fruits1 particularly figs1 dates and prunes4 ,soups are also good1 except they contain rice1 or vermicelli1 or maccaroni4 ,bran bread should be eaten regularly1 and not white4 ,the only meats should be veal or poultry4 ,as a drink lemonade is excellent1 with a little cream of tartar1 or tamarind tea1 or barley water sweetened with honey4 ,with some patients a cup of coffee1 or a glass of beer will always relieve the bowels1 especially if a glass of water is also drank after it4 ,i have known persons neglect the bowels so long that they have become completely impacted1 by the hard fces1 and could be relieved only by instruments4 ,it is very important to attend to this affection in time1 and to persevere with the means of permanent relief regularly4 ,,dysentery ,,and ,,diarrh,a4 ,it is frequently the case that pregnant females1 instead of being constipated are afflicted with severe diarrha4 ,this may arise from inflammation1 and is then attended by fever1 and extreme tenderness and soreness of the bowels4 ,most usually however it is entirely nervous1 and arises from the sympathetic irritation of the womb4 ,there is then no tenderness or soreness1 no fever1 no derangements of the appetite1 nor in fact any other symptom of any consequence4 ,if it remains long unchecked blood will be discharged1 from the extreme irritation of the intestines1 and it is then called dysentery4 ,this is nearly always accompanied by fever and general irritation4 ,sometimes there will be a constant and painful desire felt to move the bowels1 but with little power to do so1 and at the same time a burning heat and unpleasant sensation at the fundus4 ,this is called tenesmus1 and the straining from it has frequently produced abortion4 ,if the diarrha is not excessive1 and the female does not lose her appetite1 or strength1 it is better let alone1 particularly if she be of a full habit1 and disposed to fever4 ,if thought desirable to check it a little1 this may usually be done by a change in the diet4 ,rice milk1 sago1 tapioca1 and arrow-root may be taken1 white bread may be used1 and not much fluid drunk4 ,if such means are insufficient an injection may be thrown up the rectum in the morning1 of thin starch1 with a tea-spoonful of laudanum4 ,the abdomen may also be well fomented1 and a dose of ,tincture of ,rhubarb taken occasionally4 ,if the tenesmus is very troublesome1 an injection of tepid water may be used1 and the female should sit occasionally over the steam of hot water3 in extremely painful cases a few leeches may be used round the fundament1 and a hot flaxseed poultice placed over the abdomen4 ,a warm bath is also an excellent remedy with many4 ,when the diarrha still continues notwithstanding the above remedies1 resort should be had to tonics and opiates4 ,the patient should take ,port wine and ,peruvian bark1 or some ,gentian wine1 and use injections of ,starch and ,laudanum regularly4 ,cammomile tea may also be freely drunk1 and an opium pill may be taken at night4 ,above all1 the patient must endeavor to avoid all mental agitation4 ,when dysentery sets in1 every effort should be made to subdue it as early as possible4 ,half a pint of rice milk1 with ten or fifteen drops of laudanum may be taken two or three times a day1 and an injection may also be used night and morning of flaxseed1 with fifteen or twenty drops of laudanum4 ,m4 ,colombat recommends the following recipe as seldom failing to cure4 ,take the whites of six eggs and beat them up in a quart of water2 then use one-third as a drink1 and the rest as an injection4 ,a neat spoonful should be drunk every ten minutes1 and an injection used every two hours1 but not more than one small syringeful at a time4 ,a tea-spoonful of syrup of poppies1 with some loaf sugar1 may also be added to every spoonful that is drunk4 ,eggs1 jellies1 and rich soups1 with meat and wine1 if there be no inflammation1 may be taken regularly1 in addition to the articles already mentioned4 ,,dyspn,a1 ,,or ,,difficulty ,,of ,,breathing4 ,there are but few pregnant females who do not complain more or less of difficulty of breathing1 and this difficulty may arise from different causes4 ,in the earlier months it is caused by sympathetic irritation only1 the same as difficulty of swallowing4 ,in the latter months it is caused by the enlarged womb filling up the abdomen so much that the lungs in the chest are pressed upon and have not sufficient room to play freely4 ,it may also be caused by a plethoric or too full habit1 the lungs then being in reality congested4 ,the temporary difficulty of breathing which is felt in the early months1 from nervous sympathy1 needs scarcely any kind of treatment1 as it passes off naturally in a short time4 ,in severe attacks the same remedies may be used as for difficulty of swallowing before referred to4 ,that which arises in the latter months1 from pressure of the womb1 can frequently be relieved only by the patient remaining as long as possible in certain favorable positions4 ,i have known many who could never sleep except when propped nearly upright1 by means of pillows and cushions1 as immediately they assumed the recumbent position the upward pressure became so great they were nearly suffocated4 ,in such cases the patient should be careful never to eat or drink to excess1 nor take anything likely to produce wind1 because the least increase in the size of the abdomen adds to the difficulty4 ,the bowels should also be kept free1 and nothing tight or heavy in the way of clothing should be worn4 ,this difficulty is most frequently seen in those who have contracted chests1 and in those who have been accustomed to wear corsets and tight dresses4 ,a deformed pelvis may also give rise to it by forcing the womb above its usual position4 ,many females both create and increase this difficulty by binding themselves tighter than usual during pregnancy1 under the mistaken idea that it enables them to support their burden so much easier4 ,when the dyspna arises from a full habit the patient must live low1 keep the body regularly bathed and rubbed1 and the bowels freely open by an occasional seidlitz powder1 or dose of ,epsom ,salts4 ,if the difficulty becomes at any time suddenly great and alarming1 the feet should be placed immediately in hot water1 while the patient is upright2 a mustard plaster should also be put upon the chest1 and an opening injection of starch and ,castor ,oil administered as soon as possible4 ,the usual practice in such cases is to bleed from the arm1 to the extent of eight or ten ounces1 and in case no other means give relief1 this may be tried4 ,,cough4 ,like the previous affection cough is most usually produced during pregnancy by sympathetic irritation4 ,it may arise1 however from a partial congestion1 or inflammation of the lungs or bronchial tubes1 produced by a too great determination of blood to them4 ,in the merely nervous cough1 there is no expectoration1 nor any soreness or pain in the chest1 and it will frequently disappear for several days together4 ,no particular attention need be bestowed upon this cough1 unless it become so violent as to threaten abortion4 ,in that case a pill1 containing one grain of opium1 may be taken1 or from ten to fifteen drops of laudanum1 whenever the attack is severe4 ,barley water1 or gum arabic water1 may also be freely drunk1 with a large spoonful of ,syrup of ,poppies added to each pint4 ,a small dose of ,hive ,syrup1 or ,paregoric1 will also be found sometimes better than anything else4 ,an enema of ,starch and ,laudanum1 as formerly described1 will also relieve1 in some cases1 better than anything taken by the mouth4 ,the body should be kept warm1 particularly the feet1 and a mustard poultice may be placed over the chest1 if the straining at any time becomes too great4 ,some patients experience relief from an assaftida pill1 or a little musk1 and others from a small dram of cordial1 or wine4 ,if there be expectoration1 with fever1 and tenderness in the chest1 or sharp pains when a long breath is drawn1 there is reason to fear inflammation of the lungs1 or bronchitis4 ,in this case all the above means1 except the wine and stimulants1 may also be used only more freely1 and the mustard poultice must be kept on till it makes a blister4 ,the patient must live low1 her feet must be frequently bathed in hot water1 and her bowels regularly opened either with saline purgatives or enemas4 ,all that is requisite is to keep the inflammation from extending till after delivery1 when it usually subsides without any further trouble4 ,as soon as the womb is emptied1 its pressure upon the abdominal aorta ceases1 and the blood can then flow freely to the lower extremities1 and thus the lungs become relieved and the inflammation goes down4 ,,palpitation ,,of ,,the ,,heart4 ,this is also a frequent accompaniment of pregnancy1 and one that is likely to cause alarm sometimes1 from its violence4 ,unless dependant upon organic disease of the heart however1 it is in general only a nervous affection1 and passes away with delivery4 ,we may always reasonably suppose it to be nervous when it occurs only during pregnancy1 and particularly if it is irregular in its frequency and violence4 ,i have known females who were always attacked with it about the same period1 and who could therefore always tell when it was coming on1 and sometimes even how long it would last4 ,it will sometimes come on during sleep1 and so forcibly as to waken the patient instantly4 ,at other times while awake1 it will commence so suddenly that she will sink down as if struck by a powerful blow4 ,the only directions that can be given for alleviating it are1 to keep as quiet as possible1 use the bath regularly1 avoid constipation1 and live rather low1 particularly if the patient be of a full habit4 ,exercise should also be taken regularly in the open air1 but not of a violent kind4 ,she should also sleep with the head on a high pillow1 and never eat late suppers1 nor take any food that disagrees with the stomach4 ,all kinds of stimulants1 such as wine1 coffee and spices1 should be abstained from1 and all powerful emotions carefully guarded against4 ,during an attack a few drops of ,laudanum1 or an ,opium pill may be taken1 and the feet placed in hot water4 ,an ,assaftida pill is sometimes good1 or a little ,ether4 ,bleeding is generally practised in extreme cases1 but there is often considerable danger in it4 ,a too full habit is often the exciting cause of the palpitation1 as may be seen by the patient being always liable on the slightest exertion to flushed face1 dimness of sight1 ringing in the ears1 swelling of the limbs1 and puffiness of the gums1 sometimes to such an extent that the mouth will taste of blood4 ,such persons should carefully observe a moderate unstimulating and simple diet1 and never allow the bowels to remain constipated more than a single day4 ,they should also rub and wash the skin well1 and study calmness and quiet4 ,,syncope1 ,,or ,,fainting4 ,in this condition1 which is just the reverse of the former1 the heart suspends its action altogether2 the breathing ceases1 all power of motion and feeling is lost1 the face turns ghastly pale1 the eyes close1 and the individual seems as if actually dead4 ,it seldom lasts however more than five minutes1 when the pulse gradually begins to beat1 the color returns1 and the individual slowly recovers4 ,some females are liable to such attacks once a month1 others once a week1 others every few days1 and some at irregular periods4 ,they are generally preceded by a dull pain at the pit of the stomach1 fullness in the head1 yawning1 and loss of sight1 or ringing in the ears4 ,the causes that predispose to this fainting are not very well understood1 though there is no doubt but it is mainly dependant upon uterine disturbances4 ,in some females it is brought on by the sudden motions of the ftus1 or by their remaining too long in one posture4 ,in others it is produced by straining from constipation1 or by sudden fright or anger4 ,in very nervous persons it not unfrequently arises from unpleasant sights1 smells1 and sounds4 ,in fact it is caused in them much the same as a common hysterical fit1 such as is described in my ,diseases of ,woman4 ,a full habit1 and over feeding1 or drinking stimulating liquors may also bring it on1 and so on the contrary may a state of weakness and exhaustion4 ,this accident is more alarming than dangerous1 except to the child1 which may lose its life if the fainting lasts too long4 ,to recover a person from one of these fainting fits1 she should be laid upon her back on a level place1 and every part of her dress should be carefully loosed4 ,some strong odor should then be applied to the nostrils1 such as hartshorn1 vinegar1 burnt feathers1 or smelling salts4 ,the body should be well rubbed over the heart and lungs1 either with the hand or with a soft1 dry napkin4 ,cold water may also be dashed on the face1 and the hands may be well chafed4 ,if the fit still endures1 a mustard plaster may be placed on each arm1 or the whole body may be placed in a warm bath1 if convenient4 ,care should also be taken to admit the fresh air freely4 ,as soon as she begins to show signs of consciousness1 a little wine or brandy may be placed in the mouth1 and the body may be elevated a little4 ,to guard against such attacks1 the same precautions as to diet and mode of life must be observed as were directed in the article on palpitation of the heart2 and1 as this accident is most frequent in those of a hysterical habit1 they should carefully follow the advice given in the article ,hysteria1 in my ,diseases of ,woman4 ,,headache ,,and ,,dizziness ,,in ,,the ,,head4 ,each of these distressing affections1 both of which are very common during pregnancy1 may arise either from nervous excitement or from a full habit and determination of blood to the head4 ,nervous headache is generally met with in the earlier months of pregnancy1 and is characterized by being frequently periodical1 and often confined to particular spots4 ,it also commences suddenly1 from some excitement or depression of mind1 and leaves little or no distress when it is gone4 ,the headache1 which arises from a too full habit1 commences with flushing of the face1 heaviness in the eyes1 dull pain in the forehead1 and a sense of uneasiness1 with disposition to sleep or dose4 ,it seldom comes on much till the latter months of gestation4 ,headache may arise also accidentally1 from derangement of the stomach1 but this cause is easily ascertained by the furred tongue1 loss of appetite1 and bitter taste in the mouth2 it is also felt most acutely in the back of the head1 down by the neck1 and passes away immediately the stomach is corrected by an emetic1 or by fasting4 ,nervous headache during pregnancy often defies all our attempts to alleviate it1 though we sometimes succeed in doing so4 ,the best general remedies are warm baths1 and1 if the bowels are constipated1 enemas of starch and castor oil daily4 ,to these may be added occasional small doses of ,laudanum1 or an ,opium pill1 or two grains of ,camphor4 ,smelling odors1 such as ,camphor1 ,cologne1 or ,hartshorn1 will relieve some1 but will make others worse2 so that its utility can only be determined by experience4 ,when a severe attack comes on1 the patient should put her feet in warm water1 or use a warm bath1 take a few drops of ,laudanum1 or a little ,musk1 or ,valerian1 and then try to go to sleep4 ,to guard against the attack1 she must never overload the stomach1 nor take anything indigestible2 and never think too much nor allow herself to become excited or depressed4 ,when the trouble is caused by a too full habit1 she must observe the directions given in the articles on palpitation of the heart1 and ,syncope4 ,the diet must be mild and not too nutritious1 the bowels must be regularly moved every day1 chiefly by ,epsom ,salts and ,seidlitz ,powders1 and regular gentle exercise must be taken in the open air4 ,in the latter months it is especially important to attend to a severe headache immediately1 particularly when the pain is seated at the top of the head1 because it is very likely1 if unchecked1 to terminate in convulsions4 ,the means above recommended must be carefully and perseveringly applied2 the feet must be kept warm1 the bowels freely opened1 and the head kept cool by wet clothes1 or cold lotions1 or ice4 ,it is the general practice in all such cases1 if the pain does not abate soon1 and the pulse be full and quick1 to bleed freely at the arm1 and the most eminent physicians of the ,allopathic school assure us1 that the life of the patient frequently depends upon its being done promptly4 ,i have no doubt1 however1 but that relief can be generally obtained by the simple means described1 if they are used early and perseveringly4 ,,insomnia1 ,,or ,,sleeplessness4 ,there are few affections that cause more real distress during pregnancy than this4 ,many females will be utterly unable to sleep for many days and nights together1 and others can only obtain a few minutes broken and unrefreshing sleep at distant intervals4 ,there is danger1 when this state becomes highly aggravated1 that it may lead to delirium1 or that the want of rest may wear away the strength to such a degree1 that the patient will sink from mere exhaustion4 ,there are some females1 however1 who will remain without sleep1 or at most take but very little1 for a long time1 without suffering any inconvenience4 ,this affection is essentially a nervous one1 and the only means likely to relieve it are those that have a tendency to soothe and calm the nerves4 ,if the patient be surrounded by any irritating circumstances they should be at once removed1 or she herself removed from them4 ,particular attention must be paid to the diet1 so that no derangement of the stomach or bowels be kept up1 and a regular system of out-door exercise must be practised4 ,a warm bath just before going to bed1 with a good rubbing of the skin1 will frequently act like magic in procuring rest4 ,as a general rule narcotic drugs should not be used1 but in extreme cases they may be resorted to sparingly4 ,a single ,opium pill1 or a few drops of ,laudanum may be taken after the bath4 ,if the patient be thin and delicate1 she should eat meat1 eggs1 and milk1 and take a little wine1 if it causes no unpleasant symptoms4 ,indeed a glass of wine will frequently act better than ,laudanum1 and so will ale with some1 and coffee with others4 ,if the patient be of a full habit these things will be improper1 and may injure4 ,she should then be kept quiet1 and fed sparingly4 ,music has a powerful effect in many of these cases3--a slow1 solemn air1 played while the patient is reclining after her bath1 seldom fails in inducing sleep4 ,,temporary ,,affection ,,of ,,the ,,sight1 ,,hearing1 ,,and ,,smell4 ,these disorders are quite common during pregnancy1 particularly in the latter months4 ,some females will be utterly unable to distinguish any odors1 even the most powerful2 others completely lose their taste1 and others again become deaf or blind4 ,when they are caused only by the sympathetic action of the womb1 such deprivations are seldom of long duration1 though they may recur at frequent intervals4 ,in some cases they remain a considerable time1 and great fear is felt that they may become permanent1 but there is little danger of such a result4 ,i knew a lady who suddenly lost her sight when about two months gone1 and who remained totally blind till about three hours after her delivery1 when her sight returned in a moment as perfect as before4 ,the same thing has frequently been observed of the other senses4 ,in some cases the vision will not be lost but perverted1 and the patient will then see everything double1 or larger or smaller than natural1 or always of a wrong color4 ,in like manner some will hear imaginary conversations1 or will fancy everybody is shouting1 or perhaps only whispering1 though they are all the time speaking in their natural voice4 ,these perversions1 when thus produced1 need occasion no alarm1 and seldom require attention1 unless accompanied by other urgent symptoms4 ,they may arise however1 from a fullness of blood in the head1 in which case they are accompanied by a flushed face and drowsiness1 and are preceded by bright sparks flashing before the eyes1 or by ringing in the ears4 ,the treatment of all these affections should be the same as that recommended for most of the previous derangements1 particularly for ,headache1 ,syncope1 and ,palpitation of the ,heart4 ,if there be nervous excitement merely1 it must be calmed in the same way as recommended in the articles referred to1 and also in the last one on sleeplessness4 ,if the female be of a full habit1 and there is evidently a pressure of blood on the brain and nerves of the special senses1 the same means should be adopted to reduce the system1 and draw the blood to the extremities1 that have already been described4 ,in such cases these sudden deprivations of sight and hearing sometimes indicate the commencement of ,convulsions1 or ,apoplexy1 particularly if they occur during labor1 when every means should be resorted to instantly to relieve the pressure on the brain4 ,if no simpler means succeed in a reasonable time1 it is the general custom to bleed freely from the arm1 and there is no question but this frequently removes the difficulty at once1 whatever objections may be made to the practice4 ,it is also proper to say that many eminent practitioners1 who are not advocates of the lancet in general1 strenuously urge that it should be used immediately if the sight or hearing suddenly disappear in this way at any time4 ,and ,i certainly have myself known these accidents sometimes followed by a fit of ,apoplexy1 or ,convulsions1 and even death4 ,such was the case with a friend of one of my patients4 ,she found one day1 quite suddenly1 that she could only see half of any thing she looked at1 and at times it even disappeared altogether4 ,nothing was done for her1 and in about five hours after the first attack she fell speechless and died before they could lift her upon the bed4 ,it will therefore be a necessary precaution1 in all pregnant females of a full habit1 to attend rigidly to the advice that has been given1 because simple means1 used in time1 and regularly1 may prevent the necessity of stronger ones altogether4 ,in purely nervous cases of this kind no apprehension whatever need be felt1 and no such practice as bleeding is required4 ,,disordered ,,judgment1 ,,inclinations1 ,,and ,,propensities4 ,the sympathetic irritation of the uterus1 in some females produces extraordinary phenomena of this kind1 from simple desire to the most furious craving1 and from mere caprice to actual insanity4 ,there is no doubt but that many of these unusual desires1 or longings as they are called1 are either produced or much aggravated by the imagination of the patient1 and frequently would never be experienced at all1 if the idea was not suggested by other people having had the same4 ,custom and imitation are very powerful in such cases1 particularly when the nervous sensibility is much exalted4 ,still the most singular aberrations of this kind will often arise without any such adventitious aid1 and the fact should be borne in mind1 so that these temporary vagaries may be regarded with proper charity and forbearance4 ,some females will entirely change in their dispositions at these times1 the most amiable and mild becoming positively ill-natured and malicious2--the gentle will turn headstrong1 the haughty and proud will become humble1 and the gay will become melancholy1 or the sad will madly seek every kind of gaiety4 ,such things however should never be remembered1 nor be brought up against them afterwards1 for truly at such times they know not what they do6 ,women have been known while in this state1 to become thievish1 or to have an irresistible propensity to burn or kill4 ,some have even been known to exhibit great talents for music or poetry1 though ordinarily without any capacity for such things4 ,some will suddenly exhibit a most extraordinary intellect1 while others will become quite silly4 ,a medical writer tells us an instance of one female who always had an excellent sound judgment while pregnant1 but no memory1 while in her ordinary state she had a poor judgment but a most extraordinary good memory4 ,the celebrated ,baudelocque gives an account of another who could scarcely eat anything but what she stole1 while going to market2 and another writer mentions a lady who longed till she was almost delirious to bite a piece out of a baker's shoulder1 who worked opposite her window4 ,there is even an account of one who longed to eat some of her husband1 whom she dearly loved1 and who actually killed him to satisfy her appetite1 and then salted pieces of the body to keep for future use4 ,a writer named ,vives also tells us of a female whose husband paid a large sum of money for her to be allowed to bite a young man's neck1 it being evident that she would be nearly certain to miscarry unless so gratified4 ,in the year #ahaf1 at ,mons1 in ,france1 an unfortunate woman in this condition was seized with an irresistible impulse to destroy her children1 and actually drowned three of them1 and herself afterwards4 ,she had previously sent a poisoned cake also to one at school1 but fortunately it was not eaten4 ,generally speaking all these things pass away with delivery1 if not before1 unless it be actual insanity1 which sometimes remains4 ,all that can be done is to attend strictly to the general health1 keep the skin1 bowels1 and stomach1 in good action1 and remove all depressing or irritating circumstances4 ,if there be a propensity to anything decidedly injurious or dangerous1 the patient must be strictly watched1 but without its being perceived or known by her1 for fear of exciting suspicion in those who would be disposed to be cunningly secret or revengeful4 ,proper diet1 regular bathing1 and out-door exercise often correct many of these things4 ,h,,moptysis1 ,h,,matemesis ,,and ,,epistaxis4 ,these three terms mean spitting of blood1 vomiting of blood1 and bleeding from the nose1 all of which frequently occur during pregnancy4 ,spitting of blood is most usually observed in nervous women1 and in those of a full habit4 ,it is caused partly by sympathetic irritation1 and partly by the womb pressing upwards against the diaphragm and lessening the size of the chest1 which deranges the circulation in the lungs1 and causes rupture of their blood vessels4 ,the premonitory symptoms are pains round the waist1 cold extremities1 creeping of the skin1 and a sensation of anxiety or depression round the heart4 ,the attack begins by difficulty of breathing1 heat in the chest1 and dry cough1 followed by spitting up more or less bloody frothy mucus2 all which symptoms are much increased by violent exercise1 or a hot atmosphere4 ,in ordinary cases a mere spitting of blood need occasion no great alarm1 unless attended by symptoms of inflammation1 or unless the patient has had cough1 and other indications of pulmonary derangement before conception4 ,in hmatemesis the blood is vomited from the stomach1 and is in black clots1 frequently mixed with the food1 or bile1 while that which comes from the lungs in spitting on the contrary is bright red1 and quite fresh4 ,in vomiting of blood also1 there is seldom any cough or exertion of any kind4 ,the treatment of spitting of blood must be nearly the same as for many other derangements already described4 ,when there is a full habit1 the patient must live low1 keep the bowels free1 and the skin in good order1 and avoid all agitation of mind or over exertion of body4 ,an ,opium pill occasionally will be useful1 or a few drops of laudanum4 ,the cough must be combatted in the way recommended in my previous article on ,cough4 ,lemonade or tamarind tea1 with some ,syrup of ,poppies added1 may be freely drunk1 or some of the black currant root tea4 ,the treatment of ,hmatemesis is precisely the same4 ,occasionally however the blood will pass into the intestines and occasion colic1 and then it must be removed by administering an enema of starch and castor oil1 or a little manna may be taken4 ,epistaxis1 or bleeding from the nose1 is much more frequent than either of the preceding1 but is seldom of much consequence4 ,in many cases in fact it is highly beneficial1 as it relieves the head from pressure1 and thus obviates many inconveniences4 ,if it continue too long1 or becomes excessive1 it may generally be arrested by putting cold wet cloths between the eyes1 and on the cheeks1 while the head is kept elevated4 ,the feet and hands should be kept warm1 and the air breathed should be as cold as possible4 ,in extreme cases1 the nostrils may be plugged with bits of sponge1 or cotton1 or some powdered alum may be snuffed up them4 ,the best plan is to raise the hands above the head and put something very cold1 as a lump of ice for instance1 or a piece of cold iron1 between the shoulders2 this seldom fails4 ,,varicose ,,veins4 ,very often in pregnant women the veins in different parts1 but particularly of the thighs and legs will swell out in knots1 either singly or in bunches1 sometimes like strings of beads1 or like the links of a chain4 ,these are called ,varices1 and occasionally they attain a large size1 and extend to various other portions of the body1 as the external lips1 vagina1 and mouth of the womb4 ,some women in fact have them over nearly the whole body4 ,they are caused by the pressure of the womb on the large abdominal veins1 preventing the return of the blood and disturbing the balance of circulation between the veins and arteries4 ,in the majority of cases1 unless very large1 they cause but little inconvenience1 and may be let alone1 but sometimes they cause pain1 or become so full that there is danger of their bursting1 and then it is necessary to interfere4 ,the first thing to be done is to relieve the abdominal veins from the pressure of the womb1 and this may be done by the patient keeping more or less the horizontal position1 and carefully avoiding all violent exertion4 ,the swelling is always worse during the latter part of the day1 particularly if the woman has been much on her feet1 she should therefore apply a cloth roller round the limbs before she rises in the morning4 ,if this be carefully put on1 just tight enough not to interfere with the motion of the limbs1 nor totally obstruct the circulation1 it will prevent the varices to a great extent1 if not altogether4 ,brisk friction with the hand will disperse the swelling in many persons1 or warm fomentations1 but sometimes cold bathing answers better4 ,it is advisable always to disperse them as soon as possible1 for if they remain too long that part of the vein becomes permanently weakened by being overstretched1 and will be always liable to swell again from any slight cause4 ,it is particularly advisable in these cases to avoid constipation1 and also to keep the skin in good action by bathing and frictions4 ,if at any time one of these varices should burst1 it need occasion no alarm1 unless it be seated on a large vein1 and the bleeding becomes profuse4 ,to stop it1 bind on firmly over the rent any firm cold body1 as a flat stone1 or a large silver coin1 passing the bandage several times round4 ,in slight cases a simple cold compress will be sufficient1 or a little powdered alum1 or some vinegar and water4 ,in short any of the usual remedies for stopping bleeding from wounds4 ,the female must be quite still till it is stopped1 and must be careful when she begins to move about again1 because it is liable to break out afresh4 ,those of a very full habit must live low1 and avoid all stimulants1 so as not to increase the quantity of blood in the body more than is necessary4 ,it is advisable to remove the varices1 as much as possible1 before labor comes on1 particularly if they are situated on the lips1 or in the vagina1 because they may burst during delivery and cause considerable inconvenience1 or even danger4 ,it is rare that these swellings continue after delivery1 but if they should do so1 the same treatment must be persisted in as before4 ,h,,morrhoids1 ,,or ,,piles4 ,these are troublesome annoyances at any time1 but particularly during pregnancy1 and unfortunately they are very common at that time4 ,they are1 no doubt1 chiefly caused in the same way as varicose veins1 that is by the enlarged womb preventing the proper flow of the blood in the small veins1 and so causing them to swell1 and form tumors4 ,they may in fact be called varices1 as truly so as those on the limbs4 ,in many persons however they are undoubtedly brought on merely by ,constipation1 which will undoubtedly either cause them or make them much worse when otherwise produced4 ,in general they become worse as the pregnancy advances1 because the womb becomes larger and the bowels are more apt to be confined4 ,as long as they only cause inconvenience1 without any particular distress or urgent symptom1 they may be let alone1 or be slightly treated in the way of palliation1 till after delivery1 when they will disappear4 ,occasionally however1 they grow to a large size1 so as to hinder the passage of the bowels1 and prevent the patient from sitting down or walking4 ,they may then cause inflammation1 and bring on falling of the intestine1 or abortion1 by the straining which they necessitate when the bowels are moved4 ,and even if these extreme results do not follow1 there may be serious derangements of the general health1 indicated by difficulty of breathing1 sleeplessness1 headache1 and fever4 ,in short there are few of the derangements incident to pregnancy so annoying as this1 and unfortunately1 from its nature1 the sufferer dislikes to speak of it and seek the necessary assistance4 ,many prefer undergoing the most excruciating agony for months1 rather than complain1 which shows the necessity for females knowing how to treat themselves1 when possible4 ,the bleeding which sometimes takes place from ,piles is more often beneficial than otherwise1 unless it becomes excessive1 from rupture of a large vessel1 in which case1 if the wound is external1 it may be treated the same as the ruptured varicose vein2 if it be internal1 the remedies must be injected with a syringe1 or a large roll of lint or cotton may be soaked in alum water and passed up the rectum4 ,frequently bathing the thighs and perineum with cold water will be sufficient4 ,to relieve the pain and swelling1 the female should sit over the steam of hot water1 and use the warm bath4 ,if the piles are external1 they should be bathed with hot milk and ,laudanum1 or rubbed with any soothing ointment1 particularly the ,cucumber ,ointment1 mentioned in my ,diseases of ,woman1 or with ,stramonium ,ointment4 ,if they are internal the milk and ,laudanum should be injected if possible1 or some thin starch and ,laudanum1 and a stiff roll of cloth may be smeared with the ointment and introduced4 ,in general1 ointments or other greasy matters are not so good as the milk or starch4 ,in conjunction with this1 the bowels must be kept free1 either with enemas or castor oil1 or by using a seidlitz powder in the morning4 ,this is indispensable1 for if constipation exists1 no applications can render much service4 ,the patient must also avoid fatigue1 and not remain too long upon her feet1 nor sit long1 particularly on a hard seat1 and if she be of a full habit she must live low1 to avoid making too much blood4 ,it is also important1 at all times1 to avoid using drastic purgatives1 such as ,aloes1 ,colocynth1 or ,gamboge1 as they always make piles much worse1 or even cause them4 ,,dema1 ,,or ,,watery ,,swellings4 ,this affection also appears1 like the preceding1 to arise from obstructed circulation1 but instead of the blood accumulating it is merely the serum1 or watery portion of it4 ,the swellings are generally whitish1 and spread about1 and a small pit remains in them when pressed with the finger4 ,they are found on various parts of the lower limbs1 and on the groin or abdomen1 and also upon the external lips1 in which place they are often exceedingly troublesome4 ,as a general rule these swellings are of small account1 and as they disappear with delivery1 but little attention need be bestowed upon them4 ,sometimes1 however1 they become very extensive1 and so engorged that they inflame and are extremely painful4 ,they have even been known to mortify1 and cause considerable sloughing1 particularly when chafed and afterwards wet with the urine4 ,in these extreme cases there may be serious disturbance of the general health1 from the constant irritation1 and from the patient being unable to walk about4 ,i have often known the limbs and vulva covered with patches of ,erysipelas from this cause4 ,sometimes the swellings even become so large that they interfere with the process of delivery4 ,the treatment of this affection consists in rest1 particularly lying down1 saline purgatives1 regular1 and frequent washing the parts with cold milk and ,laudanum1 or with a solution of ,borax1 half an ounce to a pint of water1 to be used cold and with a tea-spoonful of ,laudanum added to it4 ,simple cold water is frequently quite sufficient4 ,in general all kinds of ointments are injurious1 but if other means fail to give relief1 the ,cucumber ,ointment may be tried4 ,the wash should always be used after urinating1 and the parts must not be rubbed1 but lightly dried with a piece of soft linen4 ,fullers earth is often an excellent application when there is chafing4 ,if the patient be of a full habit1 she must carefully diet herself1 and bathe regularly4 ,if she be thin and weak1 a generous diet will be advisable1 with meat and even a little wine4 ,,hydrorrhea1 ,,or ,,profuse ,,discharge ,,of ,,water4 ,this consists in a discharge of water1 more or less profuse1 from the vagina1 at various periods during pregnancy4 ,some females will only discharge a small quantity1 at intervals1 others will have a constant dropping1 and others again will pour out an immense quantity1 sometimes several pints1 or even quarts1 in the course of a few days4 ,in general this water is quite limpid and colorless1 but sometimes it contains much mucus1 and at other times it is tinged with blood4 ,it does not appear that this discharge leads to any evil result1 even when excessive1 and ,i only refer to it to relieve anxiety4 ,the origin of this water is not yet ascertained1 but it is generally thought to be secreted between the membranes and the womb1 and to be quite distinct from the liquor amnii4 ,,pustules1 ,,and ,,mucous ,,discharges4 ,occasionally the external lips will be covered with pustules during pregnancy1 and frequent discharges of mucus will occur from the vagina4 ,they are both however caused by the unusual action of the uterine system1 and merely require frequent bathing of the parts with milk and ,laudanum1 and regular action of the bowels4 ,the most important thing to remark in connection with them is that they have often been mistaken1 even by medical men1 for the effects of syphilitic disease1 and much distress has resulted from such mistakes4 ,,derangements ,,of ,,the ,,urinary ,,organs4 ,several derangements of the urinary organs are liable to occur during pregnancy1 partly from sympathetic irritation1 and partly from mere pressure4 ,some of these may be partially relieved1 others have to be borne as patiently as they can be till delivery removes them4 ,the swollen womb often presses on the neck of the bladder1 and hinders the passage of the urine1 or even obstructs it sometimes altogether1 and thus causes straining1 burning heat1 and great distension of the bladder4 ,in some instances this passes off as the pregnancy advances1 owing to the womb rising higher in the abdomen1 but in other cases it remains more or less1 during the whole term4 ,it is particularly important1 in such cases1 that the female should not let the difficulty remain too long unremedied1 for if the bladder be very full it may become utterly impossible to empty it by natural effort4 ,sometimes the difficulty is much lessened by lying on the back a short time before attempting to urinate1 or by raising up the abdomen with the hand at the time4 ,many females can urinate with tolerable comfort while lying on the back or abdomen1 and others are much relieved by constantly wearing a bandage4 ,constipation always makes this difficulty worse1 and sometimes even causes it1 by keeping the rectum full and thus increasing the pressure4 ,in all such cases it will be readily seen1 that forcing medicines are not only useless1 but liable to cause injury4 ,the change of position1 rest1 and supporting the abdomen are the means to be relied upon4 ,if these fail1 and the urine accumulates1 the catheter must be used4 ,a warm bath1 or fomentation with warm water and ,laudanum1 will assist1 and sometimes relieve alone4 ,to ease the burning and distress the patient must drink freely of gum water1 or barley tea1 with a little ,syrup of ,poppies4 ,there is one manuvre which1 if practised aright1 will nearly always allow the female to urinate with ease1 and fortunately she can practise it herself4 ,it consists in introducing two of the fingers into the vagina1 and raising up the womb1 as if practising the ballotment4 ,this removes the pressure from the bladder1 and the urine then escapes by natural effort4 ,a few trials will soon enable any one to do this1 particularly if they notice well the form and position of the parts1 as shown in the plates of this work4 ,a lady who heard me mention this in one of my ,lectures1 afterwards stated that the knowledge of it enabled her to dispense altogether with the catheter1 which she was previously necessitated to use during most of her pregnancy4 ,when there is merely a nervous irritation causing the difficulty1 the warm bath1 or fomentation with warm water and ,laudanum will be sufficient1 or a little ,belladonna ,ointment may be rubbed over the meatus urinarius1 while some starch and ,laudanum is injected carefully into the vagina4 ,,cramps4 ,these arise from the womb pressing on the nerves of the sacrum1 and are therefore not under the control of medicine4 ,all that can be done is to change the position of the body as much as possible1 from lying down to standing up1 and by turning from one side to another4 ,brisk rubbing with the hand will also assist in giving relief4 ,the cramps however usually disappear after delivery1 and must therefore be borne as patiently as possible till that takes place4 ,,pruritus1 ,,or ,,itching ,,of ,,the ,,external ,,parts4 ,having treated this affection fully in my ,diseases of ,woman1 ,i cannot do better than extract the article from that work on the subject4 ,this disease1 though not so immediately dangerous as some others1 is perhaps the most distressing that can be met with4 ,it consists in an intolerable and incessant itching of the parts1 which nothing seems to allay4 ,sometimes it is so bad that the female is almost tormented to death2 she cannot see company1 or walk out1 and often shuts herself up alone in her agony4 ,many have fainted from it1 and some have even become delirious4 ,i have seen patients whose hands it was necessary to tie1 to prevent them tearing themselves to pieces4 ,the causes of pruritus appear to be most of those that produce simple inflammation1 which it very frequently accompanies or precedes4 ,pregnant females are very liable to it1 and in some it will continue1 in spite of all that can be done1 till after delivery1 when it usually disappears4 ,i have known it produce abortion4 ,some females always have it at the menstrual period1 and others during nursing4 ,occasionally there is a little eruption attending it1 but not always1 though the parts are generally swollen and red4 ,parasites are sometimes the exciting cause1 and should always be destroyed immediately4 ,the treatment consists in first attending strictly to the diet1 which must be light and unirritating1 and to the regular action of the bowels and womb2 and in using the cooling washes and lotions before mentioned4 ,if the itching still continues1 use either of the following washes to the parts3--,sub4 carbonate of potash three drachms1 water four ounces2 put a tea-spoonful of this into a quart of warm water1 and use it three times a day4--,a tea-spoonful of ,eau de ,cologne to a pint of warm water4--,sulphate of ,zinc1 half a tea-spoonful to a quart of warm water4 ,both these may be used many times in the day4--,borax half an ounce1 ,sulphate of ,morphia six grains2 pure water half a pint4 ,this last seldom fails of giving relief4 ,it should be applied three or four times a day1 with a piece of soft linen1 the parts being first washed with warm soap and water4 ,a tea-spoonful of laudanum will sometimes answer as well as the six grains of ,sulphate of ,morphia4 ,caustic has been employed1 and blisters to the inside of the thighs1 but such violent remedies are seldom either necessary or serviceable4 ,i have known the parts to be deeply scarified with the lancet1 and even burnt with a red hot iron1 without at all alleviating the pruritus4 ,in young persons it seems to be often produced by constipation1 worms1 and gravel2 but it most probably depends1 essentially1 on some impurity1 or irritating quality1 in the blood1 or in the natural secretions of the parts1 which should therefore never be allowed to remain long unwashed4 ,sitting in cold water1 and the application of ice to the parts1 has given relief4 ,i have also effected many cures1 almost instantaneously1 by means of a small ,galvanic plate1 so constructed as to be worn just within the vulva4 ,all remedies must of course be applied with caution during pregnancy2 and it must be recollected that sometimes the disease will continue1 more or less1 till after delivery1 though the distress from it may be much alleviated4 ,,chapter ,,xxvii4 ,,idiopathic1 ,,or ,,primary ,,diseases ,,incident ,,to ,,pregnancy4 ,,flooding1 ,,or ,,hemorrhage4 ,flooding is one of the most dangerous accidents that occur during pregnancy1 its consequences being often of the most serious character4 ,the causes that lead to flooding are very numerous1 some of them predisposing to it1 and others immediately exciting it4 ,among these may be mentioned a too full habit1 violent exertion1 falls1 coughing1 vomiting1 straining from costiveness or violent purgatives1 forcing medicines1 criminal attempts at abortion1 overwalking1 blows on the abdomen1 too much dancing1 or running up stairs1 strong mental emotions1 fright1 or anger1 and certain excesses4 ,the immediate cause is the separation of the membrane in which the ftus is inclosed from the walls of the womb4 ,flooding may however result from the placenta growing over the mouth of the womb1 and being torn as that opens--usually about the sixth or seventh month4--7,see the article ,flooding during ,labor47 ,in most cases flooding is preceded by dull pain in the loins and groins1 and a sensation of weight and dragging4 ,similar sensations however are often produced by other causes1 which makes it difficult to predicate1 with any degree of certainty1 whether the patient is about to flood or not4 ,the very first appearance of blood from the vagina must therefore be watched for carefully1 as that removes all doubt1 and warns us to be prompt with the proper remedies4 ,sometimes a female will flood internally1 the blood being retained by the passage being closed or plugged up by clots1 or by its passing behind the membranes1 or under the centre of the placenta4 ,these internal or concealed hemorrhages are very dangerous1 as the patient may lose much blood before her condition is suspected4 ,it is therefore necessary to bear this in mind1 and carefully use every means to ascertain whether such an accident has occurred or not4 ,in general the indications are pretty plain1 the patient suffering from deep seated and distressing pains in the back and groins1 with great weakness in the limbs1 faintness1 weak pulse1 dimness of sight1 ringing in the ears1 coldness of the hands and feet1 swelling of the abdomen1 and finally fainting1 particularly if the retained blood suddenly escapes1 which it usually does4 ,in the early months there is more danger to the child from flooding than there is to the mother1 because it is nearly certain to lead to abortion4 ,in the latter months1 on the contrary1 the mother runs the greatest risk1 as the child may then live if it be expelled1 while the mother may sink and die from excessive loss of blood4 ,there are many females of a very full habit1 who suffer but little from hemorrhage1 unless it be excessive1 indeed some seem to be benefitted by it1 and are thus relieved from headache and convulsions4 ,it should1 however1 be carefully watched1 and its effects duly noted4 ,the treatment of flooding must depend materially upon its severity1 and the time when it occurs4 ,in the early months1 when the discharge is slight1 and when it causes little distress1 simple means will answer4 ,the patient must lie on her back1 on a hard mattress1 with the pelvis raised1 by means of a pillow1 higher than the rest of the body4 ,the air must be kept fresh and cool around her2 she must keep herself quiet in body and mind1 live rather low1 and drink freely of cooling drinks1 such as soda water1 lemonade1 tamarind tea1 or ice water4 ,the fullest directions for making and using all these drinks will be found in my ,diseases of ,woman4 ,if the flooding does not stop with these simple means1 external applications must be made1 of cold1 wet cloths1 or even ice1 over the abdomen1 and inside the thighs4 ,finally1 if further treatment is still needed1 cold astringent injections may be carefully thrown into the vagina4 ,cold water is perhaps as good as anything for this purpose1 and ,i have frequently known a most severe flooding checked immediately by injecting cold water into the vagina and rectum1 and applying cold wet cloths over the abdomen1 and inside the thighs4 ,some astringent drink may also assist1 such as a little syrup of comfrey1 or extract of ,rhatany1 and particularly a tea made of the root of the black currant1 as recommended in my ,diseases of ,woman4--,a handful of the root may be boiled in two quarts of water1 for twenty minutes2 it should be sweetened to taste and drunk freely4 ,the common blackberry1 or the dew berry1 is also excellent1 though not so good as the black currant4--,if the patient be nervous and irritable1 or suffer much from pain1 an opium pill may be taken1 or from ten to twenty drops of laudanum4 ,the general practice in these cases is to bleed freely and give opium6 ,and as this practice certainly does succeed in many extreme cases1 ,i should certainly recommend1 if the simpler means fail1 to resort to it at once4 ,i dislike bleeding very much1 in any cases1 and here it seems particularly inappropriate2 ,i should therefore say try almost anything and everything first1 but never obstinately refuse to do it if nothing else succeeds4 ,in some cases a plug or tampon is used1 to fill up the vagina4 ,it may be made of a roll of cloth1 cotton1 or a piece of sponge4 ,this practice1 however1 is useless in the latter months of pregnancy1 and very often fails even at other times4 ,when it succeeds it causes the blood to coagulate1 and thus closes up the mouths of the vessels4 ,quite as often1 however1 it only keeps it in1 and makes it accumulate in the womb till it all rushes away at once2 still it may be tried4 ,if the hemorrhages should occur so frequently1 or be so excessive1 in spite of all treatment1 as to endanger the safety of the patient1 there is no other resource left to save her life but to produce abortion1 because the presence of the ftus and its appendages is evidently then the irritating cause which keeps up the discharge1 and it cannot be expected to stop till the womb is emptied4 ,,abortion1 ,,or ,,miscarriage4 ,when the ftus is prematurely expelled before it can survive1 it is called an ,abortion1 but if its expulsion take place so late that it can live1 it is called ,miscarriage4 ,both these are serious accidents4 ,in abortion the child is lost1 as a matter of course1 but in miscarriage it may live1 after the seventh month4 ,the danger to the mother is considerable from both1 though greatest probably from abortion4 ,it is probable that many very early miscarriages take place unperceived1 the female suffering but little from the accident1 and the embryo being too small to be seen1 unless carefully looked for4 ,the most frequent periods for such accidents are found to be six months1 five months1 and three months2 and what is very singular1 a much greater number of male children are aborted than females1 the proportion being about sixteen to eleven4 ,these accidents are so intimately connected with flooding1 that many writers always treat of them together1 considering the flooding merely as the most frequent cause and symptom of miscarriage or abortion4 ,in speaking therefore of the immediate causes of premature expulsion of the ftus1 we place hemorrhage first1 and the causes before enumerated which produce that as being its most frequent remote ones4 ,a full habit1 with tendency to local congestion1 seems to predispose a female very much to miscarriage2 every one so constituted should carefully avoid luxurious living and an inactive life4 ,violent bodily exertion1 falls1 or blows1 or strong mental excitement are most usually the immediate causes1 though with some it will come on spontaneously without any such exciting agencies4 ,some females will miscarry many times in succession1 and always so near the same period1 that they can tell to a day or two when it will happen4 ,it seems to become a habit of the womb with them to contract at that particular time1 and the only way to break through the habit is for them to avoid becoming pregnant for some considerable time1 say two or three years after1 they may then go the full time1 but will seldom do so if they conceive immediately after having miscarried4 ,in some persons miscarriage is caused by a too eager gratification of certain desires2 but in others it may arise from the opposite cause4 ,there is a disease of the womb also by no means unfrequent1 though but little understood1 which undoubtedly causes much miscarriage1 and that is ,rheumatism of the ,womb6 ,this mostly exists before the pregnancy however1 and should be then treated according to the plan laid down in my ,diseases of ,woman4 ,miscarriage also arises in many females from a rigid state of the muscular fibres of the womb1 which not relaxing sufficiently to allow that organ to expand become irritated by the pressure they experience1 and begin to contract4 ,this contraction of the womb of course soon leads to the expulsion of its contents1 the same as in real labor4 ,women with their first children are more liable to miscarriage than others on this account1 the womb not having become habituated as it were to the necessary relaxation4 ,and this is the reason also why some females1 after suffering from this accident many times in succession at last escape it4 ,in general they miscarry early the first time1 from the womb not relaxing sufficiently1 but go a little longer the next time1 and longer still the next1 and so on till they reach the full period4 ,the fibres of the womb have gradually become accustomed to relax1 and have borne the irritation longer and longer each pregnancy1 till at last they have forborne to contract till the proper time4 ,i knew one female who miscarried twenty-one times in succession1 getting gradually nearer to the full period each time1 till at last she reached nine months1 and was rewarded with a living child4 ,sometimes the accident may be produced by a uterine tumor1 by a great quantity of water in the womb1 or even by there being more than one child1 because in either of these cases there is required more room than ordinary2 and of course from the greater expansion required1 the liability is increased4 ,various womb diseases may also be mentioned as causes1 or adhesions of its walls or ligaments to the walls of the abdomen1 and also a diseased state of the placenta4 ,the pressure of corsets and tight dresses also not unfrequently lead to the same result4 ,some general diseases undoubtedly often cause miscarriage1 such as measles1 jaundice1 scarlet fever1 consumption1 and probably many others1 particularly those in which the quality of the blood is much altered1 or the nervous power much exalted or depressed4 ,convulsions have already been mentioned as being frequent causes of miscarriage1 and all strong mental or moral impressions4 ,indeed these last causes operate more than is suspected1 and make it necessary for a pregnant female to be kept as calm in her mind as it is possible for her to be4 ,i have even known one to miscarry from a fright in a dream4 ,it is also a fact1 though not generally known1 that there are certain diseases of the father that may produce miscarriage1 and unfortunately they are of that kind that often remain for a long time in the system without much external manifestation1 so that many persons think they are perfectly free from them even while they are working such mischief4 ,the death of the child also is sure to produce miscarriage1 and this may result from various causes1 such as external injuries and violence1 or from remaining too long in the warm bath and thereby causing congestion of blood in the womb4 ,small pox and syphilis in the mother may also cause the death of the child1 though not always4 ,many having been born at full term with these diseases upon them4 ,in general the ftus is expelled very soon after it dies1 but occasionally it is retained for a considerable time1 and may not pass away till it is completely decayed4 ,it has even been known to become almost fluid1 and several months elapse before it was entirely expelled4 ,most women know when it dies1 by its seeming to fall down to the bottom of the abdomen1 like a dull weight1 and also by its feeling very cold4 ,very often1 however1 there is no indication of its death whatever4 ,m4 ,chailly mentions a case where the embryo died1 probably when about fifteen days old1 but the placenta continued to grow1 and the lady was delivered when about six months and a half gone of the dead embryo1 only about a quarter of an inch in length1 though the after-birth was nearly large enough for one of the usual size4 ,in this case it had died but not decayed1 and remained in the womb six months and a half4 ,in cases of twins also1 one will sometimes die at an early period1 but remain till the other is born at full term4 ,the growth of the placenta over the mouth of the womb1 and shortness of the chord1 have already been referred to as causes both of flooding and miscarriage2 and to these may be added monstrous or deformed ftuses1 which rarely reach the full term4 ,it is probable that there are many constitutional and individual peculiarities predisposing to miscarriage1 with which we are not much acquainted1 and which may account for the constant occurrence of that accident in many females1 notwithstanding all we can do4 ,a scrofulous taint is with good reason supposed to be one of these1 and it is probable that the disease of the placenta1 and its consequent separation from the womb1 before referred to1 is mostly caused by a taint of this kind4 ,in many instances1 where a female has miscarried from no apparent cause1 if the placenta be carefully examined it will be found dotted here and there with diseased spots1 sometimes like scrofulous sores6 ,it is advisable always to ascertain this1 and to carefully examine the ftus and its appendages4 ,in all cases the advice ,i gave to keep from being pregnant for some time1 will be found most likely to succeed in averting the accident1 both because it gives the womb time to regain its strength and break through its habit1 and also because it gives us time to operate upon the constitutional taint1 if there be reason to suppose it exists4 ,it is a curious fact1 but one often observed1 that living in certain localities even predisposes to miscarriage4 ,there is a certain district in ,france where the females are so liable to it1 that all who can do so leave the place when they become pregnant1 and thus escape the greater risk4 ,miscarriage also becomes epidemic at certain times1 and prevails like contagious diseases2 several instances of this are recorded in history4 ,bleeding is also supposed to be a cause of abortion1 and probably it may lead to it in certain states of the system1 but by no means so certainly as many suppose4 ,instances have been known of pregnant females being bled from ten to twenty times without any evil result1 even though carried so far as to make them faint4 ,mauriceau tells us of one who was bled ninety times1 and yet was delivered of a healthy living child at full term4 ,in like manner many other ordinary causes of abortion will often fail entirely of their usual effects4 ,thus ,mauriceau informs us that a female seven months gone fell upon the hard pavement from a three story window and broke her arm1 but yet did not miscarry4 ,madame ,lachapelle also tells us of a young pregnant woman who threw herself down stairs purposely1 from fear that she should have to submit to the ,cesarean operation1 she having a deformed pelvis4 ,the fall caused her death soon after1 but did not make her miscarry4 ,certain powerful medicines are also taken by some1 a very small quantity of which1 in most cases1 produces abortion immediately1 but without effecting what they desire1 though it sometimes poisons themselves4 ,indeed the power which the womb sometimes exhibits to retain its contents in spite of the most violent disturbing agencies1 is truly astonishing4 ,cases have been known even where the womb itself has been severely wounded1 and yet miscarriage did not take place2 as in the case of a poor country-woman whom ,i heard of1 who accidentally fell upon a sharp wooden stake1 and run it far into the body1 injuring the womb in a terrible manner1 but strange to say1 though far advanced in pregnancy1 she recovered and went safely through her full time4 ,i have often known women begin to flood and suffer from dreadful pain1 with other common symptoms of abortion1 as early as the second month1 and yet they went safely the full time1 though these signs continued the whole time4 ,in some cases the waters have even been partially discharged1 and yet abortion did not result4 ,m4 ,velpeau tells us of an instance where the bag of waters broke1 in a female six months gone1 and one arm of the child even came down into the vagina1 and yet the arm returned1 the discharge ceased1 and she went her full term4 ,the progress of a miscarriage varies according to the time at which it occurs1 and the causes from which it arises4 ,when it results from any violence or accident1 it usually takes place in a short time1 and is preceded by abundant flooding1 which comes on immediately4 ,the discharge of blood however1 is lesser the nearer we approach the full term1 so that a female six months gone is not in nearly so much danger from flooding as one only two or three months gone4 ,the reason is this1 in the early months nearly the whole of the ftal membranes are attached to the womb1 so that in case of their being separated1 it bleeds from nearly all its internal surface1 but in the latter months the only point of attachment is the placenta4 ,in the latter months also the womb contracts vigorously1 and so closes its vessels1 but in the early months its contractions are comparatively feeble4 ,in those cases also1 where the child has been dead a considerable time before its expulsion1 there is seldom much flooding1 the connection between it and the mother having been more or less destroyed by decay of the parts4 ,the same result mostly follows a miscarriage from internal disease1 particularly of the placenta4 ,indeed in some of these cases1 the blood-vessels connecting the ftus with the mother have been so completely destroyed1 that no blood whatever could escape from them4 ,in regard to the probable consequences of premature delivery1 it has already been remarked that it is more dangerous in the early months than the latter4 ,it may also be added that it is much more dangerous1 at any time1 when caused by violence of any kind1 or by forcing medicines1 than when it occurs naturally4 ,the danger is much increased if it occurs during fever1 or any eruptive disease1 or if the patient be suffering from diarrha or convulsions4 ,as a general rule we may say1 in all cases1 that miscarriage or abortion is always more dangerous to mother and child than natural labor1 both in its present and in its future consequences4 ,during an attack of jaundice an abortion may terminate fatally in a few hours2 and very frequently the trouble with the after treatment is very great and long-continued4 ,the treatment in an accident of this kind must vary according as we are required to prevent it1 or to remedy the evils that follow when it has occurred4 ,if an abortion be threatened from any cause1 the same general practice must be adopted as recommended for flooding1 the indications being the same4 ,i believe myself that in most cases1 except from accidental violence or internal disease1 miscarriage may be averted4 ,i knew a lady who had miscarried many times1 always at the same period1 who avoided it at last by simply preventing constipation from the first commencement of pregnancy1 and by using an enema every evening of warm starch and water1 pretty thick1 with about thirty drops of laudanum4 ,this was administered by means of a common injection pipe1 just before going to bed1 and continued till after she had quickened1 and repeated occasionally after that1 if she felt any premonitory symptoms of uterine disturbance4 ,if the patient be of a full habit1 she should also1 from the very beginning1 live low1 keep the bowels free1 and the skin in good action1 and take gentle regular exercise in the open air4 ,when all the means used are found of no avail1 and it becomes evident that the ftus must be expelled1 every endeavor should be used to assist nature in its removal as early and as safely as possible4 ,for this purpose the same treatment1 as far as practicable1 must be pursued as in a real labor4 ,if the hand can be conveniently introduced1 without undue force1 it may be so1 to remove clots1 or to take hold of any part of the ftus which may present1 and assist in its extraction4 ,in the early months considerable help may be given1 sometimes by introducing the finger into the mouth of the womb1 with a little extract of ,belladonna1 to promote its relaxation1 but no force must be exerted in doing so4 ,if any part of the after-birth can be laid hold of it should be withdrawn1 but no extraordinary effort must be used to reach it4 ,frequently it happens that a portion of the after-birth remains in spite of all attempts to take it away1 and there is a possibility that it may produce inflammation of the womb1 but no very serious apprehensions need be felt of such a result1 providing the patient is properly attended to in other respects4 ,the retained portion gradually decays1 and passes away1 merely occasioning inconvenience and being very offensive4 ,the danger from leaving it except at a very late period1 is generally thought to be less than that from using any forcible means to remove it4 ,the best means for correcting the offensive discharge are cleansing and antiseptic injections4 ,warm soap suds are very good1 or a decoction of ,peruvian bark in water4 ,strong coffee is also excellent1 or a weak solution of chloride of lime4 ,the bowels must be kept free1 and the skin carefully cleansed and well rubbed4 ,on all occasions when the hand can be introduced with moderate and safe efforts it should be so1 and the after-birth removed4 ,in conclusion it should be remarked1 that the tendency to miscarry1 like many female diseases1 is undoubtedly owing1 in great part1 to the general debility and weakness which characterizes so many women at the present day1 and which is brought on chiefly by neglect of their physical education when girls1 and by their artificial mode of life afterwards4 ,,section ,x4 ,,the ,,diseases ,,of ,,women ,,in ,,childbed1 ,,after ,,lying ,,in4 ,,chapter ,,xxviii4 ,,diseases ,,of ,,childbed4 ,,puerperal ,,fever1 ,,or ,,childbed ,,fever4 ,this is undoubtedly the most serious of all those maladies that so often follow labor4 ,it appears from medical records that puerperal fever has been known from very remote times1 and that it has frequently become epidemic1 or has spread from one to another1 like the ,cholera4 ,in hospitals this has often been observed1 and also in cities1 sometimes almost every female delivered in the place having been attacked while it prevailed4 ,there is also no doubt but that it is contagious1 or capable of being transmitted from one person to another1 like small pox4 ,numerous instances have been known where nurses and physicians have conveyed it to all whom they attended1 during a long period after having been with a single case4 ,one physician1 after attending a case of puerperal fever1 lost nine patients successively from the same disease1 before he suspected the cause1 and an old nurse assured me1 that when she was a young woman1 she was the unfortunate means of conveying it to two females whom she visited1 by merely having been in the room a short time with one who was suffering from it4 ,it is therefore highly important that all persons who may happen to be with a female so affected should not attend another case of childbirth for some time1 and particularly that they should not wear any portion of the same clothing they had then on1 and that they should bathe the whole body several times4 ,if a case occurs in a hospital or other public institution1 the female must be carefully isolated from all the others1 and none of her attendants must be permitted on any account1 to visit other puerperal patients1 till after a sufficient time has elapsed1 and every precaution has been taken4 ,the causes that produce this terrible disorder are not very well understood2 some of them probably predispose to it before delivery1 or even before pregnancy1 while others are connected with labor and its consequences4 ,among the former may be mentioned1 improper diet1 an inactive life1 anxiety of mind1 bad air1 a damp situation1 a full habit1 or great weakness1 the frequent use of stimulants1 and certain excesses6 ,the principal causes operating immediately are difficult labors1 violent treatment1 the use of instruments1 tearing away the placenta too soon1 retention of the lochia1 cold1 rising from the bed too soon1 depression or excitement of the mind1 over exertion in talking to and seeing company1 and neglect of cleanliness4 ,the most frequent cause probably is cold or damp1 which checks the lochia and the perspiration1 and leads directly to inflammation4 ,it is on this account that the complaint is nearly always worse in winter than in summer1 and prevails most in low damp situations1 and in badly ventilated apartments1 or in those insufficiently warmed4 ,in most warm countries1 and in those of an equable temperature1 where the females remain much in the open air1 and use regular exercise1 puerperal fever appears to be but little known4 ,the nature of this complaint appears to be a severe and sudden inflammation1 commencing either in the womb or some of the neighboring parts1 which1 if not arrested1 rapidly extends to all the organs of the pelvis and abdomen1 and hastens to a fatal termination with fearful speed4 ,the precise seat1 and place of commencement1 of the inflammation1 varies in different cases1 but this makes little difference either in the symptoms1 consequences1 or treatment of the disease1 and it is of but little use to give a separate name to all these various forms4 ,uterine ,phlebitis1 ,metro ,peritonitis1 ,puerperal ,metritis1 and ,puerperal ,peritonitis1 are all essentially the same complaint1 and identical with what is called ,puerperal1 or ,childbed fever4 ,the disease generally appears from the second to the fifth day after delivery1 but may be delayed as late as the fifteenth or twentieth day1 or commences as early as two or three hours after2 and has even been known to show itself before labor came on4 ,it usually begins with headache1 general debility1 uneasy feelings1 creeping of the flesh1 and chills3 then follow tremblings1 numbness of the limbs1 cold feet and hands1 with a burning heat in the body4 ,the abdomen gradually gets tender1 so that it cannot bear the slightest pressure1 sharp pains are felt in various parts of it1 and the patient continually complains of twisting and burning within4 ,she prefers to lie on her back1 with the head raised and the knees drawn up1 so as to relax the abdominal muscles4 ,very soon she complains of great thirst1 and cries out repeatedly from the sharpness of the pain2 the headache increases1 and the breathing becomes laborious4 ,hiccough generally occurs at an early stage1 and is usually accompanied or followed by vomiting and diarrha1 but sometimes by obstinate constipation4 ,the abdomen continues to swell1 and becomes still more tender1 the face is pale1 bathed with cold perspiration1 and indicates in every line the anxiety and suffering under which the patient labors4 ,the features seem to be drawn upwards1 and all together1 or pinched up1 and indeed the whole body seems to shrink4 ,in general the lochial discharge either stops altogether or lessens very much1 the breasts remain empty or nearly so1 and the pulse is weak and irregular4 ,in some few cases however1 the lochia continues to flow1 or even increases1 and the breasts remain full up to the time of death4 ,the urine is high colored and thick1 and causes smarting and burning as it passes away4 ,the tongue furs and becomes pointed1 and pale colored4 ,the eyes often seem much engorged1 and the white part become yellow1 as indeed the skin does over the whole body1 owing to derangement of the bile1 and alteration in the character of the blood4 ,in most cases the mind retains its faculties nearly till dissolution1 but there is frequently a vague sense of uneasiness and fear1 with great depression of spirits and weeping4 ,some even feel assured1 from the beginning1 that they will never recover1 and occasionally become delirious4 ,the duration of this disorder varies considerably1 though in most cases it carries off the sufferer in a short time1 frequently even in two or three days4 ,it may however last five1 ten1 or twelve days1 and has been known to do so fourteen4 ,the manner in which it terminates is also different in different cases4 ,the fluid resulting from the inflammation may either be absorbed1 or suppuration may ensue1 and the matter be discharged1 either from one of the natural passages or from an artificial opening2 or it may not be discharged at all4 ,sometimes gangrene or mortification ensues1 and sometimes the inflammation partly subsides and becomes chronic4 ,when it terminates by resolution1 which is the most favorable mode1 the patient begins to improve about the fourth or fifth day2 the pains become less acute1 the swelling and tenderness become less1 and the milk1 lochia1 and other secretions that were suppressed begin to reappear4 ,the patient is also able to lie either on the back or sides1 and soon feels conscious herself that she is improving4 ,but even when a turn for the better has decidedly taken place1 too much confidence should not be prematurely felt1 nor should there be any relaxation of attention1 for the slightest causes may bring back all the symptoms with more than their former severity4 ,when suppuration ensues1 which is most commonly the case1 a mass of fluid forms in the womb or abdomen1 and is plainly indicated1 either by its moving about or by a portion escaping from the body4 ,in this case also the pain and tenderness decreases1 and the abdomen seems less hard1 but the pulse becomes weaker1 a sense of weight is felt about the womb1 the extremities become cold1 chills come on1 and gradually the powers of the system seem to fail till complete exhaustion ensues4 ,when gangrene or mortification ensues1 the termination is nearly the same1 but more rapid1 and all the above symptoms are more marked4 ,when it passes into the chronic form1 there is but little permanent abatement in the severity of the symptoms for some time2 they partially lessen at intervals1 but return again1 sometimes with renewed vigor1 and it remains long a matter of doubt whether the disease has really passed the critical period or not4 ,recovery takes place occasionally in this form of the disease1 but more frequently the patient becomes daily weaker and more emaciated1 diarrha and slow fever set in1 the vital powers steadily sink1 and at last death ensues4 ,this fatal termination may however be delayed for an indefinite period1 and may ultimately result from ,consumption or ,dropsy1 both of which frequently follow chronic puerperal fever4 ,in regard to the probable termination of this disease1 but little hope can be entertained that it will be favorable4 ,nor are there many indications that can be relied upon with certainty1 as to what course it is likely to take4 ,in general it is favorable when the swelling subsides1 and the pains abate in severity1 and particularly if the milk and lochia begin to be secreted again4 ,the indications are also good in proportion as the symptoms are mild1 and when there is no great sympathetic disturbance of other parts of the system4 ,it is regarded as unfavorable when the pain and tenderness extends over a large portion of the abdomen1 and when the attack commences very suddenly4 ,the danger is also considered greater in proportion as the disease begins nearer to delivery2 and when its first symptoms exhibit themselves before labor it is always considered mortal4 ,it is likewise more dangerous with twins than with a single birth1 and with first children than afterwards4 ,it is seldom possible however to come to any probable conclusion till between the fifth and tenth day1 and even then it is in general a matter of great uncertainty4 ,the best treatment of this fearful disease is one of the greatest problems in medical science4 ,so many different plans have been adopted1 and with such various success1 that the history of past cases affords but little reliable data to guide us in future ones4 ,in general the most powerful antiphlogistic measures1 or those thought most likely to reduce the inflammation at once1 are immediately resorted to1 such as bleeding1 purgatives1 and cold bathing4 ,bleeding is in particular the great agent depended upon1 either from the arm1 or by cups and leeches to the abdomen and vulva4 ,dr4 ,gordon1 of ,aberdeen in ,scotland1 who once met with a regular epidemic of puerperal fever in that city1 assures us that nothing else succeeded in arresting the disorder but copious and frequent bleeding1 at the very commencement4 ,he carried it so far as to take twenty-four ounces at once1 and he says that when he did so the patient was nearly sure to recover1 but that at first1 when he only abstracted about twelve ounces1 she was as nearly sure to die4 ,in about fifty cases to which he was called in time1 he only lost five1 and taking the average of all he attended the recoveries were about two-thirds of the whole number1 which is above the usual proportion4 ,it appears however1 from the experience of the most eminent practitioners1 that the bleeding must commence early2 that the first abstraction should not be omitted beyond twenty-four hours after the first symptoms of the disease1 and should be as much earlier as possible4 ,with very few exceptions they also think ,gordon's standard of twenty-four ounces not too much4 ,indeed it is generally admitted that if the blood be not drawn at first and in large portions1 it had better not be drawn at all4 ,there may be of course many peculiar circumstances that will make bleeding improper1 which nothing but experience and observation will teach a practitioner1 but the number of such cases is thought to be small4 ,the use of leeches meets with but few advocates1 and certainly they seem to have had but partial success1 compared with the lancet4 ,dr4 ,collins of ,dublin depended chiefly upon leeches and ,calomel1 but he tells us that in eighty-eight cases fifty-six died when so treated1 while in fifteen that were freely bled from the arm only eight died4 ,in short it appears that the bleeding must be carried far enough1 at the very beginning of the disease1 to cut it short at once1 or it will be of no avail1 it being of little or no use merely to check it6 ,in conjunction with the bleeding it is also usual to give enemas of starch and castor oil1 or something similar1 and to bathe the extremities in hot water4 ,i know that this practice of bleeding meets with strong opposition from many physicians1 and that it is objected to by patients generally4 ,i myself am as much opposed to it as any one reasonably can be1 and ,i am well aware of the numerous evils which follow it1 but still it cannot be denied that ,dr4 ,gordon's plan has cured a greater number of cases of puerperal fever than any other yet tried4 ,it is true that many of those thus cured may have afterwards died of dropsy1 convulsions1 typhus and other diseases produced by the bleeding1 but then the risk they run of dying from these was less than that from the puerperal fever1 and in a choice of evils we ought to choose the least4 ,it should also be remembered that some eminent practitioners assert1 if this plan be adopted promptly and fully1 it will always cure1 or at least with very few exceptions4 ,several other modes of treatment have also been adopted to dispense with bleeding1 some of which have been much more successful than others1 though none so much so as we could desire4 ,thus some practitioners resort immediately to hot fomentations and sweating medicines1 or a hot bath if convenient1 together with brisk purgatives1 and injections4 ,some depend upon ,calomel in large doses1 with leeches to the groins and vulva4 ,others again use cold fomentations1 and cold injections both to the rectum and to the vagina4 ,others again use blisters over the abdomen1 in conjunction with purgative enemas and moderate bleeding2 but this mode seems to do but little good4 ,another plan is to give about six grains of ipecac1 and to repeat the dose several times1 at intervals of an hour or less1 in conjunction with purgatives and warm fomentations4 ,turpentine has also been used internally and by enema1 but seems to have accomplished little good4 ,perhaps the most frequent plan after bleeding1 is to rub one or two drachms of ,mercurial ,ointment well on the skin1 over the abdomen1 every two or three hours1 sometimes for several days regularly2 eight or ten grains of ,calomel being also given daily1 at the same time4 ,this brings on salivation1 and in many cases the symptoms begin to abate in severity as soon as that commences4 ,i am not aware however1 that this treatment is any more successful than bleeding1 nor do ,i think the consequences afterwards1 in a case of recovery1 are any less to be dreaded4 ,it is difficult in fact to say what plan can be best recommended1 even in the majority of cases1 and certainly no one yet tried is applicable to all1 on account of the peculiarities and varying circumstances of each4 ,if the practitioner or patient is not decidedly opposed to the bleeding plan1 that has undoubtedly the best recommendation1 from former success4 ,next to that perhaps comes the mercurial treatment1 which usually meets with as much opposition as the bleeding1 but which certainly has been frequently found efficacious4 ,the other plans have met with but little favor1 though possibly they might sometimes succeed when the rest fail4 ,if ,i were asked what ,i should advise for those who would not submit to the use either of the lancet or mercury1 ,i should say1 commence with a strong dose of ,epsom ,salts1 or ,jalap1 and repeat it in about five hours after its full operation4 ,also apply warm fomentations to the abdomen1 or put upon it a flannel bag full of hops soaked in vinegar1 as hot as it can be borne1 and put mustard poultices on the feet1 and inside of the thighs4 ,the hands must also be kept as warm as possible1 and the head cool4 ,the diet should be very spare1 and contain nothing heating or stimulating1 and cooling drinks1 such as ice water1 or cold lemonade1 should be drunk freely4 ,the purgative should be repeated at least every day1 for two or three days1 or more if the symptoms are not modified1 and the mustard poultices may be regularly used to various parts of the limbs1 for the same length of time4 ,in conjunction with these means the breasts should also be kept warm1 to promote the flow of the milk1 and injections of starch and castor oil should be thrown up the rectum daily4 ,the object being1 as far as possible1 to keep the surface of the body warm1 and to cool the internal fever1 at the same time that all the natural secretions are excited as much as possible to remove any morbid matter that may be formed4 ,it should also be mentioned that the urine sometimes stops1 or at least becomes very scanty and thick1 in which case a little sweet nitre may be given1 or if necessary the catheter must be used4 ,some bitter tea1 as boneset or chammomile1 should also be taken occasionally1 and a ,james's ,fever ,powder with it once or twice a day1 to promote perspiration2 or if there be severe pains1 a dose of ,dover's ,powders may be used instead4 ,if the disease passes the acute stage and becomes chronic1 the same means must be pursued1 and with strict regularity1 or there will be danger of its again becoming acute4 ,in all cases send for the most experienced practitioner as early as possible1 and whatever his plan may be1 if his past success proves it to be tolerably successful1 submit to it1 whether it be bleeding1 salivation1 or anything else4 ,if there be no one at hand on whom dependence can be placed1 follow the plan ,i have laid down as nearly as circumstances will allow1 but practise it fully without delay1 and till a change takes place4 ,those persons who make light of this disease1 and pretend to say that this or that simple treatment is all-sufficient1 either deceive themselves or wish to impose upon others4 ,there are few affections more serious1 as will be evident when it is borne in mind that1 on an average1 two females die out of every three attacked by it4 ,to avoid all liability to it as far as possible1 attend well to the general health during pregnancy1 have everything comfortable1 clean1 and wholesome1 during labor1 and be careful to avoid cold1 damp1 and all kinds of mental and bodily excitement afterwards4 ,the assistant also1 whoever it may be1 must be as careful and as gentle as possible1 so as to avoid all violence or undue force1 and not to hurry nature4 ,a want of attention to such simple details has1 undoubtedly1 brought on many attacks of this fearful disease that otherwise would never have been experienced4 ,,affections ,,of ,,the ,,breast ,,occurring ,,after ,,pregnancy4 ,the functions of the breasts are liable1 from many causes1 to become deranged1 and such derangements may lead to serious results1 both to the mother and the child4 ,it is a common opinion that females who nurse are not so liable to suffer in this way as those who do not1 but experience proves this opinion to be untrue2 nevertheless1 as it is the duty of mothers to nourish their own offspring1 it should be a subject of careful study to relieve them of this liability as far as possible1 or to assist them when necessary4 ,galacterrha4 ,this means an overflow1 or excessive secretion of the milk1 which sometimes takes place1 particularly in those who do not nurse4 ,at the commencement of the milk fever1 ,galacterrha needs but little attention1 but if it continue to the second or third day1 proper remedies should be applied to correct it4 ,these consist in complete rest1 both of body and mind1 cooling drinks1 and spare diet4 ,if these do not correct it soon1 a flaxseed poultice should be placed on each breast1 and the patient should be made to perspire1 either by warm teas and clothing1 or by means of steaming4 ,the bowels should also be freely opened with castor oil1 or a seidlitz powder1 and it will often benefit very much to give warm water freely to drink1 with ten grains of nitrate of potash 7saltpetre7 to the pint4 ,in those that nurse it is very seldom the case that the secretion of milk is too profuse1 unless the child has been kept too long from the breast4 ,as a general rule it should be put to nurse in a few hours after birth1 even if there be no milk1 because its suction will materially help to bring on the flow4 ,it frequently happens1 when the child is kept away till the milk comes1 that the breasts have swelled so that the nipple is buried and cannot be laid hold of well by the mouth1 in consequence of which the child does not get nourishment enough1 and the breasts not being well emptied become engorged1 and their functions deranged4 ,all this may be avoided by putting it too early4 ,sometimes however notwithstanding every precaution1 the flow of milk is excessively great1 and constitutes a real disease1 which may cause great weakness and debility4 ,in such cases it will generally be found that the diet is too stimulating or too rich1 or that the bowels have been too inactive1 and the first step towards an improvement must consist in correcting these faults4 ,the skin should also be kept active by frequent bathing and good friction1 and the quantity of nourishment taken should not be greater than the mere healthy support of the body requires4 ,in particular no stimulating liquors should be used4 ,agalaxy4--,this complaint is the reverse of the former1 as it consists in a deficient secretion of milk4 ,the causes of this deficiency are various2 sometimes it arises from a constitutional inertness of the breasts1 sometimes from insufficient nourishment1 and sometimes from profuse discharges in other parts4 ,all excesses also tend to decrease the quantity of the milk1 particularly those of a certain kind2 and it is seldom so abundant or lasting either in extreme youth or advanced age4 ,the appearance of the menses in like manner generally causes the flow to become less1 and it ceases naturally in some much earlier than in others4 ,sometimes there is a deformity in the child's mouth1 which prevents its sucking properly1 and the milk may stop for want of being completely drawn4 ,the breasts also may be diseased1 or the nipple not sufficiently prominent1 and the same difficulty be thus produced in another way4 ,in treating agalaxy1 therefore1 the first thing is to ascertain if there be no deformity or disease in either mother or child1 which prevents proper nursing4 ,if there be nothing of the kind1 it must next be ascertained whether the mother has any excessive secretion elsewhere1 such as diarrha1 great flow of urine1 or heavy sweats2 if she have1 these must be corrected4 ,it must next be seen if she takes sufficient nourishment1 and of a proper kind for her stomach and bowels4 ,sometimes a little spiced wine is excellent1 or some porter1 with white meats1 and arrow-root milk4 ,if she be of a full habit1 however1 and makes much blood1 the contrary course must be pursued1 and the diet be made low and unstimulating1 while the bowels are kept free and the skin in good action4 ,in many cases when the nipple is small1 it may be much enlarged by titillation1 just before the child is put to it1 after which the suction will increase it still more4 ,if the female be advanced in life1 or very weak1 or if she becomes pregnant1 it may be better to procure a nurse than to attempt to stimulate the flow at all4 ,the appearance of the menses need not occasion a suspension of nursing1 unless it evidently deranges the secretion of the milk1 or affects the health of the mother2 in either of which cases the child should be weaned at once4 ,engorgement of the ,breasts4--,the breasts are liable to become swollen1 or engorged1 from colds1 blows1 hard nursing from the child1 over feeding1 and from soreness or excoriations preventing them being fully emptied4 ,this state may occur at any time1 but is most frequent a few days after delivery4 ,in general there is no danger from it1 unless it be very bad or continues too long2 it may then inflame and discharge1 or become permanently hardened4 ,to prevent such accidents the breasts should always be sufficiently emptied1 either by the child or by artificial means1 and every precaution should be used against cold or violence4 ,constipation must also be guarded against1 and the diet and drink must be carefully observed1 so that it be not too feeding1 or too stimulating4 ,warm fomentations or poultices may also be used when the breasts are painful1 and a ,dover's ,powder may be given at night1 after bathing the feet in warm water1 to promote perspiration4 ,inflammation of the ,breasts4--,this is only a more advanced stage of the previous malady1 produced by the same causes1 and by want of timely attention4 ,like simple swelling1 it may arise at any time during nursing1 but is more frequent a few days after delivery4 ,as soon as the inflammation commences the breasts become red1 swollen1 and excessively tender1 particularly at one point1 which soon begins to project like a nipple1 if the disease is not stopped1 and at last bursts and discharges the contained pus4 ,sometimes the inflammation is comparatively superficial1 and extends only over a small portion of the surface1 but at other times it goes deep and spreads wide4 ,in proportion to its extent is the severity of the symptoms1 which are those of inflammation in general1 such as headache1 thirst1 fever1 general uneasiness1 and cutting pains in the part affected4 ,as soon as the abscess is formed and can be plainly discovered1 it is usual to open it immediately1 because the longer it remains the more extensive it becomes1 and the larger portion of the breast becomes diseased4 ,it is necessary however to be certain1 before making an opening1 that it is really an abscess on which we are going to operate1 for sometimes a healthy part of the breast feels very much like one1 and a mistake may easily be made2 in fact such a mistake has often been made1 and by men of experience too4 ,in the early stage of the inflammation every effort should be used to prevent an abscess from forming1 by the use of purgatives1 sweating medicines1 low diet1 cooling drinks1 and warm fomentations over the whole chest4 ,some females practice cold fomentations over the breasts1 and with good success1 in the commencement of the inflammation1 but it may increase the difficulty with others1 and1 so far as ,i have seen1 is no more generally useful than the other method4 ,the warm bath all over the body is also very serviceable in a number of cases4 ,it usually happens however1 in spite of every precaution1 that matter will form1 and its discharge become necessary4 ,as soon as this is evident1 it should be promoted as much as possible1 by hot fomentations and poultices1 till the head of the abscess is sufficiently distinct for it to be safely opened4 ,while the swelling is going on the pain is often very severe1 and it should be eased as much as possible1 by using laudanum in the fomentations1 or by putting on an opium plaster4 ,after an abscess has opened and discharged1 it should be kept open for some time1 by little pledgets of lint1 to prevent its closing up too soon1 otherwise a portion of the matter may be shut in by the wound healing over it1 and another abscess will form4 ,warm poultices and lotions should also be used afterwards1 to promote the discharge as much as possible1 but they should not be used after it has evidently begun to cease naturally4 ,in short every means pointed out should be used energetically in the first stage1 to prevent the gathering1 but if it takes place in spite of them1 then it should be hastened and discharged as early as possible1 to prevent its extending4 ,after this1 when it has evidently all escaped1 the wound may be suffered to heal1 and the patient must be enjoined to be very careful in future1 for the same accident will be very liable to reappear4 ,sometimes these abscesses become very extensive1 and remain for a long time4 ,i have known ten or twelve on one breast1 and ,i have known them to continue open for many months4 ,when this is the case it is much to be deplored1 as it is very likely indeed to destroy the breast1 and may even lead to more serious results4 ,attention therefore cannot be bestowed upon them too early or too unremittingly1 particularly if the female be scrofulous1 or of a very full habit4 ,sometimes the inflammation attacks both breasts1 and at other times only one1 in which case every effort should be exerted to prevent its extending to the other4 ,in many persons the same side is always affected1 and becomes a scape-goat as it were for the other4 ,when the means used succeed in scattering the swelling1 its dispersion is usually followed by some critical discharge1 such as diarrha1 or a great flow of urine1 or even by profuse perspiration1 which shows how nature operates in removing the diseased matter1 and cautions us not rashly to check such discharges4 ,it is a very serious matter for the swelling to indurate or harden1 as it sometimes will1 without either scattering or dispersing1 as it is then constantly liable to become worse again1 besides destroying the structure of the gland4 ,every means should therefore be used to prevent this1 by promoting its dispersion or discharge1 in the way already pointed out4 ,it is also very good in these cases to bathe frequently with alum water1 or decoction of white oak bark1 or even to rub on some of the ,ointment of ,hydriodate of ,potassa1 diluted with an equal weight of fresh lard4 ,a piece as large as a hickory nut may be well rubbed on twice a day1 for three or four days1 but it should be stopped immediately the swelling begins to subside1 and not used again unless it still remains or again increases4 ,in many cases pretty frequent friction1 with the hand anointed with a little oil1 will be all sufficient1 especially if a hot fomentation be used afterwards4 ,excoriations1 or ,cracks in the ,breasts4--,the annoyance from this cause is sometimes very great1 the pain which is experienced when the child begins to nurse being so acute that it is impossible for the mother to allow it to remain4 ,frequently ,i have known it compel weaning much earlier than was desirable1 and sometimes it has even been so bad1 that the dress could scarcely be borne against the breasts4 ,the precise cause of this liability to crack is not known1 nor do we know of any certain means to prevent it4 ,in many cases however ,i have known it prevented1 to a great extent1 by having the nipple gently sucked1 very frequently1 for six weeks or two months before childbirth4 ,this hardens it1 and if a wash of borax water be also used1 after each time1 it will be gradually prepared for its proper use4 ,our means of curing this troublesome affection are very limited1 and frequently everything fails that is tried4 ,the mucilage of ,quince seed1 prepared by bruising and boiling them in a small quantity of water1 rubbed over the sores with a soft feather1 immediately after nursing1 often does much good4 ,the mucilage from the tender tops of young sassafras sometimes succeeds better than that from the ,quince1 and a bruised leaf from the large horse-shoe ,geranium1 laid on like a poultice1 is sometimes better than either4 ,a good lotion may also be made with a quarter of an ounce of borax1 and a tea-spoonful of laudanum1 to half a pint of warm water1 to be used frequently during the day4 ,some females use a wash made of saleratus1 with considerable benefit1 and others find relief from one made of nut galls1 or white oak bark4 ,most of these means however are well known1 and many others also1 which1 like them1 sometimes succeed and often fail4 ,the artificial nipple1 or shield1 should be tried if none of these means succeed1 and frequently it will enable the mother to allow the child to nurse1 though it may not altogether prevent the pain4 ,it not unfrequently happens that the child's mouth may be diseased1 particularly with apth1 or thrush1 and this may possibly keep up the excoriations2 in like manner the state of the breasts may also influence the mouth1 and therefore the condition of each should be well ascertained when anything is the matter with either4 ,,bronchocele1 ,,or ,,swelling ,,in ,,the ,,throat4 ,this is often observed in childbed1 and sometimes even comes on during labor4 ,it is usually attributed to cold1 and no doubt it often does arise from cold1 but more frequently it is owing to sympathetic derangement1 and from violent attempts to swallow during and after the pains4 ,many females in fact cry out at those times1 that something has broken in the throat1 and they fear they are going to suffocate4 ,as a general rule the swelling gradually subsides in a short time1 without any special treatment1 but sometimes it increases and inflames1 and an abscess forms which may become very troublesome1 and even dangerous4 ,to prevent this it should be frequently treated with warm fomentations and poultices1 till the inflammation subsides1 and then with the same washes recommended for indurated or hardened breast1 in the preceding section of this chapter4 ,if the swelling becomes hard1 and remains indolent1 the ointment of hydriodate of potassa may also be prepared and used1 as there recommended4 ,,phlegmasia ,,alba ,,dolens1 ,,or ,,milk ,,leg4 ,this is a painful tumefaction or swelling of one or both of the limbs1 which comes on from the fifth to the fifteenth day after delivery4 ,it generally commences with slight pain1 or stiffness1 or cramp1 becoming more painful as it proceeds2 but1 sometimes1 shooting1 cutting pains1 of great violence1 are felt suddenly1 at the very commencement4 ,the swelling1 also1 sometimes comes on gradually1 but1 at other times1 rapidly4 ,in most cases the patient complains of a sudden pain in the groin and thigh1 which is preceded by a chill followed by fever1 and then the limb begins to enlarge4 ,most frequently the lower part swells first1 and then it extends upward1 sometimes1 even to the hip4 ,the skin1 on the swollen part1 looks white1 shining and tight1 as if ready to break2 it is also extremely painful1 so that pressure upon it can scarcely be borne4 ,it looks in fact like a thin bag of skin filled with milk1 and hence the name milk leg1 from an idea that it was really filled with milk1 which had1 by some means1 reached there from the breast4 ,this idea is erroneous1 in the sense it is usually taken2 the milk does not flow into the leg as many imagine1 nor is anything like it to be found there1 except a peculiar thin1 white matter1 when it breaks4 ,still1 however1 a sudden stoppage of the milk may cause such a swelling1 like a sudden stoppage of any other secretion1 but in no other way4 ,it is1 probably1 most frequently produced by sudden cold1 which checks that profuse perspiration into which females gradually fall immediately after delivery1 and so drives the perspirable matter within1 and causes inflammation and suppuration4 ,a difficult or prolonged labor may also lead to it1 by preventing1 for a long time1 the proper circulation of the blood through the large veins of the pelvis1 and so engorging those below4 ,or the veins may become paralyzed1 as it were1 by the pressure they have sustained1 and so become1 for a time1 unable to transmit the blood4 ,in fact1 both the veins and lymphatics become engorged1 as if tied above the limb1 and exhibit knots and bundles1 like bunches of grapes4 ,sometimes the fever will occur some days first1 and the female cannot tell what it is owing to1 till the swelling comes on2 and even this may take place so gradually1 and with so little pain1 that the limb may be very large before it is observed4 ,i have known females complain of a slight fever only1 on going to sleep at night1 and wake up in the morning with a confirmed case of milk leg2 and ,i have known others start with a sudden pain in the groin1 or hip1 and be affected in the same way1 in less than two hours4 ,the disease usually lasts from a month to seven or eight weeks1 and terminates1 either by a gradual resolution1 or scattering1 of the fluids1 or by suppuration and discharge4 ,when suppuration ensues1 there will1 sometimes1 form one or more very large abscesses1 which it may be difficult to heal1 and which may lead to serious results1 either from their extent1 or from the constitutional irritation they produce4 ,the treatment1 at first1 consists in warm fomentations1 such as those of poppy-heads1 or hops1 with cooling drinks1 purgatives1 low unstimulating diet1 and occasional doses of ,james's ,fever ,powder1 to promote perspiration4 ,this is intended to disperse the swelling1 and1 in general1 it does so4 ,if1 however1 the abscess forms and breaks1 in spite of all the means used1 it must be treated the same as abscess in the breast1 previously described4 ,in ordinary practice1 it is the general custom to bleed at the commencement of the disease1 or to apply leeches to the groin4 ,this sometimes does good1 but frequently is of no service at all1 even if it does not make matters worse4 ,i would1 however1 make the same remarks on bleeding here1 as ,i did in regard to its use in puerperal fever1 to which milk leg has a resemblance1 in some respects4 ,another practice is to use tight bandages1 the same as for varicose veins1 but ,i think the plan is not1 in general1 a successful one1 though it may be occasionally4 ,plunging the limb in cold water1 or keeping it wrapped in cold wet cloths1 has succeeded much more frequently1 and is1 with some1 a favorite remedy4 ,stramonium leaves boiled in vinegar1 and laid on hot1 will also effect a cure sometimes2 and so will bathing with hot lye or alcohol4 ,a large poultice of hops1 soaked in hot vinegar1 has also been found useful4 ,,trouble ,,with ,,the ,,urine4 ,the bladder1 from its position1 is very apt to be inconveniently pressed during the passage of the child1 and to be temporarily affected for a short time after1 in consequence4 ,sometimes1 the neck of the bladder will be paralyzed1 and the urine cannot be discharged4 ,in this case1 fomentations of warm milk and laudanum must be used1 or a warm hip bath1 if there be no danger of flooding1 and the bowels must be freely opened4 ,if this does not relieve1 the catheter must be used1 and always before the bladder is too full4 ,to avoid its becoming so1 the attendant should inquire of the female1 during the first day1 if she has urinated1 or feels any inclination that way1 so that he may know in time if the difficulty exists4 ,in general1 this paralysis passes off in the course of a day1 but may endure longer sometimes2 in which case the patient herself should speak of it4 ,cases have been known where the bladder has become so full as to burst through inattention to this matter4 ,the contrary difficulty is occasionally observed1 and the urine cannot be retained1 but it flows away as fast as it is secreted4 ,it is very seldom1 however1 that this state remains more than a single day and1 more frequently only a few hours4 ,a dash of cold water on the pubes1 and against the meatus urinarius1 has often corrected it at once1 and so has a single purgative dose4 ,if it remain after the first two days without amendment1 it is customary to put a small blister on the abdomen1 which usually relieves in a short time4 ,,appendix4 ,,on ,,preventing ,,pain ,,in ,,childbirth4 ,,use ,,of ,,chloroform ,,in ,,midwifery4 ,,an ,,enquiry ,,into ,,the ,,utility ,,and ,,propriety ,,of ,,preventing ,,the ,,pain ,,and ,,suffering ,,which ,,usually ,,attends ,,childbirth1 ,,with ,,an ,,account ,,of ,,the ,,means ,,to ,,be ,,employed ,,for ,,that ,,purpose4 ,in the preface to this work ,i remarked that a great part1 and1 perhaps1 nearly the whole1 of the suffering and danger to which parturient females are exposed1 arises1 undoubtedly1 from their bad physical education and mode of life2 and that1 in a more rational state of existence1 it was probable that both would be so slight as to excite no apprehension4 ,this improved state of things is much to be desired1 and should1 of course1 be striven for by all friends of humanity4 ,but1 in the mean time1 it is proper to consider whether there are any means by which those now living can be relieved in their hours of distress4 ,the agony which many females endure at this time is so great that there are few circumstances under which relief is more needed1 or would be more acceptable2 and ,i1 for one1 cannot subscribe to the doctrine that such relief would be improper1 unless it prove to be injurious4 ,there are some persons1 ,i know1 who say that this suffering has been ordained for woman1 and that it ought to be endured4 ,this notion1 ,i think1 needs no refutation1 it being just as unreasonable as to say that the sick should be allowed to suffer and die without assistance1 because their condition has been ordained4 ,there are others1 and men of science1 too1 who think that the pains of childbirth are necessary to its safe accomplishment1 and that they are also valuable in a moral point of view4 ,this opinion will be examined by and by1 and the facts on which it is founded1 carefully analyzed2 but it is first necessary to state the means of prevention usually employed1 and to note their mode of action1 and effects4 ,some years ago1 a celebrated physiologist1 who supposed that the chief cause of pain and difficulty in labor was the size and hardness of the child's bones1 advanced the theory that if these bones were less developed1 and softer1 the pain and difficulty would be materially lessened1 if not entirely removed4 ,he proposed1 therefore1 since the hardness of the bones is caused by the deposition of lime in them1 which is derived1 of course1 from the blood of the mother1 that she should avoid taking anything to eat or drink1 during pregnancy1 that contained lime4 ,this1 he supposed1 would keep the bones of the child soft till after birth1 and so allow them to give way and crush together during delivery1 and thus prevent the suffering and difficulty usually experienced4 ,it was also thought that the bones of the mother would be partially softened at the same time1 and give way a little1 so as to facilitate the process still more4 ,i am not aware1 however1 that this theory has ever succeeded in practice1 either in the human species or in the lower animals1 though frequently tried4 ,nature will work on her own plan1 and will develop the bones of the ftus1 while in the womb1 to a certain extent1 providing she has the means to do so2 and if these are withheld1 she is very likely to suspend its development altogether1 rather than send it forth imperfect4 ,i have known cases where everything was withheld1 for the whole period1 that contained a particle of lime1 and yet the child's bones were as hard at birth as in any other case2 the material being1 probably1 taken from the bones of the mother1 which might be thus weakened1 and made liable to displacement1 without any good result whatever4 ,it is also a question whether such a course1 supposing it to succeed1 might not be dangerous in another way1 by causing an imperfection in the child which its future growth could not overcome4 ,i have known some cases where this practice appeared to have caused abortion from imperfect development1 and several others in which there was too much reason to fear that the child was injured1 though safely born4 ,as this is1 therefore1 at best1 a very uncertain and ineffective process1 and is also1 probably1 dangerous to the mother or child1 or both1 it does not appear to me worthy of further attention1 and ,i merely allude to it in order to make the present sketch of such means complete4 ,the other means are such as do not interfere1 in any way1 with the natural processes1 but merely prevent sensation or feeling at the time of delivery4 ,mesmerism has been recommended1 and1 in some few instances1 tried1 for this purpose1 but its success has either been so small1 or its action so uncertain1 that no dependance can be placed upon it1 notwithstanding many persons assert its power4 ,opium and other powerful drugs have also been given1 but so much of them is required1 at that time1 to produce a sufficient effect1 that their use becomes dangerous4 ,other substances1 in the form of vapour1 or gas1 have also been used1 the effects of which only last for a short time1 and are not1 generally speaking1 at all dangerous4 ,among them may be mentioned nitrous oxide1 or laughing gas1 carbonic acid1 sulphuric ether1 and chloric ether1 all of which were first employed in severe surgical operations4 ,the success of these agents1 especially ether and chloroform1 in preventing pain1 is undoubted2 nor do they appear to have any other effect1 nor to prevent any necessary effort or process of nature1 except in a few cases which will be mentioned further on4 ,many hundred operations of the most severe kind1 such as cutting off limbs1 removing tumors1 stones1 and so forth1 have been performed while the patients were under the influence of these agents1 and without causing them the slightest pain2 in fact1 many remain1 during the whole process1 in a pleasant dream1 and cannot be persuaded1 when they wake1 that the dreaded operation is over4 ,the same thing has also been observed in hundreds of cases of midwifery1 both in natural labor and when instruments have been used4 ,in numerous instances the female has been put to sleep1 and safely delivered1 without knowing or feeling anything whatever1 during the whole time2 the first intimation that she had become a mother1 being the cheering cry of her newborn babe4 ,in some instances1 the state of insensibility has been continued for a long time1 and during its continuance1 the most hazardous operations have been safely performed4 ,so far as can be safely judged1 from the limited time during which such means have been used1 it appears that there is no danger whatever1 from their employment1 except when improperly administered1 and in certain peculiar conditions of the system2 which causes of danger will1 of course1 be removed by competent experience and knowledge4 ,it is highly encouraging however1 to note1 though ether and chloroform have both been used so extensively and indiscriminately1 both by those who understood their nature and those who did not1 that the cases in which they are proved to have done injury1 are not more than two or three2 and in all those that ,i have heard of1 some obvious impropriety had been committed in their use4 ,it should be borne in mind1 however1 that even if the danger from them was considerable1 we might still be justified in their use4 ,it is well known that1 in numerous cases1 the fear of suffering1 beforehand1 and its severity while being endured1 produce the most serious1 and even fatal results4 ,many a patient has passed safely through the ordinary effects of a painful operation1 and yet sunk from the mere effects of fear and physical suffering4 ,instances have even been known in which a fear of this kind has caused death1 and frequently it has given a shock from which the patient never fully recovered4 ,there is also1 frequently1 great danger from the violent efforts and struggles of a person in pain1 and many necessary operations are even prevented altogether by them2 this is often observed in difficult labors4 ,when insensibility is produced1 however1 all these causes of difficulty and danger are removed2 the patient's fears are quieted1 suffering is entirely prevented1 and there is no struggling to prevent the necessary assistance4 ,supposing1 therefore1 that the ill effects of these agents were more certain and greater in amount than has yet appeared1 it would still be a question whether the evil they really prevent is not greater than that which they possibly may cause4 ,in regard to the two agents now chiefly used1 ether and chloroform1 there is no difference in their mode of action1 but the chloroform appears to be more speedy1 certain1 and efficacious1 and is1 therefore1 the most valuable1 but proportionably more dangerous when improperly administered4 ,there are numerous instruments or inhalers1 for administering these vapors1 most of which are both costly and complicated1 and all of which may be easily dispensed with4 ,a very good plan is to take a large sponge and dip it in hot water1 then squeeze out the water and pour on the ether or chloroform1 and hold it over the mouth and nose4 ,in two or three minutes consciousness and feeling will both be gone1 and the patient will sink into a calm sleep which will last sometimes ten or fifteen minutes1 and may be kept up as long as desired1 by putting the sponge to the mouth for a few minutes whenever there are signs of waking4 ,when it is left off the patient gradually comes round as if waking from ordinary sleep1 and frequently speaks of having been in a dream1 sometimes of a very pleasant character1 but never knows what has taken place4 ,no ill effects follow1 but sometimes there is a little drowsiness or stiffness of the limbs1 which soon passes off4 ,a pocket handkerchief soaked in the fluid1 and held over the mouth and nose will answer equally well2 but whatever is used1 it must not be pressed close1 because a portion of air ought to enter with the vapor to prevent suffocation2 and it should also be removed immediately the effect is produced4 ,when it is borne in mind how much these requisites have been neglected1 and how impure the ether or chloroform has often been1 it is wonderful that more accidents have not occurred2 and the fact that so few have happened under such a state of things1 and with our little experience1 goes far to prove that there is little or no danger at all in competent hands1 with pure materials4 ,the accounts circulated in the papers of death from ether1 and fatal effects of chloroform1 have mostly been gross exaggerations1 and frequently false altogether4 ,in most of the cases where death has followed from the use of these agents1 it has been proved to arise from other causes1 and would have happened if they had not been used4 ,in one or two cases1 however1 of surgical operations1 the ether itself appears to have caused death by producing suffocation1 or congestion of the lungs2 but1 even in these1 it has been shown that it was used in an improper manner4 ,thus a young woman in ,newcastle in ,england1 inhaled ether to have a diseased toe-nail cut off1 and died4 ,it appears1 however1 that there was an evident disposition in her to congestion or rushes of blood1 and therefore she was not a fit subject1 and besides1 the ether was poured on a thick table cloth1 which1 of course1 prevented the entrance of air along with the vapor1 and thus suffocated4 ,i believe there is not a single case on record of injury resulting when due precautions have been used1 and ,i have not heard of one at all in midwifery practice4 ,ether having been the first article used1 ,i shall first give an account of its effects1 and then proceed to chloroform1 explaining the mode of administration1 and other incidental matters1 as ,i proceed4 ,the best article on ether which ,i have met with1 is a review in the ,british and ,foreign ,medical ,review for ,april1 #ahdg1 of some pamphlets on the subject1 from which ,i shall make an extract4 ,in the state of perfect etherization we believe all sensation is abolished2 in a less perfect state an obscure perception of external objects remains1 while the sense of pain is extinct4 ,the psychical state is various4 ,generally speaking1 the sense of external impressions becomes at first confused1 then dull1 then false1 with optical spectra or auditory illusions1 general mental confusion1 and then a state of dreaming or utter oblivion4 ,in the majority of cases the mind is busy in dreaming1 the dreams being generally of an active kind1 often agreeable1 sometimes the reverse1 occasionally most singular2 and1 frequently1 a great deal is transacted in the few short moments of this singular trance4 ,many of the patients who have undergone the most dreadful operations1 such as amputation of one or both thighs or arms1 extraction of the stone1 excision of bones1 extirpation of the mamma1 have readily detailed to us1 and most with wondering thankfulness1 the dreams with which1 and with which alone1 they were occupied during the operations4 ,the character of the dreams seemed to be influenced1 as in ordinary cases1 by various causes1 immediate or remote1 present or past1 relating to events or flowing from temperament4 ,a good many seemed to fancy themselves on the railway amid its whirl and noise and smoke2 some young men were hunting1 others riding on coaches2 the boys were happy at their sports in the open fields1 or the filthy lane2 the worn ,londoner was in his old haunts carousing with his fellows2 and our merry friend1 ,paddy1 of the ,london ,hospital1 was again at his fair1 wielding his shelala in defence of his friends4 ,others1 of milder mood1 and especially some of the women patients from the country1 felt themselves suddenly transported from the great city and the crowded hospital-ward to their old quiet home in the distant village1 happy once more with their mothers and brothers and sisters4 ,as with the dying gladiator of the poet1 the thoughts of these poor people-- ,were with the heart1 and that was far away4 ,some seemed transported to a less definite but still happy region1 which they vaguely indicated by saying they were in heaven2 while others had still odder and warmer visions1 which need not be particularized4 ,for the purpose of obtaining information on all the points of this most interesting subject1 we personally questioned all the patients in the ,london hospitals1 who1 at the period of our visits1 still remained in the wards after the ether-operations4 ,they were in all fifty-four1 and the great majority had been the subjects of capital operations4 ,they were unanimous in their expressions of delight and gratitude at having been relieved from their diseases without suffering4 ,in listening to their reports1 it was not always easy to remain unmoved under the influence of the conceptions thereby communicated1 of the astonishing contrast between the actual physical condition of the mangled body in its apparent tortures on the operating table of a crowded theatre1 and the really happy mental state of the patient at the time4 ,this perfect freedom from pain is proved by every case wherein the vapor has been efficiently administered1 although there are frequently the same cries uttered1 and the same motions practised as when pain is experienced which proves that nothing is prevented but the mere feeling1 which it can be of no use whatever for any one to suffer from4 ,chloroform has been more recently introduced than ether1 but has nevertheless been used quite as much1 or probably more1 and1 in general1 with still more success4 ,it was first described1 ,i believe1 by ,professor ,simpson of ,edinburgh1 at a sitting of the medical society of that city1 in ,november1 #ahdg1 and several cases were narrated1 two of which ,i quote4 ,i have employed it in obstetric practice with entire success4 ,the lady to whom it was first exhibited during parturition1 had been previously delivered in the country by perforation of the head of the infant1 after a labor of three days' duration4 ,in this1 her second confinement1 pains supervened a fortnight before the full time4 ,three hours and a half after they commenced1 ere the dilatation of the os uteri was completed1 ,i placed her under the influence of the chloroform1 by moistening with half a teaspoonful of the liquid1 a pocket-handkerchief1 rolled up in a funnel shape1 and with the broad or open end of the funnel placed over her mouth and nostrils4 ,in consequence of the operation of the fluid it was once more renewed in about ten or twelve minutes4 ,the child was expelled in twenty-five minutes after the inhalation was begun4 ,the mother subsequently remained longer soporose than commonly happens after ether4 ,the crying of the child did not1 as usual1 rouse her2 and some minutes elapsed after the placenta was expelled1 and after the child was removed by the nurse into another room1 before the patient awoke4 ,she then turned round and observed to me that she had enjoyed a very comfortable sleep1 and1 indeed1 required it as she was so tired1 but would now be more able for the work before her4 ,i evaded entering into conversation with her1 believing1 as ,i have already stated1 that the most complete possible quietude forms one of the principal secrets for the successful employment of either ether or chloroform4 ,in a little time1 she again remarked1 that she was afraid her sleep had stopped the pains4 ,shortly afterwards her infant was brought in by the nurse from the adjoining room1 and it was a matter of no small difficulty to convince the astonished mother that the labor was entirely over1 and that the child presented to her was really her own living baby4 ,perhaps ,i may be excused for adding1 that since publishing on the subject of ether inhalation in midwifery1 seven or eight months ago1 and then for the first time directing the attention of the profession to its great use and importance in natural and morbid parturition1 ,i have employed it1 with few and rare exceptions1 in every case of labor that ,i have attended1 and with the most delightful results4 ,and ,i have no doubt whatever1 that some years hence the practice will be general4 ,obstetricians may oppose it1 but ,i believe our patients themselves will force the use of it upon the profession4 ,i have never had the pleasure of watching over a series of better and more rapid recoveries1 nor once witnessed any disagreeable result follow to either mother or child1 whilst ,i have often seen an immense amount of maternal pain and agony saved by its employment4 ,and ,i most conscientiously believe that the proud mission of the physician is distinctly twofold--namely1 to alleviate human suffering1 as well as preserve human life4 ,in another part of the same publication ,professor ,simpson has another list of cases1 all equally favorable4 ,in some of these the labors were protracted many hours1 and in others1 operations with instruments were performed1 of the most terrible character1 such as would1 under ordinary circumstances1 have been attended with the most horrible suffering4 ,as this article gives an instance of nearly every kind of delivery under the influence of chloroform1 and contains also some admirable reflections upon its employment1 ,i quote it in order to make the present account complete4 ,,case #b4--,seen with ,mr4 ,carmichael2 a second labor2 she began the chloroform inhalation before the dilatation of the os uteri was entirely completed2 the child was expelled in fifty minutes afterwards4 ,i kept her under the chloroform for a quarter of an hour1 till the placenta was removed1 the binder applied1 and the body and bed-clothes were arranged and adjusted4 ,on awaking she declared that she had been sleeping refreshingly2 she was quite unaware that the child was born1 till she suddenly heard it crying at its first toilet in the next room4 ,an hour afterwards she declared she felt perfectly unfatigued1 and not as if she had borne a child at all4 ,in her first or preceding confinement she had been in severe labor for twenty hours1 followed by flooding4 ,no hmorrhage on the present occasion4 ,,case #c4--,patient unmarried2 a first labor2 twins2 the first child presented by the pelvis1 the second with the hand and head4 ,the chloroform was exhibited when the os uteri was nearly fully dilated2 the passages speedily became greatly relaxed1 7as has happened in other cases placed under its full influence17 and in a few pains the first child was born1 assisted by traction4 ,i broke the membranes of the second1 pushed up the hand1 and secured the more complete presentation of the head2 three pains expelled the child4 ,the mother was then bound up1 her clothes were changed1 and she was lifted into another bed2 during all this time she slept soundly on1 and for a full hour afterwards1 the chloroform acting in this as in other cases of its prolonged employment1 as a soporific4 ,the patient recollected nothing from the time of the first inhalations1 and was greatly distressed when not one but two living children were brought in by the nurse to her4 ,dr4 ,christison1 who was anxious to observe the effect of the chloroform upon the uterus1 went along with me to this patient4 ,,case #d4--,primipara2 of full habit2 when the first examination was made1 the passages were rigid1 and the os uteri difficult to reach4 ,between six and seven hours after labor began1 the patient1 who was complaining much1 was apathized with the chloroform4 ,in about two hours afterwards1 the os uteri was fully dilated1 and in four hours and a half after the inhalation was begun1 a large child was expelled4 ,the placenta was removed1 and the patient bound up and dressed before she was allowed to awake4 ,this patient required an unusual quantity of chloroform1 and ,dr4 ,williamson1 who remained beside her1 states to me1 in his notes of the case1 the handkerchief was moistened often1 in order to keep up the soporific effect4 ,on one occasion ,i allowed her to emerge from this state for a short time1 but on the accession of the first pain1 she called out so loudly for the chloroform that it was necessary to pacify her by giving her some immediately4 ,in all1 four ounces of chloroform were used4 ,like the others1 she was quite unconscious of what had gone on during her soporised state1 and awoke altogether unaware that her child was born4 ,,case #f4--,second labor4 ,the patient--a person of a small form and delicate constitution--bore her first child prematurely at the seventh month4 ,after being six hours in labor1 the os uteri was fully expanded1 and the head well down in the pelvic cavity4 ,for two hours subsequently it remained fixed in nearly the same position1 and scarcely1 if at all1 advanced1 although the pains were very distressing1 and the patient becoming faint and exhausted4 ,she entertained some mistaken religious feelings against ether or chloroform1 which had made her object to the earlier use of the latter2 but ,i now placed her under its influence4 ,she lay1 as usual1 like a person soundly asleep under it1 and ,i was now able1 without any suffering on her part1 to increase the intensity and force of each recurring pain1 by exciting the uterus and abdominal muscles through pressure on the lower part of the vagina and perinum4 ,the child was expelled in about fifteen minutes after the inhalation was commenced4 ,in a few minutes she awoke to ask if it was really possible that her child had been born1 and was overjoyed to be told that it was so4 ,i have the conviction1 that in this case the forceps would in all probability have been ultimately required1 provided ,i had not been able to have interfered in the way mentioned4 ,i might1 it is true1 have followed the same proceeding1 though the patient was not in an ansthetic state2 but ,i could not have done so without inflicting great agony upon her4 ,,case #g4--;,a third labor2 the patient had been twice before confined of dead premature children2 once of twins1 under the care of ,mr4 ,stone1 of ,london2 the second time of a single child under my charge4 ,the liquor amnii began to escape about one o'clock1 ,a4,m41 but without pains for some time4 ,i saw her between three and four o'clock1 with the pains commencing and the os uteri beginning to dilate4 ,in two hours afterwards1 the third stage was well advanced1 and the pains becoming very severe1 she had the chloroform exhibited to her1 and slept soundly under its influence4 ,in twenty minutes the child was born and cried very loudly without rousing the mother4 ,in about twelve or fifteen minutes more she awoke as the application of the binder was going on1 and immediately demanded if her child was really born alive1 as she thought she had some recollection of hearing the nurse say so4 ,she was rejoiced beyond measure on her son being brought in and presented to her4 ,,case #i4--;,in the ,maternity ,hospital2 first child4 ,labor began at #aj ,p4,m41 7,nov4 #bast47 ,i was desired to see her at six ,a4,m41 7#bbnd47 ,the os uteri was well dilated1 but it was evident that the pelvic canal was contracted throughout1 and the head was passing with unusual difficulty through the brim4 ,the patient was complaining much of her sufferings4 ,it was evident that it would be a very tedious1 and probably1 at last1 an instrumental case1 and one therefore calculated to test the length of time during which chloroform might be used4 ,she began to inhale it at a quarter past six1 ,a4,m41 and was kept under its influence till a quarter past seven1 ,p4,m41--the date of her delivery--thirteen hours in all4 ,from the time it was begun till the time delivery was completed1 her cries and complaints ceased1 and she slept on soundly throughout the day4 ,the bladder required to be emptied several times with the catheter4 ,the head passed the os uteri at ten ,a4,m41 and during the day1 gradually descended through the pelvis4 ,at seven ,p4,m41 ,i at last deemed it proper to deliver her by the forceps2 the head1 which was now elongated and dematous1 having by that time rested for some hours against the contracted pelvic outlet1 with little or no evidence of advancement2 the bones of the ftal cranium overlapping each other1 and the ftal heart becoming less strong and distinct in its pulsations4 ,a warm bath1 irritation of the chest1 c41 were necessary to excite full and perfect respiration in the infant4 ,whilst we were all busied with the infant1 the mother lost some blood1 but the placenta was immediately removed1 and the uterus contracted perfectly4 ,on afterwards measuring the quantity of blood lost1 it was calculated to amount to fifteen or eighteen ounces4 ,the mother's clothes were changed1 she was bound up1 and removed to a dry bed before she awoke4 ,she had at first no idea that the child was born1 and was in no respect conscious of being delivered4 ,in fact1 she had been sleeping1 according to her own account1 from the time she had begun the inhalation1 and thought she remembered or dreamed that she heard ,dr4 ,williamson1 the house-surgeon1 speak near her once or twice4 ,dr4 ,beilby1 ,dr4 ,ziegler1 c41 saw the case with me4 ,three days afterwards ,i found the mother and child perfectly well4 ,she continued to recover so rapidly1 that she insisted on leaving the hospital on the tenth day after delivery4 ,a sufficient number of such accounts as these could be collected to fill a large volume2 but these are quite sufficient for our purpose4 ,in regard to the objections to using chloroform or ether1 in midwifery1 it will be thought by most persons1 and with good reason1 too1 that the safety and success which has attended their use1 is itself a sufficient answer to all objections4 ,it was at first thought1 by some physicians1 that the expulsive force of the womb was lessened when the pain was prevented2 but this is not the case2 on the contrary1 it has been1 in many cases1 much increased4 ,it was also thought by others that there was more danger from flooding1 and convulsions1 than in ordinary cases2 but this is also equally at variance with truth1 for it appears1 beyond doubt1 after a careful examination of all the cases recorded1 that there is much less danger1 particularly from convulsions1 than when the patient is allowed to be tortured and terrified by feeling pain4 ,dr4 ,simpson remarks in another part of the article above quoted3-- ,the question which ,i have been repeatedly asked is this--,will we ever be justified in using the vapor of ether to assuage the pains of natural labor8 ,now1 if experience betimes goes fully to prove to us the safety with which ether may1 under proper precautions and management1 be employed in the course of parturition1 then1 looking to the facts of the case1 and considering the actual amount of pain usually endured1 ,i believe that the question will require to be quite changed in its character4 ,for1 instead of determining1 in relation to it1 whether we shall be justified in using this agent under the circumstances named1 it will become1 on the other hand1 necessary to determine whether1 on any grounds1 moral or medical1 a professional man could deem himself justified in withholding and not using any such safe means1 7as we at present presuppose this to be17 provided he had the power1 by it1 of assuaging the pains and anguish of the last stage of natural labor1 and thus counteracting what ,velpeau describes as those piercing cries1 that agitation so lively1 those excessive efforts1 those inexpressible agonies1 and those pains apparently intolerable1 which accompany the termination of natural parturition in the human mother4 ,since the latter end of ,january ,i have employed etherization with few and rare exceptions1 in every case of labor which has been under my care4 ,and the results1 as ,i already stated in ,,the ,,lancet1 have been1 indeed1 most happy and gratifying4 ,i never had the pleasure of watching over a series of more perfect or more rapid recoveries2 nor have ,i once witnessed any disagreeable result to either mother or child4 ,i do not remember a single patient to have taken it who has not afterwards declared her sincere gratitude for its employment1 and her indubitable determination to have recourse again to similar means under similar circumstances4 ,most have subsequently set out1 like zealous missionaries1 to persuade other friends to avail themselves of the same measure in the hour of suffering4 ,and a number of my most esteemed professional brethren in ,edinburgh have adopted it with success and results equal to my own4 ,at the same time1 ,i most sincerely believe that we are1 all of us1 called upon to employ it1 by every principle of true humanity1 as well as by every principle of true religion4 ,medical men may oppose1 for a time1 the superinduction of ansthesia in parturition1 but they will oppose it in vain2 for certainly our patients themselves and their friends will force the use of it upon the profession4 ,the whole question is1 ,i believe1 even now1 one merely of time4 ,it is not--,shall the practice come to be generally adopted8 but--,when shall it be generally adopted8 ,and1 for my part1 ,i more than doubt if any man 7rejecting willingly its benefits7 is really justified1 on any grounds1 moral or medical1 in deliberately desiring and asking his patients to shriek and writhe in their agonies for a few months1 or a few years longer1 in order that1 by doing so1 they may defer1 forsooth1 to his professional apathy1 or pander to his professional caprices and prejudices4 ,another objection has also been advanced against the employment of ether or chloroform1 the force of which must be estimated by every one for themselves4 ,it is well known that many1 if not most of the lower animals during labor1 or immediately afterward1 experience certain feelings and desires stronger than at any other time2 and it is supposed that such would be the case1 as a general rule1 with human beings1 if it were not for the pain which overpowers everything else4 ,this supposition has1 in fact1 been partly verified in a few cases2 several females having confessed1 after recovering from a painless labor under the influence of ether1 that their dreams during the sleep were of a peculiar warm character6 ,how far this may be generally the case1 of course1 we have no means of ascertaining1 nor do ,i consider it to be practically of any consequence to know1 because it can in no way interfere with the safe progress and termination of the labor1 which alone is what we are properly concerned in4 ,i have merely thought it proper to state the fact as being a singular one1 and to make my readers acquainted with it4 ,physicians are well aware that the peculiar feelings referred to are frequently produced by various causes which act on the nervous system1 such as mesmerism1 and even by strong devotional excitement4 ,i have known females with strong moral impressions who always carefully avoided both the above causes1 from having discovered their liability to produce such effects2 in fact1 this has been one objection raised to allowing mesmerists to operate upon young persons1 and several cases of moral failing having been attributed to this cause4 ,it is not at all improbable1 therefore1 that such results may occasionally occur during labor1 though we are not at all justified in assuming that they will in any particular case4 ,how far this may be considered an objection to the employment of such means1 must be however1 as ,i before remarked1 decided by all persons for themselves1 and for themselves only6 ,it is not a medical question at all4 ,notices of ,dr4 ,hollick's ,lectures4 ,,dr4 ,,hollick ,,and ,,physiology4--,the second of a series of ,lectures1 by this gentleman1 on human physiology1 and the all important truths connected with our physical constitution1 was attended by a full house1 in ,national ,hall1 last evening4 ,the time was well spent1 and so appeared to think the audience4 ,on the delivery of the first of these ,lectures on ,tuesday evening1 the speaker in a comprehensive and well-digested exordium1 placed himself and the subject right with the public4 ,his manner1 language and style1 did the first2 his sound logic1 his argument1 his candor and research1 accomplished the second4 ,apart from the interesting and apposite details of the wonders of reproduction1 the illustrations of the immutable wisdom of nature1 which teem in the animal and vegetable worlds--which ,glows in each stem1 and blossoms in each tree2 ,lives through all life1 extends through all extent1 ,spreads undivided1 operates unspent4 ,apart from all this1 ,dr4 ,hollick's ,lecture was excellent as a defence of truth1 a vindication of the right of free and unshackled inquiry1 and as a convincing refutation of that silly1 but far too prevalent opinion that there are truths of which it is better to remain in a state of ignorance4 ,had nothing else been imparted in the forcible and well defined exordium of ,dr4 ,hollick than this judicious demolition of that fallacious1 silly1 but injurious twaddle which would forbid research to pass in advance of the old landmarks prescribed by custom1 ignorance1 or a spurious morality--even that would well deserve the public patronage4 ,truths1 well set forth1 will make an impression1 whether their investigation be fashionable or not4 ,there is an affinity between the capacity to learn1 and the truths to be learned1 which always results1 when a fitting opportunity is presented1 in a free inquiry1 and the gentleman who is bringing1 in a judicious and elevated manner1 a knowledge of those fundamental principles of our corporeal existence which are abused because unknown1 will accomplish more good than half a dozen teachers of higher pretensions1 and lower ability4 ,it was gratifying to observe the decorum--the sense of respect for both speaker and subject1 that was observed throughout the evening1 which evidently shows that those who go there are actuated by higher motives than mere curiosity2 by desires more ennobling than a passing gratification2 in a word1 it was clear that those who composed ,dr4 ,h4's hearers1 were men who know and dare to think1 and who will profit by these most useful discourses4--,new ,york ,herald1 ,aug4 #g1 #ahdd4 ,,the ,,origin ,,of ,,life4--,we attended ,dr4 ,hollick's ,lecture at the ,masonic ,hall1 on ,monday evening1 and if we were to say we were delighted1 we should but feebly express the gratification we experienced4 ,it was1 in fact1 a whole series of anatomical lectures crowded into one1 and that one so divested of technicalities1 and rendered so concise1 so intelligible to the most illiterate mind1 and withal couched in such delicate as well as perspicuous language1 that the most fastidious could find no fault1 nor the idlest curiosity go away uninformed4 ,the human figure--a ,french model1 made1 we believe1 of papier mache--is beautifully constructed1 and every trifling organ is not only an accurate counterpart of nature1 but can be taken apart1 opened1 examined1 c41 with an ease that renders the study as perfect as an actual dissection1 without the desagremens that attend a scrutiny of the real subject4 ,we advise all who love knowledge1 and particularly a knowledge of their physical organization1 to attend these lectures4--,phila4 ,spirit of the ,times1 ,dec4 #d1 #ahdd4 ,at a ,meeting of the ,class attendant upon ,dr4 ,hollick's ,select ,lectures on the ,physiology and ,philosophy of the ,origin of ,life in ,plants and ,animals1 held at the ,lecture ,room of the ,museum1 ,wednesday evening1 ,december #a1 #ahdd1 ,george ,g4 ,west1 ,esq41 was called to the ,chair1 and ,samuel ,w4 ,black appointed ,secretary4 ,resolved1 ,that we have listened with unfeigned pleasure and interest to the ,course of ,lectures delivered by ,dr4 ,hollick1 and now brought to a close1 and that we deem it an act of justice to him and the community1 to express our entire confidence in his character1 ability1 and the manner of illustrating his subject1 which1 to use the words of a daily journal1 is couched in such delicate as well as perspicuous language1 that the most fastidious could find no fault1 nor the idlest curiosity go away unimproved4 ,resolved1 ,that a committee of three be appointed to tender to ,dr4 ,h4 the thanks of the ,class for his courtesy to the members in affording them every facility for obtaining information upon the subject of his ,lectures1 and that he be requested to repeat the ,course at the earliest period consistent with his other engagements4 ,published in all the ,philadelphia daily papers of ,december #ad1 #ahdd1 and signed by one hundred and forty of the most respectable and influential inhabitants4 7,see similar ,resolutions1 with over two hundred names attached1 in the ,philadelphia daily papers of ,march1 #i1 #ahdd2 also of ,march #af2 and on several other occasions47 ,from the ,philadelphia ,daily ,papers1 ,feb4 #ba1 #ahde4 ,at a meeting of the ,ladies composing ,dr4 ,hollick's ,class1 held on ,wednesday afternoon1 ,february #aith1 in the ,lecture ,room of the ,museum1 the following ,resolutions were unanimously adopted1 and ordered to be published in one or more of the city papers3 ,resolved1 ,that we have listened with great pleasure and interest to ,dr4 ,hollick's ,lectures1 and are happy to add our testimony to the many already recorded in behalf of such ,lectures3 and regarding ,dr4 ,hollick as a benefactor of his race1 and especially of our sex1 we cordially wish for him abundant success1 and ample reward in the consciousness of doing good4 ,resolved1 ,that we will exert ourselves to induce our female friends and acquaintances to avail themselves of the great and rare privilege of obtaining the valuable instruction imparted in these ,lectures in so chaste and dignified a manner4 ,signed on behalf of the meeting by ,,sarah ,,webb1 ,sec'y4 ,,susan ,,wood1 ,president4 -- ,with over #ej names attached thereto4 7,see also similar ,resolutions1 with numerous names1 on ,feb4 #bg1 #ahdf1 ,march #bj1 #ahdf1 and on ,april #aj1 #ahdf1 with over three hundred names attached47 ,,dr4 ,,hollick',s ,,lectures4--,these ,lectures continue to attract much attention1 and are commended by all who hear them4 ,during the past week ,dr4 ,h4 has given a private ,lecture and exhibition of his models to many of our prominent ,senators and public men1 all of whom expressed themselves highly gratified1 and desirous that another class should be formed to accommodate their friends who had not attended4--,national ,intelligencer1 ,jan4 #cj1 #ahdf4 ,,dr4 ,,hollick is a gentleman of no less knowledge in his profession than eloquence in his means of imparting it1 and he is certainly deserving of great credit and support for his exertions in a new field of such universal importance4 ,we commend these ,lectures with the fullest confidence to the attention of our citizens4--,n4 ,y4 ,sun1 ,aug4 #f1 #ahde4 ,,letters ,,from ,,new ,,york1 ,,no4 #aa4 99 99 99 99 ,there have been several courses of ,lectures on ,anatomy1 this winter1 adapted to popular comprehension4 ,i rejoice at this2 for it has long been a cherished wish with me that a general knowledge of the structure of our bodies1 and the laws which govern it1 should extend from the scientific few into the common education of the people4 ,i know of nothing so well calculated to diminish vice and vulgarity as universal and rational information on these subjects4 ,but the impure state of society has so perverted nature1 and blinded common sense1 that intelligent women1 though eagerly studying the structure of the ,earth1 the attraction of the ,planets1 and the reproduction of ,plants1 seem ashamed to know anything of the structure of the human ,body1 and of those ,physiological facts most intimately connected with their deepest and purest emotions1 and the holiest experience of their lives4 ,i am often tempted to say1 as ,sir ,c4 ,grandison did to the ,prude--',wottest thou not how much in-delicacy there is in thy delicacy8' ,the only ,lectures ,i happened to attend were those of ,dr4 ,hollick1 which interested and edified me much4 ,they were plain1 familiar conversations1 uttered and listened to with great modesty of language1 and propriety of demeanor4 ,the ,manikin1 or ,artificial ,anatomy1 by which he illustrated his subject1 is a most wonderful machine invented by a ,french ,physician4 ,it is made of papier mache1 and represents the human body with admirable perfection1 in the shape1 coloring1 and arrangement1 even to the minutest fibres4 ,by the removal of wires it can be dissected completely1 so as to show the locality and functions of the various ,organs1 the interior of the ,heart1 ,lungs1 c4 ,until ,i examined this curious piece of mechanism1 ,i had very faint and imperfect ideas of the miraculous machinery of the house we live in4 ,i found it highly suggestive of many things to my mind4 99 99 99 ,l4 ,m4 ,c4 ,extract from a ,letter in the ,boston ,courier of ,monday1 ,june #c;d1 #ahdd1 by ,mrs4 ,l4 ,m4 ,child4 ,,dr4 ,,hollick',s ,,lectures4--,we cordially say to those who love a scientific treat not to fail to attend4 ,more instruction is contained in those three ,lectures1 than can be mastered by a twelve month's reading4--,baltimore ,clipper1 ,march #cj1 #ahdg4 ,,writing ,,desk ,,and ,,gold ,,pen ,,presented ,,to ,,dr4 ,h4 ,by ,,one ,,of ,,his ,,lady ,,classes4 ,illustration ,,dr4 ,,hollick--,dear ,sir3 ,the members of your class1 desiring the gratification of offering you some testimonial of their personal regard1 and grateful appreciation of the benefits which you are conferring upon them and their sex generally1 respectfully request your acceptance of the accompanying writing desk4 ,were it necessary1 we might repeat our assurances that your services to humanity will be1 by us1 long and gratefully remembered4 ,the women of this generation have reason to rejoice that1 by your efforts1 a new and extensive field of information has been opened to them1 whence they may derive treasures of knowledge1 of immense importance to themselves and their posterity1 hitherto concealed within professional enclosures4 ,wishing you health and happiness1 we beg leave to subscribe ourselves1 ,truly your ,friends1 ,signed on behalf of the class by1 ,m4 ,g4 7#ejj present47 ,o4 ,w4 ,b4 ,philadelphia ,march #bj1 #ahde4 ,illustration ,,notices ,,of ,,books4 ,from the ,new ,york ,herald4 ,,outlines ,,of ,,anatomy ,,and ,,physiology1 ,,with ,a ,,dissecting ,,plate ,,or ,,the ,,human ,,organization1 by ,frederick ,hollick1 ,m4 ,d4 ,we regard this as one of the most valuable works issued in a long time4 ,it is a complete general treatise on anatomy and physiology1 and the dissected plate answers the purpose of a model of the human frame4 ,dr4 ,hollick is entitled to great credit for his laudable desire to disseminate a knowledge of subjects that are of such vital consequence to all1 but which hitherto has been monopolized by the medical profession4 ,we commend it to all as a work of great merit and usefulness4 ,from the ,patriot1 ,baltimore1 ,march #bdth1 #ahdg4 ,,outlines ,,of ,,anatomy1 c4--,dr4 ,f4 ,hollick1 whose history as the great simplifier of the human anatomy1 so well known throughout the country1 and whose public ,lectures have won for him so high a reputation1 has just published a work which he designates ,outlines of ,anatomy and ,physiology for ,popular ,use4 ,this book contains a very curiously and ingeniously arranged plate1 which opens by pieces1 so that the different parts of the organs of the human system may be seen in all their variety1 all of which are fully explained in ,english4 ,the second part of this invaluable work gives a general description of these organs and parts of the system1 under the division of bones1 muscles1 arteries1 veins1 c41 c4 ,this work should fall into the hands of every family4 ,from the ,new ,york ,argus1 ,january #i1 #ahdg4 ,,neuropathy4--,this is a new name1 but a good one1 being the title of a work by ,dr4 ,f4 ,hollick1 whose excellent ,lectures on various subjects will be remembered by many of our citizens4 ,in this work is explained the action of ,galvanism1 ,electricity and ,magnetism2 ,homopathy and ,allopathy are contrasted in theory and practice2 ,mesmerism is discussed1 and other subjects too numerous to mention1 treated in a manner at once novel and instructive4 ,dr4 ,hollick has also published a work on ,anatomy and ,physiology for ,popular ,use1 illustrated with a new dissected plate of the human organization1 of most ingenious construction4 ,of this work we shall have more to say anon4 ,it is no ordinary production4 ,from the ,new ,york ,sunday ,times and ,messenger1 ,jan4 #aj1 #ahdg4 ,,outlines ,,of ,,anatomy ,,and ,,physiology1 ,,for ,,popular ,,use1 illustrated by a new dissected plate of the human organization1 and by separate views4 ,the work is designed either to convey a general knowledge of these subjects in itself1 or as a key for explaining larger and more complete works4 ,these ,outlines should be in the hands of every body2 and ,dr4 ,hollick1 or any one else1 is a public benefactor who furthers the publication of such able1 interesting1 and truly important works4 ,from the ,pennsylvanian1 7,philadelphia17 ,jan4 #bf1 #ahdg4 ,the following in regard to two works from the pen of ,dr4 ,hollick1 of this city1 we copy from the ,washington ,union1 of the #bjth instant3-- ,,outlines ,,of ,,anatomy ,,and ,,physiology ,,for ,,popular ,,use4 ,by ,frederick ,hollick1 ,m4 ,d41 ,lecturer on ,anatomy1 ,physiology1 c4--,we regard this as an eminently useful publication4 ,it gives in a form far more condensed and intelligible than we have before seen1 a very comprehensive view of the human organization4 ,the dissected plate of the human anatomy1 which forms an interesting feature of the work1 is to us at least a novelty4 ,the explanations are drawn up with great simplicity1 and cannot be misunderstood by the general reader1 while they1 with the illustrations1 will often serve to render more clear and precise the views of scientific and professional students4 ,from the ,sunday ,mercury1 ,new ,york4 ,,dr4 ,,hollick',s ,,last ,,work--,the ,diseases of ,woman1 their ,causes and ,cure familiarly explained1 with ,practical ,hints for their prevention1 c4--,we regard this as an invaluable production1 the most useful1 in many respects1 which has yet emanated from this distinguished author and practitioner4 ,it is just the kind of work which has ever been wanted1 and is just suitable to the excellent purpose for which it was intended2 this it accomplishes most fully1 and its extensive circulation must be productive of vast practical benefit4 ,it is works of this nature and ,,character which really do good2 which exhibit plain facts in a plain manner1 and record in language simple and intelligible1 knowledge of the most vital importance to the health and consequent happiness of every daughter1 sister1 wife1 and mother in the land4 ,the work is dedicated to the ,,ladies ,,of ,,america1 and we congratulate them upon the possession of a friend at once so able1 so sincere and valuable as ,dr4 ,hollick4 ,burgess1 ,stringer ,co41 of this city1 are the publishers4 ,the ,new ,york ,sun says of this ,book3 ,,burgess ,,stringer have just issued a most invaluable work1 being a treatise upon the diseases of women1 by the celebrated ,dr4 ,hollick4 ,we have thoroughly examined the work1 and can say without hesitation1 that it should be in the hands of every mother who cares for the health of her daughters1 and every woman who values physical and mental well-being4 ,dr4 ,hollick and his publishers have done a public benefit by issuing such a book4 ,from the ,new ,york ,sunday ,times4 ,,dr4 ,,hollick',s great work1 ,,the ,,diseases ,,of ,,woman1 which will be found advertised in another column1 is truly a valuable production1 and well sustains the author's well-earned reputation4 ,it is a complete practical treatise on female diseases1 scientific enough for a medical man1 and yet so plain that every body can understand it1 and so delicately written that even the most fastidious cannot object to a single passage4 ,much of the matter it contains is quite new in this country1 even to medical men1 and of the greatest interest and importance4 ,the anatomical plates are superb1 and the whole book is excellently got up4 ,every adult female in the land should read this book2 the information it gives would prevent an incalculable amount of disease and suffering1 if possessed in time2 or it will teach the best way to cure it when unfortunately established4 ,,works ,,published ,,by ,,dr4 ,,hollick4 ,,outlines ,,of ,,anatomy ,,and ,,physiology1 ,,by ,,frederick ,,hollick1 ,m4 ,d4 ,this is the most complete1 and at the same time most simple work ever issued on the subject4 ,it is illustrated in a novel manner1 by a large colored ,plate of the ,human ,organization1 which dissects by means of separate layers1 from the surface of the ,abdomen down to the ,spine1 showing all the ,organs in their proper places1 all connected together1 and many of them in sections6 the whole being colored to life4 ,this plate is on an entire new plan1 nothing of the kind having ever before been invented2 it is almost as complete as a model1 and is invaluable for private study1 for teachers1 and for ,medical students4 ,the explanations are familiar1 and divested of technicalities3 and it is still further illustrated by separate wood-cuts throughout the work1 and a beautifully engraved portrait on ,steel of the author4 ,one volume1 quarto1 bound1 price ,one ,dollar4 ,third ,edition4 ,,neuropathy2 ,,or1 ,,the ,,true ,,principles ,,of ,,the ,,art ,,of ,,healing ,,the ,,sick4 ,,by ,,frederick ,,hollick1 ,m4 ,d4 ,being a complete practical treatise on the use of ,,galvanism1 ,,electricity1 and ,,magnetism1 in the cure of disease1 and a comparison between their powers1 and those of ,drugs or ,medicines4 ,these two works are published by ,t4 ,b4 ,,peterson1 ,no4 #ih ,chestnut-st41 ,philadelphia1 and for sale by ,booksellers and ,news ,agents generally throughout the ,united ,states4 ,,the ,,origin ,,of ,,life4 ,a complete popular ,treatise on the ,philosophy and ,physiology of ,,reproduction1 in ,plants and ,animals1 with a detailed description of human generation4 ,illustrated by colored plates of the male and female systems4 ,new being at every stage1 c4 ,published by ,nafis ,cornish1 #bfh ,pearl street1 ,new ,york4 ,price #a4 ,thirtieth ,edition1 with additional ,plates and various improvements4 ,n4 ,b4--,this is the only popular and yet strictly scientific work on the ,generative ,functions ever yet published4 ,,the ,,diseases ,,of ,,woman1 ,,their ,,causes ,,and ,,cure ,,familiarly ,,explained2 ,with ,,practical ,,hints for their prevention and for the preservation of ,female ,health4 ,by ,f4 ,,hollick1 ,m4 ,d4 ,especially designed for every ,female's ,private ,use4 ,,burgess1 ,,stringer ,,co41 corner of ,broadway and ,ann streets1 ,new ,york1 and for ,sale by all ,booksellers4 ,second ,edition4 ,price #a--cjj pages1 beautifully bound1 and illustrated with numerous splendid ,,anatomical ,,plates4 ,by remitting #a in a letter to ,t4 ,w4 ,,strong1 #ih ,nassau-st41 ,n4 ,york1 it will be forwarded to any part of the ,country4 -- ,no ,female should be without it4 ,the above works1 along with the present one1 constitute a complete practical and popular ,library of ,anatomy1 ,medicine and ,physiology4 ,they have all been purposely designed for the instruction of non-professional readers1 but at the same time are so scientifically correct1 and so complete1 that they would serve as text books for ,medical students4 ,the favor they have already met with1 and the extensive circulation they have attained1 is proof that they both meet the wants of the public and enjoy its approbation4 ,from the ,boston ,mail1 ,march #g1 #ahdh4 ,,dr4 ,,hollick',s ,,separate ,,lectures ,,to ,,ladies ,,and ,,gentlemen ,,on ,,physiology4--,the importance of adult persons1 of both sexes1 understanding themselves1 and their natural relations1 must be obvious to every thinking mind4 ,the present ignorance on these matters is1 undoubtedly1 the chief cause of the vices and sufferings which so extensively prevail1 and our only hope of a beneficial change must be founded on a proper system of public instruction4 ,this instruction is difficult to impart we admit1 and there are but few men qualified for imparting it4 ,we have no hesitation1 however1 in saying that ,dr4 ,h4 is one of these men4 ,he knows how to preserve in his subject all that intense interest which it intrinsically possesses1 and yet to divest it of everything in the slightest degree obnoxious to censure1 or even distrust4 ,he has a happy faculty of making every thing easy to be understood1 and yet avoiding the slightest approach to undue familiarity4 ,all who attend1 express themselves both surprised and delighted1 and unhesitatingly recommend his ,lectures wherever they go4 ,many of the most eminent ,ladies in our city were among his auditors last week1 and were unreserved in their expressions of approbation1 both for the ,lecture itself1 and for the becoming modesty and true refinement that characterised its delivery4 ,the present series1 which commence to-day1 has been anxiously expected1 and will no doubt be numerously attended by both sexes1 but particularly by the ,ladies1 many of whom were unable to gain admission last week4 ,illustration3 ,,the ,,gold ,,medal ,,presented ,,to ,,dr4 ,,hollick1 ,,by ,,the ,,ladies ,,of ,,philadelphia4 ,,important ,,notice ,,to ,,ladies6 ,,the ,,patent ,,elastic ,,and ,,medicated ,,pessary2 ,,for ,,the ,,relief ,,and ,,permanent ,,cure ,,of ,,prolapsus ,,uteri1 ,,or ,,falling ,,of ,,the ,,womb2 ,prolapsus ,vagina1 ,rupture of the ,bladder or ,intestine into the ,vagina2 ,retroversion1 or ,anteversion of the ,womb2 and also1 in many cases1 of ,,leucorrh,a1 or ,fluor ,albus2 invented by ,,dr4 ,,hollick1 and first described in his ,diseases of ,woman4 ,this ,instrument is ,,certain ,,to ,,cure all the above named diseases1 ,,where ,a ,,cure ,,is ,,possible4 ,it can be worn with perfect ease by young or old1 summer or winter1 night or day1 without the slightest inconvenience4 ,it is made of a soft elastic material1 which never corrodes1 and which gives way to the slightest motions of the body4 ,it can never become displaced1 nor fail to effectually support the parts1 and is so light that it only weighs one ounce4 -- ,this is the only ,instrument of the kind ever invented1 and certainly the only one that can ,,cure ,,falling ,,of ,,the ,,womb2 or be worn with ease1 to relieve it1 when incurable4 ,,dr4 ,,hollick is the only person who keeps it1 as he has ,,no ,,agent ,,any ,,where1 at present4 ,n4 ,b4--,the article is ,,patented3 but1 besides this1 ,,no ,,imitations1 however similar1 can be depended upon1 because the ,original is impregnated1 in a peculiar manner1 ,,known ,,only ,,to ,,the ,,inventor1 with a substance which imparts its ,,medicinal ,power1 and without which it would be comparatively inefficacious4 ,all the old fashioned ,,trusses1 ,,supporters1 ,,pessaries1 c41 are entirely superseded by this ,instrument1 which can only be obtained from ,dr4 ,hollick1 ,new ,york1 who will also give the necessary directions as to its use and application4 ,it may be sent any distance4 ,price--,five ,dollars4 ,,advertisement4 ,,dr4 ,,hollick is daily receiving numerous ,letters from all parts of the country1 the answering of which has hitherto been a great tax on his time1 already sufficiently occupied2 he is therefore compelled to announce1 that in future he cannot attend to any which merely request advice1 unless they contain the customary fee of ,,five ,,dollars4 ,address1 ,dr4 ,hollick1 ,new ,york4 99 99 99 99 99 ,transcriber's ,notes ,page #ci states1 ,in ,plate ,,vii4 the line marked crosses the upper strait1 or brim of the ,pelvis1 but there is no in the original image4 ,on page #cda1 ,chapter ,,xxiii was incorrectly labeled ,chapter ,,xxii4 ,that has been corrected here4 ,minor punctuation errors were corrected on pages vi1 #d1 #ac1 #ai1 #ij1 #ada1 #aea1 #bjj1 #bjb1 #bjf1 #bae1 #beh1 #bga1 #cja1 #cac1 #cbc1 #cdf1 #deg1 #dfj1 #dfd4 ,inconsistencies in hyphenation and capitalization have been retained4 ,original spellings have been retained except in the cases of these apparent typographical errors3 ,page #bi1 situate changed to situated4 7,this is the part situated between4447 ,page #ec1 tha changed to that4 7,thus some authors asserted that4447 ,page #ef1 barenness changed to barrenness4 7444or1 in other words1 which produce barrenness4447 ,page #fd1 ,tinc changed to ,tinc4 7,the ,os ,tinc1 or mouth of the ,womb47 ,page #aaf1 is changed to in in two instances4 7444,womb in a first pregnancy1 and in a female4447 ,page #ach1 expeeted changed to expected4 7444or before the expected period4447 ,page #aef1 foetal changed to ftal4 7444and covered with the ftal membranes4447 ,page #ahc1 rotale changed to rotate4 7444the head is compelled to turn1 or rotate4447 ,page #bjc1 cephalio changed to cephalo4 7444it is called the right cephalo iliac position4447 ,page #bch1 langour changed to languor4 7444falls into a quiet and pleasing langour4447 ,page #bdj1 signs changed to sign4 7444and if there is no sign of its coming4447 ,page #bdc1 subseqnent changed to subsequent4 7444being done in their subsequent labors47 ,page #bdg1 asphyxated changed to asphyxiated4 7444are most likely to become asphyxiated4447 ,page #bec1 capble changed to capable4 7444she thinks herself stronger1 and more capable4447 ,page #bee1 presentatious changed to presentations4 7444very unfavorable presentations of the ftus4447 ,page #beg1 unforseen changed to unforeseen4 7444alarmed when unforeseen difficulties occur4447 ,page #bha1 developement changed to development4 7,the development of the head cannot be ascertained4447 ,page #cjg1 cause changed to causes4 7,still such presentation occasionally causes4447 ,page #caa1 presentatations changed to presentations4 7444most dangerous of all the presentations4447 ,page #cac1 and changed to any4 7444child and pelvis from any other cause47 ,page #cbc1 recommeuds changed to recommends4 7,mauriceau recommends that women4447 ,page #ccc1 continuanee changed to continuance4 7444the continuance of pregnancy to the full period4447 ,page #ccc1 inadmissable changed to inadmissible4 7,the plug is here totally inadmissible4447 ,page #cda1 honr changed to hour4 7444may be preserved for an hour or two4447 ,page #cda1 amni changed to amnii4 7444and then if the liquor amnii4447 ,page #cdi1 introdueed changed to introduced4 7,when the first blade is properly introduced4447 ,page #cga1 distate changed to distaste4 7,this means a complete distaste4447 ,page #chj1 meat changed to neat4 7,a neat spoonful should be drunk4447 ,page #che1 weaknes changed to weakness4 7444a state of weakness and exhaustion47 ,page #che1 chlid changed to child4 7444than dangerous1 except to the child4447 ,page #cie1 unles changed to unless4 7444unless very large1 they cause4447 ,page #cig1 truely changed to truly4 7444as truly so as those on the limbs4447 ,page #djh1 mattrass changed to mattress4 7444lie on her back1 on a hard mattress4447 ,page #dji1 accummulate changed to accumulate4 7444and makes it accumulate in the womb4447 ,page #dac1 ocurrence changed to occurrence4 7444which may account for the constant occurrence4447 ,page #dah1 ccnclusion changed to conclusion4 7,in conclusion it should be remarked4447 ,page #dbb1 temblings changed to tremblings4 7444then follow tremblings1 numbness of the limbs4447 ,page #dbf1 spmptoms changed to symptoms4 7444after the first symptoms of the disease4447 ,page #dcf1 two changed to too4 7444or too unremittingly1 particularly4447 ,page #dda1 oocasional changed to occasional4 7444occasional doses of ,james's ,fever ,powder4447 ,page #dda1 ,james' fever powders changed to ,james's ,fever ,powder4 7444occasional doses of ,james's ,fever ,powder4447 ,page #dde1 recommened changed to recommended4 7,mesmerism has been recommended4447 ,page #dde1 develope changed to develop4 7444will develop the bones of the ftus4447 ,page #dej1 crowed changed to crowded4 7444on the operating table of a crowded theatre4447 ,page #deb1 minmtes changed to minutes4 7444the child was expelled in fifty minutes afterwards47 ,page #dee1 throngh changed to through4 7444with unusual difficulty through the brim47 ,page #deg1 humau changed to human4 7444natural parturition in the human mother47 ,page #dei1 coporeal changed to corporeal4 7444principles of our corporeal existence4447 ,page #dfj1 #ahdj changed to #ahdf4 7,march #bj1 #ahdf7 ,page #dfd1 ,peansylvanian changed to ,pennsylvanian4 7,from the ,pennsylvanian1 7,philadelphia17 ,jan4 #bf1 #ahdg47 ,on page #bdj1 an extra an was removed from the phrase 444to wait more than an hour444 ,on page #def1 the word of was missing from the phrase 444after a careful examination of all the cases recorded444 ,on page #deg1 an extra of was removed from the phrase the superinduction of ansthesia4