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HINTS
THE OBSTETRIC PROCEDURE 
 
HINTS
THE OBSTETRIC PROCEDURE,
              BY

    WILLIAM B. ATKINSON, M.D.,
PHYSICIAN TO THE DEPARTMENT OF OBSTETRICS AND DISEASES OF WOMEN,
        HOWARD HOSPITAL, PHILADELPHIA.
        PHILADELPHIA:

COLLINS, PRINTER, 705 JAYNE STREET.

            1875. 
YYQ
Pt878?u
1815
Entered according to Act of Congress, in the year 1875, by
        WILLIAM B. ATKINSON, M.D.,
in the OflBce of the Librarian of Congress, at Washington. 
                      TO







THE PHILADELPHIA COUNTY MEDICAL  SOCIETY,






      WHOSE MEMBERS SO KINDLY RECEIVED




                      THE





         SUBJECT MATTER OF THIS VOLUME




                     AS THE




            ANNUAL ADDRESS OF 1874,




                      WITH




GRATEFUL  REMEMBRANCE OF THE MANY HONORS AND PROOFS




         OF CONFIDENCE RECEIVED THEREFROM,





                   AND WITH AN





    EARNEST APPRECIATION OF THE VALUE PERSONALLY




              OF SUCH ORGANIZATIONS,















         IS RESPECTFULLY DEDICATED





                       BY




               THE  AUTHOR. 
 
PREFACE.
    The kind reception accorded by both the
  medical  journals  and the  profession, to the
  Annual  Address  entitled " Hints  in the Ob-
  stetric Procedure,"  delivered by  the author
  before the Philadelphia  County Medical So-
  ciety, and an almost constant demand for  it
  from all  portions of the country, have em-
  boldened  him  to  rewrite the subject matter
  of that address, and to present it in its present
  form.
    No attempt is made to exhaust the subject,
  or to offer a complete vade mecum.   The author
  merely desires to present, as clearly and com-
  pendiously as he  may, his views  in  certain
"  matters connected with the obstetric art, with
  a hope that he may thus contribute to a better
  performance of this  art, and that, while he  is 
Vlll
PREFACE.
aiding his fellow practitioners, he may divest
this branch of medicine of much of its mystery
and dread—a dread too often  shared alike by
physician and patient.
  He would  earnestly urge upon those who
propose to practise obstetrics, that they should
make themselves  thoroughly masters of the
science  and the art, that they may respond to
each call to the lying-in chamber with a proper
feeling of confidence in their  knowledge  and
skill, and at the same time a true appreciation
of the great responsibility  they thus assume.
  The great bug-bear " Meddlesome Midwifery"
has too  long acted to deter the physician from
the performance of his duty as  the  aid,  the
assistant of nature in this sacred act of the wife
and mother.
  It is a great source of regret that so many
of our  brethren, even of those who have but
recently emerged from  the care of the " fathers
in medicine," still adhere  to exploded dogmas
and  old wives'  fables, and  are too  ready to
allow the parturient woman to be guided  by
the ideas, and even follies, of those around her, 
PREFACE.                IX
in place of themselves assuming the post of
director—yea, master of the situation.  Such
seem  content with the formal visit,  and in-
quiries of the nurse, who soon comes to ignore
the doctor; and all goes well, more by good
fortune than  by  good management.  These
gentlemen would have greater assurance of a
successful result in their cases if they would
fully discharge their duty as physicians—care-
takers—and would deem nothing too  small or
unimportant in the lying-in chamber.
  " The  old axiom, ' meddlesome midwifery
is bad,' has  had great  force in obstetric prac-
tice; but it is, perhaps, better adapted to igno-
rance or partial  knowledge than to perfect
comprehension  of the  mechanical and motor
phenomena of natural labor.  I have no doubt
the time will come when these will  be so well
understood that the finger of the accoucheur.
will be in accordance with every change in the
passage of the child during parturition.  Prov-
erbs are always one-sided.   The phrase quoted
has, no doubt, been useful  in preventing  im-
proper interference, but it has also a tendency 
X                 PREFACE.
to the prevention of interference when this is
both useful and necessary."*
  "Then the physician becomes not the sub-
stitute for, but the' handmaid and assistant of
nature.  As such, the intelligent physician goes
to the bedside of his suffering  patient, in the
sore hour of her travail, with a full knowledge
of the extent of his resources, conscious of his
powers, and strong in their  possession, he an-
ticipates and  prevents  danger.   'Meddlesome
midwifery is  bad.'  Delay  and timidity  in
operating are bad."f

  * Dr. Tyler Smith, Lectures on Obstetrics, p. 367.
  f Dr. J. S. Parry, Amer. Journ. of Obstetrics, Aug.
1873, p. 191. 
CONTENTS,
Preface
False Pains
Slow Dilatation
Inefficient Pains
Ergot
Quinine
Rupture of the Membranes
Position
The Vectis
The Forceps
The Placenta
The Binder
After-Pains
Retention of the Urine
After Delivery
Purgatives .
Hemorrhage
 PAOE
   3
  13
  19
  22
  30
  32
  34
  36
,  39
.  40
.  44
.  50
.  51
.  54
.  57
.  59
.  60 
xii                  CONTENTS.
                                                 PAGE
Convulsions.......
Artificial Respiration.......'°
                                                  74
Breech Presentations.     »    •     •    •     •     •
Nourishment of the Child......79
                                                  QO
Retracted Nipple.......
Nourishment of the Woman.....83 
              HINTS
                  IN

THE OBSTETRIC  PROCEDURE.
               False Pains.
  Towards the close  of  the  pregnancy, and
prior  to the inception of the expulsive pains,
the patient, especially when  a  primipara, is
frequently attacked by more or less powerful
irregular contractions of the uterus, commonly
known as " false pains."  Some suffer in  this
way for weeks, and are consequently rendered
weak  and irritable, and less  able to endure
the true  pains necessary for  delivery when
that  act  commences.  Women, subject  to
this complication, are  generally  found  to
dread  these  pains  more than they do those
of  full  labor.   Now, as  there can  be no
advantage in  allowing  these to continue,
      2 
14
OBSTETRIC  PROCEDURE.
but, on  the  contrar}T, a positive disadvantage
it  is  the  xluty  of  the medical  attendant,
immediately upon  recognizing their nature,
to interpose for the relief of his patient.  In
order  to  truly  diagnose this  condition,  a
vaginal   examination  is  imperatively   de-
manded.
  In this connection, it  is proper to call  the
attention of the obstetrician to the importance
of making such  an  examination before he
quits  the lying-in chamber,  as,  without it,
he can  positively  know nothing.   Properly
made, such  an examination reveals the exact
state of the organs concerned in parturition,
and gives him the key to his position. Hence,
it  must be insisted upon, and the physician
should  not  allow  himself  to  be  detained
without it.  It may save many weary hours
of waiting  and watching.  In the experience
of the  author, on  one  occasion, it  revealed
the fact  that  the patient was not pregnant,
though her pains  had apparently been recur-
ring  at regular intervals  for  several hours
prior to his being summoned. 
FALSE PAINS.
15
  At this examination, he  should note  the
condition and position of the os uteri, whether
high  up or low down, rigid  or soft, closed or
patulous;  the  nature  of  the  pains,  their
relative  frequency  and   continuance,  their
effect upon the presenting part  of  the  child,
and whether the circular  fibres of  the  os are
disposed to relax before its advance; the con-
dition of the enveloping  membranes, whether
intact or broken, allowing the waters to drain
off; and  also, whether the  rectum  is empty,
or, as is too often the case, it  is  filled with
hard feces.
   He is  now prepared to  give  a  prognosis,
and  decide  as  to  the  probabilities of the
delivery.  But  let  him  be  cautious, lest he
promise more than will be performed.   Those
 who have  had  much experience  in the  ob-
 stetric  art  can readily  recall  numerous in-
 stances  where   hours  have elapsed   before
 delivery, though at first there appeared every
 reason to anticipate a speedy relief.
    If the  os is high  up and  reached with
 difficulty, but  slightly patulous and rigid, it 
16
OBSTETRIC PROCEDURE.
 may be concluded that  the  delivery  will be
 slow  and  tedious,  or  that  labor has  not
 commenced.  Under these circumstances, the
 physician  should take measures to relieve his
 patient of what is, to her, useless and exhaust-
 ing agony.  Let him at once  administer a full
 dose of some anodyne to relieve this condition.
 While,  under   peculiar  circumstances,  the
 preparations of  opium will be found  useful,
 the best remedy is Chloral.   In the vast
 majority of instances,  this article will  secure
 to the patient the most complete and refresh-
 ing sleep, from  which she awakes free from
 pain,  to continue  so  until  the  true labor
 commences, or the false pains  are replaced by
 the  proper, regular contractions  of the long
 fibres of the uterus, and a second  examination
 will reveal the fact that  during £his interval
 the rigid os has yielded, and complete  dilata-
 tion has occurred.
  On this point, I must dilate at some  leno-th
 upon the  value  of chloral.  The experience
of all who have  employed  it shows that it is
particularly applicable in these cases. Schroe- 
FALSE PAINS.
17
der says: "Chloral has been  given in tardy
and exhausting labors.   After an hour's sleep,
on  awakening,  the labor  was  very rapidly
terminated by powerful pains.  We have also
observed that by the  use  of chloral in  cases
where the  uterine action was very  painful
without  being efficacious, the labor assumed
an instantaneously  rapid course, although the
intervals between the pains had considerably
increased in duration."
  It would appear  that while chloral produces
a  calm refreshing  sleep, it  does not by any
means entirely  check the progress of  labor
when  this has commenced.   For it is invari-
ably found that dilatation has continued, and so
completely is this generally accomplished, that
on the patient awakening, a few quick pains will
often complete the delivery.  I regard the use
of this article as producing results similar to
those of anaesthetics in Surgery, and therefore
similarly indicated.  While  it  relieves, to a
marked  degree,  the  pains of travail, it also
contributes to a safe and speedy convalescence.
   These false pains generally occur in persons
                      2* 
18
OBSTETRIC  PROCEDURE.
of a rheumatic or neuralgic tendency, and are
found to  prevail more frequently  in seasons
predisposing to this form of disease.  In some
cases, they are readily controlled by enemata
of morphia or chloral.  As the latter remedy
is sometimes found to  be disagreeable when
exhibited by the mouth,  it may be well to re-
member that it has an excellent effect when
thrown into  the  rectum in a solution of gum
acacia or starch.
  At the  time of making his first  visit, the
physician, by proper inquiry, may learn much
of the probabilities of the case.   Thus, if the
term of pregnancy is not completed, these pains,
when allowed to continue, may lead to prema-
ture labor,  and it  is, therefore, more urgent
that they should be controlled.
  If there  is hemorrhage, a careful  investiga-
tion becomes  important,  especially  when  it
occurs about the  seventh  month, lest placenta
prsevia is present; or, the passage of  clots may
reveal concealed hemorrhage, which is always
more or less dangerous. 
SLOW DILATATION.
19
             Slow Dilatation.
  Where the os uteri is dilatable, but when from
any cause, as insufficient expulsive pains, the
progress is slow, much can be done by aiding
the dilatation.   It must not be understood by
this that forcible dilatation is intended, though
that sometimes becomes necessary; all who have
had much obstetric experience will agree that
in very many instances, by  the  gentle, but
firm sweep  of the finger around  the  advanc-
ing part, within the os,  the  process of expan-
sion has been greatly accelerated, and  the part
speedily caused to emerge from its grasp.  Ot
course, this manoeuvre must not be attempted
if the membranes have not  yet  ruptured, as
otherwise an additional cause of delay may be
introduced.  The  rupture  of the membranes
will claim attention further on.
  Still further to aid the complete opening of
the os uteri, the gravitation of the child and
its pressure  upon the os may be invoked.  For
this reason, the patient should be  urged to re-
main out of bed, and if possible to walk about 
20
OBSTETRIC PROCEDURE.
 the  room, aided, when  necessary, by  her at-
 tendants.  A double gain is the result:  the
 dilatation is aided, and the child is  kept  in a
 position more favorable to delivery, while the
 woman is  comforted by the  knowledge that
 she  is helping herself.   She is thus  less liable
 to become irritable and discouraged.
   Again, while  she remains  in bed,  she is
 more or less inclined to gloomy  forebodings,
 and  to become impatient under the impression
 that every pain should be the last.
   For this reason, it is always best to explain
 to her fully her  exact condition, unless some
 special  cause forbid.  Especially  to a primipa-
 rous patient is this important,  as all is strange
 to her,  and she  dreads everything,  and often
 looks for  impossibilities.  It  should  be  ex-
 plained that  this is  merely the  stage  of pre-
 paration for delivery, and much of her anxiety
and  impatience   will be relieved.   Another
point is important.   As  long as  the medical
attendant remains with  the patient,  she feels
a momentary expectation of delivery,  and is
tempted to demand his constant aid, and feels 
SLOW DILATATION.
21
neglected unless it is extended.  Hence, it is
never advisable for him to remain  when  he
finds his services are not and  will not  be  in
immediate demand.  Let him give  explicit
directions as to quiet, etc., and leave, at least
for a time.  During this interval, as  nothing
but exhaustion can be  gained by the  efforts of
the patient, she should be counselled to bear her
pains quietly, and make no expulsive efforts.
At this stage, particularly  when dilatation is
very slow  and  painful, the value of  chloral is
marked.  Even  when not  given in  sufficient
doses to produce sleep, its benefits are shown
by obtunding sensibility, without in the least
interfering  with  the  process  of  dilatation.
After a sleep or rest more or less prolonged,
she awakes to vigorous  expulsive efforts, and
for which she has  now renewed strength.  In
nearly every instance, an examination reveals
that the  circular  fibres  of the os  have  fully
given way, and that dilatation is complete.
   The reverse of this picture is seen where the
patient  is permitted to labor hour  after hour,
constantly expecting delivery,  and constantly 
22          OBSTETRIC PROCEDURE.
being  disappointed, until, exhausted, she lies
with scarcely an  effort to  bear down, and at
the last, instrumental aid becomes imperative,
perhaps to  save  both lives, and the patient
experiences  a  tedious recovery, and  has gen-
erally added to it the necessity for the  use of
the catheter for days, even if  other and more
dangerous symptoms do not supervene.
  It is in just such  cases  that  the  inexperi-
enced physician is  tempted  to employ  ergot.
Nor does this temptation come solely from his
desire  to succor his patient, for those around,
not understanding  the cause of delay,  gene-
rally  attribute it  to  insufficient pains and
expect that  the " forcing medicine" will give
them the proper strength and frequency.  (See
Ergot.)

             Inefficient Pains.
  The lack of expulsive  power in the contrac-
tions, is often the result of want of sleep.   The
more  prolonged  the  first  stage, or  that  of
dilatation, the more likely are  the subsequent 
INEFFICIENT  PAINS.
23
pains to  be wanting in power.   Hence, an
additional  advantage  is  derived from  the
exhibition of some narcotic, giving sleep, and
shortening this stage.
  The proper method of employing ergot, etc.,
will be explained hereafter.
  There  can no longer be any  doubt  that
opium frequently acts favorably by increasing
the efficiency of the pains.  Particularly is this
observed where nervous excitement is  present.
Chloral has been observed by the author in
repeated  instances  to  produce a similar effect.
Therefore, when the pains are quite inefficient,
before having recourse to ergot, the physician
should  employ  one of  these, preferably  the
latter, in sufficient  dose, say one grain of
opium, repeated if necessary,  or fifteen  to
twenty grains of chloral.  So marked has been
the increase in power of the contractions after
the  use of  chloral, that the author has been
accused  of using  " the forcing  medicine,"
meaning ergot, in several instances.
  A careful examination  should always  be
made, as the pains will sometimes be  rendered 
24          OBSTETRIC PROCEDURE.
inert by the bladder being loaded with urine.
When  this  is the case, employ the catheter,
and evacuate the bladder.
  In this connection, we  may allude to  the
occasional occurrence of cystocele.  A portion
or the whole of the bladder is driven  down
into the vagina in front of  the advancing
part,  acting as a formidable  obstacle to  the
delivery and  being  liable to rupture at any
moment.   In such  cases, the  male  catheter
will be necessary, the female being too  short,
and  often  the  compression  and deviation of
the urethral canal are so great that the blad-
der can only  be reached by a  gum  catheter.
Should the physician fail to pass the instru-
ment  in the ordinary position,  the  patient
may be made to assume  that  upon her  knees
and  elbows, when the catheter will rarely  fail
to pass with ease into the bladder.
  Another  mode of increasing uterine action,
is the passage  of the  gum  catheter within
the os  uteri and carrying  it around  between
the child and the womb.   This is particularly
useful  prior to the rupture of the  membranes, 
INEFFICIENT  PAINS.           25
but it has also been found of service after  the
partial evacuation of the liquor amnii.
   The  application of the  warm  douche  is
another  plan, and  one  which will  act a
double  part.   It excites  the  womb  to  re-
newed action, and aids the dilatation when
that is  tardy.   This is more especially  of
value where  the labor is rendered  tedious
by the rupture of the membranes  at an early
moment, and prior to the dilatation of the os.
  The use of the air-bag or  colpeurynter is
worthy of  consideration.  Whether the mem-
branes are intact or  are ruptured, this instru-
ment proves a valuable means to aid dilatation
and also excite the contractions of  the uterus.
The bag should  be   passed well  up to  the
os,  and then  rapidly filled with air or warm
water;  the latter is preferable, as it can exert
more power, being less compressible than air.
  Externally,  friction to  the body  of  the
womb will serve to increase its contractions,
just as we find it to do when we are about to
deliver the placenta.
  Along  with  friction, the   physician may
      3 
26
OBSTETRIC  PROCEDURE.
resort to pressure  of  the whole body  of the
uterus, as it were  supplementing the contrac-
tions.  This should be performed by placing
both hands  side  by side upon  the  abdomen
over the womb, and making firm downward
pressure  at the   moment of  a contraction,
imitating the pains by increasing the pressure
and then gradually lessening  it.  When an
intelligent nurse  or assistant is at hand, the
physician may  employ such  aid in  this ma-
noeuvre,  and he will  see the beneficial effects
at each effort.  Often, just at the moment of
delivery, the head is  tediously delayed in its
exit, and this plan will  obviate the  necessity
for the use of the  forceps.
   This method, however, can hardly prove of
much value unless the dilatation is almost or
wholly  completed, and  is not  recommended
except where the delivery has been checked by
the pains having  become weak, and when the
presenting part is  already about to  make its
exit.  In other cases, where  the head is still
high up, the employment of the forceps  is in-
dicated. 
INEFFICIENT  PAINS.
27
  Where the head has been delivered, and the
shoulders  are delayed, this  means becomes  of
great value;  also, when  there  is  a  breech
presentation, such aid to the uterus will often
speedily  bring  the  part down,  or facilitate
materially the other efforts of the physician.
  Sometimes, this pressure  may be performed
by means of a  broad piece of muslin  placed
above the fundus of the womb, and  the  ends
passed diagonally down on  either side  of the
woman,  and  drawn  upon  by  an  assistant
during each pain.
  The physician should never neglect  to see
that  the  bladder and  alimentary canal  are
not by their loaded condition aiding to delay
the  deliver}'.  To  the  former,  allusion has
already  been made.  When  the   rectum  is
distended with  feces, its evacuation by a full
injection of castor oil with soap  and  water
will  frequently produce  a  marked  and  agree-
able change in  the nature of the pains.  In
this  connection, it may  be  proper to mention
that the administration  of castor oil early in
labor is often found  to aid  in the dilatation of 
28          OBSTETRIC  PROCEDURE.
the os.  The author is not prepared to endorse
this article in preference to any other laxative,
though the claim has been made that it has a
specific effect upon the sphincters of both  the
rectum and  uterus.
   The use of an enema simply of warm water,
often produces an equally good effect, and at
the same time tends to make the delivery a
much more  comfortable matter both to patient
and physician.  Instances  are constantly seen
where  the patient forbears  to  aid the pains
and endeavors to prevent them, lest she should
evacuate the contents of the rectum.  Atten-
tion to this point is alwaj-s  essential and
useful.
   Before  leaving  this subject, allusion must
be made to the use of electricity.  A number
of writers have detailed cases where, by  the
passage of  an  electric current  through  the
uterus, one pole having been placed  upon  the
abdomen over the fundus uteri  and the other
passed   within  the os, the  pains  have been
greatly  increased,  or provoked,  and   the
delivery speedily accomplished. 
INEFFICIENT  PAINS.
29
  The physician should faithfully employ these
methods, and  never expose  either child or
mother  to  the  dangers of a* protracted  labor
until  he has exhausted  every means at his
command.
  Under the head of dilatation, we  may refer
to the  use of  Barnes' Dilators.  These are
small gum  bags made with  a contraction in
the middle, fiddle  shaped, which  insures their
retention when placed in position so that the
contracted  part  will occupy the  os  uteri.
When  expanded  either  by   air  or water, a
powerful force  is  brought  to bear upon the
os, and its  dilatation is rapidly  effected.  Of
course,  the  use  of  this means  is  indicated
only under particular circumstances; as when
the  os  is  rigid,  undilatable, and the  mem-
branes are  ruptured ; or when, from any cause,
speedy  delivery  is  imperatively  demanded.
The use of chloral, however, as previously in-
dicated, will generally effect  all  that  may be
required.
3* 
30
obstetric procedure.
                  Ergot.
  As a parturifacient, ergot has generally been
regarded as pre-eminent.   But it is a serious
question as to when its use is proper and indi-
cated.   And first, it may  be well to indicate
when it should not be employed.   When an
examination reveals the non-dilatation of the
os, ergot is positively contraindicated.   If it
acts at all, it only serves to lash the womb into
a fury, it sets up  an irritable condition in that
organ  which can do  no good, and may even
result  in producing  rupture of the uterus.
Therefore, before this agent is employed, the os
must be well dilated, or soft and dilatable.
  Again, by its improper  use, by causing the
walls of the womb  to grasp the body of the
child as in a clonic spasm for some time  before
it can possibly be delivered, the death of the
child is rendered almost certain.
  It is also contraindicated when some  me-
chanical  obstacle exists;  for  instance,  dis-
proportion of the head and the  pelvis ;  defor-
mity of either; the  presence of a tumor, etc. 
ERGOT.
31
  Ergot becomes of value when, by the feeble-
ness of the pains, the delivery is retarded, while
the presentation is natural, and the os is dila-
ted or readily dilatable, the head still remain-
ing high up.    When  the head is low  in the
pelvis, of course the forceps should be preferred.
The advantage of ergot when the  uterus is
inert, is that it causes  that  organ to close as
rapidly as the delivery is effected, and obviates
any tendency to hemorrhage.   When, from
this occurrence in former labors, or  from the
general feebleness of the uterine contractions,
there  is  reason  to apprehend  post-partum
hemorrhage, ergot  is especially indicated, and
should be exhibited in a full dose,  so as  to ob-
tain  its  complete effect upon the expulsion o±
the child.
   As the knowledge of the  value and  use of
the forceps  becomes  more general, and also of
the only proper method  of causing the  uterus
to deliver  itself of the after-birth,  ergot be-
comes of less frequent employment. 
32
OBSTETRIC PROCEDURE.
                  Quinine.
   As an oxytocic,  this article has been fre-
quently lauded of late years.  There can be no
doubt that it really acts as a stimulant to the
action  of the uterus, and, unless  contraindi-
cated, may be exhibited in those cases  where
the delivery is retarded by reason of inertia of
the womb.
  Dr. Albert H. Smith  of Philadelphia says :*
" It increases the activity of the normal uterine
contractions: the pains becoming more frequent
and  more intense, the  expulsive  power being
greater, while the yielding of the circular fibres
of the  os  is  more  prompt;  the contractions
maintaining  their  proper intermittent  char-
acter, the relaxation and rest in  the  interval
being complete ;  showing in  this  respect an
entirely  different action from the continuous
spasmodic contraction caused by ergot.  .  .  .
  "It promotes permanent tonic contraction of
the uterus after the expulsion of the placenta.

  * Transactions of the College of Physicians of Philadel
phia, 3d series, vol. i. p. 188. 
QUININE.
33
  " It  diminishes the lochial  discharge  to a
normal standard.
  " Its use is followed by less after-pains  than
usual in a majority of cases.
  " It reduces the frequency  of  the mother's
pulse, and relieves the nervous demoralization
so often seen in the first stage of labor.
  "Given during parturition, it never disturbs
the brain or causes its usual unpleasant effects,
even in patients who  at  other times are very
susceptible to its influence."
  He concludes—
  " That  quinia has no  inherent property of
stimulating the  gravid uterus to contraction ;
being inert as to any effect upon  the womb in
a quiescent state, and having  no decided action
in accidental labors at any period of gestation.
  "That to its property as a  general stimulant
and  promoter of vital energy and  functional
activity, and to  that alone, is due its influence
upon the uterus in normal parturition; produ-
cing then no action peculiar to itself, but merely
increasing the power of the uterus to expel its
contents by its own natural  method, convert- 
34         OBSTETRIC PROCEDURE.
ing what is a defective  or even pathological
action into a simple physiological process.
  "That by availing ourselves of this power,
we may by administering full doses of the sul-
phate of quinia at the onset of labor favor the
rapid and safe  termination  of  what  might
otherwise be a tedious and exhausting work."
  The usual  dose is fifteen grains.

        Rupture of the  Membranes.
  In making an  examination, care should be
observed lest a rupture of the membranes  is
produced.   Hence, the  examination should
not be made, except  in the  interval  between
the pains. The membranes then  being flaccid,
with care, the finger may be  swept around,  so
as thoroughly  to  inform  the physician as  to
every point necessary for  him to  know.
  This is of great importance, for it  must be
remembered  that a premature rupture of the
amnion  and  the consequent evacuation of its
contained fluid, will make what is known as a
" dry labor."  Again, as, under certain circu m- 
        RUPTURE OF THE MEMBRANES.      35
stances, turning  may  become necessary,  it
should be remembered  that this operation be-
comes extremely difficult after the waters have
been  evacuated  for some  time.   When the
membranes are intact, the fluid forms a beau-
tiful wedge-like point to produce the dilatation
of the os.  Y^hen this is wanting, we have the
blunt presenting part taking its  place, and
dilatation generally goes on more slowly and
laboriously, and with greater risk to the child.
   But when the os  is fully dilated, the tough-
ness of the membranes may  then act to retard
the delivery.  When this is the case, a rupture
may be effected by pushing  the finger firmly
against the membranes during  a pain, or if
they are exceedingly tough,  almost like parch-
ment, it may become  necessary to employ the
nail of the fore-finger, notched like a fine saw,
with which to tear  them open.   Instances are
quite common where great  delay has  been
caused by the non-rupture of the amnion, and
where delivery has  been immediate when this
manoeuvre was adopted.   Even when delivery
does not at once occur, the rupture of the mem- 
36
OBSTETRIC  PROCEDURE.
 branes can be  of  no injury, and often, by re-
 lieving the overloaded womb of a part of its
 contents, the power of contraction of the  ute-
 rine muscles is increased, and the pains are thus
 rendered more  effectual.    It is also believed
 that the contact of the child directly with the
 womb by the rupture of  the membranes, acts
 as an  excitant of uterine contraction, and is,
 hence,  recommeuded as  one of the  remedies
 for uterine inertia.

                  Position.
   In  repeated instances,  after many  weary
 hours  of labor with scarcely any  advance of
 the child, delivery has been speedily accom-
 plished by a change in  the position of  the
 woman, as in her irritable aud  restless condi-
 tion she turns from side to side, rolls upon  her
 back, or rises to relieve the bladder or rectum.
  This is a lesson which should be heeded by
 the physician, who, too often, rigorously insists
 upon the woman remaining upon the side, ex-
pecting the delivery momentarily.   Nature 
POSITION.
37
appears to urge the woman to assume  that
position which is  most advantageous for the
expulsion  of the child, and we find her instinc-
tively endeavoring to aid herself in this way.
  The position in labor varies with nations, but
when left to herself the patient is invariably
observed to take that position which will cause
the child to gravitate toward the point of exit.
This subject is one which is eminently worthy
the attention of the student of midwifery, as
he  will find in the habits  of women at this
time, much of value and interest.
  In  America  and  England, the  position is
upon the  left side.  In Germany and France,
as a general rule, it is upon  the back.  In an-
cient times,  labor-chairs of a peculiar  form
were  employed, and are even yet found  in
some places.  A common practice at one time
was to fasten two chairs together by the ad-
joining legs, the woman then  sat, as it were,
between the two,  holding  on  by  the backs.
Among the people of Ireland the position upon
the knees  is preferred, and would seem to be a
very suitable one.
      4 
38         OBSTETRIC PROCEDURE.
  The obstetrician should, from time to time,
notice the position and rate of advance of the
child.  When it is delayed, he  will often find
the presenting part pressing firmly against the
walls of the  pelvis at one point, which is the
cause of  the  delay.   He should then so place
his patient as to remedy this condition, and to
cause the presenting  part to occupy a position
as near the centre of the excavation as may be.
Much of the expulsive power of the contrac-
tions is lost by this pressure of the part against
the walls of  the passage.   The advance should
be in a line perpendicular to the plane of the
pelvic straits.  Thus, friction to a great extent
is avoided, and the action of gravitation is fully
brought into play.
  Of course,  as the passage through  the pelvis
is not a straight but a curved line, the position
may require  to be changed from time to time.
When the pressure is to one side,  it will  be
found that the womb is lying obliquely to the
opposite side.    This may be remedied by a
proper  support  of the abdominal  tumor  by
means of pillows placed  beneath  the  fundus 
THE VECTIS.
39
and body of the womb.   In many instances, a
rapid delivery will follow the adoption of such
a support.
  Prior to the entrance of the presenting part
into the pelvis, the most favorable position will
be that of a half-sitting posture.  Nothing will
so forcibly  and fully explain this  problem of
position as  a careful study of the relations of
the child to the mother, by means of a mani-
kin.

                The Vectis.
  When dilatation is complete, but  the head
is slow in engaging, by reason of a want of
dip of that  part, the vectis  proves  of great
value.   It must  always  be remembered that
this is a tractor, not a lever, for as a lever it
becomes capable  of great injury,  especially
when any point of the mother is made  the
fulcrum.  When  properly constructed, it gives
great  power as  a tractor, and enables  the
obstetrician  to  speedily  terminate the labor
when the forceps would otherwise be requisite. 
40         OBSTETRIC PROCEDURE.
It is easy of application and less formidable
than the  forceps.   Of course  it cannot  be
employed  unless  the  os   is  dilated,- and  is
almost  useless in   the  absence  of  uterine
contractions.   When the head is detained by
a  want  of dip,  that is  a  greater  or less
departure of  the chin from the breast, the
vectis  may be employed  to bring down the
vertex and  complete the  delivery.   Cases are
constantly met with where the anterior lip  of
the os forms a cap or sling over  the  head,
thus greatly lengthening  the labor; here the
vectis  acts  like  a  shoe-horn in aiding the
passage through, and the  termination of the
labor.  When it  becomes necessary  to have a
fulcrum, the  hand  of the  operator should
be employed.

               The Forceps.
   In  behalf  of the  suffering woman,  in
deprecation of the evils to which a  prolonged
labor  renders  her liable, for the sake of  the
many   infants  unnecessarily   sacrificed,   I
earnestly urge every one  who attempts  to 
THE FORCEPS.
41
practise the obstetric art, to  provide  himself
with  a proper pair of  forceps, and  then to
perfect himself by thorough study in their use.
Perhaps a large majority of cases are permitted
to suffer hour after hour without  the use of
this invaluable aid, simply  because the atten-
dant  is afraid or unable himself  to  employ
them, and hesitates to  avail himself of the
benefit of a consultation, lest he thus lose credit
with  his patient and her friends.   In  nothing
is our selfishness so apparent as when, intrusted
with the health and the lives of two beings, of
one whose loss can never be made up, and who
is truly beyond value, the physician hesitates
in  the performance of his   duty,  lest  his
reputation and his pocket may suffer by it.
   At  this  important   moment,   he  should
regard duty as paramount to everything.   He
is watched by eagle eyes; every  phase of his
conduct,  every  line  of  his  countenance, is
noted.   Much,   very  much,   of   his future
depends upon the report that shall go  from
that  room  in  relation  to his  actions.  It
matters  not what  may be the social condi-
                     4* 
42
OBSTETRIC  PROCEDURE.
tion or position of his patient;  she is a woman
in  the agony of her most sacred office, her
great  calling in life, and she demands and
should have all that skill, science, and sym-
pathy  can  give her.
  He who hesitates is lost.  For the practice
of the  " divine art of obstetrics," the physician
must be a man of prompt decision.
  I am not of those who would counsel a re-
sort to instrumental aid when unnecessary,
nor is  it justifiable to have recourse to it for
purely selfish purposes.   A tired doctor who
wants  his  rest!  But, how often does it be-
come an urgent  necessity, and alas! the medi-
cal  attendant cannot respond  to the calls  of
suffering humanity.
  It is pleasant to note that yearly this valua-
ble  adjunct is coming into more frequent use.
It is gratifying to know that accoucheurs are
learning  to look upon the application  of the
forceps in  a far different light from that  in
which  it was formerly viewed.   The early use
of this instrument would have  saved very
many  children  reported as  still-born,  and 
THE FORCEPS.              43
would equally tend  to  a more speedy and
happy recovery of the woman  herself.  When
a resort to the forceps  becomes the rule in
place of the exception, when physicians cease
to  boast  that  they " let  nature  take  her
course," regardless of what that course may
be,  then will parturition  assume a less dread-
ful  appearance,  and one  great cause for  the
avoidance of pregnancy will have been  swept
away.
  Perhaps, also, this delay in invoking instru-
mental  aid is greatly due to the old cry of
" meddlesome midwifery,"  a  cry which  has
done incalculably greater harm than  all the
errors of those who have bravely disregarded it.
  It may be asked how long shall we wait, or
rather, how early shall we  interfere?  When
the  os is fully  dilated, or so dilatable as to
oppose no obstacle, and no advance  has  been
made for one hour, it is time that help should
be  given.  Nor  is  it advisable  in  many in-
stances  to wait  this long; as soon as all ad-
vance has ceased, particularly when the mem-
branes are ruptured, and  the  amniotic liquor 
44          OBSTETRIC. PROCEDURE.
evacuated, then it  should become the desire of
the physician to terminate the labor  by em-
ploying the aid of the forceps.
  In this connection, many excellent authori-
ties might  be quoted, and the evils resulting
from prolonged  and  tedious  labor  might be
specified, but this is unnecessary.  The physi-
cian who has once intelligently applied the
forceps, and experienced the pleasure of reliev-
ing his patient in a few minutes from  what
seemed likely to be a labor of hours, will ever
after feel himself armed with  a new  and valu-
able power.
  Failing to use  it,  he seeks to supplement
the pains by other  means, often of question-
able utility, ergot  for  instance, capable of but
little good and often powerful  for harm.

              The Placenta.
  The  child having been severed from its con-
nection  with  the  placenta,   the   physician
should at  once give  his  attention to the com-
pletion of the  labor  by the  delivery of  the 
THE PLACENTA.
45
after-birth,  which  of course comprises both
the placenta and the membranes.
  There seems to be a rule with many to allow
a certain  time to elapse  before any effort is
made to aid in this delivery ; some even wait-
ing for an hour.  When the womb does  not
at once close itself and expel  the balance of its
contents,  there  can  be  no  good  reason  for
delay on the part of the attendant.  The pa-
tient is  generally  in great  need  of  repose,
which is prevented, and she is kept in a state
of inquietude by a nameless  dread  of trouble
yet in store for her.
   The advantages  of an immediate delivery
and the disadvantages of delay are so evident
that they scarcely  need recapitulation.  The
uterus, relieved of its burden, without any ob-
struction, is enabled at once  to commence the
process of involution, and by firmly closing its
sinuses, hemorrhage is prevented, and the pa-
tient is not allowed  to waste  that vital fluid
for which she will  have so  much need in the
performance of her duty as the fountain of life
for her offspring.  While the placenta remains, 
46          OBSTETRIC PROCEDURE.
 clots are more liable to form, which, by  their
 presence, give rise to more or less subsequent
 pains as the womb attempts to expel them.
 Or the  placenta, falling across the mouth of
 the womb, acts  as a  plug, and  gives  rise to
 concealed hemorrhage,  often  of an  alarming
 character.
   In the management of this, the third stage
 of labor, the plan of grasping the fundus and
 body  of the womb through the abdominal
 parietes, is  the  most sure method  of  accom-
 plishing the whole object.  The purpose is not
 only to  remove the balance of the contents of
 the womb, but also  to leave that organ firmly
 and permanently closed.  In very many cases,
 the placenta will be found in the vagina, and
 may readily be removed without further  trou-
 ble, but, under all circumstances, there may be
 seen at a glance  the benefit to be obtained by
thus causing the womb to close itself.
  It is too much the habit, both of the nurse
in the absence of the physician, and, indeed,
of the physician  himself, to endeavor to bring
away  the after-birth  by pulling  vigorously 
THE PLACENTA.             47
upon the cord.  This frequently results in the
breaking of the cord, necessitating the inser-
tion of the hand inside of the womb,  and
without a guide to seek the edge of the  pla-
centa ; or, it may produce more or less inver-
sion of  the uterus,  and  thus give  rise to
alarming symptoms.
  In this connection, it is proper to allude to
the danger of the method so plausibly taught
by Cazeaux and others.  This plan is to draw
upon  the cord with one hand, while two or
three fingers of the other are passed up along
the front of the cord, pressing it  backward,
thus causing it to play over a sort of pulley.
The theory is  that the traction  is thus made
continuously in the line of the pelvic and vagi-
nal curve,  whereas, simple traction   would
draw  the placenta forward  against the ante-
rior border of the uterine opening, expending
much of  the traction uselessly.   But, how fre-
quent is it that the cord is ready to give- way
and separate even by slight traction 1  Now,
by  this plan, we offer  an  additional  induce-
ment for the attendant to exert strong traction 
48          OBSTETRIC PROCEDURE.
upon the cord, and that, too, without his hand
outside following it down as the mass is being
drawn from the uterine cavity.
   With  firm pressure upon  the  abdominal
walls by the hand of an intelligent assistant,
or the left hand of the accoucheur, while gentle
traction  is  made upon  the cord, in the vast
number of  cases, the delivery will  be  readily
accomplished.
  The late  Professor Charles D. Meigs incul-
cated the necessity, in place of drawing upon the
cord, and thus pulling the placenta broadside
against the  opening, of reaching up  one or two
fingers to its edge, and thus unbuttoning it, so
to speak.   This simple, but truly scientific
manoeuvre, generally succeeds.
  The plan  of expulsion, now known as Crede's
method, has been employed by many practi-
tioners for  years.   Dr. Washington L. Atlee
assures the  writer that he taught  and prac-
tised a precisely similar plan as early as 1853.
  The placenta having failed to come away, by
gentle  frictions over the uterus, it  is found to
contract when  the fundus and body are grasped, 
THE PLACENTA.             49
as above remarked, with one or both hands,
and pressure is made downwards and inwards.
The fibres of the womb contract and the con-
tents  are expelled  like the kernel from the
fruit-pulp when  squeezed in the fingers.  An
immense advantage of this procedure is that it
excites the womb to a tonic contraction which
is much less liable to relax and allow of subse-
quent hemorrhage, and also greatly diminishes
the tendency  to after-pains, which  by  some
women are dreaded more  than the pangs  of
labor.
  As the mass exudes, it  should be carefully
grasped and twisted on itself a number of times
as it is withdrawn. This twists the membranes
into  a rope, and secures a  clean delivery,  in
place  of  leaving  the  torn shreds hanging  in
and from the parts, to putrefy and give rise  to
offensive odors, as well as exposing the patient
to the risk of carrying this poisonous matter
into the blood, there to produce pysemia.
5 
50
OBSTETRIC  PROCEDURE.
                 The Binder.
   We  have not yet arrived at the  point of
 omitting this in every  case.  While  many
 women are just  as well without it, and indeed
 we might say all, when we consider the usual
 condition in which  it is  found within a  very
 short time after it is applied—like a rope high
 up just beneath  the ribs, acting not only as a
 source of great discomfort, but also as a means
 of injury to the patient—still, in very many
 cases, it is  a  valuable support  to the relaxed
 abdominal  parietes.  It  generally  makes  the
 patient feel more  comfortable to  have some
 such support, and care should be taken to see
 that  it is  properly adjusted.  When it  is
 pinned, the  woman should always have room
 to  fill  her  lungs to their  utmost capacity,
 otherwise she  is compelled  to assume  the
 condition  of one with  a  broken rib, and to
 employ  the  diaphragm  almost entirely  in
 respiration, a proceeding which cannot fail to
affect injuriously the abdominal viscera, and
secondarily,  those  of  the  pelvis.    Rest  is 
AFTER-PAINS.
51
absolutely  necessary  for the pelvic contents,
that they may recover from the fatigue and
strain to which they have just been subjected;
hence the  importance  of  avoiding any such
condition as  will  expose  them  to  further
disturbance.   A bandage applied  evenly and
pinned so as to afford a gentle support to the
woman  will add greatly to  her comfort.

                After-Pains.
   A most absurd and even  dangerous notion is
often held by  the attendants, and even among
these must  frequently be included the physi-
cian, that after-pains are a necessary accompa-
niment  with  which no interference should be
made.
   As before remarked, when, by the proper
manipulation, the uterus has been compelled
to close itself completely,  expelling all  clots,
etc., as  a general rule, the  after-pains amount
to  nothing.   These  pains  indicate a  womb
obstructed in its involution by the presence of
some foreign body, as a clot, a portion of the 
52
OBSTETRIC PROCEDURE.
placenta or membranes, or, as has been known,
by the presence of a tumor.   In  some cases
there would appear to exist a peculiar irrita-
bility or  neuralgic condition  of  the  womb,
which gives rise to these excruciating pains.
They are called dolores eruenti or " blood pains,"
because they are generally  followed by a flow
of blood, and in olden times were supposed to
be necessary to  expel the superfluous  blood
from the womb.
  Whatever may be their  origin, the proper
remedial   means should  be employed.   The
patient is already  sufficiently exhausted,  and
it is exceedingly  unwise  to  allow her  to
undergo any further suffering.  Again, she  is
in need of repose, which will be more or less
broken and  unrefreshing by the recurrence of
these pains.
  A careful examination  of  the parts  will
reveal the presence of any foreign body, which
must at once be removed ; this done, some ano-
dyne in full  dose should be  given and repeated
until complete relief is obtained.
  The late Prof. Dewees was one of the earliest 
AFTER-PAINS.
53
to recognize the importance  of  this  matter,
and to urge the necessity of relief; regarding
these  pains as an  evil  of  great magnitude.
Patients  will always be found to recover more
rapidly and satisfactorily when thus  relieved.
Occasionally,  these pains are of a neuralgic
character,  which  would  be anticipated  in
persons predisposed to this affection.
   Leishman regards them as liable to pass into
inflammatory disease,' and urges  the  necessity
of attending to them.
   French accoucheurs apply belladonna in the
form of  an ointment, and Tyler Smith recom-
mends an anodyne  liniment to the breasts for
the  relief  of  these  pains.  Fordyce Barker
prefers Tully's powder, and  when the abdomen
is tympanitic, the application  of turpentine
stupes and the employment of turpentine ene-
mata.  Almost every accoucheur has  a favor-
 ite formula for the relief of after-pains.   The
 author  has found  a solution of chloral and
 morphia to act very satisfactorily.
   In purely neuralgic  cases, Prof.  Barker ap-
 plies chloroform liniment to the abdomen, and
                      5* 
54
OBSTETRIC PROCEDURE.
administers quinine in five to ten grain doses
night and morning.
  An additional  importance is given to these
pains when we reflect that abdominal pain has
been  regarded and treated  as after-pains,  or
even  as  the  initial  stage  of  inflammatory
action, when it was entirely due to

         Retention  of the Urine.
  Much  care is  often  necessary to  ascertain
whether  the  patient has passed the  proper
quantity of urine, and there is constant  lia-
bility to  unintentional deception.
  The physician should  never  fail to assure
himself  by a careful investigation, in every
case  of  doubt.   Instances  have  repeatedly
occurred where the bladder has been enormously
distended  with but  slight  discomfort  to  the
patient.  The presence  of abdominal swelling,
particularly when low down, not of a  tympa-
nitic character ;  pain on pressure, and which
also gives  rise to a  desire to urinate; a con-
stant desire to pass water, though  the patient 
RETENTION OF URINE.          55
has just performed that act; or a dribbling of
water from  the  parts—should lead to a use of
the catheter, which will speedily determine the
presence or absence of urine.
  This complication may  occur from  the be-
ginning, or  may come  on a day or two after
delivery.   One  complete  evacuation  of the
bladder will often suffice,  though this opera-
tion  may need to be  repeated once or twice
daily for several days.  It must  be borne in
mind that  too long an interval between the
evacuations may make the trouble more serious,
while the complete  relief  at  proper intervals
will  conduce to a more rapid return of the
normal functions.
  The operation, small  as it appears,  often
proves'extremely annoying and even embarrass-
ing to both  physician and patient.  It should
be performed without any  exposure  of the
parts unless this becomes absolutely necessary.
  The following simple manoeuvre rarely fails
to enable the catheter  to be passed.  Pass the
right forefinger within the vagina at its anterior
portion, and find the  urethral  canal,  which 
56
OBSTETRIC PROCEDURE.
 will be felt like a thick cord at that point; draw
 the  finger along this cord to its  termination,
 where there will  be felt a small  pit or  de-
 pression,  which is the meatus; insert the  ca-
 theter at this spot, and  press it  gently back-
 wards and  upwards, and it will readily slip
 into the  bladder.   Of course, as the catheter is
 being inserted, its outer end should be plugged,
 or stopped by a finger kept upon it, to prevent
 the  escape of the  urine before the vessel  is in
 place to receive it, or great discomfort  will be
 occasioned to the patient by the wetting of her
 clothing.  Still  better to  avoid  this, and also
 the necessity of the frequent emptying and re-
 placing of the vessel, the author has affixed to
 the outer end of the catheter, a section of India-
 rubber tubing of the same calibre as the cathe-
 ter, and of sufficient length to reach to a vessel
 placed at the side  of  the couch.
   In the performance of this operation,  no
 force should be used, as the end of the catheter
might be caught in one of the lacunae in place
of the opening of the  urethra, and  great injury
would follow a forcible attempt to push it into 
AFTER DELIVERY.
57
the bladder.  The physician is enabled to  as-
sure himself that the instrument has passed
into the urethra, by feeling it through the walls
of that canal with the finger placed as above ;
and should no urine be discharged, either the
bladder is empty, or by reason of an unusual
stretching of  the canal, the  instrument  has
failed to reach and pass the sphincter, and if
necessary a longer one must  be  used, prefer-
ably, under such circumstances, a gum catheter,
which should be passed gently up the canal,
and, as it wrere, allowed to find its way.

               After Delivery.
   The ancient tradition of the " ninth day," it
is gratifying  to  know, is fast becoming obso-
lete.   Regardless of everything, the  woman
was compelled to remain in  bed until after  the
ninth  day. In many instances,  this  day was
looked upon  with  terror, as  more dangerous
than  any  other.   Happily  superstition  no
longer sways the minds of our patients and
 nurses, and they are rapidly giving way to 
58
OBSTETRIC  PROCEDURE.
common-sense views.  From the very first, let
the patient change her position as she may
desire.  Let her sit up in the  bed, and  after
the third or fourth day she may be removed
to a couch or lounge while the bed is being
thoroughly renovated.   The  constant  recum-
bent  position in  the  bed,  especially  during
warm  weather,  is  uncomfortable  in  the ex-
treme, and is liable to cause  debility.   A wise
moderation, of course,  must be enforced, and
the patient must not be allowed to proceed to
the opposite  extreme, and  exert herself  or
remain too  long  in a sitting posture.  She
should  be   made   to  understand  her  true
condition, with  a  womb still much  larger
than natural;  its ligaments and the vagina in
a relaxed condition, all tending to produce the
various uterine troubles to which females are
so liable.
  No rule in this matter will do to govern all.
Every woman must be a law to  herself. 
PURGATIVES.
59
                Purgatives.
  From  time immemorial, a tradition of the
lying-in chamber has been " castor oil on the
third day."  This is not only unnecessary, but
generally it  proves  positively injurious.   In
common with other minor matters, this has
generally been left to the nurse, and she, regard-
less of circumstances, insists that the customary
dose shall be taken.  In very many instances,
there will be a natural action of  the bowels
within the first few days, and where this does
not  occur, a mild laxative, as the citrate of
magnesia, may be administered  should there
be any indications of it being required.
  This  uncalled-for purgation is often  posi-
tively  injurious,  increasing  the debility al-
ready present; and by the use of  castor oil, its
griping effects add to the general  discomfort.
  Prof.  Barker  thinks  the  oil  is liable  to
increase  the suffering  from   hemorrhoids,
which in very many cases are present. 
60          OBSTETRIC PROCEDURE.
               Hemorrhage.
  As this accident of labor frequently occurs
after the delivery has been accomplished, that
form will be  first considered.  To insure  the
most thorough  and permanent closure of the
uterus at the time of the delivery of the pla-
centa, is to render the  probabilities  of post-
partum  hemorrhage extremely small.  When,
however, it is observed to occur, examine first
as to the state of the womb.  If that is found
like  a hard ball  low down in the pelvis, it
may safely be  inferred  that the seat of the
hemorrhage is not to be looked for there.   A
careful  examination will detect a  ruptured
vessel in the  vagina, in  a lacerated perineum,
or even  in  the labia.  While this is not at all
of common occurrence, still, as it has been en-
countered, it  should  be  looked  for, when  the
womb seems  to  be firmly closed.  When  the
seat of the hemorrhage  is discovered, it may
be checked by the  application of compresses
soaked in some  styptic, as the subsulphate of
iron.  If external, this is more readily accom- 
HEMORRHAGE.
61
plished.  If a laceration of the perineum  be
the cause,  the hemorrhage may be checked
and the womb closed by  the  introduction of
one or more sutures.
  When the  hemorrhage  is the result  of a
want  of tonic contraction of the uterus, efforts
should at once be  made  to secure that end.
The clots should at once be removed from the
vagina, and the womb should be excited to
contract and expel all that may be within it.
To maintain the contraction, ergot or quinine
should be exhibited in full doses, and a firm
compression kept up upon the uterus, either
with a compress placed  beneath the binder, or
by the hand of an assistant.  This should  be
maintained constantly, and examinations should
be made from time to time lest concealed hemor-
rhage should occur.  Generally, the irritation
of the breasts by friction of the  nipples, or pre-
ferably by the sucking of the child, will aid in
causing the permanent contraction  of  the
uterus.
  When, from any cause, the hemorrhage still
continues, in spite of every effort, the physi-
      6 
62
OBSTETRIC  PROCEDURE.
cian should not  hesitate to throw into the
womb  with a syringe, some styptic solution,
perhaps the  best  of which is the liquor ferri-
subsulphatis.  This  may be first  employed,
half diluted with water, but that  failing, it
may be increased in strength, and should the
emergency demand, the full strength of the
officinal  liquor should  be used.   Experience
has fully shown  that  this can be relied  upon,
and that the evils,  if  any result,  are  less
than the risk  of the  death which  appears so
imminent.
  Of course, the patient should at the same time
be assisted to rally from her sinking condition
by  stimulants  and  appropriate  food.  For the
restoration of  the blood, we have nothing bet-
ter than milk, eggs, beef tea, etc.
  An important point to remember in all cases
of  hemorrhage,  is  the danger  of  fainting.
Now this cannot occur so long  as the brain is
kept full of blood, and to insure this condition
the head should be kept lower  than the body.
First, remove the pillows and bolsters; then, if
necessary, raise the lower portion of the bed so 
HEMORRHAGE.
63
as to incline the body of the patient with the
head down.  After a severe hemorrhage, this
position  should  be maintained until all dan-
ger is completely past.
   As additional  means  of restraining  the
hemorrhage, turpentine in  emulsion may  be
exhibited; the solution of subsulphate of iron
may be given along with the ergot, and gene-
rally proves a very valuable addition.  Exter-
nally,  iced cloths may be placed  upon the
abdomen, or iced water  may  be allowed to
fall from a height of several  feet  upon the
abdomen.  Some have succeeded  by the injec-
tion of iced water into  the rectum or uterus.
It is well to remember all these methods, as
one may be at  hand, or  may  succeed when
others fail.
   When free hemorrhage occurs prior to the
delivery, it may depend upon the presence of
placenta prsevia, the  detachment of the pla-
centa from its position even when not praevia,
or the rupture of a large vessel, which may be
expected  in those cases where  varicose veins
are observed to be abundant on  the thighs, etc. 
64
obstetric procedure.
Here we have reason  to believe that the same
condition  exists within the labia and  vagina,
and some of these vessels may  be broken by
the efforts of the patient.
  Under  all circumstances,  when, from the
undilated condition of the  os, or from any
other reason, the  labor  cannot be  speedily
terminated,  the vagina may be plugged, which
will check the flow, and give time for reflec-
tion.    The best means for this  purpose is the
colpeurynter, which  is easy of introduction,
and may  be readily removed either entirely or
partially to permit of an  examination of the
parts.   It has the additional advantage of act-
ing as a dilator, and  thus  preparing the parts
for delivery.
   In the absence of this, rags may be  used  to
plug the  vagina, and if necessary, the first of
these may be saturated with some styptic.
   Of course the patient must be placed in the
horizontal  position, be kept cool  and  quiet.
Where  the hemorrhage is not very great, this
alone will often cause its cessation, at  least for
a time. 
HEMORRHAGE.
65
  The utmost  vigilance must be observed, lest
the hemorrhage should  suddenly recur, and
proceed to an  alarming  extent in the absence
of aid.  Here, with the colpeurynter at hand,
the physician, and even the attendants, when
properly  instructed in its  use, can speedily
check the flow.
  In all such cases, delivery must be looked to
for permanent relief.  When the os is in a con-
dition  proper  to permit  the  passage  of  the
child, the rupture of the membranes will gene-
rally  check  the hemorrhage, at least  to  a
great degree;  then, the  delivery may be ac-
complished by any of the appropriate means.
   When the placenta  is more or less before the
way, the hemorrhage  is  best controlled by in-
troducing  the  fingers, or  hand  if necessary,
and detaching completely that portion of the
placenta which is already  partially separated,
and from which the hemorrhage proceeds; the
membranes should next  be ruptured, and the
presenting part of the child comes  down and
forms  a  plug, which  checks the hemorrhage,
almost if not  entirely.   Time is now allowed
                     6* 
66          obstetric  procedure.
for the pains to deliver, or if necessary, this
may be done by the application of the forceps.
  In  all such cases, full and permanent con-
traction of the uterus should be insured by full
doses of ergot.
   In the absence of the forceps, the delivery
may be performed by turning. Nor is it neces-
sary to wait  until the os is fully dilated.  As
soon as the dilatation is  sufficient  to  permit
the passage  of the hand in order to reach the
feet, the effort should be made to reach  up and
bring down  one or both feet.
  A guarded prognosis relative to the child
should always be given, for, in the large major-
ity of cases, its death is certain.

               Convulsions.
  The limits of a work like the  present will
not admit of anything like a full exposition of
the causes for and the kinds of convulsions
liable  to  attack the  pregnant  or parturient
female. The author, merely wishing to prepare
the practitioner for the  emergencies  of the 
CONVULSIONS.
67
obstetric art,  will  content himself by  indi-
cating the  resources at command  under such
circumstances.
  Generally, the physician is not aware of the
approach of this  complication, until like a
clap of thunder  it  bursts upon the startled
attendants in the lying-in chamber.
  It  may  be anticipated when  the  patient
shows unusual symptoms  of drowsiness, head-
ache, interference in vision, noises in the head,
or even a marked and sudden change from her
natural amiability to  great irritability.  In
short, the physician  should view with anxiety
any unusual symptoms which suddenly occur,
and particularly  so, when  there  have been
previously  much swelling of the feet or hands,
and puffiness of the face.
  With  such a manifestation, a full dose  of
bromide of potassium  or of chloral, or both
combined, as circumstances may dictate, will
often mitigate these symptoms, and carry  the
patient with safety to the termination of  the
labor.
  When  a convulsion  does occur, at  once 
68
obstetric  procedure.
procure a cessation  of the attack by ether or
chloroform by inhalation.  At the same time,
enemata of chloral may  be  thrown  into the
rectum.  The spasm having been terminated,
prepare to deliver as speedily as possible.  The
bladder must be  evacuated if  necessary, by
the catheter, and  the rectum by stimulating
enemata, and if there  has been previous  con-
stipation, free purgation should be induced by
the appropriate remedies.  Perhaps the  best
article for  this  indication is  the croton oil,
which can  be placed upon  the  tongue, and
generally acts very promptly.
  Revulsives may  be  employed,  as cold affu-
sions  to the head, mustard-baths to  the feet
and limbs,  sinapisms  to  the  whole length of
the spine.  So soon as the patient  can swallow,
if there be  the slightest indication of  a return
of the spasm, give  full doses of chloral by the
mouth.   This is almost  a specific, and  rarely
fails to counteract the convulsive  tendency.
  The most profound  quiet  must be enforced.
Vaginal  examinations  should be made as 
CONVULSIONS.              69
seldom as possible,'unless the patient is under
the anaesthetic influence.
  As efforts to  produce  dilatation are  ex-
tremely liable to  reproduce the convulsions,
the use of the dilator is of doubtful propriety.
Doubtless, free venesection in appropriate cases
will prove of value, but  such  cases are more
rare than would be  supposed.   It  would  be
the  height  of absurdity to bleed  a patient
already suffering  from  anaemia.  This  could
only be justifiable in cases of plethora.
  The action of the anaesthetics, and especially
of  the  chloral, while  checking the spasms,
tends  to procure  full   dilatation,  and  the
moment that this has  occurred sufficiently to
permit  of the passage  of the  forceps,  that
aid  should  be invoked.   When the  breech
presents, or when for any reason the use of the
forceps may be inadmissible, the feet should be
brought down and the uterus emptied of  its
contents.
  This generally causes every untoward symp-
tom to disappear.  Should the reverse obtain, 
70
obstetric procedure.
continue the chloral and other remedies as
they may be indicated.
  During   the  convulsions,  care  should  be
taken to prevent the patient from injuring her
tongue, by the insertion  of  a cork  or  pad
between the teeth; and  by gentle restraint
she should  be  kept  upon the  bed, and  not
allowed to  suffer  injury by forcible contact of
her head  or limbs with any portions  of  the
couch.

           Artificial Respiration.
  Having delivered  the child, it becomes the
duty of the accoucheur to see that its  respira-
tion is  fully and  freely performed.   When
there seems a hesitancy in this act, the  child is
generally excited to a full inspiration by a sud-
den dash of cold water upon its body,  or by a
few vigorous slaps upon the buttocks, or by al-
ternately plunging it, first  into  a  warm then
into a cold bath.  In every case, the mouth and
throat should  first be thoroughly cleared  of
mucus or any other foreign body that may ob-
struct the air passages. 
ARTIFICIAL RESPIRATION.         71
  If the child  presents an  apoplectic appear-
ance, the umbilical cord should be cut and per-
mitted to bleed, at the same time rubbing  the
limbs to promote the circulation.
  In the hurry and excitement of the occasion,
the  physician should not forget this division
and  bleeding of the cord,  as instances have
repeatedly occurred where such  neglect has re-
sulted in the death of the child from a subse-
quent hemorrhage.   Therefore, he should, as
soon as possible, carefully tie the cord, even
though the  respiration and  circulation have
not been fully established.
  It is best  not to wait too long for success by
these methods, but at once put in execution,
artificial respiration.
   Several  methods  have  been' proposed by
which to imitate the natural play of the respi-
ratory muscles.   Perhaps the best is to place
the infant in a sitting posture, and catching it
by the arms, lift it up and set it down slowly
and deliberately, say fifteen to twenty times a
minute; as it is allowed to come down, the arms
should  be brought  down and  pressed firmly 
72          OBSTETRIC  PROCEDURE.
against its sides.   This imitates the alternate
elevation and depression of the ribs, and tends
to cause the expansion of the lungs and the
consequent entrance of the  air, and its subse-
quent expulsion.
  Nothing, however, can be so effectual as the
" mouth to mouth method."   The infant hav-
ing been prepared as previously indicated, the
physician  places his mouth to that of the child
and forces  the  air directly into  its lungs; the
child's nose being held  to prevent the escape
of the air by that channel.  The chest is  then
pressed on each side  to expel the air, and these
movements are continued alternately, until the
child breathes  naturally.  This  plan is more
sure to overcome the  atelectasis,  and compel
the lungs to perform their office.
  As artificial respiration has been repeatedly
known to  succeed even after a long time has
elapsed  prior to  the child's  showing signs of
life, these  efforts should not  be too readily in-
termitted, and  particularly, so long as there is
present  any  evidence  of the heart's action.
While these efforts are being  made,  the child 
ARTIFICIAL RESPIRATION.        73
should be kept warm, and in some cases good
results have  followed  the  use of  stimulating
injections into the rectum.
  When there is reason to apprehend the pres-
ence  of  foreign  bodies  in  the air passages,
which will interfere with the respiration, these
may be removed by the insertion of a catheter
into the trachea, through  which these  bodies
may be drawn by suction.   The catheter may
also be employed  as an additional means to in-
sure the entrance of the air into  the lungs, and
the irritation  caused  by its presence often ex-
cites spasmodic attempts at inspiration.  Never
cease these efforts while the slightest evidence
of life is present, nor under any circumstances,
for  at least one hour.
  The author would take this opportunity to
caution the physician against too readily giving
a certificate that the child has been born dead.
He should remember that no child is born dead,
even though it has never  breathed, if there is
the  slightest evidence of life present.    More
particularly would this  hold good  when  the
heart's action is shown  by pulsation in the cord
       7 
74
OBSTETRIC PROCEDURE.
however feeble, and, a fortiori, when  the heart
or large vessels are felt to pulsate.
  Several instances have occurred where heir-
ship has been decided in accordance  with the
above.*

           Breech Presentations.
  Perhaps no complication of-labor is so terri-
fying to the young obstetrician, and, it may be
added, also to very many who can no  longer
be classed as  tyros in the art, than those where
the delivery of the head occurs after that of
the body.  The  reasons  for  this dread need
scarcely be discussed.  Generally, the delivery
is greatly  retarded;  then the probability of
the death of the child  adds much to the dis-
comfort of the accoucheur, who  early  recog-
nizes the  dangers, while he is not always able
to apply a remedy.
  Here, as in all other forms of labor, the gen-
eral principles, as before mentioned, apply with

  * See " Evidence of Life in the Newly-delivered Child,"
by the author. 
BREECH PRESENTATIONS.
75
still greater force.  When the labor has fully
commenced, the  physician  should remember
that he  has not the  advantage of the firm
wedge, as in a head presentation, to aid in the
dilatation of the os uteri; hence, he may very
properly  and profitably call to his aid the in-
valuable  chloral, which always acts so benefi-
cently in  procuring the  relaxation  of the
circular  fibres  of the  mouth of  the womb.
Especial  care should be had, not by any inad-
vertence to  prematurely  rupture  the mem-
branes, as  thus  is lost  one great  aid in  pro-
moting  the full dilatation, while  the child is
exposed  to greater  danger by reason of the
compression of the  cord  and the  almost cer-
tain cutting off" of its blood supply.
  But, when the rupture has occurred, every
effort must at  once be  made  to promote a
speedy termination  of  the delivery.   Still, let
nothing  be done hastily or without  due  con-
sideration.  Should  the breech  descend with-
out delay, all is well, no interference is called
for; but when  the descent is  delayed, it is
justifiable  and proper  for the accoucheur  to 
76          OBSTETRIC PROCEDURE.
bring down one leg, which  almost  invariably
will, by this much reducing the volume occu-
pying the  outlet, enable the delivery to go on
more rapidly.  The labor is  also now more at
the will of the  accoucheur, who can employ
traction as it becomes necessary.
  The condition of the child must be  the
index for the action of the physician.  When
he perceives that its life is endangered by fur-
ther delay, he may aid the descent of the body
by traction upon the leg, or by the application
of the blunt hook in the groin, at the same
time,  having compression made  above upon
the parietes of the abdomen  so as to give an
additional impetus to the downward progress.
Of course, as the child comes  down, the pres-
sure upon  the cord  becomes  more complete,
and it is best  to draw down a portion of the
cord,  and  thus  remove this  pressure to  a
certain  extent.  If  possible,  the  loop  thus
drawn down should be caused  to locate itself
in that  portion  of the  outlet which will be
most likely to secure  it from  pressure.  This
loop also serves as a  means to constantly test 
BREECH PRESENTATIONS.         77
the condition of the  foetal circulation.  In a
number of  instances, the forceps have  been
applied to the breech, and gentle traction has
thus been  made.  Still, this is a means from
which  but  little can be anticipated, and  if
unskilfully  employed would  be capable   of
resulting in great injury to the delicate  bony
structure of the foetal pelvis.
  In the absence of  the blunt hook, or some-
times  preferably, recourse may  be  had to a
fillet or band passed  over the  bend of the leg
at the groin, by which the proper amount  of
traction may be made.  Occasionally, the diffi-
culty of passing  such a band necessitates the
use of  a gum catheter or bougie, or the little
instrument with an eye on the  end of a watch
spring often employed for plugging the poste-
rior nares in cases of epistaxis.
  As the body is brought down, it must be re-
membered  that  the  arms are very liable  to
slip up alongside the head, and  thus greatly
add to the complication.   One or more fingers
may be passed up, and the  arms successively
hooked and  brought down, taking  care  to
                     7* 
78         OBSTETRIC PROCEDURE.
sweep them across the body and thus obviate
the danger of their fracture.
  The  body having been  delivered,  the final
difficulty is with the head. Too often, by rea-
son of incautious haste in bringine: down the
body, the chin has been caused to depart from
the sternum, and the head is thus placed  in
the most unfavorable condition for  its passage.
This should be  an additional reason for care
in the efforts made to hasten the birth.
  Of course, the physician now recognizes the
fact that  every  moment's delay adds  to the
probability of the  death  of  the infant.  He
should at once pass one or more fingers up to
the child's mouth and endeavor to  hook down
the chin and with it the face so  as to cause
the head  to resume  its  proper position for
delivery.  While  this is being done,  he is
making firm traction upon the body and being
aided above by abdominal compression.
  This abdominal pressure serves an additional
purpose, as very frequently, in breech presenta-
tions, the  uterus is left in  a relaxed condition, 
         NOURISHMENT OF THE CHILD.       79
and the  delivery is liable  to be followed  by
flooding.
  When the delivery is not  accomplished  by
these means, the use of the forceps is indicated.
This is performed by bending the body of the
child  up over  the  maternal  abdomen,  and
applying the blades as usual.

        Nourishment of the Child.
  The proper nourishment of the child in its
first days  of extra-uterine life demauds  the
special attention of the physician.  As soon as
the mother is rested from  her fatigue, say in
three, four, or five hours,  according to the at-
tending circumstances in each case, the infant
should be put to the breast.   Unfortunately, in
too many instances, some  officious  attendant
has already  administered  sugar, or  molasses
and  water, catnip tea, or some one of the nu-
merous  abominations of the  lying-in chamber,
and the child, surfeited or sick, is illy prepared
to make the proper efforts  to grasp the nipple,
and exert its powers of suction. This is con- 
80          OBSTETRIC  PROCEDURE.
trary to the teachings of nature, and should be
strictly prohibited.
  Rigby remarks that " it is a general practice
not to  apply the child to the breast until the
second or third day, upon the plea that there is
no  milk; a more erroneous and mischievous
plan of treatment could not be devised, for it
is  a fruitful source of  much injury as well as
suffering both to  the mother  and  her  child.
The child should be put to  the breast whether
there be  signs of milk  or not."
  Before leaving  his patient, it is the duty of
the physician to caution her and her attend-
ants against pursuing  any such course, and to
explain to them carefully  and  fully  the rea-
sons and the necessity  for the early application
of the  child to  its mother's breast.  Much of
its  future  indigestions, its colics  and  diar-
rhoeas, its sleepless nights and  whining days,
depend upon the  actions of its  care-takers in
its  early hours of life.  Nature  intended the
mother's milk and nothing  else as the food for
the infant, and  when  the  necessity does arise
for any  other  mode  of  nourishment,  it  is 
NOURISHMENT OF THE CHILD.       81
always to  be regretted, and will in the vast
number of cases result in  ill-health  and early
death.
  Another, and a great advantage obtained by
attention  to  this point, is that an early secre-
tion of milk is thus made probable, and there
is less liability to trouble with  the nipples.
At this time, when the breasts are flaccid, the
nipple is more easily  drawn out and prepared
for the office  it  has to perform.  Whereas,
when from any cause, the  child is  kept from
the breast until later, the distension is great,
the nipple  is retracted, and  suction is difficult,
and the child, meeting with  these obstacles,
quickly becomes discouraged and can with dif-
ficulty be induced to continue  its efforts.  Or,
by  the vigor  of  its  attempts to obtain  the
needed supply, the nipples become excoriated,
and thus an additional trouble is produced.   A
point that may be made an efficient aid with
the nurse, etc., is the fact  that the first milk is
of a peculiar nature, prepared especially to act
as a purgative to the child, and thus cleanse the 
82          OBSTETRIC PROCEDURE.
alimentary canal of the tarry  matters occupy-
ing it.
  This  again obviates a resort  to  castor oil
and  other  dosings so habitually  exhibited to
the infant at this time.   In this connection, it
would be well to remember that the proper
charge should be given to the  nurse  or other
attendants, as to the  avoidance of all medica-
ments, except by the advice of the physician.
  Of course, as in everything  connected with
the  parturition, due discrimination  must be
made; as,  where the nipples  are already in a
tender condition, it would be well to  postpone
the efforts at suction  until the  lacteal secretion
has really commenced and flows readily.
  Prof. Barker regards  the early application
of the child to the  breast as an  important
prophylactic measure against milk-fever.

             Retracted Nipple.
  Should the nipple  be so drawn in  that the
child is unable to grasp  it, or  can only do so
with great difficulty, the pipe should be em- 
I
NOURISHMENT OF THE WOMAN.      83
ployed to cause its elongation.  In the absence
of other means, a common clay pipe  may be
used, or even  a bottle  previously exhausted
of its air by any of the usual methods may be
applied.  The areolae  should be well anointed
prior to these applications, with lard or sweet
oil.

       Nourishment of the Woman.
  It is gratifying to  chronicle the fact that a
great change has been observed relative to the
nourishment of the female after her accouche-
ment.  It was formerly regarded as dangerous
to-allow her anything but the lightest diet,
and even yet there is  too much of that system-
atic process of starvation.  Already exhausted
by her efforts, loss of  sleep,  and loss of blood,
she rather  demands a full  diet—at least, one
which will enable her most readily to recupe-
rate  her forces.   A woman  should  not be
starved because she  has had  a baby.  Long
experience in this matter has shown  the bene-
fits to be derived from the proper nourishment
of the lying-in woman, and  the injury result-
ing from an opposite course. 
84         OBSTETRIC PROCEDURE.
  Parturition, other things being equal, is a
natural physiological  process.   Hence  there
exists no sound reason why  the woman who
has just  been  delivered should  be starved or
half dieted on water-gruel, or weak tea and
dry toast, for  days, and then gradually, even
fearfully, be permitted  to return to her usual
regimen.  On the contrary, the reverse obtains,
she requires nourishment.  Even in a perfectly
normal labor, there is more  or less exhaustion,
loss of blood and of nerve force, and generally,
she craves food, her system demands  it, and
her digestive  organs  are prepared  to accept
and assimilate it, in order  to make  good the
loss she may have undergone.   Let  her then
have  nutritious, easily digested food,  and in
sufficient quantity.  Perhaps the  earliest ob-
stetrician to take this common sense  view was
Den man, who  immediately adopted for the
woman a diet similar  in all respects to that
used by her previous to delivery.
  Leishman says:  "The old method of treat-
ment by starvation during  the first  few  days,
when the  diet  was confined  to  tea,  water 
        NOURISHMENT OF THE  WOMAN.      85
gruel, or arrowroot, finds few, if any, support-
ers  at the  present  time.   Nothing  indeed
could be more irrational than such treatment,
or more likely  to retard  recovery and dis-
courage the lacteal secretions, so that it will be
quite proper after the first  day, at least in the
great majority of instances in which  the pa-
tient has had some sleep, to give chicken soup
or beef tea, in addition to dry toast, gruel, or
arrowroot and sago, which are properly given
at this stage as being substances easy of diges-
tion."
  Schroeder says: " Immediately after deliv-
ery there is little or no appetite, and therefore,
broths, soups, an egg and  some bread are suf-
ficient.  As a beverage, milk is to be recom-
mended.  If the woman, however,  should have
an appetite, she may have sufficient meat, and
on the following days also some vegetables."
  Prof. Barker says:  " The  theory  that a
puerperal woman is in an inflammatory condi-
tion, or in a state predisposed to inflammation,
has in a great measure governed the profession,
and has been inculcated by most of the obstet-
       8 
86          OBSTETRIC PROCEDURE.
ric  authorities  from  Celsus  down  to  the
present time.  They have consequently taught
that a puerperal woman  should be  restricted
to what was termed  an antiphlogistic diet. .  .
At the present time a change of practice more
in accordance with sound physiology, reason-
ing,  and  good sense  is rapidly taking place.  .
.  . Is not the theory a strange -one  that  the
organs connected  with  parturition will  be
more rapidly restored to  their condition prior
to conception; that the metamorphosis of tis-
sue, called involution, will be more easily and
effectually  accomplished, and  that  the new
function of lactation will be more surely and
perfectly established by depriving the system
of its accustomed alimentation ?"   He contin-
ues:   "I cannot doubt that in all ages there
must have been some whose practice was gov-
erned by a sound intuitive judgment  and good
sense, and who have therefore freed themselves
from the fetters of professional tradition, and
followed a rule similar to that inculcated  by
Denman.  I should say in general terms, give
the puerperal woman as good  nutritious food 
        NOURISHMENT OF THE WOMAN.      87
as she has an appetite  for and  can easily di-
gest and  assimilate.   You will at first find
many nurses who will not  accept these views,
and they may fail to fully carry out your di-
rections in this particular ; but  my experience
has been that after a time the  intelligent ones
become enthusiastic  converts to  this course.
The woman, exhausted by labor, first needs rest.
This gained, as soon as she shows any desire
for food, give that which is most acceptable to
her, and which will best sustain her, a cup of
good  clear beef soup, or of chicken or  mutton
broth.  There  are those whose instincts and
habits lead them to prefer a cup of tea,  or
gruel, or panada.  Very well, only insist that
they take enough, then, as  soon as the appetite
will permit, guided only by this and the gen-
eral condition of the woman, and  not  by the
question of time, whether  it be the third  or
the ninth day, gradually  give  solid  food, as
birds, poultry, tenderloin of beef, or a mutton
chop.  ... By following this course of regi-
men, I believe you will find that your patients
rest and sleep better, and  their functions are 
88          OBSTETRIC PROCEDURE.
established  with less  disturbance than they
would be with a spare or  insufficient diet. . .
The function of lactation  is  thus  generally-
established without  that  disturbance  of  the
system which was called  milk-fever, and was
formerly so common.   It is certainly more in
accordance with  sound physiological  principles
to feed puerperal women upon easily digestible
nutritive  articles, than  to administer that
which contains  but little nourishment and a
larger amount of indigestible residue.  There
are many puerperal diseases mainly  due to ex-
haustion and  inanition.  In short, I will  say
that I*have seen much suffering and  many dis-
eases  in  puerperal women, where one  of  the
chief  elements was defective nutrition ; but I
have  never  seen the slightest evil result from
good, ample, judicious alimentation."
  The value of milk as an article of diet  for
the nursing  woman  has  been most forcibly
shown by the experience  of  Dr. Robert P.
Harris of Philadelphia, as detailed in a paper
published by him in  the   Amer.  Journ. of
Obstet., vol.  ii.  p.  675. This  article  of food 
        NOURISHMENT OF THE WOMAN.      89
should be in addition to  her other  diet, and
partaken  of  in  small quantities frequently
repeated.  Chocolate, cacao, and  broma made
with  a large proportion of 'milk  generally
prove  of  great  value  in similar cases,  and
should  always  be  employed  prior to  the
abandonment of all  efforts on the part of the
mother to nurse her infant.
 
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