SECTION IV.

Transcriber's Note: Italic text is denoted by _underscores_ and bold

text by =equal signs=.

[Illustration:

And Adam knew Eve his wife,

and she conceived, and bare Cain.

_Chapter IV_ GENESIS. _1st verse_]

THE

MATRON'S MANUAL

OF

MIDWIFERY,

AND THE

DISEASES OF WOMEN DURING PREGNANCY

AND IN

CHILDBED,

BEING A FAMILIAR AND PRACTICAL TREATISE, MORE

ESPECIALLY INTENDED FOR THE INSTRUCTION OF

FEMALES THEMSELVES, BUT ADAPTED ALSO

FOR POPULAR USE AMONG STUDENTS

AND PRACTITIONERS OF MEDICINE.

By FREDERICK HOLLICK, M. D.,

LECTURER ON PHYSIOLOGY AND FEMALE DISEASES,--AND

AUTHOR OF THE DISEASES OF WOMAN,--OUTLINES

OF ANATOMY AND PHYSIOLOGY

FOR POPULAR USE,--NEUROPATHY,--AND

THE ORIGIN OF LIFE.

ILLUSTRATED BY OVER 50 SPLENDID ENGRAVINGS.

NEW YORK:

PUBLISHED BY T. W. STRONG,

NO. 98 NASSAU STREET.

BOSTON:--NO. 64 CORNHILL.

1849.

Entered according to Act of Congress, in the year 1848,

By FREDERICK HOLLICK, M. D.,

in the Clerk's office of the District Court of the United States for the

Southern District of New York.

The price of this Book is One Dollar.--It may be obtained of all

Booksellers, or of T. W. STRONG, 98 Nassau-st., N. Y., who will also

send it by Post to any part of the country, on receiving One Dollar

and the Address.--N. B. All Dr. Hollick's other Books will be sent by

T. W. Strong in the same way.

PREFACE.

A short time ago I published a popular treatise on _The Diseases of

Woman_, in the non pregnant state, and in that work I announced my

intention of shortly publishing a similar one on _Pregnancy and its

diseases_. This book is the fulfilment of that promise.

Being the first _popular_, and yet strictly _scientific_ and

_practical_ book on Midwifery ever published, its preparation has

necessarily been a work of great labour and difficulty. Everything

had to be simplified; familiar explanations had to be given of

complicated processes, and illustrations had to be designed that could

be understood by my readers. Little or no assistance could be obtained

from other works on the subject, because they were either designed for

professional men; and therefore too technical, or else were too general

in their explanations, and too unsystematical, to be of any practical

use. I therefore had to write every part afresh myself, and plan a new

arrangement; and so difficult was this to do, satisfactorily, that I

have _twice before_ completed the whole work, and then commenced at the

beginning again, before I was satisfied with my own production.

As it now stands, I trust this treatise answers the purposes for

which it was intended. I have taken care to make it so complete, and

scientific, that a medical student may take it for his text book; and

at the same time I have endeavoured to so simplify it that any female,

of ordinary capacity, can fully understand both its explanations and

practical directions. All purely technical words have been avoided, or,

when absolutely necessary, they have been carefully explained. Every

topic connected with the main subjects has been discussed, and the

latest information given on every point, and from every source.

Such a work as this has long been needed. Females have been kept in

shameful ignorance, of everything connected with their own systems, and

of the wonderful phenomena in which they play so important a part. That

ignorance has led to untold evils, which can never be corrected till

they become more enlightened respecting themselves. Fortunately many

of them begin to see this, and they request, in behalf of themselves

and their sisters, that such knowledge be no longer withheld. I have

been now, for a long time, engaged in this pleasing task of female

instruction, both by my Lectures and books, and in my daily communion

with them as patients; I am therefore aware both of their great lack of

proper information, and of their strong desire for it, and I flatter

myself I also know, from experience and careful observation, the

best mode of imparting it to them. In fact, I have made it a matter

of careful study, not only to render my subject _plain_, but also

_pleasing_ and _unobjectionable_; so that the most unreflecting shall

feel an interest in it, and the most sensitive be able to study it

without pain or repugnance.

The object of this book is not to make _every_ woman a professional

Midwife, nor to induce her to dispense with proper assistance in her

hour of difficulty, but simply to explain to her the nature and manner

of child-birth, and the means by which she is to be assisted. This will

disabuse her mind of many pernicious errors--make her more patient

under her unavoidable difficulties and pains--more docile to what is

required of her, since she will see the _reason_ for it--and it will

also enable her to avoid much positive suffering, and to render great

help, in many cases, to her attendant.--In a case of emergency also,

when other assistance cannot be procured time enough, or not at all,

it will teach one female how to assist another in delivery, which

every one of them ought to be able to do. Very often it happens that a

case of this kind occurs, and the Females around, instead of knowing

how to help the sufferer, are utterly useless, and even make her

worse by their evident terror and ignorance. I have known women _die_

in child-bed, for want of the most trivial assistance, which even a

child could understand how to give, though there were elderly females,

mothers themselves, around her; but they knew not what to do. Such a

state of things is disgraceful to the boasted intelligence of the age,

and should be remedied as speedily as possible. Every Adult female, or

at least every married one, should be instructed in these things, so

that she may know how to regulate her own conduct and how to render

useful assistance to others in case of need. Ill informed women are

generally as apprehensive of danger as they are incapable of avoiding

it; and as regardless of proper advice as they are ignorant of the

reason for it.

The time, I trust, is fast coming, when every female will be taught,

as of paramount importance, everything which concerns her own welfare;

and when ignorance will no longer be considered necessary to propriety

and virtue, nor useful knowledge incompatible with the most refined

delicacy and the strictest morality. I consider it my duty to assist

in hastening that time, and I feel much pleased that my previous

efforts have been so much commended. This book I hope will be equally

acceptable, and, if possible, more useful, than those which have

preceded it.

F. HOLLICK, M. D.,

New York

INTRODUCTION.

Parturition, or the expulsion of the perfectly formed human being from

the body of its mother, is a most wonderful natural function, for

the complete and safe performance of which at the proper time, every

requisite is found to exist. Notwithstanding the contrary experience

of society, as it now exists, it is well known that extreme suffering,

and danger to life, are not necessary nor even probable accompaniments

to child-birth; for it is invariably found, when females live under

circumstances favourable to their full physical development and health,

that it occurs speedily, and with little or no difficulty or pain.

Numerous proofs of this could be given in accounts of the Indians, and

other uncivilized females, among whom parturition is regarded as an

ordinary occurrence, for which no preparation need be made, and about

which no apprehension need be felt; such facts, however, are so well

known that they only need be referred to here.

As the organization and requirements of society changes, by the

adoption of what is called civilization, the condition of woman becomes

very different to what it was originally. In many respects her lot

is much meliorated, and she has great reason to be pleased with the

change, but in other respects she has not been so fortunate.

One great evil resulting from her altered position is, a neglect of

proper physical education while young, and of the various requirements

for bodily health in after life. In consequence of which she becomes

constitutionally weaker, and more sensitive to various injurious

influences, which she possesses diminished powers to withstand.

This evil increases in proportion as civilization advances, until

at last females become so imperfectly organized, and so enervated,

that they are utterly unable to fulfil the duties assigned them, and

they either die prematurely, or pass their whole lives in suffering

and complaint. So universally is this the case at the present time,

particularly in cities, that the exempt are very rare exceptions

to a rule most lamentably general. Unfortunately, custom and false

notions have given this melancholy state the stamp of propriety, and

thrown around it the charm of fashion. The suffering invalid is called

_interesting_, and the pale faced debilitated creature, scarcely able

to crawl about, is styled _genteel_, while robust health and physical

capability is termed _coarseness_ and _vulgarity_. So infatuated,

and weak minded, have females been made on this point, that I have

actually known some of them quite chagrined because people could see

they were well and strong; and I have known others quite alarmed for

fear that they should _look_ so. A short time ago I knew a lady who,

by the adoption of a proper course of training and treatment, passed

through her confinement so quickly, and with so little exhaustion,

that she was up and travelling about in three days after, not only

without inconvenience but with pleasure and advantage. But what was

the impression made on her female friends by such a speedy recovery?

did they feel quite pleased at it, and desirous that all others should

be equally fortunate? No; but quite the contrary! She was actually

thought deserving of _reprehension_, and was stigmatized as _vulgar_ in

the extreme. One person even made the remark, that she must be _a very

common person, and no Lady_! Now what a pitiable state of ignorance,

and mental imbecility, these females must be in, to be actually _proud

of their infirmities_; and yet they are but like the majority of

their sex. If they were not so _unfortunate_ in not knowing their true

interests, they would be highly culpable, but as it is they are truly

deserving of our pity.

It must be admitted, however, that though civilization has, so far,

entailed these evils on women, it has also done much to alleviate them.

Many diseases are beneficially modified, and some are even _cured_, by

medical treatment; surgical science has also attained a high point of

perfection; and the difficulties attendant on child birth are overcome

to a great extent by obstetrical skill. But notwithstanding all this

alleviation, these evils are still deplorably great. The utmost

scientific skill to which society can ever attain, will do but little

towards effectually relieving human suffering, and removing disease,

so long as it is entirely devoted to the mere art of _curing_ and

_palliating_ as it chiefly is now. Our knowledge of the human system,

and of the causes which produce in it disease and deterioration, must

be universally disseminated, so that the whole people may see _how

these evils arise_, and how they should live, and conduct themselves,

so as to _avoid them altogether!_ or, in other words, science should

teach us how to _prevent_ disease and suffering, instead of merely how

to alleviate them. Eventually this will be done, and our females will

then pass through their travail as easily as their savage sisters do

now. Let us hope that time will soon come; and let every one esteem it

his duty, who possesses the ability, to hasten its coming, by doing all

he can to spread the necessary information to those who need it.

The happy exemption from difficulty and suffering which females enjoy

in more uncultivated states of society, and which we believe they will

ultimately enjoy universally, does not however obviate the necessity

for assistance _now_, in our state of society, and we have therefore to

explain how it can best be rendered.

It has often been a matter of dispute, both with medical men and with

moralists, whether _Men_ or _Women_ ought to assist in child-birth.

The discussion has called forth a great deal of declamation, but very

little has been said to the point on either side. It appears to me,

however, that the question may be very easily settled, if it be rightly

considered. The first requisite, and the most indispensable, in those

who are to assist in child birth is, that they should _know how to

assist_. This is paramount to every thing else. Now, if females really

did know what to do in such cases, and were fully competent to do it,

I think there is no question but they would be the _best_ assistants,

to say nothing of their being the most _proper_. There are many

things experienced by females in such situations, which can never be

understood by a man at all, though they are readily appreciated by one

of their own sex, particularly if she has been a mother herself. With

each other also there would be less disposition and less occasion for

reserve in delicate communications, and less repugnance to necessary

examination or manipulation, which could therefore be more efficiently

practised. In short, if women were undoubtedly equally competent with

men in this art, and full confidence was felt in them by their own sex,

I think it is evident they would, in every respect, be the most fitting

practitioners, and I have no doubt but they would be preferred. The

question simply arises then, whether they are so competent? And every

one able to judge, who speaks honestly, must admit that very few, if

any of them really are so. It has not been possible for them to acquire

the requisite information, nor to pursue the necessary investigations,

and therefore we cannot expect that they can be equal to those who

have. There are some women I know, who have been careful observers,

and who have had great experience, that can render all needful help _in

most cases_, but even they are apt to meet with difficulties, which

require more skill than they possess to overcome; therefore very few

like to depend upon them altogether. It is naturally argued that, as a

physician _may_ be needed, it is better to have him at first, and so be

ready for every contingency.

That females can make competent _Accoucheurs_ is proved by numerous

well known instances, among which I need only refer to MADAME

BOIVIN, and MADAME LACHAPELLE, both of whom, as practitioners and as

authors, stand in the very highest rank. These ladies are referred

to as authorities, and their works are quoted by the most eminent

Professors of the day; in fact, on many points, they have surpassed all

competitors. Further on in our work we shall have occasion to refer to

their labours, the value of which will then be seen.

It is therefore evident that females can officiate, if they are

properly instructed, which I think they ought to be, independent of the

reasons already given. That they will eventually be competent I have no

doubt, and I am proud to throw my mite of instruction in their way to

assist in making them so.

In regard to the alledged _immorality_ resulting from the present

system of men acting as Midwives, there is much exaggeration, and

much unnecessary alarm. That it is, in some respects, indelicate, and

only to be justified by necessity is true, but there is no foundation

for saying, as some do, that it leads to wide spread Profligacy

and Adultery. I should prefer to see females always able to assist

each other; but I cannot nevertheless consider the present system a

necessary cause of licentiousness.

That females were always depended upon in old times, and are now in

certain rude communities, is true, but that is no reason why they

should be depended upon under all circumstances. In our present

highly artificial state there are numerous causes at work, and

numerous difficulties experienced, unknown to more primitive times and

conditions, and we therefore require greater skill and more extensive

resources. Females have in fact become more in want of help, and less

able to assist.

At what time, and in what country, men first began to assist in cases

of labour is not recorded. They have done so however for a long time,

much longer than most people suppose. In the time of _Hippocrates_,

called the Father of Medicine, who lived _more than four hundred years

before Christ_, it appears that physicians were commonly resorted to.

In his writings we find cases described, which show that he was well

acquainted with the process of parturition, and even with some of the

most difficult operations now practised. The Israelites appear to have

employed women, as most eastern nations in fact do at the present day.

Midwifery, however, did not attract much attention, nor make much

progress, till about the middle of the sixteenth century, since when

it has been studied and practised by the most eminent Physicians and

Surgeons, and has arrived at great perfection.

Many new discoveries have been made lately, which enable us to

facilitate delivery and ease its pains, so that it is now robbed of

many of its former terrors and dangers. Some of these discoveries are

of easy application, and promise much future good; I shall carefully

describe them all, in the following pages.

F. H.

ILLUSTRATIONS.

FRONTISPIECE, Eve in the Garden of Eden.

PLATE I.--Lateral Section, of the Female Pelvis, to show the position

of the Organs in their natural state, 5. PLATE II.--Front View of the

Female Pelvis, with the External Walls removed, 9. PLATE III.--The

Uterus and its Appendages, 13. PLATE IV.--Vertical Section of the

Womb and Vagina, natural size, 18. PLATE V.--The Muscular Fibres

of the Womb, 23. PLATE VI.--Muscular Fibres of the Womb, 27. PLATE

VII.--Bones of the Pelvis, 33. PLATE VII.-_a._--Male Pelvis, to show

the difference in structure, 35. PLATE VIII.--Section of the Pelvis,

37. PLATE IX.--Diameters of the Upper Strait, 41. PLATE X.--The

Bones of the Pelvis viewed from below, 45. PLATE XI.--The Direction

of the Pelvis, 49. PLATE XII.--Section of the Uterus, with the Ovum

and appendages, at about one month, 65. PLATE XII.-_a._--Female

Breast, 77. PLATE XIII.--Breast about the Fourth Month, 90. PLATE

XIV.--Womb, at about the third, seventh and ninth months, 99. PLATE

XV.--Primipara, or the First Pregnancy.--Woman who has borne children

before, 101. PLATE XVI.--Mode of performing the Ballotment, to detect

Pregnancy, 107. PLATE XVII.--At the end of the Fifth Month, 111. PLATE

XVIII.--The neck of the Womb in a first pregnancy, and in a female

who has borne children before, at the end of the seventh month, 116.

PLATE XIX.--Fœtus in the most usual position, 121. PLATE XX.--Fœtus

in the next most frequent position, 125. PLATE XXI.--Presentation of

the Pelvis, or breech, 129. PLATE XXII.--The position of Twins, as

most usually observed, 133. PLATE XXIII.--End of the Ninth Month,

135. PLATE XXIV.--The Fœtal head, 147. PLATE XXV.--Diameters of the

Head, 151. PLATE XXVI.--Attitude of the Fœtus, 153. PLATE XXVII.--Head

just entering the upper strait, 173. PLATE XXVIII.--Head lower in

the Pelvis, 177. PLATE XXIX.--Head beginning to Rotate, 181. PLATE

XXX.--Rotation of the Head, 183. PLATE XXXI.--Head in the _right_

anterior occipito iliac position, 187. PLATE XXXII.--Delivery in a

breech presentation, 194. PLATE XXXIII.--Anterior posterior position of

the head, 195. PLATE XXXIV.--The chin just passed in presentation of

the face, 200. PLATE XXXV.--Presentation of right shoulder, 205. PLATE

XXXVI.--Descent of shoulder, 206. PLATE XXXVII.--Descent of shoulder,

207. PLATE XXXVIII.--Trunk descended, 208. PLATE XXXVIII.-_a._--State

of the parts at beginning of labor, 215. PLATE XXXIX.--Manner of

supporting the perineum, 233. PLATE XL.--Standard form of Pelvis,

271. PLATE XLI.--Masculine Pelvis, 271. PLATES XLII, XLIII, XLIV,

XLV.--Deformed Pelves, 275-279. PLATE XLVI.--Head fixed in a narrow

pelvis, 282. PLATE XLVII.--Case of Tumor, 289. PLATE XLVIII.--Case

of Polypus, 293. PLATE XLIX.--Limbs cut off by the Cord, 301. PLATE

L.--Forceps, 346. PLATE LI.--Head extracted by Forceps, 353.

TABLE OF CONTENTS.

PART I.--MIDWIFERY.

Section I.

POSITION AND USES OF THE FEMALE ORGANS.

_Page_

CHAPTER I.--Position of the Organs and Parts, 13

Internal Organs, 14

External Organs, 16

CHAPTER II.--Structure of the Principal Organs and Parts, 18

The Womb, 19

The Vagina.--Vulva.--Perineum, 29

The Pelvis, 30

CHAPTER III.--Functions of the Principal Female Organs, 50

The Womb, 50

The Ovaries.--Menstruation, 51

Conception, 54

CHAPTER IV.--Fœtal Development, 57

Fœtal Nutrition, 67

Peculiarities of the Fœtal Circulation, 70

The Breast, 74

Section II.

SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT; ITS DURATION,

AND THE PERIOD AT WHICH THE FŒTUS CAN LIVE.

CHAPTER V.--Presumptive Signs, 83

Probable Signs, 94

CHAPTER VI.--Duration of Pregnancy, 137

CHAPTER VII.--Period when the Child can live, 142

Section III.

THE FORM, SIZE AND POSITION OF THE FŒTUS, AND ITS APPENDAGES, AT

FULL TERM.

CHAPTER VIII.--Form and Size of the Body, 144

Size and Form of the Head, 144

Attitude of the Fœtus at Full term, 152

CHAPTER IX.--The Appendages of the Fœtus at term, 155

CHAPTER IX.--The Membranes, 155

The Placenta, 156

The Umbilical Cord, 157

Section IV.

THE MECHANISM OF DELIVERY IN ALL THE DIFFERENT PRESENTATIONS

AND POSITIONS OF THE FŒTUS.

CHAPTER X.--Presentations, 160

Positions, 161

Mode of ascertaining the Presentation and

Position, 164

CHAPTER XI.--The Mechanism of Delivery, in a Presentation

of the Head, 170

The Left Anterior Occipito Iliac Position, 170

Mechanism of Delivery in all other Positions

of the Head, 185

General Remarks on the Different Positions

of the Head, 189

CHAPTER XII.--Mechanism of Delivery in Presentations of

the Lower Extremities, 191

Delivery in a Breech Presentation in the left

Anterior Sacro-Iliac Position, 192

Delivery by the Breech in the Right Posterior

Sacro Iliac Position, 196

Delivery by the Breech in the Full Posterior,

or Sacro Sacral Position, 196

General Remarks on the Presentation of the

Lower Extremities, 197

CHAPTER XIII.--Mechanism of Delivery in Presentations of

the Face, 199

Delivery in the Right Posterior Mento Iliac

Position of the Face, 199

Delivery in other positions of the face, 200

CHAPTER XIV.--Mechanism of Delivery in Presentations of

the Trunk, 203

Mechanism of Delivery in Presentations of

the Trunk by Spontaneous Evolution, 204

Section V.

THE PHYSIOLOGY OF SPONTANEOUS DELIVERY, OR CHILDBIRTH, AND THE

MANNER OF CONDUCTING A NATURAL LABOR.

CHAPTER XV.--Of Delivery in General.--Different Kinds of

Delivery.--Causes of Labor, 211

Signs of Delivery, 212

CHAPTER XVI.--The Progress, Phenomena, and Duration of

Natural Labor.--First Period, 214

Second Period, 216

Duration of Natural Labor, 220

CHAPTER XVII.--The Conduct or Management of a Natural

Labor.--Preliminary Requisites, 222

Preliminary Proceedings, 223

Preparations for the Delivery, 226

Attendance after the Preparations are made,

and during the Delivery, 229

CHAPTER XVII.--Delivery of the After Birth, or Placenta and

Membranes, 239

Attentions to the Female after the Delivery

of the After Birth, 242

Attentions to the Child, 243

Accidents which may happen, 246

Subsequent Attentions to Mother and Child, 249

Concluding Remarks, 255

Section VI.

PROTRACTED AND DIFFICULT LABORS.

CHAPTER XVIII.--The Causes and Consequences of Prolonged

Labor to both Mother and Child, 259

The Consequences of Prolonged Labor, 259

CHAPTER XIX.--Causes connected with the Mother which

may impede labor, or make it difficult, 260

Inertia, or Want of sufficiently Powerful

Contraction in the Womb, 260

Rigidity of the Mouth of the Womb, Vagina

and Vulva, 264

Obliquities of the Womb, 266

Prolapsus Uteri.--Smallness or Deformity of

the Pelvis, 267

Tumors in the Pelvis, 286

Tumors externally.--Obstructions in the Vagina, 295

CHAPTER XX.--Causes connected with the child, or children,

which may impede delivery. 297

Procidentia of the Umbilical Cord, 297

Shortness of the Cord, 300

Descent of other parts with the head, 301

Twins and Triplets, 302

Excessive size of the Fœtus, or the diseased

development of certain parts, 304

Ossification of the Head, 305

Various presentations and positions of the

Fœtus, 306

Presentations of the Lower Extremities, 307

Presentations of the Shoulder, 311

Section VII.

ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.

CHAPTER XXI.--Uterine Hemorrhage, or Flooding, during

Labor, 315

CHAPTER XXII.--Eclampsia, or Convulsions during Labor, 336

CHAPTER XXIII.--Rupture of the Womb or Vagina, 341

Section VIII.

OPERATIONS WITH THE HAND AND WITH INSTRUMENTS.

CHAPTER XXIV.--Operations with Instruments.--The Forceps, 345

Other Instruments, 355

CHAPTER XXV.--Operations with the Hand.--Turning, 357

PART II.

THE DISEASES OF WOMEN DURING PREGNANCY, AND IN CHILDBED.

Section IX.

THE DISEASES OF PREGNANCY.

CHAPTER XXVI.--Sympathetic Diseases occurring during

Pregnancy.--Sickness and Vomiting, 366

Ptyalism, or Excessive Salivation, 369

Odontalgia, or Toothache, 369

Derangements of the Appetite, 371

Pyrosis.--Dysphagia, 374

Gastralgia, 375

Constipation, 377

Dysentery and Diarrhœa, 378

Dyspnœa, or Difficulty of Breathing, 380

Cough, 381

Palpitation of the Heart, 383

Syncope, or Fainting, 384

Headache and Dizziness in the Head, 386

Insomnia, or Sleeplessness, 388

Temporary Affection of the Sight, Hearing,

and Smell, 389

Disordered Judgment, Inclinations, and

Propensities, 391

Hæmoptysis, Hæmatemesis and Epistaxis, 393

Varicose Veins, 395

Hæmorrhoids, or Piles, 397

Œdema, or Watery Swellings, 399

Hydrorrhea, or Profuse Discharge of Water, 400

Pustules, and Mucous Discharges, 400

Derangements of the Urinary Organs, 401

Cramps.--Pruritus, or Itching of the External

Parts, 403

CHAPTER XXVII.--Idiopathic, or Primary Diseases Incident

to Pregnancy.--Flooding, 406

Abortion, or Miscarriage, 409

Section X.

THE DISEASES OF WOMEN IN CHILDBED, AFTER LYING IN.

CHAPTER XXVIII.--Diseases of Childbed.--Puerperal Fever,

or Childbed Fever, 420

Affections of the Breast occurring after

Pregnancy, 430

Bronchocele, or swelling in the Throat, 438

Phlegmasia Alba Dolens, or Milk Leg, 439

Trouble with the Urine, 441

APPENDIX.

ON PREVENTING PAIN IN CHILDBIRTH, 443

PART I.

MIDWIFERY.

PLATE I.

Lateral Section, or side view of the Female Pelvis, to show the

position of the Organs.

A. The Bladder.

B. The Womb.

C. The Vagina.

D. The Rectum.

_e._ The Right Ovary.

_f._ The Right Fallopian Tube.

_g._ The Os Tincæ, or Mouth of the Womb.

_h._ The Meatus Urinarius, or Mouth of the Bladder.

_i. i._ The Small Intestines.

_j. j._ The Back Bone.

_k._ The Pubic or Front Bone.

_l._ The Right External Lip, or Labium.

_m._ The Right Internal Lip, or Nymphæ.

_n._ The Hymen.

_o._ The Opening through the Hymen.

_q._ The Perineum.

_p._ The Clitoris.

(This of course shows the half of all the single Organs and the right

one only of those that are double.)

[Illustration: Plate I.

Lateral Section, or side view of the Female Pelvis, to show the

position of the Organs in their natural state.]

PLATE II.

Front View of the Female Pelvis, with the External Walls removed.

A. The Bladder.

B. The Womb.

D. The Rectum.

_e. e._ The Ovaries.

_f. f._ The Fallopian Tubes.

_i. i._ The Small Intestines.

_r. r._ The Round Ligaments.

[Illustration: Plate II.

Front View of the Female Pelvis, with the External Walls removed.]

MIDWIFERY.

SECTION I.

POSITION, STRUCTURE, AND FUNCTIONS OF THE ORGANS AND PARTS OF THE

FEMALE BODY CONCERNED IN GENERATION AND PARTURITION.

To understand the subjects treated upon in the present work, it is

necessary to have at least a general acquaintance with the structure,

position, and special uses of the principal organs and parts of the

female system. A complete acquaintance, so far as our knowledge

extends, would be advisable, but is not absolutely required, and

could not with convenience be given here. The following explanations

therefore, chiefly taken from my book on the Diseases of Woman, are

merely sufficient for the present occasion, and for reference--full

details being reserved for a separate and complete work, now preparing,

on the _Philosophy and Physiology of the Reproductive Functions_.

CHAPTER I.

POSITION OF THE ORGANS AND PARTS.

Plate I, represents one half of the Female body, supposing it to be cut

down the middle, and gives an accurate representation of the relative

position of the different organs.

Plate II, represents a front view of the Female body, with the external

walls removed, to show the relative position of the organs.

Plate III, represents the uterus and its appendages removed from the

body, so that their connections with each other may be seen.

[Illustration: PLATE III.

B. The Womb.--C. The Vagina.--_e. e._ The Ovaries.--_f. f._ The

Fallopian Tubes.--_s._ The left broad Ligament, the right one being

removed.--_r. r._ The Round Ligaments.--_g._ The Os Tincæ, or Mouth of

the Womb.]

INTERNAL ORGANS.

_The Ovaries._--(_e. e._ Plates I, II and III.)--These are two oval

shaped bodies, about the size of an almond nut, placed one on each

side, nearly in the groin. They contain a number of small round grains,

or granules, called the _ovæ_, or eggs, which are the germs of human

beings, as the eggs of birds are of their particular kind. They are

connected with the uterus by two short arms, or prolongations, and are

enclosed in the folds of the broad ligaments.

_The Fallopian Tubes._--(_f. f._ Plates I and II.)--These are two

Tubes, one on each side, beneath the Ovaries, and extending farther.

Each of them has a small passage which opens into the uterus at one

end, and opposite the Ovaries at the other. Their use is to convey the

impregnating principle to the Ovaries, at the time of conception, and

to convey the Ovæ, when impregnated, to the interior of the Womb.

_The Uterus, or Womb._--(B. Plates I, II.)--This is a hollow organ,

placed between the Bladder, which is in front, and the Rectum, which is

behind. It is connected with the Vagina, and opens into it by the small

orifice called the mouth of the womb.--(_g._ Plate I.)--The Uterus

is the organ which receives the impregnated ovum, and in which it is

developed into the human being. It is connected with the Ovaries by the

Fallopian Tubes, and with the Vagina by the Os Tincæ, and is retained

in its situation partly by its connections with other organs, and

partly by the round and broad ligaments.

_The Vagina._--(C. Plate I.)--This is the passage which leads to the

Womb from the external opening.

_The Os Tincæ, or Mouth of the Womb._--(_g._ Plates I and II.)--This is

the small orifice, opening into the Vagina, by which communication is

established with the Uterus from without.

_The Bladder._--(A. Plates I and II.)--The Receptacle of the Urine. It

is placed immediately in front, on the pubic bone, the Uterus lying

nearly on the top of it.

_The Rectum, or Termination of the large Intestine._ (D. Plates I and

II.)--This is situated behind the Vagina, and between it and the back

bone.

_The Broad Ligaments._--(_s._ Plate III.)--These are two broad folds

of membrane, which serve partly to enclose the Fallopian Tubes and

Ovaries, and partly to sustain the Womb in its place. They adhere to

the Uterus and to the walls of the Pelvis.

_The Round Ligaments._--(_r. r._ Plates II and III.) These two cords

arise from each upper corner of the Uterus, and curving downwards are

fixed by their other extremities to the pubic bone. They are partly

enclosed in the Broad Ligaments. They assist in sustaining the Uterus

in its position, and probably also they strengthen the Broad Ligaments

and prevent their rupture when the strain upon them is too great.

_Fimbriæ of the Fallopian Tubes._--(_t. t._ Plate III.) These Fimbriæ

are like Tentaculæ, or fingers, springing from the extreme ends of the

Tubes, and floating loosely in the cavity of the pelvis. Their use is

to clasp hold of the ovaries at the time of conception, so that the

fecundating principle can reach them, and also to take up the ovæ when

impregnated, and convey them into the Tube, down which they pass into

the Womb.

EXTERNAL ORGANS.

_The External Lips._--(_l._ Plate I.)--These are commonly termed the

_Labiæ externa_. They are two broad folds of membranous and adipose

substance, forming the portals to the Vulva, or entrance to the Vagina.

_The Internal Lips._--(_m._ Plate I.)--These are two smaller labiæ,

sometimes called the Nymphæ, within the first, the chief use of which

appears to be to direct the flow of the urine from the urethra.

_The Hymen._--(_n._ Plate I.)--This is a membrane generally found

in virgins, which grows over and closes more or less completely the

entrance to the Vagina. Use unknown. When it exists there is generally

a small orifice through it, by which the menses escape at each monthly

period.--(_o._ Plate I.)

_The Clitoris._--(_p._ Plate I.)--This is a small prominent organ,

about the size of a large pea, placed in the upper part of the opening

between the external lips, and immediately above the Meatus Urinarius.

It is the principal seat of venereal excitement, and is subject to many

annoying diseases.

_The Perineum._--(_q._ Plate I.)--The part between the Vulva, or

entrance to the Vagina, and the fundament. It is chiefly composed of

the muscles belonging to the neighboring parts, and assists very much

in supporting the womb.

_The Meatus Urinarius_, or Mouth of the Bladder, (_h._ Plate I.)--A

small opening by which the urine escapes, placed between the lips, and

immediately above the Vulva, or entrance to the Vagina.

These organs are all placed within, or in contact with, the lower part

of the Trunk, called the pelvis. They are all intimately connected

with each other, and some of them have most extensive and strong

sympathies with almost every other part of the system. So much so is

this the case in fact, that probably the great majority of diseases to

which females are liable arise, directly or indirectly, from Uterine or

Ovarian derangement. Very often the heart, the stomach, or some other

organ, though perfectly healthy, is thought to be diseased, and appears

to be so, merely from its sympathy with the diseased womb.

CHAPTER II.

STRUCTURE OF THE PRINCIPAL ORGANS AND PARTS.

[Illustration: PLATE IV.

Vertical Section of the Womb and Vagina, natural size.

_a. a. a._ The solid walls of the Womb cut through. _b._ That part of

the cavity, or hollow of the Womb, which is in the fundus, or top. _c._

That part of the cavity which is in the lower part, or neck, of the

Womb. _d._ The Vagina. _e. e._ The cut edges of the Vagina. _f. f._

The positions of the Fallopian Tubes, which are cut off, and down the

passages of which two needles are passed. _g._ The Os Tincæ, or Mouth

of the Womb.]

In addition to the general explanation already given, there are some of

the Female organs whose peculiar structure requires to be more fully

noticed, on account of its important influence on some of the processes

hereafter to be described.

THE WOMB.

The external appearance of the womb, viewed in front, and in connection

with its appendages, is shown in Plate III. It is placed in the Pelvis,

between the bladder and the Rectum, and at the top of the Vagina, as

seen in Plates I and II. Its internal structure is represented in

Plate IV.

The length of the Womb, after puberty, is about three inches; its

breadth at the upper part, or fundus, about two inches; and at the

cervix, or neck, about one inch. The cavity in the interior is small,

owing to the thickness of the walls, and its form is triangular. The

shape of the Womb resembles a pear, somewhat flattened, from before

backward. Previous to puberty its size is much smaller, and with those

who have had children it often exceeds the dimensions we have given.

The _Neck_, or narrow part, (_c._ Plate IV.) is much changed by

pregnancy. In virgins it is long and pointed, and somewhat enlarged

in the middle. In those who have borne children it is considerably

shorter, more obtuse, and less regular in its form. The cavity in the

Neck is larger in the middle than at either end, as will be seen in

Plate IV.

The _Os Tincæ_, or mouth of the Womb, also undergoes considerable

change from the same cause. In the young person it is merely like a

small slit, scarcely to be felt, but after pregnancy it much enlarges,

and remains more or less permanently open. The anterior lip, or the one

in front, is somewhat larger than the posterior one.

The body of the Uterus is formed of a very dense, gray colored,

muscular substance, possessing astonishing contractile power. The

interior is lined, like the Vagina, with a mucus membrane, and the

whole organ is plentifully supplied with arteries, veins, and nerves.

One of the most remarkable properties of the Womb is that of being

able to distend to an extraordinary degree, and then retract again to

nearly its original size. The force which it sometimes exhibits during

its contraction is very great, being sufficient to separate, and even

break, the bones of the mother's pelvis, and paralyze the hand of the

operator when introduced. The Muscular Fibres on which this contractile

force depends are most obvious during gestation; they then appear

very numerous, and very curiously disposed, some of them ramifying in

almost every direction, as will be seen by Plates V, VI. It is owing to

this that the Womb contracts in every conceivable direction, and thus

presses, during labor, on every part of the child's body.

PLATE V.

Figures 1 and 2.

Fig. 1. In this plate represents the Muscular Fibres a little

exaggerated, so that they can be more distinctly seen.--_a. a._ are

the orifices of the Fallopian Tubes.

Fig. 2. Represents the natural appearance, the fibres not being quite

so distinct, though sufficiently obvious.--_a. a._ The orifices of

the Fallopian Tubes.

In both Figures the Womb is supposed to be turned inside out, its

peculiar structure being more readily seen interiorly than exteriorly.

[Illustration: Plate V.

The Muscular Fibres of the Womb.]

PLATE VI.

Figures 1 and 2.

Fig 1. This represents the appearance of the Fibres externally, and

shows how they terminate in the round ligament a. b.

Fig. 2. The lines _a. b._ represent the direction of the force of the

Fundul Fibres; _c. d._ That of the Circular Muscles of the body of

the Uterus; _d. e._ The combined force of the Muscles.

The dotted lines represent the force reflected by the liquor amnii.

The dotted curved lines the direction of the circular fibres of the

body of the Uterus.

[Illustration: Plate VI.

The Muscular Fibres of the Womb.]

THE VAGINA.

The Vagina (_c._ Plate I.) is a membranous canal, lined with a mucus

membrane like the Uterus. By its upper part it is attached to the neck

of the Womb, at about two-thirds of its height--so that two-thirds of

the neck hang within the Vagina. Below, it terminates in the Vulva,

or external mouth. The upper part of the Vagina is much larger than

the lower part, particularly in those who have borne children. It is

capable of considerable distension, and after retraction, to allow of

the child passing down it from the Womb. The external mouth is called

the _Vulva_, and is usually partly closed, in the virgin state, by the

membrane called the Hymen, (_n._ Plate I.) The length of the Vagina is

from three to five inches, and its diameter from one inch to one and a

half, or even two inches in those who have borne many children.

THE VULVA.

This is the external opening, or mouth of the Vagina, through which

the child has to pass at the termination of delivery. The external and

internal lips, with the muscular and membranous tissue surrounding it,

are all capable of great distension, without injury, to allow of the

passage of the child.

THE PERINEUM.

This is the part situated between the Vulva and the Rectum. (_p._

Plate I.) It is composed of a somewhat dense and firm substance,

chiefly muscular, and, like all the other parts mentioned, is capable

of great distension. It is important, in many of the manipulations

during labor, to be well acquainted with it; and when the child's head

is passing the perineum requires supporting, to prevent its being

lacerated or broken through, an accident which often happens from want

of due attention, and which leads to the most serious consequences.

THE PELVIS.

The Pelvis is that part of the bony structure, or skeleton, of the

female, in which the generative organs are placed, and through which

the process of parturition is effected. An acquaintance with its

natural structure, and with the changes which may be produced in its

form and size, by disease and other accidents, is indispensable to

those who wish to practise or understand midwifery.

In early life the Pelvis is composed of several bones, many of which,

after puberty, grow together. In the adult female it is customary

to speak of but _four_ bones, the sacrum, the coccygis, and the two

innominata, or hip bones, (see Plates VII, VIII.) In the young female

these are divided into several distinct parts.

PLATE VII.

_Bones of the Pelvis._

_The four principal bones, as found in Mature life._--A. A. The

Ossa Ilii, or Ossa Innominata, commonly called the haunch, or hip

bones.--B. The Os Sacrum, or lower part of the back bone.--C. The

extreme termination of the back bone, called the Os Coccygis.

_The divisions into parts, as in Early life._--The Ilium, A, on each

side, is in three parts; the Ilium, properly so called, marked _a.

a._; the Pubis, marked _b. b._; and the Ischium, marked _c. c._ The

Sacrum is in five parts, marked 1, 2, 3, 4, 5.

_d._ Is the last bone of the spine, which joins the Sacrum.--_e. e._

Are the Sockets in which the upper parts of the thigh bones fit,

forming the hip joints.--_g. g._ The two rings, formed by the bones

of the Pubis and Ischium, each called the Foramen Magnum.

[Illustration: Plate VII.

Bones of the Pelvis.]

[Illustration: PLATE VII.--_a._

This represents the Male Pelvis, to show the difference in structure.

The letters correspond with those in Plate VII.]

[Illustration: PLATE VIII.

Section of the Pelvis, to show the shape and connection of those parts

not distinctly visible in the full view. The section is made down the

middle of the back bone, and through the symphysis pubes, in front. The

letters correspond with those in Plate VII.

A. The right Ilium.--B. The Sacrum.--C. The Coccygis.--_b._ The Os

Pubis.--_c._ The Os Ischinum.--_g._ The Foramen Magnum.--_o._ shows the

manner in which the coccygis is bent back through labor.]

These bones are all firmly bound together by a cartilaginous substance,

which is placed between where they touch, and is firmly attached to

each one. This union is called a _symphysis_. The one at front which

joins the pubic bones is called the symphysis pubis; the two which join

the Ossa Illii to the Sacrum are called the sacro iliac symphyses;

and that which joins the Coccygis to the Sacrum, is called the Sacro

coccygeal symphysis. The two pubic bones are separated a little in

Plate VIII, simply to show them better. The reader will bear in mind

that they are naturally connected by the cartilaginous substance which

forms the symphysis.

These articulations, or joinings, become much softened during labor,

and give way a little, but not to any extent sufficient to assist

delivery. It is a mistake to suppose that the bones separate at that

time. The only part which gives way is the sacro coccygeal symphysis,

which does relax, and allows the Os Coccygis to be pushed back by

the child's head a full inch or more, thus enlarging the inferior

strait.--(See _c._ and _o._ Plate VIII.) Sometimes this little bone

will be even broken off, when there is great disproportion between the

head and the strait. I have heard it snap like a stick breaking. There

is nothing serious nor alarming in this, however, unless it be _a first

delivery late in life_, though it may cause some pain at the time, and

a little difficulty in _sitting_ for some time after. In young persons

the symphysis is soft, and gives way easily, so that they have little

difficulty during delivery from this cause; but if a female marry late

in life, after it becomes hardened, she may suffer considerably. In

this case the coccygis is usually curved inwards considerably, and

being firmly fixed the head cannot push it back, and on that account

cannot pass, without great difficulty, and with the risk of rupturing

some of the soft parts, or breaking the coccygis completely off. There

is in fact great difficulty, and some danger, if the first pregnancy

takes place late in life.

The Pelvis is usually divided into two parts,--the _great pelvis_, or

upper part, enclosed between the wide flanges of the Ossa illii and

the upper part of the sacrum; and the _small pelvis_, or basin, which

is enclosed between the lower part of the sacrum and coccygis behind,

and the ossa ischii and ossa pubes in front. The basin is nearly

cylindrical, larger in the middle, and curved towards the front.

_The Straits of the Pelvis._--The bones of the Pelvis, it will be seen,

form a kind of broad ring, or cylinder, particularly in the basin; and

the straits are two passages, one by which the child passes into the

basin from the upper Pelvis, and the other by which it passes out from

the basin into the world.

In Plate VIII. the line marked † is the antero posterior diameter of

the _upper strait_, through which the child first passes, called also

the brim, or entrance to the Pelvis. The line marked ‡ is the diameter

of the _lower_ strait, through which the child passes into the world,

called also the outlet of the Pelvis. In Plate VII. the line marked †

crosses the upper strait, or brim of the Pelvis.

_The diameters of the Pelvis_ are the distances between the prominent

points of each strait, and are four in number for each, _those for the

upper_ strait being represented below.

PLATE IX.

_Diameters of the Upper Strait._

A B, which extends from the most prominent point of the Sacrum, to

the top of the Symphysis pubes, is called the _antero posterior_

diameter, or that from before to behind.--C D, and E F, are called

the two _oblique diameters_; they extend from each sacro iliac

symphysis, to the most prominent point of the Os Ilium on the

opposite side.--G H, is called the Transverse, or _bis iliac_

diameter, it crosses the Pelvis nearly from one hip joint to the

other.

The Sacro Antero posterior diameter measures _four inches_. The

two oblique diameters _four inches and a half_ each. The bis iliac

diameter measures _five inches_.

(By comparing this with Plate VII. the various points will be still

more apparent.)

The inferior strait has also four diameters, represented in Plate X.

[Illustration: Plate IX.

Diameters of the Upper Strait.]

PLATE X.

The Bones of the Pelvis viewed from below, looking through the

inferior strait, to show its diameters.

A B, which extends from the end of the Coccygis to the lower part

of the Symphysis Pubis, is called the _antero posterior_ diameter;

it measures _four inches_, like that of the upper strait, but is

increased a little by the bending back of the Coccygis.--C D, and E

F, are the two _oblique diameters_, also corresponding to those in

the upper strait; they measure _four inches_, but are increased a

little by the giving way of the soft parts.--G H, is the transverse,

or bis-ischiatic diameter; it measures _four inches_.

[Illustration: Plate X.

The Bones of the Pelvis viewed from below, looking through the inferior

strait, to show its diameters.]

It will thus be seen that the diameters only average from four to five

inches, but it must be remembered that the soft parts, and even one of

the bones, very readily give way, and thus they are slightly increased.

When we come to describe the form and size of the fœtal child's head,

it will be found that its diameters correspond very nearly with those

of the pelvic straits through which it has to pass, so that ordinarily

labor presents no serious difficulty. If the head be larger than

natural, from any cause, or if the Pelvis be too small, or deformed,

this mutual adaptation does not exist, and delivery of course becomes

difficult, or dangerous, and sometimes impossible. The only obstacle

therefore, which can seriously impede the expulsion of the fœtus,

or prevent it altogether, is this want of conformity, in size and

shape, between its head and the bones of the Pelvis. The _soft parts_

may retard labor considerably, by being contracted or rigid, but can

generally be made to give way, either by the efforts of nature or

by manual assistance; and the fœtal head can be reduced in size if

necessary; but insufficient size, or faulty form, in the _bones_, is

irremediable.

The various causes which produce deformity, or imperfect development,

in the Pelvis, and unnatural growth of the child's head, will be stated

in a subsequent section. For the present, we have only to do with both

in the normal state.

The importance of an accurate knowledge of the structure of the

Pelvis, and of the changes which may be induced in it, will now be

obvious; neither the theory nor the practice of Midwifery can in fact

be understood without such knowledge. It is also frequently of the

first importance to know, _previous to marriage_, whether the pelvis

of a young person is so formed that delivery can be safely effected!

Inattention to this has sacrificed the lives of many, and caused others

to live for years suffering and helpless. In another place we shall

give some plain rules and directions by which this important point may

be determined.

_The floor of the Pelvis._--The soft parts at the bottom of the basin

of the Pelvis, consisting of the perineum and various muscles, are

called the floor of the Pelvis--the only passage through which is by

the Vulva, or mouth of the Vagina. As the head of the child descends

to the bottom of the basin, it presses upon this floor, and gradually

distends it, until the Vulva is sufficiently enlarged. This delay is

advantageous, for if the passage was always large enough, or increased

in size without any difficulty, the child would pass too suddenly, and

much mischief might often result from its sudden expulsion--such as

pulling down of the womb, flooding, and the falling of the child upon

the ground.

_Direction of the passage of the Pelvis._--In most of the lower animals

the passage of the Pelvis is straight, and on a line with the body,

the two straits being opposite each other, which makes delivery much

more easy with them. Even in the negroes, and other inferior races, the

passage is much straighter than in the whites. The more perfect the

organization therefore, the more difficult is parturition; and the more

imperfect or simple the organization, the more easy is parturition.

The dotted line in Plate XI. shows the direction of the passage of the

Pelvis, in the human female, to be a curve, so that the child has to

move, during its passage, in a circle.

[Illustration: PLATE XI.

The axis, or direction, of the upper strait is denoted by the line A,

that of the lower strait by the line B, and that of the Vulva by the

line C. The force of expulsion tending to push the child in _each_

direction, it has to traverse a path intermediate with them all, or

compounded of them all, not being able to move in either alone. This

aggregate direction is denoted by the dotted curved line, which shows

the direction in which the child passes, and in which the hand must be

passed when introduced.

I is the Perineum.--The dotted line which crosses A denotes the upper

strait, and the line I the lower strait.]

CHAPTER III.

FUNCTIONS OF THE PRINCIPAL FEMALE ORGANS.

The great object for which the whole of the Female organs perform their

several functions is, _that of bringing into existence a new being_!

For this purpose they act both separately and conjointly, each one

having its specific part to play in the grand phenomenon. As already

remarked, it would not be in place here to give all the details of this

wonderful event, but merely such a description of its principal stages,

as will suffice for an understanding of the main subject of the present

treatise. I shall therefore, first give the uses of the principal

organs separately, and then explain the processes of conception, and

fœtal development.

THE WOMB.

The Womb is nothing more than the receptacle in which the impregnated

egg is placed, and in which it undergoes all the wonderful changes by

which it eventually is developed into a perfect human being. The womb

is not therefore absolutely needed in _conception_, and indeed several

cases have been known where the new being was formed without the

womb altogether, though not perfectly. Its principal use is in fœtal

development, which cannot take place perfectly in any other part of the

body.

THE OVARIES.

The Ovaries, as already remarked, are two oval-shaped bodies, placed

one on each side of the womb, and connected with it, whose use is to

form the germ or rudiment, called the ovum, or egg, from which the new

being is developed. The structure of the Ovaries is very simple, and

the manner in which they produce the ovum is not very well understood.

It is certain however, that they are indispensable to conception, being

in fact the most essential parts of the female generative system.

MENSTRUATION.

Menstruation appears to be a process resulting from the development

and healthy action of the Female organs, and is essential to their

well being. The following brief account of its nature and origin is

extracted from my _Diseases of Woman_, page 152 to 155:

"Until very recently but little was known, with any certainty,

respecting this remarkable and important phenomenon of the female

system. The most crude and visionary theories have been advanced to

explain it, and our works on medicine and physiology do nothing more

than repeat them, one after the other. The investigations of several

distinguished physiologists however, within the last few years, have

thrown a new light on this hitherto obscure subject, and explained

much that was previously unknown, or, at best, merely conjectured

upon. A brief statement of the result of those investigations will not

only be highly interesting in itself, but will materially assist in

explaining what we shall afterwards speak upon.

"It is well known that the female organs are liable, at regular

periods, to assume a peculiar action, which results in the discharge

of a fluid termed the menses. The secretion and excretion of which

are highly essential, both to the proper performance of many other

functions, and to the maintenance of the general health. Whence

comes this fluid, and what causes it to flow? These were questions

unanswered, except by mere supposition, previous to the discoveries

referred to, which we now proceed to make known.

"In the first chapter it was stated that the _Ovæ_, or eggs, contained

the rudiments or germs, from which, when impregnated by the male

principle, new human beings were developed. These ovæ, however, are

not prepared to undergo this development before the age of puberty,

nor after the change of life, nor are the whole of them fit for

conception even during the prolific period. It appears that they

become fit for fecundation in succession, during the menstrual period,

_one ovum,_ or more, _being ripened every month_! When fully perfected

it separates from the ovary and is lost, unless conception occurs, in

which case it passes along the fallopian tube into the Womb, and then

develops into the fœtus. Here then we see the cause of the menses; the

ripening of the ovum causes a local excitement, and congestion, in the

ovary and womb, which increases till the period when it is thrown off,

and then the accumulated fluid is discharged, the excitement subsides,

and a new development commences.

"This curious process is termed by some physiologists the monthly

_ponte_, or _laying of eggs_, and by others the _Ovarian labor_, or

_birth_! A small scar is left on the ovary at the point where the ovum

separates, which fades away after a time, but a number of them may

always be observed on the ovaries of those who have long menstruated.

In those who die during menstruation the ovaries are found very red,

and full of blood, and sometimes one of the ovæ will be found swelled,

and just ready to burst through, or the ruptured opening may be seen

through which it has actually escaped.

"Precisely the same phenomenon occurs in the lower animals, excepting

that their periods are more extended; some of them occurring annually,

and others at still longer intervals. Some of the monkeys even have a

species of real menstruation.

"These important facts, by enabling us to understand what causes

menstruation, give us an insight also into the nature of its

derangements, and the conditions required for their regulation. When

we call to mind also the close sympathy between the uterine organs and

every other part of the system, it shows us how important a proper

menstruation is to the general health, because without it those organs

must be diseased, and consequently every other part of the system

liable to suffer with them.

"Formerly many absurd notions prevailed respecting menstruation, which

in fact are not quite removed even now. Thus some authors asserted

that a female, while unwell, could cause various diseases, by merely

_touching_ persons! Others supposed they would curdle milk, and nearly

all believed that the menstrual fluid itself was highly poisonous,

so that females, at those times, were compelled to live apart and

approach no one. In the Old Testament there are many regulations

given, for females while menstruating, which show the prevalence of

such notions in olden times. It is scarcely necessary to say that

there is no foundation whatever for all this, as the fluid itself

differs but little from ordinary blood, and is equally innocuous.

"In like manner it was supposed, that menstruation was influenced by

the _Moon_, and only occurred at a certain period of her age. We know,

however, that females are unwell almost every hour of every day in the

year.

"The due establishment of the menstrual function is absolutely

necessary, to the perfection both of mind and body, and its regular

performance is quite as essential to the continuance of health, for

there is scarcely a single disease that its derangement will not

either cause, or at least seriously aggravate.

"It is therefore _vitally important_ to attend to this matter,

_particularly in young persons approaching puberty_! A little care

at that time, properly bestowed, may prevent years of disease and

suffering, if not untimely _death_!"

CONCEPTION.

Conception is the union of the male principle with the female ovum, or

egg, after that is perfected in the manner described in the article on

Menstruation. The precise manner in which this union is effected is

unknown, though our information in regard to it is much more extensive,

and precise, than formerly. As nearly as can be stated it occurs in the

following way:

At the time of a fruitful connection, which can only occur, it must

be remembered, when the ovum is ripe, the male principle is carried

into the Womb, (B, Plates I. and III.) and is then supposed, by some,

to meet with the ovum which has descended down the Fallopian Tube

(_f_, Plates I. and III.) from the Ovary, so that the union of the two

takes place, according to this view, either in the Fallopian Tube or

in the Womb. Others, however, suppose that the ovum does not leave the

Ovary before conception, but that the male principle passes down the

Fallopian Tube and meets it there, and that it is several days after

before it reaches the Womb. There are many facts and arguments brought

forward in support of each view, all of which will be set forth in my

forthcoming work on the reproductive functions. All that is known for

certain is, that the two principles must unite in one place or the

other, and that the ovum must pass down the Tube into the Womb, either

before impregnation, or after.

The union of the two principles in the Womb appears so likely an event

that it is scarcely possible to avoid thinking that it really does then

take place, but at the same time there are very strong reasons for

adopting the opinion that it takes place in the Ovary. Among others may

be mentioned the phenomenon of _extra uterine conception_, which will

be more fully alluded to in another place. In these cases the fœtus is

found _outside_ of the Womb, in the Tube, or the Ovary, or even in the

Abdomen, among the intestines. Such an occurrence seems to render it

almost certain that the ovum must have been fecundated in the Ovary,

because we cannot well conceive, if it were not so, how it could reach

the outside of the Womb. This difficulty is not, however, regarded

as insuperable, by the advocates of the opposite theory. Possibly

conception may occur _in both ways_.

There are many causes which prevent conception, or, in other words,

which produce _barrenness_ and _sterility_. These various causes

cannot be all explained, except in connection with a full explanation

of the process of reproduction, and of the nature of many female

diseases. In my work on "_The Diseases of Woman_," I have given a

chapter on this subject, and have also referred to the present work as

one in which it would be more fully treated. This reference, however,

was made in mistake; the subject is not needed here, but will be in

the other work, on the _reproductive functions_ in which it will be

discussed at length.

CHAPTER IV.

FŒTAL DEVELOPMENT.

The last Chapter brought us up to the point of conception, or the first

commencement of the new being. The next step is to exhibit its various

stages of development, and to show how it is nourished and maintained

in its proper position. This is requisite in order to understand the

origin of many diseases and accidents which occur during gestation, and

also to explain the various signs by which it is determined whether a

female is pregnant or not.

FŒTAL DEVELOPMENT.

The development of a perfectly formed human being from the egg in which

it originates, is one of the most astonishing phenomena that can come

under our observation, and is eminently deserving the study of every

rational being. The present explanation of it must necessarily be

brief, being merely intended to make the main subject more clear.

It has already been remarked that it is uncertain whether the ovum is

impregnated before it is brought into the Uterus, or after it arrives

there; but be that as it may, nothing has yet been discovered in the

Womb till several days after conception. Some physiologists tell us

that the rudiment of the new being may be found there about the _sixth_

day; but others again assure us that it cannot be found before the

_twelfth_, at which period our explanation of its development will

commence.

_At the twelfth day_ the ovum is about the size of a large pea, it is

composed of a vesicle containing a thick fluid, called the _germ_,

which corresponds to the opaque substance seen in the white of a

fecundated bird's egg, and of a yellowish substance, in which it

floats, called the _vitellus_, which answers to the yelk. The whole

being surrounded by two membranous coverings, the outer one called

the _chorion_, and the inner one the _amnion_. Between these is a

gelatinous substance, and within the amnion is a fluid, called the

liquor amnii. The two membranes, the liquor amnii, and the inclosed

ovum, are called the _ovulum_! Immediately after conception the uterus

begins to secrete, from its inner walls, another membrane, very

delicate, called the _decidua_. This lines the whole cavity, so that

when the ovulum passes out of the tube it is met by this lining which

seems to prevent its entrance into the womb. The ovulum, however,

presses upon it and so makes a depression, like a nest, in which it

lies. This prevents its moving about, or falling to the bottom of the

womb.

The weight of the entire ovulum is about one grain. The embryo

commences in the germ, and may now be seen about the size of a pin's

point. The vitellus removes away from it, but remains connected by a

small pedicel or thread-like tube, down which it is gradually absorbed

as nutriment. A small white thread, scarcely perceptible, may be seen

sometimes as early as this period, being the commencement of the brain

and spinal marrow. The mouth is visible also from the twelfth to the

twentieth day, and frequently the eyes. These are placed at first on

the side of the head, like those of quadrupeds, and move round to the

front afterwards.

_At twenty-five days_, the embryo is about the size of a large ant,

which it also resembles in form. It begins to have a little more

consistence, and the future bones begin to resemble cartilage, or

gristle. A small groove may be seen denoting the neck, which thus

indicates the separation of the head from the trunk. The weight is

three or four grains.

_The first month_, it is about the size of a Bee, and is somewhat like

a small worm bent together. The arms may be seen like two little warts.

They are first formed under the skin, and shoot out like buds, growing

straight from the body; afterwards they become folded together, in

a curious manner, upon the breast. The head is as large as the rest

of the body, and upon it we can now see distinctly the eyes, like

two black dots, the mouth, like a line, and also the nose. The lower

extremity is lengthened out like a tail. Weight about ten grains.

_The second month._ Every part has now become much more developed, and

the general form is that of a human being. The superior members are

much more elongated, and the inferior ones begin to be distinguished,

forming in the same manner as the others. The fingers are united

together by a membrane, like the web on a Frog's foot. In the ribs,

clavicles, and jaw bones, a few points can be seen ossified, the

cartilage beginning; to harden into bone. The rudiments of the first

teeth are also visible. The weight is about one drachm, and the length

one inch.

_At about seventy days_ the eyelids are visible, the nose becomes

prominent, the mouth enlarges, and the external ear may be seen. The

neck is well defined. The brain is soft and pulpy, and the heart is

perfectly developed.

Every organ is originally formed without either blood or blood vessels.

The circulation which afterwards takes place in them is merely for

their subsequent development. The heart is perfect in all its parts,

and even has a slight motion, before the blood is found in it.

_Three months._ All the essential parts are well defined. The eyelids

distinct, but firmly closed. The lips perfect, but drawn tightly

together. The heart beats forcibly, and in the larger vessels red blood

is seen. The fingers and toes are defined, and the muscles begin to be

apparent. The organs of generation are remarkably prominent, but still

it is somewhat difficult, at first, to distinguish the sex by these

organs, notwithstanding their development, as the principal parts in

both are nearly identical in form. It can, however, be ascertained by

other circumstances, as the form of the head, dorsal spine, thorax, and

abdomen. It now weighs about two ounces and a half, and measures four

or five inches in length.

_Four months._ The development is remarkably increased. The brain

and spinal marrow becomes firmer, the muscles distinct, and a little

cellular tissue is formed. The abdomen is fully covered in and the

intestines are no longer visible. A little of the substance called

_meconium_ even collects in the intestines, the same as is found in at

birth. It now weighs seven or eight ounces, and measures six or seven

inches. The bones are ossified in a great part of their extent, and the

rudiments of the second set of teeth are visible, under the first.

The uterus now is so large that it can no longer remain in the lower

part of the pelvis, but is compelled to rise up into the abdomen for

more room. This change of position is improperly called _quickening_!

Sometimes it takes place very gradually, so that it is scarcely

noticed, but more frequently it rises suddenly, disturbing all the

internal organs, and causing in them considerable derangement till

they accommodate themselves to the change. This occurrence often

causes unnecessary alarm, though the sickness, and other unpleasant

sensations, are always sufficiently annoying.

This stage corresponds with that in which the young of oviparous

animals breaks the shell and escapes. The human being however,

undergoes a remarkable change, and remains in the womb for a period

longer than that already past, in order to become more perfected.

From four to nine months the development is proportionally much more

rapid than during the first four months, owing to the circulation of

perfect red blood, which is now found the same as in the adult, and is

probably derived from the mother's blood vessels.

_Five months._ Every part is considerably increased in size, and become

more perfect. The lungs enlarge, and are even capable of being, to a

certain extent, dilated. The skin becomes much stronger. The situation

of the nails can be discerned. The meconium is more abundant, and lower

down in the intestines. The length is now eight or ten inches, and the

weight fifteen or sixteen ounces.

_Six months._ The nails are marked. The head becomes downy, from the

first development of the hair. A little fat is formed. Length twelve

inches, weight from one and a half to two pounds. No indications of

intellectual faculties.

_Seven months._ The whole being has rapidly progressed. The nails

are formed, the hair is perfect, in the male the testicles descend

to the scrotum, and in the female the ovaries reach the brim of the

pelvis. The bones are tolerably firm, and the meconium collects in the

large intestines. Length fourteen inches, weight about three pounds.

Intellectual functions not yet exercised.

The two remaining months are merely devoted to further increase in size

and weight. No new phenomena present themselves.

_Nine months._ Every function has become active. The skin becomes

colored, and perspiration occurs. There are no indications of the

intellectual functions, but the animal functions are remarkably active,

particularly that of _taste_, which no doubt leads to the act of

sucking, from the natural desire for its gratification. The child can

now experience all the ordinary sensations of pain, hunger, heat, and

cold, and is capable of preserving an independent existence if brought

into the world.

Plate XII. represents a section of the Uterus at about one month of

gestation, so as to show all the parts in their proper situation.

PLATE XII.

Section of the Uterus, with the Ovum and appendages, at about one

month of gestation.--_a. a. a._ The substance of the walls of the

Womb.--_b. b._ The Embryo.--_c._ The different vessels by which it

is connected with the Placenta.--_d. d._ The Placenta.--_e._ The

Vitellus.--_f. f. f._ The Membrane lining the Uterus, called the

Decidua; it is seen to be bent double, or reflected, the Embryo being

on the outside of it.--_g. g._ The Chorion, or Middle Membrane, which

is studded over with villosities, or small blood vessels.--_h. h._

The Amnion, or inner membrane, which contains the fluid called the

liquor amnii, in which the Embryo floats.--_i. i._ The blood vessels

which connect the Placenta with the Womb.--_j._ Is a plug of Mucus,

by which the mouth of the Womb is now blocked up.--_k. k._ The ends

of the Fallopian Tubes, which are cut off; these are also blocked up

with mucus, the same as the Os Tincæ.--_l._ The Os Tincæ, or mouth of

the Womb.--_m._ The Vagina.

[Illustration: Plate XII.

Section of the Uterus, with the Ovum and appendages, at about one month

of gestation.]

FŒTAL NUTRITION.

The manner in which the new being derives its nutriment, or the

material by which it grows, is, in a great measure, unknown to us,

though we certainly obtain some little information about it by a study

of the apparatus employed in the process.

For the first fifteen or twenty days the substance called the

_Vitellus_, (_e._ Plate XII.) which is analagous to the yelk of the

ordinary egg, appears to supply most, if not all of the material

that is required in the formation of the new being; and indeed this

substance does not totally disappear till after the third month, though

we cannot suppose it to be the sole source of nutriment then. It is

also supposed, by some, that the amniotic liquor, in which the fœtus

floats, may afford some nutriment, either by being swallowed, or by

being absorbed through the skin. It is certain that this fluid is

nutritive, and there is nothing impossible in its absorption, though it

is not very likely to occur to a sufficient extent. The idea that it

can be swallowed however, is erroneous, because the mouth of the Fœtus

is firmly closed while in the Womb; and besides, children have been

born alive without _mouths_, and even without _heads_, and of course

they could not have swallowed anything. It is now generally conceded

by physiologists that the material required by the Fœtus, for its

nutrition, is obtained from the blood of the mother, through the medium

of the Placenta, and the vessels in the Umbilical cord. It is, however,

a matter of dispute whether the maternal blood is sent directly, in

its ordinary state, into the body of the child, or whether it first

undergoes a preparatory process, which most modern authors suppose it

does.

From the earliest period of gestation, the middle membrane, called the

chorion, (_g. g._ P. XII.) is covered, on its outer surface, with a

number of small protuberances called _villosities_, which subsequently

become true blood vessels. About the fourth month these have increased

very much in size and number, and have all become conglomerated into

one mass, in form like a mushroom. This is called the _Placenta_.

It is almost entirely formed of blood vessels, which seem to attach

themselves at one end, by open mouths, to the open mouths of other

blood vessels on the inner walls of the uterus (_i. i._ Plate XII.)

At the other end these vessels are drawn together and lengthened out

into a long tube, called the _umbilical cord_, or _navel string_, which

finally enters the body of the child at the navel and so establishes

the connexion between it and the mother.--(_c._ Plate XII.)

The blood vessels in the placenta, umbilicus, and fœtus, like those

in the maternal body, are of two kinds, _Arteries_ and _veins_. The

arteries, which come from the _left_ side of the heart, carry the pure

blood, which contains all the materials for forming and nourishing

every part of the system. The veins contain the blood in its impure

state, and take it to the _right_ side of the heart, from whence it is

forced into the lungs to be purified by the act of breathing. The blood

is made impure by some of its constituents being absorbed, to form the

different parts of the body, and by having thrown into it a quantity of

waste and poisonous matter no longer needed.

The course of the blood, therefore, is from the left side of the

mother's heart along her arteries till it reaches the arteries of the

uterus, from them it passes into those of the placenta, and thence into

those of the umbilicus which convey it into the body of the child.

When there it circulates in its arteries, supplies the material for

its further increase and development, becomes in consequence impure,

and passes into its veins, the same as in the maternal body. From

these veins it passes into those of the umbilicus and placenta, and,

apparently, into those of the mother, by which it is conveyed to the

right side of her heart, and by its action to her lungs, to be again

purified when she breathes. This explains what was previously stated,

that the child uses the mother's heart, lungs, and stomach, while in

the womb, and has, therefore, no occasion to use its own.

The diameter of the placenta is about six inches, and its thickness

about one inch and a half. The length of the umbilical cord is from

eighteen to twenty-four inches, its diameter about half an inch. These

dimensions are, however, subject to great variation. Instances are

mentioned of the cord being five feet long, and as thick as the child's

arm. I have seen one myself four feet long. Sometimes it will be very

short, not more than eight or ten inches. It is composed of one artery

and two veins, twisted together like the strands of a cable, and of a

sheath surrounding them composed of the chorion and amnion. Between the

sheath and the vessels is a thick gelatinous fluid called the Gelatine

of Wharton.

This explanation, it must be remembered, is in fact merely

hypothetical. The direct passage of the blood through the Placenta,

from the mother's vessels into those of the cord, is denied by many

physiologists, who contend that there is an intermediate set of vessels

in the Placenta, in which it first undergoes important changes.

They also contend that the impure blood does not pass through into

the mother's veins at all, but is purified in the Placenta, and

immediately returned. Some have even averred that the Placenta is not

required at all, to supply nourishment, but is merely a purifying

organ. It is now known, however, that it is not absolutely essential

to either process, for children have been born alive, and perfectly

formed, which merely floated loosely in the amniotic liquor, having

neither Placenta nor cord, nor any other connection with the mother.

How they were nourished we cannot tell. These, however, must be

regarded merely as curious exceptions, there being little doubt but

that fœtal nutrition is ordinarily effected through the Placenta and

cord, by means of the mother's blood, somewhat in the manner we have

described.

PECULIARITIES OF THE FŒTAL CIRCULATION.

From the circumstance of the fœtus not using its heart and lungs, like

the adult, its circulation has several modifications.

The engine by which the blood is forced along its vessels is the

_heart_! This is divided into two distinct parts, each of which has

two cavities, the upper one called the _auricle_, and the lower one

the _ventricle_, which communicate with each other by curious valves.

In the adult the whole of the impure blood is poured into the right

auricle, that from the lower part of the body by the _inferior vena

cava_, and that from the upper part by the _superior vena cava_. From

the right auricle it passes into the right ventricle, which pumps it

into the lungs, by way of the pulmonary artery; here it is purified by

the act of respiration, and then brought, when pure, by the pulmonary

veins, into the left auricle, and passes from thence into the left

ventricle, which pumps it into the great aorta, and from thence into

the smaller arteries all over the body. The two sides of the heart,

therefore, do not communicate directly with each other, but there is

a strong partition between them. In the fœtus the arterial blood from

the mother, when it leaves the umbilical artery, enters first the

liver, runs through its vessels, gives off the bile found in it, and

then joins the vena cava inferior. By this passage it is taken into the

right auricle, along with the impure blood of the vena cava. From the

right auricle it passes through a hole in the partition directly into

the left auricle, instead of taking the indirect route by the lungs as

in the adult. From the left auricle it passes into the left ventricle,

and is from thence distributed by the arteries all over the body. This

opening in the partition is called the _foramen ovale_!

After birth, when the blood begins to pass through the lungs, this

passage closes up. By the eighth day it is generally obliterated, often

much sooner, though occasionally it has remained open longer without

inconvenience. In some cases the foramen ovale does not close at all.

The child then has what is called the _blue disease_! The whole body is

of a uniform leaden, or blue color, and the whole system is generally

languid and sluggish. The blue color is caused by the dark blood of

the veins mixing with that of the arteries. These children mostly die

early, but some live to be five or six years old, and one I saw twelve,

but this is rare. No remedy can be had for this affliction, and I have

never known it to cure spontaneously. Some children are so very dark

for a few days after birth as to cause great alarm. This is owing to

the foramen ovale being very open and closing slowly. No apprehension

need be experienced in such cases, as it soon subsides.

The impure blood from the upper part of the fœtal body, which is

brought down by the superior vena cava, also enters the right auricle,

but does not pass from thence through the foramen, like that from the

inferior vena cava. By a peculiar arrangement this blood is made to

pass down into the right ventricle, and from thence along the pulmonary

artery, the same as in the adult state. Only a very small portion,

however, passes into the lungs, the great part being taken along a

tube called the _ductus arteriosus_ into the great artery called the

aorta, where it begins to turn down to the lower part of the body. In

consequence of this, the arterial blood going down to the lower part of

the body, is mixed with this portion of impure, venous blood, brought

by the ductus arteriosus from the superior vena cava; while that going

to the head, and upper part of the body remains pure. And this is the

reason why the lower part is always so much smaller than the upper

part, previous to birth; it receives less pure nourishment. The head

and chest appear, at an early period, almost as large as the rest of

the body.

This circumstance also explains why, in the great majority of cases,

the _right_ arm is preferred to the _left_, and has more real power.

The place where the ductus arteriosus pours the impure blood into the

aorta, is almost immediately opposite to where the artery is given

off which feeds the left arm. In consequence of which, in most cases,

a small portion of this impure blood becomes mixed with the arterial

blood, and the left arm is, therefore, in the same situation as the

lower limbs, and like them is comparatively imperfectly developed.

The right arm is not liable to any such deprivation. In some cases

the insertion of the ductus arteriosus is lower down, so that no such

mixture occurs. Both arms are then equal, and this accounts for the

fact that in some persons there appears to be no difference. In some

cases, no doubt, early habit, or imitation, may overcome this natural

inferiority, and even give the preference to the left arm; but such

instances are rare; the general rule is the contrary, and for the

reason stated.

The ductus arteriosus closes up about the same time as the foramen

ovale.

The two veins which convey the impure blood back to the mother, to be

purified, originate from the iliac artery, in the pelvis. They pass up

the sides of the bladder towards the navel, enter the sheath of the

cord, and so reach the placenta. These vessels are obliterated about

the third or fourth day after birth, and remain afterwards in the form

of a fibrous cord.

The real source of _all_ the blood in the body of the child is a

mystery; it would certainly appear most likely for the whole of it to

be derived from the mother's vessels, but there are many circumstances

which make it probable that the child may form some itself, by

digesting the fluid it is supposed to absorb. This view is supported by

the fact that there is found in its bowels at birth, and even before,

a greenish substance like excrement, called _Meconium_. This has every

appearance of being the product of digestion, though some suppose it

to be derived from the liver. It occasionally contains hair, and other

anomalous substances.

CHAPTER IV.

THE BREAST.

The Breasts, or _Mammæ_, are not needed in the process of generation,

nor are they absolutely necessary even after birth; but as they

are naturally associated, in the majority of cases, with infantile

nutrition, and are besides liable to many derangements and diseases

during pregnancy and child-birth, it is advisable to give some account

of them.

When one of the breasts is dissected it is found to be composed chiefly

of a singular body called the _Mammary Gland_, which resembles somewhat

a very firm piece of fat, of a yellowish drab color. In the substance

of this Gland are an immense number of little cells, or vessels, in

which, by some unexplainable process, the milk is secreted, or made

from the blood. From these little vessels there proceeds small tubes

which gradually unite into larger ones, and these again into larger

ones still, until at last all the milk is poured into a few tubes,

or canals, which terminate in the nipple. The outer mouths of these

terminal canals are only slightly contracted together, so that the

suction of the child's mouth, or even the pressure of the milk, when

the breast is full, will force them open and allow the fluid to flow

out.

The following plate represents the structure of the Breast, and

explains, as far as it can be explained, the manner in which it

performs its functions.

PLATE XII.--_a._

_a. a._ The cut edges of the skin.--_b. b._ The flaps of the skin

thrown back.--_c. c. c._ The fat which covers the breast.--_d. d._

The cells of the Mammary gland.--_e. e. e._ The Tubes or canals,

which convey the milk from the Gland to the Nipple.--_f._ The Nipple,

cut down the middle, to show the ends of the milk tubes terminating

in it; these are usually about fifteen or eighteen in number.--_x._

Shows a bunch of the little cells, with the tubes proceeding from

them, as they appear when injected.

[Illustration: THE FEMALE BREAST.

Plate XII.--_a._

This Plate represents the structure of the Breast, and explains the

manner in which it performs its functions.]

Sometimes there has been seen two and even three nipples on one breast,

and in a few cases one of the breasts has had no nipple at all. The

two glands are not immediately connected, but have a very intimate

sympathy with each other. The size of the breast depends more upon the

thickness of the layer of fatty substance, than upon the development

of the gland, so that one female, with a very full bosom, may have

but little milk, while another, whose breast is but little prominent,

may have a superabundance. The graceful swell of the fully developed

breast is, however, a matter of positive utility, as well as of beauty,

because it better adapts it to the use of the child, and probably

also adds to its _pleasure_, as any one may readily conceive who will

observe the delight with which an infant, even when not nursing, will

often caress it. Sir Astley Cooper says, "The natural obliquity of the

Mamella, or nipple, forwards and outwards, with a slight turn of the

nipple upwards, is one of the most beautiful provisions in nature, both

for the mother and the child. To the mother, because the child rests

upon her arm and lap in the most convenient position for sucking; for

if the nipple and breast had projected directly forwards, the child

must have been supported before her, in the mother's hands, in a most

inconvenient and fatiguing position, instead of it reclining upon her

side and arm. But it is wisely provided by nature, that when the child

reposes upon its mother's arm it has its mouth directly applied to the

nipple, which is turned outwards to receive it, whilst the lower part

of the breast forms a _cushion_, upon which the cheek of the infant

tranquilly reposes."

With the exception of the dark _areola_, or circle, and the little

tubercles around the nipple, the breast is of the most delicate

structure and color, so that it blushes, or reddens, like the cheek,

from any sudden emotion, and goes pale during fainting.

As a general rule no milk is secreted in those who have not become

pregnant, nor in those who have passed the turn of life, but

occasionally exceptions are observed to this rule.

Bandelocque tells us of a girl only _eight_ years of age, who suckled

her little brother more than a month! And Sir Hans Sloane tells us of

a lady aged _sixty eight_, who nursed several of her grandchildren,

though she had had no child herself for twenty years! Dr. Francis, of

New York, describes the case of a lady who continued to secrete milk

regularly for _fourteen years_ after having lost her child, so that

she could always nurse an infant; and Dr. Kennedy relates an instance

of another who continued to suckle children, uninterruptedly, for

_forty-seven years_, and who had milk perfectly sweet and good even

when _eighty-one years old_! Dr. Clark, of Alabama, informs us that

a married lady, who had never been pregnant, was requested to take

charge of an infant during the night, and that to quiet it she had put

her nipple in its mouth. This was done frequently, and to the great

surprise of all it induced a flow of milk. A singular circumstance

connected with this was that the lady soon after became _pregnant_,

though previously barren! This will not appear so surprising, however,

to those who know the connection between the breasts and the womb,

and who have observed the mysterious bond of sympathy by which their

functions are united.--(See the articles on _Menstruation_, and on

_Sterility_, in my "Diseases of Woman," for other instances of this

kind.)

The structure of the male breast is precisely the same as that of

the female, but it is seldom developed. Instances have been known,

however, of the milk being secreted in men, and of children having

been nourished by it! Humboldt gives us an instance of this kind, and

Professor Hull, of Maryland, exhibited a colored man to his class, in

the year 1827, who had a large full bosom, like a female, and who had

often officiated as _wet nurse_ in the family of his mistress. The

secretion appears to have been established by his putting the children

that he had to nurse to the nipple, to quiet them. When the milk was

not needed it was found as difficult to dry it up as it is in some

females, but it was soon made to flow again, by applying a child to the

breast for a few times. This man differed _in no other respect_ from

any other man!

In the females of some races of the human kind, the mammæ attain a

surprising length, and become very flaccid, so that they hang down

to the hips, or lower, and may be thrown over the shoulder for the

child to nurse from while carried on the back. Some suppose this to

constitute a real variety of the human race, but others suppose it to

result merely from habit, which is probably correct.

When the breasts are small sized in young females, their growth may

often be promoted, but the means need not be pointed out here.

SECTION II.

SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT; ITS DURATION, AND

THE PERIOD AT WHICH THE FŒTUS CAN LIVE.

It is always desirable, and frequently of the first importance, to

be able to know whether a female is pregnant or not, both to the

accoucheur and to the individual, or even to be able to judge whether

she is probably or possibly so, or not. Sometimes this can be decided

positively, but more frequently it is a matter of great uncertainty.

The presumptive and positive signs on which a judgment can be formed

are of various kinds, most of which can be readily observed, and easily

made use of by any person in possession of the information already

given in the preceding section. They will be set forth in the following

Chapters, together with such other matter as appertains to this part of

the subject, in such a manner as will make them available either for

professional or for private use.

CHAPTER V.

SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT.

The signs of Pregnancy are of three kinds--Presumptive, Probable, and

Certain.

PRESUMPTIVE SIGNS.

The presumptive signs of pregnancy are only of value in the first

_three months_. They consist mainly of certain nervous and organic

derangements, and of certain changes in personal appearance. It is

scarcely possible to enumerate all these, nor is it necessary; we shall

therefore only specify those most important, and most generally met

with.

Colic pains, and creeping of the skin, with shuddering and fainting

fits, very frequently follow _immediately on conception_, and in many

females inform them when that event occurs. Some persons speak of

other sensations, of a peculiar nature, by which they _always_ know,

in their own cases, when they conceive; but these sensations are felt

by so few, and are so little capable of being explained or observed,

that they are of no general use. In most cases, within the first

three months, and sometimes in the first three days, the face changes

remarkably. The eyes are sunk and dull, and surrounded by a black

circle, the nose seems pinched up, the skin turns pale, and red spots,

or freckles, frequently appear. Many females also complain of a husky

dry throat, numbness in the hands and feet, and a sudden sinking at

the heart. These signs, however, are very uncertain guides; very often

none of these are felt at all during pregnancy, and sometimes they are

all experienced from other causes. One of the most constant signs,

according to some, and the most to be relied upon, is an _increase in

the size of the neck_. This I know is often very apparent, and at a

very early period. I am acquainted with females who, by simply keeping

the measure of their necks, can always tell when they are pregnant.

The increase is often considerable in a few days. In young persons of

a certain temperament however, the neck is apt to swell merely from

_marriage_, though they do not conceive; and some old nurses, we are

told, being acquainted with this fact, judge of the honesty of their

unmarried charges by such admeasurements!

This singular development is owing, probably, to a sympathetic

connection between the uterine organs and certain parts of the brain,

and large nerves in the neck.

_Suppression of the Menses_ is one of the strongest presumptive signs

of pregnancy that can be observed, but does not always _accompany_

it, and frequently arises from other causes. In the great majority of

cases, it is true, the menses cease to flow, immediately conception

occurs; sometimes they will continue for one or more periods after, and

occasionally during the whole time of gestation, even up to a few days

before delivery. This, however, is a very unusual occurrence, and the

stoppage of the menses is by no means so strong a sign that pregnancy

_has_ occurred, as their continuance is that it has _not_. Some females

are always irregular, so that pregnancy makes little difference, and

in them of course these signs are even less to be depended upon than

usual. There have cases been known even of women who have conceived

without having _menstruated_, and of others who never menstruated

except when they were pregnant; and it is not at all unusual to see

others who will conceive while nursing, and never menstruate between

the two pregnancies. Therefore we can only say that the menses

_usually_ stop when conception occurs, and that their continuance is

strong evidence that it has not occurred, but still both signs may fail.

It is also proper to remark that several medical men have advanced

the opinion that the discharge which appears during pregnancy is not

the menstrual fluid, but real blood. It has however been accurately

examined, and found in no respect to differ from the usual discharge.

In my own opinion there is no doubt but that some females really do

menstruate while pregnant.

As an instance that the presence of the menses is no proof that

pregnancy has _not_ occurred, I give the following case:--Not long

since I was requested to see a lady who was supposed to labor under

a polypus in the womb. She had been married six years, but had no

offspring. On seeing her I suggested, from certain peculiarities in

her appearance and manner, that _possibly_ she might be pregnant. The

suggestion was met with a smile, particularly by the medical attendant

who was present, and I was told that there was no sign of such a thing,

and moreover it _could not be_, for she had never stopped menstruating,

nor was there the slightest change in the breasts, nor any disturbance

in the stomach, mind, or feelings. On making the usual examination

however, I felt fully _convinced_ I was right, and told them so, but

my opinion had no other effect than to induce them not to interfere

for a time. They had been talking of an _operation_ immediately. She

still continued to menstruate for three months after, but in six weeks

from her last period was safely delivered, without assistance, of a

very fine living child. No part of the body had undergone any material

change, except the abdomen, though many of the usual changes occurred

after delivery. In this case the delay probably saved the lives of both

mother and child, and deeply grateful they all were for the escape.

In my work on the Diseases of Woman many fatal cases will be found of

pregnant females who have been killed from mistakes of this kind, owing

to a blind reliance on such uncertain signs.

_Disturbance of the Digestive Functions._--It is very seldom, indeed,

that pregnancy does not produce more or less disturbance in these

functions, though it must be remarked that _marriage_ also does the

same sometimes, even without conception. These disturbances are

generally manifested by loss of appetite; sickness, particularly in

the morning; vomiting, and depraved taste; the individual frequently

taking a fancy to the most extraordinary articles, and making herself

extremely unhappy if she cannot obtain them. Thus some have eaten

flies, spiders, mice, and other living things, and others again have

regaled themselves upon charcoal, chalk, slate pencils, and even earth

or ashes. Such freaks are called _longings_, and it is thought highly

improper not to indulge them, which is certainly right when they are

for articles not positively injurious; but I have known this notion

carried to a very injurious and absurd extent. There is no doubt but

these vagaries of the stomach arise, mainly, from its sympathy with the

uterus, but it is highly probable that they are often exaggerated, and

frequently even produced, by a morbid state of the sensibilities, and

by vacuity of mind. The tendency to imitation also, so strong in most

females, often leads to the same result. A young female who is declared

to be, or who fancies herself, pregnant, listens eagerly to all that

is said about that interesting state, by older acquaintances, and when

told that _they_ always _longed_, immediately begins to long also. I

have known young persons considerably advanced in gestation, who had

never longed at all before, do so immediately after a conversation of

this kind. It must be remembered however, that the sympathies of the

digestive organs with the womb are very strong, and that the appetite

and taste are frequently rendered very capricious at this time, so

that the female really likes or dislikes many things that she did not

before; but still I feel convinced that the absurd ways in which this

caprice exhibits itself, are often owing to the causes I have stated.

The wondering ignorance, in which most females are kept, makes them

disposed to be led away by a morbid imagination, and constantly liable

to be imposed upon by silly and erroneous statements, which they of

course implicitly believe. These longings are always the strangest, and

most frequently met with, among the most uninformed and unthinking,

though they are occasionally met with under all circumstances. As a

sign of pregnancy this longing is not much to be relied upon alone,

because marriage alone often produces it, and so do many uterine

derangements.

Usually all these disturbances disappear by the third or fourth month,

the appetite becomes regular, and sometimes even voracious, and the

digestion improves, so that the individual may become quite fat, though

previously she was very thin.

Some suffer from constipation, and others from diarrhœa, but this is

more rare.

_Nervous Derangements._--The changes produced in the minds and feelings

of pregnant females are sometimes of the most extraordinary character.

Individuals who possess, ordinarily, the most agreeable tempers, and

the most amiable dispositions, will become peevish and fretful, and

often even violently passionate and malicious. Some have even been

known to have a disposition to commit various crimes, of which they had

the greatest horror in their natural state. Others, on the contrary,

who are usually ill-tempered and unhappy, attain a charming tenderness

of manner, and a most pleasing serenity of mind. Their likings and

dislikings also change very much, so that their most valued friends

will become hateful to them, and those whom they habitually dislike

will seem endowed with every loveable quality. Some will become perfect

misanthropes, or weep and fret without intermission, while others will

exhibit the most reckless and boisterous gaiety. I have known some much

disposed to study while pregnant, and others who would draw, or paint,

most excellently, though at other times they were but indifferent

artists. In short, it is impossible to denote half the singular changes

of this kind that are thus produced. Suffice it to say that, when well

marked, they are strong presumptive signs of pregnancy, especially

when coming in connection with other evidences. It must be remembered

however, that hysteria, and some other uterine diseases, are often

accompanied by similar changes.

_Alteration in the appearance of the Breast._--The direct, and

sympathetic connection between the womb and the breast is so great that

pregnancy usually causes corresponding changes in both, though not

always. In most cases however, the breasts swell, and become painful.

The nipple becomes elevated, and the circle around it assumes a dark

brown color, and is dotted with small tubercles, from which a thin

watery liquor may often be pressed. The nipple will also enlarge, or

become erect on being rubbed, and, as gestation advances, milk may

be forced from it. Most of these signs however, may be wanting in

pregnancy, and may arise independent of it. Chronic inflammation, and

other diseases of the womb, will frequently produce them, as may be

seen in my "Diseases of Woman." _Marriage_ alone frequently causes

such symptoms, particularly in certain temperaments, and deranged

menstruation will frequently produce them.

The alteration in the color of the areola, or circle round the nipple,

is a sign much relied upon by some, but is frequently a deceptive one,

merely from want of close observation. I have known many females,

though frequently mothers, whose breasts always retained the bright

rosy color they had previous to marriage; and I have known young

unmarried females with the breasts quite dark. The peculiar hue that

arises from pregnancy however, is different from anything I ever saw in

non-pregnant females; and, though not always to be met with, is, in my

opinion, an infallible sign when present. The celebrated John Hunter

regarded this sign as an unmistakeable one, and he gave a remarkable

instance of it in his lectures. In making a _post mortem_ examination

of the body of a young female, he observed this peculiar color, and

at once proclaimed her pregnant, _though the hymen was unbroken_.

On dissection he was found to be correct--she was four months

advanced. If this sign were constant, pregnancy could nearly always be

ascertained, but frequently it does not appear. The peculiar color must

be seen to be recognized, as it cannot be accurately described; perhaps

the nearest approach to it is the shell of a fresh _ripe chestnut_, but

it is much darker in some than in others. The dark circle is nearly

always more elevated than the rest of the breast, as may be seen by

taking a profile view.

[Illustration: PLATE XIII.

_View of the Breast about the Fourth Month._--_a. a._ The Breast.--_b._

The Nipple.--_c._ The Areola, or part which becomes brown; it is

elevated above the rest of the Breast, as may be seen.--_d. d._ The

little Tubercles.]

Most frequently the breasts do not swell, nor the areola change color,

nor the tubercles appear, till about the fourth month, and frequently

much later.

All these changes in the breast are also liable to become more or less

permanent, after the first pregnancy, so that they are of much less

service, and less to be depended upon, in all succeeding ones. They

also remain, with most females, during nursing, and are therefore not

available in those who conceive while they are nursing. On the whole

however, these signs, especially in those not previously pregnant,

may be pretty confidently relied upon, and will seldom deceive an

experienced observer.

_The secretion of milk_ is, by most persons, considered a positive sign

of pregnancy, but it is not so, for it sometimes takes place in young

girls merely from the establishment of puberty, and in some females

it always occurs at each monthly period, though they have never been

pregnant. Instances have been known of women nursing other people's

children though they had never conceived themselves.

_Miscellaneous signs._--There are a few other presumptive signs, not

easily classified, some of which are of value, while others are so

uncertain, or so little available, as to be almost worthless. All these

however, it is necessary to point out, because some of them may be made

use of in cases where the more ordinary signs are absent.

In the unimpregnated state the mucus membrane, which lines the Vagina,

is of a bright rose color, but in nearly every case of pregnancy it

changes to a bluish, or purplish hue. I do not recollect a single

instance, in the course of my own observation, in which this change

has not occurred, and the same statement is made by several eminent

authors. It is true that in some young females the mucus lining is

naturally darker than it is in others, but, like the areola round the

nipple, this natural tinge is not like that produced by pregnancy. It

is of course impossible to say whether this blue tinge is _always_

produced, though I am inclined to think it is, and I should certainly

consider it an almost infallible sign when present. Parent Duchatelet

states that he was present when M. Jacquemin proved this, without a

single failure, _in four thousand five hundred cases_.

Many females are also warned of their condition by pains in various

parts of their bodies, the most frequent of which is one felt at _the

top of the head_. Some always have palpitation at the heart, and others

experience a singular kind of _fluttering_ in the womb.

Many medical men rely altogether on certain peculiarities in the

_urine_, and as this sign is really a valuable one, in some cases, I

will describe the mode of examination fully. The urine is put in a

clean vessel, and allowed to stand perfectly still. In a short time,

varying from two to six days, a number of little opaque bodies begin to

rise from the bottom, like flocks of cotton, which unite together at

the top into a thin but firm layer, or pellicle, like cream on the top

of milk. This layer is frequently so consistent that it can almost be

raised out of the vessel, by taking hold of one edge, and may be easily

drawn out by passing the finger under it. This substance is called

_kyestein_. It is of a whitish color, semi-transparent, and looks as if

it were partly crystalized. After a few days, if left undisturbed, the

urine becomes thick and muddy, and the pellicle of kyestein breaks up

and falls to the bottom. According to the experience of many medical

men, and so far as I have seen myself, this peculiar substance is

_always_ to be found in the urine of pregnant females, after the first

month, and frequently even earlier. Sometimes a substance _similar_ to

it is observed in the urine of those not pregnant, but there is, in

most of these cases, sufficient difference between them to enable any

one, who has seen both, to distinguish one from the other. The only

time, except during gestation, when real kyestein appears to be formed,

is while the milk is being secreted and not freely discharged. Thus it

may often be found when the female is weaning, and, some writers assure

us, in some cases during the whole period of nursing. On the whole

this sign is a very valuable one, and may be much relied upon.

The changes in the pulse, on which some persons rely, are of no value

whatever as a sign of pregnancy, since they are no more frequent, and

not at all different, so far as I have seen, from what ordinarily occur

from other causes.

The development of the abdomen, though an invariable accompaniment

of pregnancy, is by no means a certain sign of it, since it may be

produced by other causes; and besides, it is sometimes but little to

be observed till a late period. The peculiar manner of the development

however, is usually somewhat different from that produced by tumors,

and other diseases. Very often the abdomen will be tolerably large by

the second month, and then again become so much smaller that the female

will think she is certainly not pregnant. This is owing chiefly to

flatulence, produced by digestive disturbance during the early periods,

but which afterwards subsides. In a short time however, the uterus not

only enlarges more, but rises, and the development becomes permanent.

This circumstance of there being often _two_ developments has deceived

many, and I have known females declared to be not pregnant, simply

because the development of the abdomen went down, who, in a short time

after, exhibited unequivocal evidences of being in that condition.

The first development, or swelling, is merely similar to what often

arises from indigestion, and other causes, and is therefore no sign of

pregnancy; but the second development is accompanied by other changes,

besides being more permanent.

The linea alba, or white line, which may be seen extending from the

navel to the pubis, in the ordinary state, becomes much darker, the

skin of the abdomen wrinkles, and the umbilicus, or navel, becomes

prominent.

Swelling of the eyelids, and puffing of the face, are experienced by

some females, but are not very general, and so frequently result from

other causes that they are of little value as evidences in this case.

This, I believe, comprises all the presumptive signs of Pregnancy that

are worthy of notice. Some of them are valuable and may be depended

upon, particularly the presence of kyestein in the urine, which may

almost be called a _certain_ sign. Others of them are of little value

alone, but are useful in the way of corroboration. The more there are

of them observed together, in any case, of course the more grounds

there are for the _presumption_ that pregnancy exists, and the reverse.

It must be carefully remembered however, that these presumptive signs

are precisely those most likely to be produced by other causes,

particularly by _marriage only_; they must therefore be well weighed,

and unless very numerous, or very distinctly marked, must not be

regarded as conclusive. As already remarked, it is only during _the

first three months_ that most of these presumptive signs are taken much

notice of; after that we have others that can be more depended upon,

and which will be described in the succeeding articles.

PROBABLE SIGNS.

_End of the third month._--The probable signs now to be described are

seldom recognized before this time, and not generally with distinctness

till a still later period. They chiefly consist of certain changes in

the form, development, and position of different parts of the uterus,

to ascertain which requires an internal examination. These changes are

not observable till the end of the third month, previous to which time

we cannot be certain that the womb has really increased beyond its

normal size. And even then, when the increase is obvious, we cannot

tell how it has been produced; it is not till a much later period, till

five or six, or even seven months are elapsed, that pregnancy can be

ascertained with anything like certainty.

The changes to be noticed are in the form, and size, of the neck and

body of the womb, and in its mouth, and also in the weight of the whole

organ. No one, of course, can expect to recognize these changes who is

not acquainted with the parts in the unimpregnated state, both in the

virgin and in those who have borne children.

The mode of conducting the requisite examination is, by introducing

the index finger of the right hand, covered with oil or mucilage,

into the Vagina, and then carrying it upwards till it reaches the Os

Tincæ. By means of this finger the position and length of the neck of

the womb are ascertained, and also the state of its mouth, whether it

is opened or closed, and to what extent. If it be then placed at the

top of the neck, on the under side, and the other hand upon the fundus

of the womb externally, and pressing firmly upon it, the organ is

enclosed as it were between the two hands, so that its size and form

may be pretty accurately ascertained, and also its degree of firmness,

by which a judgment may be formed as to whether it is occupied by any

solid body, or fluid, or whether it is empty. In addition to this a

pretty accurate estimate may be made of its comparative _weight_, by

_balancing_, and raising it up on the finger. This is called by the

French _Ballotment_, and, as will be shown further on, is a valuable

means, at certain stages, of ascertaining pregnancy.--(See Plate XVI.)

The female may be examined either standing or lying down, though the

recumbent position is best, except in certain displacements of the

womb, when it is most likely to be thrown into a position in which

the neck can easily be reached by the female standing. The position

of the neck is very different in many of these displacements, and

during pregnancy, to what it is in the ordinary state, and a person not

acquainted with these changes might frequently be much puzzled to find

it. As we have already remarked, also, there are certain differences

between those who have had children and those who have not. The

following three diagrams represent the changes just spoken of at three

different periods:--

PLATE XIV.

_Figure 1_, represents the form and size of the body, neck, and mouth

of the Womb, at about the third month.

_Figure 2_, the same at about the seventh month.

_Figure 3_, the same at the ninth month.

The references are the same in all. _a._ The Neck of the Womb.--_b.

b._ The Body of the Womb.--_c._ The Os Tincæ, or Mouth of the

Womb.--_d. d._ The cut edges of the Vagina.

[Illustration: Fig. 1.

Fig. 2.

Fig. 3.

Plate XIV.

The form and size of the body, neck, and mouth of the Womb, at about

the third, seventh and ninth months.]

It will readily be seen by these diagrams that the alterations in

the neck and mouth of the womb are very marked, and of a character

easily to be ascertained by the touch. These three should be compared

with the section of the womb in Plate IV, which represents it in the

unimpregnated state.

The difference between those who have borne children, and those

who have not, is well represented in Plate XV,--the drawings being

one-third of the natural size, and representing the appearance at about

three months.

[Illustration: PLATE XV.

Primipara, or the first Pregnancy.

Woman who has borne children before.

_a. a._ The neck of the Womb.--_b. b. b._ The body of the Womb.--_c._

The Os Tincæ, or mouth of the Womb.--_d. d._ The cut edges of the

Vagina.--_e_. The Fœtus.--_f. f._ The Fallopian Tubes, Ovaries, and

Round Ligaments.--_g._ The Placenta.]

Most of the changes produced can be readily distinguished by the

finger, after seeing this representation, and making a proper

comparison between it and the natural state in Plate IV.

The Neck is not much enlarged at this period, but its lower part is

somewhat soft to the feeling. The Os Tincæ is more _rounded_ than in

the unimpregnated state, particularly in the Primipara, in whom in fact

it is nearly circular, the lips being quite smooth and closed. In the

female who has already borne children it is somewhat open, so that the

finger may often be introduced; and the lips feel rough, owing to scars

and laceration in previous deliveries. It is also larger altogether,

and softer, than in the primipara. The whole length of the neck at this

stage is about two inches.

The body of the uterus, when pressed between the two hands, will be

found much larger than ordinary, and more round, and it will feel heavy

when pushed up by the finger.

In regard to the precise value of these probable signs, it can only

be said, when they are observed, that it is certain that the womb

is enlarged, and _most probably_ from pregnancy. But at the same

time it must be remembered that several diseases, and particularly

suppressed and irregular menstruation, or the development of tumors and

polypi, will effect very similar changes, and that it is not _always_

possible to say whether they arise from these abnormal growths or from

pregnancy, though it can generally be done. But though we cannot,

in every case, say when these signs exist, that the female must be

pregnant, we can nearly always say, when they do not exist, that she

cannot be so, particularly if the other usual signs are absent.

_End of the fourth month._--By this time the neck has become a little

shorter still, and the mouth more open, but on the whole there is

not much change to be felt internally. The body of the womb however,

has now ascended above the superior strait of the Pelvis, and begins

permanently to enlarge the Abdomen. It may be distinctly felt between

the two hands, like a firm round ball, somewhat elastic, and resisting

when pressed. This is the period when the motions of the fœtus are

usually felt first, and these motions, with the ascension of the womb,

are sometimes experienced very suddenly, so as to alarm the female,

and produce certain curious sensations, with much nervous derangement.

This is called _quickening_, and, with some persons, is always so well

marked as to indicate not only their condition, but the very period,

with great precision. Many however, never experience anything at all

peculiar at this time.

It is customary for the medical attendant, as a means of making the

child move, to put his hand first in cold water, and then over the

fundus of the uterus; the sensation of cold thus conveyed usually

causing it to move immediately. Great care must be taken however,

that other motions be not mistaken for those of the child, an error

not at all uncommon. Many a female, and many a medical man also, has

been deceived in this way, particularly in cases of uterine or ovarian

dropsy, and tumor, and even in ordinary flatulence and hysteria.

Females who much desire offspring frequently deceive themselves in this

way, and it is sometimes next to impossible to convince them of their

error. Some women possess the power of _imitating_ the movements of

the child, with great exactness; and instances have been known where

they have successfully imposed, both on their friends and medical

attendants, for a long time, in this way. Mr. Dubois mentions instances

of females who possessed this extraordinary power, and who, though not

pregnant, used to present themselves to his class, for the pupils to

_ascertain the motions of the child_. In short, this sign must not be

too much relied upon, nor too confidently expected, for many females

observe no fœtal motions at all till the sixth or seventh month,

and even then very indistinctly. Sometimes also, after having been

distinctly felt, these motions will altogether stop for a long time,

and then appear again.

At this time however, _Ballotment_ can begin to be practised, though it

is not quite so certain as at a month later. The manner of performing

this important manipulation has already been partly described, and by

examining Plate XVI, and attending to the following remarks, it may be

readily understood and practised.

PLATE XVI.

This Plate represents the mode of performing the Ballotment, to

detect pregnancy. The outline of the figure is the same as in Plate

I, and most of the organs are lettered the same.

The index finger of the right hand is passed into the Vagina till it

touches the body of the Womb, the neck being thrown back, owing to

the tilting of the Fundus forward. The left hand is pressed firmly

upon the Abdomen, just over the pubic bone.

1, Is the Fœtus.--2, The Placenta, connected with the Fœtus by

the cord.--3, Is the index finger of the right hand, within the

Vagina.--4, Is the left hand.

The development of the Womb, and the change in its position, are very

well represented in the Plate, and so are the alterations in some of

the other organs. The manner in which the Bladder, A, is pressed out

of its usual shape and size, may be seen by comparing this with Plate

I. The shortening of the Vagina, and the expansion of its upper part,

are also equally obvious, and the manner in which the mouth of the

Womb is thrown back against the Rectum.

[Illustration: Plate XVI.

This Plate represents the mode of performing the Ballotment, to detect

pregnancy. The outline of the figure is the same as in Plate I, and

most of the organs are lettered the same.]

When the right hand finger (1 Plate XVI,) is carried to the top of the

Vagina, it meets with a round soft tumor, which is the head of the

child felt through the walls of the womb. As soon as this is distinctly

felt, the finger must be withdrawn a little, and then pushed suddenly

against the tumor with a jerk; this will displace the fœtus, and cause

it to rise in the liquor amnii towards the Fundus, so that the round

tumor will have disappeared. In a few moments it will sink down and

may be again felt, and again displaced in the same manner. This is

called the _Ballotment_, or balancing it on the end of the finger. The

sensation conveyed on touching the Fœtus, and when it rises after being

pushed, are so peculiar that they are not likely to be overlooked, or

mistaken for anything else, after being once experienced. The jerk is

not required to be at all violent, and had better be made at first

very slight, as it can easily be repeated a little more forcibly if

the tumor does not rise at first. Some practitioners practice the

Ballotment in this way, using the one hand only; but others place the

left hand also on the Abdomen, (4 Plate XVI,) at the same time, and

immediately after jerking _upwards_ with the right hand, they suddenly

depress the Abdomen, just over the pubes, with the fingers of the left,

so as to send the Fœtus down again more quickly and more forcibly. This

is seldom needed, but if the first way does not succeed the two hands

may be tried.

A species of ballotment may even be practised externally, in the

following way:--The fingers of the right hand are placed on the

Abdomen, just over the fundus of the womb, like the left hand in Plate

XVI, and a smart jerk is given downwards and backwards, several times

in quick succession. This also displaces the Fœtus, which may be

distinctly felt to float away, each time the percussion is made. No one

can mistake this peculiar motion who has once felt it.

Sometimes one of these manœuvres will succeed when the other fails, so

that it is well to practise them all. They may be performed with the

female either standing or lying down, and will sometimes succeed one

way when they will not the other.

It is requisite to remember that in presentations of the breech,

or trunk, the ballotment may not succeed as well as when the head

presents; or it may even fail altogether, so that when it is

unsuccessful we must not immediately conclude there is no pregnancy.

Tumors in the womb, stone in the bladder, and various uterine

displacements, may also create uncertainty, or cause failure, but these

accidents are rarely met with, and only interfere materially at an

early stage; afterwards ballotment can be practised notwithstanding

them, or auscultation may be resorted to.

In short, this mode of detecting pregnancy is one of the most certain,

and the most generally applicable, that we possess.

_End of the fifth month._--At this time the Uterus has increased

considerably in size, and has ascended so high in the Abdomen that the

Fundus is level with the umbilicus, or navel, in a first pregnancy,

though somewhat lower in those who have borne children before. This

rising of the womb makes the Vagina longer, and brings the neck of the

womb nearer to its centre. In the previous stage the neck was thrown

so far back that it was difficult to reach, but now it is much more

favorably situated, though much higher. Its substance is softer than

before, and the two lips are nearly on a level, and somewhat opened,

particularly in those who have borne children before. Indeed, in them

the point of the finger may be introduced, as seen below:--

[Illustration: PLATE XVII.

Neck of the Womb in a first Pregnancy, very slightly opened.

Neck of the Womb in a female who has borne children before, showing how

it admits of the introduction of the finger.

This is at the end of the Fifth Month, and the drawings are about

one-third of the natural size.]

Ballotment is now much more easily practised, and is more conclusive.

A new sign is also to be distinguished, by which we are furnished with

another valuable means of detecting pregnancy. The child's heart begins

to beat so strongly, and its circulation is so vigorous, that the

_sound_ of it can be _heard_ externally. The same means are taken to

ascertain this that are used in sounding the chest of an adult. If the

ear be placed on the Abdomen, over the womb, the beating of the fœtal

heart may be heard quite plainly; and if the stethoscope be used it

will be still more distinct. This practice is called _Auscultation_.

The signs furnished by it are certainly of the greatest value, and

frequently enable us to detect pregnancy with unerring certainty.

Indeed, not only can we tell by them that a child is in the womb, but

often even _the very position in which it lies_, and whether there be

_twins_, _or more_. This is done by noting where the heart is situated,

by the sound, and whether the beating is single or double.

The nature of these sounds, and the manner of detecting them, require

to be carefully explained.

If the person wishing to notice this sign is not already familiar with

the beating of the adult heart, he had better become so first. The ear

should be placed on the left side of a grown up person, on the skin,

just beneath the breast, and held very still. The heart will then be

heard to beat very distinctly, there being two sounds, a long one and a

short one, alternating with each other. When this has been listened to

for some time, the ear will be able to catch any similar sound, and the

auscultation may then be practised to detect pregnancy.

The ear must be placed on the Abdomen, about midway between the Pubes

and the umbilicus, and towards the left side. No weight should be borne

on the body, but the ear must be laid sufficiently close to exclude all

external sounds, and no motion should take place, particularly with the

clothes. If the sound be not heard in the position first assumed, move

a little, in different directions, till that point is attained where it

is most distinct. It can scarcely fail to be heard, with ordinary care.

A practised ear will sometimes distinguish the sound as early as the

fourth month, but generally it cannot be heard before the end of the

fifth, or even till the sixth month. There are several sounds that may

either be mistaken for it, or that may confuse the ear. The beating of

the mother's heart will sometimes be very distinct, as far as the lower

part of the Abdomen, but it is much slower; the child's heart throbbing

nearly twice as fast. The movements of the Fœtus, and the rumbling of

the intestines, will also interfere; but when once the proper sound has

been caught it may be kept independently of all these.

The manner in which the child lies in the womb will determine where the

heart shall be opposite, and as its position frequently varies, both in

different individuals, and at different periods, in the same person,

the sound must be sought for at several points, till the right one is

found. The most usual position will be seen in several of our plates,

and they will give sufficient indication to enable almost any one to

practise this mode of detection with success. During the early months

the child moves about a good deal, so that the sound may be heard one

day in one place, and the next in another. About the seventh month

however, it becomes more fixed, so that the place of the heart can be

pretty certainly ascertained, and thus the _position_ of the whole body

is made out, whether the head is downwards or upward, and a tolerable

idea can be formed even as to the direction of each part.

Many persons have failed in their attempts to hear the Fœtal pulsation,

but I cannot but think it must have been either from inattention, or

from not being acquainted with the sound of the heart at all. I never

recollect an instance when I could not do so, at the proper time. M.

Chailly says he does not hesitate to affirm that in every instance

they can be detected; and M. P. Dubois distinctly heard them in one

hundred and eighty-five females, out of one hundred and ninety-five,

in the other ten the child being probably dead. Indeed, the absence of

this sound is the most certain sign of the death of the Fœtus, as its

existence is of its being alive; and medical men now tell whether the

child is dead or not by these very means.

In conducting the auscultation the female must recline, and keep as

still as possible, breathing low. The Abdomen may be covered with a

single thin garment, if absolutely insisted upon; but the judgment

will be so much the more uncertain, owing both to the deadening of the

sound and to the friction of the material. The experimenter must also

recollect that if the head be held down too long, the blood will rush

to it, and cause a humming in the ears, which will confuse him; it will

therefore be better if the bed be high.

It is always best to use the _stethoscope_, as it covers only a small

space, conveys the sound more directly, and shuts out external noises

more effectually. This instrument is extremely simple, consisting

merely of a tube of wood, glass, metal, gum elastic, or almost any

other material. One end should be expanded a little, like a bell, and

the other made small, so as to fit close in the ear--the large end

being placed on the Abdomen. It may be about a foot in length, though

a little shorter or longer will not make much difference. I once used

a child's _tin trumpet_, having no regular stethoscope with me, and

succeeded with it perfectly. The large end should be pressed on the

Abdomen, and the smaller one into the ear, sufficiently close to shut

out all other sounds but those coming from the body. This is the same

instrument that the lungs are sounded with, when we want to judge of

their action and condition.

This is an invaluable means of detecting pregnancy; in fact, at the

proper time, and with due care, it may be said to be _certain_.

_End of the sixth month._--This is the period when, according to the

law, the child can live. There are no new signs at this time, but those

previously noticed are now more distinct. The neck of the womb is still

softer and shorter, and the finger can penetrate further in the passage

than before. The fundus of the womb is now above the umbilicus, in

primipara, though not so high in those who have borne children; and the

bladder is above the superior strait.

Ballotment can now be practised with certainty, the falling and rising

of the Fœtus being very distinct.

Auscultation also becomes more positive, the sounds being louder and

more easily ascertained.

_End of the seventh month._--The fundus of the womb has now risen still

higher, and the Bladder is pushed completely above the upper strait,

so that the whole length of the Urethra lies behind the pubic bone. It

is then much pressed upon and swollen, and being much longer, and bent

out of its usual course, the urine is often passed with difficulty, and

the catheter can scarcely be introduced. The upper part of the Womb

now lies over towards the _right side_ of the body, very evidently.

This direction is nearly constant, in all females, but the reason for

it is not known. There have been many theories to account for the

peculiarity, but none of them are either so plausible, or so well

supported by facts, as to be generally adopted.

The upper part of the Womb being tilted to the right side, the neck

of course points to the left, and backwards. It is now very short,

even in primipara, but in those who have borne children it is scarcely

to be distinguished at all. The finger may now be introduced, even in

primipara, half way up the neck; and in others it will reach even into

the uterine cavity.

[Illustration: PLATE XVIII.

First child.

Woman who has borne children.

The neck of the Womb in a first pregnancy, and in a female who has

borne children before, at the end of the seventh month.]

The part below the lower line here, shows that part of the neck which

is contained in the Vagina. It will easily be seen how much shorter

this part is, and how much more open the passage is, in the female who

has borne children, than in a first pregnancy.

Ballotment and Auscultation both, now afford unmistakeable evidences as

to the condition of the patient.

_End of the eighth month._--By referring to the preceding Plates, it

will be seen that the part of the neck of the Womb _above_ the Vagina,

which is placed between the two dotted cross lines, remains almost

unchanged, while the part _within_ the Vagina, or that below the lowest

line, becomes less and less, till at this time, in those who have borne

children, it can scarcely be felt at all; and even in a primipara it is

merely like a small tubercle. About this time however, the upper part

of the neck begins to shorten also, though that is not so obvious, and

therefore not so useful for our present purpose.

On making an examination, the mouth of the Womb itself may now be felt,

at the upper part of the Vagina, and far back. It is however, very

difficult to reach, on account of its position. The finger will now

pass, in those who have previously borne children, into the cavity of

the Womb itself, but in others it will scarcely reach so far.

The linea alba becomes darker at this period, and so does the areola

around the nipple. Certain peculiar marks also appear on the Abdomen,

and upper part of the thighs, almost like the _pits_ from small pox.

They are usually diamond shaped, slightly depressed, and dark in

color. They appear to be owing to the over stretching of some of the

parts under the cuticle, and which give way in consequence. In first

pregnancies, and in those who enlarge very much, these marks are

sometimes very numerous, and remain for a long time after delivery,

sometimes even they never disappear. As signs of pregnancy however,

they are but of little value, because they are often produced by other

causes that distend the Womb. None of these presumptive signs are now

needed, and therefore they are of little consequence, because there are

others more certain.

The motions of the child itself can now be generally both felt and

seen, and an experienced observer may even predicate from them, with

tolerable certainty, the position in which it lies. Ballotment, by

one hand on the Abdomen, may still be practised with success; but in

the Vagina it is difficult, because the Fœtus is both more fixed and

heavier.

Auscultation is now the surest dependence however, and may be

advantageously resorted to also as a means of determining beforehand

the position of the child. This may be done even a month earlier, but

not so certainly as now.

To understand how this important point is determined, it is only

necessary to recollect, as will be very evident, that the pulsation

will be heard the loudest immediately over the heart; and as we know

the form and general size of the Fœtus, and the manner in which it

usually lies, it becomes possible, when the position of its heart is

discovered, to trace out, from that, the position of every other part.

This will be evident by referring to Plates XIX, XX, and XXI. It will

then be seen that, if a line be drawn across the middle of the Abdomen,

the heart will be _above_ that line when the breech presents, and

_below_ it when the head presents, and on the right or left side, as

the case may be, in each position.

In case of twins there will be two pulsations, and they so much

interfere with each other that it is difficult to distinguish either.

The two children being generally disposed with the head of one to the

heels of the other, one heart will be _above_ the line, and the other

_below_, on opposite sides, as shown in Plate XXII.

PLATE XIX.

This Plate represents the Fœtus in the most usual position, the head

downwards, and the back of it presenting to the _left_ side.

The black spot _a_, shows the situation of the heart; usually

immediately under that part where the sound is heard the

strongest.--It is below the line.

[Illustration: Plate XIX.

This Plate represents the Fœtus in the most usual position, the head

downwards, and the back of it presenting to the _left_ side.]

PLATE XX.

This Plate represents the Fœtus in the next most frequent position,

the head downwards, but the back of it presenting to the _right_ side.

The black spot _a_, shows the situation of the heart as in the

previous Plate. It is now below the line, as before, but on the

opposite side.

[Illustration: Plate XX.

This Plate represents the Fœtus in the next most frequent position, the

head downwards, but the back of it presenting to the _right_ side.]

PLATE XXI.

This Plate shows the position of the Fœtus in a presentation of the

Pelvis, or breech, which happens, comparatively, but seldom.

The black spot _a_, denotes the situation of the heart, which is here

_above_ the line, instead of below.

In this case, as in the others, the heart may be on either side of

the body, according as the child faces, but always above the line.

[Illustration: Plate XXI.

This Plate shows the position of the Fœtus in a presentation of the

Pelvis, or breech, which happens, comparatively, but seldom.]

PLATE XXII.

This represents the position of Twins, as most usually observed, one

having a head presentation, and the other a breech.

The black spot _a_, on both, denotes the position of the heart, which

in one case is above the line, and in the other below.

The head however, may be on the right side instead of the left, and

so reverse the position of the two hearts, but this is very seldom

the case.

When there are more than two, the confusion and uncertainty becomes

still greater.

[Illustration: Plate XXII.

This represents the position of Twins, as most usually observed, one

having a head presentation, and the other a breech.]

At this period the signs previously observed become more distinct, but

there are few new ones. The external lips sometimes swell, and the

breathing becomes more difficult, owing to pressure on the diaphragm.

The trouble with the urine is also apt to increase, and little mucus

tubercles, like pimples, occasionally form around the Os Tincæ, and on

the upper part of the Vagina.

_End of the ninth month._--There is but little difference between this

and the previous period. The mouth of the Uterus is more open, and,

in those who have had children, the finger will pass directly into

the Womb, and feel the child, but in primipara there is still a small

portion of the neck left.

[Illustration: PLATE XXIII.

Fig. 1.

The neck of the Womb, at near the end of nine months in a primipara.

Fig. 2.

The neck of the Womb, at near the end of nine months, in a woman who

has previously borne children.]

Ballotment is now more obscure than before, as the Fœtus is very heavy,

and quite low down, and pretty firmly fixed. Auscultation is distinct

enough, but not more so than at the previous period. The swelling of

the lips, and of the veins of the legs, may increase, and so may the

difficulty with the urine; but the breathing generally becomes easier,

owing to the Womb having descended a little, and so pressing the

diaphragm less.

These comprise all the signs and indications of pregnancy that possess

any real value. Some of them, at certain times, and under particular

circumstances, may be called _positive_; such as those discovered by

Ballotment and Auscultation, and also the presence of Kyestein in the

urine. Most of the others merely make it _probable_ that pregnancy

exists, or warrant us in presuming as much. They are not to be depended

on implicitly alone, but when many of them are observed together, and

no other cause can be assigned for their production, the presumption

becomes so well supported as almost to be called a moral certainty. A

person of experience, who is familiar with all these signs, and with

the others produced by disease which resemble them, will seldom find

it difficult to decide; but still there are cases in which pregnancy

proceeds, even to its termination, with but few unusual symptoms, so

that both patient and attendant are completely at fault. This however

is very rare, and many eminent authors contend that it is _always_

possible to detect pregnancy, _after the sixth month_, and I think so

myself, unless the child be dead, in which case it will soon be evident

in another way.

CHAPTER VI.

DURATION OF PREGNANCY.

The duration of pregnancy, or the precise term of Utero Gestation, is

not fixed. It appears, from accurate observation, that there is no

absolute period determined by natural laws, and therefore there is

none laid down by human enactments. An approximation can be made, by

taking the average of a number of cases, and the period of limitation

may also be determined in the same way. The most usual period is about

nine months, or from thirty-five to forty weeks, some females going

beyond the thirty-six weeks, and others not so long. First children

are frequently born under the nine months, and more so than those that

come after; this is a fact not generally known, and ignorance of it

has often given rise to unjust suspicions. It is quite possible for

a female to be delivered, with the child at full period, in a little

over eight months after marriage, without there being any just grounds

whatever for suspecting unfaithfulness.

Dr. R. Lee, in his Lectures on the Theory and Practice of Midwifery,

gives the best summary that we have in the language, of our information

on this subject; I will therefore quote from his work, making such

comments and additions as I may think advisable.

"The Roman law fixed the period of gestation at ten lunar months. The

civil code of Prussia ordains that a child born 302 days after the

death of the husband shall be considered legitimate. By the law of

France, the legitimacy of a child cannot be called in question who is

born 300 days after the death or departure of the husband. The laws

of England declare that the usual period of human utero-gestation is

nine calendar months, or forty weeks; farther than this they do not

fix a definite period: the law is not exact as to a few days. Nine

calendar months contain only 275 days, and only 273 or 272 if February

be included. To fix bastardy on a child in Scotland, absence must

continue till within six months of the birth, and a child born after

the tenth month is accounted illegitimate.

"The difficulty of determining the precise time when impregnation

takes place in the human subject, renders it almost impossible, in any

case, to calculate with absolute certainty the duration of pregnancy.

We are, however, in possession of a sufficient number of observations

to establish the fact that the ordinary period is about forty weeks,

or 280 days; but it is certain that it does occasionally exceed

or fall short of this period by several days. As we can never be

certain of the precise day, between the periods of menstruation, when

conception occurs--whether it takes place immediately after the last

period, or before the expected period, or midway between these--it

is obvious that all calculations founded upon the cessation of the

catamenia must be extremely uncertain. The error of the calculation

will be still greater if the catamenia should have appeared, or a

discharge like the catamenia should have occurred once or twice after

conception. Impregnation most frequently takes place soon after

menstruation, but in others it does not happen till a few days before

the expected period; so that two women may have menstruated at the

same time, and one may have reached the full period three weeks before

the other; and to this extent, or nearly so, an opinion founded on the

disappearance of the catamenia may be erroneous.

"Calculations of the duration of pregnancy, founded upon what has been

observed to occur after casual intercourse, or perhaps a single act,

in individuals who can have no motive to tell us what is false, are

likely to be much more correct; and the conclusion to be drawn from

these is, that labor usually, but not invariably, comes on about 280

days after conception, a mature child being sometimes born before

the expiration of forty weeks, and at other times not until the

forty weeks have been exceeded by several days. A case came under my

observation very lately, in which I had no doubt the pregnancy existed

287 days: the labor did not take place till 287 days had elapsed

from the departure of the husband of this lady for the East Indies.

Some women are always delivered before the end of the forty weeks,

according to the usual calculation, and their children are mature.

"In the evidence given on the Gardner Peerage cause, the period

of utero-gestation was limited, but not strictly, by some of the

witnesses, to forty weeks, or 280 days; by others it was extended

to 311 days. Dr. Merriman, whose opinion is always entitled to much

respect, thinks the greatest number of women complete gestation in

the 40th week, and next to that in the 41st. Of 114 pregnancies,

calculated by him from the last day of menstruation, and in which the

children appeared to be mature, 3 deliveries took place at the end of

the 37th week; 13 in the 38th; 14 in the 39th; 33 in the 40th; 22 in

the 41st; 15 in the 42d; 10 in the 43d; and 4 in the 44th week.

"How long before the expiration of the 40 weeks a child may be born

with the power of supporting life has not been determined. Where I

have induced premature labor for distortion of the pelvis before the

end of the seventh calendar month from the last menstruation, I have

never seen a child reared. The lady of the clergyman in Fife, whose

case has lately given rise to so much discussion, was delivered 175

days after marriage, and the child lived five months. To what extent

gestation may be protracted in some cases beyond the 280 days it is

very difficult to determine, and the opinions of the most eminent

writers differ upon the subject. I should suspect some great error in

the calculation where the period of gestation exceeded 300 days. But

the experiments made on the lower animals prove that there exists in

them a great variation between the shortest and the longest gestation;

and it is difficult to comprehend why there should be a difference in

this respect in the human species."

In a trial which took place in this country, in the county of

Lancaster, Pa., as reported in the _Medical Examiner_ for June, 1846,

it was decided that Gestation may be prolonged to _three hundred and

thirteen days_! The female swore that conception must have taken place

on the twenty-third of March, 1845, and the child was not born till the

thirtieth of January, 1846, or over _eleven months_. The judge directed

the jury to return a verdict in her favor, and I suppose this case

establishes a precedent for America.

In a recent number of the _Medical Gazette_, I find a case reported

wherein the period was said to be prolonged still farther. A man left

his wife in New South Wales, he coming to England, and _twelve months_

after he left she was delivered of a child, which she claimed to be

legitimate. He denied this however, and the judge in the Consistory

Court decided, without hesitation, in his favor. Taking the medium

between these two cases therefore, it appears to be decided that the

_extreme limits_ is somewhere between _eleven_ and _twelve_ months! It

must be recollected however, that both were perfectly arbitrary, and

that, for anything known positively on the subject, both may be either

right or wrong.

Except when labor is brought on prematurely by violence, it always

commences at what would have been one of the monthly periods; or in

other words, after a certain number of _full months_, and never at any

time between! If therefore a female passes over the _ninth_ month, she

will probably go to the _tenth_. This has been proved by extensive

observation, and is only another proof of the regular method in which

nature conducts all her operations. The same law is also observed in

abortions, which generally take place at one of the months, unless

brought on suddenly by violence.

CHAPTER VII.

PERIOD WHEN THE CHILD CAN LIVE.

The precise period when the child can live, if brought into the world,

is not determined, any more than the time it may remain in the Womb.

Some children may be able to live a considerable time before the full

period of Gestation, and others may not till some time after, there

being a great difference in regard to their development.

One may be as fully developed at six, as another at seven months. The

common opinion is that the child cannot live if born before _seven

months_. This, however, is incorrect. Many instances have been known

of births at six months, and even earlier, in which the child lived,

and became strong and healthy. Van Swieten mentions the case of one

Fortunio Liceti, who was born before the sixth month. He was not

larger than the hand, but grew to the average size, and lived to be

seventy-one years old. Dr. Gunning Bedford mentions a similar case, in

his translation of Chailly's Midwifery. There are even cases mentioned

of children living at five months, but it must be borne in mind that

it is seldom possible to determine the exact period. As a general rule

however, the child does not live till after the seventh month, though

there undoubtedly have been cases where it has lived before the end

of the sixth month. The law adopts the medium period, and declares

the child capable of living at _the end of the sixth month_, and not

before. There is no reason whatever for supposing that it is less

likely to live at eight months than at seven, or that it will not live

at all at eight months, as some do.

SECTION III.

THE FORM, SIZE, AND POSITION OF THE FŒTUS, AND ITS APPENDAGES, AT FULL

TERM.

CHAPTER VIII.

FORM AND SIZE OF THE FŒTUS AT FULL TERM.

SIZE AND FORM OF THE BODY.

The average length of the Fœtus, at full term, is about twelve inches

from the head to the breech, and about eighteen inches from the head

to the feet. Its weight varies from five to eight pounds, perhaps

averaging about six, though some have been born weighing only three

pounds, or less, and some even as high as twelve. The breadth across

the shoulders is about four inches, and the same across the hips, but

both are so easily compressed that during delivery they only measure

about three inches, or three and a half at most.

SIZE AND FORM OF THE HEAD.

The head is the most important part, because it is the largest, and

usually present first. It is therefore necessary to describe it fully,

and with special reference to its importance, in the early stages of

labor, as the part by which the position is usually determined.

PLATE XXIV.

The head is generally divided into the Cranium, or that part which

contains the brain, and the Face.

_The Bones of the Cranium._--These are seven in number, viz., two

_Frontal_ Bones, or those forming the forehead; 1, 1, Figs. 1 and 2,

(Plate XXIV.)--Two _Parietal_ bones, or those forming the sides of

the head; 2, 2, Figs. 1 and 2.--The _Occipital_ bone, or that forming

the back of the head; 3, 3, Figs. 1 and 2.--And two _Temporal_ bones,

which lie over and between the ear and the eye; 4, Fig. 2.

_The Bones of the Face._--These are five in number, viz., two

_Superior Maxillary_, or upper jaw bones; 5, Fig. 2.--Two _Malar_, or

cheek bones; 6, Fig. 2.--And one _Inferior Maxillary_, or lower jaw

bone; 7, Fig. 2.

[Illustration: THE FŒTAL HEAD.

Plate XXIV.

The head is generally divided into the Cranium, or that part which

contains the brain, and the Face.]

The bones of the cranium are not closed together, as they are in the

adult, but are separated to a considerable distance, in certain parts,

and connected by a strong membrane. These membranous spaces are called

_Sutures_ and _Fontanelles_, and a knowledge of them is absolutely

necessary, as a means of ascertaining the position of the head.

_The Sutures._--The first of these spaces, which extends from the

lowest part of the middle of the forehead to the occipital bone, is

called the _Sagittal Suture_, or antero posterior Suture: A, B, C,

Figs. 1 and 2. It separates the two frontal, and the two parietal

bones. The spaces between the two frontal and the two parietal bones

are called the _Frontal Parietal Sutures_, _o. o._ Fig. 1; and those

between the two parietal bones and the occipital, _l. l._ Figs. 1 and

2, are called the _Lambdoidal Sutures_.

_The Fontanelles._--When the different Sutures meet at a point,

the membranous space is greater than at other parts, and is called

a Fontanelle. Thus when the two Frontal Parietal Sutures meet the

Sagittal Suture, at B, Figs. 1 and 2, there is quite a large diamond

shaped space between the different bones, filled up with membrane. This

is called the _Anterior Fontanelle_, or bregma. Where the Sagittal

Suture joins the two Lambdoidal there is another space, not so large,

and different in shape, being triangular; this is called the _Posterior

Fontanelle_, _c._ Figs. 1 and 2. And where each of the temporal bones

joins the parietal there are two other spaces, called the _Temporal

Fontanelles_, _t._ Fig. 2, which are also irregularly diamond shaped,

but not nearly so large as the anterior fontanelle.

It is evident that if a person can distinguish these Fontanelles, when

he touches them with his finger, he can tell what part of the head is

presenting, and hence their use.

These spaces allow of the bones lapping over each other, during

delivery, and thus the head is made smaller. They do not disappear

till sometime after birth, and in very young children the brain may be

felt, and seen to work, at the anterior fontanelle. Eventually however,

the bones come close together, and are joined by a curious kind of

dovetailing. The two frontal bones however, completely coalesce, and

form but one, in the adult.

Sometimes the bones will be very perfectly formed, and the fontanelles

nearly filled up, before birth, and then the head cannot be crushed

much smaller, and so the labor becomes both painful and difficult. This

is usually called an ossified, or solid head.

_Diameters of the Head._--The diameters of the head are the distances

between its most prominent points. They are necessary to be known

before we can judge as to the possibility of its passing the straits of

the Pelvis, in the various positions.

Generally there are reckoned _ten_ diameters, and they are represented

in the following Plate:--

[Illustration: PLATE XXV.

_Diameters of the Head._

1. The _Occipito Mental_, or from the back of the head to the chin, M,

O, Fig. 1, five inches.

2. The _Mento Bregmatic_, or from the chin to the anterior fontanelle

at the top of the head, M, O, Fig. 1, four inches.

3. The _Occipito Frontal_, or from the back of the head to the top of

the forehead, O, F, Fig. 1, four inches.

4. The _Trachelo Occipital_, or from the throat to the back of the

head, T, O, Fig. 1, four inches.

5. The _Sub Occipito Bregmatic_, or from the nape of the neck to the

top of the head, S, B, Fig. 1, three inches and a half.

6. The _Trachelo Bregmatic_, or from the top of the throat to the top

of the head, T, B, Fig. 1, about three inches and a half.

7. The _Trachelo Frontal_, or from the top of the throat to the top of

the forehead, T, F, Fig. 1, about three inches.

8. The _Sub Occipito Frontal_, or from the nape of the neck to the top

of the forehead, S, F, Fig. 1, about three inches.

9. The _Bi Parietal_, or across the head from one side to the other at

the middle of the parietal bones, the widest part, B, P, Fig. 2, three

inches and a quarter to three and a half.

10. The _Bi Temporal_, or across the head from one temporal bone to the

other, B, T, Fig. 2, about two inches and a half.]

The necessity for knowing these diameters will be obvious. It is only

by being acquainted with them, and with the straits of the Pelvis,

already described, that we can tell whether the child can pass or

not in certain positions, and how we must change its position, when

possible, to give relief.

On comparing the diameters of the head with those of the Pelvis, it

will be seen that some of them correspond in size while others do

not, so that in one position delivery can take place spontaneously,

while in another it will be difficult, and in some nearly impossible,

without assistance. Thus, for instance, if the head should present by

the occipito mental diameter, (O, M, Fig. 1,) it evidently could not

pass while in that position, because by this diameter it is five inches

in width, and the greatest diameter of the Pelvis is only about four

inches and a half. Its position must therefore be changed, and the

accoucheur must know how to change it with advantage.

ATTITUDE OF THE FŒTUS AT FULL TERM.

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

[Illustration: PLATE XXVI.

_Attitude of the Fœtus._

The arms, it will be seen, are crossed on the breast, upon which the

chin is also bent; the thighs are close together, and brought against

the Abdomen; the legs are close bent on the Thighs, and the feet are

turned up against the front of the legs, the whole body being curved

forward.]

The position in which the Fœtus most usually lies in the Womb has

already been shown, particularly in Plate XII, and in Plate XVI. The

head is downwards, and the back part of it turned to the mother's

left side. What is the cause of this almost universal position is

not certainly known. It was formerly thought to depend on the head

being heavier than the other parts, and thus sinking down; but this

supposition has been shown to be entirely without foundation. M. P.

Dubois has lately advanced the notion that it depends on an instinctive

feeling in the Fœtus itself, which directs it to take that position

by which it can most easily make its exit. This opinion appears very

reasonable, and is apparently well founded. It is well known that the

Fœtus is susceptible of various impressions while in the Womb, and

impelled by unerring instinct to take the breast immediately it is

born; nay, it has even been known to suck the finger of the assistant,

in cases of face presentation, even before birth! We can readily

believe, therefore, that it is directed to place itself in the Womb, in

the best position, the same as it is directed to take the finger in its

mouth.

In the young of many of the lower animals this is also strikingly

exemplified. The young duck in the shell taps with its little beak

against the part that is to be broken, and rushes into the water even

with a part of the shell still on its back. The young oppossums, who

are born imperfect from the Womb, shelter themselves, immediately they

come into the world, in the pouch on the mother's breast, and fasten

themselves to the mammæ till they are more perfectly grown.

It must be remarked however, that the head does not _always_ present

first, though it usually does so. Occasionally we have the breech

present, and still rarer even other parts; but these are merely

exceptional deviations, the causes of which are unknown. Out of every

sixteen children born, _fifteen_ usually come head first. This however,

will be shown better further on.

CHAPTER IX.

THE APPENDAGES OF THE FŒTUS AT TERM.

THE MEMBRANES.

The uses and arrangements of the membranes surrounding the Fœtus have

already been explained, so that little more is needed to be said here,

because they are not much different at the full term from what they are

at an earlier period, excepting perhaps that the _amnion_ is a little

more dense and firm. This membrane appears not only to surround the

Fœtus like a bag, to contain the waters, but is also reflected close on

to its body, like its skin, with which in fact it is thought by some to

be connected. The child is certainly born with this membrane still on

its body, and does not part with it till some days after birth, when it

peels off like a thin dead skin, or powder.

The _waters_, enclosed within the Amnion, (see Plate XII,) have now

increased to their greatest quantity; and there is also, in most cases,

a second body of fluid between the Amnion and the Chorion, which coming

away before the real discharge, is called the _false waters_.--(See

Plate XII.)

The quantity of the true waters, at birth, is about twenty, or from

that to thirty ounces, but is very variable. It is of a greenish color,

rather muddy, and heavier than water. It contains albumen, (white of

egg,) sulphate of soda, and lime. Ninety-eight per cent. of it however,

is pure water. It appears to be excreted, like perspiration, from the

surface of the membranes, and most likely is merely the watery portion

of the blood exuded through. The uses of this fluid are various. As

already stated, it probably supplies some nutriment to the fœtus,

which it also protects, in a great measure, from pressure and from

concussions. It also prevents the limbs from adhering, and helps to

distend the mouth of the Womb, in the earlier stages of labor, besides

affording an abundant slippery fluid for the purpose of lubricating the

passages, thus making the passage of the child more easy.--(See Plate

XII.)

The other two membranes, the Chorion and Decidua, are not of much

importance in our present explanation; and practically, in fact, the

whole three may be regarded as _one envelope_, surrounding the child

and the waters in which it floats.

THE PLACENTA.

At the full term the Placenta, (See Plate XII,) is about six or seven

inches in diameter, and nearly circular, though often irregular. Its

thickness varies from one to two inches, and is greatest where the cord

is inserted. Sometimes it is very large, or very thick, and may then be

difficult to extract, and even cause serious accidents.

As already explained the Placenta is composed of a mass of

blood-vessels, by means of which the blood of the fœtus is, in some

way, brought into contact, or commingled with that of the mother. Its

uterine face is irregular, being broken into lobes, or cotyledons,

on which may be seen a vast number of little veins and arteries,

corresponding with others on the inner surface of the Womb. Its outer

surface is of a grey red color, and covered with the fœtal membranes,

under which the large blood-vessels can be traced. The Placenta is

usually attached to one side of the Uterus, near the fundus, or at the

fundus, but sometimes it grows wholly, or in part, over the mouth of

the Womb; an occurrence which may cause serious consequences.

When there is more than one child each usually has a separate placenta,

and they are all intimately connected. In some rare cases however, one

placenta only exists with twins. Each child has also a separate amnion,

and waters; but there may be only one chorion and decidua for the

whole, or each may have a complete set of membranes itself. Instances

have been known however, of two children being enclosed in the same

amnion, and surrounded by the same waters, having but one placenta

between them.

These possible diversities show the accoucheur how necessary it is

for him, in any case of multiple pregnancy, to be sure that he has

abstracted _all_ the after birth; and they also caution him not to

proceed to unnecessary manipulations merely because it is not the same

as in other cases.

THE UMBILICAL CORD.

This is composed, as already stated, of an artery and two veins, which

twist round the artery, like the strands of a rope. These are all

enclosed in a sheath, and surrounded by a thick kind of mucus, called

the _Gelatine of Wharton_. Its thickness is about that of the little

finger, though it may be much larger, having been seen as thick as the

child's body. Its usual length is about eighteen or twenty inches, but

it has measured as much as five feet. Then again it has been found

so small that the vessels in it could not nourish the child. These

exceptional variations however, are very rare. The veins may also be

enlarged, or full of knots, and the circulation may be so much impeded

thereby as to cause abortion. The various accidents which may result

from anomalies in the cord will however, engage our attention in

another place.

SECTION IV.

THE MECHANISM OF DELIVERY IN ALL THE DIFFERENT PRESENTATIONS AND

POSITIONS OF THE FŒTUS.