Velpeau, “may be attributed to the thousands of visits of friends,
neighbors, or acquaintances, or the ceremony with which she is too often
oppressed; she wishes to keep up the conversation; her mind becomes
excited, the fruit of which is headache and agitation; the slightest
indiscreet word worries her; the slightest emotions of joy agitate her
in the extreme; the least opposition instantly makes her uneasy, and I
can affirm, that among the numerous cases of peritonitis met with at the
_Hospital de Perfectionnement_, there are very few whose origin is
unconnected with some moral commotion.”
Is it not possible to change the fashion in regard to this matter? This
remains wholly with yourselves; for we of the masculine gender have
nothing to do with it. Are you not all sisters? Why, then, be offended
with each other if you do not go to see the sick woman for a whole month
after her child is born. Could you not write her now and then a friendly
note, or send her some little delicacy to eat, which would be evidence
enough that you had not forgotten her? I am aware there are among your
sex a certain set of gossiping idlers, who do not know how to kill time
in any better way than to be gadding abroad when they are least needed.
If one is really sick and needs aid, they are the last persons in the
world to leave their homes; they are good for nothing among the sick. To
such women I care to say but little, for I consider the task of
reforming them a very hopeless one, as all experience proves. Especially
where a new method of treatment, as, for example, the water-cure, is
practiced, do these twattlers gad about, making mischief wherever they
go.
_Bathing._—It is no new thing for a woman to be bathed, and that in cold
water, soon after delivery. It was practiced among the Romans, and, as
we have seen in another part of these letters, is still the custom among
several of the savage nations.
I need not remind you, however, that this practice has, for a long time
at least, found no place among the more enlightened portions of our
race; that instead of cold water being regarded as a most estimable
remedy in childbirth, it has been considered as a very dangerous agent,
which, in truth, it is when improperly administered. Many of you can but
too easily call to mind the old notions which were instilled into your
minds on this subject; notions which you now know to be not only
erroneous, but sadly mischievous when carried out in practice.
More than ten years ago, and while I was yet a student in medicine, and
had never heard of the water-cure as practiced by the great Priessnitz,
I was in the habit of revolving these matters in my mind. It occurred to
me often, that if the Roman women, and the Indian women of different
nations, could reap so great a benefit as appeared to be derived from
ablutions performed soon after childbirth, that our own females too,
weakly although they are many of them, could gain similar advantages
from pursuing a like course. It was thus that I was led, as far back as
1843, to strike out a course of treatment for myself in these cases,
having no medical authority or precedent to go by. The result of this
treatment is now, fortunately, getting to be pretty well understood, and
the merits of the new method appreciated in almost all parts of our
country. In Europe they are altogether behind us in the improvement to
which I allude.
I need not here go into any lengthy details concerning the methods of
bathing that are proper to be adopted in the parturient state. The
numerous cases which I have given will serve as a sufficient guide, I
trust, to all of you who are concerned. I may remark, however, in
general terms, that there is no need of doing any violence in the way of
a bath; and those who have not access to the personal advice and
superintendence of a physician who understands the practice, may always
act safely by washing the patient in her bed. Thus, if a blanket or some
other extra article is placed beneath her, she may easily be washed over
the whole surface, piecemeal, a practice which, though it is neither so
thorough nor useful in most cases, as it would be to go at once into the
tub, is yet a good one, and productive of great comfort.
_The Binder, Compresses, etc._—As to the use of the wet bandage, the
compresses, etc., a few words will here be in place. If a dry bandage is
ever needed as a support, the wet one is much to be preferred to it. As
a general thing, however, we put no bandage upon the woman soon after
the birth, as will be seen by reference to the cases given in this work;
we wish to change and rewet the application frequently, and for this
reason the simple compresses are the most convenient. But when the
patient is to sit up or walk about, the wet girdle, if properly arranged
with tapes to secure it, and made pretty tight at the lower part of the
abdomen, affords a good deal of support. The wet bandage does not slip
upward and get out of place near so readily as the dry one.
It will naturally occur to you, whether the going without the
old-fashioned belly-bandage will not be likely to prove injurious to the
woman’s form. The sum and substance of this whole matter is just this:
whatever tends to weaken the constitution in general, and the abdominal
muscles in particular, must have a tendency to produce laxity of the
fibers, thus rendering the part more pendulous. On the other hand,
whatever tends to strengthen the system and to give tone to its fibers,
must have a contrary effect. Now, the dry belly-band, even when it is so
arranged as to keep its place—which it generally is not—is too apt to
become heating, and, of course, a source of debility under such
circumstances. For this reason it is plain that a cold wet girdle is
altogether better than a dry one. Nor should this even be left on too
long a time without changing and rewetting it. This should be done, as a
general thing, every three or four hours at farthest, and in warm
weather oftener.
_The Repose._—Some have feared to allow the woman to go to sleep for
some hours after delivery, fearing that she might be taken in hemorrhage
as a consequence. It is possible that a patient under such circumstances
may wake suddenly with a flooding upon her, particularly if she be too
warmly covered up in bed. But by all of the best authorities it is
regarded that the sooner the woman sleeps after she has passed through
the agony of labor the better. Sleep is, indeed, no less “nature’s sweet
restorer” under such circumstances than at other times; and it would be
most cruel to deny a patient this privilege, when it would be so
grateful and refreshing to her.
_Sitting up soon after the Birth._—I have proved satisfactorily to
myself, that there is great error abroad in this country generally in
regard to the parturient woman rising soon after the labor is past. It
appears to be the belief of physicians generally in this country, that
it is highly dangerous for a woman to sit up before some days after
accouchement. The common saying concerning the ninth day you have all of
you heard.
Velpeau, of Paris, who is higher authority by far than any old-school
man in this country, says: “After this first sleep—that is to say, after
the lapse of two or three hours—the patient should sit up in bed, and
take a little broth; _this position seems to rest her, and allows the
lochia which had accumulated in the vagina to flow readily off_.” That
is the point: it serves to REST her; that is, when a woman is tired of
lying down, both common sense and instinct declare that she should
change her position; in other words, sit up. This very same thing I have
taught strenuously for these seven or eight years, as many of you know;
and just now, while I am writing, I find that Velpeau long ago
recommended the same thing.
_Walking About._—Precisely the same principle holds good in regard to
walking and all other modes of exercise as in sitting up. A little and
often should be the rule. The cases which I shall give you will form a
sufficient guide on this point.
I have known a great many more persons to be injured by inactivity,
remaining too much in bed and in overheated rooms, than by walking about
too much and too soon.
_The Food and Drink._—I have but a word here to say on this subject. The
patient should begin directly after birth with the same kinds of food
and drink which she intends to use during the period of nursing. If she
is to eat fruit, which I consider good for her, she should take it from
the first. Prudence should, of course, be exercised in regard to
_quantity_ as well as quality of food under these circumstances.
One of the greatest and most common errors in regard to the diet soon
after labor, is that of partaking of articles which are of too fine and
concentrated a nature. The bowels tend naturally to sluggishness for
some days after confinement; hence the diet should be of an opening
nature, such as brown bread, cracked-wheat mush, good fruit in its
season, and good vegetables. It is a poor practice to keep the patient
for nine days on tea, superfine bread, toast and butter, and the like
articles. It is no wonder that women dieted in this way become
constipated, nervous, low-spirited, and feverish.
LETTER XXIX.
MANAGEMENT OF THE CHILD.
Of Separating the Umbilical Cord—Practices of different Nations—Of
Still-Birth, and Resuscitation of the Child—Washing and Dressing it.
It was necessary, in describing the three stages of labor, to pass over
for the time an important matter, namely, that which relates to our
attention to the umbilical cord. In treating of this subject, it will be
necessary for me to repeat some things which I have said in another
volume, a “Treatise on the Management and Diseases of Children.”
Soon after the birth of the child, separating the umbilical cord
requires our attention. How shall this be done? Shall we use a sharp or
a dull instrument in making the division? Shall we apply a ligature?
where, and in what manner to the cord?
It is reported of the aborigines of Brazil, that they merely bite or
chew off the cord, as many of the animal tribes are found to do. This is
imitating nature closely enough, certainly, and more so, perhaps, than
the usages of civilized society would warrant us in doing at the present
day.
Dr. William Hunter, in 1752, remarked in his manuscript lectures
concerning the method which the instinct of animals leads them to adopt,
as follows:
“I will give you an idea of their method of procedure, by describing
what I saw in a little she dog of Mr. Douglass’. The pains came on, the
membranes were protruded; in a pain or two more they burst, and the
puppy followed. You cannot imagine with what eagerness the mother lapped
up the waters, and then taking hold of the membranes with her teeth,
drew out the secundines; these she devoured also, licking the little
puppy as dry as she could. As soon as she had done, I took it up, and
saw the navel-string much bruised and lacerated. However, a second labor
coming on, I watched more narrowly, and as soon as the little creature
was come into the world, I cut the navel-string, and the arteries
immediately spouted out profusely. Fearing the poor thing would die, I
held the cord to its mother, who, drawing it several times through her
mouth, bruised and lacerated it, after which it bled no more.”
This chewing, bruising, or tearing a part in which blood-vessels exist,
causes them to contract in such a way as to prevent the occurrence of
hemorrhage. This fact we see exemplified in cases where an arm or other
limb is torn off with machinery, in which it is found that no bleeding
of consequence takes place. But if a limb is severed with a
sharp-cutting instrument, the arteries must be secured.
The New Zealanders, I am informed by a medical friend who spent some
time among that people, cut, or rather tear off the umbilical cord with
the edge of a shell, something like that of the clam or oyster of our
own country.
It matters little, however, what instrument or material is used to
effect the object in question. The cord being immediately after birth a
dead substance, possessing no sensibility whatever, we may bite it off,
or we may use a shell, a sharp knife, or a pair of good scissors or
shears, whichever method we choose, remembering always that it is of
little consequence how we do it, and that it is as natural, precisely,
for a man to exercise his ingenuity in making and using a convenient
instrument as it is for a brute to use his teeth.
In the time of Hippocrates, it was not customary to divide the umbilical
cord previously to the expulsion of the placenta. If this was slow in
coming away, the child was placed upon a pile of wool, or on a leather
bottle with a small hole in it, so that by the gradual subsidence of the
skin or pile of wool, the weight of the child might draw almost by
insensible degrees upon the placenta. In this way it was extracted
without violence.
In modern times, it has been almost universally the custom to separate
the child very soon after delivery, and before the after-birth has come
away. “As soon as the child cries lustily, proceed at once to separate
the cord,” is the common doctrine among medical practitioners. But it is
better, evidently, to wait, before this is done, until all pulsation has
ceased in the cord. If we take the cord between the thumb and finger, we
readily ascertain when its pulsation has ceased. It has a large vein in
it for the transmission of blood from the mother to the child, and two
small arteries, which return the impure or worn-out blood after it has
gone the rounds of the fetal circulation. Blood is the only nourishment
the child has while it is in the mother’s womb. Hence it would be
manifestly improper to rob the child of any portion of the fluid coming
from the mother to it.
The ancients not only waited for the expulsion of the after-birth before
tying the cord, but if the child was at all feeble or dead at birth, the
placenta, when expelled, was laid upon its belly as a comforting and
restoring application. This practice, singular as it may appear to us in
modern times, is not altogether without its philosophy; the mild, genial
warmth of the after-birth was supposed to act favorably on the feeble
powers of life, if such existed, or if it was dead, it was supposed the
infant might thus be recovered.
Speaking of later methods, Dr. Denman observes: “It has been the
practice to divide the funis (cord) immediately after the birth of the
child; and the weaker this was, the more expedition it was thought
necessary to use; for the child being supposed to be in a state similar
to that of an apoplectic patient, a certain portion of blood might, by
this means, be discharged from the divided funis, and the imminent
danger instantly removed. There is another method which I have seen
practiced, the very reverse of the preceding; for in this the loss of
any quantity of blood being considered as injurious, the navel-string
was not divided, but the blood contained in its vessels was repeatedly
stroked from the placenta toward the body of the child. In all these
different methods, and many others founded on caprice, or on directly
contrary principles, children have been treated in different times and
countries, and yet they have generally done well; the operations of
nature being very stubborn, and, happily, admitting of considerable
deviation and interruption, without the prevention of her ends.”
“There is yet, in all things,” continues this author, “a perfectly right
as well as a wrong method; and, though the advantage or disadvantage of
either may be overlooked, the propriety and advantage of the right
method must be evidently proved by individual cases, and of course by
the general result of practice. In this, as well as in many other
points, we have been too fond of interfering with art, and have
consigned too little to nature, as if the human race had been destined
to wretchedness and disaster, from the moment of birth, beyond the
allotment of other creatures.”
It is the testimony of this author, however, that some children, after
they had began to breathe, had respiration checked, and died after the
cord was divided in consequence, this having been done too soon. Beyond
a doubt, many children have been destroyed in this way, and in this, as
in many other things in the healing art, medical men have been too much
in the habit of interfering with nature, and thwarting her in her
operations.
It is the order of nature, and moreover a truly wonderful phenomenon,
that in proportion as respiration becomes established in the new-born
child, the pulsation in the umbilical cord begins to cease, first at the
placenta, and so gradually onward to the child; physiologists are
puzzled to explain the circumstance, but the fact is plain.
Hence it follows, that if the cord were left to itself, without any
ligature, it would not expose the child to hemorrhage, or other
accidents, even though it should be cut clean, and not contused or torn;
some little blood might flow from the cut end, but every thing being
left to nature, this could amount to but little, and such as would do no
harm. But for the sake of cleanliness, it is proper that a ligature
should be applied.
But it will be objected, that in some cases—though very rare—children
have been known to bleed to death at the umbilicus. This has, indeed,
happened in some few cases, in spite of ligatures, and every thing else
in the way of styptics that could be applied. But these extreme cases
are not to serve as guides in forming rules of practice. Nature has
exceptions to all her rules. Besides, we may account for many of these
occurrences, by the fact that the natural operations are often perverted
by improper treatment. Thus, if children are swathed tightly, as has
been too often the case in civilized society, compressing the chest and
the abdomen, and causing them to cry from distress, the embarrassed
state of the viscera suffices to disorder the general circulation, and
enable the blood again to pass out of the navel.
Hence, as a matter of practical safety, although it is not necessary, as
a rule, to apply a ligature to the umbilical cord, even when we cut it
very near the abdomen of the child, we had better do it, as no harm can
come from the procedure; it is possible for it to do good, even to save
the life of the child; properly applied, it is not possible for it to do
harm.
As to the point at which we divide the cord—whether at a half an inch or
an inch and a half from the abdomen—every one must be his own judge. It
is an old woman’s notion, both in this country and in the old, which was
derived from the physiology of the ancients, and which requires that the
cord should be cut very near the umbilicus if the child was a girl, and
very far from it if it is a boy; such a mode of cutting being supposed
to exert a great influence upon the development of the generative
organs.
Notwithstanding the objections of some of the old women, I have
separated the cord very near—say within half an inch of the abdomen.
This is a much neater and more cleanly mode than it is to leave two or
three inches of a dead substance to putrefy upon the child; besides, the
more cleanly the part is kept, the more quick does the healing process
take place.
“As to the ligature itself,” says Velpeau, “De la Motte advises us to
apply it at the distance of one inch, Deventer, Levret, and the moderns,
at the distance of two fingers’ breadths, others at three, four, five,
six, and even twelve inches from the abdomen. Some persons have
recommended the application of two, and in such a way that the one
nearest the abdomen should not be so tight as the other. Sometimes it
has been recommended to draw it very tightly, at others very loosely.
One person is content with a single turn, and a single knot; and another
thinks there should be two turns, and a double knot; a third, like
Planck and M. Desormeaux, makes first one turn and one knot, and then
bends the cord into a noose to tie another knot upon it.”
“A majority of the Philadelphia accoucheurs,” says Professor Meigs, of
that city, “in tying the navel-cord, pass two strong ligatures each
twice around it, securing them with two knots; the one an inch and a
half, and the other two inches and a half from the abdomen, and divide
it between the two with a pair of sharp scissors. This is a cleanly
practice in all cases, and prudent, if not essential, in twins;”
cleanly, that is, because, as the professor means the second
ligature—that is, the one that is nearest the mother—prevents the blood
coming from the placenta, and soiling the bed; the same principle I
usually adopt, only the first ligature is placed half an inch, instead
of an inch and a half from the abdomen. Sometimes, however, as in the
night, it is perhaps better to leave the cord an inch or two long, and
the next day tie it nearer the body. The ligature, since we use it at
all, should be drawn very tightly; the cord being a dead animal
substance after birth, very soon shrinks; hence if the ligature is not
very tightly drawn, it may slip off in a day or two. In tying the
ligature, we should be careful not to pull at the child, for in so doing
we might cause a rupture, or a tendency to such an occurrence.
In making the division—which is usually done with a pair of good shears
or scissors—we must be careful to avoid cutting off a finger, toe, or
the private member. The infant, in its struggles, is very apt to get
some of these parts in the way just as one is making the cut.
As to the kind of ligature: some think they must always have a narrow
tape; and hence we often find, in attending a case, that the mother has
already prepared herself with this material. But a common round thread
is to be preferred; we can draw this more tightly than we can a flat
ligature. A strong linen thread, doubled and twisted if we think it
necessary, I consider the best. “Some would not dare to use any thing
except tape,” says Velpeau; “whereas wiser persons make use of whatever
they can find at hand.”
One circumstance should be particularly noticed in regard to tying the
cord. It is said that it is possible for umbilical hernia to take place
before the child’s birth. In such case a portion of its intestine must
have protruded into cord. Hence, in such case, if we were to tie a
ligature about the cord near the body, and where the intestine is—a fact
that we can know by the cord being bulged out, or enlarged at the
part—and should cut it off so as to sever the intestine, we should
inevitably kill the child. Few practitioners have ever seen such a case;
but inasmuch as it is said that such hernia may possibly exist, we
should always watch for it. It would be easy to detect, but if one
should have any doubt as to whether there is hernia or not, he may apply
the ligature an inch or two from the child’s body, and thus make sure of
doing no harm.
It is important to remember, that at the time of, and before making the
separation, the child should be so placed as to allow the most free
respiration; it has just begun to breathe for the first time in life; it
is just as important that it has good air as it is for any of us. Many a
tender infant has been injured at the very beginning by being smothered
among the bed-clothes as soon as born. People everywhere, think it will
take cold as soon as it is exposed to the air; but think, you who
understand the anatomy and physiology of the human system, how
exceedingly delicate the fine internal net-work of its little lungs is!
And think you that the external skin is less able to bear the new
impression of the atmosphere than the lungs are?
As to difficulties at the child’s navel, I have never had them. It is
certainly a very simple thing to leave it altogether to itself, with the
exception, the second day and onward, of laying upon it a soft, clean,
wet compress, of four or five thicknesses, so that it remains constantly
moist. This water-dressing, often renewed, and kept thoroughly clean,
heals the navel more quickly than can be done in any other known way.
From what I have been able to learn, I infer that with water-dressing
this healing is effected from one fourth to one third less time than by
the usual methods.
The period of the natural separation of the cord varies considerably in
different cases. According to M. Gardien, it usually falls off on the
fourth or fifth day. M. Orfila says the fourth, fifth, or sixth day. M.
Dennis the fifth, sixth, seventh, or eighth day. M. Billard remarks,
that the desiccation is complete toward the third day, and it is on the
fourth or fifth day that the cord is separated from the abdomen.
Dr. Churchill, of Dublin, kept an account of the period of its decadence
in 200 cases, and it occurred as follows:
In 1 case it fell on the 2d day.
„ 4 cases „ 3d „
„ 20 „ „ 4th „
„ 52 „ „ 5th „
„ 81 „ „ 6th „
„ 24 „ „ 7th „
„ 10 „ „ 8th „
„ 7 „ „ 9th „
„ 1 case „ 10th „