Midwifery and the diseases of women

by Joel Shew

OF FLOODING AFTER DELIVERY.

Hemorrhage is one of the most dangerous of all circumstances connected with labor. Fortunately, however, this does not often happen; and in those cases when it does occur, it may generally be very soon arrested, provided the proper means are adopted.

This form of uterine hemorrhage not unfrequently occurs when the physician is absent. For this reason, it is necessary that I should make some remarks on the subject.

Flooding may be either external or internal. When the blood passes from the vagina, we call it external; when it does not thus pass off, but remains within the cavity of the uterus, causing the abdomen to swell and the patient to faint, we call it internal.

Here is a remarkable fact in nature. Women, in consequence of possessing the menstrual function, and being exposed to the accidents of childbirth, are more subject to hemorrhage than men. In striking accordance with this fact, it appears to have been a benevolent intention of the Creator to form the female system in such a manner that it more readily recovers from profuse loss of blood than that of the opposite sex. Under the effects of severe loss of blood, the system of a man remains pale and enfeebled for months, perhaps, while that of a woman regains its strength and color in half the time. Many a time, before I was aware of these facts, I have been fearful, and sometimes greatly alarmed at the amount of blood lost at the birth of a child, and when, to my great surprise, in a day or two the patient was up, and apparently almost as well as ever. This, then, is an important practical fact, and one well worth remembering.

In regard to the treatment of flooding after delivery, I refer you to what I have already said under the head of uterine hemorrhage. Cold, remember, is the great agent here, as all acknowledge.

If the woman faints from loss of blood—and she may also faint from mere debility—you should not be alarmed at the circumstance. People generally make a great deal too much ado when a patient faints. It should be remembered that the object nature has in causing a person to faint from loss of blood, is to arrest the heart’s action, for the most part, so that the blood may, as it were, cease its movement in the uterus, and a coagulum or plug be formed in the orifice of the bleeding vessel or vessels. This is nature’s method of arresting an hemorrhage. This being so, it is no doubt often the case that bringing a person to, is the cause of more harm than good. There should be no hurry; give the patient good air to breathe, and nature will, as a general thing, do her own work better than we can do it for her in these cases.

LETTER XXVII.
ADVICE CONCERNING LABOR.

The Medical Attendant—State of Mind—The Room—State of the Bowels—The Dress—The Bed—The Position, Exercise, Food, and Drink.

It will be inferred, from what I have already said in these letters, that I am in favor of employing a physician, male or female, in all cases of parturition. Most cases, I admit, will get along well without any medical aid whatever; but, as you are well aware, there are exceptions to all rules; and it is for these exceptions that a physician is needed.

In the first place, then, it is always advisable in labor that you call your medical attendant early. If it is worth your while to have aid at all, it is best to have it in good season. The physician himself always prefers to be called early.

Once you have fixed upon your medical attendant, resolve to be guided by him in every particular, and follow his directions faithfully. If you have, from necessity or otherwise, chosen a man-midwife, you need have none of those foolish whims which some among the so-called reformers of the present day would have you to believe.

It is always an unpleasant duty for one to attend a woman in childbed; and be assured that, of all places in the world, a delivery is the last one in which lascivious or lustful excitement is experienced. I wish you, then, one and all, to remember that if it is unpleasant for you to be attended by a man under such circumstances, it is equally so to him. If he is a conscientious and benevolent physician, he will cheerfully do that which he considers his duty to do; but as far as his own personal self is concerned, he would much rather be at home, enjoying its quiet and its sleep, if need be.

In regard to your preparation for labor, I will suppose that you have done all in your power to maintain an equable and healthful state of both mind and body, and that you are resigned to encounter whatever God in His mercy may see fit to bring upon you. If you have done all that you could for yourself, and are still willing and determined to do so, surely you should feel contented; you can do no more.

The Room.—As to the apartment in which you are to be confined, you should take the best one in the house. If possible, you should have one which is well lighted and aired, and which can be readily warmed, if there is need of raising the temperature. If it is in a city, a back room should be preferred in preference to one in front, on account of the noise of the street.

If the labor is to be a tedious one, it is particularly necessary that the air of the apartment be kept as pure as possible. Not only should the strictest attention be paid to ventilation, but all odors and perfumes should be dispensed with. These do no good, for mere hiding the bad air is not destroying it, and they always do more or less harm.

There should not be too many persons in the room when the woman is to be confined. In the country it is by far too much the fashion for a large company of women to get together on such occasions. This always renders the air of the apartment more foul than it otherwise would be, and for other reasons it ought not to be permitted.

I have many a time pitied the condition of women whom I have attended, who had but one room to live in, cook, wash, iron, and at last to be confined in; and yet those women have in general got along better than such as live in a more sumptuous way. Such women are, in fact, workers, and employment, as I have before remarked, is a most blessed thing in regard to preparing the system for the important function of labor.

The Bowels.—If the bowels should be constipated at the time when labor is about to come on—and such is likely to be the case—the woman should use clysters freely. This practice is, in fact, advisable in all cases, inasmuch as it can do no harm. If there is fecal matter in the colon, it is better that it be removed before the birth is about to take place. Hardened excrementitious matters in the lower bowel are always a hindrance to labor.

The Dress.—Formerly it was considered a matter of importance as to how a woman was dressed in labor. Different countries and provinces had their particular forms of gowns, jackets, chemises, and head-dresses. The great thing, however, to be observed, is simplicity; that is, nothing should be worn which at all interferes with the body in any of its functions or parts. If the dress is such as causes no constriction of the abdomen, the chest, or the neck, such as gives free motion to the limbs, and is of such material that it makes the body neither too hot nor too cold, it is all that is required. Generally too much clothing is worn at the time of labor. It is safer to be on the side of too great coolness than of the opposite extreme.

The Bed.—This has been called by different names; the lying-in bed, bed of labor, bed of pain, bed of misery, little bed, etc.

Some women will not make use of any sort of couch whatever. I know a lady in this city who has borne a pretty large family of children, who affirms that she gets along much better upon her hands and knees on the floor than in any other way. Some are delivered standing up, the elbows resting on some object, as the mantle-piece, bureau, the back of a chair, or some other piece of furniture, or perhaps upon the shoulders of a friend. “A strong and well-formed woman,” says Velpeau, “may be delivered in any posture, on a chair, on the floor, a bundle of straw, on foot, and on all the kinds of beds that have been proposed; so that it is only in the cases where nothing interferes with the accoucheur’s doing just what he thinks best, that he ought to attach some value to the composition of the lying-in bed; further, the only essential matter is, that the woman should lie as comfortable as possible, that she should not be incommoded, neither during the pains nor the intervals between them, and that the perineum may have room to dilate.”

Oftener than otherwise in this country, the woman is delivered on the same bed on which she sleeps. Sometimes, also, a cot is used, which also is a very convenient contrivance, since it allows of the free passing of the physician and others about it. It is, likewise, a healthful plan to move from one bed to another after labor; but this is by no means strictly necessary. Cleanliness, comfort, and good air—these are the great requisites in regard to the bed.

The Position.—If the patient is to lie upon a bed, which is doubtless the preferable plan in the majority of cases, what shall be her position?

This, like many other things, is a matter somewhat of fashion. In Great Britain the woman is always placed upon the left side, with the thighs flexed, that is drawn up toward the body, and the hips brought close to the right side of the bed. The same position is usually adopted in this country; but on the Continent, the woman is placed on her back to be delivered. This, I am inclined to think, is the most favorable, as well as most agreeable position, although perhaps not the most convenient for the medical attendant.

Exercise.—During a considerable portion of an ordinary labor, it is doubtless better for the patient, especially if she feel inclined to it, to sit up, and walk about a little from time to time. This not only affords some relief, but likewise aids in causing more efficient contraction of the uterus.

Food and Drink.—It would always be better, so far as food is concerned, for the patient to fast a meal or two before labor comes on. She should, however, be allowed all the drink she desires, pure soft water being the best she can have. If she drink pretty freely, it will be of essential service to her in keeping off feverishness, and in helping the renal organs to act properly. If the pains are tardy, taking now and then a drink of cold water, even against the inclination, will help on the pains. Even ice is used with good effect for this purpose.

LETTER XXVIII.
MANAGEMENT AFTER DELIVERY.

Importance of Attention to this Period—Evils of too much Company—Bathing—The Bandages, Compresses, etc.—Sleep—Sitting up soon after the Birth—Walking about—The Food and Drink.

Supposing that the mother has been safely delivered, the child separated, and the after-birth cast off, what advice have we to give in regard to her recovery?

I have before remarked that the birth of the secundines is the most dangerous part of labor, although not the most painful. I have now to remark, that the real danger in midwifery does not commence until after the whole birth is completed. Childbed fever, inflammation and abscess of the breasts, these are the sad mishaps which we have to fear in these circumstances, and for which I feel an anxious solicitude in your behalf.

You may think me strange when I inform you, that I have had more trouble in the practice of midwifery from the one circumstance of the woman having too much mental excitement within a few days after delivery, than from all other things combined. I am sure I am not mistaken when I assert that I have known more accidents and mishaps to occur from this one cause of seeing company too soon after the birth, than from all other causes put together. So important do I consider it for you to keep, as it were, quiet in this respect, I should think my labor in writing these letters a hundred-fold rewarded, if I could be successful in warning you of the danger of over-excitement at the time when you are getting up from confinement. As the most important advice, then, which I can give in regard to all the subjects connected with midwifery, Do not allow yourself to see company for many days after the birth.

“Most of the diseases which affect a woman in childbed,” says the great 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	„

According to Dr. Churchill, then, it would appear, that the fifth and sixth days are the ordinary periods of the detachment. The cord has been known to remain undetached as long as fifteen days; but such cases must be very rare.

Complete cicatrization is commonly effected by the end of the second week. The healing powers vary somewhat in different cases. In one case, where both the father and the mother were of scrofulous tendency, it was a number of weeks before the healing process was fully completed. The child, however, in the end did well.