University of Virginia Library

4. SEMI-RECUMBENT.

The semi-recumbent positions are by far the most frequent among the ancients, especially among the more civilized people of olden times, and among the savage races of the present day. The same position of the body is assumed by various races in very different ways, there being apparently no resemblance in the method of delivery, whilst it appears, upon more careful study, that the position of the body, the inclination of the trunk and the pelvic axis, together with the relaxed position of the thighs, is almost identical, the same end being accomplished in ways very different, peculiar to each people, and in keeping with their surroundings. Thus, the simplest of the semi-recumbent positions, which is upon a par with the customs of the rudest African races, is sitting upon the ground, upon a stone or rude cushion, with the body inclined backward, leaning against an assistant, a tree, or some other object. A marked progress is achieved, when we find the parturient woman seated in the lap of an assistant reclining against his chest, a position which reaches its greatest perfection in the obstetric chair. As the next step, I regard the dorsal decubitus, a position modified according to the circumstances of the people. In the wilds of Africa, and in the interior of our western country, the patient finds her couch upon the floor, propped up against some staves of wood or a pile of grass, whilst in the lying-in chamber of the civilized people

we find the same position assumed upon the bed, and this I look upon as the perfection of obstetric positions, the easiest, most comfortable, and advantageous.

(a.) Sitting Semi-recumbent on the Ground, upon a Stone, or Stool.

Among our Indians we find that the Otoes, Missouris, Omahas, Iowas, and nearly related tribes assume the sitting posture, the legs widely separated; but as the crisis supervenes, the patient raises herself somewhat by a rope suspended above, thus attaining an inclined, semi-recumbent position.[90] The Wakah squaw assumes a sitting posture, on the floor of the lodge, with nothing but an Indian mat under her. As soon as the labor pains come on her feet are drawn up close to the buttocks, and the legs flexed; this position is maintained until after the birth of the child and the expulsion of the placenta.[91]

The women of the Skokomish Agency, W. T., sit down with a pillow or roll of blankets resting against the perineum; one squaw supports the back, while another receives the child. This position is a slightly recumbent one, the buttocks resting on the pillow or roll of blankets.[92] The Confederated tribes of the Flatheads, Pend d'Oreilles, and Kootenais, follow a similar custom: a small box, or a piece of wood, six or eight inches high, covered with old pieces of blanket or buffalo robes, is the seat upon which the sick woman is placed; her legs are separated and flexed so that the heels almost come in contact with the seat. She is retained in that position by two assistants who hold her by the arms, and sometimes a third one stands behind and presses upon her shoulders, and in this position the child is expelled.[93]

Though apparently uncomfortable and inconvenient, and rare among the American Indians, the Kaffirs universally

adopt this obstetric position, sitting with the heels drawn up to the buttocks, the shoulders generally resting against one of the poles supporting the roof of the hut, or against some one of the female friends, who are present in full force.

FIG. 26.—Kaffir Woman in Labor.

[Description: Woman sits with her knees up, leaning against a pole. Black and white illustration.]

A somewhat similar position in labor seems to be followed in Germany by Russian emigrants who came there in 1858 (Prussian Pomerania). They, however, do not raise the shoulders so much. Dr. C. J. Egan, who makes this statement,[94] adds: "The Kaffir position is a very good one, and the woman has full power to bear down and assist her pains. Of course, in this position, no support can be given to the perineum by the hand of the attendant, but I am much inclined to think that some very useful support is

given the perineum from its resting on the firm floor of the hut, and the sudden passage of the child's head is thereby prevented.''

The Kaffir and the Indian woman sit upon the ground, whilst the somewhat more advanced half-breed, as she is often found in Southern California and New Mexico, seats herself upon a chair, and during the pains, in the same way as her Indian sister, grasps a rope suspended from the ceiling above; but, when tired out in this position, she is often found kneeling upon the ground.[95] A white sister involuntarily testifies to the efficiency of this position, at least under certain conditions,—a primipara who had been in labor for two days and was confined on the third, in a sitting posture, the pains ceasing entirely whenever she assumed a recumbent position; of this the observing attendant, Dr. Von Mansfelde, of Ashland, Neb., assured himself. In order to satisfy himself that it was not the whim of a parturient woman, he placed her on the bed, on her side and back, several times, but the hand placed upon the fundus showed complete relaxation; no sign of contraction. When replaced in the sitting posture the pains readily returned, and were very effective, the woman being delivered within two hours after dilatation of the os.

The Arab woman is seated on two flat stones, or, more properly, her buttocks are slightly supported upon two flat stones, whilst during each pain she partially raises herself by a rope which is suspended from the centre-pole of the tent. Two assistants seize the parturient woman under the shoulders, and she herself, during the pain, raises herself by the rope; they aid this motion, partially suspend her, shaking her well, as the miller does his sack of flour when he empties it, and then, as the pains cease, they drop her back upon the stones. This, at least, was the practice witnessed in several cases in 1858 by Dr. Goguel,[96] in one instance,

FIG. 27.—Oronoko Indian. Seated semi-recumbent in hammock.

[Description: Pregnant woman sits in a hammock resembling a looped rope, while an assistant stands behind her with hands on her abdomen.]

the patient being the wife of a sheik. In Massana, upon the Red Sea, the woman of the lower classes sits, in the same way, upon a flat stone, reclining against some convenient support, or held in the arms of a friend. The natives of the Antilles not unfrequently assume a sitting, semi-recumbent position. In some portions of South America, where hammocks serve so many purposes, for instance, among the Indians of the Oronoko and Guiana, the parturient woman is delivered while seated upon the hammock, which is rolled almost into a rope. The assistant stands behind to support the patient, whilst the midwife, often a very skillful woman, is seated in front, and remains to fulfill her office.[97]

A most admirable position, typically semi-recumbent, was customary in Greece and her provinces 2,200 years ago, as is proven by that interesting group, representing a labor just completed, which was discovered by General di Cesnola during his researches in Cyprus; we, moreover, have the same undeniable evidence that this marble group faithfully represents the obstetric position in Cyprus twenty-two centuries ago as we have of the correctness of the Peruvian posture at the time of the Inkas, as pictured upon the funeral urn. The native Peruvians of the present day are still confined whilst seated upon the husband's lap; and the Cypriote midwife of to-day still places her patient in the semi-recumbent position upon a low stool which she carries about with her.

In response to my inquiries, General di Cesnola kindly furnished me with the following most valuable information. He says: "The group was found among the déris of the temple at Golgoi, in 1871, and is of the best Greek epoch, say 400 B. C. The chair on which the woman is reclining, is Cypriote, and was probably used also in Greece at that period; the modern Cypriote midwives possess similar low chairs, which they carry with them when going to attend a child-birth, and I have myself seen the circumstances as shown in that group, which faithfully represents the parturition

scene of to-day. An assistant of the midwife's is kneeling behind the patient, holding her head upon her shoulder; the midwife, who is seated upon a very low stool in front of the parturient and between her separated legs, has just extracted the child which she has on her arms. The exhausted woman, seated in a semi-recumbent position on a low stool, still has her legs wide apart, but has been covered with a blanket and is left to rest for a few minutes

FIG. 28,—Labor Scene in Ancient Greece. Group in the Cesnola Collection, New York

[Description: Woman gives birth, assisted by two ghostly figures.]

previous to being replaced in her bed..... The chairs which I have seen, and especially the one which the midwife of Larnaca brought to the house of our friend, had no pillows, but two arms; and the seat, though not perforated, had a peculiar shape, with a ridge in the centre, evidently made for the purpose of keeping the legs apart as much as possible.''

Although Cyprus was held at various times by Phenicians, Assyrians, Egyptians, Persians, and Romans, this much mutilated group so unmistakably bears the imprint

of Greek art that we must look upon it as representing the custom of those people and those of Cyprus during the Greek period, and well representing it, for the position of the parturient is an admirable one, unmistakably seated, semi-recumbent, upon a low stool, which cannot be termed an obstetric chair, as is done in the description of the group in the "Transactions of the Edinburgh Obstetrical Society.''[98] Great importance is attached to it by the author of that paper, as demonstrating the antiquity of the obstetric chair, but the fallacy of this view is already well proven by the criticism of Seligman in Virchow's "Jahresbericht.''

FIG. 29.—Modern Cypriote Midwife's Chair.

[Description: Low midwife's chair, without legs and with arm rails. Black and white illustration.]

In southern India the patient walks about during the earlier stages of labor, then sits upon the ground with the thighs well separated, the back supported by an assistant, whilst the delivery itself is finally accomplished while lying upon the ground.[99]

(b.) Sitting on the Lap or between the Thighs of an Assistant who is seated on a Chair or on the Floor.

I look upon this position as identical with that on the obstretric chair, although more simple and more ancient; and I believe that it will be apparent to every one, if the relative positions are considered, that the obstetric chair is merely an imitation of the more pliable and sensitive support afforded by the husband or assistant, who is himself made to suffer whilst holding the parturient woman during

the tedious hours of labor. I am heartily in accord with the statement of Rigby, although seriously questioned by Ploss, that, "as far as we may rely upon the meagre records which history gives us upon this subject, among the more civilized people of antiquity the semi-recumbent sitting posture was by far the most common. In proof of this I will again refer to the oft-mentioned funeral urn which so vividly pictures the position of patient, husband, and nurse in the lying-in chamber during the moment of the greatest trial, during the expulsion of the child. The patient is seated in the lap of an assistant. I can hardly say whether this is the husband or a female assistant, whether it is a male or female figure; at all events she is seated in the lap of a person whose arms encircle her waist, the hands pressing firmly upon the fundus of the uterus. The midwife is seated upon a low stool, between the separated legs of the patient, and is just in the act of receiving the head of the new-born child. This vessel, called Huaco, represents a parturient scene precisely as it is still enacted among the descendants of the Incas to this day, and Dr. Coates assures me that he has, during his stay in Peru, not unfrequently acted accoucheur, the woman always taking this position with the husband behind. Upon that entire coast of South America the inhabitants seem faithfully to adhere to the customs of their ancestors, and no better proof can be found of the correctness of the representation of the labor scene depicted upon this vessel than the above statement of Dr. Coates, and of other physicians, the most interesting of which is perhaps one by Dr. Ruschenberger,[100] who, whilst in Colina, in Chili, in 1823, was called to a case of placenta previa and found a lady, a lady of rank by the way, with her feet near the foot of the bed, the knees drawn up, reclining against her husband, a rather short corpulent man, who was sitting in the middle of the bed wearing his riding cap, booted and spurred, with the legs extended on each side of her and his hands clasped in front of her chest to afford support. The antiquity of this position is also proven by a passage in Genesis (xxx. 3), which says that the Hebrew women were confined upon the lap of a female assistant.[101] In ancient Rome this position was assumed in cases either of urgent necessity, or among the poor where the obstetric chair was not to be had. Moschion teaches his readers to help themselves in this way and it seems that these teachings, revived in Italy by Joannis Michaelis of Savonarola,[102] finally found their way into Germany. In France, also, an author like De

FIG. 30.—The Scientific Posture advocated in the 16th century. From Joannis Michaelis Savonarola, 1547.

[Description: Woman seated on low y-shaped stool, with assistants behind her. Black and white illustration.]

La Motte[103] became a warm advocate of this position. Joannis Michaelis highly lauds a very low three-legged stool which serves as a seat for the assistant in whose lap the patient reclines; he speaks of it as being of great antiquity, and much esteemed by the ancient Greeks. The assistant stands behind, on a rounded knob, supporting the patient, who is seated in front, upon the forked portion of the stool. At a comparatively late period a similar method of delivery was adopted among the modern Greeks.[104] The parturient woman being seated upon a kind of tripod, behind her upon a somewhat higher stool sits an assistant whose arms are clasped over the fundus of the womb whilst the midwife is seated in front. I regard these positions as in the lap of an assistant and can certainly not look upon a simple stool, as it was probably found in any kitchen at the time, as an obstetric chair, but from that, most unquestionably, the obstetric chair takes its origin, and a very pointed statement to this effect is made by Dr. Metzler,[105] who in the early part of this century found an obstetric chair in some remote village where he little expected to see it, which had been constructed by a carpenter who had neither seen an obstetric chair nor heard of one; but his wife had found her labor so easy, while sitting upon his lap, his legs separated, that he soon obtained a reputation in his native village, so that finally not a woman in the place would be confined in any other way than upon this good man's lap; this he soon found so irksome that he constructed this chair, and, in his endeavors to copy the position assumed by himself, a very fair obstetric chair resulted.[106] The above also seems to verify the statement that certain persons seem especially fitted, and acquire a reputation for such work; in Holland they were a regular convenience at every labor, and were known as "shootsteers;'' but not only here and there in Germany, in France or Holland, but also among the early Scotch, Welsh, and English was this position frequently resorted to, and we need not be astonished to see this same custom in our own country.

We have seen how the modern Peruvians still follow the ways of the Incas, and so the descendants of these Germans, Welsh, or Scotch have not forgotten the habits of their ancestors, although they have crossed the seas and have mingled with a more enlightened civilization. It may surprise some of our city practitioners of to-day, who see little of the country population, and especially those who have not practiced in rural districts years ago, that in our

own States women are confined sitting upon the lap of the husband or an assistant; this was, of course, much more frequent thirty years ago than it is now, but I still hear of it in many of our States, especially in southern Ohio, Pennsylvania, southwestern Missouri, Georgia, and the mountain regions of Virginia

A graphic description of obstetric practice in the rural districts of Ohio is given me by Dr. E. B. Stevens of Lebanon, Ohio, and embodies all that has been written me from other States. To quote his own words: "When I commenced to practice, a good many years ago, the almost universal habit of confinement throughout the regions of southern

Ohio was about as follows: two old-fashioned, straight-backed, slip-bottom chairs made the lounge, one chair erect the other turned down; a few old comforters upon this framework completed a very comfortable couch; the husband took his seat first, astride, the wife reclining in his arms, where she remained until labor was completed, unless there was much delay, in which case the patient was walked about or assumed any other position as dictated by fancy or impulse; the position of the accoucheur was upon an inverted half-bushel measure, so placed that he sat just between the limbs of the patient. Labor completed the soiled clothes were changed and the patient was placed in bed. This position was certainly not a bad one for all parties with the exception of the husband, who, in tedious cases, suffered rather severely; but then this little tax on his affectionate nature was, in those days, considered the very least return he could make for the mischief he had occasioned.''

I have been told of this position in so many different parts of this country that it would be superfluous to refer to individual statements; it is found in Pennsylvania, and among Pennsylvania emigrants in southwestern Missouri,

the position being practically the same, but differing somewhat in the details: thus, three chairs are placed in the form of a triangle, facing towards a common centre; the husband takes his seat in one of these, and has a sheet, or broad towel, or any cloth heavy enough, bound around his thighs, leaving the knees about six inches apart. This cloth serves as a seat for the parturient, and prevents the husband's legs from spreading apart when tired by the long continued strain; the patient puts her feet on the rounds of two other chairs, while a woman, seated in each of them, takes one of the patient's hands and supports the knee next to hers.

A professional friend in this State, who, like many other practitioners, tells me that the first patient he ever delivered was confined in this position, says that since then he has delivered quite a number of women in this way, and thinks it a great help in cases where the head constantly retreats after the pain ceases; in the rural districts of Georgia both negro and white women, now and then, still

follow this custom; so, also, in Virginia. A very minute description of such a labor in the mountain districts of northwest Virginia, in the first third of this century, is given in the "New Orleans Medical and Surgical Journal'' for 1860.[107] It is not surprising to see the white man thus patiently assisting his wife in the hour of her trial; but it does seem somewhat strange that we should find this position, and the laborious duty imposed by it, undertaken by our red brethren, as the Indian braves are usually so averse to work; but I must say that it is only now and then, among the Utes and the Pueblos in Mexico, that this occurs, and they possibly have copied the Mexicans.

The Indians, and lower class of Mexicans in the vicinity of San Luis Potosi, are confined either in a kneeling position partially suspended, or sitting upon the floor. If confined in the latter position, the accouchée sits on a sheepskin on the floor, between the legs of one of the assistants, the tenedora, or holder, who is seated on a little cushion, and serves as a support to the patient, her thighs pressing against the patient's hips, and her arms encircling her waist, the hands clasped just above the fundus of the distended uterus, so that she can follow the child in its descent, and exert a gradual but strong compression; the partera, of course, takes her position in front of the patient. Sometimes, in a tedious labor, this awkward posture is retained for one or two days, with not a little suffering to the tenedora as well as the patient.[108]

The custom of the Sandwich Islanders varies very little from this, and it is a matter of some interest to note their habits, as these islands, two thousand miles west of San Francisco, were entirely unknown one hundred years ago, and even fifty years ago were perfectly barbarous; it is important to us, more especially as they still retain, in a great measure, their crude ideas and practices. Very interesting statements as to the obstetric practices in these islands are made by Dr. Charles H. Wetmore,[109] who has had a professional experience of twenty-two years upon Hawaii. When the labor is fairly commencing, the patient assumes a sitting posture upon a hard pillow or stone, her husband, or some intimate male or female friend, kneeling behind her, whose duty it is to clasp her above the abdomen in such a way that he can press down with considerable force upon the uterus and its contents, never relaxing this grasp to allow the fetus to recede. The accoucheur's position is in front; she has little to do but to receive the child. Precisely

the same custom prevails among the Andamanese, on the coast of India,[110] the only difference being that the patient and supporting husband are seated upon the ground So, also, the Bedouins,[111] the child, however, being caught in a sieve, which is held by an assistant.

I have repeatedly had occasion to refer to the nomadic and barbarous tribes of Asia, as they have so successfully

resisted the encroachments and innovations of civilization, and among them many of these, to us peculiar positions, are still retained by parturient women; but, like the Indian brave, the Asiatic warrior is little inclined to assist his suffering partner; only among the Kalmucks is the parturient woman delivered in the lap of an assistant. The patient is seated upon the knees of a vigorous young man, who also exercises considerable pressure upon the abdomen by the hands which encircle the woman's waist.[112] It seems peculiar that young men should, among some people, be chosen for this office; here he serves as an obstetric chair, and among the Brulé-Sioux a young warrior serves as a support for the parturient squaw, who suspends herself from his neck; only the Japanese see that the physician is an aged male, in case that these positions are assumed for obstetric purposes.

(c). The Obstetric Chair.

The positions we have so far considered have been almost

altogether such as required no artificial assistance and were instinctively assumed.

With the advance of the obstetric art, the support given the parturient woman by the bone and muscle of her kin, by husband or tenedora, was replaced by a form of wood; the thighs upon which she sat, the chest against which she rested, were replaced by the cut-out seat and the slanting back of the obstetric chair, which was formed so as to receive the patient in the same position which she was wont to occupy on the lap of a fellow being.

We now come to the semi-recumbent position assumed by the parturient woman whose labor takes places in the

obstetric chair, under the supervision of a midwife or physician.

The obstetric chair marks a decided era in the history of the art; but I must consider that period as a whole, and in speaking of the chair I have reference to its more characteristic features, to those points which are common to all obstetric chairs, as it is not my purpose here to describe the various obstetric chairs which were in use at different times,

marking the progress of midwifery; the modifications were too numerous. "As in our times,'' to use Dr. Goodell's very striking expression, "eminent physicians are seeking to improve the obstetric forceps, so in those days learned men did not disdain to perfect the sella lochæa obstetricia seu obstetrica.'' My intention is merely to refer to the obstetric chair as being an artificial means of placing the patient in that semi-recumbent position which I deem most advantageous to the progress of labor, and which uncivilized people of the present day, as well as civilized nations of the past, long before the day of the chair, assumed as most comfortable for the parturient woman. The subject has been exhausted by the able pen of one of our fellows, Dr. Goodell, in his article on "Some Ancient Methods of Delivery;'' and Dr. Ploss; in his work, gives so complete a history of this method of delivery that I need but refer briefly to the subject. The obstetric chair which flourished in the days of Greece and Rome was almost forgotten in the darkness of the earlier centuries of the Christian era, but seems to have survived in Italy, partly owing to the writing of Greek and Roman authorities, partly because the custom was handed down from generation to generation among the people; and from Italy it found its way across the Alps into Germany and France. By this time, however, the rude stool of ancient times had been greatly changed in shape, complicated and improved, until the low stool, as we still see it in the hands of the Cypriote midwife, is presented to us as the typical obstetric chair of the Middle Ages.

The chair is mentioned by Albertus Magnus in the thirteenth century, and in the German translation of this work, under date of 1589, an illustration is given which resembles the obstetric chair of Soranus and Moschion. In the seventeenth and earlier part of the eighteenth century the chair seems to have flourished in Germany, and also in England, and numerous modifications were introduced. Its supremacy, however, was not of long duration, and it soon yielded to the modern recumbent position, and was only retained by the more conservative people in the rural districts, who follow but slowly in the wake of any advance. Smellie[113] says: "In remote parts of England the patient sat upon a stool made in the form of a semicircle.'' This, of course, was during the time of the decline of the chair, when the dorsal and lateral decubitus had become popular.

In the seventeenth century it was to be found in the centres of medical learning, and had not yet been forced back into the rural wilds.

As a matter of curiosity. I will cite the title of a work published in 1637, in which it was warmly advocated, and I will add a brief description of the chair, in the quaint language of the book, kindly furnished me by Dr. Wise, of the Surgeon-general's Library, and it will answer for this as well as all other chairs, and will serve to show the importance attached to its various features.

"The Expert Midwife: or, an Excellent and most necessary Treatise of the Generation and Birth of Man. Wherein is contained many very Notable and Necessary Particulars requisite to be knowne and practiced: with Divers Apt and Useful Figures appropriated to this Worke. Also the Causes, signes, and Various Cures, of the most Principall Maladies and Infirmities incident to Women. Six Books compiled in Latine by the Industry of James Rueff, a Learned and Expert Chirurgion: and now translated into English for the Generall Good and Benefit of this Nation.''

"Let the stoole be made compassewise, under-propped with foure feet, the stay of it behind bending backward, hollow in the midst, covered with a blacke cloth underneath, hanging downe to the ground, by that meanes that the labouring woman may be covered, and other women sometimes apply their hands in any place, if necessity require. Let the stoole be furnished and covered with many cloths and clouts at the back and other parts, that the labouring woman receive no hurt, or the infant anywhere, strongly kicking and striving because of the paines, stirrings and motions of the mother. And after the labouring woman shall be set in her chaire about to be delivered, the midwife shall place one woman behind her back which may gently hold the labouring woman, taking her by both the armes, and if need be, the pains waxing grievous, and the woman labouring, may stroke and presse downe the wombe, and may somewhat drive and depress the infant downward. But let her place other two by her sides, which may both, with good words, encourage and comfort the labouring woman, and also may be ready to helpe and put to their hand at any time. This being done, let the midwife herselfe sit

stooping forward before the labouring woman, and let her annoint her own hands, and the womb of the labouring woman, with oile of lillies, of sweet almonds, and the grease of an hen, mingled and tempered together. For to doe this, cloth profit and help them very much which are gross, and fat, and them whose secret parts are strict and narrow, and likewise them which have the mouth of the matrix dry, and such women as are in labour of their first child.''

FIG. 37.—Delivery in the Obstetric Chair; after Ruegius. 1637.

[Description: Pregnant woman reclines in an obstetric chair, while a midwife and two friends attend her. Black and white illustration.]

The antiquity of the obstetric chair has been greatly overrated, owing to the misconception or misconstruction of the data in our possession. I have endeavored to give conscientiously the earliest positive references to the chair which we have, and that, I think, is by Moschion in the second century; but the votive group from the temple of Golgoi, in Cyprus (pictured and described above), and that famous passage from Exodus, both of which are quoted as evidences of the early use of the chair, will, I trust, cease to figure in that capacity.

The group from the Cesnola Collection has been fully

described in its proper place; and as regards that oft-quoted passage from Exodus i. 15 and 16, which is referred to by so many writers as indicating the use of the obstetric chair among the ancient Hebrews; it is translated by such, "When ye do the office of midwife to the Hebrew women, and see them upon the stool, if it be a son, then ye shall kill him,'' etc. I, however, believe, with Kotelman, that that word "ebnaim,'' which is made so much of, and is translated, as already stated, by many as chair or stool, means stones. So that the passage would read: "When ye see the woman upon the stones.'' This would prove, as is most probable, that it was the custom of the ancient Hebrews to be delivered, like the Arabs of the present day, as observed by Dr. Goguel and others, in the squatting posture, seated upon two stones. These details are more interesting than important, and it will certainly suffice, as far as the antiquity of the chair is involved, to state the fact that several Arab authorities recommended the obstetric chair in difficult labors, and that it was also advocated by Hippocrates and Soranus among the Greeks, who were usually confined in the semi-recumbent position, often in bed. These are the first authentic statements as to its use. Its history has been a checkered one. At the present day, the obstetric chair is popularly used only among the nations of the East, and, as Ploss says, "It is remarkable that it should be among the very people who rarely make use of a chair for sitting purposes.'' We find the chair now in use in Japan and China, in Turkey, Greece, Assyria, and Egypt. In Japan, it was still advocated by obstetricians in the last century; in China it is common even now, although physicians battle against it. In Turkey it is used occasionally by certain midwives, as stated by P. Eram.[114] Dr. Denham speaks of its use in the East at the present day.[115] In Syria, no respectable midwife or "diyeh'' is without her chair, as I am informed by Dr. A. J. A. Arbeely, of Damascus. The chair so used is different from any other I have seen described, and appears to be a most practical contrivance, enabling the woman to assume various inclinations of the body; it is like a rocking-chair with comfortable arms, the seat about two feet above the rockers, and cut out in a semicircle, so as to permit the expulsion of the child. An assistant holds the parturient woman by sitting behind her, or at her side, whilst the midwife remains in front to support the perineum with the palm of her hand, greased with lard or olive oil.

I have already called attention to the fact that those nations

who resort to the chair in obstetric practice rarely make use of it for ordinary purposes, and it appears highly probable to me that the absence of the rocking-chair from foreign homes may be accounted for by the fact that the only rocking-chair of which they had cognizance was the chair which the midwife carried from house to house, whenever her assistance was asked, for the relief of the child-bearing woman; this chair was then so intimately associated with the idea of suffering, of labor, and child-birth, that it did not appear as a desirable piece of furniture for parlor or sitting-room; it would have seemed improper and out of place. For similar reasons the comfortable arm-chair is an unknown luxury among certain Eastern people.

It is only within late years that the American rocking-chair has found its way across the ocean, and the increased facilities for intercourse, and the spread of a leveling civilization, will soon do away with these remnants of former times which still linger here and there. Amongst the modern Egyptians, the midwife makes use of a chair, "Kursee El-Wiladeh,'' which is covered with a shawl, or an embroidered napkin, and some flowers of the henna tree, or some roses, are tied with an embroidered handkerchief to each of the upper corners of the back; thus ornamented, the chair is conveyed before the midwife to the house. In the houses of the rich, the parturient is placed on a bed after delivery, and usually remains there from three to six days, whilst the poor women resume their ordinary occupation in a day or two.[116] I will add that Lane, like almost every other author, refers to that passage, Exodus i. 16, intending to compare the custom of using the chair among the Egyptians with that of the ancient Hebrews. In Palestine, the obstetric chair is still an honored institution, but much simplified in form, being sometimes nothing more than an old-fashioned arm-chair.

(d.) Semi-recumbent Position, Strictly Speaking.

Although I have grouped as semi-recumbent all the positions last spoken of, I will, in this subdivision, confine the use of the expression more closely, and will class as semi-recumbent, strictly speaking, only those positions in which the patient assumes the dorsal decubitus with the head and shoulders raised, the axis of the body inclined at an angle of about forty-five degrees.

Like many other of these curious positions, this one is found in our own States, but seems to have come to us from the French settlers in the north. In Vermont, some thirty years ago, a semi-recumbent position was customary, which may either be looked upon as a rude imitation of the obstetric chair, or as a semi-recumbent position, strictly

speaking, and probably the custom has not as yet entirely passed away; the women in the rural districts were confined upon a bed made of three chairs tied together, upon which a straw bed was placed, and covered with a sheet. In front of this couch sat two women, whose duty it was to take the feet of the parturient woman in their laps, whilst the accoucheur sat between them, in front of the patient, where he was supposed to remain for two or three hours during the latter part of labor, if he did his whole duty.[117] The Canadian French women are partial to the inclined

FIG. 59.—Favorite Posture of the French Canadian.

[Description: Pregnant woman reclines on an inclined surface created by propping an overturned chair against the wall and covering it with bedding.]

plane, made by turning forward and downward a high-backed chair, pressing it back against the wall of the room and making a bed upon it; though comfortable for the patient the legs of the attendant suffer from the stooping posture necessary.[118]

The custom in Japan, if I may judge from illustrations in a very complete "Japanese Midwifery,'' is a semi-recumbent position, on a mattress placed upon the floor, with the head and shoulders well elevated, so that the body is inclined at an angle of about forty or forty-five degrees. Precisely the same position is found among some of the Sioux nations,

and the Assneboine Indians, who, as I am told by the well-known Indian interpreter, F. F. Gerard, lie on their backs, the head and shoulders propped at an angle of forty or forty-five degrees. This is the position usually assumed by them, although they are sometimes confined in the kneeling posture, like most Indians.

The Ute, Comanche, Apache, Navajoe, and Nez-Percés woman is also confined in the semi-recumbent dorsal position, the head and shoulders of the patient being frequently supported in the lap of an attendant, while the patient has access to a rope or brace placed within reach.[119]

Among the Pahutes, the parturient woman is placed in her tent, on blankets and skins, in a semi-reclining position, with her hips firm on the couch; she is supported by an assistant, who sits behind her, and in whose arms she reclines; her legs are flexed, and additional assistants hold and steady the knees; a leather girdle is fastened about her above the womb, and, as expulsive pains come on, three or more women push the girdle down after the escaping child.[120]

The Comanche woman gives birth to her child in some

secluded spot not far from the camp, in the dorsal decubitus, on a low extemporized couch prepared for her under a tree. Upon this she is placed, with her feet against the trunk of a tree, lying on her back. A lariat, a small rope of buffalo or raw hide, is thrown over a branch and secured; one end of it is placed in the hands of the woman, and she is allowed to pull through as best she may.[121] This would prove that during the pains, and the expulsion of the child, the patient raises herself by the lariat, and thus assumes the semi-recumbent position.

The Hindoos seem to find the position convenient, as the

parturient woman is delivered while resting on her back in the lap of a female seated on the ground, while her knees are bent, and are supported by two other females, one sitting on either side. In order to facilitate labor the parts are lubricated with oil, and the "Dyhe,'' resting on her knees before the patient, instead of supporting the perineum, urges the patient to assist nature in expelling the child, while she introduces the fingers of her two joined hands in a conical figure into the vagina, and, by spreading them, stretches the external parts, thinking in this way to facilitate labor, whilst she unquestionably retards it.[122] I will call especial attention to the custom of the Hoopa, lower Klamath, and the Orleans-Bar tribes, as it is precisely the same as I have occasionally seen my patients occupy in the efforts of expulsion. Lying on the back, the elbows drawn upwards and resting on the ground, the knees flexed to a perpendicular, the legs more or less flexed, and the heels resting on the ground.

The dorsal decubitus, with the body at an angle of forty or forty-five degrees, was common among the Romans. Moschion describes it. Celsius[123] and Paul of Ægina[124] recommend

this position in certain obstetrical operations, and before the time of the obstetric chair it was commonly assumed in Germany. In some of the mountainous districts of Saxony the patient, semi-recumbent, shoulders elevated, is suspended during the pains and the expulsion of the child, upon a strong broad towel which is placed under the pelvis and seems to further labor most happily in many cases.[125] The Gurian women take the dorsal decubitus, but at the moment of expulsion seize a rope suspended above the bed and raise the body to the same angle which we have found among so many other people.[126] Most reasonable of all seems the semi-recumbent position as occasionally adopted in the rural districts of this country; the patient

FIG. 43.—Virginia. Semi-recumbent in bed.

[Description: Woman reclines in bed, her upper body propped up by an overturned chair covered with bedding. In each hand, she holds a rope tied to a bedpost at the foot of the bed. Black and white illustration.]

being upon a bed doubled up against inverted chairs, the feet resting against the foot board, sheets or towels being fastened to the bed posts.

A truly semi-recumbent position is that of the Boeathies[127] or red Indians of New Foundland, which is thus somewhat quaintly, but very well, described by Cormack, who says: "The patient is on her back, semi-recumbent on the ground, feet and knees against two cross stakes. There is a hole dug in the ground in front, and the chief accoucheur, a female, sits in the hollow, it being a mere convenience. Another hollow in the ground is made, a short distance beyond, for another female assistant to sit in for the purpose of

supporting the patient's head. After delivery the patient is turned around, and placed in a kneeling posture within the upright stakes. Her buttocks, too, rest on one cross stick and her body on another, which is placed under her breast; and in this position the patient remains three or four days until well, receiving the necessary attention from the female accoucheur during this time.''

Among the Turks, also, the semi-recumbent position prevails, but more erect, seated on ground, stool or chair.[128] Their customs are extremely interesting, as in many of the interior provinces they still cling to their primitive ways.

During the fifth or sixth month of pregnancy the abdomen is compressed by a firm bandage, and this pressure is kept up until full term to prevent the child from growing too large. Abortion is frequent, and is produced by breaking the membranes and allowing the water to escape. Delivery is always accomplished on the lap of an assistant, or seated in a semi-recumbent position on a bed or low stool, or even on the ground, leaning against the stump of a tree or the wall of a house, or some other convenient point. Thus we may say that it is always a sitting posture, either upon the lap of an assistant, upon the ground, or upon the obstetric chair.

Until recently, and even now in distant villages, it is still the custom for the midwife to carry with her the obstetric chair. This, according to my informant, is of a peculiar kind; a large, wooden seat, back chair with a circular opening cut into the front part of the seat, in this differing from all known forms of the obstetric chair, which consist of a mere semi-circular excavation in the seat, this, however, being a complete circle. This carrying about of the chair is the same custom which we have referred to in Syria and other Eastern countries, although the shape of the chair is different. In difficult labor the patient is placed upon a blanket held by four or six persons, and upon this she is rolled about, not tossed up and down as we have seen it customary in other countries.

During the earlier stages the patient lies at will, usually on her back, on a mattress placed on the ground; as labor advances, and the pains increase, one of the stronger of the women present takes the parturient on her lap, compresses the abdomen by her encircling arms, and urges the sufferer to bear down with all her weight. Various other methods are resorted to for the purpose of increasing the pains: thus the bent knees of the patient are constantly and severely jarred, or cold water is forcibly thrown upon the abdomen.

Their midwives are very fond of endeavoring to hasten labor by prematurely rupturing the membranes, cutting them with a sharp piece of salt—often cutting into the scalp as well.

The root of the Alizari (rubia tinctoria) is considered as an emenagogue by the nomadic Turucks, and during childbed the same remedy is resorted to to call forth the lochia when once checked.

In former times bleeding during pregnancy was resorted to with a view of preventing convulsions of the new-born, but is now pretty well given up.