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As I have treated fully of the third stage of labor in my last paper, I shall in no way here refer to it, but will at once pass to the consideration of the puerperal stage, and as so

little attention is paid to the treatment of the patient during that period, I shall confine myself to the treatment immediately after delivery, as she is then for a few moments still under the control of the midwife or attendant, and something is always done before she is permitted to go to her home or her place of retirement through the period of uncleanliness that follows.

Among the Apaches, it is deemed very essential that, as soon as the placenta is expelled, the woman should be kept on her feet, walking about for half an hour or more, so as to favor a free discharge of all retained blood and prevent its coagulation in the womb. The same custom is observed among the Dakotas, among the Flat-Heads, Pend-d'oreilles, Kootenais, and among other of the Indians of the Pacific coast, and wherever it is not especially mentioned I should suppose that the custom was at least unconsciously observed, because it is rarely the case that the Indian squaw remains abed after her confinement; she certainly moves about sufficiently to accomplish the end desired, even if it is not done with the purpose definitely in view. It will be remembered that upon the banks of a stream was the place usually sought by the laboring woman among primitive people the world over for her solitary confinement; delivered of her child she bathes in the cleansing waters—this is done by most of our Indians, by some of the natives of Africa, the inhabitants of Ceram, the still savage tribe of the Yurakere, by the natives of Bolivia, the Sandwich Islands, the Antilles, and of India. It is everywhere the same; the mother, usually with her babe in her arms, plunges into the stream to cleanse herself; or, if the labor is conducted by a midwife, she leads the patient to the water where she is washed secundem artem, redressed, and then allowed to return to her place of seclusion or to her home, and very frequently to work, according to the varying customs among different tribes.

Among many of the tribes of the Sclavonians, several buckets of warm water are poured over the patient's abdomen; the Klamaths steam themselves—a custom which they continue for several days after delivery. The Pahutes also continue their ablutions frequently for days after confinement, mother and father both indulging in frequent washings in imitation of some original first parents,

whom tradition informs them were very cleanly. The Siamese cleanse themselves with still greater thoroughness, but with fire instead of water; "with the expulsion of the child begins a month of penance for the mother—exposure to true purgatorial fires. It is ingrown into the native female mind in Siam that the most direful consequences to both mother and child will ensue, unless for thirty days after the birth of her first child—a period diminished five days at each subsequent birth —she exposes her naked abdomen and back to the heat of a blazing fire, not two feet distant from her, kept up incessantly day and night. They think the due quantity, quality, and duration of the lochial discharge depends on their exposure to the fire. And this is done in the following way: A fire place is brought in or extemporized on the floor of the lying-in chamber, by having a flat box or a simple rectangular framework of planks or trunks of banana trees, some three feet by four, filled in with earth to the depth of six inches. On this the fire is built with sticks of wood nearly or quite as large as one's wrists. By the side of this oblong frame, and in contact with it, raised to a level with the fire, a piece of board six or seven feet in length is placed, and on this a coarse mat spread; upon this, or on the bare plank itself the unfortunate woman lies quite nude, save with a narrow strip of cloth about her hips; with nothing else to secure her from a fire hot enough to roast a duck. Then, acting as her own turnspit, she exposes front and back to this excessive heat—an experience not to be coveted in any land, but in that burning clime of perpetual summer a fiery trial indeed. The husband or nurse is ever hard by, like her evil genius, to stir up and replenish the fire by night and by day. True, if it blazes up too fiercely for flesh and blood to endure, there is at hand a basin containing water and a small mop with which to sprinkle it on the flames and keep them in check; hot water alone is allowed to quench the patient's thirst. Those whom lack of merit causes to die in childbirth are buried, not cremated as is the rule with nearly all others who die in Siam. It is a custom almost universal on the entire peninsula of Indo-China and Bangkok; not only the Siamese, but the Laos, Burmese, Malays, and others practice it. The women of the Combodians improve upon the experience of those of other nationalities, for they place their couch of repose, the bench of bamboo slats on which they lie, not alongside of, but actually directly over the fire, so that the smoke and heat ascending do their full work, and they see their thirty days and nights drag slowly along, broiling on this Montezuma bed of misery The Mohammedan Malays are as observant of this custom as are the Buddhist Siamese, so that it does not seem to be of religious origin. Sir John Bowing suggests there may be some vague idea of pacification or purification connected with it (certainly purification). There is one compensation to offset the mischievous consequences of this practice: it makes the woman of that land escape the evils that result in other countries so often from resuming household duties too soon after the birth of the child. The Siamese mother is guaranteed by this custom one month at least the fullest liberty and undisturbed rest by her own fireside.''[2]

The Binder, which is now gradually passing away among civilized people, has its representative among some of the savage races: the squaw belt is used among most of the Sioux tribes, and is applied by them during confinement, either before the expulsion of the child or before the expulsion of the placenta, and is worn until the next day. It is a leather belt about four inches wide with three buckles. The Kiowas, Comanches and Wichitas use a broad bandage of buckskin, ornamented with beads, which they buckle tightly around the abdomen of the mother immediately after the completion of labor, and this bandage is thus worn for about a month. Some of the Sioux tribes use a broader belt, with a compress underneath, which is worn for a length of time. The Klatsops also make use of a squaw belt, retaining it as long as convenient to the wearer. Of some of our Indians, especially the Yumas, I am expressly told that they wear no bandage; and in old Calabar a handkerchief simply is tied around the abdomen and twisted so as to make it more like a cincture than a bandage; it is placed right over the hard contracting womb. In Syria the regular broad bandage is worn.

With regard to the time of the puerperium, or the time of rest which is given the woman in childbed, there is a greater

variation among the customs of the different tribes and people than in almost any other feature of that great physiological function of woman. Some observe no period of rest, but resume their ordinary occupation as soon as they have had their plunge in the water after the birth of the child. But among many people there is a certain time of rest and isolation which is governed more particularly by their religious beliefs of their uncleanliness; and very likely some wise law-giver infused this idea into the unwritten laws of the people, with the view of necessitating a period of rest for the young mother. We find this custom as far back as we have record, and it seems that in the period of seven and of thirty days the two periods of childbed are exemplified, first that of the lochia rubra, and secondly that of the lochia alba. With regard to the first period the puerpera should be as unclean during the time of the bloody flow as she is during the menstrual flow, and this period after the birth of a male child is fixed at seven days, but after the birth of a female at two weeks.[3]

Similar beliefs existed among many ancient people: in Athens the puerpera was considered unclean, and whoever touched her was forbidden to visit an altar; even the midwife who was present at the confinement was obliged to perform a religious cleansing of her hands at the feast of the Amphidromies, when the new-born child was carried about the family altar. When the Isle of Delos was to be made a sacred island it was forbidden that a confinement should take place within its shores.

It is evident enough why the ancient Israelites considered the puerpera unclean during the first days after childbirth, but it seems difficult to explain why this uncleanliness should have lasted seven days after the birth of a male and fourteen after that of a female child. Kotelman believes that it was because the female sex was considered the weaker, the most despised, and the one which would cause the most uncleanliness. It is remarkable that among the Greeks the same idea was prevalent.

In the second period, during the white flow, the puerpera was obliged to remain at home for thirty-three days for a boy and sixty-six days for a girl baby, but was no longer considered

unclean. We have already seen that some of our Indians seek to cleanse and purify themselves by frequent steaming, others by washing, and the Siamese by a purification of fire through a period of thirty days, which is diminished by five days for each succeeding child. According to other statements, and possibly in other parts of Siam, seven days of this fiery ordeal suffice to purify the unfortunate woman. Among the Kalmucks, a woman is regarded as unclean for three weeks after delivery, but never is she permitted to remain on her bed longer than seven days. The northern tribes of Russia, the Samojedes and others, consider the puerpera unclean for several months after confinement; her husband is very careful not to approach her, and she remains in her hut isolated, often very badly taken care of, so much so that mother and child may succumb to this neglect; only after the expiration of two months is she herself, and the tent in which the confinement took place, thoroughly smoked, and from that time on considered as clean. Ten days is the period of uncleanliness among the tribes of Alaska. In Egypt, those who are in easy circumstances remain abed for three to six days, but poor women resume their ordinary occupations, if not severe, in a day or two; in Syria, a rest of about six days in bed is permitted. In Japan, the puerpera is not placed in the usual recumbent position, but sits propped up by pillows, the mat upon which she was confined being left in place. In this upright position the woman remains for about three days, when gradually the prop behind is removed, till finally she is lying with her head on a high pillow, and at the end of three weeks she gets up and the customary congratulatory feast is given to the relations of the family. Another authority states that the patient retains the recumbent position until the twenty-first day, and then, if all has gone well, takes a bath and resumes her duties. The Yenadies of Southern India ordain a period of isolation of ten days, after which the mother returns to her household and its duties. The same is true of the Vedas, also of Southern India; the first five days after confinement are spent by the puerpera in a hut within call of the Konan, together with mother and sister or assistants; on the sixth day, she is moved to a shelter nearer to the Konan, in which she remains isolated for another five days. After the tenth day she washes with warm water and turmeric, anointing herself with oil; washing is continued for one month, when she resumes work. Dr. Shortt makes a similar report of other tribes of Southern India; he says that the woman lives in strict seclusion in a small lodge ten or twelve paces from the family home for thirty days after childbirth, frequently washing; before joining the others she has to wash all her clothes and undergo a general purification.

The Wakamba of Africa put their parturient to work four to six days after confinement. The Wazegua alone permit the woman to rest abed for fourteen days. Most of these tribes also purify by washing with hot water. The Abyssinians and the Somali use slack lime. The women of the Waswaheli sometimes insert the juice of a lemon into the vagina to hasten contraction. The Wakamba ordain a coitus about the third day, and after this the puerpera is considered clean. Among some of the African tribes the women carry an ebony staff for forty days after confinement, for the purpose of keeping off the devil.

The North American Indians seem to be less careful of their women. I am positively informed of the Sioux, the Santees, the Apaches, the Indians of the Neah-Bay Agency, as well as the natives of Ceram and of the Antilles, and the Yuricaria of Bolivia, that they practically observe no period of childbed, but go to work upon the same day or the day after that of their confinement. Other of our Indian tribes observe a certain period of rest; those of the Uinta valley take up their abode in the "wick-e-up'' in which they are confined, and return to the lodge occupied by the family after from two to four weeks, and during this period they are considered to a certain extent unclean. The women of the Laguna Pueblo remain unwashed and in bed for four days; very early on the fifth the puerpera is washed and dressed under the superintendence of a Sheaine or priest, who walks out, followed by the women, to see the sun rise and to render thanks for her safe delivery. As she walks after the Sheaine she throws corn blossoms into the air and blows them around as an offering of thanks. Thirty days after the child is born, the woman is clean and her husband returns to her, but some prefer to wait thirty-six, and others forty days. A good many

of these Indians, however, have abandoned the fifth-day superstition, the sun worship, and are cleaned or washed at once and get up as soon as they feel able to go about their work. The native Mexican woman remains abed three days; on the third day she gets up and for the first time since her confinement changes her clothing. The lochial discharge is usually abundant and continues for a long time, seldom less than forty days. At any rate it is only after a period of forty days that the woman ventures to bathe herself. After that she drinks freely of a decoction of some native plant for the purpose of increasing the discharge and bringing it to a speedy close.

Very little or no attention is paid to the food which women receive after childbirth, yet some tribes make a reasonable change in their diet. The Kalmucks feed the puerpera mainly on broth during the first days, giving her but very little mutton, the quantity of meat being gradually increased. Among other of the Russian tribes, as I have already stated, the isolation of the patient is so complete that she is but scantily nourished and glad to get anything she can, and often, together with her offspring, suffers actual want. In Syria, mutton or chicken broth is given on the first and second days, then carminative drinks, cinnamon tea and so on, for six days, after which the quantity of food is gradually increased. In Old Calabar, the patient is allowed a pot full of chop, which her husband has prepared during the labor, to be given her, and she is expected to eat a quantity of it immediately after confinement. In southern India, the natives seem to pay greater attention to the diet of the puerperal woman than in almost any other country. Certain of the native tribes live for three days after delivery on the tender leaf bud or cabbage of a kind of date palm, Phœnix sylvestris, after which rice or other food, to which they are accustomed, is partaken of. The Domber give her plain rice on the first day, and on the second chillie powder and curry-pillay is mixed with the rice. Among the Kanikars the puerpera receives as a tonic for the first day a kari (ragout) seasoned with turmeric pepper and tamarind.

The negroes of Africa, as a rule, make very little change. The Waswaheli and Nyassa give the puerpera food highly seasoned with Cayenne pepper and other spices. The Wakamba, like the natives of the Andaman islands, make

almost no change. The same I may say of our own Indians, with the exception of the Yumas, of whom I see it stated that the puerpera and the murderer are treated to the same diet; neither are allowed to eat either meat or salt for one month, for the purpose of purification. The Basuthos treat the patient cruelly in refusing her water for three days after confinement, the idea being probably the fear of too great a quantity of milk oppressing the breast. The Loango woman drinks quantities of hot water for several months in order to increase the flow of milk, and she also washes herself with a decoction of the leaves of Ricinus communis. With leaves of the same plant steeped in water, the genitals are rubbed and cleansed until the secretion ceases. The young mother, moreover, takes a great many baths in some secluded spot in a slight excavation made in the ground and laid out with mats, where cold and hot water is alternately poured over her and the body is kneaded, rubbed, and anointed.

Of the medicines used in the puerperal condition, I can only learn that in Mexico teas from native herbs are given to increase the discharge of the lochia; the same is accomplished in southern India by the use of saffron and neem leaves. In Syria, carminative drinks are given. In Siam, hot water has eased the thirst produced by the parching fire; whilst in Africa it is given to increase the flow of milk. Among the natives of Russia many of the stronger and more aromatic herbs are used in the various diseases, and many methods of treatment are resorted to in mammary affections, which seem to be very common in the puerperal state, as the remedies are so numerous. I will mention but one, on account of its peculiarity. In case of hardening of the breast, the patient places herself in front of the heated stove in order to warm the diseased part as thoroughly as possible. In the mean time some other person heats a woollen sock, which has been moistened with the urine of the patient, places it as hot as it can be borne upon her breast and attempts to keep the breast as well as the sock hot and moistened with urine; then some iron utensil, a knife or horse-shoe, chilled in ice, is placed upon the affected breast. The hotter and more moist the breast is, and the colder the iron, the more certainly will the cure be effected. I will not refer to any of the ceremonies which are here and there observed,

either upon the birth of the child, especially if a male, or upon the return of the mother from her isolated state, when cleansed and purified, to her home and her family, but will simply call attention to a remarkable feature common to the natives of the coast of Borneo and to some of our Indians. For instance, among the land Dayokas of Borneo the husband is always treated badly after the birth of the child, when he is dieted on rice and salt, and for a few days forbidden to bathe or show his face out of doors; whilst among some of our Indian tribes the father, after calling his relations and friends together and having a feast of boiled dog and other Indian delicacies spread for them, goes off and cachés himself until the child is a week old. This practice, however, is only observed by the young men who are so ashamed of the occurrence that they go to some friend and stay until they summon sufficient courage to come back, when the wife presents the child for the first time to its father. The management of the puerperal stage by the Indians of the Pacific coast has been so well described by Dr. J. Fields, formerly of the Grand Ronde Agency, Oregon, that I will quote verbatim that part of his letter referring to this subject. He says:

"The treatment resorted to is not alike in all the tribes; some with whom I have come in contact require the woman to keep on her feet the greater part of the day, taking short walks around the camp and resting only when she becomes very weary; as a support she uses a staff, an instrument through the aid of which relief comes, as the body is frequently bent forward which brings the abdominal walls immediately over the uterus against the upper end of the stick, on which she also holds her hand, as a man walks with a cane; for a period of three or four days the woman continues the prescribed walks, with an occasional hour in a reclining posture to rest her feet; then she is considered well. The object of this, as old women of the tribe informed me, is to facilitate the flow of the lochia; they think that should the woman lie in bed the blood would accumulate in the abdominal cavity and she must die.

From all I can learn about the practice of the Indians here before the white men came among them, their procedure in the after-treatment was solely for the purpose of encouraging a

free flow of the lochia, and I hear of no death from hemorrhage.

Those tribes of Indians on the Pacific coast who follow a different course of treatment, place the woman on a bed as soon after delivery as possible, securely wrap her in a blanket or some covering, and place her near the fire, where she is kept in a closely wrapped condition to escape taking cold and having fever; here she is kept for four or five days, when she at once takes charge of the babe and resumes all the duties that fall to the lot of an Indian woman.

During two and a half years' life among the Indians I neither saw nor heard of a case of puerperal fever, puerperal eclampsia or any diseases peculiar to lying-in women. Neither did a death in labor come under my observation; few women have any mammary trouble, notwithstanding their being exposed to the same cause that is a prolific source of mammary complication among white women.''

The absence of mammary trouble, as observed by Dr. Field among the Indians of the Pacific coast, is true of most peoples living in a comparatively natural state, as the chest is either exposed or only loosely draped, so that the gland is not irritated by closely fitting garments; on the contrary, it is hardened by exposure, the muscular and glandular system is strengthened, or rather allowed to develop naturally; the shape of the breast is not artificially altered, and no artificial support is given it, but the muscles are allowed to perform their functions, which is the case among civilized women only during the period of nursing, when the weakened, atrophied fibres are at once called upon to perform this service in case of a temporary hypertrophied gland, which was never asked of them under ordinary circumstances.

All parts of the organ remain more fully developed and more hardy, less liable to inflammation than among those races accustomed to the laces, straps and stays of civilization and fashion.

Among some of these people peculiarly situated, such as the Arabs (Corré), fissure of the nipples is said to be frequent, owing to a lack of care of the breasts and exposure to external violence, perhaps to the irritating sands of the desert: the usual consequences follow—inflammation, induration, and

even degeneration of the gland. They treat the fissure with a fine powder of henna, or by alum powder; in the Moorish villages a few drops of orange flower essence are added to this.

Corré observes a fact, well known in this Mississippi Valley, that the breasts in lactation, just as the uterus in its condition of activity in pregnancy and in the puerperium can, allow a local center for malarial irritation; malaria is as much at home in the vast valleys and deltas of the great rivers of Asia and Africa as it is in our own Mississippi, and milk fevers with malarial types are frequently observed, and yield as readily to quinine among the Negroes, Hindoos or Arabs as among our own people.

As our civilization suffers in comparison with the primitive state in so many of the features of generation, so it does in the nursing of the new-born. One sentence in La Mere et l'Enfant tersely states a very sore point; he truly says: "Among all people except the most civilized the mother's milk is considered the proper nourishment for the children.''

The husband, at all other times the lord and master, is placed in rather a peculiar, sometimes ludicrous position, as we have just related, among certain peoples; if ever, it is during the period of recent maternity, in child-birth and childbed, that a certain amount of regard is involuntarily paid the wife by savage peoples, and I would take issue with Corre,[4] who claims that the exclusion of men from the lying-in-room is not the result of modesty. He says: "Our feeling of shame and modesty is a refinement entirely unknown to many people, and shown by others in the most peculiar ways. Among many a woman in labor can only be attended by one of her own sex; this is because among savages woman is a most inferior being, despised and dare not aspire to the assistance of men. She is worth so little and so easily replaced; she is good for the bearing of children, to look after them, and to give satisfaction to her master, but especially to do the rough work in the fields As soon as she is a nuisance she is left, she is sold, she is killed, and sometimes she is eaten for fear of letting a good piece of meat escape.''

During this trying period at least a better feeling prevails, as is proven by many of the instances related; and Corre himself, in his extremely valuable and interesting work, tells us how the sufferings of the parturient, in Old Calabar, are concealed by the laughter and conversation of surrounding relatives, that not a cry be heard, as it would dishonor her and cause the family to repudiate her; at the same time the husband is clothed like a woman, put to bed and sighs terribly, as if he was enduring great suffering.

A similar custom formerly existed in Greenland and still prevails in Guiana, among certain Canadian tribes and the Caribeans: while the woman who has been delivered attends to her household duties in the interior of the house, her husband goes to bed and receives in her place the visits of condolence from friends and relatives. Among the ancient Corsicans a similar custom existed, and is still observed in our day in some of the regions of the Pyrenees. It is also found among certain African tribes.

This peculiar comedy is doubtless for the purpose of causing the woman to forget her trouble and give her an innocent revenge for the suffering which she alone has supported in the work of reproduction.—(Corre.)

It certainly does appear to be a certain acknowledgement of her fortitude and suffering, and shows a certain amount of respect, however passing it may be.

I have treated more particularly of the puerperium among the red races, and will add some interesting facts from the work above referred to.

In the Antilles and Guiana hemorrhages are severe, prolapses frequently caused by brutal intervention of the negroes. As soon as delivery is effected food is offered, meat or some mixture of milk, palm oil and tamarind, and after a few hours the usual labors in the house are again taken up, without going outside during six or seven days.

In China more pains are taken, but with little more understanding; the patient is put to bed but not permitted to sleep, because this might weaken her and prevent the proper circulation of the blood. She must rest upon a high bed, lie

upon her side, the knees bent, and take a cup of the urine of a child; during the first three days she must take three or four times a day a mixture of whiskey and child's urine, taking care not to take too much whiskey. Pork she must not take for six days, and no eggs for a month, because they might disturb the vessels.

Many peoples have a superstitious faith in the use of heat immediately after confinement, some instances of which I have already cited: so among the Rouconyennes a steam bath is taken in a hammock under which a large stone heated by the fire is placed; upon this water is thrown. In a few hours the usual occupations are again taken up. When the Anamite is delivered a vessel filled with hot coals is placed under her bed, and the fire kept going night and day; the stomach is rubbed twice a day with a vessel filled with hot coals. Dry food is given, spiced and very dry. At the door of the house, at the end of a long pole, a pot of charcoal is placed as a sign of labor, and that the entry is forbidden to such whose labors have been difficult or followed by death; when the lighted end of the charcoal is turned towards the interior of the house, a boy is born; if turned outwards, a girl is born. It is a custom throughout Annam that the puerpera must take a medicine consisting of a decoction of laxatives and purgatives. During the month of her child-bed her husband abstains from all work, and must give all his care to his wife and child and to make the necessary preparation for this. The mother cannot leave the house before four weeks, and in order to preserve her from the evil influences of the air she is bandaged, head and feet, with saffron. In Siam the woman is placed before the fire after delivery, and if you ask: where is so and so, the answer is given: she is before the fire.

The Hindoo woman suffers likewise; when labor is over she is placed in a small, ill ventilated room, without any other opening except the door, which is usually closed, and smoked by a wooden fire, which is constantly kept up, and condemned to isolation in a terrible atmosphere; she is, moreover, obliged to abstain from food: during the first three days she must take a powder composed of stimulating spices, and during

the next three days the same spices with certain substances boiled in water in the form of a paste; at the eleventh day only does the woman begin to live somewhat like the rest of the family, but she does not leave the room for a month.

This frequent resort to fire seems to arise from an instinctive idea to protect the puerpera from cold, but it certainly is beneficial in so far as it allows her a certain period of rest, and may it not hasten uterine contraction and prevent hemorrhage? The amount of heat applied is at least equal to that of hot water, which we now resort to for the purpose of arresting hemorrhage.

However little apparent, good reasons exist for many of these seemingly ludicrous customs, and good results often follow; harmful as they appear to us, they are probably necessitated by the peculiar customs of the people, and greater havoc among them would follow their neglect.