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MANAGEMENT OF SIMPLE CASES.

The placenta delivered in the same position which has been occupied during labor pains and the expulsion of the child.

Manual expression.—Among our Indians, as among all uncivilized nations, external manipulations are resorted to wherever good can be accomplished by them, and in obstetric practice massage and expression are freely and effectively used. The third stage of labor is a very short one, the placenta usually escaping very soon after the birth of the child; and by far the most common, the prevailing treatment in fact, is the one we will now consider. The patient and her assistants retain the positions relatively occupied during the birth of the child; the

parturient, as is commonly the case, kneeling, whilst an assistant, who kneels or stands behind her, with her arms around her waist and the palms of her hands upon the fundus of the uterus, keeps up a steady pressure upon the contracting organ, and in case that the muscular action is not sufficient for the expulsion of the after-birth, she hastens its progress by an effective kneading. Moreover, we know that the kneeling, squatting, and semi-recumbent positions are those in which the abdominal muscles can be most effectively used for the purpose of expelling any of the contents of the abdominal cavity. This is true of the Comanches, of the Klamath, the Crows, Nez-Percés, Peorias, Shawnees, of the Kiowa, Caddo, Delaware, Wyandotte, Ottawa and Seneca tribes. The Klatsops carry out this idea perhaps even more effectively by placing a bandage about the patient's abdomen immediately after the expulsion of the child, "to keep the placenta from going back further into the body.'' And I may here state that this is the ruling idea in their treatment, as they dread such an accident very much, and unless the placenta is speedily delivered, the uterus responding to their manipulations, they are at a loss what more to do, and the patient is usually left to her fate, rarely escaping the consequent septicemia. The Dakotas permit the patient, if exhausted by the labor, to leave the kneeling posture and lie down during this last stage. Some of the tribes belonging to the great Sioux nation—the Blackfeet, Uncapapas and the lower and upper Yanktonais—follow this most judicious mode of delivering the afterbirth. In case that steady pressure from above downwards upon the fundus, and kneading of the tumor, does not suffice, the abdomen is rudely kneaded with the clenched fists, in various directions, in their endeavor to push the placenta out, as I gather from an interesting description of a case of retarded delivery of the placenta among the Umpanas.

The Kootenais kneel during labor, and after expulsion of the child continue to knead the abdomen, exercising the same pressure downward as when aiding the descent of the child, and in case this fails, they introduce the hand into the vagina and remove the placenta, giving the woman one joint of an unknown root to stop the hemorrhage, following it by another joint in fifteen minutes or half an hour until it does stop, with the idea

of checking the hemorrhage gradually. They let the patient bleed to a certain extent, and if it exceeds their idea of what she may well lose, they give the root. No reason is given why they should not stop the bleeding at once. This is one of the very few tribes who have any knowledge of the removal of the placenta by the introduction of the hand in utero. The Papagos also seem to remove the placenta forcibly, if it does not speedily come by natural means. The squaws of several tribes are delivered in a squatting posture, and among them, also, the placenta is delivered precisely as the child was, the patient and her assistants retaining the same position, and the same pressure and manipulations being kept up. This is true of the women of the Laguna-Pueblo, of the Coyotero-Apaches, and some of the tribes of the Sioux nation. The Brulé, Loafer, Ogallala, Wazahzah, and Northern—among these, as well as other of the Sioux tribes, and the Kiowas, also, a change of posture is made. The squaw belt is often used, and the placenta is delivered almost immediately after the child, by the gradual tightening of the broad leather belt, which is strapped above the womb as soon as the child has appeared.

The women of the lower order of Mexicans, who are also usually delivered in the squatting posture, sometimes kneeling, follow the same custom as their Indian neighbors, but of them I am told that the third stage of labor is a much longer one. The midwife busies herself about the new-born child, while the patient is kept in her uncomfortable position, kneeling or squatting, with her rear and lateral assistants, until the placenta is expelled. This takes place seldom in less than half an hour, but generally within an hour; if not, the patient receives a more or less violent shaking, according to the exigencies of the case, the rear assistant, with her arms about the patient, actually shaking her up and down, and, if this does not answer, as a last resort, efforts are made to provoke vomiting. A decoction of some kind, either laxative or nauseating, is given the patient for the purpose of assisting the expulsion of the placenta; but among the Mexicans a cup of corn gruel, atole, is regularly given after the expulsion of the child. Among those who retain the semi-recumbent position in which they are usually delivered are the Wacos, Hoopas, lower

Klamath, and Penimonee. This is a convenience for the midwife or assistant, as she can also assume a more comfortable position, and knead the abdomen to better purpose.

The Indians of the Pacific coast follow the same custom, and they, as well as all other tribes, seem anxious to attempt the speedy expulsion of the placenta, so that an effort is always made to assist the uterus in casting off the remaining afterbirth as soon as the child has been removed, and placed in a safe place. The accoucheur makes gentle, but tolerably firm traction on the cord with one hand, and with the other manipulates the abdomen over the uterine globe. At the same time, if thought necessary, the assistant will gently press the abdomen; both hands, with the distended fingers, being laid above

the womb. At times, he does still more by kneading, with a view to pressing the secundines out of the uterine cavity, but if these efforts fail while the patient is in their usual obstetric position, the semi-recumbent, she is raised to an erect position and then, well supported, the manipulations of the uterine globe are continued, and a more firm traction is made upon the cord.

Of the Flat-heads and Pend-oreilles, I am told that the placenta, in almost every case, is delivered with neither massage nor expression nor traction on the cord, nature, unaided, completing the labor; very decided means are, however resorted to in case delay should occur, which is very rare. Among those who assume the semi-recumbent position are also the Utes, Navajoes, Apaches, and some of the Nez-Percés,

who assist nature by kneading the abdomen, but rarely by actual expression or traction upon the cord; they, however, expect to hasten the expulsion by anointing the abdomen with greasy unguents or decoctions of herbs.

The Burmese are among the very few people who adopt a dorsal decubitus as the obstetric position, and forcibly expel the placenta more by beating the abdomen than well-directed manipulations, and in extreme cases, by sitting or standing upon the abdomen and pressing with the feet upon the uterine globe.

The Makahs, of the Neah-Bay agency, retain the sitting posture in which the child is delivered, but whilst this, to them, apparently simple proceeding is always managed without professional assistance of any kind, skilled help is called as soon as the child is born. Until then nature is allowed to take its course, but as soon as the child is expelled, an old woman, who makes this a specialty, is called to deliver the afterbirth, which she does by pressing and working the abdomen constantly until the placenta and the clots are removed. This person has nothing whatsoever to do with the delivery of the child. The same position is occupied by the women of the Skokomish agency, and here, also, the very best practice is followed, the placenta being allowed to come away without any manual interference except expression over the region of the womb and a slight traction on the cord.

The Brulé Sioux and Warm Spring Indians retain the standing posture, in which the child is delivered; the midwife, standing behind the patient, aids the naturally rapid expulsion of the placenta by pressure on the fundus with her hands, varied by a kind of churning manipulation.

Intra-Abdominal Pressure.—The use of the diaphragm as a powerful aid to all efforts to expel the contents of the abdominal cavity is well-known to our midwives, and we know how frequently they direct their patients either to hold their breath or to scream, as the exigencies of the case may demand; but, fortunately, they do not resort to measures quite so violent as our Spanish neighbors in Mexico, who assist the expulsion of the placenta by vomiting the unlucky patient. Some of our Indian tribes also lay stress upon the intra-abdominal pressure, and the assistance of the diaphragm and abdominal muscles,

but only in case of retention or delayed expulsion, and hence we shall speak of this method farther on. The Somali of Central Africa, however, habitually give the patient warm mutton suet to drink after the expulsion of the child; this has a laxative effect, and, with the contents of the bowels, those of the uterus are expelled.

Traction on the Cord.—Traction upon the umbilical cord appears so natural, and is certainly so tempting a means of removing the placenta, that it is much esteemed by a class of meddlesome midwives which abounds in all civilized countries to the detriment of parturient women, but the untutored savage, guided in his practice by instinct and observation, is too shrewd to seek the removal of the retained placenta by such dangerous means.

Although it is customary, among some of our Indian tribes, to make a certain traction upon the cord, I am uniformly told that this is always done with extreme caution, and but very few make use of it to drag down the afterbirth—a manipulation fraught with so much danger, and unfortunately so common among more intelligent people.

The Crows and Creeks are usually delivered prone upon the stomach, and the placenta is rapidly expelled, either in the same posture or while standing; in rare cases it is delayed, and then it is allowed to remain until it decomposes, and, remarkable to say, pyemia rarely follows, probably on account of the naturally strong constitution of the race. Among them, gentle traction upon the funis is the only assistance accorded to nature, and if there be much resistance, it is at once stopped, and the placenta allowed to remain, in preference to attempting its delivery by stronger traction.

The Rees, Gros-Ventres, and Mandans are confined in a kneeling posture, in which the placenta also is expelled, but if it does not come away rapidly, with some little rubbing of the belly with the hands greased with turtle fat, the accoucheur pulls gently and steadily on the cord, evidently relying somewhat upon this traction for the removal of the placenta.

The worst practice is that of the Cheyennes and Arrapahoes, who retain the dorsal decubitus in which the child is expelled, but never wait for the expulsion of the placenta by the proper contraction of the womb, removing it at once by

traction upon the cord, which will often break under the rough usage to which it is subjected, and the unfortunate woman will then often suffer from severe hemorrhage, due to the retention of the placenta, as no effort is made to remove the organ after the rupture of the cord. Massage is resorted to, when the placenta does not readily respond to traction, and the accoucheur has judgment enough not to pull too hard. The Chippewas drag down the placenta by the cord, if it is not readily expelled with the assistance of external manipulation. Delivery of the placenta with the patient in a different position from the one occupied during the expulsion of the child.

A change of position is not infrequently made immediately after the birth of the child, with a view to hastening the expulsion of the after-birth. As this period of labor is a short one, an uncomfortable position, if otherwise advantageous, may be readily assumed; and, moreover, the muscular effort, which the patient involuntarily undergoes in making this change, will assist the contraction of the womb. The change most frequently made is to a standing posture. Thus the squaws of the Cattaranguts rise to their feet from the kneeling posture, which they occupied during the birth of the child, with the idea of facilitating the expulsion of the afterbirth. If this does not take place within a short time, the attendant makes traction on the cord, at the same time making downward pressure over the abdomen, while the parturient maintains the standing posture.

Dr. D. D. Taylor, surgeon U. S. Army, in detailing the labor of a Sioux squaw whom he delivered, seated cross-legged on the floor, says: "The moment I cut the cord she jumped to her feet, and, standing erect, seized the squaw-belt, a leather belt about four inches wide, which she buckled over her hips and abdomen, drawing it as tightly as her strength would permit. During this time the hemorrhage was very abundant; within a minute, however, the placenta dropped on the floor, the bleeding ceased, the womb becoming firmly contracted, and she sat down on a stool looking as if nothing unusual had happened. The belt was removed the next morning, and she remained up and went about the house as usual. I saw no

other attempt at expression used but the application of the belt, and this, I believe, is universal among the Sioux for the purpose of expelling the placenta and preventing subsequent hemorrhage.'' The Crows and Creeks, as I have already mentioned, who are often delivered prone upon the face, chest, and abdomen, rise up as soon as the child is expelled, and rest upon a stick of some sort, with the feet spread wide apart. This is to allow the blood to low very freely, and, as they think, the placenta to be more readily and easily delivered.

FIG. 49.—Use of the squaw-belt, Sioux Indians.

[Description: Woman stands with feet apart, holding belt around her abdomen. Black and white illustration.]

In the Uintah Valley agency, the parturient drinks freely of hot water, both during the second and third stages of labor, arises to her feet as soon as the child is expelled in the usual obstetric position, kneeling, places a folded cloth to her abdomen, and, leaning forward over a stout stick, rests her body upon it, thus exerting considerable pressure over the hypogastric region—a method well calculated to favor the expulsion of the placenta, which is thus delivered without any further assistance. Upon the Sandwich Islands they change the posture of the mother to the semi-erect from the sitting, in order to effect the speedy removal of the afterbirth, which they regard as very desirable and necessary. The patient assumes a semi-erect posture, more properly squatting, with the pelvis thrown backward and the knees partly flexed, the midwife at the same time supporting the child, as the cord is not cut until after the delivery of the placenta. At this juncture the patient thrusts her finger in the fauces to produce nausea or vomiting, which causes a spasmodic expulsive action of the uterus, resulting, not infrequently, in the immediate birth of the placenta and its membranes. If such is not the result, there is

FIG. 50.—Placental expression as practiced by the Indians of the Unitah Valley Agency.

[Description: Post-partum woman stands leaning upon a pole, while an attendant, newborn in lap, works to express the placenta. Black and white illustration.]

more or less excitement; the woman retains her erect position, is "loomied'' over the womb and abdomen, a sort of kneading, squeezing operation, generally performed with the hands by the attendant, until the flooding has moderated or almost ceased, when she is conducted to a stream or large containment of water, where she is washed, secundem artem, re-dressed, and returned to the house and its promiscuous inhabitants; children and all being allowed to witness the performance.

In Syria, some twenty or thirty minutes' time is given for the expulsion of the placenta, in the usual obstetric posture, in the chair; but if this does not take place, the cord is cut, and the patient put to bed for further manipulation. The Pawnees change the position of the patient in various ways,

from the squatting posture, and pull upon the cord, evidently seeking to obtain expulsion simply by the muscular contraction resulting from the motion of the patient.