As the clock struck twelve, the waters of the amnios gushed forth, and, as he says, "me baignèrent de la tête aux pieds." At the 20th pain, the head passed the inferior strait. With the 21st pain the head was born. After a rest of five minutes, the 22d pain carried the right shoulder to the sacrum and the left to the pubis, and the 23d pain expelled the child; five minutes after which the placenta was thrust forth from the organs.

The pain felt in labor is owing to the sensibility of the resisting, and not to that of the expelling organs. Thus the sharp, agonizing, and dispiriting pains of the commencement of the process, which are called grinders, or grinding pains, are surely caused by the stretching of the parts that compose the cervix and os uteri and upper end of the vagina. Pains are rarely felt in the fundus and body of the organ; and nineteen out of twenty women, if asked where the pain is, will reply that it is at the lower part of the abdomen, and in the backindicating, with their hands, a situation corresponding to the brim of the pelvis, and not higher than that-a point opposite to the plane of the os uteri.

When the pains of dilatation are completed, and the foetal presentation begins to press open the lower part of the vagina, the pain will, of course, be felt there, and is finally referred to the lower end of the rectum, the sacral region and perineum. The last pains, which push out the perineum and put the labia on the stretch, will of course be felt in those parts chiefly. The sensation, under these circumstances, is represented as absolutely indescribable, and certainly as comparable to no other pain.

The effect of the pains on the bladder and rectum might easily be foreseen; but, even where they fail to excite the sympathetic action of those parts, the descent of the foetal head, which sometimes fills up the pelvic canal as a cylinder is filled by its piston, must cause the evacuation of the entire contents of the lower rectum and bladder of urine.

The effects produced by the pains and efforts of labor upon the constitution are very striking. The woman is in the beginning anxious, irritable, and full of the most gloomy anticipations; but as the process goes on, and the expulsive efforts become more and more violent, she acquires courage and firmness and the most dogged resolution: the

patient seems like one who has a task set which she is resolved to execute as rapidly as possible; and she therefore bears the great pains of expulsion far more submissively, or courageously, than the small or dilating pains.

The actions of the woman indicate pretty clearly to the practised eye, the state of advancement of the process. Previously to the exit of the head from the os uteri, or its deep insertion into that circle, the voluntary efforts of the patient are confined to a violent grasping of things with her hands. She generally seizes the hand of a bystander, and squeezes it violently or endeavors to twist or wring it, not pull it. Such an action always indicates a grinder, or a pain of dilatation; but when an expulsive effort takes place, she not only grasps with all her force, but she pulls at anything in her reach; so that an experienced accoucheur generally can decide, upon entering the chamber during a pain, that the dilation is or is not completed, by observing whether the patient merely squeezes or presses the hands of her assistants, or, on the contrary, whether she pulls them with great violence.

The low position or situation of the presentation at length brings on a tenesmus or bearing-down sensation, which is a desire to thrust with all the forces of the abdominal muscles, whatever exists within the pelvis, beyond the limits of the body. Tenesmus is, in the beginning, controllable by the will, but when it has become exaggerated by the presence of the presenting part in the ostium vaginæ, no exhortation or fear is capable of inducing the woman to refrain from making the tenesmic effort, in certain cases; sometimes, however, the patient may be aroused from the all-absorbing tenesmic sense, and made to heed the urgent appeals of the surgeon to desist from efforts that endanger her. The urine and stool are generally expelled pretty soon after the commencement of the tenesmic pains of labor; but in some patients, the first signs of labor coincide with a disposition to go to the close stool.

In addition to the signs derived from the woman's voluntary actions, the practitioner can frequently decide upon the degree of forwardness of the labor, by attending to the nature of his patient's expressions and moans, and to her respiration. In the early stages, during the dilating pains, she either gives out her breath freely, with voice, or merely holds it, making use of no straining or bearing-down effort: and even if she be here requested to strain or bear down, as at stool, she will resist, or cannot obey the injunction.

Women cannot bear down, at the very beginning of labor. Bearing-down means an effort to expel, by contracting the muscles of the belly; but when the womb is full, its fundus at the scrobicle, and the

os at the plane of the strait, the recti muscles cannot expel, they can only hold or compress it: the same is true of the oblique and transversalis muscles. When, however, the fundus has descended low in the abdomen, having followed the os uteri, which has, by this time, been pressed down to the bottom of the excavation, then the abdominal muscles can exert a vast expulsive energy. So that, when the os uteri is nearly or quite opened, and the real expulsive pains begin, the woman not only holds her breath, but makes use of the muscles of respiration, to fix the thorax firmly, and then, in the most forcible manner, contracts the muscles of the abdomen upon the womb. If she be now enjoined to desist from bearing down, and fails to obey the injunction, it is because the tenesmus of labor, like that of dysentery, is irrepressible. The muscles that she employs in bearing down, after she has fixed the diaphragm and other muscles belonging to respiration, are the rectus abdominis, the external and internal obliqui, and the transversalis. Is it not clear that, while the fundus uteri is high up in the abdomen, the violent contraction of these muscles would have little effect in forcing the uterus downwards, but would rather compress the womb against the back part of the abdomen; while on the other hand, when the uterine globe has sunk low down in the belly, the operation of these abdominal muscles, as agents of expulsion, must become very great and cogent? I have ever found it useless to urge a woman to bear down upon a grinding pain, and always feel it incumbent upon me to cause the nurses and bystanders to desist from exhorting the patient to bear down in the early stages of labor; an exhortation which they very kindly, but very untimely, never fail to make. Such voluntary efforts cannot be beneficial in their influence on the labor, and may even become pernicious, in certain circumstances, where they not only tend to disorder the sanguine circulation, but very much to exhaust the strength.

Fig. 76.

I have placed here a cut, Fig. 76, which shows the state to which the cervix uteri must come before the full efficacy of the true expulsive, or bearingdown pains can become manifest. This is a cross section of the pelvis, with the womb. and a part of the already dilated vagina. It seems that the cervix uteri has become almost cylindrical, from being a cone, as it was before labor began. The bag of waters is seen bulging out from the fully dilated orifice. The waters are nearly ready to give wayand, in fact, there are many labors in which, as soon as the crevasse in the membranes

takes place, the child's head rushes rapidly through the orifice, and descends to the very bottom of the excavation, or is even expelled by the same single pain.

Constitutional Effects of the Pains.-Even leaving out of the question the exciting effects of the pangs and agonies of travail, we should naturally expect that the muscular exertions of the parturient subject would, as in any violent exercise, greatly accelerate the circulation of the blood, and augment its momentum; and we accordingly find the pulse to become more and more elevated as the efforts prove to be greater and greater. The heart beats with increased violence, and the pulsations amount to one hundred and upwards in the minute; even one hundred and twenty beats are not uncommon. The respiration becomes hurried in proportion, and of course the heat of the body tends to be developed pari passû with the augmentation of the circulation and respiration; so that fever would soon become intense, were it not that the most profuse diaphoresis, chiefly from the upper part of the body and head, comes on to prevent the occurrence of what would, otherwise, become a dangerous fever, and in a few instances does become so. I have already taken occasion to remark upon this excited state of the vascular system, that it is not to be deprecated except in those instances in which it goes beyond the just bounds. It is, however, always worthy of close observation, in order that any tendency to excess may be checked, by a free use of cooling drinks; by ventilation; by lightening the bedclothes; by making the patient comforta ble in her bed-appeasing her anxiety of mind by assurances of care and protection, by removing wet sheets and heated pillows; by an enema or purge; and, lastly and chiefly, by the use of the lancet.

The state of the mind is worthy of a large share of the accoucheur's regard. The most cheering and satisfactory assurances that the state and prospects of the labor will admit of, should be given, with a due observance of the truth. A woman will be more comforted and com posed by being made certain that she shall be delivered in six hours, than by a promise which she does not fully believe, that half an hour more shall put a period to her anguish. No promises should be made, that may not be implicitly relied upon by the physician him. self, as well as by the patient. One of the golden verses of Pythagoras says, σεßov ogxov-Keep thy troth.

Signs of Labor.-The signs of labor are those which we obtain from simply observing the woman's manner, and from hearing her own account of her symptoms; or they are such as we obtain from

the Touch, or examination per vaginam. For the most part, the statement of the patient herself, or that of her monthly nurse, is taken as our sufficient early evidence, and we wait for a certain degree of manifest progress before we address ourselves in a more particular manner to establish the absolute diagnosis, which cannot be very certainly done without the Touch.

Still, there may be observed the subsidence of the abdominal swelling, owing to the sinking of the apex of the uterus into the excavation, and, in some measure, to an increase of tonicity in the whole organ.

In most of the cases, the new vital activity set on foot, manifests itself by augmented moisture of the genitalia, and especially by a viscous mucus, that not a little resembles the white of eggs, which, moreover, is frequently stained with a little blood coming from the disrupted capillaries about the cervix uteri. This tenacious mucus is not yielded by the vagina, but always and only by the cervix.

An increased tendency of the bladder of urine to expel its contents also marks the beginning of labors; and the rectum is generally affected by the pelvic excitement, which prompts it to discharge of its contents.

Nausea and vomiting are frequently met with in the lying-in room, as symptoms of commencing labor; though it is true they mostly present themselves when the os uteri is about one-third dilated.

Violent and protracted tremors of the body and limbs, with clattering of the teeth, as in ague, are very generally observed, but they are unaccompanied with any chill or sense of coldness.

Finally, pain in the back and hypogastrium, lasting about twenty seconds, attended with hardening of the uterine globe, and recurring at regular equal intervals, is a sign much to be relied upon, though the vaginal taxis gives us the safest assurance by revealing the state of the os uteri,

In general, we are accustomed to note, by a watch, the length of the intervals betwixt the pains, and to form an opinion of their intensity, by the gestures or moans, or other complaint of the woman.

If the patient have reached her full term, we are free to announce, from these diagnostic signs, that labor is begun; and if, upon making examination per vaginam, we find the os uteri dilated ever so little, and the membranes rendered tense during the pains, we may be quite sure that the parturient process has commenced. The application also of the hand to the abdomen, discovers during each pain a certain hardness and rigidity of the uterine globe that give place to a flaccid and pliable softness during the absence of the pain. Such are signs of the true pains of labor.