University of Virginia Library

PART III.--MATERNITY.

CHAPTER IX.
PREGNANCY.

Nature of Conception; Pregnancy Defined; Duration of Pregnancy; the Signs of Pregnancy; Quickening; the Determination of Sex at Will; the Influence of the Male Sexual Element on the Female Organism; Heredity; Hygiene of Pregnancy; Causes of Miscarriage.

Nature of Conception.--Conception, or impregnation, is the union of the germ and the sperm cell, the result of which is a new being. On coition, the semen being received into the female organs, which are at that time in a state of turgescence, the spermatozoa, by means of their own vibratile activity, find their way into the Fallopian tubes, and here come in contact with the ovule.

The ovule is a minute cell with a transparent membrane, within which is the yolk containing the germinal

vesicle. The spermatozoon penetrates into the ovule and becomes fused with it. The processes of development begin at once to occur. There is congestion of the uterine mucous membrane out of proportion to the rest of the uterus; the ovum finds lodging here, and becomes surrounded by a membrane which incloses it in a separate sac.

Pregnancy Defined.--Pregnancy begins with conception and ends with parturition; it provides for the nutrition and the expulsion of the embryo and for its nutrition for a short time after birth.

The average duration of pregnancy is ten lunar months, or two hundred and eighty days. The date of the confinement is calculated by reckoning from the date of the last menstrual flow; count backward three months from the date of the first appearance of the last menses; to this add twelve months and seven days, five days being for the average menstrual duration and two days for the possibility of fecundation.

Duration of Pregnancy.--Many difficulties are experienced in determining the date of the expected confinement. As most pregnancies occur in married women, we cannot base any calculations on a single act of coitus. And even if there was but one, all physiologists agree that there is a variable period in different women, and in the same woman at different times, between insemination and the fertilization of the ovum. It is the moment of fecundation, or the union of the germ and sperm cells, which marks the beginning of

pregnancy. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. While it is not certainly known, it is probable that the ovum is capable of impregnation any time during its sojourn within the oviduct and before reaching the uterus, or probably for a period of about one week from the time of its escape from the Graafian follicle. The remarkable vitality of the spermatozoa even under less favorable circumstances--direct observation shows that these elements retain their movements for over nine days outside of the body--renders it almost certain that their powers of fertilization are maintained for a long time after they are deposited within the healthy female genital tract; it is believed that the spermatozoa are capable of fertilization after a sojourn of three or more weeks within the oviduct.

Consideration of these facts renders apparent the impossibility of fixing with certainty the date of the beginning of pregnancy, since conception may result from the union of the ovum liberated at the beginning of the period with the spermatozoon introduced at the end of that time; or it may result from the meeting of the male elements already within the oviduct with an ovum discharged a day or two before the occurrence of the menstrual period.

The Signs of Pregnancy.--The cessation of the

menstrual period is the sign of the greatest value in women who have been regular; but it must always be remembered that there may be an irregularity of menstruation for the first few months after marriage. The appetite is capricious; morning sickness or nausea in the morning on first getting up is a very common symptom in the early months of pregnancy; enlargement of the abdomen; in the first two months of pregnancy the abdomen is flattened and the umbilicus is depressed; after this the abdomen begins to enlarge. There is also an increase in the size of the breasts, with a deepened color of their areolae and later a watery secretion. The external genitals become swollen and of a bluish color. Feeling of the fetal movements--that is, the movements of the small parts of the child in the womb--by the mother is not always reliable, since gas in the intestines has sometimes been mistaken for this. These signs are more valuable when several exist together.

The nausea and vomiting of pregnancy, the so-called morning sickness, consists of nausea accompanied often by vomiting or retching of a glairy fiuid, showing itself most frequently on rising in the morning, but sometimes appearing after breakfast. It is aggravated by the assumption of the erect position. It may begin within a few days, but as a rule it does not show itself until the fourth week of pregnancy; and it generally ceases about the fourth month, rarely persisting throughout the entire time. In the majority of cases it does not sensibly impair the health. It is a sympathetic

disorder reflected from the uterus; it is aggravated by indigestible food, by sexual excitement, and by emotional disturbances; it is most marked in first pregnancies and in women of highly emotional natures. It is not infrequently due to some inflammation of the uterus or erosion about the external orifice, and disappears on the removal of the cause.

Mammary Changes.--During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the pelvis; consequently a genuine physiologic enlargement commences in these organs from the beginning of gestation. Their glandular structure becomes larger, fuller, and firmer; a sensation of weight or pricking is felt by the patient; the veins become more prominent. The nipples also become enlarged, more elongated, and somewhat erect. Surrounding the nipple is the areola; this becomes darker in color.

In most women a drop of watery fiuid, the so-called colostrum, may be squeezed out from the nipple at the end of the third month of pregnancy.

The signs of pregnancy are divided into the presumptive, the probable, and the positive. The presumptive signs are: menstrual suppression, morning sickness, irritable bladder, mental and emotional phenomena. The probable signs are: mammary changes, abdominal enlargement, changes in the neck of the womb, and certain changes which are felt on bimanual examination. The positive signs are: feeling the various parts of the

fetus, active movements of the fetus, and hearing the fetal heart sounds.

Functional disturbances of the bladder are quite often noticeable in the early part of the pregnancy. In the first part of the pregnancy the bladder is dragged upon, and later it is pressed upon by the enlarged uterus so that the bladder capacity is lessened and frequency of urination is the result. In the fourth month, when the uterus ascends into the abdominal cavity, these bladder symptoms subside, until the very close of the pregnancy, when by the descent of the now greatly enlarged uterus there may be even incontinence of urine.

Changes in the Abdomen.--During the first two months of the pregnancy there is a flattening of the abdominal surface, due to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and drawing the umbilicus inward. In the latter part of the fourth month there is noticeable a slight abdominal enlargement, and the umbilicus is no longer sunken. By the end of the fourth month the base of the uterus has risen two inches above the symphysis, and at the end of the thirty-eighth week it touches the lower extremity of the breast-bone; the umbilicus has been for many weeks protruding; during the last two weeks of pregnancy the uterus again descends and the woman feels more comfortable.

On the inspection of the abdomen of a pregnant woman there will be noticed a brown line which extends from the umbilicus to the pubes, and all over the surface

the presence of striae, or long purple grooves, due to the distention of the abdomen; on the sides of the abdomen and down the thighs, red, blue, or white markings, like cicatrices, may be seen.

Quickening.--Quickening is the sensation experienced by the mother as the result of the active fetal movements of the child in the womb. These movements are first felt between the eighteenth and the twentieth week; the common rule is that quickening occurs at the middle of pregnancy; that is, at four and a half months. As pregnancy advances these active motions increase in frequency and become more marked. When felt or seen by the physician, as can be done in the sixth month, fetal movements constitute a positive sign of pregnancy.

The Determination of Sex at Will.--Although this has always been a question of great interest, and the subject of much experimentation, no rule can as yet be given by which the parents can know in advance of the birth of the child what the sex will be. Dr. Schenck's theory is that the ruling factor in determining the sex is the food partaken of by the mother.

Furst believes that the differentiation may occur before, during, and a little while after the impregnation; that the chances of the development of one or another sex in one and the same woman may vary before final differentiation occurs. It is impossible to determine the sex of the embryo before the tenth week of fetal life. The cause of the differentiation, he believes, lies largely

in the good or bad state of the health of the parents; in the first instance there being an excess of females, and in the latter an excess of males, relatively speaking. He believes that there is an excess of male children when conception takes place during the post-menstrual anemia. He has investigated one hundred and ninety-three cases carefully in regard to the probable date of conception after menstruation, and there is a notable increase of male births over female in the cases where conception occurred in the first five days after menstruation; that is to say, where the woman is not so well nourished as later.

Dr. J. Griffith Davis gives as the result of her experiments in this direction, that when conception takes place three days before the menstrual period or within forty-eight hours afterward, the child will be a girl; when conception takes place ten days after the period, the child will be a boy.

Although there are a greater number of the female than the male sex in all parts of the world where reliable statistics have been taken, in all civilized countries the proportion of male births is greater than that of females. There is a greater tendency of the male offspring to die earlier, and this is seen even before birth, in the proportion of three to two. For this reason the stronger sex as applied to men has been regarded by some authors as a misnomer. They are physically weaker in early life and succumb more readily to noxious influences.

The relative age of the parents is said to be another

factor in determining the sex of the children. Seniority on the father's side gives an excess of male children; equality in the age of the parents gives a slight preponderance of females; seniority on the mother's side gives an excess of females. Men, and especially scholars, who pass a sedentary life and who exhaust their nervous force to a great extent, beget more girls than boys; so, also, a very advanced age on the part of the man diminishes the number of male offspring.

The Influence of the Male Sexual Element on the Female Organism.--Dr. Alexander Harvey, of Aberdeen, has adopted the theory of fetal inoculation. He believes that the effect is first due to the influence of the male element upon the ovum, which, in consequence of the subsequent close attachment and freely inter-communicating blood-vessels between the modified embryo and the mother, inoculates the condition of the mother with the qualities of the male; and so, on the subsequent impregnation by another male, the offspring resembles the first male and not its real parent. He even goes further, and says that it is conceivable, by successive impregnations effected by him, that the influence may be increased, and if so the younger children begotten by him, rather than the elder, might be expected, ceteris paribus, to bear their father's image. And as regards the mother, he suggests the question, whether there is not something in the popular notion that in the course of years the wife comes to resemble the husband; and that not merely in respect of

temper, disposition, or habits of thought, but in bodily appearance, which may be referable to this influence exerted by the husband on her constitution, through the medium of the fetuses in utero.

Darwin, on the other hand, considers it a most improbable hypothesis that the mere blood of one individual should affect the reproductive organs of another individual in such a manner as to affect the subsequent offspring. The analogy, he says, from the direct action of the foreign pollen on the ovaries and seed coats of the mother plant strongly supports the belief that the male element acts directly on the reproductive organs of the female, and not through the intervention of the crossed embryo.

Dr. John Brown, in reviewing the subject, says it must be conceded that the male element has an influence on the female, over and above its fertilizing influence upon the ovum. The limit of this influence is at present unknown.

Heredity.--Girls are more apt to resemble their fathers in mental traits, disposition, and constitution; while boys take after their mothers. Boys procreated by intelligent mothers will be intelligent; while it does not always follow that the sons of intelligent fathers

are intelligent. The poets Burns, Ben Johnson, Goethe, Walter Scott, Byron, and Lamartine were all born of women remarkable for vivacity and brilliance of language.

Hygiene of Pregnancy.--The health and perfection of the child depend largely upon the health and perfection of the parents at the time of its conception, as well as upon the condition of the mother during the pregnancy. Even when both parents possess a strong constitution, but one or both of them is suffering from a temporary exhaustion or malaise, the child will be born below the standard of health it ought to possess. Children born during the first year of married life seldom equal in health the children born of the same parents later; they are not only apt to be sickly, but the liability to premature death is greatly increased. For this reason it is better that the first year of married life should be allowed to pass without conception taking place. A child begotten in an intoxicated or depraved condition of a parent may be depraved itself in the same way, and is apt to be feeble-minded or idiotic.

It must be borne in mind that prenatal culture of some sort begins at the time of conception; and that on the mental as well as on the physical state of the mother, the health as well as the disposition of the child will depend to no slight extent. The prospective mother who constantly gives way to her feelings does a wrong to her unborn child. The mother is at this time more impressionable, more nervous, and more irritable

than is natural to her; and while her family should make a certain allowance for her condition, she, on her part, should not allow herself to give way to her morbid feelings. The prospective mother should not lead a life of self-indulgence, on the one hand, or, on the other, should not be weighed down with cares; she should interest herself in her usual duties, and be relieved of all anxiety possible.

Dress.--The clothing must be loose, and all compression about the waist and abdomen must be especially avoided. If the woman wears corsets, she must take them off at once, and substitute a Ferris or some similar hygienic waist. The corset prevents the proper development of the abdominal muscles, which play so important a role in the expulsion of the child from the womb, as well as in the proper growth and development of the fetus itself. If the woman has already borne children, and toward the end of the pregnancy the abdomen becomes pendulous, she will very materially add to her comfort by swearing a muslin abdominal bandage.

A woolen undersuit, or undervest and drawers, with high neck and long sleeves, must be worn winter and summer; the grade of the wool to be adapted to the season of the year. The especial necessity for wearing wool next the skin during the pregnancy is because of the intimate relation between the skin and the kidneys. Any chilling of the body at this time is apt to lead to the congestion of the kidneys. If there is already any congestion of the kidneys present, or any abdominal

pain, in addition to the undersuit an abdominal bandage should be worn. These bandages come woven in ribbed woolen, and fit the body snugly. This bandage is to be constantly worn, and, of course, changed at night. During the cold weather the stockings should also be of wool. Under no circumstances are garters allowed to be worn, as they form a constriction around the leg and interfere with the return of the venous blood to the heart, and so increase the tendency to the formation of the varicose veins. It is better not to use any means to hold the stockings up; they will be kept sufficiently well in place by the under-drawers. Low shoes should never be worn except in the hottest weather. It is of the greatest importance that the woman should be impressed with the necessity of the avoidance of taking cold, since any lung or kidney trouble is a serious complication of pregnancy.

Diet.--The diet is the same as that at any other time, only it is more necessary to guard against anything which is likely to cause indigestion. In other words, the diet should be plain, simple, and easy of digestion; nutritious and partaken of at regular intervals. In the latter part of pregnancy owing to the pressure of the enlarged uterus on the stomach, the food may have to be partaken of in smaller quantities and at shorter intervals. At this time also the appetite is abnormally large. Where it does not disagree with the patient, milk is the best adjuvant possible to the diet.

Constipation.--Constipation is the rule of pregnancy.

This is due to the great pressure that the enlarged uterus makes on the bowel; and as important as it is at all times to keep the bowels regular, it is at this time more necessary than ever that the woman should have the bowels well evacuated every day. A retention of fecal matter in the body causes the reabsorption into the blood of the toxic matters, with the resulting headaches, dizziness, loss of appetite, and intense nervousness. To obviate this tendency to constipation, plenty of fruit and vegetables should be eaten, as well as cereals if the woman is taking a good deal of outdoor exercise, otherwise the latter had better be omitted. The woman should drink plenty of water--at least three pints a day; this acts as a laxative as well as to flush out the kidneys. If, in spite of all these measures, constipation still persists, as it probably will, a seidlitz powder can be taken the first thing on rising in the morning; or from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda in a glass of water, also to be taken on rising in the morning; or one-half grain of the solid extract of cascara sagrada night and morning. The object of these is to keep the bowels open, but purgation must always be avoided.

Bladder Symptoms.--If there is any irritability of the bladder, any scalding on urination, or a very great frequency of emptying the bladder in the early months of pregnancy, a physician should be consulted at once; in the last months of pregnancy there is a desire to evacuate the bladder frequently, and sometimes at the

last there is an incontinence of urine, which is due to the descent of the uterus and the great pressure on the bladder; this condition disappears with the confinement.

Leucorrhea.--If this is present to any marked degree, the vaginal douche should be continued throughout the pregnancy; the temperature of the douche should be from 110 degrees to 112 degrees F.; it must never be taken very hot or very cold. The fountain syringe should be used, and the bag should not be hung more than three feet above the bed, so that there shall not be too much force to the stream of water.

Baths.--Warm tub-baths may be taken throughout the pregnancy, but never oftener than twice a week, and the woman should never stay in the tub longer than is absolutely necessary for the bath, as otherwise the bath is too enervating. A daily sponge-bath of cool or cold salt water at a temperature of from 80 degrees to 70 degrees F., and in the proportion of a pint of rock or sea salt to a gallon of water is most invigorating, and counteracts many of the nervous symptoms and promotes sleep and good digestion. The temperature of the room in which this bath is taken should be 72 degrees F. Shower-baths cause too great a shock to the nervous system, and they as well as foot-baths must be prohibited. Sitz-baths at a temperature from 110 degrees to 90 degrees F. may be taken just before retiring throughout the pregnancy. The frequency and duration of the bath as well as the temperature should be regulated by the attending physician. In

cases of intense nervousness and insomnia these baths have an excellent sedative effect. A pregnant woman must never under any circumstances take ocean baths, since there is always great danger that the shock of the waves will cause an abortion. Sea-voyages should be avoided because of the severe nausea and vomiting, as well as the danger that the lurching of the vessel may cause miscarriage.

The sewing-machine is a tabooed thing for the pregnant woman, because of the jarring of the pelvis which it produces. Sweeping of heavy carpets is also injurious. There must be no lifting of heavy pieces of furniture, and especially no lifting from the floor, as it interferes with the circulation in the uterus and is apt to produce miscarriage.

Driving in an easy carriage over smooth roads is permissible; dogcarts, or any conveyance which produces much jolting, must be avoided; and while driving is good, the woman should not do her own driving, on account of the danger of the jars that would be caused by the sudden pulling of the horse upon the lines. Horseback-riding and bicycling are, of course, forbidden, as are also golf, tennis, and dancing.

Exercise.--Exercise in the open air should be taken every day, when the weather is suitable, and walking is the best form of exercise. The amount will be regulated to some extent by what the woman has been accustomed to taking, and it should always stop short of fatigue. The woman should live as much as possible in

the open air, and she should attend to her ordinary duties about the house. Long railway journeys are always objectionable.

Hemorrhoids or piles are very often troublesome toward the close of the pregnancy. To overcome this, the patient should lie down immediately after the bowel movement, and remain in the recumbent position for ten or fifteen minutes. In addition, care should be taken to secure a loose movement of the bowels. Should the piles come down, applications of cloths wrung out of hot water, and held well pressed against the bowel, should be made; the piles should then be pressed back until the finger feels that the mass has been pushed above the second constriction of the bowel, which is felt to exist at about two inches above the sphincter ani muscle. Should these means not suffice, the physician must be consulted at once.

Swelling and pain of the external genitals and of the lower limbs are best relieved by the recumbent position. Should the veins of the legs be much enlarged or the feet swollen, the patient should have compression made by the wearing of elastic stockings. Or in some cases a bandage is sufficient; in this case the bandage may be made of muslin; it should be three inches wide, and, beginning at the toes, should extend up as high as the enlargement of the veins continues. This bandage should be freshly applied every morning before rising.

Pain caused by the stretching of the skin may be relieved by the inunction of the skin with cottonseed or

cocoanut oil. For severe pain in the small of the back, rubbing with soap liniment or alcohol will be found useful.

Mental Occupation.--Important as this always is, it is doubly so now. The mind should be constantly and pleasantly occupied, but no severe study should be indulged in. The emotional susceptibility is generally somewhat increased. The pregnant woman, quite excitable and irritable, readily responds to influences by which in the non-gravid condition she could not be affected. Sometimes she feels unusually well, is intellectually brightened and more active, and says she is positively happier. At other times she is despondent and morose.

Physiologists admit and observation proves that maternal emotions do affect the development and the exterior of the fetus; likewise the mental organization of the fetus may be affected. All unpleasant news, frights, and physical shocks, also scenes of suffering and distress, must be avoided, as the mind is particularly impressionable at this time. Around the patient should be thrown a gentle and protective care, and she should be treated with the considerate kindness which her condition demands. Theatres and all places where there will be a large assemblage of people should be avoided, as the close air and general bad ventilation are apt to produce vertigo and sometimes attacks of fainting.

Sleep.--During pregnancy a large amount of sleep is

required; there should be eight hours spent in sleep at night, and one hour every afternoon. Pregnant women should never do any night watching. There is unusual necessity for good ventilation during sleep at this time.

The Marital Relation.--Coitus is, as a rule, distasteful to pregnant women. It is for the best interest of the wife as well as for that of the child that all marital relation should be suspended at this time. Even uncivilized nations have condemned the privilege of sexual intercourse during pregnancy, and have visited punishment on the offender. If these relations are not wholly suspended, they must at least be at those periods which correspond to the time at which the woman would have been unwell had she not been pregnant. To the continuance of these relations throughout the pregnancy is due much of the suffering of the wife, not only then, but at the time of the labor as well; and the nourishment of the child is interfered with.

Causes of Miscarriage.--Hemorrhoids; straining at stool; excessive intercourse in the newly married; nursing; ocean-bathing; overexertion; overexcitement; a fall; any violent emotion; anger; sudden or excessive joy; a fright; running; dancing; horseback-riding; riding in a heavily built carriage over rough roads; great fatigue; lifting heavy weights; the abuse of purgative medicines; disease or displacements of the womb; and a general condition of ill health.

The danger of miscarriage is greatest during the first

three months of pregnancy. Miscarriage is a fruitful source of disease and often of danger to wives; it is said that thirty-seven out of every hundred pregnant women miscarry. Miscarriage is most apt to occur during the first pregnancy; and great care should be taken to prevent this, as the habit is easily established, and after one miscarriage has occurred, another is likely to follow, so that it is sometimes with the greatest difficulty that the woman can be made to carry the fetus to full term. Artificially produced abortions are not an infrequent cause of sterility; the young wife becomes pregnant, and has an abortion produced because she is not yet ready to give up all her pleasures; and eventually when she does become very anxious to have a child such an extent of uterine disease has been produced by the abortions that she cannot conceive.

To Prevent Miscarriage.--The life must be free from all excitement, and must be as quiet as possible without becoming monotonous; especial care must be exercised at the return of the dates for the menstrual periods.

The symptoms of miscarriage are a show of blood, more or less profuse, with intense abdominal pain; on the slightest show of blood the patient should go to bed at once and the physician should be sent for.

CHAPTER X.
THE CONFINEMENT.

Preparation for the Confinement; Signs of Approaching Labor; Symptoms of Actual Labor; the Confinement-bed; the Process of Labor.

Preparations for the Confinement.--The right time to engage the physician who is to take charge of the woman at her confinement is just so soon as the woman knows that she is pregnant. It used to be argued that, since giving birth to children was a physiologic process, there was no necessity for the woman to consult the physician until he was sent for when the labor pains began. Take the case of the woman who is for the first time pregnant; she is absolutely at sea; she has not the least idea how she ought to feel, what she ought to do or to leave undone; the result is that she often has a miscarriage which is the source of the greatest disappointment to her husband and herself, or she suffers very unnecessarily throughout the entire pregnancy, has a difficult labor, and perhaps gives birth to a sickly child.

The educated physician will explain to her what symptoms are normal and what are pathologic, and often he will be able to entirely cure the latter. It is now a well-established fact that the most serious complications of the pregnancy, and of the labor itself are caused by severe congestion or disease of the kidneys. The condition of the kidneys can only be determined by frequent examinations of the urine; during the early months of pregnancy these examinations are made once a month, and during the last month they are made every week. The amount of urine passed in the normal condition is three pints a day.

Nowhere, perhaps, is the constant vigilance of the physician so well rewarded as in the careful oversight of the pregnant woman. She goes through her entire pregnancy feeling well, and often the greatest discomfort that she suffers is due to her size; her labor and her lying-in are normal, and she gives birth to a healthy child.

Engagement of the Nurse.--This is generally left to the physician in charge of the case, since he is responsible for the safe delivery of the woman; but if the patient has any decided choice in the matter, it is acceded to unless there should be some very valid objections, and the physician always sends the nurse in view for that case to see the patient in order to ascertain if she is personally agreeable to the patient.

Choice of Room for the Confinement and Lying-in.--The room should be light, sunny, and well ventilated;

it should not be too near a water-closet. In the city as quiet a room as possible should be selected, and one that is well removed from the rest of the house, so that if necessary perfect quiet can be maintained. The room should be as cheery as possible.

The dress of the mother during the lying-in consists of a merino undervest, with high neck and long sleeves, and a nightgown, which shall be open all the way down the front. The gowns should be made of light muslin or of cambric; and there should be a sufficient number so that they may be changed every day.

Six abdominal bandages should be provided. These are made of light muslin, and they should be eighteen inches wide and long enough to go once and a third around the patient's hips at the sixth month of pregnancy, or about one yard and a quarter long; they may be made straight or to fit the patient at the sixth month. This bandage is fastened down the front; it is applied directly after the labor, and adds greatly to the patient's comfort during the lying-in.

The vulvar pads used during the lying-in are the antiseptic absorbent pads which can be obtained at any place where surgical dressings are sold; they are made of absorbent cotton, covered with cheesecloth, and sterilized.

There must be a sufficiently generous supply of sheets so that they can be changed every day, and the drawsheet as often as may be required. Nothing is so important to a good lying-in as to have a clean, well-ventilated

room, and plenty of fresh bed-linen. Cleanliness is the first requisite to antisepsis, and this is the secret of avoiding puerperal fever.

Articles to be provided for the confinement are:

• 1. An oblong douche-pan of agate-ware.
• 2. An agate bed-pan.
• 3. A bath thermometer.
• 4. Two pieces of rubber sheeting; one, one yard square, and the other two yards square.
• 5. Two sterilized bed-pads, 30 inches square by 3 to 4 inches thick.
• 6. Three dozen antiseptic absorbent pads.
• 7. One pound of sterilized absorbent cotton; twelve yards of cheese-cloth.
• 8. Six abdominal bandages, eighteen inches wide, preferably made to fit the figure at the sixth month of gestation.
• 9. Two hand-scrubs.
• 10. Four ounces of the tincture of green soap.
• 11. Bottle of corrosive sublimate tablets.
• 12. Four ounces of powdered boric acid.
• 13. Half a pint of good whisky.
• 14. Two ounces of aromatic spirits of ammonia.
• 15. Two ounces of aqua ammonia.
• 16. One pint of alcohol.
• 17. Two tubes sterilized white vaselin.
• 18. Plenty of large and small safety-pins.
• 19. Hot-water bag.

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• 20. New fountain syringe, to hold four quarts; with glass nozle.
• 21. One small basin for vomited matter.
• 22. Two very large agate basins or wash-bowls for washing doctor's hands and for antiseptic solutions.
• 23. Vessel for after-birth.
• 24. Three large pitchers; one for boiling water, one for cold boiled water, and one for antiseptic solution.
• 25. Tumbler for boric acid solution for washing baby's eyes, with fine old linen sterilized.
• 26. One dozen freshly laundered sheets, and two dozen towels.
• 27. Stocking-drawers, muslin.
• 28. Change of night-clothing warmed for the mother.
• 29. A warm blanket to receive the baby.
• 30. An infant bath-tub.
• 31. A large piece of oil-cloth to protect the floor.[1]

Baby's Outfit.--Four flannel bandages, to be made of fine, soft flannel, four inches wide, to go once and a third around the body. The edges may be pinked or whipped, but should never be hemmed; a tape is sewed on double, the ends passing around the body, and so the bandage is fastened without pinning.

Six merino shirts, with high neck and long sleeves, made to button down the front.

Cotton diaper napkins, not too large; old soft ones are preferable.

Long merino stockings which can be pinned to the napkin.

Flannel petticoats, not too long; these may be made on muslin bands, which are held up on the shoulders by means of straps. The essential in all the clothing is that it should be sufficiently loose.

Dress-slips should not be so elaborate that they cannot be washed and changed with sufficient frequency; and not so long that the baby's feet will be hampered in their movements by them. All of baby's clothes but the dress should be fastened by safety-pins.

Baby's basket should contain:

• 1. One outfit of clothes.
• 2. One tube of sterilized tape.
• 3. A pair of blunt-pointed scissors.
• 4. Large and small safety-pins.
• 5. Pieces of fine old linen; old handkerchiefs are the best.
• 6. A soft hair-brush.
• 7. A powder box and puff, with talcum powder.
• 8. Two tubes of sterilized white vaselin.
• 9. Two soft towels.
• 10. Castile soap.
• 11. Single-bulb syringe; so-called "eye and ear syringe."
• 12. A woolen shawl or wrap.

If there is no nurse available before the labor sets in, and it is necessary for the patient to see to the sterilizing of the above articles, she should first scrub off all pitchers, basins, and other utensils, as well as the douche-pan, fountain syringe, and rubber sheeting, with a brush and hot soap-suds; the hand-scrubs are to be well washed; then each article should be pinned separately in coarse towels, and put to boil for half an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing the towels, put away, and not opened till the time of the labor.

The abdominal bandages must be laundried and pinned up in separate towels until they are needed. The cheese-cloth must be laundried and then sterilized.

The vulvar pads should be pinned in an old napkin, in packages of half a dozen each; and one package is sterilized at a time by placing it in the oven until the outer covering is scorched. The linen for the baby's eyes and the cheese-cloth are treated in the same way; they are to be cut up into small pieces and sterilized as needed.

Signs of Approaching Labor.--About two weeks before labor there is a sinking of the womb. At the beginning of the ninth lunar month this was at the end of the breast-bone; it now descends to a point midway between this and the navel; the abdomen becomes smaller, the pressure on the lungs is relieved, and the woman breathes more freely. But at the same time

that the woman is relieved of the pressure on the chest, she experiences increase of the troubles in the lower extremities. There is an increase of the bladder symptoms, with a desire for frequent unrination. Constipation becomes more troublesome, and there may be hemorrhoids; the veins of the lower extremities may become greatly enlarged.

There is an increased fullness of the external genitals and a greatly augmented amount of mucous discharge. There is a feeling of anxiety and nervousness, with depression of spirits.

During the last two weeks of pregnancy patients are apt to have cramp-like pains in the lower part of the abdomen. These are often mistaken for labor pains. True labor pains are characterized by starting in the back, extending around the abdomen and toward the pubes and down the thighs; they come at more or less regular intervals of half to three-quarters of an hour, and increase in intensity with a decrease in the intervals. A strong pain is apt to be followed by two weaker ones. The so-called false pains are irregular in their occurrence.

Symptoms of Actual Labor.--First is generally the show; this is a discharge of mucous tinged with blood; at the same time the true labor pains set in. When the patient or nurse is in any doubt as to the character of the pains, or when the show appears, the physician should be summoned at once. Other symptoms are

frequent desire to empty the bladder and bowels, and a sensation of shivering.

The Confinement-Bed.--A single bed is much more convenient, but it is rarely found in a private house. The double bed is arranged as follows: The hair mattress is covered with a large rubber sheet, which is pinned with safety-pins at the corners and tucked well under the mattress; the rubber sheet must not be drawn too tightly for fear of tearing. Over this comes the sheet, and over the upper half of the bed, the draw-sheet; this is a sheet folded four double, which goes across the bed so as to come under the hips of the patient, and is tucked under the mattress at both sides. The object of this is so that it may be frequently and easily changed without disturbing the patient. The sheet, blanket, and spread which are to serve as a covering after delivery are folded back and placed on the left side of the bed.

The lower right-hand corner of the bed--the right side of the bed is that side which is toward the right hand as one stands facing the foot-board--is arranged for the confinement; on this is fastened the smaller rubber sheet, and over this the sheet is folded, and both are fastened down with safety-pins. The pillow for the patient should be placed at the upper and inner corner of the square. After the delivery the patient is lifted to the upper part of the bed and the temporary dressing is removed. A sheet and blanket are used for a covering during the confinement.

Before the labor begins it is well to fasten up the vest and gown, so that they will not be soiled, as it is important that the patient shall be moved as little as possible after the labor, as all movements tend to increase the bleeding.

The floor oilcloth must be spread at the side of the bed which is made up for the confinement, and should extend slightly under the bed.

A bureau in the room should contain the mother's and baby's clothing, bed-linen, towels, and any other articles which will be needed, all properly arranged.

The clothing for the mother and baby will be placed where it will keep warm, and the infant bathtub will be in readiness in case of sudden need for it.

All water used about the confinement must have been carefully sterilized in advance. The best way to sterilize the water is by boiling it in a large wash-boiler; whatever vessel is used must be scrupulously clean, and ought to be new. The vessel is covered over, and the water is allowed to boil for half an hour; it is then, still covered, set aside to cool. There should be three gallons each of sterilized hot and cold water; since in case of an emergency there must be plenty of water ready for use.

The various articles ordered in the confinement outfit will be at hand ready for use. It is the duty of the nurse to have everything ready for the doctor before his arrival. The patient should have a full warm tub-bath, fresh night-clothes put on, and an enema should

be at once given to unload the bowels, and this even though there may have been a bowel movement only a few hours previously. The patient should remain in bed until the arrival of the doctor. After an examination has assured the latter that all is right, she may be allowed to go around the room, with a wrapper thrown on over the night-gown.

Conveniently near the bed should be a small table, covered with one or two freshly laundried towels. This table should have on it a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable aseptic lubricant for the hands.

The Process of Labor.--The process of labor is divided into three stages. The first stage is that of dilatation; by which is meant the stretching of the mouth of the womb so that the child may pass through. At the first confinement this stage lasts about fifteen hours; at subsequent labors the length of this stage is much shorter, the average time being eight hours. The pains during this stage are sharp and cutting, and they are accompanied by a slight show of blood. The patient is fretful and nervous

The second stage of labor is called that of expulsion, because in this stage the uterus contracts down together with the abdominal muscles to expel the child from the womb and the vagina into the world. The duration of this stage in the first confinement is about an hour and a half.

The third stage of labor includes the time from the expulsion of the child till the coming away of the after-birth; the average length of this stage is from twenty minutes to half an hour.

The average length of time for the first labor is seventeen hours; and for subsequent labors from eight to eleven hours.

The bag of waters is the sac of membranes in which the child is inclosed. It contains a liquid in which the child floats; the object of the water is to protect the child from sudden shocks or any kind of injury during pregnancy. During labor this membrane with its contained water serves as a dilating wedge to assist in the opening of the womb, and it also protects the child from the direct contraction of the uterus upon it. When the waters break prematurely, the labor is much longer and more tedious; normally this should not occur before the mouth of the womb is fully dilated.

The pains of the second stage of labor are of a bearing down character, and constantly increase in force and frequency; the climax being reached as the head passes through the vulvar orifice.

A child usually lies in the womb with the head downward; the reason of this is that there is more room in the upper part of the uterus, and as the small parts of the child as it is folded upon itself take up the most space, they occupy this position, while the head lies just above the pubes. The normal position of the child is: the head is flexed on the chest, the legs on the thighs

and the thighs on the abdomen, and the hands are folded across the chest. And so the child is usually born head first.

During the stage of expulsion the head of the child is forced down slightly during each pain, to recede a little during the intervals between the pains; in this way the vagina and its external orifice are gradually stretched so that the head of the child may pass through without tearing the parts. If the head is allowed to pass through suddenly, or where the labors are rapid, as in the case of women who have given birth to several children, much mischief may be done by tearing the soft parts.

After the birth of the head there is a short interval of rest, when the shoulders are born; the rest of the body easily slips out; and with the expulsion of the after-birth the labor is over.

At the very beginning of labor the patient should be given a full warm tub-bath, and make an entire change of linen. She will usually prefer to be dressed in her night-clothing, over which during the first stage she may wear a loose wrapper; a sterilized napkin should be worn over the vulva during this stage. During the first stage, as a rule, the patient should not be confined to bed until the dilatation is well advanced; she is generally more comfortable if she is allowed to move around the room, and the pains are thereby advanced.

The only way in which the physician can determine whether labor has begun is by making an internal examination;

and this will enable him to decide as to whether it is necessary to remain or not.

The nurse should always wear a wash dress in the confinement and lying-in room.

If the labor is long, nourishment in the form of beef-tea, broths, and milk may be given. No stimulants should be given without the direction of the physician. The frequent taking of cold water is permissible.

At the beginning of the labor the family and friends must be excluded from the room, and it must be kept as quiet and as cheerful as possible.

Toilet of the Patient.--The newly born child is received in a small blanket, is well wrapped, and laid in a warm place. The nurse then turns her attention to the mother; the external genitals and soiled parts of the body are cleansed with sterilized cheese-cloth wrung out of an antiseptic solution; if the body-linen has become soiled, it is also changed, and all blood-stained articles are removed from the bed. The patient is then carefully lifted up on the permanent bed, and the vulvar pad and the abdominal bandage are applied; after which the patient is allowed to rest.

CHAPTER XI.
LYING-IN.

Management of the Lying-in; Lactation; Nursing.

Management of the Lying-in.--Immediately after the delivery the first essential for the patient is absolute quiet and rest; the room must be kept quiet and darkened, and ordinarily the patient is allowed to fall into a light sleep. During the first few hours after labor the best position for the mother is flat on the back, with only a small pillow under the head. After the first twenty-four hours the patient may be allowed to turn on the side as she prefers. Since absolute rest is the first requisite for the patient, she must be left alone with the nurse, who must see that she does not fall into too deep a sleep. If the child's cries disturb the mother, it must be taken into another room.

The lying-in room must be kept free from all odors, all soiled clothing must be at once removed from the room, and good ventilation must be insured, being careful to prevent any drafts.

While the patient is asleep, and after the baby has been attended to, the nurse should place all blood-stained articles in cold water to soak. If in the city,

the after-birth may be burned in the furnace or range; it should be well covered with coal. In the country the after-birth can be buried in a deep hole.

During the first two or three days the vulvar dressings should be changed from every three to six hours, and at all times as often as they are soiled. Each time that the dressing is renewed the external genitals and their immediate surroundings are to be carefully cleansed with sterilized water, and finally washed with a solution of boric acid, in the proportion of one tablespoonful of boric acid to one quart of water. It is convenient to keep this solution mixed and on hand, as it takes some little time to prepare it; it should be kept in a strength double that which is desired, so that it may be diluted with warm water to give the desired temperature. This solution may be poured over the parts from a small pitcher, the douche-pan having been placed under the patient before the washing began. After labor the vulva is very sensitive, so that while the greatest care must be used to remove all clots of blood and the discharge, there must be no brisk rubbing of the parts. No blood-stained linen should be permitted to remain about the patient or the bed.

Since the lying-in woman perspires freely, her skin ought to be frequently cleansed by sponging with a weak solution of alcohol in tepid water; this should be followed by friction with a towel until the skin is in a glow. Cleanliness of the bed is promoted by the use of

a draw-sheet, which is a sheet folded to four thicknesses and placed beneath the patient's hips in such a way that the upper edge of the sheet shall come under the lower part of the pillows. Air and light must be freely admitted at all times in order that the room may be bright and cheerful. For the first few weeks the eyes of the new-born infant should be shielded from all strong light.

Visitors.--For the first week after the confinement the patient should see no visitors. Even the husband or mother should not remain in the room long at a time. Nothing of a disagreeable nature should be told to the patient; and whoever goes into the sick-room should always carry the most cheerful manner, as it is highly necessary that the patient should be kept mentally as well as physically quiet at this time.

Diet.--For the first twenty-four hours the diet must be restricted to liquids, and in most cases nothing is given until the patient has had a few hours' rest. The first thing that is given to the patient should be a cup of warm milk or tea. Milk is the best diet; this may be varied with beef-tea, bouillon, mutton or chicken broth; any of these broths may be made with rice or barley to vary the flavor, but these must not be given to the patient. The patient should have six ounces of the liquid every two hours during the day and every three hours during the night.

On the second day bread well toasted through may be added to any of the liquids. On the third day

stewed or baked apples should be added to the diet. On the fourth day, and from this on, the patient will have regular meals, but the diet must be a plain one. For breakfast, stale bread, a soft-boiled egg, fruit, and a cup of tea, not too strong. For dinner, which should always be given in the middle of the day, an oyster-stew or clam broth, a lamb chop, or a very small piece of beefsteak or chicken; but with these there must be no gravies or dressings; a potato baked in the skin; raw tomatoes, if in season; apple sauce or cranberry; celery; junket, plain corn-starch, lemon jelly, plain cup-custard. From this list the diet must be arranged so as to give as much variety as possible from day to day. Midway between breakfast and dinner, and again in the middle of the afternoon, the patient should have a glass of milk. The diet should be generous, but simple.

Urination.--The feeble condition of the bladder in the first few hours after delivery frequently leads to the retention of urine. Owing to the copious secretion of urine which is so common at this time, painful and injurious distention of the bladder may result. The patient should therefore endeavor to pass her urine in at least six hours after labor, whether she feels any inclination to do so or not; the sound of running water or warm fomentations over the bladder, warm water in the douche-pan, and moderate pressure applied by the hand over the suprapubic region, are often effective in accomplishing the desired result. If all these means

fail, the catheter must be used as the last resort. During the entire lying-in the bladder should be emptied every six hours.

Evacuation of the Bowels.--There should be an evacuation of the bowels in from twenty-four to thirty-six hours after the labor. For this purpose a seidlitz powder may be given, or the liquid citrate of magnesia. If this does not suffice, an enema of warm water, to which a little soap or two teaspoonfuls of glycerin have been added, may be given. Two pints of water should be prepared; the patient will retain as much as she comfortably can, and as long as she can. The bowels should be opened daily after the first day.

After-pains are caused by the same physiologic process that causes labor pains--namely, by the contractions of the uterus. After the first confinement the after-pains are, as a rule, not severe; attention to the regular emptying of the bladder and bowels also lessens the severity of the after-pains; these pains seldom last after the second day.

The Lochia.--The discharges of the mother continue for about two weeks, and are called lochia. For the first twenty-four hours they are pure blood; the second and the third day they are of the character of bloody water; from the fourth to the sixth day they have a, greenish-yellow color, and from the tenth to the twelfth day they become pure white. Soiled napkins and dressings should never be allowed to remain in the patient's room.

Duration of the Lying-in.--This lasts for six weeks. During this time the organs of generation are returning to their normal size and condition. In order that the woman may be in the best condition possible at the end of this time, it is essential that for the first two weeks she should remain in bed; and so long as there is any blood in the discharge the woman should not be allowed to sit up. The first sitting up should be in bed, the patient being supported by a bed-rest. During the second two weeks the patient may be allowed to divide her time between the bed and the couch; in the latter part of this time she may be allowed to go around her room a very little; and for two weeks more she should remain on the same floor. The first sitting up should not last more than half an hour. Getting up and going around too soon after the confinement, "being too smart," is one of the most prolific sources of falling of the womb, and all manner of uterine trouble, by which the general health of the woman is greatly impaired.

Lactation.--If it is at all possible, every mother should nurse her own child; in the interests of both the mother and the child. So far as the mother is concerned, the process of lactation is beneficial because it hastens the return of the uterus to its normal size. Wet-nurses are known tyrants, and if the quality of the milk has anything to do with the disposition of the child, as is believed to be the case, the idea is distasteful of having a woman who belongs to the lower classes

provide nourishment for your child; and artificial feeding is one unmitigated trouble.

A deficiency of the quantity or the quality of the mother's milk can generally be remedied by the diet and attention to the health of the mother; if the deficiency in quantity persists, the mother's milk can be supplemented by artificial feeding.

There may exist certain conditions of the mother in which nursing her own infant would be inadvisable or even impossible. Syphilis contracted late in the pregnancy, and tuberculosis, are contraindications, owing to the danger of the mother infecting the child. Inversion of the nipples, their excoriation, or persistent sensitiveness may make it impossible. In marked general debility of the mother from any cause whatever, it would be injurious to the mother and the child.

After the mother and the new-born infant have had some hours of rest and sleep, it is advisable to apply the child to the breast, to receive by this first effort the small quantity of milk which is an especial provision to act as a natural purge and to start the bowels of the child into a healthy activity; this also excites the milk glands to secretion. The mother's milk in full supply may be expected in from forty to sixty hours after delivery.

Nursing.--When the mother's nipples are of the normal size and well formed, the healthy infant instinctively suckles at once when placed at the breast, but sometimes it has to be taught; by squeezing out a

few drops of milk to wet the nipple, the child will usually take hold, or a little sugar and water may be put on the nipple; a little patience and tact are all that is necessary to insure success. But the infant must be taught to nurse at once before the breasts become engorged with milk.

Under ordinary circumstances the child is to be kept at the breast for one year. But if within this time the menstrual period should recur and be profuse, or should the woman again become pregnant, the quality of the milk becomes poor, and necessitates the immediate weaning of the child; the character of the milk is also altered, and even its secretion may be checked. Nervous agitation may so alter the quality of the milk as to make it poisonous. A fretful temper, fits of anger, grief, and sudden terror not only lessen the quantity of the milk, but render it thin and unhealthful, inducing disturbances of the child's bowels, diarrhea, and so forth.

Position of the Mother When Nursing.--When in bed in the recumbent position, the mother should lie on that side from which the infant is going to nurse; when up, the mother should sit erect.

Care of the Nipples.--Immediately after each nursing the nipples should be washed off in a saturated solution of boric acid in cold water, and dried with a soft cloth. If they are disposed to crack, anoint them with cocoa-butter immediately after each cleansing. If the skin of the nipple is very sensitive, a nipple-shield should

be used for the first few days; or should the nipple become sore at any time, the shield can be resorted to. The nipple-shield must fit tightly; the best ones are made of glass with a rubber tip. In the intervals of nursing the nipple-shield should be kept in cold water after it has been thoroughly cleansed by being brushed on both sides.

The breasts are sometimes distended from an over-secretion of milk; this is relieved by saline cathartics, by abstinence from liquids, and by the use of a compression breast bandage. This is made of a straight piece of muslin, with a shallow notch cut in one edge for the neck, and, a deep one for each arm; the bandage is closely applied over the breasts, and the ends pinned in front; it is also pinned over the shoulders.

In debilitated women the supply of milk may be insufficient; the most reliable evidence of this is the fact that the infant ceases to gain in weight.

CHAPTER XII.
THE NEW-BORN INFANT.

The Infant's Toilet; the Crib; Feeding of Infants; Artificial Feeding; the Wet-nurse; Characteristics of Healthy Infants; the Stools; Constipation; Urination; Dentition.

The Infant's Toilet.--So soon as the mother has been made comfortable, the toilet of the infant is attended to. This should be made near the register or stove; and the lap of the nurse should be covered with a small flannel blanket. The baby's body will be found to be covered over with a white, greasy, somewhat cheesy substance; some sort of grease is needed for its removal; rendered lard, sweet oil, and lanolin are the best; vaselin is less effective. All of this cheesy substance must be at once removed; the most difficult parts will be in the folds and creases. The nurse should grease the palms of her hands, then take the head of the child between them, and thoroughly grease it; particular attention must be given to the ears; then come the neck, shoulders, arms, chest and back, groins, external genital organs, and lower extremities. After the child

has been thoroughly gone over, the grease should be rubbed off with a soft towel.

A rectal injection of one tablespoonful of warm water is given at once to unload the bowels of the meconium; this generally acts before the baby's toilet is completed. The meconium is the first discharge from the infant's bowels after birth, and that which had collected in the intestines during the pregnancy.

The Baby's Bath.--The baby's bath-tub is filled about one-third full of water at a temperature of 100 degrees F., tested by the thermometer. The baby is then gradually immersed in the water, with the exception of the head; this is supported on the left wrist of the nurse, which passes under the infant's neck, while her hand grasps the left shoulder; with the right hand the nurse quickly rubs over the child's head and body; the entire bath should not occupy over five minutes. The infant is then lifted out into the lap of the nurse, on which is spread a soft, warm towel, with which it is carefully dried. One of the important points in giving the infant its bath is to be sure that the groins, arm-pits, and genitals are thoroughly well dried; otherwise excoriation at these parts is sure to occur.

After this a daily tub-bath is given in the same way; soap is rarely needed; when it is, castile soap should be used; its constant use is not necessary and would only irritate the skin. These daily baths strengthen the nervous system and prevent coughs and colds. The bath should be given during the morning, one hour after

feeding, and should not last more than five minutes. The mother herself, just as soon as she is able to go around, should superintend the bath; in this way she is assured that if properly given, and will also recognize any incipient affection of the child. These daily baths should be continued till the child is four years old. Powder is not essential; but if it is desired, a plain talcum powder may be used.

The Dressing of the Cord.--After the bath the ligature which was tied around the cord at the birth of the child will be found slightly loosened; this should first be made tight, and then the cord, doubled back on itself, should be tied by the ends of the same ligature. A square of soft sterilized linen or gauze is slit up to its center; the cord is allowed to pass through this slit, which looks toward the child's right; the stump of cord is laid on the left and the ends of gauze are folded over this; the whole is kept in place by the abdominal bandage. As there is some exudation from the cord, it is necessary to change these dressings twice a day; as this exudation is of a somewhat gluey nature, it will be found that the dressings stick to the cord. In removing the gauze great care must be used not to make any traction on the cord; when the infant is placed in the bath, the water loosens the dressing and it falls off in the water; at other times it must be removed with the greatest care. There should never be any odor about the cord; it usually drops off about the fifth day.

The process of ulceration by which the cord falls off

leaves an open surface on the child's body which offers an avenue for septic infection. Great care must therefore be taken that the nurse's hands or anything which comes in contact with this surface should be perfectly clean. The dressings used must be thoroughly antiseptic.

Care should be used not to fasten the abdominal bandage too tightly; the bath is given on an empty stomach, and allowance should be made for this; the binder should be loose enough to allow two or three fingers to easily slip under it.

The Meconium.--The First discharge that comes from the bowels is of a dark, greenish color, and should come away during the first twenty-four hours; if it does not, the baby may suffer a good deal of pain, and an enema of warm water must be given. As this substance is very difficult to be washed out of napkins, the first ones used should be old and afterward be burned.

Cleansing.--Every time the napkin needs to be changed, even if it is only wet, the baby should be washed with warm water. A napkin should never be used twice without washing; it chafes the child, and it is an unsafe as well as a filthy practice; the napkin must always be removed as soon as it is wet.

The Infant's Toilet.--After the application of the binder and napkin, comes the undervest; the fingers of the nurse are passed up through the sleeve to seize the infant's hand and pull it through; as soon as it gets a little older the child will grasp a finger laid in its palm,

which greatly facilitates this part of the toilet. The stockings are next put on and pinned with safety-pins to the napkin; then comes the petticoat, the band of which is also loosely fastened with safety-pins, and with the slip the toilet is complete. All the clothing should be changed night and morning.

The eyes and mouth should be washed out with separate pieces of gauze or old linen. For the mouth, a small piece of cloth wet in warm water is wrapped around the little finger of the right hand, going into the left angle of the baby's mouth and coming out at the right, going between the gums and cheeks as well as over the tongue. This procedure should be gone through with every time preceding and following the nursing, and in this way the milk is prevented from souring in the mouth, and the digestion is kept in good condition. A sore mouth in a baby indicates carelessness on the part of the nurse.

A soft hair-brush may be used, but the scalp is too tender to permit the use of a comb.

After the toilet has been completed, the baby is laid in its crib, on the right side of the body, and warmly covered. The weaker the baby, the more attention must be paid to the external warmth. It may be necessary to place a warm-water bottle in the crib, but this must never touch the infant.

The Crib.--The infant must have its own crib, without rockers, and it must on no account be put to sleep in the same bed with its mother. In its early life it

should never be taken out of its crib except to be fed, to have its clothing changed, or to be bathed. There should be no holding on the lap, no dangling, no carrying or fussing over the new-born infant; and the more the baby is let alone, the better and healthier it will be. If baby cries, look at once to see if it needs a fresh napkin; if not, if any pins are sticking into it, if the clothing is possibly too tight; if none of these things are wrong, give it a sup of water and turn it over on the other side. The baby often becomes restless by sleeping for several hours in the same position. But on no account take the infant up out of its crib simply because it cries.

Cheerfulness and good nature on the part of the infant are dependent on its general good health. A healthy infant should not have colic, but if such is the case, there is a peculiar look of distress on the face, which indicates that the child is in pain; what is needed is warmth or medication according to the severity of the case, but never floor walking. Begin the latter procedure, and you may hope to keep it up for several years.

Ventilation.--The air is sometimes vitiated for children's uses in various ways; their nervous susceptibilities are greater than those of older people. A very little odor of tobacco may cause nausea and discomfort to an infant in arms. The atmosphere of the room should be sweet and pure and unscented. All scents and perfumes affect the nervous system, and by constant

excitation do it damage. A bouquet of flowers renders the air of a closed room too heavy.

Feeding of Infants.--During the day the infant should be put to the breast once every two hours, and once every three hours during the night. This interval of time between the feeding is necessary in order that there may be sufficient time given for digestion to take place. Regurgitation of milk soon after feeding is a sign that the stomach has been overfilled. As the infant usually falls asleep after nursing, it is necessary to waken it up at the time for the next nursing, as good digestion depends upon regularity of feeding.

For the first nursing the infant may be put to the breast in from two to six hours after the labor if the mother is sufficiently rested; from ten to twenty minutes is long enough for each nursing. Before each nursing the nipples should be carefully washed off with a solution of boric acid. The first secretion of the breasts is laxative; that is, it acts on the bowels, and makes is unnecessary to give the infant anything to take for this purpose. The breasts should be used alternately in feeding the infant, as this allows a longer time for the accumulation of the milk. For the first few days the infant needs very little food, and the mother's milk is generally sufficient.

The infant should be given a teaspoonful of cool water to drink two or three times a day, as the milk does not quench the thirst. The water should be sterilized by boiling, and be kept in an air-tight flask.

At the end of the third month the intervals of nursing for the daytime should be three hours, and the last nursing at night should be at eleven o'clock, and the first nursing in the morning at five o'clock; thus allowing the mother an interval of six hours of unbroken sleep.

The best evidence of the proper nutrition of the child is a progressive gain in weight. The child should be weighed every week. A loss of a few ounces usually takes place during the first few days after birth, so that the child does well if at the end of the first week it weighs as much as it did at birth. After the first week the weekly gain should not fall below five ounces.

The Wet-nurse.--When the mother for any reason whatever is not able to nurse her child, the best substitute is a wet-nurse. Before she is employed the wet-nurse should always be carefully examined by a physician to insure her freedom from disease. The best age is between twenty and thirty years, and the age of the child of the nurse should be at least within a month of that of the child to be nursed. The best sign of the good health of the nurse and of the condition of her milk is furnished by the health of her own child. The breasts should be well formed and the nipple of good shape. It is well, if possible, to get a woman who has borne several children, as she will understand the care of the child better. No woman who is not perfectly healthy is fit to be a wet-nurse; and even after she has been

engaged her health and her habits must be watched over.

Artificia1 Feeding.--The first requisite in artificial feeding is that the milk shall be made to correspond as nearly as possible to that of the mother. For this purpose the following formula, prepared by Rotch, of modified cow's milk is considered the best:

     

Milk	2 ounces
Cream	3 ounces
Water	10 drams
Milk-sugar	6 3/4 drams
Lime-water	1 ounce

To make one pint of the mixture for use in the twenty-four hours, take the milk and cream as soon as it comes in the morning, and mix as above directed.

No less important than the correct proportions of the ingredients, is freedom from disease germs and bacteria of putrefaction. Complete sterilization is possible by prolonged boiling; but experience has proved that under prolonged exposure to a temperature near the boiling-point certain changes take place in the albuminoids of the milk which greatly impair its digestibility. Full sterilization of milk for infant feeding has therefore practically been abandoned. It has been found that milk heated to 167 degrees F. for twenty minutes, and promptly chilled by placing on ice, remains practically sterile for twenty-four hours, and it is spared the injurious changes which take place at a higher temperature. This process is known as Pasteurization. The Arnold steam sterilizer affords a

convenient method of sterilizing; if used with the cover removed, the steam chamber being open, the temperature of the steam chamber does not exceed 170 degrees F.

It is claimed that in the Arnold steam sterilizer, with the use of a suitable gas stove, the water begins to boil at the end of two minutes after the gas is lighted. A four-ounce bottle of milk at an initial temperature of 70 degrees F. in the open steam chamber attains a temperature of 170 degrees in just one hour. An exposure of about one hour and twenty minutes in the steam chamber is therefore necessary for the Pasteurization.

The rules for sterilizing are as follows:

First, clean the bottles thoroughly; then place them in cold water, which is allowed to come to boil and boiled for ten minutes.

Second, fill each with the milk you wish to use; put in the rubber cork without the glass plug; this leaves a small opening in the rubber cork; set the bottle in the basket, then in the boiler.

Third, set in the refrigerator until needed for use.

Fourth, when wanted for use, place a bottle of the milk so prepared in the tin mug which accompanies the sterilizer; fill the mug with hot water to the height of the milk in the bottle, heat the milk to the temperature of 99 degrees F., remove the rubber cork and put on the nipple, when it is ready for use.

Fifth, cleanse the bottle immediately after using; throw away any milk that has not been used.

Sixth, if the steaming process is preferred, place the basket without the bottles in the boiler, fill the water up to, but not above, the bottom of the basket, place the bottles in the basket, and proceed as before.

It is important that the milk should be sterilized or Pasteurized as soon as it is served in the morning. Each bottle must be thoroughly washed as soon as it is emptied. Milk sterilized in this way will keep for days without spoiling, as it is hermetically sealed and all the unhealthy germs have been removed.

The most exact method for the artificial feeding of infants, and that which most nearly approaches the mother's milk, is that used by the "Walker-Gordon Laboratory," branches of which are to be found in many of the large cities.

Not only is the greatest care taken that the milk used shall be pure and sterilized ready for use, but these laboratories are equipped by special machinery which separates the important elements of the milk--namely, the fat, the milk-sugar, and the proteids. So that the physician can modify the proportions of these various ingredients of the milk to meet the necessity of the age and requirements of the infant.

When the milk contains too little sugar, the infant does not gain as rapidly in weight as it would otherwise do. Too much sugar in the milk is indicated by colic, thin, green, or acid stools, or eructations of gas from the stomach.

An excess of fat in the milk is indicated by vomiting;

too little fat causes constipation with dry hard stools. Proteids in excess are a prolific cause of colic and also of diarrhea.

Prescription blanks are furnished the physician, who fills out the percentages of fat, milk-sugar, proteids, and alkalinity, to suit the age, weight, and general condition of the child. He orders also the amount to be given at each feeding, and the number of feedings to be given in the twenty-four hours. Each bottle contains just the amount to be given at one feeding. All that the mother needs to do is to place the bottle in a receptacle containing warm water, until the milk has attained a temperature of 99 degrees F., remove the cotton stopper, and put on the nipple, when it is ready for use.

The Nursing Bottle.--This should be of clear glass, with a rounded bottom, and of such a shape as is easy to clean; so that no particles will cling around a corner which cannot be reached. The graduated bottle is the most convenient, as it enables the quantities of each of the materials used in the preparation of the feeding to be mixed in the bottle, doing away with the trouble of measuring before putting into the bottle.

Rubber Nipples.--Two nipples should be kept for alternate use, and no nipple should be used longer than two weeks. A soft rubber of conical shape is best, with an opening at the top which is not too large, so that the milk will not flow through, as it is desirable that the child should obtain the milk by suction. So soon as the feeding is over, the nipple should be removed from

the bottle, and brushed on both sides with a stiff brush. It should then be put in cold water, where it is kept until it is again wanted.

The baby should be fed slowly, from ten to twenty minutes being taken for each feeding. Sucking from an empty bottle or with a nipple in the mouth should never be permitted, as in this way the baby draws air into its stomach, which will result in colic. Each flask should contain only enough for one feeding.

In lieu of the regular sterilizing apparatus, milk may be similarly prepared by placing the milk in an ordinary glass fruit-jar with a screw lid. This is placed in a colander over a pot of boiling water; the milk should be allowed to boil in the open jar for two minutes; the jar-lid is then screwed on, and it should steam for twenty minutes longer.

The capacity of the infant stomach at birth is about one ounce, which is the average quantity of food that should be taken at one meal. The average rate of increase in the amount of food is one and a half drams a week for the first six months; subsequently somewhat less. The intervals of feeding should be two hours at birth, and increased to three hours at the end of the third month. The food should be given at a temperature of 99 degrees F. and fed directly from the sterilizing bottle.

Fresh Air.--In warm weather the baby is taken out-of-doors in from three to four weeks after birth; in cold weather not before two to three months. In the latter case it is prepared for the change by being first dressed

as for the street, with wrap and cap; the windows of the room are then opened, and the infant is carried about here. In the winter months when the baby is first taken out, it is better to carry it in the arms, as it will be kept warmer in this way, and if it does become chilled it will be more quickly noticed.

Characteristics of the Healthy Infant.--The average weight of an infant at birth is about seven pounds, and its length is about twenty inches; the extremes are four pounds or a little less up to eleven pounds. The head and trunk of the child are developed out of proportion to the limbs.

The skin of the new-born infant varies from pinkish to red; about the fourth day the color becomes somewhat yellowish; this tinge should disappear about the end of the second week, and at the same time the skin begins to peel off.This process lasts about two weeks longer, when the baby's skin takes on its normal color.

The shape of the head varies greatly, much being due to the amount of pressure during labor; but this disappears in a few days. As a rule, the large bones of the head are felt to be separated by membranous ridges called sutures; there is one on the median line on the top of the head, and at either end of the suture is a large open space, called a fontanel. The largest one is at the front of the head, and is called the anterior fontanel; it is about large enough to be covered by the tips of two fingers, and is of a lozenge shape; this opening does not close till the child is about eighteen

months old. In a healthy baby this fontanel should be on a level with the bones of the head; a slight pulsation may be noticed in it, due to the pulsations of the vessels of the brain. There is a much smaller three-cornered fontanel at the back of the suture, and one behind either ear; these soon close up with bone.

A new-born baby cannot probably do any more than distinguish light from darkness. Up to the sixth week there is an inability at coordination of the ocular muscles; after this time the eyes begin to move in an orderly manner, and they will follow a bright object moved slowly in front of them. At about the end of the second month rapid movements are perceived, as is evinced by the child's closing its eyes quickly on an object suddenly approaching it. At three months the child begins to recognize colors; the first recognized are yellow, red, pure white, gray, and black. But the faculty of distinguishing between colors is not perfected till the third year. The mother is recognized about the third month. Hearing and a sense of smell develop rapidly after birth; loud noises in its vicinity will cause a child to start during the first day after birth. By the time the child has reached three months of age it shows signs of having a mind of its own, and is capable of exercising thought. It grasps for objects, and indicates its likes and dislikes. At from eight to ten months it can utter several syllables, and at the age of one year should be able to say mama and papa; at two years it should be able to frame short sentences.

Weight of the Baby.--By the end of the sixth month the child's weight should be double what it was at birth; that is, about fourteen pounds; at the end of the twelfth month be three times as much as at birth, or about twenty pounds.

Muscular Action.--Muscular action in the new-born infant is entirely involuntary, there being no voluntary acts until about the end of the third month. Sucking and licking are largely instinctive. The movements of the arms and legs are impulsive acts, and occur during sleep, just as they did in the intra-uterine life. The act of raising the head, which is attempted about the fourth month in healthy children, is volitional, requiring not so much added strength of muscle as power of coordination. As volition develops the power of coordination gradually increases, and the child learns to perform voluntary or purposeful acts. Voluntary grasping is done after the fourth month. As the child learns to balance its head, it attempts to sit up. This act is not successfully accomplished until about the fortieth week; the child sits firmly alone when ten or eleven months old. Before this time it is necessary to support the head and spine of the child with the hand. By the third or fourth month the infant should be able to grasp things. The child begins to creep about the ninth month. The clothing should be so arranged as to allow entire freedom of motion.

It should be able to stand up by a chair by the tenth month, and be able to walk alone at the end of the first

year. It is important that parents should know this, since not knowing what a normal baby ought to be able to do, cases of birth palsy, or even an attack of paralysis due to teething, are not infrequently overlooked, not only by the mother, but even by the doctor, who attributes the inability of the child to do what other children can do at this age simply to weakness, which the child will outgrow; and thus the time passes in which the most could be done to cure the child and to prevent the subsequent deformity.

A baby should not be forced to stand or walk; a very stout baby, on account of its weight, will stand up and walk much later than a slight one, the two being equally healthy. Or if a baby has been sick, it will feel no inclination to stand up. Naturally, a child creeps before it walks, and this develops the muscles of the lower limbs, so that they will support the weight of the child in standing. By prematurely forcing a child to stand up and walk, there is danger of causing bow-legs, as the bones of the legs are still weak; the child should be discouraged from standing up too much rather than encouraged to stand up more.

Sleep.--A large proportion of the time of early infancy is spent in sleep; for the first few weeks the infant only wakens up to be fed. During sleep the eyelids should be tightly closed; a partial opening of the lids, showing the whites of the eyes, is an indication of ill health. Up to the age of six, children require twelve hours of sleep at night, besides an hour or more in the

middle of the day; the child should be permitted to sleep as long in the morning as it will.

Respiration.--The healthy infant breathes on an average forty-four times a minute; the only time the respirations can be satisfactorily counted is during sleep. When the child is awake, the respirations are hurried by slight movements of the body, crying, and so forth. The average pulse of a newborn baby is one hundred and forty; this is hurried by the same causes that hastens respirations; the pulse is most easily counted at the anterior fontanel. The average temperature of the infant is 99 degrees F. When the tip of the nose and the extremities are cold, it indicates a lowered vitality.

The nature of the child's cry indicates, variously, hunger, temper, or pain; the mother will soon learn to distinguish these varieties. If the child cries because it is hungry, the cry ceases so soon as it is fed. But a child is never to be fed simply because it cries; it must be fed on the hour by the clock. If this rule is not strictly adhered to, it will suffer all the forms of indigestion and colic that babies are heir to. If it cries because of colic, there is a drawn look on the face, and at the same time the legs are sharply flexed on the thighs and the thighs on the abdomen. If the cries are due to earache, the head will be rolled about from one side to the other. In either case nothing will stop the cries until the pain is relieved. A baby does not shed tears until the third month.

The Stools.--The stools of a very young baby fed on breast-milk should be of a yellow or orange color. There should be three or four evacuations daily; they should contain no curds. Stools of bottle-fed babies are lighter in color and more offensive.

Constipation.--Constipation is not uncommon in infancy; it may be overcome by the use of a soap suppository, or by an injection of warm soap-suds into the bowel, or by an injection of oil and water, or by gentle friction over the bowel, following the course of the large intestine.

To make the soap suppository, take a piece of castile soap about an inch long, give it the shape of a cone not any larger than the end of the little finger, and make it perfectly smooth. This is inserted to about half of its length into the rectum and held there until it causes the bowels to move.

The bowel injection is best given by means of the single-bulb syringe, known as the eye and ear syringe; the bulb holds about two tablespoonfuls of liquid. This may be warm cotton-seed oil, sweet oil, or glycerin one teaspoonful to warm water two tablespoonfuls. The nozle should be small, smooth, and well oiled. It should be very carefully introduced into the bowel, being directed a little to the left side, and the bulb gently squeezed to force the contents into the bowel. The injection is more effective if it is retained for a little while; this is accomplished by making slight pressure on the anus with a towel.

Rubbing the abdomen for about ten minutes in the direction of the large bowel is sometimes very effective in overcoming constipation; begin in the right groin and rub up as far as the border of the ribs, then across to the left, then down on the left side.

Vomiting.--Vomiting means often only that the stomach has been overfilled, and may be relieved by withholding all food for a few hours.

Urination.--The frequency of urination in a newborn baby will vary greatly with the weather and other conditions; in cool weather it is not unusual for the napkin to need changing almost every hour. Healthy urine should not stain the napkin. The new-born infant secretes very little urine until it begins to take nourishment freely. The bladder is usually emptied during birth, and very often the bowels also, so that if the child seems well and there is no malformation of the parts, the family may be assured that the apparent retention of urine is only temporary.

The use of hot fomentations over the kidneys and bladder will often hasten the evacuation of urine if it has been unduly delayed. If the secretion seems highly concentrated, a drop of sweet spirits of niter in a teaspoonful of water may be given every two hours.

Teething.--The first tooth generally appears about the end of the fourth month; in delicate children they come later. As a rule, the lower front teeth come first, coming in pairs, one tooth coming on each side of the mouth; followed in about a month by the corresponding

teeth in the upper jaw. Preceding their appearance the gums become swollen, hot, and painful, and the saliva forms in excess and runs from the mouth. The child is irritable, flushed and restless; and there usually occurs some disturbance of the bowels, commonly diarrhea. This all indicates a nervous derangement, and calls for a judicious diet and general careful oversight. The symptoms subside when the teeth are through. During teething the child manifests a desire to bite on something, and a soft rubber ring will give it great comfort.

The first set of teeth are twenty in number, and are usually cut in groups, starting about the fourth month and continuing until between the twentieth and thirtieth month, when the first dentition should be complete. As a rule there is an interval of rest between the eruption of the various groups. During dentition children are generally more peevish and fretful than usual, but there should be no general constitutional disturbance. During dentition it is of especial importance to keep the bowels well opened; it is better to have them too loose than costive; constipation at this time greatly increases the tendency to convulsions.

Bottle-fed babies are apt to cut their teeth later than those nursed at the breast. The lack of appearance of any teeth before the end of the first year indicates that the nutrition of the child is below par, or, in other words, that the child has rickets. The permanent teeth begin to appear about the sixth or seventh year.