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Title: The Prospective Mother, a Handbook for Women During Pregnancy

Author: J. Morris Slemons

Release date: December 1, 2004 [eBook #7129]
                Most recently updated: December 30, 2020

Language: English

Credits: Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo, Charles Franks and the Online Distributed Proofreading Team


*** START OF THE PROJECT GUTENBERG EBOOK THE PROSPECTIVE MOTHER, A HANDBOOK FOR WOMEN DURING PREGNANCY ***




Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo,
Charles Franks and the Online Distributed Proofreading Team.





THE PROSPECTIVE MOTHER


A Handbook for Women During Pregnancy



by

J. MORRIS SLEMONS

Associate Professor of Obstetrics,
The Johns Hopkins University.


       *       *       *       *       *


PREFACE


This book, written for women who have no special knowledge of
medicine, aims to answer the questions which occur to them in the
course of pregnancy. Directions for safeguarding their health have
been given in detail, and emphasis has been placed upon such measures
as may serve to prevent serious complications. Treatment of such
conditions has not been discussed, as it can be judiciously carried
out only by a physician who has the opportunity to observe and study
the individual patient. Furthermore, if there is to be notable
improvement in the management of cases of childbirth, the appearance
of untoward symptoms should not be awaited before consulting a
physician; on the contrary, prospective mothers must be taught that
they should be under competent medical supervision throughout
pregnancy.

At present intelligent women demand some knowledge of the anatomical
and physiological changes incident to the development of the embryo
and the birth of the child. These subjects do not readily lend
themselves to popular description, but I have told the story as
simply as possible, following in a general way the text-book of my
teacher and friend, Professor J. Whitridge Williams; indeed, my main
purpose has been to reproduce his book "in words of one syllable."
The use of a number of technical words has been unavoidable, and,
though their meaning has been given in the context, it has not been
feasible to repeat the definition every time an unfamiliar term was
used. On that account a glossary has been provided.

It is with pleasure that I avail myself of this opportunity to
acknowledge the cheerfully given assistance of many friends. In
particular I wish to thank Doctor Henry M. Hurd, until recently
Superintendent of the Johns Hopkins Hospital, for his interest and
advice. I am also under deep obligation to my friend John C. French,
of the English Department of the Johns Hopkins University, for
helpful criticism of the manuscript, and to my colleagues, Doctors
Rupert Norton and Thomas R. Boggs, for valuable assistance. To many
others--doctors, nurses, and patients--I am indebted for numerous
suggestions which have been made either consciously or unconsciously.

J. MORRIS SLEMONS.


       *       *       *       *       *


INTRODUCTION


In all branches of medicine the master word is _prophylaxis_, or
prevention, and its benefits are nowhere more strikingly illustrated
than in the practice of obstetrics. In former times every woman who
gave birth to a child or passed through a miscarriage was exposed to
grave danger of infection or child-bed fever; but at present--thanks
to the recognition of the bacterial origin of the disease and of its
identity with wound infection--this danger can be practically
eliminated by the rigid observance of surgical cleanliness and
aseptic technique. Physicians have also learned that the most
effective method of coping with other serious complications of
pregnancy and labor is by preventing their occurrence, or at least by
subjecting them to treatment in their earliest stages; for, if they
be allowed to go on to full development, the results are little
better than in times past. Furthermore, a careful examination some
weeks before the expected date of confinement enables us to recognize
the existence of abnormal presentations and of disproportion between
the size of the mother's pelvis and that of the child's head. Timely
recognition of such conditions makes appropriate treatment possible
and practically insures a successful outcome; while tardy recognition
is frequently followed by disastrous results.

These few examples give some idea of the benefits of prophylaxis in
the practice of obstetrics. Prospective mothers should understand not
only that there is an advantage in taking such precautions, but that
they may be risking their lives, or at least their future well-being,
unless they insist upon competent medical attention. It is true, of
course, that pregnancy and childbirth are generally normal processes,
but they are not always so. Fortunately, most of the abnormalities
give timely warning of their occurrence, and in most instances may be
relieved by comparatively simple measures; or, if not, they afford
indications for treatment which should lead to a happy termination.
The recognition of the existence of such conditions, however, is not
always easy, and their ideal treatment requires careful training and
sometimes the utmost nicety of judgment. Consequently, if prospective
mothers wish to be assured of the best care, they should be cautious
in the choice of their medical attendant. As the ordinary layman has
no means of determining the real qualifications of a physician, the
choice should not be made upon the advice of casual acquaintances;
but, instead, the family physician should be consulted, who, should
he feel unwilling to assume the responsibility of the case, will be
able to recommend a thoroughly competent substitute.

From my own experience as a teacher and consultant, I state without
hesitation that in no other branch of medicine or surgery are graver
emergencies encountered than in certain obstetrical complications
whose treatment involves the greatest responsibility and requires the
highest order of ability to insure a successful outcome for the
mother and her child. For these reasons a physician should be chosen
only after mature deliberation, and his services should be esteemed
much more highly than is usually the case.

In order that the principles of prevention may receive their fullest
application during pregnancy, labor, and the lying-in period, it is
also advisable that intelligent women should possess some knowledge
of the Reproductive Process in human beings. This information is
imparted by Doctor Slemons' book, which I can thoroughly recommend to
prospective mothers. The subject matter has been carefully chosen,
and the author has wisely refrained from giving advice with regard to
treatment which can be satisfactorily directed only after careful
study by a physician. At the same time he has given a clear account
of the physiology of pregnancy and labor, and has laid down sound
rules for the guidance of the patient.

One of the most important facts emphasized by Doctor Slemons is the
value of medical supervision for several weeks after the child is
born; this precaution contributes greatly toward a rapid and complete
convalescence. During the lying-in period the physician should
supervise the care of the mother and the child, should insist upon
the necessity for maternal nursing, and should keep the mother under
observation until perfectly normal conditions are regained. If the
latter duty is conscientiously fulfilled many years of invalidism may
be saved and thousands of operations rendered unnecessary.

Although there have been notable advances in the science and in the
art of obstetrics since the middle of the eighteenth century, a great
many fundamental facts must yet be learned. For example, we are
almost totally ignorant of the stimulus which causes the mother to
fall into labor approximately 280 days after the last normal
menstruation.

There are two points which I desire to impress especially upon the
readers of this book. Firstly, that the advance of the science of
obstetrics, and consequently improvements in its practice, must
depend greatly upon the cooperation of intelligent women. They must
come to realize that they will secure the best treatment only as they
demand the highest standard of excellence from their attendants; and
they can aid in securing this for their poorer sisters and their
children by interesting themselves in obstetrical charities.

Secondly, they must realize that real progress in the science of
obstetrics can be expected to proceed only from well equipped clinics
connected with strong universities, and in charge of thoroughly
trained and broad-minded men. As yet such institutions scarcely exist
in this country. Women who are anxious to promote the welfare of
their sex can find no better way of doing so than by bringing this
need to the attention of wealthy men interested in philanthropy and
education. Furthermore, they should bear in mind that most of our
important discoveries would not have been made had animal
experimentation not been available, as it is solely by this means
that modern surgical and obstetrical technique has been brought to
its present degree of perfection; and further progress can scarcely
be expected without its aid. They should remember also that whenever
they take such a well-known drug as ergot for the control of
bleeding, or make use of many other apparently simple measures, they
are unconsciously rendering tribute to this type of investigation.

J. WHITRIDGE WILLIAMS.

Johns Hopkins University,
September, 1912.


       *       *       *       *       *


CONTENTS


   I. THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
  II. THE DEVELOPMENT OF THE OVUM
 III. THE EMBRYO
  IV. THE FOOD REQUIREMENTS DURING PREGNANCY
   V. THE CARE OF THE BODY
  VI. GENERAL HYGIENIC MEASURES
 VII. THE AILMENTS OF PREGNANCY
VIII. MISCARRIAGE
  IX. THE PREPARATIONS FOR CONFINEMENT
   X. THE BIRTH OF THE CHILD
  XI. THE LYING-IN PERIOD
 XII. THE NURSING MOTHER
      GLOSSARY


       *       *       *       *       *


The Prospective Mother




CHAPTER I


THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT

The Positive Signs--The Probable Signs--The Presumptive Signs: The
Cessation of Menstruation; Changes in the Breasts; Morning Sickness;
Disturbances in Urination--The Duration of Pregnancy--The Estimation
of the Date of Confinement--Prolonged Pregnancy.

Many puzzling questions occur to the woman who is about to become a
mother. Most of these questions are reasonable and natural, and
should be frankly answered; but a false conventionality has--until
recently, at least--forbidden any open discussion of facts connected
with childbirth. The inevitable result has been that, without
experience of their own to guide them, prospective mothers have
sought advice from older women, whose experience was at best very
narrow, and whose views were often biased by tradition. Or,
distrusting such sources of information, they have consulted
technical medical works which they could not understand. Either of
these methods is very likely to result in misinformation and to cause
unnecessary anxiety. Yet no one need be alarmed by a plain, accurate
account of Nature's plan to provide successive generations of human
beings. Some trustworthy knowledge of a process so fundamental should
be part of every person's education; it is especially helpful to
women who are pregnant because it affords a rational basis for
hygienic measures which they should adopt. A popular work, however,
no matter how frank and helpful it may be, will not enable one to
dispense with professional advice. For the prospective mother no
counsel is more important than this: _Put yourself at once under
the care of a physician_.

Insistence on the importance of medical advice should not be taken to
imply that pregnancy is to be regarded as other than a normal
process. Its dangers are comparatively slight, as we should expect,
since the property of all living matter to reproduce its kind is both
fundamental and essential; the continuance of living creatures in
this world, plants as well as animals, depends upon the Reproductive
Process. And yet, natural as it is, pregnancy may be attended by
complications. Such complications, though happily rare, are to be
guarded against in every case, and that may be most effectually done
if patients are taught to remain under competent medical supervision
from the time of conception until several weeks after the child is
born. This precaution greatly reduces the frequency of annoyances
during pregnancy and also assists materially toward conducting a
birth to a safe conclusion. Moreover, if this advice is followed,
when complications do arise they will be recognized and dealt with
promptly; they will not be permitted to grow more serious until,
perhaps, they may jeopardize the life of the mother or the child or
both.

The initial symptoms of pregnancy are so widely known that in most
instances the prospective mother herself makes the diagnosis shortly
after conception has taken place; but now and then pregnancy advances
for several months unrecognized and is then detected by a physician
who has been consulted on account of symptoms which the patient has
incorrectly attributed to some other condition. On the other hand,
women sometimes suspect that they are pregnant when they are not; and
such mistakes occur because certain symptoms which are implicitly
trusted by the laity as manifestations of pregnancy are occasionally
associated with conditions quite foreign to it. It is clear that one
interested in the matter must know not only what the manifestations
of pregnancy are and when they appear, but also how far the evidence
that they give is reliable.

The signs of pregnancy may be classified, according to their
reliability, as presumptive, probable, and positive. The doubtful
evidence appears first and the infallible proof last. No one need be
surprised, therefore, if, when her suspicion is first aroused, she is
unable to decide positively whether she is pregnant. Physicians of
broad experience, possessed of facilities for observation which their
patients cannot employ, may find it necessary to make more than one
examination before they commit themselves to a definite opinion; in
some cases, though very rarely, they must wait for two or three
months to be able to do this.

THE POSITIVE SIGNS.--The earliest absolutely trustworthy
manifestation of pregnancy is the motion of the fetus. The perception
by the mother of these movements, which is spoken of as "quickening,"
generally occurs toward the eighteenth week, if she has been told to
watch for them; otherwise they may pass unnoticed until the twentieth
week or later. At first the motion, felt in the lower part of the
abdomen, is very gentle; it has been variously likened to tapping, or
to quivering, or to the fluttering of a bird's wings. As time goes on
the movements grow stronger and occur more frequently; they are,
however, perceived but rarely throughout the day and seldom interfere
with sleep. Occasionally women are annoyed by the sensation and
complain that the child is hardly ever quiet. Even these troublesome
movements are never a cause for anxiety; but prolonged failure to
feel motion after it is once well established should be reported to
the doctor.

In the first pregnancy the passage of gas through the intestines may
be mistaken for quickening long before the movements of the child are
really perceptible; but those who have once experienced quickening
will not be deceived. Whenever women who have borne children are in
doubt the sensation is almost surely not quickening. Furthermore, in
any doubtful case, the motion should be observed by a physician
before being accounted a positive sign of pregnancy. This precaution
will scarcely delay an absolutely positive diagnosis, since the
proper method of examination reveals these movements to the physician
almost as early as the patient feels them.

About the time these movements become perceptible another positive
sign is available. The physician whose ear has been trained to catch
such sounds when he listens over the lower part of the mother's
abdomen will hear the fetal heart-beat. Other sounds may be audible
there, but the character and the rate of the heart-sounds are
distinctive. Since the child's heart beats almost twice as fast as
the mother's, under ordinary conditions it is impossible to confuse
one with the other. The mother never feels the beating of the child's
heart, but occasionally she will mistake for it the throbbing of her
own blood vessels.

Ability to hear the fetal heart not only provides a means of
confirming the existence of pregnancy in doubtful cases, but also
enables the physician to reassure his patient if she fails
temporarily to feel the child move. Sometimes the presence of twins
is recognized in this way. Toward the end of pregnancy the heart
sounds are also of material assistance in determining what position
the child has permanently assumed.

There is a third positive sign of pregnancy to which the physician
has recourse, but generally it is inapplicable as early as those
already mentioned. In the latter months of pregnancy it is possible
to outline the child through the mother's abdominal wall. Although
this procedure adds little or nothing to our resources for making an
early diagnosis, the information it ultimately affords proves one of
the greatest aids in the practice of obstetrics.

THE PROBABLE SIGNS.--Obviously, phenomena for which the child is
responsible--such as have just been described--supply the most
trustworthy evidence of pregnancy; and these phenomena alone are
accepted as positive signs. But there are earlier manifestations
which intimate very strongly that conception has taken place. Shortly
after pregnancy has become established changes begin in the uterus,
as physicians call the womb, and soon reach the point where they may
be recognized by a simple examination which enables the physician to
express an opinion little less than positive. As one result of
pregnancy, for example, the supply of blood is increased to all the
organs concerned with the reproductive process. Partly on account of
this congestion and partly on account of embryonic development, the
uterus becomes altered in a number of ways. Although these changes
occur regularly in pregnancy, they may also occur when the womb is
enlarged from other causes; therefore, if a physician should make the
diagnosis of pregnancy whenever they were found, he would make it
somewhat too frequently. With a little patience, however, he excludes
the chance of being misled; a second examination, approximately four
weeks after the first, will generally place the existence of
pregnancy beyond question, for under normal conditions the degree of
enlargement which takes place in a pregnant womb during a given
interval is absolutely characteristic.

THE PRESUMPTIVE SIGNS.--Although women are most often led to suspect
that they are pregnant by symptoms which are of such doubtful
significance that they must be regarded as merely presumptive
evidence, the practical value of these symptoms is attested by the
fact that subsequent developments rarely fail to confirm the
suspicion. Perhaps they prove misleading once or twice in a hundred
cases; the number of mistakes is small, because the diagnosis is
commonly made not from only one of these doubtful signs but from a
group of them. In order of importance the doubtful or presumptive
signs of pregnancy are these: (1) cessation of menstruation, (2)
changes in the breasts, (3) morning sickness, (4) disturbances in
urination.

_The Cessation of Menstruation_.--The failure of menstruation to
appear when it is expected is nearly always the first symptom of
pregnancy to attract attention, and, as a rule, when this happens to
healthy women during the child-bearing period--which usually extends
from the fifteenth to the forty-fifth year--it may be taken to
indicate that conception has occurred. But there are exceptions to
this very good rule. Besides pregnancy we are acquainted with several
conditions that cause temporary suppression of menstruation; and to
understand its significance we must learn something of the menstrual
process itself.

Menstruation is a function of the womb and in all probability is
brought about through the influence of the ovaries. The bleeding,
popularly regarded as the entire menstrual process, is, in fact,
indicative of only one of its stages; the others give rise to no
symptoms whatever. What the stages in the menstrual process are, what
relation they bear to each other, and what the significance of the
whole process is, are problems that have been solved with the aid of
the microscope. In this way the mucous membrane lining the womb has
been studied both at the time of the periods and in the interval
between them, and we have learned that it is constantly undergoing
changes intended to facilitate the reception and the maintenance of
an embryo. Anticipating these duties the mucous membrane receives a
more abundant supply of blood; it also increases in thickness and all
the structures which enter into its composition become more active.
Unless conception takes place these preparations, which represent the
most important phase in the menstrual process, are without value; and
therefore failure to conceive means that the mucous membrane will
return to the same condition as existed before the preparations were
begun. The congestion is relieved by rupture of the smallest blood
vessels, and there follow other retrogressive steps which completely
restore the various structures to their former state. Then there is a
pause, though it is not long, until preparatory changes are again
initiated, or, as we say, another Menstrual Cycle is begun. Each
cycle lasts twenty-eight days, and includes four stages, namely, a
stage of preparation, of bleeding, of restoration, and of rest.

Although pregnancy may become established at any time during the
interval between the periods of bleeding, it is more likely to be
established just before a period is expected or shortly after it has
ceased. Furthermore, whenever conception does take place, the
preliminary preparations for the reception of the embryo are followed
by much more elaborate arrangements for its protection and nutrition.
Under these circumstances the hemorrhagic discharge does not appear.

Were there no other condition to bring about the cessation of
menstruation, the diagnosis of pregnancy would be greatly simplified.
But any one can appreciate the fact that diseases of the womb may
interfere with the menstrual process. Menstruation is influenced,
also, by the ovaries. As a result of age, for example, the ovaries
undergo changes which invariably bring about the permanent cessation
of menstruation, called the menopause. This event occurs prematurely
if both the ovaries are removed by operation. In view of these facts
it is not surprising that sometimes ovarian disorders abolish
menstruation. An impoverished state of the blood, or nervous shock
and strain, or constitutional debility may also interrupt the regular
appearance of the menstrual discharge.

The value of menstrual suppression as an evidence of pregnancy is
not, however, to be discounted to the extent that we might expect.
This is true because the ailments which lead to confusion are
relatively infrequent, and also because they exhibit characteristic
symptoms which are foreign to pregnancy. Often these symptoms are
obvious to the patient herself; if not to her, they will be obvious
to her physician. It is about the doubtful cases, naturally, that a
professional opinion is sought, and on that account physicians are
perhaps inclined to overestimate the difficulty women have in
learning for themselves whether or not they are pregnant. As a matter
of fact, it is unusual for a prospective mother to fail to reach a
correct decision--a decision for which she relies chiefly upon the
suppression of her menstrual periods.

It is doubtful whether menstruation ever continues after conception
has taken place. Instances in which the menstrual function is
believed to persist are not uncommon, and yet in all probability the
discharge regarded as menstrual has a different origin. In most cases
it should be interpreted as meaning that there is some danger of
miscarriage. Since miscarriage often occurs about the time a
menstrual period would ordinarily be expected, there is unusual
opportunity for confusing the symptoms. At all events women err much
more frequently in suspecting that they are pregnant than in
overlooking the condition. Indeed, pregnancy is not likely to be
overlooked unless menstruation has been irregular or suppressed for a
month or more previous to conception. Thus, in the case of nursing
mothers in whom menstruation is already suppressed and who are,
moreover, deprived of certain evidence that the breasts give,
pregnancy may sometimes advance several months before it is
recognized.

_The Changes in the Breasts_.--Various sensations in the breasts
are accepted by women as a reliable sign of pregnancy; thus
throbbing, tingling, pricking, or a feeling of fullness will be
mentioned by one mother or another as having given her the first
intimation that she was pregnant. A few women also find their breasts
become tender immediately after they have conceived; this may be so
marked that they cannot bear pressure. But unless such symptoms are
accompanied by definite, visible changes, they have no value as signs
of pregnancy.

About the end of the second month the nipples become larger and more
erectile, and deepen in color. The pigmented, circular area of skin
which surrounds the nipple, called the areola, also darkens. The
shade that the areola assumes will vary according to the complexion
of the individual, growing darker in brunettes than in blondes.
Ultimately, within this pigmented circle a number of elevated spots
appear about the size of a large shot. These spots betray the
presence of tiny glands always located there which, on account of the
better state of nutrition during pregnancy, grow larger, and
generally become visible.

Usually, after two menstrual periods have been missed the breasts
increase in size and firmness, and often the veins which run just
beneath the skin stand out conspicuously. Before very long it is
possible to squeeze from the breasts a fluid which many persons
believe to be milk, though it is really colostrum, a substance that
resembles milk but very slightly. At first colostrum is a clear,
white fluid, but in the later months of pregnancy it becomes yellow
and cloudy.

None of the changes in the breasts are absolutely characteristic of
pregnancy; even the secretion of colostrum has been noted in
association with various other conditions. Furthermore, as a sign of
pregnancy the presence of colostrum is totally deprived of value in
the case of a woman who has recently nursed an infant, for a small
quantity of milk or colostrum often remains in the breasts for months
after the infant is weaned. In general, however, women who have not
been pregnant before should assume that they have conceived if, after
missing a menstrual period, they note the characteristic changes in
the breasts.

_Morning Sickness_.--Soon after conception many women suffer
from nausea and vomiting, especially on rising in the morning.
"Morning sickness" usually passes off in a few hours, although it may
be more persistent. Perhaps this manifestation occurs more frequently
in the first than in subsequent pregnancies, but certainly one-half,
and probably two-thirds, of all prospective mothers suffer from it.
Usually the nausea begins just after a menstrual period has been
missed, and ceases about the third month or a little later.

But morning sickness is never counted an indication of pregnancy
unless taken in conjunction with other symptoms, for individuals who
are not pregnant may also suffer from nausea in the morning. On the
other hand, a number of prospective mothers escape morning sickness
altogether, and a few experience nausea at other times of day.

_Disturbances in Urination_.--It is not an uncommon belief that
some characteristic change occurs in the urine shortly after
conception. But this is not true; at least no change is revealed by
any method of analysis known at present. Yet there are symptoms
associated with the passage of the urine which appear very promptly
and prevail for several weeks. Chief among these is the desire to
empty the bladder frequently; some patients also have difficulty in
urination, and a few experience discomfort with it. All the bladder
symptoms gradually disappear about the fourth month, but become
prominent again toward the end of pregnancy.

Since the inclination to empty the bladder more often than usual may
be due merely to nervousness or to many other conditions, this
symptom taken alone cannot be regarded as a definite sign of
pregnancy. Indeed, it is mentioned, not because of its importance,
but to point out that it is in no way connected with the kidneys, as
patients are sometimes led to believe. It is a direct and natural
result of pregnancy. Since the womb enlarges and tilts forward at a
more acute angle than formerly, it presses against the bladder,
giving the same sensation as when the bladder is distended with
urine.

Although the presumptive signs which we have considered by no means
exhaust the list, all the others are totally untrustworthy. Each of
the more reliable symptoms, as we have seen, must be accepted
cautiously; but taken altogether, except in very unusual cases, they
may be relied upon. _If, for example, menstruation has previously
been regular and then a period is missed, the patient has good reason
to suspect she is pregnant; if the next period is also missed and
meanwhile the breasts have enlarged, the nipples darkened, and the
secretion of colostrum has begun, it is nearly certain that she is
pregnant; whether morning sickness and the desire to pass the urine
frequently are present is of no importance._ But the most
characteristic evidence, we must remember, is not available until the
eighteenth or twentieth week; then the signs of pregnancy are
unmistakable.

THE DURATION OF PREGNANCY.--After the existence of pregnancy has
become assured, perhaps the greatest interest centers about the date
upon which the birth may be expected. Even to approach accuracy in
this prediction the prospective mother must be familiar with certain
facts which she will always observe, but which, unless she
appreciates their importance early in pregnancy, she may fail to
record or to remember. In a few cases, however, such exceptional
information as knowing the date of conception does not lead to an
absolutely accurate prediction. But the deviation from the rule will
be understood only after we understand the rule itself, which is
based upon what we accept as the average duration of human pregnancy,
technically called the period of gestation.

In a broad sense, the period of gestation for each variety of mammal
is determined by the time required for embryonic development to reach
the point where the young may live independently of the mother. This
point is reached more quickly with small animals than with large. The
mouse, for example, generally brings forth its young in three weeks,
whereas the pregnancy of the elephant lasts two years. In human
beings, counting from the time of conception to the time of delivery,
pregnancy continues approximately 273 days. This number is merely an
estimate calculated from hundreds of cases in which there was no
question as to the underlying facts. Individual cases vary notably,
and indicate that two women may become pregnant on the same day and
yet not necessarily be delivered at the same date.

Irregularities in the duration of pregnancy are not limited to man.
Thus, while the mean period of gestation in the rabbit is thirty-one
days, it may be either shorter or longer by as many as eight days.
Similar variations occur in the pregnancies of all animals, and are,
moreover, notably greater among larger animals, since for such
animals the period of gestation is relatively long. For instance, the
accurate observations of veterinarians indicate that the mean period
of pregnancy in the cow is 285 days from the time of conception. This
fact notwithstanding, a competent observer found that, of 160 cows,
67 were delivered before the 280th day; 68 between the 280th and the
290th day; and 25 after the 290th day. Although nothing unnatural was
observed in any instance, the first animal was delivered 67 days
before the last, and in 5 instances gestation continued 308 days.

In ancient times it was believed that the duration of pregnancy was
of even more uncertain length in man than in the lower animals; but
since the eighteenth century thirty-nine weeks have been accepted as
the average duration of the human pregnancy when reckoned from the
day of conception. As this date is seldom known, it is most
convenient to reckon from the first day of the last menstrual period.
Estimated in this way its average duration is 280 days. As this
period corresponds to ten menstrual cycles, physicians prefer to
describe pregnancy as lasting 10 lunar months of four weeks each.
This is equivalent to 9 calendar months, in terms of which its
duration is popularly stated.

THE ESTIMATION OF THE DATE OF CONFINEMENT.--Since pregnancy is not an
absolutely fixed period, we possess no reliable means of predicting
the exact day when it will end. The most satisfactory method of
prediction consists in counting forward 280 days from the beginning
of the last menstruation or, what gives the same result, counting
backward eighty-five days from this date. _To make the calculation
in the simplest way we count back three months and add seven
days_; this addition is made because seven days generally
represents the difference between three months and eighty-five days.
If the last menstruation, for example, began on October 30th, we
count back three months to July 30th and add seven days, which gives
August 6th as the probable date of confinement.

A prospective mother should remember that this prediction is no more
than approximate. The calculation does not give the exact date of
delivery more than four or five times in a hundred cases. It is
accurate within a week in half the cases and within two weeks in
four-fifths. We also know that delivery is somewhat more likely to
occur after the expected date than before it. But perhaps we shall
get the clearest idea of the accuracy of the rule, or better still
of its inaccuracy, if we imagine twenty patients to have the same
predicted date, all of them giving birth to mature infants. The
chances are that only one of these patients will be confined upon the
day predicted; nine will be confined before and ten after it. In all
probability five of those who pass the predicted day will be
delivered within a week and four others within the second week, while
the twentieth patient will not be delivered until three weeks or more
have elapsed.

Such results clearly indicate our inability to make accurate
predictions even though pregnancy is normal in every way. Whenever
patients pass their expected date uneventfully, if they will bear in
mind that the fault lies with the method of prediction and not with
the pregnancy, they will often be saved anxiety. Frequently such
discrepancies are attributable to a false assumption, for our rule
always assumes that the conception took place immediately after a
menstrual period. While this is generally true, the number of cases
in which it occurs just before the period to be missed is by no means
inconsiderable, and in these we should not expect pregnancy to end
until two or three weeks after the day predicted by the rule.

Occasionally patients know the precise day upon which conception took
place, and prefer to estimate the day of confinement from that rather
than from the beginning of the last menstruation. They may do so by
counting back thirteen weeks from the day of conception; but this
method also is subject to error for, as we have noted, the duration
of pregnancy reckoned in this more exact manner is not constant. Such
a calculation rarely offers any advantage over that made from the
menstrual record.

Another method of estimating the date of confinement is based upon
the assumption that fetal movements are first perceived by the mother
toward the eighteenth week of pregnancy; and in consequence twenty-
two weeks generally elapse between quickening and the day of
delivery. Although such a calculation is far from certain in its
prediction, there are instances in which no other calculation can be
made. A nursing mother, for example, may become pregnant before
menstruation has been reestablished. Under these circumstances,
obviously, the date of confinement cannot be estimated in the
ordinary way, and it is then especially important to know the first
day on which the fetal movements were felt. Furthermore, it is
helpful to note this date in every case, since it serves, if for
nothing more, to confirm the prediction made from the menstrual
record. Besides the two methods just described, which are alike in
that they require the patient herself to make the necessary
observations, there is a third method of estimating how far pregnancy
has advanced, by which the physician is enabled to draw his own
conclusions. This method is based upon the fact that the womb
enlarges from month to month during pregnancy at a constant rate. Up
to the end of the third lunar month it cannot be felt through the
abdominal wall; but in the course of the fourth month, on account of
its size, it must rise into the abdominal cavity. At the beginning of
the sixth month the top of the womb is at the level of the navel, and
at the ninth reaches the ribs. The diaphragm then prevents the womb
from going higher; and two or three weeks before the end of pregnancy
it drops several inches, causing a change in the figure which is
noticeable to the patient, since her skirts hang somewhat lower than
before. From this time on she is more comfortable, because the lungs
are not crowded, and there is less interference with breathing.

These alterations in the position of the womb indicate very
satisfactorily the month to which pregnancy has advanced, but not the
week and much less the day. They do not afford a more accurate means
of predicting the date of confinement than does quickening. The
evidence gained from the position of the womb, like that afforded by
the beginning of quickening, generally confirms the prediction made
from the menstrual history; it serves only occasionally to correct
it.

PROLONGED PREGNANCY.--Since birth does not occur in many cases until
the predicted date has been passed, it will be helpful even at the
cost of repetition to sum up what we know in explanation of such
unfulfilled predictions. They are to be explained sometimes by
uncertainty as to the beginning of pregnancy, as for example by the
supposition that conception took place shortly after the last
menstrual period, whereas it actually occurred two or three weeks
later. In a few instances, however, errors of observation or of
calculation will not account for false predictions.

It is generally admitted that second pregnancies average somewhat
longer than first pregnancies; one series of statistics indicates
that the duration increases slightly with each pregnancy up to the
ninth and decreases after that. Pregnancy is protracted more
frequently in healthy women than in those who are not, and again more
frequently in those who are inactive than in those who work. With
twins, contrary to the popular belief, pregnancy is apt to end
before, not after, the expected date. The sex of the child, in all
probability, has no influence upon the duration of pregnancy.

As we might expect, individuality is also a factor in this problem.
Thus, the period of gestation with some women is regularly longer,
with others habitually shorter than the accepted average. Until
experience has demonstrated their existence, generally, such
peculiarities are overlooked. But occasionally they may be detected
from knowledge of the interval between the menstrual periods; an
unusually long interval between them, for example, would lead us to
anticipate a protracted pregnancy.

Any delay after the expected date of birth has arrived taxes the
patience of the prospective mother. The fact, however, that more than
280 days have passed since the last menstruation, does not
necessarily mean that a patient has gone "over time." Such a question
can be decided solely from the weight and length of the child. Judged
in this way, comprehensive statistics indicate that once in several
hundred cases pregnancy may be fairly called prolonged. Even in these
rare instances an examination about the time of the predicted date
makes it clear whether pregnancy should be artificially ended or be
allowed to proceed to its natural conclusion.




CHAPTER II


THE DEVELOPMENT OF THE OVUM

The Germinal Cells--Fertilization--The First Steps in Development--
The Reaction of the Uterus--The Amniotic Fluid--The Placenta--The
Umbilical Cord.

Pregnancy, besides changing the external form of the body, causes
sensations--as for example those due to fetal movements--which are so
distinctive that they cannot escape notice. These obvious evidences
of approaching motherhood naturally lead thoughtful women to wonder
about the hidden mechanism of development, a mechanism which, of
itself, causes no sensation whatever. It is for this reason, perhaps,
that a prospective mother's imagination is so apt to be unusually
active, often picturing absurd conditions as responsible for one
symptom or another. Those who give free play to the imagination in
regard to the formation and progress of the embryo are pretty certain
to arrive at erroneous if not grotesque conclusions; for example,
they may attribute a protracted pregnancy to the child's having grown
fast to the mother, a situation that cannot arise.

Of course it is not essential that a prospective mother should
understand what is happening within the womb. And upon those who
prefer to be ignorant of the mechanism of development I would not
urge another point of view, for not ignorance but the unchallenged
acceptance of "half-truths" and of totally incorrect explanations is
the chief source of harm. On the other hand, my own experience has
taught me that women who wish to know about development should be
told the truth. In accord with this is the fact that I never have
more satisfactory patients than those who have previously been
trained nurses and who, in preparing for that profession, received
instruction concerning the reproductive function of human beings.

A description of development, in order to be perfectly clear, must
begin with a word about the fundamental structure of the adult body.
Everyone knows that the various parts of the body perform different
functions; but not everyone, perhaps, realizes that, in spite of
their different functions, all the organs of the body are composed of
similar structural units, known as cells. Of course, cells are
definitely arranged according to the use for which the tissue that
they chance to compose may be designed; they have, moreover,
distinctive individual peculiarities which can be easily recognized
under the microscope; but the essential features of the cells remain
the same, wherever they may be located. That is to say, each cell is
a minute portion of living matter, or protoplasm, separated from its
neighbors by a partition, the cell-membrane; each has its own seat of
government, the nucleus, located near its center; and each, to all
intents and purposes, leads an individual existence.

THE GERMINAL CELLS.--Many of the cells in the human body are able to
produce others of their kind. This they do virtually by growing and
splitting in half; cell-division, as this splitting is called, really
represents reproduction reduced to the simplest terms. Most cells can
do no more than produce units like themselves. The bodies of women
contain, however, a type of cell which possesses a far more wonderful
power. Provided the requisite conditions for such development are
met, these cells are capable of developing into human beings. Each of
these remarkable units is called an Ovum, or egg-cell, and represents
one variety of the germinal cells. But the other variety, represented
by the Spermatozoon and developed only in the male sex, is also
required for the production of a human being.

Every ovum originates in the ovaries. These are organs peculiar to
women, having the size and shape of large almonds, and placed in the
lower part of the abdominal cavity. Though the ovaries are two in
number, one alone is sufficient for every requirement of health. It
has been estimated that the ovaries together contain at the time of
birth about 40,000 ova, distributed equally between them. Since less
than 500 ova are required to insure regularity in the menstrual
function, it is clear that, if the surgeon finds it necessary to
remove one of the ovaries, the other will provide abundantly for
menstruation and for the bearing of children. Although every ovum
that will be produced as long as a woman lives has already sprung
into existence by the time she is born, not a single one ripens for
from twelve to fifteen years. The ripening process begins about the
time of puberty, and, unless suspended through the occurrence of
pregnancy, continues until the menopause. During this period, which
is also characterized by the periodical appearance of menstruation,
one ovum ripens each month; sometimes, though rarely, several ripen
at once, and this tendency is partly responsible for twins.

The human ovum is a tiny structure, measuring about 1/125 of an inch
in diameter. With the naked eye it can barely be seen; magnified by
the microscope it appears as a little round bag made of a transparent
membrane. Briefly described, the ovum is a single cell. That is, it
belongs to the simplest class of anatomical structures, and is one of
the millions upon millions of units that make up the body. It
contains a nucleus surrounded by nutritive material, the yolk. Yet
the quantity of yolk is exceedingly small. In this particular the
human ovum differs notably from the egg of birds, as it does also in
that it lacks a shell. Obviously, a shell would not only be useless
to an embryo developing within the body of its parent, but would shut
off the nourishment, which, since the ovum contains so little, must
necessarily be provided by the mother.

When the ovum has ripened, it becomes detached from the ovary, and
enters a fleshy tube about the size of a lead pencil, known as the
oviduct. There are two of these tubes, one running from the
neighborhood of each ovary; both enter the uterus, but on opposite
sides. The ovum travels down the tube which corresponds to the ovary
where it originated. The journey is fraught with momentous
consequences, for it is during this passage through the oviduct that
the fate of the ovum is determined. If it is to develop into a living
creature, a great many conditions must sooner or later be fulfilled;
but there is one which must be promptly satisfied. Shortly after
leaving the ovary the ovum must receive the stimulus to live and
grow; otherwise it will quickly wither and die. This vital stimulus
can be imparted only by the spermatozoon.

The male germinal cell is like the female cell in the possession of a
nucleus; in other respects it is very different. Longer but much
narrower than the ovum, the tiny arrow-shaped spermatozoon is
particularly distinguished by its active motility, for it has a tail
that propels it. The human male cell must travel some distance to
reach the point where it can meet a ripe and vigorous ovum; and since
the journey is not without danger to its life, Nature has provided
that exceedingly large numbers of the male cells shall be deposited
in the vagina at the time of the marital relation. In this way, it is
made sure that some of them will travel up through the uterus and
oviducts, arriving in the neighborhood of the ovaries.

FERTILIZATION.--Convincing observations upon the lower forms of life,
especially upon fishes, have shown that when the germinal cells come
near to each other, the ovum attracts the spermatozoon. The power of
attraction which the ovum exerts may be likened, most simply, to the
influence of a magnet upon iron-filings. While there has been no
opportunity to observe such attraction between the parent cells of
human beings, its existence is not open to doubt. And it is
practically certain that these cells meet in the oviduct, even in
that portion of it which receives the ovum just as it leaves the
ovary. Thither a number of the male cells have traveled by their own
activity; several come in contact with the ovum and one, but only
one, actually enters it. Almost at the moment when they touch, the
two cells unite so intimately that all trace of the spermatozoon is
lost. Fertilization of the ovum, as this event is scientifically
termed, has as its main purpose the uniting of the nucleus of a male
germinal cell with the nucleus of the female germinal cell. This
detail has been carefully studied; we know that the nuclei quickly
blend into one, and that the particles of living matter contributed
by the male animate the female cell with a new and wonderful
activity.

In our every-day way of speaking, fertilization means conception; it
is the instant in which a living being begins its existence. There is
no longer the slightest excuse for confusion regarding the period at
which the life of the unborn child begins. Before the significance of
fertilization was understood, it was perhaps not unreasonable to
believe that life began with quickening or about the time the fetal
heart-sounds could be heard. But now we must acknowledge that both
these ideas were incorrect. The animation of the ovum at the moment
of conception marks the beginning of growth and development which
constitutes its right to be considered as a human being.

Individuality, hereditary traits, sex--all these, we may be sure--are
unalterably determined from the moment of conception. The germinal
cell forms the total contribution of the male parent to pregnancy;
therefore no other opportunity for him to influence his progeny
presents itself, and the substance which enters the ovum at the time
of fertilization must be the basis of inheritance from the father. It
is equally true, as we shall see in the next chapter, that the
nucleus of the ovum and the nucleus alone transmits maternal
qualities. The material which conveys inheritable characters can be
seen and has been identified in both germinal cells; from each of
them the fertilized ovum derives equal amounts. As the parental
nuclei unite, the material which they contain intermingles and
establishes a new being; to attain full development, it requires
nothing further from the father, and nothing save nourishment from
the mother.

THE FIRST STEPS IN DEVELOPMENT.--Although the identity of the
spermatozoon is lost at the moment of fertilization, its influence
just then begins to be asserted. In the fertilized ovum the dawn of
development is shown at first by unusual activity within and later by
alterations upon the surface. Before very long the circumference of
the cell becomes indented as if a knife had been drawn around it, and
shortly two cells appear in place of one. These two cells in turn
divide, yielding four cells which grow and divide into eight. In this
manner division follows division until a multitude of cells have
sprung into existence, all of which cling together in the shape of a
ball. Development always proceeds in the same orderly way; evidently
it is governed by fixed laws which decree that the mass shall remain
for a while in the form of a ball, though the ball, at first solid,
soon becomes hollow.

While these changes are taking place the growing ovum is carried down
the oviduct a distance of four to six inches and finally comes to
rest in the uterus, where it is to dwell during the months necessary
to its complete development. The time consumed by this journey cannot
be measured accurately; it may be as short as a few hours or as long
as several days, but in all probability it is never longer than a
week. Although the element of time is uncertain the method of
transmission is well understood. Of its own accord the ovum can move
after fertilization no better than before; it is never capable of
moving itself. The active agent of transportation is the oviduct,
which has been fitted for this purpose with millions of short, hair-
like structures that project into its interior. These are closely set
upon the inner surface of the oviduct; their outer ends are free and
continually sway to and fro like a wheat field on a windy day; and by
their motion they create a current in the direction in which the ovum
should move, namely, toward the uterus. While passing through the
oviduct, the ovum has no attachment whatever to the mother, yet
development is going on all the time. It is thus made perfectly clear
that development is not directed by the parent. This independence of
the parent, though it continues to be one of the characteristic
features of the development of the ovum, shortly becomes less
evident, for communication is set up between the mother and the ovum
as soon as it reaches the uterus. Unless we were warned, we might
easily misinterpret the significance of this attachment to the
parent. It does not permit the mother, for instance, to influence the
mind or character which the child will have. The purpose of the
attachment is twofold, namely, to anchor the ovum, and to arrange
channels by which, on the one hand, nutriment may reach the embryo,
and, on the other, its waste products may return to the mother. The
mother may influence the nutrition of the fetus; but she cannot
determine the kind of brain or liver her child will have; neither for
that matter can she alter the development of any portion of the
embryo.

After its entrance into the cavity of the uterus prepared to receive
and protect it, the mass of cells sinks into the soft, velvety lining
of the organ. Here it is entirely surrounded by tissue which belongs
to the mother. But just before implantation takes place the
architecture of the ovum is modified in such a way as to indicate the
trend of its subsequent development. We left it, a hollow ball
passing down the oviduct; had we examined the sphere more closely we
should have found its wall composed of a single layer of cells. At
one spot, however, the wall soon thickens. The thickening is due to a
specialized group of cells which gradually grows toward the hollow
center of the ball. A little later, if we study the structure as a
whole, we find it a small, distended sac, from the inner surface of
which hangs a tiny clump of tissue. The clump of cells within and the
inclosing sac as well are both requisite to the ultimate object of
pregnancy; yet they fulfill very different purposes. The clump within
will mold itself into the embryo; the inclosing sac will make
possible the continued existence and growth of the embryo by securing
and conveying to it nourishment according to its needs. These two
structures, which from now on constitute the ovum, can best be
considered separately and in the order of their development. We shall
therefore first study the sac and in the next chapter the embryo.

For a time after this sac, or ball, as you may choose to think of it,
becomes implanted in the uterus, every part of its wall shares in the
responsibility of procuring nourishment for the embryo. On this
account the wall, or capsule, is for several weeks the most
conspicuous part of the ovum. Its position is naturally advantageous,
for, since it forms the outermost region of the structure and comes
into immediate contact with the tissues of the mother, it has the
first opportunity to seize and appropriate nutriment. Consequently,
while there is still relatively little development in the embryo, the
capsule of the ovum gives evidence of rapid extension; the wall
becomes thicker, and the circumference of the sac increases. The
significant thing about this growth, however, is the fact that it
does not progress evenly. At some points cell-division is more active
than at others, with the result that the surface of the ovum speedily
loses its smooth, regular outline. Projections from the capsule
appear; they increase in number and in length; and by the end of four
weeks the ovum, as yet less than an inch in diameter, resembles a
miniature chestnut-burr. To make the comparison more accurate, we
must imagine such a burr covered with limp threads instead of rigid
spines.

These projections, the so-called Villi, push their way into the
mucous membrane of the uterus and serve a two-fold purpose. One of
their functions is to fix the ovum in its new abode; and, though the
attachment is not at first very secure, it becomes stronger in the
course of time and is capable of withstanding whatever tendency the
activity of daily life may have to loosen it. The other, and equally
important, task of the villi, the majority of which dip into the
mother's blood, is to transmit substances to and from the embryo.

We have traced thus far the earliest steps in the development of the
ovum. One portion, we observed, was promptly set apart for the
construction of the future child; this favored portion became
inclosed by all the rest of the ovum, which has a more or less
spherical form and is technically called the fetal sac. The first
duty of the sac is to take root in the womb, and the second, no less
vital, is to draw nourishment from the mother. But neither of these
functions can be performed without the participation of the uterine
mucous membrane, the soil, as it were, in which the ovum is planted.
We must now learn how the maternal tissues assume the responsibility
placed upon them.

THE REACTION OF THE UTERUS.--The womb, which is small before
marriage, is converted by pregnancy into the largest organ of the
body. The virginal uterus, shaped somewhat like a pear, and placed
with apex downward, is carefully protected within the bony basin
between the hips, which is commonly called the Pelvis. The upper and
larger part of the organ, known as the body, lies at the bottom of
the abdominal cavity; the lower part, the neck, projects into the
vagina. The cavity inside the womb communicates above with the two
oviducts and terminates below in a canal which runs through the neck
and opens into the vagina by an orifice known as the mouth of the
womb.

Pregnancy modifies every portion of the womb in one way or another;
but the most profound alterations occur in the body, in the cavity of
which the ovum has come to rest. During the forty weeks of gestation
the organ grows in weight from two ounces to as many pounds; from
three inches in length it increases to fifteen inches; and its
capacity is multiplied 500 times.

The mucous membrane which lines the cavity of the uterus responds to
the stimulus of pregnancy in a characteristic manner and with a
single purpose, namely, to promote the development of the ovum. In
connection with menstruation we noted that this membrane periodically
prepares for the reception of an ovum. And if the expected ovum has
been fertilized, its arrival is followed by arrangements for its
protection and nutrition which are far more elaborate than the
preparations for its reception. Within a few weeks the mucous
membrane becomes half an inch thick, that is, about ten times thicker
than it was; and all the elements entering into its composition,
become unusually active. The blood-vessels are congested; the glands
pour out a more elaborate secretion; and certain cells lay up a
bountiful store of material to be drawn upon in the formation of the
embryo and the building up of the structures that promote its
development.

The ovum is as likely to find a resting place at one spot as another
upon the surface of the uterine mucous membrane. The whole of that
surface has been made ready to receive it; yet the area actually
required to imbed the tiny object is extremely small. As the ovum
escapes from the oviduct and enters the womb, it is smaller, in all
probability, than the head of a pin. For at least a week after its
coming, diligent search is necessary to find the site of
implantation. Insignificant as it is at first, however, the region of
implantation later becomes very prominent, for it undergoes a
transformation that the rest of the mucous membrane does not share.
That is to say, it becomes the point of attachment of the Placenta,
an organ that has the very important function of drawing upon the
resources of the mother's blood. As the ovum sinks into this
especially prepared bed, the villi are formed. They break open the
adjacent capillaries of the mother, thus diverting her blood from its
accustomed course. The blood collects in microscopic lakes in contact
with the capsule of the ovum, and from them flows back into the
mother's veins. Through the veins it returns to her heart, by which
it is distributed through the arteries to the various regions of the
body. The tiny lakes, in which the villi hang, are thus made a part
of the mother's circulation and as such are regularly replenished
with purified blood. By this means the ovum receives a rich supply of
nutriment, and as a natural consequence its growth is rapid.

Before very long the diameter of the ovum is greater than the depth
of the mucous membrane which surrounds it. Consequently that part of
the membrane which covers it is pushed into the uterine cavity, as
the ground is raised by a sprouting seed. Growth continues, the
bulging increases, and extensive alterations are wrought both in the
womb and in the capsule of the ovum. One of these alterations will be
more easily understood if we still think of the ovum as a seed, for
it grows away from its roots just as plants do. Most of the capsule,
therefore, is removed step by step farther from its source of
nourishment, for the maternal blood-vessels do not follow the
expanding sac but retain their original position at its base. Partly
on account of the lack of nutriment thus occasioned and partly on
account of the distention caused by the contents of the sac, atrophy
occurs in the distant portions of the sac's wall. As a final result
of these two factors, the maternal tissue which covers the ovum
becomes thinned and stretched; it is pushed entirely across the
uterine cavity; and by about the twentieth week meets the opposite
side of the cavity, to which it becomes adherent. Subsequently, the
sac which incloses the embryo becomes everywhere fastened to the
inner surface of the uterus and completely fills the uterine cavity.

THE AMNIOTIC FLUID.--The great enlargement of the uterus which is so
marked a characteristic of the latter part of pregnancy is due in a
measure to the luxuriant blood-supply, for better nutrition always
causes growth. In a far larger measure, however, it is due to
distention for which the product of conception is responsible. Beside
the fetus the inclosing sac also contains a considerable quantity of
fluid. This fluid, called "The Waters" by those who have no special
knowledge of anatomy, is technically designated as the Amniotic
Fluid.

In the earlier months of pregnancy the amniotic fluid is not
abundant; later it increases rapidly, so that by the end of the
period it measures about a quart, and frequently even more. The
slightly yellow amniotic fluid is itself clear, but small particles
of dead skin and other material cast off from the surface of the
child's body are floating in it, and may cause turbidity. The absence
of odor supports the view that this fluid is not the child's urine.
The evidence thus far adduced, though not absolutely conclusive,
gives good reason to believe that "the waters" are secreted by the
inner side of the sac which incloses the fetus. Very early in
pregnancy this sac becomes a double-walled structure; and, though its
layers are intimately blended, and together measure not more than
1/16 of an inch in thickness, with a little care they can be
separated. The outer layer, which comes in contact with the inner
surface of the uterus and has to do with the matter of nutrition, is
called the Chorionic Membrane; the inner, the so-called Amniotic
Membrane, is much the stronger and is devoted to the protection of
the embryo, which it completely surrounds with fluid, at the same
time retaining the fluid within set bounds.

The amniotic fluid performs many important duties. Perhaps the first,
in point of time, is to provide sufficient room for the embryo to
grow in. Later, as the fluid increases, it permits the fetus to move
freely, and yet renders the movements less noticeable to the mother.
Again, the amniotic fluid prevents injuries that might otherwise
befall the child in case the mother wears her clothing too tight.
Harmful as the practice of tight-lacing during pregnancy is, it does
not, thanks to the presence of the amniotic fluid, result in the
disfigurement of the child. For the same reason a blow struck upon
the abdomen, as in a fall forward, is not so serious as might be
thought, since the fluid, not the child, receives the force of the
impact. Some physicians believe that the fetus swallows the amniotic
fluid and thus secures nourishment. The fluid also serves to keep the
fetus warm; or, to be more exact, protects it from sudden changes in
the temperature of the mother's environment. Normally the temperature
of the fetus is thus kept nearly one degree higher than the
temperature of the parent.

Ultimately, the amniotic fluid assists in dilating the mouth of the
womb, which remains closed until the beginning of the process that
terminates with birth. The uterine contractions at the onset of labor
compress the fluid; in turn the fluid attempts to escape but is held
in check by the amniotic membrane, which it drives into the canal
leading from the uterine cavity to the vagina. Acting like a wedge,
the fluid gradually pushes the mouth of the womb wider and wider
open, until it is large enough for the child to pass. The sac usually
ruptures when that point is reached, the fluid escapes, and in due
time the child is born. This is followed within half an hour by the
extrusion of a mass of tissue--in reality the collapsed fetal sac--
which in every language, so far as I know, is named the After-Birth.
An examination of this tissue at the time of delivery repays the
physician, for it is important to ascertain that none of it has been
left in the uterus. Our interest at present, however, is to learn how
the after-birth has assisted toward the growth of the child.

THE PLACENTA.--The after-birth has puzzled scientists as well as the
laity, and not until comparatively recent times have its origin,
structure, and use been satisfactorily explained. Its meaning
profoundly interested primitive men and stimulated their imagination
scarcely less than the mystery of conception. Some uncivilized tribes
believed that the after-birth was animated like the child;
consequently they spoke of it as "the other half," and often saved it
to give to the child in case of sickness. But generally the after-
birth was buried with religious ceremony, and was occasionally
unearthed later to discover whether the woman would have other
children; the prophecy was made according to the manner of
disintegration or some other equally absurd circumstance.

The after-birth consists of a round, fleshy cake, the placenta, to
which two very essential structures are attached. One of these,
running from one surface of the cake, is a rope-like appendage, the
umbilical cord, which links the placenta with the fetus. The other,
attached to the circular edge of the cake, is a thin veil of tissue,
in some part of which a rent will be found. Now, if we lift the
margin of the rent, we shall see that the veil and the cake together
form a sac which we are holding by the opening. This aperture through
which the fetus passed, and it was really made for that purpose, was
formerly placed over the mouth of the womb; the sac itself, distended
by the fetus and the amniotic fluid, was fastened everywhere to the
inner surface of the womb.

It is plain that we have now in our hands the fetal sac, the
development of which we have already traced from the beginning. The
wall of the sac, it will be recalled, was originally of the same
formation throughout; but when the ovum became imbedded in the womb,
that part of its capsule which remained in permanent contact with the
mother's blood underwent special development, whereas the rest of the
capsule gradually pushed away from its primary position and, becoming
stunted in its growth, even lost to some degree the development it
had attained. This latter portion, the veil that passes from the edge
of the placenta, is formed of the two membranes we have mentioned,
namely, the chorion and the amnion.

The placenta is, for the most part, a highly developed portion of the
chorionic membrane, which became specialized simply because it
happened to receive the best supply of blood. At the time of birth
the placenta measures nearly an inch in thickness, is as large around
as a breakfast-plate, and generally weighs a pound and a quarter,
that is, approximately one-sixth of the weight of the child. This
relation between the weight of the placenta and of the child is
regularly maintained; therefore, the larger the child the larger the
placenta associated with it.

The placenta has two surfaces, easily distinguished from each other.
The raw maternal surface was formerly attached to the inside of the
uterus; the fetal surface, covered by the amniotic membrane, was in
contact with the amniotic fluid. Across the fetal surface run a
number of blood-vessels containing the child's blood, converging
toward a central point at which the umbilical cord is inserted. The
point at which the cord is attached affords the simplest means of
distinguishing the two surfaces of the placenta.

Our knowledge as to how the exchange of food and excretory products
between mother and child is carried on by the placenta has been
gained chiefly through the microscope. The oldest medical writings,
as we might suppose, express very fanciful ideas regarding the nature
of embryonic development and the means by which it is made possible;
no rational view of these matters could exist until the circulation
of the blood was described by William Harvey in 1628. After this
epoch-making revelation, it was accepted as true that the mother's
blood entered the unborn child and returned to her own system. But
that view eventually became untenable, for it was proved conclusively
that there is no communicating channel between the two. For years
after that, it was believed that before birth the womb manufactured
milk to sustain the child, just as the breasts do afterwards; but
this theory also was disproved; and, as I have said, only by the use
of the microscope have we learned the truth about fetal nutrition.

When thin slices of the placenta are magnified they are found to
contain countless numbers of tiny, finger-like processes; these are
the villi, and they constitute the major portion of the organ. The
villi seen in a mature placenta are the same as those which projected
from the capsule of the young ovum, but not these alone, for many
branches have sprouted from the original projections. The primary
trunks with all their branches hang from the capsule of the ovum and
extract nutriment from the mother's blood which surrounds them, just
as the roots of a tree extract it from the soil.

The interchange of material between mother and child as carried on in
the placenta can, perhaps, be made clearer if we compare one of the
trunks and its branching villi to a human forearm, hand, and fingers.
The hand, we will imagine, is held in a basin of water, in which, by
turning on a spigot and leaving the outflow unstopped, we have
arranged that the water changes constantly. In terms of this
illustration, the water corresponds to the mother's blood, rich in
oxygen, mineral matter, and all other kinds of essential nutriment;
and the fingers are the villi. The blood-vessels in the fingers, to
go a step farther, represent the blood-vessels which exist within the
villi, connecting with the umbilical cord, and passing by that route
to the body of the child. The blood which thus circulates through the
villi, it is important to emphasize, is the child's blood; it cannot
escape through the coating of the villi, just as our blood cannot
escape through the skin of the fingers. Similarly, the mother's blood
cannot enter the child; the two circulations are absolutely separate
and distinct.

It must be noticed, moreover, that the maternal blood not only brings
to the surface of the villi everything the child needs, but it also
takes away the waste products of fetal life. Let us select one of the
foodstuffs necessary for the unborn child, and follow its course so
far as it relates to fetal nutrition. The mother's blood brings
sugar, for example, from her intestinal tract to the surface of the
villi; through the coating of the villi the sugar passes into the
fetal blood, is carried to the fetal heart, and distributed to the
various fetal organs. They burn it, deriving heat and energy, and in
return give off waste products, namely, carbonic acid gas and water,
which are taken up by the fetal blood, borne back to the placenta,
and pass again through the coating of the villi into the mother's
circulation. These waste products are then transported to the
mother's lungs and to her kidneys, and are finally thrown off from
her body. Before the child is born, therefore, the placenta, which is
an aggregation of villi, acts as its stomach, intestines, lungs, and
kidneys.

In every pregnancy the placenta serves in this way as an organ of
nutrition, arranging for the passage of food from the mother's blood
to the fetal circulation. Occasionally, it is interesting to observe,
the placenta performs a very different function, namely, the
protection of the unborn child from diseases that may attack the
mother. It is able to afford such protection, because the coating of
the villi is not permeable to all sorts of substances. In order to
pass through their walls, material must be in solution; solid bodies,
therefore, are denied admission to the fetal circulation. The most
significant result of this restriction is, perhaps, that so long as
the coating of the villi remains intact and healthful, bacteria
cannot gain access to the unborn child. Since in health there are no
bacteria in the mother's blood, this fact has no bearing upon the
average pregnancy; but in those exceptional cases in which typhoid
fever or some other infectious disease appears during pregnancy, it
is gratifying to know that Nature has provided an unusual defense
against infection of the unborn child.

That we do not know all about the interchange of substances between
mother and child must be admitted; but the essential facts, and they
alone are of interest here, have been established beyond contention.
There is no doubt whatever that the mother's blood surrounds the
placental villi but never enters the child. The fetal blood, on the
other hand, is first in the child's body, then in the villi, and then
returns to the child again. It never enters the blood-vessels of the
mother but passes to and from the placenta as long as pregnancy
lasts.

THE UMBILICAL CORD.--This rope-like structure, familiarly known as
the navel-string, which connects the placenta and the fetus, is
approximately twenty inches long; its length, therefore, is
sufficient to permit the newly born child to lie between the mother's
knees while the placenta remains attached to the womb. The cord is
about the thickness of the thumb and contains three blood-vessels,
all filled with fetal blood; in two of them the current is directed
toward the placenta, the third carries the blood back to the fetus
after it has circulated through the placental villi. In the cord the
vessels lie near together and are encased in a jelly-like substance
that protects them from injury.

So far as is known; the umbilical cord performs no service other than
to link the blood-vessels in the placenta with those in the fetus.
Simple as this may seem, it is of paramount importance in maintaining
the life of the fetus, for compression of the vessels in the cord
would shut off its nutriment. Against such accident, however, perfect
provisions have been made; both the amniotic fluid and the jelly-like
substance which surrounds the vessels are safeguards which
effectually protect the circulation from pressure that might
interrupt it.

Frequently, prospective mothers are told they must not "reach up" for
fear the cord will become entangled. Such a precaution is quite
unnecessary. No matter what the mother does, or does not, the cord
will be found around the child's neck at the time of birth in one of
every three cases. It is not difficult to understand how this
happens. The cord is longer than the uterine cavity and must fall in
coils toward the bottom of it. Now, since the fetus is free to move
it enters and withdraws from these loops, many times, in the course
of pregnancy. Finally, when it takes up a position head downward, as
it nearly always does, the head is the part of the fetus which passes
through the coil, should one happen to lie in its path. After the
head is delivered the physician always feels about the neck to
discover whether a loop of cord is there. If it is, he can release it
easily. This condition, since it occurs so frequently and since it so
rarely produces harmful consequences, should not be considered
unnatural.

After the child is born, the physician cuts the cord, and in due time
the after-birth is expelled through the same passage as was the
child. The expulsion of the after-birth frees the mother of all the
tissue derived from the growth of the ovum, for the intricate
mechanism that served to nourish and protect the embryo was almost
entirely developed from the ovum itself. It is a remarkable provision
of Nature that very little of the mother's tissue is cast off at the
end of pregnancy; and even this small portion is promptly replaced.
By about the sixth week after delivery, the wound which was made by
the separation of the fetal sac has completely healed. Meanwhile the
mucous membrane that underwent elaborate preparations to receive the
ovum, the cavity that was adjusted to its growth, and the muscle
fibers that were strengthened to insure its safe entry into the world
have all regained their original state. Except for the activity of
the breasts, the mother is left in the same physical condition as
before she became pregnant.




CHAPTER III


THE EMBRYO

The Development of Form--The Determination of Sex--Twins--The Rate
of Growth--The Newborn Infant--Heredity--Maternal Impressions.

The new human being begins existence, as I have shown, as soon as the
ovum is fertilized, though at that moment it consists merely of a
solitary cell formed by the union of the two parental cells. From a
beginning relatively simple the human body develops into the most
complex of living structures; and, startling as it may appear to be,
it is demonstrably true that every one of the millions of cells which
compose an adult has descended from the ovum. Furthermore, the
individual himself is not the entire progeny of the ovum; the
placenta and the membranes dealt with in the preceding chapter, we
saw, were also derived from that same source. They possess only a
transitory importance, to be sure, and to most persons they are less
interesting than the embryo, yet we gave them consideration before
discussing its growth because the manner in which the ovum becomes
attached to the womb and draws nutriment from the mother primarily
determines the fate of a pregnancy.

Now that we have become familiar with the arrangements for the
protection of the embryo, we are prepared to learn how it develops,
and may accept the phrase, embryonic development, to cover the whole
period of existence within the womb. In a more technical sense,
however, the use of the term _embryo_ is limited to the first
six weeks of pregnancy and designates the condition of the young
creature before it has acquired the form and the organs of the
infant; after that time the unborn child is called a _fetus_.
Embryonic development, therefore, in the strictest sense of the term,
chiefly involves the shifting of various groups of cells and the
bestowal upon them of different kinds of activity. During this period
comparatively slight growth takes place. By about the twentieth week,
the house, it may be said, is set in order; and there follows a
period marked by the rapid growth of the fetus.

THE DEVELOPMENT OF FORM.--A very old explanation of embryonic
development was that the process consisted altogether in growth.
According to that view the embryo lay curled up in the egg; at the
outset it was equipped with organs, limbs, features, and all the
other bodily structures found in an adult. In order that the ovum
might be transformed into a mature infant, only unfolding and growth
were required. After the microscope came into use, however, so simple
an explanation could no longer be accepted. Scientists soon realized
that the embryo did not exist "ready made" in the ovum, which, even
when magnified, failed to bear the faintest likeness to a human
being.

Although the microscope made impossible this very simple explanation,
it gave in return a truer, if more complex, account of the
transformation from egg to offspring. By this means it has been
definitely proved that the ovum multiplies rapidly after it has been
fertilized, and becomes, as was explained in the preceding chapter, a
sac-like structure within which hangs a tiny clump of tissue. This
inner mass of cells forms the embryo.

It has proved a difficult task to secure very young human embryos,
and many of the ideas we hold relative to the initial stages in the
development of man are based upon what has been found true in certain
mammals, the class of animals to which we belong. The youngest human
ovum known at present has already undergone about two weeks'
development, and there the embryo is represented by a flat disk. From
this stage to the stage of complete development a satisfactory series
of embryos has now been collected, but it is impossible to give here,
even in outline, a description of the evolution of the human embryo.
No one can understand this intricate subject without the aid of
diagrams, models, and other material beyond the reach of all save
laboratory workers.

By the end of the second month the development of the embryo has
advanced so far that anyone could recognize its human shape. About
that time, too, the external sexual organs make their appearance. At
first these are quite similar in both sexes; and, if they are used as
the criterion, it is possible only toward the end of the third month
to say whether the embryo is a male or female.

THE DETERMINATION OF SEX.--The fact that a number of months pass
before the sex can be distinguished by an external examination of the
fetus has led to the erroneous belief that it can be influenced
during the early part of pregnancy or actually determined at will.
Various means to accomplish this have been suggested; many of them
depend upon modifying the mother's mode of living according as a boy
or girl is desired. The most widely known of these doctrines, that of
Schenck, was to the effect that the sex of the offspring is always
that of the weaker parent. He suggested, therefore, that increasing
the vigor of the mother by an appropriate diet would produce a male
child, whereas a decrease in her strength would lead to the opposite
result. His views, however, were incorrect. After studying extensive
statistics Newcomb came to the conclusion that "it is in the highest
degree unlikely that there is any way by which a parent can affect
the sex of his or her offspring."

Moreover, the results of experimental research clearly indicate that
we shall never possess the means by which a mother may control the
sex of her child. In the main laboratory investigations have sought
to answer two questions. First, at what time is the sex of the
offspring determined? and, second, what accounts for the origin of a
male in one instance and of a female in another? The study of these
problems has been carried on chiefly in connection with insects,
worms, and fowl; but as yet insurmountable difficulties have
prevented similar investigations in higher animals. For this reason,
it is not without the greatest caution that results thus far obtained
may be assumed to apply to man.

Sufficient facts, however, have been collected to admit no doubt
regarding the answer to the first question. In most animals it is
definitely known that the sex of the offspring has been fixed when
the male cell enters the female cell, in other words, at the instant
the ovum is fertilized. Excellent reasons exist for believing that
human beings conform to this rule, and that the sex of the child is
unalterably determined at the moment conception occurs. Consequently,
any attempt to influence it after that event must prove futile.

For the present, the second question cannot be answered with equal
assurance. More than five hundred theories have been offered to
explain the relation of sex; nearly all of them have no reasonable
foundation and are only of historical interest. The view that girls
are derived from the right ovary, boys from the left, has long since
been disproven, and deserves mention merely because the laity still
believe it. Happily, during the last few years, observations and
experiments have been made which greatly advance our knowledge of the
subject and give promise of an early solution of the problem. The
controlling factor in sex determination has been narrowed down to
three possibilities; it is inherited either from the single cell
contributed by the father or from the single cell contributed by the
mother, or it is determined by the effect these two cells have upon
each other at the moment when they unite. In most animal species the
weight of authority distinctly favors placing the whole
responsibility upon the male cell.

According to recent evidence, there are two kinds of male germinal
cells; one kind giving rise to female offspring and the other to
male. In all probability, at the time of the marital relation, these
varieties are deposited in the vagina in equal numbers; and,
moreover, the mode of their production is such as to place absolutely
beyond human control the possibility of changing this ratio. Since
only one spermatozoon enters the ovum, whether or not the child will
be a boy or a girl depends entirely upon which type gains entrance.
If this explanation is correct, and it is in accord with careful
biological observations, it removes from the mother all
responsibility for the sex of her child. Furthermore, since the facts
indicate that male-producing and female-producing spermatozoa are
present in equal numbers, it follows that practically there is an
even chance that an embryo will develop into a boy or a girl.

Birth statistics bear out this conclusion, as data gathered from many
countries indicate that when long periods of time are studied 105
boys are born with a surprising regularity for every 100 girls. Thus,
the records of Berlin, Germany, for a hundred years show that the
maximum difference occurred in 1820, when the males outnumbered the
females by 4.79 per cent.; the minimum difference, which was noted in
1835, was .64 per cent. in favor of boys.

No inquiry is more often submitted to the physician by prospective
mothers than this, "Can you tell me if my baby will be a boy or a
girl?" He cannot. Many rules, to be sure, have been advocated as safe
guides toward reaching the correct answer; every midwife possesses
her individual formula which she has "never known to fail." But the
boastful success depends upon the application of some such method as
the following, which I have heard my teacher, Dr. J. Whitridge
Williams, expose to his classes. The patient is asked if a boy or
girl is desired. She confesses, and is then informed that the sex of
her child will be the opposite of her wish. When this guess proves to
be correct, there is no doubt of the prophet's wisdom; when it is
not, his honor is protected, for the parents have had their hope
fulfilled. Their happiness makes them forgetful that the guess was
wrong, or, for that matter, that it was ever made.

It was once believed that the sexes might be distinguished before
birth by the number of heart beats occurring within a minute. In a
general way, the action of this organ in females is somewhat more
rapid than in males; and so it was thought that a rate of 144 or more
indicated the female and a rate of 124 or less the male sex. But
experience has taught that this rule leads to accurate prophecy in no
more than half of the cases. As a matter of fact, no means of
definitely foretelling the sex of the child has been discovered, and
I doubt if it ever can be.

TWINS.--As every one knows, pregnancy commonly terminates with the
birth of a single child. Twins appear in approximately only one of
ninety pregnancies, while triplets are extremely rare. It is true
that even quintuplets may occur, though up to 1904 only 29 authentic
instances could be collected from the whole range of medical
literature.

Twins are most frequently born to parents whose ancestors have
established this tendency; the trait is usually inherited from the
mother's family, though occasionally it is passed on through the
father. Of course, that does not explain the cause of twins, which in
reality may result from either of two circumstances. More commonly
their genesis depends upon the ripening of two eggs at about the same
time and the fertilization of both by two different spermatozoa. The
children, in this instance known as double ovum twins, may be of the
same sex or not. On the other hand, single ovum, or identical, twins
are always of the same sex; this follows, since but one egg and but
one spermatozoon are here concerned. The incident permitting twins to
develop from a solitary ovum must occur soon after conception has
taken place. It will be remembered that the first step in the
development of the fertilized ovum consists in its dividing into two
cells. Ordinarily, both these take part in the development of one
embryo, but occasionally they separate and give rise to two.
Frequently, the presence of twins can be recognized during the latter
months of pregnancy, and accurate means are known of determining
after they are born to which variety any given pair belongs.

THE RATE OF GROWTH.--When we recall the definite and often marked
differences in the physical character of women, such as weight and
height, it is surprising to learn that the prenatal development of
their children proceeds with uniform speed. One very practical result
is that the physician is thus enabled, at the birth of a premature
infant, to estimate accurately the period of its development. Various
criteria, some of which are easy of application, aid in this
determination. For example, the length of the child is practically
constant for each of the ten lunar months into which the whole
gestation period is divided; if, therefore, the length of the newborn
infant is known, the stage of its development can always be inferred.
From the fifth month the calculation is especially simple, since the
length measured in centimeters divided by the figure 5 gives the
month to which pregnancy has advanced. Similarly, we can infer the
period of development from the weight, though the calculation is more
intricate and the method less reliable, inasmuch as the size of the
child in the latter months varies somewhat according to the weight of
its mother.

At the end of the fifth month, the weight of the fetus is from nine
to ten ounces; whereas an average infant when born at the expiration
of the full term of pregnancy, that is, with the completion of the
tenth month, weighs about seven pounds. The fetus, therefore,
acquires roundly ninety per cent, of its weight during the second
half of pregnancy, which clearly indicates that Nature reserves this
period of gestation for the fetus to increase in size, a phenomenon
less mysterious but no less important than the evolution of the
embryo.

Nothing is more valuable than the weight in affording an indication
as to whether a prematurely born infant may be reared. It is unusual
to raise a child weighing less than four pounds, which corresponds
approximately to the end of the eighth lunar month of development (a
trifle more than the seventh calendar month). After this time, the
prospect of living becomes greater in proportion to the nearness with
which the infant has approached maturity. No truth exists in the
widespread belief that the seventh-month child is favored above that
born later but before the natural end of pregnancy. Experience has
taught that the probability of success in rearing the child increases
rapidly after the seventh month. This is reasonable on the following
somewhat theoretical grounds. The digestive organs later attain a
higher state of perfection, and are better prepared to carry on their
work satisfactorily. Moreover, the gradual deposition of fat beneath
the skin during the last two months of pregnancy materially assists
in fitting the child for the conditions met with in the external
world, since the fat affords a barrier against the escape of heat
generated within the body, making it much easier to keep the child's
temperature at the normal point. Even other more technical reasons
could be given to demonstrate the error of the superstition regarding
the seventh-month child--a conviction endorsed by medical men
hundreds of years ago and as yet not discarded by the laity.

When pregnancy has reached "term," the child, having completed its
prenatal development, is ready to cope with conditions as they exist
in the external world. At term the average child is twenty inches
long and weighs 7 1/7 pounds (3,250 grams). The length is remarkably
constant; but the weight, as is well known, is often somewhat above
or below the average figure. In a general way, smaller children occur
in the first than in subsequent pregnancies, and, moreover, may be
expected when the mother is a small woman, or poorly nourished, or
has worked hard during her pregnancy. On the other hand, a tendency
to bear large children is present when the opposite conditions
prevail. It is not unusual to see infants weighing eight or nine
pounds at birth, but babies of more than ten pounds are rare, and the
fabulous, though not infrequent, reports of fifteen and twenty-pound
infants are probably not based upon actual weighings, but upon the
impression of someone who has merely seen the child or perhaps
guessed the weight from lifting it.

Although the fetus frequently changes its position during the earlier
months of pregnancy, generally by the beginning of the tenth lunar
month it has assumed a permanent posture. It has then reached such a
size that it can best be accommodated in the cavity of the uterus if
its various parts are folded together so as to give the fetus an
ovoid shape. To secure this form its back is arched forward, and its
head bent so that its chin touches its chest; its arms are crossed
just below the head, its legs raised in front of the abdomen, and its
knees doubled up. In this form the fetus occupies the smallest
possible space.

With relation to the mother the position of the child, for several
weeks before birth, is one in which its long axis is parallel to the
long axis of her body. This remains true no matter whether the head
or the buttocks are to precede at the time of birth. In ninety-seven
out of a hundred cases, however, the head lies lowermost and
consequently is the first portion of the child to be born. The
opposite position, in which the head is the last portion born, is,
even with the most skillful treatment, somewhat more serious for the
infant, though not for the mother.

THE NEWBORN INFANT.--The baby at birth is not a miniature man. As
compared with an adult its head and abdomen are relatively large, its
chest relatively small; its limbs are short in proportion to the
body; and at first glance it appears to have no neck at all. The
middle point of a baby's length is situated about the level of the
navel, whereas in a man the legs alone represent approximately half
his height. The changes after birth consist chiefly in growth; but
not altogether, since at least one organ, the thymus gland, becomes
smaller and completely disappears during childhood, and other organs,
especially the liver, are proportionately smaller in the adult than
in the infant.

The body of the infant also differs from that of the man in
possessing greater softness and flexibility. These qualities depend
upon the nature of its skeleton, which is composed of more bones than
later in life, when several have fused together to form one to give
the mature body a more rigid frame. Furthermore, the individual bones
are not so firm, consisting of an elastic material called cartilage,
so that some movements which in an adult would cause such serious
injuries as fractures and dislocations are perfectly harmless to a
newborn child.

The legs are not only short in proportion to the body but are always
curved, and the feet are held with the soles directed toward one
another, a position clearly abnormal in the adult. But every mother
should know that these are natural conditions in the infant, and are
the result of the posture of the child before birth. They soon
straighten out. The bowed legs of an adult are of an entirely
different origin, resulting from a disturbance of nutrition in
infancy called rickets.

A small amount of short wooly hair is usually found over the back of
a newborn infant. More conspicuous, however, is the presence there of
a gray, fatty substance which, though always more abundant over the
back, is at times distributed over the whole body; rarely is it
entirely absent. The material, technically named the vernix, is the
product of the glands in the skin and is a perfectly normal
secretion. After its removal, which is readily accomplished by
greasing the infant with lard or vaselin before giving the initial
bath, it never reappears.

A varying amount of hair covers the head of the infant. No
significance should be attached to the quantity, for the conviction
that exists, especially among negroes, that a heavy suit of hair for
the child occasions "heart-burn" in the mother during pregnancy is
without foundation. The color of the hair at birth does not indicate
its ultimate shade; changes are often noted during infancy. Similarly
the permanent color of the eyes is not assumed until later; at the
time of birth the eyes are generally, if not always, blue in color.

A baby's head is a matter of great concern to the family.
Occasionally, the skull is round and well shaped from the moment of
birth, but more often it is long and narrow; sometimes the form is
even startling to the inexperienced. The peculiar shape of the head
results, of course, from its passage through the birth-canal and is
not a sign of any disease. In a few weeks, or even less, the strange
appearance passes away. It is unwise to attempt to alter the shape of
the head by bandaging or massaging since the growth of the brain will
spontaneously accomplish what is desired; interference can do no
good, and may do serious harm.

Nature facilitates an appropriate molding of the head during birth so
as to permit its easy passage through the bony pelvic cavity of the
mother, and gains that end in two ways. The bones of the head remain
pliable until after the infant is born, and, further, their edges are
not welded together as in an adult, but are separated from one
another by an appreciable distance. During the act of birth the edges
are brought into contact or even overlap, materially reducing the
size of the head. Within a few hours after birth the bones again
spread apart, and some months elapse before they begin to unite; the
union is not completed until some time during the second year of
infancy.

Many mothers are anxious to know how far the senses of the infant
have developed when it enters the world. This problem has stimulated
some scientific investigation, though hardly so much as its interest
would justify. Two lines of inquiry have been pursued toward its
solution. The objective point of one of these has been to determine
how nearly the sense organs of the newborn correspond anatomically to
those of an adult; that is how perfectly has their organization been
completed. The other has been to learn how the infant reacts when the
various senses are stimulated; the interpretation of these reactions
is, however, particularly liable to error and sometimes amounts only
to guesswork.

The organization of the nerves and muscles in the eye is far from
perfect at the time of birth. The muscles act irregularly; indeed,
the lack of muscular adjustment is such that movements of the eye
likely to alarm the parents are regularly observed in very young
infants. Furthermore they cannot focus images which fall upon their
eyes. The retina, which receives visual impressions, has reached such
development at birth, however, that sensations of light can be
perceived. For example, if a lamp is suddenly flashed before the face
of a newly born baby it cries. From this and similar evidence,
indicating that strong light irritates the delicate structures of the
eye, we have learned that a nursery should not be illuminated, during
the day or night, so brightly as the rooms adults occupy. Certainly
several weeks, and probably several months, pass before an infant can
see anything save as blurs of light and darkness. Objects, such as a
hand, probably appear as shadows, which are not correctly interpreted
until late in infancy.

In regard to color vision we have as yet no reliable information
concerning children under two years of age. Infants of less than a
year have been known to distinguish certain colored papers. But such
discrimination is probably due to a difference in brightness of the
colors.

Although the organ of hearing is well developed at birth, the drum of
the ear in very young infants cannot transmit sounds, as in the
adult. For the latter kind of transmission it is necessary that the
pressure on both sides of the drum-membrane should be equal, and this
is arranged by the admission of air to the middle ear through a
passage from the throat. At the time of birth, on account of the
swollen condition of the mucous membrane which lines this passage, it
is blocked, and the middle ear is filled with fluid; these conditions
interfere with the transmission of sound, and consequently its
perception is dulled. But even in the absence of a drum-membrane an
adult can hear; the vibrations in such cases are transmitted through
the bones of the skull, and this very likely also occurs in newly
born infants. In most instances, at least, they react to a
disagreeable noise within the first twenty-four hours, and their
sensitiveness in this direction explains why the nursery should be
kept quiet.

Investigators have not come to uniform conclusions concerning the
sense of smell and of taste. In all likelihood, smell is not acute at
the time of birth. Taste probably is better perceived, yet some
newborn babies are said to suck a two per cent solution of quinin as
eagerly as milk, though stronger solutions are distasteful. According
to the best available information a young infant can detect the
difference between a sweet, bitter, sour, or salty taste only when
the tests are made with a solution possessing the quality in question
to a marked degree. It is common knowledge that babies cheerfully
suck the most tasteless objects, and it is not improbable that at
first the reaction depends upon the temperature of the object and the
feeling it creates in the mouth.

The moment it is born, a baby perceives pressure if its skin is
touched. To this sensation, however, some parts of the body are much
more sensitive than others; the tongue and lips are most sensitive of
all. Heat and cold are probably perceived more acutely by infants
than by adults; to pain, on the other hand, babies are less
sensitive. An infant is aware of the movements of its own muscles,
and also appreciates a change from one position to another, as
experienced nurses know very well, and on that account carefully
avoid keeping a baby on one side continuously.

The vast majority of movements performed by young infants are reflex
acts, that is, the cerebrum, the part of the brain with which
thinking is done, is not concerned with their performance. Of these
reflexes the most notable are sucking and swallowing, but sneezing,
coughing, choking, and hiccoughing may also be observed; stretching
and yawning have been recorded in several instances, even during the
first days of infant life. None of these movements, we must remember,
are produced consciously; the baby cannot reason and does not
recognize anyone, even its mother.

HEREDITY.--The transmission of bodily resemblance and of traits of
character from parent to child is a broad and complicated subject,
whose fundamental principles biologists are just beginning to grasp.
The facts thus far established regarding heredity relate chiefly to
plants and to the lower animals. There is no doubt whatever that the
meager knowledge we possess of heredity in man will be amplified and
will ultimately indicate on the one hand the marriages which are
advisable and, on the other hand, those which are not. Indeed, the
foundations for a science called Eugenics, which purposes to improve
the human race in this way, have already been laid. It is barely a
decade, however, since our knowledge of heredity has approached that
order and system which entitle it to be ranked as a science; and in
this brief period great strides could hardly be expected in its most
intricate field, that of human inheritance.

The modern teachings of heredity are of interest to us, nevertheless,
since they intimate the time when a child's inheritance is fixed and
the means by which hereditary characters are conveyed. To understand
these fundamental points we must recall that at the moment of
conception a male germinal cell combines with a female cell, and that
this act, which is named fertilization, brings together vital
elements from the two parents. We have seen that the spermatozoon
represents the solitary contribution of the father toward the
development of the child, and the spermatozoon, therefore, must
convey the material basis of paternal inheritance. Similarly we might
expect the ovum to be the bearer of the maternal qualities inherited
by the child. This is actually true; but much of the evidence is of a
technical character and must be omitted. Yet an experiment
successfully conducted by Castle and Phillips will indicate, even to
those who have no special knowledge of the mechanism of heredity, the
important role the ovum plays. These investigators removed the
ovaries from an albino guinea-pig, and in their place substituted the
ovaries of a black guinea-pig. "From numerous experiments it may be
emphatically stated that normal albinos mated together produce only
albinos." But in this experiment the result was otherwise, for the
albino into which the ovaries of a black guinea-pig were grafted
produced only black offspring. The color-coat of her young,
therefore, was not influenced by her own white hair, but was
determined by the eggs really belonging to the black animal from
which the ovaries were taken; in no other way can the result be
interpreted. It is certain, moreover, that the mode of transmission
of material qualities here exemplified is not exceptional; on the
contrary there is no doubt that the ovum always conveys the sum total
of the qualities the offspring inherits from the mother.

The germinal cells then contain the material basis of inheritance,
and in all probability the substance is located within the nucleus of
the cells. This substance had been seen and studied long before its
relation to the problem of heredity was suspected. Because it takes a
deeper stain than the rest of the nucleus, it stands out prominently
when the cell is treated with certain dyes, and this property
accounts for its name--chromatin. Under such conditions as prevail
just before a cell divides, the chromatic substance is broken up and
reassembled in the form of rods called chromosomes. Curiously enough
the number of rods is uniform for each species of animal, though
different numbers are characteristic of different species; the
characteristic number for man is twenty-four.

Unless some arrangement was made to prevent it, the act of
fertilization would cause the number of chromosomes in the fertilized
ovum to be double the number characteristic of the species. In man,
for example, the addition of twenty-four chromosomes from the
spermatozoon to an ovum that already contained twenty-four
chromosomes of its own would mean that after fertilization the ovum
contained forty-eight. Such a result is prevented through the process
to which we have referred in the preceding chapter as the ripening of
the ovum, and also through a similar process in the case of the
spermatozoon. These two processes lead to a reduction in the number
of chromosomes, so that finally every human germinal cell contains
twelve, and therefore when the ovum is fertilized the characteristic
number twenty-four is restored. While we know nothing of the forces
which determine, on the one hand, what elements shall be discarded by
the germinal cells and, on the other hand, what elements shall
remain, it is definitely proved that a selective process always takes
place. This fact admirably explains the variation in the
characteristics inherited by children of the same family. So far as
is known, the traits which will be passed on from either parent are a
matter of chance. Whatever these hereditary traits happen to be, the
best evidence we have indicates that the problem of a child's
inheritance is settled once for all the moment conception takes
place.

MATERNAL IMPRESSIONS.--Contrary to all that we know of heredity, the
conviction prevails among the laity that the character of a child
depends greatly upon the mother's surroundings during pregnancy: this
is the doctrine of maternal impressions. As is usual with
superstitions, this one emphasizes the unfavorable possibilities and
holds that the unborn child may be affected by the mother's unhappy
thoughts or maimed by her mental distress if she is exposed to
unpleasant sights. For this belief there is no foundation; the cases
often cited in its support may be fully explained on the grounds of
coincidence.

With the possible exception of such individuals as are spending their
lives in solitary confinement, there is scarcely a human being who
has not in the course of nine consecutive months some untoward
physical or mental experience which engraves itself upon the memory.
Prospective mothers are not apt to be exempt from a rule so general
in its application, but if by good chance one happens so to be she
will hardly fail to hear of the misfortune of others, which,
according to the doctrine of maternal impressions, may be equally
effective in interfering with the proper development of the child. We
should then rightly expect most, if not all, babies to be "marked"--
clearly a situation which does not prevail.

In order to learn how frequently prospective mothers may have
disagreeable experiences which they fear will affect the formation of
the child, I have lately asked the patients whom I have attended,
"Was there any incident during your pregnancy to which you could have
attributed the infant's condition, had it been marked?" The babies of
all those to whom the question was submitted were normal; yet without
exception those whose pregnancies just completed were their first
answered in the affirmative. It is also pertinent that one of these
patients had lost her brother by a violent and accidental death when
she was four months pregnant; a similar bereavement was suffered by
another at the eighth month; each was, however, delivered of a
perfectly healthy child. Among those with whom the recently ended
pregnancy was not the first I found some who could remember incidents
popularly believed to have an influence over the development of the
embryo; most of them, however, had given the matter so little thought
that they could not definitely recall whether such incidents had
occurred or not. From a similar series of observations covering two
thousand cases, William Hunter came to the conclusion, nearly two
hundred years ago, that there was no support for the belief in
maternal impressions.

Whenever a child does happen to develop abnormally, it must be clear
that, from the very nature of our existence, some incident can be
recalled which will satisfactorily, yet unjustly, bear the blame. It
may be confidently said, however, that, for every mother whose fears
are realized, hundreds are agreeably disappointed in finding their
babies perfectly normal. In the face of so many negative instances it
is amazing that any person, even though ignorant of medical teaching,
should be inclined to attribute abnormal development to something the
mother has seen or heard, thought or dreamt, or otherwise experienced
while she was pregnant. Yet unfortunately many do believe this. It is
worth while, therefore, to supply further evidence, and thus escape
any suspicion of unfairness in argument, to prove that maternal
impressions are unable to affect the formation of the embryo.

It is found, as a matter of experience, that the superstition
regarding maternal impressions generally begins to cause anxiety
during the second half of pregnancy; and then such an influence is
entirely out of the question. By the end of the second month the form
of the embryo has been definitely determined, and subsequently cannot
be altered. It is even true that errors in development are most apt
to occur within the two or three weeks that immediately follow
conception, and therefore occur at a time when pregnancy is not often
clearly recognized. Thus it happens that women begin to worry about
the influence their minds will have upon the formation of the child
long after its form has been established.

Incidents in the life of a prospective mother are in point of fact
equally inert so far as their influence upon development is
concerned, no matter whether they occur during the earlier or later
part of pregnancy. There is never any anatomical means by which
maternal impressions could be conveyed to the embryo. Such an
influence would have to be exerted through the placenta; and that is
impossible. There are no nerves in the placenta to carry impulses
from the mother to the child. Even the blood streams of the two
beings are kept apart; and though it is unheard of that the blood
should carry nerve impulses, if that happened to be the case, it
could not prove effective here, for the blood of the mother does not
enter the child. It is nourished by food which passes from the
mother's blood, to be sure, but there is no more reason to expect
this nutriment to exert an hereditary influence than there is to
expect an infant to grow to resemble the cow with the milk of which
it is fed. With these two possibilities eliminated, no path can be
imagined by which impulses might travel from the mother to the
embryo.

Scientific investigation has brought to light these facts, as it has
also taught the real causation of the disfigurement once attributed
to the mother's mind. Departures from the usual form of the body
occur during the earliest days of pregnancy and arise in consequence
of some irregularity in the process which molds the body-form from a
simple spherical mass of cells. Why irregularities sometimes occur is
not altogether clear; except in so far as it has been determined that
the fault lies within the embryo itself. Whenever these defects are
associated with events which have disturbed the mother's mind, it
cannot be other than a simple coincidence.




CHAPTER IV


THE FOOD REQUIREMENTS DURING PREGNANCY

The Food-stuffs: Water; Mineral Material; Protein; Carbohydrate; Fat--
What We Do to Our Food--How Much Food Is Needed During Pregnancy?--
The Importance of Liquid Nourishment--The Choice of Food--Cravings--
The Relation Between the Mother's Diet and the Size of the Child.

There is a gain in weight during pregnancy amounting finally to about
thirty pounds; exceptionally, it is as little as ten or fifteen
pounds, and, at the other extreme, as much as forty or fifty. With
individuals inclined to be stout the increase is greater, and it is
relatively greater in later pregnancies than in the first. During the
early months of pregnancy the weight generally remains stationary or
suffers a slight loss; even in those rare instances in which the
weight begins to increase shortly after conception the gain is less
marked in the earlier months than later. For the last three months
the average monthly gain has been found to be between three and a
half and five and a half pounds.

The weight gained during pregnancy is not, as can be readily
understood, permanently retained. At the time of birth, in
consequence of the expulsion of the child, the after-birth, the
amniotic fluid, and a varying amount of blood, there is necessarily a
loss of from ten to fifteen pounds. Later, as the maternal tissues,
whose growth has been stimulated during pregnancy, return to their
original condition, a further loss in weight takes place. It is not
unusual, however, for women to remain permanently better nourished
than before they became pregnant. Under ordinary conditions the food
of the prospective mother provides not only for her own wants but
also for those of the embryo. Between the two organisms there exists
a relation which resembles that existing between a house in course of
construction and the contractor who supplies the building material.
The mother furnishes what is needed to construct the "living
edifice," as Huxley called the growing embryo, but she is not
responsible for the lines of the building. The embryo is both
architect and mechanic, designing the structure and arranging the
"organic bricks" in their proper places. The work of construction
necessitates the expenditure of an appreciable amount of energy and
the creation of waste products that must be removed, lest they
accumulate and interfere with the growing structure. These waste
products leave the embryo by way of the umbilical cord and the
placenta and return thus into the mother's circulation; ultimately
they leave the mother through the same channels that carry off her
own waste. First and last, then, the nutrition of the mother and of
the child are so bound together that it has been impossible to study
them separately. Our knowledge of food requirements during pregnancy
has been obtained by measuring the food requirements of the mother
alone; and as nutrition during gestation is fundamentally the same as
nutrition at other times, it is necessary for us first to consider in
general the food needed by the human body.

THE FOOD-STUFFS.--The waste products we throw off indicate that the
substances which compose our bodies are being constantly broken down
and reduced to a condition such that they are useless to us. In
normal persons hunger signifies that they need material to replace
what has been used up. The substances thus required, if the wants of
the body are to be satisfied correctly, are called the food-stuffs;
and they are the same during pregnancy as at other times. The
foodstuffs are usually classified according to their chemical
properties; on this basis they are placed in five groups: (1) Water,
(2) Mineral Materials, (3) Proteins, (4) Carbohydrates, (5) Fats.

In view of the different purposes which the foodstuffs serve, it is
convenient to group them in another way. Thus, the carbohydrates and
the fats may be placed together because they are the body fuel; their
value consists in the heat and energy which they yield when acted
upon in the tissues. Water and mineral matter, on the other hand, are
never a source of energy; they assist in building new tissue or in
repairing tissue that already exists. The proteins are unique, in
that they may serve either purpose. Primarily the proteins are
tissue-builders, but in the absence of sufficient fat or carbohydrate
the body burns protein to secure heat and energy.

Each food-stuff, therefore, serves a distinct purpose, and some of
them render services which the others cannot perform. A man will die
if either water or mineral matter or protein is completely withdrawn
from his diet. Fat or carbohydrate, on the other hand, or even both
of them, may be excluded for some time without causing serious
inconvenience. It is true, nevertheless, that each food-stuff
performs some task better than any of the others can perform it, and
for that reason all of them should be included in the diet of an
healthy individual.

Some of the food-stuffs, such as water and table salt, come to the
body separate from the others; but generally the different types
reach us intimately mingled in the various articles of food in common
use. Foods vary greatly, however, in the amount of the different
food-stuffs they contain. The meats, for example, have a relatively
large protein content; in the vegetables starch, which is one of the
carbohydrates, predominates. As to the choice of food and the amount
that is necessary for the average person, generally the appetite is a
safe guide; but the accurate observations of physiologists have gone
so far as to determine the exact requirements of the body. Not the
least important principle taught by these investigations is to avoid
dietary fads, for in arranging a satisfactory diet the problem to be
solved is not, What is it possible to live on? but, What serves best
as nourishment? The experience of countless generations has taught us
that we thrive best on a diet which includes all five food-stuffs.

_Water_ constitutes nearly two-thirds of the weight of the body.
As water is constantly being given up in the life process, health
demands an abundant supply of liquids to replace the waste. The
average daily loss has been found to be between two and three quarts.
Of this amount the urine constitutes nearly two-thirds; and the
remaining third is eliminated through the skin, the lungs, and the
bowels. Although the deficiency thus created is met in part by the
water in our solid food, the greater part of the loss is made up by
the liquids we drink, and we are warned, in a measure, by the
sensation of thirst that they are needed.

_Mineral material_ is of the greatest importance as a
constituent of our food. It contributes to the welfare of the body in
at least three ways; (1) it gives rigidity to the bones, (2) it
supplies an essential ingredient of the living substance in all the
tissues, (3) it is present in the blood and in the other body fluids,
where it is of service in such vital processes as the beating of the
heart, the transportation of oxygen to every portion of the body, and
the maintenance of an acid or alkaline condition of the digestive
juices according as the one or the other is necessary for the
assimilation of the food.

An animal deprived of mineral food will die as surely as one deprived
of water. In arranging our diets, however, we are not compelled to
take the minerals into account, for, with the exception of table salt
(sodium chlorid), the meat and vegetables that we eat provide the
mineral material the body requires. Iron, for example, which imparts
to the blood one of its most essential qualities, occurs in
relatively large amounts in apples, spinach, lettuce, potatoes, peas,
carrots, and meats. Only now and then does it become advisable to add
iron deliberately to the diet. Similarly lime (calcium) the material
that makes the bones hard, is present in quantities ample for the
needs of the body in the bread, milk, eggs and vegetables that we
eat. The remaining mineral constituents of the body, among which the
most conspicuous are magnesium, potassium, sulphur, and phosphorus,
occur in foods which we are naturally inclined to take, so that we
secure an abundance of them unconsciously.

_Protein_, the third food-stuff which we must eat to keep alive,
contains the chemical element nitrogen in such form that it can be
incorporated in our tissues. Although most persons derive their
protein in part from meat, milk, and eggs, it is possible to satisfy
the requirements of the body on a purely vegetarian diet. Experience
has shown, however, that it is both natural and advantageous that we
employ a mixed diet.

The property of protein to build living tissue and replace tissue
waste probably depends upon several factors; but certainly one of
them is the presence of nitrogen. So intimately associated are the
consumption of the tissue substance and the elimination of nitrogen
that we have no better way of judging the amount of tissue substance
used in the body than by determining the quantity of nitrogen that
appears in its various waste products. From such investigations it
has been found that the quantity of protein required to repair the
breaking down of the tissues is not great. The average man consumes
approximately a quarter of a pound (100 to 120 grams) of protein
daily; but this quantity is in excess of his real needs. Indeed,
Chittenden has shown that for various classes of individuals, namely,
students, athletes and soldiers, half as much is sufficient. Other
physiologists, though admitting that this is true, contend that it is
inadvisable to regulate one's diet on such a slender basis. Very good
reasons are assigned for the view that more protein is needed than
just enough to counterbalance the tissue waste. Thus, in the case of
animals, it has been found that a diet low in protein finally causes
digestive disturbances and other ailments.

Although it does not seem advisable to practise rigid economy in
arranging the protein content of the diet, it is equally important
that we should not go to the other extreme. The consumption of over-
large quantities of protein, as would be the case if we lived
exclusively upon meat, increases putrefaction in the intestines and
throws unnecessary work upon the kidneys, which are the organs
chiefly concerned in getting rid of the waste products of protein.

_Carbohydrate_ is the name given the group of foodstuffs to
which the sugars belong. The food value of cane sugar, the most
familiar member of the group, was recognized even in prehistoric days
by the natives of India. By boiling the plant we call sugar-cane they
obtained a substance to which they gave the name Sakkara, and from
this our word sugar evidently originated. The roots of this plant
were carried into Europe and cultivated during the Middle Ages.
Obviously, its value was and is appreciated, since the cultivation of
the sugar-cane and the sugar-beet has become the foundation of a
great modern industry.

There are some persons, perhaps, who do not realize that beside cane
sugar many kinds of carbohydrate occur in our food. Glucose or grape
sugar, for example, occurs not only in the fruit indicated by its
name, but also in other fruits, in corn, in onions, and in the common
vegetables. Glucose is especially suited to act as nourishing food.
In keeping with that fact our digestive juices convert most of the
sugars we eat, if not all of them, into glucose, which is regularly
present in our blood. It is unnecessary to enumerate all or even the
more important compounds included in the carbohydrate group; but
everyone should know that starch is its chief member, and that after
being thoroughly digested starch enters the body as glucose and
therefore serves the same purpose as sugar.

The value of carbohydrates as a source of heat and energy may be
accurately measured, and is technically expressed in terms of a unit,
called the calorie. As the energy which our bodies require may be
estimated in the same terms, it is possible to determine whether or
not our food is equal to our wants. Very naturally the energy
requirements of any individual are influenced by his weight and by
the work he does. But we may take as a standard the results of an
extensive study of American families which indicate that women
require four-fifths as much energy-yielding food as men. It also
seems safe to conclude that a woman weighing 130 pounds who does her
own housework requires food every day having an energy-value of 2,500
calories; smaller women and those who do no work require somewhat
less. In a mixed diet the chief source of this energy--and the source
from which it is most economically obtained--is the carbohydrates.

_Fat_ yields more energy and heat than does carbohydrate, bulk
for bulk; but fat is burned by our tissues less readily. We
instinctively avoid eating a great deal of this food-stuff; in the
course of a day the average person consumes no more than one or two
ounces. The natural aversion which many feel toward fat may possibly
depend upon the difficulty with which they assimilate it. In colder
climates, however, we know fat to be a staple article of diet; and it
is not unlikely that the very conditions which make it necessary
there explain the unusual tolerance for it.

Fat is more than fuel. Deposited in our bodies, beneath the skin for
example, it prevents the escape of heat that we generate and protects
us against the penetration of cold. This food-stuff, therefore,
contributes in several ways toward maintaining the temperature of the
body at a constant level.

Our source of fat is chiefly animal food and in a smaller measure
vegetables; but the fat our food contains is not altogether
responsible for the fat in our bodies. Carbohydrates, if in excess of
momentary needs, are partly converted into fat and stored as such. A
reserve supply of nourishment is thus provided, and is drawn upon
only when the food that we consume does not contain as much energy as
we expend.

WHAT WE DO TO OUR FOOD.--With the exception of water and mineral
substances, the food-stuffs must undergo chemical alterations before
they are capable of being absorbed into the body; this is the work of
digestion. The digestive processes, the main purpose of which is to
break up the carbohydrates, proteins, and fats into substances of
much simpler chemical structure, begin in the mouth and are not
completed until some time after the food has entered the intestine.
As the food moves through the alimentary canal, it is mixed with the
various digestive juices containing ferments, such as pepsin, which
are the active agents of digestion. Although digestive processes go
on automatically, they are, in a degree that is far from negligible,
influenced by the mind. Thus, cheerfulness promotes digestion, and
not infrequently mental depression may be the direct cause of
indigestion. Indeed, it is chiefly in regard to the state of the mind
of the prospective mother that the existence of pregnancy may be said
to have a bearing, whether favorable or unfavorable, upon her
digestion.

The digestive juices are prepared in glands which lie either within
the lining of the alimentary canal or adjacent to it. In the latter
event the glands are connected with the canal by means of tubes.
These glands must be warned when to pour out their secretion, and
their very first warning usually comes from the agreeable sensations
experienced when we see, smell, or taste inviting food. If we are
hungry, our viands attractive, and our surroundings congenial, the
stimulus excites a plentiful secretion of the digestive juices;
conversely, the opposite conditions, to some extent, check their
flow.

The sight of attractive food, as we all know, "makes the mouth
water," that is, it calls forth the saliva which contains one of the
digestive ferments. Thus, at the beginning of a meal, favorable
conditions for digestion are established. The saliva, however, acts
only upon starch; and, moreover, its action upon this carbohydrate is
weak unless the food is thoroughly chewed and mixed in the mouth.
Most of us, perhaps, overlook the importance of mastication, which
not only crushes all the food-stuffs, preparing them for efficient
digestion, but also stimulates the flow of the digestive juices.
Furthermore, by thoroughly masticating our food, we know intuitively
when we have had enough, and thus avoid overeating.

In the stomach the digestion of starch is continued for a time, but
the chief work of gastric digestion concerns the proteins. They alone
are attacked by pepsin, a ferment secreted by the mucous membrane of
the stomach. Moreover, since pepsin is able to act only when an acid
is present, the gastric mucous membrane also secretes hydrochloric
acid.

Just as the digestive glands in the neighborhood of the mouth become
more active when we are conscious that desirable food is at hand, so
do the glands in the stomach. Mastication also stimulates the flow of
the gastric juice, and this flow is greater if we enjoy what we eat.
Furthermore, it has been shown that, after entrance into the stomach,
the food itself increases the flow of the digestive juices. All
articles of food are not, however, equally efficient in producing
this effect: thus meat requires more pepsin for satisfactory
digestion than bread, and consequently meat calls forth a larger
quantity of gastric juice.

Fat in all probability is not digested in the stomach; even starch
and protein are not broken down sufficiently by the time gastric
digestion is complete to permit them to be absorbed into the body.
"The value of digestion in the stomach," as Howell says, "is not so
much in its own action as in its combined action with that which
takes place in the intestine." It is even possible for satisfactory
digestion to take place without the assistance of the stomach. This
fact has been substantiated by several cases in which men have lived
for years after the stomach was removed to eradicate a disease. It is
true, nevertheless, that intestinal digestion can be performed more
economically if it begins where gastric digestion normally leaves
off.

Of the changes wrought in the food by the various digestive
processes, those which are the most profound take place in the
intestine. While the food is being moved through this organ--some
thirty feet in length--it is reduced to simple chemical fragments,
which are absorbed by the intestinal wall. Digestion in the intestine
is carried on through the agency of a number of ferments, the more
important of which are supplied in the juice manufactured by the
pancreas. The pancreatic secretion contains three separate and
distinct ferments, which act respectively upon carbohydrate, protein,
and fat. The absorption of fat, however, is materially assisted also
by the action of the bile.

A part of what we eat always escapes digestion; the unused portion,
it has been estimated, is somewhat less than one-tenth of an ordinary
mixed diet. The residue from vegetables is notably larger than the
residue from meat. The _undigested_ portions of all the food-
stuffs collect in the lowermost portion of the intestine and form a
part of the feces. Here also are gathered the _indigestible_
material we have eaten, the products of bacterial decomposition in
the intestine, and other waste substances that the body should throw
off.

HOW MUCH FOOD IS NEEDED DURING PREGNANCY?--In connection with the
development of the child we have already referred to the difference
in the purpose of the constructive processes which go on in the
earlier months of gestation and those which take place in the later
months. In a general way the first half of pregnancy is occupied with
the formation of the embryo from relatively simple structural
elements, the second half with its growth into an infant, which
acquires ninety per cent. of its substance and weight at birth after
the fifth month of embryonic development. A similar contrast may be
observed in the nutritional processes of the mother. Often, at the
beginning of pregnancy, the appetite is poor and there is
indisposition of one kind or another, with the natural result that
there is slight if any change in the mother's weight; whereas later a
period ensues when her appetite increases, her health improves, and
she gains in weight.

Since it is natural that the weight of the mother should remain
practically stationary during the early months of pregnancy, it is
clear that a diet which has previously been ample will likewise be
sufficient for some time after conception has taken place. To most
persons, however, it is not clear that the quantity of food
ordinarily eaten will suffice also during the later months of
pregnancy. On the contrary, popular opinion holds that the
prospective mother "should eat for two." It is not unimportant to
point out the erroneous character of this superstition, because
overeating during pregnancy is much more likely to provoke discomfort
than insufficient nourishment.

In order to comprehend the nutritional needs of the prospective
mother, one must keep in mind the fact that our food always serves
two purposes. These are, as we have seen, to build or to repair
tissue and to furnish heat and energy. Since these needs of the body
during pregnancy--as at all other times--are best understood when
considered in their relation to the food-stuffs which supply them, we
shall take up these various ingredients separately.

Protein, which repairs tissue and also furnishes the substance from
which new tissue is made, is used more economically during pregnancy
than when the maternal functions are inactive. As a result of this
economy the same allowance of protein which is sufficient before
conception is sufficient also during pregnancy. This fact has been
put in the clearest light by extensive observations made upon
animals. Dogs which were not pregnant, for example, have been
carefully fed so that their food should contain just enough protein
to cover the needs of the body and keep their weight constant.
Subsequently, when these animals became pregnant precisely the same
amount of protein was fed to them. The result was that they gained in
weight, and at the same time the waste products of protein they threw
off were notably diminished. Such observations, of which there have
been a large number yielding concordant results, may be safely taken
to mean that an amount of protein previously satisfactory for the
animal is also sufficient for her during pregnancy. We are forced to
conclude that protein was used more sparingly in the latter
condition--a view which has been repeatedly confirmed with regard to
human beings as well as animals. It is found, for example, that an
amount of protein competent to meet the needs of a man of a given
weight will not only provide for the wants of a woman of equal weight
while she is pregnant, but will also leave a surplus sufficient for
the growth of the fetus.

With regard to the mineral substances, likewise investigations
indicate that the "housekeeping" of the body during pregnancy
proceeds along unusually economic lines. It is not advisable,
therefore, to make any change in the diet with regard to these
substances. Attempts have been made to cut down the amount of
minerals in the food for the purpose of softening the fetal skeleton.
The success sometimes attributed to these efforts is, however, very
doubtful, for we know that the mother's tissues will be robbed of
minerals for the embryo whenever her food fails to contain them in
sufficient amount for her own needs and those of the child.
Practically speaking, the mineral content of diet during pregnancy
requires no thought, for so long as meat and vegetables are eaten in
satisfactory quantity the mineral nutrition will take care of itself.

The food-stuffs which supply heat and energy, since the amount of
energy utilized by the body during the latter months of pregnancy is
somewhat in excess of that previously required, do not follow the
same rule as the protein and the mineral matter. It has been found
that just before the fetus becomes mature the energy requirements of
the mother are approximately one-fifth greater than in the non-
pregnant condition. It is certain, however, that no extra demand for
energy exists until the fifth or sixth month of pregnancy, and that
the excessive requirement is extremely small until the last three or
four weeks. Even then the prospective mother requires less energy-
giving food than the average man.

Since the body handles carbohydrate more readily than fat, it is
preferable that whatever additional energy pregnancy necessitates
should be supplied by carbohydrates. An increase in the daily
consumption of fatty food, over and above that previously found
agreeable, is not only unnecessary but undesirable. Every-day
experience teaches that less fat taken with the meals promotes the
comfort of the prospective mother. A glass of rich milk a little
before meal time, however, not only makes up for this omission but
also prevents "heart-burn," a very common ailment of pregnancy.

Although there is an appreciable increase in the quantity of starch
and sugar utilized toward the end of pregnancy, it is generally quite
unnecessary to increase these materials correspondingly in the diet.
Nearly everyone eats more of all the food-stuffs than the body needs.
In the case of the prospective mother the surplus ordinarily taken
meets every need incident to her additional energy requirements.
Because we eat more than we need, someone has said, with as much
truth as humor, that prospective mothers "neither want nor need to
eat for two. The fact is more likely that enough for one is too much
for two." For the average woman it is wiser to take less during
pregnancy rather than more, for over-indulgence is apt to lead to
indigestion. The moment when the appetite is satisfied should be
accepted as the stopping point, and that will be instinctively
recognized if one eats deliberately, and thoroughly masticates the
food.

Regularity in the hour of eating is always healthful, and for some
prospective mothers three meals a day prove quite satisfactory. Not a
few, however, who adhere to this habit make the mistake of eating
more than is wise; and large meals are particularly inappropriate to
pregnancy. On this account most prospective mothers will be more
comfortable if they take some simple and wholesome nourishment at
fixed times between meals. Such an arrangement modifies a ravenous
appetite, and it is, at the same time, beneficial to those who are
not inclined to eat enough at the regular meals. If small amounts of
food are taken five or six times a day, a tendency to be nauseated,
which is not uncommon in the early months of pregnancy, can often be
averted. In the latter months, too, because the capacity of the
stomach is diminished through the encroachment of the enlarged womb,
frequent meals generally contribute toward comfort and health. While
the inevitable consequences of overloading the stomach are to be
avoided at all times of the day, it is especially important to
remember the disagreeable results of a hearty meal at night. The
evening meal should be a light one and should be eaten three or four
hours before going to bed.

THE IMPORTANCE OF LIQUID NOURISHMENT.--Every prospective mother
should have brought to her attention the great importance of drinking
water at regular times and in larger quantities than was formerly her
custom. Since water constitutes two-thirds of the substance of our
bodies, it is necessary, of course, for everyone; but during
pregnancy it is especially necessary for the building of new tissue
and for safeguarding the mother's kidneys. Prospective mothers would
protect themselves against a number of ailments if they were more
careful to drink a sufficient amount of liquids. They may easily
determine whether they are doing so, for whenever the urine passed
during twenty-four hours measures less than a quart, they are not
drinking enough. Generally the daily elimination of urine fluctuates
between two and three pints; a larger amount, however, is rather a
favorable indication than the reverse.

The variations in the quantity of liquids that healthy persons drink
make it impossible to say just how much anyone should take. It may be
said with confidence, however, that women who are pregnant should
consume at least three quarts of fluid every day, and by far the
greater portion of this should be water. The rest may be taken in the
form of milk, soup, cocoa, and chocolate. Against the moderate use of
tea and coffee no valid objection can be raised; the tradition that
they may cause miscarriage is incorrect. For well-known reasons the
habitual use of strong tea or coffee is always harmful, and it is,
therefore, equally as objectionable during pregnancy as at other
times. Beverages which contain a small percentage of alcohol, such as
malt and beer, may or may not be helpful; they should be regarded as
medicine, not to be taken without consulting a physician.

THE CHOICE OF FOOD.--There is no diet specifically adapted to the
state of pregnancy; the prospective mother may usually exercise the
same freedom as anyone else in the selection of food. She should,
however, choose what will agree with her and avoid that which she
cannot digest and assimilate. Personal experience in the main must
guide everyone as to what to eat, and most women may follow the
dictates of appetite after they become pregnant as safely as they did
before.

It is true, of course, that careful scientific observations have
taught not only what the nutritional requirements of the body are,
but also how the diet may be arranged to satisfy these requirements
most conscientiously and economically. "Caloric Feeding" is the name
given the method which aims to furnish an individual the exact amount
of food, and usually to furnish it at a minimum cost. Its principles
are of great practical importance to the commissary of an army or to
the purveyor of an institution which provides for large numbers of
people; but it is neither necessary nor advisable that the diet of
any healthy individual be regulated solely with a view to satisfying
the actual requirements of his or her body. Food should possess other
qualities than fuel value: first of all it must be appetizing, for
appetizing food receives the most thorough digestion.

We all know how variable are our appetites. What appeals to one will
not appeal to another, and frequently the same person has no appetite
to-day for food that she will eat with relish to-morrow. Precise
rules, therefore, to guide healthy persons in the selection of their
food are not obtainable; neither are they desirable, for the exercise
of individual preference possesses notable advantages. In order,
however, that there may not also be disadvantages, the prospective
mother, like anyone else, must be content to choose food that is
simple, wholesome, and of such a character that it will not throw an
undue burden upon the digestive organs.

During pregnancy some uncooked food should be eaten every day. Ripe
fruit answers the purpose admirably. At all seasons of the year fruit
of one variety or another, such as apples, peaches, apricots, pears,
oranges, figs, cherries, pineapples, grapes, plums, strawberries,
raspberries, and blackberries may be obtained and should have a place
in the diet. In making a choice personal taste alone need be
consulted.

Fruit contains a large proportion of water as compared with other
articles of diet; and, therefore, is especially capable of quenching
thirst. Fruit also lessens the desire for sweets, acts as a laxative,
and furnishes mineral material which the body needs. Its laxative
effect is most pronounced when it is eaten alone, as, for example, in
the morning before breakfast or at night upon going to bed; cooked
fruit taken with the meals acts much less effectively. Fruit and
vegetable salads are wholesome, but cannot be recommended
indiscriminately during pregnancy, for not infrequently the dressing
used with them causes discomfort. Under these circumstances it is
obvious that one should do without salads.

The cereals wheat, corn, rye, oats, and barley are the most prominent
source of starch in an ordinary diet. Breakfast foods manufactured
from grain are not only nutritious in themselves, but their value is
increased by the milk or cream used with them. Bread is the staple
starch-containing food in this country, and starch is our main source
of energy, but it is necessary to eat only a small quantity of bread,
if the diet includes a relatively large amount of vegetables. It is
advantageous to use bread made from unbolted flour (Graham bread) or
from corn meal, because the coarse undigested residue which they
leave stimulates the movements of the intestine and assists in
overcoming the constipation which is generally associated with
pregnancy. Pastry must be avoided by those who suffer from
indigestion; and every prospective mother should eat pastry only
occasionally, and not very much of it at any time. The best desserts
are raw and freshly cooked fruit, preserves, gelatin, custard, ice
cream, and light puddings, such as rice and tapioca.

Vegetables should be abundant in the diet of every prospective
mother. Some of them, however, are digested with difficulty, and on
this account cabbage, cauliflower, corn, egg-plant, cucumbers, and
radishes should be eaten sparingly. Occasionally it will be necessary
to exclude them from the diet altogether. Other vegetables produce
flatulence, and for that reason parsnips and beans may cause
discomfort. The prejudice, however, which exists against onions,
asparagus, and celery should not be heeded; all of them are harmless,
and celery thoroughly cooked with milk is very wholesome. Besides
these, moreover, there are many highly nutritious and easily
digestible vegetables which can be freely recommended, such as both
sweet and white potatoes, rice, peas, lima beans, tomatoes, beets,
carrots, string beans, spinach, Brussels sprouts, and lettuce.

Vegetable food contains all the material necessary to sustain life,
and some persons prefer to adhere strictly to a vegetarian diet. Most
prospective mothers, however, find a mixed diet more agreeable, and
this is sufficient reason for using it. Furthermore, no fair
objection can be raised against the use of animal food, provided the
pregnancy is normal. It is important, nevertheless, to remember that
meat contains protein in concentrated amounts, and that meat once a
day answers every need not only of the mother but also of the growing
fetus.

The ideal animal foods are milk and eggs; they contain every
ingredient necessary to repair old and to form new tissues. But
usually the prospective mother may have any animal food she wishes:
beef, veal, lamb, poultry, game, fish, oysters, and clams. The
relatively large fat-content of pork, goose, and duck renders them
indigestible for some persons, who, of course, should not eat them.

From what we have learned about foods in general and their relation
to pregnancy it is clear that the question so often asked by
prospective mothers, "Are there any special directions regarding my
diet?" may be briefly answered as follows: Under no circumstances is
the need of food increased in the first half of pregnancy. During the
last two or three months, while the most notable growth of the fetus
is in progress, there is a perceptible increase in the amount of
energy expended by the mother, and this may be readily supplied by a
glass of milk or some equally simple nourishment between meals.
Furthermore, throughout pregnancy, most women are made most
comfortable by frequent small meals; they will almost certainly
suffer discomfort if heavy meals are eaten three times a day.

The most nearly ideal diet consists of very little meat and a
comparatively rich allowance of vegetables and fruit. The food should
be chosen with regard to individual appetite and should be varied
frequently. Thorough mastication always increases the efficiency of a
diet. Thus the food will be most perfectly mixed with saliva and
broken into fragments which can be readily attacked by the digestive
juices of the stomach and the intestines.

CRAVINGS.--There is a well-known tradition that women who are
pregnant are subject to longings for one article of diet or another,
and that unless the desire be promptly gratified the child will be
"marked." In the light of what has already been said regarding
maternal impressions, this evidently is nonsense. A prospective
mother, like anyone else, does frequently desire one article of food
more than another. So long as the object of her wish is not obviously
harmful, it should be granted; but if it is not granted no harm will
come to the child.

Remarkable instances in which disgusting substances have been craved
and eaten are often talked about and have even found their way into
popular novels. The unfortunate victims of these unnatural cravings
are not of sound mind. With reference to them a physician of
unusually broad experience wrote fifty years ago, "I have never met
with any example of this sort; which leads me to infer that these
longings are more frequent in books than in the practice of our art."
This conclusion is even more fully justified to-day than when
originally expressed.

THE RELATION BETWEEN THE MOTHER'S DIET AND THE SIZE OF THE CHILD.--
With the beginning of careful, scientific study of the nutritional
problems of pregnancy, investigators were interested to learn the
source of the material which was used to build up the child's body.
Two possibilities suggested themselves: one that the material came
from the mother's food and the other that it was derived from her own
flesh. In order to determine which of these methods was the natural
one, animal experimentation was resorted to and gave identical
results in the hands of independent observers. It was found, as I
have already stated, that the same diet which had previously kept an
animal's weight constant was sufficient to meet her requirements
during pregnancy and also to provide for the growth of her offspring.
The mother animal was actually found somewhat heavier at the
termination of pregnancy than at the beginning. It seemed fair to
conclude, therefore, that nutrition had proceeded along more economic
lines, and that under these conditions the customary diet had
furnished the material for the formation of the young. Still other
observations indicated that, if the food is not sufficient for both
mother and offspring, it is Nature's plan to protect the young and
leave the mother's wants incompletely satisfied. On the other hand,
when an unnecessarily large amount of nourishment is taken, the
excess is stored partly in the young, and partly in the mother's
body.

There can be no doubt that the results of such observations upon
animals are applicable to human beings. Everyone familiar with the
practice of obstetrics knows that women who gratify enormous
appetites during pregnancy, especially if they also fail to take
exercise, give birth to large children. On the other hand, it is said
that children born during times of famine are frequently delivered
prematurely, or, if mature, they are small and puny. A similar though
much less marked contrast exists between the babies of the working
classes and the well-to-do, and clearly indicates that the weight of
the baby varies directly with the food of the mother.

The quantity of the food is more influential than its quality, though
the latter is also a factor in determining the size of the child. An
excessive amount of starch or sugar in the mother's diet is stored as
fat in the child. On this account it is reasonable to eat sparingly
of candy, cake, and other sweets; but further attempts to reduce the
weight of the fetus by discrimination against different articles of
food are not advisable.

The various theories that have been advanced with a view to reducing
the size of the child are impracticable; some of them, rigidly
carried out, would actually jeopardize the health of both beings. All
of them are designed to make the infant's bones soft and to diminish
the fat in its body. To this end, generally about two months before
the expected date of birth, the mother's diet is arranged to consist
chiefly of meat; and as far as possible she is denied candy, sweet
desserts, soup, bread, cereals, vegetables, and water. Such a diet
overlooks, among other things, the tremendous importance of liquids
to the woman who is pregnant. Certainly its indiscriminate use would
result in far more harm than good; and no one should adopt it without
minute directions from a physician.

Attempts to make the infant's bones soft by limiting the mother to
food containing extremely small amounts of lime and other minerals
are also unnatural, for we have learned that whenever the mother's
food fails to contain the material the fetus requires the mother's
tissues are called upon to supply it. Under these conditions,
therefore, her bones will give up their lime.

It is of the very first importance that the mother's nourishment be
correct from the standpoint of her own requirements, and such
treatment will also redound most beneficially to the child. She
should never fall, however, into the error of over-eating, which will
not benefit her and will cause unnecessary growth of the fetus. On
the other hand, there can be no justification for measures that tend
to weaken her. She may be careful, in other words, to avoid over-
growth of the fetus, but should not adopt a diet so restricted as to
interfere with normal development. So long as her health is
successfully maintained, she may give herself no concern as to what
the size of the child is likely to be. That is a detail which
concerns her physician, and which will be observed by him several
weeks before the expected date of birth.




CHAPTER V


THE CARE OF THE BODY

The Bowels--The Kidneys--The Skin--Bathing--Douches--Clothing--
Corsets--The Breasts.

If we stop to think it is only too apparent that the human body is a
machine. We seize energy in one form and convert it into another,
just as truly as do the windmill, the locomotive, and the dynamo. In
the case of the human machine, the latent energy of the food is
turned into the various activities of everyday life. Our bodies
utilize their fuel more perfectly than any machine that man has
invented; but they fail, nevertheless, to do so completely. And just
as the efficiency of an engine cannot be maintained unless the smoke
escapes and the ashes are raked away, so no human being can enjoy
health unless his waste products are promptly removed. The task of
removal, as most of us know, is assumed by our excretory organs,
which include the bowels, the kidneys, the skin, and the lungs.

During pregnancy the mother must get rid not only of her own waste
products, but also of those of the child. The waste products of the
child, if weighed, would not amount to a great deal; but they are by
no means negligible. So far as we can tell, it is chiefly on account
of their peculiar character that they increase the work of the
mother's excretory organs. Whatever the cause, they do increase it,
and experience has taught us that these organs must always be kept in
a healthful condition to protect both the mother and the child from
harm. Consequently a prospective mother who wishes to take proper
care of her body must, in the first place, direct her attention
toward keeping up the normal activity of all the excretory functions.

THE BOWELS.--While pregnant, nine out of ten women suffer from mild
constipation. Those who have been previously troubled with this
complaint may find it aggravated from the outset, but in most
instances it does not appear until after several months have passed.
Constipation is explained by the fact that the enlarged womb presses
against the intestines; and, as the enlargement increases,
constipation generally becomes more pronounced. No doubt there was a
time when women, perhaps unconsciously, counteracted this natural
result of pregnancy by the use of a diet consisting largely of fruit
and vegetables and also by outdoor exercise. Such measures, indeed,
still afford the simplest means of overcoming constipation.

Throughout pregnancy the bowels should move at least once every day.
When they do not, some of the waste material that should be removed
is absorbed by the body and seeks to leave it through the organs that
are already doing their full share of work. For example, under such
conditions, the kidneys, instead of exerting themselves more
vigorously, may become less active than they were.

It is everyone's duty to form the habit of having the bowels move
regularly. Now the most favorable opportunity for assisting the
intestines to empty themselves occurs shortly after meal-time, since
the involuntary movements of the intestines are most active while
digestion is in progress. It should be regarded as an imperative
duty, therefore, to grant Nature such an opportunity every morning
just after breakfast. This should be done at a definite hour, day
after day, even though the inclination is absent; and in many
instances the desired habit will be formed.

A glass of water on going to bed or on getting up has a laxative
effect; and there are other dietary measures which may be employed
with advantage. Thus, coarseness of the food, as we know, stimulates
intestinal activity, and this fact explains the peculiar value of
Graham bread, bran bread, and corn bread. Fresh fruit and vegetables
counteract constipation for two reasons, namely, because they leave
in the bowels a relatively large amount of undigested substance, and
because they contain ingredients that have a specific purgative
action. Such ingredients are especially noteworthy in rhubarb,
tomatoes, apples, peaches, pears, figs, prunes, and berries.

Enemas used as a routine measure are mischievous. They interfere with
the "tone" of the bowel-muscle so that it acts sluggishly and bring
about a condition in which the bowels will not move without
artificial stimulation. At best these irrigations remove no more than
the contents of the lower bowel, and should be employed only when
there is acute and urgent need of clearing out the rectum.

Obstinate constipation is uncommon, and strong purgatives are seldom
needed. If they become necessary, a physician should be consulted as
to what to take. Whenever dietary measures and exercise, which is
discussed in the next chapter, fail to counteract the natural
tendency toward constipation, the prospective mother may generally
resort to "senna prunes" or some equally simple and harmless
household remedy. Senna prunes are prepared as follows: Place an
ounce of dried senna leaves in a jar and pour a quart of boiling
water on them. Allow to stand two or three hours; strain off the
leaves and throw them away. To the liquor add a pound of prunes.
Cover and place on the back of the stove, allowing to simmer until
half the liquor has boiled away. Add a pint of water and sweeten to
taste, preferably with brown sugar. The prunes should be eaten with
the evening meal. The number required must be learned from
experience. Begin with half a dozen, and increase or decrease the
number, as required. The syrup is an even stronger laxative than the
prunes.

THE KIDNEYS.--Any one may judge for herself whether or not the bowels
are doing their work satisfactorily, but not so with the kidneys. For
this purpose the urine must be examined by a physician. In spite of
this fact, considerable responsibility rests upon the prospective
mother, whose duty it is to collect the specimens properly--a detail
that is apt to be neglected. It is impossible to urge too strongly
the importance of saving, at regular intervals, all the urine passed
in twenty-four hours, of protecting it from decomposition, and of
sending a sample to the physician. The intervals may be longer at
first, for the kidneys have very little extra work to do until the
sixth month. Usually, therefore, it is a satisfactory plan to send a
sample for analysis the first of each month during the early half of
pregnancy; but during the latter half one should be sent the first
and the fifteenth of each month.

To estimate the exact amount of urine passed in twenty-four hours and
to protect it properly, in the first place, the vessel in which it
will be collected should be carefully scalded out. As a further
precaution against decomposition, add a teaspoonful of chloroform to
the vessel, which should be kept covered, and not allowed to stand in
a warm room. Unless these details are conscientiously observed,
putrefaction may take place and vitiate the analysis the physician
wishes to make. The precise amount of urine which the kidneys excrete
in twenty-four hours will be determined as follows: At a convenient
time, for example at 8 A.M., empty the bladder and throw the urine
away; this marks the beginning of the observation. Subsequently, save
all the urine passed during the day and night, and finally at 8
o'clock the next morning empty the bladder and add this urine to that
previously collected. The total amount, thus collected, should be
measured.

It is unnecessary to send all the urine to the physician; six ounces,
somewhat less than half a pint, will be enough. But the physician
should know what the total amount was found to be; therefore, a
record of the measurement, the date, and the patient's name should
accompany the sample. If limited to a single fact about the urine, it
would be most helpful to know the amount passed during the twenty-
four hours. In this way, as I have already pointed out, the patient
herself may derive valuable information, for if the urine is scanty
in amount--that is, less than a quart--she should drink more water.

Unscrupulous newspaper advertisements alarm people through incorrect
statements about trouble with the kidneys. For example, they declare
that a sediment in the urine is a sign of disease; but that is false.
The mere act of cooling sometimes causes substances to crystallize
out of perfectly normal urine. Or, putrefactive changes which
frequently take place after the urine has stood for a time may cause
some of its normal constituents to be precipitated. A sediment,
either white, pink, or yellow, may indicate that the urine is too
concentrated, and consequently means that the individual should drink
water more freely; but it generally means nothing more serious. The
really important abnormal constituents of the urine, namely, albumin
and sugar, never form a sediment.

"Pain in the back" is a complaint frequently used to defraud the
public. This symptom does not indicate Bright's disease. It is
generally due to the muscles far away from the kidneys, with which,
usually, the pain has nothing whatever to do. Similarly a desire to
pass the urine frequently does not indicate any disturbance of kidney
function, but is explained by the pressure of the enlarged womb
against the bladder; it is a very annoying, yet a natural, result of
pregnancy.

THE SKIN.--The functions of the skin are at the very foundation of
health. It protects the delicate structures which it covers, assists
in the regulation of the temperature of the body, and excretes waste
products. The excretory function of the skin is always active, but we
are unconscious of this activity except on warm days and at times
when we perspire freely. In the coldest weather, however, the body
throws off what physiologists call the "insensible perspiration." The
most important measures for the care of the skin are those intended
to insure the activity of the sweat glands, namely, bathing and
proper clothing. But before considering these measures, we will
describe certain alterations in the skin which cannot escape the
notice of the prospective mother, and which she is likely to
misinterpret.

On account of the growth of the uterus the abdominal wall is
stretched during pregnancy. To a certain degree the skin yields to
the distention, but it finally cracks, and lines appear which are
commonly called "pregnancy streaks." At first they are delicate and
pink or blue in color; later they become white and more extensive.

The streaks indicate the situation of small breaks in the deeper
layer of the skin, which is less elastic than the upper layer. They
are not painful, and should never cause anxiety. Their size and
number vary with the degree of abdominal distention, which in turn
depends upon various factors, such as the size of the child and the
quantity of amniotic fluid. Although these streaks are most
frequently located upon the lower part of the abdomen, they may
extend to the outer sides of the thighs; and occasionally appear over
the breasts, since they too enlarge during pregnancy. Stretching of
the skin, of course, is not confined to pregnancy; consequently, the
same kind of streaks often appear in people who are growing stout.

Attempts to prevent or limit the pregnancy streaks prove futile.
There is a common belief that they may be prevented by the use of
vaselin, goose-grease, mutton-fat, or some one of a variety of
lotions; but this teaching is not borne out by experience. None of
these applications, however, are harmful, and there can be no
objection to using them except that they cause needless soiling of
the clothing. After the child is born the streaks fade of their own
accord, though they rarely disappear entirely.

In certain localities the skin grows darker during pregnancy. We have
already referred to the deepening of the color around the nipple as
one of the signs of pregnancy; a similar but much less pronounced
discoloration occurs about the navel, which also becomes shallow and
may begin to pout in the latter months of pregnancy. About this time,
with very few exceptions, there appears a more or less intense brown
line which runs downward from the navel in the middle of the abdomen.
Sometimes, though not very often, small dark areas, which have been
called "liver spots," appear elsewhere over the body. The name is
unfortunate, for the spots do not indicate a disorder of the liver.

At present it is generally admitted that alterations in the color of
the skin during pregnancy are due to deposits of iron. This mineral
substance, among others, as we have learned, is required for the
development of the embryo. The child is born with a supply of iron
calculated to meet its needs for about a year. Such a reserve is
necessary, as Bunge has pointed out, because human milk does not
contain enough iron to satisfy the infant's requirements. During
pregnancy, therefore, the mother's blood transports iron to the
placenta, where it can be absorbed into the child's system; and while
being thus transported some of it is deposited in the maternal
tissues. The deposits are especially frequent, as I have mentioned,
in the middle line of the abdomen, on account of the arrangement of
the blood vessels there. Deposits elsewhere may depend upon other
conditions; but whatever their cause the pigmentation vanishes a
short time after the birth.

Alterations in the color of the skin have no effect upon its
excretory function, which, indeed, generally becomes more active
during pregnancy. According to one estimate, the average person
possesses twenty-eight miles of sweat glands. If these figures are
not sufficient to demonstrate the importance of the skin as an
excretory organ, surely no one will fail to be impressed by the
tragic result which in one case followed throwing all the sweat
glands out of action. This was brought about in the case of a young
boy whose body was covered with gold leaf to provide entertainment at
a Parisian festival. The living statue was not exhibited, however,
for shortly after the youth was gilded he became ill and died.

In health more than a pint of water is eliminated through the skin
every day, and along with it waste products are removed from the
body. Exercise, hot drinks, warm weather, and heavy clothing promote
the activity of the sweat glands. Under certain circumstances
physicians endeavor to relieve the kidneys by stimulating their
patients to perspire freely. It should be clear, therefore, that when
a prospective mother naturally perspires it is a good indication.
Attempts to stop the perspiration are always ill advised; rather
should this function be encouraged by keeping the skin in good
condition with baths and warm clothing.

BATHING.--The accumulation of dead skin, grease, dust, and dried
perspiration on the surface of the body hinders the actions of the
sweat glands. Some of this material is wiped off by the clothing, and
more of it is removed by washing with plain water; but the most
effectual cleansing results from a liberal use of warm water and
soap.

Since the prospective mother must throw off the waste products of the
embryo as well as those of her own body, it is obvious that
cleanliness is never more important than during pregnancy. For this
reason she should take a tepid tub bath or shower every day. It is
not necessary that the temperature of the bath be determined with
accuracy or that it be always the same; but generally a temperature
between 80 and 90 degrees F. is found most agreeable. At this
temperature a bath is termed "indifferent," because it is neither
stimulating nor depressing; it is employed purely for cleansing the
body. Every part of the body should be well soaped, and from ten to
fifteen minutes should be given to washing all the exposed surfaces.
The best time for such a bath is just before going to bed, though
there is no objection to taking it during the day, provided that two
hours have passed since the last meal, and that another hour is
permitted to elapse before one goes out of doors or undertakes anything
that requires exertion.

Prolonged hot baths are fatiguing. They draw the blood from the
interior to the surface of the body; and during pregnancy they are
particularly depressing. Vapor and steam baths have a similar action
and should never be taken without the consent of a physician. They
serve admirably for the treatment of rare complications of pregnancy;
but, like medicine, their use should be limited to cases in which
they are clearly indicated.

Unless disagreeable results are noticed, those who have become
accustomed to cold baths may continue to take them during pregnancy,
but others should not. If, however, the temperature of the water is
modified so that it will not produce a shock, no one need omit the
morning plunge or shower which most persons find invigorating.
Sponging answers the same purpose, for the intent of the morning bath
is not to cleanse the body but to arouse the circulation. A thorough
rub-down assists in bringing the blood to the surface of the body.
Bath and massage together thus constitute a kind of skin gymnastics
especially beneficial throughout pregnancy.

Although hot foot-baths have sometimes been thought to cause
miscarriage, there is no good reason for believing they ever do. Sea-
bathing, on the contrary, may be directly responsible for such a
mishap. It is true that pregnant women sometimes indulge in surf-
bathing without harmful results; nevertheless the danger of
miscarriage they assume is not slight. The shock of the low
temperature, the exertion required to keep a firm footing, and the
pounding of the surf against the abdomen are all unfavorable
influences which more than counterbalance any advantage of such a
bath. On the other hand, there is slight risk if any in bathing in a
quiet stream or lake.

DOUCHES.--A great many women have the conviction that the vagina is
not clean and should, therefore, be regularly cleansed by means of
irrigations. This assumption is false and the treatment based upon it
is unnecessary. In structure the walls of the vagina closely resemble
the skin, but unlike the skin they do not contain glands; the vagina,
therefore, has nothing to do with the elimination of waste products
from the body. The secretion which issues from the vagina really
originates in the glands around the mouth of the womb, and serves to
protect the birth-canal against infection from harmful bacteria.

Careful examinations have shown that under normal conditions, which
of course include pregnancy, disease-producing bacteria are absent
from the vagina; in this respect the vagina is even cleaner than the
skin, for disease-producing bacteria are present on the surface of
the body. The vaginal secretion becomes more abundant during
pregnancy, and the increase is interpreted as an additional guarantee
against infection at the time of labor. So far as possible,
therefore, this natural antiseptic should not be disturbed.

The advice to abstain from douches will not be adopted by every
prospective mother without protest, for, as I have said, many women
regard them as necessary to cleanliness. Others who have delicate
skins are occasionally annoyed by the irritation of the vaginal
secretion, which is not only increased during pregnancy but has a
more pronouncedly acid character. Under extraordinary circumstances,
it may be permissible to use douches in the early part of pregnancy,
but it is practically never advisable to do so during the month
preceding the expected date of confinement. Furthermore, at no time
should the use of douches be begun without consulting a physician.

A more rational hygienic measure for the relief of itching and
smarting about the vaginal orifice consists in removing the secretion
as soon as it appears. In other words, the external parts should be
kept clean and dry. Great comfort is often derived from the use of a
"sitz-bath," which may be easily prepared by placing a small tub upon
a low stool and pouring in warm water (about 90 degrees F.) until it
is five or six inches deep. Cold sitz-baths are useful in the treatment
of hemorrhoids. Whether the bath be hot or cold, the treatment should
continue from ten to fifteen minutes, and after it the skin should be
thoroughly dried.

A special form of tub, called a "bidet," has been devised to
facilitate bathing the parts in question. The device is convenient
but expensive, and is certainly not essential. Every purpose will be
served by the small tub, provided the desired temperature of the bath
is properly maintained by changing the water as may be necessary.

CLOTHING.--In these days at least it is not idle to remark that the
first use of clothes is to keep the body warm; all other services
they are made to perform are secondary and relatively unimportant.
There are very good reasons, to be sure, for dressing neatly and even
for dressing in accord with the fashion, so long as the prevailing
styles are not harmful. Odd as it may seem, these are matters which
are not without significance for the physical well-being of a
prospective mother. Neat and comfortable clothing will help her to
overcome a natural inclination to become a "stay-at-home," and on
this account an inconspicuous way of dressing is often more valuable
than medicine. So long as they do not attract attention, most
prospective mothers go out in the day time, mingle with their
acquaintances, and attend public places of amusement. Deference to
fashion, therefore, may contribute substantially to good health.

Yet no prospective mother can afford to forget that first of all her
clothing must keep the body warm. Our clothing confines a cushion of
air which prevents the escape of the heat that we generate. Now,
since dry air conducts heat poorly and moist air conducts it readily,
the underclothes should be made of material that absorbs the
perspiration; otherwise the heat that the body generates is quickly
lost. Woolen garments effectually absorb the perspiration and should
be given the preference. Most persons who cannot wear wool next the
skin must choose cotton, since silk and linen are much more
expensive; there is not in this, however, a serious deprivation.
Cotton undergarments are perfectly hygienic; adapting their weight to
the season of the year, one will find them equally satisfactory in
summer and winter.

Except in summer every inch of the body should be covered with the
underclothing; this means that high-neck and long-sleeve shirts and
long drawers should be worn, for healthful activity of the skin can
thus be best preserved. It is well known to physicians who practice
obstetrics that the kidneys fail in their work more frequently during
the winter than the summer. To my mind, this is chiefly explained by
the way women dress. Even with light clothing the sweat glands
respond actively to the heat of summer and thus relieve the kidneys,
but in cold weather the sweat glands will not remove their share of
the waste products unless the clothing is warm.

Nature generally indicates that the body should be kept warm during
pregnancy. Many prospective mothers complain of perspiring freely;
others, if reproached because they are not clad warmly enough, reply
that they must wear light clothing to keep from perspiring. Thus they
discount or render absolutely ineffective a most important natural
safeguard against serious complications. It cannot be too strongly
emphasized that warm clothing helps to maintain healthful activity of
the kidneys quite as much as a proper amount of exercise and the
drinking of a suitable quantity of water.

The texture of the outer garments should take into account this same
quality of warmth; in other respects in selecting them personal taste
is an excellent guide. Outfitters carry a variety of maternity
garments; patterns for such garments are also sold by dealers, so
that those who cannot afford the ready-made clothes will find it easy
to have them made at home. Alterations in the clothing are compulsory
as pregnancy advances, and should be timely, made in anticipation of
inevitable development rather than in response to it. No prospective
mother need go to the extreme of "Reform Clothes"; her apparel should
illustrate both her good sense and her personal pride.

It is obviously even more harmful during pregnancy than at other
times to cramp the body by the clothing; the chest and the abdomen,
the parts most likely to be compressed, are at such times most in
need of freedom. To a slight degree natural causes always compress
the chest from below upward; and on this account nothing should be
allowed to hamper the expansion of the lungs from side to side. On
the other hand, if the waist is constricted, not the breathing
movements alone but also the growth of the womb will be interfered
with. In order to avoid such disagreeable consequences, and at the
same time to limit the extent of the maternity wardrobe, skirts may
be fitted with practical devices which permit letting out the
waistband as occasion demands. So far as possible, however, all the
clothing should be hung from the shoulders, and under no
circumstances should heavy skirts be worn.

Shoes contribute toward health, or the lack of it, more significantly
than the average person realizes. It is particularly advisable that
prospective mothers should select foot-wear with care, because their
bodies are heavier than usual. The feet are apt to become swollen in
the latter months of pregnancy, and consequently the shoes should be
roomy, but should always fit. To escape the discomfort of tight
shoes, it is generally advisable to wear a shoe an inch longer and
broader than the foot at rest.

High heels have been proved a frequent cause of back-ache; half of
such cases, in all probability, may be thus explained. High heels
tilt the body forward in such a way that the erect posture can be
maintained only by an unnatural tenseness of the back-muscles. Some
strain of this kind is inevitable during the latter months of
pregnancy on account of the enlargement and the position of the womb;
it is reasonable, therefore, to minimize it by wearing low, broad
heels.

Besides being responsible for many cases of backache, high heels add
greatly to the danger of tripping and falling; for this reason alone
they should not be worn. Improper foot-gear and not the joints
themselves deserve the blame for weak ankles. To prevent "turning the
ankle," it is not necessary to restrict oneself to high shoes, but
merely to see that the shoes that are worn have low heels and broad
soles. Such shoes provide a sure, firm footing, and this the
prospective mother particularly needs.

CORSETS.--No question connected with women's dress has provoked so
much discussion as the use of corsets. "Are corsets necessary to
health?" has been differently answered by those who would appear to
be equally competent authorities. In the time of our savage ancestors
we may safely conclude that they were not used; and, therefore, it is
really a question as to whether their continued use for generation
after generation has finally made some support of this kind
indispensable to the average woman. While that matter has not as yet
been settled, it is obvious that custom is really responsible for the
conviction of many women that they appear slovenly without corsets.
On the other hand, not a few women, unmindful of fashion, never wear
them; they testify that they are healthier for doing so. Whether this
be true or not, no one can honestly believe that corsets will soon be
banished; and the practical problem is to distinguish between those
that may do good and those certain to do harm.

During pregnancy the abdomen tends to fall forward and slightly
downward, and though it is in pregnancies after the first that this
tendency is most marked, every prospective mother will be more
comfortable if she wears some sort of support to counteract what
physicians term a "pendulous abdomen." Such a condition can be
prevented by the use of several appliances, and the device best
suited to the case should be chosen. Those who have never become
accustomed to corsets will probably find a corset-waist or an
abdominal supporter the most comfortable and useful. But the average
young woman who has previously employed a sensible, well made, and
loosely fitting corset need make no change until the third or fourth
month of pregnancy. From then on she should wear a corset especially
designed to conform with the changes that naturally occur in the
figure.

There is a plan, wrong in principle, which many adopt. Reasoning that
it will be necessary to change the corset from time to time, and
desiring to practice economy, a number of women purchase the cheapest
corset at hand. This they replace with a larger one of the same style
from time to time. The result is that an improperly fitting garment
is worn continuously; and, in the end, this plan proves almost as
expensive as, and far less suitable than, a proper corset, which
would remain serviceable throughout pregnancy, or at least until a
few weeks before confinement.

Most, and probably all, of the injuries for which corsets are
responsible result from their misuse. Naturally serious consequences
may be expected if they are worn with the design of compressing the
abdomen so as to render pregnancy less noticeable or perhaps to
conceal it altogether. Thus worn, the corset becomes not only an
instrument of torture but a source of danger both to the mother and
to the child. Fortunately there are very few women who fail to
appreciate the risk of thus striving to disguise their condition; and
generally it is the needless discomfort, the trifling ills
thoughtlessly inflicted upon themselves, that prospective mothers
must be taught to avoid.

At present there are manufactured a number of excellent maternity
corsets; but there are also worthless types, and some likely to do
harm. To judge them fairly they must be examined with regard to
several requirements. In the first place the corset should not be
stiff and should always be capable of easy adjustment; it must never
interfere with the activity of any organ. As _enceinte_, the
French word meaning pregnant, signifies, the prospective mother
should be unbound. Tight clothing, as we have already remarked,
hinders the breathing movements; it also interferes with the action
of the heart, and occasionally causes the child to assume an
unfavorable position within the uterus. The adjustment of the
maternity corset to the progressive development of the body is
generally provided for by means of extra lacings down the sides, and
by the insertion of elastic material.

The maternity corset, in the next place, must support the enlarged
uterus. Correctly shaped and worn, it extends well down in front,
fits snugly around the hips, and arches forward so as to conform to
the curve of the abdomen. In place of the arching, or "cupping" as
manufacturers call it, some maternity corsets have attached to their
lower edge limp flaps of a strong fabric which lace together. The
maternity corset-waist also should extend well under the abdomen and
fit snugly around the hips.

Finally, the corset should support the bust; the unpleasant
sensations due to congestion of the breasts can be relieved most
successfully by elevating them. It is exceedingly important, however,
that the upper part of the corset should fit loosely, for otherwise
the development of the breasts may be hindered, and the nipples
depressed. As a further precaution against pressure above and also to
secure the proper amount of support below, it is generally advisable
to begin putting on the corset while lying down. In every case the
corset should be laced from below upward; if laced in the opposite
direction it fails to lift the womb and tends to push all the
abdominal organs downward.

Any kind of corset is likely to become uncomfortable toward the end
of pregnancy; and of course should then be discarded. An abdominal
supporter made of woven linen or rubber is frequently used to
advantage during the last three or four weeks. With the first
pregnancy the supporter is rarely necessary, but with subsequent ones
it is frequently useful as early as the sixth month and is
indispensable later. A substitute for the manufactured supporter can
be made at home. Some such device often facilitates turning in bed,
and on that account may be found even more useful at night than
during the day.

THE BREASTS.--Personal hygiene during pregnancy includes the
preparation of the breasts with a view to success in nursing. All
measures which promote the health of a prospective mother also serve
to equip her for the nursing period; and in that sense the directions
just given for the care of the body, as well as the rules to follow
in the next chapter regarding a wholesome way of living, bear
directly upon lactation. But there are also local measures to be
adopted, some of which, such as supporting the breasts and avoiding
constriction by the clothing, have already been mentioned. Finally,
the nipples must be toughened and, if short or flat, they must be
drawn out, for the best supply of milk will count for nothing if the
infant cannot nurse comfortably.

Some approved method of toughening the nipples so that they will not
be injured by the sucking efforts of the infant, no matter how
vigorous, should be begun eight weeks before the expected date of
confinement; to start earlier will do no harm, but it is quite
unnecessary. A number of procedures have been advocated, but in my
own experience the following simple method is the best. The nipples
are scrubbed for five minutes, night and morning, with soap and warm
water. Generally, a soft brush, such as a complexion-brush, is
satisfactory; but if this is too harsh, at first a wash cloth may be
used. After having been thoroughly scrubbed the nipples are anointed
with lanolin and covered with a small square of clean, old linen to
prevent soiling of the clothing.

Another method widely used, but somewhat less trustworthy, consists
in bathing the nipples and applying a dilute solution of alcohol.
Formerly brandy, whiskey, or cologne were recommended, but at present
the following solution is commonly used. A tablespoonful of powdered
boric acid is added to three ounces of water and thoroughly mixed.
This is poured into a six-ounce bottle, which is then filled with
grain alcohol (95 per cent). The solution is applied twice a day with
a small piece of absorbent cotton.

Well-formed nipples need only be toughened, but depressed nipples
require additional treatment; and this should be begun about the
middle of pregnancy. The old-fashioned way of making the nipple more
prominent was to cover it with the mouth of a bottle which had
previously been warmed. The vacuum created, as the bottle cooled,
drew the nipple out. Similarly, the bowl of a clay pipe was sometimes
placed over the nipple; the patient sucked the stem, the nipple was
drawn into the bowl, and with persistence day after day success was
often attained. A similar and somewhat more aesthetic procedure is
now employed. The nipple is seized between the thumb and finger and
alternately pulled out and allowed to retract. These manipulations,
if faithfully practiced for several months, generally make the nipple
prominent enough for the infant to grasp. Occasionally patients need
to wear a contrivance sold at instrument stores which consists of a
circular piece of wood modeled to fit the breast and perforated in
the middle to accommodate the nipple. The appliance should not be
used unless a physician thinks it necessary.

Directions regarding the care of the breasts are sometimes taken
lightly, yet such care is not a minor duty. Now and then a patient
will pass through pregnancy uneventfully, will be delivered without
difficulty, and will enter upon what promises to be a rapid
convalescence when her recovery is interrupted by the development of
inflammation of the breast. Because such a complication may be
prevented, its appearance is the more to be regretted. Furthermore,
the responsibility for its prevention usually rests with the patient
herself. If she has been conscientious in preparing the nipples and
continues to watch them throughout the nursing period, the annoyance
of an abscess will almost certainly be prevented.




CHAPTER VI


GENERAL HYGIENIC MEASURES

The Need of Fresh Air--Outdoor Exercise--Massage and Gymnastics--The
Influence of Work upon Pregnancy--Relaxation and Rest--Is Traveling
Harmful?--Mental Diversion.

Besides the hygienic measures described in the preceding chapter,
whose observance should be recognized as more or less obligatory,
there are more general questions of conduct, such as exercise,
relaxation, mental occupation, and amusement, which are also
important. These measures, although frequently determined merely by
personal inclination or by the force of circumstances, nevertheless
exert a tremendous influence upon health. This fact a prospective
mother is likely to realize, for she is certain to consider not only
her own welfare but also that of the expected child; and she is
consequently concerned about details of conduct that most persons
would regard as trivial. She may, indeed, be too conscientious. Well-
meaning friends, sometimes in reply to her questions and sometimes
without solicitation, offer her a great deal of advice. Their
counsel, aside from the fact that some of it may be misleading, may
have the effect of prescribing so many rules that, if she followed
them all, she would never lose sight of the fact that she is
pregnant. Such a degree of self-consciousness is certain to make her
unduly apprehensive. The proper attitude of mind is quite the
opposite; so far as possible the prospective mother should forget
that she is pregnant. This state of mind is really the more rational,
for if a woman's daily life has previously been in accord with such
simple rules of health as everyone should adopt, the existence of
pregnancy calls for very slight changes.

It does not, for example, condemn her to inactivity and seclusion,
for it is advisable to lead a moderately active life during
pregnancy. Of course, such obvious indiscretions as prolonged
exertion, violent exercise, and fatiguing journeys should be avoided,
for transgression of the laws of health brings its own punishment,
generally in the form of discomfort, more quickly, and often more
severely, during pregnancy than at other times. Yet, on the whole, it
is more frequently necessary to emphasize to prospective mothers what
they should do than what they should avoid. This happens to be the
case because, as a rule, they are inclined to become recluses. For
fear of attracting attention they often wish to give up outdoor
exercise during the day; they stay away from public places of
amusement, and deny themselves other pleasures to which they have
been accustomed. Against this tendency they must be warned, for if
they yield to it they will surely be the worse off both physically
and mentally. Every prospective mother should make up her mind to
enjoy recreation out of doors regardless of comments.

THE NEED OF PURE AIR.--Outdoor life has been so urgently advocated of
late that the public has come to appreciate its benefits almost as
fully as do physicians. The existence of pregnancy does not lessen,
but rather enhances, the value of fresh air; in order to enjoy the
best health during this period one should spend at least two hours
out of doors every day. Neither the season of the year nor the state
of weather should modify this obligation. If the sun is shining the
"airing" is more delightful, but it should be taken in bad weather
also, on a protected porch or in a room with the windows wide open.

Even when the injunction to be regularly out of doors is observed
women are accustomed to spend the greater portion of the day in the
house, and on that account special attention must be given to keeping
the air of the house pure. Ventilation takes care of itself in
summer, when the windows are open, but in cold weather, when in our
anxiety to keep the temperature comfortable we may overlook the need
of fresh air, it demands close attention. The necessity of
ventilation at all times is due, of course, to the composition of the
atmosphere and to the changes produced in it as we breathe.

The air about us is a mixture of gases, of which oxygen and nitrogen
are the most important. Although nitrogen, which constitutes four-
fifths of the atmosphere, is taken into our lungs in breathing, we
make no use of it, but breathe it out in precisely the same condition
as we take it in. As chemically combined in the food-stuff known as
protein, nitrogen is indispensable to animal life; but our bodies
make no use of the gaseous form of nitrogen. Oxygen, on the other
hand, supports life; and though it forms less than one-fifth of the
atmospheric air, it is present in ample amount for our needs. After
we draw air into our lungs, the oxygen it contains is absorbed by the
blood and used by the tissues. In return our tissues give up a waste
product, carbonic acid gas, which is thrown off by the lungs. It is
interesting to observe that the carbonic acid gas which animals
exhale supports the life of plants, and that the plants, under the
influence of sunlight, give back pure oxygen to the atmosphere.
Obviously, the complementary relation exhibited here is of mutual
benefit.

The average person uses about four bushels of air a minute.
Consequently, rooms that are occupied must be constantly replenished
with fresh air; otherwise the point is quickly reached where the
occupants are breathing an atmosphere that is not only poor in oxygen
but saturated with carbonic acid gas and other impurities conveyed by
the breath. Foul air such as this causes headache, dizziness,
faintness, nausea, and occasionally even more serious disturbances.
Those who live in "close" rooms day after day grow pale and languid;
their appetite fails and some of their natural power of resistance
against illness is lost. Many people are unhealthy simply because
they neglect to supply their living quarters with a steady stream of
air from the outside.

While it is impossible to keep the air in any room as pure as the
outside atmosphere, perfectly satisfactory ventilation can be easily
arranged. Some of the impure air in a house is always escaping of its
own accord and its place is taken by air from the outside. Thus, the
cracks around the windows and doors let bad air out and good air in;
and, besides, most building materials are porous. These natural
paths, however, must be supplemented. The simplest device for
ventilation, which is also the best, consists in opening a window at
the top and bottom. The width of the opening may be regulated so as
to permit the air in the room to change without occasioning
disagreeable drafts; if necessary the current may be broken by a
screen of some pervious material placed in the opening.

The bed-room should always be supplied with plenty, of fresh air,
which "quiets the nerves" and helps one to sleep soundly.
Furthermore, the temperature of the bed-room should be lower than the
temperature of rooms occupied during the day. Both these requisites
will be properly met by leaving a window open at night, which may be
done throughout the year in most climates, if one puts on enough
covering. There is no danger of catching cold from sleeping with the
window open; on the contrary, breathing fresh air day and night is
one of the best ways to prevent colds.

OUTDOOR EXERCISE.--Outdoor exercise is indispensable to good health.
It benefits not only the muscles, but the whole body. By this means
the action of the heart is strengthened, and consequently all the
tissues receive a rich supply of oxygen. Exercise also promotes the
digestion and the assimilation of the food. It stimulates the sweat
glands to become more active; and, for that matter, the other
excretory organs as well. It invigorates the muscles, strengthens the
nerves, and clears the brain. There is, indeed, no part of the human
machine that does not run more smoothly if its owner exercises
systematically in the open air; and during normal pregnancy there is
no exception to this rule. Only in extremely rare cases--those,
namely, in which extraordinary precautions must be taken to prevent
miscarriage--will physicians prohibit outdoor recreation and,
perhaps, every other kind of exertion. Under such circumstances the
good effects that most persons secure from exercise should be sought
from the use of massage.

The amount of exercise which the prospective mother should take
cannot be stated precisely, but what can be definitely said is this--
she should stop the moment she begins to feel tired. Fatigue is only
one step short of exhaustion--and, since exhaustion must always be
carefully guarded against, the safest rule will be to leave off
exercising at a point where one still feels capable of doing more
without becoming tired. Women who have laborious household duties to
perform do not require as much exercise as those who lead sedentary
lives; but they do require just as much fresh air, and should make it
a rule to sit quietly out of doors two or three hours every day. It
will be found, furthermore, that the limit of endurance is reached
more quickly toward the end of pregnancy than at the beginning; a few
patients will find it necessary to stop exercise altogether for a
week or two before they are delivered.

Walking is the best kind of exercise, but long tramps are inadvisable
during pregnancy, except for those who have previously been
accustomed to them. Most women who are pregnant find that a two or
three-mile walk daily is all they enjoy, and very few are inclined to
indulge in six miles, which is generally accepted as the upper limit.
Perhaps the best way to measure a walk is by the length of time it
consumes. Accordingly, a very sensible plan is to begin with a walk
just long enough not to be fatiguing and to increase it by five
minutes each day until able to walk an hour without becoming
overtired. It is always advisable not to crowd the exercise of a day
into a single period but rather to take it in several installments,
for example, an hour in the morning, and another in the afternoon.
Under all circumstances, it must never be forgotten that the feeling
of fatigue is a peremptory signal to stop, no matter how short the
walk has been.

Very few outdoor sports can be unconditionally recommended to a
prospective mother. Because athletic exercise is either too violent
or else jolts or jars the body a great deal, it is especially
dangerous in the early months of pregnancy--the only time when it is
likely to be at all attractive. Croquet, alone, perhaps, is free from
these objections. Although golf and tennis are by no means certain to
bring on miscarriage, they involve a risk which, slight though it may
perhaps be, will not be assumed by cautious women.

Horseback riding during pregnancy is injurious. We occasionally hear
of women who have ridden horseback without immediate harmful
consequences, but they have nevertheless exposed themselves to danger
unnecessarily. It is better to give up skating and dancing also than
to run the risk of accident, especially since these diversions are
attended with some danger of falling. In a general way, whenever the
question of entering into any kind of recreation must be decided, it
is wise to err on the conservative side rather than risk overstepping
the limit of endurance and having to pay a penalty more or less
severe.

Carriage riding cannot take the place of walking and can scarcely be
classed as exercise; it is wholesome, nevertheless, because it takes
the participant out of doors and provides a change of scene. Certain
details, however, should be carefully observed; thus, a safe horse, a
carriage that rides easily, and smooth roads should be selected.
Similar advice pertains to motoring; with smooth roads, a cautious
driver, and a comfortable machine, short rides in an automobile are
not harmful. Carriage riding and motoring are particularly
serviceable as a means of getting outdoor diversion during the last
few weeks of pregnancy.

MASSAGE AND GYMNASTICS.--If a prospective mother is obliged to stay
in bed several weeks, massage may be useful; otherwise there is no
necessity for this treatment. Whenever required, massage should if
possible be given by an experienced masseuse. If this is out of the
question and the patient must rely upon one of her friends, it should
be understood that "general massage" is needed; in other words, one
part of the body after another should be gone over systematically.
With an inexperienced masseuse, however, it will be safer not to
massage the abdomen, since awkward, vigorous, or prolonged
manipulations in that locality may provoke painful uterine
contractions. Rubbing the breasts also can do no good; on the
contrary, it may do harm by bruising them.

The best time of day to have massage is in the morning, at least an
hour after breakfast. The duration of the treatment will depend upon
the patient; it should always cease as soon as she begins to feel
tired. After one has become accustomed to it, massage may generally
be continued for an hour. The room in which it is given should be
cool, and after the treatment has been completed the patient should
be wrapped warmly and left undisturbed for half an hour.

Gymnastics, like massage, are useless to those who can enjoy outdoor
exercise. Walking more perfectly strengthens the muscles which take
part in the act of birth than any system of "home calisthenics" that
has been suggested. In some conditions which make walking inadvisable
the use of calisthenics will be helpful. These exercises generally
consist in breathing movements and in movements of the extremities,
especially the legs, which bring into play the same abdominal muscles
that are used at the time of delivery. A detailed description of the
exercises is here purposely omitted, since gymnastics should not be
used unless advised by a physician, who should watch their effect and
thus be guided as to whether the patient should continue them.

THE INFLUENCE OF WORK UPON PREGNANCY.--No single influence is more
unfavorable to comfort and health during pregnancy than is idleness,
so that every prospective should occupy herself with congenial work
and fitting diversions. The kind of occupation makes no essential
difference, so long as it does not overtire either the body or the
mind. Since most women are absorbed in the affairs of the home, it
may be well to begin by saying that the existence of pregnancy by no
means requires the abandonment of domestic duties. On the contrary,
when it is convenient, the prospective mother should have a share in
the housework. She should not undertake everything that is to be done
about the house, for no matter how small the household there are
certain duties too laborious for her to attempt; these will be easily
recognized and turned over to someone else. Even with regard to those
tasks which lie within her strength she should use a little
forethought to prevent unnecessary steps.

All kinds of violent exertion should be avoided--a rule which at once
excludes sweeping, scrubbing, laundry work, lifting anything that is
heavy, and going up and down stairs hurriedly or frequently. The use
of a sewing machine is also emphatically forbidden. Treadle work is
known to be one cause of swollen feet, of varicose veins, and of
aches and pains in the legs or the abdomen. If a prospective mother
has to do her own sewing, the machine should be fitted with a hand
attachment or motor. Except for the possibility of straining the
eyes, there is no objection to sewing by hand.

Besides the activities that should be excluded because they may be
harmful, every housekeeper will find enough to keep her busy. It is
generally not a small task to suggest what others shall do and to see
that orders are properly carried out; consequently those who take no
part in the actual work may retain an absorbing interest in their
domestic affairs by directing them. Such direction, indeed, should,
toward the end of pregnancy, constitute the mother's sole
participation in the housework.

In a general way the amount and the kind of work that a woman may be
permitted to undertake during pregnancy depend upon what she has been
used to. It is not unlikely that anyone who is unaccustomed to manual
labor may injure her health and cause the pregnancy to end
prematurely if she undertakes hard work. On the other hand, women of
the working classes sometimes continue at their occupations to the
natural end of pregnancy without harmful consequences. It is
undeniable, however, that among this class miscarriages are more
frequent than among the well-to-do. Furthermore, the average birth-
weight of mature infants whose mothers have remained at work during
the last three months of pregnancy is ten per cent. less than the
average birth-weight of infants among the leisure class. This matter
of the baby's weight is not always serious in itself, but indicates
in the case of working women who are pregnant the existence of a
strain that sometimes leads to serious accidents.

The employment of women during pregnancy and immediately thereafter
is regulated by law in many countries. For example, the laws of
Holland, Belgium, England, Portugal, and Austria prohibit the
employment of women in factories during the last four weeks of
pregnancy or the four weeks following childbirth. Such employment is
unlawful in Switzerland for two weeks before and six weeks after
childbirth. There is no legal regulation of the employment of
pregnant women in either Germany or Norway, but the laws of both
countries forbid them to return to work until six weeks after they
have been delivered. Among civilized nations Turkey, Russia, Spain,
Italy, France, and the United States make no attempt to regulate
employment either before or after childbirth.

Of course there are strong sentimental reasons for relieving
prospective mothers of the necessity of earning a living, but there
are also excellent hygienic reasons against many kinds of employment.
For example, it should be unlawful to employ them in chemical
industries where, owing to their condition, they are especially
liable to be injured by the materials which they handle. Jacobi
states that the worst occupation for pregnant women is working with
metals, in particular lead; more than half of them suffer miscarriage
or premature confinement. Furthermore, the health of the child may be
endangered if the prospective mother does hard work of any kind. This
is true chiefly because she does not have appropriate intervals of
relaxation, for it is a firmly established principle that a
prospective mother must be free to rest the moment she begins to feel
tired. The least, therefore, that can be done to better prevalent
conditions among women who must work during pregnancy is to require
by law a reduction in the number of their working hours, and to
protect them from the necessity of earning a living for two months
after they have been delivered.

RELAXATION AND REST.--During the early months of pregnancy many women
complain that they feel enervated, and tire quickly even when they do
things which were formerly done with ease; this experience is so
common that it can scarcely be considered other than natural.
Curiously enough this is also the period during which the attachment
of the ovum to the womb is relatively insecure, and therefore the
inclination to be quiet is justified by the prevailing anatomical
conditions. No prospective mother should struggle against the
inclination to rest; she should yield to it in spite of the advice to
the contrary which older women are apt to give. Furthermore, it is
especially important about the time when a menstrual period would
ordinarily be expected to be guided by this impulse not to be active,
since overexertion then, more than at other times, is apt to be
followed by miscarriage. Except in rare cases the observance of this
precaution is less urgent after the fourth month, when the ovum has
become more securely attached to the womb. But again, toward the end
of pregnancy the development of the mother's body necessitates a
comparatively large amount of rest; patients who continue to exert
themselves may expect to suffer from shortness of breath and a number
of other annoyances.

In order to save needless steps and to avoid confusion and worry, it
is always helpful to map out beforehand what must be done in the
course of the day. Ideally, such a schedule should set apart
intervals for relaxation and rest. In the morning, for example, while
the housework is in progress, it is important to stop occasionally,
if only for a few moments, and lie down on a couch. After the midday
meal it is advisable to undress and go to bed. Even though one does
not fall asleep, an hour or two of complete relaxation will be
beneficial. A nap in the afternoon does not interfere with sleeping
at night provided plenty of exercise has been taken during the day.
In this way walking in the late afternoon or early evening helps to
secure a good night's rest.

During the first six or seven months, pregnancy, in itself, does not
cause sleeplessness, but later, as a natural result of the
enlargement of the womb, there are several disagreeable symptoms
which may cause broken rest at night. In the later months the weight
of the womb requires women to sleep on the side, and for some of them
this position is awkward at first. Frequently the pressure makes it
necessary to get up several times during the night to empty the
bladder. In a few cases also the compression of the chest interferes
somewhat with breathing. When insomnia is due to the pressure of the
womb against neighboring parts of the body, it can be partially
counteracted by getting into a comfortable position; but it is also
necessary to have the surroundings as conducive to sleep as possible.
Thus anyone will be much more likely to rest well if the bed-room is
large and well ventilated, if the mattress is comfortable, and if the
coverings are warm without being heavy. Finally, not the least
important detail is to occupy a single bed, so that it is possible to
turn over without fear of disturbing someone else.

In most instances, however, the inability to sleep during pregnancy--
and indeed at any time--is due to a faulty frame of mind. With
reference to the average man or woman, in his very helpful book "Why
Worry," Walton says, "it is futile to expect that a fretful,
impatient, and overanxious frame of mind, continuing through the day
and every day, will be suddenly replaced at night by the placid and
comfortable mental state which shall insure a restful sleep." Like
everyone else, the prospective mother must stop thinking when she
retires, otherwise the blood will not be diverted from the brain as
it must be to fall asleep. To aid in bringing about this condition a
number of expedients may be employed. For example, a warm bath, warm
sheets, or a hot-water bottle placed against the feet all help to
draw the blood from the brain to other parts of the body. Similarly,
a warm glass of milk or a small portion of easily digestible solid
food taken just before retiring will help to make one drowsy; on the
other hand, over-eating at the evening meal or later is not an
infrequent cause of wakefulness.

The use of narcotics is rarely necessary in the early months of
pregnancy, and the simple measures just mentioned will also generally
be found sufficient in the later months. But these procedures, or any
other except the use of strong drugs, will be ineffective unless the
individual knows how to get into the proper state of mind. This means
not only that she must be able to banish worries, regrets, and
forebodings; she must also have acquired confidence in whatever
method she employs. She must convince herself that she can sleep, or
at least that _it makes no difference if she cannot_. This
independent spirit, which is very essential, can be confidently
assumed, for if she does not sleep well it can be made up during the
next day or at least the next night. Having adopted this attitude,
and having assumed a comfortable position, which should be retained
as long as possible, the attention should be concentrated upon the
thought, "I am getting sleepy, I am going to sleep." Under these
circumstances she can hypnotize herself and "produce the desired
result more often than by watching the proverbial sheep follow one
another over the wall."

IS TRAVELING HARMFUL?--Traveling has been made so easy and alluring
that nowadays long journeys are undertaken with scarcely more concern
than was once felt when the people of neighboring towns exchanged
visits. Thus modern facilities have introduced a new factor into the
problem of the way to live during pregnancy. It is a well-known fact
that traveling is sometimes attended with risk to the prospective
mother, though the danger is exaggerated in the popular estimation.
For this the newspapers are chiefly to blame. They inform the public
of the cases in which embarrassing situations have arisen, but there
is no record of the thousands of pregnant women who travel without
any mishap.

What the effect of traveling is likely to be is very difficult to
predict under any circumstances, and the question cannot be answered
at all unless the specific conditions presented by each case are
taken into account. In a general way the points to be considered are
the vigor of the patient, the period of pregnancy at which she has
arrived, and the character of the journey she wishes to undertake.
Prudent women will never attempt to decide this question for
themselves, but will always obtain professional advice. The
disapproval of the physician, no doubt, will sometimes cause keen
disappointment; but conservative advice is the best and should always
be followed.

To be on the safe side a prospective mother who has previously had a
miscarriage should not travel at any time during pregnancy; others
are not obliged to follow this stringent rule except during the first
sixteen and the last four weeks of pregnancy. In the former period
there is some danger of miscarriage because traveling may cause
separation of the relatively loose attachment of the ovum. In the
latter period the muscle-fibers of the womb are usually irritable and
therefore the rolling of a ship or the jolting of a car may set up
painful contractions which in some instances expel the fetus.
Generally there is the least risk of accident between the eighteenth
and the thirty-second weeks, though patients should be careful even
during this interval not to travel at the time when a menstrual
period would ordinarily be expected.

The length of the journey and the ease with which it can be made are
also important features to be considered. Obviously there will be
less danger of mishap from a short trip than from a long one; if
possible, therefore, long journeys by rail should be broken so as to
afford opportunity for rest. Railroad trips which do not exceed two
or three hours are generally not so fatiguing that they must be
prohibited, provided the individual is perfectly well. Traveling by
boat is less tiresome than traveling by rail and, if equally
convenient, the boat should be given the preference. Long automobile
tours are attended with considerable risk of miscarriage and,
therefore, are forbidden.

MENTAL DIVERSION.--As a rule good health prevails throughout
pregnancy; it would be enjoyed even more frequently if many
prospective mothers did not think so much about the fact that they
are pregnant. For this deplorable self-consciousness the spirit of
the age is in part to blame; there never was a time, in all
probability, when people took such a keen interest in all matters
pertaining to health. It is also true, however, that fuller
instruction is needed now because the temptations to depart from a
regular, temperate way of living have notably increased.

At all events the point has now been reached where the average man or
woman knows something of anatomy, physiology, and the laws of
hygiene. Such knowledge should be helpful, and generally is, but if
it causes anyone to think incessantly about the workings of the body,
to that person it is detrimental. We all know such individuals. They
are made miserable because they scrutinize functions, like the
beating of the heart, that go on automatically and should be left
unobserved, or they minutely analyze their feelings and misinterpret
normal sensations as the evidence of disease.

The tendency to be introspective is especially pronounced in women
who are pregnant, and this is readily explained by the reciprocal
relations between the mind and the body. If the prospective mother
correctly interpreted the changes which occur in her body, as well as
the sensations for which these changes are responsible, she would
escape the uneasiness of mind that causes many sorts of discomfort.
It is unfortunately true, however, that her lack of familiarity with
the facts about pregnancy and her belief in unfounded traditions
frequently lead to the misinterpretation of natural conditions. An
anxious frame of mind also causes real ailments to assume an
importance out of all proportion to their actual significance.

Patients who have followed my advice to place themselves in the care
of a physician as soon as they clearly recognize the existence of
pregnancy will receive his assistance in properly estimating the
significance of what they notice. This service is by no means the
least the obstetrician renders his patients. His opinion should
always be sought when symptoms are not understood; but it is not
unusual for patients to bring to the doctor's attention many
complaints that would pass unnoticed if they taught themselves to
restrain the imagination, to refrain from pessimistic reflections,
and to divert their thoughts from themselves to outside affairs.

Generally it is during the early months of pregnancy that patients
are most likely to be self-centered, and consequently suffer from
many annoyances that either proceed from or are exaggerated by this
faulty frame of mind. During this period a prospective mother is not
fully aware of the meaning of pregnancy. Toward the twentieth week,
however, she perceives the movements of the child and her thoughts
are turned to it instinctively. About this time many of the
discomforts of pregnancy disappear and there ensues a period of
unusually good health. Perhaps it would be going too far to give this
more wholesome altruistic mental attitude the entire credit for the
relatively better health of the second half of pregnancy, but without
doubt it is a most important factor.

Such then is the influence of the mind over the body that anyone who
wishes to cultivate good health must correct the faulty habit of
always thinking of herself. The most suitable form of diversion will
depend upon personal taste. Domestic duties absorb the attention of
most prospective mothers, but domestic duties should not occupy them
exclusively. Outdoor recreation is necessary and serves the double
purpose of strengthening mind and body. Public amusements should also
be patronized; no prospective mother has the right to sacrifice
herself to pride. Music, the various arts, a systematic course of
reading, the acquisition of a foreign language--all these are
commendable forms of diversion, and others will occur to anyone.
Obviously the avocation will be most happily chosen if it directs the
attention into channels likely to lead to the greatest pleasure.




CHAPTER VII


THE AILMENTS OF PREGNANCY

Nausea and Vomiting--Heartburn--Flatulence--Defective Teeth--Pressure
Symptoms: Swelling of the Feet; Varicose Veins; Hemorrhoids;
Shortness of Breath--Leucorrhea--Toxemias.


Most of the ailments to which prospective mothers are liable are
merely the natural manifestations of pregnancy, exaggerated to such
an extent as to cause inconvenience and discomfort. In the early
months, for example, persistent nausea and vomiting may become the
source of great annoyance, and later the pressure of the womb against
neighboring structures may cause a variety of symptoms. It does not
follow, however, that any of these ailments will necessarily appear.
On the contrary, many women are more healthy during pregnancy than at
any other time.

Occasionally illness is charged to pregnancy with which in reality
pregnancy has nothing to do. While awaiting the birth of a child,
just as at other times, women may suffer from coughs or colds, from
aches or pains, from malaria, pneumonia, typhoid fever, or in fact
from any disease. It is evident that such complications are
accidental; and, though pregnancy confers no immunity against them,
it does not, on the other hand, render women more susceptible to all
kinds of ailment.

And yet there are diseases for which pregnancy is directly
responsible. These are, to a very large extent, preventable; and,
though they occur rarely, precautions for their prevention should be
taken in every case of pregnancy. By far the most important members
of this group are the toxemias of pregnancy. These, as will be
explained later, cause symptoms which the patient herself may
recognize, and her physician may often detect their presence still
earlier by alterations in the composition of the urine. For this
reason routine examination of the urine during pregnancy is a means
of prevention indispensable for safeguarding the health of the
prospective mother.

A number of ailments of which prospective mothers may complain do not
require treatment with medicine. This, however, will not be taken to
imply that there is no need to consult a physician. On the contrary,
and it cannot be emphasized too strongly, the prospective mother
should _seek professional service whenever there is anything about
her condition she does not understand_. Sometimes, when she thus
consults the physician, he will explain to her that what she has
noticed is merely one of the natural manifestations of pregnancy and
that she can have no control over it; at other times he will suggest
changes in her mode of life which will very likely afford her relief.
The frequency with which physicians find that ailments may be
corrected by the adoption of hygienic measures indicates that such
ailments are more often due to ignorance or carelessness than to the
existence of disease.

NAUSEA AND VOMITING.--We have already learned that nausea, especially
in the morning on rising from bed, frequently corroborates the
suspicion of a woman that she has become pregnant. So commonly,
indeed, is this symptom expected that most women take no account of
it other than as an evidence that they have conceived, and
consequently do not complain of it. A few who have heard the old
adage, "a sick pregnancy means a safe one," which incidentally is not
correct, actually accept nausea as a favorable sign. In other cases
the nausea is not to be dismissed so lightly; and a relatively small
group of patients suffer from persistent vomiting. When prospective
mothers are questioned systematically, it appears that at least one-
half and perhaps two-thirds of them experience more or less
discomfort from sick stomach. Generally this begins shortly after a
menstrual period has been missed and ceases six or eight weeks later;
it persists occasionally until the movements of the child have been
perceived.

Nausea and vomiting are limited, in the vast majority of cases, to
the early morning, but some patients are annoyed only after meals,
and a few at irregular intervals during the day. The fact that the
attacks do not always appear at the same time, and that they differ
in severity, indicates that different causes may be concerned in
their production. And it is true that there are several kinds of
vomiting that occur during pregnancy, although the classification
interests only physicians. The laity, however, should understand that
the treatment of any given case will vary according to the class to
which it belongs, and therefore the occurrence of troublesome
vomiting should be promptly reported to the physician.

Most frequently it will be found that there is nothing serious the
matter. The vomiting ceases or, at least, it becomes less troublesome
as soon as the diet has been more carefully arranged, constipation
has been corrected, or other hygienic details, such as outdoor
recreation and mental diversion, have received the attention
requisite for good health. In a much smaller group of cases the
restoration of the womb to a proper position or the treatment of some
other local condition, which can generally be remedied without
difficulty, is all that is necessary. But finally, in extremely rare
instances, the vomiting of pregnancy is due to a definite disease
whose existence may be recognized by special methods of analyzing the
urine. In any case, if the physician is given an opportunity to make
the necessary observations and thus determine the variety of the
vomiting, no time will be lost in beginning effective treatment. In
an overwhelming majority of the cases, as I have said, nothing
serious will be found; and then the control of the vomiting will lie
within the power of the patient herself.

Since nausea is usually experienced in the morning on rising from the
recumbent to the upright posture, measures to prevent an attack
should be begun even before the patient raises her head from the
pillow. In the first place something to eat should be taken as soon
as she awakens. The most satisfactory results follow eating two or
three pieces of crisp toast or a Bent's cracker (sold by grocers),
either of which should be thoroughly chewed and swallowed without
taking anything to drink. Good results are also obtained, though less
uniformly, from eating other food, such as fruit, oatmeal, or eggs.
The benefit secured from this procedure is explained, perhaps, by the
activity of the digestive organs and the effect of that activity upon
the circulation of the blood. The food eaten before rising is not
intended to take the place of breakfast, which ordinarily will be
eaten later. Furthermore, it is essential to remain in bed until half
an hour after the food was taken; and not to rise then unless
perfectly comfortable. Anyone who is inclined to be nauseated should
get up slowly and dress leisurely, sitting down as much as possible
while putting on the clothes. If breakfast is not desired at once, it
should not be forced, but some food should be eaten between early
morning and noon.

It is an exceedingly good rule to bend every effort toward escaping
the initial attack of nausea, for in this way one soon gains
confidence, and overcomes the depressing habit of being continually
on the watch for the symptom, lest she be taken unawares.
Exceptionally, however, patients feel more comfortable if they vomit
in the morning; this may be helpful, for example, if a large meal has
been eaten just before retiring the previous night.

Next to morning sickness in point of frequency comes the disposition
to be nauseated about meal time. Those who vomit after the meal is
finished are frequently inclined to eat soon again; and there is no
reason why they should not. Sick stomach after meals may be due to
several causes, such as eating hurriedly, eating too much, or
selecting food that is difficult to digest. If a meal is bolted the
stomach may be overloaded before the appetite is appeased; and
consequently those who eat too much are fortunate when the stomach
rejects the excess. Eating slowly and masticating the food
thoroughly, we know, is the proper way to insure taking no more than
is needed.

One of the most valuable precautions against persistent nausea
consists in taking small amounts of food five or six times during the
day. Directions regarding the frequency of meals and the choice of
food have been given in Chapter IV, to which the reader may refer. It
may be repeated, however, that a prospective mother should naturally
avoid anything which she knows is likely not to agree with her. On
the other hand, she is almost certain not to be nauseated by any
article of food for which she has an appetite.

Lying down for a short while after meals frequently serves to prevent
an attack of vomiting. It is a good rule, furthermore, at whatever
time of day the sensation of nausea may occur, to lie down
immediately. An ice bag or cloths wrung out of cold water, if applied
to the abdomen, often give relief; warm applications occasionally
serve the same purpose better. Some patients prevent nausea by
constantly wearing a flannel bandage about the abdomen.

Many instances of the vomiting of pregnancy cannot be explained by
errors in diet, for the attacks come on repeatedly whether the
stomach contains food or not. Under these circumstances mental
influences frequently have to be reckoned with. Indeed, in most cases
of vomiting of pregnancy dietetic and other hygienic measures are of
no avail unless the patient learns to divert her attention from
troublesome thoughts.

That the brain can exert an influence over the stomach is a fact well
substantiated both by physiological experiment and by medical
observation. In all probability there is a definite spot in the
brain, called the "vomiting center," the irritation of which causes
retching and the upheaval of the contents of the stomach. As this
nervous mechanism is possessed by everyone, it is not called into
existence by the advent of pregnancy. Nevertheless, it seems likely
that pregnancy renders it more sensitive, and it is certain that
pregnancy establishes new means by which the center may be
stimulated. This admission does not imply, however, that the
prospective mother must submit to inevitable discomfort, for she can
and should muster the strength to resist it.

Time and again an unhappy frame of mind exaggerates or prolongs the
vomiting of pregnancy. Thus, disappointment, anxiety, grief, fright,
and other types of mental uneasiness not only magnify the discomfort
but sometimes are its sole cause. The curious cases in which the
husband suffers from nausea while his wife is pregnant are explained
by mental influences. As a result of the same kind of influence,
women who imagine themselves to be pregnant often suffer from violent
vomiting, which ceases as soon as they discover their error. On the
other hand, women who for several months remain ignorant of the fact
that they are pregnant rarely suffer from sick stomach.

Any kind of worry may be and often is the direct cause of the
vomiting of pregnancy, though patients are often unwilling to confess
it; and occasionally do not seem to know what it is that troubles
them. In any event, having received the assurance of her physician
that there is nothing serious the matter, the prospective mother who
is annoyed by nausea should make every effort not to become self-
centered. She should have congenial companionship and should interest
herself in pursuits outside of, as well as within, her home. Of all
the measures that may be employed to overcome this manifestation of
pregnancy the most fundamental and essential is mental diversion.

HEARTBURN.--Obviously, it would not be fair to consider indigestion
as one of the ailments peculiar to pregnancy, for anyone is liable to
suffer from indigestion. Yet dyspeptic symptoms, more especially
heartburn and flatulence, occur so frequently at this time that
something should be said regarding their causation and treatment.

A burning sensation rising from the stomach into the throat,
familiarly called heartburn, is generally due to an overabundant
secretion of hydrochloric acid, which is, as we have learned, a
normal constituent of the gastric juice. Of late, the conditions
which influence its secretion have been the subject of laboratory
investigation, which has disclosed, among other interesting facts,
the way to _prevent_ heartburn. These experiments have taught
that the introduction of fat into the stomach shortly before a meal
decreases the amount of acid secreted during digestion. Consequently,
anyone who is troubled by heartburn and wishes to avoid it _should
take a tablespoonful of olive oil, a cup of cream, or a glass of rich
milk fifteen or twenty minutes before meal-time_.

On the other hand, fatty food eaten with the meals prolongs the stay
of food in the stomach and causes an increase in the secretion of
hydrochloric acid. An excess of the acid, as we have just learned, is
favorable to the development of heartburn. Therefore, as a further
precaution against this source of discomfort, it is advisable not to
use a large amount of butter or of salad oil, and to refrain from
fried food, rich desserts, or any other article of diet known to
contain a relatively large amount of fat.

Once it has developed, heartburn will be aggravated by taking cream
or olive oil. The most rational _curative measures_ then consist
in diluting the acid by drinking a couple of glasses of water and in
counteracting (neutralizing) the acid by taking a teaspoonful of
baking soda (bicarbonate of soda) or a tablespoonful of limewater;
and, if necessary, either of these doses may be repeated. Patients
often adopt the very sensible habit of carrying with them a block of
magnesium carbonate, which they nibble whenever the symptom appears.

FLATULENCE.--The distention of stomach and intestines with gas,
technically called flatulence, may be associated with heartburn or
appear independently. The gas arises from the action of bacteria upon
the food. There can be little doubt that flatulence occurs so
regularly during pregnancy because the pressure of the enlarged womb
prevents the contents of the intestine from moving along as rapidly
as they have done previously.

To be relieved from this source of discomfort, it is necessary, in
the first place, that the bowels should be regularly evacuated; very
often nothing further is required than to overcome the habit of
constipation. Occasionally, however, the diet must be arranged so as
to exclude food which is likely to form gas. For example, parsnips,
beans, corn, fried food, candy, cake, and sweet desserts, all of
which are known to cause flatulence, should be avoided; in aggravated
cases the allowance of starchy food of every kind should be cut down
to small portions.

Since the production of gas in the intestine is due to the action of
bacteria sometimes relief from flatulence is secured only after the
administration of intestinal antiseptics. Drugs, however, will be
prescribed by the physician, and will not be employed until the
simpler hygienic measures have failed. Similarly, the physician
should decide whether it is advisable for the patient to drink milk
inoculated with harmless bacteria (The Bulgarian Bacillus) which has
lately been placed on the market. The bacteria thus administered in
the milk are antagonistic to the intestinal bacteria that produce
gas, and consequently have been recommended for the treatment of
flatulence. If this commercial product cannot be conveniently
obtained, one may use instead tablets containing the bacteria, which
can be supplied by druggists.

DEFECTIVE TEETH.--Unless suitable precautions are observed, the
digestive disturbances of pregnancy have a tendency to injure the
teeth. The regurgitation of the acid contents of the stomach, for
example, may cause cavities to develop or may enlarge those that
already exist. In all probability the damage done in this way--and
not the removal of lime from the teeth for the formation of the
child's skeleton, as some have thought--is responsible for the origin
of the saying that "every child costs a tooth." This notion is of
course absurd, yet it is quite true that toothache and the decay or
loosening of the teeth are not infrequently associated with
pregnancy. On this account, throughout the period of pregnancy
particular care should be given the teeth.

One of the very first duties of a prospective mother, after she knows
that conception has taken place, is to visit her dentist. This step
is very important as a means of insuring the teeth against such
harmful influence as pregnancy may have upon them. If the dentist
finds the teeth in poor condition, the patient should consent to have
them treated immediately. That this is the reasonable course seems
sufficiently obvious, yet the majority of women have been slow to
adopt such a view.

For a long time dental work of every description was incorrectly
believed to have an untoward effect upon the development of the
child; and the extraction of a tooth, it was thought, would surely be
followed by miscarriage. Although the extraction of teeth is not
frequently undertaken nowadays, I have known several prospective
mothers who required the operation, and who had it performed without
experiencing a single untoward symptom. Very naturally dental work
should be restricted during pregnancy to that which is absolutely
necessary, and temporary fillings generally suffice; but whatever is
needed should be done without delay.

Brushing the teeth after meals and removing particles of food that
may have been caught between them--important enough at all times--are
of even greater importance during pregnancy. If the gums are sore and
the teeth show a tendency to loosen, the best tooth-paste is one
containing potassium chlorate.

An alkaline mouth-wash should be used several times a day; after an
attack of vomiting it is always advisable to rinse the mouth with
such a solution. As a wash either lime water or milk of magnesia, or
a solution of bicarbonate of soda may be used; they are equally good.
Lime water may be prepared at home inexpensively in the following
way: Place a teacupful of builders' lime in a large bowl and add two
quarts of water; thoroughly mix and allow to settle. Pour off and
throw the water away, since it often contains impurities. Add two
quarts of water again and allow the mixture to stand three or four
hours, stirring occasionally. Strain through a piece of muslin into
bottles and keep well corked. One tablespoonful of this solution
should be added to a glass of water to obtain the proper strength for
a mouth-wash.

PRESSURE SYMPTOMS.--Because human beings walk erect, and not on all
fours, they are liable to suffer from various ailments of pregnancy
that quadrupeds escape. Thus the upright posture is the chief factor,
at least, in causing such complaints as swollen feet, varicose veins,
hemorrhoids, and cramps in the legs. The attention of patients should
be called to the source of these troubles, for in most instances they
can be prevented by forethought and prudence.

During the last two or three months of pregnancy every prospective
mother should carefully avoid being too much on her feet; she should
lie down, as has already been emphasized, at regular times of day and
frequently sit down to rest. Proper support for the abdomen, such as
is afforded by a correct corset or a maternity supporter, lifts the
pregnant uterus, and to a notable extent relieves of pressure the
structures beneath it. On the other hand, incorrectly made corsets,
the use of circular garters, and running a sewing machine by foot-
power all aggravate the pressure symptoms of pregnancy.

_Swelling of the Feet_.--So long as the swelling is confined to
the feet and legs it does not mean that there is trouble with the
kidneys; the swelling is satisfactorily explained by the pressure of
the enlarged uterus upon the veins which pass through the lower part
of the abdomen and conduct the blood from the legs on its way back to
the heart. The womb is rarely heavy enough during the first half of
pregnancy to interfere with the flow of blood through these vessels,
but in the last few months such interference is very common.

Generally the limbs are equally affected, yet occasionally the
swelling is more marked on one side or the other. The characteristic
changes begin in the feet. The skin covering the back of the foot
becomes tense and has a waxen appearance; it is easily indented,
bearing for a moment the imprint of anything that is pressed against
it. Often the swelling extends no higher than the ankles, but it may
involve the calves, the thighs, or even the vulva, which is the
region between the thighs.

If the swelling remains slight, no attention need be paid to it. But
if it becomes extensive or painful, nothing will give relief except
going to bed. Patients observe for themselves that the swelling
lessens during the night, and from this usually learn that the proper
treatment is rest. When it is absolutely impossible to remain in bed
long enough for the swelling to disappear, the next best plan is to
accept every opportunity, during the day, to sit down and prop up the
feet.

_Varicose Veins_.--The distention of the surface veins of the
legs, the condition known as varicose veins, is not a peculiarity of
pregnancy. Anyone who must be on his feet a great deal is liable to
suffer from this ailment. It is true, nevertheless, that pregnancy
increases the likelihood of the development of varicose veins. The
walls of the vessel are generally able to withstand whatever strain
is placed upon them during the first pregnancy, and usually the
varicosed condition does not develop until after there have been
several pregnancies.

As a rule, both legs are similarly affected, but if only one, it is
more likely to be the right. This is explained by the fact that the
position of the child within the womb is ordinarily such as to cause
greater pressure on the vessels of the right side. For the same
reason when the legs are unequally affected, generally the veins of
the right side are the larger. In any case, however, the birth of the
child removes the source of the interference, and during the lying-in
period, provided that the patient remains quiet for a sufficient
length of time, the vessels regain their normal caliber. Once they
have been distended, however, the veins remain more susceptible to
engorgement. Consequently, in order not to increase the strain these
vessels naturally bear during the latter months of pregnancy, the
precautions just mentioned for the avoidance of all the pressure
symptoms should be strictly observed. Upon the first intimation that
the veins are becoming dilated, a patient should be unusually careful
to keep off her feet all that she can. Only in extreme cases will it
be compulsory to go to bed. But, if the veins are large and painful,
she should stay in bed until material improvement has taken place.
Subsequently she should wear a flannel bandage, snugly applied, about
the leg from the toes to a point somewhat above the knee; the bandage
should extend higher whenever the veins of the thigh also are
dilated. In putting on the bandage the heel may be left uncovered;
after leaving the foot a turn of the bandage will be taken around the
ankle and thence applied upward. A flannel bandage may be easily made
at home. Bias strips are cut about three inches in width and sewed
together end to end so that the joining will lie flat. Unless the
bandage must extend far above the knee, eight yards will be a
sufficient length.

Elastic stockings, which may be purchased from a druggist, serve the
same purpose as the bandage, but are very much less durable. Even if
worn during the day they should be taken off at night; and when
protection of the veins is required after going to bed, the bandage
is the most sanitary way of securing it.

The danger that one of the vessels will break may be disregarded, if
they are constantly protected by the measures that have been
mentioned. In the event of accident, however, make firm pressure over
the bleeding point with a freshly laundered handkerchief, and apply
an ice bag outside the dressing until the doctor arrives.

_Hemorrhoids_.--Hemorrhoids are caused in the same way as
varicose veins of the legs. The two conditions differ merely in point
of location; but hemorrhoids, on account of their location, are much
more exposed to irritation.

Although the development of hemorrhoids cannot always be prevented,
it is a well-known fact that constipation renders the chance of their
appearance much greater. In a measure, therefore, regular, daily
evacuation of the bowels serves to prevent the ailment, and also to
cure it, once it has developed. But walking and even standing
aggravate hemorrhoids. The recumbent posture, as might be expected,
is of itself frequently enough to give relief. It is much more likely
to do so, however, if the hips are elevated by placing a pillow under
them.

In severe cases it is helpful to restrict the diet for a few days
until the congestion and acute suffering have subsided. If the
hemorrhoids protrude, they should be replaced (which the patient may
generally do for herself), and an ice bag should be applied to the
seat of pain. Various ointments and suppositories of different
composition are valuable in the treatment of this ailment, but, as
not all cases are relieved by the same medicine, a physician should
be consulted to learn what is most suitable in any given instance.

Hemorrhoids often grow progressively worse as pregnancy advances, and
are frequently aggravated immediately after the birth of the child;
but they generally disappear within a few weeks. Whenever a natural
cure is not thus effected, it may become necessary to resort to
surgical treatment. Operative procedures, however, should not be
undertaken during pregnancy, since the condition is likely to
reappear before the child is born.

_Cramps in the Legs_.--There are nerves as well as blood vessels
that the pregnant uterus may press upon, and pressure of this kind
may cause pain. At times the pain is definitely localized at the
point where the nerve is pressed upon; under these circumstances the
discomfort is felt in the lower part of the back. On the other hand,
the pain may be referred to the point where the nerve ends. In this
way is explained not only pain in the leg but also those sensations
of numbness and tingling which prospective mothers not infrequently
complain of. The presence of these pressure symptoms is usually
limited to the last few weeks of pregnancy. They often begin about
the time the child's head enters the bony canal through which it is
ultimately born; engagement of the head, as this is called, occurs
simultaneously with the dropping of the waist-line, that is, about
two or three weeks before delivery. From the time the head is engaged
all the pressure symptoms become somewhat more intense.

From the very nature of their causation, it is clear that cramps in
the legs are difficult to treat. The recumbent posture lessens the
discomfort, and, if in addition the hips are elevated, absolute
comfort will occasionally be secured. Whether or not the
administration of medicine is advisable must be determined by the
physician who has the opportunity to see the patient. The birth of
the child, of course, removes the cause of the pressure and
permanently relieves this discomfort.

_Shortness of Breath_.--Besides the ailments caused by the
downward pressure of the pregnant uterus, there are also symptoms due
to its upward growth. Thus shortness of breath is regularly noted
toward the end of pregnancy, and, as has already been mentioned, it
is one of the reasons for exercising leisurely.

Unlike the other pressure symptoms, shortness of breath is ordinarily
aggravated by the recumbent posture, for lying flat on the back
increases the compression of the chest. At night, which is frequently
the time when difficulty in breathing is most pronounced, the patient
may, if necessary, sleep propped up in bed. For this purpose an
appliance called a back-rest may be used, but an extra pillow under
the head and shoulders is usually sufficient.

LEUCORRHEA.--The meaning of the white discharge from the vagina known
as leucorrhea is variable: at times it indicates the existence of an
ailment requiring treatment, and at other times it does not. To be on
the safe side, therefore, anyone who is troubled by leucorrhea should
obtain her physician's opinion as to its significance.

Normally, as we learned in Chapter V, there is an increase in the
vaginal secretion during pregnancy; but this fact is rarely
noticeable until the latter months. Usually it is pronounced only
during the last few weeks. At that time, owing to its antiseptic
qualities, this pale white fluid should not be disturbed by the use
of douches. In the early months of pregnancy, however, leucorrhea may
cause such inconvenience as to demand medical treatment.

While itching is the most disagreeable effect of such a vaginal
discharge, it should be known that itching is not always due to
leucorrhea. Thus it may be caused by a highly concentrated urine, and
in that event will be relieved by drinking a larger amount of water;
or it may be due to the presence of unusual constituents in the
urine. Skin diseases also cause itching; and light haired people,
since they have more delicate skins that brunettes, are especially
susceptible to these ailments. To such skin affections soap and water
may be very irritating; so that when they exist it is often advisable
to cleanse the parts with olive oil. In other cases, ointments are
required and will be prescribed by the physician.

Itching of the skin over the extremities or over the whole body, it
is clear, cannot be attributed to leucorrhea, but in these very rare
cases the irritation would seem to be caused by some waste product
which is being eliminated through the sweat glands. We do not know
what the substance is, but, as the symptom appears so seldom, it must
be due to an unusual kind of waste product or else to one whose
elimination normally occurs through other channels. The affection of
the skin thus brought about is really a very mild kind of poisoning,
and since the offending substance arises in the body of the patient
herself the condition is called an autointoxication. Effective
treatment consists in drinking water freely and taking a cathartic,
for the one stimulates the kidneys and the other the bowels to assist
in getting rid of the cause of the trouble.

TOXEMIAS.--In order to understand what are known as the
toxemias of pregnancy, we must remember that the nutrition of our
bodies involves three separate and distinct sets of processes. What
we eat is, in the first place, digested and absorbed into the body;
secondly, the products of digestion are utilized by the tissues; and,
finally, the waste material is thrown off from the body. Any one of
these processes may be carried out in a way that is not consistent
with health. Most of us realize that disturbances may occur in the
course of digestion, and we are also aware that the excretory organs
occasionally fail to do their work in a satisfactory way. But what
laymen, perhaps, do not appreciate is that the intermediary steps--
between the time when the food is absorbed and the time when the
waste material is finally eliminated--may not be taken precisely as
health requires. Of course, any person may be the subject of one or
another of these nutritional disorders, but unquestionably such
disorders are somewhat more frequent during pregnancy than at other
times. Nor is this difficult to understand, for the nutritional
processes of two beings are here linked together. They generally
proceed harmoniously, but if they do not there results an
autointoxication of the mother which is called a toxemia.

Such toxemias, with extremely rare exceptions, do not occur in the
early months, but are associated with the period of the active growth
of the fetus, namely, the second half of pregnancy. For this reason,
and for some others which do not concern us here, it seems probable
that the nutritional processes of the child are primarily responsible
for these ailments. This view, however, must be somewhat modified,
for experience has clearly taught that the efficiency with which the
maternal excretory organs do their work has a great deal to do with
the effect that the fetal waste products have upon the mother. On
this account she has been urged to pay attention to personal hygiene.
It is also necessary, however, that she should become acquainted with
the symptoms which give warning that the excretory organs are acting
imperfectly.

Autointoxication can almost always be prevented. The means of
prevention are neither mysterious nor difficult to carry out; they
lie within the power of every prospective mother, for they consist
merely of what has already been discussed, namely, the intelligent
regulation of the diet, the care of the body, and a correct ordering
of the daily life. To the chapters dealing with these subjects
reference should be made and particular attention should be paid to
what has been said concerning:

  (1) Wearing suitably warm clothes,
  (2) Bathing regularly,
  (3) Taking a proper amount of exercise,
  (4) Drinking water liberally,
  (5) Avoiding an excessive quantity of meat,
  (6) Guarding against constipation.

At present the value of prevention in the treatment of the toxemias
of pregnancy is so clearly recognized that charitable organizations
employ nurses to visit women of the poorer classes during pregnancy
in order to instruct them about the measures that I have just
indicated. Remarkable results have already been obtained. In one
clinic where this method has been adopted the frequency of all kinds
of toxemia, I am told, has notably diminished, and serious types are
not permitted to develop. Similar results should be obtained in
private practice when patients place themselves under medical
supervision at the beginning of pregnancy. Under these favorable
circumstances symptoms of autointoxication probably occur not oftener
than once in every hundred pregnancies, but nine out of ten of them,
being promptly recognized, yield readily to relatively simple
treatment.

The early detection of such complications depends largely upon the
patient herself. As has been emphasized--and it cannot be said too
frequently--she should not fail to submit, at appropriate intervals,
a specimen of urine for examination. It is by such an examination
generally that the development of a toxemia is first detected.
Occasionally, however, significant signs will attract the patient's
attention before there is any change in the urine. For that reason,
it is important to notify the physician if any of the following
symptoms appear:

  (1) Serious vomiting.
  (2) Persistent headache.
  (3) Dizziness.
  (4) Puffiness about the face.
  (5) Blurring of vision, or the appearance of black
      spots before the eyes.
  (6) Neuralgic pains, especially in the pit of the stomach.

It must be clearly understood, however, that any of these symptoms
may be present without indicating that a toxemia is developing.
Nevertheless, they should be brought to the physician's attention
without delay, and, at the same time, a specimen of urine should be
given him for examination.

Although the kidneys are not responsible for all the toxemias of
pregnancy, an analysis of the urine affords the most definite means
of determining whether or not such a condition is present. When thus
detected, prompt treatment will guarantee to the patient almost
certain relief. On the other hand if, as usually happens, the
analysis shows conclusively that there is nothing serious the matter,
this reassurance fully justifies the trouble taken to secure it.




CHAPTER VIII


MISCARRIAGE

Frequency--Causes and Prevention--Habitual Miscarriage--Warning
Symptoms--After-effects--Criminal Abortion--Therapeutic Abortion--
Premature Delivery.

We have learned that forty weeks are required for the full
development of the human embryo, but this fact carries no assurance
that pregnancy will last so long; in reality, it may end abruptly at
any time. If growth is interrupted before the twenty-eighth week (the
seventh lunar month), the infant will be too immature to live. Even
when born alive, it will usually perish within a few hours, or a few
days at most. Children born during the seventh month have
occasionally survived; but the prevalent belief that they are more
likely to do so than if born a month later is erroneous. That
superstition originated at a time when great virtue was ascribed to
numbers. Since seven was a sacred number, it was considered more
auspicious to be born in the seventh month than in the eighth.
Universal experience, however, teaches us that the likelihood of
rearing a premature child is, by a rapidly increasing proportion, the
greater for every week that it remains within the uterus. This is
precisely what we should expect, for the period of its existence
there measures the perfection of its development; and that, under
ordinary conditions, determines how strong and hardy the child will
be.

Although during the first six months the outlook for the infant will
be equally unfavorable at whatever time pregnancy may be interrupted,
physicians prefer to distinguish cases which terminate in the earlier
part of this period from those which terminate in the latter part.
For technical reasons, the sixteenth week represents a natural point
of division. A birth which takes place before that time is called an
abortion; one which takes place between the sixteenth and the twenty-
eighth week is called a miscarriage. The anatomical reasons which
justify such a distinction do not concern us here, and the matter
deserves mention merely because the same terms are often employed in
a very different sense by the laity. As most of us know, the
interruption of pregnancy results sometimes from purely natural
causes, and sometimes from the employment of artificial means. As a
rule, persons who are unacquainted with medical terminology call a
birth of the former kind a miscarriage, and reserve the term abortion
for an interruption of pregnancy that is deliberately provoked.
Physicians, however, make no such distinction. They use these words,
as I have said, simply to indicate how far development has progressed
before the termination of pregnancy. Since the term abortion is apt
to carry with it the implication of a criminal act, confusion will be
avoided if we agree for the time to depart from strictly medical
usage and designate as miscarriage the spontaneous termination of
pregnancy prior to the twenty-eighth week.

FREQUENCY.--Early interruption of pregnancy is extremely common. Some
sociologists declare that it is becoming more and more frequent, and
see in it a grave national danger. French statesmen attribute the
alarming decline of the birth-rate in their country, in great part,
to a rapid increase in the number of pregnancies which end
prematurely. Reliable English and German statistics indicate that of
the pregnancies which come under the observation of physicians
approximately twenty per cent, end in miscarriage. In our own
country, though extensive and complete data are not available, it is
likely that the incidence is equally high.

The actual frequency of miscarriage is generally underestimated.
Patients themselves often do not know what has really happened. When
the accident occurs a few days after conception, bleeding may be its
only evidence, which will almost certainly be misinterpreted as an
irregularity of menstruation; and professional advice will not often
be thought necessary. Moreover, in other cases in which the true
situation is appreciated the patient does not feel sick enough to
seek medical assistance. If it were possible to include in the
statistics all these cases as well as those which are concealed
because intentionally provoked, the frequency with which pregnancy is
interrupted during the early months would be found somewhat greater
than is usually supposed.

If we omit the miscarriages which occur within the first few weeks of
pregnancy, and which consequently often escape detection, the
majority of cases fall within the second and third months. After the
fourth month has passed, the probability of such an accident, though
not excluded, is greatly diminished. Some statistics recently
published by Taussig make this clear. In a series of several hundred
cases of miscarriage, one hundred and fifty-seven instances occurred
in the second month, two hundred and twenty-two in the third month,
seventy-three in the fourth month, thirty-seven in the fifth month,
and five in the sixth month. This order of frequency might be
anticipated from the anatomical conditions which prevail during the
early months of pregnancy, since the attachment of the embryo to the
mother is at first relatively insecure, but gradually grows firmer,
and becomes as secure as it ever will be by about the fifth month.

It is noteworthy that miscarriage occurs much less commonly in the
first than in subsequent pregnancies. Indeed, a somewhat greater
liability to the accident with each succeeding pregnancy goes far
toward explaining the greater frequency of miscarriage among women
who have passed the thirty-fifth year than among those who are
younger.

CAUSES AND PREVENTION.--We have seen that the proportion of
pregnancies which end in miscarriage is quite formidable. But this
should not be true, as the accident is frequently preventable, and
many of these accidents could be avoided by the cooperation of
patients. As self-denial and personal inconvenience are often
essential, it is only fair to explain their value. Furthermore, the,
patient who appreciates the reason for certain directions the
physician gives becomes responsible to herself, and is much more
likely to carry them out than is one who is cautioned without
receiving a satisfactory explanation. At best, however, the advice
which the physician is able to offer will be imperfect, for it must
not be imagined that everything is known concerning the causation and
prevention of miscarriage. While our knowledge is so imperfect we
must be content to make the most of what we possess. It must be added
that no suggestion such as can be given here will enable anyone to
dispense with her own medical adviser. On the contrary, if there is
reason to fear miscarriage, the prospective mother should be
encouraged to seek his counsel as early as possible. Aside from the
hygienic measures which she may learn to carry out for herself,
various drugs are often of great value in preventing miscarriage.
Since these are not applicable to all cases, they should be employed
only upon medical advice.

Very early miscarriages may be explained by the loose attachment of
the ovum during the first six weeks of pregnancy. This tiny, living
sphere, it will be recalled, reaches the womb a few days after
conception, and adheres to the uterine mucous membrane. At first,
however, its roots are short and delicate, and not so capable of
anchoring the ovum as they become later. It is only toward the end of
the eighteenth week that the union between the womb and its contents
becomes firm.

From what we have learned in Chapter II regarding the anatomical
conditions in the early days of pregnancy it is obvious that we need
not be greatly surprised at the frequency of miscarriage. On the
other hand, it must not be forgotten that there are many natural
safeguards against accident: to mention only one, the uterus is
ingeniously swung in the abdominal cavity so as to afford a large
measure of protection against mechanical shock. Usually, the
provisions nature has made are sufficient to resist forces from
without which tend to dislodge the ovum. Now and then it happens that
the most irrational acts will not interrupt pregnancy; indeed, they
often seem particularly inert when practised intentionally.

Fear of loosening the ovum from its uterine attachment prompts
experienced women to caution prospective mothers against any kind of
sudden or violent effort. Their advice, however, is often needlessly
alarming; a great many traditional precautions lack a reasonable
basis. Thus, no harm can possibly result from sleeping with the arms
above the head; nor from "over-reaching," as when hanging a picture,
though a fall under such circumstances might be dangerous.

Patients who have been warned by one experience should always be on
their guard if they would avoid repeated miscarriages; others need
only lead a sensible, hygienic life, a matter we have already
discussed in the chapters dealing with the care of the body and the
way to live. For the sake of emphasis, I may here repeat that no
prospective mother should become fatigued from any cause; sweeping,
moving heavy furniture, lifting heavy articles, and running a sewing
machine are not to be attempted. But household duties which do not
require strong muscular effort are better assumed than not.

Amusements which may cause jolting, or expose one to the danger of
falling, involve some risk of miscarriage. Short rides in a carriage
or an automobile over smooth roads are free from objection. Railway-
travel and sea-voyages are not advisable in the early months; after
the eighteenth week they may be undertaken with a greater degree of
safety, provided comfortable accommodations are assured, and the
patient has never had a miscarriage.

A few physicians, even at present, attribute the interruption of
pregnancy to strong emotions, including intense joy or sorrow, anger,
fright, or even jealousy. Without denying altogether the possibility
of such an influence, we may be sure that its importance is greatly
exaggerated. It is not unusual to see patients who are able to recall
a mental shock of some kind shortly before the miscarriage occurred;
nevertheless, in such cases diligent search will usually reveal a
physical cause for the accident.

Another popular fallacy relates to the effect of drugs upon
pregnancy. The use of castor oil and other strong purgatives do not
interrupt it. Should the administration of any cathartic be followed
by miscarriage, some fault inherent preexisted in the pregnancy, and
no amount of precaution would have enabled the patient to reach full
term successfully. Quinin in tonic doses may be taken with impunity,
and even larger quantities are being constantly used for the cure of
malaria without doing the pregnancy any harm. Many other drugs are
reputed to have great efficacy in causing the expulsion of the
product of conception; unfortunately, they are too well known to
require enumeration. They are usually unreliable, and are absolutely
inefficient in doses small enough not to endanger the mother's life,
provided the pregnancy is a healthy one.

Instances in which miscarriage is attributed to the use of some drug
are quite common, and we cannot dismiss them without a word of
explanation. Such cases generally fall into one of two classes. Often
a drug is given credit for efficiency where conception has been
erroneously suspected. Shortly after the menstrual date passes, some
medicine is resorted to, and the subsequent phenomenon, regarded as
the interruption of pregnancy, is really no more than normal
menstruation. In another group of cases miscarriage does actually
occur, although the medicine employed plays only a minor role in its
production. In such instances the irritation which the drug occasions
is the last link in a chain of events leading up to the miscarriage,
but the main factor lies in some fundamental imperfection in the
pregnancy. Physicians recognize a variety of these imperfections, and
know that they may be located in the womb, in the embryo, or in the
tissues which unite the one with the other. As an intimate knowledge
of pathology is often necessary to recognize the underlying, and
therefore the actual, cause of the miscarriage, it is not at all
surprising that patients frequently err in their interpretations of
such accidents, and emphasize unimportant matters.

It would lead us too far afield to attempt to discuss every cause of
miscarriage. Nevertheless, there are some very important ones, not
yet mentioned, which should be understood by the laity, as
appreciation of their significance may avert trouble. In some
instances, on the other hand, the accident is unavoidable; to know
this should afford the patient a large measure of comfort.

Irregularities in the position of the womb are often responsible for
miscarriage. Such a condition may exist in women who have not borne
children, but it is far more likely to occur as a result of
childbirth. After delivery, the enlarged womb becomes the seat of
intricate changes, the purpose of which is the restoration of the
organ to the condition which existed before conception. It dwindles
in size, and gradually drops to its accustomed location within the
pelvic cavity. Six weeks are usually required for these changes.

At the time of birth it is impossible to predict whether the womb
will finally resume a satisfactory position. Accordingly, an
examination two to four weeks later is essential. In four out of five
patients the organ will be found in its proper location, but, even
though it is not, suitable measures adopted at once will generally
serve to replace and hold it in good position. On the other hand, if
the malposition is not recognized until months or years later, simple
procedures will prove inefficient, and a surgical operation will
become necessary. Were there no other reason for a careful
examination at the end of the lying-in period, it would be amply
justified by the information which it gives relative to the position
of the uterus.

Although there can be no doubt that the routine correction of uterine
displacements shortly after labor would go far toward restricting the
occurrence of subsequent miscarriage, it would be incorrect to leave
the impression that miscarriage will always occur if the uterus is
out of its normal position. Not infrequently the changes wrought by
pregnancy will cause the uterus to right itself spontaneously.

Another important cause of miscarriage consists in abnormalities in
the lining of the uterus. Through inherent defect or acquired disease
this tissue may become unsuited for anchoring or nourishing an ovum.
In either event, a surgical procedure, known as curettage, affords
the most likely means of restoring it to a healthful state. The
operation removes the old lining; and a new one quickly develops,
which is often more capable of fulfilling the purpose for which it is
intended.

An appreciable number of miscarriages depend upon conditions over
which medical skill has no control. Under such circumstances, though
the accident may be regretted, there is no room for remorse or
censure. Often the embryo should bear the blame; if its development
is imperfect or if it dies, miscarriage usually occurs very promptly.

We are familiar also with a few maternal conditions which seriously
affect the embryo, often seriously enough to cause its expulsion,
alive or dead. In this respect, certain constitutional disorders are
preeminent. Bright's disease and diabetes are prejudicial to the
development of the embryo; women suffering from either of them must
be watched with great care. Occasionally, such pregnancies come to a
premature end in spite of every precaution. Various infectious
diseases, as typhoid fever and pneumonia, also are fatal to the
embryo if the causative bacteria pass into it. Fortunately this
rarely happens, since the placenta generally affords an effectual
barrier to their entrance into the embryo. Organic diseases of the
mother's heart also may bring about miscarriage. A patient thus
affected should place herself under the supervision of a physician as
soon as conception is suspected.

Now and then physicians are completely at a loss to explain cases of
miscarriage. Our ignorance is unfortunate, particularly when repeated
miscarriages have occurred and their causation cannot be detected.

HABITUAL MISCARRIAGE.--Experience teaches that women who have had one
miscarriage must be more careful than other prospective mothers if
they would escape a repetition of the accident. Persons who know
themselves to be subject to miscarriage should regard no precaution
as too burdensome. Not only should they avoid motoring, driving,
railroad journeys, sea voyages, and every kind of strenuous exertion,
they must accept every opportunity to be quiet and rest. Often such
hygienic care yields sufficient protection; but occasionally medicine
is also necessary.

A number of causes are at hand to explain habitual miscarriage, but,
in fairness, it must be acknowledged that physicians are not able to
interpret all cases. With one class of patients the muscle fibers of
the womb are peculiarly irritable, whereas in another its lining
proves incapable of firmly anchoring the ovum. Moreover, derangements
of organs which do not belong to the reproductive group may be
responsible for the habit.

It is a curious fact that the accident is most likely to occur when
menstruation would be expected were the individual not pregnant.
Obviously, extraordinary precaution is advisable at such times, and
if the patient would avoid even the slightest risk, she should not
leave her bed. The same purpose will not be served by sitting quietly
in a chair, nor by reclining on a couch; complete relaxation and
composure are secured only when one lies flat on the back, loosely
attired in sleeping garments. I have known several persons with a
tendency toward miscarriage who overcame it in this way. Recently one
of them who had been delivered prematurely on two former occasions,
and who was anxious for a successful issue to her third pregnancy,
was willing to remain in bed practically the whole period of
gestation. She had her reward; a well-developed infant was born at
full term, and has continued to thrive.

Prolonged rest in bed, some will say, is debilitating. While that may
be true to a degree, untoward effects can always be avoided by
systematic massage of the extremities. The abdomen should not be
subjected to such manipulations, for they will occasionally provoke
painful contractions of the uterus and defeat the purpose of staying
in bed.

Patients who are not disposed to undergo a long period of enforced
rest, no matter what profit may be promised, should at least consent
to keep in bed during that period of pregnancy at which a previous
miscarriage took place. We know that the event is particularly apt to
recur at such a time. Specifically, it is important to remain in bed
one week before and one week after the date in question.

When pregnancies follow one another in rapid succession, the
liability to miscarriage is notably increased. A natural interval
between births has been provided, an interval which depends upon the
mother nursing her child. Ideally, menstruation, and with it the
ripening of the ova (egg-cells), does not occur while the breasts are
active; but when the infant does not suckle, the ovaries regularly
resume their function in a very short time. Since the circumstances
attending miscarriage always deprive the mother of the opportunity of
nursing, another pregnancy may quickly ensue unless these facts are
appreciated.

Those who anticipate the possibility of a premature interruption of
pregnancy should realize that the marital relation is inadvisable
after conception has taken place. For others, who have no reason to
expect irregularity in the course of pregnancy, such a precaution is
unnecessary. None the less, women who marry late in life or who first
conceive toward the time of the menopause will do well to follow the
same rule. The risk of accident may be very slight, but conservative
persons will not assume it when the likelihood of subsequent
conception is doubtful.

Not infrequently the fundamental reason for habitual miscarriage lies
in some anatomical abnormality which a surgical operation alone can
correct. As the necessity for interference can be determined only
after a careful examination, recommendations of wide application are
not possible. Nothing short of painstaking study of each case will
afford a basis for advice and action.

SYMPTOMS.--Very definite warning usually precedes a miscarriage, but
the threatening symptoms vary greatly in severity and duration. If
appropriate measures are taken promptly, these symptoms may disappear
with no harmful result Everyone concedes that bleeding and pain are
the chief indications of impending miscarriage, although an
occasional patient, profiting by former experience, may find other
signs prophetic in her own case.

Mature women, accustomed to the regular monthly function of their
sex, are prone to treat with indifference a slight discharge of blood
occurring during pregnancy. Indeed, it is widely believed that
menstruation frequently continues after conception. In point of fact,
however, it is very unusual in early pregnancy, and becomes entirely
impossible after the fourth month. Accordingly, whenever vaginal
bleeding is noticed, some other explanation should be sought; and the
patient who would adopt the wisest plan should assume that she is
threatened with miscarriage. There are other possibilities, but these
are for her doctor to consider.

It is true that small hemorrhages are not necessarily followed by
miscarriage. One may even experience slight loss of blood repeatedly,
and yet give birth to a healthy child at the natural end of
pregnancy. None the less, bleeding, however moderate, should always
excite suspicion, as we know it usually denotes the breaking to some
degree of the connection between mother and child. The extent of the
separation usually determines the degree of the hemorrhage, which in
turn indicates the seriousness of the accident. The fate of the fetus
will depend upon the area of placenta, which has been incapacitated.
Flooding, however, always imperils the fetus, and generally warrants
the inference that so much of the placenta has been separated as to
render further development impossible. On the other hand, so long as
the hemorrhage does not exceed the customary flow at the monthly
periods, the life of the child is rarely endangered; while a
chocolate-colored discharge, and even the loss of small clots, may
continue indefinitely without doing serious harm. Under such
circumstances, however, the patient should communicate with her
medical adviser, and should save for his inspection whatever may be
expelled.

Pain, the other conspicuous symptom of threatened miscarriage, has
not a uniform significance. Since it frequently occurs during the
course of pregnancy in association with a number of conditions, it is
not a reliable sign of danger. Moreover, the susceptibility to pain
varies; thus, of two patients in the same stage of threatened
miscarriage one may suffer intensely, while the other remains
comparatively comfortable.

Typically, the onset of miscarriage is attended by discomfort in the
small of the back, which may be continuous, but more often is
intermittent. If preventive measures are instituted at the outset,
there is hope of relieving the discomfort and averting the
miscarriage; but if the warning goes unheeded, the pain will
gradually shift to the lower part of the abdomen and become more
severe. It often happens that the cramp-like abdominal pain of
threatened miscarriage is confused with that associated with
intestinal indigestion. A simple test will sometimes decide the
question. If due to the latter cause, the discomfort will usually
yield to a teaspoonful of paregoric, whereas it will be without
effect if miscarriage is imminent. Exceptions to this rule are not
uncommon, yet a better one cannot be given; as a physician, even
after considering the technical evidence, may find it impossible to
decide at once whether or not miscarriage is threatened.

No confidence can be placed in many so-called signs of miscarriage,
though implicitly trusted by the laity. Lassitude, depression of
spirits, and general bodily ill-feeling may forecast the interruption
of pregnancy; but more frequently they have no such significance. The
same estimate holds true of other symptoms, including diarrhea and a
persistent inclination to empty the bladder. Nor does fever always
lead to the termination of pregnancy. A moderate rise of temperature
is without significance; but high fever, persisting for several days,
may result in the death of the fetus and subsequent miscarriage.
Nevertheless, prolonged febrile affections, such as typhoid fever,
frequently leave pregnancy unharmed.

So long as the symptoms are confined to slight bleeding and mild
attacks of pain, physicians regard miscarriage merely as threatened.
If the bleeding increases, the outlook becomes less favorable, and,
as I have said, miscarriage is inevitable when it amounts to
flooding. Likewise, rupture of the sack containing the fetus, with
escape of the amniotic fluid, indicates that the culmination of
events will not long be delayed.

The most favorable outcome is when the entire contents of the womb
are spontaneously expelled, which unfortunately does not always
occur. There is, to be sure, rarely any difficulty in the natural
birth of the fetus, for its meager development prevents serious
complications. The separation and extrusion of the placenta, on the
contrary, are apt to be imperfect when pregnancy ends in the early
months, and medical attention is necessary to determine whether the
uterus has been emptied completely. This is particularly important,
because the retention of placental tissue affords opportunity for
several unpleasant complications; and neglect in this regard accounts
in part for the belief that miscarriage is certain to leave women
irreparably broken in health.

AFTER-EFFECTS.--No one will deny that invalidism follows the untimely
interruption of pregnancy more often than the birth of children at
full term. This is not due, as is sometimes said, to the fact that a
miscarriage differs from a normal birth in that it is unnatural, for
other reasons are apparent. One of them, the retention of placental
tissue, has just been mentioned, but serious consequences resulting
from it are almost inexcusable, for, although the placenta may
separate less readily and be cast off less thoroughly after
miscarriage, modern medical skill can successfully cope with such
conditions. Another fruitful source of unfortunate after-effects is
the imprudence of the patient. Women should remain in bed fully as
long after a miscarriage as after the birth of a mature infant; if
they would consent to do so, many ill-effects would be averted. But
physicians frequently encounter strong opposition to precautionary
measures such as this. Many patients argue, illogically, that less
precaution is necessary since pregnancy failed to attain its natural
conclusion, and infer that the earlier that it ends the more quickly
one may leave the bed. In point of fact, even greater precaution is
required than if all had gone normally. Still a third cause for ill-
health may be found in physical ailments which antedated the
miscarriage but were not recognized until after its occurrence.

Invalidism which follows pregnancy and which may be fairly regarded
as chargeable to it depends, in most instances, upon an infection
acquired at the time of delivery. Infection occurs more frequently
when pregnancy ends during the early months, because in this category
is included the great majority of criminal abortions, which are
usually induced without regard for surgical cleanliness. Fatal
complications, or serious consequences which narrowly escape a fatal
ending, are common among women who attempt to rid themselves of an
unwelcome pregnancy. As they are ignorant of aseptic precautions,
their manipulations must necessarily contaminate the site of
operation; for this reason and others as well women who attempt to
perform an abortion upon themselves imperil their lives. The danger
is scarcely less when abortion is induced unlawfully by incompetent
operators; for lack of skill, the need of secrecy, and the desire of
haste all interfere with necessary aseptic technique. Everyone knows
that sad accidents befall those who submit to such operations; but it
is not generally recognized that these cases are largely responsible
for the ill-repute borne by miscarriage in general. On the other
hand, properly supervised miscarriages are attended by no greater
danger and probably less than delivery at full term.

CRIMINAL ABORTION.--The destruction of a pregnancy, except when its
continuance threatens the life of the patient, is forbidden by law.
The important ethical and religious aspects of the act which the law
thus stigmatizes as criminal we may properly neglect. Although
various religions present a diversity of teaching relative to its
moral nature, all agree in regarding it as sinful. Equally important,
however, is the fact that no matter what opinion anyone may hold as
to the morality of the act he is bound to obey the law. This is
apparently not clearly understood by the laity, for many persons
think that a physician may terminate pregnancy whenever he is so
inclined. If the liability to criminal prosecution which a physician
would assume should he comply with a request for the means of
destroying pregnancy were clearly realized, patients would not
beseech him to incur the risk of heavy find and long imprisonment
merely to gratify their own convenience or to save them from
disgrace.

The Common Law, an inheritance from England, enriched with
authoritative decisions by our own courts, is the groundwork of the
law in all the States, and its principles are binding in the absence
of express statutes. At Common Law, abortion is punishable as
_homicide_ when the woman dies or when the operation results
fatally to the infant after it has been born alive. If performed for
the purpose of killing the child, the crime is _murder_; in the
absence of such intent, it is _manslaughter_. _The woman who
commits an abortion upon herself is likewise guilty of the crime._

The great majority of those who desire the interruption of pregnancy
feel they have not assumed an illegal position so long as they avoid
instrumental procedures. That is not correct, for even at Common Law
it is a misdemeanor to bring about the death of an unborn child _by
the use of drugs or by any other means_.

At Common Law there was a difference of opinion as to whether all
induced abortions were illegal. Many courts formerly held that
quickening was a necessary prerequisite; but under the modern
statutes, practically without exception, the law disregards the
period of pregnancy at which the abortion is provoked. Since the time
of conception determines the beginning of embryonic development, to
prove that the act was committed before fetal movements were
perceived is no longer a valid defense. This has been emphatically
stated by Judge Coulter, of Pennsylvania, who said: "_It is not the
murder of a living child which constitutes the offense, but the
destruction of gestation by wicked means and against nature. The
moment the womb is instinct with embryonic life and gestation has
begun, the crime may be perpetrated._"

Each commonwealth has enacted its own statutes for the regulation of
abortion. In many states, simply _to seek the means for destroying
pregnancy is a criminal act_. Thus, Indiana, perhaps the most
progressive of the States in reconstructing its criminal code to
accord with modern sociological teaching, has enacted a law which I
quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page
1029. "Every woman who shall solicit of any person any medicine, drug
or substance, or thing whatever and shall take the same, or shall
submit to any operation or other means whatever with intent thereby
to procure a miscarriage, except when done by a physician for the
purpose of saving the life of the mother or child, shall, on
conviction, be fined not less than ten dollars, and be imprisoned in
the county jail not less than thirty days nor more than one year." To
include the woman as a party to the crime is a signal mark of
progress toward bringing abortion under effective legal control.
Heretofore, the perpetrator alone has been responsible, and in most
States he remains so, while the woman is regarded as a victim.
Clearly, that is unjust, for criminal abortions are rarely, if ever,
performed without application by the subject of the operation.
According to most of the statutes no distinction is made between the
attempt at abortion and its accomplishment. Irrespective of the
outcome, those who supply drugs or employ instruments purposing the
destruction of pregnancy are guilty of the offense.

An extensive analysis of the various State laws is unnecessary; the
mention of a few statutes, selected from different sections of the
country, will suffice to indicate the character of prevalent
legislation. Massachusetts imprisons those found guilty of abortion
for a period of three years or less, and permits a fine of one
thousand dollars. In Pennsylvania the same prison sentence is
imposed, though the fine may not exceed five hundred dollars. Three
years is the minimum imprisonment in Virginia, and a maximum of ten
years is allowed. Colorado's law duplicates that of Massachusetts.
California imposes no fine, and prescribes a sentence of from two to
five years in the State prison. All the statutes make the offense
much graver when the woman dies as a result of the practice. Under
these circumstances, the crime never takes lower rank than
manslaughter; and generally it is murder.

Evidently we possess sufficiently stringent laws regarding criminal
abortion; yet, as everyone knows, they do not prevent perpetration of
the crime. On good authority, we are informed that eighty thousand
unlawful abortions are performed annually in New York, in spite of a
possible penalty of four years in the State prison. This is due in
part to difficulty in securing evidence and failure to prosecute when
evidence could be gathered, but more particularly to the fact that
the general public does not appreciate the gravity of the offense.
The same feeling is illustrated in the advertising of abortifacients.
Newspapers and magazines unhesitatingly carry, under the guise of
remedies to regulate the health of women, notices of drugs and
equipment intended to destroy pregnancy. This is expressly forbidden
by many statutes. [Footnote: Thus, the Maryland law provides that
"any person who shall knowingly advertise, print, publish, distribute
or circulate any pamphlet, printed paper, book, newspaper notice,
advertisement or reference containing words or language or conveying
any notice, hint, or reference to any person or to the name of any
person, real or fictitious, from whom, or to any place, house, shop,
or office, where any poison, drug, mixture, preparation, medicine, or
noxious thing or any instrument or means whatever; or from whom
advice, direction, information or knowledge may be obtained for the
purpose of causing the miscarriage or abortion of any woman pregnant
with child, at any period of pregnancy, shall be punished by
imprisonment in the penitentiary for not less than three years, by a
fine of not less than five hundred dollars, nor more than one
thousand dollars, or by both, in the discretion of the court."]

The knowledge that prohibitory laws exist is sufficient to deter
reputable physicians from illegal practice; whereas known laxity in
the enforcement of the law continually tempts unscrupulous persons to
provoke abortion. Among the poorer classes the procedure is
undertaken by ignorant women, while persons in more comfortable
circumstances avail themselves of the services of medical men who are
usually incompetent and value money above professional honor. The net
result is an unpardonable death-rate and a large proportion of
invalids. Aside from the legal aspect of the act, the element of
personal danger would seem a warning to be heeded by women who
contemplate becoming a party to this crime.

THERAPEUTIC ABORTION.--If a woman is suffering from tuberculosis or
some organic affection, pregnancy may add a serious strain upon the
already crippled machinery of her body. Occasionally gestation itself
may cause changes which threaten life. In either event the duty of
the physician is plain. The law is acquainted with such emergencies,
and explicitly permits the termination of pregnancy when undertaken
to relieve or cure such conditions. When performed to restore health
the operation is called therapeutic abortion.

The Maryland law, for example, grants the right to induce abortion
whenever two or more physicians see the patient and agree that "no
other method will secure the safety of the mother." Similar rules are
prescribed by the statutes of other States, but none concedes the
right of abortion as a means of keeping the woman from suicide.

Since therapeutic abortions are legal, they may be done openly; hence
the operation is performed in appropriate surroundings and with every
refinement of surgical technique. These fortunate conditions
materially alter the outlook; serious consequences of the operation
itself need not be feared. Competent surgeons, employing modern
methods, may perform hundreds of abortions without the loss of a
single patient. Moreover, pregnancy may be terminated safely and
expeditiously at any time; the lay view which regards abortion as
more serious after the second month than before it is a relic of days
gone by.

PREMATURE DELIVERY.--In the introduction to this chapter we noted
that the infant becomes viable after the twenty-eighth week, which
marks in a practical sense, the transition of the fetus from an
immature to a premature stage of development. In point of frequency,
premature delivery ranks far below either abortion or miscarriage.

Unlawful interference with pregnancy generally proceeds from a desire
to avoid offspring, and lacks incentive after the infant becomes
capable of living independently. Criminal operations, therefore, are
not a conspicuous cause of premature delivery. Occasionally
physicians resort to artificial means to end gestation during the
later months in order that organic complications may be relieved; but
most premature births occur spontaneously. Sometimes they are due to
ill-health, while in other instances no evidence of disease is found
in either mother or child. Careful study of the individual patient,
however, is generally helpful toward the prevention of repeated
premature delivery.

The course of premature labor closely resembles delivery at full
term. But it is shorter because the infant is small; and the
subsequent loss of blood is not so great. The recovery of the mother
is never retarded by the fact of earlier delivery, though the
conditions which caused it may prevent rapid convalescence.

The outlook for the infant depends upon a great many factors. Most
important among them is the perfection of its development, which may
be estimated most satisfactorily from its weight and length.
Occasionally children have been reared when they weighed as little as
three pounds, but hope that they will survive should not be
entertained unless they weigh four pounds or more. This is attained
about eight weeks before maturity, and corresponds to a length of
forty centimeters (16 inches), measured from the crown of the head to
the heel. Premature children perish, most frequently, either from
incomplete development of their heat-regulating apparatus, which
predisposes them to pneumonia, or from imperfections in the digestive
functions, which increase the liability to malnutrition. To overcome
the first danger, incubators have been devised and have become
familiar to everyone through public exhibitions. A basket or box
supplied with hot-water bottles answers the same purpose, and has the
advantage of better ventilation. The second danger can be overcome
only by proper feeding. Breast-milk provides the most reliable
nourishment for premature infants. If the mother cannot supply it, a
wet-nurse should be procured, and, if the infant has not the strength
to suckle, the milk should be drawn from the breast and fed with a
medicine-dropper or a spoon.

In addition to providing proper food and maintaining an even body-
temperature, care must also be taken to protect these infants from
various harmful influences such as too much handling, strong light,
and loud noises. Although every precaution be observed, frequently
all counts for nothing; but if the child does thrive, there is no
reason for worry about its ultimate development. When a premature
infant lives, the same chances for adult health await it as it would
have had if born in its due time.




CHAPTER IX


THE PREPARATIONS FOR CONFINEMENT

Engaging the Nurse--Desirable Qualities in the Nurse--Preliminary
Visits of the Nurse--The Necessary Supplies for Confinement--The
Baby's Outfit--Sterilization--The Choice and Arrangement of a Room--
The Bed--The Preliminary Visit of the Doctor--When to Call the
Doctor--Personal Preparations--The Care of Obstetrical Patients at
the Hospital.

Prospective mothers are anxious to learn how they shall prepare for
the approaching confinement. They desire their preparations to be
thorough, reliable, and in accord with the most approved methods of
treatment, for they realize that preparations along these lines will
not only prevent haste and confusion at the time of birth, but will
also promote a satisfactory convalescence. Apparently trivial details
often safeguard confinement against serious accident. Indeed,
measures which aim at the prevention of illness form the chief asset
of modern obstetrics, and of these none takes higher rank than the
maintenance of strict cleanliness during and after childbirth. This
fact fortunately is widely appreciated at present, and not a few
women inquire voluntarily the means of observing the proper
precautions. It is true, of course, that even today many women are
delivered in filthy rooms and upon dirty beds, and that in spite of
such surroundings some of them make a good recovery. Yet grave
complications develop much more frequently among those who have not
paid attention to the preparations for confinement.

The surgical dressings and other supplies do not require attention in
the early months of pregnancy. A number of articles, invaluable when
delivery occurs at full term, are useless if the fetus is immature
and cannot live, and therefore it is unnecessary to provide them
until two or three months before the confinement is expected. In the
event of a miscarriage what is needed can be procured upon very short
notice. But, on the other hand, delivery subsequent to the twenty-
eighth week may require all the equipment useful at full term so that
everything should be in readiness by that time.

ENGAGING THE NURSE.--As soon as the existence of pregnancy is clearly
recognized the patient should select the doctor and the nurse who
will attend her. Prompt selection of a nurse will assure the widest
choice, for proficient nurses are in demand and book engagements far
in advance of the date they will be needed. Furthermore, it is a
relief to the patient to have her attendants selected. The
possibility of premature delivery never interferes with engaging the
nurse very early in pregnancy, for that accident releases both
patient and nurse from their contract.

Nurses demand that the date be specified upon which an engagement
shall begin, as, unless their calendar is definitely arranged, they
are unable to earn a livelihood. This leads to a question which is
difficult to answer, for the precise day of delivery is uncertain;
consequently to fix the beginning of the engagement may prove a
troublesome matter. On the one hand, there is risk of having to pay
the nurse for a time before her services are actually needed; on the
other, a false economy may result in the absence of the chosen nurse
at the critical moment. In finding a way out of this dilemma a
patient must be guided by her means and the location of her home.
Those who can afford it will not hesitate to employ a nurse from one
to two weeks in advance of the expected date of confinement; and for
those who live where nurses cannot be procured quickly, a similar
course is recommended. But persons of only moderate resources, living
in a city where, in an emergency, a substitute can be gotten from the
local "Nurses' Directory," will find it convenient to engage the
nurse from the calculated date. The substitute will remain with the
patient until the arrival of the nurse originally engaged.

Occasionally, it may happen that a patient will prefer to keep the
substitute. Such a course, however, would be unjust to the nurse who
was first selected, unless she could immediately secure other work.
She has reserved a definite period of her time for the patient, and
probably has declined work which seemed likely to conflict with the
engagement already made. She is fairly entitled, therefore, to assume
charge of the case, and the patient who refuses to make the change is
obligated to pay her according to the terms of the agreement.

How long will a nurse be needed after the child is born? The answer
to this question may be altered by so many circumstances that a hard
and fast rule cannot be given. Before the advent of "Trained Nurses,"
obstetrical patients were cared for by "Monthly Nurses," so called
because they remained one month with their patients. It is, likewise,
customary to keep the trained nurse four weeks after the birth; but
whenever possible it would be well to retain her six weeks, since
this period elapses before the mother has entirely regained her
normal physical condition. Those who can afford to keep a trained
nurse six months or a year are exceptional, but very fortunate.

Someone may feel that the suggestions I have made are not suitable to
her case. Very likely they may not be; to cover all the possibilities
could scarcely be expected, for every case has its problems and
peculiarities. After consultation with her physician each patient
will decide what is particularly advisable for her. Nevertheless, I
would emphasize the importance of securing a competent nurse and
retaining her for at least four weeks. Even with those who must guard
their expense account the truest economy will lie in such a course.
Whenever lack of resources seems likely to prevent this arrangement,
the patient who is looking to her best interests should enter a
hospital where excellent care can be provided at a cost within her
means.

DESIRABLE QUALITIES IN THE NURSE.--It is rarely advisable to select
as nurse a member of the family or an intimate friend. Some of the
motives governing such a course--sentiment, mutual devotion, and the
desire to be humored--are inconsistent with the best kind of nursing.
If the nurse knows the patient intimately, undue anxiety may
interfere with her judgment; thoroughness in routine duties may be
hindered by mistaken consideration for the patient; and in an
emergency sympathy rather than reason may guide her. A successful
nurse must satisfy at least two requirements; she must be capable
professionally and also personally agreeable to her patient. Some
regard advanced years as essential to the first of these
qualifications, but this does not necessarily hold good.

The personal qualities generally welcome in a nurse are neatness,
thoughtfulness, a sympathetic nature, an even disposition, and a
cheerful view of life. Since a short interview is insufficient for
taking the measure of a nurse, patients usually rely upon the opinion
of someone else in selecting her. The judgment of her former patients
is frequently prejudiced in one direction or the other, and such an
estimate must always be accepted with caution. Much the most
trustworthy method is to allow the physician to select her. He will
know nurses who possess the requisite qualities, and certainly he is
most competent to judge their professional attainments. If the choice
of a nurse be left to the doctor, the two are sure to work
harmoniously, and the patient will benefit by their cooperation.
Otherwise she may suffer because of their dissensions, for, if the
doctor is accustomed to one procedure and the nurse to another,
misunderstandings may occur, although both methods yield equally good
results. Whenever he does not select her, she should be asked to
confer with him long before the case is due. Obviously, a physician
cannot be held responsible for a nurse's ability unless he is
acquainted with her training and methods of work.

In an effort to economize, many are inclined to employ "half-trained"
or "practical nurses." When the confinement is not the first and
there is no reason to anticipate any irregularity during labor or
thereafter, I can see no vital objection to such an arrangement. It
is of the first importance, however, to be assured that the
"practical nurse" is neat and appreciates the necessity of keeping
everything about the patient scrupulously clean. But competent nurses
who charge less than the customary fee will be hard to find. The
recommendations which these women receive are apt to be even more
misleading than in the case of trained nurses, because more is
expected of the latter. My experience has taught me that patients
form particularly unreliable opinions of practical nurses, and I have
frequently witnessed incompetence in such women which was overlooked
by the patient.

A low-priced nurse is seldom a cheap one, as her shortcomings may be
reflected in the health of the mother or the infant long after she
has left the case. Especially when the baby is the first, the mother
will depend upon the nurse for instruction which should be both sound
and thorough. The principles taught her will be put into practice and
utilized for many months, playing a vital part in the training of the
infant. It becomes essential, therefore, to secure a nurse who will
give the baby a good start, and instruct the mother along right
lines. Perhaps this is less needful if the mother has learned her
lesson from previous experiences. But even then a good nurse relieves
her of responsibility and materially assists her to a quick and
lasting convalescence. In the end the most proficient nurses are the
least expensive.

THE PRELIMINARY VISITS OF THE NURSE.--Many of the precautions which
safeguard a confinement should be considered by the patient and the
nurse together. The character and quantity of the supplies, the
choice of a room for delivery and subsequent convalescence, the
proper clothing for the infant--all these are problems which may be
solved most satisfactorily in the light of the nurse's experience and
the resources at hand. Two visits are usually sufficient to arrange
these details. An interview early in pregnancy, soon after the nurse
has been selected, provides an opportunity to lay plans and
especially to review the list of articles needed at delivery. Such
articles as are already in the house may be checked off; the others
may be procured at leisure. Eight to ten weeks before the expected
date of the confinement the nurse should pay a second visit and
should inspect the supplies to see that they are complete. Certain
articles which I shall indicate must be sterilized. As this procedure
is more reliable when carried out by an experienced person it will be
convenient to have all the dressings finished by the time of the
nurse's second visit, in order that she may sterilize them.

The question may arise as to whether the nurse shall come to the
patient upon the date for which she has been engaged or shall wait
until summoned. From the physician's standpoint it is often more
acceptable to have the nurse in the house a few days before the
confinement, though some patients strongly object to this. Provided
the nurse may be got quickly at any time of day or night, there can
be no objection to leaving the decision to the patient herself.

THE NECESSARY SUPPLIES FOR CONFINEMENT.--As to just what a
confinement outfit should contain physicians differ to some extent;
but this disagreement pertains rather to luxuries than essentials. In
the lists here suggested nothing essential has been omitted, although
economy, as far as is consistent with good judgment, has been kept in
mind. Any article not included in my list which the doctor or nurse
in attendance recommends may be noted in the space for memoranda.

Some patients prefer to take no part in preparing the supplies for
confinement. Indeed, the demand for a ready-made confinement outfit
has become large enough to lead several firms to put them upon the
market. These outfits differ in completeness and vary in price from a
few dollars up to fifty. The majority of patients, however, still
attend to such details themselves, and will find a list of the
needful supplies convenient.

_Make-up and Sterilize_:
  7 Dozen Sanitary Pads.
  2 Sanitary Belts.
  2 Delivery Pads.
  5 Dozen Gauze Sponges.
  2 Dozen Gauze Squares.
  4 Dozen Cotton Pledgets.
  2 Sheets.
  Bobbin for tying the Cord.
  A Pair of Obstetrical Leggins.
  A Dozen and a Half Towels (Diapers).

_Obtain from the Druggist_:
  100 Bichlorid of Mercury Tablets.
  100 grams Chloroform.
  4 ounces Powdered Boric Acid.
  4 ounces Tincture Green Soap.
  1 pint Grain Alcohol.
  A small jar of White Vaselin.
  A cake of Castile Soap.
  A two-ounce Medicine Glass.
  A Medicine Dropper.
  A bent glass Drinking Tube.

_The following articles should be in the house, ready for use._

  An ample supply of Towels, Sheets, and Gowns.

  A new Hand-Brush; the cheap variety with wooden back and stiff
  bristles is preferable.

  Two slop Jars or enamel Buckets with Covers.

  A two-quart Fountain Syringe; an old one may be substituted provided
  it has been thoroughly boiled.

  Three Basins and a one-quart Pitcher of agate or enamel-ware.

  A Douche-Pan; the "perfection Bed-Pan" is preferable.

  Two pieces of Rubber-Sheeting are required, one large enough to cover
  the mattress of a single bed (2 x 1-1/2 yds.), the other smaller (1 x
  3/4 yd.). Should this be too expensive, the best substitute is white
  table oil-cloth.

The nurse will explain how the various surgical dressings are made,
but, as the patient may forget some of the directions, all the
details will be given here. At least three to four pounds of
absorbent cotton will be used in the dressings. To make the pads
entirely of absorbent cotton is very expensive. The cheaper cotton-
batting is therefore employed to give them body, and they are faced
only upon one side with the absorbent material. Furthermore, the
rolls of absorbent cotton, as purchased, may be separated into three
or four layers, one of which is thick enough for the facing. About
six rolls of the batting should be purchased.

Surgical gauze, which tradespeople sometimes call dairy-cloth, is the
most suitable material for covering the pads. Bleached cheese cloth
will answer the same purpose, but it is more expensive and rather
heavy. Approximately thirty-five yards of the gauze, which comes in a
thirty-six-inch width, will be needed. When the supplies are
finished, they are wrapped in separate bundles and sterilized. Old
muslin or some of the diapers are generally used for covers.

_The sanitary pads_, also called vulval or perineal pads, absorb
the discharge which always occurs after delivery. They are made of
absorbent cotton and cotton-batting covered with gauze; a convenient
size is ten inches long and three to four inches wide. Their
thickness is approximately an inch, one-third of which is composed of
absorbent cotton.

_The sanitary belt_ is used to hold these pads in place. Very
satisfactory ones are made of two strips of unbleached muslin, three
inches wide. The first of these must be long enough to reach around
the waist; the second, which passes over the pad, is somewhat shorter
and has two parallel slits in one end; through which the waist-band
passes at the back; the three free ends are pinned together in front.

_The delivery pads_ are made of the same materials as the
sanitary pads; preferably a yard square and four inches thick. A
rather heavy top-layer of absorbent cotton must be used in them, and
they should be quilted or tacked at several points to prevent
slipping. A rubber pad is ill adapted for use during delivery. Some
absorbent material made into proper shape proves much more
satisfactory since it can be thoroughly sterilized and can be thrown
away after it has been used.

I am told that cotton-waste is a good substitute for absorbent cotton
in the delivery pads. It is inexpensive, and will be rendered capable
of absorbing fluids after it has been boiled in washing soda and
dried in the sun. Each delivery pad should be separately wrapped and
sterilized.

_Gauze sponges_ will be needed by the doctor; about five dozen
should be prepared. The gauze is cut in eighteen-inch squares.
Opposite edges are folded toward one another, about two inches being
lapped each time; this finally yields a seven or eight-ply strip,
which is wrapped into appropriate shape about two fingers. The
ravelled ends are then tucked into the roll. It is most satisfactory
to divide the sponges and sterilize them in two bundles.

Small pieces of gauze about two inches square will also be needed in
caring for the baby's eyes and mouth. Several dozen should be cut,
and they may all be sterilized together.

_Cotton pledgets_ are simply bits of absorbent cotton the size
of a hen's egg, the rough edges of which have been twisted together.
A small pillow-case full of them ought to be made up and sterilized.

_Obstetrical leggins_ are preferably made of canton flannel;
they are cut to fit loosely and should reach the hip. If they are
prepared so as to extend to the waist at the sides, they may be held
in place by a waistband, and in this way will prevent unnecessary
exposure without interfering with the doctor. They should be
sterilized.

_Towels_, if used at all, should be without fringe. It is
economical not to employ them, but to use diapers in their place.
Three packages, each containing six diapers, should be sterilized.

_Sterilized sheets_ are often useful at the delivery; more than
two are never needed. They should be wrapped separately for the
sterilization.

_Sterilized bobbin_ is generally used for tying the cord.
Several pieces are cut in nine-inch lengths and sterilized in a
single package.

_A dressing for the cord_ will be required, but there is no
necessity for preparing a special one. It is generally satisfactory
to wrap the cord in one of the sterile gauze sponges which has been
previously soaked in alcohol.

Several methods of drying up the cord give equally good results, and
it is usually a good plan to allow the nurse to dress it as she
wishes, since the employment of a method with which she is familiar
will more likely insure a satisfactory result in her hands. A
dressing popular with many nurses is prepared as follows: In a piece
of muslin four inches square cut a small circular opening; double the
linen and dust boric acid between the folds. If this method is
preferred, several of the dressings should be prepared and sterilized
together.

THE BABY'S OUTFIT.--Preparations for the infant may be thorough
without being elaborate. Instinctively, the prospective mother leans
toward extravagance in fitting out her baby's wardrobe, and easily
slips into the error of providing too much. Time and energy are
frequently devoted to an extensive wardrobe which the infant quickly
outgrows; in consequence many articles must be made over before they
are used. Even with modest resources a prospective mother can acquire
everything the baby really needs.

A very sensible plan, in my judgment, is to prepare what will be
wanted during the first two months; subsequently, articles may be
made or bought as they are needed. Accordingly, the quantity of
wearing apparel and the nursery supplies I have suggested pertain
only to the early weeks of infant life. Although no essential has
been omitted, the outline is plain and economical.

At present, outfitters supply a variety of ready-made, garments for
the infant and conveniences for the nursery; in many of them notable
ingenuity is displayed which aims at the child's comfort or the
saving of labor to the mother. Catalogs of these articles, which are
often expensive, are furnished by dealers.

In preparing clothing for the new-born, several principles must be
kept in mind. The first is that the garments must be warm without
being unduly heavy; and another that they should be roomy, permitting
perfect freedom of motion. A third no less important principle is
simplicity. Adornment of the clothing gratifies the mother, but does
not serve a single useful purpose. The lists which follow include all
that is necessary for the young infant; they will also serve as a
basis for elaboration if a more lavish outfit is desired.

_Necessary Clothing_.
  4 Abdominal Flannel Bands.
  3 Undershirts.
  4 flannel Skirts.
  4 Night Gowns.
  12 White Slips.
  3 Knit Bands.
  4 Dozen Diapers.
  Cloak and Cap.

_Nursery Equipment_.
  An old Blanket.
  Assorted Safety Pins.
  Soft Damask Towels.
  Wash Cloths.
  Hot-Water Bag with Canton Flannel Covers.
  Talcum Powder.
  Olive Oil.
  Bassinet.

_Additional Articles; Convenient but Not Essential_.
  Rubber Bathtub.
  Rubber Bath-Apron.
  Flannel Apron.
  Bath Thermometer.
  Bath Hamper.
  Quilted Mattress Covering.
  Baby Scales.
  Screen.
  Low Chair without Arms.
  Drying Frames.

STERILIZATION.--Now and again, those who follow very rigid rules to
avoid infection during childbirth are criticized for their pains. The
general public has not yet grasped the true relation of bacteria to
this condition; a relation which, indeed, first became clear to
medical men within comparatively recent years. The development of our
knowledge of the nature of infection forms one of the most
entertaining chapters in obstetrics, and provides a simple way of
showing the genuine need of preventive measures. Several observant
physicians had previously suspected the character of "child-bed
fever" (as infection of the mother was once called), but convincing
proof of its contagious nature was not forthcoming until the middle
of the nineteenth century, when signal facts were pointed out by
three men, each working independently, though all came to similar
conclusions. The evidence they gathered should have left no one
doubtful that the disease is contagious, and largely preventable. On
the contrary, bitter opposition was encountered for the time, and
only within the last two decades has their teaching found wide
practical application.

In 1843 Oliver Wendell Holmes published the paper on "The
Contagiousness of Puerperal Fever," which is now preserved in his
volume of "Medical Essays." Physicians were startled to be frankly
told the responsibility they assumed if they neglected the truth
taught by epidemics of this disease. "The dark obituary calendar"
which marked the progress of these epidemics clearly indicated that
"the disease is so far contagious as to be frequently carried from
patient to patient by physicians and nurses." A violent controversy
followed this arraignment, and, consequently, the preventive measures
which Holmes so convincingly urged were not adopted as promptly as
they should have been. The full justice of his conclusions has since
been universally admitted, and medical men now find it difficult to
understand how anyone could have taken issue with the sentiment which
he expressed. "For my part," Holmes said, "I had rather rescue one
mother from being poisoned by her attendant than claim to have saved
forty out of fifty patients to whom I had carried the disease."

But the most important early observations upon child-bed fever were
made in 1847 by a young Hungarian, Semmelweiss, while he was an
assistant in the large Lying-in Hospital in Vienna. In thoroughness,
power of conviction, and practical value his work was masterful. It
is no exaggeration to regard his observations as the rock upon which
antiseptic surgery, the glory of the nineteenth century, was built.

Semmelweiss had been seeking an explanation of the dreadful scourge,
and his mind was ready for the reception of the truth when it was
revealed through the death of one of his colleagues. This physician
injured his finger accidentally in performing an autopsy upon a
patient who had died from child-bed fever. And the condition
disclosed by examination of his body after death was identical with
that found in cases of child-bed fever. Here then was the clew; the
disease was contagious. Semmelweiss was ignorant of Holmes' views;
what had happened before his eyes suggested to him that the disease
was due to a poison which could be conveyed from one person to
another. Moreover, his interest and his power of insight led to
further comparison. Clearly, the open wound on the physician's finger
had been the portal through which the poison entered; but where was
there a similar portal in obstetrical patients? The answer was plain.
The birth-canal at the time of delivery is always an open wound.
There the poison entered, and child-bed fever was a wound infection!

Several years later Tarnier, who was to become an eminent
obstetrician, but was then a student in Paris, chose the diseases of
the lying-in period as the subject for his graduating thesis. He was
unacquainted with the work either of Holmes or of Semmelweiss, and
approached the problem from still another standpoint, drawing
attention to the much higher deathrate among women delivered amid
unsanitary surroundings. Tarnier also considered that the disease was
a form of poisoning, that it was contagious, and that measures should
be instituted to protect patients against it.

Of these pioneers, by far the greatest credit is due Semmelweiss, who
devoted his life to the problem, although his opinions continually
met with scepticism and even ridicule. More convincing proof than he
could furnish was demanded before his contemporaries would believe
that child-bed fever was due to lack of precaution. Fortunately the
evidence was soon produced. In 1880, Pasteur obtained bacteria from
the organs which had been infected, and was able to grow the bacteria
in his laboratory; thus the ultimate cause of the disease became
firmly established. With the harmful agents in their hands, Pasteur
and his followers were enabled to study their characteristics and to
recommend means of destroying them.

Much as we must regret that the warnings of Holmes and of Tarnier
passed unheeded; lamentable as may be the blindness of the generation
of Semmelweiss to the truths revealed by his research, it is not
surprising that such radical teaching met with a hostile reception.
As we measure time in retrospect from the vantage ground of to-day,
the three to four decades required for full acceptance of their
revolutionary doctrines seem a brief span. Antiseptic methods would
not have prevailed so quickly as they did, had not the same epoch
which gave us a Pasteur also given a surgeon with a receptive mind,
ready to seize and apply the discoveries of the French genius. This
was the great service of Joseph Lister. Impressed with Pasteur's
studies on fermentation, Lister saw an analogy between this process
and the putrefaction of wounds, a condition which he was eager to
prevent. He had reason to believe that carbolic acid would check
decomposition, and he employed a weak solution of it in the treatment
of wounds; later he devised a "carbolic spray," by means of which
when his operations were performed the atmosphere round about might
be sterilized.

It is but a short step from antiseptic operations to our own era of
aseptic surgery, and that a step in the direction of simplicity. Now
we know that the sterilization of the air is rarely necessary and
have dispensed with Lister's elaborate apparatus. Furthermore, and of
far greater moment, experience has taught that the destruction of
bacteria before they have opportunity to come in contact with the
wound is more effective than efforts to kill them as they approach or
after they have invaded the tissues. Initial freedom from bacteria is
the ideal of asepsis; to secure it, the modern surgeon is ever
watchful of the cleanliness of his hands, his instruments, his
dressings, and of the site of operation or whatever may come near it.

The importance of the changes wrought by the adoption of aseptic
methods requires no emphasis, for the marvels of modern surgery are
even more impressive to laymen than to the medical profession.
Everybody now understands that strict cleanliness is indispensable to
the success of a surgical operation. But the general public has not
fully awakened to the same profound necessity in connection with
childbirth, although it was child-bed fever that called forth the
observations and experiments upon which modern surgical technique
rests.

Although most obstetrical patients appreciate the fact that there is
an advantage in sterilized dressings and sanitary surroundings, few
realize the risk they run without them. One must know the mournful
history of the past to be adequately impressed with that danger, for
we no longer see the epidemics of childbed fever which formerly swept
over communities, sacrificing ten of every hundred women as they
became mothers. Precaution is no less necessary on that account; the
scourge would be rampant again if the reins were loosened.

Most instances of puerperal infection are, it is true, referable to
lack of care. Nevertheless, the complication develops now and then
where all precautions have been conscientiously observed. Under such
conditions the infection will in all likelihood be a mild one, and a
tedious convalescence usually proves its most disagreeable feature.
Such stringent preventive measures as are now practiced in many
hospitals have reduced the frequency of infections to the point where
only one fatal case, or even less, occurs in a thousand deliveries.
These rare cases remind us that vigilance must never be relaxed, and
that patients who are confined at home require just as much care as
those in hospitals, where conditions are the best to prevent
infection and the complications, which follow.

The first essential toward the avoidance of infection in obstetrical
cases is clean dressings. Naturally, these should be clean to the
sight, but it is in invisible dirt that serious danger lurks;
bacteria are the causative agents of this disease. Experiments have
taught the bacteriologist that disease-producing organisms are killed
in half an hour when subjected to a high atmospheric pressure and the
temperature of steam. Special apparatus has been constructed for
carrying out the procedure. It is unnecessary for our purposes,
however, since the essential conditions may be secured, though with
less convenience, in any kitchen. If a prospective mother finds it
awkward to do the sterilizing at home, and her nurse is unable to
take charge of the matter, she may arrange with a local hospital or
the nearest nurses' directory to sterilize her dressings. Yet a very
little ingenuity suffices to do the work at home with perfect
satisfaction. Installments of the smaller bundles may be sterilized
in a galvanized bucket. To do this place an inverted bowl, with a
depth of three to four inches, at the bottom, and pour in water until
the bowl is almost covered. A breakfast plate rests on the bowl, and
upon this the dressings are stacked; a second larger plate which fits
the top of the bucket is utilized as a lid to close in the
sterilizing chamber. This will not accommodate the larger packages; a
more satisfactory method for all of them is to use a wash-boiler in
which has been swung a muslin hammock.

To arrange the latter form of home sterilizer, cut an oblong piece of
unbleached muslin large enough to sink far down into the boiler and
run a drawing-string of stout cord about the edge. Cover the bottom
of the boiler with several inches of water; tie the hammock in place,
passing the cord beneath the handles of the boiler to hold the muslin
securely. Pack in the dressings, which have been wrapped in
appropriate bundles; put the lid in place, thus closing the
sterilizing chamber, and leave the dressings exposed to the steam for
at least half an hour. After the operation has been completed, the
bundles are taken out of the boiler and allowed to dry in the air.
They must not be opened until the occasion for which the supplies
were prepared arrives; awaiting this event, they are laid away in a
convenient closet or drawer.

A word of caution may be added concerning a method of sterilization
employed at home more frequently, perhaps, than any other. According
to this procedure, the supplies are wrapped in paper, thrust into a
hot oven, and left there until the paper is scorched. From the
standpoint of economy as well as of thoroughness, this method is
likely to prove unsatisfactory. Frequently, the dressings themselves
are scorched; I have known patients to ruin several installments of
their supplies in this way. Moreover, dry heat is not so trustworthy
as steam for sterilizing purposes.

Judicious management means the preparation of the supplies necessary
for confinement before turning to the selection of the infant's
outfit. Ordinarily, both these tasks should be finished by the end of
the eighth month, and final arrangements for the approaching delivery
will then claim attention. If the patient expects to remain at home,
she must decide which is the best room to occupy; she will wonder how
it ought to be equipped, and she will be anxious to learn what
personal preparations are advisable at the beginning of labor.

Intelligent answers to these questions are important. A patient
should request the physician to criticize her plans when he pays the
preliminary visit four to five weeks prior to the expected date of
confinement. If she has acted unwisely in any respect, he will point
it out, and may suggest changes which will enable her to employ to
the best advantage the resources at hand.

THE CHOICE AND ARRANGEMENT OF A ROOM.--An old-fashioned custom, which
relegated obstetrical patients to the most secluded part of the
house, with little regard for comfort and still less for hygiene, has
now few, if any, adherents. There is an advantage, to be sure, in
having a quiet room; but this qualification may be secured in a room
well located with regard to other essentials. Selection of a suitable
room is not a trivial point. In most cases, since patients ordinarily
remain for convalescence in the same room in which the infant is
born, the chamber must serve a two-fold purpose. A number of
requirements, therefore, must be met, and they must all be kept in
mind when the room is chosen.

We have seen that the act of birth, natural as it is, may have a very
unnatural sequel if precautions against infection are treated
lightly. It is proper, therefore, that the delivery-room should be as
clean as care can make it. Such radical measures as may be employed
in sterilizing the dressings are here out of the question; if
possible, they would be absurd. Infection usually develops because
harmful bacteria come in contact with the patient. For that reason,
an infection is more likely to be communicated by the dressings than
by articles about the room, which only become a source of danger when
the dirt upon them is transferred by an attendant.

An acceptable delivery-room may be arranged in any home; it is by no
means necessary to duplicate the equipment of a modern hospital. To
choose a room convenient to the bathroom will be found advantageous
not only at the time of birth but throughout the lying-in period. The
furnishing should be simple and scrupulously clean; indeed, it is
improbable that one of these good points can be secured without the
other. Furthermore, the preparation of the room should be completed
well in advance of the date of confinement.

A large collection of furniture interferes with the nursing, and also
increases the difficulty of keeping the room free of dust. It is
sound advice, therefore, to remove everything which will not serve
some good purpose during the delivery. Should any article be wanted
later, it can be brought back to its accustomed place. The furniture
may be conveniently limited to a bed, a bureau, a washstand, a table,
and several chairs, one of them a large, comfortable rocker, which
will prove invaluable during the early part of labor.

To approach perfect conditions, bric-a-brac, needless hangings, and
everything that might collect dust should be temporarily removed. A
profusion of pictures does not accord with the best sanitation of a
room devoted to the treatment of obstetrical patients; those which
are to be left upon the wall ought to be taken down and wiped
carefully with a damp cloth. Other desirable preparations would be
instinctively undertaken by the modern housekeeper, and it may seem
presumption to mention that the room itself ought to be subjected to
most thorough cleaning. It is well to leave the floor bare or merely
covered with freshly cleaned rugs. Carpeting is difficult to protect
against soiling and is not sanitary. If left down, the carpet should
be covered with some suitable material, firmly stretched and tacked
in place.

We know that the air in most households does not contain disease-
producing bacteria; but the presence of any contagious disease
materially alters the situation, and may imperil the convalescence of
an obstetrical patient. Preferably, one should never select a room in
which there has lately been sickness, and under no circumstances may
such a room be used until carefully fumigated. The more conspicuous
diseases which for at least several months absolutely disqualify an
apartment for obstetrical purposes are diphtheria, pneumonia,
pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of
all varieties, and every sort of discharging sore.

When possible, two adjoining rooms should be given over to the mother
and the infant; if this is impracticable, the single room should be
large, easily ventilated, well lighted, and heated in such a way as
to permit a change of temperature without difficulty. All these
features help to make convalescence comfortable and free from petty
annoyances. A room which has a southern or eastern exposure proves
grateful for those who must remain indoors; frequently, this will be
beyond reach, but a room getting the sun's rays directly during part
of the day will always be available, and the selection should be made
with that requirement in mind. At the time of birth and for the first
few days which follow, a patient may not appreciate this feature;
ultimately she will understand the need of sunlight better than the
need for the more technical, and therefore the more impressive,
preparations.

THE BED.--Now that housekeepers recognize how easily such furniture
can be kept clean, few homes are without a brass or an iron bedstead;
they are equally sanitary. Undoubtedly, this kind of bedstead
fulfills the needs of an obstetrical patient much better than any
other; and, if at hand, it should be used. The single bedstead is the
most acceptable, and the mattress ought to be at least twenty inches
above the floor. A low, wide bed interferes with proper management of
the delivery and later handicaps the nurse in taking care of the
patient. Wooden blocks may be used to raise a bed which otherwise
would be too low. It is well worth while to provide them if one
desires good nursing, for no attendant can do her best when she must
continuously bend over a very low bed.

The location of the bed at the time of delivery is not an unimportant
matter; it must always be placed so that the brightest possible light
will shine over the foot. Since birth often occurs at night, one
should make certain that the artificial lighting of the room is good,
and place the bed most advantageously in reference to it; at the same
time the necessity of a good light from the windows, when delivery
occurs during the day, should not be forgotten. The head of the bed
may be placed against the wall, but both sides must remain freely
accessible not only at the time of delivery but also throughout the
lying-in period.

A smooth, firm mattress, made in one piece, should be provided. One
which has been used several years and possibly worn in a hollow will
require renovation to be made comfortable. A feather bed should not
be used under any circumstances. The mattress must be protected; and
protection is best secured by means of a large piece of rubber
sheeting. The regulation household sheet covering the rubber should
be tucked well under the mattress at the ends and sides; in that way
the rubber sheeting will be held firmly. Since the part of the bed
where the hips rest will be most exposed to soiling, the protection
of this area is usually reinforced by a "draw sheet." To arrange
this, a cotton sheet is doubled so as to make a strip about one yard
wide and two yards long; the smaller piece of rubber sheeting is laid
between the folds. The draw sheet will reach from the middle of the
back to the knees; its ends should be tucked under the sides of the
mattress, to which it is fastened by means of large safety pins.
After delivery, the draw sheet may be removed without disturbing the
mother, who will thus be assured a clean, dry, and comfortable bed.

The bed-clothes covering the patient during labor will vary with the
season of the year, but should always be light; in summer a single
sheet will suffice, and in winter a blanket will likely be needed.
For sanitary reasons, a freshly laundered sheet should also be placed
outside the blanket until the delivery has been completed; later, it
may be replaced with a light spread. Two pillows will be needed, and
it is very convenient to have one of hair, the other of feathers.
While there is no necessity for sterilizing the bed-clothes, it is
advisable to use linen which has been recently laundered and kept
well protected from dust. Among the poor, infection from soiled bed-
linen is not uncommon.

THE PRELIMINARY VISIT OF THE DOCTOR.--No teaching of medical science
has been given greater prominence of late than the principle of
prevention. In obstetrics it finds a particularly wide field of
application, and its practice is responsible for removing many of the
former terrors of childbirth. We have just learned that preventive
measures effectually reduce the frequency of puerperal infection, and
in an earlier chapter we saw the value of routine examination of the
urine as a means of anticipating other complications. Moreover, the
benefit of promptly reporting to the physician anything that does not
seem to be as it should has been urged constantly, for in this way is
afforded the earliest opportunity to treat complications. Similarly a
visit from the doctor about four weeks before the expected date of
confinement is indispensable to skillful management of the delivery;
neglect of this precaution is sometimes responsible for bad results.

At this visit the physician not only becomes familiar with the
general health of his patient, but he also notes certain facts which
will have a direct bearing upon the course of labor. By means of a
few simple measurements he may accurately determine the character of
the pelvis, the bony structure through which the fetus passes. When
they are compared with what we know as the normal measurements, a
very good idea is gained as to whether the birth-canal will present
any obstacle to the passage of the child; and, if it will, there is
opportunity to deliberate what treatment may be necessary. Since
another factor in the problem, namely, the size of the child, cannot
be accurately predicted, occasionally the physician may hesitate to
express as definite an opinion as the patient may wish. Nevertheless,
though it may be impossible to learn every detail, the available
information well repays the time and trouble expended. In nine out of
ten cases nothing whatever is found out of the way; the result is an
assurance which always justifies the examination.

During this examination the position of the child is also
ascertained. By means of a series of painless manipulations through
the abdominal wall of the mother, the head, the body, and the
extremities of the child may be mapped out, and the conclusions
verified by locating the fetal heart-sounds. In this regard, also,
the physician usually finds normal conditions. The most favorable
presentation, that in which the head is the part to be born first,
occurs in ninety-seven of every hundred cases. When less favorable
conditions are recognized, they may frequently be corrected at once;
but should that prove impossible, with foreknowledge of the
presentation, the physician will be more competent to conduct the
delivery.

With a clear understanding of the character and value of the
information gathered at the preliminary examination, patients are not
likely to refuse it. If they do, the risks should be fully explained
to them. Some physicians decline to assume the responsibility of a
patient who will not permit these observations. Such a decision is
rarely necessary, for in my experience the patient's consent has
never been difficult to obtain. Many women now regard the visit as
part of the routine attention, and inquire when it will be made.

The appropriate time for this examination, as I have indicated, is
approximately one month prior to the calculated date of confinement.
Before this period, we have no assurance that the presentation which
is found will continue until the time of birth. The fetus frequently
alters its position as long as it is not large enough to fill out the
cavity of the womb, consequently it is only during the last month of
pregnancy that the final presentation can be determined. But to defer
the examination after the period I have specified is unsafe since we
lack an exact method of fixing the day of confinement, and too long a
delay might render a preliminary examination impossible.

Aside from its relation to the observations just outlined, the
preliminary visit provides an opportunity for the physician to
criticize the preparations which have been made, and for the patient
to inquire about the personal preparation advisable at the beginning
of labor. She will also learn the signs which indicate that labor has
begun and will be told what to do when they appear. Although
physicians may not agree in all these directions, there can be no
difference of opinion relative to the essential points. At least, the
rules given here will serve to bring the patient and the doctor to a
definite understanding as to the course he desires her to follow.

WHEN TO CALL THE DOCTOR.--During the last two or three weeks of
pregnancy not a few patients are more comfortable than they have been
for several months. About this time the womb usually drops somewhat
and relieves the pressure which has interfered with breathing. These
changes, however, do not promote comfort in every direction; more
freedom for the organs of the chest means compression of the
structures below the womb; consequently, the inclination to empty the
bladder and for the bowels to move becomes more frequent. Patients
complain also of cramps in the legs and experience difficulty on
walking. This order of events enables some women to recognize the
approach of delivery. Of course there is other evidence when labor
actually begins. Its onset may be indicated in one of three ways,
namely, by periodic pains, by a gush of water from the vagina, or by
a discharge of blood as though the patient were taken unwell. Each of
these unmistakable signs is a sufficient reason for notifying the
doctor.

At the onset of labor, dragging pains are usually felt at the back,
but sometimes in the lower part of the abdomen. The rhythm with which
they come and go identifies them more certainly than any other
feature, though this indication is not entirely reliable, for
intestinal colic also causes rhythmical pain. At first the uterine
contractions which occasion the discomfort are weak and appear at
long intervals. Gradually they become stronger and closer together.
When the interval between them has been shortened to half an hour or
less their significance is fairly certain, provided the abdomen
becomes tense and hard with each pain, remaining comparatively soft
between them.

When contractions begin during the day or early evening, the
physician will be glad to have immediate notification in order that
he may arrange his appointments and thus be free to attend the
patient when she needs his services. On the other hand, if they begin
between 11 P.M. and 7 A.M. the nurse, who will always be summoned
with the very first warning, should be allowed to decide when the
doctor is to be called. Unless other instructions have been given,
she will usually wait until the interval between the contractions is
five to ten minutes.

Usually the symptoms make it clear that labor has begun, but
occasionally the greatest difficulty will be experienced in deciding
whether the discomfort has not some other origin. Uncertainty may
prevail not only because of the similar effects of colic, but also
from the fact that uterine contractions do not always have the same
value. Preliminary pains may appear several days, or even weeks,
before the actual onset of labor. Now and then the "false" pains
cease, and after a period of comfort efficient contractions are
established. There is never difficulty in recognizing the latter;
doubt always relates to the preliminary pains, which may subside or
may pass into the efficient type. We lack a method of foretelling
which turn they will take; developments may be calmly awaited, with
the assurance that ample warning will precede the birth.

A slight mucous discharge from the vagina is frequently seen toward
the end of pregnancy and may be disregarded, but a gush of watery
fluid always means that the sac which contains the fetus has
ruptured. Uterine contractions generally follow within a few hours,
though in a few instances they will not appear for a number of days.
Under any circumstances the event ought to be promptly reported to
the doctor. Similarly, he should be notified whenever bleeding from
the vagina occurs, since it is important to have him determine its
significance.

Anyone who supposes that patients are more likely to be infected when
delivery occurs so quickly that there is not time for the doctor to
arrive overlooks the leading factor in the production of this
complication. Unless harmful bacteria are introduced into the birth-
canal and lodge there, infection is impossible. Bacteria never enter
of their own accord; they are usually carried into the vagina by
means of an examining finger or some other foreign body. Accordingly,
with the exception of those instances in which local inflammation
already exists, there is no reason to fear infection when delivery
proceeds so rapidly that internal examinations are not required.

PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in
the house, she will arrive in time to assist the patient in making
the final arrangements for delivery. Should the nurse be delayed, the
patient herself may make certain preparations to insure personal
cleanliness, another very important factor in the prevention of
infection.

The presence of hair and the folding of the skin about the outlet to
the birth-canal render the disinfection of this area somewhat
difficult. It is advisable, therefore, to clip the hair as short as
possible and, while bathing the whole body, to scrub the region in
question with especial thoroughness. Before the bath an enema of
soap-suds should be taken to clear the rectum of material which
otherwise might be expelled during the birth and contaminate the
field of delivery. The bath-towels and the gown which are used should
have been freshly laundered.

Other especial preparation of the delivery-field will be made later
by the nurse. But whenever labor progresses so rapidly that neither
the nurse nor the doctor arrives before the child is born, such
preparations as I have indicated will be sufficient, for more minute
precautions are unnecessary unless an internal examination must be
made.

THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of
obstetrical patients are attended at home, and there is no reason why
this should not be. Generally it is unfair to urge a woman to go to a
hospital if she has already passed through a normal confinement and
there is no reason to anticipate trouble in the approaching one; on
the other hand, if any complication whatever is anticipated, the
patient should certainly enter a hospital. Furthermore, it frequently
proves advantageous to do so where the pregnancy is the first, though
no complication is expected and none develops. The average labor with
the first child lasts somewhat longer than with subsequent ones, and
in consequence there is greater opportunity for the patient's family
or friends to interfere with the management of the case, which never
benefits a patient, and is sometimes a serious handicap. Then again,
the cramped apartments, so common in these days, are poorly adapted
to the treatment of sickness of any sort and should induce many
obstetrical patients to choose the hospital. There are, besides,
other features which favor this course, such as economy, convenience,
and safety. From my own experience, which includes the care of
patients both at home and at the hospital, I am convinced that, as a
rule, the latter is much more satisfactory.

Most cities now have institutions which provide a room and all the
essential care, exclusive of the doctor's services, at approximately
the cost of a trained nurse at home; luxuries will naturally add to
the expense in hospitals as quickly as elsewhere. If one considers
the various items connected with attention at home, such as the
maintenance of the nurse and of the patient, the cost of the
equipment necessary for confinement, the additional household
laundry, and the sundry other details, it is clear that hospital
treatment becomes distinctly economical. Moreover, the uncertainty of
the date of confinement may necessitate paying a nurse for a longer
or shorter period before the birth. Expense at the hospital, on the
contrary, usually begins when the patient enters; and if she lives in
the city it is rarely advisable for her to leave home until the
beginning of labor. Even aside from the matter of expense some women
prefer the hospital, since in this way they avoid the technical
preparations for the birth.

Much more vital, however, is the care patients receive in the
hospital, for rigid adherence to surgical cleanliness is exemplified
in the hospital as it can be nowhere else. Infections rarely develop
there. Formerly these accidents were more common in the hospital than
in the home, but conditions are now reversed and fatalities
predominate among those delivered in private houses. The modern
theory of asepsis has, to be sure, been widely accepted and is
practiced so far as possible wherever obstetrical patients are
attended, but only in the hospital can the underlying principles be
applied with complete thoroughness and persistence. The hospital is
constantly alert, whereas in private houses carelessness or
ignorance, or both, often lead to lax technique. As a result,
statistical evidence indicates that two to three infections occur
among those delivered at home for one at the hospital.

In the event of an emergency during labor, the hospital affords
another distinct advantage in its staff of trained attendants. Of
course they may be brought to one's home, yet not without some delay
and extra expense; whereas in the hospital their assistance is
instantly available. In institutions charity patients are often
delivered under more favorable auspices than are the wealthy at their
homes. Convalescence likewise is favored at the hospital, since the
rules which control the admission of visitors guard the mother from
exhaustion and annoyance. Moreover, isolation such as can only be
secured in a hospital is conducive to a well-trained baby.

Patients debating what course to follow often ask when they must
leave home, what they should take with them, and how long they ought
to remain at the hospital. The attending circumstances will alter the
answers to these questions, but in a general way the following
directions will serve as a guide.

Ordinarily, the patient may remain at home until the first warning of
labor. Departure from this rule is justified if the patient becomes
unduly anxious about reaching the hospital in time, especially when
she lives some distance from the institution, or if there is any
doubt of securing accommodations. In either event, she should go to
the hospital at least one week before the confinement is expected.
There is no danger in riding to the hospital after labor has begun;
frequently, the ride exerts a helpful influence and shortens the
labor.

Whatever is to be taken to the hospital should be packed in a bag
several weeks before the predicted date of confinement and put in a
convenient place so that one may be spared the trouble of gathering
it at the last minute. Beside her usual toilet articles, the mother
will require several gowns, a dressing-robe, and bedroom slippers.
Clothing for the child will also be needed since most institutions
stipulate that the infant use its own wearing apparel. If
impracticable to transport the entire wardrobe when the mother enters
the hospital, so much may be taken as will be needed during the first
few days, and other articles may be brought as the need of them
arises. The personal laundry of both mother and infant is usually
done outside the institution.

Surgical dressings of every description are provided by the hospital.
Those who intend to enter a hospital, therefore, may disregard the
list of articles necessary for confinement. Similarly, the
sterilization, the preparations of the room and of the bed, and
personal preparations will be of interest only to the patient who
intends to stay at home.

It is not always possible for the physician to say how long a patient
should remain at the hospital; the rapidity of the mother's
convalescence and the progress of the child, both important factors,
cannot be accurately foretold. Frequently, it is a good plan to
remain until the infant is four weeks old, but the majority of
patients are dismissed at a somewhat earlier date. In no instance,
however, should the mother be allowed to leave before the infant is
two weeks old. Even when given the privilege of leaving so early she
will always understand that competent assistance must be provided at
home, for the mother should not resume her routine duties until six
weeks after the birth.




CHAPTER X


THE BIRTH OF THE CHILD

The Cause of Labor--The Course of Labor--The Stage of Dilatation--The
Stage of Expulsion--The Placental Stage--The Effect of Labor upon
the Child--Meddling--Justifiable Intervention--Management of Birth
without the Doctor--Methods of Reviving the Child.

The birth of a child is an act of nature, an act generally performed
as satisfactorily as any other bodily function. Birth has, however,
so deep a meaning for the mother, as well as for her family and her
friends, and is, above all, so vital to the future of the race, that
it has naturally become the subject of many impressive superstitions.
Primitive peoples have invariably embodied in their religion their
views of the origin of life and the phenomena of its inception. With
these mysteries Greek and Roman mythology dealt extensively, as did
also the myths of the Phoenicians, the Egyptians, the Chinese, and
the people of ancient India. No race, indeed, has lacked its own
interpretation of childbirth, and no phase of the process has failed
to have attributed to it a supernatural significance. A number of
these superstitions still distress women on the eve of motherhood. To
correct exaggerations and to deny many utterly false impressions of
childbirth there is no better way than to give a frank account of
what does actually occur. I shall adhere to a purely physiological
description of the event, for, although I appreciate fully the fact
that its sociological and sentimental aspects are perhaps equally
important, these are not, in my opinion, pertinent to a medical
discussion.

In a scientific sense the act of birth may be described as a series
of muscular contractions which widen the birth-canal and expel the
contents of the pregnant womb. Since the process requires an
expenditure of energy, it has come to be called labor. Intrinsically,
labor does not differ from many other physiological acts. The heart
drives blood into the arteries; the bladder empties itself; the
intestine moves its contents and finally expels the undigested
residue. All these acts strongly resemble that of birth; but they
also differ from it, for the head of the fetus is a hard body which
resists being molded to the shape of the passageway through which it
enters the world. To this resistance the pain which accompanies
delivery is largely due. And yet even in this respect the act of
birth is not unique; certain circumstances lead to painful
contractions of the muscle fibers in the intestine and less
frequently of those in other organs.

It is natural to ask what purpose is served by the pain associated
with labor; and a moment's reflection will make it clear that one
reason for the discomfort is the warning which it gives of the
approach of birth. If the mother were not thus cautioned, she might
be delivered under very awkward circumstances, and even under such
conditions that occasionally the infant would perish the instant it
was born. All mammals suffer in giving birth to their young, though
with quadrupeds the period of suffering is shorter, for the upright
posture of man has changed the shape of the pelvis, rendering birth
somewhat more difficult. Anyone who observes the lower animals
preparing for delivery will be convinced that they also are
responding to pain, the most compelling call of nature.

That the suffering is at all essential to the mother's love for her
child I cannot believe. Under certain circumstances, as for example
when the Cesarean operation is performed before the onset of labor,
the delivery is painless; yet I have never known a mother less
devoted to her child on that account. Biology throws no light upon
the relation of the "curse of Eve" to present-day confinements.

THE CAUSE OF LABOR.--It is evident that, in a general way, the
muscular contractions of the womb cause the birth of the child; but
before we thoroughly understand the act, science must discover what
stimulates the muscle to contract. Although careful research has thus
far failed to disclose the source and character of the stimulus, it
has taught many properties of the contractions themselves. Their
force has been measured and found to increase as the end of labor is
approached; the pressure they exert varies between nine and twenty-
seven pounds. We also know that the patient can neither hasten nor
delay the contractions voluntarily. Strong emotions are believed to
accelerate them at times, and we find a very extraordinary
illustration of this effect recorded in I Samuel, IV, 19, where we
read: "Phineas' wife was with child, near to be delivered; and when
she heard the tidings that the ark of God was taken, and that her
father-in-law and her husband were dead, she bowed herself and
travailed; for her pains came upon her." On the other hand, and much
more familiarly, excitement checks the contractions after they have
begun. Every obstetrician has heard patients say that with his
arrival the pains died down. Yet such an influence is never
permanent; the contractions soon reappear, and labor advances as
though no interruption had occurred.

For the artificial induction of labor, the physician has at his
disposal means that resemble the method sometimes employed by nature.
Suitable appliances introduced into the womb provoke contractions,
and labor proceeds step by step as if the stimulus were a normal one.
Nature does not, however, ordinarily employ mechanical irritation to
start the uterine contractions. The initial factor is more remote
and, as I have said, is not yet well understood.

Since, as everyone admits, delivery occurs with conspicuous
regularity about the end of the fortieth week of pregnancy, and
pregnancy corresponds, therefore, to ten menstrual cycles, some have
been led to believe that labor and menstruation have a common basis.
The truth of this supposition, however, must be doubtful until we
know the cause of menstruation. Yet it is a matter of common
observation that the uterus becomes unusually irritable about the
time when the tenth menstrual period would be due. Strong purgatives
administered with other drugs on or after the calculated date
frequently bring about delivery, whereas previous attempts of this
kind prove unsuccessful. To account for this peculiar irritability of
the uterus about the fortieth-week of pregnancy, microscopical
changes in its tissues have been suggested but sought in vain. Nor
will the distention of the organ explain it.

A great many theories have been offered to explain the causation of
labor, but they have now only an historical interest. To-day we are
just beginning to learn the correct methods of studying the problem.
The experience of ages has firmly established the fact that the fetus
is expelled when ready to enter the world, or as we say, when it has
become mature. But how does the fetus assert its maturity? There is
the kernel of the matter; that is the real problem, a problem for the
solution of which, happily, we possess better facilities than have
heretofore existed. One solution that has been suggested assumes that
the fetus loses ultimately its power to assimilate the nourishment
provided through the mother's blood. In consequence, it is argued,
the material which previously enabled the fetus to grow now collects--
in the maternal circulation, stimulating the womb to contract.

A part of this explanation, namely, that the material which
stimulates the muscle fibers, whatever it may be, is a chemical
substance and that it circulates in the mother's blood, is almost
certainly true. There are, however, very weighty reasons for
believing that this substance has not the character of food. A more
plausible supposition is that the fetus produces this material in the
course of its natural living processes, and the substance would
accordingly be a waste-product.

THE COURSE OF LABOR.--The current view that labor begins in the early
evening and generally ends during the night is incorrect. This
impression has grown out of the fact that the whole process
frequently consumes twelve hours and must in such an event include
some part of the night. Statistical evidence indicates that almost as
many births occur at one hour of the twenty-four as another; to be
precise, only five per cent. more children are born between 6 P.M.
and 6 A.M. than between 6 A.M. and 6 P.M.

As already pointed out, labor commonly begins with transient
discomfort in the lower part of the back. At first the uterine
contractions are far apart; they last but a moment and cause only
twinges of pain. Gradually, the preliminary contractions give place
to others of more definite character, which appear at intervals of
five to ten minutes. Estimates of the total length of labor will vary
according as one counts from the first warning or from the advent of
typical contractions which we hear called "pains of the right kind."
These generally continue for about four hours, and this period
represents the average length of time the physician remains
constantly with his patient. Estimates which include the initial
symptoms are longer, varying from ten to eighteen hours. Prolonged
labors are rare; and extremely short labors are also infrequent,
though now and again it will be only an hour or two from the very
first pain until the child is born.

To predict absolutely the length of labor for any particular patient
is impossible. The averages calculated from large groups of cases
have no more than a broad scientific interest; when applied to any
individual they are apt to be very misleading. Thus, from statistics
we should expect the first labor to be longer than subsequent ones,
but we are often surprised by an unusually rapid delivery.

To facilitate description, labor is divided into stages which are
conveniently designated the first, the second, and the third. During
the first stage the way is prepared for the expulsion of the child;
at the end of the second stage the child is born; the third stage is
occupied with the separation and the expulsion of the after-birth.
The progress of labor may be ascertained from time to time by means
of suitable examinations. Whereas formerly vaginal examination was
the only method which served this purpose, we are now acquainted with
several. For example much of the information necessary for the proper
management of delivery may be gained from examination of the
patient's abdomen; and this may be supplemented by observations too
technical to consider here.

Occasionally I have heard doctors accused of negligence because they
failed to make numerous vaginal examinations. Censure of this kind
generally is unjust, for discretion in limiting the number of vaginal
examinations provides against infection a guarantee which cannot be
overestimated. In many cases, of course, they are still invaluable
toward determining what treatment should be pursued, yet they are
never employed to the extent once customary. Moreover, physicians
have learned to take extraordinary precautions whenever vaginal
examinations must be made.

Anyone who practices obstetrics in these days appreciates how careful
he must be, especially of the cleanliness of his hands. Energetic
scrubbing with soap and water and the free use of antiseptics, as
physicians now employ both these measures, appear ridiculous to some
women who have witnessed deliveries under a less stringent regime.
They may be bold enough to express their disapproval. They may remind
us that many women have been successfully delivered without such
care. And in this they are correct; we know that nine of every ten
mothers passed through childbirth uneventfully before modern
precautions were dreamed of. Such precautions as are now taken,
however, are necessary to secure the safety of the tenth patient. And
it is because they are anxious that all their patients shall enjoy
the greatest possible security that physicians dare not omit any
precaution.

Disinfection of the physician's hands does not entirely exclude the
danger of infection through vaginal examinations. Although he may
have been most conscientious, there is some risk of carrying
contaminating material into the birth-canal from the region about the
opening of the vagina. Unless that region has been satisfactorily
disinfected, sterilizing the dressings and cleansing the hands may
become a waste of time. Sensible patients, therefore, will never
object to the preparations which the nurse is instructed to make.

THE STAGE OF DILATATION.--For reasons which are sufficiently clear,
the womb must remain closed while fetal development is in progress;
but under normal conditions, when this development is complete, the
mouth of the womb dilates and the infant is expelled. The infant
never takes an active part in its birth, although physicians once
thought it did and attributed tedious labors to stubbornness on its
part. The error has been corrected in medical teaching, but many
persons unacquainted with the facts cling to the idea that the infant
forces its own way out of the womb.

At the end of pregnancy the mouth of the womb is small, too small,
often, to admit an instrument as broad as a lead pencil. It is
obvious, therefore, that very radical changes must be wrought before
the infant can pass. The door, as it were, must be widely opened.
This phenomenon, which we call dilatation of the womb, is brought
about by involuntary contractions of the muscle fibers in its wall,
every point of which they draw upward. Now, the top of the womb is
directly opposite its mouth, consequently the contractions inevitably
pull its lips wider and wider apart. Ordinarily another factor is
concerned in this mechanism. To understand the whole process we must
recall that a fluid surrounds the fetus, and that this fluid is
contained within elastic membranes. The uterine contractions compress
the fluid, drive the membranes, like a wedge, into the mouth of the
womb and spread its lips apart. Thus, to the pulling effect just
mentioned, a pushing force is added. After full dilatation has been
accomplished and the membranes can serve no further purpose, they
rupture; as the midwife puts it, "the bag of waters breaks." The
quantity of fluid which escapes will vary. Occasionally, a huge gush
will drench the patient's clothing; but more often what is lost at
first amounts to only a few teaspoonfuls, though small quantities of
fluid often dribble away with subsequent contractions.

Although not the rule, it is by no means unusual for the membrane to
rupture at the onset of labor, or at least before the mouth of the
womb is fully dilated. Exceptionally, rupture occurs a few days
before labor begins; and still longer intervals, though extremely
rare, have been recorded. Whenever the membranes rupture prematurely,
the pushing force of the uterine contractions becomes less effective,
though the pulling force is never impaired. Under these
circumstances, which occasion what is called a "dry labor," delivery
is apt to proceed slowly, yet that does not follow necessarily, for
the part of the fetus which happens to lie over the mouth of the womb
may act as efficiently as the unruptured membrane would.

During the first stage, the longest of the three, the patient is
comfortable between the contractions and generally interests herself
in some diverting occupation. The presence of the physician can be of
no assistance then, and patients rarely demand it. Usually, they are
satisfied to know he is ready to come when called. It is wrong to
deceive patients with various recommendations from which they will
vainly expect help during this stage; their welfare is best served
when they are left alone. Generally the advice of well-meaning
friends will be as harmless as it is futile, yet I must emphasize
that during the first stage straining to expel the fetus is ill
advised. Such effort will surely be ineffective then and may exhaust
the patient; in that event it becomes harmful, for she will be
fatigued when she most needs strength.

Since, during the first stage, the progress of delivery is not
influenced by what the patient may choose to do, she may follow her
own inclinations. The average patient will be restless and will keep
on her feet most of the time; alternately she will walk or stand
still as one or the other happens to make her more comfortable. As a
contraction begins she often seeks support, leaning upon a chair or
bending over the foot of the bed, and presses with her hands against
the lower part of her back. Patients may sit down or lie down
whenever they wish; if so inclined they may even go to sleep.

Most patients take no food during the whole course of labor, but, if
nourishment is desired, there is no reason for abstaining from it.
They may always drink water as freely as they like, and may also have
milk, weak tea or coffee, or broth; but alcoholic beverages should
never be taken without the specific consent of the physician. This
same caution applies to strong coffee and tea. If desired, crackers
or toast and rice or other cereals may be eaten in reasonable
quantity. For fear of vomiting a patient will occasionally be told
not to partake of any food. This advice is given, not because the
symptom is alarming, but to save her needless annoyance. Indeed,
vomiting frequently indicates that dilatation is well advanced, and,
therefore, may generally be regarded as an encouraging sign.
Ordinarily a persistent inclination to have the bowels move has the
same significance. On the other hand, a constant desire to empty the
bladder is more prominent at the onset of labor than later.

To know the moment which marks the transition from the first to the
second stage of labor can be of no benefit to the patient; but for
the medical attendant the greatest interest centers about this point.
Casual observation sometimes enables the physician to recognize it,
for characteristically at the close of the first stage the whole
picture changes. In a typical case the membranes will rupture at this
instant, expulsive efforts will begin, and, as we have just learned,
there may be symptoms referable to pressure. Moreover, a blood-tinged
discharge, spoken of as the "show," usually makes its appearance
about the same time. Since slight bleeding frequently occurs at the
beginning of labor, or a little later, this manifestation, like all
others, may not be implicitly trusted to indicate the end of the
first stage. Such uncertainty, however, is a matter of no great
consequence, for in the absence of all these symptoms the physician
may, if necessary, accurately determine the degree of dilatation by
an internal examination.

THE STAGE OF EXPULSION.--The term delivery has been broadly applied
to include the whole of labor. More strictly, its use should be
limited to the second stage, for this period alone is concerned with
the actual birth of the child. Although dilatation has been
completed, the uterine contractions continue, devoting their force to
emptying the womb. In this they now receive assistance from the
voluntary contractions of the abdominal muscles.

The second stage is very much shorter than the first; for this reason
and others, too, it proves much less trying. As the child is moved
downward through the birth-canal, the mother usually appreciates for
herself that she is making headway; whereas in the first stage she
may know of progress only through what she is told. Moreover, it is
possible in this stage for the physician, by means of inhalations of
chloroform, to relieve her of the pain attending the expulsion of the
child.

Since the anesthetic properties of chloroform were discovered by an
obstetrician who was searching for a drug with which to lessen the
pain of childbirth, the facts connected with the discovery have a
peculiar interest for mothers. Sir James Y. Simpson had always been
anxious for some means to prevent the suffering endured during
surgical operations "without interfering with the free and healthy
play of the natural functions." He, therefore, welcomed the
introduction of ether anesthesia from America; and in January, 1847,
at the Edinburgh Medical School, administered ether to an obstetrical
patient. This was the first instance in which an anesthetic was
employed at the time of childbirth. Since ether, to his mind, had
certain shortcomings, Simpson set about finding another anesthetic,
and devoted all his spare time to testing the effect of numerous
drugs upon himself. How he came to try chloroform has been vividly
told by one of his neighbors. [Footnote: "Late one evening, it was
the 4th of November, 1847, Dr. Simpson, with his two friends and
assistants, Drs. Keith and Duncan, sat down to their somewhat
hazardous work in Dr. Simpson's dining room. Having inhaled several
substances, but without much effect, it occurred to Dr. Simpson to
try a ponderous material which he had formerly set aside on a lumber-
table, and which, on account of its great weight, he had hitherto
regarded as of no likelihood whatever; that happened to be a small
bottle of chloroform. It was searched for and recovered from beneath
a heap of waste paper. And with each tumbler newly changed, the
inhalers resumed their vocation. Immediately an unwonted hilarity
seized the party--they became bright-eyed, very happy, and very
loquacious--expatiating upon the delicious aroma of the new fluid.
But suddenly there was talk of sounds being heard like those of a
cotton mill, louder and louder; a moment more, and then all was
quiet--and then a crash! On awakening, Dr. Simpson's first perception
was mental--'This is far stronger and better than ether,' said he to
himself. Hearing a noise, he turned round and saw Dr. Duncan beneath
a chair, quite unconscious, and snoring in a most determined manner.
More noise still and much motion. And then his eyes overtook Dr.
Keith's feet and legs making valorous attempts to overturn the supper
table. By and by Dr. Simpson having regained his seat, Dr. Duncan
having finished his uncomfortable and unrefreshing slumber, Dr. Keith
having come to an arrangement with the table and its contents, the
_sederunt_ was resumed. Each expressed himself delighted with
this new agent, and its inhalation was repeated many times that
night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place
and turn at the table, and fell asleep, crying: 'I'm an angel! Oh,
I'm an angel!'"--Quoted from "The Life of Sir James Young Simpson,"
by H. Laing Gordon; Masters of Medicine Series.]

The introduction of chloroform met with violent opposition, not upon
medical grounds alone, but also for moral and religious reasons. "To
check the sensation of pain in connection with the visitations of
God," zealous theologians announced, "was to contravene the decrees
of an all-wise Creator." Simpson reminded them "that the Creator,
during the process of extracting the rib from Adam, must necessarily
have adopted a somewhat similar artifice--for did not God throw Adam
in a deep sleep?" Nevertheless, a number of years passed before the
prejudice against artificial sleep was overcome. Chloroform only
became popular after Queen Victoria consented to its use at the birth
of her seventh child, Prince Leopold, in 1853.

There is still some difference of opinion regarding the routine
employment of chloroform in obstetrical practice, though the weight
of authority favors its use during the contractions at the end of the
second stage, providing always that no preexisting organic
derangement renders the drug dangerous. Under no circumstances,
however, should chloroform be given in the first stage, and seldom at
the beginning of the second. Prolonged administration will exert an
injurious influence upon both mother and child; under these
conditions it ultimately weakens the uterine contractions and delays
the delivery. Such an effect must be avoided, since it would endanger
the life of the child by asphyxiation as well as exhaust the mother.
On the other hand, a few drops of chloroform inhaled with each pain
toward the end of the second stage will dull sensibility, although
consciousness remains unaffected. When the drug is thus administered,
the uterine contractions are scarcely, if at all, altered, and the
assistance which the patient is willing to give herself generally
becomes more powerful. Should the anesthetic have the opposite
effect, it must be withheld; but that is seldom necessary. As the
head advances the anesthesia is deepened, and the mother sleeps
soundly while the child is being born.

As long as dilatation is in progress, the patient may sit up or walk
about; but with the advent of the second stage she should go to bed,
for there she will be able to make the best use of the expulsive
pains. The appropriate posture for delivery is still the subject of
dispute, though modern views in no instance advocate the unnatural
absurdities formerly supported by custom or superstition. Students of
ethnology relate that among savage tribes almost every conceivable
position was advocated for women in labor. Subsequently it became
customary to have delivery take place in specially constructed chairs
which are still used in semi-enlightened countries. With civilized
nations at present women are always delivered in bed; yet national
peculiarities still prevail. Some physicians favor what is known as
the English position, in which the patient lies on her left side with
her face inclined toward the chest, the trunk bent toward the knees,
and the legs drawn up toward the abdomen. The majority of
obstetricians, however, prefer that the patient should lie flat on
her back. With the average case, and from the standpoint of facility
in delivery, which of these postures happens to be chosen is a matter
of indifference. But it is so much less awkward for the physician
when the patient is on her back that this position has been widely
adopted in America.

During the expulsion of the child the mother intuitively desires to
help herself; generally she cannot resist straining, and rarely needs
encouragement. Assisting the uterine contractions with voluntary
muscular effort, the act commonly described as "bearing down," may be
performed most effectively when the patient is lying on her back. The
knees are drawn up and spread apart; the feet are braced against some
firm object; the hands grasp straps fastened at the foot of the bed;
and the head is slightly raised so as to bring the chin near the
chest. When the contraction begins the patient takes a deep breath
and holds it while she strains vigorously, as if to make her bowels
move. All voluntary effort should cease as the contraction wears
away, for straining between the contractions can accomplish nothing.
Her own inclination to "bear down" will clearly indicate to the
patient when she ought to act.

In the second stage patients regularly experience a feeling of
pressure against the rectum, and this sensation, since it depends
upon a low position of the child's head, is a welcome sign. Cramps in
the legs also indicate progress, for they result from similar
pressure against nerves adjacent to the lower part of the birth-
canal. The cramps disappear immediately after the child is born, and
are consequently never dangerous. Straightening out the legs or
rubbing them usually gives relief. Most women, however, complain
during the expulsive period only of pain in the back, and find
nothing so grateful as firm pressure over this region.

Energetic efforts quickly bring the head to the outlet of the birth-
canal, where it may be seen, at first only during the contractions,
but later during the pauses as well. The crown of the child's head is
generally directed upward and becomes fixed against the pubic bones
of the mother, which lie just in front of the bladder. Around this
firm pivot the child's head rotates upward, and, as a result of the
movement, forehead, eyes, nose, mouth, and chin successively emerge
from the birth-canal. Following the birth of the head, natural forces
turn the body upon one side, the better to accommodate the shoulders
to the passageway. After these are born, the rest of the body slips
easily into the world, and the second stage ends.

THE PLACENTAL STAGE.--Although the third stage is chiefly concerned
with the separation and the delivery of the after-birth, on which
account it is known as the placental period, the description of other
no less remarkable events belongs here. Even after the infant is born
the umbilical cord extends from its navel to the placenta, just as it
has done throughout pregnancy. Among larger mammals separation of the
new-born from the mother is brought about in one of two ways;
sometimes the activity of the young breaks the navel-string, though
more frequently the mother bites it in two. Both these methods, we
are told, have been employed by savages; but at the beginning of
civilization it became customary to sever the cord with a cutting
tool, and the tie thrown round it represents the first attempt of man
to ligate blood-vessels. Ordinarily there is no need for haste in
this operation. On the contrary, some delay is often of advantage,
since an appreciable quantity of blood that otherwise would remain in
the placenta is thus given opportunity to enter the infant's body.
According to present ideas, as long as the heart-beat can be felt in
the cord it should not be tied.

The sleep induced toward the close of the previous stage lasts for a
few minutes, so that most patients are unconscious through the
greater part of the brief placental stage. Before the influence of
the anesthetic has worn off, the physician has an excellent
opportunity to sew up any laceration which may have occurred in the
course of delivery. Slight injuries are not uncommon, especially if
the confinement be the first, for the most skillful treatment often
fails to prevent them. Since superficial tears are never serious if
promptly closed, it is not their occurrence, but the failure to
recognize them, or to sew them up when they are recognized, that
deserves condemnation.

After the birth of the child the womb becomes smaller, its walls grow
thicker, and the cavity within is narrowed. This series of changes
partly detaches the placenta, but the separation depends chiefly upon
the uterine contractions. These contractions also force the after-
birth into the vagina, whence it may ultimately be dislodged by the
patient if she bears down again. Usually, however, it is preferable
to save her further efforts of this kind, and, as a routine, the
physician places one hand upon the abdominal wall, grasps the womb,
and, during the contraction, makes firm pressure downward. The
maneuver expels the after-birth, which consists of the placenta, the
membranes, and the umbilical cord. Then the empty womb will form a
hard, spherical mass about the size of the child's head, lying just
above or to one side of the bladder.

Slight bleeding also occurs during the third stage, and further loss
of blood follows the removal of the after-birth. The total loss
varies between a half pint and a pint, though larger amounts may be
noted occasionally without appreciable effect upon the mother.
Naturally, large, robust women can spare much more blood than those
who are anemic. And yet pregnancy invariably prepares the mother for
a loss of blood that would alarm anyone unfamiliar with obstetrical
practice. Often the woman just delivered is not harmed by a
hemorrhage that would endanger the life of a healthy man. This may
seem paradoxical, but it is not; for the surplus blood, which
formerly performed important duties in connection with the nutrition
of the fetus, must now be removed to readjust the mother's
circulation.

In a very small number of cases an unduly large loss of blood follows
the expulsion of the placenta. Fortunately, by treatment which
consists usually in spurring Nature to more vigorous action we are
well equipped to deal with this emergency. A wonderful mechanism has
been provided by Nature to control excessive bleeding after delivery.
If the forces upon which this mechanism depends are sluggish, the
physician stimulates them. As in the preceding stages, the muscle
fibers of the uterus supply the power in question, and because of
this role an observant obstetrician once called them, "living
ligatures." Certain of these fibers encircle the mouths of the blood-
vessels which have been left open through the detachment of the
placenta. When they contract the vessels are squeezed, impeding the
escape of blood. The necessity of this action explains the
contractions which continue even after the placenta has been
expelled, when they are vigorous enough to cause discomfort they are
spoken of as "after-pains." After-pains seldom follow the birth of
the first child, but they regularly follow later confinements. In any
case, such contractions do not persist very long, for tiny clots form
within the blood vessels and effectually close them. As soon as the
lining of the womb has been restored the clots are absorbed, leaving
the organ in much the same condition as before conception took place.

THE EFFECT OF LABOR UPON THE CHILD.--Unless the experience of
countless generations had taught us otherwise, we should fear the
child would be injured by its passage through the birth-canal.
Immediately after the birth evidence of the journey is seldom
wanting, but it quickly disappears.

The unusual size of the infant's brain requires the head to be large,
and bestows upon it a contour which differs from that of the mother's
pelvic cavity. Since the bones of the pelvis are rigid, while those
of the fetal skull are malleable, the head is molded as it descends
into the pelvic cavity, so that its passage may be made the easier.
As the result of this process of accommodation the skull becomes
relatively longer from crown to chin than in adults. Within a few
weeks, however, the modification vanishes. If an infant is born with
the buttocks first, the head does not linger in the birth-canal, a
fact which in such cases explains the pleasing shape of the skull,
which emerges with the contour determined by fetal growth.

Whenever a soft swelling appears over that portion of the scalp which
was foremost during the birth, the curiosity of the family is
aroused; but the swelling is harmless and subsides quickly. It
originates for the same reason that a finger swells if too tight a
ring is worn, which, as everyone knows, is because of interference
with the circulation. Just as the swelling of the finger disappears
when the constriction is removed, so the swelling of the scalp
subsides shortly after the child is born. Usually no trace of it can
be found the next day; but even when more persistent it will always
vanish after a short time.

For the child the most notable result of labor relates to the
revolutionary changes in its mode of existence. Up to the time of
birth the fetus received nourishment by way of the placenta, but
after separation from the mother another source of food must be
found. The health of the tissues, perpetually in need of oxygen,
requires that the lungs act very promptly. Contact with the air,
which is cooler than the previous environment of the child, irritates
the nerve-endings in the skin; in response to the sensation thus
produced breathing is established automatically. Whenever the
temperature stimulus proves insufficient, physicians employ a
stronger one, spanking the child until it cries lustily. Crying not
only expands the lungs, but also has a favorable influence upon
needful alterations in the fetal circulation.

The lungs, since they must from this time on provide oxygen for the
infant, need to receive more blood than formerly. The vessels leading
toward them must be widely opened, and structures which previously
diverted the blood-stream to the navel must be closed. The intricate
shifting of forces which produces the change cannot be understood
without a knowledge of anatomy; it will suffice for us to know that
the blood is drawn into the vessels of the lungs with each
inspiration. Other changes also occur. On account of some of these,
namely, certain alterations in the blood current through the heart,
physicians once taught that newly born infants should always be laid
upon the right side. Except in very unusual cases, that precaution is
now regarded as unnecessary.

Of all the elements essential to nutrition, oxygen is the only one
required immediately after birth; as the child enters the world well
stocked with all the others. Babies are not born hungry, as many
people seem to think. Neither is their crying a proof of it, for, as
we have observed, they have other very good reasons for crying; nor
is their readiness to suck anything that comes in contact with the
mouth, for they will behave in the same way while they are receiving
an abundance of nourishment through the umbilical cord. Many hours
pass before a newly born infant can possibly need food. Indeed, it
could survive a week or longer without taking anything, by mouth,
except water. The ability to suckle at birth merely indicates that
the infant is prepared to utilize the mechanism which nature will now
employ to sustain it.

After the umbilical cord has been severed the blood vessels within it
can serve no further purpose. Consequently the remnant of this
structure attached to the child's abdomen begins to shrivel. Formerly
the care of the stump was considered a trivial matter; when
cleanliness was neglected decomposition caused more rapid separation
than takes place under the treatment which it now receives. No
annoyance should be felt because the cord hangs on a long time;
indeed, such an experience means it has been given exceptionally good
care. Separation rarely occurs before the end of a week. It may be
deferred for two weeks, or even longer, if the stump has been kept
perfectly clean. After the shriveled cord drops off, the skin around
the navel contracts, leaving a small raw area which discharges a
yellow fluid for two or three days before the healing is complete.

MEDDLING.--In selecting a physician the patient will almost certainly
have been guided by her confidence in his ability. It may seem
strange, therefore, to insist that he be allowed to conduct the
delivery as he thinks best. Nevertheless, suggestions from outsiders
are so common, especially if the labor be at all prolonged, that it
seems appropriate to warn patients to pay no attention to such
advice. In the heat of excitement well-meaning relatives are
sometimes inclined to interfere, and women who are not members of the
family occasionally wish to discuss their experiences, irrelevant as
they may be.

The patient's intimate friends, quite naturally, have the keenest
personal interest in the event, an interest that of itself
disqualifies them from reasoning calmly at the time. Their influence
may be positively harmful if they persuade the physician to undertake
procedures which his judgment convinces him are inadvisable. Should
he turn a deaf ear, they will think him lacking in sympathy; but
should he adopt their suggestions he would assume the full
responsibility, and would perhaps be censured later by the very
persons whom he sought to please. There can be no question of the
proper course for him to pursue. Any influence which such entreaties
may have will always be in the direction of too early interference,
which is fraught with danger to mother and child alike. The master-
word is patience, and it applies alike to the mother herself, to the
doctor, and to her friends.

Almost always the whole duty of the doctor consists in watching the
progress of labor, so that he may be ready to render assistance
should it be needed. Until the second stage begins there is no real
necessity for him to remain in the room. Indeed, it is better for him
not to do so after he has made sure that satisfactory conditions
prevail, for his judgment will be less biased if the patient is not
continuously under his observation.

JUSTIFIABLE INTERVENTION.--It is quite true that in the progress of
the birth difficulties now and then arise; yet they are far less
common than rumor would lead us to believe. The unusual always
attracts attention, often receiving greater emphasis than it merits.
The particulars of confinement provide no exception to this rule; a
delivery which requires artificial aid will be talked about, while
hundreds that terminate naturally pass without comment. In this way
the public gets an exaggerated notion of the frequency of difficult
labors. Moreover, the nature of the trouble is usually distorted, for
reports of medical events are apt to be incorrect, and errors
multiply with each rehearsal. Obstetrical patients who wish, so far
as possible, to escape the depressing influence of such inaccurate
reports will be most likely to succeed if they follow the advice to
select a physician at the beginning of pregnancy. When this is done
the physician will have opportunity to explain or discredit alarming
rumors, a task which it is usually necessary for him to perform, for
there are always some persons who feel that a prospective mother
should listen to everything that they have heard of childbirth.

The most frequent cause for intervention during labor is
insufficiency of the muscular contractions to overcome the resistance
of the birth-canal. Unusual resistance of this kind explains the
longer labors of women who have passed middle life before becoming
pregnant. They may need to exercise more patience than younger women,
though they have no greater reason to apprehend serious difficulties.
Whenever rigidity of the muscles adjacent to the birth-canal arrests
delivery the physician may employ the obstetrical forceps, which have
been in use since the seventeenth century.

Although it is widely known that physicians sometimes terminate labor
in this way, the public estimate of the merits and of the limitations
of the instrument is so inexact that the truth about it should be
understood. Obstetrical forceps were devised by one of the
Chamberlens, a family of French Huguenots who fled to England in
1569. The invention was long kept a secret; therefore its date cannot
be fixed, nor even the inventor clearly identified, though everyone
agrees that he was a member of this family. Clearly the instrument
had been in use for some generations prior to Hugh Chamberlen, who
translated from French into English the foremost obstetrical textbook
of his time. The book, published in 1672, does not contain a
description of the forceps, but in his preface Hugh Chamberlen refers
to delay in delivery, saying, "My father, my brothers, and myself
(though none else in Europe as I know) have by God's blessing and our
own industry attained to and long practiced a way to deliver women
without prejudice to them or their infants in this case." It is not
questioned that the forceps was the secret that his ancestors and he
himself employed so long and so profitably. About a century ago what
are probably the original models of the instrument were discovered in
a country home of Essex which once belonged to the Chamberlens; there
they had been hidden in a trunk in the garret. The box in which they
were concealed contained four pairs of forceps, representing
different stages in their development, besides other instruments and
a number of letters which established their ownership.

After an unsuccessful attempt to sell the family secret in Paris,
Hugh Chamberlen found a purchaser in Amsterdam. The privilege of
using it in Holland was then granted physicians for a monetary
consideration, and that practice continued until two philanthropists
purchased the secret to make it public. It was ultimately learned,
however, that the sale was a swindle, for the device which the
purchasers obtained consisted of only half the genuine instrument.
The real secret was revealed by a son of Hugh Chamberlen, who bore
the same name as his father; but probably the first accurate printed
description of the forceps was made by Samuel Chapman, in his
treatise on obstetrics which appeared in 1733. Subsequently they came
into general use, and, with many modifications, remain the most
important instrument in the obstetrician's equipment. There can be no
exaggeration in the claim that the instrument has done more to save
human life than any other surgical appliance.

The obstetrical forceps have been of such great service in
diminishing the number of still-born infants that they were once
called the child's instrument. The need of its employment in behalf
of the child may be determined by careful observation of the fetal
heart-sounds, which are heard over the mother's abdomen, and by means
of which one may learn the condition of the child. Signs of danger
are extremely uncommon so long as dilatation of the womb is not
complete, for any strain which labor may impose upon the child will
usually occur during its passage through the pelvis. Most often,
therefore, the head has reached the outermost part of the birth canal
before extraction becomes advisable.

The forceps are used also on behalf of the mother, if the
continuation of labor seems likely to throw undue stress upon her. On
this account the physician frequently resorts to them if his patient
is suffering from pneumonia, typhoid fever, or any acute illness at
the time of labor. Other maternal indications for their use include
various chronic derangements, well exemplified by certain diseases of
the heart. Furthermore, even when there are no preexisting
complications forceps are employed on account of exhaustion or other
conditions which may develop during the course of labor. It must be
clearly understood, however, that the physician alone can determine
when intervention is justified, as well as what operative procedure
is most appropriate; for even though good reasons for terminating
labor exist, forceps cannot be properly used unless nature has
already fulfilled very definite requirements. By no chance can the
patient, much less her friends, decide this matter. And besides, none
but a trained observer can detect the symptoms which clearly indicate
Nature's incompetence to effect delivery. Disregard of these truths
by the family with consequent urging that something be done must be
held partly responsible for the reckless use of the instrument. It
will be a step in the right direction, therefore, when the laity
comes to understand that the value of the instrument generally
pertains to the welfare of the child, and that, in any event, its use
will be harmful if employed before the womb has been completely
dilated.

Although forceps can be employed only in cases of head presentation,
intervention may be warranted when some part of the fetus other than
the head will be born first. Two or three times in every hundred
patients we meet with breech presentations, that is, cases in which
the buttocks precede; after their expulsion, the body, the arms, and
the head follow. Breech presentations occur more frequently among
women delivered prematurely, as might be expected since an
examination eight to ten weeks before the calculated date reveals a
larger percentage of breech presentations than a similar examination
about the normal end of pregnancy. In explanation of these results we
accept the view that the size of the fetus at the earlier date does
not require nicety of adaptation to the cavity of the womb, whereas
at term, unless the child is small, the best accommodation is secured
when the head lies downward.

Most breech cases are delivered spontaneously; if not, the outlook
for the mother is no less favorable on that account. Assistance, when
undertaken, is usually prompted in the interest of the child, which
will be seized by the legs and extracted if there are indications to
terminate labor. Purely as a precautionary measure, a second
physician will often be called about the time the stage of expulsion
begins. Foresight of this kind must give the patient confidence
rather than alarm her. Indeed, should operative intervention of any
kind become necessary in the practice of obstetrics, the inclination
of the doctor to call an assistant must be regarded as an evidence of
superior judgment.

MANAGEMENT OF BIRTH WITHOUT A DOCTOR.--A prospective mother should
not be left alone during the four weeks prior to the expected date of
delivery, for it is important that during this period aid may be
quickly summoned in the event of an emergency. However, if the
confinement be the first, ample warning of delivery will always be
given. Even in a later confinement several hours will probably elapse
between the preliminary signs and the birth itself. It is extremely
rare to have labor progress so rapidly that the child is born before
the doctor arrives. Under such circumstances, if the nurse be present
she will be master of the situation; whenever she has been unable to
reach the patient, someone near by should be called to render what
assistance may be needed. A labor which advances so rapidly that
skilled assistance cannot be procured is proof in itself that
everything is going in an ideal manner, and that interference is not
necessary. Although the doctor may not arrive until after the child
is born, he frequently renders valuable service in expelling the
placenta or in sewing up lacerations. No one should presume then that
there is never need for a physician after the second stage is over.

If the suggestions made in the preceding chapter are heeded,
immediately after labor begins the room will be set in order and the
bed will be properly protected; the patient will take a tub-bath and
will put on a freshly laundered nightgown. The sterilized dressings
are then placed where they can be easily reached, but are not opened
until needed. Antiseptic tablets have been procured, and, following
the directions on the bottle, it will be simple to make up a solution
of bichlorid of mercury of a strength of 1-1,000.

After the contractions become strong and return at intervals of five
minutes, or if the waters have broken, the patient should go to bed;
the knees should be drawn up and spread apart, but bearing down with
the pains should not begin until the inclination is irresistible,
since this forbearance will make the delivery slower and thus afford
protection against lacerations which physicians ordinarily seek to
prevent by the use of chloroform. In the absence of a doctor it is
never permissible to administer this or any other anesthetic. As long
as a physician familiar with its action gives the chloroform untoward
results need not be feared in obstetrical cases; but the risk would
be too great to allow anyone to give it who was unacquainted with the
early signs of an over-dose. Again, fear of accident should prevent
patients from using the closet when labor is progressing rapidly, for
an inclination to empty the bladder or the rectum often signifies
that birth is about to take place. Even though this is true, if there
is need, patients may try to use the bed-pan.

About the time when the patient goes to bed the attendant prepares to
render such assistance as may be required. First she should scrub her
hands thoroughly with soap and water and subsequently soak them in
the bichlorid solution for five minutes, or longer if there be no
need for haste. A large delivery-pad is then placed under the
patient, the leggins put on, and, from this moment, the outlet of the
birth-canal should be exposed to view. After the scalp of the child
comes into sight, the attendant is not to leave the bed-side, though
she must keep "hands off" until the head has been completely
expelled.

A pause occurs between the birth of the head and of the rest of the
body. It is usually safe to await further expulsive contractions, but
should the child's face turn a dusky blue, which indicates that it
needs to breathe, the patient is to be advised to strain vigorously
and to make firm pressure over the womb with both her hands. At the
same time the attendant must pull the child downward, having seized
its chin with one hand and the back of its head with the other. The
straining of the mother combined with traction by the attendant will
be certain to effect delivery quickly. As soon as the child is born,
it should take a breath and begin to cry. If it does not cry of its
own accord, it can usually be made to do so by holding it up by the
feet and slapping it on the back several times. Subsequently the
child is placed between the patient's legs in such a way as to
prevent stretching of the cord. Usually the nurse will leave it in
this position and turn her attention to the mother.

After the birth of the child it is easy to feel through the mother's
abdominal wall, which has now become lax and flabby, the organs which
lie beneath it. The top of the womb, once just below the edge of the
ribs, may now be found about the level of the uppermost part of the
hip bones, a position which it keeps until detachment of the after-
birth begins. As the after-birth peels off, the firmly contracted
womb gradually rises in the abdominal cavity, and by the time when
the separation has been completed reaches the region of the navel.

While these changes, which naturally require from ten to thirty
minutes and occasionally longer, are taking place, the attendant must
wait patiently; attempts to hurry the separation of the placenta are
never wise, for they may lead to excessive bleeding. No effort should
be made to bring away the after-birth by pulling upon the cord. It is
equally unwise for inexperienced persons to press upon the womb in
the hope of pushing out the placenta. To encourage the mother to
strain just as she did in assisting the birth of the child would
always be a safer plan. And if that is ineffective, further delay is
necessary; in several instances a natural separation of the placenta
has repaid me for waiting as long as two hours. Prolonged delay may
be annoying, yet, provided that the doctor arrives within a
reasonable time, it can scarcely lead to anything more serious than
annoyance. Rather than authorize frantic efforts to remove the
afterbirth, I should much prefer to have a patient of my own call
another doctor.

If the after-birth comes away of its own accord, as will generally
happen when due patience has been exercised, it may be severed from
the child and put aside for the inspection of the doctor, for he
should learn by examining it whether everything has come away
properly. The cord must be securely tied in two places with the
sterilized bobbin mentioned in the list of articles for confinement.
One ligature is applied about two inches from the child's abdomen,
the other an inch nearer the placenta; the cord is then cut between
them with a pair of sterile scissors. Anyone fearful of injuring the
infant may prevent accident by spreading a diaper under the part of
the cord to be severed. This precaution also protects the bed from
soiling, for there will be a single spurt of blood the instant the
cord is cut. So long as the child is in good condition there is no
urgent need of this operation. If the child is breathing
satisfactorily it may generally be deferred until the doctor arrives.
When this course is chosen the attendant will wrap the infant in a
warm blanket, place it along with the after-birth in a safe spot, and
subsequently devote herself to making the mother comfortable.

The vulva and neighboring parts are bathed with a 1-1000 bichlorid
solution. Soiled dressings are removed, the gown changed, and, if
necessary, clean sheets put on the bed. A sterile sanitary pad is
placed over the vulva and a fresh one substituted as often as
necessary, but none of the pads should be destroyed. All the
dressings must be saved so that the doctor may see how much blood has
been lost. As we have learned, bleeding regularly occurs while the
placenta is separating and thereafter; excessive bleeding will rarely
follow a normal delivery if the attendant has heeded the precaution
to leave everything to nature. If ever the loss of blood should
become alarming before the doctor arrives, it is advisable to raise
the foot of the bed, to keep the patient quietly on her back, to
grasp the womb through the abdominal wall, and to massage it
constantly until the nearest physician can be gotten.

Of these directions the most important is that which relates to the
management of the womb, for in cases in which labor has been normal
in other respects the relaxation of its muscle is most often
responsible for flooding. What to do in this event must therefore be
made plain. First the patient should try to empty her bladder, and,
if she cannot, pressure made above the organ will usually expel the
urine. The attendant will then take her seat on the edge of the bed,
facing the patient's feet, and will locate the womb. When there is
flooding one may expect to recognize the womb as a large, rather soft
mass lying in the mid-line of the abdomen with its upper margin
somewhat above the navel. With one hand, or with both if necessary,
the mass is grasped in such a way that the fingers cover the top of
it and pass backward toward the spinal column; the thumb remains in
contact with the front of the organ. The womb is stroked and squeezed
much as one kneads dough, and for this reason the procedure is
technically called kneading. Such manipulations cause the muscle
fibers to contract firmly, and in consequence the blood vessels are
tightly closed and bleeding ceases. Similarly, cold applications to
the abdominal wall tend to provoke uterine contractions; placing over
the womb an ice-cap or towels wrung out of cold water and doubled
several times often have a beneficial influence when there is a
tendency toward relaxation. Some physicians also recommend that the
child be placed at the breast, since suckling is known to cause
uterine contractions. There are other measures which are occasionally
employed, but they should be used only by physicians, for in the
hands of an inexperienced person they may do more harm than good.

Very often a slight chill follows labor. It has a nervous origin and
need never give uneasiness; a drink of warm milk, hot-water bags to
the feet, and extra blankets will be sure to make the mother
comfortable. On the other hand, excitement of any kind aggravates
this condition. In general, recently delivered patients must be kept
quiet no matter how well they feel. A few hours of sleep, or, at
least, of repose, are justified by the fatigue incident to labor, and
nothing should be permitted to interfere with it.

METHODS OF REVIVING THE CHILD.--Complications which interfere with
the child's vitality rarely occur when labor proceeds so rapidly that
there is not time to get a doctor. Nevertheless a description of
child-birth would be incomplete without reference to the measures
intended to revive asphyxiated infants.

Such measures aim, first of all, to make the infant breathe for
itself, and if breathing does not begin promptly we resort to
artificial respiration. Mucus in the mouth or in the lower air-
passages hinders the entrance of air into the lungs; consequently it
is the duty of the attendant to remove this mucus by means of gauze
or some light fabric wrapped about a finger and passed backward over
the tongue. In most cases nothing else will be necessary. But if
breathing is not immediately established, the child should be grasped
by the feet with one hand and held downward while its back is
vigorously slapped with the other. Usually, it gasps at once; when it
does not, the attendant may stroke its face and chest with her hand,
which has been previously held in cold water for a moment; or she may
dash a handful of cold water upon its body. With very rare exceptions
these procedures make the child cry.

One must always be alert to see the very first attempt at breathing,
for unduly prolonged manipulations may defeat their own object; the
natural inclination always is to do too much rather than not enough.
In some instances, however, the measures thus far indicated will not
prove successful, and, if not, the cord must be tied and cut through,
for subsequent treatment cannot be conveniently carried out while the
child remains attached to the placenta. As soon as the cord is
severed the child is placed in a tub of warm water, about the normal
temperature of the body, and is moved about in the bath for a few
moments, the attendant watching closely all the while, for the
breathing is often very superficial. Should signs of beginning
respiration not appear, the attendant should grasp the child by the
shoulders, dip it up to the neck in a basin of cold water and quickly
return it to the warm tub. This operation may be repeated five or six
times; generally the instant the child touches the cold water it
draws up its feet, opens its eyes, and cries. One must take care that
the plunge lasts but a moment; if the child becomes chilled efforts
to revive it will likely be unsuccessful. Indeed, the necessity for
keeping it warm must be constantly borne in mind.

With the very exceptional cases in which hot and cold tubs are
ineffective, the following method becomes valuable. Wrap the child in
a blanket and lay it face downward upon a table or chair, allowing
the head to hang over the edge. Roll the body on one side or a little
beyond; then slowly roll it back upon its face and onward to the
other side. This maneuver is repeated fourteen times to the minute,
but not more frequently. When properly performed it secures a flow of
air to and from the lungs with the same rapidity as in the normal
respiration of an infant. Efforts to revive the child must not be
quickly given up, as a successful outcome occasionally requires half
an hour of work or even longer. One method after another should be
tried in the order which I have indicated. A physician always
perseveres so long as the heart-sounds can be heard; but, since an
inexperienced person might be unable to decide upon this point, the
most reliable course for the layman is to persist in the
resuscitation until the physician arrives.




CHAPTER XI


THE LYING-IN PERIOD

The Changes in the Uterus--The Lochia--The Return of Menstruation--
Other Restorative Changes: The Loss in Weight; The Abdominal Wall;
The Pelvic Floor--The Care of the Patient: The Elimination of Waste
Material; Cleanliness; The Diet; The Environment; The Time for
Getting up--The Final Examination.

A generation ago physicians were accustomed to see their obstetrical
patients only at the time of labor. No preliminary examination was
thought necessary, and after the delivery visits were not made unless
the family became alarmed and requested them. When thus asked to come
back the physician sometimes found that an infection had developed;
occasionally the breasts were giving trouble, or some other
difficulty in the care of the mother or of the infant was baffling
the nurse. It is now recognized that the medical attendant should not
wait for the appearance of untoward symptoms. Although the strict
observance of the various precautions which I have already emphasized
should lead and usually do lead to an uneventful convalescence, it is
none the less true that the danger of infection and of other
immediate complication has not passed until several weeks after
delivery. For this reason and also because skillful guidance of the
mother at this time will prevent unwelcome sequels in the later years
of life, physicians now extend their watchfulness beyond the hour of
birth. The number of visits ordinarily required is not large. In each
case, to be sure, the circumstances will determine the number; but,
as a rule, ten visits, if properly distributed, will be sufficient.
During the month succeeding delivery these visits should be made in
about this order: a daily visit for the first five days, subsequently
one upon the seventh, the tenth, the fourteenth, the twenty-first,
and the twenty-eighth day.

At the conclusion of labor there begins a series of changes which are
the reverse of those incident to pregnancy, and which restore the
body to its original condition. Six weeks are generally required for
these alterations. They should leave the mother in _perfect_
health, but traces of pregnancy are not entirely effaced; even in the
absence of outward evidence, if a woman has ever given birth to a
child a thorough internal examination will disclose the fact.

The initial steps in these restorative processes are taken most
promptly and effectively when patients remain in bed. The traditional
custom of doing so has given to the first few weeks following
delivery the popular name, "the Lying-in Period." To these weeks
physicians usually apply the technical term _puerperium_, the
child's period, a designation which brings to mind the secretion of
milk which, though not a retrogressive change, is, nevertheless, one
of the most distinctive results of childbirth.

Radical as the bodily changes in progress at this time are, the
lying-in period is not a period of illness. But there is, perhaps, no
other time in a woman's life when she may cross the boundary between
sickness and health so easily; for here nature tolerates no trifling.
Not infrequently puerperal patients who are feeling well attempt too
much, and suffer a more or less serious set-back; it is an all-
important duty of the obstetrician, therefore, to restrain them from
harmful activity. In my experience patients yield to restraint most
readily, and secure the best results, if I explain to them the
anatomical facts which should guide the management of the lying-in
period.

THE CHANGES IN THE UTERUS.--Since of all the organs the uterus
undergoes during pregnancy the most extensive development, it also
holds the place of prominence during the lying-in period. Immediately
after delivery the womb weighs two pounds and measures some eight
inches in height, five in breadth, and four in thickness. In the
course of a few days it begins to dwindle in size, gradually sinking
in the abdomen until it lies entirely within the pelvic cavity.
Toward the end of five or six weeks it resumes the position occupied
before conception, regains approximately its original dimensions, and
weighs two ounces. We speak of the process which leads to these
results as the _involution_ of the uterus. Since a great deal
depends upon the rapidity with which involution progresses, we must
understand just what it is and how it may be influenced.

The muscle of the womb, to which this property of involution belongs,
is an aggregation of thousands of individual fibers. In response to
excellent nutrition during pregnancy, these fibers have grown thick
and strong, in order that they may furnish the power needed at the
time of labor. When this purpose has been fulfilled each fiber
becomes smaller and gradually passes into a resting stage the better
to preserve its vigor. It is the shrivelling of the individual
fibers, therefore, which accounts for the total reduction in the size
of the womb.

Although the source of the stimulus which causes the muscle-fibers to
atrophy is not so clear as we should like it, we are acquainted with
certain influences to which involution is susceptible. Of these none
merits so much attention as the influence of the breasts. The
intimate relation between the breasts and the uterus manifests itself
in such a variety of ways and with such force that no one doubts its
existence. Thus, if a nursing mother becomes pregnant her infant is
usually deprived of sufficient nourishment or suffers some digestive
disturbance; if not, and the mother, ignorant of her condition,
continues with the breast feeding, she may jeopardize the newly begun
pregnancy. Very likely she will be warned of the fact by the signs of
threatened miscarriage. More frequently, but in quite the same way,
we find that nursing causes uterine contractions in the early part of
the lying-in period, when they are called after-pains. Women who
experience them tell us they are more severe while the infant nurses;
and they also say that the discomfort disappears after several days,
a fact which indicates that involution has made notable headway. The
physician is not dependent on such evidence, however; for a simple
examination reveals at any time how far involution has progressed. By
this means we have learned that nursing facilitates the involution
process. On the other hand, it is found to be true, as we should
naturally expect, that women who decline to suckle the infant recover
from childbirth somewhat less rapidly than those who follow nature's
plan. In this fact, therefore, is found a selfish motive, yet a very
good one, which should impel mothers to perform this exceedingly
important duty.

Aside from the change in the mass of the uterus, notable results of
involution relate to its mouth and to its ligaments, for these
structures are also chiefly muscle. The mouth of the womb, lately
stretched to permit the exit of the child, gapes widely for a time;
but ultimately its lips are drawn together, the tissues which compose
them stiffen, and the canal which they enclose is narrowed to almost
microscopical dimensions. When involution is complete, the uterus has
so far regained its virginal character that no trace of childbirth
remains other than a few small fissures in the margin of its mouth.

It is the office of the ligaments to hold the uterus in proper
position. In consequence of pregnancy they have been stretched, and,
as we might anticipate, after the contents of the womb are expelled
the ligaments hang loosely from its sides, very much as sails hang
when a breeze dies down. Immediately after delivery, therefore, the
ligaments give the womb little or no support; eventually they shorten
and tighten, readily accommodating themselves to the existing
conditions. Until the accommodation is perfected, it is especially
desirable to permit no pressure which might push the womb backward.
It is for this reason that many obstetricians object to the time-
honored custom of applying a tight bandage about the abdomen at the
conclusion of labor; for, though bandaging is not always harmful, it
has a distinct tendency to misplace the womb. A friend who has served
as an assistant in one clinic where patients were bandaged regularly
and in another where they were not, tells me that displacements of
the womb were much more common among women treated by the former
method.

While the process of involution is altering the shape and size of the
womb, other forces are at work within the organ to provide its cavity
with a new mucous membrane. In character and in extent the inner
surface of the womb, left raw and bleeding at the conclusion of
labor, is comparable to the wound which would result if some accident
removed the skin from the palms of both hands. No one would question
the wisdom of guarding such an injury to the hands; but cleanliness
is even more necessary to the prompt and healthful restoration of the
uterine mucous membrane. However, the wound within the uterus is so
far from the surface of the body that it need not be directly covered
with a surgical dressing; sterile pads are kept over the vulva to
exclude contaminating material until the healing is completed. Since
bleeding ceases after that point is reached, we have no difficulty in
knowing when the mucous membrane has been restored.

THE LOCHIA.--The vaginal discharge which regularly follows the
termination of pregnancy gets its name from the Greek word
_lochia_. At first the discharge is pure blood, because it
issues exclusively from the vessels left open by the removal of the
after-birth. The greater part of the blood flows out of the birth
canal, but frequently some of it collects in the cavity of the uterus
or of the vagina; there it coagulates, and the clots may not be
expelled until several days later. In that event, as whatever effect
the bleeding may have had has long since passed, the appearance of
the clots is usually no occasion for alarm.

The amount of lochia varies, and will likely fall below the average
in small or anemic women and rise above it in those who are large or
robust. Then again, the discharge is less profuse if considerable
blood has been lost immediately after the labor. For the first ten
days the total quantity seldom exceeds eight or ten ounces; after
that time it is so small that it cannot be accurately estimated.
Formerly much larger amounts were considered normal, and, therefore,
it is probable that modern aseptic treatment of child-birth has
lessened the subsequent loss of blood. Toward the end of a week the
lochia changes from a bright red to a brownish color, because the
discharge now includes certain products of disintegration. Somewhat
later the lochia consists almost entirely of mucus, being only
streaked with blood; but there will be an increase in the bleeding
when the patient gets up; and injudicious activity may cause
flooding. A slight bloody discharge may be expected to continue until
five or six weeks after the child was born.

A faint but characteristic odor to the lochia proves very
disagreeable to some patients, and on that account it was formerly
customary to give them a daily douche throughout the lying-in period.
This was before the characteristics of the puerperal uterus and the
nature of infection were thoroughly understood. Most physicians are
now convinced that the early use of douches is rarely beneficial; and
since there is danger of washing infectious material from the lower
part of the vagina into the uterus, they may, if given prior to the
second week after delivery, actually do harm. Consequently douches
are not now used in a routine way. Whenever irrigations are indicated
the doctor will prescribe them. Late in the puerperium vaginal
douches are unobjectionable, and patients may take them unassisted,
for then the fluid will not penetrate the womb so long as it has a
free escape from the outlet of the vagina. Moreover, it is immaterial
if some of the fluid should pass into the womb, for its lining will
have been largely restored by this time, and at points where
restoration is incomplete defenses have been thrown up against
infection.

THE RETURN OF MENSTRUATION.--On account of the dilatation at the time
of labor women who have previously suffered with menstruation may
look forward to relief after child-birth. Menstruation generally
becomes as painless as the flow of the lochia; and so far as a
patient can tell the two phenomena are identical. Actually, however,
they bear no relation to each other. The fact that the cavity of the
uterus has been deprived of its lining is responsible for the lochia,
whereas the menstrual discharge occurs in spite of the lining,
through which it breaks at regular intervals in response to a
stimulus that is absent for a longer or shorter period after the
birth of a child.

In the latter part of the puerperium there may be doubt as to whether
a discharge is menstrual or lochial; though, if necessary, an
examination of the interior of the womb would always settle the
question, for structural changes in the uterine mucous membrane form
the most characteristic feature of menstruation. If, therefore, small
bits of this tissue are removed and studied under the microscope, a
definite conclusion can be reached. Physicians may resort to such an
examination when the significance of a discharge is not clear without
it; but other evidence usually enables them to decide the matter.

The secretion of milk often exerts an influence upon the
reestablishment of menstruation. Under ideal circumstances the mother
does not menstruate while she nurses her infant; whereas, if the
breasts are not in use, the menstrual function returns six to eight
weeks after delivery. Other pertinent clinical facts also lend weight
to the opinion that the activity of the breasts, more technically
called lactation, should not only prevent menstruation but also
hinder the ripening of egg-cells in the ovary. Thus, the nursing
infant has a potent influence upon the reproductive function of its
mother, enabling it to preserve its food supply; for in the event of
conception the milk usually decreases in amount or becomes of an
inferior quality. To secure this protective influence should prove a
strong incentive for the mother to nurse her child; in barely half
the cases, however, is it effective throughout a year. One-third of
nursing mothers, statistics indicate, begin to menstruate about two
months after delivery, and month by month the proportion gradually
increases.

Since menstruation appears so frequently during lactation, it cannot
be considered abnormal. It does not follow that the function will
become permanently reestablished after a patient has menstruated
once; in many instances several months elapse before there is another
period, and in a few cases there will be only one period during the
year the child suckles. Nevertheless, when the function has once made
its appearance extraordinary precaution should be exercised to avert
a return, and about the time its reappearance would be expected the
woman should go to bed for several days. Although this measure may
prove futile, we know of no other so likely to prove successful.

Menstruation is more apt to return prematurely after the birth of the
first child than of later ones. This may be due in part to a kind of
accommodation of the maternal organism to the reproductive process as
one pregnancy follows another; but I am convinced that it is also due
in part to the greater physical and mental composure of experienced
mothers. Until a woman has learned the unwelcome consequences she is
apt to take over household duties before she is equal to the task, or
she may engage in too strenuous amusements; and most mothers err in a
too energetic care of the baby.

OTHER RESTORATIVE CHANGES.--Many of the restorative changes in the
mother's body are either so intricate or so devoid of practical
significance that we may pass them by; though all of them have great
interest for the specialist, and some have occasioned bitter
controversy. The alterations in the heart, for instance, have been
the subject of a prolonged dispute between French and German
scientists. The former still assert that this organ regularly
enlarges during pregnancy and subsequently returns to its normal
size. The Germans deny both these contentions. Certainly the
alterations are insignificant from a practical standpoint; otherwise
competent observers would not disagree.

The really important changes in the body, other than those pertaining
to the uterus, are familiar to women who have passed through
pregnancy; but other prospective mothers may not understand that they
will regain the bodily condition which existed before conception.

_Loss in Weight_.--While the weight lost during the lying-in
period is not so vital as some other alterations, many have a keen
interest in it. In addition to the loss of ten to fifteen pounds at
the time of birth, a further loss occurs in the course of a few
weeks. Diminution in the size of the uterus is responsible for the
loss of nearly two pounds, and the lochial discharge for at least
another; but the chief factor concerned is the removal of water from
the tissues, many of which have become dropsical toward the end of
pregnancy. Altogether patients do not lose less than ten pounds
during the lying-in period, and often lose a great deal more. The
average loss for the first week alone is said to equal one-twelfth of
the patient's weight at the conclusion of labor; the total loss for
the whole of the puerperium corresponds to one-tenth of her weight at
the beginning of it. Variations from the rule are attributed to
individual peculiarities of nutrition. In general, stout women lose
more than slender ones, but with all types the loss is greater if the
mother nurses her infant. On the other hand, a generous diet tends to
counteract any loss in weight whatever.

_The Abdominal Wall_.--Much more important than the question of
weight is the recovery of the abdominal wall from the strain imposed
by the enlargement of the womb. In normal cases, to be sure, there is
very slight disproportion between the size of the pregnant uterus at
term and the capacity of the abdomen, yet the abdominal wall
invariably suffers a little stretching and unless it retains its
elasticity, the viscera are deprived of essential support, and cause
more or less discomfort.

The restorative changes in the abdominal wall involve the skin, the
fatty tissues, and the muscles. As soon as the distention has been
relieved the skin falls into folds, less noticeable if the pregnancy
was the first; and the muscles become so flabby that one has no
difficulty in pushing the wall backward until it touches the tissues
which cover the spinal column. Within a few weeks, if all goes well,
the muscles regain their "tone." Coincidently, the excessive fat over
the abdomen is absorbed. The skin becomes smooth, and its
pigmentation fades completely; but the pregnancy streaks rarely
vanish entirely, although they always become very much less
noticeable.

Whether or not the abdominal wall will recover from the distention of
pregnancy depends entirely upon the muscles. As the lying-in period
advances each fiber should gradually shorten until the whole muscular
structure becomes as firm and tight as it ever was. But this takes
time, and no artifice can hasten the repair. Perfect recovery is most
likely with the body in a recumbent position, which relieves the
muscles from any strain. These facts are better appreciated than
formerly, hence most physicians encourage their obstetrical patients
to remain in bed somewhat longer than their mothers did. Generally
nothing else will be required, and only under extraordinary
circumstances will nature need assistance. Thus, if there has been
unusual distention, as, for example, that due to twins, the muscular
impairment may be extreme; or if pregnancies follow one another in
quick succession the strain becomes so nearly continuous that there
is not sufficient time for adequate repair. Whenever nature does need
encouragement calisthenics of some kind are advisable. These
systematic exercises, which the patient practices in bed and flat on
her back, are usually begun about a week after delivery, though there
may be some reason for beginning them earlier or later than this.

The physician will always select the proper calisthenics, but the
following "movements" generally prove satisfactory. To exercise the
muscles at the front of the abdomen one leg after the other is raised
and lowered; as this is being done the knee will be bent (flexed) at
first, but later the leg may be held straight (extended). Other
muscles come into play when the feet are alternately brought together
and separated as widely as possible. A third movement which exercises
the muscles at the side of the abdomen consists in raising the
shoulders from the bed and twisting the trunk so that the weight of
the chest rests now on the right, now on the left elbow. When these
movements can be performed fifteen or twenty minutes without fatigue
more vigorous exercises may be adopted. For example, the buttocks,
together with the lower part of the back, are raised off the bed,
while the shoulders, elbows, and the heels remain stationary. A day
or so before getting up the patient should practice alternately
raising herself from the recumbent to the sitting posture and
returning to the above position without assistance from the arms.

The value of bandaging the abdomen immediately after delivery as a
means of strengthening the abdominal muscles is questionable; though
physicians agree to the advantages of a supporter after patients are
out of bed. We constantly see perfect restoration of these muscles
without the early use of a binder; in fact, women who have employed
it throughout the lying-in period do not secure an efficient
abdominal wall more frequently than others who began its use two
weeks after they were delivered. Even those physicians who advocate
an early application of the binder concede that it works harm in
certain cases and do not recommend it indiscriminately.

Those who postpone for a fortnight the use of the binder will escape
the tendency it has to cause displacements. By this time the
involution will have advanced so far that the womb lies within the
pelvic cavity, where it is surrounded by the hip bones, which protect
it from external forces that otherwise would influence its position.
When permitted to get up patients ought to use a binder, because it
counteracts the feeling of "falling to pieces" of which some complain
when the abdominal walls are not comfortably supported. But there is
no evidence to show that a binder plays any part in restoring the
figure. When, in spite of ample rest, the abdominal muscles fail to
recover completely, we have no better way of strengthening them than
by use of calisthenics or massage.

_The Pelvic Floor_.--Second only in importance to having the
womb restored to its original position is the necessity of
restoration of the pelvic floor. This structure, also called the
_perineum_, we should know, lies between the thighs, shuts in
the bottom of the abdomen, and prevents prolapse of the viscera. In
women it forms the lower portion of the birth-canal, enclosing the
aperture through which the child enters the world. Although
intelligent management of labor is of the greatest value for the
protection of the pelvic floor, under certain circumstances it may be
impossible to preserve it intact; injury to it is the rule when the
first child is born, and not unusual in later births. There can be no
doubt regarding the advisability of uniting the edges of a tear;
indeed, to do so immediately is the very first essential toward
restoring the pelvic floor to its wonted integrity. But even though
tears are sewn up successfully, there is invariably some relaxation
of the perineum until the restorative process, which here again
chiefly concerns the muscles, has been given opportunity to become
effective.

As with all the restorative changes in the lying-in period, to rest
calmly in bed favors the perfect recovery of the pelvic floor more
than anything else. Keeping the thighs together during the first few
days undoubtedly assists tears in healing, but that precaution is not
always necessary, and when it is the physician will call attention to
the fact. The really important matter, as I have said, is that the
upright position should not be resumed until the pelvic floor has
become firm.

THE CARE OF THE PATIENT.--Now we have learned enough of the manifold
changes in the lying-in period to appreciate the fact that patients
require medical direction even though they are feeling perfectly
well. The view held by former generations that women can get along
without a doctor and with any sort of nursing is partly responsible
for the existence of gynecology, the branch of medicine which deals
with the diseases of women. Recently delivered women should be
treated as surgical patients, not because they are ill, but to keep
them from becoming so.

If the patient desires the highest degree of protection an
experienced nurse is indispensable, for she will make systematic
observations which would consume too much of the doctor's time for
his personal attention, yet without which he would not be
sufficiently conversant with his patient's condition to guide her
properly. The temperature, the rate of the pulse, and of the
respiration should be recorded at regular intervals during the day
and night. An elevation of temperature at the conclusion of labor
need give no uneasiness, for experience has shown that it generally
subsides within a few hours. Moreover, slight elevations in the
course of the following week are so frequent that obstetricians have
agreed to regard as a normal temperature for this period 100.4
degrees instead of the usual normal of 98.4 degrees. The pulse-rate
most frequently does not depart from what is characteristic for the
individual, though about one-fifth of puerperal women have a slowing
of the pulse, a phenomenon of favorable significance. Any difficulty
in breathing that may have existed in the latter part of pregnancy
disappears when the abdominal distention is relieved, and the
respiratory rate becomes normal. So long as the body is getting rid
of the tissue-substance essential to pregnancy, but now without any
purpose, more than the usual amount of waste material is present in
the expired air.

_The Elimination of Waste Material_.--As we might expect from
the loss in body weight, the excretory organs are particularly active
during the lying-in period. In quantity the loss of water exceeds all
the other waste-products together; and pronounced activity of the
kidneys or of the sweat glands may become a source of annoyance.
Since it is undesirable to interfere with these functions, whatever
inconvenience either may cause will be borne with less complaint if
the patient understands that a large loss of water at this time
indicates a healthful condition of the body.

Shortly after delivery there may be difficulty in emptying the
bladder; and, under such circumstances, the doctor or nurse used to
catheterize the patient immediately; this habit once begun, it was
often necessary to repeat the operation day after day, or, for that
matter, several times a day. But as physicians came to know more of
the relations of bacteria to inflammation of the bladder, they grew
more cautious, and preferred to wait a long time before resorting to
the catheter. The reward of this patience was to find that, with
remarkably few exceptions, puerperal women ultimately void of their
own accord. Accordingly catheterization after child-birth is now
postponed, and is never performed until a number of devices to get
the patient to void spontaneously have been tried without success.
Often urination follows putting a hot-water bottle over the bladder;
or pouring warm water over the vulva; or placing the patient upon a
bed-pan from which steam is rising. When these and other devices well
known to every nurse are not effective, catheterization becomes
necessary. With the elaborate precautions taken to avoid infection of
the bladder, catheterization is now performed with very slight risk.

Constipation, for various reasons, becomes a regular feature of the
lying-in period. The confinement in bed, restricted diet, relaxation
of the abdominal wall, and sensitiveness about the region of the
rectum, all have a tendency to prevent spontaneous movements of the
bowels. As one of these influences after another is removed the
bowels begin to act naturally. Childbirth may cause chronic
constipation, but this sequel would occur much less often if a little
care were taken to prevent it.

The routine use of enemas deserves to be condemned. I see no
objection to an occasional enema if purgative medicine has been taken
without effect, but constant use of them, more than likely, will
result in the enema habit. Similarly, long-continued administration
of strong purgatives tends to make them a permanent necessity. While
in bed if medicine is taken every other day the bowels will have
opportunity on the intervening days to move spontaneously, though we
do not really expect them to move naturally until six or eight weeks
after the delivery, when the patient is able to take as much exercise
as she likes. Toward the end of the second week, however, mild
laxatives generally prove effective, and it is important to select
one the dose of which may be gradually decreased. Senna prunes, which
were described in Chapter V, fill the purpose very well. Six or eight
of them may be needed at first, but the number may be gradually
reduced, until finally none are necessary.

_Cleanliness_.--In view of the excessive elimination of waste
products from the body, the maintenance of cleanliness during the
lying-in period may require the use of a large amount of linen.
Occasionally patients perspire so freely that the night clothes have
to be changed several times in twenty-four hours, and the bed linen
only a little less frequently. But at any cost it is imperative not
to hinder but rather to promote this function and to keep the skin in
a healthful condition through bathing and massage. Nurses are taught,
on this account, to give a warm soap and water bed-bath in the
morning and an alcohol rub at night. Patients are usually allowed to
take tub-baths after the third week.

Local cleanliness, which is a matter of the very first importance,
can only be attained through bathing the vulva with an antiseptic
solution and the use of sterile pads. At first the pads are changed
very frequently, but after the discharge becomes less profuse they
are renewed at intervals of four to six hours.

_The Diet_.--For the first week of the lying-in period not all
patients are given the same diet, and the physician always leaves
specific directions regarding it. Generally the diet consists of
liquids, such as milk and broths, for a couple of days; under some
circumstances liquid nourishment is continued longer. As the appetite
increases easily digestible but nutritious food is added, and before
long the patient resumes her ordinary diet.

The modern tendency is to give solid food and to give it in
substantial amounts much earlier than was once customary;
restrictions, none the less, are still observed so long as the
patient remains in bed. With the body at rest, its food requirements
are diminished and hearty meals are unnecessary. If convalescence
proceeds satisfactorily such wide latitude in the choice of food is
permissible that the nurse may regulate the diet, consulting the
physician whenever necessary.

_The Environment_.--A large, bright room that can be quickly
heated and easily ventilated adds notably to the comfort of the
lying-in period. The windows may be opened through the greater part
of the day and at night should always be left so. To make thorough
airing of the apartment more feasible and to protect the mother from
annoyance when the baby cries, it is more satisfactory to have the
baby occupy an adjoining room where the nurse sleeps within call.
Under any circumstances some arrangement must be made so that the
mother's rest at night will not be broken needlessly.

No pains should be spared to keep the patient quiet for at least ten
days. Household cares and petty worries materially delay
convalescence. During this period only a limited number of the
immediate members of her family ought to see her, and their visits
should be brief. Unfortunately, if too many relatives and friends
visit her a number of questions will be repeatedly asked which are
decidedly wearing on any patient.

_The Time for Getting Up_.--How long a woman should stay in bed
after the birth of a child is a question which has given rise to
prolonged discussion. The majority of obstetricians adhere to the
traditional ten days; but there are advocates of a longer period and
advocates of a shorter one. The generalizations of many writers upon
this subject are too sweeping, for exceptions may be found to any
rule. Each patient is best counselled when the advice given is based
upon her own condition and particularly upon the progress made in the
involution of the uterus, which does not advance with the same
rapidity in all cases.

More or less in imitation of the custom among savages, Charles White,
in 1776, recommended that women should not remain in bed longer than
a day or two after child-birth. Very likely the inadaptability of the
method to civilized women soon became apparent; at any rate his
suggestion was not widely adopted, and had been completely forgotten
until a few years ago, when the custom was revived in one of the
German clinics. The innovation met with violent opposition in Europe,
and, so far as I know, has found but scant favor in America.

Generally patients are allowed to sit up in bed toward the end of the
first week, but if there are stitches, sitting up is deferred until
ten days or later, when the stitches have been removed. Under the
most favorable circumstances, however, sitting up in bed becomes
wearisome, for the weight of the body does not fall upon the spine,
as it should; and besides the extended position of the legs is
fatiguing. No one should force herself to keep this posture, for at
best it does no more than relieve monotony. The exercises previously
suggested prepare her much more effectually for getting upon her
feet.

Between the tenth and the fifteenth day patients may leave the bed
and sit quietly in a chair. The condition of the uterus, the
character of the lochia, and the firmness of the pelvic floor will
determine the day, but usually it proves wiser to defer it until
fully two weeks have lapsed. As a rule, the patient remains out of
bed an hour the first day, two the second, three the third, and so on
until she is up all day. She should not attempt to walk until the
second or third day. At first she should take only a few steps, but
gradually she may increase the number and finally walk with freedom
and ease. Several reasons make it advisable for patients to remain
four weeks on the floor where they have been confined; going up and
down stairs is especially tiresome, and, of still greater importance,
patients pass from the doctor's control as soon as they go down
stairs. For fear of overtaxing the strength none of the household
cares should be assumed before the fourth week, and not all of them
then, for women are not capable of resuming their accustomed duties
fully until the sixth week; and some are not strong enough to do so
until a somewhat later date.

Since patients generally feel well during the lying-in period they
are apt to object to remaining in bed two weeks. Most of them
acquiesce as soon as they understand the organic changes in progress
and appreciate the lasting benefits of a temporary forbearance, but a
few must be made to realize that very serious penalties may be
attached to undue haste. For the latter it might be better if the
alarming consequences of getting up too early--discomfort,
hemorrhage, and collapse--occurred more frequently than they do. As
it happens, the ill-effects of such indiscretion are not usually felt
immediately; when too late the lesson is learned that many of the
operations upon women in the later years of life are dependent on
imprudent conduct just after the first child was born.

THE FINAL EXAMINATION.--Looking to complete restoration of the
woman's health, the modern management of obstetrical cases breaks
decisively with tradition at three points. An utter disregard of
precaution has given way to very careful preparations before and at
the time of labor; definite rules for the management of the lying-in
period are carried out under the supervision of the physician; and
finally, prompted by the same impulse, the physician examines his
obstetrical patients before discharging them. Satisfactory conditions
are generally found; if they are, it is a great comfort to be assured
of the fact; and if not, timely treatment of the abnormality may
readily correct it; with delay, on the other hand, treatment often
becomes more formidable.

The end of the fourth week of the lying-in period proves a convenient
time for this examination. As yet the restorative changes in the
reproductive organs have not been completed, but one may definitely
say by this time whether or not they will culminate in a satisfactory
manner. Besides, making the examination while the changes are in
progress sometimes enables the physician to treat approaching
complications before they actually develop. Thus, when the pelvic
floor has not regained its strength sufficiently, the patient will be
advised to forego the liberty in moving about ordinarily granted at
this time. When the womb inclines to an improper position, a
temporary support may be introduced to hold it where it belongs;
later, upon removing the device, the womb usually retains a good
position. Again, there are conditions which a douche will relieve,
and still others benefited by medicinal treatment. If an abnormality
is recognized which cannot at once be treated to the best advantage,
arrangements will be made for such prompt treatment that the woman
will not become an invalid. Instead of placing obstacles in the way,
patients should rather insist upon this examination, for it is
important in guarding their future health.

Now and then patients are kept under observation for a longer period,
but, as a rule, they are discharged as well as examined at the end of
four weeks. They may also discard the abdominal binder about this
time and put on corsets, which, however, should not be tightly worn.
Although thrown upon her own resources from this moment, the patient
will clearly understand that she must continue to exercise sound
discrimination in what she does. And here, of course, we encounter
the greatest difficulty in offering practical advice, for what one
may do easily will overtax another. Generally speaking, going up and
down stairs more than once a day is inadvisable until another two
weeks have passed. Likewise the mother who would adopt a conservative
policy will not take full charge of her baby before it is six weeks
old, though there can be no objection if she wishes to direct its
care. The same advice applies to running the household. Over-
exertion, no matter what the source, delays convalescence from child-
birth to such an extent that the safe plan is always to err on the
side of doing too little, rather than to run the risk of doing too
much.




CHAPTER XII


THE NURSING MOTHER

The Breasts--Human Milk--The Technique of Nursing--Hygiene of the
Mother: Diet; Psychic Influence; Recreation and Rest--The
Supplementary Bottle--Weaning.


When the obstetrician pays his final visit the mother usually has
ready a number of questions, most of which anticipate difficulties in
the care of the baby. At that time, however, minute and far-reaching
directions cannot always be given. Unforeseen peculiarities in the
development of the child may modify such general principles for the
management of infants as could be laid down in advance. With a few
exceptions, therefore, mothers require during the early years of a
baby's life skilled advice as to his upbringing--advice for which
neither instinct nor haphazard counsel is a safe substitute. It is an
excellent plan, and one which is becoming more and more popular, to
have a physician supervise the care of the baby through the period of
most active growth. According to this plan, the mother, even though
her baby is well and developing as it should, consults the physician
at regular intervals, once a month for example, and upon these
occasions secures help in solving problems which are certain to
present themselves. Such an arrangement shows a merited appreciation
of the proverbial "ounce of prevention," and when serious
difficulties do arise materially counteracts the tendency to panic
which is exhibited by so many young mothers.

Among the problems which the mother must solve, that of nutrition
outranks all others in importance; and unless the infant is nourished
with human milk, it also exceeds them in perplexity. For, although
great advances have been made in artificial feeding, science has not
yet removed all the intricacies and dangers involved in the use of
the bottle. On the other hand, mothers who nurse their babies rarely
meet with difficulty. Human milk is perfectly adapted to the wants of
the infant; and all substitutes, though carefully designed to
duplicate it, are only partially successful. We have learned how to
modify cow's milk so that in chemical constituents, at least, it is a
very close imitation of human milk; but human milk possesses, in
addition to its chemical properties, other desirable qualities which
cannot be instilled into an artificial food. We must agree,
therefore, that attempts to disseminate a wider knowledge of the
correct principles of bottle-feeding do not have the highest aim. Our
real need is a vastly greater proportion of women who nurse their
children.

THE BREASTS.--For success in nursing the first essential is healthful
breasts. With this the largeness or smallness of a breast has nothing
to do, for size is no more an index of its capacity for producing
milk than is the weight of a woman an index of her energy. The breast
is not a warehouse, but a factory, with very limited storage capacity
for its product. Differences of size are generally to be explained by
the variable amount of fatty-tissue the breast contains. And so far
as the secretion of milk is concerned the fat is entirely passive; it
fills in the space between the glandular elements; and a layer of fat
just beneath the skin protects the glands against external influences
that otherwise might disturb their activity. Stripped of their fatty
envelope the structures which actually secrete the milk and convey it
to the nipple resemble a miniature cluster of grapes. Each tiny,
spherical gland corresponds to one of the grapes and contains a
cavity lined with cells which manufacture the milk. From this cavity
the milk flows through a microscopic tube which unites with similar
tubes to form a larger one; this in turn joins others of its kind;
and so on, until ultimately the milk enters a relatively large duct--
the figurative stem of the cluster--which conducts the milk to its
destination. There are from ten to fifteen of these terminal ducts;
each drains a separate group of glands, but all end in the nipple.

Shortly after conception the breasts become congested; in consequence
they enlarge, become tender, and begin to show swollen veins beneath
the skin. The most significant alteration, however, occurs in the
cells which line the glands; these increase in size at first; and
then, by a process of cell division, their number multiplies. After
pregnancy has advanced six to eight weeks these cells begin to
elaborate the thin, watery fluid called colostrum. Contrary to
popular belief, the quantity of colostrum is not prophetic of the
character of the milk; there is no ill-omen, to be sure, in a
plentiful secretion, but a meager one is quite as likely to be
followed by successful lactation. At present we are unable to predict
by any means either the quantity or the quality of the milk which a
prospective mother will produce.

Some writers contend that influences which come into play during
girlhood ultimately affect the capacity of the breast for making
milk; for example, irregular habits in youth and the wearing of
improper styles of clothing are said to be particularly detrimental
influences. Of course, a healthful mode of life at the time when a
girl is approaching maturity reacts favorably upon her development in
every way, and naturally enough the breasts share this benefit; but
the relation between unhygienic habits at about the time of puberty
and a subsequent deficiency in lactation has been exaggerated by many
writers. It is impracticable, certainly, to institute special
measures to prepare the breasts for their function until the need of
such measures is clearly evident. Throughout pregnancy clothing about
the breasts should be loosely worn. If the nipples are not already
prominent they should be drawn out; and about six or eight weeks
before confinement is expected they should be given the treatment
described in Chapter V.

For the first day or so after the infant begins to nurse its efforts
have a tendency to injure the skin which covers the nipple; and
unless measures to render the nipple resistant have been previously
adopted, nursing may cause the mother considerable discomfort.
Moreover, it is extremely important throughout lactation to keep the
skin covering the nipple free from abrasions, for if it cracks
bacteria have thus an opportunity to enter the glands and set up an
acute inflammation which may result in the formation of an abscess.
This complication is to be avoided, not only because of the
unpleasant symptoms which attend it, but also because for the time it
brings the usefulness of the breast to an end. Fortunately an abscess
seldom impairs the breast permanently.

At any period of lactation there may be an overproduction of milk. In
this event the breasts are likely to become distended, hard, and very
tender. Most frequently "caked breasts," as this condition is called,
develop a few days after delivery, when the secretion of milk is just
beginning, for at first the secretion is more plentiful than need be.
Generally twenty-four hours later there is an adjustment between the
supply of nourishment and the natural demands of the infant.
Occasionally a longer interval elapses before the breast is
completely emptied at each nursing.

Formerly it was customary, whenever the breasts became tense and
uncomfortable, to express an excess of milk by means of massage; but
this mode of treatment lost favor as soon as physicians realized that
massage stimulated the glands to greater activity. Drawing the milk
with a breast-pump has a somewhat similar though less potent
influence, and, because pumping often affords relief when the breasts
are distended, there is rarely any objection to it. In the light of
modern experience, however, most physicians prefer to avoid
manipulation of the breast so far as possible, and generally resort
to other measures to relieve the mother's discomfort. Thus most
patients are made comfortable if an appropriate bandage is used to
transfer the weight of the breasts from the arm-pits and the front of
the chest to the bones of the shoulder-girdle. It may be necessary
also in some cases to swathe the breasts in warm cloths; in others
cold applications are more acceptable; the choice between these
methods will vary with the time of year, and usually may be left to
the patient herself. Now and then medicine will be employed to
relieve the pain, but the administration of drugs to diminish the
production of milk is inadvisable. It is never very long before the
amount of milk becomes adjusted to the infant's wants, and then
distention disappears spontaneously. No artifice can bring about the
adjustment as ideally as nature does.

During the later months of lactation the liability of the breasts to
over-filling is slight, provided the infant empties them regularly
and completely. Nevertheless, so long as a mother is nursing her
child she must be careful to keep the breasts in a healthful
condition. They require support, yet must not be compressed. And they
should be covered with clothing which will adequately protect them
from sudden changes of temperature. This latter precaution, perhaps,
requires more emphasis than formerly, on account of the present
popularity of motoring; for the chill which one experiences when
driving fast may have a very unpleasant effect upon a nursing mother
unless her breasts are carefully protected. Occasionally fever and
neuralgic pains in the breasts are caused by motoring, or by exposure
to the air-current from an electric fan playing directly upon them.
But even under these circumstances an abscess need not be feared
unless the nipples are sore.

_Human Milk_.--Between the time of birth and the beginning of
lactation there is always an interval during which the breasts
secrete colostrum, just as they do throughout pregnancy. Although the
nutritional value of this fluid is not great, it is doubtful if
colostrum serves any other essential purpose than as nourishment.
Possibly it also stimulates the intestines to expel the material
which has collected within, them during fetal development, yet we
know the bowels will move without a purgative; and often do so long
before the infant is placed at the breast. Typically, the secretion
of milk begins the third day after delivery; yet in perfectly normal
patients it may appear as early as the second or as late as the
fifth, and occasionally lactation does not begin until the baby is
more than a week old.

As to what starts the secretion of milk we have only a vague idea;
but we know that when the flow is once established its continuation
depends primarily upon the sucking efforts of the infant. If nursing
is discontinued the secretion dwindles and the breasts dry up. On the
other hand, the strong, persistent stimulus of the infant's suckling
gradually brings the secretion to a high degree of efficiency. Within
the first two weeks, therefore, the daily secretion increases from a
few ounces to a pint or more. Subsequently the output fluctuates
between one and two quarts daily, according to the demands made upon
the breasts; the secretion is larger, consequently, if there are
twins. Astounding yields of milk have been recorded, as in the case
of a wet-nurse in a German institution who nursed a number of infants
and became capable of supplying three to four quarts daily.

That newborn infants thrive better on human milk than on any other
nourishment is a conviction that must come home to every one who has
had even a limited experience. It keeps the babies in health, serves
to make them grow, and promotes the development of all their organs
as nothing else will. Because there are present in this fluid all the
elements necessary for nutrition, physiologists have called it a
perfect food. Quantitatively its most important ingredient is water,
which constitutes about 86 per cent. of its weight. It also contains
about 7 per cent. of milk-sugar, 4 per cent. of butter fat, 2 per
cent. of protein, and 0.2 per cent. of mineral matter.

The milk of all animals contains a relatively small quantity of
mineral matter; judged from this standpoint, the mineral matter would
seem of minor importance, but it is actually as vital as any other
constituent. Without it the bones would hot harden properly; and
other services which it performs are absolutely essential to life. As
we should expect, human milk contains all the mineral ingredients
necessary for the development of the infant; indeed, with the single
exception of iron, they are present in the precise amounts in which
they are needed. In this omission, however, nature is guilty of no
oversight, since the infant has already been provided by the time of
birth with a rich supply of iron.

THE TECHNIQUE OF NURSING.--Since the mother should have opportunity
to recuperate from the fatigue of labor, physicians generally
recommend that an interval of at least twelve hours elapse between
the birth of the infant and the time it is first put to the breast.
Moreover, the best interests of the infant demand that it be kept
warm and left undisturbed while becoming accustomed to its new
environment. There is no immediate need of food; and if there were,
nature does not fit the mother to supply it, for at this time the
breasts contain merely small quantities of colostrum.

Some babies nurse vigorously at the outset, but later, discouraged
because they get so little, become indifferent and restless, or even
decline to take the breast. And the mother, who is handicapped by
inexperience and by the awkwardness of nursing in a recumbent
position, often feels desperate. Fortunately technical difficulties
are confined to the first few days, and, trying as they sometimes
are, no one should be discouraged or imagine that she is incapable of
nursing; for practically every woman who persists will succeed.

For a week or ten days the mother will nurse in the recumbent
posture. She turns to one side or the other, according as the right
or left breast is used, and holds the corresponding arm to receive
and support the baby, which will lie beside her. Then with the
opposite hand she holds the breast, placing her thumb above and her
fingers below so as to keep it from the baby's face, for only in this
way can the infant breathe freely. One must also remember that the
infant draws the milk into the terminal ducts chiefly with the back
of its mouth, and drains the ducts by compressing the base of the
nipple with its jaws; the infant therefore should take into its mouth
not only the nipple, but also the areola, the area of deeply colored
skin round about it. Mothers frequently disregard these directions,
and the failure of their infants to nurse properly may be thus
explained, for it is impossible to secure undisturbed nursing unless
they are obeyed.

Generally the breasts are employed alternately, but both may be used
at each nursing if one is insufficient. To fix the duration of the
nursings arbitrarily is impossible; from ten to fifteen minutes
generally proves satisfactory, but in each case systematic
observations of the change in the baby's weight, of the character of
its stools, and of its general condition must determine how long to
leave it at the breast. The common error, unfortunately, is to be
over-indulgent, and, as a result, infants are more frequently ill
because the nursings are too long, than too short. Furthermore, the
duration of the feedings can never be gauged accurately if the infant
is allowed to nap while nursing.

The successful training of a baby begins with the development of
regular habits of nursing. The old-fashioned custom of allowing the
baby to nurse whenever it cried, tacitly--and incorrectly--assumed
that it could have no other sensation than hunger. As a matter of
fact an infant may have pain from overfeeding. Again, it may be
thirsty, or uncomfortable from the pricking of a pin, from the
monotony of one position, from a soiled napkin, or from neglect of
many simple details in its care. Any of these things make a baby cry,
for it has no other means by which it can express disapproval.

So long as the breasts contain colostrum the nursings should be at
least three hours apart during the day; at night it is preferable not
to disturb the mother at all. As soon as milk appears the interval is
usually shortened to two hours during the day. In many cases,
however, the three-hour interval will be retained even after the milk
appears, for otherwise the infant may not become hungry and will fail
to nurse as strongly as it should. The following schedule is adapted
to the average infant:

           Age                 Interval During     Total Number
                                   the Day          of Feedings
  From  1st  to    4th week       2      hours            9
    "   4th   "    8th  "         2-1/2    "              8
    "   2nd   "    4th month      3        "              7
    "   4th   "   10th   "        3        "              6
    "  10th   "   12th   "        4        "              5

After the first few days most young infants require one feeding in
the middle of the night, which is usually given about 2 A.M. The day
feedings then begin at 6 A.M., and are repeated at regular intervals
until 9 or 10 P.M. The daily bath should be scheduled so that a
feeding will be due just after the bath has been completed. If asleep
when the next succeeding feeding falls due, the infant should not be
waked, but at other times nothing should interfere with the
regularity of the schedule. Occasionally there may be difficulty in
getting the child to nurse during the day, but it must be taught to
do so; otherwise it will want to nurse throughout the night.

At no time should an infant remain in the bed with its mother after
it has finished nursing; at night this rule must be rigidly enforced,
for mothers have been known to fall asleep and smother the baby, an
accident known as over-lying. Infants can frequently be trained to go
without feeding in the middle of the night even when a month old; and
such training is always advisable, since it affords the mother
opportunity for six or eight hours' continuous sleep.

Before and after each nursing the mothers' nipple should be cleansed
with a solution of boric acid made by placing a tablespoonful of the
powder in a tumbler which is then filled with water. Such cleansing
protects the breasts against infection, a complication which the
nursing mother must spare no pains to prevent. Now and then, in spite
of conscientious efforts to harden them, the nipples become sore. If
they crack, the baby's mouth must not come in direct contact with
them, since nursing with a cracked nipple is a common source of a
gathered breast. Fortunately when a nipple cracks we may employ a
shield, obtainable at any drug-store, which enables the infant to
nurse without any danger to the mother. Most babies will take the
shield as well as the breast itself; nevertheless, its use should be
discontinued as soon as the nipple heals, for while the shield is
used the secretion of milk is not stimulated as vigorously as when
the infant nurses directly from the breast. In the rare cases in
which the shield cannot be used satisfactorily the infant must be
taken from the breast temporarily and given a bottle. Radical as this
advice may appear, the mother must consent to follow it, for, as I
have pointed out, to permit an infant to nurse a cracked nipple is
extremely hazardous. When treatment is begun promptly the cracks will
generally heal within twenty-four hours.

HYGIENE OF THE MOTHER.--Since the mammary glands manufacture their
product from the constituents of the mother's blood and their
activity is controlled by her nerves, it is clear that her physical
condition and her state of mind will influence the secretion of milk.
Intelligent women who understand this desire to know how they should
live that they may best insure an ample supply of good milk.
Fortunately the first important step toward success has been taken
when a mother wishes to nurse her baby; but there are also necessary
wholesome food, habits conducive to health, and a mind free from
worry.

It is unfortunate that current beliefs throw many restrictions about
nursing-mothers which are unreasonable and unsupported by scientific
investigation. There was a time when mothers did not question their
ability to nurse, they assumed this duty as a matter of course.
Indeed, they were compelled to do so, since refined methods of
artificial feeding had not as yet been devised. Among the
agricultural class, even to-day, it is exceptional for mothers to
fail to nurse their children, if they are provided with the ordinary
comforts of life. But women who live at the higher tension of city
life are frequently unsuccessful, because they are more inclined to
be nervous or because they disregard, among other things, the need of
fresh air, plain food, or regular habits. It is wrong to suppose that
elaborate rules of conduct are necessary for nursing mothers; the
instruction they require is simple and scarcely different from that
to be given anyone who desires good health. If she lead a wholesome
existence a woman will not only nurse her child successfully but will
gain in strength.

_Diet_.--In manufacturing centers, where a large proportion of
the women are employed in confining work, the percentage of mothers
who are able to nurse their children is exceedingly small;
consequently the infant mortality is very high. Better nourishment
for the mother, it has seemed, would render her more capable of
successful lactation, and would decrease or even eliminate badly
executed artificial feeding, and would therefore reduce the death
rate among the babies. In a few foreign cities the idea has been put
into practice. Free restaurants have been established for working
mothers, and they have thus been enabled to perform their maternal
duties much more successfully. Incidentally it has been shown that
nourishment may be supplied mother and infant at a smaller cost than
proper artificial food for the infant alone.

The quantity of nourishment required by nursing mothers is not so
large as might be expected, and in many instances it is over-feeding
rather than under-feeding that must be guarded against. Very accurate
observations have been made which indicate that during the early
weeks of nursing no more food is needed than at other times; in all
probability this remains true throughout the whole period of
lactation. Over-eating, as many of us know, is a frequent cause of
indigestion. It is of the first importance, therefore, that nursing
mothers should not take more food than they can assimilate, for
indigestion will provoke disturbances in the milk which in turn will
make the baby uncomfortable. For a similar reason mothers should have
their meals at regular intervals.

As a rule the appetite is a reliable guide not only as to how much to
eat, but also as to the choice of food, for without exception what is
good for the mother is good also for the child. Generally the diet
should be a mixed one, consisting of milk, gruels, soups, vegetables,
bread, and meat. In order that monotony may not dull the appetite, no
one article of food should be employed continuously. With this
exception food should be selected with regard only for its
wholesomeness and digestibility. All food is milk-making food; no
sharp distinctions between the various kinds can be recognized. Milk,
because it contains all the elements necessary for perfect nutrition,
is particularly wholesome. Water also, since it forms such a large
proportion of their milk, should be taken freely by nursing mothers.
Generally it proves advantageous to take milk or some other
nutritious drink between meals and again before retiring at night,
but the danger of ruining in this way the appetite for solid food
must not be overlooked.

It ought to be unnecessary to say that a nursing mother should deny
herself any article of food, no matter how much she may want it, if
she knows it will disagree with her; but she must remember also that
the same article of food will not necessarily disagree with other
mothers. Generalizations of this kind are largely responsible for the
wrongful tendency to reject from the dietary many altogether harmless
articles. There would be little left for a nursing mother to eat if
she avoided every article of food which one person or another assures
her will damage her milk.

No belief regarding what a nursing mother should eat is held more
widely, I suppose, than that she should abstain from salads,
tomatoes, and fruits which contain acid. This view is erroneous. The
very idea upon which it is based is incorrect, since acids are
neutralized as soon as they pass from the stomach to the intestines
and cannot enter the milk. With certain persons some varieties of
fruit invariably cause indigestion. Lactation does not correct such
an individual peculiarity, and a nursing mother who knows she
possesses it will act accordingly. Occasionally those who have no
such idiosyncrasy worry after they have eaten something which
contains an acid because they have heard it will do harm. In such
cases it is the mental state of the woman which disturbs her milk and
upsets the baby. With the exception of those who have such an
idiosyncrasy and those inclined to worry, nursing mothers may partake
of fruits and salads with impunity.

There are vegetables, of which the onion and turnip are good
examples, that contain ingredients that find their way unaltered into
the milk. So long as these do not disturb the mother their presence
has no unfavorable influence upon the child. Similarly a number of
substances appear in the milk when administered as medicine to the
mother. In one way this is fortunate, for under certain circumstances
it provides a very satisfactory method of treating unhealthy children
without giving the medicine directly. In another respect, however, it
is a disadvantage, for it sometimes interferes with giving the mother
purgatives, which she may need. So far as possible, therefore, the
taking of medicine should be limited during lactation, and certainly
no drug should be employed without the advice of a physician.

Time and again some drug, some beverage, usually one that contains
alcohol, or some special article of food has been recommended as a
means of increasing an inadequate secretion of milk, but thus far all
attempts in this direction have failed of general application. There
are at present on the market widely advertised preparations for which
astounding efficiency is claimed. None of them, however, has a
definite or consistent value; and it is unfortunately true that no
substance has yet been discovered that has the specific action of
increasing the production of milk.

_Psychic Influence_.--Although the nerves of the breast which
regulate the secretion of milk do their work whether the mother wills
it or not, her state of mind has an influence over the process, just
as it has over digestion. No one doubts that our minds influence our
digestions as has been so clearly proved by the skillful experiments
of Pawlow, an eminent Russian physiologist. Cheerfulness promotes
perfect assimilation of the food, whereas mental depression decreases
the secretion of the digestive juices or checks them altogether. In a
similar way, perhaps, we shall some day have explained to us the
unquestioned fact that mothers who maintain a happy disposition nurse
their babies efficiently, while those who are inclined to worry often
experience real or imaginary troubles with lactation.

The most striking manifestations of such psychic influences are those
in which, as a result of some strong passion or deep sorrow, the
secretion of milk suddenly ceases altogether. Fortunately such
effects occur rarely and are never permanent. After a few hours at
most the secretion is reestablished; and if there are alterations in
the quality of the milk, these will correct themselves just as
quickly.

More common, and therefore much more important, are cases in which,
because the mother allows herself day after day to worry over one
thing or another, the secretion of milk suffers permanent disturbance
in quantity or in quality. Sometimes worrying lest the milk will be
unsatisfactory causes it to become so. Generally, however,
unnecessary anxiety for the baby is to blame. Again and again, when
there is really nothing out of the way, inexperienced mothers make
themselves miserable because they fear something may go wrong. Such a
state of mind always invites trouble; not infrequently it is the
direct cause of insufficient or unwholesome milk. The self-assurance
gained through taking care of the first baby is responsible more than
anything else for the greater success mothers have in nursing
subsequent children.

The mother who is nursing her first baby should take success for
granted, and never mistrust her ability to succeed. If the physician
has been asked to visit the baby regularly, as was suggested at the
beginning of this chapter, he will quickly detect the evidence of
failure should failure be imminent. His opinions should be accepted
and his directions followed, for by so doing the mother will most
readily acquire the assurance which is so necessary to success. The
habit, easily fallen into, of paying attention to promiscuous advice
is unwholesome, for such advice is injudiciously given and is usually
incorrect. More often than not the counsel of well-meaning friends
only serves to perplex and distress the mother.

_Recreation and Rest_.--Next to worry no influence upon
lactation is more detrimental than neglect of recreation and rest.
Both are very necessary to a nursing mother, for without them she
will soon begin to exaggerate minor troubles and even to worry though
nothing is wrong. A mother who has the care of a baby added to other
responsibilities may have extraordinary difficulty in finding time
for outdoor exercise, for congenial companionship, or for diversion
of any kind. Occasionally it may seem almost impossible even to get
time for sleep, a necessity so fundamental to health that, as we
should expect, a mother deprived of it would fail utterly in nursing
her infant. Difficult as it may seem, however, the mother must find
time for recreation, for if she does not there will follow
disturbances, generally in the quantity, or sometimes in the quality,
of her milk.

Keeping in mind that whatever benefits the mother will react
favorably upon the infant, one should regulate exercise during
lactation with regard to the kind and the amount of exercise to which
she has been previously accustomed. Walking usually fulfils all the
requirements satisfactorily, and there is ordinarily no reason why
nursing mothers should not participate in sports that are unattended
by violent exertion. Exhausting sports, however, must be shunned,
because fatigue has the same injurious effect upon the secretion of
milk as lack of exercise.

As might be expected, women who are frail are most susceptible to the
strain of nursing, especially if they fail to get sufficient rest.
All nursing mothers ought to have at least eight hours of sleep in
the twenty-four. The night-feeding, generally advisable for the first
six to eight weeks, does not break the mother's rest longer than half
an hour if the baby is well trained. But if a baby that has not been
properly trained turns night into day and keeps the mother awake for
long intervals, the milk will quickly deteriorate. Under such
circumstances someone must relieve the mother of the care of the
infant during the night; she should not be disturbed even to nurse
it. The night-feeding will then be supplied artificially; as will
also one feeding during the day in order that the mother may have
opportunity for exercise and diversion.

THE SUPPLEMENTARY BOTTLE.--At first glance it may seem that in the
suggestion that the infant be given one artificial feeding each day
the mother's comfort alone has been considered. As a matter of fact,
however, the adoption of the plan benefits mother and infant alike.
The diversion and recreation which the mother, thus relieved of her
maternal duties for from four to six hours, has time to secure
becomes a direct benefit to the infant. Not infrequently by pursuing
this plan, mothers who would otherwise be incapable of nursing are
assured successful lactation. The child, moreover, having thus become
accustomed to the bottle, is much more easily denied the breast when
the time for weaning comes.

Objections have been raised to giving the baby even one bottle when
the mother has an ample supply of milk, but none of them are valid.
Since cow's milk is acknowledged to be less easy of digestion than is
human milk, it will occur to someone that there is danger of
upsetting the baby by giving it a bottle. But this need not be
feared; extensive experience has shown that if an infant is getting
human milk of satisfactory quality at all its feedings during the
twenty-four hours, save one or two, at these times it will digest
properly modified cow's milk without the least inconvenience. Nor is
it true that if once a day cow's milk is substituted for that of the
mother, the infant will come to prefer the bottle to the breast.
There is no danger, on the other hand, that the mother's milk will
dry up. Very thorough investigation of these objections has failed to
substantiate them in the least.

Of course, it will be necessary in preparing the supplementary
feeding to take the same precautions as if the infant were on the
bottle exclusively. To avoid contamination of the milk care must be
exercised to have everything perfectly clean that comes in contact
with it. And it will be necessary also to vary from time to time both
the strength and the amount of the feeding. These alterations will be
made most successfully if left to the judgment of a physician who is
familiar with the development of the infant and who may be guided
accordingly.

WEANING.--Occasionally, even before they are delivered, women express
the conviction that they will be incapable of nursing. A few mothers
who take this attitude, which it would seem is becoming more and more
common, make no attempt at nursing, and others give it up after a
very short trial. Premature weaning is practiced among the women of
two widely different classes: those who are unwilling to deny
themselves social pleasures, and those who, because they must earn a
living, cannot be encumbered with maternal duties. A still larger
class, however, are those mothers who wean the baby for neither of
these reasons, but rather because they become discouraged and
conclude that there is something wrong with their milk. In this way
many infants are weaned without sufficient reason. Before giving up
nursing her child a mother should submit several samples of the milk
for analysis. If it is unfit for the infant, reliable evidence of the
fact will often be secured in this way.

With the exception of tuberculosis, physicians recognize no condition
that necessarily unfits a mother for nursing. As we have already
seen, pregnancy is generally incompatible with lactation; in the
event of conception the mother's milk almost always takes on
qualities which render it unsatisfactory for the infant, and yet
occasionally pregnancy advances several months before these changes
in the milk occur. Meanwhile the infant suffers no inconvenience, and
often in these cases the symptoms of threatened miscarriage give the
first intimation of the mother's condition. Under all circumstances,
however, nursing should cease as soon as the mother recognizes that
she is pregnant, for probably no woman is strong enough to provide
nourishment for her infant and for the development of the embryo
simultaneously.

Menstruation, on the other hand, rarely if ever provides a good and
sufficient reason for weaning. In the great majority of instances
this function is re-established before lactation ends. There may be a
reduction in the amount of milk during menstruation, but if the
infant has been given the breast as usual, the supply increases as
soon as the period ends. Qualitative disturbances which would render
the milk unfit for use are practically never a consequence of
menstruation.

It may happen as the infant grows older that the flow of milk will
diminish; then the breast feedings will of necessity be more
frequently replaced by the bottle, and the question of weaning will
settle itself. But if the time of weaning is a matter of choice, it
should be approximately coincident with certain notable developments
in the infant's digestive functions, which occur toward the end of
the first year. The fact that the infant is prepared to take other
food is outwardly shown by the appearance of teeth, of which there
are usually six or eight at the end of the year.

If the suggestion regarding the daily substitution of one bottle for
the mother's milk has been adopted, there will be no difficulty in
discontinuing breast-feeding whenever it is desirable; otherwise an
infant may raise strong objection to the change. The mother, on the
other hand, will not be seriously inconvenienced by the weaning,
provided she leaves her breasts alone.

Until recently mothers were advised to employ a very elaborate
treatment for drying up the breasts. The diet was restricted, and as
far as possible liquids of every kind were forbidden; strong
purgatives were administered daily; and, in addition, the breasts
were covered with some ointment, swathed in cotton, and tightly
compressed with a bandage. Fortunately, we now realize that none of
these measures are required. When nursing is discontinued the breasts
are apt to become distended and uncomfortable. They require support
while the distention lasts, which is never very long, and if they
become painful, medicine may be employed to give relief. But other
measures, some of which occasionally do harm, are absolutely
unnecessary, for, at whatever period of lactation the breasts cease
to be used, they dry up spontaneously.




GLOSSARY


[Footnote: The Century Dictionary has been freely used for these
definitions.]


ABNORMAL.--Irregular; deviating from the natural or standard type.

ABORTIFACIENT.--Whatever is used to produce an abortion.

ABORTION.--The expulsion of the embryo during the first four months
of pregnancy.

AFTER-BIRTH.--The mass of tissue expelled from the uterus at the end
of labor. It includes the placenta, the umbilical cord, and the
membranes of the ovum.

ALIMENTARY CANAL.--The digestive tract. It begins with the mouth,
includes the stomach and the intestines, and ends with the rectum.

AMNIOTIC FLUID.--The liquid inclosed within the amniotic membrane.

AMNIOTIC MEMBRANE.--The innermost of the two membranes which envelop
the embryo; the lining membrane of the closed sac familiarly called
"the bag of waters."

ANEMIA.--A deficiency of some of the constituents of the blood.

ANATOMY.--The science which deals with the structure of the body.

ANTISEPTIC.--Anything which destroys bacteria.

AREOLA.--The colored, circular area about the nipple.

ARTERY.--A vessel through which the blood flows away from the heart.

ASEPSIS.--The exclusion of disease-producing bacteria.

ASEPTIC.--Free from injurious bacteria.

ASPHYXIA.--The extreme condition caused by lack of oxygen in the
blood, brought about by interrupted breathing.

ASSIMILATION.--The process by which living creatures digest and
absorb nutriment so that it becomes part of the substance composing
them.

ATROPHY.--To waste away.

AUTO-INTOXICATION.--Poisoning by material formed within one's body.

BACTERIA (the plural of bacterium).--Exceedingly minute, spherical,
oblong, or cylindrical cells which are concerned in putrefactive
processes. Some varieties cause disease.

BACTERIAL DECOMPOSITION.--Putrefaction brought about by the action of
bacteria.

BIOLOGY.--The science which deals with the phenomena of life.

BIRTH-CANAL.--The passage through which the child enters the world.
It is composed of the uterus and the vagina, and is surrounded by the
pelvic bones.

BLADDER.--A thin, distensible sack acting as a reservoir for the
urine between the time it is secreted by the kidneys and leaves the
body.

BREECH.--The buttocks.

CESAREAN OPERATION.--The operation by which the child is taken out of
the uterus by an incision through the abdominal wall.

CALORIE.--The unit ordinarily employed by scientists to measure heat.

CAPILLARIES.--The minute blood vessels which form a network between
the terminations of the arteries and the beginnings of the veins.

CARBOHYDRATE.--Any one of a group of chemical substances of which
starch and sugar are the most familiar members.

CARBONIC ACID GAS.--An animal waste product eliminated in the breath.
In daylight plants absorb it energetically from the atmosphere
through their leaves, and decompose it, assimilating the carbon, and
returning the oxygen to the air.

CARTILAGE.--A firm, elastic tissue; gristle. From this material many
of the bones develop.

CATHETERIZE.--To empty the bladder by means of a tube-like instrument
which is introduced into the passage through which the urine normally
leaves the bladder.

CELL.--One of the microscopical structural units which make up our
bodies.

CELL-DIVISION.--The process by which a single cell becomes two cells.

CEREBRUM.--The portion of the brain which is the seat of mental
activity.

CHORIONIC MEMBRANE.--The outermost of the two membranes which
surround the embryo.

CHROMATIN.--A substance within the nucleus of a cell which has a
special affinity for certain staining agents.

CHROMOSOMES.--One of the pieces into which the chromatin is broken
during the act of cell-division.

CLINICAL.--Pertaining to the sick-bed.

COLOSTRUM.--The fluid secreted by the breasts during pregnancy and
for two or three days after the birth of the child.

CONTRACTION.--The act by which the muscle fibers of the uterus become
shorter and press upon its contents.

CURETTAGE.--Scraping out the lining of the uterus.

DELIVERY.--The birth of the child.

DIAGNOSIS.--The determination of either normal or abnormal states of
the body.

DIAPHRAGM.--The muscular partition between the chest and the abdomen.

DIETETIC.--Pertaining to the diet.

DUCT.--A tube which conveys the secretion from a gland.

EMBRYO.--The offspring before it has assumed the distinctive form and
structure of the parent.

ENEMA.--A quantity of fluid injected into the rectum.

ENGAGEMENT.--The entrance of the fetus into the birth-canal.

ETHNOLOGY.--The science which deals with the character, customs, and
institutions of races of men.

EUGENICS.--The science which deals with the improvement of the human
race by better breeding. (Davenport.)

EXCRETION.--Waste substance thrown off from the body.

FEBRILE.--Attended with fever.

FETUS.--The unborn child after the third month of development.

FOOD-STUFF.--Anything used for the sustenance of man.

FUNCTION.--The discharge of its duty by any organ of the body.

GASTRIC JUICE.--The digestive fluid secreted by the wall of the
stomach.

GERMINAL CELLS.--The structural units from which a new individual
takes origin. The cell contributed by the mother is called an egg-
cell or ovum; that contributed by the father, a spermatozoon.

GESTATION.--Same as pregnancy.

GLAND.--An organ which separates certain substances from the blood,
and pours out a material, usually fluid, peculiar to itself.

HYGIENE.--That department of medical knowledge which relates to the
preservation of health; sanitary science.

INANITION.--The condition which results from insufficient
nourishment.

INFECTION.--A disease due to bacteria.

INTESTINE.--The bowels; the long membranous tube extending from the
stomach to the rectum.

INVOLUTION.--The process by which the uterus returns after child-
birth to its former size and position.

LACTATION.--The secretion of milk.

LIGAMENT.--A band of tissue serving to bind one part of the body to
another.

LIGATURE.--Anything that serves for tying a blood-vessel.

LOCHIA.--The discharge continuing for several weeks after the birth
of a child.

LOTION.--Any liquid holding in solution medicinal substances intended
for application to the skin.

LUNAR MONTH.--A month of twenty-eight days.

MAMMAL.--The highest order of animal, namely, one which suckles its
young.

MAMMARY.--Relating to the breast.

MASTICATION.--The act of chewing.

MENOPAUSE.--The permanent abolishment of the menstrual process, which
generally occurs between the 45th and the 50th years.

MICRO-ORGANISMS.--Bacteria and other living agents of disease which
are visible only with the aid of the microscope.

MISCARRIAGE.--The termination of pregnancy prior to the seventh
month.

MUCOUS MEMBRANE.--The lining of certain cavities of the body, such as
the mouth, stomach, intestine, uterus, etc.

MUCUS.--The material manufactured by the glands in a mucous membrane.

MUSCLE-FIBERS.--The muscle-cells.

NARCOTICS.--Drugs which produce sleep.

NITROGEN.--One of the chemical elements.

NUCLEUS.--A clearly defined area found in every cell which seems to
be its seat of government.

OBSTETRICS.--The branch of medicine which deals with the treatment
and care of women during pregnancy and child-birth.

OVARY.--The organ which contains the egg-cells or ova.

OVIDUCTS.--Two tubes, each of which leads from the neighborhood of
one of the ovaries; both terminate in the uterus.

OVUM.--An egg: the cell contributed by the mother to her offspring.

OXYGEN.--One of the chemical elements.

PATHOLOGY.--The branch of medicine which deals with the altered
structure and activity of diseased organs.

PEPSIN.--A ferment found in the digestive juice secreted by the
stomach.

PELVIC FLOOR.--The muscles, ligaments, and other tissues which form
the bottom of the basin inclosed between the hips.

PELVIS.--The bony ring formed chiefly by the hip bones. Posteriorly
the ring is completed by the sacrum.

PERINEUM.--The region extending backward from the outlet of the
vagina to the rectum; it is the most essential part of the pelvic
floor.

PHYSIOLOGY.--Scientific knowledge of the manner in which the various
parts of the body perform their duties.

PIGMENT.--Any coloring matter.

PLACENTA.--The organ through which the communication between the
mother and the offspring is established. One of its surfaces is
attached to the wall of the uterus; at about the middle point of the
other surface the umbilical cord takes its origin.

PRENATAL.--Pertaining to the period before birth.

PROTEIN.--A food-stuff which is distinguished by the fact that it
contains nitrogen and is a tissue builder.

PROTOPLASM.--The living substance in the cells which compose our
bodies.

PUBERTY.--Sexual maturity in human beings.

PUBIC BONES.--The part of the pelvis which forms an arch in front of
the bladder.

PUERPERIUM.--The same as the lying-in period.

RETINA.--The innermost coat of the eye-ball and the one which
receives visual impressions.

RICKETS.--A disease of infancy characterized by softening of the
bones.

SECRETION.--The product of the activity of a gland.

SEDIMENT.--The material which settles to the bottom of any liquid.

SPERMATOZOON (plural spermatozoa).--The microscopic cell contributed
by the male parent, which stimulates the ovum to begin its
development.

SUPPOSITORY.--A medicinal substance made into the form of a cone to
be introduced into the rectum.

TERM.--The time of expected delivery.

THERAPEUTIC.--Concerned with the treatment of disease.

THYMUS GLAND.--A structure located behind the breast bone near the
root of the neck. Only traces of it are found in adult life.

TISSUE.--An aggregation of similar cells in a definite fabric, as
muscle, nerve, gland, etc.

TUBES.--The oviducts.

UMBILICAL CORD.--The structure carrying the blood vessels which pass
between the placenta and the child's navel.

UTERUS.--The womb: a hollow muscular organ designed to receive,
protect, nourish, and expel the product of conception.

VAGINA.--The canal through which the child passes from the uterus
into the world.

VEIN.--A vessel through which the blood flows back to the heart.

VERNIX.--The fatty substance deposited over the skin of the newly
born infant.

VIABLE.--Capable of living.

VILLI (singular villus).--The microscopic, finger-like processes
which hang from one of the surfaces of the placenta and are
surrounded by the mother's blood.

VISCERA.--The internal organs which occupy the cavities of the chest
and the abdomen.

VULVA.--The folds of tissue which surround the outlet of the vagina.





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