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diff --git a/old/61476-0.txt b/old/61476-0.txt deleted file mode 100644 index 4b56c3a..0000000 --- a/old/61476-0.txt +++ /dev/null @@ -1,12721 +0,0 @@ -The Project Gutenberg EBook of Obstetrics for Nurses, by Charles B. Reed - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Obstetrics for Nurses - -Author: Charles B. Reed - -Release Date: February 21, 2020 [EBook #61476] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK OBSTETRICS FOR NURSES *** - - - - -Produced by Richard Tonsing, Mark C. Orton, and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - - - - - OBSTETRICS - FOR NURSES - - - BY - - CHARLES B. REED, M.D., - - Obstetrician to Wesley Memorial Hospital, Chicago. - - - _ONE HUNDRED THIRTY ILLUSTRATIONS_ - - - ST. LOUIS - - C. V. MOSBY COMPANY - - 1917 - - - - - COPYRIGHT, 1917, BY C. V. MOSBY COMPANY - - - _Press of - C. V. Mosby Company - St. Louis_ - - - - - TO HIS LOYAL FRIEND - - EUGENE S. GILMORE - - THIS BOOK IS AFFECTIONATELY DEDICATED BY THE AUTHOR - ------------------------------------------------------------------------- - - - - - PREFACE - - -It might seem that an apology was necessary for presenting a new -textbook on obstetrics for nurses when so many are to be had for the -asking. But when a teacher is rarely or never satisfied with his own -work it is too much to expect that he will ever fully endorse the -product of another. It may be therefore largely a personal matter that -none of the existent books seem to exhibit the fullness of information, -the conciseness of expression, and the emphasis due to certain subjects -that the present writer would hope to find. - -The necessities apparently demand such an arrangement of our obstetrical -doctrine that the book may serve for class instruction and at the same -time be complete enough for post-graduate reference. - -To secure this much discrimination is necessary. The confusion attendant -upon overabundance must be avoided as well as the discouragement that is -not infrequently produced by a large book or a periphrastic style. - -Hitherto there has been a tendency to teach the nurse too little rather -than too much but conditions have changed. Vocational instruction is not -only more methodical and far reaching but it is developmental. The -present day nurse expects not merely to assist the physician and earn a -stipulated reward, but she is constantly alert to attain her own -maturity as a professional woman. - -To be a capable and intelligent assistant it is not sufficient to have a -clear comprehension of her particular duties, but she must have a -defined and critical conception of what the doctor is aiming to -accomplish. - -This is especially true in obstetrics where the nurse has the additional -responsibility of giving support and counsel to her patient in the -various emergencies that arise. Moreover, to attain her intellectual -maturity the nurse must strive unremittingly to understand the -complicated processes that take place under her observation. - -She must cooperate with her doctor whose associate she is and secure the -confidence of her patient who relies upon her for guidance in the perils -she is facing. For childbirth is a peril. It is no longer the normal -process it once was. Civilization has changed the shape of the pelvic -bones, altered the muscles of parturition and weakened the nerve centers -that control the event. - -The birth of a child is equal in severity and seriousness to many of the -major operations. It is not an affair to be entered upon lightly nor -managed without the utmost foresight and care. - -The dangers that are recognized and prepared for in this book by what -may seem to some to be an extravagant technic, are very real dangers, -extremely subtle, and against them at times every precaution and every -defense proves unavailing. - -Nevertheless, skill, thoughtfulness, and above all, cleanliness, will -avert the worst, as well as unhappily the most common of these -disasters. If our nurses could be convinced of this, the difficulties -and apprehensions of childbirth would be greatly diminished. - -The nurse should see to it that her patient is surrounded by all the -precautions and safeguards against infection that she would demand for a -member of her own family. This means of course that her work will be far -more exacting and onerous but also it will save many nights of anxiety -and not infrequently a life. - -This book represents the obstetric ideas and technic which the writer -has endeavored for years to impress upon his students and nurses with -such emendations and changes as experience and scientific progress have -suggested. It is a selective essence distilled from the recurrent -harvests that workers in this field have brought forth during centuries -of consecrated effort. To all these forerunners the writer acknowledges -a deep personal indebtedness. - -In the preparation of the book thanks are due particularly to Charlotte -Gregory, Head Nurse of the Wesley Maternity, whose rare ability as -teacher, technician and executive and whose untiring vigilance has been -a leading factor in securing and maintaining the high state of -efficiency in this department. She has kindly contributed Chapters XXIII -and XXIV, together with valuable suggestions and criticisms in other -portions of the text. - -The author also takes pleasure in acknowledging his obligations to -Florence Olmstead, Head Nurse of the Dispensary of the Northwestern -University Medical School, whose long experience in feeding babies gives -to her words an unquestioned authority. Chapter XXII is almost entirely -her work. - -To the various publishers who have courteously allowed the reproduction -of valuable illustrations from the books of other writers thanks are -also extended, and to his own publishers especially for their cordial -and sympathetic cooperation the author wishes to express his warmest -gratitude. - - C. B. R. - - Chicago, 1917. - - - - - CONTENTS - - - CHAPTER I - PAGE - - ANATOMY 17 - - CHAPTER II - - PHYSIOLOGY 33 - - CHAPTER III - - NORMAL PREGNANCY 51 - - CHAPTER IV - - HYGIENE OF NORMAL PREGNANCY 66 - - CHAPTER V - - ABNORMAL PREGNANCY 74 - - CHAPTER VI - - ABNORMAL PREGNANCY (CONTINUED) 89 - - CHAPTER VII - - PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR 98 - - CHAPTER VIII - - THE MECHANISM OF NORMAL LABOR 120 - - CHAPTER IX - - THE CARE OF THE PATIENT DURING NORMAL LABOR 129 - - CHAPTER X - - THE NORMAL PUERPERIUM 151 - - CHAPTER XI - - UNUSUAL PRESENTATIONS AND POSITIONS 165 - - CHAPTER XII - - OPERATIONS 179 - - CHAPTER XIII - - MINOR OPERATIONS 200 - - CHAPTER XIV - - COMPLICATIONS IN LABOR 214 - - CHAPTER XV - - COMPLICATIONS IN LABOR (CONTINUED) 228 - - CHAPTER XVI - - THE ABNORMAL PUERPERIUM 242 - - CHAPTER XVII - - INFECTION 255 - - CHAPTER XVIII - - THE CARE OF THE CHILD 265 - - CHAPTER XIX - - THE CARE OF THE CHILD (CONTINUED) 278 - - CHAPTER XX - - THE CARE OF THE CHILD (CONTINUED) 287 - - CHAPTER XXI - - THE CARE OF THE CHILD (CONTINUED) 298 - - CHAPTER XXII - - INFANT FEEDING 310 - - CHAPTER XXIII - - CLEANLINESS AND STERILIZATION 323 - - CHAPTER XXIV - - DIETS AND FORMULÆ 330 - - CHAPTER XXV - - SOLUTIONS AND THERAPEUTIC INDEX 340 - - - - - ILLUSTRATIONS - - - FIG. PAGE - - 1. The normal female pelvis 18 - - 2. The planes of the brim, the cavity, and the outlet 19 - - 3. Visceral relations 20 - - 4. Uterus and appendages 22 - - 5. Normal position of pelvic organs 24 - - 6. The external genitals 25 - - 7A. Varieties of hymen 27 - - 7B. Varieties of hymen 28 - - 8A. The excreting ducts of the mammary gland 29 - - 8B. Lobules and duct of the mammary gland 29 - - 9. Nipple, areola, and the glands of Montgomery 30 - - 10. Supernumerary milk glands in the axillæ 31 - - 11. The three ages of the breast 31 - - 12. Development of the ovary 34 - - 13. Graafian follicles 35 - - 14. Human spermatozoa 36 - - 15. The chorionic villi about the third week of pregnancy 38 - - 16. Diagram illustrating relations of structures of the - human uterus at the end of the seventh week of - pregnancy 39 - - 17. Maternal surface of the placenta and membranes 40 - - 18. Fœtal surface of human placenta 41 - - 19. The egg at term with uterus removed 42 - - 20. Normal attitude of fœtus 43 - - 21. Fœtal skulls showing sutures 44 - - 22A. and B. Child’s head at term, showing diameters 45 - - 23. The fœtal circulation 49 - - 24. Gravid uterus at the end of the eighth week 52 - - 25. Striæ gravidarum 54 - - 26. Bimanual examination 60 - - 27. Abdominal enlargement at different months of pregnancy 63 - - 28. Height of the uterus at various months of pregnancy 64 - - 29. Twins 83 - - 30. Diagram representing the sites for the various forms - of tubal pregnancy 90 - - 31. Abdominal binder with crosspiece to hold vulvar pads 100 - - 32. T-binder, used in all cases after the fifth day post - partum 100 - - 33. Breast binder 101 - - 34. Baby’s dress with winged sleeves 102 - - 35. The bag of waters begins to act on the cervix 111 - - 36. The effect of the pains. The cervix before labor - begins 112 - - 37. The effect of the pains. The cervix begins to be - “effaced” 112 - - 38. The effect of the pains. The cervix is effaced, and - the dilatation of the os begins 113 - - 39. The effect of the pains. The cervix is effaced and the - os continues to dilate 113 - - 40. The cervix is effaced and the os dilated 115 - - 41. Child in second stage of labor 116 - - 42. The head passing over the perineum 117 - - 43. Normal expulsion of the placenta according to Schultze 118 - - 44. The child in left-occipito-anterior position 122 - - 45. The child in right-occipito-anterior position 123 - - 46. The descent of the head in right-occipito-anterior - position 124 - - 47. Internal anterior rotation and extension of the head - in a left-occipito-anterior position 124 - - 48. Extension 125 - - 49. Extension completed. Expulsion 125 - - 50. A cephalhæmatoma 127 - - 51. Points of greatest intensity of fœtal heart tones 130 - - 52. Handling forceps, kept sterile in a jar of alcohol 132 - - 53. Palpation. What is in the pelvis? 134 - - 54. Palpation. What is in the fundus? 135 - - 55. Palpation. Where is the back? Where are the small - parts? 136 - - 56. Patient draped for internal examination 137 - - 57. Delivery in side position 141 - - 58. Sheet twisted into a sling 147 - - 59. Repair of perineum 148 - - 60. The progress of involution 152 - - 61. The breech. Left-sacro-anterior position 166 - - 62. The breech. Left-sacro-posterior position 167 - - 63. Extraction of the breech 170 - - 64. Breech delivery. Extraction of the trunk 171 - - 65. Breech delivery. Delivering the shoulder 172 - - 66. The delivery of the after-coming head by the - Smellie-Veit maneuver 172 - - 67. Shoulder presentation 173 - - 68. Face presentation 175 - - 69. Descent of the chin in face presentation 176 - - 70. Delivery in face presentation 177 - - 71. Exaggerated lithotomy position 181 - - 72. Dorsal position when assistants are available 182 - - 73. Instruments for artificial delivery of the head 183 - - 74. Forceps operation. Introduction of the left blade 186 - - 75. Forceps operation. The introduction of the right blade 187 - - 76. Forceps operation. Locking the handles 187 - - 77. Forceps operation. The way the blades should grasp the - fœtal head 188 - - 78. Forceps operation. Traction on the handles 189 - - 79. Forceps operation. The delivery of the head 189 - - 80. Version. Seizing a foot 190 - - 81. Version. The child rotates as pressure is made upon - the head and traction upon the foot 191 - - 82. Version is complete when the knee appears at the vulva 192 - - 83. The Walcher position 194 - - 84. The Wiegand compression of the child’s head to force - it into the pelvis 195 - - 85. The Naegele perforator 196 - - 86. Apparatus for getting a sterile specimen of urine from - an infant 201 - - 87. Tampon of the uterus 203 - - 88. Tampon of vagina 204 - - 89. Pean forceps 208 - - 90. Hand bulb syringe; and Vorhees bags; bag rolled and - grasped by Pean forceps ready for introduction 209 - - 91. Vorhees bag in place 210 - - 92. Episiotomy 212 - - 93. Various forms of pelvic deformity 215 - - 94. The pelvimeter 216 - - 95. The various diameters of the inlet 216 - - 96. Measuring the distance between the anterior superior - spines of the pelvis 217 - - 97. Measuring the external conjugate 218 - - 98. Measuring the diagonal conjugate with the finger 219 - - 99. Various forms of placenta prævia 229 - - 100. The knee-elbow posture 236 - - 101. The knee-chest posture 236 - - 102. The exaggerated lithotomy position obtained with a - sheet sling 237 - - 103. The improvised Trendelenburg position 237 - - 104. The dorsal position with stirrups 238 - - 105. Dorsal position across the bed 239 - - 106. Flexed dorsal position with feet on the table 240 - - 107. The Sims position 241 - - 108. Examples of imperfect nipples 245 - - 109. A standard nipple shield 246 - - 110. A standard breast pump 251 - - 111. Germs most frequently found in cases of puerperal - fever 256 - - 112. Rubber bath tub 266 - - 113. The Pettit cord clamp 268 - - 114. Standard breast pump; Standard nursing bottle; the - breast tray; the Wansbrough lead nipple shield; the - Brophy nipple for harelip and cleft palate 271 - - 115. Proper position of mother while nursing child 274 - - 116. Proper method of taking rectal temperature 276 - - 117. Method of passing the tracheal catheter 279 - - 118. Byrd’s method of artificial respiration. Extension and - inspiration 280 - - 119. Byrd’s method of artificial respiration. Beginning - flexion and expiration 280 - - 120. Byrd’s method of artificial respiration. Flexion and - compression 281 - - 121. Method of giving gavage 284 - - 122. Apparatus for gavage or lavage 286 - - 123. Cleft palate nipple 288 - - 124. The device for feeding the child with cleft palate 288 - - 125. Device for assisting the cleft palate child to nurse 289 - - 126. Method of strapping an umbilical hernia 290 - - 127. Proper position for introduction of a suppository 299 - - 128. Hydrocephalus 307 - - 129. Anencephalus 308 - - 130. Elements of human milk 312 - - - - - OBSTETRICS FOR NURSES - - - - - CHAPTER I - ANATOMY - - -The study of obstetrics is an investigation of the passage, the -passenger, and the driving powers of labor, as well as of the various -complications and anomalies that may attend the process of reproduction. - -The passage is composed of a bony canal, called the pelvis, and the soft -tissues which line and almost close its outlet. - -=The pelvis= is made up of four bones; the sacrum, the coccyx, and two -other large structures of irregular shape, called the hip, or innominate -bones. Joined by cartilage and held in place by ligaments, they form a -cavity or basin which, in the male is deep, narrow, small and -funnel-shaped, while in the female, slighter bones, expanded openings -and wider arches make a broad, shallow channel, through which the child -is born. - -The bony pelvis is divided for description into two parts, the upper or -false pelvis, and the lower or true pelvis. The upper pelvis is formed -by the wings of the innominate bones and has but two functions of -importance to child-bearing. It acts as a guide to direct the child into -the true passage, and when measured by the pelvimeter, it gives -information as to the shape and size of the inlet to the true pelvis. -The true pelvis is of most concern to the obstetrician, because -anomalies in its size or shape may impede the progress of labor or -render it impossible. The pelvis is divided conveniently into three -parts: the brim, the outlet, and the cavity. - -The _brim_, _inlet_, or _upper pelvic strait_, is the boundary line -between the false and true pelvis. It is traced from the upper border of -the symphysis along the iliopectineal line on both sides to the -promontory of the sacrum. The shape and size of this opening varies much -in different races and individuals, both normally and through disease; -and when pathologically altered, both shape and size may exercise a -marked influence on the course of labor. In American women, the outline -of the brim is roughly heart-shaped, like an ovoid with an indentation -where the promontory of the sacrum impinges upon the opening. - -[Illustration: Fig. 1.—The normal female pelvis. (Eden.) The lines _ab_ -and _cd_ divide the pelvis into the right and left anterior and the -right and left posterior quadrants. _ab_ indicates the anteroposterior -diameter of the brim, _cd_ shows the transverse diameter while _gh_ and -_ef_ represent, respectively, the right and left oblique diameters.] - -The brim or inlet has four important diameters to be remembered; -important because the hard, round head of the child must pass through -them by accommodating its diameters as favorably as possible to those of -this opening. These diameters are named respectively the anteroposterior -or conjugate diameter, the transverse, and the right and left oblique -diameters. The two oblique diameters attain their greatest importance -when the pelvis is irregularly distorted, but the others are essential -in every case where labor impends. It is to secure an estimate of these -latter diameters that the bony prominences are measured. This upper -opening lies not horizontally, but in oblique relation to the body in -standing position, and the weight of the abdominal viscera rests largely -upon the bones and in consequence does not crowd into the inlet unless -forced in by corsets or faulty habits. - -[Illustration: Fig. 2.—The planes of (_a_) the brim, (_b_) the cavity -and (_c_) the outlet. (Eden.)] - -Passing through the brim, a cavity is found below it, midway between the -inlet and outlet, which is nearly round in shape. This is the -“excavation,” or the _true pelvis_. Then comes the _outlet_, bounded in -front by the pubic arch and soft parts, and behind by the coccyx pushed -back as far as it can go. It is ovoid in shape, but the long axis of -this ovoid lies at right angles with the axis of the ovoid inlet. - -We find, therefore, a succession of three geometric figures or planes -through which the head must pass by means of a spiral motion called -rotation. These figures are inclined to one another so markedly in front -that a line drawn through the center of each will curve forward at both -ends, one end passing out near the umbilicus, the other through the -vulva. This is known as the axis of the pelvis or the curve of Carus. - -[Illustration: Fig. 3.—Visceral relations. (Redrawn from Gray.)] - - - THE SOFT PARTS - -Inside the pelvis are the organs of generation with their accessory -structures and supporting tissues. - -Of first importance are the ovaries, tubes and uterus, together with the -vagina. These special structures are the true genital organs. They are -bounded in front by the bladder, behind by the rectum, above by the -abdominal viscera, and surrounded everywhere by muscular, mucous and -fatty tissues, which support them and aid their function. - -=The Vagina.=—The vagina is a hollow organ, about four inches long, -attached to the cervix above and the vulva below. It is an elastic -sheath bounded in front by the bladder and behind by the rectum. Under -normal conditions, this tube easily admits one or two fingers, but -during labor it dilates enormously to allow the head to pass. The vagina -is lined with a thick mucous membrane, ridged and roughened by folds, -which are called rugæ. Thus a continuous channel connects the ovary with -the outside and through it pass, at appropriate times, the ovule, the -menstrual blood, the uterine secretions, the child, the placenta, and -the lochia. - -=The Uterus.=—The uterus (womb) is a pear-shaped organ, flattened from -before backward, and composed of unstriped or involuntary muscle cells -and connective tissue. Normally the virgin uterus measures from two and -one-half to three inches in length, and weighs about two ounces. It is -suspended in the middle of the pelvis by strong ligaments, so that the -fundus inclines gently forward against the bladder. When the bladder -fills, the uterus is pushed backward. Most of the organ is internal, but -a small part of the lower pole is grasped by the vagina, in which the -lower end with its invaluable aperture, the os, dips and swings. The -part above the vagina is called the body or fundus, and is covered with -the serous membrane (peritoneum) that lines the abdominal cavity. Below -the fundus is the cervix or neck, which lies partly above and partly -within the vagina. The cavity of the uterus is usually closed by the -apposition of the walls. The inner surface is covered with a peculiar -kind of membrane called the endometrium, which is highly vascular. The -uterine cavity opens into the vagina through the os, which is small and -round in the nulliparous woman, and slit-shaped or gaping in the woman -who has borne a child. - -[Illustration: Fig. 4.—Uterus and appendages. On either side of the -uterus will be seen the ovary, the fimbriated extremity of the tube, the -tube, and the round ligament. The vagina lies open below. (Lenoir and -Tarnier.)] - -=Fallopian Tubes.=—On either side of the upper end of the uterus are the -orifices of the Fallopian tubes, through which the egg, escaping from -the ovary, finds access to the uterine cavity. These tubes extend -outward from the uterus about four inches, and terminate in a -bell-shaped opening with long, ragged fingers which hang loosely down -toward the ovary. The tubes are lined by epithelial cells having -hair-like projections, (ciliæ) which wave automatically toward the -uterus. Thus impelled by a gentle current, the egg moves definitely -along the tube toward the uterus and against this current the -spermatozoa force their way to meet and fertilize the egg. - -=The Ovaries.=—On either side of the pelvis, close to the fringed end of -the Fallopian tube and attached to it, lies a small, hard, almond-shaped -organ, called the ovary. This is the intrinsic sexual gland of the -female. It contains the small cells which are to ripen and become eggs. -Each ovary is said to contain about thirty-six thousand eggs, or ovules. - -=The Bladder.=—The bladder lies between the pubic bone and the uterus. -It is a reservoir for urine, filled by means of two little tubes called -ureters, that run down from the kidneys. It drains through the urethra -which opens just below the pubic bone in front of, and just above, the -vaginal opening. The bladder should be emptied frequently during labor. - -=The Anus.=—The large bowel (colon) terminates in an opening near the -middle of the genital crease. This opening is called the anus. It is -closed by a contracting muscle, the sphincter, which acts like a -puckering string. Just inside of the opening is a group of large veins -which may become enlarged, inflamed, and bleed during pregnancy. They -are then called hæmorrhoids. - -=The Rectum.=—Upward from the anus and to the left of the uterus extends -the rectum. This is the end of the intestinal canal and is supplied with -an abundance of nerves. When the head presses upon it, it gives the -sensation of a bowel movement, and warns the observer of the low -position of the head. The anus pouts as the head comes down and the -anterior walls become visible. In severe cases of labor, the sphincter -is sometimes torn. The bowels should be emptied by an enema as early as -possible in the first stage of labor. - -=The Peritoneum.=—The peritoneum is a thin, glistening, serous membrane, -which lines the abdominal cavity and drops down from above over the -uprising tops of the bladder and uterus. Folding together at the sides -and extending to the walls of the pelvis, it encloses the tubes and -round ligaments in deep, flat masses, called the broad ligaments. This -is the structure that becomes so perilously inflamed (peritonitis) when -infected by germs that find entrance through the genital passage. - -[Illustration: Fig. 5.—Normal position of pelvic organs, seen from above -and in front. They are enveloped in peritoneum. (Bougery and Jacob, in -American Text Book.)] - - - THE EXTERNAL GENITALS - -The external genitals form the vulva. Under this name are included the -mons veneris, the labia majora, the labia minora, the clitoris, the -vestibule, the hymen and the glands of Bartholin. - -The entire groove from the mons veneris to a point well up on the sacrum -forms a deep fold or crevice, which is known as the _genital crease_. -That part of the genital crease lying between the anus and vulva is -technically known as the _perineum_ (q.v.) - -[Illustration: Fig. 6.—The external genitals. (Redrawn from Gray.)] - -=The Mons Veneris.=—The mons veneris is a gently rounded pad of fat -lying just above the junction of the pubic bones (the symphysis). The -overlying integument is filled with sebaceous glands and covered with -hair at puberty. - -=The Labia Majora.=—The labia majora are the large lips of the vulva. -They are loose, double folds of skin extending downward from the mons -veneris to the anterior boundary of the perineum and covered externally -with hair. Normally they lie in apposition and conceal the vaginal -opening. They correspond to the male scrotum. - -=The Labia Minora.=—The labia minora, or nymphæ, are two small folds of -skin and mucous membrane, that extend from the clitoris obliquely -downward and outward for an inch and a half on each side of the entrance -to the vagina. On the upper side, where they meet and invest the -clitoris, the fold is called the prepuce, but on the under side they -constitute the frænum. - -The labia minora are sometimes enormously enlarged in the black races -and are then called the Hottentot apron. - -=The Clitoris.=—The clitoris is an erectile structure analogous to the -erectile tissue of the penis. The free extremity is a small, rounded, -extremely sensitive tubercle, called the glans of the clitoris. About -the clitoris there forms a whitish substance called smegma. This is a -good culture medium for germs and must be carefully sponged away when -the vulva is prepared for delivery. - -=The Vestibule.=—The vestibule is bounded by the clitoris above, the -labia minora on the sides, and the vaginal orifice below. It contains -the opening of the urethra, which is called the meatus urinarius. - -=The Hymen.=—The hymen is a thin fold of membrane which closes the -vaginal opening to a greater or lesser extent in virgins. It varies much -in shape and consistency. It is sometimes absent, or it may persist -after copulation, hence its presence or absence can not be considered a -test of virginity. When torn, the edges shrink up and form little -irregularities called carunculæ myrtiformes. - -[Illustration: Fig. 7 _A_.—Varieties of hymen. (American Text Book.)] - -=Bartholin Glands.=—Bartholin glands are located on each side of the -commencement of the vagina. Each gland discharges by a small duct just -external to the hymen. They are often the seat of a chronic gonorrhœal -inflammation and must be watched carefully, lest infection extend to the -mother after labor, or to the eyes of the child in passing. - -[Illustration: Fig. 7 _B_.—Varieties of hymen. (American Text Book.)] - -=The Perineum.=—The perineum is a body of muscle, fascia, connective -tissue, and skin, situated between the vagina and the rectum. The vagina -bends forward and the rectum backward, so a triangular area is left -between them which is filled by the perineal body. It is about two -inches long from before backward, and becomes progressively thinner the -deeper it extends. - -[Illustration: Fig. 8 _A_.—The excreting ducts of the mammary gland. -(Lenoir and Tarnier.)] - -[Illustration: Fig. 8 _B_.—Lobules and duct of the mammary gland. -(Lenoir and Tarnier.)] - -The perineal body is flattened out and compressed by the passage of the -head and in many cases torn. (Thirty per cent of primiparas and ten to -fifteen per cent of multiparas.) It should be repaired immediately. - -=The Mammary Glands.=—The mammary glands are secondary but highly -important parts of the genital system. They are formed by a dipping down -of skin glands and they perform the special function of secreting milk. - -The breast is made up of fifteen or twenty lobes, each of which, like a -bunch of grapes, clusters about and discharges into a single tube which, -in turn, leads to the nipple. The area between the lobes is filled with -fat and connective tissue. - -[Illustration: Fig. 9.—Nipple, areola, and the glands of Montgomery. -(Eden.)] - -The _nipple_ is pink or darkly pigmented. It is composed of erectile -tissue and under stimulation, it rises from the surface of the gland so -that it is easily taken into the mouth. - -[Illustration: Fig. 10.—Supernumerary milk glands in the axillæ. They -may be found also below the breasts. (Witkowski.)] - -[Illustration: Fig. 11.—The three ages of the breast—virginity, -maturity, and senescence. (Witkowski.)] - -Surrounding the nipple is a darkly pigmented area from one inch to four -inches in diameter that is called the _areola_. It contains hard, -shot-like nodules, the glands, or tubercles, of Montgomery. These often -secrete milk and sometimes become infected. It occasionally happens that -more than two breasts may be found on the human female, and not -infrequently pieces of mammary tissue may be discovered in the axilla or -on the chest or back. - -The mammary gland is undeveloped at birth, but, nevertheless it may fill -with milk (witches’ milk). At puberty, after marriage, and during -pregnancy, the gland reaches maturity. It is only after delivery, -however, that the functional climax is attained. - - - - - CHAPTER II - PHYSIOLOGY - - -=Ovulation.=—Ovulation is the process whereby the eggs are discharged -from the Graafian follicle which matures and protects them in the ovary. -The egg is a true cell with one, and sometimes more than one, nucleus. - -The ripening of the eggs, as well as their discharge, is attended with -much general disturbance and great physical changes. This phenomenon -begins from the twelfth to the fifteenth year, depending on race, -climate, occupation and temperament, and marks the transition of the -individual from childhood into maturity. - -This period is called _puberty_. At this time the breasts enlarge, the -hips round out, the vagina, uterus and external genitals increase in -size. Hair appears upon the vulva, the emotions become more evident, and -modesty develops through a consciousness of sexual difference and -attraction. - -Simultaneously a new function appears— - -=Menstruation.=—Menstruation may be defined as a process wherein a -bloody fluid is discharged from the uterus at regularly recurring -periods between puberty and the menopause, _except_ during pregnancy and -lactation. It is a hæmorrhage which in some way is closely associated -with ovulation, but it is not known positively which is the precedent of -the other, or whether one causes the other. - -Menstruation is not essential to pregnancy, for pregnancy may occur when -the flow is normally absent, as before puberty, after the menopause, or -during lactation. Nevertheless, regularity of menstruation is the rule -in fertile women and clinicians agree that while conception _may_ occur -at any part of the menstrual cycle, it is _most likely_ to happen just -before or just after the menstrual flow. - -The best authorities at present support the theory that ovulation -usually occurs soon after the close of the menstrual period. This is -confirmed by the similarity of the physical changes that take place in -the endometrium during menstruation and after conception. - -[Illustration: - - Fig. 12.—Development of the ovary (after Wiedersheim). _A_, an - ingrowth of the germinal epithelium, forming a cell-cord, which - breaks up into primitive Graafian follicles; _B_, a primitive - Graafian follicle, with its contained primitive ovum; _C_, _D_, _E_, - later stages in the development of the Graafian follicle. (Crossen.) -] - -As the period of the flow approaches, the lining membrane of the uterus -becomes hyperæmic and swollen with blood, serum, and glandular -secretions. The blood vessels are engorged, the glands become longer and -more tortuous, little hæmorrhages appear, and the superficial epithelium -is thrown off. A large amount of mucus is produced by the increased -activity of the glands, and all is discharged into the vagina as a -bloody, incoagulable flow with an odor of marigolds. The process -continues usually from three to seven days, when the discharge ceases -and the endometrium slowly resumes its uncongested state. - -[Illustration: Fig. 13.—Graafian follicles. One contains two ovules -which, if fertilized, will produce twins. If all three ovules are -fertilized, triplets will result. (Bumm.)] - -Meanwhile, the psychic and bodily conditions have not remained -unaffected. The nervous system is disturbed, the disposition is -irritable and capricious and the head may ache. The woman takes cold -easily. She is indisposed to exertion from a sense of languor and -malaise. Pain may develop in the back, or cramps in the pelvis, so -severe as to keep the woman in bed. Frequently the approach of the -period is signalized by skin changes, such as a marked odor or an -eruption of acne pustules. - -The flow usually returns every twenty-eight days, but it may vary within -normal limits from twenty-one to thirty days. The flow continues at such -intervals regularly from puberty to the menopause (change of life), -which occurs between the ages of forty-five and fifty. - -=Conception, or Fertilization.=—This is the process wherein the male -element (spermatozoon) meets and unites with the female egg. From what -is known from investigations of lower animals, this meeting usually -takes place in the Fallopian tube. - -[Illustration: Fig. 14.—Human spermatozoa. _h_, head; _c_, intermediate -portion; _t_, tail. (Williams.)] - -The egg expelled from the ovary is carried into the open end of the tube -by peritoneal currents and passed on toward the uterus by the waving -action of the hair-like outgrowths of the cells (ciliæ) that line the -tube, aided, possibly, by the tubal muscle. - -The spermatozoon makes its way upward from the vagina by means of its -tail. This activity, like the tail of a fish, or snake, or as a boat is -sculled, drives the cell forward through the thin layer of fluid that -covers the mucous membranes. - -The arrow-shaped spermatozoon travels at a rate that completes the -passage to the ovary in twenty-four hours, but spermatozoa may lie in -wait for the egg a considerable time, as is shown by the fact that they -have been found alive in Fallopian tubes removed three and a half weeks -after copulation. As soon as the male and female elements approach each -other, they exercise a powerful magnetic attraction, which draws them -together, and as soon as they touch, the two cells unite and the -spermatozoon almost immediately disappears. - -Only one spermatozoon is required for the fertilization of an egg, and -hence enormous numbers must perish without achieving their destiny. - -The fertilized egg has become the _ovum_, and originally 1/125 of an -inch in diameter, it now begins to grow, and filled with a new energy, -it passes down the tube and enters the uterus. Here it comes into -contact with the soft mucosa and digs a hole for itself—a nest, very -much as a warm bullet might sink into ice or snow—and is soon completely -surrounded by a proliferating tissue called the decidua. The woman is -now pregnant. The menstrual flow does not appear, and local and -systematic changes are inaugurated. - -The egg enlarges rapidly. Little glove-finger-like projections (the -villi) appear on its surface and dip down into the maternal tissues. -Through these villi the egg gets nourishment until about the twelfth -week, when the placenta forms. Externally the ovum resembles a chestnut -burr. As the egg grows, the villi on the surface find it more and more -difficult to secure nutriment, and _except at one place_, all gradually -shrink and disappear. At this significant point, they increase greatly -in size, number, and complexity to form the thick, cake-like placenta. - -The egg or ovum is simply a growing cyst, filled with a fluid, normally -sterile, in which the developing embryo lives and swims. This fluid is -the liquor amnii and it is retained by a cystic wall made up of two -layers—the chorion, which represents the original cell membrane, and the -amnion, which develops out of the fœtus. At maturity, the ovum will -contain from one to two pints of liquor amnii. - -[Illustration: Fig. 15.—The chorionic villi about the third week of -pregnancy. (Edgar.)] - -=The Liquor Amnii.=—The liquor amnii is of vast importance to the child. -It allows free movement for the growing limbs and body, protects the -child from sudden changes of temperature, prevents injury both from -without and within, saves the child from birthmarks and deformities by -keeping it from contact with the surrounding walls, and in labor -lubricates the passages for the advancing part. In a measure, too, it -probably serves as a food. In labor it forms a pouch called the _bag of -waters_, which aids in dilating the os. - -[Illustration: Fig. 16.—Diagram illustrating relations of structures of -the human uterus at the end of the seventh week of pregnancy. (American -Text Book.)] - -Gradually, as nutrition becomes more abundant at the site of the growing -placenta, a stalk-like structure thrusts out from the fœtal abdomen and -forms an attachment with the formative placenta. This is called the -ventral stalk and as soon as the communication with the placenta is -established, it is combined with other parallel structures and becomes -vascularized, to form the umbilical cord. - -[Illustration: Fig. 17.—Maternal surface of the placenta and membranes. -The cord protrudes from the cavity which held the fœtus. (Edgar.)] - -=The Umbilical Cord.=—The umbilical cord at maturity measures from five -to fifty inches in length and from one-half to one inch in thickness. -The cord is composed of a gelatinous connective tissue, called Wharton’s -jelly, in the midst of which lie the twisted vessels (two arteries and a -vein) that supply the embryo with air and food and carry off the waste. - -=The Placenta.=—The placenta or “after-birth” is an oval or circular -somewhat flattened disc, six to ten inches in diameter, and -three-quarters to one and one-half inches thick. It weighs about a pound -and a half. It is the organ of respiration and nutrition for the fœtus. - -[Illustration: Fig. 18.—Fœtal surface of human placenta. (Eden.)] - -[Illustration: Fig. 19.—The egg at term with uterus removed and child -showing through the membranes. (Edgar.)] - -It is formed about the third month _outside_ the membranes covering the -child and is more or less loosely attached to the uterine wall. The -umbilical cord is attached to its fœtal surface, inside the ovum. Like a -flat sponge it takes oxygen, blood, and the nourishing fluids from the -blood vessels in the uterine wall, carries them to the child by means of -the umbilical vein, and carries back the carbonized blood and waste -products by the umbilical arteries to the placenta, and there returns -them to the maternal blood for disposal. The blood of the veins is -bright red, and of the arteries, dark and turbid. - -[Illustration: Fig. 20.—Normal attitude of fœtus (complete flexion). -(Barbour.)] - -There is no direct communication between the maternal tissues and the -placenta, hence all the changes occur by osmosis, and by the activity of -the cells which form the walls of the villi. - -=The liver= of the child is large and active. The stomach and intestines -functionate mildly. The kidneys act, and urine is discharged into the -liquor amnii, which the child occasionally swallows. - -During development, the movements of the child become more and more -pronounced. Arms, legs, and entire body participate in turn. Periods of -rest are also observed. Gradually the child assumes a definite attitude -in the uterus. It becomes more and more folded and flexed to accommodate -its size to the limitations of space. The head bends on the chest, the -arms are folded, the thighs flex against the abdomen, the legs on the -thighs, and even the back ultimately becomes convex. It attains a -complete flexion, the normal attitude of the child. As maturity -approaches, the head becomes more and more palpable and seeks its usual -location in the lower pole of the uterus, resting on the pelvic brim. - -[Illustration: Fig. 21.—Fœtal skulls showing sutures. Note the -differences between the anterior and posterior fontanelles. (Eden.)] - -[Illustration: Fig. 22 _A_.—Child’s head at term (from side), showing -diameter. (American Text Book.)] - -[Illustration: Fig. 22 _B_.—The child’s head at term (from above), -showing diameters and fontanelles. (American Text Book.)] - -=The fœtal skull= at maturity (at term) is still incompletely ossified. -The bones are thin and pliable and separated at their edges by intervals -of unossified membrane which form the sutures and fontanelles. Thus the -skull is compressible to a slight degree and capable of much change in -shape. It can be measurably moulded by the uterine contractions to suit -the pelvis. - -In front, the two coronary sutures meet the frontal and sagittal sutures -to produce a kite-shaped figure, called the large or anterior -fontanelle, or the bregma. Behind, the lambdoidal suture meets the -sagittal suture to form the small or posterior fontanelle. - -The large fontanelle is made up of four bones and four angles; the -small, of three bones and three angles, and are usually easy to -differentiate. Furthermore, the difference between these fontanelles is -of great importance in labor, since by it the observer is enabled to -determine the position of the head. In America, the shape of the head is -that of an ovoid with the long diameter anteroposterior -(Dolico-cephalic). Thus it happens that when the head is completely -flexed, the smallest diameters are presented for delivery. - -The important diameters of the head, with their measurements and names, -are as follows: - -Nape of neck to center of bregma, 9.5 cm.—Suboccipito-bregmatic -diameter. Occipital protuberance to root of nose, 11.25 -cm.—Occipito-frontal diameter. Between the eminences of parietal bones, -9.25 cm.—Biparietal diameter. Between anterior ends of coronal sutures, -8 cm.—Bitemporal diameter. - -The smallest circumference is that of the suboccipito-bregmatic plane, -which comes into relation with the brim of the pelvis when the flexion -of the head is complete. It measures 27.5 centimeters. - -The fœtus grows at a definite rate throughout gestation and so regularly -that the increase is rarely simulated by any other condition. - -To find the probable length of the fœtus at any given time, square the -month of the pregnancy (up to five) and the result is the fœtal length -in centimeters. After the fifth month, multiply the number of the month -by five. Thus: - - - 7th month ×5=35 cm., the approximate length of the fœtus at the lunar - month.—(Hasse’s rule.) - -=The Mature Fœtus.=—Although subject to considerable variation, the -fœtus at term will weigh about seven and one-fourth pounds, and measure -50 cm. in length. The weight is far more uncertain than the length, and -therefore not so reliable as a sign of maturity. - -To obtain an estimate of the weight of the child at any given month of -the pregnancy, the number of lunar months minus 2, is squared and -divided by 2, and the result is the average weight of the child at that -time in hundreds of grams. Thus: - - - 8th month −2=6. 6×6=36. 36÷2=18, or in hundreds of grams, 1800, the - weight of the child.—(Tuttle’s rule.) - -Differences between the mature and immature fœtus: - - _Mature_ _Immature_ - - 1. Skin smooth, plump, pink 1. Skin lax, wrinkled, dull red in - covered with vernix caseosa. color; little vernix caseosa. - - 2. Generous amount of subcutaneous 2. Subcutaneous fat scanty. - fat. - - 3. Hair abundant and from 1 to 2 3. Hair on scalp short. - inches long. - - 4. Lanugo mostly absent. 4. Lanugo present all over body. - - 5. Nails project from finger tips. 5. Short nails on fingers and - toes. - - 6. Skull bones in contact except 6. Skull sutures open. - at fontanelles. - - 7. Length 50 cm. born. 7. Moves and cries feebly when - - 8. Weight five to eight pounds. 8. Weight less than five - pounds. - - 9. Cartilage in ear well - developed. - - 10. Navel in middle of body. - - 11. Testes have descended in the - male, and the labia majora in - the female usually cover the - labia minora. - - 12. Moves and cries vigorously when - born. - -=The Fœtal Circulation.=—The placenta is an organ of nutrition as well -as respiration, and through the umbilical vessels the food materials are -brought to the fœtus and the waste products removed. - -Surrounded by the jelly of Wharton that fills out the cord, and running -in and out between the two arteries, the umbilical vein passes into the -fœtal abdomen and divides into two branches, one, the larger, -short-circuits directly into the inferior vena cava. This branch is -called the ductus venosus. The other joins the portal vein and passes -through the liver, after which it also enters the vena cava. - -Thus the heart is fed with a mixed blood, part coming fresh from the -placenta and part coming up from the lower half of the fœtus. This blood -is poured into the right auricle, where it becomes mixed again with the -blood coming down from the upper pole of the fœtus through the superior -vena cava. - -[Illustration: Fig. 23.—The fœtal circulation. (Edgar.)] - -Now a small part goes down into the right ventricle and is forced into -the pulmonary arteries to supply the lungs. But the lungs are not -functionating, hence the greater part is again short-circuited through -the ductus arteriosus into the arch of the aorta, where it meets with -the great volume of blood which passed over into the left auricle -through the hole in the septum between the right and left auricles, -called the _foramen ovale_, thence down into the left ventricle and out -through the aorta to supply the rest of the fœtal body. - -With the exception of the ductus venosus and the ductus arteriosus and -the foramen ovale, the circulation is the same as in the adult. - -The blood in the descending aorta again divides and part goes on to -supply the lower extremities while the greater part leaves the internal -iliac arteries by means of the hypogastric vessels and returns through -the umbilical arteries to the placenta for oxygenation. - -As soon as the child is born, the fœtal structures are altered. The -child breathes, the pulmonary circulation is established and the ductus -arteriosus is closed. The placental circulation is abolished, and the -ductus venosus and the hypogastric arteries are converted into solid -fibrous cords. Owing to the immediate change of pressure in the -auricles, the foramen ovale closes and the circulation assumes the adult -type. - - - - - CHAPTER III - NORMAL PREGNANCY - - -The entire body participates in the changes brought about by pregnancy. -The hips and breasts become fuller, the back broadens, and the woman -puts on fat. She becomes mature in appearance, but, of course, the -phenomena connected with alterations in the breasts and genitals are -most important, and late in pregnancy, most conspicuous. - -The uterus exhibits the most marked alteration. From an organ that -weighs two ounces, it becomes the largest in the body, and increases in -size from two and one-half or three inches to fifteen inches. The -typical pear-shape becomes spheroidal near the end of the third month, -becomes pyriform again at the fifth month, and continues thus until -term. - -Up to the fourth month the walls become thicker, heavier and more -muscular, but as pregnancy advances, more and more tissue is demanded, -until at the end, a muscle wall of only moderate thickness protects the -ovum. Meanwhile the muscular functions of contractibility and -irritability are greatly increased. - -At the fourth month the womb, which has occupied a position of -anteversion against the bladder, rises out of the pelvis. It is now an -abdominal organ and as it gets heavier and heavier, it rests a certain -amount of its bulk on the brim of the pelvis. About the sixth month, the -uppermost part of the uterus (fundus) is at the level of the umbilicus. -At the eighth month, the fundus is found a little more than midway -between the umbilicus and the ensiform cartilage. About two weeks before -term, it reaches its highest point, the ensiform cartilage, and then -sometimes sinks a little lower in the abdomen. - -The ovum, or egg, does not completely fill the uterine cavity at first, -but grows from its side like a fungus until the third month. Then the -uterine cavity is entirely occupied and thereafter the egg and the -uterus develop at an equal rate. As the uterus rises in the abdomen, it -rotates to one side, usually the right, forward on its vertical axis. - -[Illustration: Fig. 24.—Gravid uterus at the end of the eighth week. -(Braune.)] - -The blood vessels and lymphatics also increase in size, number, and -tortuosity. Many of the veins become sinuses as large as the little -finger. This increased amount of fluid both within and without the -uterus has a marked effect upon its consistency. The walls of the -uterus, vagina, and cervix become softened, infiltrated and more -distensible. There is also an increase in size and in number of the -muscle cells. - -During pregnancy the uterine muscle exhibits a definite functional -activity. Intermittent contractions occur, feeble at first, but growing -markedly stronger as pregnancy advances. These are the contractions of -Braxton Hicks. They are irregular and painless, but can be felt by the -examining hand. At term they merge into, and are lost in, the regular, -painful contractions of labor. - -The breasts can not be said to be fully developed until lactation has -occurred, nevertheless, the glands show pronounced changes as a result -of marriage and pregnancy. - -The size of the gland, as well as the size and appearance of the nipple -and areola, varies greatly in different women; but under the stimulation -of pregnancy the whole gland enlarges, including the connective tissue -stroma. - -About the fourth month a pale yellow secretion can be squeezed from the -nipple. This is called _colostrum_. The pigmentation extends over a -wider area and deepens in color, while the increased vascularity is -shown by the appearance of the blue veins under the thin tender skin. -Light pinkish lines sometimes radiate from the nipple. These are striæ -and are more evident in blondes. - -The milk comes into the breasts about the third day after labor, and -normally continues to flow for six, to ten or twelve months. - -Why the pregnancy and labor induce such marked mammary activity is not -known, but the fact is patent. - -=The skin= reacts both mechanically and biologically to the stimulus of -pregnancy. - -[Illustration: Fig. 25.—Striæ Gravidarum. (Edgar.)] - -_Striæ Gravidarum._—Striæ gravidarum appear on the abdomen similar to -those observed on the breasts and are due to the same cause—mechanical -stretching. When fresh, they are pinkish in color and variable in length -and breadth, but attain the greatest size below the umbilicus. -Occasionally they extend to the thighs and buttocks. - -After labor, they become pale, silvery, and scar-like and are called -linea albicantes. They are sometimes found in other conditions than -pregnancy, such as tumors or ascites. - -_Increased Pigmentation._—Pigmentation is not limited to the breasts. On -the abdomen, a dark line will appear between the umbilicus and the -pubes. This is the linea nigra, and it becomes most conspicuous in the -latter half of pregnancy. In the groins, the axillæ, and over the -genitals, the deposit is common, and sometimes patches appear on the -face, either discrete or in coalescence, to form a continuous -discoloration, called chloasma; or when extensive, the “mask of -pregnancy.” The pigmentation is absorbed, or at least greatly -diminished, after labor. The sebaceous and sweat glands are more active. - -_The hair_ may fall out and the teeth decay. “With every child a tooth,” -is the cry of tradition. These changes are due to imperfect nutrition, -or to the presence of toxins in the circulation. - -_Eruptions_ of an erythematous, eczematous, papular or pustular type are -not uncommon; and itching, either local or general, may make life -miserable. - -=The blood= undergoes certain modifications that are fairly constant. -The total amount is increased, but the quality is poorer, especially by -an increase in water and white cells and a diminution of red cells. The -amount of calcium is slightly increased and the fibrin is diminished up -to the sixth month, when it rises to normal again at term. - -=The heart= is slightly hypertrophied on the right side and blood -pressure somewhat raised. A marked increase in blood pressure is -suggestive of eclampsia. - -=The thyroid gland= enlarges frequently, both as a consequence of -menstrual irritation and of pregnancy. Goiters may show an increase of -development, which remains after labor. - -=The urine= is diminished in amount, but increased in frequency of -evacuation. The bladder is more irritable during the first and last -months, and micturition may be painful and unsatisfactory. The kidneys -must be watched carefully during gestation. - -=The nervous system= is disordered in most women, but especially in -those of neurotic tendencies. - -Irritability, insomnia, neuralgia of face or teeth, or perversion of -appetite in the so-called “longings” are the more common manifestations. - -Cramps occur in the muscles of the legs, owing to varicose veins or -pressure upon the lumbar and sacral plexus of nerves. - -=The lungs= are crowded by the growing uterus and the respiration -interfered with. - -=The liver= is enlarged, but functionally it is less competent, and -constipation is common. - -It is probable that most of the changes enumerated above are due to the -circulation through the body of some definite product of fœtal activity, -which is more or less toxic in character. The more pronounced effects of -this toxin will be studied under the abnormal conditions of pregnancy. - -Generally, if the pregnancy is normal, the whole body responds to the -stimulating influence. After the nausea and vomiting of the early months -subside, the woman feels energetic and ambitious. She is eager to do -something at all times and feels fatigue but slightly. Music, literature -or housework engages her attention and is zealously and joyfully -practiced. The world seems bright and the thought of her labor does not -bring solicitude, but pleasant anticipations. The body fills out in all -directions and the woman takes on the appearance of maturity. - - - DIAGNOSIS OF PREGNANCY - -The presence of pregnancy is naturally determined by the recognition of -those changes in the maternal system which the growing ovum produces. - -During the _second half_ of the period the fœtus can be made out -distinctly by palpation, or by its movements, and the heart tones -observed by auscultation. - -During the _first half_ this is impossible and the diagnosis must be -made from subjective symptoms elicited from the patient and upon -physical signs observed by the physician. - -It is of extreme practical importance to be able to recognize a -pregnancy at all periods. The _subjective symptoms_ of the first half -are—amenorrhœa, morning sickness, irritability of the bladder, -discomfort and swelling of the breasts, enlargement of the abdomen and -quickening; but the appearance of any or all of these phenomena is not -to be regarded as conclusive, but merely as a presumption that pregnancy -exists. Either through ignorance, intent to deceive, or from -pathological conditions, any or all of these symptoms may be present, -but not until the tenth week are the changes in the uterus sufficiently -definite to confirm a diagnosis unless the circumstances are especially -favorable. - -=Amenorrhœa.=—Cessation of the menses is practically invariable in -pregnancy. One or two periods may occur after conception, but care must -be used to exclude other causes of hæmorrhage. Sudden cessation of the -periods in a healthy woman of regular habits who is not near the -menopause, is strongly suggestive of pregnancy. Why a developing ovum -causes an immediate arrest of menstruation is not understood. - -Amenorrhœa may occur in consequence of chlorosis, heart disease, -hysteria, tuberculosis, fright, grief, and some forms of insanity; a -change from a low to a high altitude, or an ocean voyage not -infrequently causes the flow to remain absent for one or more months. In -addition to its value as a presumptive symptom, the amenorrhœa affords a -common and convenient method of estimating the date of confinement. The -method is fallacious but practical, and will be discussed later. - -=Morning Sickness.=—This symptom is not invariable. It is most frequent -in primiparas, but not so likely to occur in subsequent pregnancies. It -usually appears about the second month, shortly after the first period -missed. It varies in intensity. Some women have a little nausea on -arising and no further trouble during the day, others are nauseated and -vomit either on rising or after the first meal, and yet others after -each meal; but the general health is not ordinarily affected and the -tongue remains clean. Some cases are of extreme severity (hyperemesis) -and will be discussed elsewhere. - -The morning sickness is probably toxic in origin. It must be remembered -that chronic alcoholism is accompanied by morning sickness, but with it -the tongue is furred. - -=Irritability of bladder= is shown by a frequency of urination. It is -caused by the congestion and stretching of the tissues that lie between -the uterus and bladder and hold them in relation to one another. After -the third month an accommodation is established and the symptom does not -reappear until late in pregnancy, when the pressure of the heavy uterus -tends to keep the bladder empty. If especially annoying, this -irritability may be much relieved by putting the patient in the -knee-chest position night and morning. - -=Enlargement of the breasts= is common in primiparas, but this, with -changes in the areola, may occur at menstrual periods in nervous women. -Tingling, pricking and shooting sensations may also be noted. - -=Enlargement of the abdomen= is only noticeable toward the latter part -of the first half, when the uterus rises out of the abdomen. - -=Quickening= means “coming to life,” and refers to the first movements -of the fœtus that are felt by the mother. It is described as similar to -the flutter of a bird in the closed hand. It is sometimes accompanied by -nausea and faintness. Quickening usually occurs about the seventeenth -week of pregnancy, and continues to the end. Gas in the intestines will -sometimes simulate quickening. - -The movements are important in the second half as indicating that the -child is alive. - -=Physical Signs.=—During the first weeks no conclusive changes occur -that can be detected by examination, and unless conditions are -especially favorable, the earliest time for the definite diagnosis of -pregnancy is the eighth week. Previous to this it is presumptive only. - -At the eighth week, the breasts may show enlargement and tenderness, -with some secretion. In the multipara, this sign has no significance. -Secretion is present sometimes in the breast of nonpregnant women with -uterine disease (fibroids). - -Examination of the abdomen at this time is of little value, but changes -in the uterus can be detected by careful bimanual examination. It is -needless to say that all internal examinations should be made with the -utmost care and gentleness. - -Softening of the lips of the os (Goodell’s sign) may be found, but it -must not be confused with erosions of the os. The os of a nonpregnant -woman feels like the tip of the nose, and that of the pregnant woman -like the lips. - -[Illustration: Fig. 26.—Bimanual examination. (Edgar.)] - -The increased size and globular shape must also be considered as -confirmatory. - -=Hegar’s Sign.=—The upper part of the uterus is soft and distended by -the ovum, the lower part is soft and not filled out by the ovum. Between -the two is an isthmus that is compressible between the fingers of one -hand in the vagina, and of the other upon the abdomen. When found, this -sign is of great value. - -At the eighth week, pregnancy can be regarded as highly probable by the -conjunction of the following symptoms and signs: Amenorrhœa, morning -sickness, irritability of bladder, slight breast changes in primiparas, -lips of os externum softened, uterine body enlarged, softened, and -nearly globular in shape, and Hegar’s sign. - -=Abderhalden’s test= is a serum reaction based on the well established -principle that the introduction into the blood of an organic foreign -substance leads to the formation of a ferment to destroy it. -Abderhalden’s plan was to discover whether the blood of a pregnant woman -contained a ferment capable of destroying placental protein. It is a -very complicated test, and subject to many inaccuracies and numerous -sources of error. At the same time, the main features of this reaction -have been confirmed, and when it is worked out, it will be of immense -value not alone in early uterine pregnancies, but in extrauterine -pregnancy. This view very properly demands that pregnancy be regarded as -a parasitic disease. It is practicable as early as the sixth week to -make a diagnosis, and it only fails in possibly ten per cent of the -cases. The negative test is equally definite as eliminating pregnancy. - -=Sixteenth Week.=—Morning sickness and urinary symptoms have disappeared -but amenorrhœa remains. Enlargement of the breasts is noticeable, as -well as the increased pigmentation. The uterus begins to rise above the -symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is -softer. The characteristic dull lavender coloration of the vulvar mucous -membrane is now evident. It is due to the congestion and is called -Jacquemins’ sign. - -=Two New Signs.=—Irregular, painless contractions of the uterus (Braxton -Hicks’ sign), and ballottement. - -The contractions of Braxton Hicks now become more easily palpable. - -Ballottement consists in the detection in the uterus of a movable solid -body surrounded by fluid. In a standing position, the fœtus rests in the -lower part of the uterus, just above the cervix. The woman stands with -one foot on a low stool, and two fingers of one hand are pushed into the -vagina until they touch the cervix, the other hand is placed on the -fundus. A smart upward blow by the internal hand is transmitted to the -fœtus, and it can be felt to leave the cervix, strike lightly the -tissues underneath the external hand, and return to the cervix. It is -simulated by so few things, and so rarely, that in practice it must be -regarded as a positive sign. - -During the second half, the subjective symptoms are of minor importance -since unmistakable evidence is furnished by the physical signs. The -symptoms of this period are mostly discomforts. Increased intraabdominal -pressure brings on edema of the feet, cramps in the legs, varicose veins -of the legs and vulva, dyspnœa, and palpitations. - -=Twenty-sixth Week.=—About the twenty-sixth week, or, at the end of the -sixth calendar month, the hypertrophy of the breasts, the presence of -secretion, and the marked pigmentation are unmistakable. The abdominal -protrusion is now clearly visible, and the fundus will be found at the -level of the upper border of the umbilicus. - -Spontaneous fœtal movements appear and may be felt by the palpating -hand. - -Auscultation reveals the uterine souffle and the fœtal heart sounds. The -heart sounds and the fœtal movements, when obtained by the observer, are -positive signs. - -Uterine souffle is a soft, blowing murmur, synchronous with the mother’s -pulse. It is best heard at the lower parts of the lateral borders of the -uterus. It is due to the passage of blood through the greatly dilated -uterine arteries. It may be heard also in cases of fibroid tumors of the -uterus. - -[Illustration: Fig. 27.—Abdominal enlargement at third, sixth, ninth, -and tenth months of pregnancy. (Williams.)] - -[Illustration: Fig. 28.—Height of the uterus at various months of -pregnancy. (Bumm.)] - -The fœtal heart sounds are the most anxiously sought for of all the -signs of pregnancy. They are conclusive. They not only determine the -diagnosis, but afford valuable information during labor, and nurse and -student should lose no opportunity of becoming familiar with them. The -heart tones can be heard as early as the twenty-sixth week, but they -become more and more distinct as pregnancy advances. They vary from 140 -to 160 beats to the minute at the twenty-sixth week, and at term, from -120 to 140. When they rise above 160 or sink below 120, some danger -threatens the child. The fœtal heart tones have _no significance_ as an -indication of sex. - -Funic souffle is the sound made by the passage of blood through the -umbilical cord when a loop accidentally lies under the tip of the -stethoscope. It is synchronous with the fœtal heart tones, but of no -great practical importance when the heart tones can be obtained. - -Determination of the period to which pregnancy has advanced is sometimes -important. This can be approximated by a calculation of the time that -has elapsed since the last period, or from the date on which quickening -has occurred. Measurement of the height of the fundus and comparison -with such scales as Spiegelberg’s, may be carried out, but it is not -often required. - -A method of estimation in gross, that is approximately correct, in many -cases depends on the observation of the steady growth of the womb. - -Thus, the uterus rises out of the pelvis at the fourth month, and may be -found well above the symphysis pubis. At the fifth month the fundus is -midway between the symphysis and the umbilicus. At the sixth month it -reaches the umbilical level. At the eighth month it is a little more -than midway between the umbilicus and the ensiform cartilage, which it -attains in another month, the ninth. Then it usually sinks a little, -especially in primiparas during the last two or three weeks. This is -called _lightening_. - - - - - CHAPTER IV - HYGIENE OF NORMAL PREGNANCY - - -The time of confinement can never be accurately determined, because the -onset of labor is purely an accident, dependent on many factors. -Furthermore, conception does not take place necessarily at the time of -intercourse, and we have no means of knowing whether conception occurred -_just after_ the last period present or _just before_ the first period -missed. So there is always a possible error of three weeks. - -Pregnancy in the human family normally lasts from 275 to 280 days, and -the approximate date of confinement can be obtained by the following -convenient rules: - -1. Take the first day of the last menstruation, count back three months -and add seven days. - -2. Or, assuming that quickening occurs at the seventeenth week, count -ahead twenty-two weeks from the day on which quickening was observed. - -3. Or, count two weeks from the day of lightening. - -4. Or, with a pelvimeter, get the length of the fœtus by Ahlfeld’s rule -(measure from symphysis to breech of child, subtract two cm. for -thickness of abdominal wall and multiply by two. The result is the -length of the child in centimeters) and compare with fifty centimeters, -which is the average length of a mature child. After the seventh month, -the child in utero grows at the rate of about 1 cm. a week (0.9 cm.). - -5. Or, by the tape, according to Spiegelberg’s standard of growth, as -previously mentioned. - -The hygienic rules to be observed during pregnancy are founded on three -basic principles: (1) To watch attentively the different organs and see -that they functionate normally; (2) To eliminate all those conditions -that favor the premature expulsion of the egg; and (3) To provide, so -far as possible, for the normal gestation and the physiological delivery -of the child. These factors will be taken up in detail. - -=The Diet.=—The appetite is usually somewhat increased, but it is -unnecessary to indulge the stomach on the ground that the mother “must -eat for two.” Longings, however, should be gratified so far as the -demand is not for unwholesome things. Food should be simple and plainly -cooked. Meat is permitted in moderation unless some organic change -exists to contraindicate it. Rich pastries and gravies should be -avoided, but cereals, fruits and vegetables should be used in abundance. -It may be better to eat four times a day instead of three. Fluids should -be taken freely, from one to two quarts daily. Milk is especially -valuable, and alkaline, natural and charged waters, such as Vichy and -seltzer, are useful. Wine, beer and other alcohols should not be taken, -or if the patient is habituated to their use, the amount should be -restricted on account of danger to the pregnancy and danger to the -child. - -In contracted pelves it is sometimes desired to furnish a special diet, -with the idea of controlling the size of the child (see Prochownick’s -Diet, p. 332) but this is an emergency. Certain books on maternity, -designed for popular reading, advocate diets that are supposed, by -depriving the child of lime salts, to keep its bones soft and make the -labor easy. If it succeeds, the child will be injuriously affected. If -it does not succeed, the claim is false. - -=Exercise.=—Exercise should be taken, but it should not be violent, nor -attended by risk. Golf, swimming, tennis, dancing, horseback or bicycle -riding and fast driving in automobiles should be forbidden, lest -abortion follow. General exhaustion must be avoided and all conditions -that even approximate traumatism. Walking and slow driving are best, and -housework is excellent up to a mild degree of fatigue. Travel should be -restricted. If exercise is not feasible, massage will furnish the -required stimulation to the circulation. The menstrual epochs are -peculiarly favorable to abortive influences. - -=The Bowels.=—Most women have a tendency to constipation during -pregnancy. Many times this can be corrected by increasing the -“roughening” in the food; more vegetables and fruits, bran bread and -muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and -especially potatoes, baked and eaten, skin and all. Prunes, figs, and -dates are valuable aids. Agar may be eaten three or four times daily. -Russian oil (liquid petrolatum), taken in tablespoon doses three times -daily, is an adjuvant, and finally, some form of cascara or aperient -pill may be taken, if necessary. - -Violent cathartics should not be used at all, and enemas as little as -possible; only when _quick_ results are necessary. - -=Heartburn.=—Heartburn is a frequent complication, especially in the -later months. It is due to an inordinate secretion of acid in the -stomach. Soda mint tablets, bicarbonate of soda, and magnesia, in cake -or as milk of magnesia, will relieve. The magnesia is also a laxative. - -=The kidneys= require particular care during pregnancy, and in every -case the urine should be examined monthly, up to the fifth month, and -every two weeks thereafter, until the last six weeks, when a weekly test -should be made. - -The amount passed in twenty-four hours should be measured. Three pints -is an average quantity. Albumin, sugar, and casts must be looked for and -reported. Albumin may or may not be a serious symptom. Casts are -significant of nephritis and indicate danger. Sugar may be lactose and -be derived from the milk secreted in the breast. Edema of feet, hands -and eyelids must always be investigated, with the possibility in mind, -of heart and kidney lesions. Blindness, dizzy spells, headaches and -spots before the eyes are always alarming symptoms until their innocence -is established. - -Through constant watchfulness of the urine, many cases of eclampsia may -be averted. - -=Bathing= is more important in pregnancy than at other times. The more -the skin secretes, the less the burden on the kidneys. The skin must be -kept warm, clean, and active. Then again, during pregnancy the skin is -often unusually sensitive and only the mildest soaps and blandest -applications can be used. The water must be neither hot nor cold, but -just a comfortable temperature. Cold bathing, whether shower, plunge, or -sitz, must be denied. Sea bathing is also unwise. The warm tub bath of -plain water or with bran answers all conditions until the expected labor -is near, then the warm shower or sponge bath should be substituted, lest -germs from the bath water enter the vagina. - -If the kidneys need aid, a hot pack may be used; but in all cases, -frequent rubbing of the skin with a coarse towel should follow the bath. - -=The dress= must be warm, loose, simple and suspended from the -shoulders. To prevent chilling, wool or silk, or a mixture of both, -should be worn next to the skin,—light in summer and heavy in winter. - -The patient must be sensibly clad in broad, loose, low-heeled shoes. -There should be no constriction about chest or abdomen. Circular garters -must not be worn. If a corset is insisted upon, it must support the -abdomen from below and _lift it up_. No corset is admissible that pushes -down on the abdomen. This is especially true if the woman has borne one -or more children and has a pendulous abdomen. The breasts may get heavy -and require the rest and ease supplied by a properly fitting bust -supporter. - -=Fainting= is an annoying symptom in some women. It may come when -quickening is first perceived, or from the excitement of crowds, or from -hysteria. It usually passes quickly. The pallor is not deep, the pulse -is not affected, and consciousness is not lost. It does not affect the -ovum. Heart trouble should be excluded, and the daily habits of dress, -diet, and bowels investigated. Smelling salts will usually suffice for -the attack. - -=The abdominal walls= may be strengthened by appropriate exercise before -and after gestation, so that the muscles will preserve their tone. After -delivery nursing the child will help greatly in the preservation of the -waist line and figure, by aiding involution. - -About the seventh month in primiparas, the abdomen gets very tense and -in places the skin is stretched until it gives way and forms striæ. This -tightness can be relieved to a considerable degree by inunctions of -cocoanut oil or albolene. - -Pain in the abdomen at this time may be due to mechanical distention, to -strain on the muscles, to stretching of operative adhesions, to gas, -constipation, or appendicitis. The physician should be informed of it. -In every case, constipation, swelling of feet, hands or eyelids, -blurring of vision, ringing in the ears, vomiting, persistent backache, -or the passage of blood, no matter how slight, should be reported to the -doctor. - -=The Breasts=.—There should be no pressure on the glands and they should -be warmly covered. The nipples must be kept clean and soft by soap and -water, and about a month before the labor is expected, the nipple should -be anointed with albolene or cocoanut oil and rubbed and pulled for a -few minutes every night. This removes the crusts and dried secretions -that collect on the nipple and prepare it for the macerating action of -the baby’s mouth. No alcohol or strongly astringent washes should be -used. Injuries must be avoided. If the nipples become tender they may be -protected from external irritation by the lead nipple shield or by a -wooden shield with a hollow center, such as Williams recommends. - -=Leucorrhœa.=—This is one of the commonest discomforts of pregnancy, and -the sense of uncleanliness, if the discharge is excessive, as well as -the resulting irritation, may demand attention. It must be kept in mind, -however, that the normal vaginal discharge of a healthy pregnant woman -is strongly germicidal and should not be douched away without definite -indications. - -Vaginal douches of warm boric acid solution will do for cleanliness, but -the douche bag must not be higher than the waist. Stronger and more -antiseptic solutions are potassium permanganate 1:5000, or chinosol -1:1000. A suppository may be used, consisting of extract belladonna, gr. -ss; tannic acid, gr. v, and boroglyceride dr. ss. - -=Sexual intercourse= is distasteful to most pregnant women, but -sometimes the inclination is intensified. - -Coitus often causes much pelvic discomfort and may be an influential -factor in producing abortion. It should be forbidden during the early -months, at all menstrual epochs, and for at least two weeks before -labor. The uterus may be infected by germs beneath the foreskin and -hæmorrhage may follow the act if the placenta is low. In healthy -persons, at the instance of the female, intercourse in moderation is -permissible. - -=The mental condition= should be placid without either excitement or -fatigue. Anxiety should be dissipated by cheerful company and -surroundings. Judicious amusement is desirable and a congenial -occupation, but neighbors who tell frightful tales of disaster in labor, -or nurses who relate the details of their critical cases, are equally to -be avoided. - -Many women of neurotic temperament dread the labor desperately. They are -sure that death impends and they dwell with tragic interest on the -stories of complicated cases related by thoughtless or malicious -neighbors. The nurse can do much to allay these apprehensions by -cheerfulness, optimism, and gentleness. Her buoyant temperament will -drive away the patient’s fears just as effectively as the assurances of -the physician. - -Great allowances must be made for attacks of irritability, for the -changes going on in the woman’s pelvis keep her in a capricious and -whimsical condition. A good book to read at this time is, the -“Prospective Mother,” by Slemons. - -=The subject of maternal impressions= is the cause of much anxiety -during pregnancy. It is safe to assure the mother that it is nearly -impossible to mark her child by emotional stress. There is no -demonstrable nervous communication between mother and child, and most of -the deformities that occur and are attributable to shock, etc., can be -explained by our knowledge of intrauterine changes. Furthermore, the -same deformities occur in lower animals, to which it is difficult to -ascribe such high nervous organization. - -Many of the birthmarks, supposedly due to shock, occur too late in the -pregnancy to affect the child, even if it were possible, for the child -is completely formed before the fourteenth week. - -=The Determination of Sex.=—It is not possible to know in advance of -delivery whether the child will be a male or a female. It is equally -impossible to determine or even to influence the sex of the coming -child. Many theories have been advanced, and much talent has been wasted -in trying to solve this problem. - -Reasoning by analogy from the facts obtained from lower animals, the sex -of the child is unalterably decided the moment conception occurs. The -responsibility for the decisions seems to lie with the male cell. All we -really know is that the sexes appear in the ratio of 100 girls to 106 -boys. - - - - - CHAPTER V - ABNORMAL PREGNANCY - - -After the diagnosis of pregnancy has been satisfactorily established, no -further internal examinations are necessary in the absence of special -indications, until about the thirtieth week. - -At this time a series of complete physical examinations may be required -to determine the presentation and position of the child, the presence -and rate of fœtal heart tones, the diameters of the head, the length and -approximate maturity of the child, as well as the condition of the bony -and soft passages of the mother. - -It is thus that an appreciation of the obstetrical problem is secured -and a course laid out for its successful solution. - -Pregnancy is not a disease, but a normal function; but the woman is -exposed, nevertheless, to many grave risks that are peculiar to her -condition and to many complications accidental or otherwise which are -more serious on account of her pregnancy. - -=The Toxæmias.=—The growing ovum brings about changes in the maternal -metabolism that are manifested by characteristic symptoms which in other -better known conditions are recognized as due to toxæmia. Therefore, -while there is no positive proof as yet that these symptoms, arising -during pregnancy, are toxæmic in origin, the evidence goes to show that -they are; and, therefore, should be classified as toxic. - -Postmortem findings in eclampsia and pernicious vomiting such as -extensive thromboses, cell necrosis, and interstitial hæmorrhages are -very suggestive. - -Clinical findings in regard to the excretion of nitrogen (urea, ammonia, -uric acid, etc.), the occurrence of acidosis, elevation of blood -pressure, fever, diminished excretion, coma and convulsions, all point -to toxæmia. - -It is the minor disturbances, however, that the nurse will come in -contact with most. They are nearly all toxæmic in origin, and a brief -description of them must be given, together with suggestions for their -management. - -=Salivation or Ptyalism.=—In the majority of cases, saliva is not -especially noticeable; but at times the secretion shows an enormous -increase, and may even demand abortion. Patients will have saliva -running constantly from the mouth. The amount may reach a pint or a -quart a day, and the skin of the lower lip becomes greatly inflamed. - -The only satisfactory _treatment_ is a rigorous milk diet on the theory -that the disturbance is an intoxication. In extreme cases abortion may -be indicated. - -=Gingivitis.=—The gums may become inflamed, spongy and hæmorrhagic -during pregnancy, usually in patients of low vitality. If a generous -diet and astringent mouth washes do not relieve the condition, the milk -diet should be considered. - -=Toothache and Dental Decay.=—The patient may be given hypophosphites, -and the teeth should be put in good condition by a dentist. - -=Constipation= has already been referred to. Strong cathartics should be -avoided lest abortion follow. - -=Condylomata of pregnancy= occur most frequently around the labia, -perineum, and anus. They are wart-like growths that develop slowly or -quickly and may remain discrete or cover the entire area with masses as -small as beans or as large as cauliflowers, which in appearance they -much resemble. The etiology is obscure, but they are generally -associated with irritating vaginal discharges, such as an old gonorrhœa. - -_Treatment_ consists in stopping the discharge or neutralizing it, and -in keeping the growths dry with a salicylic acid dusting powder. (See -Therapeutic Index.) - -=Pruritus= is often distressing. The itching may be limited to the -genitals or appear on other parts of the body. It may be due to the -irritation of local discharges or to a condition of the nervous system, -arising from toxæmia. Astringent douches and protective ointments will -relieve some cases. - -Bromides and milk diet, bran or alkaline baths give good results, and -local applications of sedative lotions and ointments containing menthol, -carbolic acid or cocaine (cautiously) will aid. The woman in some -instances becomes almost frantic, and tears at the vulva with her nails -until it bleeds. - -The iodine treatment of Hensler is simple and often effective. If no -skin changes are visible and but little leucorrhœa, the vulva is -thoroughly prepared as for a vaginal operation, dried and painted with a -10 per cent solution of tincture of iodine. Generally one application -suffices, but when the leucorrhœa is bad, it may be necessary to repeat -the treatment on the third and fifth day thereafter. Between treatments, -the vulvar surfaces and even the vaginal walls (by insufflation) are -kept dry with zinc oxide powder. If all measures fail and exhaustion is -imminent, emptying the uterus may be advisable. - -=Herpes= is an inflammatory, superficial eruption, characterized by red -patches, blisters, or pustules. It is accompanied by burning, itching, -and nervous depression. The origin is probably toxic and the termination -may be fatal. Milk diet, soothing lotions, and, if necessary, abortion, -constitute the means of treatment. - -=Areas of pigmentation= (the chloasmata) are not amenable to treatment. -They usually disappear after labor. - -=Albuminuria of Pregnancy.=—Albuminuria is so common as to be almost -physiological when the amount of albumin is small. When the amount of -albumin in the urine is large, it may be due to pre-existing disease, -which is first discovered when the urinalysis is made during pregnancy. -(Chronic nephritis?). - -If it makes its debut during gestation and continues as a mere trace -without casts, it is spoken of as the albuminuria of pregnancy, but the -patient must be watched with great care, since the albuminuria may be a -premonitory sign of eclampsia. - -Albuminuria and eclampsia must be considered together, because, while -the two conditions may exist separately, they are most frequently -associated, and it is believed that they have a common causation. It is -true that most cases of albuminuria terminate favorably, yet the higher -the albumin content, the greater the danger of eclampsia. - -Albumin appears in the urine in from three to five per cent of all -pregnancies. It is more common in the latter half of gestation and the -attacks differ greatly in severity. - -_Symptoms._—In the early stages the urine shows an abundant, pale fluid -of low specific gravity. - -The seriousness of the case is generally indicated by the amount of -albumin, although this is not a reliable guide as to the danger of -eclampsia. Casts and red and white blood corpuscles are occasionally -found. The output of urea usually remains normal, but diminution usually -occurs in connection with eclampsia. Anæmia and anasarca are common, but -it is a hopeful clinical sign that the cases of extensive edema rarely -develop eclampsia. - -In albuminuria of pregnancy there is a large fœtal mortality which, to a -degree, is independent of eclampsia. The infant dies _in utero_ or is -born feeble, or prematurely. - -=Eclampsia= is the sudden appearance of convulsions in the course of -pregnancy. It may precede, follow, or accompany albuminuria. It occurs -rarely in the absence of albuminuria in a woman who was apparently in -good health. The two phenomena are best explained as a consequence of -toxæmia due to poisons at present unidentified. - -_Treatment_ of the albuminuria is treatment for impending eclampsia. -Regular examination of the urine is indispensable. The presence of -albumin suggests toxæmia. The daily output of urine and the output of -urea must be compared, for a fall in urea is a premonitory sign of -eclampsia. The bowels and the skin should be stimulated, respectively, -by saline cathartics, hot baths and packs. The digestive organs must be -spared as much work as possible, especially the liver. Water is given in -abundance, and milk is the staple diet. Koumiss, butter milk and ice -cream may be allowed. As the patient improves, vegetables are allowed. -The food should be salt-free; and alcohol, as well as rich, indigestible -things should be forbidden. In the milder cases boiled fish and a little -chicken may be permitted. - -The course of the disease and the condition of the patient is determined -by frequent examinations of the urine, while in all serious cases an -examination of the fundus of the eye must be made to detect a possible -albuminuric retinitis. - -The treatment of eclampsia will be considered under the complications of -labor, where the attack usually begins. - -=Pyelitis of pregnancy= is an acute, and rarely, a chronic infection of -the pelvis of the kidney, due to the Bacillus coli. It usually appears -after the fourth month (fifth to eighth) and attacks by preference the -right side. Extension to the kidney substance, ureters, and bladder is -occasionally observed. - -_Symptoms._—Sudden, acute abdominal pain, at first diffuse, but after a -few hours, becoming localized in the right side, and on this account is -often confused with appendicitis, especially as vomiting is not -infrequent. A chill may mark the onset and the temperature rise to 103° -F. or 104° F. The bowels are constipated, the tongue coated, and there -is tenderness over the kidney. The urine is scanty, turbid, slightly -albuminous and contains pus and epithelium in the urinary canal. A -culture reveals the bacillus which has obtained access to the kidney, -either by extension of the ureter from the bladder, by direct invasion -of the tissues from the adjacent colon, or through the circulation. - -_Treatment._—The diet should be fluid and mostly milk, the bowels should -be moved freely and frequently. The urine is alkalinized with sodium -citrate, since the Bacillus coli lives only in an acid medium. As the -symptoms subside, urotropin may be administered. If the patient does not -improve within two weeks, abortion must be seriously considered. -Nephrotomy is not to be thought of unless abortion has failed. - -=Hyperemesis Gravidarum.=—The nausea and vomiting of pregnancy is so -usual as to be regarded as normal. It usually ceases from the fourth to -the fifth month spontaneously; has no ill effect upon the ovum, and may -respond readily to treatment. - -Hyperemesis comes on at the same period and exhibits all stages of -violence, from the mild form above described, to cases that end fatally. - -Three classes of this serious disorder may be distinguished as -associated (Eden), neurotic, and toxæmic vomiting. - -Associated vomiting is the vomiting that comes with gastric ulcer or -cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease. -These conditions must be excluded in diagnosis. - -Neurotic vomiting—severe and persistent nausea and retching—is common in -pregnant women of the nervous type. It does not lead to loss of flesh -ordinarily; the urine is somewhat diminished in quantity from the lack -of fluids, but the amount of nitrogen excreted remains normal. This is -important. - -Toxæmic vomiting includes a small but very important class of cases, for -all are severe and intractable and some end in death. - -_Clinical Features._—The normal nausea and vomiting may seem unusually -severe. It persists and gets worse. Then vomiting occurs when no food is -taken and nothing is held on the stomach. The vomit is stained with bile -or blood. The tongue remains clean, and the general condition is good. - -Next, weight is lost and the pulse quickens. A persistent pulse of over -100 is serious. The tongue becomes coated, sordes develops, -sleeplessness and muscular twitching appear, and the patient complains -of epigastric pain. Abortion may now occur and the condition clear up. - -In its final stage, the urine becomes scanty and albuminous, icterus may -appear and the temperature rise to 100° F. or more, though sometimes it -is subnormal. The pulse may go to 120. Delirium and coma supervene, and -emptying the uterus is of no value. Fifty per cent of these bad cases -die. - -The especially prominent points to be noted are the urine, which shows -acetone, albumin and blood, either one or all, as well as an increased -amount of ammonia. A persistently rapid pulse, marked loss of flesh, -coated tongue, jaundice and delirium are regularly present. - -_Treatment._—Organic disease must be excluded and a diagnosis of -pregnancy strongly evident. - -For the neurotic type, the patient must be segregated from her friends, -and a competent, cheerful nurse put in charge. A cool, darkened room is -best. If the patient can be transferred to a hospital, the results are -more satisfactory. Here the isolation from external interests and -irritations can be made complete. The patient does not talk, even the -nurse comes with food, attends to the obvious necessities, and departs -in silence. Once a day a sedative bath is given (see Baths, p. 325) and -medication in kind and frequency as the conditions demand. - -In any case, the patient should be put to bed and fed carefully every -two or three hours on milk, peptonized food or barley water. If this is -not retained, albumin water may be given for twenty-four hours at -regular intervals, or rectal alimentation may be tried after stopping -all foods by mouth. Iced champagne, seltzer or Vichy, either alone or -with milk, may be tried. A dry diet is sometimes effective, rusk, toast, -toasted shredded wheat biscuit, crackers, etc., taken early in the -morning, as one eats cheese. No exercise is permitted except such -muscular and nervous excitation as may be derived from massage or the -sedative bath. - -Drugs are sometimes of great value—the bromides, in full doses, or 1 m. -doses of tincture of iodine, well diluted, every hour; or bismuth with -hydrocyanic acid; or cocaine or oxalate of cerium. Occasionally good -results are reported from a capsule of pepsin, 2 gr. and ¼ gr. silver -nitrate given just before meals; and adrenalin in 10 drop doses may be -considered. Extract of corpus lutea has been tried by Hirst with -favorable results. - -Sinapisms to the epigastrium and ice bags to the spine have been found -useful, and washing out the stomach is efficient at times. In washing -out the stomach, be sure the stomach tube is _iced_ before it is -introduced. - -When the case gets worse in spite of treatment and acidosis supervenes, -bicarbonate of soda may be given in sixty grain doses every four hours, -by rectum, if necessary, until the urine gives an alkaline reaction. - -Glucose as a readily assimilable carbohydrate may be given in doses up -to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum, -1000 c.c. in twenty-four hours by drop method. - -_The obstetric treatment_ is the emptying of the uterus. To be effective -the abortion must be done before the condition of the patient is -desperate. It is most favorable before the febrile stage. If the -vomiting persists in spite of treatment and is accompanied by -emaciation, a pulse of over 100, albumin in the urine, with an increase -of the ammonia output, the pregnancy should be terminated at once. If -the patient can not go to a hospital, the nurse should prepare the room -as described for operations. - -After emptying the uterus, the vomiting usually ceases but much labor is -thrown upon the nurse in supplying nourishment and caring for an -exhausted and whimsical patient. - -The back must be inspected daily for decubitus (bed sores) and her -position changed frequently. A daily rub with alcohol and water (50 per -cent) followed by an oil inunction will be valuable. The teeth and gums -should be cleaned with gauze, wrapped around the finger and dipped in -solution of boric acid. No brush should be used. - -[Illustration: Fig. 29.—Twins. (Lenoir and Tarnier.)] - -=Multiple Pregnancy.=—Twins occur about once in ninety labors, triplets, -once in seven thousand. - -Heredity and multiparity seem to be the only recognized predisposing -factors. The more pregnancies a woman has, the more liable she is to -have twins. - -Twins may occur through a division of the primitive cell through the -fertilization of two ova from the same or different ovaries, or by -fertilization of a single ovum having two nuclei. (See Fig. 13). The -former are called binovular twins, and may or may not be of the same -sex. The latter are called uniovular twins and are always of the same -sex. Twins are usually somewhat smaller than a single child, and -frequently associated with hydramnios. Binovular twins have separate -placentæ and uniovular twins have one placenta, with separate cords. - -Twin pregnancies usually go into labor earlier than the single child, -possibly on account of the over-distention of the uterus. - -_The diagnosis_ is occasionally difficult and at other times easy. Two -sets of heart tones must be distinguished and differentiated by their -variation in frequency, heard at the same time by different observers. -The presence of twins may be strongly suspected also when the external -measurements of child and uterus greatly exceed the average. In such -cases a systematic and persistent search must be made for the two fœtal -heart tones. - -_The delivery_ is generally uncomplicated, unless the chins become -locked. - -=Displacements of the Uterus.=—In most cases displacements of the uterus -are a consequence of conception in organs that are previously -retroflected or retroverted. They rarely produce symptoms until the end -of the third month, when the attention is directed to the bladder. There -may be absolute retention or a constant dribbling from a full bladder -(ischuria paradoxa), possibly associated with pain. If recognized early, -an attempt should be made to replace the uterus by posture (knee chest) -and when replaced, to hold it by pessary or tampon. The prone position -in bed will aid. - -After retention has occurred, the patient should be put to bed and the -bladder catheterized regularly every eight or ten hours for three or -four days. As a rule, the organ will rise spontaneously into the -abdomen. If it does not, it is probably incarcerated under the -promontory, and the physician must try to replace the uterus by -manipulation or by continuous pressure, but in bad cases, he will empty -the uterus before the condition of the patient becomes too serious. - -In multiparas with weak abdominal walls, or women with spinal curvature -or contracted pelves, the uterus may fall forward and, passing between -the recti muscles, continue to drop until the fundus lies lower than the -symphysis pubis. - -_Management_, until labor occurs, may be made more effective by using a -strong, well-fitting abdominal bandage. - -=Malformation of the uterus= may possess an obstetric interest at times. -The double uterus (uterus didelphys) and the uterus with a rudimentary -horn (uterus bicornis) are examples. These are congenital conditions, -due to imperfect development, and pregnancy may take place in one or -both sides. If in one side only, the other half will also exhibit the -softening and other changes as in normal cases. Binovular twins may be -the result of a pregnancy in each side. - -=Pressure Symptoms.=—_Edema_ of legs and sometimes of the vulva occurs -during the last trimester. It is due to increased intraabdominal -pressure and to direct interference with the return circulation by the -pressure of the heavy uterus on the iliac veins at the brim of the -pelvis. The urine should be examined for albumin and the patient put in -the horizontal position if the edema is troublesome. - -_Varicose veins_ of legs and vulva may cause much distress. The limbs -should be bound with flannel spirals or with rubber bandages in the -recumbent position, or elastic stockings may be obtained. Operation -during pregnancy is not to be considered. The vulva can only be relieved -by a double bandage, which is sewed at the point where it crosses the -vulva, and buckled or tied to a waistband above the hips, both before -and behind. This brings support to the vulva. If the veins rupture, the -part should be elevated and compressed with an aseptic pad. - -_Hæmorrhoids_ may either appear or grow worse late in pregnancy. If they -protrude, they should be replaced. Ointments and iced applications may -be used and the bowels kept loose. - -_Cramps_ may occur in the muscles of the legs, due sometimes to the -varicose veins and sometimes to pressure on the lumbosacral plexus. - -=Moles.=—Mole is the name given to an ovum which is destroyed by disease -of its coverings during the early months of gestation. Two kinds are -known, the blood mole (carneous mole, fleshy mole, or hæmatoma mole) and -the hydatidiform mole (vesicular mole). - -The blood mole results from progressive or recurrent slight hæmorrhages -during the first three months of pregnancy, but hæmorrhages insufficient -in quantity to produce an abortion. The blood forms a clot, which may be -retained for several months and become solidified. - -Hydatidiform mole is a disease of the young chorionic villi, -characterized by the growth of an immense number of irregular clusters -and chains of grape-like cysts from the very minute to bodies -four-fifths of an inch in diameter. The causation is unknown. - -Both forms occur in the first half of the pregnancy and are -characterized by undue enlargement of the uterus and hæmorrhagic -discharge. - -=Diseases of the Membranes.=—_Hydramnios_, or polyhydramnios, is the -name applied to the condition where an excess of liquor amnii is formed. -The amount normally present varies, but anything in excess of four pints -could be called hydramnios. Six gallons have been reported. Since the -source of the liquor amnii is not positively known, the etiology of -hydramnios must be equally obscure. - -It is occasionally associated with morbid conditions of the mother, such -as hepatic or cardiac dropsy, but more frequently with developmental -anomalies of the fœtus. - -Since the mother is usually healthy and the fœtus frequently deformed, -the theory is advanced that the disease is fœtal in origin. It -frequently occurs with twin pregnancies, and in the first months it is -most plausible that the liquor amnii is in some way derived from the -fœtus. - -The disease is more common in multiparas. It is generally slow in onset, -but it may be acute, and an immense amount of fluid may be formed in a -few weeks. - -_The symptoms_ are those due to pressure from the extremely large -uterus. - -_The treatment_, if interference with heart or lungs becomes pronounced, -is puncture of the membranes. The child need not be considered for it is -usually dead or deformed. - -_Oligohydramnios_ is the condition where the liquor amnii is deficient -in amount. It gives no maternal symptoms, but it is the cause of many -birthmarks and fœtal deformities (club-foot, spinal curvature, wry-neck, -ankylosis of joints). - -Amniotic adhesions are usually associated with oligohydranmios and cause -deformities by amputation of limbs, strangulation of cord, and -production of six fingers. - -=The placenta= may show anomalies of size and shape. Thus, there may be -two lobes, or three. There may be the main placenta and a small -out-lying mass connected by membrane and vessels with the larger -segment. The cord may be inserted in the middle or at the edge and -yellowish-white masses called infarcts may be found in its substance. - -Unusual size and weight of the placenta are suggestive of syphilis. - -=Abnormal conditions of the fœtus= may arise from primary or transmitted -disease or from errors of development. The developmental errors may be -monsters, _hydrocephalus spina bifida_, etc., which may not influence -the pregnancy. The most commonly transmitted disease is syphilis, which -may produce abortion, premature labor, or a child born with syphilitic -skin changes on palms and soles, as well as internally. - - - - - CHAPTER VI - ABNORMAL PREGNANCY (Cont’d) - - -=Extrauterine Pregnancy.=—This is a pregnancy which occurs outside the -uterus, and while the event usually happens in the tube, cases have been -reported where the egg developed in the ovary or abdomen. - -The ovum, owing to some delay in passage to the uterus, is fertilized -either in the ovary or in the tube, and by reason of a chronic -inflammation of the tube or pelvis, or of overgrowth does not succeed in -reaching the uterus at all. - -As the ovum develops, the tube expands, but it does not possess the -power of growing into a large organ like the uterus, hence a sudden jar, -a strain, or a blow may cause it to rupture and discharge the egg into -the abdomen (ruptured tubal pregnancy) or force it out through the end -of the tube (tubal abortion). - -This phenomenon may be accompanied by a severe or even fatal hæmorrhage; -or the prostration may pass off in a few days or weeks, and leave the -patient well. - -In the early stages the ovum is absorbed, but after the pregnancy -becomes more advanced, it may remain as a tumor, or require an operation -for its removal. - -Infection may occur and the mass ulcerate its way into neighboring -organs (rectum, vagina, or bladder) and discharge itself in a long, -suppurative process. - -Most cases of ectopic (extrauterine)gestation present definite and even -dangerous symptoms between the second and fourth month. The _symptoms_ -are those of pregnancy, together with irregular hæmorrhages from the -uterus, which may result in the expulsion of pieces of tissue or of -membrane. Besides this, there is a vomiting and acute irregular pain on -one side, associated with a sense of fullness. Such symptoms should be -brought to the attention of the physician, who will learn the true -condition of the pelvis by internal examination, conducted as gently as -possible so as not to produce rupture. - -If rupture occurs, it will be ushered in by a sharp lancinating pain on -one side, followed by faintness, nausea, vomiting, prostration, rapid -pulse, sighing respiration, and collapse. The temperature is subnormal -and death may occur in a few hours, unless an operation is done. - -[Illustration: Fig. 30.—Diagram representing the sites for the various -forms of tubal pregnancy. 1, interstitial pregnancy; 2, isthmial -pregnancy; 3, ampullar pregnancy; 4, infundibular pregnancy; 5, -tubo-ovarian pregnancy. (Gilliam.)] - -In cases of tubal abortion (where the ovum escapes through the end of -the tube) the symptoms are very similar, but the patient soon rallies -and gradual recovery takes place. - -If the diagnosis is made before rupture or abortion the _treatment_ is -laparotomy. If rupture occurs, the laparotomy must be done immediately -to check the hæmorrhage, which threatens the life of the patient. In -tubal abortion, if the diagnosis is certain, some delay may be permitted -under extreme watchfulness of the nurse and physician. In such case, the -nurse will keep the patient absolutely quiet and forbid exertion of any -kind. - -If operation is necessary, the utmost gentleness must be used in -preparing the abdomen. The tincture of iodine application to the site of -the incision is sufficient preparation, and, of course, an abundance of -sterile gauze, cotton, and towels should be supplied, as in every case -where laparotomy is done. - -If the rupture occurs while the nurse is present, the doctor should be -notified at once, and if not at home, another doctor should be summoned. -Meanwhile, the nurse prepares the room, solutions and utensils for an -abdominal operation. Immediate incision to check the hæmorrhage and -remove the mass offers the greatest safety. - -The after-care is the same as for any laparotomy, with the additional -duty of making up the lost blood as soon as possible by nourishing -foods, normal saline solution by rectum, and, if necessary, by -hypodermoclysis. - -=Acute fevers= are a serious complication of pregnancy on account of the -danger of abortion or premature labor, which may come on either from the -associated high temperature or from the transmission of the disease to -the ovum. - -The following diseases are known to affect the fœtus _in utero_: -cholera, yellow fever, small pox, scarlet fever, typhoid, measles, -erysipelas, meningitis and syphilis. - - - CHRONIC INFECTIONS - -=Tuberculosis= does not affect fertility or the course of the pregnancy, -but the progress of the disease is hastened, and the maternal death -accelerated. - -The question of artificial abortion in the early months must be -seriously considered, and if the case goes on to term, the child must -not be nursed or cared for by the mother. - -=Syphilis= is the most frequent systemic cause of the interruption of -pregnancy. It is a blood disease, due to an organism, called spirochæta -pallida, and it appears in three distinct stages. The first is the -primary stage, wherein a hard, nodular ulcer appears on some part of the -body, as the vulva, lips, gums, tonsils, or hand. It is _not always_ -venereal in origin. The second stage begins six or eight weeks after the -sore, and is marked by a general eruption of red spots, chronic sore -throat, falling hair, and rheumatic pains in the joints. The third stage -is the name given to the later conditions of the disease which affect -the bones, blood vessels, and nervous system. - -Infection of the ovum may usually be traced to the father, who may -transmit syphilis at any stage of the disease. In the third stage, the -child alone will be infected; the mother escapes. - -The mother may or may not transmit the disease, depending on the period -of pregnancy wherein her infection occurs. If she gets the disease at, -before, or just about, the time of conception, she will abort three -times out of four, and the ovum will show definite lesions. If infected -later, abortion occurs less frequently; and if the disease is contracted -late in pregnancy, the child may be born apparently free from infection. - -_Symptoms._—A child with congenital syphilis will show the eruption of -coppery spots, blisters on palms and soles, deep cracks on the feet, -snuffles, cracks and ulcers around the mouth and rectum, and the weakly, -marasmic condition of the body. - -The diagnosis in suspected cases can be rendered more certain by the -Wassermann reaction. This is a laboratory test of the blood which should -always be made before a wet nurse is allowed to nurse a child, or before -a suspected child is nursed by a clean woman. In all cases of -transfusion of blood, it is imperative. - -_Treatment._—Antisyphilitic treatment of an infected mother or child by -salvarsan, mercury, and potassium iodide must be carried out vigorously -in all cases. - -The syphilitic patient must be prevented from spreading the infection by -having dishes and utensils of her own, which are kept sterile. -Discharges are collected and burned, and the nurse in charge of these -cases must carefully cover her hands with rubber gloves, and see that -all cracks and fissures are properly protected from contact with sources -of infection. - -=Gonorrhœa= is an acute or chronic disease of the mucous membranes due -to a germ called the gonococcus. - -Beginning with a sharp inflammatory disturbance of the urethra or -vagina, it may pass slowly up through the genital passage and produce -chronic and permanent disabilities, such as sterility, pus tubes, and -pelvic peritonitis. - -_The symptoms_ are painful urination, painful inflammation of the -vagina, with a purulent discharge. During pregnancy all these symptoms -are intensified, and warty growths (condylomata) may appear on the -vulva. - -If infection occurs after pregnancy has begun, the course of the -gestation is rarely affected, as the uterus is closed to germ invasion. -During delivery, however, there is a serious danger of infection of -mouth or eyes of the child if they come in contact with the discharge. - -_Prophylaxis._—The eyes at birth must be immediately instilled with a -drop or two of 1 per cent solution of silver nitrate in water. This is -_not neutralized_ by normal saline. Great care must be used that the -discharge does not come in contact with the eyes of the mother or -attendants, lest infection follow. - -_Treatment._—Scrupulous cleanliness must be observed. Douches of -potassium permanganate, 1:5000, or painting the vagina with iodine or -solution of silver nitrate, or suppositories of argyrol or protargol -furnish the best means of treatment before labor. - -Neither syphilis nor gonorrhea is _necessarily_ caused by venereal -infection. They may be spread by barbers, dentists, physicians, and -nurses,—by anyone who is unclean; and may be acquired innocently -everywhere. - -These diseases should not be discussed by the nurse or physician except -with the patient. Certainly nothing from the sick room should be -repeated elsewhere. - -=The valves of the heart= are not uncommonly found to be diseased in -pregnancy, the mitral being the most often affected, either as an -insufficiency or as a stenosis (a narrowing of the mitral opening). -Mitral stenosis is the most serious of all heart complications of -pregnancy, and where this is present, a woman should be advised to avoid -conception. - -In other mitral lesions, many pregnancies may be successfully passed, if -compensation is maintained; but every one brings further damage to the -already weakened heart, and reduces its reserve of force. If the heart -breaks down early in pregnancy, and does not respond to medication, -abortion should be induced. In the second half of pregnancy, the mother -should be given the prior chance, but the child should be saved, if -possible. - -=Renal diseases=, such as nephritis, may not only induce abortion by -destroying the fœtus, but the kidney lesion may be greatly aggravated by -the pregnancy. The most careful observation of the patient’s condition, -the regular examination of the urine, and the scientific management of -the diet is necessary to relieve the work on the kidneys and keep the -patient in a moderate degree of health. - -It is the duty of the nurse to protect her patient against fatigue and -chill, and to see that the proper diet is followed; but other symptoms, -such as headache and disturbance of vision and developing edema, must be -noted and reported to the physician at once. - -=Diseases of Liver.=—Acute yellow atrophy is a rare condition, which, -for reasons unknown, is promoted by pregnancy. - -_The symptoms_ are intense headache and pain in the abdomen, possibly -accompanied by vomiting and purging, which are soon followed by coma. -There is generally a certain amount of jaundice. The urine is diminished -in amount and contains albumin, casts, and sometimes blood. There is no -known treatment, and the end is death. - -=Diabetes= is seldom found associated with pregnancy. Its presence is -unfavorable to conception and to gestation. Mother and child are both -less secure. Abortion or premature labor is the rule. - -=The hæmorrhages= of pregnancy in the first half generally mean -abortion, and in the last half, either placenta prævia or premature -detachment of the normally implanted placenta (see p. 228). - -=Abortion= is the expulsion of the ovum before the fœtus is viable, that -is, before it is capable of maintaining life after birth. This means the -twenty-eighth week, or the seventh month. Subsequent to the seventh -month, the interruption is called premature labor. Abortion is a -miniature labor, consisting of a stage of dilatation, a stage of -expulsion, and a stage of involution. - -The interruption of the pregnancy may occur spontaneously or be induced. -In spontaneous cases the causes may be sought in diseases of the ovum, -or in the mother, in injuries to the uterus or its contents, and such -systemic affections as syphilis, Bright’s disease, alcoholism, lead -poisoning, etc. - -Abortions happen about once in every five or six pregnancies, and more -frequently at the third month than at any other time. - -_The symptoms_ are hæmorrhage and pain. The _dangers_ are hæmorrhage and -infection. - -Infection is most common and most serious in abortions that are brought -about mechanically. - -Hæmorrhage, in some degree, is an invariable symptom, which has its -origin in the separation of the ovum from the uterine wall. Hæmorrhage -from the uterus is serious at whatever stage of pregnancy it appears. - -The duty of the nurse is to put the patient in a cool, dark room, on her -back, elevate the foot of the bed, put ice bags on the lower abdomen, -and summon the attending physician, with the hope that an abortion can -be averted. Bromides and opium are the drugs most to be relied upon. -Opium may be given in suppository, 1 grain night and morning. - -If the hæmorrhage is alarmingly profuse and the nurse is skillful and -clean, under exceptional circumstances she may pack the vagina with -sterile cotton while waiting for the doctor. Then the room should be set -for operation. - -=Dead Ovum.=—The ovum may be discharged in pieces or in a single -complete mass. - -The egg may die at any period of the pregnancy, and be discharged in a -few hours, or it may not be expelled for weeks, if at all. Fœtal death -in the uterus may have its cause on the paternal side in a father too -old or too young, or affected with such diseases as diabetes, nephritis, -tuberculosis, syphilis, or chronic lead poisoning; on the maternal side, -the same diseases, plus cancer, anæmia, insufficient food, and -inflammation of the uterus; on the part of the embryo, syphilis or any -transmitted or primary disease of the ovum. - -The results of retention of the dead ovum vary with the case. Infection -of the ovum is rare, except where the membranes have ruptured and an -open channel exists. No harm follows the death of the fœtus, except in -the presence of infections, all other changes are benign. The embryo in -the first and second months may be absorbed, but at later periods, it -becomes macerated petrified, or otherwise altered. - -Among the _signs_ of fœtal death are prolonged cessation of fœtal -movements after being definitely observed, chilliness, languor and -malaise of the mother, sense of weight in abdomen, and possibly a bad -taste in the mouth. Furthermore, the uterus does not correspond to the -period of pregnancy, and may have become smaller. Retrogressive changes -take place in the breasts. - -The diagnosis is only certain when the heart tones are persistently -absent, or the macerated head of the fœtus is felt through the partly -dilated os as a flabby bag of bones. - -_Treatment_ in noninfective cases is expectant. Spontaneous expulsion -will occur sooner or later and there is no necessitous indication for -interference. Local signs of putrefaction, however, make the immediate -emptying of the uterus necessary. - - - - - CHAPTER VII - PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR - - -=The Nurse.=—Scientific obstetric nursing is a specialty that enlists -the interest of exceptional women only. - -It demands a high sense of duty, a strong physique, broad training, -unusual judgment, and rare tact. The nurse must be professionally -aseptic and personally clean. She should keep herself free from odors, -and bathe at least three times a week. The presence of pus anywhere on -her body disqualifies her _at once_, and she should report off duty. - -The compensation should always be somewhat higher than for other work, -because there are two patients to be cared for. - -An obstetric nurse should specialize in her work, and not take -infectious cases. Unhappily the haphazard character of the onset of -labor presents a difficulty. The patient frequently can not afford to -have the nurse for a long time in advance of labor, and the nurse whose -income is limited by the number of her cases can not afford to be idle. -Hence, it is better for two nurses to work in alternation with one -another, so that one is always available in an emergency. - -Both doctor and nurse should visit the lying-in room before labor -begins, and plan its rearrangement. At least a week before the expected -confinement, the chamber selected should be thoroughly cleaned and the -woodwork wiped off. Curtains, draperies and bric-a-brac and all useless -furniture should be removed. Carpets must be taken up, or at time of -confinement, well protected. Rugs can be easily managed. A chair, a bed, -and the various tables for instruments and solutions are all that are -required. - -The nurse usually is called to the case first, and upon her falls the -responsibility of the diagnosis and the burden of the preparation. As -soon as she arrives and satisfies herself that the patient is really in -labor, she puts the final touches to the room. In her own mind she goes -over all possible emergencies and prepares to meet them. - -The following supplies should be in the house for the labor: - - 3 hand basins, 10 inches in diameter. - 3 hand brushes. - 1 two-quart douche bag. - 15 yards nonsterile gauze. - 2 lb. each of cotton batting and absorbent cotton for making bed - pads. - 2 pieces of rubber sheeting 1 by 2 yards. - 5–yd. jar of borated gauze. - 4 oz. lysol (or ziratol). - 100 c.c. of Squibb’s chloroform. - 2 oz. green soap. - 2 oz. solid albolene. - 8 oz. alcohol. - ½ oz. ergotol. - ½ oz. bismuth subnitrate and ½ oz. boric acid powder mixed. - 1 nail file. - -=Nurse’s outfit consists of the following:= Nail file, surgical -scissors, catheter (silver is best), hypodermic syringe with tablets of -morphine, strychnine, and digitalis; two fever thermometers, one for -mouth and one for rectum; a pair of tissue forceps and a razor. - -Some time before the labor, the nurse should call on the patient and -establish a working acquaintance. It adds greatly to her authority and -to the patient’s confidence in her. Her advice will be sought on a -multitude of subjects, partly real and partly to try her out. - -[Illustration: Fig. 31.—Abdominal binder with crosspiece to hold vulvar -pads.] - -[Illustration: Fig. 32.—T-binder, used in all cases after the fifth day -post partum.] - -=Sterilizing= may be done in a hospital, or, if this is not feasible, -the nurse should go to the house two or three weeks before the expected -labor and sterilize in an Arnold or Rochester sterilizer the following -articles: - - ½ doz. sheets. - 3 doz. towels. - 2 pillow slips. - 3 abdominal binders of unbleached cotton, 16 in. wide and 36 in. - long, folded and hemmed. - 4 T bandages. - 3 breast binders. - 2 jacket parts of pajama suits. - 3 pairs of long white stockings. - 3 packages of vulvar dressings (see Preparation of Supplies, p. - 326). - 2 obstetric pads 1 by 36 by 36 inches. - 1 pillow slip full of cotton pledgets for sponges. - 1 jar applicators (cotton twisted about toothpicks). - 1 jar of gauze pledgets for perineorrhaphy and cord dressings. - Everything must be neatly wrapped and labeled. - -[Illustration: Fig. 33.—Breast binder.] - -[Illustration: Fig. 34.—Baby’s dress with winged sleeves.] - -=Infant’s Outfit.=— - - 12 plain slips 27 inches long of dimity or nainsook (with winged - sleeves). - 3 long sleeve shirts, silk and wool (size No. 2). - 6 pinning blankets, made of outing flannel, if it is a winter - baby. - 3 bands, 6 by 18 inches, clip or notch edges, do not hem. - 3 petticoats, flannel bottoms and muslin waists, without sleeves - and with small button on shoulders. - 3 outing flannel wrappers. - 6 plain, soft muslin dresses. - 3 (Arnold) knitted night gowns, light weight. - 4 doz. light weight cotton diapers, 20 x 40 inches. Bird’s-eye - linen is the best. Wash and dry these in the air before using. - 4 soft towels (linen preferred). - 2 quilted pads. - 4 soft wash cloths. - 4 wool wrapping blankets. - 1 pair scales that weigh ounces and fractions thereof. - 4 oz. of olive oil or benzoated lard. - 4 oz. of alcohol (95 per cent). - ¼ lb. boric acid crystals. - ½ lb. absorbent cotton. - 1 cake of castile soap. - 2 oz. solid albolene. - ½ oz. subnitrate of bismuth powder and ½ oz. of powdered boric - acid mixed. - 1 bed pan. - 2 basins, holding 2 quarts each. - 1 papier mache, rubber, or enamel ware bathtub. - -=Anæsthetics.=—Excessive pain is destructive and disintegrating to the -vital forces. Many a woman who has passed through a particularly severe -labor remembers her experience with a horror that forever precludes its -repetition. - -This is the day of relative painlessness in labor, and all the world is -striving to make childbirth easier and less lethal. No woman, unless she -herself requests it, should be permitted to go through the agony of -labor without an anæsthetic, judiciously selected and carefully -administered. - -Pain-deadening agents are numerous and inexpensive, and it is only a -matter of experience and judgment to choose a method that will reduce -the suffering of childbirth to a minimum. The second and first stages of -labor, in the order named, demand the most in the way of relief. - -A prolonged first stage with nagging, violent and apparently useless -pains may devitalize the patient more than short, but acute pains of the -second stage. In the first stage, under proper selection of cases and -experienced supervision, “Twilight Sleep” will be successful in seventy -to eighty per cent of the cases. - -By success, is meant that the patient is relatively free from pain. When -the drugs do not relieve pain, the case is a failure (fifteen per cent), -although in no case, when properly given, is the mother or child -endangered. Morphine solution ⅙ gr. and scopolamine hydrobromid 1/200 -gr. to 1/150 gr. is the customary dosage for the first injection. -Another injection of 1/200 gr. is given in a half or three-quarters of -an hour. The room is darkened, talking is forbidden, and the family -exiled. The patient gets red in the face and very thirsty, the pulse is -rapid but full. She answers questions very slowly and drowsily, awakes -for her contraction but goes right off to sleep again. In this condition -she is kept through bi-hourly repetitions of the scopolamine until the -delivery. It is this half waking and half sleeping condition that -suggested the name of “Twilight Sleep.” - -Morphine and scopolamine will relieve the pains of the first stage -without greatly protracting the labor. The same drugs may and probably -will prolong the duration of the second stage. The first dose should be -given as soon as the patient is well started in labor. - -“Twilight Sleep” is at present a hospital procedure, and the technic so -exacting as to weary the attendants greatly. It can not be employed -until the woman has definitely gone into labor and is at least three -hours away from delivery. It is not serviceable where the pains are weak -and shallow; and it must be used with wise circumspection, if at all, in -the presence of complications. - -For the second stage, there is a choice of three drugs: gas, chloroform, -and ether. Like twilight sleep each is open to some objection, but each -may be of the greatest assistance if used under appropriate indications -and conditions. - -Gas has one advantage, in that it in no way interferes with the pain -activities; and Lynch and Davis have shown that with a proper admixture -of oxygen, it may be given with comparative safety for the two or three -hours which may mark a normal second stage. To administer it a competent -machine for mixing the gas is necessary. It should not be given to -patients who have bad hearts, high blood pressure, or toxæmia. Neither -is it a satisfactory anæsthetic when the head delivers, for the mother -being less relaxed and more rigid, the legs and muscle action are harder -to control and unnecessary perineal lacerations are liable to occur. The -patient is instructed to take several deep breaths just as the uterine -contraction comes on and the gas bags supply about 75 per cent nitrous -oxide and 25 per cent oxygen. As the pain passes off the oxygen is -increased and the nitrous oxide diminished until the mind is again -clear. - -To save the perineum and better to control the patient, when the head is -about to pass the vulva, it is wiser to abandon the gas for chloroform -or ether. - -Obstetrical operations, such as forceps and version, require ether or -chloroform, and not gas. The dangers vary with the anæsthetic chosen, as -well as the amount and the method of administration. Ether affects the -respiration, chloroform attacks the heart. Ether must not be given near -an open flame. Chloroform is not explosive but is decomposed by fire -into an irritating gas. Chloroform must be diluted with 90 per cent of -air, hence the mask must be open, or the napkin held free from the face, -so that plenty of air can enter. Ether and chloroform, when given “_a la -reine_;” i. e., a few drops on the mask at the beginning of each pain -and increased up to the acme, is relatively free from danger. They have -the additional advantage that the sleep may be instantly deepened if -operation is required. Chloroform, it is now believed, predisposes -mildly to post partum hæmorrhage. Davis has shown that neither ether, -gas, nor chloroform affects the child injuriously if the administration -is intermittent and not too greatly prolonged. - -To summarize: Morphine and scopolamine combined is a first stage -analgesic, which has too much value to be neglected. - -Gas, if an apparatus is to be had, may work well for the greater part of -the second stage, while for operations, or for the period of expulsion, -during which the head passes the perineum, chloroform and ether give -bests results. Moreover, chloroform “_a la reine_” may be given safely -and efficiently by a competent nurse and in many instances _must_ be -given by the nurse, if at all. - -When the perineum bulges, or the head becomes visible at the vulva, the -nurse should anoint the lips, cheeks and tip of the nose with cold cream -or olive oil, to avoid burning the skin, and lay two or three -thicknesses of handkerchief or gauze over the nose (an inhaler is best). -An abundance of room must be left underneath and at the sides of the -mask for air to enter. - -At the beginning of the pain a few drops of chloroform are poured on the -cloth and the patient instructed to breathe vigorously. The cloth is -removed as soon as the pain ceases and when the next contraction comes -on, the process is repeated. As the head passes the perineum, the -chloroform should be pushed to complete anæsthesia, both to save -suffering and to give the doctor full control of the perineum. When the -nurse gives the anæsthetic, she should watch the doctor for his signal -to increase the vapor or remove the mask. - -_Summary._—Cover the eyes with a wet towel and anoint the face with -cream or oil before using chloroform. Remove false teeth, if present. - -Obstetric degree—a few drops on mask at beginning of each pain. - -Surgical degree—complete anæsthesia. - -Watch pulse and respiration. - -A nurse should never leave a patient who has had an anæsthetic until she -is conscious. Vomiting is especially dangerous. - -=Normal Labor.=—Labor is the process by which a fœtus of viable age is -expelled from the uterus. - -By normal labor is meant a case where the fœtus presents by the vertex -and terminates naturally without artificial aid, or complications. It -varies greatly in severity, duration and danger to mother and child. A -first labor is more prolonged and difficult than later confinements. A -woman in her first delivery is called a primipara, in subsequent cases, -a multipara. - -The _date_ at which labor comes on is difficult to determine accurately. -The average duration of pregnancy is from 275 to 280 days, forty weeks, -or ten lunar months, but conception does not occur necessarily at the -time of coitus, nor is it possible to know with any certainty when it -does occur. - -Labor may occur two weeks earlier than calculated, with benefit to the -mother, and no harm to the child; but if the woman goes over time, the -child becomes much larger and the labor harder and more dangerous to -both. - -=Causes of Labor.=—Why labor should occur at all is not known. Many -theories have been advanced, none of which is entirely satisfactory. -Some of the best known are the growing irritability of the uterus -accompanied by an increase in the frequency and strength of the -intermittent uterine contractions or increasing distention of the -uterus. Thus it is believed that when the uterus is distended up to a -certain point, it will try to relieve itself like the bladder, or a -baby’s stomach. It may be that any one of the following factors, or all -of them acting together, are influential. - -Dilatation of the cervix by the presenting part. - -Increasing distention of the lower half of the uterus with pressure on -neighboring nerve structures. - -The circulation of fœtal products of metabolism (toxins) acting on the -nerve centers. - -The menstrual periodicity. - -Heredity and habit. - -Physical and emotional causes. - -The onset of labor probably is not purely accidental, and yet it is so -inconstant in appearance and so indifferently early or late, that it has -every appearance of being an affair of chance. The time when labor will -come on is highly speculative in general, but the phenomenon is preceded -by certain definite symptoms: - -The lightening. - -False pains. - -Show. - -Rupture of membranes. - -The pains. - -_Lightening._—About two weeks before labor, especially in a primipara, -the uterus and the head sometimes descend into the pelvis. The body of -the child falls forward and the abdomen protrudes, the stomach is -flatter, the patient breathes easier and feels, as she says, “lighter.” -But walking is more difficult, the bladder is stimulated to frequent -evacuations and the rectum is compressed. - -This occurrence is a premonitory sign of labor, and also favorable -inasmuch as it demonstrates that this particular head is not too large -to pass this particular pelvis. - -_False pains_ may appear, especially in multiparas, from two to four -weeks before labor. In some of these cases the pains may be due to gas -or indigestion and respond to hot applications and enemas, or there may -be definite uterine contractions, as shown by the hardness of that organ -during a pain, but the phenomena are irregular and therefore not typical -of labor pains. - -Usually they pass off in a few hours, but if the patient is nervous, the -doctor or nurse may be called needlessly. The patient, therefore, should -be instructed to have the pains timed by the watch for half an hour or -an hour. If they are regular during this period, the physician should be -notified. Upon his arrival, an internal examination will reveal the true -character of the disturbance by the condition of the cervix and os. - -_The show_ is a discharge of thick, white mucus, slightly stained with -blood. This is the mucus plug which occludes the cervix during pregnancy -and when the os begins to dilate, the mass is released and passes out. -Labor usually comes on vigorously within twelve hours. - -_The membranes_ may rupture before labor begins and much fluid escape. -The advantage of the dilating bag of water and lubricating qualities of -the liquor amnii are thus lost. Such a labor is called a “dry birth” and -is frequently slow, exhausting, and extremely painful. - -_The pains_ are the subjective manifestations of the powers of labor. -The forces concerned are uterine and abdominal muscles, principally -assisted by those of the back, legs, and arms. Their constricting action -on the nerve fibers in the walls of the uterus is the cause of the pains -in the first stage. The onset may be violent and go on to a quick -delivery, but generally the inception is more insidious. - -The _irregular_, _painless_ contractions, (of Braxton Hicks) that were -mentioned on an earlier page, gradually at term change their character -and become _regular_ and _painful_. - -At first they may be slight and vague, lasting only half a minute and -separated by intervals of ten or fifteen minutes and scarcely attract -the patient’s attention. They are felt chiefly in the abdomen. - -More or less rapidly they increase in frequency, severity and duration. -They last from a minute to a minute and a half and come every three -minutes. The whole uterus hardens and its outline is clearly defined -during the contraction; it relaxes and becomes soft in the interval. The -woman is now in labor. The pains become grinding and the patient feels -that she is not accomplishing anything, yet under the influence of these -contractions the cervix is effaced and the os is dilated. - -=The Course of Labor.=—Labor is divided for convenience into three -stages as follows: - -The _first stage_, from the beginning of pains until the complete -dilatation of the os. - -The _second stage_, from the complete dilatation of the os to the -delivery of the child. - -The _third stage_, from the delivery of the child to the expulsion of -the placenta. - -The _first stage_ is the stage of dilatation. - -Usually at term, the cervix is columnar and unshortened, the canal -intact, and closed at both ends, as shown in Fig. 36. - -In multiparas the outer opening will usually admit the tip of the -finger. - -As labor proceeds, the cervix is _effaced_, the os slowly dilates, and -the bag of waters forms. - -_The Bag of Waters._—When the cervix is effaced and only the os remains, -the lower end of the egg with its fluid restrained by the membranes, -bulges forward into the canal. The fœtal head, or breech presses into -the pelvis, and the fluid in the membranes, compressed between the -presenting part above and the cervix below, is called the bag of waters. - -When the contraction comes on the longitudinal muscular fibers of the -uterus are drawn upward and the bag of waters becomes tense and pushes -farther and farther down into the opening; and by its even and universal -pressure, mechanically and slowly increases the size of the opening -which the muscular traction is pulling apart. At the same time, the -fluid around the child prevents, for a time, direct and injurious -compression on the body. When no definite cervical projection can be -felt, and when the teat-like protrusion of the cervix has disappeared, -the cervix is said to be effaced. - -[Illustration: Fig. 35.—The bag of waters begins to act on the cervix. -(Eden.)] - -The os now begins to stretch and widen, the bag of waters becomes more -and more evident, vomiting occurs, and at last, when the os has expanded -to a diameter of four inches (ten centimeters), the membrane can -withstand the pressure no longer. It ruptures, a certain amount of fluid -escapes, the presenting part comes down against the opening, and like a -valve, prevents the outflow of the waters from above. - -[Illustration: Fig. 36.—The effect of the pains. The cervix before labor -begins. (Bumm.)] - -[Illustration: Fig. 37.—The effect of the pains. The cervix begins to be -“effaced.” (Bumm.)] - -[Illustration: Fig. 38.—The effect of the pains. The cervix is effaced, -and the dilatation of the os begins. (Bumm.)] - -[Illustration: Fig. 39.—The effect of the pains. The cervix is effaced, -and the os continues to dilate. (Bumm.)] - -Sometimes the labor may be preceded by some hours (two or three), or -days (two or three), even weeks (two or three), by the rupture of the -membrane, and sometimes when the structure is thick and tough, the -rupture may be delayed until well into the second stage, or even until -the child is born. In the latter case, the head comes out, covered with -membrane. In the old days, this was called being “born with a caul.” It -was supposed to be a lucky omen, but it was lucky only that the babe -escaped suffocation. The membrane should be torn open quickly. - -The duration of this stage is variable. It is much longer in primiparas -than multiparas. It averages sixteen hours in the former, and eight -hours in the latter. Vomiting during this stage is quite common, but the -pulse and temperature remain normal. The first stage of labor is usually -under the entire control of the nurse. It is her responsibility. - -With complete dilatation of the os, the _second stage_, or stage of -expulsion, begins, whether the membranes rupture or not. The presenting -part, usually the head, passes from the cervix into the vagina. The -vagina in turn gradually dilates from above downward until uterus, -cervix and vagina form a single, wide channel of the same diameter. The -child is driven forward by the uterine contractions, strongly reinforced -by the abdominal muscles, which the patient uses vigorously. The onset -of each pain is accompanied by a deep inspiration, followed by straining -or bearing down with the abdominal muscles as in a highly exaggerated -bowel movement. The patient holds her breath, braces her feet, fastens -her hands on bed or attendant, and uses all the trunk muscles in the -effort. The face becomes congested, the pulse quickened, she perspires -some, and groans deeply during the contraction. The pain is extreme and -is due partly to the stretching of the vagina and vulva and partly to -the distention of deeper sensitive structures. - -When the head reaches the pelvic floor, the first change observed in the -external genitals is the stretching (bulging) of the perineal body. -Next, the anus becomes turgid, dilates slightly, the anterior wall -becomes visible, and the hairy scalp of the child appears at the vulva. -The actual expulsion of the head in a primipara is accomplished by a -series of prolonged and severe contractions, accompanied by violent -straining. - -[Illustration: Fig. 40.—The cervix is effaced, and the os dilated. The -second stage begins. (Eden.)] - -[Illustration: Fig. 41.—Child in second stage of labor with bag of -waters unruptured and presenting at the vulva. (Braune, from Barbour.)] - -A short pause ensues, followed in two or three minutes by a return of -the pains, which expel first the shoulders and then the trunk. As the -body escapes it is followed by a rush of blood-stained liquor amnii. -This is the fluid that has been pent up in the uterus by the obstructing -body of the child. The second stage lasts about two hours in a primipara -and from fifteen minutes to one hour in a multipara. - -_The third stage_ is the delivery of the after-birth. The after-birth -sometimes called the secundines, consists of placenta, umbilical cord, -and membranes. - -[Illustration: Fig. 42.—The head passing over the perineum. (Bumm.)] - -After the expulsion of the fœtus, the uterus undergoes a sudden -diminution in size. It is about as large as the child’s head, and the -fundus lies near the level of the umbilicus. The contractions still -persist feebly, but they are practically painless, and the patient is -greatly relieved, possibly sleeping. - -In from ten to thirty minutes, the uterus becomes smaller, harder, more -globular in shape and more movable. The patient brings the voluntary -muscles of the abdomen strongly into action again. The nurse presents a -sterile basin and the physician sustains and slowly twists the membranes -free from their final attachment and out of the uterus. When the -placenta passes the vulva, a moderate sized blood clot follows it. - -[Illustration: Fig. 43.—Normal expulsion of the placenta like an -inverted umbrella according to Schultze. (Williams.)] - -The uterus is now much smaller, and hard and firm in consistency, but -for some hours the contractions are intermittent, and while this -continues, there is risk of hæmorrhage. - -_General Effects._—The mother’s pulse is quickened during the -contraction. The fœtal heart beats more slowly and feebly during a -contraction, but quickly recovers in the interval. - -The amount of blood lost during labor averages from ten to sixteen -ounces. The temperature may be elevated one or two degrees in a woman of -moderate physique, while one with a fragile body may present the signs -and symptoms of surgical shock. The chill, pallor, cold limbs and body, -rapid and feeble pulse with subnormal temperature, suggest to the nurse -at once the proper _treatment_. Heat, to all parts of the body, warm -covers and hot milk or coffee. If hæmorrhage is present and the uterus -relaxed, the nurse should immediately inject pituitrin (15 ♏︎) into the -deltoid muscle and notify her attending physician. - - - - - CHAPTER VIII - THE MECHANISM OF NORMAL LABOR - - -The powers of labor are primarily the uterine contractions strongly -aided by the muscles of the abdomen and diaphragm. Some assistance is -given by the fixation of the legs and arms and sometimes by gravity, -when a sitting or standing position is maintained. - -The resistances are the bony pelvis and its relatively soft coverings of -muscle and fascia. - -The problem is to get the awkwardly shaped passenger through the -curiously shaped passage. - -In the first, and a part of the second stage, the uterine contractions -do not act directly upon the body of the child, for the latter is -surrounded by a wall of liquor amnii. - -Pressure is transmitted by a fluid medium in all directions, hence, the -weak part of the wall, which is the cervix, must give way. While the -membranes remain intact, or when sufficient fluid is retained, no amount -of pressure can injure the fœtus. When the membranes rupture, the force -of the pains is exerted directly upon the child to drive it forward, and -prolonged pressure may produce injurious effects through compression of -fœtus, placenta, or cord. - -The progress of labor is registered usually by watching the advance of -the fœtal head. - -The relation of the head to the pelvic brim is of great importance, as -it travels much faster and easier in certain positions than in others. -The term “presentation” is used to designate that part of the child -which enters or tends to enter the pelvic inlet. - -The presentation is named from the part of the child which comes into -apposition with the brim. Thus, one speaks of a vertex presentation, or -a breech presentation, or a shoulder presentation. The presentation is -determined externally by palpation. - -The vertex presents in 96 per cent of all labors. With the vertex -presenting, the head may occupy any one of four positions. The term -“position” is used to explain the relation which the most distinctive -feature of the presenting part bears to the quadrants of the pelvic -inlet. Thus, the most distinctive feature or landmark of the vertex is -the occiput, which is the point of direction, and so again, the position -is the relation of the point of direction to the brim of the pelvis. The -_point of direction_ is the part that takes precedence in the process of -delivery. Thus, in all cases where the occiput is in advance, the -occiput is the point of direction and the position is called occipital. -Where the chin is in advance, it is mental (_mentum_ is Latin for chin.) -In breech cases, the sacrum is the point of direction. - -The pelvis is divided by the transverse and anteroposterior diameters -into four quadrants named respectively the left anterior, the right -anterior, and the right and left posterior. (See Fig. 1.) Thus, in a -vertex presentation the back of the child may be (and in 53 per cent is) -to the front and to the left. - -The occiput is the point of direction, and lies in relation to the -left anterior quadrant of the pelvis, and is spoken of as a -left-occipito-anterior position. Similarly a right-occipito-anterior -position is named, and right- and left-occipito-posterior positions. -These occur respectively in about 21 per cent, 14 per cent and 11 per -cent of the cases. (Eden.) - -In passing the pelvis, the fœtus not only follows the curved line of the -pelvic axis, but it describes a certain series of movements which alter -its relations to the pelvis. - -[Illustration: Fig. 44.—The child in left-occipito-anterior position. -(Lenoir and Tarnier.)] - -There are five of these movements: _flexion, descent, internal anterior -rotation, extension_, and _external restitution_. - -=Flexion.=—Flexion is usually present before labor begins. That is, the -head is bent down until the chin touches the breast. This may be -modified by various conditions, but so far as it becomes extended, the -mechanism is disturbed and the labor complicated, since large and less -favorable diameters are brought to delivery. - -[Illustration: Fig. 45.—The child in right-occipito-anterior position. -Shows the flexion of the head intensified at the beginning of labor. -(Eden.)] - -Flexion is increased by pressure against the pelvic brim as labor -begins. - -=Descent.=—As the driving force of the contractions becomes effective, -the head passes the inlet and descends to the pelvic floor. When the -large diameters of the head (biparietal) have passed the inlet, the head -is said to be engaged. - -[Illustration: Fig. 46 _A_.—The descent of the head in -right-occipito-anterior position. Seen from below. (Edgar.) Fig. 46 -_B_.—Side view.] - -[Illustration: Fig. 47.—Internal anterior rotation and extension of the -head in a left-occipito-anterior position. (American Text Book.)] - -=Internal Rotation.=—The head most frequently enters the brim with the -occiput to the left and anterior (obliquely) because it finds more room -and an easier passage; but upon passing this strait and entering the -roomy, true pelvis, the head must rotate so that the long diameter of -the head will conform to the long diameter of the pelvic outlet, which -lies in a direction just opposite to the long diameter of the inlet or -brim; hence, the occiput turns forward under the pubic arch. This -movement is due largely to the sloping pelvic floor and the necessity of -accommodation between the head and pelvis as the child is driven -forward. - -[Illustration: Fig. 48.—Extension. _A_, the chin leaves the chest; _B_, -extension in progress. (Eden.)] - -[Illustration: Fig. 49.—_A_, extension completed; _B_, expulsion. -(Eden.)] - -Rotation is much retarded or entirely stopped when the head is extended -instead of flexed or when it enters the inlet with the occiput posterior -instead of anterior. - -=Extension.=—After internal, anterior rotation, the head emerges at the -vulva, the occiput coming out first, then in succession the vertex, -forehead and face and chin. As the chin rolls out over the perineum, it -moves away from the chest wall—it becomes extended. - -=External Restitution.=—While the head is passing through the outlet, -the shoulders are entering the pelvic inlet, and so soon as the head is -released from the restraint of the vagina, it naturally falls into its -normal relation to the fœtal back; hence in the position now discussed, -it turns toward the left. - -Therefore, we may summarize the mechanism in a normal -left-occipito-anterior position of the head by saying: The head is -flexed and forced into the pelvis. It descends to the pelvic floor. The -occiput rotates to the front of the pelvis and impinges against the -symphysis. Extension ensues in consequence of the necessity for an -accommodation between the pelvis and the advancing head, and during this -extension, the head delivers over the perineum. External restitution -follows. - -=The Effect of Labor on the Fœtal Head.=—As the head passes through the -canal, it is _moulded_ by contact with the resistances. The degree of -moulding is proportionate to the pressure required to drive it through. -Thus, in a large head, or a relatively small pelvis, the moulding may be -extreme, and changes in the scalp are common. - -_Caput Succedaneum_.—Since all parts of the scalp are in contact with a -resistant wall, except in the center of the birth canal, an effusion of -serum takes place here, which is due to the obstruction of the venous -circulation. - -[Illustration: Fig. 50.—A cephalhæmatomata. Do not confuse with caput -succedaneum. (Bumm.)] - -Swelling occurs in the subcutaneous cellular tissue, and a tumor -forms—the caput succedaneum—which spontaneously disappears in -twenty-four or forty-eight hours. It is useful in confirming the -diagnosis of the position. - -=Cephalhæmatoma.=—Following labor a tumor is sometimes found upon the -head, which is often confused with a caput succedaneum. - -This tumor is caused by an effusion of blood beneath the periosteum or -the covering of the bone—usually a parietal bone. It is sometimes single -and sometimes double, and it varies in size from a filbert to a peach. -The swelling never extends across a suture. The effusion takes place -gradually, and may not appear for a day or so after birth. The cause is -unknown, for it occurs after normal and easy, as well as after -difficult, deliveries, and after breech, as well as vertex, cases. - -At first it fluctuates, then becomes hard, and in a few weeks or months -is gradually absorbed. If symptoms of cerebral pressure develop, it must -be remembered that hæmatoma may occur inside as well as outside the -cranium. - -No treatment is necessary. Puncture is inadvisable. In extremely rare -instances the tumor may suppurate and require incision. - - - - - CHAPTER IX - THE CARE OF THE PATIENT DURING NORMAL LABOR - - -Every case of labor must be conducted with the most scrupulous attention -to surgical cleanliness on the part of the patient, doctor and nurse. -Puerperal infection in most cases is due to the introduction of -disease-producing microbes into the wounded genital canal. To be sure, -the successful enforcement of surgical cleanliness is attained only in -good hospitals, but it can be approximated in a private house if the -patient insists upon delivery at home. - -A nurse or doctor who is clean of person, is most apt to have an -“aseptic conscience.” The possession of such a conscience may entail -financial sacrifices, but it has many compensations. Neither the nurse -nor the doctor is doing justice to the patient, nor to the profession, -who indiscriminately takes pus cases, contagious diseases, and -confinements. The public will soon learn that such a nurse and such a -doctor are unsafe attendants. - -How may the nurse know that the patient is in labor? This is the final -assumption that must be confirmed or refuted when the nurse is called to -her case. It is ascertained partly by the history and partly by the -conditions found. - -Thus, the patient may report the passage of a piece of blood-stained -mucus, and the nurse will observe that the contractions of the uterus -are regular, rhythmical and painful. She will observe that when the -patient complains of pain, the uterus gets hard. She will also observe -the definite regularity of the contractions by timing them. - -Under such conditions, the doctor should be called at once if the -symptoms develop between 7 A. M. and 11 P. M. If the pains begin in the -night, say from 11 P. M. to 7 A. M., the doctor need not be called -unless he has requested it, or, unless in the judgment of the nurse or -the anxiety of the patient, it is desirable for him to see her. - -[Illustration: Fig. 51.—Points of greatest intensity of fœtal heart -tones. _V_, vertex presentations; _B_, breech presentations. (Eden.)] - -When the doctor is notified he will want to know, and the well trained -nurse will be able to inform him, when the pains began, their strength, -duration and frequency. He will want to know whether or not the -membranes have ruptured. Many doctors also require, and a well trained -nurse who specializes in obstetrics should be able to say by external -examination, whether the head seems high or low, as well as the position -and frequency of the fœtal heart tones. - -In the hospital the following rules for summoning the resident physician -may be found useful: - - 1. For multipara, when pains are regular and five minutes apart. - - 2. For primipara, when pains are regular and two minutes apart, or - when head is visible if pains are less frequent. - - 3. If a precipitate is imminent, delivery must be delayed until - arrival of attending man by— - - (a) Turning patient on side with legs straight; - - (b) Instructing patient to breathe deeply or to cry out with mouth - wide open; then - - (c) Place sterile towel over vulva, and at time of pain prevent - expulsion by compressing the head by means of locking the hands - over a towel on the vulva. - -It is possible thus to delay delivery two hours, or until the doctor -arrives. _Do not permit a precipitate._ - -After the nurse has completed her preliminary observation, she starts -her history, notes the character of the pains, the pulse, temperature -and respiration. All unusual phenomena should be recorded; and after the -visit of her attending man, his examination, if any, and the conditions -found, are put down. Then she prepares the patient and sets up the room -for the delivery. - -=Preparation.=—As soon as the patient is known to be in labor, the -bowels are thoroughly cleansed with a soapsuds enema. A toilet jar -should be used and not the water closet. The bladder must be emptied at -the time of preparation and at frequent intervals throughout the labor. -As soon as the bowels and bladder are emptied, the patient is given a -bath and thoroughly soaped. The shower is preferred lest the water, -contaminated by bacteria from the skin and external genitals, should -enter and pollute the vagina. - -[Illustration: Fig. 52.—Handling forceps, kept sterile in a jar of -alcohol.] - -The hair should be braided in two braids. The vulva and perineum are -shaved. No patient will object to this when its importance as a feature -of protection against blood poisoning is explained to her. - -Scrub thighs, hips, and abdomen as far as the navel with soap and warm -water, then sterile water, followed by a 2 per cent solution of lysol. -Care must be taken to remove the smegma and dried secretions from the -folds of the vulva. Put on a fresh pad, a clean gown, and long -stockings. A loose wrapper over all permits the patient to move about. -(See Chapter XXIII.) - -Guests are forbidden, and the immediate family is kept at a distance—if -possible. - -An air of buoyancy, composure, and competence should prevail in the sick -room, and the patient should be cheered and encouraged in every possible -way. - -During the first stage, the patient may be up and about, as this diverts -the mind. She may assist in the arrangement of the room which should -always be the best room in the house. It should be well warmed and close -to the bathroom. All unnecessary furniture and hangings should be -removed, as previously described. After the room has been put in order, -the bed is made. - -=Making the Bed.=—Put mattress pad over mattress and cover with rubber -sheet or oil cloth, and spread a sheet over all. Then a smaller rubber -sheet is put on, extending from under the pillows to a couple of feet -from the foot. A plain muslin sheet goes over the rubber, then the -delivery pad. - -When the bed is ready, a small table or stand should be placed near the -head, on which is put the anæsthetic, the mask and the oil or cold -cream. The patient may be lightly covered with a sheet or a sheet and -blanket. - -During the first stage, light and easily digested food and drinks may be -served, either cold or hot, as the patient prefers. - -When the doctor arrives he may want to examine the patient either -externally or internally, or both. So a sheet is thrown across the lower -part of the body and the night-dress pulled up as far as the breasts. - -=For the external examination= the doctor washes his hands in warm water -and green soap and scrubs with the nail brush for five minutes. This -period should be prolonged to fifteen minutes, if, by any mischance, the -hands have been in contact with pus or infectious material. It is -extremely difficult to get them even approximately clean after such an -experience. - -[Illustration: Fig. 53.—Palpation. What is in the pelvis? (Eden.)] - -He now palpates the abdomen, notes the location of the head and back, -finds and counts the heart tones, measures the pelvis and child, -estimates the descent of the head and the character of the pains. - -[Illustration: Fig. 54.—Palpation. What is in the fundus? (Eden.)] - -If he thinks an internal examination is necessary, he will now return to -the bathroom, pare and clean his nails, scrub hands and arms to elbows -for ten minutes in running water with green soap and a sterile brush, -soak the hands in lysol solution 0.5 per cent for five minutes. -Bichloride of mercury solutions have no place in obstetrics. They ruin -instruments and hands, and are valueless for asepsis since the mercury -unites with the albumin of the mucoid discharges and forms an albuminate -of mercury, which is inert. The bichloride solutions also are -nonlubricating, harsh and astringent, as well as poisonous, as soon as -the mucoid protection has been removed. When the doctor takes his hands -from the lysol solution, they should be wiped on a sterile towel. A -sterile gown is put on, if possible. If it is not available, he should -be careful not to touch anything that may destroy or contaminate his -preparation. The hands are powdered and sterile rubber gloves pulled on -(one will do.). - -[Illustration: Fig. 55.—Palpation. Where is the back? Where are the -small parts? (Eden.)] - -The nurse, meanwhile, has wrapped the legs of the patient in the ends of -a sterile sheet, the bulk of which covers the abdomen. The knees are -spread apart. The vulva cleansed with pledgets of cotton soaked in lysol -solution. One or two pledgets are used on either side of the vulva and -the same number for cleansing the introitus. - -The fingers are now introduced. - -The internal examination may be conveniently postponed until the waters -break, or it may be omitted altogether if the heart tones of the child -remain good, the labor progressive, and the head continually advances -into the pelvis, as determined by the external examination. The great -advantage of an internal examination at this time is the diagnosis of -the degree of dilatation and the assurance that the cord has not been -washed down into the vagina by the rush of fluid. - -If the first stage is prolonged, the nurse should try to get the patient -to rest, and she should herself snatch a few moments of repose if -possible. - -[Illustration: Fig. 56.—Patient draped for internal examination. -(Williams.)] - -The condition of the os and the character of the pains may make the -doctor feel safe in leaving the house, but his whereabouts and telephone -number should be ascertained and the exact time of his return. - -=Second Stage.=—During this stage, the patient should go to bed and the -doctor should remain nearby. The nurse may observe the vulva at -intervals and note bulging, if present, or she may press a finger -against the soft parts outside the labia and see if the hard resistant -head has come into the outlet. - -The pains are severe and all accessory muscles are called into action. -Partial anæsthesia should be maintained in most cases, which should -merge into complete narcosis as the head passes the vulva. The nurse may -have to administer this. - -When this stage begins, or is well under way, the patient should be -prepared. A _sterile pad_ should be placed under her, then a _sterile -bed pan_. The nurse having prepared her hands and arms as previously -directed for the doctor, scrubs abdomen, legs, and vulva with green soap -and warm water, followed by lysol solution 0.5 per cent and a rinsing -with sterile water. The cleansing of the patient should take about ten -minutes. Cover with a sterile towel and put on the sterile linen. - -If in the hospital, the drums have been packed for sterilization so that -when they are opened each article will appear in the order of its need: - - _No. 1._ (Beginning at the bottom.) A receiving blanket, which has - a ticket, marked with the weight of the blanket, attached to - it. - 1 abdominal binder with pad holder attached. - 1 pillow slip folded half way back. - 1 gown for patient. - 2 surgeon’s gowns. - 3 sheets. - 1 pair surgical stockings folded half way. - 1 surgeon’s gown for nurse. - _No. 2_ contains cotton pledgets. - _No. 3_ contains strips of gauze and combination pads. - -=Application of Sterile Linen—Normal Case.=—Sterile linen is to be -applied as follows, by a clean nurse; - - 1. Lay sheet across foot of bed and half way up. - - 2. Put surgical stocking on one foot and draw sheet up for foot to - rest upon. - - 3. Second foot as above. - - 4. Lay sterile sheet across bed under patient, letting ends hang. - - 5. Lay sterile sheet over abdomen of patient. - -In many hospitals the sterile stockings and protective sheet are all -made in one piece, which greatly simplifies the application of the -linen. - -As soon as the second stage begins, the packet containing the -perineorrhaphy and cord set, carefully sterilized, is brought out and -placed in convenient reach of the doctor. - -This set contains— - - 8 in. forceps. - 2 scissors curved on the flat. - 1 dissecting forceps. - 1 duck bill speculum. - 1 needle holder. - 1 metal catheter. - 8 gauze sponges. - 1 medicine dropper. - 1 cord clamp, or - 2 cord tapes. - 2 case numbers, attached. - 12 needles, 4 round, 4 half-curved cervix needles, and 4 skin - needles. - -This is the stage of expulsion and the patient may want to pull or push -on something to aid the straining effort. Unless the nurse needs time to -set up the room or to get the doctor, this tendency may be encouraged. - -A sterile sheet may be attached to the foot of the bed and the ends -(corners) given into the patient’s hands as a knot or loop to pull on, -or she may push upward against the head of the bed. Under no -circumstances must she be permitted to touch or contaminate the clean -linen in her movements, either consciously or unconsciously. The hands -should be restrained, if necessary, to avoid this. - -The face may be sponged and a cold towel laid across the eyes. Rubbing -of the back and legs will bring great comfort, and cramps of the limbs -may be removed by straightening the legs and rubbing the muscles -underneath. Everything is now ready for the delivery. If the husband -insists upon being in the room, he should take off his coat and vest and -wear a gown, or if the labor is in the home, drop a clean night robe -over his clothes. - -The prepared room will show at close hand-reach, the basins of -solutions, the pledgets of cotton, tape or clamp for cord, scissors, -nitrate of silver solution (1 per cent) for the eyes, with dropper, the -sterile douche can in readiness for hæmorrhage and a large reserve of -supplies. Whatever anæsthetic has been chosen for the second stage, is -now administered. Throughout this stage, the heart tones of the child -must be watched, as well as those of the mother, for intra-partum death -may occur at any moment. - -A second examination may be desirable now to confirm the diagnosis and -to secure an estimate of the advance. As a rule, the examinations should -be as few as possible on account of the danger of infection. - -This is the period of greatest responsibility for the doctor whose duty -it is to watch and, if necessary, to restrain the advance of the head in -order to protect the perineum from rupture. - -This may be done at times most successfully, or in the case of too few -assistants, most desirably, by _delivery on the side_. To secure this, -as the head becomes more and more visible, the woman is turned upon her -left side; a pillow rolled tightly and pinned in a sterile covering is -placed between the knees, and a sheet flung across the body. - -[Illustration: Fig. 57.—Delivery in side position. The hands should be -gloved and the upper leg raised on a hard cushion or pillow. (American -Text Book.)] - -The hips must be brought to the edge of the bed while the chest and head -are pulled over to the other edge of the bed, leaving the legs just -enough space to double up along the side of the bed parallel with its -long axis. - -The doctor may now sit on the edge of the bed, or on a high stool at the -back of the patient and facing the buttocks. This is a most convenient -and easily managed position. - -As the head is born, the fæcal matter, blood and discharges must be -sponged away, and the field kept clean, with the whole perineum visible. -Always sponge from vagina toward rectum and throw away the sponge. -Should the hand touch nonsterile things or septic material, like fæces, -the glove must be changed. The _hands must be kept surgically clean_. - -It is a part of the nurse’s duty tactfully to warn the doctor when such -a thing occurs, as it may happen accidentally while his attention is -concentrated elsewhere, and a conscientious man will be grateful for the -information. As the head passes the perineum the anæsthesia should be -deepened. - -As soon as the head is born and the first respiration established (see -Asphyxia, p. 278), the cord is cut and clamped. There is rarely any -necessity for haste in this maneuver. The eyes are treated, and if in a -hospital, a numbered tape is tied about the wrist and a tape with a -corresponding number about the mother’s wrist. - -The baby is now placed in the receiving blanket on its right side, with -artificial warmth at its back and feet. The head must be lower than the -body so any retained mucus can drain out of nose and mouth. Meanwhile, -the doctor (or nurse) keeps a hand on the fundus of the uterus to watch -its contraction, see that it does not balloon up, and massage it -occasionally if necessary while he awaits the onset of the third stage. - -=Third Stage.=—The patient is turned upon her back as soon as the child -is delivered. The pulse and face must be watched for signs of -hæmorrhage. While waiting for the placenta, the perineum is examined to -note the degree of laceration, if any. To do this, the vulva must be -spread apart with clean fingers so as to bring the posterior wall into -view, and the discharge is sponged away with cotton pledgets taken from -the lysol solution and squeezed dry. - -The patient may now have the saturated dressings removed and clean, dry -ones substituted. The new pads catch the oozing blood and give an -estimate of its amount. - -At this time, if desirable, the perineum can be repaired. The woman is -partly unconscious, the tissues numbed, and the needle hurts much less -than it will later. Nevertheless, anæsthesia may be required. - -In a period varying from a few minutes to an hour, the hand on the -uterus will note a hardening, the mass will become smaller, more -globular, and rise slightly in the abdomen. A gush of blood appears at -the vulva and usually the placenta follows. If it does not, or if -hæmorrhage or the condition of the mother requires it earlier, the -uterus may be compressed (see Credé expression) and the placenta -constrained to deliver. - -The nurse holds a sterile basin for its reception. As the mass drops -into the pan, the membranes drag after and it should be gently twisted, -or the loose portions drawn upon until the end slips out. The placenta -is set aside for examination, and ergot or pituitrin may be given to -enforce the uterine contraction. The process of expulsion is generally -assisted by a strong voluntary contraction of the abdominal muscles. - -After a short rest, the blood is washed off the genitals, clean linen -and clean pads applied, and the abdominal binder or girdle is put on to -hold the pads. Warm blankets are thrown over the patient and within an -hour, a glass of hot milk is administered. - -The legs should be kept together, and in case of hæmorrhage, the feet -crossed. - -The placenta is now inspected and not only its completeness or -incompleteness noted, but anomalies of every kind should be looked for. - - - IMMEDIATELY AFTER LABOR - -Perineorrhaphy must be done if required. - -A lacerated cervix is _not_ to be repaired at this time, except in case -of hæmorrhage, for the tissues are greatly swollen, and if sutures are -put in tight enough to allow for sufficient shrinkage, they will cut -through; while if not tight, they will be useless in twenty-four hours. - - -=Care of Mother=.— - - 1. Cleanse genitals with lysol solution 0.5 per cent from above - downward. - - 2. Put on sterile pad, with pad holder and binder. - - 3. Wash face and hands. - - 4. Take temperature, pulse, and respiration. - - 5. Glass of hot milk. - - 6. Keep on back four hours. Watch uterus for hæmorrhage and keep firm - by occasional massage. - - 7. Put tape with case number on arm. - - -=Care of Child=.— - - 1. Clamp for the cord. - - 2. Place on right side with head lower than breech. - - 3. Keep warm and watch for cord hæmorrhage. - - 4. Treat eyes with silver nitrate solution 1 per cent, or argyrol - solution, 15 per cent. Do not neutralize the 1 per cent silver - nitrate solution. - - 5. Put tape with case number corresponding to mother’s on arm. - -To preserve the perineum from rupture is an important duty, and in a -definite percentage of cases, unsuccessful. Nevertheless, it is a duty, -which, in the absence of the doctor, may fall upon the nurse. How shall -she meet it? - -The greatest danger to the perineum comes from a too rapid advance of -the head; hence, the nurse retards the delivery by putting the woman on -her side where she can not bear down so successfully, and instructs her -to cry out with her pains. She may also delay the labor by holding the -head back with a clean pad until the vulva stretches to its fullest -capacity. - -The rules which the doctor follows in protecting the perineum as the -head advances, may be thus summarized. - - 1. Deliver the patient on her side. - - 2. Maintain flexion of head. - - 3. Delay extension of the head. - - 4. Give chloroform to retard delivery and to prevent precipitate - delivery. - - 5. Deliver between pains, if possible, by Ritgen’s maneuver - (modified). - - 6. Do episiotomy, if necessary. - -=Perineorrhaphy.=—Lacerations of the perineum occur in about 30 per cent -of all primiparas and in from 10 to 15 per cent of multiparas. They -occur when the child is large or too rapidly delivered, and when the -orifice is small or the tissues inelastic. - -For convenience, the lacerations of the perineum are divided for -description into three degrees. - -The _first degree_ involves only the fourchette and a small portion of -the mucosa. It is rarely more than one-half an inch in depth and -requires no attention except cleanliness by the nurse. - -The _second degree_ may tear a variable distance into the perineal body, -sometimes so deeply as to expose the sphincter ani. It is usually on one -side, but may appear on both sides, and be accompanied by prolongations -into the vagina. - -The _third degree_ passes through the sphincter and sometimes well up -the rectal wall. This is also called a complete tear. - -The lacerations of the perineum which require sutures should be attended -to _at once_ unless the patient’s condition is critical. In such cases -the repair may wait from twelve to twenty-four hours. - -For this operation the nurse will assemble and boil for fifteen minutes: - - 2 pairs of scissors. - 2 tissue forceps, one with teeth and one without. - 1 bull-dog forceps. - 3 artery forceps. - 6 needles, 3 full and 3 half-curved. - 1 dressing forceps. - 1 needle holder. - -Suture material of catgut and silkworm gut should be ready in sterile -containers. The catgut should be the twenty-day chromicized, No. 3 and -4. Even then the strands are quickly absorbed when the lochial -secretions flow over them. - -Silkworm gut is better, but hard to remove from the vagina; hence it is -customary to use catgut inside the vagina and silkworm gut for the -sutures outside. - -The nurse renews the supplies of gauze and cotton sponges. Hot solutions -are prepared, and the patient brought into a position on table or -_across the bed_ so that the best light may be had. The legs may be held -by the husband or nurse, or both. If help is inadequate, a sheet sling -can be utilized. This is made by twisting the sheet from corner to -corner and passing it rope-like over the shoulders, and back of the -neck. Then each end is tied above the patient’s knee on either side as -the legs are flexed in an exaggerated lithotomy position. - -The sutures are now introduced and tied loosely from below upward and -from within outward. If tied too tightly, they will cut through. The -success of the operation depends on two things: the care with which the -levator ani, if torn, is found and restored; and the scrupulous -cleanliness obtained by the nurse in her after-care. If the stitches -become sore, a few drops of sterile glycerine should be applied with an -applicator. - -[Illustration: Fig. 58.—Sheet twisted into a sling. The patient lies on -the unrolled portion. The rolled cords bearing against the shoulders are -tied to the legs below the knees. See Fig. 102. (American Text Book.)] - -If catgut is used inside the vagina, the counting of the stitches is -gratuitous, since they absorb without removal. If silkworm gut is used, -the number of sutures must be recorded, lest one be overlooked in -removal. - -Binding the legs together after repair is not required, but the sutures -must be given aseptic care after each bowel movement, each urination, -and when the pads are changed, if they have become contaminated. The -sutures are removed on the tenth day. - -[Illustration: Fig. 59.—Repair of perineum. Sutures in place. -(Hammerschlag.)] - -After _complete tears_, the bowels are kept constipated for two or three -days, and then moved with a high enema of sweet oil, followed by castor -oil by mouth. After the bowel movement, the nurse should wash out the -rectum with normal saline solution. The nurse must look carefully at the -stitches every time the pad is changed and note if the swelling is -increasing or diminishing, if there is irritation or tenderness, or if -they are cutting out through the tissues. - -The external sutures are usually left long and tied together in a knot, -to prevent the ends from sticking into the patient. If she complains of -this, the ends may be wrapped in sterile gauze. During the progress of -the case the nurse must watch for and report any sign of fluid passing -from bowel through the vagina. - -The perineorrhaphy being completed, the woman is permitted to rest -though the nurse will make frequent examinations of pulse and -respiration. She will note the look of the face and the hardness of the -uterus. The pad should be watched and the amount of blood discharged, -duly estimated. If the flow does not diminish or if the uterus should -balloon up, the doctor should be notified and the nurse meanwhile should -give a dram of ergot (fluid extract) by mouth or an ampoule of aseptic -ergot hypodermically. - -The doctor should remain within call of the patient for at least an hour -after delivery. - -In the hospital the following rules may be used as a concise guide for -the conduct of the third stage: - - - CONDUCT OF THIRD STAGE. - - Keep patient on back and keep a hand on fundus. Note amount of blood - lost, its character, its flow, and whether steady or in gushes. - The placenta should detach itself normally in thirty minutes. - After thirty minutes, expulsion may be assisted by— - - (1) Early expression. - - (a) Massage, rub and knead the uterus, until it hardens under the - hand. - - (b) Seize contracted uterus by fundus with full hand, fingers - behind and thumb in front. - - (c) Push slowly but firmly toward the pelvic outlet. - - - (2) Credé expression. - - Same maneuver as above, except that the fundus is compressed - between thumb and fingers while the downward movement is - progressing. - - - Conditions for Credé expression: - - (a) Uterus must be contracted. - - (b) Uterus must be in median line. - - (c) Bladder must be empty. - - - If not successful, wait ten minutes and then repeat maneuver. _Never_ - make traction on the cord. _Never_ use ergot until uterus is - empty. - - If placenta does not come away within an hour, manual removal must be - considered. In case of hæmorrhage, it must be removed at once. - - Carefully inspect placenta and be sure it is complete. (See Post - Partum Hæmorrhage, p. 232.) - - When the patient is put to bed, the bloody sheets and towels are put - to soak in cold water, and after several rinsings, may be sent to - the laundry. Drapings stained with fæcal matter must be cleansed - separately. - - - - - CHAPTER X - THE NORMAL PUERPERIUM - - -The puerperium is the name given to the period succeeding the birth of -the child as far as the time of the complete restoration of the -genitals. It may last from six to ten weeks, or even longer if -complicated. - -When the labor is completed, the most urgent desire of the patient is -for rest. She is thoroughly exhausted in nerves and body. A post partum -chill may appear,—a slight shiver that may last a quarter of an hour. -Since the pulse and temperature remain unaffected, this phenomenon may -be regarded merely as a sign of prostration or nervous revulsion. - -In the course of the first three days, the _temperature_ may rise to -100° F. in a case entirely normal. It has no pathological significance -unless persistent or increasing. The temperature should be taken night -and morning, and in complicated cases every four hours. All temperatures -over 100° F., after the initial rise and descent just described, must be -regarded as septic. - -The _pulse_ does not rise with the temperature of the first three days, -but remains firm or even falls a little. When the pulse rises and the -temperature sinks, it means hæmorrhage. - -The _urine_ is usually increased for the first few days and then returns -to the normal for that patient. The labor affects the patient like a -surgical operation. - -The _digestion_ is disturbed. The appetite is gone, and the stomach must -be treated gently until its tone is restored. The body in repose is less -urgent in its demands for food. Liquids in abundance form the staple -diet for the first two days. For the next three days, semisolids may be -added, and after the milk is well established, a general diet is -desirable; but so long as the mother nurses her child, the liquids must -preponderate in most cases. - -[Illustration: Fig. 60.—The progress of involution on the various days -of the puerperium. (von Winchkel, from Knapp.)] - -Meanwhile, certain changes are taking place in the pelvis that are -highly important. - -=Involution= is the process undergone by the uterus in returning to its -normal nonpregnant state. This shrinkage can be followed abdominally and -is registered by the nurse in the number of finger-breadths or -centimeters above the symphysis pubis. - -Edgar gives the rate of shrinkage as follows: - - After delivery, 5.92 in. long, or 15.8 cm. - 2nd day, 4.63 in. long, or 11.30 cm. - 3rd day, 4.37 in. long, or 11.10 cm. - 6th day, 3.42 in. long, or 8.48 cm. - 8th day, 2.55 in. long, or 6.40 cm. - 10th day, 2.22 in. long, or 5.60 cm. - -The rate of involution not only varies greatly with different women, but -varies much after the different labors of the same woman. - -Ordinarily at the end of the first week the fundus should lie midway -between the navel and the pubes, and should shrink rapidly thereafter. - -The necessity for watching the rate of involution is imperative for a -number of reasons. If involution is slow, or stops, it may indicate -fatigue of the muscle from multiparity or over-distention (twins, -hydramnios, etc.) or it may follow a post partum hæmorrhage. -Subinvolution may also indicate infection, the retention of clots, or -pieces of placenta. It happens also when the woman gets up too soon or -does not nurse her child and thereby delays the restoration of her -waistline, as well as diminishes her resistance to disease. - -=The binder= is objectionable to some doctors on the ground that it -favors retroversion of the uterus during involution. - -This would be a plausible theory when the uterus is high, if it were not -that the vertebræ of the patient and the pelvic brim keeps the uterus -from being pushed out of its place and after the uterus descends into -the pelvis the gentle pressure of the binder evenly distributed over the -abdomen can not affect it appreciably. Furthermore, the uterus in -involution shows a persistent tendency toward anteflexion and -anteversion. - -The binder is merely a girdle put on just tight enough to hold in place -the bandage that supports the perineal pads and to allow the patient -more easily to grow accustomed to the sudden change in intraabdominal -pressure which the delivery of the child creates. However, if the doctor -objects to a binder, it may be left off with safety. - -=The Lochia.=—When the placenta is delivered, the uterus normally closes -down and all gross hæmorrhages cease; but for the next two weeks or -possibly longer, a vaginal discharge continues. For the first few days -it is hæmorrhagic in character and it is called lochia rubra, and -consists mostly of fluid blood with occasional small clots. By the -fourth day, usually it has become brown and thinner. It is now called -lochia serosa. By the tenth day, it is yellowish-white, and is called -lochia alba. - -The lochia is the wastage from the shrinking uterus, and is made up of -red blood corpuscles, epithelial cells, leucocytes, and pieces of -broken-down deciduæ. The entire lining of the uterus is loosened, -discharged and a new one formed during the puerperium. The lochia is -regularly infected by bacteria in the vagina. If involution is slow, the -lochial discharge may be prolonged. - -=The After-Pains.=—The puerperium is not infrequently accompanied by -painful contractions of the uterus called after-pains. These are more -common in multiparas and serve a useful purpose in maintaining a -definite contraction of the uterus. - -If the pains are at all severe, they are a suggestive symptom of the -retention of blood clots, a fragment of placenta, or of membrane. This, -of course, will occur either in a primipara or multipara. In all cases -the after-pains must be differentiated from gas and from the pains of -pelvic inflammation. - -Gas pains can be relieved by hot spiced drinks, asafœtida and the high -rectal tube. - -=Subinvolution= is treated by the administration of fluid extract of -ergot, in twenty to twenty-five drop doses, three or four times daily. -This will bring about the discharge of the irritating fragment or clot, -and the nurse can aid the process by gently massaging the uterus several -times daily or by giving a hot vaginal douche. Codeine may be used for -after-pains if absolutely necessary. - -=Diet in Normal Cases.=—There is no restriction on the kind of food the -patient may take, so long as she can digest it cleanly and without gas. -Acids or alkalies, cold or hot, rich or otherwise, fruits, meats or -vegetables, all go to the formation of good milk if properly digested. -The old idea that acids should not be eaten is fallacious. There is more -acid in the stomach normally, than could be added in a meal made up -entirely of citrus fruits. At the same time, the heavy foods should be -avoided on account of the serious demand on the liver and kidneys in the -absence of exercise. - -On the other hand, if the breasts are engorged, the fluids must be -reduced to a minimum, and a relatively dry diet enforced. - -The patient loses about one-ninth of her previous body weight in the -course of labor and the puerperium. - -=The breasts= are made ready for lactation twelve hours after delivery -by cleansing with sterile green soap and warm water and bathing in 50 -per cent alcohol. Next, the nipple is attended to, and the infant is put -to the breast. - -The nipple is prepared by cleansing it with an applicator soaked in -fresh boric acid solution, and after nursing, the same process is -repeated. This is routine, whether the mother is in bed or walking -about. In the latter case, the mother must be taught to care for her own -breasts. - -The child is put to the breast every three hours and given six feedings -a day. This leaves a six hour interval at night, which is very necessary -for the mother’s rest and for the child. If the babe is feeble, seven or -eight feedings in the twenty-four hours may be required for the first -two weeks. - -At first the breast only secretes a thick, yellowish secretion called -colostrum, of which the child gets from a drachm to an ounce. It is a -mild laxative. - -The irritation of the nipple by the child’s mouth is begun as early as -possible in order to stimulate the breasts to secrete milk and the -uterus to contract, and thus aid involution and the preservation of the -maternal figure. - -The milk usually “comes in” on the third day and is accompanied by a -sense of distention and moderate pains in the breasts. The glands may be -hot, hard and swollen, but normally there is no rise of temperature with -the inflow of the milk, except with nervous women who stand pain badly. -There is no such thing as milk fever. If fever appears at this time, an -infection must be suspected. - -The engorgement of the glands may become so great that the nipples are -drawn in and nothing is left for the child to grasp. If the engorgement -becomes too painful, fluids are removed from the diet list, and saline -cathartics administered, while ice packs are applied to both breasts. -Heat should never be used _except_ for the purpose of hastening -suppuration. - -This engorgement, or so-called “caking” of the breasts is not due to the -milk, but to the infiltration of the connective tissue around the glands -with serum and blood which stimulate the glands to secrete. The -distention usually disappears in twenty-four or forty-eight hours, -especially if the child is sturdy. Massage of the breasts only increases -their activity and tends to make the trouble worse. - -The weight of the glands may be considerable and require the application -of a light supporting breast binder. Pillows under them will also give -relief at times. - -In putting the child to breast, the mother should lie on the side with -the arm raised and the child is dropped into the hollow thus created, -facing the mother (see Fig. 113). In this position the nipple will most -easily and conveniently slip into the child’s mouth. The child should -nurse fifteen or twenty minutes and then be removed. The toilet of the -nipple is made by cleansing with boric solution as previously described, -and then placing not gauze but a piece of aseptic cotton cloth over it, -after which the binder is readjusted. (See Breast Covers, p. 326.) - -=The menstrual flow= ceases during lactation as a rule, but not -invariably. The flow returns in from four to six weeks after delivery, -if the child is not nursing, and about the same time after lactation -ceases. There is a popular idea that conception can not occur during -lactation, and many women injuriously prolong lactation in the hope of -avoiding another child. The theory is fallacious and conception during -lactation is not uncommon. - -=The Bowels.=—A lying-in woman is regularly constipated. Lack of -exercise, a nutritious diet, but one with a minimum of wastage, together -with relaxed abdominal walls, contribute to a condition that is -primarily due to changes in intraabdominal pressure, which follow the -delivery. For weeks the intestines have been under pressure and -irritation by the growing uterus, and when this is suddenly removed the -intestines become sluggish. - -On the morning of the second day the patient should receive an ounce of -castor oil. This dose, suspended in black coffee, beer, orange juice, or -sherry wine can be taken by nearly everyone. In from four to six hours a -normal saline, or soapsuds enema is given. The enema may be repeated -daily, or if this is objectionable to the patient, the castor oil or -Russian oil, may be given as a routine. Saline cathartics should not be -used unless there is an oversupply of milk. - -There is sometimes a good deal of gas following labor, which can be -removed by the 1–2–3 enema (see Enema, p. 335). In giving enemas, the -nurse must use great care to avoid touching or infecting an injured -perineum. - -Many women secrete less gas and are agreeably influenced mentally by a -five grain pill of asafœtida taken thrice daily. - -=Urination.=—One of the commonest difficulties after labor concerns -micturition. - -Owing to the swollen and bruised condition of the urethra and the nerves -supplying the neck of the bladder, the usual stimuli do not act and the -woman, conscious of a painful distention, is unable to pass water. The -helplessness is increased by her position in bed. - -The nurse must make every effort to have the bladder emptied naturally. -The process is aided by letting the water run from the faucet into the -toilet basin, by using hot applications to bladder or vulva, by allowing -warm, sterile water to run down over the vulva and perineum, by an -enema, by putting smelling salts to the nose, by using slight pressure -over the bladder, or by having the patient sit up on the bedpan. - -If these measures fail and moral suasion is fruitless, the bladder must -be catheterized at the end of twelve hours. The two dangers of -catheterization are injury to mucous membrane, and infection. Many cases -of cystitis have resulted from an unclean catheter or the improper use -of a sterile instrument. - -To catheterize a patient, she is first given aseptic care during which -particular attention is paid to the meatus. This should be cleansed with -an applicator dipped in a solution of boric acid. Next, the nurse -prepares her hands by scrubbing ten minutes in hot running water with -sterile nail brush and green soap. The catheter either of soft rubber or -glass, is boiled for fifteen minutes and passed, not by touch, but by -sight, and the flow is received in a clean basin and the amount -recorded. As soon as the urine ceases to flow freely, the tip of the -index finger is placed tightly over the end of the catheter and the -instrument is gently withdrawn. The finger is placed over the end of the -catheter not only to avoid the dripping of urine as it is removed, but -especially to prevent the disagreeable sensations produced by the inrush -of air. - -Usually one catheterization is sufficient, and every time the bladder -fills, the nurse must take the time and trouble to make the patient -urinate spontaneously, if possible, for some women form a catheter -habit, from which it is difficult to break them. After natural urination -and after catheterization, the aseptic care should be repeated. - -=The Genitals.=—The vulvar pads should be changed as often as they are -soiled. Four a day is an average number, and six or eight in the first -three days is not unusual. Every time the pad is changed, the nurse -should give aseptic care, and extra attention whenever the bowels and -bladder are emptied. - -The dried secretions should be washed off with sterile sponges, wiping -always toward the rectum and throwing away the sponge. Smegma collects -in the folds of the labia and about the clitoris. This should be -carefully sponged away. If it becomes dry and hard, oil or albolene will -soften it and facilitate its removal. Plenty of soap and warm water -should be used, then with a pitcher or douche point, the whole area is -irrigated with a solution of lysol 1 per cent. Especial care is given to -the stitches if any are present. No traction must be made on the ends of -the sutures, and if unusual soreness is complained of, the doctor should -inspect them at his next visit. - -The nurse should be careful not to get lochia on her hands as the -discharge contains germs which she may carry to herself, to the baby, or -to the patient’s breasts or eyes. - -Painful swelling of the vulva, or edema of the rectal protrusion may be -relieved by hot boric dressings or by ice bags to the anus. - -=The vaginal douche= is rarely employed at present except under specific -indications. - -If the involution is slow, it is safer to use ergot by mouth, rather -than the hot vaginal douche, as sometimes recommended. The douche is a -frequent source of infection, as well as a useless procedure. -Nevertheless, a dainty woman gets much comfort mentally, as well as -physically, if she is kept clean and free from odors; hence if the -lochial discharge becomes offensive on the fifth day or sixth day, as -sometimes happens, a single hot vaginal douche may be permitted. A -1:5000 solution of potassium permanganate, or a teaspoonful of -formaldehyde to a quart of water, or a chinosol solution 1:1000 may be -used. - -=Rest.=—Since the patient will be in bed from eight days to two weeks in -normal cases, she must be made as happy and comfortable as possible, and -nothing contributes so much to her satisfaction as a cheerful, competent -nurse. Her mind is at ease about herself and her child, and the -companionship of the nurse can be made one of the pleasantest -recollections of her illness. - -Any patient who is at all reasonable can be managed by a tactful nurse -without the consciousness of being opposed or directed. Gossip, hospital -stories, criticism of other cases, other nurses, or of doctors should be -avoided. The patient is deeply interested in her own case, and the -private troubles of the nurse do not concern her nor enlist her -attention for more than a few polite but unpleasant moments. - -The nerves of the patient are highly sensitized, and therefore she -should sleep as much as possible at night, and take an additional nap in -the afternoon. Only the members of the family should be allowed to see -the patient the first week, and they but for a short time. It takes the -strength of the patient unnecessarily to see guests even though they be -close friends. Importunate visitors may be pacified frequently by a view -of the baby. The patient must be spared all household responsibilities, -and if necessary, the nurse must take charge. Tact must be used to avoid -being dictatorial, either to family or servants. If anything unusual -arises, the nurse must show no surprise, annoyance, or bewilderment. -Everything is attended to quietly, firmly, and without friction. - -=Getting Up.=—It is a tradition that the woman is lazy who does not get -out of bed by the ninth day. - -There are three factors to be considered, the progressive involution of -the uterus, the strength of the patient, and the presence of stitches. -Involution may be complete on the fifth day, but the prostration from -the labor may make the woman indifferent to arising. She may be strong -enough to rise on the third day, but the uterus is large and heavy, and -the erect position will put an unnecessary strain on the supports which -may retard involution and cause displacement or disease later. Also, it -is not desirable for a woman to sit up until her perineum is well on the -road to restoration. - -In general, the woman should not get up until the uterus has gone down -into the pelvis and is nonpalpable. If this is the case on the fifth day -and she feels strong, she may get up. If she is not strong, time will be -saved by staying in bed until her vigor returns, whether it is ten days -or twenty. - -Getting up may be followed by a return of the bloody discharge. This may -come from subinvolution, from a relaxed and flabby uterus, from a -cervical tear, or from change in posture. - -If there has been a retroversion before pregnancy, lying prone with an -occasional knee chest position for a few moments will aid. Massage and -passive exercises while in bed will aid the patient to recover and to -maintain her strength. Even after she is up and about, she should lie -down frequently during the day and always when nursing the babe, until -she feels quite normal again. - -For the hospital the following standing orders may be followed: - - - =Standing Orders—Puerperium= - - _Breasts:_ - - 1. Prepare for lactation 12 hours after delivery. - - (a) Clean breasts and nipples with soapy water and green soap. - - (b) Sponge with sterile water. - - (c) Sponge with boric solution. - - (d) Sterile compresses over nipples and adjust binder. - - 2. Babe to breast immediately after breast preparation. - - 3. Every morning apply fresh compresses over nipples and oftener, - if necessary. - - 4. Cleanse nipples with boric solution (use applicator) before and - after each nursing. - - To dry up milk: - - Restrict fluids; give saline cathartics; apply ice bags to - breasts, as needed; for pain give codeine solution ¼ to ½ - gr. hypodermically, if necessary. - - _Do not massage, do not bind, do not pump. Let breasts alone._ - - When breast is inflamed: - - Apply ice bags constantly until pain subsides and temperature - goes down. Watch for signs of suppuration. - - - _Genitals:_ - - 1. S.S. enema each morning, followed by aseptic care. - - Cleanse from above downward—1 per cent solution of lysol and - cotton pledgets. - - 1 pledget for each side. - - 1 pledget for center. - - 1 pledget for rectum (last). - - External douche of sterile water. - - Dry sterile pad. - - 2. Aseptic care following all bowel movements and urination. - - - _Routine:_ - - 1. Record pulse and temperature twice a day, unless otherwise - ordered. - - 2. Bladder must be emptied in twelve hours. If all persuasive - means fail (may sit up in bed), catheterize. - - 3. Make daily records of conditions of uterus (firmness and - height), breasts and nipples. - - 4. No vaginal douche unless ordered. - - 5. Diet: liquid two days; semisolid two days; then general. - - 6. Watch for hæmorrhage. - - 7. Keep uterus firm by occasional massage. - - 8. All cases to have castor oil, 1 ounce within thirty-six hours - after delivery (before noon). - - 9. Woman may get up as soon as uterus can not be felt above pubes, - if there is no contraindication. - -The history sheet should be kept accurately and should show every -incident in the course of the lying-in period. - -The condition of the bowels, bladder, and lochia, the temperature, pulse -and respiration and the height of the fundus above the symphysis from -day to day must be set down in finger-breadths or centimeters. - -For the hospital, the following system will be found useful in -establishing a routine. - - - =Nurse’s Record= - - - _First Stage._ - - 1. When pains began. - - 2. Frequency and duration of pains. - - 3. Character vaginal discharge. - - 4. Time membranes ruptured. - - (a) Artificial. - - (b) Spontaneous. - - - _Second Stage._ - - 1. Time second stage began and ended. - - 2. Anæsthetic. - - 3. Mode of delivery. - - 4. Who delivered. - - 5. Sex of child. - - (a) Living. - - (b) Dead. - - 6. Perineum. - - (a) Condition. - - (b) Repair. - - - _Third Stage._ - - 1. Method. - - (a) Spontaneous. - - (b) Early expression. - - (c) Credé expression. - - (d) Manual removal. - - 2. Placenta delivery. - - (a) Time. - - (b) Size. - - (c) Complete or incomplete. - - (d) Length of cord. - - 3. Note. - - (a) Hæmorrhage. - - (b) Quantity. - - (c) Color. - - (d) Clots. - - General condition—was case number put on mother and child? - - Other treatments. - - Medications. - - Condition of uterus. - - Temperature, pulse and respiration before leaving delivery room. - - Signed .......................... - (Nurse’s Name.) - - - - - CHAPTER XI - UNUSUAL PRESENTATIONS AND POSITIONS - - -=Breech Presentation.=—The pelvic pole enters the inlet first, once in -thirty cases and more commonly in primiparas than otherwise. - -_Etiology._—Anything that interferes with or deranges the laws of normal -gestation will predispose to, or produce this anomaly. - -Thus, if the head is too large, as in hydrocephalous, or if the fœtus is -too movable, as in hydramnios, or if an obstacle, like placenta previa, -contracted pelvis or tumors prevent the proper approach of the head to -the inlet, the mechanism will be disturbed and a breech or possibly a -shoulder presentation will result. - -Abnormal flaccidity of the uterine or abdominal walls, prematurity or -twins also contribute definitely to its occurrence. - -_The attitude_ of the child generally retains its normal aspect of -complete flexion. This pose, however, is not maintained invariably for -on occasion the buttocks and genitals may rest upon the inlet while one -or both feet may be extended on the thighs and lie beside the neck, or -the thighs may be extended while the knees remain flexed, and what is -known as a knee presentation, or if the foot comes down, a footling -presentation results. - -_Positions._—The sacrum is the most prominent bony landmark of the -breech, hence the positions are named from the relation this bone bears -to the four quadrants of the inlet. - -[Illustration: Fig. 61.—The breech. Left-sacro-anterior position. -(Lenoir and Tarnier.)] - -We have therefore in their order of frequency the following -designations: Left-sacro-anterior, where the sacrum lies to the left of -the median line of the mother’s body and in front; right-sacro-anterior, -where the sacrum lies to the right and in front; right-sacro-posterior, -where the bone lies near the mother’s vertebral column, and on the right -side; and the left-sacro-posterior position, where the bone occupies a -corresponding place on the left side. - -_Diagnosis._—The recognition of this presentation is most easily secured -by external abdominal palpation in pregnancy, which may be reinforced -during labor by the internal examination. - -[Illustration: Fig. 62.—The breech. Left-sacro-posterior position. -(Lenoir and Tarnier.)] - -Externally the palpating fingers at the pelvic brim will note the -absence of the hard, round head, and feel a mass, softer, quite -irregular in shape, and less defined than customary. Movements also may -be appreciated that would be too far down in the uterus if the head was -presenting. - -Next the hard, spherical tumor of the head can be outlined somewhere in -the fundus, and the heart tones, instead of being below the umbilicus -will be on the same level or even higher. - -Vaginally the cervix is not filled out, the presenting part does not -come down, but after labor has begun the distinctive features of the -breech gradually become more evident, as they are driven into the -pelvis. - -One or both feet, or the buttocks, may be recognized. The examining -finger may possibly enter the anus and be stained with meconium or -pinched by the sphincter, which differentiates this orifice from the -mouth. - -One after another the characteristic landmarks appear until the -diagnosis can not be doubtful. As soon as the sacrum is found or the -legs definitely placed, the position can be named. - -_Mechanism._—The hips always enter the inlet in one of the oblique -diameters and the back is turned to the same part of the uterine wall as -in the corresponding vertex positions. - -The acts described in the mechanism for vertex deliveries show a -somewhat different order. Descent is first, then comes internal anterior -rotation, which brings the anterior hip under the symphysis and its -delivery is quickly followed by the posterior hip, which rolls out over -the perineum. - -The body advances, as a rule, with the back toward the front of the -mother. The shoulders with arms folded move under the pubic arch and -then the head delivers in a state of flexion. The head, of course, has -no caput and it is not moulded. - -This mechanism may be greatly impeded or complicated at any stage of the -movement. The advance may be retarded to a pathological degree, the -belly may be large and as it passes along the canal one or both arms may -be stripped up alongside the head or even into the back of the neck. The -head may be arrested at the inlet by the arms, by its degree of -deflexion, or by pelvic contraction. - -The rotation may not take place, or it may be abnormal, and the belly of -the child look forward toward the mother’s. Any of these variations adds -further to the difficulty of the labor and to the danger of the partners -in the event. - -Artificial aid may be required which brings with it the possibility of -sepsis. - -The fœtal mortality which averages five per cent is due mostly to -asphyxiation. Interference with the supply of oxygen begins as soon as -the cord passes the vulva and the child must be delivered in eight -minutes from that time, or perish. Partial detachment of the placenta -may also cut off the oxygen to a fatal degree, and the child may be -unable to breathe when born on account of mucus sucked into the trachea -by premature efforts at respiration. - -Minor accidents also occur, such as fractures, dislocations, and -paralysis from injury to the nerve trunks. - -_Management._—In the interest of the child, this presentation is -occasionally converted into a vertex by external version during the last -weeks of pregnancy or in labor before the membranes have ruptured. It is -difficult, however, to maintain the vertex over the inlet. The woman -must be kept quiet in a horizontal posture and long roller splints -applied to the side of the child in utero and bound on. - -In primiparas, this is nearly impossible, and it is wiser, in the -absence of some great necessity to warn the parents of the conditions -and dangers and let them share in the responsibility. - -[Illustration: Fig. 63.—Extraction of the breech. Traction on one leg. -(Hammerschlag.)] - -When the labor begins, the bag of waters must be kept from rupture as -long as possible and when it finally breaks, an internal examination -should be made to see if the cord has come down. If this happens it may -be necessary to expedite the delivery by external assistance. - -[Illustration: Fig. 64.—Breech delivery. Extraction of the trunk by -pulling on the hips. (Hammerschlag.)] - -The doctor brings down a foot, if it is not already down, or pulls on -the breech until the feet drop out. Compression of the cord must be -always in mind. It is always compressed after the umbilicus has passed -the navel. The shoulders are delivered by seizing the feet with the -operating hand and swinging the body out of the way. This brings the -posterior shoulder, which should be first, into the hollow of the -pelvis. Extraction is then completed by what is called the Smellie-Veit -maneuver. The child is put astride one arm, the first finger of which is -hooked into the child’s mouth to maintain flexion. The fingers of the -other hand then grasp the shoulders of the child astride the back of the -neck and traction is made downward in the axis of the inlet until the -head slips into the excavation. - -[Illustration: Fig. 65.—Breech delivery. Delivering the shoulder. The -body is swung strongly upward and outward to bring posterior shoulder -into the pelvis. (Hammerschlag.)] - -[Illustration: Fig. 66.—The delivery of the after-coming head by the -Smellie-Veit maneuver. (Hammerschlag.)] - -If the head is delayed at the inlet, it may be necessary to put the -woman in the Walcher position (q. v.) and for the nurse to use the -Wiegand compression (q. v.). The feet _must not_ be fastened in stirrups -for breech cases. - -[Illustration: Fig. 67.—Shoulder presentation. Left-scapulo-anterior -position. (Lenoir and Tarnier.)] - -Forceps are _not_ recommended for application to the breech as they do -not fit and are liable to slip off and injure both child and mother. The -fingers are best. - -Forceps are _not_ recommended for the after-coming head unless the child -is dead. If the child lives, the Smellie-Veit is more-successful; and if -the child dies, the cranioclast, if possible, will save the mother much -suffering and avoid some injury to the tissues. - -=Transverse or Shoulder Presentations.=—These are cases in which the -long axis of the child lies directly across or obliquely across the long -axis of the uterus. - -The shoulder (scapula) is the bony landmark, and the part which most -frequently impends over the inlet. This presentation probably occurs -once in two hundred labors. - -It is due to the same conditions that were given for breech cases; -namely, weak abdominal or uterine muscles, pelvic contraction, placenta -previa, hydramnios, and twins. - -It is easily recognized in pregnancy, and must not be neglected, for it -is impossible of delivery without first changing it into a longitudinal -presentation. If this correction is not done, rupture of the uterus is -liable to occur, with the consequent death of both mother and child. - -The _treatment_ is invariably version. - -=Face and Brow Presentations.=—The face presents once in about three -hundred labors. In this case, the head is completely extended so that -the occiput rests against the back of the neck. The trunk and spine are -straightened out while the legs and arms remain in the normal attitude -of flexion. - -The causes of these anomalies must be sought in those conditions which -bring about the deflexion of the chin. The most common are pelvic -contraction, large child, placenta previa, hydramnios, goiter, -anencephalus and multiparity. - -[Illustration: Fig. 68.—Face presentation. (Bumm.)] - -Face positions take their names from the location of the chin -(mentum—Latin). Thus the most frequent face position is the -right-mento-posterior. - -The diagnosis is not easy and may not be conclusive until the bony -prominences of the face, such as the nose and orbital ridges can be -distinguished by vaginal examination. - -[Illustration: Fig. 69.—Descent of the chin in face presentation. -(Bumm.)] - -The delivery is protracted from three to five hours beyond the average -by this complication, and the mortality is higher both for mother and -child. The face is badly swollen and disfigured, but the normal -condition of the tissues will be restored by the end of a week. Most -face cases terminate spontaneously, but operative interference is not -infrequent on account of danger to mother or child. - -Version or manual correction of the presentation may be done before -engagement. - -Forceps is the operation of choice after the head is fixed in the -pelvis, but it may be necessary to precede the delivery by a preparatory -pubiotomy, or in case of failure, to do a craniotomy on the dead child. - -If the chin does not rotate forward under the symphysis, the labor is -impossible without pubiotomy or the destruction of the child. In -general, the case should be left to nature unless some definite -indication to interfere develops. - -[Illustration: Fig. 70.—Delivery in face presentation. (Bumm.)] - -The brow presents much more rarely than the face, possibly once in a -thousand labors. It is due to the same conditions as bring about the -presentation of the face. The mortality for both mother and child is -higher than in face cases. The whole labor is harder and longer, besides -being more dangerous to life and to tissues. - -This presentation, if recognized before the head is fixed, should be -converted into a breech by version, but after the head comes down, it -may be possible by hand or forceps to deliver either as a face or as an -occipito-posterior, but otherwise the cranioclast must be considered. - -=Occipito-posterior position= is the name given to vertex cases wherein -the occiput lies in one or the other of the two posterior quadrants of -the pelvic inlet. - -These labors are necessarily prolonged, both in the first and second -stages, because the mechanism of delivery is deranged by the larger -diameters brought into relation with the bony canal and by the -ineffectiveness of the contractions. - -The pains in the second stage may become violent and extremely painful, -but the labor does not advance appreciably. After a little experience, -mere observation of the course of the labor will cause the suspicion to -arise in the mind of a competent nurse that the occiput is posterior. -The diagnosis will be cleared up by the doctor’s internal examination, -which shows the large fontanelle anterior and the sagittal suture -running backward. - -The head is partially deflexed and it may not be possible at first to -find the small fontanelle. - -The position terminates by delivery uncorrected, by spontaneous rotation -into an anterior position, or is corrected by the doctor. - -Correction should not be attempted until it is apparent that the anomaly -will not right itself, which it will do in four cases out of five. - - - - - CHAPTER XII - OPERATIONS - - -Complications during labor may arise from abnormal positions of the -head, such as face or brow; from abnormal presentations of the child, -such as breech, transverse or shoulder; from twin labors; or from -prolapse of a part like the foot, arm or cord. - -The mother may be responsible for some of these abnormalities through -having a contracted pelvis, a rigid os, or a rigid pelvic floor. - -The uterus, too, may functionate abnormally by acting too vigorously, as -in precipitate labor, or too slowly, as in uterine inertia. The -membranes may rupture prematurely and produce a dry birth. - -There may be hæmorrhages before labor (ante partum hæmorrhage) during -labor (intra partum), and after labor (post partum hæmorrhage), or the -labor may be preceded, accompanied, or followed by that extreme example -of toxæmia known as eclampsia. - -Face and brow presentations are rare and come to the attention of the -nurse only when an operation is required for their relief. Further -conditions may arise, such as danger to mother or child, which demand an -acceleration of the labor. - -If the head is engaged, forceps is the operation most commonly -undertaken, and if not engaged, the problem may be solved either by an -early version and extraction or by forceps later. The dangers to the -mother are not usually difficult to diagnose if the case has been -followed carefully. - -Signs of danger to child must be looked for constantly. Such are: - -(a) Alteration of the heart tones. - -(b) Retardation of pulse in cord between pains. - -(c) Escape of meconium is _not_ significant unless occurring in the -pain-free interval, when it may signify hypercarbonization of blood and -a threat of asphyxiation. - -The preliminaries for the performance of these operations may now be -described, and the indications and conditions briefly tabulated. - -The _preparation_ should be standardized so that the same set-up of the -room will do for all of the major obstetrical operations, except -Cæsarean section. - -The kitchen table is generally regarded as a satisfactory operating -table. Its length is sufficient for delivery when the legs are doubled -up. The table should be covered with a blanket or comfort on which it -laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so -folded above the place for the patient’s hips, and so pinned at the -sides, that all drainage will flow off into a bucket or jar at the foot. - -In front of the table is placed a straight-backed chair with flat seat. -To the right of the operator, as he faces the table, stands a bench, or -two chairs, side by side; or, if possible, another table. This is -covered with a clean sheet for the reception of the instruments. To the -operator’s left, another table similarly prepared carries the solutions, -sponges, etc. Every operation for delivery should have tape and cord -scissors within easy reach, as well as facilities for the resuscitation -of the child. - -The light should come from behind the operator and fall full upon the -field of operation. The room should be warm. - -The patient is laid upon the table and her knees elevated in the -exaggerated lithotomy position. If there are assistants enough, one can -stand on either side and hold a knee, if not, a sheet sling can be made -and slung round the patient’s shoulders and tied to the knees as -previously described. - -[Illustration: Fig. 71.—Exaggerated lithotomy position. The legs are -held by a sheet sling. The vulva should be shaved. (Williams.)] - -An anæsthetic will be required. If a doctor can not be had, this duty -will fall to the nurse. - -A sterile douche bag hangs near the table. A bath tub of hot water must -be provided and a tracheal catheter must be ready for the removal of -mucus from the child’s windpipe. An abundance of hot and cold sterile -water must not be overlooked. In the hospital the following synopsis for -the placing of the linen may be found useful: - - -=Sterile Linen for Operative Case.—= - - - Bring patient to foot of bed. - - Put in the stirrups. (For breech deliveries _do not_ use stirrups.) - - Same order as for normal case except that feet are put in stirrups - instead of on bed. - -[Illustration: Fig. 72.—Dorsal position when assistants are available. -(Hammerschlag.)] - - Sterile sheet under patient extends now from basin under bed to - buttocks. - - Combination pad over field of operation. - - Sterile sheet over abdomen. - -The genitals of the patient are now cleansed with all care and attention -described for labor. If this has been done within an hour, she need only -be sponged off thoroughly with lysol solution (1 per cent). The feet and -legs are covered with stockings, the body kept warm, and protected by -sheets and blankets, if necessary. - -_Every_ operative delivery is preceded by catheterization. - -All instruments are boiled for thirty minutes and brought to the table -in the same container in which they are sterilized. The hot water has -been poured off and a cool, weak solution of lysol (0.5 per cent) added. - -[Illustration: Fig. 73.—Instruments for artificial delivery of the head. -_A_, Braun’s blunt hook; _B_, Cranioclast (Auvard); _C_, Axis traction -forceps (Webster); _D_, Low forceps (Simpson).] - -=Forceps.=—Before using forceps it should be determined that the woman -can not deliver the child unaided, or can not be permitted to do so -without too great expenditure of physical and nervous energy. The exact -conditions must be recognized as to the location and position of the -head, the condition of the fœtal heart tones and the size of the pelvis. -When the head is high up, the axis traction instrument is employed and -patient put in Walcher’s position for the traction. - -Axis traction forceps are extremely dangerous to mother and child, and -should be avoided wherever possible. - -The following instruments are required: - - The obstetric forceps. - 2 eight-inch forceps. - 6 artery forceps. - 1 vulsellum forceps. - 1 tissue forceps. - 1 needle forceps and 6 needles. - 2 vaginal retractors. - 1 pair dressing forceps. - 1 douche point. - 1 silver catheter. - Suture material—both catgut and silkworm gut. - -Besides these instruments, the nurse will also have solution basins as -described for normal labor. For operations outside of hospitals, the -nurse need not be clean, as her duties will consist for the most part in -changing solutions, refilling basins, handing towels, etc., all of which -can be done with sterile forceps. - -The following summary may be serviceable for advanced study or -reference: - - - PREPARATION.— - - Thorough asepsis, both subjective and objective. - - Patient should be pulled down to the foot of the labor bed with - feet in the stirrups, or put upon the kitchen table or across - the bed with the legs held in the lithotomy position. (For - breech cases, legs should not be fastened.) - - Bladder and rectum must be empty. - - Anæsthetic is necessary. - - The position of the head must be accurately known. - - Facilities for the treatment of asphyxia neonatorum must be at - hand. - - - CONDITIONS.— - - Cervix effaced and os dilated, except when maternal or fœtal life - is threatened. - - Bag of waters must be ruptured. - - The head must be engaged. - - The child should be living. - - - INDICATIONS.— - - Insufficiency of the powers of labor. - - Deep transverse arrest of the head. - - Complications in labor, such as: - - Eclampsia. - - Fever. - - Acute or chronic disease. - - Hernia—especially if incarcerated. - - Placenta previa. - - Prolapse of the cord. - - Face and brow presentations. - - Contracted pelvis. - - Occipito-posterior positions. - - - DANGERS FROM FORCEPS.— - - _Injuries to Child._—Overcompression, especially with axis - traction forceps or in contracted pelvis. - - Crushing of soft parts, or such lesions as abrasions, pressure - marks, hæmatomata, swelling of face and eyelids. - - Bone injuries: Spoon-shaped depression where the head has been - dragged through a narrow inlet; fissures in the parietal or - frontal bones; fractures. When axis traction forceps are applied - antero-posteriorly, the occipital bone may be sprung inwards - until it cuts the medulla. - - Compression of the cord, especially if it is around the neck. - - Hæmorrhage from the middle meningeal artery. - - Injury to eye. - - Erb’s paralysis. - - Laceration of ears when the forceps are removed. - - Facial paralysis from pressure of the blade. - - - _Injury to Mothers._— - - Infection. - - Improper application of the blades _outside_ the cervix uteri. - - Soft parts torn by too rapid extraction. When os is not - dilated, it is first pulled down and then torn. The tear may - extend into the vaginal vault. Fistulæ may be produced. - - Prolapse of the uterus from prolonged traction. - - Vaginal tears from the blades or from malplaced head. - - Slipping of blades. Traction must be _not against_ the - symphysis, but down. - -The forceps commonly used in this country (Simpson or Elliott) are so -made that the left blade must be introduced first on account of the -lock. - -The mortality for the child in forceps cases is about six per cent. - -[Illustration: Fig. 74.—Forceps operation. The left blade, in the left -hand, is introduced first into the left side of the mother so that the -curve of the blade fits the child’s head (inside the cervix). -(Hammerschlag.)] - -The axis traction instrument is used but seldom by good obstetricians, -since the danger to mother and child in this operation is very serious -and it should be reserved for emergencies of exceptional character. -Pubiotomy may precede the operation with advantage in many cases. -Asphyxia of the child and maternal hæmorrhage must be prepared for. - -[Illustration: Fig. 75.—Forceps operation. The introduction of the right -blade. (Hammerschlag.)] - -[Illustration: Fig. 76.—Forceps operation. Locking the handles. -(Hammerschlag.)] - -[Illustration: Fig. 77.—Forceps operation. The way the blades should -grasp the fœtal head. (Hammerschlag.)] - -[Illustration: Fig. 78.—Forceps operation. Traction on the handles. -(Hammerschlag.)] - -[Illustration: Fig. 79.—Forceps operation. The delivery of the head. -(Hammerschlag.)] - -[Illustration: Fig. 80.—Version. Seizing a foot. (Hammerschlag.)] - -=Version (Turning).=—Version is a maneuver for altering the presentation -of the child while it is still in the uterus. A vertex may be converted -into a breech, a breech into a vertex or a transverse into either a -vertex or a breech. - -[Illustration: Fig. 81.—Version. The child rotates as pressure is made -upon the head and traction upon the foot. (Hammerschlag.)] - -Version usually means that a transverse or a vertex presentation is -changed into a breech and is followed by the extraction of the child. -The operation is serious and not to be undertaken without definite -indications. There is always the risk of sepsis and rupture of the -uterus as well as a high probability of a dead child. Perineorrhaphy is, -if anything, more frequent after this operation than after forceps. - -[Illustration: Fig. 82.—Version is complete when the knee appears at the -vulva. (Hammerschlag.)] - -PREPARATIONS.—The room and patient are arranged as for forceps, except -that the stirrups can not be put in. The legs must be held by -assistants, for the delivery of the after-coming head may be complicated -and require the Walcher position, which can not be quickly obtained if -the legs are fast. Only eight minutes are allowed for the delivery of -the child after the navel passes the vulva, if it is expected to live. - - - The bladder and rectum must be empty. - - Asepsis must be rigid and both subjective and objective. - - The dorsal position on a table is imperative. - - The diagnosis must be accurate and the anæsthesia carried to the - surgical degree. - - Facilities for treating asphyxia neonatorum must be provided. - -The following summary of the indications and conditions may be -convenient for reference. - - - INDICATIONS.—Contracted pelvis. (Consider pubiotomy.) - - Abnormal position of the head. (Face position with chin - posterior.) - - Prolapse of cord or an extremity with a presentation of the head. - - Placenta previa. - - Transverse position after the seventh month. - - Any condition requiring rapid delivery. - - - CONDITIONS.—Cervix effaced and os dilated. - - Uterus not in tetanus nor contracted down over the child. - - The fœtus must be movable. - - The head should not be engaged. - -The _Walcher position_ is produced by bringing the patient down to the -end of the table so that the sacrum rests upon the edge. The thighs and -legs are allowed to hang down of their own weight and the patient is -restrained from falling off by traction upwards on the axillæ. - -In the Walcher position the diameter of the pelvic inlet is increased -from ⅓ to ½ inch (1 cm.) and thereby the delivery of heads that -otherwise could not pass becomes possible. - -In addition to the Walcher position other measures may be required to -help the head through. Thus, traction from below may be carried to the -limit of safety and in spite of the Walcher position the head may not -pass the inlet. - -Then pressure from above is added. This maneuver will have to be -executed in many cases by the nurse. - -The fingers palpate the head above the pubes. Then one or both fists are -placed upon the abdomen over the head and force is exerted to crowd the -head down into the pelvis. This is known as the _Wiegand compression_. - -For the operations destructive to the child, craniotomy or decapitation, -the same arrangements are made. - -[Illustration: Fig. 83.—The Walcher position. (American Text Book.)] - -=Cranioclasis= is the crushing of the fœtal skull so that in its reduced -condition the child can be delivered and the mother’s life spared. In -addition to the solutions, the only instruments required are the Auvard -cranioclast, a Naegele perforator, and a douche bag with glass, or any -tip that can be sterilized. - -In many of these cases, _both_ mother and child could be saved if seen -early enough to have a Cæsarean operation. - -=Decapitation= is done to save the maternal life in cases of transverse -or shoulder presentation. The preparations are the same as already -described for forceps and version and the only instrument needed is a -Braun blunt hook. (Fig. 73.) - -[Illustration: Fig. 84.—The Wiegand compression of the child’s head to -force it into the pelvis. (Hammerschlag.)] - -=Cæsarean section= is the delivery of the child through an opening in -the abdomen. - -It is made necessary by contraction of the pelvic bones, or by the -presence of a fleshy or bony mass which diminishes the size of the -inlet. It may be required on account of the closure of the vagina or -cervix by scars or on account of urgent conditions of the mother, such -as eclampsia, heart disease, and sometimes placenta previa. - -The technic is simple, but good judgment must be used in knowing when to -do it. Many operators find it so easy that they prefer it to the harder -but safer obstetrical operations. - -[Illustration: Fig. 85.—The Naegele perforator. (Hammerschlag.)] - -The time of election is when the woman is at term but not in labor. -This, of course, can be determined by the history, but more certainly by -careful measurements of the child. - -When it becomes necessary to operate on a woman who has been in labor a -long time and especially if she has been examined frequently, the -mortality is disproportionately high. - -It is a hospital operation, but may be done in the house. If not an -emergency, the bowels are emptied by a laxative and enema the day -before. Regular preparations for laparotomy are made, plus the equipment -necessary for tieing the cord and resuscitating the child. A table must -be found large enough to hold the patient in the horizontal position at -full length. Solutions of lysol 1 per cent and sterile water are placed -on each side of the table. The instrument table carries towels and -suture material as well. - -On a stand behind the operator is placed the hot bath and tracheal -catheter. This center is presided over by someone skilled in the -treatment of respiratory difficulties in the new born. Altogether, five -assistants are required for the operation: an anæsthetizer, a clean -nurse, and a nonsterile nurse to manage supplies, an operating assistant -and one to take charge of the child. - -Rubber gloves must be worn by the clean assistants. - - _Instruments.—_ - - 2 scalpels. - 2 scissors. - 8 eight-inch forceps. - 10 six-inch artery forceps. - 4 sponge carriers. - 4 tenaculum forceps. - 2 rat-toothed tissue forceps. - 4 full curved round needles for uterine wall. - 4 smaller needles for the fascia. - 2 Hagedorn needles for the skin. - 2 needle holders. - 1 dressing forceps. - Plenty of suture material, both catgut (No. 3 and 4) and - silkworm gut for the abdominal wall. - - - _Supplies.—_ - - 1 doz. laparotomy sponges with metal rings sewed in or - a long tape attached. - 6 large laparotomy pads. - 1 large pillow slip full of sterile cotton. - Sponges. - 1 laparotomy sheet. - 1 dozen towels. - 1 pair of leggins. - Gowns and head dressings (gauze will do) for the operator and - assistants; rubber gloves, basins and accessories. All are - sterilized. - -If the woman has been examined, the vagina should be sponged out with -tincture of iodine. The abdomen is shaved, scrubbed with green soap, -nail brush, and hot water for five minutes. It is then rinsed with ether -and painted with iodine. - -The presentation of the child, the presence and location of the heart -tones must be determined before operation. - -The patient is anæsthetized with ether, chloroform or gas. - -The incisions are made; the child delivered to the proper assistant; the -placenta and membranes removed; the sponges counted; and the uterus and -abdominal wall sutured. - -_After-care._—The nurse watches the patient for sighing respiration, -rapid pulse, pallor, and other symptoms of hæmorrhage, either external -or internal. Artificial heat is supplied. Hæmorrhage from vagina should -be looked for. It is normal. Salt solution by hypodermoclysis may be -required. Hot water by mouth in small sips or tap water by rectum (drop -method) will relieve the thirst. Morphine may be given if pain is -extreme. An enema may be given on the second day or calomel may be -started in the morning of the second day. Distention from gas, with or -without nausea and vomiting, hiccough and rise of temperature are all -signs of danger. No milk should ever be given on account of the gas it -causes. - -The child is put to breast as usual after twelve hours. - -The stitches are to be taken out on the tenth or twelfth day. - -=Symphyseotomy= is a separation of the pelvis at the pubic joint and is -done with a scalpel or a specially devised knife. - -=Pubiotomy= is the division of the pelvis, three or four centimeters to -the right or left of the pubic joint. The division passes through the -pubic bone and is usually done with a serrated wire called the Gigli -saw. It is introduced subcutaneously by a special instrument called a -pubiotomy needle. Both symphyseotomy and pubiotomy are preparatory to -delivery. Pubiotomy is the more desirable and successful operation. The -ends of the severed bones separate from one and a half to two inches, -and the child delivers easily through the enclosed opening. The -after-care is usually simple. - - _Instruments.—_ - - 1 scalpel. - 2 Gigli saws. - 1 pubiotomy needle. - 6 artery forceps. - 3 eight-inch forceps. - 1 needle holder. - 2 retractors. - Suture material and sponges as usual. - -The hips are strapped in circumference with zinc adhesive plaster to -support the bones. - -The danger of infection of the wound from the lochia is always present. -The main difficulty is in moving the patient, who is more than usually -helpless. The bony ring of the pelvis is broken and she can not raise -her leg. The repair is cartilaginous at first, but solidifies in a few -months so that locomotion is not impaired. Especial pains must be taken -to avoid bed sores. - - - - - CHAPTER XIII - MINOR OPERATIONS - - -=Aseptic Care.=—Place patient on a clean bed pan. It need not be -sterile. Drape with a sheet and arrange it so the fold may be easily -raised by nurse’s elbow. Have sterile basin with cotton pledgets to be -filled with solution of lysol 1 per cent. Lysol must be put in basin -first and the water added. Take to bedside. Nurse scrubs her hands ten -minutes with a sterile brush, hot water, and green soap. Use no towel, -no gloves. Keep hands wet and clean. Cleanse vulva with wet pledgets -from above downward. Apply sterile pad. - -=Sterile Specimen.=—To get a sterile specimen of urine without catheter, -give aseptic care, tampon vagina with large pledget of sterile cotton. -Have patient urinate in a sterile basin. Remove tampon. - -=Sterile Specimen from Child.=—Take a glass test tube and thrust its -round end through a hole in a square piece of adhesive plaster. Push it -down until the plaster is caught and stopped by the enlarged rim at the -mouth of the tube, with adhesive side of plaster on same side as opening -of tube. Fasten the tube over the male penis or female vulva by applying -the plaster to the surrounding skin. Leave until full. - -=Aseptic Douche.=—Boil douche point and basin. Leave point in sterile -basin. Fill douche can with sterile water, temperature 104° to 110° F. -Put clean bedpan under patient who is draped with a sheet. Have at hand -a sterile basin containing solution of lysol 0.5 per cent, or boric acid -5 per cent in which cotton pledgets are immersed. Scrub the hands as for -aseptic care. Cleanse the vulva with cotton pledgets, washing always -toward the anus, and use each pledget but once. Adjust the douche point -and introduce it just inside the labia. The douche can should be only a -trifle higher than the pelvis. When can is empty, apply a sterile pad. - -[Illustration: Fig. 86.—Apparatus for getting a sterile specimen of -urine from an infant.] - -If the douche is to be used as a deodorant after the fifth day of the -puerperium, either of the following solutions may be employed: Potassium -permanganate, 1:5000; formaldehyde 1 dram to quart, or chinosol 1:1000. - -=The vaginal douche= may be used in cases of gonorrhœal infection in -pregnancy during the last weeks, in the hope of avoiding infection of -the child’s eyes. - -It is given like the aseptic douche (q. v.) with potassium permanganate -1:5000, or chinosol 1:1000. It should be hot (112° to 120° F.), and be -begun not long before term, so that in case labor comes on, the danger -to the child will be minimized. The reservoir must not be too high, nor -the douche point inserted much beyond the labia. The woman should be on -her back and the douche point should be rubber or glass. - -=Removal of Sutures.=—On, or about, the tenth day the removal of sutures -is required. - -The nurse will sterilize by boiling, 1 pair of long-handled, -sharp-pointed scissors, 1 pair of tissue forceps, and if the sutures -extend far into the vagina, a vaginal retractor. - -A basin of lysol solution (1 per cent) with cotton sponges, a sterile -towel to lay the instruments on, a dish to receive the soiled dressings, -sutures and discarded sponges, completes the arrangement. - -The patient is now draped with sheets as for examination. The doctor -prepares his hands as for operation. The nurse holds the limbs of the -patient in lithotomy position and the operation is begun. - -=Uterine Tampon.=—Packing the uterus is mostly employed for hæmorrhage -after labor. The patient, therefore, has been prepared and only fresh -sponging with lysol solution is required. - -The _instruments_ are, 1 vaginal retractor, 1 pair of dressing forceps, -1 vulsellum forceps and a jar of gauze, four to six inches wide and ten -or twelve feet long. Always use a single continuous strip. A very large -quantity is necessary to fill the uterine cavity. Any sterile gauze may -be used, but weak iodoform is satisfactory. - -[Illustration: Fig. 87.—Tampon of the uterus. (Hammerschlag.)] - -The vagina is held open with retractors, the cervix seized with a -tenaculum and pulled down, the end of the gauze strip is then carried -into the uterus as far as the fundus, the dressing forceps withdrawn and -a new length carried in until the cavity is packed tightly from the -fundus clear to the os. - -Care must be taken that the strip of gauze is not contaminated by -vaginal contact during the introduction. A pad and binder are now -applied. If no instruments are at hand, or there is not time to -sterilize, then the nurse can grasp the fundus through the abdominal -wall with her hand and push the cervix down to the vulva where the gauze -can be pushed in by the doctor’s fingers, if necessary. - -The tampon acts as a hæmostatic through its direct mechanical pressure, -and dynamically by stimulating the uterus to contract. It should be -removed in from twelve to twenty-four hours. - -[Illustration: Fig. 88.—Tampon of vagina. (American Text Book.)] - -=To tampon the vagina= the woman lies on her back across the bed, with -her feet on the knees of the doctor, who sits facing her. A sterile -retractor holds back the posterior wall of the vagina. - -With a pair of dressing forceps the doctor seizes the pledgets of cotton -or gauze out of the lysol solution and carries them one by one as far as -they will go, in various directions around the cervix. One is pushed -forwards toward the bladder, the next back toward the rectum, the next -in the middle, and so on until no more can be introduced. A pad and -binder are applied tightly. - -=The uterine douche= is sometimes employed for hæmorrhage. The field of -operation and the doctor’s hands are prepared as usual. The nurse cools -the boiled douche water down to 120° F. and if ordered, adds 2 drams of -sterile salt to each quart. - -The _instruments_ are a vaginal retractor, a long uterine douche point, -and one vulsellum forceps. - -The cervix is seized and brought down, the long douche point connected -with the tube from the reservoir is carried to the fundus and the water -started. Care must be used that the return flow is free and -unobstructed. - -This method is most satisfactory in uterine hæmorrhage after the uterus -has been entirely emptied. It stimulates a prolonged and profound -uterine contraction. - -=Intravenous Injections.=—The vein in the front of the elbow is usually -chosen. (Median basilic or median cephalic.) A rubber bandage or -tourniquet is wound tightly about the middle of the upper arm to make -the veins stand out prominently. The surface of the skin should be -sterilized for operation by scrubbing with green soap and hot water and -rinsing with 50 per cent alcohol, followed by 1:2000 solution of -bichloride, or by the application of tincture of iodine. - -The hypodermic needle is then introduced after expulsion of all the -contained air and the piston is drawn up until the blood enters. This -assures the operator that the needle has entered the vein. The bandage -is now loosened and the solution of the drug is introduced very slowly. - -Intravenous infusion or transfusion is given in the same way. The fluid -(normal saline?) must be running from the needle as it is introduced. - -=Hypodermoclysis= is the introduction of normal saline solution, under -the skin, or under the breasts. The solution may be transfused also into -a vein. - -By this operation, the quantity of fluid in the vessels is greatly -increased and a circulatory stimulant is provided. Normal saline also -promotes diuresis and aids in the removal of wastage. - -The principal dangers arise from too great rapidity or too large a -quantity of the flow. - -The skin should be sterilized at the point of attack by a coating of -tincture of iodine. - -The _instruments_ required are, a bath thermometer, a douche can -(fountain syringe) with long tubes and an aspirating needle. A -hypodermic needle will do, but the reservoir must be well elevated since -the caliber is so small. Ordinarily the reservoir need be held only two -or three feet above the point of discharge. The water should be flowing -through the needle when it enters the tissues. If the fluid is to be -introduced under the skin, the best place is in the loose region between -the hips and the ribs in front. If under the mammary gland, the needle -must go _below_ and under the gland from the outside edge, not into the -gland. If into a vein, such additional instruments will be needed as a -rat-toothed tissue forceps, a pair of sharp-pointed scissors, a knife -and some fine catgut. From four to sixteen ounces of fluid may be used -at a temperature varying from 105° to 110° F. - -The openings where the needles entered are closed by cotton and -collodion. - -=Curettage of uterus= is done for abortion or puerperal sepsis when -foreign fragments are left in the uterus. The room is prepared as for -delivery. - -The instruments are: - - 1 vaginal retractor. - 1 vulsellum forceps. - 1 long uterine douche point. - 2 dull curettes. - 2 sharp curettes of different sizes, together with gauze for - packing the uterus. - -Rubber gloves should be worn both by nurse and physician as much for -personal protection as for the patient’s safety. In many cases of -incomplete abortion or of puerperal sepsis the endometrium is more -satisfactorily curetted with the gloved fingers. - -=Abortion= may be indicated in many of the early complications of -pregnancy, such as hyperemesis, nephritis, uncompensated heart lesions, -tuberculosis, insanity, hydramnios, incarcerated retroversions of the -uterus and the presence of hæmorrhage. These cases require the operation -to be undertaken and finished by the doctor, but other conditions -develop wherein, without volition on the part of the patient or doctor, -the abortion begins. Some may be saved, but at times the attempt is -futile. - -If the emptying of the uterus seems inevitable, the function of the -physician is to see that the process is finished as quickly and cleanly -as possible. - -This may be done in the early stages by packing the cervix and vagina -with iodoform gauze and administering ergot in twenty-five drop doses -thrice daily. - -In case of dangerous hæmorrhage from spontaneous abortion, the vagina -can be tamponed with cotton pledgets or gauze by a clean nurse while -awaiting the arrival of the doctor. - -When the uterus has partially emptied itself and the retained fragments -prevent the complete contraction and allow of serious bleeding, or if -the fragments are septic, then their removal is required. This is done -by the finger or curette. - -The preparation of rooms, patient and doctor are the same whether the -operation is for therapeutic or incomplete abortion. These have been -described. - -The instruments are: - - 1 pair dressing forceps. - 2 vaginal retractors. - artery forceps. - 2 curettes of different sizes. - 2 vulsellum forceps. - 1 long uterine douche point. - 1 pair Goodell dilators. - 1 douche can. - -[Illustration: Fig. 89.—Pean forceps.] - -=The induction of labor= at or near term is done for pelvic contraction, -maternal disease, for danger threatening mother or child, or to avoid -the birth of a post-mature child. A variety of methods may be employed, -but the Vorhees bag is best. - -_Technic._—Assemble, and sterilize by boiling twenty minutes, a Vorhees -bag No. 3 or 4, Simon speculum or vaginal retractor, 1 pair long Pean -forceps, 2 pairs vulsellum forceps, 1 dressing forceps, 2 pairs -compression forceps, 1 Goodell dilator, 1 tenaculum forceps, Davidson -hand bulb syringe with glass tubes and rubber connections for the bag. - -Patient, prepared as for delivery, is placed upon the table in -exaggerated lithotomy position. Stirrups will serve. - -The vagina is retracted, a smear made from cervix, and the mucous -membrane wiped clean with pledgets of gauze on forceps. - -Anæsthesia is only occasionally necessary even in primiparas. - -[Illustration: Fig. 90.—_A_, Hand bulb syringe; _B_ and _C_, Vorhees -bags; _D_, Bag rolled and grasped by Pean forceps ready for -introduction.] - -Before using, the apparatus must be tested by forcibly filling the bag -with sterile solution. - -One lip and sometimes both are seized by vulsellum forceps and brought -down. Usually, even in primiparas, the os is sufficiently patulous to -admit the bag—if not, dilate. - -[Illustration: Fig. 91.—Vorhees bag in place.] - -The bag, emptied of residual air and fluid, is rolled up into a compact -mass like a cigarette, seized with Pean forceps so that the tips extend -just to the end of the bag. Turn the concavity of forceps toward -patient’s left leg and introduce. As the bag enters turn the mass to the -left—a quarter turn—so that when operation is completed the forceps -curve faces upward. Release the lock on forceps. Connect the tube of the -bag with syringe tube and force the solution slowly into bag. Pean -forceps may be removed as bag fills. Remove vulsellum. Tie tube of bag -with tape when bag is full—disconnect syringe. Put sterile pad on either -side of tube. - -If pains do not start within an hour, or if compression is desired as in -placenta prævia or a more rapid dilatation, then a weight of one or two -pounds is attached by a tape to the protruding tube and passed over the -foot of the bed. - -=Digital dilatation of cervix= may be indicated in cases of rigid os or -where prolonged labor or some danger to mother or child requires the -hastening of the delivery. - -No instruments are needed, but a complete anæsthetic is necessary. - -Thorough asepsis must be observed. The patient’s genitals and the -doctor’s hands are prepared as described for labor, and rubber gloves -are imperative. - -The gloved hands and the vagina and vulva are well rinsed with lysol -solution 1 per cent. The operation must be done carefully, patiently and -gently, lest the cervix be lacerated. - -The hand is introduced into the vagina, and first the thumb and index -finger are introduced into the os and separated as widely as possible, -then the second finger and so on, until the dilatation is complete. -(Hirst’s method.) - -Another method is the introduction of the tips of both index fingers, -back to back. Force exerted will dilate the canal so second fingers may -also be inserted. Then patiently and gently the rigid ring of the os is -overcome. (Edgar’s method.) - -=Episiotomy.=—This is a clean incision of the vulva, which is done to -avoid an apparently inevitable and ragged tear of the perineum. - -The _instruments_ required are either a blunt tipped knife or a pair of -blunt scissors. - -The operation may be done on one or both sides depending on the amount -of room required. The incision begins at a point just above the lower -third of the vulvar outlet when distended by the head, and passes -obliquely downward and outward. This severs unimportant tissues only, -instead of allowing the valuable perineal body to suffer. It makes a -clean wound that heals readily, instead of a ragged tear through bruised -tissue. The cut is high enough to be free from the constant bath in -infectious lochia, which troubles the healing of the usual perineal -laceration. - -[Illustration: Fig. 92.—Episiotomy. (Hammerschlag.)] - -=Rectal Infusion (Drop Method).=—A douche bag containing normal saline -solution is hung near the bed and kept warm with an electric pad, a hot -flatiron, or by a hot water bag on either side. The tube ends in a -catheter which is inserted into the rectum. The tube is clamped so that -only a drop of solution can escape each second. - -=Wet packs= are both sedative and antipyretic and may be employed for a -local or a general effect. - -For bronchitis the pack may be applied to the chest only as follows: The -child (or adult) is stripped in a warm room (75° F.) and the chest -swathed front and back with a thick towel wrung out of hot water -(temperature 105° to 110° F.) Over this a woolen shirt may be drawn or a -blanket wrapped, and the patient put to bed. After six or eight hours, -the dressing is removed in a warm room, a hot bath administered, and the -body well rubbed with alcohol, and dried. The treatment may be repeated -if necessary. Do not burn the patient by applications too hot. - -The general pack is most serviceable in reducing temperature and -producing a diaphoresis to relieve the kidney and cleanse the system, as -in eclampsia. For this purpose the entire body, naked, is rolled in a -sheet wrung out of hot water and then put between heavy blankets in bed. -The pulse should be taken frequently and the temperature recorded at -intervals. A cool application to the head is very soothing. - -The patient sweats profusely and hot drinks may be given to promote a -more abundant diaphoresis. Usually the patient drops off to sleep as the -fever subsides. Twenty to forty minutes is the average duration of such -a treatment. - -When the pack is removed, the patient is wrapped at once, without -drying, in warm blankets, and left for an hour or so. - - - - - CHAPTER XIV - COMPLICATIONS IN LABOR - - -_Pelvic contraction_ is not infrequently the cause of difficult or -prolonged labor. The deformity is most commonly due to rickets in -childhood. - -There are many forms of pelvic contraction, but in this country only two -are at all common; the generally contracted, and the flat pelvis. - -The generally contracted pelvis is, in the main, a well shaped pelvis, -only its measurements are smaller than normal. - -The flat pelvis is marked by a shortening of the anteroposterior -diameter of the inlet. It looks as if it had been pressed together from -before backward while in a soft condition. - -These and other deformities will be recognized in advance of labor by -the routine application of the pelvimeter. - -The value of this instrument is so great, that no competent man does -obstetrical work at the present time without using the pelvimeter as a -routine. - -The average diameters in normal pelves may be tabulated as follows: - -Interspinous—between the anterior superior iliac spines—25 cm. - -Intercristal—between the iliac crests—28 cm. - -External conjugate—taken from the upper border of the symphysis to the -depression below the last lumbar vertebra—20.5 cm. Take 9.5 cm. from -this to get the true conjugate. - -[Illustration: Fig. 93.—Various forms of pelvic deformity compared with -the normal inlet. (Bumm.)] - -The circumference of the hips just below the iliac crests and above the -trochanters—90 cm. It is taken with a tape line. These are the usual -external measurements. - -The internal measurements are made with the fingers. - -[Illustration: Fig. 94.—The pelvimeter.] - -[Illustration: Fig. 95.—The various diameters of the inlet with the -lengths given in cubic centimeters. (Williams.)] - -[Illustration: Fig. 96.—Measuring the distance between the anterior -superior spines of the pelvis. (Williams.)] - -The diagonal conjugate is the distance from the lower border of the -symphysis to the promontory of the sacrum. It should measure 12.5 cm. -The first and second fingers are passed into the vagina and pushed up -until the tip of the second finger touches the promontory of the sacrum. -The finger of the other hand marks the depth of the examining fingers -just below the symphysis. The distance is measured when the finger is -withdrawn, and 1.5 cm. is subtracted. The result is the true conjugate. -These measurements carefully made and the deduction judicially -estimated, give one a fairly approximate idea of size and shape of the -pelvic inlet. The aim of nearly all the pelvic measurements is to get -not only the size and shape of the inlet, but so far as possible, a -working estimate of the anteroposterior diameter of the brim, which is -the most important of all the diameters. In normal cases this should be -11 cm. - -[Illustration: Fig. 97.—Measuring the external conjugate. (Williams.)] - -Thus, taking 9.5 cm. from the external conjugate (20.5 cm.) gives 11 cm. - -Subtracting 1.5 cm. from the diagonal conjugate as obtained with the -fingers as above described, (12.5 cm.) gives 11 cm. The subtraction is -made to compensate for the thickness of the pubic bone and its -inclination outwards. - -[Illustration: Fig. 98.—Measuring the diagonal conjugate with the -finger. (Eden.)] - -A circumference of 90 cm. corresponds to an inlet of 11 cm. in its -anteroposterior diameter, and every variation of 5 cm. in this -circumference makes a difference of 1 cm. (either larger or smaller) in -the anteroposterior diameter. - -Thus, 95 cm. in circumference=12 cm. in the diameter; and 85 cm. in -circumference=10 cm. - -Complications increase in proportion to the degree of contraction in the -pelvis. - -The most frequent difficulties superinduced by the small pelvis are -prolapse of the cord, malpresentation and malpositions of the head, -prolonged labor, and a large increase in the number of assisted -deliveries. - -All the possibilities and probabilities in a given case will be -carefully worked out before labor by the conscientious obstetrician, and -Cæsarean section, induction of premature labor, pubiotomy, forceps, or -version and extraction, will be done with a sure foreknowledge. - -=Prolapse of the cord= complicates labor once in about two hundred -cases. It is most likely to occur when the presenting part does not -enter or does not entirely fill the opening, as in transverse or -shoulder presentations, or vertex presentations with small inlets. - -The mother is not endangered by this mishap, but the babe is lost in -from 35 to 60 per cent of the cases. - -The diagnosis is easily made when a loop of cord protrudes from cervix -or vulva, and the pulsation will differentiate it from everything else. - -If the cord does not pulsate, the family should be informed that the -child is dead and the case may be allowed to terminate normally. - -If it still pulsates, the woman should be placed in the knee-chest -position for ten or fifteen minutes, then upon the side, opposite to -that on which the cord has prolapsed, and back again as soon as possible -to the knee-chest position. A chair may be used to produce a -Trendelenburg position by placing it so that the edge of seat and top of -back rest on the bed. Then the patient puts her legs over the lower -rungs and lies with her back against the chair back and her head on the -bed. - -If the cervix is effaced and the os partly dilated, reposition may be -attempted either with the finger or a male catheter. - -The operation will, of course, succeed most easily if done in the -knee-chest position, with gravity to aid. - -If the cord can be pushed back, a Vorhees bag may be inserted to keep it -from coming down again. This holds back the cord, dilates the canal and -stimulates the pains. - -When the bag comes out, version and extraction can and should be done at -once. - -In general, the following summary may be useful: - - - =Prolapse of Cord= - - - _Causes._— - - Contracted pelves. - - Breech and transverse presentations. - - Malposition of head, or face and forehead presentation. - - Hydramnios. - - Accident. - - Low insertion of placenta. - - - _Diagnosis._— - - Before rupture of membranes careful examination will show - pulsating cord in advance of head. - - After rupture the cord may be felt in vagina. - - - _Dangers._— - - To mother:—None but those due to causative condition. - - To child:—Compression of the cord and asphyxiation. - - Contraction of exposed vessels of cord. - - Patient may lie on cord. - - Twenty-five per cent die as a rule under best conditions. - - Fifty per cent when left to nature. - - - _Treatment of Cephalic Presentation._— - - Extraction of child or reposition of cord, depending upon the - degree of dilatation. - - If cervix is small, replace and fill cervix with Vorhees bag. - - When cervix admits hand, either replace or do version and - extraction. - - With head engaged, reposition or version is not possible. - - Child living:—Rapid delivery with forceps. - - Child dead:—Craniotomy or leave to nature. - - Prolapse of one or both hands may take place. If the head is - engaged, no interference should be attempted. If not, - replacement or version may be done. - -The soft parts may also complicate the labor process. - -No time need be spent here on the rarer forms of obstruction due to -uterine or ovarian tumors. - -=Rigidity of the cervix, or os= is not uncommon. - -This may be due to a dense, almost cartilaginous consistence of that -tissue, to premature rupture of the bag of waters, to weak, inefficient -contractions in the first stage, or to a steel-spring-like contraction -of the muscular fibers of the os. - -In all cases the first stage of labor is greatly prolonged, but so long -as the membranes are intact, the child is in no danger. - -Two kinds of cases are met with, those in which the pains are violent, -and those in which they are weak and shallow. In the first class, as -soon as the condition is recognized, a dose of morphine sulphate, ⅙ gr. -and scopolamine hydrobromide 1/150 gr. should be given, hypodermically. -The rigid ring relaxes under the influence of the narcotic, and labor -proceeds rapidly and almost painlessly. Chloroform may be substituted if -the morphine and scopolamine are not at hand. If the cervix is effaced -and only the rigid ring of the os prevents the completion of the labor, -or if the above methods fail, then the patient may be anæsthetized and -the rigidity overcome by the fingers. This is an emergency that should -not be attempted until all else has failed and some danger arises that -makes it necessary to hasten the delivery. (See Minor Operations, p. -211). - -Where the constriction is due to unusual density of the cervix or to -cicatricial tissue, it is sometimes necessary to make incisions under -aseptic precautions so that the rigid ring may expand. - -Weak and inefficient contractions can sometimes be stimulated -satisfactorily by the introduction of a Vorhees bag. - -=Rigidity of the pelvic floor= may be due to inadequate elasticity of -the tissues as in old primiparas or in young women who have ridden -horseback for many years in the cross-saddle position. - -The head may come down to the pelvic floor but will not advance further. -If the tissues of the vulva do not, or can not yield sufficiently after -appropriate time has been allowed, episiotomy may be done. (See Minor -Operations, p. 211.) - -The uterus itself may functionate abnormally. - -=Precipitate labor= is an over rapid advance of the child wherein the -stages of labor are merged into one another and the child expelled in -two or three pains. - -It may be due to unusual capacity of the pelvis, or to strong -contractions which the patient is not aware of, or both. These cases -predispose to post partum hæmorrhage and to serious lacerations of -cervix and perineum. - -The child is usually delivered in an undesirable place, such as a toilet -basin or a street car, and perishes from the fall, from cold, from -umbilical hæmorrhage, or lack of facilities for revival. - -The nurse who is watching a case is responsible for the prevention of a -precipitate. If the event impends, the woman must be placed upon her -side with legs straight, and she should be instructed to cry out with -every pain. Chloroform may be given and the head forcibly held back. - -=Uterine Inertia.=—A sluggish state of the uterus may characterize the -labor and the contractions will be slow, shallow and inefficient. The -intervals may be prolonged, although the patient complains bitterly of -pain. - -The condition is seen most frequently in multiparas and is due to -defective innervation of the uterus or to imperfect reflexes, and in -primiparas also it may be due to the newness of the function that is -suddenly called into play, or to contracted pelvis. Many times the -trouble results from overfatigue and want of sleep. If this is the case, -the remedy may be found in the administration of morphine sulphate ⅙ gr. -and scopolamine 1/150 gr. The pains are diminished or abrogated while -the contractions continue. The scopolamine may be repeated if necessary. -Under proper indications and conditions this treatment is harmless, both -to mother and child, but requires supervision on the part of the nurse -or physician. - -If the patient is not overly fatigued, the introduction of a Vorhees -bag, as described under the head of Induction of Labor (p. 208) will -dynamically increase the strength and frequency of the contractions, -mechanically aid the effacement of the cervix and the dilatation of the -os, and shorten the first stage anywhere from six to twelve hours. - -As soon as the os is dilated, pituitrin may be given under due -precautions, as hereafter indicated. Pituitrin has but little influence -on the nonfunctionating organ, but acts well on a uterus which is -definitely contracting. It should not be given during the first stage, -since when the uterus contracts, there must be an adequate opening for -the advance of the child. Five to seven minims is the usual dose, -injected into the deltoid muscle. The injection may be repeated in an -hour, if required, since the effects, which begin about five minutes -after the injections, will pass off in fifty-five minutes. - -By the use of pituitin many operative procedures are altered or avoided. -A high forceps case may be converted into a case for the low -instruments, and the latter in many instances avoided altogether. - -The use of pituitin may be briefly summarized as follows: - - - =Pituitrin= - - (Use no alcohol to cleanse syringe or skin before injection.) - - - _Indications._— - - 1. Inertia uteri or weak, shallow pains in second stage. - - 2. Multiparity. - - 3. Post partum hæmorrhage. - - 4. To avoid use of forceps or to reduce a high forceps case to a - low one. - - 5. Cæsarean section. - - If the patient is a multipara, sterile linen should be on and - attendants ready for the delivery before an injection is given. - - - _Conditions._— - - 1. Cervix effaced. - - 2. Os admits three fingers. (Better if membranes have ruptured.) - - 3. Head should be engaged. - - 4. No mechanical obstacle to delivery such as tumors or markedly - contracted pelvis, etc. - - - _Dangers of Long Labors._— - - Compression of cord. - - {Vesicovaginal fistulæ. - Necrosis of maternal tissues. { - {Rectovaginal fistulæ. - - Infection—peritonitis. - - Necrosis of skin over skull. - - Necrosis of cranium. - - Fracture of skull. - - Death of child. - - Maternal exhaustion and prolonged convalescence. - -=Premature rupture of the membranes= not infrequently occurs from -over-distention, when twins or hydramnios is present, or at any stage of -the pregnancy when the membranes are weak. The liquor amnii flows off, -not all at once, but after the first gush by intermittent discharges, -depending on the painless uterine contractions and the accuracy with -which the head fits the pelvis. Labor usually comes on in from twelve to -forty-eight hours, but it _may_ be postponed for a month. - -The labor is sometimes more painful and prolonged on account of the -absence of the fluid wedge and the generous lubrication of the channel -which is supplied by the liquor amnii. - -The danger of infection of the amniotic cavity with consequent death of -the child is always to be apprehended after the escape of the liquor -amnii. Also the fœtal parts may prolapse and complicate the labor; or if -the cord comes down, the child may be imperiled by its compression. - -If near term, the rupture of the membranes is not of great importance -though the case must be watched attentively. Daily observation must be -made of the fœtal heart tones, the amount of liquor amnii flowing away, -and the presence or absence of infection. If labor does not determine in -a few days or if the heart tones rise above 160 or go below 120, labor -must be inaugurated. (See Induction of Labor, p. 208.) - -=Rupture of the uterus= is the most serious accident that occurs in -labor. It happens about once in three thousand confinements. The tear is -usually in the lower part of the uterus and follows a prolonged period -of labor, where the child is in a transverse presentation, and, -therefore, impossible to deliver, or the pelvis is too small or the -child too large. It may also follow ill-advised or unskillful efforts to -change the presentation by the introduction of the hand into the uterus. -Occasionally rupture is produced by external violence, such as blows or -kicks upon the abdomen. - -It is imperative to be able to recognize the symptoms when rupture -impends or actually occurs. - - -_Signs of Threatened Rupture of Uterus._— - - 1. High position of the contracting ring—especially its obliquity. The - contracting ring is a ridge-like formation that may be found - running across the anterior and lower portion of the uterus. - - 2. High position of fundus. - - 3. Tension of round ligaments. - - 4. Rotation of uterus about its long axis. - - 5. Tenderness to pressure of lower uterine segment. - - 6. Contractions persistent with no pain-free interval. - - -_Signs of Actual Rupture of Uterus._— - - 1. Hæmorrhage is one of the earliest and most significant signs, and - may be either external or internal. - - 2. Cessation of uterine contractions either abruptly or gradually. - - 3. Extreme pain felt by patient. - - 4. Recession of presenting part. - -The patient gives a sharp cry and has the feeling that something has -given way. Signs of shock rapidly supervene. A predisposition to rupture -may be present from the scars of a Cæsarean section, uterine tumors, and -degeneration of the muscle. - -_The treatment_ depends upon the degree of the injury, and if -investigation shows that the uterus has opened into the abdominal -cavity, immediate laparotomy is done. In other cases, the morcellation -and removal of the child by the natural passage may permit the use of a -uterine pack and avert the necessity for an abdominal operation. The -child is usually dead and need not be considered. - - - - - CHAPTER XV - COMPLICATIONS IN LABOR (Cont’d) - - -=Vomiting= in labor frequently occurs near the end of the first stage. -It is due to the sympathetic excitement of the nerves of the stomach as -the last fibers of the os uteri give way. It requires no treatment. - -Hyperemesis in labor is very rare, but when it does occur, the delivery -should be expedited. - -=Hæmorrhages= may occur either before, during, or after labor. -Hæmorrhage is always serious. - -Hæmorrhage before labor arises either from a premature detachment of a -normally implanted placenta or from placenta prævia. The first is -sometimes called “accidental hæmorrhage” to distinguish it from the -latter, or “unavoidable hæmorrhage.” - -=Accidental hæmorrhage= may be the result of an injury or a blow, but in -many cases, there is no such history. The hæmorrhage is most frequent in -the later months of pregnancy, and may be without any apparent cause. -The hæmorrhage may be entirely inside the uterus (concealed hæmorrhage) -or it may appear externally. - -The hæmorrhage, when concealed, takes place back of the placenta or -between the membranes and the uterine wall. If the hæmorrhage is -concealed, it is usually followed by an attempt to expel the child. If -the hæmorrhage is pronounced, systems of shock appear. - -_The diagnosis_ is made by the symptoms which are summarized in -differentiating this condition from placenta prævia (p. 231). - -From this affection, nearly all the children and half the mothers die. - -[Illustration: Fig. 99.—Various forms of placenta prævia compared with -normal attachment of the placenta. (American Text Book—Williams.)] - -When the hæmorrhage is external and slight, the _treatment_ may possibly -be expectant for twelve hours, if carefully watched, but usually the -symptoms become so serious that immediate emptying of the uterus is -required either by the Vorhees bag, digital dilatation, version and -extraction, or Cæsarean section, the method chosen being dependent upon -the amount of the hæmorrhage, the vigor of the mother and the condition -of the cervix, os, pelvis, and child. - -=Placenta prævia= is the name given to a placenta that is attached low -down in the uterus so that its margin or a large part of its mass -overlies the os. This happens through the action of the egg which embeds -itself too far down on the endometrium—too close to the cervix. - -Three different kinds are known and named from their manner of -encroaching on the os, as marginal, partial, or central implantation of -the placenta. - -The hæmorrhage is from a loosening of the placental attachment owing to -the stretching and growth of the uterus. - -_There is only one symptom of placenta prævia—sudden, painless, -causeless hæmorrhage._ The bleeding seldom appears before the -twenty-eighth week, and no suspicion of a placenta prævia may arise -before the appearance of hæmorrhage, which, as a rule, _is soon -repeated_. - -Labor frequently comes on prematurely and malpresentations naturally -result from the inability of the presenting part to fit itself into the -pelvis. - -There is no bag of waters, hence the first stage is longer and bloodier -and fraught with much danger. - -Interference is regularly indicated to save the life of the mother, -while the child also has a high mortality. Puerperal infection is not -uncommon. - -Placenta prævia is always an emergency. If the patient can be kept under -observation in a good hospital, one may temporize, but under other -conditions the uterus must be emptied at once, even if only a single -hæmorrhage has developed. The indications are, (a) to control the -bleeding, and (b) to empty the uterus. The life of the child must be -disregarded and the mother alone considered. - -If the contractions have not begun, they should be stimulated by the -introduction of a Vorhees bag, which, at the same time, dilates the -canal and mechanically shuts off the bleeding vessels by compression. In -introducing the bag, the membranes may be ruptured so the bag will pass -into the uterine cavity. When the implantation is central, the finger -must tear a hole through the placenta, and through this opening pass the -bag inside the uterus. - -If the os is partially dilated, version may be done, and a foot brought -down. The leg may then be pulled upon until it compresses the bleeding -area and the traction maintained with a slowly developing pressure -sufficient to check the hæmorrhage, until dilatation is advanced enough -for delivery. Occasionally good results are obtained by tightly packing -the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. -204.) - -Cæsarean section may be done in the interests of the child, as well as -the mother. - -The fœtal mortality in placenta prævia is said to be 60 per cent and the -maternal 10 per cent. - - _Differential diagnosis between_ - - _Accidental hæmorrhage_ _and_ _Placenta prævia_ - - Usually occurs in later months. Any time after the twenty-eighth - week. - - May be concealed or open. Always open and external. - - Soon followed by labor pains. Labor need not occur. - - Uterus becomes larger if bleeding Uterus remains same size. - is concealed. - - Uterus hard and woodeny. Uterus, normal consistency. - - In severe cases, signs of shock In severe cases, signs of shock - whether hæmorrhage is external or follow the invariable external - internal. hæmorrhage. - - No placenta can be felt. Placenta can be felt through the - os. - - Hæmorrhage continues. Hæmorrhage intermittent. - - No history of previous attack. Possibly history of previous - attack. - - No contractions after labor begins Contractions as usual. - in serious cases. - - No bogginess of cervix. Cervix boggy. - -Hæmorrhages may occur _during labor_ from retention of the major part of -the placenta while a portion is detached. This may be due to -pre-existent disease, such as endometritis, or from uterine inertia. - -Normally the placenta will separate and be discharged within an hour -after labor and in the absence of hæmorrhage it may go even longer than -this with safety. The occurrence of severe hæmorrhage, however, requires -the immediate cleaning out of the uterus by inserting the hand and -peeling the placenta from its attachments. - -=Post partum hæmorrhage= includes all hæmorrhages that occur after the -delivery of the placenta. - -The “flooding” as it is called by the laity, is most apt to come on -either immediately or within an hour or so after labor. If it comes on -_after_ the first twenty-four hours, it is called secondary hæmorrhage. -Such predisposing causes as over-distention from twins may be present, -but the hæmorrhage may follow a perfectly easy and apparently normal -labor so suddenly and so profusely that the woman may die in half an -hour. - -There are four causes for post partum hæmorrhage: namely, (a) uterine -exhaustion (atonia uteri); (b) mechanical obstacles to retraction, such -as clots or retention of pieces of placenta or membrane; (c) and -lacerations of some part of genital passage, such as the vulva, vagina, -cervix, or lower uterine segment; and (d) the systemic condition known -as hæmophilia. - -“Bleeders” (hæmophilias) are women whose blood lacks coagulability, -owing to the absence of fibrin-producing elements. - -Post partum hæmorrhage is usually an external hæmorrhage, but the woman -may bleed to death into her own uterus. - -Besides the external signs, the patient may show the symptoms of acute -anæmia, such as the rapid pulse, hurried, shallow respiration, pallor, -cold sweat, yawning, dizziness, etc. - -Nearly all these cases can be saved by prompt recognition and efficient -_treatment_. - -The first step is to grasp the uterus. If the hæmorrhage is due to a -tear low down, the uterus may be hard, but generally it is relaxed and -requires vigorous massage with both hands before it shows any signs of -contraction. In the absence of the doctor, the nurse must know how to -undertake this maneuver. The uterus, after labor and especially when -relaxed, is sometimes difficult to identify and the nurse can only make -deep massage in the pelvis until the organ responds and its hard -globular mass can be appreciated. As soon as the uterus contracts, clots -and contained blood are expelled, and in many cases its bleeding ceases -at once. (See Conduct of Third Stage, p. 149.) - -It may be necessary to keep the uterus contracted by manual massage in -this way for several hours. As soon as possible, the nurse, or someone -whom she directs, prepares a hypodermic of pituitrin—10 to 15 ♏︎. An -injection of ergot may follow because its effect is more lasting than -pituitrin. Next, a hot douche is made ready and the materials for -packing the uterus are assembled. - -When the doctor arrives, he sterilizes his hands, puts on gloves and -introduces two fingers or the whole hand into the uterus to remove clots -or any retained fragments of placenta. - -The hot intrauterine douche may follow, and if the contraction is not -firm and the hæmorrhage checked, the uterus must be packed with gauze. -If hæmorrhage comes from cervix, it should be grasped with long forceps, -pulled down, and sutured. If from perineum, pack first, and afterward -sutures may be introduced. - -If the patient is exsanguinated, the foot of the bed is raised, coffee -given by mouth, camphorated oil hypodermically, and normal saline -transfused under the breasts. - -Pituitrin may be continued in larger doses. 1 c.c. will raise the blood -pressure very definitely. Adrenalin also may be employed for this -purpose. - -The following summary may be found convenient: - - - =Post Partum Hæmorrhage= - - - _Etiology, Functional.—_ - - Atony of the uterus, especially after rapid artificial or natural - emptying of the organ. - - More common after uterus has previously been greatly distended. - - Premature version and extraction. - - Hydramnios and twins. - - Imperfect development of uterine musculature. - - Precipitate labors. - - Haste or improper management of third stage. - - - _Etiology, Mechanical.—_ - - Retention of placenta—partial, total or solitary cotyledons. - - Inversion of the uterus. - - Placenta succenturiata. - - Inflammation of decidua serotina. - - Conduct of third stage, i.e., wait until placenta separates. - - - _Etiology, Systemic, Hæmophilia.—_ - - _Kind of hæmorrhage._ - - Hæmorrhage _before_ expulsion of placenta due to laceration of the - soft parts, or - - Partial release of placenta and failure of uterus to contract, or - - Placenta may be attached to periphery or to one side. - - Attempts to expel placenta without waiting for uterine contraction - are sometimes productive of hæmorrhage. - - Hæmorrhage _after_ expulsion of placenta. - - Hæmorrhage in interval between pains—comes from placental site. - - Hæmorrhage in stream not checked by uterine contraction is due to - laceration of the canal. - - Hæmorrhage in abnormal quantities at beginning of pains. - - Pure atony—comes early. - - Hæmophilia again. - - - _Diagnosis.—_ - - Palpation of uterus through abdomen. - - Placental site excluded from contraction (paralysis). - - View of vulva. - - Injuries. Flow continuous, fluid and bright red, shows arterial - origin, probably from cervix. Examine. - - Atony—bleeding at intervals, clotted and dark. - - Hæmorrhage from a tear begins at once. - - Uterus contracted and hæmorrhage continues. Look for tear. - - If hæmorrhage does not begin within ten or fifteen minutes after - labor it is not from a tear. - - Always have hæmophilia in mind. - - - _Management.—_ - - Third stage must be conducted properly. - - Before expulsion of placenta—early expression. - - Credé or manual removal—then secure contraction by massage. - - Pituitrin, Ergot, or both. - - - _After Third Stage.—_ - - Restore an inverted uterus. Repair lacerations. See that cavity is - clear and clean. - - Massage, intrauterine hot water douche, hand in uterus and hand - outside and rub, ergot. - - Pituitrin hypodermically. Pack uterus with sterile gauze or weak - iodoform gauze. Strict asepsis for all intrauterine maneuvers. - - _Treat_ anæmia with transfusion, elevation of foot of bed, coffee, - external heat, hot rectal enemas, stimulation, bandaging of - legs. - - Strychnine sulphate, adrenalin, or camphorated oil may be required - in usual dosage. - - Hypodermoclysis. (See Minor Operations, p. 206.) - -After the bleeding stops, the food must be most nutritious—milk, eggnog, -rich soups, chicken and mutton broths, oyster stew, and beef steak as -soon as she can take it. A diet of fluids and stimulating foods that -raise the blood pressure will most quickly relieve the symptoms. - -[Illustration: Fig. 100.—The knee-elbow posture. (Bumm.)] - -[Illustration: Fig. 101.—The knee-chest posture.] - -=Eclampsia= occurs in the last three months of pregnancy as a rule, and -most frequently just before or during labor. - -In about one sixth of the cases only, the attack may follow labor. The -attack is characterized by violent convulsions, which come on with -little or no warning unless the urine has been carefully watched. - -[Illustration: Fig. 102.—The exaggerated lithotomy position obtained -with a sheet sling. (American Text Book.)] - -[Illustration: Fig. 103.—The improvised Trendelenburg position. -(American Text Book.)] - -The _prodromal symptoms_ have already been described under albuminuria -in pregnancy (p. 77). The marked features may be repeated for emphasis: -_persistent headaches_, _disorders of vision_, spots before the eyes, -blindness, edema of cheeks, eyelids, feet and hands, _pain at the pit of -the stomach_, _dizziness_, _nausea and vomiting_ and ringing in the -ears. Suddenly the convulsion occurs, the facial muscles twitch, then -the limbs and body are shaken by violent muscular spasms. The body -becomes rigid, the tongue protrudes and the face is livid and cyanotic. -The spasm usually lasts from one to five minutes and is succeeded by -coma that lasts an hour or more. In some instances there is no return to -consciousness before the next attack, which comes on every hour or half -hour, though occasionally only one seizure is noted. - -[Illustration: Fig. 104.—The dorsal position with stirrups. (Dorland’s -Dictionary.)] - -The blood pressure is greatly increased and the urine is diminished, the -temperature rises to 101° or 102° F. When death ensues, it is most -frequently due to edema of the lungs or cerebral hæmorrhage. - -The greater the number of convulsions, the more serious the outlook as -to life, and it is said that after twenty seizures fifty per cent of the -mothers die. Under the best treatment approximately fifty per cent of -the babies die. - -[Illustration: Fig. 105.—Dorsal position across the bed. (Bumm.)] - -There is no routine treatment for eclampsia. - -The principles of management for the attack are (1) to empty the uterus, -on the theory that the disease is a toxæmia of gestational origin, (2) -to eliminate the poison, and (3) to control the convulsions. - -The albumin in the urine and other eclamptic symptoms demand urgent -attention in prophylaxis. - -For the pre-eclamptic period (see Albuminuria of Pregnancy, p. 77) a -rigid milk diet is indicated. The bowels, kidneys, skin and blood -vessels must all be brought into service. - -In the full blooded patient, venesection may be done and after drawing -off ten or twelve ounces of blood, an equal amount of normal saline may -be poured into the same vein. - -[Illustration: Fig. 106.—Flexed dorsal position with feet on the table. -(American Text Book.)] - -Subcutaneous transfusion or the submammary introduction of saline -solution may be done. The skin is stimulated by hot wet packs and the -bowels by saline cathartics and frequent irrigation of the colon. - -During the attack, the patient must be kept from injuring herself. A -spoon wrapped in gauze or a small, long roller bandage should be slipped -between the teeth to keep the tongue from injury. The clothing must be -loosened or removed. No food, but only water is given by mouth, until -the patient is conscious. - -The convulsions are controlled by morphine, chloral, or both. - -Morphine sulphate, ¼ gr. is given hypodermically, followed in an hour by -30 gr. of chloral by mouth. Two hours later the morphine is repeated and -six hours after the first dose of chloral, it is repeated. In this -method (Stroganoff’s), four doses of chloral and six of morphine are -given in twenty-four hours. That is all. When the stomach will not -retain the chloral it may be given by rectum in milk. If a general -anæsthetic is used, it should not be chloroform, but ether. - -[Illustration: Fig. 107.—The Sims position. (Kelly.)] - -The labor, if begun, should be expedited by forceps, or version and -extraction. Bleeding during delivery should be looked upon as desirable. -If more rapid measures of delivery seem demanded and obstacles exist, -such as pelvic contraction, imperfect dilatation, or the prospect of a -prolonged first stage, Cæsarean section or forcible delivery -(accouchment forcé) may be attempted. - -If the labor has not begun, when the convulsion occurs and a quick -delivery by the normal passage does not seem feasible, then the Cæsarean -operation may be the best treatment. - - - - - CHAPTER XVI - THE ABNORMAL PUERPERIUM - - -The practice of obstetrics has many features that are very gratifying to -the nurse and physician. - -Instead of a surgical operation, which has come unexpectedly and -undesired; a disaster in which some part of the body is removed or -altered by means of a procedure associated with extreme pain, mental -tribulation and large expense, a much-wished for addition is brought to -the family, with pain, to be sure, but a pain that is soon forgotten in -the general joy. This is the normal condition that causes the nurse and -the doctor to rejoice that such a delightful specialty has been chosen. - -Then comes a case in which the labor may be complicated by some dreadful -anomaly, or the puerperium burdened or disordered by some unwelcome -invasion that tortures the souls of the family and may cost the life of -the mother, or child, or both. - -At such a time the nurse and the doctor feel the full weight of their -responsibility, and after a series of anxious days and sleepless nights, -they wonder why they did not choose gardening or a clerical position for -their life work. - -The disorders of the puerperium are many and various, but naturally the -breasts and the pelvic organs are most frequently affected. - -=The breasts= of the human female are not reservoirs of milk like the -cow’s, but a pair of highly sensitive organs that functionate and -produce only as the demand is made. It follows that when the milk comes -in, the breasts become engorged and all the neighboring structures are -involved in the new process. However, it is not milk that is overfilling -the breasts, but serum, lymph and venous blood, which congest the -tissues surrounding the glands and produce a hard painful mass. - -The breasts become heavy, hot, and painful; supernumerary glands in the -axillæ enlarge, but there is no fever. There is but little more reason -for a fever when the mammary gland begins to functionate than when the -lungs fill for the first time except in the case of nervous patients who -bear discomfort badly. - -If fever appears simultaneously with the milk, the cause must be sought -in some atrium of infection, possibly in the breasts, but usually -elsewhere. There is no such thing as “milk fever.” The enlarged glands, -the tense mottled skin on which blue veins run visibly here and there, -the nipple, flattened and drawn into the swelling, so that the child can -not grasp it with the mouth, all produce a sense of disorder that ought -to be associated with fever—but is not. This is the “caked breast” of -the laity, and if let alone, the hyperæmia subsides and the function -remains. The temperature in possibly two cases out of five may rise to -100° F. for twenty-four hours, but it promptly subsides. These -temperatures generally occur in neurotic women. - -If the breasts are irritated by binders, breast pumps, or massage,—like -the blacksmith’s arm, with exercise—the trouble, if not increased, is at -least much slower in disappearing. - -It is reported that the young virgins of some African tribes nurse the -babies in the family, the breasts being stimulated to produce milk -largely by massage. - -If the condition of the breasts becomes too painful, the liquids by -mouth are reduced to the last degree, saline cathartics are given until -frequent watery stools result, one or more ice bags are applied to each -breast and codeine sulphate may be given at night. The child nurses -every four hours only. Williams was the first to show that no tight -binder is necessary, but only a supporting bandage. The tight binder is -a cruel and useless barbarism that has been abandoned by progressive -physicians. No massage is allowed; no pumps; no irritation whatever, and -in twenty-four hours the trouble has disappeared. Hot dressings to the -breast are equally archaic. They should _never_ be applied to any breast -unless it is desired to hasten suppuration. - -If the child dies, or for any reason can not nurse (inverted nipple, -cleft palate, harelip) and it becomes necessary to dry up the milk, the -treatment for “caked breast” is continued. After twenty-four hours the -breasts are comfortable and rarely give trouble again. - -_Cracks, Fissures and Abrasions of the Nipple._—The care of the nipples -should be inaugurated about six weeks before labor, as elsewhere -described: - -The nipple must be inspected and its possibilities determined, early in -pregnancy, if possible, for many varieties of badly shaped and -ill-developed nipples exist which may make nursing difficult or -impossible. - -Imperfect nipples especially are predisposed to fissure and crack, and -will require extreme care on the part of the nurse. She should inspect -them before and after each nursing and sedulously use cleanliness and -asepsis in her management. In normal and tranquil as well as in neurotic -women, the nipple may become so sore as absolutely to preclude nursing, -and this entails much additional work on the nurse and mother, as well -as considerable peril for the child. The condition usually begins as a -fissure or crack, and is accompanied by much pain. It is serious, -furthermore, in another aspect since all breaks in the surface of the -nipple are avenues of infection that may result in mastitis. The child -may produce fissures or abrasions by rubbing the nipple with his mouth, -by pulling too hard, or by the habit of holding it in his mouth and -macerating it with his gums when he has finished nursing. - -[Illustration: Fig. 108.—Examples of imperfect nipples. (American Text -Book.)] - -The child must not be left at the breast after he has nursed, but the -nipple should be gently removed from the child’s mouth by passing one -finger in beside the nipple. Fissures and abrasions usually occur within -ten days if at all. Abrasions or erosions are due to the wearing away of -the epithelial covering of the nipple in patches more or less extensive. - -Thin-skinned blonde women suffer more than those with dark, dense oily -skins. - -A _fissure_ is a distinct separation of tissue that goes deeply into the -underlying substance. - -A _crack_ is a long abrasion which may deepen into a fissure. - -Both fissure and crack may affect the top, the side of the apex, or the -base of the nipple. They may be either longitudinal or circular. The -entire nipple must be kept under observation and the instant a raw -surface is detected, _treatment_ must begin. - -[Illustration: Fig. 109.—A standard nipple shield. (American Text -Book.)] - -Compound tincture of benzoin, liberally applied, is a favorite and -successful remedy. Our routine is to apply a paste made of equal parts -of castor oil and subnitrate of bismuth. This is put on after the child -nurses, and must be removed carefully before the next nursing. Sometimes -the child’s stools become black and constipated and the trouble may be -traced to imperfect removal of the bismuth preparation. - -Whatever medication is used, the nipple must be protected from injurious -friction by the clothing. This is best done by the hat-shaped lead -nipple shield, which is placed over the nipple and held in place by a -light binder. The shield should be boiled before use. - -To protect the nipple during nursing, a glass shield may be used for a -day or so, but not long enough for the babe to get accustomed to it, -else he will form a habit hard to break. This shield must be taken apart -after use, washed and kept in saturated solution of boric acid until the -next nursing. - -If all these measures fail, the fissure must be touched with a nitrate -of silver stick once, or have a 2 per cent solution of nitrate of silver -applied night and morning. It may be necessary to take the child from -the breast for a day or so, in which case he nurses the other breast and -the side with the bad nipple is pumped. - -The care of the nipple is highly important since the apprehension and -the actual pain of each nursing may prevent sleep, destroy the appetite, -and diminish the milk. If begun early, most fissures will heal in -twenty-four to forty-eight hours. - -=Mastitis.=—From three to five per cent of lying-in women have mastitis -in the European clinics, but the records in America show a much smaller -number. - -The disease occurs most frequently in blondes and in primiparas. It is -most apt to appear during the first two weeks, when the congestion -accompanying the new mammary function produces a stasis that favors the -growth of germs, which may enter through the abrasion or fissures of the -nipple produced by zealous activity of the child’s gums. But it may also -occur when the child’s first teeth come and the nipple is again exposed -to injury. At times it is impossible to find a plausible excuse for its -occurrence. - -Mastitis is usually described in three forms: The (a) parenchymatous or -glandular type, which affects the substance of the gland or the -enveloping connective tissue; in (b) subcutaneous mastitis the -connective tissue beneath the skin is attacked; and in (c) the -sub-glandular variety, the infection finds a lodging between the gland -and the chest wall. - -Mastitis is always due to the presence of microorganisms which in many -cases gain access to the gland through fissures or abrasions by means of -the lymphatics. In other instances the germs may be in the blood and a -local stasis may encourage the infection. Still again, they seem to -enter through the normal nipple openings. - -_Symptoms._—The parenchymatous inflammation begins with a chill, and the -temperature promptly rises to 102° to 105° F. The pulse is high. The -patient complains of headache and thirst. Examination reveals hard, -tender nodules in some part of the gland. The skin may or may not be -reddened. - -If the trouble has begun in the connective tissue, the skin will be -diffusely reddened, the nodule ill-defined, the temperature will rise -gradually and the chill may be absent. - -_Treatment._—The breast is put at rest. No tight binder is applied, no -breast pump, no massage. No heat is allowable. - -Ice bags surround the gland night and day. The liquids by mouth are -restricted and saline cathartics given. Codeine may be administered for -pain. Usually the symptoms subside without suppuration in from one to -two days. - -Should the inflammation persist for more than two or three days, in most -cases the tissue will break down and form a _mammary abscess_. When it -is evident that suppuration has begun, heat may be applied to the gland -and the process accelerated. The abscess may be superficial or deep and -will be diagnosed by a bogginess in a circumscribed area or by -fluctuation. The abscess must be opened as soon as possible. - -The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol -solution and cotton sponges are made and sterile gauze for packing. The -hands are surgically prepared and rubber gloves worn. If an anæsthetic -is required, gas may be used, or chloroform. The incision is made -radially from the nipple so as to minimize the injury to the milk ducts. -A gauze drain may be required for a few days. - -In the _after-care_, the nurse must be scrupulously clean and not convey -contagion from the breast to the woman’s genitals, to the child’s eyes, -navel or vagina, nor to her own person. - -=Excess of milk= is rare, but may be observed for a short time after the -glands fill. It seldom requires treatment, but saline cathartics, -restriction of fluids, and putting the child on a four-hour schedule -will reduce it. Pads may be worn if it runs away freely. - -=Scarcity of milk= is only too common. There may be enough at first and -the quantity gradually diminish, or it may be deficient from the very -beginning. - -The faulty secretion may be due to the age of the mother, to disease -(anæmia), to bad nutrition, or to overwork. It may follow a premature -child. Compression of the breasts by corsets or tight dresses may -prevent development. The amount of gland tissue is very important. Many -women have large, fat breasts, but a small glandular development. Mental -conditions, such as fright, worry, and anxiety, will diminish the flow -of milk or stop it altogether. - -_Symptoms._—The child is fretful, goes to sleep after nursing but soon -wakes up, or may nurse awhile, and then finding it useless, will cry and -refuse the nipple. He loses weight and when weighed before and after -feeding, the scales scarcely vary. No secretion or very little can be -squeezed from the breasts. The child may be given a bottle after which -he goes to sleep. - -_Treatment._—When the gland tissue is defective, no treatment can -succeed. - -The appetite must be improved by bitter tonics and the mind relieved of -its anxieties, if possible. Change of scenery may help. The fluids must -be increased, milk, cocoa, chocolate and gruel must be pushed, and such -vegetables added as corn and beets. Oyster stews, clams, lobsters, and -crabs will help. The diet must be full and nutritious with especial -stress on those foods that raise the blood pressure. Malt drinks or -champagne may avail in some cases. Exercise in moderation is desirable. - -Artificial stimulation of the breast sometimes succeeds. Massage will -irritate the glands, increase the congestion, and promote functional -activity; or a Bier vacuum apparatus may be put over the gland several -times a day and the air pumped out. The breast should be kept distended -for fifteen to twenty minutes. There is difficulty in this country in -getting glass bells of sufficient size. - -=Galactorrhœa= is the name applied to an abundant secretion of milk poor -in quality toward the end of a long lactation or after the child is -weaned. The symptoms are an almost constant flow of milk with resultant -anæmia. - -_Treatment._—Elix. of iron, quinine and strychnine with compression of -the gland. A dry diet and the avoidance of all irritation of the breasts -will aid. - -To “dry up the milk,” follow the treatment for “caked breast.” - -[Illustration: Fig. 110.—A standard breast pump. (American Text Book.)] - -=Quality of the milk= may be such that the child will not take it or, if -taken, it fails to nourish. In some cases this is due to overlong, or to -irregular, periods between feedings; for when the nursing interval is -too short, the milk becomes too rich, when too long, it becomes thinner -and less nutritious. - -Fright, anxiety or anger may change the character of the milk so that -colic, vomiting, and diarrhœa and indigestion are produced in the child. -A wet nurse becomes homesick and the milk dries up. It may become -extremely indigestible, as shown in cases where a wet nurse quarrels -with her husband and her foster child develops green stools. If the -mother’s milk does not agree, the child may be put on feedings for -twenty-four or forty-eight hours, while the milk, pumped from the -breast, is sent to a laboratory for analysis. If a return to the breast -is unsatisfactory, artificial feedings or a wet nurse must be supplied. - -=Removal of the child from the breast= may be required for a variety of -reasons. Thus, the mother’s addiction to alcohol or opium is good ground -for taking away the child. Arsenic, bromides and iodides of potassium, -saline cathartics, salicylates, alcohol, opium and belladonna must be -given to the mother with great caution during lactation, for they pass -over into the milk. - -Acute diseases, such as erysipelas, pneumonia, diphtheria, typhoid, -malaria, pronounced puerperal sepsis or persistently high fever from any -cause, usually dries up the milk; while cardiac lesions, unless well -compensated, chronic anæmia and tuberculosis, obviously demand the -removal of the child for the sake of both. Sometimes a new conception, -especially when the milk becomes poor in the last half of gestation, -compels the mother to wean her babe. - -A syphilitic woman may nurse her own child, provided her condition is -good and the child also is syphilitic. - -Theoretically, the return of menstruation in no way affects the nursing -child, unless the blood is lost to the point of anæmia. Yet cases do -occur in which the child has indigestion, colic and bad stools, as well -as loses weight, when the mother is menstruating. - -The quality of the milk is sometimes altered, but only for a day or so, -and the child should continue at the breast unless some definite -indication for removal arises. - -=Weaning= ordinarily is completed by the ninth month, but the child -should never be carried beyond the twelfth month on account of changes -in the character of the milk. - -When a child is weaned, the substitution of an artificial food may be -made gradually,—a bottle a day, two bottles a day, etc., until, in a -couple of weeks, the breasts are at rest. - -The excessive prolongation of lactation is shown upon the mother by -impairment of the health. The patient is pale, weak, anæmic, fretful, -and thin. Headaches, dizziness, loss of appetite, and constant fatigue -will be complained of. - -The _treatment_ is to remove the child at once and put the mother on -stimulating drugs and foods. A change of air and scenery, if possible, -will be highly beneficial. - -=The wet nurse= is always a tribulation, which must be endured until the -child can be put on artificial food. She should have a Wassermann test -before entering upon her duties. Syphilis, tuberculosis, and gonorrhœa -must be guarded against. She must be kept like the family cow, in a -placid frame of mind, fed on nutritious food that is not too rich, and -exercised enough to keep the blood circulating. - -Light housework and duties that take her out of doors part of the time -are advisable. Her moral character can only be assured through those who -have known her. If she brings her own child with her, she will need -watching to provide for an equable distribution of the milk. The first -few days is never a criterion of a wet nurse’s effectiveness. Change of -food and surroundings may interfere with her usefulness. - -=Gas= may complicate the puerperium after Cæsarean section, and even -after normal labor. A rectal tube of soft rubber may be passed as high -as possible into the bowel and left for some time, or enemas of S. S., -turpentine, asafœtida, or milk and molasses may be given. By mouth -calomel or mag. cit. is valuable. - -=Headache= in the puerperium should be watched carefully, and the cause -discovered. Pain in the head may be a habit with the patient, or it may -be a symptom of some complication either present or developing, such as -toxæmia, eclampsia, or acute yellow atrophy of the liver. In general, it -is due to milder conditions like exhaustion, too many visitors, -excitement, nerves, or insomnia. - -=After-pains.=—Sometimes patients are greatly annoyed by after-pains. -The pain may be due to a clot retained in the uterus or possibly a -stimulation of the uterus when the child goes to breast. Gentle massage -of uterus, or ergot, quinine, or codeine may be required to bring about -the expulsion of the clot or to control the pain. A reasonable degree of -after-pain is of favorable significance. (See p. 154.) - - - - - CHAPTER XVII - INFECTION - - -Puerperal fever is a wound infection. - -The conditions of the pelvic organs during labor and post partum, are -well adapted to receive and develop microorganisms, for the healthy -antimicrobic power of the vaginal secretion is absent or diminished. - -A long and exhausting labor, possibly accompanied by hæmorrhage, or -terminated by an operation, has diminished the immunity and broken the -resistance of the tissues to a dangerous degree. - -The mucous membrane of vulva and vagina are torn and bruised, the -vitality lowered, and the surface covered with bloody lochia, which is -an excellent nutritive medium for microbic development. The uterus is a -vast, open wound, filled with fibrin, blood clot, and decomposing -tissue, while the whole pelvis is maintained at exactly the proper -temperature for germ propagation. - -Through these wounds, toxins are carried into the circulation, and -germs, nourished upon the abundant and favorable culture media, pass -through the uterine walls or by way of the lymph channels first into the -adjacent tissues and thence to all parts of the body. - -Certain definite organisms reach the disintegrating tissues and produce -a putrefaction. They do not, however, once their work is done, pass into -the body. But in producing putrefaction, they also produce injurious -poisons, called toxins, which do enter the body and cause an absorptive -fever known as sapræmia. - -[Illustration: - - Fig. 111.—Germs most frequently found in cases of puerperal fever. - (Kelly’s Gynecology.) 1, streptococci (in chains); 2, gonococci; 3, - tubercle bacilli (not a source of puerperal infection); 4, bacillus - coli communis; 5, staphylococcus pyogenes aureus; 6, bacillus - aerogenes capsulatus. -] - -Other organisms are the pus microbes, which begin their growth in any -favorable location and continue to spread and flourish onward and inward -by blood vessel, tissue or lymphatic, until overpowered by the -resistances of the body, or until by general sepsis, they have killed -the patient. These are the streptococcus, staphylococcus, bacillus coli -and bacillus pyocyaneus. These are the germs that the nurse or the -doctor may bring to the patient on hands, clothing, or hair. These are -the organisms against which our scrupulous asepsis and antisepsis is -directed. It is against them and their activities that the doctor and -nurse prepare by the long and painful scrubbing of the hands and elbows, -the rubber gloves, by the shaving and scrubbing of the patient, and by -all the paraphernalia and equipment that go to furnish the modern -lying-in-chamber or delivery room. It is on account of these germs that -the conscientious doctor or nurse lies awake nights and painfully -reviews his technic when his patient has a temperature, and it is on -their account that he shudders at the callous disregard of human life -that is shown by those who do not observe the known laws of asepsis. - -It is true that many women escape when the attendant is unclean, but -this is due to a splendid immunity, and in no way absolves the man or -woman who neglects his asepsis and has patient after patient running -temperatures, some of whom are bound to die or be crippled for life. It -is for this reason that a surgeon should do surgery and not general -practice; it is for this reason that an obstetrician should limit -himself to the care of women in childbirth and not endanger them by -taking cases of scarlet fever, erysipelas, and unclean surgery. - -In country practice, all kinds of work must be done since there are not -enough men to specialize, but it is inexcusable in the city where a man -can always be clean and keep clean, if he is willing to forego the -income derived from attendance upon septic and infectious cases. Any -article not surgically clean may contaminate the patient by contact; but -ulcers, suppurating wounds, abscesses, and hands improperly or -insufficiently cleaned are the deadliest causes of post partum -temperature. - -Infections are said to be either self-produced or brought to the patient -from without. - -The only organism that is demonstrably self-infectious is the -gonococcus, which may be present in the vagina before labor and may -infect the puerperal woman; but it is wiser, safer, and more nearly -accords with the facts, to regard all infections as alien borne, as -brought to the patient and introduced by the unclean hands or -instruments of her medical attendants. - -=Prevention.=—A conscientious and capable nurse or doctor will not go -from an infected case to a confinement. Both will keep their bodies -clean, the teeth filled, and pyorrhœas scraped and treated. The -occurrence of pus anywhere on the body is sufficient reason for the -doctor to give up his confinements for a time, and the nurse to report -off duty. - -No raw, and but few mucous surfaces should be touched by the fingers of -the attendants, where a sterile instrument can be used. - -The nurse should never make vaginal examinations unless an emergency -exists, and then only when her instruction has been thorough and her -experience great. Every examination is a possible source of danger, no -matter how carefully the hands and patient are prepared. The nurse is -not to change the pads without washing her hands, and she must wash her -hands always after changing the pads, before dressing the navel of the -child. - -The navel or eyes of the child may be infected easily by the hands of -nurse, doctor, or patient. The breasts of the mother may be infected by -the hands of nurse, doctor or patient. The vulva and vagina of the -puerperal woman is highly susceptible to infection from the hands of -nurse, doctor or patient. - -_Rule._—_All temperatures arising in the puerperium are due to -infection, unless satisfactorily explained by finding the source._ The -possibility of a slightly elevated temperature from insignificant causes -may be kept in mind, but such temperatures are transient and yield -quickly to appropriate treatment or to none at all. - -Puerperal infection is most apt to appear during the first week of the -lying-in period, and it generally develops about the third or fourth day -post partum. If the symptoms come on later than this, there is always a -hope that the infection has taken its origin in something else than the -labor. - -_Symptoms._—In mild cases, a rapid pulse, headache, and a temperature of -101° or 102° F. may be the only symptoms. Severe cases begin with a -chill, followed by a marked rise of temperature. The temperature is -always irregular and generally remittent. - -The pulse rises to 120 or 130 beats a minute, headache and prostration -appear, occasionally associated with vomiting. - -The flow of lochia may be either increased or diminished and either -offensive or free from odor. Foul-smelling lochia is a sign of -putrefaction but not necessarily of sepsis. - -At the same time there is some tenderness in the lower part of the -abdomen, usually most marked at the sides of the uterus. The uterus is -larger than it should be, and not hard, but doughy and sensitive to -touch. - -The involution is arrested, except in cases of pure septicæmia. This is -an important reason for the daily observation and recording of the -regular descent of the organ. - -The disease runs a variable and more or less prolonged course and the -prognosis is always doubtful until the event. Signs of grave import are: -repeated chills, insomnia, pulse above 120, persistent vomiting and -meteorism, with dry, brown tongue. - -_Treatment._—Mild cases without chill when the uterus is large and the -lochia sometimes offensive, are usually sapræmic. Free catharsis, ergot -in full doses, and a half-sitting position to aid drainage will cause -the symptoms to subside in two or three days. - -In the severe type, the treatment is mostly a case for careful nursing. -The more energetically the doctor acts, the more liable he is to do -harm. The patient needs all her strength to fight the disease, and -should not be required to fight the consequences of injudicious -interference. - -There is still some discussion about the advisability of assuring -oneself that the uterus contains no remnants of the labor. Some feel -that this should be determined by curetting the uterus with finger or -instrument and following the operation with an intrauterine douche. If -this is the view of the attending man, the nurse must aid, for the -responsibility is his and not hers. - -On the other hand, the weight of authority at present seems inclined to -the view that any remnant of the labor will drain out naturally or be -expelled by ergotdriven contractions without the necessity of opening up -new raw surfaces by interference and thus spreading the infection. - -The main idea is to promote drainage in every way possible. No curette, -no douche, no uterine packing. Nevertheless, the vulva may be cleansed -and the vagina carefully retracted and by appropriate means a culture -obtained from the uterus. If this shows streptococci, all local -treatment is to be abandoned at once. - -In general, the food must be fluid, and as nutritious as possible. This -means milk, beef and mutton broths, oyster stew, etc. The nourishment -must be pushed artfully and ingeniously. Alcohol is not indicated. The -bowels are kept open. - -Normal saline, drop method, by rectum, will promote diuresis, skin -action, and supply the body with the much needed fluid. Subinvolution is -controlled by ergot in full doses. The room must be light and as many -windows opened as the weather will permit. Frequent change of posture, -from side to side, from dorsal to prone and especially to the -half-sitting position, will give the patient comfort and prevent -decubitus (bed sores). The daily bath with an alcohol rub, keeps the -skin in good condition and eases the mind. - -The child should be taken from the breast, because the milk is poor in -quality and quantity and it may be infectious. Besides, the mother needs -all her strength. Nature usually solves the problem by drying up the -milk. - -All pads soiled by the patient should be collected in paper bags or -rolled in newspapers and burned. Sheets, towels, and pillow slips must -be boiled in the house and not sent to the laundry. They should be -soaked for half a day in a 2 per cent solution of lysol before being -washed, and exposed to the hot sun for a day or so afterward, if -possible. No comforts should be used on the bed, and the blankets must -be left suspended in the room when it is fumigated at the conclusion of -the case. All dishes and utensils can be boiled. Plenty of air and -sunshine are essential for the cure of the patient and to prevent the -spread of the disease. - -_The nurse_ must use every precaution to avoid carrying the infection to -herself or others. Rubber gloves should be worn while changing the -dressing. It is better to have the child cared for by another nurse. The -nurse must get her rest and some exercise out of doors every day. It -rejuvenates her and reacts to inspire the patient. - -When she leaves the case the nurse should boil her linen and wash her -hair with soapsuds and hot water, and bathe frequently. - -=Milk Leg.=—This is an infection characterized by swelling of one, or -rarely, both, limbs, from the foot to the groin. The leg is white from -the edema, and as the condition is associated with fever and since the -milk diminishes or disappears about the same time, it was thought in -former days that the milk went to the leg. - -The cause of the swelling is a phlebitis of the external iliac or -femoral vein which becomes thrombosed or so filled with clots that the -return circulation is impeded. - -_Symptoms._—The attack is signalized by a rise of temperature to 102° to -104° F. There is headache, pain in the affected limb, and general -prostration. It is a true sepsis. - -The disease appears usually in the latter part of the second week of -puerperium, when the patient has begun to congratulate herself that all -danger is over. In many cases the doctor has yielded to importunity and -let the patient get up before involution was sufficiently advanced and -the patient will report that she got up too early. - -The limb must be immobilized and kept warm. The immobility should be -maintained for at least ten days after the fever has subsided and the -pain gone. - -The convalescence may be protracted over weeks and months. - -=Bed sores= may complicate a long convalescence. Bathing with alcohol or -alcohol and alum, and the frequent change of the patient’s position will -usually prevent them. Rubber rings and sheeting should not be used if it -can be avoided. Ointments containing zinc are of great value in the cure -of this affection. - -=Phlebitis=, in minor degree or in localized sections, may occur in the -veins of the leg and the site of the invasion will be outlined as red -lines or as irregular nodules. Some fever may attend the condition. Rest -of the affected member, with ice bags for the pain, constitute the -treatment. Bed sores must be guarded against. - -=Sudden death= in the puerperium is a shocking disaster. Rapid death may -follow the complications of labor accompanied by hæmorrhage, such as -placenta prævia, rupture of the uterus, etc.; but death may be _sudden_, -without warning, from pulmonary embolism, acute myocarditis, fatty -degeneration of the heart, or the entrance of air into the uterine -veins. This may happen several days after labor in a woman who is -passing through a convalescence apparently normal in every respect. Such -an event is probably due to a =thrombus= which may form in any of the -veins of the body, but more frequently in those of the pelvis and legs. -In the latter it may be recognized by hard lumps that form somewhere -along the course of the veins in consequence of a phlebitis. There is -always the menace that some fragment of this mass, which is merely a -hard clot of blood, may become detached and float off in the circulation -to other parts of the body, such as heart, lungs, or brain (embolism), -and by interference with those structures, produce paralysis or instant -death. When a thrombus is diagnosed, the affected part must be kept as -quiet as possible. No massage is permissible. Tincture of iodine or 20 -per cent ichthyol may be applied. The woman should remain quiet for at -least ten days after the apparent disappearance of the symptoms. - - - - - CHAPTER XVIII - THE CARE OF THE CHILD - - -Hitherto the mother and the complications and changes peculiar to her -condition have been selectively considered, to the neglect of the child; -but the labor being over, and the nurse having assured herself that the -uterus is hard, that there is no hæmorrhage, and that the mother is -resting, now turns to the child lying in its blanket. A hot water bag, -carefully tested, should lie at its feet wrapped in toweling or napkins. - -The eyes have already received the Credé treatment, 1 per cent solution -of silver nitrate or possibly a 15 per cent solution of argyrol for -prevention of ophthalmia, and a thorough cleansing comes next. - -In a warm room, away from drafts, the nurse takes the child in her lap, -or on a table, with a blanket underneath. She first anoints the child -all over, either with benzoated lard, liquid albolene, sterile vaseline, -or olive oil. This softens the vernix caseosa that covers the child and -aids its removal. - -The skin is wiped carefully with cotton or a soft cloth, paying -particular attention to the folds of the groin, the arm pits, and the -genitals. The nostrils are gently wiped out with applicators dipped in -oil. - -The child must be covered as much as possible during the operation and -the work finished quickly. The whole period should not exceed twenty -minutes. - -During the cleansing process the nurse should look closely for anomalies -or anatomical imperfections, like an imperforate anus or urethra, -supernumerary digits, etc. - -=The Bath.=—Daily, until the cord comes off, the baby is sponged with -oiled pledgets, followed by a spray bath, or a sponging with lukewarm -water and castile soap. The child must not be put into a full bath tub -on account of danger of infecting the umbilicus. The bath water in a tub -or basin quickly becomes filled with bacteria from the surface of the -child’s body and may be conveyed quite easily to a raw wound. - -[Illustration: Fig. 112.—Rubber bath tub.] - -All discharges must be wiped away, and the buttocks cleansed with oil. -If the skin becomes irritated by urine or otherwise, the child should be -well covered with talcum powder, especially in the folds of the groin -and in the genital crease. All infants are benefited by a little mild -massage after the bath. - -If other babies are handled, a child with infected eyes, or skin -eruptions, must be quarantined and cared for separately by a special -nurse. The color of the skin should be pink, changing under manipulation -to red. If there is mucus in the mouth, it may be wiped out with an -applicator, if in the throat, the child may be held up by the feet and -the head drawn back for a few minutes so that gravity will aid the -discharge of the obstruction. - -After cleansing the skin, the nurse sterilizes her hands and dresses the -cord. The gauze which was temporarily wrapped around the stump is -removed, the cord and adjacent skin washed with alcohol and dried. The -stump is powdered above and at the sides with a mixture of equal parts -of boric acid and subnitrate of bismuth, and then wrapped in gauze. The -band is put on, the temperature taken, and the baby dressed. Some -physicians prefer to have the cord dressed in 95 per cent alcohol, which -is frequently renewed. The normal separation of the cord takes place -through a kind of dry gangrene, which should be favored by dry rather -than wet dressings. The 95 per cent alcohol does not remain at 95 per -cent after it is exposed to air, hence it does not absorb moisture from -the cord as absolute alcohol would. However, the attending man is -responsible, and his orders must be followed. - -=The Umbilicus.=—The cord may be severed as soon as the child has cried -lustily or the cessation of pulsation may be awaited, in either case the -child secures a little more blood, which gives him a better start in -life. - -Two tapes are tied about the cord, one close to the skin margin of the -child and the cord is cut between them. A kind of mummification or dry -gangrene normally develops and the stump falls off, as a rule, about the -fifth day, leaving a moist, granulating area, which forms the umbilicus. - -A metal clamp may be used in place of a tape to compress the cord. The -advantage of the clamp is that on account of its greater width and -rigidity it does not cut through the cord when applied. Furthermore, it -can be made and kept more nearly aseptic. It does not soak up the juices -from the cord and form a culture medium for germs. It can be removed on -second day. The cord usually comes off a day or so sooner than when the -tape is used. - -[Illustration: Fig. 113.—The Pettit cord clamp.] - -The care of the cord is extremely important, as many infections can be -transmitted through it to the child. At each dressing the cord is -inspected, and whether it is dry or moist, offensive or inodorous, -should be noted. These facts, with the falling off of the cord, are put -down on the history sheet as they are observed. The binder, after each -removal, is not pinned, but sewed on. The sewing should begin below and -go up in order to have the tightness low down. - -=Eyes.=—After the first instillation of silver nitrate solution, a -reaction appears with redness, swelling, and discharge, which passes off -without treatment in two or three days. During the bath, care must be -used not to get anything into the eyes nor anything from the eyes or -nose upon the navel. - -At each dressing the nurse should irrigate the edges of the lids gently -with boric acid solution. If the eyes become red, swollen, and have a -purulent discharge after the second day, the case is possibly ophthalmia -and they must be watched with extreme vigilance. A smear should be taken -for the microscope and preparations made for energetic treatment. - -The following summary may be of service in memorizing the routine of -nursery procedure. - - - =Nursery Rules= - - 1. Keep temperature of nursery 68° to 72° F. - - 2. During bath, keep temperature of nursery 75° to 80° F. - - 3. Temperature of bath water 98° to 99° F. - - 4. Never use a diaper that has not been laundered. - - 5. Tie case number on child’s arm before leaving delivery room. - - 6. Watch cord for hæmorrhage. - - 7. Record temperature, stools and urine. - - 8. Give water freely between feedings. - - 9. Put to breast twelve hours after birth, and every three hours - thereafter until the child begins to gain, then one and - _possibly_ (?) two night feedings may be omitted. - - 10. Change binder daily. - - 11. Oil bath first, then shower bath on subsequent days. - - 12. Dress cord with alcohol 95 per cent, dry and apply bismuth - subnitrate and boric acid powder (equal parts) into crevices - beneath clamp or tape and under edges of the crust. Change - dressing daily. Cord should fall off fifth day. Report failure to - do so. - - 13. Clamp may be removed on second day. - - -_Routine for the Child._— - - 1. Temperature. - - 2. Undress. - - 3. Weight. - - 4. Shower bath. - - 5. Dress cord—record condition. - - 6. Binder daily until discharged. - - 7. Diaper and dress. - - 8. Sponge eyes with boric solution. - - 9. Cleanse nostrils with albolene. - - 10. Brush hair. - - 11. Drink of warm water. - - 12. Observe case number daily. - -=Clothing.=—(See Infant’s Outfit, p. 101.) The clothing must be light, -loose, warm, and not irritating to the skin. The outside garment should -have wing sleeves which permit free motion of the hands, but do not -permit them to reach the eyes. - -The band of plain outing flannel should always be worn for the first few -weeks. - -Birds-eye linen makes the best diapers on account of its superior -absorbent qualities. - -The feet must be kept warm by stockings, and artificial heat, if -necessary. On hot days much of the clothing may be removed and the -shirt, band and diaper may be all that are needed. - -The care of the shirts and bands is part of the daily duty of the nurse. -They must be washed daily, either by the nurse herself or under her -supervision, as they are easily injured. After washing, in soft water, -if possible, and with wool soap, they must be dried on a stretcher. -Diapers must be put directly into cold water. Fæces may be brushed off -with a whisk broom, and the napkin rinsed, boiled and again rinsed. No -diaper should be used a second time until this has been done. No bluing -may be used on the diapers and the soap must be mild, otherwise chafing -and intertrigo will follow. - -The infant’s toilet basket must contain: - - 4 soft bath towels. - 1 pound of absorbent cotton. - 1 dozen wash cloths of soft material. - 1 small hair brush. - 1 pair nail scissors. - Talcum powder. - Bath thermometer. - Hot water bottle. - Albolene. - Castile soap. - 8 oz. boric acid solution. - 8 oz. benzoated lard. - Paper bags for waste. - Pitchers and basins. - -[Illustration: Fig. 114.—_A_, standard breast pump; _B_, standard -nursing bottle; _C_, the breast tray; _D_, the Wansbrough lead nipple -shield; _E_, the Brophy nipple for harelip and cleft palate.] - -=Weight.=—The weighing of the child should precede, for convenience, the -first cleaning of the skin and the daily bath. The child is either put -on the scale naked or weighed in a blanket, and the weight of the -blanket, ascertained before or after, is subtracted. The daily weight -record is just as important as the temperature. A scale that registers -ounces and fractions thereof must be used, and the child should be -guarded from falling during the performance. Usually the child loses -from eight ounces to a pound the first week, but it should gain back to -its birth weight, by the end of the second week. If the child does not -gain, it may be due to lack of milk from the breast, and the weight may -be taken before and after feeding to verify or refute the suspicion. - -=The mouth= should be inspected each morning, but not cleansed with the -boric acid solution unless definitely indicated. Spots or any unusual -appearance should be reported. - -=The Genitals.=—The vulva of the female infant usually requires but -little care besides cleanliness. There is sometimes a whitish discharge -which disappears spontaneously in a few days. It is a drainage of -vernix, smegma and epithelium from the vagina and labia. - -With a male, the prepuce must be inspected when the child is about a -week old. If it is long and the orifice small, circumcision may be -suggested. Under any circumstances, the foreskin must be retracted, the -adhesions broken up, and the smegma removed. This must be repeated daily -until the adhesions do not recur. The maneuver should be done the first -few times by the physician, for fear of a paraphimosis. - -=Sleep= in the newborn is normally quite deep and almost continuous, -probably twenty-two hours a day, for the first week. The rather fast -respiration of the child, even when sleeping, is no cause for alarm. A -healthy infant breathes about twenty-five times a minute. The child -should not be rocked, carried about, exhibited, or handled more than -necessary. It should not sleep with the mother, lest it become too hot -or too cold, be overwhelmed by bedding, or overlaid by the mother. - -=Bowels.=—The first stools are black and tar-like,—this is meconium. It -disappears by the end of the first week. The presence or absence and the -character of an evacuation, as well as the number in twenty-four hours, -must be daily recorded. For a breast-fed child, there should be three or -four a day, for the first ten days and the number should gradually -diminish until a routine of two a day is obtained. - -=The diaper= of bird’s-eye linen should be large and thick; two may be -used if required. They should be carefully washed after soiling. Bluing -must not be used, because where this substance comes in contact with the -skin, irritation follows. - -=Weaning= should be brought about by the gradual substitution of other -foods, somewhere between the sixth and twelfth months. - -=Urination= should be copious. The child is always wet, and frequent -changes are necessary to keep the skin from getting raw and sore. - -Both bowels and bladder should be emptied within the first twenty-four -hours. Failure to do so should be reported, as an imperforate anus or -urethra may exist. - -Frequently a piece of ice whittled out like a lead pencil and passed -into the rectum will stimulate urination. - -Catheterization is practically never necessary. The child _may_ go three -days without injury, but the condition of the bladder above the pubes -must be attentively watched and its degree of fullness appreciated by -percussion. - -=Nursing.=—The child should be put to the breast twelve hours after -birth and every three hours thereafter—no more and no less without -definite reasons. - -If the child is strong and vigorous, only one feeding may be given at -night, and even this may be omitted in some cases where the child gets -an abundance of food. Six or seven feedings a day are enough. The child -should stay at the breast from fifteen to twenty minutes, depending on -its activity and the rapidity of the milk flow, and then be removed. It -must not be permitted to sleep at the breast. - -[Illustration: Fig. 115.—Proper position of mother while nursing child. -(Witkowski.)] - -Care must be used that the child gets the nipple _over_ the tongue and -not under it. Many infants have to be taught to nurse. This may be due -to a lack of strong animal instinct in many cases. There may be an -abundance of milk and a good nipple, but the child will not learn to -nurse without a vast expenditure of time, patience, and energy on the -part of the nurse. Squeezing a little milk into the mouth or filling a -nipple shield with milk will sometimes aid in educating the infant, or -even starting the supply with a pump, as many nurses do, is -advantageous. Certain drugs, like castor oil and turpentine, taken by -the mother, may affect the taste of the milk, and be reason enough for -the refusal of the child to take hold. Other drugs like mercury, -arsenic, potassium iodide, and alcohol may go over in the milk to the -nursing child. - -If the child is weak or premature, the milk must be pumped from the -breast and fed to it until strength comes. The difficulty about this is -the bad habit acquired, but there is no way to avoid it. - -A child should get at each feeding half an ounce of milk to each pound -of weight. The capacity of the stomach at various months is given by -Hirst as, first week, ½ oz.; second week, 2½ oz.; third and fourth week, -3 oz.; third month, 5 oz.; fifth month, 9 oz.; ninth month, 12½ oz. Holt -says that the capacity at birth should be one ounce, and increase at the -rate of an ounce a month up to the sixth month. - -As hunger stimulates the gastric and salivary glands, so the sight of -the child arouses some emotional center in the mother, which starts the -milk, and the mouth of the child provides an additional stimulus of -great power. About fourteen ounces is secreted by the seventh day, and -after the second month the daily average rises to three or four pints. -Milk secretion is favored by drugs and foods that raise the blood -pressure and diminished by substances that lower the blood pressure. - -There may be too little milk in the breasts, and if so, the child will -lose weight daily; also the child will waken before nursing time, fret, -refuse water, but greedily seize the nipple if it is presented. It will -continue to nurse long after its time is up and cling and cry when -removed. The breast itself may seem flabby and loose, and no milk, or -very little, can be pressed from the nipple. - -Normally, the breasts feel full and tense, both to patient and nurse, -just before feeding time. The real test, however, is in taking the -weight of the child before and after feeding. Where the milk is -insufficient, the scales will not vary, and after a few repetitions the -nurse can be certain. An infant should be handled as little as possible -after feeding lest the milk be vomited. - -[Illustration: Fig. 116.—Proper method of taking rectal temperature.] - -=Temperature= of the newborn child varies from 98° to 99° F. It should -be taken morning and evening, or oftener, if complications are -suspected. - -The temperature often goes up on the third or fourth day, and may stay -up for several days. This phenomenon is called by some a _starvation_ or -_inanition fever_. The temperature may go to 106° F. and the rise is -generally associated with a hot dry skin, dry lips, weak pulse, -restlessness, and great prostration. The fontanelle may be sunken and -the cry sinks to a fretful, feeble whine. - -It is important that the fever should be recognized and treated, since -the condition may terminate fatally. The _etiology_ is obscure. The -fever should not be confounded with pyogenic infections, for these -rarely begin before the fifth or sixth day. - -The _treatment_ is simple. Give water regularly every two hours by -mouth, and rectal flushings of normal saline twice daily. The symptoms -rapidly subside if the child is properly nourished. Hence the breasts -should be inspected and the child weighed before and after feeding. -Usually the milk is poor and scanty. If the temperature does not soon -fall the child should be put to another breast or artificial feedings -should be instituted. - - - - - CHAPTER XIX - THE CARE OF THE CHILD (Cont’d) - - -=Heart.=—The heart tones while in the uterus may vary between 138 and -150 per minute, but when higher than 160 or lower than 120, danger is -near. After delivery, the heart runs from 130 to 140, and during the -first year gradually drops to 115, approximately. - -=Asphyxia neonatorum= is a condition, wherein, for some reason, the -child fails to breathe after delivery. Out of every one hundred babies -born, about six will die at birth or within the first ten days, and a -large proportion of them from asphyxia in some form. - -Asphyxia is found in two degrees: asphyxia livida (blue) and asphyxia -pallida (white). - -In the first, the child is deeply cyanosed. This may be due to patency -of the foramen ovale, and yet it is a question whether this cyanosis is -not really a normal process. The child does not undertake its first -respiration because it needs oxygen, but because an excess of carbon -dioxide (CO_{2}) in the blood acts as a stimulant to the respiratory -center, which is thus set to work, with the result that oxygen is taken -in. The blue asphyxias, therefore, may be only the first step in the -physiological process of respiration. In these cases, the pulse is -strong and full, and the muscular tone is preserved, as well as the -sensibility of the skin. - -In the second degree, the condition is quite different. The face is pale -though the lips may be blue. The heart is irregular and many times can -not be felt. The cord is soft and flaccid, with its vessels nearly -empty. The reflexes are abolished, the skin and extremities cold. A few -convulsive efforts at breathing may occur, but they soon cease. - -_Treatment_ is directed first, to opening up the respiratory passage. -The child is held up by the feet so the mucus, blood, and fluids may -escape from the mouth. Compression of the chest wall will aid. The -tracheal catheter is passed into the trachea and the mucus sucked out. -Next, the skin reflexes are stimulated by slapping the back, or -buttocks, and by blowing upon the face. - -[Illustration: Fig. 117.—Method of passing the tracheal catheter. -(Hammerschlag.)] - -The child at this time may be dipped in a tub of very warm water, (112° -F.) and the chest and face sprinkled with cold water. Meanwhile, -Laborde’s method of traction on the tongue may be tried. The tongue is -seized with tongue forceps (handkerchief, napkin, or piece of gauze will -do) and rhythmically drawn out and released about ten times per minute. - -Further, the Byrd method of artificial respiration must be employed. - -[Illustration: Fig. 118.—Byrd’s method of artificial respiration. -Extension and inspiration. (Edgar.)] - -[Illustration: Fig. 119.—Byrd’s method of artificial respiration. -Beginning flexion and expiration. (Edgar.)] - -The back of the child is held in the right hand, so that the thumb and -forefinger grasp the neck loosely, the other hand holds the buttocks -from behind and the body is slowly but firmly flexed between them until -the thorax is compressed, then the grip is relaxed and the body widely -extended to allow the air to rush into the lungs. This maneuver should -be repeated about twelve times per minute. When the heart ceases to -beat, the child is dead and respiration can not be established. - -[Illustration: Fig. 120.—Byrd’s method of artificial respiration. -Flexion and compression. Note position of child which aids the escape of -fluids from the mouth and nose. (Edgar.)] - -The same treatment is employed for the apnœic child born in Cæsarean -section and the oligopnœic child born under “Twilight Sleep.” The method -called “Schultze Swinging” is not to be recommended generally, on -account of the chilling which is so necessarily associated with the -exposure. The nurse should learn to practice all these methods of -resuscitation. - -After the child breathes it must be watched carefully for at least -forty-eight hours, lest the symptoms recur, and the child die. - - - =Asphyxia Neonatorum—= - - (a) Livida—body congested—blue. - - (b) Pallida—body limp and pale. - - Remember possibility of patent foramen ovale. - - - _Etiology._— - - Too long compression of cord. - - Diminished irritability of medulla. - - Compression of brain during extraction. - - Shock during version. - - Aspiration of mucus. - - - _Treatment._— - - Hold child by heels with head pulled back to straighten the - trachea, and wipe out mouth and pharynx _gently_ with cotton - wound about the finger. - - Stimulate skin reflexes by slapping and blowing. - - Tracheal catheter, artificial respiration (Byrd) 8 to 10 times per - minute. - - Hot and cold bath alternately—rub the skin and knead the muscles. - - Laborde’s method of traction on tongue 10 to 12 times per minute. - - Continue efforts so long as heart beats. - -=Convulsions= occur not infrequently during the first few weeks. They -may develop as a result of injuries to the head during labor, or as a -symptom of toxæmia. They may arise from constipation, from intestinal -indigestion with curds, from fever or from hæmophila. Meningitis and -other infections are associated with this symptom, and occasionally -atelectasis. They may also be the manifestation of a spasmophilic -diathesis. The attack may begin with such premonitory phenomena as -restlessness, muscular twitching, and staring of the eyes, but more -frequently the onset is without warning. The facial muscles are -contracted, the neck thrown back, the hands clenched and the extremities -spasmodically cramped and tightened. There may be frothing of the mouth -and consciousness is lost. Respiration is feeble, shallow and irregular. -The face is discolored and strange rattling noises come from the larynx. -The bowels and bladder may move involuntarily. The attack lasts from a -few minutes to half an hour. - -Convulsions are not serious in all cases. - -The responsibility for the management of this complication usually falls -upon the nurse. She calls the doctor, to be sure, but the attacks in -many cases have ceased and the child may either be dead or out of danger -of a recurrence before his arrival. - -The hot bath is a universal remedy and quite as efficient as anything. -The temperature should be taken and the bowels washed out. - -If the fontanelles are tense when the doctor arrives, a spinal puncture -may relieve the tension. A specimen of the blood is drawn through a -needle and sent to the laboratory for examination. - -The cause must be found, if possible, and removed. A change of food may -be all that is required. Cod-liver oil may be added to the diet in dram -doses, three times a day, and milk curds, suspended in arrow-root water. -For the acute condition, chloral hydrate is best. It is given by rectum, -one or two grains in an ounce of water, and may be repeated in four -hours. - -=Atelectasis= is the name given to a failure of the lungs wholly to -expand during the efforts at respiration. The child may live for weeks -with this affection, but usually it expires within a few days. - -In this condition, the child has a constant tendency to get blue, the -color deepens, and death may occur in spite of every aid. The treatment -may be permanently efficacious in some cases, but in most, the revival -is only temporary. Again, the child may live, but in a weakly, declining -state for days, until death comes. - -Aside from the physical signs of dullness elicited by percussion over -the lungs, the most conspicuous _symptoms_ are the cyanosis and the -intermittent but persistent whining cry. - -[Illustration: Fig. 121.—Method of giving gavage. (Grulee.)] - -_Treatment_ is by daily or hourly spanking, and by alternating hot and -cold baths, by sprinkling with cold water or by massage to stimulate the -skin reflexes. The treatment may have to be repeated every twenty or -thirty minutes, and the earlier it is instituted, the more persistently -carried out, the _more chance of success_. - -=Exercise= is just as important to the infant as to the adult. The -kicking of the legs, moving of the arms and lusty cry are all means of -stimulating the circulation, the muscular development, and the expansion -of the lungs. The position should be changed occasionally in the crib -from back to side and from side to back. Also the child’s legs and back -should be rubbed and massaged until the skin is red every time the bath -is given. - -=Flushings.=—The child is laid across the lap, or on a table. A rubber -sheet is so arranged that the discharge will drain away. - -A soft rubber catheter, No. 18–20 French scale, is attached to a small -funnel. The apparatus is boiled and filled with normal saline, or -sterile water, at a temperature of 85° F. to 95° F. Half a pint to a -pint may be required. - -The catheter is oiled and passed into the rectum just beyond the -sphincter. It must not go farther. The funnel is then raised and the -fluid flows into the bowel. This flushing must not be confused with the -administration of an enema for constipation, for which, however, it is -often an excellent substitute. - -=Gavage= is forced feeding by means of a tube. A soft rubber catheter or -tube, about No. 7, French scale, is lubricated with albolene, vaseline -or sweet oil. The upper end is connected with a small tube or glass -funnel holding two or three ounces. - -The child is laid upon its back in the arms of mother or nurse, the -baby’s arms are held and the head steadied. - -In case of diphtheria or scarlet fever, the tube may be passed through -the nose and down the pharynx and into the œsophagus five or six inches, -or even into the stomach. It is more convenient and easier when possible -to pass it through the mouth directly into the stomach. The food is then -poured into the funnel, which, by elevation, empties itself into the -stomach. If regurgitated, more food must be given. When withdrawn, the -tube should be pinched to prevent leakage into the trachea. - -[Illustration: Fig. 122.—Apparatus for gavage or lavage. (Tuley.)] - -The great danger in these cases is the ease of overfeeding. - -=Lavage= or washing of the stomach may be performed in the same way with -the above apparatus, when necessary. As soon as the stomach is filled, -the tube is lowered and the fluid siphoned out. - - - - - CHAPTER XX - THE CARE OF THE CHILD (Cont’d) - - -=Tongue-tie= is not met with so frequently as in the old days. If the -child can suck and nurses energetically, this complication can be -excluded. It may, however, occur. In such a case, the frænum is -unusually broad and seems to extend clear to the tip of the tongue, -which apparently is bound down to the gum and to the floor of the mouth. - -The thin membrane may be snipped with the scissors close to the tongue -and then torn back with the finger. - -=Harelip and cleft palate= interfere with nursing and require continual -attention to keep mucus out of the throat. Brophy has a rubber flap -placed over the nipple of the bottle in such a way as to occlude the -split tissue and thus enables the child to get nourishment. - -These babies must be fed systematically by gavage, if necessary, until -the deformity can be repaired. - -=Hernia= at the navel is a common complication of infancy. It is not due -to crying, to improper tying of the cord, nor to neglect by the nurse, -as frequently charged. It is a congenital fault, wherein the cord -opening does not close, and in time, crying and straining will drive the -intestines out of the aperture like a pouch. The defect is revealed by -the bulging outward of the navel when the child cries. Ordinarily the -breach will close of its own accord. - -[Illustration: Fig. 123.—Cleft palate nipple. (Brophy.)] - -[Illustration: Fig. 124.—The device for feeding the child with cleft -palate at the breast. (Brophy.)] - -_Treatment_ consists in folding up the skin of the abdomen so that the -groove will be over the umbilicus and include it. Then adhesive tape is -put on to hold it. The surfaces of skin thus coming in contact should be -dusted with rice powder or stearate of zinc. Another method of treatment -is to place a wooden button form, round side down, on cotton, over the -opening, and bind it on with a zinc adhesive plaster. The dressing -should be changed at least once a week. - -=Inguinal hernia= usually heals spontaneously also, but a truss may be -required. - -[Illustration: Fig. 125.—Device for assisting the cleft palate child to -nurse. (Brophy.)] - -=Hæmorrhage= of the newborn is either accidental or spontaneous. -_Accidental_ hæmorrhage may arise from an imperfectly tied cord, or it -may be an effusion, through compression or rupture, into any of the -internal organs, such as the brain, lungs, or abdominal viscera. These -latter conditions rarely give rise to symptoms, and are seldom -recognized during life. There is no treatment. - -The intracranial hæmorrhages are open to diagnosis through the presence -of pressure symptoms, but these, too, are impervious to treatment unless -a vessel can be tied, like the middle meningeal artery. - -_Spontaneous_ hæmorrhages may develop during the first few days of life -from sepsis, syphilis, Buhl’s disease, hæmophilia, and true melæna -neonatorum. The fragile condition of the blood vessels, the great -changes in the blood and circulation after birth, as well as -constitutional dyscrasias, are etiological factors of importance. All -the causes are not as yet known. - -[Illustration: Fig. 126.—Method of strapping an umbilical hernia.] - -The blood may come from the umbilicus, the mucous membranes of the eyes, -nose, mouth, stomach and intestines. It may be effused into the tissues -beneath the skin, or into any organ of the body. Marked nosebleed is -generally syphilitic in origin. - -As a rule hæmorrhages in the newborn are most common in males, and -strongly hereditary. - -The tendency to bleed lasts only a few weeks, and if recovery takes -place, it is permanent. In some cases, however, where hæmorrhage has -developed in the brain, clots may form in important centers, and the -child be permanently paralyzed in speech, sight, hearing, or -intelligence. - -_Symptoms_ of hæmorrhage begin during the first week and almost never -after the twelfth day. The appearance of blood is the earliest and the -most definite sign. The bleeding may come first from the umbilicus, or -from the stomach, or from the intestines (melæna neonatorum). The amount -lost is small, but the oozing is continuous. The temperature may be high -or subnormal, and may or may not be due to the hæmorrhage. The skin is -pale, the pulse feeble, prostration marked, and weight is lost rapidly. -Convulsions are not infrequent. - -_The diagnosis_ of the condition is simple. It is only necessary to be -certain that the blood is really effused, and not a temporary or -accidental event such as the regurgitation of swallowed blood. Black -tarry stools will show blood if placed in water. - -The _prognosis_ is not good. About two-thirds of these babies die. - -_The treatment_ is to stop the hæmorrhage by ligature, suture, or -compression if possible and to alter the character of the blood by -adding to its fibrin content. This is brought about, if at all, by the -administration of coagulose, coagulen ciba, or by transfusion from an -adult—preferably the father. - -=Paralysis of the face (Bell’s paralysis)= may follow the use of -forceps. The prognosis is favorable. Paralysis of the nerve in the neck -(musculospiral) is sometimes known as Erb’s paralysis. It happens in -consequence of difficult breech deliveries or of vertex labors when much -force is required to extract the shoulders. - -The deltoid, biceps, and other muscles are affected so that the arm can -not be raised. The failure to raise one arm will be the symptom that -will attract the attention of the nurse. Some cases recover in a month -or so, either spontaneously or by the aid of electricity. If not, the -injured nerve must be cut down upon and its continuity restored. - -=Ophthalmia neonatorum= is an infection of the eyes of the newborn by -the gonococcus. The infection occurs as the child passes through the -vagina or vulva, or when an unclean finger is put into the eye. - -The reaction is violent. The discharge at first is thin, then thick, -pus. If untreated, the eyesight may be lost by ulceration. In the -asylums twenty-five per cent of the inmates are blind from this -infection; and as late as 1896, seven per cent of the blindness in the -state of New York could be traced to this avoidable disease. - -_The preventive treatment_ consists in the frequent douching of the -vagina before labor with potassium permanganate solution 1:5000, or -chinosol 1:1000. After labor, a drop or so, of 1 per cent solution of -nitrate of silver is dropped into each eye and _not_ neutralized. - -_After the infection has occurred_, iced compresses are applied to the -eye, night and day, and a solution of argyrol 15 to 20 per cent -instilled into the outer corner, twice a day. In female infants with -ophthalmia, the vagina must be watched for discharge which does not fail -to appear in most cases. Argyrol (20 per cent) should be injected with a -medicine dropper and left to drain out spontaneously. All dressings used -about the child should be destroyed, and the nurse should use the most -scrupulous cleanliness and care of her own person. - -=Separation of the cord= may be delayed in puny babies and in cases -where the cord is large and thick. - -Some of these cases are doubtless due to a patency or fistulous -condition of the urachus. Usually the separation may be hastened by -touching the constrictured part with silver nitrate. Or, if the cord -does not separate before the second week, it may be desirable to cut off -the hanging fragment and touch the base with silver nitrate or dust with -alum powder. - -=Granulations= may protrude like a mulberry from the stump of the navel -(“proud flesh”). These are touched with nitrate of silver stick. - -=Menstruation= may appear occasionally from the vulva of the newborn. It -is really a hæmorrhage, a menstrual flow, which is associated with -uterine activity, but rarely significant. There is no treatment. It -disappears spontaneously. - -=The breasts of the newborn= may fill with milk and become indurated and -tender. Nothing should be done to them. Let them alone and the swelling -will subside in a few days and the milk (“witches’ milk”) disappear. - -=Icterus= may develop from the third to the sixth day. The child becomes -yellow and stays yellow for a week, when the color gradually leaves. It -is thought to be due to the liberation of some embryonic residue in the -fœtus, but nothing is known certainly. For the simple form no treatment -is required. Recovery is prompt and uneventful. However, jaundice is -associated with other conditions that prove fatal, hence every icterus -should be watched carefully until it disappears. - -=Child’s Nails.=—The nails are frequently rough and ragged at ends and -sides. They should be smoothly trimmed lest they become infected at the -junction with the skin and give rise to paronychia. If infection does -occur, the skin and flesh may be pushed back with a sterile applicator, -and the point touched with peroxide of hydrogen. A syphilitic history -may be traced in some of the babies. - -=Thrush= is a form of contagious soreness, characterized by white flakes -or patches on the mucous membrane of mouth or anus which look like milk, -but can not be wiped off. - -It is due to a vegetable fungus and occurs most frequently among anæmic -or poorly nourished babies or those suffering from harelip. It is -associated with symptoms of indigestion. - -It may always be prevented by keeping the mouth and nipples clean, as -directed on another page, and by keeping the bottles and rubber nipples -in a solution of boric acid when not in use. When the disease appears, -the mouth must be swabbed three or four times a day with an applicator -soaked in saturated solution of boric acid. This is curative. - -=Aphthæ or stomatitis= is the name given to whitish vesicles, followed -by superficial ulcers that occur upon the inside of mouth and lips of -the infant. It is rare in the newborn child. Boric acid solution is -cleansing, and stick alum, frequently applied, will effect a cure. - -=Wheals, urticaria or “stomach spots”= appear as generally distributed -small spots about the size of a split pea, with a white center and a red -periphery. They appear about the third day and last twenty-four hours. - -They may be mistaken for insect bites and they may, or may not, be -accompanied by temperature, which is probably only a coincidence. - -The wheals disappear spontaneously without treatment. - -=Bednar’s disease= is characterized by the appearance of two ulcers on -the hard palate, one on either side and just above the spot where the -last tooth will erupt. It is most liable to occur in sickly infants and -supposedly arises from the abrading of the mucous membrane by a rubber -nipple or through the rough cleansing of the mouth. It is very resistant -to treatment. The child must be put in good condition by attention to -the nourishment and the spots touched with tincture of iodine on an -applicator. - -=The exudative diathesis= is indicated superficially by a definitely -bounded red patch on either cheek, which is not relieved, or only -temporarily, by the common ointments and powders. The mother says the -“face is chapped,” or that the baby has a “milk eczema.” Otherwise the -skin is pale. - -These children are frequently fat, but the tissue is flabby. The urine -is sometimes ammoniacal. There is no marked disturbance of temperature. -Fretfulness and constipation are the principal symptoms. - -The condition is due to too much fat in the food. A skimmed-milk diet is -best for a time. The fat can be added gradually until the limit of -tolerance is found. - -If chalky masses appear in the stools, the fat must be reduced again. -Occasionally the child must be taken off the milk entirely, and a soup -or gruel diet substituted. - -For local application, the following formula is sometimes beneficial: -(Grulee.) - - ℞ Naphthalene ℥i - Starch ʒiv - Zinc stearate ʒiv - M. - Sig. Apply frequently. - -=The “cradle cap”= is a frequent sign of the exudative diathesis in its -milder stages. - -The term is applied to a yellowish-gray patch over the large fontanelle. -The mother calls it “dirt,” which she finds hard to remove and it always -recurs. The mass is composed of dry scales, which gradually change into -an eczema. Vaseline or sweet oil left on over night makes the removal of -the scales quite easy the next day. If a raw surface is left, zinc -ointment should be applied. The diet must be changed as previously -described. - -=Erythema=, especially of the diaper region, is sometimes a -manifestation of congenital syphilis. It is usually limited to the inner -side of the thighs, the perineum, scrotum or vulva, and buttocks. It -must be associated with other and more characteristic signs, however, -such as snuffles, cachexia, etc., before it becomes diagnostic of -syphilis. Most erythemas of this area are due to irritation from moist -or soiled diapers, but other factors may be important. Bluing in the -diaper, gastrointestinal troubles, and circulatory disturbances are -contributing causes. The local treatment is the same as for intertrigo. -If the child is syphilitic, systemic measures must be instituted. - -=Intertrigo=, or chafing, is a form of eczema due to moisture, bluing in -the diapers or uncleanliness. The child should be cleaned with oil -instead of water, and well powdered with stearate of zinc or zinc -ointment may be used. Talcum powder which contains boric acid is -contraindicated. - -=Pemphigus neonatorum= is an eruption of blisters or blebs which seem to -follow infection from the maternal passages or to be communicated by -other babies who have the disease. - -From three to fourteen days after birth, the blebs develop on the -abdomen, neck or thighs, and show a tendency to spread to other parts of -the body. The vesicles vary in size from one-fourth of an inch to two -inches in diameter, and contain a serous, purulent, or bloody fluid. -Other signs of general sepsis may appear. - -_In diagnosis_ care must be used to exclude syphilis, which also -exhibits blebs, but usually on the soles of the feet or the palms of the -hands. Besides, a nonsyphilitic child is generally better nourished. The -prognosis is unfavorable if the child is weakly, if the blebs spread -rapidly over a large area, or if the infection attacks the umbilicus. - -_Treatment._—A rigid quarantine must be enforced. In the hospital no new -cases can be admitted. The alimentation must be increased, the blisters -evacuated, and the surfaces cleaned and covered with a 25 per cent -ointment of ichthyol, or an ointment of ammoniated mercury 2 per cent. - -=Strophulus, red gum, or miliaria rubra= are names applied to an -inflammation of the sweat glands when their secretion is retained. It is -a “sweat rash” characterized by an eruption of scattered red papules or -small vesicles which commonly appear on the cheeks or neck of young -infants, or where skin surfaces come in contact. It is due to excessive -clothing or heat. It is really a prickly heat. The _treatment_ consists -in the removal of the cause, and a generous use of stearate of zinc -powder or rice powder. - - - - - CHAPTER XXI - THE CARE OF THE CHILD (Cont’d) - - -=Constipation= in the newborn may come from many causes. The amount of -food may be so inadequate that no residue is left, and the bowels move -only once in forty-eight hours. Over-stimulation of the bowel by castor -oil or colonic flushings in the early weeks of life to correct colic may -diminish its sensitiveness and produce atonic constipation. In the -artificially fed infant too much fat in the food is a very common cause -of the trouble. - -_Treatment._—Correct the amount of fat in the milk. If the child is -breast-fed, the mother’s diet should be non-nitrogenous and vegetables -should preponderate. Drugs should not be given until all else has been -tried. Gluten suppositories will furnish a mild irritation to the -rectum. Orange juice and prune juice may be given, or Mellin’s food or -oatmeal water added to the milk. Milk of magnesia ½ to 1 teaspoonful, or -Husband’s magnesia, in same dosage, may be given daily. Senna is also -efficacious. - -=Diarrhœa= is generally significant of an error in diet which is usually -a plain indigestion, though there may be too much sugar in the food. - -The stools are more frequent and always softer than usual, possibly -fluid. - -Diarrhœa means increased intestinal action due to irritation from -_something_. It may be due to indigestion, to the presence of hard -curds, to acidosis, or it may accompany almost any disease of infancy as -a symptom merely. The odor is due to gases formed in the canal by -bacterial action. There is but little odor in fermentation, but much in -putrefaction. Mucus appears either as balls or strings. The balls come -from the small intestine, strings from colon. Blood indicates ulceration -at some point in the bowel, or an erosion just above the sphincter. - -[Illustration: Fig. 127.—Proper position for introduction of a -suppository. (Grulee.)] - -Fatty curds may be either white, granular, sand-like masses, or small, -soft, and yellow. The protein curd is large and smooth, or white and -bean-like. Both occur only when the artificially fed infant is given raw -milk (Brenneman). If the milk is boiled for two minutes these masses -will not form. - -The cause must be determined. The frequent stools, however, are -exhausting, and may have to be checked with opiates or mechanical -astringents. - -When due to indigestion, all food by mouth may be stopped for two or -three days and only barley water administered. - -In a breast-fed child, diarrhœa is sometimes checked by diluting the -milk with a little barley water, given just before nursing. With these -infants, not much change in the sugar content can be made by alterations -of the maternal diet, but where artificial food is used, the amount of -sugar is easily reduced to a satisfactory degree. - -=Colic= is a cramp-like pain of the bowels. Previous to the attack the -child is restless, expels some gas, and has the “colic smile,” which -leads the mother to believe the child is quite well. When the attack -comes on, the thighs are flexed on the abdomen, and the legs on the -thighs. The child has a sharp cry, that is nearly continuous, but in -some way related to the nursing period, for the attack comes on a few -minutes, and sometimes an hour, after taking the breast. The belly is -rigid, the arms wave aimlessly. Diarrhœa may be present, and the -movements are accompanied by much flatus. Distention is nearly always -present. When the belly is tapped it gives a drum-like note and the -child belches gas, sometimes accompanied by milk, which seems to -relieve. - -_Treatment._—Colonic flushings to relieve the bowel of irritating curds. -The child may be laid face down with a bag of hot water under the belly. -Mixture of asafœtida gtts. xx to xl, or whiskey and hot water should be -given for the attack, followed later by a full dose of castor oil. The -diet should be rigorously investigated. - -=Vomiting= may or may not be serious. The child may nurse too rapidly or -too much, and the over-distended stomach simply empties itself. Many -infants “spit up” their excess of milk, and thus relieve themselves. -This is a simple regurgitation, usually of unchanged milk, though it may -be acid from admixture with the gastric juice. - -Vomiting, in a breast-fed child, may come during an attack of colic when -the eructations of gas appear. It may be a symptom of gastrointestinal -intoxication, of too much fat in the food, too short intervals between -feedings, or too much sugar in the food. - -Projectional vomiting awakens suspicion of a pyloric stenosis or -meningitis, and must be reported to the physician at once. - -Vomiting which occurs within twenty minutes after feedings is not -serious ordinarily, even though gas and large curds are expelled, but -all vomiting later than this, is significant of a pathology. - -_Treatment._—Regulation of the hours of feeding is most important, and -next, the character of the food. If the child vomits an hour or so after -nursing, it may be that the milk is too rich (fat). Try a longer -interval, or give an ounce or so of cereal water before putting the -child to the breast. - -=Prematurity= exposes the child to three distinct dangers, which arise, -respectively, from atmosphere, food, and infection. Very few children -born before the seventh month survive. A child born at the eighth month, -or with a weight of three pounds, or more, can be saved almost always. -The premature child up to the time of birth, has been protected very -carefully against temperature variations by the liquor amnii, and when -suddenly precipitated into a new environment, which its vitality barely -tolerates, the consequences are serious. - -These infants have a poor heat production, and the natural warmth of the -body must be preserved. This is best done by incubators, which supply -air and moisture in stable and appropriate amounts. Chilling of the -child for even a few moments may be fatal. A room may be fitted up to -produce the necessary conditions of light, air, heat and moisture. The -child, wrapped in sheets of cotton, except the face, is then covered -with a blanket, and surrounded by a temperature varying from 88° to 95° -F., which is gradually lowered to 80° F. as the child gains strength. An -occasional whiff of oxygen, as prescribed for an atelectatic child, is -sometimes advantageous. - -_Bathing._—Premature infants must not be bathed, but the skin should be -cleansed with cotton and warm sweet oil or albolene. All unnecessary -handling is to be avoided. - -_Food._—Breast milk is the secret of success with these cases. Since -most of the infants are too weak to take the nipple, the breasts must be -pumped, and the child fed with spoon or pipette. - -The interval between the feedings depends a little on the amount taken, -but it should not be less than one and one-half hours, nor more than two -hours. As the child gains, the interval may be lengthened to three -hours. Lack of sufficient nourishment is shown by cyanosis and loss of -weight, and overfeeding, by vomiting and diarrhœa. - -The child must be fed by hand until strong enough to nurse the breast. -In certain cases of prematurity, as well as in diseases like pneumonia, -scarlet fever, and diphtheria, the child must be fed by gavage. -Nutritive inunctions of benzoated lard or cod-liver oil are also -valuable, not only for the passive exercise supplied, but for the -absorption of a certain amount of the unguent. - -=Marasmus= means wasting, but the term is applied to infants that -steadily lose weight. The bodies of infants are so largely composed of -fluid, that loss of weight occurs quite easily and rapidly. Loss of -weight may be sudden or gradual. It comes on rapidly after acute -diarrhœa, either with or without vomiting, or it may follow persistent -vomiting without diarrhœa. - -Malnutrition from defective feeding is the most common cause of wasting -in infants. This may be from lack of sufficient food or lack of proper -ingredients, as well as irregularity of intervals, and disease. Rickets, -congenital stenosis of the pylorus, congenital syphilis, and -tuberculosis are all possible factors in the etiology. - -In any case, no treatment can be instituted until these conditions have -been confirmed or excluded. - -=Pyloric stenosis= (the account follows Grulee) may be a thickening of -the muscular coat of the outlet of the stomach (pylorus) or a spasmodic -contraction. The condition is most frequent in males and in the first -born. - -_Symptoms_ usually begin before the second week. There is constipation -with small ribbon-like stools, and the urine is scanty. The most marked -sign, however, when it is present, is the excessive, uncontrollable -vomiting, which ordinarily occurs fifteen to thirty minutes after -eating, but may be delayed for several hours. The vomiting may be of the -common type, but more frequently it is projectile in character, like -that seen in meningitis. The contents of the stomach are violently -expelled, sometimes several feet. Physical examination may reveal the -stomach bulging under the arch of the ribs and peristaltic waves moving -back and forth across its surface. The pylorus itself may sometimes be -felt as a lump or tumor. - -_Prognosis._—About fifty per cent die. - -_Treatment._—Dietetic and surgical. Grulee recommends small amounts of -food, poor in fat, be given at short intervals. If this fails, operation -is required. - -=Pneumonia= in the newborn most frequently results from the aspiration -of mucus out of the maternal passages as the child is born. This may -happen when the cord is compressed, or at any time when a partial -asphyxiation impels the child to try to breathe. - -It may also come on when a feeble child has been chilled by a prolonged -first bath. - -The disease develops about twenty-four hours after birth in a child -apparently well. The temperature rises, respiration becomes rapid, and -cough develops. The child is fretful, restless, refuses the nipple, and -gasps for breath. It may become cyanotic. The prognosis in newborn -infants is very serious. - -_Treatment_ is stimulation. A mustard bath will benefit where the -respiration is rapid and the child blue. Tincture of digitalis may be -administered in drop doses every three or four hours. Carbonate of -ammonia, ¼ gr., in mucilage of acacia, half a dram, may be given for -cough. - -Child must be fed on mother’s milk _pumped from breast_. - -=Snuffles= may be due to improper clothing, to drafts of air, or to -syphilis. If due to cold, camphorated oil may be rubbed on the nose and -the passages kept clean with an applicator soaked in albolene. If this -fails, a small pellicle of anæsthone may be placed in each nostril, and -the child laid upon its back until the ointment melts and runs back into -the pharynx. - -=Furuncles= (boils) may be numerous. They come from irritation of the -skin by atmosphere, soap, water, and clothing, whereby infection enters. -This is especially liable to occur in the hair. - -Keep the boils washed with boric acid solution and open them as soon as -the focus, or head, appears. - -=Phimosis= is such a close adjustment of the prepuce to the glans penis -that it can not be retracted. In some cases there may be obstruction to -the outflow of urine, but generally a tiny portion of the glans can be -seen. The prepuce may or may not be redundant. This condition makes -cleanliness impossible and balanitis may result. - -On account of the straining required to urinate, prolapsus ani, hernia, -and hydrocele of the cord sometimes develop. Symptoms may arise from -preputial adhesions, as well as phimosis. Frequent or difficult -micturition, nocturnal incontinence, priapism, pruritus, and -masturbation may develop out of the irritation, as well as nervous -manifestations, such as insomnia and night terrors. - -The condition should be recognized and corrected in infancy. If the -adhesions are dense, an incision can be made down the dorsum of the -prepuce, the tissue forcibly separated from the glans, and the flaps cut -off. Stitches may be required. In other cases circumcision may be -necessary. - -=Paraphimosis.=—When a prepuce with a small orifice is forcibly -retracted over the glans, it occasionally happens that it cannot be -pulled forward again. If allowed to remain this way, the parts will -swell, and the penis become strangulated as if with a ligature. - -The danger arises from the stoppage of the circulation, which may be -followed by ulceration and gangrene. - -Reduction must be brought about by manipulation, if possible, but where -this fails, the constricting band must be cut through and sedative -applications used. - -=Balanitis= is inflammation of the prepuce from the decomposition of -smegma, which collects under a tight foreskin. The condition is quickly -relieved by cleanliness and a few applications of vaseline or zinc oxide -ointment. Circumcision should not be done until the inflammation has -subsided. - -=Circumcision=, either as a physical necessity or as a religious rite, -is frequently performed. - -The nurse prepares a table with sterile linen, a basin with antiseptic -solution and sponges, sterile towel, and sterile vaseline, with a roll -of gauze bandage an inch wide. - -The object of the operation is to remove the prepuce and leave the glans -exposed. - -The instruments needed are a pair of sharp scissors, a pair of -dissecting forceps, two pairs of artery forceps, small, full curved -needles, and fine catgut. - -The nurse gives the child some gauze to suck, which has been soaked in -brandy and sugar-water, brandy one dram to an ounce of water. Then -taking her place at the child’s head, she flexes the thighs back upon -the abdomen, and widely separates them. The field of operation is -thoroughly washed with soap and warm water, the prepuce is then -retracted and the smegma wiped away. Then the body and limbs should be -covered with clean linen, except the penis, or a sterile towel may be -used with a hole in it through which the penis is drawn. The redundant -tissue is removed and fine catgut sutures put in. - -The operation being completed, the wound is covered with sterile -vaseline and wrapped with a sterile gauze bandage, leaving the end of -the glans exposed. - -[Illustration: Fig. 128.—Hydrocephalus. (Bumm.)] - -The gauze and vaseline are changed whenever saturated with urine. -Healing ought to be complete by the seventh day. The nurse should -examine the dressing at frequent intervals during the first twenty-four -hours, since serious hæmorrhages may occur from vessels that have not -been included in the sutures. - -=Priapism= is a condition of functional fullness and firmness of the -penis that is more than ordinarily constant. Its importance lies in the -fact that it may be a symptom of spinal irritation, balanitis, worms, or -phimosis. - -=Spina bifida= is the most common congenital deformity. It is -characterized by a fluid tumor, which protrudes from an opening in the -vertebral column. It may appear anywhere along the spine, but is found -most frequently in the lumbar or cervical region. The deformity is -supposedly due to an arrest of development. It is nearly always fatal -inside of two weeks, though cases have been known to reach mature years. - -[Illustration: Fig. 129.—Anencephalus. (Williams.)] - -There is no treatment except protection from injury. - -=Hydrocephalus= is sometimes, but not necessarily, associated with -_spina bifida_. - -The ventricles of the head are filled with cerebrospinal fluid, and the -fontanelles are widely separated. The cause of the anomaly is unknown. - -This condition may render labor difficult or impossible until the -diagnosis is made and the skull perforated. Rupture of the uterus may -result from the futile efforts to expel the child. If born alive, the -child nearly always dies, or if it grows up, the intelligence is -imperfect in most cases. - -=Anencephalus= is a monster, having a body, but only a part of a head. -The eyes protrude, the tongue may hang from the mouth, and the brain is -under-developed. - -=Sudden death= of infants that are apparently healthy comes with a shock -to the physician as well as the parents, and in some instances, no -plausible reason can be assigned for it. Apoplexy, pneumonia and -stoppage of the trachea by milk curds may explain some cases. -Suffocation by lying on the face in wet bedding, or overlying by the -mother will account for others. Internal hæmorrhage into lungs, pleura, -stomach, or brain is also known to be causative. - - - - - CHAPTER XXII - INFANT FEEDING - - -A well fed infant is a happy little animal, who sleeps approximately -twenty-two hours a day, and gains from four to six ounces a week. If -properly fed at the breast, this condition is easily obtained; but if -artificial food is necessary, the resources and skill of the attendants -may be tried to the utmost before the welcome result is brought about. - -The feeding of infants may be considered under three heads, (1) the -breast; (2) breast and bottle combined (mixed feeding); and (3) -artificial, which is really modified cow’s milk. - -Breast feeding has been taken up elsewhere, but the same care should be -taken in feeding from the bottle as in feeding from the breast, so far -as concerns the intervals between the feedings and the duration of the -same. Since it takes from one to two hours longer for cow’s milk to -digest than it does for mother’s milk the longer interval of three or -four hours between feedings is better for the artificially fed child. -With such an interval there will be less vomiting, less colic, less -tendency to overfeed, and a better natured baby. - -One feeding should be omitted at night, and if possible, two. - -Length of time for taking the bottle depends somewhat on the child, but -it should not exceed fifteen minutes, as a rule. - -=Supplemental Feeding.=—A mother who has too little milk may have it -supplemented by a modified mixture in one of two ways. - -First, the quantity furnished by the breast must be determined by -weighing the infant before and after feeding, and then the total amount -for twenty-four hours can be deduced. With this information, it is not -difficult for the doctor to know how much cow’s milk to prescribe. The -supplemental feeding may be given by alternating the bottle and the -breast, or by giving the breast and following it immediately with the -bottle. In the meantime, the mother must be put on tonics with an -abundance of fluids, and a generous diet that will raise the blood -pressure, in the hope that the milk will increase sufficiently to enable -her to feed the child entirely from the breast. - -When it becomes necessary to substitute some other food for the breast -milk, it means that the milk of some other mammal must be modified for -the purpose. The most convenient and abundant source of supply is the -cow. - -While in many respects cow’s milk is similar to mother’s milk, it is in -reality quite a different product. Mother’s milk is taken, undiluted, -directly from the breast, while cow’s milk is given from a bottle, hours -after milking, and not only must it be diluted, but certain ingredients -must be added to aid its digestibility. - -When taken into the stomach in its natural state, mother’s milk is a -liquid, while under the same conditions, cow’s milk forms a semisolid -gelatinous mass. - -It is essential that the milk should be as fresh, clean, and free from -bacteria as possible, and this can be approximated only in certified -milk. This milk is required by law to have its constituents definitely -standardized. Thus, there must be 4 per cent of fat, 4 per cent of -protein, and 4 per cent of sugar, and it must be so free from bacteria -that not more than 10,000 per cubic centimeter can be found. The cattle -also are tuberculin tested. The following comparison is from Holt: - - _Mother’s Milk_ _Cow’s Milk_ - - Sp. Gr. av. 1.031 av. 1.031. - Fat 4. % Fat 4. % - Protein 1.50% Protein 3.50% - Sugars 7. % Sugars 4.50% - Salts .2 % Salts .75% - Water 87.3 % Water 87.3 % - Reaction Alkaline Reaction Acid - Bacteria Very few Bacteria Many - - Both range from 1.026 to 1.06. - -[Illustration: Fig. 130.—Elements of human milk. (Eden.)] - -The fats are substantially the same, but the fat of cow’s milk is less -easily digested than the fat of mother’s milk. - -The protein of mother’s milk is virtually half lactalbumin and half -casein, which is only slightly coagulated into soft flocculent curds by -the action of rennin and acids, while the casein of cow’s milk is nearly -three times greater in amount than the lactalbumin and is coagulated -into coarse, tough curds. - -The sugars in both cases are lactose in solution, but mother’s milk -contains a much higher percentage. - -Cow’s milk contains three times the quantity of salts found in human -milk, but the water is the same in both. - -So, while the two milks seem in comparison to be much alike, in reality -they are quite different; hence it is necessary to modify cow’s milk in -such a way as to make it not like mother’s milk chemically, but to make -it _act_ like mother’s milk. - -It is extremely difficult to bring up an infant on artificial food, and -inasmuch as half the infants that die during the first year, perish from -intestinal disorders, it is imperative that every resource should be -exhausted before the breast feedings are abandoned. It is fallacious to -believe that anyone can feed a baby, or that feeding consists merely in -trying one food after another until one is found to agree. Only a -competent physician should prescribe the food, and he should study his -problem and make his modifications just as he would alter his medicines -for a particular disease. - -However, it is necessary for the nurse to know how to carry out the -doctor’s orders intelligently and how to report to him the conditions -present. - -In prescribing for the child, the doctor usually has some definite -outline in his mind, such as - - - Age and weight. _Example_: 3 months old; weight 10 pounds; 7 - feedings; 1 every 3 hours. - - Interval, three hours. - - Amount in each bottle, four ounces. - - Formula: - - Milk, 12 oz. - - Diluent, 16 oz. (Cereal water or plain water.) - - Sugar, ½ oz. - - Flour ball, if any, ½ oz. - - Boil if ordered. - -The infant should not take more than two ounces of milk to a pound of -weight in each twenty-four hours. - -=Proprietaries.=—Baby foods are not to be recommended nor condemned. -They are placed on the market as substitutes for mother’s milk with -definite instructions as to preparation. They are also very expensive. -They are not to be condemned, because many of them are invaluable when -used in connection with cow’s milk. Sometimes a child will not tolerate -anything but malted or condensed milk, or Nestle’s food, for example. -The malt sugars, such as Horlick’s and Mellin’s, are easily assimilated, -fattening, and laxative. - -All foods in the modification of milk should be of the best. The -standard sugars are Merck’s milk sugar, Mead’s Dextri Maltose, -Nährzucker, cane sugar, and Mellin’s and Horlick’s foods. Robinson’s -barley flour or Johnson’s are the best known. Imperial granum is a -partially dextrinized flour and corresponds to the home-made “flour -ball.” - - - FOOD PREPARATION - -=Buttermilk Made from a Culture.=—Bring two quarts of milk to a boil, -cool to the temperature required for inoculation (80° to 100° F., -depending on the culture employed). Introduce the culture, and allow it -to stand at the temperature of the room until a solid clabber forms. -Place on ice, whip with an egg beater or break up with a churn before -using. If a fat-free buttermilk is desired, use skimmed instead of whole -milk. - -There are many kinds of buttermilk cultures on the market, but Hansen’s -is considered one of the best, because it is not too acid, besides -which, it has a good flavor, and the culture can be utilized over and -over for a week or ten days. - -In preparing a subsequent portion, it is only necessary to use two or -three ounces of the first buttermilk, which may be reserved for the -purpose. This amount is introduced into the freshly boiled milk, instead -of the original powder, and the preparation is continued exactly as -described for the mother culture. - -In every case the mixture must be placed on ice as soon as the clabber -forms, as it becomes too sour otherwise. - -=Eiweiss Milk.=—Heat one quart of whole milk to 145° F. and coagulate -with pepsin, rennin, or chymogen, which is 10 per cent rennin. Let it -stand until clabbered, which takes about ten minutes. Pour into a gauze -bag and let it stand until all the whey is drained off. To the dry curd, -add ½ ounce of flour ball, and one pint of skimmed buttermilk, the whole -to be rubbed through a very fine wire mesh sieve (as fine as a -tea-strainer, at least), three separate times; or, it may be ground -twice through a special mill to break up the curd as minutely as -possible. Add a pint of water and measure. There should be a quart and -three or four ounces over. Place upon a slow fire and bring to a boil -while stirring constantly. Boil two minutes, then cool, strain, measure, -and add water to make up for evaporation. Shake well before measuring, -as the curd is heavy and settles to the bottom. - -=Peptonized Milk.=—(See p. 338.) - -=Whey.=—To a pint of fresh, warm cow’s milk, add rennin as pepsin, or -chymogen, and stir until mixed. Let it stand until coagulation is -complete. Then the curd should be broken up with a fork, and the whey -drained off through coarse muslin. This removes the coagulable proteins -from the milk. A ten per cent cream can be had at home by allowing a -quart of milk to stand for six hours and then using the upper -one-fourth. - -=Whey-Cream Mixture.=—Make whey as described and mix with cream, in the -proportion of whey 1½ ounces to cream, 1 dram for each feeding. - -=Barley Water. No. 1.=—Use one ounce of barley pearls to a quart of -water. Wash thoroughly, put on a slow fire and boil for six hours. Add -water to make up for evaporation, and add a pinch of salt. Strain and -cool rapidly. - -=Barley Water. No. 2.=—Use one heaping teaspoonful of Robinson’s patent -barley flour to each pint of cold water. Boil twenty minutes and add -water to make up for evaporation. Add a little salt, strain and cool -rapidly. - -=Other cereal waters=, like rice and oatmeal, are made like barley water -No. 1, and in the same proportion. - -=Flour Ball.=—Take four cups of ordinary wheat flour and wrap it in a -piece of muslin, and tie it tightly. Drop the mass into boiling water -and boil six hours. Then take it out, cool it and remove the outer -peeling with a sharp knife. Break into small pieces, the size of an -English walnut, and dry thoroughly in a slow oven. Pulverize in a mill -or meat-grinder, sift and keep in a dry place. - -=Milk= may be sterilized, pasteurized, or boiled. - -_Sterilization_ kills both germs and spores, but it is not nearly so -necessary as it is to have the right proportion of sugar and fats. Place -in an autoclave and keep at a temperature of 160° F. for an hour. - -_Pasteurization_ is desirable when a good, clean milk is not attainable. -It kills the germs, but not the spores. The process must be carefully -attended to, or the milk will sour more easily. Heat a quart of milk to -160° F. for twenty minutes. Cool rapidly to 40° F. - -_Boiling milk_ for two minutes kills all bacteria, and renders the -casein more easy of digestion and prevents the formation of curds. - - - PUTTING FOODS TOGETHER - -=Whole milk= contains 4 per cent fat, and must be thoroughly shaken -before it is measured, for otherwise one child will get all the fat and -another all the skimmed milk. - -=Fat-free, or skimmed milk=, contains about 0.1 per cent fat. The cream -has been removed by a siphon or centrifuge. If unable to get a fat-free -milk from a dairy, the cream can be removed from a quart of whole milk -quite easily with a siphon. - -=Sugars and flours= should be weighed when used, for they vary greatly -in volume. - -In using flour ball or imperial granum, the flour must be mixed with -water or cereal water, to make a smooth paste and brought to a boil. If -the milk is to be boiled also, add the milk to the paste and boil all -together. Cool and strain. - -All baby feedings should be strained, as tiny lumps of food will clog -the rubber nipple and the nurse may think the baby is not taking its -feedings well. The following is a typical formula: - - Whole milk 15 oz. } - Barley water 15 oz. } - Sugar ½ oz. } 5×6×4 - Flour ball ½ oz. } - Boil two minutes. } - -Weigh the sugar and flour ball and make a paste with the barley water. -Shake the whole milk, measure out 15 oz. in the graduate, and add the -barley water mixture. Boil two minutes. Cool in running water, strain -bottle and put on ice. The figures at the side mean that five feedings -of six ounces each are to be given at four-hour intervals. - -It is necessary to cool all feedings as soon as modified, and keep them -on ice for preservation until used. - -The only accurate way is to make up the whole quantity for twenty-four -hours, put into separate bottles the exact amount of each feeding and -give at the time ordered, after the bottle has been properly warmed. In -warming the food, care must be used to get it neither too hot nor too -cold; 100° F., or when it feels warm to the back of the hand, is about -right. The child should be held in the arms while taking the bottle. - -A buttermilk feeding must not be heated to more than 100° F. because it -curdles and can not be used. - -=The rubber nipples= should be washed thoroughly after use, boiled once -a day, and kept in boric acid solution. - -=The necessary articles= for home modification of milk can be obtained -anywhere. One set of utensils should be kept for this purpose -exclusively and boiled each time before the food is prepared. A list is -convenient: - - - A 16 ounce glass graduate. - - One tablespoon and one teaspoon may be used for measuring purposes, if - unable to get a satisfactory scale. - - 1 2–quart aluminum cooking dish. - - 1 long-handled aluminum spoon. - - 1 fine wire mesh strainer, thirty holes to the inch. - - 1 dozen bottles, 5 ounce size if the child is small, and 10 ounce if - the child takes large feedings. - -The bottles should have wide mouths, straight sides, and round bottoms, -which clean easily. Paper caps or corks that fit tightly should be used -instead of cotton stoppers. Close rubber caps are best, for, as the milk -cools, a vacuum is created, the rubber is drawn in and the milk remains -air-tight until opened. If infants are kept on a milk diet alone for too -long at a time, they do not thrive so well, hence as early as six -months, other things may be given. At this stage, the most desirable -additions to the food would be cereal, farina or cream of wheat, orange -juice, vegetable broth, toast crumbs, etc. The administration of orange -juice should be started when the child is only a few weeks old. - -The quantity of all these foods may be increased as the child gets -older, and by the end of a year the diet is broadened still further. -Beside a quart of whole milk, it may have thickened soups, vegetables, -such as cauliflower, spinach, carrots, creamed celery and a little baked -potato. Fruits, orange juice, grape fruit juice, prune sauce, apple -sauce and scraped apple may be given, but no bread. In place of bread, -use toast, Huntley and Palmer wafers and biscuits, and soda or oatmeal -crackers. Sweet desserts should be avoided, but flavored junket or -simple custard is unobjectionable. - -No meats are permitted until the child is eighteen months old, except, -perhaps, a little crisp bacon, or a bone to suck. - -None of these supplemental foods should be given between meals, but -always at the feeding hour. The above list supplies a dietary so varied -that no child will tire of it. - -In reporting the condition of the infant to the physician, the following -form may be used to advantage. It is a clear cut, concise summary of -what he wishes to know. - - - Infant’s Daily Report - - 1. _Food_: Does baby take it all? Is he satisfied? - - 2. _Bowel movements_: How many in last 24 hours? What is the color? - Are they hard, soft, or watery? Any odor? Any curds? Any slime? - Any blood? Any colic? Much gas? - - 3. _Does baby vomit?_ When? How much? - - 4. _Does baby sleep well?_ _Is he good natured?_ - - 5. _Any fever?_ _What is the weight?_ - -=Significant Symptoms and Conditions.=—In an artificially fed baby, the -normal condition of the bowels is constipation. The stools are formed, -alkaline in reaction, rather hard, and usually only one a day. - -The stools should have a characteristic color, according to the food -taken. Thus: - -_Sugar or starch_ will color the movement a dark brown, like vaseline. - -_Too much fat_ gives a pale yellow stool, almost white, like putty. - -_Eiweiss_ feedings show as a pale yellow, somewhat like the fatty -stools, but constipated. - -_Barley water_ gives a brown liquid stool. - -_Starvation stools_ are thin, slimy, dark brown or green. - -_The consistency_ of the movements is also important. - -Too much sugar or starch means diarrhœa, with thin, green, acid stools, -and much gas and regurgitation, or, sometimes foamy, mucous discharges. - -_Diarrhœa_ may also be due to indigestion. Mucus in the stools usually -signifies intestinal irritation. - -_Constipation_ may exceed the normal limits of the artificially fed -child when the food contains too much fat. - -_Bad odors_ of the stools result from putrefaction. - -_Colic_ means imperfect digestion with gas. There is less colic when the -intervals between the feedings are lengthened. - -_Curds_ are of two kinds. The soft friable ones due to fat, and the hard -bean-like masses of protein. Curds occur with feedings of raw milk only, -and though associated with symptoms of indigestion, they signify -overfeeding. If the sugar content of the food is low, the child will -gain very slowly. - -_Vomiting_ is an important phenomenon. It may be due to overfeeding, to -excess of sugar or fat in the food, or to pyloric stenosis. Excess of -fat is shown by vomiting and regurgitation of small quantities of food -one or two hours after feeding. It may be associated with constipation. - -If vomiting occurs immediately after feeding, it is probably due to the -taking of an excessive amount, or to the too rapid ingestion of the -regular bottle. If the vomiting takes place later than twenty minutes -after feeding, it is probably pathological. It may be the result of -indigestion, meningitis, or of pyloric stenosis (q. v.). - -For the first weeks of life, mother’s milk should be obtained at all -hazards, if possible, but if this is not to be had, the artificial -feedings may be started. - -A desirable milk modification for the first weeks of life should begin -with a low food value. For example, a child one week old weighing seven -pounds, should start on a formula like this: - - Whole milk 7 oz. - Water 7 oz. - Cane sugar ½ oz. - Boil two minutes. - -This will make seven feedings of 2 oz. each, and one is given every -three hours with one feeding omitted at night. - -Cane sugar is _less_ liable to produce colic than sugar of milk. - -Lime water, or sodium citrate may be added, if the child vomits, or if -other indications arise. Both are alkalies. - -The strength of the mixture, as well as the quantity, must be increased -as the child gets older and it is seen that the formula will agree. - -The percentage of protein is kept down by dilution, with plain or cereal -water, while fats (as cream) and sugars are added to make up the -strength lost by the dilution. - - - - - CHAPTER XXIII - CLEANLINESS AND STERILIZATION - - -=The nurse= is called to a case on account of her special -qualifications, but also she should lead her patient in all things, even -in gentility. It is her part to anticipate the wants of the patient, and -regard it as a reproach if the patient has to remind her that it is time -for food, medicine, bath, or for child to come to the breast. -Regularity, promptness, and thoughtfulness must be supreme. Be on hand -when the doctor calls and stay until he goes. Be as cheerful as Mark -Tapley, however dreary the prospect, and do not make noises either by -the swish of overstarched skirts, the squeak of shoes, or the moving of -equipment. Above all things, the nurse must keep her patient’s room, her -patient, and her own person rigorously clean. She should not allow her -hands to touch infectious material without protection by rubber gloves. -This is as necessary for her own safety as for the patient and family. -Her hands should be manicured frequently, her hair shampooed at short -intervals, and her teeth kept in order. If the hands get hard, take a -teaspoonful of sodium carbonate and one of chloride of lime, mix in the -palm of the hand with enough water to make a cream, and rub well into -palms and about the nails. Rinse in clean water. (Weir.) - -The nurse’s dress should be neat, always mended, and carefully adjusted. -The nurse who is slovenly in appearance will be slovenly in her mind and -slovenly in her work. She should not wear her uniform on the street. It -is bad taste, unprofessional, and unsanitary. - -She should bathe at least three times a week. There is always some odor -of perspiration about the body, and especially around the axillary -spaces which are filled with hair. Nothing is more offensive and -nauseating than being leaned over and waited on by a person who has a -strong body smell. - -The prodigal use of warm water and soap will aid, but there are large -sebaceous glands in the armpits and their decomposing excretions are -retained by the hair so lastingly that more radical measures are -necessary. The axillæ should be shaved at least once a month, and then -the soap and water becomes more efficacious. After thorough cleansing, -the armpits should be dredged with Babcock’s Motiya powder, and the -annoying and offensive odor will disappear. - -If the patient is a refined and dainty woman, who may happen to be -afflicted with the same misfortune, she will be deeply grateful to the -nurse who tells her how to get rid of it. - -That some doctors, unfortunately, have strong odors about the person—the -mixed effluvia of tobacco, alcohol, bad teeth, and uncleanliness—is no -excuse for the nurse. The doctor should know better, but at all events, -his offense rarely needs to be suffered more than a few minutes at a -time, while the nurse is in constant attendance. - -The trained nurse should be polite to, but not familiar with servants, -as she is looked upon as the highest type of the professionally educated -gentlewoman, and she must be constantly alert that her reputation in -this respect is not diminished. - - - BATHS - -=Hot Baths.=—Temperature from 98° F. to 120° F. - -Water should be tepid at first and the hot water gradually added until -the required degree is obtained. - - _Warm bath_ 92° F. to 98° F. - _Tepid_ 85° F. to 92° F. - _Cold_ 33° F. to 65° F. - -=Sedative Bath.=—The patient is stripped and stands for an hour in the -hydrotherapy room, while a hot spray is played up and down the spine. -The temperature of the water is 104° F. to begin with, and gradually -increased to the point of toleration. - -=An alkaline bath= is prepared by adding an ounce of sodium carbonate to -each gallon of water. - -=Bran Bath.=—Add two ounces of bran to each gallon of water. Mix the -bran in a small amount of boiling water and add to the bath water. - -=Mustard Bath.=—To three gallons of water at a temperature of 105° F. -add a tablespoonful of mustard. Leave the child in the water for five -minutes, all the while rubbing and stroking the limbs and back. Then -wrap naked in a warm blanket and leave for half an hour. - - - STERILE DRESSINGS—ANTISEPTIC SOLUTIONS—STERILIZATION OF INSTRUMENTS - -The preparation of sterile dressings, antiseptic solutions and the -sterilization of instruments, is particularly the work of the nurse, -whether in the hospital or in a private home. The following directions -are therefore desirable: - -As soon as the nurse is sure her patient is in labor, she boils a milk -bottle, fills it two-thirds full of 95 per cent alcohol, puts a pledget -of sterile cotton in the bottom and then boils a pair of dressing -forceps, which are placed, handle up, in the alcohol. (See Fig. 52, page -132.) _With this forceps, she handles all clean dressings, instruments, -and rubber goods that may be contaminated by touch._ - -=Dressings and Supplies.=—The necessary dressings and supplies may be -prepared one or two weeks before labor according to the following -instructions: - -_Five Yard Packing._—Draw threads at either end of five yard lengths of -gauze to its full width. Fold the cut edge across until it lies -one-third the distance from the opposite side. Next, fold the double -edge over, and bring it to the outside edge of the first fold. Keep it -perfectly straight. When folded full length, roll from the end and wrap -in strong muslin wrappers. Sterilize in the autoclave or Arnold -sterilizer. - -_Pads for the Vulva._—Unroll a whole bale of common cotton and cover it -with a ½ inch thickness of absorbent cotton. Cut in lengths of 12 in. by -4 in. wide. Cover with gauze cut 12 by 14 inches, and fold the ends of -gauze over absorbent cotton. Roll from the end, wrap in paper, seal, and -sterilize. - -_Pledgets._—Tear two yard strips, lengthwise of the roll of absorbent -cotton, pull from these, three inch pieces, roll them in the hands until -round, place in clean bags, and sterilize. - -_Breast Covers._—Squares of old, soft muslin 4 by 4 inches, with all -strings removed, make the best dressings for the nipple. Do not use -gauze, because the papillæ of the nipple may get caught in the mesh and -when it is taken off, the tender nipple is irritated or abraded. - -_Breast Binders._—These are made of single material, because they would -be too warm otherwise. They are sleeveless and jacket-shaped and measure -16 inches from shoulder to waist, 40 inches long, and 10 inches for the -arm scallop. A binder of this size, if properly adjusted, will fit a -patient of any size. Three will be sufficient for the case. - -_Abdominal Binders._—The abdominal and breast binders are worn during -the bed period only. The abdominal binder is made of unbleached muslin, -double material, 14 by 40 inches, and hemmed. In the center of the back, -on the lower edge, a curved space, six inches wide, is cut out to -prevent the binder from getting soiled. To this curved edge, the pad -holder is attached by two safety pins, one on either side. The abdominal -binder is adjusted by pinning firmly above the fundus, and loosely -below. - -_Pad holders_ are made of unbleached muslin, and measure 6 by 16 inches. - -_Cord Dressings._—Cut squares of surgical lint 4 by 4 inches, and cut -through to the center on one side. Gauze may be used, but it is not -ideal. - -_Nursery Cotton._—Tear absorbent cotton into narrow lengths and pull out -small one inch pieces. Roll them, place in a clean bag and sterilize. - -_Applicators._—Use absorbent cotton and toothpicks. Tear off small -pieces of cotton, moisten the toothpick point with water, place in the -middle of the cotton, and roll firmly. - -_Gauze Sponges._—Cut gauze into squares 6 by 6 inches, and fold from -each side to the center. This brings all the ragged edges inside. Fold -into squares, place in jars, and sterilize. - -=Sterilization of Instruments.=—Place scalpels in carbolic acid 95 per -cent for ten minutes. Lift with sterile forceps, and put in a basin of -95 per cent alcohol for ten minutes. In the absence of carbolic acid and -alcohol, the scalpels may be dropped in a 2 per cent solution of lysol -for twenty minutes. Cleanse with hot sterile water. (_Do not boil -scalpels_; it dulls the sharp edges.) - -All other instruments may be placed in a sterilizer (dishpan or wash -boiler) with enough water to completely cover them; boil twenty minutes. -Cool in sterile pan, which may be set in cold water. Do not use soda on -the instruments during sterilization, as it makes a thick, gummy -precipitate on the metal. - -_The sterile handling forceps_ must be immersed at all times for -two-thirds their length in 95 per cent alcohol. - -_Brushes._—After using, all brushes should be thoroughly washed, boiled, -and dried, wrapped in waxed papers, and sterilized in the autoclave. In -the absence of the autoclave, boil thirty minutes. - -_Basins, pitchers, and douche pans_ are sterilized by wrapping in strong -muslin bags and put to boil for forty-five minutes in the basin boiler -or wash boiler. They will not remain sterile longer than one week, even -when kept in a clean place and well wrapped. Bedpans should be washed in -a strong solution of soap and water, rinsed every morning and boiled for -thirty minutes. - - -=Sterilization of Rubber Goods.—= - -_Tracheal Catheters._—Drop in a solution of bichloride 1:5000 and leave -for twenty minutes. Lift with sterile forceps into a basin of warm -sterile water and leave for ten minutes, or until used. - -_Vorhees Bags._—Boil twenty minutes. The bags and catheters may be given -a longer life by keeping them in a 25 per cent solution of glycerine and -water when not in use. Kerosene vapor is also preservative. - -_Rubber Catheter._—Boil twenty minutes. - -_Hot Water Bags, Ice Caps, Rubber Bed Rings._—Soak in 10 per cent lysol -solution for two hours, wash with warm water, and dry thoroughly. The -inside of the ice caps can be dusted with powder. - -Never leave rubber gloves in a damp place or lying in a solution. It -stretches them and weakens the rubber. To sterilize, they must be washed -in a strong solution of soap and water, dried, and paired. Then they are -wrapped in a heavy cloth covering and put in the autoclave for twenty -minutes. - -_Wet Process for Rubber Gloves._—Wrap in gauze or cloth and boil for -thirty minutes. Lift with sterile forceps and place in lysol solution 1 -per cent until used. They are easily drawn on by filling them with the -solution as the hand goes in. - -_The autoclave_ is not always available, but an Arnold or Rochester -sterilizer is readily portable, and takes the place of the hospital -machine. - -=Fumigation of rooms= is sometimes necessary. Remove all curtains, bed -linen, and other washable fabrics from the room. Open the drawers of -dressers, doors of closets, and loosen up and separate everything left -so the air can get to it. Close the windows and seal the crevices with -cotton and make the room as air-tight as possible. Place a large pan -containing six ounces of potassium permanganate crystals in the center -of the room. Pour over this twelve ounces of formalin, close and seal -the outside doors of the room and leave for twelve hours. If the case -has been a very septic one, it is always a good plan to wash the walls -of the room before using again. The insides of the drawers and the bed -should be thoroughly washed with water and green soap. A formaldehyde -lamp is also quite satisfactory if obtainable. - - - - - CHAPTER XXIV - DIETS AND FORMULÆ - - -The nurse should serve everything in the most cleanly and appetizing way -if it is only a cup of tea; and all waste, soiled dishes, napkins, and -excreta must be removed as delicately as possible. - -=Diet for Pregnancy.=—Fresh fish, boiled, broiled or baked; and -shell-fish raw or cooked,—any way but fried. - -Meat, once or twice a day, except when contraindicated by condition of -the kidneys. Veal is best omitted. - -All farinaceous foods and vegetables may be eaten freely. - -Desserts should be plain, but tempting. - -No alcohol is taken without direct permission from the doctor, and -coffee and tea should be limited. - -=Diet for Puerperium.=—First two days, milk, buttermilk, soup, gruel, -cocoa, toast and tea, chicken, oyster and clam broth. - -In the next two days, under ordinary conditions, the diet is increased -and made somewhat heavier. - -Semisolids are added like milk-toast, eggs, poached or boiled soft, -oysters, clams and boiled fish. - -After the milk comes in, the woman is put on a general diet as fast as -she can digest it. - -=Farinaceous diet—melons and oranges.=— - -_Breakfast._—Cereal, coffee with milk and sugar, if desired, bread and -butter, corn bread, rolls, toast, muffins, hominy, cereal with cream. - -_Lunch._—Vegetable soups, bread, butter, potatoes, beans, rice, macaroni -and cereal, peas, buttermilk, pudding, such as rice, tapioca, bread -cornstarch, jellies, fruit juices, pumpkin, squash, turnips, tomatoes, -etc. - -_Dinner._—Bread, butter, milk-toast, hominy, rice, celery, fruit salads, -lettuce, apples, pears, prunes, stewed fruits or fresh melons, etc. - -_The following diets are routine at many hospitals_: - -=General Diet.=—Full tray of food in season as furnished by the -hospital. Three meals daily. - -=Light Diet.=—Foods from the following list may be selected, and served -three or five times daily, as desired: - -Soups of all kinds. When leguminous foods are employed, their outer -coverings must be removed by rubbing them through a sieve or colander. - -Vegetables of all kinds, except green vegetables (provided they have -been reduced to a pasty consistency). Those with excess of fiber or -cellulose, such as turnips, celery, asparagus, and cabbage, should be -chopped after thorough boiling, then mashed, while those having tunics -should be sieved or colandered. - -Grain foods of all kinds thoroughly cooked, excepting corn preparations -containing much cover, as hulled corn. - -Prepared foods such as tapioca, macaroni, and vermicelli, require -prolonged cooking. - -Meats, scraped beef. - -Eggs, soft boiled, raw or soft poached. - -Bread of all kinds, stale, home-made. - -Puddings, ices. - -Beverages, all kinds unless otherwise ordered. - -=Forced Diet.=—This includes the general diet with the addition of one -quart of whole milk and four eggs. The milk may be given plain or as an -eggnog at seven, ten, three, and eight o’clock. The eggs may be given -raw or cooked soft in any form. - -=Milk Diet.=—Twelve ounces of whole milk (375 c.c.) may be given every -two hours; i. e., at six, eight, ten, twelve, two, four, five, and eight -o’clock, or the patient may sip it at her pleasure. - -The milk may be given raw, boiled, diluted with plain water, lime water, -Vichy, seltzer, or Apollinaris to taste. The daily amount should include -three quarts of whole milk. Koumiss, buttermilk and milk soups are -sometimes allowed. Note the exact amount taken, and give reasons for -failure. Watch the stools for undigested milk. - -=Liquid Diet.=—Whole milk, buttermilk, koumiss, beef tea, or beef, -chicken, mutton, oyster, or clam broth, in eight ounce portions, or two -ounces of beef juice, every two hours. Lemonade, orangeade, ice cream, -or fruit ices, at intervals and amounts as desired. - -=Ulcer Diet.=—Whole milk and cream, equal parts, three ounces every two -hours. Sodium bicarbonate, thirty grains, in a small amount of water, to -be given before and thirty minutes after feeding. Albumin water, soft -boiled eggs, scraped beef, custard, and cream soups to be added later by -direction of the physician. No seasoning except salt is allowed. - -=Prochownik Diet.=—This diet is advised where some necessity exists for -preventing a large child. It is administered in the last six weeks of -pregnancy only. - -_Breakfast._—Small cup of coffee, two slices of toast (1 ounce). - -_Lunch._—Small piece of meat, fish or an egg, a little sauce. A -vegetable prepared with fat, lettuce, a small piece of cheese. - -_Dinner._—Same as lunch with three slices of bread and butter, and a -little milk. - -A pint of water daily is allowed; taken in sips it lasts longer. - -Soup, water, beer (all fluids) and sugar, pastry, and potatoes are -forbidden. - -=Skimmed Milk Diet (Karell).=—Skimmed milk, to which a pinch of salt is -added, 3 to 6 ounces, three or four times daily, increasing the amount -gradually, taken slowly to allow thorough mixture with saliva, warmed in -winter, room temperature in summer. - -=Acute Nephritis Diet.=—Whole milk, 1000 c.c.; cream, 250 c.c.; water, -150 c.c.; stewed fruit, well sweetened, 50 c.c. - -Bread, well buttered, may be toasted, 150 gm. (equal to three slices). - -Green salad of lettuce, celery, apple, pear or grape fruit, and served -either with olive oil, or with a mayonnaise dressing made from olive -oil, egg and lemon juice, with salt (but no pepper or condiments) may be -given in two small portions daily. - -Cooked cereals (cream of wheat, etc.) with cream and sugar, one portion -equal to about two ounces, once daily. - -The above represents a daily fluid intake of about 1500 c.c. The diet is -to be given in “three meals,” at eight, one, and six o’clock, with fluid -nourishment at eleven, three, and nine o’clock. - - - RECTAL FEEDING - -Nutrient enemas should be given every six hours, unless otherwise -ordered. It is necessary to cleanse the lower bowel with a saline or -soapsuds enema at least once a day. The cleansing enema should be given -one hour before the nutrient enema is to be given. The proper quantity -for the nutrient enema is four to six ounces for an adult, and one to -three ounces for a child. Nutrient enemas should be given slowly at very -low pressure, the level of the fluid in the can being not over eight to -ten inches above the level of the rectum. If the injected material is -thick, a piston syringe may be required. The patient should be placed -upon the left side with the hips well elevated and should be kept in -that position for fifteen to twenty minutes after the enema has been -given. The tube should be oiled and not be inserted more than three or -four inches. The temperature of the enema should be about 98 degrees. If -there is a strong tendency to evacuate the enema, pressure should be -made against the rectum with a pad. - -The following nutrient enemas may be ordered by name. - -=Glucose Enema.=—Glucose (dextrose, grape sugar) 1 ounce, normal salt -solution 5 ounces. - -The glucose should first be dissolved in hot water. The amount of -glucose may be increased, upon order, if no irritation is produced. - -=Pancreatinized Milk Enema.=—Add 1 tube of peptonizing powder, or 1 to 2 -drams of “Pancreatic solution” to 1 pint of skimmed milk. Stir well and -place in a warm water bath for one-half hour. Add 1 dram of salt. - -=Milk and Egg Enema.=—Thoroughly beat the whites of 2 eggs, add ⅓ dram -of salt, and 6 ounces of skimmed milk. Add one tube of peptonizing -powder, or 1 to 2 drams of “pancreatic solution,” stir well, and place -in a warm water bath for one-half hour. - -=Milk, Egg, and Beef Juice Enema.=—Mix the beaten whites of 2 eggs, 2 -ounces of fresh beef juice, 6 ounces of skimmed milk, and ⅓ dram of -salt. Add 1 tube of peptonizing powder, or 1 to 2 drams of “pancreatic -solution,” stir well, place in a warm water bath for one-half hour. - -=Milk and Glucose Enema.=—Add 1 tube of peptonizing powder to 6 ounces -of skimmed milk, stir well, place in a warm water bath for one-half -hour. Add 3 drams of glucose and ⅓ dram of salt. - - - ELIMINATIVE ENEMAS - - =Impaction Enema.—= - - Castor oil or olive oil, 1 ounce. - - Soapsuds (100° F.), 1 quart. - - Mix as thoroughly as possible, add one dram of spirits of - turpentine beaten up with the yoke of one raw egg. - - - =S. S. and G. Enema.—= - - Soapsuds, 1 quart. - - Glycerine, 1 ounce. - - - =Asafœtida Enema.—= - - Milk of asafœtida, 8 ounces. - - Water, 8 ounces. - - - =1–2–3 Enema.—= - - Magnesium sulphate, 1 ounce. - - Glycerine, 2 ounces. - - Water, 3 ounces. - - - =Milk and Molasses Enema.—= - - Milk, ordinary cooking molasses in equal parts, possibly 8 ounces - of each. Heat, but do not boil. - - - =Turpentine Enema.—= - - Soapsuds, 1 pint. - - Turpentine, 1 dram. - - It acts quickly and effectively. - -All enemas should be given through a colon tube. The patient should be -on the left side and the temperature of the injection should be about -100° F. - - - DIET LIST - -=Albumin Water.=—Take white of 1 egg, stir until separated. Add a little -lemon juice and 1 pint of water. Ice and serve. Sugar or salt may be -used. - -=Barley Water.=—Wash 2 ounces of barley with cold water. Boil for 5 -minutes in fresh water. Strain. Then cover with 2 quarts of water and -cook slowly down to 1 quart. Flavor with thinly cut lemon rind and -sugar. Do not strain unless patient requests. - -=Beef Juice.=—Cut into cubes 1½ inches each, 1 pound round steak. Place -in a clean, ungreased pan, and fry one and one-half minutes on each -side. Pour into hot meat press and apply pressure. In absence of a -press, a potato ricer may be used. Season with salt and pepper. May be -served iced or heated by putting in double boiler and stirred all the -time. Do not allow to curdle. - -=Beef Tea.=—Put 1 pound of finely chopped round steak into a quart glass -jar, fill with cold water. Place jar in kettle of warm water. Leave over -slow fire for four hours. Strain, season with salt and pepper. - -=Champagne Whey.=—Boil 8 ounces milk for fifteen minutes. Strain through -cheesecloth. Add 1½ ounces champagne. - -=Chicken Broth.=—Skin and chop in small pieces one small or one-half -large fowl. Boil bones and all with one blade of mace, a sprig of -parsley, and 1 tablespoonful of rice, 1 crust of bread and 1 quart of -water, for one hour. Skim from time to time. Strain through coarse -colander and season to taste. - -=Cinnamon Water.=—One-half ounce stick cinnamon, 2 cups boiling water. - -Break sticks in small pieces. Add water, boil twenty minutes. Strain and -serve hot or cold. - -=Clam Broth.=—Wash thoroughly 6 large clams in shell. Put in kettle with -1 cup of cold water, bring slowly to boil, and keep temperature for one -minute. Pour off broth and serve hot. Add salt and pepper. - -=Eggnog.=—Beat an egg, white and yolk separately. Add to the yolk 1 dram -of vanilla extract, a pinch of salt and 4 oz. fresh milk, and 1 dram of -sugar. Add ½ dram of sugar to white of egg, stir a portion into the -glass and heap remainder upon top of glass. - -=Egg Cordial.=—One egg white, 1 teaspoon sugar, 1 tablespoon brandy, 2 -grains salt, 2 tablespoons cream. - -Beat white until stiff. Add cream, continue beating, add other -ingredients, and serve cold. - -=Egg Lemonade.=—Beat 1 egg and 1 teaspoonful of sugar until very light, -add ¼ cake of yeast dissolved in one-fourth cup of water, two -tablespoonfuls of sugar, pour into bottles with patent stopper, fill -bottles only two-thirds full, cork tightly. Shake well. Allow to stand -on ice twenty-four hours. - -=Flaxseed Tea.=—One ounce of whole flaxseed, 1 ounce powdered sugar, ½ -ounce licorice root, 1 ounce lemon juice. Pour over these materials 1 -quart of boiling water and allow to stand four hours. Strain off liquor. - -=Gum Arabic Water.=—Dissolve 1 ounce of gum arabic in 1 pint boiling -water. Add ½ ounce sugar, a wineglassful of sherry, and juice of one -lemon. Serve with ice. - -=Junket.=—Take ½ pint of fresh milk in a saucepan. Add 1 teaspoonful of -essence of pepsin, stir just enough to mix. Pour into custard cups. Let -stand until firmly curded. Serve plain or with grated nutmeg. Sherry may -be added. - -=Koumiss.=—Heat four cups of milk, then cool; when lukewarm, add ¼ cake -of yeast dissolved in one-fourth cup of water, two tablespoonfuls of -sugar, pour into bottles with patent stopper, fill bottles only -two-thirds full, cork tightly. Shake well, allow to stand on ice -twenty-four hours. - -=Milk Shake.=—White of 1 egg, 1 ounce sugar, 1 ounce chipped ice, 1 -ounce cream. Shake in milk shaker two minutes. Add milk to fill glass. -Flavor with vanilla and lemon. - -=Mutton Broth.=—Boil slowly 1½ pounds of lean loin mutton, including the -bone. Add a little salt and ½ onion. Pour broth into a basin. Skim off -fat when cool. Warm as used. - -=Oatmeal Gruel.=—One teacup oatmeal flakes, cover with 1 quart cold -water. Place on slow fire and soak three hours. Strain, add 4 -teaspoonfuls of sugar and 1 teaspoonful of salt. - -=Oatmeal Water.=—Cover 1 teacupful oatmeal with 1 quart cold water. Let -it stand two hours. Stir often. Strain. Serve with salt, sugar and ice. - -=Peptonized Milk. Warm Process.=—Dissolve the contents of Fairchild’s -peptonizing tube in 4 tablespoonfuls cold water. Add to 1 pint of milk. -Put in glass jar, and place jar in vessel of warm water. Heat slowly to -115° F. Stir slowly and allow it to remain thirty minutes. Place on ice -at once to check further digestion. - -=Peptonized Milk. Cold Process.=—In a clean quart bottle, put one -peptonizing powder (Fairchild). Add 1 teacupful of cold water. Shake. -Add 1 pint fresh cold milk. Shake well. Place on ice. Do not heat before -using. - -=Rice Water.=—Pick over and wash 2 tablespoonfuls of rice. Put in a -saucepan with 1 quart of boiling water; simmer two hours. When rice is -dissolved, strain. Add teaspoonful salt. Serve warm or cold. Sherry may -be added. - -=Rum Punch.=—Two teaspoonfuls powdered sugar, 1 egg well beaten, warm -milk, 1 large wineglassful; 4 ounces Jamaica rum. Flavor with nutmeg. - -=Scraped Beef.=—Place on breadboard a round steak. Scrape with -table-knife but do not take any shreds of muscle. Salt and pepper. -Spread on thin slices of bread. Place in toaster until seared. - -=Toast Water.=—Three slices of stale bread well browned, but do not -burn. Put in a pitcher, pour over them 1 quart boiling water. Cover -closely, and allow to stand until very cold. Strain. Wine and sugar may -be added, to stimulate. - -=Wine Whey.=—Put 1 quart new milk in a saucepan and place over fire. -Stir until nearly boiling. Add 2 ounces of sherry wine. Boil slowly for -fifteen minutes. Skim off curds as they arise. Add 1 tablespoonful -sherry. Skim again, then strain through gauze. - - - - - CHAPTER XXV - SOLUTIONS AND THERAPEUTIC INDEX - - - =Acid, Boric.= 5 dr. in a pint of water makes a 4% solution, or 1:25. - - =Acid, Carbolic.= 15 ♏︎ in a quart of water makes a 0.1% solution, or - 1:1000. 5 dr. to the quart makes a 2% solution; and 1¼ oz. to the - quart, a 5% solution. - - =Chinosol.= 15 gr. to the quart of water makes a solution of 1:1000. - - =Formalin.= 1 dr. to the quart of water makes a solution of about - 1:500. - - =Mercury Bichloride.= 15 gr. to the quart of water makes a 0.1% - solution, or 1:1000. 1½ gr. to the quart makes a 0.01% solution, - or 1:10,000. - - =Normal Salt Solution.= 2 dr. of salt to the quart of water, or 0.9%. - - =Physiological Salt Solution.= Take normal salt solution as given - above and to every 3½ oz. add 15 gr. of carbonate of soda. - - =Potassium Permanganate.= 2½ dr. to the quart makes a 1% solution. 3 - gr. to the quart makes a 1:5000 solution. - - =Silver Nitrate.= 4½ gr. to the ounce of water or 1 gr. to 1–7/10 dr. - makes a 1% solution. - - =Ziratol.= 2½ teaspoonfuls to a quart of water makes a 1% solution. - -For general reference the following valuable table is appended: - - PERCENTAGE SOLUTION TABLE - - BY ALFRED I. COHN, PHAR. D., in _Merck’s Report_ - - ════════╤══════════════════════════════════════════════════════════════ - Quantity│ - of │ - solution│ GRAINS OF SALT OR DRUG REQUIRED TO MAKE SOLUTIONS OF - to be │ PERCENTAGE STRENGTH INDICATED - made │ - ────────┼──────┬──────┬──────┬──────┬──────┬──────┬──────┬──────┬────── - │ 0.5% │ 1% │ 2% │ 3% │ 4% │ 5% │ 6% │ 8% │ 10% - ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── - ½ fl. oz│ 1.15│ 2.3│ 4.6│ 6.9│ 9.3│ 11.7│ 14.1│ 19. │ 24. - 1 fl. oz│ 2.3 │ 4.6│ 9.2│ 13.9│ 18.6│ 23.4│ 28.2│ 37.9│ 47.9 - 2 fl. oz│ 4.6 │ 9.2│ 18.4│ 27.8│ 37.2│ 46.8│ 56.4│ 75.8│ 95.8 - 3 fl. oz│ 6.9 │ 13.8│ 27.6│ 41.7│ 55.8│ 70.2│ 84.6│ 113.7│ 143.7 - 4 fl. oz│ 9.2 │ 18.4│ 36.8│ 55.6│ 74.4│ 93.6│ 112.8│ 151.6│ 191.6 - 5 fl. oz│ 11.5│ 23. │ 46. │ 69.5│ 93. │ 117. │ 141. │ 189.5│ 239.5 - ────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴────── - ════════╤═════════════════════════════════════════════════════════════════════ - Quantity│ - of │ - solution│ GRAINS OF SALT OR DRUG REQUIRED TO MAKE SOLUTIONS OF PERCENTAGE - to be │ STRENGTH INDICATED - made │ - ────────┼──────┬──────┬──────┬──────┬──────┬──────┬──────┬──────┬──────┬────── - │ 15% │ 20% │ 25% │ 50% │1:500 │1:1000│1:2000│1:3000│1:4000│1:5000 - ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── - ½ fl. oz│ 36.8│ 50.2│ 65.│ 151.2│ 0.46│ 0.228│ 0.12│ 0.075│ 0.06│ 0.05 - 1 fl. oz│ 73.5│ 100.3│ 130.│ 302.5│ 0.91│ 0.456│ 0.23│ 0.15 │ 0.12│ 0.09 - 2 fl. oz│ 147. │ 200.6│ 260.│ 605. │ 1.8 │ 0.91 │ 0.46│ 0.3 │ 0.23│ 0.18 - 3 fl. oz│ 220.5│ 301. │ 390.│ 907.5│ 2.7 │ 1.37 │ 0.68│ 0.46 │ 0.34│ 0.27 - 4 fl. oz│ 294. │ 401.2│ 520.│1210. │ 3.64│ 1.82 │ 0.91│ 0.61 │ 0.46│ 0.36 - 5 fl. oz│ 367.5│ 501.5│ 650.│1512.5│ 4.55│ 2.28 │ 1.14│ 0.76 │ 0.57│ 0.46 - ────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴────── - -The table shows the quantity of drug required to yield a given _volume_ -of solution of the percentage strength desired. Thus, to make one fluid -ounce of a 5 per cent solution it is merely necessary to dissolve 23.4 -grains of the salt in _sufficient water to make one fluid ounce_. - - - - - THERAPEUTIC INDEX - - -_Young’s Rule for Dosage_: The age of the child is divided by the age of -the child plus 12, and the result is the appropriate dose for the child. -The doses given below are for the adult unless otherwise specified. - - =Absorbent.= A medicine or dressing that promotes absorption, such as - potassium iodide, Tr. iodine, glycerine, or hot vaginal douches. - - =Adrenalin.= The blood-raising principle of the suprarenal glands. It - is hæmostatic and astringent. Acts somewhat like digitalis on the - heart. - - _Uses._—Vomiting of pregnancy, increased glandular activity, - hæmorrhage, inflammation of mucous membranes. - - _Dose._—Internally, 5–10 m. of the 1:1000 solution. Externally, - the solution of 1:1000 or 1:10,000 may be applied. - - =Albolene.= An oily white substance obtained from petroleum. It is - used on the nipples and skin of the mother and to remove the - vernix caseosa from the skin of the child. - - =Aloin, Strychnia, and Belladonna.= A laxative pill which usually - contains aloin ⅙ gr., strychnia sulph. 1/60 gr., and Belladonna - 1/12 gr. - - =Ammonia Carbonate.= Antispasmodic, stimulant, and expectorant. - - _Uses._—Stimulant to heart. Stimulating expectorant in pneumonia - and bronchitis. - - _Dose._—5–20 grains in mucilage or syrup. - - =Anæsthone.= A mixture of adrenalin chloride (0.1%) and chlorotone - (5%) in an ointment base of wool fat and petrolatum. Astringent, - antiseptic, anesthetic and germicide. Useful application to - swollen mucous membranes or in coryza. - - =Argyrol= (_Silver Vitellin_). Antiseptic and germicide. - - _Uses._—Like Silver Nitrate, but less irritating to the tissues. - 3–5% solution in water is an injection for gonorrhœa. 15% solution - dropped in the eyes of the newborn may prevent ophthalmia. 25% - solution may be used twice a day as a remedy for existing - ophthalmia, but the strength should be reduced after three or four - days. 10–15% solution is used as an injection in cystitis. An - ounce or more of the solution may be left in the bladder until the - next evacuation. - - =Asafœtida.= A fetid gum resin. Carminative, antispasmodic, mild - stimulant, and expectorant. - - _Uses._—Gas pains of adults and infants. Hysteria and indigestion. - - _Dose._—5–10 gr. t.i.d. For infantile colic, an emulsion called - the mistura of asafœtida may be used in 2–4 dram doses. For adults - 1–2 tablespoonfuls. - - =Belladonna.= Nervine, mydriatic, sedative, narcotic, antispasmodic - and anodyne. Makes the throat dry and dilates the pupils. - - _Uses._—Night sweats, nervous cough, pain, incontinence of urine - and to restrain glandular activity. - - _Dose._—Fl. ext. 1–3 ♏︎; dry ext. ½–1 gr. Tincture 8–20 ♏︎. Solid - ext. ½¼ gr. All for adults. For infants, proportionately less. - _See Rule for Dosage._ - - =Benzoin.= Antiseptic and externally a styptic and protective for - sores. - - _Uses._—Sore nipples and urticaria. Lard is also benzoinated for - use in removing vernix caseosa. Compound Tr. of benzoin contains, - benzoin, purified aloes, storax, balsam of Peru, and alcohol. - - =Benzoinal.= Albolene mixed with benzoin. - - =Bismuth Subnitrate.= A white heavy powder. Antiseptic and astringent. - - _Uses._—Subacute gastritis, pyrosis, diarrhœa and vomiting of - pregnancy. Particularly desirable in infancy because it is free - from arsenic, lead and silver. - - _Dose._—5–60 gr. in the adult. - - =Boric Acid= (_Boracic Acid_). A white crystalline powder. Antiseptic. - - _Uses._—As a dressing and lotion for eyes, navel, mouth, nipples, - and all mucous surfaces. In solution to preserve the sterility of - rubber nipples until they are needed. - - _Dose._—Internally, 5–15 gr. Solutions are usually about 4% or 5%. - A saturated solution in water is about 6%. In hot water 25%. - - =Boroglyceride.= An antiseptic paste of boric acid and glycerine. When - an excess of glycerine is present the preparation is called - boroglycerol. - - _Uses._—An oxydizer in endometritis. It is applied to the cervix - on cotton tampons. - - =Calcium= (_Lime_). Stomach sedative, soothes the irritated or burned - skin, corrects hyperacidity, increases the clotting power of the - blood (?). - - Lime water is a saturated solution of calcium hydrate and is used - for nausea, to break up the curds of milk, and to increase its - digestibility. It is mildly constipating. - - =Calomel.= _See Mercury._ - - =Camphor.= A solid volatile oil. Nerve sedative. Anaphrodisiac. - Antispasmodic. Stimulant. - - _Uses._—The monobromated camphor is given internally for hysteria, - neuralgia, and as a hypnotic. - - _Dose._—1–10 gr. - - =Camphorated Oil.= A solution of camphor in cottonseed oil. - Rubefacient and stimulant. - - _Uses._—Internally in collapse. Externally as an application to - the child for colds of chest and nose. - - _Dose._—5–20 ♏︎ hypodermically in collapse. The injection should - be made deep into the muscle. - - =Carbolic Acid= (_Phenol_). Derived from coal tar. Antiseptic, - deodorant and local anæsthetic. - - _Uses._—Vomiting of pregnancy, pruritus, eczema, sterilization of - instruments. Usual solution is 2½% to 5%. For sterilization of - knives, scissors and other sharp instruments the 95% is used. In - pruritus, the following wash will aid: carbolic acid, 12 dr., - glycerine 2 dr., alcohol, 4 ʒ water q.s. 1 pt. Apply. - - =Cascara Sagrada.= Stimulant laxative, and cathartic. Useful in - pregnancy, but after labor there is evidence that it may go over - in the milk to the child. - - _Dose._—Fl. ext. 10–20 ♏︎. The Hinkle pill contains cascara. - - =Castor Oil.= Oil expressed from the seeds of the castor plant. A - cathartic. Acts in four or five hours. - - _Dose._—For adults, ½ oz. to 1 oz. For infants 10 to 60 drops - given with a dropper—not with a spoon. - - Castor oil cocktail.—Rinse out the glass with lemon juice or - whiskey. Pour in teaspoonful of lemon juice and a teaspoonful of - whiskey, add castor oil in amount required, cover with whiskey and - give. - - A paste is made from the mixture of castor oil and bismuth - subnitrate in equal parts, which is an excellent preparation for - sore nipples. - - _Cerium Oxalate (and Cerium Valerianate)._ Sedative and nerve - tonic. The oxalate is a white crystalline powder, odorless and - tasteless. - - _Uses._—Vomiting of pregnancy, seasickness. - - _Dose._—2–10 gr. several times daily. - - =Charcoal.= Administered in tablet form or as a powder between two - slices of buttered bread. - - _Uses._—Acid stomach. Vomiting of pregnancy. - - =Chinosol.= Nonpoisonous, nonirritating and odorless. Antiseptic - deodorant, styptic and analgesic. Dissolves instead of coagulates - secretions. - - _Uses._—Antiseptic solutions for hands and sponges, deodorizing - wash for vagina post partum, intrauterine douche, wash for - gonorrhœa and cystitis. - - _Dose._—For douche or hand solution 1:1000 or 1:5000. For dusting - powder, 1 part to 10 or 20 of starch, talcum, boric acid, or - bismuth subnitrate. - - Chinosol will corrode unplated steel. It may be mixed with salt, - but not with soap. - - =Choral Hydrate.= White crystal masses. Pungent in odor and taste. - Hypnotic, antispasmodic, antiseptic and analgesic. - - _Uses._—Insomnia, eclampsia, convulsions, and to restrain - secretion of milk. - - _Dose._—By mouth, 10–30 gr. By rectum, not to exceed 60 gr. In - infants 1–2 gr. by rectum in an ounce of water. - - =Chymogen.= A preparation of rennin (10%) made by Armour & Company. - - =Coagulen Ciba.= A physiological nontoxic styptic, prepared from the - natural coagulants of the blood. A 10% solution in water will - hasten the beginning and end of coagulation. May be applied to - bleeding surfaces directly, or given under the skin, into the - muscle, or into a vein. 3½% to 5% solution in distilled water, - should be sterilized by boiling 2–3 minutes. Do not filter. - Inject. - - =Cocaine Hydrochlorate.= Anæsthetic, sedative, anodyne, anti-pruritic. - - _Uses._—Vomiting of pregnancy, with _caution_. - - _Dose._—Internally ½–1½ gr. Externally a 4%–10% solution in water. - - =Codeine.= Alkaloid of opium. Less narcotic than morphine. - - _Uses._—After-pains and pain of over-distended breasts. - - _Dose._-¼–1½ gr. by mouth. ¼–¾ gr. hypodermically. - - =Compound Licorice Powder.= _See Senna._ - - =Condylomata.= - - _Use_— - - ℞ Acid. Salicyl. gr. x - Acid Boric. gr. xxx - Calomel. ʒ i - M. - Sig.: Apply twice daily. - - =Digitalis.= Cardiac tonic. Diuretic. Stimulant. - - _Uses._—Weak heart. Syncope. Collapse. - - _Dose._—For adult: of the tincture, 5–15 ♏︎, fl. ext. 1–3 ♏︎, ext. - gr. 1/6½. - - _Digipuratum._ A preparation of digitalis from which the inactive - substances have been removed. It is used in the same conditions as - digitalis. - - _Dose._—The tablets contain 1½ gr. and one is given four times - daily until ten are taken. _Then stop._ Hypodermically. Each viol - contains 1 c.c. of fluid and equals 1½ gr. of digipuratum. Each - dose contains enough of the active principle of digitalis to kill - a 30 gm. frog. - - =Ergot= (_Fungus of Rye_). Contracts unstriped muscle fiber. - - _Uses._—To check hæmorrhage after labor. To promote involution. - Must not be given in labor until the uterus is empty. - - _Dose._—By mouth 15–60 ♏︎ of the fl. ext. Hypodermically, 10–20 ♏︎. - - =Ergotole, Ergotine.= Concentrated solutions of ergot, 2½ times as - strong as the fluid extract. They are sterilized and preserved in - glass ampoules. - - _Uses._—See =Ergot=. - - _Dose._—30–60 ♏︎. - - =Green Soap.= A soap made of linseed or other oil, potash, alcohol and - water. - - “The adoption by the U. S. Pharmacopoeia of the term Sapo Viridis - (green soap) is unfortunate, since soft soap even if made from - green hempseed oil will become brown-yellow unless artificially - colored.”—U. S. Dispensatory. - - =Hæmophilia.= A condition of the blood wherein its clotting power is - diminished or absent. - - Coagulen, horse serum, or diphtheria antitoxin may be given - hypodermically. Direct transfusion of blood from another is best. - - =Hyoscine, Morphine, and Cactin.= (H. S. & C. Tablets). A proprietary - combination of drugs. The action is said to be similar to that of - morphine and scopolamine. - - =Iodine, Tincture.= - - _Uses._—To sterilize the skin before operation. In vomiting of - pregnancy it is sometimes effective. Drop doses may be given well - diluted. Externally it is applied to ulcers, as in Bednar’s - disease, and sometimes as a dressing for the cord. In pruritus - vulvæ it is a valuable application. - - =Iron.= Tonic emmenagogue. - - _Uses._—To increase the number of red blood corpuscles. To raise - blood pressure and to increase the secretion of milk. - - _Dose._—3–5 gr. Blaud’s pill contains the carbonate in a form that - is easily assimilated. - - =Laxatives.= Laxatives are unirritating and excite moderate - peristalsis. Sulphur, magnesia, cassia, manna, cascara sagrada, - the Hinkle pill, and the A, B, & S pill are usually mild in - action. - - =Lysol.= Disinfectant and antiseptic for hands and instruments. It is - a brown syrupy fluid made from coal tar oil, which is distilled - and mixed with fat, soap, etc. It has a creosote odor and contains - 50% cresol. Readily soluble in water. Prepared in ½–4% solutions. - - =Magnesia, Calcined.= Antacid and cathartic. Comes in white cakes. - - _Uses._—Acid stomach, vomiting of pregnancy, “heartburn,” and - constipation. - - _Dose._—30–120 gr. - - =Magnesia, Milk of.= A mixture of magnesia and water. Has the same - properties as the above. - - _Dose._—For adults, 2–3 teaspoonfuls. For infants, ¼–2 - teaspoonfuls. - - =Magnesia Sulphate= (_Epsom Salts._). Saline cathartic. - - _Uses._—The profuse watery stools produced by magnesia are - valuable aids to elimination when the kidneys are overworked or - defective. In congestion of the breasts and threatened eclampsia, - or in any case where it is desirable to drain off waste or - dehydrate the system. - - _Dose._—1 teaspoonful daily in hot water before breakfast. ½–1 oz. - as a single dose or 1 oz. by rectum, as in the =1–2–3 enema.= - - =Menthol= (_Mint Camphor, Japanese Peppermint_). Analgesic, - antiseptic, anæsthetic, and vascular stimulant. - - _Uses._—In pruritus vulvæ, vomiting of pregnancy, and hæmorrhoids. - - _Dose._—By mouth 3–5 gr. In tampons, one part to five of oil. In - ointments one part to sixteen. To the vulva for pruritus, use the - spirits in 5% solution. - - =Mercury= (_Hydrargyrum_). Cathartic, alterative, antisyphilitic, - antiseptic and disinfectant. Readily absorbed by the unprotected - mucous surface and relatively inert when the membrane is covered - by a discharge. Solutions of the bichloride when used as a lotion - unite with the albumin of a mucous discharge and form an - albuminate of mercury, which is inactive. Bichloride solutions - have small place in obstetrics. They are hard on the hands and - destructive to instruments. Other agents like lysol, ziratol and - chinosol have satisfactory germicidal properties and in addition - are nonpoisonous, lubricative and cleansing. - - Mercury should only be given to the infant in the form of calomel - (the mild chloride). The dose is 1/12-⅛ gr., repeated if - necessary. - - =Morphine.= Alkaloid of opium. - - Antispasmodic, hypnotic, analgesic and narcotic. - - _Uses._—To relieve pain, produce sleep, check diarrhœa, and to - control the pain, as well as the contractions of abortion. To - relax a rigid os. - - _Dose._—In “Twilight Sleep” and rigid os the first dose is Morph. - sul. 1/6¼ gr. and scopolamine Hydrobromid 1/200–1/150. The - scopolamine to be repeated if required, in one-half or - three-quarters of an hour. The usual dose of morphine - hypodermically is 1/12½ gr. - - =Nitroglycerine= (_Glonoin_). Vasomotor dilator, arterial stimulant. - - _Uses._—For the prostration following hæmorrhage. - - _Dose._-½00–1/50 gr. hypodermically. - - =Novocaine.= Local anæsthetic, similar to cocaine, but less toxic. For - local anæsthesia in solutions of 0.25% to 2% usually in - association with adrenalin (5–10 drops of the 1:1000 solution to - each 10 c.c. of novocaine solution). - - =Nux Vomica.= The plant from which strychnia is derived. Tonic, - stomachic, and stimulant to muscle, nerve, and heart. - - _Uses._—Bitter tonic and stimulant. Vomiting of pregnancy and - agalactia. - - _Dose._—Ten drops of the tincture in water before meals. - - =Opium.= The concrete juice of the poppy. Relieves pain. Constipates. - - _Uses._—Hæmorrhoids in adults, colic and diarrhœa in infants. - - _Dose._—One grain in suppository night and morning for adult. For - infant, as paragoric only. Two to five drops only, not repeated. - _Children bear opium badly._ - - =Pepsin.= A ferment in the gastric juice that digests proteins. In - commerce it is obtained from the pig. - - _Uses._—Imperfect digestion. - - _Dose._—For adult, 10–15 grs. For infant, 2 gr. - - =Phenolphthalein.= A nonofficial coal tar derivative. Mild laxative. - - _Dose._—2–3 gr. Phenolax and chocolax are preparations of the - drug. - - =Pituitary Extract= (_Pituitrin_). A substance derived from the - infundibular portion or the posterior lobe of the hypophysis - cerebri. Nontoxic, stimulant to unstriped muscle. - - _Uses._—Uterine inertia, post partum hæmorrhage, Cæsarean section - and tympany. Will not produce abortion nor premature labor. May be - tried in acute anæmia to raise the blood pressure. - - _Dose._—5–15 ♏︎. Repeated if necessary. - - =Potassium (or Sodium) Bromide.= White granular powder. Soluble, 1 to - 5 in water. Sedative, hypnotic, antiepileptic. - - _Uses._—Neurasthenia, convulsions, nymphomania, vomiting of - pregnancy. - - _Dose._—20–60 gr. In enema with chloral. Pot. bromide 40 gr. and - chloral 20 gr. in several ounces of water or milk. - - =Potassium Iodide.= Alterative emmenagogue. Uric acid solvent. - - _Uses._—Syphilis rheumatism, swellings, slow inflammations, - excessive secretion of milk. - - _Dose._—2–10 gr. increased as required. - - =Potassium Permanganate.= Dark purple opaque prisms. Soluble in water - 1 to 16. Disinfectant, deodorant, antiseptic, astringent. - - _Uses._—As an injection in leucorrhœa and gonorrhœa, 1:5000 - solution. - - =Purgatives.= Simple purgatives produce free discharges from the - bowels with some griping. Senna, aloes, rheubarb, castor oil, and - calomel are examples. Saline purgatives are followed by profuse - watery evacuations. Magnesia sulphate, and citrate, potassium and - sodium tartrate, and sodium phosphate belong to this class. - - Drastic purgatives bring about a violent action of the bowels with - much griping and tenesmus. Such are jalap, colocynth, elaterium, - and croton oil. Hydrogogue purgatives combine the results of the - salines and drastics. They have much griping with profuse watery - stools. The hydrogogues are elaterium, gamboge, croton oil, and - potassium bitartrate. - - =Quinine Sulphate.= (Derived from Cinchona bark.) Antipyretic, tonic, - antiperiodic, antiseptic, emmenagogue and ecbolic. - - _Uses._—Valuable stimulant in a slow first stage. It is combined - with castor oil to bring on labor at term. Castor oil 1 oz. and - quinine sulphate 10 gr. is given as the first dose, followed in an - hour by another 10 gr. of quinine, and an hour later by another. - - _Dose._—2–20 gr. - - =Regulin.= A mixture of agar-agar in dry form with extract of cascara - sagrada. - - _Uses._—A laxative in chronic constipation. - - _Dose._—Teaspoonful to tablespoonful in stewed fruit or mashed - potatoes, once daily. - - =Russian Oil= (_Liquid Petrolatum_). Laxative in pregnancy and - puerperium. Acts mechanically and as a lubricant. Not unpleasant - to take. - - _Dose._-½ oz. at bedtime, and, if necessary, before each meal. May - be given to breast-fed babies in doses of gtts. xv three times - daily. - - =Senna.= Laxative and purgative. Acts especially on the large - intestine. Sometimes passes over in the milk to the child. - - _Dose._—Fl. ext. 1–4 teaspoonfuls. In compound licorice powder the - dose is 30–80 gr. (about 10 gr. of senna to the dose). - - =Silver Nitrate.= Caustic, antiseptic, stimulant, irritant and - antigonorrhœic. Table salt neutralizes it. - - _Uses._—2% solution in water for pruritus vulvæ. 1% solution - dropped into the eyes of the newborn to prevent ophthalmia - neonatorum. Do not neutralize the 1% solution. ¼ gr. silver - nitrate with 2 gr. of pepsin in capsule for pernicious vomiting of - pregnancy. - - =Sodium Bicarbonate= (_Baking powder_). Antacid, antirheumatic. - - _Uses._—Gout, dyspepsia, acid stomach, acidosis, vomiting of - pregnancy. Soothes the skin when burned. - - =Sodium Chloride.= (Salt.) - - For normal saline use 10 gr. to 3½ oz. of water. For physiological - salt solution, add 15 gr. of Sod. Carb. to every 3½ oz. of normal - saline as made above. - - =Sodium Citrate.= A white odorless, granular powder with cooling salty - taste. - - _Uses._—Diuretic, antipyretic and refrigerant. Retards the - coagulation of albumin in milk and aids the digestibility of - proteins. May be indicated in gout and cystitis. - - _Dose._—Internally, 15 to 60 gr. In the modification of cow’s milk - about two grains should be used for each ounce of the mixture. - - =Spirits of Nitre, Sweet= (_Spirit Nitrous Ether_). 4% solution of - nitrous ether in alcohol. Diaphoretic, diuretic, antipyretic, - stimulant, antispasmodic. - - _Uses._—Fever, dropsy, vomiting of pregnancy, colic, anuria. - - _Dose._—For adult, 20–60 gtts. For infants small doses often - repeated. - - =Stramonium= (_Jimson Weed_). Hypnotic, narcotic, antispasmodic. - - _Uses._—For hæmorrhoids take Ung. Stramonii and Ung. Galli in - equal amounts and apply. - - =Urotropin.= A white powder soluble in water. Urinary antiseptic, - diuretic. - - _Uses._—Cystitis, typhoid bacilli in urine, gout. It makes the - urine irritatingly acid when given long. It does not act in - alkaline media. - - _Dose._—7½–10 gr. well diluted. - - =Valerian.= Anodyne, stimulant, antispasmodic and nervine. - - _Uses._—Hysteria, hypochondriasis, headache. - - _Dose._—30–60 ♏︎ of the fl. ext. by mouth, or by rectum 2 oz. of - the following mixture may be used P.R.N. for hysteria: - - Pot. Brom. 1 oz. - Ext. Valerian fl. dr. vi. - Normal saline q.s. oz xii. - - =Veratrum Viride= (_Hellebore_). Sedative, emetic, diaphoretic, - diuretic. Retards the heart’s action without weakening it. - - _Uses._—Eclampsia. - - _Dose._—1 to 4 ♏︎ of the fl. ext. is given hourly until the pulse - comes down to 80. - - =Veronal.= Safe, reliable hypnotic. - - _Uses._—Insomnia from hysteria, neurasthenia, and mental - disturbance. - - _Dose._—5 to 15 gr. dissolved in hot tea, milk, or water. May - repeat. - - =Zinc.= Tonic, astringent, antispasmodic. - - _Uses._—Stearate of zinc is a valuable dressing in excoriations of - buttocks and external genitals. - - =Zinc Ointment.= It is indicated for bedsores (decubitus) eczema, - herpes, and intertrigo. Zinc ointment contains one part of zine - oxide to four parts of benzoinated lard. - - =Ziratol.= A mixture of phenols in soap, water, and glycerine. - Antiseptic, deodorant and germicide. Relatively odorless, easily - soluble and does not injure hands, instruments, or rubber. It is - said to be only ⅐ as toxic as carbolic acid. Used in solutions of - 0.5% up to 5%. - - - - - GLOSSARY - - [Adapted from Dorland and Standard Dictionaries] - - - =Ab-nor´mal.= Not normal; contrary to the usual structure or - condition. - - =A-bor´tion.= 1. The expulsion of the fœtus before it is viable. 2. - Premature stoppage of a morbid or a natural process. - - =Ab-ra´sion.= 1. A rubbing or scraping off. 2. A spot rubbed bare of - skin or mucous membrane. - - =Ab´scess.= A localized collection of pus in a cavity formed by the - disintegration of tissues. - - =Ac-couch´e-ment.= Delivery in childbed; confinement. - - =Ac´e-tone.= 1. A colorless liquid found in pyro-acetic acid and in - naphtha. 2. Any member of the series to which the normal or typical - acetone belongs. - - =A´ci-do´´sis.= Acid intoxication of the system from the elaboration - or too much acid by faulty metabolism or the imperfect disposition - of normal amounts of acid. - - =A-ci´nus=, pl. _acini_. One (acini, more than one) of the smallest - lobules of a compound gland. - - =Al´bo-lene.= An oily white substance derived from petroleum. - - =Al´bu-mi-nu´´ri-a.= The presence of albumin in the urine. - - =Al´ka-line.= Having the reaction of an alkali. - - =A´men-or-rhœ´´a.= Absence or abnormal stoppage of the menses. - - =Am-mo´ni-a.= A colorless alkaline gas, NH_{3}, of penetrating odor, - and soluble in water, forming ammonia-water. Ammoniacal urine - contains ammonia, which is one form of nitrogen excretion. - - =An-æ´mi-a.= A condition in which the blood is deficient in quantity - or in quality. - - =An´æs-the´´si-a.= Loss of feeling or sensation, especially loss of - tactile sensibility, though the term is used for loss of any of the - other senses. - - =An´æs-thet´´ic.= 1. Without the sense of touch or of pain. 2. A drug - that produces anæsthesia. - - =An´al-ge´´si-a.= Absence of sensibility to pain. - - =An-aph´ro-dis´´i-ac.= A drug that allays sexual desire. - - =An´a-sar´´ca.= An accumulation of serum in the cellular tissues of - the body. - - =An´en-ceph´´al-ous.= Having no brain. - - =An´ky-lo´´sis.= Abnormal rigidity or stiffness of a joint. - - =An´o-dyne.= A medicine that relieves pain. - - =An´te par´tum.= Latin for “before delivery.” - - =An-te´ri-or.= Situated in front of, or in the forward part of. - - =An´ti-pe´ri-od´´ic.= A drug that tends to prevent recurrent attacks - of disease. - - =An´ti-sep´´tic.= 1. Preventing decay or putrefaction. 2. A substance - destructive to poisonous germs. - - =A-pe´ri-ent.= Mildly cathartic. - - =Ap-nœ´a.= The absence of respiration—especially that form which - occurs in a child delivered by the Cæsarean operation. - - =A-re´o-la.= The darkish ring around the nipple. - - =As-ci´tes.= Dropsy (an accumulation of fluid) in the abdomen. - - =A-sep´sis.= Absence of septic matter, or freedom from infection. - - =As-phyx´i-a.= Suffocation. - - =As-trin´gent.= 1. Causing contraction and arresting discharges. 2. An - agent that arrests discharges. - - =At´e-lec-ta´´sis.= Imperfect expansion of the lungs at birth; partial - collapse of the lung. - - =At´on-y.= Lack of normal tone or strength. - - =A´tri-um.= (_L._, a hall.) The point of entrance of a bacterial - disease. - - =At´ti-tude.= A posture or position of the body. The relation which - the various parts of the child’s body bears to its own long axis. - The attitude of the fœtus normally is complete flexion. - - =Aus´cul-ta´´tion.= The act of listening for sounds within the body. - - =Bac-te´ri-a.= The vegetable microorganisms (Schizomycetes) especially - the short-rod forms. - - =Bal´an-i´´tis.= Inflammation of the glans penis. It is usually - associated with phimosis. - - =Bal-lotte´ment.= The diagnosis of pregnancy by pushing up the uterus - by a finger inserted into the vagina so as to cause the embryo to - rise and fall again like a heavy body in water. - - =Bar´tho-lin glands.= The vulvo-vaginal glands. - - =Bleb.= A skin vesicle filled with fluid. A blister. - - =Breg´ma.= The point on the surface of the skull at the junction of - the coronal and sagittal sutures. - - =Cæ-sa´re-an sec´tion.= (Named from Julius Cæsar, who is said to have - been thus born). Delivery of the fœtus by an incision through the - abdominal and uterine walls. - - =Ca´put.= Any head, or head-like structure. - - =Ca´put suc´ce-da´´ne-um.= A swelling formed on the presenting part of - the fœtus during labor. It is due to the effusion of fluid into the - subcutaneous tissues of the scalp and its retention there. - - =Car-min´a-tive.= Drugs that stimulate the circulation, the mental - faculties, and intestinal peristalsis. Asafœtida, camphor, capsicum, - cardamon, chloroform, ether, ginger, horseradish, mustard, and the - oils of anise, cloves, spearmint, nutmeg and valerian are - carminatives. - - =Car´ne-ous.= Fleshy. - - =Cath´e-ter, tra´che-al.= A long slender tube designed for - introduction into the babe’s trachea as a means of sucking out - mucus. - - =Cath´´e-ter-ize´.= To introduce a tube and draw off fluid, as urine - or mucus. - - =Caul.= 1. The great omentum. 2. A piece of amnion which sometimes - envelopes a child’s head at birth. - - =Cell.= 1. Any one of the minute protoplasmic masses which make up - organized tissue. - - =Ceph-al´ic.= 1. Pertaining to the head. 2. A medicine for the head. - - =Ceph´al-hæ-ma-to´´ma.= 1. A tumor or swelling filled with blood - beneath the pericranium. - - =Cer´vix.= The neck or any neck-like part. - - =Chlo-as´ma.= The yellowish brown spots or patches that appear on the - skin of pregnant women. - - =Cic´a-tri´´cial.= Pertaining to, or of the nature of, a cicatrix. - - =Ci-ca´trix.= A scar; the mark left by a sore or wound. - - =Cil´i-a.= 1. The eyelashes. 2. Minute lash-like processes that - characterize certain cells. - - =Cli´mac-ter´´ic.= A particular epoch of the ordinary term of life at - which the body is believed to undergo a radical change—especially - applied to the menopause. - - =Cli-ni´cians.= Men who teach and explain diseases by showing actual - cases. - - =Clit´o-ris.= The sensitive organ of the female, homologous with the - penis in the male. - - =Coc´cyx.= The small bone situated at the end of the sacrum. The very - last portion of the spine. - - =Col-lapse´.= A state of extreme prostration and depression with - failure of circulation. - - =Col´les’ mem´brane.= A layer of tough sensitive fascia back of the - perineum and on either side of the vagina. - - =Co-los´trum.= The first fluid secreted by the mammary glands after - functional activity begins. It contains casein and more albumen than - milk, as well as numerous fatty globules. - - =Col´peu-ryn´´ter.= A dilatable bag, used to distend the vagina. - - =Co´ma.= Profound stupor occurring in the course of a disease or after - severe injury. - - =Co´ma-tose.= Pertaining to, or affected with, coma. - - =Com´pli-ca´´tion.= A disease or diseases concurrent with another - disease. - - =Con-cep´tion.= The fecundation of the ovum. - - =Con´dyl-o´´ma.= A wart-like excrescence near the anus or vulva. It - may be as large as a cauliflower. - - =Con-gen´i-tal.= Born with a person; existing at or before, birth. - - =Con´ju-gate.= The anteroposterior diameter of the pelvic inlet. - - =Cor´o-nal.= Pertaining to the crown of the head, as the coronal - suture. - - =Cra´dle cap.= The dirty looking patch of epithelial scales and - sebaceous material that develops over the anterior fontanelle of - babies who have the exudative diathesis. - - =Cra´ni-ot´´o-my.= The cutting in pieces of the fœtal head to - facilitate delivery. - - =Cre-dé Expression.= The maneuver in which the uterus is grasped in - the hollow of the hand and squeezed and pressed down upon to aid in - the expulsion of the placenta. - - =Cre-dé Treatment.= The instillation of a 1% solution of nitrate of - silver into the eyes of the newborn to prevent ophthalmia. - - =Curd.= The coagulum of milk, consisting mainly of casein. - - =Cy´an-o´´sis.= Blueness of the skin, often due to cardiac - malformation causing insufficient oxygenation of the blood. - - =Cys-ti´tis.= Inflammation of the bladder. - - =De-cid´u-a.= The membranous structure produced in the uterus during - gestation and thrown off after parturition. =D. reflexa=, the part - of decidua which is reflected upon and surrounds the ovum. =D. - serotina=, the late decidua; the part of the decidua vera which - becomes the maternal portion of the placenta. _D. Vera_, the true - decidua; the portion of the decidua which lines the uterus. - - =De-cu´bi-tus.= 1. An act of lying down. 2. A bed-sore. - - =De-hy´drate.= To remove the water. - - =Di´a-be´´tes.= A disease marked by an habitual discharge of an - excessive quantity of urine and the presence of sugar therein. - - =Di´´aph-o-re´sis.= Perspiration, and especially profuse perspiration. - - =Di´´aph-o-ret´ic.= 1. Stimulating the secretion of sweat. 2. A - medicine that increases the perspiration. - - =Di-ath´e-sis.= Natural or congenital predisposition to a special - disease. - - =Dif´fer-en´´tial.= Pertaining to a difference, or differences. - - =Dis-crete´.= Separate lesions which do not blend or coalesce. - - =Di´u-re´´sis.= Increased secretion of urine. - - =Dor´sum.= The back or any part corresponding to the back as the - dorsum of the penis or foot. - - =Duc´tus ve-no´sus.= A fœtal blood vessel connecting the umbilical - vein with the post-cava. - - =Dys-cra´si-a.= A depraved state of the system, and especially of the - blood, due to constitutional disease. - - =Dysp-nœ´a.= Difficult or labored breathing. - - =Dys-to´ci-a.= Painful or slow delivery or birth. - - =Ec-bol´ic.= An agent that accelerates labor. - - =E-clamp´si-a.= A sudden attack of convulsions, especially one of a - peripheral origin. - - =Ec-top´ic.= Out of the normal place. - - =E-de´ma.= Swelling due to effusion of watery liquid into the - connective tissue. - - =Em´bo-lism.= The plugging of an artery or vein by a clot or - obstruction which has been brought to its place by the - blood-current. - - =Em´bry-o.= The fœtus in its earlier stages of development, especially - before the end of the third month. - - =Em-men´a-gogue.= A drug that aids or stimulates menstruation. - - =E-mul´sion.= An oily or resinous substance divided and held in - suspension through the agency of an adhesive, mucilaginous, or other - substance. - - =En´do-me´´tri-um.= The mucous membrane that lines the cavity of the - uterus. - - =En-gage´ment.= The head is said to be engaged when the largest - diameters have passed the inlet. - - =En´si-form.= Shaped like a sword. - - =Ep´i-si-ot´´o-my.= Surgical incision of the vulvar orifice laterally - for obstetric purposes. - - =E-ro´sion.= An eating or gnawing away. - - =Er´y-the´´ma.= A morbid redness of the skin due to congestion of the - capillaries, of many varieties. - - =E´ti-ol´´o-gy.= The study or theory of the causation of any disease. - - =Ex-co´´ri-a´tion.= Any superficial loss of substance such as that - produced on the skin by scratching. - - =Ex´os-mo´´sis= (_Ex-os-mose_). Diffusion or osmosis from within - outward. - - =Ex-san´guin-a´´tion.= An exhaustion of the blood from a part or the - whole of the body. - - =Ex-trac´tion.= The process or act of pulling or drawing out, - particularly the removal of a child by pulling either with hands or - forceps. - - =Ex´tra-u´´ter-ine.= Situated or occurring outside of the uterus. - - =Ex´´u-da´tive di-ath´e-sis.= A congenital predisposition to eczema in - various parts of the body, as well as to infections of the - respiratory tract. - - =Fæ´ces= (_or fe´ces_). The excrement or undigested residue of the - food discharged from the bowels. - - =Fen´es-tra-ted.= (_L._, fenestrum, a window.) Pierced with one or - more openings, like windows. - - =Fer´ment.= Any substance that causes fermentation in other substances - with which it comes in contact. - - =Fi´brin.= A substance which, becoming solid in shed blood, plasma and - lymph, causes the coagulation of these fluids. - - =Fil´let.= 1. A loop-shaped structure. 2. A loop, as of cord or tape, - for making traction. - - =Fis´sure.= A cleft or groove, normal or other. - - =Fis´tu-la.= A deep, sinuous ulcer, often leading to an internal - hollow organ. - - =Flu´id ex´tract.= A concentrated solution of the active principle of - a drug in such strength that 1 c.c. of the product equals 1 gr. of - the crude drug. The fluid is a mixture of alcohol, water and - glycerine in varying proportions. One may be omitted. - - =Fœ´tus= (_or fe´tus_). The unborn offspring of any animal that brings - forth living progeny; the child in the womb after the third month. - - =Fon´ta-nelle´´.= Any one of the unossified spots on the cranium of a - young infant. It is so named because it rises and falls like a - fountain. - - =Fo-ra´men.= A hole or perforation, especially a hole in a bone. - - =Four-chette´.= The fold of mucous membrane at the posterior junction - of the labia majora. - - =Fræ´num= (_or fre´num_). A fold of the integument or of the mucous - membrane that checks, curbs, or limits the movements of an organ in - part—as the frænum of the tongue. - - =Func´tion.= The normal or proper action of an organ or set of organs. - - =Func´tion-al.= Of or pertaining to a function. - - =Fun´dus.= The base or part of a hollow organ remotest from its mouth. - - =Ga-lac´tor-rhœ´´a.= Excessive secretion of milk. - - =Ga-vage´.= Feeding by the stomach tube; also the therapeutic use of a - very full diet. - - =Gen´it-als.= The reproductive organs. - - =Ger´´mi-cide´.= An agent that destroys germs. - - =Ges-ta´tion.= Pregnancy. - - =Glans cli-tor´i-dis.= The distal or outside end of the clitoris. - - =Glans pe´nis.= The head, or terminal end, of the penis. - - =Gon-or-rhœ´a.= A contagious catarrhal inflammation of the genital - mucous membrane. - - =Graaf´i-an fol´li-cle.= Any one of the small spherical ovarian - bodies, each of which contains an ovum. - - =Hæm´o-phil´´i-a.= A condition of the system wherein bleeding occurs - readily, and the blood clots slowly or not at all. - - =Hæm´or-rhage.= A copious escape of blood from the vessels; bleeding. - =Accidental h.=, hæmorrhage during pregnancy, due to premature - detachment of the placenta. =Post partum h.=, that which occurs soon - after labor, or childbirth. =Unavoidable h.=, that which results - from the detachment of a placenta prævia. - - =Hæm´or-rhoid.= A pile, or vascular tumor of the rectal mucous - membrane. - - =Hy-dat´id.= An encysted vesicle containing an encysted fluid. From - the _Greek_ “_Hydatis_,” meaning a drop of water. - - =Hy-dat´i-form.= Resembling a hydatid in form. - - =Hy-dram´ni-os.= Dropsy of the amnion. - - =Hy´dro-ceph´´a-lous.= A fluid effusion within the cranium. This - disease is marked by enlargement of the head, with prominence of the - forehead, atrophy of the brain, mental weakness, and convulsions. - - =Hy´giene.= The science of health and of its preservation. - - =Hy´men.= The membranous fold which partially or wholly occludes the - external orifice of the vagina, at least during virginity. - - =Hy´per-em´´e-sis.= Excessive vomiting. =H. gra-vi-da´rum=, excessive - vomiting of pregnancy. - - =Hy´per-æ´´mi-a.= Excess of blood in any part of the body. - - =Hy-per´tro-phy.= The morbid enlargement or overgrowth of a part. - - =Hyp-not´ic.= A drug that induces sleep. - - =Hy´po-der-moc´´ly-sis.= The introduction, into the subcutaneous - tissues, of fluid in large quantity. - - =Hy´po-gas´´tric.= Of or pertaining to the lower anterior region of - the abdomen in the middle line of the body. The hypogastric arteries - arise from the internal iliac in addition to the branches given off - from those vessels in the adult. - - =Hy´po-phos´´phite.= Any salt of hypophosphorous acid. - - =Ic´ter-us.= Jaundice. - - =Id´i-o-syn´´cra-sy.= An effect abnormal to the one usually produced. - An effect peculiar to the individual. - - =Im-mu´ni-ty.= The condition of being immune or exempt from disease, - especially the condition arising from inoculation, or from a - peculiar resistance of the organism. - - =Im´preg-na´´tion.= 1. The act of fecundation or of rendering - pregnant. 2. The process or act of saturation, a saturated - condition. - - =In´farct.= A mass of substance extravasated either into the substance - of an organ or into a vessel due to the obstruction to the - circulation. - - =In´´fan-tile´ pel´vis.= A pelvis which has not responded to the - developmental stimulation of the sexual glands at puberty, and - therefore remains in its infantile shape. A masculine pelvis. - - =In´´fan-tile´ u´ter-us.= An undeveloped uterus. - - =In-fec´tion.= The communication of disease from one person to - another, whether by effluvia or by contact, mediate or immediate; - also the implantation of disease from without. - - =In´fil-tra´´tion.= To cause a liquid or gas to penetrate or enter by - pores or interstices. - - =In´flam-ma´´tion.= A morbid condition characterized by pain, heat, - redness and swelling. - - =In-nom´in-ate.= Not having a name, as the innominate bone. - - =In-som´ni-a.= Inability to sleep; abnormal wakefulness. - - =In´ter-sti´tial.= Pertaining to, or situated in, the interstices or - interspaces of a tissue. - - =In´ter-tri´´go.= A chafe, or chafed patch of the skin; also the - erythema or eczema that may result from a chafe of the skin. - - =In-tro´i-tus.= The entrance to any cavity or space. - - =In-ver´sion.= A turning inward, inside out, upside down, or other - reversal of the normal relation of a part. - - =In´vo-lu´´tion.= 1. A rolling or turning inward. 2. The return of the - uterus to its normal size after parturition. 3. A retrograde change, - the reverse of evolution. - - =Is-chu´ri-a par-a-dox´a.= A condition in which the bladder is - over-distended with urine, although the patient continues to - urinate, generally in dribbles. - - =Jaun´dice.= Yellowness of the skin, eyes, and secretions, due to the - presence of bile pigments in the blood. - - =La´bi-a.= Lip-shaped organs. The external folds of the vulva, labia - majora, and the internal folds of the vulva, labia minora. - - =Lac´e-ra´´tion.= 1. The act of tearing. 2. A wound made by tearing. - - =Lac-ta´tion.= 1. The secretion of milk. 2. The period of the - secretion of milk. 3. Suckling. - - =Lan-u´go.= The fine hair on the body of the fetus. - - =Lav-age´.= The irrigation or washing out of an organ, such as the - stomach or bowel. - - =Le´sion.= Any hurt, wound or local degeneration. - - =Leu´cor-rhœ´´a.= A whitish, viscid discharge from the vagina and - uterine cavity. - - =Light´en-ing.= The sense of lightness and easier breathing that - follows the descent of the head into the pelvis during the last - three weeks of pregnancy. It is most likely to occur in primiparas. - - =Lo´chi-a.= The vaginal discharge that takes place during the first - week or two after childbirth. - - =Lymph.= A transparent slightly yellow liquid of alkaline reaction - which fills the lymphatic vessels. - - =Mal-aise´.= An uneasiness or indisposition, discomfort or distress. - - =Mal´po-si´´tion.= Abnormal or anomalous position. - - =Mam´ma.= The mammary gland; the breast. - - =Mam´ma-ry.= Pertaining to the Mamma. - - =Ma-ras´mus.= Progressive wasting and emaciation, especially such a - wasting in young children when there is no obvious or ascertainable - cause. - - =Mas-sage´.= The systematic, therapeutic friction, stroking and - kneading of the body. - - =Mas-ti´tis.= Inflammation of the breast. - - =Me-a´tus.= A passage or opening, as the meatus urinarius. - - =Me-læ´na ne-o-na-to´rum.= The passage of dark pitchy stools - containing blood pigments and blood that has been extravasated into - the alimentary canal of the newborn babe. - - =Mem´brane.= A thin layer of tissue which covers a surface or divides - a space or organ. - - =Men´o-pause.= The period when menstruation normally ceases; the - change of life. - - =Mis-car´riage.= Abortion; premature expulsion of the fœtus; birth of - the fœtus before the twenty-eighth week. - - =Milk leg= (_Phlegmasia Alba Dolens_). A condition developing in one, - and rarely, in both, legs, after delivery. It is due to occlusion of - the veins of the pelvis and leg by thrombosis or to septic - inflammation of the pelvic connective tissue. - - =Mole.= 1. A fleshy mass or tumor formed in the uterus by the - degeneration or abortive development of an ovum. 2. A nevus; also a - brownish spot on the skin. - - =Mons ven´er-is.= A rounded prominence at the symphysis pubis of a - woman. - - =Mor-bid´i-ty.= The condition of being diseased or morbid. - - =Mor´cel-la´´tion.= Division and piecemeal removal. - - =Mu´cus.= The viscid watery secretion of the mucous glands. - - =Mul-tip´ar-a.= A woman who has borne more than one child. - - =Mum´mi-fi-ca´´tion.= Dry gangrene; also the drying up and shrivelling - of the fœtus. - - =Myd´ri-at´´ic.= A drug that dilates the pupil. - - =Nau´se-a.= Tendency to vomit; sickness at the stomach. - - =Ne-cro´sis.= Death of a tissue, especially of a bone. - - =Ne-phri´tis.= Inflammation of the kidney. - - =Neu-rot´ic.= 1. Pertaining to or affected with a neurosis. 2. - Pertaining to the nerves. - - =Neu´tra-lize.= To render neutral or ineffective. - - =Ni´tro-gen.= A colorless gaseous element found free in air. - - =Nod´u-lar.= 1. Like a nodule or node. 2. Marked with nodules. - - =Nu´cle-us.= 1. a spheroid body within a cell, forming the essential - and vital part. 2. A mass of gray matter in the central nervous - system. 3. In chemistry, the central element in the molecule of a - compound. - - =Nu´tri-ent.= Nourishing; affording nutriment. - - =Nym´phæ.= The labia minora. - - =Ob-stet´rics.= The art of managing childbirth cases; that branch of - surgery which deals with the management of pregnancy and labor. - - =Ob-ste-tri´cian.= One who practices obstetrics. - - =Oc´ci-put.= The back part of the head. - - =Ol´i-go-hy-dram´´ni-os.= Scantiness of the liquor amnii. - - =Ol´i-gop-nœ´´a.= A delay following the birth of a child before the - first respiration is established. - - =Oph-thal´mi-a.= Severe inflammation of the eye or of the conjunctiva. - - =Or´gan.= Any part of the body having a special function. - - =Os.= (_L._, a mouth.) The orifice in the uterus or vagina. - - =Os-mo´sis.= The passage of a fluid through a membrane. - - =O´va.= Latin plural of ovum, egg. - - =O´vu-la´´tion.= The formation and discharge of an unimpregnated ovum - from the ovary. - - =O´vule.= 1. The ovum within the Graafian vesicle. 2. Any small - egg-like structure. - - =O´vum.= 1. An egg. 2. The female reproductive cell which, after - fertilization, develops into a new member of the same species. - - =Ox´y-di´´zer.= Anything that combines with oxygen. - - =Pal-pa´tion.= The act of feeling with the hand; the application of - the fingers with light pressure to the surface of the body for the - purpose of determining the consistence of the parts beneath in - physical diagnosis. - - =Par-al´y-sis, Erb’s.= 1. Same as birth-palsy. 2. Partial paralysis of - the brachial plexus affecting various muscles of the arm and - chest-walls. It is revealed by an inability to lift the arm toward - the head. - - =Par-al´y-sis facial (Bell’s).= Paralysis of the face, due to lesion - of the facial nerve or of its nucleus. - - =Par´a-me-tri´´tis.= Inflammation of the parametrium, or cellular - tissue about the uterus. - - =Par´a-phi-mo´´sis.= Retraction of a narrow or inflamed foreskin which - can not be replaced. - - =Pa-ren´chy-ma.= The essential or functional elements of an organ as - distinguished from its stroma or framework. - - =Pa-ri´e-tal.= Of, or pertaining to, the walls of a cavity. - - =Par´o-nych´´i-a.= Infection and suppuration about the junction of - nails and skin. - - =Par´ox-ysm.= A sudden recurrence or sudden intensification of - symptoms. - - =Path-o-log´ic.= Pertaining to pathology. - - =Pa-thol´o-gy.= That branch of medicine which treats of the essential - nature of disease, especially of the structural and functional - changes caused by disease. - - =Pel-vim´e-ter.= An instrument for measuring the various diameters of - the pelvis. - - =Pel-vim´e-try.= The act of determining the dimensions of the pelvis - by means of a pelvimeter. - - =Per´i-ne-or´´rha-phy.= Suturation of the perineum, performed for the - repair of a laceration. - - =Per´i-ne´´um.= The space or area between the anus and the genital - opening. - - =Pe-riph´e-ry.= The outward part or surface. - - =Per´i-to-ne´´um.= The serous membrane which lines the abdominal - walls. - - =Per´i-to-ni´´tis.= Inflammation of the peritoneum. - - =Per´i-stal´´sis.= A worm-like movement by which the alimentary canal - propels its contents. - - =Per-ni´cious.= Tending to a fatal issue. - - =Phe-nom´e-non.= Any remarkable appearance; any sign or objective - symptom. - - =Phys´i-o-log´´ic.= Pertaining to physiology. - - =Phys´i-ol´´o-gy.= The science which treats of the functions of the - living organism and its parts. - - =Phi-mo´sis.= Tightness of the foreskin such that it can not be drawn - back over the glans. - - =Phle-bi´tis.= Inflammation of a vein. - - =Pig´men-ta´´tion.= The deposition of coloring matter. - - =Pla-cen´ta præ´vi-a.= A placenta which intervenes between the - intrauterine cavity and the inner orifice of the cervical canal. - - =Pla-cen´ta suc´cen-tur´i-a´´ta.= An accessory or subsidiary placenta. - - =Pled´get.= A small compress or tuft as of wool or lint. - - =Pleth´o-ra.= A condition marked by vascular turgescence, excess of - blood and fullness of pulse. - - =Po-dal´ic.= Pertaining to, or accomplished by means of, the feet. - - =Pol´y-hy-dram´´ni-os.= Excess in the amount of the liquor amnii in - pregnancy. - - =Po-si´tion.= 1. The attitude or posture of a patient. 2. The relation - of the presenting part of the fœtus to the quadrants of the maternal - pelvis. - - =Pos-te´ri-or.= Situated behind or toward the rear. - - =Post par´tum.= After delivery. - - =Pre´ma-ture.= 1. Occurring before the proper time. 2. An infant born - before its proper term, but viable. - - =Pre´ma-tu´´ri-ty.= The condition of a child that has been delivered - before term, and before maturity or ripening has taken place. - - =Pre-mon´i-tory.= Serving as a warning. - - =Pre´puce.= The fold of skin covering the glans penis; the foreskin. - - =Pres´en-ta´´tion.= 1. The appearance in labor of some particular part - of the fœtal body at the os uteri. 2. That part of the fœtal body - which first shows itself at the os in labor. - - =Pri-mip´a-ra.= A woman who has given birth, or who is giving birth, - to her first child. - - =Prod´ro-mal.= Premonitory. Indicating the approach of an event, - phenomenon, or disease. - - =Prog-no´sis.= A forecast as to the probable result of an attack of - disease; the prospect as to recovery from a disease afforded by the - nature and symptoms of the case. - - =Pro-jec´tion-al vom´i-ting.= Sudden violent emesis. - - =Pro-lapse´.= The falling down, or sinking, of a part or viscus. - - =Pro-lep´sis.= The anticipation and nullification of complications - before they arise. - - =Prom´´on-to´ry.= A projecting eminence or process. - - =Pro´phy-lax´´is.= The prevention of disease. - - =Pro´te-in.= Any one of a group of nitrogenized, noncrystallizable - compounds similar to each other, widely distributed in the animal - and vegetable kingdoms, and forming the characteristic constituents - of the tissues and fluids of the animal body. They are formed by - plants, the animal organism receiving them as food and transforming - and assimilating them. They all contain carbon, hydrogen, nitrogen, - oxygen and sulphur. Some of the most important are albumin, casein, - legumin, fibrin, myosin and glutin. - - =Psy´chic.= Pertaining to the mind. - - =Pu´bes.= That part of the lower central hypogastric region which, in - the adult, is covered with hair. The pubic region. - - =Pu´bic.= Pertaining to the pubes, or os pubis. - - =Pu´ber-ty.= The age at which the reproductive organs become - functionally operative. - - =Pu´bi-ot´´o-my.= (_He-bos´te-ot´´omy._) The operation of cutting - through the pubic bone, lateral to the median line. - - =Pu-er´pe-ral.= Pertaining to childbirth. - - =Pu´er-pe´´ri-um.= The period or state of confinement. The puerperium - is the time succeeding labor which is necessary for the restoration - of the genitals to their condition previous to pregnancy, or as near - it as possible. It varies from 6 weeks to several months. - - =Pu´ru-lent.= Consisting of or containing pus. - - =Py-æ´mia.= Blood-poison of microbic origin. - - =Py´e-li´´tis.= Inflammation of the pelvis or the kidney. - - =Py´or-rhœ´´a.= A discharge of pus, especially from infection around - the roots of the teeth. - - =Py-ro´sis.= Heartburn. Acidity of the stomach. Eructations of acid. - - =Re´flex-es.= Reflected actions or movements. Impulses received and - transmitted by the nervous system without conscious volition. - Involuntary responses to irritation. Automatic movements. - - =Re-frig´e-rant.= Relieving fever and thirst. A cooling remedy. - Acidulous drinks and evaporating lotions are refrigerant. - - =Re-gur´gi-ta´´tion.= 1. The casting up of undigested food. 2. A - backward flowing of the blood through the left auriculo-ventricular - opening, on account of imperfect closure of the mitral valve. - - =Re´lax-a´´tion.= 1. A lessening of tension. 2. A mitigation of pain. - - =Re´nal.= Pertaining to the kidney. - - =Res´ti-tu´´tion.= 1. An act or process of restoration. 2. The - rotation of the presenting part of the fœtus outside of the vagina. - - =Re´tro-gres´´sive.= Going or moving backward. Passing from a better - to a worse condition. - - =Re´tro-ver´´sion.= The tipping of an entire organ backward. - - =Rick´ets.= (_Ra-chi´tis._) A constitutional disease of childhood in - which the bones become soft and flexible from retarded ossification, - due to deficiency of the earthy salts. - - =Ro-ta´tion.= The process of turning around an axis. - - =Rough´en-ing.= Any rough, coarse food that gives bulk to the - intestinal contents without much nutrition. - - =Ru´be-fa´´ci-ent.= An agent that reddens the skin. - - =Ru´gæ.= Wrinkles or folds. - - =Rup´ture.= 1. Forcible tearing or breaking of a part. 2. Hernia. - - =Sa´crum.= The triangular bone situated at the end of the spine. It is - formed of five vertebræ, amalgamated and wedged in between the two - innominate bones. - - =Sag´it-tal.= Shaped like, or resembling, an arrow. - - =Sal´i-va´´tion.= An excessive discharge of saliva. - - =Sal´pin-gi´´tis.= Inflammation of an oviduct or of the eustachian - tube. - - =Sal´´var-san´.= A compound invented by Ehrlich for the treatment of - diseases caused by the Spirillæ, such as syphilis and recurrent - fever. It is popularly called 606. - - =Sa-præ´mi-a.= Poisoning of the blood by the absorption of toxins from - localized infections as from the uterus. - - =Scap´u-la.= The shoulder blade. - - =Scro´tum.= The pouch which contains the testicles and their accessory - organs. - - =Se-ba´ceous.= 1. Pertaining to sebum or suet. 2. Secreting a greasy - lubricating substance. - - =Se-cre´tion.= 1. The process or function of separating various - substances from the blood. 2. Any secreted substance. - - =Sec´un-dines.= All that remains in the uterus after the birth of the - child is called secundines—placenta, membrane and cord. - - =Se´men.= 1. A seed or seed-like fruit. 2. The thick whitish liquid - fecundating secretion produced in coition. - - =Shock.= Sudden vital depression, due to an injury or emotion which - makes a sinister impression upon the nervous system. - - =Show.= The appearance of blood that foreruns a labor or menstruation. - - =Sin´a-pism.= A plaster or paste of ground mustard-seed; a mustard - plaster. - - =Sin´ci-put.= The portion of the head lying in front of the anterior - or large fontanelle. - - =Si´nus.= 1. A recess, cavity or hollow space. 2. A dilated channel - for venous blood, found chiefly within the cranium and uterus during - gestation. 3. An air-cavity, in one of the cranial bones, especially - one communicating with the nose, such are the ethmoidal frontal - maxillary and sphenoidal sinuses. 4. A suppurating channel or - fistula. - - =Smeg´ma.= A thick, cheesy, ill-smelling secretion found under the - prepuce and around the labia minora. - - =So-lu´tion.= 1. The process of dissolving. 2. A liquid containing - dissolved matter. - - =Sor´des.= The dark brown matter which collects on the lips and teeth - in low fevers. - - =Spas´mo-phil´´ic di-ath´e-sis.= Is a condition characterized by an - increased elective irritability and a tendency to spasm, like - contractions of one or more groups of muscles. (Grulee). - - =Spe-cif´ic.= 1. Pertaining to a species. 2. Produced by a single kind - of microorganism. 3. A remedy specially indicated for any particular - disease. - - =Sper´ma-to-zo´´on.= The motile generative element of the semen which - serves to impregnate the ovum. - - =Spi´na bif´i-da.= Congenital cleft of the vertebral column with - meningeal protrusion. - - =Spi´ro-chæ´´te.= A genus or form of flexile spirobacteria. - - =Sta´sis.= A stoppage of the flow of fluid in any organ or any part of - the body. - - =Ste-no´sis.= Narrowing or stricture of a duct or canal. - - =Ster´ile.= Nonfertile. - - =Ster´il-i-za´´tion.= The act or process of rendering sterile. - - =Still-birth.= The birth of a dead fœtus. - - =Stim´u-lant.= 1. Producing stimulation. 2. An agent or remedy that - produces stimulation. - - =Strep´to-coc´´cus.= A genus or form of bacterial organism, which - grows in consecutive links, like a chain. - - =Stri´a=, pl. _striæ_. Streaks or lines. - - =Stro´ma.= The tissue which forms the ground substance, framework, or - matrix of an organ. - - =Styp´tic.= Astringent, an agent for arresting hæmorrhage. - - =Sub´in-vo-lu´´tion.= Incomplete involution; failure of a part to - return to its normal size and condition after enlargement from - functional activity. - - =Sup-pos´i-to-ry.= An easily fusible medicated mass to be introduced - into the vagina, rectum, or urethra. - - =Su´ture.= 1. Surgical stitch or seam. 2. The line of junction of - adjacent cranial or facial bones. - - =Sym´phys-e-ot´´o-my.= The division of the fibrocartilage of the - symphysis pubis in order to facilitate delivery by increasing the - anteroposterior diameter of the pelvis. - - =Sym´phy-sis.= The line of junction and fusion between bones - originally distinct. The symphysis pubis. - - =Syn´chro-nous.= Occurring at the same time. - - =Syph´i-lis.= A contagious venereal disease leading to many structural - and cutaneous lesions, due to a microorganism called the spirochæta - pallida. - - =Tam´pon.= A plug made of cotton, sponge, or oakum. - - =Te-nac´u-lum.= A hook-like instrument for seizing and holding - tissues. - - =Te-nes´mus.= Straining, especially ineffectual and painful straining. - - =Throm´bus.= A plug or clot in a vessel remaining at the point of its - formation. - - =Tinc´ture.= The solution of medicinal substances in fluids other than - water or glycerine. There is usually about one part of the drug to - eight of alcohol. - - =Tis´sue.= An aggregation of cells, fibers and various cell-products - forming a structural element. - - =Tox-æ´mi-a.= Blood poisoning. - - =Tox´in.= Any poisonous albumin produced by bacterial action. - - =Trau´ma.= A blow, wound, or other violent injury. - - =Trau´ma-tism.= A condition of the system due to injury. - - =Tu´mor.= 1. Swelling; morbid enlargement. 2. A neoplasm. A mass of - new tissue which persists and grows independently of its surrounding - structures, and which has no physiologic use. - - =Tym´pa-ni´´tis.= Distention of the abdomen from gas. - - =Um-bil´i-cal.= Pertaining to the umbilicus. - - =Um-bi-li´cus.= The navel. - - =U´ra-chus.= A cord that extends from the apex of the bladder to the - navel. It represents the remains of the canal in the fœtus which - joins the bladder with the allantois. - - =U-re´a.= A white crystallizable substance from the urine, blood and - lymph. - - =U-re´ter.= The fibro-muscular tube which conveys the urine from the - kidney to the bladder. - - =U-ræ´mi-a.= The presence of urinary constituents in the blood and the - toxic condition produced thereby. - - =U-re´thra.= A membranous canal conveying urine from the bladder to - the surface and in the male conveying the seminal ejaculations. - - =U´rin-al´´y-sis.= The chemical analysis of urine. - - =U´ter-us.= The hollow muscular organ which provides lodgement for the - fœtus from conception to birth. The womb. - - =U´ter-us bi-cor´nis.= A womb wherein the two sides have been - incompletely joined during development, and two horns, or - protrusions, appear on the fundus. - - =U´ter-us di-del´phys.= A womb in which there has been separate - development and incomplete fusion of the two sides. - - =U´ter-us du´plex.= A double uterus. - - =U´ter-us sep´tate.= A uterus that is divided by a partition or - septum. - - =Var´i-cose veins.= Of the nature of, or pertaining to, a varix. The - permanent dilatation of a vein. - - =Ven´e-sec´´tion.= The opening of a vein for the purpose of letting - blood. - - =Ven´tral stalk.= An embryonic process which is the rudimental - precursor of the umbilical cord. It is known as the ventral stalk - because somewhat later in the course of development it becomes - attached to the ventral (abdominal) surface of the embryo. - - =Ver´nix cas´e-o´´sa.= A fatty substance that covers the skin of the - fœtus. - - =Ver´sion=. The act of turning, especially the manual turning of the - fœtus in delivery. =External v.=, that which is performed by outside - manipulation. =Internal v.=, version performed by the hand - introduced into the uterus. =Braxton Hicks’ Version=, a version done - with the whole hand in the vagina and two fingers entering the - uterus through the partially dilated os. - - =Ves´i-cal.= Pertaining to the bladder. - - =Vi´a-bil´´i-ty.= Able to live after birth. - - =Vil´li.= 1. The finger-like projections that develop on the outside - of the egg and connect it vascularly and otherwise with the uterus; - a vascular chorionic tuft. 2. A minute club-shaped projection from - the mucous membrane of the intestine. - - =Vul-sel´lum.= A forceps with teeth on the ends of the jaws. - - =Walch´er’s position.= The patient on the back with the hips at the - edge of the table and the legs hanging down. - - =Whar´ton’s jelly.= The soft pulpy connective tissue that constitutes - the largest part of the umbilical cord. - - =Womb.= Same as uterus. - - - - - INDEX - - - A - - Abderhalden test for pregnancy, 61 - - Abdomen: - care of, 70 - changes in pregnancy, 59 - weakness of, 85 - - Abortion, 95 - etiology, 207 - management, 207 - - Accessory articles of diet, 319 - - Accidental hæmorrhage, 228 - - After-birth, 41, 117 - - After-pains, 154, 254 - relief of, 154 - - Albuminuria, 77 (_see_ Eclampsia) - - Amenorrhœa, 57 - during lactation, 158 - in the nonpregnant, 58 - - Amnion, 38 - adhesions, 87 - - Anæsthetics, 103, 138, 142 - - Anencephalus, 309 - - Anus, 23 - - Aphthæ, 294 - - Areola, 31 - - Asepsis in delivery, 142 - - Aseptic care, 200 - - Asphyxia neonatorum, 278 - methods of resuscitation, 279 - - Atelectasis, 283 - - Attitude of child, 165 - - - B - - Baby: - anencephalus, 309 - aphthæ, 294 - asphyxia, 142, 278 - balanitis, 306 - bath, 266 - bowels, 273 - breasts, 293 - care after delivery, 144 - care at birth, 142 - circumcision, 306 - cleansing, 265 - clothing, 270 - colic, 299 - constipation, 298 - convulsions, 282 - cradle cap, 295 - diarrhœa, 298 - exercise, 284 - eyes, 268 - furuncles, 305 - flushings, 285 - gavage, 285 - genitals, 272 - hæmorrhage, 289 - harelip and cleft palate, 287 - heart, 278 - hernia, 287 - hydrocephalus, 308 - icterus, 293 - lavage, 286 - marasmus, 303 - menstruation, 293 - mouth, 272 - nails, 289 - nursing periods, 273, 156 - paraphimosis, 305 - phimosis, 305 - pneumonia, 304 - prematurity, 301 - priapism, 308 - respiration, first, 142 - routine for, 270 - significant symptoms and - conditions, 320 - sleep, 272 - snuffles, 304 - spina bifida, 308 - temperature, 276 - thrush, 294 - tongue-tie, 287 - toilet basket, 271 - umbilicus, 267 - urticaria, 294 - vomiting, 300 - weight, 271 - - Bag of waters, 39, 110 - - Balanitis, 306 - - Ballottement, 62 - - Barley water, 316 - - Baths, 69, 325 - - Bed, making, 133 - - Bed-linen, care of, 150 - - Bed sores, 263 - - Bednar’s disease, 294 - - Bichloride solution, 135 - - Birthmarks and deformities, 72, 87 - - Binder, 153 - - Bladder, 23 - after delivery, 159 - in pregnancy, 56, 58 - - Bleeders, 232, 290 - - Blood, in pregnancy, 55 - - Bowels, in pregnancy, 68 - in puerperium, 157 - - Breast milk, quantity, 275 - - Breasts, 30 - caked, 156, 243 - care of, 71 - changes due to marriage and pregnancy, 53, 59 - inflow of milk, 53 - massage, 156 - nursing periods, 156 - of puberty, 33 - preparation for lactation, 155 - removal of child, 252, 261 - sensations in pregnancy, 59 - supernumerary, 31 - - Breech presentation, 168 - - Brow presentation, 177, 179 - - Buttermilk, 314 - - - C - - Cæsarean section, 195 - - Caput succedaneum, 127 - - Case record, nurse’s, 131 - - Catheterization, - after delivery, 159 - before operations, 183 - - Caul, 114 - - Cephalhæmatoma, 128 - - Cervix, effacement, 110 - repair, 144, 211 - - Child (_see_ Baby) - - Chill in puerperium, 151 - - Chloasma, 55 - - Chloroform in labor, 103 - - Chorion, 38 - - Circumcision, 306 - - Clamp for cord, 268 - - Clitoris, 26 - - Coitus, 71 - - Colic, 300 - - Colostrum, 53 - - Conception, 36 - - Condylomata, 75 - - Confinement, estimating date, 58, 66 - - Constipation, 68, 298 - - Contraction of pelvis, 214 - - Contractions of Braxton Hicks, 53, 62, 109 - - Convulsions, of child, 282 - of mother, 236 - - Cord, umbilical, 40 - attachment to placenta, 42 - cutting, 142 - granulations of, 293 - prolapse of, 220, 137 - separation, 292 - - Cow’s milk vs. breast milk, 311 - - Cradle cap, 295 - - Cramps, 56, 86 - - Cranioclasis, 194 - - Curettage of uterus, 206 - in abortion, 207 - - Curve of Carus, 20 - - - D - - Decapitation, 194 - - Delivery, asepsis during, 142 - care of mother after, 144 - on side, 140 - - Diabetes and pregnancy, 95 - - Diapers, 270, 273 - bluing on, 270, 296 - - Diarrhœa of child, 298 - - Diet in puerperium, 152, 155 - - Diets, 336 - - Doctor, 130 - when to call, 131 - what to report, 131, 319 - - Douche, vaginal, 202 - aseptic, 200 - in pregnancy, 71, 160 - intrauterine, 205, 233 - - Dress in pregnancy, 69 - - Drugs affecting the milk, 275 - - Dry birth, 225 - - Ductus arteriosus, 49 - venosus, 48 - - - E - - Eclampsia, 78 - blood pressure in, 55 - symptoms and management, 237 - wet packs in, 231 - - Ectopic pregnancy, 89 - - Edema, 69 - - Enemas, eliminative, 355 - nutrient, 334 - - Episiotomy, 211 - - Ergot, 143 - after delivery, 150 - in abortion, 207 - in post partum hæmorrhage, 233 - - Eruptions on the skin, 55 - - Erythema, 296 - - Ether in labor, 103 - - Examination of patient, 134, 140 - - Excavation of pelvis, 19 - - Extrauterine pregnancy, 89 - - Exudative diathesis, 295 - - Eye symptoms in pregnancy, 69 - - - F - - Face presentation, 174, 179 - - Fallopian tubes, 22 - - Fainting, 70 - - Fevers and pregnancy, 91 - - Flour ball, 316 - - Flushings, 285 - - Fœtus, attitude, 44 - circulation, 48 - diameters of head, 46 - fontanelles, 46 - heart tones, 63, 180 - movements, 44, 62 - rate of growth, 46 - rule for estimating length, 47 - rule for estimating weight, 47 - signs of danger to, 180 - signs of death, 97 - signs of maturity, 47 - - Food mixings, 317 - preparation for infants, 314 - - Foramen ovale, 50 - - Forceps, application, 186 - conditions for, 185 - dangers of, 185 - in breech cases, 173 - in face presentations, 176 - indications for, 185 - preparations for, 183 - - Fumigation, 329 - - Furuncles, 305 - - - G - - Galactorrhœa, 250 - - Gas analgesia, 104 - - Gas pains, 154, 158, 253 - - Gavage, 285 - - Genital crease, 25 - - Genitalia, care after delivery, 142, 148 - preparation for delivery, 131 - preparation for operation, 182 - - Getting up, 161 - - Gingivitis, 75 - - Glands, Bartholin, 27 - mammary, 30 - Montgomery, 31 - thyroid, 56 - - Glossary, 351 - - Glycosuria, 69 - - Gonorrhœa and pregnancy, 93 - - Goodell’s sign, 60 - - Gossip, 161 - - Graafian follicle, 33 - - Gums in pregnancy, 75 - - - H - - Hæmorrhage, accidental, 228 - in abortion, 207 - in labor, 144, 119, 143 - in the newborn, 289 - in pregnancy, 95 - post partum, 232, 234 - unavoidable, 228 - uterine douche for, 205 - - Hæmorrhoids, 86 - - Hair, 55, 132 - - Hands, care of, 160, 323 - sterilization of, 134 - - Harelip and cleft palate, 287 - - Head, descent, 123 - expulsion of, 115 - effect of labor on, 126 - extension, 126 - external restitution, 126 - flexion, 123 - internal rotation, 124 - - Headache, 237, 254 - - Heart changes in pregnancy, 55 - lesions in pregnancy, 94 - - Heart tones, fœtal, where - heard, 130 - significance, 137 - when membranes rupture prematurely, 226 - - Hegar’s sign, 60 - - Hernia, 287 - - Herpes in pregnancy, 76 - - Hospital drums, packing, 138 - - Hottentot apron, 26 - - Hydramnios, 87 - and malpresentations, 175 - and twins, 84 - - Hydrocephalus, 308 - - Hymen, 26 - - Hypodermoclysis, 206 - - Hyperemesis gravidarum, 79 - - - I - - Icterus, 293 - - Induction of labor, 208 - - Infant feeding, 310 - outfit, 101 - - Infection, 226, 255 - - Injections, eliminative, 335 - intravenous, 205 - nutrient, 334 - - Insomnia, 56 - - Intertrigo, 296 - - Involution, 152, 160, 161 - - - J - - Jacquemins’ sign, 62 - - Jaundice, of child, 293 - of mother, 95 - - - K - - Kidneys of child, 44 - of mother, 56, 68, 95 - - - L - - Labia majora, 25 - minora, 26 - - Labor, care during, 140 - induction of, 208 - precipitate, 223 - preparations for, 130, 138, 326 - signs of, 129 - vomiting in, 228 - - Lactation and menstruation, 157 - - Lavage, 286 - - Leucorrhœa, 71 - - Lightening, 65, 108 - - Linea albicantes, 55 - nigra, 55 - - Liquor amnii, 38 - in disease, 87 - - Liver, of child, 44 - of mother in pregnancy, 56, 95 - - Lochia, 154 - and the hands, 160 - - Longings, 56 - - Lungs in pregnancy, 56 - - - M - - Malæna neonatorum, 290 - - Marasmus, 303 - - Mask of pregnancy, 55 - - Mastitis, 247 - - Maternal impressions, 72 - - Membranes, 110 - premature rupture, 225 - relation of rupture to labor, 114 - rupture of, 109, 114 - - Menstruation, definition of, 33 - during lactation, 157 - in infant, 298 - physiology of, 34 - relation to conception and pregnancy, 33 - systemic effects, 35 - - Milk fever, 243 - - Milk, elements of human, 312 - excess of, 249 - fat-free, 317 - inflow, 156 - peptonizing, 338 - pasteurizing, 316 - quality, 251 - scarcity, 249 - sterilization, 316 - to dry up, 163 - whole milk, 317 - - Milk leg, 262 - - Mind in pregnancy, 72 - - Moles, 80 - - Monsters, 88, 308 - - Mons veneris, 25 - - Morning sickness, 58 - - Multiple pregnancy, 83 - - - N - - Nausea, 58 - - Nervous system, 56 - - Neuralgia, 56 - - Nipple, 30 - care of, 71 - cracks and fissures, 244 - imperfect, 245 - preparation for lactation, 155 - rubber, 318 - - Normal labor, 107 - amount of blood lost, 119 - causes of, 107 - course of, 110 - date of onset, 107 - duration of first stage, 114 - duration of second stage, 114 - general effects, 118 - mechanism, 120 - subjective phenomena, 115 - - Nurse, 98 - and cleanliness, 129, 323 - and history sheet, 131 - in obstetrics, 98 - in puerperal fever, 262 - outfit, 99 - qualifications, 323 - sterilizing, 101 - - Nursery rules, 269 - - Nursing periods, 156 - - Nursing the child, 293 - - - O - - Odors of person, 324 - - Oligohydramnios, 87 - - Operations, preparations for, 180 - why required, 179 - - Ophthalmia neonatorum, 93, 142, 192 - - Os, digital dilatation, 211 - physiology of dilatation, 111 - rigidity of, 222 - - Ovaries, 23 - - Ovulation, 33 - - Ovum, 33 - death of, 96 - fertilization, 36 - implantation, 37 - mode of progress, 23 - relation to uterine cavity, 52 - - - P - - Packs, wet, 213 - - Pains, after, 154 - cause of, 109 - character of, 115, 131, 138 - false, 108 - from gas, 154 - regularity of, 110, 130 - - Palpation, 134 - - Paralysis, facial, 291 - of shoulder (Erb’s), 291 - - Paraphimosis, 305 - - Patient, care of, after delivery, 144 - during second stage, 137 - examination of, 74, 133 - in first stage, 133 - loss of weight post partum, 155 - preparation of, 131, 138 - rest, 160 - visitors, 133, 161 - - Pelvic floor rigidity, 223 - - Pelvis, 17 - brim, 18 - contracted, 214 - diameters, 214 - false, 17 - measurements, 214 - quadrants of, 121 - shape, 18 - true, 17 - upper strait, 18 - - Pemphigus neonatorum, 296 - - Perineorrhaphy, 144 - instruments, 139, 145, 146 - after-care, 147 - - Perineum, 28, 25 - head on, 115 - preservation, 145 - repair, 143, 144 - torn in labor, 30 - - Peritoneum, 24 - - Peritonitis, (_see_ Infection) - - Phimosis, 305 - - Phlebitis, 263 - - Physical signs of pregnancy, 59 - - Pigmentation, 55, 77 - - Pituitrin, 143, 224 - - Placenta prævia, 29 - - Placenta, 41 - anomalies, 88 - early expression, 149 - infarcts, 88 - conditions for Crede expression, 150 - manual removal, 150 - - Pneumonia in child, 304 - - Point of direction, 121 - - Position, occipito-posterior, 178 - of breech, 165 - of face, 175 - of head, 121 - Walcher, 193 - - Pregnancy, Abderhalden’s test for, 61 - age of, 65 - albuminuria in, 77 - at fourth month, 61 - bowels in, 68 - cathartics in, 68 - condylomata, 75 - constipation in, 75 - cramps, 86 - diabetes in, 95 - diagnosis, 57 - duration of, 66, 107 - extra uterine, 89 - fevers and, 91 - general effects, 56 - gingivitis, 75 - gonorrhœa, 93 - hæmorrhages, 95 - hæmorrhoids in, 86 - heart disease and, 94 - heartburn, 68 - herpes, 76 - hydramnios in, 87 - hygiene of, 66 - hyperemesis in, 79 - kidneys in, 68 - local effects, 51 - maternal changes, 51 - mental conditions in, 72 - pressure symptoms, 85 - probable signs, 61 - pruritus, 76 - pyelitis, 79 - salivation, 75 - signs at 26th week, 62 - syphilis, 92 - toothache, 75 - toxæmias, 74 - tuberculosis, 92 - varicose veins, 85 - vomiting in, 79 - - Prematurity, 301 - - Presentation, definition, 120 - frequency of vertex, 121 - of breech, 165 - of face and brow, 174 - transverse, 174 - - Pressure symptoms, 85 - - Priapism, 308 - - Proprietary foods, 314 - - Pruritus in pregnancy, 76 - - Ptyalism, 75 - - Puberty, 33 - - Pubiotomy, 198 - after-care, 199 - - Puerperal fever, 255 - disposal of excreta, 261 - etiology, 255 - nurse and, 262 - prevention, 258 - symptoms, 259 - treatment, 260 - - Puerperium, 151 - diet in, 152 - laxatives, 158 - standing orders for, 162 - - Pulse in puerperium, 151 - - Pyelitis, 79 - - Pyloric stenosis, 303 - - - Q - - Quickening, 59 - - - R - - Rectal feeding, 333 - - Rectal infusions, 212 - - Rectum, 23 - in labor, 23, 142 - - Red gum, 297 - - Renal disease, 95 - - Rest, 160 - - Room, setting up, 130, 180 - - Rubber gloves, 136 - - Rubber nipples, 318 - - - S - - Salivation, 75 - - Second stage of labor, 114 - - Sex, determination of, 65, 72 - - Sexual relations, 71 - - Sheet sling, 146, 181 - - Show, 109, 129 - - Skin, changes, 54 - care of, 69 - eruptions, 55 - pigmentation, 55, 77 - striæ gravidarum, 54 - - Snuffles, 304 - - Solutions, 340 - percentage table of, 341 - - Souffle, funic, 65 - uterine, 63 - - Spermatozoa, 36 - - Spina bifida, 308 - - Standing orders for nurse, 164 - for puerperium, 163 - - Starvation fever, 276 - - Sterile linen, application, 138, 182 - - Sterilization, 101, 323 - dressings, 325 - instruments, 327 - rubber goods, 328 - - Stitches, care of, 160 - removal, 202 - - Stomach capacity of child, 275 - - Subinvolution, 155, 260, 261 - - Subjective signs of pregnancy, 57, 59 - - Sudden death of infant, 309 - of mother, 263 - - Sugar in urine, 69 - - Sugars and flours, 317 - - Supplemental feedings, 310 - - Supplies for house, 99 - for sterilization, 101 - preparation of, 326 - - Symphyseotomy, 198 - - Syphilis and fœtus, 88 - and pregnancy, 92 - of placenta, 88 - - - T - - Tampon of uterus, 202 - of vagina, 204 - - Temperature in puerperium, 151 - - Third stage of labor, 117, 142, 143 - conduct of, 149 - - Thrombus, 263 - - Thrush, 294 - - Thyroid gland, 56 - - Toilet basket, 271 - - Tongue-tie, 287 - - Toothache, 75 - - Toxæmia, 74 - - Transfusion, 205 - in eclampsia, 240 - - Tubercles of Montgomery, 31 - - Tuberculosis and pregnancy, 92 - - Twilight sleep, 103 - - Twins, 83 - - - U - - Umbilicus, 267 - - Unavoidable hæmorrhage, 228 - - Urination, after delivery, 158 - of child, 273 - - Urine, 56 - in pregnancy, 77 - in puerperium, 151 - sterile specimen, 200 - sterile specimen from child, 200 - - Urticaria, 294 - - Utensils for milk modification, 318 - - Uterus, anatomy, 21 - changes in pregnancy, 51, 59 - curettage, 206 - displacements, 84 - height at various months of pregnancy, 64 - inertia, 223 - malformations, 85 - rupture, 226 - - Uterine souffle, 63 - - - V - - Vagina, anatomy, 21 - attachments, 21 - distensibility, 21 - - Vaginal tampon, 204 - in abortion, 207 - - Varicose veins, 85 - - Ventral stalk, 40 - - Version, 190, 192, 193 - - Vestibule, 26 - - Vessels of cord, 48 - - Villi, 37 - - Visitors, 133, 161 - - Vomiting, 300, 321 - in pregnancy, 79 - in labor, 228 - uncontrollable, 79 - - Vorhees bag, 224, 230 - - Vulva, anatomy, 24 - care of, 143 - preparation, 132 - - - W - - Walcher position, 173, 193 - - Weaning, 252, 273 - - Wet nurse, 253 - - Wharton’s jelly, 40 - - Whey, 315 - - Wiegand compression, 173, 194 - - Witch’s milk, 32 - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Silently corrected typographical errors and variations in spelling. - 2. Anachronistic, non-standard, and uncertain spellings retained as - printed. - 3. Enclosed italics font in _underscores_. - 4. Enclosed bold font in =equals=. - - - - - -End of Project Gutenberg's Obstetrics for Nurses, by Charles B. Reed - -*** END OF THIS PROJECT GUTENBERG EBOOK OBSTETRICS FOR NURSES *** - -***** This file should be named 61476-0.txt or 61476-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/1/4/7/61476/ - -Produced by Richard Tonsing, Mark C. 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