path: root/61476-0.txt

*** START OF THE PROJECT GUTENBERG EBOOK 61476 ***

                               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-nϫa.= 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-rhϫa.= 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 THE PROJECT GUTENBERG EBOOK 61476 ***