initial commit of ebook 7129HEADmain

1 files changed, 9333 insertions, 0 deletions

diff --git a/7129.txt b/7129.txt
new file mode 100644
index 0000000..3472387
--- /dev/null
+++ b/7129.txt
@@ -0,0 +1,9333 @@
+The Project Gutenberg EBook of The Prospective Mother, by J. Morris Slemons
+
+Copyright laws are changing all over the world. Be sure to check the
+copyright laws for your country before downloading or redistributing
+this or any other Project Gutenberg eBook.
+
+This header should be the first thing seen when viewing this Project
+Gutenberg file.  Please do not remove it.  Do not change or edit the
+header without written permission.
+
+Please read the "legal small print," and other information about the
+eBook and Project Gutenberg at the bottom of this file.  Included is
+important information about your specific rights and restrictions in
+how the file may be used.  You can also find out about how to make a
+donation to Project Gutenberg, and how to get involved.
+
+
+**Welcome To The World of Free Plain Vanilla Electronic Texts**
+
+**eBooks Readable By Both Humans and By Computers, Since 1971**
+
+*****These eBooks Were Prepared By Thousands of Volunteers!*****
+
+
+Title: The Prospective Mother
+       A Handbook for Women During Pregnancy
+
+Author: J. Morris Slemons
+
+Release Date: December, 2004 [EBook #7129]
+[Yes, we are more than one year ahead of schedule]
+[This file was first posted on March 13, 2003]
+
+Edition: 10
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THE PROJECT GUTENBERG EBOOK THE PROSPECTIVE MOTHER ***
+
+
+
+
+Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo,
+Charles Franks and the Online Distributed Proofreading Team.
+
+
+
+
+
+THE PROSPECTIVE MOTHER
+
+
+A Handbook for Women During Pregnancy
+
+
+
+by
+
+J. MORRIS SLEMONS
+
+Associate Professor of Obstetrics,
+The Johns Hopkins University.
+
+
+       *       *       *       *       *
+
+
+PREFACE
+
+
+This book, written for women who have no special knowledge of
+medicine, aims to answer the questions which occur to them in the
+course of pregnancy. Directions for safeguarding their health have
+been given in detail, and emphasis has been placed upon such measures
+as may serve to prevent serious complications. Treatment of such
+conditions has not been discussed, as it can be judiciously carried
+out only by a physician who has the opportunity to observe and study
+the individual patient. Furthermore, if there is to be notable
+improvement in the management of cases of childbirth, the appearance
+of untoward symptoms should not be awaited before consulting a
+physician; on the contrary, prospective mothers must be taught that
+they should be under competent medical supervision throughout
+pregnancy.
+
+At present intelligent women demand some knowledge of the anatomical
+and physiological changes incident to the development of the embryo
+and the birth of the child. These subjects do not readily lend
+themselves to popular description, but I have told the story as
+simply as possible, following in a general way the text-book of my
+teacher and friend, Professor J. Whitridge Williams; indeed, my main
+purpose has been to reproduce his book "in words of one syllable."
+The use of a number of technical words has been unavoidable, and,
+though their meaning has been given in the context, it has not been
+feasible to repeat the definition every time an unfamiliar term was
+used. On that account a glossary has been provided.
+
+It is with pleasure that I avail myself of this opportunity to
+acknowledge the cheerfully given assistance of many friends. In
+particular I wish to thank Doctor Henry M. Hurd, until recently
+Superintendent of the Johns Hopkins Hospital, for his interest and
+advice. I am also under deep obligation to my friend John C. French,
+of the English Department of the Johns Hopkins University, for
+helpful criticism of the manuscript, and to my colleagues, Doctors
+Rupert Norton and Thomas R. Boggs, for valuable assistance. To many
+others--doctors, nurses, and patients--I am indebted for numerous
+suggestions which have been made either consciously or unconsciously.
+
+J. MORRIS SLEMONS.
+
+
+       *       *       *       *       *
+
+
+INTRODUCTION
+
+
+In all branches of medicine the master word is _prophylaxis_, or
+prevention, and its benefits are nowhere more strikingly illustrated
+than in the practice of obstetrics. In former times every woman who
+gave birth to a child or passed through a miscarriage was exposed to
+grave danger of infection or child-bed fever; but at present--thanks
+to the recognition of the bacterial origin of the disease and of its
+identity with wound infection--this danger can be practically
+eliminated by the rigid observance of surgical cleanliness and
+aseptic technique. Physicians have also learned that the most
+effective method of coping with other serious complications of
+pregnancy and labor is by preventing their occurrence, or at least by
+subjecting them to treatment in their earliest stages; for, if they
+be allowed to go on to full development, the results are little
+better than in times past. Furthermore, a careful examination some
+weeks before the expected date of confinement enables us to recognize
+the existence of abnormal presentations and of disproportion between
+the size of the mother's pelvis and that of the child's head. Timely
+recognition of such conditions makes appropriate treatment possible
+and practically insures a successful outcome; while tardy recognition
+is frequently followed by disastrous results.
+
+These few examples give some idea of the benefits of prophylaxis in
+the practice of obstetrics. Prospective mothers should understand not
+only that there is an advantage in taking such precautions, but that
+they may be risking their lives, or at least their future well-being,
+unless they insist upon competent medical attention. It is true, of
+course, that pregnancy and childbirth are generally normal processes,
+but they are not always so. Fortunately, most of the abnormalities
+give timely warning of their occurrence, and in most instances may be
+relieved by comparatively simple measures; or, if not, they afford
+indications for treatment which should lead to a happy termination.
+The recognition of the existence of such conditions, however, is not
+always easy, and their ideal treatment requires careful training and
+sometimes the utmost nicety of judgment. Consequently, if prospective
+mothers wish to be assured of the best care, they should be cautious
+in the choice of their medical attendant. As the ordinary layman has
+no means of determining the real qualifications of a physician, the
+choice should not be made upon the advice of casual acquaintances;
+but, instead, the family physician should be consulted, who, should
+he feel unwilling to assume the responsibility of the case, will be
+able to recommend a thoroughly competent substitute.
+
+From my own experience as a teacher and consultant, I state without
+hesitation that in no other branch of medicine or surgery are graver
+emergencies encountered than in certain obstetrical complications
+whose treatment involves the greatest responsibility and requires the
+highest order of ability to insure a successful outcome for the
+mother and her child. For these reasons a physician should be chosen
+only after mature deliberation, and his services should be esteemed
+much more highly than is usually the case.
+
+In order that the principles of prevention may receive their fullest
+application during pregnancy, labor, and the lying-in period, it is
+also advisable that intelligent women should possess some knowledge
+of the Reproductive Process in human beings. This information is
+imparted by Doctor Slemons' book, which I can thoroughly recommend to
+prospective mothers. The subject matter has been carefully chosen,
+and the author has wisely refrained from giving advice with regard to
+treatment which can be satisfactorily directed only after careful
+study by a physician. At the same time he has given a clear account
+of the physiology of pregnancy and labor, and has laid down sound
+rules for the guidance of the patient.
+
+One of the most important facts emphasized by Doctor Slemons is the
+value of medical supervision for several weeks after the child is
+born; this precaution contributes greatly toward a rapid and complete
+convalescence. During the lying-in period the physician should
+supervise the care of the mother and the child, should insist upon
+the necessity for maternal nursing, and should keep the mother under
+observation until perfectly normal conditions are regained. If the
+latter duty is conscientiously fulfilled many years of invalidism may
+be saved and thousands of operations rendered unnecessary.
+
+Although there have been notable advances in the science and in the
+art of obstetrics since the middle of the eighteenth century, a great
+many fundamental facts must yet be learned. For example, we are
+almost totally ignorant of the stimulus which causes the mother to
+fall into labor approximately 280 days after the last normal
+menstruation.
+
+There are two points which I desire to impress especially upon the
+readers of this book. Firstly, that the advance of the science of
+obstetrics, and consequently improvements in its practice, must
+depend greatly upon the cooperation of intelligent women. They must
+come to realize that they will secure the best treatment only as they
+demand the highest standard of excellence from their attendants; and
+they can aid in securing this for their poorer sisters and their
+children by interesting themselves in obstetrical charities.
+
+Secondly, they must realize that real progress in the science of
+obstetrics can be expected to proceed only from well equipped clinics
+connected with strong universities, and in charge of thoroughly
+trained and broad-minded men. As yet such institutions scarcely exist
+in this country. Women who are anxious to promote the welfare of
+their sex can find no better way of doing so than by bringing this
+need to the attention of wealthy men interested in philanthropy and
+education. Furthermore, they should bear in mind that most of our
+important discoveries would not have been made had animal
+experimentation not been available, as it is solely by this means
+that modern surgical and obstetrical technique has been brought to
+its present degree of perfection; and further progress can scarcely
+be expected without its aid. They should remember also that whenever
+they take such a well-known drug as ergot for the control of
+bleeding, or make use of many other apparently simple measures, they
+are unconsciously rendering tribute to this type of investigation.
+
+J. WHITRIDGE WILLIAMS.
+
+Johns Hopkins University,
+September, 1912.
+
+
+       *       *       *       *       *
+
+
+CONTENTS
+
+
+   I. THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
+  II. THE DEVELOPMENT OF THE OVUM
+ III. THE EMBRYO
+  IV. THE FOOD REQUIREMENTS DURING PREGNANCY
+   V. THE CARE OF THE BODY
+  VI. GENERAL HYGIENIC MEASURES
+ VII. THE AILMENTS OF PREGNANCY
+VIII. MISCARRIAGE
+  IX. THE PREPARATIONS FOR CONFINEMENT
+   X. THE BIRTH OF THE CHILD
+  XI. THE LYING-IN PERIOD
+ XII. THE NURSING MOTHER
+      GLOSSARY
+
+
+       *       *       *       *       *
+
+
+The Prospective Mother
+
+
+
+
+CHAPTER I
+
+
+THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
+
+The Positive Signs--The Probable Signs--The Presumptive Signs: The
+Cessation of Menstruation; Changes in the Breasts; Morning Sickness;
+Disturbances in Urination--The Duration of Pregnancy--The Estimation
+of the Date of Confinement--Prolonged Pregnancy.
+
+Many puzzling questions occur to the woman who is about to become a
+mother. Most of these questions are reasonable and natural, and
+should be frankly answered; but a false conventionality has--until
+recently, at least--forbidden any open discussion of facts connected
+with childbirth. The inevitable result has been that, without
+experience of their own to guide them, prospective mothers have
+sought advice from older women, whose experience was at best very
+narrow, and whose views were often biased by tradition. Or,
+distrusting such sources of information, they have consulted
+technical medical works which they could not understand. Either of
+these methods is very likely to result in misinformation and to cause
+unnecessary anxiety. Yet no one need be alarmed by a plain, accurate
+account of Nature's plan to provide successive generations of human
+beings. Some trustworthy knowledge of a process so fundamental should
+be part of every person's education; it is especially helpful to
+women who are pregnant because it affords a rational basis for
+hygienic measures which they should adopt. A popular work, however,
+no matter how frank and helpful it may be, will not enable one to
+dispense with professional advice. For the prospective mother no
+counsel is more important than this: _Put yourself at once under
+the care of a physician_.
+
+Insistence on the importance of medical advice should not be taken to
+imply that pregnancy is to be regarded as other than a normal
+process. Its dangers are comparatively slight, as we should expect,
+since the property of all living matter to reproduce its kind is both
+fundamental and essential; the continuance of living creatures in
+this world, plants as well as animals, depends upon the Reproductive
+Process. And yet, natural as it is, pregnancy may be attended by
+complications. Such complications, though happily rare, are to be
+guarded against in every case, and that may be most effectually done
+if patients are taught to remain under competent medical supervision
+from the time of conception until several weeks after the child is
+born. This precaution greatly reduces the frequency of annoyances
+during pregnancy and also assists materially toward conducting a
+birth to a safe conclusion. Moreover, if this advice is followed,
+when complications do arise they will be recognized and dealt with
+promptly; they will not be permitted to grow more serious until,
+perhaps, they may jeopardize the life of the mother or the child or
+both.
+
+The initial symptoms of pregnancy are so widely known that in most
+instances the prospective mother herself makes the diagnosis shortly
+after conception has taken place; but now and then pregnancy advances
+for several months unrecognized and is then detected by a physician
+who has been consulted on account of symptoms which the patient has
+incorrectly attributed to some other condition. On the other hand,
+women sometimes suspect that they are pregnant when they are not; and
+such mistakes occur because certain symptoms which are implicitly
+trusted by the laity as manifestations of pregnancy are occasionally
+associated with conditions quite foreign to it. It is clear that one
+interested in the matter must know not only what the manifestations
+of pregnancy are and when they appear, but also how far the evidence
+that they give is reliable.
+
+The signs of pregnancy may be classified, according to their
+reliability, as presumptive, probable, and positive. The doubtful
+evidence appears first and the infallible proof last. No one need be
+surprised, therefore, if, when her suspicion is first aroused, she is
+unable to decide positively whether she is pregnant. Physicians of
+broad experience, possessed of facilities for observation which their
+patients cannot employ, may find it necessary to make more than one
+examination before they commit themselves to a definite opinion; in
+some cases, though very rarely, they must wait for two or three
+months to be able to do this.
+
+THE POSITIVE SIGNS.--The earliest absolutely trustworthy
+manifestation of pregnancy is the motion of the fetus. The perception
+by the mother of these movements, which is spoken of as "quickening,"
+generally occurs toward the eighteenth week, if she has been told to
+watch for them; otherwise they may pass unnoticed until the twentieth
+week or later. At first the motion, felt in the lower part of the
+abdomen, is very gentle; it has been variously likened to tapping, or
+to quivering, or to the fluttering of a bird's wings. As time goes on
+the movements grow stronger and occur more frequently; they are,
+however, perceived but rarely throughout the day and seldom interfere
+with sleep. Occasionally women are annoyed by the sensation and
+complain that the child is hardly ever quiet. Even these troublesome
+movements are never a cause for anxiety; but prolonged failure to
+feel motion after it is once well established should be reported to
+the doctor.
+
+In the first pregnancy the passage of gas through the intestines may
+be mistaken for quickening long before the movements of the child are
+really perceptible; but those who have once experienced quickening
+will not be deceived. Whenever women who have borne children are in
+doubt the sensation is almost surely not quickening. Furthermore, in
+any doubtful case, the motion should be observed by a physician
+before being accounted a positive sign of pregnancy. This precaution
+will scarcely delay an absolutely positive diagnosis, since the
+proper method of examination reveals these movements to the physician
+almost as early as the patient feels them.
+
+About the time these movements become perceptible another positive
+sign is available. The physician whose ear has been trained to catch
+such sounds when he listens over the lower part of the mother's
+abdomen will hear the fetal heart-beat. Other sounds may be audible
+there, but the character and the rate of the heart-sounds are
+distinctive. Since the child's heart beats almost twice as fast as
+the mother's, under ordinary conditions it is impossible to confuse
+one with the other. The mother never feels the beating of the child's
+heart, but occasionally she will mistake for it the throbbing of her
+own blood vessels.
+
+Ability to hear the fetal heart not only provides a means of
+confirming the existence of pregnancy in doubtful cases, but also
+enables the physician to reassure his patient if she fails
+temporarily to feel the child move. Sometimes the presence of twins
+is recognized in this way. Toward the end of pregnancy the heart
+sounds are also of material assistance in determining what position
+the child has permanently assumed.
+
+There is a third positive sign of pregnancy to which the physician
+has recourse, but generally it is inapplicable as early as those
+already mentioned. In the latter months of pregnancy it is possible
+to outline the child through the mother's abdominal wall. Although
+this procedure adds little or nothing to our resources for making an
+early diagnosis, the information it ultimately affords proves one of
+the greatest aids in the practice of obstetrics.
+
+THE PROBABLE SIGNS.--Obviously, phenomena for which the child is
+responsible--such as have just been described--supply the most
+trustworthy evidence of pregnancy; and these phenomena alone are
+accepted as positive signs. But there are earlier manifestations
+which intimate very strongly that conception has taken place. Shortly
+after pregnancy has become established changes begin in the uterus,
+as physicians call the womb, and soon reach the point where they may
+be recognized by a simple examination which enables the physician to
+express an opinion little less than positive. As one result of
+pregnancy, for example, the supply of blood is increased to all the
+organs concerned with the reproductive process. Partly on account of
+this congestion and partly on account of embryonic development, the
+uterus becomes altered in a number of ways. Although these changes
+occur regularly in pregnancy, they may also occur when the womb is
+enlarged from other causes; therefore, if a physician should make the
+diagnosis of pregnancy whenever they were found, he would make it
+somewhat too frequently. With a little patience, however, he excludes
+the chance of being misled; a second examination, approximately four
+weeks after the first, will generally place the existence of
+pregnancy beyond question, for under normal conditions the degree of
+enlargement which takes place in a pregnant womb during a given
+interval is absolutely characteristic.
+
+THE PRESUMPTIVE SIGNS.--Although women are most often led to suspect
+that they are pregnant by symptoms which are of such doubtful
+significance that they must be regarded as merely presumptive
+evidence, the practical value of these symptoms is attested by the
+fact that subsequent developments rarely fail to confirm the
+suspicion. Perhaps they prove misleading once or twice in a hundred
+cases; the number of mistakes is small, because the diagnosis is
+commonly made not from only one of these doubtful signs but from a
+group of them. In order of importance the doubtful or presumptive
+signs of pregnancy are these: (1) cessation of menstruation, (2)
+changes in the breasts, (3) morning sickness, (4) disturbances in
+urination.
+
+_The Cessation of Menstruation_.--The failure of menstruation to
+appear when it is expected is nearly always the first symptom of
+pregnancy to attract attention, and, as a rule, when this happens to
+healthy women during the child-bearing period--which usually extends
+from the fifteenth to the forty-fifth year--it may be taken to
+indicate that conception has occurred. But there are exceptions to
+this very good rule. Besides pregnancy we are acquainted with several
+conditions that cause temporary suppression of menstruation; and to
+understand its significance we must learn something of the menstrual
+process itself.
+
+Menstruation is a function of the womb and in all probability is
+brought about through the influence of the ovaries. The bleeding,
+popularly regarded as the entire menstrual process, is, in fact,
+indicative of only one of its stages; the others give rise to no
+symptoms whatever. What the stages in the menstrual process are, what
+relation they bear to each other, and what the significance of the
+whole process is, are problems that have been solved with the aid of
+the microscope. In this way the mucous membrane lining the womb has
+been studied both at the time of the periods and in the interval
+between them, and we have learned that it is constantly undergoing
+changes intended to facilitate the reception and the maintenance of
+an embryo. Anticipating these duties the mucous membrane receives a
+more abundant supply of blood; it also increases in thickness and all
+the structures which enter into its composition become more active.
+Unless conception takes place these preparations, which represent the
+most important phase in the menstrual process, are without value; and
+therefore failure to conceive means that the mucous membrane will
+return to the same condition as existed before the preparations were
+begun. The congestion is relieved by rupture of the smallest blood
+vessels, and there follow other retrogressive steps which completely
+restore the various structures to their former state. Then there is a
+pause, though it is not long, until preparatory changes are again
+initiated, or, as we say, another Menstrual Cycle is begun. Each
+cycle lasts twenty-eight days, and includes four stages, namely, a
+stage of preparation, of bleeding, of restoration, and of rest.
+
+Although pregnancy may become established at any time during the
+interval between the periods of bleeding, it is more likely to be
+established just before a period is expected or shortly after it has
+ceased. Furthermore, whenever conception does take place, the
+preliminary preparations for the reception of the embryo are followed
+by much more elaborate arrangements for its protection and nutrition.
+Under these circumstances the hemorrhagic discharge does not appear.
+
+Were there no other condition to bring about the cessation of
+menstruation, the diagnosis of pregnancy would be greatly simplified.
+But any one can appreciate the fact that diseases of the womb may
+interfere with the menstrual process. Menstruation is influenced,
+also, by the ovaries. As a result of age, for example, the ovaries
+undergo changes which invariably bring about the permanent cessation
+of menstruation, called the menopause. This event occurs prematurely
+if both the ovaries are removed by operation. In view of these facts
+it is not surprising that sometimes ovarian disorders abolish
+menstruation. An impoverished state of the blood, or nervous shock
+and strain, or constitutional debility may also interrupt the regular
+appearance of the menstrual discharge.
+
+The value of menstrual suppression as an evidence of pregnancy is
+not, however, to be discounted to the extent that we might expect.
+This is true because the ailments which lead to confusion are
+relatively infrequent, and also because they exhibit characteristic
+symptoms which are foreign to pregnancy. Often these symptoms are
+obvious to the patient herself; if not to her, they will be obvious
+to her physician. It is about the doubtful cases, naturally, that a
+professional opinion is sought, and on that account physicians are
+perhaps inclined to overestimate the difficulty women have in
+learning for themselves whether or not they are pregnant. As a matter
+of fact, it is unusual for a prospective mother to fail to reach a
+correct decision--a decision for which she relies chiefly upon the
+suppression of her menstrual periods.
+
+It is doubtful whether menstruation ever continues after conception
+has taken place. Instances in which the menstrual function is
+believed to persist are not uncommon, and yet in all probability the
+discharge regarded as menstrual has a different origin. In most cases
+it should be interpreted as meaning that there is some danger of
+miscarriage. Since miscarriage often occurs about the time a
+menstrual period would ordinarily be expected, there is unusual
+opportunity for confusing the symptoms. At all events women err much
+more frequently in suspecting that they are pregnant than in
+overlooking the condition. Indeed, pregnancy is not likely to be
+overlooked unless menstruation has been irregular or suppressed for a
+month or more previous to conception. Thus, in the case of nursing
+mothers in whom menstruation is already suppressed and who are,
+moreover, deprived of certain evidence that the breasts give,
+pregnancy may sometimes advance several months before it is
+recognized.
+
+_The Changes in the Breasts_.--Various sensations in the breasts
+are accepted by women as a reliable sign of pregnancy; thus
+throbbing, tingling, pricking, or a feeling of fullness will be
+mentioned by one mother or another as having given her the first
+intimation that she was pregnant. A few women also find their breasts
+become tender immediately after they have conceived; this may be so
+marked that they cannot bear pressure. But unless such symptoms are
+accompanied by definite, visible changes, they have no value as signs
+of pregnancy.
+
+About the end of the second month the nipples become larger and more
+erectile, and deepen in color. The pigmented, circular area of skin
+which surrounds the nipple, called the areola, also darkens. The
+shade that the areola assumes will vary according to the complexion
+of the individual, growing darker in brunettes than in blondes.
+Ultimately, within this pigmented circle a number of elevated spots
+appear about the size of a large shot. These spots betray the
+presence of tiny glands always located there which, on account of the
+better state of nutrition during pregnancy, grow larger, and
+generally become visible.
+
+Usually, after two menstrual periods have been missed the breasts
+increase in size and firmness, and often the veins which run just
+beneath the skin stand out conspicuously. Before very long it is
+possible to squeeze from the breasts a fluid which many persons
+believe to be milk, though it is really colostrum, a substance that
+resembles milk but very slightly. At first colostrum is a clear,
+white fluid, but in the later months of pregnancy it becomes yellow
+and cloudy.
+
+None of the changes in the breasts are absolutely characteristic of
+pregnancy; even the secretion of colostrum has been noted in
+association with various other conditions. Furthermore, as a sign of
+pregnancy the presence of colostrum is totally deprived of value in
+the case of a woman who has recently nursed an infant, for a small
+quantity of milk or colostrum often remains in the breasts for months
+after the infant is weaned. In general, however, women who have not
+been pregnant before should assume that they have conceived if, after
+missing a menstrual period, they note the characteristic changes in
+the breasts.
+
+_Morning Sickness_.--Soon after conception many women suffer
+from nausea and vomiting, especially on rising in the morning.
+"Morning sickness" usually passes off in a few hours, although it may
+be more persistent. Perhaps this manifestation occurs more frequently
+in the first than in subsequent pregnancies, but certainly one-half,
+and probably two-thirds, of all prospective mothers suffer from it.
+Usually the nausea begins just after a menstrual period has been
+missed, and ceases about the third month or a little later.
+
+But morning sickness is never counted an indication of pregnancy
+unless taken in conjunction with other symptoms, for individuals who
+are not pregnant may also suffer from nausea in the morning. On the
+other hand, a number of prospective mothers escape morning sickness
+altogether, and a few experience nausea at other times of day.
+
+_Disturbances in Urination_.--It is not an uncommon belief that
+some characteristic change occurs in the urine shortly after
+conception. But this is not true; at least no change is revealed by
+any method of analysis known at present. Yet there are symptoms
+associated with the passage of the urine which appear very promptly
+and prevail for several weeks. Chief among these is the desire to
+empty the bladder frequently; some patients also have difficulty in
+urination, and a few experience discomfort with it. All the bladder
+symptoms gradually disappear about the fourth month, but become
+prominent again toward the end of pregnancy.
+
+Since the inclination to empty the bladder more often than usual may
+be due merely to nervousness or to many other conditions, this
+symptom taken alone cannot be regarded as a definite sign of
+pregnancy. Indeed, it is mentioned, not because of its importance,
+but to point out that it is in no way connected with the kidneys, as
+patients are sometimes led to believe. It is a direct and natural
+result of pregnancy. Since the womb enlarges and tilts forward at a
+more acute angle than formerly, it presses against the bladder,
+giving the same sensation as when the bladder is distended with
+urine.
+
+Although the presumptive signs which we have considered by no means
+exhaust the list, all the others are totally untrustworthy. Each of
+the more reliable symptoms, as we have seen, must be accepted
+cautiously; but taken altogether, except in very unusual cases, they
+may be relied upon. _If, for example, menstruation has previously
+been regular and then a period is missed, the patient has good reason
+to suspect she is pregnant; if the next period is also missed and
+meanwhile the breasts have enlarged, the nipples darkened, and the
+secretion of colostrum has begun, it is nearly certain that she is
+pregnant; whether morning sickness and the desire to pass the urine
+frequently are present is of no importance._ But the most
+characteristic evidence, we must remember, is not available until the
+eighteenth or twentieth week; then the signs of pregnancy are
+unmistakable.
+
+THE DURATION OF PREGNANCY.--After the existence of pregnancy has
+become assured, perhaps the greatest interest centers about the date
+upon which the birth may be expected. Even to approach accuracy in
+this prediction the prospective mother must be familiar with certain
+facts which she will always observe, but which, unless she
+appreciates their importance early in pregnancy, she may fail to
+record or to remember. In a few cases, however, such exceptional
+information as knowing the date of conception does not lead to an
+absolutely accurate prediction. But the deviation from the rule will
+be understood only after we understand the rule itself, which is
+based upon what we accept as the average duration of human pregnancy,
+technically called the period of gestation.
+
+In a broad sense, the period of gestation for each variety of mammal
+is determined by the time required for embryonic development to reach
+the point where the young may live independently of the mother. This
+point is reached more quickly with small animals than with large. The
+mouse, for example, generally brings forth its young in three weeks,
+whereas the pregnancy of the elephant lasts two years. In human
+beings, counting from the time of conception to the time of delivery,
+pregnancy continues approximately 273 days. This number is merely an
+estimate calculated from hundreds of cases in which there was no
+question as to the underlying facts. Individual cases vary notably,
+and indicate that two women may become pregnant on the same day and
+yet not necessarily be delivered at the same date.
+
+Irregularities in the duration of pregnancy are not limited to man.
+Thus, while the mean period of gestation in the rabbit is thirty-one
+days, it may be either shorter or longer by as many as eight days.
+Similar variations occur in the pregnancies of all animals, and are,
+moreover, notably greater among larger animals, since for such
+animals the period of gestation is relatively long. For instance, the
+accurate observations of veterinarians indicate that the mean period
+of pregnancy in the cow is 285 days from the time of conception. This
+fact notwithstanding, a competent observer found that, of 160 cows,
+67 were delivered before the 280th day; 68 between the 280th and the
+290th day; and 25 after the 290th day. Although nothing unnatural was
+observed in any instance, the first animal was delivered 67 days
+before the last, and in 5 instances gestation continued 308 days.
+
+In ancient times it was believed that the duration of pregnancy was
+of even more uncertain length in man than in the lower animals; but
+since the eighteenth century thirty-nine weeks have been accepted as
+the average duration of the human pregnancy when reckoned from the
+day of conception. As this date is seldom known, it is most
+convenient to reckon from the first day of the last menstrual period.
+Estimated in this way its average duration is 280 days. As this
+period corresponds to ten menstrual cycles, physicians prefer to
+describe pregnancy as lasting 10 lunar months of four weeks each.
+This is equivalent to 9 calendar months, in terms of which its
+duration is popularly stated.
+
+THE ESTIMATION OF THE DATE OF CONFINEMENT.--Since pregnancy is not an
+absolutely fixed period, we possess no reliable means of predicting
+the exact day when it will end. The most satisfactory method of
+prediction consists in counting forward 280 days from the beginning
+of the last menstruation or, what gives the same result, counting
+backward eighty-five days from this date. _To make the calculation
+in the simplest way we count back three months and add seven
+days_; this addition is made because seven days generally
+represents the difference between three months and eighty-five days.
+If the last menstruation, for example, began on October 30th, we
+count back three months to July 30th and add seven days, which gives
+August 6th as the probable date of confinement.
+
+A prospective mother should remember that this prediction is no more
+than approximate. The calculation does not give the exact date of
+delivery more than four or five times in a hundred cases. It is
+accurate within a week in half the cases and within two weeks in
+four-fifths. We also know that delivery is somewhat more likely to
+occur after the expected date than before it. But perhaps we shall
+get the clearest idea of the accuracy of the rule, or better still
+of its inaccuracy, if we imagine twenty patients to have the same
+predicted date, all of them giving birth to mature infants. The
+chances are that only one of these patients will be confined upon the
+day predicted; nine will be confined before and ten after it. In all
+probability five of those who pass the predicted day will be
+delivered within a week and four others within the second week, while
+the twentieth patient will not be delivered until three weeks or more
+have elapsed.
+
+Such results clearly indicate our inability to make accurate
+predictions even though pregnancy is normal in every way. Whenever
+patients pass their expected date uneventfully, if they will bear in
+mind that the fault lies with the method of prediction and not with
+the pregnancy, they will often be saved anxiety. Frequently such
+discrepancies are attributable to a false assumption, for our rule
+always assumes that the conception took place immediately after a
+menstrual period. While this is generally true, the number of cases
+in which it occurs just before the period to be missed is by no means
+inconsiderable, and in these we should not expect pregnancy to end
+until two or three weeks after the day predicted by the rule.
+
+Occasionally patients know the precise day upon which conception took
+place, and prefer to estimate the day of confinement from that rather
+than from the beginning of the last menstruation. They may do so by
+counting back thirteen weeks from the day of conception; but this
+method also is subject to error for, as we have noted, the duration
+of pregnancy reckoned in this more exact manner is not constant. Such
+a calculation rarely offers any advantage over that made from the
+menstrual record.
+
+Another method of estimating the date of confinement is based upon
+the assumption that fetal movements are first perceived by the mother
+toward the eighteenth week of pregnancy; and in consequence twenty-
+two weeks generally elapse between quickening and the day of
+delivery. Although such a calculation is far from certain in its
+prediction, there are instances in which no other calculation can be
+made. A nursing mother, for example, may become pregnant before
+menstruation has been reestablished. Under these circumstances,
+obviously, the date of confinement cannot be estimated in the
+ordinary way, and it is then especially important to know the first
+day on which the fetal movements were felt. Furthermore, it is
+helpful to note this date in every case, since it serves, if for
+nothing more, to confirm the prediction made from the menstrual
+record. Besides the two methods just described, which are alike in
+that they require the patient herself to make the necessary
+observations, there is a third method of estimating how far pregnancy
+has advanced, by which the physician is enabled to draw his own
+conclusions. This method is based upon the fact that the womb
+enlarges from month to month during pregnancy at a constant rate. Up
+to the end of the third lunar month it cannot be felt through the
+abdominal wall; but in the course of the fourth month, on account of
+its size, it must rise into the abdominal cavity. At the beginning of
+the sixth month the top of the womb is at the level of the navel, and
+at the ninth reaches the ribs. The diaphragm then prevents the womb
+from going higher; and two or three weeks before the end of pregnancy
+it drops several inches, causing a change in the figure which is
+noticeable to the patient, since her skirts hang somewhat lower than
+before. From this time on she is more comfortable, because the lungs
+are not crowded, and there is less interference with breathing.
+
+These alterations in the position of the womb indicate very
+satisfactorily the month to which pregnancy has advanced, but not the
+week and much less the day. They do not afford a more accurate means
+of predicting the date of confinement than does quickening. The
+evidence gained from the position of the womb, like that afforded by
+the beginning of quickening, generally confirms the prediction made
+from the menstrual history; it serves only occasionally to correct
+it.
+
+PROLONGED PREGNANCY.--Since birth does not occur in many cases until
+the predicted date has been passed, it will be helpful even at the
+cost of repetition to sum up what we know in explanation of such
+unfulfilled predictions. They are to be explained sometimes by
+uncertainty as to the beginning of pregnancy, as for example by the
+supposition that conception took place shortly after the last
+menstrual period, whereas it actually occurred two or three weeks
+later. In a few instances, however, errors of observation or of
+calculation will not account for false predictions.
+
+It is generally admitted that second pregnancies average somewhat
+longer than first pregnancies; one series of statistics indicates
+that the duration increases slightly with each pregnancy up to the
+ninth and decreases after that. Pregnancy is protracted more
+frequently in healthy women than in those who are not, and again more
+frequently in those who are inactive than in those who work. With
+twins, contrary to the popular belief, pregnancy is apt to end
+before, not after, the expected date. The sex of the child, in all
+probability, has no influence upon the duration of pregnancy.
+
+As we might expect, individuality is also a factor in this problem.
+Thus, the period of gestation with some women is regularly longer,
+with others habitually shorter than the accepted average. Until
+experience has demonstrated their existence, generally, such
+peculiarities are overlooked. But occasionally they may be detected
+from knowledge of the interval between the menstrual periods; an
+unusually long interval between them, for example, would lead us to
+anticipate a protracted pregnancy.
+
+Any delay after the expected date of birth has arrived taxes the
+patience of the prospective mother. The fact, however, that more than
+280 days have passed since the last menstruation, does not
+necessarily mean that a patient has gone "over time." Such a question
+can be decided solely from the weight and length of the child. Judged
+in this way, comprehensive statistics indicate that once in several
+hundred cases pregnancy may be fairly called prolonged. Even in these
+rare instances an examination about the time of the predicted date
+makes it clear whether pregnancy should be artificially ended or be
+allowed to proceed to its natural conclusion.
+
+
+
+
+CHAPTER II
+
+
+THE DEVELOPMENT OF THE OVUM
+
+The Germinal Cells--Fertilization--The First Steps in Development--
+The Reaction of the Uterus--The Amniotic Fluid--The Placenta--The
+Umbilical Cord.
+
+Pregnancy, besides changing the external form of the body, causes
+sensations--as for example those due to fetal movements--which are so
+distinctive that they cannot escape notice. These obvious evidences
+of approaching motherhood naturally lead thoughtful women to wonder
+about the hidden mechanism of development, a mechanism which, of
+itself, causes no sensation whatever. It is for this reason, perhaps,
+that a prospective mother's imagination is so apt to be unusually
+active, often picturing absurd conditions as responsible for one
+symptom or another. Those who give free play to the imagination in
+regard to the formation and progress of the embryo are pretty certain
+to arrive at erroneous if not grotesque conclusions; for example,
+they may attribute a protracted pregnancy to the child's having grown
+fast to the mother, a situation that cannot arise.
+
+Of course it is not essential that a prospective mother should
+understand what is happening within the womb. And upon those who
+prefer to be ignorant of the mechanism of development I would not
+urge another point of view, for not ignorance but the unchallenged
+acceptance of "half-truths" and of totally incorrect explanations is
+the chief source of harm. On the other hand, my own experience has
+taught me that women who wish to know about development should be
+told the truth. In accord with this is the fact that I never have
+more satisfactory patients than those who have previously been
+trained nurses and who, in preparing for that profession, received
+instruction concerning the reproductive function of human beings.
+
+A description of development, in order to be perfectly clear, must
+begin with a word about the fundamental structure of the adult body.
+Everyone knows that the various parts of the body perform different
+functions; but not everyone, perhaps, realizes that, in spite of
+their different functions, all the organs of the body are composed of
+similar structural units, known as cells. Of course, cells are
+definitely arranged according to the use for which the tissue that
+they chance to compose may be designed; they have, moreover,
+distinctive individual peculiarities which can be easily recognized
+under the microscope; but the essential features of the cells remain
+the same, wherever they may be located. That is to say, each cell is
+a minute portion of living matter, or protoplasm, separated from its
+neighbors by a partition, the cell-membrane; each has its own seat of
+government, the nucleus, located near its center; and each, to all
+intents and purposes, leads an individual existence.
+
+THE GERMINAL CELLS.--Many of the cells in the human body are able to
+produce others of their kind. This they do virtually by growing and
+splitting in half; cell-division, as this splitting is called, really
+represents reproduction reduced to the simplest terms. Most cells can
+do no more than produce units like themselves. The bodies of women
+contain, however, a type of cell which possesses a far more wonderful
+power. Provided the requisite conditions for such development are
+met, these cells are capable of developing into human beings. Each of
+these remarkable units is called an Ovum, or egg-cell, and represents
+one variety of the germinal cells. But the other variety, represented
+by the Spermatozoon and developed only in the male sex, is also
+required for the production of a human being.
+
+Every ovum originates in the ovaries. These are organs peculiar to
+women, having the size and shape of large almonds, and placed in the
+lower part of the abdominal cavity. Though the ovaries are two in
+number, one alone is sufficient for every requirement of health. It
+has been estimated that the ovaries together contain at the time of
+birth about 40,000 ova, distributed equally between them. Since less
+than 500 ova are required to insure regularity in the menstrual
+function, it is clear that, if the surgeon finds it necessary to
+remove one of the ovaries, the other will provide abundantly for
+menstruation and for the bearing of children. Although every ovum
+that will be produced as long as a woman lives has already sprung
+into existence by the time she is born, not a single one ripens for
+from twelve to fifteen years. The ripening process begins about the
+time of puberty, and, unless suspended through the occurrence of
+pregnancy, continues until the menopause. During this period, which
+is also characterized by the periodical appearance of menstruation,
+one ovum ripens each month; sometimes, though rarely, several ripen
+at once, and this tendency is partly responsible for twins.
+
+The human ovum is a tiny structure, measuring about 1/125 of an inch
+in diameter. With the naked eye it can barely be seen; magnified by
+the microscope it appears as a little round bag made of a transparent
+membrane. Briefly described, the ovum is a single cell. That is, it
+belongs to the simplest class of anatomical structures, and is one of
+the millions upon millions of units that make up the body. It
+contains a nucleus surrounded by nutritive material, the yolk. Yet
+the quantity of yolk is exceedingly small. In this particular the
+human ovum differs notably from the egg of birds, as it does also in
+that it lacks a shell. Obviously, a shell would not only be useless
+to an embryo developing within the body of its parent, but would shut
+off the nourishment, which, since the ovum contains so little, must
+necessarily be provided by the mother.
+
+When the ovum has ripened, it becomes detached from the ovary, and
+enters a fleshy tube about the size of a lead pencil, known as the
+oviduct. There are two of these tubes, one running from the
+neighborhood of each ovary; both enter the uterus, but on opposite
+sides. The ovum travels down the tube which corresponds to the ovary
+where it originated. The journey is fraught with momentous
+consequences, for it is during this passage through the oviduct that
+the fate of the ovum is determined. If it is to develop into a living
+creature, a great many conditions must sooner or later be fulfilled;
+but there is one which must be promptly satisfied. Shortly after
+leaving the ovary the ovum must receive the stimulus to live and
+grow; otherwise it will quickly wither and die. This vital stimulus
+can be imparted only by the spermatozoon.
+
+The male germinal cell is like the female cell in the possession of a
+nucleus; in other respects it is very different. Longer but much
+narrower than the ovum, the tiny arrow-shaped spermatozoon is
+particularly distinguished by its active motility, for it has a tail
+that propels it. The human male cell must travel some distance to
+reach the point where it can meet a ripe and vigorous ovum; and since
+the journey is not without danger to its life, Nature has provided
+that exceedingly large numbers of the male cells shall be deposited
+in the vagina at the time of the marital relation. In this way, it is
+made sure that some of them will travel up through the uterus and
+oviducts, arriving in the neighborhood of the ovaries.
+
+FERTILIZATION.--Convincing observations upon the lower forms of life,
+especially upon fishes, have shown that when the germinal cells come
+near to each other, the ovum attracts the spermatozoon. The power of
+attraction which the ovum exerts may be likened, most simply, to the
+influence of a magnet upon iron-filings. While there has been no
+opportunity to observe such attraction between the parent cells of
+human beings, its existence is not open to doubt. And it is
+practically certain that these cells meet in the oviduct, even in
+that portion of it which receives the ovum just as it leaves the
+ovary. Thither a number of the male cells have traveled by their own
+activity; several come in contact with the ovum and one, but only
+one, actually enters it. Almost at the moment when they touch, the
+two cells unite so intimately that all trace of the spermatozoon is
+lost. Fertilization of the ovum, as this event is scientifically
+termed, has as its main purpose the uniting of the nucleus of a male
+germinal cell with the nucleus of the female germinal cell. This
+detail has been carefully studied; we know that the nuclei quickly
+blend into one, and that the particles of living matter contributed
+by the male animate the female cell with a new and wonderful
+activity.
+
+In our every-day way of speaking, fertilization means conception; it
+is the instant in which a living being begins its existence. There is
+no longer the slightest excuse for confusion regarding the period at
+which the life of the unborn child begins. Before the significance of
+fertilization was understood, it was perhaps not unreasonable to
+believe that life began with quickening or about the time the fetal
+heart-sounds could be heard. But now we must acknowledge that both
+these ideas were incorrect. The animation of the ovum at the moment
+of conception marks the beginning of growth and development which
+constitutes its right to be considered as a human being.
+
+Individuality, hereditary traits, sex--all these, we may be sure--are
+unalterably determined from the moment of conception. The germinal
+cell forms the total contribution of the male parent to pregnancy;
+therefore no other opportunity for him to influence his progeny
+presents itself, and the substance which enters the ovum at the time
+of fertilization must be the basis of inheritance from the father. It
+is equally true, as we shall see in the next chapter, that the
+nucleus of the ovum and the nucleus alone transmits maternal
+qualities. The material which conveys inheritable characters can be
+seen and has been identified in both germinal cells; from each of
+them the fertilized ovum derives equal amounts. As the parental
+nuclei unite, the material which they contain intermingles and
+establishes a new being; to attain full development, it requires
+nothing further from the father, and nothing save nourishment from
+the mother.
+
+THE FIRST STEPS IN DEVELOPMENT.--Although the identity of the
+spermatozoon is lost at the moment of fertilization, its influence
+just then begins to be asserted. In the fertilized ovum the dawn of
+development is shown at first by unusual activity within and later by
+alterations upon the surface. Before very long the circumference of
+the cell becomes indented as if a knife had been drawn around it, and
+shortly two cells appear in place of one. These two cells in turn
+divide, yielding four cells which grow and divide into eight. In this
+manner division follows division until a multitude of cells have
+sprung into existence, all of which cling together in the shape of a
+ball. Development always proceeds in the same orderly way; evidently
+it is governed by fixed laws which decree that the mass shall remain
+for a while in the form of a ball, though the ball, at first solid,
+soon becomes hollow.
+
+While these changes are taking place the growing ovum is carried down
+the oviduct a distance of four to six inches and finally comes to
+rest in the uterus, where it is to dwell during the months necessary
+to its complete development. The time consumed by this journey cannot
+be measured accurately; it may be as short as a few hours or as long
+as several days, but in all probability it is never longer than a
+week. Although the element of time is uncertain the method of
+transmission is well understood. Of its own accord the ovum can move
+after fertilization no better than before; it is never capable of
+moving itself. The active agent of transportation is the oviduct,
+which has been fitted for this purpose with millions of short, hair-
+like structures that project into its interior. These are closely set
+upon the inner surface of the oviduct; their outer ends are free and
+continually sway to and fro like a wheat field on a windy day; and by
+their motion they create a current in the direction in which the ovum
+should move, namely, toward the uterus. While passing through the
+oviduct, the ovum has no attachment whatever to the mother, yet
+development is going on all the time. It is thus made perfectly clear
+that development is not directed by the parent. This independence of
+the parent, though it continues to be one of the characteristic
+features of the development of the ovum, shortly becomes less
+evident, for communication is set up between the mother and the ovum
+as soon as it reaches the uterus. Unless we were warned, we might
+easily misinterpret the significance of this attachment to the
+parent. It does not permit the mother, for instance, to influence the
+mind or character which the child will have. The purpose of the
+attachment is twofold, namely, to anchor the ovum, and to arrange
+channels by which, on the one hand, nutriment may reach the embryo,
+and, on the other, its waste products may return to the mother. The
+mother may influence the nutrition of the fetus; but she cannot
+determine the kind of brain or liver her child will have; neither for
+that matter can she alter the development of any portion of the
+embryo.
+
+After its entrance into the cavity of the uterus prepared to receive
+and protect it, the mass of cells sinks into the soft, velvety lining
+of the organ. Here it is entirely surrounded by tissue which belongs
+to the mother. But just before implantation takes place the
+architecture of the ovum is modified in such a way as to indicate the
+trend of its subsequent development. We left it, a hollow ball
+passing down the oviduct; had we examined the sphere more closely we
+should have found its wall composed of a single layer of cells. At
+one spot, however, the wall soon thickens. The thickening is due to a
+specialized group of cells which gradually grows toward the hollow
+center of the ball. A little later, if we study the structure as a
+whole, we find it a small, distended sac, from the inner surface of
+which hangs a tiny clump of tissue. The clump of cells within and the
+inclosing sac as well are both requisite to the ultimate object of
+pregnancy; yet they fulfill very different purposes. The clump within
+will mold itself into the embryo; the inclosing sac will make
+possible the continued existence and growth of the embryo by securing
+and conveying to it nourishment according to its needs. These two
+structures, which from now on constitute the ovum, can best be
+considered separately and in the order of their development. We shall
+therefore first study the sac and in the next chapter the embryo.
+
+For a time after this sac, or ball, as you may choose to think of it,
+becomes implanted in the uterus, every part of its wall shares in the
+responsibility of procuring nourishment for the embryo. On this
+account the wall, or capsule, is for several weeks the most
+conspicuous part of the ovum. Its position is naturally advantageous,
+for, since it forms the outermost region of the structure and comes
+into immediate contact with the tissues of the mother, it has the
+first opportunity to seize and appropriate nutriment. Consequently,
+while there is still relatively little development in the embryo, the
+capsule of the ovum gives evidence of rapid extension; the wall
+becomes thicker, and the circumference of the sac increases. The
+significant thing about this growth, however, is the fact that it
+does not progress evenly. At some points cell-division is more active
+than at others, with the result that the surface of the ovum speedily
+loses its smooth, regular outline. Projections from the capsule
+appear; they increase in number and in length; and by the end of four
+weeks the ovum, as yet less than an inch in diameter, resembles a
+miniature chestnut-burr. To make the comparison more accurate, we
+must imagine such a burr covered with limp threads instead of rigid
+spines.
+
+These projections, the so-called Villi, push their way into the
+mucous membrane of the uterus and serve a two-fold purpose. One of
+their functions is to fix the ovum in its new abode; and, though the
+attachment is not at first very secure, it becomes stronger in the
+course of time and is capable of withstanding whatever tendency the
+activity of daily life may have to loosen it. The other, and equally
+important, task of the villi, the majority of which dip into the
+mother's blood, is to transmit substances to and from the embryo.
+
+We have traced thus far the earliest steps in the development of the
+ovum. One portion, we observed, was promptly set apart for the
+construction of the future child; this favored portion became
+inclosed by all the rest of the ovum, which has a more or less
+spherical form and is technically called the fetal sac. The first
+duty of the sac is to take root in the womb, and the second, no less
+vital, is to draw nourishment from the mother. But neither of these
+functions can be performed without the participation of the uterine
+mucous membrane, the soil, as it were, in which the ovum is planted.
+We must now learn how the maternal tissues assume the responsibility
+placed upon them.
+
+THE REACTION OF THE UTERUS.--The womb, which is small before
+marriage, is converted by pregnancy into the largest organ of the
+body. The virginal uterus, shaped somewhat like a pear, and placed
+with apex downward, is carefully protected within the bony basin
+between the hips, which is commonly called the Pelvis. The upper and
+larger part of the organ, known as the body, lies at the bottom of
+the abdominal cavity; the lower part, the neck, projects into the
+vagina. The cavity inside the womb communicates above with the two
+oviducts and terminates below in a canal which runs through the neck
+and opens into the vagina by an orifice known as the mouth of the
+womb.
+
+Pregnancy modifies every portion of the womb in one way or another;
+but the most profound alterations occur in the body, in the cavity of
+which the ovum has come to rest. During the forty weeks of gestation
+the organ grows in weight from two ounces to as many pounds; from
+three inches in length it increases to fifteen inches; and its
+capacity is multiplied 500 times.
+
+The mucous membrane which lines the cavity of the uterus responds to
+the stimulus of pregnancy in a characteristic manner and with a
+single purpose, namely, to promote the development of the ovum. In
+connection with menstruation we noted that this membrane periodically
+prepares for the reception of an ovum. And if the expected ovum has
+been fertilized, its arrival is followed by arrangements for its
+protection and nutrition which are far more elaborate than the
+preparations for its reception. Within a few weeks the mucous
+membrane becomes half an inch thick, that is, about ten times thicker
+than it was; and all the elements entering into its composition,
+become unusually active. The blood-vessels are congested; the glands
+pour out a more elaborate secretion; and certain cells lay up a
+bountiful store of material to be drawn upon in the formation of the
+embryo and the building up of the structures that promote its
+development.
+
+The ovum is as likely to find a resting place at one spot as another
+upon the surface of the uterine mucous membrane. The whole of that
+surface has been made ready to receive it; yet the area actually
+required to imbed the tiny object is extremely small. As the ovum
+escapes from the oviduct and enters the womb, it is smaller, in all
+probability, than the head of a pin. For at least a week after its
+coming, diligent search is necessary to find the site of
+implantation. Insignificant as it is at first, however, the region of
+implantation later becomes very prominent, for it undergoes a
+transformation that the rest of the mucous membrane does not share.
+That is to say, it becomes the point of attachment of the Placenta,
+an organ that has the very important function of drawing upon the
+resources of the mother's blood. As the ovum sinks into this
+especially prepared bed, the villi are formed. They break open the
+adjacent capillaries of the mother, thus diverting her blood from its
+accustomed course. The blood collects in microscopic lakes in contact
+with the capsule of the ovum, and from them flows back into the
+mother's veins. Through the veins it returns to her heart, by which
+it is distributed through the arteries to the various regions of the
+body. The tiny lakes, in which the villi hang, are thus made a part
+of the mother's circulation and as such are regularly replenished
+with purified blood. By this means the ovum receives a rich supply of
+nutriment, and as a natural consequence its growth is rapid.
+
+Before very long the diameter of the ovum is greater than the depth
+of the mucous membrane which surrounds it. Consequently that part of
+the membrane which covers it is pushed into the uterine cavity, as
+the ground is raised by a sprouting seed. Growth continues, the
+bulging increases, and extensive alterations are wrought both in the
+womb and in the capsule of the ovum. One of these alterations will be
+more easily understood if we still think of the ovum as a seed, for
+it grows away from its roots just as plants do. Most of the capsule,
+therefore, is removed step by step farther from its source of
+nourishment, for the maternal blood-vessels do not follow the
+expanding sac but retain their original position at its base. Partly
+on account of the lack of nutriment thus occasioned and partly on
+account of the distention caused by the contents of the sac, atrophy
+occurs in the distant portions of the sac's wall. As a final result
+of these two factors, the maternal tissue which covers the ovum
+becomes thinned and stretched; it is pushed entirely across the
+uterine cavity; and by about the twentieth week meets the opposite
+side of the cavity, to which it becomes adherent. Subsequently, the
+sac which incloses the embryo becomes everywhere fastened to the
+inner surface of the uterus and completely fills the uterine cavity.
+
+THE AMNIOTIC FLUID.--The great enlargement of the uterus which is so
+marked a characteristic of the latter part of pregnancy is due in a
+measure to the luxuriant blood-supply, for better nutrition always
+causes growth. In a far larger measure, however, it is due to
+distention for which the product of conception is responsible. Beside
+the fetus the inclosing sac also contains a considerable quantity of
+fluid. This fluid, called "The Waters" by those who have no special
+knowledge of anatomy, is technically designated as the Amniotic
+Fluid.
+
+In the earlier months of pregnancy the amniotic fluid is not
+abundant; later it increases rapidly, so that by the end of the
+period it measures about a quart, and frequently even more. The
+slightly yellow amniotic fluid is itself clear, but small particles
+of dead skin and other material cast off from the surface of the
+child's body are floating in it, and may cause turbidity. The absence
+of odor supports the view that this fluid is not the child's urine.
+The evidence thus far adduced, though not absolutely conclusive,
+gives good reason to believe that "the waters" are secreted by the
+inner side of the sac which incloses the fetus. Very early in
+pregnancy this sac becomes a double-walled structure; and, though its
+layers are intimately blended, and together measure not more than
+1/16 of an inch in thickness, with a little care they can be
+separated. The outer layer, which comes in contact with the inner
+surface of the uterus and has to do with the matter of nutrition, is
+called the Chorionic Membrane; the inner, the so-called Amniotic
+Membrane, is much the stronger and is devoted to the protection of
+the embryo, which it completely surrounds with fluid, at the same
+time retaining the fluid within set bounds.
+
+The amniotic fluid performs many important duties. Perhaps the first,
+in point of time, is to provide sufficient room for the embryo to
+grow in. Later, as the fluid increases, it permits the fetus to move
+freely, and yet renders the movements less noticeable to the mother.
+Again, the amniotic fluid prevents injuries that might otherwise
+befall the child in case the mother wears her clothing too tight.
+Harmful as the practice of tight-lacing during pregnancy is, it does
+not, thanks to the presence of the amniotic fluid, result in the
+disfigurement of the child. For the same reason a blow struck upon
+the abdomen, as in a fall forward, is not so serious as might be
+thought, since the fluid, not the child, receives the force of the
+impact. Some physicians believe that the fetus swallows the amniotic
+fluid and thus secures nourishment. The fluid also serves to keep the
+fetus warm; or, to be more exact, protects it from sudden changes in
+the temperature of the mother's environment. Normally the temperature
+of the fetus is thus kept nearly one degree higher than the
+temperature of the parent.
+
+Ultimately, the amniotic fluid assists in dilating the mouth of the
+womb, which remains closed until the beginning of the process that
+terminates with birth. The uterine contractions at the onset of labor
+compress the fluid; in turn the fluid attempts to escape but is held
+in check by the amniotic membrane, which it drives into the canal
+leading from the uterine cavity to the vagina. Acting like a wedge,
+the fluid gradually pushes the mouth of the womb wider and wider
+open, until it is large enough for the child to pass. The sac usually
+ruptures when that point is reached, the fluid escapes, and in due
+time the child is born. This is followed within half an hour by the
+extrusion of a mass of tissue--in reality the collapsed fetal sac--
+which in every language, so far as I know, is named the After-Birth.
+An examination of this tissue at the time of delivery repays the
+physician, for it is important to ascertain that none of it has been
+left in the uterus. Our interest at present, however, is to learn how
+the after-birth has assisted toward the growth of the child.
+
+THE PLACENTA.--The after-birth has puzzled scientists as well as the
+laity, and not until comparatively recent times have its origin,
+structure, and use been satisfactorily explained. Its meaning
+profoundly interested primitive men and stimulated their imagination
+scarcely less than the mystery of conception. Some uncivilized tribes
+believed that the after-birth was animated like the child;
+consequently they spoke of it as "the other half," and often saved it
+to give to the child in case of sickness. But generally the after-
+birth was buried with religious ceremony, and was occasionally
+unearthed later to discover whether the woman would have other
+children; the prophecy was made according to the manner of
+disintegration or some other equally absurd circumstance.
+
+The after-birth consists of a round, fleshy cake, the placenta, to
+which two very essential structures are attached. One of these,
+running from one surface of the cake, is a rope-like appendage, the
+umbilical cord, which links the placenta with the fetus. The other,
+attached to the circular edge of the cake, is a thin veil of tissue,
+in some part of which a rent will be found. Now, if we lift the
+margin of the rent, we shall see that the veil and the cake together
+form a sac which we are holding by the opening. This aperture through
+which the fetus passed, and it was really made for that purpose, was
+formerly placed over the mouth of the womb; the sac itself, distended
+by the fetus and the amniotic fluid, was fastened everywhere to the
+inner surface of the womb.
+
+It is plain that we have now in our hands the fetal sac, the
+development of which we have already traced from the beginning. The
+wall of the sac, it will be recalled, was originally of the same
+formation throughout; but when the ovum became imbedded in the womb,
+that part of its capsule which remained in permanent contact with the
+mother's blood underwent special development, whereas the rest of the
+capsule gradually pushed away from its primary position and, becoming
+stunted in its growth, even lost to some degree the development it
+had attained. This latter portion, the veil that passes from the edge
+of the placenta, is formed of the two membranes we have mentioned,
+namely, the chorion and the amnion.
+
+The placenta is, for the most part, a highly developed portion of the
+chorionic membrane, which became specialized simply because it
+happened to receive the best supply of blood. At the time of birth
+the placenta measures nearly an inch in thickness, is as large around
+as a breakfast-plate, and generally weighs a pound and a quarter,
+that is, approximately one-sixth of the weight of the child. This
+relation between the weight of the placenta and of the child is
+regularly maintained; therefore, the larger the child the larger the
+placenta associated with it.
+
+The placenta has two surfaces, easily distinguished from each other.
+The raw maternal surface was formerly attached to the inside of the
+uterus; the fetal surface, covered by the amniotic membrane, was in
+contact with the amniotic fluid. Across the fetal surface run a
+number of blood-vessels containing the child's blood, converging
+toward a central point at which the umbilical cord is inserted. The
+point at which the cord is attached affords the simplest means of
+distinguishing the two surfaces of the placenta.
+
+Our knowledge as to how the exchange of food and excretory products
+between mother and child is carried on by the placenta has been
+gained chiefly through the microscope. The oldest medical writings,
+as we might suppose, express very fanciful ideas regarding the nature
+of embryonic development and the means by which it is made possible;
+no rational view of these matters could exist until the circulation
+of the blood was described by William Harvey in 1628. After this
+epoch-making revelation, it was accepted as true that the mother's
+blood entered the unborn child and returned to her own system. But
+that view eventually became untenable, for it was proved conclusively
+that there is no communicating channel between the two. For years
+after that, it was believed that before birth the womb manufactured
+milk to sustain the child, just as the breasts do afterwards; but
+this theory also was disproved; and, as I have said, only by the use
+of the microscope have we learned the truth about fetal nutrition.
+
+When thin slices of the placenta are magnified they are found to
+contain countless numbers of tiny, finger-like processes; these are
+the villi, and they constitute the major portion of the organ. The
+villi seen in a mature placenta are the same as those which projected
+from the capsule of the young ovum, but not these alone, for many
+branches have sprouted from the original projections. The primary
+trunks with all their branches hang from the capsule of the ovum and
+extract nutriment from the mother's blood which surrounds them, just
+as the roots of a tree extract it from the soil.
+
+The interchange of material between mother and child as carried on in
+the placenta can, perhaps, be made clearer if we compare one of the
+trunks and its branching villi to a human forearm, hand, and fingers.
+The hand, we will imagine, is held in a basin of water, in which, by
+turning on a spigot and leaving the outflow unstopped, we have
+arranged that the water changes constantly. In terms of this
+illustration, the water corresponds to the mother's blood, rich in
+oxygen, mineral matter, and all other kinds of essential nutriment;
+and the fingers are the villi. The blood-vessels in the fingers, to
+go a step farther, represent the blood-vessels which exist within the
+villi, connecting with the umbilical cord, and passing by that route
+to the body of the child. The blood which thus circulates through the
+villi, it is important to emphasize, is the child's blood; it cannot
+escape through the coating of the villi, just as our blood cannot
+escape through the skin of the fingers. Similarly, the mother's blood
+cannot enter the child; the two circulations are absolutely separate
+and distinct.
+
+It must be noticed, moreover, that the maternal blood not only brings
+to the surface of the villi everything the child needs, but it also
+takes away the waste products of fetal life. Let us select one of the
+foodstuffs necessary for the unborn child, and follow its course so
+far as it relates to fetal nutrition. The mother's blood brings
+sugar, for example, from her intestinal tract to the surface of the
+villi; through the coating of the villi the sugar passes into the
+fetal blood, is carried to the fetal heart, and distributed to the
+various fetal organs. They burn it, deriving heat and energy, and in
+return give off waste products, namely, carbonic acid gas and water,
+which are taken up by the fetal blood, borne back to the placenta,
+and pass again through the coating of the villi into the mother's
+circulation. These waste products are then transported to the
+mother's lungs and to her kidneys, and are finally thrown off from
+her body. Before the child is born, therefore, the placenta, which is
+an aggregation of villi, acts as its stomach, intestines, lungs, and
+kidneys.
+
+In every pregnancy the placenta serves in this way as an organ of
+nutrition, arranging for the passage of food from the mother's blood
+to the fetal circulation. Occasionally, it is interesting to observe,
+the placenta performs a very different function, namely, the
+protection of the unborn child from diseases that may attack the
+mother. It is able to afford such protection, because the coating of
+the villi is not permeable to all sorts of substances. In order to
+pass through their walls, material must be in solution; solid bodies,
+therefore, are denied admission to the fetal circulation. The most
+significant result of this restriction is, perhaps, that so long as
+the coating of the villi remains intact and healthful, bacteria
+cannot gain access to the unborn child. Since in health there are no
+bacteria in the mother's blood, this fact has no bearing upon the
+average pregnancy; but in those exceptional cases in which typhoid
+fever or some other infectious disease appears during pregnancy, it
+is gratifying to know that Nature has provided an unusual defense
+against infection of the unborn child.
+
+That we do not know all about the interchange of substances between
+mother and child must be admitted; but the essential facts, and they
+alone are of interest here, have been established beyond contention.
+There is no doubt whatever that the mother's blood surrounds the
+placental villi but never enters the child. The fetal blood, on the
+other hand, is first in the child's body, then in the villi, and then
+returns to the child again. It never enters the blood-vessels of the
+mother but passes to and from the placenta as long as pregnancy
+lasts.
+
+THE UMBILICAL CORD.--This rope-like structure, familiarly known as
+the navel-string, which connects the placenta and the fetus, is
+approximately twenty inches long; its length, therefore, is
+sufficient to permit the newly born child to lie between the mother's
+knees while the placenta remains attached to the womb. The cord is
+about the thickness of the thumb and contains three blood-vessels,
+all filled with fetal blood; in two of them the current is directed
+toward the placenta, the third carries the blood back to the fetus
+after it has circulated through the placental villi. In the cord the
+vessels lie near together and are encased in a jelly-like substance
+that protects them from injury.
+
+So far as is known; the umbilical cord performs no service other than
+to link the blood-vessels in the placenta with those in the fetus.
+Simple as this may seem, it is of paramount importance in maintaining
+the life of the fetus, for compression of the vessels in the cord
+would shut off its nutriment. Against such accident, however, perfect
+provisions have been made; both the amniotic fluid and the jelly-like
+substance which surrounds the vessels are safeguards which
+effectually protect the circulation from pressure that might
+interrupt it.
+
+Frequently, prospective mothers are told they must not "reach up" for
+fear the cord will become entangled. Such a precaution is quite
+unnecessary. No matter what the mother does, or does not, the cord
+will be found around the child's neck at the time of birth in one of
+every three cases. It is not difficult to understand how this
+happens. The cord is longer than the uterine cavity and must fall in
+coils toward the bottom of it. Now, since the fetus is free to move
+it enters and withdraws from these loops, many times, in the course
+of pregnancy. Finally, when it takes up a position head downward, as
+it nearly always does, the head is the part of the fetus which passes
+through the coil, should one happen to lie in its path. After the
+head is delivered the physician always feels about the neck to
+discover whether a loop of cord is there. If it is, he can release it
+easily. This condition, since it occurs so frequently and since it so
+rarely produces harmful consequences, should not be considered
+unnatural.
+
+After the child is born, the physician cuts the cord, and in due time
+the after-birth is expelled through the same passage as was the
+child. The expulsion of the after-birth frees the mother of all the
+tissue derived from the growth of the ovum, for the intricate
+mechanism that served to nourish and protect the embryo was almost
+entirely developed from the ovum itself. It is a remarkable provision
+of Nature that very little of the mother's tissue is cast off at the
+end of pregnancy; and even this small portion is promptly replaced.
+By about the sixth week after delivery, the wound which was made by
+the separation of the fetal sac has completely healed. Meanwhile the
+mucous membrane that underwent elaborate preparations to receive the
+ovum, the cavity that was adjusted to its growth, and the muscle
+fibers that were strengthened to insure its safe entry into the world
+have all regained their original state. Except for the activity of
+the breasts, the mother is left in the same physical condition as
+before she became pregnant.
+
+
+
+
+CHAPTER III
+
+
+THE EMBRYO
+
+The Development of Form--The Determination of Sex--Twins--The Rate
+of Growth--The Newborn Infant--Heredity--Maternal Impressions.
+
+The new human being begins existence, as I have shown, as soon as the
+ovum is fertilized, though at that moment it consists merely of a
+solitary cell formed by the union of the two parental cells. From a
+beginning relatively simple the human body develops into the most
+complex of living structures; and, startling as it may appear to be,
+it is demonstrably true that every one of the millions of cells which
+compose an adult has descended from the ovum. Furthermore, the
+individual himself is not the entire progeny of the ovum; the
+placenta and the membranes dealt with in the preceding chapter, we
+saw, were also derived from that same source. They possess only a
+transitory importance, to be sure, and to most persons they are less
+interesting than the embryo, yet we gave them consideration before
+discussing its growth because the manner in which the ovum becomes
+attached to the womb and draws nutriment from the mother primarily
+determines the fate of a pregnancy.
+
+Now that we have become familiar with the arrangements for the
+protection of the embryo, we are prepared to learn how it develops,
+and may accept the phrase, embryonic development, to cover the whole
+period of existence within the womb. In a more technical sense,
+however, the use of the term _embryo_ is limited to the first
+six weeks of pregnancy and designates the condition of the young
+creature before it has acquired the form and the organs of the
+infant; after that time the unborn child is called a _fetus_.
+Embryonic development, therefore, in the strictest sense of the term,
+chiefly involves the shifting of various groups of cells and the
+bestowal upon them of different kinds of activity. During this period
+comparatively slight growth takes place. By about the twentieth week,
+the house, it may be said, is set in order; and there follows a
+period marked by the rapid growth of the fetus.
+
+THE DEVELOPMENT OF FORM.--A very old explanation of embryonic
+development was that the process consisted altogether in growth.
+According to that view the embryo lay curled up in the egg; at the
+outset it was equipped with organs, limbs, features, and all the
+other bodily structures found in an adult. In order that the ovum
+might be transformed into a mature infant, only unfolding and growth
+were required. After the microscope came into use, however, so simple
+an explanation could no longer be accepted. Scientists soon realized
+that the embryo did not exist "ready made" in the ovum, which, even
+when magnified, failed to bear the faintest likeness to a human
+being.
+
+Although the microscope made impossible this very simple explanation,
+it gave in return a truer, if more complex, account of the
+transformation from egg to offspring. By this means it has been
+definitely proved that the ovum multiplies rapidly after it has been
+fertilized, and becomes, as was explained in the preceding chapter, a
+sac-like structure within which hangs a tiny clump of tissue. This
+inner mass of cells forms the embryo.
+
+It has proved a difficult task to secure very young human embryos,
+and many of the ideas we hold relative to the initial stages in the
+development of man are based upon what has been found true in certain
+mammals, the class of animals to which we belong. The youngest human
+ovum known at present has already undergone about two weeks'
+development, and there the embryo is represented by a flat disk. From
+this stage to the stage of complete development a satisfactory series
+of embryos has now been collected, but it is impossible to give here,
+even in outline, a description of the evolution of the human embryo.
+No one can understand this intricate subject without the aid of
+diagrams, models, and other material beyond the reach of all save
+laboratory workers.
+
+By the end of the second month the development of the embryo has
+advanced so far that anyone could recognize its human shape. About
+that time, too, the external sexual organs make their appearance. At
+first these are quite similar in both sexes; and, if they are used as
+the criterion, it is possible only toward the end of the third month
+to say whether the embryo is a male or female.
+
+THE DETERMINATION OF SEX.--The fact that a number of months pass
+before the sex can be distinguished by an external examination of the
+fetus has led to the erroneous belief that it can be influenced
+during the early part of pregnancy or actually determined at will.
+Various means to accomplish this have been suggested; many of them
+depend upon modifying the mother's mode of living according as a boy
+or girl is desired. The most widely known of these doctrines, that of
+Schenck, was to the effect that the sex of the offspring is always
+that of the weaker parent. He suggested, therefore, that increasing
+the vigor of the mother by an appropriate diet would produce a male
+child, whereas a decrease in her strength would lead to the opposite
+result. His views, however, were incorrect. After studying extensive
+statistics Newcomb came to the conclusion that "it is in the highest
+degree unlikely that there is any way by which a parent can affect
+the sex of his or her offspring."
+
+Moreover, the results of experimental research clearly indicate that
+we shall never possess the means by which a mother may control the
+sex of her child. In the main laboratory investigations have sought
+to answer two questions. First, at what time is the sex of the
+offspring determined? and, second, what accounts for the origin of a
+male in one instance and of a female in another? The study of these
+problems has been carried on chiefly in connection with insects,
+worms, and fowl; but as yet insurmountable difficulties have
+prevented similar investigations in higher animals. For this reason,
+it is not without the greatest caution that results thus far obtained
+may be assumed to apply to man.
+
+Sufficient facts, however, have been collected to admit no doubt
+regarding the answer to the first question. In most animals it is
+definitely known that the sex of the offspring has been fixed when
+the male cell enters the female cell, in other words, at the instant
+the ovum is fertilized. Excellent reasons exist for believing that
+human beings conform to this rule, and that the sex of the child is
+unalterably determined at the moment conception occurs. Consequently,
+any attempt to influence it after that event must prove futile.
+
+For the present, the second question cannot be answered with equal
+assurance. More than five hundred theories have been offered to
+explain the relation of sex; nearly all of them have no reasonable
+foundation and are only of historical interest. The view that girls
+are derived from the right ovary, boys from the left, has long since
+been disproven, and deserves mention merely because the laity still
+believe it. Happily, during the last few years, observations and
+experiments have been made which greatly advance our knowledge of the
+subject and give promise of an early solution of the problem. The
+controlling factor in sex determination has been narrowed down to
+three possibilities; it is inherited either from the single cell
+contributed by the father or from the single cell contributed by the
+mother, or it is determined by the effect these two cells have upon
+each other at the moment when they unite. In most animal species the
+weight of authority distinctly favors placing the whole
+responsibility upon the male cell.
+
+According to recent evidence, there are two kinds of male germinal
+cells; one kind giving rise to female offspring and the other to
+male. In all probability, at the time of the marital relation, these
+varieties are deposited in the vagina in equal numbers; and,
+moreover, the mode of their production is such as to place absolutely
+beyond human control the possibility of changing this ratio. Since
+only one spermatozoon enters the ovum, whether or not the child will
+be a boy or a girl depends entirely upon which type gains entrance.
+If this explanation is correct, and it is in accord with careful
+biological observations, it removes from the mother all
+responsibility for the sex of her child. Furthermore, since the facts
+indicate that male-producing and female-producing spermatozoa are
+present in equal numbers, it follows that practically there is an
+even chance that an embryo will develop into a boy or a girl.
+
+Birth statistics bear out this conclusion, as data gathered from many
+countries indicate that when long periods of time are studied 105
+boys are born with a surprising regularity for every 100 girls. Thus,
+the records of Berlin, Germany, for a hundred years show that the
+maximum difference occurred in 1820, when the males outnumbered the
+females by 4.79 per cent.; the minimum difference, which was noted in
+1835, was .64 per cent. in favor of boys.
+
+No inquiry is more often submitted to the physician by prospective
+mothers than this, "Can you tell me if my baby will be a boy or a
+girl?" He cannot. Many rules, to be sure, have been advocated as safe
+guides toward reaching the correct answer; every midwife possesses
+her individual formula which she has "never known to fail." But the
+boastful success depends upon the application of some such method as
+the following, which I have heard my teacher, Dr. J. Whitridge
+Williams, expose to his classes. The patient is asked if a boy or
+girl is desired. She confesses, and is then informed that the sex of
+her child will be the opposite of her wish. When this guess proves to
+be correct, there is no doubt of the prophet's wisdom; when it is
+not, his honor is protected, for the parents have had their hope
+fulfilled. Their happiness makes them forgetful that the guess was
+wrong, or, for that matter, that it was ever made.
+
+It was once believed that the sexes might be distinguished before
+birth by the number of heart beats occurring within a minute. In a
+general way, the action of this organ in females is somewhat more
+rapid than in males; and so it was thought that a rate of 144 or more
+indicated the female and a rate of 124 or less the male sex. But
+experience has taught that this rule leads to accurate prophecy in no
+more than half of the cases. As a matter of fact, no means of
+definitely foretelling the sex of the child has been discovered, and
+I doubt if it ever can be.
+
+TWINS.--As every one knows, pregnancy commonly terminates with the
+birth of a single child. Twins appear in approximately only one of
+ninety pregnancies, while triplets are extremely rare. It is true
+that even quintuplets may occur, though up to 1904 only 29 authentic
+instances could be collected from the whole range of medical
+literature.
+
+Twins are most frequently born to parents whose ancestors have
+established this tendency; the trait is usually inherited from the
+mother's family, though occasionally it is passed on through the
+father. Of course, that does not explain the cause of twins, which in
+reality may result from either of two circumstances. More commonly
+their genesis depends upon the ripening of two eggs at about the same
+time and the fertilization of both by two different spermatozoa. The
+children, in this instance known as double ovum twins, may be of the
+same sex or not. On the other hand, single ovum, or identical, twins
+are always of the same sex; this follows, since but one egg and but
+one spermatozoon are here concerned. The incident permitting twins to
+develop from a solitary ovum must occur soon after conception has
+taken place. It will be remembered that the first step in the
+development of the fertilized ovum consists in its dividing into two
+cells. Ordinarily, both these take part in the development of one
+embryo, but occasionally they separate and give rise to two.
+Frequently, the presence of twins can be recognized during the latter
+months of pregnancy, and accurate means are known of determining
+after they are born to which variety any given pair belongs.
+
+THE RATE OF GROWTH.--When we recall the definite and often marked
+differences in the physical character of women, such as weight and
+height, it is surprising to learn that the prenatal development of
+their children proceeds with uniform speed. One very practical result
+is that the physician is thus enabled, at the birth of a premature
+infant, to estimate accurately the period of its development. Various
+criteria, some of which are easy of application, aid in this
+determination. For example, the length of the child is practically
+constant for each of the ten lunar months into which the whole
+gestation period is divided; if, therefore, the length of the newborn
+infant is known, the stage of its development can always be inferred.
+From the fifth month the calculation is especially simple, since the
+length measured in centimeters divided by the figure 5 gives the
+month to which pregnancy has advanced. Similarly, we can infer the
+period of development from the weight, though the calculation is more
+intricate and the method less reliable, inasmuch as the size of the
+child in the latter months varies somewhat according to the weight of
+its mother.
+
+At the end of the fifth month, the weight of the fetus is from nine
+to ten ounces; whereas an average infant when born at the expiration
+of the full term of pregnancy, that is, with the completion of the
+tenth month, weighs about seven pounds. The fetus, therefore,
+acquires roundly ninety per cent, of its weight during the second
+half of pregnancy, which clearly indicates that Nature reserves this
+period of gestation for the fetus to increase in size, a phenomenon
+less mysterious but no less important than the evolution of the
+embryo.
+
+Nothing is more valuable than the weight in affording an indication
+as to whether a prematurely born infant may be reared. It is unusual
+to raise a child weighing less than four pounds, which corresponds
+approximately to the end of the eighth lunar month of development (a
+trifle more than the seventh calendar month). After this time, the
+prospect of living becomes greater in proportion to the nearness with
+which the infant has approached maturity. No truth exists in the
+widespread belief that the seventh-month child is favored above that
+born later but before the natural end of pregnancy. Experience has
+taught that the probability of success in rearing the child increases
+rapidly after the seventh month. This is reasonable on the following
+somewhat theoretical grounds. The digestive organs later attain a
+higher state of perfection, and are better prepared to carry on their
+work satisfactorily. Moreover, the gradual deposition of fat beneath
+the skin during the last two months of pregnancy materially assists
+in fitting the child for the conditions met with in the external
+world, since the fat affords a barrier against the escape of heat
+generated within the body, making it much easier to keep the child's
+temperature at the normal point. Even other more technical reasons
+could be given to demonstrate the error of the superstition regarding
+the seventh-month child--a conviction endorsed by medical men
+hundreds of years ago and as yet not discarded by the laity.
+
+When pregnancy has reached "term," the child, having completed its
+prenatal development, is ready to cope with conditions as they exist
+in the external world. At term the average child is twenty inches
+long and weighs 7 1/7 pounds (3,250 grams). The length is remarkably
+constant; but the weight, as is well known, is often somewhat above
+or below the average figure. In a general way, smaller children occur
+in the first than in subsequent pregnancies, and, moreover, may be
+expected when the mother is a small woman, or poorly nourished, or
+has worked hard during her pregnancy. On the other hand, a tendency
+to bear large children is present when the opposite conditions
+prevail. It is not unusual to see infants weighing eight or nine
+pounds at birth, but babies of more than ten pounds are rare, and the
+fabulous, though not infrequent, reports of fifteen and twenty-pound
+infants are probably not based upon actual weighings, but upon the
+impression of someone who has merely seen the child or perhaps
+guessed the weight from lifting it.
+
+Although the fetus frequently changes its position during the earlier
+months of pregnancy, generally by the beginning of the tenth lunar
+month it has assumed a permanent posture. It has then reached such a
+size that it can best be accommodated in the cavity of the uterus if
+its various parts are folded together so as to give the fetus an
+ovoid shape. To secure this form its back is arched forward, and its
+head bent so that its chin touches its chest; its arms are crossed
+just below the head, its legs raised in front of the abdomen, and its
+knees doubled up. In this form the fetus occupies the smallest
+possible space.
+
+With relation to the mother the position of the child, for several
+weeks before birth, is one in which its long axis is parallel to the
+long axis of her body. This remains true no matter whether the head
+or the buttocks are to precede at the time of birth. In ninety-seven
+out of a hundred cases, however, the head lies lowermost and
+consequently is the first portion of the child to be born. The
+opposite position, in which the head is the last portion born, is,
+even with the most skillful treatment, somewhat more serious for the
+infant, though not for the mother.
+
+THE NEWBORN INFANT.--The baby at birth is not a miniature man. As
+compared with an adult its head and abdomen are relatively large, its
+chest relatively small; its limbs are short in proportion to the
+body; and at first glance it appears to have no neck at all. The
+middle point of a baby's length is situated about the level of the
+navel, whereas in a man the legs alone represent approximately half
+his height. The changes after birth consist chiefly in growth; but
+not altogether, since at least one organ, the thymus gland, becomes
+smaller and completely disappears during childhood, and other organs,
+especially the liver, are proportionately smaller in the adult than
+in the infant.
+
+The body of the infant also differs from that of the man in
+possessing greater softness and flexibility. These qualities depend
+upon the nature of its skeleton, which is composed of more bones than
+later in life, when several have fused together to form one to give
+the mature body a more rigid frame. Furthermore, the individual bones
+are not so firm, consisting of an elastic material called cartilage,
+so that some movements which in an adult would cause such serious
+injuries as fractures and dislocations are perfectly harmless to a
+newborn child.
+
+The legs are not only short in proportion to the body but are always
+curved, and the feet are held with the soles directed toward one
+another, a position clearly abnormal in the adult. But every mother
+should know that these are natural conditions in the infant, and are
+the result of the posture of the child before birth. They soon
+straighten out. The bowed legs of an adult are of an entirely
+different origin, resulting from a disturbance of nutrition in
+infancy called rickets.
+
+A small amount of short wooly hair is usually found over the back of
+a newborn infant. More conspicuous, however, is the presence there of
+a gray, fatty substance which, though always more abundant over the
+back, is at times distributed over the whole body; rarely is it
+entirely absent. The material, technically named the vernix, is the
+product of the glands in the skin and is a perfectly normal
+secretion. After its removal, which is readily accomplished by
+greasing the infant with lard or vaselin before giving the initial
+bath, it never reappears.
+
+A varying amount of hair covers the head of the infant. No
+significance should be attached to the quantity, for the conviction
+that exists, especially among negroes, that a heavy suit of hair for
+the child occasions "heart-burn" in the mother during pregnancy is
+without foundation. The color of the hair at birth does not indicate
+its ultimate shade; changes are often noted during infancy. Similarly
+the permanent color of the eyes is not assumed until later; at the
+time of birth the eyes are generally, if not always, blue in color.
+
+A baby's head is a matter of great concern to the family.
+Occasionally, the skull is round and well shaped from the moment of
+birth, but more often it is long and narrow; sometimes the form is
+even startling to the inexperienced. The peculiar shape of the head
+results, of course, from its passage through the birth-canal and is
+not a sign of any disease. In a few weeks, or even less, the strange
+appearance passes away. It is unwise to attempt to alter the shape of
+the head by bandaging or massaging since the growth of the brain will
+spontaneously accomplish what is desired; interference can do no
+good, and may do serious harm.
+
+Nature facilitates an appropriate molding of the head during birth so
+as to permit its easy passage through the bony pelvic cavity of the
+mother, and gains that end in two ways. The bones of the head remain
+pliable until after the infant is born, and, further, their edges are
+not welded together as in an adult, but are separated from one
+another by an appreciable distance. During the act of birth the edges
+are brought into contact or even overlap, materially reducing the
+size of the head. Within a few hours after birth the bones again
+spread apart, and some months elapse before they begin to unite; the
+union is not completed until some time during the second year of
+infancy.
+
+Many mothers are anxious to know how far the senses of the infant
+have developed when it enters the world. This problem has stimulated
+some scientific investigation, though hardly so much as its interest
+would justify. Two lines of inquiry have been pursued toward its
+solution. The objective point of one of these has been to determine
+how nearly the sense organs of the newborn correspond anatomically to
+those of an adult; that is how perfectly has their organization been
+completed. The other has been to learn how the infant reacts when the
+various senses are stimulated; the interpretation of these reactions
+is, however, particularly liable to error and sometimes amounts only
+to guesswork.
+
+The organization of the nerves and muscles in the eye is far from
+perfect at the time of birth. The muscles act irregularly; indeed,
+the lack of muscular adjustment is such that movements of the eye
+likely to alarm the parents are regularly observed in very young
+infants. Furthermore they cannot focus images which fall upon their
+eyes. The retina, which receives visual impressions, has reached such
+development at birth, however, that sensations of light can be
+perceived. For example, if a lamp is suddenly flashed before the face
+of a newly born baby it cries. From this and similar evidence,
+indicating that strong light irritates the delicate structures of the
+eye, we have learned that a nursery should not be illuminated, during
+the day or night, so brightly as the rooms adults occupy. Certainly
+several weeks, and probably several months, pass before an infant can
+see anything save as blurs of light and darkness. Objects, such as a
+hand, probably appear as shadows, which are not correctly interpreted
+until late in infancy.
+
+In regard to color vision we have as yet no reliable information
+concerning children under two years of age. Infants of less than a
+year have been known to distinguish certain colored papers. But such
+discrimination is probably due to a difference in brightness of the
+colors.
+
+Although the organ of hearing is well developed at birth, the drum of
+the ear in very young infants cannot transmit sounds, as in the
+adult. For the latter kind of transmission it is necessary that the
+pressure on both sides of the drum-membrane should be equal, and this
+is arranged by the admission of air to the middle ear through a
+passage from the throat. At the time of birth, on account of the
+swollen condition of the mucous membrane which lines this passage, it
+is blocked, and the middle ear is filled with fluid; these conditions
+interfere with the transmission of sound, and consequently its
+perception is dulled. But even in the absence of a drum-membrane an
+adult can hear; the vibrations in such cases are transmitted through
+the bones of the skull, and this very likely also occurs in newly
+born infants. In most instances, at least, they react to a
+disagreeable noise within the first twenty-four hours, and their
+sensitiveness in this direction explains why the nursery should be
+kept quiet.
+
+Investigators have not come to uniform conclusions concerning the
+sense of smell and of taste. In all likelihood, smell is not acute at
+the time of birth. Taste probably is better perceived, yet some
+newborn babies are said to suck a two per cent solution of quinin as
+eagerly as milk, though stronger solutions are distasteful. According
+to the best available information a young infant can detect the
+difference between a sweet, bitter, sour, or salty taste only when
+the tests are made with a solution possessing the quality in question
+to a marked degree. It is common knowledge that babies cheerfully
+suck the most tasteless objects, and it is not improbable that at
+first the reaction depends upon the temperature of the object and the
+feeling it creates in the mouth.
+
+The moment it is born, a baby perceives pressure if its skin is
+touched. To this sensation, however, some parts of the body are much
+more sensitive than others; the tongue and lips are most sensitive of
+all. Heat and cold are probably perceived more acutely by infants
+than by adults; to pain, on the other hand, babies are less
+sensitive. An infant is aware of the movements of its own muscles,
+and also appreciates a change from one position to another, as
+experienced nurses know very well, and on that account carefully
+avoid keeping a baby on one side continuously.
+
+The vast majority of movements performed by young infants are reflex
+acts, that is, the cerebrum, the part of the brain with which
+thinking is done, is not concerned with their performance. Of these
+reflexes the most notable are sucking and swallowing, but sneezing,
+coughing, choking, and hiccoughing may also be observed; stretching
+and yawning have been recorded in several instances, even during the
+first days of infant life. None of these movements, we must remember,
+are produced consciously; the baby cannot reason and does not
+recognize anyone, even its mother.
+
+HEREDITY.--The transmission of bodily resemblance and of traits of
+character from parent to child is a broad and complicated subject,
+whose fundamental principles biologists are just beginning to grasp.
+The facts thus far established regarding heredity relate chiefly to
+plants and to the lower animals. There is no doubt whatever that the
+meager knowledge we possess of heredity in man will be amplified and
+will ultimately indicate on the one hand the marriages which are
+advisable and, on the other hand, those which are not. Indeed, the
+foundations for a science called Eugenics, which purposes to improve
+the human race in this way, have already been laid. It is barely a
+decade, however, since our knowledge of heredity has approached that
+order and system which entitle it to be ranked as a science; and in
+this brief period great strides could hardly be expected in its most
+intricate field, that of human inheritance.
+
+The modern teachings of heredity are of interest to us, nevertheless,
+since they intimate the time when a child's inheritance is fixed and
+the means by which hereditary characters are conveyed. To understand
+these fundamental points we must recall that at the moment of
+conception a male germinal cell combines with a female cell, and that
+this act, which is named fertilization, brings together vital
+elements from the two parents. We have seen that the spermatozoon
+represents the solitary contribution of the father toward the
+development of the child, and the spermatozoon, therefore, must
+convey the material basis of paternal inheritance. Similarly we might
+expect the ovum to be the bearer of the maternal qualities inherited
+by the child. This is actually true; but much of the evidence is of a
+technical character and must be omitted. Yet an experiment
+successfully conducted by Castle and Phillips will indicate, even to
+those who have no special knowledge of the mechanism of heredity, the
+important role the ovum plays. These investigators removed the
+ovaries from an albino guinea-pig, and in their place substituted the
+ovaries of a black guinea-pig. "From numerous experiments it may be
+emphatically stated that normal albinos mated together produce only
+albinos." But in this experiment the result was otherwise, for the
+albino into which the ovaries of a black guinea-pig were grafted
+produced only black offspring. The color-coat of her young,
+therefore, was not influenced by her own white hair, but was
+determined by the eggs really belonging to the black animal from
+which the ovaries were taken; in no other way can the result be
+interpreted. It is certain, moreover, that the mode of transmission
+of material qualities here exemplified is not exceptional; on the
+contrary there is no doubt that the ovum always conveys the sum total
+of the qualities the offspring inherits from the mother.
+
+The germinal cells then contain the material basis of inheritance,
+and in all probability the substance is located within the nucleus of
+the cells. This substance had been seen and studied long before its
+relation to the problem of heredity was suspected. Because it takes a
+deeper stain than the rest of the nucleus, it stands out prominently
+when the cell is treated with certain dyes, and this property
+accounts for its name--chromatin. Under such conditions as prevail
+just before a cell divides, the chromatic substance is broken up and
+reassembled in the form of rods called chromosomes. Curiously enough
+the number of rods is uniform for each species of animal, though
+different numbers are characteristic of different species; the
+characteristic number for man is twenty-four.
+
+Unless some arrangement was made to prevent it, the act of
+fertilization would cause the number of chromosomes in the fertilized
+ovum to be double the number characteristic of the species. In man,
+for example, the addition of twenty-four chromosomes from the
+spermatozoon to an ovum that already contained twenty-four
+chromosomes of its own would mean that after fertilization the ovum
+contained forty-eight. Such a result is prevented through the process
+to which we have referred in the preceding chapter as the ripening of
+the ovum, and also through a similar process in the case of the
+spermatozoon. These two processes lead to a reduction in the number
+of chromosomes, so that finally every human germinal cell contains
+twelve, and therefore when the ovum is fertilized the characteristic
+number twenty-four is restored. While we know nothing of the forces
+which determine, on the one hand, what elements shall be discarded by
+the germinal cells and, on the other hand, what elements shall
+remain, it is definitely proved that a selective process always takes
+place. This fact admirably explains the variation in the
+characteristics inherited by children of the same family. So far as
+is known, the traits which will be passed on from either parent are a
+matter of chance. Whatever these hereditary traits happen to be, the
+best evidence we have indicates that the problem of a child's
+inheritance is settled once for all the moment conception takes
+place.
+
+MATERNAL IMPRESSIONS.--Contrary to all that we know of heredity, the
+conviction prevails among the laity that the character of a child
+depends greatly upon the mother's surroundings during pregnancy: this
+is the doctrine of maternal impressions. As is usual with
+superstitions, this one emphasizes the unfavorable possibilities and
+holds that the unborn child may be affected by the mother's unhappy
+thoughts or maimed by her mental distress if she is exposed to
+unpleasant sights. For this belief there is no foundation; the cases
+often cited in its support may be fully explained on the grounds of
+coincidence.
+
+With the possible exception of such individuals as are spending their
+lives in solitary confinement, there is scarcely a human being who
+has not in the course of nine consecutive months some untoward
+physical or mental experience which engraves itself upon the memory.
+Prospective mothers are not apt to be exempt from a rule so general
+in its application, but if by good chance one happens so to be she
+will hardly fail to hear of the misfortune of others, which,
+according to the doctrine of maternal impressions, may be equally
+effective in interfering with the proper development of the child. We
+should then rightly expect most, if not all, babies to be "marked"--
+clearly a situation which does not prevail.
+
+In order to learn how frequently prospective mothers may have
+disagreeable experiences which they fear will affect the formation of
+the child, I have lately asked the patients whom I have attended,
+"Was there any incident during your pregnancy to which you could have
+attributed the infant's condition, had it been marked?" The babies of
+all those to whom the question was submitted were normal; yet without
+exception those whose pregnancies just completed were their first
+answered in the affirmative. It is also pertinent that one of these
+patients had lost her brother by a violent and accidental death when
+she was four months pregnant; a similar bereavement was suffered by
+another at the eighth month; each was, however, delivered of a
+perfectly healthy child. Among those with whom the recently ended
+pregnancy was not the first I found some who could remember incidents
+popularly believed to have an influence over the development of the
+embryo; most of them, however, had given the matter so little thought
+that they could not definitely recall whether such incidents had
+occurred or not. From a similar series of observations covering two
+thousand cases, William Hunter came to the conclusion, nearly two
+hundred years ago, that there was no support for the belief in
+maternal impressions.
+
+Whenever a child does happen to develop abnormally, it must be clear
+that, from the very nature of our existence, some incident can be
+recalled which will satisfactorily, yet unjustly, bear the blame. It
+may be confidently said, however, that, for every mother whose fears
+are realized, hundreds are agreeably disappointed in finding their
+babies perfectly normal. In the face of so many negative instances it
+is amazing that any person, even though ignorant of medical teaching,
+should be inclined to attribute abnormal development to something the
+mother has seen or heard, thought or dreamt, or otherwise experienced
+while she was pregnant. Yet unfortunately many do believe this. It is
+worth while, therefore, to supply further evidence, and thus escape
+any suspicion of unfairness in argument, to prove that maternal
+impressions are unable to affect the formation of the embryo.
+
+It is found, as a matter of experience, that the superstition
+regarding maternal impressions generally begins to cause anxiety
+during the second half of pregnancy; and then such an influence is
+entirely out of the question. By the end of the second month the form
+of the embryo has been definitely determined, and subsequently cannot
+be altered. It is even true that errors in development are most apt
+to occur within the two or three weeks that immediately follow
+conception, and therefore occur at a time when pregnancy is not often
+clearly recognized. Thus it happens that women begin to worry about
+the influence their minds will have upon the formation of the child
+long after its form has been established.
+
+Incidents in the life of a prospective mother are in point of fact
+equally inert so far as their influence upon development is
+concerned, no matter whether they occur during the earlier or later
+part of pregnancy. There is never any anatomical means by which
+maternal impressions could be conveyed to the embryo. Such an
+influence would have to be exerted through the placenta; and that is
+impossible. There are no nerves in the placenta to carry impulses
+from the mother to the child. Even the blood streams of the two
+beings are kept apart; and though it is unheard of that the blood
+should carry nerve impulses, if that happened to be the case, it
+could not prove effective here, for the blood of the mother does not
+enter the child. It is nourished by food which passes from the
+mother's blood, to be sure, but there is no more reason to expect
+this nutriment to exert an hereditary influence than there is to
+expect an infant to grow to resemble the cow with the milk of which
+it is fed. With these two possibilities eliminated, no path can be
+imagined by which impulses might travel from the mother to the
+embryo.
+
+Scientific investigation has brought to light these facts, as it has
+also taught the real causation of the disfigurement once attributed
+to the mother's mind. Departures from the usual form of the body
+occur during the earliest days of pregnancy and arise in consequence
+of some irregularity in the process which molds the body-form from a
+simple spherical mass of cells. Why irregularities sometimes occur is
+not altogether clear; except in so far as it has been determined that
+the fault lies within the embryo itself. Whenever these defects are
+associated with events which have disturbed the mother's mind, it
+cannot be other than a simple coincidence.
+
+
+
+
+CHAPTER IV
+
+
+THE FOOD REQUIREMENTS DURING PREGNANCY
+
+The Food-stuffs: Water; Mineral Material; Protein; Carbohydrate; Fat--
+What We Do to Our Food--How Much Food Is Needed During Pregnancy?--
+The Importance of Liquid Nourishment--The Choice of Food--Cravings--
+The Relation Between the Mother's Diet and the Size of the Child.
+
+There is a gain in weight during pregnancy amounting finally to about
+thirty pounds; exceptionally, it is as little as ten or fifteen
+pounds, and, at the other extreme, as much as forty or fifty. With
+individuals inclined to be stout the increase is greater, and it is
+relatively greater in later pregnancies than in the first. During the
+early months of pregnancy the weight generally remains stationary or
+suffers a slight loss; even in those rare instances in which the
+weight begins to increase shortly after conception the gain is less
+marked in the earlier months than later. For the last three months
+the average monthly gain has been found to be between three and a
+half and five and a half pounds.
+
+The weight gained during pregnancy is not, as can be readily
+understood, permanently retained. At the time of birth, in
+consequence of the expulsion of the child, the after-birth, the
+amniotic fluid, and a varying amount of blood, there is necessarily a
+loss of from ten to fifteen pounds. Later, as the maternal tissues,
+whose growth has been stimulated during pregnancy, return to their
+original condition, a further loss in weight takes place. It is not
+unusual, however, for women to remain permanently better nourished
+than before they became pregnant. Under ordinary conditions the food
+of the prospective mother provides not only for her own wants but
+also for those of the embryo. Between the two organisms there exists
+a relation which resembles that existing between a house in course of
+construction and the contractor who supplies the building material.
+The mother furnishes what is needed to construct the "living
+edifice," as Huxley called the growing embryo, but she is not
+responsible for the lines of the building. The embryo is both
+architect and mechanic, designing the structure and arranging the
+"organic bricks" in their proper places. The work of construction
+necessitates the expenditure of an appreciable amount of energy and
+the creation of waste products that must be removed, lest they
+accumulate and interfere with the growing structure. These waste
+products leave the embryo by way of the umbilical cord and the
+placenta and return thus into the mother's circulation; ultimately
+they leave the mother through the same channels that carry off her
+own waste. First and last, then, the nutrition of the mother and of
+the child are so bound together that it has been impossible to study
+them separately. Our knowledge of food requirements during pregnancy
+has been obtained by measuring the food requirements of the mother
+alone; and as nutrition during gestation is fundamentally the same as
+nutrition at other times, it is necessary for us first to consider in
+general the food needed by the human body.
+
+THE FOOD-STUFFS.--The waste products we throw off indicate that the
+substances which compose our bodies are being constantly broken down
+and reduced to a condition such that they are useless to us. In
+normal persons hunger signifies that they need material to replace
+what has been used up. The substances thus required, if the wants of
+the body are to be satisfied correctly, are called the food-stuffs;
+and they are the same during pregnancy as at other times. The
+foodstuffs are usually classified according to their chemical
+properties; on this basis they are placed in five groups: (1) Water,
+(2) Mineral Materials, (3) Proteins, (4) Carbohydrates, (5) Fats.
+
+In view of the different purposes which the foodstuffs serve, it is
+convenient to group them in another way. Thus, the carbohydrates and
+the fats may be placed together because they are the body fuel; their
+value consists in the heat and energy which they yield when acted
+upon in the tissues. Water and mineral matter, on the other hand, are
+never a source of energy; they assist in building new tissue or in
+repairing tissue that already exists. The proteins are unique, in
+that they may serve either purpose. Primarily the proteins are
+tissue-builders, but in the absence of sufficient fat or carbohydrate
+the body burns protein to secure heat and energy.
+
+Each food-stuff, therefore, serves a distinct purpose, and some of
+them render services which the others cannot perform. A man will die
+if either water or mineral matter or protein is completely withdrawn
+from his diet. Fat or carbohydrate, on the other hand, or even both
+of them, may be excluded for some time without causing serious
+inconvenience. It is true, nevertheless, that each food-stuff
+performs some task better than any of the others can perform it, and
+for that reason all of them should be included in the diet of an
+healthy individual.
+
+Some of the food-stuffs, such as water and table salt, come to the
+body separate from the others; but generally the different types
+reach us intimately mingled in the various articles of food in common
+use. Foods vary greatly, however, in the amount of the different
+food-stuffs they contain. The meats, for example, have a relatively
+large protein content; in the vegetables starch, which is one of the
+carbohydrates, predominates. As to the choice of food and the amount
+that is necessary for the average person, generally the appetite is a
+safe guide; but the accurate observations of physiologists have gone
+so far as to determine the exact requirements of the body. Not the
+least important principle taught by these investigations is to avoid
+dietary fads, for in arranging a satisfactory diet the problem to be
+solved is not, What is it possible to live on? but, What serves best
+as nourishment? The experience of countless generations has taught us
+that we thrive best on a diet which includes all five food-stuffs.
+
+_Water_ constitutes nearly two-thirds of the weight of the body.
+As water is constantly being given up in the life process, health
+demands an abundant supply of liquids to replace the waste. The
+average daily loss has been found to be between two and three quarts.
+Of this amount the urine constitutes nearly two-thirds; and the
+remaining third is eliminated through the skin, the lungs, and the
+bowels. Although the deficiency thus created is met in part by the
+water in our solid food, the greater part of the loss is made up by
+the liquids we drink, and we are warned, in a measure, by the
+sensation of thirst that they are needed.
+
+_Mineral material_ is of the greatest importance as a
+constituent of our food. It contributes to the welfare of the body in
+at least three ways; (1) it gives rigidity to the bones, (2) it
+supplies an essential ingredient of the living substance in all the
+tissues, (3) it is present in the blood and in the other body fluids,
+where it is of service in such vital processes as the beating of the
+heart, the transportation of oxygen to every portion of the body, and
+the maintenance of an acid or alkaline condition of the digestive
+juices according as the one or the other is necessary for the
+assimilation of the food.
+
+An animal deprived of mineral food will die as surely as one deprived
+of water. In arranging our diets, however, we are not compelled to
+take the minerals into account, for, with the exception of table salt
+(sodium chlorid), the meat and vegetables that we eat provide the
+mineral material the body requires. Iron, for example, which imparts
+to the blood one of its most essential qualities, occurs in
+relatively large amounts in apples, spinach, lettuce, potatoes, peas,
+carrots, and meats. Only now and then does it become advisable to add
+iron deliberately to the diet. Similarly lime (calcium) the material
+that makes the bones hard, is present in quantities ample for the
+needs of the body in the bread, milk, eggs and vegetables that we
+eat. The remaining mineral constituents of the body, among which the
+most conspicuous are magnesium, potassium, sulphur, and phosphorus,
+occur in foods which we are naturally inclined to take, so that we
+secure an abundance of them unconsciously.
+
+_Protein_, the third food-stuff which we must eat to keep alive,
+contains the chemical element nitrogen in such form that it can be
+incorporated in our tissues. Although most persons derive their
+protein in part from meat, milk, and eggs, it is possible to satisfy
+the requirements of the body on a purely vegetarian diet. Experience
+has shown, however, that it is both natural and advantageous that we
+employ a mixed diet.
+
+The property of protein to build living tissue and replace tissue
+waste probably depends upon several factors; but certainly one of
+them is the presence of nitrogen. So intimately associated are the
+consumption of the tissue substance and the elimination of nitrogen
+that we have no better way of judging the amount of tissue substance
+used in the body than by determining the quantity of nitrogen that
+appears in its various waste products. From such investigations it
+has been found that the quantity of protein required to repair the
+breaking down of the tissues is not great. The average man consumes
+approximately a quarter of a pound (100 to 120 grams) of protein
+daily; but this quantity is in excess of his real needs. Indeed,
+Chittenden has shown that for various classes of individuals, namely,
+students, athletes and soldiers, half as much is sufficient. Other
+physiologists, though admitting that this is true, contend that it is
+inadvisable to regulate one's diet on such a slender basis. Very good
+reasons are assigned for the view that more protein is needed than
+just enough to counterbalance the tissue waste. Thus, in the case of
+animals, it has been found that a diet low in protein finally causes
+digestive disturbances and other ailments.
+
+Although it does not seem advisable to practise rigid economy in
+arranging the protein content of the diet, it is equally important
+that we should not go to the other extreme. The consumption of over-
+large quantities of protein, as would be the case if we lived
+exclusively upon meat, increases putrefaction in the intestines and
+throws unnecessary work upon the kidneys, which are the organs
+chiefly concerned in getting rid of the waste products of protein.
+
+_Carbohydrate_ is the name given the group of foodstuffs to
+which the sugars belong. The food value of cane sugar, the most
+familiar member of the group, was recognized even in prehistoric days
+by the natives of India. By boiling the plant we call sugar-cane they
+obtained a substance to which they gave the name Sakkara, and from
+this our word sugar evidently originated. The roots of this plant
+were carried into Europe and cultivated during the Middle Ages.
+Obviously, its value was and is appreciated, since the cultivation of
+the sugar-cane and the sugar-beet has become the foundation of a
+great modern industry.
+
+There are some persons, perhaps, who do not realize that beside cane
+sugar many kinds of carbohydrate occur in our food. Glucose or grape
+sugar, for example, occurs not only in the fruit indicated by its
+name, but also in other fruits, in corn, in onions, and in the common
+vegetables. Glucose is especially suited to act as nourishing food.
+In keeping with that fact our digestive juices convert most of the
+sugars we eat, if not all of them, into glucose, which is regularly
+present in our blood. It is unnecessary to enumerate all or even the
+more important compounds included in the carbohydrate group; but
+everyone should know that starch is its chief member, and that after
+being thoroughly digested starch enters the body as glucose and
+therefore serves the same purpose as sugar.
+
+The value of carbohydrates as a source of heat and energy may be
+accurately measured, and is technically expressed in terms of a unit,
+called the calorie. As the energy which our bodies require may be
+estimated in the same terms, it is possible to determine whether or
+not our food is equal to our wants. Very naturally the energy
+requirements of any individual are influenced by his weight and by
+the work he does. But we may take as a standard the results of an
+extensive study of American families which indicate that women
+require four-fifths as much energy-yielding food as men. It also
+seems safe to conclude that a woman weighing 130 pounds who does her
+own housework requires food every day having an energy-value of 2,500
+calories; smaller women and those who do no work require somewhat
+less. In a mixed diet the chief source of this energy--and the source
+from which it is most economically obtained--is the carbohydrates.
+
+_Fat_ yields more energy and heat than does carbohydrate, bulk
+for bulk; but fat is burned by our tissues less readily. We
+instinctively avoid eating a great deal of this food-stuff; in the
+course of a day the average person consumes no more than one or two
+ounces. The natural aversion which many feel toward fat may possibly
+depend upon the difficulty with which they assimilate it. In colder
+climates, however, we know fat to be a staple article of diet; and it
+is not unlikely that the very conditions which make it necessary
+there explain the unusual tolerance for it.
+
+Fat is more than fuel. Deposited in our bodies, beneath the skin for
+example, it prevents the escape of heat that we generate and protects
+us against the penetration of cold. This food-stuff, therefore,
+contributes in several ways toward maintaining the temperature of the
+body at a constant level.
+
+Our source of fat is chiefly animal food and in a smaller measure
+vegetables; but the fat our food contains is not altogether
+responsible for the fat in our bodies. Carbohydrates, if in excess of
+momentary needs, are partly converted into fat and stored as such. A
+reserve supply of nourishment is thus provided, and is drawn upon
+only when the food that we consume does not contain as much energy as
+we expend.
+
+WHAT WE DO TO OUR FOOD.--With the exception of water and mineral
+substances, the food-stuffs must undergo chemical alterations before
+they are capable of being absorbed into the body; this is the work of
+digestion. The digestive processes, the main purpose of which is to
+break up the carbohydrates, proteins, and fats into substances of
+much simpler chemical structure, begin in the mouth and are not
+completed until some time after the food has entered the intestine.
+As the food moves through the alimentary canal, it is mixed with the
+various digestive juices containing ferments, such as pepsin, which
+are the active agents of digestion. Although digestive processes go
+on automatically, they are, in a degree that is far from negligible,
+influenced by the mind. Thus, cheerfulness promotes digestion, and
+not infrequently mental depression may be the direct cause of
+indigestion. Indeed, it is chiefly in regard to the state of the mind
+of the prospective mother that the existence of pregnancy may be said
+to have a bearing, whether favorable or unfavorable, upon her
+digestion.
+
+The digestive juices are prepared in glands which lie either within
+the lining of the alimentary canal or adjacent to it. In the latter
+event the glands are connected with the canal by means of tubes.
+These glands must be warned when to pour out their secretion, and
+their very first warning usually comes from the agreeable sensations
+experienced when we see, smell, or taste inviting food. If we are
+hungry, our viands attractive, and our surroundings congenial, the
+stimulus excites a plentiful secretion of the digestive juices;
+conversely, the opposite conditions, to some extent, check their
+flow.
+
+The sight of attractive food, as we all know, "makes the mouth
+water," that is, it calls forth the saliva which contains one of the
+digestive ferments. Thus, at the beginning of a meal, favorable
+conditions for digestion are established. The saliva, however, acts
+only upon starch; and, moreover, its action upon this carbohydrate is
+weak unless the food is thoroughly chewed and mixed in the mouth.
+Most of us, perhaps, overlook the importance of mastication, which
+not only crushes all the food-stuffs, preparing them for efficient
+digestion, but also stimulates the flow of the digestive juices.
+Furthermore, by thoroughly masticating our food, we know intuitively
+when we have had enough, and thus avoid overeating.
+
+In the stomach the digestion of starch is continued for a time, but
+the chief work of gastric digestion concerns the proteins. They alone
+are attacked by pepsin, a ferment secreted by the mucous membrane of
+the stomach. Moreover, since pepsin is able to act only when an acid
+is present, the gastric mucous membrane also secretes hydrochloric
+acid.
+
+Just as the digestive glands in the neighborhood of the mouth become
+more active when we are conscious that desirable food is at hand, so
+do the glands in the stomach. Mastication also stimulates the flow of
+the gastric juice, and this flow is greater if we enjoy what we eat.
+Furthermore, it has been shown that, after entrance into the stomach,
+the food itself increases the flow of the digestive juices. All
+articles of food are not, however, equally efficient in producing
+this effect: thus meat requires more pepsin for satisfactory
+digestion than bread, and consequently meat calls forth a larger
+quantity of gastric juice.
+
+Fat in all probability is not digested in the stomach; even starch
+and protein are not broken down sufficiently by the time gastric
+digestion is complete to permit them to be absorbed into the body.
+"The value of digestion in the stomach," as Howell says, "is not so
+much in its own action as in its combined action with that which
+takes place in the intestine." It is even possible for satisfactory
+digestion to take place without the assistance of the stomach. This
+fact has been substantiated by several cases in which men have lived
+for years after the stomach was removed to eradicate a disease. It is
+true, nevertheless, that intestinal digestion can be performed more
+economically if it begins where gastric digestion normally leaves
+off.
+
+Of the changes wrought in the food by the various digestive
+processes, those which are the most profound take place in the
+intestine. While the food is being moved through this organ--some
+thirty feet in length--it is reduced to simple chemical fragments,
+which are absorbed by the intestinal wall. Digestion in the intestine
+is carried on through the agency of a number of ferments, the more
+important of which are supplied in the juice manufactured by the
+pancreas. The pancreatic secretion contains three separate and
+distinct ferments, which act respectively upon carbohydrate, protein,
+and fat. The absorption of fat, however, is materially assisted also
+by the action of the bile.
+
+A part of what we eat always escapes digestion; the unused portion,
+it has been estimated, is somewhat less than one-tenth of an ordinary
+mixed diet. The residue from vegetables is notably larger than the
+residue from meat. The _undigested_ portions of all the food-
+stuffs collect in the lowermost portion of the intestine and form a
+part of the feces. Here also are gathered the _indigestible_
+material we have eaten, the products of bacterial decomposition in
+the intestine, and other waste substances that the body should throw
+off.
+
+HOW MUCH FOOD IS NEEDED DURING PREGNANCY?--In connection with the
+development of the child we have already referred to the difference
+in the purpose of the constructive processes which go on in the
+earlier months of gestation and those which take place in the later
+months. In a general way the first half of pregnancy is occupied with
+the formation of the embryo from relatively simple structural
+elements, the second half with its growth into an infant, which
+acquires ninety per cent. of its substance and weight at birth after
+the fifth month of embryonic development. A similar contrast may be
+observed in the nutritional processes of the mother. Often, at the
+beginning of pregnancy, the appetite is poor and there is
+indisposition of one kind or another, with the natural result that
+there is slight if any change in the mother's weight; whereas later a
+period ensues when her appetite increases, her health improves, and
+she gains in weight.
+
+Since it is natural that the weight of the mother should remain
+practically stationary during the early months of pregnancy, it is
+clear that a diet which has previously been ample will likewise be
+sufficient for some time after conception has taken place. To most
+persons, however, it is not clear that the quantity of food
+ordinarily eaten will suffice also during the later months of
+pregnancy. On the contrary, popular opinion holds that the
+prospective mother "should eat for two." It is not unimportant to
+point out the erroneous character of this superstition, because
+overeating during pregnancy is much more likely to provoke discomfort
+than insufficient nourishment.
+
+In order to comprehend the nutritional needs of the prospective
+mother, one must keep in mind the fact that our food always serves
+two purposes. These are, as we have seen, to build or to repair
+tissue and to furnish heat and energy. Since these needs of the body
+during pregnancy--as at all other times--are best understood when
+considered in their relation to the food-stuffs which supply them, we
+shall take up these various ingredients separately.
+
+Protein, which repairs tissue and also furnishes the substance from
+which new tissue is made, is used more economically during pregnancy
+than when the maternal functions are inactive. As a result of this
+economy the same allowance of protein which is sufficient before
+conception is sufficient also during pregnancy. This fact has been
+put in the clearest light by extensive observations made upon
+animals. Dogs which were not pregnant, for example, have been
+carefully fed so that their food should contain just enough protein
+to cover the needs of the body and keep their weight constant.
+Subsequently, when these animals became pregnant precisely the same
+amount of protein was fed to them. The result was that they gained in
+weight, and at the same time the waste products of protein they threw
+off were notably diminished. Such observations, of which there have
+been a large number yielding concordant results, may be safely taken
+to mean that an amount of protein previously satisfactory for the
+animal is also sufficient for her during pregnancy. We are forced to
+conclude that protein was used more sparingly in the latter
+condition--a view which has been repeatedly confirmed with regard to
+human beings as well as animals. It is found, for example, that an
+amount of protein competent to meet the needs of a man of a given
+weight will not only provide for the wants of a woman of equal weight
+while she is pregnant, but will also leave a surplus sufficient for
+the growth of the fetus.
+
+With regard to the mineral substances, likewise investigations
+indicate that the "housekeeping" of the body during pregnancy
+proceeds along unusually economic lines. It is not advisable,
+therefore, to make any change in the diet with regard to these
+substances. Attempts have been made to cut down the amount of
+minerals in the food for the purpose of softening the fetal skeleton.
+The success sometimes attributed to these efforts is, however, very
+doubtful, for we know that the mother's tissues will be robbed of
+minerals for the embryo whenever her food fails to contain them in
+sufficient amount for her own needs and those of the child.
+Practically speaking, the mineral content of diet during pregnancy
+requires no thought, for so long as meat and vegetables are eaten in
+satisfactory quantity the mineral nutrition will take care of itself.
+
+The food-stuffs which supply heat and energy, since the amount of
+energy utilized by the body during the latter months of pregnancy is
+somewhat in excess of that previously required, do not follow the
+same rule as the protein and the mineral matter. It has been found
+that just before the fetus becomes mature the energy requirements of
+the mother are approximately one-fifth greater than in the non-
+pregnant condition. It is certain, however, that no extra demand for
+energy exists until the fifth or sixth month of pregnancy, and that
+the excessive requirement is extremely small until the last three or
+four weeks. Even then the prospective mother requires less energy-
+giving food than the average man.
+
+Since the body handles carbohydrate more readily than fat, it is
+preferable that whatever additional energy pregnancy necessitates
+should be supplied by carbohydrates. An increase in the daily
+consumption of fatty food, over and above that previously found
+agreeable, is not only unnecessary but undesirable. Every-day
+experience teaches that less fat taken with the meals promotes the
+comfort of the prospective mother. A glass of rich milk a little
+before meal time, however, not only makes up for this omission but
+also prevents "heart-burn," a very common ailment of pregnancy.
+
+Although there is an appreciable increase in the quantity of starch
+and sugar utilized toward the end of pregnancy, it is generally quite
+unnecessary to increase these materials correspondingly in the diet.
+Nearly everyone eats more of all the food-stuffs than the body needs.
+In the case of the prospective mother the surplus ordinarily taken
+meets every need incident to her additional energy requirements.
+Because we eat more than we need, someone has said, with as much
+truth as humor, that prospective mothers "neither want nor need to
+eat for two. The fact is more likely that enough for one is too much
+for two." For the average woman it is wiser to take less during
+pregnancy rather than more, for over-indulgence is apt to lead to
+indigestion. The moment when the appetite is satisfied should be
+accepted as the stopping point, and that will be instinctively
+recognized if one eats deliberately, and thoroughly masticates the
+food.
+
+Regularity in the hour of eating is always healthful, and for some
+prospective mothers three meals a day prove quite satisfactory. Not a
+few, however, who adhere to this habit make the mistake of eating
+more than is wise; and large meals are particularly inappropriate to
+pregnancy. On this account most prospective mothers will be more
+comfortable if they take some simple and wholesome nourishment at
+fixed times between meals. Such an arrangement modifies a ravenous
+appetite, and it is, at the same time, beneficial to those who are
+not inclined to eat enough at the regular meals. If small amounts of
+food are taken five or six times a day, a tendency to be nauseated,
+which is not uncommon in the early months of pregnancy, can often be
+averted. In the latter months, too, because the capacity of the
+stomach is diminished through the encroachment of the enlarged womb,
+frequent meals generally contribute toward comfort and health. While
+the inevitable consequences of overloading the stomach are to be
+avoided at all times of the day, it is especially important to
+remember the disagreeable results of a hearty meal at night. The
+evening meal should be a light one and should be eaten three or four
+hours before going to bed.
+
+THE IMPORTANCE OF LIQUID NOURISHMENT.--Every prospective mother
+should have brought to her attention the great importance of drinking
+water at regular times and in larger quantities than was formerly her
+custom. Since water constitutes two-thirds of the substance of our
+bodies, it is necessary, of course, for everyone; but during
+pregnancy it is especially necessary for the building of new tissue
+and for safeguarding the mother's kidneys. Prospective mothers would
+protect themselves against a number of ailments if they were more
+careful to drink a sufficient amount of liquids. They may easily
+determine whether they are doing so, for whenever the urine passed
+during twenty-four hours measures less than a quart, they are not
+drinking enough. Generally the daily elimination of urine fluctuates
+between two and three pints; a larger amount, however, is rather a
+favorable indication than the reverse.
+
+The variations in the quantity of liquids that healthy persons drink
+make it impossible to say just how much anyone should take. It may be
+said with confidence, however, that women who are pregnant should
+consume at least three quarts of fluid every day, and by far the
+greater portion of this should be water. The rest may be taken in the
+form of milk, soup, cocoa, and chocolate. Against the moderate use of
+tea and coffee no valid objection can be raised; the tradition that
+they may cause miscarriage is incorrect. For well-known reasons the
+habitual use of strong tea or coffee is always harmful, and it is,
+therefore, equally as objectionable during pregnancy as at other
+times. Beverages which contain a small percentage of alcohol, such as
+malt and beer, may or may not be helpful; they should be regarded as
+medicine, not to be taken without consulting a physician.
+
+THE CHOICE OF FOOD.--There is no diet specifically adapted to the
+state of pregnancy; the prospective mother may usually exercise the
+same freedom as anyone else in the selection of food. She should,
+however, choose what will agree with her and avoid that which she
+cannot digest and assimilate. Personal experience in the main must
+guide everyone as to what to eat, and most women may follow the
+dictates of appetite after they become pregnant as safely as they did
+before.
+
+It is true, of course, that careful scientific observations have
+taught not only what the nutritional requirements of the body are,
+but also how the diet may be arranged to satisfy these requirements
+most conscientiously and economically. "Caloric Feeding" is the name
+given the method which aims to furnish an individual the exact amount
+of food, and usually to furnish it at a minimum cost. Its principles
+are of great practical importance to the commissary of an army or to
+the purveyor of an institution which provides for large numbers of
+people; but it is neither necessary nor advisable that the diet of
+any healthy individual be regulated solely with a view to satisfying
+the actual requirements of his or her body. Food should possess other
+qualities than fuel value: first of all it must be appetizing, for
+appetizing food receives the most thorough digestion.
+
+We all know how variable are our appetites. What appeals to one will
+not appeal to another, and frequently the same person has no appetite
+to-day for food that she will eat with relish to-morrow. Precise
+rules, therefore, to guide healthy persons in the selection of their
+food are not obtainable; neither are they desirable, for the exercise
+of individual preference possesses notable advantages. In order,
+however, that there may not also be disadvantages, the prospective
+mother, like anyone else, must be content to choose food that is
+simple, wholesome, and of such a character that it will not throw an
+undue burden upon the digestive organs.
+
+During pregnancy some uncooked food should be eaten every day. Ripe
+fruit answers the purpose admirably. At all seasons of the year fruit
+of one variety or another, such as apples, peaches, apricots, pears,
+oranges, figs, cherries, pineapples, grapes, plums, strawberries,
+raspberries, and blackberries may be obtained and should have a place
+in the diet. In making a choice personal taste alone need be
+consulted.
+
+Fruit contains a large proportion of water as compared with other
+articles of diet; and, therefore, is especially capable of quenching
+thirst. Fruit also lessens the desire for sweets, acts as a laxative,
+and furnishes mineral material which the body needs. Its laxative
+effect is most pronounced when it is eaten alone, as, for example, in
+the morning before breakfast or at night upon going to bed; cooked
+fruit taken with the meals acts much less effectively. Fruit and
+vegetable salads are wholesome, but cannot be recommended
+indiscriminately during pregnancy, for not infrequently the dressing
+used with them causes discomfort. Under these circumstances it is
+obvious that one should do without salads.
+
+The cereals wheat, corn, rye, oats, and barley are the most prominent
+source of starch in an ordinary diet. Breakfast foods manufactured
+from grain are not only nutritious in themselves, but their value is
+increased by the milk or cream used with them. Bread is the staple
+starch-containing food in this country, and starch is our main source
+of energy, but it is necessary to eat only a small quantity of bread,
+if the diet includes a relatively large amount of vegetables. It is
+advantageous to use bread made from unbolted flour (Graham bread) or
+from corn meal, because the coarse undigested residue which they
+leave stimulates the movements of the intestine and assists in
+overcoming the constipation which is generally associated with
+pregnancy. Pastry must be avoided by those who suffer from
+indigestion; and every prospective mother should eat pastry only
+occasionally, and not very much of it at any time. The best desserts
+are raw and freshly cooked fruit, preserves, gelatin, custard, ice
+cream, and light puddings, such as rice and tapioca.
+
+Vegetables should be abundant in the diet of every prospective
+mother. Some of them, however, are digested with difficulty, and on
+this account cabbage, cauliflower, corn, egg-plant, cucumbers, and
+radishes should be eaten sparingly. Occasionally it will be necessary
+to exclude them from the diet altogether. Other vegetables produce
+flatulence, and for that reason parsnips and beans may cause
+discomfort. The prejudice, however, which exists against onions,
+asparagus, and celery should not be heeded; all of them are harmless,
+and celery thoroughly cooked with milk is very wholesome. Besides
+these, moreover, there are many highly nutritious and easily
+digestible vegetables which can be freely recommended, such as both
+sweet and white potatoes, rice, peas, lima beans, tomatoes, beets,
+carrots, string beans, spinach, Brussels sprouts, and lettuce.
+
+Vegetable food contains all the material necessary to sustain life,
+and some persons prefer to adhere strictly to a vegetarian diet. Most
+prospective mothers, however, find a mixed diet more agreeable, and
+this is sufficient reason for using it. Furthermore, no fair
+objection can be raised against the use of animal food, provided the
+pregnancy is normal. It is important, nevertheless, to remember that
+meat contains protein in concentrated amounts, and that meat once a
+day answers every need not only of the mother but also of the growing
+fetus.
+
+The ideal animal foods are milk and eggs; they contain every
+ingredient necessary to repair old and to form new tissues. But
+usually the prospective mother may have any animal food she wishes:
+beef, veal, lamb, poultry, game, fish, oysters, and clams. The
+relatively large fat-content of pork, goose, and duck renders them
+indigestible for some persons, who, of course, should not eat them.
+
+From what we have learned about foods in general and their relation
+to pregnancy it is clear that the question so often asked by
+prospective mothers, "Are there any special directions regarding my
+diet?" may be briefly answered as follows: Under no circumstances is
+the need of food increased in the first half of pregnancy. During the
+last two or three months, while the most notable growth of the fetus
+is in progress, there is a perceptible increase in the amount of
+energy expended by the mother, and this may be readily supplied by a
+glass of milk or some equally simple nourishment between meals.
+Furthermore, throughout pregnancy, most women are made most
+comfortable by frequent small meals; they will almost certainly
+suffer discomfort if heavy meals are eaten three times a day.
+
+The most nearly ideal diet consists of very little meat and a
+comparatively rich allowance of vegetables and fruit. The food should
+be chosen with regard to individual appetite and should be varied
+frequently. Thorough mastication always increases the efficiency of a
+diet. Thus the food will be most perfectly mixed with saliva and
+broken into fragments which can be readily attacked by the digestive
+juices of the stomach and the intestines.
+
+CRAVINGS.--There is a well-known tradition that women who are
+pregnant are subject to longings for one article of diet or another,
+and that unless the desire be promptly gratified the child will be
+"marked." In the light of what has already been said regarding
+maternal impressions, this evidently is nonsense. A prospective
+mother, like anyone else, does frequently desire one article of food
+more than another. So long as the object of her wish is not obviously
+harmful, it should be granted; but if it is not granted no harm will
+come to the child.
+
+Remarkable instances in which disgusting substances have been craved
+and eaten are often talked about and have even found their way into
+popular novels. The unfortunate victims of these unnatural cravings
+are not of sound mind. With reference to them a physician of
+unusually broad experience wrote fifty years ago, "I have never met
+with any example of this sort; which leads me to infer that these
+longings are more frequent in books than in the practice of our art."
+This conclusion is even more fully justified to-day than when
+originally expressed.
+
+THE RELATION BETWEEN THE MOTHER'S DIET AND THE SIZE OF THE CHILD.--
+With the beginning of careful, scientific study of the nutritional
+problems of pregnancy, investigators were interested to learn the
+source of the material which was used to build up the child's body.
+Two possibilities suggested themselves: one that the material came
+from the mother's food and the other that it was derived from her own
+flesh. In order to determine which of these methods was the natural
+one, animal experimentation was resorted to and gave identical
+results in the hands of independent observers. It was found, as I
+have already stated, that the same diet which had previously kept an
+animal's weight constant was sufficient to meet her requirements
+during pregnancy and also to provide for the growth of her offspring.
+The mother animal was actually found somewhat heavier at the
+termination of pregnancy than at the beginning. It seemed fair to
+conclude, therefore, that nutrition had proceeded along more economic
+lines, and that under these conditions the customary diet had
+furnished the material for the formation of the young. Still other
+observations indicated that, if the food is not sufficient for both
+mother and offspring, it is Nature's plan to protect the young and
+leave the mother's wants incompletely satisfied. On the other hand,
+when an unnecessarily large amount of nourishment is taken, the
+excess is stored partly in the young, and partly in the mother's
+body.
+
+There can be no doubt that the results of such observations upon
+animals are applicable to human beings. Everyone familiar with the
+practice of obstetrics knows that women who gratify enormous
+appetites during pregnancy, especially if they also fail to take
+exercise, give birth to large children. On the other hand, it is said
+that children born during times of famine are frequently delivered
+prematurely, or, if mature, they are small and puny. A similar though
+much less marked contrast exists between the babies of the working
+classes and the well-to-do, and clearly indicates that the weight of
+the baby varies directly with the food of the mother.
+
+The quantity of the food is more influential than its quality, though
+the latter is also a factor in determining the size of the child. An
+excessive amount of starch or sugar in the mother's diet is stored as
+fat in the child. On this account it is reasonable to eat sparingly
+of candy, cake, and other sweets; but further attempts to reduce the
+weight of the fetus by discrimination against different articles of
+food are not advisable.
+
+The various theories that have been advanced with a view to reducing
+the size of the child are impracticable; some of them, rigidly
+carried out, would actually jeopardize the health of both beings. All
+of them are designed to make the infant's bones soft and to diminish
+the fat in its body. To this end, generally about two months before
+the expected date of birth, the mother's diet is arranged to consist
+chiefly of meat; and as far as possible she is denied candy, sweet
+desserts, soup, bread, cereals, vegetables, and water. Such a diet
+overlooks, among other things, the tremendous importance of liquids
+to the woman who is pregnant. Certainly its indiscriminate use would
+result in far more harm than good; and no one should adopt it without
+minute directions from a physician.
+
+Attempts to make the infant's bones soft by limiting the mother to
+food containing extremely small amounts of lime and other minerals
+are also unnatural, for we have learned that whenever the mother's
+food fails to contain the material the fetus requires the mother's
+tissues are called upon to supply it. Under these conditions,
+therefore, her bones will give up their lime.
+
+It is of the very first importance that the mother's nourishment be
+correct from the standpoint of her own requirements, and such
+treatment will also redound most beneficially to the child. She
+should never fall, however, into the error of over-eating, which will
+not benefit her and will cause unnecessary growth of the fetus. On
+the other hand, there can be no justification for measures that tend
+to weaken her. She may be careful, in other words, to avoid over-
+growth of the fetus, but should not adopt a diet so restricted as to
+interfere with normal development. So long as her health is
+successfully maintained, she may give herself no concern as to what
+the size of the child is likely to be. That is a detail which
+concerns her physician, and which will be observed by him several
+weeks before the expected date of birth.
+
+
+
+
+CHAPTER V
+
+
+THE CARE OF THE BODY
+
+The Bowels--The Kidneys--The Skin--Bathing--Douches--Clothing--
+Corsets--The Breasts.
+
+If we stop to think it is only too apparent that the human body is a
+machine. We seize energy in one form and convert it into another,
+just as truly as do the windmill, the locomotive, and the dynamo. In
+the case of the human machine, the latent energy of the food is
+turned into the various activities of everyday life. Our bodies
+utilize their fuel more perfectly than any machine that man has
+invented; but they fail, nevertheless, to do so completely. And just
+as the efficiency of an engine cannot be maintained unless the smoke
+escapes and the ashes are raked away, so no human being can enjoy
+health unless his waste products are promptly removed. The task of
+removal, as most of us know, is assumed by our excretory organs,
+which include the bowels, the kidneys, the skin, and the lungs.
+
+During pregnancy the mother must get rid not only of her own waste
+products, but also of those of the child. The waste products of the
+child, if weighed, would not amount to a great deal; but they are by
+no means negligible. So far as we can tell, it is chiefly on account
+of their peculiar character that they increase the work of the
+mother's excretory organs. Whatever the cause, they do increase it,
+and experience has taught us that these organs must always be kept in
+a healthful condition to protect both the mother and the child from
+harm. Consequently a prospective mother who wishes to take proper
+care of her body must, in the first place, direct her attention
+toward keeping up the normal activity of all the excretory functions.
+
+THE BOWELS.--While pregnant, nine out of ten women suffer from mild
+constipation. Those who have been previously troubled with this
+complaint may find it aggravated from the outset, but in most
+instances it does not appear until after several months have passed.
+Constipation is explained by the fact that the enlarged womb presses
+against the intestines; and, as the enlargement increases,
+constipation generally becomes more pronounced. No doubt there was a
+time when women, perhaps unconsciously, counteracted this natural
+result of pregnancy by the use of a diet consisting largely of fruit
+and vegetables and also by outdoor exercise. Such measures, indeed,
+still afford the simplest means of overcoming constipation.
+
+Throughout pregnancy the bowels should move at least once every day.
+When they do not, some of the waste material that should be removed
+is absorbed by the body and seeks to leave it through the organs that
+are already doing their full share of work. For example, under such
+conditions, the kidneys, instead of exerting themselves more
+vigorously, may become less active than they were.
+
+It is everyone's duty to form the habit of having the bowels move
+regularly. Now the most favorable opportunity for assisting the
+intestines to empty themselves occurs shortly after meal-time, since
+the involuntary movements of the intestines are most active while
+digestion is in progress. It should be regarded as an imperative
+duty, therefore, to grant Nature such an opportunity every morning
+just after breakfast. This should be done at a definite hour, day
+after day, even though the inclination is absent; and in many
+instances the desired habit will be formed.
+
+A glass of water on going to bed or on getting up has a laxative
+effect; and there are other dietary measures which may be employed
+with advantage. Thus, coarseness of the food, as we know, stimulates
+intestinal activity, and this fact explains the peculiar value of
+Graham bread, bran bread, and corn bread. Fresh fruit and vegetables
+counteract constipation for two reasons, namely, because they leave
+in the bowels a relatively large amount of undigested substance, and
+because they contain ingredients that have a specific purgative
+action. Such ingredients are especially noteworthy in rhubarb,
+tomatoes, apples, peaches, pears, figs, prunes, and berries.
+
+Enemas used as a routine measure are mischievous. They interfere with
+the "tone" of the bowel-muscle so that it acts sluggishly and bring
+about a condition in which the bowels will not move without
+artificial stimulation. At best these irrigations remove no more than
+the contents of the lower bowel, and should be employed only when
+there is acute and urgent need of clearing out the rectum.
+
+Obstinate constipation is uncommon, and strong purgatives are seldom
+needed. If they become necessary, a physician should be consulted as
+to what to take. Whenever dietary measures and exercise, which is
+discussed in the next chapter, fail to counteract the natural
+tendency toward constipation, the prospective mother may generally
+resort to "senna prunes" or some equally simple and harmless
+household remedy. Senna prunes are prepared as follows: Place an
+ounce of dried senna leaves in a jar and pour a quart of boiling
+water on them. Allow to stand two or three hours; strain off the
+leaves and throw them away. To the liquor add a pound of prunes.
+Cover and place on the back of the stove, allowing to simmer until
+half the liquor has boiled away. Add a pint of water and sweeten to
+taste, preferably with brown sugar. The prunes should be eaten with
+the evening meal. The number required must be learned from
+experience. Begin with half a dozen, and increase or decrease the
+number, as required. The syrup is an even stronger laxative than the
+prunes.
+
+THE KIDNEYS.--Any one may judge for herself whether or not the bowels
+are doing their work satisfactorily, but not so with the kidneys. For
+this purpose the urine must be examined by a physician. In spite of
+this fact, considerable responsibility rests upon the prospective
+mother, whose duty it is to collect the specimens properly--a detail
+that is apt to be neglected. It is impossible to urge too strongly
+the importance of saving, at regular intervals, all the urine passed
+in twenty-four hours, of protecting it from decomposition, and of
+sending a sample to the physician. The intervals may be longer at
+first, for the kidneys have very little extra work to do until the
+sixth month. Usually, therefore, it is a satisfactory plan to send a
+sample for analysis the first of each month during the early half of
+pregnancy; but during the latter half one should be sent the first
+and the fifteenth of each month.
+
+To estimate the exact amount of urine passed in twenty-four hours and
+to protect it properly, in the first place, the vessel in which it
+will be collected should be carefully scalded out. As a further
+precaution against decomposition, add a teaspoonful of chloroform to
+the vessel, which should be kept covered, and not allowed to stand in
+a warm room. Unless these details are conscientiously observed,
+putrefaction may take place and vitiate the analysis the physician
+wishes to make. The precise amount of urine which the kidneys excrete
+in twenty-four hours will be determined as follows: At a convenient
+time, for example at 8 A.M., empty the bladder and throw the urine
+away; this marks the beginning of the observation. Subsequently, save
+all the urine passed during the day and night, and finally at 8
+o'clock the next morning empty the bladder and add this urine to that
+previously collected. The total amount, thus collected, should be
+measured.
+
+It is unnecessary to send all the urine to the physician; six ounces,
+somewhat less than half a pint, will be enough. But the physician
+should know what the total amount was found to be; therefore, a
+record of the measurement, the date, and the patient's name should
+accompany the sample. If limited to a single fact about the urine, it
+would be most helpful to know the amount passed during the twenty-
+four hours. In this way, as I have already pointed out, the patient
+herself may derive valuable information, for if the urine is scanty
+in amount--that is, less than a quart--she should drink more water.
+
+Unscrupulous newspaper advertisements alarm people through incorrect
+statements about trouble with the kidneys. For example, they declare
+that a sediment in the urine is a sign of disease; but that is false.
+The mere act of cooling sometimes causes substances to crystallize
+out of perfectly normal urine. Or, putrefactive changes which
+frequently take place after the urine has stood for a time may cause
+some of its normal constituents to be precipitated. A sediment,
+either white, pink, or yellow, may indicate that the urine is too
+concentrated, and consequently means that the individual should drink
+water more freely; but it generally means nothing more serious. The
+really important abnormal constituents of the urine, namely, albumin
+and sugar, never form a sediment.
+
+"Pain in the back" is a complaint frequently used to defraud the
+public. This symptom does not indicate Bright's disease. It is
+generally due to the muscles far away from the kidneys, with which,
+usually, the pain has nothing whatever to do. Similarly a desire to
+pass the urine frequently does not indicate any disturbance of kidney
+function, but is explained by the pressure of the enlarged womb
+against the bladder; it is a very annoying, yet a natural, result of
+pregnancy.
+
+THE SKIN.--The functions of the skin are at the very foundation of
+health. It protects the delicate structures which it covers, assists
+in the regulation of the temperature of the body, and excretes waste
+products. The excretory function of the skin is always active, but we
+are unconscious of this activity except on warm days and at times
+when we perspire freely. In the coldest weather, however, the body
+throws off what physiologists call the "insensible perspiration." The
+most important measures for the care of the skin are those intended
+to insure the activity of the sweat glands, namely, bathing and
+proper clothing. But before considering these measures, we will
+describe certain alterations in the skin which cannot escape the
+notice of the prospective mother, and which she is likely to
+misinterpret.
+
+On account of the growth of the uterus the abdominal wall is
+stretched during pregnancy. To a certain degree the skin yields to
+the distention, but it finally cracks, and lines appear which are
+commonly called "pregnancy streaks." At first they are delicate and
+pink or blue in color; later they become white and more extensive.
+
+The streaks indicate the situation of small breaks in the deeper
+layer of the skin, which is less elastic than the upper layer. They
+are not painful, and should never cause anxiety. Their size and
+number vary with the degree of abdominal distention, which in turn
+depends upon various factors, such as the size of the child and the
+quantity of amniotic fluid. Although these streaks are most
+frequently located upon the lower part of the abdomen, they may
+extend to the outer sides of the thighs; and occasionally appear over
+the breasts, since they too enlarge during pregnancy. Stretching of
+the skin, of course, is not confined to pregnancy; consequently, the
+same kind of streaks often appear in people who are growing stout.
+
+Attempts to prevent or limit the pregnancy streaks prove futile.
+There is a common belief that they may be prevented by the use of
+vaselin, goose-grease, mutton-fat, or some one of a variety of
+lotions; but this teaching is not borne out by experience. None of
+these applications, however, are harmful, and there can be no
+objection to using them except that they cause needless soiling of
+the clothing. After the child is born the streaks fade of their own
+accord, though they rarely disappear entirely.
+
+In certain localities the skin grows darker during pregnancy. We have
+already referred to the deepening of the color around the nipple as
+one of the signs of pregnancy; a similar but much less pronounced
+discoloration occurs about the navel, which also becomes shallow and
+may begin to pout in the latter months of pregnancy. About this time,
+with very few exceptions, there appears a more or less intense brown
+line which runs downward from the navel in the middle of the abdomen.
+Sometimes, though not very often, small dark areas, which have been
+called "liver spots," appear elsewhere over the body. The name is
+unfortunate, for the spots do not indicate a disorder of the liver.
+
+At present it is generally admitted that alterations in the color of
+the skin during pregnancy are due to deposits of iron. This mineral
+substance, among others, as we have learned, is required for the
+development of the embryo. The child is born with a supply of iron
+calculated to meet its needs for about a year. Such a reserve is
+necessary, as Bunge has pointed out, because human milk does not
+contain enough iron to satisfy the infant's requirements. During
+pregnancy, therefore, the mother's blood transports iron to the
+placenta, where it can be absorbed into the child's system; and while
+being thus transported some of it is deposited in the maternal
+tissues. The deposits are especially frequent, as I have mentioned,
+in the middle line of the abdomen, on account of the arrangement of
+the blood vessels there. Deposits elsewhere may depend upon other
+conditions; but whatever their cause the pigmentation vanishes a
+short time after the birth.
+
+Alterations in the color of the skin have no effect upon its
+excretory function, which, indeed, generally becomes more active
+during pregnancy. According to one estimate, the average person
+possesses twenty-eight miles of sweat glands. If these figures are
+not sufficient to demonstrate the importance of the skin as an
+excretory organ, surely no one will fail to be impressed by the
+tragic result which in one case followed throwing all the sweat
+glands out of action. This was brought about in the case of a young
+boy whose body was covered with gold leaf to provide entertainment at
+a Parisian festival. The living statue was not exhibited, however,
+for shortly after the youth was gilded he became ill and died.
+
+In health more than a pint of water is eliminated through the skin
+every day, and along with it waste products are removed from the
+body. Exercise, hot drinks, warm weather, and heavy clothing promote
+the activity of the sweat glands. Under certain circumstances
+physicians endeavor to relieve the kidneys by stimulating their
+patients to perspire freely. It should be clear, therefore, that when
+a prospective mother naturally perspires it is a good indication.
+Attempts to stop the perspiration are always ill advised; rather
+should this function be encouraged by keeping the skin in good
+condition with baths and warm clothing.
+
+BATHING.--The accumulation of dead skin, grease, dust, and dried
+perspiration on the surface of the body hinders the actions of the
+sweat glands. Some of this material is wiped off by the clothing, and
+more of it is removed by washing with plain water; but the most
+effectual cleansing results from a liberal use of warm water and
+soap.
+
+Since the prospective mother must throw off the waste products of the
+embryo as well as those of her own body, it is obvious that
+cleanliness is never more important than during pregnancy. For this
+reason she should take a tepid tub bath or shower every day. It is
+not necessary that the temperature of the bath be determined with
+accuracy or that it be always the same; but generally a temperature
+between 80 and 90 degrees F. is found most agreeable. At this
+temperature a bath is termed "indifferent," because it is neither
+stimulating nor depressing; it is employed purely for cleansing the
+body. Every part of the body should be well soaped, and from ten to
+fifteen minutes should be given to washing all the exposed surfaces.
+The best time for such a bath is just before going to bed, though
+there is no objection to taking it during the day, provided that two
+hours have passed since the last meal, and that another hour is
+permitted to elapse before one goes out of doors or undertakes anything
+that requires exertion.
+
+Prolonged hot baths are fatiguing. They draw the blood from the
+interior to the surface of the body; and during pregnancy they are
+particularly depressing. Vapor and steam baths have a similar action
+and should never be taken without the consent of a physician. They
+serve admirably for the treatment of rare complications of pregnancy;
+but, like medicine, their use should be limited to cases in which
+they are clearly indicated.
+
+Unless disagreeable results are noticed, those who have become
+accustomed to cold baths may continue to take them during pregnancy,
+but others should not. If, however, the temperature of the water is
+modified so that it will not produce a shock, no one need omit the
+morning plunge or shower which most persons find invigorating.
+Sponging answers the same purpose, for the intent of the morning bath
+is not to cleanse the body but to arouse the circulation. A thorough
+rub-down assists in bringing the blood to the surface of the body.
+Bath and massage together thus constitute a kind of skin gymnastics
+especially beneficial throughout pregnancy.
+
+Although hot foot-baths have sometimes been thought to cause
+miscarriage, there is no good reason for believing they ever do. Sea-
+bathing, on the contrary, may be directly responsible for such a
+mishap. It is true that pregnant women sometimes indulge in surf-
+bathing without harmful results; nevertheless the danger of
+miscarriage they assume is not slight. The shock of the low
+temperature, the exertion required to keep a firm footing, and the
+pounding of the surf against the abdomen are all unfavorable
+influences which more than counterbalance any advantage of such a
+bath. On the other hand, there is slight risk if any in bathing in a
+quiet stream or lake.
+
+DOUCHES.--A great many women have the conviction that the vagina is
+not clean and should, therefore, be regularly cleansed by means of
+irrigations. This assumption is false and the treatment based upon it
+is unnecessary. In structure the walls of the vagina closely resemble
+the skin, but unlike the skin they do not contain glands; the vagina,
+therefore, has nothing to do with the elimination of waste products
+from the body. The secretion which issues from the vagina really
+originates in the glands around the mouth of the womb, and serves to
+protect the birth-canal against infection from harmful bacteria.
+
+Careful examinations have shown that under normal conditions, which
+of course include pregnancy, disease-producing bacteria are absent
+from the vagina; in this respect the vagina is even cleaner than the
+skin, for disease-producing bacteria are present on the surface of
+the body. The vaginal secretion becomes more abundant during
+pregnancy, and the increase is interpreted as an additional guarantee
+against infection at the time of labor. So far as possible,
+therefore, this natural antiseptic should not be disturbed.
+
+The advice to abstain from douches will not be adopted by every
+prospective mother without protest, for, as I have said, many women
+regard them as necessary to cleanliness. Others who have delicate
+skins are occasionally annoyed by the irritation of the vaginal
+secretion, which is not only increased during pregnancy but has a
+more pronouncedly acid character. Under extraordinary circumstances,
+it may be permissible to use douches in the early part of pregnancy,
+but it is practically never advisable to do so during the month
+preceding the expected date of confinement. Furthermore, at no time
+should the use of douches be begun without consulting a physician.
+
+A more rational hygienic measure for the relief of itching and
+smarting about the vaginal orifice consists in removing the secretion
+as soon as it appears. In other words, the external parts should be
+kept clean and dry. Great comfort is often derived from the use of a
+"sitz-bath," which may be easily prepared by placing a small tub upon
+a low stool and pouring in warm water (about 90 degrees F.) until it
+is five or six inches deep. Cold sitz-baths are useful in the treatment
+of hemorrhoids. Whether the bath be hot or cold, the treatment should
+continue from ten to fifteen minutes, and after it the skin should be
+thoroughly dried.
+
+A special form of tub, called a "bidet," has been devised to
+facilitate bathing the parts in question. The device is convenient
+but expensive, and is certainly not essential. Every purpose will be
+served by the small tub, provided the desired temperature of the bath
+is properly maintained by changing the water as may be necessary.
+
+CLOTHING.--In these days at least it is not idle to remark that the
+first use of clothes is to keep the body warm; all other services
+they are made to perform are secondary and relatively unimportant.
+There are very good reasons, to be sure, for dressing neatly and even
+for dressing in accord with the fashion, so long as the prevailing
+styles are not harmful. Odd as it may seem, these are matters which
+are not without significance for the physical well-being of a
+prospective mother. Neat and comfortable clothing will help her to
+overcome a natural inclination to become a "stay-at-home," and on
+this account an inconspicuous way of dressing is often more valuable
+than medicine. So long as they do not attract attention, most
+prospective mothers go out in the day time, mingle with their
+acquaintances, and attend public places of amusement. Deference to
+fashion, therefore, may contribute substantially to good health.
+
+Yet no prospective mother can afford to forget that first of all her
+clothing must keep the body warm. Our clothing confines a cushion of
+air which prevents the escape of the heat that we generate. Now,
+since dry air conducts heat poorly and moist air conducts it readily,
+the underclothes should be made of material that absorbs the
+perspiration; otherwise the heat that the body generates is quickly
+lost. Woolen garments effectually absorb the perspiration and should
+be given the preference. Most persons who cannot wear wool next the
+skin must choose cotton, since silk and linen are much more
+expensive; there is not in this, however, a serious deprivation.
+Cotton undergarments are perfectly hygienic; adapting their weight to
+the season of the year, one will find them equally satisfactory in
+summer and winter.
+
+Except in summer every inch of the body should be covered with the
+underclothing; this means that high-neck and long-sleeve shirts and
+long drawers should be worn, for healthful activity of the skin can
+thus be best preserved. It is well known to physicians who practice
+obstetrics that the kidneys fail in their work more frequently during
+the winter than the summer. To my mind, this is chiefly explained by
+the way women dress. Even with light clothing the sweat glands
+respond actively to the heat of summer and thus relieve the kidneys,
+but in cold weather the sweat glands will not remove their share of
+the waste products unless the clothing is warm.
+
+Nature generally indicates that the body should be kept warm during
+pregnancy. Many prospective mothers complain of perspiring freely;
+others, if reproached because they are not clad warmly enough, reply
+that they must wear light clothing to keep from perspiring. Thus they
+discount or render absolutely ineffective a most important natural
+safeguard against serious complications. It cannot be too strongly
+emphasized that warm clothing helps to maintain healthful activity of
+the kidneys quite as much as a proper amount of exercise and the
+drinking of a suitable quantity of water.
+
+The texture of the outer garments should take into account this same
+quality of warmth; in other respects in selecting them personal taste
+is an excellent guide. Outfitters carry a variety of maternity
+garments; patterns for such garments are also sold by dealers, so
+that those who cannot afford the ready-made clothes will find it easy
+to have them made at home. Alterations in the clothing are compulsory
+as pregnancy advances, and should be timely, made in anticipation of
+inevitable development rather than in response to it. No prospective
+mother need go to the extreme of "Reform Clothes"; her apparel should
+illustrate both her good sense and her personal pride.
+
+It is obviously even more harmful during pregnancy than at other
+times to cramp the body by the clothing; the chest and the abdomen,
+the parts most likely to be compressed, are at such times most in
+need of freedom. To a slight degree natural causes always compress
+the chest from below upward; and on this account nothing should be
+allowed to hamper the expansion of the lungs from side to side. On
+the other hand, if the waist is constricted, not the breathing
+movements alone but also the growth of the womb will be interfered
+with. In order to avoid such disagreeable consequences, and at the
+same time to limit the extent of the maternity wardrobe, skirts may
+be fitted with practical devices which permit letting out the
+waistband as occasion demands. So far as possible, however, all the
+clothing should be hung from the shoulders, and under no
+circumstances should heavy skirts be worn.
+
+Shoes contribute toward health, or the lack of it, more significantly
+than the average person realizes. It is particularly advisable that
+prospective mothers should select foot-wear with care, because their
+bodies are heavier than usual. The feet are apt to become swollen in
+the latter months of pregnancy, and consequently the shoes should be
+roomy, but should always fit. To escape the discomfort of tight
+shoes, it is generally advisable to wear a shoe an inch longer and
+broader than the foot at rest.
+
+High heels have been proved a frequent cause of back-ache; half of
+such cases, in all probability, may be thus explained. High heels
+tilt the body forward in such a way that the erect posture can be
+maintained only by an unnatural tenseness of the back-muscles. Some
+strain of this kind is inevitable during the latter months of
+pregnancy on account of the enlargement and the position of the womb;
+it is reasonable, therefore, to minimize it by wearing low, broad
+heels.
+
+Besides being responsible for many cases of backache, high heels add
+greatly to the danger of tripping and falling; for this reason alone
+they should not be worn. Improper foot-gear and not the joints
+themselves deserve the blame for weak ankles. To prevent "turning the
+ankle," it is not necessary to restrict oneself to high shoes, but
+merely to see that the shoes that are worn have low heels and broad
+soles. Such shoes provide a sure, firm footing, and this the
+prospective mother particularly needs.
+
+CORSETS.--No question connected with women's dress has provoked so
+much discussion as the use of corsets. "Are corsets necessary to
+health?" has been differently answered by those who would appear to
+be equally competent authorities. In the time of our savage ancestors
+we may safely conclude that they were not used; and, therefore, it is
+really a question as to whether their continued use for generation
+after generation has finally made some support of this kind
+indispensable to the average woman. While that matter has not as yet
+been settled, it is obvious that custom is really responsible for the
+conviction of many women that they appear slovenly without corsets.
+On the other hand, not a few women, unmindful of fashion, never wear
+them; they testify that they are healthier for doing so. Whether this
+be true or not, no one can honestly believe that corsets will soon be
+banished; and the practical problem is to distinguish between those
+that may do good and those certain to do harm.
+
+During pregnancy the abdomen tends to fall forward and slightly
+downward, and though it is in pregnancies after the first that this
+tendency is most marked, every prospective mother will be more
+comfortable if she wears some sort of support to counteract what
+physicians term a "pendulous abdomen." Such a condition can be
+prevented by the use of several appliances, and the device best
+suited to the case should be chosen. Those who have never become
+accustomed to corsets will probably find a corset-waist or an
+abdominal supporter the most comfortable and useful. But the average
+young woman who has previously employed a sensible, well made, and
+loosely fitting corset need make no change until the third or fourth
+month of pregnancy. From then on she should wear a corset especially
+designed to conform with the changes that naturally occur in the
+figure.
+
+There is a plan, wrong in principle, which many adopt. Reasoning that
+it will be necessary to change the corset from time to time, and
+desiring to practice economy, a number of women purchase the cheapest
+corset at hand. This they replace with a larger one of the same style
+from time to time. The result is that an improperly fitting garment
+is worn continuously; and, in the end, this plan proves almost as
+expensive as, and far less suitable than, a proper corset, which
+would remain serviceable throughout pregnancy, or at least until a
+few weeks before confinement.
+
+Most, and probably all, of the injuries for which corsets are
+responsible result from their misuse. Naturally serious consequences
+may be expected if they are worn with the design of compressing the
+abdomen so as to render pregnancy less noticeable or perhaps to
+conceal it altogether. Thus worn, the corset becomes not only an
+instrument of torture but a source of danger both to the mother and
+to the child. Fortunately there are very few women who fail to
+appreciate the risk of thus striving to disguise their condition; and
+generally it is the needless discomfort, the trifling ills
+thoughtlessly inflicted upon themselves, that prospective mothers
+must be taught to avoid.
+
+At present there are manufactured a number of excellent maternity
+corsets; but there are also worthless types, and some likely to do
+harm. To judge them fairly they must be examined with regard to
+several requirements. In the first place the corset should not be
+stiff and should always be capable of easy adjustment; it must never
+interfere with the activity of any organ. As _enceinte_, the
+French word meaning pregnant, signifies, the prospective mother
+should be unbound. Tight clothing, as we have already remarked,
+hinders the breathing movements; it also interferes with the action
+of the heart, and occasionally causes the child to assume an
+unfavorable position within the uterus. The adjustment of the
+maternity corset to the progressive development of the body is
+generally provided for by means of extra lacings down the sides, and
+by the insertion of elastic material.
+
+The maternity corset, in the next place, must support the enlarged
+uterus. Correctly shaped and worn, it extends well down in front,
+fits snugly around the hips, and arches forward so as to conform to
+the curve of the abdomen. In place of the arching, or "cupping" as
+manufacturers call it, some maternity corsets have attached to their
+lower edge limp flaps of a strong fabric which lace together. The
+maternity corset-waist also should extend well under the abdomen and
+fit snugly around the hips.
+
+Finally, the corset should support the bust; the unpleasant
+sensations due to congestion of the breasts can be relieved most
+successfully by elevating them. It is exceedingly important, however,
+that the upper part of the corset should fit loosely, for otherwise
+the development of the breasts may be hindered, and the nipples
+depressed. As a further precaution against pressure above and also to
+secure the proper amount of support below, it is generally advisable
+to begin putting on the corset while lying down. In every case the
+corset should be laced from below upward; if laced in the opposite
+direction it fails to lift the womb and tends to push all the
+abdominal organs downward.
+
+Any kind of corset is likely to become uncomfortable toward the end
+of pregnancy; and of course should then be discarded. An abdominal
+supporter made of woven linen or rubber is frequently used to
+advantage during the last three or four weeks. With the first
+pregnancy the supporter is rarely necessary, but with subsequent ones
+it is frequently useful as early as the sixth month and is
+indispensable later. A substitute for the manufactured supporter can
+be made at home. Some such device often facilitates turning in bed,
+and on that account may be found even more useful at night than
+during the day.
+
+THE BREASTS.--Personal hygiene during pregnancy includes the
+preparation of the breasts with a view to success in nursing. All
+measures which promote the health of a prospective mother also serve
+to equip her for the nursing period; and in that sense the directions
+just given for the care of the body, as well as the rules to follow
+in the next chapter regarding a wholesome way of living, bear
+directly upon lactation. But there are also local measures to be
+adopted, some of which, such as supporting the breasts and avoiding
+constriction by the clothing, have already been mentioned. Finally,
+the nipples must be toughened and, if short or flat, they must be
+drawn out, for the best supply of milk will count for nothing if the
+infant cannot nurse comfortably.
+
+Some approved method of toughening the nipples so that they will not
+be injured by the sucking efforts of the infant, no matter how
+vigorous, should be begun eight weeks before the expected date of
+confinement; to start earlier will do no harm, but it is quite
+unnecessary. A number of procedures have been advocated, but in my
+own experience the following simple method is the best. The nipples
+are scrubbed for five minutes, night and morning, with soap and warm
+water. Generally, a soft brush, such as a complexion-brush, is
+satisfactory; but if this is too harsh, at first a wash cloth may be
+used. After having been thoroughly scrubbed the nipples are anointed
+with lanolin and covered with a small square of clean, old linen to
+prevent soiling of the clothing.
+
+Another method widely used, but somewhat less trustworthy, consists
+in bathing the nipples and applying a dilute solution of alcohol.
+Formerly brandy, whiskey, or cologne were recommended, but at present
+the following solution is commonly used. A tablespoonful of powdered
+boric acid is added to three ounces of water and thoroughly mixed.
+This is poured into a six-ounce bottle, which is then filled with
+grain alcohol (95 per cent). The solution is applied twice a day with
+a small piece of absorbent cotton.
+
+Well-formed nipples need only be toughened, but depressed nipples
+require additional treatment; and this should be begun about the
+middle of pregnancy. The old-fashioned way of making the nipple more
+prominent was to cover it with the mouth of a bottle which had
+previously been warmed. The vacuum created, as the bottle cooled,
+drew the nipple out. Similarly, the bowl of a clay pipe was sometimes
+placed over the nipple; the patient sucked the stem, the nipple was
+drawn into the bowl, and with persistence day after day success was
+often attained. A similar and somewhat more aesthetic procedure is
+now employed. The nipple is seized between the thumb and finger and
+alternately pulled out and allowed to retract. These manipulations,
+if faithfully practiced for several months, generally make the nipple
+prominent enough for the infant to grasp. Occasionally patients need
+to wear a contrivance sold at instrument stores which consists of a
+circular piece of wood modeled to fit the breast and perforated in
+the middle to accommodate the nipple. The appliance should not be
+used unless a physician thinks it necessary.
+
+Directions regarding the care of the breasts are sometimes taken
+lightly, yet such care is not a minor duty. Now and then a patient
+will pass through pregnancy uneventfully, will be delivered without
+difficulty, and will enter upon what promises to be a rapid
+convalescence when her recovery is interrupted by the development of
+inflammation of the breast. Because such a complication may be
+prevented, its appearance is the more to be regretted. Furthermore,
+the responsibility for its prevention usually rests with the patient
+herself. If she has been conscientious in preparing the nipples and
+continues to watch them throughout the nursing period, the annoyance
+of an abscess will almost certainly be prevented.
+
+
+
+
+CHAPTER VI
+
+
+GENERAL HYGIENIC MEASURES
+
+The Need of Fresh Air--Outdoor Exercise--Massage and Gymnastics--The
+Influence of Work upon Pregnancy--Relaxation and Rest--Is Traveling
+Harmful?--Mental Diversion.
+
+Besides the hygienic measures described in the preceding chapter,
+whose observance should be recognized as more or less obligatory,
+there are more general questions of conduct, such as exercise,
+relaxation, mental occupation, and amusement, which are also
+important. These measures, although frequently determined merely by
+personal inclination or by the force of circumstances, nevertheless
+exert a tremendous influence upon health. This fact a prospective
+mother is likely to realize, for she is certain to consider not only
+her own welfare but also that of the expected child; and she is
+consequently concerned about details of conduct that most persons
+would regard as trivial. She may, indeed, be too conscientious. Well-
+meaning friends, sometimes in reply to her questions and sometimes
+without solicitation, offer her a great deal of advice. Their
+counsel, aside from the fact that some of it may be misleading, may
+have the effect of prescribing so many rules that, if she followed
+them all, she would never lose sight of the fact that she is
+pregnant. Such a degree of self-consciousness is certain to make her
+unduly apprehensive. The proper attitude of mind is quite the
+opposite; so far as possible the prospective mother should forget
+that she is pregnant. This state of mind is really the more rational,
+for if a woman's daily life has previously been in accord with such
+simple rules of health as everyone should adopt, the existence of
+pregnancy calls for very slight changes.
+
+It does not, for example, condemn her to inactivity and seclusion,
+for it is advisable to lead a moderately active life during
+pregnancy. Of course, such obvious indiscretions as prolonged
+exertion, violent exercise, and fatiguing journeys should be avoided,
+for transgression of the laws of health brings its own punishment,
+generally in the form of discomfort, more quickly, and often more
+severely, during pregnancy than at other times. Yet, on the whole, it
+is more frequently necessary to emphasize to prospective mothers what
+they should do than what they should avoid. This happens to be the
+case because, as a rule, they are inclined to become recluses. For
+fear of attracting attention they often wish to give up outdoor
+exercise during the day; they stay away from public places of
+amusement, and deny themselves other pleasures to which they have
+been accustomed. Against this tendency they must be warned, for if
+they yield to it they will surely be the worse off both physically
+and mentally. Every prospective mother should make up her mind to
+enjoy recreation out of doors regardless of comments.
+
+THE NEED OF PURE AIR.--Outdoor life has been so urgently advocated of
+late that the public has come to appreciate its benefits almost as
+fully as do physicians. The existence of pregnancy does not lessen,
+but rather enhances, the value of fresh air; in order to enjoy the
+best health during this period one should spend at least two hours
+out of doors every day. Neither the season of the year nor the state
+of weather should modify this obligation. If the sun is shining the
+"airing" is more delightful, but it should be taken in bad weather
+also, on a protected porch or in a room with the windows wide open.
+
+Even when the injunction to be regularly out of doors is observed
+women are accustomed to spend the greater portion of the day in the
+house, and on that account special attention must be given to keeping
+the air of the house pure. Ventilation takes care of itself in
+summer, when the windows are open, but in cold weather, when in our
+anxiety to keep the temperature comfortable we may overlook the need
+of fresh air, it demands close attention. The necessity of
+ventilation at all times is due, of course, to the composition of the
+atmosphere and to the changes produced in it as we breathe.
+
+The air about us is a mixture of gases, of which oxygen and nitrogen
+are the most important. Although nitrogen, which constitutes four-
+fifths of the atmosphere, is taken into our lungs in breathing, we
+make no use of it, but breathe it out in precisely the same condition
+as we take it in. As chemically combined in the food-stuff known as
+protein, nitrogen is indispensable to animal life; but our bodies
+make no use of the gaseous form of nitrogen. Oxygen, on the other
+hand, supports life; and though it forms less than one-fifth of the
+atmospheric air, it is present in ample amount for our needs. After
+we draw air into our lungs, the oxygen it contains is absorbed by the
+blood and used by the tissues. In return our tissues give up a waste
+product, carbonic acid gas, which is thrown off by the lungs. It is
+interesting to observe that the carbonic acid gas which animals
+exhale supports the life of plants, and that the plants, under the
+influence of sunlight, give back pure oxygen to the atmosphere.
+Obviously, the complementary relation exhibited here is of mutual
+benefit.
+
+The average person uses about four bushels of air a minute.
+Consequently, rooms that are occupied must be constantly replenished
+with fresh air; otherwise the point is quickly reached where the
+occupants are breathing an atmosphere that is not only poor in oxygen
+but saturated with carbonic acid gas and other impurities conveyed by
+the breath. Foul air such as this causes headache, dizziness,
+faintness, nausea, and occasionally even more serious disturbances.
+Those who live in "close" rooms day after day grow pale and languid;
+their appetite fails and some of their natural power of resistance
+against illness is lost. Many people are unhealthy simply because
+they neglect to supply their living quarters with a steady stream of
+air from the outside.
+
+While it is impossible to keep the air in any room as pure as the
+outside atmosphere, perfectly satisfactory ventilation can be easily
+arranged. Some of the impure air in a house is always escaping of its
+own accord and its place is taken by air from the outside. Thus, the
+cracks around the windows and doors let bad air out and good air in;
+and, besides, most building materials are porous. These natural
+paths, however, must be supplemented. The simplest device for
+ventilation, which is also the best, consists in opening a window at
+the top and bottom. The width of the opening may be regulated so as
+to permit the air in the room to change without occasioning
+disagreeable drafts; if necessary the current may be broken by a
+screen of some pervious material placed in the opening.
+
+The bed-room should always be supplied with plenty, of fresh air,
+which "quiets the nerves" and helps one to sleep soundly.
+Furthermore, the temperature of the bed-room should be lower than the
+temperature of rooms occupied during the day. Both these requisites
+will be properly met by leaving a window open at night, which may be
+done throughout the year in most climates, if one puts on enough
+covering. There is no danger of catching cold from sleeping with the
+window open; on the contrary, breathing fresh air day and night is
+one of the best ways to prevent colds.
+
+OUTDOOR EXERCISE.--Outdoor exercise is indispensable to good health.
+It benefits not only the muscles, but the whole body. By this means
+the action of the heart is strengthened, and consequently all the
+tissues receive a rich supply of oxygen. Exercise also promotes the
+digestion and the assimilation of the food. It stimulates the sweat
+glands to become more active; and, for that matter, the other
+excretory organs as well. It invigorates the muscles, strengthens the
+nerves, and clears the brain. There is, indeed, no part of the human
+machine that does not run more smoothly if its owner exercises
+systematically in the open air; and during normal pregnancy there is
+no exception to this rule. Only in extremely rare cases--those,
+namely, in which extraordinary precautions must be taken to prevent
+miscarriage--will physicians prohibit outdoor recreation and,
+perhaps, every other kind of exertion. Under such circumstances the
+good effects that most persons secure from exercise should be sought
+from the use of massage.
+
+The amount of exercise which the prospective mother should take
+cannot be stated precisely, but what can be definitely said is this--
+she should stop the moment she begins to feel tired. Fatigue is only
+one step short of exhaustion--and, since exhaustion must always be
+carefully guarded against, the safest rule will be to leave off
+exercising at a point where one still feels capable of doing more
+without becoming tired. Women who have laborious household duties to
+perform do not require as much exercise as those who lead sedentary
+lives; but they do require just as much fresh air, and should make it
+a rule to sit quietly out of doors two or three hours every day. It
+will be found, furthermore, that the limit of endurance is reached
+more quickly toward the end of pregnancy than at the beginning; a few
+patients will find it necessary to stop exercise altogether for a
+week or two before they are delivered.
+
+Walking is the best kind of exercise, but long tramps are inadvisable
+during pregnancy, except for those who have previously been
+accustomed to them. Most women who are pregnant find that a two or
+three-mile walk daily is all they enjoy, and very few are inclined to
+indulge in six miles, which is generally accepted as the upper limit.
+Perhaps the best way to measure a walk is by the length of time it
+consumes. Accordingly, a very sensible plan is to begin with a walk
+just long enough not to be fatiguing and to increase it by five
+minutes each day until able to walk an hour without becoming
+overtired. It is always advisable not to crowd the exercise of a day
+into a single period but rather to take it in several installments,
+for example, an hour in the morning, and another in the afternoon.
+Under all circumstances, it must never be forgotten that the feeling
+of fatigue is a peremptory signal to stop, no matter how short the
+walk has been.
+
+Very few outdoor sports can be unconditionally recommended to a
+prospective mother. Because athletic exercise is either too violent
+or else jolts or jars the body a great deal, it is especially
+dangerous in the early months of pregnancy--the only time when it is
+likely to be at all attractive. Croquet, alone, perhaps, is free from
+these objections. Although golf and tennis are by no means certain to
+bring on miscarriage, they involve a risk which, slight though it may
+perhaps be, will not be assumed by cautious women.
+
+Horseback riding during pregnancy is injurious. We occasionally hear
+of women who have ridden horseback without immediate harmful
+consequences, but they have nevertheless exposed themselves to danger
+unnecessarily. It is better to give up skating and dancing also than
+to run the risk of accident, especially since these diversions are
+attended with some danger of falling. In a general way, whenever the
+question of entering into any kind of recreation must be decided, it
+is wise to err on the conservative side rather than risk overstepping
+the limit of endurance and having to pay a penalty more or less
+severe.
+
+Carriage riding cannot take the place of walking and can scarcely be
+classed as exercise; it is wholesome, nevertheless, because it takes
+the participant out of doors and provides a change of scene. Certain
+details, however, should be carefully observed; thus, a safe horse, a
+carriage that rides easily, and smooth roads should be selected.
+Similar advice pertains to motoring; with smooth roads, a cautious
+driver, and a comfortable machine, short rides in an automobile are
+not harmful. Carriage riding and motoring are particularly
+serviceable as a means of getting outdoor diversion during the last
+few weeks of pregnancy.
+
+MASSAGE AND GYMNASTICS.--If a prospective mother is obliged to stay
+in bed several weeks, massage may be useful; otherwise there is no
+necessity for this treatment. Whenever required, massage should if
+possible be given by an experienced masseuse. If this is out of the
+question and the patient must rely upon one of her friends, it should
+be understood that "general massage" is needed; in other words, one
+part of the body after another should be gone over systematically.
+With an inexperienced masseuse, however, it will be safer not to
+massage the abdomen, since awkward, vigorous, or prolonged
+manipulations in that locality may provoke painful uterine
+contractions. Rubbing the breasts also can do no good; on the
+contrary, it may do harm by bruising them.
+
+The best time of day to have massage is in the morning, at least an
+hour after breakfast. The duration of the treatment will depend upon
+the patient; it should always cease as soon as she begins to feel
+tired. After one has become accustomed to it, massage may generally
+be continued for an hour. The room in which it is given should be
+cool, and after the treatment has been completed the patient should
+be wrapped warmly and left undisturbed for half an hour.
+
+Gymnastics, like massage, are useless to those who can enjoy outdoor
+exercise. Walking more perfectly strengthens the muscles which take
+part in the act of birth than any system of "home calisthenics" that
+has been suggested. In some conditions which make walking inadvisable
+the use of calisthenics will be helpful. These exercises generally
+consist in breathing movements and in movements of the extremities,
+especially the legs, which bring into play the same abdominal muscles
+that are used at the time of delivery. A detailed description of the
+exercises is here purposely omitted, since gymnastics should not be
+used unless advised by a physician, who should watch their effect and
+thus be guided as to whether the patient should continue them.
+
+THE INFLUENCE OF WORK UPON PREGNANCY.--No single influence is more
+unfavorable to comfort and health during pregnancy than is idleness,
+so that every prospective should occupy herself with congenial work
+and fitting diversions. The kind of occupation makes no essential
+difference, so long as it does not overtire either the body or the
+mind. Since most women are absorbed in the affairs of the home, it
+may be well to begin by saying that the existence of pregnancy by no
+means requires the abandonment of domestic duties. On the contrary,
+when it is convenient, the prospective mother should have a share in
+the housework. She should not undertake everything that is to be done
+about the house, for no matter how small the household there are
+certain duties too laborious for her to attempt; these will be easily
+recognized and turned over to someone else. Even with regard to those
+tasks which lie within her strength she should use a little
+forethought to prevent unnecessary steps.
+
+All kinds of violent exertion should be avoided--a rule which at once
+excludes sweeping, scrubbing, laundry work, lifting anything that is
+heavy, and going up and down stairs hurriedly or frequently. The use
+of a sewing machine is also emphatically forbidden. Treadle work is
+known to be one cause of swollen feet, of varicose veins, and of
+aches and pains in the legs or the abdomen. If a prospective mother
+has to do her own sewing, the machine should be fitted with a hand
+attachment or motor. Except for the possibility of straining the
+eyes, there is no objection to sewing by hand.
+
+Besides the activities that should be excluded because they may be
+harmful, every housekeeper will find enough to keep her busy. It is
+generally not a small task to suggest what others shall do and to see
+that orders are properly carried out; consequently those who take no
+part in the actual work may retain an absorbing interest in their
+domestic affairs by directing them. Such direction, indeed, should,
+toward the end of pregnancy, constitute the mother's sole
+participation in the housework.
+
+In a general way the amount and the kind of work that a woman may be
+permitted to undertake during pregnancy depend upon what she has been
+used to. It is not unlikely that anyone who is unaccustomed to manual
+labor may injure her health and cause the pregnancy to end
+prematurely if she undertakes hard work. On the other hand, women of
+the working classes sometimes continue at their occupations to the
+natural end of pregnancy without harmful consequences. It is
+undeniable, however, that among this class miscarriages are more
+frequent than among the well-to-do. Furthermore, the average birth-
+weight of mature infants whose mothers have remained at work during
+the last three months of pregnancy is ten per cent. less than the
+average birth-weight of infants among the leisure class. This matter
+of the baby's weight is not always serious in itself, but indicates
+in the case of working women who are pregnant the existence of a
+strain that sometimes leads to serious accidents.
+
+The employment of women during pregnancy and immediately thereafter
+is regulated by law in many countries. For example, the laws of
+Holland, Belgium, England, Portugal, and Austria prohibit the
+employment of women in factories during the last four weeks of
+pregnancy or the four weeks following childbirth. Such employment is
+unlawful in Switzerland for two weeks before and six weeks after
+childbirth. There is no legal regulation of the employment of
+pregnant women in either Germany or Norway, but the laws of both
+countries forbid them to return to work until six weeks after they
+have been delivered. Among civilized nations Turkey, Russia, Spain,
+Italy, France, and the United States make no attempt to regulate
+employment either before or after childbirth.
+
+Of course there are strong sentimental reasons for relieving
+prospective mothers of the necessity of earning a living, but there
+are also excellent hygienic reasons against many kinds of employment.
+For example, it should be unlawful to employ them in chemical
+industries where, owing to their condition, they are especially
+liable to be injured by the materials which they handle. Jacobi
+states that the worst occupation for pregnant women is working with
+metals, in particular lead; more than half of them suffer miscarriage
+or premature confinement. Furthermore, the health of the child may be
+endangered if the prospective mother does hard work of any kind. This
+is true chiefly because she does not have appropriate intervals of
+relaxation, for it is a firmly established principle that a
+prospective mother must be free to rest the moment she begins to feel
+tired. The least, therefore, that can be done to better prevalent
+conditions among women who must work during pregnancy is to require
+by law a reduction in the number of their working hours, and to
+protect them from the necessity of earning a living for two months
+after they have been delivered.
+
+RELAXATION AND REST.--During the early months of pregnancy many women
+complain that they feel enervated, and tire quickly even when they do
+things which were formerly done with ease; this experience is so
+common that it can scarcely be considered other than natural.
+Curiously enough this is also the period during which the attachment
+of the ovum to the womb is relatively insecure, and therefore the
+inclination to be quiet is justified by the prevailing anatomical
+conditions. No prospective mother should struggle against the
+inclination to rest; she should yield to it in spite of the advice to
+the contrary which older women are apt to give. Furthermore, it is
+especially important about the time when a menstrual period would
+ordinarily be expected to be guided by this impulse not to be active,
+since overexertion then, more than at other times, is apt to be
+followed by miscarriage. Except in rare cases the observance of this
+precaution is less urgent after the fourth month, when the ovum has
+become more securely attached to the womb. But again, toward the end
+of pregnancy the development of the mother's body necessitates a
+comparatively large amount of rest; patients who continue to exert
+themselves may expect to suffer from shortness of breath and a number
+of other annoyances.
+
+In order to save needless steps and to avoid confusion and worry, it
+is always helpful to map out beforehand what must be done in the
+course of the day. Ideally, such a schedule should set apart
+intervals for relaxation and rest. In the morning, for example, while
+the housework is in progress, it is important to stop occasionally,
+if only for a few moments, and lie down on a couch. After the midday
+meal it is advisable to undress and go to bed. Even though one does
+not fall asleep, an hour or two of complete relaxation will be
+beneficial. A nap in the afternoon does not interfere with sleeping
+at night provided plenty of exercise has been taken during the day.
+In this way walking in the late afternoon or early evening helps to
+secure a good night's rest.
+
+During the first six or seven months, pregnancy, in itself, does not
+cause sleeplessness, but later, as a natural result of the
+enlargement of the womb, there are several disagreeable symptoms
+which may cause broken rest at night. In the later months the weight
+of the womb requires women to sleep on the side, and for some of them
+this position is awkward at first. Frequently the pressure makes it
+necessary to get up several times during the night to empty the
+bladder. In a few cases also the compression of the chest interferes
+somewhat with breathing. When insomnia is due to the pressure of the
+womb against neighboring parts of the body, it can be partially
+counteracted by getting into a comfortable position; but it is also
+necessary to have the surroundings as conducive to sleep as possible.
+Thus anyone will be much more likely to rest well if the bed-room is
+large and well ventilated, if the mattress is comfortable, and if the
+coverings are warm without being heavy. Finally, not the least
+important detail is to occupy a single bed, so that it is possible to
+turn over without fear of disturbing someone else.
+
+In most instances, however, the inability to sleep during pregnancy--
+and indeed at any time--is due to a faulty frame of mind. With
+reference to the average man or woman, in his very helpful book "Why
+Worry," Walton says, "it is futile to expect that a fretful,
+impatient, and overanxious frame of mind, continuing through the day
+and every day, will be suddenly replaced at night by the placid and
+comfortable mental state which shall insure a restful sleep." Like
+everyone else, the prospective mother must stop thinking when she
+retires, otherwise the blood will not be diverted from the brain as
+it must be to fall asleep. To aid in bringing about this condition a
+number of expedients may be employed. For example, a warm bath, warm
+sheets, or a hot-water bottle placed against the feet all help to
+draw the blood from the brain to other parts of the body. Similarly,
+a warm glass of milk or a small portion of easily digestible solid
+food taken just before retiring will help to make one drowsy; on the
+other hand, over-eating at the evening meal or later is not an
+infrequent cause of wakefulness.
+
+The use of narcotics is rarely necessary in the early months of
+pregnancy, and the simple measures just mentioned will also generally
+be found sufficient in the later months. But these procedures, or any
+other except the use of strong drugs, will be ineffective unless the
+individual knows how to get into the proper state of mind. This means
+not only that she must be able to banish worries, regrets, and
+forebodings; she must also have acquired confidence in whatever
+method she employs. She must convince herself that she can sleep, or
+at least that _it makes no difference if she cannot_. This
+independent spirit, which is very essential, can be confidently
+assumed, for if she does not sleep well it can be made up during the
+next day or at least the next night. Having adopted this attitude,
+and having assumed a comfortable position, which should be retained
+as long as possible, the attention should be concentrated upon the
+thought, "I am getting sleepy, I am going to sleep." Under these
+circumstances she can hypnotize herself and "produce the desired
+result more often than by watching the proverbial sheep follow one
+another over the wall."
+
+IS TRAVELING HARMFUL?--Traveling has been made so easy and alluring
+that nowadays long journeys are undertaken with scarcely more concern
+than was once felt when the people of neighboring towns exchanged
+visits. Thus modern facilities have introduced a new factor into the
+problem of the way to live during pregnancy. It is a well-known fact
+that traveling is sometimes attended with risk to the prospective
+mother, though the danger is exaggerated in the popular estimation.
+For this the newspapers are chiefly to blame. They inform the public
+of the cases in which embarrassing situations have arisen, but there
+is no record of the thousands of pregnant women who travel without
+any mishap.
+
+What the effect of traveling is likely to be is very difficult to
+predict under any circumstances, and the question cannot be answered
+at all unless the specific conditions presented by each case are
+taken into account. In a general way the points to be considered are
+the vigor of the patient, the period of pregnancy at which she has
+arrived, and the character of the journey she wishes to undertake.
+Prudent women will never attempt to decide this question for
+themselves, but will always obtain professional advice. The
+disapproval of the physician, no doubt, will sometimes cause keen
+disappointment; but conservative advice is the best and should always
+be followed.
+
+To be on the safe side a prospective mother who has previously had a
+miscarriage should not travel at any time during pregnancy; others
+are not obliged to follow this stringent rule except during the first
+sixteen and the last four weeks of pregnancy. In the former period
+there is some danger of miscarriage because traveling may cause
+separation of the relatively loose attachment of the ovum. In the
+latter period the muscle-fibers of the womb are usually irritable and
+therefore the rolling of a ship or the jolting of a car may set up
+painful contractions which in some instances expel the fetus.
+Generally there is the least risk of accident between the eighteenth
+and the thirty-second weeks, though patients should be careful even
+during this interval not to travel at the time when a menstrual
+period would ordinarily be expected.
+
+The length of the journey and the ease with which it can be made are
+also important features to be considered. Obviously there will be
+less danger of mishap from a short trip than from a long one; if
+possible, therefore, long journeys by rail should be broken so as to
+afford opportunity for rest. Railroad trips which do not exceed two
+or three hours are generally not so fatiguing that they must be
+prohibited, provided the individual is perfectly well. Traveling by
+boat is less tiresome than traveling by rail and, if equally
+convenient, the boat should be given the preference. Long automobile
+tours are attended with considerable risk of miscarriage and,
+therefore, are forbidden.
+
+MENTAL DIVERSION.--As a rule good health prevails throughout
+pregnancy; it would be enjoyed even more frequently if many
+prospective mothers did not think so much about the fact that they
+are pregnant. For this deplorable self-consciousness the spirit of
+the age is in part to blame; there never was a time, in all
+probability, when people took such a keen interest in all matters
+pertaining to health. It is also true, however, that fuller
+instruction is needed now because the temptations to depart from a
+regular, temperate way of living have notably increased.
+
+At all events the point has now been reached where the average man or
+woman knows something of anatomy, physiology, and the laws of
+hygiene. Such knowledge should be helpful, and generally is, but if
+it causes anyone to think incessantly about the workings of the body,
+to that person it is detrimental. We all know such individuals. They
+are made miserable because they scrutinize functions, like the
+beating of the heart, that go on automatically and should be left
+unobserved, or they minutely analyze their feelings and misinterpret
+normal sensations as the evidence of disease.
+
+The tendency to be introspective is especially pronounced in women
+who are pregnant, and this is readily explained by the reciprocal
+relations between the mind and the body. If the prospective mother
+correctly interpreted the changes which occur in her body, as well as
+the sensations for which these changes are responsible, she would
+escape the uneasiness of mind that causes many sorts of discomfort.
+It is unfortunately true, however, that her lack of familiarity with
+the facts about pregnancy and her belief in unfounded traditions
+frequently lead to the misinterpretation of natural conditions. An
+anxious frame of mind also causes real ailments to assume an
+importance out of all proportion to their actual significance.
+
+Patients who have followed my advice to place themselves in the care
+of a physician as soon as they clearly recognize the existence of
+pregnancy will receive his assistance in properly estimating the
+significance of what they notice. This service is by no means the
+least the obstetrician renders his patients. His opinion should
+always be sought when symptoms are not understood; but it is not
+unusual for patients to bring to the doctor's attention many
+complaints that would pass unnoticed if they taught themselves to
+restrain the imagination, to refrain from pessimistic reflections,
+and to divert their thoughts from themselves to outside affairs.
+
+Generally it is during the early months of pregnancy that patients
+are most likely to be self-centered, and consequently suffer from
+many annoyances that either proceed from or are exaggerated by this
+faulty frame of mind. During this period a prospective mother is not
+fully aware of the meaning of pregnancy. Toward the twentieth week,
+however, she perceives the movements of the child and her thoughts
+are turned to it instinctively. About this time many of the
+discomforts of pregnancy disappear and there ensues a period of
+unusually good health. Perhaps it would be going too far to give this
+more wholesome altruistic mental attitude the entire credit for the
+relatively better health of the second half of pregnancy, but without
+doubt it is a most important factor.
+
+Such then is the influence of the mind over the body that anyone who
+wishes to cultivate good health must correct the faulty habit of
+always thinking of herself. The most suitable form of diversion will
+depend upon personal taste. Domestic duties absorb the attention of
+most prospective mothers, but domestic duties should not occupy them
+exclusively. Outdoor recreation is necessary and serves the double
+purpose of strengthening mind and body. Public amusements should also
+be patronized; no prospective mother has the right to sacrifice
+herself to pride. Music, the various arts, a systematic course of
+reading, the acquisition of a foreign language--all these are
+commendable forms of diversion, and others will occur to anyone.
+Obviously the avocation will be most happily chosen if it directs the
+attention into channels likely to lead to the greatest pleasure.
+
+
+
+
+CHAPTER VII
+
+
+THE AILMENTS OF PREGNANCY
+
+Nausea and Vomiting--Heartburn--Flatulence--Defective Teeth--Pressure
+Symptoms: Swelling of the Feet; Varicose Veins; Hemorrhoids;
+Shortness of Breath--Leucorrhea--Toxemias.
+
+
+Most of the ailments to which prospective mothers are liable are
+merely the natural manifestations of pregnancy, exaggerated to such
+an extent as to cause inconvenience and discomfort. In the early
+months, for example, persistent nausea and vomiting may become the
+source of great annoyance, and later the pressure of the womb against
+neighboring structures may cause a variety of symptoms. It does not
+follow, however, that any of these ailments will necessarily appear.
+On the contrary, many women are more healthy during pregnancy than at
+any other time.
+
+Occasionally illness is charged to pregnancy with which in reality
+pregnancy has nothing to do. While awaiting the birth of a child,
+just as at other times, women may suffer from coughs or colds, from
+aches or pains, from malaria, pneumonia, typhoid fever, or in fact
+from any disease. It is evident that such complications are
+accidental; and, though pregnancy confers no immunity against them,
+it does not, on the other hand, render women more susceptible to all
+kinds of ailment.
+
+And yet there are diseases for which pregnancy is directly
+responsible. These are, to a very large extent, preventable; and,
+though they occur rarely, precautions for their prevention should be
+taken in every case of pregnancy. By far the most important members
+of this group are the toxemias of pregnancy. These, as will be
+explained later, cause symptoms which the patient herself may
+recognize, and her physician may often detect their presence still
+earlier by alterations in the composition of the urine. For this
+reason routine examination of the urine during pregnancy is a means
+of prevention indispensable for safeguarding the health of the
+prospective mother.
+
+A number of ailments of which prospective mothers may complain do not
+require treatment with medicine. This, however, will not be taken to
+imply that there is no need to consult a physician. On the contrary,
+and it cannot be emphasized too strongly, the prospective mother
+should _seek professional service whenever there is anything about
+her condition she does not understand_. Sometimes, when she thus
+consults the physician, he will explain to her that what she has
+noticed is merely one of the natural manifestations of pregnancy and
+that she can have no control over it; at other times he will suggest
+changes in her mode of life which will very likely afford her relief.
+The frequency with which physicians find that ailments may be
+corrected by the adoption of hygienic measures indicates that such
+ailments are more often due to ignorance or carelessness than to the
+existence of disease.
+
+NAUSEA AND VOMITING.--We have already learned that nausea, especially
+in the morning on rising from bed, frequently corroborates the
+suspicion of a woman that she has become pregnant. So commonly,
+indeed, is this symptom expected that most women take no account of
+it other than as an evidence that they have conceived, and
+consequently do not complain of it. A few who have heard the old
+adage, "a sick pregnancy means a safe one," which incidentally is not
+correct, actually accept nausea as a favorable sign. In other cases
+the nausea is not to be dismissed so lightly; and a relatively small
+group of patients suffer from persistent vomiting. When prospective
+mothers are questioned systematically, it appears that at least one-
+half and perhaps two-thirds of them experience more or less
+discomfort from sick stomach. Generally this begins shortly after a
+menstrual period has been missed and ceases six or eight weeks later;
+it persists occasionally until the movements of the child have been
+perceived.
+
+Nausea and vomiting are limited, in the vast majority of cases, to
+the early morning, but some patients are annoyed only after meals,
+and a few at irregular intervals during the day. The fact that the
+attacks do not always appear at the same time, and that they differ
+in severity, indicates that different causes may be concerned in
+their production. And it is true that there are several kinds of
+vomiting that occur during pregnancy, although the classification
+interests only physicians. The laity, however, should understand that
+the treatment of any given case will vary according to the class to
+which it belongs, and therefore the occurrence of troublesome
+vomiting should be promptly reported to the physician.
+
+Most frequently it will be found that there is nothing serious the
+matter. The vomiting ceases or, at least, it becomes less troublesome
+as soon as the diet has been more carefully arranged, constipation
+has been corrected, or other hygienic details, such as outdoor
+recreation and mental diversion, have received the attention
+requisite for good health. In a much smaller group of cases the
+restoration of the womb to a proper position or the treatment of some
+other local condition, which can generally be remedied without
+difficulty, is all that is necessary. But finally, in extremely rare
+instances, the vomiting of pregnancy is due to a definite disease
+whose existence may be recognized by special methods of analyzing the
+urine. In any case, if the physician is given an opportunity to make
+the necessary observations and thus determine the variety of the
+vomiting, no time will be lost in beginning effective treatment. In
+an overwhelming majority of the cases, as I have said, nothing
+serious will be found; and then the control of the vomiting will lie
+within the power of the patient herself.
+
+Since nausea is usually experienced in the morning on rising from the
+recumbent to the upright posture, measures to prevent an attack
+should be begun even before the patient raises her head from the
+pillow. In the first place something to eat should be taken as soon
+as she awakens. The most satisfactory results follow eating two or
+three pieces of crisp toast or a Bent's cracker (sold by grocers),
+either of which should be thoroughly chewed and swallowed without
+taking anything to drink. Good results are also obtained, though less
+uniformly, from eating other food, such as fruit, oatmeal, or eggs.
+The benefit secured from this procedure is explained, perhaps, by the
+activity of the digestive organs and the effect of that activity upon
+the circulation of the blood. The food eaten before rising is not
+intended to take the place of breakfast, which ordinarily will be
+eaten later. Furthermore, it is essential to remain in bed until half
+an hour after the food was taken; and not to rise then unless
+perfectly comfortable. Anyone who is inclined to be nauseated should
+get up slowly and dress leisurely, sitting down as much as possible
+while putting on the clothes. If breakfast is not desired at once, it
+should not be forced, but some food should be eaten between early
+morning and noon.
+
+It is an exceedingly good rule to bend every effort toward escaping
+the initial attack of nausea, for in this way one soon gains
+confidence, and overcomes the depressing habit of being continually
+on the watch for the symptom, lest she be taken unawares.
+Exceptionally, however, patients feel more comfortable if they vomit
+in the morning; this may be helpful, for example, if a large meal has
+been eaten just before retiring the previous night.
+
+Next to morning sickness in point of frequency comes the disposition
+to be nauseated about meal time. Those who vomit after the meal is
+finished are frequently inclined to eat soon again; and there is no
+reason why they should not. Sick stomach after meals may be due to
+several causes, such as eating hurriedly, eating too much, or
+selecting food that is difficult to digest. If a meal is bolted the
+stomach may be overloaded before the appetite is appeased; and
+consequently those who eat too much are fortunate when the stomach
+rejects the excess. Eating slowly and masticating the food
+thoroughly, we know, is the proper way to insure taking no more than
+is needed.
+
+One of the most valuable precautions against persistent nausea
+consists in taking small amounts of food five or six times during the
+day. Directions regarding the frequency of meals and the choice of
+food have been given in Chapter IV, to which the reader may refer. It
+may be repeated, however, that a prospective mother should naturally
+avoid anything which she knows is likely not to agree with her. On
+the other hand, she is almost certain not to be nauseated by any
+article of food for which she has an appetite.
+
+Lying down for a short while after meals frequently serves to prevent
+an attack of vomiting. It is a good rule, furthermore, at whatever
+time of day the sensation of nausea may occur, to lie down
+immediately. An ice bag or cloths wrung out of cold water, if applied
+to the abdomen, often give relief; warm applications occasionally
+serve the same purpose better. Some patients prevent nausea by
+constantly wearing a flannel bandage about the abdomen.
+
+Many instances of the vomiting of pregnancy cannot be explained by
+errors in diet, for the attacks come on repeatedly whether the
+stomach contains food or not. Under these circumstances mental
+influences frequently have to be reckoned with. Indeed, in most cases
+of vomiting of pregnancy dietetic and other hygienic measures are of
+no avail unless the patient learns to divert her attention from
+troublesome thoughts.
+
+That the brain can exert an influence over the stomach is a fact well
+substantiated both by physiological experiment and by medical
+observation. In all probability there is a definite spot in the
+brain, called the "vomiting center," the irritation of which causes
+retching and the upheaval of the contents of the stomach. As this
+nervous mechanism is possessed by everyone, it is not called into
+existence by the advent of pregnancy. Nevertheless, it seems likely
+that pregnancy renders it more sensitive, and it is certain that
+pregnancy establishes new means by which the center may be
+stimulated. This admission does not imply, however, that the
+prospective mother must submit to inevitable discomfort, for she can
+and should muster the strength to resist it.
+
+Time and again an unhappy frame of mind exaggerates or prolongs the
+vomiting of pregnancy. Thus, disappointment, anxiety, grief, fright,
+and other types of mental uneasiness not only magnify the discomfort
+but sometimes are its sole cause. The curious cases in which the
+husband suffers from nausea while his wife is pregnant are explained
+by mental influences. As a result of the same kind of influence,
+women who imagine themselves to be pregnant often suffer from violent
+vomiting, which ceases as soon as they discover their error. On the
+other hand, women who for several months remain ignorant of the fact
+that they are pregnant rarely suffer from sick stomach.
+
+Any kind of worry may be and often is the direct cause of the
+vomiting of pregnancy, though patients are often unwilling to confess
+it; and occasionally do not seem to know what it is that troubles
+them. In any event, having received the assurance of her physician
+that there is nothing serious the matter, the prospective mother who
+is annoyed by nausea should make every effort not to become self-
+centered. She should have congenial companionship and should interest
+herself in pursuits outside of, as well as within, her home. Of all
+the measures that may be employed to overcome this manifestation of
+pregnancy the most fundamental and essential is mental diversion.
+
+HEARTBURN.--Obviously, it would not be fair to consider indigestion
+as one of the ailments peculiar to pregnancy, for anyone is liable to
+suffer from indigestion. Yet dyspeptic symptoms, more especially
+heartburn and flatulence, occur so frequently at this time that
+something should be said regarding their causation and treatment.
+
+A burning sensation rising from the stomach into the throat,
+familiarly called heartburn, is generally due to an overabundant
+secretion of hydrochloric acid, which is, as we have learned, a
+normal constituent of the gastric juice. Of late, the conditions
+which influence its secretion have been the subject of laboratory
+investigation, which has disclosed, among other interesting facts,
+the way to _prevent_ heartburn. These experiments have taught
+that the introduction of fat into the stomach shortly before a meal
+decreases the amount of acid secreted during digestion. Consequently,
+anyone who is troubled by heartburn and wishes to avoid it _should
+take a tablespoonful of olive oil, a cup of cream, or a glass of rich
+milk fifteen or twenty minutes before meal-time_.
+
+On the other hand, fatty food eaten with the meals prolongs the stay
+of food in the stomach and causes an increase in the secretion of
+hydrochloric acid. An excess of the acid, as we have just learned, is
+favorable to the development of heartburn. Therefore, as a further
+precaution against this source of discomfort, it is advisable not to
+use a large amount of butter or of salad oil, and to refrain from
+fried food, rich desserts, or any other article of diet known to
+contain a relatively large amount of fat.
+
+Once it has developed, heartburn will be aggravated by taking cream
+or olive oil. The most rational _curative measures_ then consist
+in diluting the acid by drinking a couple of glasses of water and in
+counteracting (neutralizing) the acid by taking a teaspoonful of
+baking soda (bicarbonate of soda) or a tablespoonful of limewater;
+and, if necessary, either of these doses may be repeated. Patients
+often adopt the very sensible habit of carrying with them a block of
+magnesium carbonate, which they nibble whenever the symptom appears.
+
+FLATULENCE.--The distention of stomach and intestines with gas,
+technically called flatulence, may be associated with heartburn or
+appear independently. The gas arises from the action of bacteria upon
+the food. There can be little doubt that flatulence occurs so
+regularly during pregnancy because the pressure of the enlarged womb
+prevents the contents of the intestine from moving along as rapidly
+as they have done previously.
+
+To be relieved from this source of discomfort, it is necessary, in
+the first place, that the bowels should be regularly evacuated; very
+often nothing further is required than to overcome the habit of
+constipation. Occasionally, however, the diet must be arranged so as
+to exclude food which is likely to form gas. For example, parsnips,
+beans, corn, fried food, candy, cake, and sweet desserts, all of
+which are known to cause flatulence, should be avoided; in aggravated
+cases the allowance of starchy food of every kind should be cut down
+to small portions.
+
+Since the production of gas in the intestine is due to the action of
+bacteria sometimes relief from flatulence is secured only after the
+administration of intestinal antiseptics. Drugs, however, will be
+prescribed by the physician, and will not be employed until the
+simpler hygienic measures have failed. Similarly, the physician
+should decide whether it is advisable for the patient to drink milk
+inoculated with harmless bacteria (The Bulgarian Bacillus) which has
+lately been placed on the market. The bacteria thus administered in
+the milk are antagonistic to the intestinal bacteria that produce
+gas, and consequently have been recommended for the treatment of
+flatulence. If this commercial product cannot be conveniently
+obtained, one may use instead tablets containing the bacteria, which
+can be supplied by druggists.
+
+DEFECTIVE TEETH.--Unless suitable precautions are observed, the
+digestive disturbances of pregnancy have a tendency to injure the
+teeth. The regurgitation of the acid contents of the stomach, for
+example, may cause cavities to develop or may enlarge those that
+already exist. In all probability the damage done in this way--and
+not the removal of lime from the teeth for the formation of the
+child's skeleton, as some have thought--is responsible for the origin
+of the saying that "every child costs a tooth." This notion is of
+course absurd, yet it is quite true that toothache and the decay or
+loosening of the teeth are not infrequently associated with
+pregnancy. On this account, throughout the period of pregnancy
+particular care should be given the teeth.
+
+One of the very first duties of a prospective mother, after she knows
+that conception has taken place, is to visit her dentist. This step
+is very important as a means of insuring the teeth against such
+harmful influence as pregnancy may have upon them. If the dentist
+finds the teeth in poor condition, the patient should consent to have
+them treated immediately. That this is the reasonable course seems
+sufficiently obvious, yet the majority of women have been slow to
+adopt such a view.
+
+For a long time dental work of every description was incorrectly
+believed to have an untoward effect upon the development of the
+child; and the extraction of a tooth, it was thought, would surely be
+followed by miscarriage. Although the extraction of teeth is not
+frequently undertaken nowadays, I have known several prospective
+mothers who required the operation, and who had it performed without
+experiencing a single untoward symptom. Very naturally dental work
+should be restricted during pregnancy to that which is absolutely
+necessary, and temporary fillings generally suffice; but whatever is
+needed should be done without delay.
+
+Brushing the teeth after meals and removing particles of food that
+may have been caught between them--important enough at all times--are
+of even greater importance during pregnancy. If the gums are sore and
+the teeth show a tendency to loosen, the best tooth-paste is one
+containing potassium chlorate.
+
+An alkaline mouth-wash should be used several times a day; after an
+attack of vomiting it is always advisable to rinse the mouth with
+such a solution. As a wash either lime water or milk of magnesia, or
+a solution of bicarbonate of soda may be used; they are equally good.
+Lime water may be prepared at home inexpensively in the following
+way: Place a teacupful of builders' lime in a large bowl and add two
+quarts of water; thoroughly mix and allow to settle. Pour off and
+throw the water away, since it often contains impurities. Add two
+quarts of water again and allow the mixture to stand three or four
+hours, stirring occasionally. Strain through a piece of muslin into
+bottles and keep well corked. One tablespoonful of this solution
+should be added to a glass of water to obtain the proper strength for
+a mouth-wash.
+
+PRESSURE SYMPTOMS.--Because human beings walk erect, and not on all
+fours, they are liable to suffer from various ailments of pregnancy
+that quadrupeds escape. Thus the upright posture is the chief factor,
+at least, in causing such complaints as swollen feet, varicose veins,
+hemorrhoids, and cramps in the legs. The attention of patients should
+be called to the source of these troubles, for in most instances they
+can be prevented by forethought and prudence.
+
+During the last two or three months of pregnancy every prospective
+mother should carefully avoid being too much on her feet; she should
+lie down, as has already been emphasized, at regular times of day and
+frequently sit down to rest. Proper support for the abdomen, such as
+is afforded by a correct corset or a maternity supporter, lifts the
+pregnant uterus, and to a notable extent relieves of pressure the
+structures beneath it. On the other hand, incorrectly made corsets,
+the use of circular garters, and running a sewing machine by foot-
+power all aggravate the pressure symptoms of pregnancy.
+
+_Swelling of the Feet_.--So long as the swelling is confined to
+the feet and legs it does not mean that there is trouble with the
+kidneys; the swelling is satisfactorily explained by the pressure of
+the enlarged uterus upon the veins which pass through the lower part
+of the abdomen and conduct the blood from the legs on its way back to
+the heart. The womb is rarely heavy enough during the first half of
+pregnancy to interfere with the flow of blood through these vessels,
+but in the last few months such interference is very common.
+
+Generally the limbs are equally affected, yet occasionally the
+swelling is more marked on one side or the other. The characteristic
+changes begin in the feet. The skin covering the back of the foot
+becomes tense and has a waxen appearance; it is easily indented,
+bearing for a moment the imprint of anything that is pressed against
+it. Often the swelling extends no higher than the ankles, but it may
+involve the calves, the thighs, or even the vulva, which is the
+region between the thighs.
+
+If the swelling remains slight, no attention need be paid to it. But
+if it becomes extensive or painful, nothing will give relief except
+going to bed. Patients observe for themselves that the swelling
+lessens during the night, and from this usually learn that the proper
+treatment is rest. When it is absolutely impossible to remain in bed
+long enough for the swelling to disappear, the next best plan is to
+accept every opportunity, during the day, to sit down and prop up the
+feet.
+
+_Varicose Veins_.--The distention of the surface veins of the
+legs, the condition known as varicose veins, is not a peculiarity of
+pregnancy. Anyone who must be on his feet a great deal is liable to
+suffer from this ailment. It is true, nevertheless, that pregnancy
+increases the likelihood of the development of varicose veins. The
+walls of the vessel are generally able to withstand whatever strain
+is placed upon them during the first pregnancy, and usually the
+varicosed condition does not develop until after there have been
+several pregnancies.
+
+As a rule, both legs are similarly affected, but if only one, it is
+more likely to be the right. This is explained by the fact that the
+position of the child within the womb is ordinarily such as to cause
+greater pressure on the vessels of the right side. For the same
+reason when the legs are unequally affected, generally the veins of
+the right side are the larger. In any case, however, the birth of the
+child removes the source of the interference, and during the lying-in
+period, provided that the patient remains quiet for a sufficient
+length of time, the vessels regain their normal caliber. Once they
+have been distended, however, the veins remain more susceptible to
+engorgement. Consequently, in order not to increase the strain these
+vessels naturally bear during the latter months of pregnancy, the
+precautions just mentioned for the avoidance of all the pressure
+symptoms should be strictly observed. Upon the first intimation that
+the veins are becoming dilated, a patient should be unusually careful
+to keep off her feet all that she can. Only in extreme cases will it
+be compulsory to go to bed. But, if the veins are large and painful,
+she should stay in bed until material improvement has taken place.
+Subsequently she should wear a flannel bandage, snugly applied, about
+the leg from the toes to a point somewhat above the knee; the bandage
+should extend higher whenever the veins of the thigh also are
+dilated. In putting on the bandage the heel may be left uncovered;
+after leaving the foot a turn of the bandage will be taken around the
+ankle and thence applied upward. A flannel bandage may be easily made
+at home. Bias strips are cut about three inches in width and sewed
+together end to end so that the joining will lie flat. Unless the
+bandage must extend far above the knee, eight yards will be a
+sufficient length.
+
+Elastic stockings, which may be purchased from a druggist, serve the
+same purpose as the bandage, but are very much less durable. Even if
+worn during the day they should be taken off at night; and when
+protection of the veins is required after going to bed, the bandage
+is the most sanitary way of securing it.
+
+The danger that one of the vessels will break may be disregarded, if
+they are constantly protected by the measures that have been
+mentioned. In the event of accident, however, make firm pressure over
+the bleeding point with a freshly laundered handkerchief, and apply
+an ice bag outside the dressing until the doctor arrives.
+
+_Hemorrhoids_.--Hemorrhoids are caused in the same way as
+varicose veins of the legs. The two conditions differ merely in point
+of location; but hemorrhoids, on account of their location, are much
+more exposed to irritation.
+
+Although the development of hemorrhoids cannot always be prevented,
+it is a well-known fact that constipation renders the chance of their
+appearance much greater. In a measure, therefore, regular, daily
+evacuation of the bowels serves to prevent the ailment, and also to
+cure it, once it has developed. But walking and even standing
+aggravate hemorrhoids. The recumbent posture, as might be expected,
+is of itself frequently enough to give relief. It is much more likely
+to do so, however, if the hips are elevated by placing a pillow under
+them.
+
+In severe cases it is helpful to restrict the diet for a few days
+until the congestion and acute suffering have subsided. If the
+hemorrhoids protrude, they should be replaced (which the patient may
+generally do for herself), and an ice bag should be applied to the
+seat of pain. Various ointments and suppositories of different
+composition are valuable in the treatment of this ailment, but, as
+not all cases are relieved by the same medicine, a physician should
+be consulted to learn what is most suitable in any given instance.
+
+Hemorrhoids often grow progressively worse as pregnancy advances, and
+are frequently aggravated immediately after the birth of the child;
+but they generally disappear within a few weeks. Whenever a natural
+cure is not thus effected, it may become necessary to resort to
+surgical treatment. Operative procedures, however, should not be
+undertaken during pregnancy, since the condition is likely to
+reappear before the child is born.
+
+_Cramps in the Legs_.--There are nerves as well as blood vessels
+that the pregnant uterus may press upon, and pressure of this kind
+may cause pain. At times the pain is definitely localized at the
+point where the nerve is pressed upon; under these circumstances the
+discomfort is felt in the lower part of the back. On the other hand,
+the pain may be referred to the point where the nerve ends. In this
+way is explained not only pain in the leg but also those sensations
+of numbness and tingling which prospective mothers not infrequently
+complain of. The presence of these pressure symptoms is usually
+limited to the last few weeks of pregnancy. They often begin about
+the time the child's head enters the bony canal through which it is
+ultimately born; engagement of the head, as this is called, occurs
+simultaneously with the dropping of the waist-line, that is, about
+two or three weeks before delivery. From the time the head is engaged
+all the pressure symptoms become somewhat more intense.
+
+From the very nature of their causation, it is clear that cramps in
+the legs are difficult to treat. The recumbent posture lessens the
+discomfort, and, if in addition the hips are elevated, absolute
+comfort will occasionally be secured. Whether or not the
+administration of medicine is advisable must be determined by the
+physician who has the opportunity to see the patient. The birth of
+the child, of course, removes the cause of the pressure and
+permanently relieves this discomfort.
+
+_Shortness of Breath_.--Besides the ailments caused by the
+downward pressure of the pregnant uterus, there are also symptoms due
+to its upward growth. Thus shortness of breath is regularly noted
+toward the end of pregnancy, and, as has already been mentioned, it
+is one of the reasons for exercising leisurely.
+
+Unlike the other pressure symptoms, shortness of breath is ordinarily
+aggravated by the recumbent posture, for lying flat on the back
+increases the compression of the chest. At night, which is frequently
+the time when difficulty in breathing is most pronounced, the patient
+may, if necessary, sleep propped up in bed. For this purpose an
+appliance called a back-rest may be used, but an extra pillow under
+the head and shoulders is usually sufficient.
+
+LEUCORRHEA.--The meaning of the white discharge from the vagina known
+as leucorrhea is variable: at times it indicates the existence of an
+ailment requiring treatment, and at other times it does not. To be on
+the safe side, therefore, anyone who is troubled by leucorrhea should
+obtain her physician's opinion as to its significance.
+
+Normally, as we learned in Chapter V, there is an increase in the
+vaginal secretion during pregnancy; but this fact is rarely
+noticeable until the latter months. Usually it is pronounced only
+during the last few weeks. At that time, owing to its antiseptic
+qualities, this pale white fluid should not be disturbed by the use
+of douches. In the early months of pregnancy, however, leucorrhea may
+cause such inconvenience as to demand medical treatment.
+
+While itching is the most disagreeable effect of such a vaginal
+discharge, it should be known that itching is not always due to
+leucorrhea. Thus it may be caused by a highly concentrated urine, and
+in that event will be relieved by drinking a larger amount of water;
+or it may be due to the presence of unusual constituents in the
+urine. Skin diseases also cause itching; and light haired people,
+since they have more delicate skins that brunettes, are especially
+susceptible to these ailments. To such skin affections soap and water
+may be very irritating; so that when they exist it is often advisable
+to cleanse the parts with olive oil. In other cases, ointments are
+required and will be prescribed by the physician.
+
+Itching of the skin over the extremities or over the whole body, it
+is clear, cannot be attributed to leucorrhea, but in these very rare
+cases the irritation would seem to be caused by some waste product
+which is being eliminated through the sweat glands. We do not know
+what the substance is, but, as the symptom appears so seldom, it must
+be due to an unusual kind of waste product or else to one whose
+elimination normally occurs through other channels. The affection of
+the skin thus brought about is really a very mild kind of poisoning,
+and since the offending substance arises in the body of the patient
+herself the condition is called an autointoxication. Effective
+treatment consists in drinking water freely and taking a cathartic,
+for the one stimulates the kidneys and the other the bowels to assist
+in getting rid of the cause of the trouble.
+
+TOXEMIAS.--In order to understand what are known as the
+toxemias of pregnancy, we must remember that the nutrition of our
+bodies involves three separate and distinct sets of processes. What
+we eat is, in the first place, digested and absorbed into the body;
+secondly, the products of digestion are utilized by the tissues; and,
+finally, the waste material is thrown off from the body. Any one of
+these processes may be carried out in a way that is not consistent
+with health. Most of us realize that disturbances may occur in the
+course of digestion, and we are also aware that the excretory organs
+occasionally fail to do their work in a satisfactory way. But what
+laymen, perhaps, do not appreciate is that the intermediary steps--
+between the time when the food is absorbed and the time when the
+waste material is finally eliminated--may not be taken precisely as
+health requires. Of course, any person may be the subject of one or
+another of these nutritional disorders, but unquestionably such
+disorders are somewhat more frequent during pregnancy than at other
+times. Nor is this difficult to understand, for the nutritional
+processes of two beings are here linked together. They generally
+proceed harmoniously, but if they do not there results an
+autointoxication of the mother which is called a toxemia.
+
+Such toxemias, with extremely rare exceptions, do not occur in the
+early months, but are associated with the period of the active growth
+of the fetus, namely, the second half of pregnancy. For this reason,
+and for some others which do not concern us here, it seems probable
+that the nutritional processes of the child are primarily responsible
+for these ailments. This view, however, must be somewhat modified,
+for experience has clearly taught that the efficiency with which the
+maternal excretory organs do their work has a great deal to do with
+the effect that the fetal waste products have upon the mother. On
+this account she has been urged to pay attention to personal hygiene.
+It is also necessary, however, that she should become acquainted with
+the symptoms which give warning that the excretory organs are acting
+imperfectly.
+
+Autointoxication can almost always be prevented. The means of
+prevention are neither mysterious nor difficult to carry out; they
+lie within the power of every prospective mother, for they consist
+merely of what has already been discussed, namely, the intelligent
+regulation of the diet, the care of the body, and a correct ordering
+of the daily life. To the chapters dealing with these subjects
+reference should be made and particular attention should be paid to
+what has been said concerning:
+
+  (1) Wearing suitably warm clothes,
+  (2) Bathing regularly,
+  (3) Taking a proper amount of exercise,
+  (4) Drinking water liberally,
+  (5) Avoiding an excessive quantity of meat,
+  (6) Guarding against constipation.
+
+At present the value of prevention in the treatment of the toxemias
+of pregnancy is so clearly recognized that charitable organizations
+employ nurses to visit women of the poorer classes during pregnancy
+in order to instruct them about the measures that I have just
+indicated. Remarkable results have already been obtained. In one
+clinic where this method has been adopted the frequency of all kinds
+of toxemia, I am told, has notably diminished, and serious types are
+not permitted to develop. Similar results should be obtained in
+private practice when patients place themselves under medical
+supervision at the beginning of pregnancy. Under these favorable
+circumstances symptoms of autointoxication probably occur not oftener
+than once in every hundred pregnancies, but nine out of ten of them,
+being promptly recognized, yield readily to relatively simple
+treatment.
+
+The early detection of such complications depends largely upon the
+patient herself. As has been emphasized--and it cannot be said too
+frequently--she should not fail to submit, at appropriate intervals,
+a specimen of urine for examination. It is by such an examination
+generally that the development of a toxemia is first detected.
+Occasionally, however, significant signs will attract the patient's
+attention before there is any change in the urine. For that reason,
+it is important to notify the physician if any of the following
+symptoms appear:
+
+  (1) Serious vomiting.
+  (2) Persistent headache.
+  (3) Dizziness.
+  (4) Puffiness about the face.
+  (5) Blurring of vision, or the appearance of black
+      spots before the eyes.
+  (6) Neuralgic pains, especially in the pit of the stomach.
+
+It must be clearly understood, however, that any of these symptoms
+may be present without indicating that a toxemia is developing.
+Nevertheless, they should be brought to the physician's attention
+without delay, and, at the same time, a specimen of urine should be
+given him for examination.
+
+Although the kidneys are not responsible for all the toxemias of
+pregnancy, an analysis of the urine affords the most definite means
+of determining whether or not such a condition is present. When thus
+detected, prompt treatment will guarantee to the patient almost
+certain relief. On the other hand if, as usually happens, the
+analysis shows conclusively that there is nothing serious the matter,
+this reassurance fully justifies the trouble taken to secure it.
+
+
+
+
+CHAPTER VIII
+
+
+MISCARRIAGE
+
+Frequency--Causes and Prevention--Habitual Miscarriage--Warning
+Symptoms--After-effects--Criminal Abortion--Therapeutic Abortion--
+Premature Delivery.
+
+We have learned that forty weeks are required for the full
+development of the human embryo, but this fact carries no assurance
+that pregnancy will last so long; in reality, it may end abruptly at
+any time. If growth is interrupted before the twenty-eighth week (the
+seventh lunar month), the infant will be too immature to live. Even
+when born alive, it will usually perish within a few hours, or a few
+days at most. Children born during the seventh month have
+occasionally survived; but the prevalent belief that they are more
+likely to do so than if born a month later is erroneous. That
+superstition originated at a time when great virtue was ascribed to
+numbers. Since seven was a sacred number, it was considered more
+auspicious to be born in the seventh month than in the eighth.
+Universal experience, however, teaches us that the likelihood of
+rearing a premature child is, by a rapidly increasing proportion, the
+greater for every week that it remains within the uterus. This is
+precisely what we should expect, for the period of its existence
+there measures the perfection of its development; and that, under
+ordinary conditions, determines how strong and hardy the child will
+be.
+
+Although during the first six months the outlook for the infant will
+be equally unfavorable at whatever time pregnancy may be interrupted,
+physicians prefer to distinguish cases which terminate in the earlier
+part of this period from those which terminate in the latter part.
+For technical reasons, the sixteenth week represents a natural point
+of division. A birth which takes place before that time is called an
+abortion; one which takes place between the sixteenth and the twenty-
+eighth week is called a miscarriage. The anatomical reasons which
+justify such a distinction do not concern us here, and the matter
+deserves mention merely because the same terms are often employed in
+a very different sense by the laity. As most of us know, the
+interruption of pregnancy results sometimes from purely natural
+causes, and sometimes from the employment of artificial means. As a
+rule, persons who are unacquainted with medical terminology call a
+birth of the former kind a miscarriage, and reserve the term abortion
+for an interruption of pregnancy that is deliberately provoked.
+Physicians, however, make no such distinction. They use these words,
+as I have said, simply to indicate how far development has progressed
+before the termination of pregnancy. Since the term abortion is apt
+to carry with it the implication of a criminal act, confusion will be
+avoided if we agree for the time to depart from strictly medical
+usage and designate as miscarriage the spontaneous termination of
+pregnancy prior to the twenty-eighth week.
+
+FREQUENCY.--Early interruption of pregnancy is extremely common. Some
+sociologists declare that it is becoming more and more frequent, and
+see in it a grave national danger. French statesmen attribute the
+alarming decline of the birth-rate in their country, in great part,
+to a rapid increase in the number of pregnancies which end
+prematurely. Reliable English and German statistics indicate that of
+the pregnancies which come under the observation of physicians
+approximately twenty per cent, end in miscarriage. In our own
+country, though extensive and complete data are not available, it is
+likely that the incidence is equally high.
+
+The actual frequency of miscarriage is generally underestimated.
+Patients themselves often do not know what has really happened. When
+the accident occurs a few days after conception, bleeding may be its
+only evidence, which will almost certainly be misinterpreted as an
+irregularity of menstruation; and professional advice will not often
+be thought necessary. Moreover, in other cases in which the true
+situation is appreciated the patient does not feel sick enough to
+seek medical assistance. If it were possible to include in the
+statistics all these cases as well as those which are concealed
+because intentionally provoked, the frequency with which pregnancy is
+interrupted during the early months would be found somewhat greater
+than is usually supposed.
+
+If we omit the miscarriages which occur within the first few weeks of
+pregnancy, and which consequently often escape detection, the
+majority of cases fall within the second and third months. After the
+fourth month has passed, the probability of such an accident, though
+not excluded, is greatly diminished. Some statistics recently
+published by Taussig make this clear. In a series of several hundred
+cases of miscarriage, one hundred and fifty-seven instances occurred
+in the second month, two hundred and twenty-two in the third month,
+seventy-three in the fourth month, thirty-seven in the fifth month,
+and five in the sixth month. This order of frequency might be
+anticipated from the anatomical conditions which prevail during the
+early months of pregnancy, since the attachment of the embryo to the
+mother is at first relatively insecure, but gradually grows firmer,
+and becomes as secure as it ever will be by about the fifth month.
+
+It is noteworthy that miscarriage occurs much less commonly in the
+first than in subsequent pregnancies. Indeed, a somewhat greater
+liability to the accident with each succeeding pregnancy goes far
+toward explaining the greater frequency of miscarriage among women
+who have passed the thirty-fifth year than among those who are
+younger.
+
+CAUSES AND PREVENTION.--We have seen that the proportion of
+pregnancies which end in miscarriage is quite formidable. But this
+should not be true, as the accident is frequently preventable, and
+many of these accidents could be avoided by the cooperation of
+patients. As self-denial and personal inconvenience are often
+essential, it is only fair to explain their value. Furthermore, the,
+patient who appreciates the reason for certain directions the
+physician gives becomes responsible to herself, and is much more
+likely to carry them out than is one who is cautioned without
+receiving a satisfactory explanation. At best, however, the advice
+which the physician is able to offer will be imperfect, for it must
+not be imagined that everything is known concerning the causation and
+prevention of miscarriage. While our knowledge is so imperfect we
+must be content to make the most of what we possess. It must be added
+that no suggestion such as can be given here will enable anyone to
+dispense with her own medical adviser. On the contrary, if there is
+reason to fear miscarriage, the prospective mother should be
+encouraged to seek his counsel as early as possible. Aside from the
+hygienic measures which she may learn to carry out for herself,
+various drugs are often of great value in preventing miscarriage.
+Since these are not applicable to all cases, they should be employed
+only upon medical advice.
+
+Very early miscarriages may be explained by the loose attachment of
+the ovum during the first six weeks of pregnancy. This tiny, living
+sphere, it will be recalled, reaches the womb a few days after
+conception, and adheres to the uterine mucous membrane. At first,
+however, its roots are short and delicate, and not so capable of
+anchoring the ovum as they become later. It is only toward the end of
+the eighteenth week that the union between the womb and its contents
+becomes firm.
+
+From what we have learned in Chapter II regarding the anatomical
+conditions in the early days of pregnancy it is obvious that we need
+not be greatly surprised at the frequency of miscarriage. On the
+other hand, it must not be forgotten that there are many natural
+safeguards against accident: to mention only one, the uterus is
+ingeniously swung in the abdominal cavity so as to afford a large
+measure of protection against mechanical shock. Usually, the
+provisions nature has made are sufficient to resist forces from
+without which tend to dislodge the ovum. Now and then it happens that
+the most irrational acts will not interrupt pregnancy; indeed, they
+often seem particularly inert when practised intentionally.
+
+Fear of loosening the ovum from its uterine attachment prompts
+experienced women to caution prospective mothers against any kind of
+sudden or violent effort. Their advice, however, is often needlessly
+alarming; a great many traditional precautions lack a reasonable
+basis. Thus, no harm can possibly result from sleeping with the arms
+above the head; nor from "over-reaching," as when hanging a picture,
+though a fall under such circumstances might be dangerous.
+
+Patients who have been warned by one experience should always be on
+their guard if they would avoid repeated miscarriages; others need
+only lead a sensible, hygienic life, a matter we have already
+discussed in the chapters dealing with the care of the body and the
+way to live. For the sake of emphasis, I may here repeat that no
+prospective mother should become fatigued from any cause; sweeping,
+moving heavy furniture, lifting heavy articles, and running a sewing
+machine are not to be attempted. But household duties which do not
+require strong muscular effort are better assumed than not.
+
+Amusements which may cause jolting, or expose one to the danger of
+falling, involve some risk of miscarriage. Short rides in a carriage
+or an automobile over smooth roads are free from objection. Railway-
+travel and sea-voyages are not advisable in the early months; after
+the eighteenth week they may be undertaken with a greater degree of
+safety, provided comfortable accommodations are assured, and the
+patient has never had a miscarriage.
+
+A few physicians, even at present, attribute the interruption of
+pregnancy to strong emotions, including intense joy or sorrow, anger,
+fright, or even jealousy. Without denying altogether the possibility
+of such an influence, we may be sure that its importance is greatly
+exaggerated. It is not unusual to see patients who are able to recall
+a mental shock of some kind shortly before the miscarriage occurred;
+nevertheless, in such cases diligent search will usually reveal a
+physical cause for the accident.
+
+Another popular fallacy relates to the effect of drugs upon
+pregnancy. The use of castor oil and other strong purgatives do not
+interrupt it. Should the administration of any cathartic be followed
+by miscarriage, some fault inherent preexisted in the pregnancy, and
+no amount of precaution would have enabled the patient to reach full
+term successfully. Quinin in tonic doses may be taken with impunity,
+and even larger quantities are being constantly used for the cure of
+malaria without doing the pregnancy any harm. Many other drugs are
+reputed to have great efficacy in causing the expulsion of the
+product of conception; unfortunately, they are too well known to
+require enumeration. They are usually unreliable, and are absolutely
+inefficient in doses small enough not to endanger the mother's life,
+provided the pregnancy is a healthy one.
+
+Instances in which miscarriage is attributed to the use of some drug
+are quite common, and we cannot dismiss them without a word of
+explanation. Such cases generally fall into one of two classes. Often
+a drug is given credit for efficiency where conception has been
+erroneously suspected. Shortly after the menstrual date passes, some
+medicine is resorted to, and the subsequent phenomenon, regarded as
+the interruption of pregnancy, is really no more than normal
+menstruation. In another group of cases miscarriage does actually
+occur, although the medicine employed plays only a minor role in its
+production. In such instances the irritation which the drug occasions
+is the last link in a chain of events leading up to the miscarriage,
+but the main factor lies in some fundamental imperfection in the
+pregnancy. Physicians recognize a variety of these imperfections, and
+know that they may be located in the womb, in the embryo, or in the
+tissues which unite the one with the other. As an intimate knowledge
+of pathology is often necessary to recognize the underlying, and
+therefore the actual, cause of the miscarriage, it is not at all
+surprising that patients frequently err in their interpretations of
+such accidents, and emphasize unimportant matters.
+
+It would lead us too far afield to attempt to discuss every cause of
+miscarriage. Nevertheless, there are some very important ones, not
+yet mentioned, which should be understood by the laity, as
+appreciation of their significance may avert trouble. In some
+instances, on the other hand, the accident is unavoidable; to know
+this should afford the patient a large measure of comfort.
+
+Irregularities in the position of the womb are often responsible for
+miscarriage. Such a condition may exist in women who have not borne
+children, but it is far more likely to occur as a result of
+childbirth. After delivery, the enlarged womb becomes the seat of
+intricate changes, the purpose of which is the restoration of the
+organ to the condition which existed before conception. It dwindles
+in size, and gradually drops to its accustomed location within the
+pelvic cavity. Six weeks are usually required for these changes.
+
+At the time of birth it is impossible to predict whether the womb
+will finally resume a satisfactory position. Accordingly, an
+examination two to four weeks later is essential. In four out of five
+patients the organ will be found in its proper location, but, even
+though it is not, suitable measures adopted at once will generally
+serve to replace and hold it in good position. On the other hand, if
+the malposition is not recognized until months or years later, simple
+procedures will prove inefficient, and a surgical operation will
+become necessary. Were there no other reason for a careful
+examination at the end of the lying-in period, it would be amply
+justified by the information which it gives relative to the position
+of the uterus.
+
+Although there can be no doubt that the routine correction of uterine
+displacements shortly after labor would go far toward restricting the
+occurrence of subsequent miscarriage, it would be incorrect to leave
+the impression that miscarriage will always occur if the uterus is
+out of its normal position. Not infrequently the changes wrought by
+pregnancy will cause the uterus to right itself spontaneously.
+
+Another important cause of miscarriage consists in abnormalities in
+the lining of the uterus. Through inherent defect or acquired disease
+this tissue may become unsuited for anchoring or nourishing an ovum.
+In either event, a surgical procedure, known as curettage, affords
+the most likely means of restoring it to a healthful state. The
+operation removes the old lining; and a new one quickly develops,
+which is often more capable of fulfilling the purpose for which it is
+intended.
+
+An appreciable number of miscarriages depend upon conditions over
+which medical skill has no control. Under such circumstances, though
+the accident may be regretted, there is no room for remorse or
+censure. Often the embryo should bear the blame; if its development
+is imperfect or if it dies, miscarriage usually occurs very promptly.
+
+We are familiar also with a few maternal conditions which seriously
+affect the embryo, often seriously enough to cause its expulsion,
+alive or dead. In this respect, certain constitutional disorders are
+preeminent. Bright's disease and diabetes are prejudicial to the
+development of the embryo; women suffering from either of them must
+be watched with great care. Occasionally, such pregnancies come to a
+premature end in spite of every precaution. Various infectious
+diseases, as typhoid fever and pneumonia, also are fatal to the
+embryo if the causative bacteria pass into it. Fortunately this
+rarely happens, since the placenta generally affords an effectual
+barrier to their entrance into the embryo. Organic diseases of the
+mother's heart also may bring about miscarriage. A patient thus
+affected should place herself under the supervision of a physician as
+soon as conception is suspected.
+
+Now and then physicians are completely at a loss to explain cases of
+miscarriage. Our ignorance is unfortunate, particularly when repeated
+miscarriages have occurred and their causation cannot be detected.
+
+HABITUAL MISCARRIAGE.--Experience teaches that women who have had one
+miscarriage must be more careful than other prospective mothers if
+they would escape a repetition of the accident. Persons who know
+themselves to be subject to miscarriage should regard no precaution
+as too burdensome. Not only should they avoid motoring, driving,
+railroad journeys, sea voyages, and every kind of strenuous exertion,
+they must accept every opportunity to be quiet and rest. Often such
+hygienic care yields sufficient protection; but occasionally medicine
+is also necessary.
+
+A number of causes are at hand to explain habitual miscarriage, but,
+in fairness, it must be acknowledged that physicians are not able to
+interpret all cases. With one class of patients the muscle fibers of
+the womb are peculiarly irritable, whereas in another its lining
+proves incapable of firmly anchoring the ovum. Moreover, derangements
+of organs which do not belong to the reproductive group may be
+responsible for the habit.
+
+It is a curious fact that the accident is most likely to occur when
+menstruation would be expected were the individual not pregnant.
+Obviously, extraordinary precaution is advisable at such times, and
+if the patient would avoid even the slightest risk, she should not
+leave her bed. The same purpose will not be served by sitting quietly
+in a chair, nor by reclining on a couch; complete relaxation and
+composure are secured only when one lies flat on the back, loosely
+attired in sleeping garments. I have known several persons with a
+tendency toward miscarriage who overcame it in this way. Recently one
+of them who had been delivered prematurely on two former occasions,
+and who was anxious for a successful issue to her third pregnancy,
+was willing to remain in bed practically the whole period of
+gestation. She had her reward; a well-developed infant was born at
+full term, and has continued to thrive.
+
+Prolonged rest in bed, some will say, is debilitating. While that may
+be true to a degree, untoward effects can always be avoided by
+systematic massage of the extremities. The abdomen should not be
+subjected to such manipulations, for they will occasionally provoke
+painful contractions of the uterus and defeat the purpose of staying
+in bed.
+
+Patients who are not disposed to undergo a long period of enforced
+rest, no matter what profit may be promised, should at least consent
+to keep in bed during that period of pregnancy at which a previous
+miscarriage took place. We know that the event is particularly apt to
+recur at such a time. Specifically, it is important to remain in bed
+one week before and one week after the date in question.
+
+When pregnancies follow one another in rapid succession, the
+liability to miscarriage is notably increased. A natural interval
+between births has been provided, an interval which depends upon the
+mother nursing her child. Ideally, menstruation, and with it the
+ripening of the ova (egg-cells), does not occur while the breasts are
+active; but when the infant does not suckle, the ovaries regularly
+resume their function in a very short time. Since the circumstances
+attending miscarriage always deprive the mother of the opportunity of
+nursing, another pregnancy may quickly ensue unless these facts are
+appreciated.
+
+Those who anticipate the possibility of a premature interruption of
+pregnancy should realize that the marital relation is inadvisable
+after conception has taken place. For others, who have no reason to
+expect irregularity in the course of pregnancy, such a precaution is
+unnecessary. None the less, women who marry late in life or who first
+conceive toward the time of the menopause will do well to follow the
+same rule. The risk of accident may be very slight, but conservative
+persons will not assume it when the likelihood of subsequent
+conception is doubtful.
+
+Not infrequently the fundamental reason for habitual miscarriage lies
+in some anatomical abnormality which a surgical operation alone can
+correct. As the necessity for interference can be determined only
+after a careful examination, recommendations of wide application are
+not possible. Nothing short of painstaking study of each case will
+afford a basis for advice and action.
+
+SYMPTOMS.--Very definite warning usually precedes a miscarriage, but
+the threatening symptoms vary greatly in severity and duration. If
+appropriate measures are taken promptly, these symptoms may disappear
+with no harmful result Everyone concedes that bleeding and pain are
+the chief indications of impending miscarriage, although an
+occasional patient, profiting by former experience, may find other
+signs prophetic in her own case.
+
+Mature women, accustomed to the regular monthly function of their
+sex, are prone to treat with indifference a slight discharge of blood
+occurring during pregnancy. Indeed, it is widely believed that
+menstruation frequently continues after conception. In point of fact,
+however, it is very unusual in early pregnancy, and becomes entirely
+impossible after the fourth month. Accordingly, whenever vaginal
+bleeding is noticed, some other explanation should be sought; and the
+patient who would adopt the wisest plan should assume that she is
+threatened with miscarriage. There are other possibilities, but these
+are for her doctor to consider.
+
+It is true that small hemorrhages are not necessarily followed by
+miscarriage. One may even experience slight loss of blood repeatedly,
+and yet give birth to a healthy child at the natural end of
+pregnancy. None the less, bleeding, however moderate, should always
+excite suspicion, as we know it usually denotes the breaking to some
+degree of the connection between mother and child. The extent of the
+separation usually determines the degree of the hemorrhage, which in
+turn indicates the seriousness of the accident. The fate of the fetus
+will depend upon the area of placenta, which has been incapacitated.
+Flooding, however, always imperils the fetus, and generally warrants
+the inference that so much of the placenta has been separated as to
+render further development impossible. On the other hand, so long as
+the hemorrhage does not exceed the customary flow at the monthly
+periods, the life of the child is rarely endangered; while a
+chocolate-colored discharge, and even the loss of small clots, may
+continue indefinitely without doing serious harm. Under such
+circumstances, however, the patient should communicate with her
+medical adviser, and should save for his inspection whatever may be
+expelled.
+
+Pain, the other conspicuous symptom of threatened miscarriage, has
+not a uniform significance. Since it frequently occurs during the
+course of pregnancy in association with a number of conditions, it is
+not a reliable sign of danger. Moreover, the susceptibility to pain
+varies; thus, of two patients in the same stage of threatened
+miscarriage one may suffer intensely, while the other remains
+comparatively comfortable.
+
+Typically, the onset of miscarriage is attended by discomfort in the
+small of the back, which may be continuous, but more often is
+intermittent. If preventive measures are instituted at the outset,
+there is hope of relieving the discomfort and averting the
+miscarriage; but if the warning goes unheeded, the pain will
+gradually shift to the lower part of the abdomen and become more
+severe. It often happens that the cramp-like abdominal pain of
+threatened miscarriage is confused with that associated with
+intestinal indigestion. A simple test will sometimes decide the
+question. If due to the latter cause, the discomfort will usually
+yield to a teaspoonful of paregoric, whereas it will be without
+effect if miscarriage is imminent. Exceptions to this rule are not
+uncommon, yet a better one cannot be given; as a physician, even
+after considering the technical evidence, may find it impossible to
+decide at once whether or not miscarriage is threatened.
+
+No confidence can be placed in many so-called signs of miscarriage,
+though implicitly trusted by the laity. Lassitude, depression of
+spirits, and general bodily ill-feeling may forecast the interruption
+of pregnancy; but more frequently they have no such significance. The
+same estimate holds true of other symptoms, including diarrhea and a
+persistent inclination to empty the bladder. Nor does fever always
+lead to the termination of pregnancy. A moderate rise of temperature
+is without significance; but high fever, persisting for several days,
+may result in the death of the fetus and subsequent miscarriage.
+Nevertheless, prolonged febrile affections, such as typhoid fever,
+frequently leave pregnancy unharmed.
+
+So long as the symptoms are confined to slight bleeding and mild
+attacks of pain, physicians regard miscarriage merely as threatened.
+If the bleeding increases, the outlook becomes less favorable, and,
+as I have said, miscarriage is inevitable when it amounts to
+flooding. Likewise, rupture of the sack containing the fetus, with
+escape of the amniotic fluid, indicates that the culmination of
+events will not long be delayed.
+
+The most favorable outcome is when the entire contents of the womb
+are spontaneously expelled, which unfortunately does not always
+occur. There is, to be sure, rarely any difficulty in the natural
+birth of the fetus, for its meager development prevents serious
+complications. The separation and extrusion of the placenta, on the
+contrary, are apt to be imperfect when pregnancy ends in the early
+months, and medical attention is necessary to determine whether the
+uterus has been emptied completely. This is particularly important,
+because the retention of placental tissue affords opportunity for
+several unpleasant complications; and neglect in this regard accounts
+in part for the belief that miscarriage is certain to leave women
+irreparably broken in health.
+
+AFTER-EFFECTS.--No one will deny that invalidism follows the untimely
+interruption of pregnancy more often than the birth of children at
+full term. This is not due, as is sometimes said, to the fact that a
+miscarriage differs from a normal birth in that it is unnatural, for
+other reasons are apparent. One of them, the retention of placental
+tissue, has just been mentioned, but serious consequences resulting
+from it are almost inexcusable, for, although the placenta may
+separate less readily and be cast off less thoroughly after
+miscarriage, modern medical skill can successfully cope with such
+conditions. Another fruitful source of unfortunate after-effects is
+the imprudence of the patient. Women should remain in bed fully as
+long after a miscarriage as after the birth of a mature infant; if
+they would consent to do so, many ill-effects would be averted. But
+physicians frequently encounter strong opposition to precautionary
+measures such as this. Many patients argue, illogically, that less
+precaution is necessary since pregnancy failed to attain its natural
+conclusion, and infer that the earlier that it ends the more quickly
+one may leave the bed. In point of fact, even greater precaution is
+required than if all had gone normally. Still a third cause for ill-
+health may be found in physical ailments which antedated the
+miscarriage but were not recognized until after its occurrence.
+
+Invalidism which follows pregnancy and which may be fairly regarded
+as chargeable to it depends, in most instances, upon an infection
+acquired at the time of delivery. Infection occurs more frequently
+when pregnancy ends during the early months, because in this category
+is included the great majority of criminal abortions, which are
+usually induced without regard for surgical cleanliness. Fatal
+complications, or serious consequences which narrowly escape a fatal
+ending, are common among women who attempt to rid themselves of an
+unwelcome pregnancy. As they are ignorant of aseptic precautions,
+their manipulations must necessarily contaminate the site of
+operation; for this reason and others as well women who attempt to
+perform an abortion upon themselves imperil their lives. The danger
+is scarcely less when abortion is induced unlawfully by incompetent
+operators; for lack of skill, the need of secrecy, and the desire of
+haste all interfere with necessary aseptic technique. Everyone knows
+that sad accidents befall those who submit to such operations; but it
+is not generally recognized that these cases are largely responsible
+for the ill-repute borne by miscarriage in general. On the other
+hand, properly supervised miscarriages are attended by no greater
+danger and probably less than delivery at full term.
+
+CRIMINAL ABORTION.--The destruction of a pregnancy, except when its
+continuance threatens the life of the patient, is forbidden by law.
+The important ethical and religious aspects of the act which the law
+thus stigmatizes as criminal we may properly neglect. Although
+various religions present a diversity of teaching relative to its
+moral nature, all agree in regarding it as sinful. Equally important,
+however, is the fact that no matter what opinion anyone may hold as
+to the morality of the act he is bound to obey the law. This is
+apparently not clearly understood by the laity, for many persons
+think that a physician may terminate pregnancy whenever he is so
+inclined. If the liability to criminal prosecution which a physician
+would assume should he comply with a request for the means of
+destroying pregnancy were clearly realized, patients would not
+beseech him to incur the risk of heavy find and long imprisonment
+merely to gratify their own convenience or to save them from
+disgrace.
+
+The Common Law, an inheritance from England, enriched with
+authoritative decisions by our own courts, is the groundwork of the
+law in all the States, and its principles are binding in the absence
+of express statutes. At Common Law, abortion is punishable as
+_homicide_ when the woman dies or when the operation results
+fatally to the infant after it has been born alive. If performed for
+the purpose of killing the child, the crime is _murder_; in the
+absence of such intent, it is _manslaughter_. _The woman who
+commits an abortion upon herself is likewise guilty of the crime._
+
+The great majority of those who desire the interruption of pregnancy
+feel they have not assumed an illegal position so long as they avoid
+instrumental procedures. That is not correct, for even at Common Law
+it is a misdemeanor to bring about the death of an unborn child _by
+the use of drugs or by any other means_.
+
+At Common Law there was a difference of opinion as to whether all
+induced abortions were illegal. Many courts formerly held that
+quickening was a necessary prerequisite; but under the modern
+statutes, practically without exception, the law disregards the
+period of pregnancy at which the abortion is provoked. Since the time
+of conception determines the beginning of embryonic development, to
+prove that the act was committed before fetal movements were
+perceived is no longer a valid defense. This has been emphatically
+stated by Judge Coulter, of Pennsylvania, who said: "_It is not the
+murder of a living child which constitutes the offense, but the
+destruction of gestation by wicked means and against nature. The
+moment the womb is instinct with embryonic life and gestation has
+begun, the crime may be perpetrated._"
+
+Each commonwealth has enacted its own statutes for the regulation of
+abortion. In many states, simply _to seek the means for destroying
+pregnancy is a criminal act_. Thus, Indiana, perhaps the most
+progressive of the States in reconstructing its criminal code to
+accord with modern sociological teaching, has enacted a law which I
+quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page
+1029. "Every woman who shall solicit of any person any medicine, drug
+or substance, or thing whatever and shall take the same, or shall
+submit to any operation or other means whatever with intent thereby
+to procure a miscarriage, except when done by a physician for the
+purpose of saving the life of the mother or child, shall, on
+conviction, be fined not less than ten dollars, and be imprisoned in
+the county jail not less than thirty days nor more than one year." To
+include the woman as a party to the crime is a signal mark of
+progress toward bringing abortion under effective legal control.
+Heretofore, the perpetrator alone has been responsible, and in most
+States he remains so, while the woman is regarded as a victim.
+Clearly, that is unjust, for criminal abortions are rarely, if ever,
+performed without application by the subject of the operation.
+According to most of the statutes no distinction is made between the
+attempt at abortion and its accomplishment. Irrespective of the
+outcome, those who supply drugs or employ instruments purposing the
+destruction of pregnancy are guilty of the offense.
+
+An extensive analysis of the various State laws is unnecessary; the
+mention of a few statutes, selected from different sections of the
+country, will suffice to indicate the character of prevalent
+legislation. Massachusetts imprisons those found guilty of abortion
+for a period of three years or less, and permits a fine of one
+thousand dollars. In Pennsylvania the same prison sentence is
+imposed, though the fine may not exceed five hundred dollars. Three
+years is the minimum imprisonment in Virginia, and a maximum of ten
+years is allowed. Colorado's law duplicates that of Massachusetts.
+California imposes no fine, and prescribes a sentence of from two to
+five years in the State prison. All the statutes make the offense
+much graver when the woman dies as a result of the practice. Under
+these circumstances, the crime never takes lower rank than
+manslaughter; and generally it is murder.
+
+Evidently we possess sufficiently stringent laws regarding criminal
+abortion; yet, as everyone knows, they do not prevent perpetration of
+the crime. On good authority, we are informed that eighty thousand
+unlawful abortions are performed annually in New York, in spite of a
+possible penalty of four years in the State prison. This is due in
+part to difficulty in securing evidence and failure to prosecute when
+evidence could be gathered, but more particularly to the fact that
+the general public does not appreciate the gravity of the offense.
+The same feeling is illustrated in the advertising of abortifacients.
+Newspapers and magazines unhesitatingly carry, under the guise of
+remedies to regulate the health of women, notices of drugs and
+equipment intended to destroy pregnancy. This is expressly forbidden
+by many statutes. [Footnote: Thus, the Maryland law provides that
+"any person who shall knowingly advertise, print, publish, distribute
+or circulate any pamphlet, printed paper, book, newspaper notice,
+advertisement or reference containing words or language or conveying
+any notice, hint, or reference to any person or to the name of any
+person, real or fictitious, from whom, or to any place, house, shop,
+or office, where any poison, drug, mixture, preparation, medicine, or
+noxious thing or any instrument or means whatever; or from whom
+advice, direction, information or knowledge may be obtained for the
+purpose of causing the miscarriage or abortion of any woman pregnant
+with child, at any period of pregnancy, shall be punished by
+imprisonment in the penitentiary for not less than three years, by a
+fine of not less than five hundred dollars, nor more than one
+thousand dollars, or by both, in the discretion of the court."]
+
+The knowledge that prohibitory laws exist is sufficient to deter
+reputable physicians from illegal practice; whereas known laxity in
+the enforcement of the law continually tempts unscrupulous persons to
+provoke abortion. Among the poorer classes the procedure is
+undertaken by ignorant women, while persons in more comfortable
+circumstances avail themselves of the services of medical men who are
+usually incompetent and value money above professional honor. The net
+result is an unpardonable death-rate and a large proportion of
+invalids. Aside from the legal aspect of the act, the element of
+personal danger would seem a warning to be heeded by women who
+contemplate becoming a party to this crime.
+
+THERAPEUTIC ABORTION.--If a woman is suffering from tuberculosis or
+some organic affection, pregnancy may add a serious strain upon the
+already crippled machinery of her body. Occasionally gestation itself
+may cause changes which threaten life. In either event the duty of
+the physician is plain. The law is acquainted with such emergencies,
+and explicitly permits the termination of pregnancy when undertaken
+to relieve or cure such conditions. When performed to restore health
+the operation is called therapeutic abortion.
+
+The Maryland law, for example, grants the right to induce abortion
+whenever two or more physicians see the patient and agree that "no
+other method will secure the safety of the mother." Similar rules are
+prescribed by the statutes of other States, but none concedes the
+right of abortion as a means of keeping the woman from suicide.
+
+Since therapeutic abortions are legal, they may be done openly; hence
+the operation is performed in appropriate surroundings and with every
+refinement of surgical technique. These fortunate conditions
+materially alter the outlook; serious consequences of the operation
+itself need not be feared. Competent surgeons, employing modern
+methods, may perform hundreds of abortions without the loss of a
+single patient. Moreover, pregnancy may be terminated safely and
+expeditiously at any time; the lay view which regards abortion as
+more serious after the second month than before it is a relic of days
+gone by.
+
+PREMATURE DELIVERY.--In the introduction to this chapter we noted
+that the infant becomes viable after the twenty-eighth week, which
+marks in a practical sense, the transition of the fetus from an
+immature to a premature stage of development. In point of frequency,
+premature delivery ranks far below either abortion or miscarriage.
+
+Unlawful interference with pregnancy generally proceeds from a desire
+to avoid offspring, and lacks incentive after the infant becomes
+capable of living independently. Criminal operations, therefore, are
+not a conspicuous cause of premature delivery. Occasionally
+physicians resort to artificial means to end gestation during the
+later months in order that organic complications may be relieved; but
+most premature births occur spontaneously. Sometimes they are due to
+ill-health, while in other instances no evidence of disease is found
+in either mother or child. Careful study of the individual patient,
+however, is generally helpful toward the prevention of repeated
+premature delivery.
+
+The course of premature labor closely resembles delivery at full
+term. But it is shorter because the infant is small; and the
+subsequent loss of blood is not so great. The recovery of the mother
+is never retarded by the fact of earlier delivery, though the
+conditions which caused it may prevent rapid convalescence.
+
+The outlook for the infant depends upon a great many factors. Most
+important among them is the perfection of its development, which may
+be estimated most satisfactorily from its weight and length.
+Occasionally children have been reared when they weighed as little as
+three pounds, but hope that they will survive should not be
+entertained unless they weigh four pounds or more. This is attained
+about eight weeks before maturity, and corresponds to a length of
+forty centimeters (16 inches), measured from the crown of the head to
+the heel. Premature children perish, most frequently, either from
+incomplete development of their heat-regulating apparatus, which
+predisposes them to pneumonia, or from imperfections in the digestive
+functions, which increase the liability to malnutrition. To overcome
+the first danger, incubators have been devised and have become
+familiar to everyone through public exhibitions. A basket or box
+supplied with hot-water bottles answers the same purpose, and has the
+advantage of better ventilation. The second danger can be overcome
+only by proper feeding. Breast-milk provides the most reliable
+nourishment for premature infants. If the mother cannot supply it, a
+wet-nurse should be procured, and, if the infant has not the strength
+to suckle, the milk should be drawn from the breast and fed with a
+medicine-dropper or a spoon.
+
+In addition to providing proper food and maintaining an even body-
+temperature, care must also be taken to protect these infants from
+various harmful influences such as too much handling, strong light,
+and loud noises. Although every precaution be observed, frequently
+all counts for nothing; but if the child does thrive, there is no
+reason for worry about its ultimate development. When a premature
+infant lives, the same chances for adult health await it as it would
+have had if born in its due time.
+
+
+
+
+CHAPTER IX
+
+
+THE PREPARATIONS FOR CONFINEMENT
+
+Engaging the Nurse--Desirable Qualities in the Nurse--Preliminary
+Visits of the Nurse--The Necessary Supplies for Confinement--The
+Baby's Outfit--Sterilization--The Choice and Arrangement of a Room--
+The Bed--The Preliminary Visit of the Doctor--When to Call the
+Doctor--Personal Preparations--The Care of Obstetrical Patients at
+the Hospital.
+
+Prospective mothers are anxious to learn how they shall prepare for
+the approaching confinement. They desire their preparations to be
+thorough, reliable, and in accord with the most approved methods of
+treatment, for they realize that preparations along these lines will
+not only prevent haste and confusion at the time of birth, but will
+also promote a satisfactory convalescence. Apparently trivial details
+often safeguard confinement against serious accident. Indeed,
+measures which aim at the prevention of illness form the chief asset
+of modern obstetrics, and of these none takes higher rank than the
+maintenance of strict cleanliness during and after childbirth. This
+fact fortunately is widely appreciated at present, and not a few
+women inquire voluntarily the means of observing the proper
+precautions. It is true, of course, that even today many women are
+delivered in filthy rooms and upon dirty beds, and that in spite of
+such surroundings some of them make a good recovery. Yet grave
+complications develop much more frequently among those who have not
+paid attention to the preparations for confinement.
+
+The surgical dressings and other supplies do not require attention in
+the early months of pregnancy. A number of articles, invaluable when
+delivery occurs at full term, are useless if the fetus is immature
+and cannot live, and therefore it is unnecessary to provide them
+until two or three months before the confinement is expected. In the
+event of a miscarriage what is needed can be procured upon very short
+notice. But, on the other hand, delivery subsequent to the twenty-
+eighth week may require all the equipment useful at full term so that
+everything should be in readiness by that time.
+
+ENGAGING THE NURSE.--As soon as the existence of pregnancy is clearly
+recognized the patient should select the doctor and the nurse who
+will attend her. Prompt selection of a nurse will assure the widest
+choice, for proficient nurses are in demand and book engagements far
+in advance of the date they will be needed. Furthermore, it is a
+relief to the patient to have her attendants selected. The
+possibility of premature delivery never interferes with engaging the
+nurse very early in pregnancy, for that accident releases both
+patient and nurse from their contract.
+
+Nurses demand that the date be specified upon which an engagement
+shall begin, as, unless their calendar is definitely arranged, they
+are unable to earn a livelihood. This leads to a question which is
+difficult to answer, for the precise day of delivery is uncertain;
+consequently to fix the beginning of the engagement may prove a
+troublesome matter. On the one hand, there is risk of having to pay
+the nurse for a time before her services are actually needed; on the
+other, a false economy may result in the absence of the chosen nurse
+at the critical moment. In finding a way out of this dilemma a
+patient must be guided by her means and the location of her home.
+Those who can afford it will not hesitate to employ a nurse from one
+to two weeks in advance of the expected date of confinement; and for
+those who live where nurses cannot be procured quickly, a similar
+course is recommended. But persons of only moderate resources, living
+in a city where, in an emergency, a substitute can be gotten from the
+local "Nurses' Directory," will find it convenient to engage the
+nurse from the calculated date. The substitute will remain with the
+patient until the arrival of the nurse originally engaged.
+
+Occasionally, it may happen that a patient will prefer to keep the
+substitute. Such a course, however, would be unjust to the nurse who
+was first selected, unless she could immediately secure other work.
+She has reserved a definite period of her time for the patient, and
+probably has declined work which seemed likely to conflict with the
+engagement already made. She is fairly entitled, therefore, to assume
+charge of the case, and the patient who refuses to make the change is
+obligated to pay her according to the terms of the agreement.
+
+How long will a nurse be needed after the child is born? The answer
+to this question may be altered by so many circumstances that a hard
+and fast rule cannot be given. Before the advent of "Trained Nurses,"
+obstetrical patients were cared for by "Monthly Nurses," so called
+because they remained one month with their patients. It is, likewise,
+customary to keep the trained nurse four weeks after the birth; but
+whenever possible it would be well to retain her six weeks, since
+this period elapses before the mother has entirely regained her
+normal physical condition. Those who can afford to keep a trained
+nurse six months or a year are exceptional, but very fortunate.
+
+Someone may feel that the suggestions I have made are not suitable to
+her case. Very likely they may not be; to cover all the possibilities
+could scarcely be expected, for every case has its problems and
+peculiarities. After consultation with her physician each patient
+will decide what is particularly advisable for her. Nevertheless, I
+would emphasize the importance of securing a competent nurse and
+retaining her for at least four weeks. Even with those who must guard
+their expense account the truest economy will lie in such a course.
+Whenever lack of resources seems likely to prevent this arrangement,
+the patient who is looking to her best interests should enter a
+hospital where excellent care can be provided at a cost within her
+means.
+
+DESIRABLE QUALITIES IN THE NURSE.--It is rarely advisable to select
+as nurse a member of the family or an intimate friend. Some of the
+motives governing such a course--sentiment, mutual devotion, and the
+desire to be humored--are inconsistent with the best kind of nursing.
+If the nurse knows the patient intimately, undue anxiety may
+interfere with her judgment; thoroughness in routine duties may be
+hindered by mistaken consideration for the patient; and in an
+emergency sympathy rather than reason may guide her. A successful
+nurse must satisfy at least two requirements; she must be capable
+professionally and also personally agreeable to her patient. Some
+regard advanced years as essential to the first of these
+qualifications, but this does not necessarily hold good.
+
+The personal qualities generally welcome in a nurse are neatness,
+thoughtfulness, a sympathetic nature, an even disposition, and a
+cheerful view of life. Since a short interview is insufficient for
+taking the measure of a nurse, patients usually rely upon the opinion
+of someone else in selecting her. The judgment of her former patients
+is frequently prejudiced in one direction or the other, and such an
+estimate must always be accepted with caution. Much the most
+trustworthy method is to allow the physician to select her. He will
+know nurses who possess the requisite qualities, and certainly he is
+most competent to judge their professional attainments. If the choice
+of a nurse be left to the doctor, the two are sure to work
+harmoniously, and the patient will benefit by their cooperation.
+Otherwise she may suffer because of their dissensions, for, if the
+doctor is accustomed to one procedure and the nurse to another,
+misunderstandings may occur, although both methods yield equally good
+results. Whenever he does not select her, she should be asked to
+confer with him long before the case is due. Obviously, a physician
+cannot be held responsible for a nurse's ability unless he is
+acquainted with her training and methods of work.
+
+In an effort to economize, many are inclined to employ "half-trained"
+or "practical nurses." When the confinement is not the first and
+there is no reason to anticipate any irregularity during labor or
+thereafter, I can see no vital objection to such an arrangement. It
+is of the first importance, however, to be assured that the
+"practical nurse" is neat and appreciates the necessity of keeping
+everything about the patient scrupulously clean. But competent nurses
+who charge less than the customary fee will be hard to find. The
+recommendations which these women receive are apt to be even more
+misleading than in the case of trained nurses, because more is
+expected of the latter. My experience has taught me that patients
+form particularly unreliable opinions of practical nurses, and I have
+frequently witnessed incompetence in such women which was overlooked
+by the patient.
+
+A low-priced nurse is seldom a cheap one, as her shortcomings may be
+reflected in the health of the mother or the infant long after she
+has left the case. Especially when the baby is the first, the mother
+will depend upon the nurse for instruction which should be both sound
+and thorough. The principles taught her will be put into practice and
+utilized for many months, playing a vital part in the training of the
+infant. It becomes essential, therefore, to secure a nurse who will
+give the baby a good start, and instruct the mother along right
+lines. Perhaps this is less needful if the mother has learned her
+lesson from previous experiences. But even then a good nurse relieves
+her of responsibility and materially assists her to a quick and
+lasting convalescence. In the end the most proficient nurses are the
+least expensive.
+
+THE PRELIMINARY VISITS OF THE NURSE.--Many of the precautions which
+safeguard a confinement should be considered by the patient and the
+nurse together. The character and quantity of the supplies, the
+choice of a room for delivery and subsequent convalescence, the
+proper clothing for the infant--all these are problems which may be
+solved most satisfactorily in the light of the nurse's experience and
+the resources at hand. Two visits are usually sufficient to arrange
+these details. An interview early in pregnancy, soon after the nurse
+has been selected, provides an opportunity to lay plans and
+especially to review the list of articles needed at delivery. Such
+articles as are already in the house may be checked off; the others
+may be procured at leisure. Eight to ten weeks before the expected
+date of the confinement the nurse should pay a second visit and
+should inspect the supplies to see that they are complete. Certain
+articles which I shall indicate must be sterilized. As this procedure
+is more reliable when carried out by an experienced person it will be
+convenient to have all the dressings finished by the time of the
+nurse's second visit, in order that she may sterilize them.
+
+The question may arise as to whether the nurse shall come to the
+patient upon the date for which she has been engaged or shall wait
+until summoned. From the physician's standpoint it is often more
+acceptable to have the nurse in the house a few days before the
+confinement, though some patients strongly object to this. Provided
+the nurse may be got quickly at any time of day or night, there can
+be no objection to leaving the decision to the patient herself.
+
+THE NECESSARY SUPPLIES FOR CONFINEMENT.--As to just what a
+confinement outfit should contain physicians differ to some extent;
+but this disagreement pertains rather to luxuries than essentials. In
+the lists here suggested nothing essential has been omitted, although
+economy, as far as is consistent with good judgment, has been kept in
+mind. Any article not included in my list which the doctor or nurse
+in attendance recommends may be noted in the space for memoranda.
+
+Some patients prefer to take no part in preparing the supplies for
+confinement. Indeed, the demand for a ready-made confinement outfit
+has become large enough to lead several firms to put them upon the
+market. These outfits differ in completeness and vary in price from a
+few dollars up to fifty. The majority of patients, however, still
+attend to such details themselves, and will find a list of the
+needful supplies convenient.
+
+_Make-up and Sterilize_:
+  7 Dozen Sanitary Pads.
+  2 Sanitary Belts.
+  2 Delivery Pads.
+  5 Dozen Gauze Sponges.
+  2 Dozen Gauze Squares.
+  4 Dozen Cotton Pledgets.
+  2 Sheets.
+  Bobbin for tying the Cord.
+  A Pair of Obstetrical Leggins.
+  A Dozen and a Half Towels (Diapers).
+
+_Obtain from the Druggist_:
+  100 Bichlorid of Mercury Tablets.
+  100 grams Chloroform.
+  4 ounces Powdered Boric Acid.
+  4 ounces Tincture Green Soap.
+  1 pint Grain Alcohol.
+  A small jar of White Vaselin.
+  A cake of Castile Soap.
+  A two-ounce Medicine Glass.
+  A Medicine Dropper.
+  A bent glass Drinking Tube.
+
+_The following articles should be in the house, ready for use._
+
+  An ample supply of Towels, Sheets, and Gowns.
+
+  A new Hand-Brush; the cheap variety with wooden back and stiff
+  bristles is preferable.
+
+  Two slop Jars or enamel Buckets with Covers.
+
+  A two-quart Fountain Syringe; an old one may be substituted provided
+  it has been thoroughly boiled.
+
+  Three Basins and a one-quart Pitcher of agate or enamel-ware.
+
+  A Douche-Pan; the "perfection Bed-Pan" is preferable.
+
+  Two pieces of Rubber-Sheeting are required, one large enough to cover
+  the mattress of a single bed (2 x 1-1/2 yds.), the other smaller (1 x
+  3/4 yd.). Should this be too expensive, the best substitute is white
+  table oil-cloth.
+
+The nurse will explain how the various surgical dressings are made,
+but, as the patient may forget some of the directions, all the
+details will be given here. At least three to four pounds of
+absorbent cotton will be used in the dressings. To make the pads
+entirely of absorbent cotton is very expensive. The cheaper cotton-
+batting is therefore employed to give them body, and they are faced
+only upon one side with the absorbent material. Furthermore, the
+rolls of absorbent cotton, as purchased, may be separated into three
+or four layers, one of which is thick enough for the facing. About
+six rolls of the batting should be purchased.
+
+Surgical gauze, which tradespeople sometimes call dairy-cloth, is the
+most suitable material for covering the pads. Bleached cheese cloth
+will answer the same purpose, but it is more expensive and rather
+heavy. Approximately thirty-five yards of the gauze, which comes in a
+thirty-six-inch width, will be needed. When the supplies are
+finished, they are wrapped in separate bundles and sterilized. Old
+muslin or some of the diapers are generally used for covers.
+
+_The sanitary pads_, also called vulval or perineal pads, absorb
+the discharge which always occurs after delivery. They are made of
+absorbent cotton and cotton-batting covered with gauze; a convenient
+size is ten inches long and three to four inches wide. Their
+thickness is approximately an inch, one-third of which is composed of
+absorbent cotton.
+
+_The sanitary belt_ is used to hold these pads in place. Very
+satisfactory ones are made of two strips of unbleached muslin, three
+inches wide. The first of these must be long enough to reach around
+the waist; the second, which passes over the pad, is somewhat shorter
+and has two parallel slits in one end; through which the waist-band
+passes at the back; the three free ends are pinned together in front.
+
+_The delivery pads_ are made of the same materials as the
+sanitary pads; preferably a yard square and four inches thick. A
+rather heavy top-layer of absorbent cotton must be used in them, and
+they should be quilted or tacked at several points to prevent
+slipping. A rubber pad is ill adapted for use during delivery. Some
+absorbent material made into proper shape proves much more
+satisfactory since it can be thoroughly sterilized and can be thrown
+away after it has been used.
+
+I am told that cotton-waste is a good substitute for absorbent cotton
+in the delivery pads. It is inexpensive, and will be rendered capable
+of absorbing fluids after it has been boiled in washing soda and
+dried in the sun. Each delivery pad should be separately wrapped and
+sterilized.
+
+_Gauze sponges_ will be needed by the doctor; about five dozen
+should be prepared. The gauze is cut in eighteen-inch squares.
+Opposite edges are folded toward one another, about two inches being
+lapped each time; this finally yields a seven or eight-ply strip,
+which is wrapped into appropriate shape about two fingers. The
+ravelled ends are then tucked into the roll. It is most satisfactory
+to divide the sponges and sterilize them in two bundles.
+
+Small pieces of gauze about two inches square will also be needed in
+caring for the baby's eyes and mouth. Several dozen should be cut,
+and they may all be sterilized together.
+
+_Cotton pledgets_ are simply bits of absorbent cotton the size
+of a hen's egg, the rough edges of which have been twisted together.
+A small pillow-case full of them ought to be made up and sterilized.
+
+_Obstetrical leggins_ are preferably made of canton flannel;
+they are cut to fit loosely and should reach the hip. If they are
+prepared so as to extend to the waist at the sides, they may be held
+in place by a waistband, and in this way will prevent unnecessary
+exposure without interfering with the doctor. They should be
+sterilized.
+
+_Towels_, if used at all, should be without fringe. It is
+economical not to employ them, but to use diapers in their place.
+Three packages, each containing six diapers, should be sterilized.
+
+_Sterilized sheets_ are often useful at the delivery; more than
+two are never needed. They should be wrapped separately for the
+sterilization.
+
+_Sterilized bobbin_ is generally used for tying the cord.
+Several pieces are cut in nine-inch lengths and sterilized in a
+single package.
+
+_A dressing for the cord_ will be required, but there is no
+necessity for preparing a special one. It is generally satisfactory
+to wrap the cord in one of the sterile gauze sponges which has been
+previously soaked in alcohol.
+
+Several methods of drying up the cord give equally good results, and
+it is usually a good plan to allow the nurse to dress it as she
+wishes, since the employment of a method with which she is familiar
+will more likely insure a satisfactory result in her hands. A
+dressing popular with many nurses is prepared as follows: In a piece
+of muslin four inches square cut a small circular opening; double the
+linen and dust boric acid between the folds. If this method is
+preferred, several of the dressings should be prepared and sterilized
+together.
+
+THE BABY'S OUTFIT.--Preparations for the infant may be thorough
+without being elaborate. Instinctively, the prospective mother leans
+toward extravagance in fitting out her baby's wardrobe, and easily
+slips into the error of providing too much. Time and energy are
+frequently devoted to an extensive wardrobe which the infant quickly
+outgrows; in consequence many articles must be made over before they
+are used. Even with modest resources a prospective mother can acquire
+everything the baby really needs.
+
+A very sensible plan, in my judgment, is to prepare what will be
+wanted during the first two months; subsequently, articles may be
+made or bought as they are needed. Accordingly, the quantity of
+wearing apparel and the nursery supplies I have suggested pertain
+only to the early weeks of infant life. Although no essential has
+been omitted, the outline is plain and economical.
+
+At present, outfitters supply a variety of ready-made, garments for
+the infant and conveniences for the nursery; in many of them notable
+ingenuity is displayed which aims at the child's comfort or the
+saving of labor to the mother. Catalogs of these articles, which are
+often expensive, are furnished by dealers.
+
+In preparing clothing for the new-born, several principles must be
+kept in mind. The first is that the garments must be warm without
+being unduly heavy; and another that they should be roomy, permitting
+perfect freedom of motion. A third no less important principle is
+simplicity. Adornment of the clothing gratifies the mother, but does
+not serve a single useful purpose. The lists which follow include all
+that is necessary for the young infant; they will also serve as a
+basis for elaboration if a more lavish outfit is desired.
+
+_Necessary Clothing_.
+  4 Abdominal Flannel Bands.
+  3 Undershirts.
+  4 flannel Skirts.
+  4 Night Gowns.
+  12 White Slips.
+  3 Knit Bands.
+  4 Dozen Diapers.
+  Cloak and Cap.
+
+_Nursery Equipment_.
+  An old Blanket.
+  Assorted Safety Pins.
+  Soft Damask Towels.
+  Wash Cloths.
+  Hot-Water Bag with Canton Flannel Covers.
+  Talcum Powder.
+  Olive Oil.
+  Bassinet.
+
+_Additional Articles; Convenient but Not Essential_.
+  Rubber Bathtub.
+  Rubber Bath-Apron.
+  Flannel Apron.
+  Bath Thermometer.
+  Bath Hamper.
+  Quilted Mattress Covering.
+  Baby Scales.
+  Screen.
+  Low Chair without Arms.
+  Drying Frames.
+
+STERILIZATION.--Now and again, those who follow very rigid rules to
+avoid infection during childbirth are criticized for their pains. The
+general public has not yet grasped the true relation of bacteria to
+this condition; a relation which, indeed, first became clear to
+medical men within comparatively recent years. The development of our
+knowledge of the nature of infection forms one of the most
+entertaining chapters in obstetrics, and provides a simple way of
+showing the genuine need of preventive measures. Several observant
+physicians had previously suspected the character of "child-bed
+fever" (as infection of the mother was once called), but convincing
+proof of its contagious nature was not forthcoming until the middle
+of the nineteenth century, when signal facts were pointed out by
+three men, each working independently, though all came to similar
+conclusions. The evidence they gathered should have left no one
+doubtful that the disease is contagious, and largely preventable. On
+the contrary, bitter opposition was encountered for the time, and
+only within the last two decades has their teaching found wide
+practical application.
+
+In 1843 Oliver Wendell Holmes published the paper on "The
+Contagiousness of Puerperal Fever," which is now preserved in his
+volume of "Medical Essays." Physicians were startled to be frankly
+told the responsibility they assumed if they neglected the truth
+taught by epidemics of this disease. "The dark obituary calendar"
+which marked the progress of these epidemics clearly indicated that
+"the disease is so far contagious as to be frequently carried from
+patient to patient by physicians and nurses." A violent controversy
+followed this arraignment, and, consequently, the preventive measures
+which Holmes so convincingly urged were not adopted as promptly as
+they should have been. The full justice of his conclusions has since
+been universally admitted, and medical men now find it difficult to
+understand how anyone could have taken issue with the sentiment which
+he expressed. "For my part," Holmes said, "I had rather rescue one
+mother from being poisoned by her attendant than claim to have saved
+forty out of fifty patients to whom I had carried the disease."
+
+But the most important early observations upon child-bed fever were
+made in 1847 by a young Hungarian, Semmelweiss, while he was an
+assistant in the large Lying-in Hospital in Vienna. In thoroughness,
+power of conviction, and practical value his work was masterful. It
+is no exaggeration to regard his observations as the rock upon which
+antiseptic surgery, the glory of the nineteenth century, was built.
+
+Semmelweiss had been seeking an explanation of the dreadful scourge,
+and his mind was ready for the reception of the truth when it was
+revealed through the death of one of his colleagues. This physician
+injured his finger accidentally in performing an autopsy upon a
+patient who had died from child-bed fever. And the condition
+disclosed by examination of his body after death was identical with
+that found in cases of child-bed fever. Here then was the clew; the
+disease was contagious. Semmelweiss was ignorant of Holmes' views;
+what had happened before his eyes suggested to him that the disease
+was due to a poison which could be conveyed from one person to
+another. Moreover, his interest and his power of insight led to
+further comparison. Clearly, the open wound on the physician's finger
+had been the portal through which the poison entered; but where was
+there a similar portal in obstetrical patients? The answer was plain.
+The birth-canal at the time of delivery is always an open wound.
+There the poison entered, and child-bed fever was a wound infection!
+
+Several years later Tarnier, who was to become an eminent
+obstetrician, but was then a student in Paris, chose the diseases of
+the lying-in period as the subject for his graduating thesis. He was
+unacquainted with the work either of Holmes or of Semmelweiss, and
+approached the problem from still another standpoint, drawing
+attention to the much higher deathrate among women delivered amid
+unsanitary surroundings. Tarnier also considered that the disease was
+a form of poisoning, that it was contagious, and that measures should
+be instituted to protect patients against it.
+
+Of these pioneers, by far the greatest credit is due Semmelweiss, who
+devoted his life to the problem, although his opinions continually
+met with scepticism and even ridicule. More convincing proof than he
+could furnish was demanded before his contemporaries would believe
+that child-bed fever was due to lack of precaution. Fortunately the
+evidence was soon produced. In 1880, Pasteur obtained bacteria from
+the organs which had been infected, and was able to grow the bacteria
+in his laboratory; thus the ultimate cause of the disease became
+firmly established. With the harmful agents in their hands, Pasteur
+and his followers were enabled to study their characteristics and to
+recommend means of destroying them.
+
+Much as we must regret that the warnings of Holmes and of Tarnier
+passed unheeded; lamentable as may be the blindness of the generation
+of Semmelweiss to the truths revealed by his research, it is not
+surprising that such radical teaching met with a hostile reception.
+As we measure time in retrospect from the vantage ground of to-day,
+the three to four decades required for full acceptance of their
+revolutionary doctrines seem a brief span. Antiseptic methods would
+not have prevailed so quickly as they did, had not the same epoch
+which gave us a Pasteur also given a surgeon with a receptive mind,
+ready to seize and apply the discoveries of the French genius. This
+was the great service of Joseph Lister. Impressed with Pasteur's
+studies on fermentation, Lister saw an analogy between this process
+and the putrefaction of wounds, a condition which he was eager to
+prevent. He had reason to believe that carbolic acid would check
+decomposition, and he employed a weak solution of it in the treatment
+of wounds; later he devised a "carbolic spray," by means of which
+when his operations were performed the atmosphere round about might
+be sterilized.
+
+It is but a short step from antiseptic operations to our own era of
+aseptic surgery, and that a step in the direction of simplicity. Now
+we know that the sterilization of the air is rarely necessary and
+have dispensed with Lister's elaborate apparatus. Furthermore, and of
+far greater moment, experience has taught that the destruction of
+bacteria before they have opportunity to come in contact with the
+wound is more effective than efforts to kill them as they approach or
+after they have invaded the tissues. Initial freedom from bacteria is
+the ideal of asepsis; to secure it, the modern surgeon is ever
+watchful of the cleanliness of his hands, his instruments, his
+dressings, and of the site of operation or whatever may come near it.
+
+The importance of the changes wrought by the adoption of aseptic
+methods requires no emphasis, for the marvels of modern surgery are
+even more impressive to laymen than to the medical profession.
+Everybody now understands that strict cleanliness is indispensable to
+the success of a surgical operation. But the general public has not
+fully awakened to the same profound necessity in connection with
+childbirth, although it was child-bed fever that called forth the
+observations and experiments upon which modern surgical technique
+rests.
+
+Although most obstetrical patients appreciate the fact that there is
+an advantage in sterilized dressings and sanitary surroundings, few
+realize the risk they run without them. One must know the mournful
+history of the past to be adequately impressed with that danger, for
+we no longer see the epidemics of childbed fever which formerly swept
+over communities, sacrificing ten of every hundred women as they
+became mothers. Precaution is no less necessary on that account; the
+scourge would be rampant again if the reins were loosened.
+
+Most instances of puerperal infection are, it is true, referable to
+lack of care. Nevertheless, the complication develops now and then
+where all precautions have been conscientiously observed. Under such
+conditions the infection will in all likelihood be a mild one, and a
+tedious convalescence usually proves its most disagreeable feature.
+Such stringent preventive measures as are now practiced in many
+hospitals have reduced the frequency of infections to the point where
+only one fatal case, or even less, occurs in a thousand deliveries.
+These rare cases remind us that vigilance must never be relaxed, and
+that patients who are confined at home require just as much care as
+those in hospitals, where conditions are the best to prevent
+infection and the complications, which follow.
+
+The first essential toward the avoidance of infection in obstetrical
+cases is clean dressings. Naturally, these should be clean to the
+sight, but it is in invisible dirt that serious danger lurks;
+bacteria are the causative agents of this disease. Experiments have
+taught the bacteriologist that disease-producing organisms are killed
+in half an hour when subjected to a high atmospheric pressure and the
+temperature of steam. Special apparatus has been constructed for
+carrying out the procedure. It is unnecessary for our purposes,
+however, since the essential conditions may be secured, though with
+less convenience, in any kitchen. If a prospective mother finds it
+awkward to do the sterilizing at home, and her nurse is unable to
+take charge of the matter, she may arrange with a local hospital or
+the nearest nurses' directory to sterilize her dressings. Yet a very
+little ingenuity suffices to do the work at home with perfect
+satisfaction. Installments of the smaller bundles may be sterilized
+in a galvanized bucket. To do this place an inverted bowl, with a
+depth of three to four inches, at the bottom, and pour in water until
+the bowl is almost covered. A breakfast plate rests on the bowl, and
+upon this the dressings are stacked; a second larger plate which fits
+the top of the bucket is utilized as a lid to close in the
+sterilizing chamber. This will not accommodate the larger packages; a
+more satisfactory method for all of them is to use a wash-boiler in
+which has been swung a muslin hammock.
+
+To arrange the latter form of home sterilizer, cut an oblong piece of
+unbleached muslin large enough to sink far down into the boiler and
+run a drawing-string of stout cord about the edge. Cover the bottom
+of the boiler with several inches of water; tie the hammock in place,
+passing the cord beneath the handles of the boiler to hold the muslin
+securely. Pack in the dressings, which have been wrapped in
+appropriate bundles; put the lid in place, thus closing the
+sterilizing chamber, and leave the dressings exposed to the steam for
+at least half an hour. After the operation has been completed, the
+bundles are taken out of the boiler and allowed to dry in the air.
+They must not be opened until the occasion for which the supplies
+were prepared arrives; awaiting this event, they are laid away in a
+convenient closet or drawer.
+
+A word of caution may be added concerning a method of sterilization
+employed at home more frequently, perhaps, than any other. According
+to this procedure, the supplies are wrapped in paper, thrust into a
+hot oven, and left there until the paper is scorched. From the
+standpoint of economy as well as of thoroughness, this method is
+likely to prove unsatisfactory. Frequently, the dressings themselves
+are scorched; I have known patients to ruin several installments of
+their supplies in this way. Moreover, dry heat is not so trustworthy
+as steam for sterilizing purposes.
+
+Judicious management means the preparation of the supplies necessary
+for confinement before turning to the selection of the infant's
+outfit. Ordinarily, both these tasks should be finished by the end of
+the eighth month, and final arrangements for the approaching delivery
+will then claim attention. If the patient expects to remain at home,
+she must decide which is the best room to occupy; she will wonder how
+it ought to be equipped, and she will be anxious to learn what
+personal preparations are advisable at the beginning of labor.
+
+Intelligent answers to these questions are important. A patient
+should request the physician to criticize her plans when he pays the
+preliminary visit four to five weeks prior to the expected date of
+confinement. If she has acted unwisely in any respect, he will point
+it out, and may suggest changes which will enable her to employ to
+the best advantage the resources at hand.
+
+THE CHOICE AND ARRANGEMENT OF A ROOM.--An old-fashioned custom, which
+relegated obstetrical patients to the most secluded part of the
+house, with little regard for comfort and still less for hygiene, has
+now few, if any, adherents. There is an advantage, to be sure, in
+having a quiet room; but this qualification may be secured in a room
+well located with regard to other essentials. Selection of a suitable
+room is not a trivial point. In most cases, since patients ordinarily
+remain for convalescence in the same room in which the infant is
+born, the chamber must serve a two-fold purpose. A number of
+requirements, therefore, must be met, and they must all be kept in
+mind when the room is chosen.
+
+We have seen that the act of birth, natural as it is, may have a very
+unnatural sequel if precautions against infection are treated
+lightly. It is proper, therefore, that the delivery-room should be as
+clean as care can make it. Such radical measures as may be employed
+in sterilizing the dressings are here out of the question; if
+possible, they would be absurd. Infection usually develops because
+harmful bacteria come in contact with the patient. For that reason,
+an infection is more likely to be communicated by the dressings than
+by articles about the room, which only become a source of danger when
+the dirt upon them is transferred by an attendant.
+
+An acceptable delivery-room may be arranged in any home; it is by no
+means necessary to duplicate the equipment of a modern hospital. To
+choose a room convenient to the bathroom will be found advantageous
+not only at the time of birth but throughout the lying-in period. The
+furnishing should be simple and scrupulously clean; indeed, it is
+improbable that one of these good points can be secured without the
+other. Furthermore, the preparation of the room should be completed
+well in advance of the date of confinement.
+
+A large collection of furniture interferes with the nursing, and also
+increases the difficulty of keeping the room free of dust. It is
+sound advice, therefore, to remove everything which will not serve
+some good purpose during the delivery. Should any article be wanted
+later, it can be brought back to its accustomed place. The furniture
+may be conveniently limited to a bed, a bureau, a washstand, a table,
+and several chairs, one of them a large, comfortable rocker, which
+will prove invaluable during the early part of labor.
+
+To approach perfect conditions, bric-a-brac, needless hangings, and
+everything that might collect dust should be temporarily removed. A
+profusion of pictures does not accord with the best sanitation of a
+room devoted to the treatment of obstetrical patients; those which
+are to be left upon the wall ought to be taken down and wiped
+carefully with a damp cloth. Other desirable preparations would be
+instinctively undertaken by the modern housekeeper, and it may seem
+presumption to mention that the room itself ought to be subjected to
+most thorough cleaning. It is well to leave the floor bare or merely
+covered with freshly cleaned rugs. Carpeting is difficult to protect
+against soiling and is not sanitary. If left down, the carpet should
+be covered with some suitable material, firmly stretched and tacked
+in place.
+
+We know that the air in most households does not contain disease-
+producing bacteria; but the presence of any contagious disease
+materially alters the situation, and may imperil the convalescence of
+an obstetrical patient. Preferably, one should never select a room in
+which there has lately been sickness, and under no circumstances may
+such a room be used until carefully fumigated. The more conspicuous
+diseases which for at least several months absolutely disqualify an
+apartment for obstetrical purposes are diphtheria, pneumonia,
+pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of
+all varieties, and every sort of discharging sore.
+
+When possible, two adjoining rooms should be given over to the mother
+and the infant; if this is impracticable, the single room should be
+large, easily ventilated, well lighted, and heated in such a way as
+to permit a change of temperature without difficulty. All these
+features help to make convalescence comfortable and free from petty
+annoyances. A room which has a southern or eastern exposure proves
+grateful for those who must remain indoors; frequently, this will be
+beyond reach, but a room getting the sun's rays directly during part
+of the day will always be available, and the selection should be made
+with that requirement in mind. At the time of birth and for the first
+few days which follow, a patient may not appreciate this feature;
+ultimately she will understand the need of sunlight better than the
+need for the more technical, and therefore the more impressive,
+preparations.
+
+THE BED.--Now that housekeepers recognize how easily such furniture
+can be kept clean, few homes are without a brass or an iron bedstead;
+they are equally sanitary. Undoubtedly, this kind of bedstead
+fulfills the needs of an obstetrical patient much better than any
+other; and, if at hand, it should be used. The single bedstead is the
+most acceptable, and the mattress ought to be at least twenty inches
+above the floor. A low, wide bed interferes with proper management of
+the delivery and later handicaps the nurse in taking care of the
+patient. Wooden blocks may be used to raise a bed which otherwise
+would be too low. It is well worth while to provide them if one
+desires good nursing, for no attendant can do her best when she must
+continuously bend over a very low bed.
+
+The location of the bed at the time of delivery is not an unimportant
+matter; it must always be placed so that the brightest possible light
+will shine over the foot. Since birth often occurs at night, one
+should make certain that the artificial lighting of the room is good,
+and place the bed most advantageously in reference to it; at the same
+time the necessity of a good light from the windows, when delivery
+occurs during the day, should not be forgotten. The head of the bed
+may be placed against the wall, but both sides must remain freely
+accessible not only at the time of delivery but also throughout the
+lying-in period.
+
+A smooth, firm mattress, made in one piece, should be provided. One
+which has been used several years and possibly worn in a hollow will
+require renovation to be made comfortable. A feather bed should not
+be used under any circumstances. The mattress must be protected; and
+protection is best secured by means of a large piece of rubber
+sheeting. The regulation household sheet covering the rubber should
+be tucked well under the mattress at the ends and sides; in that way
+the rubber sheeting will be held firmly. Since the part of the bed
+where the hips rest will be most exposed to soiling, the protection
+of this area is usually reinforced by a "draw sheet." To arrange
+this, a cotton sheet is doubled so as to make a strip about one yard
+wide and two yards long; the smaller piece of rubber sheeting is laid
+between the folds. The draw sheet will reach from the middle of the
+back to the knees; its ends should be tucked under the sides of the
+mattress, to which it is fastened by means of large safety pins.
+After delivery, the draw sheet may be removed without disturbing the
+mother, who will thus be assured a clean, dry, and comfortable bed.
+
+The bed-clothes covering the patient during labor will vary with the
+season of the year, but should always be light; in summer a single
+sheet will suffice, and in winter a blanket will likely be needed.
+For sanitary reasons, a freshly laundered sheet should also be placed
+outside the blanket until the delivery has been completed; later, it
+may be replaced with a light spread. Two pillows will be needed, and
+it is very convenient to have one of hair, the other of feathers.
+While there is no necessity for sterilizing the bed-clothes, it is
+advisable to use linen which has been recently laundered and kept
+well protected from dust. Among the poor, infection from soiled bed-
+linen is not uncommon.
+
+THE PRELIMINARY VISIT OF THE DOCTOR.--No teaching of medical science
+has been given greater prominence of late than the principle of
+prevention. In obstetrics it finds a particularly wide field of
+application, and its practice is responsible for removing many of the
+former terrors of childbirth. We have just learned that preventive
+measures effectually reduce the frequency of puerperal infection, and
+in an earlier chapter we saw the value of routine examination of the
+urine as a means of anticipating other complications. Moreover, the
+benefit of promptly reporting to the physician anything that does not
+seem to be as it should has been urged constantly, for in this way is
+afforded the earliest opportunity to treat complications. Similarly a
+visit from the doctor about four weeks before the expected date of
+confinement is indispensable to skillful management of the delivery;
+neglect of this precaution is sometimes responsible for bad results.
+
+At this visit the physician not only becomes familiar with the
+general health of his patient, but he also notes certain facts which
+will have a direct bearing upon the course of labor. By means of a
+few simple measurements he may accurately determine the character of
+the pelvis, the bony structure through which the fetus passes. When
+they are compared with what we know as the normal measurements, a
+very good idea is gained as to whether the birth-canal will present
+any obstacle to the passage of the child; and, if it will, there is
+opportunity to deliberate what treatment may be necessary. Since
+another factor in the problem, namely, the size of the child, cannot
+be accurately predicted, occasionally the physician may hesitate to
+express as definite an opinion as the patient may wish. Nevertheless,
+though it may be impossible to learn every detail, the available
+information well repays the time and trouble expended. In nine out of
+ten cases nothing whatever is found out of the way; the result is an
+assurance which always justifies the examination.
+
+During this examination the position of the child is also
+ascertained. By means of a series of painless manipulations through
+the abdominal wall of the mother, the head, the body, and the
+extremities of the child may be mapped out, and the conclusions
+verified by locating the fetal heart-sounds. In this regard, also,
+the physician usually finds normal conditions. The most favorable
+presentation, that in which the head is the part to be born first,
+occurs in ninety-seven of every hundred cases. When less favorable
+conditions are recognized, they may frequently be corrected at once;
+but should that prove impossible, with foreknowledge of the
+presentation, the physician will be more competent to conduct the
+delivery.
+
+With a clear understanding of the character and value of the
+information gathered at the preliminary examination, patients are not
+likely to refuse it. If they do, the risks should be fully explained
+to them. Some physicians decline to assume the responsibility of a
+patient who will not permit these observations. Such a decision is
+rarely necessary, for in my experience the patient's consent has
+never been difficult to obtain. Many women now regard the visit as
+part of the routine attention, and inquire when it will be made.
+
+The appropriate time for this examination, as I have indicated, is
+approximately one month prior to the calculated date of confinement.
+Before this period, we have no assurance that the presentation which
+is found will continue until the time of birth. The fetus frequently
+alters its position as long as it is not large enough to fill out the
+cavity of the womb, consequently it is only during the last month of
+pregnancy that the final presentation can be determined. But to defer
+the examination after the period I have specified is unsafe since we
+lack an exact method of fixing the day of confinement, and too long a
+delay might render a preliminary examination impossible.
+
+Aside from its relation to the observations just outlined, the
+preliminary visit provides an opportunity for the physician to
+criticize the preparations which have been made, and for the patient
+to inquire about the personal preparation advisable at the beginning
+of labor. She will also learn the signs which indicate that labor has
+begun and will be told what to do when they appear. Although
+physicians may not agree in all these directions, there can be no
+difference of opinion relative to the essential points. At least, the
+rules given here will serve to bring the patient and the doctor to a
+definite understanding as to the course he desires her to follow.
+
+WHEN TO CALL THE DOCTOR.--During the last two or three weeks of
+pregnancy not a few patients are more comfortable than they have been
+for several months. About this time the womb usually drops somewhat
+and relieves the pressure which has interfered with breathing. These
+changes, however, do not promote comfort in every direction; more
+freedom for the organs of the chest means compression of the
+structures below the womb; consequently, the inclination to empty the
+bladder and for the bowels to move becomes more frequent. Patients
+complain also of cramps in the legs and experience difficulty on
+walking. This order of events enables some women to recognize the
+approach of delivery. Of course there is other evidence when labor
+actually begins. Its onset may be indicated in one of three ways,
+namely, by periodic pains, by a gush of water from the vagina, or by
+a discharge of blood as though the patient were taken unwell. Each of
+these unmistakable signs is a sufficient reason for notifying the
+doctor.
+
+At the onset of labor, dragging pains are usually felt at the back,
+but sometimes in the lower part of the abdomen. The rhythm with which
+they come and go identifies them more certainly than any other
+feature, though this indication is not entirely reliable, for
+intestinal colic also causes rhythmical pain. At first the uterine
+contractions which occasion the discomfort are weak and appear at
+long intervals. Gradually they become stronger and closer together.
+When the interval between them has been shortened to half an hour or
+less their significance is fairly certain, provided the abdomen
+becomes tense and hard with each pain, remaining comparatively soft
+between them.
+
+When contractions begin during the day or early evening, the
+physician will be glad to have immediate notification in order that
+he may arrange his appointments and thus be free to attend the
+patient when she needs his services. On the other hand, if they begin
+between 11 P.M. and 7 A.M. the nurse, who will always be summoned
+with the very first warning, should be allowed to decide when the
+doctor is to be called. Unless other instructions have been given,
+she will usually wait until the interval between the contractions is
+five to ten minutes.
+
+Usually the symptoms make it clear that labor has begun, but
+occasionally the greatest difficulty will be experienced in deciding
+whether the discomfort has not some other origin. Uncertainty may
+prevail not only because of the similar effects of colic, but also
+from the fact that uterine contractions do not always have the same
+value. Preliminary pains may appear several days, or even weeks,
+before the actual onset of labor. Now and then the "false" pains
+cease, and after a period of comfort efficient contractions are
+established. There is never difficulty in recognizing the latter;
+doubt always relates to the preliminary pains, which may subside or
+may pass into the efficient type. We lack a method of foretelling
+which turn they will take; developments may be calmly awaited, with
+the assurance that ample warning will precede the birth.
+
+A slight mucous discharge from the vagina is frequently seen toward
+the end of pregnancy and may be disregarded, but a gush of watery
+fluid always means that the sac which contains the fetus has
+ruptured. Uterine contractions generally follow within a few hours,
+though in a few instances they will not appear for a number of days.
+Under any circumstances the event ought to be promptly reported to
+the doctor. Similarly, he should be notified whenever bleeding from
+the vagina occurs, since it is important to have him determine its
+significance.
+
+Anyone who supposes that patients are more likely to be infected when
+delivery occurs so quickly that there is not time for the doctor to
+arrive overlooks the leading factor in the production of this
+complication. Unless harmful bacteria are introduced into the birth-
+canal and lodge there, infection is impossible. Bacteria never enter
+of their own accord; they are usually carried into the vagina by
+means of an examining finger or some other foreign body. Accordingly,
+with the exception of those instances in which local inflammation
+already exists, there is no reason to fear infection when delivery
+proceeds so rapidly that internal examinations are not required.
+
+PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in
+the house, she will arrive in time to assist the patient in making
+the final arrangements for delivery. Should the nurse be delayed, the
+patient herself may make certain preparations to insure personal
+cleanliness, another very important factor in the prevention of
+infection.
+
+The presence of hair and the folding of the skin about the outlet to
+the birth-canal render the disinfection of this area somewhat
+difficult. It is advisable, therefore, to clip the hair as short as
+possible and, while bathing the whole body, to scrub the region in
+question with especial thoroughness. Before the bath an enema of
+soap-suds should be taken to clear the rectum of material which
+otherwise might be expelled during the birth and contaminate the
+field of delivery. The bath-towels and the gown which are used should
+have been freshly laundered.
+
+Other especial preparation of the delivery-field will be made later
+by the nurse. But whenever labor progresses so rapidly that neither
+the nurse nor the doctor arrives before the child is born, such
+preparations as I have indicated will be sufficient, for more minute
+precautions are unnecessary unless an internal examination must be
+made.
+
+THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of
+obstetrical patients are attended at home, and there is no reason why
+this should not be. Generally it is unfair to urge a woman to go to a
+hospital if she has already passed through a normal confinement and
+there is no reason to anticipate trouble in the approaching one; on
+the other hand, if any complication whatever is anticipated, the
+patient should certainly enter a hospital. Furthermore, it frequently
+proves advantageous to do so where the pregnancy is the first, though
+no complication is expected and none develops. The average labor with
+the first child lasts somewhat longer than with subsequent ones, and
+in consequence there is greater opportunity for the patient's family
+or friends to interfere with the management of the case, which never
+benefits a patient, and is sometimes a serious handicap. Then again,
+the cramped apartments, so common in these days, are poorly adapted
+to the treatment of sickness of any sort and should induce many
+obstetrical patients to choose the hospital. There are, besides,
+other features which favor this course, such as economy, convenience,
+and safety. From my own experience, which includes the care of
+patients both at home and at the hospital, I am convinced that, as a
+rule, the latter is much more satisfactory.
+
+Most cities now have institutions which provide a room and all the
+essential care, exclusive of the doctor's services, at approximately
+the cost of a trained nurse at home; luxuries will naturally add to
+the expense in hospitals as quickly as elsewhere. If one considers
+the various items connected with attention at home, such as the
+maintenance of the nurse and of the patient, the cost of the
+equipment necessary for confinement, the additional household
+laundry, and the sundry other details, it is clear that hospital
+treatment becomes distinctly economical. Moreover, the uncertainty of
+the date of confinement may necessitate paying a nurse for a longer
+or shorter period before the birth. Expense at the hospital, on the
+contrary, usually begins when the patient enters; and if she lives in
+the city it is rarely advisable for her to leave home until the
+beginning of labor. Even aside from the matter of expense some women
+prefer the hospital, since in this way they avoid the technical
+preparations for the birth.
+
+Much more vital, however, is the care patients receive in the
+hospital, for rigid adherence to surgical cleanliness is exemplified
+in the hospital as it can be nowhere else. Infections rarely develop
+there. Formerly these accidents were more common in the hospital than
+in the home, but conditions are now reversed and fatalities
+predominate among those delivered in private houses. The modern
+theory of asepsis has, to be sure, been widely accepted and is
+practiced so far as possible wherever obstetrical patients are
+attended, but only in the hospital can the underlying principles be
+applied with complete thoroughness and persistence. The hospital is
+constantly alert, whereas in private houses carelessness or
+ignorance, or both, often lead to lax technique. As a result,
+statistical evidence indicates that two to three infections occur
+among those delivered at home for one at the hospital.
+
+In the event of an emergency during labor, the hospital affords
+another distinct advantage in its staff of trained attendants. Of
+course they may be brought to one's home, yet not without some delay
+and extra expense; whereas in the hospital their assistance is
+instantly available. In institutions charity patients are often
+delivered under more favorable auspices than are the wealthy at their
+homes. Convalescence likewise is favored at the hospital, since the
+rules which control the admission of visitors guard the mother from
+exhaustion and annoyance. Moreover, isolation such as can only be
+secured in a hospital is conducive to a well-trained baby.
+
+Patients debating what course to follow often ask when they must
+leave home, what they should take with them, and how long they ought
+to remain at the hospital. The attending circumstances will alter the
+answers to these questions, but in a general way the following
+directions will serve as a guide.
+
+Ordinarily, the patient may remain at home until the first warning of
+labor. Departure from this rule is justified if the patient becomes
+unduly anxious about reaching the hospital in time, especially when
+she lives some distance from the institution, or if there is any
+doubt of securing accommodations. In either event, she should go to
+the hospital at least one week before the confinement is expected.
+There is no danger in riding to the hospital after labor has begun;
+frequently, the ride exerts a helpful influence and shortens the
+labor.
+
+Whatever is to be taken to the hospital should be packed in a bag
+several weeks before the predicted date of confinement and put in a
+convenient place so that one may be spared the trouble of gathering
+it at the last minute. Beside her usual toilet articles, the mother
+will require several gowns, a dressing-robe, and bedroom slippers.
+Clothing for the child will also be needed since most institutions
+stipulate that the infant use its own wearing apparel. If
+impracticable to transport the entire wardrobe when the mother enters
+the hospital, so much may be taken as will be needed during the first
+few days, and other articles may be brought as the need of them
+arises. The personal laundry of both mother and infant is usually
+done outside the institution.
+
+Surgical dressings of every description are provided by the hospital.
+Those who intend to enter a hospital, therefore, may disregard the
+list of articles necessary for confinement. Similarly, the
+sterilization, the preparations of the room and of the bed, and
+personal preparations will be of interest only to the patient who
+intends to stay at home.
+
+It is not always possible for the physician to say how long a patient
+should remain at the hospital; the rapidity of the mother's
+convalescence and the progress of the child, both important factors,
+cannot be accurately foretold. Frequently, it is a good plan to
+remain until the infant is four weeks old, but the majority of
+patients are dismissed at a somewhat earlier date. In no instance,
+however, should the mother be allowed to leave before the infant is
+two weeks old. Even when given the privilege of leaving so early she
+will always understand that competent assistance must be provided at
+home, for the mother should not resume her routine duties until six
+weeks after the birth.
+
+
+
+
+CHAPTER X
+
+
+THE BIRTH OF THE CHILD
+
+The Cause of Labor--The Course of Labor--The Stage of Dilatation--The
+Stage of Expulsion--The Placental Stage--The Effect of Labor upon
+the Child--Meddling--Justifiable Intervention--Management of Birth
+without the Doctor--Methods of Reviving the Child.
+
+The birth of a child is an act of nature, an act generally performed
+as satisfactorily as any other bodily function. Birth has, however,
+so deep a meaning for the mother, as well as for her family and her
+friends, and is, above all, so vital to the future of the race, that
+it has naturally become the subject of many impressive superstitions.
+Primitive peoples have invariably embodied in their religion their
+views of the origin of life and the phenomena of its inception. With
+these mysteries Greek and Roman mythology dealt extensively, as did
+also the myths of the Phoenicians, the Egyptians, the Chinese, and
+the people of ancient India. No race, indeed, has lacked its own
+interpretation of childbirth, and no phase of the process has failed
+to have attributed to it a supernatural significance. A number of
+these superstitions still distress women on the eve of motherhood. To
+correct exaggerations and to deny many utterly false impressions of
+childbirth there is no better way than to give a frank account of
+what does actually occur. I shall adhere to a purely physiological
+description of the event, for, although I appreciate fully the fact
+that its sociological and sentimental aspects are perhaps equally
+important, these are not, in my opinion, pertinent to a medical
+discussion.
+
+In a scientific sense the act of birth may be described as a series
+of muscular contractions which widen the birth-canal and expel the
+contents of the pregnant womb. Since the process requires an
+expenditure of energy, it has come to be called labor. Intrinsically,
+labor does not differ from many other physiological acts. The heart
+drives blood into the arteries; the bladder empties itself; the
+intestine moves its contents and finally expels the undigested
+residue. All these acts strongly resemble that of birth; but they
+also differ from it, for the head of the fetus is a hard body which
+resists being molded to the shape of the passageway through which it
+enters the world. To this resistance the pain which accompanies
+delivery is largely due. And yet even in this respect the act of
+birth is not unique; certain circumstances lead to painful
+contractions of the muscle fibers in the intestine and less
+frequently of those in other organs.
+
+It is natural to ask what purpose is served by the pain associated
+with labor; and a moment's reflection will make it clear that one
+reason for the discomfort is the warning which it gives of the
+approach of birth. If the mother were not thus cautioned, she might
+be delivered under very awkward circumstances, and even under such
+conditions that occasionally the infant would perish the instant it
+was born. All mammals suffer in giving birth to their young, though
+with quadrupeds the period of suffering is shorter, for the upright
+posture of man has changed the shape of the pelvis, rendering birth
+somewhat more difficult. Anyone who observes the lower animals
+preparing for delivery will be convinced that they also are
+responding to pain, the most compelling call of nature.
+
+That the suffering is at all essential to the mother's love for her
+child I cannot believe. Under certain circumstances, as for example
+when the Cesarean operation is performed before the onset of labor,
+the delivery is painless; yet I have never known a mother less
+devoted to her child on that account. Biology throws no light upon
+the relation of the "curse of Eve" to present-day confinements.
+
+THE CAUSE OF LABOR.--It is evident that, in a general way, the
+muscular contractions of the womb cause the birth of the child; but
+before we thoroughly understand the act, science must discover what
+stimulates the muscle to contract. Although careful research has thus
+far failed to disclose the source and character of the stimulus, it
+has taught many properties of the contractions themselves. Their
+force has been measured and found to increase as the end of labor is
+approached; the pressure they exert varies between nine and twenty-
+seven pounds. We also know that the patient can neither hasten nor
+delay the contractions voluntarily. Strong emotions are believed to
+accelerate them at times, and we find a very extraordinary
+illustration of this effect recorded in I Samuel, IV, 19, where we
+read: "Phineas' wife was with child, near to be delivered; and when
+she heard the tidings that the ark of God was taken, and that her
+father-in-law and her husband were dead, she bowed herself and
+travailed; for her pains came upon her." On the other hand, and much
+more familiarly, excitement checks the contractions after they have
+begun. Every obstetrician has heard patients say that with his
+arrival the pains died down. Yet such an influence is never
+permanent; the contractions soon reappear, and labor advances as
+though no interruption had occurred.
+
+For the artificial induction of labor, the physician has at his
+disposal means that resemble the method sometimes employed by nature.
+Suitable appliances introduced into the womb provoke contractions,
+and labor proceeds step by step as if the stimulus were a normal one.
+Nature does not, however, ordinarily employ mechanical irritation to
+start the uterine contractions. The initial factor is more remote
+and, as I have said, is not yet well understood.
+
+Since, as everyone admits, delivery occurs with conspicuous
+regularity about the end of the fortieth week of pregnancy, and
+pregnancy corresponds, therefore, to ten menstrual cycles, some have
+been led to believe that labor and menstruation have a common basis.
+The truth of this supposition, however, must be doubtful until we
+know the cause of menstruation. Yet it is a matter of common
+observation that the uterus becomes unusually irritable about the
+time when the tenth menstrual period would be due. Strong purgatives
+administered with other drugs on or after the calculated date
+frequently bring about delivery, whereas previous attempts of this
+kind prove unsuccessful. To account for this peculiar irritability of
+the uterus about the fortieth-week of pregnancy, microscopical
+changes in its tissues have been suggested but sought in vain. Nor
+will the distention of the organ explain it.
+
+A great many theories have been offered to explain the causation of
+labor, but they have now only an historical interest. To-day we are
+just beginning to learn the correct methods of studying the problem.
+The experience of ages has firmly established the fact that the fetus
+is expelled when ready to enter the world, or as we say, when it has
+become mature. But how does the fetus assert its maturity? There is
+the kernel of the matter; that is the real problem, a problem for the
+solution of which, happily, we possess better facilities than have
+heretofore existed. One solution that has been suggested assumes that
+the fetus loses ultimately its power to assimilate the nourishment
+provided through the mother's blood. In consequence, it is argued,
+the material which previously enabled the fetus to grow now collects--
+in the maternal circulation, stimulating the womb to contract.
+
+A part of this explanation, namely, that the material which
+stimulates the muscle fibers, whatever it may be, is a chemical
+substance and that it circulates in the mother's blood, is almost
+certainly true. There are, however, very weighty reasons for
+believing that this substance has not the character of food. A more
+plausible supposition is that the fetus produces this material in the
+course of its natural living processes, and the substance would
+accordingly be a waste-product.
+
+THE COURSE OF LABOR.--The current view that labor begins in the early
+evening and generally ends during the night is incorrect. This
+impression has grown out of the fact that the whole process
+frequently consumes twelve hours and must in such an event include
+some part of the night. Statistical evidence indicates that almost as
+many births occur at one hour of the twenty-four as another; to be
+precise, only five per cent. more children are born between 6 P.M.
+and 6 A.M. than between 6 A.M. and 6 P.M.
+
+As already pointed out, labor commonly begins with transient
+discomfort in the lower part of the back. At first the uterine
+contractions are far apart; they last but a moment and cause only
+twinges of pain. Gradually, the preliminary contractions give place
+to others of more definite character, which appear at intervals of
+five to ten minutes. Estimates of the total length of labor will vary
+according as one counts from the first warning or from the advent of
+typical contractions which we hear called "pains of the right kind."
+These generally continue for about four hours, and this period
+represents the average length of time the physician remains
+constantly with his patient. Estimates which include the initial
+symptoms are longer, varying from ten to eighteen hours. Prolonged
+labors are rare; and extremely short labors are also infrequent,
+though now and again it will be only an hour or two from the very
+first pain until the child is born.
+
+To predict absolutely the length of labor for any particular patient
+is impossible. The averages calculated from large groups of cases
+have no more than a broad scientific interest; when applied to any
+individual they are apt to be very misleading. Thus, from statistics
+we should expect the first labor to be longer than subsequent ones,
+but we are often surprised by an unusually rapid delivery.
+
+To facilitate description, labor is divided into stages which are
+conveniently designated the first, the second, and the third. During
+the first stage the way is prepared for the expulsion of the child;
+at the end of the second stage the child is born; the third stage is
+occupied with the separation and the expulsion of the after-birth.
+The progress of labor may be ascertained from time to time by means
+of suitable examinations. Whereas formerly vaginal examination was
+the only method which served this purpose, we are now acquainted with
+several. For example much of the information necessary for the proper
+management of delivery may be gained from examination of the
+patient's abdomen; and this may be supplemented by observations too
+technical to consider here.
+
+Occasionally I have heard doctors accused of negligence because they
+failed to make numerous vaginal examinations. Censure of this kind
+generally is unjust, for discretion in limiting the number of vaginal
+examinations provides against infection a guarantee which cannot be
+overestimated. In many cases, of course, they are still invaluable
+toward determining what treatment should be pursued, yet they are
+never employed to the extent once customary. Moreover, physicians
+have learned to take extraordinary precautions whenever vaginal
+examinations must be made.
+
+Anyone who practices obstetrics in these days appreciates how careful
+he must be, especially of the cleanliness of his hands. Energetic
+scrubbing with soap and water and the free use of antiseptics, as
+physicians now employ both these measures, appear ridiculous to some
+women who have witnessed deliveries under a less stringent regime.
+They may be bold enough to express their disapproval. They may remind
+us that many women have been successfully delivered without such
+care. And in this they are correct; we know that nine of every ten
+mothers passed through childbirth uneventfully before modern
+precautions were dreamed of. Such precautions as are now taken,
+however, are necessary to secure the safety of the tenth patient. And
+it is because they are anxious that all their patients shall enjoy
+the greatest possible security that physicians dare not omit any
+precaution.
+
+Disinfection of the physician's hands does not entirely exclude the
+danger of infection through vaginal examinations. Although he may
+have been most conscientious, there is some risk of carrying
+contaminating material into the birth-canal from the region about the
+opening of the vagina. Unless that region has been satisfactorily
+disinfected, sterilizing the dressings and cleansing the hands may
+become a waste of time. Sensible patients, therefore, will never
+object to the preparations which the nurse is instructed to make.
+
+THE STAGE OF DILATATION.--For reasons which are sufficiently clear,
+the womb must remain closed while fetal development is in progress;
+but under normal conditions, when this development is complete, the
+mouth of the womb dilates and the infant is expelled. The infant
+never takes an active part in its birth, although physicians once
+thought it did and attributed tedious labors to stubbornness on its
+part. The error has been corrected in medical teaching, but many
+persons unacquainted with the facts cling to the idea that the infant
+forces its own way out of the womb.
+
+At the end of pregnancy the mouth of the womb is small, too small,
+often, to admit an instrument as broad as a lead pencil. It is
+obvious, therefore, that very radical changes must be wrought before
+the infant can pass. The door, as it were, must be widely opened.
+This phenomenon, which we call dilatation of the womb, is brought
+about by involuntary contractions of the muscle fibers in its wall,
+every point of which they draw upward. Now, the top of the womb is
+directly opposite its mouth, consequently the contractions inevitably
+pull its lips wider and wider apart. Ordinarily another factor is
+concerned in this mechanism. To understand the whole process we must
+recall that a fluid surrounds the fetus, and that this fluid is
+contained within elastic membranes. The uterine contractions compress
+the fluid, drive the membranes, like a wedge, into the mouth of the
+womb and spread its lips apart. Thus, to the pulling effect just
+mentioned, a pushing force is added. After full dilatation has been
+accomplished and the membranes can serve no further purpose, they
+rupture; as the midwife puts it, "the bag of waters breaks." The
+quantity of fluid which escapes will vary. Occasionally, a huge gush
+will drench the patient's clothing; but more often what is lost at
+first amounts to only a few teaspoonfuls, though small quantities of
+fluid often dribble away with subsequent contractions.
+
+Although not the rule, it is by no means unusual for the membrane to
+rupture at the onset of labor, or at least before the mouth of the
+womb is fully dilated. Exceptionally, rupture occurs a few days
+before labor begins; and still longer intervals, though extremely
+rare, have been recorded. Whenever the membranes rupture prematurely,
+the pushing force of the uterine contractions becomes less effective,
+though the pulling force is never impaired. Under these
+circumstances, which occasion what is called a "dry labor," delivery
+is apt to proceed slowly, yet that does not follow necessarily, for
+the part of the fetus which happens to lie over the mouth of the womb
+may act as efficiently as the unruptured membrane would.
+
+During the first stage, the longest of the three, the patient is
+comfortable between the contractions and generally interests herself
+in some diverting occupation. The presence of the physician can be of
+no assistance then, and patients rarely demand it. Usually, they are
+satisfied to know he is ready to come when called. It is wrong to
+deceive patients with various recommendations from which they will
+vainly expect help during this stage; their welfare is best served
+when they are left alone. Generally the advice of well-meaning
+friends will be as harmless as it is futile, yet I must emphasize
+that during the first stage straining to expel the fetus is ill
+advised. Such effort will surely be ineffective then and may exhaust
+the patient; in that event it becomes harmful, for she will be
+fatigued when she most needs strength.
+
+Since, during the first stage, the progress of delivery is not
+influenced by what the patient may choose to do, she may follow her
+own inclinations. The average patient will be restless and will keep
+on her feet most of the time; alternately she will walk or stand
+still as one or the other happens to make her more comfortable. As a
+contraction begins she often seeks support, leaning upon a chair or
+bending over the foot of the bed, and presses with her hands against
+the lower part of her back. Patients may sit down or lie down
+whenever they wish; if so inclined they may even go to sleep.
+
+Most patients take no food during the whole course of labor, but, if
+nourishment is desired, there is no reason for abstaining from it.
+They may always drink water as freely as they like, and may also have
+milk, weak tea or coffee, or broth; but alcoholic beverages should
+never be taken without the specific consent of the physician. This
+same caution applies to strong coffee and tea. If desired, crackers
+or toast and rice or other cereals may be eaten in reasonable
+quantity. For fear of vomiting a patient will occasionally be told
+not to partake of any food. This advice is given, not because the
+symptom is alarming, but to save her needless annoyance. Indeed,
+vomiting frequently indicates that dilatation is well advanced, and,
+therefore, may generally be regarded as an encouraging sign.
+Ordinarily a persistent inclination to have the bowels move has the
+same significance. On the other hand, a constant desire to empty the
+bladder is more prominent at the onset of labor than later.
+
+To know the moment which marks the transition from the first to the
+second stage of labor can be of no benefit to the patient; but for
+the medical attendant the greatest interest centers about this point.
+Casual observation sometimes enables the physician to recognize it,
+for characteristically at the close of the first stage the whole
+picture changes. In a typical case the membranes will rupture at this
+instant, expulsive efforts will begin, and, as we have just learned,
+there may be symptoms referable to pressure. Moreover, a blood-tinged
+discharge, spoken of as the "show," usually makes its appearance
+about the same time. Since slight bleeding frequently occurs at the
+beginning of labor, or a little later, this manifestation, like all
+others, may not be implicitly trusted to indicate the end of the
+first stage. Such uncertainty, however, is a matter of no great
+consequence, for in the absence of all these symptoms the physician
+may, if necessary, accurately determine the degree of dilatation by
+an internal examination.
+
+THE STAGE OF EXPULSION.--The term delivery has been broadly applied
+to include the whole of labor. More strictly, its use should be
+limited to the second stage, for this period alone is concerned with
+the actual birth of the child. Although dilatation has been
+completed, the uterine contractions continue, devoting their force to
+emptying the womb. In this they now receive assistance from the
+voluntary contractions of the abdominal muscles.
+
+The second stage is very much shorter than the first; for this reason
+and others, too, it proves much less trying. As the child is moved
+downward through the birth-canal, the mother usually appreciates for
+herself that she is making headway; whereas in the first stage she
+may know of progress only through what she is told. Moreover, it is
+possible in this stage for the physician, by means of inhalations of
+chloroform, to relieve her of the pain attending the expulsion of the
+child.
+
+Since the anesthetic properties of chloroform were discovered by an
+obstetrician who was searching for a drug with which to lessen the
+pain of childbirth, the facts connected with the discovery have a
+peculiar interest for mothers. Sir James Y. Simpson had always been
+anxious for some means to prevent the suffering endured during
+surgical operations "without interfering with the free and healthy
+play of the natural functions." He, therefore, welcomed the
+introduction of ether anesthesia from America; and in January, 1847,
+at the Edinburgh Medical School, administered ether to an obstetrical
+patient. This was the first instance in which an anesthetic was
+employed at the time of childbirth. Since ether, to his mind, had
+certain shortcomings, Simpson set about finding another anesthetic,
+and devoted all his spare time to testing the effect of numerous
+drugs upon himself. How he came to try chloroform has been vividly
+told by one of his neighbors. [Footnote: "Late one evening, it was
+the 4th of November, 1847, Dr. Simpson, with his two friends and
+assistants, Drs. Keith and Duncan, sat down to their somewhat
+hazardous work in Dr. Simpson's dining room. Having inhaled several
+substances, but without much effect, it occurred to Dr. Simpson to
+try a ponderous material which he had formerly set aside on a lumber-
+table, and which, on account of its great weight, he had hitherto
+regarded as of no likelihood whatever; that happened to be a small
+bottle of chloroform. It was searched for and recovered from beneath
+a heap of waste paper. And with each tumbler newly changed, the
+inhalers resumed their vocation. Immediately an unwonted hilarity
+seized the party--they became bright-eyed, very happy, and very
+loquacious--expatiating upon the delicious aroma of the new fluid.
+But suddenly there was talk of sounds being heard like those of a
+cotton mill, louder and louder; a moment more, and then all was
+quiet--and then a crash! On awakening, Dr. Simpson's first perception
+was mental--'This is far stronger and better than ether,' said he to
+himself. Hearing a noise, he turned round and saw Dr. Duncan beneath
+a chair, quite unconscious, and snoring in a most determined manner.
+More noise still and much motion. And then his eyes overtook Dr.
+Keith's feet and legs making valorous attempts to overturn the supper
+table. By and by Dr. Simpson having regained his seat, Dr. Duncan
+having finished his uncomfortable and unrefreshing slumber, Dr. Keith
+having come to an arrangement with the table and its contents, the
+_sederunt_ was resumed. Each expressed himself delighted with
+this new agent, and its inhalation was repeated many times that
+night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place
+and turn at the table, and fell asleep, crying: 'I'm an angel! Oh,
+I'm an angel!'"--Quoted from "The Life of Sir James Young Simpson,"
+by H. Laing Gordon; Masters of Medicine Series.]
+
+The introduction of chloroform met with violent opposition, not upon
+medical grounds alone, but also for moral and religious reasons. "To
+check the sensation of pain in connection with the visitations of
+God," zealous theologians announced, "was to contravene the decrees
+of an all-wise Creator." Simpson reminded them "that the Creator,
+during the process of extracting the rib from Adam, must necessarily
+have adopted a somewhat similar artifice--for did not God throw Adam
+in a deep sleep?" Nevertheless, a number of years passed before the
+prejudice against artificial sleep was overcome. Chloroform only
+became popular after Queen Victoria consented to its use at the birth
+of her seventh child, Prince Leopold, in 1853.
+
+There is still some difference of opinion regarding the routine
+employment of chloroform in obstetrical practice, though the weight
+of authority favors its use during the contractions at the end of the
+second stage, providing always that no preexisting organic
+derangement renders the drug dangerous. Under no circumstances,
+however, should chloroform be given in the first stage, and seldom at
+the beginning of the second. Prolonged administration will exert an
+injurious influence upon both mother and child; under these
+conditions it ultimately weakens the uterine contractions and delays
+the delivery. Such an effect must be avoided, since it would endanger
+the life of the child by asphyxiation as well as exhaust the mother.
+On the other hand, a few drops of chloroform inhaled with each pain
+toward the end of the second stage will dull sensibility, although
+consciousness remains unaffected. When the drug is thus administered,
+the uterine contractions are scarcely, if at all, altered, and the
+assistance which the patient is willing to give herself generally
+becomes more powerful. Should the anesthetic have the opposite
+effect, it must be withheld; but that is seldom necessary. As the
+head advances the anesthesia is deepened, and the mother sleeps
+soundly while the child is being born.
+
+As long as dilatation is in progress, the patient may sit up or walk
+about; but with the advent of the second stage she should go to bed,
+for there she will be able to make the best use of the expulsive
+pains. The appropriate posture for delivery is still the subject of
+dispute, though modern views in no instance advocate the unnatural
+absurdities formerly supported by custom or superstition. Students of
+ethnology relate that among savage tribes almost every conceivable
+position was advocated for women in labor. Subsequently it became
+customary to have delivery take place in specially constructed chairs
+which are still used in semi-enlightened countries. With civilized
+nations at present women are always delivered in bed; yet national
+peculiarities still prevail. Some physicians favor what is known as
+the English position, in which the patient lies on her left side with
+her face inclined toward the chest, the trunk bent toward the knees,
+and the legs drawn up toward the abdomen. The majority of
+obstetricians, however, prefer that the patient should lie flat on
+her back. With the average case, and from the standpoint of facility
+in delivery, which of these postures happens to be chosen is a matter
+of indifference. But it is so much less awkward for the physician
+when the patient is on her back that this position has been widely
+adopted in America.
+
+During the expulsion of the child the mother intuitively desires to
+help herself; generally she cannot resist straining, and rarely needs
+encouragement. Assisting the uterine contractions with voluntary
+muscular effort, the act commonly described as "bearing down," may be
+performed most effectively when the patient is lying on her back. The
+knees are drawn up and spread apart; the feet are braced against some
+firm object; the hands grasp straps fastened at the foot of the bed;
+and the head is slightly raised so as to bring the chin near the
+chest. When the contraction begins the patient takes a deep breath
+and holds it while she strains vigorously, as if to make her bowels
+move. All voluntary effort should cease as the contraction wears
+away, for straining between the contractions can accomplish nothing.
+Her own inclination to "bear down" will clearly indicate to the
+patient when she ought to act.
+
+In the second stage patients regularly experience a feeling of
+pressure against the rectum, and this sensation, since it depends
+upon a low position of the child's head, is a welcome sign. Cramps in
+the legs also indicate progress, for they result from similar
+pressure against nerves adjacent to the lower part of the birth-
+canal. The cramps disappear immediately after the child is born, and
+are consequently never dangerous. Straightening out the legs or
+rubbing them usually gives relief. Most women, however, complain
+during the expulsive period only of pain in the back, and find
+nothing so grateful as firm pressure over this region.
+
+Energetic efforts quickly bring the head to the outlet of the birth-
+canal, where it may be seen, at first only during the contractions,
+but later during the pauses as well. The crown of the child's head is
+generally directed upward and becomes fixed against the pubic bones
+of the mother, which lie just in front of the bladder. Around this
+firm pivot the child's head rotates upward, and, as a result of the
+movement, forehead, eyes, nose, mouth, and chin successively emerge
+from the birth-canal. Following the birth of the head, natural forces
+turn the body upon one side, the better to accommodate the shoulders
+to the passageway. After these are born, the rest of the body slips
+easily into the world, and the second stage ends.
+
+THE PLACENTAL STAGE.--Although the third stage is chiefly concerned
+with the separation and the delivery of the after-birth, on which
+account it is known as the placental period, the description of other
+no less remarkable events belongs here. Even after the infant is born
+the umbilical cord extends from its navel to the placenta, just as it
+has done throughout pregnancy. Among larger mammals separation of the
+new-born from the mother is brought about in one of two ways;
+sometimes the activity of the young breaks the navel-string, though
+more frequently the mother bites it in two. Both these methods, we
+are told, have been employed by savages; but at the beginning of
+civilization it became customary to sever the cord with a cutting
+tool, and the tie thrown round it represents the first attempt of man
+to ligate blood-vessels. Ordinarily there is no need for haste in
+this operation. On the contrary, some delay is often of advantage,
+since an appreciable quantity of blood that otherwise would remain in
+the placenta is thus given opportunity to enter the infant's body.
+According to present ideas, as long as the heart-beat can be felt in
+the cord it should not be tied.
+
+The sleep induced toward the close of the previous stage lasts for a
+few minutes, so that most patients are unconscious through the
+greater part of the brief placental stage. Before the influence of
+the anesthetic has worn off, the physician has an excellent
+opportunity to sew up any laceration which may have occurred in the
+course of delivery. Slight injuries are not uncommon, especially if
+the confinement be the first, for the most skillful treatment often
+fails to prevent them. Since superficial tears are never serious if
+promptly closed, it is not their occurrence, but the failure to
+recognize them, or to sew them up when they are recognized, that
+deserves condemnation.
+
+After the birth of the child the womb becomes smaller, its walls grow
+thicker, and the cavity within is narrowed. This series of changes
+partly detaches the placenta, but the separation depends chiefly upon
+the uterine contractions. These contractions also force the after-
+birth into the vagina, whence it may ultimately be dislodged by the
+patient if she bears down again. Usually, however, it is preferable
+to save her further efforts of this kind, and, as a routine, the
+physician places one hand upon the abdominal wall, grasps the womb,
+and, during the contraction, makes firm pressure downward. The
+maneuver expels the after-birth, which consists of the placenta, the
+membranes, and the umbilical cord. Then the empty womb will form a
+hard, spherical mass about the size of the child's head, lying just
+above or to one side of the bladder.
+
+Slight bleeding also occurs during the third stage, and further loss
+of blood follows the removal of the after-birth. The total loss
+varies between a half pint and a pint, though larger amounts may be
+noted occasionally without appreciable effect upon the mother.
+Naturally, large, robust women can spare much more blood than those
+who are anemic. And yet pregnancy invariably prepares the mother for
+a loss of blood that would alarm anyone unfamiliar with obstetrical
+practice. Often the woman just delivered is not harmed by a
+hemorrhage that would endanger the life of a healthy man. This may
+seem paradoxical, but it is not; for the surplus blood, which
+formerly performed important duties in connection with the nutrition
+of the fetus, must now be removed to readjust the mother's
+circulation.
+
+In a very small number of cases an unduly large loss of blood follows
+the expulsion of the placenta. Fortunately, by treatment which
+consists usually in spurring Nature to more vigorous action we are
+well equipped to deal with this emergency. A wonderful mechanism has
+been provided by Nature to control excessive bleeding after delivery.
+If the forces upon which this mechanism depends are sluggish, the
+physician stimulates them. As in the preceding stages, the muscle
+fibers of the uterus supply the power in question, and because of
+this role an observant obstetrician once called them, "living
+ligatures." Certain of these fibers encircle the mouths of the blood-
+vessels which have been left open through the detachment of the
+placenta. When they contract the vessels are squeezed, impeding the
+escape of blood. The necessity of this action explains the
+contractions which continue even after the placenta has been
+expelled, when they are vigorous enough to cause discomfort they are
+spoken of as "after-pains." After-pains seldom follow the birth of
+the first child, but they regularly follow later confinements. In any
+case, such contractions do not persist very long, for tiny clots form
+within the blood vessels and effectually close them. As soon as the
+lining of the womb has been restored the clots are absorbed, leaving
+the organ in much the same condition as before conception took place.
+
+THE EFFECT OF LABOR UPON THE CHILD.--Unless the experience of
+countless generations had taught us otherwise, we should fear the
+child would be injured by its passage through the birth-canal.
+Immediately after the birth evidence of the journey is seldom
+wanting, but it quickly disappears.
+
+The unusual size of the infant's brain requires the head to be large,
+and bestows upon it a contour which differs from that of the mother's
+pelvic cavity. Since the bones of the pelvis are rigid, while those
+of the fetal skull are malleable, the head is molded as it descends
+into the pelvic cavity, so that its passage may be made the easier.
+As the result of this process of accommodation the skull becomes
+relatively longer from crown to chin than in adults. Within a few
+weeks, however, the modification vanishes. If an infant is born with
+the buttocks first, the head does not linger in the birth-canal, a
+fact which in such cases explains the pleasing shape of the skull,
+which emerges with the contour determined by fetal growth.
+
+Whenever a soft swelling appears over that portion of the scalp which
+was foremost during the birth, the curiosity of the family is
+aroused; but the swelling is harmless and subsides quickly. It
+originates for the same reason that a finger swells if too tight a
+ring is worn, which, as everyone knows, is because of interference
+with the circulation. Just as the swelling of the finger disappears
+when the constriction is removed, so the swelling of the scalp
+subsides shortly after the child is born. Usually no trace of it can
+be found the next day; but even when more persistent it will always
+vanish after a short time.
+
+For the child the most notable result of labor relates to the
+revolutionary changes in its mode of existence. Up to the time of
+birth the fetus received nourishment by way of the placenta, but
+after separation from the mother another source of food must be
+found. The health of the tissues, perpetually in need of oxygen,
+requires that the lungs act very promptly. Contact with the air,
+which is cooler than the previous environment of the child, irritates
+the nerve-endings in the skin; in response to the sensation thus
+produced breathing is established automatically. Whenever the
+temperature stimulus proves insufficient, physicians employ a
+stronger one, spanking the child until it cries lustily. Crying not
+only expands the lungs, but also has a favorable influence upon
+needful alterations in the fetal circulation.
+
+The lungs, since they must from this time on provide oxygen for the
+infant, need to receive more blood than formerly. The vessels leading
+toward them must be widely opened, and structures which previously
+diverted the blood-stream to the navel must be closed. The intricate
+shifting of forces which produces the change cannot be understood
+without a knowledge of anatomy; it will suffice for us to know that
+the blood is drawn into the vessels of the lungs with each
+inspiration. Other changes also occur. On account of some of these,
+namely, certain alterations in the blood current through the heart,
+physicians once taught that newly born infants should always be laid
+upon the right side. Except in very unusual cases, that precaution is
+now regarded as unnecessary.
+
+Of all the elements essential to nutrition, oxygen is the only one
+required immediately after birth; as the child enters the world well
+stocked with all the others. Babies are not born hungry, as many
+people seem to think. Neither is their crying a proof of it, for, as
+we have observed, they have other very good reasons for crying; nor
+is their readiness to suck anything that comes in contact with the
+mouth, for they will behave in the same way while they are receiving
+an abundance of nourishment through the umbilical cord. Many hours
+pass before a newly born infant can possibly need food. Indeed, it
+could survive a week or longer without taking anything, by mouth,
+except water. The ability to suckle at birth merely indicates that
+the infant is prepared to utilize the mechanism which nature will now
+employ to sustain it.
+
+After the umbilical cord has been severed the blood vessels within it
+can serve no further purpose. Consequently the remnant of this
+structure attached to the child's abdomen begins to shrivel. Formerly
+the care of the stump was considered a trivial matter; when
+cleanliness was neglected decomposition caused more rapid separation
+than takes place under the treatment which it now receives. No
+annoyance should be felt because the cord hangs on a long time;
+indeed, such an experience means it has been given exceptionally good
+care. Separation rarely occurs before the end of a week. It may be
+deferred for two weeks, or even longer, if the stump has been kept
+perfectly clean. After the shriveled cord drops off, the skin around
+the navel contracts, leaving a small raw area which discharges a
+yellow fluid for two or three days before the healing is complete.
+
+MEDDLING.--In selecting a physician the patient will almost certainly
+have been guided by her confidence in his ability. It may seem
+strange, therefore, to insist that he be allowed to conduct the
+delivery as he thinks best. Nevertheless, suggestions from outsiders
+are so common, especially if the labor be at all prolonged, that it
+seems appropriate to warn patients to pay no attention to such
+advice. In the heat of excitement well-meaning relatives are
+sometimes inclined to interfere, and women who are not members of the
+family occasionally wish to discuss their experiences, irrelevant as
+they may be.
+
+The patient's intimate friends, quite naturally, have the keenest
+personal interest in the event, an interest that of itself
+disqualifies them from reasoning calmly at the time. Their influence
+may be positively harmful if they persuade the physician to undertake
+procedures which his judgment convinces him are inadvisable. Should
+he turn a deaf ear, they will think him lacking in sympathy; but
+should he adopt their suggestions he would assume the full
+responsibility, and would perhaps be censured later by the very
+persons whom he sought to please. There can be no question of the
+proper course for him to pursue. Any influence which such entreaties
+may have will always be in the direction of too early interference,
+which is fraught with danger to mother and child alike. The master-
+word is patience, and it applies alike to the mother herself, to the
+doctor, and to her friends.
+
+Almost always the whole duty of the doctor consists in watching the
+progress of labor, so that he may be ready to render assistance
+should it be needed. Until the second stage begins there is no real
+necessity for him to remain in the room. Indeed, it is better for him
+not to do so after he has made sure that satisfactory conditions
+prevail, for his judgment will be less biased if the patient is not
+continuously under his observation.
+
+JUSTIFIABLE INTERVENTION.--It is quite true that in the progress of
+the birth difficulties now and then arise; yet they are far less
+common than rumor would lead us to believe. The unusual always
+attracts attention, often receiving greater emphasis than it merits.
+The particulars of confinement provide no exception to this rule; a
+delivery which requires artificial aid will be talked about, while
+hundreds that terminate naturally pass without comment. In this way
+the public gets an exaggerated notion of the frequency of difficult
+labors. Moreover, the nature of the trouble is usually distorted, for
+reports of medical events are apt to be incorrect, and errors
+multiply with each rehearsal. Obstetrical patients who wish, so far
+as possible, to escape the depressing influence of such inaccurate
+reports will be most likely to succeed if they follow the advice to
+select a physician at the beginning of pregnancy. When this is done
+the physician will have opportunity to explain or discredit alarming
+rumors, a task which it is usually necessary for him to perform, for
+there are always some persons who feel that a prospective mother
+should listen to everything that they have heard of childbirth.
+
+The most frequent cause for intervention during labor is
+insufficiency of the muscular contractions to overcome the resistance
+of the birth-canal. Unusual resistance of this kind explains the
+longer labors of women who have passed middle life before becoming
+pregnant. They may need to exercise more patience than younger women,
+though they have no greater reason to apprehend serious difficulties.
+Whenever rigidity of the muscles adjacent to the birth-canal arrests
+delivery the physician may employ the obstetrical forceps, which have
+been in use since the seventeenth century.
+
+Although it is widely known that physicians sometimes terminate labor
+in this way, the public estimate of the merits and of the limitations
+of the instrument is so inexact that the truth about it should be
+understood. Obstetrical forceps were devised by one of the
+Chamberlens, a family of French Huguenots who fled to England in
+1569. The invention was long kept a secret; therefore its date cannot
+be fixed, nor even the inventor clearly identified, though everyone
+agrees that he was a member of this family. Clearly the instrument
+had been in use for some generations prior to Hugh Chamberlen, who
+translated from French into English the foremost obstetrical textbook
+of his time. The book, published in 1672, does not contain a
+description of the forceps, but in his preface Hugh Chamberlen refers
+to delay in delivery, saying, "My father, my brothers, and myself
+(though none else in Europe as I know) have by God's blessing and our
+own industry attained to and long practiced a way to deliver women
+without prejudice to them or their infants in this case." It is not
+questioned that the forceps was the secret that his ancestors and he
+himself employed so long and so profitably. About a century ago what
+are probably the original models of the instrument were discovered in
+a country home of Essex which once belonged to the Chamberlens; there
+they had been hidden in a trunk in the garret. The box in which they
+were concealed contained four pairs of forceps, representing
+different stages in their development, besides other instruments and
+a number of letters which established their ownership.
+
+After an unsuccessful attempt to sell the family secret in Paris,
+Hugh Chamberlen found a purchaser in Amsterdam. The privilege of
+using it in Holland was then granted physicians for a monetary
+consideration, and that practice continued until two philanthropists
+purchased the secret to make it public. It was ultimately learned,
+however, that the sale was a swindle, for the device which the
+purchasers obtained consisted of only half the genuine instrument.
+The real secret was revealed by a son of Hugh Chamberlen, who bore
+the same name as his father; but probably the first accurate printed
+description of the forceps was made by Samuel Chapman, in his
+treatise on obstetrics which appeared in 1733. Subsequently they came
+into general use, and, with many modifications, remain the most
+important instrument in the obstetrician's equipment. There can be no
+exaggeration in the claim that the instrument has done more to save
+human life than any other surgical appliance.
+
+The obstetrical forceps have been of such great service in
+diminishing the number of still-born infants that they were once
+called the child's instrument. The need of its employment in behalf
+of the child may be determined by careful observation of the fetal
+heart-sounds, which are heard over the mother's abdomen, and by means
+of which one may learn the condition of the child. Signs of danger
+are extremely uncommon so long as dilatation of the womb is not
+complete, for any strain which labor may impose upon the child will
+usually occur during its passage through the pelvis. Most often,
+therefore, the head has reached the outermost part of the birth canal
+before extraction becomes advisable.
+
+The forceps are used also on behalf of the mother, if the
+continuation of labor seems likely to throw undue stress upon her. On
+this account the physician frequently resorts to them if his patient
+is suffering from pneumonia, typhoid fever, or any acute illness at
+the time of labor. Other maternal indications for their use include
+various chronic derangements, well exemplified by certain diseases of
+the heart. Furthermore, even when there are no preexisting
+complications forceps are employed on account of exhaustion or other
+conditions which may develop during the course of labor. It must be
+clearly understood, however, that the physician alone can determine
+when intervention is justified, as well as what operative procedure
+is most appropriate; for even though good reasons for terminating
+labor exist, forceps cannot be properly used unless nature has
+already fulfilled very definite requirements. By no chance can the
+patient, much less her friends, decide this matter. And besides, none
+but a trained observer can detect the symptoms which clearly indicate
+Nature's incompetence to effect delivery. Disregard of these truths
+by the family with consequent urging that something be done must be
+held partly responsible for the reckless use of the instrument. It
+will be a step in the right direction, therefore, when the laity
+comes to understand that the value of the instrument generally
+pertains to the welfare of the child, and that, in any event, its use
+will be harmful if employed before the womb has been completely
+dilated.
+
+Although forceps can be employed only in cases of head presentation,
+intervention may be warranted when some part of the fetus other than
+the head will be born first. Two or three times in every hundred
+patients we meet with breech presentations, that is, cases in which
+the buttocks precede; after their expulsion, the body, the arms, and
+the head follow. Breech presentations occur more frequently among
+women delivered prematurely, as might be expected since an
+examination eight to ten weeks before the calculated date reveals a
+larger percentage of breech presentations than a similar examination
+about the normal end of pregnancy. In explanation of these results we
+accept the view that the size of the fetus at the earlier date does
+not require nicety of adaptation to the cavity of the womb, whereas
+at term, unless the child is small, the best accommodation is secured
+when the head lies downward.
+
+Most breech cases are delivered spontaneously; if not, the outlook
+for the mother is no less favorable on that account. Assistance, when
+undertaken, is usually prompted in the interest of the child, which
+will be seized by the legs and extracted if there are indications to
+terminate labor. Purely as a precautionary measure, a second
+physician will often be called about the time the stage of expulsion
+begins. Foresight of this kind must give the patient confidence
+rather than alarm her. Indeed, should operative intervention of any
+kind become necessary in the practice of obstetrics, the inclination
+of the doctor to call an assistant must be regarded as an evidence of
+superior judgment.
+
+MANAGEMENT OF BIRTH WITHOUT A DOCTOR.--A prospective mother should
+not be left alone during the four weeks prior to the expected date of
+delivery, for it is important that during this period aid may be
+quickly summoned in the event of an emergency. However, if the
+confinement be the first, ample warning of delivery will always be
+given. Even in a later confinement several hours will probably elapse
+between the preliminary signs and the birth itself. It is extremely
+rare to have labor progress so rapidly that the child is born before
+the doctor arrives. Under such circumstances, if the nurse be present
+she will be master of the situation; whenever she has been unable to
+reach the patient, someone near by should be called to render what
+assistance may be needed. A labor which advances so rapidly that
+skilled assistance cannot be procured is proof in itself that
+everything is going in an ideal manner, and that interference is not
+necessary. Although the doctor may not arrive until after the child
+is born, he frequently renders valuable service in expelling the
+placenta or in sewing up lacerations. No one should presume then that
+there is never need for a physician after the second stage is over.
+
+If the suggestions made in the preceding chapter are heeded,
+immediately after labor begins the room will be set in order and the
+bed will be properly protected; the patient will take a tub-bath and
+will put on a freshly laundered nightgown. The sterilized dressings
+are then placed where they can be easily reached, but are not opened
+until needed. Antiseptic tablets have been procured, and, following
+the directions on the bottle, it will be simple to make up a solution
+of bichlorid of mercury of a strength of 1-1,000.
+
+After the contractions become strong and return at intervals of five
+minutes, or if the waters have broken, the patient should go to bed;
+the knees should be drawn up and spread apart, but bearing down with
+the pains should not begin until the inclination is irresistible,
+since this forbearance will make the delivery slower and thus afford
+protection against lacerations which physicians ordinarily seek to
+prevent by the use of chloroform. In the absence of a doctor it is
+never permissible to administer this or any other anesthetic. As long
+as a physician familiar with its action gives the chloroform untoward
+results need not be feared in obstetrical cases; but the risk would
+be too great to allow anyone to give it who was unacquainted with the
+early signs of an over-dose. Again, fear of accident should prevent
+patients from using the closet when labor is progressing rapidly, for
+an inclination to empty the bladder or the rectum often signifies
+that birth is about to take place. Even though this is true, if there
+is need, patients may try to use the bed-pan.
+
+About the time when the patient goes to bed the attendant prepares to
+render such assistance as may be required. First she should scrub her
+hands thoroughly with soap and water and subsequently soak them in
+the bichlorid solution for five minutes, or longer if there be no
+need for haste. A large delivery-pad is then placed under the
+patient, the leggins put on, and, from this moment, the outlet of the
+birth-canal should be exposed to view. After the scalp of the child
+comes into sight, the attendant is not to leave the bed-side, though
+she must keep "hands off" until the head has been completely
+expelled.
+
+A pause occurs between the birth of the head and of the rest of the
+body. It is usually safe to await further expulsive contractions, but
+should the child's face turn a dusky blue, which indicates that it
+needs to breathe, the patient is to be advised to strain vigorously
+and to make firm pressure over the womb with both her hands. At the
+same time the attendant must pull the child downward, having seized
+its chin with one hand and the back of its head with the other. The
+straining of the mother combined with traction by the attendant will
+be certain to effect delivery quickly. As soon as the child is born,
+it should take a breath and begin to cry. If it does not cry of its
+own accord, it can usually be made to do so by holding it up by the
+feet and slapping it on the back several times. Subsequently the
+child is placed between the patient's legs in such a way as to
+prevent stretching of the cord. Usually the nurse will leave it in
+this position and turn her attention to the mother.
+
+After the birth of the child it is easy to feel through the mother's
+abdominal wall, which has now become lax and flabby, the organs which
+lie beneath it. The top of the womb, once just below the edge of the
+ribs, may now be found about the level of the uppermost part of the
+hip bones, a position which it keeps until detachment of the after-
+birth begins. As the after-birth peels off, the firmly contracted
+womb gradually rises in the abdominal cavity, and by the time when
+the separation has been completed reaches the region of the navel.
+
+While these changes, which naturally require from ten to thirty
+minutes and occasionally longer, are taking place, the attendant must
+wait patiently; attempts to hurry the separation of the placenta are
+never wise, for they may lead to excessive bleeding. No effort should
+be made to bring away the after-birth by pulling upon the cord. It is
+equally unwise for inexperienced persons to press upon the womb in
+the hope of pushing out the placenta. To encourage the mother to
+strain just as she did in assisting the birth of the child would
+always be a safer plan. And if that is ineffective, further delay is
+necessary; in several instances a natural separation of the placenta
+has repaid me for waiting as long as two hours. Prolonged delay may
+be annoying, yet, provided that the doctor arrives within a
+reasonable time, it can scarcely lead to anything more serious than
+annoyance. Rather than authorize frantic efforts to remove the
+afterbirth, I should much prefer to have a patient of my own call
+another doctor.
+
+If the after-birth comes away of its own accord, as will generally
+happen when due patience has been exercised, it may be severed from
+the child and put aside for the inspection of the doctor, for he
+should learn by examining it whether everything has come away
+properly. The cord must be securely tied in two places with the
+sterilized bobbin mentioned in the list of articles for confinement.
+One ligature is applied about two inches from the child's abdomen,
+the other an inch nearer the placenta; the cord is then cut between
+them with a pair of sterile scissors. Anyone fearful of injuring the
+infant may prevent accident by spreading a diaper under the part of
+the cord to be severed. This precaution also protects the bed from
+soiling, for there will be a single spurt of blood the instant the
+cord is cut. So long as the child is in good condition there is no
+urgent need of this operation. If the child is breathing
+satisfactorily it may generally be deferred until the doctor arrives.
+When this course is chosen the attendant will wrap the infant in a
+warm blanket, place it along with the after-birth in a safe spot, and
+subsequently devote herself to making the mother comfortable.
+
+The vulva and neighboring parts are bathed with a 1-1000 bichlorid
+solution. Soiled dressings are removed, the gown changed, and, if
+necessary, clean sheets put on the bed. A sterile sanitary pad is
+placed over the vulva and a fresh one substituted as often as
+necessary, but none of the pads should be destroyed. All the
+dressings must be saved so that the doctor may see how much blood has
+been lost. As we have learned, bleeding regularly occurs while the
+placenta is separating and thereafter; excessive bleeding will rarely
+follow a normal delivery if the attendant has heeded the precaution
+to leave everything to nature. If ever the loss of blood should
+become alarming before the doctor arrives, it is advisable to raise
+the foot of the bed, to keep the patient quietly on her back, to
+grasp the womb through the abdominal wall, and to massage it
+constantly until the nearest physician can be gotten.
+
+Of these directions the most important is that which relates to the
+management of the womb, for in cases in which labor has been normal
+in other respects the relaxation of its muscle is most often
+responsible for flooding. What to do in this event must therefore be
+made plain. First the patient should try to empty her bladder, and,
+if she cannot, pressure made above the organ will usually expel the
+urine. The attendant will then take her seat on the edge of the bed,
+facing the patient's feet, and will locate the womb. When there is
+flooding one may expect to recognize the womb as a large, rather soft
+mass lying in the mid-line of the abdomen with its upper margin
+somewhat above the navel. With one hand, or with both if necessary,
+the mass is grasped in such a way that the fingers cover the top of
+it and pass backward toward the spinal column; the thumb remains in
+contact with the front of the organ. The womb is stroked and squeezed
+much as one kneads dough, and for this reason the procedure is
+technically called kneading. Such manipulations cause the muscle
+fibers to contract firmly, and in consequence the blood vessels are
+tightly closed and bleeding ceases. Similarly, cold applications to
+the abdominal wall tend to provoke uterine contractions; placing over
+the womb an ice-cap or towels wrung out of cold water and doubled
+several times often have a beneficial influence when there is a
+tendency toward relaxation. Some physicians also recommend that the
+child be placed at the breast, since suckling is known to cause
+uterine contractions. There are other measures which are occasionally
+employed, but they should be used only by physicians, for in the
+hands of an inexperienced person they may do more harm than good.
+
+Very often a slight chill follows labor. It has a nervous origin and
+need never give uneasiness; a drink of warm milk, hot-water bags to
+the feet, and extra blankets will be sure to make the mother
+comfortable. On the other hand, excitement of any kind aggravates
+this condition. In general, recently delivered patients must be kept
+quiet no matter how well they feel. A few hours of sleep, or, at
+least, of repose, are justified by the fatigue incident to labor, and
+nothing should be permitted to interfere with it.
+
+METHODS OF REVIVING THE CHILD.--Complications which interfere with
+the child's vitality rarely occur when labor proceeds so rapidly that
+there is not time to get a doctor. Nevertheless a description of
+child-birth would be incomplete without reference to the measures
+intended to revive asphyxiated infants.
+
+Such measures aim, first of all, to make the infant breathe for
+itself, and if breathing does not begin promptly we resort to
+artificial respiration. Mucus in the mouth or in the lower air-
+passages hinders the entrance of air into the lungs; consequently it
+is the duty of the attendant to remove this mucus by means of gauze
+or some light fabric wrapped about a finger and passed backward over
+the tongue. In most cases nothing else will be necessary. But if
+breathing is not immediately established, the child should be grasped
+by the feet with one hand and held downward while its back is
+vigorously slapped with the other. Usually, it gasps at once; when it
+does not, the attendant may stroke its face and chest with her hand,
+which has been previously held in cold water for a moment; or she may
+dash a handful of cold water upon its body. With very rare exceptions
+these procedures make the child cry.
+
+One must always be alert to see the very first attempt at breathing,
+for unduly prolonged manipulations may defeat their own object; the
+natural inclination always is to do too much rather than not enough.
+In some instances, however, the measures thus far indicated will not
+prove successful, and, if not, the cord must be tied and cut through,
+for subsequent treatment cannot be conveniently carried out while the
+child remains attached to the placenta. As soon as the cord is
+severed the child is placed in a tub of warm water, about the normal
+temperature of the body, and is moved about in the bath for a few
+moments, the attendant watching closely all the while, for the
+breathing is often very superficial. Should signs of beginning
+respiration not appear, the attendant should grasp the child by the
+shoulders, dip it up to the neck in a basin of cold water and quickly
+return it to the warm tub. This operation may be repeated five or six
+times; generally the instant the child touches the cold water it
+draws up its feet, opens its eyes, and cries. One must take care that
+the plunge lasts but a moment; if the child becomes chilled efforts
+to revive it will likely be unsuccessful. Indeed, the necessity for
+keeping it warm must be constantly borne in mind.
+
+With the very exceptional cases in which hot and cold tubs are
+ineffective, the following method becomes valuable. Wrap the child in
+a blanket and lay it face downward upon a table or chair, allowing
+the head to hang over the edge. Roll the body on one side or a little
+beyond; then slowly roll it back upon its face and onward to the
+other side. This maneuver is repeated fourteen times to the minute,
+but not more frequently. When properly performed it secures a flow of
+air to and from the lungs with the same rapidity as in the normal
+respiration of an infant. Efforts to revive the child must not be
+quickly given up, as a successful outcome occasionally requires half
+an hour of work or even longer. One method after another should be
+tried in the order which I have indicated. A physician always
+perseveres so long as the heart-sounds can be heard; but, since an
+inexperienced person might be unable to decide upon this point, the
+most reliable course for the layman is to persist in the
+resuscitation until the physician arrives.
+
+
+
+
+CHAPTER XI
+
+
+THE LYING-IN PERIOD
+
+The Changes in the Uterus--The Lochia--The Return of Menstruation--
+Other Restorative Changes: The Loss in Weight; The Abdominal Wall;
+The Pelvic Floor--The Care of the Patient: The Elimination of Waste
+Material; Cleanliness; The Diet; The Environment; The Time for
+Getting up--The Final Examination.
+
+A generation ago physicians were accustomed to see their obstetrical
+patients only at the time of labor. No preliminary examination was
+thought necessary, and after the delivery visits were not made unless
+the family became alarmed and requested them. When thus asked to come
+back the physician sometimes found that an infection had developed;
+occasionally the breasts were giving trouble, or some other
+difficulty in the care of the mother or of the infant was baffling
+the nurse. It is now recognized that the medical attendant should not
+wait for the appearance of untoward symptoms. Although the strict
+observance of the various precautions which I have already emphasized
+should lead and usually do lead to an uneventful convalescence, it is
+none the less true that the danger of infection and of other
+immediate complication has not passed until several weeks after
+delivery. For this reason and also because skillful guidance of the
+mother at this time will prevent unwelcome sequels in the later years
+of life, physicians now extend their watchfulness beyond the hour of
+birth. The number of visits ordinarily required is not large. In each
+case, to be sure, the circumstances will determine the number; but,
+as a rule, ten visits, if properly distributed, will be sufficient.
+During the month succeeding delivery these visits should be made in
+about this order: a daily visit for the first five days, subsequently
+one upon the seventh, the tenth, the fourteenth, the twenty-first,
+and the twenty-eighth day.
+
+At the conclusion of labor there begins a series of changes which are
+the reverse of those incident to pregnancy, and which restore the
+body to its original condition. Six weeks are generally required for
+these alterations. They should leave the mother in _perfect_
+health, but traces of pregnancy are not entirely effaced; even in the
+absence of outward evidence, if a woman has ever given birth to a
+child a thorough internal examination will disclose the fact.
+
+The initial steps in these restorative processes are taken most
+promptly and effectively when patients remain in bed. The traditional
+custom of doing so has given to the first few weeks following
+delivery the popular name, "the Lying-in Period." To these weeks
+physicians usually apply the technical term _puerperium_, the
+child's period, a designation which brings to mind the secretion of
+milk which, though not a retrogressive change, is, nevertheless, one
+of the most distinctive results of childbirth.
+
+Radical as the bodily changes in progress at this time are, the
+lying-in period is not a period of illness. But there is, perhaps, no
+other time in a woman's life when she may cross the boundary between
+sickness and health so easily; for here nature tolerates no trifling.
+Not infrequently puerperal patients who are feeling well attempt too
+much, and suffer a more or less serious set-back; it is an all-
+important duty of the obstetrician, therefore, to restrain them from
+harmful activity. In my experience patients yield to restraint most
+readily, and secure the best results, if I explain to them the
+anatomical facts which should guide the management of the lying-in
+period.
+
+THE CHANGES IN THE UTERUS.--Since of all the organs the uterus
+undergoes during pregnancy the most extensive development, it also
+holds the place of prominence during the lying-in period. Immediately
+after delivery the womb weighs two pounds and measures some eight
+inches in height, five in breadth, and four in thickness. In the
+course of a few days it begins to dwindle in size, gradually sinking
+in the abdomen until it lies entirely within the pelvic cavity.
+Toward the end of five or six weeks it resumes the position occupied
+before conception, regains approximately its original dimensions, and
+weighs two ounces. We speak of the process which leads to these
+results as the _involution_ of the uterus. Since a great deal
+depends upon the rapidity with which involution progresses, we must
+understand just what it is and how it may be influenced.
+
+The muscle of the womb, to which this property of involution belongs,
+is an aggregation of thousands of individual fibers. In response to
+excellent nutrition during pregnancy, these fibers have grown thick
+and strong, in order that they may furnish the power needed at the
+time of labor. When this purpose has been fulfilled each fiber
+becomes smaller and gradually passes into a resting stage the better
+to preserve its vigor. It is the shrivelling of the individual
+fibers, therefore, which accounts for the total reduction in the size
+of the womb.
+
+Although the source of the stimulus which causes the muscle-fibers to
+atrophy is not so clear as we should like it, we are acquainted with
+certain influences to which involution is susceptible. Of these none
+merits so much attention as the influence of the breasts. The
+intimate relation between the breasts and the uterus manifests itself
+in such a variety of ways and with such force that no one doubts its
+existence. Thus, if a nursing mother becomes pregnant her infant is
+usually deprived of sufficient nourishment or suffers some digestive
+disturbance; if not, and the mother, ignorant of her condition,
+continues with the breast feeding, she may jeopardize the newly begun
+pregnancy. Very likely she will be warned of the fact by the signs of
+threatened miscarriage. More frequently, but in quite the same way,
+we find that nursing causes uterine contractions in the early part of
+the lying-in period, when they are called after-pains. Women who
+experience them tell us they are more severe while the infant nurses;
+and they also say that the discomfort disappears after several days,
+a fact which indicates that involution has made notable headway. The
+physician is not dependent on such evidence, however; for a simple
+examination reveals at any time how far involution has progressed. By
+this means we have learned that nursing facilitates the involution
+process. On the other hand, it is found to be true, as we should
+naturally expect, that women who decline to suckle the infant recover
+from childbirth somewhat less rapidly than those who follow nature's
+plan. In this fact, therefore, is found a selfish motive, yet a very
+good one, which should impel mothers to perform this exceedingly
+important duty.
+
+Aside from the change in the mass of the uterus, notable results of
+involution relate to its mouth and to its ligaments, for these
+structures are also chiefly muscle. The mouth of the womb, lately
+stretched to permit the exit of the child, gapes widely for a time;
+but ultimately its lips are drawn together, the tissues which compose
+them stiffen, and the canal which they enclose is narrowed to almost
+microscopical dimensions. When involution is complete, the uterus has
+so far regained its virginal character that no trace of childbirth
+remains other than a few small fissures in the margin of its mouth.
+
+It is the office of the ligaments to hold the uterus in proper
+position. In consequence of pregnancy they have been stretched, and,
+as we might anticipate, after the contents of the womb are expelled
+the ligaments hang loosely from its sides, very much as sails hang
+when a breeze dies down. Immediately after delivery, therefore, the
+ligaments give the womb little or no support; eventually they shorten
+and tighten, readily accommodating themselves to the existing
+conditions. Until the accommodation is perfected, it is especially
+desirable to permit no pressure which might push the womb backward.
+It is for this reason that many obstetricians object to the time-
+honored custom of applying a tight bandage about the abdomen at the
+conclusion of labor; for, though bandaging is not always harmful, it
+has a distinct tendency to misplace the womb. A friend who has served
+as an assistant in one clinic where patients were bandaged regularly
+and in another where they were not, tells me that displacements of
+the womb were much more common among women treated by the former
+method.
+
+While the process of involution is altering the shape and size of the
+womb, other forces are at work within the organ to provide its cavity
+with a new mucous membrane. In character and in extent the inner
+surface of the womb, left raw and bleeding at the conclusion of
+labor, is comparable to the wound which would result if some accident
+removed the skin from the palms of both hands. No one would question
+the wisdom of guarding such an injury to the hands; but cleanliness
+is even more necessary to the prompt and healthful restoration of the
+uterine mucous membrane. However, the wound within the uterus is so
+far from the surface of the body that it need not be directly covered
+with a surgical dressing; sterile pads are kept over the vulva to
+exclude contaminating material until the healing is completed. Since
+bleeding ceases after that point is reached, we have no difficulty in
+knowing when the mucous membrane has been restored.
+
+THE LOCHIA.--The vaginal discharge which regularly follows the
+termination of pregnancy gets its name from the Greek word
+_lochia_. At first the discharge is pure blood, because it
+issues exclusively from the vessels left open by the removal of the
+after-birth. The greater part of the blood flows out of the birth
+canal, but frequently some of it collects in the cavity of the uterus
+or of the vagina; there it coagulates, and the clots may not be
+expelled until several days later. In that event, as whatever effect
+the bleeding may have had has long since passed, the appearance of
+the clots is usually no occasion for alarm.
+
+The amount of lochia varies, and will likely fall below the average
+in small or anemic women and rise above it in those who are large or
+robust. Then again, the discharge is less profuse if considerable
+blood has been lost immediately after the labor. For the first ten
+days the total quantity seldom exceeds eight or ten ounces; after
+that time it is so small that it cannot be accurately estimated.
+Formerly much larger amounts were considered normal, and, therefore,
+it is probable that modern aseptic treatment of child-birth has
+lessened the subsequent loss of blood. Toward the end of a week the
+lochia changes from a bright red to a brownish color, because the
+discharge now includes certain products of disintegration. Somewhat
+later the lochia consists almost entirely of mucus, being only
+streaked with blood; but there will be an increase in the bleeding
+when the patient gets up; and injudicious activity may cause
+flooding. A slight bloody discharge may be expected to continue until
+five or six weeks after the child was born.
+
+A faint but characteristic odor to the lochia proves very
+disagreeable to some patients, and on that account it was formerly
+customary to give them a daily douche throughout the lying-in period.
+This was before the characteristics of the puerperal uterus and the
+nature of infection were thoroughly understood. Most physicians are
+now convinced that the early use of douches is rarely beneficial; and
+since there is danger of washing infectious material from the lower
+part of the vagina into the uterus, they may, if given prior to the
+second week after delivery, actually do harm. Consequently douches
+are not now used in a routine way. Whenever irrigations are indicated
+the doctor will prescribe them. Late in the puerperium vaginal
+douches are unobjectionable, and patients may take them unassisted,
+for then the fluid will not penetrate the womb so long as it has a
+free escape from the outlet of the vagina. Moreover, it is immaterial
+if some of the fluid should pass into the womb, for its lining will
+have been largely restored by this time, and at points where
+restoration is incomplete defenses have been thrown up against
+infection.
+
+THE RETURN OF MENSTRUATION.--On account of the dilatation at the time
+of labor women who have previously suffered with menstruation may
+look forward to relief after child-birth. Menstruation generally
+becomes as painless as the flow of the lochia; and so far as a
+patient can tell the two phenomena are identical. Actually, however,
+they bear no relation to each other. The fact that the cavity of the
+uterus has been deprived of its lining is responsible for the lochia,
+whereas the menstrual discharge occurs in spite of the lining,
+through which it breaks at regular intervals in response to a
+stimulus that is absent for a longer or shorter period after the
+birth of a child.
+
+In the latter part of the puerperium there may be doubt as to whether
+a discharge is menstrual or lochial; though, if necessary, an
+examination of the interior of the womb would always settle the
+question, for structural changes in the uterine mucous membrane form
+the most characteristic feature of menstruation. If, therefore, small
+bits of this tissue are removed and studied under the microscope, a
+definite conclusion can be reached. Physicians may resort to such an
+examination when the significance of a discharge is not clear without
+it; but other evidence usually enables them to decide the matter.
+
+The secretion of milk often exerts an influence upon the
+reestablishment of menstruation. Under ideal circumstances the mother
+does not menstruate while she nurses her infant; whereas, if the
+breasts are not in use, the menstrual function returns six to eight
+weeks after delivery. Other pertinent clinical facts also lend weight
+to the opinion that the activity of the breasts, more technically
+called lactation, should not only prevent menstruation but also
+hinder the ripening of egg-cells in the ovary. Thus, the nursing
+infant has a potent influence upon the reproductive function of its
+mother, enabling it to preserve its food supply; for in the event of
+conception the milk usually decreases in amount or becomes of an
+inferior quality. To secure this protective influence should prove a
+strong incentive for the mother to nurse her child; in barely half
+the cases, however, is it effective throughout a year. One-third of
+nursing mothers, statistics indicate, begin to menstruate about two
+months after delivery, and month by month the proportion gradually
+increases.
+
+Since menstruation appears so frequently during lactation, it cannot
+be considered abnormal. It does not follow that the function will
+become permanently reestablished after a patient has menstruated
+once; in many instances several months elapse before there is another
+period, and in a few cases there will be only one period during the
+year the child suckles. Nevertheless, when the function has once made
+its appearance extraordinary precaution should be exercised to avert
+a return, and about the time its reappearance would be expected the
+woman should go to bed for several days. Although this measure may
+prove futile, we know of no other so likely to prove successful.
+
+Menstruation is more apt to return prematurely after the birth of the
+first child than of later ones. This may be due in part to a kind of
+accommodation of the maternal organism to the reproductive process as
+one pregnancy follows another; but I am convinced that it is also due
+in part to the greater physical and mental composure of experienced
+mothers. Until a woman has learned the unwelcome consequences she is
+apt to take over household duties before she is equal to the task, or
+she may engage in too strenuous amusements; and most mothers err in a
+too energetic care of the baby.
+
+OTHER RESTORATIVE CHANGES.--Many of the restorative changes in the
+mother's body are either so intricate or so devoid of practical
+significance that we may pass them by; though all of them have great
+interest for the specialist, and some have occasioned bitter
+controversy. The alterations in the heart, for instance, have been
+the subject of a prolonged dispute between French and German
+scientists. The former still assert that this organ regularly
+enlarges during pregnancy and subsequently returns to its normal
+size. The Germans deny both these contentions. Certainly the
+alterations are insignificant from a practical standpoint; otherwise
+competent observers would not disagree.
+
+The really important changes in the body, other than those pertaining
+to the uterus, are familiar to women who have passed through
+pregnancy; but other prospective mothers may not understand that they
+will regain the bodily condition which existed before conception.
+
+_Loss in Weight_.--While the weight lost during the lying-in
+period is not so vital as some other alterations, many have a keen
+interest in it. In addition to the loss of ten to fifteen pounds at
+the time of birth, a further loss occurs in the course of a few
+weeks. Diminution in the size of the uterus is responsible for the
+loss of nearly two pounds, and the lochial discharge for at least
+another; but the chief factor concerned is the removal of water from
+the tissues, many of which have become dropsical toward the end of
+pregnancy. Altogether patients do not lose less than ten pounds
+during the lying-in period, and often lose a great deal more. The
+average loss for the first week alone is said to equal one-twelfth of
+the patient's weight at the conclusion of labor; the total loss for
+the whole of the puerperium corresponds to one-tenth of her weight at
+the beginning of it. Variations from the rule are attributed to
+individual peculiarities of nutrition. In general, stout women lose
+more than slender ones, but with all types the loss is greater if the
+mother nurses her infant. On the other hand, a generous diet tends to
+counteract any loss in weight whatever.
+
+_The Abdominal Wall_.--Much more important than the question of
+weight is the recovery of the abdominal wall from the strain imposed
+by the enlargement of the womb. In normal cases, to be sure, there is
+very slight disproportion between the size of the pregnant uterus at
+term and the capacity of the abdomen, yet the abdominal wall
+invariably suffers a little stretching and unless it retains its
+elasticity, the viscera are deprived of essential support, and cause
+more or less discomfort.
+
+The restorative changes in the abdominal wall involve the skin, the
+fatty tissues, and the muscles. As soon as the distention has been
+relieved the skin falls into folds, less noticeable if the pregnancy
+was the first; and the muscles become so flabby that one has no
+difficulty in pushing the wall backward until it touches the tissues
+which cover the spinal column. Within a few weeks, if all goes well,
+the muscles regain their "tone." Coincidently, the excessive fat over
+the abdomen is absorbed. The skin becomes smooth, and its
+pigmentation fades completely; but the pregnancy streaks rarely
+vanish entirely, although they always become very much less
+noticeable.
+
+Whether or not the abdominal wall will recover from the distention of
+pregnancy depends entirely upon the muscles. As the lying-in period
+advances each fiber should gradually shorten until the whole muscular
+structure becomes as firm and tight as it ever was. But this takes
+time, and no artifice can hasten the repair. Perfect recovery is most
+likely with the body in a recumbent position, which relieves the
+muscles from any strain. These facts are better appreciated than
+formerly, hence most physicians encourage their obstetrical patients
+to remain in bed somewhat longer than their mothers did. Generally
+nothing else will be required, and only under extraordinary
+circumstances will nature need assistance. Thus, if there has been
+unusual distention, as, for example, that due to twins, the muscular
+impairment may be extreme; or if pregnancies follow one another in
+quick succession the strain becomes so nearly continuous that there
+is not sufficient time for adequate repair. Whenever nature does need
+encouragement calisthenics of some kind are advisable. These
+systematic exercises, which the patient practices in bed and flat on
+her back, are usually begun about a week after delivery, though there
+may be some reason for beginning them earlier or later than this.
+
+The physician will always select the proper calisthenics, but the
+following "movements" generally prove satisfactory. To exercise the
+muscles at the front of the abdomen one leg after the other is raised
+and lowered; as this is being done the knee will be bent (flexed) at
+first, but later the leg may be held straight (extended). Other
+muscles come into play when the feet are alternately brought together
+and separated as widely as possible. A third movement which exercises
+the muscles at the side of the abdomen consists in raising the
+shoulders from the bed and twisting the trunk so that the weight of
+the chest rests now on the right, now on the left elbow. When these
+movements can be performed fifteen or twenty minutes without fatigue
+more vigorous exercises may be adopted. For example, the buttocks,
+together with the lower part of the back, are raised off the bed,
+while the shoulders, elbows, and the heels remain stationary. A day
+or so before getting up the patient should practice alternately
+raising herself from the recumbent to the sitting posture and
+returning to the above position without assistance from the arms.
+
+The value of bandaging the abdomen immediately after delivery as a
+means of strengthening the abdominal muscles is questionable; though
+physicians agree to the advantages of a supporter after patients are
+out of bed. We constantly see perfect restoration of these muscles
+without the early use of a binder; in fact, women who have employed
+it throughout the lying-in period do not secure an efficient
+abdominal wall more frequently than others who began its use two
+weeks after they were delivered. Even those physicians who advocate
+an early application of the binder concede that it works harm in
+certain cases and do not recommend it indiscriminately.
+
+Those who postpone for a fortnight the use of the binder will escape
+the tendency it has to cause displacements. By this time the
+involution will have advanced so far that the womb lies within the
+pelvic cavity, where it is surrounded by the hip bones, which protect
+it from external forces that otherwise would influence its position.
+When permitted to get up patients ought to use a binder, because it
+counteracts the feeling of "falling to pieces" of which some complain
+when the abdominal walls are not comfortably supported. But there is
+no evidence to show that a binder plays any part in restoring the
+figure. When, in spite of ample rest, the abdominal muscles fail to
+recover completely, we have no better way of strengthening them than
+by use of calisthenics or massage.
+
+_The Pelvic Floor_.--Second only in importance to having the
+womb restored to its original position is the necessity of
+restoration of the pelvic floor. This structure, also called the
+_perineum_, we should know, lies between the thighs, shuts in
+the bottom of the abdomen, and prevents prolapse of the viscera. In
+women it forms the lower portion of the birth-canal, enclosing the
+aperture through which the child enters the world. Although
+intelligent management of labor is of the greatest value for the
+protection of the pelvic floor, under certain circumstances it may be
+impossible to preserve it intact; injury to it is the rule when the
+first child is born, and not unusual in later births. There can be no
+doubt regarding the advisability of uniting the edges of a tear;
+indeed, to do so immediately is the very first essential toward
+restoring the pelvic floor to its wonted integrity. But even though
+tears are sewn up successfully, there is invariably some relaxation
+of the perineum until the restorative process, which here again
+chiefly concerns the muscles, has been given opportunity to become
+effective.
+
+As with all the restorative changes in the lying-in period, to rest
+calmly in bed favors the perfect recovery of the pelvic floor more
+than anything else. Keeping the thighs together during the first few
+days undoubtedly assists tears in healing, but that precaution is not
+always necessary, and when it is the physician will call attention to
+the fact. The really important matter, as I have said, is that the
+upright position should not be resumed until the pelvic floor has
+become firm.
+
+THE CARE OF THE PATIENT.--Now we have learned enough of the manifold
+changes in the lying-in period to appreciate the fact that patients
+require medical direction even though they are feeling perfectly
+well. The view held by former generations that women can get along
+without a doctor and with any sort of nursing is partly responsible
+for the existence of gynecology, the branch of medicine which deals
+with the diseases of women. Recently delivered women should be
+treated as surgical patients, not because they are ill, but to keep
+them from becoming so.
+
+If the patient desires the highest degree of protection an
+experienced nurse is indispensable, for she will make systematic
+observations which would consume too much of the doctor's time for
+his personal attention, yet without which he would not be
+sufficiently conversant with his patient's condition to guide her
+properly. The temperature, the rate of the pulse, and of the
+respiration should be recorded at regular intervals during the day
+and night. An elevation of temperature at the conclusion of labor
+need give no uneasiness, for experience has shown that it generally
+subsides within a few hours. Moreover, slight elevations in the
+course of the following week are so frequent that obstetricians have
+agreed to regard as a normal temperature for this period 100.4
+degrees instead of the usual normal of 98.4 degrees. The pulse-rate
+most frequently does not depart from what is characteristic for the
+individual, though about one-fifth of puerperal women have a slowing
+of the pulse, a phenomenon of favorable significance. Any difficulty
+in breathing that may have existed in the latter part of pregnancy
+disappears when the abdominal distention is relieved, and the
+respiratory rate becomes normal. So long as the body is getting rid
+of the tissue-substance essential to pregnancy, but now without any
+purpose, more than the usual amount of waste material is present in
+the expired air.
+
+_The Elimination of Waste Material_.--As we might expect from
+the loss in body weight, the excretory organs are particularly active
+during the lying-in period. In quantity the loss of water exceeds all
+the other waste-products together; and pronounced activity of the
+kidneys or of the sweat glands may become a source of annoyance.
+Since it is undesirable to interfere with these functions, whatever
+inconvenience either may cause will be borne with less complaint if
+the patient understands that a large loss of water at this time
+indicates a healthful condition of the body.
+
+Shortly after delivery there may be difficulty in emptying the
+bladder; and, under such circumstances, the doctor or nurse used to
+catheterize the patient immediately; this habit once begun, it was
+often necessary to repeat the operation day after day, or, for that
+matter, several times a day. But as physicians came to know more of
+the relations of bacteria to inflammation of the bladder, they grew
+more cautious, and preferred to wait a long time before resorting to
+the catheter. The reward of this patience was to find that, with
+remarkably few exceptions, puerperal women ultimately void of their
+own accord. Accordingly catheterization after child-birth is now
+postponed, and is never performed until a number of devices to get
+the patient to void spontaneously have been tried without success.
+Often urination follows putting a hot-water bottle over the bladder;
+or pouring warm water over the vulva; or placing the patient upon a
+bed-pan from which steam is rising. When these and other devices well
+known to every nurse are not effective, catheterization becomes
+necessary. With the elaborate precautions taken to avoid infection of
+the bladder, catheterization is now performed with very slight risk.
+
+Constipation, for various reasons, becomes a regular feature of the
+lying-in period. The confinement in bed, restricted diet, relaxation
+of the abdominal wall, and sensitiveness about the region of the
+rectum, all have a tendency to prevent spontaneous movements of the
+bowels. As one of these influences after another is removed the
+bowels begin to act naturally. Childbirth may cause chronic
+constipation, but this sequel would occur much less often if a little
+care were taken to prevent it.
+
+The routine use of enemas deserves to be condemned. I see no
+objection to an occasional enema if purgative medicine has been taken
+without effect, but constant use of them, more than likely, will
+result in the enema habit. Similarly, long-continued administration
+of strong purgatives tends to make them a permanent necessity. While
+in bed if medicine is taken every other day the bowels will have
+opportunity on the intervening days to move spontaneously, though we
+do not really expect them to move naturally until six or eight weeks
+after the delivery, when the patient is able to take as much exercise
+as she likes. Toward the end of the second week, however, mild
+laxatives generally prove effective, and it is important to select
+one the dose of which may be gradually decreased. Senna prunes, which
+were described in Chapter V, fill the purpose very well. Six or eight
+of them may be needed at first, but the number may be gradually
+reduced, until finally none are necessary.
+
+_Cleanliness_.--In view of the excessive elimination of waste
+products from the body, the maintenance of cleanliness during the
+lying-in period may require the use of a large amount of linen.
+Occasionally patients perspire so freely that the night clothes have
+to be changed several times in twenty-four hours, and the bed linen
+only a little less frequently. But at any cost it is imperative not
+to hinder but rather to promote this function and to keep the skin in
+a healthful condition through bathing and massage. Nurses are taught,
+on this account, to give a warm soap and water bed-bath in the
+morning and an alcohol rub at night. Patients are usually allowed to
+take tub-baths after the third week.
+
+Local cleanliness, which is a matter of the very first importance,
+can only be attained through bathing the vulva with an antiseptic
+solution and the use of sterile pads. At first the pads are changed
+very frequently, but after the discharge becomes less profuse they
+are renewed at intervals of four to six hours.
+
+_The Diet_.--For the first week of the lying-in period not all
+patients are given the same diet, and the physician always leaves
+specific directions regarding it. Generally the diet consists of
+liquids, such as milk and broths, for a couple of days; under some
+circumstances liquid nourishment is continued longer. As the appetite
+increases easily digestible but nutritious food is added, and before
+long the patient resumes her ordinary diet.
+
+The modern tendency is to give solid food and to give it in
+substantial amounts much earlier than was once customary;
+restrictions, none the less, are still observed so long as the
+patient remains in bed. With the body at rest, its food requirements
+are diminished and hearty meals are unnecessary. If convalescence
+proceeds satisfactorily such wide latitude in the choice of food is
+permissible that the nurse may regulate the diet, consulting the
+physician whenever necessary.
+
+_The Environment_.--A large, bright room that can be quickly
+heated and easily ventilated adds notably to the comfort of the
+lying-in period. The windows may be opened through the greater part
+of the day and at night should always be left so. To make thorough
+airing of the apartment more feasible and to protect the mother from
+annoyance when the baby cries, it is more satisfactory to have the
+baby occupy an adjoining room where the nurse sleeps within call.
+Under any circumstances some arrangement must be made so that the
+mother's rest at night will not be broken needlessly.
+
+No pains should be spared to keep the patient quiet for at least ten
+days. Household cares and petty worries materially delay
+convalescence. During this period only a limited number of the
+immediate members of her family ought to see her, and their visits
+should be brief. Unfortunately, if too many relatives and friends
+visit her a number of questions will be repeatedly asked which are
+decidedly wearing on any patient.
+
+_The Time for Getting Up_.--How long a woman should stay in bed
+after the birth of a child is a question which has given rise to
+prolonged discussion. The majority of obstetricians adhere to the
+traditional ten days; but there are advocates of a longer period and
+advocates of a shorter one. The generalizations of many writers upon
+this subject are too sweeping, for exceptions may be found to any
+rule. Each patient is best counselled when the advice given is based
+upon her own condition and particularly upon the progress made in the
+involution of the uterus, which does not advance with the same
+rapidity in all cases.
+
+More or less in imitation of the custom among savages, Charles White,
+in 1776, recommended that women should not remain in bed longer than
+a day or two after child-birth. Very likely the inadaptability of the
+method to civilized women soon became apparent; at any rate his
+suggestion was not widely adopted, and had been completely forgotten
+until a few years ago, when the custom was revived in one of the
+German clinics. The innovation met with violent opposition in Europe,
+and, so far as I know, has found but scant favor in America.
+
+Generally patients are allowed to sit up in bed toward the end of the
+first week, but if there are stitches, sitting up is deferred until
+ten days or later, when the stitches have been removed. Under the
+most favorable circumstances, however, sitting up in bed becomes
+wearisome, for the weight of the body does not fall upon the spine,
+as it should; and besides the extended position of the legs is
+fatiguing. No one should force herself to keep this posture, for at
+best it does no more than relieve monotony. The exercises previously
+suggested prepare her much more effectually for getting upon her
+feet.
+
+Between the tenth and the fifteenth day patients may leave the bed
+and sit quietly in a chair. The condition of the uterus, the
+character of the lochia, and the firmness of the pelvic floor will
+determine the day, but usually it proves wiser to defer it until
+fully two weeks have lapsed. As a rule, the patient remains out of
+bed an hour the first day, two the second, three the third, and so on
+until she is up all day. She should not attempt to walk until the
+second or third day. At first she should take only a few steps, but
+gradually she may increase the number and finally walk with freedom
+and ease. Several reasons make it advisable for patients to remain
+four weeks on the floor where they have been confined; going up and
+down stairs is especially tiresome, and, of still greater importance,
+patients pass from the doctor's control as soon as they go down
+stairs. For fear of overtaxing the strength none of the household
+cares should be assumed before the fourth week, and not all of them
+then, for women are not capable of resuming their accustomed duties
+fully until the sixth week; and some are not strong enough to do so
+until a somewhat later date.
+
+Since patients generally feel well during the lying-in period they
+are apt to object to remaining in bed two weeks. Most of them
+acquiesce as soon as they understand the organic changes in progress
+and appreciate the lasting benefits of a temporary forbearance, but a
+few must be made to realize that very serious penalties may be
+attached to undue haste. For the latter it might be better if the
+alarming consequences of getting up too early--discomfort,
+hemorrhage, and collapse--occurred more frequently than they do. As
+it happens, the ill-effects of such indiscretion are not usually felt
+immediately; when too late the lesson is learned that many of the
+operations upon women in the later years of life are dependent on
+imprudent conduct just after the first child was born.
+
+THE FINAL EXAMINATION.--Looking to complete restoration of the
+woman's health, the modern management of obstetrical cases breaks
+decisively with tradition at three points. An utter disregard of
+precaution has given way to very careful preparations before and at
+the time of labor; definite rules for the management of the lying-in
+period are carried out under the supervision of the physician; and
+finally, prompted by the same impulse, the physician examines his
+obstetrical patients before discharging them. Satisfactory conditions
+are generally found; if they are, it is a great comfort to be assured
+of the fact; and if not, timely treatment of the abnormality may
+readily correct it; with delay, on the other hand, treatment often
+becomes more formidable.
+
+The end of the fourth week of the lying-in period proves a convenient
+time for this examination. As yet the restorative changes in the
+reproductive organs have not been completed, but one may definitely
+say by this time whether or not they will culminate in a satisfactory
+manner. Besides, making the examination while the changes are in
+progress sometimes enables the physician to treat approaching
+complications before they actually develop. Thus, when the pelvic
+floor has not regained its strength sufficiently, the patient will be
+advised to forego the liberty in moving about ordinarily granted at
+this time. When the womb inclines to an improper position, a
+temporary support may be introduced to hold it where it belongs;
+later, upon removing the device, the womb usually retains a good
+position. Again, there are conditions which a douche will relieve,
+and still others benefited by medicinal treatment. If an abnormality
+is recognized which cannot at once be treated to the best advantage,
+arrangements will be made for such prompt treatment that the woman
+will not become an invalid. Instead of placing obstacles in the way,
+patients should rather insist upon this examination, for it is
+important in guarding their future health.
+
+Now and then patients are kept under observation for a longer period,
+but, as a rule, they are discharged as well as examined at the end of
+four weeks. They may also discard the abdominal binder about this
+time and put on corsets, which, however, should not be tightly worn.
+Although thrown upon her own resources from this moment, the patient
+will clearly understand that she must continue to exercise sound
+discrimination in what she does. And here, of course, we encounter
+the greatest difficulty in offering practical advice, for what one
+may do easily will overtax another. Generally speaking, going up and
+down stairs more than once a day is inadvisable until another two
+weeks have passed. Likewise the mother who would adopt a conservative
+policy will not take full charge of her baby before it is six weeks
+old, though there can be no objection if she wishes to direct its
+care. The same advice applies to running the household. Over-
+exertion, no matter what the source, delays convalescence from child-
+birth to such an extent that the safe plan is always to err on the
+side of doing too little, rather than to run the risk of doing too
+much.
+
+
+
+
+CHAPTER XII
+
+
+THE NURSING MOTHER
+
+The Breasts--Human Milk--The Technique of Nursing--Hygiene of the
+Mother: Diet; Psychic Influence; Recreation and Rest--The
+Supplementary Bottle--Weaning.
+
+
+When the obstetrician pays his final visit the mother usually has
+ready a number of questions, most of which anticipate difficulties in
+the care of the baby. At that time, however, minute and far-reaching
+directions cannot always be given. Unforeseen peculiarities in the
+development of the child may modify such general principles for the
+management of infants as could be laid down in advance. With a few
+exceptions, therefore, mothers require during the early years of a
+baby's life skilled advice as to his upbringing--advice for which
+neither instinct nor haphazard counsel is a safe substitute. It is an
+excellent plan, and one which is becoming more and more popular, to
+have a physician supervise the care of the baby through the period of
+most active growth. According to this plan, the mother, even though
+her baby is well and developing as it should, consults the physician
+at regular intervals, once a month for example, and upon these
+occasions secures help in solving problems which are certain to
+present themselves. Such an arrangement shows a merited appreciation
+of the proverbial "ounce of prevention," and when serious
+difficulties do arise materially counteracts the tendency to panic
+which is exhibited by so many young mothers.
+
+Among the problems which the mother must solve, that of nutrition
+outranks all others in importance; and unless the infant is nourished
+with human milk, it also exceeds them in perplexity. For, although
+great advances have been made in artificial feeding, science has not
+yet removed all the intricacies and dangers involved in the use of
+the bottle. On the other hand, mothers who nurse their babies rarely
+meet with difficulty. Human milk is perfectly adapted to the wants of
+the infant; and all substitutes, though carefully designed to
+duplicate it, are only partially successful. We have learned how to
+modify cow's milk so that in chemical constituents, at least, it is a
+very close imitation of human milk; but human milk possesses, in
+addition to its chemical properties, other desirable qualities which
+cannot be instilled into an artificial food. We must agree,
+therefore, that attempts to disseminate a wider knowledge of the
+correct principles of bottle-feeding do not have the highest aim. Our
+real need is a vastly greater proportion of women who nurse their
+children.
+
+THE BREASTS.--For success in nursing the first essential is healthful
+breasts. With this the largeness or smallness of a breast has nothing
+to do, for size is no more an index of its capacity for producing
+milk than is the weight of a woman an index of her energy. The breast
+is not a warehouse, but a factory, with very limited storage capacity
+for its product. Differences of size are generally to be explained by
+the variable amount of fatty-tissue the breast contains. And so far
+as the secretion of milk is concerned the fat is entirely passive; it
+fills in the space between the glandular elements; and a layer of fat
+just beneath the skin protects the glands against external influences
+that otherwise might disturb their activity. Stripped of their fatty
+envelope the structures which actually secrete the milk and convey it
+to the nipple resemble a miniature cluster of grapes. Each tiny,
+spherical gland corresponds to one of the grapes and contains a
+cavity lined with cells which manufacture the milk. From this cavity
+the milk flows through a microscopic tube which unites with similar
+tubes to form a larger one; this in turn joins others of its kind;
+and so on, until ultimately the milk enters a relatively large duct--
+the figurative stem of the cluster--which conducts the milk to its
+destination. There are from ten to fifteen of these terminal ducts;
+each drains a separate group of glands, but all end in the nipple.
+
+Shortly after conception the breasts become congested; in consequence
+they enlarge, become tender, and begin to show swollen veins beneath
+the skin. The most significant alteration, however, occurs in the
+cells which line the glands; these increase in size at first; and
+then, by a process of cell division, their number multiplies. After
+pregnancy has advanced six to eight weeks these cells begin to
+elaborate the thin, watery fluid called colostrum. Contrary to
+popular belief, the quantity of colostrum is not prophetic of the
+character of the milk; there is no ill-omen, to be sure, in a
+plentiful secretion, but a meager one is quite as likely to be
+followed by successful lactation. At present we are unable to predict
+by any means either the quantity or the quality of the milk which a
+prospective mother will produce.
+
+Some writers contend that influences which come into play during
+girlhood ultimately affect the capacity of the breast for making
+milk; for example, irregular habits in youth and the wearing of
+improper styles of clothing are said to be particularly detrimental
+influences. Of course, a healthful mode of life at the time when a
+girl is approaching maturity reacts favorably upon her development in
+every way, and naturally enough the breasts share this benefit; but
+the relation between unhygienic habits at about the time of puberty
+and a subsequent deficiency in lactation has been exaggerated by many
+writers. It is impracticable, certainly, to institute special
+measures to prepare the breasts for their function until the need of
+such measures is clearly evident. Throughout pregnancy clothing about
+the breasts should be loosely worn. If the nipples are not already
+prominent they should be drawn out; and about six or eight weeks
+before confinement is expected they should be given the treatment
+described in Chapter V.
+
+For the first day or so after the infant begins to nurse its efforts
+have a tendency to injure the skin which covers the nipple; and
+unless measures to render the nipple resistant have been previously
+adopted, nursing may cause the mother considerable discomfort.
+Moreover, it is extremely important throughout lactation to keep the
+skin covering the nipple free from abrasions, for if it cracks
+bacteria have thus an opportunity to enter the glands and set up an
+acute inflammation which may result in the formation of an abscess.
+This complication is to be avoided, not only because of the
+unpleasant symptoms which attend it, but also because for the time it
+brings the usefulness of the breast to an end. Fortunately an abscess
+seldom impairs the breast permanently.
+
+At any period of lactation there may be an overproduction of milk. In
+this event the breasts are likely to become distended, hard, and very
+tender. Most frequently "caked breasts," as this condition is called,
+develop a few days after delivery, when the secretion of milk is just
+beginning, for at first the secretion is more plentiful than need be.
+Generally twenty-four hours later there is an adjustment between the
+supply of nourishment and the natural demands of the infant.
+Occasionally a longer interval elapses before the breast is
+completely emptied at each nursing.
+
+Formerly it was customary, whenever the breasts became tense and
+uncomfortable, to express an excess of milk by means of massage; but
+this mode of treatment lost favor as soon as physicians realized that
+massage stimulated the glands to greater activity. Drawing the milk
+with a breast-pump has a somewhat similar though less potent
+influence, and, because pumping often affords relief when the breasts
+are distended, there is rarely any objection to it. In the light of
+modern experience, however, most physicians prefer to avoid
+manipulation of the breast so far as possible, and generally resort
+to other measures to relieve the mother's discomfort. Thus most
+patients are made comfortable if an appropriate bandage is used to
+transfer the weight of the breasts from the arm-pits and the front of
+the chest to the bones of the shoulder-girdle. It may be necessary
+also in some cases to swathe the breasts in warm cloths; in others
+cold applications are more acceptable; the choice between these
+methods will vary with the time of year, and usually may be left to
+the patient herself. Now and then medicine will be employed to
+relieve the pain, but the administration of drugs to diminish the
+production of milk is inadvisable. It is never very long before the
+amount of milk becomes adjusted to the infant's wants, and then
+distention disappears spontaneously. No artifice can bring about the
+adjustment as ideally as nature does.
+
+During the later months of lactation the liability of the breasts to
+over-filling is slight, provided the infant empties them regularly
+and completely. Nevertheless, so long as a mother is nursing her
+child she must be careful to keep the breasts in a healthful
+condition. They require support, yet must not be compressed. And they
+should be covered with clothing which will adequately protect them
+from sudden changes of temperature. This latter precaution, perhaps,
+requires more emphasis than formerly, on account of the present
+popularity of motoring; for the chill which one experiences when
+driving fast may have a very unpleasant effect upon a nursing mother
+unless her breasts are carefully protected. Occasionally fever and
+neuralgic pains in the breasts are caused by motoring, or by exposure
+to the air-current from an electric fan playing directly upon them.
+But even under these circumstances an abscess need not be feared
+unless the nipples are sore.
+
+_Human Milk_.--Between the time of birth and the beginning of
+lactation there is always an interval during which the breasts
+secrete colostrum, just as they do throughout pregnancy. Although the
+nutritional value of this fluid is not great, it is doubtful if
+colostrum serves any other essential purpose than as nourishment.
+Possibly it also stimulates the intestines to expel the material
+which has collected within, them during fetal development, yet we
+know the bowels will move without a purgative; and often do so long
+before the infant is placed at the breast. Typically, the secretion
+of milk begins the third day after delivery; yet in perfectly normal
+patients it may appear as early as the second or as late as the
+fifth, and occasionally lactation does not begin until the baby is
+more than a week old.
+
+As to what starts the secretion of milk we have only a vague idea;
+but we know that when the flow is once established its continuation
+depends primarily upon the sucking efforts of the infant. If nursing
+is discontinued the secretion dwindles and the breasts dry up. On the
+other hand, the strong, persistent stimulus of the infant's suckling
+gradually brings the secretion to a high degree of efficiency. Within
+the first two weeks, therefore, the daily secretion increases from a
+few ounces to a pint or more. Subsequently the output fluctuates
+between one and two quarts daily, according to the demands made upon
+the breasts; the secretion is larger, consequently, if there are
+twins. Astounding yields of milk have been recorded, as in the case
+of a wet-nurse in a German institution who nursed a number of infants
+and became capable of supplying three to four quarts daily.
+
+That newborn infants thrive better on human milk than on any other
+nourishment is a conviction that must come home to every one who has
+had even a limited experience. It keeps the babies in health, serves
+to make them grow, and promotes the development of all their organs
+as nothing else will. Because there are present in this fluid all the
+elements necessary for nutrition, physiologists have called it a
+perfect food. Quantitatively its most important ingredient is water,
+which constitutes about 86 per cent. of its weight. It also contains
+about 7 per cent. of milk-sugar, 4 per cent. of butter fat, 2 per
+cent. of protein, and 0.2 per cent. of mineral matter.
+
+The milk of all animals contains a relatively small quantity of
+mineral matter; judged from this standpoint, the mineral matter would
+seem of minor importance, but it is actually as vital as any other
+constituent. Without it the bones would hot harden properly; and
+other services which it performs are absolutely essential to life. As
+we should expect, human milk contains all the mineral ingredients
+necessary for the development of the infant; indeed, with the single
+exception of iron, they are present in the precise amounts in which
+they are needed. In this omission, however, nature is guilty of no
+oversight, since the infant has already been provided by the time of
+birth with a rich supply of iron.
+
+THE TECHNIQUE OF NURSING.--Since the mother should have opportunity
+to recuperate from the fatigue of labor, physicians generally
+recommend that an interval of at least twelve hours elapse between
+the birth of the infant and the time it is first put to the breast.
+Moreover, the best interests of the infant demand that it be kept
+warm and left undisturbed while becoming accustomed to its new
+environment. There is no immediate need of food; and if there were,
+nature does not fit the mother to supply it, for at this time the
+breasts contain merely small quantities of colostrum.
+
+Some babies nurse vigorously at the outset, but later, discouraged
+because they get so little, become indifferent and restless, or even
+decline to take the breast. And the mother, who is handicapped by
+inexperience and by the awkwardness of nursing in a recumbent
+position, often feels desperate. Fortunately technical difficulties
+are confined to the first few days, and, trying as they sometimes
+are, no one should be discouraged or imagine that she is incapable of
+nursing; for practically every woman who persists will succeed.
+
+For a week or ten days the mother will nurse in the recumbent
+posture. She turns to one side or the other, according as the right
+or left breast is used, and holds the corresponding arm to receive
+and support the baby, which will lie beside her. Then with the
+opposite hand she holds the breast, placing her thumb above and her
+fingers below so as to keep it from the baby's face, for only in this
+way can the infant breathe freely. One must also remember that the
+infant draws the milk into the terminal ducts chiefly with the back
+of its mouth, and drains the ducts by compressing the base of the
+nipple with its jaws; the infant therefore should take into its mouth
+not only the nipple, but also the areola, the area of deeply colored
+skin round about it. Mothers frequently disregard these directions,
+and the failure of their infants to nurse properly may be thus
+explained, for it is impossible to secure undisturbed nursing unless
+they are obeyed.
+
+Generally the breasts are employed alternately, but both may be used
+at each nursing if one is insufficient. To fix the duration of the
+nursings arbitrarily is impossible; from ten to fifteen minutes
+generally proves satisfactory, but in each case systematic
+observations of the change in the baby's weight, of the character of
+its stools, and of its general condition must determine how long to
+leave it at the breast. The common error, unfortunately, is to be
+over-indulgent, and, as a result, infants are more frequently ill
+because the nursings are too long, than too short. Furthermore, the
+duration of the feedings can never be gauged accurately if the infant
+is allowed to nap while nursing.
+
+The successful training of a baby begins with the development of
+regular habits of nursing. The old-fashioned custom of allowing the
+baby to nurse whenever it cried, tacitly--and incorrectly--assumed
+that it could have no other sensation than hunger. As a matter of
+fact an infant may have pain from overfeeding. Again, it may be
+thirsty, or uncomfortable from the pricking of a pin, from the
+monotony of one position, from a soiled napkin, or from neglect of
+many simple details in its care. Any of these things make a baby cry,
+for it has no other means by which it can express disapproval.
+
+So long as the breasts contain colostrum the nursings should be at
+least three hours apart during the day; at night it is preferable not
+to disturb the mother at all. As soon as milk appears the interval is
+usually shortened to two hours during the day. In many cases,
+however, the three-hour interval will be retained even after the milk
+appears, for otherwise the infant may not become hungry and will fail
+to nurse as strongly as it should. The following schedule is adapted
+to the average infant:
+
+           Age                 Interval During     Total Number
+                                   the Day          of Feedings
+  From  1st  to    4th week       2      hours            9
+    "   4th   "    8th  "         2-1/2    "              8
+    "   2nd   "    4th month      3        "              7
+    "   4th   "   10th   "        3        "              6
+    "  10th   "   12th   "        4        "              5
+
+After the first few days most young infants require one feeding in
+the middle of the night, which is usually given about 2 A.M. The day
+feedings then begin at 6 A.M., and are repeated at regular intervals
+until 9 or 10 P.M. The daily bath should be scheduled so that a
+feeding will be due just after the bath has been completed. If asleep
+when the next succeeding feeding falls due, the infant should not be
+waked, but at other times nothing should interfere with the
+regularity of the schedule. Occasionally there may be difficulty in
+getting the child to nurse during the day, but it must be taught to
+do so; otherwise it will want to nurse throughout the night.
+
+At no time should an infant remain in the bed with its mother after
+it has finished nursing; at night this rule must be rigidly enforced,
+for mothers have been known to fall asleep and smother the baby, an
+accident known as over-lying. Infants can frequently be trained to go
+without feeding in the middle of the night even when a month old; and
+such training is always advisable, since it affords the mother
+opportunity for six or eight hours' continuous sleep.
+
+Before and after each nursing the mothers' nipple should be cleansed
+with a solution of boric acid made by placing a tablespoonful of the
+powder in a tumbler which is then filled with water. Such cleansing
+protects the breasts against infection, a complication which the
+nursing mother must spare no pains to prevent. Now and then, in spite
+of conscientious efforts to harden them, the nipples become sore. If
+they crack, the baby's mouth must not come in direct contact with
+them, since nursing with a cracked nipple is a common source of a
+gathered breast. Fortunately when a nipple cracks we may employ a
+shield, obtainable at any drug-store, which enables the infant to
+nurse without any danger to the mother. Most babies will take the
+shield as well as the breast itself; nevertheless, its use should be
+discontinued as soon as the nipple heals, for while the shield is
+used the secretion of milk is not stimulated as vigorously as when
+the infant nurses directly from the breast. In the rare cases in
+which the shield cannot be used satisfactorily the infant must be
+taken from the breast temporarily and given a bottle. Radical as this
+advice may appear, the mother must consent to follow it, for, as I
+have pointed out, to permit an infant to nurse a cracked nipple is
+extremely hazardous. When treatment is begun promptly the cracks will
+generally heal within twenty-four hours.
+
+HYGIENE OF THE MOTHER.--Since the mammary glands manufacture their
+product from the constituents of the mother's blood and their
+activity is controlled by her nerves, it is clear that her physical
+condition and her state of mind will influence the secretion of milk.
+Intelligent women who understand this desire to know how they should
+live that they may best insure an ample supply of good milk.
+Fortunately the first important step toward success has been taken
+when a mother wishes to nurse her baby; but there are also necessary
+wholesome food, habits conducive to health, and a mind free from
+worry.
+
+It is unfortunate that current beliefs throw many restrictions about
+nursing-mothers which are unreasonable and unsupported by scientific
+investigation. There was a time when mothers did not question their
+ability to nurse, they assumed this duty as a matter of course.
+Indeed, they were compelled to do so, since refined methods of
+artificial feeding had not as yet been devised. Among the
+agricultural class, even to-day, it is exceptional for mothers to
+fail to nurse their children, if they are provided with the ordinary
+comforts of life. But women who live at the higher tension of city
+life are frequently unsuccessful, because they are more inclined to
+be nervous or because they disregard, among other things, the need of
+fresh air, plain food, or regular habits. It is wrong to suppose that
+elaborate rules of conduct are necessary for nursing mothers; the
+instruction they require is simple and scarcely different from that
+to be given anyone who desires good health. If she lead a wholesome
+existence a woman will not only nurse her child successfully but will
+gain in strength.
+
+_Diet_.--In manufacturing centers, where a large proportion of
+the women are employed in confining work, the percentage of mothers
+who are able to nurse their children is exceedingly small;
+consequently the infant mortality is very high. Better nourishment
+for the mother, it has seemed, would render her more capable of
+successful lactation, and would decrease or even eliminate badly
+executed artificial feeding, and would therefore reduce the death
+rate among the babies. In a few foreign cities the idea has been put
+into practice. Free restaurants have been established for working
+mothers, and they have thus been enabled to perform their maternal
+duties much more successfully. Incidentally it has been shown that
+nourishment may be supplied mother and infant at a smaller cost than
+proper artificial food for the infant alone.
+
+The quantity of nourishment required by nursing mothers is not so
+large as might be expected, and in many instances it is over-feeding
+rather than under-feeding that must be guarded against. Very accurate
+observations have been made which indicate that during the early
+weeks of nursing no more food is needed than at other times; in all
+probability this remains true throughout the whole period of
+lactation. Over-eating, as many of us know, is a frequent cause of
+indigestion. It is of the first importance, therefore, that nursing
+mothers should not take more food than they can assimilate, for
+indigestion will provoke disturbances in the milk which in turn will
+make the baby uncomfortable. For a similar reason mothers should have
+their meals at regular intervals.
+
+As a rule the appetite is a reliable guide not only as to how much to
+eat, but also as to the choice of food, for without exception what is
+good for the mother is good also for the child. Generally the diet
+should be a mixed one, consisting of milk, gruels, soups, vegetables,
+bread, and meat. In order that monotony may not dull the appetite, no
+one article of food should be employed continuously. With this
+exception food should be selected with regard only for its
+wholesomeness and digestibility. All food is milk-making food; no
+sharp distinctions between the various kinds can be recognized. Milk,
+because it contains all the elements necessary for perfect nutrition,
+is particularly wholesome. Water also, since it forms such a large
+proportion of their milk, should be taken freely by nursing mothers.
+Generally it proves advantageous to take milk or some other
+nutritious drink between meals and again before retiring at night,
+but the danger of ruining in this way the appetite for solid food
+must not be overlooked.
+
+It ought to be unnecessary to say that a nursing mother should deny
+herself any article of food, no matter how much she may want it, if
+she knows it will disagree with her; but she must remember also that
+the same article of food will not necessarily disagree with other
+mothers. Generalizations of this kind are largely responsible for the
+wrongful tendency to reject from the dietary many altogether harmless
+articles. There would be little left for a nursing mother to eat if
+she avoided every article of food which one person or another assures
+her will damage her milk.
+
+No belief regarding what a nursing mother should eat is held more
+widely, I suppose, than that she should abstain from salads,
+tomatoes, and fruits which contain acid. This view is erroneous. The
+very idea upon which it is based is incorrect, since acids are
+neutralized as soon as they pass from the stomach to the intestines
+and cannot enter the milk. With certain persons some varieties of
+fruit invariably cause indigestion. Lactation does not correct such
+an individual peculiarity, and a nursing mother who knows she
+possesses it will act accordingly. Occasionally those who have no
+such idiosyncrasy worry after they have eaten something which
+contains an acid because they have heard it will do harm. In such
+cases it is the mental state of the woman which disturbs her milk and
+upsets the baby. With the exception of those who have such an
+idiosyncrasy and those inclined to worry, nursing mothers may partake
+of fruits and salads with impunity.
+
+There are vegetables, of which the onion and turnip are good
+examples, that contain ingredients that find their way unaltered into
+the milk. So long as these do not disturb the mother their presence
+has no unfavorable influence upon the child. Similarly a number of
+substances appear in the milk when administered as medicine to the
+mother. In one way this is fortunate, for under certain circumstances
+it provides a very satisfactory method of treating unhealthy children
+without giving the medicine directly. In another respect, however, it
+is a disadvantage, for it sometimes interferes with giving the mother
+purgatives, which she may need. So far as possible, therefore, the
+taking of medicine should be limited during lactation, and certainly
+no drug should be employed without the advice of a physician.
+
+Time and again some drug, some beverage, usually one that contains
+alcohol, or some special article of food has been recommended as a
+means of increasing an inadequate secretion of milk, but thus far all
+attempts in this direction have failed of general application. There
+are at present on the market widely advertised preparations for which
+astounding efficiency is claimed. None of them, however, has a
+definite or consistent value; and it is unfortunately true that no
+substance has yet been discovered that has the specific action of
+increasing the production of milk.
+
+_Psychic Influence_.--Although the nerves of the breast which
+regulate the secretion of milk do their work whether the mother wills
+it or not, her state of mind has an influence over the process, just
+as it has over digestion. No one doubts that our minds influence our
+digestions as has been so clearly proved by the skillful experiments
+of Pawlow, an eminent Russian physiologist. Cheerfulness promotes
+perfect assimilation of the food, whereas mental depression decreases
+the secretion of the digestive juices or checks them altogether. In a
+similar way, perhaps, we shall some day have explained to us the
+unquestioned fact that mothers who maintain a happy disposition nurse
+their babies efficiently, while those who are inclined to worry often
+experience real or imaginary troubles with lactation.
+
+The most striking manifestations of such psychic influences are those
+in which, as a result of some strong passion or deep sorrow, the
+secretion of milk suddenly ceases altogether. Fortunately such
+effects occur rarely and are never permanent. After a few hours at
+most the secretion is reestablished; and if there are alterations in
+the quality of the milk, these will correct themselves just as
+quickly.
+
+More common, and therefore much more important, are cases in which,
+because the mother allows herself day after day to worry over one
+thing or another, the secretion of milk suffers permanent disturbance
+in quantity or in quality. Sometimes worrying lest the milk will be
+unsatisfactory causes it to become so. Generally, however,
+unnecessary anxiety for the baby is to blame. Again and again, when
+there is really nothing out of the way, inexperienced mothers make
+themselves miserable because they fear something may go wrong. Such a
+state of mind always invites trouble; not infrequently it is the
+direct cause of insufficient or unwholesome milk. The self-assurance
+gained through taking care of the first baby is responsible more than
+anything else for the greater success mothers have in nursing
+subsequent children.
+
+The mother who is nursing her first baby should take success for
+granted, and never mistrust her ability to succeed. If the physician
+has been asked to visit the baby regularly, as was suggested at the
+beginning of this chapter, he will quickly detect the evidence of
+failure should failure be imminent. His opinions should be accepted
+and his directions followed, for by so doing the mother will most
+readily acquire the assurance which is so necessary to success. The
+habit, easily fallen into, of paying attention to promiscuous advice
+is unwholesome, for such advice is injudiciously given and is usually
+incorrect. More often than not the counsel of well-meaning friends
+only serves to perplex and distress the mother.
+
+_Recreation and Rest_.--Next to worry no influence upon
+lactation is more detrimental than neglect of recreation and rest.
+Both are very necessary to a nursing mother, for without them she
+will soon begin to exaggerate minor troubles and even to worry though
+nothing is wrong. A mother who has the care of a baby added to other
+responsibilities may have extraordinary difficulty in finding time
+for outdoor exercise, for congenial companionship, or for diversion
+of any kind. Occasionally it may seem almost impossible even to get
+time for sleep, a necessity so fundamental to health that, as we
+should expect, a mother deprived of it would fail utterly in nursing
+her infant. Difficult as it may seem, however, the mother must find
+time for recreation, for if she does not there will follow
+disturbances, generally in the quantity, or sometimes in the quality,
+of her milk.
+
+Keeping in mind that whatever benefits the mother will react
+favorably upon the infant, one should regulate exercise during
+lactation with regard to the kind and the amount of exercise to which
+she has been previously accustomed. Walking usually fulfils all the
+requirements satisfactorily, and there is ordinarily no reason why
+nursing mothers should not participate in sports that are unattended
+by violent exertion. Exhausting sports, however, must be shunned,
+because fatigue has the same injurious effect upon the secretion of
+milk as lack of exercise.
+
+As might be expected, women who are frail are most susceptible to the
+strain of nursing, especially if they fail to get sufficient rest.
+All nursing mothers ought to have at least eight hours of sleep in
+the twenty-four. The night-feeding, generally advisable for the first
+six to eight weeks, does not break the mother's rest longer than half
+an hour if the baby is well trained. But if a baby that has not been
+properly trained turns night into day and keeps the mother awake for
+long intervals, the milk will quickly deteriorate. Under such
+circumstances someone must relieve the mother of the care of the
+infant during the night; she should not be disturbed even to nurse
+it. The night-feeding will then be supplied artificially; as will
+also one feeding during the day in order that the mother may have
+opportunity for exercise and diversion.
+
+THE SUPPLEMENTARY BOTTLE.--At first glance it may seem that in the
+suggestion that the infant be given one artificial feeding each day
+the mother's comfort alone has been considered. As a matter of fact,
+however, the adoption of the plan benefits mother and infant alike.
+The diversion and recreation which the mother, thus relieved of her
+maternal duties for from four to six hours, has time to secure
+becomes a direct benefit to the infant. Not infrequently by pursuing
+this plan, mothers who would otherwise be incapable of nursing are
+assured successful lactation. The child, moreover, having thus become
+accustomed to the bottle, is much more easily denied the breast when
+the time for weaning comes.
+
+Objections have been raised to giving the baby even one bottle when
+the mother has an ample supply of milk, but none of them are valid.
+Since cow's milk is acknowledged to be less easy of digestion than is
+human milk, it will occur to someone that there is danger of
+upsetting the baby by giving it a bottle. But this need not be
+feared; extensive experience has shown that if an infant is getting
+human milk of satisfactory quality at all its feedings during the
+twenty-four hours, save one or two, at these times it will digest
+properly modified cow's milk without the least inconvenience. Nor is
+it true that if once a day cow's milk is substituted for that of the
+mother, the infant will come to prefer the bottle to the breast.
+There is no danger, on the other hand, that the mother's milk will
+dry up. Very thorough investigation of these objections has failed to
+substantiate them in the least.
+
+Of course, it will be necessary in preparing the supplementary
+feeding to take the same precautions as if the infant were on the
+bottle exclusively. To avoid contamination of the milk care must be
+exercised to have everything perfectly clean that comes in contact
+with it. And it will be necessary also to vary from time to time both
+the strength and the amount of the feeding. These alterations will be
+made most successfully if left to the judgment of a physician who is
+familiar with the development of the infant and who may be guided
+accordingly.
+
+WEANING.--Occasionally, even before they are delivered, women express
+the conviction that they will be incapable of nursing. A few mothers
+who take this attitude, which it would seem is becoming more and more
+common, make no attempt at nursing, and others give it up after a
+very short trial. Premature weaning is practiced among the women of
+two widely different classes: those who are unwilling to deny
+themselves social pleasures, and those who, because they must earn a
+living, cannot be encumbered with maternal duties. A still larger
+class, however, are those mothers who wean the baby for neither of
+these reasons, but rather because they become discouraged and
+conclude that there is something wrong with their milk. In this way
+many infants are weaned without sufficient reason. Before giving up
+nursing her child a mother should submit several samples of the milk
+for analysis. If it is unfit for the infant, reliable evidence of the
+fact will often be secured in this way.
+
+With the exception of tuberculosis, physicians recognize no condition
+that necessarily unfits a mother for nursing. As we have already
+seen, pregnancy is generally incompatible with lactation; in the
+event of conception the mother's milk almost always takes on
+qualities which render it unsatisfactory for the infant, and yet
+occasionally pregnancy advances several months before these changes
+in the milk occur. Meanwhile the infant suffers no inconvenience, and
+often in these cases the symptoms of threatened miscarriage give the
+first intimation of the mother's condition. Under all circumstances,
+however, nursing should cease as soon as the mother recognizes that
+she is pregnant, for probably no woman is strong enough to provide
+nourishment for her infant and for the development of the embryo
+simultaneously.
+
+Menstruation, on the other hand, rarely if ever provides a good and
+sufficient reason for weaning. In the great majority of instances
+this function is re-established before lactation ends. There may be a
+reduction in the amount of milk during menstruation, but if the
+infant has been given the breast as usual, the supply increases as
+soon as the period ends. Qualitative disturbances which would render
+the milk unfit for use are practically never a consequence of
+menstruation.
+
+It may happen as the infant grows older that the flow of milk will
+diminish; then the breast feedings will of necessity be more
+frequently replaced by the bottle, and the question of weaning will
+settle itself. But if the time of weaning is a matter of choice, it
+should be approximately coincident with certain notable developments
+in the infant's digestive functions, which occur toward the end of
+the first year. The fact that the infant is prepared to take other
+food is outwardly shown by the appearance of teeth, of which there
+are usually six or eight at the end of the year.
+
+If the suggestion regarding the daily substitution of one bottle for
+the mother's milk has been adopted, there will be no difficulty in
+discontinuing breast-feeding whenever it is desirable; otherwise an
+infant may raise strong objection to the change. The mother, on the
+other hand, will not be seriously inconvenienced by the weaning,
+provided she leaves her breasts alone.
+
+Until recently mothers were advised to employ a very elaborate
+treatment for drying up the breasts. The diet was restricted, and as
+far as possible liquids of every kind were forbidden; strong
+purgatives were administered daily; and, in addition, the breasts
+were covered with some ointment, swathed in cotton, and tightly
+compressed with a bandage. Fortunately, we now realize that none of
+these measures are required. When nursing is discontinued the breasts
+are apt to become distended and uncomfortable. They require support
+while the distention lasts, which is never very long, and if they
+become painful, medicine may be employed to give relief. But other
+measures, some of which occasionally do harm, are absolutely
+unnecessary, for, at whatever period of lactation the breasts cease
+to be used, they dry up spontaneously.
+
+
+
+
+GLOSSARY
+
+
+[Footnote: The Century Dictionary has been freely used for these
+definitions.]
+
+
+ABNORMAL.--Irregular; deviating from the natural or standard type.
+
+ABORTIFACIENT.--Whatever is used to produce an abortion.
+
+ABORTION.--The expulsion of the embryo during the first four months
+of pregnancy.
+
+AFTER-BIRTH.--The mass of tissue expelled from the uterus at the end
+of labor. It includes the placenta, the umbilical cord, and the
+membranes of the ovum.
+
+ALIMENTARY CANAL.--The digestive tract. It begins with the mouth,
+includes the stomach and the intestines, and ends with the rectum.
+
+AMNIOTIC FLUID.--The liquid inclosed within the amniotic membrane.
+
+AMNIOTIC MEMBRANE.--The innermost of the two membranes which envelop
+the embryo; the lining membrane of the closed sac familiarly called
+"the bag of waters."
+
+ANEMIA.--A deficiency of some of the constituents of the blood.
+
+ANATOMY.--The science which deals with the structure of the body.
+
+ANTISEPTIC.--Anything which destroys bacteria.
+
+AREOLA.--The colored, circular area about the nipple.
+
+ARTERY.--A vessel through which the blood flows away from the heart.
+
+ASEPSIS.--The exclusion of disease-producing bacteria.
+
+ASEPTIC.--Free from injurious bacteria.
+
+ASPHYXIA.--The extreme condition caused by lack of oxygen in the
+blood, brought about by interrupted breathing.
+
+ASSIMILATION.--The process by which living creatures digest and
+absorb nutriment so that it becomes part of the substance composing
+them.
+
+ATROPHY.--To waste away.
+
+AUTO-INTOXICATION.--Poisoning by material formed within one's body.
+
+BACTERIA (the plural of bacterium).--Exceedingly minute, spherical,
+oblong, or cylindrical cells which are concerned in putrefactive
+processes. Some varieties cause disease.
+
+BACTERIAL DECOMPOSITION.--Putrefaction brought about by the action of
+bacteria.
+
+BIOLOGY.--The science which deals with the phenomena of life.
+
+BIRTH-CANAL.--The passage through which the child enters the world.
+It is composed of the uterus and the vagina, and is surrounded by the
+pelvic bones.
+
+BLADDER.--A thin, distensible sack acting as a reservoir for the
+urine between the time it is secreted by the kidneys and leaves the
+body.
+
+BREECH.--The buttocks.
+
+CESAREAN OPERATION.--The operation by which the child is taken out of
+the uterus by an incision through the abdominal wall.
+
+CALORIE.--The unit ordinarily employed by scientists to measure heat.
+
+CAPILLARIES.--The minute blood vessels which form a network between
+the terminations of the arteries and the beginnings of the veins.
+
+CARBOHYDRATE.--Any one of a group of chemical substances of which
+starch and sugar are the most familiar members.
+
+CARBONIC ACID GAS.--An animal waste product eliminated in the breath.
+In daylight plants absorb it energetically from the atmosphere
+through their leaves, and decompose it, assimilating the carbon, and
+returning the oxygen to the air.
+
+CARTILAGE.--A firm, elastic tissue; gristle. From this material many
+of the bones develop.
+
+CATHETERIZE.--To empty the bladder by means of a tube-like instrument
+which is introduced into the passage through which the urine normally
+leaves the bladder.
+
+CELL.--One of the microscopical structural units which make up our
+bodies.
+
+CELL-DIVISION.--The process by which a single cell becomes two cells.
+
+CEREBRUM.--The portion of the brain which is the seat of mental
+activity.
+
+CHORIONIC MEMBRANE.--The outermost of the two membranes which
+surround the embryo.
+
+CHROMATIN.--A substance within the nucleus of a cell which has a
+special affinity for certain staining agents.
+
+CHROMOSOMES.--One of the pieces into which the chromatin is broken
+during the act of cell-division.
+
+CLINICAL.--Pertaining to the sick-bed.
+
+COLOSTRUM.--The fluid secreted by the breasts during pregnancy and
+for two or three days after the birth of the child.
+
+CONTRACTION.--The act by which the muscle fibers of the uterus become
+shorter and press upon its contents.
+
+CURETTAGE.--Scraping out the lining of the uterus.
+
+DELIVERY.--The birth of the child.
+
+DIAGNOSIS.--The determination of either normal or abnormal states of
+the body.
+
+DIAPHRAGM.--The muscular partition between the chest and the abdomen.
+
+DIETETIC.--Pertaining to the diet.
+
+DUCT.--A tube which conveys the secretion from a gland.
+
+EMBRYO.--The offspring before it has assumed the distinctive form and
+structure of the parent.
+
+ENEMA.--A quantity of fluid injected into the rectum.
+
+ENGAGEMENT.--The entrance of the fetus into the birth-canal.
+
+ETHNOLOGY.--The science which deals with the character, customs, and
+institutions of races of men.
+
+EUGENICS.--The science which deals with the improvement of the human
+race by better breeding. (Davenport.)
+
+EXCRETION.--Waste substance thrown off from the body.
+
+FEBRILE.--Attended with fever.
+
+FETUS.--The unborn child after the third month of development.
+
+FOOD-STUFF.--Anything used for the sustenance of man.
+
+FUNCTION.--The discharge of its duty by any organ of the body.
+
+GASTRIC JUICE.--The digestive fluid secreted by the wall of the
+stomach.
+
+GERMINAL CELLS.--The structural units from which a new individual
+takes origin. The cell contributed by the mother is called an egg-
+cell or ovum; that contributed by the father, a spermatozoon.
+
+GESTATION.--Same as pregnancy.
+
+GLAND.--An organ which separates certain substances from the blood,
+and pours out a material, usually fluid, peculiar to itself.
+
+HYGIENE.--That department of medical knowledge which relates to the
+preservation of health; sanitary science.
+
+INANITION.--The condition which results from insufficient
+nourishment.
+
+INFECTION.--A disease due to bacteria.
+
+INTESTINE.--The bowels; the long membranous tube extending from the
+stomach to the rectum.
+
+INVOLUTION.--The process by which the uterus returns after child-
+birth to its former size and position.
+
+LACTATION.--The secretion of milk.
+
+LIGAMENT.--A band of tissue serving to bind one part of the body to
+another.
+
+LIGATURE.--Anything that serves for tying a blood-vessel.
+
+LOCHIA.--The discharge continuing for several weeks after the birth
+of a child.
+
+LOTION.--Any liquid holding in solution medicinal substances intended
+for application to the skin.
+
+LUNAR MONTH.--A month of twenty-eight days.
+
+MAMMAL.--The highest order of animal, namely, one which suckles its
+young.
+
+MAMMARY.--Relating to the breast.
+
+MASTICATION.--The act of chewing.
+
+MENOPAUSE.--The permanent abolishment of the menstrual process, which
+generally occurs between the 45th and the 50th years.
+
+MICRO-ORGANISMS.--Bacteria and other living agents of disease which
+are visible only with the aid of the microscope.
+
+MISCARRIAGE.--The termination of pregnancy prior to the seventh
+month.
+
+MUCOUS MEMBRANE.--The lining of certain cavities of the body, such as
+the mouth, stomach, intestine, uterus, etc.
+
+MUCUS.--The material manufactured by the glands in a mucous membrane.
+
+MUSCLE-FIBERS.--The muscle-cells.
+
+NARCOTICS.--Drugs which produce sleep.
+
+NITROGEN.--One of the chemical elements.
+
+NUCLEUS.--A clearly defined area found in every cell which seems to
+be its seat of government.
+
+OBSTETRICS.--The branch of medicine which deals with the treatment
+and care of women during pregnancy and child-birth.
+
+OVARY.--The organ which contains the egg-cells or ova.
+
+OVIDUCTS.--Two tubes, each of which leads from the neighborhood of
+one of the ovaries; both terminate in the uterus.
+
+OVUM.--An egg: the cell contributed by the mother to her offspring.
+
+OXYGEN.--One of the chemical elements.
+
+PATHOLOGY.--The branch of medicine which deals with the altered
+structure and activity of diseased organs.
+
+PEPSIN.--A ferment found in the digestive juice secreted by the
+stomach.
+
+PELVIC FLOOR.--The muscles, ligaments, and other tissues which form
+the bottom of the basin inclosed between the hips.
+
+PELVIS.--The bony ring formed chiefly by the hip bones. Posteriorly
+the ring is completed by the sacrum.
+
+PERINEUM.--The region extending backward from the outlet of the
+vagina to the rectum; it is the most essential part of the pelvic
+floor.
+
+PHYSIOLOGY.--Scientific knowledge of the manner in which the various
+parts of the body perform their duties.
+
+PIGMENT.--Any coloring matter.
+
+PLACENTA.--The organ through which the communication between the
+mother and the offspring is established. One of its surfaces is
+attached to the wall of the uterus; at about the middle point of the
+other surface the umbilical cord takes its origin.
+
+PRENATAL.--Pertaining to the period before birth.
+
+PROTEIN.--A food-stuff which is distinguished by the fact that it
+contains nitrogen and is a tissue builder.
+
+PROTOPLASM.--The living substance in the cells which compose our
+bodies.
+
+PUBERTY.--Sexual maturity in human beings.
+
+PUBIC BONES.--The part of the pelvis which forms an arch in front of
+the bladder.
+
+PUERPERIUM.--The same as the lying-in period.
+
+RETINA.--The innermost coat of the eye-ball and the one which
+receives visual impressions.
+
+RICKETS.--A disease of infancy characterized by softening of the
+bones.
+
+SECRETION.--The product of the activity of a gland.
+
+SEDIMENT.--The material which settles to the bottom of any liquid.
+
+SPERMATOZOON (plural spermatozoa).--The microscopic cell contributed
+by the male parent, which stimulates the ovum to begin its
+development.
+
+SUPPOSITORY.--A medicinal substance made into the form of a cone to
+be introduced into the rectum.
+
+TERM.--The time of expected delivery.
+
+THERAPEUTIC.--Concerned with the treatment of disease.
+
+THYMUS GLAND.--A structure located behind the breast bone near the
+root of the neck. Only traces of it are found in adult life.
+
+TISSUE.--An aggregation of similar cells in a definite fabric, as
+muscle, nerve, gland, etc.
+
+TUBES.--The oviducts.
+
+UMBILICAL CORD.--The structure carrying the blood vessels which pass
+between the placenta and the child's navel.
+
+UTERUS.--The womb: a hollow muscular organ designed to receive,
+protect, nourish, and expel the product of conception.
+
+VAGINA.--The canal through which the child passes from the uterus
+into the world.
+
+VEIN.--A vessel through which the blood flows back to the heart.
+
+VERNIX.--The fatty substance deposited over the skin of the newly
+born infant.
+
+VIABLE.--Capable of living.
+
+VILLI (singular villus).--The microscopic, finger-like processes
+which hang from one of the surfaces of the placenta and are
+surrounded by the mother's blood.
+
+VISCERA.--The internal organs which occupy the cavities of the chest
+and the abdomen.
+
+VULVA.--The folds of tissue which surround the outlet of the vagina.
+
+
+
+
+
+End of Project Gutenberg's The Prospective Mother, by J. Morris Slemons
+
+*** END OF THE PROJECT GUTENBERG EBOOK THE PROSPECTIVE MOTHER ***
+
+This file should be named 7129.txt or 7129.zip
+
+Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo,
+Charles Franks and the Online Distributed Proofreading Team.
+
+Project Gutenberg eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the US
+unless a copyright notice is included.  Thus, we usually do not
+keep eBooks in compliance with any particular paper edition.
+
+We are now trying to release all our eBooks one year in advance
+of the official release dates, leaving time for better editing.
+Please be encouraged to tell us about any error or corrections,
+even years after the official publication date.
+
+Please note neither this listing nor its contents are final til
+midnight of the last day of the month of any such announcement.
+The official release date of all Project Gutenberg eBooks is at
+Midnight, Central Time, of the last day of the stated month.  A
+preliminary version may often be posted for suggestion, comment
+and editing by those who wish to do so.
+
+Most people start at our Web sites at:
+https://gutenberg.org or
+http://promo.net/pg
+
+These Web sites include award-winning information about Project
+Gutenberg, including how to donate, how to help produce our new
+eBooks, and how to subscribe to our email newsletter (free!).
+
+
+Those of you who want to download any eBook before announcement
+can get to them as follows, and just download by date.  This is
+also a good way to get them instantly upon announcement, as the
+indexes our cataloguers produce obviously take a while after an
+announcement goes out in the Project Gutenberg Newsletter.
+
+http://www.ibiblio.org/gutenberg/etext03 or
+ftp://ftp.ibiblio.org/pub/docs/books/gutenberg/etext03
+
+Or /etext02, 01, 00, 99, 98, 97, 96, 95, 94, 93, 92, 92, 91 or 90
+
+Just search by the first five letters of the filename you want,
+as it appears in our Newsletters.
+
+
+Information about Project Gutenberg (one page)
+
+We produce about two million dollars for each hour we work.  The
+time it takes us, a rather conservative estimate, is fifty hours
+to get any eBook selected, entered, proofread, edited, copyright
+searched and analyzed, the copyright letters written, etc.   Our
+projected audience is one hundred million readers.  If the value
+per text is nominally estimated at one dollar then we produce $2
+million dollars per hour in 2002 as we release over 100 new text
+files per month:  1240 more eBooks in 2001 for a total of 4000+
+We are already on our way to trying for 2000 more eBooks in 2002
+If they reach just 1-2% of the world's population then the total
+will reach over half a trillion eBooks given away by year's end.
+
+The Goal of Project Gutenberg is to Give Away 1 Trillion eBooks!
+This is ten thousand titles each to one hundred million readers,
+which is only about 4% of the present number of computer users.
+
+Here is the briefest record of our progress (* means estimated):
+
+eBooks Year Month
+
+    1  1971 July
+   10  1991 January
+  100  1994 January
+ 1000  1997 August
+ 1500  1998 October
+ 2000  1999 December
+ 2500  2000 December
+ 3000  2001 November
+ 4000  2001 October/November
+ 6000  2002 December*
+ 9000  2003 November*
+10000  2004 January*
+
+
+The Project Gutenberg Literary Archive Foundation has been created
+to secure a future for Project Gutenberg into the next millennium.
+
+We need your donations more than ever!
+
+As of February, 2002, contributions are being solicited from people
+and organizations in: Alabama, Alaska, Arkansas, Connecticut,
+Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois,
+Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts,
+Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New
+Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio,
+Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South
+Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West
+Virginia, Wisconsin, and Wyoming.
+
+We have filed in all 50 states now, but these are the only ones
+that have responded.
+
+As the requirements for other states are met, additions to this list
+will be made and fund raising will begin in the additional states.
+Please feel free to ask to check the status of your state.
+
+In answer to various questions we have received on this:
+
+We are constantly working on finishing the paperwork to legally
+request donations in all 50 states.  If your state is not listed and
+you would like to know if we have added it since the list you have,
+just ask.
+
+While we cannot solicit donations from people in states where we are
+not yet registered, we know of no prohibition against accepting
+donations from donors in these states who approach us with an offer to
+donate.
+
+International donations are accepted, but we don't know ANYTHING about
+how to make them tax-deductible, or even if they CAN be made
+deductible, and don't have the staff to handle it even if there are
+ways.
+
+Donations by check or money order may be sent to:
+
+Project Gutenberg Literary Archive Foundation
+PMB 113
+1739 University Ave.
+Oxford, MS 38655-4109
+
+Contact us if you want to arrange for a wire transfer or payment
+method other than by check or money order.
+
+The Project Gutenberg Literary Archive Foundation has been approved by
+the US Internal Revenue Service as a 501(c)(3) organization with EIN
+[Employee Identification Number] 64-622154.  Donations are
+tax-deductible to the maximum extent permitted by law.  As fund-raising
+requirements for other states are met, additions to this list will be
+made and fund-raising will begin in the additional states.
+
+We need your donations more than ever!
+
+You can get up to date donation information online at:
+
+https://www.gutenberg.org/donation.html
+
+
+***
+
+If you can't reach Project Gutenberg,
+you can always email directly to:
+
+Michael S. Hart <hart@pobox.com>
+
+Prof. Hart will answer or forward your message.
+
+We would prefer to send you information by email.
+
+
+**The Legal Small Print**
+
+
+(Three Pages)
+
+***START**THE SMALL PRINT!**FOR PUBLIC DOMAIN EBOOKS**START***
+Why is this "Small Print!" statement here? You know: lawyers.
+They tell us you might sue us if there is something wrong with
+your copy of this eBook, even if you got it for free from
+someone other than us, and even if what's wrong is not our
+fault. So, among other things, this "Small Print!" statement
+disclaims most of our liability to you. It also tells you how
+you may distribute copies of this eBook if you want to.
+
+*BEFORE!* YOU USE OR READ THIS EBOOK
+By using or reading any part of this PROJECT GUTENBERG-tm
+eBook, you indicate that you understand, agree to and accept
+this "Small Print!" statement. If you do not, you can receive
+a refund of the money (if any) you paid for this eBook by
+sending a request within 30 days of receiving it to the person
+you got it from. If you received this eBook on a physical
+medium (such as a disk), you must return it with your request.
+
+ABOUT PROJECT GUTENBERG-TM EBOOKS
+This PROJECT GUTENBERG-tm eBook, like most PROJECT GUTENBERG-tm eBooks,
+is a "public domain" work distributed by Professor Michael S. Hart
+through the Project Gutenberg Association (the "Project").
+Among other things, this means that no one owns a United States copyright
+on or for this work, so the Project (and you!) can copy and
+distribute it in the United States without permission and
+without paying copyright royalties. Special rules, set forth
+below, apply if you wish to copy and distribute this eBook
+under the "PROJECT GUTENBERG" trademark.
+
+Please do not use the "PROJECT GUTENBERG" trademark to market
+any commercial products without permission.
+
+To create these eBooks, the Project expends considerable
+efforts to identify, transcribe and proofread public domain
+works. Despite these efforts, the Project's eBooks and any
+medium they may be on may contain "Defects". Among other
+things, Defects may take the form of incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other
+intellectual property infringement, a defective or damaged
+disk or other eBook medium, a computer virus, or computer
+codes that damage or cannot be read by your equipment.
+
+LIMITED WARRANTY; DISCLAIMER OF DAMAGES
+But for the "Right of Replacement or Refund" described below,
+[1] Michael Hart and the Foundation (and any other party you may
+receive this eBook from as a PROJECT GUTENBERG-tm eBook) disclaims
+all liability to you for damages, costs and expenses, including
+legal fees, and [2] YOU HAVE NO REMEDIES FOR NEGLIGENCE OR
+UNDER STRICT LIABILITY, OR FOR BREACH OF WARRANTY OR CONTRACT,
+INCLUDING BUT NOT LIMITED TO INDIRECT, CONSEQUENTIAL, PUNITIVE
+OR INCIDENTAL DAMAGES, EVEN IF YOU GIVE NOTICE OF THE
+POSSIBILITY OF SUCH DAMAGES.
+
+If you discover a Defect in this eBook within 90 days of
+receiving it, you can receive a refund of the money (if any)
+you paid for it by sending an explanatory note within that
+time to the person you received it from. If you received it
+on a physical medium, you must return it with your note, and
+such person may choose to alternatively give you a replacement
+copy. If you received it electronically, such person may
+choose to alternatively give you a second opportunity to
+receive it electronically.
+
+THIS EBOOK IS OTHERWISE PROVIDED TO YOU "AS-IS". NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, ARE MADE TO YOU AS
+TO THE EBOOK OR ANY MEDIUM IT MAY BE ON, INCLUDING BUT NOT
+LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A
+PARTICULAR PURPOSE.
+
+Some states do not allow disclaimers of implied warranties or
+the exclusion or limitation of consequential damages, so the
+above disclaimers and exclusions may not apply to you, and you
+may have other legal rights.
+
+INDEMNITY
+You will indemnify and hold Michael Hart, the Foundation,
+and its trustees and agents, and any volunteers associated
+with the production and distribution of Project Gutenberg-tm
+texts harmless, from all liability, cost and expense, including
+legal fees, that arise directly or indirectly from any of the
+following that you do or cause:  [1] distribution of this eBook,
+[2] alteration, modification, or addition to the eBook,
+or [3] any Defect.
+
+DISTRIBUTION UNDER "PROJECT GUTENBERG-tm"
+You may distribute copies of this eBook electronically, or by
+disk, book or any other medium if you either delete this
+"Small Print!" and all other references to Project Gutenberg,
+or:
+
+[1]  Only give exact copies of it.  Among other things, this
+     requires that you do not remove, alter or modify the
+     eBook or this "small print!" statement.  You may however,
+     if you wish, distribute this eBook in machine readable
+     binary, compressed, mark-up, or proprietary form,
+     including any form resulting from conversion by word
+     processing or hypertext software, but only so long as
+     *EITHER*:
+
+     [*]  The eBook, when displayed, is clearly readable, and
+          does *not* contain characters other than those
+          intended by the author of the work, although tilde
+          (~), asterisk (*) and underline (_) characters may
+          be used to convey punctuation intended by the
+          author, and additional characters may be used to
+          indicate hypertext links; OR
+
+     [*]  The eBook may be readily converted by the reader at
+          no expense into plain ASCII, EBCDIC or equivalent
+          form by the program that displays the eBook (as is
+          the case, for instance, with most word processors);
+          OR
+
+     [*]  You provide, or agree to also provide on request at
+          no additional cost, fee or expense, a copy of the
+          eBook in its original plain ASCII form (or in EBCDIC
+          or other equivalent proprietary form).
+
+[2]  Honor the eBook refund and replacement provisions of this
+     "Small Print!" statement.
+
+[3]  Pay a trademark license fee to the Foundation of 20% of the
+     gross profits you derive calculated using the method you
+     already use to calculate your applicable taxes.  If you
+     don't derive profits, no royalty is due.  Royalties are
+     payable to "Project Gutenberg Literary Archive Foundation"
+     the 60 days following each date you prepare (or were
+     legally required to prepare) your annual (or equivalent
+     periodic) tax return.  Please contact us beforehand to
+     let us know your plans and to work out the details.
+
+WHAT IF YOU *WANT* TO SEND MONEY EVEN IF YOU DON'T HAVE TO?
+Project Gutenberg is dedicated to increasing the number of
+public domain and licensed works that can be freely distributed
+in machine readable form.
+
+The Project gratefully accepts contributions of money, time,
+public domain materials, or royalty free copyright licenses.
+Money should be paid to the:
+"Project Gutenberg Literary Archive Foundation."
+
+If you are interested in contributing scanning equipment or
+software or other items, please contact Michael Hart at:
+hart@pobox.com
+
+[Portions of this eBook's header and trailer may be reprinted only
+when distributed free of all fees.  Copyright (C) 2001, 2002 by
+Michael S. Hart.  Project Gutenberg is a TradeMark and may not be
+used in any sales of Project Gutenberg eBooks or other materials be
+they hardware or software or any other related product without
+express permission.]
+
+*END THE SMALL PRINT! FOR PUBLIC DOMAIN EBOOKS*Ver.02/11/02*END*
+