The prospective mother; a handbook for women during pregnancy

Glass
Book

COPYRIGHT DEPOSIT

THE PROSPECTIVE
MOTHER

A HANDBOOK FOR WOMEN
DURING PREGNANCY

BY

J. MORRIS SLEMONS

ASSOCIATE PROFESSOR OF OBSTETRICS,
THE JOHNS HOPKINS UNIVERSITY.

SECOND EDITION

NEW YORK AND LONDON
D. APPLETON AND COMPANY

1921

Copyright, 1912, 1921, by
D. APPLETON AND COMPANY

JUN -8 1921

Printed in the United States of America

©CU617249

PREFACE JO THE SECOND EDITION

The revision of this handbook is prompted by the no-
table progress in the sound practice of obstetrics dur-
ing the last decade. The value of systematic blood-
pressure determinations for safeguarding the health
of prospective mothers has become firmly estab-
lished. The ductless glands, with a role still mysterious
in many ways, are known to influence the course of
pregnancy; they must have a place to make the story
more complete. Improvements in the regulation of
the infant's feedings also deserve the attention of every
mother. On the other hand, the laity should know
that certain innovations of promise have not stood the
test of a fair trial: in this category belong a method
of blood examination devised for the diagnosis of preg-
nancy and also a form of treatment at the time of
birth called "twilight sleep."

The advance of practical obstetrics received a great
impetus from the activity of the Children's Bureau of
the Federal Government ; and, recently, interest in the
problems of mothers and infants was intensified by
the effects of the war. That the public has been
aroused to the need for better obstetrical practice is
more gratifying to no one than to the conscientious
physician; but, familiar with the wide gaps in our

vi PREFACE

knowledge of the reproductive process, he also appre-
ciates the need for advance in the scientific aspects of
the subject.

Many, many basic truths regarding the structure,
the function and the derangement of the female gen-
erative organs remain obscure. In this field discov-
eries are forever a boon to womankind. Progress
along these lines requires the establishment of special
clinics devoted to the treatment and the study of ob-
stetrical complications and gynecological diseases.
Women's Clinics, as they are called, await develop-
ment in this country. Since they contribute to the
welfare of the infant as well as of the mother, the
establishment of such clinics aims at the betterment
of the race itself. Certainly no finer opportunity
offers for the wise use of wealth.

PREFACE TO THE FIRST EDITION

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. Di-
rections for safeguarding their health have been given
in detail, and emphasis has been placed upon such
measures as may serve to prevent serious complica-
tions. Treatment of such conditions has not been dis-
cussed, 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 med-
ical supervision throughout pregnancy.

At present intelligent women demand some knowl-
edge of the anatomical and physiological changes inci-
dent to the development of the embryo and the birth
of the child. These subjects do not readily lend them-
selves to popular description, but I have told the story
as simply as possible, following in a general way the

vn

viii PREFACE

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 un-
avoidable, 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 op-
portunity to acknowledge the cheerfully given assist-
ance 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 assist-
ance. To many others — doctors, nurses, and patients
• — I am indebted for numerous suggestions which have
been made either consciously or unconsciously.

J. Morris Slemons.

Johns Hopkins University.

CONTENTS

CH&PTER PAG8

I. The Signs of Pregnancy and the Date of

Confinement I

II. The Development of the Ovum ... 22

III. The Embryo .47

IV. The Food Requirements During Pregnancy *j2
V. The Care of the Body 99

VI. General Hygienic Measures .... 123

VII. The Ailments of Pregnancy . . . . 144

VIII. Miscarriage 168

IX. The Preparations for Confinement . . 195

X. The Birth of the Child . 236

XL The Lying-in Period 275

XII. The Nursing Mother . . . . 301

Glossary 327

Index . . . 335

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 Ductless
Glands — 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 an-
swered ; but a false conventionality has — until recently,
at least — forbidden any open discussion of facts con-
nected 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 con-
sulted technical medical works which they could not
understand. Either of these methods is very likely

2 THE PROSPECTIVE MOTHER

to result in misinformation and to cause unnecessary
anxiety. Yet no one need be alarmed by a plain, ac-
curate 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 com-
paratively slight, as we should expect, since the prop-
erty 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, de-
pends upon the Reproductive Process. And yet, nat-
ural as it is, pregnancy may be attended by complica-
tions. 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 an-
noyances during pregnancy and also assists materially
toward conducting a birth to a safe conclusion. More-
over, if this advice is followed, when complications do

THE SIGNS OF PREGNANCY 3

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 symp-
toms which are implicitly trusted by the laity as mani-
festations 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 posi-
tive. The doubtful evidence appears first and the in-
fallible proof last. No one need be surprised, there-
fore, if, when her suspicion is first aroused, she is un-
able 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 examina-
tion before they commit themselves to a definite opin-
2

4 THE PROSPECTIVE MOTHER

ion ; 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 trust-
worthy manifestation of pregnancy is the motion of
the fetus. The perception by the mother of these
movements, which is spoken of as "quickening/* gen-
erally 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 percepti-
ble; 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 doubt-
ful case, the motion should be observed by a physician
before being accounted a positive sign of pregnancy.
This precaution will scarcely delay an absolutely posi-

THE SIGNS OF PREGNANCY 5

tive diagnosis, since the proper method of examina-
tion reveals these movements to the physician almost
as early as the patient feels them.

About the time these movements become percepti-
ble 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 ^vill 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 re-
assure his patient if she fails temporarily to feel the
child move. Sometimes the presence of twins is rec-
ognized in this way. Toward the end of pregnancy
the heart sounds are also of material assistance in de-
termining what position the child has permanently as-
sumed.

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 out-
line the child through the mother's abdominal wall.
Although this procedure adds little or nothing to our
resources for making an early diagnosis, the informa-

6 THE PROSPECTIVE MOTHER

tion it ultimately affords proves one of the greatest
aids in the practice of obstetrics.

The Probable Signs.— Phenomena for which the child
is responsible supply the most trustworthy evidence
of pregnancy; and these phenomena alone are
accepted as positive signs. But there are earlier mani-
festations which intimate very strongly that concep-
tion has taken place. Shortly after pregnancy has
become established changes begin in the uterus, 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, the supply of blood is increased to
all the organs concerned with the reproductive process.

Partly because of this congestion and partly because
of embryonic development, the uterus becomes altered
in a number of ways. Although these changes occur
regularly in pregnancy, they may 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 some-
what too frequently. With a little patience, however,
he excludes the chance of being misled; a second ex-
amination, approximately four weeks after the first,
will generally place the existence of pregnancy be-
yond question, for under normal conditions the de-
gree of enlargement which takes place in a pregnant
womb during a given interval is absolutely charac-
teristic. It is generally supposed that some character-
istic change occurs in the blood during pregnancy, but
thus far none has been demonstrated.

THE SIGNS OF PREGNANCY 7

The Presumptive Signs.— Although women are most
often led to suspect that they are pregnant by symp-
toms 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 subsquent developments rarely fail to con-
firm the suspicion. Perhaps they prove misleading
once or twice in a hundred cases; the number of mis-
takes 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 at-
tention, and, as a rule, when this happens to healthy
women during the child-bearing period — which usu-
ally extends from the fifteenth to the forty-fifth year
• — it may be taken to indicate that conception has oc-
curred. But there are exceptions to this very good
rule. Besides pregnancy we are acquainted with sev-
eral 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 tlie
entire menstrual process, is, in fact, indicative di

8 THE PROSPECTIVE MOTHER

only one of its stages; the others give rise to no
symptoms whatever. What the stages in the men-
strual 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 main-
tenance 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 ex-
isted before the preparations were begun. The con-
gestion 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 in-
itiated, or, as we say, another Menstrual Cycle is
begun. Each cycle lasts twenty-eight days, and in-
cludes four stages, namely, a, stage of preparation, of
bleeding, of restoration, and of rest.

Although pregnancy may become established at any
I time during the interval between the periods of bleed-

THE SIGNS OF PREGNANCY 9

ing, 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 em-
bryo are followed by much more elaborate arrange-
ments 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 appre-
ciate the fact that diseases of the womb may interfere
with the menstrual process. Menstruation is influ-
enced, also, by the ovaries. As a result of age, for
example, the ovaries undergo changes which invaria-
bly bring about the permanent cessation of menstrua-
tion, called the menopause. This event occurs prema-
turely if both the ovaries are removed by operation.
In view of these facts it is not surprising that some-
times ovarian disorders abolish menstruation. An im-
poverished 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

/

/

io THE PROSPECTIVE MOTHER

is about the doubtful cases, naturally, that a profes*
sional opinion is sought, and on that account phy-
sicians are perhaps inclined to overestimate the diffi-
culty 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 re-
garded 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 ordi-
narily be expected, there is unusual opportunity for
confusing the symptoms. At all events women eir
much more frequently in suspecting that they are
pregnant than in overlooking the condition. Indeed,
pregnancy is not likely to be overlooked unless men-
struation 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 sup-
pressed and who are, moreover, deprived of certain
evidence that the breasts give, pregnancy may some-
times 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

THE SIGNS OF PREGNANCY ir

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 accom-
panied by definite, visible changes, they have no value
as signs of pregnancy.

About the end of the second month the nipples be-
come 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 com-
plexion of the individual, growing darker in bru-
nettes than in blondes. Ultimately, within this pig-
mented circle a number of elevated spots appear about
the size of a large shot. These spots betray the pres-
ence of tiny glands always located there which, on ac-
count of the better state of nutrition during preg-
nacy, 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 co-

12 THE PROSPECTIVE MOTHER

lostrttm has been noted in association with various
other conditions. Furthermore, as a sign of preg-
nancy 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 in-
fant 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" usual-
ly 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 nau-
sea 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 morn-
ing 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;

THE SIGNS OF PREGNANCY ij

at least no change is revealed by any method of analy-
sis known at present Some patients have difficulty in
urination, and a few experience discomfort with it
All the bladder symptoms usually disappear about the
fourth month, but become prominent again toward
the end of pregnancy.

The inclination to empty the bladder more often
than usual may be due merely to nervousness, and
therefore cannot be regarded as a trustworthy sign.
While in no way connected with the kidneys, 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 dis-
tended with urine.

The Ductless Glands. — Our bodies contain a num-
ber of small organs architecturally like glands, but
because they are not supplied with the channels or
ducts through which glands ordinarily empty them-
selves, anatomists hesitated to classify them. Ulti-
mately, however, they learned that the secretion is
absorbed directly by the blood. The fact that the
products of these glands enter the circulation correctly
indicates their important character; they profoundly
influence the way in which all our organs work.

One of the functions of the ovaries places them in
this group of glands. Every month there appears in
one ovary or the other a slowly growing, spherical
structure which at the height of its development at-
tains a diameter of about a half-inch and after having
served its purpose gradually disappears. The corpus

14 THE PROSPECTIVE MOTHER

luteum, as this is called on account of its faint yellow
color, plays a fundamental part in providing the
requisite stimulus for those changes which occur in
the uterus during menstruation. And its activity dur-
ing pregnancy is even more essential; when concep-
tion takes place the structure grows to more than
twice its usual size.

Other ductless glands include the adrenals, located
near the kidneys, the pituitary body at the base of the
brain, and the thyroid with the para-thyroids at the
front of the neck. Almost certainly while pregnancy
exists these glands perform more than their usual task
and they increase in size, though, on account of their
location, the enlargement is imperceptible except in the
case of the thyroid gland, which not infrequently
causes a slight f uHness of the neck that continues until
the end of pregnancy and then subsides.

It must be said that our knowledge of the influence
of these glands upon the course of pregnancy is
meager indeed. A few established facts, however,
plainly point toward an intimate relationship between
the ductless glands on the one hand, and the repro-
ductive organs on the other. The pituitary body, for
example, contains a substance acting powerfully upon
the uterine muscle. Without multiplying illustrations
it is perhaps sufficient to express the conviction that
with a broader knowledge of the ductless glands
physicians will acquire the means to reach a positive
diagnosis of pregnancy at an earlier period than is
now possible.

Although the presumptive signs which we have

THE DATE OF CONFINEMENT 15

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 cau-
tiously; 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 sus-
pect 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,
sAt^tSxjntarly certain that she is pregnant; whether
^morning sickness and the desire to pass thr& urine fre-
quently are present is of no importance. But the
most characteristic evidence, we must remember, is
nut available until the eighteenth or twentieth week;
then the signs of pregnancy are unmistakable.

TEe 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.

The period of gestation for each variety of mam-

16 THE PROSPECTIVE MOTHER

mal is determined by the time required for embry-
onic development to reach the point where the young
may live independently of the mother. This point
is reached more quickly with small animals. 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 is merely
an estimate calculated from hundreds of cases in
which there was no question as to the underlying
facts. Individual cases vary notably ; two women may
become pregnant on the same day and yet not nec-
essarily be delivered at the same date.

Irregularities in the duration of pregnancy are not
limited to man. Thus, while the mean period of ges-
tation 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. For instance, 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

THE DATE OF CONFINEMENT 17

man than in the lower animals ; but thirty-nine weeks
are now 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 pos-
sess 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 cal-
culation 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

18 THE PROSPECTIVE MOTHER

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 nor-
mal in every way. Whenever patients pass their ex-
pected 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 anx-
iety. 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

THE DATE OF CONFINEMENT 19

by counting back thirteen weeks from the day of con-
ception; but this method is subject to error, for the
duration of pregnancy reckoned in this 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 confine-
ment is based upon the assumption that fetal move-
ments are first perceived by the mother toward the
eighteenth week of pregnancy; and in consequence
twenty-two weeks generally elapse between quicken-
ing and the day of delivery. Although such a calcu-
lation is far from accurate, there are instances in which
no other can be made. A nursing mother, for ex-
ample, may become pregnant before menstruation has
been reestablished. Under these circumstances, the
date of confinement cannot be estimated in the ordin-
ary way, and it is then especially important to know
the first day on which the fetal movements were felt.
Futhermore, it is helpful to note this date in every
case, since it serves 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 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, it rises into the abdominal cavity. At

3D THE PROSPECTIVE MOTHER

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 noticeable change in the figure, 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 preg-
nancy 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 quick-
ening. Generally they confirm the prediction made
from the menstrual history, and only occasionally
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 calcu-
lation 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

THE DATE OF CONFINEMENT 2I

slightly with each pregnancy up to the ninth and de-
creases after that. Pregnancy is protracted more fre-
quently 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 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 habit-
ually shorter than the accepted average. Until ex-
perience 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, once in
several hundred cases pregnancy may be fairly called
prolonged. Even in these rare instances an examina-
tion 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 de-
velopment, 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 con-
clusions ; 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

22

DEVELOPMENT OF THE OVUM 23

of the mechanism of development I would not urge
another point of view, for not ignorance but the un-
challenged 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 in-
struction concerning the reproductive function of
human beings.

A description of development, in order to be per-
fectly clear, must begin with a word about the funda-
mental 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 ac-
cording to the use for which the tissue that they
chance to compose may be designed ; they have, more-
over, distinctive individual peculiarities which can be
easily recognized under the microscope; but the es-
sential 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, separ-
ated from its neighbors by a partition, the cell-mem-
brane; each has its own seat of government, the nu-
cleus, located near its center; and each, to all intents
and purposes, leads an individual existence.

24 THE PROSPECTIVE MOTHER

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 repre-
sents 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 devel-
oping 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 va-
riety, represented by the Spermatozoon and developed
only in the male sex, is also required for the produc-
tion 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 to-
gether 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 men-
strual 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 bear-
ing 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

DEVELOPMENT OF THE OVUM 25

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 preg-
nancy, 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 micro-
scope it appears as a little round bag made of a trans-
parent 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 cor-

26 THE PROSPECTIVE MOTHER

responds to the ovary where it originated. The jour-
ney 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 spermato-
zoon.

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 with-
out danger to its life, Nature has provided that ex-
ceedingly large numbers of the male cells shall be de-
posited in the vagina at the time of the marital rela-
tion. In this way, it is made sure that some of them
will travel up through the uterus and oviducts, ar-
riving 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-

DEVELOPMENT OF THE OVUM 27

filings. While there has been no opportunity to ob-
serve such attraction between the parent cells of hu-
man being's, its existence is not open to doubt. And
it is practically certain that these cells meet in the ovi-
duct, 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 acknowl-
edge that both these ideas were incorrect. The ani-
mation of the ovum at the moment of conception
marks the beginning of growth and development

28 THE PROSPECTIVE MOTHER

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 nu-
cleus of the ovum and the nucleus alone transmits ma-
ternal qualities. The material which conveys inherit-
able 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 develop-
ment, it requires nothing further from the father, and
nothing save nourishment from the mother.

The First Steps in Development. — Although the iden-
tity of the spermatozoon is lost at the moment of fer-
tilization, 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 di-
vide, yielding four cells which grow and divide into
eight. In this manner division follows division until

DEVELOPMENT OF THE OVUM 29

a multitude of cells have sprung into existence, all of
which cling* together in the shape of a ball. Develop-
ment always proceeds in the same orderly way; evi-
dently 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. Al-
though the element of time is uncertain the method
of transmission is well understood. Of its own ac-
cord 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 develop-
ment is going on all the time. It is thus made per-
fectly clear that development is not directed by the
parent. This independence of the parent, though it

30 THE PROSPECTIVE MOTHER

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 an-
chor 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

DEVELOPMENT OF THE OVUM 31

find it a small, distended sac, from the inner sur-
face 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 inclos-
ing sac will make possible the continued existence
and growth of the embryo by securing and convey-
ing 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 em-
bryo.

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 ac-
count 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 outer-
most 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. Con-
sequently, while there is still relatively little develop-
ment 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

32 THE PROSPECTIVE MOTHER

result that the surface of the ovum speedily loses its
smooth, regular outline. Projections from the cap-
sule 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 chest-
nut-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 with-
standing whatever tendency the activity of daily life
may have to loosen it. The other, and equally import-
ant, 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 iria-

DEVELOPMENT OF THE OVUM 33

ternal tissues assume the responsibility placed upon
them.

The Eeaction of the TTterns. — 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 Pel-
vis. The upper and larger part of the organ, known
as the body, lies at the bottom of the abdominal cav-
ity ; 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 va-
gina 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 altera-
tions 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 multi-
plied 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 mem-
brane periodically prepares for the reception of an
ovum. And if the expected ovum has been fertilized,
its arrival is followed by arrangements for its pro-

34 THE PROSPECTIVE MOTHER

tection 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 cer-
tain 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 develop-
ment.

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. Insignifi-
cant as it is at first, however, the region of implanta-
tion 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

DEVELOPMENT OF THE OVUM 35

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 vari-
ous 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 altera-
tions are wrought both in the womb and in the cap-
sule 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 re-
moved step by step farther from its source of nourish-
ment, 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 re-
sult 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

36 THE PROSPECTIVE MOTHER

about the twentieth week meets the opposite side of
the cavity, to which it becomes adherent. Subse-
quently, 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 lat-
ter part of pregnancy is due in a measure to the luxur-
iant 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 yel-
low amniotic fluid is itself clear, but small particles
of dead skin and other material cast off from the sur-
face 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 evi-
dence thus far adduced, though not absolutely con-
clusive, gives good reason to believe that "the waters"
are secreted by the inner side of the sac which in-
closes the fetus. Very early in pregnancy this sac
becomes a double-walled structure; and, though its
layers are intimately blended, and together measure

DEVELOPMENT OF THE OVUM 37

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 re-
taining the fluid within set bounds.

The amniotic fluid performs many important du*
ties. 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 in-
juries 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 im-
pact. 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 th«

38 THE PROSPECTIVE MOTHER

mouth of the womb, which remains closed until the be-
ginning of the process that terminates with birth.
The uterine contractions at the onset of labor com-
press 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 cav-
ity 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 scien-
tists as well as the laity, and not until comparatively
recent times have its origin, structure, and use been
satisfactorily explained. Its meaning profoundly in-
terested primitive men and stimulated their imagina-
tion 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

Development of the ovum 39

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

40 THE PROSPECTIVE MOTHER

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 devel-
oped portion of the chorionic membrane, which be-
came specialized simply because it happened to receive
the best supply of blood. At the time of birth the pla-
centa 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 sur-
face 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 car-
ried on by the placenta has been gained chiefly
through the microscope. The oldest medical writ-
ings, 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

DEVELOPMENT OF THE OVUM 41

of the blood was described by William Harvey in
1628. After this epoch-making revelation, it was ac-
cepted as true that the mother's blood entered the un-
born 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 after-
wards; 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 pro-
jected 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 fin-
gers. 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

42 THE PROSPECTIVE MOTHER

water changes constantly. In terms of this illustra-
tion, 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. Simi-
larly, 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 every-
thing the child needs, but it also takes away the waste
products of fetal life. Let us select one of the food-
stuffs 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,

DEVELOPMENT OF THE OVUM 43

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 circula-
tion. 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 pro-
tection, because the coating of the villi is not permea-
ble 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 circula-
tion. The most significant result of this restriction is,
perhaps, that so long as the coating of the villi re-
mains intact and healthful, bacteria cannot gain ac-
cess 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 ad-
mitted; 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.

44 THE PROSPECTIVE MOTHER

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, fa-
miliarly 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 con-
tains three blood-vessels, all filled with fetal blood;
in two of them the current is directed toward the pla-
centa, 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 in-
jury.

So far as is known, the umbilical cord performs no
service other than to link the blood-vessels in the pla-
centa 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 sub-
stance which surrounds the vessels are safeguards
which effectually protect the circulation from pressure
that might interrupt it.

Frequently, prospective mothers are told they must

DEVELOPMENT OF THE OVUM 45

not "reach up" for fear the cord will become entan-
gled. Such a precaution is quite unnecessary. No mat-
ter 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 al-
ways 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 em-
bryo 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

46 THE PROSPECTIVE MOTHER

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 re-
gained 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 — Hered-
ity— 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, start-
ling 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 im-
portance, to be sure, and to most persons they are less
interesting than the embryo, yet we gave them con-
sideration before discussing its growth because the
manner in which the ovum becomes attached to the
womb and draws nutriment from the mother primar-
ily determines the fate of a pregnancy.

47

48 THE PROSPECTIVE MOTHER

Now that we have become familiar with the ar-
rangements 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 tech-
nical sense, however, the use of the term embryo is
limited to the first six weeks of pregnancy and desig-
nates 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 vari-
ous groups of cells and the bestowal upon them of
different kinds of activity. During this period com-
paratively 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 con-
sisted altogether in growth. According to that view
the embryo lay curled up in the Qgg; 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 in-
fant, 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.

THE EMBRYO 49

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 fer-
tilized, and becomes, as was explained in the preced-
ing 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 rela-
tive 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 al-
ready 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 col-
lected, but it is impossible to give here, even
in outline, a description of the evolution of the
human embryo. No one can understand this intri-
cate 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

50 THE PROSPECTIVE MOTHER

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 sug-
gested; 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 in-
correct. 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 ac-
counts 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 difficult

THE EMBRYO 51

ties have prevented similar investigations in higher
animals. For this reason, it is not without the great-
est 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 in-
stant 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 an-
swered with equal assurance. More than five hun-
dred theories have been offered to explain the rela-
tion 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 de-
serves mention merely because the laity still believe it.
Happily, during the last few years, observations and
experiments have been made which greatly ad-
vance 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

52 THE PROSPECTIVE MOTHER

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, more-
over, the mode of their production is such as to place
absolutely beyond human control the possibility of
changing this ratio. Since only one spermatozoon en-
ters the ovum, whether or not the child will be a boy
or a girl depends entirely upon which type gains en-
trance. If this explanation is correct, and it is in ac-
cord 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 i» 1835,
was .64 per cent, in favor of boys.

THE EMBRYO 53

No inquiry is more often submitted to the physi-
cian 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 mid-
wife possesses her individual formula which she has
"never known to fail." But the boastful success de-
pends 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 con-
fesses, 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 dis-
tinguished 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

54 THE PROSPECTIVE MOTHER

appear in approximately only one of ninety pregnan-
cies, 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 ripen-
ing of two eggs at about the same time and the fer-
tilization 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 sper-
matozoon are here concerned. The incident permit-
ting twins to develop from a solitary ovum must occur
soon after conception has taken place. It will be re-
membered 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 be-
longs.

The Bate of Growth.-- When we recall the definite

THE EMBRYO 55

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 re-
sult 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 determina-
tion. For example, the length of the child is prac-
tically 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 di-
vided by the figure 5 gives the month to which preg-
nancy has advanced. Similarly, we can infer the
period of development from the weight, though the
calculation is more intricate and the method less reli-
able, 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 aver-
age 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, there-
fore, acquires roundly ninety per cent, of its weight
during the second half of pregnancy, which clearly
indicates that Nature reserves this period of gesta-
tion for the fetus to increase in size, a phenomenon

56 THE PROSPECTIVE MOTHER

less mysterious but no less important than the evolu-
tion of the embryo.

Nothing is more valuable than the weight in af-
fording 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 corre-
sponds 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 be-
fore 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 fit-
ting the child for the conditions met with in the ex-
ternal 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 super-
stition regarding the seventh-month child — a convic-
tion endorsed by medical men hundreds of years ago
and as yet not discarded by the laity.

THE EMBRYO 57

When pregnancy has reached "term," the child, hav-
ing 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 remarkab2y 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 as-
sumed 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 heid bent so
that its chin touches its chest; its arms are crossed
just below the head, its legs raised in front of the

58 THE PROSPECTIVE MOTHER

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 nine-
ty-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 heavJ
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 alto-
gether, since at least one organ, the thymus gland, be-
comes smaller and completely disappears during child-
hood, and other organs, especially the liver, are pro-
portionately 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 EMBRYO 59

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 move-
ments 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, tech-
nically 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

6o THE PROSPECTIVE MOTHER

occasions "heart-burn" in the mother during preg-
nancy is without foundation. The color of the hair
at birth does not indicate its ultimate shade; changes
are often noted during infancy. Similarly the per-
manent color of the eyes is not assumed until later;
at the time of birth the eyes are generally, if not al-
ways, 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 start-
ling 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, fur-
ther, their edges are not welded together as in an
adult, but are separated from one another by an ap-
preciable 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

THE EMBRYO 61

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 pur-'
sued 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 some-
times 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 develop-
ment 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,

62 THE PROSPECTIVE MOTHER

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 any-
thing 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 re-
liable 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 can-
not 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 di-
rection explains why the nursery should be kept quiet.

THE EMBRYO 63

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 new-
born babies are said to suck a two per cent, solution
of quinin as eagerly as milk, though stronger solu-
tions 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 taste-
less 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 re-
flexes the most notable are sucking and swallowing,

64 THE PROSPECTIVE MOTHER

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 re-
late 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. Only
recently, however, has our knowledge of heredity
approached that order and system which entitles it to
be ranked as a science ; and its practical application to
human problems as yet has not been extensive.

The modern teachings of heredity are of special in-
terest to us, since they intimate the time when a child's
inheritance is fixed and also 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

THE EMBRYO 65

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 pa-
ternal inheritance. Similarly we might expect the
ovum to be the bearer of the maternal qualities in-
herited 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 technical 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.

66 THE PROSPECTIVE 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 be-
fore a cell divides, the chromatic substance is broken
up and reassembled in the form of rods called chromo-
somes. Curiously enough the number of rods is uni-
form 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 con-
tained 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

THE EMBRYO 67

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 ad-
mirably 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 wre
have indicates that the problem of a child's inheri-
tance 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 unfavor-
able 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 foun-
dation; 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 ex*

68 THE PROSPECTIVE MOTHER

empt 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, ac-
cording to the doctrine of maternal impressions, may
be equally effective in interfering with the proper de-
velopment of the child. We should then rightly ex-
pect 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
often 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 with-
out 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 preg-
nancy was not the first I found some who could re-
member incidents popularly believed to have an in-
fluence 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 in-
cidents had occurred or not. From a similar series of
observations covering two thousand cases, William

THE EMBRYO 69

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 ab-
normally, 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 agree-
ably disappointed in finding their babies perfectly nor-
mal. 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 ab-
normal development to something the mother has seen
or heard, thought or dreamt, or otherwise experi-
enced while she was pregnant. Yet unfortunately
many do believe this. It is worth while, therefore, to
supply further evidence, and thus escape any sus-
picion of unfairness in argument, to prove that ma-
ternal 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 deter-
mined, 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 fol-
low conception, and therefore occur at a time when

70 THE PROSPECTIVE MOTHER

pregnancy is not often clearly recognized. Thus it
happens that women begin to worry about the influ-
ence 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 preg-
nancy. 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 un-
/ heard 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 con-

THE EMBRYO

71

sequence of some irregularity in the process which
molds the body-form from a simple spherical mass of
cells. Why irregularities sometimes occur is not al-
together clear; except in so far as it has been de-
termined 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 amount-
ing 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 indi-
viduals 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

72

FOOD REQUIREMENTS 73

child, the after-birth, the amniotic fluid, and a vary-
ing 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 un-
usual, however, for women to remain perma-
nently better nourished than before they became preg-
nant.

Under ordinary conditions the food of the prospec-
tive mother provides not only for her own wants but
also for those of the embryo. Between the two or-
ganisms there exists a relation wrhich 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, design-
ing the structure and arranging the "organic bricks"
in their proper places. The work of construction ne-
cessitates 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 wTaste products
leave the embryo by way of the umbilical cord and
the placenta and return thus into the mother's cir-
culation; 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

74 THE PROSPECTIVE MOTHER

impossible to study them separately. Our knowledge
of food requirements during pregnancy has been ob-
tained 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 food-
stuffs are usually classified according to their chemical
properties ; on this basis they are placed in five groups :
(i) Water, (2) Mineral Materials, (3) Proteins, (4)
Carbohydrates, (5) Fats.

In view of the different purposes which the food-
stuffs 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 re-
pairing tissue that already exists. The proteins are
unique, in that they may serve either purpose. Pri-
marily the proteins are tissue-builders, but in the ab-

FOOD REQUIREMENTS 75

sence of sufficient fat or carbohydrate the body burns
protein to secure heat and energy.

Each food-stuff, therefore, serves a distinct pur-
pose, 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 ex-
ample, 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, gen-
erally 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 investi-
gations 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 genera-

76 THE PROSPECTIVE MOTHER

tions 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. Al-
though 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 wel-
fare of the body in at least three ways; (i) it gives
rigidity to the bones, (2) it supplies an essential in-
gredient 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 ac-
cording 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

FOOD REQUIREMENTS 77

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 be-
come 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 mag-
nesium, 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 consump-
tion 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

78 THE PROSPECTIVE MOTHER

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 (ioo 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 in-
dividuals, namely, students, athletes and soldiers, half
as much is sufficient. Other physiologists, though ad-
mitting 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 pro-
tein 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 diges-
tive 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 kid-
neys, which are the organs chiefly concerned in get-
ting rid of the waste products of protein.

Carbohydrate is the name given the group of food-
stuffs 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

FOOD REQUIREMENTS 79

Sakkara, and from this our word sugar evidently
originated. The roots of this plant were carried into
Europe and cultivated during the Middle Ages. Ob-
viously, 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 ex-
ample, 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 com-
pounds included in the carbohydrate group ; but every-
one 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 natu-
rally 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 ex-

80 THE PROSPECTIVE MOTHER

tensive study of American families which indicate
that women require four-fifths as much energy-yield-
ing 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 carbo-
hydrates.

Fat yields more energy and heat than does carbo-
hydrate, 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 aver-
age 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 neces-
sary 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, con-
tributes in several ways toward maintaining the tem-
perature 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 con-
tains is not altogether responsible for the fat in our
bodies. Carbohydrates, if in excess of momentary

FOOD REQUIREMENTS 81

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 Pood. — 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 pur-
pose of which is to break up the carbohydrates, pro-
teins, and fats into substances of much simpler chemi-
cal structure, begin in the mouth and are not com-
pleted 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 proc-
esses 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 indiges-
tion. 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 con-
nected with the canal by means of tubes. These
glands must be warned when to pour out their secre-
tion, and their very first warning usually comes from

82 THE PROSPECTIVE MOTHER

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 thor-
oughly 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 thor-
oughly masticating our food, we know intuitively
when we have had enough, and thus avoid over-
eating.

In the stomach the digestion of starch is continued
for a time, but the chief work of gastric digestion con-
cerns 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

FOOD REQUIREMENTS 83

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 diges-
tion 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 suf-
ficiently 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 with-
out 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 in-
testinal 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 num-
ber of ferments, the more important of which are

84 THE PROSPECTIVE MOTHER

supplied in the juice manufactured by the pancreas.
The pancreatic secretion contains three separate and
distinct ferments, which act respectively upon carbo-
hydrate, 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 resi-
due from meat The undigested portions of all the
food-stuffs collect in the lowermost portion of the in-
testine 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 develop-
ment. A similar contrast may be observed in the nu
tritional processes of the mother. Often, at the be-
ginning of pregnancy, the appetite is poor and there

FOOD REQUIREMENTS 85

is indisposition of one kind or another, with the natu-
ral 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 o£
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 over-
eating during pregnancy is much more likely to pro-
voke 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 ma-
ternal functions are inactive. As a result of this

86 THE PROSPECTIVE MOTHER

economy the same allowance of protein which is suf-
ficient before conception is sufficient also during preg-
nancy. 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 di-
minished. 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 si/Jsfactory for the animal is also sufficient
for her during pregnancy. We are forced to con-
clude that protein was used more sparingly in the lat-
ter condition — a view which has been repeatedly
confirmed with regard to human beings as well as ani-
mals. 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 in-
vestigations indicate that the "housekeeping" of the
body during pregnancy proceeds along unusually eco-
nomic lines. It is not advisable, therefore, to make
any change in the diet with regard to these substances.

FOOD REQUIREMENTS 87

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
©f 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 preg-
nancy, and that the excessive requirement is ex-
tremely 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.

88 THE PROSPECTIVE MOTHER

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 ail-
ment 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 inci-
dent 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-indulg-
ence 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 recog-
nized if one eats deliberately, and thoroughly masti-
cates 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 inap-
propriate to pregnancy. On this account most pros-

FOOD REQUIREMENTS 89

pective 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 is beneficial to those not in-
clined to eat enough at regular meals. If small
amounts of food are taken five or six times a day, a
tendency to be nauseated can often be averted. In
the latter months of pregnancy the capacity of the
stomach is diminished through the encroachment of
the enlarged womb, and frequent meals contribute
toward comfort and health. While the inevitable con-
sequences of overloading the stomach are to be
avoided at all times, it is especially important to re-
member the disagreeable results of a hearty meal at
night. The evening meal should be a light one. At
bedtime, especially if there is a disposition toward
morning nausea, it is helpful to take a glass of milk
with crackers or a slice of bread.

The Importance of Liquid Mourisliment.' — Every pros-
pective 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 neces-
sary for the building of new tissue and for safeguard-
ing 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-

90 THE PROSPECTIVE MOTHER

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 con-
sume 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, co-
coa, and chocolate. Against the moderate use of tea
and coffee no valid objection can be raised ; the tradi-
tion 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 any-
one 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.

FOOD REQUIREMENTS §>i

It is true, of course, that careful scientific observa-
tions have taught not only what the nutritional re-
quirements of the body are, but also how the diet may
be arranged to satisfy these requirements most con-
scientiously 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 pro-
vides 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 satisfy-
ing 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 fre-
quently the same person has no appetite to-day for
food that she will eat with relish to-morrow. Pre-
cise 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 char-
acter that it will not throw an undue burden upon the
digestive organs.

During pregnancy some uncooked food should be

92 THE PROSPECTIVE MOTHER

eaten every day. Ripe fruit answers the purpose ad-
mirably. At all seasons of the year fruit of one va-
riety or another, such as apples, peaches, apricots,
pears, oranges, figs, cherries, pineapples, grapes, plums,
strawberries, raspberries, and blackberries may be ob-
tained and should have a place in the diet. In mak-
ing a choice personal taste alone need be consulted.

Fruit contains a large proportion of water as com-
pared with other articles of diet; and, therefore, is
especially capable of quenching thirst. Fruit also les-
sens the desire for sweets, acts as a laxative, and fur-
nishes mineral material which the body needs. Its
laxative effect is most pronounced when it is eaten
alone, as, for example, in the morning before break-
fast 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 recom-
mended indiscriminately during pregnancy, for not
infrequently the dressing used with them causes dis-
comfort. 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 neces-
sary 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

FOOD REQUIREMENTS 93

flour (Graham bread) or from corn meal, because the
coarse undigested residue which they leave stimulates
the movements of the intestine and assists in over-
coming 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, cus-
tard, 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 di-
gested 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 rea-
son parsnips and beans may cause discomfort. The
prejudice, however, which exists against onions, as-
paragus, 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, Brus-
sels 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

94 THE PROSPECTIVE MOTHER

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 ani-
mal food, provided the pregnancy is normal. It is
important, nevertheless, to remember that meat con-
tains 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 ques-
tion 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 preg-
nancy. 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 sup-
plied by a glass of milk or some equally simple nour-
ishment 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.

FOOD REQUIREMENTS 95

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 de-
sire 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 sub-
stances 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 long-
ings 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.

96 THE PROSPECTIVE MOTHER

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, in-
vestigators 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 con-
stant 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 in-
dicated 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 ob-
servations upon animals are applicable to human

FOOD REQUIREMENTS 97

beings. Everyone familiar with the practice of ob-
stetrics knows that women who gratify enormous ap-
petites 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 determin-
ing 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 dis-
crimination 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 imprac-
ticable ; some of them, rigidly carried out, would actu-
ally 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 des-
serts, soup, bread, cereals, vegetables, and water. Such
a diet overlooks, among other things, the tremendous

98 THE PROSPECTIVE MOTHER

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 un-
natural, 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 justifica-
tion 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 her-
self no concern as to what the size of the child is
likely to be. That is a detail which concerns her phy-
sician, 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 every-
day life. Our bodies utilize their fuel more per-
fectly 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 or-
gans, 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

8 99

ioo THE PROSPECTIVE MOTHER

means negligible. So far as we can tell, it is chiefly
on account of their peculiar character that they in-
crease the work of the mother's excretory organs.
Whatever the cause, they do increase it, and ex-
perience 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 ex-
cretory 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 in-
stances 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 gen-
erally becomes more pronounced. No doubt there was
a time when women, perhaps unconsciously, counter-
acted 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 af-
ford 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 ex-
ample, under such conditions, the kidneys, instead of

THE CARE OF THE BODY ioi

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 them-
selves occurs shortly after meal-time, since the in-
voluntary movements of the intestines are most ac-
tive while digestion is in progress. It should be re-
garded 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 note-
worthy 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

102 THE PROSPECTIVE MOTHER

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 neces-
sary, 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. Be-
gin 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 satis-
factorily, but not so with the kidneys. For this pur-
pose 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.

THE CARE OF THE BODY 103

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 inter-
vals 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 precau-
tion against decomposition, add a teaspoonful of chlo-
roform 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 de-
termined as follows: At a convenient time, for ex-
ample at 8 a. m., empty the bladder and throw the
urine away; this marks the beginning of the observa-
tion. 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 col-
lected, should be measured.

It is unnecessary to send all the urine to the phy-
sician; six ounces, somewhat less than half a pint,

I«4 THE PROSPECTIVE MOTHER

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 peo-
ple through incorrect statements about trouble with
the kidneys. For example, they declare that a sedi-
ment 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. A sedi-
ment, 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" does not indicate Bright's dis-
ease. It is due to muscles with which the kidneys
have nothing to do. Similarly a desire to pass the
urine frequently does not indicate disturbances of kid-
ney function, but is explained by the pressure of the
enlarged womb against the bladder.

Besides analysis of the urine the estimation of
the blood pressure provides trustworthy evidence of
renal efficiency. Sometimes an elevation of blood

THE CARE OF THE BODY 105

pressure during pregnancy precedes the usual urinary
signs of renal insufficiency, and since treatment in
these cases is most effective when undertaken early,
the physician values most highly that method afford-
ing the promptest opportunity for corrective meas-
ures. In this way blood pressure observations at ap-
propriate intervals have proved to be one of the great-
est safeguards for the prospective mother.

The Skin. — The functions of the skin are at the very
foundation of health. It protects the delicate struc-
tures which it covers, assists in the regulation of the
temperature of the body, and excretes waste products.
Its excretory function is always active, but we are
unconscious of this activity except on warm days and
when we perspire freely. In cold weather the body
throws off what physiologists call "insensible perspira-
tion." 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 de-
scribe certain alterations in the skin which the pros-
pective mother is likely to misinterpret.

Because of the growth of the uterus the abdominal
wall is stretched. To a certain degree the skin yields
to distention, but finally cracks and pink or blue lines
appear which are called "pregnancy streaks."

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

io§ THE PROSPECTIVE MOTHER

in turn depends upon various factors, such as the size
of the child and the quantity of amniotic fluid. Al-
though 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 preg-
nancy. Stretching of the skin, of course, is not con-
fined 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 dis-
coloration 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 excep-
tions, 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 un-

THE CARE OF THE BODY 107

fortunate, 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 oth-
ers, as we have learned, is required for the develop-
ment 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 sys-
tem; 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 suffi-
cient to demonstrate the importance of the skin as an
excretory organ, surely no one will fail to be im-
pressed 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

io8 THE PROSPECTIVE MOTHER

was covered with gold leaf to provide entertainment
at a Parisian festival. The living statue was not ex-
hibited, 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 circum-
stances 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.

Bathing1.— 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 rea-
son 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 8o° and

•■

THE CARE OF THE BODY 109

900 R 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 depress-
ing. Vapor and steam baths have a similar action and
should never be taken without the consent of a phy-
sician. 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 modi-
fied so that it will not produce a shock, no one need
omit the morning plunge or shower which most per-
sons 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 thor-
ough rub-down assists in bringing the blood to the

no THE PROSPECTIVE MOTHER

surface of the body. Bath and massage together thus
constitute a kind of skin gymnastics especially bene-
ficial 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 con-
trary, 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 convic-
tion that the vagina is not clean and should, there-
fore, 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 noth-
ing to do with the elimination of waste products from
the body. The secretion which issues from the va-
gina 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 nor-
mal conditions, which of course include pregnancy,
disease-producing bacteria are absent from the vagina;

THE CARE OF THE BODY in

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 infec-
tion 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 neces-
sary to cleanliness. Others who have delicate skins
are occasionally annoyed by the irritation of the va-
ginal secretion, which is not only increased during
pregnancy but has a more pronouncedly acid charac-
ter. Under extraordinary circumstances, it may be
permissible to use douches in the early part of preg-
nancy, but it is practically never advisable to do so
during the month preceding the expected date of con-
finement. 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 con-
sists 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 pre-
pared by placing a small tub upon a low stool and
pouring in warm water (about 900 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

112 THE PROSPECTIVE MOTHER

fifteen minutes, and after it the skin should be thor-
oughly 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 cer-
tainly 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 prospec-
tive 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 medi-
cine. 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

THE CARE OF THE BODY 113

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 per-
fectly 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 sum-
mer. 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 prod-
ucts 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 re-
proached because they are not clad warmly enough,
reply that they must wear light clothing to keep from
perspiring. Thus they discount or render absolutely

114 THE PROSPECTIVE MOTHER

ineffective a mast important natural safeguard against
serious complications. It cannot be too strongly em-
phasized that warm clothing helps to maintain health-
ful 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 re-
spects in selecting them personal ta,ste is an excellent
guide. Outfitters carry a variety of maternity gar-
ments; 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 il-
lustrate 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 in-
terfered with. In order to avoid such disagreeable
consequences, and at the same time to limit the extent

THE CARE OF THE BODY 115

of the maternity wardrobe, skirts may be fitted with
practical devices which permit letting out the waist-
band as occasion demands. So far as possible, how-
ever, all the clothing should be hung from the shoul-
ders, 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 conse-
quently the shoes should be roomy, but should always
fit. To escape the discomfort of tight shoes, it is gen-
erally 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 lat-
ter months of pregnancy on account of the enlarge-
ment 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 back-
ache, 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 them-
selves deserve the blame for weak ankles. To prevent
"turning the ankle/' it is not necessary to restrict

Ii6 THE PROSPECTIVE MOTHER

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 pros-
pective 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 mat-
ter has not as yet been settled, it is obvious that cus-
tom 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 fash-
ion, never wear them; they testify that they are health-
ier for doing so. Whether this be true or not, no
one can honestly believe that corsets will soon be ban-
ished; and the practical problem is to distinguish be-
tween those that may do good and those certain to do
harm.

During pregnancy the abdomen tends to fall for-
ward and slightly downward, and though it is in preg-
nancies after the first that this tendency is most
marked, every prospective mother will be more com-
fortable if she wears some sort of support to counter-
act what physicians term a "pendulous abdomen."
Such a condition can be prevented by the use of sev-

I

THE CARE OF THE BODY 117

eral 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 pre-
viously 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 continuous-
ly; and, in the end, this plan proves almost as expen-
sive 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. Nat-
urally 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 be-
comes not only an instrument of torture but a source
of danger both to the mother and to the child. For-
tunately there are very few women who fail to ap-
preciate the risk of thus striving to disguise their con-

n8 THE PROSPECTIVE MOTHER

dition ; 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 ex-
cellent 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 adjust-
ment ; it must never interfere with the activity of any
organ. As enceinte, the French word meaning preg-
nant, signifies, the prospective mother should be un-
bound. 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 sup-
port 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 fab-
ric 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 un-

THE CARE OF THE BODY 119

pleasant 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 ihe 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 uncomfort-
able 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 di-
rections just given for the care of the body, as well
as the rules to follow in the next chapter regarding a

120 THE PROSPECTIVE MOTHER

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 men-
tioned. Finally, the nipples must be toughened and, if
short or flat, they must be drawn out, for the best sup-
ply 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 be-
gun eight weeks before the expected date of confine-
ment ; to start earlier will do no harm, but it is quite
unnecessary. A number of procedures have been ad-
vocated, but in my own experience the following sim-
ple 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 thor-
oughly 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 apply-
ing a dilute solution of alcohol. Formerly brandy,
whiskey, or cologne were recommended, Tbut at pres-
ent the following solution is commonly used. A table-
spoonful 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

THE CARE OF THE BODY 121

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 cre-
ated, as the bottle cooled, drew the nipple out. Simi-
larly, the bowl of a clay pipe was sometimes placed
over the nipple ; the patient sucked the stem, the nip-
ple 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 accommo-
date 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 preg-
nancy uneventfully, will be delivered without difficulty,
and will enter upon what promises to be a rapid con-
valescence when her recovery is interrupted by the

122 THE PROSPECTIVE MOTHER

development of inflammation of the breast. Because
such a complication may be prevented, its appearance
is the more to be regretted. Furthermore, the re-
sponsibility for its prevention usually rests with the
patient herself. If she has been conscientious in pre-
paring 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 — Re-
laxation and Rest — Is Traveling Harmful? — Mental Diver-
sion.

Besides the hygienic measures described in the pre-
ceding 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 im-
portant. These measures, although frequently deter-
mined 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 de-
tails of conduct that most persons would regard as triv-
ial. 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

123

124 THE PROSPECTIVE MOTHER

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 pre-
viously 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 trans-
gression of the laws of health brings its own punish-
ment, 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 fre-
quently 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 attract-
ing attention they often wish to give up outdoor ex-
ercise during the day; they stay away from public
places of amusement, and deny themselves other pleas-
ures 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

GENERAL HYGIENIC MEASURES 125

up her mind to enjoy recreation out of doors regard-
less of comments.

The Need of Pure Air. — Outdoor life has been so ur-
gently 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 "air-
ing" 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 it-
self in summer, when the windows are open, but in
cold weather, when in our anxiety to keep the tem-
perature 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. Al-
though 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

126 THE PROSPECTIVE MOTHER

same condition as we take it in. As chemically com-
bined 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 oxy-
gen to the atmosphere. Obviously, the complemen-
tary 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; other-
wise 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*

GENERAL HYGIENIC MEASURES 127

While it is impossible to keep the air in any room
as pure as the outside atmosphere, perfectly satisfac-
tory 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 build-
ing materials are porous. These natural paths, how-
ever, 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 open-
ing.

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 requi-
sites 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 i;he 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

128 THE PROSPECTIVE MOTHER

heart is strengthened, and consequently all the tissues
receive a rich supply of oxygen. Exercise also pro-
motes 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 mo-
ment 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

GENERAL HYGIENIC MEASURES 129

is reached more quickly toward the end of pregnancy
than at the beginning ; a few patients will find it neces-
sary to stop exercise altogether for a week or two be-
fore 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 in-
crease it by five minutes each day until able to walk
an hour without becoming overtired. It is always ad-
visable 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 ath-
letic 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, per-
haps, is free from these objections. Although golf and
tennis are by no means certain to bring on miscar-

130 THE PROSPECTIVE MOTHER

riage, 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 dan-
ger 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 de-
cided, 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 whole-
some, nevertheless, because it takes the participant
out of doors and provides a change of scene. Cer-
tain details, however, should be carefully observed;
thus, a safe horse, a carriage that rides easily, and
smooth roads should be selected. Similar advice per-
tains 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 treat-
meat. Whenever required, massage should if possible

GENERAL HYGIENIC MEASURES 131

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 mas-
sage" 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, vigor-
ous, 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 dura-
tion 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, mas-
sage 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 walk-
ing inadvisable the use of calisthenics will be help-
ful. These exercises generally consist in breathing
movements and in movements of the extremities, es-
pecially the legs, which bring into play the same ab-
dominal muscles that are used at the time of delivery.
10

i32 THE PROSPECTIVE MOTHER

A detailed description of the exercises is here pur-
posely 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 pros-
pective 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 prospec-
tive 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 house-
hold 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, laun-
dry 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

^

GENERAL HYGIENIC MEASURES 133

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 be-
cause 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 di-
recting them. Such direction, indeed, should, toward
the end of pregnancy, constitute the mother's sole par-
ticipation 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 conse-
quences. 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

134 THE PROSPECTIVE MOTHER

weight is not always serious in itself, but indicates hi
the case of working women who are pregnant the ttx-
istence of a strain that sometimes leads to serious ac-
cidents.

The employment of women during pregnancy and
immediately thereafter is regulated by law in many
countries. For example, the laws of Holland, Bel-
gium, France, 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 Switzer-
land for two weeks before and six weeks after child-
birth. 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,
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 earn-
ing a living, but there are also excellent hygienic rea-
sons against many kinds of employment. For ex-
ample, it should be unlawful to employ them in chem-
ical industries where, owing to their condition, they
are especially liable to be injured by the materials
which they handle. Jacobi states that the worst occu-
pation for pregnant women is working with metals,
in particular lead ; more than half of them suffer mis-
carriage or premature confinement. Furthermore, the
health of the child may be endangered if the prospec-

GENERAL HYGIENIC MEASURES 135

tive 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 re-
quire by law a reduction in the number of their work-
ing 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 ener-
vated, 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 dur-
ing 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 condi-
tions. 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 im-
pulse not to be active, since overexertion then, more
than at other times, is apt to be followed by miscar-
riage. 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

136 THE PROSPECTIVE MOTHER

womb. But again, toward the end of pregnancy the
development of the mother's body necessitates a com-
paratively large amount of rest; patients who continue
to exert themselves may expect to suffer from short-
ness of breath and a number of other annoyances.

In order to save needless steps and to avoid con-
fusion and worry, it is always helpful to map out be-
forehand 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 ad-
visable to undress and go to bed. Even though one
does not fall asleep, an hour or two of complete relaxa-
tion 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 inter-
feres somewhat with breathing. When insomnia is

GENERAL HYGIENIC MEASURES 137

due to the pressure of the womb against neighboring1
parts of the body, it can be partially counteracted by
getting into a comfortable position ; but it is also neces-
sary to have the surroundings as conducive to sleep as
possible. Thus anyone will be much more likely to
rest well \i 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 com-
fortable 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 condi-
tion 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,

138 THE PROSPECTIVE MOTHER

over-eating at the evening meal or later is not an in>
frequent 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 ex-
cept 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 can-
not. 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 fol-
low 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 preg-
nancy. It is a well-known fact that traveling is some-

GENERAL HYGIENIC MEASURES 139

times attended with risk to the prospective mother,
though the danger is exaggerated in the popular es-
timation. 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 ac-
count. 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 jour-
ney she wishes to undertake. Prudent women will
never attempt to decide this question for themselves,
but will always obtain professional advice. The dis-
approval 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 fol-
low 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 in-

140 THE PROSPECTIVE MOTHER

stances 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 con-
sidered. Obviously there will be less danger of mis-
hap from a short trip than from a long one; if pos-
sible, 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, pro-
vided 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 pref-
erence. Long automobile tours are attended with con-
siderable risk of miscarriage and, therefore, are for-
bidden.

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 prob-
ability, 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 temp-
tations to depart from a regular, temperate way of
living have notably increased.

At all events the point has now been reached where

GENERAL HYGIENIC MEASURES 141

the average man or woman knows something of anat-
omy, physiology, and the laws of hygiene. Such
knowledge should be helpful, and generally is, but if
it causes anyone to think incessantly about the work-
ings 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 pro-
nounced in women who are pregnant, and this is read-
ily explained by the reciprocal relations between the
mind and the body. If the prospective mother cor-
rectly 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 unfor-
tunately true, however, that her lack of familiarity
with the facts about pregnancy and her belief in un-
founded traditions frequently lead to the misinterpre-
tation of natural conditions. An anxious frame of
mind also causes real ailments to assume an import-
ance out of all proportion to their actual significance.

Patients who have followed my advice to place them-
selves 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 opin-

142 THE PROSPECTIVE MOTHER

ion 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 reflec-
tions, and to divert their thoughts from themselves to
outside affairs.

Generally it is during the early months of preg-
nancy 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 preg-
nancy. Toward the twentieth week, however, she per-
ceives 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 rela-
tively 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 recrea-
tion is necessary and serves the double purpose of
strengthening mind and body. Public amusements

GENERAL HYGIENIC MEASURES 143

should also be patronized; no prospective mother has
the right to sacrifice herself to pride. Music, the vari-
ous arts, a systematic course of reading, the acquisi-
tion 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; Vari-
cose Veins; Hemorrhoids; Shortness of Breath — Leucor-
rhea — 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 be-
come the source of great annoyance, and later the pres-
sure 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 com-
plications are accidental ; and, though pregnancy con-

144

AILMENTS OF PREGNANCY 145

fers 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 ex-
tent, preventable; and, though they occur rarely, pre-
cautions 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 phy-
sician may often detect their presence still earlier by
alterations in the composition of the urine. For this
reason routine examination of the urine during preg-
nancy is a means of prevention indispensable for safe-
guarding 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 prospec-
tive 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 fre-
quency with which physicians find that ailments may
be corrected by the adoption of hygienic measures in-

146 THE PROSPECTIVE MOTHER

dicates that such ailments are more often due to ig-
norance 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. Gen-
erally 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 ma-
jority of cases, to the early morning, but some pa-
tients are annoyed only after meals, and a few at ir-
regular 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

AILMENTS OF PREGNANCY 147

only physicians. The laity, however, should under-
stand that the treatment of any given case will vary
according to the class to which it belongs, and there-
fore the occurrence of troublesome vomiting should
be promptly reported to the physician.

Most frequently it will be found that there is noth-
ing 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 out-
door 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
ti

148 THE PROSPECTIVE MOTHER

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 ob-
tained, though less uniformly, from eating other food,
such as fruit, oatmeal, or eggs. The benefit secured
from this procedure is explained, perhaps, by the ac-
tivity 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. Fur-
thermore, 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 lei-
surely, 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. Excep-
tionally, 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 re-
tiring the previous night.

Next to morning sickness in point of frequency
comes the disposition to be nauseated about meal time.

AILMENTS OF PREGNANCY 149

Those who vomit after the meal is finished arc fre-
quently 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 over-
loaded before the appetite is appeased; and conse-
quently 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 per-
sistent nausea consists in taking small amounts of food
five or six times during the day. Directions regard-
ing 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 pros-
pective 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 fre-
quently 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 im-
mediately. 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 can-

150 THE PROSPECTIVE MOTHER

not 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 stom-
ach is a fact well substantiated both by physiological
experiment and by medical observation. In all prob-
ability 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 stom-
ach. As this nervous mechanism is possessed by every-
one, it is not called into existence by the advent of
pregnancy. Nevertheless, it seems likely that preg-
nancy renders it more sensitive, and it is certain that
pregnancy establishes new means by which the cen-
ter may be stimulated. This admission does not im-
ply, however, that the prospective mother must sub-
mit to inevitable discomfort, for she can and should
muster the strength to resist it.

Time and again an unhappy frame of mind exag-
gerates or prolongs the vomiting of pregnancy. Thus,
disappointment, anxiety, grief, fright, and other types
of mental uneasiness not only magnify the discom-
fort 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

AILMENTS OF PREGNANCY 151

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 phy-
sician 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 in-
terest 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 con-
sider indigestion as one of the ailments peculiar to
pregnancy, for anyone is liable to suffer from indi-
gestion. 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 cailed 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 in-
fluence its secretion have been the subject of labora-

152 THE PROSPECTIVE MOTHER

tory 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. Conse-
quently, 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 des-
serts, 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 cura-
tive measures then consist in diluting the acid by drink-
ing 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 sen-
sible habit of carrying with them a block of magnesium
carbonate, which they nibble whenever the symptom
appears.

Flatulence. — The distention of stomach and inte*-

AILMENTS OF PREGNANCY 153

tines 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 intes-
tine 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 re-
quired than to overcome the habit of constipation. Oc-
casionally, 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 flatu-
lence is secured only after the administration of intes-
tinal antiseptics. Drugs, however, will be prescribed by
the physician, and will not be employed until the sim-
pler hygienic measures have failed. Similarly, the phy-
sician should decide whether it is advisable for the pa-
tient 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

154 THE PROSPECTIVE MOTHER

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 ob-
served, 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 al-
ready 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 infrequent-
ly 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 influ-
ence as pregnancy may have upon them. If the den-
tist 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

AILMENTS OF PREGNANCY 155

upon the development of the child; and the extrac-
tion of a tooth, it was thought, would surely be fol-
lowed 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 experi-
encing a single untoward symptom. Very naturally
dental work should be restricted during pregnancy to
that which is absolutely necessary, and temporary fill-
ings generally suffice; but whatever is needed should
be done without delay.

Brushing the teeth after meals and removing par-
ticles 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 teacupf ul
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 oc-
casionally. Strain through a piece of muslin into
bottles and keep well corked. One tablespoonful of

156 THE PROSPECTIVE MOTHER

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 al-
ready 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 be-
neath 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 satis-
factorily 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

AILMENTS OF PREGNANCY 157

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 oc-
casionally 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 in-
dented, 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 dur-
ing the night, and from this usually learn that the
proper treatment is rest. When it is absolutely im-
possible to remain in bed long enough for the swelling
to disappear, the next best plan is to accept every op-
portunity, 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

//

158 THE PROSPECTIVE MOTHER

the first pregnancy, and usually the varicosed condi-
tion 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 ex-
plained 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 nor-
mal 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 becom-
ing 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. Subse-
quently she should wear a flannel bandage, snugly
applied, about the leg from the toes to a point some-
what above the knee; the bandage should extend
higher whenever the veins of the thigh also are di-

AILMENTS OF PREGNANCY 159

lated. 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 pro-
tection 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 con-
stipation renders the chance of their appearance much
greater. In a measure, therefore, regular, daily evacu-

160 THE PROSPECTIVE MOTHER

ation 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 re-
cumbent 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 gen-
erally disappear within a few weeks. Whenever a
natural cure is not thus effected, it may become neces-
sary to resort to surgical treatment. Operative pro-
cedures, however, should not be undertaken during
pregnancy, since the condition is likely to reappear be-
fore 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

AILMENTS OF PREGNANCY 161

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 numb-
ness and tingling which prospective mothers not in-
frequently complain of. The presence of these pres-
sure 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 re-
cumbent posture lessens the discomfort, and, if in ad-
dition the hips are elevated, absolute comfort will oc-
casionally be secured. Whether or not the adminis-
tration 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 dis-
comfort.

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

i62 THE PROSPECTIVE MOTHER

breath is ordinarily aggravated by the recumbent pos-
ture, for lying flat on the back increases the compres-
sion 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 shoul-
ders 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 requir-
ing 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 itch-
ing 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

w_— ^—

AILMENTS OF PREGNANCY 163

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 pre-
scribed by the physician.

Itching of the skin over the extremities or over the
whole body, it is clear, cannot be attributed to leucor-
rhea, 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 nor-
mally 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 con-
sists 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
12

164 THE PROSPECTIVE MOTHER

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 satisfac-
tory way. But what laymen, perhaps, do not appre-
ciate 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 pre-
cisely as health requires. Of course, any person may
be the subject of one or another of these nutritional
disorders, but unquestionably such disorders are some-
what more frequent during pregnancy than at other
times. Nor is this difficult to understand, for the nu-
tritional processes of two beings are here linked to-
gether. 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

AILMENTS OF PREGNANCY 165

necessary, however, that she should become acquainted
with the symptoms which give warning that the ex-
cretory 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 intelli-
gent 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 ob-
tained. In clinics where this method has been
adopted the frequency of all kinds of toxemia has
notably diminished, and serious types are not per-
mitted to develop. Similar results should be ob-
tained in private practice when patients place them-
selves under medical supervision at the beginning of

166 THE PROSPECTIVE MOTHER

pregnancy. Under these favorable circumstances
symptoms of autointoxication probably occur not
oftener than once in every hundred pregnancies, but
nine out of ten of these cases, upon being promptly
recognized, yield readily to relatively simple treat-
ment.

The early detection of such complications depends
largely upon the patient herself. As has been em-
phasized— and it cannot be said too frequently — she
should not fail to submit, at appropriate intervals, a
specimen of urine for examination. Blood-pressure
observations, also, should be made by the physician
from time to time. It is by such examinations gener-
ally 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 or the blood-pressure. For that reason, it is
important to notify the physician if any of the follow-
ing symptoms appear:

(i) 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

AILMENTS OF PREGNANCY 167

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 de-
tected, 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 jus-
tifies the trouble taken to secure it*

CHAPTER VIII
MISCARRIAGE

Frequency — Causes and Prevention — Habitual tfiscarriage
— 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 im-
mature 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 oc-
casionally 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 pre-

168

MISCARRIAGE 169

cisely what we should expect, for the period of its
existence there measures the perfection of its develop-
ment ; 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 lat-
ter 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 ana-
tomical 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 some-
times from purely natural causes, and sometimes from
the employment of artificial means. As a rule, per-
sons who are unacquainted with medical terminology
call a birth of the former kind a miscarriage, and
reserve the term abortion for an interruption of preg-
nancy that is deliberately provoked. Physicians, how-
ever, make no such distinction. They use these words,
as I have said, simply to indicate how far develop-
ment has progressed before the termination of preg-
nancy. 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

170 THE PROSPECTIVE MOTHER

strictly medical usage and designate as miscarriage the
spontaneous termination of pregnancy prior to the
twenty-eighth week.

Frequency. — Early interruption of pregnancy is ex-
tremely common. Some sociologists declare that it is
becoming more and more frequent, and see in it a
grave national danger. Reliable European 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 mis-
interpreted as an irregularity of menstruation; and
professional advice will not often be thought neces-
sary. 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 in-
clude 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. During the period
of the Great War the frequency of criminal abor-
tions was said to increase enormously in some of the
stricken countries, and it is doubtful that the re-
sponsible conditions will be quickly improved. In
America, unless the laws can be more rigidly en-
forced, we shall find ourselves facing the same peril.

MISCARRIAGE 171

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 acci-
dent, though not excluded, is greatly diminished.
The statistics 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 ex-
plaining 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 pro-
portion 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 pa-

172 THE PROSPECTIVE MOTHER

tients. 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 re-
sponsible 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 mis-
carriage. Since these are not applicable to all cases,
they should be employed only upon medical ad-
vice.

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 con-
ception, 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

MISCARRIAGE 173

week that the union between the womb and its con-
tents becomes firm.

From what we have learned in Chapter II regard-
ing 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 ab-
dominal 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 at-
tachment prompts experienced women to caution pros-
pective 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 re-
sult 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 dis-
cussed in the chapters dealing with the care of the

174 THE PROSPECTIVE MOTHER

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 house-
hold duties which do not require strong muscular ef-
fort 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 auto-
mobile 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, pro-
vided comfortable accommodations are assured, and
the patient has never had a miscarriage.

A few physicians, even at present, attribute the in-
terruption 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

MISCARRIAGE 175

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 men-
strual date passes, some medicine is resorted to, and
the subsequent phenomenon, regarded as the interrup-
tion of pregnancy, is really no more than normal men-
struation. 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 imperfec-
tion 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

176 THE PROSPECTIVE MOTHER

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 acci*
dents, 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 in-
stances, on the other hand, the accident is unavoid-
able; 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 ex-
isted before conception. It dwindles in size, and grad-
ually 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 po-

MISCARRIAGE 177

sition. On the other hand, if the malposition is not
recognized until months or years later, simple proce-
dures will prove inefficient, and a surgical operation
will become necessary. Were there no other reason
for a careful examination at the end of the ly-
ing-in period, it would be amply justified by the in-
formation 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 infre-
quently 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 be-
come unsuited for anchoring or nourishing an ovum.
In either event, a surgical procedure, known as curet-
tage, 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 in-
tended.

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 de-

178 THE PROSPECTIVE MOTHER

wlopment is imperfect or if it dies, miscarriage usually
occurs very promptly.

We are familiar also with a few maternal condi-
tions which seriously affect the embryo, often se-
riously enough to cause its expulsion, alive or dead.
In this respect, certain constitutional disorders are
preeminent. Bright' s disease and diabetes are preju-
dicial to the development of the embryo ; women suf-
fering from either of them must be watched with great
care. Occasionally, such pregnancies come to a pre-
mature end in spite of every precaution. Various in-
fectious 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 un-
fortunate, 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

MISCARRIAGE 179

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 be-
long 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 de-
livered prematurely on two former occasions, and
who was anxious for a successful issue to her third
pregnancy, wTas 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.
13

180 THE PROSPECTIVE MOTHER

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 pur-
pose 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 dur-
ing that period of pregnancy at which a previous mis-
carriage took place. We know that the event is par-
ticularly 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 suc-
cession, 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 ripen-
ing 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 oppor-
tunity of nursing, another pregnancy may quickly
ensue unless these facts are appreciated.

Those who anticipate the possibility of a prema-
ture interruption of pregnancy should realize that the
marital relation is inadvisable after conception has
taken place. For others, who have no reason to ex-

MISCARRIAGE 181

pect 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 like-
lihood of subsequent conception is doubtful.

Not infrequently the fundamental reason for ha-
bitual 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 ap-
plication are not possible. Nothing short of painstak-
ing 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 meas-
ures are taken promptly, these symptoms may disappear
with no harmful result. Everyone concedes that
bleeding and pain are the chief indications of impend-
ing miscarriage, although an occasional patient, profit-
ing by former experience, may find other signs pro-
phetic in her own case.

Mature women, accustomed to the regular monthly
function of their sex, are prone to treat with indif-
ference a slight discharge of blood occurring during
pregnancy. Indeed, it is widely believed that men-
struation frequently continues after conception. In
point of fact, however, it is very unusual in early
pregnancy, and becomes entirely impossible after the

182 THE PROSPECTIVE MOTHER

fourth month. Accordingly, whenever vaginal bleed-
ing is noticed, some other explanation should be
sought; and the patient who would adopt the wisest
plan should assume that she is threatened with mis-
carriage. 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 acci-
dent. The fate of the fetus will depend upon the area
of placenta, which has been incapacitated. Flooding,
however, always imperils the fetus, and generally war-
rants the inference that so much of the placenta has
been separated as to render further development im-
possible. On the other hand, so long as the hemor-
rhage does not exceed the customary flow at the
monthly periods, the life of the child is rarely en-
dangered; while a chocolate-colored discharge, and
even the loss of small clots, may continue indefinitely
without doing serious harm. Under such circum-
stances, however, the patient should communicate with
her medical adviser, and should save for his inspec-
tion whatever may be expelled.

Pain, the other conspicuous symptom of threatened

MISCARRIAGE 183

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 pre-
ventive measures are instituted at the outset, there is
hope of relieving the discomfort and averting the mis-
carriage; 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 indi-
gestion. 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 im-
minent. 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 miscar-
riage 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.

184 THE PROSPECTIVE MOTHER

The same estimate holds true of other symptoms, in-
cluding diarrhea and a persistent inclination to empty
the bladder. Nor does fever always lead to the ter-
mination of pregnancy. A moderate rise of tempera-
ture is without significance; but high fever, persist-
ing for several days, may result in the death of the
fetus and subsequent miscarriage. Nevertheless, pro-
longed febrile affections, such as typhoid fever, fre-
quently 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 in-
creases, the outlook becomes less favorable, and, as I
have said, miscarriage is inevitable when it amounts
to flooding. Likewise, rupture of the sack contain-
ing the fetus, with escape of the amniotic fluid, indi-
cates 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 at-
tention is necessary to determine whether the uterus
has been emptied completely. This is particularly im-
portant, because the retention of placental tissue af-
fords opportunity for several unpleasant complica-
tions; and neglect in this regard accounts in part for

MISCARRIAGE 185

the belief that miscarriage is certain to leave women
irreparably broken in health.

After-effects. — No one will deny that invalidism fol-
lows 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 mis-
carriage differs from a normal birth in that it is un-
natural, for other reasons are apparent. One of them,
the retention of placental tissue, has just been men-
tioned, 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 success-
fully 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 ma-
ture infant; if they would consent to do so, many ill-
effects would be averted. But physicians frequently
encounter strong opposition to precautionary meas-
ures 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 recog-
nized until after its occurrence.

Invalidism which follows pregnancy and which may
be fairly regarded as chargeable to it depends, in

186 THE PROSPECTIVE MOTHER

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 seri-
ous consequences which narrowly escape a fatal end-
ing, 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 wrho attempt
to perform an abortion upon themselves imperil their
lives. The danger is scarcely less when abortion is in-
duced unlawfully by incompetent operators; for lack
of skill, the need of secrecy, and the desire of haste
all interfere with necessary aseptic technique. Every-
one 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 preg-
nancy, 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 re-

MISCARRIAGE 187

garding 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 in-
tent, 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 inter-
ruption of pregnancy feel they have not assumed an
illegal position so long as they avoid instrumental pro-
cedures. 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

188 THE PROSPECTIVE MOTHER

as to whether all induced abortions were illegal.
Many courts formerly held that quickening was a nec-
essary 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 consti-
tutes 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

MISCARRIAGE 189

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 perpe-
trator alone has been responsible,, and in most States
he remains so, while the woman is regarded as a vic-
tim. 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 instru-
ments 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. Massa-
chusetts 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 mini-
mum 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 prac-
tice. Under these circumstances, the crime never takes
lower rank than manslaughter; and generally it is
murder.

190 THE PROSPECTIVE MOTHER

Evidently we possess sufficiently stringent laws re-
garding 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 evi-
dence 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.*

The knowledge that prohibitory laws exist is suf-
ficient to deter reputable physicians from illegal prac-
tice; whereas known laxity in the enforcement of the
law continually tempts unscrupulous persons to pro-
voke abortion. Among the poorer classes the pro-

* 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 what-
ever; 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 hun-
dred dollars, nor more than one thousand dollars, or by both, in
the discretion of the court."

MISCARRIAGE 191

cedure is undertaken by ignorant women, while per-
sons in more comfortable circumstances avail them-
selves 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 ma-
chinery 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 ac-
quainted with such emergencies, and explicitly per-
mits 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 ap-
propriate surroundings and with every refinement of
surgical technique. These fortunate conditions ma-

192 THE PROSPECTIVE MOTHER

terially alter the outlook; serious consequences of the
operation itself need not be feared. Competent sur-
geons, employing modern methods, may perform hun-
dreds 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 fre-
quency, 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 in-
dependently. Criminal operations, therefore, are not a
conspicuous cause of premature delivery. Occasion-
ally physicians resort to artificial means to end gesta-
tion 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 de-
livery at full term. But it is shorter because the in-

MISCARRIAGE 193

fant is small ; and the subsequent loss of blood is not
so great. The recovery of the mother is never re-
tarded by the fact of earlier delivery, though the con-
ditions which caused it may prevent rapid conva-
lescence.

The outlook for the infant depends upon a great
many factors. Most important among them is the per-
fection of its development, which may be estimated
most satisfactorily from its weight and length. Occa-
sionally children have been reared when they weighed
as little as three pounds, but hope that they will sur-
vive 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 di-
gestive functions, which increase the liability to mal-
nutrition. To overcome the first danger, incubators
have been devised and have become familiar to every-
one through public exhibitions. A basket or box sup-
plied with hot-water bottles answers the same purpose,
and has the advantage of better ventilation. The sec-
ond 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.

194 THE PROSPECTIVE MOTHER

In addition to providing proper food and maintain-
ing an even body-temperature, care must also be taken
to protect these infants from various harmful influ-
ences 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 Pre-
liminary 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 treat-
ment, 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 con-
valescence. Apparently trivial details often safeguard
confinement against serious accident. Indeed, meas-
ures 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 clean-
liness during and after childbirth. This fact fortu-
nately 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 to-
" 195

196 THE PROSPECTIVE MOTHER

day 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 com-
plications develop much more frequently among those
who have not paid attention to the preparations for
confinement.

The surgical dressings and other supplies do not re-
quire 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 can-
not 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 pre-
mature delivery never interferes with engaging the
nurse very early in pregnancy, for that accident re-
leases both patient and nurse from their contract.

Nurses demand that the date be specified upon
which an engagement shall begin, as, unless their cal-

PREPARATIONS FOR CONFINEMENT 197

endar is definitely arranged, they are unable to earn
a livelihood. This leads to a question which is diffi-
cult to answer, for the precise day of delivery is un-
certain; consequently to fix the beginning of the en-
gagement 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 re-
sources, living in a city where, in an emergency, a sub-
stitute can be gotten from the local "Nurses' Direc-
tory/' 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 pre-
fer 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 pa-
tient, 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

198 THE PROSPECTIVE MOTHER

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, custom-
ary 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 con-
dition. Those who can afford to keep a trained nurse
six months or a year are exceptional, but very fortu-
nate.

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 ex-
pected, for every case has its problems and peculiari-
ties. After consultation with her physician each pa-
tient will decide what is particularly advisable for
her. Nevertheless, I would emphasize the import-
ance 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.

PREPARATIONS FOR CONFINEMENT 199,

Desirable Qualities in the Nurse. — It is rarely advis-
able 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 re-
quirements; she must be capable professionally and
also personally agreeable to her patient. Some re-
gard 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 direc-
tion 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 pro-
fessional attainments. If the choice of a nurse be
left to the doctor, the two are sure to work har-
moniously, and the patient will benefit by their co-
operation. Otherwise she may suffer because of;

200 THE PROSPECTIVE MOTHER

their dissensions, for, if the doctor is accustomed to
one procedure and the nurse to another, misunder-
standings may occur, although both methods yield
equally good results. Whenever he does not select
her, she should be asked to confer with him long be-
fore 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 em-
ploy "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 scru-
pulously 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 particu-
larly 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

PREPARATIONS FOR CONFINEMENT 201

her will be put into practice and utilized for many-
months, playing a vital part in the training of the in-
fant. 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 pre-
vious experiences. But even then a good nurse re-
lieves 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 Uurse. — 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 con-
venient to have all the dressings finished by the time

202 THE PROSPECTIVE MOTHER

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 ac-
ceptable 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 objec-
tion 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, al-
though 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 at-
tendance 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 them-
selves, and will find a list of the needful supplies con-
venient.

PREPARATIONS FOR CONFINEMENT 203

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 woodec
back and stiff bristles is preferable.

Two slop Jars or enamel Buckets with Covers.

204 THE PROSPECTIVE MOTHER

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 pre-
ferable.

Two pieces of Rubber-Sheeting are required, one
large enough to cover the mattress of a single bed
(2 x iy2 yds.), the other smaller (ix^ yd.).

Should this be too expensive, the best substitute is
white table oil-cloth.

MEMORANDA

MEMORANDA

«S

-**6 THE PROSPECTIVE MOTHER

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 cot-
ton-batting is therefore employed to give them body,
and they are faced only upon one side with the ab-
sorbent material. Furthermore, the rolls of absorb-
ent 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 pur-
chased.

Surgical gauze, which tradespeople sometimes call
dairy-cloth, is the most suitable material for cover-
ing 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
\vhich 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 un-

PREPARATIONS FOR CONFINEMENT 207

bleached 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 ab-
sorbent cotton must be used in them, and they should
be quilted or tacked at several points to prevent slip-
ping. A rubber pad is ill adapted for use during de-
livery. 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 inexpen-
sive, 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.

208 THE PROSPECTIVE MOTHER

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 leg gins 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 gen-
erally 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

PREPARATIONS FOR CONFINEMENT 209

good results, and it is usually a good plan to allow
the nurse to dress it as she wishes, since the employ-
ment 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 pre-
ferred, 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 ac-
quire everything the baby really needs.

A very sensible plan, in my judgment, is to prepare
what will be wanted during the first two months ; sub-
sequently, articles may be made or bought as they are
needed. Accordingly, the quantity of wearing ap-
parel and the nursery supplies I have suggested per-
tain 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

210 THE PROSPECTIVE MOTHER

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 '. aust be warm without being unduly heavy ;
and another that they should be roomy, permitting
perfect freedom of motion. A third no less impor-
tant principle is simplicity. Adornment of the cloth-
ing 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 Tiannel 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.

_— — ■

PREPARATIONS FOR CONFINEMENT 211

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.

212 THE PROSPECTIVE MOTHER

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 entertain-
ing 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 mid-
dle of the nineteenth century, when signal facts were
pointed out by three men, each working independ-
ently, though all came to similar conclusions. The
evidence they gathered should have left no one doubt-
ful that the disease is contagious, and largely prevent-
able. On the contrary, bitter opposition was encoun-
tered 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

PREPARATIONS FOR CONFINEMENT 213

to patient by physicians and nurses." A violent con-
troversy followed this arraignment, and, consequently,
the preventive measures which Holmes so convinc-
ingly 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 ex-
pressed. "For my part," Holmes said, "I had rather
rescue one mother from being poisoned by her at-
tendant 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 Hun-
garian, Semmelweiss, while he was an assistant in
the large Lying-in Hospital in Vienna. In thorough-
ness, power of conviction, and practical value his work
was masterful. It is no exaggeration to regard his
observations as the rock upon which antiseptic sur-
gery, 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 au-
topsy 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 ignor-
ant of Holmes' views; what had happened before his

214 THE PROSPECTIVE MOTHER

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 in-
sight 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 de-
livery 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 sub-
ject for his graduating thesis. He was unacquainted
with the work either of Holmes or of Semmelweiss,
and approached the problem from still another stand-
point, drawing attention to the much higher death-
rate among women delivered amid unsanitary sur-
roundings. 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 pro-
duced. In 1880, Pasteur obtained bacteria from the
organs which had been infected, and was able to grow

PREPARATIONS FOR CONFINEMENT 215

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 fol-
lowers 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 Semmel-
weiss 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 pre-
vent. 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

216 THE PROSPECTIVE MOTHER

sterilization of the air is rarely necessary and have
dispensed with Lister's elaborate apparatus. Further-
more, 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 ap-
proach or after they have invaded the tissues. Ini-
tial 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 dress-
ings, 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 im-
pressive 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 child-
birth, although it was child-bed fever that called forth
the observations and experiments upon which mod-
ern 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 his-
tory of the past to be adequately impressed with that
danger, for we no longer see the epidemics of child-
bed fever which formerly swept over communities,,
sacrificing ten of every hundred women as they be-

PREPARATIONS FOR CONFINEMENT 217

came 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 precau-
tions 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 pre-
ventive measures as are now practiced in many hospi-
tals 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 pa-
tients 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 infec-
tion 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 causa-
tive 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 se-
cured, though with less convenience, in any kitchen.

218 THE PROSPECTIVE MOTHER

If a prospective motner 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. In-
stallments 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 bot-
tom 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 ex-
posed 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

PREPARATIONS FOR CONFINEMENT 219

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 fre-
quently, 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 un-
satisfactory. 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 steriliz-
ing 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 ex-
pects 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 be-
ginning of labor.

Intelligent answers to these questions are impor-
tant. A patient should request the physician to criti-
cize her plans when he pays the preliminary visit four
to five weeks prior to the expected date of confine-
ment. If she has acted unwisely in any respect, he

220 THE PROSPECTIVE MOTHER

will point it out, and may suggest changes which will
enable her to employ to the best advantage the re-
sources at hand.

The Choice and Arrangement of a Boom. — An o 1 d-
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 ordi-
narily 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, there-
fore, 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. In-
fection usually develops because harmful bacteria come
in contact with the patient. For that reason, an in-
fection is more likely to be communicated by the dress-
ings than by articles about the room, which only be-
come a source of danger when the dirt upon them is
transferred by an attendant.

An acceptable delivery-room may be arranged in

PREPARATIONS FOR CONFINEMENT 221

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 ad-
vantageous not only at the time of birth but through-
out the lying-in period- The furnishing should be
simple and scrupulously clean; indeed, it is improb-
able that one of these good points can be secured with-
out 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, need-
less hangings, and everything that might collect dust
should be temporarily removed. A profusion of pic-
tures 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

222 THE PROSPECTIVE MOTHER

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 sti-crched 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 sit-
uation, and may imperil the convalescence of an ob-
stetrical 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 dis-
qualify an apartment for obstetrical purposes are
diphtheria, pneumonia, pleurisy, erysipelas, scarlet
fever, typhoid fever, tuberculosis of all varieties, and
tevery 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 com-
fortable and free from petty annoyances. A room
which has a southern or eastern exposure proves
grateful for those who must remain indoors; fre-
quently, this will be beyond reach, but a room get-
ting 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

PREPARATIONS FOR CONFINEMENT 223

birth and for the first few days which follow, a pa-
tient 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 bed-
stead 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 handi-
caps 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 oc-
curs during the day, should not be forgotten. The
head of the bed may be placed against the wall, but

224 THE PROSPECTIVE MOTHER

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 us-
ually 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 al-
ways 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

PREPARATIONS FOR CONFINEMENT 225

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 for-
mer 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. More-
over, the benefit of promptly reporting to the physi-
cian 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. Sim-
ilarly a visit from the doctor about four weeks be-
fore the expected date of confinement is indispensable
to skillful management of the delivery; neglect of
this precaution is sometimes responsible for bad re-
sults.

At this visit the physician not only becomes fa-
miliar with the general health of his patient, but he
also notes certain facts which will have a direct bear-
ing upon the course of labor. By means of a few

226 THE PROSPECTIVE MOTHER

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 pa-
tient may wish. Nevertheless, though it may be im-
possible to learn every detail, the available informa-
tion 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 veri-
fied 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 condi-
tions are recognized, they may frequently be corrected
at once ; but should that prove impossible, with fore-
knowledge of the presentation, the physician will be
more competent to conduct the delivery.

PREPARATIONS FOR CONFINEMENT 227

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 experi-
ence 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 pe-
riod, 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 preg-
nancy 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 out-
lined, 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

16

228 THE PROSPECTIVE MOTHER

they appear. Although physicians may not agree in
all these directions, there can be no difference of opin-
ion 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 pro-
mote comfort in every direction; more freedom for
the organs of the chest means compression of the
structures below the womb; consequently, the incli-
nation 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,

PREPARATIONS FOR CONFINEMENT 229

for intestinal colic also causes rhythmical pain. At
first the uterine contractions which occasion the dis-
comfort are weak and appear at long intervals. Grad-
ually 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, pro-
vided 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 appoint-
ments 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 es-
tablished. There is never difficulty in recognizing the
latter; doubt always relates to the preliminary pains,

230 THE PROSPECTIVE MOTHER

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 fre-
quently 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 rup-
tured. Uterine contractions generally follow within
a few hours, though in a few instances they will not
appear for a number of days. Under any circum-
stances the event ought to be promptly reported to
the doctor. Similarly, he should be notified whenever
bleeding from the vagina occurs, since it is impor-
tant 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 compli-
cation. 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 ex-
amining finger or some other foreign body. Accord-
ingly, 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 as-
sist the patient in making the final arrangements for

PREPARATIONS FOR CONFINEMENT 231

delivery. Should the nurse be delayed, the patient
herself may make certain preparations to insure per-
sonal 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 disin-
fection of this area somewhat difficult. It is advis-
able, therefore, to clip the hair as short as possible
and, while bathing the whole body, to scrub the re-
gion im 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 pro-
gresses so rapidly that neither the nurse nor the doc-
tor arrives before the child is born, such preparations
as I have indicated will be sufficient, for more minute
precautions are unnecessary unless an internal ex-
amination 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 trou-
ble in the approaching one ; on the other hand, if any
complication whatever is anticipated, the patient
should certainly enter a hospital. Furthermore, it

232 THE PROSPECTIVE MOTHER

frequently proves advantageous to do so where the
pregnancy is the first, though no complication is ex-
pected and none develops. The average labor with
the first child lasts somewhat longer than with subse-
quent ones, and in consequence there is greater oppor-
tunity 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 handi-
cap. Then again, the cramped apartments, so com-
mon in these days, are poorly adapted to the treat-
ment 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 doc-
tor'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 treat-
ment becomes distinctly economical. Moreover, the
uncertainty of the date of confinement may necessi-
tate paying a nurse for a longer or shorter period be-
fore the birth* Expense at the hospital, on the con-

PREPARATIONS FOR CONFINEMENT 233

trary, 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 re-
ceive in the hospital, for rigid adherence to surgical
cleanliness is exemplified in the hospital as it can be
nowhere else. Infections rarely develop there. For-
merly these accidents were more common in the hos-
pital than in the home, but conditions are now re-
versed and fatalities predominate among those deliv-
ered in private houses. The modern theory of asep-
sis has, to be sure, been widely accepted and is prac-
ticed so far as possible wherever obstetrical patients
are attended, but only in the hospital can the under-
lying principles be applied with complete thorough-
ness 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 infec-
tions occur among those delivered at home for one at
the hospital.

In the event of an emergency during labor, the hos-
pital 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

234 THE PROSPECTIVE MOTHER

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 bed-
room slippers. Clothing for the child will also be
needed since most institutions stipulate that the in-

PREPARATIONS FOR CONFINEMENT 235

fant 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 per-
sonal laundry of both mother and infant is usually
done outside the institution.

Surgical dressings of every description are pro-
vided by the hospital. Those who intend to enter a
hospital, therefore, may disregard the list of articles
necessary for confinement. Similarly, the steriliza-
tion, 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 prog-
ress 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 bod-
ily 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 in-
variably 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 Phoeni-
cians, 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 pro-
cess has failed to have attributed to it a supernatural
significance. A number of these superstitions still
distress women on the eve of motherhood. To cor-

236

BIRTH OF THE CHILD 237

rect 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, perti-
nent to a medical discussion.

In a scientific sense the act of birth may be de-
scribed as a series of muscular contractions which
widen the birth-canal and expel the contents of the
pregnant womb. Since the process requires an ex-
penditure 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 de-
livery 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 or-
gans.

It is natural to ask what purpose is served by the
pain associated with labor; and a moment's reflec-
tion will make it clear that one reason for the dis-
comfort is the warning which it gives of the approach

238 THE PROSPECTIVE MOTHER

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 mam-
mals 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 diffi-
cult. Anyone who observes the lower animals pre-
paring 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 under-
stand the act, science must discover what stimulates
the muscle to contract. Although careful research
has thus far failed to disclose the source and charac-
ter 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

BIRTH OF THE CHILD 239

the patient can neither hasten nor delay the contrac-
tions voluntarily. Strong emotions are believed to
accelerate them at times, and we find a very extraor-
dinary 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, ex-
citement checks the contractions after they have be-
gun. Every obstetrician has heard patients say that
with his arrival the pains died down. Yet such an in-
fluence is never permanent; the contractions soon re-
appear, 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 con-
tractions. The initial factor is more remote and, as
I have said, is not yet well understood.

Since, as everyone admits, delivery occurs witfi
conspicuous regularity about the end of the fortieth
week of pregnancy, and pregnancy corresponds, there-
fore, 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

240 THE PROSPECTIVE MOTHER

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 irrita-
bility of the uterus about the fortieth week of preg-
nancy, microscopical changes in its tissues have been
suggested but sought in vain. Nor will the disten-
tion 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 pos-
sess 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 pre-
viously enabled the fetus to grow now collects in the
maternal circulation, stimulating the womb to con-
tract.

A part of this explanation, namely, that the ma-

BIRTH OF THE CHILD 241

terial 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-prod-
uct.

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 con-
sumes 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 in-
tervals 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

242 THE PROSPECTIVE MOTHER

the physician remains constantly with his patient.
Estimates which include the initial symptoms are
longer, varying from ten to eighteen hours. Pro-
longed 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 calcu-
lated from large groups of cases have no more than
a broad scientific interest; when applied to any in-
dividual 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 sur-
prised 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 as-
certained from time to time by means of suitable ex-
aminations. 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 manage-
ment 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 negli-

BIRTH OF THE CHILD

243

gence because they failed to make numerous vaginal
examinations. Censure of this kind generally is un-
just, 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 precau-
tions whenever vaginal examinations must be made.

Anyone who practices obstetrics in these days ap-
preciates 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 phy-
sicians now employ both these measures, appear ridic-
ulous 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 precau-
tion.

Disinfection of the physician's hands does not en-
tirely exclude the danger of infection through vagi-
nal examinations. Although he may have been most
17

244 THE PROSPECTIVE MOTHER

conscientious, there is some risk of carrying contami-
nating 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 suf-
ficiently 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, al-
though physicians once thought it did and attributed
tedious labors to stubbornness on its part. The error
has been corrected in medical teaching, but many per-
sons 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 in-
fant 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 contrac-
tions 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 con-
tractions inevitably pull its lips wider and wider
apart. Ordinarily another factor is concerned in this

BIRTH OF THE CHILD 245

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. Occasion-
ally, a huge gush will drench the patient's clothing;
but more often what is lost at first amounts to only a
few teaspoon fuls, 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 neces-
sarily, 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

246 THE PROSPECTIVE MOTHER

generally interests herself in some diverting occupa-
tion. The presence of the physician can be of no
assistance then, and patients rarely demand it. Us-
ually, 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 ad-
vice 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 deliv-
ery is not influenced by what the patient may choose
to do, she may follow her own inclinations. The aver-
age 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 bev-

BIRTH OF THE CHILD 247

e rages should never be taken without the specific con-
sent 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 occa-
sionally be told not to partake of any food. This ad-
vice is given, not because the symptom is alarming,
but to save her needless annoyance. Indeed, vomit-
ing frequently indicates that dilatation is well ad-
vanced, and, therefore, may generally be regarded as
an encouraging sign. Ordinarily a persistent inclina-
tion to have the bowels move has the same significance.
On the other hand, a constant desire to empty the
Madder 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 recog-
nize 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 begin-
ning of labor, or a little later, this manifestation,
like all others, may not be implicitly trusted to in-
dicate the end of the first stage. Such uncertainty,

248 THE PROSPECTIVE MOTHER

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 dila-
tation 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 com-
pleted, the uterine contractions continue, devoting their
force to emptying the womb. In this they now receive
assistance from the voluntary contractions of the ab-
dominal 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 chloro-
form, to relieve her of the pain attending the expul-
sion 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 in-
terest for mothers. Sir James Y. Simpson had al-
ways been anxious for some means to prevent the
suffering endured during surgical operations "with-
out interfering with the free and healthy play of the

BIRTH OF THE CHILD 249

natural functions." He, therefore, welcomed the in-
troduction of ether anesthesia from America; and in
January, 1847, at the Edinburgh Medical School, ad-
ministered 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 anaesthetic, and devoted all his spare time to
testing the effect of numerous drugs upon himself.

The introduction of chloroform met with violent
opposition, not upon medical grounds alone, but also
for moral and religious reasons. "To check the sen-
sation of pain in connection with the visitations of
God," zealous theologians announced, "was to con-
travene the decrees of an all-wise Creator." Simpson
reminded them "that the Creator, during the process
of extracting the rib from Adam, must 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.

Nitrous oxide gas has proved a reliable anaesthetic
in obstetrical practice; some physicians regard it as
the most satisfactory anaesthetic of all those now avail-
able. However, its employment probably will be re-
stricted to hospitals, for its administration requires an
apparatus rather cumbersome for transportation and
an assistant specially trained to operate it. The cost
of nitrous oxide, higher than that of ether or chloro-

850 THE PROSPECTIVE MOTHER

form, is likely to be another potent factor opposing the
extensive use of gas as an obstetrical anaesthetic.

"Twilight sleep/' which gained notoriety through
the comments of newspapers and magazines, is a kind
of semiconsciousness induced chiefly by the administra-
tion of a drug called scopolamin. While under the
influence of this narcotic, patients appear to suffer in
the same way as those who do not receive an anaes-
thetic, but fail to remember their experience. The
effect of the drug upon the mother is so pronounced
that the physician must keep close track of her pulse
rate, respirations and mental reactions. Not infre-
quently the effect upon the infant is unfavorable; it
may be deeply asphyxiated, and occasionally resusci-
tation is impossible.

There is still some difference of opinion regard-
ing the best method of anaesthesia 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 organic derange-
ment exists. Under no circumstances should chloro-
form or ether 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, whiffs of an anaesthetic inhaled
with each pain toward the end of the second stage

BIRTH OF THE CHILD 251

will dull sensibility, although consciousness remains
unaffected. When the anaesthetic 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 with-
held; but that is seldom necessary. As the head ad-
vances 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 sec-
ond 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 cus-
tom 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 spe-
cially constructed chairs which are still used in semi-
enlightened countries. With civilized nations at pres-
ent 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 ob-
stetricians, 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

252 THE PROSPECTIVE MOTHER

postures happens to be chosen is a matter of indif-
ference. But it is so much less awkward for the phy-
sician when the patient is on her back that this posi-
tion has been widely adopted in America.

During the expulsion of the child the mother in-
tuitively desires to help herself; generally she cannot
resist straining, and rarely needs encouragement. As-
sisting the uterine contractions with voluntary mus-
cular 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 contrac-
tion 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 in-
clination 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 sensa-
tion, 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

BIRTH OF THE CHILD 253

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 out-
let 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 gen-
erally 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 pas-
sageway. 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 in-
fant is born the umbilical cord extends from its navel
to the placenta, just as it has done throughout preg-
nancy. 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 be-
ginning of civilization it became customary to sever

254 THE PROSPECTIVE MOTHER

the cord with a cutting tool, and the tie thrown round
\ 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 oppor-
tunity to sew up any laceration which may have oc-
curred 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 pre-
vent 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 ulti-
mately 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

BIRTH OF THE CHILD 255

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 mem-
branes, 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 de-
livered 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

256 THE PROSPECTIVE MOTHER

which this mechanism depends are sluggish, the phy-
sician 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 ob-
stetrician once called them "living ligatures." Cer-
tain of these fibers encircle the mouths of the blood-
vessels which have been left open through the detach-
ment 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 ex-
pelled, when they are vigorous enough to cause dis-
comfort 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 Chili— Unless the ex-
perience of countless generations had taught us other-
wise, 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 want-
ing, 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

BIRTH OF THE CHILD 257

fetal skull are malleable, the head is molded as it de-
scends 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 por-
tion 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 in-
terference with the circulation. Just as the swelling
of the finger disappears when the constriction is re-
moved, 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 nourish-
ment 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

258 THE PROSPECTIVE MOTHER

in the skin; in response to the sensation thus pro-
duced breathing is established automatically. When-
ever the temperature stimulus proves insufficient, phy-
sicians 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 altera-
tions in the fetal circulation.

The lungs, since they must from this time on pro-
vide oxygen for the infant, need to receive more blood
than formerly. The vessels leading toward them
must be widely opened, and structures which pre-
viously diverted the blood-stream to the navel must
be closed. The intricate shifting of forces which pro-
duces 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 be-
have in the same way while they are receiving an

BIRTH OF THE CHILD 259

abundance of nourishment through the umbilical cord.
Many hours pass before a newly born infant can pos-
sibly need food. Indeed, it could survive a week or
longer without taking anything, by mouth, except
water. The ability to suckle at birth merely indi-
cates that the infant is prepared to utilize the mechan-
ism 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. Con-
sequently 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 treat-
ment 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 excep-
tionally 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 in-
sist 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 pro-
longed, that it seems appropriate to warn patients to
18

260 THE PROSPECTIVE MOTHER

pay no attention to such advice. In the heat of ex-
citement well-meaning relatives are sometimes in-
clined to interfere, and women who are not members
of the family occasionally wish to discuss their ex-
periences, 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 harm-
ful if they persuade the physician to undertake pro-
cedures which his judgment convinces him are inad-
visable. 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 per-
sons 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 con-
sists 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 satis-
factory conditions prevail, for his judgment will be
less biased if the patient is n<? continuously under his
observation.

BIRTH OF THE CHILD 261

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 re-
ports will be most likely to succeed if they follow the
advice to select a physician at the beginning of preg-
nancy. 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 per-
form, 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

262 THE PROSPECTIVE MOTHER

rigidity of the muscles adjacent to the birth-canal
arrests delivery the physician may employ the obstetri-
cal forceps, which have been in use since the seven-
teenth century.

Although it is widely known that physicians some-
times 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 under-
stood. 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 ob-
stetrical 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 my-
self (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 preju-
dice 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

BIRTH OF THE CHILD 263

trunk in the garret. The box in which they were
concealed contained four pairs of forceps, represent-
ing 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 con-
sideration, and that practice continued until two phi-
lanthropists purchased the secret to make it public.
It was ultimately learned, however, that the sale was
a swindle, for the device which the purchasers ob-
tained consisted of only half the genuine instrument.
The real secret was revealed by a son of Hugh Cham-
berlen, 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 modifica-
tions, remain the most important instrument in the
obstetrician's equipment. There can be no exaggera-
tion 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

264 THE PROSPECTIVE MOTHER

of the child. Signs of danger are extremely uncom-
mon so long as dilatation of the womb is not com-
plete, 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 un-
due 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. Further-
more, even when there are no preexisting complica-
tions forceps are employed on account of exhaustion
or other conditions which may develop during the
course of labor. It must be clearly understood, how-
ever, that the physician alone can determine when
intervention is justified, as well as what operative pro-
cedure 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 be-
sides, none but a trained observer can detect the symp-
toms 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

BIRTH OF THE CHILD 265

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 ex-
pulsion, 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 adapta-
tion 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 precau-
tionary measure, a second physician will often be

/

266 THE PROSPECTIVE MOTHER

called about the time the stage of expulsion begins.
Foresight of this kind must give the patient confi-
dence rather than alarm her. Indeed, should opera-
tive 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 prospec-
tive 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 de-
livery will always be given. Even in a later confine-
ment 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 cir-
cumstances, 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 can-
not 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 ar-
rive 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.

BIRTH OF THE CHILD 267

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 pro-
tected; 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 direc-
tions on the bottle, it will be simple to make up a so-
lution 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 irre-
sistible, 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 acci-
dent 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.

268 THE PROSPECTIVE MOTHER

About the time when the patient goes to bed the at-
tendant 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 vigor-
ously 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.

BIRTH OF THE CHILD 269

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 upper-
most 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 grad-
ually 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 tak-
ing 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 pull-
ing upon the cord. It is equally unwise for inex-
perienced 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 in-
stances a natural separation of the placenta has repaid
me for waiting as long as two hours. Prolonged de-
lay 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 after-
birth, I should much prefer to have a patient of my
own call another doctor.

270 THE PROSPECTIVE MOTHER

If the after-birth comes away of its own accord, as
will generally happen when due patience has been ex-
ercised, 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 ap-
plied 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
i-iooo bichlorid solution. Soiled dressings are re-
moved, 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.

BIRTH OF THE CHILD 271

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 every-
thing to nature. If ever the loss of blood should be-
come alarming before the doctor arrives, it is advis-
able 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 some-
what 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 con-
tact 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

272 THE PROSPECTIVE MOTHER

to contract firmly, and in consequence the blood ves-
sels are tightly closed and bleedihg ceases. Similarly,
cold applications to the abdominal wall tend to pro-
voke 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 physi-
cians also recommend Jhat the child be placed at the
breast, since suckling is known to cause uterine con-
tractions. There are other measures which are oc-
casionally employed, but they should be used only by
physicians, for in the hands of an inexperienced per-
son 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 com-
fortable. On the other hand, excitement of any kind
aggravates this condition. In general, recently de-
livered patients must be kept quiet no matter how well
they feel. A few hours of sleep, or, at least, of re-
pose, 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 be-

BIRTH OF THE CHILD 273

gin 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 down-
ward 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 at-
tempt at breathing, for unduly prolonged manipula-
tions may defeat their own object; the natural incli-
nation 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 sub-
sequent 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 atten-

274 THE PROSPECTIVE MOTHER

dant 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 be-
comes 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 man-
euver 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 in-
fant. 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 diffi-
culty in the care of the mother or of the infant was
baffling the nurse. It is now recognized that the medi-
cal attendant should not wait for the appearance of
untoward symptoms. Although the strict observance
of the various precautions which I have already em-
phasized should lead and usually do lead to an un-
eventful convalescence, it is none the less true that the
danger of infection and of other immediate compli-
cation has not passed until several weeks after de-
19 275

276 THE PROSPECTIVE MOTHER

livery. For this reason and also because skillful guid-
ance of the mother at this time will prevent unwel-
come 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 de-
termine the number; but, as a rule, ten visits, if prop-
erly 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 four-
teenth, 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 ef-
faced; even in the absence of outward evidence, if a
woman has ever given birth to a child a thorough in-
ternal 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 puerpe-
rium, 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.

THE LYING-IN PERIOD 277

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 ex-
tensive development, it also holds the place of promi-
nence 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 de-
pends upon the rapidity with which involution pro-
gresses, we must understand just what it is and how
it may be influenced.

The muscle of the womb, to which this property of

278 THE PROSPECTIVE MOTHER

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 grad-
ually passes into a resting stage the better to pre-
serve its vigor. It is the shrivelling of the individual
fibers, therefore, which accounts for the total reduc-
tion 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 influ-
ences 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 ex-
istence. Thus, if a nursing mother becomes pregnant
her infant is usually deprived of sufficient nourish-
ment or suffers some digestive disturbance; if not, and
the mother, ignorant of her condition, continues with
the breast feeding, she may jeopardize the newly be-
gun 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

THE LYING-IN PERIOD 279

which indicates that involution has made notable head-
way. The physician is not dependent on such evi-
dence, however; for a simple examination reveals at
any time how far involution has progressed. By this
means we have learned that nursing facilitates the in-
volution 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 child-
birth somewhat less rapidly than those who follow
nature's plan. In this fact, therefore, is found a sel-
fish 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 dimen-
sions. 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 liga-
ments hang loosely from its sides, very much as sails
hang when a breeze dies down. Immediately after de-
livery, therefore, the ligaments give the womb little

280 THE PROSPECTIVE MOTHER

or no support; eventually they shorten and tighten,
readily accommodating themselves to the existing con-
ditions. 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 mis-
place 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 sur-
face of the womb, left raw and bleeding at the con-
clusion 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

THE LYING-IN PERIOD 281

that point is reached, we have no difficulty in know-
ing 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 be-
low 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, there-
fore, 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

282 THE PROSPECTIVE MOTHER

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 ac-
count it was formerly customary to give them a daily
douche throughout the lying-in period. This was be-
fore 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 pene-
trate 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 di-
latation at the time of labor women who have pre-
viously suffered with menstruation may look forward
to relief after child-birth. Menstruation generally be-
comes as painless as the flow of the lochia; and so far
as a patient can tell the two phenomena are identical.

THE LYING-IN PERIOD 283

Actually, however, they bear no relation to each other.
The fact that the cavity of the uterus has been de-
prived 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 ques-
tion, for structural changes in the uterine pucous
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 evi-
dence usually enables them to decide the matter.

The secretion of milk often exerts an influence upon
the reestablishment of menstruation. Under ideal cir-
cumstances 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 pre-
vent 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

284 THE PROSPECTIVE MOTHER

in the event of conception the milk usually decreases
in amount or becomes of an inferior quality. To se-
cure 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 indi-
cate, begin to menstruate about two months after de-
livery, 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 ap-
pearance extraordinary precaution should be exer-
cised to avert a return, and about the time its reap-
pearance 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

THE LYING-IN PERIOD 285

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 con-
troversy. 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 Ger-
mans deny both these contentions. Certainly the al-
terations 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 altera-
tions, 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 respon-
sible for the loss of nearly two pounds, and the lochial
discharge for at least another; but the chief factor

286 THE PROSPECTIVE MOTHER

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 abdomi-
nal 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 preg-
nant 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 in-
volve 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

THE LYING-IN PERIOD 287

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 com-
pletely; but the pregnancy streaks rarely vanish en-
tirely, 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 en-
courage their obstetrical patients to remain in bed
somewhat longer than their mothers did. Generally
nothing else will be required, and only under ex-
traordinary 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 con-
tinuous that there is not sufficient time for adequate
repair. Whenever nature does need encouragement
calisthenics of some kind are advisable. These sys-
tematic exercises, which the patient practices in bed
and flat on her back, are usually begun about a week

z88 THE PROSPECTIVE MOTHER

after delivery, though there may be some reason for
beginning them earlier or later than this.

The physician will always select the proper calis-
thenics, 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 abdo-
men 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 sta-
tionary. 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 ab-
dominal muscles is questionable; though physicians
agree to the advantages of a supporter after patients
are out of bed. We constantly see perfect restora-
tion of these muscles without the early use of a
binder ; in fact, women who have employed it through-

THE LYING-IN PERIOD 289

out the lying-in period do not secure an efficient ab-
dominal 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 dis-
placements. 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 com-
plain 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 strength-
ening 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

2Q0 THE PROSPECTIVE MOTHER

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 re-
covery of the pelvic floor more than anything else.
Keeping the thighs together during the first few days
undoubtedly assists tears in healing, but that precau-
tion is not always necessary, and when it is the phy-
sician will call attention to the fact. The really im-
portant 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 di-
rection 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 nurs-
ing is partly responsible for the existence of gyne-
cology, the branch of medicine which deals with the
diseases of women. Recently delivered women should

THE LYING-IN PERIOD 291

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 protec-
tion an experienced nurse is indispensable, for she will
make systematic observations which would consume
too much of the doctor's time for his personal atten-
tion, 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 in-
tervals 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 eleva-
tions in the course of the following week are so fre-
quent that obstetricians have agreed to regard as a
normal temperature for this period 100.4 degrees in-
stead 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 dif-
ficulty in breathing that may have existed in the latter
part of pregnancy disappears when the abdominal dis-
tention 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 with-
out 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
20

2Q2 THE PROSPECTIVE MOTHER

organs are particularly active during the lying-in
period. In quantity the loss of water exceeds all the
other waste-products together; and pronounced ac-
tivity of the kidneys or of the sweat glands may be-
come a source of annoyance. Since it is undesirable
to interfere with these functions, whatever inconveni-
ence either may cause will be borne with less com-
plaint 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 neces-
sary 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 inflam-
mation 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. Accord-
ingly catheterization after child-birth is now post-
poned, and is never performed until a number of de-
vices to get the patient to void spontaneously have
been tried without success. Often urination follows
putting a hot-water bottle over the bladder; or pour-
ing 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.

THE LYING-IN PERIOD 293

With the elaborate precautions taken to avoid infec-
tion of the bladder, catheterization is now performed
with very slight risk.

Constipation, for various reasons, becomes a reg-
ular 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. Child-
birth 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 con-
demned. 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 re-
sult in the enema habit. Similarly, long-continued
administration of strong purgatives tends to make
them a permanent necessity. While in bed if medi-
cine is taken every other day the bowels will have op-
portunity on the intervening days to move spon-
taneously, though we do not really expect them to
move naturally until six or eight weeks after the de-
livery, when the patient is able to take as much ex-
ercise as she likes. Toward the end of the second
week, however, mild laxatives generally prove effec-
tive, 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

294 THE PROSPECTIVE MOTHER

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 pa-
tients 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 pro-
mote 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 phy-
sician always leaves specific directions regarding it.
Generally the diet consists of liquids, such as milk and
broths, for a couple of days; under some circum-
stances 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 LYING-IN PERIOD 295

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 thor-
ough 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 wor-
ries materially delay convalescence. During this
period only a limited number of the immediate mem-
bers 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

2q6 THE PROSPECTIVE MOTHER

should stay in bed after the birth of a child is a ques-
tion which has given rise to prolonged discussion.
The majority of obstetricians adhere to the tradi-
tional ten days; but there are advocates of a longer
period and advocates of a shorter one. The generali-
zations 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 sav-
ages, 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 ap-
parent; 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 vio-
lent 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

THE LYING-IN PERIOD 297

should force herself to keep this posture, for at best
it does no more than relieve monotony. The ex-
ercises 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 re-
mains out of bed an hour the first day, two the sec-
ond, 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 over-
taxing 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 under-
stand the organic changes in progress and appreciate

298 THE PROSPECTIVE MOTHER

the lasting benefits of a temporary forbearance, but
a few must be made to realize that very serious penal-
ties 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 re-
storation of the woman's health, the modern man-
agement of obstetrical cases breaks decisively with
tradition at three points. An utter disregard of precau-
tion has given way to very careful preparations be-
fore 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. Sat-
isfactory 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, treat-
ment 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

THE LYING-IN PERIOD 299

satisfactory manner. Besides, making the examina-
tion while the changes are in progress sometimes en-
ables the physician to treat approaching complications
before they actually develop. Thus, when the pelvic
floor has not regained its strength sufficiently, the pa-
tient 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 re-
tains a good position. Again, there are conditions
which a douche will relieve, and still others benefited
by medicinal treatment. If an abnormality is recog-
nized which cannot at once be treated to the best ad-
vantage, 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 re-
sources from this moment, the patient will clearly un-
derstand that she must continue to exercise sound
discrimination in what she does. And here, of course,
we encounter the greatest difficulty in offering prac-
tical advice, for what one may do easily will overtax
another. Generally speaking, going up and down stairs

300 THE PROSPECTIVE MOTHER

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 conva-
lescence 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 —
The Interval between Feedings — Hygiene of the Mother: Diet;
Psychic Influence; Recreation and Rest — Dehydration Fever
— 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 di-
rections cannot always be given. Unforeseen pe-
culiarities 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 ex-
ceptions, therefore, mothers require during the early
years of a baby's life skilled advice as to his up-
bringing— advice for which neither instinct nor hap-
hazard 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 ex-
ample, and upon these occasions secures help in solving

301

302 THE PROSPECTIVE MOTHER

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 at-
tempts to disseminate a wider knowledge of the cor-
rect principles of bottle-feeding do not have the
highest aim. Our real need is a vastly greater propor-
tion of women who nurse their children.

The Breasts. — For success in nursing the first es-
sential 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

THE NURSING MOTHER 3<*

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. Dif-
ferences 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 con-
gested; 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

304 THE PROSPECTIVE MOTHER

thin, watery fluid called colostrum. Contrary to pop-
ular 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 the quantity
of the milk which a prospective mother will produce,
but almost without exception its good quality is
assured.

Some writers contend that influences which come
into play during girlhood ultimately affect the ca-
pacity 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 detri-
mental 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 meas-
ures to prepare the breasts for their function until the
need of such measures is clearly evident. Through-
out pregnancy clothing about the breasts should be
loosely worn. If the nipples are not already promi-
nent they should be drawn out; and about six 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

THE NURSING MOTHER 305

which covers the nipple; and unless measures to ren-
der the nipple resistant have been previously adopted,
nursing may cause the mother considerable discom-
fort. Moreover, it is extremely important through-
out 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 at-
tend 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 over-
production 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 be-
tween the supply of nourishment and the natural de-
mands 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 treat-
ment lost favor as soon as physicians realized that
massage stimulated the glands to greater activity.
Drawing th^ milk with a breast-pump has a some-

306 THE PROSPECTIVE MOTHER

what similar though less potent influence, and, be-
cause pumping often affords relief when the breasts
are distended, there is rarely any objection to it. In
the light of modern experience, however, most phy-
sicians prefer to avoid manipulation of the breast co
far as possible, and generally resort to other measures
to relieve the mother's discomfort. Thus most pa-
tients 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 her-
self. 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. Never-
theless, so long as a mother is nursing her child she
must be careful to keep the breasts in a healthful con-
dition. They require support, yet must not be com-
pressed. And they should be covered with clothing
which will adequately protect them from sudden
changes of temperature. This latter precaution, per-

THE NURSING MOTHER 307

haps, requires more emphasis than formerly, on ac-
count 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. Occasion-
ally 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 dur-
ing 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 co-
lostrum 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 be-
fore 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

21

308 THE PROSPECTIVE MOTHER

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 out-
put fluctuates between one and two quarts daily, ac-
cording 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 develop-
ment of all their organs as nothing else will. Be-
cause there are present in this fluid all the elements
necessary for nutrition, physiologists have called it a
perfect food. Quantitatively its most important in-
gredient 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 stand-
point the mineral matter would seem of minor im-
portance, but it is actually as vital as any other con-
stituent. Without it the bones would not harden
properly; and other services which it performs are

THE NURSING MOTHER 309

absolutely essential to life. As we should expect,
human milk contains all the mineral ingredients nec-
essary 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. More-
over, 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 co-
lostrum.

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 in-
experience 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 nurs-
ing; for practically every woman who persists will
succeed.

/

310 THE PROSPECTIVE MOTHER

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 sup-
port 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. To
fix the duration of the nursings arbitrarily is impos-
sible; from ten to thirty 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 de-
termine how long to leave it at the breast. Further-
more, 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*

THE NURSING MOTHER 311

fashioned custom of allowing the baby to nurse when-
ever 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 over-
feeding. 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.

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 pro-
tects the breasts against infection, a complication
which the nursing mother must spare no pains to pre-
vent. 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 con-
tact 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, ob-
tainable 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 direfctly from the breast. In
the rare cases in which the shield cannot be used sat-
isfactorily the infant must be taken from the breast

312 THE PROSPECTIVE MOTHER

temporarily and given a bottle. Radical as this ad-
vice 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.

The Interval Between Feedings. — With a number of
new methods available for the study of the problem,
physicians have recently endeavored to ascertain pre-
cisely how long a period should elapse between the
feedings of a young infant. The adjustment of the
interval must take into account the welfare of the
infant and the mother. Besides the daily meas-
urement and analysis of the mother's milk, elaborate
data have been collected relative to the caloric require-
ments of the infant; careful estimations have been
made of the energy it expends. Utilizing the X-rays,
we have learned the period of time the stomach
requires to empty itself; and the same method has
revealed peculiarities in the contractions of this organ,
whenever one is hungry. Although such methods
have a distinct value in clarifying the underlying
principles of nutrition, I doubt if any practical test
of developmental progress will ever be more reliable
than the change in the infant's weight. This should
be followed in every case and on that basis the adjust-
ment of the interval between nursings will usually be
made.

One result of a renewed interest in this question
has been the demonstration of the satisfactory char-
acter of a longer interval between nursings than has

THE NURSING MOTHER 313

been popular heretofore. The routine use of the two-
hour schedule has been abandoned, even during the
early weeks of infant life. Every one agrees that this
exacting routine imposes upon the mother and except
in extraordinary cases does not benefit the infant.

So long as the breasts contain colostrum, the nurs-
ings should be at least four hours apart during the
day; at night it is preferable not to disturb the mother
at all. Even after the milk appears it is generally ad-
visable to adhere to this schedule during the day, and
not infrequently the four-hour interval will prove sat-
isfactory throughout the period of lactation. On the
other hand, some physicians strongly favor the three-
hour interval because of the stimulation the pro-
duction of milk derives from more frequent nursing.
Probably, neither schedule should be adopted as a
matter of routine; each case should be studied and a
schedule chosen that is suited to the individual.
Our own experience teaches that a great many, though
not all, infants thrive when nursed at a four-hour in-
terval during the day; if that schedule proves unsatis-
factory, the three-hour interval is tried.

After the first few days 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., according as the three or four-hour plan is
used. The daily bath should be scheduled so that a
feeding will be due just after the bath has been com-
pleted. Occasionally there may be difficulties in get-
ting the child to nurse during the day, but it must be

314 THE PROSPECTIVE MOTHER

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 overlying. Infants can frequently be trained
to go without feeding in the middle of the night even
when a few months old, and such training is advisable
since it affords the mother opportunity for eight
hours' continuous sleep.

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 im-
portant 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 unrea-
sonable 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

THE NURSING MOTHER 315

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, be-
cause 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 sup-
pose 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 whole-
some 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 success-
fully. Incidentally, it has been shown that nourish-
ment 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

3i6 THE PROSPECTIVE MOTHER

many instances it is over-feeding rather than under-
feeding that must be guarded against. Very accurate
observations have been made which indicate that dur-
ing 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-eat-
ing, as many of us know, is a frequent cause of indi-
gestion. It is of the first importance, therefore, that
nursing mothers should not take more food than they
can assimilate, for indigestion will provoke disturb-
ances 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 also good 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 ex-
ception food should be selected with regard only for
its wholesomeness and digestibility. All food is milk-
making food; no sharp distinctions between the vari-
ous kinds can be recognized. Milk, because it con-
tains 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 ad-
vantageous to take milk or some other nutritious
drink between meals and again before retiring at

THE NURSING MOTHER 317,

night, but the danger of ruining in this way the ap-
petite 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 dis-
agree with other mothers. Generalizations of this
kind are largely responsible for the wrongful ten-
dency 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 con-
tain 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 cer-
tain persons some varieties of fruit invariably cause
indigestion. Lactation does not correct such an in-
dividual 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 in-

318 THE PROSPECTIVE MOTHER

clined to worry, nursing mothers may partake of
fruits and salads with impunity.

There are vegetables, of which the onion and tur-
nip 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 ad-
ministered as medicine to the mother. In one way
this is fortunate, for under certain circumstances it
provides a very satisfactory method of treating un-
healthy children without giving the medicine directly.
In another respect, however, it is a disadvantage, for
it sometimes interferes with giving the mother purga-
tives, which she may need. So far as possible, there-
fore, 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 at-
tempts in this direction have failed of general ap-
plication. There are at present on the market widely
advertised preparations for which astounding effi-
ciency 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

THE NURSING MOTHER 319

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 in-
fluence our digestions as has been so clearly proved
by the skillful experiments of Pawlow, an eminent
Russian physiologist. Cheerfulness promotes per-
fect assimilation of the food, whereas mental de-
pression 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 unques-
tioned fact that mothers who maintain a happy dis-
position nurse their babies efficiently, while those who
are inclined to worry often experience real or imagi-
nary 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 af milk sud-
denly ceases altogether. Fortunately such effects oc-
cur 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

320 THE PROSPECTIVE MOTHER

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 in-
sufficient or unwholesome milk. The self-assurance
gained through taking care of the first baby is respon-
sible 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 pro-
miscuous* 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 out-
door exercise, for congenial companionship, or for

THE NURSING MOTHER 321

diversion of any kind. Occasionally it may seem al-
most 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 regu-
late 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. Ex-
hausting sports, however, must be shunned, because
fatigue has the same injurious effect upon the secre-
tion of milk as lack of exercise.

As might be expected, women who are frail are
most susceptible to the strain of nursing if they
fail to get sufficient rest. The night-feeding, gener-
ally advisable for the first few months, 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.

322 THE PROSPECTIVE MOTHER

Dehydration Fever — The occurrence of a slight rise
in the infant's temperature during the early days of
life is well known to physicians, who at first attrib-
uted the phenomenon to an inadequate supply of nour-
ishment and called it "inanition fever." Later, this
explanation was proved incorrect. What the infant
really needs is water to drink. As soon as this detail
is given the attention it deserves, the temperature be-
comes normal ; "dehydration fever" then is the correct
designation of the infant's reaction when we neglect
to give it water.

Dehydration fever is not a serious complication, and,
as I have indicated, the remedy is a very simple one.
The chief reason for bringing the phenomenon to the
notice of young mothers lies in the impressive way it
teaches that babies should have water to drink. The
water is given most conveniently in a bottle with a
satisfactory nipple; the quantity ordinarily adminis-
tered at one time is an ounce. It should be offered the
infant several times during the day between nursings
and also at night when it is awake. The child, more-
over, having thus become accustomed to the bottle, is
much more easily denied the breast when the time for
weaning comes.

Of course, it will be necessary to take the same pre-
cautions as if the infant were being given an artificial
feeding. The water should be boiled, allowed to cool
and administered at about the same temperature as
the body. To avoid contamination of the water care
must be exercised to have everything clean that comes
in contact with it. Specific directions, however, may

THE NURSING MOTHER 323

be given more satisfactorily by the physician who is
familiar with the case.

Weaning. — Occasionally, even before they are de-
livered, 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.

With the exception of tuberculosis, physicians rec-
ognize no condition that necessarily unfits a mother for
nursing. As we have already seen, pregnancy is gen-
erally incompatible with lactation; in the event of con-
ception the mother's milk almost always takes on
qualities which render it unsatisfactoroy for the in-
fant, and yet occasionally pregnancy advances several
ception the mother's milk almost always takes on
qualities which render it unsatisfactory for the in-
fant, and yet occasionally pregnancy advances several

months before these changes in the milk occur.
Under all circumstances, however, nursing should
cease as soon as the mother recognizes that she is

324 THE PROSPECTIVE MOTHER

pregnant, for probably no woman is strong enough
to provide nourishment for her infant and for the de-
velopment of the embryo simultaneously.

Menstruation, on the other hand, rarely if ever pro-
vides 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. Quali-
tative disturbances which would render the milk unfit
for use are practically never a consequence of men-
struation.

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 not-
able 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 administration
of water from a bottle 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

THE NURSING MOTHER 325

by the weaning, provided she leaves her breasts alone.:
Until recently mothers were advised to employ a
yery 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 ad-
ministered 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 unneces-
sary, for, at whatever period of lactation the breasts
cease to be used, they dry up spontaneously.

GLOSSARY

Abnormal. — Irregular ; deviating from the natural or stand-
ard 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 mem-
branes which envelop the embryo; the lining mem-
brane 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.
|The Century Dictionary has been freely_used for these definitions*

327

328 GLOSSARY

Aseptic. — Free from injurious bacteria.

Asphyxia. — The extreme condition caused by lack of a?cy-
gen 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 mi-
nute, spherical, oblong, or cylindrical cells which
are concerned in putrefactive processes. Some vari-
eties 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 kid-
neys 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 net-
work 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.

GLOSSARY 329

Carbonic Acid Gas. — An animal waste product eliminated
in the breath. In daylight plants absorb it energetic-
ally 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 ma-
terial 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 mem-
branes 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 ab-
normal states of the body.

Diaphragm. — The muscular partition between the chest and
the abdomen.

Dietetic — Pertaining to the diet.

330 GLOSSARY

Duct. — A tube which conveys the secretion from a gland.

Embryo. — The offspring before it has assumed the distinc-
tive form and structure of the parent.

Enema. — A quantity of fluid injected into the rectum.

Engagement. — The entrance of the fetus into the birtb-
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 develop-
ment.

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 extend-
ing from the stomach to the rectum.

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

GLOSSARY

33i

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 sub-
stances 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 menstrua!
process, which generally occurs between the 45th and
the 50th years.

Micro-organisms. — Bacteria and other living agents of dis-
ease which are visible only with the aid of the micro-
scope.

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 neigh-

332 GLOSSARY

borhood 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 out-
let of the vagina to the rectum; it is the most essen-
tial 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 com-
pose 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.

GLOSSARY 333

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 deoosited over the skin of the

newly born infant.
Viable. — Capable of living.

Villi (singular villus). — The microscopic, finger-like pro-
cesses 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.

INDEX

Abdominal wall, changes in,
during pregnancy, 105.
restoration of, after child-
birth, 286.
Abortion, after-effects of,
185, 186.
definition of, 169.
laws prohibiting the per-
formance of, 186.
permitted to restore
health, 191.*
Adrenals, 14.

Advice, professional, 2, 146.
promiscuous, 1, 123, 260,

319-
After-birth, description, 38.;
detachment of, at the end

of labor, 254.
expulsion of, 255, 269.
After-pains, 256, 278.
Air, composition of, 125.
pure and impure, 126.
Amniotic fluid, origin of, 36.
quantity of, 245
uses of, 37.
Amniotic membrane, 37.
Amusements, 142, 174.
Anesthetic during the second
stage of labor, 248.

335

Antisepsis, 212.
Appetite, 90.

as a guide for nursing

mothers, 315.
unnatural types of, during

pregnancy, 95, 97.
Artificial respiration, 274.
Asphyxia of the new-born,

272.
Assistance during labor, 261.
Athletic sports, 129.
Atmosphere, 125.
Automobiling, 130, 140, 174,

307.

Baby, new-born, 58 (see
also Infant).

Backache, due to the mus-
cles of the back, 104.
improper shoes as a cause

of, 115.
one of the symptoms at
the beginning of labor,
228.

Bacteria, the cause of child-
bed fever, 212.

"Bag of waters," 36, 245.

Bandaging after child-birth,
280, 288.

336

INDEX

Bathing, 108.

a precaution against com-
plications, 165.
in the surf, no.
Bearing-down, 252.
Bed for confinement, 223.
Bidet, 112.

Binder, abdominal, use of,
during pregnancy, 119.
Birth, average duration of,
241.
hour of, 241.

management of, without
the doctor, 266.
Birth-marks, 68, 95.
Bladder, irritability of, 12.
Bleeding, during pregnancy,
182, 230.
following labor, 255, 271.
natural provisions for the

control of, 256.
treatment of, when exces-
sive after child-birth,
271.
Blood pressure, 104.
Bowels, 100.
Breast, abscess of, 305.
"caked," 305.
care of, 119, 302.
growth of, during preg-
nancy, 10.
inflammation of, 122, 305.
massage of, 131, 305.
method of "drying-up,"

324.
sensations in, 10, 119.
structure of, 303.

Breast-feeding, advantages
of, 278, 308 (see also Lac-
tation and Milk, human).

Breast-pump, 305.

Breast-supporter, 306.

Breath, shortness of, 161.

Breathing, beginning of, in
the new-born, 258.
physiology of, 126.

Breech presentation, 265.

Calculation of the date of

confinement, 16.
Calisthenics, 288.
Carbohydrates, as food, 78

(see also Sugar and

Starch),
quantity of, needed during

pregnancy, 87.
Cathartics, 100 (see also

Purgatives).
Cell, the female, 24.
the male, 26.
the structural unit of our

bodies, 23.
Cell-division, the first step

in development, 28.
Child, new-born, 58.
prematurely born, 168, 193.
size of, 97, 133.
Child-bed fever, 212 (see also

Puerperal infection).
Chloroform, 248, 267.
Chorionic membrane, 37.
Chromosomes, 66.
Circulation of blood through

the placenta, 40.

V

INDEX

337

Cleanliness, 108.

at the time of birth,

231.
during the lying-in period,
280, 294.
Clothing, 112.
for the infant, 209.
suitably warm, a precau-
tion against complica-
tions, 165.
Clots, 281.

Colostrum, 11, 304, 307.
Complications, accidental,
during pregnancy, 144.
Conception, 27, 67.
Confinement, bed for, 223.
estimation of the expected

date of, 16.
personal preparations for,

231.
room for, 220.
supplies for, 202.
Constipation, 100, 165, 293.
Contractions of the uterus,

229, 238.
Convalescence after child-
birth, 275.
Cord, umbilical, 44, 253, 259.
Corpus luteum, 13.
Corsets, 116.

Cramps in the abdomen,
229.
in the legs, 160, 252.
Cravings, 95.
Croquet, 129.

Crying, the value of, to the
new-born, 258.

Dancing, 130.
Date of confinement, 16.
Delivery, premature, 192.
Development, the first steps

in, 28.
Diet, choice of, during preg-
nancy, 90.
during labor, 246.
during the lying-in period,

294.
while nursing an infant,

314-
Digestion, 82.

Diversion, mental, 140, 321.
Dizziness, 166.
Douches, during pregnancy,

no.
following child-birth, 282,

299.
Dress, 112.
Driving, 130.
Drugs, the use of, during

lactation, 293, 306, 317.
Drying-up the milk, 307,

322> 324.

Ear, in the new-born, 62.

Egg-cell, 24.

Embryo, development of, 49.

Employment of women dur-
ing pregnancy, 134.

Enema, 101, 231, 293.

Ether, 249.

Eugenics, 64.

Examination, preliminary,

during pregnancy, 225.

vaginal, during labor, 242.

338

INDEX

Examination when the pa-
tient is discharged, 298.

Examinations of the urine,
102.

Exercise, outdoor, during
pregnancy, 127, 165.
while nursing the in-
fant, 320.

Eye, development of, in the
new-born, 61.

Food, what we do to, 81.

Foodstuffs, 74.

Forceps, the obstetrical, 262.

Form, development of, by
the embryo, 48.

Fright without influence
upon embryonic devel-
opment, 69.

Fruit, laxative value of, 92,
100.

Face, puffiness about, 166.
False labor pains, 229.
Fat, as food, 80.

quantity of, needed dur-
ing pregnancy, 88.
Fatigue, 128, 174, 320.
Feces, 84.

Feeding, artificial, of in-
fants, 313.

breast, technique of, 309.
Feet, swelling of, 156.
Fertilization of the ovum, 26.
Fetus, definition of, 48.

growth of, 54.

position of, in uterus, 58.
Fever, child-bed or puerpe-
ral, 212.

dehydration, 322.
Flatulence, 152.
Flooding, 182.
Food, constituents of, 74.

purposes served by, 85.

selection of, during preg-
nancy, 84, 90.

while nursing the in-
fant, 315.

Games, 129.

Garters, 156.

Gas in the intestines, 152.

anaesthesia, 249.
Germinal cells, 24.
in relation to the problem
of heredity, 66.
Gestation, period of, 14.
Getting up, time for, after

child-birth, 295.
Glands, digestive, 81.
ductless, 13.
mammary, 313.
sweat, 107.
uterine, no.
Golf, 129.

Greasing the abdomen, as a
means of preventing the
'pregnancy streak s,"
106.
Growth of the fetus, 54.
Gymnastics, 130.

Head of the new-born in-
fant, 60, 257.
Headache, 126, 166.

INDEX

339

Heartburn, 88, 151.
Heart-sounds, fetal, 5.
Hemorrhage, after child-
birth, 255.
control of, 256, 271.
during pregnancy, 182.
Hemorrhoids, 159.
Heredity, 28, 64.
Horseback-riding, 130.
Hospital treatment of cases

of confinement, 231.
Hygiene of the nursing
mother, 313. t

Impressions, maternal, 67.
Indigestion, 151, 164.
Infant, care of, 301.

favorable conditions for
the development of,
308.
new-born, 58.
outfit for, 209.
the premature, 192.
weight of, 57.
Infection, puerperal, conta-
giousness of, 212.
means of prevention of,

216.
relation of bacteria to,

215.
Involution of the uterus,

277.
Iron, a constituent of milk,

309.
relation of, to discolora-
tion of the skin, 107.
Itching, in, 162.
23

Kidneys, action of, 102.
not responsible for in-
creased frequency of
urination, 13.
relation of, to the toxe-
mias of pregnancy, 166.
Kneading the uterus to con-
trol bleeding after child-
birth, 271.

Labor, 237.

anesthetic during the sec-
ond stage of, 249, 267.
cause of, 233.
conduct of patient during,

246.
course of, 241.
difficult, 261.

division of, into stages,
242.
first stage, 244.
second stage, 248.
third stage, 253.
duration of, 241.
effect of, upon the child,

256.
food during, 246.
management of, without

the doctor, 266.
premature, 192.
symptoms at the beginning
of, 228, 241.
Lacerations at the time of

birth, 254.
Lactation, food during, 314.
influence of the mind
upon, 318.

340

INDEX

Lactation, influence of recre-
ation upon, 320.
preparations for, 120, 304.

Laws regarding the perform-
ance of abortion, 186.

Legs, cramps in, 160, 252.
swelling of, 156.
varicose veins of, 157.

Leucorrhea, 162.

Lime water, 155.

Liquids, as nourishment,
89.

"Liver spots," 106.

Lochia, 281.

Longings for special kinds
of food, 95.

Male cell, 26.

Mammary glands, 313 {see
also Breasts).

Marital relation, 26, 180.

Massage, general, 130.
of breasts, 305.

Mastication, 82.

Maternal impressions, 67.

Meals, frequent, a precau-
tion against nausea, 149.
number of, 88.

Meat, as food, 94, 165.

Membranes, 37, 245, 247.

Mental diversion, 140.

Milk, cow's, 321.
human, 302.

composition of, 307.
daily quantity of, 308.
factors influencing the
supply of, 313, 319.

Mineral material, as food,

76.

quantity of, needed during
pregnancy, 86, 98.
Miscarriage, after-effects of,

185.

causes of, 171.

drugs as a means of caus-
ing, 175-

frequency of, 170.

habitual, 178.

liability to, about the time
menstruation would be
due, 135.

warning symptoms of,
181.
Morning sickness, 12, 148.

Nausea, a sign of preg-
nancy, 12.
frequency of, 146.
measures for the relief of,
148.
Navel, care of the infant's,

259-
changes in the mother's,

during pregnancy, 106.

Navel-string, 44, 253, 259.

Neck of the womb, 33.

Nipples, alterations in, &

sign of pregnancy, II.

care of, 106, 119.

cleansing of, 312.

"cracked," 305, 313.

inverted, 120, 304.
Nipple-shield, 313.

INDEX

341

Nuclei, union of two, neces-
sary to the reproductive
process, 27.
Nurse, engaging the, 196.
preliminary visits of, 201.
qualifications of, 199.
Nursing the infant, diet
while, 314.
effect of, upon the involu-
tion of the uterus, 278.
technique of, 309.
Nutrition of the unborn
child, 30, 35, 41, 44, 73,
96, 257.

Outfit, baby's, 209.
Ovary, anatomy of, 24.

a ductless gland, 13.
Overexertion, 135.
Oviducts, 25, 29.
Ovum, 24.

attachment to uterus, 30.

growth of, 28.

Pain in the back, 104, 181,
228.
in the legs, 160.
in pit of stomach, 166.
Parathyroids, 14
Pelvic floor, restoration of,

after child-birth, 289,
Pelvis, the bony, 33, 60, 256.
Perspiration, 105, 108, 113.
Physician, advice of, 2, 146.
preliminary visit of, 225.
visits of, during the lying-
in period, 275.

Physician, when to call, for

the birth, 228.
Piles, 159.
Pituitary gland, 14.
Placenta, expulsion of, 253.

structure of, 38.
Pregnancy, duration of, 14.

positive signs of, 4.

presumptive signs of, 7.

probable signs of, 6.

prolonged, 19.
Pregnancy-streaks, 105, 106.
Prevention, of miscarriage,
172, 180.

of puerperal infection,
195, 212, 217, 231, 243.

of toxemia, 165.
Protein, as food, 77.

quantity needed, 86.
Prunes, senna, 102.
Puerperium, 275 .
Purgatives, during preg-
nancy, 100.

following child-birth, 293.

negligible as a cause of
miscarriage, 174.

Quickening, a sign of preg-
nancy, 4.
as a means of predicting
the date of confinement,
18.

Quinin, 175.

Reaching up, 45, 173.
Recreation, 124, 128, 320,
321.

342

INDEX

Relaxation, 135.
Respiration of the infant,

257.
Rest, 135.

Resuscitation, methods of,

272.

Riding on horseback, 130.

Room for confinement, 220.

Saliva, 82.

Self-consciousness, 141, 150.
Senna prunes, 102.
Sense organs, development

of, in the new-born, 61.
Sewing machine, the use of,

during pregnancy, 132.
Sex, control of, 28, 50.
recognition of, before

birth, 53.
Sexual intercourse during

pregnancy, 180.
Shoes, 115.

"Show," a symptom of la-
bor, 247.
Skating, 130.
Skin, care of, 105.
darkening of, during

pregnancy, 11, 106.
Sleep, 136, 320.
Smell, development of, in

the new-born, 63.
Spermatozoon, 26.
Starch, as food, 79, 92.
Sterilizing, importance of.

211.
methods of, 218.
Sugar, as food, 79.

Supplies for confinement, 202.
Supporter, abdominal, 119,
288.
breast, 306.
Surf-bathing, no.
Sweat glands, action of, 107.
Swelling of the face, 166.

of the feet, 156.
Symptoms, at onset of la-
bor, 278.
due to pressure, 156.
of miscarriage, 181.
to report promptly to the
doctor, 166.

Tears, advantage of repair-
ing immediately, 254.
cause of subsequent ill-
health, 289.

Teeth, care of, 154.

Tennis, 129.

Thyroid gland, 14.

Touch, sense of, in the new-
born, 63.

Toxemias of pregnancy, 163.

Traveling, 138.

Tubes, 25, 29.

Twins, 53.

Twilight sleep, 250.

Umbilical cord, function of,
44.
treatment of, 253, 259.

Underclothing, 113.

Urination, increased fre-
quency of, during preg-
nancy, 12.

INDEX

343

Urine, examination of, 102,
145, 166.

method of collecting, 103.

sediment in, 104.
Uterus, anatomy of, 33.

changes in, during preg-
nancy, 34.

dilatation of, during la-
bor, 244.

restoration of, after child-
birth, 176, 277,

unfavorable effect upon,
from use of abdominal
binder, 280.

Vagina, 33.

Vaginal discharge, no.

Vegetables, as food, 93.

Vegetarian diet, 93.

Veins, swollen, 157.

Ventilation, 125.

Villi, 32, 34, 41.

Vision, disturbances in the

mother's, 166.
Visitors, 205.
Vomiting, 12, 14, 150, 166.

Walking, 129, 131.
Waste-products, during the
lying-in period, 291.

of the fetus, 99.

of the mother, 84, 164.
Water, loss of by body, 76.

importance of, during
pregnancy, 75, 89, 165.

laxative value of, 101.

the infants' need of, 322.
"Waters, the bag of," 36,

245-
breaking of, 230, 247.
Weaning, 322.

Weight, gain in, during
pregnancy, 72, 85.
loss in, during the lying-
in period, 285.
of the new-born infant,

57.
Womb, 33 (see also Uterus).

Work, influence of, upon

pregnancy, 132.
Worry, 151.
effect of, upon lactations

318.

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