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Copyright, 1912, 1921, by 

JUN -8 1921 

Printed in the United States of America 



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 


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. 


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 



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. 



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 



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 


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 


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- 


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- 


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- 

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- 


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 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 


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- 


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 

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 




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 


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 

None of the changes in the breasts are absolutely 
characteristic of pregnancy; even the secretion of co- 


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 

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; 


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 


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 


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- 


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 


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 


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 


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 


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 


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. 



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 



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. 


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 


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 

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- 


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- 

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- 


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 

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 


which constitutes its right to be considered as a human 

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 


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 


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 

After its entrance into the cavity of the uterus 
prepared to receive and protect it, the mass of cells 
sinks into the soft, velvety lining of the organ. Here 
it is entirely surrounded by tissue which belongs to 
the mother. But just before implantation takes place 
the architecture of the ovum is modified in such a way 
as to indicate the trend of its subsequent development. 
We left it, a hollow ball passing down the oviduct; 
had we examined the sphere more closely we should 
have found its wall composed of a single layer of cells. 
At one spot, however, the wall soon thickens. The 
thickening is due to a specialized group of cells which 
gradually grows toward the hollow center of the ball. 
A little later, if we study the structure as a whole, we 


find it a small, distended sac, from the inner 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- 

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 


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- 


ternal tissues assume the responsibility placed upon 

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- 


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- 

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 


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 


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 


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« 


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 


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 


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 


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, 


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. 


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- 

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 


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 


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. 


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. 



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. 


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 

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


end of the third month to say whether the embryo is 
a male or female. 

The Determination of Sex.— The fact that a number 
of months pass before the sex can be distinguished 
by an external examination of the fetus has led to the 
erroneous belief that it can be influenced during the 
early part of pregnancy or actually determined at will. 
Various means to accomplish this have been 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 


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 

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 


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. 


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 


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- 

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


and often marked differences in the physical character 
of women, such as weight and height, it is surprising 
to learn that the prenatal development of their children 
proceeds with uniform speed. One very practical 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 


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. 


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 


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 hea v J 
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 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 


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 


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, 


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. 


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, 


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 


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. 


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 


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 w r e 
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* 


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 


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 


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- 



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. 



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 



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- 

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 w r hich 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 w T aste 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 


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- 


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- 


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 


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 


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 


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- 


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- 

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 


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 


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- 

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 


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 


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 


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 


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 

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. 


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. 


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- 


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- 


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. 


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 


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 


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 

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 


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. 


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. 


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 

There can be no doubt that the results of such ob- 
servations upon animals are applicable to human 


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 

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 


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. 


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 


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 


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 


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. 


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, 


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 


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 


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- 


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 

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 


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. 

Bathing 1 .— 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 



90 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 


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; 


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 90 F.) until it is five 
or six inches deep. Cold sitz-baths are useful in the 
treatment of hemorrhoids. Whether the bath be hot 
or cold, the treatment should continue from ten to 


fifteen minutes, and after it the skin should be 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 


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 


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 


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 


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 

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- 



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- 


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- 


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 


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 


with grain alcohol (95 per cent.). The solution is 
applied twice a day with a small piece of absorbent 

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 


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. 



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- 

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 



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 


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 


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* 


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- 

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 

Outdoor Exercise. — Outdoor exercise is indispensable 
to good health. It benefits not only the muscles, but 
the whole body. By this means the action of the 


heart is strengthened, and consequently all the tissues 
receive a rich supply of oxygen. Exercise also 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 


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 

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- 


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 


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 

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. 


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 



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 


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- 

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- 


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 

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 


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 


due to the pressure of the womb against neighboring 1 
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, 


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- 


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- 


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- 

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 


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 

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- 


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 


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. 



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- 



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- 


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 


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 


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. 


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- 


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 

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 


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- 


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 

Flatulence. — The distention of stomach and inte*- 


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 

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 


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 


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 


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 


interfere with the flow of blood through these vessels, 
but in the last few months such interference is very 

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 



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- 


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 

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- 


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 


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- 

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

Unlike the other pressure symptoms, shortness of 


breath is ordinarily aggravated by the recumbent 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_— ^— 


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 

Toxemias. — In order to understand what are known 

as the toxemias of pregnancy, we must remember that 

the nutrition of our bodies involves three separate and 

distinct sets of processes. What we eat is, in the first 

place, digested and absorbed into the body; secondly, < 

the products of digestion are utilized by the tissues; 

and, finally, the waste material is thrown off from the 


body. Any one of these processes may be carried 
out in a way that is not consistent with health. Most 
of us realize that disturbances may occur in the course 
of digestion, and we are also aware that the excretory 
organs occasionally fail to do their work in a 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 


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 


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- 

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 

It must be clearly understood, however, that any 
of these symptoms may be present without indicating 
that a toxemia is developing. Nevertheless, they 
should be brought to the physician's attention without 


delay, and, at the same time, a specimen of urine should 
be given him for examination. 

Although the kidneys are not responsible for all 
the toxemias of pregnancy, an analysis of the urine 
affords the most definite means of determining whether 
or not such a condition is present. When thus 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* 


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- 



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 


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. 


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- 


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- 

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 


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 

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 


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 


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 


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 

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- 


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 

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- 

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- 


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 

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 


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, w T as willing to remain in bed practically 
the whole period of gestation. She had her reward; 
a well-developed infant was born at full term, and 

has continued to thrive. 


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


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 


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, 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. 


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 

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 


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 


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 w r ho 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- 


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 

At Common Law there was a difference of opinion 


as to whether all induced abortions were illegal. 
Many courts formerly held that quickening was a 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 


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 


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." 


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 

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- 


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 

The course of premature labor closely resembles de- 
livery at full term. But it is shorter because the in- 


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- 

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 


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. 



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 


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 

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- 


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 

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 


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- 

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. 


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; 


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 


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 


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 

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- 


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. 


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 

A Douche-Pan; the "perfection Bed-Pan" is pre- 

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

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





The nurse will explain how the various surgical 
dressings are made, but, as the patient may forget some 
of the directions, all the details will be given here. At 
least three to four pounds of absorbent cotton will be 
used in the dressings. To make the pads entirely of 
absorbent cotton is very expensive. The cheaper 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- 

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- 


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. 


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 


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 

At present, outfitters supply a variety of ready- 
made garments for the infant and conveniences for 
the nursery; in many of them notable ingenuity is 


displayed which aims at the child's comfort or the 
saving of labor to the mother. Catalogs of these 
articles, which are often expensive, are furnished by 

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 

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. 

_— — ■ 


Hot- Water Bag with Canton Flannel Covers. 
Talcum Powder. 
Olive Oil. 


Additional Articles; Convenient but Not Essential. 

Rubber Bathtub. 

Rubber Bath- Apron. 

Flannel Apron. 

Bath Thermometer. 

Bath Hamper. 

Quilted Mattress Covering. 

Baby Scales. 


Low Chair without Arms. 

Drying Frames. 


Sterilization. — Now and again, those who follow 
very rigid rules to avoid infection during childbirth 
are criticized for their pains. The general public 
has not yet grasped the true relation of bacteria to 
this condition; a relation which, indeed, first became 
clear to medical men within comparatively recent 
years. The development of our knowledge of the 
nature of infection forms one of the most 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 


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 


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 


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 


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- 


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 

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. 


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 


the supplies were prepared arrives; awaiting this 
event, they are laid away in a convenient closet or 

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 


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 


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 


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 
t every sort of discharging sore. 

When possible, two adjoining rooms should be 
given over to the mother and the infant; if this is 
impracticable, the single room should be large, easily 
ventilated, well lighted, and heated in such a way as 
to permit a change of temperature without difficulty. 
All these features help to make convalescence 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 


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 


both sides must remain freely accessible not only at 
the time of delivery but also throughout the lying-in 

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 


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- 

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 


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. 


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 

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 



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, 


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, 


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 


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 


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- 


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 


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- 


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. 


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- 



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- 

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 


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 

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 


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 


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- 

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


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- 

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 


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- 



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- 

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 


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 


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 


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- 


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 

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, 


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 


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- 


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 


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 


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 


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 


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 


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 

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 


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 

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 


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 


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 


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 


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 


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 


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 


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 


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 


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 



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. 


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 

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. 


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. 


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. 


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. 


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 


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- 


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- 


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 


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 


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. 


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 


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 


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 


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 

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 


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 


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. 


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 


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 

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 

Menstruation is more apt to return prematurely 
after the birth of the first child than of later ones. 
This may be due in part to a kind of accommodation 
of the maternal organism to the reproductive process 
as one pregnancy follows another ; but I am convinced 
that it is also due in part to the greater physical and 
mental composure of experienced mothers. Until a 
woman has learned the unwelcome consequences she 


is apt to take over household duties before she is 
equal to the task, or she may engage in too strenuous 
amusements ; and most mothers err in a too energetic 
care of the baby. 

Other Restorative Changes. — Many of the restorative 
changes in the mother's body are either so intricate 
or so devoid of practical significance that we may 
pass them by; though all of them have great interest 
for the specialist, and some have occasioned bitter 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 


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 

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 


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 

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 


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- 


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 


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 

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 


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 


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. 


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 


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 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 

The Time for Getting Up. — How long a woman 


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 

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 


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 


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 


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 


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. 



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 



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 


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 


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 

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 


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 

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- 


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 c o 
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- 


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 



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 


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- 

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 



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 

The successful training of a baby begins with the 
development of regular habits of nursing. The old* 


fashioned custom of allowing the baby to nurse 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 


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 

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 


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 


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 


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 


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 


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- 


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 

Psychic Influence. — Although the nerves of the 


breast which regulate the secretion of milk do their 
work whether the mother wills it or not, her state of 
mind has an influence over the process, just as it has 
over digestion. No one doubts that our minds 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 


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 


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. 


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 


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 


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- 

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 


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. 


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 

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 

Anemia. — A deficiency of some of the constituents of the 

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* 



Aseptic. — Free from injurious bacteria. 

Asphyxia. — The extreme condition caused by lack of a?cy- 
gen in the blood, brought about by interrupted 

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 

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 


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 

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. 


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- 

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- 

Food-stuff. — Anything used for the sustenance of man. 

Function. — The discharge of its duty by any organ of the 

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 

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. 



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- 

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, 

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 

Ovary. — The organ which contains the egg-cells or ova. 

Oviducts. — Two tubes, each of which leads from the neigh- 


borhood of one of the ovaries; both terminate in the 

Ovum. — An egg: the cell contributed by the mother to her 

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. 


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 

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 

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 

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. 


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, 

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. 


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, 

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


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, 

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

"Bag of waters," 36, 245. 

Bandaging after child-birth, 
280, 288. 



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, 
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, 
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," 

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 

quantity of, needed during 

pregnancy, 87. 
Cathartics, 100 (see also 

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. 




Cleanliness, 108. 

at the time of birth, 

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, 

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, 
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, 

while nursing an infant, 

Digestion, 82. 

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

following child-birth, 282, 

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

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

3 22 > 3 2 4. 

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. 



Examination when the pa- 
tient is discharged, 298. 

Examinations of the urine, 

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, 

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," 
Growth of the fetus, 54. 
Gymnastics, 130. 

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



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

relation of bacteria to, 

Involution of the uterus, 

Iron, a constituent of milk, 

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

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, 

course of, 241. 
difficult, 261. 

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

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. 



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, 

"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, 


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


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, 
Morning sickness, 12, 148. 

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

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. 



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, 
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, 

Quinin, 175. 

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



Relaxation, 135. 
Respiration of the infant, 

Rest, 135. 

Resuscitation, methods of, 


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. 

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

Supplies for confinement, 202. 
Supporter, abdominal, 119, 
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, 
treatment of, 253, 259. 

Underclothing, 113. 

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



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, 

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, 

Womb, 33 (see also Uterus). 

Work, influence of, upon 

pregnancy, 132. 
Worry, 151. 
effect of, upon lactation s 




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