Whitcomb & Barrows Digitized by the Internet Archive in 2016 https://archive.org/details/obstetricsfornur00dele_0 From an old Italian wax carving, evidently modeled after Hunter’s plates. one of OBSTETRICS FOR NURSES BY JOSEPH B*J^lLEE, A.M., M.D. Professor of Obstetrics, Northwestern University Medical School ; Obstet^ rician to Mercy, Wesley, Provident, Cook County, and Chicago Lying-in Hospitals; Lecturer in the Nurses’ Training Schools of Same FOURTH EDITION, THOROUGHLY REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY *914 •Dm IM MSilui Ut. - iLiEfifiBt OffiSrMW HIU, MA Q2IW Copyright, 1904, by W. B. Saunders and Company. Reprinted October, 1904 Revised, reprinted, and recopyrighted July, 1906. Reprinted February, 1907, and November, 1907. Revised, reprinted, and recopyrighted June, 1908. Reprinted January, 1909, June, 1909, January, July and October, 1910, March, August and November, 1911. Reprinted March, 1912,. October, 1912, and February, 1913. Revised, entirely reset, reprinted, and recopyrighted July, 1913. Copyright, 1913, by W. B. Saunders Company. Reprinted August, 1914, and November, 1914 PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO “THE WOMAN ABOUT TO BECOME A MOTHER OR WITH THE NEW-BORN INFANT UPON HER BOSOM, WHEREVER SHE BEARS HER TENDER BURDEN,” THIS BOOK IS RESPECTFULLY DEDICATED, PREFACE TO THE FOURTH EDITION For this, the fourth edition, both text and illus- trations were thoroughly worked over. In the text few changes were necessary, the fundamentals of ob- stetric nursing remaining about the same from year to year. Several subjects were added, such as the after-care of fistula operations, Momburg’s treatment for hemorrhage, and blood transfusion. The chapter on Infant Feeding was revised by Dr. F. X. Walls; that on Cesarean Section was much amplified in view of the more generalized performance of the operation, and the latest scientific discoveries of interest to the nurse were mentioned. A number of new illustrations have been added, and some of the old replaced by improved drawings and photographs. Four new colored plates also have been inserted. Joseph B. De Lee. 5028 Ellis Avenue, Chicago, III. 7 PREFACE Although this book is intended primarily for nurses, the author believes that medical students will find some- thing of value in it, since the duties of a nurse often de- volve upon them in their early years of obstetric practice. There are really two subjects considered in the book, — obstetrics for nurses and the actual obstetric nursing, — and the author has sought to combine them so that the relations of one to the other might be natural and mutually helpful in presenting this branch of medicine in a clear and interesting form. The illustrations are nearly all original, and were made expressly for the work. The photographs were taken by the author from actual scenes, and the reader is in- vited to study the details, as especial care was taken to render the pictures true to life in every respect. The text is the outgrowth of eight years’ lecturing to the nurses of four different training schools. For the preparation of the dietary the author acknowl- edges his thanks to Mrs. E. E. Koch, Superintending Nurse of the Chicago Lying-in Hospital, and for the chapter on the Infant’s Layette he is indebted to Miss Katherine DeWitt, who does private nursing for many of his cases. 9 TO PREFACE Dr. F. X. Walls kindly allowed the publication of a method of milk modification devised by him. Further, the author thanks those nurses and internes who have aided and posed in the settings for the photo- graphs, and the publishers, who have spared no effort in the production of the illustrations. JOSEPH B. DeLEE, CONTENTS Introduction PAGE 7-7 PART I Anatomy and Physiology of the Reproductive System CHAPTER I Anatomy of the Female Generative Organs 21 The Bony Pelvis, 21 — Varieties of Pelves, 26 — The Soft Parts, 28 — The Uterus, 28 — The Bladder, 31 — The Rectum, 31 — The Peritoneum, 31 — The External Genitals, 31 — The Vulva, 32 — The Perineum, 33 — The Anus, 34 — The Breasts, 35. CHAPTER II Physiology 37 The Function of Reproduction, 37 — Ovulation, 37 — Puberty, 37 — Menstruation, 38 — Conception, 40 — The Physiology of the Fetus in the Uterus, 46— The Placenta, 46. CHAPTER III Pregnancy, Labor, and the Puerperium 49 Maternal Changes in Pregnancy, 49 — Labor, 54 — Lighten- ing, 55 — False Pains, 56 — The Show, 57 — The Labor Pains, 58 — The Bag of Waters, 59 — The Puerperium, 61 — The Uterus, 61 — The Lochia, 63 — The Breasts, 65 — General Changes in the Puerperium, 66 — The Kidneys, 66 — The Bowels, 67 — The Skin, 67 — The Mental Condition, 67. CHAPTER IV The Newborn Infant 68 The Baby in the First Weeks, 68 — The Cry of a Newborn Infant, 68 — Sleep, 69 — Temperature, 69 — The Skin, 69 — The Navel, 70 — The Baby’s Bowels, 70 — The Kidneys, 70 — The Weight, 71. 11 12 CONTENTS CHAPTER V The Hygiene of Pregnancy Diagnosis of Pregnancy, 73 — Diagnosis of Time of Confine- ment, 74 — Mode of Living for the Pregnant Woman, 75 — Dress, 75 — Preservation of the Figure, 78 — The Diet, 80 — Exercise, 81 — The Mind during Pregnancy, and Maternal Impressions, 82 — The Determination of Sex, 83 — The Bowels, 84 — The Kidneys, 86 — Toxemia, 87 — Bathing, 87 — Care of the Genitals, 89 — Care of the Breasts, 89 — The En- gagement of the Nurse, 90 — Rules for the Obstetric Nurse, 92 — Sterilizing, 92 — The Nurse’s Visit, 95. CHAPTER VI The Infant’s Layette The Wardrobe, 97 — Nursery Conveniences, 100. PART II Nursing During Labor and in the Puerperium CHAPTER I Care during Labor Care during the First Stage, 103 — Preparation of the Room, 105 — Preparation of the Bed, 107 — Preparation of the Patient, 109 — Preparation for the Doctor, no — The Diet in the First Stage, 113 — The History-sheet, 114 — General In- structions, 1 14 — -The Husband, 117 — When to Summon the Doctor, 117 — Care during Second Stage, 118 — Scopolamin and other Anesthetics, 120 — Care during Third Stage, 125 — Perineorrhaphy, 129 — The First Care of the Newborn Child, 132 — Care after the Third Stage, 134. CHAPTER II Care during the Puerperium Daily Care of the Mother, 135 — The Breasts, 135 — Care of the Genitals, 138 — Special Care in Cases of Complete Laceration of Perineum, 140 — The History-sheet, 141 — Diet, 141 — The Bowels, 144 — The Bladder, 145 — Catheteri- zation, 146 — Sleep, 147 — General Treatment, 147 — Visitors, 148 — The Time of Getting Up, 148 — Nursing after Patient is Up, 150. CHAPTER III Care of the Child Visitors, 15 1 — Bathing, 151 — Care of the Navel, 154 — The Eyes, 155 — The Bowels, 156 — The Diaper, 159 — Urination, 159 — Nursing, 160 — The Diet, 164 — Weighing the Infant, 166 — The Temperature, Pulse, and Respiration, 167 — Training the Baby, 167. PAGE 73 97 103 135 CONTENTS 13 CHAPTER IV PAGE Presentations and Positions 169 The Diagnosis of Presentation and Position, 173 — Breech Cases, Shoulder, or Transverse Presentation, 177. CHAPTER V Obstetric Operations 178 Preparation for Operation, 180 — Preparation of the Room, 183 — Preparation of the Patient, 184 — Preparation of In- struments, 187 — Light and Heat, 187 — Anesthesia, 188 — Care after Operations, 188 — Care of the Child, 189— Care of the Mother, 190 — Major Operations, 190 — The Forceps, 190 — Duties of Nurse during Forceps Operation, 193 — The Walcher Position, 195 — The Breech Extraction, 196 — Version, 197 — Decapitation, 197 — Craniotomy, 198 — Prepa- ration for Mutilating Operations, 200 — Baptism, 200 — Cesarean Section, 201 — Preparation for Cesarean Section, 203 — Light, Heat, and Anesthetic, 207 — The Operation, 208 — The After-care, 209 — Convalescence, 210 — Vaginal Cesarean Section, 210 — Symphysiotomy, 21 1 — Pubiotomy or Hebos- teotomy, 21 1 — The Operation, 212 — After-care of Sym- physiotomy and Pubiotomy, 214 — Minor Operations, 217 — Preparation of Patient for Examination, 217- — Perineor- rhaphy, 218 — Removal of Sutures, 220 — Uterine Tampon- ade, 220 — The Douche, 222 — The Vaginal Douche, 223 — The Uterine Douche, 224 — -Uterine Curettage, 224 — The Administration of Saline Solution, 225 — The Induction of Premature Labor, 230 — Therapeutic Abortion, 234. PART III The Pathology of Pregnancy, Labor, and the Puerperiom CHAPTER I Obstetric Complications 237 Disorders of Pregnancy, 237 — Nausea and Vomiting, 237 — Hyperemesis Gravidarum, 238 — Prevention of Decubitus, 242 — Toxemia of Pregnancy, 242 — Edema of the Extremities, 243 — Varicose Veins, 243 — Leukorrhea, 245 — Pruritus, 245 — Pendulous Abdomen, 246 — Pain in the Abdomen, 247 — Heartburn, 248 — The Teeth, 248 — Frequent Urination, 248 — Fainting, 248 — Melancholia, 249 — Hemorrhages dur- ing Pregnancy, 249 — Abortion, 249 — Placenta Pnevia, 250 — Premature Detachment of the Placenta, 251 — Extra-uterine Pregnancy, 252 — Duties of the Nurse, 255 — Eclampsia, 256. CHAPTER II Complications during Labor 262 Breech Presentation, 269 — Prolapse of the Cord, 270 — Hem- orrhages during Labor, 272 — Postpartum Hemorrhage, 272. 14 CONTENTS CHAPTER III Complications of the Puerperium Puerperal Infection, 279 — Frequency and Source, 283 — The Prevention of Puerperal Infection, 284 — The Asepsis of the Nurse, 285 — Symptoms, 286 — Treatment of Puerperal Infection, 287 — Nourishment, 289 — Rectal Infusion of Saline Solution, 289 — Medicinal Treatment, 293 — Surgical Treatment, 293 — The Child, 293 — The Nurse, 294 — The Plistory-sheet, 295 — Disinfection, 296 — Puerperal Throm- bosis, 297 — Phlegmasia alba dolens, 297 — After-pains, 299 — Tympany, 299 — Constipation, 300 — Vesico- vaginal Fistula, 301 — Cystitis, 303 — Headache, 304 — Puerperal Insanity, 304. CHAPTER IV Complications of the Puerperium ( Continued ) Diseases of the Breasts, 307 — Simple Engorgements, 307 — - Abnormalities of the Nipples, 312 — Cracks, Fissures, and Blisters of the Nipple, 313 — Mastitis, 315 — Galactorrhea or Excess of Milk, 321 — Agalactia or Scarcity of Milk, 321 — Abnormal Milk, 325 — Drying up the Milk, 326 — Care of a Wet-nurse, 326. CHAPTER V The Disorders of the First Weeks of Life Affections of the Digestive Organs, 328 — Indigestion, 328 — Colic, 329 — Difficult Nursing, 330 — Vomiting, 330 — Con- stipation, 330 — Diarrhea, 331 — Green Stools, 332 — Inani- tion Fever, 333 — Thrush or Sprue, 333 — Bednar’s Aphthae, 334 — Marasmus, 334 — Affections of the Respiratory Tract, 335 — -Snuffles, 335 — Coryza, 336 — Bronchitis and Pneumo- nia, 336 — Cyanosis or Blue Babies, 337 — Affections of the Urinary Organs, 337 — Delayed Urination, 337 — Uric Acid, 338 — Phimosis, 338 — Circumcision, 338 — Dilatation, 341 — Affections of the Skin, 341 — Jaundice, 341 — Eruptions of the Skin, 342 — Vesicular Eruptions, 342 — Chafing, or Eciema Intertrigo, 343 — Other Affections of the Newborn Infant, 344 — -Enlargement of the Breasts, 344 — Vulvitis, 345 — Menstruation, 345— Delayed Separation of the Cord, 345 — Granulations of the Navel, 345 — Infections of the Newborn, 346 — Infection of the Umbilicus, 346 — Infection of the Eyes, or Ophthalmia Neonatorum, 347 — Care of the Nurse Herself, 352 — Infection of the Mouth and Throat, 352 — Hemorrhages in the Newborn, 352 — Operative Injuries, 353 — Injuries to the Brain, 355 — Caput Succedaneum, 356 — Cephalhe- matoma, 356 — Congenital Deformities, 356 — Monstrosities, 356 — Harelip, 356 — Cleft Palate, 356 — Occlusion of the Anus or Imperforate Anus, 356 — Tongue-tie, 357 — Supernumerary Fingers and Toes, 358 — Hernia, 358 — Sundry Complications, 358 — Convulsions, 358 — Lockjaw or Tetanus, 359 — Com- plications due to the Use of Hot-water Bags, 359 — Overlying the Child, 360 — Asphyxia Neonatorum, 360. CONTENTS 15 CHAPTER VI PAGE The Care of Premature Infants 365 The Incubator or Couveuse, 368 — Care of the Incubator, 373 — The Ventilation, 375 — The Bed, 375 — The Dress, 376 —Warm Feet, 377— The Diet, 378 — Method of Feeding, 380 — The Bath, 384 — The Care of the Eyes, Nose, Mouth, etc., 385 — General Care, 386 — Removal from the Incubator, 386 — The Particular Diseases of Premature Infants, 387 — Thrush or Sprue, 388 — Nasal Infection, 388 — Cyanosis, 389 — Atelectasis Pulmonum, 390 — Convulsions, 390. CHAPTER VII Infant Feeding 392 Contraindications to Maternal Nursing, 393 — Obtaining Milk for Analysis, 394 — Substitutes for Mothers’ Milk, 395 — Amount of Food at a Feeding, 400 — The Caloric Method of Feeding, 402 — Filling the Bottles, 403 — Sterilization of Milk, 403 — Quality of the Milk, 404 — Whey, 406 — Peptonized Milk, 407— Barley-water, 407 — Beef-juice, 408 — Artificial Infant Foods, 408. APPENDIX Visiting Nursing in Obstetric Practice 411 Care during Fabor Among the Destitute, 41 1 — Duties dur- ing the Puerperium, 414. Hospital vs. Home Nursing 419 Ward Care, 419 — In the Nursery, 420 — Recording of Symp- toms, 421 — Prevention of Accidents, 421 — Orders, 422 — Relations to the Patient, 423 — Economy, 423 — Methods of Sterilization, 424 — Sterilization of the Hands, 424 — Ftir- bringer’s Method, 425 — Hot-water and Alcohol Method of Ahlfeld, 425 — Halsted’s Permanganate Method, 425 — Author’s Method, 426 — Rubber Gloves, 426 — Sterilizers, 430 — Sterilization by Dry Heat, 431 — Preparation of In- struments, 432 — Sterilization of Brushes, 433 — Preparation of Dressings, 433 — Newspapers, 435 — Lysol Gauze for Tam- ponade, 435 — Plain Sterilized Gauze, 437 — Iodoform Gauze, 437 — Gelatin Gauze, 437 — Suture Material, 438 — Catgut, 438 — Silk, 438 — Linen Suture Yarn, 439 — Linen Bobbin for Tying the Cord, 439 — Basins, Pitchers, Douche-cans, Bed- pans, etc., 439 — Gowns, Aprons, Leggins, Towels, Sheets, and Pillow-slips, 440 — Tables, Chairs, the Bed, and other Fur- niture, 440 — Sterilizing Apartments, 440 — Preparation of Solutions, 441 — Sterile Water, 441 — Bichlorid of Mercury Solutions, 442 — Carbolic Acid Solution, 443 — Lysol Solution, 443 — Formalin Solution, 443 — Chinosol, 443 — Creolin, 443 — Salt Solution, 443 — Boric Acid Solution, 444. 16 CONTENTS The Obstetric Nurse The Nurse’s Dress, 446 — Deportment, 446 — Venereal Dis- eases, 448 — Gonorrhea, 448 — Syphilis or “Specific Disease,” 449 — General Consideration of Venereal Disease, 451. Dietary List of Diets, 452: — Absolute Milk Diet, 452 — Liquid Diet, 452 — Semisolid Diet, 452 — Diet for the Prevention of Over- growth of the Child, 452 — Prochownik’s Diet, 452 — Recipes, 453 — Albumin or Egg-water, 453— Barley-water, 453 — Beef-tea, 453 — Beef-juice, 453 — Beef-tea with Acid, 453 — Cereal Extract, 454 — Chicken Broth, 454 — Clam Broth, 454 —Champagne Whey, 454— Egg Lemonade, 454— Eggnog, 454 — Flaxseed Tea, 455 — Flour-ball, 455 — Gum-arabic Water, 455 — Junket, 455 — Koumiss, 455 — Meat Cure, 455 — Meat Diet, Raw, 456 — Meat-extract Ice, 456 — Milk and Egg, 456 — Milk Digested with Acid, 456 — Milk, Peptonized, Cold Process, 456 — Warm Process, 457 — Milk-toast, Pep- tonized, 457 — Milk, Sterilized, 457 — Milk-shake, 457 — Mutton Broth, 457 — Nutritious Coffee, 457 — Rice-water, 458 — Rum Punch, 458 — Toast-water, 458 — Whey, 458 — Wine Whey, 458 — Rectal Feeding, 459 — General Rules, 459 — Salt Solution, 459 — Peptonized Milk, 45c, —Peptonized Milk with Egg, 459 — Digested Beef, 460 — Fe e ng Through the Skin. 460 — Nasal Feeding, 461. Glossary PACK 444 452 Index 463 489 Obstetrics for Nurses INTRODUCTION Statistics show that of every 250 women who become pregnant, at least 1 dies. Seven per cent, of the deaths of women between the ages of twenty and forty years are due to puerperal infection. Con- servatively estimated, 20,000 women die every year in the United States from the immediate and remote effects of childbirth. Thousands of women enter our hospitals each year for the repair of injuries acquired during delivery, and seek- ing relief from the diseases caused by child-bearing. Nearly one- third of the blind people in this world have lost the light of day because of the ignorance or the carelessness of the attendants at the time of birth. What are the causes of these evils? The standard of obstetric practice is low. The people are allowed to believe that labor is a natural process and requires no special care. Therefore men with the best minds, with the greatest skill, find their endeavors better rewarded in other fields of medical practice. The public will not recognize, either with appreciation or with remuneration, the strenuous labors of the ac- coucheur, the nights’ rest lost, the interference with his other practice, the nervous wear and tear, and the actual technical skill he exhibits. Small wonder then 2 17 INTRODUCTION 18 that the field is deserted save by those who do the work to maintain a family clientele. The nurse may do much to aid the physician in obtain- ing from the public that recognition for obstetrics that the specialty so justly deserves. First, she may urge on the woman the importance of consulting the accoucheur early in pregnancy, so that complications may be anticipated and avoided. Second, she may aid the physician in obtaining aseptic conditions during the labor. The nurse should prepare for a con- finement just as she would prepare for a vaginal hyster- ectomy. She will meet opposition in this endeavor, especially from the older members of the family, but quiet insistence will be successful. She may explain to the patient that all the preparations are not because trouble is expected, but for the purpose of preventing trouble, and that accidents are more likely to occur if such preparations are not made. The nurse may allay the alarm of the parturient and the family when the accoucheur asks for sufficient medi- cal assistance. Most deliveries are accomplished by the physician alone, with the nurse and such help as the husband and a courageous neighbor may give. The accoucheur often has to work over a low bed, and in a small room with insufficient light. The people, from long custom, regard this proceeding as good. It is bad. This makeshift method is unjust — unjust to the par- turient, to the unborn child, and to the doctor and the nurse. No surgeon tolerates such conditions. Compare the advantages of the surgeon in his capa- cious operating room, with good light, sterile utensils, many nurses and assistants, with the plight of the obstetrician. Thus it is not far to go to explain the exist- ence of the evils referred to in the opening paragraphs. Why should not the woman about to perform the INTR OD UCTION 19 highest function of the race, at the most interesting, most endearing, and the crucial moment of her life, enjoy the greatest benefits, the finest art that the science of medicine affords? Thus in many ways the nurse may smooth the path for the advance of the obstetric art. She becomes really a missionary, spreading the gospel of good obstetrics. By the power of good example and by precept she will instil in the public mind a knowledge of the impor- tance of obstetrics and will engender a respect for the art which will soon result in a demand for higher standards of practice, and this demand will draw to the specialty the best medical and nursing talent the community possesses. Thus her efforts will redound to the benefit of the medical profession, of which she is a part, and lastly and mostly to the community — the people. Only in this way may we hope to see the frightful mortality tables shrink, and our hospitals emptied of women seeking relief from the injuries and diseases caused by pregnancy and labor. In this book the subject is divided into three parts. In the first part the anatomy and physiology of the whole reproductive cycle is considered — that is, a de- scription is given of the various processes, the changes in the genitals and general system, occurring during pregnancy, labor, and the puerperium. The second part deals with the conduct or manage- ment of pregnancy, labor, and the puerperium. The nurse is told how to care for a woman during each of these periods of the normal reproductive cycle. The third part treats of the pathology of pregnancy, labor, and the puerperium. In this part are considered, from the nurse’s standpoint, the complications which may disturb the normal course of the three stages of 20 INTR 0D UCTION reproduction, and how the nurse may do her share of the work of saving both patients from their baneful effects. In addition, there follow a few chapters on allied sub- jects, such as dietary, visiting nursing, and hospital and home nursing. by keeping these divisions of the subject in mind the nurse will find the study much simplified, and the book will be more easily grasped and rendered applicable to every-day practice. It is not to be understood that the treatment recom- mended in this book is to take the place of the doctor’s orders. The nurse should learn the practice of the physician with whom she works, and carry out this prac- tice in his cases. The author hopes that the book will be of help to her when she is on her own responsibility and for her general information. PART I ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM CHAPTER I ANATOMY OF THE FEMALE GENERATIVE ORGANS The parts of the woman’s person with which the ob- stetric nurse has particularly to do are the pelvis, includ- ing the soft parts, and the breasts. The Bony Pelvis. — The bony pelvis (Figs. 1-3) is that part of the skeleton interposed between the trunk 21 Fig. 1. — Normal female pelvis. 22 ANATOMY OF FEMALE GENERATIVE ORGANS and the thighs. It consists of four bones — two ossa innominata , the sacrum, and the coccyx. These are so Fig. 2 . — Female pelvis with ligaments, viewed from above (Dickinson). Fig. 3 . — Female pelvis with ligaments, viewed from below (Dickinson). united that they form two cavities — a greater or upper, or false pelvis, a smaller or lower, or true pelvis. THE BONY PEL VIS 23 The innominate bones flare outward like flanges, and leave a space in front which is filled out by the abdom- inal muscles, and behind, above the sacrum, the spinal column completes the false pelvis. The false pelvis is Fig. 4. — Female pelvis showing through torso. The uterus and adnexa are indicated in white. like a flat funnel, and has the function of directing bodies in the abdomen into the true pelvis. The broad flanging ossa innominata, with the abdominal wall, support the abdominal contents. 24 ANATOMY OF FEMALE GENERATIVE ORGANS The true or small pelvis is just below the large pelvis; behind, it is made up of the sacrum and the coccyx; at the sides, by the innominate bones; and in front, by the rami of the innominate bones. In front it is only 2 inches high, but behind it is 6 inches. The bony pelvis is exceedingly irregular in outline, having many notches, and several openings through which various structures — muscles, nerves, blood-vessels, etc. — pass. In general, the shape of the cavity of the true pelvis is that of an elbow of stovepipe. Where the true and false pelves join there is a more or less marked rim. This place is called the inlet, brim, or upper strait, the pelvis being narrower here (Figs. 2, 5). At the lower end of the true pelvis is the outlet (Figs. 3,6). The inlet is shaped like a flattened heart; the outlet, an antero- posterior ellipse, so that an ovoid body like the baby’s head, passing through the inlet in the transverse diam- eter, in order to escape from the outlet must turn its long diameter to correspond with the long diameter of the outlet (Figs. 7, 8). This occurs during labor and is called “rotation.” Since the cavity of the pelvis is curved — a bent canal -the head must slide along it, taking a curved course; THE BONY PEL VIS 25 and since the anterior part of the curve is shorter than the posterior, the part of the head lying behind will have Fig. 7. — Head of fetus at the inlet of the pelvis. Long diameter of head lies transversely. to travel a greater distance than the part lying in front. These are the things which the doctor must consider when he studies the mechanism of labor. Fig. 8. — Head of fetus at the outlet of the pelvis. Long diameter of head lies anteroposteriorly, ready to escape from pelvis. The pelvis is set into the body in such a way that when the woman is standing not all the weight of the 26 ANATOMY OF FEMALE GENERATIVE ORGANS abdominal viscera is forced down into its cavity: part is borne by the abdominal wall and pubis. When a woman constricts the abdomen in any way, as by a corset or a girdle, the viscera are forced downward, and since the false pelvis is a funnel leading into the true pelvis, the organs here are pressed down, and this may bring about prolapse of the uterus, blad- der, etc. (See Fig. 36.) Fig. 9. — Normal pelvis. Inlet in solid color. The pubes or symphysis pubis is the anterior junction of the two innominate bones. It is covered by a thick pad of fat, the mons veneris, and is strongly hirsute in most women. The pelves of two women are never ex- actly alike. Not one pelvis in 20,000 is exactly symmet- ric. There are characteristics in pelves as regards race, age, environment, occupation, and disease. Varieties of Pelves. — In general, there are four va- rieties of pelves — large, small, flattened, and distorted. THE BONY PELVIS 27 Finally, there are all sorts of combinations of these. A description of the various forms of pelves would fill Fig. 10. Fig. 12. Fig. 13. Figs. 10-13. — Fig. 10. Flat pelvis. Fig. 11. Generally contracted pelvis. Fig. 12. Generally contracted and flat pelvis. Fig. 13. Osteomalacic pelvis. The inlet in each case is shown in solid color. All were photographed to same scale. several volumes, and cannot be given here, but pictures of a few of the most marked deformities are presented (Figs. 10-13). The importance of deformed pelves is 28 ANATOMY OF FEMALE GENET AT/VE ORGANS great. If a pelvis is too large, the child may be forced through too quickly and tear the Soft parts, or may come in anomalous positions. If the pelvis is too small, the mechanical disproportion between the size of the pelvis and of the baby may make the delivery of the latter im- possible, or so difficult as to endanger its life or that of its mother. The same may be said of the other forms of contracted pelvis. Everything depends on the kind of contraction and its degree. A large woman seldom has a small pelvis; a very small woman seldom has a large pelvis. The Soft Parts. -The pelvis is lined and covered with soft tissues, some of which act simply as fillers; others are muscles for various working functions. Then there are special organs, as the bladder, uterus, vagina, rectum, and finally there are the blood-vessels and nerves. The large pelvis is lined with muscles, and is completed in front by the abdominal muscles. These serve to in- crease the funnel shape and to support somewhat the abdominal contents. The small pelvis has few muscles, but many important organs, vessels, nerves, etc. The Uterus. — This organ (Figs. 14, 15) occupies the middle of the pelvis, being suspended in the con- nective tissue and peritoneum from the walls of the pelvis. It is a flattened, pear-shaped body, 2\ inches long, ii inches wide, I inch thick, and weighs from 2 to 2i ounces. It is a firm organ, but when pregnant it grows very soft and increases enormously in size and capacity. It has two parts — the fundus and the cervix. The cavity of the uterus is usually closed by apposition of the walls; it is long, narrow, and flattened. The cervix has a little round opening called the os, through which the uterine secretions, the menstrual blood, during labor the ovum, and during the puer- THE SOFT PARTS 2 9 perium the lochial discharges, pass. In virgins it is a round opening; in women who have had children, a transverse slit. The uterus is attached at the middle of the cervix to the vagina , a sheath 4 inches long, terminating at an Fig. 14. — Section showing bladder, uterus, and rectum. Red line indicates the peritoneum. opening in the skin called the vulva. The vagina is a very elastic tube and lies between the bladder and the rectum. In ordinary conditions it will admit one or two fingers, but during labor it stretches to 4 or 5 inches in diameter. The uterus has, leading outward from its upper corners, two tubes — the Fallopian tubes. These 30 ANATOMY OF FEMALE GENERATIVE ORGANS are about the size of a crow’s quill, are tortuous, growing larger as they leave the uterus, to terminate in trumpet- shaped ends fringed with delicate streamers called JlmbricB. The canal of the tube likewise grows larger after it leaves the uterus. Thus there is a free passage through the vulva, the vagina, the os, the cervix, the uterine body, and the tubes to the fimbriated ends open- ing out into the peritoneal cavity. The organs just named are composed of walls more or less thick, made up of muscle and connective tissue, lined throughout with mucous membrane, and covered Fig. 15. — Uterus, tubes, and ovaries. On the right the ovary and tube have been laid open by peritoneum for part of the distance. The mucous membrane varies in quality in different portions of the canal, according to the function required of the part: at the vulva it is delicate and very sensitive; in the vagina, rough and strong; in the cervix and uterus, very vascular and velvety. In the uterus and tubes the epi- thelium is covered with a microscopic down which has the function of automatic waving like a field of wheat in the wind, thus propelling toward the outlet any object lying on the surface. The layers of peritoneum covering the anterior and posterior walls of the uterus meet at the sides of the organ THE EXTERNAL GENITALS 31 and form flattened bands stretching to the side walls of the pelvis, containing vessels, nerves, and a little fat, and called the broad ligaments. These have great import- ance in obstetrics. Attached to the posterior side of each broad ligament, and connected with one of the fim- briae or streamers of the Fallopian tube, is a little body, in shape and size like an almond, hard, fibrous, and dimpled — this is the ovary. The Bladder. -This organ (Fig. 14) lies in front of the uterus, behind the pubis. From the bladder, lying along the side of the cervix, the ureters run up out of the pelvis to the kidneys. In front of the vagina, just behind and below the pubis, lies the urethra , a small tube about the size of a lead-pencil, leading from the bladder to open in the upper part of the vulva The bladder empties itself through the urethra. The urethra ends in the vestibule of the vulva, the opening being called the meatus urinarius. The Rectum. — Behind the uterus, to the left side, lies the rectum (Fig. 14), or the last portion of the intestinal canal. It is continuous with the sigmoid flexure of the colon above, and terminates at the skin below in the anus. The rectum is a large, slightly convoluted tube, of much strength and great distensibility. Its course upward and to the left is noteworthy. A rectal tube in passing should take these directions. The Peritoneum. -The pelvic peritoneum, a thin, glis- tening, veil-like structure, a part of the general abdominal peritoneum, comes down from above and covers the top of the bladder, the uterus, the tubes, and the rectum. Thus a woman who has an infection of the genital organs may develop general peritonitis by simple continuity of surface. (See red line in Fig. 14.) The External Genitals. — The outlet of the bony pelvis is filled in by muscles and covered by skin. At 32 ANATOMY OF FEMALE GENE RATIVE ORGANS the sides of the lower end of the trunk the thighs are inserted, and between the two thighs lies a space called the genital crease or fold. This area extends anteriorly to the pubis and posteriorly to the sacrum, and when the thighs are separated it presents a small extent of sur- face, but when the legs lie close together the space is reduced to a deep groove. The front part of this region is occupied by the vulva, or external genitalia, the back part by the anus, while between these two is a small body composed of skin and muscle, called the perineum. The Vulva (Fig. 16). -This is made up of two more or less heavy lips or labia — the labia majora — composed of skin and fat, covered with hair, and abun- dantly supplied with sebaceous glands. The labia terminate anterior- ly in the mons veneris , a pad of fat covering the pubis. Behind they spread out in the peri- neum. Beneath and be- tween the labia majora are two smaller labia, called, in contradistinc- tion, the labia minora, made up of thin skin and mucous membrane. Anteriorly the labia minora meet and form a hood, which covers a little erectile organ, the clitoris; pos- teriorly they disappear at the sides of the outlet of the vagina. The clitoris is attached to the under surface of THE EXTERNAL GENITALS 33 the pubis, and is a little elongated mass of blood-vessels covered by mucous membrane. It is protected by the hood aforementioned. It is very sensitive. Under the hood, smegma, a whitish, flaky material, being the dried secretions, is likely to collect and form a lodging place for germs, an important point for the nurse to know. It is a serious error of technic for the nurse to leave smegma under the hood of the clitoris in her prepara- tion of the patient for labor or operation. Below the clitoris is a flat, triangular area, covered by mucous membrane — the vestibule — at the lower part of which are two little raised ridges with an opening between them — the mouth of the urethra, the meatus urinarius — through which the urine is voided. Below this opening is the outlet of the vagina, sur- rounded by a fringe of mucous membrane called the hymen. The hymen lies at the opening of the junction of the vagina with the vulva, is a thin, circular structure, and tears when the child pushes through if it has not been torn during the first conjugal relation. The shape of the hymen varies in different women: some have hardly any; in others it covers the opening of the vagina and may have only a pin-hole perforation, or, in rare cases, no opening at all. It may be sickle-shaped or have several perforations. Between the hymen and the terminations of the two labia majora in the perineum is a boat-shaped depression — the fossa navicularis; and at the junction of the two labia majora is the posterior commissure or fourchet , a band of skin forming part of the fossa navicularis. The Perineum. — The perineum lies between the vagina and the anus. It is composed of skin, connective tissue, and muscle, separating the vulva from the anus, Since the vagina leads forward and the anus backward, there is a triangular space between their outer termina- 3 34 ANATOMY OF FEMALE GENERATIVE ORGANS tions. This space is filled up by the triangular perinea } body. During labor, when the head comes down through the vagina, it stretches the vulva open and pushes the perineum backward against the anus and rectum, flatten- ing it out. During the passage of the child the perineum is often torn, which is unfortunate, as the integrity of the tissues and organs above it is partly dependent upon this structure. Of more importance are the tears of the pelvic floor, which are hard to find and are usually overlooked by the general practitioner. When the peri- neum is torn deeply the anus and rectum may be laid open. This is a sad accident, as the woman may thus lose control of the bowel. Immediate repair of all injuries should be made. The Anus. — About ij inches below the fourchet is a deep, pigmented, puckered opening — the anus. This is the outlet of the rectum. The skin of the perineum dips down into the anus a short distance to meet the mucous membrane of the rectum. Underneath the skin and mucous membrane lies a network of large veins. If these veins become overdistended with blood, as occurs sometimes during labor, they form very painful masses, called hemorrhoids , or piles. The anus is held closed by a circular muscle, in size and shape not unlike a broad wedding ring — the sphincter ani. This muscle controls the passage of feces and gas. It is occasionally torn during delivery, the so-called “complete laceration,” and if not success- fully repaired allows the rectal contents to escape un- hindered. This condemns the patient to social ostra- cism, and the accoucheur, therefore, bends every effort to preserve this small but important muscle. THE BREASTS 35 THE BREASTS The breasts belong to the genitalia, since they take an important part in generation. They are located over the anterior part of the chest, but in very rare cases may be located in other parts of the body or be more than two in number. One woman had five— on the chest, back, side, and thigh. They are glands modified from skin glands to perform a different function, and belong to the compound racemose clustering type. Each breast is made up of lobes; these are divided into lobules, and each lobule is composed of minute cells or acini. A tube from each lobule leads into a main canal, which opens on the surface of the nipple as a fine duct. These tubes collect the milk from the acini and discharge it through the nipple (Fig. 1 7) . Before opening on the nipple each duct enlarges, forming a spindle-shaped cavity, called the sinus lac- tiferus. Each lobe of the breast may be likened to a bunch of grapes, and the milk- ducts to the stems. Each breast has from fifteen to twenty lobes, and the ducts leading from these lobes are all brought together in f ig. 17. — Semidiagrammatic section of the nipple. Between the a functionating female breast. lobes or bunches the irregu- lar spaces are filled with fat and connective tissue. The gland rests on a bed of connective tissue, which 36 ANATOMY OF FEMALE GENE FA FIVE OF G A NS separates it from the chest muscles, ribs, and inter- costal spaces. The outside of the gland is covered by skin which is more delicate than that of the remainder of the body, and allows the blue veins to show through. The nipple is raised \ to \ inch above the surface. In brunets it is darkly pigmented, in blondes it is pink. At its base is a circular area, likewise pink or pigmented -The areola. This area contains small nodules, the tubercles of Montgomery , which grow more prominent during pregnancy. These are little glands, and occa- sionally a few drops of milk may be squeezed from them. They also are liable to infection. CHAPTER II PHYSIOLOGY THE FUNCTION OF REPRODUCTION Ovulation. — The main function of the ovary is the production of ova or eggs. It probably possesses other functions as a blood and nerve regulator, but we do not understand them. It elaborates an internal secre- tion and this affects other organs of the body, particularly the uterus. The ovary of a newborn child contains from 20,000 to 50,000 ova. These ova remain quiescent until the girl is about eight or ten years old, when they begin to develop to maturity and are periodically expelled from the ovary. This function is called ovulation. Ovulation is the ripening of an ovum and its discharge from the ovary. The greatest activity of the ovary occurs at the time of puberty — that is, from the twelfth to the sixteenth year. Puberty. — This is the period at which the individual becomes capable of reproduction. It begins in males from the fourteenth to the seventeenth year; in females, from the twelfth to the fifteenth year. The changes occur more rapidly and are more marked in the female. They are both physical and psychical. The body develops quickly and the breasts enlarge. The external genitals increase in size and become covered with hair. The mind changes in the three parts : the will, the in- tellect, and the emotions. The will becomes uncertain and hysteric manifestations are common The emo- tions develop, together with a sense of modesty. 37 PHYSIOLOGY 38 This transformation is the outward expression of the changes going on in the internal organs of generation — the ovaries, uterus, and tubes. Though ability to repro- duce is present at puberty, fitness is not. The best year for the woman’s first child is about the twenty- third, but children have been born to mothers of nine and of sixty- two years. The advent of puberty is marked by the inauguration of a new function — menstruation. Menstruation may be defined as the appearance, monthly, of a discharge of blood from the genitals, attended by general symptoms of malaise and disturbed nerve equilibrium and local symptoms of congestion of the uterus and neighboring organs. It is one of the Fig. 18 — Three weeks’ ovum in sac (natural size). Note the fine shaggy coat, the threadlike villi. external indications of the changes in the ovary produced by ovulation and the stimulation of the whole nervous system which this function causes. The uterus presents most marked changes during menstruation. It is en- larged, softened, and turgid with blood. The mucous membrane is much thickened, soft, presenting a deep-red, velvety appearance. Blood oozes from the surface, mixes with the natural, but augmented secretions from the whole genital tract, and altered in color and odor, escapes from the vulva. After from three to seven days the discharge ceases, the tumefaction of the uterus and mucosa disappears, and the latter has resumed its smooth, pink appearance. THE FUNCTION OF REPRODUCTION 39 Menstruation presents many peculiarities as to fre- quency, duration, amount, and quality in different women. In some women it recurs every twenty-one days; in others, every twenty-eight or thirty days. It lasts from three to seven days — usually five days. In some races, as the Orientals, the first menses appear at the age of thirteen; in others, as the Europeans, at four- teen and fifteen years. Normally there is no actual Fig. 19. — Six weeks’ ovum in sac (natural size). The little fetus, about the size and shape of a kidney bean, is inside the translucent sac. pain, though many women do suffer some soreness and distress. Women are more nervous and irritable during the period, more subject to cold, headaches, etc. Some women experience about midway between the periods symptoms resembling those of the menses, but without any bloody discharge. Ovulation usually occurs every month at the time of menstruation, and the ovum is expelled from the ovary, passes down the Fallopian tube through the uterus, and 40 PHYSIOLOGY is lost with the menstrual blood. The changes in the mucosa of the uterus were designed to prepare it for the reception of the ovum, in case it should be made fertile by union with a male element, and to favor its attach- ment to the uterus and its further development there. This preparation of the mucous membrane of the uterus is called nest-building. Conception. — The union of the female element, the ovum, with the male element, the spermatozoid, is called 3 4 Fig. 20. — Early human embryos, all enlarged about two and a half times: i, Second week; 2, third week; 3, fourth week; 4, fifth week; am, amnion; uv, umbilical or vitelline vesicle; als, allantoic or abdominal stalk; c, brain-vesicles; h, heart; 0, optic vesicle; ot, otic vesicle; ol, olfactory pit; s, somites; cd, caudal process (His). fertilization, fecundation, impregnation, or conception. This union may occur in the tube or in the uterus — pre- sumably in the tube. After it occurs, and only then, the ovum thus fertilized readily becomes attached to the velvety uterine mucosa. No menstruation occurs, and the mucosa undergoes the changes incident to pregnancy. The woman is now pregnant, and mighty changes are inaugurated in the little ovum clinging weakly to the THE FUNCTION OF REPRODUCTION 41 mucous membrane of the uterus, and also in nearly every part of the woman’s body. At the very beginning the ovum is a tiny vesicle, hardly visible to the naked eye; in two weeks it has grown to the size of a large pea, and in four weeks to that of a walnut. It is a sac covered with a shaggy coat of deli- cate branched threads called villi. (See Fig. 18.) These villi dip into the uterine surface and bring nutrition and Fig. 21. — Two months’ pregnancy, showing the fetus in the uterus (one-half natural size). oxygen from the mother to the child. At this time the child is hardly recognizable as such. At eight weeks the ovum has attained the size of a lemon, and the surface has become differentiated into a protecting part and a nutritive part — the placenta. The villi at one portion of the ovum have grown enormously, are intertwined into a compact mass attached to the uterus, supplied with blood from the maternal circulation, and communicating 42 PHYSIOLOGY by means of the umbilical cord with the body of the child. The mass of intertwined villi is called the placenta. The rest of the covering of the ovum not occupied by the placenta is simply the membranes, serving to contain a fluid in which the child swims, and shutting the interior off from the outside world. The fluid is called liquor amnii. The child at this time is completely formed; it is Fig. 22. — Fetuses of the second, third, and fourth months of pregnancy (three- fifths natural size). about 3 inches long, the head being nearly as large as the rest of the body. At sixteen weeks the ovum is about as large as a man’s two fists, and presents in miniature all the appear- ances of the ovum at term. At nine months, or “term,” or “full time,” the completion of pregnancy, the uterus resembles in size and shape a watermelon. The child lies in it, usually with head down, completely formed, THE FUNCTION OF REPRODUCTION 43 ready for delivery. (See Frontispiece and Plate II.) The placenta is well developed, lying usually on one side of the uterus, far from the internal os. The umbilical cord connects the placenta with the child ; it is as thick as the little finger and much twisted. The liquor amnii is usually about enough to fill up the spaces left between the body of the child and the uterine walls lying against it. The head o f the fetus throughout pregnancy is mark- edly developed, and during delivery usually gives more trouble than the body. The vault of the skull is made up of four bones : at the sides are the parietal bones ; at the front, the frontal; at the back, the occipital bone. The bones forming the vault of the cranium are not joined fast together as in the adult, but are connected by soft membranes, leaving sutures and fontanels at their contiguous borders (Figs. 23, 24). Between the parietal bones is the sagittal suture; between the parietal and occipital bones, the lambdoid suture; between the parie- tal and frontal bones, the coronary, and in the frontal bone, the frontal suture. Where the two parts of the frontal and the two parietal bones meet lies an open, four- cornered, lozenge-shaped space filled in by membrane, called the anterior or large fontanel , and where the parietal and occipital bones meet lies the posterior or small fon- tanel. This is really no opening, but the meeting of three sutures. This arrangement of bones, sutures, and fontanels is designed to allow the head to mold and adapt itself to the mother’s pelvis during labor, so that it may pass through with the least resistance and injury to both head and pelvis. After a prolonged labor in a primipara the head is sometimes drawn out almost to a sausage shape. Should the child have been delivered with the face first, a corresponding molding takes place and the head assumes a different shape. During the first days after labor the bones resume their proper relation to each 44 PHYSIOLOGY Fig. 23. — Fetal skull at term, showing fontanels. Side view, showing the coronary suture to left; the lambdoid below and to the right; the lateral suture below and in the center (Dickinson). Fig. 24. — Fetal skull at term. Seen from above and showing the small fontanel at upper pole of figure; the large or anterior fontanel below; the sagittal suture in the center; the coronary suture at the sides of the large fontanel; the frontal suture leading down from the large fontanel (Dickinson). THE FUNCTION OF REPRODUCTION 45 other, the overlapping sutures broaden, the bones them- selves straighten out, and the deformity, which may have alarmed the mother, disappears. The child in the uterus lies folded together : the legs are bent on the thighs, the thighs on the belly, the forearm on the arm, the arms across the chest, the head bent down over the breast (Figs. 25, 26). There are not in- frequent changes in the attitude of the child, for ex- Fig. 25. — Side view of fetus, showing Fig. 26. — Front view of fetus, showing the attitude it holds in the uterus. the attitude it holds in the uterus. ample, the chin may leave the chest and be stretched upward, in so-called face presentation, or the arms may leave the chest and prolapse before the head. At term the infant weighs about 7 pounds; the pla- centa, 1 1 pounds, and there is about 1 quart of liquor amnii. The average weight for the newborn girl is 7 pounds; for the boy, 7 } pounds. The boys, therefore, give more trouble in delivery, and consequently more of 46 PHYSIOLOGY them die. The first child is usually smaller than sub- sequent children; io-pound babies are rare, and chil- dren weighing over 12 pounds at birth are very excep- tional indeed. THE PHYSIOLOGY OF THE FETUS IN THE UTERUS The general metabolism of the child is similar to that of the adult. The fetus has, however, no respiratory function, very insignificant digestive action, and little skin function, since these are hardly necessary, its mother performing them for it. It has its own heat-producing and regulating mechanism, as is shown by the fact that the child’s temperature is \ degree higher than that of its mother. It gets oxygen from the mother through the placenta, also water and food prepared for assimilation. A small portion of the food comes from the liquor amnii which the infant swallows. The waste-products from the child, and the carbon dioxid which the adult exhales from the lungs, in the infant pass through the placenta to the mother, and are excreted by her organs. All this is accomplished by way of the placenta. The Placenta. — This organ resembles a flat cake. The umbilical cord leading from the child is inserted on one side, while the other is attached to the inner surface of the uterus. The mother’s blood flows in and around the placenta. After the child is delivered the placenta is separated from the wall of the uterus and expelled. This important organ is made up of a number of lobes, each lobe containing a large number of trees of chorionic villi. A villus is a tiny, fingerlike filament which dips into the maternal blood in the placenta and through which the above-mentioned changes take place. A de- scription of the villi would take too many pages. Each nurse should shred or tease a piece of placenta with a PLATE J Diagrams to show the relations of the maternal and fetal circulations. PHYSIOLOGY OF THE FETUS IN THE UTERUS 47 pin, and float it in a glass of water, when the fine ele- ments or villi will be prettily shown (Fig. 27). The blood of the child flows through the vessels of the cord to the placenta, then through the inside of the villi, and the villi dip into the maternal blood, and since there is no direct connection between the blood of the fetus and that of the mother, the changes must occur by osmosis and the vital cellular activity of the wall of the villus. Water, oxygen, and food go to the fetus through the villus; carbon dioxid and waste-products go from the fetus to the mother in the same way. The villi, there- fore, are like the roots of a tree, drawing water and sus- tenance from the ground. The sap of the tree within the roots does not get into the ground, yet water and susten- ance get into the sap through the outer covering of the roots. The blood of the fetus, laden with carbon dioxid and waste materials, goes to the placenta through the umbilical arter- ies, and returns to the child by the umbilical vein, carrying oxygen, water, and food. (See Plate I) . The blood of the umbilical vein is red, while that in the arteries is venous, or dark, which is the reverse of the usual. The liver of the child is very active, and, therefore, large. It reaches half-way to the navel. The stomach and intestines have weak digestive power. The child drinks the liquor amnii, as is shown by the lanugo which Fig. 27. — A piece of placenta teased and hung in a glass of water. 48 PHYSIOLOGY is found in the meconium. The kidneys act and the urine is voided into the liquor amnii. This action is very small indeed, and may not begin until labor has begun. The child moves about, changing from uncomfortable positions to others. It sometimes has hiccup and it sucks its thumb in the uterus, and tiny respiratory move- ments are sometimes observed. The hiccup is an in- teresting phenomenon. The women say they can dis- tinguish regular attacks of hiccups. The child makes rhythmic, jerky movements, recurring about eighteen to the minute. Often the infant stretches, and the mother gets to know its habits, which may correspond with those after birth. The child has periods of rest and activity. Sometimes the activity is so great as to dis- turb the mother’s rest and require treatment. The men- tal conditions of the fetus have been the subject of much speculation. While the child suffers pain when hurt, the sensation is not as developed during birth as it is shortly after. CHAPTER III PREGNANCY, LABOR, AND THE PUERPERIUM MATERNAL CHANGES IN PREGNANCY The development of a new life in the uterus, the per- formance of the new function — reproduction — is at- tended with decided changes in the whole being of the woman. No part of the body fails to feel the stimulus of the reproductive function. These changes are divided into two classes: first, local changes — those found in the genitals and the breasts; second, general changes — those involving the rest of the body. Local Changes.- -The uterus in the virgin state is small, weighing about 2 ounces. It grows during preg- nancy to a sac so large that it reaches almost to the ribs, and weighs, when empty, about 2 pounds. As preg- nancy advances the walls of the uterus grow thicker and more powerful, the muscle-fibers become stronger and increase in number, and the uterine muscle develops the functions of contractility and retractility to a high degree. The uterus grows of itself faster than the grow- ing ovum distends it, and when the child is ready for delivery the uterus is a powerful hollow muscle. It ex- pels the child and after-birth with great force, and gentleness withal. The blood-vessels also increase in size and number. Some of the veins are as large as the finger, especially those in that part of the uterus to which the placenta is attached. The lymphatics throughout the pelvis are also enlarged. The vagina 4 49 50 PREGNANCY, LABOR , AND THE PUERPERIUM and vulva become softer, more dilatable, and there is an actual increase in size. All these changes are brought about by nature in preparation of the parts for the safe delivery of the child. The uterus is developed into a strong muscular engine, while the vagina and vulva are softened and prepared for the great distention they will suffer when the child is forced through them. The breasts enlarge early in pregnancy: sometimes there are a tingling and a sensation of fulness and Fig. 28. — The breast in pregnancy. Brunet. Shows the primary areola and a marked secondary areola. weight as early as the fifth week. The nipple enlarges and becomes more erectile. The primary areola darkens by the deposit of pigment, the tubercles of Mont- gomery in it enlarge, and the areola is puffy and slightly raised. (See Fig. 28.) Later in pregnancy a little clear fluid streaked with yellow can be ex- pressed from numerous openings on the nipple. This is called colostrum. Around the primary areola some- times a secondary areola forms. The secondary areola is commoner in brunets, and resembles dusty paper with a sprinkling of water drops. This pigmentation of the MATERNAL CHANGES IN PREGNANCY 51 breasts is especially marked in brunets, and in negresses the nipples may be almost black. Light purplish, radi- ating lines sometimes appear around the periphery of the breasts. These are called linea or striae gravidarum, are more numerous in blondes, and, after nursing is com- pleted, remain as fine, white, linear scars. Blue veins often show through the skin, which is a sign of good omen, as it promises a sufficient milk supply. Sometimes the breasts grow so large and heavy that some form of artificial support is necessary. General Changes. -Every tissue and fiber in the woman’s body feels the impetus of pregnancy. Mau- riceau said that pregnancy was a disease of nine months’ duration. This is not strictly true, though many women suffer much throughout the whole period. Many women feel best while pregnant, and some are perma- nently benefited. Pregnancy tests the integrity of every organ in the body, and if any one of them is diseased the fact will usually be brought out. The blood is increased in amount in the last months of pregnancy and its clotting power augmented, nature thus preparing for the loss of blood during labor. The heart is a little enlarged ; the veins of the legs are usually more or less varicose, thus forming reservoirs of blood. The thyroid gland in the neck, the spleen, and all the blood-making organs increase in size and activity. The lungs are pushed upward by the uterine tumor, but their capacity is increased, as the chest is actually broadened. The respiration becomes thoracic. If the uterus is over distended, it pushes the abdominal organs up against the diaphragm, interferes with the action of this muscle, and thus causes great difficulty in breathing. The Urine . — The total quantity of urine is increased. The specific gravity is often low. Sugar in traces is sometimes present, also albumin in traces, but these are 52 PREGNANCY, \ LABOR, AND THE PUERPERIUM always significant, and the patient requires close obser- vation and a physician’s care. The sugar is usually milk-sugar from the breasts. True diabetes is very seri- ous. The kidneys and liver are the weak spots of the patient during pregnancy and deserve special attention. The patient usually puts on fat. The hips round out and there is a gain in weight — usually one-thirteenth of the ordinary weight in the non-pregnant state; but the woman may get very fat. Part or all of this may disap- pear afterward, especially if the mother nurses her infant. It seems as if nature lays up a stock of heat and energy in the form of fat for the labor and lactation. The skin often turns darker, especially in brunets and in all women there is some pigmentation of the linea alba, the navel, and the nipples. The pigment is largely reabsorbed after delivery. Occasionally the face is al- most covered with a brownish pigmentation resembling freckles closely run together — the so-called “mask of pregnancy.” This likewise disappears nearly completely after labor. The sebaceous and sweat-glands are more active, and the active perspiration makes the patient more liable to colds. Lineae or striae gravidarum, the purplish lines described as occurring on the breasts, ap- pear on the abdomen in larger number and sometimes on the thighs (Fig, 29). These striae are due to the stretch- ing of the skin, and are more common in some women than in others. Occasionally they are absent, though the woman has had several children. The Mouth . — The salivary secretion is increased, some- times pathologically, so that there is constant dribbling of saliva. This latter is called ptyalism and is similar to the excessive vomiting of pregnancy, with which it is fre- quently associated. The physician is to be informed of it. The teeth easily decay. There is an old saying, “every child a tooth.” This decay is due to the change MATERNAL CHANGES IN PREGNANCY 53 in the secretions in the mouth, not, probably, to the child using up the lime salts of the body. (For the Treatment, see page 248.) The patient is sometimes sick at the stomach in the morning — the so-called “morning sickness ” — and this Fig. 29. — Striae gravidarum. is one of the diagnostic points of pregnancy. Taste is perverted; the patient craves all sorts of unusual things, which are sometimes indigestible. One may humor these peculiar cravings if the article is not harmful. Sometimes these cravings evidence insanity, as in the case of a woman who craved a bite of her husband’s arm 54 PREGNANCY, LABOR , AND THE PUERPERIUM and actually took it. The wife of Camerius, a famous botanist of the sixteenth century, enjoyed herself during pregnancy by breaking eggs on her husband’s face. Owing to the cramped position of the bowels, con- stipation is a common symptom, which grows worse as pregnancy advances and always requires treatment. (See page 84.) The Nervous System . — Women are more sensitive and irritable during pregnancy; sometimes there is a change in character, for example, pyromania, kleptomania de- veloping. Sweet-tempered women may be soured, and vice versa. Sometimes they are morally uncertain, showing impaired judgment of right and wrong. Neural- gias, especially of the face and teeth, are common. One must exercise care in the extraction of teeth to relieve the pain, as healthy teeth may be needlessly sacrificed. Sometimes there is prickling of the skin in the extremi- ties, or a general itching which may resist treatment. It is thus seen how gestation tests the integrity of every structure in the body. LABOR Pregnancy begins with conception and ends with the expulsion of the fetus and secundines from the parturient canal. It lasts normally ten lunar months, forty weeks, two hundred and eighty days, though the time may be two weeks more or less. In some women the fetus de- velops quicker than in others, a child at eight months equaling the children of others at nine months. The process by which the fetus and secundines are expelled is called labor. If labor should come on two weeks before its expected time, or at any previous period in the last three lunar months of pregnancy, we call it prema- ture. The child is viable at the end of seven lunar months or twenty-eight weeks. It is not strong and may LABOR 55 die shortly after birth. Any interruption of pregnancy after viability of the child, but before two weeks before the expected time of labor, we call premature labor. Should a woman go into labor and expel the product of conception before the child is viable — that is, capable of carrying on extra-uterine existence — we speak of abor- tion. Abortion , therefore, is the interruption of preg- nancy before the end of the twenty-eighth week. The women call all premature interruptions of gestation “miscarriage”; the term abortion to them means a criminal process, and, therefore, if one employs it, one should not fail to explain its scientific significance. When labor is over the uterus immediately begins to return to its original size. This is called involution. At the same time a powerful stimulus is given to the breasts — lactation is established. Labor may, therefore, be defined as that function by which the fetus and secundines are expelled through the natural passages, the retrogressive changes in the genitals started, and the secretion of milk inaugurated. There are three points to this definition. The cause of labor — what influences the uterus which has carried its burden so long, suddenly and violently to expel it — is not known. Labor does not usually come on without warning: there are premonitory symptoms. Usually the woman feels heavy and unwieldy in the last weeks, her gait is laborious, the bowels may become loose, urination more frequent, a free discharge of mucus from the genitals may be noted, and she has fleeting pains in the abdomen and elsewhere. There are three distinct signs that the time is nearing — lightening, false pains, and the show. i. Lightening. In the last two weeks, especially in primiparae, the child’s head sinks into the pelvis and its body falls a little forward. The uterus sinks down and forward with the child. The waist-line lowers, the stom- 56 PREGNANCY, , LABOR , AND THE PUERPER/UM ach region is flatter, the navel more prominent. The patient breathes easier, but walks less well. The head, entering the small pelvis, interferes with the bladder and frequent urination results. The rectum suffers also, and the bowels are constipated. This phenomenon is called “ lightening” or “ dropping” by the people, and is sometimes attended with slight pains similar to labor- pains (Figs. 30 and 31). It is a good sign, indicating that there is no mechanical disproportion between the Fig. 30- Fig. 31. Figs. 30 and 31. — Silhouettes of a woman before and after lightening occurs. head and the pelvis — that is, that the head is not too large for the pelvis. 2. False Pains. — Sometimes, especially in multi- part, for a few days to three weeks before labor the patient is annoyed by pains in the abdomen. These often occur at night and pass off by morning; they are sometimes due to gas in the bowels, when they are re- lieved by castor oil and an enema. They are sometimes due to painful uterine contractions, which subside after a hot bath, a warm drink, and an enema. In rare LABOR 5 7 cases an anodyne is needed. These false pains are annoying, as they may closely resemble actual labor and summon the physician and nurse unnecessarily. 3. The Show. -A few hours to twenty-four hours before labor really begins there is a discharge from the vagina of thick mucus, more or less stained with blood. This is called the show, and is the plug of mucus which fills the cervical canal during pregnancy. Sometimes the show is absent or appears after labor has been in prog- ress for a while. If there is any pure blood with the show it is unusual, and the physician should be notified. The bag of waters may rupture as the first indication of approaching labor. This is undesirable, because the most favorable means of dilating the mouth of the uterus is thus lost. The patient then has what is known as a “dry labor,” which is often slow, tedious, and painful. Labor is divided into three stages: The first stage extends from the time of beginning of the labor-pains to the complete dilatation of the os uteri. It is called the period of dilatation. The bag of waters usually ruptures at the end of the first stage. The second stage comprises the period from the time of complete dilatation of the cervix to the end of the expulsion of the child. It is called the period of ex- pulsion. The third stage extends from the time of expulsion of the child until the after-birth has been expelled, and the uterus has contracted down on itself. It is called the placental stage. If one observes a labor critically, the process makes the impression of being a mechanical operation, consisting of the action of some expellent power on the fetus and pla- centa, forcing them through the maternal parts into the external world. Thus the factors of this mechanical operation are: the powers (the forces that prepare the 58 PREGNANCY, LA BOP, AND THE PUEKPERIUM way and drive the child, etc., along), the passages (the cervix, vagina, vulva), and the passengers (the child, placenta, etc.). The passengers — the child and placenta — have been described on pages 41-46. The passages, too — the pelvis, vagina, and vulva — have been described on pages 21-28. The powers remain to be studied. They are mainly two — the uterus, a hollow, strongly muscular organ, and the abdominal muscles. The abdominal muscles act during the second stage of labor as they do in procuring an evacuation of the bowels, that is, by bearing down or straining. The force thus exhibited is sometimes enormous, and the patient may injure herself if it is not properly restrained. The uterus acts by rhythmic con- tractions called “pains.” All three stages of labor are characterized by pains. These pains represent uterine contractions, and the two terms are used synonymously. Uterine contraction in all languages is expressed by the same word that means pain — for example, in German, Wehen; Italian, dolor es; French, douleurs. The Tabor-pains. — The uterus contracts at irregu- lar intervals throughout pregnancy, but there is no pain. Late in pregnancy there may be some pain, but usually when the uterine contractions become painful labor has begun, and this is our most reliable outward sign of the advent of labor. When the “pains” begin and become rhythmic we consider the woman in labor. If one observes the abdomen when a pain comes on — that is, when the uterus contracts — one feels the organ harden all over; it rises toward the ribs and stands out more prominently. With a strong pain the uterus becomes almost boardlike in hardness. As the pain goes away the uterus softens and loses its sharp contour, and the abdomen flattens. LABOR 59 In the beginning of labor the pains are far apart, but as it progresses the intervals decrease gradually, being one hour, thirty minutes, fifteen, ten, six, five minutes, until, toward the very end, one pain follows almost im- mediately after the other. The nurse may judge the rapidity of the labor by the frequency and strength of the pains. The parturient feels the pains at first in her back (the “kidney pains” of the French), and they are not so painful, but as labor goes on they are felt more to the front and are severer. When the woman is well on in the first stage she describes the pains as grinding, later as cutting, and in the second stage they are “bear- ing-down” pains. The pains or the uterine contractions, aided by the action of the abdominal muscles, are the most important powers of labor. The Bag of Waters. — The first effect of the uterine contraction is the formation of the “bag of waters.” That part of the fetal sac, or the membranes inclosing the child, which covers the internal os is forced into the os from within outward. The cervix being the point of least resistance in the uterus, when the uterus contracts it forces the liquor amnii in this direction. The os being covered by the membranes, these latter are forced out in the form of a pouch. This pouch is called the bag of waters, and it has important functions. First, it dilates the cervix and the vagina gently, evenly, and safely; second, it protects the baby from injurious pressure on any one part, because when the uterus contracts the force exerted presses equally in all directions, answering to the law of pressure on fluids; third, it protects the cord from prolapsing; and fourth, if there is infection in the vagina, it prevents this from getting into the uterus or into the baby’s eyes. (See Plate II.) Some authors call the whole fetal sac the “bag of waters.” When the cervix is completely opened, so that the 60 PREGNANCY, LAB OP, AND THE PUERPERIUM uterine cavity forms a continuous canal with the vagina (the parturient canal), the membranes usually rupture, but they may not until later, or may rupture before the pains begin. This last then leads to a so-called “dry labor.” If the baby is born with the membranes cover- ing its head, it is said to be born with a “caul,” and it is considered a lucky omen. When the uterus contracts, everything in it is forced out in the direction of the cervix. The child is forced against the os, and, when this is large enough, the head passes through it into the vagina. The pains, aided now Fig. 32 . — Diagram showing the advancement of the head through the pelvis (Leishman) . by the voluntary bearing-down efforts of the woman, drive the head along the vagina. The perineum now begins to darken in color and to bulge outward, and the anus opens, so that the anterior rectal wall lies exposed. The pains are about two minutes apart and very strong. The vulva begins to open, and soon the wrinkled scalp is visible (Fig. 32). Under the actions of the pains and strong pressing efforts of the mother the vulva is dilated so as to allow the passage of the child. Sometimes the parts will not dilate, but tear, or the doctor has to incise the vulva to permit the escape of the child. This A PLATE II 0 Placenta Contraction Ring * ectum Bladder wRectum Urethra K Bag of Waters Braune’s frozen section of a woman who died at the end of the first stage of labor. Shows the bag of waters at the vulvar outlet. PURRPERWM 6l operation is called episiotomy. After the head is deliv- ered the face turns to one side and there is a short pause, after which the shoulders come, followed at once by the trunk. The child gives a sneeze or a gasp, and soon cries lustily. Now come blood, liquor amnii, sometimes meconium, and the ends of the membranes. The pains cease and the patient feels much relieved. The second stage is ended; the third stage begins. After a short rest, during which the uterus may be felt as a roundish body the size of a cocoanut, lying under the navel, the pains recommence — the after-pains. These bring about the separation and expulsion of the placenta. Sometimes there is a little hemorrhage with each pain. The pains recur every three or five minutes. Soon the cord slides down a little from the vulva and the patient bears down, or the doctor presses on the uterus and the after-birth appears. The nurse receives it in a sterile basin, or the physician takes it, gently pulling on the membranes, which strip off slowly from the uterus. There is always more or less blood when the placenta comes, and a little more follows it. The uterus now contracts down into a hard ball behind the pubis, and the third stage of labor is ended. The puerperium is now begun — the woman is a puerpera. If she has already borne children the after-pains continue more or less severely, and for a period of one or more days. THE PUERPERIUM The puerperium is characterized by the return of the genital organs to their previous condition and the de- velopment of the breasts for the function of lactation, that is, to carry still further the function of reproduction. Retrogressive changes occur in the genitalia; progress- ive changes, in the breasts. The uterus, which after labor is the size of a small 62 PREGNANCY, LABOR , AND THE PUERPERIUM cocoanut and weighs about 2 pounds, by a process of fatty degeneration and absorption quickly diminishes in volume. The nurse can observe this by feeling daily the fundus of the uterus and measuring from its top to the pubis. On the first day the uterus is high — even Fig- 33- — Height of uterus postpartum, the bladder empty: L, After labor; 1 , first day; 2 , second day, etc. above the navel; on the third day it is eight fingers’ breadth above the pubis; on the fifth day, six fingers’. On the twelfth day it is at the pubis, and after this normally cannot be felt through the abdomen (Fig. 33). If the bladder or rectum is full the uterus is pushed up higher (Fig. 34). PUEKPERIUM 63 The I/Ochia.- -The lining membrane of the uterus, the endometrium, is cast off and renewed during the puerperium. This is attended by a flow of fluid from the genitals called the lochia. The lochia varies in ap- pearance and consistence from day to day, and varies in different women, also with the kind of labor the patient has had. On the first day the lochia is bloody — lochia cruenta. Sometimes there are clots. If these are large, the case is abnormal. Note the expulsion of the clots, mem- brane, etc., on the history-sheet, and save anything abnormal for the doctor’s inspection, either fresh, wrapped in a wet cloth, or in 50 per cent, alcohol. On the second and third days the lochia is still bloody, but there is quite an admixture of serum. It is called lochia sanguinolenta , or is said to be serosan- guineous. For a few days now the lochia is creamy and reddish. After the sixth day there is quite an admixture of fatty detritus and pus-corpuscles, which Fig. 34. — Uterus pushed up by full bladder. 64 PREGNANCY, LABOR , AND THE PUERPERIUM make the discharge purulent — lochia purulenta. Later in the puerperium there is only a watery clear dis- charge — lochia serosa. Sometimes the bloody lochia persists for several weeks. Microscopically, about the third day, the lochia contains red and white blood-cor- puscles, epithelium from the genital tract, bits of necrotic or dead endometrium, or decidua , and millions of microbes. These germs are not virulent unless the puerpera is septic or unless they are introduced into conditions favorable to their growth. Thus the lochia of one puerpera might, if introduced into the vagina, infect another puerpera. Nurses have infected their fingers by the lochia of normal puerperae, and that infection may be carried from here to the breasts is generally admitted. The amount of lochial discharge varies from day to day and in different women. It varies also according to the nature of the labor and the conduct of the third stage. Women who menstruate freely have profuse lochia; operative cases have much for the first few days; when the uterus has been thoroughly emptied at a labor the discharge is scanty. The lochia may be pent up in the uterus and give rise to fever. The odor of the lochia changes during the continuance of the flow, being at first bloodlike; later it resembles that characteristic of the patient. A foul or putrid odor is always indicative of infection, though the infec- tion may not be serious. (See chapter on Puerperal Infection.) The vulva and the vagina after labor are dark, bruised, and more or less torn and abraded. There is, usually in primiparae, more or less swelling. This edema is quickly absorbed, also the ecchymoses. All these processes are grouped together and called “in- volution.” Involution, then, may be defined as that PUERPERIUM 65 group of processes occurring when the uterus and other genital organs return to their usual conditions. The health of the woman depends on the involution proceed- ing undisturbed. The breasts take on their greatest activity during the puerperium. Whereas the processes going on in the pelvic genitalia are retrogressive, bringing those structures back to their previous condition, the changes occurring in the breasts are progressive — designed to further carry on the function of reproduction. On the first day the infant obtains the secretion known as colostrum. This is rather indigestible and produces catharsis. Even of the colostrum there is very little the first day, so that the infant practically starves. On the second day there is more secretion in the breasts, and it is quite yellow from the admixture of butter-fat. On the second day in multiparae, and on the third in primiparae, there is usually a rush of blood and lymph into the breasts. They are swollen, enlarged, turgid with blood, painful and tender, and feel hot. The patient, when the engorgement is marked, may be in much distress. The breasts are sometimes so large and hard that the nipple is flattened and the baby cannot grasp it for nursing. Since the breasts are thus not emptied, the engorgement is not relieved. This condition is popularly thought to be a rush of milk to the breasts, but it is nothing but an acute engorgement of the organs. No milk is formed, but it is ready to be formed, and needs only the stimulation of nursing. Should the child not nurse the engorgement would gradually subside. If it nurses the milk is made, and mostly during the nursing itself. In multiparae, and after lactation is established, the breasts having formed the habit of making milk at certain periods, do so, and thus there comes to be a little milk in the breasts; but 5 66 PR E GNANC y, LABOR , AND THE PUERPERIUM this is not the rule, nor is the quantity large, and herein lies the fallacy of pumping the breasts continually to relieve them. It is not overfilling with milk that is giving the trouble, but lymphatic and venous engorge- ment, and measures for relief should be directed toward these. Under appropriate treatment the engorgement subsides spontaneously in a day or so, and the func- tion of lactation is gradually established. (For Treat- ment, see p. 308.) The engorgement of the breasts is not accompanied by fever. There is no such thing as “milk-fever.” When there is fever about the time that lactation is being established, its cause must be sought elsewhere, and some form of sepsis will usually be found. GENERAL CHANGES IN THE PUERPERIUM The general condition of the woman during the lying-in period is different in some respects from that of other women. The temperature is sometimes a little higher than normal. It may rise to 99. 5 0 F. and not be pathologic, though the writer is accustomed to regard every rise above 99° F. with suspicion. Any- thing above ioo° F. is certainly indicative of disease. The pulse ought to be below 88. If higher, there is usually something wrong, as hemorrhage, infection, heart disease, etc. Sometimes a woman has naturally a rapid heart. Kidneys. -The patient passes much urine during this time — polyuria — therefore the nurse should see that the bladder is not overfilled, because it may cause hemorrhage from the uterus and cystitis. When the bladder is overfilled it makes a soft tumor above the pubis (see Fig. 34), pushing the uterus up and to one side. Retention of the urine after labor is common. If the bladder overflows, this condition is called ischuria GENERAL CHANGES IN THE PUERPERIUM 6y paradoxa. The inability to urinate is due to several causes: first, the horizontal position in bed, some patients finding it impossible to urinate lying down; second, to the bruising and swelling of the urethra caused by the labor; third, the abdominal walls are weak from overstretching during pregnancy. In hys- teric women and after some operations the amount of urine may reach from 3 to 5 quarts. Bowels. Constipation is the rule because the patient is quiet on her back, and because the abdominal muscles are stretched and the intestines inactive from being in a cramped position so long. Not seldom there is tympanites. In pathologic cases this may require special treatment. Rarely it is fatal. The skin is active, the patient sweats freely, and therefore is more subject to chilling — an important hint. There is, too, a peculiar and somewhat charac- teristic odor about the patient. This may be altered by disease, as uremia or sepsis. The mental condition is altered, the patient being more susceptible to nervous influences; therefore the general desire to keep parturient women free from all worry and excitement. In Roman times a criminal was safe if he took refuge in the house of a puerpera, and even the tax-gatherer was debarred. It is claimed by some that a puerperal woman is so sensitive to nervous shock that such may cause an acute rise of temperature. The writer has seen a few instances where the fever could not well be explained on any other grounds, but such a diagnosis is hard to prove. CHAPTER IV THE NEWBORN INFANT THE BABY IN THE FIRST WEEKS As soon as the child is born close observation will show tiny respiratory movements of the chest; then comes a gasp or a sneeze which clears the air-passages; then a short cry; finally, the lusty crying. These few moments are crucial. The change from the uterine circulation of the blood to the extra-uterine is now taking place. The lungs are expanding; the blood- currents are taking the directions they are permanently to follow. Should the lungs not expand fully, sufficient air cannot enter and the child remains blue, and if the condition is marked, it will die after a period of from two to forty-eight hours. During this time each breath drawn by the infant is marked by an expiratory grunt or whining cry. It is pitiful to hear, and soon the infant becomes unconscious and finally comatose. This condition is called atelectasis pulmonum , and is much more common in premature infants. The res- piration of even a healthy infant is irregular, and for a few hours the child may be a little bluish around the mouth and nose, but this disappears fully, being re- placed by the healthy pink or red. The cry of a newborn infant is lusty at first, then the infant quiets and cries only when hungry, un- comfortable, disturbed, or sick. A whining cry is sug- gestive of atelectasis, prematurity, and illness; a sharp, 68 THE BABY IN THE FIRST WEEKS 69 high-pitched cry, of cerebral trouble; a sharp, loud cry with kicking of the legs, of hunger or colic ; a fretful cry, with borborygmus (rumbling in the bowels) and green- ish stools, of indigestion. Sleep. — The newborn infant sleeps nearly all the time when it is not disturbed. After a week, but some- times sooner, it usually begins to show signs of intelli- gence. It moves in its sleep, and occasionally muscu- lar jerks may be seen, due to a jar or sudden light. If the child does not sleep, something is wrong. The temperature varies normally from 98° to 99 0 F., usually it is 98.4° F. In premature infants the tem- perature is 97 0 to 98.6° F. or lower if they are not kept warm. The normal pulse-rate is from 120 to 140 a minute. The respirations are 38 to 44 a minute. The pulse is made more rapid by the least disturbance. It is difficult to count and is felt best in the temple and while the child sleeps. The skin is at first bluish pink, becoming in a few hours pink or red. At birth it is more or less covered with a white, thick, cheesy material, the vernix caseosa, which is composed of epithelial cells, lanugo, and seba- ceous secretion accumulated on the skin during intra- uterine life. During the first days the skin dries and may crack in the folds; it may desquamate in more or less large flakes. In many babies — over half — there is a yellowish color to the skin after the third day, the so-called icterus neonatorum , or jaundice of the newborn. It has several causes, but the exact nature is is not known. If the jaundice is slight the general health of the baby is not affected, and the skin clears in a few days; but if the child is deeply jaundiced the con- dition may indicate a serious disease. These cases are slow to lose the yellow color. The children remain for a long time weak, small, and puny. 7 ° THE NEWBORN INFANT The Navel. The umbilical cord is tied and cut off J to i inch from the skin margin. The stump of the cord in a few days shrivels up to a thin, tough strand. At the edge of the skin, where the cord has been in- serted, a line of granulation forms which separates the stump of the cord. The cord usually drops off from the fifth to the fifteenth day; it may be sooner or later than this. The process is one of aseptic necrosis, the wound healing by granulation and cicatrization. Care- ful asepsis must be observed in the treatment of the stump, so that sepsis does not interfere with the process. The Baby’s Bowels. — For the first three days the infant passes a thick, dark-green, tarry material, called meconium. This has been accumulating in the bowel since the fetus was very small, as it is found in the intestine of fetuses expelled in the early months of pregnancy. When the child is from three to five days old the movements are brownish in color, and then gradually there is an admixture of yellow from the food. By the sixth day usually the green has entirely disap- peared and the movements are pure yellow. This is the normal process. The green may persist longer in some cases. The odor of a healthy baby’s stools is not bad, resembling somewhat that of sour milk, and the color should be golden yellow. There should be no mucus in them, and the water-line outside the solid part of the bowel movement should not be more than | inch wide. Greenish, frothy, slimy, foul-smelling, acrid stools betoken intestinal disease. A continuance of the brown color shows insufficient food. The Kidneys. — The newborn infant generally passes urine in the first few hours. This must be watched for, and if absent the parts must be inspected for evidence of obstruction. Sometimes the napkin is stained with a reddish, brick-dust-like deposit, the so- THE BABY IN THE FIRST WEEKS 7 l called uric acid. In the kidneys of children dying in the first days this same deposit is frequently found. The urine in these cases is too concentrated and requires dilution, which is accomplished by the free adminis- tration of liquids, especially water. The Weight. —The infant loses weight during the first four to eight days, and then begins to regain it. By the eleventh day it again weighs as much as when born. Children vary much in this regard, depending on their constitution and on the food they get. If breast fed, and the supply is abundant, the initial loss may be small, and the birth-weight may be regained before the fifth day (Fig. 35). Under contrary condi- tions the child may weigh less in three weeks than it did when born. This is especially true of premature infants, as they lose relatively more — sometimes a quarter — of their whole weight. They regain it slowly, often remaining stationary for weeks before the little body begins to grow. Girls sometimes have a little whitish discharge from the vagina, and rarely they menstruate. This lasts one to five days and is not of serious moment. Occasionally it is too profuse, when a drop of extract of ergot, three times daily, may be needed. 72 THE NEWBORN INFANT Fig. 35. — Weight-chart of a normal infant. CHAPTER V THE HYGIENE OF PREGNANCY Under this caption those duties will be treated which fall to the lot of the nurse during pregnancy. She is often consulted about various incidents of the gravid state, first of which is the diagnosis of the condition itself. Diagnosis of Pregnancy.— This is not always easy, even late in pregnancy, and in the early months may not be made positively even by an expert accou- cheur. The nurse has the following points on which to base a diagnosis of pregnancy: 1. The Cessation of the Menses in a Healthy Woman . — If a woman in good health ceases to menstruate during the period of reproductive life, the probability is very strong that pregnancy exists. 2. The Morning Sickness. — If a woman apparently healthy is affected with morning nausea and vomiting, there is a presumption of pregnancy, but no more than a presumption. Together with the absence of the menses, the symptom has more value. 3. Enlargement of the Breasts and the Areolar Signs . — These evidences are very strong, but not certain, be- cause nervous women may show them at their men- strual periods. Shooting pains in the breasts, promi- nence of the nipples, puffiness of the areola, pigmenta- tion, and colostrum may be noticed. 73 74 THE HYGIENE OF PREGNANCY 4. Quickening or u Feeling Life” — Since this is a sub- jective sign — that is, felt by the woman — it has no positive value. Even matrons have imagined feeling a child in the abdomen when none was there. A mother of nine children prepared a complete outfit for the tenth, which she imagined she felt. One patient of the author felt labor-pains when she was not even pregnant. 5. Palpation of the Fetus , of Fetal Movements , and Hearing the Fetal Heart-tones. — These are the only cer- tain signs of pregnancy, but may only seldom be elicited before the fourth month. The physician has other means of diagnosis, includ- ing the blood-serum test just discovered. Diagnosis of Time of Confinement. This can never be exactly determined. An error of two weeks either way is always possible, because we do not know when the gestation begins or when it ends. The time of conception is not known, labor is more or less accidental, being sometimes brought on by external causes, and the length of pregnancy varies in different women, and in the same woman at different times. Therefore all state- ments as to the exact time that labor will occur are conjectural. Experience, however, has shown that we can arrive at an approximate date, which, for practice, is quite satisfactory, if not wholly so. 1. Count back three months from the first day of the last normal menstruation and add seven days. For ex- ample, Mrs. X. menstruated last beginning October 10th: July 17th is set for confinement. 2. Count twenty- two weeks from the day of quicken- ing for a primipara, and twenty-four weeks for a multi- para. 3. Count two hundred and eighty days from the sup- posed date of impregnation. 4. Count two weeks from the time of lightening. MODE OF LIVING FOR THE PREGNANT WOMAN 75 5. The physician will measure the fetus by means of the pelvimeter and the cephalometer, and by general palpation of its body, and, judging from its size and con- sistence, will say that the child is about thus and thus far along in development. Outside of the error due to uncertain human judgment there are other fallacies, be- cause some children at eight months are larger than others at term and even those carried over time. Thus if a gravida has a small fetus, it is unsafe to say that she is far from term. The author delivered a 3- pound baby from a woman who was beyond the ninth month of pregnancy, and on the same day another child, in the eighth month of pregnancy, that weighed 8 pounds. MODE OF LIVING FOR THE PREGNANT WOMAN Dress. -The dress of a pregnant woman should be simple and warm. There should be no heavy skirts. There must be no circular constriction at any part of the body, which means that round garters, corsets, tight skirt-bands, etc., must not be worn. Closed drawers are essential. It is best to wear wool next to the skin — heavy in winter, light in summer — but many women do not do so. All skirts should hang from the shoulders, from a waist or by means of suspenders. The secret of a proper abdominal dress for pregnant women is that there should be no pressure on the womb from above downward, but the uterus should rather be supported from below. If a woman presses the uterus down by the corset, all the abdominal organs are displaced: the intestines upward against the stomach and diaphragm; the uterus is forced down against the pubis and into the pelvis, pressing on the bladder (Fig. 36). All the organs in the pelvis are crowded down and venous congestion results, with its train of dangers, immediate and future. 76 THE HYGIENE OF PREGNANCY The supports of the uterus and abdomen are weakened, and later “high stomach,” enteroptosis, or prolapse of the abdominal viscera, and displacement of the uterus develop. Further, the growth of the child is interfered with and deformities, such as club-foot, may thus be caused. Fig. 36. — Corset pushing the uterus, child, and other organs down into the pelvis. Several corsets or waists especially designed for preg- nant women are on the market. Some of the best are those made by the Patterson and the Kabo Maternity (Figs. 37, 38) waist manufacturers. In the latter half of pregnancy most women, and expecially the multipart, enjoy much comfort from a well-fitting abdominal supporter such as is worn after laparotomy. This helps the abdominal wall to carry the weight of the child. (See Fig. 129.) MODE OF LIVING FOR THE PREGNANT WOMAN 77 Should the breasts grow large and distress the patient by their weight, care should be taken that sufficient Fig* 37* — The Kabo abdominal sup- porter, front view. Fig. 38. — The Kabo abdominal sup- porter, side view. support be given. This is as much needed to avoid injury of the delicate organs as to insure comfort. 73 THE HYGIENE OF PREGNANCY The pregnant woman should wear low-heeled shoes — the so-called common-sense shoe with broad toes. High- heeled shoes are distinctly injurious, causing pain in the back and bearing-down sensations in the abdomen. A glance at the figure of a pregnant woman will show how this comes about. Owing to the development of the abdominal tumor, which tends to pull the trunk forward, the woman throws her shoulders back and straightens her neck. This balances the figure, but it makes a sharp angle in the small of the back. It gives the gravida a peculiar pose and gait which did not escape the eye of Shakespeare, who called it the “pride of pregnancy.” Now if, in addition, the pregnant woman wears high heels, the trunk is pushed still further for- ward, and to save herself from falling the gravida throws her head and shoulders very far back, making a sharper bend in the lumbar region. This causes pain here and overstretches the abdominal wall in front. It is sad to contemplate how the beautiful female form is dis- torted at the behest of fashion, but it is sadder to think of the physical misery and injury to health these behests cause. Preservation of the Figure. -Naturally and properly, women are desirous that the function of child- bearing should not leave the person in an ungainly shape, for example, with protuberant abdomen. The most common complaint is that the patient develops a “high stomach” after labor. It may be remembered that the Roman women had abortions performed so that they need not suffer the disfigurement produced by child-bearing. Certain changes in the body are the necessary results of child- birth and beautify the figure, although some women do not look at it in this light. Such are the general rounding of the hips, broadening of the bust, the more mature PRESERVATION OF THE FIGURE 79 and matronly appearance. It is natural for some women to put on fat after delivery, and nothing done before, during, or after confinement will prevent it. An excess- ive accumulation is, however, amenable to the usual treatment for obesity. Antifat medicines should not be taken during pregnancy, and never without the physi- cian’s order. For the prevention of “high stomach” or extreme prominence of the lower abdomen much may be done. The condition is caused by weakness of the abdominal muscles, or even by a separation of the recti muscles, when the woman is said to have a “rupture.” As the result of either, the intestines fill with gas and fall for- ward; sometimes the kidneys become movable, or even the liver prolapses. The muscles give way under the stretching produced by the growing uterus, and, of course, will give way sooner if there are twins or an un- usually large child, or if the abdominal walls are weak. If corsets are worn during pregnancy, they add to the strain on the lower abdomen and thus favor muscular weakness. High-heeled shoes are another factor. Over- straining during labor and inattention to the bowels after labor are also causative. To prevent the muscular insufficiency, one must begin with the girl. She should develop herself as does the boy, with active sports — - rowing, swimming, climbing, etc. When a young woman, she should not “lace” and thus paralyze the abdomen. Healthy exercise of the whole body should form part of her daily routine. The abdomen may need some support during the last three months of pregnancy, which may be obtained by one of the maternity corsets recommended. A special abdominal binder, as the Patterson, may sometimes be needed, and this in multi- par ae with already weakened walls or with twins, poly- hydramnios, etc. After the birth of the child the 8o THE HYGIENE OF PREGNANCY nurse should see that the bowels are regularly emptied and that the gas does not accumulate in the intestines. The binder after labor does not prevent “high stomach/’ and while the writer recommends it (see Treatment of the Puerperium), the most benefit obtained from it is when the patient first leaves the bed. To bring the abdominal walls back to their original tonus the nurse may, after the uterus has shrunk into the pelvis, give them a daily five-minute massage. To prevent the overstretching of the skin and the formation of the lineae or striae gravidarum, our efforts are not very successful, but the writer recommends albolene as an inunction. Several such remedies are much vaunted in newspaper advertisements. Massage of the skin with oil or fat does help prevent striae. Women whose legs become swollen and full of im- mense varicose veins should wear rubber stockings. This, in its marked form, is a congenital defect and un- preventable. The Diet. —The diet of the pregnant woman should be simple, but not strict. The amount of meat and broths should be small — meat once a day only. Starches fried in fat and rich pastry should be avoided. Other- wise a liberal diet may be allowed, especially plenty of water, milk, and all the milk-products. Cereals, fruits, and vegetables should be eaten, especially fruit, to loosen the bowels. Women sometimes reduce the food taken in the last three months with the idea of restraining the growth of the child. This, if overdone, is unwise. Cer- tain books advise a special diet to reduce the bone salts in the skeleton of the fetus and thus insure an easy labor. It is questionable if the desired effect could be ob- tained without first injuring the mother, and, further, the child would probably suffer from rickets. In women with contracted pelves a specially restricted diet has EXERCISE 8l been tried with a view to restraining the development of the child and thus insuring its passage; the results are not certain. (See p. 452.) On the other hand, the gravida, thinking she must feed two persons, must not overeat. She should be advised that her usual habits should continue in pregnancy. No wine or other alcoholics may be taken, first, because of the danger, exaggerated during pregnancy, of contracting the liquor habit; second, because of a demonstrable bad effect on the offspring. The evil effects of alcoholics on the infant were recognized even in biblical times. It is said that Samson’s mother ab- stained from wine during her pregnancy. A child conceived while the father is intoxicated may be dull, stupid, or diseased. Diogenes was aware of this fact, which recent experiments on guinea-pigs have proved. Exercise. — A moderate amount of exercise must be taken each day, but the patient should always stop short of fatigue. A woman cannot develop muscle during pregnancy to make labor easier; she should have done this before. If active exercise tires her too much, a general massage may be given, always avoiding the breasts, the abdomen, and the veins. Walking in the open air and in the sunlight must be urged, always, of course, short of fatigue. No golf, tennis, dancing, or swimming is permissible during pregnancy. Sewing on the machine should be restricted. The patient may go to the theater, but must avoid crowds for fear of getting into a crush. She must avoid gatherings in close rooms, especially with stove- heat, because of the danger of coal-gas, etc., injuring the child. She should not travel much, and if travel is necessary, should go in the most comfortable way ob- tainable. If a patient has a history of abortions or a known tendency, travel should be prohibited. Long 6 82 the hygiene of pregnancy trolley rides may bring on premature labor, and the same may be said of automobile riding on rough roads. The Mind During Pregnancy and Maternal Impressions. —The pregnant woman should lead a placid, quiet life, avoiding mental as well as physical fatigue and excitement. The patient should read good books and avoid medical subjects. It is not necessary for her to be acquainted with the processes of labor and its various complications. From medical books pub- lished for the laity she will obtain erroneous impressions regarding the function, and groundless fears will be en- gendered in her mind. J “ Maternity,” by Dr. Henry D. Fry, may be recommended, as may also “Woman and Marriage,” by Margaret Stephens. The patient must not be allowed to worry over her condition and her approaching labor. So far as possible she should be removed from association with gossiping neighbors, who take pleasure in recounting the diffi- culties and dangers of parturition, and the relation of wonderful cases — and the nurse must not be guilty of the same offense. If there is a tendency to melancholia, the physician is to be informed of it. A change of scene may be ordered. There is a popular notion, handed down from the ages, that a woman’s condition of mind may influence her unborn child mentally and physically. Statistics tend to prove that the mothers of great men nearly always were characterized by great intelligence, superior intellectual attainments, or religious devotion, and that great-minded fathers less often procreated chil- dren that became great. The evil effects of alcoholism during pregnancy have already been alluded to. Most physicians do not believe that the state of the mother’s mind during pregnancy can affect the fetus. They base this disbelief on the fact, which cannot be THE DETERMINATION OF SEX 33 doubted, that there exists no connection, either nervous or vascular, between the child and its mother. That a fright or shock can so alter the milk of a nursing mother that the nursling may be seized with convulsions is a fact. Reasoning from analogy, one would believe that the same effect could be produced on the child in the uterus. A fright or shock may bring on abortion or premature labor by causing a hemorrhage in the placenta. If a woman believes that by reading good books her child will be intellectual; that by studying good pic- tures and sculpture her child will be artistic; that by engaging in the science of mechanics her child will be mechanical, the belief may be encouraged, as it conduces to the general welfare of both, even though there is no scientific basis for the belief. That a fright, such as seeing an ugly object or de- formity, will produce a like deformity in the unborn child is not scientifically proved. Cases reported in evidence of such effect can usually be explained by coin- cidence, if untruthfulness be excluded. The fetus is completely formed at the eighth week, and the shock or impression to which the deformity is usually ascribed almost always occurs after this time. The limits of this book do not permit the presentation of the many theories and reasons for and against the proposition, but suffice it to say that the nurse may comfort the mother with the statement that maternal impressions do not affect the physical well-being of the child. The Determination of Sex.- 4 ^Even if it were pos- sible, it is doubtful if it would be desirable that parents be able to influence the sex of the unborn child. We do not know what causes produce the two sexes in the ratio of 106 males to 100 females, a ratio that obtains the world over. 8 4 THE HYGIENE OF PREGNANCY Many investigators have studied the subject and end- less theories have been propounded, but nature still hides the secret of the production of sex. As far as we know at present, the sex of the child is already deter- mined in the ova in the ovaries of the girl, even before puberty, and, therefore, no external influences can affect the sex of the infant during pregnancy. It is a matter of chance whether a male or a female ovum is the one to be fertilized by the male element. The subject is by no means closed, and perhaps nature will give up her secret in time. To diagnose whether a male or a female child will be born is also beyond our ken. All statements in this regard, it must be admitted, are guesses. The rapidity of the fetal heart-tones may be used as a basis of the guess. If the child’s heart beats faster than 140 a minute, we say a girl will be born; if below 130, a boy, leaving the intervening numbers as of doubtful signifi- cance. The Bowels. — Attention to the intestinal tract during pregnancy is of the utmost importance because most serious consequences may be the cost of the neglect of the same. Most women -perhaps 9 out of 10 — are costive during pregnancy, and the relief of chronic con- stipation requires great effort, patience, and persistence. A long-standing habit cannot be cured during pregnancy, and usually we must resort to medicines, but they are always avoided if possible. The general rules for curing constipation are the same during pregnancy as out of it, and are as follows: __ 1 . Have the patient make it an unfailing habit to go to stool at a certain hour each day. Usually the best time is shortly after breakfast. Should no movement occur at the time — and straining is not permitted — the action of the rectum may be provoked by a glycerin sup- THE BOWELS 85 pository or an enema. As the habit is established, these means are omitted. She must never resist the desire to go to stool at any time. 2. Every morning, just after rising, and every evening, just before retiring, the patient should drink a glass of cool water and eat some fruit — an apple or an orange. Between meals she should drink water freely. 3. Her diet should contain fruit and vegetables in abun- dance, especially spinach, peas, beans, barley, tomatoes, corn, and foods of this kind. No tea is allowed, but a little coffee may be taken at breakfast. To the diet may be added bran and molasses biscuits, of which there are several kinds on the market. 4. Every night before retiring let the patient inject into the rectum 6 to 8 ounces of com- mon olive oil by means of a hard-rubber syringe and catheter (Figs. 39, 40). The oil remains over night in the rectum, soothes the mucosa, and allays a possible spasm of the bowel. In the morning the bowels will move or may be aided by a plain water enema. If these rules prove insufficient, let the patient eat prunes, figs, and dates, warning her to chew them very thoroughly. It is good that the patient have some Fig. 39. — Tin funnel with rec- tal tube for oil enemata. 86 THE HYGIENE OF PREGNANCY system about this, for example, that she begin eating one prune the first day, increasing one each day up to ten, then decreasing to one, then up again. There is a little mental suggestion in this. If the patient is not pregnant, abdominal massage may be practised, and the results are usually good. If constipation persists we resort to drugs, and, of them all, fluidextract of cascara sagrada ( Rhamnus purshiana) is the best. Alternate, after a month’s use, with Pluto water or other saline laxative and phenol- phthalein, all, of course, with the physician’s order. Fig. 40. — Hard-rubber syringe and soft-rubber rectal tube (small) for oil enemata. Enemata are useful only for temporary relief, not for daily and continuous employment, because they dilate and weaken the bowel and may irritate it. The cascara should be given in increasing doses, like the prunes, in- creasing 1 drop each day up to 30 drops, then decreas- ing. The bitter extract is the best, administered in capsules; 5-grain empty capsules are filled with the medicine in proper dosage just before it is taken. The Kidneys. -These organs are generally conceded to be the weak spot during pregnancy, and, therefore, they require particular watching and care. The urine should be examined every three weeks during pregnancy, and oftener if there is any reason to suspect trouble. The test should be made for albumin, sugar, specific gravity, the amount of urea, and microscopically for casts, etc. The total amount passed in twenty-four hours is of utmost importance — it should be at least 50 ounces. If there are casts or albumin, the case is usually one of nephritis, or should be considered such, and danger apprehended. The physician should also be notified if not enough urine is passed. Edema of the feet and swelling of the hands and eyelids are always significant, though they need not come from kidney dis- ease, and should be reported to the physician. Toxemia. — There is a condition found during preg- nancy due to improper functioning of internal organs or insufficient elimination from the organs of excre- tion; it is called toxemia, and produces symptoms from the stomach, as hyperemesis gravidarum or ex- cessive vomiting; symptoms from the brain, as eclamp- sia, persistent headache, etc. The patient should take care of her kidneys, and follow the rules laid down under Dress, Diet, Bathing, and Bowels, which have the health of these organs in view. (See chapter on Complications.) Bathing - . — The skin during pregnancy is more ac- tive than usual and requires more care: first, to avoid chilling; second, to keep up its function as an excretory organ. The patient should bathe daily or often during the week. The bath should be tepid — 88° to 90° F. Cold bathing, cold plunges, cold showers, sitz-baths, ocean bathing, and hot baths are all proscribed during preg- nancy. Abortion has repeatedly been caused by surf- bathing. If the kidneys are not acting well the phy- sician may prescribe warm (98° F.) baths, followed by sweating in bed. After the bath the gravida must avoid chilling the skin. For the sometimes profuse perspiration a tepid bath 88 THE HYGIENE OF PREGNANCY Fig. 41. — Sanitary seat cover. Take a piece of tissue paper, 15 x 20 inches, fold as in 1, cut as in 2. The center (3) is laid on the water in the closet bowl to prevent splashing; the large piece (4) covers the seat. After use it is cast into the bowl. Several, folded like 5, should be carried while traveling. followed by a vigorous rub with a “salt towel” is effica- cious. A salt towel is made by wringing a coarse bath CARE OF THE BREASTS 89 towel out of a strong salt solution and drying it. In the week before labor and during labor the tub-bath had better not be employed, because of the danger of the wash- water gaining entrance into the vagina. The shower-bath must be substituted. This advice is espe- cially needed for multipart. Care of the Genitals. — Since the secretions from the genitals are augmented — leukorrhea being a common complaint — daily ablutions of the parts are essential to keep them free from eczematous eruptions and to avoid odor. Multipart, especially, because of the patency of the introitus, may contract infections of the vulva and vagina from street dust and by contact with dirty water- closet seats. The patient is instructed to wear closed drawers, certainly in the later months of pregnancy, and she should provide herself with sanitary seat covers for use when away from home (Fig. 41). If the vulva is enlarged by varicose veins, the woman must be instructed to avoid injury which might cause a fatal hemorrhage. Care of the Breasts. — The breasts require care from early girlhood to fit them for the important func- tion of lactation. It is a great misfortune if a woman can- not nurse her infant, and no effort should be spared to prevent such a calamity. From the time of puberty the growing organs should be protected from pressure, so that the whole gland may develop properly. At all times and especially during athletic exercises care should be taken to avoid injury Mothers should be taught to provide for the development of the reproductive organs of their girls as well as for the development of their brains. During pregnancy, if the breasts are large and heavy, some form of supporter should be used. The surface 9 o THE HYGIENE OF PREGNANCY should be washed daily with soap and warm water, using care to remove the branny scales from the nipples, and then the latter anointed with cocoa-butter or albolene. In blondes with very tender skin the following lotion may be applied to the nipples each morning for a week, to be followed by the use of albolene for a week: 1$. Glycerite of tannin \ ounce; Compound spirit of lavender i “ Water 3 ounces. No strongly astringent washes or alcohol should be used; the nipples must not be hardened, but rather kept soft and pliable. The nipples should be relieved of all compression. If they are flat, gentle attempts to draw them out may be made night and morning. The breasts should at all times be protected from injury, which some time later might become the starting-point of a mastitis. The Engagement of the Nurse. — The author be- lieves that obstetric nursing requires higher skill than any other form of nursing, comprising, as it does, sur- gical, medical, and infant nursing. It is more arduous, surely. For these reasons only the best nurses should adopt this specialty, and the author believes the re- muneration should be higher than for work in the other branches of the profession. An obstetric nurse should not take infectious cases. She should allow sufficient time between engagements. It is better for the nurse to be at the house a few days or a week before the day of labor, but most women prefer to wait until labor has begun before sending for the nurse, which is a very un- comfortable way, since this keeps the nurse waiting at her home and she may not be accessible when wanted. Occasionally an arrangement is made whereby the nurse remains at her home for a stated time before the labor, LIST OF ARTICLES FOR OBSTETRIC CASES 9 being paid by agreement half or full salary. It is wise to have such agreements made in writing, though it is not customary. The time a nurse is called depends, of course, upon the time set for the confinement, and since this can never be determined accurately, the nurse seldom knows when she will be summoned. A certain date is usually agreed upon, from which time the nurse awaits a call. The nurse may take short, clean cases up to this date, or, if they promise to run over the day of her obstetric engagement, with the stipulation that she will be allowed to leave when the call comes. The patient is usually supplied by the doctor with a list of articles to get. This list is one furnished to his patients by the writer: List of Articles for Obstetric Cases 2 hand-basins of graniteware, medium size. 2 hand-brushes, wooden backs. i new 2-quart douche-bag. 1 “Perfection” bed-pan. Rubber sheeting enough to cover the bed and a piece a yard square. 30 yards of bleached dairy cloth. 2 pounds of aseptic absorbent cotton. 5 -yard jar borated gauze. 100 bichlorid of mercury tablets. 4 ounces of lysol. 4 ounces of boric acid crystals. 1 ounce of camphorated oil. 2 ounces solid albolene. One rubber catheter, size 14 French scale. Water pitchers and vessels for the storing of sterilized water, if not in the house, should be procured. 92 THE HYGIENE OF PREGNANCY INSTRUCTIONS FOR THE OBSTETRIC NURSE Sterilising. — A few weeks before the labor the nurse should go to the patient’s house and sterilize the following articles: 1. Six sheets. 2. Two dozen towels, old and soft ones, but without holes. 3. Six pillow-cases. vr r (NJ ^rp e^v 9 " Fig. 42. — T-binder or pad-holder. ) J 4. Four abdominal binders. These are of unbleached cotton cloth, 16 inches wide and 36 inches long, doubled and hemmed. 5. Four “pad-holders” or T-bandages, similar to the menstrual pad-holder (Fig. 42). 6. Three breast-binders of the size and shape given herewith (Fig. 43). INSTRUCTIONS FOR THE OBSTETRIC NURSE 93 7. Two night-dresses, of the smoking- jacket pattern for the mother, or two of the confinement jackets illus- trated here (Fig. 44). Fig. 44. — Jacket used during confinement. Chicago Lying-in Hospital pattern. 94 THE HYGIENE OF PREGNANCY 8. Two pairs of long stockings for the mother, so- called “opera lengths/’ or, if obtainable, the obstetric leggings illustrated here (Fig. 45). 9. Two men’s gowns or surgical gowns, for the hus- band, if he is to be in the lying-in chamber, and the anesthetizer. 10. Two obstetric pads of absorbent cotton, 1 inch thick and 1 yard square, covered on each side with gauze, and tacked. In lieu of these some nurses use squares of mattress pad material; 4^ yards make six pads. After delivery these are washed and then are suitable for the baby’s bed. Four thicknesses of newspaper wrapped in a bath towel make an excellent pad. 11. Several dozen ordinary menstrual pads of cotton, covered with gauze, and which are long enough to be pinned to the binder before and behind. 12. A pillow-case full of sterile cotton pledgets, the size of a lemon, for use as sponges during labor. These are cheap and good. 13. One Mason jar full of applicators, cotton wound on tooth-picks (Fig. 46). 14. Two Mason jars of gauze pledgets for perineor- rhaphy and cord dressings should also be very carefully sterilized. Covered sponges, described on page 434, are excellent for perineorrhaphy, are cheaper than gauze, and as good. Each package should be neatly covered with napkins INSTRUCTIONS FOR THE OBSTETRIC NURSE 95 and distinctly labeled, so that confusion may be avoided at the time of labor. After thorough sterilization and drying, they should be packed carefully away and protected from dust. The basins, brushes, douche-bag, and pitchers should all be sterilized and put away aseptically, so as to be ready for use in case of emergency. (See page 424 for Methods of Sterilizing.) Sterilization is best accomplished by steam, and there are several instruments on the market doing good work. The Rochester, Arnold, or Boeckman sterilizer, with Fig. 46. — Cotton-wrapped tooth-picks, known as applicators. proper management, does equally as good work as the large high-pressure apparatus. Maternity boxes may be purchased from the medical supply houses at prices varying from $5 to $20. They contain the various articles required, all sterilized, ready for use. The Nurse’s Visit. — It is a good plan for the nurse to call on the patient occasionally during the pregnancy. The young mother will need instruction regarding her dress, diet, and mode of life. The baby’s layette will also be a subject for discussion. 9<5 THE HYGIENE OE PREGNANCY The nurse may do much to encourage the patient for her approaching trial, and give her advice regarding the health of both mother and child. She should acquaint the patient with the phenomena of beginning labor, so that the physician may be notified promptly, and tell her what to do if the baby should come very quickly. The nurse may discover some dangerous complication threatening, as eclampsia or placenta praevia, and will notify the attending accoucheur. The patient should be instructed to take no douches, and not to insert the finger in the parts, during the latter weeks of pregnancy. CHAPTER VI THE INFANT'S LAYETTE The nurse, is often consulted by the young mother regarding the baby’s layette. This list is intended sim- ply to guide her in the selection of the needed articles . 1 THE WARDROBE Six straight hands , 18 inches long and 5 inches wide, made of flannel, with the edges pinked, not hemmed. These will be used for the first two months. Six knit hands with shoulder-straps, of silk and wool for a winter baby, of cotton for a summer baby. These bands will lose their elasticity with the first washing and become useless unless they are properly dried. They must not be hung up to dry or laid out flat. After washing and rinsing they should be wrung out by hand, tightly, and left in that tight roll to dry, near a fire. Six knit shirts , of silk and wool for winter, of cotton for summer. It is better to get the second size, as the first size is outgrown in a few weeks. Six pinning blankets for a winter baby; they are not necessary in summer. These should be made entirely of flannel. A piece 24 inches square may be sewed onto a flannel band (18 by 6 inches) in flat plaits, allowing the band to project 2 inches at each end. Six flannel skirts for a winter baby. Eight flannel skirts for a summer baby, four for day and four for night. (A winter baby wears a skirt and 1 This chapter was written by Miss Katherine DeWitt. 7 97 9 8 THE INFANT'S LAYETTE stockings by day, a pinning blanket and socks at night. A summer baby wears skirts by day and night, except in very hot weather, when a shirt band, diaper, and dress or night-dress are sufficient.) lire skirts should be made with a waist, either of flannel or of muslin, or they may be cut all in one piece, after a Gertrude or princess pattern. In any case the skirt must be sup- Fig. 47. — Infant’s dress for the first weeks. Back view. ported from the shoulders and must open in the back, so that it may be put on with the dress. Four dresses of the Warren pattern (Fig. 47). These are made of light-weight twilled flannel, are sleeveless, open at the bottom, and have a single slit at the back of the yoke. This dress is especially valuable for hospital work. It keeps the hands warm and prevents the child THE WARDROBE 99 from scratching its face and infecting its eyes. It is easily and quickly changed. For the first two weeks of life it is highly recommended, and subsequently as a night-dress. For summer use they may be made of fine Canton flannel. Twelve dresses , not more than i yard long from neck to hem. These may be made by any simple “slip” pattern or with a yoke. They should be simple, as they are prettier and more comfortable when not loaded with ruffles or embroidery. Very narrow lace or inser- tion, fine tucking, hem-stitching, and feather-stitching are the most attractive trimmings. Six night-dresses of light-weight twilled flannel — some- thing almost as light as cashmere, made by a “slip” pattern. These should be of good size, as the baby will wear long night-dresses after being put into short clothes. Six pairs of white woolen stockings for a winter baby. Six pairs of socks. Six dozen diapers of cotton diaper-cloth. This should be shrunk before the diapers are cut off, otherwise they will not fold square. They should be made twice as long as they are broad, and should be of two sizes, medium (20 by 40 inches) and large (26 by 52 inches). Two dozen cheese-cloth diapers , made of 1 yard of cheese-cloth folded twice, so that the diaper is J yard square and has four thicknesses. These are just the right size for first diapers, and are soft without ironing. They can be used for inside diapers later. They should be stitched around the edges and diagonally. Several blankets for wrapping about the baby, made of flannel, cashmere, or knit of wool. The last are by far the best. A good size is 1 yard square for cash- mere or flannel, 1 yard by ij yards for the knit ones. The baby’s outdoor garments can be provided after its arrival. IOO THE INFANT'S LAYETTE NURSERY CONVENIENCES The Bed . — This may be a wicker bassinet, a large clothes-basket (which is quickly outgrown), or a crib. Whatever is used as a bed, should be provided with a hair mattress. A baby who sleeps with a bed-pillow under its body and a down pillow under its head is lying with its spine curved and is being kept much too warm, so that it will easily take cold or have earache. The Fig. 48. — Best infant scales. hair mattress should be covered with a square of rubber sheeting, then with a square of mattress covering, 1 yard each way. The mattress covering can be bought by the yard, and four pads will be needed. Over the mattress pad a cambric sheet is laid ; have six of these on hand — they are used under, but not over, the baby. They should be made large enough to tuck under the mattress well on all sides. For covering, one may have two light-weight blankets NURSERY CONVENIENCES IOI made of flannel, bound with wash-ribbon, and two light comforters made of cotton or wool, covered with cheese- cloth, silkaline, or silk, and tied with silk floss or ribbon. A hair-pillow with four cases made of linen should be provided, though the baby should not sleep on it until he is six months old. Good scales (Fig. 48). The fancy infant scales are not reliable. The best scale is the ordinary grocer’s even balance, with iron weights for the pounds and a bar for the ounces. A bath-tub of rubber, white enamel, or papier-mache. Small-sized clothes-bars. These will be used for airing the baby’s clothes and holding its towels. Two bath aprons of flannel (38 by 27 inches), made with a hem top and bottom. Through the upper hem a wash-ribbon is run to tie about the waist. Six old soft damask towels. If these cannot be ob- tained, nice baby towels can be made from linen diaper- cloth, but they should be frequently scrubbed and boiled to make them soft. A wicker hamper or shallow basket, lined with muslin and holding the following toilet articles: 6 washcloths of shaker flannel, 6 inches square. 1 small soft sponge. 1 cake of old Castile soap. 1 bath thermometer. 1 tube albolene (solid). 1 comb and brush. 3 dozen safety-pins, three sizes. Powdered stearate of zinc in shaker. A package of applicators (tooth-picks wound with cotton). (See Fig. 46.) 1 jar sterile navel dressings. Small, wide-mouthed bottles of alcohol and boric acid solution. 102 THE INFANT'S LAYETTE Bottle of pure olive oil or a jar of benzoinated lard. Needle and thread. Several old, soft handkerchiefs. Package of sterilized cotton sponges. Screen — not a bamboo screen with curtains hung on rods, but one with a firm square frame, solidly covered with cretonne, burlap, or denim, so that it affords real protection from drafts or light. One 2-quart hot-water bag. A low chair without arms. Two hand-basins. The nurse will find this list quite complete, and may select from it the articles needed as far as the patient’s circumstances will permit. PART II NURSING DURING LABOR AND IN THE PUERPERIUM CHAPTER I CARE DURING LABOR How will the nurse tell when labor begins? First, by the show, which occurs a few hours before labor; second, by the pains. If the woman complains of pains first in the back, then drawing around to the front, and at the same time the uterus hardens (contracts), and if these sensations recur at gradually lessening intervals, it is safe to say the woman is in labor. Third, by the dilatation of the os uteri. Fourth, by the rupture of the hag of waters. The nurse is not allowed to examine the patient inter- nally without instructions from the physician. The opening of the os is the most certain sign of labor. Without an internal examination the best observer may make a mistake as to the onset of labor, since the patient may have “false pains” at regular intervals. These may lead the physician to think the woman is in labor. Later the pains subside and the doctor calls the episode a “false alarm.” The subsidence of pain may even occur after some dilatation of the os has taken place. These uncertainties are very annoying to patient, doctor, and nurse. Care During the First Stage.— As soon as labor is declared, the nurse begins to surround the patient with 103 104 CARE DURING LABOR all the protective measures of asepsis and antisepsis that her art affords, and from now on nothing is neglected that will save the patient from puerperal infection. The general rules of asepsis are identical with those practised in the most particular operating room. The care to be observed is identical with that observed in the course of a laparotomy, because the danger of infection is almost equal to opening the abdomen. The diffi- culties in attaining obstetric asepsis, however, are greater than in surgery, so that success achieved by the obstetric nurse is entitled to higher credit. A woman is liable to infection from the time labor begins until she has been up and around a week. Even before and after this time, if the germs introduced are virulent, she may be infected. A physician returning from a case of erysipelas had the unfortunate thought to examine his wife, who had been delivered seventeen days before. The woman died a few days later from infection. A student, in examining a woman a few days before labor, caused a fatal puerperal infection. A nurse doing obstetric nursing should keep away from infectious cases, and, when she has been exposed, must make a complete change of clothing, take a full bichlorid bath, and shampoo her hair. At least a week must elapse from the time of her attendance on a pus or scarlet fever case, or other infectious diseases, before she assumes the care of a parturient woman. During this week she should take several scrub baths and sham- poo her hair carefully. In practice it is hard to reconcile these duties, but the danger is too great to neglect such precautions. Other measures will be considered later under the heading of Puerperal Infection. It might be said here that the reasons for these extra precautions in the case of the nurse are that she comes into such inti- mate contact with the mother and babe, and for so long a CARE DURING THE FIRST STAGE 05 period of time, and so often during the day has to treat both surgically, as there are open wounds. It is, there- fore, highly essential that she be aseptic. Preparation of the Room. — The sunniest and best room in the house should be selected for the labor. It should be near the bath-room, and should be properly heated. Plenty of light should be provided at night- time — a very important point. The room should be cleared of all unnecessary furniture. Heavy curtains and all bric-a-brac should be removed. If there is carpet on the floor, the area around the bed should be protected by a large rubber mackintosh or several layers of newspapers. Rugs should be removed without raising dust. Two plain chairs, a kitchen table, a sewing table, and a rocker for the patient complete the furniture. In some families the nurse may meet objections to what they term unnecessary preparations. The patient’s mother perhaps was not delivered with so much fuss and ado. Here a little tact and explanation will clear the way. One cannot force advancement on the people — one must smooth them into it. The nurse has her sterilized things at hand, usually on the dresser, which has been cleared of the toilet articles and covered with a sheet. She has a pitcher of hot, and one of cold, sterile water, each covered with a hood, in the room. The wash-stand, with basin, in which the physician and nurse wash their hands, should be thor- oughly scrubbed, and a new piece of soap placed in a clean soap-dish. This wash-stand and soap should be reserved for the physician and nurse. A jar of sterile hand-brushes and a nail-file complete the number of articles on the wash-stand. The wall around the table on which the hand solu- tions are set should be protected, using a newspaper, so that the decorations will not be marred, and io6 CAKE DURING LABOR throughout the case the nurse should exert constant care of the furniture and utensils of the house, so that they will not be broken or injured by solutions, by hot basins, etc. One may err with too much zeal, therefore the nurse should not make too great display of preparation, which might alarm the patient. The general arrangement of the room is like the diagrams (Figs 49, 50). Fig. 49. — Diagram of room arranged for normal confinement. Naturally, one will not always find conditions in prac- tice which enable one to arrange everything as here given, but the diagrams will show what is needed and how things may be conveniently placed. The nurse who knows the principles of asepsis will easily adapt herself to the exigencies of the individual case. CARE DURING THE FIRST STAGE O 7 The Preparation of the Bed. All hangings must be removed and the bed wiped with i : 1000 bichlorid solu- tion on a damp cloth. The foot board of the bed is to be covered with a sheet, pinned securely and evenly. If the bed has a box-spring, the valance should be re- moved or pinned up securely; then the side of the spring should be covered with some impervious material which Fig. 50. — Diagram of same room as shown in Fig. 49, arranged for operation. hangs below the side rails or boards. Three table boards or shelves from a bookcase should be put in the middle of the bed between the mattress and the spring, so as to prevent sagging in the middle. The mattress is now covered with a rubber sheet, over this comes a full sheet, then the small rubber sheet, on this a sheet folded once, the draw-sheet across the bed, and then all are securely io8 CARE DURING LABOR pinned with large safety-pins. The patient should be warmly covered, depending on the season. In winter she may need a hot- water bag at the feet. Occasionally one applied to the small of the back relieves the pains. The sterile sheets are put on at the first if there is a supply; if not, the bed is dressed with sterile things only Fig. 51. — Patient across the bed, with preparations for the internal examina- tion. Sheet used to drape patient. To the right is a sewing table with anti- septic solutions. when the second stage draws nigh. The nurse should have a clean light blanket for the patient, not a soiled old comforter. The best in the house is not too good for the parturient. No one, unless dressed in a sterile gown, may sit or lean on the bed, and a sheet or pillow that has fallen on the floor must not be put back on the bed. When a CARE DURING THE FIRST STAGE Og patient is delivered on the side, something is needed to part the knees, and the nurse folds a pillow, covers it with newspapers, and then pins a sterile pillow-slip securely over it. (See Fig. 61.) Preparation of Patient. — As soon as the patient is known to be in labor, the bowels must be thoroughly emptied by a soap-and-water or saline flushing. This must be repeated once or twice if the labor is slow and long. An enema may not be given in the second stage without the doctor’s permission. The nurse must pay strict attention to the bowels and bladder, and call the accoucheur’s notice to the fact that either is not emptied regularly. The parturient should void urine every four hours, and if she does not, she must be catheterized. After the flushing the pudenda are shaved. The author cannot understand the position of those accouch- eurs who will not shave an obstetric patient, but do so for a simple gynecologic operation. I am convinced that many cases of puerperal fever are due to the lack of surgical preparation of the patient. A little tact and explanation will readily overcome possible objections. Shaving is best accomplished with a safety razor with the patient on a table in the lithotomy position. In hospitals a shampoo table is used. The patient is then given a full shower-bath. The body is well drenched with warm water, then, with a bath-brush or a rough wash-cloth and green soap, all portions are briskly lathered. Particular care is given the area between the ensiform cartilage and the knees. The vulva is thor- oughly soaped, and any smegma removed from the clitoris . This should be emphasized. The patient then stands under the shower again, and all the lather is thoroughly removed with friction. (An ordinary hand- spray or bath-ring will suffice.) Putting the patient in I IO CARE DURING LABOR a tub is not so aseptic a procedure as this one, because the particles washed off the skin may find their way into the vagina. While this danger is not great in primiparae, it is present in multiparae. After the bath, before the patient is dried, the trunk is washed with i : 1500 bichlorid from the ensiform to the knees, making the application of the solution to the genitals particularly thorough. Some physicians prefer lysol, 1 per cent., and other antiseptics for this purpose. While washing the genitals the nurse holds a sponge in the introitus to prevent wash- water or other solution from running into the vagina, and in washing the anal region a sponge that has passed over the anus must not pass over the vulvar orifice, but should always be thrown away. Sterile underclothes are now put on. The hair is braided in two firm braids. The patient wears a loose house-wrap- per. The confinement room must be warm enough so that the patient does not require heavy clothing. The patient is instructed not to touch the parts , and she must not sit on a water-closet after this preparation. A sterile slop jar is provided for use in the confinement room, and a sterile bed-pan for use on the confinement bed. Preparation for the Doctor. Plenty of water for the physician to wash his hands, a nail-cleaner, and sterile brushes are provided, and antiseptic solutions are prepared according to his practice, which the nurse must inquire about. One per cent, lysol, 1 : 1000 bichlorid, 1 : 1000 sublamin, and 2 per cent, creolin are commonly used. (See pages 442, 443.) Some accoucheurs sterilize the hands and lubricate the examining fingers with sterile vaselin. Other physicians use sterilized rubber gloves, which is by far the best way. A sterile gown or apron is provided for the doctor to wear during the examination. CARE DURING THE EIRST STAGE I I I Both abdominal and vaginal examinations are usually made. For the abdominal, the patient is brought to the side of the bed or lies on a couch, and the physician determines the position of the child by palpating the Figs. 52, 53. — Two types of pelvimeters. uterus, and counts the heart-beats. The accoucheur measures the pelvis, if he has not already done so, using for this purpose an instrument known as a pelvimeter (Figs. 52, 53). To prepare the patient for this exam- ination a sheet is thrown over the lower part of the I 12 CARE DURING LABOR body and just covers the pubic region ; the night-dress is drawn up over the chest and covered by a towel, so that the abdomen alone is exposed (Fig. 54). After the external examination the patient is prepared for the internal examination (Fig. 55). The bed clothes are neatly folded over the foot-board of the bed, the knees are drawn up and separated, a sheet is thrown with its center over the pubis, on the bias; the opposite corners are drawn around each leg so as to cover it; the other two corners are drawn, one over the face and the other to form a flap between the knees. This is lifted up when the physician is ready to pass the hand for exami- nation. The vulva is again washed by the nurse with 1 : 1500 bichlorid or 1 per cent, lysol, and a bit of cotton soaked in the solution is left between the labia, which the phys- ician removes when he inserts the finger into the vagina. While the examination is being made the flap of the sheet may be dropped over the arm of the examiner. After the examination the vulva is cleansed again with solution and a sterile pad applied. These aseptic pre- cautions are repeated before and after each and every examination. CARE DURING THE FIRST STAGE 13 The Diet in the First Stage. — Most patients have no appetite after labor begins, but they must not be allowed to starve, since this causes faintness, which may delay 8 CARE DURING LABOR 114 the labor. Serious postpartum hemorrhage may result from the general weakness. Light semisolid food, especially food drinks, must be urged at regular intervals during the labor, especially if it is prolonged. During summer the drinks from the soda-fountain may be given. The food should be daintily served, and with quiet insistence the nurse can usually succeed in getting the patient to take sufficient nourishment. Some patients vomit throughout labor. Some food must, neverthe- less, be given. The History =sheet. — As soon as a nurse arrives on a case she should start a record, and note the a. m. and p. m. temperature, pulse, and respiration, and other things of importance. This record may be very valuable if the patient later develops a complication. The happenings during labor, the strength and frequency of pains, the frequency of the child’s heart-tones, the number of internal examinations made, the findings, the local and other treatment, the amount of sleep, the food taken — all should be noted on the record with great care. Not alone does this keep the nurse in practice and pre- vent her from becoming careless and desultory in her work, but it also has a good effect on the physician, stimulating him to better effort, and giving him a high opinion of the good qualities of the nurse and of the nursing profession in general. Outside of all this, it is of distinct benefit to the patient, in that a carefully kept record will shed light on any complication that might arise in the course of the case. General Instructions. — The patient must be en- couraged by the nurse to bear her pains bravely, but too much sympathy is harmful, because the patient then thinks she is in a serious condition. No babbling rela- tives or friends should be allowed in the room, and the nurse must tell no stories of her obstetric exploits or of CARE DURING THE FIRST STAGE I 15 harrowing cases had with physicians. The patient will at once imagine these are perhaps her fate. The confine- ment room should be quiet, cheerful, and hopeful. The patient should be left much alone, so that the bowels and Fig. 56. — A labor case in Holland in the seventeenth century (Witkowski). bladder may be attended to, and other services rendered by the nurse. Throughout the whole labor the nurse should see that the patient’s person is not unnecessarily exposed, but she must not err with too much zeal, because at some periods of the labor exposure of the body is necessary. For CARE DURING LABOR 116 many centuries women were delivered under a heavy sheet (Fig. 56), all the laws of asepsis being defied. The parturient must also be protected from drafts, since during labor the skin is moist and sensitive to chilling. During winter the patient often needs a hot- water bag at the feet. During the first stage the patient may be up and walk around, lying down occasionally on the sofa. This helps Fig. 57. — Physician assisting parturient, and teaching her how to use her powers to best advantage. the pains and takes her mind off them. As the second stage approaches, the pains coming closer together, and the patient complaining of their cutting or tearing character, the parturient will feel safer in bed on her back. She thus awaits the rupture of the bag of waters. When the waters break, the doctor usually makes an examination to see if the cord has prolapsed, to deter- WHEN TO SUMMON THE DOCTOR 117 mine the amount of dilatation of the cervix, and the posi- tion the head occupies in the pelvis. The patient may request that her husband be present in the room. During the first stage no objection may be made to this. During the second stage in most cases the husband may be excused unless he is needed as an assistant. He is dressed in one of the sterile night- gowns and washes his hands carefully. If the first stage is prolonged, the nurse should see that both the patient and herself get some rest. The nurse should obtain some sleep, so that she will be able to stand the strain during the delivery and after. Self- sacrifice on the part of the nurse here is not good policy in the end. When to Summon the Doctor. It is best for the nurse to obtain exact instructions from the physician as to when he wishes to be called. Some accoucheurs allow the nurse to take pelvic measurements, to watch the fetal heart-tones, to make internal examinations, and actually conduct the labor until the head is about ready for delivery. Others place less responsibility on the nurse. The physician should be notified when labor declares itself. After he knows that everything is in good condi- tion he usually leaves the woman to the nurse, returning from time to time until the second stage begins, then re- maining until labor is completed. As a general rule the doctor should be summoned when the pains are at three- minute intervals, when they are regular and very strong, and certainly when there is bulging of the perineum. A good way for the nurse to determine if the head is ad- vancing is to press upward alongside the pubis, as in Fig. 58. At first a hard resistance is felt deep in, which becomes more marked as the pains force the head down on to the perineum. If the head can thus be felt the i8 CARE DURING LABOR physician is to be summoned. A rectal examination will also show the advance of the head. The physician should be called earlier to a multipara than to a primi- para, because in the former the second stage is shorter. Of course the nurse must notify the doctor if the fetal heart- tones grow irregular, or too slow, or too fast; if the parturient complains of headache or other symp- Fig. 58. — Determining the rate of advance of the head by pressing in the peri- neum. toms of eclampsia, if there is hemorrhage, or fever, or when anything disturbs the normal course of labor. In the author’s opinion such responsibilities in practice are too great to be placed on the nurse. Care During Second Stage. -When the patient arrives in the second stage, the bed is dressed with sterile sheets unless already so prepared. The aseptic confine- ment jacket (see Fig. 44) and leggings (see Fig. 45) are CARE DURING SECOND STAGE 1 19 put on, and extra clothing and unnecessary things are removed. This period is the stage of expulsion, and the patient may want to pull on something as an aid to her bearing-down efforts. Unless the nurse is strong, she should not allow the patient to pull much on her hands, but should tie a sheet to a strong post at the foot of the bed and let the patient pull on this. If the patient, as is often the case, wishes to hold a human hand, have the husband prepare his hands and put on a sterile gown. Fig. 59. — Nurse curing cramp in leg during labor. He may thus help in the labor. The nurse should save her strength as much as possible, because obstetric work is hard. The patient may feel better if pressure is made on the small of her back, or if that part be briskly rubbed, which the nurse may do. A hot- water bag may also be applied to the base of the spine. Occasionally washing the hands and face with cold water is also grateful. If the patient should have a cramp in her leg, which not seldom happens, the nurse stretches the limb out forcibly 20 CARE DURING LABOR and pulls the foot toward the knee, as shown in Fig. 59. It is the understanding of these details of nursing and caring for the patient’s comfort that distinguishes the successful from the unsuccessful nurse. Some patients are unruly, and persist, against advice, in putting the hands on the sterile abdominal towel or even on the vulva. In such a case the nurse should ster- ilize the parturient’s hands with 1 : 1000 bichlorid or tie them loosely at the head of the bed. Fig. 60. — Sewing table arranged near bed during second stage. Carries basin of 1 per cent, lysol and i: 1500 bichlorid (or other solutions as ordered), with sponges, pitcher of hot sterile water, pile of sterile towels, saucer with sterile tape, scissors, and artery forceps. When the pains are strong and frequent the physician usually gives the patient an anesthetic to the obstetric degree — that is, to partial anesthesia. Scopolamin and morphin, pantopon, chloral, and other drugs are used to alleviate the suffering of the first stage. If the nurse is not familiar with the physiologic action of these remedies she should ask the physician what effect she should look for. In the second stage ether and chloroform are given. Ether is preferred by the author, as it damages the liver less. CARE DURING SECOND STAGE 121 The nurse now surveys the room to see if everything is in readiness for the delivery. She should see to it that the following things are ready: A basin of hand solution for the physician ; a basin of pledgets soaking in an anti- septic solution (what these solutions are the doctor tells the nurse) ; tape for tying the cord, and scissors for cut- ting same, in a glass or saucer with a little i per cent, lysol solution over them; warm saturated boric acid solution for washing the eyes, and some gauze pledgets to open the lids with; nitrate of silver solution, i per cent., and salt solution or whatever drug the doctor pre- fers for preventing ophthalmia neonatorum. A steril- ized douche-pan is in readiness, and the sterile douche- bag is gotten ready so that it can be filled with hot i per cent, lysol solution, and hung up near the bed for use in an emergency (postpartum hemorrhage) with a mini- mum of delay. The nurse should have a good reserve of sterile pledgets, towels, sheets, hot and cold water, and she should know just where to put her hand on them when needed. The baby’s basket contains a warm receiver, a hot- water bag, and a warm wool blanket. The nurse should have a baby bath-tub nearby, with bath thermometer and plenty of hot water in case the child is asphyxiated when it comes and the accoucheur calls for a hot bath. One of the sterile obstetric pads is put under the patient and the body is covered by a sterile sheet. If the patient is dressed with sterile leggings and jacket, all that is needed is to lay a sterile towel over the abdo- men, letting one end drop between the thighs. For delivery on the back the woman lies as in Fig. 62, but if the physician prefers delivery on the side, the hips are brought to the side of the bed, and the pillow before described is placed between the knees (Fig. 61). The 122 CARE DURING LABOR patient is now protected from infection and exposure by a sterile sheet and towels. During delivery the nurse’s duties will consist of wait- ing on the doctor; renewing supplies of pledgets and solutions; adjusting the towels, pillow, sheet, etc., and little attentions about the patient, one of which is caring for any discharge from the rectum. If the enema has Fig. 61. — Arrangement for delivery on side in a home. Hot and cold sterile water in pitchers. One basin has bichlorid, 1 11500; another, i \ per cent, lysol so- lution. Scissors, cord tape, artery clamp, and catheter lie in a saucer in 1 per cent, lysol solution. A pile of sterile towels and the nurse’s hand forceps are on the table. At the extreme left is the warm receiver for the infant. not completely emptied the lower bowel, as the head comes down the contents of the bowel are forced out and cause considerable annoyance to the accoucheur on account of the danger of infection from the feces getting into the vagina. Women have died from this. Aside from the danger of infection, the patient is much dis- tressed about it; therefore the nurse should never allow her to learn that such an occurrence has taken place. The discharges from the anus are received in large CARE DURING SECOND STAGE 123 pledgets of cotton soaked in 1 : 1500 bichlorid, taking care that nothing touches the vulva, and the perineum must be sponged with the same solution, always rubbing from the vulva toward the anus, and not using the same pledget twice. Should the physician soil his hand, he will resterilize it, after which the nurse replenishes the antiseptic solution. Fig. 62. — Patient arranged for the conduct of the third stage of labor. When the child is coming through the vulva, the nurse may have to administer the anesthetic, which is done as follows: The bottle is arranged for dropping by cutting a long slit in the side of the cork. An ether can may be provided with an excellent dropper as in Fig. 63. A handkerchief or an inhaler may be used. Just as the pain comes on 15 drops of the drug are 24 CARE DURING LABOR dropped on the handkerchief; after a few moments a little more is put on, and as the height of the pain passes the mask is removed from the face. Toward the end of delivery the administration is more continuous, but ceases immediately the head is born. The nurse watches the doctor for instructions as to whether he wishes more or less of the anesthetic given. When ether is used one should not be too near an open flame, since the Fig. 63. — Ether can with safety-pin as dropper. vapor is explosive. Chloroform is decomposed by an open flame into irritating and poisonous vapors. As soon as the head is born the nurse must have ready warm boric solution for the eyes and gauze pled- gets for wiping out the nose, mouth, and throat. Soft old linen or lintine is the best for this purpose. When the baby comes, it is received in a warm towel, and allowed to lie a short distance from the mother, the nurse taking care that it should not pull on the cord, and that the mother does not lie on it or squeeze its head between CARE DURING THE THIRD STAGE 25 her legs (see Fig. 62). The child must not be exposed, because it is very subject to chilling, being so wet. In maternities the infant should now be marked, to avoid every chance of confusion in the nursery. Its name, written on a square of adhesive, is placed on its back, or a distinguishing number tied on its wrist. A basin or bed-pan is placed under the vulva. Now the doctor calls for the bowl with tape for cord and scissors, and ties and cuts the cord. After the baby is separated from its mother it is wrapped in a warm re- ceiver and placed in the warm basket, on its side, with the head lower than the body, so that mucus can run out of the throat and mouth. It is immaterial which side the child lies on. The nurse must watch the infant closely to see that it does not choke and that it does not kick all the covers off; that it is not near a window or in a draft, and that the cord does not bleed. The nurse may have to delegate some of these duties to the father or some relative if her services are required by the patient or by the doctor. Care During the Third Stage. — As the child leaves the vagina the nurse or doctor should follow down the receding uterus with the hand placed on the abdomen — this to prevent hemorrhage (Fig. 64). Since some phys- icians do not practice this, the nurse should obtain in- structions. When the child is delivered the uterus is the size of a cocoanut, and the nurse grasps it in the full hand and notes whether it is hard or soft. If too soft, she gives it a gentle massage until it hardens, and, as a rule, there is no trouble. If the nurse is uncertain as to its condition, let her not hesitate to ask the physician about it. As soon as the cord is tied the doctor usually takes the uterus, and the nurse is now free to rearrange and refill basins, see a little to the baby, and to get things ready for the placenta. 26 CARE DURING LABOR After the child is removed the nurse takes away, if necessary, gently and without jarring the patient, all the soiled towels, etc., from about her, and puts a folded, dry, warm sheet under her, or the other sterile obstetric pad. A sterilized basin or bed-pan is again slipped snugly Fig. 64. — iN'urse holding the uterus during third staj CARE DURING THE THIRD STAGE 27 under the vulva to catch all discharges. This prevents soiling the bed and gives the accoucheur an idea of the quantity of blood the patient is loosing. The nurse ob- serves and notes the amount of blood in the clothes, so as to form some estimate of the total amount lost. The patient is then arranged and made comfortable and covered with a clean blanket, which is protected by a sheet from being soiled. If the nurse is to guard the uterus (see Fig. 64), she must observe the following points: 1. That the uterus is hard, and that when it relaxes a little, as it should, it does not balloon out with blood. 2. She must look between the thighs every three minutes to see if blood is accumulating in the basin or on the clean sheet she has placed there. 3. She must keep her finger on the patient’s pulse and her eye on the patient’s face, to detect unusual rapidity of one and paleness of the other. If there is a hemorrhage, the nurse must firmly but gently massage the uterus. The thumb lies in front, the fingers on the back, of the uterus, and together they de- scribe circles on the organ, wiping the abdominal wall over the uterus — not kneading the abdominal wall, but the uterus. Of course, the physician is informed of it. The nurse will notice when the after-pains come on that the uterus gets very hard and rises up under the hand. These contractions of the uterus loosen and expel the placenta. The contractions of the uterine muscle also prevent postpartum hemorrhage. During the active uterine contraction the hand may be removed from the fundus. The separation of the placenta is shown by the uterus rising up in the abdomen, up above the navel, and the cord advancing from the vulva. It is usually time now to expel the placenta, though many physicians arbitrarily wait thirty minutes. 128 CARE DURING LABOR When the physician is ready to do this, the nurse presses the sterile basin against the perineum, the cord is dropped into it, and the after-birth is gently expelled from the vulva, from which it drops slowly into the basin. The membranes are carefully pulled from the uterus by gentle, steady traction, so that they do not tear off. The physician will inspect the placenta and mem- branes carefully to see if no piece of either is left in the uterus— a serious danger — therefore the nurse will place the basin containing them where he may see them before he leaves the house. It would not be improper for the nurse to call the physician’s attention to this point if he should forget it, and the information obtained might later be of signal service. After the placenta and membranes are removed the physician inspects the vagina and vulva to discover the presence and extent of the lacerations of the birth-canal. If none are found, soiled towels are taken away and a clean sheet spread under the patient. The hand guards the uterus, noting the same points as before. The physician usually does this, but the nurse may have to do it. A short period of rest is given the woman, then the blood-stains are washed off, using cool sterile water unless the room be cold, when warm water should be used. Great care should be taken not to rub, hurt, or infect the vulva. A sterile pad is placed against it to catch the discharges. The bed is now dressed. During these manipulations the patient must not be roughly tossed about. Whenever the parturient is turned or lifted, one hand must be on the uterus, seeing that it is hard, and the legs must be tightly closed to- gether. This precaution is to prevent air from being drawn into the vagina and thence into the large veins of the uterus, thus causing air-embolism, which is usually fatal; this is an important warning. The confinement PERINEORRHAPHY I29 jacket is removed, and a clean plain night-gown is put on. The abdominal binder is now applied. This is broad, going from the ensiform to the hips, and is pinned from above downward. No pads are needed under it. PERINEORRHAPHY If a perineorrhaphy must be done, or, as the woman may express it, if it is necessary to “put in stitches,” the plan of procedure must be altered. While waiting for the placenta the nurse prepares for the operation. The necessary instruments are: Three pairs scissors. Three tissue forceps. Four short artery forceps, two 8-inch forceps. Two needle-holders. Six curved needles. Three vaginal retractors, two large and one small. Two vulsellum forceps and two cervix forceps. Long uterine packing forceps. Catheter, and, if a douche is to be given, a uterine douche point. Suture material is usually catgut and silkworm gut, which may be boiled with the instruments unless already sterilized. The nurse refills the basins with hot solutions, sees that there is a good supply of pledgets, preferably gauze, or covered sponges, and that the light is good. Things are arranged as in Fig. 87. After the placenta is out, the patient is slowly moved across the bed, or — and the writer heartily recom- mends this — she is put on a table, and the basins, in- struments, etc., arranged as for a major operation. Too many women date lifelong invalidism to the neglect of proper repair of injuries of the pelvic floor, and one 9 CARE DURING LABOR I 3 0 should not spare any effort to secure primary union of such lacerations. It goes without saying, that better results may be obtained when the accoucheur has his work comfortably arranged than when he must operate FERINE ORRHA PH Y 131 over a low bed in a strained attitude, where it is difficult to carry out the demands of an aseptic technic. In the absence of sufficient trained assistance the husband or a courageous woman may be asked to hold the patient’s legs; or the sheet-sling (see Fig. 90) may be used. An anesthetic is often not necessary, most women being able to stand the pain, and further, the parts are not so sensitive at this time, as they have been benumbed by the stretching caused by the child. When the operation is completed, the nurse should ask the physician to catheterize the patient, and at the same time show her where the urethral orifice is, as some- times the bruising and tearing caused by the delivery make it so swollen that she is unable to recognize it by the usual landmarks. Lacerations of the perineum are of three degrees: first, through the fourchet; second, to but not through the sphincter of the anus; and the third degree, through the anus into the rectum. The last form is a very seri- ous accident, as the patient loses control of the bowel unless repair can be successfully made. There is a popular notion that when a woman acquires a laceration of the perineum during labor, it is the phys- ician’s fault. While it is true that by a proper conduct of labor most lacerations and nearly all serious ones can be avoided, still it is also true that sometimes the peri- neum will tear like wet blotting-paper, and no skill can save it. In communities where the above notion is prevalent the physician is often tempted to neglect the repair of lacerations of the perineum, as he will acquire a reputation of “ tearing his women.” His neighbor does not have lacerations because he does not put in so many “ stitches.” The nurse may do much to assist the conscientious physician by explaining to the family the frequency of injuries to the pelvic floor and the 32 CARE DURING LABOR necessity for their repair. Good obstetrics is thus furthered. When the mother is in bed and made comfortable, the room is aired and darkened a little, and ordered neatly, so that the patient may obtain some well-earned rest. Temperature, pulse, and respiration are taken and recorded, and a warm drink is given. After this the soiled towels, sheets, etc., are gathered together and put to soak in cold water. The linen soiled with fecal matter should be soaked separately, and those articles that are very bloody should be rinsed out before being put with the rest. After soaking in several changes of cold water and thorough rinsing, they may be sent to the laundry. Hot water should not be used on bloody clothes, as the heat coagulates the blood in the mesh and thus permanent stains are left. Towels wet with bi- chlorid should also be well rinsed before being boiled, as the mercury stains cannot be removed. Cotton sponges and the placenta must not be thrown into the water-closet. They clog the pipes. THE FIRST CARE OF THE NEWBORN CHILD The nurse assures herself that the mother is in good condition, that the uterus is firm, and that there is no hemorrhage from the vulva. She then takes the infant, after arranging all her material for oiling and dressing it, near the radiator or fire, away from a strong light or draft. The eyes are attended to usually by the physician. He has simply washed the lids outside and inside with boric solution, or he has used Crede’s or some similar treatment. For Crede’s method or the nitrate of silver method the nurse prepares a weak solution of com- mon salt, and has a i or 2 per cent, nitrate of silver solu- tion at hand. The lids are gently separated, and 1 drop of the silver solution put in each eye. It is then neutral- THE FIRST CARE OF THE NEWBORN CHILD 1 33 ized with the saline solution. Unless the silver solution is made fresh every day or so, severe “nitrate reactions” of the conjunctiva may result. Lately, 10 per cent, solution of protargol, or 25 per cent, argyrol, is being used for the prevention of ophthalmia neonatorum. The infant is oiled all over with warm olive oil, albo- lene, or benzoated lard, great care being taken that the hand does not rub anything into the eyes. The vernix caseosa is thus softened and dissolved. Use the oil freely, especially in the groins and armpits, where the vernix gathers, and wipe the child dry with a warmed soft towel. Do this quickly, and keep the infant covered as much as possible. The child may be held on the lap or placed on a pillow on a table. The room should be warm. After this the hands are sterilized and the umbilical cord stump is dressed. First the stump and adjacent skin are washed thoroughly with 1 per cent, lysol solution or pure alcohol, then wrapped in dry, sterile gauze; then the sterile binder is applied. The baby’s temperature is now taken, after which the child is quickly dressed and put in a warm crib on either side, with the head low. The infant, especially if it is premature or if it was delivered by a hard operation and was more or less asphyxiated, must be watched carefully until it is known to have a good hold on life. Sometimes such infants are found dead in their cribs, and often they secrete large amounts of mucus, which chokes them. This mucus may be sucked into the lungs and cause atelectasis (incom- plete unfolding of the lungs), pneumonia, and sepsis. The child’s color should be pink or red, its cry should be vigorous, and if it sleeps, it should be calm, and not grunt or whine with each expiration. If there is a rat- tling in the throat, the nurse should wipe the mucus out with the little finger covered with a soft cloth — gently, so as not to scratch the mouth. The infant may be sus- 134 CARE DURING LABOR pended by the feet for a few minutes to allow the mucus to run out, and when replaced in the crib should be put on the side with the head lower than the chest and sup- ported by a small pillow. Sometimes a sip of water given to the child carries the mucus down with it. The infant usually needs a hot-water bag, even in summer. It should not be needful to admonish the nurse that the bag be water-tight and not hot enough to burn. CARE AFTER THE THIRD STAGE While the nurse is attending to the infant she should look after the mother a little also, noting her color, rest- fulness, the rapidity and strength of the pulse, the firm- ness of the uterus, and the amount of bloody discharge. She must early detect a hemorrhage if one occurs, and determine if the patient is in good condition and not shocked, which is done by observing the above symptoms. The normal flow of blood from the genitals in the first two hours after delivery will not exceed 2 ounces, and there will be no clots. If there is more discharge, the nurse should massage the uterus and give 1 dram of ergot. The puerpera should lie on the back for three hours after delivery, after which she may be turned on her side, supported by a pillow at the back. If the uterus has been packed with gauze, the nurse is to sup- port the abdomen carefully while moving the woman, since brusque motion may tear the uterine muscle over the packing. Headache is a very important symptom during and after labor. It should always be reported to the phys- ician. An examination of the urine for albumin, and of the patient for other signs of impending eclampsia will be made. One of the duties of the attendant at this time is the filling out of a birth certificate. \; CHATTER II CARE DURING THE PUERPERIUM First, last, and all the time during the puerperium the nurse must consistently practice asepsis in everything that concerns the genitals and the breasts in the mother, and the eyes, nose, mouth, and navel in the child. The nurse must remember that while she is only in small part responsible for the asepsis of the labor, the major part being assumed by the physician, she is in large part responsible for the asepsis of the puerperium of both mother and baby. She dare not relax her vigilance at any period of her attendance on the case. DAILY CARE OF THE MOTHER The Breasts. — After the mother has slept, usually about eight hours, the nurse prepares the breasts. They are gently washed with soap and water, then with bichlorid, i : 1500, which is allowed to dry in. A loose breast-binder is now applied, simply to prevent the gland from sagging. Tertullian tells us that the Roman women used a breast-binder made in the temples and possessing mystic powers. A short time after this the baby is applied to the nipple (Fig. 66). Before and after each nursing the nipple is washed with saturated boric solution, poured fresh from a bottle, not kept in a glass, and using steril- ized cotton pledgets on tooth-picks — so-called “applica- tors” (Fig. 68). No further treatment is required unless the nipple is tender, when it may be anointed with sterile 135 CARE DURING THE PUERPERIUM 136 albolene or cocoa-butter. The fingers do not come in contact with the nipple at all; if it is necessary to do this, the hands must be disinfected. The baby is put to the breast every four hours until the milk comes, Fig. 66. — Woman in proper position for nursing an infant. DAILY CADE OF THE MOTHER 137 Fig. 67. — The mammillaris. (From a painting in Pompeii — Witkowski.) Fig. 68. — The breast tray and its contents. then every three hours during the day and every four hours during the night. The first nursing is at 7 A. m., the last at 10 p. m., and the child is put to the breast 38 CARE DURING THE PUERPERIUM once in the interval to 7 a. m., at about 2 a. m. Later in the puerperium the child is allowed to sleep as long as it will, and finally it is habituated to sleep all night through. Some physicians prefer the four-hour interval for robust children. When the milk “comes in,” which usually occurs on the third day, the breasts need more support from the breast-binder. The treatment of cracks, engorgement, and other conditions of the breast will be taken up in the chapter on Complications. Too much care and too careful asepsis cannot be given the breasts, as infection, with resulting abscess and impaired nipples, with re- sulting necessary weaning of the child, must be avoided. Care of the Genitals. — Every four hours, and after each bowel movement and urination, the vulva is dressed. The patient is put on a douche-pan, the nurse provides everything she will need close at hand, and arranges the patient and coverings. Then she sterilizes her hands, or uses sterile rubber gloves, gently separates the labia, and pours, from a narrow-lipped pitcher, a solution of lysol, 1 per cent., or bichlorid, 1 : 2000, over the parts. A little of the solution may run into the vagina. After this she dries the vulva with gentle pressure by means of cotton pledgets, puts on a sterile pad, and adjusts it with a T-bandage, or pins the ends of the pad to the abdominal binder. This dressing must not be too tight, and the binder must not be soiled or wrinkled. A few physicians desire the patient tightly bound up in a long binder reaching nearly to the knees. Fig. 69 shows such a binder applied. When a dressing is to be made, the nurse removes the pins at the sides and slides the binder up over the hips. After the first day these attentions are not needed so often — only every six hours — unless there is much lochial discharge. Fig. 69— The long binder applied. (From a photograph taken at the Chicago Lying-in Hospital.) DAILY CADE OF THE MOTHER 139 140 CARE DURING THE PUERPERIUM If there are stitches in the perineum, the nurse must redouble her carefulness and not pull on the ends or knots in any of the manipulations, as in passing the bed-pan under the patient, removing the pads, etc. The physician’s best work may thus be spoiled. If the patient complains of the stitches hurting her, the nurse should inspect the wound to see if they are cutting through, in which case she should notify the doctor. Sometimes there is marked swelling of the vulva on the second day. The doctor may order warm, moist, medi- cated applications to the parts. If left to her own de- vices, the nurse may apply a warm boric solution dress- ing to relieve the swelling and pain. It is not necessary to bind the knees together after perineorrhaphy unless the physician so orders. Often after several days a whitish substance forms in the creases of the vulva. This is composed of epithelial scales and dried and coagulated secretions. It may be removed by anointing the parts freely with sterile albolene. After an hour the softened and dissolved material may be gently rubbed off. The parts about the vulva need an occasional washing with soap and water. The hands must never be soiled with lochial dis- charges. This is an important injunction, because these discharges are infectious, and they may infect the puerpera in the next bed, the mother’s breasts, or the umbilicus or the eyes of the infant, and also the finger of the nurse. Special Care in Cases of Complete laceration of the Perineum. — In cases where the sphincter ani has been torn and sutured the nurse will ask the phys- ician for special instructions regarding the diet, and the attention to the bowels, i. e., cathartics and enemata. Often liquid diet will be ordered for four or five days DIET 14 and food free from seeds and woody fiber. Some physicians give opium to bind up the bowels. Eight hours before the bowels are to move for the first time the nurse will inject 6 ounces of sterilized olive oil into the rectum. This softens the fecal mass and lubricates the passage. Just before the bowels are to move an enema of 6 ounces of warm salt solution is given. Under no circumstances should the patient be allowed to strain during the evacuation. The tend- ency to strain is due to the presence of a hard mass of feces in the rectum. If the nurse detects such a tendency she should pass the index-finger, gloved, into the rec- tum, and gently soften and break up the mass by pressing it against the sacrum. No pressure may be made on the line of sutures. A saline enema (6 ounces) is now given and the patient instructed to retain it as long as possible. Subsequent evacuations are aided in the same manner. The History-sheet. -Every morning, after bowels and bladder are empty, the nurse measures the height of the fundus of the uterus from the pubis and notes it on her history-sheet as follows: Fundus 6 x, meaning six fingers’ breadth from the pubis. She also notes the character and amount of the lochia, as described on page 63, and must not forget to note and call the doctor’ at- tention to clots, membranes, etc., expelled, and to all unusual occurrences. If everything progresses smoothly, the nurse’s notes on her record may be a little neglected by the attending accoucheur, but if a complication should arise, he will be grateful indeed for all the infor- mation he will find there. Therefore let the history- sheet always be neatly and accurately kept until the case is discharged. Diet. — There was an old notion that a woman after labor must be kept on a milk-and-water diet, in the fear 142 CARE DURING THE TVER PER I UM that errors in eating would cause puerperal fever and other diseases. This notion has some basis, although nowadays we give the puerpera a much more liberal dietary. If a healthy person is put to bed, one must restrict his diet or he will become ill, and the same is true of a puerpera. Lack of exercise causes the organs to work less, and a quiet body needs less food. If food is given in large quantities, it is not properly oxidized or assimilated and “clogs the system” with waste matters. The excretory organs are thus given more work to do, and they are not in fit condition because of the lack of exercise. Headache, lassitude, an odor to the skin, tympany, high-colored urine, even graver troubles, may be the evidences of overfeeding. During the first eighteen hours after the labor the patient should have liquids in amounts sufficient to quench her thirst. After a few hours a cup of broth or tea and a small slice of buttered toast, a glass of milk, plain or with seltzer, may be given. On the second day, tea, coffee, milk-toast, oyster-stew, salt wafers, and chocolate may be added. On the third day after the bowels have freely moved the amounts may be increased and the patient may have soups, thickened with rice, barley, etc., bread and butter, cereal foods, and stewed fruits, omitting the strongly acid. In summer ice-cream and ices are allowable. On the fourth day a small piece of meat, as a chop, the breast of chicken, or squab, may be given at noon. Fresh fish is also now allowable. The other meals are prepared from the diet- ary of the preceding days. On the fifth day a small piece of tender steak, eggs, light puddings, blanc-mange, baked apple, jellies, and other delicacies may be given. Tea and coffee are given sparingly and should not be strong. Fresh vegetables are allowed with salt or cream DIET H3 dressing, not vinegar. Baked potatoes, beans, and peas are best omitted, as they produce tympany. Stewed fruits, as prunes, dried apples, and peaches, bran and molasses biscuits are given for their laxative effect. After the fifth day the diet is as above, and this has been found sufficient for the patient until she is up and about. Three meals a day are served. At ten in the morning a glass of cool milk, and at three in the afternoon a cup of chocolate with a wafer are given Occasionally an egg-nog is prepared instead of the chocolate at three. At midnight, after the nursing, a glass of hot milk or malted milk is usually administered. Throughout the puerperium the nurse will see that the patient drinks pure water freely, to make up the loss caused by the free action of the skin and kidneys and the fluid required for making milk. Foods to be Avoided . — Acid fruits, as lemons, grape- fruit, oranges (sour), plums, strawberries, boiled toma- toes, onions. These are likely to cause colic in the in- fant, but after a few weeks the mother should add these to her diet to accustom the infant to them. Potatoes, beans, peas, lentils, and turnips cause flatus and tym- pany in the mother, and sometimes in the child, and should also be avoided until the mother is up and about. Highly spiced dishes, heavy sauces, spiced sauces, dress- ings, such as French and Mayonnaise, are all to be avoided — they throw too much work on the kidneys. Should the physician order the liquids restricted on account of the breasts, the nurse will leave out the milk, tea, coffee, chocolate, and fresh fruits, but give a certain amount of water. If the patient has had eclampsia or is threatened with it, the physician may order milk and hot water as the sole articles of food. 144 CARE DURING THE PUERPERIUM The Bowels. -Puerperae are almost invariably con- stipated. Strict attention must be given to see that the patient has at least one good alvine evacuation every day. The nurse should ask the physician what she should do, getting minute instructions. The practice of the Chicago Lying-in Hospital is as follows: On the morning of the second day the patient receives i ounce of oleum ricini (castor oil) suspended in whisky and sherry wine, or administered in soft gelatin capsules. Fig. 70. — Castor oil in glass ready for administration. To suspend the castor oil, as shown in the illustration (Fig. 70), the medicine-glass is wet with the sherry, and 1 dram of the same left in it. The oil is then poured on the sherry, and, just before the dose is given, 1 dram of whisky is flowed on top. The oil forms a ball. This is followed in six hours by a saline enema. Every day for the first week the patient receives a saline enema, and if this does not produce a free daily evacuation, fluid- extract of cascara sagrada in 15-drop doses is given THE BLADDER 145 thrice daily. The medicine is put in empty capsules just before it is administered. This method is better than giving a single large dose, although sometimes, administered in this manner, the baby’s bowels are made loose. In this case give a single dose of 30 drops after the ten o’clock nursing, and the effect on the child will be avoided. In giving enemata the nurse should exercise great care to avoid injuring a sutured perineum in passing the rub- ber enema-tube. The tube should be passed by sight, under good illumination, and pressed downward at first toward the coccyx, and then slightly upward. A long tube is not necessary. It need pass only a few inches beyond the anus. If the breasts are too much engorged, a saline cathar- tic — for example, effervescent citrate of magnesia— may be given instead of the oil, cascara, or enemata, as the free, watery movements reduce the fluids in the breasts. If the nurse cannot get the patient’s bowels to move properly, she should notify the physician. It is of great importance that the bowels move freely, because some- times fever may result from their neglect. Castor oil is, in the writer’s opinion, the best cathartic when adminis- tered as described. It was known and cultivated by the Egyptians five hundred years before Christ. The Bladder. During labor the urethra and bladder are bruised more or less. The urethra is bent down and sometimes torn from its attachments, so that there is slight prolapse, which causes a kinking of the channel. As a result of this and the swelling from the contusion, plus the horizontal position, the patient cannot urinate. There may be a spasm of the neck of the bladder. The bladder must be emptied within ten hours after labor, and at least three times daily thereafter, and if the patient cannot void urine the bladder must be catheter- 10 146 CAKE DURING T11E PUERPERIUM ized. Before doing this several expedients should be tried : 1. Place the patient on a warm douche-pan, half -full of warm water, cover her, and leave her alone. 2. Allow the water to run in the wash-stand, so that she may hear it, the patient being arranged on the bed- pan as before; nurse leaves the room. 3. Wet a large pledget of cotton with warm sterile water and put it on the pubis; the water dripping over the parts may start the flow of urine. 4. A hot fomentation over the bladder, patient on bed-pan. 5. Give the patient a bottle of smelling salts. 6. Give patient an enema. When the bowels move the patient may urinate. 7. Pressure over the bladder with the hand— gently carried out. 8. Raise the patient with pillows to a half-sitting position. Some physicians allow the patient to sit up. 9. The catheter. With these measures the nurse may use a little sug- gestion, and she should leave the patient alone, because some people cannot relax the sphincter of the bladder unless alone and quiet. The catheter should be used only when all other means fail, because of the great danger of causing a cystitis. Sometimes a little glycerin applied to the urethra starts the flow, and lately pitui- trin has been given for the purpose. Catheterization. -The nurse prepares the patient as for a dressing, sterilizes her hands, and washes off the vulva, and particularly the urethral orifice, with an anti- septic solution. This opening should be swabbed out with lysol solution, 1 per cent., with an applicator. The sterile rubber catheter is passed by sight, never by GENERAL TREATMENT 14 7 touch, and the urine is caught in a clean vessel, so as to note its character and amount. Cases are rare where more than one catheterization is needed, but it may be necessary to draw the urine every eight hours for a few days. The physician is usually asked for permission to catheterize; at least he should be acquainted with the necessity for it, and per- haps he will prescribe a diuretic. Sleep. —It is highly important that the puerpera obtain sufficient actual sleep as well as rest. One of the symptoms, and perhaps a cause, of puerperal insanity is lack of sleep. After the patient has been cared for on the completion of labor she is allowed to sleep as long as possible and the room is darkened and quieted to favor this. Sub- sequently the nurse must arrange the duties of the day so that the puerpera has a little nap in the afternoon and at least six hours good sleep at night. If the puerpera is persistently sleepless the physician should be notified. General Treatment. — This is the same as for any bed patient as regards bathing, changing bed, and so forth. Unless the weather makes it agreeable, a full bath is not needed every day, but may be given twice a week. Daily, however, the whole body may be sponged with alcohol and water, 1 to 3 parts, paying especial attention to the axillae. There should be plenty of light and fresh air in the lying-in chamber. Sun and air are not harmful by any means. In the olden time both were feared, and the puerpera was kept in semidarkness all the time, and all air excluded to prevent her trom catch - ing cold. It was thought that “catching cold” caused puerperal infections and mastitis, but now we know these complications are due to infection and are in high degree preventable by proper asepsis. Free ventilation and light are strong opponents to infection. The nurse, CARE DURING THE PUERPERIUM 148 while providing both, must see that at no time either mother or child is exposed to a direct draft, and that the bright light does not fall directly on the eyes of either. After the first week the nurse may give the patient a general light massage. She should avoid the inside of the legs, where there are veins, and the uterus and breasts. Passive motions of the arms, legs, and trunk are also sometimes recommended. These exercises while away the tedium of the bed, improve the circula- tion, and hasten the return of the patient’s strength. The temperature, pulse, and respiration should be taken at least three times a day — about 7 a. m., 3 and 10 p. m. — and record made of them on the history- sheet. Other points to be noted are how much the patient has slept, her general condition, also her diet, enemata and bowel movements, catheterizations, the number and amount of urinations, all medicines given, the doctor’s visits, and all unusual occurrences. Visitors. -The lying-in room should be quiet and restful. The puerpera must be given opportunity to recover from the strain of labor and recuperate her strength from the exhaustion of pregnancy and delivery. Therefore only the nearest relatives are to be allowed in the lying-in chamber during the first week. Even these visits should be very short. Aside from the nervous disturbance caused by too many visitors, there is the danger of the introduction of contagion. The Time of Getting Up. — This varies in the prac- tice of different physicians. While most accoucheurs allow the woman to get out of bed on the tenth day, others allow this only in the third or fourth week. A very few physicians allow the women to get up when they feel able for it, even if it is the second day. The attending physician will specify what the nurse should do in these cases. The writer’s practice is to allow the GENERAL TREATMENT 1 49 woman to sit up in bed on the ninth day, to get out into a rocker or Morris chair on the tenth, stand on her feet Fig. 71. — Mother nursing infant when out of bed. A low rocker without arms and a low foot-stool provide an unstrained attitude. on the eleventh, have the freedom of the room on the twelfth, and go down stairs on the fifteenth day. In operative cases these acts are postponed a day or two, So CARE DURING THE PUERPERIUM depending on the patient’s strength. Nurses say that while the women are physically able to get up at the end of the second week, their getting out of bed brings a host of callers and household duties which are too great a strain, therefore it is better for the puerpera to stay an extra time in bed recuperating. When the patient gets up she should wear the abdomi- nal binder, and in some cases a binder or jockey strap may be worn for several weeks with comfort. Corsets may be resumed after the fourth week. Occasionally the lochia rubra reappear on arising from bed. In such an event a rest on the couch for a few days will bring relief. If not, the physician is to be notified. The first menses after labor, usually about the sixth week, are likely to be very profuse. Recovery is the rule. The patient may take a tub-bath after the third week. Nursing- After the Patient is Up. — The breasts should be supported by a light breast-binder or sup- porter. The same aseptic care is practised as when the puerpera was in bed, as mastitis may come on at any time during lactation. The woman is warned about infection and instructed how to prevent it. When up the mother holds her infant as in Fig. 71, sitting on a low rocker, a shawl over her shoulders and her foot on a low stool. CHAPTER III CARE OF THE CHILD The child is usually kept in its basket in the mother’s room during the day, but at night it is taken to an ad- joining apartment, so as to allow the mother to rest. Visitors. — None but the husband, father, and the mother or other near relative are allowed in the lying-in chamber for the first week. After this a few near friends are admitted. The nurse must be assured that no visitor is allowed to enter who has been near a contagious dis- ease, as measles, scarlatina, diphtheria, la grippe, “cold in the head,” or pus cases, carbuncles, etc. Altogether, the puerpera should not be required to make too fre- quent effort to receive visitors, and the nurse may do much by tactfully reducing the number and length of the visits. Further, the child must not be disturbed by being exhibited to curious, if friendly, neighbors and relatives. Bathing". — Until the umbilicus is healed the child should not be put in the full bath. Daily the head and face are sponged with lukewarm water, using a little Castile soap if necessary. The buttocks when soiled are sponged with cool water. The body is gently rubbed with benzoinated lard; this is removed by means of a soft towel, which is usually all that is needed to keep the infant sweet and clean. After the cord is off and navel cicatrized the child is given a full bath. In summer the child may be given a sponge-bath instead of the oiling, because the perspiration and fat macerate the skin. 151 152 CARE OF THE CHILD Ordinarily no dusting-powder is needed, but if the infant shows a tendency to chafe — that is, if there is any intertrigo — a powder of stearate of zinc should be evenly applied after the bath. Much powder should not be used, and no friction is to be employed, because this rubs off the delicate epithelium. Where the skin is Fig. 72. — Arrangements for bathing the infant. already eroded, no friction is at all allowable, the nurse laying the cloth on the skin and rubbing her finger over it similarly to the use of an ink-blotter. In obstinate cases the physician will prescribe an ointment. The nurse should pay especial attention to the ears, the palms, the axillae, and the groins, and in girls take care not to injure the external genitals. To remove the whitish secretions BATHING 53 which sometimes accumulate in the little labial folds, albolene is very successful. The nostrils are cleaned with cotton wrapped smoothly on a tooth-pick (an ap- plicator), after softening the mucus with benzoinated lard or albolene. Fig- 73- — Proper method for holding the infant during the bath. The fingers and thumb are distributed over the head and shoulders, so that the child cannot slip out, and also when it kicks that it cannot strike its head against the sides of the tub. The thermometer may be removed after the child is im- mersed. In hospitals, where there is danger of carrying an in- fection on the skin, such as pemphigus or gonorrhea, from one child to another, special precautions are neces- sary: First, the nurse must watch for and report at once to her superior any eruption or sore, however slight, on the infant, and note the same on her record. 54 CARE OF THE CHILD Second, the nurse individualizes the babies as much as possible, i. e. } she disinfects her hands and the tub, uses a sterile washcloth, etc., for each infant. Third, she isolates a child under suspicion, provides separate tub, lard, clothes, etc., dresses it wearing rubber gloves, or delegates these duties to another. Its clothes are thrown into a 3 per cent, carbolic solution before being sent to the laundry. Only by extreme care can spread- ing of the infection be prevented. Care of the Navel. — The original dressing is allowed to remain as long as possible. If the babe is oiled, not bathed, or given only a half-bath each day, it is seldom necessary to change the cord dressing. This should be done whenever it is displaced or soiled by urine. The gauze is soaked off with 1 : 2000 bichlorid solution, washed with same or 70 per cent, alcohol, and dressed again with dry sterile gauze. If the cord is moist, a thorough washing with 95 per cent, alcohol will improve it. No powders are used unless ordered by the physician. In this manipulation the nurse need touch the cord only with the cotton pledget. The navel is treated exactly as a surgical wound. The binder must be smoothly adjusted and sewed on, taking care that it is not too tight, impeding the infant’s respiration. The nurse should observe and note the conditions of the cord, whether it is moist or dry, whether the line of separation is red and angry or clean and pink; whether or not there is a purulent discharge; if there be any odor — in other words, whether the navel is healing properly or not. (See Plate III, opposite page 351.) The falling off of the cord should be noted, and the antiseptic treatment of the wound continued until it is cicatrized and healed over. Occasionally a little bloody oozing comes from the cord or from the surface left after it separates. The doctor may prescribe the appli- THE EYES 55 cation of a little powdered alum to the spot, or a mix- ture of starch and alum. The Eyes. -There are two important injunctions regarding the eyes : the first is to prevent infection from getting into them, and the second is to avoid mechanical injury, as the wiping of rough sleeves, scratching with rough clothes, or too brisk manipulations. During the oiling or bath extreme care must be exer- cised to prevent fluid getting into the eyes, and this pre- caution must be observed throughout the puerperium. The skin of the infant may be infected with gonorrheal virus, and this, getting into the eyes, sets up severe in- flammation, which may cause blindness. If the Crede method for preventing ophthalmia neo- natorum has been used, there may be, in three to six hours, some inflammatory reaction of the eyelids, with redness, swelling, and seropurulent secretion. No alarm need be felt at this. Cold applications to the lids and a few irrigations of the conjunctival sac with 2 per cent, boric acid or normal salt solution will relieve it. If a freshly made nitrate solution is used such reactions are exceptional. Every morning the nurse washes the outsides of the lids with cotton wet in saturated solution of boric acid. In normal cases this care is all that is needed, but should there be a continued mucopurulent discharge which glues the lids together, this must be gently soaked off with warm boric solution and the eyes irrigated with the same several times daily. Should a slight conjuncti- vitis resist this mild treatment, the doctor will prescribe a collyrium of sulphate of zinc or similar astringent, or one of the newer preparations of silver, as protargol or argyrol. If on the second day or later a thin, cloudy discharge appears between the lids and runs down the cheek, and 56 CARE OF THE CHILD the lids become swollen and of deep red color, little floc- culi of fibrinopus being seen on them, the case is serious; the physician must be notified at once by telephone, be- cause the case is one of ophthalmia neonatorum and requires instant and vigorous treatment. (See pages 347-352-) The Bowels. —Unless the meconium is thoroughly evacuated, it is a good plan to give the infant castor oil at Fig. 74. — Rectal irrigator. A simple funnel will answer as well. the same time the mother takes hers — that is, on the morning of the second day. If the bowels do not move freely, this is the best cathartic for infants. The castor oil is dropped into the child’s mouth from a medicine- THE BOWELS 57 dropper, not given from a spoon. Only in this way can one be sure the infant obtains the right dose. The nurse should observe closely the number and character of the bowel movements, and note the same on her history-sheet. The condition of the infant is read from the bowel movements. If the infant is rest- less and colicky, with audible borborygmus (rumbling in the bowels), a colonic flushing of normal salt solution (0.6 per cent.) may be given. This is done with a soft- rubber catheter (size No. 10 or 12 American scale), to which is attached a little funnel or the barrel of a glass syringe (Fig. 74). The salt solution is allowed to run in and out, 2 or 3 ounces at a time, for five or ten minutes, until the bowel is well cleansed and evacuated. The room should be warm and the infant exposed as little as possible. The tube and funnel are boiled and sterile water used to make the salt solution. The child is laid on its side across the nurse’s knee. A rubber drainage sheet is arranged under the buttocks of the infant, and thus the discharges are conducted into a jar on the floor (Fig. 75). A catheter cannot be passed very far into the sigmoid flexure, and an attempt to do so is dangerous. If the tube is inserted beyond the sphincter, it is enough. Anything un- usual (blood, mucus) is to be saved for the physician’s inspection. If the bowel movements are acrid and irritating, the anal region may become deeply eroded. This can almost always be prevented, but if the condition of the bowels cannot be improved, and especially if the baby is fed by the bottle, the disease is obstinate and hard to cure. There is danger in allowing the buttocks to be- come sore — danger of infection. When the diaper is changed the buttocks and thighs are sponged off with a soft cloth and cool water, using 58 CARE OF THE CHILD little and gentle friction. If the skin is healthy, no powder is needed, but if there are redness and beginning Fig. 75. — Giving a colonic flushing. The infant rests on its left side, warmly covered. A towel covers the rubber drainage sheet. irritation, stearate of zinc powder is applied, although not enough to form flakes. UR IN A TION 159 If an erosion forms or threatens, no water at all may be used, but the buttocks are cleansed with the finest olive oil procurable (not vaselin), and the excess is re- moved with gentle pressure with an old linen towel or lintine. The cloth is used as one would use an ink- blotter. The stearate of zinc is also sometimes useful here, but if it fails, the pure oxid of zinc ointment may be applied. The physician’s advice should be asked regarding all erosions, as they may indicate a constitu- tional taint. These instructions are not to take the place of the physician’s prescription, but are given to those nurses who have to do much on their own responsibility. Attention to the intestinal tract is of prime import- ance in preventing and curing this “chafe,” or eczema intertrigo. The Diaper. — It is important to have a large, thick, soft diaper, flatly folded and smoothly applied. Gauze diapers are useful for the first week. The use of rubber sheeting to prevent soiling the dress is bad; for this pur- pose an extra diaper should be wrapped around the trunk of the infant. The diapers should be scrupulously clean, and soap alkali and washing-powder thoroughly rinsed out of them. If strong soaps are not thoroughly taken out of the fabric in the laundry, they irritate the delicate skin of the babe and may cause eczema. The same may be said of all the infant’s clothes. A diaper wet with urine must be washed in water and dried before being used again. Even though the infant’s urine is clear, when dried it gives off an odor and is irritating. In boys the diaper must be applied a little differently than in girls, care being taken that the parts are not pressed into an uncomfortable position. Urination. — The infant should urinate freely, and, since it does so, is often wet. Unless the diaper is 6o CARE OF THE CHILD frequently changed the skin will macerate and the nates become sore or chafed. The nurse should insist on hav- ing washed diapers for the infant. If the urine is allowed to dry on them, the salts concentrate and irritate the tender skin. If the child passes the reddish brick-dust sediment described before and known as uric acid, this should be noted; it calls attention to the fact that the child needs more water. If the child does not urinate within a few hours after birth, the nurse should carefully inspect the parts to determine the existence of any abnormality of structure. If she suspects such, the physician should be notified. In order to get the infant to urinate, it should be given water freely; then it should be held sitting in a bowl of warm water for five minutes; a warm fomentation over the kidneys, a prolonged saline solution colonic flushing — all these may be used to stimulate the flow of urine. The condition may go thirty-six hours without danger. In one case the infant passed no urine for three days and did not suffer. Catheterization is necessary only in the rarest cases. It must be remembered that the child may urinate, unobserved, in its bath, or the urine, being colorless, leaves no stain on the diaper and evaporates before the nurse notices the latter. If the condition is obstinate, the physician will usually order a diuretic, of which the sweet spirit of niter is a favorite. Nursing*. — The child should be put to the breast after the mother has rested, which is usually about eight hours after birth, then every four hours until the milk comes in, then every three hours during the day and once during the night. The best hours to choose depend on circumstances. In the home, 7 and 10 A. M., 1, 4, 7, and 10 p. m., and once about 2 or 3 a. m., are usually the best. Before and after each nursing, if necessary, the NURSING 6l diaper is changed. Occasionally, if the tongue is coated it may be cleaned with cotton pledgets wrapped around the finger and saturated with boric solution. The nurse should be careful not to scratch the delicate mucous membrane, as it may easily be infected. Should the whitish pellicle on the tongue not come off readily, a pinch of baking-powder on the surface will accomplish it. The mouth requires no routine treatment. To try to disinfect the child’s mouth to prevent breast infection is futile. In fact, the writer believes such attempts favor infection by making sores in the mouth at the angle of the jaws. Before nursing the nipple is washed with boric solution on an applicator, and afterward likewise, and if there is any soreness at all, the nipple is anointed with albolene or cocoa-butter. Neither before nor after nursing is the infant’s mouth to be washed. Each nursing should last not over fifteen minutes, and the infant must be watched to see that it gets enough. The babe must suck and swallow too. If the breast is dry the child will suck, but will have nothing to swallow. A good supply is shown by the milk running out of the infant’s mouth. It must not be allowed to sleep at the breast, because this macerates the nipple and favors the formation of cracks, which may easily lead to infection and mastitis. By adhering to these rules the child soon learns cor- rect habits, which make the whole period of infancy healthier and less troublesome. In the long intervals between nursings the child may need a little warm water, but not more than 3 ounces a day, and it should not get into the habit of water- tippling — lying with the bottle in its mouth all night. Some children do not take to the nipple well, but fret and fuss over the nursing. This is sometimes due to too full breasts, a small or flat nipple, or because the milk 11 1 62 CARE OF TIIE CHILD does not agree with the child, or because there is none there. Sometimes the milk is salty or bitter, which may be true of only one breast, or the milk may flow readily from one breast and not from the other. The child will prefer the easier side always. Various expedients may be tried to get the child to nurse: First, squeeze a little milk in the child’s mouth. Second, put a nipple-shield (Fig. 76) full of sterile water over the nipple; the child will empty this, and will into the child’s mouth. Sixth, pump the milk and feed the child from a bottle until it is stronger and feels the sensation of hunger. The nurse must be convinced that the child gets suffi- cient nourishment. If there is no milk in the breast the child swallows air, and then suffers both colic and hunger. Some infants, especially little ones, fall asleep after nursing, and are “good children,” but lose weight steadily and die of marasmus. If there is any doubt about the child getting enough milk at each nursing, it should be accurately weighed before and after being put to the breast. These weights are recorded, and the difference represents the amount swallowed. It is Fig. 76.— Glass nipple- shield. learn to suck the milk following. Third, put a hot wet compress over the nipple for a few minutes before nursing to bring the “milk to the surface” — really to facilitate the making of milk. Fourth, start the flow with a breast-pump (Fig. 77), and then put the infant to the breast. Fifth, use, especially if the child is weak or premature, the teterelle. (See Fig. 196.) The mother sucks the milk into the bulb and then allows it to run NURSING A 2 °3 Fig. 77. — Breast-pump. Chicago Lying-in Hospital pattern. Diagram shows method of using it. Rubber bulb must always be vertical, so that milk never gets into it. One should pump with short, gentle squeezes, not to exhaust all the air, but to imitate the sucking of the infant. Only the glass portion of the apparatus need be boiled. 164 CARE OF THE CHILD not necessary to undress the babe for these weighings. Adding these amounts for twenty-four hours gives the daily amount of nourishment. Herewith is a table show- ing the daily amounts taken by an infant for the first three weeks: TABLE 1 Number of Nursings. Average Amount Drunk at Each Nursing. , Total Grams. Total Ounces. 1st day 2 2.5 grams 5.0 grams 1 I? drams 2(1 “ 5 29.0 “ 145.0 u 4 f ounces 3 d “ 6 41.0 “ 246.0 8* U 4th CC 7 58.8 “ 411.6 13I u 5th CC 6 67-5 “ 405.0 135 (C 6th “ 7 73 -o “ 511.0 a 17 u 7th “ 6 £ £ 92.2 553-2 u i8| “ 8th “ 7 97.0 “ 679.0 “ 22I ic 9th “ 6 93 -o “ 558.0 (C i8f a 10th “ 7 86.0 “ 692.0 “ 23 “ nth “ 6 96.0 “ 576.0 “ 195 cc 12th “ 6 93 -o “ 558.0 “ i8f a 13th cc 7 86.0 “ 602.0 20 cc 14th “ ... 7 91.0 “ 637.0 “ 214 u 15th “ 6 93 -o “ 558.0 u i8f “ 1 6 th u 7 90.0 “ 630.0 11 21 u 17th “ 7 92.0 “ 644-0 (C 2l| u 1 8th “ 6 96.0 “ 576.0 “ i 9 i cc 19th u . 7 105.0 “ 1 735 -o 24I u 20th “ . 6 112.0 “ 672.0 “ 22\ u 2ISt i 7 102.0 “ j 714.0 u 23 f The Diet. — For the first few days there is nothing but colostrum in the breasts and the baby gets this. The colostrum is laxative, because indigestible. The child needs water besides, which should be given every two hours, 1 ounce at a time. Most children are satis- fied with these for the first two days, but sometimes it is necessary to administer food and water, and unless these are given the child will fret, cry, even develop fever — the so-called “starvation or thirst fever.” One must 1 This table is from Ahlfeld, and was from his own child. THE DIET 165 be very careful not to call all fevers of the newborn starvation fevers, because most of them are due to sep- sis — intestinal, bronchial, or from the navel or throat. A fever later, especially when the child is on artificial food, is often due to intestinal fermentation, and sub- sides after castor oil and a colonic flushing have been ad- ministered. In a maternity hospital the child can obtain nourishment for the first few days from one of the nursing women in the wards, but in private practice, if the mother has no milk, artificial food must, if needed, be substituted. A dram of cream to an ounce of water, or weak milk of “peptogenic powder” may be given to tide the infant over until the secretion in the mother’s breasts is established. Before putting a child to any breast but that of its mother , the nurse must know that neither is syphilitic nor otherwise diseased. After the milk comes these foods should be discon- tinued. Should the mother permanently have no milk, or not enough, or milk of poor quality, artificial feeding must be resorted to, which is really a great calamity, or a wet-nurse must be procured, which is the lesser of the two evils. It is hard, sometimes impossible, to find a good wet-nurse, in which case the child must be given artificial food — a difficult and often unsatisfactory task. The nurse should urge the mother to nurse her infant, and only give up in the presence of real danger to herself or because the milk does not agree with the baby. Re- markable as it may seem, the milk of some mothers acts like an irritant intestinal poison to the infant and may produce enteritis or even death. If there is a scarcity of mother’s milk, one may try to stimulate the glands, first, by daily massage, cold bathing of the whole body, giving much fluid to drink — espe- cially milk, water, cocoa, gruels, and oyster-stews, but no tea, coffee, beer, or malt liquors. The two last fatten the CARE OF THE CHILD 1 66 patient and reduce the milk-supply. A strong baby is the best stimulant to the breasts, and if this fails to bring milk, usually there is no gland tissue there, and all efforts will be futile. Occasionally the milk-supply is not abundant until the patient is up and about and takes out-door exercise. If the baby must be reared on the bottle, the first dif- ficulty is to select the proper food, and infants show remarkable peculiarities in this way. Some will thrive on a preparation that seems to poison the next. Medical opinion also sways from one kind of feeding to another. (See chapter on Infant Feeding.) If the mother can give the baby only one nursing a day, she should do so, because there is something in mother’s milk that the finest chemistry cannot find nor imitate — a life-giving something — and it helps the baby to digest and assimilate the supplied food. Weighing the Infant.— The child should be weighed directly after birth; it should be naked, but protected from the cold. Thereafter, every day before its bath, its weight should be taken and recorded. The scale used should be an “even balance” grocer’s scale, with a scoop on one side and iron weights on the other (Fig. 48). A sliding weight on a scale-bar in front gives the ounces. The scoop should be wired fast to its supports, so that the infant cannot shake it off. A napkin is placed in the scoop, and one of exactly the same size is folded up on the weight plate. These balance, and the actual weight of the infant is thus easily obtained. If there is any suspicion that the child does not obtain enough nourishment from the mother, it should be weighed before and after each nursing, and the differ- ence will show how much the babe has ingested. The amount varies with the age of the infant — 1 or 2 drams TRAINING THE BABY 67 the first few days to 2 or 3 ounces by the tenth day; it varies in different infants, some taking less than others, this being governed somewhat by the child’s size, and it varies at different nursings, a large nursing usually being followed by a lighter one, which means that the appetite of the child varies. The Temperature, Pulse, and Respiration.— These should be taken A. m. and p. m. — certainly the temperature, and, when possible, the others also. The infant should have a record-sheet of its own, and all notable occurrences recorded. It is very difficult to count the respirations, and even normally they are irregu- lar. With a little practice the pulse can be readily counted, the best place being just in front of the ear and when the child sleeps. The radial pulse is also sometimes countable. The room in which the child lies should be airy, and kept at a temperature of about 72 0 F. It must be light, but the infant must not lie in too bright a glare. The child’s feet are often cold, so a hot-water bag must be used, sometimes even in summer. The bag should be warm, not hot, so as not to burn the infant. The child must not lie with dresses moist from urination or vom- iting, from a leaky hot-water bag, or from a bottle given it to drink. All these precautions are especially necessary with premature or weak infants. Training the Baby. — The infant must not be dis- turbed except for needed attention and for nursing. It must not be on show to all the relatives and friends. It must be handled carefully, and when being lifted up the head must always be supported and not allowed to fall to the back or side. When bathing the child the large abdomen or breasts must not be pressed too hard. After nursing the child must not be jarred, because it 1 68 CARE OF THE CHILD may regurgitate the milk. The nurse must not allow the infant to get into bad habits— for example, water- tippling, peppermint-tippling, sucking on a nipple or the finger, water- and whisky-tippling, sleeping with its mother or other person, being taken up when it cries, held, rocked, or carried, etc. By proper training the child may be taught to sleep nearly the whole night through, to sleep between nurs- ings, and to cry only when hungry, uncomfortable, or sick. Adherence to the above rules will bring this about. CHAPTER IV PRESENTATIONS AND POSITIONS Heretofore labor has been spoken of as if it occur- red with the child always presenting by the head. Such is by no means the case. The fetus may present any part of its body to the parturient passage. The term “presentation” has reference to that part of the fetus which presents itself at the internal os first for delivery. The most common presentations are occipital, breech, shoulder, face, and brow. Of all presentations, 96 per cent, are occipital and 2J per cent, are breech. In order to study the mechanism of labor the phys- ician must know what position the child holds in relation to the mother’s pelvis. Fig. 78. — Diagram of the four quadrants of the pelvis. The pelvis, therefore, is divided into four quadrants as follows: Left anterior, left posterior, right anterior, and right posterior (Fig. 78). The technical term “position” has reference to the relation the presenting part bears to these four quadrants 169 170 PRESENTATIONS AND POSITIONS of the mother’s pelvis — for example, if the occiput oc- cupies the left anterior portion of the mother’s pelvis, we speak of an occipito left anterior position— O. L. A. We choose arbitrarily a prominent point in the pre- senting part from which to determine the relation of the presenting part to the four quadrants of the pelvis. PRESENTATIONS AND POSITIONS 171 This point is called the “point of direction.” In vertex presentations the point of direction is the occiput; in breech presentations, the sacrum; in face presentations, the chin; in shoulder presentations, the scapula. When a doctor seeks to determine the presentation and position, he must find out what part of the fetus is presenting and then what relation the point of direction bears to the pelvis, which gives him the position. Sacro left anterior. Sacro right posterior. Fig. 80. — Two of the positions of breech presentation. The most common presentations are vertex (often called occipital), breech, face, shoulder, and brow. In breech cases the feet may be doubled under the child, as a tailor sits on a bench; the feet, one or both, may fall down and be visible at the vulva (single or double footling); the knee may come down, or, curiously, the legs may be extended upward along the chest so that the toes are against the face. These last are difficult cases, although most often breech deliveries are spontaneous. In each of these presentations we have four or more positions: for the occiput, left occipito-anterior, O. L. A.; 72 PRESENTATIONS AND POSITIONS right occipito-anterior, 0. D. A.; right occipito-posterior, 0. T). P.; and left occipito-posterior, O. L. P. (Fig. 79). Mento right posterior. Mento left anterior. Fig: 81. — Two of the positions of face presentation. The abbreviations are those of the Latin terms used for these positions. Scapula left anterior. Scapula right posterior. Fig. 82. — Two of the positions of shoulder presentation. For the breech, the sacrum is the point of direction, and we have the sacro left anterior, sacro right posterior, etc. (Fig. 80). For the face, the chin is the point of DIAGNOSIS OF PRESENTATION AND POSITION 1 73 direction, and we speak of mento left anterior, mento right posterior, etc. (Fig. 81). In shoulder presentations we have scapula left anterior, scapula right posterior, etc. (Fig. 82). The Diagnosis of Presentation and Position. It is often desirable that the nurse be able to tell whether or not the presentation is normal. Particularly is this > o Fig. 83. — Is the ovoid longitudinal or transverse? true in country practice. With a little experience the nurse will learn how to determine the position of the child in the uterus in most cases. There are four prin- ciples in this diagnosis which may be put in the form of questions : 1. Is the uterine ovoid longitudinal or transverse? (Fig. 83). If longitudinal, the child lies in either head or 1 74 PRESENTATIONS AND POSITIONS breech presentation. The nurse lays her hands along the flanks of the patient, and brings the large uterus between them. If the greatest diameter lies parallel with the mother, the uterine ovoid is longitudinal. 2. What is over the inlet? (Fig. 84). The nurse places the hands over the lower abdomen and presses inward Fig. 84. — What is over the inlet? with the finger-tips until she feels the lower pole of the child. If this is hard and round, it is the head; if soft and irregular, the breech. 3. What is in the fundus? (Fig. 85). The hands are placed in a corresponding position on the top of the uterus, and the same points noted. 4. Where is the hack? One hand is placed on each side DIAGNOSIS OF PRESENTATION AND POSITION 1 75 of the uterus and, pressing inward with them alter- nately, the nurse determines which side is more resistant. The more resistant side represents the back. With these points of information one can usually con- struct the diagnosis. For example, if the ovoid is longi- tudinal, the head over the inlet, the breech in the fundus, and the back on the left side, the case is one of occipito left anterior or posterior. There are many finer points Fig. 85. — What is in the fundus? in this method of diagnosis which the physician practices, but which cannot be gone into here. Of all the presentations, the occipital is the most favorable for mother and child, and of the four positions of the occiput, O. L. A. is the best. Fortunately, this is the one most commonly met in practice. The nurse is aware that the head, in order to pass through the pelvic canal, must rotate horizontally on the 76 PRESENTATIONS AND POSITIONS neck, so as to bring its long axis to correspond with the anteroposterior diameter of the outlet. If the occiput is in the left anterior quadrant of the pelvis, it has only to rotate a small part of a circle to get in front; but if the occiput be in the right or left posterior quadrant of the Fig. 86. — Wiegand-Martin method of delivering the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim. pelvis, it has to rotate nearly half a circle to get in front under the pubis. This rotation takes a long time, is painful and tedious, so that sometimes the patient’s strength gives out before it is accomplished. Then the doctor must aid her with the resources of art. These are called “posterior positions,” and the accoucheur DIAGNOSIS OF PRESENTATION AND POSITION 1 77 usually prefers not to meet them. On page 262 is a description of labor in occipital presentation. Breech Cases. -The mechanism of breech deliveries is this: under strong pains the breech comes through the vulva and rises up toward the pubis, the accoucheur simply receiving the child as it appears. The legs now drop out as the child emerges; the patient bears down strongly, and the shoulders are delivered, after which, unless there is some abnormal delay, the head comes with the face over the perineum. Should there be any delay in the delivery of the shoul- ders, the patient is exhorted to bear down, and an assist- ant, the nurse or the husband, makes steady pressure over the top of the uterus, thus forcing the child down. If this is not successful, the doctor delivers the arms gently, then inserts the fingers into the infant’s mouth, and, with the other hand over the fundus of the uterus, carefully and slowly brings the face over the perineum, after which the occiput comes from behind the pubis (Fig. 86). Shoulder or Transverse Presentation. — When the child presents other than longitudinally we speak of transverse presentation. The laity call it a “cross birth,” and it is a serious accident, for, unless the infant can be turned so that its long axis corresponds with the long axis of the mother, either one or both of the lives will be lost. As soon as such an unusual condition is dis- covered the accoucheur will turn the child into a more favorable presentation. This operation is called version. 12 CHAPTER V OBSTETRIC OPERATIONS The frequency of obstetric operations in some locali- ties is out of proportion to the actual demands. The practitioner, trusting to the safety promised by the new aseptic and antiseptic technic, attempts and performs many operations which in former years were considered dangerous and were employed only in extreme condi- tions. As a result of this the mortality of child-bearing women has not decreased as much as it should have done by grace of sterile operating. Those men who have command of a good aseptic technic are the ones that appreciate the dangers of all operations and the safety of leaving the case to nature, while those men who cannot practice asepsis properly are the ones that are bold in operating, basing their confidence on the success ob- tained by their skilful and more conservative confreres. The general practitioner will attempt obstetric opera- tions of the gravity of capital laparotomies when he would not think of performing the latter himself, but would send the patient to a skilled abdominal surgeon. The idea of a specialist in obstetrics is fast gaining ground among the better educated classes, and they are demanding a higher standard of obstetric work from their doctor, and, when this demand is unsatisfied, are seeking the accoucheur who devotes his time and efforts to this particular work. The general mortality of eclampsia is 33 per cent. ; of placenta praevia, 15 per cent. ; of rupture of the uterus, 60 per cent., and yet inexperienced practitioners will under- 178 OBSTETRIC OPERATIONS 179 take the care of these cases unconcernedly, while if the patient had appendicitis the best surgeon obtainable would be called, although the mortality from appen- dicitis is seldom more than 10 per cent., and in some hands only 3 per cent. The child-bearing woman is neglected, both in regard to her medical attendance and her nursing, and it is largely her own fault. She does not demand the highest obstetric skill in her accoucheur, nor does she always pick out the best obstetric nurse obtainable. While for a surgical or gynecologic operation or for a medical con- sultation all considerations are brushed aside and the best man selected, for a confinement some “old friend of the family,” or “a married man,” or “one who does not make so many preparations,” or “one who does not charge so much,” is selected, the patient entirely forgetting that conditions may arise that will suddenly throw her into unprepared, unskilful hands, where, to save her infant’s or her own life, the most rapid, dextrous operating may be necessary. For her nurse, some “monthly” nurse or a “woman that has nursed many cases” is often chosen, and in the emergency which so often arises the unwise mother or the innocent babe is the sufferer. Lack of space prevents going further into this vitally important subject, but these propositions may be easily defended by reference to the state mortality records and case-books of the gynecologists. 1. Except in women of perfect health, labor is not a physiologic process, and is always beset with dangers of no little gravity to both mother and infant. 2. The importance of a labor is minimized by the public and also by the general practitioner, and to a much greater extent is the seriousness of the obstetric complications underrated. i8o OBSTETRIC OPERATIONS 3. The practice of obstetrics requires the highest kind of surgical skill, a complete and consistent technic, a special and extended experience in normal and patho- logic labors, a clear head, unbefogged by alcoholics, a steady hand — not one trembling from use of tobacco or other drugs — a brave and courageous spirit, one that, seeing danger, steps boldly in to rescue one or both lives from peril, and a sympathetic heart, yet one strong enough to allow the mother to suffer pain when it is for her good. Added to these must be the willing sacrifice of the personal comfort and convenience which obstetric work so often demands. The public, by honoring the obstetrician and remuner- ating him properly for his arduous labors, will draw to this specialty the best minds and the most skilful hands, and thus serve its own interests better than it is now doing. There should be at least one obstetric specialist in every community. These remarks apply with equal force to the nursing. Preparation for Operation. —The general rules of surgical nursing apply in every way to obstetric cases. Everything that is liable to come in contact with the patient must be sterile. It is not true that the strin- gent rules of asepsis in general surgery may be disre- garded in obstetrics. Therefore the nurse will need no advice to prepare sterile towels, sheets, pledgets, gauze, basins, brushes, hot and cold sterile water, etc. All these things the obstetric, as well as the general, sur- geon needs. Obstetric operating is more bloody than any other, and there are many factors which make it the most mussy. Such are liquor amnii, meconium, vemix caseosa, and sometimes urine of the baby, the bowel movements and urination of the mother, all of which discharges not seldom take place during the delivery. Aside from the PREPARATION FOR OPERATION 181 necessity of using much linen and many pledgets, there is great danger of infecting the mother from the fecal matter. Deaths have occurred because of it. Further, obstetric operating requires more exposure of the field than any other, and the patient may take cold. Frequent changes of the position or attitude of the patient may be required, so that sterile sheets are thereby disarranged. The nurse must see, therefore, that the patient is not too much exposed, either to cold or to infection. Obstetric operations are not the de- liberate technics of the surgeon, but often necessarily rough and rapid, and with the exhibition of much phys- ical strength. The nurse must not lose her presence of mind and imagine the patient will be tom to pieces, though, sadly enough, in unskilled hands, such may be literally true. Properly, a man may use power of 150 pounds and not injure the patient or the baby. Im- properly used, 10 pounds may do damage. Obstetric operating is full of surprises and acute emer- gencies, therefore the nurse must keep her mind focused on the doctor’s work. If she has the room, tables, sup- plies, etc., properly prepared and arranged things will go more smoothly. So she should, as a labor pro- gresses, like a general during the battle, frequently survey the field to assure herself that everything is in readiness. If, as the labor goes on, the possibility of an operation is considered, the nurse should provide a suitable oper- ating table. Most physicians, unfortunately, content themselves with putting the patient across the bed. This is to avoid alarming the patient, but while the doctor may spare the woman a little nervousness, he often does her and her babe real injury and is unjust to himself. I know that both women and babies have been lost be- cause the physician did not avail himself of the best OBSTE ERIC OPERA TIONS 182 auxiliaries obtainable for his work. It goes without saying that an operation can be better performed on a proper table than on a low, back-breaking bed. The physician who does not insist on the best possible conditions in which to work is unfair and unkind to the mother and babe, and unjust to his art. The accoucheur should have plenty of assistants for obstetric operations. A rational mind cannot under- stand why an accoucheur, when fully able to do other- Fig. 87. — A room in a private home arranged for operation. In the center is the kitchen table with a Kelly pad made of newspapers, and covered with a sheet. To the right is a euchre-table carrying a pile of sterile towels, a jar of pledgets, a bottle of sutures, and the instrument pan. On the left is a sewing- table with one bowl of 1 per cent, lysol, one bowl of 1 : 1000 bichlorid, each with pledgets, a pitcher of fresh hot lysol solution, and a saucer containing scissors and tape for the cord. wise, should work short handed in such difficult and serious operations, when the surgeon, for his simplest operations, has an anesthetizer, at least one other assistant, and one or sometimes two nurses. This lack of assistants throws extra work on the nurse and often overtaxes her strength. If no other nurses or physicians are obtainable, the nurse should call some courageous woman to hold the limbs of the patient while on the table. The husband usually cannot be relied on; he is likely to faint. PREPARATION OF THE ROOM 183 The room should be arranged to resemble as closely as possible the operating room of a lying-in hospital, and every house has the necessary tables, basins, etc., so that this can almost always be done if the will is there (Fig. 87). The instruments vary with the operation to be performed. Preparation of the Room. A kitchen or library table makes an excellent operating table; a sewing- table Fig. 88. — Diagram of room arranged for operation. does well for the instruments and basins; a euchre-table gives additional space. Two kitchen chairs with a table board on them make an excellent side table. A blanket is folded so as to make a pad to put under the patient; this is covered with newspapers. A roll of newspapers is shaped like a Kelly pad, covered with a rubber sheet, or, in the absence of this, with more newspapers, and 184 OBSTETRIC OPERATIONS pinned in shape with large safety-pins. Over all is thrown a clean sheet. Care is taken to protect the floor around the place of operation. A rug is removed; carpet is covered with heavy paper or a rubber sheet. The sewing-table is put on one side of the operator, within easy reach, and yet far enough away not to inter- fere with his motions. It holds the hand solution (with a brush in it) , the basin of pledgets lying in an antiseptic solution (to wash the parts with), and a saucer with a catheter, scissors, artery clamp, and tape for tying the cord lying in lysol solution. The other table stands on the other side in a corresponding position. It carries the pan of boiled instruments, a pile of clean or, preferably, sterilized towels, a jar of sterile pledgets, and the suture material. A kitchen chair is placed before the table for the operator (Fig. 88). Not far away the nurse places a pillow covered with towels, with a tracheal catheter handy, and next to it a bath-tub with hot water. These preparations are for the resuscitation of the newborn if it should arrive asphyxi- ated. The hot- water bag is wrapped in the baby receiver and placed on the pillow. The sterile douche-bag is gotten in readiness, being hung near the table, and the solutions in the basins are replenished and warmed by the addition of hot water just before the patient is placed on the table. Then the nurse assures herself that she has a good supply of hot and cold sterile water. Preparation of the Patient. — If the woman comes to operation in the course of an ordinary labor, she is already partly prepared and needs only an antiseptic washing after she comes on the table. If the operation is an emergency, the patient had better be prepared on the table, and then the ordinary surgical method is here employed — shaving carefully the hair, scrubbing with PREPARATION OF THE PATIENT 185 soap and water, with bichlorid 1 : 1500, or lysol 1 per cent., or both. Some operators use tincture of iodin. (See p. no.) The nurse should ask the accoucheur if she is to give the patient a vaginal douche and catheter- ize her. Most operators dispense with douches nowa- days, and catheterization is usually done after the pa- tient is put on the table. Fig. 89. — Patient in modified lithotomy position for operative delivery. After the preparation, sterile leggings are put on and the body protected by a blanket and sterile sheets. The exact position a parturient should hold, for operative delivery from below, is shown in Fig. 89. The buttocks are brought 3 inches over the edge of the table. The Kelly pad should have no sleeve, nor should the air- I 86 OBSTETRIC OPERATIONS cushion project beyond the edge of the table. The legs are held in a modified lithotomy position by an assistant, on each side, with one hand on the instep of the foot and the other at the knee. If there is a lack of assistants to hold the legs, the patient is arranged as in Fig. 90, with a sheet supporting the limbs. A large square sheet is rolled together on the bias, the middle placed around the shoulders, and the ends are Fig. 90. — Lithotomy position with limbs supported by a sheet-sling. tied securely around the outside of the limb just below the knee. After the knot is firmly tied, for additional security the end of the sheet is pinned. The sheet should be stretched over the shoulder, not over the back of the neck. The nurse must remember that this position is very fatiguing to the patient, even under an anesthetic, and the limbs should be stretched out occasionally during LIGHT AND HEAT I 87 the operation, and the sheet removed at the first oppor- tunity after it. Preparation of Instruments. The physician will usually select such instruments as he will need for the particular operation to be performed, but the nurse should familiarize herself with the names and appearance of those commonly used, so as to get for him whatever asked. The instruments should be boiled in a 1 per cent, soda or a 1 per cent, borax solution for at least five minutes before the operation. If the physician carries a pan in his satchel for this purpose, it is much better than if the nurse has to use the wash-boiler, fish-boiler, roasting-pan, or other large household utensil. In gen- eral it is best to use as few house utensils as possible in this work. Nickeled instruments tarnish if boiled in water without an alkali. For this purpose soda bicar- bonate or washing-soda is used, 1 dessertspoonful to 1 quart of water, borax in the same proportion, or a little lysol. Lists of the instruments needed for the most com- mon operations will be found with the descriptions of these operations. Light and Heat. These two important factors must receive adequate attention. In the daytime the opera- tive end of the table is put toward the window, and at night toward the center of best light. In country prac- tice a sufficient number of good lamps, filled and trimmed, should be at hand. The room must be warmed, as the patient is often much exposed, and the child too should be given a warm welcome. When the operation is prolonged, and in abdominal work, a few warm-water bottles should be laid alongside the chest and arms. In hospitals the operating table may be provided with a hot-water pan or an electric heating pad. Both must be watched for overheating. OBSTETRIC OPERATIONS l88 The bed should be warmed for the reception of the patient after the delivery, although usually there is not so much shock following obstetric operations as follows severe surgical measures. Anesthesia. —The nurse occasionally has to admin- ister the anesthetic, but she should always have it under- stood that the physician assumes the responsibility. It is best, in such cases (which, in the writer’s opinion, should not occur), for the physician to put the patient to sleep and let the nurse continue the narcosis. For operations the full surgical anesthesia is employed. In justice to all concerned, an anesthetizer ought to be employed. The face should be smeared with vaselin to avoid the unpleasant burns that may be produced by chloroform, and care should be taken that none of the latter is dropped into the eye. In small rooms, where gas is burning and chloroform is used, the gas decomposes the chloroform and irritating vapors are liberated. These vapors are more active in the presence of steam, and they are poisonous when concentrated. Fatalities have been reported. Cough- ing and sore throat are the milder symptoms. To avoid these evil effects the nurse will provide free ventilation in the confinement room. The author prefers ether as an anesthetic. While the danger of explosion from an open flame is present, or- dinary care will obviate it. The mask and bottle should not be within 8 feet of the grate or less than 3 feet from the gas jet. Ether vapor is heavy and sinks to the floor. Care After Operations.— After the delivery the physician has usually cleansed the vulva of blood, but he leaves the nurse to clean the nates and limbs. This she does with a towel wet with warm solution, taking extreme care not to approach the perineum with the CARE OF THE CLILD 1 89 cloth or disturb any packing that might have been inserted. The abdominal binder with T, holding the vulvar dress- ing, is now snugly applied, after which the patient is removed to her bed. Great care and gentleness are re- quired during this procedure so as not to jar the woman, and the head must be held low, so that fainting is pre- vented. The nurse now has to rearrange the room while the physician or his assistant watches the patient and the infant; she cannot do all three. Bloody pads, pledgets, and the placenta (the last only after the physician has inspected it) are wrapped in newspapers and sent out to be burned. Bloody towels and sheets are thoroughly rinsed in cold water and wrung dry before being sent to the laundry. The instruments are thoroughly washed in cold water and scrubbed with a brush, especial care being given the locks, hinges, and corrugations. Then the darkened spots are scoured with damp Hand Sapolio, the instru- ments then scalded, and dried out of a hot lysol solution; being hot, they dry quickly and do not rust. After septic operations the instruments should be boiled in an alkaline solution before being put away. Care of the Child. -After operative delivery the child requires special guarding, as it is likely to choke up with mucus, or it may become cyanotic because its lungs, not having been fully unfolded (atelectasis), do not present enough air surface for oxygenation of the blood. If the infant is troubled with mucus, this should be removed by the little finger covered with a soft linen cloth. Then the child should be placed on its side, with the head lower than the chest; the mucus thus escapes from the side of the mouth. A little water may be given. It carries the mucus down with the swallow- ing action. 190 OBSTETRIC OPERATIONS Should the infant turn blue, the case is serious and the physician should be notified. While he is coming the child may die, so the nurse must do something to save it. (See chapter on Asphyxia Neonatorum.) The nurse may glance at the navel to see if it is securely ligated, and that there is no hemorrhage from it. If the head of the babe has been injured by the forceps, great care is required to prevent infection. In the absence of instructions from the physician the little wounds are washed with 1 : 2000 bichlorid solution, dried, and dressed with sterile gauze sewed on the head like a cap. The physician’s attention should be directed to these and other unusual conditions of the newborn. It is important that a child delivered by an operative pro- cedure be kept specially warm, as it suffers shock. This is a fact not sufficiently appreciated. Care of the Mother. — The usual attention given the mother after labor will suffice here unless the opera- tion has been very difficult, with lacerations of the soft parts, or of a special nature, as symphysiotomy or cesarean section. The bed should be warmed, the uterus watched carefully for relaxation and hemorrhage; the room should be aired and darkened. After-treatment of special operations will follow the description of same. MAJOR OPERATIONS The Forceps. The most common operation is the application of forceps. When the woman has labored hard and long, and in spite of her best efforts cannot de- liver the head through the pelvis, the physician lends her aid by means of the forceps. This instrument should never be applied until the woman has proved her inability to deliver the infant or to deliver it quickly enough for its safety or her own. The baby may be a little larger than MAJOR OPERATIONS l 9 l usual, or the parts not so elastic and dilatable as neces- sary, or the nervous system may prove unequal to the strain of labor. This last is more common in the deli- cately bred woman. Fig. 91. — Simpson’s forceps. The instrument was invented by a member of the Chamberlen family in 1683, and was held for many years as a secret. It consists of two blades which are applied separately to the sides of the head and locked. By traction on the handles the head is delivered, the body Fig. 92. — Tarnier’s axis-traction forceps. Below is one of the traction rods. following (Fig. 91). Unless properly applied and manipulated the instrument may do great injury to the mother’s organs, and also damage the child more or less permanently. The axis-traction forceps (Fig. 92) is larger than the Simpson, the type of ordinary forceps. The axis- 192 OBSTETRIC ORE RATIONS Fig. 93. — Delivery of the head, after episiocomy. (A photograph.) Fig. 93a. — Head just delivered. (A photograph.) Fig. 94. — Delivery of anterior shoulder. Nurse holds ready swab for wiping out baby’s mouth. (A photograph.) Fig. 94a. — Delivery of posterior shoulder. (A photograph.) INSTRUMENTS FOR FORCEPS OPERATION 1 93 traction instrument is used when the head is high up, therefore the operation is often called the high forceps operation. This latter is attended with a higher mor- tality for the mother and infant. It is very bloody, and nearly always the mother’s tissues suffer severe injury. The baby is also frequently marked. Later it may die of hemorrhage in the brain. List of Instruments for Forceps Operation Obstetric forceps, ordinary or axis-traction, as ordered. Two long artery forceps. Four short artery forceps. Two vulsellum forceps. (See Fig. 96.) Two tissue forceps. Three scissors (one long). Two needle-holders, six needles. Two large perineal retractors, or specula. One long uterine packing forceps. (See Fig. hi.) One uterine douche-tube. Suture material: silkworm-gut or catgut, as ordered. (See chapter on Sterilization of Supplies.) One catheter (soft rubber). Stethoscope. Salt solution needle. Two tracheal catheters for aspirating mucus from trachea; these must not be boiled. The supplies, as sheets, towels, gowns, sponges, basins, pitchers, etc., required are identical with those needed for normal labor. Duties of Nurse During Forceps Operation. The nurse, having prepared everything as described, and having enough help, will only need to wait on the operator, handing him such things as he needs. She need not have absolutely sterile hands — in fact, had 13 194 OBS TE TRIG OPERA TIONS better not be expected to touch aseptic things. When necessary to replenish basins, she should touch only the outside; when necessary to supply sponges, she carries them with a sterile dressing forceps. For this purpose THE WALCHER POSITION 195 she provides a tall, wide-mouthed jar, with a 1 per cent, lysol solution, in which the forceps stand when not in use. (See Fig. 219, page 446.) It is remarkable what dexterity a nurse acquires in handling sterile towels, pledgets, etc., with the long dressing forceps. When the child is born, she washes the eyes with boric solution, as directed under Normal Labor. Now she may have to grasp the uterus. The duties resemble much those required at a normal confinement. During difficult high forceps deliveries, and also when in breech deliveries the after-coming head gives trouble Fig. 96. — Vulsellum forceps with teeth protected to prevent injury to rubber gloves while operating. in passing through the pelvis, the patient is sometimes ordered put in the Walcher position (Fig. 97). The Walcher Position. ^This attitude of the patient cannot be held long, as it is very fatiguing. The nurse allows the legs to fall very slowly and gently toward the floor, until they rest in the position shown in Fig. 97. 1 The sacrum must rest just on the end of the table, which is protected by a soft blanket; the back arches up, as can be seen in the illustration; the shoulders rest on 1 This figure and many of the others were photographed from a model by the author. The woman was attired in a closely fitting union suit, and great attention was paid to the finest details, so as to get a scientifically correct picture. OBSTETRIC OPERATIONS 196 the table. The legs are held securely, so that the patient does not slide off the table. As soon as the head is well down in the pelvis, the legs are put back into the pose they have in Fig. 89. Fig. 97. — The Walcher position. Breech Extraction. In some breech labors, in spite of powerful pains, the breech will not come down, and the doctor finds it necessary to help nature deliver the child. As in forceps cases, the child may be a little too large, or the maternal parts a little too small or too rigid. DECAPITATION 97 The accoucheur, after the same preparations as for any major operation, folds the hand into a narrow cone, inserts it into the uterus, grasps a foot, and gently draws this down into the vulva. Now, by steady trac- tion, the infant is drawn out, first by one foot, then by the leg, then the thigh, then aided by drawing on the other leg, proceeding carefully. The shoulders some- times cause great difficulty, and the operator throughout has a great task to avoid fracturing the bones. When the head is to come, two fingers are inserted into the child’s mouth; the other hand is over the nape of the neck, and, aided by an assistant pressing from the outside over the uterus, the head is delivered. The instruments necessary for breech extraction are the same as those for forceps operation, as it is sometimes necessary to apply the forceps to the after-coming head, and frequently lacerations are to be repaired. Version. — This means turning the child from an un- favorable presentation to a favorable or normal presenta- tion. In practice we have most commonly version from a shoulder presentation to a breech presentation. The operation is often difficult and laborious, and sometimes very dangerous. The child is often lost by the untimely detachment of the placenta, and the uterus is sometimes ruptured in the effort to turn the child. Rupture of the uterus is a sad accident, as even with the best treatment over 60 per cent, of the mothers and 98 per cent, of the children die. The preparations for version are the same as for the forceps operation, and to the instruments should be added two version slings. These are of §-inch tape and each 1 yard long; they are applied around the leg or arm which has been delivered, so as to aid subse- quent extraction. Decapitation. — When a labor in which the child presents transversely, that is, a “cross-birth,” is allowed 9 8 OBSTETRIC OPERATIONS to go on and has become neglected, the child is found wedged into the pelvis so that it cannot be turned nor straightened out so as to be extracted lengthwise. These cases are called “neglected transverse presentations,” and are very formidable. In such emergencies the accoucheur is compelled to cut the child into two parts and deliver each separately. The section is usually made at the Fig. 98. — Braun’s decapitation hook. neck, but sometimes the trunk is divided. The neck is divided by means of strong scissors or a blunt hook in- vented by Carl Braun (Fig. 98). It is a horrible oper- ation, and fortunately rare. Craniotomy. — This is another of the mutilating operations on the fetus, and consists of opening the skull of the infant with sharp scissors or a long trephine, evacuating the brain matter, then crushing the bones together so as to reduce the size of the head, and extract- ing it after this reduction in size. Fig. 99 shows the crushing instrument; Fig. 100, a common form of per- forator. Embryotomy is a term used to designate all the mutilating operations on the child. Cranioclasis means the crushing of the child’s head, and cephalo-tripsy the same, but without opening the skull. When per- CRANIOTOMY I99 formed on a child already dead these operations are disagreeable enough, but when the obstetrician is called upon to sacrifice the child’s life by them, truly they require moral courage. Yet conditions arise in which the accoucheur stands before dreadful alternatives— to try to save the infant will almost surely lead to the mother’s death; to sacrifice the infant will almost surely save the mother. The question is a difficult one; it is delicate, it is serious, because both lives usually hang in the balance either way, and many considerations not medical in their nature, such as religion and social status, enter into it. At no place in all medicine and surgery does the physician meet a more heart-felt, perplexing, and weighty question. Fig. 100. — Smellie’s perforating scissors. The conditions which usually lead to this difficulty are those of mechanical disproportion between the baby and the maternal parts. The baby is too large or the parts (pelvis or soft passages) are too small to allow a natural delivery. If the patient cannot deliver herself, and if labor cannot be accomplished by forceps or by extrac- tion by the breech, the questions arise, Shall we reduce the bulk of the infant, or shall we remove the child by a new passage (cesarean section), or shall we enlarge the pelvis (symphysiotomy) ? The last two operations are quite safe if performed very early in labor, before the patient is infected or ex- hausted. If performed late, when either infection or exhaustion is present, the mortality is very high, while the craniotomy has hardly any mortality. If the child 200 OBSTETRIC OPERATIONS is dead, the question is simple, but if it is alive, the de- cision is extremely difficult, and requires the highest kind of obstetric judgment. The author’s practice is this : If the woman is in prime condition — that is, if she is not infected, her earlier attendants having been aseptic, and if she has not been in labor long and no attempts at operative delivery have been made — he strongly counsels removal to a good hos- pital and the performance of cesarean section or pubiot- omy. If the conditions are not favorable for a success- ful abdominal delivery or opening of the pelvis, he ad- vises the sacrifice of this child, and the performance of cesarean section or premature delivery in the next pregnancy. Unfortunately, most labors are conducted in a blind manner, and the difficulty is not recognized until opera- tive attempts, sometimes to the number of fifteen, have been made and proved fruitless. Then only is special skill called in, and in such forlorn cases one is to be con- gratulated if the mother can be brought through alive, even though not whole. Early recognition of impending difficulties will avoid most of them, and this is the reason why specially skilled attendants should be employed for all obstetric cases. Preparation for the Mutilating Operations. The nurse will prepare for craniotomy, decapitation, and the other operations of this class as for any major obstetric operation. The instruments are shown in Fig. ioi. After the child is delivered the head should be reshaped by filling it with cotton and sewing up the injured skin. The feelings of the family should be spared as much as possible. Baptism. —If the family is Catholic, the nurse, unless the physician has attended to the matter, should arrange CE SATE AN SECTION 201 for the baptism of the child when the possibility presents that it will die. The physician may give the child intra-uterine baptism. Even a non- Catholic may administer these rites, and the nurse will do much for the mental comfort of her patient if she sees that her religious beliefs are con- formed with. Fig. ioi. — I nstruments for embryotomy. Cesarean Section. -This operation does not take its name from Caesar, but from a Latin word, cedere , mean- ing to cut. There is no evidence that Caesar was deliv- ered by this means. The first authentic cesarean section on the living was performed about three hundred years ago by a swine-gelder on his own wife. Thirteen mid- wives and barbers had exhausted their skill on the poor woman. She recovered! The scene of a modern cesa- 202 OBSTETRIC ORE RAT/OIVS rean section differs from that of one given by Mercurio in Italy in 1595 (Fig. 102). Delivery by the abdominal route is performed when the maternal passages are so obstructed — as by con- Fig. 102. — A cesarean section in Italy in the sixteenth century (Witkowski). tracted pelvis or scars in the soft parts, or by tumors, such as fibroids, wedged in the pelvis — that the child has no room to pass. Sometimes there is room enough for a child that is reduced in size by mutilation to pass CESAREAN SECTION 203 through, but not for a living child. In these cases the physician may do the abdominal delivery to save the child. The operation consists of seven steps: (1) Opening the abdomen; (2) incision in the uterus; (3) removal of the child; (4) removal of the placenta and secundines; (5) careful suture of the uterus; (6) peritoneal toilet; (7) suture of the abdominal wall. Sometimes the uterus is removed also. This is called a Porro operation. Ordinarily, cesarean section is not a hard operation, and performed in a good hospital, at an early period of labor, it is not very dangerous, the mortality being about 3 per cent, in the most favorable cases and in skilful hands. Performed late, after many examinations have been made by questionable fingers or after operations have even been attempted, cesarean section has a very high mortality, and the children also often die, so that even if the mother lives the object for which she has been hazarded is lost in the end. Preparation for Cesarean Section. — The preparations for this operation are mainly those for laparotomy in general. In addition, provision is made for the child. A preparatory course of treatment extending over several days is desirable, but not absolutely necessary. Daily warm baths with brisk scrubbing of the trunk from the ensiform to the knees, a light laxative with enemata, plain nourishing food, plenty of rest in bed, and walks in the sunshine are all valuable in rendering the patient more resistant to the dangers besetting the operation. The urine is examined for evidences of nephritis, and the vaginal discharge, for gonorrheal infection. The method of disinfection of the skin varies with dif- ferent practitioners. One commonly used is as follows: (1) Shaving, from ribs to half-way to knees, and well down the flanks; (2) scrubbing with soft brush and 204 OBSTETRIC OPERATIONS tincture of green soap for five minutes; (3) rinsing with plain water; (4) scrubbing with soft brush or coarse cloth and alcohol, 95 per cent., three minutes; (5) scrub- bing with 1 : 1500 bichlorid for three minutes; or (6) scrubbing with lysol, 1 per cent., three minutes; (7) BASIN ■ STAND □ □ □ TABLE. WITH CIO TABLE. WITH INSTRUMENTS. SUTURE MATERIAL, ETC. ^IRS^ASSISTANT CLEAN\ NURSE ^BATH TUB ^ O' (HOT9 (COLD) WATER TABLE WITH TRACHEAL CATHETER, TOWELS, ETC. o .0 r* b o Fig. 103. — Diagram of a room arranged for cesarean section. gauze saturated with 1 per cent, lysol is allowed to cover the abdomen until the operator is ready; then (8) the ab- domen is washed with sterile water. The sterile laparot- omy sheet is now adjusted. Some operators use alcohol entirely as a disinfectant, others rely on tincture of green soap. Before going on the table the patient is catheter- SUPPLIES NEEDED FOR CESAREAN SECTION 2C>5 ized. Tincture of iodin is not recommended. The vulva is also prepared, but no vaginal manipulations are made unless ordered. For the operation five assistants are necessary: An anesthetizer, a first assistant, an assistant to hand instru- ments and sponges, one to receive and revive the child, and a nurse, not aseptic, to handle supplies and render general services about the patient. The less the num- ber of hands in the case, the better. All assistants should wear sterile rubber gloves, and extra care is to be taken that there are no perforations in them. The arrangement of tables and assistants is shown in Fig. 103. List of Supplies Needed for Cesarean Section Twelve small laparotomy sponges. These are of four thicknesses of gauze, 6 inches square, sewed around the edges and carrying a piece of tape 10 inches long firmly fastened to one corner, with a ring or hard object at- tached to the end. Six large laparotomy pads. These are of six thick- nesses of gauze, 12 inches square, sewed and tacked, but without tapes. One jar of small surgical gauze sponges or pledgets. One sterile receiver for the baby. One laparotomy sheet. Two plain sterile sheets. One dozen towels. One pair leggings. Six gowns and head-pieces (Fig. 104). Four pairs rubber gloves. Five basins. One pitcher, besides hot- and cold-water supply pitchers. 206 OBS TE TRIC OPERA TIONS These articles are sterilized according to the usual methods. The antiseptic solutions are prepared accord- ing to the physician’s usual practice. Fig. 104. — Head- and mouth-guard. Pattern of Mercy Hospital, Chicgao. The Instruments for Cesarean Section Two scalpels. Three scissors, one angular. Three tenaculum forceps. CESAREAN SECTION 207 Three sponge-carriers. Twelve artery clamps. Eight long pedicle clamps. Two needle-holders. Two broad retractors. Two rat- toothed tissue forceps. One long uterine packing forceps. Eight full curved round needles, ij inches, for uterus. Six shorter, half-curved spear-pointed needles for fascia. Two long straight needles for skin. One glass hypodermic syringe. One dozen large safety-pins. Adrenalin, 1 : 10,000, and pituitrin in glass ampoules. Suture material. The physician will order this. No. 6 silk for the uterus; No. 1 catgut for the peritoneum; No. 2 catgut for fascia; and medium silkworm-gut for the skin, are usually used. Some operators use catgut throughout. Light, Heat, and Anesthetic. — Special arrangement must be made for light if the section is to be performed in a private home. The room must be quite warm — at least 8 o° F. — as the peritoneum is much exposed, and it is well that the air be damp, so that there is no dust. The operating table should be covered with an electric heating pad, or a few hot-water bottles laid alongside the patient. She must be guarded from chilling. The anesthetic usually given is ether. Just before the anes- thetic is started a hypodermic of aseptic ergot or of pitui- trin is administered. The nurse should provide a little tray with the anesthetic, a working and tested hypoder- mic syringe, strychnin tablets, camphorated oil, aromatic spirits of ammonia, and ether, ready for the anesthetist. Tongue forceps are not necessary; a skilful anesthetist 208 OBSTETRIC OPERATIONS will hardly ever use them. Oxygen should be at hand. The Operation. —The field having been prepared, the sterile sheet and towels being arranged and pinned, and the patient sound asleep, a long incision is made in the middle line, through which the uterus is delivered. It is at once covered with sterile towels wrung out of hot water. The operator rapidly cuts into the uterus, de- livers the child by the feet, clamps the cord in two places, cuts between, and hands the infant at once to an assist- ant or a nurse who stands beside him holding a warm blanket for it. The operator pays no attention to the child, as he has to continue the operation, but the assist- ant’s duty is to revive the infant. The child usually is slow in beginning to breathe, because the change from intra- to extra-uterine conditions came so quickly. Patience and the usual methods of resuscitation almost always succeed. (See page 360.) The operator removes the placenta and membranes, and then covers the uterus with the large laparotomy pads or hot towels. The temperature of the water from which these towels are wrung should be 120° F. The uterus, if it is not removed by the Porro operation, is now carefully sewed up again, then the peritoneal toilet is performed, and the abdomen is closed. The nurse has carefully counted the laparotomy pads and sponges and notified the operator at once if any are missing. The dressing of the wound is made by laying a strip of gauze over it and covering both with collodion. An antiseptic powder may be used instead, and over this a large oc- clusive dressing. Adhesive straps are now placed to support the abdom- inal wall, but care is to be taken not to make them too tight. CESAREAN SECTION 209 STEPS OF OPERATION Operator. 1. Puts on gloves. 1. 2. Incision in skin. 2. 3. Incision of fascia. 3. 4. Incision of peritoneum. 4. 5. Incision of uterus, and 5. delivery of child. 6. Hemorrhage. 6. 7. Suture of uterus. 7. 8. Peritoneal toilet. 8. 9. Sewing peritoneum. 9. 10. Sewing fascia. 10. 1 1 . Sewing skin. 1 1 . Nurse. Adjusts sheets. Hands knife to operator, artery clamps to assistant. Second knife to operator. Scissors to operator, tissue for- ceps to assistant. Two artery clamps for cord. Sterile receiver for infant. Wet hot large pads, injection of 1:10,000 adrenalin into uterus, suture material. No. 2 catgut or No. 6 silk on round pointed needles. Small pads wet with sterile water, or stick sponge in secure holder. No. 1 catgut on same needles. Count pads. No. 2 catgut on sharp-pointed short needles. Silk-gut or linen on long straight needle. There are several varieties of cesarean section — the extraperitoneal, the transperitoneal, the flank operation — but the classic operation is the one here described. The After=care. -This is identical with that of all laparotomies. The nurse watches for signs of internal hemorrhage, increasing pulse-rate, decreasing fulness of pulse, pallor, rapid respiration, yawning, sighing, etc. The reaction from shock should be noted, likewise its absence. Persistent vomiting is always suspicious. In addition to these the nurse must look for external bleeding from the genitals, as patients may have post- partum hemorrhage after cesarean section. The abdomi- nal dressing occasionally requires some adjustment that it does not slip and expose the wound. Should the patient vomit persistently; should hemor- rhage appear externally; should the patient not rally quickly from the shock of the operation or should this 14 210 OBSTETRIC OPERATIONS even deepen; or should internal hemorrhage be suspected, the physician must be notified without delay. Hot water, i ounce at a time and freely, will assuage the extreme thirst, and salt solution per rectum, i pint every six hours, will help to do the same. Milk and lime-water are given for the first twelve hours, after which liquid diet is ordered. The nurse must obtain written orders from the phys- ician regarding all these details if she is not familiar with his practice. The instructions here given are to indicate the general course of treatment and for the general in- formation of the nurse. The bowels should move on the second or third day, but if the patient passes flatus no trouble need be anticipated in this direction. The physician usually orders a cathartic, to be followed by a colonic flushing, the composition of which the nurse should ascertain from him. Some physicians avoid cathartics. Extreme tympany, persistent nausea and vomiting, obstinate constipation, severe pain, hiccup, fever occur- ring at any time after the operation, are to be noted on the history-sheet, and the doctor’s attention drawn to them. Sometimes they indicate a beginning peritonitis. The child does not require any other care than that given after normal labor. It is put to the breast twelve hours after the operation if everything goes well, and regularly, as per schedule given on page 160. Convalescence. — The sutures are usually removed on the eleventh day. The physician may apply adhesive strips or a firm binder to support the wound. The patient sits up at the end of one or three weeks, depend- ing on the practice of the operator. Vaginal Cesarean Section. -When rapid delivery is indicated and the cervix uteri is tightly closed the quickest way to empty the uterus is by an operation PUBIOTOMY OR HEB OSTEOTOMY 211 called vaginal cesarean section. The anterior wall of the vagina is incised and the bladder pushed forward, away from the uterus, and then the anterior wall of the uterus is divided with scissors, making an opening large enough for the extraction of the child. The perineum is also incised if necessary. After delivery is completed all the structures are reunited by suture. The preparations by the nurse are the same as for forceps operation plus those for vaginal extirpation of the uterus (hysterectomy). Symphysiotomy. This is the section of the pubic joint which allows the innominate bones to separate, and thus the cavity of the pelvis is enlarged. The operation was invented by Sigault, a medical student, in 1773, but was discarded because of its dreadful mortality. Sigault’s case, the wife of a gendarme, dragged out a miser- able existence after its performance on her, but Sigault was given a medal for devising it. About 1892 there was a revival of the operation, because the blessings of asepsis rendered it quite safe. But now it is falling off in favor, pubiotomy and cesarean section taking its place. Pubiotomy or hebosteotomy is a new operation, and at the present writing the enthusiasm with which it was received, like many innovations in medicine, has already become moderated by adverse experience. The operation resembles symphysiotomy with the exception that not the joint, but the bone near the joint is opened. A wire saw invented by Gigli is used, and the section is often done subcutaneously. Symphysiotomy being almost completely displaced by pubiotomy, the latter operation will be described. There are three stages in the procedure : (1) The saw- ing open of the pelvis; (2) the delivery of the child; (3) the repair of lacerations. 212 OBSTE TR IC OPERA T/ONS The Operation. -The patient is prepared as for any major obstetric operation, and lies on the table with the limbs partly extended. The Gigli or wire saw is carried a Fig. 105. — Pubiotomy needles: a, Bumm’s; b, Doderlein’s. around the back of the pubic bone through either a small incision or a puncture. The introduction is effected by means of a large needle or a special carrier (Fig. 105). After the bone is severed the child is de- PUBIOTOMY OR HE BOS TE O TO M\ 213 livered by forceps or version, or the case left to nature. The ends of the bone separate 1 or 2 inches during the delivery and the sides of the pelvis are supported by the assistants. The hemorrhage and lacerations, if present, are at- tended to, the bladder catheterized to see if it is injured, and the patient carefully carried to bed. Four assistants are needed besides the nurse. List of Instruments Two trays, to be kept separate. First Tray: One scalpel. Two Gigli wire saws (Fig. 106). One special carrier or large needle (Fig. 105). Scissors. One broad grooved director. Four artery clamps. Four 8-inch pedicle clamps. Needle-holder. Four full-curved, spear-pointed needles, if inches. Two retractors. Uterine sound or metal catheter. Second Tray: Forceps, axis-traction forceps, and all instruments given under Forceps Operation. (See p. 194.) The operator is careful not to mix the instruments of the two trays. The first tray is used for the opening of the pelvis and closing the wounds afterward. The second tray is used for the second stage of the operation — the delivery part. The vagina is considered septic, and this is the reason for the two separate trays of instruments. After delivering the child the operator resterilizes his hands, or draws on new sterile gloves before going again 214 OB S' 7 E ERIC OPERA TIONS to the pubic wound. This is one of the main dangers of the operation, that the pubic wound will become infected from the vagina, and the nurse has to do her share to prevent it in the puerperium. After=care of Symphysiotomy and Pubiotomy.— It is highly important that the patient be given intelligent nursing, as she is practically paraplegic after such opera- tions. For the first few days she does not have the use of her limbs — she cannot raise the hips and should not PUB10T0MY OR HEBOSTEOTOMY 215 try to do so. The integrity of the pelvic girdle is tem- porarily destroyed. The patient, after the operation, is dressed with ad- hesive strips about the pelvis to support the bones in apposition, or this is done by a tight binder strapped on. She is placed on a special symphysiotomy bed, if one is obtainable, though this is not absolutely necessary; any nurse can improvise such an apparatus, the idea being to have the bed arranged so that the patient may be raised up for the use of the bed-pan and for dressings. The plumber may make a frame of J-inch iron gas-pipe, 32 by 66 inches, or long enough to fit inside the bed. The nurse then covers this frame with strong muslin, as shown in Fig. 107. At the middle, where the buttocks will lie, the strips of muslin are to be pinned at the side with strong safety-pins. When the patient is raised off the bed these strips are unpinned and access to the gen- itals is thus obtained. This frame may be raised by means of four ropes attached to the corners and running through pulleys in the ceiling, or it may be lifted onto four hooks hanging on the head and foot of the bed, as shown in Fig. 108. 2l6 OBSTETRIC ORERATIONS The bed is dressed as usual, the frame is laid on it, and the patient lies on the muslin strips. When neces- sary to make a dressing or give the patient the usual attentions, the frame is raised about 12 inches. The strips beneath the vulva are loosened and drawn aside. This arrangement simplifies extraordinarily the after- care of these cases, which at best is trying and tedious. The nurse should watch for a hematoma, a blood-clot MINOR OPERATIONS 21 7 around the pubic joint, which is not infrequent after hebosteotomy, and for signs of injury to the bladder. If a retention catheter has been inserted the nurse must be sure that it is draining without interruption. (See F'g- iSS-) Particular care is necessary to prevent the lochia from gaining access to the wound in the mons pubis. To avoid this the nurse adjusts the vulvar pad firmly above, loosely below, so that the lochia will have free flow downward, and arranges the wound dressing so as to keep the wound covered. Catheterization is particularly difficult because the patient is not allowed to separate the limbs more than a few inches. By turning the toes inward the nurse may part the knees without causing much pain. After two weeks the frame may usually be dispensed with. Several weeks may pass before the patient is able to resume her household duties. MINOR OPERATIONS Minor operations are as important as any, and should be prepared for with the usual aseptic care. Preparation for Obstetric Examination. The nurse is expected to arrange a patient for the digital obstetric or gynecologic examination quickly and neatly. A basin of i per cent, lysol solution, a supply of pledgets, and a sheet are necessary. If the physician desires the patient across the bed she is placed as in Fig. 51. The sheet is laid on the bias over the trunk, the opposite corners are wrapped around the legs, while the two re- maining corners are draped one over the body, and the other to form a flap which hangs between the thighs till the examination is about to be made. The nurse will sponge the parts carefully herself before the physician inspects them, and will report to him the presence of 2 1 8 OBSTETRIC ORE RATIONS bloody, purulent, or odorous discharge. The patient’s limbs, as shown in Fig. 51, are supported by the nurse. They may be allowed to rest on two chairs or on the knees of the physician. Occasionally the nurse is requested to arrange the patient obliquely on the bed with one foot resting on a chair (Fig. 109). Fig. 109. — Patient obliquely in bed, draped with a sheet, prepared for internal examination. One limb rests on a chair, the other on the edge of the bed. The buttocks are near the edge of the bed, which is protected by a newspaper covered with a towel. Perineorrhaphy. -The most common of minor oper- ations is perineorrhaphy, or the repair of lacerations of the pelvic floor. Most physicians repair these tears immediately after labor. Others leave them for two weeks, and a very few defer operation to a period of several months afterward. MINOR OPERATIONS 219 For a perineorrhaphy after labor the patient is usually put across the bed in the lithotomy position (Fig. 90). If the laceration is more than small, it is wiser to use the table, as much better work can be done. The operation has already been described on p. 129. The after-treatment of stitches does not differ much from the usual. Extra care must be taken not to. pull Fig. 1x0. — Patient across the bed, draped with a sheet, for removal of sutures. The instruments lie in the basin in which they were boiled or upon a sterile towel: Speculum, 2 artery forceps, x tissue forceps, 2 scissors. on the knots when a dressing is made or a bed-pan is used; also that the suture ends do not catch in the dressing and drag on the wound Should the patient complain of the ends of the sutures pricking her, the nurse may wrap them in sterile gauze or let them lie between two layers of gauze. At each dressing notice is taken of any signs of irritation, swelling, special tender- 220 OBSTETRIC OPERATIONS ness, or pus-formation, or of cutting around the stitches or line of union, and a note is made of same on the record- sheet. The parts around the wound should occasionally be washed with soap and water to remove dried secretions and macerated epithelium. Removal of Sutures. — Catgut does not need to be removed; silk and silkworm-gut do. This is done on about the tenth day. The nurse sterilizes two sharp-pointed scissors, one long, one short, artery forceps, one tissue forceps, and a short, narrow, highly polished speculum (Fig. no). The physician requires excellent light. The provisions for asepsis are as usual (sterile gloves, etc.), and the arrangement of the patient, tables, and basins is similar to that used when the perineorrhaphy was done. As there is often a shortage of assistants, the nurse should arrange everything in readiness for the physician to wait on himself. Then she holds the legs as in Fig. iio. The sheet-sling may be used or each foot placed on a chair. The patient should rest quietly for several hours after the sutures are removed. Uterine Tamponade. -The tamponade or packing of the uterus with gauze is done to control postpartum hemorrhage, and also by some accoucheurs in the treat- ment of puerperal sepsis. The physician needs specula, vulsellum forceps, long uterine packing forceps (Fig. in), MINOR OPERATIONS 221 and a jar of sterilized or antiseptic gauze. This gauze should be J yard wide and 12 yards long, and packed in jars from below upward, so that when needed it may be served right out of the jar (Fig. 112). If the avail- Fig. 1x2. — The operation of packing the uterus, showing how the nurse holds the gauze near the vulva. 222 OBSTETRIC ORE RATIONS able gauze is rolled, the roll may be served out of a sterile basin, or from two forceps attached to the center, as in Fig. 113. The patient is arranged across the bed or on a table in the lithotomy position. For this operation the limbs may be supported on chairs. The nurse wraps the jar in a sterile towel and holds it against the buttock, about 2 inches below and to the side of the vulva. The physician picks up the end of the gauze with long forceps and carries it into the uterus, which he has Fig. X13. — Showing how nurse unrolls gauze by means of two forceps as the doctor packs it into the uterus. Rubber gloves, etc., are, of course, used in actual practice. drawn down with vulsella, or steadies with two fingers of the other hand (Fig. 112). After the uterus is packed a pad is applied, and then the binder. Special care must be taken in moving pa- tients that are tamponed, as the uterus may stretch dan- gerously tight over the packing or even rupture if the patient is tossed about. The Douche. — The practice of vaginal and uterine douching after labor has undergone nearly a complete reversal in the last fifteen years. Whereas formerly it THE DOUCHE 223 was thought that douching aided recovery and prevented puerperal infection, accumulated experience has proved that the irrigations in normal cases are at least super- fluous, and indicated only in pathologic cases. Even here medical opinions differ as to their value. The vaginal douche is a much simpler procedure than the uterine douche, and the latter the nurse ought not be called upon to give, although with a little special instruc- tion she can learn to practice it. The dignity nowadays accorded the uterine douche places the responsibility on the physician. The Vaginal Douche. —The arrangement for giving the douche is pictured in Fig. 151. The aseptic prepara- tions are as usual. For vaginal douching the patient lies on her back in bed on a douche-pan, which should be sterile. The douche-bag and nozzle should be freshly sterilized, and sterilized water, saline solution, lysol used, according to special order. For the vaginal douche the point is inserted 2 \ inches downward and backward, avoiding the perineum. The bag should be no more than 2 feet above the patient, and the return flow from the vagina must be free, which is accomplished by pressing the tube slightly against the side of the vulva. The nurse must have sterile hands or wear rub- ber gloves. One quart is usually sufficient. The patient is asked to bear down a little to express any liquid re- maining in the vagina, the parts are gently dried, and the douche pan is removed. The nurse observes and notes any clots or shreds that have come away, and also the odor of the discharge. If bichlorid or carbolic acid is ordered as a douche, it should be followed by sterile water, and care taken that the proportion is right and the mixture perfect. Cases of fatal poisoning are recorded due to neglect of these precautions, which are as necessary in private homes as in hospitals. 224 OBSTETRIC OPERATIONS The Uterine Douche. -For this the patient is usually placed across the bed or on a table, as often it is com- bined with a digital palpation of the interior of the womb. A broad speculum, two vulsellum forceps, a long uterine applicator, and a uterine douche point should be boiled. Sterile tubes for cultures should be provided. Plenty of sterile water is needed, as these douches are often copious. The patient is placed on a Kelly pad or on a rubber sheet draped over a roll of newspapers. The floor is properly protected and a drainage pail pro- vided. The patient must be kept quiet after this operation. Not seldom it is followed by a chill and rise of tem- perature. Uterine Curettage. -This operation is done in the treatment of puerperal infection, and its object is to remove pieces of decidua or placenta that are retained and decomposing in the uterus. Physicians differ as to the advisability of the practice. It is also performed in cases of abortion. The preparations are the same as for a major opera- tion — table, anesthetic, hot and cold sterile water, sterile gloves, etc. The instruments required are specula, curets, as the physician selects, uterine packing forceps, cervix forceps, vulsella, uterine douche tube, scissors, sterile glass for specimen, test-tubes for cultures. A basin of sterile water in which the operator may rinse the curet of adherent particles of tissue should be placed at his side. Gauze — -iodoform, lysol, or plain sterilized — for packing the uterus may be needed. Since these operations are done for septic cases the nurse should be careful of her hands, not to prick her fingers on the instruments, and not to carry infection to the mother’s breasts or the child’s eyes or navel. LIST OF INSTRUMENTS FOR HYPODERMOCLYSIS 225 The Administration of Saline Solution. One of the most precious additions to our means for saving life is the use of saline solution transfusion. In the olden time blood from another person was transfused in cases of severe hemorrhage, and many cases are on record of such heroic sacrifice, but only recently has the direct transfusion of human blood been practicable and safe. In 1881 Schwartz showed that salt solution could be used for supplying loss of blood in animals, and von Ott and Bischoff were the first to employ the measure in the treatment of anemic patients. There is but little doubt in the minds of surgeons and accoucheurs that the use of salt solution for their various purposes saves lives. An expensive apparatus, though more convenient, is not necessary except in hospitals, where the operation is frequently done. The saline solution may be injected under the skin (hypodermoclysis) or by intravenous administration. List of Instruments for Hypodermoclysis One 2 -quart douche-bag or can with tube 6 feet long. One 1 -quart measure. Fig. 1 14. — Author’s needle used for hypodermoclysis, with stem and protecting cover. One bath-thermometer, registering over 212 0 F. This is removed from its wooden case. One salt solution needle (Fig. 114). 15 226 OBSTETRIC ORE RATIONS For intravenous transfusion add: One small sharp scalpel. Two small curved needles. One sharp-pointed scissors. Two fine rat- toothed dissecting forceps. Three artery forceps. One fine-pointed medicine-dropper or special trans- fusion cannula (Fig. 115). Several strands of silk. One tourniquet for the arm. Do not forget to remove it before the fluid is injected. In a private house the nurse will proceed as follows: The 2-quart douche-bag or can and tube, the 1 -quart measure, and the bath-thermometer are put on to boil in 1 per cent, soda solution. The rubber goods must be c Fig. 1 1 5. — Glass cannula for intravenous transfusion. wrapped in several layers of towel. They are boiled vigorously, tightly covered for fifteen minutes, and are rinsed, inside and out, with hot sterile water. The instruments are sterilized separately and served out of the pan in which they were boiled. Salt solution, 0.7 per cent., is that most generally employed, though sometimes other chemicals are added. It is made by dissolving 2 drams of common table salt in 1 quart of water. In practice 2 teaspoonfuls to 1 quart will give accurate enough dosage. Unless the salt has been previously sterilized, the solution when made up must be boiled vigorously for fifteen minutes, in a tightly covered vessel. Distilled water should not be used, the small amount of calcium in hydrant water being needed by the SALT SOLUTION 227 blood. This fact is supported by physiologic ex- periment. After boiling the required time the solution is poured into the douche-bag, the mouth of same stoppered with a large pledget of sterile cotton, and the side of the bag held under the cold-water tap. The thermometer is Fig. 1 1 6. — Cooling the prepared saline solution under the cold-water tap. inserted alongside the cotton (Fig. 1 16). In this way the solution is quickly brought to the right temperature- no 0 to 120 0 F. — as ordered. By the time the fluid reaches the patient, passage through the long tube will have cooled it off several degrees. The skin is prepared by scrubbing with water and soap, 228 OBSTETRIC OPERATIONS with lysol and alcohol, or by painting heavily with tincture of iodin. For subcutaneous transfusion (Fig. 1 17) the area under the breasts is often selected; for intravenous (Fig. 118), Fig. 1 1 7. — The subcutaneous administration of saline solution. the large vein in the bend of the elbow. With the sub- cutaneous method the bag is raised 5 feet above the patient to obtain sufficient pressure; for the intravenous method a height of 18 inches gives sufficient force. Fig. 118. — The intravenous administration of saline solution. SALT SOLUTION 229 A shorter tube is used. The puncture under the breast may be sealed with collodion, with adhesive plaster, or closed with a Michel clip. In the absence of either, the solution may be prevented from escaping from the needle 230 OBS TE ERIC OPERA T10NS puncture by holding a pledget soaked in alcohol over it for a few minutes. The wound in the bend of the elbow is dressed aseptically under firm compression. The Induction of Premature Tabor. -This opera- tion is quite often done, the reasons being: contracted pelvis in the mother (a small, premature child may pass) ; threatened convulsions (eclampsia) ; placenta praevia, and many others. There are several methods, the most reliable ones being the insertion of rubber catheters into the uterus (Krause) ; of long strips of gauze, and of rubber bags filled with water after being laid inside the cervix. With extreme asepsis the induction of labor has, of itself, no mortality, and the women do not sicken. If antiseptic precautions are neglected the operation is dangerous. Preparations are the same as for any major obstetric operation. Instruments Needed For the rubber-bag method, a colpeurynter or Barnes’ bag (Figs. 1 19, 120). A long uterine dressing forceps. Two specula. Two vulsella. Scissors. Two short artery forceps. One bulb or piston syringe, in working order. One strand linen bobbin, 20 inches long. For Krause’s method, add two soft-rubber solid bougies (size 16, American). For the gauze method, add a tubular packer (Fig. 1 21) and a supply of sterile gauze to fit the instrument. The catheters and all soft-rubber goods are sterilized by boiling in pure water for thirty minutes in a tightly closed vessel. They must be wrapped in at least four THE INDUCTION OF PREMATURE LABOR 23 I Fig. 1 19. — Various types of balloon dilators: a, b, Voorhees’; c, Carl Braun’s colpeurynter; d, Barnes’; e, Hirst’s; /, Champetier de Ribes’; g, air pessary; h, Pomeroy’s; i, bougie. 232 OBSTETRIC OPERATIONS layers of a thick towel to insure them against being burnt by lying against the hot metal. Hard-rubber syringes are sterilized by formalin or prolonged immer- sion in i : 500 bichlorid. Fig. 120. — Filling the colpeurynter. THE INDUCTION OF PREMATURE LABOR 233 A vaginal douche is usually given, and the patient is placed across the bed or on a table, as for any obstetric operation. The object of the operation is to induce labor-pains, to inaugurate labor, after which the case is left to nature or treated as any labor coming on spontaneously at the same period of pregnancy. Fig. 1 21. — Tubular gauze packer. The bougies lying in the uterus irritate it to contrac- tion, as does also the rubber bag. The latter, in addi- tion to being an irritant, mechanically dilates the cervix. Pains come on in a few minutes or hours, or perhaps not for days, although it is not usual for the doctor to leave the instrument in the uterus for this length of time. The procedure is sometimes very tedious. If the labor is induced before term, the nurse should have the in- cubator ready. (See pages 368-374.) She should enter the advent of the labor-pains on the history-sheet, 234 OBSTETRIC OPERATIONS and record the time of each pain until they are well established. Therapeutic Abortion. — This term is used to dis- tinguish the operation of ending the pregnancy before the child is viable from the criminal operations performed by midwives and professional abortionists. Fig. 122. — The instruments for the treatment of abortion and the operation of curettage: Lower row: uterine douche nozzle; 3 placenta forceps; uterine packing forceps; tubular uterine packer with pronged plunger; curets, four sizes; uterine dilators, two sizes. The upper row: 2 sounds; 1 artery clamp; 2 scissors; 2 retractors; 2 vulsellum forceps. Some operators prefer Hegar’s graduated bougie dilators (Fig. 123). Perhaps the saddest commentary on our “modern civilization,” on our “higher thought,” on our “ethical movement,” is the increase of the practice of criminal abortion. Nurses are not long in training before they see how alarmingly this crime has spread, and they see, THERAPEUTIC ABORTION 235 too, the lives lost and the homes wrecked by it. A nurse should never be party to such a procedure. It is murder and often suicide, and by gentle counsel she should dissuade the woman from entertaining the thought of its commission. Fig. 123. — Three sizes of Hegar’s dilators. There are twenty-four sizes. Very rarely the conscientious physician is compelled to sacrifice a tender life in the mother’s womb. Such occasions are: Uncontrollable vomiting, Bright’s disease, and a few others. The accoucheur feels here, as he did while doing a craniotomy on the living child, that the best interests of the mother, the family, and the com- munity are served by this sacrifice. The operation, how- 236 OBSTETRIC OPERATIONS ever, awakens feelings of greatest delicacy; it involves heavy and painful responsibilities, and no physician will perform it without the counsel and moral support of at least one of his confreres. The preparations are the same as for the induction of labor, the instruments are the same, with the addition of uterine dilators and curets (Fig. 122). A basin with sterile water is to be provided in which the operator may float particles cureted out for inspec- tion. The parts of the fetus removed piecemeal, arms, legs, etc., should be fitted together to make sure that the whole body has been extracted. The after-care is identical with that of the normal puerperium. PART III THE PATHOLOGY OF PREGNANCY, LABOR, AND THE PUERPERIUM CHAPTER I OBSTETRIC COMPLICATIONS DISORDERS OF PREGNANCY Ordinarily pregnancy and parturition are considered normal processes, but they are attended with many dis- comforts, so that the patient is often rendered miserable, and these conditions run so close to the pathologic that the dividing line is very narrow. Mauriceau, a famous French obstetrician, said pregnancy is a disease of nine months’ duration. Some women feel better while preg- nant than at any other time. Nausea and Vomiting. -About one-third of preg- nant women have this symptom. It varies much in dif- ferent women and in succeeding pregnancies. If the patient retains most of her food, if the general health is not concerned, the physician usually is not alarmed, but prescribes only mild palliative measures. Such are: (i) Waking the patient at about 6 a.m. and giving her a cup of coffee with a bit of toast, the patient resting an hour or two afterward; (2) counterirritation over the stomach; (3) the knee-chest position (see Fig. 124); (4) mild medi- cines, as oxalate of cerium and bismuth; (5) laxatives. 237 238 OBSTETRIC COMPLICATIONS Hyperemesis Gravidarum. If the woman vomits continually, if her health begins to suffer, the case is serious and must be handled firmly. Symptoms of the ordinary nausea becoming “uncontrollable” or “per- 24. — The knee-chest position. HYPEREMESIS GRAVIDARUM 239 nicious” are: Constancy of nausea and great frequency of vomiting; exhaustion; loss of weight and of sleep; salivation; hematemesis; fever, and rapid pulse. The last three show that the disease is far advanced. The nursing of a case of hyperemesis gravidarum requires the highest kind of nursing skill and culinary ability. Besides the administration of the prescribed medicines the nurse may have to assist at washing out of the stom- ach, the application of electricity, hypodermic injection of saline solution, gynecologic treatment of the patient, such as raising the uterus with tampons or the colpeu- rynter, even the operation of therapeutic abortion. The actual nursing and feeding contribute immensely to the success of the physician’s remedies. The pleasantest and airiest room in the house should be selected for the patient. It should be darkened. She should be left alone with her nurse, all friends and nearly all relatives being excluded. It is sometimes beneficial to exclude every one — the husband also — for a week or more. The nurse should distract the patient’s mind from herself and from the idea of vomiting; there- fore the emesis basin should be hidden until actually required. A soap-and-water bath is given daily, followed by a rub with eau de Cologne or Florida water. The appe- tite is tempted with light foods served in the daintiest possible manner, using the whitest linen and the prettiest dishes. Occasionally a few sips of champagne may settle the stomach, so that food can be retained, or a hypoder- mic of heroin is given just before the food is taken, or bromide given per rectum. At the beginning the following may be the dietary: Milk and lime-water or seltzer, ice cold. A strong beef-broth served in a cup, with salted wafers. 240 OBSTETRIC COMPLICATIONS Cold custard. Rice and milk, with cinnamon. A sliver of white meat of chicken, with buttered toast. Strong oyster broth. Strained oyster-stew. Toast and hot milk, with sugar. Ice-cream and ices. Cream soups, with wafers. Fig. 125. — The “Ideal” drinking glass. The food should be given while the patient is in the horizontal position, and she should lie perfectly quiet for a few minutes afterward. The “Ideal” drinking glass (Fig. 125) is very convenient for drinking in this position. Should these measures fail, liquid diet will have to be ordered. This consists of milk, milk and seltzer or lime- water, peptonized milk, plenty of water, beef, mutton, and chicken broths, albumin- water, sugar-water, barley- H YPEREMESIS GRA VIDA R UM 24I water, and beef-juice. 1 Some patients do better on solid food, toast, crackers, and meat, the liquids being supplied by rectum. If the patient vomits in spite of all this, the physician will usually order everything by mouth stopped and rec- tal feeding instituted. Physicians seldom allow patients to continue long in this condition, as a turn for the worse may come on sud- denly, and the patient be lost before measures for saving her can be instituted. Occasionally, even when condi- tions appear quite serious, the woman suddenly ceases to vomit, demands food, and retains it. Sometimes a psychic shock, or mental influence, or the phenomenon of “quickening” must be accepted as the cause, and not the doctor’s medicines. Should a consultation of physicians decide to terminate the pregnancy as the only hope of saving the patient, the nurse will set about preparing as for a major operation. (See Therapeutic Abortion, pp. 234, 235.) Shock is marked in these cases, and ample provision ought to be made to combat it. After the operation the vomiting nearly always ceases or becomes less. Was the operation performed too late, acute exhaustion super- venes and the patient sleeps away. Careful nursing after the operation is needed, and all the intricate arts of the cook will be useful. Nourishment should be given as previously indicated. If the rectum tolerates it, rectal feeding is practised in addition, and inunctions of ben- zoinated lard are made. Some of the lard is absorbed as a food. To supply liquids to the body, salt solution may be given by the drop method per rectum or by hy- podermoclysis, and everything done to bring the patient quickly back to a normal state of nutrition. 1 Formulas for the preparation of these foods will be found under Dietary, p. 452. 16 242 OBSTETRIC COMPLICATIONS Prevention of Decubitus. — The sacrum and bony prominences must be inspected several times daily and an incipient bed-sore treated at once. Frequent change of position, the use of air-cushions, an invalid bed, and absolute cleanliness will prevent decubitus. Daily wash- ings with 25 per cent, alcohol, followed by a gentle rub- bing with sterile olive oil, will aid in prevention. The mouth in cases of hyper emesis becomes reddened, tender, often bleeding, and teeth and lips accumulate sordes. If the patient becomes delirious, the resem- blance to a typhoid case is striking. The nurse cleans the tongue and gums carefully (as the mucous membrane is easily scratched) with boric acid solution containing 3 per cent, lemon-juice. No brush may be used on the teeth. The finger is covered with a napkin or pledget and is gently rubbed over them. Care is to be taken to prevent the patient from gagging. Throughout such a case the nurse should see that the patient gets sleep, here, without doubt, nature’s sweetest restorer. Toxemia in Pregnancy. -Closely allied to hyper- emesis gravidarum is the toxemia of pregnancy. By this is meant that poisonous products (toxins) have accumu- lated in the blood. During pregnancy the general chemic changes going on in the woman’s body are more active, and, in addition, there is an increase of waste matter — that produced by the child. Should the mother’s liver or her kidneys, or both, be unable to handle and excrete these waste-products, they accumu- late as toxins in the blood, producing toxemia. This is a dangerous condition and requires active treatment by the physician. The symptoms are headache, dizziness, cloudiness of mind and of vision, dry, muddy skin, deficient urination (the urine is high colored and strong), constipation, brown, furred tongue, etc. VARICOSE VEINS 243 The physician treats these cases by restricting the patient to a milk diet for a while, and then, as improve- ment appears, cereals are given, and then a vegetarian diet. At the same time saline cathartics are administered and warm baths — in urgent cases, the hot pack. Unless successfully treated, toxemia may result in eclampsia. Edema of the Extremities.— Frequently, late in pregnancy the feet swell up, becoming dropsical. The Fig. 126. — Varicose veins of the lower extremity in a pregnant woman at term (Hirst). symptom is usually unimportant, but it should be re- ported to the physician. The edema is due to mechan- ical obstruction to the return flow of the blood, but it may indicate disease of the kidneys, Bright’s disease, or heart disease, and will be the cause of earnest solicitude to the doctor. Varicose Veins. — Varicosities of the veins in the legs and around the vulva are quite common in advanced 244 OBSTE TRIC COMPL ICA T/ONS pregnancy in multipart. Primiparae and women who take good care of themselves are less troubled with Fig. 127. — The treatment of varicose veins by means of strips of adhesive plaster. Seldom necessary to cover the whole limb. them. In some cases the enlargement of the veins is so great as to cause real distress, as burning, itching, and pain in the legs and lower pelvis (Fig. 126). PRURITUS 245 The treatment consists in the institution of a hygienic mode of life, as given under Hygiene of Pregnancy (p. 75). There should be no circular constriction at any part of the body, especially no round garters, corsets, or tight waistbands. The return of blood to the heart must be unhindered. The feet must be kept off the floor as much as possi- ble, and rubber stockings or a flannel bandage worn during the day. A flannel bandage does not do any good unless well applied and kept in place. Adhe- sive plasters give considerable relief in these cases. Strips are cut 1 inch wide and 7 inches long These are placed in a spiral direction partly around the leg be- low and over the largest varicosities (Fig 127). These strips support the column of blood in the veins. They are applied while the patient is recumbent. The woman should be cautioned against injuring the enlarged vessels by scratching or striking against objects, as dangerous and even fatal hemorrhage has resulted. The patient is instructed that should such a hemorrhage occur, she should apply firm pressure to the bleeding point and notify her physician without a moment’s delay. I^eukorrhea. During the first months of pregnancy there is a slight increase in the vaginal discharge, and toward the end also. No treatment is required. If the discharge is profuse, especially if yellow or greenish, the physician ought to be consulted, as an infection of the genitals may exist which may endanger the patient’s health and the baby’s eyes. Douches should not be given without the physician’s order. Leukorrhea may be caused by pelvic congestion, evidenced by large varicosities. Pruritus, or itching of the pudenda, is sometimes a very trying symptom. Without visible lesion of the parts the patient is annoyed by a more or less intense 246 OBSTETRIC COMPLICATIONS itching of the vulva. This may be general over all the body. It may be so intense that the woman loses sleep, and it becomes, in very rare instances, unless relieved, a condition dangerous to life. In these cases a nervous element is present. The physician will lay out a course of treatment, but the nurse may use household remedies, Fig. 128. — Position of the child and the uterus in a case of pendulous abdomen (Dickinson). such as bathing with washing-soda solution, weak car- bolic solution, peppermint-water, etc. If dependent on an irritating vaginal discharge or on “ thrush,” which sometimes occurs, appropriate treat- ment is instituted. Pendulous Abdomen. — This condition, called “rup- ture” by the laity, is produced by a weakening of the abdominal wall or even a separation of the muscles, / PAINS IN THE A PH OMEN 247 allowing the uterus to fall far forward (Fig. 128) or even hang down between the knees. It causes drawing sensa- tions in the abdomen, pain in the back, frequent urina- tion, and discomfort in walking Relief may be obtained by supporting the uterine tumor with an abdominal binder (Figs. 37, 38) or sling hanging from the shoulder. The knee-chest position aids a little too in relieving the symptoms. Pendulous ab- domen in a primipara in- dicates that something is wrong. It may render labor difficult. To a certain ex- tent it is preventable. (See p. 78.) The jockey strap or combination binder shown in Fig. 129 aids in its pre- vention. It is worn for a month or more after getting up from the puerperium. Pains in the Abdomen. — Many women complain of pains in various parts of the abdomen. These are due to intestinal colic, impaction of feces, appendicitis, trac- tion on adhesions, stretch- ing of the abdominal wall, wearing of corsets or tight waistbands, carrying infants on the uterine prominence, and varicose veins in the pelvis. With the cause, the nurse will find the remedy. The knee-chest posture will relieve pressure symptoms; laxatives are exhibited, and hot camphorated oil, chloroform, or other liniment applied to the skin. If Fig. 129. — Combination binder or jockey strap applied. 248 OBSTETRIC COMPLICATIONS marked and constant, the physician ought to be in- formed of it. Heart -burn. Indigestion and heart-burn are fre- quent and annoying symptoms in pregnancy. The physician will prescribe the usual remedies. Home remedies that give relief are: soda-mint tablets, 1 to 3 dissolved in the mouth, salted nuts chewed fine, and milk of magnesia, 1 to 3 dessertspoonfuls, as needed. Sometimes the stomach must be washed to afford relief. The teeth in some patients show a tendency to decay. Cavities should be filled and bad teeth extracted as in the non-pregnant state, but long, tiring gold fillings and bridge work should be postponed. Milk of mag- nesia held in the mouth for three minutes three times a day will relieve the acidity of the saliva and help pre- serve the teeth. Frequent Urination. In the first few months this is a common symptom. It passes away, to return again when the head sinks in the pelvis at the time of lighten- ing. If the condition is aggravated, destroying the patient’s peace by day and her rest by night, the physician should be consulted. It is sometimes due to the uterus being turned back and imprisoned in the pelvis, the mal- position distorting and compressing the urethra. The bladder fills almost to bursting and then overflows (ischuria paradoxa). The catheter should always be used to aid the diagnosis, but extreme care should be taken not to injure the urethra by making a false passage. Cystitis and ureteritis may occur. If there is no path- ologic basis for the frequent urination, the knee-chest posture will relieve the discomfort somewhat. Fainting - . — Some women are much annoyed by this condition. Without apparent cause, or on the occasion of a little excitement, or by being in a close room, the HEMORRHAGE DURING PREGNANCY 249 gravida feels faint, and may even fall to the ground. In a few moments the attack has passed. The writer has observed this condition. It is not a real faint, as the pulse is good, and the face only slightly paled, though in some instances it may be an actual fainting. Consciousness is not lost. One must be sure that there is no real heart disease present. This symptom may be present from the fourth month ; it does not influence the pregnancy, though most distress- ing to the patient. The diet should be regulated — non- nitrogenous; the excretions should be stimulated; the patient should avoid crowds, excitement, and irrational dress. The harmlessness of the condition should be explained to her to allay the alarm it naturally causes. The physician occasionally prescribes a tonic. Melancholia. — Some women, especially if from a neurotic family and of neurotic tendency, anticipate their coming confinement with increasing dread. While most women at some time or other during pregnancy imagine they are going to die before they are through with it, these patients develop an actual idea, a fixed fear, of death, and thus the border-line of insanity is reached. The general symptoms of melancholia may appear. The writer has noticed an apparent relation between this ner- vous condition and the toxemia described in this chapter. The nurse may do much by a cheerful bearing and re- assurances to allay unnatural alarms in the patient, but the physician should be consulted if the condition is at all pronounced. Hemorrhages During Pregnancy. — The whole reproductive cycle is attended with the possibility of hemorrhage from the genitals. In the early months abortion may be the cause of the hemorrhage. Abortion. — This means the interruption of pregnancy before the seventh month. The child is not viable before 250 OBSTE TRIC COM PLICA TIONS the twenty-eighth week. The symptoms of abortion are bleeding from the uterus and pains — miniature labor pains. The nurse, finding the woman with threatened abor- tion, should put her to bed and send for her physician. If the woman is bleeding too profusely, she should, while waiting for him, pack the vagina as tightly as she can with sterile cotton, under the usual asepsis, or send for the nearest doctor. Then she should prepare every- thing for operation, so as to avoid delays when the phys- ician arrives. Placenta Praevia. — This is the development of the placenta, in part or in toto, in the lower uterine segment. Thus a portion of the placenta comes to lie over the in- ternal os, in the way of the child, and thus the name “praevia” (Fig. 130). The placenta is usually located near the top of the uterus, out of the way of harm, but when it is placed near the cervix — that is, in placenta praevia — it is loos- ened from its attachment when the os begins to dilate, thus causing hemorrhage. The condition is serious, published statistics giving a maternal death-rate of from 10 to 38 per cent., and a fetal death-rate of 50 per cent. If a woman has one, and especially if she has more than one, uterine hemorrhage in the latter half of the pregnancy, it is usually due to placenta praevia. Of course, if a woman bleeds from hemorrhoids, it is not in this category. A painless, causeless uterine hemorrhage in the last three months of pregnancy means almost al- ways placenta praevia. The nurse must notify the physician at once if there is, during pregnancy, the slightest show of blood. If she is the only one present during a severe bleeding, to tam- pon the vagina and to elevate the foot of the bed would be her only recourse. HEMORRHAGE DURING PREGNANCY 251 Premature Detachment of the Placenta. — This means the dislocation of the placenta from its normal site. It is sometimes called abruptio placentae, meaning that the placenta is torn from its bed. It is a very rare and very fatal accident, 50 per cent, of the mothers and nearly all Fig. 130. — Central placenta praevia, the os partly dilated (Hunter). the children being lost. It is usually due to injury, the patient hitting against the corner of a table or being struck on the abdomen. The symptoms are those of internal hemorrhage — pallor, fainting, weak pulse, etc. The hemorrhage may be external too. The nurse’s duties in the last two complications will 252 OBS TE TR/C COMPL ICA TIONS be to prepare for delivery, for the application of a col- peurynter, tamponade, or even cesarean section. Extra-uterine Pregnancy. -Extra-uterine preg- nancy, or ectopic gestation, is a rare condition, though, since its recognition has become easier, it is found more frequently than in the olden time. It is the development of the pregnancy outside the uterine cavity. Normally the ovum passes down the fallopian tube into the cavity of the uterus, pursuing its further development there. If, however, it is arrested in the tube and grows here, Fig. 13 1. — Extra-uterine (tubal) pregnancy, before rupture of the sac. an ectopic gestation of the tubal variety results. The tubal is the common form of the anomaly, but the child may develop in the ovary or even in the abdomen. Extra-uterine pregnancy is a serious condition, though in a few cases a spontaneous cure results. The ac- coucheur does not wait for this, but considers almost every case an indication for immediate operation. In those cases where spontaneous cure occurs, the ovum is either discharged from its bed and absorbed, or, if the child has attained considerable size, labor comes on, EXTRA- UTERINE ERE GNANC Y 253 without, of course, the delivery of the fetus. The child dies and either is changed into a hard, chalky mass, called a lithopedion, or stone-child, in which condition it may remain for years; or the whole ovum becomes infected and breaks down into pus and necrotic debris. The sac may ulcerate through the neighboring structures — the bladder, vagina, rectum, or abdominal wall — and the bones of the infant are discharged thus, one at a time. If the patient survives this long suppuration, after many Fig. 132. — Extra-uterine (tubal) pregnancy, after rupture of the sac. months the whole mass is thus gotten rid of. Most cases of ectopic gestation present alarming symptoms between the second and fourth months, due to rupture of the tube and intraperitoneal hemorrhage, which necessitates the accoucheur’s interference. As the ovum grows it distends the tube (Fig. 13 1). The fallopian tube has a thin wall, and, unlike the uterus, does not hypertrophy to accommodate the growing 254 OBSTE TRIC COMP LIC A TIONS ovum. The tube, as the result of the distention, on the occasion of a sudden jar to the abdomen, a blow, straining at stool, etc., bursts (Fig. 132). The ovum is wholly or partly expelled into the free peritoneal cavity, and more or less profuse hemorrhage takes place from the walls of the tube. This hemorrhage may be mild and the patient may then recover without treatment (rare), or the hemorrhage may be severe, and the most heroic measures must be instituted to save the woman’s life. The cause of ectopic gestation is usually found in dis- ease of the appendages or congenital anomaly. Chronic tubal inflammation or pelvic peritonitis is usually causa- tive. The condition may occur twice. Symptoms. — The patient has the symptoms of preg- nancy, but menses, in small amount, may appear, and pieces of membrane may be discharged. In addition, there are usually pain and a sensation of fulness on the affected side. Should such symptoms come to the knowledge of the nurse, she should advise the patient to consult her doctor. The physician may discover a tumor alongside the uterus, which, taken in conjunction with the suspicion of pregnancy, usually leads to the diagnosis. The symptoms of rupture are very promi- nent, though not always easy to differentiate from those due to other conditions. The patient complains of an agonizing pain low down in the side, and this may last for an hour or more. Then the symptoms of internal hemorrhage and shock super- vene — nausea, vomiting, anxiety, prostration, precordial oppression, pallor, pearly conjunctivae, rapid pulse, rapid breathing, and, if aid is not given, death in collapse. If the first hemorrhage is not fatal, the patient may have another, or several. These are cases that require heroic treatment. EXTRA- UTERINE PRE GNANC Y 255 Duties of the Nurse. If a nurse is placed in charge of a case of extra-uterine pregnancy before the rupture of the sac, her main solicitude will be to prevent the rupture. To accomplish this, she will not allow the patient to turn in bed without aid ; will not permit strain- ing during urination or defecation; and, in general, will keep the patient as free as possible from the slightest exertion. If the case is chronic and the fetus gone on to lithopedion formation, these rigorous rules need not be enforced, although the patient should observe more than ordinary care. In preparing such a patient for operation, only the gentlest manipulation of the abdomen is permissible. Rough scrubbing might rupture the sac and precipitate a fatal hemorrhage. The nurse should acquaint herself with the symptoms of rupture, so as to be able to in- form the accoucheur at the earliest moment. She should also obtain from him concise instructions regarding what he wishes her to do in the emergency As soon as the nurse takes charge of such a case, she should begin to prepare for the operation, which usually is not long de- layed. In a quiet, unostentatious manner, the nurse may provide and sterilize all the utensils, linen, gauze, etc., necessary for abdominal section. Each night io gallons of water should be boiled and set away to cool. If not used, it is thrown away. Thus the nurse is pre- pared for all emergencies. Half the battle is already w r on by efficient preparation. Should the nurse diagnose the bursting of the sac and the occurrence of intra-abdominal hemorrhage, she should elevate the foot of the bed, apply a tight ab- dominal binder, and put an ice-bag on the abdomen. The physician should at once be notified; if he is not within call, one of his close associates; or, failing these, the nearest doctor. While waiting for aid, the nurse 256 OBS TE TRIC COMPL ICA TIONS prepares the room for operation (see p. 183), provides an abundance of sterile water, salt solution (0.7 per cent.), sterile sheets, towels, pitchers, basins, etc. Laparotomy will usually have to be done, and a good nurse will have saved much time in getting ready for it beforehand. The preparations and instruments are the same as for cesarean section. The after-care is that usual for laparotomies (see p. 209) plus extra effort to replace the blood the patient has lost. To accomplish this, saline solution is given by hypodermoclysis and by rectum. Nourishing foods and tonics are administered, general massage, fresh air, and the best hygienic measures are practised. (See Treat- ment of Hemorrhage, p. 277.) Eclampsia. The word “eclampsia” means to flash out, and has reference to the suddenness of the onset of the disease. Eclampsia is the occurrence of convulsions followed by coma during pregnancy, labor, or the puer- perium. The acting causes of eclampsia are unknown. It is supposed that the convulsions and coma are due to a poisoning of the blood — a toxemia. This toxemia may be caused by inefficient action of the liver, insuffi- cient elimination by the kidneys, improper processes going on in the placenta, imperfect chemic changes in the intestines, etc. There may be truth in all these theories. It is certain that there are many varieties of toxemia, and not all produce convulsions. No matter what the primary cause, the kidneys are usually involved. There are almost always evidences of a more or less acute nephritis. Symptoms. -Usually there are prodromal or premoni- tory signs of the trouble for a few days. The patient has headache, ocular disturbance, spots before the eyes, twitching of the muscles of the calves or of the face, a boring pain in the epigastrium, vomiting, ringing in the ECLAMPSIA 25 7 ears, etc. Sometimes there is a tendency to coma, and these are the worst cases. At times there is extensive edema of the feet. Suddenly the patient falls down unconscious and in a convulsion. The mouth is drawn to the side, the facial muscles twitch, then the arm, next the leg, then the whole body is shaken violently by strong muscular spasms. The patient may bite the tongue severely and bloody foam appears on the lips. This part of the spasm is succeeded by a period of rigidity. The patient is stiff, the respiration ceases, and the body becomes cyanotic. The heart beats violently and then weakens, and the patient may die in such a convulsion. Though it seems much longer, the spasm seldom lasts more than sixty seconds, and at the end the patient takes a long inspira- tion The breathing now becomes stertorous or snoring, the cyanosis mostly disappears, and the patient lies in deep coma. This coma may last an hour or longer. Another convulsion may occur in twenty minutes to a few hours, or there may be only one, or the seizures may recur the next day. The greater the number of convul- sions, the greater is the danger. Deep coma and great cyanosis likewise give a gloomy outlook. If the patient has a strong regular pulse, running not over no, with red face (not cyanosis), the promise is good for recovery. If she develops edema of the lungs, death almost always results. Treatment. -The nurse must report to the physician at once if she finds albumin in the urine at any of her analyses or if the patient presents any of the prodromal symptoms mentioned. Taken in time, one can usually prevent the convulsions, which is a great feat, since the mortality of eclampsia is about 25 per cent. The patient is put at once on an absolute milk and water diet, and may be given sedatives by the physician. The bowels, 17 2 5 8 OB S TE TR/C CO MPL ICA TIONS kidneys, and skin are stimulated to action, Unless the symptoms disappear rapidly, labor is brought on. If the convulsions have set in or are imminent, the nurse should prevent the patient from injuring herself. She must be placed in bed, with many soft pillows, and her dress removed. The patient must not be left alone one minute. The room must be darkened, and all noises shut out. No talking , jarring the bed , or slamming of the doors may be permitted. Only the nurse and the phys- ician should be with the patient. Great care must be taken that the patient does not bite her tongue ; this is a real danger. If the patient has false teeth, they should be removed; if bridge work or crowns, the nurse takes care that they are not broken. The best method of pre- venting injury to the teeth is by means of an ordinary wooden clothes-pin (Fig. 133). This is covered with a piece of gauze sewed on tightly, a string is tied to it, and it is hung near the head of the bed, within easy reach all the time. When the patient opens her mouth, as is usual at the beginning of the convulsion, the clothes-pin is placed between the jaws, so that when the muscles contract they bring the teeth together on the prongs of the pin, the elasticity of the prongs preventing injury to the teeth, jaws, and tongue. The nurse now prepares everything for the doctor’s coming and for operation. During the progress of the case the patient may have had cathartics, and, being comatose, the movements occur in the bed. When changing the patient, great care must be taken to prevent infection of the vulva, and also to avoid jarring her too much, because it sometimes brings on convulsions. Sometimes the patient is given hot packs to promote diaphoresis, and thus excretion of toxins by the skin. The nurse must not allow a hot pack to last over twenty minutes; she must keep an ice-bag on the head or a cold ECLAMPSIA 259 wet towel around the neck, and she must watch the pa- tient continually, because sometimes death occurs dur- ing the sweating process. If bricks or hot irons are used for the hot pack, the nurse must see that they do not burn the patient. In her tossing about and in the con- vulsions the patient displaces the blankets; severe burns have thus been caused. When the pack is re- moved, great care is to be taken to avoid chilling. Fig. 133. — Prevention of tongue injuries by means of the clothes-pin. The covered clothes-pin is the one used. Photograph of eclampsia case taken during the stage of stertorous breathing. Note swollen tongue. Oxygen may be given, and salt solution by hypoder- moclysis. When narcotics — morphin, chloral, etc. — are given, the nurse must watch the effect of these drugs, because they may act with unusual strength. All these medicines and all the treatments, the number of convul- sions, and condition of the patient should be recorded carefully on the history-sheet. Altogether, nursing an 26 o OBSTETRIC COMPLICATIONS eclampsia case requires the highest kind of obstetric nursing skill. No nourishment is given until the patient can swallow, unless by stomach-tube, and throughout the nurse must exercise great vigilance to prevent water, medicine, Fig. 134. — Treatment of edema of the lungs. Head is supported, and the nurse raises the shoulder so as to allow free expansion of the chest. mucus, and blood from the mouth and throat being drawn into the lungs. This is a serious affair, causing bronchopneumonia and often death. If the patient develops edema of the lungs, the nurse turns her on the side with the head hanging over the edge of the bed, so as to allow the frothy mucus to run out of the mouth ECLAMPSIA 26l (Fig. 134). The shoulder must be supported or the patient’s breathing will be interfered with. If the tongue of a comatose patient falls back into the throat, asphyctic conditions may arise. The jaw should then be held forward to free the respiration. Eclampsia is an awe-inspiring condition, and the patient’s life, as well as that of her child, often depends on the coolness and judgment of their attendants. Recovery from eclampsia takes place slowly. The coma disappears in from one to four days. The child is not to be allowed to nurse till conscious- ness has been clear for several days. The mother may repudiate her own child, which should give rise to the suspicion that insanity is threatening. Mental aberra- tion is a not uncommon sequel of eclampsia. CHAPTER II COMPLICATIONS DURING LABOR The most common complication which the nurse will meet is delivery of the child before the doctor comes. The physician is usually quite chagrined if the baby arrives before he does. How much the nurse may retard the delivery so as to await the doctor is an im- portant question. If the patient is having strong pains, the nurse should keep her on her side and not allow her to bear down. The nurse should know the doctor’s practice, what physicians usually assist him, and, if the accoucheur is not obtainable, should send for one of the men known to him, unless the family expresses other preference. It is not advisable for the nurse to assume the responsibility of the case alone. While generally there is no danger, it may be her lot to lose an infant, and thus she may be unfairly censured. It is not justi- fiable for the nurse to hold the head back forcibly until the doctor comes. She may hold it back so as to allow time for the perineum to stretch, as she has seen the doctor do, but more than this may injure the child or the mother. If she has to conduct the labor, let her observe the same rules regarding protection of the peri- neum as those practised by the physician: 1. Allow the head to come through slowly. 2. Keep the head well flexed and against the pubic arch. 3. Deliver the patient on the side. 4. Deliver the head between pains. 262 COMPLICATIONS DURING LABOR 263 When the nurse finds she is alone with the case, she should allay the fears of the family by telling them that the fact that the child is coming so quickly is proof that everything is right and the labor is normal. She places the patient on the left side and toward the light, and, after sterilizing her hands, puts on her steril- ized gloves, assumes the position the doctor would, with one hand between the limbs of the patient, whose knees are separated by a pillow. (See Fig. 61.) A basin of solution with pledgets is nearby, and the nurse carefully catches any discharges from the rectum without soiling her fingers. She also swabs the parts generously with the antiseptic solution. Lysol, 1 per cent., is good, or 1 : 1500 bichlorid. As the perineum bulges and the scalp shows she gently restrains the head by pressure on it with the fingers, not by pressure on the perineum. With each pain she allows the head to come down a little more. The patient should be admonished not to bear down too hard, and thus the nurse will allow the head to come through very slowly. After the perineum is stretched so that it seems as if the head may come through, in the interval between pains the patient is asked to bear down a little and the head will come. After a few moments the pains force the shoulders out and then the trunk fol- lows. (See Figs. 135-141.) When the head is born, the nurse wipes mucus from the head and eyes and from the nose and mouth, so that when the child gasps, nothing can be drawn into the lungs. After the child is born, the nurse playes it a short distance from the mother, so that she cannot press it or the cord, and both patients are covered warmly. (See Fig. 62.) The woman is slowly turned on her back, keeping the legs tight together. The nurse sits beside the patient, holding the uterus with her hand, but not massaging it unless there is hemorrhage or the uterus balloons out 264 COMPLICATIONS DURING LABOR Fig. 135. — Delivery of patient on the side. Nurse, with one hand between thighs, gently represses the head during the pains. The right hand is nearby to help hold the head back if the pain is too strong. The hands should not be soiled with rectal discharges. Fig. 136. — The two hands placed on the head (not on the perineum), with gentle force, evenly distributed, hold the head back, allowing it to advance only a very little with each pain. The right hand holds a sponge with which the nurse bathes the vulva as the head recedes. DELIVERY OF PATIENT ON THE SIDE 265 Fig. 137. — The nurse allows the head to come down during a pain, controlling its descent with the left hand. The right hand is about to be placed on the head as the perineum is getting quite distended, which is shown by the shiny appearance of the skin. The sponge is used to wipe a little mucus from the anus which is being forced open by the advancing head. Fig. 138. — The head is about to escape from the vulva. The nurse pushes it upward against the pubic arch with the right hand, while the fingers of the left hand try to strip the anterior edges of the vulva back behind the occiput. The head is then allowed to roll up over the pubis, the perineum slipping over the child’s face and under its chin. 266 COMPLICATIONS DURING LABOR Fig. 139. — The head is delivered. The nurse steadies it with the left hand, and wipes eyes, nostrils, and mouth with a sponge squeezed dry from an anti- septic solution. Fig. 140. — The shoulders are being delivered. The nurse holds the head with the left hand, and with the right she crowds the shoulder upward toward the pubis so as to avoid too much distention of the perineum by the trunk. Note how the occiput has rotated to the side, as it lay in the uterus. DELIVERY OF PATIENT ON THE SIDE 267 under the hand. In this position she should wait for the arrival of the doctor. She must not tie and cut the cord unless the mother bleeds or unless the placenta comes. She may wait, in the absence of hemorrhage, as above indicated, an hour or more, without endangering the patient or the infant. Fig. 141. — The child is delivered. With the left hand the nurse grasps the uterus. With the right she lays the child alongside the lower thigh of the mother, and steadies it while the mother is being turned on her back. This is done as follows: the right foot of the mother, the upper one, is removed from the pillow and placed on the edge of the bed just outside the baby’s head. Then the left knee is grasped and raised in the air so that the patient’s hips are brought to the middle of the bed, after which the foot is placed on the bed. The patient is now in position for the conduct of the third stage. (See Fig. 62.) When these photographs were taken gloves were omitted for artistic reasons. Should it be desirable to separate the child, the nurse ties and cuts the cord as shown in Figs. 142 and 143, tying tightly and using sterile tape; then, after removing the infant, she folds a clean sheet under the patient and brings the limbs closely together. Then the nurse lays 268 COMPLICATIONS DURING LABOR Fig. 142. — Tying the umbilical cord. The cord is tied § inch from the skin margin. Fig. 143. — Cutting the umbilical cord. The cord is severed \ inch from the ligature. BREECH PRESENTATION 269 her hand lightly on the uterus and awaits the spontane- ous termination of the third stage. Almost always the physician arrives at this time, and if he does not, the nurse pursues the safer course by insist- ing that another be called. Should she be compelled by hemorrhage, either inter- nal or external, to end the labor herself, she expresses the placenta by gently squeezing the uterus at the height of an after-pain and pressing the placenta out at the same time. As the placenta appears she grasps it in the full hand, and with light, even traction draws the membranes after it. Neither haste nor excitement is necessary. The placenta must be saved for the doctor’s inspection, and he should also be requested to examine the perineum for lacerations The nurse should guard the uterus for thirty minutes after delivery of the placenta, and if it shows a tendency to relax, may administer a dram of ergot. BREECH PRESENTATION If the infant should come by the breech, the nurse’s duties are more onerous. Fortunately, this accident is quite rare. As soon as the breech of the infant ap- pears at the vulva, the nurse brings the woman across the bed with her hips a little over the edge, and the feet supported on chairs. As the child emerges she receives it in a warm towel with sterile hands. When the shoulders are to come through, the patient is ex- horted to bear down, and the husband or a neighbor makes downward pressure on the uterus. When the arms are delivered the nurse inserts two fingers in the child’s mouth, and, with the other hand placed over the lower abdomen, makes gentle traction downward and out with the one, and pressure with the other, so that the head comes upward and out. In this gentle 270 COMPLICATIONS DURING LABOR fashion the head is delivered (Fig. 86). Care is now taken to clear the throat of mucus and revive the child from the mild asphyxia which is not unusual. (See Asphyxia, pp. 360-364.) The rest of the labor is as above described. Should the case be a twin labor, the nurse will wait for nature to bring the second child. Assistance here is urgently indicated. PROLAPSE OF THE CORD Once in about 400 cases the umbilical cord prolapses and appears at the vulva. This is a very serious acci- dent for the child, since many times the infant is thus lost by compression of the cord and the resulting asphyxia. For the mother, it is not dangerous unless operations are undertaken to save the child. Fig. 144. — The elevated Sims position. The nurse will easily recognize the cord when it appears at the vulva, and must send for the physician without an instant’s delay. While waiting for him, she places the patient in the knee-chest position (Fig. 124), and, with sterile fingers, pushes the cord back into the vagina after washing it with warm antiseptic solution. The cord is retained in the vagina by a pledget of cotton, Fig. 145. — The Trendelenburg posture in bed, using a chair to elevate the pelvis. PROLAPSE OF THE CORD 271 or the nurse holds the vulva together; under no con- dition should the cord be allowed to lie outside exposed. The patient quickly tires of the knee-chest position, and the nurse then allows her to fall slowly onto two pillows on her side, in the elevated Sims position (Fig. 144). 2J2 COMPLICATIONS DURING LABOR Preparations for operation should now be made, as the physician, when he comes, will wish to make an attempt to save the child’s life. He may order the Trendelenburg posture for the patient, which the nurse obtains by putting a chair, inverted, in the bed, padding it with thin pillows, and arranging the person on it as shown in Fig. 145. Usually patients complain of dysp- nea and distress when kept in the knee-chest and Trendelenburg postures for any length of time, so that in such cases the elevated Sims position is preferable, as it is more comfortable. Various complications, described under those of preg- nancy, may first appear during labor ; such are eclampsia, placenta praevia, and detachment of the placenta. HEMORRHAGE DURING LABOR A woman may have an unusually bloody “show”; she may have a little hemorrhage when the cervix is dilating, toward the completion of the dilatation, due to slight tearing of the cervix As the head is being delivered, there is not seldom bleeding from the tearing perineum or clitoris. Placenta praevia and detachment of the placenta occur sometimes during labor, and give rise to profuse and often dangerous bleeding. After the baby is born the patient may bleed more or less profusely. This last form of hemorrhage we term Postpartum Hemorrhage. We designate all bleed- ing after the child is born postpartum hemorrhage, although, strictly speaking, the term should apply only after the placenta is delivered. The laity call such loss of blood a “flooding,” and truly the appellation is some- times deserved. Postpartum hemorrhage is caused either by a lacera- tion of some part of the genital tract or from atony of the uterus. The laceration is usually made by an POSTPARTUM HEMORRHAGE 273 operative labor, as forceps or breech extraction, but it may occur, although rarely, in spontaneous delivery. Atony of the uterus is rare, and may be caused by general weakness of the mother, retention in the uterus of a piece of placenta or of clots, after overdistention of the uterus, disease of its structure, etc. The symptoms of postpartum hemorrhage are those of external bleeding and the effects of the loss of blood on the patient — pale face and lips, cold sweat on the forehead, rapid running pulse, rapid breathing, yawning; the patient complains of being dizzy, faint, “clutching at the heart” (precordial anxiety), has ringing in the ears, and is sometimes blind. If the bleeding is not soon con- trolled, the symptoms aggravate, the woman is restless, has cramps in the muscles, becomes unconscious, and dies. Happily, such extreme cases are rare, and with the exception of a woman whose blood is pathologically altered so that it will not clot, nearly all patients can be saved by the means we now have at our command. If the hemorrhage comes on before the placenta is out, the doctor usually removes the latter; if the hemorrhage should come on after the placenta is out, the physician massages the uterus, gives ergot, a hot uterine douche, swabs the uterus with vinegar, packs it full of gauze, or adopts other means of controlling the loss of blood. The bleeding that occurs after the physician has left the house is what concerns the nurse in actual practice. A woman in the first two hours after the placenta is delivered may lose 3 ounces of blood without there being any danger. If the uterus is hard and not too large, this is all right. If more than this amount oozes away; if there are clots; and if the loss keeps up, the physician should be notified. Should the patient be sud- denly taken with a profuse hemorrhage, her life may depend upon rapid action of the nurse, and it is, therefore, 18 2;4 COMPLICATIONS DURING LABOR highly essential that the latter retains her presence of mind. The first thing to do is to grasp the uterus and massage it vigorously. The uterus may not be easily outlined, being only a big boggy mass in the lower abdomen. The nurse kneads this until it contracts. The physician must be notified, and if he is too far away, the nearest one obtainable should be sent for. But the nurse can- not always wait for the doctor. She may administer a dram of ergot. If her massage has the desired effect, the hemorrhage ceasing and the uterus remaining hard, this is all that is necessary; the nurse may wait, guarding the uterus. If not, the flow continuing, she at once gives a hot vaginal douche (120° F.), inserting the tube about 7 inches and giving the tube the upward and forward direction of the parturient canal. If this does not stop the hemorrhage, the nurse should pack the vagina as tightly as possible with gauze, cotton, handker- chiefs, or anything at hand that is sterile. After the vagina is tightly packed the nurse places her fist against the packing at the vulva, and with the other hand presses the uterus down against the pelvis (Fig. 146). If her arm is not strong enough to keep up firm pres- sure, the husband will have to help. In this way the hemorrhage can be controlled, or at least mitigated, until the doctor comes. Throughout the nurse must keep her presence of mind, must act coolly and confidently, and not neglect her antiseptic precautions. While doing these things, the nurse has the foot of the bed raised three feet from the floor by means of a table; she gives the patient some strong hot coffee, a hypo- dermic of strychnin, grain, or camphorated oil, if necessary. While the doctor is coming she has the husband, under her direction, provide towels, hot water, etc., for POSTPARTUM HEMORRHAGE 275 eventual operation. Fortunately, the nurse is rarely called on to assume such grave responsibilities. The writer knows of only two instances, and here massage with a dose of ergot accomplished all that was necessary. The nurse’s duties while assisting the physician at a case of postpartum hemorrhage are many. She must 2 y 6 COMPLICATIONS DURING LABOR see that the patient is not exposed to chilling, that she is kept warm by hot- water bottles, that there is an abun- dance of hot and cold sterile water for douches, hypo- dermoclysis, and hand solutions. The physician may wish to tampon the uterus, and for this will need a jar of sterile or antiseptic gauze. (See p. 435 for description Fig. 147. — Momburg’s belt. of method of preparing the gauze and p. 220 for descrip- tion of operation.) When a hot douche is ordered, the nurse should ask the degree wanted, and often the fluid has a temperature of 1 1 5 0 to 120 0 F Sterile water or 1 per cent, lysol solution is usually ordered. The nurse should be skilful POSTPARTUM HEMORRHAGE 277 in giving hypodermic injections, and should never be found with a defective syringe. When the bed is ordered elevated, a table at least 30 inches high is to be placed under the foot; a box on the table adds to the elevation (Fig. 146). A new method of treating hemorrhage is the Momburg belt (Fig. 147) . The aorta is compressed by a rubber constrictor in a manner similar to that used in amputations of the ex- tremities. A piece of drainage-tube 1 yard long and 1 inch in diameter is used. If the case is so serious as to demand salt solution transfusion, the nurse prepares for same. (See p. 225 for details.) Should the patient faint or feel like it, smelling salts may be applied to the nostrils and a stimu- lant hypodermic injection be given The physician may order ether, whisky, camphorated oil, or aromatic spirits of ammonia to be given hypodermically. Cases like this impress upon the laity the importance of skilful and sufficient attendants, even for a normal labor. After=care. — This is highly important. It requires much care to nurse the exsanguinated woman back to health. The bed should be left raised until the phys- ician orders it lowered, which may be in from one to four days. When lowering is ordered, the nurse lets it down a foot every hour until it is horizontal. Fainting may result if it is lowered suddenly. The diet is carefully regulated. Liquids in abundance, short of causing emesis, are given. Rectal injections of saline solution may be ordered. (See p. 289.) When food is acceptable, milk, eggs, meat-juice, and, later, broiled steak, the marrow of bone, and vegetables rich in blood salts (as spinach and lettuce) are given. The physician may order a blood tonic and a trip to the sea- shore to complete the recovery. While the patient is in bed she must not raise her head until the nurse deems it 2yS COMPLICATIONS DURING LAP OR safe. This is to prevent fainting. She may move in bed during the first few days only with great deliberation, this precaution being intended to prevent heart embol- ism. When the nurse gives such a patient a bath she should not rub the limbs too vigorously, as clots some- times form in the large veins and hard friction might loosen them. They would then float in the blood-stream to the heart or lungs, perhaps causing fatal embolism. CHAPTER III COMPLICATIONS OF THE PUERPERIUM Nothing gratifies the physician more than to have the patient and her babe make a rapid and uncomplicated recovery from the confinement. If a puerperal woman takes ill, the whole house is thrown into gloom, and if the child should sicken, the mother becomes at once nervous and restless, fearing her new joy is to be taken away. A death during confinement or after seems much worse than at any other time, and, truly, no woman ought to lose her life under these painful, interesting, and sympathetic circumstances. The greatest danger to the puerperal woman is PUERPERAL INFECTION Puerperal infection may be defined as a disease, febrile in nature, but sometimes non-febrile, resulting from in- fection of the genital tract at any point of its extent. A woman after labor can have fever from many causes, as sore throat, typhoid, intestinal and urinary disease, but when the symptoms point to an infection of the par- turient canal in any portion of its length, she is suffering from puerperal infection. In olden time there was very prevalent an acute febrile disease afflicting puerperae, and more or less epidemic, which was called puerperal fever. This was often fatal, and usually very severe, and with definite characteristics, so that it came to be con- sidered a specific fever which affected only lying-in women, and was to be classed by itself, like typhus and 279 280 complications of the puerperium other special diseases. Now it is generally recognized that puerperal fever is nothing more nor less than septi- cemia, similar to sepsis after surgical operations. The term “puerperal fever” is now occasionally applied to the severer forms of puerperal infection, but it is best to drop the term entirely, or make it synonymous with puerperal infection. Puerperal infection (or fever), then, is nothing more nor less than infection of the genital tract, and, like all in- fections, may be mild or severe, local or general, and of many varieties; like other infections, too, it may be pre- vented. The history of puerperal fever is interesting. It was known and written of a thousand years before Christ. In the Ayur Veda of Susruta it is mentioned, and the father of medicine, Hippocrates, who lived 400 b. c., writes of it, saying there was an epidemic and “the daughter of Telebulos died of it on the sixth day.” It prevailed all through the ages, and when hospitals were started it broke out with greater fury. In the Paris Hotel Dieu in 1664 it killed 10 per cent, of the women confined. In 1823 it carried off 19 per cent. — nearly 1 in 5— of the women confined in the Vienna Maternity. The cause of the disease was unknown. It was as- cribed to a stoppage of the lochial flow, to a turning in- ward of the milk, to catching cold, to atmospheric con- ditions, etc. In the early part of the last century Den- man, of England, taught that it could be carried from one patient to another by the doctor or midwife, and that the doctor could carry it from his erysipelas and suppu- rating cases. The credit for having recognized the cause of puer- peral infection and forcing the knowledge of it on the medical profession belongs to Semmelweis (Fig. 148), of Budapesth, Hungary. Semmelweis, then a young intern PUERPERAL INFECTION 28 in the Obstetric Clinic of the General Hospital of Vienna, in 1846 noticed that the midwives’ clinic adjoining had a low mortality— about 1.5 per cent. — while the clinics where students were taught and he practised had 15 per cent. This galled him, as his was a conscientious nature. The difference between the clinics was so marked that the servants had quarrels over the conditions, and the Fig. 148. — Ignatz Semmelweis, the discoverer of the cause, and the inventor of the means for the prevention, of childbed fever, or puerperal infection. midwives did not fail to taunt the medical assistants with the facts. Semmelweis worked hard and long to find the solution of the trouble, and did not succeed until a sad accident showed it to him. His friend, Kolletschka, infected his finger at a postmortem and died of sepsis. Semmelweis saw the autopsy of his friend, and was struck with the 282 COMPLICATIONS OF THE PUERPERIUM similarity of the postmortem findings to his own findings in the puerperal fever cases. Eureka! Semmelweis now argued that the cadaveric poisons were carried on the hands of the students and physicians to the lying-in women. It was a fact. The students would go directly from the morgue to the confinement room. It was a wonder that any women escaped. Semmelweis immediately ordered the students and assistants to clean their finger-nails (a novel procedure in those days) and to wash their hands with chlorin water — the best deodorant they possessed at that time — and the results were striking. The mortality in his clinic sank below that of the midwives’ clinic. Soon Semmel- weis learned that there were other causes of puerperal fever. In the confinement room were 13 beds. A woman in bed No. 1 had a gangrenous cancer of the cervix; 12 other patients (parturient women) in the confinement room were examined by the doctors who had examined the first. Eleven of the 12 women died of childbed fever. Thus he developed his theory as it is held and accepted to-day, that puerperal fever is caused by the introduction into the genitals, from without, of septic material. Oliver Wendell Holmes, of Boston, had tried before this to prove to the medical profession that puerperal fever was a “private pestilence,” and that the doctor could and did carry it about, but his teaching was not fully accepted, nor was that of Semmelweis, either here or abroad, until Pasteur, Koch, and others developed the science of bacteriology. To Semmelweis, however, belongs the undying credit of having proved the cause of this fearsome scourge and having pointed out the manner of its prevention, and his name must be mentioned with that of Jenner and PUERPERAL INFECTION 283 other great savers of human life. The slowness of the medical world in accepting his theory and his constant effort to force it to do so drove him crazy He died in an insane hospital, fatefully enough, just as did his friend Kolletschka, from an infected wound acquired at an autopsy. Frequency and Source.— It is sad to have to say that thousands of women are sacrificed every year to this dread disease. That 6000 women die from it in the United States every year is a very conservative estimate. In the maternities a case of sepsis is rare, and a fatality from infection is almost unknown, but in pri- vate practice the disease is still frequently met with, although in a milder form than in the olden time. The number of women dating permanent invalidism from a mild infection during childbirth is legion. More women die and are wounded in confinement every year than men die and are wounded on the field of battle. It has been well said that the confinement room is the woman’s battlefield. Where does the infection come from? From a case of puerperal infection; infected abortions; from the lochia of puerperal women (not necessarily with fever); from a menstruating woman; from any suppurating sur- face — for example, ulcers, abscesses, phlegmon, running ear, ozena; from erysipelas, scarlet fever, and diphtheria cases; from the dirt under the finger-nails — in short, any- thing that is not absolutely sterile will, if introduced into the genital tract, cause infection. It is certain that the vagina of even a normal, healthy pregnant woman contains bacteria, and these are some- times virulent; and it is true that under certain circum- stances these germs may enter the system and cause dis- ease. We call this auto-infection. Nature protects the woman from infection by the following means: First, the 284 COMPLICA TIONS OP THE PUERPERIUM patient has a natural immunity against infection; she can overcome a certain amount, and this varies much in different women and in the same woman at different times. The writer believes that the woman brought up and living in squalor can stand infection better than the delicately bred woman. What the nature of this immunity is we do not know. We, therefore, do not trust to such uncertain protection in treating our obstet- ric cases. Second, the vagina has bactericidal power. Third, the germs are not carried upward in a normal labor, but down and out, the liquor amnii and the blood helping to wash them out. The great danger is in the doctor or the nurse carrying them up into the uterus. The Prevention of Puerperal Infection. -Never was the saying truer than here that an ounce of preven- tion is worth a pound of cure. As yet we know no cer- tain cure for infection that has once obtained a foothold in the genitals, but we can almost absolutely prevent the introduction of alien bacteria. In the rarest instances the patient herself is responsible for her illness, but the rule is that the patient, should she present any form of sepsis, has been infected from the outside. The carrier of this infection to the genital tract may be the doctor, the nurse, the patient herself, the husband, or some one else, and these facts indicate how extensive must be our efforts to preserve the parturient from danger. For the doctor, there are two grand principles for the prevention of infection: first, to reduce to a minimum the necessary injuries (tears, bruises, etc.) of labor; second, to see that nothing infected comes in contact with the genital tract. The doctor, therefore, will not interfere unnecessarily in the conduct of the labor, will not examine too much, but, in short, will allow as natural a course of labor as possible. PUERPERAL INFECTION 285 The Asepsis of the Nurse. — A nurse will not go from an infected case to a labor. A full week should elapse, during which time she should bathe and shampoo her hair frequently. She should take care of her person, have her teeth sound, and attend to any possible catarrh. The hands require special care. The arts of the manicure are not to be despised, which advice may well apply to physicians. Constant scrubbing and the use of strong antiseptics ruin the skin, therefore rubber gloves should be used wherever possible. A smooth skin is easily cleansed; a rough one, not. Rings are never to be worn while in attendance on a confinement case. The nurse wears a freshly laundered uniform in the confinement room, and does not go on the street with it. This is neither asepsis nor good taste. A needed warning to the nurse is never to relax the stringency of her aseptic precautions. It is so easy to grow careless and desultory. But a day of reckoning will surely come, and if a nurse feels she is responsible for some dear mother’s death her remorse will be un- assuageable. The nurse’s duties during the labor are to provide the sterile basins, solutions, pledgets, towels, etc., just the same as for a laparotomy. Her hands should be as sterile as possible throughout the labor, but she may not touch aseptic things or the patient until she has taken time thoroughly to sterilize her hands. She must not insert her fingers in the patient’s genitals without express orders from the physician. A long forceps with which to hand things to the doctor is very convenient. When not in use, these forceps may be kept in a tall jar (an olive bottle, for example) of 1 per cent, lysol solution. These forceps are a necessary part of the nurse’s outfit. During the puerperium the hands must be sterilized each time the genitals are dressed. The nurse should 286 COMPLICATIONS OF THE PUERPERIUM arrange everything needed near the bed, and then ster- ilize her hands for the dressing. Gloves are used by many nurses with much satisfaction. Others use the sterile dressing forceps. The vigilance against infection should last throughout the puerperium. The same care must be exercised in the dressing of the umbilicus of the infant. Many children die every year from infection of the navel, and this is preventable. The eyes of the infant, too, may be infected by the fingers of the nurse. Of great importance is the asepsis of the breasts. The nurse may carry infection to them from the lochia or other source, and cause mastitis and abscess. As it is impracticable, though desirable, to sterilize the hands each time the baby is put to the breast, the nurse must take care that the fingers do not come in contact with the nipple. If this is necessary, the hands must be clean. These aseptic precautions must be doubled if there is a crack, fissure, or blister on the nipple The use of ster- ilized cotton applicators for washing the nipple is to be highly recommended. Altogether, the contact of the fingers with the parturient is to be systematically avoided and sterile things substituted, as gloves, applicators, etc. A woman who escapes a mastitis for two months will almost surely be able to finish nursing without trouble. Thus the chief duty of the nurse during the puerperium is to fight germs at all the points where they attack the mother and babe, and success will attend only con- scientious and continuous efforts. Symptoms. — The symptoms of puerperal infection are very varied. Usually a severe attack is evidenced by malaise, a chill, fever, rapid pulse, and all the symp- toms that accompany a febrile attack. Locally there are usually pain around the uterus, altered, not neces- sarily foul-smelling, lochia, sometimes cessation of the PUERPERAL INFECTION 287 same; the little wounds around the vulva take on an unhealthy aspect, and in some cases signs of peritonitis develop, while in others abscesses form. The cases are of all degrees of severity, and their courses are irregular, except when the infection is severe. Here a peritonitis almost always carries the patient off in a few days. It is impossible to go further into this subject here, because it is a very large one. Every puerperal woman that has fever is not neces- sarily septic, but sepsis is the first thing to be thought of, and we shut out other causes — sore throat, mastitis, constipation, and the essential fevers like typhoid — before coming to a positive diagnosis of puerperal infection. That a woman may have fever from the bowels is pos- sible, but simple constipation does not cause it. Some- times a sharp rise of temperature subsides completely and finally when the bowels were thoroughly evacuated. One must be very careful not to call a fever in the puer- perium intestinal in origin without careful examination and mature deliberation. Treatment of Puerperal Infection. -In this dis- ease as much may be expected from good nursing as from medical and surgical treatment. Every effort is made to develop the patient’s resisting powers, to strengthen her so that she can throw off the disease. For this, her surroundings should be the best obtainable; the outdoor treatment of such cases has been tried with success; at all events, a bright, sunny room, well venti- lated and free from noises, should be selected; household worries should be kept from her, and the family should be admonished to be cheerful and not show the patient signs of anxiety. Visitors should not be allowed until convalescence is well established. The skin excretes poisons, and the nurse will, there- fore, see that this function is not interfered with. A 288 COMPLICATIONS OF THE PUERPERIUM daily sponge-bath with water containing a little eau de Cologne or Florida water and a soap-and-water bath every third day are sufficient. If the patient has a chill, the nurse surrounds her with hot-water bottles, gives her a hot drink, and covers her up warmly. When a sweat comes on, the nurse sees that the puerpera does not take cold by rubbing the body with a little warm water and alcohol. If the course of the disease is prolonged, the nurse will institute proper treatment to prevent bed-sores, as gentle washing with weak alcohol, followed by a little oil, the use of salves, making a ring of adhesive plaster with carded wool in the center, the use of a felt cushion, of the air- cushion, frequent change of position, etc. One of the best means to prevent bed-sores, as well as to preserve the strength of the patient, is the use of an invalid bed. The patient is elevated on this for the attentions to the genitals, bowel movements, etc., and also to relieve the sacrum from continuous pressure. In the absence of an invalid bed, the symphysiotomy frame (see Fig. 107) does equally good service. The dressings of the vulva need be frequent, as the discharges are irritating, sometimes even corrosive. Antiseptics should not be too strong. The physician’s advice should be sought here. The bowels will need attention. If there is diarrhea, the physician will usually prescribe something; if con- stipation, the nurse will probably be instructed to give enemata. The nurse should call the physician’s atten- tion to the state of the intestinal canal and the character of the evacuations. If there is much tympany the physician may order turpentine stupes to the abdomen, and the nurse sees that they do not blister. He may also order carminative enemata or the rectal tube. For abdominal symptoms of peritonitis, ice or hot applica- PUERPERAL INFECTION 289 tions may be applied to the belly; there should be ordy one layer of cloth between an ice-bag and the skin. Should the patient become delirious the nurse must watch her, not leaving her alone a minute, as she may jump out of the window or destroy her infant. An acute mania may develop in these cases. Septic patients are often placed in the Fowler position, that is, a half-sitting posture, to favor uterine drainage. For this purpose a back-rest is used, or the head of the bed is raised. Nourishment. — Liquid diet is ordered at the begin- ning, but if the case promises to continue a length of time, semisolid nourishment may be ordered. (See Dietary, p. 452.) Nourishment should be pressed on the patient, and the appetite tempted with all the art the nurse possesses. If the stomach should prove in- tolerant, the strongest ally in fighting this disease is lost, therefore the nurse should not err on the side of too much zeal. There are many new food preparations on the market, such as somatose, peptonoids, and tropon, but the best results are obtained if the patient can eat and digest well- prepared. home foods. In the vomiting of peritonitis both doctor and nurse stand powerless. Washing the stomach helps only for a short time. In extreme wasting, inunctions of ben- zoinated lard are recommended, and, as an aid, rectal alimentation. Salt solution may be given hypodermic- ally or by the rectum. Rectal infusion of saline solution by the drop method is much used in the treatment of puerperal sep- sis (Fig. 149) ; 2 teaspoonfuls of common salt in 1 quart of warm water give the right proportion. The douche-bag is hung on the bed-post with a hot-water bag alongside, both wrapped in a towel. The hot- water bag keeps the saline solution warm. The douche-bag tube is connected 19 29O COMPLICATIONS OF THE PUERPERIUM with a small catheter, and by means of a pair of artery forceps the tube is clamped so as to allow the solution Fig. 149. — Continuous administration of saline solution per rectum. The douche-bag is wrapped with the hot-water bag in a large towel. Thus the heat of the solution is maintained during the prolonged administration. The artery forceps regulates the flow. to drip from the catheter about one drop each second. This is called the “drop method.” The catheter is then placed in the rectum. Sometimes the salt water is PUERPERAL INFECTION 29I absorbed as fast as it flows in; again, the patient cannot retain it long. Usually the patient has to be placed on a bed-pan, which is very uncomfortable unless a rubber Fig. 150. — Vacuum bottle used as irrigator. The cork shown at the side carries two glass pipes, the rubber tube being attached to the shorter one. utensil is at hand. Instead of the douche bag a vacuum bottle may be used, arranged as in Fig. 150, or an elec- tric light may be immersed in the solution. COMPLICATIONS OF THE PUERPERIUM 2 9 2 Fig. 151. — Arrangement for giving vaginal douche. The dressings and enemata are prepared for in the same manner. PUERPERAL INFECTION 293 The salt water stimulates the lymphatics of the pelvis and helps to wash the poisons out of the system. Medicinal Treatment. -Unfortunately, we possess no medicine that is a specific for infections. Antistrepto- coccic serum, vaccines, Crede’s ointment, and other remedies may be exhibited by the physician. At one time alcohol was much used, and, to a small extent, still has a place in the treatment. When given, whisky or brandy was preferred and in large doses. The fever is best treated by cool sponging. Ice-packs are too depress- ing, and the cold bath involves too much disturbance of the patient. Sometimes a warm pack reduces the tem- perature better. Surgical Treatment. —The nurse may be called upon to assist at internal examinations of the patient, to pre- pare for uterine douches, for curettage, even for major operations by the vaginal or abdominal route. The methods of preparation for all these are given in appro- priate chapters, so that repetition is unnecessary. The nurse should not be expected to give uterine douches, although the physician may instruct her to do so. A uterine douche is a more serious matter than was for- merly thought. Vaginal douches may be ordered fre- quently given, but many physicians are changing their practice in this regard too. The writer does not use them in sepsis. The arrangement for giving the vaginal douche is shown in Fig. 151. When an abscess forms around the uterus, the physician may open it, and in some cases the uterus itself is removed. The Child. —It is best for the patient not to nurse the baby if her illness is at all severe — first, because she has not the vitality; second, her milk is none too good for the infant; third, the infant may become infected by be- ing so close to a focus of infection. As it is, the babe runs great danger of infection through the nurse unless the 294 COMPLICATIONS OF THE PUERPERIUM latter is fully alive to the situation and takes the extra- ordinary precautions necessary. The nurse, if there is only one, should use sterile rubber gloves whenever she touches the discharges of the mother, and another pair when she dresses the navel of the child. It is better to have a special nurse for the infant. If the child does not nurse, the breasts should not be pumped in the hope of preserving the milk. Pumping will not preserve the supply if nursing is long interrupted, and it may lead to an abscess in the breast. The milk will return itself if the child is put again to the breast after not too long an interval. The author has seen the milk return after three weeks. The child may be with its mother very little, and precautionary meas- ures should be constant in preventing infection from reaching its navel, eyes, and throat. The Nurse. For difficult cases of puerperal infection two nurses are really needed, and there is plenty of work for both. It is better if one nurse takes the mother and the other the child. The nurse should insist on getting at least six consecutive hours of sleep daily and several hours of recreation in the sunny part of the day, which should be her opportunity to go out and revivify her blood with fresh air and sunshine. The patient, too, will be better for it. The nurse must be careful not to infect her own hands. Fatalities are known. She must, therefore, care for all cracks and hang-nails. It is wise to use rubber gloves for the vulvar dressings, for this reason as well as for those previously mentioned. If the slightest irritation is observed on the hands, the physician’s advice should be sought. Infection of the nurse’s eyes has occurred, therefore the nurse should, as should all hospital or sick-bed attendants, learn to avoid rubbing the eyes and face while on duty. PUERPERAL INFECTION 295 History Sheet. —The temperature in septic cases is very irregular, and the physician will wish it taken every GRAPHIC CLINICAL CHART. the temperature; the dotted line, the pulse. four hours, also the pulse and respiration. A full history sheet should be kept and all unusual occurrences noted. Graphic history sheets aid the physician in acquainting 296 COMPLICATIONS OF THE PUERPERIUM himself with the case, therefore the nurse should learn how to make them (Fig. 152). Disinfection. —All pads and cloths soiled by the dis- charges from the patient should be wrapped in newspa- pers as soon as removed and burned. Sheets, towels, etc., should be thrown into a tub of 3 per cent, carbolic solu- tion and allowed to soak several hours before they are sent to the laundry. In the laundry the time of boiling the clothes should be at least forty minutes, and the boiler must be tightly closed. The blankets used about the patient should be washed like other bed-linen. An effort is to be made to limit the infection to the room occupied by the patient. The nurse, therefore, keeps her utensils together, protects tables and other furniture from being soiled by the discharges, and keeps the bath-room free from infection. The physician should be provided with a sterile gown for his visit or examination, and with sterile soap and towel for his hands on leaving. The discharges from the vulva, from abscesses, or from wounds should be caught in antiseptic dressings, and these surfaces kept clean by frequent dressings. The room is kept free from odor by full ventilation and sunlight. A sun-bath will do the patient good. After the case is terminated the patient is given a new bed; the mattress she occupied is burned, and the bed taken down into the yard and scrubbed and carbolized. Basins are boiled and furniture scrubbed with 3 per cent, carbolic solution. The room is thoroughly fumi- gated with formalin (see p. 440), and, in general, the case treated as one of the contagious diseases, although it is not contagious in the accepted sense of the term. On leaving the case the nurse sends all the clothes she wore while on it to the laundry, and after a full bath and hair shampoo dons aseptic apparel. For the next four PUERPERAL THROMBOSIS 29 7 days a daily full bath and hair shampoo, using a great deal of soap, are recommended. The nurse may ask why she is required to undergo such thorough cleansing, when the physician goes about among such heterogeneous cases without as many precautions. Let her remember that the physician stays with each patient but a few minutes, and has a change of air between each two calls, while she is in the infected atmosphere nearly seventeen hours out of the twenty-four. Then, too, if she goes to a new patient susceptible to infection, her more intimate association with the case invites sepsis, even if she carries but very little with her. PUERPERAL THROMBOSIS The blood in the veins of the legs may stagnate and clot; this is called thrombosis. The return circulation being thus shut off, the part becomes edematous. Usu- ally there is little fever with this — a mechanical throm- bosis due to poor circulation and to the fact that the veins are enlarged and tortuous. The element of danger in these thromboses is that a bit of clot may break off and, carried by the blood-stream, reach heart and lungs. This is called embolism, and is often fatal. The nurse will seek to prevent embolism by keeping the affected limb very quiet for several days, and by not rubbing or mas- saging it. Care should be exerted when the patient moves in bed and when the limb is bathed. If an infection proceeds from the sides of the uterus and attacks the cellular tissue and the veins about the pelvis, a condition called phlegmasia alba dolens results. By the laity this is called “milk-leg,” and refers to the ancient notion that it is due to “driving in of the milk.” It really is an infection which travels along the veins and the cellular tissue of the pelvis. One or both legs may be affected. The limb is swollen and painful, 298 COMPLICATIONS OF THE PUERPERIUM and the skin is tense and white, almost translucent. It is very tender to the touch. Convalescence takes weeks or months, and often the leg remains swollen or swells when the patient is long on her feet. The nurse will be instructed to keep the patient very quiet, to elevate the limb a little (Fig. 153), to apply a warm, moist dressing, a bandage, or special medicines. Fig. 153. — The box used for elevating the leg in phlegmasia alba dolens. It is smoothly padded with cotton covered with gauze. An air cushion is placed under the tendo Achilles. If the foot tends to fall outward it may be supported by a light adhesive strap to the foot-board. In summer this may be made of wire netting. The foot must not be allowed to support the bed clothes, as “drop foot” will result. A cradle is used to prevent this. Bed-sores will result from poor nursing of the case. Later on, when the fever is gone and signs of inflammation are absent, the doctor may prescribe gentle massage. Sometimes these cases are only part of a general blood-poisoning or pyemia, and then they are really serious, usually fatal. TYMPANY 2 99 AFTER-PAINS Primiparae, unless the uterus contains a clot, are not troubled with painful uterine contractions after the child is born — “ after-pains ” as they are called. Multipart are annoyed by them, and they increase in severity with succeeding puerperiums. They are due to lack of tonicity in the uterine muscle, or to the presence of a clot or a bit of placenta in the uterine cavity, in which case they are especially beneficial, as they expel the foreign body. In all cases they are of good omen, though the patient may suffer considerable distress. If the nurse tells the patient this fact, it may help her to bear with them until they disappear, which almost al- ways occurs within forty-eight hours. During the nurs- ing of the infant the after-pains aggravate, due to the nervous stimulation of the uterus through the breasts — a fact we make use of in practice to get the uterus to contract. In some women the after-pains are of special severity, and the physician should be informed of it, so that he may prescribe an anodyne. Household remedies are warm fomentations over the uterus; a salt solution enema; compression of the abdomen; a warm drink, soda-mint tablets, and suggestion, the nurse trying to divert the patient’s attention. When a clot or other foreign material is in the uterus, the physician may wish to remove it. Preparations are made as for the douche, p. 224. TYMPANY Occasionally after delivery the intestines fill up with gas and the abdomen becomes as large as, and some- times larger than, it was before the birth of the child. The condition rarely may become dangerous or even fatal. It seems to be a paresis of the intestinal walls or stomach similar to that sometimes occurring after 300 COMPLICATIONS OF THE PUERPERIUM abdominal section. The physician’s attention should be called to it early, and he will prescribe some carmina- tive by mouth or by rectal injection. Asafetida has proved valuable in these cases. Turpentine stupes and the high rectal tube are also used. An enema of milk and molasses, of each i pint, is very effective. Chamo- mile tea makes a pleasant enema The abdominal binder should be removed. Abdominal massage is practised only on the physician’s order. If the tympany is due to a peritonitis, the outlook is gloomy Nearly all cases not due to inflammation rapidly subside under treatment. CONSTIPATION Difficulty may be experienced in getting the bowels to move during the puerperium. In one case the author found a tumor almost as large as the uterus at term filling up the lower abdomen, composed of feces. If cathartics and ordinary flushings prove insufficient, high colonic irrigation with inspissated ox-gall and glycerin may be ordered, or it may be necessary, if the fecal impaction is lower, to remove the mass with the fingers and suitable scoop-like instruments. An ox-gall enema is prepared as follows: i dram of inspissated ox-gall- is mixed with 2 ounces of glycerin into a smooth paste; with constant stirring water is poured into it until the amount is 1 quart. The mixture is injected slowly into the bowel and retained several hours if possible. For removing hardened feces from the rectum the patient is brought to the edge of the bed, warmly covered, be- cause the operation requires some time, and the nurse, with rubber gloves on, under an intermittent stream of salt solution, loosens and breaks up the masses. After the rectum is emptied, a few ounces of sterile olive oil or vaselin (liquefied by heat) are injected to allay the irritation. VESICOVAGINAL VISTULA 301 VESICOVAGINAL FISTULA In cases of excessively prolonged labor or of instru- mental delivery, it occasionally happens that the wall between the bladder and vagina is torn or sloughs out. The resulting communication between the two cavities is called a vesicovaginal fistula. If such a communication Recto- vaginal Vesicocervical. Ureterovaginal. — Vesicovaginal. Recto- perineal. Urethrovaginal. Vaginoperineal. Fig. 154. — Sites of fistulas. is made with the rectum it is called a rectovaginal fistula (Fig. 154) . In the former case the urine will escape from the vagina continually; in the latter, the feces and gas will continually soil the vagina. The nurse will have extra work keeping the parts clean until they are suffi- ciently recovered to permit a plastic operation. After vesicovaginal fistula operations usually a per- 302 COMPLICATIONS OF THE PUERPERIUM manent catheter is inserted and continuous drainage of the bladder is maintained. The success of the operation depends largely upon the nurse, because if she allows the catheter to be plugged with urinary salts or to be kinked, the bladder will become overdistended, and, Fig. 155. — Permanent catheter in place, draining into bottle hung at the side of the bed. The rubber tube must be rigid enough to resist compression by the thigh. since the urethra is blocked, the urine will find exit through the stitches, thus spoiling the operator’s best work. A No. 16, French scale, soft-rubber catheter is placed in the bladder and fastened to the thigh with adhesive CYSTITIS 303 plaster (Fig. 155). A large glass connector unites it with a stout rubber tube (lumen \ inch), leading under the thigh into the mouth of a large bottle hanging at the side of the bed. The nurse observes the urine dripping from the free end of the tube, and she must at once in- vestigate any stoppage of the flow. The dripping must be uninterrupted. Night and morning the catheter is removed and a new one inserted, which must also be done if the urine ceases to flow. Medicines are usually given to prevent excessive deposition of salts in the catheter, which is the greatest menace to success. CYSTITIS Inflammation of the bladder is an occasional compli- cation of the puerperium. It is usually due to infecting catheterizations, but in some cases injury to the bladder during labor predisposes to the infection. The nurse can read a warning here — to be always aseptic in her catheterization. The symptoms of cystitis are painful and frequent urination, vesical tenesmus, pain over the bladder, ten- derness on pressure, pus and blood in the urine; later, alkaline fermentation in the bladder. The treatment is both internal and local. The patient will be given some urinary antiseptic, like urotropin, and the physician will perhaps order the bladder washed out with saline solution or some weak antiseptic. Wash- ing the bladder is simple, the preparation being the same as for catheterization. After the urine is drawn off, the tube of the douche-bag is attached to the cath- eter and the bladder allowed to fill. The bag is held 18 inches above the pubes. The water is then allowed to escape, and this lavage is repeated several times at each sitting. If the physician wishes to cystoscope the patient, that 304 COMPLICATIONS OF THE PUERPERIUM is, look into the bladder, the nurse will prepare for this in the same manner as if she were going to wash out the organ. In addition she should provide a tall jar for solution in which to place the cystoscope, a sterile syringe holding 2 ounces, and i pint of sterile water as clear as crystal. This water the physician uses to distend the bladder while he is looking into it with the cystoscope. Cystoscopes (excepting the simple tubular ones) must not be boiled, and are to be delicately handled. HEADACHE A woman should not complain of headache during the puerperium. If a headache comes on after labor, the nurse should watch for other symptoms of eclampsia. If a woman has lost much blood at the labor she may suffer from an anemic headache. There is a headache from exhaustion, from too much excitement, as too many or irritating visitors, from hunger, from too much ergot, and from insomnia. Sometimes the eyes are at fault, and the patient may have to wear eye-glasses in bed, and if a woman with weak eye muscles looks down at her baby all the time it is nursing she may acquire a headache from eye-strain. Constipation is another cause of headache, and neurasthenia also. The physician will inquire into the cause and seek the remedy, but the nurse may do much both in prevention and cure by exercising her art — nursing. PUERPERAL INSANITY This sad accident is not very infrequent. It occurs most often in women with an hereditary taint of insanity in the family, in cases of toxemia during pregnancy, after eclampsia, and after sepsis postpartum. Melancholia and mania are both found, and one may lead to the other. In both forms suicidal tendencies are marked, and the PUERPERAL INSANITY 305 mother may try to destroy the child. After recovery she may repudiate her own infant, or only slowly learn to love it. The symptoms of beginning puerperal insanity are sleeplessness, anorexia, delusions of sight, hearing, smell, loss of love for the infant, even hating it. The patient may become acutely maniacal, with extreme and exhaust- ing jactitation, and try to jump out of the window; or she may lie apathetic and melancholy, but may suddenly make an attempt to kill herself or the baby. Treatment. — There are three important parts of the nursing care of such cases: First, prevent the patient from committing suicide and from killing the baby; second, procure sleep; third, keep up the nutrition. To accomplish the first — prevention of suicide — the patient should be isolated in a room whose windows are barred. If they are completely covered with double wire fly-netting nailed down it is sufficient, and does not give the patient the idea of a prison. All pictures and extra furniture should be removed, and everything that has a polish which may give reflections and which the patient may misconstrue; also everything that is sharp or cut- ting, as glass, table-knives, or forks. Nothing movable save the table, divan, and chairs should be at hand. The patient must not be left alone an instant. Two nurses are absolutely necessary. When the child is with the mother, the nurse must watch her very sharply, as she may strangle the little one before it can be drawn away from danger. The general rules for nursing the insane are applicable here, and it is desirable that a nurse having such special training be employed. For the exhausting jactitation, gentle restraint may be absolutely necessary, but one should remember that restraint is also exhausting to the patient. 20 30 6 COMPLICATIONS OF THE PUERPERIUM Procuring Sleep . — The physician will prescribe som- nifacient drugs, of which hyoscin, scopolamin, morphin, opium, and chloralamid are usually selected; but the nurse may do much to procure rest for the patient. Let her give the enema and the bath in the evening, or an alcohol rub, with general massage, followed by a cup of hot malted milk or an eggnog. Absolute quiet must reign throughout the house, and no visitors be allowed. The patient must sleep. N ourishment . — This is of great importance and diffi- cult, because the appetite is gone and the patient may try to die by starving herself. She may imagine herself too wicked for the food given her, or have other delusions, and the nurse may make use of her delusions to insinuate food. All the art of cookery and the arts of the nurse are to be used to provide sufficient nourishment, and the nurse should keep an accurate record of the daily amounts ingested, so as to be able at all times to show the phys- ician that the puerpera is not suffering. Should the patient refuse nourishment, she will have to be fed with a stomach-tube. Saline solution is sometimes administered hypodermic- ally. It may make the patient hungry. If the mother has milk, she may nurse the infant. Let the nurse watch them carefully; usually the milk secretion diminishes, or the infant does not thrive, and it is best to wean it. These cases require from two to eight months for re- covery, although occasionally this may never be com- plete. An important question is the removal of the patient to a sanatorium. In the writer’s opinion, this is usually by far the best course. If the patient can have skilled nurses and all the care she could get in the sana- torium at her own home, with complete isolation, she may be as well cared for at home. CHAPTER IV COMPLICATIONS OF THE PUERPERIUM- (Contmued) DISEASES OF THE BREASTS The most common disorder affecting the breasts is simple engorgement. The general notion is that the breasts are overfilled with milk. This is true only in part. While a small amount of milk forms spontane- ously in the breasts, the symptoms are due to lymphatic and venous engorgement. One can see this in some cases, even the skin being edematous. The engorge- ment occurs on the second, third, or fourth day, when the “milk comes in,” and it may occur at the time of sud- denly weaning the child, when the usual relief of engorge- ment produced by nursing is absent. Symptoms. — The breasts are very heavy, painful, and hot; they feel warm, but there is no rise of body tem- perature. There is no such thing as “milk-fever” — a fever the ancients ascribed to the engorgement of the breasts on the third or the fourth day. Fever at such times is usually due to infection. Examination of the breasts shows them to be much enlarged, tender, some- times edematous, and of a bluish, mottled appearance. The nipple is flattened so that the child cannot grasp it, and the secretion of milk may be suspended — the breasts are choked up with swelling. The part of the gland running up into the axilla enlarges too, and the patient cannot bring her arm to the side. 307 308 complications of the puerperium If left alone, the engorgement gradually disappears, the gland becomes soft, and the milk flows readily when the child nurses. If irritated by too much or too rough massage, by breast-pumps, and too frequent nursing, the engorgement is slower in going down, but it will gradu- ally disappear. Treatment. The practises of physicians vary. Some apply heat; others, cold. Usually orders are given to bind the breasts tightly (Fig. 156). A saline cathartic is often given to draw the blood away from the breasts. Fig. 156. — The breast-binder applied. Massage is practised only on the physician’s order, and the same is advised in regard to the breast-pump. Neither massage nor the breast-pump is to be employed when there are signs of inflammation in the breasts. The practice of the author is as follows: If the en- gorgement is severe and causes much pain, a saline laxative is ordered, and liquids by mouth are restricted. The infant is allowed to nurse only every four hours. The breasts are tightly bandaged and an ice-bag is applied to each of them. These measures will almost DISEASES OF THE BREASTS 309 always prove adequate. If they do not, the nurse gently massages the breast for five minutes and then reapplies the binder. If this brings no relief, which is unusual, a hot boric dressing is applied. Aseptic gauze is wrung out of hot boric acid solution, both breasts snugly padded with it, and over all a layer of oiled silk and a bandage are placed. This is sometimes more grateful to the patient than the ice. If compression is wished in addi- Fig. 157. — Massage of breast: Even compression of entire breast. First motion. tion, a round oatmeal bowl may be inverted over each breast and bandaged on. Massage is carried out as follows: The nurse sterilizes her hands and anoints the breasts with sterile albolene or oil. The first motion (Fig. 157) is one of even com- pression of the whole breast. Both hands are spread out as evenly and smoothly as possible over the breast, and firm compression exerted against the chest. The 310 COMPLICATIONS OF THE PUERPERIUM Fig. 158. — Massage of breast: Pressing the lymph in the direction of the peripheral lymph- vessels. Second motion. Fig. 159. — Diagram of the breast strokings in the second motion. The shaded portion of the arrows shows the increase in pressure of the stroke. DISEASES OF THE BREASTS 311 blood and lymph are thus pressed out and away from the gland. On removing the fingers the nurse may see depressions in the surface. This pressure is not painful, — just the contrary. After this even pressure has been practised a few minutes and all the gland covered, gentle circular strokings are made from the nipple toward the periphery (Fig. 158). The four fingers make circles around the nipples, pressing harder as they go away from Fig. 160. — Massage of breast: Wiping the milk toward the nipple. Third motion. the nipple (Fig. 159). The breast is steadied by the other hand. The idea is to press the lymph out of the breast. After circling the breast twice, the third motion is in- stituted (Fig. 160). One hand steadies the breast, while four fingers of the other hand wipe the milk toward the nipple. Any milk formed is thus squeezed out of the nipple. This is the least important of the three motions. 312 COMPLICATIONS OF THE PUERPERIUM The last maneuver is a repetition of the first, and nearly always the patient will feel much relieved by the procedure, even though no milk has been expressed. The breasts are now bandaged smoothly and tightly. Abnormalities of the Nipples. -The normal nipple varies much in different women. Fig. 161 gives silhouettes of many forms. If the nipple is flat, or even depressed, the child may be unable to get hold of it. Normal nipple. Polypoid nipple. Flat nipple. Mulberry nipple. Inverted nipple. Bifid or split nipple. Fig. 1 6 1. — Diagram of variously formed nipples. Engorgement of the breast is common, and if fruitless efforts at nursing are persisted in, cracks occur and abscess may be the final result. If the child cannot quickly develop a nipple sufficient for sucking, and if the milk does not flow readily with the use of a nipple-shield it is best to discontinue nursing. During pregnancy attempts should be made to develop undersized and de- pressed nipples. (See p. 89.) DISEASES OF THE BREASTS 313 If the nipple is congenitally fissured, as the mulberry nipple; bifid, as the double nipple, or pedunculated, the tendency to crack is marked, and trouble with nursing is inevitable. Cracks, Fissures, and Blisters of the Nipple. — These are very important, because they sometimes ren- der nursing difficult or impossible, to the detriment of the infant, and they may also lead to mastitis, with abscess. The integrity of the nipple must, therefore, be preserved. The nurse should frequently inspect the nipples, to de- tect a crack or blister in its incipiency, especially if the patient complains of tenderness when the babe grasps the nipple. If she cannot find a crack with the unas- sisted eye, a magnifying-glass in good light will usually show one. Sometimes there is an unexplained sensitive- ness of the nipple. This occurs in neurotic women, and may be so acute as to forbid nursing, even though there is a good milk-supply. Sometimes the infant bites the nipple unnecessarily. It is a habit, and should be cured by gently patting him on the back until he learns better. Sometimes the baby will not let go of the nipple, pre- ferring to keep it in the mouth, even when not nursing.* This must not be allowed. To remove the nipple from the infant’s mouth without hurting the nipple, insert the little finger into the mouth at the angle of the lips and let the air in. Cracks are longitudinal or circular; the latter are the worst. A crack may deepen into a fissure, and a fissure, if transverse, may partly amputate the nipple. If longi- tudinal, it may split the nipple. A blister often precedes a crack, and a little superficial ulcer may result from a blister. Blondes are more liable to these affections than brunets, and red-haired women seem particularly predisposed, perhaps because their skin is so thin and delicate. The precautions to be taken during preg- 3 14 COMPLICATIONS OF THE PUERPERIUM nancy are given on page 89, under The Hygiene of Pregnancy. As soon as a crack is discovered, it should be reported to the physician and treatment should be instituted. A great many methods are employed. The author uses the following, but the nurse will do well to get exact in- structions from the attending physician: First, the in- tervals of nursing are lengthened to four hours and the breasts used alternately; second, Wansbrough’s leaden nipple-shields (Fig. 162) are applied. These are little shields made of thin lead having the shape of a sugar-loaf hat. They are scoured with Sapolio, boiled, and then ap- plied to the nipples, being supported by a bandage. The Fig. 162 . — Wansbrough’s leaden nipple-shield. theory is that the lactic acid in the milk acts on the lead, and the nipple is bathed continuously in a sort of lead- water application. This explanation has been ques- tioned, but the fact remains that the little appliance is very successful in curing cracked and ulcerated nipples. To hasten the cure, or if the leaden shields are not used, the crack or blister is brushed with a 2 per cent, solution of nitrate of silver. If there is a deep fissure or ulcer, it is best to begin the treatment by touching it up with a 20 per cent, solution of nitrate of silver and then apply the shields. Before nursing the shield is removed, the nipple washed with boric solution, and a glass nipple-shield applied. DISEASES OF THE BREASTS 315 (See Fig. 76.) To get the infant to nurse with this shield it is well to fill it with sterile water before inverting it over the nipple. The child sucks out the water and the milk follows. The teterelle may also be used. Should the milk start with difficulty, a hot application will bring it to the surface. Sometimes the above treatment fails, although the author is very seldom thus disappointed. In these cases he uses astringents, and the best is nitrate of silver. The nipple is washed with a 2 per cent, solution of it morning and evening, and it is allowed to dry in, in the sunlight. If the fissure is a deep one, the child should be kept from that breast for a few days. In this time, with the nitrate of silver application and the leaden shields, the fissure will have healed sufficiently to allow nursing with the glass shield or the teterelle. It is not necessary to say here that extreme asepsis must be practised to keep these cracks from being in- fected; the glass nipple shields must be boiled twice a day, and when not in use should be kept in saturated boric solution. They are placed in this solution only after thorough rinsing inside and out with scalding water. Milk curdles in the folds of the rubber, and for its removal the rubber needs to be turned inside out. Among the hundreds of remedies for cracked nipples, only compound tincture of benzoin, glycerin, glycerin with boric acid, collodion, collodion with antiseptics, castor oil and bismuth, and alcohol need be mentioned. They may be used as succedanea. A dressing of 70 per cent, alcohol applied for four hours a. m. and p. m. sometimes cures when the other remedies fail. Mastitis. — Inflammation of the mammary gland or the tissues about it is called mastitis. There are four varieties. The inflammation may be in the skin around 3 16 COMPLICA 7I0NS OF THE PUERPERIUM the nipple, or a little abscess may form in one of the tubercles of Montgomery. The inflammation may be in one or more lobes of the gland the so-called paren- chymatous form, or glandular mastitis. If the inflam- matory process occurs in the fat and loose tissue between the lobes, we speak of periglandular cellulitis or phleg- monous mastitis, and if the infection travels beneath the gland to the connective tissue which fastens the mamma to the chest-wall, we find pus under the gland, and speak of submammary abscess. This is very serious and, fortunately, rare. The commonest is the paren- chymatous variety, and it is the most amenable to treatment. The cause of all these forms is infection. Germs obtain access to the gland and set up inflammation. The different varieties spoken of are made by the dif- ferent routes which the germs travel before they cause the inflammation. Normally, many breasts contain germs, but these are either naturally harmless or they require special conditions to make them virulent. Such conditions are cracks, fissures, ulcers of the nipple, bruis- ing of the breasts, either by too brisk massage or other injury, too much pumping of the breasts, squeezing of the breasts, and efforts to get them to secrete milk when they cannot do it. It is a question if simple milk stasis causes abscess. Surely engorgement itself does not. Over- stimulation of the breast may result in infection and abscess. Infection is often carried directly to the breasts on the fingers of patient or nurse from the lochia, from an infected umbilicus, or from any source of infection. As a rule, these cases may be prevented by proper pro- tection of the organ and continual watchfulness in avoid- ing infection. If there are cracks or fissures, asepsis must be especially thorough, as it is here that the infection usually gains entrance. DISEASES OF THE BREASTS 3 1 J Symptoms. — The symptoms of mastitis are pain in the affected breast, and particularly in one spot, and ten- derness and swelling of the same; there may be a chill, and there is nearly always fever, which may reach 105° F. The pulse is high, and we observe all the manifesta- tions of a febrile attack — headache, malaise, pains in the bones, hypersensitiveness to light, etc The part of the breast that is inflamed is hot and tender, and later may be reddened. If, under treatment, the fever and other symptoms abate within forty-eight hours, one may feel encouraged that an abscess will not form If the fever remains high for more than two days, one will have to fear this outcome. With proper treatment the prognosis is good. In almost all cases an abscess can be prevented. Treatment. — As soon as the nurse detects the first signs of inflammation of the breast she notifies the attend- ing physician, and until he comes she withholds entirely the child from the breast, and applies a very tight breast- binder. The physician may order ice applications. These must usually be kept up constantly for forty- eight hours. Two large ice-bags are applied to each breast and they are kept half-full, so that they be not too heavy on the chest (Fig. 163). The breasts are supported by the binder, and the ice-bags lie directly on this, not separated trom the skin by enough cloth to prevent the cold from reaching the gland (Fig. 164). The skin must feel really cool to the touch, or no good is being derived from the ice. If the patient becomes chilly, a hot-water bag is applied to the feet and the arms are wrapped in flannel. A saline cathartic is usually ordered, and the liquids in the diet are re- stricted. With these measures the inflammation almost always subsides without suppuration. The ice-bags are removed one by one after the patient has had a normal temperature for twelve hours. The child is put 3 1 8 COMPLICATIONS OF THE PUERPERIUM Fig. 163. — Breasts covered with ice-bags. A thin gauze binder over all holds the bags in place. DISEASES OF THE BREASTS 319 back to the breast twenty-four hours after the fever is gone and at least six hours after the last ice-bag is re- moved. The nurse may be asked if the milk will not perma- nently dry up if the child does not nurse for several days. Experience shows that it does not. Even non-pregnant women can start the breasts to secrete milk by putting a vigorous infant to the nipple. A maid who was given the care of an infant at night kept it quiet by letting it ICE - BAGS. .. Fig. 164. — Schematic section of body, showing relation of ice-bags to breasts. suck on the nipple. Milk appeared and she wet-nursed the child. The same occurrence was noticed in a woman forty-nine years old whose daughter died in labor. She suckled the child, although her bosom had not been pressed by an infant for fourteen years. No massage or pumping of the breasts is allowable at any time during the treatment of mastitis. Should an abscess form, the condition being shown by irregular temperature, chills, and softening and redness of the 320 COMPLICATIONS OF THE PUERPERIUM inflamed portion of the breast, the nurse will be required to prepare for operation — that is, for draining the breast. Ordinary surgical rules are observed here; repetition is not necessary. After the abscess is opened the nurse, having to dress it, should be careful not to carry the infection to the woman’s genitals or to the baby’s navel. Rubber gloves should be used for dressing the breast. Fig. 165. — Bier’s congestion treatment of mastitis. Suppuration is often prolonged, and there may be a suc- cession of abscesses, fairly riddling the breasts and dis- figuring them. In addition, the general health may suffer, therefore in these prolonged cases the nurse will arrange for a generous diet, outside living, and all the factors making for rapid recuperation. The latest treatment of mastitis is the “congestion therapy” of Bier. A large dome-shaped glass is in- DISEASES OF THE FEE A STS 32 I verted over the breast and the air exhausted from it by means of a pump (Fig. 165). The bell is applied sev- eral times a day for thirty minutes. The physician must be asked for accurate instructions regarding its use. Galactorrhea, or Excess of Milk. — This is not a common condition, and when it occurs, is seldom per- sistent. After a few weeks the activity subsides to a normal that is sufficient for the infant. If the clothing is soiled by the constant leakage of milk, sufficient pads or a glass reservoir shield should be placed to catch the overflow, and a snug breast-binder should be constantly worn. The patient should reduce the amount of water drunk and of starches eaten. The bowels should be moved daily by saline cathartics. The infant should be put to the breasts less often, and regularity is to be in- sisted on. Medicines are sometimes given to check the secretion of milk. These are belladonna and iodid of potassium. The nurse should watch for their physiologic effects, as some women have an idiosyncrasy for them. Agalactia, or Scarcity of Milk. -This condition is much more common than galactorrhea. It is little less than a calamity when a woman is unable to nurse her child. That a woman should refuse to nurse her infant when she has milk and is well is unpardonable. Unfortunately, a large number of women cannot nurse, either because of ill health or because they have no milk. Many children die, either directly of the want of mother’s milk, or indirectly of children’s diseases to which they fall easy prey if they have been brought up by the bottle. The custom of giving children to wet-nurses or to others to be brought up on the bottle is an ancient one. Caesar reproached the Roman women for doing it and for squandering their affection on dogs and monkeys. The writer has noticed a decided improvement among women in regard to nursing their children. 21 322 COMPLICATIONS OF THE PUERPERIUM Causes. ^The causes of deficient milk-supply are general weakness or ill-health, worry, lack of nourish- ment, a puny baby, malformation of the breasts or the nipples, and absence of gland tissue. In the last class of cases the breasts may be large with fat deposit. If there is no gland tissue, it is useless and dangerous to try to stimulate the secretion of milk. Symptoms. -The symptoms of deficient milk-supply are: first, the distress of the child — its loss in weight; second, the pain in the breasts and the absence of secre- tion. , The child is unsatisfied with the nipple; he may suck for a short while, but, finding nothing there, will refuse it and cry. After supplemental feeding he goes to sleep. When there is plenty of milk, the mother can feel it leave the breast and see the infant swallow. There are also some drops of “white nourishment” around the mouth. These are all absent in agalactia. Weighing the child before and after nursing proves the func- tioning of the breast. If the mother persists in nursing after the supply has diminished, the act comes to be attended with pain in the breasts, radiating around to the back, first only during the nursing, later in the intervals also. Unless nursing is interrupted, serious inroads on the woman’s health may result. Treatment. — If there is not enough milk in the breasts an attempt may be made to stimulate the secretion by diet, cool baths, and massage of the breasts. Medi- cines have very uncertain, if any, action. Pituitrin has recently been tried, also thyroid extract. The physician may prescribe a malt extract, somatose, or other preparation vaunted to stimulate the secretion. The author’s experience with malt preparations is that they often fatten the patient and dry up the milk. By increasing the liquids in the diet the total quantity of milk may sometimes, not always, be increased. When DISEASES OF THE BREASTS 323 the milk-supply is not augmented, the patient puts on fat. The patient is given milk in large quantities, water, very weak tea, chocolate, oatmeal and barley gruels, and oyster-stews, in addition to her regular diet. The effect is not permanent, and too much water thins the blood. Alcoholic drinks should be restricted or, better, avoided, and certainly by a mercenary wet-nurse. Alcoholics are not good for the infant. Fig. 166. — Massage of breast to stimulate the flow of milk: First motion. Cool full baths stimulate the skin and the breasts also. They may be taken daily and at about 8o° to 84° F. The whole body should be briskly rubbed with a coarse towel, avoiding the mammae. Bier’s method of producing artificial engorgement has been applied to the breast to stimulate the flow of milk. The results thus far have been fair. Massage of the breasts stimulates the formation of milk. When massaging the breasts for this purpose the 324 COMPLICATIONS OF THE PUERPERIUM rules given on pages 309-310 do not apply. One wishes here to irritate the gland. This is done by raising the whole breast from the chest wall (Fig. 166) and working it gently between the fingers. Care should be used not to bruise the delicate organ, as an abscess may result. The gland is then held against one hand, while the tips of the outspread fingers of the other hand make circular movements all around its periphery (Fig. 167). Fig. 167. — Massage of breast to stimulate the flow of milk: Second motion. Electricity has been tried, with indifferent success. The best stimulant for the milk secretion is a vigorous infant. One should not be discouraged too soon, as the estab- lishment of the milk secretion is sometimes slow. In one case sufficient milk diet did not come until the fifth month. Often after the patient is up and gets outdoors the milk comes in large quantities. One may be misled to believe that this is the action of some special drug or of feeding. DISEASES OF THE BREASTS 325 If, however, the measures instituted have no effect, it is wiser to discontinue them as soon as this fact is apparent. Too great zeal in forcing the breasts to act may result in mastitis. The milk secretion has been known to cease completely on a sudden fright experienced by the woman, and it has been observed that a quiet, placid life con- tributes to a normal and continued flow of milk. Abnormal Milk. Remarkable as it may seem, the milk of the mother, although plentiful, may not agree with the child. The writer has seen cases where it seemed to act like an irritant intestinal poison, and fatal- ities have even been reported. These cases have all been neurotic mothers, and most of them in the higher classes. Chemic and microscopic examinations have not given satisfactory explanations. The condition may or may not recur in the subsequent pregnancies. The child will refuse the breast, in which case the milk may have a foreign taste, or it will vomit the ingested milk or have a diarrhea from it, sometimes with fever. The milk may appear yellower and thicker in these cases, showing either a persistence of the colostrum or an in- crease in fat and protein — that is, it is too rich. Curi- ously, sometimes a child will refuse one breast and accept the other; in a case of this kind the milk of one breast was said to be salty. If the milk is believed to disagree with the child, causing green, acrid stools, the nursing should be dis- continued for forty-eight hours, the breasts being regu- larly emptied in the meantime by the breast-pump. The child is fed on a substitute milk, and at the end of this period another trial is made of the mother’s milk. If it again causes intestinal disturbance, the wisest course to pursue is to obtain a wet-nurse for the child. If the mother’s milk is deficient in one or the other in- gredient, the physician will instruct the nurse to add this 326 COMPLICATIONS OF THE PUERPERIUM or that preparation of sugar, cream, barley-water, etc., to each feeding. Drying- Up the Milk. -When it is necessary to dry up the milk, the physician will usually instruct the nurse to bind the breasts up as tightly as the woman can toler- ate it, to reduce the liquids in her diet, and to give her daily a saline cathartic. Before applying the binder the breasts thould be emptied by a strong infant or breast- pump, and sterilized with soap and water and a bichlorid solution. The binder is not disturbed unless the phys- ician wishes an ointment, of which belladonna is the favorite, applied. Systemic effects have been observed from belladonna ointment applied to the breasts. Experience has shown that it is better to leave the breasts entirely alone after the above treatment, and not to massage or pump them. Care of a Wet-nurse. — If the mother cannot nurse her babe, a wet-nurse should be recommended. The family may not be able to employ one, or it may be im- possible to obtain a suitable one, but the fact stands out that the best nourishment for a newborn babe is mother’s milk, and no effort should be spared to provide the same. Only the two reasons given above ought to be allowed in the discussion of the engagement of a wet-nurse. The author is aware that a wet-nurse at all times is not an unalloyed blessing, and sometimes even an almost in- tolerable nuisance, but the family should be encouraged to bear with much for the sake of the infant. After a few months, when the child has gotten a good start, the wet-nurse may be dispensed with — if really necessary. The physician will select the woman, and having satis- fied himself that she is healthy and has good milk, has no syphilitic or nervous disorders, will ask the nurse to look after her. The wet-nurse on arrival should be received quietly, allowed to bathe, and should then rest DISEASES OF THE BREASTS 327 a few hours in bed. This is to quiet the usual excite- ment and perhaps alarm occasioned by her new surround- ings. The nurse can do much to make her feel at home. The first milk of the breast is pumped out, and, after the woman has rested, the child is allowed to nurse. The milk may be scanty for a day or so, probably because of the mental disturbance alluded to. A wet-nurse should do light work about the house, and she must take exercise out-of-doors. The nurse takes care that she is cleanly about her person, her teeth perfect, that her bowels are kept in good order, and that she has sufficient sleep. Anything abnormal in these matters should be reported to the physician. The diet is important. Let the woman have those things to which she has been accustomed. If a woman who is accustomed to brown bread, soup-meat, and pota- toes is allowed to eat rich pastries, fried meats, and heavy sauces, she will put on fat and the milk will dry up. The cook is to be instructed not to allow the wet-nurse to eat indigestibles and acids, as these affect the milk. It is fatuous to try to keep the milk by plying the wet-nurse with beer, malt extracts, rich foods, liquids, etc. If the milk is increased in amount, the quality is bad. A change of wet-nurses is needed. Should the woman men- struate, there is apt to be some slight disturbance of the infant’s bowels, but usually not sufficient to contra- indicate nursing. All these precautions are particularly needed in the case of a premature infant. If plain living, with light household duties, a moderate amount of exercise out-of-doors, and a quiet, undisturbed life do not give a good milk-supply, another wet-nurse is to be selected. CHAPTER V THE DISORDERS OF THE FIRST WEEKS OF LIFE There are many conditions which arise during the first weeks of life — some mild, some serious — which the nurse ought to know. She has often to diagnose them and report them to the physician. It is well that she be acquainted with some of the methods of treatment, although in the individual case she obtains directions from the physician. AFFECTIONS OF THE DIGESTIVE ORGANS Indigestion heads the list in frequency of disorders of digestion. The causes are too frequent nursing, irregular feeding, letting the child drink too much or too fast, inappropriate food, especially common in artificially fed children, and exposure to cold. Overfeeding and overdrinking are very common. Indigestion is a symp- tom of intestinal infection. The symptoms are restlessness, colic, vomiting, diar- rhea, rumbling in the bowels (borborygmus), discharge of gas by mouth or rectum, and excoriations around the anus. The stools are green, acrid, foamy, and contain much mucus and clumps of undigested milk. There may be a little fever. The treatment consists in removing the causes men- tioned. The physician may prescribe pepsin or other remedies, beginning the treatment with 15 drops of castor oil. He may order food withheld for a short 328 AFFECTIONS OF THE DIGESTIVE ORGANS 329 period, and barley- or rice-water substituted. The nurse regulates the hygiene of the infant, but gives neither drugs nor household remedies without instructions. Colic is one of the symptoms of indigestion, al- though it may occur when the stomach and bowels are acting well It is due to similar causes — errors in amount, quality, and time of the feedings. A bottle-fed baby almost never escapes many attacks of colic, and breast-fed infants not seldom suffer from it. It seems as though the intestinal canal requires time to get into sys- tematic action. If the child is not kept warm, it is likely to suffer from colic. Symptoms of colic are crying, with drawing up of the feet; often the child is awakened from sleep by colic, when it emits a short, sharp cry; rumbling in the bowels and passage of gas by the rectum, whereupon the colic ceases; and the symptoms of indigestion, if this is causa- tive. The treatment of the colic should begin with the re- moval of the cause — that is, regulation of the diet, a cath- artic for constipation, and warm clothing, especially about the feet and abdomen. Household remedies in great numbers are given by nurses, but it is better to avoid them and get orders from the physician. If the nurse is alone, she may give the child a salt solution colonic flushing. Then it is laid on a warm- water bag for a while or cuddled up warmly against the nurse’s breast. A drink of hot water, plain or with a few drops of essence of peppermint, is given. The nurse must not give a child whisky, paregoric, or other drug without express permission. The writer found a case where the nurse had been giving the babe creme de menthe until the little one was a toper. Gastric lavage is sometimes ordered for colicky babies, as well as many medicines, of which calomel and the 330 DISORDERS OF THE FIRST WEEKS OF LIFE aromatics are the commonest. Opium is used with great circumspection in infants. Difficulty in Nursing. -The causes of difficulty in nursing are: ignorance, the babe must learn to suck; tongue-tie, cleft palate, and hare-lip; occlusion of the nasal passages, impeding breathing; sore mouth, as thrush and Bednar’s aphthae; diseases of the lung, as pneumonia, bronchitis, atelectasis; diseases of the brain, causing apathy and coma; prematurity, the infant feels no hunger and may “ sleep away.” The breast itself may be at fault; the nipples may be too small or depressed; the gland may be so engorged that the babe cannot take hold; the milk may not agree, having perhaps a foreign taste; or there may be no milk there. With the cause the nurse will have the remedy. Vomiting. — This is a symptom of many diseases, but principally of indigestion and gastro-enteritis. In- fants normally vomit in the first weeks, and it may be due to overfilling of the stomach or to the fact that the stomach is situated favorably for regurgitation at this tender age. Only when the vomiting is persistent and attended with evident nausea or contains bile, blood, etc., is the symptom significant. There may be a pyloric stenosis or mechanical occlusion of the lower gut, in which case constipation will accompany the emesis. The treatment of vomiting is nil unless there is a real sick- ness behind it. The child may nurse a little shorter period than fifteen minutes, and should be handled care- fully afterward. If the child should vomit blood, bile, or anything but milk, the nurse must notify the doctor at once. Constipation. -Newborn infants are seldom costive, although in later months this is not uncommon. In the first days the bowels may not move because a plug of tough mucus has accumulated in the rectum (Fig. 168). AFFECTIONS OF THE DIGESTIVE OR G A NS 33 1 After this is gotten rid of the evacuations occur normally. In the first days, too, the bowels may not move because the anus is absent. This is a very serious condition, and requires operation; it should be re- ported to the physician without delay. In these cases the infant soon commences to vomit, but the general health is interfered with only late. Constipation may be due to insufficient food, to a lack of water, and to habit. The treatment consists of: first, regulation of the diet, colonic flush- ings, the use of castor oil or other laxative; later, massage. Glycerin and soap suppositories are not rec- ommended. Gluten suppositories and oil enemata may be used as in the adult. After the cord is off and the navel healed, light abdominal massage is practised. Cathartics may be given the mother to act on the child through the milk. Diarrhea. — This is much more frequent in the first weeks than constipation, and is more difficult to cure. The ingestion of the colos- trum causes a physiologic diarrhea, it being evidently nature’s object to get rid of the meconium in this way as soon as possible after birth. The writer has found that children do better if this tarry material is early gotten rid of, and, therefore, pre- scribes for all babies 10 drops of castor oil on the second day. If the milk is too rich in fats or proteins the infant may have a diarrhea, and if the mother is taking laxa- Fig. 168. — Plug of mu- cus from the rectum of a newborn child. Upper part stained by meco- nium. 332 DISORDERS OF THE FIRST WEEKS OF LIFE tives the child feels their effects. Oftenest diarrhea is caused by gastro-intestinal infection, and then is usu- ally attended by fever. Occasionally the infant has frequent watery movements of a yellow color and normal odor, and does not apparently suffer. These cases are not serious, simply being due to indigestion, and will get well if the child is made to nurse more slowly, and if the milk is diluted a little — for example, by giving some barley-water before the nursing. Often the condition of the bowels will not be satisfactory until the mother is up and out-of-doors. This seems to regu- late the function of the mammary glands. Green Stools. — The nurse should inspect and note the character of the child’s evacuations. If they are ab- normal, the doctor ought to know it. Normally the stools are dark green for two days, then brownish, then with the addition of yellow, and soon all golden yellow. If the meconium is a long time in coming away, castor oil should be given to clear the intestinal tract, as this material is prone to decompose. If the child does not obtain enough food, the stools are scanty and brownish until the deficiency is supplied. The stools should be semisolid, and the water margin around the solid part should be about J inch wide. There should be no lumps or curds; the odor is that of sour milk — not offensive. There is very little mucus — not enough to give a glossy appearance — and the move- ment should not be frothy. If the stools are green, slimy, frothy, and full of whitish lumps, the child has in- digestion. If the stools are, in addition, sharp, with a strong odor, and if the child has fever, an inflammation in the gastro-intestinal tract is present. In these cases the movements are so sharp and acrid that the buttocks and perineum of the infant are eroded, even ulcerated. AFFECTIONS OF THE DIGESTIVE OF G A NS 333 Such stools and such ulcerations are decidedly more common with bottle-fed infants. The nurse, in treating such a case, after following the physician’s orders, may seek to improve the condition of the mother by providing mental quiet, good air and food, and regularity of feed- ing and nursing the baby. Medicines, of which calomel is a favorite, are often given to correct the abnormal intestinal conditions. If blood appears in the stools the case is called melena neonatorum. The blood, unless in large amounts, is dark — almost black. The red color comes out if the napkin is wet with water. The nurse will notify the physician at once, as the condition is serious. Inanition Fever. — In the first days, before the milk comes, the infant may have a sudden rise of temperature — sometimes as high as 105° F., usually not over 103° F. In marked cases there are severe cerebral symptoms, even convulsions. The writer is very skeptical about these cases being due to starvation or thirst, but thinks that, more likely, they are due to bowel infection. Treatment consists of giving 15 drops of castor oil, a saline solution colonic flushing, much water to drink, and mother’s milk. Cool bathing for the fever or an ice-bag to the head may be needed should cerebral symptoms develop. Thrush or Sprue. — This is an affection of the mouth, due to the growth of a vegetable fungus on the mucous membrane. The fungus is called Saccharomyces albi- cans or Monilia albicans, and may readily be seen under the microscope. The tongue, gums, and inside of the cheeks are covered with a whitish pellicle, in spots or larger plaques, which cannot be as easily wiped off as can milk, but when rubbed hard leaves a bleeding surface. Thrush is due to uncleanliness. It may be favored by poor health, and, therefore, is commoner in weak, sickly, and premature infants, but it is always due to neglect of 334 disorders of the first weeks of life the mouth, and should not occur. In weak and prema- ture infants thrush, by interfering with the nourishment, and in rare cases by growing down into the stomach, may be the direct cause of death. The treatment requires persistence and care, especially in premature infants. After each feeding the mouth should be washed with saturated solution of borax, not boric acid. A piece of cotton is wrapped around the little finger, saturated with the solution, and with this the surface is gently gone over, removing all loose material. A daily application of a 2 per cent, nitrate of silver solu- tion will hasten the cure. After the application of silver nitrate 2 drops of castor oil are put in the mouth to allay the irritation. A weak peroxid solution is also helpful. No sugar preparations or honey are to be used, and care is necessary to avoid hurting the delicate mouth. Bednar’s Aphthae. Far back in the mouth, where the lower jaw is connected with the upper jaw and where the cheek runs into the pharynx, is stretched a ligament. Over this ligament the mucous membrane is very thin, and in appearance white. If the nurse, when cleaning the mouth, rubs too hard at the back of the cheek, she will rub off the delicate epithelium over the ligament mentioned and produce a superficial ulcer — perhaps one on each side. These ulcers, called Bednar’s aphthae, interfere with nursing because they are painful, and they may lead to infection, with fever and serious illness. Prophylactically, the nurse will use only the gentlest force in cleansing the mouth. A daily application of 2 per cent, nitrate of silver to the ulcer is a very efficient remedy. Marasmus. — This term is used to designate those cases of simple but obstinate wasting in infants. Pro- nounced cases of marasmus do not occur as early as the period with which we are dealing, but among premature AFFECTIONS OF THE RESPIRATORY TRACT 335 infants marasmus is one of the greatest dangers. The autopsies on children dead of marasmus show very little that is characteristic, yet the main symptom of the disease, excessive and continual wasting of the whole body, shows that the whole organism is profoundly affected. The disease is due to errors of nourishment, and there- fore occurs almost invariably in bottle-fed infants. It seems that such children cannot thrive on anything but the natural food, and will waste away and die in spite of the best care and most expert preparation of other foods. It must also be borne in mind that when an infant has actually begun to be marantic from im- proper nourishment, it may be difficult or impossible to get it to assimilate even mother’s milk. There is a strong hint in this fact — not to waste too much time in trying various foods, but if not speedily successful in getting suitable nourishment, to provide mother’s milk at any cost. The symptoms of marasmus are those of simple wast- ing: loss of weight, until the little body is almost skin and bone, protuberant belly, loss of appetite, indigestion, and extreme susceptibility to all diseases, which take on a very fatal character. Treatment may be summed up as follows: mother’s milk and fresh air with sunlight. AFFECTIONS OF THE RESPIRATORY TRACT Fortunately, newborn infants seldom suffer with se- vere pneumonia, bronchitis, etc., but a child may easily take cold unless proper care is observed, and, once started, a catarrh is not easy to cure. Snuffles is usually due to a slight rhinitis of innocent nature, but it may be due to a constitutional taint (syphilis), and the symptom should at once be reported 336 DISORDERS OE THE FIRST WEEKS OF LIFE to the physician. If it is attended with a skin eruption, a blood disease is all the more probable. For a simple coryza, a little warmed oil placed in the nostrils and rubbing the bridge of the nose with cam- phorated oil are sufficient. The condition disappears in a few days. Care is indicated in order to prevent the inflammation from going down into the lungs. The infant should be kept warm and not be allowed to get chilled when being changed or oiled. The bath had bet- ter be omitted for a few days. Bronchitis and Pneumonia. -In young infants in- flammation of the bronchial tubes is a serious matter, because pneumonia is so prone to develop. The causes are usually infection by the air or by aspirating infectious vaginal secretions during delivery. Children delivered by operations are much more likely to develop pneu- monia. Treatment is entirely symptomatic. The phys- ician may order stimulants, of which carbonate of am- monia is a favorite. Oxygen may be employed. Nar- cotics are usually rejected as dangerous. The wet-pack is the best means of reducing temperature. The nurse wrings a soft diaper out of water at a temperature speci- fied by the physician — usually from 85° to 90° F. — and wraps it loosely around the chest. Over it comes one layer of soft flannel. This pack remains in place two hours, when it may be renewed. The cool bath may also be used to reduce temperature. The water should be ioo° F. at the start, and be reduced to 94 0 F. while the infant is immersed. The bath should not last over five minutes. While in the bath the child must be watched for symptoms of shock. If weakened at all, a little whisky on the tongue and a warm- water bag are needed. The mainstay in the treatment is mother’s milk. With- out it few children recover. The child must be held in the arms a great deal, and its position frequently changed AFFECTIONS OF THE URINARY ORGANS 33 7 —this to prevent the blood from stagnating in the lungs. The air in the room must be warm, moist, and fresh. Only good nursing will save these little sufferers. Cyanosis, or Blue Babies. When a child is born with congenital heart disease, or when the wall between the two sides of the heart does not close fully, the blood is not completely oxygenated in the lungs, and the skin of the infant remains bluish or cyanotic. The hands and feet are cold. This disease has been called morbus caeruleus. These children may grow, but they die young, being extremely susceptible to outward influences, as overexertion, indigestion, the eruptive fevers, etc. Occasionally apparent recovery occurs. There is a condition in newborn infants, more common in cases of prematurity, where the lungs do not unfold and expand as they should. This is called atelectasis, and is very fatal. The children are blue, as the ones just described, but the condition is more quickly fatal. In either case if the child survives it becomes a narrow- chested weakling. Treatment is tonic in either case, and later on sys- tematic efforts are to be made to develop the chest by graduated muscular exercise and by all kinds of athletic sports to strengthen the heart. These must be taken under the control of a physician, to avoid overdoing it. Injurious influences should be held from the growing child, such as violent exercise, violent emotions, excess in diet, and extreme heat and cold. AFFECTIONS OF THE URINARY ORGANS Delayed Urination. -The nurse may notice that the infant does not urinate for a day or so after delivery, and inspection of the parts gives no reason for it. This delay is more common after operative deliveries, when the child has fever or jaundice, in the children of primiparae, 90 338 DISORDERS OF THE FIRST WE FA'S OF LIFE and in premature infants. If the parts are normal, no alarm need be felt. The babe sometimes passes water in the bath, and since the urine is colorless, this is not observed, or the stain on the diaper is likewise not seen. The physician may order a diuretic medicine, as sweet spirit of niter (spiritus aetheris nitrosi), and ask the nurse to give the child a great deal of warm water to drink. As aids may be used a moist warm dressing around the pelvis and warm stupes to the abdomen and kidneys. A warm sitz-bath may be given. The cathe- ter is rarely required. If the anuria is prolonged, the physician may pass the catheter to assure himself that the passage is free. Spontaneous cure is the rule. Uric Acid. -The napkins of the newborn are not in- frequently found to be stained with urine containing little reddish or brownish crystals. These are composed of uric acid or of urates, and indicate that the urine is con- centrated. These salts are occasionally found deposited in the kidneys. A free flow of urine washes them out on to the napkin. The child may cry with a little pain as the sharp crystals are passing. The symptom is similar in cause and significance to the anuria just con- sidered, and requires the same treatment. Phimosis. In boys the orifice of the prepuce is sometimes so small that the urine cannot readily escape, causing the infant pain and difficulty in urination. There is actual danger in this condition, because, since the skin cannot be retracted, the secretions decompose underneath and serious inflammation may result. The physician may dilate the preputial opening, he may in- cise it so as to allow the retraction of the skin, or he may perform the operation of circumcision. Circumcision. — Among orthodox Jewish families the ritual circumcision is performed when the child is eight days old. AFFECTIONS OF THE URINARY ORGANS 339 The nurse may see the ancient ceremony in all its in- teresting details performed by the ordained circumcisor — the “Mohel.” The anesthetic employed is whisky and water 1:4, with a little sugar added. A bit of soft cake is wrapped in a corner of a handkerchief, tied with thread, wet with the whisky, and given the child to suck a few minutes before and during the operation. The nurse will often be shocked by the lack of asepsis practised. Little can be done by the nurse to avoid in- fection of the wound, which not seldom occurs, although it is rare for the infant to die. Many infants have died from hemorrhage. If, as often happens, the ceremony is made the occasion of a large “party,” the nurse must see that the mother is kept free from excitement and too many visitors. Even in families that have dropped the stricter orthodox beliefs the circumcision is practised, but the physician almost always performs the operation. The nurse will make the usual preparations for minor surgery Only scissors, rat-toothed forceps, and a few artery clamps are necessary. Stitches may or may not be used. The anesthetic used by the “Mohels” may be employed, and the infant will usually sleep several hours afterward, by which time the initial pain is gone. It would be well for the nurse to have a styptic powder of dried alum in readiness, as sometimes there is obstinate hemorrhage. The infant is wrapped warmly and laid on its back, with the thighs flexed on the belly, and held by the nurse with hands covered by a sterile towel. The child must be held firmly, because, though simple, the opera- tion is delicate. The basin of hand solution and instru- ments are arranged conveniently as shown in Fig. 169. The first dressing, which may be moist or dry, accord- ing to individual operators, should be left on six or eight hours. The nurse must watch carefully for secondary 340 DISORDERS OF THE FIRST WEEKS OF LIFE Fig. 169. — Infant prepared for circumcision. Nurse stands on the left. On the right is a euchre table, protected with newspaper and sterile towel, holding basin of weak antiseptic solution and the instruments. The nurse’s hands are covered by a sterile towel. AFFECTIONS OF THE SKIN 341 hemorrhage. To remove dressings, they must first be soaked with sterile water. For the first two days the part is covered with a moist 1 per cent, boric acid dress- ing. After this a little vaselin may be used. Care should be taken to allow no gauze to adhere to the glans, and the diaper must be arranged so as to exert no com- pression. Should there be secondary hemorrhage, the nurse should wrap the organ tightly with gauze powdered with dry alum, and notify the physician at once. Until he arrives the nurse can exert constant circular com- pression and thus prevent serious loss of blood. Heal- ing takes place in from three to seven days, and the child may be peevish and fretful until the source of irritation has disappeared. Dilatation. — Some physicians make a routine practice of dilating the prepuce and drawing it behind the glans as a part of the daily toilet of the child. It may be necessary first to incise the edge of the orifice before the skin will go back. After the first retraction the nurse will be instructed to carry out the procedure. This is done by slowly slipping the skin back toward the pubis until the whole glans is exposed. Smegma is now cleaned off with vaselin, and the skin brought forward again. A lubricant is always applied. AFFECTIONS OF THE SKIN Jaundice. — A yellowish discoloration of the skin in newborn infants, called icterus neonatorum, in milder or severer gradations, is present in fully 40 per cent, of cases. It appears from the third to the sixth day, and affects the whole body. There are several theories as to its cause, as disorganization of the blood, inefficiency of the liver, causing an accumulation of bile in the blood, sepsis, etc. The writer believes that the worst forms are due to sepsis. 342 DISORDERS OF THE FIRST WEEKS OF LIFE In the milder cases the child is unaffected, but when the skin is very yellow, especially if the whites of the eyes are icteric, the general health of the infant suffers. In some cases eyen the secretions from the nose, eyes, and other orifices are yellow. The bowels are usually out of order, and the infant gains slowly. The physician may prescribe medicines, but the nurse’s duties will con- sist in providing an assured and adapted nourishment for the child, and giving colonic flushings to clear the bowel and to stimulate excretion of the bile by way of the kidneys and skin. The mother should be assured that the jaundice will fully disappear. Eruptions on the Skin. -The skin of newborn babies is not always clear and smooth at birth. The writer has seen infants born with blisters from pin-head to finger-nail size and with raised eruptions of various kinds. The skin of some infants desquamates completely after birth, the epithelium coming off in large or small flakes. The epithelium may loosen in the palms of the hands in a large piece, and the nurse will need to use care in removing it. Later the skin may desquamate as the result of fevers, or from intestinal disorders or toxemia, and the scaling much resembles that of scarlatina. Vesicular Eruptions. — Tiny water-blisters on a red base, occurring closely set around the forehead, neck, and in the body folds, are due to sweating and to too warm clothing, or to a tender skin after the use of water or soap and water. This is popularly called “red gum.” If there is no redness around the vesicles, the term “white gum” is applied. The scientific name for the affection is strophulus (this has nothing to do with scrofula) or miliaria. Prickly heat is the same affection, but in an aggravated form, with inflammation around the vesicles. All three are caused by the sweat-glands being oc- TREATMENT 343 eluded, allowing the sweat to accumulate under the closed openings of the glands in the skin. They all cause the infant more or less discomfort, but most dis- tress comes from prickly heat. Sometimes the blisters run together and form blebs, or they may become pustular, when the case is not simple, as above described, but belongs to a class of skin infec- tions some of which are serious and contagious. An eruption of irregular, reddish-brown spots with uneven borders, fading to a copper color, is strongly suggestive of blood taint in the infant. If with this the child has snuffles, and if the region around the anus is reddened, eroded, and cracked, the suspicion of syphilis is grounded. The nurse must exercise constant pre- caution that she does not infect herself through the child. Chafing, or Bcsema Intertrigo.— In fat babies the skin in the folds is likely to macerate and become irri- tated. A watery exudation occurs, which may decom- pose and cause little abscesses. This is especially common in bottle-fed infants. Treatment The treatment of all these affections, except that of constitutional eruptions, is based on the principles of absolute cleanliness and dryness of the affected skin. For the heat-rashes the child should be dressed in the lightest clothes, and on hot days left partly undressed, out of the way of drafts, for short periods during the greatest heat. The bath may be employed without soap, and the skin thoroughly dried without rubbing. The cloth is laid on the skin and the fingers are rubbed over it. Then stearate of zinc powder is applied to the affected parts. Finest powdered rice starch is also good. Powders containing boric acid should not be used. 344 DISORDERS OF THE FIRST WEEKS OF LIFE Boric acid powder irritates the skin. For the intertrigo the same treatment is employed, and the folds are kept apart with a thin layer of cotton or old linen, which is fre- quently changed. In some cases water acts as a direct irritant and must be discontinued ; this should always be done if the affection proves rebellious to treatment. Any other measure will be ordered by the physician. All eruptions should be noted on the record-sheet and shown to the physician. It must be remembered that insect-bites, irritating dye-stuffs, or insufficiently washed clothes may cause eruptions on the delicate skin of newborn babes. OTHER AFFECTIONS OF THE NEWBORN INFANT Enlargement of the Breasts.— A few weeks after birth the nurse may notice that the breasts of the infant are enlarged. They may contain milk, which the old German midwives called “Hexenmilch,” or witches’ milk. This engorgement of the breasts disappears un- treated. If the nurse rubs the surface too roughly or tries to squeeze the milk out, she may bruise the delicate organ and cause an abscess. In girls this is a very serious matter, as the gland is thus destroyed and the function of nursing rendered impossible. Treatment. —The breasts are bathed, carefully anointed with camphorated oil, padded lightly with cot- ton, and a smooth little breast-binder is applied and sewed on. This lies undisturbed for five days, when the engorgement will have disappeared. During the neces- sary handling of the infant, the fact of the breasts being engorged should be borne in mind and the region not touched. If an abscess forms, which is quite unusual under this treatment, it should be opened speedily to prevent com- plete destruction of the gland. The physician, there- OTHER AFFECTIONS OF THE NEWBORN INFANT 345 fore, ought to be apprised daily of the condition of the infant. Vulvitis. — In female infants a moderate inflamma- tion of the vulva may exist, and there may be consider- able mucous discharge. No treatment save cleanliness, care to avoid injury, and the application of albolene is necessary. Menstruation. — Once in about 50 cases of female infants a bloody, apparently menstrual, discharge ap- pears on the napkin. In one case it was so profuse that the little one’s health was affected. She was listless and limp for a few days. The bloody discharge almost never means anything pathologic, but it may, and should, therefore, be promptly reported. Treatment is usually unnecessary. In the case cited, 1 drop of ergot was given three times. Delayed Separation of the Cord. — In puny chil- dren and in cases where the cord was large and thick, or where a hemorrhage occurred near its insertion, the process of gangrene and separation of the cord is very slow and may be delayed beyond two weeks. The falling of the cord may be hastened by simple means. A little collar of cotton is made and saturated with 95 per cent, alcohol and placed around the base of the stump, which is then dressed as usual. Another method is to paint the stump and its insertion with 2 per cent, nitrate of silver. Only in rarest cases is it necessary to snip the remaining strands of tissue with scissors (aseptic). Granulations of the Navel. — These sometimes form and cause a continual watery discharge, at times bloody, from the depressed surface. To cure them early, wiping with 2 per cent, nitrate of silver suffices; later they may have to be ligated and cut off. 346 DISORDERS OF THE FIRST WEEKS OF LIFE INFECTIONS OF THE NEWBORN A child is sometimes infected before it leaves the womb by bacteria floating in the blood of the mother, but for practical purposes we consider the infant, when born, sterile. Being an aseptic medium, it is at once attacked by germs from all sides. These germs gain entrance through the mouth, the eyes, the navel, the vulva, and any accidental wound. The little one is very susceptible to infection, and if these germs are at all virulent, they may overcome the slight resistance it offers The duty of the nurse, therefore, is mainly to pre- vent infection of the newborn. The principle of this prevention is: asepsis of all things coming in contact with the eyes, the mouth, the navel, the genitals, and accidental wounds. Of course, those surfaces exposed to air will be contaminated by air-infection, but in pri- vate practice this danger is minimal, although in general hospitals, where pus is present, it must always be con- sidered. The fingers of the nurse may be soiled by lochial discharges or from handling bed-pans or other non-sterile articles, and without proper disinfection she may dress the navel or wash the mouth. The clothes of the infant may have been mixed with infected linen, the rubber nipples and other utensils used by the infant when feeding may not have been boiled, the milk may be impure — indeed, the sources of infection are innumerable. Infection of the Umbilicus. — The stump of the cord separates in two ways — by dry and by moist gan- grene. Dry gangrene is the normal method. Moist gangrene is the quicker, but more dangerous, and is ab- normal. Infection of the stump and at the line of union of the stump and abdomen shows itself by redness, edema, swelling of the skin, and an unhealthy appear- ance under the edge of the cord, even to the presence of a few drops of pus. There may be an odor to the cord, PLATE III The cord stump has dropped off, the base is covered with pink granu- lations, now being covered with epithelium. Infected umbilicus. Fourth day. Note, area of swelling and redness, the pus and the moist stump of cord. INFECTIONS OF THE NEWBORN 347 and the child may have fever, which may reach 103° F. In severer cases the navel may ulcerate, or an inflamma- tion may extend more or less over the belly, or the in- fection travels along the vessels inside the abdomen until the liver is involved, and general, fatal blood-poisoning results. The importance of asepsis of the navel may, therefore, be appreciated by the nurse. If there are any signs of inflammation about the navel, the nurse will re- port it to the physician. He may make tiny incisions into the inflamed area for drainage, and then apply a wet, weak, antiseptic dressing — 50 per cent, alcohol is some- times used. Antiseptic powders are preferred by some physicians. Should the cord become moist, with an appreciable odor, the nurse must correct the condition early, as it may lead to graver infection. The stump is wrapped in cotton, saturated with 50 per cent, alcohol, and then dressed as usual. Every eight hours this dressing is renewed, and three dressings will ordinarily suffice. Antiseptic powders, as boric acid, salicylic acid, iodoform, and starch, are occasionally employed. Infection of the Byes, or Ophthalmia Neona- torum. — Ophthalmia neonatorum is an acute purulent inflammation of the mucous membrane of the eyes of the newborn. While a few other germs may be causative, the most common cause is the gonococcus of Neisser, or the gonorrhea germ (Fig. 170). It gains access to the eyes from the vagina while the infant is passing through, or it is wiped into the eyes by the nurse or doctor when the infant is given its first attention (the bath, etc.), or it is allowed to get in during the first days of life from an infected bath-tub or the finger of the nurse, or perhaps the mother herself while the child is being handled. In whatever way the germ gains entrance, it quickly sets up a violent inflammation of the conjunctiva. At first the lids grow red, then there is a thin, irritating dis- 348 DISORDERS OF THE FIRST WEEKS OF LIFE charge, with yellowish flakes. After a few hours this be- comes purulent and the lids become so swollen that the eyes are closed (Plate IV). Unless active and constant treatment is instituted, the inflammation gains headway, the cornea may ulcerate away, and the whole eye be de- stroyed One-third of the blindness in the world is caused by this dreadful affection, and it is primarily venereal in origin. If ever a nurse has the opportunity to show of what she is capable, now is the time. Really Fig. 170. — Diplococcus of Neisser, the gonorrhea germ, taken from the pus of the eye. at least two nurses are demanded in a case of ophthalmia. Treatment must be unremitting, and each order of the doctor must be punctually carried out. Prevention. — If a woman is known to have gonorrhea, or if there is a foul discharge, the doctor may wish the vagina douched antiseptically several times during labor, and extra care taken that nothing gets into the eyes at any time. In all cases directly the head is born the face PLATE IV Acute ophthalmia neonatorum. INFECTIONS OF THE NEWBORN 349 is wiped with pledgets squeezed dry out of a weak bi- chlorid or lysol solution; then the lids may be opened, and warm boric solution allowed to flush out the con- junctival sacs. After this, the Crede method, or some equally reliable method of prevention, is used. If a case occurs or is suspected in a nursery where there are other children, the infant is to be isolated at once, sepa- rate utensils used for it, its clothes disinfected before being sent to the laundry, and the nurse should not touch anything that will be used for the other infants. Treatment. In the first stage of the disease the phys- ician may order ice applied to the eyes. If only one eye is affected, the nurse protects the other one by covering it with cotton and holding this in place with adhesive plaster. The arms of the baby must be bound down to the sides, so that infection may not be carried by them. The covered eye should be inspected every four hours for evidences of beginning infection. The application of ice to the eyes is shown in Fig. 171. A large piece of pure ice is placed in a sterile basin and saturated solution of boric acid is poured over it. Bits of sterile cotton the size and shape of a 5 -cent piece are moistened in the boric solution and laid on the ice to cool. The infant is placed on a warm- water bag, then on a pillow on a table, and snugly covered up. The nurse then seats herself comfortably at the head, and places the ice-cold pledgets on the lids, changing them every minute, and throwing the waste into a paper bag at the side. The order may be to keep up the application of cold for twenty-four hours and not to interrupt it while the child is nursing. The secretions must be frequently removed from under the lids, because they are very acrid and erode the deli- cate cornea. This is the great danger of the disease. For removing the pus from the eye the best method is a stream of saline solution or boric solution. The nurse 350 DISORDERS OF THE FIRST WEEKS OF LIFE arranges things as in Fig. 172. In the can or douche- bag is the solution as ordered, of a temperature of about 70° F. The bag hangs 20 inches above the infant’s head, and the tube is armed with an ordinary medicine- dropper tip, with a large opening. The force of the water must not be too great. The nurse arranges the Fig. 17 1. — Arrangement for application of ice to the eyes. child on her lap on a rubber drainage-sheet leading into a bucket. The left hand steadies the child; the right holds the point in the fingers, wdiile the ball of the hand rests on the side of the infant’s head, pressing it gently against the knee, thus steadying it. The point is directed at the inner corner of the lower eye, so that the force of the stream washes everything from under and from the INFECTIONS OF THE NEWBORN 351 inner corner of the lid outward. The infant usually opens the eye under the gentle force of the stream, but if it does not, the left hand may be used to separate the lids. Some nurses find it more convenient to place the infant Fig. 172. — Arrangement for irrigation of the eyes. The pledget in the left hand is placed against the cheek to prevent the fluid from getting into the nostrils and mouth. on a table, as in Fig. 171, for the eye irrigation. These irrigations may be needed for weeks or even months. The physician may make applications of nitrate of silver to the lids, or may prescribe the newer remedies, protargol or argyrol. Atropin is sometimes used to 352 DISORDERS OF THE EIRST WEEKS OF LIFE dilate the pupil, and the nurse should watch for its toxic effects. Conscientious nursing alone will save the light of day for the babe. Care of the Nurse Herself. During all this prolonged course of treatment the nurse should protect herself from infection. This is done, first, by never touching her own eyes during the treatment of such a case without pre- vious thorough sterilization of the hands; second, avoid- ing spattering solutions, used for irrigation, on her person or dress. Infection of the Mouth and Throat. — One of these, thrush, has already been considered. The gono- coccus may infect the throat, and the child may have a pharyngitis due to streptococci. The writer has noticed pharyngitis with fever more commonly in general hos- pitals that accept maternity cases. Cases are reported where the infection invaded the Eustachian tube, the middle ear, and thus reached the brain. A strepto- coccic septicemia may result from gastro-intestinal infection. HEMORRHAGES IN THE NEWBORN Quite a number of children are lost at a very early period of life through hemorrhage. This is a subject of which little is positively known. The newborn may have more or less profuse hemorrhage from the bowels — the so-called melena neonatorum, so named because the blood is black; there may be hematemesis; hemorrhage from the navel; from all mucous surfaces, or into the skin. The child may be a “bleeder.” The nurse can do nothing but compress a bleeding spot favorably situ- ated until medical aid can be obtained. The physician may order gelatin administered, or calcium chlorid or saline solution, or perhaps all three, and the nurse should make the necessary preparations. Nowadays hemor- OPERATIVE INJURIES 353 rhage is treated by the injection into the child of blood drawn from an adult, or of human blood-serum, or that of the horse or rabbit. OPERATIVE INJURIES During obstetric operations the nurse may marvel at the amount of force used by the accoucheur, fearing that both mother and child may be destroyed. While it is Fig. 173. — Left facial paralysis following delivery by forceps (Budin). true that in many cases both escape entirely, it is also true that in not a few cases both mother and babe are seriously and irreparably injured. Bones of the arm and leg are not seldom broken, the skull may be fractured, or a hemorrhage in the brain may be caused by difficult operative deliveries. Minor injuries are pressure-marks by the forceps on the head and face, facial paralysis, and bruising of the face, with swelling of the eyes. Infants born in face presentation are much disfigured. The 23 354 DISORDERS OF THE FIRST WEEKS OF LIFE lips are swollen and the face mottled with hemorrhages in the skin. The facial paralysis (Fig. 173), while it distorts the face a great deal, almost always disappears before the end of a week. The swelling of the eyes and face goes down in a few days. Pressure-marks left by the forceps crust over and dry, healing taking place underneath. If they are deeper, Fig. 174 . — Showing how a caput succedaneum is formed. extending into the bone, a bit of skin, or even a bit of bone, may ulcerate off, with the production of pus. The antiseptic care given ordinary surgical wounds is applied in these cases. Antiseptic solutions should be very weak when applied to infants, as they are susceptible to chemic poisoning. When the physician has set broken bones, the nurse will see that the dressings remain in place, sewing them OPERATIVE INJURIES 355 securely if necessary; that they do not become soiled by urine, vomit, or other discharges; that they do not cut the infant or cause chafing, and that the parts below do not swell from too tight bandaging. Injuries to the Brain. It is best for the infant if it comes into the world easily, without assistance from art. No matter how skilfully the accoucheur may deliver the fetus, his method is brute force compared Fig. 175. — Double cephalhematoma. This followed a spontaneous and rela- tively easy delivery. with the smooth process of nature, and almost always the infant suffers injury. True, this injury may be slight, or not even apparent at the time, but evidence is accumulating that birth-injuries lead to nervous dis- eases later in life, as headaches, imbecility, epilepsy, insanity. More light is needed on this subject. Diffi- cult operative deliveries may produce hemorrhages, small or large, in the brain. These may produce cyanosis, con- 356 DISORDERS OF THE FIRST WEEKS OF LIFE vulsions, and death within a few days, or, if the child recovers, permanent paralysis remains. Caput succedaneum is a swelling on the top of the newborn infant’s head (Fig. 174), found at birth, due to the pressure and venous congestion it undergoes during delivery. The edema disappears in from a few hours to a day. Cephalhematoma is a blood tumor on the cranium of the infant, lifting the periosteum from the bone (Fig. 175). It appears, after a day or so, as a roundish, soft, painless, fluctuating swelling on either side of the head. Depend- ing on their size, cephalhematomata persist for weeks or months, but they will gradually be absorbed. The mother’s fears may thus be allayed. Few physicians operate in such cases. CONGENITAL DEFORMITIES It is w.ell that monstrosities are so seldom capable of extra-uteiine existence, since they are not uncommon. Fig. 176. — Nipple for babies with cleft palate (Starr). When a monster is born, the nurse should not allow the mother to see it, and it should be hidden from the gaze of curious relatives or friends. The mother must never know she has given birth to such an infant. If the child is born with a harelip or a cleft palate, nursing may be so seriously interfered with that the general health may suffer. Mucus accumulates in the CONGENITAL DEFORMITIES 357 throat and may cause pneumonia. To avoid this the child is to be kept in a partly sitting position. The physician may provide a special nursing nipple for such cases (Fig. 176), or direct that the child be fed by gavage until strong enough to bear operation. Occlusion of the anus or imperforate anus the nurse will discover when she comes to take the infant’s temperature and by the fact that the bowels do not move. The physician is to be informed at once, as an operation must be immediately undertaken to make a Fig. 177. — Adhesive plaster applied for the cure of umbilical hernia passage. Occasionally the bowel is occluded higher up, and laparotomy may be performed. The result is al- most uniformly fatal. Tongue-tie is a very simple condition, but it may be the cause of the child’s not nursing properly, and is often overlooked. The tip of the tongue is attached to the gum of the lower jaw by a thin band. This should be nicked at the edge with scissors, and then torn back by the finger-tip. The physician is to do this, as there is sometimes persistent and perhaps dangerous oozing. 358 DISORDERS OF THE FIRST WEEKS OF LIFE Supernumerary fingers and toes should be re- moved when the child is a few weeks old. Hernia. Umbilical hernia is quite common, and is due to imperfection of the abdominal wall at the navel, and not to improper tying of the cord. Spontaneous cure is the rule, and this may be hastened by a 2 -inch strip of adhesive plaster, placed so as to hold the navel together from the sides (Fig. 177). First the skin should be disinfected and dried with alcohol. Inguinal and femoral hernias are rare. Premature children may have them. They often heal spontane- ously, although they are more likely to need a truss than the navel hernia. The prognosis is good. SUNDRY COMPLICATIONS Convulsions.- In the first three weeks infants may have spasms from cerebral injuries received during labor, such as fracture of the skull and hemorrhage in the brain ; second, from intestinal disorders associated with a gen- eral toxemia; third, from the so-called “starvation fever,” which the author believes is an auto-intoxication or in- fection; fourth, from tetanus or lockjaw infection; fifth, from cerebrospinal meningitis the result of infection, usually from the navel; sixth, from atelectasis pulmonum — this is commoner in premature infants. Very often, preceding the actual convulsion the child will show premonitory symptoms. These are twitching of the muscles of the face or extremities, stiffness of the jaws or of the body (in tetanus the stiffness of the jaw is marked), refusal to nurse, continual sucking or swal- lowing movements, a staring expression in the eyes, and a short, high-pitched, sharp cry without any apparent cause for it. When the nurse observes these things, or if she is surprised by the actual spasm, she will inform the physician at once. Little can be done until he SUNDRY COMPLICATIONS 359 arrives. Should the infant stop breathing after the con- vulsion, or if the cyanosis is too prolonged, a warm full bath may be given and a few drops of diluted whisky poured down the infant’s throat. Oxygen, if at hand, may be administered. The physician may order sedative medicines, as bromid and chloral, and ice to the head. lockjaw, or tetanus, is due to infection, usually of the navel, with the tetanus bacillus. Dust or dirt, nothing else, is the cause, and it means some lack of asepsis in the tying and cutting of the cord, or its after-care. The first symptom the nurse may note is the general illness of the child, then refusal to nurse, then stiffness of the jaws; now come rigid convulsions — the body may become as stiff as a ruler. Treatment has been fruitless, although perhaps with the antitetanus serum there may be more hope of saving the child. In hospitals care must be taken not to carry the infection from one infant to another. Complications Due to the Use of Hot-water Bag’s. -The hot-water bag itself should not be a com- plication of the first infancy, but it not infrequently is so. Nurses cannot be too earnestly admonished to watch warm-water bags applied to children and patients in general. If a bag leaks or if the cover or the child’s skin is moist, the danger is greater. The bag should never feel hot to the skin. The nurse should not trust the sensitiveness of the hand, because the skin here is tough and cannot judge high temperatures. The bag should feel just comfortably hot to the cheek. It must be well stoppered and perfect. The baby must be dry. The electric pads on the market also are not safe, but require watching. Breaks in the insulation of the wires may allow a short circuit and set the bed on fire. 360 DISORDERS OF THE FIRST WEEKS OF LIFE Overlying the Child. When the infant is permitted to lie with its mother, the latter, turning in her sleep, may strangle it. The nurse will find the child dead in the bed. In cases of illegitimacy the question of deliberate infanti- cide will come up. Asphyxia Neonatorum. —Children sometimes die of asphyxia while still in the uterus, but more often they are lost through this accident during or just after delivery. The asphyxia may be caused by too early separation of the placenta, by compression of the umbilical cord, or by pressure on the brain. Before delivery, the physician knows the infant is in danger of asphyxia by the irregu- larity of the heart-tones and the passage of meconium. Fig. 178. — The tracheal catheter. This should never be boiled, as it is woven and varnished. It is sterilized in bichlorid solution or formaldehyd vapor. There are two degrees of asphyxia, called asphyxia livida and asphyxia pallida, the first being mild, the lat- ter, severe. In livid asphyxia the child is dark blue and stiff and the face is swollen ; in pallid asphyxia the child is pale, except around the mouth, which is blue, the body is limp as a rag, and the heart beats faintly or not at all. Unless the child can soon be gotten to respire regu- larly, it will die. Treatment. — This consists of removal of foreign mat- ter from the air-passage, preservation of the body heat, and artificial respiration. The physician may aspirate mucus, blood, etc., that may have been drawn into the windpipe, by means of a tracheal catheter (Fig. 178), or he may hold the infant as in Fig. 1 79 and wipe the mucus from the back of the throat. By compressing the chest SUNDRY COMPLICATIONS 36l the mucus may be brought out of the trachea within reach of the finger. The infant is then placed in a hot bath (106 0 F.). Some physicians place the infant alter- Fig. 179. — Resuscitation, of an asphyxiated infant. nately in hot and cold water — a severe shock to the little one, and a procedure the author has never found necessary. In mild cases these measures suffice to bring about 362 DISORDERS OF THE FIRST WEEKS OF LIFE normal breathing, but in asphyxia pallida the respiratory apparatus is paralyzed, and the physician or nurse must perform artificial respiration until the nerve-centers re- cover enough to carry on the function. There are many methods of substitute breathing, but the nurse may practice only a few, the others being dan- gerous and for the physician to employ. A simple method is shown in Fig. 179. The child is supported by the feet, with the forehead resting on a Fig. 180. — Author’s modification of Byrd’s method of resuscitation of as- phyxiated infant. First motion. Expiration. Child is nearly inverted to allow fluids to run into the throat, from which they are removed by the finger. table, so that the head is pressed a little backward. Mucus, blood, etc., are removed from the fauces, and then, with the thumb over the back and the fingers over the front of the chest, the nurse makes light compression. This forces the chest together, and, by suddenly relaxing the pressure, the elasticity of the ribs opens the chest and air can be heard to rush in. This maneuver is repeated twenty times a minute. Another method, known as Byrd’s, consists in alter- nately folding and unfolding the child like a book (Figs. SUNDRY COMPLICATIONS 363 180, 18 1). Sylvester’s method, used so much in resus- citating drowned persons, may also be employed (Figs. 182, 183). It consists of alternately stretching the arms high above the head and pressing them down fast to the sides. The physician may insert a tube into the trachea and blow air directly into the lungs. Oxygen is some- times used, and with success. Fig. 1 81. — Author’s modification of Byrd’s method of resuscitation of as- phyxiated infant. Second motion. Inspiration. Child’s head is raised, and whole body strongly extended. Throughout all these procedures continual care is to be taken not to cool the babe too much. The skin is wet, the child shocked, and it refrigerates rapidly. In fact, sometimes the child dies because of too violent and prolonged manipulations intended for resuscitation. The hot bath, warm flannel receivers, and the warm- water bag, gentle friction with a warmed hand under cover, all tend to keep up the babe’s temperature. 364 DISORDERS OF THE FIRST WEEKS OF LIFE After the child has begun to breathe, it should be warmly clad, placed in an airy room surrounded by warm-water bottles, or, if there was much shock, in the incubator for a few hours. Fig. 182. — Sylvester’s method of performing artificial respiration. First motion. Expiration. The arms are pressed firmly against the chest. The infant is covered with a warmed towel during all these maneuvers. Infants revived from asphyxia occasionally develop a secondary asphyxia which is worse than the first, as it is due to atelectasis pulmonum or hemorrhages into its brain. The child is, therefore, to be carefully Fig. 183. — Sylvester’s method of performing artificial respiration. Second motion. Inspiration. The arms are stretched firmly above the head. watched for signs of returning cyanosis and for the char- acteristic grunt or moan. Since hemorrhage may occur in the brain, the nurse will watch for symptoms of cere- bral irritation, although treatment of such accidents is not hopeful. CHAPTER VI THE CARE OF PREMATURE INFANTS The care of premature infants requires the highest kind of nursing skill and the greatest self-sacrifice and devotion. The results, however, are gratifying in the extreme, as nearly every child that can respire and digest food can be saved. These children grow up and are strong, so that there is no argument for refusing them the necessary care. There is a popular notion that children of the eighth month of pregnancy have less chance of survival than those of seven months. This notion, like many others, is a popular fallacy, although it is very old, dating from the time of Hippocrates, who said that the weakness of the eight months’ child was due to its being tired with efforts to leave the uterus, whereas if it waited until the ninth month it was sufficiently strong. The longer the infant remains in the womb, the stronger it becomes, although if the pregnancy goes too far over time, the child may die. We regard as prema- ture all children born before three weeks of the normal end of pregnancy. Depending on the degree of prema- turity, the children present the following characteristics: They are small, weighing from 2 to 5 pounds; the skin is red, thin, and the blood-vessels show through; the body is partly covered with a fuzzy growth of fine hair called lanugo; the nose has little white comedones; the ears are soft and pliable; the child looks old, especially after a 365 366 THE CARE OF PREMATURE INFANTS week, when the loss of weight has occurred, and the little body is shriveled ; the cry is weak and whining, but most of the time the infant lies in a peculiar stupor; the temperature has a tendency to be subnormal and very irregular; the bowels are sluggish; the urine is scanty; later jaundice is usually marked. The initial loss of weight is relatively greater in prema- ture infants, and the return to the birth-weight is much slower, requiring some twenty to thirty days (Fig. 184). Since the appetite is often in abeyance, these little mites would starve to death unless fed forcedly. The lungs of premature infants are slow to unfold, remaining in a condition called atelectasis pulmonum. This is usually fatal, unless properly relieved. Latterly our knowledge of premature infants has in- creased, and we are more successful in rearing them. To be successful requires three things: first, mother’s milk; second, good nursing; third, a good incubator. That heat is absolutely necessary for premature infants was known since ancient times. In the Middle Ages premature infants were wrapped in the skin of a sheep with the wool on, or put in a jar of feathers. Later they were enveloped in cotton. Sterne, in the middle of the eighteenth century, relates how the child of a physician was raised by the “same artifice that one used to make chickens hatch in Egypt. He put his son in an oven, properly constructed, heated regularly, the temperature of which was regulated by suitable instruments.” Nothing came of this suggestion. In 1857 Denuce described a double-walled bath-tub, with water in the interspace, for the rearing of feeble in- fants. In 1866 Crede, of Leipsic, used an identical con- trivance, although he did not publish it until 1884. In 1880 Tarnier had Odile Martin, a poultry raiser of the Jardin de Plantes, Paris, constructed an infant incubator Fig. 184. — Premature infant’s weight chart. THE CARE OF PREMATURE INFANTS 367 on the plan of a chicken incubator. It was installed in the Maternite, and could hold several children. Winckel constructed a permanent bath in which the child floated, thus avoiding the rapid evaporation and to imitate Fig. 185. — Winckel’s permanent bath for premature infants. more closely the liquor amnii (Figs. 185, 186). This bath is obsolete now. Some hospitals have a double- walled room, properly ventilated and heated to 84° F. all the year round. The discomfort of the attendants and Fig. 186. — Winckel’s permanent bath for premature infants. the danger of spreading infection among these suscep- tible infants are the objections to this method. The individual incubator connected separately with the out- side of the house by an air-intake pipe is the best. 368 THE CARE OF PREMATURE INFANTS THE INCUBATOR OR COUVEUSE There are several, made of wood and of metal, on the market. Some open at the top, others at the front. Some, as the Auvard, are heated by hot-water bottles, some by hot air, some, as the Sharp and Smith, by hot water (Fig. 187). Most are heated by hot water, which is by far the best method, because the temperature is kept evenly. Most incubators have no automatic heat regulation, and with such the nurse must carefully watch the thermometer which is placed inside, and provide more Fig. 187. — The Sharp and Smith incubator. or less heat as needed. Both overheating and chilling are to be avoided. A few instruments have automatic heat regulation, but even here the nurse must occasion- ally consult the thermometer to assure herself that the thermostat (or heat regulator) is working properly. In all incubators heated by steam or hot water the nurse must see that the supply of water does not run low. This endangers the infant and also the apparatus. The ventilation of the incubator is highly important. The writer has never seen a closed incubator ventilate THE INCUBATOR OR COUVEUSE 369 properly unless it was connected with the air outside the building. All incubators of the box type require the lid to be left slightly open, to insure the infant an adequate fresh-air supply. This is especially necessary in summer. The air seems to stagnate. The incubator should be raised at least 2 feet from the floor, and should be free from exposure to drafts, dust, and chilling. It must be lighted, because for the first week the infant requires close watching. If an incubator of modern type cannot be obtained, one can improvise a warm nest for the infant by means of a large clothes-basket well lined with blankets, a soft pillow, and six or eight hot- water bottles. These are changed frequently. With constant attention such a makeshift will do better work than most of the incuba- tors on the market. Every city should be provided with an “incubator station.” This is a plant connected, preferably, with a lying-in hospital, consisting of several incubators and the necessary specially trained nurses, wet-nurses, and mechanical appurtenances. To these stations children could be brought, even from great distances, for that par- ticular care which special training and practice only are able to bestow. The station of the Chicago Lying-in Hospital is a model of this class, and deserves a short description here: As shown in Figs. 188 and 189, the incubators are of steel and glass, and embody principles of heating and air circulation used in no others. They are heated by a hot-water pan placed 5 inches below the infant’s bed. The boiler for heating the water in the pan may be seen at the right side. The system is identical with that used in the hot-water heating of houses. The heat regu- lator is above the boiler, and, once set at the desired temperature, requires no attention. The child is handled 24 370 THE CARE OF PREMATURE INFANTS through the two doors in front, and is fed through the sliding window on the left. On the left also is a box containing a glass of water. This is for moistening the Fig. 1 88. — Two of the incubators of the system at the Chicago Lying-in Hospital. air. The air, fresh from the sunny outside, is led by a 3 -inch flue directly into the box, passing through a cotton filter. The opening from the box into the heating THE INC UBA TOR OR COUVEUSE 371 Fig. 189. — Diagrammatic section of incubator system in Chicago Lying-in Hospital: a. Pipe bringing air from outside; b, damper; c, cotton filter; e, glass of water in moisture-box;/, screen to distribute air evenly under warming-pan; g, water-pan; h, flue conducting air into bed-chamber; j, bed; k, draft plate to lead air out of bed-chamber into flue l; l, escape flue; m, chimney; n, anemoscope; 0, ethyl-chlorid disks; p, lever; q, cover of air-flue over heater; r, hot- water boiler; v, gas-burner; x, air- vent to hot- water system; y, exit flue through ceiling; z, filling cup for the hot-water heating system. The dotted line shows the course of the air through the instrument. chamber of the incubator is closed by a sliding damper, by which the amount of air admitted to the apparatus is regulated. The air is heated by passing around a large 372 THE CARE OF PREMATURE INFANTS pan of water (connected by pipes with the water boiler on the outside), and, after circulating around the infant, is automatically removed through a flue on the top of the box. A little wheel in this flue (an anemoscope) indi- cates the current of air. The child lies in a basket sus- Fig. 190. — Incubator ambulance open, showing electric light, thermometer, infant’s basket with eiderdown flannel mattress, and coverlet. pended over the hot-water pan; the mattress on which it lies is of eiderdown. A delicate thermometer is fastened near the side win- dow, so that it may be easily read, and a hygrometer, to indicate the degree of moisture, hangs in the back. The room in which the incubators are installed has also THE INCUBATOR OR COUVEUSE 373 a natural ventilation through the ceiling to a space under the eaves, which is likewise ventilated. The schematic drawing will show the tortuous current of air; the nurse may follow the dotted line in its windings from below the floor, through the apparatus, and out through the ceiling. This is an ideal arrangement, as it provides a certainty of fresh, filtered, moistened air, and even in stormy weather precludes a draft through the incubator. Many children have to be brought from distances, sometimes of many miles, and for such transporta- Fig. iqi . — I ncubator ambulance closed, ready for transportation of infant. During transit the child is closely observed through a window in the top. tion an ambulance incubator is provided (Figs. 190, 191). This is a perfect incubator in miniature, with a circu- lating hot-water system heated from the outside by an alcohol lamp, well ventilated, and lighted by electricity. It is 21 inches long, 11 inches wide, and n inches high, and can be easily carried by one person. Care of the Incubator. The temperature should, as a general rule, be kept at about 87° F. It may fluctu- ate from 86° to 91 0 F. without being dangerous. If the infant is strong or less premature, or if it sweats too 374 THE CARE OF PREMATURE INFANTS much at this temperature, the regulator should be set at 86° F. or even 84° F. If the child is very premature or if its temperature persists in remaining low, the in- cubator must be warmer, being set at 91 0 or even 93 0 F. This, however, is seldom necessary for any length of time — two or three days at most, when a temperature of 87° F. is more desirable. With a little practice the nurse gets to know what degree of heat is best suited to the particular infant. As the child grows older the tempera- ture of the apparatus is maintained at 84° or 8o° F., and then the infant is placed inside only at night, being put in a warm basket during the day. With incubators without automatic heat regulation the nurse must consult the thermometer placed alongside the child, and increase or decrease the heat by the means provided in the particular apparatus. With a little ex- perience the nurse can judge by putting her hand inside the incubator whether the air is of the right temperature, but this must not be relied on. The moisture is important. In incubators of the style last described this is provided for by hanging a piece of gauze in the water-glass of the moisture box at the left. Should the hygrometer or, what is just as reliable, the dry mouth and lips of the babe show that moisture is needed, this may be easily accomplished by placing a small flat pan of water under the bed on the warming- pan. In incubators of the Auvard pattern the moisture is provided by a sponge hung near the head of the in- fant. This sponge must be wet frequently and sterilized daily, as it is not a clean thing. In summer less moisture is needed than in winter. The hot-water system of the large steel incubators re- quires little attention. The filling is done through the cup on the right side, and the system must be filled and water stand in the cup before the gas-burner is lighted. THE INCUBATOR OR COUVEUSE 375 Every day a little water is supplied to replace that lost by evaporation. In the old-fashioned incubators or in improvised bas- kets the hot- water bottles must be frequently changed. In those with steam boilers great care must be taken that the kettle does not boil dry. The Ventilation. — If the incubator is provided with a flue and wheel, or anemoscope, the nurse can easily see that air is passing through the apparatus by the motion of the wheel. This wheel must be delicate and sensitive, or it will fail to show the circulation of air. The nurse must see that the bearings of the wheel are free from dust and slightly oiled. Great care is necessary in hand- ling it because of its delicacy. If there is no indicator of this kind, and in box incubators, it is safest to leave the sliding cover or door open a trifle, and protected from drafts by hanging a towel over it. This is necessary in summer in all apparatus not connected with the outside air. In addition, the ventilator openings provided in the incubator are left free. In winter or in very windy local- ities those incubators connected directly with the out- side air need a little watching. While experience has shown that they can accommodate themselves to a change from 45 0 above to 8° below zero, and also func- tionate in a gale blowing 60 miles an hour, still the little life inside is so delicate and precious that one must be assured the apparatus is working properly. In winter the damper in the air-flue is kept almost closed; in sum- mer, wide open. The Bed. — The incubator bed should be of eiderdown. No rubber sheet is used. No pillow is needed. Some- times it may be necessary to lower the infant’s head, which is done by raising the foot of the basket. Cotton has been found objectionable as a mattress for the tiny 376 THE CARE OE PREMATURE INFANTS babies; it is used for the larger ones and after the little ones have developed. The Dress.- This should be of the finest wool flannel obtainable, and made as simple as possible. The idea of wrapping the infants in cotton and oil is a popular fallacy and costs lives. As soon as a premature infant is bom, it should be wrapped in warm wool flannel and placed in the incubator. If no incubator is at hand, until proper provision can be made the child, wrapped in a warm woolen blanket, is surrounded by warm-water bottles and kept in a very warm room. The nurse will note THE INCUBATOR OR COUVEUSE 3 77 how the necessity of heat is emphasized. The Chicago Lying-in Hospital has received 60 or more infants, completely refrigerated, even though oiled and wrapped in cotton. A simple bag, 34 inches long and 20 inches wide at the bottom, stitched around the neck, without sleeves, has been found the best (Fig. 192). It is open at the bottom, so that the infant may be “changed” without trouble, and long enough to double over and make a sort Fig. 193. — Incubator infant as it lies in the apparatus, showing the dress folded up over the body, making a blanket, and the shawl over the head and shoulders. of cover reaching to the shoulders. The child is covered by a light, wool-flannel blanket which makes a sort of hood over the head (Fig. 193) ; the abdominal binder is of wool, the diaper alone being of cotton material. After the child is removed from the incubator it natur- ally requires heavier clothing. Warm Feet. -Even in the best incubators the child’s feet may be cold; this is due to poor circulation. A warm-water bag should be laid under the feet, carefully 378 THE CARE OF PREMATURE INFANTS protected so that it shall not burn. The temperature of the infant, taken by the rectum, may be elevated by this warm-water bag, a fact to be borne in mind in reporting or recording a fever. The Diet. — Without question, mother’s milk is the food for premature infants, and should be obtained at any expense of money and effort. It must come from a healthy woman whose own baby is thriving. For this reason an incubator station is better connected with the lying-in hospital or it must have a staff of wet-nurses. Feeding must begin a few hours after birth to avoid exhaustion and to combat the great initial weight-loss. For the smallest infants from 5 to 20 drops of a two- thirds mother’s tnilk in water are given every thirty minutes with a medicine-dropper. If the child retains this, the amount is increased to 30 or 40 drops. After from twenty-four to thirty-six hours the intervals are lengthened to an hour, and later to two hours. Diet Table Used at the Chicago Lying-in Hospital For Infants Weighing Less than J Pounds 1st day, every 30 minutes, 15 drops: Water 1 part, milk 2 parts. 2d “ “ hour, 30 “ “ 1 “ 2 “ 3d “ “ “ 40 “ “ 1 “ “ 2 “ 4th “ “ 1 -V hours, 1 dram: “ 1 “ “2 “ 5th “ “ i\ “ 1 “ Pure mother’s milk. 6th “ “ 2 “ * i| drams: “ “ 7th “ “ 2 “ if For Infants Weighing Less than 1800 Grams (j lbs. 12 ozs .) Total quantity. Every hour about 1 st day 63 gm. ( 2 oz. \ dr.) 45 drops. 2d “ 127 “ ( 4 oz. \ dr.) 66 3d “ 151 “ ( 5 oz.) 4 drams. 4th “ 200 “ ( 63 ! OZ.) 2 U 5th “ 224 “ ( 7 oz. 2 dr.) 2 “ 15ml 6 th “ 230 “ ( 7 oz. 4 dr.) 2\ u 7th “ 263 “ ( 8| ! OZ.) 2 “ 45HH 8th “ 281 “ ( 9 oz.) 3 U 9 th “ 303 “ (10 oz.) • • • 3§ 66 THE INCUBATOR OR COUVEUSE 379 For Infants Weighing from 1800 to 2200 Grams (3 lbs. 12 ozs. -4 lbs. 9 ozs.) Total quantity. 1st day 120 gm. ( 4 oz.) .... 2d “ 173 “ (sioz.). ... 3d “ 247 “ (8oz.) 4th “ 281 “ ( 9 oz.) 5th “ 312 “ (10 oz.) 6th “ 347 “ (11 oz. 2 dr.) 7th “ 364 “ (11 oz. 7 dr.) 8th “ 393 “ (12 oz. 5 dr.) 9th “ 404 “ (13 oz.) Every hour about 75 drops. 2j drams. 2 i “ 3 i “ 4 4i 4 \ For Infants Weighing from 2200 to 2300 Grams {4 lbs. 9 ozs. -5 lbs. 4 ozs.) Total quantity 1st day 153 gm. ( 5 oz.) 2d “ 266 “ ( 8 oz. 5 dr.) 3d “ 299 “ (10 oz.) 4th “ 341 “ (n oz.) 5th “ 365 “ (n oz. 7 dr.) 6th “ 390 “ (12 oz. 5 dr.) 7th “ 400 “ (13 oz.) 8th “ 413 “ (13 oz. 3 dr.) 9th “ 418 “ (13 oz. 4 dr.) Every hour about 1 1 drams. 3 3h “ 3i “ 4 4* 4\ “ 4f “ 5 One cannot follow this table exactly, some infants re- quiring less, others more, than herein stated; some in- fants require diluted milk for weeks. A small child that is several weeks old requires more than a larger infant in the first days. Occasionally a 3 -pound baby will drink 1 ounce of milk every two hours. As a general rule the child is allowed as much as it can be induced to swallow, and the appetite varies day and hour. One must not overfeed, because of the danger of indigestion and regurgitation. The former invites intestinal ca- tarrh, while the latter may lead to choking and asphyxia- tion. On the other hand, one must give sufficient nourishment, because the spark of life is faint and the child cannot express hunger. Feeding must, therefore, begin soon after birth, and be carefully and consistently practised. If the infant does not get enough food, it will lose weight, it will lie in a peculiar stuporous condi- 380 THE CARE OF PREMATURE INFANTS tion, and will be subject to attacks of fainting, some- times with marked cyanosis. The amount of each feeding must be recorded, and if the infant nurses at the breast, it must be weighed on a delicate scale before and after nursing, the difference representing the amount obtained. The total in twenty- four hours gives the amount ingested by the infant. It Fig. 194. — The nursing bottle for prema- Fig. T95. — The feeding-dropper, ture infants. Capacity, 1 ounce. should be equivalent to about one-fifth of the child’s weight. Thus a child weighing 3 pounds should be fed about 9 ounces of milk a day. If the child shows any symptoms of indigestion, a little peptic salt is given with each feeding. Method of Feeding. — If the infant can suck and swallow, the milk is given by means of a small vial and THE INCUBATOR OR COUVEUSE 38 1 a tiny nipple (Fig. 194). If the child can swallow but not suck, the milk is dropped into the throat with a feeding-dropper (Fig. 195). The breast-pump that draws the milk, the bottle, the dropper, the nipples, etc., Fig. 196. — The practice of gavage. must always be sterile to avoid infecting the intestinal tract. Should the child neither suck nor swallow, it must be fed by means of a method known as gavage, introduced by Tarnier, of Paris (Fig. 196). This consists simply of 382 THE CARE OF PREMATURE INFANTS feeding by means of a stomach- tube. The tube used is a soft-rubber catheter, size 8, American scale, for the tiny babes, and No. 10 for the larger ones. It is attached to a small funnel or the glass part of a nipple-shield. When the proper amount of milk is obtained, which is done by means of a breast-pump (see Fig. 77), it is diluted and warmed, and the tube, etc., steril- ized. The infant is placed on the lap with the face upward and a little to one side (Fig. 196). The tube is filled with milk, clamped with the fingers, passed into the throat, and quickly into the stomach. A depth of 4 inches is usually right. The child swallows the tube sometimes with avid- ity. Then the measured quantity of milk is slowly poured in, taking care that air is not permitted to enter. Then the tube is withdrawn with a rather quick motion, the child is held quiet for a few moments, after which it is carefully replaced in the incubator on its side. The child must be watched for a few minutes to see that the milk does not regurgitate and strangle it. Fig. 197. — The teterelle, showing front and side view. Above and to the left a glass bulb to collect saliva that might flow down the tube. THE INCUBATOR OR COUVEUSE 383 Overfeeding is very prone to occur with gavage, therefore one must refer to the table herein given, and watch the infant for signs of distress, as abdominal Fig. 198. — The teterelle in use. distention, vomiting, indigestion, etc. Tiny infants are fed in the incubator through the side window or by partly removing the cover of those constructed on the 384 THE CARE OF PRE MATURE INFANTS box pattern, but after the child is strong enough it is fed on the lap of the nurse, in a warm room, and protected from drafts. For gavage one must remove the infant from the couveuse. As soon as the babe can be put directly to the breast, this should be done, as nothing can match the life-giving fountain. If the nipple is too large, or if the milk does not flow readily, a teterelle (Fig. 197) may be used. The nurse compresses the tube leading from the bulb with the fingers, the mother draws the milk into the bulb, and then the nurse allows it to flow into the child’s mouth (Fig. 198). A pump may be used instead. One should see that the infant has sufficient water. Since the interior of the incubator is warm and the skin is thin, evaporation is rapid, and, therefore, the little body dries out. If mother’s milk is positively unobtainable, we are forced to rely on substitute feeding. The Bath. -Premature infants should be handled as little as possible, because it is depressing to them. A bath such as is usually given to infants may throw them into collapse. The practice of smearing the infant with vaselin or sweet oil is bad, as it refrigerates the little body. The skin must be kept clean and the pores open or the infant will not thrive. As soon as the child is born it is covered warmly, and, in a hot room, the whole body is anointed with warm benzoinated lard. This is carefully and quickly wiped off, under cover, with a hot towel. The child is immediately placed in the incubator. If the infant is very weak the first dressing is postponed several hours or until it has recovered from the shock of birth and the unavoidable exposure afterward. Daily for the first week the whole body is anointed with finest benzoinated lard, an animal fat that sinks into the skin and furnishes a small amount of food. The face THE INC UBA TOR OR COUVEUSE 385 and buttocks are occasionally washed with warm water. When the infant is sturdier, it is given what is known as a “dip” every other day. This is a gentle immersion into water at 103° F. for not over thirty seconds. Then the little body is quickly lifted into a warm towel and dried. After this the whole body is anointed with the benzoinated lard. The bath as usually given is not employed until the child is quite vigorous. The Care of the Byes, Nose, Mouth, etc.— The eyes are not given any attention except ordinary cleanli- ness, and the same may be said of the nose, ears, and mouth. Extraordinary care must be used not to injure or abrade the tender mucous membranes, as the infant is very susceptible to infection, which may easily gain en- trance in this manner. Each morning the mouth may be washed with boric acid solution, but this is not needed if the tongue is clean. In girls the vulva must be handled with extreme delicacy and care be taken not to infect it. The buttocks are so tender that the skin cracks and in- flames easily, especially if the bowel movements, from indigestion or enteritis, are sharp and irritating. In such cases no water should be used, and the treatment de- scribed on page 343 should be minutely carried out. In boys the diaper should be applied loosely, thus avoiding compression of the delicate external organs. The meatus urinarius should be inspected frequently, as a tiny bit of dried secretion might stop the flow of urine. The infant must not lie long after urination or bowel movement before changing, first, because the discharges decompose quickly in the warm incubator and befoul the air in it; second, because the skin around the nates will become inflamed, and third, because it may lead to in- fection of the child. The change must be made quickly and gently, with the smallest amount of exposure, and the child returned to the incubator without delay. Some 25 386 THE CARE OF PREMATURE INFANTS incubators are arranged to allow this attention without removal of the child. General Care. -Every day during the anointing the infant is given a general massage. This comprises gentle rubbing of the skin, kneading of the muscles of the ex- tremities, and bending of the joints. That this must be extremely gentle and tentative at the start and more vigorous as the child grows stronger is not necessary to say. If the child is very premature, these attentions are given every other day. They are not omitted, because the infant needs some stimulation to bring it out of the torpid state in which it usually lies, and which disposes it to stagnation of the blood in the extremities and the lungs. The child should lie alternately on the two sides for the same reason. The temperature is taken by the rectum morning and evening, and every four hours if there is fever. Every other day the infant is weighed naked, and care should be taken that the little body is not chilled. For the weighing the babe is wrapped in a hot diaper. A record is kept of all these things. Removal from the Incubator. — This depends on the age of the child and the rate of growth. As a general rule, when the temperature remains normal for days, when the child is about 4J to 4J pounds in weight, we remove it to its cradle. This varies, of course; so the length of stay is from five days to six weeks. There should be no haste in removing the child, as it will thrive better in the apparatus, having less to contend with. Operative cases are removed when they have recovered from the shock of the delivery. Some infants, even though small, are uncomfortable in the incubator, and sweat profusely, cry, and are fretful. These cases, which are rare, do better in a warm crib. Often these symptoms denote fever due to some other cause, which, being relieved, the infant is comfortable again in the DISEASES OF PREMATURE INFANTS 387 incubator. The change from the incubator to the crib must be made gradually. If the incubator is of the box pattern, the lid is removed for part of the day. If the couveuse has automatic heat regulation, this must not be done, as opening the doors disturbs the thermostat; here the infant is gradually accustomed to being outside by being kept in a warm crib or on the nurse’s lap for longer and longer periods. After a while it is placed in the incubator only at night, and if it bears this treatment well, it is left in the crib entirely. THE PARTICULAR DISEASES OF PREMATURE INFANTS These children may have all the affections of full- term newborn infants. These illnesses are very severe, however, and the premature infant is subject to certain particular conditions. After atelectasis, sepsis carries away most of these mites of humanity, and the nurse’s main function is to guard against it at all points of entry. The entry is through the body orifices — mouth, nose, navel, especially the last — and from the gastro-intestinal tract and lungs. Infections of the navel are rare since the antiseptic treat- ment of the stump is practised. Infection through the lungs is not uncommon, but is hard to diagnose, as the symptoms of pneumonia are obscure. Fever is often absent and there is no cough. A fatal epidemic of bron- chitis was started in an incubator nursery in Paris from one of the wet-nurses who had caught an ordinary “cold in the head.” Forty children succumbed. Infection of the gastro-intestinal tract is easy to find, since there is usually diarrhea, with sharp, irritating, green, foamy, or offensive stools, and there are often fever, tympanites, and vomiting. The infection of the digestive tract may come from the mouth, from the air in the incubator, from the food given, 388 THE CARE OF PREMATURE INFANTS from the fingers of the attendant, and from the bottles, nipples, etc., used. The importance, therefore, of abso- lute and constant cleanliness needs no emphasis. The child sometimes suffers from simple indigestion. This is nearly always the case if bottle-feeding is neces- sary. Even with mother’s milk it may occur, being due to insufficient digestive power of the tract. The little organs are not sufficiently developed. The symptoms of indigestion are vomiting, loose bowels, with curds, but with less evidence of fermentation in the stools, and pro- gressive loss of weight. In treating these cases one must be sure that the infant is not being overfed. A small feeding is given several times to see if the stomach will tolerate it. The milk must be properly diluted. The simple addition of “peptic salt” to the milk will often correct the condition. Peptic salt is made by mix- ing i part of finest table-salt with 9 parts of best scale pepsin : } grain is given with each feeding. Thrush or sprue is commoner in premature babies than in others. It is due to uncleanliness and is pre- ventable. The treatment recommended on page 333 is practised, but the nurse uses greater gentleness not to injure the delicate mucous membrane of the mouth. Nasal Infection. —An affection which has been ob- served not infrequently at the incubator station of the Maternite in Paris, but with which we have had no ex- perience, is an ulcerative rhinopharyngitis due to decom- position of food which the baby regurgitates into the nares. Profuse discharge from the nose, soon becoming purulent, ulceration of the mucous membrane even to the bone, with the development of “saddle-nose” similar to that of syphilis, are reported. Sometimes this infec- tion causes a bronchopneumonia and general sepsis. The treatment is one of local cleanliness and antisepsis, which, however, is not easy to practice. DISEASES OF PREMATURE INFANTS 389 Cyanosis. —A frequent condition is what we call “cyanotic attacks” or “blue spells.” The infant sud- denly ceases to breathe, turns blue, and may die unless immediate action is taken. Sometimes, however, the attack passes over and the infant regains its color, but is apparently weaker. These blue spells are due to two causes, which are directly opposite in their nature; there- fore it is difficult to treat the condition. First, they are the result of weakness. Dr. O. W. Holmes says, “The little waif is too tired to pull at the twenty-four oars of respiration.” The babe simply forgets to breathe. The treatment of such a case is first to relieve the collapse by artificial respiration, a hot bath, and stimulation with a little coffee, a drop of whisky, or oxygen. If the nose of the child is stopped up sufficient obstruction may result as to cause death. Since the cause of the cyanotic attacks is exhaustion, it is important that the infant receive sufficient food and that it be assimilated. The feeding must begin right after birth; food should be given in small quantities, and then in increasing amounts as the stomach will tolerate it. The other causes of the cyanotic attacks are overfeed- ing and choking. If the stomach is overdistended it interferes with the heart’s action. Regurgitation of food may occur, when small particles may be caught in the trachea and strangle the infant. To cure this condition it is simply necessary to recog- nize the cause. To prevent the child from choking the nurse must watch it very carefully until its actions are well known, and it must be laid gently on its right side after the feeding. The child must not be left alone for a minute. In these cases the advantages of a modern in- cubator are apparent, as one may keep the infant under constant observation. Should the child be found choking, the nurse must at 390 THE CARE OF PREMATURE INFANTS once hold it up by the legs, and with the little finger, protected by gauze or a soft towel, seek to remove the obstruction from the throat. If this is not successful, the chest should be squeezed from before backward, in the manner illustrated in the section devoted to instruc- tion for resuscitating asphyxiated babies. As a rule, these means suffice, but if they do not, the tracheal catheter must be employed to free the air-passages of obstruction. Needless to add, the accident is often fatal, owing to the delay and difficulty in dislodging particles that have once gained access into the lungs. The most fatal complication of premature infants is atelectasis pulmonum. This means that the lungs of the child have not unfolded; the air, therefore, cannot get into them, and the child nearly always dies of more or less rapid asphyxia. Infants whose lungs have not unfolded do not be- come red or pink, but retain a blue color. They are often called “blue babies,” although this term should be reserved for infants born with heart disease. The ate- lectatic baby does not cry with vigor, but whines, and each expiration is attended by a grunt or a light groan. It has cyanotic attacks. Unless the child can be made to cry vigorously and naturally and the healthy pink or red be brought back to the skin, it will almost inevitably die. Gradually it becomes unconscious, and dies in spite of every attempt to restore the natural breathing. The means employed to cure the condition are the hot bath, getting the infant to cry by spankings and rubbings or electricity, artificial respiration, even forcible attempts to inflate the lungs with a catheter in the trachea. Convulsions in incubator babies are due to asphyxia or to indigestion, with toxemia, sepsis, and the causes act- ing with full- term children. (See p. 358 for details of treatment.) DISEASES OF PREMATURE INFANTS 39 In conclusion, a few words about the desirability of saving these weakling additions to society, Mothers often ask if the children will grow up to be vigorous and strong, and the question may be answered in the affirma- tive. Many of the children nursed in the incubator system at the Chicago Lying-in Hospital are being kept under observation, and are thriving. Older statistics tell of the successful rearing of these undeveloped children, and, to emphasize all, one may recall that Victor Hugo was a premature child, and was, in his own words, “colorless, sightless, voiceless, and so poor a weakling that all despaired of him save his mother.” CHAPTER VII INFANT FEEDING 1 Mothers’ milk, first and always, is the proper food for infants. The cemeteries bear witness to the truth of this statement. There is no doubt that infants nursed at the breast have a lower mortality and resist sickness better than bottle-fed babies. One would hardly believe that a healthy woman would refuse to nurse her offspring, yet it is true now and has been for centuries. Caesar re- proached the Roman women for giving their children to mercenary nurses, and moralists of all epochs have con- tended against the practice. Aulius Gellius, in his Attic Nights; Erasmus, in his Colloquies; Montaigne, in his Essays, and many others besides physicians refer to and condemn the custom. It has been said that no man be- came great who was raised on the bottle. The author is glad to bear witness that the modern woman is recognizing more and more the right of her babe to her personal care and to be nourished at her own breasts. The argument of the ancient philosophers is triumphing at last. Nowadays the mother considers it little less than a calamity when she cannot nurse her infant. Unfortunately, many women have undevel- oped breasts or a gland that secretes nothing, or nipples that a child cannot grasp, or her general health is so poor — from tuberculosis, for example — that nursing is 1 This chapter was thoroughly revised by Dr. F. X. Walls. 392 CONTRAINDICATIONS TO MATERNAL NURSING 393 impossible. In these cases a wet-nurse must be em- ployed or artificial feeding be instituted. Contraindications to Maternal Nursing. -These are: General poor health from tuberculosis; severe anemia; advanced Bright’s disease; severe epilepsy, insanity; diabetes; diseases of the breasts, as abscess and mastitis; absence of nipples; inverted nipples, and when the milk does not agree with the infant. Honest effort should be made to get the breasts into a condition satisfactory for nursing, and patience should prevail. If the mother cannot nurse her child, the employment of a wet-nurse should be suggested. This is usually met with great disapproval or even absolute refusal, but the nurse should aid the doctor in trying to convince the family that human milk is best for the baby. Often one will have to compromise on bottle feeding for a time to see if it agrees well, with the understanding that if the child does not thrive, a wet-nurse is to be obtained. For premature infants or those that are not flourishing on bottle feeding no compromise may be made — mothers’ milk must be obtained at any expenditure of effort or money. If the mother can nurse part of the time, it is better than nothing, and prepared milk is given to complete the feeding. Mothers’ milk is a living thing, not simply nourishment, and this is the reason it cannot be success- fully imitated. It contains a living ferment. The author has seen tiny infants brought to the maternity starved, weak, and faint, and after even a single nursing they have revived as if strong cordial had been admin- istered. It is often observed that when the mother’s milk does not agree with the infant, or when there is an insufficient supply during the first weeks, the conditions disappear after the mother has gotten up and out-of- 394 INFANT FEEDING doors and has gone about her usual duties. The quality of the milk seems to alter. Sometimes the mother’s milk is too rich in fats, as evidenced by the regurgitation of heavy curds and pass- ing of undigested movements, with colic. To remedy this let the child have \ ounce of pure water before nursing, and reduce the time of nursing to ten minutes or less. If there is too much sugar in the milk, as shown by colic, green stools, and diarrhea, the same treatment is given. For the first condition — excessive fats — the physician may advise the patient to live on a more vegetarian diet and drink more water. She is made to take outdoor exercise, especially walking. For the excess of sugar in the milk a reduced diet with much water will also be recommended, but the patient may have some meat. If the milk is poor in fat and proteins, as shown by chemic analysis, a full diet of meat, vegetables, and cereals will be ordered. If this does not improve the quality of the milk, the child will need additional feedings. If the mother can give but one or two nursings a day she should be urged to do so, or if a permanent wet-nurse cannot be obtained, some poor mother might be gotten to come to the house once or twice daily to feed the infant, a sort of visiting wet-nurse, or mothers’ milk might be procured from a neighboring maternity. Obtaining- Milk for Analysis. — For chemic anal- ysis of human milk at least 2 ounces are needed. This is obtained with a breast-pump which has been pre- viously boiled in plain water. The first milk is discarded unless the amount promises to be scanty, and the last milk — the “ strippings” — is not used, as it contains too much fat. The milk is poured into a clean, dry, sterile bottle, corked (not with cotton), and sent to the labora- SUBSTITUTES FOR MOTHERS' MILK 395 tory. The best test of the quality of the milk is the condition of the child. Substitutes for Mothers’ Milk. — Of these, many are vaunted, but few even come near qualifying. Cows’ milk is most generally used, modified to suit the require- ments of the individual child, but goats’ milk and asses’ milk have also been tried, both here and abroad. In chemic composition asses’ milk comes nearest the human, and in Paris, at one of the maternities, the experiment of using such milk was tried, but with indifferent success. Cows’ milk must be “modified” before it is a suit- able food for an infant. The term “modified milk” means milk that is altered or changed by the addition of water, sugar, etc., and these modifications are un- limited. The principles which underlie the modifica- tion of cows’ milk for infant feeding are two: First, to change the cows’ milk into one resembling as closely as possible human milk, and, second, to adapt the milk to the nutritive requirements and digestive possibilities of the individual infant. It is essential that the composition of human and cows’ milk be known. Table of Two Milks Compared Human. Cows'. Fat 3.5 per cent. Protein 1.5 4.0 Sugar 7-o 4-3 “ Salt 0.7 Water 87.3 87.0 “ The chief differences in these milks, chemically con- sidered, are in the proteins, the sugars, and the salts. The fats are in the same proportion in the two milks, though not of the same kind. In the human milk the 39 6 INFANT FEEDING fats are less acid and more easily assimilated. The protein of cows’ milk is nearly three times greater than that of human milk, and is also very different in its com- position, containing a larger amount of casein than human milk. The sugar in cows’ milk is less than that of human milk and is of the same kind, known as lactose or milk-sugar. The salts in cows’ milk are three times in excess of those of human milk, and, according to recent research, the difficulty in the digestion of cows’ milk is in great part dependent upon the excess of salts and their different chemic composition. From the foregoing it may be seen that if milk were diluted with twice as much water the proportion of protein and salts would approximate the amount found in human milk, but with this dilution of milk the fats and sugars would be greatly reduced, and it would be necessary to supply these two ingredients to have the mixture resemble human milk. This may be done by adding cream and milk-sugar to the mixture. Such a mixture as the following closely resembles human milk: Cream i part. Milk i “ Lactose solution (5 per cent.) 4 parts. To render the mixture alkaline an alkali is to be added, such as lime-water, 5 per cent., or bicarbonate of soda or citrate of soda, 2 grains to 1 ounce of pure milk. Such a food might meet the first indication in the modification of cows’ milk, but it might not agree with the second. No matter how closely cows’ milk is made to approach human milk, there is always a great differ- ence between them, and the digestive peculiarities of the infant may demand special modification. In practice it is important, when giving a cows’ milk mixture to a SUBSTITUTES FOR MOTHERS' MILK 397 young infant or to any child for the first time, to begin with a much weaker food than the nutritive requirements of the child would indicate, and as soon as the child’s tolerance for milk will permit the strength of the formula may be cautiously increased. The mixture, when first given to an infant, should be boiled at least three to five minutes. Boiling kills all bacteria in milk and renders it easier of digestion by making impossible the formation of large curds in the baby’s bowels. No attention need be paid to the re- puted constipative effect of boiling milk. There exist in most large cities laboratories for the modification of milk, of which the Walker- Gordon laboratory is a type. This labora- tory bears the same relation to the physician regarding the infant’s food as does the pharmacy regarding drugs. The physician writes a prescription calling for milk having certain percentages of fat, sugar, and proteins, stating the amount of each feeding and the number. The laboratory prepares, or modifies, the milk exactly according to the prescription and sends the bottles neatly sealed, in a special basket, to the patient’s house. A sample prescription is here given: 1$. For Baby Johnson, 1200 Calumet Avenue. Fat 3.0 per cent. Sugar 6.0 “ Proteins 1.0 “ Alkalinity 5.0 “ Heat at 155 0 F. Number of feedings, 7. Amount at each feeding, 4 ounces. June 1 , igij. John Smith, M. D. In the absence of a milk laboratory, or where this is prohibited on account of expense or by preference, the nurse may modify cows’ milk at home with just as good success. The laboratory is convenient, but not neces- sary. In practice she will need cream, milk, milk-sugar or maltose, sterile water, and sodium citrate (Fig. 199). 398 INFANT FEEDING Bottled milk is most convenient to use for this pur- pose. In cities bottled milk is always obtainable. Bottled cream of a fairly constant percentage — about 1 6 per cent. — is also sold. In the country and in towns freshly skimmed milk may be used as fat-free milk, and the skimmed cream for the cream dilutions, as it con- tains about 1 6 per cent, of fat. If one has bottled milk, it is best to use it for all the modifications unless the exact percentage of fat in delivered cream is known. Fig. 199.— Apparatus required for milk modification. The cream is obtained from the top of quart bottles of milk that have stood for eight hours. The upper 6 ounces contain about 16 per cent, of cream. Milk is obtained from the bottom of the same bottle. The lower 8 ounces are used as fat-free milk, being almost free from cream, and this milk furnishes a part of the proteins for the finished product. It must be remem- bered that cream or upper milk contains almost as much proteins as the whole milk — that is, 4 per cent. The “upper” and “lower” milk can be obtained by siphon- SUBSTITUTES FOR MOTHERS' MILK 399 age. A drinking-tube is bent V shaped, so that one limb is 4 inches and the other 8f inches long. A piece of rubber tubing 8 inches long is also provided. To obtain the cream or “ upper milk/’ the rubber tube is Fig. 2oo. — The milk siphon in action. fastened on the long arm of the V-tube, the tube is then filled with sterile water, and the rubber clamped with the fingers. The short end is immersed in the bottle, and the cream will flow over into a graduate held underneath (Fig. 200). 400 INFANT FEEDING To obtain the “ under milk ” the same tube is used, but the piece of rubber tubing is attached to the shorter limb. The tube is filled with sterile water, the end of the rubber tube is clamped by the fingers, and the long glass end is put in the bottle. Its lower opening will come close to the bottom of the bottle and fat-free milk will siphon over into the graduate. One may pour off the cream from the top of the milk, or one may dip it out with a special little dipper, but with a little practice the nurse will become dextrous with the siphon, and it is the best and cleanest way. Two of the ingredients for modi- fied milk are now at hand — 16 per cent, cream and fat- free milk As a diluent boiled water is used, though sometimes other liquids, as barley-water or oatmeal- gruel, may be preferred. Milk-sugar may be weighed or measured out in the powder. If maltose is preferred, it is obtained in one of the malted milk foods or dextri- maltose. In practice the nurse dissolves the sugar in sterile water, adds the soda, and filters the solution through sterile absorbent cotton if it is not clear. Now the re- quired amounts of milk and cream are added, the whole poured into the thoroughly cleansed bottles, stoppered securely, sterilized, and set away in the ice-box. Amount of Food at a Feeding. — The amount of food will vary according to the age and individuality of the infant. A general rule might be stated, that the amount of food in twenty-four hours should equal one- sixth to one-eighth of the baby’s weight. If a baby weighed 12 pounds, the amount in twenty-four hours would be between 24 and 32 ounces. In the first six months the babe might have at each feeding an amount in ounces equal to its age in months plus one. The interval between feedings should be of such length as will permit ample time for digestion. A four- AMOUNT OF FOOD AT A FEEDING 401 hour interval during the first year, even from birth, is the optimum period. Many children need food oftener, therefore in practice they are fed every three hours, which is the minimum period that food should be given to a normal baby. The infant should be allowed from ten to twenty minutes to take his bottle. If the food is taken too hurriedly, indigestion may result, and if too long a time is occupied with the bottle, the interval be- tween the feedings is encroached on. The table presented here is for an average infant. A small infant will require less; a large one, more. The frequency of the feedings will corre- spond with that of the usual nursings. Period of life. Number of feedings. Hours between feedings. Night feedings. Amount of each feeding. Total for twenty-four hours. 3d to 7th day 7 3 I l|-2 OZ. IO-15 oz * 2d and 3d weeks . . 7 3 I 2 ~3 j OZ. 15-22 OZ. 4th and 5 th weeks 1 6 3h O 3 §~4 oz. 20-24 OZ. 6th week to 3d month 5 4 O 4 "5 oz. 24-32 OZ. 3d to 6th month.. . 5 4 O 5 -7 oz. 30-35 OZ. 6th to 9th month . 5 4 O 6|-8 oz. 32-40 OZ. 9th to 12th month. 5 4 0 1 7 -9 oz. 35-45 oz. For feeding infants during the first four weeks the following formulas may be used: Sample Formulas Formula No. I — Useful from the third day to end of second week: The nurse will take Approximate percentages. Cream (16 per cent.) 2 ounces. Fat 2.0 per cent* Milk None. Proteins 0.5 “ Lactose (milk-sugar) 5 drams. Sugar 5.0 “ Sodium citrate 4 grains or 7 drams of lime-water. Sterilized water to make. . . 14 ounces. Divide into seven feedings, 2 ounces each. 26 402 INFANT FEEDING Sample Formulas Formula No. II — For use in the third week: The nurse will take Approximate percentages. Cream (16 per cent.) 2 >\ ounces. Fat 2.5 per cent* Milk None. Proteins 0.6 “ Sugar (lactose) 1 ounce. Sugar 5.5 Sodium citrate 7 grains or 10 drams of lime-water Sterilized water to make. . . 20 ounces. Divide into seven feedings, 3 ounces each. Formula No. Ill — For use in the fourth week: The nurse will take Approximate percentages. Cream (16 per cent.) 4 ounces. Fat 3.0 per cent. Milk 1 ounce. Protein 1.0 “ Sugar (lactose) 1 “ Sugar 6.0 “ Sodium citrate 10 grains or 10 drams of lime-water. Sterilized water to make. . . 21 ounces. Divide into six feedings, 3^ ounces each. The Caloric Method. —Experiments have proved the infant’s stomach requires three to four hours for the digestion of a feeding, which is more time than is usually allowed. It has been found that the indigestion usually laid at the door of the proteins is often due to too much fat, and the troubles ceased when whole milk was substituted for cream in the feeding mixtures. Overfeeding, as to time, amount, and concentration, has been oftener recognized as the cause of trouble than underfeeding. Thus the need has been felt for some check on the amount of food which the infant should receive, and Heubner, of Berlin, has suggested the caloric method. The calorie, or heat-unit, is the amount of heat required to raise the temperature of a kilogram of water i° C. In the human these heat-units or calories are derived from the food. An infant before the sixth month requires not more STERILIZATION OF MILK 403 than 45 calories per pound of weight daily, therefore a child of 10 pounds would require 450 calories in its daily food. About 30 calories per pound are used for supplying heat and energy, the balance being used for regeneration of tissue and to provide for growth. 1 gram of fat contains 9.1 calories. 1 “ protein contains 4.3 calories. 1 “ carbohydrate contains 4.3 calories. 1 ounce of cream (16 per cent.) contains 54 calories. 1 “ milk (4 per cent.) contains 21 calories. 1 “ skimmed milk contains 10 calories. 1 “ whey contains 7 calories. 1 “ sugar contains 120 calories. 1 “ malt contains 100 calories. 1 “ flour (barley, wheaten) contains 100 calories. 1 “ most proprietary foods contains 100 calories. By multiplying the number of ounces of these ingre- dients in the total daily amount of food by their caloric equivalent we obtain the total calories ingested, and may decide if the infant is obtaining too much food. Filling the Bottles. — Smooth, round bottles are preferred for nursing (Fig. 201). They are thoroughly rinsed with water and cleaned out with a brush and soda if there is any scum on the glass. Then the bottles and a funnel for filling are sterilized. For convenience, the feeding bottles, funnel, siphon, graduate, and mixing bottle are all sterilized at once at the beginning of the preparation of the infant’s food for the day. An Ar- nold sterilizer is very good for this purpose. The siphon and tube should be rinsed clear after each using. If a scum settles on the glass, a few drops of nitric acid will dissolve it. The bottles are filled with the required amount of modified milk, stoppered with plugs of non- absorbent cotton, and sterilized. Sterilisation of Milk. Heating milk to the boil- ing-point (2 1 2 0 F.) renders it easy of digestion Some pediatrists prefer to heat the milk only to 155 0 F. This 404 INFANT FEEDING has been found to render the milk sufficiently sterile, and does not alter its taste. The process is called pas- teurization, after the inventor, Pasteur. A special pasteurizer is, of course, desirable, but the nurse can do very well, with a little more trouble, by using a tin pail large enough to hold the seven bottles and tall enough to allow the lid to be adjusted. A thick towel is laid at the bottom of the pail, the bottles set on it, the pail three-quarters filled with cold water, and quickly brought to a boil. Just before the water begins to boil the pail is re- moved from the stove and set in a cool place When cooled, the bottles are placed on ice (Fig. 202). The nurse may, also, bring the water up to 155 0 F., as shown by the thermometer, and hold it at this temperature for fifteen minutes. Before feeding, the milk is heated to 95 0 F., a plain, freshly boiled rubber nipple is used, and the baby fed by hand. It is a bad practice to adjust the bottle so the infant can feed itself. The child loses the nipple or sucks air, or the milk flows around its neck, wet- ting the dress and bed and causing colds. Milk not drunk at the nursing is to be thrown away. After nursing, the bottle and nipple are thoroughly rinsed inside and out and set aside in a clean place for sterik ization. Milk must not be kept in a vacuum bottle, warm, ready for night feedings. Quality of the Milk. — Milk from a herd of cows, or “mixed milk,” is better than “one cow’s milk,” as the variations of the constituents are not so great Milk Fig. 201. — A hygienic nursing bottle. QUALITY OF THE MILK 405 from the fancy breeds of cows should not be chosen. Experience has shown that the hardy breeds, Durham, Ayrshire, and Holstein, give the best milk for babies. In cities to which milk has to be transported from long distances pasteurization or sterilization is usually neces- sary, and always in summer. If the milk is obtained under aseptic precautions, as do the Walker- Gordon companies, the “certified milk” firms, and a few others, raw milk may often be used, though the author prefers Fig. 202. — Old-fashioned ice-box with milk rack standing in ice- water. to sterilize it in addition. “Certified milk” is a milk that comes from disease-free cattle that are properly fed and pastured, hygienically stabled and groomed before milking; a milk that is received in sterile cans through a gauze and absorbent cotton filter, quickly cooled to a temperature below 40° F. and kept at this temperature till it reaches the consumer, a period which should not exceed twenty-four hours. For the methods of modification recommended in this chapter milk bottled on the farm is necessary. 406 INFANT FEEDING Where bottled milk is not procurable, skimmed milk may be used for the “lower milk” and the cream that has been skimmed off used for the “upper milk.” The nurse must be sure that the milk is fresh, that it is not contaminated by standing uncovered, or by being left in a refrigerator together with decaying vegetables or meat. Milk attracts the odors of other things in the refrigerator and acquires a foreign taste. A special little refrigerator ought to be used for the milk, and the bottles, if they are kept at a low temperature, should be immersed up to their necks in ice-water. Before a bottle is opened the outside should be carefully cleansed. Abso- lute asepsis must prevail in the handling and the modi- fication of milk. A slight browning of the milk, heated with lime-water, is due to caramel. A convenient method for the home modification of milk is the “materna” glass (Fig. 203). This is a large paneled graduate with the amounts of the various ingredients needed for modifying milk to suit the different periods of infancy stamped in the glass on each of six panels. Whey. —If the “lower milk” is coagulated with rennet or junket tablets or essence of pepsin and the curd strained off, the liquid remaining is the whey. To make whey, the nurse takes 1 pint of milk at body temperature BARLE Y- WA TER 407 and adds J grain of rennet or one-half a junket tablet, dissolved in a little water. In thirty minutes the curd has formed. The mixture is strained through a napkin without too firm pressure, and then placed on ice. If it is to be added to cream, the whey must first be heated to 1 55 0 F. for ten minutes, or the cream will curdle. Whey is a valuable food, especially in weak, premature infants, and in cases of indigestion, where human milk cannot be obtained. It contains 0.5 to 1 per cent, of proteins, 4 per cent, of sugar, and o to 1 per cent, of fat. It may be used instead of skimmed milk, and may be added to the various modifications given in this chapter. It will often be borne by weak stomachs when nothing else agrees. The reason for this lies in the fact that the proteins of whey are more digestible and resemble more the proteins of human milk. Peptonized milk is sometimes used for a limited period. (See Dietary, p. 456.) Barley-water. — Notwithstanding the theory that very young infants do not digest starches, the writer has found that many of them will exist on barley-water for several days and that digestive disturbances will subside under its use. It is also useful as a diluent instead of boiled water, and may increase the digestibility of cows’ milk. Barley-water is prepared as follows: Two tablespoon- fuls of pearl barley are washed, then soaked in water for three hours or more. This water is decanted, and 1 quart of fresh water added. The mixture is allowed to boil two hours, adding water to keep up the amount — 1 quart. Strain through fine cheese-cloth. A pinch of salt may be added Keep on ice. A quicker method is practised by means of Robinson’s barley flour. Twelve ounces of water are slowly stirred into an even tablespoonful of the flour in a bowl. The 408 INFANT FEEDING mixture is then boiled fifteen minutes and strained as before. Oatmeal-water is prepared as is barley-water. This is used where the child is costive. If diarrhea exists, barley- or rice-water is preferred. Beef-juice. — Even very young infants may need a preparation of beef, although the occasion is rare. Beef- juice is best prepared by lightly broiling a piece of lean, tender steak and pressing out the juice with a meat- press or lemon-squeezer. A little salt is added, the required amount taken, and the balance immediately put on ice. The Cold Method . — Meat is chopped fine, put in a Mason jar, and water (one-quarter by bulk) is added. The mixture is allowed to stand for one-half hour and then squeezed through a meat-press. Sometimes a few drops of hydrochloric acid are added or a pinch of salt. Beef-juice may be added to modified milk, to barley- water, or given plain, well diluted. Extract of beef is useless for infant feeding. Com- mercial preparations of beef — as peptonoids, beef-jelly, etc. — are seldom, if ever, needed. The writer believes that fresh meat-juice prepared at home is better than preserved stuffs. Artificial Infant Foods. — Of these, there are a host of advertised preparations, including condensed milk. The nurse will not be called upon to recom- mend any given brand of food. In spite of the beau- tiful pictures in the advertising columns of magazines, these foods are generally harmful when used without medical supervision. The physician may prescribe this or that food when he sees that the child requires the ingredients the given food possesses, but the nurse is not expected to do this. There is no doubt that rickets, ARTIFICIAL INFANT FOODS 409 scurvy, and other constitutional diseases and weaknesses are traceable to proprietary foods. Babies that are fat from these foods are usually not healthy babies. Proprietary foods may be used to help out the breast nursing, to provide starch for modified milk when this is desired, when the child is weaned, and for temporary feeding at other times, all of which are decisions to be made by the medical adviser. APPENDIX VISITING NURSING IN OBSTETRIC PRACTICE In many large cities eleemosynary visiting nurses’ associations provide for the home care of poor women who cannot leave their families to go to a maternity for confinement. This is really a great boon for poor women, and is a long step in the direction of good obstetrics. Care During Tabor Among the Destitute. It would seem impossible to obtain anything like aseptic results in the hovels and the country huts in which many children are born, yet, with a little trouble, by simplifying the methods, one may do as successful work in such practice as in the best maternity. This is proved by the record of the Chicago Lying-in Hospital and Dispensary, where, out of 16,000 consecutive labor cases treated exclusively by the officers of the institution in the houses of the poorest of Chicago, only 3 women have died from puerperal infection. If visiting nurses are to help poor women at the time of labor it is necessary to provide certain aids for good work, though one can improvise everything but soap and water. The things requisite are taken to the case in a large satchel. Figure 204 shows the contents of the one used in the service of the Chicago Lying-in Hospital and Dispensary. 411 412 APPENDIX List of Articles in Labor Satchel One pair rubber gloves. One pair leggings. One jar sterile cotton pledgets. One jar sterile pads, and cord dressing. Three small milk pans of granite ware. Two brushes, one box green soap. Two towels. One newspaper. One ounce fluidextract of ergot. Fig. 204. — The labor satchel, and its contents. One bottle boric acid solution. One bottle lysol. One bottle bichlorid tablets. One bottle tape for cord (sterile). One bottle 1 per cent, nitrate of silver, with medicine- dropper. One pair scissors. One artery forceps. One baby scale. One measuring tape. One pelvimeter. VISITING NURSE IN OBSTETRIC PRACTICE 413 One tracheal catheter. One sterile soft-rubber catheter. One douche-can with tube and point (sterile). One labor record, one birth return, one visiting nurse’s record. On arrival at the parturient’s house, the patient is pre- pared by giving an enema, then shaving the pudendal hair, thorough scrubbing with soap and water from ensi- form to knees, followed by a wash with 1 : 1000 bichlorid. A clean nightdress and wrapper are put on the patient and the bed prepared with clean sheets if obtainable. If not, the bed is spread with clean newspapers. The accumulated litter is removed from the bed and room, also all unnecessary furniture, bedding, children, dogs, etc. Provision is made for good light and also a supply of clean newspapers. These are used under the patient during delivery, over tables, chairs carrying the solution basins, and, in the absence of sheets, may be placed over the patient to protect her from the dirty comforters or blankets often supplied. If there is time the papers are sterilized by baking. The patient is delivered on the side, because this carries the pudenda well out of the bed, which is likely to sag deeply. The whole secret of doing aseptic obstetrics in a city hovel or country hut is to bear in mind that only the small cleansed area of the vulva is sterile, and every- thing else in the environment is infected. If every- thing that comes in contact with the vagina and this small sterilized area is aseptic (e. g ., hands, sponges, instruments), the woman will not be infected. When the child is born it is laid in a clean towel, and after the cord is cut the stump is dressed antiseptically. The babe is oiled, not bathed, and wiped dry with a clean towel. It is then placed safely near the stove. The placenta is received in a scalded plate or a folded 4 r 4 APPENDIX newspaper, the edge of which has been wet with bichlorid, or in a sterile basin if obtainable. After delivery a clean newspaper covered with a towel is placed under the patient, or the bed is dressed with clean linen. A roller towel is applied for the binder. Duties During the Puerperium. The nurse visits the puerpera each morning, and spends one-half to one hour with her and the baby. Duties at Each Visit . — The infant is to be dressed first. A full bath or inunction is given, the navel is dressed aseptically, and the rules given under sections on Care of Child carried out as fully as possible. Until the umbilicus is healed the child is not to have a full bath, because the bath-tub in such practice is anything but aseptic. Occasionally a tin dish-pan makes the best bath- tub for later use. The eyelids are cleansed with plain water, the diaper is changed, and the infant left in as comfortable a place as the house affords, away from drafty cracks or windows, secure from the attacks of flies, mos- quitoes, vermin, and other household pests. The infants in this field of practice suffer much from bowel disorders, which are due to improper feeding, too fre- quent nursing, errors of diet of the mother, the adminis- tration of all sorts of teas, as saffron tea for jaundice, camomile, fennel tea, etc. Direct infection of the intestinal tract is encouraged by dirty bottles, nipples or fingers, flies, etc. The nurse should admonish and in- struct the mother regarding these dangers and the man- ner of avoiding them, though her efforts may not have the desired success through the ignorance, not the un- willingness, of the people. Infants under these circum- stances suffer much from skin eruptions, which are due to insects, filth, coarse and cheaply dyed garments, im- pure soap or oil used for inunction, wrapping the babe too warmly, and the general unhygienic surroundings. VISITING NURSE IN OBSTETRIC PRACTICE 415 Under such discouraging conditions it is remarkable and commendable that anything like success in treatment can be obtained, but an intelligent nurse interested in her work can really do wonders. The writer has seen evi- dences of this on many sides in his institutional practice. The nurse each day takes the child’s temperature and records it, with any unusual symptoms, on the record- sheet (Fig. 205). THE CHICAGO LYING-IN HOSPITAL AND DISPENSARY floln Office at Hospital. 294 Ashland Boulevard n f p#t' An l 1 NURSE’S RECORD -CHILD Date...... A. ML r m Dey. Temp Poise Rasp..... Stools Urine. Date Dav Temn Stoole Sleep 'Nursing Cry. . Eyes — « . . ..1 U mbilicua ...... Skin . Treatment Stools .... Sleep Eves Fig. 205. — Child’s record-sheet for visiting nurse (j size). After the infant has been attended to, the nurse gives the mother some care. A full bath every fourth day and daily washings of face, hands, and axillae are sufficient. The breasts are dressed, using boric acid solution and sterile pledgets, and the binder applied. The binder may be improvised out of a roller towel. The genitals are washed with 1 per cent, lysol solution and a fresh pad adjusted. Another roller towel makes an abdominal 4i 6 APPENDIX binder. A clean nightdress and combing the hair com- plete the toilet. It is unnecessary to say that when dressing the navel of the infant, the breasts, and the genitals of the mother the nurse should scrub her hands with green soap and water and sterilize them in lysol or bichlorid solution. If the visiting nurse must do other work besides obstetric, THE CHICAGO LYING-IN HOSPITAL AND DISPENSARY Main Office at Hospital, 294 Ashland Boulevard VISITING NURSE'S RECORD- MOTHER Name of Patient .Address. Appl. No.. Date "P Ml Day. Tem P Pulse ....Keep Signature. Bowels Bladder General Condition Breasta Nipples Milk Uterus ( height above pubis ) Tenderness Lochia Treatment Date P M Day. Tem P Pulse Reap Signature . Bowels Bladder General Condition ureasis Uterus (heigh above pubis) p* Day. Temp Pulse Resp Signature : Bladder Fig. 206. — Mother’s record-sheet for visiting nurse (M size). such as dressing ulcers, abscesses, attending pneumonia cases, the precautions she is required to take are much more rigorous. It would be better if the duties could be dissociated. The obstetric work must be done first in the morning; the nurse should wash her hands with especial care before touching aseptic things and wounds (the navel, breasts, and genitals), and she should sterilize her hands each VISITING NURSE IN OBSTETRIC PRACTICE 4 1 7 time after touching an infected case. The use of rubber gloves will spare the skin many of the discomforts caused by frequent sterilizations and corroding anti- septics. Rubber gloves find their greatest usefulness in district nursing. After dressing the patient, the bed is made as nicely as possible with the linen available, and the patient’s tem- perature and pulse taken and recorded, together with such other items of interest as the nurse may discover. The nurse also records what services she rendered and the length of time of the visit (Fig. 206). She secures suffi- Fig. 207. — The visiting nurse’s satchel and its contents. cient ventilation in the lying-in room, if this is possible, and sees that the litter and accumulated rubbish are removed. She instructs the patient and the family as to the importance of cleanliness in these cases, and tries to obtain for the patient as comfortable and undisturbed a puerperium as the circumstances will permit. If an enema is to be given, the nurse attends to this, or instructs some member of the family to do it. If there are sutures in the perineum, the nurse had better give it herself. In order to do this work well, the articles needed 27 418 APPENDIX should be taken by the nurse to the case. Fig. 207 shows such an outfit, being the one used by the nurses of the Chicago Lying-in Hospital. List of Articles in Postpartum Visiting Bag One brush and one tin box green soap. One pan for hand solution. One jar of cotton or gauze pledgets. One jar of vulval and umbilical pads. One towel for nurse’s hands. One bottle of saturated solution of boric acid. One bottle of sterile bobbin for retying cord if neces- sary. One bottle of bichlorid tablets labeled “Poison." One bottle of lysol labeled “Poison.” (All poisons are kept in brown bottles and plainly labeled.) Extra history-sheets. Visiting nursing is becoming more and more in demand by people in moderate circumstances; they are unable to employ a trained nurse, but, by having skilled service for the morning attentions, they manage to do very well the rest of the day with what help the family may render. This is a very good plan from very many points of view. For the patient, it provides good scientific care; for the doctor, a security from uncleanly interference in his work, and it opens up a field of nursing to which those nurses who cannot stand the strain of continual service, night and day, may go. The plan is simple, the nurse going to the house in the morning and rendering such attentions as the case demands. Naturally, she will find more favorable surroundings and more things to work with than in the eleemosynary practice just referred to. IIOPSITAL VS. HOME NURSING 419 HOSPITAL ys. HOME NURSING One would think that hospital and home nursing are identical, and so they are in principle, but they differ much in practice. The methods described in this book apply equally as well to hospital as to home practice. The same diligent and consistent antisepsis must be practised in the home as in the hospital. Statistics prove conclusively that more women die from infection at home than in the maternities. While formerly the maternity was a dreadful place, with a mortality of 10 per cent, or more, now a well-conducted lying-in hospital is the safest refuge for the parturient woman. The dangers of infection are here known and avoided, while in the home the attendants work in fancied secur- ity. Some lying-in hospitals have no mortality from infection year after year. The methods of sterilization practised in hospitals and at home will be considered in the next chapter; here need be emphasized only the danger of carrying infection from one patient to another in hospitals. Ward Care. — A large number of puerperae should not be put in one ward, five beds being considered enough, even with free ventilation. The nurse should remember that even a healthy puerpera may infect the one in the next bed. This, of course, is especially likely if a puer- pera is not well — has fever or fetid lochia. The nurse, therefore, between dressings must sterilize her hands and provide fresh antiseptic solutions and pledgets. Should any patient have an odor to the lochia, if the vulva becomes swollen, or little gray patches appear, and especially if the puerpera begins to be feverish, the nurse must immediately notify the head nurse on the floor, who will notify the physician. The nurse at once adopts extra precautions until the patient is ordered isolated. 420 APPENDIX These are : Setting aside special basins, pitcher, and bed- pan for the use of the suspected case, and the wearing of rubber gloves when dressing her. These gloves are to be sterilized after each dressing Pads from the vulva must not be touched by the fingers, but are to be handled with dressing forceps and burnt at once. Indeed, the entire dressing may be made by means of the forceps. It is convenient to throw all pads, etc., into large paper bags or wrap them in newspapers (see Fig. 151). The bed linen is soaked one hour in 3 per cent, carbolic solu- tion before being sent to the laundry. In this manner the spread of infection may be prevented. If, in hospital work, infection is carried from one patient to another, it is a lasting disgrace. In the nursery the same diligent watchfulness is required to prevent infection of the eyes, mouth, navel, and intestinal canal from being carried from one baby to another. The nurse, therefore, looks for the first signs of ophthalmia, for the first spot of thrush on the tongue or gums, for the first irritation around the navel, and for the first evidence of intestinal disorder in the bowel move- ments. If an infant presents evidences of a beginning conjunctivitis or any other infection, it must be isolated at once and the head nurse notified. Dresses and linen from the infant are to be soaked an hour in a 3 per cent, carbolic acid solution before being sent to the laundry; the nurse provides completely separate utensils for it, and does not touch any of the other children in the nursery before she has carefully disinfected her hands. As soon as the nature of the case is fully declared, the physician will give instructions re- garding the further treatment. It is hardly less of a disgrace than carrying infection, if in a nursery ophthalmia is carried from one child to another, if thrush attacks the mouths of several babies, HOSPITAL VS. HOME NURSING 421 if a navel infection appears, or if an epidemic of intestinal disorder sickens a number of the children. Epidemics of thrush in lying-in hospitals are due to errors in steril- izing the nursing-bottles and nipples, letting several chil- dren use, without boiling, the same nipple, and carrying the infection from one mouth to another on the finger. These same causes obtain for intestinal infection. Epi- demics of umbilical infection are very rare, and are always proof of grossest carelessness somewhere. An epidemic of pneumonia may start from a “cold in the head.” While there is danger of the communication of infec- tion through the air, contact, direct or indirect, is responsible for the largest number of cases. Recording of Symptoms. -The hospital nurse should remember to record and report to her senior every unusual symptom observed in either mother or babe. Now her duty is ended, and any oversight will not be laid at her door. In general, the nurse should carefully and neatly chart the usual entries, as pulse, temperature, and respiration, and all unusual occurrences. A neat, accurate, and com- plete history-sheet is an indication of a good nurse. Prevention of Accidents. — Every year the author hears of an accident occurring in a hospital, such as burns with hot-water bottles, overdose of medicine, bi- chlorid poisoning from douches, etc. Ordinarily, phys- icians recommend the hospital with considerable con- fidence, but the frequency of such accidents will do much to destroy this feeling. Can they be prevented? Yes, in almost every case. Once in a while a combination of circumstances will occur that no human mind could foresee, but this is rare. Usually, some one has blundered, and, in the author’s experience, carelessness, thoughtlessness, and 422 APPENDIX a slipshod method of work are more often to blame than ignorance. While in an institution every one is expected to do his whole duty and do it well, and do it well all the time, the nurse cannot rely implicitly on every one else, but must use her own judgment to see if those things concerning her and her work are done right. For ex- ample, if the night nurse makes carbolic solution and the day nurse sees pure acid floating at the bottom of the bottle, she will not use it for fear of burning the patient. If another nurse fills a hot-water bottle for her, she should herself test its heat before applying it to the patient. Too much caution cannot be enjoined regarding the use of poisons. A nurse should not administer a poison unless she knows its nature, its physiologic action, and its dosage. Not knowing any one of the three, she should inform herself at the earliest moment. To avoid administering poison by mistake all bottles containing it should be of colored glass, or special poison bottles are to be used; they should be plainly labeled “poison,” and the nurse should read the label once before and once after measuring off the required amount. Orders. — A continued order is one that is kept up day after day. As such orders are often copied from one history- sheet to another, or from one medicine-slip to another, the nurse must be accurate in carrying them over. Should she notice an error, or what seems to be an error, in the copying, she should consult the head nurse before administering the dose. In hospitals continued orders are liable to be carried longer than really necessary, and in such cases the nurse is justified in asking the physician if she should continue this or that medicine. The nurse should not accept verbal orders, but should hand the history-sheet or order book to the physician for HOSPITAL VS. HOME NURSING 423 his entry. If the order is given by telephone she should enter it “Verbal Order, Dr. X.,” giving exact time. Relations to the Patient. -Most people dread even the word hospital, and this dread is not unfounded. If the word “hospital” could be made identical in meaning with the word “home,” this dread would vanish. It is the hospital nurse’s duty to make each patient feel as if she was in her own home. It is pleasantly surprising how much can be done in this direction if only the will is there. An obstetric case is more than a medical case, and, in addition to aseptic and skilful nursing, the ex- pectant mother requires womanly sympathy. She must not be treated as “material.” A hospital can be deco- rated and furnished very much like a home without straining the requirements of asepsis; if hospital authori- ties would appreciate this fact, the modern movement in favor of hospitals for the sick would receive remarkable impetus. But, finally, it is the nurse — the personality of the nurse — that makes the atmosphere around the institution, just as it is the spirit of the hostess that breathes in every object about the home. Economy. -The hospital nurse — and the hospital doctor — must often be accused of wastefulness. Most hospitals are supported either wholly or in part by money contributed by the charitably inclined. It often requires the most strenuous efforts of a large board of managers to raise funds sufficient to meet current expenses and to provide the improvements needed. The public has a right to demand that hospital authorities expend the money intrusted to them in the most economic manner, so that the largest number may receive the benefit. Wilfully or thoughtlessly to increase the cost of conduct- ing an institution is to limit the institution’s power of doing good, and some one will suffer. Further, some one will have to give the money to make up the loss caused 424 APPENDIX by wastefulness. Wilful wastefulness is, therefore, very close to stealing. The nurse who is extravagant with linen throws un- necessary work on the laundry. If foods are allowed to spoil, the culinary department shows a needless deficit. If gauzes, sponges, and dressings are wasted, the medi- cal supply bills become too large. All these drains together make a burden which might prove too much for the institution. “Little wastes in great establish- ments, constantly occurring, may defeat the energies of a mighty capital” (Lyman Beecher). METHODS OF STERILIZATION Obstetric asepsis while equally as minute as surgical, is much less cumbersome. There is one fundamental difference in the technics of the two arts — the fact that the obstetrician is always working in or near an infected field. The vagina is seldom really sterile, and the rectum is so close to the field of operation that it is a constant menace. The accoucheur, therefore, cannot practice, during a labor, the nice aseptic methods of the surgeon; he must practice antisepsis. As far as dressings, sutures, etc., are concerned, the accoucheur insists on their being absolutely aseptic, as does the surgeon. The fact that the obstetric case cannot be handled as a clean surgical case does not excuse either doctor or nurse from responsibility if the patient sickens from infection. If both doctor and nurse have conscientiously and con- sistently carried out the best methods of antisepsis known, and even then the patient takes ill of infection, both may feel that they are blameless in this regard — but only under the condition mentioned. Sterilisation of the Hands. -Scientifically, it is impossible to sterilize the hands. Germs may be found in the skin after all sterilizations as usually practised. METHODS OF STERILIZATION 425 Practically, it has been found that several methods give good results. The most important factor in being able to sterilize the hands is not to get them infected. The day has passed when a physician could dabble his fingers in pus and then feel clean after washing them. Never get any infectious material of any kind on the hands! All such things should be touched with forceps or rubber gloves, and they should not be allowed to contaminate the clothing. Take good care of the skin, so that the epidermis is always smooth and free from cracks and fissures. The arts of the manicure may not be despised. It is not vanity that prompts the obstetric nurse to desire smooth , white hands. 1. Fiirbringer’s Method. -Pare finger-nails and re- move subungual dirt with a dull instrument Scrub for from five to ten minutes with hot water and green soap. Soak hands in 95 per cent, alcohol for one minute. Soak in 1 : 1000 bichlorid three minutes. Sublamin, a new mercury preparation, is now used in place of bichlorid, in the same proportions. It is said to injure the hands less and to be as strongly bactericidal. 2. Hot Water and Alcohol Method of Ahlfeld. -Pare finger-nails and remove subungual dirt Scrub with soap and hot water for from three to five minutes; 95 per cent, alcohol rubbed in three to five minutes with flannel, which wraps the hand until ready to operate. Ahlfeld claims that this method will produce perfect sterilization of the skin. 3. Halsted’s Permanganate Method. -Pare finger- nails and remove subungual dirt. Scrub with soap and hot water for from five to ten minutes. Immerse hands and forearms in hot saturated solution of permanganate of potash until arms are stained deep brown. Immerse 426 APPENDIX in saturated solution of oxalic acid until skin is decolor- ized. Rinse in sterile water or sterile lime-water. Some surgeons use bichlorid in addition. 4. Author’s Method. -Wash the street-dirt from hands and forearms, using much soap and working the soap well under the nails, which should be short. Clean under the nails with a dull metal nail-cleaner. Scrub in hot running water and green soap for ten minutes. Scrub in 1 per cent, lysol, or 1 : 1000 bichlorid or 1 : 1000 sublamin, or both, three full minutes. Scrub in 95 per cent, alcohol one minute. When scrubbing the skin, a sterile brush made of tampico fiber should be used. These brushes may be boiled; bristle brushes stand boiling poorly. The folds of the fingers and palms must be opened up so that the fibers of the brush can get into them. To get the fibers of the brush under the nails the fingers must be stretched out. This draws the finger-tip from the nail. If the finger-tips are pressed together, the brush cannot get under the nail. The whole hand and forearm must be gone over systematically, so that no portion is missed. N. B. — After the hands are sterilized, it requires con- stant thoughtfulness to prevent one from infecting them by touching unsterile objects. Rubber Gloves. — These are by all means the best method of aseptic operating, but the gloves must be perfect and sterile. Before putting on gloves the hands are to be sterilized in the usual manner. Some operators use cotton gloves and some draw them on over the rubber gloves. Methods of Sterilizing Gloves. — (1) Boiling in plain water for twenty minutes and putting on, wet with some antiseptic solution. (2) Boiling in water for twenty minutes; drying by sterile hands; powdering with ster- METHODS OF STERILIZATION 427 ile talcum or starch, inside and out; wrapping in sterile towels for future use. Whenever the nurse boils gloves or rubber of any kind, as colpeurynters or douche-bags, she should wrap them securely in at least four layers of thick toweling; otherwise they will be scorched and ruined by lying Fig. 208. — Testing rubber gloves by overfilling with very hot water. against the hot metal. Rubber gloves do not stand fre- quent boiling, becoming swelled and brittle. They will last a much greater length of time if steamed in the steam sterilizer. Author's Method of Sterilizing Rubber Gloves . — The gloves are tested for imperfections by filling them up with very hot water and drying the outside (Fig. 208). 428 APPENDIX If the water escapes, even in the smallest amount, the glove is discarded. Another, but not as good, way is to Fig. 209. — Author’s glove sterilizer. The gloves are first sterilized, hanging free in the steam chamber. With sterile hands they are wrapped loosely in paper, two distinct wrappings, enclosing also a bottle of talcum or starch powder. Now they are sterilized again for forty-five minutes, dried thoroughly on the radiator, and stored in a clean box. hold the inflated glove under water, when, if there is a puncture, a tiny stream of air-bubbles will escape from METHODS OF STERILIZATION 429 it. The gloves are washed thoroughly inside and out with soap and water, and then with hot 1 per cent, lysol solution. They are carefully dried inside and out and then laid in a box with a good supply of talcum powder. The box is shaken briskly, covering the gloves generously Fig. 210. — Showing how articles hang in the steam chamber. The paper to wrap the gloves in, the 2 -dram vials full of talcum or starch, and the towels, on which to do the work of wrapping, are all sterilized together. with powder. The gloves are then turned outside in and the powdering process repeated. A special glove steril- izer may be employed, or the gloves may be placed in any steam sterilizer (Figs. 209, 210). Hot air should not be turned into the sterilizer. A piece of cotton is laid inside each glove, and it is then wrapped loosely in a towel or 430 APPENDIX paper. They should be sterilized alone in the apparatus, being placed as far from the flame as possible, and the steam should flow forty-five minutes. If a high-pressure apparatus is used, thirty minutes are sufficient. When taken out, the gloves, inclosed in their sterile towels, should be wrapped in sterile paper or laid away in a clean box. Before using them the operator washes off the talcum powder with alcohol or antiseptic solution. The author has used gloves prepared in this way for fourteen years with complete satisfaction. Fig. 211. — The Rochester sterilizer. Sterilisers. — For practical sterilization it is not necessary to have the majestic and expensive sterilizers used by most hospitals. Moist steam under moderate pressure will kill all germs in forty minutes. If the steam is very dry, as occurs in high-pressure sterilizers or auto- claves, the germs are not so readily killed. Low-pressure sterilizers, as the Arnold, the Rochester (Figs. 211, 212), or the Boeckman, all of which are built on the Schimmel- bush plan, are very efficient because the steam is wet. and experiment and experience have shown that very reliable results are obtained with these instruments. METHODS OF STERILIZATION 431 The obstetric nurse should possess a small portable ster- ilizer which she can send to the houses of her patients; there are several on the market. In the absence of special apparatus the wash-boiler and the stove-oven render inestimable service. The ob- jection to the wash-boiler is that the cottons, gauzes, linens, etc., steamed therein become quite damp or even moist. This objection may be overcome by drying the articles afterward in the oven of the kitchen stove, taking care that they are not burned. Fig. 212. — The Rochester sterilizer open. Sterilisation by Dry Heat. The oven of the stove may be used for sterilizing all supplies save rubber and suture material. The oven should be heated to the tem- perature required to bake bread, and articles to be steril- ized are kept in it for three hours. Newspapers should be wrapped around them, and the required heat is shown by the light browning of the paper. Great care is neces- sary to prevent scorching of linen and gauze. The writer has only occasionally made use of this method of sterilization. Sterilization by means of antiseptic solution is rarely employed for dressings, gauzes, linens, etc. For tables, 432 APPENDIX beds, walls, etc., scrubbing with soap and water and then with an antiseptic solution is usually deemed sufficient, because sterile things are not supposed to touch them. PREPARATION OF INSTRUMENTS Obstetric instruments should be boiled in i per cent, soda or i per cent, borax solution. If no washing- or baking-soda is at hand, a little lysol or sodium hydrate will do. An alkali is necessary, because it prevents the instruments from rusting and secures better sterilization. Boiling for five minutes in such a soda solution with the vessel covered is sufficient, but if the instruments have possibly been infected, a ten-minute period is better. If instruments are to be kept aseptic for a time before being used, the soda solution should not be poured off or the cover removed. Soft-rubber goods are wrapped in at least four layers of a thick towel and boiled twenty minutes in plain water in a covered vessel. Hard-rub- ber instruments and tracheal catheters must not be boiled. They are disinfected by formaldehyd vapor or by immersion in strong bichlorid solution. Cystoscopes (excepting the simple tubes) are disinfected by formal- dehyd vapor or by lysol or carbolic solutions, not bi- chlorid. After being used, instruments are scrubbed with a brush and cold water, paying particular attention to the locks, corrugations, and crevices; then they are rinsed in a hot i per cent, lysol solution and dried out of the latter. Stains on the instruments are removed by scrub- bing with Sapolio on a moist cloth. After use on septic cases the instruments should be boiled before being put away. Imperfections in the instruments and loss of nickel-plating are to be reported to the proper authority. If a nurse finds an instrument whose construction she PREPARATION OF DRESSINGS 433 does not understand, it would be well to learn about it before taking it apart or trying to put it together, as she may do it damage. STERILIZATION OF BRUSHES After use on a septic case brushes are destroyed. Old brushes with very soft fibers are discarded, yet a brush must not be so stiff that it scratches the epidermis. Such scratches become lodging places for germs. They are thoroughly washed with soap and water, rinsed, and then steamed in the sterilizer for forty-five minutes. Brushes are best kept dry, wrapped in cloth containers. A brush once used is not used again by another, or for a more advanced period of the hand sterilization. Brushes should not be allowed to litter up the washstand; this is neither aseptic nor tidy Two jars for brushes should be at hand — one filled with sterile, the other for the used brushes. Many errors of asepsis are committed in the use and care of hand-brushes in an otherwise flawless system. PREPARATION OF DRESSINGS Cotton coming in unsealed cartons is not sterile. For use as sponges or pledgets, pieces of suitable size are made from the roll and sterilized in a pillow-case or in glass jars. Cotton pledgets are better large than small. Gauze pledgets, as used in surgical work, would be very expensive in obstetrics, as so many are used, and they must be quite large. Cotton answers the purpose well, but if gauze is preferred, the nurse may make a pledget of cotton, covering it with one layer of gauze. These are called “ covered sponges,” and have all the advan- tages of gauze with the cheapness of cotton (Figs. 213- 216). These covered sponges are packed into jars, covered with a layer of cotton, and sterilized one hour in 28 434 APPENDIX PREPARATION OF DRESSINGS 435 flowing steam. The jars are very loosely covered dur- ing sterilization; after it, the covers are screwed down tightly. Pads or vulvar dressings are made by folding a piece of absorbent cotton 3x8 inches into a piece of gauze 12 inches square, leaving the ends long. They are wrapped in towels or cotton-cloth sacks, and sterilized in flowing steam for one hour, dried in the sterilizer, and laid away in a dust-proof box. Newspapers. — One of the handiest articles in the lying-in room is the clean newspaper. The newspaper fresh from the press is practically clean, and is very useful to receive discharges, soiled pledgets, pads, etc., which are thereupon wrapped up and burned. The nurse should, if the opportunity is given, sterilize, as she would a package of towels, a bundle of clean news- papers. Tysol Gauze for Tamponade. -Two widths of gauze are required in packing the uterus, depending on the time of pregnancy. For use in the early months a strip about 3 inches wide is best, the gauze being cut into 5-yard lengths, and loose threads carefully removed from the edges. Woven bandages are purchasable and are preferable to cut muslin. For packing the uterus at or near full term these narrow strips would be useless. Here the gauze is cut J-yard wide, into lengths of 13 yards. The selvedge and cut edge are folded in, and each length is made into a bundle. The bundles are then thoroughly rinsed in running water, wrung dry by hand, and boiled for twenty minutes in 0.5 per cent, lysol solution. A pair of rubber gloves, two sheets, and a metal clothes-wringer are now sterilized by steam or boiling. Wearing the gloves, the nurse runs the bundles through the wringer, using considerable pressure. Then the strips are packed into sterilized Mason jars Fig. 217. — Gauze for uterine tamponade. Shows the method of packing into the jar in layers from the bottom. or others that are large enough, packing smoothly in circles from below upward (Fig. 217). Thus the tarn- PREPARATION OF DRESSINGS 43 7 ponade can be made directly from the jar. The gauze must not be rolled and then placed in jars. The tops of the jars are filled with layers of cotton, the lids are screwed down tight, and the jars are put in the sterilizer. They are sterilized on two successive days, two hours each time. The jars are then wrapped in three layers of paper, sterilized again, and put away in a clean place. Thus prepared, gauze will keep sterile for years. Plain sterilised gause is prepared by cutting the gauze, as it comes from surgical supply-houses, into the requisite lengths, as just given, packing into the jars as described, and sterilizing in the steam-chamber every day for three days, two hours each time. High-pressure sterilizers if overheated will scorch the gauze, rendering it brittle. A piece of such gauze may break off and be inadvertently left in the wound. Gauze coming from surgical supply-houses should not be trusted unless it is in sealed containers. Iodoform gause is very seldom used in obstetric practice, and the various methods of preparation need not be detailed here. Other drugs are used in preparing gauze, as chinosol, vioform, boric acid, bichlorid, thymol; non-absorbent gauze is also sometimes used instead of the absorbent. From extensive experience the author can recommend the lysol gauze as prepared in the manner described. Gelatin Gause. — Gelatin favors coagulation of the blood, and is sometimes used to impregnate gauze intro- duced into the uterus for the control of postpartum hem- orrhage. In emergency 2 ounces of pure French gelatin are dissolved in 20 ounces of boiling water and the mix- ture boiled vigorously over a very hot fire with constant stirring for at least fifteen minutes. The solution is poured over the gauze just before its introduction. In hospitals gelatin is prepared in 10 per cent, solution and 438 APPENDIX sterilized, so as to be always ready for use. Merck & Co. have put on the market a sterile and non-toxic gelatin in sealed glass bulbs, which is by far preferable. Suture Material. —In obstetric work, without doubt, silkworm gut is the best material for suture. Method of Preparation . — It should be washed with tincture of green soap and water, wound in little rings containing three strands each, boiled in plain water for thirty minutes, and placed with sterile forceps in sterile glass bottles containing i : 1000 bichlorid. The tops of the bottles are covered with cotton, and in this way the gut will keep sterile for months. Some operators, and especially those in private practice, prefer to boil the gut just before the operation or with the instruments. The nurse should see that it is thoroughly washed with soap and water first. Catgut. -Many hospitals and most doctors in private practice buy catgut already prepared. It comes in sealed paper envelopes or in glass tubes or bottles. The steril- ization of catgut is a difficult matter, and there are many methods; for example: (i) Boiling in cumol; (2) boiling in alcohol under pressure; (3) boiling in saturated solu- tion of ammonium sulphate; (4) soaking in ether, bi- chlorid, alcohol, and juniper oil; (5) soaking in iodin solutions, (6) iodoform solutions, etc. The writer hardly thinks it necessary to describe all these methods, and refers the nurse to surgical text-books for the details. Silk. — This is not much used in obstetric practice. It is best prepared by thorough washing in hot water with tincture of green soap, boiling in 1 per cent, lysol solu- tion for thirty minutes, and rinsing thoroughly in sterile water just before use. Some physicians sterilize it in the steam sterilizer with the dressings. The preliminary washing with soap and water is not to be neglected. Silk should not be wound on glass with sharp corners. PREPARATION OF DRESSINGS 439 If sterilized and kept, it deteriorates after a time, no matter what solution is used as a preservative. Linen Suture Yarn. -This is occasionally used, and is sterilized like silk. Linen Bobbin for Tying the Cord. — Ordinary linen bobbin J-inch wide is the best and cheapest material for tying the umbilical cord. It is cut into lengths of 15 inches, washed with soap and water, wrapped in gauze, boiled in 1 per cent, lysol solution, and then kept Fig. 218. — Nickel-plated reel on which the douche-can tube is sterilized, to prevent kinking. in glass-stoppered bottles dry or in alcohol. In private practice two lengths are boiled with the scissors and kept in 1 per cent, lysol solution until needed for tying the cord. Basins, pitchers, douche-cans, bed-pans, etc., used during a labor are all to be sterilized. In private practice they are boiled for thirty minutes in the wash- boiler with the cover on, and then wrapped in sterile pillow-slips If basins are required in a hurry, one granite basin may be inverted over another, water placed 440 APPENDIX in the lower, and boiled for twenty minutes. China bowls and pitchers may be scrubbed with Sapolio, scalded with boiling water, and rinsed with 2 per cent, lysol solu- tion. If there is time, however, all the utensils should be boiled. In hospitals they are wrapped in special holders and sterilized in the steam sterilizer. Rubber tubing when sterilized is liable to kink at the bends and prove useless when most urgently needed. To avoid this it should be rolled on a spool (Fig. 218). Douche-bags of rubber are first washed out with table salt and water, using much friction to rid the interior of the sulphur and dust, then filled with gauze, and steamed or boiled. Kelly pads are not boiled, but scrubbed with soap and water, and then with strong bichlorid or lysol solution. Gowns, aprons, leggings, towels, sheets, and pillow-slips for use in the confinement room are wrapped in towels or special holders, pinned securely, labeled distinctly, and sterilized by steam for forty-five minutes. They are dried in the sterilizer and placed in a clean box or closet. Tables, chairs, bed, and other furniture in the confinement room are washed with a soft cloth and soap and water, then with 1 : 1000 bichlorid or 3 per cent, carbolic acid solution. In hospitals, where pus is present, this sterilization must be particularly thorough, and in all instances the tables are covered with several layers of sterile towels before operations, so that sharp- pointed needles may not pierce through. Sterilising Apartments. — After infectious cases the room occupied by the patient is to be disinfected. A simple and very efficient method is the following: The room is allowed to air thoroughly, all the windows being opened, the bedding scattered on chairs, closet doors left ajar, and bureau drawers drawn out. Then the room is PREPARATION OF SOLUTIONS 44I tightly closed, the cracks, flues, and doors being sealed with paper. It is allowed to warm up thoroughly. Formaldehyd vapor is generated as follows: A 2 -quart milk pail is wrapped in a piece of asbestos paper and set inside a papier-mache water pail, dry. For a room 1 5 feet square 5 ounces of potassium permangan- ate are put in the tin pail. When everything is ready the nurse places the apparatus in the center of the room to be sterilized, then pours 20 ounces of formalin on the potash, and, holding her breath, beats a hasty retreat, closing and sealing the door behind her. After twelve hours the room is widely opened and allowed to air thoroughly for two or three days if pos- sible. If it is desired to dissipate the fumes of formalin quickly, ammonia may be spread around. The ceiling, floor, walls, and furniture are now washed with soap and water and new linen put on the bed. Formaldehyd lamps are sometimes used for fumi- gating, but they are not more efficient than the method described, which is recommended by the Illinois State Board of Health. Sulphur is seldom used now for fumigation. It ruins household articles, while formalin does not. In my opinion, the washing and airing of the room do more good than the fumigation. PREPARATION OF SOLUTIONS Physicians differ widely in their choice of antiseptic solutions, and the nurse will do best if she becomes thoroughly acquainted with the desires of her physician in this regard. Sterile Water. — In hospitals this is prepared in the large sterilizers, being filtered before being boiled under pressure by steam or gas In private homes the nurse should scrub the wash-boiler thoroughly with sand- soap, rinse it, and boil about 8 gallons of water for 442 APPENDIX forty minutes, setting it to cool, well covered up. In country practice the water should be carefully strained through cotton, as it often contains foreign matter, some- times living. A dipper should be boiled and kept, wrapped in a sterile pillow-slip, for ladling purposes, Hot sterile water may be taken from the tea-kettle, which should always be kept full and boiling on the stove. In flats or apartments in cities the nurse should remember that between i and 5 A. m. the heat goes down and the hot- water supply may fail. Even in cities with a known good water-supply antiseptic solutions should always be made with previously sterilized water. One should not trust the antiseptic (bichlorid, lysol, creolin) to disinfect the water. An epidemic of tetanus is said to have resulted in a hospital where such trust was imposed in creolin. In all cases, therefore, where possible, boiled water should be employed. Bichlorid of Mercury Solutions. — In private prac- tice the nurse will use tablets, dissolving them in hot water and adding cool to bring up the required dilution. Strengths of 1 : 1000 and 1 : 1500 are usually employed. Too much caution cannot be enjoined to exercise care to avoid poisoning with bichlorid. In making up stock solutions of bichlorid, the powder or tablets should be completely dissolved in boiling water and the solution filtered through cotton. No bits of undissolved poison should be left in the bottle. When used for douches, the solution must be injected under low pressure and a douche of sterile water given afterward. In anemic women or in cases of kidney or intestinal disease, this poison must be used only with the greatest circumspection. Some physicians have dis- carded it entirely; the author uses it very little. Sublamin is a new mercurial antiseptic, said to be as strongly bactericidal as bichlorid, but less toxic to the PREPARATION OF SOLUTIONS 443 patient and less irritating to the hands, even when used in concentration. Carbolic Acid Solution. -The pure crystals are mixed with 5 per cent, of alcohol, or the 95 per cent, acid may be purchased. To make a 5 per cent, solu- tion, the required amount is dissolved in boiling water with constant and vigorous stirring. No acid should form in globules in the bottle. After the acid is all dis- solved and the solution cooled, it is filtered through cot- ton in a glass funnel. To make 1 gallon of 5 per cent, carbolic acid solution 6j ounces of the 95 per cent, solu- tion are needed. Lysol Solution. — Lysol is a proprietary antiseptic containing 50 per cent, of kresol, or cresylic acid and tincture of green soap Liquor cresolis compositus is the official name for the preparation, which any chemist can prepare. Only for brevity is the proprietary name used in the text. It is employed in 1, ij, and 2 per cent, solutions. In hospitals it is made up, as carbolic is, in 5 per cent, solution (6j ounces to the gallon), and diluted with sterile water as needed. In private prac- tice the solutions are made from the pure drug : 3 drams to 1 quart of water make a 1 per cent, solution. The nurse should always measure these drugs and not trust to guesswork. Formalin Solution. — For douches, 30 drops of fresh formalin are mixed with 1 pint of sterile water; for the hands, 1 dram to 1 pint. Chinosol. — This drug belongs to a rather large class of proprietary antiseptics. It is not much employed. It is a light-yellow powder and is dissolved in water, strengths of from 1 : 2000 to 1 : 500 being used. Creolin is also used, like lysol. Salt Solution. — For use as a wash or douche, saline solution is prepared by adding 1 dram of pure sterilized 444 APPENDIX table-salt to i pint of water. When used for hypo- dermoclysis or intravenous injection, the solution is pre- pared with boiling water and cooled down to the tem- perature desired. A convenient way to sterilize salt is to fill 2 -dram vials, cork securely, and sterilize daily for three days, one hour each day. A 2 -dram vial contains just enough salt to make 1 quart of 0.6 per cent, solution. If the solution must be made in the absence of prepared salt, the boiling must be done after the salt is dissolved. (See p. 225.) Salt solution should be made fresh, just before injection. It does not keep well. Boric Acid Solution. -Boric or boracic acid dis- solves in water only to 4 per cent., and this is the strength usually employed. Two handfuls of the crystals are placed in a gallon bottle and boiling water poured in. The bottle is shaken vigorously until all the crystals are dissolved; then it is set in a cold place. When the ex- cess of boric acid has crystallized out, the clear solution may be decanted from the top into a separate bottle. This is better than to use the bottle with the crystals at the bottom, as they often are poured out when not wanted. THE OBSTETRIC NURSE The author wishes that more nurses would prepare themselves for obstetric work and adopt it as a specialty. True, it is hard, but a woman in good health, who knows how to manage things, can systematize her duties so that she will get along very comfortably. If, in addition, the nurse will insist on a proper amount of sleep and oppor- tunity for outdoor recreation being afforded her, she will enjoy long years of usefulness in this fascinating branch of medicine. Nurses often take too little rest and do not go out at all during the first week. In well-to-do fam- THE OBSTETRIC NURSE 445 ilies the nurse should be relieved at night by another, and in those less fortunate some one will be accessible for relief of the nurse by day. The nurse must not think this is selfish — on the contrary, she will do better work for both mother and babe if she is well and strong. Obstetric nurses often form most intimate and pleasant friendships with their patients, and they find they have a personal interest and satisfaction in seeing the child grow and develop. This alone should attract to this specialty the best women in the profession. To do good work, the nurse should be well prepared, and she should have her affairs so arranged that she is accessible at all times and ready for all emergencies. She should have her satchel packed at all times when awaiting a call. She should read up her cases and do some postgraduate work occasionally to save herself from rustiness. She should take with her to the obstetric case a book on obstetric nursing and consult it when anything unusual arises. List of Articles Needed by the Obstetric Nurse One hypodermic syringe and needles in working order. Two tested thermometers, one for mother and one for babe. One razor, safety pattern. One pair surgical scissors. One pair tissue forceps. One long dressing forceps for use during labor in hand- ling sterile things (Fig. 219). One pair rubber gloves. One rectal tube. One sterile douche-bag or can. One portable sterilizer. (See Figs. 211, 212.) One white operating gown. 44 6 APPENDIX It is better if the patient provides her own rubber goods, but in country practice the nurse may need them. Some nurses find a Kelly pad useful, but just as good a pad may be made with news- papers. The Nurse's Dress. - This should always be of wash material, of a quiet, restful color, and should not be worn in the street. This is neither good taste nor aseptic. The sleeves should be made so that they may be rolled up above the elbow, and stiff cuffs should not be worn. They rub into the in- fant’s eyes when the child is “changed” and may injure them. It might be added that the nurse should always appear neat and clean while on duty. During the night the nurse is so frequently disturbed that some form of wrapper should be provided. Except in rare instances the nurse should never try to rest in her uniform. Deportment. -A discus- Fig. 219— Nurse’s dressing sion of this point is not needed forceps in tall bottle of lysol j n tbis book but a f ew b j ts 0 f solution. advice may not be out of place. Never forget the dignity of the profession of nurs- ing; at the same time, always remember that even THE OBSTETRIC NURSE 447 menial duties are compatible with it and even may be demanded. The rules of asepsis must never be neglected or relaxed in severity, even if the physician does not practice them or if the circumstances are difficult to control. The keenest and most constant attention to the details of asepsis alone will guarantee the puerperal woman that safety she so richly deserves. The lying-in chamber should always be neat, temper- ate, and inviting, and the disturbing elements of the world outside of it should never enter. The nurse should, under no circumstances, allow dis- agreements to arise between herself and the servants, and when the mother of the house is ill she should aid as much as possible in the conduct of the household affairs. She should increase the duties of the family and the servants as little as possible. The nurse should never gossip about her cases. Family secrets are too sacred to be even hinted at or to be referred to without names. He who tells even the smallest part of a secret loses his hold on the rest. People can often draw inferences which render the information direct. This bit of advice cannot be too deeply im- pressed. The nurse — and the doctor too — must abstain from the relation of bad cases or wonderful operations, etc., be- cause the patient easily takes alarm and will imagine herself to be singled out for each accident related. The nurse must allow no complication to disturb the even- ness of her mind and action, and if the doctor is to be called for some complication, the patient must not know it. The nurse should not allow the infant to acquire bad habits, such as sucking the fingers, sucking an empty rubber nipple, water-tippling, peppermint- and sugar- APPENDIX 448 water-tippling, or even the whisky habit, or lying with its mother or other person. By gentle persistence the nurse may engender good habits of living at a very tender age, for which the individual may be grateful all his days. VENEREAL DISEASES Unfortunately, these affections are not uncommon in obstetric practice, although usually we see the effects only, not the disease in its florid stages. Gonorrhea.- This is an inflammation of the urethra and vulva produced by the gonococcus of Neisser. It affects the pelvic organs slowly, one after the other, and causes chronic inflammatory changes of permanent char- acter in them. Sterility from tubal disease or pelvic abscess may result, and if pregnancy supervenes, puer- peral peritonitis may be the final outcome. If a child is born before the disease is cured, the gon- orrheal germ may obtain access to the eyes and cause an inflammation resulting in blindness. (See p. 347.) The discharges from a gonorrheal case are highly in- fectious. The woman may infect her own eyes, she may carry the infection to others, and cases are known wdiere infected towels caused epidemics of gonorrheal vulvitis in schools for girls. Thus the nurse may appreciate the importance of treat- ing a case of gonorrhea as she w r ould the other infectious diseases. The symptoms of pelvic gonorrhea are pain, smarting on urination, pain and soreness in the pelvis, discharge of greenish-yellow pus, slight febrile movements, and, later, the symptoms of disease of the organ most affected, as pyosalpinx or peritonitis. During pregnancy the disease aggravates, the discharge being very profuse and often fetid and irritating. Warty VENEREAL DISEASES 449 growths may appear on the genitals, and an eczema intertrigo develop there. Treatment. The physician will order medicines to keep the urine in an antiseptic condition. Douches of various antiseptics may be ordered, the vulva and vagina may be painted with iodin, nitrate of silver, etc., or tam- pons of ichthyol inserted. Iodoform gauze packing is occasionally employed. It is wisest to get the disease well on the road to cure before the child is born, to avoid ophthalmia neonatorum and puerperal peritonitis. During labor the vagina may have to be douched with lysol solution, and after the infant is born exceedingly rigorous precautions are observed to prevent any infec- tion gaining access to the eyes. Syphilis or “ Specific Disease.” — The latter term is used so that the laity may not understand the harsh meaning of the diagnosis. While gonorrhea is usually a local affection, syphilis is a blood disease, becoming at once a constitutional taint which is almost ineradicable, and is transmissible even to the third generation. There are three stages in the disease: The first stage is the primary sore or the point of entrance of the infec- tion. This is a hard ulcer and may occur on the vulva, in the vagina, or on any part of the body, as the lip, the tonsil, or the hand, as not infrequently happens to phys- icians in their gynecologic examinations. Syphilis is not always venereal in origin. Lues is another name for syphilis. The second stage begins six to ten weeks after the sore appears, and is evidenced by a rose-red, fading to copper colored, general eruption, headache, falling hair, pains in the bones, and sore throat. There are superficial ulcers in the mouth and around the vulva and anus. In these two stages the disease is highly infectious. The third or tertiary stage occurs later in life, perhaps 29 450 APPENDIX after many years, and shows the effects of the disease in the bones, blood-vessels, vital organs, and nervous system. If a man marries while in the first or second stages, he transmits the affection to his wife and to the offspring. If the disease has no external signs — is latent — he trans- mits the poison to the offspring, the mother being in- fected from the child. In the former case, abortion or premature labor usually terminates the pregnancy. In the latter case, a dead and macerated or a live but syphilitic infant is born. Signs of syphilis in the newborn child are: a general skin eruption of rose spots; blebs on the soles and palms; snuffles; cracks and superficial ulcers around the anus and mouth; marasmus, and the Wassermann blood test. Should a nurse notice the symptoms mentioned in either the mother or child, the physician must be noti- fied. Prevention of Contagion. —The syphilitic patient must have her own knife, fork, dishes, etc. Discharges are collected in antiseptic dressings, which are burned. The nurse must care for her own hands with the utmost regard, using rubber gloves during necessary contact with infected parts, as sore mouth and ulcerated geni- tals. The same precautions are to be observed in hand- ling a syphilitic infant. None but the mother will be allowed to nurse a syphilitic child. Treatment. During pregnancy the disease becomes more virulent, and at all times it requires vigorous treat- ment. Mercurial baths, mercurial inunctions, hypo- dermic injections of mercury, salvarsan (“606”), internal administration of mercury, are all employed. Iodid of potassium is given later. As these drugs are given in large and increasing doses, the nurse will watch for mercurialization (salivation, fetid breath, sore mouth, VENEREAL DISEASES 451 loosening of the teeth, etc.), iodism (frontal headache, coryza, stiffness in throat, pustular eruption on the face and body), and arsenical poisoning (nausea, vomit- ing, diarrhea, prostration, edema). Tonic medicines are also given, as a severe form of anemia often develops. The treatment of a syphilitic child is the same in prin- ciple as that of the adult. General Consideration of Venereal Disease. A nurse must never let the patient know that she has discovered such an affection. It must not be thought that because a patient has venereal disease it must have been acquired in illicit relations. Physicians and nurses have acquired syphilis in the course of their work. Men have acquired it in the barber’s chair; washwomen, from washing infected linen; patients in the dentist’s chair or under operation, from in- fected instruments. A physician, using a eustachian catheter, infected 35 patients with syphilis! These same possibilities exist with gonorrhea. Guarded speech, therefore, is' obligatory on the nurse, as scandal is easily started and endless domestic woe may be inaug- urated by the nurse dropping the merest hint regarding the nature of the malady. If she is questioned regard- ing the manifestations of disease, she should quietly but firmly refer the inquiry to the physician. Nor may she speak of the disease or of its symptoms to any of her friends or other physicians, as they may recognize the description and connect it with the patient. “He who tells even the smallest part of a secret loses his hold on the rest.” 452 APPENDIX DIETARY 1 LIST OF DIETS Absolute Milk Diet. Milk, whey, matzoon, kou- miss, buttermilk, junket, water. Three quarts of milk daily are given, a glassful every two hours. I/iquid Diet. -Water, milk, matzoon, koumiss,junket, buttermilk, whey, tea, coffee, toast-water, rice-water, egg-water, lemonade, broths, beef-tea, beef-juice, oyster- stew minus oysters. Semisolid Diet. -All the above plus eggnog, milk- toast, cereal foods (boiled), ice-cream, corn-starch pud- ding, blanc-mange, soft-boiled eggs, scraped beef, cream soups, purees and soups thickened with rice, barley, or farina. Diet for the Prevention of Overgrowth of the Child. — This diet must not be prescribed by the nurse, as it is the physician’s province. It is inserted here for the sake of completion. Prochownik arranged it, and claims that the women who follow it out consistently have small but perfectly developed children. The author’s results do not fully justify this claim. Fred- erick the Great recommended his niece, the Princess of Orania, not to overnourish her child during pregnancy, and the notion is widespread that the amount of food partaken by the mother during pregnancy affects the size of the child. PROCHOWNIK’S DIET Breakfast . — Small cup of coffee; two slices of toast (i ounce) . Dinner . — Small piece of meat or fish or an egg, a little sauce, a vegetable prepared with fat, lettuce, a small piece of cheese. 1 This section was written largely by Mrs. E. E. Koch. RECIPES 453 Supper . — The same, with a few slices of bread and butter and a little milk. Water, soup, potatoes, pastries, sugar, and beer are forbidden. About i pint of water daily is drunk. The diet should be adhered to during the last ten or twelve weeks, always, of course, under medical control. RECIPES 1 Albumin or Egg- water. — Stir white of one egg into a pint of water ice cold. Do not beat or shake. Sugar, salt, or powdered cinnamon to taste. Barley-water. -Wash 2 ounces (wineglassful) of pearl barley with cold water. Boil five minutes in fresh water. Decant water. Pour on 2 quarts of boiling water; boil down to 1 quart. Flavor with thinly cut lemon-rind, add sugar or cinnamon to taste; strain. If the mixture is allowed to boil down to 1 pint, strained, put on ice, a good barley-jelly results. Beef-tea. -Free 1 pound of lean beef from fat, ten- don, cartilage, bone, and vessels; chop fine, put into 1 pint of cold water to digest two hours. Simmer on range or stove three hours, but do not boil. Make up for water lost by adding cold water, so that 1 pint of beef-tea represents 1 pound of beef. Strain through cheese-cloth without pressure. Should be clear. Beef-juice.— Cut a thin, juicy steak into pieces i| inches square; brown separately one and one-half min- utes on each side over a hot fire ; squeeze in a hot lemon- squeezer or meat-press; flavor with salt and pepper. May add to milk or pour on toast. Beef-tea with Acid. One and a half pounds of beef (round) cut in small pieces; same quantity of ice, broken small. Let stand in deep vessel twelve hours. Strain thoroughly and forcibly through coarse towel. 1 Largely from Thomas’ Dietary. 454 APPENDIX Boil quickly ten minutes in porcelain vessel. Let cool. Add \ teaspoonful of acid (dilute phosphoric acid) or acid phosphate to the pint. Cereal Extract. -Take 2 soupspoonfuls each of corn, barley, oats, rye, maize, and bran; boil in 4 quarts of water three hours; allow to cool and then strain. If necessary, add enough water to make 1 quart. A pal- atable yellowish fluid is obtained, which may be improved by the addition of milk or powdered cinnamon for children. Chicken Broth. -Skin and chop fine a small chicken or half a large fowl; boil it, bones and all, with a blade of mace, a sprig of parsley, a tablespoonful of rice, and a crust of bread in 1 quart of water for an hour, skim- ming it from time to time. Strain through soup- strainer. Clam Broth. — Wash thoroughly 6 large clams in shell; put in kettle with 1 cup of water; bring to boil and keep there one minute; the shells open, the water takes up the proper quantity of juice, and the broth is ready to pour off and serve hot. Champagne Whey.- Boil J pint of milk; strain through cheese-cloth. Add wineglassful of champagne. Egg Lemonade. -Beat 1 egg with 1 tablespoonful of sugar until very light; stir in 3 tablespoonfuls of cold water and juice of small lemon; fill glass with pounded ice, shake in milk-shaker for fully two minutes, pour in clean glass. Should be drunk through straw. Eggnog. — Scald some new milk by putting it, con- tained in a jug, into saucepan of boiling water, but do not allow it to boil. When cold, beat fresh egg with a fork in a tumbler with some sugar. Beat to a froth, add a dessertspoonful of brandy, and fill tumbler with scalded milk. Serve cold. May shake with ice in milk-shaker; strain. If desired, may use sherry instead of brandy, or RECIPES 455 omit the alcohol entirely, and grate a little nutmeg or cinnamon in glass. Flaxseed Tea. —Flaxseed (whole), i ounce; white sugar, i ounce (heaped tablespoonful); licorice-root, | ounce (2 small sticks, crushed well); lemon-juice, 4 tablespoonfuls. Pour on these materials 2 pints of boiling water; let stand in a hot place four hours; strain off the liquor. Flour-ball. -Take 1 pint of flour and pack tightly in small muslin bag; throw into boiling water and boil five or six hours; cut off the outer sodden portion; grate the hard core fine; blend thoroughly with a little milk, and stir into boiling milk to the desired thickness. Gum-arabic Water. -Dissolve 1 ounce of gum arabic in 1 pint of boiling water; add 2 tablespoonfuls of sugar, a wineglassful of sherry, and juice of a large lemon; cool and add ice. Junket. Heat 1 pint of fresh milk just luke-warm; add 1 teaspoonful of essence of pepsin or half a rennet tablet; stir enough to mix. Flavor, if desired, with sugar, grated nutmeg, and brandy. Pour into custard cups; let stand in cool place until firmly curded. Koumiss. — Take citrate of magnesia bottle with shift- ing cork; put in it 1 pint of milk, J cake of Fleischmann’s yeast, or 1 tablespoonful of fresh lager-beer yeast (brewers’), i tablespoonful of white sugar, reduced to syrup; shake well and allow to stand in refrigerator two or three days, when it may be used. It will keep there indefinitely if laid on its side. Much waste can be saved by preparing the bottles with ordinary corks wired in position and drawing off the koumiss with a champagne tap. Meat Cure. — Procure slice of steak from top of round — fresh meat without fat; cut meat into strips, removing all fat, gristle, etc., with knife. Put meat 456 APPENDIX through mincer at least twice. The pulp must then be well beaten in roomy saucepan with cold water or skimmed beef-tea to consistence of cream. The right proportion is i teaspoonful of liquid to 8 of pulp; add black pepper and salt to taste; stir mince briskly with wooden spoon the whole time it is cooking, over slow fire or on cool part of covered range, until hot through and through and the red color disappears. This requires about one-half hour. When done, it should be a soft, smooth, stiff puree of the consistence of a thick paste. Serve hot. Add for first few meals the softly poached white of an egg. Meat Diet, Raw. -Scrape pulp from a good steak, season to taste, spread on thin slices of bread; sear bread slightly and serve as sandwich. Meat-extract Ice. — Express all the juice from i pound of fresh beef. Add J pound of sugar, 3 teaspoon- fuls of fresh lemon- juice (except in dyspeptics), 1 table- spoonful of cognac, well stirred with yolks of 3 eggs. May flavor with vanilla Freeze. Milk and I£gg. Beat milk with salt to taste; beat white of egg until stiff; add egg to milk and stir. Flavor with grated nutmeg or cinnamon. Milk Digested with Acid. -Add 20 drops of dilute hydrochloric acid to 1 pint of water; stir, add the acidu- lated water to 1 quart of fresh milk, stirring as it is added. If the milk is not alkaline, make it so before adding the water by adding lime-water until litmus-paper shows the proper reaction; boil twenty minutes on a slow fire in narrow-necked vessel to prevent too much evapo- ration. The proportions of milk and water may be modi- fied to suit the case. Milk, Peptonized: Cold Process. In a clean quart bottle put 1 peptonizing powder (extract of pancreas, 5 grains; bicarbonate of soda, 15 grains) or the contents RECIPES 457 of one peptonizing tube (Fairchild); add i teacup of cold water; shake; add i pint of fresh cold milk; shake the mixture again. Place on ice; use when required without subjecting to heat. W arm Process. — Mix peptonizing powder with water and milk as described above ; place bottle in water so hot that the whole hand can be held in it for a minute with- out discomfort; keep the bottle there ten minutes; then put on ice to check further digestion. Do not peptonize long enough to render milk bitter. Milk-toast, Peptonized. -Over 2 slices of toast pour 1 gill of peptonized milk (cold process); let stand on back of stove for thirty minutes. Serve warm, or strain and serve fluid portion alone. Plain light sponge- cake may be similarly given. Milk, Sterilized. — Put the required amount of milk in clean bottles (if for infants, each bottle holding enough for one feeding) . Plug mouths lightly with rubber stop- pers or non-absorbent cotton; immerse to shoulders in kettle of cold water; boil twenty minutes or, better, steam thirty minutes in ordinary steamer; push stoppers in firmly; cool bottles rapidly and keep in refrigerator. Warm each bottle just before using. Milk-shake. -White of 1 egg, 1 dram of sugar, 2 tablespoonfuls of chipped ice, 1 ounce of cream. Shake in milk-shaker two minutes. Add cold milk to fill glass; flavor with vanilla or lemon. Mutton Broth. —Lean loin of mutton, ij pounds, including bone; water, 3 pints. Boil gently until tender, throwing in a little salt and onion, according to taste. Pour broth into saucepan; when cold, skim off fat. Warm up as wanted. Nutritious Coffee. Dissolve a little isinglass or gelatin (Knox) in water; put \ ounce of freshly ground coffee into saucepan with 1 pint of new milk, which 458 APPENDIX should be nearly boiling before the coffee is added; boil both together for three minutes. Clear it by pouring some of it into a cup and dashing it back again ; add the isinglass, and leave it to settle on back of stove for a few minutes. Beat an egg in a breakfast-cup and pour the coffee upon it; if preferred, drink without the egg. Rice-water. -Pick over and wash 2 tablespoonfuls of rice ; put into granite saucepan with 1 quart of boiling- water; simmer two hours, when rice should be softened and partially dissolved; strain; add saltspoonful of salt; serve warm or cold. May add 2 tablespoonfuls of sherry or port. Rum Punch. -White sugar, 2 teaspoonfuls; 1 egg, stirred and beaten; warm milk, 1 large wineglassful; Jamaica rum, 2 to 4 teaspoonfuls; nutmeg. Toast-water. — Toast 3 slices of stale bread to dark brown, but do not burn; put into a pitcher; pour over them 1 quart of boiling water; cover closely and let stand on ice until cold ; strain. May add wine and sugar. Whey. —Boil 1 pint of milk with 1 or 2 teaspoonfuls of lemon-juice; strain in muslin, expressing all fluid from the curd. Break the curd up first, and much fat and some finely divided casein will be expressed with the whey. For infants, use rennet tablet or junket tablet, J grain to 1 pint, and keep warm ten minutes. If no fat is wanted, strain gently through fine napkin. Wine Whey. Put 2 pints of new milk in saucepan and stir over clear fire until nearly boiling; then add 1 gill (2 wineglassfuls) of sherry and simmer one-quarter of an hour, skimming curd as it rises. Add 1 table- spoonful more sherry, and skim again for a few minutes; strain through coarse muslin. May use 2 tablespoonfuls of lemon-juice instead of wine. RECTAL FEEDING 459 RECTAL FEEDING General Rules. — Cleanse the rectum morning and evening with an enema of io ounces of sterile saline solution (0.6 per cent.). Arrange time so that cleansing comes one hour before the nutritive enema. Inject high into the sigmoid flexure, using the soft-rubber rectal tube for adults and the soft velvet-eye No. 12 or 14 cath- eter for children. Use sweet oil or vaselin as a lubricant, but not glycerin. Expel all air from the tube. Inject slowly from 2 to 8 ounces of the prepared food, warmed to body temperature. Do not inject oftener than once in six hours, except in emergencies. Aid retention of food by placing patient on the left side, the hips elevated by a pillow, a soft compress retained against the anus for twenty to thirty minutes. If the rectum becomes irri- table, notify the physician; he may prescribe from 5 to 20 drops of tincture of opium with the nutrient enema, or the same amount of tincture, or J to 1 grain of extract of opium, one-half hour before the enema. This dosage must not be often repeated. Apply 2 per cent, cocain solution to painful hemorrhoids, but by order only. Salt solution is often given postpartum in the treat- ment of anemia from severe hemorrhage. If the uterus and vagina are tamponed, the lower bowel will sometimes hold a quart. The anus should be supported by firm pressure through a folded towel. Later, saline solution is administered in smaller doses, 8 ounces every four hours, or by the drop method. Peptonized Milk. — In this case the milk is thor- oughly peptonized, requiring two hours. From 6 to 8 ounces are injected every six or eight hours. Peptonized Milk with Hg’g'. —While peptonizing milk, add 2 eggs to each pint. Peptonize two hours at body temperature and set on ice. 460 APPENDIX This food is also readily absorbed — 3 eggs, a tea- spoonful of salt, 1 ounce of starch, and \ pint of milk. Digested Beef. —To 1 tablespoonful of minced lean beef add 4 tablespoonfuls of cold water; gradually heat to boiling. Rub through a fine sieve, and, when luke- warm, add one peptonizing tube (Fairchild) or an equiva- lent amount of liquid pancreatin (P. D. & Co.). Inject at once. May be diluted more if necessary. Any combination of eggs, milk, and meat may be pep- tonized and injected, or mixed with peptonizing powder and injected at once, the digestion or peptonization to go on in the rectum. Liquid peptonoids, peptones, somatose, etc., are some- times used, but the author recommends the freshly pre- pared foods. Dextrin is sometimes given per rectum. Formula: Dextrin, 50; 9 to 10 per cent, salt solution, 250 grams. Grape-sugar, 60 grams (2 ounces), milk, 250 c.c. (8 ounces), may be given, or the same amount of corn- starch in milk or malted milk plain. Alcohol is sometimes used, but the rectum soon be- comes intolerant of all feeding, and more harm than good is accomplished. Glucose is absorbed in moderate quan- tities by the rectum, and also emulsified animal oils. Under all methods of rectal feeding the patient does not obtain sufficient calories or heat-units to maintain a proper balance of nutrition. FEEDING THROUGH THE SKIN One may introduce a small amount of nourishment through the skin by inunctions of lard. This is especially valuable in babies with wasting diseases. Hypodermically, salt solution may be injected in large quantities — up to 2 quarts daily — to replace liquid losses from profuse diarrhea or constant vomiting, as in hyper- NASAL FEEDING 461 emesis gravidarum. It has also been suggested to add soluble foods to the hypodermic injection, but practical results are not yet published. Our attempts are as yet experimental. NASAL FEEDING In unconscious patients it is sometimes possible to introduce liquids, food, and medicine through a tube passed into the nose and thence into the upper esoph- agus. A stomach-tube of small size (about No. 16, American scale) is oiled and passed gently along the floor of the nose (not upward toward the eye) until it reaches half-way to the stomach (about 12 inches). The nurse makes sure that the tube is not in the windpipe by putting her ear to the open end ; if air rushes in and out, the tube is in the trachea. It is taken out and reinserted, bending the head slightly on the chest while so doing. After the tube is passed and there is no doubt about its being in the esophagus, the liquid is slowly poured into the funnel and the tube quickly withdrawn. The nurse must take care that the stomach is not over- filled by too frequent and too copious feedings. GLOSSARY [The American Illustrated Medical Dictionary has been largely used in the preparation of this glossary. The numbers at the end of the definition indicate the page in the text describing the subject.] A. Abactus venter (ab-ak'tus ven'- I ter) [L.]. Induced abortion. Abdomen ' ab-do'men). The belly; that portion of the body which lies between the thorax and the pelvis. Abdominal ( ab-dom'in-al). Per- taining to the abdomen. A. deliv- ery, delivery of the child through an incision in the abdomen ; Cesarean section A. gestation, pregnancy oc- curring outside of the uterus in the free abdominal cavity. A. preg- nancy, same as Abdominal gestation. A. section, cutting through the ab- dominal wall into the abdominal cav- ity ; Cesarean section; celiotomy; laparotomy. Ablactation ( ab-lak-ta'shun) . The weaning of a child ; cessation of the secretion of milk. p. 326 Abnormal (ab-nor'mal). Unnat- ural ; contrary to the usual structure or condition. Abortifacient (ab-or-tif-a'shent). 1. Causing abortion. 2. A drug ca- pable of producing abortion or mis- carriage. Abortion (ab-or'shun). The expul- sion of the fetus during first 28 weeks of pregnancy, or before it is viable. P- 55 - Abrasion (ab-ra'zhun). A rub- bing-off of a portion of skin or mu- cous membrane. A spot from which the skin or mucous membrane has been rubbed. Abruptio placentae. Premature ! detachment of the normally implanted I placenta, p. 251. Abscess (ab'ses). A collection of pus in a cavity. Absorbent (ab-sor'bent). 1. Tak- ing up by suction. 2. A dressing or medicine which takes up moisture. Accouchement (ah - koosh - maw') [Fr.] . Delivery ; the act of being de- livered. A. force (for-sa'), rapid ar- tificial delivery. Done in case of placenta prsevia or eclampsia. Accoucheur (ah-koosh-er') [Fr.]. An obstetrician. Accoucheuse (ah-koosh-ez') [Fr.]. A midwife. Acid (as'id). 1. Sour; having properties opposed to those of the alkalis. 2. A chemical compound which has the power of uniting with an alkali to form a new compound called a salt. A. reaction, the turn- ing of litmus-paper red ; a test for the presence of acids. Acinus (as'in-us), pi., a'cini. 1. Any one of the smallest lobules of a compound gland, like the liver. 2. One of the small air-sacs of the lungs. Acme (ak'me). The crisis or criti- cal stage of a disease. Acrid (ak'rid). Pungent; irritating. Acute (ak-ut / ). 1. Sharp-pointed. 2. severe. The term is applied to diseases which have severe symptoms but are of short duration. Adnexa (ad-nek'sah) [L. pi.]. Ap- pendages or adjunct parts ; especially those of the uterus — the ovaries and tubes. Uterine a., the ovaries and Fallopian tubes. Fig. 15. After-birth (after-berth). The placenta, with the membranes and umbilical cord. pp. 41-46. After-care (after-liar). The caje or nursing of convalescents. After-pains (af'ter-panz). Pains due to the contraction of the uterus 463 464 GLOSSARY after the placenta has been expelled. I pp. 61, 299. Agalactia (ah-gal-ak'she-ah). Ab- 1 sence of the milk secretion, p.321. Albolene (al'bo-len). An oily white substance made from petro- leum. The solid resembles vaselin, and is used in making ointments. The liquid is used for spraying the nose and throat. Albuminuria (al-bu-min-u're-ah). The presence of albumin in the urine. p. 86. Alimentation ( al -i m-en-ta'shun) . The act of taking nourishment. Alkaline (al'kal-in). Having the properties of an alkali. A. reaction, the turning of litmus-paper blue. Alvine (al'vin). Pertaining to the stomach or bowels. A. dejections, the feces. Amenorrhea (am - en - or-re 'ah). Absence of the menstrual flow. Amnii, Liquor (am'ne-i li'kwor). The water surrounding the fetus in the uterus, p. 42. Amnion (am'ne-on). The most internal membrane containing the waters which surround the fetus in the uterus, p. 42. Amniotic (am-ne-ot'ik). Pertain- ing to the amnion. A. sac, the mem- branes surrounding the fetus in the uterus. Anemia (an-e'me-ah). 1. De- ficiency in the quantity or quality of the blood: it may be general or local. 2. Deficiency in the number of red blood-corpuscles. Anemic (an-em'ik). Having anemia. Anemoscope (a-nem'o-skop). 1. An instrument to indicate the direc- tion of air-currents. 2. The little wheel in the outlet flue of an incuba- tor. p. 37^. Anencephalus (an-en-sef'al-us). A single monster born without cra- nium or brain. Anesthesia ' an - es - the ' zhe - ahh Loss of feeling or perception ; it may be general or local. Anesthetic Can - es-thet 'ikh 1. Having no preception or sense of touch. 2. A drug capable of pro- ducing anesthesia, p. 120. Anesthetist (an-es'thet-ist). A per - 1 son skilled in administering anes- thetics. Ankyloglossia (ang-kil-o-glos'se- ah). Tongue-tie. p. 357. Ankylosis ang-kil-o'sis). Stiffen- ing of joints. A joint which has be- come immovable. Annular (an'u-lar). In the form of a ring. Anorexia (an-o-rek'se-ah). Loss of appet.te for food. Anteflexion (an-te-flek'shun). A bending fn ward, as of the uterus, Ante partum (an-te par'tum) [L.]. Before t.ie birth of a child. Anterior (an-te're-or). Situated in front of. Anthelmintic (an-thel-min'tik). 1. Destroying worms. 2. A remedy for intestinal worms. Antiseptic (an-te-sep'tik). Pre- venting sepsis, pus-formation, or pu- trefaction. Among the best common antiseptics are alcohol, creasote, car- bolic acid, corrosive sublimate (bi- chlorid of mercury), chlorin, char- coal, boric acid, tannic acid, lysol. A. dressing, a surgical dressing con- taining an antiseptic. A. surgery, sur- gery with proper use of antiseptics. Anus (a'nus) [L.]. The external open ng of ihe rectum, pp. 31-34. Apathetic (ap-a-thet'ik). Without emo ion. Iad.fferent to surroundings. Aphthse (af'the). Small whitish erosions on the mucous membrane of the mouth. See Bednars a. p. 334. Areola (ar-e -o'lah). The pig- mented ring around the nipple. Secondary a., a slightly pigmented ring just outside the areola, some- times observed after the fifth month of pregnancy, p. 36. Argyrol (ar'jir-ol). A drug; a preparation of silver. Arterial ar-te're-alV Pertaining to an artery. A. blood, the bright red blood in the arteries, which has been aerated, or charged with oxygen in the lungs. A. hemorrhage, hemor- rhage from an artery. Artery nr'ter-e'. One of the ves- sels carrying blood from the heart ; so called because the ancients thought thev contamed air. Articular (ar-tik'u-lar). Pertain- ing to a joint. GLOSSARY 465 Articulation (ar-tik-u-la'shun). A joint ; the junction of two bones. Ascites (as-si'tez). An accumula- tion of serous fluid in the free ab- dominal cavity. Dropsy of the abdomen. Asepsis (ah-sep'sis). Without sep- sis ; freedom from infection ; surgical cleanliness. Aseptic (ah-sep'tik). In a surgi- cally clean manner. Asphyxia (as-fix'e-ah). Suspended animation ; interrupted respiration ; that state in which there is complete suspension of the powers of m.nd and body. A. neonato rum, asphyxia of the new-boin. p. 360. Aspirating needle ( as-pir-a'ting ne'dl,. A hollow needle attached to a suction syringe : used for withdraw- ing fluids from the body. Assimilate (as-sim'i-late). To con- vert food into chyle and blood ; to change food into a substance like the living body. Astringent (as-trin'jent). Having the power to diminish excessive dis- charges. Atelectasis (at-el-ek'tas-is). 1. Imperfect expansion of the lungs at birth. 2. Partial collapse of the lungs, p. 337. Atony (at'on-e). Lack of normal tone or strength. Atrophic (at-rof'ik). Not properly nourished ; showing atrophy. Atrophied (at'ro-fed). Wasted; having atrophy. Atrophy (at'ro-fe). Wasting or emaciation with loss of strength, but without fever. Autoclave < aw'to-klav). A high pressure steam-sterilizer. Autoinfection. Infection from germs living in the vagina not intro- duced from without, p. 283. Autotransfusion ( aw"to-trans-fu'- zhun). The forcing of blood into the vital parts of the body by bandaging or elevating the limbs. Avicenna (av-i-sen'ah). Moham- medan physician. Born 980; died 1037. Axilla (nk-sil'lah). The arm-pit. Axis-traction (ak'sis-trak'shun). Pulling or drawing on the head of the child during delivery, in the direc- tions normally followed by the head 30 during birth — i. e., in the axis of the pelvis. A.-t. forceps, obstetric for- ceps with an attachment for producing axis-traction, p. 191. B. Bacteria (bak-te're-ah) [L.]. Plu- ral of Bacterium. Vegetable micro- organism. Bag of Waters. The membranes enclosing the liquor amnii and the fetus. Sometimes applied to that portion of the membranes which pro- trude into the os. p. 59. Ballottement (bal-ot-maw'). The diagnos.s of pregnancy by pushing up the uterus by a finger inserted into the vagina, so as to cause the fetus to rise and fall again like a heavy body in water. Barnes’ bags (barnz). Rubber bags used to dilate the cervix uteri, p. 231. Basiotribe (ba'se-o-trib). An in- strument for crushing the base of the fe'al skull. Basiotripsy (ba ' se - o -t rip - se). Crush. ng the fetal skull with a basio- tribe. Baudelocque (bo-del-ok'). A fa- mous French obstetrician. Born 1746; died 1810. B.’s diameter, the external conjugate diameter of the pelvis, measured from the last lumbar spine behind to the top of the pubic bone in front. Bednar’s aphthae (bed-nars' af'- the). Shallow ulcers in the back part of the mouth of the new-born. They are caused by badly shaped rubber nipples, or by force in cleansing the mouth, p. 334. Bimanual (bi - man ' u-al). Per- formed with both hands. B. palpa- tion, examination of the pelvic or- gans of a woman with one hand on the abdomen and two fingers of the other hand in the vagina. Binder (bin'der). A broad band passed tightlv around the abdomen after childbirth, pp. 92, 308. Birth (berth). 1. The delivery of a child. 2. That which is born. B.- mark, “ mother’s mark “ maternal mark.” A blemish on the skin found at birth, p. 83. 4 66 GLOSSARY Bistoury (bis'too-re). A small knife for surgical purposes. Blennorrhea (blen-nor-re'ah). An excessive secretion of the mucous glands of any mucous membrane. Borborygmus (bor-bo-rig'mus), pi., borborygmi [L.]. A rumbling noise made by gases in the bowels. Bougie (boo-zhe') [Fr.]. A slender instrument for introduction into the urethra, esophagus, uterus, vagina, or rectum. Breast-pump (brest-pump). An instrument for drawing the milk out of the breast, p. 163. Breech (brech). The buttocks. B. delivery, labor in which the breech presents and is delivered first, p. 177. Brim (brim). The upper edge of the pelvis ; the inlet, or superior strait. Figs. 1,5,9. C Calorie (kal'o-re). The amount of heat which the combustion of a given material will develop in raising one kilogram of water from o° to i° C. p. 402. Capillary (kap'il-la-re). 1. Re- sembling hair in size. 2. One of the minute blood-vessels which form a network between the minute arteries and veins. Caput (ka'put), pi., cap'ita [L.]. The head, including the skull and face. C. incunia'tum, impaction of the fetal head during labor. C. suc- ceda'neum, a dropsical swelling on the presenting part of the head during labor, due to lack of pressure on that part. p. 356. Carbohydrate (kar -bo -hi' drat). One of a group of chemical com- pounds of which sugar, starches, and gums are the most important. Carbon dioxid (kar'bon di-ox'id). Carbonic acid gas. Caries (ka're-ez). Decay of the bones or teeth. Carminative (kar-min'at-iv). A drug. A remedy for flatulence, tending to relieve same. Cartilage (kar'til-ej). Gristle; a pearly white, glistening substance formed at the articular surfaces of bones. Ensiform c., the cartilage I at the lower extremity of the breast- bone. Casein (ka'se-in). The principal proteid of milk and the basis of cheese. Caseo'sa, Ver'nix. The greasy, whitish substance which covers the skin of the fetus, p. 69. Cast (kast). A model of a hollow organ, especially one of the tubules of the kidney, and found in the urine. Carminative. A remedy which aids the expulsion of gas in the bowels or stomach, p. 288. Cathartic ( kath-ar'tik). 1. Purga- tive or purging. 2. A drug that in- creases evacuation from the bowels. Catheter (kath'et-er). A slender tubular instrument for withdrawing fluids from a cavity of the body or for distending a passage. Tracheal C., a woven catheter used for aspirat- ing foreign substances from the wind- pipe of the child, and for blowing air into the lungs, p. 360. Cauli kawl). A portion of the am- niotic membrane which sometimes covers the child’s head at birth. Celiotomy ( se-le-ot'o-me). Ab- dominal section ; laparotomy ; open- ing the abdomen. Cell (sel). 1. Any one of the minute | masses of protoplasm of which organ- ized tissue is composed. 2. One of the chambers holding the fluids of a galvanic battery. 3. A small, partly closed space, as an air-cell. Cellulitis (sel-u-li'tis). Inflamma- tion of cellular tissue ; especially purulent inflammation of the loose subcutaneous tissue. Cephalhematoma (sef"al-he-mat- o'mah). A blood-tumor occurring on the head of the new-born infant. P- 356 . Cephalic 1 sef-al'ik). Pertaining to the head. C. pole, the head of the fetus. C. presentation, the presen- tation of any part of the head of the fetus in delivery, p. 169. Cephalotomy (sef-al-ot'o-me). The operation of cutting or breaking down the fetal head; craniotomy. Cephalotribe (sef'al-o-trib). An instrument for crushing the fetal head. Cephalotripsy (sef'al - o - trip - se). t The operation of crushing the fetal GLOSSARY 467 skull with the cephalotribe. See Craniotomy. Cerebrospinal (ser"e-bro-spi'nal). Relating to the brain and spinal cord. C. fluid, the clear fluid in the ven- tricles of the brain and in the central canal of the spinal cord. Cervix (ser'vix) [L.]. The neck or any neck-like part, especially the back part. C. u'teri, the neck or narrow lower end of the uterus. Cesarean section ( se-za're-an). The operation of cutting through the abdominal walls and through the walls of the uterus, and delivering the child through these incisions, p. 201. Chafe (chaf). 1. To fret and wear by rubbing. 2. The reddened, irri- tated skin in the folds of fat babies, p. 159. Chloasma (klo-az'mah). An affec- tion of the skin in which there are patches with a yellowish or brown- ish discoloration. C. gravid'arum, chloasma which occurs during preg- nancy. C. uteri'num, the mask of pregnancy, p. 52, Fig. 71. Chorea (ko-re'ah). St. Vitus’ dance ; a nervous disease in which there are convulsive movements. Chorion (ko're-on). The more ex- ternal of the fetal membranes. Chromicized catgut (kro'mis-izd kat'gut). Catgut treated with chromic acid. It is used for sutures and liga- tures. Chronic (kron'ik). Long-contin- ued; the opposite of acute. Cicatricial ( sik-at-rish'al). Relat- ing to a cicatrix or scar. Cicatrix (sik-a'trix or sik'at-rix), pi., cica' trices [L., “scar”]. A scar. The mark left by a sore or wound. Cilia (sil'e-ah). The eyelashes. Circulatory (sir'ku-la-to-re). Re- lating to the circulation. C. system, the heart, arteries, veins, and capil- laries, taken as a whole. Circumcision (ser-kum-sizh'un). The removal of all or a part of the foreskin, or prepuce, p. 338. Cleft palate (kleft pal-at). A con- genital split in the roof of the mouth, so that the nose and mouth form one cavity, p. 356. Climacteric (kli-mak-ter'ik). The cessation of menstruation in women. Clitoris (klit ' o - ris). A small, elongated, erectile body, situated at the anterior part of the vulva. Clonic spasms (klon-ik). Spasms in which the contractions and relaxa- tions alternate, as in eclampsia. Clyster (klis'ter). An enema. Coagulated (ko - ag ' u - lat - ed). Clotted. Coaptation (ko-ap-ta'shun). The fitting together of displaced parts, as the ends of a fractured bone. Collapse (kol-laps'). 1. To fall in. 2. Extreme depression or complete prostration of the vital powers, with failure of circulation. Collyrium ( kol-ir'e-um). An eye- | wash or salve for the eyes. Colostrum (ko-los'trum) [L.]. The first fluid secreted by the mammary glands after delivery. It contains less casein and more albumin than the or- dinary milk, as well as numerous fatty globules. C. -corpuscles, the granu- lar cells found in colostrum, p. 65. Colpeurynter ( kol'pu-rin-ter). A I dilatable bag used to distend the vagina, p. 231. Colpeurysis (kol-pu'ris-is). Dila- tation of the vagina by means of the colpeurynter. Coma (ko'mah) [L.]. Profound stupor or drowsiness occurring in the course of certain diseases, as eclamp- sia, or after severe injury. Comatose (ko 'mat - os). Affected with coma. Comedo (kom-e'do), pi., comedo' nes. “ Black-heads.” The dried plugs of sebaceous matter sometimes found in the pores of the skin. In the new- born they are white. Conception (kon-sep'shun). The impregnation of the ovum by the spermatozoid. The beginning of pregnancy, p. 40. Condy’s fluid ( kon'dez). An anti- septic preparation of permanganate of potash. Congenital (kon-jen'it-al). Exist- ing at or before birth. Congestion 1 kon-jest'yun). Exces- | sive accumulation of blood in a part. Conjugata vera (kon-ju-ga'ta | ve'ra) [L.]. The internal pelvic diam- 468 GLOSSARY eter measured from the promontory of the sacrum to the upper margin of the pubic joint. Conjunctiva! kon-junk-ti'vahjfL.]. The mucous membrane which lines the eyelids and covers the eyeball. Conjunctival (kon - junk ' tiv - al). Relating to the conjunctiva. Conjunctivitis (kon-junk-tiv-i'tis). Inflammation of the conjunctiva. Contraindiction (kon"tra - in - di - ka'shun). A condition that renders some particular line of treatment im- proper or undesirable. Convalescence (kon - val - es ' ens). The stage of recovery. Convalescent kon-val-es'ent). Re- gaining health after illness. C. diet, any simple, easily digested food suit- able for a convalescent patient. Convulsion (kon - vul ' shun). A spasm ; a series of violent involun- tary contractions of a muscle or set of muscles. Coprostasis (kop-ros'tas-is). Cos- tiveness ; constipation ; undue reten- tion of feces in the bowels. Cornea (kor'ne-ah). The trans- parent, convex, and nearly circular anterior portion of the eyeball. Coronal (kor'o-nal). Relating to the crown of the head. C. or coro- nary suture, the suture formed by the junction of the frontal with the parietal bones. Coryza (ko-ri'zah). Cold in the head ; an acute catarrh of the nasal mucous membrane. Couveuse (koo-vez') [Fr.]. An in- cubator. p. 368. Cranioclasis (kra - ne - ok ' las - is). The crushing of the fetal skull. See Craniotomy, p. 198. Cranioclast ( kra'ne-o-klast). An instrument for crushing the fetal skull, p. 198. Craniotomy(kra-ne-ot'o-me). The operation of cutting or breaking down the fetal head. C. scissors, an S- shaped scissors for performing crani- otomy. p. 199. Crede’s method for preventing ophthalmia (kreh-days'). The appli- cation of a drop 2 per cent, silver nitrate solution to the eye of the new- born, followed by normal salt solution. C.’s method of expelling placenta, a method of expelling the placenta. The operator grasps the fundus of the uterus (through the abdominal wall) and with moderate pressure squeezes out the placenta, “ as the seed of a ripe cherry compressed between the fingers.” Crenasol (kren'as-ol). A disinfec- tant. Crotchet (krot'chet). A curved, hook-like instrument for extracting the fetus after craniotomy ; it is no longer used. Curd (kurd). The coagulum of milk. It is mostly casein. Curet (ku-ret') [Fr.]. A kind of scraper or spoon for removing growths or other materials from the walls of cavities. Curetment (ku-ret'ment). Same as Curettage, p. 224. Curettage (ku-ret-tazh'). Treat- ment by the curet. p. 224. Cutaneous (ku-ta'ne-us). Pertain- ing to the skin. Cutis (ku'tis). 1. The skin. 2. The true skin, or cutis vera. Cyanosis (si-an-o'sis), Blueness of the skin caused by deficient amount of oxygen in the blood, p. 337. Cyanotic (si - an - ot ' ikj. Affected with cyanosis. Cystitis (sis-ti'tis). Inflammation of the bladder, p. 303. Cystoscope (sis'to-skop). An in- strument for examining the interior of the bladder. To cystoscope : to look into the bladder. D. Debility (de-bil'it-e). Weakness ; loss of power. Decapitation (de - kap - it-a' shun). The removal of the head of the fetus in embryotomy, p. 197. Decidua (de-sid'u-ah). The mem- branous structure produced during pregnancy and thrown off after par- turition. It is composed of the greatly changed mucous membrane of the uterus. D. reflex'a, that portion of the decidua which is reflected over the ovum, surrounding it. D. serot'- ina, that part of the decidua which lies under the maternal portion of the GLOSSARY 469 placenta. D. ve'ra, that portion of the decidua which lines the uterus. Decomposition (de"kom-po-zish'- un). 1. The separation of compound | substances into their constituent parts. 2. Putrefaction or decay. Decubitus tde-ku'bit-us). 1. The act of lying down. 2. A bed-sore, p. 242. Defecation (def-ek-a'shun). Evacu- ation of the bowels. Delirium (de-lir'e-um). Derange- ment of the mind, characterized by wandering speech, wakefulness, and excitement. Delivery (de-liv'er-e). 1. The ex- pulsion or extraction of the child at birth. 2. Removal of a part from the body — e. g., the placenta. Denudation (den-u-da'shun). 1. The act of laying bare. 2. The re- moval of the epithelium. Denuded (de-nu'ded). Laid bare. Desquamation (des-kwa-ma'shun). The peeling off of skin in flakes. Detritus (de-tri'tus). Broken-down material, waste. Diagnosis di-ag-no'sis). The art or science of distinguishing one dis- ease from another by means of signs and symptoms. Diagnostic (di-ag-nos'tik). Dis- tinctive ; indicating the nature of a disease ; furnishing a diagnosis. Diaphoresis (di"af-o-re'sis). Per- spiration, especially profuse perspira- tion. Diaphoretic (di'af-o-re'tik). 1. Causing diaphoresis. 2. A drug that causes sweating. Diaphragm di'af-ram). The mus- culomembranous partition between the chest and abdomen, and the most important muscle of respiration. Diathesis (di-ath'es-is). Natural predisposition to a certain disease. Diet (di'et). 1. Victuals; habitual food. 2. Course of food selected with reference to a particular state of health. D. sheet, a written or printed diet-list. Dietary (di'et-a-re). A regular or [ systematic scheme of diet. Dietetic ''di-et-et'ik). Pertaining to diet. D. treatment, treatment of disease by means of a regulation of diet. Differential (dif-fer-en'shal). Dis- criminating; showing a difference. D. diagnosis, discriminating between two diseases which present a similar group of symptoms. Dilute (di-lewt'j. 1. To make thin. 2. To diminish the strength, flavor, or color of. 3. To become thin or attenuated. Disintegration (dis - in - te-gra'- shun). Decay. The separation of a substance into its component parts. Diuresis (di-u-re'sis). Increased secretion of urine. Diuretic (di-u-ret'ik). 1. Produc- ing diuresis. 2. A drug that causes increased flow of urine. Douche (doosh). A stream of water directed against a part or into a cavity, p.222. Dropsy (drop'se). The abnormal accumulation of serous fluid in the tissues or cavities of the body. Duct (dukt). A passage with well- defined walls ; especially, a tube for the passage of a secretion or fluid. Ductus (duk'tus). A duct. D. ar- terio'sus, a blood-vessel in the fetus communicating directly between the pulmonary artery and the aorta. D. veno'sus, a bipod-vessel in the fetus communicating directly between the umbilical vein and the descending vena cava. Dysmenorrhea (dis"men-or-re'- ah). Painful or difficult menstrua- tion. Dyspnea (disp-ne'ah). Difficult or labored breathing. Dystocia, Dystokia (dis-to'se-ah, dis-to'ke-ah). Painful, slow, or dif- ficult labor. Fetal d., dystocia due to malposdion or malformation of the fetus. Maternal d., dystocia due to some deformitv on the part of the mother. Placental d., difficulty in removing the placenta. E. Ecchymosis (ek-ke-mo'sis). An extravasation of blood under the skin or mucous membrane. Eclampsia (ek-klamp'se-ah). A sudden attack of convulsions occur- ring during pregnancy, labor, or just after labor, p. 256. 4;o GLOSSARY Ectopic (ek-top'ik). Out of the normal place. E. gestation, preg- nancy in which the fetus is not in the uterus. See Extra-uterine pregnancy. E. pregnancy, same as Ectopic ges- tation. E. sac, the amniotic sac and its coverings in ectopic gestation, p. 252. Eczema (ek'ze-mah). A non-con- tagious skin disease whose prominent manifestations are the formation of small vesicles closely crowded to- gether, and an intolerable itching and burning of the affected part. E. in- tertri'go, an eczematous condition in the folds of fat babies ; chafe, p. 343 - Eczematous (ek-zem'at-ous). Af- fected with eczema. Eliminate (e-lim'in-at). To ex- pel ; to throw off waste matter. Elimination (e-lim-in-a'shun). The act of throwing off waste matter. Emaciation (e-ma-she-a'shun). A wasted condition of the body. Loss of flesh. Embolism (em 'bol-izm). The plugging of a blood-vessel by a clot or other obstruction which has been carried to this place by the blood current. Air e., passage of air in injurious quantities to the heart and circulation, p. 128. Embolus (em'bo-lus). A clot or other obstruction of a blood-vessel which has been carried from a distant vessel and lodged in a smaller one, obstructing the circulation. Embryo (em'bre-o). The fetus before the end of the third month of development. Embryotomy (em-bre-ot'o-me). The destruction of the fetus in the uterus, p. 198. Emetic (e-met'ik). 1. Causing vomiting. 2. A drug which causes vomiting. Emmenagogue (em-men'ag-og). 1. A drug having the power to stim- ulate the menstrual flow. 2. Aiding the function of menstruation. Emprosthotonos (em-pros-thot'o- nos). Spasm causing the body to bend forward. Emulsion (e-mul'shun). A milk- like mixture prepared by uniting oil and water by means of another sub- stance, usually a mucilage. Emunctory le-munk'to-re). 1. Ex- cretory. 2. An excretory duct. Enema (en'e-mah). A medicine or fluid injected into the rectum, either to procure an evacuation or for nourishment. Enervation (en-er-va'shun). Lan- guor; weakness; lack of nervous energy. Engagement (en-gaj'-ment). The entrance of the fetal head into the superior strait of the pelvis. Ensiform (en'si-form). Sword- shaped. E. appen'dix, E. car'tilage, E. pro'cess, the lower extremity of the breast-bone. Enteritis ien-ter-i'tis). Inflamm 1- tion of the small intestine. Epidemic (ep-id-em'ik). 1. A dis- ease which is widely prevalent. 2. The season of prevalence of an epi- demic disease. Epilepsy (ep'il-ep-se). The falling sickness ; a chronic nervous disease characterized by convulsions or fits, and in which there is loss of con- sciousness. Epileptic (ep-e-lep'tik). 1. Per- taining to epilepsy. 2. A person af- fected with epilepsy. Epileptiform (ep-e-lep'te-form). Resembling epilepsy. See Eclampsia. Episiotomy (ep-iVe-ot'o-me). An incision of the vulvar orifice, to per- mit the fetus to pass. p. 61. Epithelium (ep-ith-e'le-um). Cuti- cle, the covering of the true skin and mucous membrane. Ergot ( er'got). A drug having the power to stimulate uterine contrac- tion. It is used to check hemorrhage after labor, and to arrest hemorrhages from any organ; to relieve congestion of the brain and spinal cord. Dose, 15-60 minims (1-4 c.c.). Ergotin (er'go-tin). The active principle of ergot. Dose, \ grain (0.0042-0.033 gm.). Erosion (e-ro'zhun). An eating or gnawing away ; a kind of ulcera- tion. Erysipelas (er-is-ip'el-as). An acute contagious disease caused by a germ, Streptococ'cus ery sip el' at is, and characterized by chill, high fever, and GLOSSARY 47 intense local redness and swelling of the skin and mucous membrane. Eustachian tube (u-sta'ke-an tub). The canal extending from the phar- ynx to the middle ear, or tympanum. E. valve, a semilunar valve in the heart at :he opening of the inferior vena cava. Eutocia, Eutokia (u-to'she-ah, u-to'ke-ah). Normal labor. Evacuation (e-vak-u-a'shun). i. The act of moving the bowels. 2. The discharge from the bowels. Evisceration (e - vis - er -a'shun). Removal of the bowels or viscera from the body. Obstetric e., removal of viscera of the fetus in embryotomy. Exacerbation (ex-as-er-ba'shun). 1. Increase in severity of the symp- toms of a disease. 2. The stage of periodic increase in the severity of symptoms. Excoriation (ex-ko-re-a'shun). A superficial loss of substance, p. 342. Excrement (ex'kre-ment). Feces. That which is excreted by the bowels. Excrete (ex-kret). To throw off, as waste matter, by a normal dis- charge. Excretion (ex-kre'shun). 1. The process of excreting. 2. The mate- rial which has been excreted. Exostosis (ex-os-to'sis). A bony growth on the surface of a bone or tooth. Expiration (ex-pi-ra'shun). The act of expelling air from the lungs. Expiratory 1 ex-plr'a-to-re). Per- taining to expiration. Expire (ex-plr'). 1. To expel the breath. 2. To die. Expulsive (ex-pul'siv). Driving or forcing out. E. pains, those occur- ring during the second stage of labor. E. stage, the second stage of labor, p. 118. Exsanguination (ex-sang-gwin-a'- shun). The condition of being with- out blood, p. 277. Extension (ex-ten'shun). A term applied to that stage in the delivery of the fetal head when the chin is no longer flexed on the chest. The oppo- site of flexion. Extra-uterine (ex-trah-u'ter-in). Outside the uterus. E. life, life after birth. E. pregnancy, pregnancy in which the fetus is not contained in the uterus, but in some organ outside the uterus. Ectopic gestation, p. 232. Extravasation (ex - trav - as -a shun). The escape of a fluid from its normal vessel or cavity into the sur- rounding tissues. Exudation (ek-su-da'shun). Ooz- ing ; slow escape of liquid. F. Facial (fa'shal). Pertaining to the face. p. 354. Faeces (fe'sez). See Feces. Fallopian (fal-lo'pe-an) preg- nancy. Pregnancy occurring in the Fallopian tubes ; same as tubal preg- nancy. F. tubes, the oviducts: two canals leading from the ovaries to the body of the uterus. Fig. 15. Farinaceous (far-in-a'shus). Con- taining flour : said of certain diets. Fauces (faw'ses). The back part of the mouth leading into the pharynx. Febrile (feb'ril). Pertaining to fever. Feverish. Fecal (fe'kal). Pertaining to feces ; containing feces. Feces (fe'sez). The excrement or undigested residue of the food dis- charged from the bowels. Fecundation (fe-kun-da'shun). The fertilization of the ovum by means of the spermatozoid. p. 40. Fenestrated ( fen'es-tra-ted). Hav- ing openings, or fenestra. Fetus (fe'tus) [L.]. The child in iitero from the end of the third month of development till birth. Fillet (fil'let). A loop of tape used for making traction. Finger cot (fing'ger kot). A thin rubber covering for the finger. Occa- sionally used as a dressing for a wound of the finger. Fissure (fish'ur). A crack or nar- row opening, p. 313. Flex (flex). To bend, as a joint. Flexion (flex'shun). 1. The act of bending. 2. The state or condition of being bent. F. stage, that stage in labor in which the chin of the fetus is pressed against its breast. Flocculus (flok'u-lus), pi ..floc'culi 472 GLOSSARY [L.]. A small shred or flake, usually floating in a liquid. Fontanel, Fontanelle (fon-tan-el'). The quadrangular space at the junc- tion of the frontal with the two pari- etal bones in infants. “ The soft spot.” The other junctions of the cranial bones are also called fonta- nels. p. 43. Foramen (for-a'men), pi., foram'- ina [L.]. A hole or opening, especi- ally through bone. F. ova'le, an opening in the partition between the auricles in the fetus. Forceps (for'seps). A two-bladed instrument for grasping and holding that to which it is applied. Obstetric f., the instrument used to extract the child's head. p. 190. Formaldehyd (for-mal'de-hid). 1. A powerful disinfectant gas. 2. An aqueous solution of the gas is used as a surgical antiseptic and preservative for specimens, p. 443. Formula (for'mu-lah). 1. A pre- scribed method for preparing a medi- cine. 2. A combin ition of symbols used to express the chemical consti- tution of a substance. Fornix (for'nix). Arch or vault. F. of the vagina, the hollow plrces between the cervix and the anterior, posterior, and lateral walls of the vagina. Fourchet (foor-shet') [Fr.]. The fold of mucous membrane at the pos- terior junction of the labia majora. Friable (fri'ab-l). Easily pulver- ized. Function (funk'shun). The special office of an organ. Fundus (fun'dus) [L.]. The base or part of a hollow organ remotest from its mouth. F. u'teri, the part of the uterus which is most remote from the cervix or os. Funis (tu'nis). The umbilical cord. Furunculus (fu-rung'ku-lus). A boil. G. Galactagogue (gal-ak'tag-og). 1. Increasing the secretion of milk. 2. A drug having the power to increase the flow of milk. p. 322. Galactorrhea ( gal-ak-tor-rhe'ah). Excessive secretion of milk. p. 321. Galactostasis. Cessation or stag- nation of the milk-secretion. Gastric (gas'trik). Pertaining to the stomach. Gavage (gah-vazh') [Fr.]. 1. Feeding by the stomach-tube. 2. The employment of a very full diet. p. 381. Genital (jen'it-al). Pertaining to generation, or to the organs of gen- eration. p. 31. Genupectoral (je-nu-pek'tor-al). Relating to the knees and chest. G. position, “knee -chest position.' 1 That posture in which the patient rests on the knees and chest, the thighs extending upward, the but- tocks being as high as possible, p. 238. Germicidal ( jer-mis-i'dal). De- structive to germs. Germicide ( jer'mis-Id). An agent having the power to destroy germs. Gestation ( jes - ta ' shun). Preg- nancy. p. 49. Gland (gland). An organ which separates a fluid from the blood. Glandular (gland'u-lar). 1. Hav- ing the nature of a gland. 2. Fur- nished with glands. Gians (glanz), pi glan' des. Latin for Gland. The distal end or head of the penis or clitoris, p. 339. Graafian follicle (grah'fe-an fol'- lik- 1 ). Small spherical bodies in the ovary, each containing an ovum. Granulation (gran-u-la'shun). The formation in wounds of small, rounded, fleshy masses ; also a mass so formed. Gravid uterus (grav'id u'ter-us). Pregnant uterus. Gravida (grav'id-ah) [L.]. A preg- nant woman. Gravidity (grav - id ' it - e) . Preg- nanev. Gum, red (gum). Strophulus, a reddish eruption on the skin of the new-born. White g., strophulus al- bus ; a whitish eruption on the skin of the new-born. p. 342. Gynecic (jin-e'sik). Relating to women. Gynecologist ( jin - e - kol ' o-jist). One who is skilled in gynecology. Gynecology ( jin-e-kol'o-je). That branch of medicine which treats of I women’s constitution and diseases. GLOSSARY 473 H. Harelip (har'lip). A congenital slit in the upper lip, sometimes double. P- 356 . Hebosteotomy. Section of the bone at the side of tne pubic symphysis, — pubiotomy. Hematoma An accumulation of blood in the tissues. Hematemesis (hem-at-em'es-is). The vomiting of blood. Hematosalpinx (hem"at - o - sal'- pinx). Distention of the Fallopian tube with blood. Hemorrhage (hem'or-rej). The escape of blood from its natural chan- nels. p. 272. Hemorrhoid (hem'or-roid). A pile; a vascular tumor of the mucous mem- brane of the rectum. External h., appearing external to the anus. In- ternal h., within the anus. p. 34. Hernia (her'ne-ah) [L.]. The pro- trusion of an organ, or part of an or- gan, through an abnormal opening; rupture, p. 358. Heterogeneous (het"er-o-je / ne- us). Of dissimilar nature. High forceps (hi for'seps). The application of the forceps to the fetal head as it enters the brim of the pel- vis. p. 193. Hirsute (her'sut). Covered with hair. Homogeneous ( ho - mo - je'ne-us). Of a similar nature. Hydragogue (hi'dra-gog). A drug having the power to increase the glandular secretions, and producing profuse watery discharges from the bowels. Hydrometer (hi-drom'et-er). An instrument for measuring the specific gravitv of fluids. Hygiene (hi-jen'). The science of health and its preservation. Hygienic (hi-je-en'ik). Pertaining to hygiene or to health. Hygrometer (hi-grom'et-er). An instrument for measuring the mois- ture of the atmosphere, p. 372. Hymen (hi'men). The membranous fold which partly closes the entrance to the vagina, especially in the virgin. Hyperemesis (hi- per-em'e-sis). Excessive vomiting, p. 238. Hypersecretion (hi"per-se-kre / - shun . Excessive secretion. Hypertrophy (hi-per'tro-fe). The unnatural overgrowth of an organ or part. Hypodermatic, Hypodermic (hi"- po - der - mat ' lk, hi-po-der'iriik ). 1. Pertaining to the application of medi- cine under the skin. 2. A medicine introduced under the skin. H. in- jection, the injection of medicine or nutrient solutions under the skin. H. needle, the hollow needle of a hypo- dermic syringe. H. syringe, a small syringe for injecting fluid under the skin. Hypodermoclysis (hi " po - der - mok'lis-is). Introduction into the subcutaneous tissue of fluids in large quantity, p. 225. Hypogastric arteries (hi-po-gas'- trik). The umbilical arteries. They form part of the umbilical cord. Hysteria (his - te're - ah). A ner- vous disease, mainly of young women, characterized by lack of control over acts and emotions. Hysterotomy (his-ter-ot'o-me). Cesarean section, p. 201. I. Icterus neonatorum (ik'ter-us ne- o-na'tor-um). The jaundice some- times seen in the new-born. pp. 69, 34i- Iliac (il'e-ak). Pertaining to the ilium or flank. I. artery, one of the two branches of the abdominal aorta. I. fossa, the broad, shallow cavity at the upper part of the inner surface of the ilium. Ilium (il'e-um), pi., il'ia |~L.]. The broad, flat, upper part of the innomi- nate bone. Impregnation (im-preg-na'shun). The act of making pregnant ; fecun- dation. p. 40. Impression, maternal (im-presh'- un, mat-er'nal). The effect produced on the fetus in utero by the mental and other experiences of the mother during pregnancy, p. 82. Inanition fever (in-an-ish'un fe'- ver). A fever in infants, due to wast- ing of the body from lack of nourish- ment. p. 333/ 474 GLOSSARY Incise (in-siz'). To cut in or into, as with a knife. Incised wound (in-sizd' woond). A wound made with a sharp knife. Incision i in-sizh'un). A wound made by cutting ; a cut. Incontinentia paradoxa (in-kon- tin-en'she-ah par-ad-oks'ah). Filling of the bladder with urine, overflow and dribbling away of urine, pp. 67, 248. Incubator (in'ku-ba-tor). An ap- paratus for rearing prematurely born children ; a couveuse. p. 368. Indurated (in'du-ra-ted). Hard- ened ; rendered hard. Induration (in-du-ra'shun). An abnormally hard spot or place. Infection (in-fek'shun). 1. The communication of disease from one person to another. 2. The agent by which a disease is conveyed. Septic i., infection caused by pus-producing germs, p. 279. Infectious (in-fek'shus). Liable to be communicated by infection. Inflammation (in-flam-ma'shun 1. A diseased condition characterized by heat, pain, redness, and swelling, with or without fever. Infusion (in - fu ' zhun). 1. The I steeping of a substance in water to ' obtain its medicinal properties. 2. The injection of a hot normal salt solution, 0.6 per cent., into a blood- vessel or subcutaneous tissue. Arte- rial i., infusion into an artery Sub- cutaneous i., injection of the salt solution into the loose subcutaneous tissue. The usual locations are under the breast and over the shoulder- blades. Venous i., infusion into a vein. Fig. 118. Ingesta (in-jes'tah). Food taken into the stomach. Ingestion (in-jest'shun). The act of taking food into the stomach. Inhalation (in-hal-a'shun). 1. The drawing of air or other vapor into the I lungs. 2. A substance to be inhaled I as a vapor. Inlet (in'let). The upper limit of ' the cavity of the pelvis. Fig. 5. Innominate (in-nom'in-at). Not ! having a name ; nameless. I. bone, the hip-bone ; it consists of the ilium, the ischium, and the os pubis. Innominatum (in-nom-in-a'tum). The innominate bone. Fig. 4. Insomnia (in-som'ne-ah 1. Inabil- ity to sleep ; abnormal wakefulness, p. 306. Inspiration (in-spi-ra'shun ). The act of drawing air into the lungs. Inspiratory (in'spir-a-to-re). Per- taining to inspiration. I. muscles, those muscles which, by their con- traction, assist in inspiration. Intertrigo (in-ter-tri'go). A chaf- ing of the skin in moist situations, as about the anus and vulva, and in the arm-pits; chafe, p. 343. Intestine (in-tes'tin). The bowel. The long membranous tube that ex- tends from the stomach to the anus. Introitus. (in-tro-i-tus). The en- trance to the vagina. Inunction (in-unk'shun). The a< t of applying an ointment with friction. In utero (in u'ter-o). Inside the uterus. Inversion (in-ver'shun). Turning inside out or upside down. I. of the uterus, the turning inside out of the uterus. It may be due to pulling on the cord, a heavy placenta, or to the violent efforts of the patient. Involution (in-vo-lu'shun). The return of the uterus to its normal size after labor, p. 64. Irrigation (ir-ig-a'shun). 1. Wash- ing by a stream of water or other lo- tion. 2. The liquid used for irrigation. Ischium) is'ke-um), pi., is'chia[ L.]. The lower, posterior part of the in- nominate bone. It is separate from it in fetal life and infancy. Ischuria (is-ku're-ah ). Difficult urination. I. paradox'a, overflow of the full bladder. See Incontinentia paradoxa. pp. 67, 248. J. Jactitation (jak-tit-a'shun). The tossing and restlessness of a patient in acute disease. Jaundice (jawn'dis) [L., ic'terus\. Yellowness of the skin, eyes, and se- cretions, due to the presence of bile- pigments in the blood. Icterus, pp. 69, 341. Jelly of Wharton (jel'e). The soft pulpy tissue of the umbilical cord. GLOSSARY 475 K. Kleptomania (klep-to-ma'ne-ah). A nervous affection characterized by a desire to steal. Knee-chest position (ne-chest po- zish'un). That position in which the patient rests flat on the chest and knees, with the hips elevated as high as possible, and the thighs extending vertically ; same as genu-pectoral, p. 238. Kumiss (koo ' mis). A nutritive food prepared originally from mare’s milk, now from cow’s milk. Kyphosis (ki-fo'sis). Hump- backed curvature of the spine. L. Labia (la'be-ah) [L.]. The plural of la'bium. Lips, or parts resembling lips. L. majo'ra, the folds of skin and fat which form each side of the vulva. L. mino'ra, the folds of mucous membrane inside the labia majora ; the nymphae. Labor (la'bor). Parturition. The expulsion of the fetus from the uterus. Dry 1., labor in which there is a lack of amniotic fluid. Induced 1., labor artificially brought on. Missed 1., retention of the dead fetus in the uterus beyond the normal period of pregnancy. Precipitate 1., labor of abnormally short duration. Prema- ture 1 ., labor occurring before the normal time. Spontaneous 1., labor without artificial aid. Laceration (las-er-a'shun). 1. The act of tearing. 2. A wound made by tearing; in obstetrics, referring to the perineum, pp. 131, 139. Lactation (lak-ta'shun). 1. The secretion of milk. 2. The period of milk-secretion. 3. The suckling of the infant, p. 65. Lacteal (lak'te-al). 1. Pertaining to milk. 2. One of the intestinal lymphatics that take up chyle. L. calculus, a concretion of thickened milk in one of the milk-ducts. L. swelling, a swelling of the breast from an accumulation of milk. Lactiferous (lak-tif'er-us). Pro- ducing or conveying milk. pp. 35,65. Lactometer (lak-tom'e-ter). An instrument for finding the specific gravity of milk. Lambdoid, Lambdoidal (lam'- doid, lam-doi'dal). Shaped like the Greek letter A or A. L. suture, the suture between the occipital and the two parietal bones, p. 44. Lanugo (lan-u'go) [L.]. 1. The fine hair on the body of the fetus. 2. The fine hair found on nearly all the body except the palms and soles, p. 365- Laparotomy (lap-ar-ot'o-me). 1. Surgical incision through the flank ; celiotomy. 2. Abdominal section at any point. Larynx (lar'inx). The organ of voice ; the upper part of the trachea or wind-pipe. Laxative (lak'sat-iv). Slightly purgative ; a medicine which is mildly cathartic. Layette (la-et') [Fr.]. Infant’s wardrobe, p. 97. Lesion (le'zhun). 1. Any hurt, wound, or local degeneration. 2. A diseased condition of a tissue. Lethargic (le-thar'jik). In a state of lethargy. Lethargy (leth'ar-je). Stupor or coma. Marked drowsiness. Leukorrhea, Leucorrhea flu-kor- re'ah). A whitish discharge from the vagina and uterus; the whites. Ligature (lig'at-ur). A thread or wire for tying a blood-vessel or stran- gulating a part. Lightening (lit'en-ing). The sink- ing of the head into the pelvis in the last weeks of pregnancy, p. 55. Linea (lin'e-ah). Latin for Line. A line. L. al'ba [L. “ white line ”]. The central tendinous line extending from the sternum to the pubic bone. Linese albican'tes, “ striae gravi- darum.” Shining, whitish, and pur- plish lines on the abdomen of preg- nant women and those who have borne children. They are some- times due to distention from other causes, pp. 51, 52. Liquor (li'kwor), pi., liquo'res [L.]. A fluid or liquid. L. am'nii, the fluid contained in the amniotic sac, and surrounding the child, p. 42. Lithopedion (lith - o - pe ' de - on). 476 GLOSSARY “Stone-child.” A fetus that has died and become changed into a hard mass of calcareous matter. Lithotomy (lith-ot'o-me). The re- moval of a stone by cutting into the bladder; cystotomy. L. position, the patient lies on the back, with the legs and thighs well flexed, the knees widely separated, and hips well over the edge of the table, pp. 185, 186. Lochia (lo'ke-ah). The vaginal and uterine discharge occurring for several days after delivery. L. al/ba, the whitish discharge normal after the first ten days of the puerperal state. L. cruen'ta, L. ru'bra, the blood- stained discharge occurring the first week after delivery. L. sanguin- olen'ta, the watery bloody discharge from the third to sixth day. L. sero- sa, the pinkish or serous discharge after the first ten days. pp. 63, 64. Lochial (lo'ke-al). Pertaining to the lochia. Low forceps (15 for'seps). For- ceps applied to the fetal head at the outlet of the pelvis, p. 190. Lues. Syphilis, p. 449. Lying-in (li-ing-in'). The puer- peral state. L.-i. fever, puerperal fever. L.-i. hospital, a hospital for the care of women during pregnancy and labor and after confinement : a maternity. Lysis (li'sis). Gradual decline of fever. M. Macerated (mas'er-a-ted). Soft- ened and broken up by long-con- tinued action of a fluid or by a di- gestive process. Malaise (mal-az') [Fr.]. Discom- fort or uneasiness ; indisposition. Malposition 1 mal-po-zish'un). Ab- normal position. Malpractice (mal-prak'tis). Im- proper or injurious practice; unskil- ful or injurious medical or surgical treatment. Mamma (mam'mah). The breast; the mammary gland, p. 65. Mammary (mam'ar-e). Pertain- ing to the breast. Mania (ma'ne-ah). A form of in- sanity in which there are excitement, delusions, and tendency to violence. P- 3 ° 4 - Maniacal (ma-ni'ak-al). Affected with mania. Manual (man'u-al). Pertaining to the hands ; performed by the hands. Marantic (mah-ran'tik). Having the nature of marasmus, p. 334. Marasmus (mar-az'mus). A dis- ease of young children in which there are progressive wasting and emaci- ation. p. 334. Massage (mas-sazh'). The sys- tematic employment of friction, kneading, and stroking of the body as a treatment for disease, pp. 148, 309. Mastitis (mas-ti'tis). Inflamma- tion of the breast, p. 315. Maternal (mat-urn'al). Pertaining to the mother; derived from the mother. M. impression, the effect produced on the fetus in utero by the mental and other experiences of the mother during pregnancy, p. 82. Maternity (mat-er'nit-e). 1. M tnerhood. 2. A lying-in hospital. M. nurse, an obstetric nurse. Mauriceau (maw-re-so'). A famous French obstetrician who lived in the eighteenth century. Meatus (me-a'tus), pi., mea'ti [L. for “ passage”]. A passage or open- ing. M. urina'rius, the external opening of the urethra, pp. 31, 33. Meconium (me-ko'ne-um) [L.]. The dark-green substance found in the large intestine of the fetus, and evacuated during the first days. p. 7 °. Median, Mesial (me'de-an, me'- she-al). Middle. Melancholia (mel-an-ko'le-ah). A form of insanity with depression of spirits and gloomy forebodings, pp. 249, 304. Melena (mel-e'nah). 1. The pas- sage of dark, pitchy feces, stained with blood-pigments, or containing blood. 2. The vomiting of altered blood ; black vomit, p. 333. Membrane (mem'bran). A thin layer of tissue covering a surface or dividing a space. Mucous m., lining of cavities which communicate with the external air. Serous m., the lining of one of the great body cavi- ties. GLOSSARY 477 Membranes (mem'brans). A term to indicate theamniotic sac. p. 59. Menopause (men ' o - pawz). “ Change of life.” The period at which menstruation ceases. Menses (men'sez). The normal monthly flow of blood from the uterus, pp. 38, 73, 345. Menstrual (men'stru-al). Relat- ing to the menses. Menstruate (men'stru-at). To have the monthly flow . Menstruation (men-stru-a'shun). The monthly flow ; the menses ; the function of menstruating, p. 38. Mento- anterior (men"to-an-te'- re-or). Having the chin directed for- ward. p. 173. Mentoposterior (men"to-pos-te'- re-or). Having the chin directed backward, p. 173. Microscopic (mi - kro - skop ' ik). Visible only with the aid of a micro- scope. Micturition (mik-tu-rish'un). Uri- nation. Midwife (mid'wif). A woman who attends women in labor. Miscarriage (mis-kar'rij). A term used by the laity to describe the ex- pulsion of the fetus at any time dur- ing pregnancy, p. 55. Modification (mod /, if-ik-a / shun). An alteration ; a change of form or condition, p. 397. Mole (mol). A fleshy mass formed in the uterus by the degeneration of an ovum in the early months of preg- nancy. Mons veneris. The large pad of fat over the pubes, p. 32. Monster (mon'ster). A fetus formed with an excess, a deficiency, or a malposition of parts. Monstrosity (mon-stros'it-e). A monster. Montgomery’s glands (mont- gom'er-ez). Sebaceous glands in the areola around the nipple, p. 36. Monthlies (month'lez). The menses, p. 38. Morbid (mor'bid). Diseased; per- taining to disease. Morbidity (mor-bid'it-e). 1. The condition or state of being diseased. 2. The sick rate or proportion of dis- ease to health in a community. Mother's mark (muth'erz). Birth- mark ; nevus. Mucosa (mu-ko'sah). Mucous membrane. Mucous (mu'kus). Pertaining to or resembling mucus. M. membrane, the membranous lining of all cavities of the body which communicate with the external air. Mucus (mu'kus). The viscid watery secretion of the mucous glands. Multigravida ( m ul-te-grav 'id -ah ) . A woman who has been pregnant several times. Multipara (mul - tip 'ar - ah). A woman who has borne several children. Mummification (mum"mif-ik-a'- shun). The drying and shriveling up of the fetus. N. Narcotic (nar-kot'ik). 1. Produc- ing sleep or stupor. 2. A drug capa- ble of producing sleep and relieving pain. Nates (na'tez). The buttocks. Nausea (naw'se-ah). Tendency to vomit. Sickness at the stomach. Navel (na'vel). The umbilicus. N.- string, the umbilical cord. Neonatorum (ne-o-na-to'rum). Of the new-born. Neonatus (ne-o-na'tus). The new- born. p. 68. Nephritis (nef-ri'tis). Inflammation of the kidney. Neurotic (nu-rot'ik). Nervous. Affected with a nervous disease. Neutral (nu'tral). Indifferent. Not decided nor pronounced. N. reaction, a reaction that is neither acid nor al- kaline ; not turning litmus -paper either red or blue. Nevus (ne'vus). 1. A birth-mark. 2. A spot on the skin, either congen- ital or acquired after birth. Nitrogenous (ni-troj'en-us). Con- tain ; ng nitrogen. Nodular (nod'u-lar). Like a nod- ule ; having nodules. Nodule (nod'ul). A small rounded mass ; a small node. Normal (nor'mal). Natural ; ac- cording to rule. Nutrient (nu'tre-ent). 1. Nourish- 478 GLOSSARY ing. 2. A nutritious substance. N. enema, an injection into the rectum j of easily digested food in liquid form. p. 459. Nutriment (nu'trim-ent). Nour- ishment. Nutrition (nu-trish'un). 1. The process of assimilating food. 2. Nour- ishment. Nutritious (nu-trish'us). Nourish- ing. Nutritive ( nu'trit-iv). Same as nu- trient. N. enema, nutrient enema. P- 459- Nymphse (nim'fe). The labia minora, p. 32. 0 . Obstetric, Obstetrical (ob-stet'- rik, ob-stet'rik-al). Pertaining to midwifery or obstetrics. Obstetrician (ob-stet-rish'un). An accoucheur ; one who is skilled in the delivery of women in labor. Obstetrics (ob-stet'riks). The science and art of assisting women through pregnancy and labor and during the puerperium ; midwifery. Occiput (ok'sip-ut) [L.]. The back part of the head. p. 171. Oleum ricini (o'le-um ris'in-i). Castor oil. Dose, 3-8 drams, p. 144. Oligohydramnios (ol " ig - o - hi- dram'ne-os). Scarcity of the amniotic fluid. Opacity (o-pas'it-e). An opaque spot ; inability to transmit the rays of light. Ophthalmia (of-thal'me-ah). In- flammation of the eye or of the mucous membrane lining the eyelids. 0. neonato'rum, ophthalmia of the new-born. p. 347. Organ (or'gan). Any part of the body having a special function. Os (os). Latin for month. 0. u'teri, the mouth of the uterus. 0. u'teri exter num, the external opening of the canal of the cervix. 0. u'teri in- ter'num, the internal opening of the canal of the cervix, p. 28. Os (os). Latin for bone. 0. in- nomina'tum, innominate bone. Osmosis (os-mo'sis). The passage of a fluid or of salts through a mem- brane. Outlet (out'let). The lower limit of the cavity of the pelvis. Figs. 6, 8. Ovarian (o-va're-an). Pertaining to the ovary. Ovary (o'va-rc). The female sexual gland in which the ova are devel- oped. The ovaries are situated in the pelvis, on either side of the uterus, p. 31. Fig. 15. Oviduct (o'vid-ukt). The Fallo- pian tube, which carries the ovum from the ovary to the uterus. Fig. I S- Ovisac (o'vis-ak). Graafian follicle, which see. Ovulation ( o - vu - la'shun). The formation and discharge of the un- impregnated ovum from the ovary. P- 37- Ovule (o'vul). The ovum within the Graafian follicle. Ovum (o'vum). 1. An egg. 2. The female reproductive cell. The hu- man ovum is about inch in diam- eter. p. 37. Oxytocic (oks-e-to'sik). 1. Hasten- ing delivery. 2. A drug which hastens delivery. Ozena (o-ze'nah). A disease of the nose with an offensive discharge. P. Pack the uterus. To tampon the uterus, p. 220. Pallor (pal'lor). Paleness ; lack of color, pp. 273, 277. Palpation (pal-pa'shun). Exam- ination by the hand or by the sense of touch. Obstetric p., palpation of the abdomen of the pregnant woman, to learn the size, position, and pres- entation of the fetus, p. 173. Palpitation (pal-pit-a'shun). Un- duly rapid action of the heart. Paraplegia (par - ah - pie ' je - ah). Paralysis affecting the lower half of the body. Paralysis of both legs. Usually associated with paralysis of the lower half of the trunk. Paregoric (par-e-gor'ik). Cam- phorated tincture of opium. An ano- dyne. Dose, 5-75 min. for an adult. Parietal (par-i'et-al). Pertaining to the walls of a cavity or organ. P. bones, the two large bones forming | the sides and top of the skull, p. 44. GL OSSAR J 479 Paroxysm (par'oks-izm). A sudden recurrence or increased severity of symptoms. A periodic attack of symp- toms. Paroxysmal (par - oks - iz ' mal). Having paroxysms. Parturient (par-tu're-ent). Child- bearing. Giving birth. P. canal, the uterus and vagina considered as one canal. P. woman, a woman in labor. Parturition (par-tu-rish'un). The process of giving birth to a child. Pasteur (pas - ter'). A noted French physician ; born, 1822; died, 1899. Pasteurization (pas " tur - iz - a shun). The checking of fermentation (especially in milk) by heating to a temperature of from 155 0 to 170° Fahrenheit for thirty minutes. Paternal (pa-ter'nal). Relating to or derived from the father. Pathologic, Pathological (path-o- loj'ik, path-o-loj'ik-al). Morbid; dis- eased. Pathology (path - ol ' o - je). The science which treats of the nature of disease and the changes in the body caused by disease. Pedunculated (pe-dung'ku-la-ted) . Having a peduncle or stem. Pellicle (pel'ik-l). A thin skin or film. A film on the surface of a liquid. Pelvimeter (pel-vim'e-ter). An in- strument for measuring the diameters of the pelvis, p. in. Pelvimetry (pel-vim'et-re). The measurement of the pelvis. External p., external measurements. Internal p., internal measurements, p. in. Pelvis (pel' vis). The basin-shaped ring of bone at the lower extremity of the trunk. It is formed in front and at the sides by the innominate bones, and behind by the sacrum and coccyx, pp. 21, 26. Pemphigus (pem'fig-us). An erup- tion on the skin consisting of large flat blebs filled with serum or pus. Pepsin (pep'sin). 1. A ferment of the gastric juice which digests pro- teids. 2. That used as a medicine is derived from the stomach of pigs. Dose, 10-15 grains. Peptic salt ( pep'tik sawlt). A com- bination of table salt and scale pepsin, p. 388. Perforator (per'fo-ra-tor). An in- strument for piercing the bones of the fetal head. Fig. 100. Perineorrhaphy ( per"e-ne-or'ra- fe). The operation of suturing a tear or laceration of the perineum, pp. 129, 218. Perineum (per-e-ne'um). The tissue between the anus and vulva. P- 32. Periphery (per-if'er-e). The cir- cumference; the portion farthest from the center. Peristalsis (per-is-tal'sis). The worm-like movements by which the stomach and bowels propel their contents. It is produced by the contraction of the circular and lon- gitudinal muscular fibers of these organs. Peristaltic (per-is-tal'tik). Per- taining to peristalsis. Peritoneal (per"it-o-ne'al). Per- taining to the peritoneum. Peritoneum (per // it-o-ne'um). A serous membrane which lines the ab- dominal walls and covers all the or- gans contained in the abdomen. Peritonitis (per // it-o-ni'tis). In- flammation of the peritoneum. Pernicious (per-nish'us) 1 Danger- ous; tending toward a fatal result. Perspiration (per-spir-a'shun). 1. Sweat. 2. The function of sweat- ing. Pessary (pes'sar-e). An instru- ment placed in the vagina to act as a support to the uterus. Phantom (fan'tum). An effigy of a child or mother used to illustrate the mechanism of labor. P. pregnancy, pseudocyesis; a peculiar enlargement of the abdomen sometimes occurring in hysterical women and resembling the abdomen of a pregnant woman. P. tumor, a tumor of the abdomen due to flatus or the contraction of the muscles of the abdomen ; phan- tom pregnancy. Pharmacopeia t far // mak-o-pe'ah). A book containing directions for pre- paring medicines. Published by au- thority in the United States every ten years. Phenomenon (fe-nom'en-on), pi., 480 GLOSSARY phenom' ena. Any remarkable ap- pearance. Any sign or symptom. Phimosis ifi-mo'sis). A tightness of the foreskin so that it cannot be drawn back to uncover the glans of the penis. Phlegmasia alba dolens ( fleg-ma' zhe-ah al'ba do'lens). “ Milk leg.” Inflammation of the femoral vein oc- casionally following labor and typhoid fever. It is characterized by a pain- ful swelling of the leg without red- ness. p. 297. Phlegmatic (fleg-mat'ik). Slug- gish, heavy, dull. Phlegmon (fleg'mon). Inflamma- tion of connective tissue with the for- mation of an abscess. Physical (fiz'ik-al). Pertaining to nature or to the body. Physiologic (fiz"e-o-loj'ik). Per- taining to physiology; normal. Physiology (fiz- e - ol'o -je). The science which treats of the living body and its parts and functions. Physique (fi-zek'). Natural con- stitution ; physical structure of a person. Physometra (fi-so-me'trah). Dis- tention of the uterus with gas or air. Pigment (pig'ment). 1. Coloring- matter found in organs and tissues of the body. 2. A dye or paint. A paint-like medicinal preparation to be applied to the skin. Pigmentary (pig'men-ta-re). Per- taining to pigment. Pigmentation (pig-men-ta'shun). The deposit of pigment in a part. The discoloration of a part by pig- ment. See Chloasma, p. 52. Pipet (pi-pet') [Fr.]. A slender glass tube used for transferring liquids. Placenta (pla-sen'tah). The after- ' birth ; the round flat organ in the pregnant uterus which establishes communication between mother and child, pp. 42, 46. P. prse'via, a placenta which is situated over the internal os. It may cause fatal hemor- rhage. p. 250. Pledget (pled 'jet). A plug; a sponge ; a small compress or tuft. P- 43 . 3 - Plethora (pleth'o-rah, pleth-o'rah). A condition in which there is an ex - 1 cess of blood in the vessels. It is at- tended by a feeling of fulness in the head, florid complexion, and a ten- dency to nose-bleed. Plethoric (pleth-or'ik, pleth'or-ik). Full-b.ooded. Pleura (piu'rah). The serous mem- brane that lines the cavities of the chest and covers the lungs. Pleural (plu'ral). Pertaining to the pleura. Podalic (po-dal'ik). Relating to, or by means of, the feet. P. ver'- sion, the turning of the child in the uterus so that the feet are made to present. Pole (pol). Either extremity of any axis. Polyhydramnios ( pol"e-hi-dram'- ne-os). Excessive amount of liquor amnii. Polyuria(pol-e-u're-ah). Increased urination, p. 66. Position (po-zish'un). 1. The atti- tude of a patient. 2. The attitude of the fetus in the uterus; the relation which the head of the child bears to the mother’s pelvis. If the child’s occiput is pointing toward the left side of the mother, it is a left position, p. 169. Posterior (pos-te're-or). Situated behind or to the rear. Postnatal (post-na'tal). Occurring after birth. Postpartum (post-par'tum). Oc- curring after delivery. P-p. chill, a chill lasting several minutes which often follows delivery. P-p. hemor- rhage, hemorrhage following deliv- ery. p. 272. P-p. shock, the ex- haustion following labor. Postpuerperal post - pu - er ' per- al). Occurring after child-birth. Precordia (pre-kor'de-ah). The fore part of the thorax ; the region in front of the heart. Precordial (pre-kor'de-al). Per- taining to the precordia. Pregnancy (preg'nan-se). Gesta- tion ; the condition of being with child. The duration of pregnancy is about 2R0 days. p. 49. Pregnant preg'nant). With child; gravid. Premature (pre-mat-iir'). Occur- ring before the proper time. P. in- GLOSSARY 481 fant, an infant born of a premature labor. P. labor, labor occurring from the twenty-eighth to the thirty-eighth week of pregnancy. P. respiration, respiration of the child before it is completely born. Premonitory (pre-mon'it-o-re). Serving as a warning. P. pains, uterine pains occurring before the beginning of true labor. Prepuce ( pre'pus). The foreskin ; the fold of skin which covers the glans penis. P. of the clitoris, the fold of mucous membrane which covers the glans of the clitoris. Presentation (pre - zen - ta ' shun). That portion of the fetus which occu- pies the lower segment of the uterus and first enters the birth-canal, p. 169. Primigravida (prim-ig-rav'id-ah ) . A woman pregnant for the first time. Primipara (pri-mip'-ah-rah). A woman who is giving or who has given birth to her first child. Prognosis (prog-no'sis). A forecast as to the probable result of a disease. Prognostic symptom (prog-nos'- tik simp'tum). A symptom from which a prognosis may be made. Prognosticate (prog - nos'tik - at). To make a prognosis. Prolapse (pro ' laps). A falling down of an organ. P. of the cord, the descent of the umbilical cord along with or ahead of the presenting part of the fetus, p. 270. P. of the uterus, “ falling of the womb.” Promontory (prom'on-to-re). A projection or prominence. P. of the sacrum, the upper projecting part of the sacrum. Fig. 1. Prophylactic (pro-fil-ak'tik). Per- taining to prophylaxis ; preventive. Prophylaxis '(pro-fil-ax'is). The prevention of disease ; preventive treatment. Protargol (pro-tar'gol). A soluble yellowish powder; a preparation of silver. It is a germicide used in gon- orrhea and sore eyes and wounds, p. 35i. Protein (pro'te-in). An important class of organic compounds, includ- ing albumin, casein, gluten, and fibrin, forming the important part of the tissues of the body. p. 395. 31 Pruritus (pru-ri'tus). Intense itching, p. 245. Pseudocyesis (su " do - si-e ' sis). False pregnancy ; phantom tumor, p. 74- Psychic, Psychical (si'kik, si'kik- al). Pertaining to the mind. Psychosis (si-ko'sis). Any disease or disorder of the mind. Ptyalism (ti'al-izm). Excessive se- cretion of saliva, p. 52. Puberty (pu'ber-te). The age at which the organs of reproduction be- come functionally active, p. 37. Pubes, Pubis (pu'bes, pu'bis). 1. The os pubis ; the pubic bone. It is the anterior portion of the os innom- inatum, but in fetal life it is a sepa- rate bone. 2. The external part of the generative region, which is more or less covered with hair after puberty, p. 26. Pubic (pu'bik). Pertaining to the pubes, p. 26. Pubiotomy (pu-be-ot'o-me). Sec- tion of the os pubis at one side of the symphysis for the purpose of enlarg- ing the pelvis, p. 211. Pudenda (pu-den'dah). Plural of Pudendum, p. 31. Pudendum (pu-den'dum). The ex- ternal genitals, especially of the fe- male. p. 31. Puerpera (pu-er'pe-rah). A woman in child -bed. p. 61. Puerperal (pu-er'per-al). Relating to child-bed. P. convulsions, those occurring during or immediately after labor. P. eclampsia, same as puer- peral convulsions. See Eclampsia. P fever, fever due to infection dur- ing or immediately after labor; puer- peral infection. P. insanity, P. mania, insanity developing in the latest period of pregnancy or just after labor. P. state, the condition of a woman during the ten days after labor or during the period of con- valescence after labor, p. 61. Puerperium (pu-er-pe' re-um). The period or state of confinement after labor, p. 61. Pulmonary ( pul'mo-na-re). Per- taining to the lungs. Pulsation (pul-sa'shun). A throb or rhythmic beat, as of the heart. Purpura (pur'pu-rah). A disease 482 GLOSSARY in which there are purple patches 1 on the skin and mucous membrane, due to hemorrhage under the skin. There may or may not be fever present. Purpuric fpur-pur'ik). Relating to purpura. Purulent (pu'ru-lent). Consisting of or containing pus. Pus (pus). A liquid, the product of inflammation, made up of white blood-cells and a thin fluid, which is found in abscesses and on the surface of sores ; matter ; corruption. Pyosalpinx (pi-o-sal'pinks). A col- lection of pus in the Fallopian tube. Pyromania (pi-ro-ma'ne-ah). A nervous affection characterized by a desire to set fire to things. Q. Quickening. First perception by the mother of the movements of the child in utero. “Feeling life’ 1 occurs from the fifteenth to twentieth week. R. Racemose (ras'em-os). Resembling a bunch of grapes, p. 35. Rachitic 1 rak-it'ik). Affected with rickets. R. pelvis, a pelvis deformed by rickets, p. 27, Rachitis (rak-i'tis). Rickets. Ramus (ra'mus), pi., ra'mi. The arms of the innominate bones which I unite and form the pubes. Rational (rash'un-al). 1. Reason- able. 2. Based on reasoning. R. symptoms, subjective symptoms — those given by the patient. Reaction (re-ak'shun). 1. Re- sponse to stimulation. 2. The phe- nomena caused by chemicals acting j upon one another. Rectal rek'tal). Pertaining to the rectum. R. alimentation, the ad- ministration of food by injecting it into the rectum, p. 459. Rectum (rek'tum). The lower part of the large intestine lying in the pelvis and terminating at the anus. | P- 31- Reflex (re'flex). 1. Reflected. 2. | A term applied to certain involuntary movements. Regurgitation (re-ger-jit-a'shun> 1. A flowing back. 2. The passive vomiting of infants. 3. The return of food to the mouth unaccompanied by nausea. Relaxation (re-lak-sa'shun). 1. Lack of muscular tone and strength. 2. A lessening of tension. Remission (re-mish'unj. An abate- ment of symptoms. Renal (re'nal). Pertaining to the kidney. Respiration (res-pir-a'shun). The act of breathing, including inspira- tion and expiration. Restitution (res-tit-u'shun). The rotation of the presenting part of the fetus, outside the birth-canal, so that it looks in the same direction that it did before entering the pelvis. Resuscitation ( res - us - it-a'shun 1. The restoration to consciousness of one who is apparently dead. p. 362. Retained placenta (re-tand'). A placenta not expelled by the uterus after labor. Retention (re-ten'shun). The per- sistent keeping within the body of matters that should normally be ex- creted. R. of urine, a condition in which the urine cannot be voluntarily discharged, p. 66. Rhinitis (rin'i-tis). Inflammation of the mucous membrane of the nose. Rickets (rik'ets). A constitutional disease of infants and young children in which there is lack of earthy salts in the bones. It results in deformi- ties and curvatures of the bones. It is frequently due to bad air and food. Rotation (ro-ta'shun). The act of turning round on an axis. R. stage Of labor, a movement in labor by which the occiput turns to the front or rear. pp. 24, 25. Rupture (rup'tur). 1, A forcible tearing of a part. 2. A hernia, p. 358 . S. Saccharum lactis (sak'ar-um lak- tis). Sugar of milk. p. 397. Sacro-anterior (sa"kro-an-te're- GLOSSARY 483 or). Having the sacrum pointing to I the front, pp. 171, 172. Sacro-posterior (sa^kro-pos-te'- re-or). Having the sacrum pointing to the back. pp. 171, 172. Sacrum (sa'krum). The triangu- lar bone which forms the back of the pelvis. Above, it articulates with the spinal column, and below with the coccyx. It is formed by the fusion of the five sacral vertebrae, p. 22. Sagittal (saj'it-tal). Shaped like an arrow. S. suture, the suture between the two parietal bones, pp. 43, 44. Saliva (sal-i'vah). Spittle; the clear, viscid, alkaline digestive fluid secreted by the salivary glands in the mouth. It contains a ferment, ptyalin, which converts starch into maltose. Salivation (sal-iv-a'shun). An ex- cessive flow of saliva; ptyalism. pp. 52, 45°- Saturated solution (satsh ' er-a- ted). A solution which will not contain any more of a given sub- stance. Scalpel (skal'pel). A small straight knife with a convex cutting edge. Scapula (skap'u-lah). The shoul- der-blade. Scopolamin (sko-pol-am'in). A new drug derived from the scopolo- mina japonica, often used in combi- nation with morphine for the produc- tion of anesthesia, p. 120. Scrotum (skro'tum). The pouch j which contains the testicles. Sebaceous (se-ba'shus). 1. Pertain- ing to sebum or fat. 2. Secreting a greasy substance or sebum. Sebum (se'bum). A thick, semi- liquid substance, composed of fat and broken-down epithelial cells, which is discharged upon the skin. Secretion (se-kre'shun). 1. The process of separating various sub- stances from the blood. 2. Any se- creted substance. Secundines (se-kun'dinz). The j after-birth and membranes, pp. 40, 46. Segmentation (seg-men-ta'shun). The division into parts, more or less similar, especially that which takes place in the fertilized ovum. Semen (se'men). 1. A seed. 2. j The fluid secreted by the male gen- erative organs. Semilunar (sem-il-u'nar). Shaped like a crescent. Sepsis (sep'sis). Infection by bac- teria. p. 279. Septic (sep'tik). Produced by or due to infection. Serous (se'rus). Having the nature of serum. Serum (se'rum). The clear, straw- colored liquid which, in the clotting of blood, separates from the clot and corpuscles. Shock (shok). Sudden depression of the vital powers due to an injury or powerful emotion. That due to injury is surgical shock; that due to emotion is mental shock. Show (sho). 1. The blood-tinged discharge of mucus from the cervix preceding labor, p. 57. 2. The vag- inal discharge of menstruation. Sigmundine, Justine isig-mun'- den). A midwife who lived in the seventeenth century. Sims, J. Marion (simz). A noted American gynecologist who lived in the nineteenth century. S. position, the patient lies on the left side, and the chest, the right knee, and thigh well drawn up, the left arm along the back or over the edge of the table, p. 270. S’s speculum, a vaginal speculum or retractor. Siphon, Syphon (si'fon). A bent tube by which liquid may be trans- ferred from one vessel to another over an intervening elevation. Fig. 199. Skim milk (skim milk). Milk from which the cream has been removed ; it contains from 1 to 2 per cent. fat. P- 398- Smegma 1 smeg'mah). The secre- tion of the sebaceous glands under the prepuce and around the labia minora, p. 109. S. embryo'num, vernix caseosa. (Rare.) Soda-bicarbonate. Baking soda. Dose, 5-30 grains, p. 432. Soda-carbonate. Washing soda. Solution (so-lu'shun). 1. The pro- cess of dissolving. 2. A liquid con- taining dissolved matter. Sordes (sor'dez). The foul matter which collects on the lips and teeth in typhoid and other fevers and con- ditions. Sound (sownd). An instrument to 484 GLOSSARY be introduced into a cavity to detect a foreign body or dilate a stricture. Spastic (spas'tik). A term applied to muscle that is rigidly contracted. Specific (spe-sif'ik). 1. Pertaining to species. 2. Produced by a single kind of organism. 3. A remedy which has a peculiar efficiency in a certain disease. S. disease. 1. A disease produced by a specific cause. 2. The term is sometimes restricted to syph- ilis. p. 449. S. gravity, the weight of a substance compared with an equal volume of another substance taken as a standard. Hydrogen is the standard for gases and distilled water for liquids. Spermatozoid (sper-mat-o-zo'id). Same as Spermatozoon. Spermatozoon (sper-mat-o-zo'on). pi., spermatozoa. The motile, micro- scopic, sexual element of the semen — the male element of fertilization. Spir'itus Athens Nitro^si. Sweet sp rits of niter; dose, 3 %SY S. frumen'ti, whisky. Sprue (sproo). Thrush ; a sore mouth of infants, with the formation of whitish patches and superficial ulcers, p. 333. Stasis (sta'sis). Stagnation ; non- movement : usually applied to fluids. Sterile (ster'il). 1. Barren. 2. Not containing micro-organisms ; aseptic ; surgically clean. Sterility (ster-il'it-e). The con- dition of being barren. Inability to become pregnant. Sterilization (ster - il - iz - a'shun). The process of rendering an object free from germs, p. 92. Sterilizer ister'il-i-zer). An appa- ratus for sterilizing, p. 430. Still-born. Born dead. p. 360. Stimulant (stim'u-lant). 1. Stimu- lating. 2. A medicine which pro- duces stimulation. Stimulate (stim'u-lat). To excite to functional activity. Stimulus (stim'u-lus). An agent that excites to functional activity. Stool (stool). The feces discharged from the bowels. Streptococcus (strep-to-kok'us). A variety of micro-organisms. It causes the severest child-bed infec- tions. Stria (stri'ah), pi., stri'ce. A streak or line. S. gravida'rum, the striae seen on the abdomen of women who are or have been pregnant. See Linea albicantes. pp. 51, 52. Strophulus ( strof'u-lus). An erup- tion of infants called "tooth-rash" or “ gum-rash.” p. 342. Stupor (stu'por). Unconscious- ness, partial or complete. Styptic (stip'tik). 1. Astringent. 2. A remedy that is markedly astrin- gent and hemostatic. Subcutaneous (sub-ku-ta'ne-us). Under the skin. S. injection. See Hypodermic injection. Succedaneum (suk-se-da'ne-um i. A medicine that may be substituted for another of like properties. Caput s., a dropsical swelling on the pre- senting part of the fetal head during labor, due to lack of pressure on the part and pressure on the surrounding area. p. 356. Superior strait (su-pe're-or). The upper border of the true pelvis ; the inlet ; the brim. p. 24. Suppository (sup-oz'it-o-re). An easily fusible medicated mass intro- duced into the rectum, urethra, or vagina. Suppuration (sup-u-ra'shun). The formation of pus. Suppurative (sup'u-ra-tiv). Pro- ducing or discharging pus. Suture (su'tur). 1. A surgical stitch or seam. p. 129. 2. The material used for a suture. 3. The line of union between two bones of the head or face. pp. 43, 44. Symphysiotomy (sim-fiz-e-ot'o- me). The operation of severing the ligaments and cartilage forming the pubic joint or symphysis. Done in difficult labor, p. 211. Symphysis 1 sim'fiz-is). 1. A kind of firm joint. 2. The term is used to refer to the symphysis pubis or union between the two pubic bones, p. 26. Synchondrosis (sin-kon-dro'sis). The union of bones by means of elas- tic cartilage. Syncope (sin'ko-pe). Fainting; a swoon ; a more or less complete sud- den failure of respiration and heart action, p. 273. Syphilis (sif'il-is). An infectious GLOSSARY 485 disease, usually venereal in origin, very chronic and obstinate in nature, p. 449. T. Tampon (tam'pon). 1. A plug of cotton, gauze, or other material, placed in a cavity to stop a hemor- rhage or absorb secretions. 2. To place a tampon, p. 220. Tamponade, Tamponage (tam'- pon-ad, tam'pon-aj). The use of the tampon, p. 220. Tamponing (tam'pon-ing). The act of using the tampon, p. 220. T-bandage. A bandage shaped like the letter T ; used to retain dress- ings of the vulva in place, p. 92. Tenaculum (ten-ak'u-lum). A hook-shaped instrument; ahook. T. forceps, a forceps armed with hooks ; a volsella. p. 195. Tenesmus (ten-es'mus). Straining ; ineffectual straining at stool or at urination; a feeling of desire to strain at stool, etc. Testicle (tes'tik-l). One of the two male organs in the scrotum, analo- gous to the ovary in women. Tetanus (tet'an-us). Lockjaw; a disease caused by the bacillus of tet- anus, and in which there are tonic spasms of some of the voluntary mus- cles, first noticed in the muscles of I jaw and throat. Thermostat (ther'mo-stat). An apparatus for automatically regulat- ing heat. p. 368. Thoracic (tho-ras'ik). Pertaining to the thorax. Thorax (tho'raks). The part of the body above the diaphragm. It con- tains the heart and lungs. Thrombosis (throin'bo-sis). The formation of a thrombus or clot in a vessel, p. 297. Thrombotic (throm-bot'ik). Per- taining to or of the nature of a throm- bus. p. 297. Thrombus (throm'bus). A clot in a blood-vessel remaining at the point of its formation. Thrush (thrush). Sore mouth; sprue. Caused by a vegetable fungus called Monilia albicans, pp. 333, 388. Tissue ( tish'u). An aggregation of [ cells forming a structure with a defi- nite function. Torsion (tor'shun). Twisting. T. of the umbilical cord, the spontane- ous twisting of the cord in uiero. Toxemia (tok-se'me-ah). A condi- tion due to the presence of toxins in the blood. These toxins may be the product of bacterial action, or they may be effete matter which should be excreted, pp. 87, 242. Trachea (tra'ke-ah). The wind- pipe ; the air-tube leading from the larynx to the bronchi. Tracheal catheter ( tra'ke-al). A slender tube or catheter for drawing mucus and fluids from the trachea in case of asphyxiation, and blowing air into the lungs, p. 360. Traction (trak'shun). The act of drawing or pulling. Transfusion (trans-fu' shun). 1. The transfer of blood from one per- son to another. 2. The introduction into the blood-vessels of any liquid, as salt solution, p. 225. Trendelenburg position (tren'- del-en-berg). The patient lies flat on the back. The end of the table is elevated so that the hips are raised to an angle of 45 0 . The legs hang over the end of the table. Used in ab- dominal operations and in the treat- ment of prolapse of the cord. p. 271. Tubercle (tu'ber-kl). A rounded nodule or elevation. Tuberculosis (tu-ber-ku-lo'sis). An infectious disease caused by tu- bercle bacilli, and characterized by the formation of tubercles. In the lungs it is called consumption. Tumor (tu'mor). 1. A swelling. 2. A new growth ; a tissue which grows independent of surrounding struc- tures and has no physiologic use. A tumor which tends to recur after removal is malignant ; one which does not is benign. Tympanites (tim-pan-i'tez). Dis- tention of the bowels or peritoneal cavity with air or gases. p. 299. Uterine t., distention of the uterus with gas. Phvsometra. Typhoid fever (ti'foid). A spe- cific fever due to the Bacillus typhosus, and following a particular course T. state, a condition of great physical 486 GLOSSARY exhaustion, with stupor and delirium, resembling that found about the close of the second week of typhoid. It may occur in toxemia and puerperal infection. U. Ulcer (ul'ser). An open sore. Ulcerate (ul'ser-at). To form an ulcer; to be affected with ulcers. Umbilical (um-bil'ik-al). Pertain- ing to the umbilicus or navel. U. arteries, the arteries forming part of the umbilical cord. U. cord, the cord connecting the placenta with the um- bilicus of the fetus. It is made up of the umbilical arteries and veins and a jelly-like substance called “ Whar- ton’s jelly.” p. 43. U. hernia, her- nia at the navel. U. veins, the veins of the umbilical cord. Umbilicus (um - bil - i 'kus). The navel ; the site of entrance of the umbilical vessels into the abdomen, p. 346. Urea (u-re'ah). The principal solid of the urine ; it carries off most of the waste nitrogenous products of the body. Uremia (u-re'me-ah). The toxic condition produced by the presence of urinary constituents in the blood. It is due to diminution of excretion by way of the urine and is marked by nausea, vomiting, dizziness, head- ache, and coma. Uremic (u-re'mik). Affected with uremia. Urethra (u-re'thrah). The mem- branous canal leading from the blad- der to the surface of the body. p. 31. Urethral ( u-re'thral). Pertaining to the urethra, p. 31. Uric acid (u'rik). A crystallizable acid found in urine. It is nearly in- soluble, and when retained in the system is thought to produce gout and rheumatism. Urinal (u'rin-al). A vessel to re- ceive urine. 1 Urinalysis (u - rin - al'is - is). The analysis of urine. Urinary (u'rin-a-re). Pertaining to urine. Urinate (u'rin-at). To pass urine from the bladder. Urination (u-rin-a'shun). The act of passing the urine from the bladder. Urine ( u'rin). The fluid secreted by the kidneys, stored in the bladder, and discharged through the urethra. Incontinence of u., inability to re- tain urine in the bladder, so that it escapes involuntarily ; incontinentia paradoxa, filling of the bladder, with overflow and dribbling away of urine. Retention of u., inability to pass the urine. Suppression of u., arrested secretion of urine by the kidneys. Urinometer ( u-rin-om'et-er). An instrument for determining the spe- cific gravity of urine. Uterine (u'ter-in). Pertaining to the uterus or womb. U. appendages, the Fallopian tubes and the ovaries. U. atony, weakness of the uterine muscle ; term used during and after labor. U. colic, pains in the uterus from any cause except labor pains. U. gestation, normal pregnancy U. inertia, lack of contractile power of the uterus during labor : ‘ ‘ weak pains atony. U. involution, the process by which the uterus regains its ordinary size and shape after labor. U. mole, a mass in the uterus con- sisting of a dead fetus and its envel- opes. U. phlebitis, a form of puer- peral fever. U. pregnancy, normal pregnancy. U. probe, a long, flexi- ble probe for exploring the uterus. U. sinuses, the veins of the uterus enlarged by pregnancy. U. sound, a uterine probe. U. tubes, Fallopian tubes, U. wound, the area from which the placenta has been re- moved. Uterus (u'ter-us). The womb; the hollow muscular organ in which the fetus is normally developed, p. 28. V. Vagina (vaj-i'nah). The curved canal extending from the cervix of the uterus to the vulva, pp. 29, 64. Vaginal (vaj'in-al). Pertaining to the vagina. V. examination, exam- ination of the pelvic organs by means of the finger introduced into the vag- ina. V. speculum, an instrument for holding the vagina open in order that its interior may be inspected. GLOSSARY 487 Valance (val'anz). Hanging dra- pery about a bedstead, p. 107. Varicose (var'ik- 5 s). 1. Unnatur- ally swollen or dilated ; a term ap- plied to veins. 2. Pertaining to a varix. p. 243. Varicosity (var-ik-os'it-e). 1. A varicose condition of the veins. 2. A varix. p. 243. Varix (va'rix). An enlarged tortu- ous vein. p. 243. Vascular ( vas ' ku - lar). Having blood-vessels ; full of blood-vessels. Vascularity (vas-ku-lar'it-e). The condition of being vascular. Vectis (vek ' tis). A curved lever for making traction on the fetal head during labor ; almost obsolete now. Vein (van). A blood-vessel carry- ing blood to the heart. Venous (ve'nus). 1. Pertaining to the veins. 2. Contained in the veins. V. blood, the dark-colored blood | collected from the tissues and carried by the veins to the heart. It is dark from the lack of oxygen and the pres- ence of carbon dioxid. V. circula- tion, the circulation of blood through the veins. V. congestion, the en- gorgement of an organ with venous blood, due to an obstruction to its return to the heart. Vernix caseosa (ver'nix ka-se-o'- sah). “ Cheesy varnish.” The greasy substance which covers the skin of the fetus, p. 69. Version ( ver'shun). 1. The act of turning. 2. The turning of the fetus in utero by the obstetrician to facili- tate delivery, p. 197. Vertebra i ver'te-brah). Any one of the thirty-three bones of the spinal column. Vertex (ver'tex). 1. Head. 2. The crown of the head. V. presentation, the presentation of the top of the fetal head in labor, pp. 171, 172. Vertigo (ver'tig-o). Dizziness; giddiness; “swimming of the head.” Vesical (ves'ik-al). Pertaining to the bladder. Vesicle (ves'ik-l). 1. A small blad- der or sac containing liquid. 2. A small blister on the skin or mucous membrane, p. 342. Vesicular (ves-ik'u-lar). 1. Com- posed of small, sac-like bodies. 2. Composed of vesicles or blisters on the skin. p. 342. Vestibule (ves'tib-ul). 1. The oval cavity of the internal ear. 2. The space between the labia minora, be- low the clitoris, just above the en- trance to the vagina, p. 33. Viability (vi-ab-il'it-e). Ability to live. p. 365. Viable (vi'ab- 1 ). Able or likely to live outside the uterus. Said of a fetus that is sufficiently developed to live outside the uterus, p. 365. Villus (vil'us), pi., vil'li. 1. One of the small vascular projections of the placenta which help attach it to the wall of the uterus and through which the nourishment of the child is provided, pp. 41, 46. 2. One of the club-shaped projections from the mu- cous membrane of the intestines. Virulent (vir'u-lent). Exceedingly | poisonous or harmful ; having the nature of virus. Virus (vi'rus). 1. Any animal poison. 2. Especially that poison which is produced by and able to im- part disease. The poison is due to the presence of disease-producing or- ganisms or fluids. Viscus (vis'kus), pi., vis'cera. Any organ contained within the cavities of the body, especially the abdomen. Visual (viz ' u - al). Pertaining to vision or sight. Vital (vi'tal). Essential to life. Pertaining to life. Vitality (vi - tal ' it - e). The vital principle. The vital power. Volsella, Volsellum, (vol-sel'ah, vol-sel'um). A forceps the ends of whose blades are furnished with sharp hooks, p. 195. Vulsella, Vulseilum (vul-sel'ah). Same as Volsella. p. 195. Vulva (vul ' vah ). The external genitals of the female, pp. 29, 32. W. Walcher’s position (val'tsher). The patient lies on her back with the buttocks raised and well over the table, the legs hanging down. In this position the true conjugate diam- eter of the pelvis is increased nearly half an inch. p. 195. 488 GLOSSARY Wassermann reaction. A test of the blood which shows the presence of syphilis, p. 450. Wet-nurse (wet-nurs). A woman who suckles the child of another, p. 326. Wharton’s gelatin, Wharton’s jelly (whar'tonzj. The jelly-like tissue which makes up the greater part of the umbilical cord. Whites (whitz). Leukorrhea. Winckel’s disease (wink'lz). An extremely fatal disease in the new- born, marked by jaundice, bloody urine, hemorrhage, and cyanosis. Malignant jaundice. Witches’ milk (witsh'ez). The milky fluid secreted by the breast of the new-born. p. 344. Womb (woom). The uterus, p. 28. INDEX Abdomen, pains in, in pregnancy, 247 pendulous, in pregnancy, 246 Abdominal supporter in pregnancy, 76 Kabo, 77 Ablactation, 326 Abnormal milk, 325 Abnormalities of nipples, 312 Abortion, 55, 249 instruments for treatment of, 234 therapeutic, 234 Abruptio placentae, 251 Abscess, sub mammary, 316 Accidents, prevention of, 421 Acid, boric, solution of, 444 carbolic, solution of, 443 uric, in urine, 338 Acini of breast, 35 After-birth. See Placenta. After-pains, 61, 299 Agalactia, 321 Bier’s treatment in, 323 causes, 322 electricity in, 324 massage of breasts in, 323 pituitrin in, 322 symptoms, 322 thyroid extract in, 322 treatment, 322 Ahlfeld’s method of sterilization of hands, 425 Air pessary, 231 Air-embolism, 128 in third stage of labor, 128 Albumin, 453 Albuminuria, 86 Alcohol in pregnancy, 81 Ambulance, incubator, 372, 373 Anesthesia, 188 in second stage of labor, 1 23 Anesthetic in cesarean section, 207 Ankyloglossia, 357 Anus, 31, 34 imperforate, 357 occlusion of, 357 Apartments, sterilization of, 440 Aphthae, Bednar’s, 334 Applicators, 95, 135 Aprons, sterilization of, 440 Areola of pregnancy, 36 Areolar signs in diagnosis of preg- nancy, 73 Argyrol in prevention of ophthal- mia neonatorum, 133 Artificial infant foods, 408 respiration, 362 Byrd’s method, 362 De Lee’s modification, 362, 363 Sylvester’s method, 363 Asepsis of breasts during puerpe- rium, 286 of nurse during puerperium, 285 Asphyxia livida, 360 neonatorum, 360 489 490 INDEX Asphyxia neonatorum, treatment, 360 pallida, 360 Atelectasis, 189, 337 pulmonum, 68 of premature infants, 390 Auto-infection, 283 Auvard incubator, 368 Axis- traction forceps, 19 1 Bag of waters, 59 Balloon dilators, 231 Bands, infant’s, 97 Baptism of child, 200 Barley-water, 407, 453 Barnes’ bag, 231 Basins, sterilization of, 439 Bath, Winckel’s permanent, for premature infants, 367 Bathing infant, 151 in pregnancy, 87 in puerperium, 147 of premature infant, 384 Bearing-down pains, 59 Bed of incubator, 375 of newborn infant, 100 preparation of, for first stage of labor, 107 symphysiotomy, 216 Bed-frame, symphysiotomy, 215 Bednar’s aphthae, 334 Bed-pans, sterilization of, 439 Bed-sores, prevention of, in preg- nancy, 242 Beef, digested, by rectum, 460 Beef-juice, 408, 453 Beef-tea, 453 with acid, 453 Belt, Momburg’s, 276 Bichlorid of mercury solutions, preparation of, 442 Bier’s method of treating mastitis, 320 treatment in agalactia, 323 Bifid nipple, 312 Binder, breast-, 93 applied, 308 long, 138 T-, 92 Birth certificate, 134 Birth-mark, 83 Bladder, 31 anatom)'- of, 31 in puerperium, 145 inflammation of, in puerperium, 303 Blankets, infant’s, 97 Blisters of nipple, 313 water-, 342 Blood in pregnancy, 50 Blue babies, 68, 367, 390 spells of premature infants, 389 Bones, innominate, 23 Borborygmus, 157, 328 Boric acid solution, 444 Bottle, nursing, for premature in- fants, 380 Bottles, filling of, 403 Bowels in pregnancy, 84 in puerperium, 67, 144 of newborn infant, 70, 156 Brain, injuries to, in birth, 355 Braun’s colpeurynter, 231 cranioclast, 198 decapitation hook, 198 Breast, acini of, 35 anatomy of, 35 asepsis of, during puerperium, 286 care of, during puerperium, 135 diseases of, 307 engorgement of, in puerperium 6S, i45, 307 INDEX 49 1 Breast, enlargement of, as sign of pregnancy, 73 in newborn, 344 in pregnancy, 50 care of, 77, 89 in puerperium, 65 inflammation of, 315 massage of, 309-231 in agalactia, 323 tray and contents, 137 Breast-binder, 93 applied, 308 Breast-pump, 163 Breech delivery, forceps in, 196 mechanism of, 177 presentation, 177, 269 Brim of pelvis, 24 Broad ligaments, 31 Bronchitis, 336 Broth, chicken, 454 clam, 454 mutton, 457 Brushes, sterilization of, 433 Bumm’s pubiotomy needle, 212 Byrd’s method of artificial respira- tion, 362 De Lee’s modification, 362, 363 Caloric method of feeding, 402 Cannula, glass, for intravenous transfusion, 226 Caput succedaneum, 356 Carbolic acid solution, 443 Castor oil, administration of, 144 Catgut, sterilization of, 439 Catheter, tracheal, 360 Catheterization after pubiotomy, 217 in puerperium, 146 Caul, 60 Cephalhematoma, 356 I Cephalotripsy, 198 Cereal extract, 454 Certified milk, 405 I Cervix uteri, 28 Cesarean section, 201 after-care, 209 arrangement of room, 204 convalescence, 210 instruments for, 206 light, heat, and anesthetic, 207 list of supplies needed for, 205 operation, 208 preparation for, 203 steps of, 203, 209 vaginal, 210 Chafe, 159 Chafing, 343 treatment, 343 Champagne whey, 454 Champetier de Ribes’ bag, 231 Chicago Lying-in Hospital, diet table at, 378 incubator station, 369 Chicken broth, 454 Child, care of, 151 overgrowth of, diet for preven- tion of, 452 Chinosol, 443 Chloral in second stage of labor, 1 20 Circumcision, 338 Clam broth, 454 Cleft palate, 356 nipple for babies with, 356 Clitoris, 32 Coccyx, 22 Coffee, nutritious, 457 I Colic, 329 Colostrum, 50, 65 Colpeurynter, Braun’s, 231 Composition of milk, 395 Conception, 40 Congenital deformities, 356 49 2 INDEX Conjunctivitis in infant, treatment of, 155 Constipation in infant, 1 56, 330 in pregnancy, 54 in puerperium, 300 Contracted pelvis, 27 Convulsions, 358 in pregnancy, 256 in premature infant, 390 Cord. See Umbilical cord. Coronary suture, 43 Corsets after delivery, 150 in pregnancy, 76 high stomach from, 75 Coryza, 336 Couveuse, 368. See also Incuba- tor. Covered sponges, 433 Cracks of nipple, 313 Cramp in leg during second stage of labor, 119 Cranioclasis, 198 Cranioclast, Braun’s, 198 Craniotomy, 198 Crede’s method for prevention of ophthalmia neonatorum, 132 Creolin, 443 Cross-birth, 177, 197 Curettage, uterine, 224 Cyanosis, 337 in premature infants, 389 Cystitis in puerperium, 303 De Lee’s glove sterilizer, 428 long uterine packing forceps, 220 method of sterilization of hands, 426 of rubber gloves, 427 modification of Byrd’s method of artificial respiration, 362, 363 needle for hypodermoclysis, 225 Decapitation, 197 Decapitation hook, Braun’s, 198 Decubitus in pregnancy, prevention of, 242 Deformed pelves, 27 Deformities, congenital, 356 Delayed separation of cord, 345 urination, 337 Deportment of nurse, 446 Destitute, care during labor among, 411 Detachment, premature, of pla- centa, 251 Dextrin by rectum, 460 Diaper, 159 changing of, 157 Diapers, 99 Diarrhea in infants, 331 Diet for infants, 164 for prevention of overgrowth of child, 452 for wet-nurse, 327 in first stage of labor, 113 in incubator, 378 in pregnancy, 80 in puerperium, 141 liquid, 452 list of, 452 milk, 452 Prochownik’s, 452 raw meat, 456 semisolid, 452 Dietary, 452 Diet-table in Chicago Lying-in Hospital, 378 Difficulty in nursing, 330 Digested beef by rectum, 460 Digestive organs of child, affec- tions of, 328 Dilatation in phimosis, 341 Dilators, balloon, 231 Hegar’s, 235 Diplococcus of Neisser, 348 INDEX 493 Disinfection in puerperal infection, 296 Disorders of first weeks of life, 328 Doctor, preparation for, in first stage of labor, no when to summon, 117 Doderlein’s pubiotomy needle, 212 Dolores, 58 Douche, 222 uterine, 224 vaginal, 223 Douche-cans, sterilization of, 439 Douleurs, 58 Dress in pregnancy, 75 of infant, 98 of nurse, 446 Dressings, sterilization of, 433 Drinking glass, ideal, 240 Drop method of giving salt solution by rectum, 289, 290 Dropper, feeding-, 380 Dropping, 56 Dry heat, sterilization by, 431 labor, 57, 60 Drying up milk, 326 Eclampsia, 256 symptoms, 256 treatment, 257 Economy in hospital work, 423 Ectopic pregnancy, 252. See also Extra-uterine pregnancy. Eczema intertrigo, 159, 343 treatment, 344 Edema of extremities in pregnancy, 243 of lungs, treatment, 260 Egg and milk, 456 lemonade, 454 Eggnog, 454 Egg-water, 453 Electricity in agalactia, 324 ! Elevated Sims’ position, 270 Embolism, air-, 128 in third stage of labor, 128 puerperal, 297 Embryotomy, 198 instruments for, 201 j Enema, ox-gall, 300 Engorgement of breasts in puer- perium, 145, 307 Enlargement of breasts as sign of pregnancy, 73 in newborn, 344 I Enteroptosis after pregnancy, 76 Episiotomy, 61 Eruptions on skin in infants, 342 vesicular, in infants, 342 Ether, administering of, in second stage of labor, 123 Examination, obstetric, prepara- tion for, 217 Excess of milk, 321 Exercise in pregnancy, 81 Extra-uterine pregnancy, 252 duties of nurse, 255 symptoms, 254 Eyes, application of ice to, 349 infant’s, care of, 155 infection of, 347 irrigation of, 349, 351 of newborn infant, care of, 132 of premature infant, care of, 385 ! Facial paralysis after forceps de- livery, 353, 354 j Fainting in pregnancy, 248 Fallopian tubes, 29 fimbriae of, 30 • False pains of labor, 56. 103 pelvis, 22, 23 Feces, green, 332 , Fecundation, 40 I Feeding, infant, 392 494 INDEX Feeding, infant, amount of food, 400 caloric method, 402 nasal, 461 premature infant, method of, 380 rectal, 459 through skin, 460 Feeding-dropper, 380 Feeling life as sign of pregnancy, 74 Feet, keeping warm, in incubator, 377 Femoral hernia, 358 Fertilization, 40 Fetus, head of, in pregnancy, 43 hiccup of, 48 in diagnosis of pregnancy, 74 in uterus, physiology of, 46 liver of, 47 Fever, inanition, 333 milk-, 307 starvation, 164, 358 thirst, 164 Filling of bottles, 403 Fimbriae, 30 Fingers, supernumerary, 358 Fissures of nipple, 313 Fistula, rectovaginal, in puerpe- rium, 301 vesicovaginal, in puerperium, 301 Flannel shirts, infant’s, 97 Flat nipple, 312 pelvis, 27 Flaxseed tea, 455 Flour-ball, 455 Fontanels, 43 anterior or large, 43 posterior or small, 43 Foods, artificial infant, 408 to be avoided in puerperium, 143 Forceps, axis-traction, 191 De Lee’s long uterine packing, 220 Forceps in breech extraction, 196 operation, 190 duties of nurse, 193 list of instruments for, 193 Walcher position, 197 Simpson’s, 191 Tarnier’s axis- traction, 191 vulsellum, 195 Forceps-delivery, injuries in, 353 Forceps-marks, 353, 354 Formaldehyd vapor, generation of, 441 Formalin solution, 443 Fossa navicularis, 33 Fourchet, 33 Frontal suture, 43 , Fundus uteri, 28 Furb ringer’s method of steriliza- tion of hands, 425 Furniture, sterilization of, 440 Galactorrhea, 321 Gauze, gelatin, 437 iodoform, 437 lysol, 435 packer, tubular, 233 plain sterilized, 437 Gavage, Tarnier’s method of, in premature infants, 381 I Gelatin gauze, 437 I Generative organs, anatomy of, 21 Genital crease, 32 Genitals, care of, in mother, 138 external, 31 in pregnancy, care of, 89 Gigli wire saws, 214 Glass cannula for intravenous transfusion, 226 nipple-shield, 162 Gloves, rubber, sterilization of, 426 De Lee’s method, 427 Gonorrhea, 448 INDEX 495 Gonorrhea, treatment of, 449 Gowns, sterilization of, 440 Granulations of navel, 345 Grape-sugar by rectum, 460 Green stools, 332 Gum, red, 342 white, 342 Gum-arabic water, 455 Halsted’s method of sterilization of hands, 425 Hands, sterilization of, 424 Ahlf eld’s method, 425 De Lee’s method, 426 Fiirb ringer’s method, 425 Halsted’s method, 425 Harelip, 356 Headache during and after labor, i 34 in puerperium, 304 Head-and-mouth guard, 206 Heart-burn in pregnancy, 248 Heat and light in operating room, 187 dry, sterilization by, 431 in cesarean section, 207 prickly, 342 rash, 342, 343 Hebosteotomy, 21 1 Hegar’s dilators, 235 Hematoma after pubiotomy, 216 Hemorrhage during labor, 272 in pregnancy, 249 of newborn, 352 postpartum, 272 after-care of, 277 Hemorrhoids, 34 Hernia, 358 femoral, 358 inguinal, 358 umbilical, 358 Hexenmilch, 244 Hiccup of fetus, 48 High stomach after pregnancy, 76, 78 Hirst’s bag, 231 History sheet during puerperium, 141 in first stage of labor, 114 in puerperal infection, 295 Home nursing vs. hospital nursing, 419 Hook, Braun’s decapitation, 198 Hospital nurse, relations to patient, 423 nursing vs. home nursing, 419 work, economy in, 423 Hot-water bags, complications due to, 359 Hygiene of pregnancy, 73 Hymen, 33 Hyperemesis gravidarum, 238 Hypodermoclysis, 225 instruments for, 225 Ice, application of, to eyes, 349 Icterus neonatorum, 69, 341 Ideal drinking glass, 240 Imperforate anus, 357 Impregnation, 40 Inanition fever, 333 Incubator, 368 ambulance, 372 Auvard, 368 bed of, 375 care of, 373 diet in, 378 keeping feet warm in, 377 moisture of, 374 removal of premature infant from, 386 Sharp and Smith, 368 station, 369 temperature of, 373 496 INDEX Incubator, ventilation of, 368, 375 I Indigestion in child, 328 in premature infant, 388 Induction of premature labor, 230 I instruments for, 230 Infant, baptism of, 200 bathing of, 151 care of, 151 after operative delivery, 189 of bowels, 156 of eyes, 155 of navel, 154 conjunctivitis in, treatment of, i55 constipation in, 156 delivery of, before doctor arrives, 262 diet for, 164 feeding, 392 amount of food, 400 caloric method, 402 foods, artificial, 408 layette, 97 newborn, 68. See also Newborn infant. nursing of, 160 premature, atelectasis pulmo- num of, 390 bathing of, 384 blue spells of, 389 care of, 365 general, 386 convulsions of, 390 cyanosis of, 389 diseases of, 387 eyes of, care of, 385 feeding-dropper for, 380 incubator for, 368 indigestion in, 388 infection in, 387 massage of, 386 method of feeding, 380 Infant, premature, mouth of, care of, 385 nasal infection in, 388 nose of, care of, 385 nursing bottle for, 380 removal of, from incubator, 386 saddle-nose of, 388 sprue in, 388 Tarnier’s method of gavage in, 381 thrush in, 388 Winckel’s permanent bath for, 367 pulse of, 167 respiration of, 167 scales, 101 temperature of, 167 training of, 167 urination in, 159 wardrobe of, 97 weighing of, 166 Infection, auto-, 283 in premature infant, 387 nasal, in premature infants, 388 of eyes, 347 of mouth, 352 of newborn, 346 of throat, 352 of umbilicus, 346 puerperal, 279. See also Puer- peral infection. Inflammation of bladder in puer- perium, 330 of breast, 315. See also Mastitis. Inguinal hernia, 358 Injuries, operative, of newborn, 353 to brain in birth, 355 Innominate bones, 23 Insanity, puerperal, 304 nourishment in, 306 prevention of suicide in, 305 salt solution in, 306 INDEX 49 7 Insanity, puerperal, sleep in, 306 treatment of, 305 Instruments for embryotomy, 201 for induction of premature labor, 230 for pubiotomy, 213 for treatment of abortion, 234 preparation of, for operation, 187 I sterilization of, 432 Inverted nipple, 312 Involution of uterus, 55, 64 Iodoform gauze, 437 Irrigation of eyes, 349, 351 Irrigator, rectal, 156 Ischuria paradoxa, 248 in puerperium, 66 Itching of pudenda in pregnancy. 245 Jacket, confinement, 93 Jaundice of newborn, 69, 341 Junket. 455 Kabo abdominal supporter, 77 Kidney pains, 59 Kidneys in pregnancy, 86 in puerperium, 66 of newborn infant, 70 Knee-chest position, 238 Koumiss, 355 Labia majora, 32 minora, 32 Labor, 54 after-pains of, 61 care during, 103 among destitute, 41 1 complications during, 262 delivery of child before doctor arrives, 262 dropping as sign of, 56 32 Labor, dry, 57, 60 false pains of, 56, 103 first stage of, 57 care during, 103 diet in, 113 general instructions in, 114 history-sheet in, 114 preparation for doctor in, no of bed for, 107 of patient for, 109 of room for, 105 when to summon doctor, 1 1 7 headache during and after, 134 hemorrhage during, 272 lightening as sign of, 55 nursing during, 103 pains, 58, 103 false, as sign of labor, 56, 103 period of dilatation, 57 of expulsion, 57 placental stage, 57 powers of, 58 premature, 54, 55 induction of, 230 instruments for, 230 premonitory symptoms, 55 satchel, list of articles in, 412 second stage of, 57 administering ether in, 123 anesthesia in, 123 care during, 118 chloral in, 120 cramp in leg during, 119 morphin in, 120 pantopon in, 120 scopolamin in, 120 show as sign of, 57, 103 signs of, 54 stages of, 57 third stage of, 57 air-embolism in, 128 498 Labor, third stage of, care after, 134 during, 125 guarding uterus in, 125, 127 expelling placenta in, 127 lacerations of perineum in, 131 complete, special care in, 140 perineorrhaphy in, 129 Lacerations of perineum, complete, in third stage of labor, spe- cial care in, 140 in third stage of labor, 13 1 Lambdoid suture, 43 Lanugo, 365 Layette, infant’s, 97 Leg, cramp in, during second stage of labor, 119 milk-, 297 Leggings, obstetric, 94 sterilization of, 440 Lemonade, egg, 454 Leukorrhea in pregnancy, 245 Ligaments, broad, 31 Light and heat in operating room, 187 in cesarean section, 207 Lightening, 55 Linea gravidarum, 51, 52 Linen bobbin, 439 suture yarn, sterilization of, 439 Liquid diet, 452 Liquor amnii, 42, 59 cresolis compositus, 443 Lithotomy position, 185, 186 Liver of fetus, 47 Livid asphyxia, 360 Lochia, 63 care of, after pubiotomy, 217 cruenta, 63 odor of, 64 Lochia purulenta, 64 sanguinolenta, 63 serosa, 64 serosanguineous, 63 Lockjaw, 359 Lues, 449 I Lungs, edema of, treatment, 260 in pregnancy, 51 Lysol gauze, 435 solution, 443 Major operations, 190 Mammary gland. See Breast. Mania in puerperium, 304 Marasmus, 334 Mask of pregnancy, 52 Massage in puerperium, 148 of breast, 309-312 in agalactia, 323 of premature infant, 386 Mastitis, 315 Bier’s method of treating, 320 etiology, 316 symptoms, 317 treatment, 317 Materna glass, 406 Maternal changes of pregnancy, 49 impressions, 82 nursing, contraindications to, 393 Meat cure, 455 diet, raw, 456 Meat-extract ice, 456 Meatus urinarius, 31, 33 Meconium, 70 Melancholia in pregnancy, 249 in puerperium, 304 Melena neonatorum, 333, 352 Menses, cessation of, in diagnosis of pregnancy, 73 I Menstruation, 38 in newborn, 345 i uterus during, 38 INDEX [ INDEX 499 Mental condition in puerperium, 67 I Mercury, bichlorid of, preparation of solutions of, 442 Milk, abnormal, 325 amount required for feedings, table of, 401 and egg, 456 certified, 405 composition of, 395 diet, 452 digested with acid, 456 drying up, 326 excess of, 321 human and cows’, table of com- parison, 395 obtaining of, for analysis, 394 lower, obtaining of, 400 mixed, 404 modification of, 395 apparatus for, 398 mothers’, substitutes for, 395 peptonized, 407 by rectum, 459 cold process, 456 warm process, 457 with egg, by rectum, 459 quality of, 404 scarcity of, 321 siphon, 399 sterilization of, 403, 457 under, obtaining of, 400 upper, obtaining of, 398 witches’, 344 Milk-fever, 66, 307 Milk-leg, 297 Milk-shake, 457 Milk-sugar, 396 Milk-toast, peptonized, 457 Mind in pregnancy, 82 Minor operations, 217 Miscarriage, 55 Mixed milk, 404 I Modification of milk, 395 apparatus for, 398 Moisture of incubator, 374 Momburg’s belt, 276 Mons veneris, 32 Monstrosities, 356 Montgomery’s tubercles, 36 Morbus caeruleus, 337 Morning sickness, 53 in diagnosis of pregnancy, 73 Morphin in second stage of labor, 120 Mother, care of, after operative de- livery, 190 during puerperium, daily care of, 135 Mothers’ milk, substitutes for, 395 Mouth in pregnancy, 52 infection of, 352 of premature infant, care of, 385 Mouth-and-head guard, 206 Mulberry nipple, 312 Mutilating operations, preparation for, 200 Mutton broth, 457 Nasal feeding, 461 infection in premature infants, 388 Nausea in pregnancy, 237 Navel, care of, 154 granulations of, 345 of newborn infant, 70 Needle, De Lee’s, for hypodermo- clysis, 225 pubiotomy, 212 Neglected transverse presentations, 198 | Neisser, diplococcus of, 348 Nervous system in pregnancy, 54 Nest-building, 40 Neuralgia in pregnancy, 54 500 INDEX Newborn infant, 68 affections of, 328 atelectasis pulmonum of, 68 bed of, 100 bowels of, 70 cry of, 68 eyes of, care of, 132 first care of, 132 weeks of, 68 jaundice of, 69 kidneys of, 70 navel of, 70 outfit for, 97 skin of, 69 sleep of, 69 temperature of, 69 wardrobe of, 97 weight of, 45, 71 Newspapers, sterilization of, 435 Nipple, 36 abnormalities of, 312 bifid, 312 blisters of, 313 cracks of, 313 fissures of, 313 flat, 312 for babies with cleft palate, 356 inverted, 312 mulberry, 312 polypoid, 312 split, 312 Nipple-shield, glass, 162 Wansbrough’s, 314 Nitrate of silver method for preven- tion of ophthalmia neonatorum, 132 Nose of premature infant, care of, 385 saddle-, of premature infant, 388 Nourishment in puerperal infection, 289 insanity, 306 Nurse, 444 articles needed by, 445 asepsis of, during puerperium, 285 care of, in infection, 352 delivery of child by, 262 deportment of, 446 dress of, 446 duties of, during forceps opera- tion, 193 in extra-uterine pregnancy, 255 engagement of, 90 hospital, relations to patient, 423 in puerperal infection, 294 instructions for, 92 visiting, duties of, during puer- perium, 414 satchel of, 417 visits of, 93 wet-, care of, 326 Nursery, care in, 420 conveniences, 100 Nursing after patient is up, 150 bottle for premature infants, 380 difficulty in, 330 during labor, 103 puerperium, 103 hospital, vs. home, 419 maternal, contraindications to, 393 of infant, 160 visiting, 41 1 Nutritious coffee, 457 Oatmeal-water, 408 Obstetric cases, list of articles for, 91 complications, 237 examination, preparation for, 217 leggings, 94 operations, 178 Occipital presentation, four posi- tions of, 1 71 INDEX 501 Occlusion of anus, 357 Operating room, light and heat in, 187 Operations, 178 care after, 188 forceps, 190. See also Forceps operation. in private home, 181 major, 190 minor, 217 mutilating, preparation for, 200 preparation for, 180 of instruments for, 187 of patient for, 184 of room for, 183 Operative injuries of newborn, 353 Ophthalmia neonatorum, 347 care of nurse in, 352 Crede’s method for prevention of, 132 prevention of, 348 treatment of, 349 Orders, 422 Os uteri, 28 Ossa innominata, 22 Osteomalacic pelvis, 27 Ovary, 31 Overgrowth of child, diet for pre- vention of, 452 Overlying child, 360 Ovulation, 37, 39 Ovum, 40 Ox-gall enema, 300 Packing uterus with gauze, 220 Pad-holder, 92 Pains, after-, 61, 299 bearing-down, 59 false, of labor, 56, 103 in abdomen in pregnancy, 247 kidney 59 labor, 58, 103 Palate, cleft, 356 nipple for babies with, 356 Pallid asphyxia, 360 Pantopon in second stage of labor, 120 Paralysis, facial, after forceps de- livery, 353, 354 Patient, preparation of, for first stage of labor, 109 for operation, 184 Pelves, varieties of, 26 Pelvimeters, 111 Pelvis, anatomy of, 21 brim of, 24 contracted, 27 deformed, 27 false, 22, 23 flat, 27 inlet of, 24 osteomalacic, 27 outlet of, 24 small, 24 soft parts of, 28 true, 22, 24 upper strait of, 24 Pendulous abdomen in pregnancy, 246 Peptic salt, 388 Peptonized milk, 407 by rectum, 459 cold process, 456 warm process, 457 with egg by rectum, 459 milk-toast, 457 Perineal body, 34 Perineorrhaphy, 129, 218 Perineum, 32, 33 lacerations of, complete, in third stage of labor, special care in, 140 in third stage of labor, 13 1 I Peritoneum, 31 502 IXDEX Permanganate method of steriliza- tion of hands, 425 Pernicious vomiting, 238 Pessary, air, 231 Phimosis, 338 Phlegmasia alba dolens, 297 Piles, 34 Pillow-slips, sterilization of, 440 Pitchers, sterilization of, 439 Pituitrin in agalactia, 322 Placenta, 41, 42, 46, 61 abruption of, 251 examination of, 269 expelling of, 127 prasvia, 250 premature detachment of, 251 Pneumonia, 336 Point of direction, 171 Polypoid nipple, 312 Polyuria in puerperium, 66 Pomeroy’s bag, 231 Position, 169 diagnosis of, 173 knee-chest, 238 lithotomy, 185, 186 posterior, 176 Sims’, elevated. 270 Trendelenburg, in bed, 271 Walcher, 195 for forceps operation, 196 Posterior positions, 176 Postpartum hemorrhage, 272 after-care, 277 visiting bag. 417, 418 Pregnancy, 49 abdominal supporter in, 76 alcohol in. 81 areolar signs of. 73 bathing in, 87 bed-sores in, prevention of, 242 blood in, 50 bowels in, 84 Pregnancy, breast in, 50, 73 breasts in, care of, 77, 89 cessation of menses in healthy woman as sign of, 73 constipation in, 54 convulsions in, 256 corsets in, 76 high stomach from, 75 decubitus in, prevention of, 242 diagnosis of, 73 diet in, 80 disorders of, 237 dress in, 75 eclampsia in, 256 ectopic, 252. See also Preg- nancy, extra-uterine. edema of extremities in, 243 enlargement of breasts as sign of 73 enteroptosis after, 76 exercise in, 81 extra-uterine, 252 duties of nurse, 255 symptoms of, 254 fainting in, 248 feeling life as sign of, 74 fetus as sign of, 74 frequent urination in, 248 general changes in, 51 genitals in, care of, 89 head of fetus in, 43 heart-bum in, 248 hemorrhage in. 249 high stomach after, 76, 78 hygiene of, 73 h)-peremesis gravidarum, 238 itching of pudenda in, 245 kidneys in, 86 length of, 54 leukorrhea in, 245 local changes in, 49 lungs in, 51 INDEX 503 Pregnancy, mask of, 52 maternal changes of, 49 impressions in, 82 melancholia in, 249 mind in, 82 mode of living in, 75 morning sickness in, 53, 73 mouth in, 52 nausea of, 237 nervous system in, 54 neuralgia in, 54 pains in abdomen in, 247 pendulous abdomen in, 246 preservation of figure in, 78 pride of, 78 pruritus in, 245 ptyalism in, 52 quickening as sign of, 74 shoes in, 78 skin in, 52, 87 taste in, 53 teeth in, 52, 248 toxemia in, 87, 242 urine in, 51 uterus in, 49 vagina in, 49 varicose veins in, 80, 243 vomiting in, 237 vulva in, 50 Premature detachment of placenta, 251 infant, atelectasis pulmonum of, 390 bathing of, 384 blue spells of, 389 care of, 365 general, 386 convulsions of, 390 cyanosis of, 389 diseases of, 387 eyes of, care of, 385 feeding-dropper for, 380 Premature infant, incubator for, 367 indigestion in, 388 infection in, 387 massage of, 386 method of feeding, 380 mouth of, care of, 385 nasal infection in, 388 nose of, care of, 385 nursing bottle for, 380 removal of, from incubator, 386 saddle-nose of, 388 sprue in, 388 Tarnier’s method of gavage in, 381 thrush in, 388 WinckePs permanent bath for, 367 labor, 54, 55 induction of, 230 instruments for, 230 Presentation, 169 and position, 169 breech, 177, 269 diagnosis of, 173 occipital, four positions of, 171 shoulder, 177 transverse, 177 neglected, 198 Pressure-marks from forceps, 353, 354 Prickly heat, 342 Pride of pregnancy, 78 Prochownik’s diet, 452 Prolapse of cord, 270 Proprietary infant foods, 408 Protargol in prevention of oph- thalmia neonatorum , 133 Pruritus in pregnancy, 245 Ptyalism, 52 Puberty, 37 504 INDEX Pubes, 26 Pubiotomy, 21 1 after-care, 214 care of lochia after, 217 catheterization after, 217 hematoma after, 216 instruments for, 213 needles, 212 operation, 212 Pudenda, itching of, in pregnancy, 245 Puerperal embolism, 297 infection, 279 disinfection, 296 frequency and source, 283 history of, 280 sheet, 295 medicinal treatment, 293 nourishment, 289 prevention of, 284 rectal infusion, 289 salt solution, 289 surgical treatment, 293 symptoms of, 286 the child, 293 the nurse, 294 treatment of, 287 insanity, 304 nourishment in, 306 prevention of suicide in, 305 salt solution in, 306 sleep in, 306 treatment, 305 thrombosis, 297 Puerperium, 61 abnormal milk in, 325 abnormalities of nipples in, 312 agalactia in, 321 asepsis of breasts during, 286 of nurse during, 285 bath in, 147, 151 bladder in, 145 Puerperium, bowels in, 67, 144 breasts in, 65 care of, 135 care during, 135 catheterization in, 146 complications of, 279 constipation in, 300 cystitis in, 303 diet in, 141 diseases of breasts in, 307 drying up milk in, 326 duties of visiting nurse during, 414 engorgement of breast in, 65, 145, 307 excess of milk in, 321 foods to be avoided in, 143 galactorrhea in, 321 general changes in, 66 treatment, 147 genitals in, care of, 138 headache in, 304 history-sheet during, 141 inflammation of bladder in, 303, 315 insanity in, 304 ischuria paradoxa in, 66 kidneys in, 66 massage in, 148 mastitis in, 315 mental condition in, 67 mother during, daily care of, 135 nursing after patient is up, 150 during, 103 polyuria in, 66 pulse in, 66, 148 rectovaginal fistula in, 301 respiration in, 148 retention of urine in, 66 scarcity of milk in, 321 skin in, 67 sleep in, 147 INDEX 505 Puerperium, temperature in, 66, 148 I time of, diagnosis, 74 of getting up, 148 tympany in, 299 urethra in, 145 uterus in, 61 vagina in, 64 vesicovaginal fistula in, 301 visitors during, 148, 15 1 vulva in, 64 Pulse in puerperium, 66, 148 of infant, 167 Pump, breast-, 163 Punch, rum, 458 Quality of milk, 404 Quickening as sign of pregnancy, 74 Rash, heat, 342, 343 Recipes, 453 Rectal feeding, 459 infusion in puerperal infection, 289 irrigator, 156 Rectovaginal fistula in puerperium, 301 Rectum, 31 Red gum, 342 Reproduction, function of, 37 Reproductive system, anatomy and physiology of, 21 Respiration, artificial, 362 Byrd’s method, 362 De Lee’s modification, 362, 363 Sylvester’s method, 363 in puerperium, 148 of infant, 167 Respiratory tract of infants, affec- tions of, 335 Retention of urine in puerperium, 66 Rice-water, 458 Rochester sterilizer, 430 Room for operation, preparation of, 183 preparation of, for first stage of labor, 105 Rotation, 24 Rubber gloves, sterilization of, 426 De Lee’s method, 427 Rum punch, 458 Sacrum, 22 Saddle-nose of premature infant, 388 Sagittal suture, 43 Salt, peptic, 388 solution, 443 administration of, 225 by rectum, 459 drop method of giving, 289, 290 in puerperal infection, 289 insanity, 306 through skin, 460 Salvarsan in syphilis, 450 Sanitary seat covers, 88 Satchel, labor, list of articles in, 41 2 visiting nurse’s, 417 i Saws, Gigli wire, 214 Scales, infant, 101 Scarcity of milk, 321 Scissors, Smellie’s perforating, 199 Scopolamin in second stage of labor, 120 j Semisolid diet, 452 Semmelweis and puerperal infec- tion, 280 I Separation of cord, delayed, 345 j Sex, determination of, 83 Sharp and Smith incubator, 368 Sheets, sterilization of, 440 | Shield, nipple-, 314 506 INDEX Shirts, infant’s, 97 Shoes in pregnancy, 78 Shoulder presentation, 177 Show, 57, 103 Silk, sterilization of, 438 Silver nitrate method for preven- tion of ophthalmia neonatorum, 132 Simpson’s forceps, 191 Sims’ position, elevated, 270 Sinus lactiferus, 35 Siphon, milk, 399 Skin, affections of, in infants, 342 feeding through, 460 in pregnancy, 52, 87 in puerperium, 67 of newborn infant, 69 Skin-eruptions in infants, 342 Sleep in puerperium, 147 of newborn infant, 69 Smellie’s perforating scissors, 199 Snuffles, 335 Solutions, preparation of, 441 Spasms, 358 Specific disease, 449 Spermatozoid, 40 Sphincter ani, 34 Split nipple, 312 Sponges, covered, 433 Sprue, 333 in premature infant, 388 Starvation fever, 164, 358 Sterile water, preparation of, 441 Sterilization, 92 by dry heat, 431 methods of, 424 of apartments, 440 of basins, 439 of bed-pans, 439 of brushes, 433 of catgut, 438 of douche-cans, 439 Sterilization of dressings, 433 of furniture, 440 of gowns, aprons, etc., 440 of hands, 424 Ahlfeld’s method, 425 De Lee’s method, 426 Fiirbringer’s method, 425 Halsted’s method, 425 of instruments, 432 of linen suture yarn, 439 of milk, 403 of newspapers, 435 of pitchers, 439 of rubber gloves, 426 De Lee’s method, 427 of silk, 438 of sutures, 438 Sterilized milk, 457 Sterilizer, De Lee’s glove, 428 Rochester, 430 Sterilizers, 430 Stockings, infant’s, 99 obstetric, 94 Stomach, high, after pregnancy, 76, 78 Stools, green, 332 Striae gravidarum, 51, 52 Strophulus, 342 Submammary abscess, 316 Sugar, grape-, by rectum, 460 Supernumerary fingers, 358 toes, 358 Suture material, preparation of, 438 yarn, linen, sterilization of, 439 Sutures, 43 removal of, 220 Sylvester’s method of artificial res- piration, 363 Symphysiotomy, 21 1 after-care, 214 bed, 216 bed-frame, 215 INDEX 50 7 Symphysis pubis, 26 Symptoms, recording of, 421 Syphilis, 449 prevention of contagion in, 450 treatment of, 450 Tamponade, lysol gauze for, 435 uterine, 220 Tarnier’s axis-traction forceps, 191 method of gavage in premature infants, 381 Taste in pregnancy, 53 T-bindec, 92 Tea, flaxseed, 455 Teeth in pregnancy, 52, 248 Temperature in puerperium, 66, 148 of incubator, 373 of infant, 167 of newborn infant, 69 Tetanus, 359 Teterelle, 382, 383 Therapeutic abortion, 234 Thirst fever, 164 Throat, infection of, ^5^2 Thrombosis, puerperal, 297 Thrush, 333 'Z in prematur^infants, 388 Thyroid extract in agalactia, 322 Toast-water, 4.58 Toes, supernumerary, 358 Tongue-tie, 357 Towels, sterilization of, 440 Toxemia in pregnancy, 87, 242 Tracheal catheter, 360 Training of infant, 167 Transverse presentation, 177 neglected, 198 Trendelenburg posture in bed, 271 True pelvis, 22, 24 Tubercles of Montgomery, 36 Tubular gauze packer, 233 Tympany in puerperium, 299 Umbilical cord, 43 delayed separation of, 345 prolapse of, 270 hernia, 358 Umbilicus, infection of, 346 Ureters, 31 Urethra, 31 in puerperium, 145 Uric acid in urine, 338 Urinary organs of infants, affec- tions of, 337 Urination, delayed, in infant, 337 difficult postpartum, 66 frequent, in pregnancy, 248 in infant, 159 Urine in pregnancy, 51 retention of, in puerperium, 66 uric acid in, 338 Uterine curettage, 224 douche, 224 tamponade, 220 Uterus, 38 broad ligaments of, 31 care of, during third stage of labor, 125, 127 cervix of, 28 during menstruation, 38 fetus in, physiology of, 46 fundus of, 28 in pregnancy, 49 in puerperium, 61 involution of, 55, 64 os of, 28 packing of, with gauze, 220 shape and size of, at term, 42 Vagina, 29 in pregnancy, 49 in puerperium, 64 j Vaginal cesarean section, 210 douche, 223 j Varicose veins in pregnancy, 80, 243 508 INDEX Veins, varicose, in pregnancy, 80, 243 Venereal diseases, 448 general consideration, 451 Ventilation of incubator, 368, 375 Vernix caseosa, 69 Version, 197 Vesicovaginal fistula in puerperium, 301 Vesicular eruptions in infants, 342 Vestibule, 33 Villi, 41, 46 Visiting bag, 417, 418 nurse, duties of, during puerpe- rium, 414 satchel of, 417 nursing, 41 1 Visitors during puerperium, 148, 151 Visits of nurse, 95 Vomiting in child, 330 in pregnancy, 237 pernicious, 238 Voorhees’ bag, 231 Vulsellum forceps, 195 Vulva, 29, 32 anatomy of, 32 in pregnancy, 50 in puerperium, 64 Vulvitis in newborn, 345 Walcher position, 195 for forceps operation, 196 Wansbrough’s nipple-shield, 314 Ward, care in, 419 Wardrobe, infant’s, 97 Warm feet of incubator infant, 377 Warren dresses, 98 Water, sterile, preparation of, 441 Water-blisters, 342 Waters, bag of, 59 j Wehen, 58 Weighing of infant, 166 Weight chart of newborn infant, 72 of newborn infant, 45, 71 Wet-nurse, care of, 326 Whey, 406, 458 champagne, 454 wine, 458 White gum, 342 Wiegand-Martin method of de- livering after-coming head, 176 Winckel’s permanent bath for pre- mature infants, 367 Wine whey, 458 Wire saws, Gigli, 214 Witches’ milk, 344 Yarn, linen suture, sterilization of, 439 DATE DUE DEC - i ip U 201-5503 PRINTED IN U.S.A.