LIBRARY OF CONGRESS, Gtijjap ®opj|rtg^t % Shelf .JL3LA3 UNITED STATES OF AMEIU A. OBSTETRICAL NURSING FULLERTON. BY THE SAME AUTHOR. NURSING IN ABDOMINAL SURGERY AND DISEASES OF WOMEN. 12mo. 284 Pages. 70 Illustrations. Cloth, $1.50. *%* The immediate success of Dr. Fulkrton's " Handbook of Obstetrical Nursing," a third edition of which has just been pub- lished, has encouraged her to prepare this manual on another and very important branch of the science and art of nursing. Dr. Fullerton has demonstrated that she not only knows what to say, but that she has the happy faculty of saying it in a plain, practical style that interests as well as instructs. Synopsis of Contents. — The Surgical Nurse — The Germ Theory of Disease — Asepsis and Antisepsis — Abdominal Section — The Pre- paration of the Room — The Preparation of Sponges — Sterilization of Instruments, etc—Preparation of the Patient — Preparation of Operator and Assistants — The Nurse's Duties During Operation — The Nurse's Duties After Operation and During Convalescence — Management of Complications — The Pelvic Organs in Women — Diseases of Women — General Nursing in Pelvic Diseases — Pre- parations for Gynaecological Examinations — Preparation for Gynae- cological Operations — Preparation of Patient, Operator, and Assist- ants — Duties of Nurse During Operation — Special Nursing in Gynaecological Operations — Diet for the Sick. From The Bulletin of Johns Hopkins Hospital. — "An excellent text-book for nurses. * * * The style is pleasant and readable. * * * Such an attempt to occupy a new field so successfully carried out is most praise- worthy." From the Philadelphia Medical News. — •' Dr. Fullerton has clearly discerned the requirements in the training of nurses for this special work, namely, the inculcation of knowledge that will give an intelligent idea of the work before them and the insistence upon habits of promptness and forethought. For both the physician and nurse this book presents the important points in a clear and impressive way." P. BLAKISTON, SON & CO., Publishers, Philadelphia. A HANDBOOK OF OBSTETRICAL NURSING FOR NURSES, STUDENTS, AND MOTHERS. COMPRISING THE COURSE OF INSTRUCTION IN OBSTETRICAL NURSING GIVEN TO THE PUPILS OF THE TRAINING SCHOOL FOR NURSES CONNECTED WITH THE WOMAN'S HOSPITAL OF PHILADELPHIA. BY ANNA M. FULLERTON, M.D., PHYSICIAN IN CHARGE OF, AND OBSTETRICIAN AND GYNAECOLOGIST TO, THE WOMAN'S HOSPITAL OF PHILADELPHIA, ETC. THIRD REVISED EDITION. ILLUSTRATED. PHILADELPHIA: P. BLAKISTON, SON & CO., IOI2 WALNUT STREET. 1893. Copyright, 1892, by Anna M. Fullerton, M.D. PRESS OF WM. F FELL & CO.. 1220-24 SANSOM STREET, PHILADELPHIA TO Dr. ANNA E. BROOMALL, PROFESSOR OF OBSTETRICS IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA, ATTENDING OBSTETRICIAN AND GYNAECOLOGIST, AND FORMER PHYSICIAN-IN-CHARGE, OF THE WOMAN'S HOSPITAL OF PHILADELPHIA, THIS VOLUME IS AFFECTIONATELY DEDICATED. PREFACE TO THIRD EDITION The present edition of this work has been revised by the addition of a chapter on pelvic anatomy and by the introduction of several important details in the application of modern methods of antisepsis to midwifery. Considerable new matter has also been introduced in the chapter on the "Ailments of Early Infancy." The fact that within three years this little book has reached its third edition, and that I have been asked to permit its translation into three foreign languages, would seem to prove that it has, to a gratifying extent, proved to its readers the value of scientific nursing in averting the dangers of child- birth and reducing the mortality of early infancy. ANNA M. FULLERTON. vn PREFACE TO SECOND EDITION. In this second edition of my book, the main revisions have been made in the chapter on the care of the new-born infant, in which I have endeavored to bring the subject up to the present standard of our knowledge. I would acknowledge in this connection the valuable aid afforded me by the articles of Dr. T. M. Rotch on the subject and the analytical work of Dr. H. Leffmann. I trust that these additions may serve to make life healthier and happier for infancy. ANNA M. FULLERTON. August, 1891. Vlll PREFACE . The teachings embodied in this little book are chiefly the substance of a series of lectures deliv- ered, yearly, by Dr. Anna E. Broomall to the nurse- pupils of the Woman's Hospital of Philadelphia. The methods advocated by Dr. Broomall are strictly observed in the practical work of the Maternity connected with the Woman's Hospital — a building mainly planned by Dr. Broomall and built during her administration as Physician-in- Charge of the Woman's Hospital. The excellent results attained by an adherence to these methods prove the value of cleanliness, antisepsis and eternal vigilance on the part of the nurse, in averting the dangers of childbirth and reducing the mortality of early infancy. The great importance of a thorough understand- ing of the many little details of scientific nursing on the part of the physician leads me to trust that ix X PREFACE. this little book may be of value to physician as well as nurse ; and since both of these must have the entire support, sympathy, and assistance of the patient in their efforts for her well-being, the direc- tions herein given as to preparations to be made, and rules of action to be observed, will, it is hoped, enable the patient to work in harmony with those who are working for her good. My thanks are due to Dr. Broomall for her kindly advice and encouragement in the comple- tion of this handbook, and to Dr. Louise L. Wylie for valuable assistance given in the preparation of the illustrations. ANNA M. FULLERTON. Woman's Hospital of Philadelphia, December^ 1889. CONTENTS. CHAPTER I. PAGE The Pelvis and Genital Organs, . . 17 CHAPTER II. Signs of Pregnancy, 26 CHAPTER III. Management of Pregnancy, 31 CHAPTER IV. Accidents of Pregnancy, 52 CHAPTER V. Germs and Antisepsis, 58 CHAPTER VI. Application of Antisepsis to Confinement Nursing, 65 CHAPTER VII. Preparations for the Labor, 77 CHAPTER VIII. Signs of Approaching Labor, and the Process of Labor, ... 89 xi Xll CONTENTS. CHAPTER IX. page Duties of the Nurse During Labor, 95 CHAPTER X. Accidents and Emergencies of Labor, , 114 CHAPTER XL Care of the New-born Infant, 132 CHAPTER XII. Management of the Lying-in, 168 CHAPTER XIII. Characteristics of Infancy in Health and Disease, 209 CHAPTER XIV. Ailments of Early Infancy, 221 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Normal Pelvis, ....'. 18 2. External Genitalia, 20 3. Cavity of Uterus and Fallopian Tubes, 22 4. Abdominal Belt, . . . , 34 5. Spiral Reverse Bandage of Lower Extremity, 38 6. Nipple Protector, 43 7. Jenness-Miller Chemilette, 44 8. Jenness-Miller Divided Skirt, . 44 9. Union Undergarment, 45 10. Jenness-Miller Leglette, 45 11. The Equipoise Waist, . . .-« 47 12. Occlusion Dressing (Dr. Garrigues'), 79 13. Nightingale Wrap, 81 14. Sylvester's Method of Resuscitation (First Movement), . . 118 15. Sylvester's Method of Resuscitation (Second Movement), 119 16. Schultze's Method of Resuscitation (First Movement), . . 121 17. Schultze's Method of Resuscitation (Second Movement), . 122 18. Position of Patient in Hemorrhage after Labor, 128 19. Home-made Bathtub and Crib, 141 20. The Lactometer, 148 21. Sterilizer (Dr. Louis Starr), 160 22. Graduated Nursing Bottle (Dr. Louis Starr), . ... 163 23. Rubber Nipple (Starr), 165 24. Nipple Shield, 182 25. Variously Shaped Nipples, 183 26. Figure-of-Eight Bandage of One Breast, 184 xiii XIV LIST OF ILLUSTRATIONS. FIG. PAGE 27. Figure-of- Eight Bandage of Both Breasts, 185 28. Garrigues' Breast Bandage, 186 29. Breast Pump, 188 30. Handkerchief Bandage of Breast, 189 31. Worcester's Y-Bandage, 191 32. Obstetrical Breast Support, 192 ^. Diagram Showing Eruption of Milk Teeth, 219 34. Tarnier's Couveuse, 223 35. Auvard's Couveuse (Interior View), 227 36. Auvard's Couveuse (Exterior View), , 228 37. Swaddled Baby, 229 38. Single-bulb Syringe (Starr), 242 "He shall gather the lambs with His arm and carry them in His bosom, and shall gently lead those that are with young. ' ' — Isaiah, Chap, xl, v. ii. OBSTETRICAL NURSING CHAPTER I. THE PELVIS AND GENITAL ORGANS. The pelvis is that part of the skeleton found The P elvis - between the lower end of the spinal column and the thigh bones. It consists of four bones, the sacrum, the coccyx, and the right and left innomi- nate or hip bones. These bones form a canal through which the child passes during labor. Various measurements or diameters are taken from ^ t s s ure " certain parts of the pelvis to determine the capacity of this canal. It is important that every pregnant woman should have her pelvis measured by the physician whom she expects to have attend her in labor, in order that it may be discovered whether her pelvis is at all under size, so that special pre- cautions may be taken in time to prevent difficulty in the delivery. These measurements should be taken not later than the seventh month of preg- nancy, as it may be desirable, for the sake of both '7 i8 OBSTETRICAL NURSING. Internal genital organs. External genital organs. mother and child, that the physician should induce premature labor. The canal of the pelvis contains the internal organs of generation, viz., the uterus, Fallopian tubes, and ovaries ; and the bladder and rectum besides. The external organs are called the pudenda or vulva. Immediately above the pubic bone, or anterior Fig. i. Normal Pelvis. Mons veneris. Labia majora. border of the pelvis, is a cushion of fat, usually covered with hair. This is called the " mons veneris. " On each side of the opening of the vulva are the "labia majora," or large lips. Lying be- THE PELVIS AND GENITAL ORGANS. 1 9 neath these and concealed by them, in young women, are two thin folds of flesh, named the " labia minora " or " nymphae." They join together above, N y m P hse and at their junction is a small projecting body called the "clitoris." The small triangular space clltorls - between the clitoris and the nymphae is the vesti- bule. The opening of the urethra (the " meatus urina-J^H s us rius"), through which the urine escapes from the bladder, is in the middle of the lower border of the vestibule. It is very important that the nurse should know the exact position of the meatus urinarius, as she will frequently be called upon to pass the catheter. Below the vestibule is the orifice of the vagina, Vagina. the canal leading to the uterus or womb. In virgins a delicate membrane, usually crescentic in shape, blocks the entrance to the vagina. This is the hymen. The hymen is usually ruptured at marriage, but Hymen, a woman may be a virgin, yet have no hymen ; in some cases it persists even after marriage and offers an obstruction at childbirth. A woman who has borne children has a few fleshy projections at the orifice of the vagina, the only remains of the hymen, called the " carunculse myrtiformes." Be- tween the vulva and the anus is a mass of flesh, the space on the surface measuring one and one-half 20 OBSTETRICAL NURSING, Perineum. inches in length. During the birth of the child this becomes greatly distended, and thins like rubber. This is the perineum. It may be torn Fig. External Genitalia. i. The right large lip. 2. The fourchette. 3. Right nympha. 4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of vagina. 8. Hymen. 10. Mons veneris. 11. Anal orifice. during labor to a greater or less extent ; sometimes it is completely torn into the bowel. That part of the perineum in the virgin which forms the pos- THE PELVIS AND GENITAL ORGANS. 21 terior border of the vulva is called the "fourchette." It is merely a fold of skin and is almost always torn in a first labor. Behind the perineum is the anus or orifice of the rectum, the lower part of the Anal orifice - bowel. The vagina is a canal connecting the external with the internal organs of generation. The uterus Uterus - is at the top of the vagina. In front of the uterus is the bladder, and behind and to the left the rectum. A secretion of mucus keeps the vagina moist. There should, however, be no discharge in a per- fectly healthy woman. During pregnancy, and as a result of ill-health or local inflammation, the natural secretion may be greatly increased, and the patient is then said to have " the whites." In labor ^™f s „ the discharge is very greatly increased, so as to aid the birth of the child. The uterus is a pear-shaped organ, three inches in length, one and one-half inches in breadth, and about one inch in thickness. It weighs a little over an ounce in its normal condition in a virgin. After child-bearing it remains larger and heavier than before. That portion of the uterus which communicates with the vagina is called the neck or cervix. The chief portion of the organ above this Cervix, is called the body, and the rounded upper surface the fundus. The opening in the cervix which 22 OBSTETRICAL NURSING. Os uteri. Fallopian tubes. communicates with the vagina is called the " os uteri." That portion of the cervix in front of the os uteri is the anterior lip, while that part which lies behind is the posterior lip. The Fallopian tubes are two canals which pass from each side of the upper portion of the uterus. They are from three to four and one-half inches long, and will admit the passage of a bristle. Each Fig Cavity of Uterus and Fallopian Tubes. A. Superior border of fundus of womb. B Cavity of the womb. C Cavity of the neck of the womb. D. Canal of the Fallopian tube. E. The fim- briated extremity. F. F. The ovaries. G. The cavity of the vagina. Ovaries. ends in a trumpet-shaped opening surrounded by a fringe of small projections called " fimbriae." This is called the fimbriated extremity. When the ovum (or egg) escapes from the ovary it is received by the Fallopian tube and reaches the cavity of the uterus in this way. The ovaries are two small flattened bodies about THE PELVIS AND GENITAL ORGANS. 23 an inch long and half an inch thick. They lie about an inch from the fundus of the uterus on each side, in the folds of the broad ligament. The broad ligaments are folds of peritoneum, a thin glistening membrane which covers the uterus and all the pelvic organs, and by means of which the uterus is suspended in the pelvis. The bladder and rectum being covered with the same tissue, there is an intimate connection between the three, so that if one is deranged the others are likely to be also. The breasts are considered as belonging to the The breasts - external organs of generation. They are two glands situated on the front of the chest, one oh each side of the breast-bone. They vary in size and shape in different women, and during preg- nancy they enlarge greatly. They secrete milk for the nourishment of the child. The nipple at the apex of the gland is a conical- shaped projection. The milk-ducts all come toward it from the differ- ent parts of the breast and open on its surface. The areola is a pink or brown circle which sur- rounds the nipple. There is an intimate connection between the breasts and the uterus. Pain in the breast may be the result of disease of the uterus. The secretion of milk is called Jactation. Menstruation is a bloody discharge from the M uterus every month. It begins usually about the tion. 24 OBSTETRICAL NURSING. age of fourteen and recurs every month except during pregnancy, or while a woman is nursing. It ceases at the change of life or menopause (be- tween forty-five and fifty). At puberty, that is when this function first ap- pears, the girl becomes a woman, the breasts en- large and the pelvis increases in size. The organs of generation become ready to perform the func- tions of reproduction. The menstrual flow recurs every twenty-eight days and lasts about four days. The quantity of blood lost at a period is from four to eight ounces. Different women vary much in this respect. The discharge is blood mixed with mucus. Its color is dark red. Any peculiarity in color, or the appearance of any clots in the dis- charge, will need to be noticed by the nurse and the discharge kept for the doctor's inspection. There is usually a feeling of discomfort at the men- strual period, with headache, pains in the back, breasts, etc. These symptoms are more severe in some women than in others. Conception. Conception most usually takes place immediately or very soon after a period. This is not an invari- able rule, as women have become pregnant before menstruation has been established, or even after the menopause. They may also become pregnant while nursing. A nurse is so often questioned on these points THE PELVIS AND GENITAL ORGANS. 25 that it is well for her to have information concern- ing them. Always endeavoring to discourage the inquisitiveness of mere prurient curiosity, she should aim to give wise counsel concerning matters of which her patient may hesitate to speak to her physician. In doing so the nurse should, however, speak to the physician of any matters of importance concerning the condition of the patient, which she may thus learn, and ask his counsel as to the advice she should give. CHAPTER II SIGNS OF PREGNANCY. Suspicious signs. pr| n n anc ^he sl S ns °f pregnancy may be divided into three classes : the suspicious, the probable, and the certain. Under the head of suspicious signs may be classed the many nervous sensations which are apt to accompany early pregnancy ; as, general discom- fort, sudden changes of temperature, headache, toothache, giddiness, faintness, changes in disposi- tion. Of the probable signs one of the earliest and mlnsTru- 11 of most constant is the stoppage of the monthly flow in a person who has been regular. This may be, however, caused by other conditions than preg- nancy. Thus, change in one's mode of living, a new climate, or general ill-health may produce the same result. In the early months of marriage we may also have an irregularity in menstruation where there is no pregnancy. On the other hand, in rare instances, we may have the monthly flow persisting for some months or throughout the entire 26 Probable signs ation. SIGNS OF PREGNANCY. 2J pregnancy. It is then generally scanty and short in duration. A deepening in the color of the vagina and vulva, ^i^f^ by which they take on a purplish hue, is another vag,na - sign, and is caused by the enlargement of the blood- vessels and a stoppage of the circulation, due to pressure from the enlargement of the uterus. This coloration may be caused to some extent by tumors. Increase in the size of the breasts occurs in the Dev fiop- ment of early months of pregnancy with a deposit of color- breasts - ing matter in the areola, or ring which surrounds the nipple. Some of this coloring matter seems to extend irregularly over the outer margin of the ring, and is called the " secondary areola" or " areola of Montgomery." With this distention of the breasts there is also a secretion found in them — a watery fluid, sometimes yellowish in color, known as " colostrum." Temporary distention of the breasts, with the accumulation of this secretion, may occur in a slighter degree as an accompaniment of menstrua- tion, or it may persist for a long time-after a woman has stopped nursing her infant. Enlargement of the abdomen, which begins Enlar gf- <=> » o ment of about the third month of pregnancy, is another abdomen - important sign. Yet this may also be caused by tumors, or by flatulence, or the deposit of fat in the abdominal walls. 28 OBSTETRICAL NURSING. Striae." Brown-line tumors, and mask" of preg- nancy. Morning sickness. " Quicken- ing." Marks upon the abdomen, due to the rapid stretching of the skin, sometimes occur in great numbers, and are called "striae," owing to the fact of their resemblance to the marks left by whip- lashes. These marks sometimes extend down upon the thighs. This, too, may be caused by The " brown line" of pregnancy is the deposit of pigment in the median line of the abdo- men. This may exist when there is no pregnancy, as also may the peculiar browning of the skin found in irregular patches over the face, particularly on the forehead, and called the "mask of pregnancy/' " Morning sickness," another sign, begins early in the second month or at the time of the first missed period. It is generally confined to the first three months and is largely a nervous symptom. It varies much, however, in degree and time of occurrence. Sometimes it is simply a slight feeling of sickness at the stomach occurring early in the morning ; again, it may persist throughout the entire day, or it may occur one day and not again for several days. Sometimes it continues throughout the entire pregnancy, and is then dangerous because of the constant loss of food. Sometimes it occurs early in the pregnancy, then disappears to reappear in the last month, when there is direct pressure upon the stomach. " Quickening" — or the appreciation of the move- SIGNS OF PREGNANCY. 29 ments of the child by the mother — is another prob- able sign, and is first experienced about the middle of pregnancy. A woman who has previously borne children feels this sensation about two weeks earlier than one pregnant for the first time. There are other probable signs of pregnancy ^^.p^- which would come only under the observation of the physician. As they require considerable know- ledge of obstetrics and skill in the conducting of a» examination for the discovery of pregnancy, we will not do more than refer to them here. The positive signs of pregnancy as agreed upon \ Positive gns. by most obstetricians are but two : the direct ap- preciation of the parts of the child by touch, and the " foetal pulse," or heart sounds of the child. The " foetal pulse" is, as a rule, twice as fast as the pulse of the mother. It is hardly strong enough to be heard, even by experienced ears, much before the 5th month — or end of the 20th week — rarely heard well before the 24th week. The ordinary method of reckoning the probable Methods of y o x reckoning date of confinement is as follows : Learn on what terminati <> n or preg- day the last monthly flow began, then count three nancy - months backward (or nine months forward) and add seven days. For example, say that a woman was unwell last on March 15, counting three months back, gives December 15; add seven days, and we have December 22 as the probable 30 OBSTETRICAL NURSING. date of her confinement. When, for any reason, it is impossible to make the calculation by this method, it may be computed by adding four and a half months to the date of quickening in the case of a woman pregnant for the first time, and five months in the case of one who has previously borne children. The third method, that of adding forty weeks, or t,en lunar months, to the date of conception is too uncertain to be of much practical use. Examina- tion of the patient by an intelligent physician who knows and appreciates the distinctive signs of the several months offers a fourth method of comput- ing the date of pregnancy. CHAPTER III. MANAGEMENT OF PREGNANCY. The management of pregnancy consists, for the^"^ 011 t0 most part, in greater attention to the laws of health. health - The increased activity of all the organs of the body, together with the disturbances caused by pressure, necessitates this. Constipation is an almost invariable accompani- £™ stipa " ment of pregnancy. In the early months it is a sympathetic condition ; later, the effect of direct pressure upon the bowels. It is also, undoubtedly, in part due to the want of exercise. The treatment of constipation is the same as in other conditions, except that only mild laxatives are used. Regularity in attention to the bowels, a glass • of cold water at night and again in the morning, liquids (either milk or water), not taken with the meals, but in the intervals, a teaspoonful of common salt in the water occasionally, the use of uncooked fruit and coarse bread, the avoidance of starches and fine flour — all these are helpful in overcoming this condition. There is an objection to the use of 31 32 OBSTETRICAL NURSING. sugared fruits, as confections of fruit, senna leaves, etc., because of their liability to disturb the stomach. Prunes are, perhaps, the least objectionable ; licorice powder, because of the senna which it contains, is apt to cause griping pains. Rhubarb is, perhaps, the best of the mild laxatives. A small piece of rhubarb root, the size of a pea, may be taken at night, followed by a glass of water. If there is an objection to its taste, it may be taken in pill form. Cream of tartar, a half a teaspoonful being taken at night in a cup of cold water, is often efficient. In some cases it may be necessary to repeat the dose in the morning. Massage of the abdomen, so efficient in the man- agement of constipation, should never be resorted to in the pregnant state, as it is apt to excite uterine contractions, and may lead to a miscarriage. There is an objection to the too frequent use of enemata on the same ground ; also, the habit is thus ac- quired of depending upon this stimulus, and over- distention of the bowel is the result. It may be necessary, however, occasionally to alternate an enema with a laxative, especially when the patient suffers from piles. Diarrhoea. Diarrhoea is rather a rare disturbance of preg- nancy, but it sometimes occurs as a direct result of constipation — small, hardened masses forming in the bowel, known as " scybala," which produce an MANAGEMENT OF PREGNANCY. 33 irritation of the mucous lining. The use of rhu- barb night and morning, in the manner described above, until all the masses are removed from the bowels, will serve to check the diarrhoea. Changes in the urinary organs are mainly due to Theurinar y o J c> J organs. direct pressure. In the first three months of preg- nancy there is direct pressure on the bladder, hence great irritation, due to interference with the disten- ^ n e bility tion of the bladder, producing a constant desire to bladder - pass water. For this the recumbent position is the only help. The uterus rises in the abdomen at the end of the third month, and the bladder being thus relieved from pressure, this symptom passes away. The tendency from the fourth to the ninth month Retention of J urine. is to the accumulation of urine, because there is less than the proper irritability of the bladder, the , organ being flattened between the uterus and the abdominal wall, and its walls thereby suffering a partial paralysis. In the last month there is incontinence of urine, Inconti - ' nence 01 because the pressure is so great that there is no urlne - room for the accumulation of urine. During labor there is pressure upon the neck of Retention of r r urine in last the bladder and urethra, leading to retention. This m ° nth of ' o pregnancy. may exist for the last two weeks of pregnancy. Necessity for the use of the catheter is confined, as a rule, to this period. The distention of the blad- der may impede labor. With the drawing up of 3 34 OBSTETRICAL NURSING. Excessive acidity of urine. the uterus the bladckr is drawn up and the urethra elongated, hence the use of the long rubber cathe- ter, known as the English catheter, will be neces- sary. Nos. 8 and 9 are those ordinarily used. Sometimes irritability of the bladder is due to excessive acidity of the urine. A physician will generally prescribe some alkali to overcome this condition, as a drop of liquor potassa in a table- spoonful of milk once in three or four hours, or the Fig. 4. Abdominal Belt. Use ot binder. Excoriation of vulva. use of mucilaginous drinks, as flaxseed tea, barley water, milk, etc., may relieve the distress. When the abdominal walls are much stretched and the uterus falls upon the bladder, this may be remedied by the use of the binder or an abdominal supporter. Incontinence of urine leads to the excoriation and reddening of the parts about the vulva. Fre- MANAGEMENT OF PREGNANCY. 35 quent washing with warm water and borax or pure castile soap relieves the irritation. Diachylon or zinc ointment is best when an ointment is needed. Incontinence is sometimes the result of over- Over-dis- tention of distention of the bladder. Here the use of the bladder - catheter is indicated. A nurse, unless thoroughly experienced, should ^ e ° t f er never attempt passing the catheter in the case of a pregnant woman, as serious injury may be done to the soft parts in a bungling attempt. In all cases she should have the sanction of the physician before so doing. The kidneys are especially subjected to pressure ^® e s from the seventh to the ninth month of pregnancy. A passive congestion is thus produced, which may lead to the occurrence of albuminuria, or albumin Albumin - ' una. in the urine. This is an evidence of a drain upon the blood which the physician needs to watch very carefully. It is customary, therefore, for physi- cians to examine the urine of patients whom they Exam j na : 1 J tion of urine. expect to attend, at least once a week, from the seventh month on to the termination of pregnancy. A specimen obtained by the use of the catheter is the best for the purpose, if the patient be troubled by a discharge from the vagina. There is a natural increase in the amount of^ c o r ^ s t e o j. n urine passed by a pregnant woman, but the increase unne - is mainly in the water. Therefore the urine will Leucor- rhoea. 36 OBSTETRICAL NURSING. be lighter colored than usual. The reaction of the urine should be acid. Should the reaction be alkaline, or the quantity of urine diminished rather than increased in amount, the fact should be reported to the patient's physi- cian. Leucorrhcea, a discharge from the vagina, com- monly known as " the whites," is much increased often during pregnancy, and is due to the greater activity in the secretion of all the mucous mem- branes. If a vaginal discharge be of a white, yellow, or green color, it indicates inflammation of the vagina itself. The discharge, on reaching the vulva and coming in contact with the air, decomposes and becomes irritating. Cleanliness is important in overcoming the effects of this. The itching induced by it is sometimes very obstinate, and generally worse at night. A solution of borax and water for bathing the parts, or carbolic acid, 15 to 201^ to a pint of water, will often give relief. Should vaginal injections be ordered by the physician, they should be given with great caution. A fountain syringe should be used, which produces a continu- ous stream. The interrupted stream should never be employed. In some conditions of excessive discharge the physician may prescribe tannic acid suppositories to be used nightly in the vagina. After a thorough drying of the parts surrounding MANAGEMENT OF PREGNANCY. 37 the vulva, they may be dusted with a powder con- sisting of one part powdered camphor to four parts starch. This often gives great relief. Calomel powder may be used in the same way. Hemorrhoids, or piles, are often very trouble- ^idTor some during the latter part of pregnancy. Lying piles - down immediately after a movement of the bowels, and remaining in the recumbent position for ten to fifteen minutes, will tend to relieve them, also care in obtaining a daily evacuation of the bowels, and the use of means to secure as soft a movement as possible. Should the piles come down they should be fomented by cloths wrung out in hot water, to which a little Pond's Extract or fluid extract of hamamelis may be added — one tablespoonful, or two, to one pint of water — and when shrunken, anointed with cold cream or cosmoline and re- turned into the bowel. Sometimes the case is so aggravated as to neces- sitate keeping the patient in bed for a time. A physician should of course be consulted about the treatment. The swelling; and pain of the external organs of swelling ot x ° lower limbs. generation and of the lower limbs, resulting from pressure and the over-distention of the blood- vessels, is best relieved by the recumbent posture. Should the veins of the leg be much enlarged, or the feet swollen, the patient should have com- 38 OBSTETRICAL NURSING. pression made over them by the application of a bandage (the spiral-reverse of the lower limb), or Fig. 5. Spiral Reverse Bandage of Lower Extremity. she should wear an elastic stocking, such as may be obtained of any good instrument maker. For MANAGEMENT OF PREGNANCY. 39 the bandage the best material is flannel cut bias, the width being about three inches. The bias bandage makes more even compression. Great harm may result from the neglect of enlarged veins, as they sometimes become so distended as to burst. Prof. T. S. K. Morton has devised a method of putting on a spiral bandage of the lower extremity, which retains its place better than that just described, which is apt to loosen when the patient moves about. Dr. Morton begins the application of his bandage as in the ordinary spiral reverse bandage of the lower limb, but carries oblique turns up and down the limb until its sur- face is entirely covered, in place of making reverses. When this bandage is further secured in place by carrying a running line of stitches up both the inner and outer side of the limb, it keeps its place per- fectly and is quite as serviceable as an elastic stocking. Pain caused by the stretching of the walls of the J. a i n f 5 om r «' o distention 01 abdomen may be relieved by thorough inunction ^ b a d n ° s minal of the skin. Cotton-seed, olive or cocoanut oil may be used for the purpose. Severe pains in the back, neuralgic in character and so severe sometimes as to prevent the patient from sleeping, may yield to change of position, relieving pressure. Rubbing with soap liniment, volatile liniment, whiskey, or any liniment not too Pains in back. 40 OBSTETRICAL NURSING. active, is helpful. Warm hip-baths may sometimes be prescribed by a physician. ictTvity e of The salivary glands are in some cases very active gland! 7 during pregnancy, inducing so excessive a secre- tion of saliva as to cause the patient great annoy- ance. This trouble is generally very intractable, and may refuse to yield to all treatment, ceasing only with parturition. Astringent washes, as of tannic acid, alum, myrrh, etc., may be tried, as also the use of pieces of ice. Physicians sometimes use atropia in small doses. Its use requires careful watching. Bad teeth. Bad teeth, which occur so often during preg- nancy, are said to be due to acidity of the saliva. A little baking soda or prepared chalk placed in the mouth at night will counteract the effect of this „.,,. acidity when it exists. The question is often asked Filling or J J- teSh^urin whether there is any danger in having the teeth pregnancy. fln ec j or attended to during pregnancy. There is always some danger, because a certain amount of nerve-irritation is the result. If the patient be suffering, however, it is better to have them filled by a temporary rubber filling, which causes little pain or irritation, than to lose rest in consequence of toothache. Extraction of the teeth should only be allowed when absolutely essential. If the pain be simply a neuralgic pain, it is better to wait. Vomiting is, as has been said in the- preceding MANAGEMENT OF PREGNANCY. 4 1 chapter, a most common accompaniment of preg- vomiting of nancy. It more frequently exists, perhaps, with the first pregnancy than any other. The act is accom- plished, as a rule, without much effort. Diet seems to have but little effect upon it. Various articles have been recommended for it, as rice-water, beef- tea, barley-water, the various gruels ; the yolk of a hard-boiled cgg } scraped beef in the form of sand- wiches, ice-cream, cracked ice, etc. In some cases one or other of these seems to relieve the irritation. A cup of coffee, weak tea, or milk, taken warm early in the morning before the patient raises her head from the pillow, will often act as a preventive. In extreme cases of vomiting rectal feeding must be resorted to. In obstinate vomiting it is important that the physician should examine for the position of the uterus or the existence of ulcerations or erosions. It must not be forgotten that the constant loss of food may be so great a drain upon the patient's strength as to endanger her life. As this symptom is so largely sympathetic, the proper use of bro- mides or other nerve sedatives prescribed by a physician may be of great use in checking it. Care of the breasts in a pregnant woman neces- £ are ° f the r o breasts. sitates careful attention to the prevention of com- pression. Full development should be permitted 42 OBSTETRICAL NURSING. by the looseness of the clothing. The importance of the proper dressing of growing girls cannot be overestimated in this connection. Did mothers realize the evils — of which the atrophy of the breasts is but one — resulting from tight lacing, there would be fewer unhealthy women and fewer mothers unable to nurse their offspring. The nipples should be prevented from rubbing, and the skin over the nipples should be strengthened by using the Nipple bath, nipple-bath — filling a small, wide-mouthed bottle one-third full of cold water and inverting it over the nipples daily, from five to ten minutes at a time. Sometimes a little cologne-water or alcohol is added to the nipple-bath. Keeping ofif scabs and con- cretions of various kinds from the surface of the nipples by the use of a little oil is also admissible. The use of the nipple-protector, which will be referred to more fully in the chapter on the man- agement of the lying-in, is of great importance where there is a tendency to flattening of the nipple, to remove the pressure of the clothing. The clothing of a pregnant woman should be worn loose from the very beginning, both because the breasts begin to enlarge early and corsets inter- fere with their development, and because any amount of pressure upon the intestines tends to produce uterine displacements, which are especially Use of oil. Nipple protector. Clothing. MANAGEMENT OF PREGNANCY. 43 dangerous during pregnancy, as they predispose to abortion. The clothing should all be supported from the shoulders. Many new dress reform systems are now in hygienic J J dressing. vogue, having for their object the great desideratum of adjusting woman's dress so as to make it both healthful and beautiful. Fortunately, in this enlight- ened age ideas of physical culture are so modifying old-time ideas of beauty that the wasp waist, the Fig. 6. Nipple Protector. multitudinous and voluminous skirts, the awkward and deforming bustle, the high-heeled boot, are fast becoming relics of the past. Among the dress- reform systems now in existence there is none so fully meets my views of healthful and beautiful dressing as the Jenness-Miller System. But few garments constitute the costume, and these are so constructed as to allow perfect freedom of every part of the body. A complete costume for summer wear, according to this system, would consist in the chemilette — a 44 OBSTETRICAL NURSING. combined"chemise and pair of drawers — around the waist of which buttons may be fastened, to which the second article of dress, the divided skirt or Fig. 7. Fig. 8. Jenness-Miller Divided Skirt. Jenness-Miller Chemilette. Turkish leglette, is buttoned. The latter is made so full that it takes the place of petticoats, and the dress may be comfortably worn over it. Should the dress be of some very sheer material, one addi- MANAGEMENT OF PREGNANCY. 45 tional muslin petticoat may be worn, similarly fastened to the waist of the chemilette. If a person is accustomed to wearing merino or silk underwear both summer and winter, the jersey-fitting union Fig. 9. Fig. 10. Union Undergarment. Jenness-Miller Leglette. under-garment may be worn beneath the chemilette, or, the latter being dispensed with, the Jenness- Miller " model bodice," or the Equipoise waist and divided skirt, may be worn alone over the union under-garment.* *The Delsarte waist, more recently devised, has a similar object, in meeting the hygienic and artistic requirements of woman's dress. 46 OBSTETRICAL NURSING. For winter wear, plain leglettes of flannel, cash- mere or silk, or the same material as the dress, may be worn over the union under-garment and directly beneath the dress. Thus under-skirts are entirely dispensed with and all the clothing is supported from the shoulders. The skirts of winter dresses, being comparatively heavy, should be fastened to a waist of their own which has comfortably-cut armholes. Garters fastened to the waist are discountenanced, according to this system — as they should be, for they produce too much dragging on the waist, and the spiral-spring Duplex Ventilated garter is recom- mended to be worn until something better is de- vised. It is probable that the fashion will come into vogue of combining the stockings with the union under-garment, when garters will be done away with entirely. It is well for the stockings to be of wool or silk. The shoes or slippers worn should be comfortable and with broad soles and low hpels. Slender women can well wear the chemilettes, dispensing with all boned waists. Stout women, having busts, find more comfortable the model bodice, or the Equipoise waist,* which, I believe, is *This, wilh the other garments mentioned, may be obtained through the Dress Reform Emporiums in Philadelphia, or similar agencies in other cities. MANAGEMENT OF PREGNANCY. . 47 not one of the garments of this system, but an exceedingly comfortable one, in my opinion. Mrs. Jenness-Miller is now devising some form of breast support which aims to support the weight of the breasts from the shoulders, so that waists contain- ing bones may not be regarded as a necessity, even by the stout. Both the " model bodice " and Equi- FlG. The Equipoise Waist. poise waist (the latter of which I prefer) contain bones, but dispense with the front steels, so injurious in the ordinary corset. For the changes in shape induced by advanced pregnancy the union under-garments will need to be of larger size than those ordinarily worn (about two sizes larger). Many beautiful designs for dresses and other outer-garments have been devised by Mrs. 48 OBSTETRICAL NURSING. Miller, patterns for which may be obtained of the Jenness-Miller Co., in New York, or its agencies in other cities. Before leaving the subject I would mention, as one especially praiseworthy feature of this system, the perfect use of the arms permitted by the ingeniously devised patterns for sleeves and shoulder straps. If the skirts are not fastened to a properly constructed waist as described, they should be supported by suspenders. binden m When the abdominal walls are much relaxed, from stretching, allowing the womb to fall forward, it is well to use an abdominal binder or belt, especi- ally during the last month of pregnancy. This helps to keep the uterus in proper position. Fiannd Flannel should be worn — at least during preg- underwear. ° x ° nancy — both summer and winter. A lighter flannel can be substituted in summer for that which would be worn in winter. The use of flannel is to prevent chilling of the surface, and this is especi- ally important where — as in pregnancy — the kid- neys are overworked. It is important also for the condition of the heart and lungs. Coughs often cause premature labors. The jersey-fitting knit union under-garment, before referred to, may be obtained in all grades and sizes and is well suited to the purpose. Bathing. Bathing is very necessary for a patient during her pregnancy, as at other times. As regards the MANAGEMENT OF PREGNANCY. 49 character of the bath, she can do as she has been accustomed to, using warm or cold water. A change from warm to cold water, or vice versa, is, however, not allowable. A sponge-bath, followed by brisk rubbing, is the most desirable. The skin is thus kept in good condition. Shower-baths should be avoided. Sea voyages are injurious, because of the danger voyages. of receiving falls or blows in consequence of the motion of the vessel, and also because of the lia- bility to sea-sickness induced by them. When it is absolutely necessary to take a sea voyage, there is probably least danger in the last three months of pregnancy, because the placenta, or afterbirth, is then well developed and its attachment to the uterus close. The regulation of the diet during pregnancy is ^egntnc^ of great importance. A patient should eat heartily for breakfast and dinner, but the evening meal should be light, especially from the seventh month on to the close of pregnancy. This meal should consist of stale bread, with butter and cooked fruit, as stewed apples, and a glass of milk or weak tea. Digestion is less active in the latter part of the day, and often a hearty meal may prove the direct exciting cause of convulsions. The food should be plain, wholesome, nourishing, well-cooked, and chosen in each case with special reference to the 4 50 OBSTETRICAL NURSING. avoidance of digestive disturbances and constipa- tion. Meat in moderate quantity, broths, milk, eggs, and fresh fruit should constitute an important part of the dietary. Pastry and confections should be avoided. Fruit diet. There is a mistaken theory prevalent in this day that a mother, by abstaining from certain kinds of food, as meat, eggs, milk, etc., and confining herself chiefly to a fruit diet, may thus, by preventing the hardening of the bones of the child, do away largely with the pains of labor. The truth of the matter is this: that during pregnancy all the func- tions of the mother's body are especially active in promoting the development of the child, hence an insufficient supply of essentially nourishing food will first affect the mother's system and render her unfit for the demands upon her strength at the time of parturition. Should a restriction to the fruit diet effect what it is claimed to do as regards the infant, it would result in the production of sickly, rachitic children, poorly developed mentally and physically. Exercise. Moderate exercise is essential during pregnancy. Walking on a level, not riding, is the best form of exercise. A daily walk should be taken, not, how- ever, after nightfall. The patient should avoid lift- ing — in fact, all straining movements — and most MANAGEMENT OF PREGNANCY. 5 I particularly should she avoid the use of the sewing- machine. There is sufficient proof that the mother's emo- Surround- ings. tions influence the child to render it important that her surroundings during pregnancy should be as pleasant as possible, and that she should avoid fright or any violent emotion. CHAPTER IV. ACCIDENTS OF PREGNANCY. Hemor- rhage. Recumbent position. Note to physician. Preserva- tion of discharges. A discharge of blood from the womb, known as " uterine hemorrhage," may occur at any time dur- ing the pregnancy, and is usually a sign that the patient is threatened with a miscarriage. However slight the flow, the nurse should have the patient lie down until the doctor has been told of its occur- rence, and decides what the patient should do. A note should be sent to the doctor, telling just what has happened, and clearly making him understand the urgency of the symptoms — that is, the amount and character of the flow — and the condition of the patient. A nurse should not trust to a verbal mes- sage, as the physician may fail to respond to the call promptly, not being aware of the urgency of the symptoms. The patient should be required to use the bed pan, or, at least, a vessel the contents of which can be thoroughly examined, both for the bowels and the passage of urine. All discharges, soiled clothing, clots, etc., should be carefully saved for the inspection of the physician. 52 ACCIDENTS OF PREGNANCY. 53 Meantime, an effort should be made on the part Efforts of of the nurse to control the flow. The patient should control flow, lie with her head low, and a pillow under her hips ; she should not be warmly covered, plenty of cool, fresh air should be admitted into the room, and she should be kept excedingly quiet. Should the symptoms become more urgent, the Toprevent patient being threatened with fainting, the head may faintin s- be lowered by raising the foot of the bed, placing bricks or chairs under it in such a way as to make a decided inclined plane of the bed. The patient should be fanned, given hartshorne to inhale, and her limbs rubbed, to keep them warm, with alcohol or whiskey. Small doses of whiskey or aromatic spirits of ammonia may be given her in cold water, if able to swallow, or black coffee, or tea, not too warm. If there is much blood flowing from the vulva, vaginal injections of hot water, at a tempera- Actions. ture of about no° to 115 , may be kept up until the flow ceases. Alarming hemorrhages are often the result of Causes of hemor- accidents, falls, or blows, or they may be caused by rha ges . heavy lifting. Hemorrhage from a low attachment of the pla- Unavoidable centa, or afterbirth, or when the afterbirth occupies ^^" an unusual position — that is, at the side of or over the mouth of the womb — occurs without any history of accident. It takes place at any time from the 54 OBSTETRICAL NURSING. Hemor- rhage from rupture of varicose vein. Miscar- riages. Prevention of mis- carriages. Precaution during men- struation. seventh month of pregnancy on to its termination, and without any premonitions of its coming. It may occur at night while a patient is lying in bed. The management of this condition would be the same as that described above, until the doctor comes. Women suffering from enlarged, swollen veins, " varicose veins," or " varices," of the lower extremi- ties, if not careful in keeping the limbs bandaged or supported by elastic stockings, may have hemor- rhage occur by the bursting of one of these over- distended veins. The amount of blood lost may be so great as to imperil the patient's life. Should such a rupture of a vessel occur, compression should be made just below the point of rupture, to control the bleeding, until the physician, who should have been sent for, arrives, when he will resort to the measures necessary for securing against further hemorrhage. Miscarriages are apt to recur, hence a patient who has once suffered from one, should be cau- tioned to take additional care of herself during any subsequent pregnancy. Any sensation of weight about the hips, with the recurrence of a " show," or slight discharge of blood, and cramp-like pains should warn her to lie down and send for her phy- sician. Such a patient should also take the precau- tion to lie down as much as possible (if not in bed, on a lounge) during the time when, under other ACCIDENTS OF PREGNANCY. 55 circumstances, she would have her monthly flow. Any patient having had a number of miscarriages should keep herself under the care of her physician from a very early date in the pregnancy, being placed under a regular course of treatment. It is well, in this connection, to speak of the im- After . treat . portance of care in the after-treatment of miscar- ™rrilgL mis ~ riages. Not uncommonly, patients, especially of the working classes,- get up and go about their work a day or two after the occurrence. This is a dangerous proceeding, for, though the ill-effects may not be felt for a time, chronic disease of the uterus is apt to result. If the pregnancy terminates before the fourth month it is commonly called an abortion. Between the fourth and seventh month it is a miscarriage, and after the seventh month, if before term, a premature labor. It is really necessary to give more time to the Confinement recovery from the effects of an abortion, than to t0 recovery from a confinement at term, and the pa- tient should be willing to remain in bed at least a week or ten days, or longer, if thought best by her physician. The patient should not leave her bed so long as any discharge of blood continues. Premature rupture of the membranes enclosing premature the child, with a discharge of colorless liquid, com- membranes. monly known as " breaking of the waters/' is another of the accidents of pregnancy, and is invariably 56 OBSTETRICAL NURSING. followed, within a few days, at least, by the expul- sion of the child. The patient will complain of her clothing becoming wet, either by a sudden dis- charge of a quantity of liquid, or by a slow but continuous flow. The nurse can assure herself that this liquid is not urine by her sense of smell. The smell of urine is characteristic. With the amniotic liquid surrounding the child, there is almost an entire absence of smell, a peculiar, faint, musty odor being alone recognizable. Saving It is best, in removing this wet clothing from the clothing for . . , . inspection, patient, to set it away, that the physician may judge for himself of the character of the liquid. The pa- tient should at once lie down, not taking the erect position for any cause, not even for defecation and urination, and the physician should be sent for, with a written statement as to what has occurred. It is important that the physician should see the patient as soon after the rupture of the membranes as possible, because the sudden loss of water may have brought about changes in the position of the child which may endanger its life. The loss of the entire amount of liquid contained in the sac would cause also difficulties in the delivery, or what is known as Dry labor. " 3. diy labor." Convui- Convulsions may sometimes occur during the sions. pregnancy. The symptoms which threaten this trouble are extreme restlessness and uneasiness ACCIDENTS OF PREGNANCY. 57 on the part of the patient ; severe headache, often confined to one side of the head; disorders of vision, as seeing things double, or seeing but the part of an object, sometimes very imperfect vision, and occasionally absolute loss of sight ; twitchings of the muscles, especially of the face, may occur. The convulsion is ushered in by this restlessness and twitchings, beginning first about the eyes and ex- tending rapidly to the mouth, arms, and lower extremities. The movements are not violent, hence the patient is not likely to throw herself out of bed. The physician should be sent for; meantime, the nurse should see that the patient is kept lying down, that her clothing is well loosened, especially about the head and chest, that plenty of fresh air enters the room, and that the patient is kept from biting her tongue. A folded handkerchief or towel slipped in between the teeth pushes back the tongue and prevents the teeth from coming down upon it. The patient's feet should be kept warm and head cool. The members of the family must be kept calm and prevented from meddlesome interference, for the attempt to make the patient swallow any stimulant while struggling and unconscious may result very disastrously. Should the attending physician live too far away or be delayed in coming, the nearest physician Should be sent for. CHAPTER V. GERMS AND ANTISEPSIS. One of the most important things for an obstetric nurse to know is the meaning of the term " anti- Antisepsis, sepsis," and the method by which antisepsis may be carried out in her work. Literally, the term " antisepsis " means "against sepsis or putrefaction," and refers to the application of means by which objects may be rendered en- tirely free of all poisonous elements. Germs Dust, as we know, is everywhere present in the wherefound - atmosphere, and consequently settles upon every- thing exposed to it. This dust consists, as has been found, of very minute organisms, which, when they are planted in a suitable soil, grow and multi- ply very rapidly, producing, as a result of their activity, the poisonous fluids and gases which characterize the process of putrefaction, ptomaines. These products are called ptomaines. The sub- stances thus formed, when absorbed into the blood, give rise to the symptoms of blood-poisoning. It may, therefore, be plainly seen that the simple 58 GERMS AND ANTISEPSIS. 59 neglect of measures to destroy these dust germs may, by allowing decomposition of the natural discharges, lead to septic poisoning. It has been found, as a matter of experience, that Poisonous x properties. other diseases besides those commonly classed under the head of " child-bed fever," or " puerperal sepsis," may be induced by these small germs, and this explains why it is so very important that ery- sipelas, scarlet fever, or other acute contagious diseases should be avoided by those engaged in obstetric practice. A nurse leaving such a case to go to a confinement case will do so at the risk of her patient's life, for puerperal fever will almost certainly be induced by the germs which she carries from the former case. The minute bodies known as germs are, we see, ciassifi- greatly to be dreaded. They are of three kinds — germs. first, those to whose action most of the infective diseases are attributed, and which are divided, according to their shape, into micrococci, round- shaped bodies; bacteria, oval-shaped bodies; bacilli, rod-shaped bodies of varying length ; and spirillse, or spiral, thread-like bodies ; second, yeasts ; third, moulds. To give an idea of their size, it has been said of size, one of the most common forms of germs (the rod- like), were fifteen hundred of them put end to end 6o OBSTETRICAL NURSING. Growth. Conditions of growth. Method of growth. they would scarcely reach across the head of an ordinary pin. Their rate of growth, too, is very rapid, a com- mon estimate being that they double themselves once or twice every hour. Thus, in the course of twenty-four hours a solitary germ may become a colony of between sixteen and seventeen millions. Warmth, moisture, and a certain amount of organic matter are the conditions which favor their development. Most, but by no means all, forms of bacteria require air ; some, however, can only develop in the absence of air. Germs may grow by division ; that is, one of them may have a constriction form about its middle which finally becomes a complete partition, so that two distinct germs are thus formed. These simi- larly divide, and thus their number multiplies. Another method of growth is by spore formation. At one or more points in a rod an oval spot appears which becomes brighter and clearer. These spots are spores, and when fully developed they become free, the rest of the rod dissolving away. These spores retain their vitality for years, ready at any moment when suitable conditions are provided to develop into fully formed germs. It is extremely difficult to destroy the vitality of these spores. Many antiseptics which readily kill the adult germs GERMS AND ANTISEPSIS. 6l will not harm the spores — or only do so after a much longer time than that necessary for the adult germ. Even where the antiseptics do not kill, however, they may retard the development of these germs and thus prevent their doing injury. In all germ diseases a battle is fought between the patient's body and the germs with which it is infected. If the germs are present in small quantity only, it is possible the resisting power of the body may enable them to be overcome. If, however, the general health is impaired by conditions r • r i • i favoring overwork, deficient food, overcrowding, or other sepsis, depressing influences, the patient w T iil be more likely to succumb to the attack. This explains why some patients escape under the same condi- tions in which others suffer from blood-poisoning. Lying-in patients are especially liable to germ Proclivity infection, both because the labor leaves them in a during r 11 i lying-in. state of exhaustion and because there are always certain open surfaces present upon or within such a patient's body — so that these serve as direct avenues for the entrance of poison into the system. The site within the uterus from which the placenta or after-birth is detached is one of these ; others being the fissures or lacerations about the neck of the uterus, the vagina, or perineum. This shows 62 OBSTETRICAL NURSING. the importance of protecting from decomposing discharges all such open surfaces. Experiment has shown that bruised tissues are especially liable to destructive inflammation from the action of germs. This explains why first labors and difficult and tedious labors are most apt to be followed by septic infection. Should such a labor be followed by the occur- rence of sloughing wounds, it is therefore especially important that any discharges from the wound should not be retained, but kept carefully removed by means of antiseptic irrigation, etc. Care should be taken that the antiseptics used should not be in sufficient strength, however, to irritate the wound, as this may increase the trouble. Any condition such as an attack of inflamma- tion, exposure to cold, or disordered digestion, because it lowers the vitality of the body, tends to increase the tendency to septic infection. Besides the diseases resulting from the classes yea"t-hrf££ °f germs most commonly concerned in the pro- duction of putrefactive changes in the body, we have some which are due to " mould-infection " and the action of yeasts — which are also lowly organ- isms existing in great numbers in the atmosphere, and capable of setting up destructive changes in tissues. It is the "moulds" which are the cause Diseases due to mould- and yeas tion GERMS AND ANTISEPSIS. 63 of food spoiling when allowed to stand exposed to the air. The disease known as " thrush," which is characterized by grayish patches forming upon the mucous membrane of the mouth and adjacent parts, is due to a parasite which is one of the " yeasts." A number of skin diseases are caused by the growth of " moulds." In order to prove the fact that animal fluids will Ex P eri .- 1 ments in not undergo putrefaction if germs are excluded ^ a o cteri- from them, a series of very interesting experi- ments were made for a class in one of the London hospitals recently, to illustrate some of the most common errors in nursing. These can be repeated for class instruction anywhere. A series of glass tubes were taken, into which some sterilized beef-tea or beef-jelly was introduced. Into two of these tubes scrapings from under the finger-nails were placed, and in one the little specks shapings * ' L from finger were soon seen to eat their way into the jelly, nails - followed by a trail of microbes. In the other tube a dense mass of moulds developed, and the beef-jelly was transformed into a dark brown color. Into a third tube apiece of cotton used in wiping Discharge r r from vulva. the vulva of a lying-in woman, previous to passing the catheter, was dropped, with the result of show- ing almost immediately a mass of germs which descended into the jelly, liquefying it by their pres- 64 OBSTETRICAL NURSING. ence, while the cotton, owing to the air it contained, floated on the surface. A drop or two of urine from the bladder of a Urine in patient suffering from inflammation which had case ot x ° cystitis. resulted from the use of an impure catheter, was introduced into a fourth tube containing the steril- ized beef-jelly. This caused the jelly from above downward to be converted into a dirty-looking yellow fluid, whilst a whitish mass of germs accumulated on the surface of the jelly. The importance of antiseptic precautions in the nursing of infants was well illustrated by two other experiments. Into a tube containing some of the Sour milk, sterilized beef-jelly a drop of sour milk was placed ; very rapidly a mouldy coating appeared over the surface of the jelly. When we think of a similar process taking place in the digestive tract of an infant, we can realize why babies should suffer so greatly from careless management of their food. scrapings Another tube had introduced into it some scrap- from "thrush." ings from the mouth of a child suffering with "thrush." Colonies of snowy-white germs ap- peared which, as they grew larger, became of a greenish color and spread with great rapidity. As object lessons serve to impress the import- ance of facts, these experiments serve to keep before us the importance of antiseptic precautions in the care of mother and child. CHAPTER VI. APPLICATION OF ANTISEPSIS TO CONFINEMENT NURSING. The use of antiseptics has almost entirely anni- Antiseptic hilated puerperal fever, commonly known as ''child- bed" fever. This disease, as we know, is simply blood-poisoning or septicaemia, and is caused by the entrance through a wound of some poisonous material into the blood. In the simplest and most natural labors slight tears are apt to exist either about the external parts or about the neck of the uterus. There is always a wound inside of the uterus at the place where the placenta or after-birth was attached. In difficult labors there may be extensive wounds. Septicaemia, or blood-poisoning, may be caused Causes of ■ . . biood- by a piece of placenta or blood-clot being retained poisoning. in the uterus or birth canal after the delivery, and there putrefying. It may also be caused by the patient's attendants having some poisonous material on their hands, instruments, or various appliances, and bringing these in contact with her wounds. 5 65 Preventive measures. 66 OBSTETRICAL NURSING. Dirty hands, dirty finger-nails, unclean bed-pans, soiled clothing, etc., may be the cause of the trouble. Sponges should never be used in the lying-in room. Artificial sponges made of anti- septic cotton enclosed in gauze may be substituted. The poisonous material which might be thus con- veyed to the wounds of the lying-in woman must be guarded against by the most scrupulous attention to thorough cleanliness. Antiseptics are chemical substances which have the power of destroying the germs of putrefactive change or rendering them inert. They should, therefore, be systematically used in all cases of labor to prevent septic germs from entering the wounds and giving rise to puerperal fever. The antiseptics most generally employed in the mater- nity wards of the Woman's Hospital are carbolic acid, corrosive sublimate, permanganate of potas- sium, iodoform, chlorinated lime, boracic acid, salicylic acid, oxalic acid, and tincture of iodine, according to the purpose for which each is designed. Solutions of corrosive sublimate should not be put into a metal dish, as the metal is thus corroded. The strength of all antiseptics is impaired by ad- mixture with soap, so that one should not wash with soap in an antiseptic fluid. The following rules, indicating the antiseptic precautions observed in the maternity wards of the ANTISEPSIS IN CONFINEMENT NURSING. 6 1 / Woman's Hospital, will illustrate the precautions to be observed in all confinement nursing : — RULES TO BE OBSERVED BY NURSES.* 1. The nurses on duty in the maternity wards isolation, shall have no communication v/ith the general wards of the Hospital. They shall be transferred to separate dormitories from those occupied by nurses on duty in the general wards. They shall give especial attention to personal cleanliness. 2. They shall not touch the genital organs of a patient without having first thoroughly disin- Disinfection fected their hands. If their hands have come in ° contact with any foul discharges, this cleansing shall be accomplished as follows : 1st. Thoroughly wash the hands with soap and water, scrubbing them well with a clean nail brush. 2d. Wash the hands in a saturated solution of permanganate of potassium, which colors them brown. 3d. Bleach the hands by washing them in a saturated solution of oxalic acid. 4th. Rinse them thoroughly clean in boiled, filtered water; and, 5th, Dip them for a few moments in a solution of bichloride of mercury (corrosive sublimate), of the strength of from 1-1000 to 1-4000, or a solution of carbolic acid * Rules for preparation of the patient for labor are given else- where. 68 OBSTETRICAL NURSING. Antiseptic dressings. two per cent. The washing with permanganate of potassium and oxalic acid solution may be omitted where foul discharges have not been handled. 3. Bottles containing solutions of corrosive sub- limate 1- 1 000, and carbolic acid 1-40, shall be placed on the wash-stand in every ward and de- livery room. The solutions of permanganate of potassium and oxalic acid shall be kept ready for use in the bath rooms. A small jar of carbolized vaseline shall be kept in each room. 4. The dressings removed from a patient shall at once be carried out of the room and burned in the furnace. 5. Immediately before the application of a fresh dressing the nurse shall irrigate the external geni- talia with either a corrosive sublimate solution 1-4000, or carbolic 1-40; dry the parts with a piece of antiseptic lint, and then apply the occlu- sion dressing. (Directions for preparation of anti- septic dressings are given elsewhere.) 6. If the patient be a primipara (a patient with her first child), an iodoform suppository (30 grs.) shall be introduced into the vagina for a week, once daily. Catheters 7. Metal and glass catheters shall be cleansed vaginal ° nozzles, etc. after each use by boiling, and kept in the intervals of use in a solution of carbolic acid 1-40. Vaginal nozzles shall be similarly treated, Each ANTISEPSIS IN CONFINEMENT NURSING. 69 patient shall have a separate vaginal nozzle for her exclusive use. Soft rubber catheters, after a thorough cleansing with soap and water, shall be kept in a solution of corrosive sublimate i-iooo. Before using the catheter the nurse shall anoint it with a little carbolized vaseline. 8. Syringes shall be cleansed after each use, by Syringes. having an antiseptic solution pumped through them. No vaginal injections shall be given during the lying-in, except after a direct order from the physician. 9. If vaginal injections are required to be given Vaginal injections. when there is much fetid discharge from the vagina, an injection of permanganate of potassium (a sat. solution) may be given in preference to the ordinary solution of 1-4000 corrosive sublimate or 1-40 carbolic acid. The nurse should always carefully report the occurrence of any odor in the discharge. 10. All rubber sheets used about the patients' Rubber sheets. beds shall be washed in a solution of corrosive sublimate 1-1000 or carbolic acid 1-20. 11. All clothing removed from patients or their soiled cloth, beds, soiled with discharges, shall be at once taken to the soak-tubs at the wash-house. When the blood has been soaked out in cold water they shall be placed in a disinfectant solution of carbolic acid 70 OBSTETRICAL NURSING. 1-20, for an hour, and then put through the ordinary processes of the wash. All soiled clothing shall be at once removed from patients' rooms. Deaths. 12. On the death of any patient in the maternity the body shall be at once wrapped in a bichloride sheet (i-iooo) and removed to the mortuary. visitors. 13. No one shall be allowed to visit the Hospital who is engaged in the dissecting rooms, or attending post-mortem examinations, or doing work in opera- tive surgery upon the cadaver. No one attending infectious cases shall be admitted to the lying-in wards. No visitors shall be admitted to see patients in the maternity unless provided with a special pass from the physician in charge. Disinfection 1 4. Each room vacated by a patient shall be of rooms. . fumigated with sulphur before it is again occupied. The straw contained in the mattress upon which she lay shall be burned and the ticking boiled and then refilled with fresh straw for the next case. The bed, stands, etc., shall be wiped off with a solution of corrosive sublimate or carbolic acid when the room is reopened after fumigation. Precautions jc The mother's nipple and the baby's mouth in nursing. J rr J shall be washed with a solution of boracic acid before and after each nursing. ANTISEPSIS IN CONFINEMENT NURSING. 7 1 16. The baby's cord shall be kept dressed with a The dress- powder containing salicylic acid, I part, to starch, 5 cord. parts, which shall be changed as often as necessary. 17. Immediately after delivery the baby's eyes Baby's eyes. shall be washed with a saturated solution of boracic acid or one of nitrate of silver (1 gr. to the ounce) as directed. Every nurse should know how to watch for Thes y m P- y toms of symptoms which may indicate that there is an]? oison [ n g J *■ J trom the use undue absorption of the antiseptic employed taking ° f c * ntisep " place. As to the selection of the antiseptic employed, the choice will be dependent upon the physician. If the nurse is obliged to depend upon herself, certain points must be taken into consideration. Thus she must remember that patients with kidney disease are especially susceptible to poisoning from the effect of corrosive sublimate. Ansemic or bloodless patients bear both carbolic acid and cor- rosive sublimate badly. Children are particularly susceptible to carbolic acid. The poisoning from antiseptic agents in confine- ment nursing most frequently occurs from the use of the antiseptic agent in the vaginal douche. It is not unusual, when carbolic acid has been Car boiic employed for some time, to find the urine of a darkfng. po1 greenish color ; also to find that it contains albu- symptoms and treat- men. One or more of the following symptoms ment. 72 OBSTETRICAL NURSING. may also be present: sickness or nausea, increased flow of saliva, difficulty in breathing, an anxious expression, sometimes fever, and always great weakness. Should any of these symptoms arise, the doctor should be at once notified. The patient may be stimulated b}^ repeated small doses of brandy, and external friction should be employed. If carbolic acid has been swallowed, the first thing to do is to get rid of the poison by the ad- ministration of an emetic, as by copious draughts of mustard and water or salt and water; or the stomach should be washed out with the stomach- pump. The easiest and one of the best things to use after this would be sweet oil or cotton-seed oil in large quantities. The patient's body must be kept very warm by hot blankets and rectal enemata of beef-tea, or milk and whisky used. Corrosive The mouth and bowels are most apt to be first sublimate poisoning, affected by the absorption of corrosive sublimate. Any tenderness or sponginess of the gums must be noticed, or increase in the amount of saliva. Loose- ness of the bowels also requires the immediate discontinuance of the drug. Headache, dizziness, pains in the abdomen, lowering of temperature, sweats, and general prostration, with albuminous and sometimes bloody urine, are other symptoms which may arise from the same cause. ANTISEPSIS IN CONFINEMENT NURSING. 73 The drug must be stopped at once, the abdominal pain relieved by the use of poultices, a soothing diet of rice-milk or arrow-root, etc., employed, and such medicines given as the doctor may direct. If the drug is swallowed by mistake, the same treatment would have to be followed as in the case of carbolic acid poisoning, except that it is best at once to administer the whites of two or three eggs to form an insoluble albuminate of mercury in the stomach, so that it may not be readily absorbed but brought up by the use of a subsequent emetic. In mild cases, sleeplessness, headache, loss of memory, are the main symptoms, but in severe cases mania, melancholia, or hallucinations may T J , ' J Iodoform develop from iodoform poisoning. Sometimes P° isonin s- there is considerable rise of temperature. The withdrawal of the drug and the support of the patient's strength constitute the main line of treat- ment. Sometimes the use of about ten grains of cream of tartar, every hour for a time, has been found of advantage. Permanganate of potassium, boracic acid, and Permangan- ...... r . ate of potas- sahcylic acid are harmless, so far as toxic effects are smm, bor- acic acid, concerned, but have not the same power. salicylic 1 r acid. Chloride of lime and chlorinated soda are of chloride of value as antiseptics because of the chlorine which chlorinated is set free in their solutions. A small quantity, as sc from a half to one drachm of the powdered chlo- 74 OBSTETRICAL NURSING. ride of lime, may be dissolved in a pint or more of water. The chlorinated soda is found in a preparation known as Labarraque's solution, of which a tea- spoonful to a pint of water makes a solution strong enough for a vaginal injection. If to each ounce of this solution about four grains of permanganate of potash is added, the value of the solution as an antiseptic agent is greatly increased. Condy's fluid contains, as its active ingredient, permanganate of potash, about eight grains to the ounce of water. A teaspoonful of Condy's fluid to the pint of water makes a solution suitable for a vaginal injection. It is not likely that poisoning would occur from the use of any of these agents. Permanganate of potassium and Condy's, fluid are objectionable because of the brown stain they produce when dropped on clothing.* ifaToom 1 . 011 Rooms are generally disinfected, as after cases * Lysol is a coal-tar product now largely used as a disinfectant in several surgical and lying-in clinics in Germany. It is claimed to be superior to carbolic acid, creolin and other preparations of the same kind in its germicidal action, and it possesses powerful deodorizing properties. It is perfectly soluble in water, and its solutions are soapy in character, removing all dirt (fatty or resinous spots, etc.), which does away with the necessity for soap in cleans- ing. It is used in ^, I, and 2 per cent, solutions in midwifery and surgery. Disinfect! ANTISEPSIS IN CONFINEMENT NURSING. 75 of septicaemia, etc., by burning sulphur in the pro- portion of at least three pounds for every thousand cubic feet of air space. To secure any good re- sults, close the apartment as closely as possible by stopping up all apertures through which the gas might escape, by means of wet rags, which may be stuffed into the cracks around doors, win- dows, etc. The sulphur is put into a deep tin pan, which is placed upon two bricks, in a tub partly filled with water, in the middle of the room. A little alcohol may be poured on the sulphur, which is then set on fire, or a few live coals placed in the pan. The fumes should be kept in the apartment from twelve to twenty-four hours, after which doors and windows should be thrown open, and it should be subjected to free ventilation. All surfaces in the room must be then washed off with a carbolic solution (2 per cent.), or corrosive sublimate I-IOOO. Infected underclothing, bedding, etc., are best underdoth- destroyed by fire, if of little value. To disinfect Sc! them we may employ — (a) Boiling for at least a half hour. (p) Immersion in corrosive sublimate, sol. 1-1000, for three or four hours. (c) Immersion in a 5 per cent, carbolic sol. To avoid the discoloring effects of these solu- tions, clothing taken from them should be thor- 7 6 OBSTETRICAL NURSING. Outer garments. Mattresses and blankets. Water- closets, etc. oughly rinsed out in clear water before it is sent to the laundry. Outer garments which would be injured by boiling water or a disinfecting solution, may be sterilized — (a) By exposure to dry heat at a temperature of 230 F. (no° C). (J?) By the steaming process in a suitable appara- tus. Mattresses and blankets should be disinfected in the same way. If these means are not available, mattresses may have their covering removed, and washed and boiled separately, the contents being immersed in boiling water for a half hour. Solutions of copperas (sulphate of iron) or green vitriol, in the proportion of 1^ pounds to a gallon of water, are good and also very cheap. Slaked lime and chloride of lime may be used for privy vaults. Solutions of the chloride of lime may be used also in water-closets, but there is danger of chok- ing up the pipes if the solutions contain consider- able deposit. Carbolic acid solutions, 5 per cent., or bichloride 1-1000 may be used instead of the above. CHAPTER VII. PREPARATIONS FOR THE LABOR. The relations between nurse and patient begin from the time the engagement is made for a nurse's attendance upon the confinement. The nurse is generally consulted beforehand as Advice to ° J patient. to the articles that will be needed at the time of the confinement and for the baby's outfit. Also, she is sometimes asked concerning the choice of a room for the labor and lying-in. The room is a most important consideration. It choice of x room. should be light, having the free entrance of sun- light ; quiet and well ventilated. It should not be too near a water-closet; in fact, it is far better to have the water-closet out of the house entirely; There should be no stationary washstand in the confinement room ; or, if this cannot be avoided, the connection with the sewer pipe should be cut off, or the holes and escape pipe in the basin plugged up, the basin being kept filled with fresh water frequently changed. No slop jar or any vessel containing wash water, discharges, etc., 77 y8 OBSTETRICAL NURSING. should be allowed in the room. An ounce of prevention, in the way of keeping jdisease germs out of the room, is worth more than a pound of cure. Mother's As re g arc [ s the mother's dress, she should be advised to have a sufficient number of good-sized merino or flannel vests, to be able to change night and morning, so that the same vest shall not be worn both day and night. These are more readily changed if opened all the way down the front and fastened with tapes. The free action of the skin after delivery necessitates the use of flannel or merino to prevent chilling. If a long night-dress is worn, there is no necessity for the chemise. The night-dress, also, should be opened all the way down the front, as it renders easier for the patient the frequent changes which are necessary. Suf- ficient night-dresses and vests should be provided to make it possible for the clothing to be changed every day. Abdominal Two or three abdominal bandages, also, should bandages. . . ^ _ ., . be provided, either fitted to the patients person or straight. If fitted, the bandages should be pre- pared when the patient is about six months preg- nant, to be the right size after delivery. The bandages should extend from the pubic bone (the bone just above the external generative organs) to the breast bone, being about a half-yard wide and PREPARATIONS FOR THE LABOR. 79 long enough to go once around the body and overlap one-third. "It is best made of soft muslin doubled, the seams being turned in at the edges. Large safety-pins should be provided for fastening this bandage down the front. Where the breasts are large and pendulous, some ^east es bandage may be required for their support. An abdominal bandage may be used for this purpose, though it is rather wider than is necessary. Fig. 12. Occlusion Dressing (Dr. Garrigues). When the physician does not require the anti- septic dressings, now almost universally used, at least two dozen napkins of diaper linen should be Napkins. provided for the mother, as very frequent changes of the napkin are essential during the first few days after the delivery, while the discharges are free. The antiseptic dressings used in the Woman's^ 1 ^ Hospital, of Philadelphia,. are essentially the same 80 OBSTETRICAL NURSING. as those recommended by Dr. Garrigues, of New York, known as the occlusion dressing. They con- sist of a piece of dry patent lint, 6X8 inches, which has previously been rendered antiseptic by satura- tion in a solution of bichloride of mercury 1-1000. This is placed, doubled in its width, so as to make a dressing, 3X8 inches, directly over the external organs of generation. This lint is covered by a piece of gutta-percha tissue, 4X9 inches, which is wet in a 1-4000 solution of bichloride of mercury. Perineal These dressings are kept in place by a napkin of sublimated cheese cloth, 18 inches square, folded to form a diagonal, 5 inches in width, within whose folds a pad of oakum is enclosed. The napkin is tightly fastened to the abdominal bandage, both anteriorly and posteriorly, by means of safety-pins, and the access of air to the vagina is thus pre- vented. These dressings are changed at least once in three hours, the dressing removed being at once burned. It is seldom necessary to continue the dressings longer than two weeks. They should be kept up, however, so long as the discharge persists. Quantity After the above statement, it will be seen that needed. a nurse should have the patient obtain of each of the articles comprising the dressing the following quantity: Cheese cloth, 12 yards; gutta-percha tissue, 1 yard ; patent lint, 2 yards ; oakum, ]/ 2 to 1 pound. PREPARATIONS FOR THE LABOR. 8l The cheese cloth may be obtained at any dry- ^^ e ed goods store, and prepared by first thoroughly washing with soft-soap and boiling, and then wringing it out in a solution of bichloride ofo f r Xese° n mercury i-iooo. The patent lint should be ren- 1 c i 1 n ° t t . hand Fig. 13. Nightingale Vv'rap. dered antiseptic in the same way. The gutta- percha tissue, patent lint, and oakum may be obtained at a drug store ; the gutta-percha tissue may be more readily obtained directly from a rub- ber store, where the syringe also may be bought. In winter it is well for the mother to be provided 6 82 OBSTETRICAL NURSING. Nightingale w ith a " Nightingale wrap." This is made of two yards of flannel of ordinary width. A straight slit, six inches deep, is cut in the middle of one side, the points so formed being turned back to form a collar. The corners farthest from this collar are also turned back to form cuffs. The whole may be bound or pinked around the edge and fastened by means of buttons or ribbons. Rubber For the confinement bed the patient should pro- cloth for con- finement vide two pieces of rubber cloth, a yard and a half square. For a single bed two rubber army blan- kets may be used, if, as in the maternity practice in the Woman's Hospital, it is desired to cover the whole bed. The arrangement of the bed will be explained in a later chapter. White rubber gum- cloth is the best when it is obtained in the piece. If the patient is poor, table oil-cloth may be used ; it is cheaper and answers the purpose as well, or layers of newspapers tacked together will make very good temporary pads. o?i°cTo h ^ piece of floor oil-cloth is the best protection for the carpet at the side of the bed. Precautions. Rubber-cloth should never be used but for one confinement. The rubber cracks when folded and put away and no longer serves its purpose of pro- tecting the bed. Then, too, it is very important to be sure that everything about the confinement bed is perfectly fresh and clean. Hence a rubber-cloth PREPARATIONS FOR THE LABOR. 83 used for confinement should neither be borrowed nor lent. Sleeping on rubber-cloth makes a person per- Effect of spire, hence it is desirable to get rid of it as soon ?ubber g ° as one can. It is seldom necessary to use it after the fifth or sixth day. Other articles necessary to have on hand will be other articles for half a dozen old sheets, about a dozen towels, a confine - ' ' ment room. new syringe (a fountain syringe, large size, is the best), a bed-pan (French pattern), nail-brush, white Castile soap, a jar of cosmoline or vaseline. I desire, in this connection, to emphasize the fact The x syringe. that the syringe should be a new one. This is an antiseptic precaution. Hence advise the patient strongly against the use of any syringe which may have been used for other purposes, however well it may work. Of course the borrowing of such an article from a neighbor or friend should be strongly discountenanced. Regarding the baby's clothes — if they are made infant's too elaborate they will not be washed often enough, hence they should be plain. As the depressing influences of cold are very injurious to babies, the clothing should be warm, hence a flannel garment with long sleeves and high neck should be worn next the skin — the thickness varying with the sea- son of the year. The activity of the life processes make it important that every organ of the body 84 OBSTETRICAL NURSING. shall be unimpeded in its action and free from pres- sure, hence the clothes should be very loose and light \x\ weight. bab tfitf ° r ^he on ly articles absolutely needed to constitute an outfit are, ist, a soft flannel shirt, with high neck and long sleeves, opened in front. This is ve^t. under " better than the merino vests or the knit shirts, which shrink on washing, and are then difficult to put on and take off. 2d. A binder, or bandage of fine, soft flannel, four inches wide, and long enough to go around the abdomen once and lap over about one-third. This should be made without a hem, the raw edge being overstitched to prevent ravel- The binder. [ n g The binder is best fastened by means of two pieces of tape attached to one of its edges. This arrangement does away with the necessity for pins in fastening the binder, the pieces of tape being simply wound around the body to secure the binder and tucked in at one edge. Some prefer the knitted w T ool band, made of single zephyr and Knitted knitted in the ribbed stitch, as wristlets or mittens wool band. 7 are often knit, to permit of greater elasticity. These bands are made a little narrower in the centre than at either extremity, so as to be held in place better. They are made perfectly circular, just like a wrist- let, and are so elastic that they can readily be drawn up over the limbs and adjusted to the body. 3d. Napkins. A napkin of cotton or linen diaper is the best ; Can- PREPARATIONS FOR THE LABOR. 85 ton flannel makes a very poor baby's napkin, as it becomes stiff when washed. Napkins are generally made too large for a new-born baby, and require to be folded into too many thicknesses. A napkin which when folded once is half a yard square is of ample size. The number of napkins supplied should be generous, so as to permit of frequent washing and thorough airing. Napkins should always be fastened by safety-pins. For the pro- Protection tection of the outer garments from dampness due from dampness. to frequent urination, it is well to have a second napkin folded and laid beneath the baby's hips. The use of rubber-cloth over the napkin for this purpose is much to be condemned, as it overheats the parts and makes the skin tender. 4th. A flannel slip of heavier or lighter texture, according F ! annel to the season, serves the purpose both of petticoat and dress. This should be made just long enough to cover the baby's feet — about twenty-five inches from neck to hem, and should be fastened in front. The ordinary fashion of making a baby's clothes Length of very long is objectionable because of the greater gar weight of the clothes preventing free movement of the child's limbs and the development of its mus- cles. The object of fastening the clothing in front rather than in the back is to avoid the necessity of the baby's lying on the uneven surfaces produced by buttons, tapes, and hems, which no doubt are 86 OBSTETRICAL NURSING. Socks. Support from shoulders. often a source of discomfort to its tender skin. 5th. Knit woolen socks are necessary to keep the baby's feet warm, and it is well to have them extend pretty well up the leg, reaching even to the knee, as cold feet are often an exciting cause for colic. The above are the only essential articles of cloth- ing for a baby. Should the mother prefer, for the sake of effect, to see her baby in white muslin, a Muslin slip, slip of muslin can be worn over the flannel slip. These garments do away with all waistbands and the constriction of the chest thereby induced. Should the garments be made with waistbands, they should be supported from the shoulders by means of straps, or armholes should be made in the bands, just as in the case of an older child; they will not need then to be drawn so tightly around the child to be retained in place. A blanket is not needed to wrap the baby in, in a room at the temperature of the lying-in room — from 68° to yo° ; but should it be carried from one room to another, or when it sleeps, a blanket, or some wrap, ranging in weight with the season, will need to be tlirown over it. When a baby has but little hair on its head, and shows a tendency to catch cold readily, a plain cambric or light flannel cap may be employed as a head covering. This is a preventive against ca- tarrhal troubles affecting the nose and throat. Blanket wrap. Cambric cap. PREPARATIONS FOR THE LABOR. 87 A recent journal has described an outfit for babies which has obtained much favor among mothers. It is called, I believe, the " Gertrude Suit," and con-^ rtrude " sists of three garments ; the first, or undergarment, is made of soft flannel, and is long enough to ex- tend from the neck to ten inches below the feet. The next garment, cut in the same way, but a half inch larger and five inches longer, is made of mus- lin. Over these comes the "slip," also Princess style, and the only one of the garments with long sleeves. (This is the most objectionable feature of the suit ; a baby's arms should be well covered.) It has a longer skirt than either of the other gar- ments. All are fastened behind by small buttons. These three garments are put together and all slipped on to the baby at one time, facilitating the process of dressing very much. In our opinion, however, this suit has not the Advantages r ' y of Woman's same advantages as that worn in the Maternity Hospital of the Woman's Hospital of Philadelphia, and first described. The fastening of the clothing in front, the fewer number of articles comprising the ward- robe, and the fact that they may be very easily taken off and put on, while they meet all the re- quirements of warmth, looseness, and lightness, make this outfit preeminently a comfort to the baby. The articles provided for the baby-basket may be the baby's the following : — 88 OBSTETRICAL NURSING. Three or four pieces of linen bobbin, about eight inches long. A pair of blunt-pointed scissors. Large and small safety pins. Several small squares of soft linen, about four inches square, for dressing the cord, and two inches square, for washing the eyes and mouth. A soft hairbrush. A powder box and puff, with lycopodium or fine starch powder. (The scented powders are often irritating.) A small jar of cold cream. Two soft towels. A full suit of clothes, as described above, for the baby. A woolen shawl or wrap. CHAPTER VIII. SIGNS OF APPROACHING LABOR— THE PROCESS OF LABOR. Certain changes take place during the latter part ^ Indications ap- of the ninth month which indicate that labor is f a r b °o r ching approaching. One of these is the sinking of the sinking of 11 i i *-t-»i . r j_-\ abdominal abdominal enlargement. Ine upper part ol tne e niar g e- womb, which has at the beginning of the ninth m month been high enough to reach the pit of the stomach, comes down gradually to a point about midway between the extremity of the breast bone and the navel. This sinking of the womb is known as " descent" or " settling" of the child, and indi- cates that the head of the child, which is ordinarily the part to be born first, has stretched the lower part of the womb and is finding its way into the cavity of the pelvis, through which it must pass in the birth. Great relief to the mother results from Relief in breathing. this descent of the womb, as the lungs are no longer pressed upon to the same extent as before. The change in the position of the womb produces, Swe]lingof however, an increased amount of pressure on the lower ex tremities, lower portions of the body. Swelling of the lower pressure. s 9 " False pains. pains. 9O OBSTETRICAL NURSING. limbs is apt to result in consequence of this, and Piles. walking is rendered difficult. Piles or hemorrhoids are apt to form, and irritability of the bladder to exist. During the last two weeks of pregnancy patients are apt to suffer from what are known as " false pains." These are cramp-like pains, so much like labor pains that patients are often deceived by them, and led to imagine that the labor is really coming on. They are called " false pains " to dis- tinguish them from the pains of labor, which are •. recognize, from what has been said in a preceding chapter of the pains characterizing the different stages of labor, whether the patient is really in labor or not, also, how much time is probably left for the making of preparations. She can learn from when pains 1 . iri rr i began. the patient, in the intervals of her suffering, when the pains first began, how often they occur, whether the waters have broken, etc., so that she may know what message to send the doctor, should the neces- 5 ^^^ o ' the sity exist for so doing. After this duty has been per- P h y sician - formed, if labor has really begun, the nurse should give herself to the preparation of the patient and the room for the confinement. Preparation of the patient : The nurse should Preparation inquire of the patient whether her bowels have been ° pa freely moved recently. If not, a simple enema of soap and water may be given for the purpose of clearing out the lower bowel and making the ^^ n t0 second stage of labor easier and cleaner. Inquiry should be made as to whether the patient ladder? 11 to has passed water freely. If not, she should be urged 98 OBSTETRICAL NURSING. to make the attempt, and, if not successful, the physician should be notified. Warm bath. It is desirable, if there is time, to have the patient F^sh take a full warm bath and put on entirely fresh clothing. L J clothing. v a n -inaf tic ^ vaginal injection of some antiseptic solution injection. ma y ^^ ^ e g{ ven ^ anc [ the parts about the external generative organs washed off with an antiseptic solution. In the Woman's Hospital the vaginal in- jection consists of a solution of bichloride of mer- cury 1-8000. The external parts are washed off with a similar solution of 1-2000 or 1-4000. Preparation Tablets of bichloride of mercury may be obtained of antiseptic solutions, at any apothecary's, one of which, if added to a pint Bichloride of * *" * x mercury. Q f water, will give, as a rule, a solution of 1-1000, from which solutions of varying strength may be made up by the addition of more or less water. Thus, on adding seven parts of water to one part of the bichloride solution 1-1000, a solution of 1-8000 may be obtained. It is always desirable that the nurse should have a little porcelain or agate-ware gill measure, by which she can readily and quickly prepare these solutions. If tablets cannot be obtained, powders of 7^ grs. each of bichloride of mercury, if added to a pint of water, will give a solution of 1-1000. Creoiine. Creoline, a coal-tar preparation, four times DUTIES OF THE NURSE DURING LABOR. 99 stronger in its antiseptic properties than carbolic acid, may be used in place of bichloride of mercury. To make this, 1 drachm of the creoline should be added to the pint of water. Creoline, though not so strongly antiseptic as bichloride of mercury, has greatly come into favor of late, both because it does not have the same corroding effect on instru- ments which may be used, and because there is less liability of poisoning than in the use of bichloride of mercury. An objection has been raised to the^?^| c °^ nt use of creoline for vaginal injections, as it is claimed that its admixture with blood produces a tarry pre- cipitate. The coagulation of albumen in vaginal discharges, by the action of corrosive sublimate, is similarly claimed to deteriorate the value of the latter as an antiseptic agent. In cases when there is excessive discharge it is better, therefore, to sub- stitute a solution of permanganate of potassium, or carbolic acid. A nurse should never lose sight of the fact that Da . n § erof & poisoning. the corrosive sublimate (bichloride of mercury) tablets are a deadly poison, hence there should be no neglect as to care in their handling. Carbolic solutions are used in place of either embolic 1 acid. of the above by some physicians. A two per cent, solution of the latter may be made up by adding 2y 2 drachms to the pint of water. When the patient seems to be in active labor, the IOO OBSTETRICAL NURSING. Position until after examina- tion. Arrange- ment of hair. Confinement outfit. Necessity for exami- nation by physician. Prepara- tions for this examination. nurse should keep her lying down until after the physician has made an examination. He will then state whether the patient may sit up or walk about the room. Because of her long confinement to bed the hair of the patient should be arranged so that it will be most comfortable and not readily tangled. The best arrangement is that of parting the hair down the back of the head and braiding it into two plaits — one behind each ear. This leaves a smooth sur- face at the back of the head to lie upon. The outfit of the patient during the labor should consist of a merino vest, long night-dress, a pair of large, roomy, open drawers, and a pair of stock- ings. While walking about the room, and until the second stage of labor begins, she can wear a wrapper over the rest of her clothing and have on a pair of bedroom slippers, which can be easily slipped off when she needs to lie down. The patient should be told by the nurse of the necessity for an examination by the physician, particularly if this is her first labor. When the physician comes, the patient should be placed on the bed, near its edge, lying on her back or side, as he may prefer, with her limbs drawn up toward the abdomen. Her clothing should be lifted above the hips, and a sheet, or some light covering, used to protect the lower part of the body from exposure. DUTIES OF THE NURSE DURING LABOR. IOI A chair should be placed for the physician on the same side of the bed, close to its edge, facing the patient as she lies ; a jar of cosmoline or vaseline should be brought him, and all the necessary mate- rials provided for the oroper cleansing of his hands cleansing of * * a <-> physician s both before and after the examination; soap, nail- hands - brush, warm water and towels, and some disinfect- ant solution, as a bichloride of mercury solution of the strength 1-2000, or creoline, a drachm to the pint of water.* The preparation of the room and bed will next Preparation ,, , . ofroom. require the nurse s attention. These preparations should be made as quietly as systematic possible. The nurse should have learned before- mem of articles hand where things are, and she should have had needed. them so arranged that but little will need to be done at the time, except to put them where they will be most convenient for use. It is well, if the patient is walking about, to have her go into the next room while the bed is made up. A single bed is always the most convenient in o7a P stngie 0n the management of a patient, but such are rarely found in private houses. The preparation of a single bed would be as follows : First, the mattress — preferably of hair — covered by a pad and rubber- * Some physicians prefer the use of a saturated solution of permanganate of potassium, regarding it as a more thorough antiseptic. 102 OBSTETRICAL NURSING. " Perma- nent bed. " Tempor- ary bed." Preparation of double bed. " Tempo- rary dressing.' protective across the middle of the bed, or covering the bed entire. (Rubber army-blankets are used in the Woman's Hospital for this purpose.) The under sheet covers this rubber, and a draw-sheet — a sheet folded four times in its length and placed across the portion of the bed upon which the hips would rest — comes next. (The folded side of the draw-sheet should be toward the head of the bed.) This constitutes the first dressing, or what is known as the " permanent bed." The different articles constituting this dressing are securely fastened down by safety-pins. Over the " permanent bed" comes the " temporary bed," consisting of a second gum blanket, covering the entire bed, a second under-sheet and draw-sheet. Covering these are the upper sheet, blanket, and spread. After the confinement, the " temporary bed " can be drawn from under the patient, leaving her lying on the " permanent bed." The change is accom- plished with much greater ease for both patient and nurse than the changing of the various articles separately. The double bed found in most private houses is arranged as follows : First, the ordinary dressing of the bed, the hair-mattress, pad, rubber-protective, under-sheet, and draw-sheet. Upon top of this dressing, at the lower right-hand corner of the bed, a " temporary dressing" should be arranged, about DUTIES OF THE NURSE DURING LABOR. IO3 a yard and a half square, consisting of a rubber protective, or the paper pad before described, se- curely fastened down to the bed beneath, and covered, if rubber, simply by a folded sheet, like- wise fastened down by safety-pins. If the paper pad is used, an old comfortable or blanket will be needed beneath the sheet. The pillow for the patient should be placed at the upper and inner corner of this square. After the delivery, she can be lifted to the upper part of the bed, and the "temporary dressing" removed. The sheet, blanket, and spread which are to serve as her covering after the delivery can be kept from soiling during the labor if folded upon themselves several times and carried to the extreme edge of^ 1 emporary the left side of the bed. Another sheet and blan- a ^ange- ment of ket may be used as temporary covering during the covers - delivery. It is so important that a patient shall be moved as little as possible immediately after the labor, because of the tendency to bleeding pro- duced by motion, that the nurse should study carefully the best methods of protecting patient and bed from soiling, so that it will be necessary to do but little in the way of changing the clothing. The piece of floor oil-cloth must be spread at Protection ■ L x of floor at the side of the bed, extending from a foot to afoot sideofbed - and a half under the bed. There should be a bureau with a set of drawers, 104 OBSTETRICAL NURSING. System in arranging articles in bureau drawers. Change of clothing for mother. Articles for baby's basket. or a closet, with shelves, in the room, given up to the nurse for the keeping of the various articles she may need, and these articles should be con- veniently arranged so that there may be no confu- sion in obtaining them when required at any time. One drawer or shelf should contain sheets ; another towels and napkins and soft, clean muslin or linen rags, to be used as napkins during the delivery ; a third should contain changes of underwear for the patient, and a fourth the baby's wardrobe. A change of clothing for the mother should be placed — if it is warm weather — in the sun by a window ; if in winter, by the register or stove, so as to be dry and warm should it be needed. The baby's suit should in the same way be aired and warmed. The baby's basket should be placed on a chair or stand near the register, with all the necessary articles for its toilet and bath — a baby's bath-tub or an ordinary foot-tub, soft towels, nurse's flannel bathing-apron, a little rendered lard in a jar, etc. Two pieces of bobbin, each eight inches in length, should be put in a little vessel containing some bichloride solution, 1-4000. These, with a pair of blunt scissors, should be placed where they can be conveniently reached for the tying of the cord: Some small squares of soft muslin or linen should be placed where they will be convenient for the immediate cleansing of the child's eyes after DUTIES OF THE NURSE DURING LABOR. 105 expulsion of the head. A flannel blanket or good warm flannel petticoat should be provided for re- ceiving the child upon its birth. The baby's crib should also be prepared for its reception. Beneath the bed there should be two chambers Receptacles needed. — one for urine and one for the afterbirth, or a tin basin may be provided for the latter. Some receptacle should be in readiness for the ^strum^us. doctor's instruments, should they have to be used. The small pitcher which ordinarily accompanies the modern chamber sets serves this purpose very nicely. A vessel for the patient to vomit in should be on Receptacle hand — a chamber, or even a chamber-lid, will do to vomit in. very well. A basin filled with a warm solution of bichloride Foranti - septic of mercury, 1-4000 or 1-2000, should stand near the solution - bed, so that the nurse or physician may repeatedly cleanse the external organs of generation of all discharges during the progress of the labor. The solution in this basin should be frequently changed. A sufficient number of soft linen or muslin rags soft linen or will also be necessary for this purpose. pieces 1 ! Agate, porcelain, or china basins are necessary Kind of when bichloride solutions are used. For creoline needed, ordinary tin basins will do. The nurse should never allow anything from the kitchen to be pressed into service for such an occa- io6 OBSTETRICAL NURSING. Other articles. needed. Plentiful supply of hot water. Stimulants. sion. The indiscriminate use of pans, basins, cups, and saucers is certainly vulgar, to say the least. The " eternal fitness of things " should never be lost sight of. A urinal, or a soap-cup, which is a good substi- tute ; a silver catheter, and an English rubber cathe- ter, No. 8 or No. 9 ; a bed-pan, and the other re- ceptacles for the various purposes above referred to, may be placed for convenience beneath the bed. A towel-rack near by should contain at least half a dozen fresh towels. A few napkins, a supply of soft rags, a jar of cos- moline, a waste-bucket or slop-jar, with a lid, should be found in the room ; and an abundant supply of hot and cold water. As soon 'as the patient is known to be in labor, the nurse should go to the kitchen to see that the fire is good, and that plenty of water is put on to boil. An arrangement should also be made by which some member of the family will be prepared to respond to the nurse's call for more hot water when it is required. The abdominal bandage for the patient, with a set of the dressings and a pin- cushion containing safety-pins, should be placed on the stand beside the bed. A bottle of whisky or brandy and one of harts- horn should be provided. A pitcher of cool water and a tumbler should be DUTIES OF THE NURSE DURING LABOR. IO7 found in the room, as the patient may need a refresh- ing drink during the progress of the labor. A feeder is best provided for the patient's use, as she can then drink Iving down. The arrangement of the patient's clothes to keep Arrange- o Jr r ment of them from soiling during the expulsive stage ofp^^' 5 labor will require some care on the part of the nurse. The night-dress or vest should be folded or rolled up beneath the arm-pits and fastened with safety-pins over the right side of the chest. If the patient wears large drawers, no further protection than the cover-sheet maybe necessary. Some pre- fer having a sheet adjusted around the waist, above the abdomen, and pinned under the clothing to the right side, the long end of the sheet which remains, and which should be the anterior part, is plaited up and fastened also beneath the right arm by means of safety-pins. The sheet thus resembles a skirt opened at the right side. During the early stage of labor the nurse will nmst ° f need to encourage the patient, and by a sensible, stage of rst quiet, yet cheerful bearing keep her strong. It is Encom-age- of no use for patients to hold their breath and bear™^ ance down during each pain in this stage, and nurses ^ e n anng should never urge their patients to do so. It should efforts ' be left to the physician to decide when bearing- down efforts are desirable. The pressure of thebadT" nurse's hand upon the back during a pain often gives io8 OBSTETRICAL NURSING. Nourish- ment. Vomiting. Cramps. Exclusion of company. great relief to the patient, while the occasional bathing of the face and hands with cold water is refreshing. Frequent sips of cold water may be permitted. Nourishment in the form of beef-tea, gruel, milk, and tea may be given from time to time if the labor be long. No stimulants should be given without the direction of the physician. Vomiting is a troublesome though not necessarily a dangerous symptom during delivery. In fact, the relaxation it produces is often desirable. If it is excessive, however, a little iced soda water may check it. Cramps in the lower limbs are a very frequent accompaniment of the second stage of labor. Re- lief may be obtained by stretching the limb straight out, gently rubbing the painful muscles, or grasping and holding them. Friends and neighbors should, if possible, be excluded from a confinement room. Their injudi- cious tales and expressions of sympathy are often absolutely painful. The nurse has to manage this with great tact. She can generally succeed best by stating to the friends that it is the physician's wish she should do so, and her relations toward the physician require that she should implicitly observe his directions. If the nurse does not allow herself to become familiar with her patients, but maintains DUTIES OF THE NURSE DURING LABOR. IO9 a quiet dignity in the carrying out of her directions, her requests will generally be observed. Tact is a magic wand by which human beings Tact. can accomplish miracles in the way of subduing the obstinate. Happy is the nurse who possesses it ! The best rule for acquiring it is the Golden Rule, " Do unto others as you would that they should do to you." A strict observance of this will insure a kindness of tone and manner in the making of requests which will win consent when it would not otherwise be granted. One of the most important duties of the nurse changing of napkins during the confinement is the frequent changing of and other j. o o antiseptic napkins, draw-sheets, towels, etc, used about the measures. patient. Also the frequent renewal of the antiseptic solutions to be used about her, or for the doctor's hands. Antisepsis means, literally, " against poisoning," Antisepsis. and implies the careful removal of all sources of poisoning, such as would come from decomposing blood and discharges or dirty articles. The physi- cian's and nurse's hands, therefore, require a special preparation for the labor in their thorough disinfec- tion. During the course of the labor the hands should be thoroughly cleansed with a bichloride solution whenever they have touched anything unclean, or whenever they come in contact with the genital organs. no OBSTETRICAL NURSING. Position for delivery. Position during third, stage of labor. Prepara- tions for receiving child. Protection of mother. Cleansing of baby's eyes. Removal of child. The patient may be delivered on her back or lying on her left side. When the physician desires the change of position, the nurse must help the patient to turn on her side and bring her hips close down to the edge of the bed. The upper or right limb will then have to be supported by the nurse, in order to well separate the thighs until the delivery is effected. (When there is insufficient help, a pillow may be used between the knees.) She will have to get on the bed close to the patient for this, and hold the leg at knee and ankle. After the child has come, she should help to turn the patient in the bed, bring a flannel wrap to put the baby in as it lies on the bed before the tying of the cord, and throw a covering over the mother's chest. She should then wipe the baby's eyes with a fine, soft piece of linen dipped in tepid water, or a satu- rated solution of boric acid ; should bring the doctor the scissors and bobbin, and have ready a sheet for receiving the child and a vessel for the afterbirth. She should hold the sheet doubled upon her outstretched arms, the side toward her being held up by her chin. On receiving the baby with its flannel covering, she allows the edge of the sheet held up by her chin to drop down over the child. She then folds over the hanging ends, so as thoroughly to cover the child, and places the little bundle in a crib, to await further attentions, DUTIES OF THE NURSE DURING LABOR. Ill until the mother has been made comfortable. Should the child breathe imperfectly, the physician will give it his own attention or direct the nurse what to do. The vessel containing the afterbirth, if the latter ^ b °f th has been detached from the child, may be placed temporarily under the bed, to await the physician's examination. If the cord has not yet been tied, the vessel may be put in the crib with the baby. Many physicians do not tie the cord, or navel-string until there is no further pulsation in the vessels. Should the physician not desire to do so, the cleansing • mother after nurse should next attend to the cleansing of the labor, mother's external parts by means of soft cloths dipped in a solution of bichloride of mercury i- 4000. Many physicians make a practice of using ay^^ ns vaginal injection of some disinfectant solution immediately after delivery. It will be the nurse's duty to prepare this should it be called for. The Removal of " temporary dressing "should be removed from the Sothing. patient, and she should be gently lifted on to the upper portion of the bed. The binder and dress- of binder and dress- ings must next be applied. ings. " The binder must be rolled up to half its length, and the rolled portion passed beneath the patient's back. It is then caught on the other side and un- rolled, straightened so as to be free from wrinkles, 112 OBSTETRICAL NURSING. and made to encircle the hips tightly. The over- lapping ends are then fastened together by means of safety-pins down the front." The middle por- tion of the bandage should be tightened first, as the firmest pressure should be directly over the upper portion of the womb. The lower portion of the bandage is fastened next, and the pins in the upper portion placed last, as this does not need to be so firmly applied. The antiseptic dressings should next be applied in the order described in a preceding chapter. The napkin is spread out and fastened to the abdominal bandage anteriorly, so as to fit over the convexity of the upper portion of the external organs of gener- ation and extend from groin to groin. Posteriorly it is fastened to the abdominal bandage by but one safety-pin. This makes an " occlusion dressing." Making The patient's body-clothing should then be un- comfortable, fastened and drawn down (her drawers and stock- ings should have been removed with the " tempor- ary dressing "). The coverings of the bed are drawn up over her, and she is allowed to lie quietly until the nurse cleans up the room and makes pre- parations for washing the baby. " w y a S tch a " s ^he physician generally remains with the patient an hour after the delivery, taking her temperature and pulse, and w r atching the condition of the womb, to insure against danger of hemorrhage from want of proper contractions. DUTIES OF THE NURSE DURING LABOR. II3 After the doctor leaves, this duty devolves upon Nurse's the nurse, who should examine the dressings fre- the P h ys i- 1 r C * an l eaves « quently to see that the bleeding is not too profuse, and place her hand over the lower part of the abdo- men to feel the womb, which, if properly contracted, should be a round, hard body about the size of a child's head, immediately above the pubic bone, and not reaching higher than the navel. The con- sideration of the accidents of labor and the care of the infant will be treated in other chapters. CHAPTER X. ACCIDENTS AND EMERGENCIES OF LABOR. Absence of physician during delivery. Occurrence of pains. Second stage of labor. Lateral position. Women who have borne children before are apt to have rapid labors, hence a nurse should be on her guard when in attendance upon such a patient, watching for the symptoms of approaching labor, and notifying the physician earlier than she would feel warranted in doing with a patient expecting her first confinement. As soon as the nurse suspects that labor pains have begun, she should put her patient to bed. When " bearing-down " pains begin, the patient should not get up even to use the cham- ber. A bed-pan should be used. The patient should not be allowed, when the pains come on, to catch hold of anything to increase the force of her effort. Above all, the nurse should not tell her to bear down. The strength of the pains is somewhat modified if the patient is kept on her side. This position is also safer for the perineum, which does not so directly get the full force of a pain as when the patient lies on her back. The left side is preferable, 114 ACCIDENTS AND EMERGENCIES OF LABOR. 115 as it enables the nurse to use her right hand to greater advantage. Should the child's head come down so that it can Care of perineum. be seen at the entrance to the vagina, the nurse should place herself on the right side of the bed, and as the patient lies on her left side, with the hips well drawn to the edge of the bed, the nurse should gently hold back the baby's head during a pain. s ^?, or ^ of d This is to prevent a tear from occurring by the sud- den expulsion of the head. She should favor the gradual stretching of the parts. She should avoid interfering in any way, as in making efforts to en- large the opening by stretching it with the fingers, etc. All such attempts will inevitably result in harm. When the opening is sufficiently stretched, the head will slip out of itself. The passage of the Delivery of child's head is rendered easier if the patient's knees are separated by a pillow. The nurse should sim- ply continue to support the head with her hand, and as soon as the head is born her left hand should be placed over the mother's abdomen, rest- ing upon the womb, which may be distinctly felt^P° f through the abdominal walls. The pressure of the hand acts as a stimulant to the womb and induces good contractions. A tendency to hemorrhage is thus averted. The right hand of the nurse should support the child's head. With one finger she . should feel around the baby's neck to learn whether Il6 OBSTETRICAL NURSING. it is encircled by a loop of the navel-string or cord. Loosening If so, she should gently pull first on one side and of cord. ' & J r then on the other, of the cord, to see which end gives. This loosens the pressure and prevents the stoppage of the circulation in both cord and child's neck. ?ody! eryof When, after a pause, the pains start up again to expel the rest of the child's body, the nurse had better have some one instructed how to hold the womb properly, as both her own hands will be needed to receive the body of the child as it is ex- pelled. The mother herself may be shown how to make this pressure over the womb. If there is no one to make this compression of the womb, the nurse should try to manage the baby with one hand and keep up the pressure over the lower Care of part of the abdomen with the other. The flannel infant. wrap for the baby may be put close up to the mother's hips, and the nurse can manage with one hand to lay the baby down on this, cover it up, and draw it far enough away from the mother's hips to keep it out of the discharges. She should see that the baby's mouth is free from liquids. The little finger of her right hand acting as a hook, the end of the finger should be passed in at one corner of the baby's mouth and out at the other corner, thus scooping out any liquids that may have been drawn in during the birth. She should be careful ACCIDENTS AND EMERGENCIES OF LABOR. II7 to see that the cord is not dragged upon and that the baby breathes well. Babies usually cry lustily just after the birth. This should be a welcome sound to both nurse and mother, as it ensures ex- pansion of the lungs. Occasionally, a child will be born with what is known as a "veil" or "caul," a£^ ul „ portion of the membranes, drawn tightly over the face. This may cause death from suffocation unless it is quickly seized by the fingers and torn off, so as to free the child's mouth and nose. If the baby is apparently lifeless when born, Resusdta- besides the measures spoken of for clearing its infant - mouth of liquids, it may be turned over on its face, to empty out the discharges from the air- passages, and efforts should be made to start breathing. The head of the child should be lowered, to keep as much blood there as possible. The back may be slapped — several short, quick slaps given over the buttocks. A stream of cold water may be poured on the chest just for a moment, and this repeated several times. If these fail, the nurse may breathe into the Artificial breathing baby's mouth. To do this properly, the baby's nose should be held, the nurse's lips placed closely over the baby's open mouth, as she breathes into it, then the nurse's mouth is removed and the grasp on the nose loosened, the sides of the child's chest being pressed upon to press out the air. The u8 OBSTETRICAL NURSING. number of breaths given by the nurse in a minute should not at first exceed twelve. Sylvester's Another valuable method of carrying on artifi- method. # J ° cial respiration is known as Sylvester's method. The baby is placed on its back, with a roll made by Fig. 14. Sylvester's Method of Resuscitation (First Movement). a towel placed under its shoulders. The head is thrown back. The arms are then slowly lifted and carried well up over the head. They are held in ACCIDENTS AND EMERGENCIES OF LABOR. I I9 this position until five can be slowly counted. By this movement the ribs are elevated, the chest ex- panded, and a vacuum produced in the lungs into which the air rushes ; or, in other words, the move- Fig. 15. ment produces " inspiration." The arms are then carried slowly downward, placed by the side, and pressed inward against the chest. This forces out the air and produces " expiration." These move- 120 OBSTETRICAL NURSING. ments should be slow, repeated about fifteen times during each minute, and should be carried on until the breathing becomes regular. Should there be no sign of life, the efforts at resuscitation should not be abandoned for at least two hours after the birth. mithoT' 5 A third method, which, however, requires the separation of the baby from the afterbirth, is most excellent. It is known as Schultze's method. It would be more apt to be practiced by a physician, because it necessitates the early and quick tying of the cord and is only of advantage when practiced at once after the delivery. The method is as fol- lows : The child is seized by the shoulders and upper arms and swung head downward above the operator's head. The weight of the lower part of the body is thus thrown upon the chest, and any liquids which may have been drawn into the air- passages are thus forced out. Being held thus for a time, while the operator counts five, the body is then brought down in reversed position between the operator's knees. The weight of the lower extremi- ties is thus made to drag upon the chest and enlarge its capacity for the entrance of air. These two movements may be kept up for considerable time.* * The order of these movements as given by Schultze is reversed. The upward movement is practiced first in the Woman's Hospital, as it is found that the air-passages are thus best cleared of mucus and discharges before an act of inspiration is encouraged. ACCIDENTS AND EMERGENCIES OF LABOR. 121 Fig. 16. Schultze's Method of Resuscitation (First Movement). 122 OBSTETRICAL NURSING. Warm baths. Alternating with artificial respiration, warm baths Fig. 17. Schultze's Method of Resuscitation (Second Movement). may be employed from time to time. The tem- perature of the bath should be ioo° Fahr. After ACCIDENTS AND EMERGENCIES OF LABOR. 1 23 breathing is established, the child should be placed After-care, in warm wraps, with bottles of hot water around it. If all is well with the child, it is best not to tie Tying of cord. the cord until all pulsation ceases in it. This measure is thought to save the child some loss of blood. As the pulsation may last for an hour or more after the delivery, the afterbirth is generally expelled before the cord is tied. To tie the cord, two pieces of bobbin, each eight inches long, dipped in a bichloride solution 1-4000, or in some other antiseptic solution, should be used. The first liga- ture should be placed three inches from the child's abdomen. The string should be carried under- neath the cord. In making the first tie, two twists instead of one should be taken to keep it from slip- ping. If the thumbs are placed upon the string in tying, the ligature can be drawn more tightly, and the grasp of the ends of the bobbin is more secure. The second knot is tied the same way. ' The ends may then be looped, making a bow-knot. The cord should be stripped, that is, the blood remain- ing in the vessels squeezed out toward the afterbirth, before each ligature is thrown around it. The second ligature is one inch further away from the insertion of the cord into the child's abdomen. After this second ligature is tightened, hold the cord with the forefinger and middle finger at the ligature nearest the child, the thumb and other 124 OBSTETRICAL NURSING. fingers at the other ligature, and cut it with a pair of dull scissors between these points. The extrem- ities of the scissors are thus made to look toward the palm of the hand, and a sudden movement on the part of the child does not result in the same danger to it as there would be were the points not thus protected. After the cord is cut, squeeze the remaining blood out from the end next the child. The scissors for this purpose are preferably dull, as the more ragged wound thus produced favors the closure of the blood-vessels. This lesson may be learned from nature, the lower animals gnawing off the cord after giving birth to their young, and thus no doubt decreasing the danger of bleeding. Position The best position for the mother during the stage of delivery of the afterbirth is on her back, hence, she may be turned after the nurse has satisfied her- self that the baby is in good condition. Twins. Very occasionally, on placing her hand over the abdomen, after the delivery of the child, the nurse may feel another child there. In this case she must simply keep the womb well contracted by rubbing it gently through the abdominal walls, and wait for nature to go on with the work of expulsion. This baby must be cared for as the other. Delivery of The afterbirth generally comes away within twenty minutes after the child's birth. Two or three pains occur, during which the nurse should ACCIDENTS AND EMERGENCIES OF LABOR. 125 keep the womb in the middle line of the abdomen and make gentle pressure backward and downward. With her right hand she should seize the afterbirth and membranes and twist them around several times to make a cord of the membranes, so that they may not tear, but all be expelled at once. A discharge of blood and some clots generally follows the delivery of the afterbirth. The nurse's left hand should still be kept carefully over the womb, which should feel hard and firm and should not reach above the navel. If it does not feel firm, rub- bing over the lower part of the abdomen should again be resorted to until the round, hard body is felt. If the afterbirth does not come for an hour, and the physician has not yet come, send for another doctor. After the afterbirth has come, it should be put Examina- in a clean vessel, and, if detached from the baby, afterbirth. put in an adjoining room for the doctor to examine when he comes. Insist upon his seeing it, to find out whether it is all there. Have the baby removed to its crib and placed on its right side and properly covered. Watch the womb carefully until the doctor comes. Care after third stcisrG If it be firmly contracted, and no more blood be of labor, flowing from the vagina, place some dry napkins or a clean sheet under the patient, and wash off the 126 OBSTETRICAL NURSING. Cleansing of thighs and surrounding parts with warm water con- taining bichloride in the strength of 1-4000, and dry with a soft cloth. change of Slip the soiled clothing- from under the patient, clothing. * o r 1 Binder and and then apply the binder and dressings, and make her comfortable. Report. Breech delivery. Hemor- rhage. As soon as the doctor comes, report to him the exact time when the waters broke, when the baby was born, and when the afterbirth came. It is always best for a nurse to keep a written report with a statement of what she did. She should not, however, neglect her patient for the purpose of per- fecting her report. Sometimes a nurse has the misfortune to be the only attendant at a breech delivery, that is, instead of the child's head coming first, the breech passes out from the birth-canal. Delivery in this manner is very dangerous to the life of the child. The nurse should do absolutely nothing here, as she would only make matters worse in trying to assist. These deliveries are long enough, as a rule, to give ample time for the summoning of some doctor to take charge of the case. In all breech cases the child is apt to need to be resuscitated, if it is alive at all ; hence plenty of warm water, etc., should be ready for the bath. Flooding from the womb, or " uterine hemor- rhage," is apt to occur either within the first twenty- ACCIDENTS AND EMERGENCIES OF LABOR. 1 27 four to forty-eight hours after the birth, when it is called "primary hemorrhage;" or, it may occur some days after, when it is " secondary hemor- rhage." The appearance of blood, either a constant oozing or a sudden gush from the vagina, is, of course, the earliest symptom. A pulse of over ioo in a patient freshly confined should make the nurse exceedingly watchful in this respect, as it betokens a liability to hemorrhage. Should the flow continue, the patient becomes pale, faint, restless, gasps for breath, and finally dies unless the hemorrhage is checked. A nurse should, of course, have the physician sent for at once, although he may have just left the house, or another doctor should be summoned. In the meantime, her first thought should be of the uterus and its probable condition of relaxation. The ban- dage, if applied, should be hastily removed and the hand placed over the lower part of the abdomen. If the womb is not felt, rub vigorously until it con- tracts and is felt again as a round, hard body. Keep on rubbing and holding. The nurse should never take her hand off the abdomen until the doc- tor comes. Direct some one else to take the pillows from under the patient's head, have the foot of the bed elevated, to keep the blood in the head and prevent fainting, which induces heart-clot. Have the foot of the bed placed on the seats of chairs. 128 OBSTETRICAL NURSING. The patient may be fanned, cold water given her to drink, hartshorn to smell. She should not be allowed even to turn in bed or lift her head. If the doctor has left ergot, one teaspoonful of the fluid extract may be given in a tablespoonful of water. Fig. 18. Position of Patient in Hemorrhage after Labor. The patient should receive this without lifting her head. Plenty of hot water should be on hand, the water in the tea-kettle boiling. If the physician delays his coming and the flow continues, repeated hot-water injections of about U5°-I20° should be given into the vagina. Convulsions. Convulsions may come on during the labor as during the pregnancy. Their management would ACCIDENTS AND EMERGENCIES OF LABOR. 1 29 be the same as that suggested for convulsions during pregnancy. Other accidents, such as rupture of the uterus Rupture of x uterus. or the coming down of an arm or hand, or the navel- _ . 25 ' Prolapses. string in advance of the usual part to come first, are conditions in which the nurse can do nothing, except to keep the patient as quiet as she can, and meddle as little as possible until the doctor comes, for whom, of course, she must at once send. At no time, in the management of a case, should Demeanor & 'of nurse. a nurse express surprise or consternation, nor should her manner indicate that she has such feel- ings. Like a true soldier, she must bravely and quietly face the most critical situations and meet their demands. She should by her manner give the mother to feel that all life's vicissitudes are best met by a quiet self-control. Fortunately, deaths during delivery in this en- Liability to ctcciQcnts lightened age are few ; for the methods of averting during accidents at such times have been so thoroughly studied, that accidents themselves are very rare. As operative procedures during the course of aPrepara- tions for delivery may have to be resorted to very suddenly obstetrical operations. and unexpectedly, a nurse should have things in readiness should the emergency arise. The especial preparations necessary will consist in the making of a cone of stiff paper, into- which a towel is fitted, for the purpose of giving the patient ether ; arrange- 9 1 30 OBSTETRICAL NURSING. ments for an abundant supply of hot water, to be had at a moment's notice ; facilities for making up antiseptic solutions quickly ; a small pitcher con- taining a warm two per cent, creoline solution for the physician's instruments ; some kind of grease, as carbolized cosmoline, for lubricating these instru- ments when desired ; English rubber catheter and urinal conveniently at hand ; a basin with a two per cent, carbolic solution for needles, sutures, and scissors ; absorbent cotton in small pads, or soft linen rags dipped in an antiseptic solution, to be used instead of sponges j sufficient protection for the floor at the side of the bed ; and preparations for resuscitation of the infant. The position of the patient for most obstetric operations will be across the bed, with her hips well s-bed." over the edge. This is called a " cross-bed." Physicians generally call simply for a cross-bed, in desiring the nurse to make preparations for an operation, and she should understand that this refers to the arrangement of protectives and sheets, adjust- ment of pillow, and placing of patient in proper position. Should there not be a sufficient number of persons to have one hold each leg, chairs should be placed in such a way at the side of the bed as to support the widely separated feet. A chair for the physician should be placed between these, facing the bed. As there is usually some assistant to give 'cross- ACCIDENTS AND EMERGENCIES OF LABOR. I3I the ether, the nurse will need to help in keeping the limbs apart and in giving the physician any other aid she can in the supply of the various articles as they are needed. Should the physician desire her to give the ether, her whole attention should be devoted to administering the anaesthetic and seeing that the patient keeps in good condition. Strict watch should be kept over the respirations and the pulse. Difficult breathing, or a stoppage in the respirations, weakness or irregularity of the pulse, blueness of the face and lips, should at once be called to the physician's notice, the ether cone being re- moved from the patient's face. After the patient is once well under ether, it takes but little to keep up the anaesthesia, so that the nurse should use the ether sparingly ; a few drops every few minutes upon the towel are, as a rule, sufficient. After etherization the patient may vomit, and there will be greater tendency to bleeding because of the relaxation induced by the anaesthesia, hence the nurse should exercise special^ watchful- ness and care over the patient. The vomit- ing is often relieved by a mustard paste over the stomach, while the bleeding may be controlled by the hand placed over the lower part of the abdomen, which, by making pressure over the womb, insures good contractions. After the nausea is relieved, ergot, if prescribed by the physician, may be given. CHAPTER XL CARE OF THE NEW-BORN INFANT. The mother being made comfortable after her delivery, the nurse should turn her attention to the infant. Everything needed for the baby's first" toilet should be collected and placed conveniently at hand, near the register, stove, or open fireplace. Prepara- The nurse should put on a flannel apron, or pin tions for the * ~ ' r first bath. a crib-blanket or flannel petticoat over her lap. The best bath-apron is one consisting of two pieces of flannel fastened to the same waistband. The lower piece is the one on which the baby lies ; the upper serves as a covering. A pitcher of warm water and one of cold must be provided, the baby's bath-tub being placed near them, the baby-basket, suit of aired clothing, and jar of rendered lard or oil within reach. The nurse should pick the baby up with its wraps and place it in her lap as she seats herself on a low chair or stool near the fireplace. The baby will be found to be covered over por- tions of its body by a white, greasy substance, called 132 Vernix caseosa. CARE OF THE NEW-BORN INFANT. 1 33 " vernix caseosa," or " cheesy varnish. " This sub- stance is found in greatest quantity on portions of the body subjected to friction while in the womb, hence it serves to protect the child's skin. Some kind of grease is needed for its removal. Its removal. Rendered lard and oil are the best. Cosmoline is not so good, as it is stififer than the other two — not so soluble a fat. All this cheesy substance must come away with the first washing, as, if left, it irri- tates the skin and produces sores. The most diffi- cult parts of the body to cleanse are the folds or creases. The nurse should take a piece of lard about the size of a walnut, rub it over the palms of both her hands, and then, taking the child's head between her hands, rub the grease thoroughly in, giving especial attention to the ears. A second piece of lard of the same size will be needed for the neck, shoulders, arms, chest, and back ; a third piece for the groin, external generative organs, and lower limbs. The creases and folds about the generative organs, especially of a little girl baby, need very careful cleansing. When the baby has been thus thoroughly gone over, she should take the corner of a dry sheet and rub off the grease. Many phy- sicians prefer not having the baby bathed after this greasing. It may then be dressed and laid in its crib. Should the bath be preferred, the nurse should Thebath - 134 OBSTETRICAL NURSING. wrap the baby up in her flannel apron, draw the bath-tub toward her, and prepare the bath, filling the bath-tub about one-third full of warm water at a temperature of ioo° F., tested by the thermom- eter. A wall-thermometer, costing fifteen cents, may be obtained at any drug-store for the purpose. The baby is then placed in the tub, its entire body, excepting its head, being immersed for a moment or two beneath the water. The nurse should keep the baby from slipping from her grasp by allowing its head to rest against her left wrist and hand, while the fingers of the same hand obtairi a secure grasp under the child's left arm-pit. After the dip, the child is lifted out on to the nurse's lap again, where a soft, warm towel should have been spread for its reception. In this it should be wrapped and thoroughly dried. Great care must be taken to see that the arm-pits, groins, and other parts of the body where creases exist are entirely free from moisture. After the first bath, the child receives, as a rule, but a sponge-bath daily until the cord drops, when the daily plunge-bath may be given. The baby should always be thoroughly washed with simple warm water over the parts of the body soiled every time the napkin needs to be changed. Soap does not need to be used. Its frequent use would irritate the skin, and the parts can be per- fectly cleansed without it. CARE OF THE NEW-BORN INFANT. 1 35 The use of powder in the folds and creases of the Powder. body is not essential. The main object is to keep rubbing surfaces dry, and should the nurse properly attend to this duty after the bath, this, with the use of flannel next the baby's skin, ought to be suffi- cient to effect the purpose. Should a powder be desired, some very fine, unirritating powder, such as lycopodium, might be used. Many of the scented powders contain substances which are irri- tating to the skin. After the baby has been dried, the stump of the Dressing cord or navel-string should be attended to. Make a loop of the stump, doubling it back upon itself, and tying it tightly by means of the ends of the bobbin left from the first ligature. Slit up a square of soft linen to its centre. ' It is well to have rendered this antiseptic by dipping in a bichloride solution 1 -1000 or 2000 before drying. Put this around the cord, which is slipped through the slit (the slit looks upward toward the child's head), fold over the ends, and turn the whole upon the left side. Some physicians will direct that no dressing be placed around the cord. In fact, sometimes there is no ligature placed around it, but it is simply well stripped of the blood and jelly-like substance which help to compose it, and thus allowed to dry. The placing of the loop of cord with its dressings on the left side of the child's body is to avoid pres- jelly. I36 OBSTETRICAL NURSING. sure upon the liver, which is larger than any other organ in the infant's body at birth, so large, in fact, as to extend quite down to the navel. The abdominal bandage is put on over the dressing to hold the latter in place. Some use antiseptic gauze in the dressing of the cord. A drying powder, consisting of one part salicylic acid and five parts starch, is an antiseptic application which it is often desirable to employ. Wharton's A clear substance exudes from the cord as it shrinks which wets the dressings, so that it is neces- sary to change the piece of linen quite often the first day or two. A cord kept dry by the frequent change of dressings will have no odor about it, and will drop, on an average, by the fifth day. The base from which the cord dropped may continue moist for a few days, and is best dressed by dusting over it a little of the starch and salicylic acid powder before spoken of, and placing a small compress of antiseptic linen or gauze over it. The navel-dressing is kept in place by the application of the flannel binder, which should be carefully adjusted, so as not to compress the abdomen too tightly. After the bandage is fastened, the nurse's hand, used flatwise, should be easily slipped in between the bandage and the baby's skin. Should safety-pins be used in fastening the bandage, they should be placed in front and not at the back, or they may cause the baby The binder. CARE OF THE NEW-BORN INFANT. 1 37 discomfort in lying. The bandage fastened by the tapes, which is simply wound around the body, is safer on this account. Great importance should be given to the proper care of the navel, as it offers an open surface on the child's body through which poisonous matter may be taken into the blood, causing " infantile sepsis," or the blood-poisoning of infants. Before the dressing of the cord, a napkin should The napkin. have been laid beneath the hips of the infant, as there is very apt to be a free discharge of a dark, greenish matter from the bowels shortly after the birth. This is known as " meconium." It should "Meco- nium." always come away within the first twenty-four hours after birth, and may continue to come at intervals for three or four days. When it does not come away freely the baby may suffer considerable pain. A soap suppository or a small injection of warm water will bring about relief, causing an evacuation of the bowels. This substance is very difficult to wash out of napkins, hence, it is a good plan to have a soft piece of old muslin placed inside the napkin to catch the discharge. This may be burned when removed. The baby should be washed every time the nap- lf^f^ e kin needs to be changed, even if it is only wet. washin s . o j J and care in Warm water should be used. A napkin should napkins. never be used twice without washing. The habit I38 OBSTETRICAL NURSING. of hanging up a napkin wet with urine, allowing it to dry, and using it again is not only filthy, but un- safe, as it renders the napkin irritating to the skin and a source of possible septic infection. For the same reason a napkin should be changed as soon as it is wet or soiled. Though the work may be irksome, a nurse should not weary of it; for it is only by eternal vigilance that the child can be kept in good condition. Under-vest. After the application of the binder and napkin, the baby's under-vest, or little, long-sleeved, high- necked flannel shirt, should be put on. This should be fastened in front by safety-pins, or small, flat buttons or tapes. If the shirt is too large, folds should be made at the sides to make it fit better; never in the back, because of the ridge this would produce under the surface upon which the baby lies. socks and The socks come next and then the flannel slip, constituting the only other garment the baby needs. The petticoat with slip, or Gertrude suit, may be used instead, if desired. washing of The eyes and mouth should each be washed out eyes and mouth. w ith a separate soft piece of linen dipped in warm water. t^e U hair g T^e baby's hair, if it has any, may be brushed with a soft baby-brush. No comb should be used, as the scalp is too tender. CARE OF THE NEW-BORN INFANT. 1 39 The baby should then be placed in its crib, on its right side, and warmly covered. The weaker the baby is, the warmer it will need to be kept. Stone jars, when filled with hot water, are nice for this purpose placed around the child, but care should be exercised not to let these bottles be placed so near as to cause a burn. In another chapter we will consider the care of premature infants. The weighing of the baby devolves often upon Weighing the nurse. A steelyard being provided, the nurse may place the nude child in a napkin, tied or pinned securely at the corners. This napkin may be swung on to the hook of the steelyard as it is held up. The pointer will then indicate the number of pounds weight. The average weight of a new-born baby is 3250 grammes (about seven pounds). In the Woman's Hospital the ordinary grocer's pan-scales are used, the weights being represented in grammes. The daily weight is taken and recorded on a card which hangs by a ribbon or string to the baby's crib, so that its daily condition may be carefully watched. For a comparison of the approx- 140 OBSTETRICAL NURSING. imate weights in the metric and avoirdupois scales, I append the following table of equivalents : — Relation of Avoirdupois to Metric Weights. AVOIRDUPOIS GRAMMES. POUNDS. 1 453-592 2 907.18 3 1360.78 4 1814.37 5 2267.96 AVOIRDUPOIS GRAMMES. POUNDS. 6 2721.55 7 3I75-I4 8 3628.74 9 4082.33 10 4535-92 Loss of weight for first few days. The evening bath. The crib. Combined bath-tub and crib. For the first three or four days a baby will lose weight, as it does not take in enough nourishment to make up for the loss it sustains by the newly- acquired activity of bowels, bladder, and skin. At the end of the first week the baby should weigh about what it did at the birth. After that it should gain, on an average, thirty grammes a day (about one ounce). A sponge-bath is sometimes given the baby at the close of the day, when its clothing is changed for the night ; but this is not necessary, if it has been properly attended to when the napkins have been changed. The fresh clothing at night is always essential. The baby's crib should have no rockers. All unnecessary swinging, rocking, and jolting of babies only serves to make them nervous and more trou- blesome to take care of. A convenient and inex- pensive crib and bath-tub combined, especially for CARE OF THE NEW-BORN INFANT. 141 traveling, is described in one of the numbers of " Babyhood," thus : " The frame is made some- thing like a cot-bed. Straight pine sticks may be used. The legs, one inch and a half square by thirty inches long, are crossed and pivoted in the middle on a centre bar. The side bars, one inch by two inches and thirty-six inches long, are securely fastened to the top of the legs. Smaller bars join Fig. 19. Home-made Bath-tub and Crib. the legs near the bottom to stiffen the frame. A piece of heavy rubber-cloth, one yard and a quarter long and thirty inches wide, has an inch-wide hem on each end for a casing, and is drawn up to eigh- teen or nineteen inches with heavy braid (a leather strap would probably be better). This makes the ends of the tub. Along the side bars of the 142 OBSTETRICAL NURSING. Separate bed from mother. Proper training of infants. Feeding of infants. Time. frame are tacked with brass-headed tacks the sides of the cloth, the braid (or rubber straps) being securely fastened to the ends. A small plait in the cloth at each corner, about an inch from the end, gives a fuller shape to hold the water (when it is in use as a bath-tub). The tub (or crib), when not in use, can be folded and set away out of sight, or it may be carried in the bottom of a large traveling- trunk when on a journey. The frame may be made of walnut or cherry, with turned legs, etc., if so de- sired. A pillow put in the tub makes a comfortable and portable crib for the baby. Children should never sleep in the same bed with their mothers. It is unsafe because there is danger of their being overlaid, and it is unhealthy because of the discharges, breath, etc., of the mother. A baby may be trained to be contented and happy as it lies in its crib. If from its earliest days it is taken up simply to be fed, and receive the necessary attentions for keeping it clean and com- fortable, it will not become the little tyrant a child develops into when foolishly spoiled by its mother. Babies should be fed but once in two hours during the day, and every three hours during the night, unless premature, when they can take less and should be fed every hour. An interval is necessary between the feedings in order that the CARE OF THE NEW-BORN INFANT. I43 stomach may rest and be prepared properly to carry on its work of digestion. Hence, the habit some mothers have of letting babies nurse whenever they cry simply serves to produce indigestion, as well as to spoil the child.* , For its first nursing the baby may be put to the Cursing. breast an hour or two after the labor, if the mother is sufficiently rested. The nipples should, before each nursing, be carefully washed off with cold water: The early secretion of the breasts, known as " colostrum/' helps to rid the baby's bowels of their dark, tarry contents, as it is laxative. It is important that the breasts should be used alter- nately in feeding the infant, as this allows a longer time to elapse for the accumulation of milk. For the first day or two the baby needs comparatively little food. Should it seem to be hungry, however, and the mother unable to satisfy it, a teaspoonful or two of warm water or diluted peptonized cow's milk, prepared according to the suggestions to be given later, may be administered at regular intervals. Before and after each feeding, the baby's mouth should be carefully washed out with a piece of soft linen dipped in warm water or a saturated solution of * It has been observed that when the periods between nursing were short the milk was more condensed, a fact which throws light on the dyspeptic phenomena occurring in babies who are fed too often. — Rotch. 144 OBSTETRICAL NURSING. boracic acid. This is to prevent the particles of milk remaining in the mouth from producing sore- ness by souring. a drink of Two or three times daily a baby should be given cold water. J J & a teaspoonful of cold water to drink, as babies suffer from thirst just as their elders do. The cold water assists, also, in keeping the bowels from becoming constipated. The water should be boiled and kept in an air-tight flask, insufficient Should the mother not have sufficient milk for milk. her baby, it may have the bottle every other time, the additional food being selected with reference to the child's age and powers of digestion. The When a mother has no milk, the best substitute wet-nurse. 7 is a good wet-nurse. A wet-nurse should always be carefully examined by a physician, that her free- dom from disease may be fully determined before she is employed. She should be between twenty and thirty years of age, and have good, not neces- sarily large, breasts, well-shaped nipples, and an abundant supply of milk. The condition of her own child should be considered, whether it be thriving or sickly, and especially whether there be any evidence of special disease. It is well, too, to try to get a woman who has had more than the one child, as a woman who has borne several children has, by experience, learned to understand and manage babies. CARE OF THE NEW-BORN INFANT. I45 The first milk that comes in the breast, and which Fore-miik. appears in any quantity, about the eighth month of pregnancy, is called " fore-milk," or " colostrum," from a word which means " glue." It is turbid, yellowish, gluey, alkaline in reaction, and easily sours. It differs from true milk in having a higher specific gravity or weight ; it also contains more salts and more albumen, and is more difficult to digest. It is laxative in its effect upon the baby's bowels. Physicians not unfrequently examine afor^uSing- specimen of this secretion under the microscope, to learn what the prospect is as to the mother's nurs- ing the child. If, in the last two months^of preg- nancy, the colostrum is scanty, and under the microscope there are but few oil globules, the patient will probably have poor milk and small in quantity. If the colostrum is abundant but thin, like gum water, not gluey and without yellowish streaks, it is probable that the milk will be watery and not nourishing. It may be either scanty or abundant. If the colostrum be plenty, with yellowish streaks and full of milk globules, the milk will be abundant and good in Duration o* quality. The secretion of colostrum may continue from six to eight days. If it continues longer it is a great disadvantage, and the mother may have to give up nursing because of the ichild's inability to digest the nourishment thus afforded. 10 secretion, Character- istics of human milk. Difference between human and cows' milk. Regulation of nursing to meet special demands. I46 OBSTETRICAL NURSING. Human milk should have a specific gravity of 1028-1034. It is slightly alkaline in reaction ; that is, it will turn red litmus-paper blue, and it contains the following ingredients : — Water, * . 87-88 Total solids, 13-12 Fat,' f . 3-4 Albuminoids, 1-2 Sugar, 7.0 Ash, 0.2 —Rotch. It differs from cows' milk in having a higher specific gravity, more solids, less water, and one-fifth the amount of albuminoids. The milk retained longest in the breast — the first milk drawn by the baby at each nursing — is the thinnest ; the last, the richest. When, therefore, a baby seems to suffer from indi- gestion because of its mother's milk being too rich for it, it should take the first secretion from each breast at each nursing instead of drawing all the milk from one breast. One or two teaspoonfuls of water given the baby before each nursing have the same object. Should it, on the contrary, not seem to thrive because of the food not being sufficiently rich, the thin milk should be pumped or drawn out of each breast by the nurse or mother before the * According to the analyses of Dr. H. Leffmann the percentage of fat rarely reached 4, ranging between 2.5 and 3 as a rule, while the albuminoids were usually a fraction over 1 per cent. CARE OF THE NEW-BORN INFANT. 1 47 baby is allowed to draw. The two breasts are estimated to contain about two ounces of milk at one time. * The question of how to increase the secretion of stimulation ' . . _.. , . . of increased milk is a very important one. I he best way is by secretion. a judicious regulation of the mother's or wet-nurse's diet. There are no medicines which are entirely satisfactory for the purpose of stimulating the secre- tions. Therefore a nurse can do more than a doctor in this line by careful feeding of her patient. A mixed diet is the best for making milk. Beer and all kinds of liquors, as porter, etc., do more to fatten the mother or nurse than to make milk ; therefore they are to be avoided. The special diet for a nursing woman is laid down in another chapter. Good human milk should be three per cent, cream. f To determine the character of milk — human or Testing cows' milk — an instrument known as the lacto- meter, or milk-tester, may be used, aided by the microscope. . — _ . , , ■* * The use of from 1-5 drops of cod-liver oil, according to the age of the child, given three times daily, has been found to be a valuable supplement to the food when a mother's milk lacks richness. — Dr. A. E. Broomall. f As a general rule, the amount of fat may be increased by in- creasing the amount of meat in the diet, and the amount of albumen decreased by moderate exercise. Too little fat and too .much casein make poor milk — Rotch. 148 OBSTETRICAL NURSING. The lacto- meter. Determina- tion of proportion of cream. Fig. 20. The lactometer consists of a cylindrical glass vessel, or beaker, which should contain the milk to be tested, and a specific gravity glass, which is to be floated in the liquid. This glass is graduated and marked at certain points with certain letters and figures. Thus, W, P., and F. The W. stands for "water," P. for "pure," and F. for " fat." Between the W. and P., at different points, are the fractions, %> % %- Should the weighted glass sink in the liquid so that the surface of the liquid reached the mark W., the liquid tested w r ould have the same specific gravity as water. Should the surface of the liquid reach the mark *^, if it is milk that is tested, it would be y milk and y water. If the mark ]/ 2 is touched, it is y 2 water and y 2 milk. In this way the adulteration of the milk with water is detected. Should the level of the liquid stand at P., we would have pure milk. Pure cream would raise the weighted glass so that the level of the liquid would stand at F. An ordi- nary urinometer may be used to obtain the specific gravity of milk in a similar way. Dr. Louis Starr suggests a good way to discover the proportion of CARE OF THE NEW-BORN INFANT. I49 cream in any given sample of milk : A narrow piece of paper, four inches long, is divided in its upper half inch by cross-markings into twelve equal parts. This paper is then pasted on the beaker of the lactometer with the marked portion uppermost, the lower edge touching the bottom of the beaker. Enough milk is then poured in to come just to the top of the paper, and the whole set aside for twenty-four hours. The cream rises and appears as a yellow layer at the top. This layer should have the depth of ten or twelve spaces, as marked on the paper. On examination under the microscope, if there ^ cr j°" ex are but few oil globules in a specimen of milk, and of^fk on if these oil globules be small, the milk is poor. On the other hand, if the oil globules in milk are too large, this becomes a cause for its indigestibility. Should menstruation begin with a nursing Effect of mother, the milk may be so affected as to disagree tbn on with the child. Ordinarily, the menstrual flow does not recur until the eighth month after delivery. The appearance of the flow need not lead to a ces- sation of nursing, unless the milk should seem to disagree with the child. The character and quantity of the milk is impaired by deep or violent emotions; thus, anxiety, fear, anger, etc., will greatly detract from a woman's ability to be a good wet-nurse. menstrua- tion on secretion. ISO OBSTETRICAL NURSING. Effect of pregnancy on lactation. Artificial feeding. Character- istics of cows' milk. Analysis of human and cows' milk. Pregnancy always deteriorates the character of milk and is an indication for weaning a nursing child. When the mother's milk utterly fails, and a wet- nurse cannot be had, hand-feeding becomes neces- sary. For this purpose diluted, sterilized cows' milk may be used. Cows' milk has a specific gravity of 1.029. The milk obtained from stall-fed cows gives an acid re- action; that from pasture-fed cows a less acid reac- tion. Could the latter be obtained directly from the cow its reaction would be slightly alkaline, as with human milk. An analysis of the same quan- tity of woman's milk and cows' milk is reported as yielding the following results : — woman's milk Water, 87.88 parts. Total solids, . .12.13 Fat, .... Albuminoids, Milk-sugar, . Ash, . . . . Bacteria . . 4.00 1. 00 7,00 0.2 not present. cows' MILK 86.87 P arts 13.14 a 4.00 a 4.00 a 4.5 a 0.7 a present. Points of difference. The woman's milk for this analysis was obtained directly from the breast. The cows' milk was, as it is ordinarily obtained in cities, about twenty-four hours old. By an examination of this analysis, it will be seen that the proportion of coagulable substances of CARE OF THE NEW-BORN INFANT. 1 5 I cows' milk is much greater than in human milk. This is where the difficulty in its digestion lies. Casein of human milk coagulates in light curds; in cows' milk in firm, hard curds. The kind of food required by different babies will £ f u f ^ y vary with their constitutions. As a rule, a mother's J^g^ milk is the best food for her child, and makes a good gauge to start from in the preparation of an artificial food to take its place or act as a supplement when there is an insufficient supply. If, therefore, a care- ful analysis is made of a mother's milk and a mixture prepared which shall, so far as possible, contain the same constituents in the same propor- tion, we may hope that the baby will thrive on it. A steady increase in the baby's weight will be the best index by which we can judge of the nutritive qualities of the food it is taking. For the first four or five months of its life, a child should gain on an average twenty to thirty grammes (about one ounce) daily. For the remainder of the first year of life, a daily gain of from ten to fifteen grammes will mark satisfactory progress. In the comparatively few cases in which a Necessity mother's milk does not appear to have proper nutria analysis. tive or digestive properties, it should be similarly examined to discover in what direction the deficiency lies, and the artificial food should be pre- pared so as to supply the lack. The nutritive con- 152 OBSTETRICAL NURSING. Prepa- ration of cows' milk. Quality of cream. stituents of milk are the albuminoids, fat, and^milk- sugar. Cows' milk contains about four times the quantity of albuminoids found in human milk, so that it requires to be diluted with four times as much water to represent the same percentage of albuminoids. Since the amount of fat in human and cows' milk are about equal, this dilution would greatly decrease the percentage of fat. Also since cows' milk contains a much smaller quantity of sugar of milk than is found in human milk, the same dilution would be greatly deficient in sugar. In preparing a mixture from cows' milk, there- fore, which may correctly represent human milk, fat, in the form of cream, and sugar of milk must be added. Cream varies very much in richness, hence it is desirable to know what percentage of fat is represented by the cream used in compounding a mixture. A chemical analysis of the cream is necessary for accuracy of result in such determina- tion. It has been suggested that to prevent too much variation in the percentage of fat, the cream should be obtained of the same person from milk that has been allowed to stand each day for the same length of time and in the same temperature. A mixture made up according to the following rule probably most nearly resembles the average CARE OF THE NEW-BORN INFANT. 1 53 human milk. To make one pint of the mixture for use in twenty-four hours, take milk and cream (twenty per cent.) as soon as it comes in the morn- ing, and mix as follows : — Milk, ' fgij Cream, f*^ iij Water, f g x Milk sugar, 3 63 Put in a flask in the steamer and steam for twenty minutes ; then remove the flask from the steamer, and when still slightly warm add lime-water f§j. Place on ice, and give the proper amount at the proper feeding time. (Rotch) The object in steaming the mixture is to sterilize it, for human milk is sterile, and for that reason more digestible than cow's milk — which, although sterile while in the udder, becomes contaminated as it is placed in vessels and transferred from place to place. It is believed by some that this steaming or boiling of milk has a tendency to decrease its digestibility. The danger from this source, how- ever, is probably much less than that which would arise from the presence of germs in the milk, such as have been shown to exist. " Fractional steriliza- tion/' the heating of milk in a water-bath for several days in succession up to a more moderate degree of heat than that required for complete sterilization, 154 OBSTETRICAL NURSING. is said not to have the same effect in decreasing the digestibility of milk. Lime water is added to make the mixture alka- line, all human milk being slightly alkaline. It should not be placed in the flask before boiling or steaming, because experimentation has shown that the lime undergoes some change in the process of boiling which causes a discoloration of the milk and the deposit of a sediment. Experi- ment has shown that water is the most efficient diluent to be employed in making these mixtures, as it gives a much finer curd with acids, when so used, than can be obtained by an admixture with barley-water or any of the prepared foods. Having thus determined by analysis the quality of the food required for an infant, the quantity must be determined and frequency of feeding. Quantity As to quantity, the observations made by Dr. of food. A J * Ssnitkin, of St. Petersburg, have led to the formula- tion of a rule by which one one-hundredth of the baby's weight should be taken as the figure with which to begin the computation, and to this should be added one gramme for each day of life. A table prepared by Dr. Rotch, of Boston, has arranged in very convenient form the quantity and intervals of feeding for the first year of a child's life:— CARE OF THE NEW-BORN INFANT. 1 55 GENERAL RULES FOR FEEDING. (Rotch.) Age. Intervals of Feeding. Number of Feedings IN 24 Hours. Average Amount at Each Feeding. Average Amount in 24 Hours. ist week. 2 hours. 10 1 ounce. 10 ounces. 1-6 weeks. "2% hours. 8 1^-2 ounces. 12-16 ounces. 6-12 weeks and possibly to 6th month. 3 hours. 6 3-4 ounces. 18-24 ounces. At 6 months. 3 hours. 6 6 ounces. 36 ounces. At 10 months. 3 hours. 5 8 ounces. 40 ounces. Another table arranged by Dr. Rotch shows the amount required at each feeding, according to the weight of the child. DETERMINATION OF AMOUNT OF FOOD BY WEIGHT IN CASES OF SPECIAL DIFFICULTY Initial Each Feeding. Weight. EARLY DAYS. at 15 DAYS. AT 30 DAYS. 3000 grammes. 30 grammes. (About 1 ounce.) 30 + 15=45 grammes. (About i]/ 2 ounces.) 30+30=60 grammes. (About 2 ounces.) 4500 grammes. 45 grammes. (About 1% ounces) 45 + 15=60 grammes. (About 2 ounces ) 45+3o=75 grammes. (About 2% ounces.) 6000 grammes. 60 grammes. (About 2 ounces.) 60 + 15=75 grammes. (About 2% ounces.) 60+30=90 grammes. (About 3 ounces.) I56 OBSTETRICAL NURSING. A new-born infant's stomach holds about \*4 ounces. The average daily quantity of food re- quired for the first 2-3 months is 20 ounces ; after 3 months, 23 ounces ; after 4 months, 27 ounces ; 6-12 months, 30 ounces. The child's appetite, however, if it be healthy, is a good gauge. During the first month 1^ ounces of the prepared cow's milk may be given at each feeding, and twelve feedings given daily. Peptonized food diluted has been employed with great success by some physicians where the diges- tive powers in early childhood seemed at fault. The following formula may be used for the purpose : — Into a clean quart bottle put one measure, or five grains, of extractum pancreatis (Fairchild's), and one measure, or fifteen grains, of bicarbonate of soda, and a gill of cold water; shake, then add a pint of fresh cold milk, and shake the mixture again. Place the bottle in water about iio° or 1 1 5 °, or so hot, that the whole hand can be held in it without discomfort for a minute. Keep the bottle there for twenty minutes. At the end of that time put the bottle on ice to check further digestion and keep the milk from spoiling. If heat cannot be conveniently provided, after the ingredients have been thoroughly mixed and CARE OF THE NEW-BORN INFANT. I 57 shaken, the bottle may be placed on ice and allowed to stand for an hour before it is used. It must be remembered that peptonized milk cannot be sterilized or it becomes unfit for food — the process of digestion being carried so far as to curdle the milk and render it extremely unpalatable. If an additional aid to the digestion should be necessary, a little pepsine may be given to the child just before each feeding, or the pepsine may be placed in the nursing bottle just as the child takes it. Pancreatic extract and soda, if used, will need to be given about an hour after the meal. A preparation of peptonized milk, which has been much used by Dr. Broomall, is the following : — Peptonized milk, 6 tablespoon fuls Milk-sugar, ^ teaspoonful Barley water, 2 tablespoonfuls Lime water, ..." 1 tablespoonful Another favorite formula in Philadelphia is that of Dr. Meigs, known as Meigs' Food: — 2 parts cream. 1 pait milk. 2 parts lime water. 3 parts su^ar water. The sugar water is prepared by putting eighteen tablespoonfuls milk sugar to a pint of water. Dr. Louis Starr gives a very useful dietary for infants, which has also met with great success. 158 OBSTETRICAL NURSING. Those formulae which especially concern the obstetric nurse are as follows : — Diet for first week : — Cream 2 teaspoonfuls Whey,* . . 3 teaspoonfuls Water (hot), 3 teaspoonfuls Milk sugar, }{ teaspoonful for each portion ; to be given every two hours, from 5 a. m. to 11 p. m., and in some cases once or twice at night, amounting to twelve fluid ounces of food per day. Diet from the second to the sixth week : — Milk, I tablespoonful Cream, 2 teaspoonfuls Milk sugar, % teaspoonful Water, 2 tablespoon fuls for one portion, to be given every two hours, from 5 a. m. to 11 p. m., amounting to seventeen fluid ounces of food per day. The proportion of milk in the mixture and the quantity given at one time are carefully increased during the succeeding weeks. un-^offood The temperature of the food should be 99 Fahr. It is a great mistake to make it too hot. The * Whey is made by adding three teaspoonfuls of wine of pepsine to a quart of warm, fresh milk, and placing the mixture near the fire for two hours. The curd is removed by straining through muslin. CARE OF THE NEW-BORN INFANT. I 59 warming of the child's food should be accomplished by setting the filled nursing bottle into a vessel of hot water. It may be heated quickly over a gas jet by setting the bottle into a tin mug filled with ■ water and holding it over the flame. Suggestions concerning the modification of food, when milk thus Artificial prepared does not agree with infants, will be given '„ ppf e S m ent in another chapter. When the mother's supply of£ i £ mher ' s milk is scanty, and the baby cries with hunger, oc- casional meals of the above preparations will be a great aid in its management. In the artificial feeding; of infants in the Woman's sterilization r of milk. Hospital, sterilized milk is used for the various pre- parations employed, as a rule. By sterilizing milk is meant the process of de- stroying any poisonous matter which may have found its way into it. Exposure to the atmosphere and admixture with particles of dust and dirt during its transportation, with want of care as to cleanliness of vessels, etc., in which the milk is kept, induce certain fermentative changes, which cause it to sour and to produce digestive disturbances. Steriliza- tion destroys the germ of poisonous matter by sub- jecting the milk to a high degree of heat under pressure. Many forms of apparatus have been Apparatu^ devised for this purpose. The one in use at the tion - Woman's Hospital is called Blair's Sterilizing i6o OBSTETRICAL NURSING. Apparatus.* It is very similar in general construc- tion to the one devised by Dr. Louis Starr and shown in the cut. This consists of an oblong case Into this a movable of tin fitted with a tight cover Fig. 21. Sterilizer (Dr. Louis Starr).f wire basket, holding ten bottles, is placed. The bottles are of flint glass, graduated and fitted with rubber corks having a glass plug fitted into an * Arnold's steam sterilizer has also been employed more recently with very satisfactory result. By this arrangement the milk is steamed instead of boiled. f " Hygiene of the Nursery." CARE OF THE NEW-BORN INFANT. l6l opening in their centres. The rules for using the Rules for .... r sterilizing sterilizing apparatus are as follows : — milk. ist. Cleanse the bottles thoroughly. 2d. Fill each with the milk you wish to use, put in the rubber cork without the glass plug (this leaves a small opening in the rubber cork) ; set the bottle in the basket, then in the boiler ; fill the boiler with water almost as high as the milk in the bottle ; boil about ten minutes, or, better, as Dr. Starr expresses it, " until the expansion that pre- cedes boiling has taken place in the milk ;" then put the glass plugs tightly in each stopper and boil for fifteen or twenty minutes more. Should the rubber corks incline to come out during the second boiling, put them in firmly. 3d. Keep in a cool place till needed for use. 4th. When to be used, place a bottle of the milk thus prepared in the tin mug which accompanies the apparatus. Pour hot water in the mug until it is as high as the milk in the bottle. Heat the milk to the temperature desired for feeding (99 ° Fahr.) ; remove the rubber cork and put on rubber nipple, and feed. 5th. Cleanse each bottle immediately after the milk in it is used. Do not keep milk in a bottle that has had some used out of it. 6th. If the steaming process is preferred, place the basket, without the bottles, in the boiler, fill 11 1 62 OBSTETRICAL NURSING. Length of time sterilized milk will keep. Conveni- ence when traveling. Nursing bottles and rubber nipples. with water up to but not above the bottom of the basket, place the bottles in the basket, and proceed as before. Milk should be sterilized as soon as possible after it has been served each morning. Each bottle, when emptied, should be thoroughly washed. If the whole contents of the bottle are not used after it is opened, the remainder must not be used for the child nor allowed to remain in the bottle. Milk sterilized in this way will keep for days without spoiling, as it is hermetically sealed and has been deprived of all unhealthy germs. Dr. Louis Starr makes the assertion that it will keep for eighteen days if the heating is continued for thirty minutes. Sterilized milk is useful when traveling, as it may be carried without any trouble, the difficulty ol obtaining fresh milk being thus overcome. Its use makes the management of babies during the heat of summer much easier. A word remains to be said concerning feeding bottles and rubber nipples. The bottle should be of clear glass, with a rounded bottom, of a shape convenient to clean, so that no particles may cling about corners which cannot be reached, serving as a source of trouble afterward. The graduated bottle is very nice, as it enables the quantity of each of the materials used CARE OF THE NEW-BORN INFANT. 163 in the preparation of the feeding to be mixed directly in the bottle, instead of being first measured out in a graduate. Feeding-bottles with India-rubber tubes are very Fig. 22. Graduated Nursing Bottle (Dr. Louis Starr), objectionable, for the tubes are difficult to keep clean, and a drop or two of milk left behind will often be sufficient to turn the next supply sour, 164 OBSTETRICAL NURSING. causing the infant much sickness and suffering. Nurses are prone, also, with these tubes, to place the baby in its crib with the bottle of milk by its side and the nipple in its mouth. The heat of the child's body tends to sour the milk, the liquid may run low, and the child suck in considerable air. The neck of the bottle should always be kept filled with the liquid while the child is nursing, hence the position of the bottle must be changed. A feeding-bottle fitted with a rubber nipple requires to be held in the nurse's hand during the feeding, and is, on that account, to be preferred. There should always be two nursing-bottles for each baby, one being kept under water or filled with a soda solution' while the other is in use. Immediately cleaning of a ft e r the meal the bottle should be cleaned, etc. nursing ' bottle. Scalding water should be used, and then the bottle filled or placed beneath a solution of bicarbonate of sodium — ordinary baking soda— a teaspoonful to the pint, until it is again needed, when the soda solution should be emptied out and the bottle thor- oughly rinsed with cold water. Some use salicyl- ate of sodium for the cleansing solution in prefer- ence to the bicarbonate. Two nipples should be in use at the same time, being used alternately, and no nipple should be used longer than two weeks. A soft rubber nipple of conical shape is the best, because it can be more Rubber nipples. CARE OF THE NEW-BORN INFANT. 1 65 readily cleaned. The black rubber is generally softer than the white, and is to be preferred. The opening at the top of the nipple should not be too large, as that would permit the milk to flow through, when the suction produced by the child's mouth is necessary to the food being taken in a natural man- c1 ner. So soon as the meal is over, the nipple should oi be removed from the bottle, brushed with a stiff brush, wet with cold water on the outside, then turned inside out and similarly brushed on its inner Fig. 23. eansing rubb< nipple. Rubber Nipple (Starr). surface. It should then be put in cold water and allowed to stand until wanted. A nurse's sense of smell should be keen enough to enable her to detect the slightest sourness about a bottle or nipple. The baby should be fed slowly — taking often ten Tim ? , J J ■■ o required to twenty minutes for its meal. Sucking from an for feedin s- empty bottle should never be permitted. Pre . It is a bad plan to make the whole day's supply^*"™ 1 66 OBSTETRICAL NURSING. of food in the morning, unless the facilities for keeping it are such as to insure against its spoiling. When a sterilized preparation is used, it is desirable to have the whole amount prepared at once in a number of small flasks, each containing the amount for one feeding. The sterilization of the quantity of milk to be used during the day may all, however, be accom- plished at one time. improvised In lieu of the regular sterilizing apparatus, milk a P e pLratul may be similarly boiled in a water-bath formed by any ordinary boiler, the milk being contained in a glass fruit-jar with a screw lid. After coming to the boiling-point, or boiling about two minutes without the lid, the latter may be screwed on and the boiling continued. A better way is to put the jar in a colander placed over a steaming tea-kettle in place of the lid. The milk should be allowed to boil in the open jar for about two minutes ; the jar lid then being screwed down, it should steam for twenty minutes. Free Besides good food and sufficient warmth, babies need an abundant supply of fresh air, hence the room should be kept pure and wholesome. The daily In fine weather, after the first three or four weeks, a baby should be carried out in the open air every day for a time. . It is preferable to carry the child in the arms, airing. CARE OF THE NEW-BORN INFANT. 1 67 rather than to place it in a baby-coach. It can thus be kept warmer, and any evidence of chilling will be sooner detected by the appearance of the baby's face. CHAPTER XII. MANAGEMENT OF THE LYING-IN. Rest. Immediately after the delivery it is necessary that the patient should have rest. The room should be kept exceedingly quiet and the shades drawn down so as to subdue the light. Light sleep. The patient may be allowed to sleep, but the nurse, during this time, should watch her very carefully, as there is a liability to bleeding when the sleep is too deep, owing to the general relaxa- tion induced by sleep. She should draw the bed- clothes up at one side from time to time, to see how much blood is lost. There should be no unpleasant smell about a confinement room, plenty of fresh air should be allowed to enter, and all discharges should be at once removed from the room. While the patient sleeps, and after the child has received proper attention, the nurse should place the soiled sheets, towels, and all articles stained with blood in cold water to soak. The afterbirth, also, should be disposed of. If 1 68 Absence of odor. Attention to soiled clothing. Care of afterbirth Duties of nurse as MANAGEMENT OF THE LYING-IN. 1 69 in the country, it should be buried in a hole dug in the yard, two or more feet deep. It should never be thrown down a water-closet or privy. In the city it is best to burn it at night. It may be put in the range or stove and well covered up with coals. Clots of blood may safely go down the water-closet, as they readily dissolve. To return to the soiled clothing left after a con- finement — though a trained nurse will not often be^ffhuig called upon to attend to the washing of these articles, there will be times when it would be better that she should do so, both to save the patient expense and trouble and to prevent their lying about too long. At any rate, she should know how it should be done. Should the clothing be put to soak before the blood has dried into it, and allowed to remain for a few hours, the water being changed as often as needed, the washing will not be difficult. As a rule, it is not best that a nurse should leave her patient or the baby long enough to attend to this wash, hence it is advisable to have it put out or done by some one else in the house. The soaking ought, however, always to be attended to by the nurse, because it facilitates the subsequent washing. In the after-care of the patient the nurse should attend to the washing of the mother's and baby's 170 OBSTETRICAL NURSING. Visitors. Puerperal mania. Food of lying-in patient. Dietary of the lying-in. napkins. She should, if needed, wash the baby's flannels and slips. For a week a newly-confined patient should see no visitors. Even the husband should not remain in the room long at a time. No painful or exciting news should be communicated to the patient, as a distressing form of mental trouble to which lying- in women are prone may be thus induced. This is known as " puerperal mania/' After the patient rouses from her first sleep she is generally hungry. The nurse should have learned from the physician before he left what he would prefer her having. A cup of warm milk or tea — not too hot — may be given directly after the confinement when ether has not been taken, and this followed in three or four hours by a light meal, as toast and tea or gruel. With regard to the diet of the lying-in, nurses must be prepared to follow the rules of the physicians for whom they work. Some physicians allow considerable variety in the food from the beginning. The following directions concerning the diet are given to the nurses of the Woman's Hospital : <4 It should be remembered in the diet of the lying-in woman, that the amount of liquids must be limited, not only until after the secretion of milk, but also until the supply of milk adapts itself to the MANAGEMENT OF THE LYING-IN. I/I demand, for the first five or six days after the confinement. As soon as the patient is made comfortable after the birth, she should have a cup of warm milk or weak tea or warm water and milk. First meal time : Plate of milk toast or bowl of oat- meal gruel, or saucer of wheat germ or boiled rice. Second meal : Cup of weak tea or warm milk, dry toast, or milk toast, or water toast, or soda crackers soaked in hot milk. Third meal: Saucer of oatmeal mush^or wheaten grits, with a cup of tea or warm milk, with Graham biscuit or dry toast. Forenoon, afternoon, bedtime : Lunch, a cup of warm milk, with a piece of dried bread or zwie- back. Second Day. — The same as above. Third Day. — The same, with the addition of stewed apples or baked apples for supper. Fourth Day. — Breakfast: Soft-boiled egg f dried bread, stewed fruit, and cup of milk or weak tea. Dinner : Plain beef or mutton-broth, dried bread, and farina or junket. Supper : Baked apples or stewed prunes, saucer of wheat germ and zwieback. Fifth Day. — Breakfast : Cup of weak coffee or cocoa, mutton-chop, oatmeal mush, dried bread, and a sweet orange or ripe apple. 172 OBSTETRICAL NURSING. Dinner : Beef or mutton-broth or oyster-stew, baked potato, stewed tomatoes, dried bread, farina, junket, or rice. Supper : Stewed fruit, Indian-meal mush, and zwie- back. Sixth Day. — Ordinary plain diet, avoiding salads, sour fruit, fried or highly-seasoned meats, fancy desserts, or sweets of any kind." * This holds good of all subsequent meals. The above dietary will require to be modified when special indications arise. Should the patient's tem- perature rise to ioo° Fahr., or above, she should be kept on liquid diet, as milk and beef-tea alter- nately every two hours. As liquids favor the secretion of milk, liquid food should constitute a large proportion of the nourish- ment taken by nursing women throughout the lying-in, provided there is not a tendency to over- secretion. The diet should be plentiful and nutri- tious, but selected carefully with reference to its digestibility. As the patient must remain inactive for some time, it will not do for her to eat the starchy vegetables, pastry, or warm breads, for all these require very active powers of digestion. A nurse should thoroughly understand the art of cooking, and be able to provide her patient with * Dr. Anna E. Broomall. MANAGEMENT OF THE LYING-IN. 1 73 palatable and nutritious dishes, daintily and prettily served on a tray, until, with the physician's consent, she takes her place at the family table. Even then a nursing woman will need to receive some nour- ishment, as gruel, beef-tea, milk etc., between the regular meals, for she must not only .provide for herself but her child. The lying-in lasts six weeks. During this time Duration of J fe m ^ lying-in. the organs of generation are returning so far as possible to their former condition. It is important that the patient should have rest, and for at least £enttobed two weeks of this time should be in bed. The process of changes by which the womb shrinks to its normal size is known as" involution." t ion/° u ~ This process is favored by the patient lying as much as possible on her back, so that the womb does not incline too much to one side or the other. The patient may be carefully propped up a little by pillows on the third or fourth day so that she shall be in a semi-reclining position. This facilitates the drainage of the uterus. Care must be taken not to permit her to move herself too much, as a hemor- rhage may be thus started. The discharges of the mother continue about two « Lochia." weeks, and they are called the " lochia." For the first twenty-four hours they are blood ; the second and third day, watery blood ; from the fourth to the sixth day they have a greenish-yellow coloration, 174 OBSTETRICAL NURSING. and from the tenth to the twelfth day they become white. This white discharge may continue for a long time after the confinement. The character of the discharge will indicate the process of involution, hence the physician should see daily the napkins or dressings removed from the patient. Soiled napkins and dressings should never be kept in the patient's room, but in some closed vessel, as a clean chamber or a slop jar, with a close-fitting lid, in another room. The existence of the least odor about the discharge should at once be brought to changes of the physician's attention. If napkins are used, they napkins and L J x ' J dressings. w ju ne ed to be changed during the first day about every two hours, sometimes oftener, the second and third day about every three hours, the fourth and fifth day every four hours, until, by the tenth day, about three changes are sufficient. The anti- septic dressings are changed, as a rule, every three hours until the discharge ceases. If it be very scant, a change once in six hours may be sufficient. These antiseptic dressings should be burned. The napkins should be soaked in cold water until the blood is well out of them, and then thoroughly washed and boiled. The boiling is sufficient, if properly done, to render them aseptic, but, as an additional precaution, they may be wrung out in oYn^pklns a 1-2000 bichloride solution before drying. The dressings, patient should be washed off each time the napkin MANAGEMENT OF THE LYING-IN. 1 75 is changed with a warm antiseptic solution, as 1-4000 of the bichloride of mercury. Care should Cleansing .of patient. be taken not to irritate the parts. Instead of -using a soft cloth to wash off the parts, the water may be poured in a small stream over them, and a soft, dry cloth pressed gently over them to remove all mois- ture. Especial care should be taken where there are stitches not to pull upon them in any way. One daily washing of the entire body is, as a rule, Bathing, desirable. The doctor's advice, however, should be asked concerning the matter. This wash, when given as a sponge-bath, need not exhaust the patient, nor cause too much movement of her body. The patient should never feel chilly during this bath ; should she do so, the bath must at once be stopped. The bath should, of course, be given under cover. The increased activity of the skin neces- sitates especial cleanliness, and the daily bath is found, when properly given, to be very refreshing. Frequent changes of bed and body clothing, too, are necessary — the body clothing, if possible, daily until the discharges cease. The bladder is frequently paralyzed after confine- The ment, as a result of the pressure to which it has been subjected during the birth. When it is filled beyond a certain limit, it may respond to the irrita- tion and a little urine be voided, but the bladder not be emptied. The nurse can tell by the amount I76 OBSTETRICAL NURSING. passed whether the patient has probably emptied the bladder or not. The secretion of urine early in the lying-in is very free, hence the quantity passed should never be scant. By placing the hand over the lower part of the abdomen, the bladder may be felt as a soft tumor on one or the other side, above the pubic bone, the womb being felt as a harder mass pushed to the opposite side. Use of The catheter should not be used without the catheter. physician's sanction, but a nurse should never forget to ask very particularly about this matter before he leaves the house after the delivery. It is generally undesirable to allow a patient to go longer than six hours without freely emptying the bladder. As over-distention of the bladder prevents proper con- tractions of the womb, and as a relaxed womb is a frequent cause of after-pains, it is best to have the bladder quite frequently emptied during the first twenty-four hours. Hence, if the catheter is per- mitted to be employed, it may be well to use it about three hours after delivery for the first time (the physician having used it, if necessary, immedi- ately after delivery). Its subsequent use should be limited to about once in six hours, unless its more frequent use is demanded by the interference with the contractions of the womb caused by over distention of the bladder. The patient should be encouraged to make a trial to urinate as soon as MANAGEMENT OF THE LYING-IN. 1/7 possible, so that the use of the catheter may be en- tirely dispensed with. Great care is necessary in Precautions .in use of the use of the catheter: ist, to see that the instru- catheter] ment is thoroughly clean and kept clean ; 2d, to see that none of the vaginal discharges are carried into the bladder during its introduction ; 3d, to do no injury to the mother's parts or give her needless pain. The instrument, or silver catheter, should be thoroughly boiled if there is any doubt about its being aseptic. When withdrawing it the outer extremity should be kept lowered, so that all the urine remaining may flow out from it, and no sedi- ment settle in the closed end to become a source of contamination at some future time. It should then be thoroughly washed in hot water, which should be allowed to flow through it from the inner toward the outer extremity, carrying out any sediment from the urine, and it may be. kept during the intervals of its use in an antiseptic solution — a two per cent. solution of creoline or carbolic acid. To prevent the carrying of the vaginal discharges into the urethra the parts should be carefully washed off with an antiseptic solution, either by irrigation or by means of a soft cloth, before the insertion of the catheter. The index finger of the nurse's right hand (which Method ot should each time be thoroughly cleansed in an catheter. 12 178 OBSTETRICAL NURSING. antiseptic solution) should be slipped into the vagina as far as the second joint, and made to follow the anterior vaginal wall down in the median line to the vaginal entrance, when a little elevation of the surface will be felt, immediately above which the orifice of the urethra is to be found. If the finger be held with its palmar surface upward and resting lightly upon this elevation, the finger being held horizontally, a catheter * slipped along it will enter the small orifice of the urethra. Should the extremity of the catheter seem to meet with any obstruction after its entrance into the urethra, a slight withdrawal and rotation of the instrument will generally carry it in. The use of the catheter need not involve the slightest exposure of the patient. A cultivated touch will enable a nurse to do better than by sight in its use. Hence, it may all be done under cover. SSm in F° r ^ e ^ rst twenty-four to forty-eight hours after delivery, particularly if the labor has been a difficult one, there is a considerable swelling of the parts, which offers a mechanical hindrance both to voluntary urination and the passage of the catheter. Great gentleness is therefore required in the neces- sary manipulations. This swelling in an ordinary case should disappear at the end of twenty-four to * Glass catheter. urination from oedema. tion. MANAGEMENT OF THE LYING-IN. 1 79 forty-eight hours. Should the inability to urinate persist after this, it is in all probability due to the condition of paralysis before referred to. Especial medication by the physician, as the use of muscle and nerve tonics, fomentation over the lower part of the abdomen and external generative organs, hot water in a bed-pan, placed beneath the patient's hips, may serve to stimulate voluntary urination. The attempt to induce this should be made each time before a resort to the catheter, as the constant use of the latter will only keep up the difficulty. As a rule, there is no movement of the bowels Constipa- for the first three days, constipation being due to paralysis of the bowels caused by the pressure of the gravid womb upon the bowels. Regulation of the food will do much to correct this habit, as a laxative diet composed mainly of brown bread, oat- meal gruel, prunes, etc. An occasional enema of warm soapsuds may be needed, or from a tea- spoonful to a tablespoonful of glycerine may be injected into the lower bowel, or a glycerine or gluten suppository be given. If these means do not suffice, some medication may be needed. The laxative chosen by the physician will depend upon {^r the condition of the breasts, as well as its liability to affect the milk. Should the breasts be over-distended, a saline laxative will be preferred. Thus, two teaspoonfuls ce of laxative. l8o OBSTETRICAL NURSING. of Rochelle salts in a half-tumblerful of cold water may be given, an additional tumblerful of pure water being taken after it. Sulphate of magnesia or Epsom salts may be used in the same way, or a teaspoonful of cream of tartar may be taken night and morning in a cup of sweetened water. When the secretion of milk is scanty, a vegetable laxative is to be preferred, as rhubarb, aloes, or cascara sagrada. Enema of At times there is such impaction of the contents oil. L of the lower bowel that an oil injection will be needed. A gill of cotton-seed oil may be intro- duced into the lower bowel and retained for three or four hours, after which a small soap and water injection will lead to a thorough evacuation of the bowel. Care of The care of the nipples and breasts is very nipples and . xr i • i i breasts. important. It this matter has received proper atten- tion during the pregnancy, there will be compara- tively little trouble during the lying-in. It is important to keep the nipples clean. Milk should not be allowed to collect about them, hence imme- diately after nursing, while they are swollen and soft, they should be washed ; a soft piece of linen maybe used and cold water or a saturated solution of boracic acid, after which they may be dried with a soft cloth. This should be repeated after every nursing. MANAGEMENT OF THE LYING-IN. l8l If the skin of the nipple be unusually thin, it is Use of best to avoid having the baby pull directly upon shield. the nipple until the milk flows freely, hence a nipple shield should be used, at least for the first two or three days, if not longer. Should the nipple become sore at any time, the f^^ll^ 1011 nipple shield should again be resorted to and used ni PP les - until the sore is healed. Some application, as a ten per cent, solution of tannic acid in tincture of myrrh, balsam of Peru, or a weak solution of nitrate of silver, according to the order of the physician, may be painted with a camel's-hair brush over the cracks in the nipple while it is soft and swollen, immediately after nursing.* For any nipple shield to work perfectly it mustQ ual £ iesof fit tightly, hence an entire rubber shield is not so shield - good as some others. Some shields are made of part metal and part rubber, others part rubber and part glass. The cheapest are the ordinary glass shields with rubber nipples. These cost about fifteen cents and are quite as good as those that are higher priced. A shield is not good if it allows the nipple to be drawn out too far. In the intervals of nursing the * It is better at night, when the applications cannot be kept con- stantly renewed, to anoint the nipples with a little borated cold cream after cleansing. This helps to prevent cracking. 182 OBSTETRICAL NURSING. Nipple protectors. rubber nipple should be kept in cold water after having been turned inside out and thoroughly cleaned with a brush. Nipple protectors are worn only in the intervals of nursing, or during pregnancy, for shaping the nipple.* These may be made of lead, glass, or Fig. 24. Nipple Shield. wood. Leaden protectors keep the nipples soft in the intervals of nursing, and have a healing effect upon the abrasions and cracks of a tender nipple. Unless care be taken, however, to cleanse the nipple thoroughly before the, baby nurses, there is danger of lead-poisoning. Nipple protectors of glass and wood, being open at the top, are intended more to keep the clothing of the patient off the tender * See Fig. 6, page 43. MANAGEMENT OF THE LYING-IN. 183 nipple.* The nipple may, in addition, be kept moist in the intervals of nursing by the application over it of a piece of absorbent cotton saturated with a mixture of one part glycerine to two parts water. Nipples vary much in shape — thus they may be Variation in shape of nipples. Fig. 25. Cone-shaped. Hollow. Mushroom-shaped. Depressed. cone-shaped, hollow, mushroom-shaped, and de- pressed. The cone-shaped nipple is the best, as it can becone- readily seized by the child's mouth, and the pres-ni PP ie. sure of the baby lips does not constrict the nipple * There is a form of nipple protector made of glass which also acts as a reservoir to catch the overflow of milk in cases where it flows involuntarily from the nipple. This is very nice in preventing the constant wetting of the patient's clothing. 1 84 OBSTETRICAL NURSING. at its base, so as to prevent the free escape of milk from the mouths of the milk ducts which open at Mushroom- the top of the nipple. The mushroom-shaped shaped a x x i nipple. Fig Figure-of-eight of One Breast. Hollow- nipple. nipple has so narrow a base that the free flow of milk may be thus prevented. The hollow nipple is apt to get sore from two causes: first, by the forcible suction made by the child in emptying the breast ; second, by the accu- MANAGEMENT OF THE LYING-IN. 185 mulation of milk in the depressed portion of the apex. The depressed nipple differs from the last class Depressed 1 A nipple. in the fact that there is no elevation of the nipple Fig. 27. Figure-of-eight of Both Breasts. above the surface of the breast, but where the nipple should be there is a corresponding depression. Very little may be done for such a nipple, and all 1 86 OBSTETRICAL NURSING. Bandaging of breasts. efforts to make a nipple by drawing it out must generally be abandoned, as they simply irritate the tender skin. It is best when nipples of this class exist to abandon the idea of nursing the child, and prevent the accumulation of milk in the breasts by bandag- ing. This should also be done where there is a previous history of breast abscess — the breast Fig. 28. Garrigues' Breast Bandages. affected being thus bandaged to prevent the attempt at secretion by the gland. The firmest bandage is the figure-of-eight of the breasts, which maybe applied to one or both of the breasts according to need. If it cannot be used, the wide, straight bandage, similar to an abdominal bandage, may be employed, or the straight bandage with straps to fasten it over the shoulders, accord- ing to the pattern used by Dr. Garrigues, of New MANAGEMENT OF THE LYING-IN. 1 87 York. Were the milk permitted to accumulate in the breast, and there be no ready outlet for it, " caked breast " would be apt to ensue. By " caked breast" is meant a collection of milk^'Caked J breast. in one or the other part of the breast, due to block- ing up of a milk-duct. The indications for its relief are to empty the breast. The milk may be drawn out by a baby if there be a proper nipple, or by the use of the breast-pump. The breast may be gently rubbed with warm oil^g t ingof and stroked from the base toward the nipple to aid in carrying the milk toward the mouths of the milk ducts. Camphor liniment is sometimes used as an inunction, alone or combined with laudanum, but unless it is the intention to help to dry up the milk, camphor should be avoided. The use of fomentations before rubbing greatly ^°™ enta " helps to soften up the breast. By fomentations is meant the application of flannels wrung out in hot water, constantly changed as they cool. These applications should be continued for fifteen to twenty minutes at a time. After their use if the baby be put to the breast or the breast-pump be used, "the milk will generally flow quite freely. Those breast-pumps are the best which depend Breast 11 L pumps. for suction on the power of the mouth. The Phoenix breast-pump is the one generally preferred. They maybe used by the nurse, or a patient may i88 OBSTETRICAL NURSING. use such a pump herself should a nurse not be present. Hand pumps are not good, as too much force is apt to be used in making suction — the nip- ple may thus be torn off. Where a breast-pump cannot be had, a simple contrivance may be resorted to for emptying the breasts which is often very effective. A bottle filled with very hot water may be emptied of its contents, and while still hot the Fig. 29. Breast Pump. mouth of the bottle closely applied over the nipple. As the bottle cools the nipple is drawn up into the neck of the bottle, and the flow of milk induced. When the breasts are pendulous, handkerchief bondage of bandages, properly applied, make a good support. Their application is as follows : " The base of the handkerchief, folded as a triangle, should be placed obliquely across the chest and under one breast, Handker- chief MANAGEMENT OF THE LYING-IN. 189 with the apex or summit of the triangle over the corresponding shoulder ; one angle is carried over the opposite shoulder, the other under the axilla, or armpit, of the same side. These ends should be Fig. 30. / 1 Handkerchief Bandage for Breast tied on the back of the shoulder, and the apex of the triangle pinned to them." — (Smith.) Should both breasts need support, a similar ban- dage may be applied to the other breast. To pre- 190 OBSTETRICAL NURSING. Modifica- tion of handker- chief bandage of breast. Straight bandage of breast. Double Y bandage. vent the base of one or both of these bandages from slipping up, the ordinary handkerchief bandage has been modified in the Woman's Hospital by the addition of a belt around the waist, of a strip of muslin or ordinary roller bandage, to which the base of the bandage may be fastened by safety-pins. A simple straight bandage, with a compress to lift the outer, pendulous portion of each breast, is sometimes used. Another bandage, which has the advantage of not requiring to be removed when the baby nurses, is the double-Y bandage, used in the Boston Lying- in Hospital. The manner of putting it on is thus described by Dr. Worcester : " A single T bandage is first made by folding a napkin lengthwise so that for an average-sized patient it shall be 32 in. long by 3 in. wide. At the middle of this, and at. right angles to it, is pinned, just between its folds, a nap- kin of the same size, similarly folded. This T ban- dage is next made into a Y bandage, by making a diagonal fold in the middle of the cross-piece and fastening the corners of the plait with safety-pins on the outside. The bandage is now ready to put on. The tail-piece is passed under the woman's back, snug up to her armpits, so that the fork of the Y just clears one nipple when that breast is held upward and inward on the chest. The tail-piece on the other side is carried up on the chest directly MANAGEMENT OF THE LYING-IN. I 9 I over the breast. The arms of the Y are then brought over the chest, one above and the other Fig. 31. Worcester's Y Bandage. The upper figure shows the double Y breast bandage in position ; the lower left-hand figure shows how the Y bandage is made. The third figure shows how the double Y bandage is completed by fasten- ing the arms of the Y to the tail-piece on the patient's opposite side. below the breasts, and their ends pinned to the tail- piece, so as to hold both breasts in similar posi- tion. A compress of soft linen may be placed 192 OBSTETRICAL NURSING. between the bandage and the outside of the breasts and also between the breasts, to prevent their chaf- ing. To keep the bandage from slipping down straps of muslin may be passed over the shoulders and pinned back and front. To keep it from slip- ping up, it may be fastened to the abdominal bandage." The bandages referred to are very use- ful while the patient is in bed, but when she begins to sit up and wear ordinary clothing they will be Fig. 32. Obstetrical Breast Support, with Knitted Bosoms. found to be cumbersome. Some such breast sup- port as is shown in Fig. 32 may then be found very useful. It may be obtained at the Dress Reform Emporium, in Philadelphia, and at similar agencies in other cities. Gathered There is nothing in the care of a lying-in patient breasfs. > ° . for which a nurse receives more blame than in the occurrence of gathered breasts. Abscesses will sometimes come, however, in spite of all precau- tions, even before confinement. Extreme watchful- MANAGEMENT OF THE LYING-IN. 1 93 ness and a prompt reporting of any symptoms of beginning trouble, as chilliness, hardness of the breasts, sore nipples, etc., will do much to avert them. It must never be forgotten that sore nipples, Septic & rr ' inflamm by offering an open surface upon the mother's body, £° e n a °f may become avenues of septic infection. Dirty hands or dirty garments touching these surfaces or poison from the baby's mouth may thus enter the mother's system. One of the most serious forms of inflammation of the breast may thus result from blood-poisoning. If the breast has once gathered, there will be a tendency for it to gather again. Should an abscess threaten by beginning inflamma- tion of the breast, the treatment will, of course, be directed by the physician. What milk is in the breast must be drawn out, and some means used to prevent further secretion. Belladonna breast plas- ters were atone time much used, the circular breast plasters being obtained at any drug store. The belladonna ointment spread on patent lint, shaped to the breast, is preferred by some physicians. Simple compression of the breast by a firm bandage is generally sufficient, without the aid of other measures, in the checking of the secretion Should the breast gather, lancing is inevitable, and the sooner the better, so that a nurse should keep the physician carefully informed as to the condition of the breast. Flaxseed poultices may 13 194 OBSTETRICAL NURSING. need to be applied for a time, both before and after lancing. These poultices, to do any good, should be applied as hot as possible. The nurse can test the heat of the poultice by laying her cheek against it. If she can bear this application without finding it too hot, the patient will also probably be able to bear it. If the poultice be made on flannel it will not lose its heat as quickly as when made on muslin. The poultices will require changing about once in two hours, or often enough to keep them warm ; and should be kept up until the abscesses point and are evacuated. The nurse should encourage the patient to have an abscess lanced, and should have prepared, at the time of the operation, the antiseptic solutions preferred for the physician's hands and for washing out the abscess cavity, a syringe, if possible, a pus-pan having a concave side to fit closely under the breast, some charpie (linen threads arranged in bundles, for packing abscess cavities), soft towels, and some absorbent cotton to be used in place of sponges for cleansing the breast. Before the operation, the breast should be washed off with an antiseptic solution. Between the appli- cations of the different poultices the breast should be similarly washed off by the nurse. The physician will probably desire to wash out the abscess cavity daily so long as the discharge of pus continues, in which case the nurse should have MANAGEMENT OF THE LYING-IN. 1 95 everything in readiness at the time of his expected visit. Sometimes milk runs constantly from the breasts. Constant J now of milk, Much may be done to prevent this by regular nursing. If it persists, the amount of liquid in the food should be restriced. Sometimes the milk runs from the opposite breast while the baby is nursing at one. There is no way to prevent this. Some mothers collect it as it drops in a small bottle or cup and feed it to the baby. If the mother has only sufficient milk for half insufficient the day, the baby had better be artificially fed by day, the breast milk being reserved for the night, as giving less trouble when the care of the child devolves upon her. After-pains are the same as labor-pains, being After-pains, caused by contractions of the womb. They are called after-pains because they occur after confine- ment. A woman, after the birth of her first baby, seldom has after-pains. They may occur with vary- ing severity in women who have previously borne children. If the bladder and the bowels are properly attended to, and the womb kept well contracted, the patient is not likely to suffer much from after-pains. These pains seldom last over the second day. Should they do so, it is probable that the patient is threatened with some inflammation. I96 OBSTETRICAL NURSING. The occurrence of after-pains should, of course, be at once reported to the doctor, and such meas- ures for relief carried out as he may suggest. The womb will be found to be in two entirely different conditions with the occurrence of these pains. Hence, we divide the pains into two classes, the " expulsive" and the " spasmodic," or " neu- ralgic." si^ X " ul " With expulsive after-pains the womb, as it is felt S?S!T through the abdominal walls, will be found to be large and soft, and the patient will often pass clots. The bladder will be frequently found to be over-full and the womb pushed high up or to one side. The indications are to empty the bladder and to secure good contractions of the womb. After the bladder is emptied the pain may be relieved by the applica- tion of a hot poultice over the lower part of the abdomen, and simple fluid extract of ergot may be given, if desired by the physician (j4 teaspoonful every three hours), until the womb is well contracted. A nurse should never give any medicine without the direction of the physician. Before entire relief is obtained it may be necessary for the physician to injecttons!" 6 break down and wash out the clots within the womb. The nurse should slip drawers and stockings on the patient in preparation for this operation, as she may need to lie across the bed with her hips drawn MANAGEMENT OF THE LYING-IN. 1 97 to its edge. A bed-pan, syringe, antiseptic solu- tions, receptacle for waste water, and rubber pro- tective for bed and floor should be prepared. When spasmodic after-pains occur, the womb is Spasmodic 1 after-pains. felt in the lower part of the abdomen as a firm, round ball of stony hardness. This is caused by a spasm of the muscle fibres in the womb. The remedies which would help expulsive pains would only aggravate this condition. Something must be employed which will quickly relax the spasm. The most efficient agent is_ chloroform liniment, which may be applied on flannel over the lower part of the abdomen. The active counter-irritation thus produced will give relief. Should the spasm be very severe, the physician may apply pure chloro- form sprinkled on blotting-paper, for a few seconds, over the lower part of the abdomen until it well reddens the skin. Should no chloroform liniment be at hand, a warm flaxseed poultice may help to some extent, though not so efficient, as a rule. A careful report should be kept by the nurse, The report. from which the physician can learn all that has transpired in the intervals of his visits. Sheets of paper ruled and having headings, as in the following plan, are used in the Woman's Hos- pital. 198 OBSTETRICAL NURSING. I 5 S ° S OS S w OS •JLNHWHAOIM iHM-oa 'HNIHa H z w < « H Q < u s w a • Q •JSHH • •JIM3X •asina •haoh ■3iva S MANAGEMENT OF THE LYING-IN. 1 99 The occurrence of pain, any complaint of chilli- Special ness or a decided chill, rise of temperature, rapid to be r reported. pulse, sleeplessness, headache, want of appetite, etc., should be carefully noted and brought to the physi- cian's attention. For the first week or ten days it is well to take the temperature and pulse in the morning, at noon, and in the evening ; after which, if the patient is doing well, the morning and evening temperature and pulse will be sufficient. Should the slightest complaint of chilliness beChiii. made, the nurse should place extra covers around the patient, hot-water bottles, if necessary, to warm her up, and at the same time give her a warm drink, as a cup of hot tea or even hot water. The temperature should always be taken after a Rise f complaint of chilliness, and taken quite frequently, tur^ 6 ™" as every hour or two, when, if it be found to be rising, a note should at once be sent to the physician, who may want, under the circumstances, to see the patient at once or institute some new line of treatment. Pain may be temporarily relieved by Pains. the application of a hot flaxseed poultice. Grave in- flammatory and septic troubles are ushered in by such symptoms as the above, hence no time should be lost in notifying the physician of their oc- currence. The use of blisters, poultices, packs, vaginal in- ^ve!? 6 ™ 1 200 OBSTETRICAL NURSING. jections, and medicinal remedies required in the treatment of the various forms of " puerperal fever " must, of course, be in exact accordance with the physician's directions. Such troubles are generally septic, that is, arise from blood-poisoning; and one very important duty of the nurse will be to see that the patient takes sufficient nourishment to combat the poison in the blood. Stimulants should never be given without a physician's advice, but when ordered great care should be exercised in their faithful administration. Egg-nog, milk-punch, whisky-punch, wine-whey, milk in the various liquid and semi-liquid prepara- tions, beef-tea, broths, etc., will be called for. The nurse should be ready with devices to tempt her patient to eat, and thus give the most important aid to the arrest of the disease. The support of the strength, with extreme cleanliness and thorough antisepsis, will do much to arrest the course of the terrible maladies due to blood-poisoning. Puerperal The existence of any sores about the vulva or vagina, when discovered by the nurse, should at once be reported to the doctor. These are espe- cially dangerous when they take on a grayish sur- face, as this indicates that they have already become infected by poison. If the disease is not arrested here, the whole system may be involved. ulcers. MANAGEMENT OF THE LYING-IN. 201 A swelling of one or both legs sometimes comes Milk leg. on after delivery. It is ushered in by acute pain and lines of redness accompanying the swelling — the vessels of the groin, under the knee, or in the leg will often feel like cords. This is due to an in- flammation involving the veins. Sometimes blood clots form in the veins, which may be dislodged and carried to the heart and lungs, when they are the source of the gravest danger. Sometimes abscesses form in the leg. The great danger of clots being carried in the blood current makes absolute quiet imperative. The patient should lie flat on her back, and the limb be elevated on pillows or on an in- clined plane, such as the fracture-box used in certain fractures of the lower extremity. The application of some soothing ointment, as iodine and belladonna ointment in equal parts, over the cord-like veins, a hot flaxseed poultice being kept over the ointment, will help to relieve pain and diminish inflammation. The whole limb should be kept warm by a wrapping of cotton batting. The limb is most comfortable when slightly bent at the knee joint. Should the weight of the bed-clothing cause pain a cradle may be made of barrel hoops for lifting them off the limb. The cradle is also very useful in cases of peritonitis when the same difficulty exists. Lying-in women should not be subject to bed- Bed _ sore! 202 OBSTETRICAL NURSING. sores, but should some complication occur, as in some form of blood-poisoning, or should some other disease attack the patient during this time, necessitating long lying, special care is necessary to prevent bedsores. The parts of the body sub- jected to most pressure should be kept thoroughly dry and rubbed with alcohol and alum (a saturated solution) once or twice daily. A little cosmoline may then be rubbed into the skin, or some drying powder, as zinc or starch, may be used. When a sore occurs it must be dressed, according to the physician's order, with zinc ointment or cosmoline. All pressure should be kept off it, if possible, by the adjustment of pads and pillows or a rubber-ring cushion. man r ia eral Puerperal mania is a form of mental trouble which may affect lying-in patients, particularly when they are exhausted from any cause, whether it be mental worry or physical ill-health. In true mania the patient may be violent and very difficult to control. In the melancholic type of this trouble she is exceedingly depressed, distrusts her best friends, and cannot be roused to take an interest in her surroundings. Removal As soon as it is noticed that the patient's mind is of infant. A not well balanced the baby should be removed from the room, only being brought to the mother when asked for. The nurse should then keep a MANAGEMENT OF THE LYING-IN. 203 close watch over it, as one of the chief symptoms of this trouble is a strong aversion to the baby and desire to destroy it. It should never be forgotten that an insane pa- importance x ofwatcn- tient should not be left alone for a moment. The fulness - insane are very cunning, and though apparently asleep, may be but watching their opportunity to indulge in some mad freak, as jumping out of the window, dashing down the stairway and out of the doors, etc. The windows, therefore, should be in some way protected. A nail or screw may be driven into the window-casing so as to prevent the raising of the sash, except so far as ventilation re- quires. The door had best be kept locked, the nurse keeping the key. The treatment will mainly consist in keeping up Treatment. the nourishment and in kind, gentle, tactful man- agement. The patient should be made to interest herself in outside things, by the judicious turn given to the conversation by the nurse, by engage- ment in some kind of fancy-work, or in games which will help to divert the mind. She should not be crossed, neither should she be deceived. The nurse should so manage her as to inspire a thorough confidence and liking toward her on the part of the patient. If she has not these, she had best give' up the case, as she will not be able to help the patient. 204 OBSTETRICAL NURSING. Forced, or Should the patient absolutely refuse to eat, the artificial ... -. . . feeding. physician may direct the nurse to introduce the food into the stomach by means of a rubber tube passed through the nostril and down the oesopha- gus, or gullet. Care should be taken to do no injury in the introduction of this tube, which should be well greased with cosmoline and made to follow closely the direction of the passages it is made to enter. A funnel is then connected with the outer extremity, through which the milk or broth, etc., may be poured into the stomach. Securing of Should the patient be exceedingly restless and patient. disposed to jump out of bed, to her own detriment, she may be fastened into the bed by means of a sheet, doubled lengthwise, placed over the middle portion of the body from the arm-pits to below the knees and carried under the bed, to be fastened either beneath the bed or to one side of it. The feet may be bound together loosely at the ankles by a piece of roller bandage and fastened to the footboard of the bed. The hands may be bandaged together (being placed the one on top of the other) by means of a roller bandage, though this is not necessary except when they are used to do herself Trans- iniury. Where patients are so violent as to need ference to J J x an institu- suc h restriction, however, it is better to have them tion for the ' 7 insane. removed to some institution for the insane as soon as possible, where there is better provision made MANAGEMENT OF THE LYING-IN. 205 for their management. The use of sedative reme- dies by the physician will generally prevent the necessity for resorting to such extreme measures for confining the patient in ordinary cases. Medicines should, of course, never be left in the -P rotection 7 from patient's room, even when the nurse is there, unless poisoning. under lock and key. The duration of this malady varies from weeks to months, in some cases be- coming chronic. Convalescence is generally very gradual. Patients may have long periods of lucid thought, and seem apparently well, only to unex- pectedly return to their vagaries ; so that the nurse should never relax her quiet vigilance while in charge of the case. The old time-honored belief that a woman should The first sitting-up sit up on the ninth day is subject to many excep-^^ er tions, which should be understood by the nurse as well as by the physician. The true gauge is the progress of involution. This may be determined by the height of the uterus (which ought to sink behind the pubic bone before the patient is allowed to sit up) and by the character of the discharges. So long as there is any blood in the discharges the patient should not sit up, for this is an indication that involution, or the shrinking of the womb, is not going on properly. This condition is known as " sub-involution," and if neglected may lead top^jj v °- chronic disease of the womb. The use of the re- 2o6 OBSTETRICAL NURSING. cumbent or semi-recumbent posture, frequent hot injections given by the nurse, or electricity admin- istered by the physician, may be necessary to over- come it. Let the patient understand the wisdom of her confinement to bed under such circum- stances, and she will generally yield gracefully to the necessity. The first sitting-up should be in bed, the patient's back being supported by a bed- rest. Should no bed-rest be found in the house, a chair turned upside down, with its back toward the patient, over which a pillow is placed, offers a very good substitute. After sitting up in bed for a day or two, from a half-hour to an hour if there be no discharge, the patient may have her flannel wrapper and stockings and bedroom slippers put on, and be allowed to sit up in an easy chair. It must be remembered that this is the time when the patient will be most susceptible to cold, therefore every precaution must be taken to prevent her exposure to draughts. Should the patient seem to grow tired before the half-hour or hour is up, she should be put back in bed. The interval for sitting up may be gradually increased from day to day, until she is up the greater part of the day. No going up and down stairs should be permitted until the physician sanc- tions it, which is, in ordinary cases, about the fifth, MANAGEMENT OF THE LYING-IN. 207 or sixth week, when one such journey a day is generally permitted. That there may be no misunderstanding between observance J ° ofphysi- physician and nurse, the orders of the physician cjan'^ in every case should be immediately set down in writing when given, so that by constant reference to them the nurse may do her full duty by the patient. It is well, for this purpose, to have a piece of paper ruled so that at the right side there shall be two columns, one headed A.M., the other P.M. The stated hours for the administration of medicine or carrying out of treatment may then be placed opposite the special directions for each, and a pencil mark be drawn through the figure representing the hour when the matter has been attended to. An order board, as used in the Woman's Hos-°^ r e d r # pital, is prepared as follows : — Orders for Treatment of Mrs. Richards, Oct. 10, 1889. Full breakfast, dinner, and supper, . . „ A teaspoonful of medicine (light or dark), Sponge bath, Lunch of gruel or beef-tea, Glass of milk at bedtime, To sit up half an hour with bed-rest, . . A.M. 6 6.30 10 9 P.M. 12, 6 I2.3O, 6.3O 3 8 Nurse's Name- 208 OBSTETRICAL NURSING. A fresh board should be prepared for each day's work. In ordinary cases, which run an uneventful course, these boards, with the hours crossed off, serve the purpose of a report as well. CHAPTER XIII. CHARACTERISTICS OF INFANCY IN HEALTH AND DISEASE. A healthy baby, if born at full term, should w l\ghft{ weight 3250 grammes, or about seven pounds. ItSbaTy. 01 length should be, on an average, 50 cm., or twenty Average inches. The head and trunk of the child are developed ^is of de- out of proportion to the limbs, so that the navel is velopment - below the middle of the child's body. This greater development of the upper part of the body is due to the fact that in the womb this portion of the child's body receives the greater amount of nour- ishment. The subsequent growth consists largely in the development of the lower limbs. The skin of a new-born baby varies in color from skin. a pink to a decided red. The redness is more marked in premature babies. From the third to the fourth day this redness disappears, and the peculiar yellowish tinge, known as " baby jaun-!^^ e „ dice," appears, as a result of the changes in the circulation. This is not true jaundice. This yel- lowish tinge of the skin should disappear by the H • 209 2IO OBSTETRICAL NURSING. The form. Shape of head. Effect of pressure. Sutures. end of the second week. At the same time that the skin begins to change color, from the third to the fourth day, it begins to scale or peel off. This is most noticeable about the fifth day, and lasts about sixteen days. The baby's limbs should be plump and well- rounded. The abdomen is prominent, as compared with the chest. The shape of the head varies very much. At times it is perfectly rounded, again it will be elon- gated and oval-shaped. Pressure during labor, either from the walls of the pelvis or as a result of the use of instruments, will cause at times considerable temporary distor- tion in the shape of the head. To allay swelling and prevent discoloration induced by bruising, fomentations may be used, either of simple hot water or hot water containing a little fluid extract of hamamelis. When there has been a good deal of pressure on the baby's head during the birth, the bones will sometimes override each other, and this will be shown by elevations or ridges upon the baby's head, which soon disappear when the head is no longer subjected to pressure. These ridges, which are converted into soft grooves on the removal of pressure, indicate the separation between the dif- ferent bones of the head, and are called " sutures." FEATURES OF INFANCY IN HEALTH AND DISEASE. 211 The larger soft places are called " fontanelles." The Fontanels, largest is on top of the head just above the fore- head. It is called the " anterior fontanelle," com- monly known as "the opening of the head." It is about large enough for the tips of two fingers to cover, when of normal size, and is kite-shaped. A much smaller three-cornered fontanelle is found at the back of the head and two behind the ears. These very soon fill up with bone. The large anterior opening does not close entirely closure of until a child is about eighteen months of age. fonuneUe. Should it remain open longer, it is a sign of con- stitutional weakness. In a healthy baby the sur- face of this fontanelle should be on a level with the surrounding bones of the skull. A slight pulsation Pulsation of & & JT fontanelle. may be noticed in it, due to the pulsation of the blood vessels in the brain. Should the fontanelle be much depressed at any time, it would indicate a ^ epression low state of vitality. Care should be taken not tb fontanelle - permit any undue pressure on this part of the baby's Avoidance head, as the brain here lies very near the surface. ° pre The fashion some old monthly nurses have of trying to shape the head by the pressure of the hands is dangerous, as the brain may be thus injured. As the head bones are soft, the child should not be allowed to lie too continuously on either side or on the back, as this will cause flatten- ing of the part pressed upon. 212 OBSTETRICAL NURSING. Changes in weight. Average daily gain, Loss and gain. For the first two days of a baby's life it loses weight, but by the third day it begins to gain, and by the end of the first week it should weigh what it did at birth. The average daily gain is 30 grammes, about 1 oz. The following facts con- cerning the early changes in weight are obtained from Gregory : — An infant born at full term weighs from 6 to 7 pounds, 7 pounds being an average weight. For the first two or three days of life there is a loss of 4 ounces to 7 ounces, then a regular gain, so that by the eighth to the ninth day the initial loss has been made good. The following figures express the average daily loss and gain during the first six days of life : — First day, . Second day, Third day, Fourth day, Fifth day, Sixth day, Loss of 139 grammes, or nearly 5 ounces. " 64 " " 2j^ounces. Gain of 33 " about I ounce. " 50 " " i^founces. " 50 " " I jounces. " 36 " " 1 jounces. The child's weight should be doubled in the fifth month, and trebled in the twelfth month. The baby should be able to hold up its head in the sixteenth week, at the same time sitting up. It should stand by the thirty-eighth week. It should " take notice" and be able to grasp things by the third to the fourth month. FEATURES OF INFANCY IN HEALTH AND DISEASE. 2 1 3 It is important that a nurse should know the above facts as to the child's development, to be able to report satisfactorily concerning its condition to the physician in attendance. A large proportion of the time of early infancy Sleep> is spent in sleep. The more premature the baby, the more constantly does it sleep. During sleep the eyelids should be tightly closed. A partial separation of the lids, showing the whites of the eyes, is an indication either of some disease, or of pain, from whatever cause. The respirations of a healthy baby when awake Respira- , ..... tions. may be very irregular, some inspirations being shallow and others deep — at times hurried, and again slow. The only time when the respirations can be satisfactorily counted is when the child is asleep, for then the breathing is more regular. The rise and fall of the abdomen may then be noted (for the breathing of an infant is abdominal). The number of respirations in a minute average 44. So quiet is the healthy breathing of early infancy that there is no motion of the nostrils or of the lips, or even of the chest, to indicate the incoming and out- going; of air. Fever, colic, and lung trouble will b fe ' ' & Increase in greatly increase the number of respirations in a respirations. minute, making them mount up to 60 or 80, or even higher. Nervous excitement has a similar effect, though this is temporary. 214 OBSTETRICAL NURSING. Slowing of respirations. Painful breathing. ; Cyanosis. Infantile pulse. Tempera- ture Sub-normal tempera- ture. In brain trouble, a slowing of the respirations occurs, so that they may get down to 8 in a minute. When the act of breathing is painful a moan or cry accompanies each act of respiration. The expan- sion of the nostrils with each inspiration indicates a want of sufficient air space in the lungs. In con- nection with any lung trouble a bluish coloration of the lips and face generally is a bad symptom, as it indicates that sufficient air does not enter the lungs to purify the blood. Little reliance is to be placed upon the pulse of a baby as indicative of disease, for it is characteris- tic of the infantile pulse that it is very rapid, very easily affected by external or internal causes, and notably irregular. The average pulse of the new- born baby is 140. If a baby is well-nourished, it is too fat to enable the pulse in the radial artery to be counted. Hence the pulse is more easily obtained in the temple or at the ankle. If not thus readily obtained, the heart beats may be counted by holding the hand over the baby's heart. The temperature of a child of this age is also subject to rapid changes, the result of slight causes. The average temperature is 99 ° Fahr., but a cold or an attack of indigestion may cause a sudden increase, with as sudden a return to normal when the cause is removed. A sub-normal temperature is an indication of FEATURES OF INFANCY IN HEALTH AND DISEASE. 21 5 lowered vitality, the result of some drain upon the system, as of an exhaustive diarrhoea, or of some constitutional weakness. This fall of tem- perature is a dangerous symptom in infants. The tip of the nose and the extremities of the child, if Symptoms 1 of lowered cold, also indicate a condition of low vitality, and vitality. require that the child should receive very especial care from the nurse as to the supply of food and warmth. In fever the back of a child's head feels very hot, as also do the palms of the hands. The cries of a child form a special language by which The its needs may be made known. Every nurse a a c?y. age( should learn to distinguish the peculiarity in the different kinds of cries, so as to meet the varying demands thus indicated. A healthy, well-trained baby rarely cries, unless hungry, when the cry will of hunger. be constant and very persistent until the want is satisfied ; the upper part of the body is moved at the same time, especially the arms and head. The cry induced by ear-ache is also unappeasable, and Ear-ache. generally accompanied by a drawing of the hand up to the head. A similar gesture accompanies the cry induced by brain trouble, which is a shrill Brain trouble. scream, often waking the child during sleep. A cry accompanying a cough is an indication of ^| le pain in the chest. The paroxysmal character of colic is indicated by the characteristic cry which colic. accompanies it — a sharp, sudden cry — the limbs at 2l6 OBSTETRICAL NURSING. the same time being drawn up toward the abdomen. An evacuation of the bowels may precede or follow the cry. Sore mouth. If, in nursing, a baby seizes the nipple by the mouth and drops it suddenly with a cry, doing this repeatedly, there is in all probability some soreness of the mouth, which should be discovered and Secretion of treated. However heartrending the cry, the baby tears. does not secrete tears until the third month of in- fancy. Hence the common saying, that a baby cannot suffer pain because it sheds no tears while crying, is not supported by fact. Facial A wrinkling of the forehead vertically, produced expression. ,,.-'•■ ■, i • i • by drawing the eyebrows together, indicates pam about the head. A sharpening or play of the nos- trils exists in lung troubles. A drawn look about the mouth is found with digestive troubles, as flatu- movelnents ^ en ^ c °li c - The stools of a very young baby fed on breast milk should be of a yellow or orange color. Three or four evacuations a day are natural. They should contain no curds. Stools of bottle- fed babies are lighter and more offensive. The Urination, number of times a new-born baby urinates will vary much with the weather and the conditions under which the child is placed. It is not unusual in cold weather for the napkin to need changing almost every hour. Healthy urine should not stain the napkin. FEATURES OF INFANCY IN HEALTH AND DISEASE. 2\J Mothers and nurses are often much troubled by Retention the failure of an infant to pass urine or faeces for and faeces. the first few hours or days of its life. A careful examination of the anus or external opening of the bowel will soon show whether there is any imper- imperforate J l anus or forate condition of the rectum, which may cause urethra - the retention of faeces. Closure of the urethra is so rare that retention of urine is very seldom seen. The new-born infant secretes but very little urine until it begins to take nourishment freely. The bladder is usually emptied during the process of birth, as also is very frequently the case with the bowels, so that if the child seems well and there is no malformation of the parts, the family may be assured that the condition is only temporary. The use of fomentations over the kidneys and bladder will frequently hasten the evacuation of urine if it be unduly delayed. If the secretion seems highly concentrated, as is shown by the brickdust deposit sometimes found on the baby's diaper, a drop of sweet spirits of nitre in a tea- spoonful of water may be given once in two hours. Should the child seem to suffer pain from the retention of the contents of the bowel, an ounce of warm water or olive oil injected into the rectum will usually produce a satisfactory evacuation. Should a laxative by the mouth be needed, the physician must be consulted. A teaspoonful of 218 OBSTETRICAL NURSING. Dentition. Early dentition. Symptoms accompany- ing dentition. Eruption of teeth. sweet oil often serves the purpose very nicely, or a few grains of manna dissolved in milk. The teeth sometimes appear prematurely. A child may be born with one or more teeth already cut. These are usually imperfect, and fall out in a short time, to be replaced by the milk-teeth. The latter are twenty in number and are usually cut in groups, starting about the fourth month and con- tinuing till between the twentieth and thirtieth months, when the first dentition should be com- plete. Girls are more apt to cut their teeth early than boys ; and, as an early dentition is usually an easy one, it is fortunate for the child to have it occur early. Even under normal conditions the edges of the gums in teething become swollen, rounded, and reddened as the teeth come near the surface. The saliva is at the same time increased in quantity, and the mouth is heated and uncomfortable, so that the child desires constantly to bite upon any object that may be at hand. A healthy child should not suffer in any way from the process of dentition, and when the point of the tooth comes through the gum the local symptoms may vanish. These are cut in groups, there being an interval of rest be- tween the eruption of each group. The following diagram will illustrate the order in which the teeth are cut. The numbers I to 5 FEATURES OF INFANCY IN HEALTH AND DISEASE. 219 show to how many groups the several teeth belong and the order in which the groups appear. The letters a and b show the order in which the teeth in each group appear. Bottle-fed babies are more apt to be late cutting J ate . . 1 <=> dentition. Fig. 33- or 4 2 a & 2 2 3_ 3 113 b & Diagram Showing Eruption of Milk Teeth.* 1. Between the fourth and seventh months. Pause of three to nine weeks. 2, 2, 2, 2. Between the eighth and tenth months. Pause of six to twelve weeks. 3, 3, 3, 3, 3, 3. Between the twelfth and fifteenth months. Pause until the eighteenth month. 4, 4, 4, 4. Between the eighteenth and twenty- fourth months. Pause of two to three months. 5, 5, 5, 5. Between the twentieth and thirtieth months. their teeth than those that are breast-fed. If no teeth have appeared when the child is a year old, we may know that the child's general nutrition * From Starr, " Diseases of the Digestive Organs in Infancy and Childhood." 220 OBSTETRICAL NURSING. is at fault, or it may have the disease known as rickets. demftilTn Bottle-fed babies are also apt to have their teeth come through the gum in irregular order. This frequently is an indication of lack of health, although sometimes it is a family peculiarity. Milk teeth. The first set of teeth which the child has is called the temporary set. It consists of twenty teeth, known as milk teeth. CHAPTER XIV. THE AILMENTS OF EARLY INFANCY. It is not proposed in this chapter to take up all Definition • r • of infancy. the ailments of infancy, for the term "infancy " comprises a time beginning with the birth of the child and lasting until the first dentition. The obstetric nurse remains with the patient from four to six or eight weeks. During this time many deviations from the normal, healthy state may be met with in the child, and these she should be quick to observe and know how to manage. One of the most important conditions of this p r period is "prematurity," a result of the too early birth of the child. A premature birth is one that occurs at any time after the child is "viable," that is, capable of living after its birth. The term of viability has been set viability. at twenty-eight weeks, or seven lunar months. Deliveries occurring previous to this time are called " miscarriages." It may be that with improved methods of man- agement, the period of viability may be placed at 221 rema- turity. 222 OBSTETRICAL NURSING. an earlier date, but this is as yet a matter for proof.* It has generally been conceded that a child born at six lunar months cannot live, that at seven months it stands little chance, that at eight months its chances are better, and at nine still better. The popular notion that an eight-month baby (counting the calendar months) does not stand as good a chance of living as a seven-month baby is altogether wrong. Great care is needed for prema- ture babies. They especially need regular feeding and to be kept very warm. The skin, being thin and delicate, will also require very careful attention. Until within a few years the matter of keeping the baby sufficiently warm was exceedingly difficult The to manage. The French invention of the " cou- "couveuse." veuse) " or " brooder," has simplified the matter very much. It was first used in some of the French lying-in hospitals in 1 88 1. Since then it has come into quite general use in France, being employed even in private houses. Many different forms of the apparatus now exist. Theone most commonly used in France is Tarnier's invention. This has been used for some time with great satisfaction in the Woman's Hospital, of Philadelphia. * The French claim that by means of gavage and the couveuse, or hatching-cradle, the actual period of viability has approached six months of intra-uterine life. THE AILMENTS OF EARLY INFANCY. 223 It consists of a wooden box, whose interior is divided into an upper and lower compartment. There is a space about four inches wide at one end of the upper compartment which communicates with the floor below. Here two or three large sponges on a wire stem are placed. The lid of the box at the. opposite end contains a chimney, in which a helix rests on a pivot. Fig. 34- Tarnier's Couveuse. The upper compartment of the box is intended for the baby ; in the lower end are several stone jars, which are to be kept filled with very hot water. At the end of the box furthest away from the open space which communicates with the chamber above, a register is fixed, which may be opened or closed at will. The air enters through the register, is 224 OBSTETRICAL NURSING. heated by passing over the hot stone jars, moistened by the wet sponges in the space between the upper and lower chambers, and finds its exit from the chimney, in which it keeps the little wheel revolv- ing. The motion of this wheel indicates whether the circulation of air within the couveuse is perfect or not. A thermometer fastened to one side of the interior of the box assists in the regulation of the temperature, which should be kept at from 85 ° to 95 Fahr., according to the indications in each case. A frame containing a pane of glass forms the top of the box. Through this the record of the temperature and the condition of the child can be watched.* The following directions for the use of the cou- veuse are given by Dr. Auvard, who superintended its introduction into the Maternite, at Paris : — Directions -p Q k ee p U p an even temperature, one of the stone jars should be refilled every hour, hour and a half, or two hours. The apparatus being more difficult to heat when it stands in a draught of air, it should be placed so as to avoid this. Should the temperature rise too high, the cover * Dimensions of couveuse for a single infant; Width, 36 cen- timetres; length, 65 centimetres; height, 55 centimetres. For twins, a larger case is necessary, which holds a correspondingly greater amount of hot water. THE AILMENTS OF EARLY INFANCY. 22 5 may be slipped down a little, so as to allow of the entrance of air from above, or the inferior register may be opened so as to admit a larger quantity of air. The partial closure of the register so as to admit less air would help to raise the temperature when it tends to fall below the desired point, as also would the addition of hotter water to the jars. The child should be placed in the upper com- partment of the couveuse as in its cradle, being removed simply for nursing, its bath, and toilette. When removed from the couveuse, care should be taken to have the temperature of the room suffi- ciently warm. Auvard sets this temperature at 61.2 . We should be inclined to require a higher temperature, as from yo° to 75 ° Fahr. The length of time the child remains in a cou- veuse will vary from fifteen days to thr.ee weeks, a month, or even more. It should not be removed permanently until it has acquired sufficient vigor to live in the ordinary atmosphere of the apartment. To accustom the child to this atmosphere, it should, as it grows stronger, be removed for an hour at a time from the couveuse during the warmest part of the day. It is best to continue the use of the apparatus at night for some time after the child becomes accus- tomed by day to removal from the couveuse, for 15 226 OBSTETRICAL NURSING. the danger of chilling from changes in the atmos- phere is greater at night. Auvard recommends the use of the couveuse in all cases where the vitality of the child is enfeebled either by external causes, as cold, or internal causes, as prematurity, congenital feebleness, cya- nosis, or " blue disease," wasting, or other general maladies enfeebling to the new-born. To overcome the difficulty in the management of this couveuse, owing to the necessity for the fre- quent removal of the hot water jars, Auvard has devised an improvement, which is shown in Figs. 31 and 32. A cylindrical reservoir of metal takes the place of the hot-water jars in the lower compartment of the couveuse. This reservoir is filled by means of a metallic funnel fastened to one end of the box and communicating with the cylinder through a metallic tube. The overflow of the cylinder is provided for by a curved metallic tube at the lower part of the cylin- der beneath the inlet through which the reservoir is filled. The air enters by a register on one side of the couveuse instead of at the end, as in Tarnier's apparatus. The other portions of the apparatus are the same as Tarnier's. THE AILMENTS OF EARLY INFANCY. 227 The metallic cylinder is capable of holding ten litres of liquid (a litre is a little over a quart). To start the apparatus, about five litres of boiling water should be poured in, after which three litres may be poured in every four hours. When ten Fig. 35. Auvard's Couveuse (Interior View).* litres are contained in the cylinder, the overflow- pipe carries off the excess. Auvard suggests having two vessels, capable of holding three litres each, keeping one under the escape-pipe and the * Archives de Tocologie. 228 OBSTETRICAL NURSING. other over the fire, reheating the water in the ves- sel filled by the escape-pipe and having it in readi- ness for the next change. The two vessels may be thus used alternately, and but little time con- sumed in the heating of the apparatus as compared with that required in the use of Tarnier's invention. Fig. 36. c§> Auvard's Couveuse (Exterior View). To empty the cylinder, a rubber tube is attached to the escape-pipes, by which it is made to act as a siphon — a small quantity of water poured into the cylinder through the funnel being sufficient to start the liquid. THE AILMENTS OF EARLY INFANCY. 229 Before the couveuse was known premature Cotton , . . - , swaddling. babies were swaddled in cotton, in order to be kept sufficiently warm. The directions for doing this are as follows : — Take a square baby-blanket and place it diagon- ally on the table or bed. Turn down one corner for four inches distance, to come up over the baby's head. Spread over this blanket a lap of raw cotton. Have the baby's napkin and binder Fig. 37. Swaddled Baby. on and a flannel undervest. Make a cap out of the cotton, fitting it over the baby's head and bringing it down well under the chin. Then roll the baby up in the cotton lap. Bring the blanket around this firmly, so as to hold it; the portion of the blanket on the baby's right being brought over and tucked in on the left side, the portion on the left being correspondingly folded over toward the right. The corner of the blanket left at the feet is 23O OBSTETRICAL NURSING. then folded up over the front, and the whole held in place by means of a strip of muslin bandage or ribbon. The bandage is first applied beneath the chin, crossed under the back, again crossed in front, the ends being brought forward to fasten in a bow- knot at the feet. The great disadvantages of this method may be seen in the restriction it gives to the movements of the child's limbs and the difficulty of determining when the child's napkin needs changing, also the frequent exposure of the child during these changes to the ordinary atmosphere. An ingenious method of maintaining the body- heat of a baby, and one readily accomplished in any household, is described as follows by Dr. Rey- nolds : — "A large basket should be thickly lined with heated blankets or other flannels. A number of bottles, filled with very hot water, should be so arranged around the sides of the receptacle that they can be removed and reinserted without dis- turbance of the infant. The child is wholly covered, with the exception of its face, with well-warmed cotton-batting, and is laid between the bottles ; and the cradle is then covered with a thick blanket, a space at the end which corresponds to the child's head being left open to permit the entrance of air. A thermometer should be laid beside the child ; THE AILMENTS OF EARLY INFANCY. 23 I and one or more of the bottles should be refilled with hot water whenever the temperature is seen to fall below 8y° F. J he water should not, on the other hand, be so hot as to raise the temperature of the contained air much above 90 F." If the baby be .very weak, it may be necessary to stimulate it for two or three days by giving it a drop or two of brandy, with or without a drop of aromatic spirit of ammonia, in a teaspoonful of warm water once in two hours. The length of time a premature baby should be kept in its close quarters is dependent upon the progress it makes, or until the gain in weight and strength brings it up to the standard of a baby at full term. A seven-months child, if strong enough, may be dressed when it is four weeks old and allowed to nurse. Great care, however, must continue to be exercised until the child reaches full term. The skin of a premature baby should be well protection greased after every bath, or some oil, as cotton or ° sweet oil, may be used, and will serve the double purpose of protecting the skin and giving nourish- ment by absorption. The child should be fed every hour. As it is Food. usually too weak to suck, it is safer to feed the baby with a spoon or with a dropper, to make sure 232 OBSTETRICAL NURSING. of its obtaining a sufficient amount of food. From one to two teaspoonfuls should be given every hour. Breast milk is, of course, the best. It may be drawn from the mother's breast and fed to the child while warm. The nurse should introduce her little finger into the child's mouth and allow the milk to trickle slowly down the finger, so as to enter the mouth drop by drop, while the child sucks the finger. Should the mother have no milk, the first week's feeding recommended by Dr. Starr, or sterilized peptonized milk diluted two thirds with boiled and filtered water, should be used — if no wet-nurse can be had as a substitute. Should the baby drink badly and throw up a Gavage. large proportion of the liquid given to it, " gavage " may have to be resorted to. The physician must authorize the nurse to carry this out, for she should never undertake it otherwise. The directions for practicing gavage, as given by Dr. Louis Starr, are as follows : — The apparatus used is quite simple, being nothing more than a urethral catheter of red rubber (No. 14-16, French), at the open end of which a small glass funnel is adjusted. The infant upon whom gavage is to be practiced is placed on the knee, with its head slightly raised ; the catheter, being wet, is introduced as far as the base of the tongue, THE AILMENTS OF EARLY INFANCY. 233 whence, by the instinctive efforts at swallowing, it is carried as far down as the oesophagus (or gullet) and into the stomach. The liquid food is next poured into the funnel, and by its weight soon finds its way into the stomach. After a few seconds the catheter must be removed, and here is the great point in the opera- tion ; it must be removed with a rapid motion and at once, for if it be withdrawn slowly all the food introduced will be vomited. Mother's milk is the best for gavage, as at any time, but other kinds of food may be used. The amount given and the number of meals will vary w r ith the age and strength of the child. From a teaspoonful to a dessertspoonful at one time is sufficient for a very young child, given every hour. Too much food would produce indigestion. As the child grows stronger this mode of feeding may be made to alternate with nursing. Diluted steril- ized milk peptonized may be used for the alternate feedings. Colic is a very troublesome affection of infancy. Colic. It corresponds to the dyspepsia of grown people, and indicates that the food is either improper in quality or quantity. A colicky cry is a sudden, sharp cry, the baby drawing up its feet and legs at the same time. The feet are generally cold, and one indication for treatment is to w T arm them ; 234 OBSTETRICAL NURSING. Spice plaster. warm socks or woolen stockings should be worn, or hot bottles applied to them. Counter- The abdomen should also be kept warm by the irritation g x J and warmth, application of heated flannels, or a spice poultice, wrung out in hot whisky, or a flaxseed poultice, and kept applied until the baby gets relief. To make a spice plaster, a teaspoonful each of ground allspice, cloves, cinnamon, ginger, and cay- enne pepper, with four teaspoonfuls of flaxseed meal, may be quilted into a bag of flannel, 4x8 inches, which will fit entirely over the baby's abdo- men. When the spicy smell is lost the plaster is no longer good for use. Warm oil rubbed gently in over the abdomen for ten to fifteen minutes at a time, will often give relief by leading to the expulsion of the wind causing the pain. If the application of heat is not sufficient, anise- seed tea should be given. It is made as follows : — Over a half-teaspoonful of anise-seed pour a half- teacupful of boiling water. Allow it to steep a few minutes, until the water tastes strongly of the anise-seed. A half-teaspoonful of this may be given warm every ten minutes until the baby has had four doses. This brings up wind from the stomach, and thus gives relief. Simple hot water will help in the same way should anise-seed not be on hand. Catnip tea may be made and used accord- on inunction. Anise seed tea. THE AILMENTS OF EARLY INFANCY. 235 ing to the same directions. These teas are preferred to the drop doses of gin so frequently given. Frequent stools do not always indicate diarrhoea. Frequent . . . stools. For the first six weeks of its life a child averages three or four movements every twenty-four hours, after which it has about two a day until it is two years old. A natural passage for an infant would be of a mushy consistency and a yellow or orange color. It should contain no curds. Bottle-fed babies have whiter and more offensive stools than breast-fed babies. In diarrhoea there is a change in consistence or appearance. A liquid stool, or one colored green or white or like putty would be abnormal. The presence of curds also would show an inability to digest the food properly. If, therefore, these curds exist in the stools, or the ^ Iodif j c r a - ' ' > tion 01 iood. matters vomited be curdy, the indication would be to use some alkali or a small quantity of some thickening substance, as barley-water, gelatine, or one of the prepared foods intended to serve the same purpose, or the milk may be peptonized. Lime-water is the alkali most usually employed. Lime-water Lime-water contains but about half a grain of lime to the fluidounce of water, so that at least a third of the feeding should be lime-water where it is used to correct indigestion. To make lime-water apiece 236 OBSTETRICAL NURSING. of lime about the size of the fist should be placed in an earthen vessel ; about three or four quarts of water may be poured over this, strained thoroughly, and then allowed to settle. The water should be used only from the top of the vessel. It is better to filter it before use. The vessel may be kept filled with water so long as any of the lime remains in it, when it will be necessary to add more lime. When lime-water cannot be obtained, a small powder of baking soda — three or four grains — may be added to the nursing-bottle. These rules apply when the baby is artificially fed. Should the baby be nursing the breast a teaspoonful of lime-water mixed with an equal quantity of boiled and filtered water may be given it before each time it is put to the breast. Of the thickening substances used to help in the digestion of food, barley-water is one of the best. wafeT To make barley-water a gill of boiling water should be poured over a teaspoonful of washed pearl bar- ley, freely ground in a coffee-mill and boiled for a quarter of an hour, then strained. It should be mixed with milk in the proportions required, two- thirds, a half, or one-third. Gelatine. Gelatine is sometimes used instead of barley- water. A piece an inch square of plate gelatine is put into a half tumblerful of cold water and allowed to stand about three hours. This mav then be THE AILMENTS OF EARLY INFANCY. 237 turned into a teacup and set in a pan of hot water and boiled. The gelatine thus dissolves, and when allowed to cool, forms a jelly, of which one or two teaspoonfuls may be added to a feeding. Of the various kinds of ''infants' food," those inj" fen j 8 \, 7 ' foods. which the starch has been made into dextrine or grape sugar are the best. " Mellin's Food" and " Horlick's Food " belong to this class. A tea- spoonful of these dissolved in a little hot water — about a tablespoonful — may be added to the milk for the feeding. These starch foods cannot be well borne by a child before it is five or six months old, as a rule.* Condensed milk contains a large proportion of Condensed sugar, hence tends to make fat. It is not as nour- ishing as many other forms of food. Babies fed on it, though large, are generally far from strong, and are very apt to suffer from indigestion. A careful regulation of the diet, as suggested by Dr. Broom- sill's Dr. Anna Broomall, for the early weeks of infancy, dietary. with the addition of barley-water, lime-water, or gelatine, as indicated, in place of plain water, has been found most satisfactory in the care of infants in the Woman's Hospital. The use of water alone * The prepared foods are not to be recommended, notwithstanding their efficacy in certain cases. Made by the quantity — their com- position is of necessity often uncertain, and they must frequently be stale as obtained for use. 238 OBSTETRICAL NURSING. as a diluent is preferred. When curds are per- sistently found in the stools, it is sometimes of advantage to slightly thicken the milk by the addition of a little prepared wheat flour, barley, oat-meal, or Graham flour. In using wheat the following recipe may be employed : Tie a pint of dry wheat flour into a piece of stout muslin and boil nine hours ; scrape off the outer crust and the inside will be found to be a dry ball ; grate this as needed and add about two teaspoonfuls to a pint of water, which when boiled may be used in diluting the child's milk in the proportion desired, instead of using plain water. After the sixth month, four teaspoonfuls may be used in place of two. Dr. J. Lewis Smith recom- mends allowing the flour, tightly tied up in a bag, to stand under water for about a week, the water being allowed occasionally to boil during this time. The flour is thus rendered more digestible. Ground barley, oatmeal, or Graham flour may similarly be boiled in water in the proportion of a dessertspoonful to the pint. An equal quantity of milk may be poured in while the water is boiling, and the whole may be boiled together from about twenty minutes to a half-hour and then strained. An ounce of cream and a little milk sugar may be added to this. Dr. Keating recommends this preparation as excellent for an infant after its THE AILMENTS OF EARLY INFANCY. 239 fourth month, when he considers that it is best to make the use of the bottle alternate with the breast in the feeding of an infant, especially if the mother is not very strong. If she has substituted the bottle for some of the Weaning. feedings as early as at the age of six months, the child will not suffer from the process of weaning. In fact, a child often weans itself, refusing to take the breast milk during the later months. When the child is very weak and vomits con- Substitutes ' for stantly — milk, especially, seeming to disagree with miik-foods. it — some of the following measures may be resorted to : small and repeated quantities of barley-water, gum-arabic water, or wine-whey may be used, a teaspoonful every half-hour or hour ; sometimes the white of an egg may be shaken up in a bottle of warm w T ater and a couple of grains of lactopeptine or Fairchild's liquor pancreaticus may be added, with a little milk sugar, and this may be given the child in teaspoonful doses ; as the child's stomach grows stronger, teaspoonful doses of peptonized milk may be tolerated. No child should be fed too continuously on the prepared foods alone. Fresh milk should be used whenever possible, as a disease known as scurvy often arises from long use of stale scurvy, preparations. An occasional drink of water is essential to a baby, however young. The water should be boiled 24O OBSTETRICAL NURSING. and kept air-tight to be free from germs. From a teaspoonful to a tablespoonful may be given occa- sionally during the intervals of nursing. Infants under four months of age should be fed upon milk alone in some of its forms. Miik-foods. When breast milk cannot be had and cows' milk seems to disagree, some of the " milk foods," as Carnrick's Soluble Food, Anglo-Swiss, Gerber's, or American Swiss, may be tried. Care must be taken to see that the preparations are fresh before using. Farinaceous The farinaceous foods, as Blair's Wheat, Hubbell's foods. . ' ' Wheat, Imperial Granum, and the home-made pre- parations before described, should not be used until the child is at least four months old. If in the use of the latter the child's bowels become constipated or it suffers from colic or is restless at night and loses its appetite, some of the Liebig Liebig foods may be tried, as Mellin's, Malted Milk, Lactated Food, etc. The directions for the use of these foods come with the various packages con- taining them and are readily. followed. Milk, as a rule, in some form or other, should be used in making up these preparations, otherwise they will not contain sufficient nourishment. Period of A mother, although healthy, should not nurse nursing. ° J her child longer than for one year, as her milk does not contain sufficient nourishment. tion. THE AILMENTS OF EARLY INFANCY. 24 1 Constipation is not an infrequent occurrence in Constipa- infancy. Its management consists principally in the use of mechanical irritants for stimulating the bowels ; thus, a soap suppository, an injection of warm oil or water, gentle friction over the bowel, especially following the direction of the large bowel from right to left, are among the most effective methods for overcoming this condition. The soap suppository is made by taking a piece of Castile soap, about one inch long, and shaping it into a cone and making it very smooth, so that it will not be larger around than the end of the little finger. This should be gently insinuated about half its length into the bowel and held in the opening until it excites the bowel to act. The bowel injection may be given by means of the single-bulb syringe, known as the " eye and ear syringe/' The bulb holds about two table- spoonfuls of liquid. This may be warm cotton-seed oil, sweet oil, or warm water. The nozzle used should be small, smooth, and well oiled. It should be very carefully introduced into the bowel, being directed a little to the left side, and the bulb gently squeezed to force the contents into the bowel. It is best that the liquid should be retained for a little time before it is forced out. The keeping up of a slight pressure over the entrance to the bowel for a short time will aid this. 16 242 OBSTETRICAL NURSING. Rubbing the abdomen for about ten minutes (either with or without oil) in the direction of the large bowel — that is, upward on the right side as far as the border of the ribs, then across to the left side and down this side to the pelvis, is often effi- cient in overcoming constipation. Fig. 38. Single-bulb Syringe "(Starr). Of medicinal measures, glycerine, gluten, or cacao-butter suppositories may be resorted to, or manna may be given, a piece the size of a pea in the child's milk one, two, or three times a day, or a spoonful of water sweetened with dark-brown sugar. THE AILMENTS OF EARLY INFANCY. 243 Should the child be on artificial food, oatmeal-water may be substituted for barley-water in the prepara- tion of the food. Babies vomit very easily, because their stomachs vomiting. are placed more vertically in the body than when they grow older, and over-feeding will cause them to bring up the amount in excess of what the stomach can hold. This vomiting is, of course, not serious. Should the vomited matter be sour and curdy, the child seem to suffer from nausea, weak- ness, or fever, it indicates a condition of indigestion which should receive attention. The management would largely consist in the regulation of the quality and the quantity of the food, as has just been said. Thrush is a disease due to want of care of the Thrush. baby's mouth. If milk be allowed to collect on the tongue, it sours, and the presence of this acid favors the development of thrush, which is really a vegetable parasite. White patches may be seen on the soft palate, inside the cheeks, lips, and tongue. The attempt to rub off these patches causes bleed- ing. Gastric catarrh and diarrhoea usually accom- pany this trouble. Care in cleansing the child's mouth after each nursing will prevent the occur- rence of thrush. Its treatment consists in the use of an alkaline wash, as borax and water (twenty 244 OBSTETRICAL NURSING. grains to the ounce), or some antiseptic wash pre- scribed by the physician.* "Red gum." " Red gum " is an eruption which comes out over the baby in the first or second week of its life. Sometimes these little points of elevation on the "u^i h,i ' te s ^ m are white. The eruption is then called " white gum." These eruptions are due to changes in the skin and irritation from exposure to air, and are not serious. They rarely last over a week. Blisters. The occurrence of little blisters on the child's body, especially on the palms of the hands and soles of the feet, is a matter of more moment and should at once be brought to the attention of the physi- cian, as also should sores around the finger nails. These indicate a condition of the blood for which the use of remedies prescribed by the physician will be necessary. rhaa?-the Sometimes a whitish, glairy discharge comes whites." f rom the privates of little girl babies. This is sim- ply the matter found there at birth. Occasionally a little blood may be mixed with it, the result of an abrasion in the vagina, and may last a day or two. The nurse need not be afraid to remove this matter ; in fact, if left, it causes irritation of the skin. Urine. A healthy baby usually wets its napkin very fre- * Boracic acid (ten grains to the ounce of water) is very good. A teaspoonful of this may be swallowed by the child occasionally. THE AILMENTS OF EARLY INFANCY. 245 quently — It may be, every hour during the day, and four or five times at night. Sometimes several hours may pass and yet the napkin remain dry. Either of these conditions may exist in health, being dependent largely upon the weather, the food, etc. If urine is not passed for twelve hours, the condition should be reported. The nurse may try to make the baby urinate by using fomentations over the bladder and kidneys before reporting the matter to the physician. The skin of new-born babies is soft and thin, andcareof skin in ex- apt to become sore, especially when two surfaces coriations - rub. First, a little crack is noticed, next day this will have widened until, sometimes, a large surface is left bare. To prevent this, proper care of the baby from the very beginning is important. Never use soap. Use warm water in washing it, either plain w T arm water or water w r ith sufficient powdered borax to make it soft, and wash the part very care- fully ; wipe or mop carefully with a soft cloth. Then, to prevent further rubbing of the parts, par- ticularly if the skin be broken, use a piece of patent lint or soft Canton flannel, with some salve, as zinc ointment, containing twenty grains of boric acid to the ounce, spread over it, and carried into the crease between the rubbed surfaces. This should be changed at least three times a day, or as often as the baby soils the napkin. 246 OBSTETRICAL NURSING. sore eyes. Baby's sore eyes generally come about from some infection of the eyes through the mother's dis- charges at the time of the birth, or in lying-in hospitals one baby infects another. Hence, should care be taken to cleanse the eyes immediately after the delivery with a saturated solution of boric acid, or even clean, warm water, they may be prevented, as a rule, from getting sore. In many hospitals a drop of a two per cent, solution of nitrate of silver is dropped into the eyes after douching them well with boiled water at 98 F. Should the inflamma- tion occur, however, the nurse must remember that the affection is contagious, through the- matter which forms in the eye. This matter is capable of setting up an inflammation elsewhere, as when a towel used about the eyes may produce a similar inflammation about the privates ; a scratch or wound in the hands may be affected by it. The discharge from affected eyes is greenish- white. The poison it contains is not destroyed by drying; it catches and clings to the room, as the poison of smallpox. Hence, a nurse's hands should be thor- oughly cleansed after washing the eyes, and the nails cleaned with a nail-brush. The cloths used in washing the eyes should be burned at once after using. The greatest precautions must be taken not to carry the poison. The nurse's chief care, apart from preventing the spread of the trouble, in such THE AILMENTS OF EARLY INFANXY. 247 a case, would be to keep the eye or eyes free of the discharge by frequent cleansings with warm water gently syringed into the eye from the inner toward the outer angle, the lids being held everted by their gentle separation by the thumb and finger of one hand.* This washing may need to be done every hour. The baby's hands should be kept down by fastening a towel around the child's body, pinning it in the back. The baby may be held between the nurse's knees and its head inclined over a basin, which will receive the water from the washing. Another basin should contain the clear water to be used. Should only one eye be sore, in placing the baby in its crib, or laying it down at any time, the nurse should be careful to place it with the sore eye down, so that any discharge from it may not enter the other eye. Any further irritation, as of a strong light, should be prevented by keeping the baby in a darkened place. Want of attention in these cases may cause a child the loss of its sight. A room occupied by a baby with sore eyes must afterward be carefully disinfected. Snuffles, or a cold in the head, shown by watery Snuffles. eyes, sneezing, stopping up the nose, hence diffi- culty in nursing, should be managed by keeping the nose cleaned out by means of soft linen twisted * A warm saturated solution of boracic acid is even more efficacious. 248 OBSTETRICAL NURSING. Discharge from ears. Enlarge ment of breasts. into a cone, greasing the nose well afterward with a little oil by carrying it up the nostrils on a twist of cotton, greasing the outside of the nose between the eyes, and keeping the baby warm. If the baby has no hair, the head may be kept warm by a little mull (or in winter thin flannel) cap. Running at the ears is generally very serious in new-born babies, especially when the discharge is matter or blood. Some trouble with the brain may be indicated, hence the physician should be told of it as soon as it is noticed. Of course, the discharge entering the ears at the time of the birth should be carefully excluded from this disorder. The breasts of new-born babies often swell. Generally this occurs about the seventh day or during the second week. Occasionally they gather, and must then be lanced by the physician. Nothing should be done for this swelling, except to see that the clothing is Moulding of loose. It disappears in a few days, as a rule. The same may be said of swellings on the head or about the face, which are due to pressure during the birth. One form of scalp tumor may last several weeks before its entire disappearance. The latter is the result of temporary injury to the bone, and not simply the ordinary swelling which comes from interference with the circulation of the blood in the soft tissues of this portion of the scalp. A child may be born with some deformity, as head Scalp tumors. Deformi- ties. THE AILMENTS OF EARLY INFANCY. 249 hare-lip, or cleft-palate, or club-foot, or extra fin- gers and toes, or there may be some malformation about the external organs of generation or the bowel. Whatever the deformity may be, the nurse should avoid letting the mother know anything about it until the physician has told her of it. The shock produced by the knowledge may do the mother much injury; hence the physician should bear the responsibility of making the announce- ment. A nurse will need considerable tact in managing this, as the mother is apt to ask to see her baby very soon after its birth. An excuse may be made by stating the necessity for washing and dressing the child first, or it may be asleep and the nurse hesitate to disturb it. Quite frequently the bridle beneath the baby's Tongue, tongue is too short, and interferes with the free movement of the tongue. This is called " tongue- tie." It may prevent the child's nursing, and thus interfere with its nutrition. If the baby can extend the tip of the tongue beyond its lips, it is not prob- able that there will need to be anything done, as the baby ought to be able to suck a good nipple with ease. If the nurse should introduce the tip of her little finger into the baby's mouth and allow the child to draw on it for a few minutes, she can tell whether the act of sucking can be properly accomplished. Should it not be able to suck, the tie. 25O OBSTETRICAL NURSING. attention of the physician should be called to the matter, as the bridle will have to be nicked — an operation following which there may be consider- able loss of blood, hence it should not be attempted except by a physician. fVom d thf Bleeding from the cord or navel string may cord. occur within a few hours after birth. It may be that the cord has not been tied sufficiently tight, or there may have been a very thick cord, which, in shrinking, has loosened the ligature. If, after tying, the cord has been looped back upon itself and tied in a single double bow-knot, this may be untied by the nurse and fastened more tightly, so that the bleeding may be controlled, or another ligature may be thrown around the cord a little nearer the body of the child than the first one. Should this not check the hemorrhage, the nurse should hold the cord firmly between thumb and finger, making compression until the physician, who should be sent for, arrives.* "Failing" The cord commonly falls off about the fifth day. of cord. J m * The process of ulceration, by which it falls off, leaves an open surface on the child's body which * Bleeding from the base of the stump after the cord has fallen is a more difficult condition to manage. The physician needs sometimes to control the hemorrhage by a ligature drawn beneath transfixion pins. The nurse must keep up pressure over the site until the doctor comes. THE AILMENTS OF EARLY INFANCY. 25 I • offers an avenue for septic infection. Great care should therefore be taken that the nurse's hands and anything else that comes in contact. with this surface are perfectly clean. Should any moisture exist about the stump, the use of the antiseptic powder of salicylic acid and starch, before spoken of, or some other drying powder of the kind, is indicated. It is necessary, also, to see that the dressing used is thoroughly antiseptic. Whenseptic infection does exist, it shows itself irr the occurrence navel! " of inflammation around the navel or some other part of the body ; the child loses flesh, has fever, becomes puny and emaciated, and abscesses form in various places. In the majority of cases it dies, not having sufficient vitality to survive the poison- ing.* The physician will, of course, prescribe the treat- ment for such a child ; the nurse will be required to see that these directions are faithfully carried out, and especially that the child gets all the nourish- ment and stimulation required. Umbilical vegetations are either soft, jelly-like Umbilical -. -, . , , , , vegetations. growths, or, which is more common, hard protuber- ances sometimes the size of a hickory-nut. They are not painful and seldom bleed. The physician some- * Sometimes the inflammation takes on the character of erysipelas. 252 OBSTETRICAL NURSING. Jaundice of infancy. True jaundice. times removes them by ligature. The softer forms maybe touched with caustic and thus made to shrink. A peculiar yellowish coloration of the skin is to be noticed with babies a few days after the birth. This disappears, as a rule, by the end of the second week, and is due to changes in the circulation. Should the jaundice be very marked and seem to persist warm baths once or twice a day, with gentle friction over the liver with soap liniment, helps, with free action of the bowels, to overcome the condition. Jaundice of the new-born baby is sometimes the result of disease of the liver. The color is then very marked. The baby grows thin rapidly and appears sick. The stools are apt to be clay-colored. When the child is suffering from blood-poisoning, the peculiar coloration of the skin is due to this cause. Buhl's disease is an obscure disease of new-born babies, thought to be due to fatty degeneration of the internal organs. It results fatally, as a rule, within the first few days. There is a tendency to hemorrhage from various parts of the body. In some families known as "bleeders," the ten- dency to hemorrhage may be transmitted to the child, particularly if it be a boy. It is necessary to watch for any such tendency very closely. Convulsions. Convulsions may occur in very young infants at varying periods after their birth, according to the Buhl's disease. Bleeders. THE AILMENTS OF EARLY INFANCY. 253 .cause which excites them, as, injury during labor, indigestion, brain trouble, or other causes. The convulsive seizure is generally preceded by twitch- ings of the limbs, a rolling-up of the eyeballs, so that a large part of the whites of the eyes is seen, the thumbs are drawn into the palms of the hands, and the fingers tightly clasped over them, or the toes may be turned upward or drawn downward. During the convulsion the child grows rigid. When the attack comes on the nurse should quickly undress the child and place it in a warm bath. A tablespoonful of mustard added to the water will help to stimulate the skin, and the con- vulsion will gradually subside. The child, on its removal from the bath, may be wrapped in a heated blanket, and allowed to perspire freely. On the recurrence of the convulsion, the same measure of placing the child in the bath should be resorted to, until the physician comes and institutes such other treatment as he may think proper. Bruises, the result of falls or blows, should be Bruises. treated by the repeated application of hot com- presses. This will relieve pain and prevent swell- ing, and the black and blue coloration of the skin which would otherwise result. The occurrence of a fall or blow should be care- ^^ s s and fully reported by a nurse, as the child should be carefully examined for the discovery of any injury 254 OBSTETRICAL NURSING. the serious consequences of which may be averted by prompt treatment. The occurrence of paleness or vomiting after any such accident is a serious symptom and should receive immediate attention by the physician. Fever. A hot, dry skin may accompany various of the disorders of infancy, notably inflammatory condi- tions of the digestive organs and of the lungs. The normal temperature of a new-born baby is 90 Fahr., the pulse 140, the respiration 44. Should the child seem to be ailing, its tempera- ture should be taken. A clinical thermometer may be held the requisite number of minutes in the groin or in the folds of the neck. Some slip the bulb of the thermometer into the rectum. Should the temperature be raised, the pulse rapid, and the respiration hurried and difficult, some lung trouble probably exists. Pneumonia is a very common Lung disease with infants. A catch in the breath, noisy troubles. t # * breathing, a distention of the nostrils on taking an inspiration, would indicate the same thing. % The frequent rubbing of the chest with some counter- irritant liniment, as St. John Long's liniment, the use of the cotton-jacket for the protection of the chest, and, if the child is very feverish, the use of a drop of sweet spirits of nitre in a teaspoonful of water once in two hours, will constitute the nurse's management of the case until the doctor has seen THE AILMENTS OF EARLY INFANCY. 255 the baby and laid down his plan of treatment. The cotton-jacket is made by taking a high-necked, long- Cotton- jacket. sleeved merino vest a size or two larger than would be needed by the baby for ordinary wear, opening it down the front, and fastening tapes an inch or two from each edge in front, by which the jacket may be closed. The inner surface of this vest, back and front, should be quilted with sheep's wool or cotton-batting, the outer surface with oiled silk or oiled muslin. This makes a very warm covering for the chest. Cyanosis, or "blue disease" comes from the Cyanosis or r 1 r • 1 • i 1 " blue imperfect closure of an opening which exists in the disease." heart before birth. The baby is called a " blue baby," and is very delicate in consequence of this imperfection in its circulation. Such babies gener- ally die, if not during infancy, some time during early childhood. With great care they sometimes live, and the opening in the heart gradually closes up. The special care required is to keep the child warm and to handle it very carefully, so that it may be subjected to no jar or nervous fright. The child should be kept lying on its right side, or on its back, in order that there may be as little interfer- ence as possible with the action of the heart, and that the tendency of the blood to flow through this opening in the upper chambers of the heart — from right to left — may be overcome. 256 OBSTETRICAL NURSING. Rickets. Rickets is a disease of the bones — the result of poor nutrition. There is not sufficient deposit of earthy matter in the bones, hence they remain too soft and are subject to all kinds of distortions in consequence of this. The child may be bow-legged and is stunted in its growth, curvatures of the spine may exist, or an unnaturally large head, known as hydrocephalus, or " water on the brain." The baby having this disease is very weak, can- not hold up its head well, perspires very freely, especially about the head. The complexion is very white. The baby has constant trouble with its bowels, having green stools nearly all the time. The opening in the front of the head is depressed and the child seems to waste. As the baby grows older, unless well cared for, the evidences of disease increase, the joints are enlarged, the baby cannot support itself on its limbs, its teeth are slow in coming, etc. The mother can do much for the health of her child, while still carrying it, by a careful regard for her own general health. After the baby's birth it should be kept well nourished, to overcome any tendency to this disease. Salt baths, oil baths, and the use of tonics ordered by the physician, as cod-liver oil, together with careful attention to the quality and quantity of nourishment, will do much to prevent the progress of rickets. THE AILMENTS OF EARLY INFANCY. 257 The question often arises as to how soon a baby Vaccina- should be vaccinated, particularly 'if smallpox be prevalent. As a matter of experience, it is found that the vaccination does not " take" well before the third month, though, if a younger baby is to be exposed to the poison, it would be well to have it vaccinated. Vaccination should be avoided, if possible, when the baby's health is run down from any cause, also at the time of teething. A peculiar and distressing form of rash sometimes occurs, or there is a great deal of inflammation following the vaccination, leading the parents to imagine that the baby has been poisoned by the virus used. An insight into the frailty of human life in its The world's earliest days proves how much the world owes to debt to nurses and the faithfulness of mothers and nurses, and should mothers. be a stimulus to scientific research in the discovery of improved methods for the management of in- fancy. 17 INDEX Abdominal bandages, 78 belt, 34 binder, 48, 11 1, 136 Absence of physician during labor, 114 Accidents of labor, 114-131 of pregnancy, 52-57 After-birth, care of, 111, 168 delivery of, 124-125 After-pains, 195-197 Ailments of early infancy, 221-257 Albuminuria, 35 Analysis of human and cows' milk, 150 Anise-seed tea, 234 Antisepsis, 58-64 during labor, 98-101, 109 Antiseptic dressings, 68, 79 (Garrigues'), 79- 80 precautions after labor, 126, 1 73- 175 Antiseptics, 65-76 Anus, 21 Apparatus for sterilization of milk, 1 59.. l6 ° Application of antisepsis to confine- ment nursing, 65-76 Arrangement of patient's clothing during labor, 107 Articles needed for baby's basket, 88- 104 in confinement room, 78-83, 106 Artificial breathing, 1 17-122 feeding of infants, 150-166 Average length of new-born baby, 209 weight of new-born baby, - .209 Avoidance of pressure of foetal head , 211 Auvard's couveuse, 227-228 B. Bag of waters, 92 Bandaging of breasts, 183-186, 189- 192 Barley water, 236 Bathing after delivery, 175 during pregnancy, 48 of new-born infants, 132-135 Bearing-down pains, 93, 107 Bed-sores, 201 Bichloride of mercury, 98 Binder (infant's), 136 Bladder during lying-in, 175-178 pregnancy, 33-35 Bleeders, 252 Bleeding from cord, 250 Blisters, 244 Blood-poisoning, causes of, 65, 66 prevention of, 66 Blue disease, 255 Bowel movements of infancy, 216, 235 Breast bandages, 79 pump, 188 Breasts, care of, 181-195 function of, 23 development of, 27 Breech delivery, 126 " Brown line " of pregnancy, 28 Bruises, 253 Biihl's disease, 252 c. Caked breast, 187 Call for nurse, 95 259 260 INDEX. Carbolic acid solution, 99 Care after third stage oflabor, 125-126 of after-birth, 111 of breasts in pregnancy, 41 of breasts in lying-in, 180, 186- T 95. of infant at birth, 1 16-123 of napkins, 137 of new-born infant, 132-144 of new-born infant's eyes and mouth, 71, 138 of perineum, 115 of navel cord, 71 Catheter, use of, during lying-in, 175- 178 in pregnancy, 35 Caul, 117 Cervix, 21 Cessation of menstruation, 26 Changes of clothing, 104, 126 in urinary organs during pregnancy, 33-35 in weight of infant, 139-140, 212 Characteristics of infancy, 209-220 Chemilette, 43-44 Chill, 199 Chloride of lime, 73 Cleansing of baby's eyes, 71, no of catheter, 68 of mother after labor, in, 126, 175 of nursing bottle, 164 of physician's hands, 101 of rubber nipple, 165 Clitoris, 19 Closure of fontanelle, 211 Clothing during pregnancy, 42-48 Colic, 233 Colostrum, 145 Company, 108, 170 Conception, 24 Condensed milk, 237 Condy's fluid, 74 Cone-shaped nipple, 183 Confinement room, 77 outfit, 100 Constant flow of milk, 195 Constipation, 31, 179, 241 Convulsions, 56, 128 of infancy, 252 Cooking for lying-in patients, 172- „ T 73 . ; Cotton-jacket, 255 Couveuse, 222-228 Cramps during labor, 108 Creoline, 98 Cross-bed, 130 Cry in brain trouble, 215 in colic, 215 in lung trouble, 215 of earache, 215 of hunger, 215 Cyanosis, 214 255 D. Daily airing of infant, 166 Deepened color of vulva, 27 Deformities of new-born, 248 Delivery of head, 115 of body, 116 Demeanor of nurse, 129 Dentition, 218 Depressed nipple, 185 Depression of fontanelles, 211 Descent of child, 89 Development of breasts, 27 Diarrhoea, 32, 33 Diet during pregnancy, 49, 50 Dietary of lying-in, 170, 172 Discharge from ears, 248 from vulva, 63 Diseases due to mould and yeast infec- tion, 62, 63 Disinfection of clothing and bedding, 75 ' of hands, 67 of rooms, 70, 75 of water-closets, 76 Divided skirt, 44 Double Y bandage of breasts, 190, 192 Drawing of teeth during pregnancy, 40 Dressing of cord, 135 " Dry labor," 56 E. Earache, 215 Effects of menstruation on lactation, 149 of pregnancy on lactation, 150 Emergencies of labor, 114 Enlargement of abdomen, 27 Equipoise waist, 47 Etherization during labor, 131 Examination by physician, 100 of urine, 35 Excessive acidity of urine, 34 Excoriation of vulva, 34 Exercise during pregnancy, 50 INDEX. 26l Expulsion of after-birth, 64 of child, 64 Expulsive after-pains, 196 F. Facial expression in infancy, 216 Falling of cord, 250 Fallopian tubes, 22 False pains of labor, 90 Farinaceous foods, 240 Feeding of infant, 142 of premature infant, 231, 233 Fever of infancy, 254 Figure-of-eight of breast, 184, 185 First sitting-up after delivery, 205 Flannel underwear, 48 Fomentations, 187 Fontanelles, 211 Food recipes, 157, 159 Forced feeding in puerperal mania, 204 Fore-milk, 145 Form of new-born baby, 210 Fruit diet during pregnancy, 50 Garrigues' breast bandage, 186 Garters, 46 Gathered breasts, 192 Gavage, 232 Gelatin, 236 Genital organs, 18 Germs, 58, 64 Gertrude suit, 87 Graduated nursing-bottle, 162, 163 H. Handkerchief bandage of breast, 188 Hemorrhage after labor, 126, 128 during pregnancy, 52, 53 from rupture of varicose veins, 54 Hemorrhoids, 37, 90 Hollow nipple, 184 Hygienic dressing, 43-48 Hymen, 19 Imperforate anus, 217 Improvised sterilizing apparatus, 166 Incontinence of urine, '33 Infancy, 221 Infant's binder, 136, 84 blanket wrap, 86 caps, 86 clothing, 84-88 crib, 140, 141 flannel slip, 85 foods, 142, 156,237 socks, 86, 138 undervest, 84,138 Injuries, 253, 254 Insufficient milk, 144, 195 Intrauterine injections, 196 Involution, 173 Irritability of bladder, 33 J. Jaundice of infancy, 209, 252 K. Kidneys during pregnancy, 35 Knitted wool band, 84 L. Labarraque's solution, 74 Labia majora, 18 Lactation, 143-147 Lactometer, 148 Lancing of breasts, 193, 194 Language of a cry, 215 Lateral position during labor, 83 Laxatives during lying-in, 179, 180 Leglettes, 45 Length of new-born baby, 209 Leucorrhcea, 21, 36 of infancy, 244 Liebig foods, 240 Lime-water, 235 Lochia, 173 Lung troubles, 215, 254 Lying-in, duration of, 173 M. Management of lying-in, 168, 208 of pregnancy, 31, 51 Mask of pregnancy, 28 262 INDEX. Mastitis in infancy, 248 Meatus urinarius, 19 Meconium, 137 Menstruation, 23 Message to physician, 97 Methods of reckoning termination of pregnancy, 29, 30 Microscopic examination of milk, 149 Milk (cows'), 150, 151 (human), 150 Milk-foods, 240 Milk-leg, 201 Miscarriages, 54, 55 Modification of infant's food, 235 Mons veneris, 18 Morning sickness, 28 Mother's dress during labor, 78 Moulding of the head of new-born in- fant, 248 Mushroom nipple, 184 N, Napkins, after care of, 174, 175 changes of. 109 for infant, 84, 85 for mother, 79 Nightingale wrap, 81 Nipple bath, 42 protector, 42, 43, 181, 182 shape of, 183 shield, 181, 182 Nipples, 162 165 care of during lying-in, 181- 184 sore, 181, 182 Nourishment during labor, 108 Nurse dress, 95, 96 report, 197, 198 Nursing, 145 bottle, 162 Nymphae, 19 Observations of pains, 97 Obstetrical breast support, 192 Occlusion dressing, 79, 80 Odors in lying-in room, 168 Oil enema, 180 inunctions, 234 Order board, 207 Os uteri, 22 Outfit for baby, 84, 88 Ovaries, 22 Over-distention of bladder, 35 P. Pain during lying-in, 199 from distention of abdominal walls, 39 in back during pregnancy, 39 Painful breathing, 214 Pains of first stage of labor, 93 Pelvis, 17 Pelvis, measurements of, 17 Peptonization of milk, 156, 157 Perineal pad, 80 Perineum, 20 care of, 115 Poisoning from carbolic acid, 71, 72 from corrosive sublimate, 72 from iodoform, 73 Position during second stage of labor, no during third stage of labor no, 124 Positive signs of pregnancy, 29 Powder, 185 Premature rupture of membranes, 55, ^9 2 Prematurity, 221 Preparation of cows' milk for infants. 152, 154 of antiseptic solutions, 98, 99 of confinement room, 101 of double bed, 102 of patient for labor, 97, 100 of permanent bed, 102 of single bed, 101, 102 Preparations for labor, 77, 88 for obstetrical opera- tions, 129, 131 Pressure on foetal head, 210 Probable signs of pregnancy, 26-29 Process of labor, 91-94 Prolapses, 129 Protection of bed during labor, 82, 103 of floor during labor, 82, 103 Ptomaines, 58 Puerperal fever, 199 anemia, 170, 202-204 ulcers, 200 Pulsation of fontanelle, 211 Pulse of infancy, 214 Q- Quantity of food required for infants, 154 Quickening, 28 INDEX. 263 R. Receptacles needed in confinement- room, 105 Red gum, 244 Respirations of infancy, 213, 214 Resuscitation of infant, 117, 123 Rest for lying-in patient, 168 Retention of urine, 217 Rickets, 256 Rise of temperature during lying-in, 199 Rubber nipples, 164 sheets, 69 Rules for antisepsis in confinement nursing, 67, 71 for sterilization of milk, 161, 162 Rupture of uterus, 129 Salivary glands during pregnancy, 48 Scalp tumors, 248 Schultze's method of resuscitating,i2o- 122 Scurvy, 239 Sea-voyaging during pregnancy, 49 Second stage of labor, 91 Secretion of tears in pregnancy, 216 Securing of maniacal patients, 204 Sepsis during lying-in, 61, 62 Septic infection of navel, 251 inflammation of breasts, 193, x 94 ; Serious symptoms during lying-in, 199 Shape of new-born baby's head, 210 Signs of approaching labor, 89-93 of pregnancy, 26-29 Skin of new-born baby, 209, 231, 245 Sleep after delivery, 168 of infancy, 213 Snuffles of infancy, 246 Soiled clothing after labor, 69, 70, in Sore eyes of infancy, 246 mouth, 216 nipples, 180-182 Spasmodic after-pains, 197 Spice plaster, 234 Stages of labor, 91, 114 Sterilization of milk, 159 Stimulants, 106 Straight bandage of breasts, 190 Striae, 28 Subinvolution, 205 Surroundings during lying-in, 61-62 Suspicious signs, 26 Sutures, 210 Swaddled baby, 229 Swelling of breasts of infancy, 248 of extremities, 37, 89 of vulva after delivery, 178 Sylvester's method of resuscitation, 118-120 Symptoms of lowered vitality, 215 Symptoms of poisoning from use of antiseptics, 71-73 Syringe, 83 single bulb, 242 System, 104 Tact, 109 Tarnier's couveuse, 223 Teeth during pregnancy, 40 Temperature of infancy, 114, 255 of infant's food, 158, 159 Temporary bed, 102-103 Testing milk, 147 Third stage of labor, 91 Thrush, 63, 64, 243 Time required for feeding infants, 165 Tongue-tie, 249 Training of infants, 142 Treatment of caked breasts, 187 of puerperal mania, 203 True pains of labor, 90 Twins, 124 Tying of cord, 123 u. Umbilical vegetations, 251 Union under-garment, 48 Urination in infancy, 216, 244 Urine, acidity of, 34 examination of, 35 incontinence of, 33-34 increased amount of, 35 in cystitis, 64 in pregnancy, 33-34 retention of, 33 Use of catheter, 176 Uterus, 21 V. Vaccination, 257 Vagina, 19 264 INDEX. Vaginal injections, 53, 69, 111 Ventilation, 166 Vernix caseosa, 132 Viability, 221 Visitors during lying-in, 70, 170 Vomiting during labor, 108 of infancy, 243 of pregnancy, 41 w. Wash dresses, 96 Weaning, 239 Weighing the baby, 139 Weight of new-born baby, 139 Wet-nurse, 144 Wharton's jelly, 136 White gum, 244 CATALOGUE No. 7, DECEMBER, 1892. A CATALOGUE OF Books for Students. INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAGE New Series of Manuals, 2,3,4,5 Obstetrics 1©, Anatomy, . 6 Pathology, Histology, . . 11 Biology, . II Pharmacy, . . . .12 Chemistry, . . 6 Physical Diagnosis, . . n Children's Diseases, • 7 Physiology, . . . . n Dentistry, , 8 Practice of Medicine, . n, 12 Dictionaries, 8, 16 Prescription Books, . .12 Eye Diseases, . 8 ?Quiz-Compends? . 14,15 Electricity, . • 9 Skin Diseases, . . .12- Gynaecology, . 10 Surgery and Bandaging, . 13. Hygiene, • 9 Therapeutics, . . 9 Materia Medica, . • 9 Urine and Urinary Organs, 13; Medical Jurisprudence . 10 Venereal Diseases, . . 13. Nervous Diseases, . 10 PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers. LARGE STOCK OF ALL STUDENTS' BOOKS, AT THE LOWEST PRICES. 1012 Walnut Street, Philadelphia. %* For sale by all Booksellers, or any book will be sent by mail,, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. Price ic^cents I 3 °°° Q uestions on Medical Subjects. "An excellent Series of Manuals." — Archives of Gynecology. A NEW SERIES OF STUDENTS' MANUALS On the various Branches of Medicine and Surgery. Can be used by Students of any College. Price of each, Handsome Cloth, $3.00. Full Leather, $3.50 The object of this series is to furnish good manuals for the medical student, that will strike the medium between the compend on one hand and the prolix text- book on the other — to contain all that is necessary for the student, without embarrassing him with a flood of theory and involved statements. They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best — good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shows that the series has met with popular favor. No. 1. SURGERY. 318 Illustrations. Third Edition. A Manual of the Practice of Surgery. By Wm. J. Walsh am, m.d., Asst. Surg, to, and Demonstrator of Surg, in, St. Bartholomew's Hospital, London, etc. 318 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. " It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word — practical." — The Medi- cal Bulletin. " Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had very great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. 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Reese, m.d., Professor of Medical Juris- prudence and Toxicology in the Medical Department of the University of Pennsylvania ; Physician to St. Joseph's Hospital. Third Edition. Cloth, 3.00; Leather, 3.50 NERVOUS DISEASES. Gowers. Manual of Diseases of the Nervous System. A Complete Text-book. By William R. Gowers, m.d., Prof. Clinical Medicine, University College, London. Physician to National Hospital for the Paralyzed and Epileptic. Second Edition. Revised, Enlarged, and in many parts Rewritten. With many new Illustrations. Octavo. Vol. I. Diseases of the Nerves and Spinal Cord. 616 pages. Cloth, 3.50 Vol. II. Diseases of the Brain and Cranial Nerves. General and Functional Diseases. Nearly Ready. Ormerod. Diseases of Nervous System, Student's Guide to. By J. A. Ormerod, m.d. , Oxon.,F.R.c.p. (London), Member Path- ological. Clinical, Ophthalmological, and Neurological Societies, Physician to National Hospital for Paralyzed and Epileptic and to City of London Hospital for Diseases of the Chest, Demon- strator of Morbid Anatomy, St. Bartholomew's Hospital, etc. With 75 Wood Engravings. Cloth, 2.00 OBSTETRICS AND GYNAECOLOGY. Davis. A Manual of Obstetrics. By Edw. P. Davis, Clinical Lecturer on Obstetrics, Jefferson Medical College, Philadelphia.. Colored Plates, and 130 other Illustrations. i2mo. Cloth, 2.00 Byford. Diseases of Women. The Practice of Medicine and Surgery, as applied to the Diseases and Accidents Incident to Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology in Rush Medical College and of Obstetrics in the Woman's Med- ical College, etc., and Henry T. Byford, m.d., Surgeon to the Woman's Hospital of Chicago. Fourth Edition. Revised and Enlarged. 306 Illustrations, over 100 of which are original. Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 Lrewers' Diseases of "Women. A Practical Text-book. 139 Illustrations. Second Edition. Cloth, 2.50 Parvin's Winckel's Diseases of "Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Morris. Compend of Gynaecology. Illustrated. Cloth, 1.00 "Winckel's Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel, Professor of Gynaecology, and Director of the Royal University Clinic for Women, in Munich. Authorized Translation, by J. Clifton Edgar, m.d., Lecturer on Obstetrics, University Medical Col- lege, New York, with nearly 200 handsome Illustrations, the majority of which are original. 8vo. Cloth, 6.00 ; Leather, 7.00 J9&~ See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 11 Obstetrics and Gynecology : — Continued. Landis' Compend of Obstetrics. Illustrated. 4th Edition,, Enlarged. Cloth, 1.00; Interleaved for Notes, 1.25 Galabin's Midwifery. By A. 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Illustrated. Sixth Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 Kirke's Physiology. New 13th Ed. Thoroughly Revised and Enlarged. 502 Illustrations, some of which are printed in colors. (Blakiston's Authorized Edition?) Cloth, 4.00; Leather, 5.00 Landois' Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Fourth Edition. Translated and Edited by Prof. Stirling. 845 Illustrations. Cloth, 7.00; Leather, 8.00 " With this Text-book at his command, no student could fail in his examination." — Lancet. Sanderson's Physiological Laboratory. Being Practical Ex- ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 2.00; Leather, 2.50 49* See pages 14 and IS for list 0/ ? Quiz-Compends t 12 STUDENTS' TEXT-BOOKS AND MANUALS. Practice : — Continued. Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 Part i. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System, and Nervous System; Diseases of the Blood, etc. Physicians* Edition. Fourth Edition. Including a Section on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 From John A. Robinson, M.D., Assistant to Chair of Clinical Medicine t now Lecturer on Materia Medica, Rush Medical Col- lege, Chicago. '* Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged, and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine." PRESCRIPTION BOOKS. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. Just Ready. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions, and Abbreviations used in Prescriptions, Explanatory Notes, Grammatical Construction of Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. Sixteenth Edition. 32mo. Cloth, 1.00; Pocket-book style, 1.25 PHARMACY. Stewart's Compend of Pharmacy. Based upon Remington's Text-book of Pharmacy. Third Edition, Revised. With new Tables, Index, Etc. Cloth., 1.00 ; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, ph.d., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, ph.g., Professor of Pharmacy in, and Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. Cloth, 2.00 SKIN DISEASES. Anderson, (McCall) Skin Diseases. A complete Text-book, with Colored Plates and numerous Wood Engravings. 8vo. Cloth, 4.50; Leather, 5.50 Van Harlingen on Skin Diseases. A Handbook of the Dis- eases of the Skin, their Diagnosis and Treatment (arranged alpha- betically). By Arthur Van Harlingen, m.d., Clinical Lecturer on Dermatology, Jefferson Medical College ; Prof, of Diseases of the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. With colored and other plates and illustrations. i2mo. Cloth, 2.50 See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. IS SURGERY AND BANDAGING. Moullin's Surgery. 500 Illustrations (some colored), 200 of which are original. 2d Ed. Cloth, net 7.00; Leather, net 8.00 Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students, and Hospital Surgeons. By W. H. A. Jacobson, b a. Oxon., f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 Horwitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By Orville Horwitz, b.s., m.d., Demonstrator of Surgery, Jefferson Medical College. 4th edition. Enlarged and Rearranged. 136 Illustrations and 84 Formulae. i2mo. Cloth, 1. 00 ; Interleaved for the addition of Notes, 1.25 *:}.*The new Section on Bandaging and Surgical Dressings con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation of Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. Third Edition. By Wm. J. Walsham, m.d., f.r c s., Asst. Surg, to, and Dem of Practical Surg, in, St. Bartholomew's Hospital; Surgeon to Metropolitan Free Hospital, London. With 318 Engravings. See j>age 2. Cloth, 3. 00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Fourth Edition. i2mo. Interleaved. Cloth, 1.00 Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations, nmo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis or the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. of Penna; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 Memminger. Diagnosis by the Urine. Illustrated. Cloth, 1.00 Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. 7th Ed. Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 2.0a VENEREAL DISEASES. Hill and Cooper. Student's Manual of Venereal Diseases, with Formula?. Fourth Edition. i2mo. Cloth, 1.0a See pages 14 and 15 for list of ? Quiz- Contp ends f PQUIZ-COMPENDS? The Best Compends for Students' Use in the Quiz Class, and when Pre- paring for Examinations. Compiled in accordance with the latest teachings of promi- nent Lecturers and the most popular Text-books. They form a most complete, practical, and exhaustive set of manuals, containing information nowhere else col- lected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over two hundred and fifty illustrations, many of which have been drawn and engraved specially for this series. The authors have had large experience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. Cloth, each $1.00. Interleaved for Notes, $1.25. No. 1. HUMAN ANATOMY, " Based upon Gray." Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. 16 Lithograph Plates, New Tables, and 117 other Illustrations. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon U. S. Army, Professor of Practice, Cooper Medical College, San Fran- cisco. Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System, and Nervous System; Dis- eases of the Blood, etc. *#* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Sixth Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, Penn'a College of Dental Surgery; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged, with new Illustrations. No. 5. OBSTETRICS. Illustrated. Fourth Edition. By Henry G. Landis, m.d., Prof, of Obstetrics and Diseases of Women in Starling Medical College, Columbus, O. Revised Edition. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? ;No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including many unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surg. U. S. Army ; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. 'No. 7. GYNECOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. 45 Illustrations. Wo. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fourth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations, and other operations; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 84 Formulae and 136 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. Third Edition, Revised and Rewritten, with Index. 'No. 11. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph. g., Quiz-Master at Philadelphia College of Pharmacy. Third Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm. R. Ballou, m.d., Prof, of Equine Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. By Geo. W. Warren, d.d.s., Clinical Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. "Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. These books are constantly revised to keep up with the latest teachings and discoveries, so that they contain all the new methods and principles. No series of books are so complete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject under consideration. Illustrated Descriptive Circular Free. GOULD'S NEW Medical Dictionary. Based on Recent Medical Literature. Small 8vo, Half Morocco, as above, with Thumb Index, . . $4.25 Plain Dark Leather, without Thumb Index, 3.25 A compact, concise Vocabulary, including all the Words and Phrases used in medicine, with their proper Pronunciation and Definitions. " One pleasing feature of the book is that the reader can almost invariably find the definition under the word he looks for, without being referred from one place to another, as is too commonly the case in medical dictionaries. The tables of the bacilli, micrococci, leucomai'nes and ptomaines are excellent, and contain a large amount of information in a limited space. The anatomical tables are also concise and clear. . . . We should unhesitatingly recommend this dictionary to our readers, feeling sure that it will prove of much value to them/' — American Journal of Medical Science. JUST PUBLISHED. GOULD'S POCKET DICTIONARY. 12,000 Medical Words Pronounced and Defined. Cloth, $1.00; Leather, #1.25 % 4