WY 157 C772n 1915 54510150R NATIONAL LIBRARY OF MEDISi: NLN Q52fl7M57 b 3NiDia3w jo Aavaan ivnouvn 3NOia3w jo Aavaan ivnouvn 3NOia3w jo Aavaan ivnoilv o 3 Q- NATIONAL IIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL IIBRARY OF MEDICIN NLM052874576 3NOI03W jo Aavaan ivnouvn 3NiDia3w jo Aavaan ivnoij A NURSE'S HANDBOOK OF OBSTETRICS A NURSE'S HANDBOOK OF OBSTETRICS BY / JOSEPH BROWN COOKE, M.D. FELLOW OF THE NEW YORK OBSTETRICAL SOCIETY, ETC Seventh Edition, Revised and Reset BY CAROLYN E. GRAY, R.N. SUPERINTENDENT OF CITY HOSPITAL SCHOOL OF NURSING, BLACKWELL'S ISLAND, NEW YORK CITY AND MARY ALBERTA BAKER, R.N. LATE SUPERINTENDENT OF ST. LUKES' HOSPITAL, JACKSONVILLE, FLA. PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY C /f;5j (X'V>-v~-*-f' 157 (1117 h. 1315 Copyright, 1903, by J. B. Lippincott Company Copyright, 1905, by J. B. Lippincott Company Copyright, 1907, by J. B. Lippincott Company Copyright, 1909, by J. B. LIPPINCOTT Company Copyright, 1911, by J. B. Lippincott Company ;., Copyright, 1913, by J. B. Lippincott Company Copyright, 1915, by J. B. Lippincott Company \/ PRINTED BY J. B. LIPPINCOTT, COMPANY, PHILADELPHIA, U. S. A. NOV-9 1915 ' j ©CLA416274 ^ To the Pupils of the City Hospital School of Nursing for whose use this book was especially written, it is most cordially dedicated by The Author PREFACE TO THE SEVENTH EDITION In revising this book for the seventh edition, it was thought best to present the subject matter in a somewhat different grouping. The text has been considerably changed and much new material added upon current nursing subjects, as well as fifty new illustrations and a number of colored plates. It is hoped this book will still prove to be a guide and stim- ulus to all who follow the traditions and highest ideals of the nursing profession. Since 1903 its text has been a model which has found much favor. The revision was made possible through the courtesy of Honorable John A. Kingsbury, Com- missioner of Charities, and the co-operation of the officials, doctors and nurses of City Hospital, and various maternity hospitals in New York City. September, 1915. C. E. Gray, R.N. M. A. Baker, R.N. CONTENTS CHAPTER PAGE I.—Introduction........................................ 19 II.—Anatomy............................................ 28 III.—Anatomy (continued)................................. 34 IV.—Physiology........................................... 43 V.—Physiology (continued)............................... 48 VI.—The Physiology of Pregnancy........................ 67 VII.—The Phenomena of Labor............................ 75 VIII.—The Physiology of the Puerperium................... 80 IX.—The Signs and Symptoms of Pregnancy............... 84 X.—The Mechanism of Labor............................ 91 XI.—The Management of Pregnancy...................... 102 XII.—Preparations for Labor.............................. 118 XIII.—Preparations for Labor (continued).................. 125 XIV.—The Conduct of Labor............................... 135 XV.—The Management of the Puerperium................. 162 XVI.—Pathology of Pregnancy............................. 183 XVII.—Operative Delivery.................................. 214 XVIII.—Abortion and Miscarriage........................... 244 XIX.—Accidents and Emergencies........................... 253 XX.—Pathology of the Puerperium........................ 274 XXI.—The Care of the Normal Infant..................... 290 XXII.—The Ideal Nursery and Layette..................... 299 XXIIL—The Accidents, Injuries, and Diseases of the New-Born 317 XXIV.—The Premature and Feeble Infant................... 348 XXV.—Infant Feeding...................................... 360 XXVT.—Obstetrical Nursing....................,............ 393 XXVIL—Diets.......................................;........ 397 Appendix............................................. 401 Key to Pronunciation................................. 413 Glossary............................................... 415 Index.................................................. 453 LIST OF ILLUSTRATIONS FIGURE PAGE I. The normal female pelvis.................................... 28 2. The pelvic inlet............................................ 30 3. Male and female pelvis...................................... 31 4. Female pelvis deformed by osteomalacia....................... 32 5. Harris's pelvimeter......................................... 32 6. Measuring the distance between the crests of the ilia............ 32 7. Internal pelvimetry......................................... 33 8. External organs of generation................................ 34 9. Internal organs of generation................................ 36 10. The internal organs of generation, seen from above............. 37 11. The uterus and its appendages............................... 37 12. The cavity of the uterus.................................... 38 13. Ovary and tube of a girl twenty-four years old................. 40 14. Mammary gland of a woman during lactation.................. 41 15. Longitudinal section through ovary of a woman twenty-two days after the last menstruation................................ 43 16. Longitudinal section of ovary of a woman on the first day of men- struation .............................................. 44 17. Human spermatozoa....................................... 48 18. First stages of segmentation of the ovum of a rabbit............ 49 19. Uterus with decidua in beginning pregnancy................... 51 20. Normal position of foetus in utero............................ 52 21. Fetal surface of the placenta................................. 54 22. Maternal surface of the placenta............................. 54 23. Human ovum at the end of the first month..................... 55 24. Outline of human embryo of about four weeks................. 56 25. Human foetus at the end of the third month................... 56 26. Skeleton of infant at term................................... 57 27. Fetal skull, side view........................................ 59 28. Diagram of circulation after birth. Adult type................. 62 29. Diagram of circulation before birth. Fetal type................ 63 30. Striae gravidarum, or Lineas albicantes........................ 68 31. The breasts in pregnancy.................................... 71 32. Abdominal pigmentation.................................... 72 33. Preserving the perineum..................................... 78 34. Preserving the perineum..................................... 78 35. Using the full hand in retarding the progress of the head........ 78 36. Emergence of the forehead and face.......................... 78 37. Delivery of the anterior shoulder............................. 78 13 14 LIST OF ILLUSTRATIONS FIGURE PAGE 38. Expressing the placenta by the method of Cred^................ 78 39. Twisting the membrane into the form of a rope to prevent tearing. . 78 40. Inspecting the placenta...................................... 78 41. Marked pigmentation of breast............................... 87 42. Size of the uterus at each month of pregnancy................. 89 43. Vertex presentation......................................... 92 44. Flexion of head during second stage.. .*........................ 94 45. Extension of the head in anterior presentations of the vertex..... 95 46. External rotation........................................... 96 47. Internal rotation and extension............................... 97 48. Shape of head of child born in face presentation................ 98 49. Shape of head of child born in brow presentation............... 98 50. Face presentation.......................................... 98 51. Breech presentation......................................... 99 52. Prolapse of arm in transverse presentation.................... 99 53. Usual method of palpating the abdomen...................... 100 54. Abdominal binder.......................................... 103 55. Showing manner of elevating bed............................. 129 56. Arrangement of sheets for vaginal examination................. 138 57. Esmarch outfit for the administration of chloroform............. 142 58. Administration of chloroform................................. 143 59. Administration of ether..................................... 147 60. Square knot............................................... 153 61. Granny knot............................................... 154 62. Delivery of placenta and membranes.......................... 155 63. Delivery of the head in breech cases.......................... 156 64. Arms extended in breech delivery............................. 158 65. Locked twins... „........................................... 159 66. Holding the fundus after delivery............................. 162 67. Abdominal binder.......................................... 169 68. Glass catheter.............................................. 173 69. Proper method of inserting catheter........................... 175 70. Method of withdrawing catheter.............................. 175 71. Proper method of introducing douche-tube..................... 178 72. Varicosities of the lower extremities........................... 189 73. Ectopic gestation........................................... 207 74. Placental attachment....................................... 209 75. Internal version............................................ 214 76. Combined or bipolar version.................................215 77. "External version"......................................... 216 78. Forceps applied to head of brim.............................. 218 79. Walcher posture.............................<.............218 80. Ready for vaginal operation.................................. 219 81. Sterile pillow cases for covering the limbs.....................'. 220 LIST OF ILLUSTRATIONS l5 FIGURE PAGE 82. Kitchen table utilized for operating table......................221 83. Elliott's forceps............................................222 84. Simpson's forceps.......................................... 223 85. Tucker-McLane forceps..................................... 223 86. Tarnier axis-traction forceps................................. 223 87. Barnes's bags..............................................224 88. Champetier de Ribes bag.................................... 225 89. Bulb and valve, or "Davidson" syringe....................... 225 90. Method of inserting bag..................................... 226 91. Method of inflating bag..................................... 227 92. Pelvic tumor preventing delivery............................. 228 93. Kelly pad in position under patient........................... 229 94. Sterile salt solution in flasks................................. 230 95. Sponge made of cotton and gauze............................ 230 96. Sponge holder.............................................. 230 97. Intestinal pad of folded gauze................................ 231 98. Gauze packing............................................. 231 99. Saline infusion............................................. 232 100. Galbiati knife.............................................. 234 101. Nurse's proper operating gown............................... 235 102. Doctor's proper operating gown.............................. 235 103. Naegele's perforator......................................... 239 104. Braun's cranioclast......................................... 239 105. Tarnier's basiotribe......................................... 239 106. Impacted shoulder presentation.............................. 240 107. Braun's key-hook........................................... 240 108. Braun's hook applied....................................... 241 109. Long, blunt scissors. For decapitation and evisceration......... 241 110. Bougie for the induction of labor............................. 242 in. Sims's position............................................. 243 112. Author's leg-holder......................................... 247 113. Robb's leg-holder........................................... 247 114. Sims's speculum........................................... 248 115. Schroeder's vaginal retractor................................. 248 116. Bullet-forceps.............................................. 248 117. Modified Goodell-Ellinger dilator..........'................... 248 118. Uterine sound.............................................. 249 119. Placenta-forceps with heart-shaped jaws........................ 249 120. Curettes................................................... 249 121. Sponge-holder.............................................. 249 122. Two-way catheter.......................................... 250 123. Concealed hemorrhage...................................... 254 124. Rupture of the uterus....................................... 257 i6 LIST OF ILLUSTRATIONS FIGURE PAGE 125. Complete inversion of the uterus............................. 258 126a. Prolapse of the umbilical cord............................... 260 126b. Knee-chest position........................................ 260 127. Manual extraction of the placenta............................ 263 128. Murphy saline drip apparatus................................ 269 129. Aspirating needle............................'............... 270 130. Hypodermoclysis........................................... 271 131. Figure-of-eight ligature. For controlling secondary hemorrhage from the umbilicus....................................... 273 132. Tray with everything needed for the care of the breasts.........279 133. Massage of the breast....................................... 280 134. Nursing bottles and rubber nipples........................... 282 135. Author's breast-binder...................................... 284 136. Pattern of author's breast-binder............................. 286 137. Oiling and dressing the new-born infant....................... 291 138. Method of dressing the umbilical cord......................... 294 139. Infant's crib with adjustable sides............................ 300 140. Practical infant's crib....................................... 301 141. Double wash-basin.......................................... 302 142. Paper bags pinned together.................................. 302 143. A. Infant's dressing screen. B. Infant's dressing table..........303 144. Method to secure air for infant in a city apartment............305 145. Another view of Fig. 144.................................... 306 146. Diaper shaped according to pattern.......................... 307 147. Ideal infant clothing........................................ 313 148. Patterns of infant's clothing................................. 314 149. Band and shirt fastened with tapes........................... 315 150. Slapping upon back to induce respiration...................... 318 151. Snapping the finger upon the soles of the feet to stimulate respi- ration .................................................. 319 152. Byrd's method of resuscitation. Expiration.................... 321 153. Byrd's method of resuscitation. Inspiration................... 322 154. Artificial respiration. Expiration............................ 324 155. Artificial respiration. Inspiration............................. 325 156. Sylvester's method combined with tongue traction.............. 327 157. Schultze's swinging method. Expiration...................... 328 158. Schultze's swinging method. Inspiration...................... 330 159. Removal of mucus with aspirating catheter.................... 331 160. Warm bath combined with tongue traction.................... 332 161. Facial paralysis............................................ 333 162. Caput succedaneum........................................ 333 163. Double cephalhematoma................................... 334 164. Technic of applying ice compresses to the eye.................. 336 165. Technic of irrigating eye..................................... 338 LIST OF ILLUSTRATIONS l7 FIGURE pAGE 166. Thumb-forceps............................................. 339 167. Spina bifida of dorsal lumbar region.......................... 340 168. Spina bifida. Spontaneous cure.............................. 341 169. Opisthotonos............................................... 344 170. Electrically heated infant incubator........................... 350 171. Gas heated infant incubator................................ 352 172. Tarnier's incubator, interior.................................. 353 173. English breast-pump........................................ 356 174. Feeder for premature infant.................................. 357 175. Infant premature at thirty weeks............................. 358 176. Soft, flabby breasts......................................... 361 177. Two-ounce vial with nipple.................................. 363 178. Articles required for the preparation of artificial food ............ 383 179. Nursing bottles............................................. 385 180. Testing size of opening in nipple.............................. 386 181. Steam sterilizer............................................. 390 182. Freeman pasteurizer........................................ 390 183. Operating gown and case.................................... 393 184. Scales and hammock for weighing infant....................... 394 185. Sponge attached to safety-pin with snaps..................... 405 186. Delivery bag............................................... 408 187. Nurse's bag................................................ 410 188. Contents of bag............................................411 A NURSE'S Handbook of Obstetrics i Introduction The art of nursing the obstetrical patient is practised by various classes of people. We are very prone to consider only the doctor and the trained nurse. Statistics, however, demand consideration of other factors. Taking any city or town in the United States, we find that a woman about to present her most valuable gift to the world, a healthy child, if not provided with hospital care away from the family, may be cared for: i. By the doctor, in his out-patient and country practice. 2. The nurse midwife. 3. The graduate nurse in private, hospital, visiting nurse and rural Red Cross work. 4. Various orders of nursing sisterhoods. 5. A trained midwife from schools of midwifery abroad. 6. The midwife trained in American schools of midwifery, such as Bellevue. 7. The correspondence school graduate. 8. The untrained nurse. 9. The licensed midwife. 10. The unlicensed midwife occasionally. 11. Relatives of the patient. 12. Neighbors. The dominant issue of the present-day teaching is preven- tion of waste. All civilization is striving, by every means pos- sible, to conserve and add to the vital resources of the nation. A few daring bacteriologists have done research work which 19 20 A NURSE'S HANDBOOK OF OBSTETRICS. has given us perhaps our greatest influence and inspiration to this end, in preventive and curative medicine. This knowledge is in a large measure rendered ineffective by the dense amount of deep ignorance concerning the facts of life. Tradition, prejudice, and social customs all tend to sur- round the practice of obstetrics with conditions which are largely responsible for the following figures which are inserted as an example of some of the results of the care given at childbirth. The figures are by Doctor Haven Emerson, Deputy Commissioner of the Department of Health of the City of New York. IN NEW YORK CITY FOR THE YEAR I914 Number of births reported by physicians....................... 87,650 Number of births reported by midwives....................... 52,997 Number of infant deaths under ten days reported by physicians. . 3,683 Number of infant deaths under one year....................... 13,312 Number of cases of ophthalmia neonatorum reported by physicians 14 Number of cases of ophthalmia reported by midwives........... 12 Number of deaths in 1914 from puerperal sepsis1................ 407 Number of midwives practising in New York City.............. 1,448 These figures and facts are not dull, but force the logical conclusion that the most essential fact of obstetrics is a knowl- edge and a following of a high standard of asepsis. This fact cannot be brought before the public too emphatically, too clearly, or too often. It is the definite duty of every nurse to follow the medical profession closely, and by utilizing every opportunity that sym- pathy and tact may devise, to teach unceasingly the doctrine of prenatal care and the need of the best obstetrical assistance. Nature makes lavish efforts to protect the expectant mother from infection. This is interfered with by contact infection thirty-five per cent, of these deaths were in women who had been attended by midwives prior to the development of the sepsis, which ended in their deaths. It is approximately estimated that between six and seven thousand deaths from puerperal sepsis occurred in the United States in the same year. INTRODUCTION. 21 from the family, from visitors, from the patient herself, and from the nurse or doctor. Aside from the natural immunity possessed by healthy tis- sues against infection, there is the vaginal secretion, which is usually spoken of as being a natural antiseptic. What is meant is, that while swarming with bacteria, these bacteria manufac- ture lactic acid, and no pus organism can survive in an acid medium. Normally the changes in the soft parts of the reproductive organs during pregnancy and labor are accompanied by an increased amount of vaginal secretion. Beyond this there is the closed door to infection of the uterus itself, by means of a mucous mass or plug, called the operculum. At the end of the first stage of labor the membranes rupture, the liquor amnii carries with it the vaginal contents and a large percentage of the bacteria. The vaginal walls enlarge during the actual passage of the child; this is followed by the remaining liquor amnii, and, finally, by the delivery of the placenta; so that there is left but little chance for bacteria to survive. The whole object of asepsis is to prevent infection of the uterus from the outside. Obviously this resolves itself into a principle of prevention of infection during labor, and the practice of rigid asepsis and faultless technic on the part of the doctor and nurse. Every case of puerperal sepsis, with rare exception, proves that infection has been introduced from the outside by septic hands, septic instruments, or septic matter from the vulva or va- gina carried by douches or instruments into the uterus. The septic infection comes from anything not sterile. This is occa- sionally unavoidable, owing to complicated instrumental or oper- ative delivery, but a pyogenic infection has no more place in ob- stetrics than in surgery, and it can be almost as certainly pre- vented. Septic infection from the hands may be prevented by proper cleansing, wearing of gloves, and then by using the hands only when imperatively demanded. 22 A NURSE'S HANDBOOK OF OBSTETRICS. Septic infection from instruments may be prevented by proper cleansing and boiling; then proper technic in the treat- ments or douching will prevent the carrying of infection from the vulva or vagina. Whether the infection is mild and results in invalidism, or whether it is virulent and causes death, the nurse who is in- telligent and conscientious will feel strongly her responsibility. POINTS FOR THE OBSTETRICAL NURSE Pasteur said: " It is within the power of man to cause all parasitic diseases to disappear from the world." Fatal cases of puerperal sepsis in a hospital are almost unknown. They should be equally rare in the home; and if proper care is exercised this will be the case. The purpose of this elementary review is to lessen the total of 6000 deaths per year in the United States. It is hoped that all who read it will consider it seriously, whether they are graduates, undergraduates, midwives or lay helpers. Bacteria are vegetable organisms. Pathogenic bacteria are those organisms which cause morbid or diseased changes in human tissues. Infection is the communication of disease from one person to another. The term is also used to denote the agent by which disease is conveyed. Septic infection is infection caused by septic organisms. Sepsis is infection by bacteria. Asepsis means without sepsis; that is surgical cleanliness or freedom from infection. Aseptic means in a surgically clean manner. Pyogenic relating to pus-forming organisms. Sterile means entire absence of living organisms of any kind. Sterilization is the process of rendering an object free from germs. Antiseptic means preventing sepsis or pus formation or putrefaction. (1) No one should undertake obstetrical nursing who has INTRODUCTION. 23 any pus infection whatever, or who has been recently exposed to a communicable disease. In such a case, report the exact condition to the obstetrician and act under his orders. Carry out thoroughly a system of disinfection. (2) Articles for emergency use, packings, dressings, treat- ments, etc., should be sterile and in readiness; neglect to provide these is criminal. Wisdom lies in the prevention of infection and in preparation for emergencies. (3) Prepare all essentials for doctor (see list). Prepare all essentials for nurse (see list). Prepare all essentials for mother (see list). Prepare all essentials for infant (see list). (4) Hands must be thoroughly scrubbed under running water for five minutes with any good soap and a clean nail brush; use particular care between the fingers and around the nails. Cut the nails close and manicure often. Soak in biniodide of mercury 1: 1000, or sponge with alcohol 95 per cent. Wear rubber gloves, previously sterilized by washing and boiling for five minutes. (5) Fingers must never be used where an applicator or forceps can be made to serve. These are to be kept in a jar filled with 2 per cent, solution of lysol or 95 per cent, alcohol. (6) Use sterilized soap. (7) Never use grease as a lubricant. It is always dirty, and it destroys rubber. Use lysol, 2 per cent., or a sterile emul- sion made from soap. (8) Never catheterize a patient unless all possible means to avoid it have been tried; and then only by express order of the doctor, and with exact technic. (9) A nurse should not renew a vulva pad after removing a bed-pan from her patient until she has made her hands sur- gically clean. (10) Especial care is essential to prevent infection of vulva, bladder, and breasts. (11) A cord dressing will not be reinforced or renewed until the nurse has surgically clean hands. (12) She will never leave a patient's breast exposed, but will protect it by a sterile dressing, and use sterile cotton swabs 24 A NURSE'S HANDBOOK OF OBSTETRICS. when cleansing the nipple, at all times treating both breast and nipple as open wounds. (13) So long as she is with her patient she will keep a complete daily record of patient and infant, charting all physi- cian's visits and treatments. (14) She may use a fountain syringe for enemata, but an agate irrigator with cover and separate tubing carefully boiled is essential for infusions and for sterile uses. (15) She will tactfully instruct her patient not to infect herself or infant, and will strive to prevent the baby from developing bad habits. Failure to do this is inexcusable. (16) She will handle conditions so that the equipment the home affords may be utilized to the advantage of the patient, and by her resourcefulness and adaptability render the eco- nomic drain upon the family income as small as possible, without sacrificing a single principle of asepsis. (17) The nurse should prove a continuous exponent of personal hygiene, in person, uniform, and habits. (18) She must never relax in vigilance, duty, judgment, or loyalty. The feminist movement is strongly pushing forward a de- mand from women themselves for better obstetrics, for better training and judgment on the part of both doctors and nurses. They are less willing to accept inferior service, and demand that the best help available be given them. Operations are often attempted at home that should in justice to the mother and child be performed in hospitals. Lack of adequate assistance or equipment and improper sur- roundings not infrequently render recovery problematical. The patients and families must be taught that this is highly im- proper and that the obstetrician must have adequate assistance and remuneration. Good judgment, swift decisions, and quick action are in demand from the obstetrician. He should have assistants and a nurse worthy this need. Only with a large intelligence and sympathy, trained in technic, plus experience, can a nurse fulfil her opportunity. Private nursing lays greater responsibility upon her than does her hospital work. She must INTRODUCTION. 25 have a sufficient knowledge of psychology to follow the mental processes of her patient. Thus, the nurse should secure her patient's confidence, and persuade her to place herself in the care of a physician as soon as possible; she should help her to live a normal life, induce her to eat proper food, take suffi- cient exercise, secure enough rest, and happily to await her baby's coming. She should ward off dread of suffering by being able to promise that a good obstetrician will not let her suffer too much actual anguish. She should make real to her that the care of her infant begins nine months before it is born ; that the baby requires only a few articles of a very special kind and that these should be in readiness; that her own re- turn to normal health and comfort, as well as her child's best chance for life, lies in her preparing to nurse it, and that all the earth does her honor. When on the case, dignity, efficiency, cleanliness and quiet are most essential. Too many objectionable traits, such as gossiping, relating personal details, reciting history of cases, disturbing domestic regime, discourtesy, etc., when placed in the balance beside skill, are found to outweigh efficiency, and the nurse becomes a menace to the well-being of her patient. The strength and force of character possessed by a nurse will enable her to become a tower of strength to the expectant mother, and by proper suggestion and direction of her mind the actual realization of her sufferings may be much lessened. If the nurse is unintelligent or unobservant of her patient's attitude of mind, she may undo all the efforts of the physician to encourage and assist. It should be a part of her training, and it is her duty, to help her patient mentally as well as physically. In a paper read recently before one of the great medical societies of New York the gynaecologist was styled " that obstet- rical camp-follower," and this characterization may well serve as a text for a dissertation on obstetric nursing. Practically all women who consult the gynaecologist are mar- ried, have borne children, and date their troubles from the birth of one or another child, and it is safe to say that the compara- tively few unmarried women who seek advice for the relief of 26 A NURSE'S HANDBOOK OF OBSTETRICS. pelvic disorders would be in infinitely worse condition than they are if they had passed through the ordeal of pregnancy and labor. The amount of good for womankind that nurses can accom- plish by the dissemination of judicious advice concerning the requirements of the pregnant state and by intelligent care of parturient and puerperal cases, probably exceeds in many ways the best efforts of the physician. Especially among primi- gravidae does this hold true, for women who have never borne children are often remarkably diffident in regard to their condi- tion, and unless the early symptoms of pregnancy are exception- ally severe, they will neglect to place themselves under medical care until much mischief may have been done. When nurses, as a class, will impress upon women who may come under their notice the importance, not only to themselves but to their infants, of consulting and implicitly following the directions of a skilful obstetrician as soon as they have reason to suspect that they are pregnant, they wall save a large number of these patients many visits to the gynaecologist in after years. A nurse can, with propriety, volunteer advice of this kind when a physician, taking the same stand, would often be unjustly suspected of ulterior motives, and her opportunities for doing so are greater than his in the exact proportion in which a woman will discuss a delicate subject with another woman more fre- quently and more freely than with a man. Regarding nursing in the light of a noble profession, closely allied to that of medicine, no opportunity for aiding and perma- nently benefiting humanity will ever be overlooked, and scientific supervision of pregnancy, labor, and the puerperium can do more in this respect than all other branches of nursing com- bined. As the writer has expressed in another place, let the pregnant woman be taken in hand at the very beginning of her pregnancy and put in condition to withstand the ordeal through which she has to pass, much as the athlete is " trained" for months before the encounter in which he is to figure. It may be stated, as a general rule, that no woman should die INTRODUCTION. 27 or even be seriously invalided as a result of pregnancy if she is under proper care from the beginning Qf gestation, and it rests with the nurses of modern times more than with the physicians to see that every woman is afforded such care and attention as will insure the successful outcome of her case. The key-note of success in obstetric practice lies in a thor- ough knowledge of the patient's exact condition long before labor occurs and in ample preparation for delivery and after care, so that the labor may be conducted with every attention to aseptic detail and modern surgical method. Twentieth century civilization has, done much to retard the physical development of women in general, and, among those who are in a position to afford the services of a graduate nurse, very few have sufficiently robust constitutions and normally de- veloped pelves and generative organs to make labor and its after effects anything but a matter of considerable moment. Unless the physician has been afforded an opportunity to build up their general health and keep a watchful eye on the behavior of their bodily functions, and unless the nurse has made careful and judicious preparations for conducting their labors in a thoroughly aseptic manner, complications may arise at the last moment which may result in permanent invalidism, if not in the death, of the mother or child. Obstetric nursing presents many unattractive features, for after labor there are two patients instead of one to be cared for, but it offers so many and so great opportunities for the advance- ment of " preventive medicine" that the writer cannot but look with considerable disfavor upon that large and constantly in- creasing class of hospital nurses who regard maternity cases as entirely beneath their dignity and who leave these unfortunate patients in the care of unskilled attendants, only to nurse them afterwards when they reach the operating-table of the gynae- cologist. II Anatomy THE PELVIS The pelvis (Fig. i) is that portion of the skeleton which lies between the spinal column and the lower extremities. It is Fig. i.—The normal female pelvis. (Garrigues.) A, sacrum; 2?, coccyx; C, crest of the ilium ; £>, acetabulum ; £, spine of the ischium ; F, symphysis pubis; G, spine of the pubis ; H, obturator foramen ; /, tuberosity of the ischium ; J, J, J, linea terminalis. composed of four bones,—the sacrum and coccyx behind, and the innominate bones (ossa innominata) at the sides and in front. Each innominate bone (os innominatum) is divided by anato- mists into three parts,—the ilium, the ischium, and the pubis. The ilium, which is the largest portion of the bone, is broad, thin, concave on its inner aspect, and lies above the narrow con- stricted portion of the pelvis. Like its fellow of the opposite side, it is joined to the sacrum behind, and its upper flaring 28 ANATOMY. 29 border forms the prominence of the hip, or crest of the ilium, commonly spoken of as the " hip bone." The pubis joins directly in front, in the median line, with its opposite fellow, and closes, anteriorly, the cavity of the pelvis. The ischium, which is that portion of the innominate bone lying beneath the ilium, is not of importance to the obstetric nurse, although it is of interest to know that it occasionally pre- sents bony projections (exostoses) of sufficient size to obstruct the descent of the head during labor. The sacrum is a triangular, wedge-shaped bone, consisting of five rudimentary vertebrae welded together, and lies at the back part of the pelvis, between the ilia (plural of ilium), closing in the cavity behind. Its upper surface, or base, is broad and flat, and supports the spinal column ("backbone") and with it the entire weight of the body. Its apex points downward and forward, and to it is attached The coccyx, a very small triangular bone, resembling some- what in appearance a miniature sacrum and being possibly the remains of a prehistoric caudal appendage, or tail. Regarded as a whole, the pelvis may be described as a deep, bony basin resting on the upper extremities of the two femora (plural of femur), or thigh bones, and supporting the spinal column, which carries the weight of the trunk, the head, and the upper limbs. The flaring surfaces of the ilia make a sort of funnel to guide the foetus into this basin, which, having no bottom, forms a bony canal through which the child has to pass at the time of labor. The most constricted portion of the pelvis is called the brim, or inlet (Fig. 2), and is, naturally, of the greatest obstetric im- portance; for, as a chain is only as strong as its weakest link, so is a canal only as broad as its narrowest part, and, except in certain cases of deformity, any child that can pass safely through the brim can be delivered without any further difficulty. The brim of the pelvis is bounded behind by that portion of the upper anterior surface of the sacrum, which projects farthest forward and is called the "promontory of the sacrum;" on the sides by the lower borders of the ilia; and in front by the two A NURSE'S HANDBOOK OF OBSTETRICS. pubic bones, which meet in the median line and form the "sym- physis pubis." Fig. 2.—The pelvic inlet. (Garrigues.) A B, anteroposterior or true conjugate diame- ter; CD, left oblique diameter; E F, right oblique diameter; G H, transverse diameter; A S, sacrocotyloid distance; IK, crest of the ilium. The contour of the inlet is more or less heart-shaped because of the jutting forward of the promontory of the sacrum, and the most important diameter of the pelvis is the distance between the promontory and the symphysis. If this is normal (ten centi- metres, or about four and one-quarter inches), it is almost cer- tain that the entire pelvis is normal, and that the child can be born without any serious difficulty. The articulations (joints) of the pelvis, which possess ob- stetric importance, are four in number. Two are behind, between the sacrum and the ilia on either side, and are termed the sacro- iliac synchondroses (plural of synchondrosis) ; one is in front, between the two pubic bones, and is called the symphysis pubis; and the last, of little consequence, is that between the sacrum and coccyx,—the sacro-coccygeal articulation. ANATOMY. 31 All of these articular surfaces are lined with fibro-cartilage, which becomes thickened and softened during pregnancy, and a certain definite, though very limited, motion in the joints is essential to a normal labor. Even an ankylosis of the sacro- coccygeal articulation, preventing the tilting backward of the coccyx at the time of delivery, may necessitate the use of for- ceps, and, in the operation of symphyseotomy, which consists in cutting through the symphysis; pubis and so separating the pubic bones, no increase in the capacity of the pelvis could be secured were it not for a very distinct hinge-like motion at the sacro-iliac synchondroses. The pelvis is lined with muscular tissue, which provides a smooth slippery surface over which the foetus has to pass during labor, and its bones are bound together by ligaments, which become softened and slightly lengthened as pregnancy advances. Comparing the female with the male pelvis (Fig. 3), we find that the former is especially adapted to the uses for which Fig. 3.—Male and female pelvis. A, male pelvis—narrow, heavy, compact; B, female pelvis—broad, light, capacious. it is designed. It is shallow, but very capacious, lighter in struc- ture and smoother than the male pelvis, which is deep, conical, rougher for muscular attachment, and more compact. The entire problem in obstetrics consists in the safe passage of the fully developed foetus through the pelvis of the mother. Slight pelvic contractions, resulting in tedious or instrumental 32 A NURSE'S HANDBOOK OF OBSTETRICS. deliveries, are comparatively common, while any such marked de- formity as depicted in Fig. 4 would render labor by the natural Fig. 4.—Female pelvis deformed by osteomalacia. (Garrigues.) passages entirely out of the question. For these reasons the pelvis of every pregnant woman should be measured carefully at a sufficiently early date to enable the physician to determine definitely the proper course to pursue. Fig. 5.—Harris's pelvimeter. The external pelvic neeasurements are taken with an instru- ment called a pelvimeter (Fig. 5), which acts on the principle Fig. 6—Measuring the distance, iliac crests. ANATOMY. 33 of a carpenter's or plumber's calipers. The patient lies on her side or back, according to the diameters to be measured, with the abdomen exposed, as shown in Fig. 6. The internal pelvic measurements, for determining the actual diameters of the brim, are usually made by inserting two fingers into the vagina and up to the promontory of the sacrum and estimating the various dimensions in this manner (Fig. 7). Fig. 7.—Internal pelvimetry. Measuring the distance between the promontory of the sacrum and the lower border of the symphysis pubis. The importance of the knowledge gained through the skilful performance of external and internal pelvimetry cannot be over- estimated, and it should never be neglected in the case of a woman pregnant for the first time nor in any case in which the patient has suffered previously from difficult or tedious labors. In cases of slight contraction the induction of labor two or three weeks before term may be all that is necessary, while the existence of marked deformity may call for the performance of Caesarean section as the only alternative. It is to be kept in mind that the higher we ascend in the social scale the more frequently do we encounter pelvic deformities of varying de- grees, due to faulty development superinduced by lives of luxury and indolence, and that the class of patients coming under the care of the graduate nurse presents a far greater proportion of such deformities than is found among women in the lower walks of life. 3 Ill Anatomy (continued) the female organs of generation The female organs of generation are divided into two groups, the external and the internal, which are connected by the vagina. The external organs, taken as a whole (Fig. 8), constitute the vulva, and consist of— Fig. 8.—External organs of generation. A, A, labia majora; B, B, labia minora? C, meatus urinarius; D, clitoris; E, mons veneris; F, perineum ; G, anus; H, entrance to vagina. The mons veneris, a firm, cushion-like formation covered with hair and lying directly over the symphysis pubis. The labia majora, or greater lips, made up of adipose tissue (fat) and covered externally with skin and hair and internally with mucous membrane. They begin in the median line at the lower border of the mons veneris and extend downward and 34 ANATOMY. 35 backward, on either side, to meet at a point termed the four- chette, which is almost invariably torn at the first labor. The labia minora, or lesser lips, lie entirely within the vulva, except in the case of infants and of women who have borne chil- dren or are much emaciated. They are covered entirely with mucous membrane, and their upper extremities are divided into two parts, one passing above and one below (and so forming a hood for) The clitoris. This is a small reddish tubercle situated about half an inch behind the upper and anterior junction of the labia majora. The meatus urinarius, commonly spoken of as the " meatus" is the external opening of the urethra, which is the canal (about one and one-half inches in length) leading to the bladder. The meatus lies directly back of the clitoris and about three-quarters of an inch from it. When the labia are separated it appears as a small dimple in the median line under the symphysis. The vagina is a musculo-membranous canal, five to six inches in length, leading from the vulva to the uterus and lying wholly within the true pelvis. It is lined with mucous membrane, the secretion of which possesses marked germicidal properties. In consequence of this fact the vagina is always aseptic except in the presence of disease or very soon after direct infection from without, and for this reason a vaginal douche should never be given before labor unless it is specially ordered by the physician. Under ordinary circumstances such a douche can do no good, and it is certain to do actual harm by removing the natural and aseptic lubricant of the vagina, even if it does not, through carelessness of preparation or administration, introduce infection where none had existed previously. The internal organs of generation (Figs. 9 and 10) consist of the uterus, the Fallopian tubes, and the ovaries. The uterus, or womb (Fig. 11), is a hollow, pear-shaped organ about three inches in length in the non-pregnant state. It is composed of muscular tissue, covered externally almost wholly with peritoneum and internally with mucous membrane, and is suspended in the pelvis by means of a number of ligaments 36 A NURSE'S HANDBOOK OF OBSTETRICS. arranged in pairs and stretching across, from the uterus to the sides of the pelvis or to other pelvic organs. This arrangement of the ligaments is such that the uterus is allowed considerable freedom of motion, and its position varies slightly with respira- tion, with the posture of the woman, and with the condition of the bowels and bladder. In other words, the uterus has no Fig. 9.—Internal organs of generation. (Keating and Coe.) Showing the uterus in its normal position between the bladder and the rectum. The vagina lies between the lower border of the bladder and the meatus urinarius above and the rectum and anus below separated from the latter by the perineum. intimate attachment to any fixed point, but hangs in the pelvis in a way to permit of its enormous enlargement during preg- nancy,—from about the size of an egg before conception has occurred to that of a fairly large pumpkin at the time of labor. The uterus lies in about the centre of the pelvis, below the brim, with the bladder in front and the rectum behind, so that, of ANATOMY. 37 Fig. io.—The internal organs of generation, seen from above. (Keating and Coe.; Fig. ii.—The uterus and its appendages. (Keating and Coe.) The ovaries are the almond- shaped bodies lying between the uterus and the extremities of the Fallopian tubes. 38 A NURSE'S HANDBOOK OF OBSTETRICS. necessity, a full rectum will force it forward and a distended bladder will tilt it backward. Its upper, rounded border is called the fundus, and its lower, narrowed portion the cervix, while that part between the fundus and the cervix is termed the body of the uterus. The cervix projects into the vagina for a distance of about half an inch, much as a cork projects into the neck of a bottle. Fig. 12.—The cavity of the uterus. (Garrigues.) c, vagina; e, external os; d, internal os: /, fundus, the letter being placed over the entrance of the Fallopian tube. The spaces between the sides of that part of the cervix which extends into the vagina and the vaginal walls are termed for- nices (plural of fornix), and are divided into four parts. The anterior fornix is between the anterior wall of the cervix and the anterior vaginal wall; the posterior fornix is between the pos- terior vaginal wall and the posterior wall of the cervix; the lateral fornices are the spaces between the cervix and the vaginal walls on either side. The cavity of the uterus (Fig. 12) is lined with mucous membrane, and is divided into two parts,—the cavity of the body and the cavity of the cervix. The cavity of the body is tri- ANATOMY. 39 angular in shape, with its apex pointing downward, while that of the cervix is spindle-shaped. There are three openings into the cavity of the uterus. The external opening, called the external os (Latin for mouth), is in the centre of the cervix as it projects into the vagina. It is very small in the non-pregnant state, barely admitting a probe, but at the time of labor it dilates to a size sufficient to permit the passage of the foetus. The other openings are at the upper angles of the triangular cavity of the body and lead into the Fallopian tubes, which will be described later. As the Fallopian tubes open directly into the peritoneal cavity, it will be seen that there is a direct avenue from the peritoneum to the outer world, through the Fallopian tubes, the uterus, and the vagina. The cavity of the cervix is slightly distended above the ex- ternal os, to become contracted again at its junction with that of the body. This second contraction is termed the internal os, and it is because of these two points of contraction that the cavity of the cervix acquires its spindle shape. The Fallopian tubes (see Fig. n) are two trumpet-shaped tubes, from four to five inches in length, extending from the upper angles of the uterus, just below the fundus, towards the sides of the pelvis. Between their outer extremities and the uterus, on either side, are found The ovaries (Fig. 13), which are the germ-producing organs of the woman and about the size and shape of an English walnut. Each ovary contains in its substance at birth a vast number of germs or ovules (from Latin, meaning "little eggs"), and, beginning at about the time of puberty and occurring at or about every menstrual period, one or possibly two of these ovules enlarges, approaches the surface of the ovary, escapes into the Fallopian tube, and so passes on into the uterus. The ovule which has " matured" in this way is the only one that can be impregnated by the male germ, and if there is no male element present in the Fallopian tube, where impregnation usually occurs, nothing results beyond the usual menstrual phe- nomena. The perineum (see Fig. 9) can hardly be considered as A NURSE'S HANDBOOK OF OBSTETRICS. belonging to the organs of generation, but it may best be de- scribed in this chapter. Briefly, and as far as the nurse is con- cerned, it is the triangular mass of tissue which separates the vagina from the rectum. Its upper surface is covered by the Fig. 13.—Ovary and tube of a girl twenty-four years old. (Waldeyer.) U, uterus, T, tube; LO, ovarian ligament; o, ovary; x, limit of peritoneum ; b, cicatrices of ruptured Graafian follicles. lower wall of the vagina, its posterior surface is in contact with the rectum, and its external surface is covered with skin and lies between the lower angle of the vulva and the anus. The perineum forms % the floor of the genital canal, and in certain difficult labors it is torn, when the head is born, to an extent varying all the way from a slight nick in the skin to a deep lacer- ation extending through the anus into the rectum itself. The mammae (mammary glands or breasts) are two highly specialized sebaceous glands located on either side of the an- terior wall of the chest between the third and seventh ribs. They secrete the milk which serves as the sole nourishment of the infant during the early months of its life, and they are abun- dantly supplied with nerves and blood-vessels and intimately connected, by means of the sympathetic system, with the uterus and other generative organs. This sympathetic relation is espe- cially noticeable when the infant nurses immediately after birth THE BREASTS. 41 and reflex uterine contractions result from the irritation of the nipple caused by the suckling. The breasts of a woman who has never borne a child are conical or hemispherical in form, but their size and shape vary greatly in women who have nursed one or more infants. The breasts are made up of glandular tissue and fat, and each organ is divided into fifteen or twenty lobes, which are separated from each other by fibrous and fatty walls and sub- divided into numerous lobules (little lobes) (Fig. 14). The Fig. 14.—Mammary gland of a woman during lactation, with lactiferous ducts and sinusei. (Luschka.) lobules are composed of acini (plural of acinus), in which the milk is formed, and as the ducts approach the nipple they are dilated to form little reservoirs in which the milk is stored, but contract again as they pass into the nipple. The external surface of the breast is divided into three por- tions, as follows: (a) The white, smooth, and soft area of skin extending from the circumference of the gland to the areola, (b) The areola, which surrounds the nipple and is of 42 A NURSE'S HANDBOOK OF OBSTETRICS. a delicate pinkish hue in blondes and a darker rose-color in brunettes. Under the influence of gestation the areola becomes darker in shade, and this pigmentation which is more marked in brunettes than in blondes, constitutes, in many cases, a valu- able sign of pregnancy (see Figs. 31 and 36). (c) The nipple, a large conical papilla projecting from the centre of the areola and having at its summit the openings of the milk ducts. IV Physiology OVULATION AND MENSTRUATION As stated in the previous chapter, the ovaries contain in their substance, at birth, a great number (about seventy thousand) of undeveloped ova or " eggs," and it is unnecessary to say that these ova are microscopical in size. Beginning, in this climate, at about the thirteenth year of age and occurring about once a month, one of these ova enlarges and approaches the surface of the ovary. This enlarged ovum, lying directly under the surface of the ovary, constitutes what is known as the Graafian follicle (Fig. 15), and projects slightly, Fig. 15.—Longitudinal section through ovary of a woman twenty-two days after the last menstruation. (Leopold.) m.f., mature Graafian follicle; pr., most prominent point of follicle, where the rupture may be expected. like a small pimple. The Graafian follicle then becomes thinned at one point, where it soon bursts and allows the ovum to escape into the Fallopian tube (Fig. 16). 43 44 A NURSE'S HANDBOOK OF OBSTETRICS. Once within the Fallopian tube, the ovum makes its way into the uterus, and, if unimpregnated by the male element, it loses its vitality in a few days and is cast off with the menstrual flow. Fig. 16.—Longitudinal section of ovary of a woman on the first day of menstruation, with one burst follicle opening on the surface and other follicles in different stages of development. (Leopold.) When, however, the male germ is present it meets and pene- trates the ovum, usually while it is still in the Fallopian tube. The ovum thus impregnated passes on, as before, into the uterus, but instead of being cast out in the menstrual discharge it becomes adherent to the wall of the uterus and develops into the foetus and its envelopes, the point of attachment to the uterine wall being the site of the placenta in later months. It is, of course, evident that of the vast number of ova con- tained in the ovaries, a comparatively small number ever mature and are prepared for fertilization by the male element, and that of these, so prepared by maturation and discharge from the ovary, very few are actually impregnated; for the impregnated ova of any woman are accurately measured by the number of her children plus the number of her miscarriages. This lavish provision of nature against any possible inter- ference with the propagation of the human race is also found in the male, for, of thousands of male elements (spermatozoa) deposited at one time within the vagina, very few make their way through the external os and the uterus to the Fallopian tube, and, of these, but one is successful in penetrating the wall of the ovum and causing pregnancy. Ovulation.—The process, by which the ovum develops and is cast out from the ovary into the Fallopian tube, to be impregnated or not, as the case may be, is termed ovulation, PUBERTY. 45 and while it is usually accompanied by menstruation, neither process is dependent upon the other. The accuracy of this last statement is shown by the follow- ing incontrovertible facts: Without ovulation there can be no pregnancy, and yet pregnancy has occurred before the es- tablishment of menstruation ; it has occurred after menstrua- tion has ceased; and it not infrequently occurs during lactation, when menstruation is suppressed. On the other hand, menstru- ation may occur independently of ovulation, for it has been known to take place after the ovaries and tubes have been removed on both sides. Puberty.—Puberty, in females, is the time of life at which menstruation is first established, and occurs in the temperate zones about the thirteenth year. In tropical countries it is as early as the eighth or ninth year, while in the extreme north it may be delayed until the seventeenth or eighteenth year. Adolescence, which is the period between puberty and maturity, is characterized by rapid physical changes. The ex- ternal genitals enlarge and the pubic hair appears. The hips broaden and the breasts enlarge. Along with the physical are psychical developments. The girl rapidly matures in mind and, unless properly directed, the lack of established mental balance may become serious. This transition period, from girlhood to womanhood, is one of the most critical in the life of every woman. Delicately bred girls require special safeguarding to- ward the end of perfect physical development. Proper hygienic conditions with regard to food, exercise, fresh air and sleep, with an entire absence of excitement, is to be insisted upon. Excessive study is contraindicated, and the habit of spending the first day of menstruation in bed or until all pain has disappeared is the only safe rule to follow. Menstruation.—This is the periodical discharge of blood from the cavity of the uterus, and occurs throughout the child- bearing period at regular intervals of about twenty-eight days, except during pregnancy and lactation, when it is usually sup- pressed entirely. Next to twenty-eight days the most common A NURSE'S HANDBOOK OF OBSTETRICS. interval is thirty days. Occasionally it occurs every twenty- one days without any appreciable derangement of health. The duration of the flow should be from four to five days and the amount of blood lost from five to six ounces. Regularity is the chief characteristic of a normal menstruation. At the begin- ning and again at the end of the menstrual life, marked ir- regularity may persist for from one to two years. In normal, well-developed women, when no constitutional disease exists, the symptoms preceding and accompanying the flow may be a feeling of weight and congestion in the pelvis, fulness and tingling in the breasts, and slight headache or backache. Excessive pain before or during the menstrual period, if accompanied by general symptoms, points to some disturbance of the pelvic organs, which, in turn, may be due to constitutional disease. In another very large class of women, the symptoms ac- companying menstruation are far more severe. The sensation of weight and congestion in the pelvis becomes excruciating, the backache almost unbearable, and with the intense head- ache may be associated nausea, or even vomiting of a distress- ing type. Where there is no deformity or disease, these cases may be controlled in youth by hygiene, later by a normal in- terest in the great world of out-of-doors. Monotony and confinement lead to morbid introspection or violent excitement. These cases are largely found in the extremes of indolence, and luxury, on the one hand, and great poverty and privation, on the other hand; and the women who suffer in this way are usually pale, thin, and anaemic, though occasionally stout and plethoric. All marked abnormalities of menstruation are of direct ob- stetrical importance; for a patient presenting such abnormal symptoms is certainly suffering from the effects of a displaced or undeveloped uterus, and a deformity or slight contraction of the pelvis will be found in a fair proportion of cases. Menopause.—The menopause, climacteric, or "change of life," occurs at or about the forty-third year. Before menstru- MENSTRUATION. 47 ation ceases, the periods become irregular for a few months. The majority of women are apt to suffer nervously and often develop vague hysterical symptoms. Pregnancy may occur at this age and a patient may regard the cessation as indicating this. Nurses need only to be re- minded that discussion of a diagnosis must be conservative and the patient should be referred to her physician. V Physiology (continued) fetal development The ovum, originating in the ovary and discharged through the Graafian follicle at or about the time of menstruation, passes into the Fallopian tube, where, if pregnancy is to occur, it meets the male element or spermatozoon. The spermatozoon, shaped plG I7._Human spermatozoa. (Retzius.) A, front view of a spermatozoon ; B,side view; A, head; m, middle piece; /.tail; e, end piece. like a tadpole, with head and long tail (Fig. 17), penetrates the wall of the egg-like ovum and conception has taken place. The interior of the ovum, corresponding somewhat to the yolk of an egg and now containing the spermatozoon, divides into two parts, each part containing half of the yolk and half of the spermatozoon. Each of these parts divides in the same way, and each subdivision again divides and subdivides until the interior of the ovum is filled with a mass of minute divisions of the original yolk and spermatozoon (Fig. 18). These are called " cells," and keep on dividing and subdividing in the same man- ner to' form the foetus and its envelopes. As each separate cell THE OVUM. 49 contains part of the maternal element (ovum) and part of the paternal element (spermatozoon), it is not difficult to under- stand why the child partakes of the characteristics of both father and mother. !.—First stages of segmentation of the ovum of a rabbit. (Allen Thomson, aft, Edward van Beneden's description.) During this process of subdivision of the ovum, which is called segmentation, the entire mass passes slowly on through the Fallopian tube until it emerges into the cavity of the uterus. Once within the cavity, it lodges in one of the folds of the mucous lining, usually in the region of the fundus, and the bor- ders of this fold reach up around it to hold it firmly and prevent its dislodgement (Fig. 19). The mucous membrane lining the uterus undergoes certain changes at each menstrual period, and, as it was formerly sup- posed to be cast off with the menstrual flow and a new mem- brane formed before the next period occurred, it was called dccidua (Latin, deciduus, falling off). It it now understood that little or no tissue from the lining of the uterus is lost in the monthly discharge, but the old name is still retained, al- though the elaborate distinctions between the " decidua of men- struation" and the " decidua of pregnancy" are no longer dis- 4 5° A NURSE'S HANDBOOK OF OBSTETRICS. cussed as formerly. Upon the occurrence of pregnancy there can be, of course, no " falling off " of the uterine lining, no matter what may once have been thought to have taken place at the monthly flow, or the ovum itself would be cast away at the same time and abortion or miscarriage would result. The uterine lining contains a vast number of little creases or folds and the impregnated ovum, after passing from the Fallopian tube into the uterus, lodges in one of these and be- comes securely attached to the mucous membrane, usually near the upper part of the organ, as has already been said. Once securely fixed at this point, the walls of the fold in which the ovum is lodged begin to grow up around it until they meet and enclose it as in a shell. This little shell, containing the impregnated ovum, is made up of decidua, and there is other decidua lining the rest of the uterine cavity upon which this '" shell" and its contents lie, much as would a wart in the palm of the hand when the hand was tightly closed. Thus we have, in pregnancy, three kinds of decidua,— (a) that upon which the ovum rests as soon as it lodges in the fold of the mucous membrane, called dccidua serotina; (b) that which folds up around the ovum to encapsulate it, called decidua reflexa; and (c) that which lines the remainder of the uterine cavity, called decidua vera or " true" decidua. These terms, " decidua serotina" and " decidua reflexa," date back to the time when it was believed that the uterine lining was cast off at every menstruation, and before any very clear understanding had been reached as to the manner of the forma- tion of the decidua of pregnancy. At the present day the ex- pressions decidua- basilis and dccidua capsidaris, respectively, are undoubtedly in better usage, but as they are not so gen- erally accepted they will receive no further notice here. As the ovum enlarges, the decidua reflexa also increases in size until, at about the fourth month when the embryo entirely fills the uterine cavity, it meets and blends with the decidua vera at every point. On the decidua serotina, or point of attachment between the impregnated ovum and the uterine wall, is formed what is known THE DECIDUA. 51 as the placenta, through which the foetus receives its nourish- ment and oxygen from the mother and which will be described later. The decidua reflexa, both before and after it has blended with the decidua vera, forms the outer covering of the amniotic sac, Fig. 19.—Uterus with decidua in beginning pregnancy. (Ruge.) o.i., internal os; o, ovum, covered by decidua reflexa; d, decidua vera. or " bag of membranes," which is lined with a transparent mem- brane called the amnion and filled with a pale, straw-colored liquid, the amniotic fluid or liquor amnii, in which the foetus floats. Considering, now, the foetus at or near the time of labor, we find it floating in a straw-colored liquid, which is contained in 52 A NURSE'S HANDBOOK OF OBSTETRICS. a sac, the " bag of membranes," or amniotic sac, and which lies within the uterus and fills it entirely (Fig. 20). The function of the amniotic sac is to protect the foetus from blows or other injuries that may be inflicted on the mother, while, at the same time, allowing it considerable freedom of motion; to provide it with nourishment and oxygen through the placenta; and, at the time of labor, to dilate the neck of the uterus by forcing its way down through the internal os and stretching the cervix in every direction. Fig. 20.—Normal position of fcetus in utero. (Garrigues.) Extremities completely flexed; occiput presenting, and back of child to left of mother and directed towards the front. (First, or left occipito-anterior, position,—" L. O. A.") Except at one point, which corresponds to the point of at- tachment of the impregnated ovum to the uterine wall, the amniotic sac consists of three layers. The inner, called the amnion, which secretes the liquor amnii, is thin and transparent; the middle layer, called the chorion, is thicker and translucent; while the outer layer is made up of decidua reflexa and decidua vera fused together. THE PLACENTA. 53 At the point of attachment of the ovum to the uterine wall, however, a different formation is found. Instead of a thin, veil- like membrane, a thick spongy mass, called the placenta, is de- veloped. It, too, is covered on its inner (fetal) surface with amnion, under which is a layer of chorion, but its outer surface is composed of dccidua serotina. The placenta (Figs. 21 and 22) is a circular mass about eight inches in diameter; one to one and a half pounds in weight, and one inch in thickness at its centre, thinning out considerably towards the periphery. It forms part of the bag of membranes, and may be regarded as a large thickened area in the sac, attached firmly to the uterine .wall. It is made up almost wholly of blood-vessels, which throw out loops into the uterine tissue to interlock with somewhat similar loops in the vessels of the uterus, but there is no direct connection between the uterine and placental vessels and no actual interchange of blood. The blood of the foetus is pumped by the fetal heart through the placental vessels, and gives up its waste products to, and takes on oxygen from, the maternal blood, much as the blood of an adult is oxygenated by passing through the lungs in vessels that lie closely in contact with the air-spaces. This process, by which waste products and oxygen can pass from fetal to maternal blood, and vice versa, through the walls of the vessels without any actual mingling of the blood currents, is called osmosis. The placenta and foetus are connected by means of the funis, or umbilical cord, usually about twenty inches in length and the size of the forefinger. It leaves the placenta at about its centre and enters the abdominal wall of the foetus at a point called the umbilicus, or " navel," a trifle below the middle of the median line in front. The placenta is formed during the second month of gesta- tion, but is not fully developed until the third month, after which it steadily increases in size as pregnancy advances. The umbilical cord is formed about the fourth week, and, like the placenta, increases in size with the advancement of pregnancy. It is made up of two arteries and one large vein, 54 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 21.—Fetal surface of the placenta. (Garrigues.) The filmy membrane about the circumference is the ruptured amniotic sac. Fig. 22.—Maternal surface of the placenta. (Garrigues.) THE FCETUS. 55 which are twisted upon each other, and these are protected by a soft, transparent, bluish-white, gelatinous substance called " Wharton's jelly." During the early months of pregnancy the fcetus, or " em- bryo'' as it is usually called, bears no resemblance whatever to the human form. At the end of four weeks the ovum (Fig. 23) is merely a spongy-looking sphere containing a small, curved, gelatinous mass, with no evidence of head or extremities (Fig. 24), and if an abortion occurs at this time it is almost invariably lost in the discharge of blood. By the end of the third month it has increased considerably in size, being about four inches in length and weighing about Fig. 23.—Human ovum at the end of the first month. Actual size. (Wood's Museum, Bellevue Hospital, No. 1193.) three and one-half ounces (Fig. 25). The head is now devel- oped, and is by far the largest part of the fcetus, being nearly one-third its entire size. The neck and extremities are also formed and the fingers are separated. The skin is of a pale rose-color and very thin and delicate. The placenta is distinctly developed, and the genital organs are formed sufficiently to per- mit recognition of the sex. From this time on the embryo is called the fcetus. Development progresses rapidly as the weeks go by, and at the end of the sixth month marked changes have occurred. The fcetus is now about twelve inches long and weighs about 56 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 24.—Outline of human embryo of about four weeks. Enlarged four times. (Allen Thomson.) Fig. 25—Human foetus at the end of the third month. Three-fifths actual size (Garrigues.) THE FCETUS. 3/ Fig. 26.—Skeleton of infant at term, showing large head, large anterior fontanelle, small thorax, cartilaginous sternum, tilted pelvis, and bow-legs. Warren Museum, Harvard University. (Rotch.) 58 A NURSE'S HANDBOOK OF OBSTETRICS. a pound. Faint evidences of the eyelashes and eyebrows have appeared, and the skin is darker and firmer. During the seventh month development is extremely rapid, and by the end of this period the fcetus is about fifteen inches long and weighs from three to four pounds. The eyelids can now be opened, and the skin is firmer, lighter in color than before, and covered with a greasy, sebaceous deposit, called " vernix caseosa," which is most abundant in the folds of the integument, and especially in the axillae and groin. This is probably the earliest time at which a child can be born with any reasonable prospect of living. During the eighth month development is slower, and by the end of the ninth, or at " full term," the infant is plump, com- pletely formed, and ready to perform the functions of respira- tion, digestion, and excretion. It is from eighteen to twenty- two inches in length and weighs from six and one-half to seven and one-half pounds. The nails are fully developed and reach the ends of the finger-tips, the hair is long and full, and the skin is firm and paler than at any other previous time. The head of the fully developed fcetus (Fig. 26) is still the largest part of its body, although it has been growing propor- tionately smaller throughout the entire period of gestation. It is oval, or egg-shaped, and it is divided into two parts, the cranium and the face. The cranium (Fig. 27) is the portion possessing the greatest obstetric importance, because, if it can pass safely through the pelvic canal, there is seldom, if ever, any difficulty in delivering the rest of the body. It is made up of eight bones, joined together firmly at the base but separated at the vertex, or top of the head. The sphenoid, ethmoid, and tzvo temporal bones lie at the base of the cranium, and are of no interest to the obstetric nurse. The frontal, occipital, and two parietal bones are, however, of great importance, and form the upper part of the cranium, separated at the time of birth by membranous intervals called sutures, the intersections of which are termed fontanelles. m H Fig. 27.—Fetal skull, side view. (Garrigues.) Actual size. The coronal suture extends from the top of the head downward on either side to the point E; the lambdoidal suture from the back forward, on either side, to the point F. The sagittal suture is not shown, but is indicated by the upper margin of the illustration, passing backward across the coronal suture (anterior fontanelle), and ending at the lambdoidal suture (posterior fontanelle). 60 A NURSE'S HANDBOOK OF OBSTETRICS. By means of this formation of the fetal skull the bones can overlap each other somewhat during labor and so diminish materially the size of the head during its passage through the pelvis. This process of overlapping is called "moulding" and, after a long labor with a large child and a snug pelvis, the head is often so well moulded that several days elapse before it returns to its normal shape. The sutures of the cranium are five in all, but those sepa- rating the parietal and temporal bones on either side are unim- portant, as they cannot be reached by the examining finger during labor. The coronal suture separates the frontal from the two parie- tal bones, the lambdoidal suture separates the occipital from the parietal bones, and the sagittal, or " greater suture " divides the frontal bone into two parts, crosses the coronal suture, separates the parietal bones from each other, and ends at the lambdoidal suture behind. The anterior fontanelle, large and diamond-shaped, is at the intersection of the sagittal and coronal sutures, while at the junction of the sagittal with the lambdoidal suture is the small, triangular, posterior fontanelle. The sutures and the posterior fontanelle ossify shortly after birth, but the anterior fontanelle remains open until the child is over a year old, constituting the familiar " soft spot" just above the forehead of an infant. By feeling one or another of the sutures or fontanelles, and considering its relative position in the pelvis, the physician is enabled to determine accurately the position of the head at the beginning of labor. The foetus lies in the uterus in a state of complete flexion. Its body is arched forward, its head is bent upon the chest, its arms lie close to its body, with the forearms flexed and crossed in front. The thighs are flexed upon the body and the legs upon the thighs, while the feet are crossed like the hands. In nearly all cases the head points downward and the breech lies at the fundus. This is probably because the head, being the heaviest part of the fcetus, would naturally sink to the lowest part of the uterus. FETAL CIRCULATION. 61 The fcetus receives its nourishment and oxygen from the mother's blood into its own through the medium of the placenta. The fetal heart pumps blood through the umbilical cord into the placental vessels, which, looping in and out of the uterine tissue and lying in close contact with the uterine vessels, per- mit an interchange, through their walls, of waste products from child to mother and of nourishment and oxygen from mother to child. As has been said, this interchange is effected by the process of osmosis, and there is no mingling of the two blood- currents. In other words, no maternal blood actually goes to the fcetus, nor does any fetal blood reach the mother. The fetal circulation is so arranged that this passage of blood to the placenta through the umbilical arteries and back through the umbilical vein is possible up to the time of birth, but ceases entirely the moment the child breathes and so begins to take its oxygen directly from its own lungs. In order to understand, even in a general way, the course of the fetal blood-current, it must be borne in mind that, in the infant after birth, as in the adult, the venous blood passes from the two venae cavae into the right auricle of the heart, thence to the right ventricle, and through the pulmonary artery to the lungs, where it gives up its waste products and takes on a fresh supply of oxygen. After oxygenation the so-called arterial blood flows from the lungs, through the pulmonary vein to the left auricle, thence to the left ventricle, and out through the aorta, to be distributed to all parts of the body and eventually collected, as venous blood, in the two venae cavae and discharged again into the right auricle (Fig. 28). In the fcetus there are certain structures necessary to the performance of fetal circulation, but of no use after respiration has commenced and the flow of blood through the umbilical and placental vessels has ceased. Consequently these structures are abandoned as soon as the child cries, and shortly after birth they either disappear entirely or are converted into fibrous cords, and remain in after life as fetal structures only. The most important of these, and the one that must close promptly and effectually at birth if the child is to live for any 62 A NURSE'S HANDBOOK OF OBSTETRICS. DESC VENA CAVff £9 ARTERIAL BLOOD fc&$| VENOUS BLOOD Fig. 28.—Diagram of circulation after birth. Adult type. FETAL CIRCULATION. 63 ARTERIAL BLOOD VENOUS/ BLOOD Fig. 29.—Diagram of circulation before birth. Fetal type. 64 A NURSE'S HANDBOOK OF OBSTETRICS. length of time, is the foramen ovale,—a valve-like opening between the right and left auricles. The others are the ductus arteriosus, connecting the aorta and the pulmonary artery; the ductus venosus, connecting the umbilical vein and the ascending vena cava; and the two hypogastric arteries, springing from the internal iliacs and passing out of the abdomen, through the navel, into the cord, where they become the umbilical arteries. Keeping in mind the course of the blood-current after birth, when these fetal structures have ceased to exist as blood-passages. we can trace the fetal circulation from the placenta, where it is oxygenated before birth, back to its starting-point (Fig. 29). The arterial (oxygenated) blood flows up the cord through the umbilical vein and passes into the ascending vena cava, partly through the liver but chiefly through the ductus venosus which connects these two vessels. It is because of the fact that the liver receives a considerable supply of freshly vitalized blood direct from the umbilical vein that it is, proportionately, so large in the newly born child. From the ascending vena cava the current flows into the right auricle and directly on to the left auricle through the foramen ovale, thence into the left ventricle, and out through the aorta. The blood which goes up to the arms and head returns through the descending vena cava to the right auricle again, but instead of passing through the foramen ovale as before, the current is deflected downward into the right ventricle and out through the pulmonary artery, partly to the lungs (for purposes of nutri- tion only), and partly again into the aorta through the ductus arteriosus. The blood in the aorta, with the exception of that which goes to the head and upper extremities, and which has already been accounted for, passes downward to supply the trunk and lower limbs. The greater part of this blood finds its way through the internal iliacs to the hypogastric arteries, and so back through the cord to the placenta, where it is again vitalized; but a small amount passes back into the ascending vena cava, partly through the liver and partly from the lower extremities, to mingle with fresh blood from the umbilical vein and again make the circuit of the entire body. MULTIPLE GESTATION. 65 As soon as the child is born it cries and inflates its lungs. This causes the ductus arteriosus to contract, and blood no longer passes from the pulmonary artery into the aorta. At the same time the foramen ovale closes and the blood from the venae cavae, which is discharged into the right auricle, passes at once into the right ventricle, to be sent through the pulmonary artery to the lungs for oxygenation. When the cord is tied and cut the current of blood through the umbilical vessels (arteries and vein) ceases and the blood is dammed back through the hypogastric arteries to the internal iliacs and shut off completely in the umbilical vein and ductus venosus. These processes, which occur instantaneously, change the entire course of the blood-current and convert the fetal circu- lation into the ordinary adult type. The foramen ovale remains closed and eventually disappears, and the ductus arteriosus, ductus venosus, and hypogastric arteries shrivel up and are con- verted into fibrous cords in the course of ten or fifteen days. When, as occasionally happens, two or more embryos develop in the uterus at the same time the condition is known as multiple gestation. This is of very rare occurrence, twins being encountered but once in 90 pregnancies, triplets but once in 8000, and quadruplets but once in 370,000. These figures, of course, vary considerably, but they serve to show the extreme rarity of multiple concep- tions. In twin pregnancies the most common combination of sex is a boy and a girl; the next in frequency is two boys; and the least common of all is two girls. Heredity plays an important part in the causation of twins, often making certain families conspicuous on this account, and the hereditary trait is most frequently handed down through the father. Twins are usually due to the fertilization of two separate ova, either from the same or from different Graafian follicles, but they may result from the double impregnation of a single ovum by two spermatozoa or from the complete fusion of a single germ. 5 56 A NURSE'S HANDBOOK OF OBSTETRICS. Triplets come from the double impregnation or complete fusion of one ovum and the simultaneous single fertilization of another, while quadruplets may be regarded as double twins. In the case of twins it is to be borne in mind that as both umbilical cords may come from the same placenta, the maternal end of the cord attached to the first-born must be tied securely before it is cut, lest the unborn child bleed to death. The nurse, from whom skill in ante-partum diagnosis is not to be expected, should make it a point to tie securely both the fetal and the ma- ternal end of every cord before cutting, in view of the possi- bility of the existence of twins. The development of the fcetus in multiple pregnancies does not differ from that of single impregnation, except that the in- fants are apt to be small and feeble, usually one being decidedly weaker and more frail than the other. VI The Physiology of Pregnancy By the physiology of pregnancy is meant a consideration of those changes, both local and general, which affect the maternal organism as a result of pregnancy, but which sub- side at or before the end of the puerperium and leave the woman in practically the same condition in which she was before conception occurred. In other words, these changes are to be regarded as normal, unavoidable, and purely temporary, for they are present in varying degree in every instance, and in the case of a physically perfect woman there should be no traces of them left after convalescence is complete. It must be understood that this statement does not refer to certain skin-markings, which will be described later, or to the slight and unimportant lacerations of the genital tract which in- variably accompany a first labor, but only to such conditions as would have a tendency to affect the general health or even the comfort of the woman. Local Changes.—The uterus increases in size to make room for the growing foetus. It becomes more vascular and the thickened, growing mucous membrane becomes the de- cidua of pregnancy. At the end of four months it has risen out of the pelvis. Its muscular walls become much stronger and more active, and the abdomen must enlarge to accommodate the growing uterus. The mechanical effect of this distention of the abdominal wall causes, in the later months of pregnancy, the formation of certain reddish or bluish streaks in the skin covering the sides of the belly and the anterior and outer aspects of the thighs. These streaks are known as "strife gravidarum," or "lineoz albicantes," and are due to the stretching, rupture, and atrophy of the deep connective tissue of the skin. They grow lighter after labor has taken place, and finally take on the 67 68 A NURSE'S HANDBOOK OF OBSTETRICS. silvery whiteness of cicatricial tissue. In subsequent preg- nancies new reddish or bluish lines may be found mingled with old silvery white striae. Fig. 30.—Stria gravidarum, or Linea; albicantes, showing also abdominal pigmenta- tion especially marked around navel, and protrusion of umbilicus. Multigravida at term. Twins. The number, size, and distribution of stria gravidarum vary exceedingly in different women, and patients are occasionally seen in whom there are no such markings whatever, even after repeated pregnancies. As the striae are due solely to the stretching of the cutis, they are not peculiar to pregnancy, but may be found in other conditions which cause great abdominal distention, such as dropsy and the presence of large tumors of rapid growth. PHYSIOLOGY OF PREGNANCY. 69 Coincident with the uterine and abdominal enlargement the umbilicus is pushed upward until, at about the seventh month, its depression is completely obliterated and it forms merely a dark- ened area in the smooth and tense abdominal wall. Later it is raised above the surrounding integument and projects to about the size of a hickory-nut. While these changes in the uterus and abdomen are going on the vagina and external genital organs are being prepared for the passage of the fcetus at the time of labor. The parts are thickened and softened and their vascularity is greatly increased. This increase in the blood-supply of the genital canal gives to the tissues a dark-violet hue, in great contrast to the ordinary pinkish color of the parts, and often described as a valuable sign of pregnancy. Towards the end of gestation the vaginal secretion is in- creased in amount to serve as a lubricant at the time of delivery. The changes in the breasts are such as will prepare these organs for the performance of nursing, and begin to show them- selves shortly after the occurrence of conception (Fig. 31). The breasts become larger, firmer, and more prominent, and the nipples increase in size, grow sensitive, and are easily stimulated to erectility. The pinkish areola about the nipple of the woman who has never borne a child grows larger and darker until it becomes brown or, in some cases, almost black. This change in the color of the tissue surrounding the nipple is most pro- nounced in decided brunettes and less marked in women of the blonde type. The sebaceous glands which surround the nipple to the number of about a dozen, and are known as the " glands of Montgomery," become enlarged into little rounded elevations under the influence of pregnancy, and are then called the " tu- bercles of Montgomery" (see Fig. 41.) The distention of the skin covering the breasts also causes the formation of " striae" similar in every respect to those already described as occurring in the abdominal integument. Like the abdominal striae, these markings vary greatly in different sub- jects and not infrequently are entirely absent. After the third month the breasts contain a thin, bluish-white, 70 A NURSE'S HANDBOOK OF OBSTETRICS. translucent fluid known as " colostrum," consisting chiefly of fat corpuscles, epithelial cells, and " colostrum corpuscles." Colostrum is the only substance secreted by the breast until about the third day after labor, when the true milk is formed. It contains practically no nourishment, but is of value to the infant during the early days of its life because of its marked laxative effect. Systemic Changes.—The blood of the pregnant woman is increased in amount and in its fluid constituents, while the red cells are proportionately diminished. These changes fre- quently cause disturbance of the circulatory apparatus and the left side of the heart is appreciably enlarged in order to per- form the extra work of pumping this increased quantity of blood through the body. In certain cases the fluid constituents of the blood are increased to such a degree that marked swell- ing (oedema) of the legs, thighs, and external genitals may occur. This oedema must not be confused with that due to kidney disorder; and any swelling of the extremities must be reported at once to the physician. The lungs are subjected, in the later months of pregnancy, to pressure from the underlying uterus, and the patient may suffer severely from cough and dyspnoea. Owing to the in- crease in the total quantity of the maternal blood, and because of the fact that the mother is called upon to oxygenate not only her own blood, but, by osmosis, that of her infant as well, the work of the lungs is markedly increased and the elimination of carbonic acid gas is much greater than in the non-pregnant state. The digestive, secretory, and excretory organs are likewise taxed to a high degree; for the pregnant woman must, in order to nourish both her child and herself, form more blood, digest more food, and excrete more waste products. After a few weeks these increased demands on the digestive organs begin to manifest themselves by causing nausea and vomiting, and the patient is fortunate if these symptoms do not cause her great distress up to about the middle of gestation. DIGESTIVE DISTURBANCES. 71 The appetite also is apt to be capricious in the early months, and, owing to the nausea, it may be greatly diminished. As pregnancy advances and the digestive apparatus seems to become accustomed to its new conditions, these disagreeable features gradually disappear, and the patient usually eats heartily and gains in weight and strength. Her increase in flesh is often noticeable, and the deposits of fat are most marked Fig. 31.—The breasts in pregnancy; A, in a brunette; B, in a blonde. At or near full term. about the breasts, abdomen, and hips, giving a rounded fulness to her figure. The body temperature probably undergoes no change during pregnancy, although it is said by some writers to rise a fraction of a degree towards night. This point is not firmly established, and any regular, though slight, evening exacerbation of tem- perature should be reported to the attending physician. The skin is affected by an increased activity of the seba- ceous and sweat-glands and the hair-follicles. A marked im- provement in the growth of the hair is often noticeable at this time, and many women whose hair was thin and brittle before 72 A NURSE'S HANDBOOK OF OBSTETRICS. the occurrence of conception find it long and luxuriant at the end of the puerperium. The increased activity of the sweat- glands is due to their efforts to assist the kidneys in the elimina- tion of the waste material. Palpitation of the heart is not uncommon, and is due in the early months of pregnancy to sympathetic, nervous disturb- ance, and toward the end of gestation to the pressure of the enlarged uterus. Pigmentation.—In addition, there are also deposits of pig- ment in various parts of the integument, most noticeable about Fig. 32.—Abdominal pigmentation. Deposits of pigment in median line and protrusion of umbilicus clearly shown. Primigravidae at about the eighth month. the nipples and umbilicus and along the median line of the abdomen from the mons Veneris to the navel. In certain cases, also, irregular spots or blotches of a muddy brown color, re- sembling large freckles of varying size and shape, appear on the face, and dark rings form under the eyes. These facial deposits, which in rare instances may be distributed over the entire body, are known as "chloasmata" (plural of chloasma), or " masque des femmes enceintes," and often cause the patient great mental distress; but her mind can be relieved by the assurance that they will disappear after labor, if not before. The pigmentation of the breasts and abdomen, however, never THE URINE OF PREGNANCY. 73 disappears entirely, though it is usually much less pronounced after the birth of the child. All of these pigmentary deposits vary exceedingly in size, shape, and distribution, and are usually more marked in bru- nettesi than in blondes. The abdominal and, especially, the mammary markings are present in almost every case, but the facial deposits are of comparatively rare occurrence, especially in their exaggerated forms. Pelvis.—The pelvis shows certain changes due to pregnancy which are manifested by a thickening and softening of the cartilage lining the joints. This, combined with a tipping backward of the spinal column and a throwing back of the head and shoulders, necessary to enable the woman to maintain her balance in the erect posture, gives the patient a peculiar "wobbly" gait, quite characteristic of pregnancy and especially noticeable in short women. Urine.—The urine of pregnancy is decidedly increased in amount, and is usually of a pale straw-color and low specific gravity. Owing to the pressure on the bladder from the en- larged uterus, and also because of the increase in the total quantity of urine to be voided in each twenty-four hours, the act of urination is usually very frequent and occasionally most uncomfortably so. Traces of albumin are to be found at one time or another in the urine of practically every pregnant wo- man, and while, in the majority of cases, this albuminuria is purely physiological and transitory, it may be of a progressive type and indicate renal disturbance of a serious nature. In like manner, glucose (sugar) is to be found at times in the urine of pregnancy, and, while its presence may be of no special significance, it should be carefully watched. Hence regular and more or less frequent examinations of the urine are necessary throughout the entire period of ges- tation, and it is part of the nurse's duty to her patient to see that specimens are secured at proper intervals and sent to the attending physician for analysis, at least every three weeks. In cases where there is a history of previous kidney disease, or with patients who have suffered from scarlet fever or diph- 74 A NURSE'S HANDBOOK OF OBSTETRICS. theria, the importance of regular urinary examinations at fre- quent intervals cannot be too strongly emphasized, for, at any time under the influence of pregnancy, a latent nephritis may light up and assume most dangerous proportions. Nervous System.—The effect of pregnancy on the nervous system varies greatly, and, while some women may entirely escape such manifestations, the majority of patients present more or less altered mental and emotional characteristics, vary- ing all the way from fretfulness and peevishness to actual in- sanity of a. melancholy or even a maniacal type. In rare in- stances the change is quite to the opposite extreme, and a woman who is ordinarily of an irritable disposition becomes exceed- ingly amiable and agreeable. The most evenly balanced woman is subject to these emotional changes, and it is impossible to foretell how pregnancy will affect any given patient, but in general it may be said that the psychical factor enters largely into the question, and that the more strongly the woman desires a child the more apt will she be to go through her pregnancy without disagreeable nervous manifestations. Moreover, the higher the patient stands in the social scale the more likely is her nervous system to break down under the strain of pregnancy, and the nurse who may never have wit- nessed any such complications during her hospital training will encounter many such women in the private practice of her pro- fession. It is to be borne in mind that none of the conditions de- scribed in this chapter is such as should cause special discomfort to a healthy woman whose pregnancy is proceeding in a natural manner, and any symptom that becomes unduly prominent should be reported to the physician at once. VII The Phenomena of Labor Labor occurs at the end of pregnancy, and is also known by the various names of "delivery," "confinement" "lying-in," and "parturition." The usual time for labor to take place is two hundred and eighty days (ten lunar months, or nine calendar months) after the occurrence of conception. This period varies somewhat, and it is possible for a child to be born and live after only about two hundred and twenty days of utero-gestation. These cases are, of course, extremely rare, and it goes without saying that the more nearly the pregnancy reaches its normal duration the better will be the development of the child and the better its chances for living. The only exceptions to this rule are in cases where the mother is suffering from a disease that greatly imperils the life of the child, or where the child is very large or the pelvis very small, and the induction of premature labor exposes the infant to less risk than would a difficult operative delivery at full term. The popular belief that a seven-months baby has better chances for life than one born at eight months is the most arrant nonsense. It probably arises from the fact that a child born at seven months is positively known to be premature, and so re- ceives the most careful attention after birth, while an eight- months baby is so nearly a full-term infant that its prematurity is often overlooked and it receives no special attention, and may die from some inadvertent neglect of small but important details. After it is dead the fact that it was one month prema- ture is brought out and commented upon. In other cases the pregnancy may exceed its usual duration of two hundred and eighty days, but probably it never goes more than three weeks over term under any circumstances, and three hundred days may be regarded as the extreme limit. In France this point has been made a matter of legislation, and an infant 75 76 A NURSE'S HANDBOOK OF OBSTETRICS. born at any time within three hundred days after the death of its mother's husband is regarded by law as legitimate and enti- tled to property rights in the father's estate, while one born even twenty-four hours after this period is deprived of the right of inheritance. The cause of labor is probably due to the fact that at the end of pregnancy the uterus is stretched to its greatest possible extent, while the fcetus continues to grow larger. The muscular fibres of the uterus resent this over-distention and put an end to it by contracting and forcing the fcetus out of the womb. This theory is borne out by the fact that in twin pregnancies, or in other cases where the uterine contents is unusually large, prema- ture labor is very likely to occur, showing that when a certain degree of distention is reached labor will begin. The premonitory symptoms of labor are usually well marked in the case of a first pregnancy, but in some instances, and especially with women who have borne children, they may be entirely absent. When they do occur they may begin at any time up to two, or even three, weeks before the actual onset of labor. They are due chiefly to the sinking down of the uterus into the pelvis preparatory to the engagement of the fetal head in the pelvic brim. This relieves the pressure on the diaphragm and so lessens or stops the cough, dyspnoea, and other unpleasant symptoms of the last weeks. While the sinking of the uterus relieves the pressure above the diaphragm, it increases that on the pelvic viscera, causing constipation and irritability of the bladder. On the whole, however, the woman feels more com- fortable than she did before the sinking of the uterus. In addi- tion to the symptoms due to alterations in pressure there are occasional slight uterine contractions occurring at irregular inter- vals and causing the woman no discomfort beyond sensation of faint and indefinite cramp-like pains in the abdomen. Labor is divided, for convenience of description, into three distinct stages. The first stage begins with the first true labor-pain and ends with the complete dilatation of the os uteri. The second stage begins with the end of the first and ends with the birth of the child. STAGES OF LABOR. 77 The third stage begins with the end of the second and ends with the delivery of the placenta and membranes. In normal cases the first stage is longer than the second and third together, for after the os is fully dilated the labor pro- gresses rapidly. Labor-pains are merely the rhythmical contractions of the uterine muscle, and are called " pains " because of the suffer- ing that accompanies them. The incorrectness of the term is evident when one occasionally hears a woman say, " I always have easy labors; my pains never hurt me at all." The term is synonymous with uterine contraction. The Phenomena of the First Stage.—The pains are short, slight, and separated by long intervals, usually about half an hour. They do not cause the patient any particular discom- fort, and are not accompanied by any straining of the abdominal muscles. What little pain there is is located in the back, and the patient is usually on her feet and walking about. If the woman has never borne a child or seen a labor, she is commonly in rather a jocular frame of mind, and often expresses great contempt for the reputed suffering of child-birth. A little later, however, the entire picture changes. The pains last longer and are more severe, and recur at more frequent intervals. The patient is still walking about, but at the begin- ning of each pain she grasps a chair-back or some other piece of furniture, and, leaning heavily against it, " grunts " audibly when the pain is at its height. Even now the pains are not specially severe, and between them the patient is usually cheerful and still of the belief that labor is not such a terrible thing after all. As the hours go by the pains become more and more frequent, until they are only five or six minutes apart, while at the same time they last longer and are more severe. The patient is now tired and fretful, and begins to complain bitterly that the end will never come and that something must be done to relieve her. Her entire disposition changes and her face bears an expression of anxiety and dread. She may be nauseated, or even vomit, and her bowels and bladder are emptied every few minutes. At the acme of each pain she usually moans slightly, and in the 78 A NURSE'S HANDBOOK OF OBSTETRICS. intervals she says little, except to ask for water, or other attention, and complain of the slow progress she is making. This picture indicates that dilatation of the os uteri is nearly, if not entirely, complete, and the nausea and vomiting are favor- able symptoms for they are accompanied by relaxation of the tissues. At or about this time the amniotic sac, which, from the begin- ning of labor, has been forcing its way down through the os and dilating it in every direction, usually ruptures and the fluid escapes with an audible gush. Even without a vaginal examination it is usually easy to tell from the appearance of the patient that the first stage of labor is at an end. It may have lasted anywhere from one to twenty- four hours, and is always protracted if the membranes rupture before dilatation of the os is complete. The Phenomena of the Second Stage.—The patient is now in bed and the pains are severe, long (fifty to one hundred seconds), and occur at intervals of every two or three minutes. The abdominal muscles are now brought into play, and as a pain occurs the woman " bears down " with all her strength, so that her face becomes red and even cyanotic, and the large vessels in her swollen neck pulsate violently. At the beginning of a pain she begins to mumble fretfully, and as it reaches its height she concentrates all her voice into a peculiar frenzied cry, so charac- teristic of labor that one who has ever heard it would recognize it at once, even amid the most improbable surroundings. With it all, however, the woman does not complain as much now as during the first stage, and, instead of plying the nurse and physician with impatient demands for relief, she devotes her entire energy to delivering herself, and at times seems almost oblivious of her surroundings. Towards the end of the second stage, when the head is well down in the vagina, its pressure often causes small particles of fecal matter to be expelled from the rectum at the occurrence of every pain. This must receive most careful attention in order to avoid infection. The pains are now occurring so rapidly that there is scarcely Fig. 33.—Preserving the perineum. Fig. 34.—Another case. Preserving the perineum. Fig. 35-—The same case. Farther advanced. It is becoming necessary to use thefull hand in retarding the progress of the head. Fig. 36.—The same case again. Emergence of the forehead and face. No perineal tear visible as yet. Fig. 37.—The same case continued. Delivery of the anterior shoulder. Note the congestion of the child's face. Fig. 38.—Expressing the placenta by the method of Crede. Fig. 39.—Twisting the membrane into the form of a rope to prevent tearing. Fig. 40.—Inspecting the placenta. STAGES OF LABOR. 79 any interval between them, and finally, with a sharp, agonized shriek, the head is born and the mother lies gasping for breath and sighing contentedly. One or two more pains are enough to effect the birth of the body, and practically all of the labor is over. The Phenomena of the Third Stage.—Towards the end of the second stage the placenta has become detached from the uterine wall and lies loosely in the womb or partly in the vagina. After the birth of the child the uterus contracts firmly on the placenta, and there is a period of from ten to thirty minutes in which no pains occur and the exhausted muscles rest from their exertions. A little blood trickles from the vagina, and finally, with one short and not very severe pain, the placenta and mem- branes are expelled and the uterus contracts firmly and per- manently. The total duration of labor in normal cases averages about ten hours, the greater part of which time is taken up by the first stage; but the time may vary from one or two to even twenty-four hours without being in any way injurious to the patient. VIII The Physiology of the Puerperium The puerperium, also called the " puerperal state" and the " lying-in state," is practically a period of convalescence extend- ing from the end of the third stage of labor to the time when the patient has fully recovered from its effects. While, in nor- mal cases, it cannot properly be called a pathological condition, it is so nearly on the border line between health and disease that it must be most carefully watched lest serious complications develop suddenly and unexpectedly. Immediately after labor the patient experiences a sense of exhaustion, which is soon followed by a feeling of delightful comfort and repose. Her child is born, her sufferings have ceased, and she usually passes from a state of perfect content- ment into drowsiness, and finally into sound and natural sleep. Every effort should be made to encourage this state of affairs, and the necessary toilet of the patient and arrangement of the room must be made as quietly and expeditiously as possible, while all visitors, except possibly the husband or mother, are to be rigidly excluded. A chill occurring immediately after labor, and due partly to a disturbance of equilibrium between external and internal temperature, caused by the excessive perspiration in the stage of greatest muscular exertion, and partly to the sudden removal of a large mass of tissue from the abdominal cavity, is not of infrequent occurrence and has no unfavorable significance. A warm bed, hot-water bottles, and a drink of warm tea are all that is needed to control it effectually. The pulse of the puerperal woman should show a marked drop in frequency, due probably to greatly lessened arterial ten- sion. It usually goes down to about 60, and even a fall to 40 beats per minute is not uncommon. This is always a favorable symptom, while a rapid pulse after labor is to be regarded with 80 PULSE AND TEMPERATURE. 8l suspicion as an indication of shock or possibly of concealed hemorrhage. The temperature of the patient usually rises slightly, and while 100.50 F. is generally regarded as the limit in normal cases, patients occasionally show a somewhat higher tempera- ture without ill effects. In judging of the significance of the temperature the pulse is the best guide, for a puerperal pa- tient with a slow pulse is not likely to do badly even if her tem- perature is a little high. Nevertheless, the nurse should report at once to the physician a temperature of over 100.50 F. or a pulse of over 100, and such a patient must be watched most carefully for the possible development of further unfavorable symptoms. The uterus begins to return to its normal condition with the beginning of labor. This process is called "involution," and consists partly in the contraction of the womb and partly in the destruction of certain of its tissues, which are carried away not only in the discharge of blood and serum that follows later, but by means of the general circulation as well. The normal process of involution requires about six weeks, and at the end of that time the uterus should be, as nearly as it ever will be, in the condition it was in before pregnancy occurred. It never re- turns to exactly the virgin state, but may approach it very closely if there have been no lacerations of the cervix. Involution is favored and hastened by everything that tends to make the puerperium perfectly normal, and is delayed by the opposite condition. It is on this account that breast-feeding of the infant is urged in the interest of the mother, for the reflex connection between the breasts and the uterus is so well estab- lished that the irritation of the nipple in nursing acts as a power- ful stimulus to uterine contractions. " Subinvolution" is the term used to describe the condition which exists when involution is not complete at the time when it should be. It is a chronic condition, characterized by a large and flabby uterus usually more or less chronically congested, and causes the patient much discomfort and disturbance of health until it is corrected. 6 82 A NURSE'S HANDBOOK OF OBSTETRICS. The vaginal walls, the vulva, and all other tissues that have become hypertrophied during pregnancy also undergo a process of involution in their return to their normal condition, and the abrasions and lacerations of the genital canal caused by the passage of the fcetus heal completely during the puerperium. Lochia is the name given to the discharges that come from the uterus and vagina for about three weeks after the birth of the child. At first the discharge consists almost entirely of blood, which escapes from the placental site on the uterine wall, mixed with a small amount of mucus and particles of decidua. This should not have large clots or membrane or be in excessive amount. It is known as " lochia rubra " (red lochia), or " lochia cruenta," and lasts about three days, when it gradually changes to a pinkish color due to the admixture of a considerable amount of serum from the healing surfaces; it is known as " lochia sanguinolenta." Towards the eighth or ninth day the lochia is thinner, less in amount, and of a greenish-yellow color with characteristic odor, and is known as " lochia purulenta "; by the end of the third week the discharge usually disappears. The lochia should never, at any time, have an offensive odor, although it possesses a peculiar animal emanation which is quite characteristic. Premature suppression of the lochial discharge may be caused by cold, fright, grief, or other emotion, and is usually dependent upon a relaxed condition of the uterus. Late return of blood in the discharge, after it has once dis- appeared, often occurs when the patient gets up too soon, and is not of any serious import if she returns to her bed for a few days longer. But anything abnormal passed must be promptly reported to the physician and also saved for his inspection. " After-pains" are painful contractions of the womb occur- ring after labor and due to its efforts to expel a blood-clot which has formed within it when it was in a state of relaxation. After- pains are more common in women whose tissues are soft and flabby, and so are seen less frequently in primiparae than in those who have borne many children. They occur at intervals, like labor-pains, and often are said by the patient to cause her more suffering than the labor-pains themselves. The proper manage- RETENTION OF URINE. 83 ment of the fundus uteri will insure firm and permanent con- traction, and is the best preventive against after-pains. When they are at all severe they interfere markedly with the patient's rest and comfort, and the physician will usually find it necessary to remove the clot from the uterus to effect a cure. Under or- dinary circumstances they will disappear spontaneously about the fourth day. Retention of urine is not uncommon during the first two or three days after labor, owing to the swollen condition of the urethra and the tissues surrounding it. Its treatment is dis- cussed in the following chapter. Constipation after labor is the rule rather than the excep- tion, because of the relaxed condition of the intestinal and abdominal muscles and the inability of many persons to empty the bowels while in the dorsal position on the bed-pan. As the rectum has been, or should have been, emptied by enema at the beginning of labor, nothing further is needed until about two days have elapsed, when the physician usually orders a simple cathartic, such as castor oil. The appetite of the patient is usually somewhat diminished during the early part of the puerperium, and this, combined with the fact that all of her excretions are markedly increased, causes her to lose flesh to the amount of from nine to twelve pounds before she begins to gain in weight. '" Milk fever" is a term occasionally, and incorrectly, used to describe a slight and unimportant rise of temperature that occurs about the third day and subsides in a few hours. This was long supposed to be due to the development of milk in the breasts, which occurs at the same time, but it is now known to depend entirely on a very slight infection due to the un- avoidable introduction of a few bacteria into the genital tract. The author believes, however, that the mere discomfort, due to tension in the early days of lactation, unless steps are promptly taken to relieve it, is not infrequently responsible for this phe- nomenon, independently of any infection whatever. It is quite a regular occurrence, and should never last more than a day. Directions for nursing and care of the breasts will be found in another chapter. IX The Signs and Symptoms of Pregnancy As stated in the introductory chapter, it is highly desirable for the pregnant woman to be under medical care from as early a date as possible, and as women who suspect that they are pregnant are very apt to discuss the matter with a nurse before consulting a physician, the first duty of the nurse under such circumstances is to advise the patient of the importance of seeking medical counsel at once. More than half the women who present themselves at the physician's office late in pregnancy have nurses engaged for their confinements, and yet it seldom happens that these patients visit the physician by the direction of their nurses. In short, it would seem that nurses and physicians do not work together in such matters to the extent that they should, and it rests with the nurses to bring about a more harmonious state of affairs. Naturally, before advising a patient to consult a physician in regard to a suspected pregnancy, the nurse will wish to be reasonably sure in her own mind that conception has actually occurred. There are many signs and symptoms which point to the existence of pregnancy, some of which can readily be recog- nized by the nurse, while others can only be made out accurately by one who has had a thorough medical training. Of these signs, but three are absolutely indicative of preg- nancy, and of these, two may be absent if the fcetus has died in the womb. Moreover, these " positive" signs are not present until about the middle of gestation, when the physician can usually make a diagnosis without them by the " circumstantial evidence" of a combination of earlier and less significant symp- toms. While, in the great majority of cases, the early diagnosis of pregnancy is extremely easy to one familiar with such condi- 84 MORNING SICKNESS. 85 tions, it occasionally presents many difficulties, even to the skilled observer, and in rare instances no positive statement can be made until one or another of the three positive signs has appeared. The signs of pregnancy are divided by most writers into three groups', and in the following table those which are appre- ciable to the educated nurse are printed in heavy-faced type. A. PRESUMPTIVE SIGNS. 1. Menstrual Suppression. 2. Vomiting. ("Morning Sickness.") 3. Irritability of the Bladder. 4. Mental and Emotional Phenomena. ("Morbid Longings, etc.") B. PROBABLE SIGNS. 1. Mammary Changes. (Enlargement of the Breasts, Shooting Pains, Pigmentation, etc.) 2. Bimanual Signs. (Size of Uterus, Hegar's Sign, etc.) 3. Abdominal Changes. (Size, Shape, Pigmenta- tion, etc.) 4. Changes in Cervix. (Size, Shape, Consistency, etc.) 5. Violet Color of the Vaginal Mucous Membrane. 6. Uterine Murmur. 7. Intermittent Uterine Contractions. C. POSITIVE SIGNS. 1. Passive Fetal Movements. (" Ballottement.") 2. Active Fetal Movements. ("Quickening.") 3. Fetal Heart Sounds. Cessation of menstruation and morning vomiting are placed first in the list of Presumptive Signs because the former is the symptom usually first noticed by the patient and the latter is the one that is most likely to bring her to the physician. Irritability of the bladder, characterized by very frequent and often more or less painful voiding of the urine, is also apt to be the first symptom of pregnancy. This may occur very 86 A NURSE'S HANDBOOK OF OBSTETRICS. shortly after conception and before the next menstrual period is due, and as it is often ascribed by the patient to " catching cold," or to some other trivial cause, it is not, as a rule, men- tioned except in response to the questioning of the physician. This irritability is due to the pressure, on the bladder, of the recently impregnated uterus, which has a tendency to tip for- ward and settle down deeply in the pelvis, and, when accom- panied or followed by stoppage of the menstrual flow it is, in a married woman, very suggestive of pregnancy. If this combination of symptoms is followed by vomiting on arising in the morning, or even by nausea at this time, the diag- nosis becomes more probable than ever. The usual character of this form of vomiting is that of a sudden, paroxysmal emptying of the stomach, occurring the moment the patient gets out of bed. Under normal conditions, it may continue until about noon, the stomach promptly reject- ing any food or drink that may be swallowed. After twelve or one o'clock the irritability of the stomach usually ceases, and the patient has no further trouble or discomfort until the next day, when the whole affair is repeated. This symptom begins, as a rule, about the end of the second month, but it may be noticed at any time after conception has occurred, even as early as the third or fourth day. It generally stops by the end of the fourth or fifth month, and vomiting occurring late in pregnancy is always to be regarded with suspicion, as indica- tive of some severe systemic disturbance of toxaemic origin. Mental and emotional phenomena are, fortunately, not very common, but they may be noticed in some cases. For example, a woman of the most amiable disposition may, under the influence of pregnancy, become exceedingly disagreeable and fretful, while, on the other hand, one of great asperity may, rarely, go to the opposite extreme and take on the qualities of a veritable saint. In the same way, articles of food and forms of amusement, ordinarily unthought of, may suddenly be demanded, and in rare instances the most unusual and even disgusting impulses may be fostered. The writer has had recently under CHANGES IN THE BREAST. 87 his care a woman who, when pregnant, developed an irresistible appetite for raw potatoes. The changes in the breast include enlargement of the entire gland on both sides; a sense of fulness, and shooting or tingling pains in these organs; and darkening of the tissues surrounding the nipples (Fig. 41)- Temporary slight enlarge- Fig. 41.—Marked pigmentation of breast. Tubercles of Montgomery and a drop of milk on the nipple plainly shown. ment of the breasts and sensations of weight and fulness are, of themselves, of no significance, for, in many women they may be noticed at the ordinary menstrual periods, but the darkening of the areola around the nipples and the presence of a silvery white fluid (colostrum), which can be squeezed out of the breast, constitute, in a woman who has never borne children, very significant signs of pregnancy. If, however, the woman has had a child, the areolar pigmentation from the previous preg- nancy will remain, and it is not unusual for colostrum to be present for months or even years after it has once appeared. Thus, while it is apparent that these breast symptoms are not of much account in the case of a woman who has borne chil- 88 A NURSE'S HANDBOOK OF OBSTETRICS. dren, they are of great significance if the patient has never been pregnant before. The abdominal changes are supposed to begin with a flat- tening of the abdominal wall in the early weeks of gestation, due to the tipping forward and sinking of the uterus, to which reference has already been made as causing irritability of the bladder. This supposititious flattening has given rise to the old French saying,— " Ventre plat, Enfant il y a;" which doggerel, being translated freely and with equal poetic feeling, would read,— " In a belly that is flat There's a child, be sure of that;" but, as King has said, " One can't be sure of that," by any means. In the first place, the uterus at this time is so small that no change in its position would have any tendency to appreciably flatten or otherwise affect the contour of the ab- dominal wall, and even if such a change did occur it would be so slight that it is highly improbable that it would ever be noticed by the patient or brought to the attention of the physi- cian or nurse. The pigmentation of the abdomen, extending up the median line and surrounding the umbilicus is, in a woman who has never borne children, almost diagnostic of pregnancy, but, like the pigmentation of the breast, it varies exceedingly in different subjects, being often entirely absent in decided blondes and exceptionally well marked in pronounced brunettes. In women who have borne children previously this pigmentation remains from the former pregnancies, and cannot be depended upon as a diagnostic sign. The size of the abdomen in pregnancy corresponds with the increase in the size of the uterus, which, at the end of the third month is at the level of the symphysis pubis, at the end of the sixth month at the level of the umbilicus, and towards the end of the ninth month at the ensiform cartilage. Mere ab- PASSIVE FETAL MOVEMENTS. 89 dominal enlargement may be due to a number of causes, such as an accumulation of fat in the abdominal wall, dropsy, uterine or ovarian tumors, and the like. If, however, the uterus Fig. 42.—Size of the uterus at each month of pregnancy. The fundus reaches the symphysis at the third month, the umbilicus at the sixth month, and the ensiform cartilage at the middle of the eighth month, after which it sinks a little before labor begins. can be distinctly felt to have enlarged in the proportions stated above, pregnancy may properly be suspected. The nurse cannot be expected to make out this uterine enlargement until the fundus is well above the symphysis, so this sign is of no value to her as a means of early diagnosis. The nurse will hardly be called upon to inspect the vaginal mucous membrane for evidences of pregnancy, but it may be said that, owing to pressure and consequent congestion within the pelvis, this mucosa becomes thickened and of a dark violet or purple color instead of its customary pinkish tint in the non- pregnant state. This sign is of no special value in women who have borne children, and as it may be due to any form of con- gestion or to the presence of new growths or varicosities within the pelvis, it is very unsatisfactory at best. Passive fetal movements (" ballottement,'' from the French ballotter, to toss up like a ball) can only be made out by the physician skilled in obstetric examinations, but the active movements of the fcetus within the uterus are readily 9° A NURSE'S HANDBOOK OF OBSTETRICS. recognized after the fifth month by placing the hand firmly against the abdominal wall over the uterus and holding it there until the fcetus is felt to kick vigorously, as it does every few minutes. This sign is unmistakable to the examiner, although the patient may sometimes imagine the movements of gases in the intestines to be the motions of a fcetus within the uterus. If the child is dead these movements will not be felt, but there will usually be a history of the previous occurrence of such fetal activity. The sounds of the fetal heart are often heard with great difficulty by the physician, and it is not to be expected that a nurse will always be able to make them out. Occasionally, however, in the latter months of pregnancy and with all con- ditions favorable, the nurse will be able to hear the fetal heart- beat, like the ticking of a watch under a pillow, by placing the ear firmly against the abdominal wall. The fetal heart should make from one hundred and thirty to one hundred and fifty beats to the minute, and is absolutely distinct from the maternal pulse. Like active fetal movements, this sign will not be discovered if the child is dead. Having decided, from one or more of the above signs, that the woman is probably pregnant, or if there is any doubt as to her condition, she should be directed to consult, at once, the physician who is to attend her during her confinement. The probable date of the labor may be computed by taking the first day of the last menstruation, counting back three months, and adding seven days. This will give a date which is to be regarded as the middle of a period of two weeks during which the labor may be expected to occur. Thus, if the woman's last menstruation began on June 14, count back three months to March 14 and add seven days, making March 21. She may then be told that her labor will probably take place between March 14 and March 28. Remember that this is merely an approximate date, for the exact time of impregnation can seldom be determined, and it is not at all certain that the woman will go her complete term of two hundred and eighty days after impregnation, even if that date were positively known—so the exact date for delivery can never be definitely known. X The Mechanism of Labor In studying the mechanical phenomena that accompany de- livery it is necessary to consider three factors,—the " passenger" (fcetus) ; the "passages" (uterus, vagina, and vulva) ; and the forces of labor, which impel the " passenger" through the " pas- sages" into the world. The forces of labor may be subdivided into two classes,—the expulsive forces, situated in the muscular fibres of the uterus and assisted by the powerful abdominal mus- cles ; and the resistant forces, which consist of the resistant powers of the tissues composing the cervix, the vaginal floor, and the perineum. These two classes of forces must be very nearly balanced, but with the expulsive force slightly in excess, if the labor is to be normal. If the resistant forces are in excess, labor cannot occur without operative interference, and if the expulsive force greatly exceeds the resistant force a precipitate labor will result, with probable severe laceration of the maternal soft parts and with great danger to both mother and child. The "passenger" (fcetus) lies in the womb in a state of complete flexion, and we have to consider its presentation and its position, for unless these are both normal, or can be made normal, the labor cannot be normal. Presentation refers to that part of the fcetus which " pre- sents" at the brim of the pelvis at the beginning of labor. For example, if the head lies in the brim ready to come down into the vagina the case is said to be one of " vertex" presentation; while if the breech is first to appear, it is called " breech" pres- entation. Position has to do with the relation of the presenting part to the pelvis. Thus, in a vertex presentation, the back of the head (occiput) may point to the front or to the back of the 9i A NURSE'S HANDBOOK OF OBSTETRICS. pIG- 43.— Vertex presentation. (Bumm.) A, left occipito-anterior (L. O. A.); B, right occipito-anterior (R. O. A.); C, right occipito-posterior (R. O. P.); D, left occipito- posterior (L. O. P.). VERTEX PRESENTATION. 93 pelvis. The occiput never points exactly forward or backward in the median line, but is always directed to one side or the other of the middle. Consequently we may have any one of four positions in a vertex presentation,—namely: Occiput to left of front, or left occipito-anterior. (" L. O. A.") Occiput to right of front, or right occipito-anterior. ("R. O. A.") Occiput to right of back, or right occipito-posterior. (" R. O. P.") Occiput to left of back, or left occipito-posterior. (" L. O. P.") Vertex presextations (Fig. 43) occur in nearly all cases (ninety-seven per cent.), probably because the head is the heaviest part of the fcetus, and so has a natural tendency to sink to the bottom of the uterus. The position of more than half (seventy per cent.) of all vertex presentations is with the occiput to the front and to the left of the median line. This is called the " left occipito-anterior" position of the vertex, and is usually abbreviated by physicians as " L. O. A.," an expression with which the nurse will become very familiar in the course of her obstetrical training. " L. O. A." is by far the most common of all positions, and as, for this reason, it may be regarded as the normal position of the fcetus in utero it is also occasionally styled the " first" position. In the same way, the other positions of the vertex, " R. O. A.," " R. O. P.," and " L. O. P.," are sometimes called, respec- tively, the second, third, and fourth positions of the vertex. In order that the vertex, or top of the head, may present, the head must be "flexed;" that is, tipped forward on the chest; and this flexion increases as labor progresses until the head has passed through the brim of the pelvis and is in the vagina (Fig-44). While the head is descending in this way the occiput is grad- ually rotated forward (in anterior cases) until it lies in the median line in front and under the symphysis pubis. This rota- tion is due to the action of the funnel-shaped walls or "inclined A NURSE'S HANDBOOK OF OBSTETRICS. planes" of the pelvis, which turn the head in the right direction much as a ball may be rolled down a winding gutter or trough. Fig. 44.—Flexion of head during second stage. (Pinard and Varnier.) The shaded head shows the minor flexion at the beginning of labor, and the unshaded the stronger flexion as labor progresses, oc, oc', occiput. As soon as the completely flexed head has passed through the pelvic brim and lies with the occiput under the symphysis, the process of " extension" begins. The chin is now raised from the infant's chest and sweeps down over the posterior vaginal wall and perineum into the world (Fig. 45). The occiput, which has been practically stationary under the symphysis, where it has acted as a pivot during the extension of the head, is now born, and the most difficult part of the labor is over. Almost immediately after the birth of the head it is again rotated in a quarter-circle, so that its back points to the same side that it did at the beginning of labor. This is called " exter- nal rotation," or "restitution" (Fig. 46), and is caused by the action of the inclined planes of the pelvis on the shoulders of the infant, which are rotated like the head as they pass down through the pelvic canal. " External rotation" is of interest to the physician, as it enables him to verify his diagnosis of posi- tion, made at the beginning of labor. If the case is " L. O. A.," FLEXION AND EXTENSION. 95 the back of the head will, after external rotation, point to the left side of the mother, as it did before labor began. Fig. 45.—Extension of the head in anterior presentations of the vertex. (Garrigues.) We have, then, to consider during labor in anterior positions of the vertex (" L. O. A." and " R. O. A."), Flexion, Rotation, Extension, and Restitution of the head, all accompanied by De- scent (Fig. 47). If, instead of being flexed, the head, in a vertex case, is ex- tended or tipped backward on the body of the child at the begin- ning of labor, the case will become one of "face" presentation. This is one of the most serious complications that can arise in connection with labor, for if the face cannot be changed by the physician into a vertex presentation, the child cannot be born, except in rare instances, without operative interference of one kind or another (Fig. 48). 96 A NURSE'S HANDBOOK OF OBSTETRICS. "Brow" presentations are those midway between face and vertex, and occur when the head is neither fully flexed nor fully Fig. 46.—External rotation. (Garrigues.) The case was originally L. O. A., and the vertex now points to the left thigh of the mother. extended (Fig. 49). Because of the "wobbly" position of the head, brow cases usually convert themselves into either face or vertex presentations before labor is very far advanced. Hap- pily, the most common outcome of a brow case is spontaneous conversion into a vertex presentation. Either a brow or face presentation may occur in any one of four positions, named according to the direction in which the chin points (Fig. 50). Breech presentations are those in which the breech instead of the vertex presents at the pelvic brim. They are fairly com- INTERNAL ROTATION AND EXTENSION. mon, and the chief difficulty in their management lies in the fact that, during the descent of the body, the arms of the fcetus are liable to become extended above the head and interfere Fig. 47.—Internal rotation and extension. (Tarnier and Chantreuil.) seriously with its passage through the pelvis (see Fig. 64). Breech presentations occur in any one of four positions, named according to the direction in which the sacrum of the infant points (Fig. 51), thus: Left sacro-anterior ("L. S. A.") Right sacro-anterior (" R. S. A.") Right sacro-posterior ("R. S. P.") Left sacro-posterior ("L. S. P.") In breech cases the infant often passes meconium from its rectum during the course of the labor, and if, after the mem- branes are ruptured and the liquor amnii has escaped, the nurse finds a black, tarry discharge coming from the patient's vagina, she may very properly suppose that the case is one of breech presentation. 7 98 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 48.—Shape of head of child born in face presentation. (Char- pent ier.) Fig. 49.—Shape of head ot child born in brow presentation. (Charpentier.) Fig. 50.—Face presentation. (Bumm.) BREECH PRESENTATION. 99 Fig. 51.—Breech presentation. (Bumm.) A left sacro-anterior; B right sacro-postenoi Fig. 52.—Prolapse of arm in transverse presentation. (Tarnier and Chantreuil.) ioo A NURSE'S HANDBOOK OF OBSTETRICS. Other presentations, all of which are very rare, are those of the foot, arm (Fig 52), or shoulder. The study of the special mechanism of the different presenta- tions and positions is one of great interest, but the brief outline given of the mechanism in anterior positions of the occiput is all that directly concerns the nurse. All other cases are more or less abnormal, and, as their progress is usually slow, their manage- ment must be left entirely in the hands of the medical attendant. OBSTETRICAL DIAGNOSIS This is made in five ways : (1) Inspection ; (2) palpation 5(3) vaginal examination; (4) auscultation; (5) pelvimetry. Nurses are expected to know whether a presentation is normal Fig. 53.—Usual method of palpating the abdomen. The palms of hands are used. or otherwise, as the work in rural, sparsely settled localities may often require of her knowledge not demanded in her hospital training. Only under most unusual conditions would she be ex- pected to do this in any other way than by inspection and pal- pation, and with this1 she should thoroughly familiarize herself. For palpation she lays both hands, gently always, flat upon the abdomen (Fig. 53). If done in any other manner than this the stimulation of her fingers will cause the abdominal muscles OBSTETRICAL DIAGNOSIS. IOI to contract. She can (excluding all other possible findings) so palpate the uterus in a definite routine way as to decide the pres- entation and position of the fcetus. i. She should ascertain what is lying at the fundus of the uterus by feeling with both hands—generally a little to the left or in the median line will be felt one pole of the fcetus. She must decide which pole it is by observing three points: (a) Its relative consistency. The head is harder than the breech. If the placenta lies between the head and the hand—this cannot be determined, however, in this way. (b) Its shape. If the head, it will be round and hard and the transverse groove of the neck may be felt. The breech has no groove; and sometimes the feet may be felt. (c) Its mobility. The head will move from the neck. The breech only with the trunk. 2. She should feel for the back of the fcetus with both hands, pressing the uterus between the hands at about the level of the umbilicus. She will either feel:— (a) The firm back or the irregular outline of the limbs. She will know, if the back lies in the long axis of the uterus, that the head or breech presents. If the back lies horizontally or obliquely across the uterus, the presentation is, of course, transverse. 3. She will feel if the pelvic brim is empty or ascertain what part presents by means of pelvic palpation, known as Pawlik's grip. It consists in placing the fingers over the centre of Pou- part's ligament on the left side and the thumb on the right cor- responding spot and by pressing together feel either the head or breech as she did when palpating the fundus. Thus she will feel : 1. The head or breech at the fundus. 2. The back or limbs at the level of the umbilicus. 3. She may find the back of the fcetus horizontally or obliquely across the uterus. This position must be remedied by an operation known as version. Owing to the fact that any position in which the child's long axis does not correspond to the long axis of the mother is a serious condition and will be fatal to one or both lives, it is im- portant that it be discovered as early as possible. XI The Management of Pregnancy When the pregnant woman consults the physician in refer- ence to her condition, he will first determine the duration of the gestation and the probable date of the expected labor, and then give the patient some general hygienic rules for her guidance during her pregnancy. It is not only proper, but important, for the nurse to have a clear understanding of the nature of these directions: Clothing.—Corsets and any other garments that constrict or compress the chest, waist, or abdomen must be laid aside from the first, and the skirts supported from the shoulders by means of some form of "corset-waist." There are a number of ma- ternity corsets on the market, the best known being the Jenness- Miller and the Ferris Maternity or Berthe May corset. The reasons for this rule are many and important. In the first place, anything that compresses the chest retards greatly the development of the breasts, which should be marked during preg- nancy, and by so doing tends to flattening or even depression of the nipples. Both of these conditions will interfere with the function of lactation, even if they do not render it entirely impos- sible ; and as the proper performance of nursing has a direct and powerful effect on the involution of the uterus and its return to its normal condition after labor, any such interference exerts a most unfavorable influence on the convalescence of the mother as well as upon the health of the infant thus deprived of its natural form of nourishment. Moreover, pressure on the chest walls, especially as it is in- creased from day to day by the gradual enlargement of the breasts without any compensating loosening of the corsets, pre- vents necessary expansion of the lungs and hinders the working of the heart, already hypertrophied as a normal result of preg- nancy. The harmful consequences of such conditions can readily be seen, for it is not difficult to understand that a woman who has to supply oxygen for herself and another being, and who 102 WEARING APPAREL. 103 must eliminate, with her own blood, the waste products of an unborn infant as well as those of her own body, must neces- sarily have her respiratory and circulatory organs unhampered if she is to perform these tasks in a thoroughly normal way. The injurious results of pressure about the waist and ab- domen are much the same. Respiration is affected by interfer- ence with the play of the abdominal muscles and the diaphragm; circulation is impeded by pressure on the large abdominal blood- vessels ; the normal action of the kidneys, liver, and digestive or- gans is seriously hampered ; and, lastly, the full development of the infant is markedly interfered with. The use of corsets and the practice of " lacing " during preg- nancy are usually due to a desire on the part of the mother to con- ceal her condition as long as pos- sible, coupled with ignorance of the disastrous results that may, and often do, follow the em- ployment of such means of concealment. Most women will abandon these devices at once when their dangers have been carefully explained. Loosely fitting garments do more to conceal the progressive abdominal enlargement of pregnancy than can be accomplished by lacing or other mode of constricting the figure. If for any reason a maternity corset is not desired, comfort for the pendulous breasts and abdomen may be secured by wear- ing a maternity binder. This affords relief from the weight and movements of the child. Instead of the breast supporter a well- fitting brassiere, if properly adjusted, will serve the purpose equally well. But these supports must be perfectly fitted to the constantly enlarging figure. Undergarments should be made of wool, of a weight suited to the season of the year, and should extend down to the ankles and cover the arms to the wrists. Fig. 54-—Abdominal binder. To be worn during pregnancy. 104 A NURSE'S HANDBOOK OF OBSTETRICS. Wool is insisted upon, to the exclusion of cotton or linen, because it absorbs perspiration as rapidly as it is excreted, and so keeps the skin dry at all times. When the integument is damp with perspiration, as it is in hot weather or after exertion, if cotton or linen underwear is worn, any sudden chilling of the sur- face will close the capillaries and drive a considerable amount of blood to the interior of the body, causing congestion of the in- ternal organs. At the same time, this chilling of the surface and contraction of the capillaries prevent further perspiration, and so throw an additional strain on the kidneys, now congested through increased blood-supply and overworked by the addition of fetal to the maternal elimination. Outer garments are to fit loosely, and must be enlarged as occasion requires. There are on the market a wide selection in all varieties of goods and patterns, the principle upon which they are built being the avoidance of all constriction to breasts and abdomen, and the hanging of all weight upon the shoulders. Garters that encircle the leg tend to the development of vari- cose veins in the lower extremities, and are to be discarded in favor of some form of stocking supporters attached to the corset- waist or extending over the shoulders. It will be remembered that arteries have muscular tissue in their walls, while veins have little or none, and that arteries stand open when empty, while veins collapse. Hence any constriction of an extremity affects the vein far more than the arteries, and blood, which meets with no obstruction whatever in its flow down the extremity through an artery, will, on its return through the vein, find at the point of constriction sufficient closure of the vessel to dam it back and so stretch the vein wall that a varicosity is formed. As there is already a marked tendency in this direction, by reason of the enlarged and constantly enlarging uterus imped- ing return circulation from the lower extremities by compres- sion of the great abdominal vessels, corsets or garters tend to aggravate the condition. Garters that encircle the leg should never be worn, even by unmarried women, for the tendency to varicosities is always present, and when once formed they never disappear but grow worse from year to year. WEARING APPAREL. 105 Shoes.—Comfortable, well-fitting shoes are the only foot cov- ering to be considered during pregnancy. High heels interfere with a proper poise of the body and throw weight upon the lower abdomen in addition to the strain caused by the growing uterus. The shoes may have to be worn a larger size because of the tendency of the feet to swell. If walking is to be a pleasure and not a pain, proper shoes must be worn. Exercise in the open air should be taken daily throughout the entire course of pregnancy, and, of all forms of exercise, walking is, without question, the best. Smooth roads are to be selected for the daily jaunts, and they must be so regulated as to distance that the woman will arrive home exhilarated, but just within the point of fatigue. A woman of ordinarily good physique, beginning her walks early in pregnancy, should start with about one mile and in- crease the distance half a mile a day until six miles are covered. When this distance is reached it is to be regarded as the regular daily task if it can be accomplished comfortably, but if it prove to be exhausting it must be cut down to a more suitable length. While six miles a day is not too much for a strong healthy woman accustomed to out-door life, and may safely be taken as a standard for comparison, it must never be forgotten that many patients of frailer constitution can be allowed only two or three miles a day, and no woman should ever be urged to undertake more than her strength will permit. The final test lies in the condition in zvhich the patient re- turns home. If she is tired and worn out, the distance has been too great, while if she is invigorated and refreshed at the end of her walk, it has been beneficial. Moderately stormy days need not interfere with the usual outing if the woman is properly dressed for the weather, with rain coat, high storm boots, and rubbers or overshoes. The dangers of chilling the body, and consequent congestion of the internal organs, must always be kept in mind, and if, by any accident, a pregnant woman is inadvertently exposed to in- clement weather and returns home cold and exhausted, steps must be taken at once to stimulate surface circulation and restore warmth to the body. 106 A NURSE'S HANDBOOK OF OBSTETRICS. A hot drink of milk or tea should be given, and then, after all clothing has been removed, the patient is to be rubbed vigorously, wrapped in warm blankets, and surrounded with external heat. As soon as she is perfectly comfortable and entirely free from all chilly sensations, the blankets are removed and she is again rubbed briskly with warm, diluted alcohol and dressed in warm clothing, unless she prefers to remain in bed between sheets. She is to lie in the blankets only long enough to get thor- oughly warm and not until she begins to perspire. Walking is preferred during pregnancy to every other form of exercise, because it stimulates the muscular activity of the entire body, and in the later months it distinctly favors the des- cent of the fetal head into the pelvis, insures complete flexion, and shortens materially the first stage of labor. Moreover, it is available to all women, no matter what their circumstances in life may be. Aside from walking there are very few forms of out-door exercise that meet the requirements of the pregnant woman. Dancing and horseback riding are too violent and driving not sufficiently invigorating; tennis is too uneven and tiresome, and croquet too tame and uninteresting; while golf in moderation and automobiling over smooth roads are debatable questions, and may possibly be permitted, especially if the latter is una- voidable. But a continuous motion may induce the onset of premature labor. Walking is the best of all, and if any of the other permissible forms are allowed it should be only at rare intervals and on special occasions. Of in-door exercise there is only one form worthy of con- sideration. Massage combined with passive movements is some- times most helpful where the oedema interferes with the blood circulation. (Massage of the breasts and abdomen must of course be carefully avoided.) This consists in stimulating the abdominal muscles by lying on the back on the bed or floor and, with the arms folded over the chest or the hands clasped back of the head, rising to a sitting posture without drawing up the legs or raising the heels. This is to be repeated several times until a slight sense of fatigue is experienced, and should IN-DOOR EXERCISE. 107 be begun early in pregnancy and practised twice daily, in the morning before arising and at night just before retiring. If this form of exercising the abdominal muscles is found to be too difficult, as is often the case, the patient may, instead, lie on her back and raise the feet slowly in the air, first one foot at a time and then both feet together. This should only be done by order of the obstetrician and never on the patients initiative. The sewing machine is a most potent factor in the causation of miscarriages and must be used to a very restricted degree, if at all. It is quite a simple matter to attach electric power to a sewing machine, so the objection to its use is much lessened. The lifting and carrying of heavy weights or a child, all un- necessary stair climbing, and every form of violent exertion must studiously be avoided. The patient should avoid crowds and all conditions affording her a sense of discomfort. Bathing at frequent, stated intervals is of the utmost im- portance, and baths should be taken daily when possible. Warm water and an abundance of soap are to be used, for it is essential to keep the skin in good condition and the pores free, lest per- spiration be interfered with and too great a strain be thrown upon the kidneys. The relation of perspiration to the action of the kidneys is little understood by the laity, and most persons are unaware that the skin of an adult excretes, in twenty-four hours, from one and one-half to two pints of fluid, or nearly as much as is eliminated in the form of urine, and that if perspiration were to cease entirely, the kidneys would be unable to perform the double task which would be required of them, and death would inevitably result within a few hours. Baths are best taken at night, just before retiring, and fol- lowed with a brisk rub, but a morning bath may be allowed, even with tepid or cool water (850 to 900 F.) if the patient has always been accustomed to one. Salt water " still " bathing is usually beneficial when practised under proper conditions, but bathing is distinctly contraindicated throughout the entire period of gesta- tion. As routine, cold baths, cold sponges, cold shower baths must all be prohibited. At the last month many physicians advise the 108 A NURSE'S HANDBOOK OF OBSTETRICS. use of a shower bath or spray, or sponge of the proper tem- perature to avoid the possible entrance into the vagina of the water in a bath tub. This is logical and recommends itself. In addition it is often most difficult for the patient to get in and out of the ordinary bath tub unless she has help. Sleep, in greater amount than usual, is required by the preg- nant woman, and, in addition to the regular sleep at night, a nap of one or two hours in the afternoon is highly desirable. // the patient is unable to sleep in the daytime, the afternoon nap should not be entirely given up, but she should lie down on the bed or couch and rest quietly for an hour or two every day. The bedroom should be of good size on the south or east side and in a quiet part of the house, and thoroughly well ventilated. Even on the coldest winter nights a window can be opened a few inches at the top and bottom to insure a free circulation of fresh air. If the bed is, necessarily, so situated that it is in the direct line of draft, a screen may be placed at its side, or, if such a piece of furniture is not available, one may be improvised. The teeth of a pregnant woman are apt to undergo certain destructive changes, which have given rise to the old saying, " For every child, a tooth." This disorder is supposed to be due to increased acidity of the saliva, which is itself increased in amount, and it may result in caries of a rapidly progressing type. In addition, the gums may grow soft and spongy, and even bleed or become ulcerated. In rare instances there is a persistent toothache, not due to any lesion of the tooth or gums, but of reflex origin. As a precautionary measure, the woman should have her teeth examined and put in order by a competent dentist early in pregnancy, for painful or protracted dental operations performed during the period of gestation have been known to bring on mis- carriage. After the teeth have been thoroughly cleaned and any exist- ing cavities temporarily filled, further trouble can usually be averted by the frequent and systematic use of an alkaline mouth- wash. Phillips' " Milk of Magnesia " meets this indication per- fectly, and, after brushing the teeth, the mouth should be rinsed THE DIET. 109 with a.properly prepared solution before and after each meal, as well as after arising and before retiring. If the teeth have been properly put in order by a dentist in the early weeks of pregnancy, and if this after-care has been faithfully followed out by the patient, any pain or soreness of the teeth, mouth, or gums which does not subside promptly should be reported at once to the physician. The diet of the pregnant woman is to be carefully regulated, and only such articles of food are to be taken as will not over- tax the already hard-worked organs of elimination. This is a nice question about which there is much difference of opinion. The general popular idea is that a pregnant woman must be given a large amount of nourishing food, because " she must eat for two." It is now generally conceded that if her food is sufficient to properly nourish her body before she becomes pregnant, the same amount is all she requires while pregnant. Again, the popular idea still persists that the size of the child may be controlled by restricting the diet of the mother. This has not been incontrovertably demonstrated and the belief is seriously questioned. A fruit diet is supposed to make labor easier by a softening of the child's bones. This theory of bone salt seems to be disproved and the fruit in quantity is quite as much a bone salt diet as is the average three meals provided. In addition there is danger to the mother and a chance of rickets for the child. A special diet may be ordered by the doctor known as Prochownik's diet. It is quite simple, and can be procured by the most humble. The claim is made for it that, if systema- tically adhered to, the results will be perfectly normal, small in- fants. This theory has failed to meet with general acceptance. The proper diet for the pregnant woman is a simple, ordinary mixed diet. It must be carefully regulated to avoid throwing waste upon the kidneys, and foods which are difficult of digestion must not be taken. Among the latter are such articles as pastries, pickles, salads, pork, cabbage, and all articles fried in fat, whether meats or starches. Fruits, vegetables, cereals, buttermilk, cocoa, milk and its products with abundance of water, should be eaten in normal amounts. The one rule to follow at this time is to A NURSE'S HANDBOOK OF OBSTETRICS. limit the use of meat and broths. Authorities seem to agree on meat but once a day. The occasional craving of pregnant wo- men for unusual articles of food must be kept in mind, and any desire of this kind may be granted with safety when the articles demanded agree perfectly with the patient and are not of too exceptional a nature. Any marked perversion of appetite should, of course, be reported promptly to the physician. Too much em- phasis cannot be laid upon the avoidance of alcoholic liquors. These are eventually depressants, though slightly stimulating at the time. Nervous muscular and secretive glands are all de- pressed. Investigation at different times indicates that the in- fluence of alcohol upon the germ plasm of male and female at time of conception and during pregnancy is to prevent the de- velopment of normal progeny. Never before has such un- mistakable warning been sounded against the danger of develop- ing a dependence upon alcohol as at the present time. Its ill effects are always definite, but during pregnancy the dangerous results are imminent and, unless specially ordered by a physician, alcohol is to be entirely omitted from the patient's diet. Some women seem to require more food than three meals a day. This may be supplied by eating fruit (such as oranges, apples, prunes or figs) upon rising and before retiring; a glass of milk with a cracker may be taken between meals. Eclamptic Toxaemia.—The exact cause of toxaemia during pregnancy is still a question; and while many theories have been advanced in explanation of this phenomenon, none has been ac- cepted definitely by the entire medical profession. One general statement may be made, however, and it a suffi- ciently safe working theory for the nurse to keep in mind and regard at all times as a correct explanation of the cause of eclamptic toxaemia. This is, that eclamptic convulsions are due to a storing up in the system of matter which should have been eliminated either by the kidneys, the liver, or the digestive tract. It will be remembered that the mother has to eliminate not only her own waste products, but those of her infant as well; and that, at the same time, her organs of elimination are handicapped by pressure from the growing uterus and by the other disturbances THE BOWELS. Ill in the general working of the bodily functions that always accom- pany pregnancy. This pressure and the accompanying disorders of nutrition increase as pregnancy advances, and the danger of digestive disturbances grows greater from week to week. Even in the early months, when the pressure is slight and the functions of the emunctories have not been seriously affected, the diet must be carefully regulated to avoid a break-down when the strain is greatest. While many patients will conscientiously follow directions expressed in a general way only, certain women will pay no at- tention to anything but the most explicit rules, and with such unruly cases the diet-sheet given in the chapter on diets may be used to advantage. This list is, of course, only a general outline of the proper diet during gestation, for, as already stated, no absolute laws can be made to fit every case, and the likes and dislikes of the patient are never to be disregarded entirely. Food must be of such a character that the patient enjoys her meals thoroughly and gains regularly in weight and strength from day to day. Bowels.—The bowels of the pregnant woman are to be watched carefully, and at least one satisfactory evacuation should be secured daily. The functions of the bowels, kidneys, and skin are intimately connected, and neglect of any of these organs is a serious matter. Constipation will probably be encountered, as nearly all women are more or less constipated, owing largely to a lack of hygienic habits. This condition is aggravated during pregnancy and the serious consequences are proportionately in- creased. The attending physician will usually order just such measures for its relief as would apply to the condition if the woman were not pregnant. Personal habits of intelligent daily hygiene are the best vital resource a pregnant woman has, and, fortunately, the present- day tendency is very strongly to emphasize the preventive value of all these matters of exercise, sleep, diet, care of the skin, bowels and kidneys, beginning with the training of the infant and carrying the principle through life. The result, however, of A NURSE'S HANDBOOK OF OBSTETRICS. lack of proper habits must be combated as intelligently as pos- sible. Pregnant women are advised to live systematically, to eat proper foods, such as farinaceous foods, vegetables, and fruits. The patient should take two quarts of water daily; she should obey the faintest inclination to evacuate the bowels and adhere to a schedule, going to the closet at exactly the same hour each day. While there, she should be warm and undisturbed; and she may find that much assistance may be derived from drink- ing a glass of hot water before breakfast. The doctor may order a soap suds enema, or injections of olive oil into the rectum at night to make a movement possible in the morning, or he may prefer drugs to the enemata, depend- ing upon the cause of the constipation. Usually cascara sagrada (Rhannus Purshiana) will be ordered at bed-time, in doses of from one-half to one teaspoonful, gradually increasing the amount. Glycyrrhiza Pulv. is sometimes effective. If the con- stipation is obstinate, it is well to administer a gentle saline laxative, such as the effervescent solution of citrate of magnesia or Seidlitz powder every third or fourth morning before break- fast. Castor oil or aloes must of course not be used. The mere mechanical effect of an overloaded bowel is to in- crease the pressure on the vital organs in a pelvis which is al- ready filled to its utmost capacity. The danger of absorption in the intestines from an accumulation of excrementitious matter in the system is very great. Never employ massage for constipation if pregnancy exists. Diarrhoea is also a condition that cannot be safely neglected, for even if it is of simple origin and not due to any serious in- testinal disturbance, it may, if allowed to continue, be enough to undermine the patient's strength to a dangerous degree. Pro- longed or severe diarrhoea is often a direct cause of miscarriage as well, and any such condition of the intestinal tract which is not controlled promptly should be reported to the physician with- out delay. Kidneys.—Of all organs of the body perhaps none requires a larger degree of care during pregnancy than the kidneys. If THE BREASTS. H3 at any time the amount of urine falls below normal, 50 ounces, an immediate report should be made. A specimen of urine is to be sent for examination every three weeks during pregnancy and once a week during the last two months. Where the patient has a previous history of symptoms suggesting toxaemia the doc- tor may order it sent more often. This specimen must be a sterile twenty-four-hour specimen of eight ounces, with complete sta- tistics as to amount passed in twenty-four hours, name, address and date. This is to be pasted upon the bottle to avoid possible mistake. The significance of many examinations is lost because of carelessness in this matter. The examination should be care- fully done and measures at once adopted to combat the findings of casts or albumin. This should be sent to reach the doctor in the forenoon, so that it may be examined the same day. Any oedema of the face, particularly the eyelids, the hands and feet, any headache or dizziness, must be instantly regarded and re- ported to the physician. Breasts.—These organs must always be protected from con- striction or pressure of any kind. The relief from weight has been suggested in the paragraph on clothing. They must be pre- pared for nursing by careful attention to the condition and de- velopment of the nipples, for, if the infant is unable to nurse, both it and its mother will suffer more or less. The effect of stimulation of the breasts, by suckling, on the involution of the uterus has already been mentioned, and it will readily be understood that the infant will thrive better on breast milk than on any other kind of food. The breast should be bathed night and morning with soap and warm water, to keep the skin in the best possible condition, and after the bathing they are to be sponged briskly with water as cold as the patient can bear, to stimulate the activity of the glandular tissue. The nipples, no matter how well developed and healthy they may be, are to be anointed every night with white vaseline or albolene, which is to be carefully removed in the morning with castile soap and warm water. This is to soften and remove the colostrum which the breasts secrete during the latter part of 6 114 A NURSE'S HANDBOOK OF OBSTETRICS. pregnancy, and which, if undisturbed, will form hard crusts on the nipples and excoriate the delicate tissues beneath. Nipples which are not treated in this way and upon which crusts of colostrum are allowed to remain are often extremely sensitive or even exquisitely painful when nursing is begun, and are especially liable to the formation of erosions or fissures which may prevent nursing entirely, either because of the suffering caused by the suckling or by the development of inflammation in the breast itself. If the nipples are small, flattened, or depressed, they should be drawn out with the forefinger and thumb and held for five minutes night and morning throughout the entire two months preceding the labor. This will often develop them to a surpris- ing degree, and nipples that at first seem absolutely unfitted for nursing can frequently be made sufficiently prominent by this treatment to meet the needs of the child perfectly. The patient can, of course, do this herself after the nurse has instructed her in the proper method; but, as has been stated in a previous chap- ter, she must be cautioned as to the possibility of irritating the uterine muscle to contraction by too vigorous manipulation of the nipples, and warned to stop this treatment at once should any uncomfortable symptoms develop in the uterus or lower abdomen. If there are erosions, fissures, or other diseased condition of the nipples, the physician should be consulted, and he will pre- scribe appropriate treatment. Nervous Condition.—To the woman of the present day, freed as she is from much of the ignorance, superstition, and traditions of a generation ago, the period of pregnancy should be, if it proceeds normally, a period of much mental and physical quiet, comfort, and happiness. She should be spared every phase of physical and mental irritation possible. When ap- proached in the proper way, even children can be brought to co- operate and materially help in securing for the waiting mother a degree of calm, daily routine which will do much to prevent the development of abnormal nervous symptoms. The long waiting, with the hopes and fears accompanying her MATERNAL IMPRESSIONS. H5 condition, may depress the patient, and the physical discomfort may irritate her; but these troubles can always be met by rest, good reading matter, and an interest in a larger world than her own condition. The care of a physician is her best anchor. She should not indulge in too much reading or in thinking of the physiological process of her condition. Here again her self-control will be the result of a life time of habit, and patholo- gical mental disturbances are exceedingly rare. The patient's fears occasionally gain control, and this calls for a tactful restraint over her more exaggerated moods. A welcome baby is apt to enjoy the blessing of a happy mother. Any deviation from a normal condition seeming to indicate excessive nervousness or melancholia must be promptly reported to the physician. As a general rule for the guidance of the nurse in the management of pregnancy it is safest and wisest to report to the physician any condition that causes the patient special discomfort or that seems to be at all unusual. maternal impressions and the control of sex By a maternal impression is understood an effect on the physical development of an unborn infant due to some shock, fright, accident, or other profound nervous strain sustained by the mother during the course of her pregnancy. The possibility of phenomena of this kind is believed by a great number of individuals, among whom may be counted many of the highest intelligence, and children are frequently seen with birth-marks, harelips, supernumerary fingers or toes, and other deformities and disfigurements of various types, all of which are attributed to some form of nervous impression from which the mother suffered during the period of gestation. It is safe to say, however, that the supposed connection be- tween these unfortunate occurrences and any mental state of the mother may be traced to coincidences, or to the imagination in every case, and the nurse should be informed on this subject in order that she may be able to reassure such expectant mothers, as may be apprehensive that their children will be " marked." Il6 A NURSE'S HANDBOOK OF OBSTETRICS. The effects of heredity must not be confused with the subject under discussion, and it must be borne in mind that certain traits and characteristics and certain diseases may be transmitted from the mother to her unborn child. Also, a mother who is in a markedly debilitated condition, or one who is given to excesses of any kind, such as the habitual use of alcohol, morphine, or other drugs, cannot be expected to give birth to a healthy, robust infant; and, for this reason, such a parent may be the mother of a deformed, disfigured, or partially developed child. Maternal impressions, however, are to be considered as sup- posedly affecting the physical development of the child as a result of a sudden profound shock transmitted entirely from without. While, perhaps, it cannot be said that this is an absolute im- possibility, it may be stated with the utmost positiveness that such an effect can occur no more easily before the birth of the infant than after it is in its mother's arms. It will be remembered that the ovum in which the fcetus de- velops is nothing more than an egg of a peculiar kind, and that the child within it is, from the very first, an absolutely indepen- dent organism developing by itself, and not connected in any very intimate way with the mother. There is no mingling of the fetal and maternal blood-currents, and the blood of the fcetus merely gives up its waste products and takes in oxygen in the placenta as does that of the mother in her lungs. The placenta is merely a thickened area in the sac formed by the amnion and chorion, and the whole may be regarded as the shell (soft, to be sure) of the egg in which the child is being formed. It is true that the placental structure penetrates to a certain depth into the tissues of the uterine walls, but it can no more be regarded as part of the maternal organism than can the roots of a tree be considered as part of the earth into which they extend. Moreover, the umbilical cord, which is the only direct at- tachment of the fcetus to the placenta, is absolutely devoid of nerves, and no matter how much the placenta may be regarded as part of the mother, it is clear that there is no actual nerve connection between the two. MATERNAL IMPRESSION. 117 In a word, the ovum, with its contained fcetus, merely finds in the uterus a suitable nest for its development, and it is a fact that, except for the practical difficulties in the way, no mother is absolutely necessary to the development of her child after conception has occurred. If we could solve the practical prob- lem of transferring the fertilized ovum from the oviduct or uterus of one woman to that of another, the process of development would go on just the same, much as a hen's egg may be hatched by any hen or even in a purely mechanical incubator. That this statement is not idle speculation is proved by the fact that, in Edinburgh, two impregnated ova from a rabbit were transplanted to the oviduct of another rabbit of entirely dif- ferent breed, and this second rabbit eventually gave birth to two rabbits of the first variety, together with several others of her own kind. It should be said in explanation that both rabbits were impregnated at the same time by males of their own breeds, respectively, in order that the oviduct and uterus of the rabbit to whom the ova were to be transferred should be in exactly the necessary stage of gestational development. Thus it will be seen that the connection between a fcetus and its mother is practically no more intimate before birth, while it lies in, and absorbs its nourishment from, her uterus, than after delivery, when it rests upon, and takes its nourishment from, her breast; and that the opportunity for nerve impulses to pass from one to the other is equally impossible in either case. The question of the possibility of controlling the sex of unborn infants so that parents may beget male or female children at will has received much attention of late, and the nurse will often be interrogated in this connection. The most recent teaching goes to show that, for the present at least, this is a matter entirely beyond the power of the human mind. None of the many theories and methods that have been advanced from time to time has proved in any way reliable, and where results may seem to have been secured, the probability of coincidence must always be enough to overthrow any positive conclusions. XII Preparations for Labor THE PATIENT'S PREPARATION The average mother will need little argument to convince her that the early placing of herself under the observation and care of an obstetrician is her first duty to herself and child. She will desire to possess such accurate knowledge regarding the hygiene of pregnancy as will conserve the best interests of herself and children. Ignorance and disregard of scientific truths regarding the facts of life are often followed by tragedy. If she is wise she will concentrate her intelligence upon doing the obvious reasonable, and wholesome thing, in order to be as far as possible a poised, normal, healthy woman. Her doctor's advice, care, and watchfulness may be depended upon to avert and combat complications should they arise, and she should be strongly en- couraged to control her instinct for introspection and investiga- tion of the details of the entire physiological process of child- bearing. Instead, let her report often to her doctor, and send unfailingly for his examination every three weeks during preg- nancy a sterile, eight-ounce, twenty-four-hour urine specimen properly marked. Carrying out the best physical and mental hygiene during the whole period of pregnancy possible to her condition and circumstances, will most certainly bear good fruit for herself and child. As previously stated, obstetrical nursing demands a woman of superior intelligence, judgment, and special training. A lack of proper background of character and personality is almost as great a bar to success as is a lack of proper technic. The Nurse.—In the engaging of the nurse, the actual date of confinement cannot, of course, be given. Nurses should be selected only because of their special fitness, and on no other ground should they be considered. If patients can possibly be brought to appreciate the value of expert nursing at this time 118 THE NURSE. 119 and allow the doctor to employ the nurse, the responsibility for her work is thus squarely placed upon his shoulders and there is no division of responsibility. When other factors enter into the selection complications may inevitably be expected. Obstetrical nurses properly qualified usually receive a higher rate of pay than do those engaged in other forms of nursing. The majority of Nurses' Directories have stringent rules concerning general nursing when done by the obstetrical nurse. If she specializes she will, of course, take no contagious cases. If she does general nursing, she will refuse all contagious work for a period of at least one month before her engagement. Much argument about the necessity for this procedure exists at present, owing to the latest teaching concerning communicable diseases. But the carelessness of a few nurses and the susceptibility of an obstetrical case for some infectious diseases make it im- perative that a nurse use every safeguard that will render the danger less. All her personal effects that may have been ex- posed, without exception, must be thoroughly fumigated in ac- cordance with Board of Health rules. Then all articles that can be washed and boiled must be carefully handled. She, herself, must by a thorough bath and 95 per cent, alcohol rub, a shampoo, completed with a generous application of 95 per cent, alcohol and a persistent use of a nose and mouth antiseptic spray, spare no effort to make herself a safe obstetrical nurse. Pus in any form, such as an otitis, otopyosis, boils, pustules, T. B., as well as a very recent attack of a contagious disease, most certainly disqualify a nurse. The lesser ills of colds, sore throat, tonsilitis, or bronchitis must be left to a physician to decide. Rather than make a change, it is quite customary for the doctor to permit the nurse to go on duty, but she owes it to herself that every possible care be taken to avoid infecting her patients. The close nursing and the time covered make very possible an unfortunate outcome, unless she fully realizes her duty. This can be met best by observing those rules of personal and gen- eral hygiene which tend to properly preserve her own health. Occasionally nurses lose time waiting for cases, and this forms one of its most objectionable features in the eyes of the 120 A NURSE'S HANDBOOK OF OBSTETRICS. average nurse. Nurses should not be called at the last moment. It is an objectionable custom, as it defeats, oftentimes, the very strongest argument for employing an efficient nurse, namely, through lack of time surgical cleanliness cannot always be se- cured. It is essential that some definite arrangement be made as to the nurse's engagement. The doctor will usually arrange this matter and very properly suggest that payment be made at the usual rate from a certain date, or he may arrange for half pay for the waiting period, the nurse either being on call or at the home of the patient. She even may, with the doctor's permission, accept calls to clean and brief cases, always with the full understanding that she is on call. In any event it is not justice to expect her to lose days, even weeks, without full re- muneration, and usually her doctor will assume direction of affairs and protect her best interests. She must be very careful not to let her cases overlap. Having completed her engagement of her doctor and nurse, the patient will next direct her interest to her own preparations for delivery. The number of patients preferring to be confined in a hospital is rapidly increasing, as a recognition of the many advantages enjoyed is becoming more general. To the average woman who expects to possess comfort and enjoy a feeling of safety, it appeals very strongly. It is cheaper, much safer, and offers every possible convenience. It provides against every emergency, and obviates all interruptions to the domestic routine, other than a temporary absence from the home. Its economy is a strong factor in its favor. A special nurse is more often required for maternity cases than not, if the fastidious, dainty tastes of the patient are to be satisfied. This, of course, with her board is a special expense to the patient, but places a nurse always at her disposal. If such a delivery is not available because of lack of hospital facilities, or the preference is for a home accouchement, the mother will proceed with her own preparations. Beginning at a sufficiently early date in pregnancy to enable her to have all her preparations made at least one month before THE MOTHER'S OUTFIT. 121 labor is expected to occur, the prospective mother should make ready the articles which will be required at the time of her con- finement. This outfit may be divided into two parts: one consisting of the articles needed for the mother's use, and the other of the supplies which will be required by the infant. In many cases the physician will give the patient a list of the supplies he wishes her to get, but where the matter is left in the hands of the nurse the following outfit will usually prove satisfactory: Six abdominal binders, one and three-quarters yards long by three-quarters yard wide; made of the cheapest grade of un- bleached muslin. This muslin comes in a width of three-quarters yard, and ten and one-half yards are required to make the neces- sary number of binders. They should be torn in the proper length and then washed and ironed, to make them soft and com- fortable. The cheapest grade of muslin is recommended because the more expensive, and consequently heavier, quality does not take the pins as well and is stiff and uncomfortable when in use. Two obstetrical pads for the bed, each twenty-four inches square and made of cheese-cloth stuffed with cotton batting (not absorbent cotton) until it is three or four inches thick. They should be " tacked " or tufted to keep the cotton from slipping, and are for use under the patient's buttocks during the first few hours after labor when the flow is greatest. One dozen clean towels, preferably old soft ones without fringe. These are to be pinned up in another towel and laid away with the other things. They are for use only about the patient, and are not for the hands of the physician or nurse. New diapers may be used in place of the towels if desired, but old ones may never be employed for this purpose. Fifty yards of gauze or cheese-cloth. Safety-pins, two papers of large and one of small size, in addition to those required for preparing the bed. One new nail-brush for the nurse. The physician should bring his own. The best for this purpose are those with plain wooden backs, costing five or ten cents each. 122 A NURSE'S HANDBOOK OF OBSTETRICS. Four pounds of absorbent cotton. Tincture of green soap, six ounces. Four breast binders, pattern illustrated. Six T-binders. Two pieces of rubber sheeting, each one and one-half yards square. Of this sheeting one piece may as well be of the so-called " enamel cloth " (white) which is often used for cover- ing kitchen table and shelves, and is much less expensive. This piece may be used for covering the bed upon which the patient is delivered, and, afterward, cut into smaller pieces for the baby's bed or bassinette. The other piece, of the regular quality to be had of the druggist, is for use on the patient's bed during the puerperium and, later, by the baby, who will require it for the following three or four years. Two pairs long white cotton stockings. Two suits white pajamas. To be worn during labor. The trousers to be ripped into two stockings. The seam to be hemmed, the band cut through the back and two wide iapes applied. This leaves a wide space before and behind, allowing complete freedom to the doctor and at the same time affording the least exposure to the patient. The nurse may tie a bandage above the knee, keeping any fulness out of the way. The result is an ideal ob- stetrical suit much like the Sloane Maternity stocking so widely used. Sterile towels will, of course, protect the area of opera- tion by being placed over the pajamas. The sterile white cotton stockings and the jacket complete an effective obstetrical outfit. The T-binder preserves the perineal pad in position. One fresh clean dressing gown. Six soft old night dresses. Four pounds cotton batting. Two ounces lysol. One hundred bichloride or biniodide of mercury tablets. Two OUNCES tincture of iodine. Eight ounces saturated solution of boric acid. Two ounces albolene. One pint 95 per cent, alcohol. One bed-pan. One covered irrigator with complete attachments. THE MOTHER'S OUTFIT. 123 Two wash-basins, preferably of agate- or enamel-ware; after boiling, these will be needed for solutions at the time of the labor; afterwards for bathing the patient's genitals during the puerperium ; and still later for use about the infant. Oxe slop-jar or pail with lid, made perfectly clean and used during labor for receiving soiled sponges, towels, as well as any solutions or discharges that can be directed into it. One tub in which to immerse the infant. One bowl, for cracked ice. Six pitchers or vessels, to hold hot and cold water. A good supply of clean towels (in addition to the dozen already mentioned), and plenty of sheets, pillow-cases, and night-gowns for the patient's use. Nothing is more annoying to the physician than to call for a clean sheet or night-gown at such a time, and find that it is not to be had. Clean towels, al- most without number, are needed in the lying-in room. The chapter on The Normal Infant contains a list of the necessary outfit for the infant. TO BE STERILIZED Gauze packing 10-yard length y2-yard wide, sterile, and in sterile jar; for uterine packing. Four dozen perineal pads of cotton covered with gauze to fit the patient and meet the binder. In packages of three each. One pound of absorbent cotton sponge balls, 3 inches in diameter; in a preserve jar. Fifty gauze sponges, 4 inches square, for operative use; in a preserve jar. One test tube containing umbilical tape, with cotton plug and rubber cap. A supply of assorted sizes old linen squares, in a jar. TWO I YARD SQUARES OF MATTRESS PAD MATERIAL. Two PAIRS OF LONG white cotton STOCKINGS. Two suits of pajamas, for the patient. One suit of pajamas, for husband. One dozen soft old towels. Two dozen towels. 124 A NURSE'S HANDBOOK OF OBSTETRICS. Twelve sheets. Six pillow-cases. Two night-dresses. Six abdominal binders. Six T-binders. Six breast binders. Two papers of safety-pins. Four brushes, two each in a preserve jar. One-half pint milk bottle, to hold the solution for nurse's forceps. The irrigator, tubing, bed-pan, wash-basin, pitcher, should all be scrubbed, boiled, and wrapped in a sheet and placed away. The dressings can often be made by the patient if she is shown, otherwise they are prepared and sterilized by the nurse. Econ- omy in the use of all supplies is imperatively demanded of the nurse. Much complaint is heard of the great extravagance of many otherwise valuable women. It is usually a simple matter to have the necessary sterilization of supplies done, as a great many hospitals or nurses' directories arrange for this. Usually a small charge is made. Many dif- ferent sets of obstetrical outfits are on the market. These are not always satisfactory, and are expensive. Some hospitals rent very complete obstetrical baskets, the articles outside of the dressings to be returned. This is a very desirable and con- venient arrangement, as the sterilization may be investigated and technic verified. A nurse may possess a small portable sterilizer; several good ones are on the market. Sterilization may be properly done in the patient's home with one of these. Occasionally the nurse may go to the patient's home and in the absence of other facilities proceed, as she has been taught, to boil, steam and dry the small packages, all indelibly marked upon their cotton wrappings. All the surgical dressings and cord dressings, however, must be freshly purchased. Such steriliza- tion is at best not perfect and should not be relied upon for such dressings, XIII Preparations for Labor (continued) These begin with the making or purchase of the supplies described in the preceding chapter, and end with the selection, furnishing, and preparation of the lying-in room. The room in which the confinement is to take place is to be chosen with great care, for it must serve first in the capacity of a hospital operating-room and afterwards meet the requirements of a cheerful and comfortable bedchamber, in which every want of a convalescent patient can be met promptly and satisfactorily. For these reasons there are two prime factors in the choice of the room which can never be safely overlooked. First, it must be scrupulously and surgically clean; and second, it must be bright, spacious, properly lighted, well heated, and thoroughly ventilated. The nurse is, of course, limited in her selection of a room for this purpose to the possibilities of the house in which the patient resides, but no room is too good for the business in hand, and she is at perfect liberty to make use of even the parlor or dining- room if it seems best suited to her needs. Naturally, the nurse will avoid putting the family to any unnecessary inconvenience, but her first thought must always be in the interest of her patient. The ideal lying-in room is one that is large, sunny, provided with an open fire-place, and with a well-equipped bath-room adjoining, or at least on the same floor. It should be situated in a part of the house that is quiet and as far as possible from the odors of the kitchen and other unpleasant features. The nurse must make sure that the room has not been occu- pied within at least six months by a patient suffering from any contagious, infectious, or suppurative disease, and if such is found to have been the case the room is to be condemned and another, though possibly a less convenient one, chosen in its place. If, for any reason, it is impossible to make use of another 125 126 A NURSE'S HANDBOOK OF OBSTETRICS. room, the infected one is to be thoroughly disinfected in ac- cordance with the rules of the Board of Health with which every nurse should be familiar, and then entirely dismantled, and re- painted and repapered throughout. In any event, the lying-in room is to be thoroughly cleaned and all the wood-work wiped off with damp cloths at least two weeks before the expected date of the labor; and all curtains, draperies, portieres, and other articles that can collect dust are to be banished. In the same way, all unnecessary furniture is to be removed and only enough left to make the room comfortable and cheerful. Carpets should be taken up if possible. When this is not possible, they should be well protected by a large rubber sheet, or by many thicknesses of newspaper covered with sheets and tacked down. Rugs can be easily removed without causing dust and confusion. The patient will need a comfortable chair and a firm single metal bed. These are now very common and are generally found in every home. The doc- tor will need a plain table, from a hall or kitchen. The nurse will need a table for supplies. Another table or chairs will be needed, and the bureau and washstand will occupy the balance of space properly required. All this can be quietly and expeditiously arranged, and the nurse may secure the patient's approbation of this preparation if the matter is intelligently and tactfully presented. In the event of an emergency arising and every second of time being valuable, the wisdom of the arrangement is obvious. The pa- tient may be much interested and assist the nurse in planning the arrangement of furniture and supplies. If this is carefully arranged and the patient made to under- stand what is required, the household will be much less upset than when a sudden demand for instantly required articles is made upon it. In hospitals the details for maternity work are complete. In homes of small means, the economy of the preparations is of vital importance to the patient. The nurse can be most helpful here, by her ability to confine requirements to the limit of efri- THE INFANT'S BED. 127 ciency and safety with the minimum domestic upheaval and expense. In short, the room is to be as clean and free from dust- collecting and germ-breeding articles as it is possible to make it, and the nurse who has been thoroughly drilled in aseptic and antiseptic methods will understand what is required without further argument. The infant should never, under any circumstances, be allowed to sleep with its mother, and its bed may be either the crib that it is to occupy during its childhood or a bassinette designed for use only in its infancy. In emergency cases, where neither of these is at hand, a temporary bed may be made for the baby out of a fcox, a large trunk-tray, or a bureau drawer; or it may sleep on a couch or in a large arm-chair. Two ordinary cane-seated chairs, placed against the wall and with a hair pillow or cushion for a mattress, make an excellent temporary bed. Bassinettes may be purchased in any style and at any price to suit the taste and the pocket-book of the purchaser, or a very pretty one may be made at home with a clothes-basket as a basis and barrel hoops wound with ribbon to support the draperies. As a rule, the chief objection to the bassinette is its great depth, and as an infant needs plenty of fresh air it is not; benefited by spending the greater part of its time at the bottom of a deep basket, surrounded and entirely shut in by curtains and hangings. In selecting or designing a bassinette, the top of the infant's bed should never be more than four inches below the top of the basket or framework, and if the nurse finds one ready for use in which this depth is exceeded she should raise the level of the bed by placing under it a folded blanket or a pillow. The bed should be of hair and never of feathers, or the infant will sink down into it and be hot and uncomfortable from the first. These bassinettes are dainty in appearance, but far from desirable. A metal bassinette or crib is better from every point of view. A specially good type is one which can be swung within the mother's reach when necessary. The mother's bed should be the best that the house affords, for the period of convalescence after labor is the more trying to 128 A NURSE'S HANDBOOK OF OBSTETRICS. the patient the more nearly it is normal; and unless her bed is a comfortable one it is often a very difficult matter to persuade her to keep in it for the required number of days. The springs should be good and the mattress firm and solid. Unless it is absolutely necessary this bed should never be the one in ivhich the woman is confined, and for this purpose a single metal bed with a very lozv foot bar should be provided. The many advantages of a single metal bed have made the latter extremely popular, and few homes are unwilling to purchase one, if their desirability for delivery is properly represented. Their possession in a home is a real economy, as some provision must always be made for the nurse. Couches are often insanitary and generally uncomfortable; cots are always unsightly as well as uncomfortable, particularly for a heavy patient. If the metal bed purchased be very plain and as high as 28 inches, it will not only serve for the patient's use but later on the nurse may use it. Afterwards it may prove of special service for any member of the family in case of sickness. If the usual double bed with box mattress is encountered, all draperies must be detached, the bed scrubbed with soap and water and washed off with 2 per cent, solution of lysol, and the head- and foot-boards covered with sterile sheets immovably fastened. If the labor takes place in an ordinary double bed, it is ex- tremely difficult for either the physician or the nurse to " get at " the patient conveniently, on account of its width and the pres- ence of the head-board and foot-board; while if any operative work becomes necessary, or an emergency arises, the awkward- ness of the situation is more marked than ever. On the other hand, if a single bed is used the patient is accessible from all sides, and the case can be managed as easily and conveniently as on a hospital operating-table. The preparation of the bed or beds depends upon whether one or two are to be used. If but one bed is provided, it must be so arranged that, after the labor, it can be rearranged quickly and easily and put into a clean and comfortable condition with- out disturbing the patient to any great extent. The best way PREPARATION OF BED FOR LABOR 129 to accomplish this is to first prepare the bed as it is to be during the puerperium and, then to add the necessary preparations for the labor. The mattress is to be supported from below by means of boards slipped in between it and the springs, so that it will be perfectly firm and level during the labor and not sag down in the slightest degree. Boards may be made expressly for this Fig. 55.—Showing manner of elevating bed, showing draw-sheet and rubber sheet folded back, leaving fresh bed beneath. purpose, or table-leaves or slats from another bed may be used. They are to lie crosswise of the bed, at a point directly under the patient's buttocks, and should be removed at the conclusion of labor. Their use facilitates all the work about the patient, and by keeping the mattress perfectly flat prevents the blood and other discharges from collecting in a pool under the patient's back. The mattress is now to be covered with a piece of rubber 9 130 A NURSE'S HANDBOOK OF OBSTETRICS. sheeting pinned securely at the sides and corners so that it will not slip; over this is to be placed a white sheet pinned in the same way, and over this a draw-sheet, also carefully pinned. This is the correct arrangement of the sheets for the puer- perium, and they must be protected for the labor by covering them with another rubber sheet or " enamel cloth " and white sheet, both of which are to be pinned securely all around. After the labor is over the uppermost white sheet and rubber sheet are removed, and the patient lies on the white sheet and draw-sheet underneath. If two beds are used, the mattress of the cot on which the labor is to occur is supported with boards, as in the first in- stance, and protected with a rubber sheet covered with a white sheet, both of which are securely pinned on all sides. The other bed is then made ready (in the manner already described) with rubber sheet, white sheet, and draw-sheet. On the draw-sheet should be placed one of the obstetrical pads from the maternity outfit, in such a position that it will come directly under the patient's buttocks when she is laid in bed. Unless the various coverings are carefully and securely pinned they will become greatly disordered by the tossing and turning of the patient, and in protracted cases they may even be torn entirely from the mattress and cast on the floor. The nurse should see that the provisions for lighting the room at night are ample, and that it is warm and comfortable in every way. The hair about the vulva should be closely clipped and the parts shaved. This is part of the ordinary routine in hospitals, and a skilful nurse handling a safety razor occupies a very few minutes at this. These final preparations are usually most distasteful to the patient, but tact and intelligence will usually overcome all objections. If this procedure is strenuously op- posed, the nurse will, of course, withhold argument, and exer- cise great care in the cleansing of the external genitals. Occasionally the doctor prefers not to have the patient shaved or even clipped closely. It is best to be informed of his wishes. The physician should be summoned as soon as labor-pains be- PREPARATION OF PATIENT. 131 gin, unless he has given definite instructions to the contrary. Some physicians prefer not to be called to a case until, in the opinion of the nurse, the first stage is nearly at an end, but even under these circumstances it is better that he should know that the woman is in labor, so that he will be prepared to respond promptly to the second call. After the messenger has been despatched for the doctor the patient should be given an enema of soapsuds, one pint, and spirits of turpentine, one teaspoonful. This will effectually empty the lower bowel, and render the labor not only easier but infinitely more cleanly, and must never be neglected. This may have to be repeated and the nurse must watch closely the move- ments of bowels and urine, reporting promptly failure to secure movement or inability to urinate normally. It is distinctly to be remembered that enemata may be given through a rubber bag. But the bag, even if new, is improper for use in administering an infusion, hypodermoclysis, or sterile douche. It cannot be cleansed properly, and boiling it for twenty minutes soon destroys it. These bags are very apt to be used for many objectionable purposes, even boiling not rendering them safe for sterile obstetrical practice. The use of such bags is a grave and very common fault, and it vitiates the other- wise dependable technic of many doctors and nurses. The same tubing should never be used for sterile treatment and enema. There is rarely time to thoroughly boil it, even granted that there are facilities; and the risk should never be taken. Enamel covered cans are the safest for a nurse to use. They may be easily and thoroughly cleaned and boiled and leave no doubt as to their aseptic condition. The patient should now receive a thorough general bath with plenty of soap and warm water. After the bath her hair is to be well brushed and braided in two braids, and she is to be dressed in sterile pajamas, sterile stockings, and slippers, over which she will wear a wrapper or bath-robe than can be slipped off and on easily, preferably new, but certainly freshly laundered. While taking the bath, the patient should be caused to stand in the tub, which is to be partly filled with warm water so that her feet will 132 A NURSE'S HANDBOOK OF OBSTETRICS. not be chilled, and then given a thorough sponge-bath, after which she may be showered, either with a spray or with water poured over her from a pitcher. This is to be more than ordinarily cleansing. It should in- clude a brisk scrub, using surgeons' soap and crash cloth over the whole body, particularly the area of possible operative ex- posure, and paying special attention to the vulva. This is to be followed by a flushing with warm water, to remove the soap; then a pitcher of lysol solution, I per cent, is flushed over this area, or 95 per cent, alcohol applied with a sterile sponge. The vulva then receives a final cleansing. Here, as always, the spong- ing is toward the rectum. The patient is given a friction rub. The sterile pad is now put in place and held by a T-binder and the patient is instructed not to touch it. In rural districts or in tenements neither bath-tubs nor showers may be available. The patient must then stand upright in a tub of warm water and the same method be followed. While the patient is occupied with her bath the lying-in chamber is to be prepared for the labor, and the bed or beds prop- erly made up. If the patient has been sleeping in the bed in which she is to be confined, it is to be completely dismantled and supplied with clean bedding throughout. A chair is to be placed at the right side of the bed, facing the head, *or the physician, and a table (preferably a low cutting-table) covered with sterile white towels should stand within easy reach of his right hand. The slop-jar or pail is to be placed so that the apron of the physi- cian's Kelly pad will drain into it. Many physicians have discarded the Kelly pad in actual ob- stetrical work, on the ground that its use is not practical and on account of the difficulty in properly cleaning and disinfecting it. Where one pad is carried about and used for all purposes its use is vicious. If the doctor prefers to use one, the nurse must see that it is thoroughly scrubbed with a brush, and soap, then rinsed off with a solution of bichloride of mercury 1: 1000, wrapped in a towel, and boiled for five minutes. From this moment the use of the water-closet must be absolutely forbidden. Evacuations of urine and faeces are to PREPARATION OF ROOM FOR DELIVERY. 133 be received in a boiled vessel, which is to be removed at once from the room, emptied, cleaned thoroughly, boiled for five minutes, and returned with as little delay as possible. The vulva pad, which must, of course, be removed when the rectum or bladder is emptied, is in every instance to be replaced by a fresh, clean one after the parts have been sponged according to the technic given. The nurse should see that the lying-in room is warm, well lighted, and arranged according to directions; that all supplies are at hand and in order; that there is an ample supply of cold boiled water; that there is a good fire in the kitchen stove, unless a gas stove is available, and that plenty of water is actually boiling; that the instructions relative to the patient have been conscientiously carried out; and, lastly, that all children and other unnecessary individuals are out of the way. Unless the doctor requires his help, it is not usual for the husband to remain in the room after the first stage, the doctor usually excusing him. From the moment the nurse comes on duty she will keep a careful record of her patient. This she will continue, however long the case may be. The room will be furnished as follows at time of delivery: A single metal bed, with a firm spring, and made up according to technic for delivery. Small zvooden table with chair, at head of the bed, for anaes- thetist's supplies. Here also will be the hypodermic syringe and needle, tested and ready for instant use. The two 2-quart jars of sterile saline solution, kept warmed by being placed in hot water, ergotole, ergot, tincture of iodine, sterile solution of cam- phor in olive oil, alcohol, pituitrin, or other drugs, asked for by the physician. The tray for the Crede's treatment, and a kidney basin for emesis. All of these should be in instant reach and with no chance for confusion. Doctor's Table. Scrubbed thoroughly, and covered with a sterile towel. Basin containing a 2 per cent, solution of lysol, and cotton sponges, for bathing the vulva. Basin of hand solu- tion of lysol, 1 per cent. Dish or tray with tape, forceps, two 134 A NURSE'S HANDBOOK OF OBSTETRICS. artery clamps, scissors and rubber catheter, pair of rubber gloves pitcher of hot sterile water, and six sterile towels. This must be within reach of his right hand. Bureau for sterile, packages and solution of lysol, 2 per cent., for cleansing vulva. Jar of lysol, 2 per cent, for nurse's forceps, gowns for use of physician and nurse, suits for patient and husband will all be plainly marked and so easily distinguished. Package of gloves for doctor and nurse will be here, unless they were sterilized by boiling for 10 minutes and have been put in a basin of sterile solution on the doctor's table. Washstand for scrub-up technic. Follow the technic of the doctor in attendance. Generally a doctor will prefer to do the preliminary cleansing in the bath-room with running hot water. The boiled tampico fibre brushes will be ready in a sterile 2 per cent, solution of lysol, the covered jars preventing contamination. Tincture of green soap is always used. After scrubbing with care and cleansing around and under finger-nails with file, the hands may be soaked in solution of bichloride of mercury, 1: 2000, for five minutes, or 95 per cent, alcohol may be sponged over them for five minutes, or lysol, 2 per cent., or carbolic, 1: 1000, or soda and lime, or permanganate and oxalic acid. Whatever his choice, the solution must be prepared, and all abundance of boiled water must be at command. Small foot or infant bath-tub on chair for resuscitation of infant by immersion with an attached bath thermometer. Basket for infant with hot-water bottle and blanket. Sterile bed-pan. Sterile irrigation outfit for infusions or douches. Abundance of sterile pitchers and vessels. All exposed surfaces on bed, tables, bureau, and washstand must have sterile covers. A covered slop-jar or pail. A hook or bandage on irrigator handle to facilitate attach- ment. A chair for the doctor. The mother's preparation for the infant is outlined in the chapter on " The Ideal Nursery " and will be found to be a conservative guide. XIV The Conduct of Labor Normal labor may be defined as labor which is terminated without artificial assistance and which leaves the mother in good condition, beyond a slight feeling of exhaustion and sense of fatigue. It might perhaps better be termed " unassisted labor," for surely an easy and rapid breech delivery, which occasionally occurs and which is in one sense to be regarded as a distinct abnormality, is to be preferred to a protracted and difficult vertex case which subjects the mother to great suffering and more or less shock. For practical purposes, then, so far as the nurse is concerned, we may regard as normal any labor which is accomplished within a reasonable length of time without manual or instrumental interference. In the cases most likely to come under the care of the trained nurse in private practice she will often be summoned several days or even weeks before the onset of labor, and so will be in a position to observe its phenomena from the very first. It is assumed that all the preparations named have been made, and that everything is in readiness for the expected event. For a varying period before the establishment of true labor- pains the patient will often suffer from so-called " false pains," and the nurse must be able to distinguish between them and effective uterine contractions. False pains may begin as early as three or four weeks before the termination of pregnancy, and they are merely exag- gerations of the intermittent uterine contractions which occur throughout the entire period of gestation, combined with the effects of pressure on the abdominal tissues as the uterus and its contents settle down in the pelvis. They occur at decidedly irregular intervals, are confined chiefly to the lower part of the 135 136 A NURSE'S HANDBOOK OF OBSTETRICS. front and sides of the abdomen and groin, never extending around to the back, and are short and ineffective. They are more annoying than painful, and are never accompanied by any actual " bearing-down" sensation. The primigravida often re- gards them as true labor-pains, and marvels at the ease with which she bears them, but the woman who has borne children or the experienced obstetric nurse is seldom if ever misled by them. True labor-pains occur with a regularity that is almost perfect, and if they are timed by the clock it will be found in the majority of cases that, at the beginning, they will occur at inter- vals of about half an hour and that the periods between them will be exact almost to a minute. In timing the pains in this way the nurse should not let the patient know what she is doing, as the knowledge may have a suggestive influence on their fre- quency. The gradation between false and true pains is an almost im- perceptible one, the first indication of the appearance of true pains being usually the establishment of this regularity in their recurrence. Soon, however, the true pains begin to take on their characteristic qualities. They become longer and somewhat more painful. Beginning in the back they extend around to the front, the sensations in the front of the abdomen remaining after those in the back have ceased, and they are accompanied by a distinct " bearing-down" feeling. True pains cannot be said to be especially painful in the early part of the first stage, but the patient usually realizes fully that her labor has begun, and her face often wears a somewhat anxious expression, with a slight flushing and drawing of the features at the acme of the pain. As soon as the nurse has decided, from the character of the pains, that labor has actually commenced, she should notify the physician in charge of the case. It does not necessarily follow that he will respond personally to this notification, but it is proper that he should know that his patient is in labor, so that he can arrange his time and engagements and be ready to answer promptly the second and peremptory call. If the patient is to TRUE LABOR-PAINS. 137 go to a hospital for confinement, the order to start is usually given by the attending physician ; and the nurse must have matters so ordered that she may start with her patient at a moment's notice. If there is no nurse the patient must be ready to go when the true pains begin. As soon as the physician has been notified the nurse should begin to arrange the room for the labor, being guided as to haste by the frequency of the pains. The room is to be warm (700 to 720 F.), well lighted and well ventilated ; hot and cold sterile water and provision for boiling the physician's instruments are to be provided; and the needed supplies described are to be arranged in a convenient manner and place. The patient is to receive an enema of soap- suds, one pint, and spirits of turpentine, one teaspoonful, and is then given a warm bath, as described, or by sponging, as the circumstances will permit. The external genitals are to be cleansed with special care, and the pudendal hair, if long and abundant, must be clipped short with scissors or shaved with a safety razor. The patient's hair is to be braided neatly in two braids; she is dressed in a sterile suit of pajamas arranged as directed for obstetric use, or a pair of woven obstetrical stockings. If no such preparations have been made a clean night-gown with slippers, and bath-robe may suffice; and a vulva pad is applied and pinned to a band, to protect the parts and absorb any dis- charge that may escape from the vagina. From the beginning of the true pains the patient is not to be allowed to use the water-closet under any circumstances what- ever, and if the enema of soapsuds and turpentine has been effective, she will have no occasion to do so except to empty the bladder. This need, however, will usually be frequent, and the urine is to be voided in a clean vessel, which is to be removed at once from the room, cleaned thoroughly, and returned with as little delay as possible. It will, of course, be necessary to remove the vulva pad when the urine is voided, and after the act has been accomplished the external genitals are to be bathed care- fully and a fresh vulva pad applied. A pad that has once been 138 A NURSE'S HANDBOOK OF OBSTETRICS. removed must never be replaced, no matter how clean it may appear to be, and there can be no exception to this rule because of the danger of carrying infection to the vulva. The woman is to be encouraged to keep on her feet the greater part of the time, to favor descent of the head into the pelvis, and the nurse should endeavor to make this trying ordeal as light as possible by cheering words and a hopeful manner. The patient is to be dissuaded from attempting to help herself by voluntary straining of the abdominal muscles, for such efforts do no good at this time and only exhaust her and wear out her strength; and it is even a good plan to keep up her energy during the first stage by providing some light refreshment, such as tea and toast or soda-biscuits, of which she can partake when- ever she feels so disposed. If the membranes rupture in the first stage the danger of prolapse of the cord must be kept in mind, and the physician should be notified immediately, but this should be done without the patient's knowledge, for, especially if it is her first labor, the accident is apt to cause her great alarm. She should be informed at once of the nature of the watery discharge, and assured that it is a perfectly natural phenomenon and of no consequence whatever. If her night-gown or other garments have become soaked with amniotic fluid, they must be replaced at once with dry clothing. When the pains occur as often as every five minutes the phy- sician is to be summoned peremptorily, and even sooner than this if he lives at a considerable distance from the patient or in case there is any difficulty in getting word to him. Many phy- sicians give the nurse positive orders as to when they wish to be called, but in the absence of any such explicit directions she may regard the above rule as a safe guide in the majority of cases. This degree of frequency in the occurrence of the pains is a fair indication of the beginning of the second stage of labor, and when the pains take on the characteristic features of those of the second stage the diagnosis of the condition is not at all difficult. The pains of the second stage arc longer, much more severe Fig. 56.—Arrangement of sheets for vaginal examination. PRELIMINARY EXAMINATION. 139 and the patient's face is suffused zvith blood until, at the height of the pain, it is almost cyanotic, zvhile the neck szuells and the large blood-vessels stand out like knotted ropes and pulsate violently. As soon as it is apparent that the patient is in or near the second stage of labor she is to be put to bed, for at this time the os uteri is, of course, fully dilated, and if she is allowed to remain on her feet precipitate labor may occur. As a rule, the patient is quite willing to go to bed when this period of labor is reached, and in many cases she is unable to keep up any longer even if she were allowed to do so. The nurse should have ready, on the arrival of the physician, hot water, soap, a nail-brush for the disinfection of his hands, antiseptic solution (usually bichloride solution, 1 to 2000) sterile rubber gloves and solution of lysol, 2 per cent, or lubrichondrin. As many physicians, unfortunately, neglect to provide them- selves with an apron or gown, the nurse should also have in readiness a small clean sheet, which can be pinned around his neck and again about the waist, making a fairly good substitute for an operating-gown. After the arrival of the physician he will, of course, take charge of the further management of the case, and, if the patient is still on her feet, decide when she is to be put to bed. If the case is at all advanced the physician will wish to make a vaginal examination at once, in order to determine the amount of dilatation of the cervix and inform himself as to the progress that the woman has made, and while he is disinfecting his hands the nurse will prepare the patient for examination. The woman is to lie on her back, on the right side of the bed near the edge, covered with two clean sheets, each folded in half and arranged as follows: one sheet is to lie across the bed, covering her lower limbs and extending from the foot-board to a point midway between the patient's knees and hips; the other, covering the rest of her body, also lies crosswise of the bed and overlaps the first by a few inches (Fig. 56). Before the sheets are finally adjusted the nurse will remove the vulva pad and carefully bathe the external genital organs with warm sterile A NURSE'S HANDBOOK OF OBSTETRICS. water and tincture of green soap, and a fresh piece of absorbent cotton, using the sponge in dressing forceps and not in her fingers. When the physician has completed the disinfection of his hands and put on a pair of boiled rubber gloves, the nurse will squeeze some lubrichondrin from a collapsible tube on his index and middle fingers, taking care that neither the tube nor her own hand comes in contact with the examining fingers. The patient should now be directed to draw up and widely separate her knees, while the nurse raises the upper of the two sheets so that the physician can see the vulva, and holds it in such a position that ft cannot come in contact with his hands, but serves as a screen to prevent the woman from appreciating the extent to which she is exposed. The writer prefers this method to the older one of covering the limbs and abdomen with a single sheet arranged in " horse- shoe " form which is always getting in the way or becoming disarranged, and which, from the nature and method of its ad- justment, is far more suggestive to the patient than the one described in detail. If the physician's outfit contains a Kelly pad, it is to be placed under the patient, with its apron draining into the slop-jar or pail, and covered with a clean towel tucked well under the edges of the pad, so that it will not easily slip out of place. The nurse is to see that fresh solutions for the hands are always ready and at a proper temperature (ioo° F.) ; that soiled or bloody towels and sponges are removed at once from the room, or at least kept out of sight as far as possible ; that scissors and tape for tying the umbilical cord and boric acid wipes for the infant's eyes and mouth are ready the moment they are needed; and that a warm woolen blanket is provided to wrap the baby in as soon as it is born. All the instruments required are, of course, to be provided by the physician, and he will, on his arrival, hand over to the nurse whatever he thinks he may need for the particular case, which are to be boiled at once for fifteen minutes so that they will be ready the moment they are called for. In perfectly nor- mal cases about all that are needed are scissors, catheter, and CONDUCT OF SECOND STAGE. 141 douche-tube, but some physicians add to these a dressing-forceps and a tenaculum or volsellum. In emergency cases, when there is nothing at hand, an ordinary pair of clean scissors and a piece of new white cotton twine may be boiled and used for cutting and tying the cord. During the second stage, when the pains are most severe, the nurse should use every art at her command to encourage the patient with reassuring words and helpful assistance. A great deal can be done to add to the comfort of the patient by holding her hands at the height of the pains and, in the intervals between them, by rubbing her back and legs, which are often lame and cramped. Many women like to have something to pull on as the pains occur, and there is no objection to fastening a twisted sheet to the foot of the bed, on which the patient can brace herself, as it were, when her suffering is most severe. Ether or chloroform is indicated at this stage unless there are positive objections to its use, and in normal cases the duty of ad- ministering the anaesthetic usually falls to the nurse. The patient's face should first be well anointed with vaseline to prevent irrita- tion of the skin by the drug, her clothing is to be loosened about the waist and neck to remove any possible interference with res- piration, and false teeth, chewing gum, or any other foreign sub- stance that may be in the mouth is to be taken out, lest it should be swallowed as the patient loses consciousness. In these cases the chloroform is to be given to the " obstetrical degree " only. That is to say, it is to be administered only at the beginning of each pain and continued only as long as the pain lasts. This will be enough to benumb the nervous system and " take the edge off the suffering," but the patient will at no time be entirely unconscious, and in the intervals between the pains she will be perfectly rational. In operative cases, where complete surgical anaesthesia is required, the nurse should not be expected to shoulder the responsibility of administering the anaesthetic, espe- cially as her services will undoubtedly be needed as direct assist- ant to the operator, and another physician should be called in to act as anaesthetist. 142 A NURSE'S HANDBOOK OF OBSTETRICS. The best method of administering chloroform is with the Esmarch outfit (Fig. 57), which consists of a mask and a dropper bottle. The bottle is filled about half full of chloroform and corked, and when the stoppers are removed from both the little tubes that pass through the cork the contents will escape in a fine stream from the smaller of the two when the bottle is tilted to the proper angle. Before beginning the administration of the anaesthetic the skin of the face must be anointed with vaseline and the eyes shielded with a folded towel as a pro- Fig. 57.—Esmarch outfit for the administration of chloroform. Dropper-bottle and mask. tection against the irritating action of the drug. The mask is placed over the nose and mouth of the patient at the begin- ning of a pain and the material with which it is covered is kept wet with the anaesthetic as long as the pain lasts (Fig. 58). The mask is to be removed from the face at the end of each pain and not replaced until the beginning of the next one, and a close watch must be kept of the patient's pulse and especially of her breathing and the general appearance of her countenance. Irreg- ularity of the pulse, failure of respiration, and sudden pallor are all danger symptoms, and the physician s attention must be called to them at once if they appear. In the absence of the Esmarch inhaler the drug may be administered on a small handkerchief folded square and held over the face about an inch and a half from the nose. Care must CHLOROFORM. H3 be taken not to let the handkerchief approach the face closely, for, unlike ether, which is to be inhaled in its full strength, chlo- roform must be diluted zvith a large proportion of air (ninety per cent.) to be taken zvith safety. When chloroform is administered at night by either gas- or lamp-light, many persons, including physicians and nurses, suffer from irritation of the larynx of a most severe type, due, probably, Fig. 58.—Administration of chloroform. Patient's eyes protected by folded towel; . third finger of nurse's right hand taking pulse at the facial artery under the margin of the jaw. to the disintegration of the drug by the flame and the liberation of chlorine gas. This causes paroxysms of coughing which often make it necessary for the sufferer to leave the room, and in one case at least death has resulted from the violence of the attack. The patient usually escapes because she is anaesthetized to such a degree that the irritating effect of the chlorine is unnoticed by her larynx. 144 A NURSE'S HANDBOOK OF OBSTETRICS. This untoward action of the drug can usually be prevented by keeping a good-sized cloth soaked with ammonia hanging from the chandelier or near the lamp. The ammonia will com- bine with the chlorine to form the bland and unirritating muriate of ammonium. Care must be taken, of course, to avoid over- doing the matter and making the remedy as bad as the disease by filling the room to suffocation with the fumes of ammonia, but this will not happen if the ammonia cloth is merely kept wet with the liquid. It must hang near the light, and if any irritating effects of the chloroform are felt more ammonia must be used, for a sufficient quantity will almost invariably produce the de- sired result. Until recently ether was rarely used in obstetrical practice, though it has always found favor with certain operators. Chloro- form being much easier to administer, had always been considered (when administered to the obstetrical degree) as attended with little or no danger. This fancied security is disproved by recent investigation and it has been found to be far from possessing innocent freedom from risk. There seems to be a strong leaning toward ether as the less dangerous drug, in cases even suggest- ing involvement of the mother's kidneys or liver. Chloroform is said to produce in susceptible patients a very grave " selective " poisonous effect upon the liver of both infant and mother, resulting in alarming symptoms of toxaemia, and seemingly it is responsible for a serious jaundice in both pa- tients, along with other symptoms. For this reason, the use of ether is more general than formerly. Its use near an open fire- place or gas flame is dangerous. However, if great care is used and the can opened and kept at a considerable distance from the flame, there is said to be no danger. The method of administration of ether differs materially from that of chloroform, and, while ether is in many ways the safer of the two drugs, its proper exhibition calls for greater skill and experience and will not, ordinarily, be required of the nurse unless she has had special training in its use. In emer- gencies, however, the nurse may be called upon to anaesthetize a ETHER. 145 patient with ether instead of chloroform, and a brief description of its administration may be of value in this place. As in chloroform anaesthesia, the patient's clothing must be loosened at every point, so that her respiration will be absolutely unhampered, and any false teeth or other loose objects must be removed from her mouth. The woman lies flat on her back, with no pillow under her head, and during the entire period of anaes- thesia the neck must be extended and the lower jaw held up by pressure against the chin to prevent closure of the epiglottis and interference with respiration. Several towels must be within easy reach, as vomiting is very apt to occur during the inhalation of the drug. Many forms of inhalers, some of them decidedly complicated, have been devised for the administration of ether, but in the emergency cases that may fall to the nurse an improvised " cone," made of folded newspaper covered with a towel or muslin, will usually be employed. The cone may be put together with safety- pins or needle and thread, and the towel or muslin should cover it inside as well as out. It should be of such a size that it will fit snugly over the patient's mouth and nose, and its depth should be from six to seven inches. A piece of absorbent cotton or a crumpled gauze about the size of a lemon is placed inside the cone and saturated with ether, care being taken that it is wedged securely in the inhaler with sufficient space between it and the patient's face to allow free vaporization of the drug. The cone is now placed over the patient's nose and mouth, but a short distance away from her face to avoid the choking sensation caused by the too sudden exhibition of the anaesthetic in its full strength. As soon as the woman's throat and lungs have become ac- customed to the irritating action of the vapor, the cone is to be brought gradually towards her face until it fits over it snugly. The gauze or cotton inside the cone should be kept saturated with the drug, and for this purpose about a drachm of ether must be poured in every two or three minutes. In doing this the bottle or can is to be uncorked and the cone removed for 10 146 A NURSE'S HANDBOOK OF OBSTETRICS. an instant only, as the fresh ether is added, and replaced imme- diately over the face. A very few inspirations of air will be enough to delay the action of the anaesthetic materially. After five or ten minutes, and often when the patient seems to be passing quietly into a state of unconsciousness, she may suddenly begin to struggle violently and use all her strength to tear the cone from her face and get off the table or out of bed. This is due to the primary exhilarating effect of the drug, and is a condition to be watched for in every case. The patient is partly anaesthetized, as will be evident from her incoherent speech and unnatural behavior, and she must be securely held by assistants and fresh ether given freely until she becomes quiet again. The essential point in controlling the struggles of a par- tially anaesthetized patient consists in keeping all her limbs ex- tended at full length so that she cannot get a " purchase" on anything. Her arms must be held straight out at her sides, so that she cannot bend her elbows, and sufficient downward press- ure must be exerted just above her knees to prevent her drawing up her legs. At about this time the patient will often begin to vomit, and at the first sign of retching her head is to be turned as far as possible to one side to allow the vomited matter to escape from her mouth and prevent its possible entrance into the larynx. As this is done the lower jaw is to be drawn upward and" for- ward as much as possible, and fresh ether must be administered freely, for the vomiting will stop as soon as the anaesthesia is complete. The mouth must be wiped out frequently with a towel, or with gauze or cotton in an ordinary sponge-holder, and care must be taken that the tongue is well forward and has not fallen back and occluded the throat. Complete anaesthesia will be attained in from ten to twenty minutes after beginning the administration of ether, and it is maintained by adding about a drachm of ether to the cone every four or five minutes. During ether narcosis the patient's face should be slightly ETHER. 147 flushed, but never pale or cyanotic; her respiration deep, pos- sibly stertorous (snoring), but never irregular; and her pulse full, of good quality, fairly rapid, but never intermittent. The nurse should not only watch the respiratory movements of the chest and abdomen, but make sure that respiration is properly carried on by noting that ether vapor actually escapes through the cone with each expiratory act. Fig. 59.—Administration of ether. Cone held snugly over face ; chin raised upward and forward and pulse taken at facial artery. As the patient's wrist is not usually within the reach of the anaesthetist, the pulse may be taken at the facial artery as it passes under the edge of the lower jaw at about the middle; at the temporal artery, just in front of the ear; or at the posterior temporal artery, directly above the ear at the margin of the hairy scalp (Fig. 59). When, however, there is any doubt as to the character of the pulse taken at these points, it should al- ways be counted at the wrist as well. The open method of ad- ministering ether is simple and quite effective. A wet cotton sponge is placed on each eyelid and the eyes covered with a 148 A NURSE'S HANDBOOK OF OBSTETRICS. folded towel. The Esmarch apparatus is used. A towel folded about its outer margin is brought around either side and crossed. This secures excellent results, as the ether may be slowly dropped without raising the cone. The danger signals in ether anaesthesia are a pallid or cyanotic face, irregularity or shallowness of respiration, and irregularity or extreme rapidity of pulse. In the majority of cases in which the administration of ether will fall to the nurse the physician will first anaesthetize the pa- tient himself, and whenever the nurse is in the slightest doubt as to the subsequent condition of the woman under operation, she should call upon the physician for assistance or advice with- out delay. A nurse should enhance every opportunity to perfect herself in the knowledge of anaesthesia; if she has a rural prac- tice such knowledge is a rich possession. As soon as the baby is born, the nose and mouth cleared of all mucus, and the cord is tied and cut, the infant, wrapped in a warm blanket, is to be removed to a safe place, out of harm's way, and the nurse is to return at once to the assistance of the physician. From time to time, as opportunities offer, she should glance at the child to make sure that it is breathing properly, that the mouth and nose are free from mucus, and that there is no bleeding from the cord. Some obstetricians do not tie the cord at all, simply clamping it for one-half hour after it is cut. The nurse will do well to look carefully and incessantly after such cases. Again, many doctors tie the cord at the body junction, leaving only a small amount of tissue to retract. If the infant is well wrapped up and in a warm place it needs no further atten- tion until the placenta is delivered and the mother made entirely clean and comfortable. The after-birth is usually expelled in from fifteen to thirty minutes after the birth of the child, and the nurse must have ready for its reception a bowl or other sterile vessel covered with a warm bichloride towel, in zvhich it is to remain until it has been examined by the physician and he has given his consent to its destruction. The importance of this examination of the DELIVERY BY THE NURSE. 149 placenta lies in the fact that it enables the physician to know if any part of it or of the membranes has been left behind in the uterus. The nurse will usually be called upon from time to time to relieve the physician in holding the fundus, and while she is so occupied he will doubtless take advantage of the opportunity to inspect the infant for deformity or malformation of any sort. Every moment that is not occupied with other matters is to be devoted to putting the room in order and making the patient clean and comfortable, so that the evidences of the labor may be gotten out of the way with as little delay as possible. Delivery by the Nurse.—In certain cases the nurse will find it necessary to manage the entire labor herself, either because of precipitate labor or through delay in securing the services of a physician. It is needless to say that such cases progress rapidly, and that almost before any careful preparations can be made the pains are recurring with such frequency and severity that the patient must be put to bed and given the undivided attention of the nurse. It seldom or never happens that the nurse and her patient are entirely alone, and usually the husband, some female relative or friend, or a servant can be called upon to place a small bowl in boiling water, cool quickly, add one bichloride tablet to one quart of water making a 1: 2000 solution, or prepare some sort of an antiseptic solution, and place it on a chair or table by the side of the patient for the nurse's hands. The boric acid wipes for the infant's eyes and mouth can also be called for, and, as there is never any special hurry about tying and cutting the umbilical cord, there is usually time for the scissors and tape to be boiled in a shallow dish with just enough water to cover them. If the patient is fully dressed, as may be the case in precipi- tate labor, some one should take off her shoes and stockings and remove her clothing as rapidly as possible, but without any show of excitement, by cutting or ripping it if necessary. She should then be helped into a night-gown or, if this cannot be done, i5o A NURSE'S HANDBOOK OF OBSTETRICS. covered with clean sheets and blankets; and a pad or thickly folded sheet should be slipped under her buttocks in an effort to protect the bedding and carpet from blood and other dis- charges. All these matters may be attended to by the direction of the nurse as she sits or stands by the patient's side and watches carefully the progress of the case, and if she keeps her wits about her and does not lose her head she will have no diffi- culty in securing an immediate mastery of the entire situation. She should leave some one in her place, carefully scrub her hands, use an antiseptic solution, apply her sterile gloves and gown. She should have these articles at hand not expecting for an instant to care for any patient without them. She may, if there is no time to scrub up, put on the sterile gloves. Even precipitous labor does not exempt a nurse from responsibility for results. She will, with cotton sponges, clean the external genitals care- fully, while clean towels placed under the buttocks and about the thighs will do much to prevent the possibility of infection. The room, the bed, and the patient are all to be prepared for the labor as carefully as the time will allow, and in those cases in which the nurse is called upon to conduct the delivery merely because of prolonged delay in the arrival of the physician, she will, of course, have everything in complete readiness. The nurse can deliver the patient and retain more freedom of movement if she is delivered on her side, lying on the left side along the right side of her bed. The nurse will sit on the bed, using her left hand between the limbs and her right free to apply solutions, sponge, etc. This is possible, because the pa- tient's legs are widely separated by two or more pillows folded and covered with a sheet. As the head comes down and begins to distend the perineum the nurse must watch it carefully, and prevent undue stretching of the parts by holding it back at the acme of each pain. This in- terference with the descent of the head to prevent its sudden ex- pulsion through the vulva and consequently laceration of the tissues may be kept up for fifteen minutes or more, or until the DELIVERY BY THE NURSE. 151 parts are stretched to their utmost capacity and the head escapes in spite of every effort to hold it. The essential points are to delay the descent of the head until complete dilatation has taken place and to prevent its sudden delivery if possible and deliver the head between pains. If at any time faeces are expelled from the rectum the same should be deftly received in a towel and sponges and solution used skilfully. The nurse will then change her gloves and solution, arrange fresh towels, and proceed. This will occur less often if enemata have been properly given and ex- pelled, and infection so near the vulva at this time is fraught with great danger. If the membranes have not ruptured, they may, when the case- is under the management of the nurse, be left intact until they appear at the vulva, resembling more than anything else in appearance the rounded end of a large bologna sausage. As soon as they protrude in this way and the nurse has convinced herself by careful examination that the presenting object is the amniotic sac filled with fluid, and not any part of the fcetus itself, the patient is to be informed of the nature and harmlessness of the discharge of waters which is about to occur and the sac is to be ruptured. This may be done easily and quickly by cutting through the tissue with the finger-nail at the height of a pain, and after a towel has been placed against the vulva to receive the gush of waters. As soon as the head is born the nurse should feel about the neck for the umbilical cord, and if it is found, it should be drawn gently to one side or the other until it can be slipped over the head. No force should be used in loosening the cord, for fear of injuring it and causing bleeding. The mouth, eyes, nose, and throat of the infant are now to be carefully cleansed from blood and mucus with boric acid solution, and the face must be held up so that it does not lie in the pool of blood and liquor amnii between the mother's thighs. There is no occasion whatever for haste in the delivery of the body, even if the face of the infant becomes distinctly cy- anotic, and the mother and others in the room may be assured A NURSE'S HANDBOOK OF OBSTETRICS. that everything is satisfactory and that there is no danger or cause for alarm. In another moment the uterus will again con- tract and the body of the child will be expelled. If only the shoulders appear there is no harm in passing a finger, which has been carefully rinsed in the antiseptic solu- tion into the axilla and gently extracting the posterior arm. The body will now almost fall out of the vagina, and the infant is to be laid on its right side, between the mother's legs in a sterile towel to cover the cord, and covered with a warm woollen cloth or the nearest substitute for this which can be secured, pre- viously sterilized. If the child does not cry vigorously it may be spanked ener- getically but without too much force, or held up by its heels and slapped sharply on the back four or five times. If this is not successful, a little ice-water may be splashed briskly on its chest, but usually the slapping will suffice. In holding the baby up by its heels care must be taken that no traction is allowed to come on the umbilical cord. The instant the child is bom the nurse, or one of those pres- ent in the room, must place a hand on the patient's abdomen and grasp the fundus firmly (see Fig. 66), and this pressure is to be maintained zvithout interruption for the next full hour, par- ticularly if there is the slightest tendency toward relaxation of the uterine muscles, or the face, pulse or other symptoms indicate possible hemorrhage before any is visible. As this is a very tiresome procedure, it is well for those having the matter in hand to relieve each other at fairly frequent intervals. The correct way to hold the fundus is described in detail. There need be no hurry about tying the umbilical cord, and the nurse may safely wait until the pulsations in it have ceased or grown very faint. The first ligature is to be placed about three inches from the infant's abdomen, to leave room for subse- quent tying in case of hemorrhage, and the second ligature two or three inches from the first. It is a good plan to tie a third tape around the cord, close to the vulva, to serve as a guide to the descent of the placenta. As the after-birth is forced out of TYING THE CORD. 153 the uterus the cord will also escape from the vagina, and the progress of this expulsion can be estimated by watching this third ligature, which at the beginning was as close to the vulva as possible. The ligature should be tied with a " square knot " (Fig. 60), for the ordinary, or so-called " Granny " knot, will almost surely Fig. 60.—Square knot. slip, after a short time, no matter how tightly it may have been drawn when it was applied. The characteristic feature of the " square knot " lies in the fact that both ends pass under the same side of the loop, as shown in the figure, while in the "Granny knot"' one end passes under and one over. If hemor- rhage occurs from the cord after it has been tied and the child dies or even is seriously weakened by loss of blood great blame will attach to the nurse, and it will be an extremely difficult mat- ter for her to free herself from the stigma of either neglect or incompetency. Consequently, the nurse who intends to practise obstetrics should make it a point to perfect herself in the method of tying a square knot until she can do so instinctively, and so avoid the possibility of any such accident as has been suggested. It will avail her nothing that the case was an emergency one and that she did her best under most trying and unusual conditions, for people who are desirous of having children allow nothing to escape the fury of their wrath if anything untoward occurs in the conduct of the case, and the fully trained nurse of to-day is regarded by many as the equal of the physician in technical skill. It is a very easy matter to learn to tie the square knot snugly and securely, and when this is done properly there will be no danger of its slipping or of secondary hemorrhage from the cord, A NURSE'S HANDBOOK OF OBSTETRICS. except in the case of feeble or premature children in whom the tendency to bleeding is very great and who must always be watched with the utmost care. As many of the precipitate labors which will fall to the care of the nurse will be cases of premature birth, she must be extremely careful about tying the cord securely, and inspect it for hemorrhage at frequent in- tervals, tying it a second, or even a third time, if necessary. The cord must always be tied in tzvo places and cut between the ligatures, for if this is not done and the case should chance Fig. 6i.—Granny knot. to be one of twins, the unborn child might possibly bleed to death from the maternal end of the severed cord. As soon as the cord is cut and covered with a sterile towel, the infant, wrapped in a blanket, is to be removed to a safe place, and the nurse should take charge of the fundus for a few minutes, at least, to make sure that it is hard and firm. If it is found to be soft and flabby vigorous kneading of the uterus should be practised until it again contracts properly. There need not be the slightest haste about the delivery of the placenta, and while it is usually expelled in from fifteen to thirty minutes after the birth of the child, no harm will result if it is delayed for an hour or more, provided there is no excessive bleeding. It is to be remembered that the uterus is resting during this period, and that when its muscular fibres have recovered from the exhaustion of the labor they will contract firmly and expel the after-birth. Under no circumstances should traction be made on the cord in an effort to pull the placenta out of the vagina, for this will probably result merely in tearing the cord from its attachment, while in rare cases, when the placenta has not entirely separated from the uterine wall, the womb itself may be dragged inside out, causing the condition known as inversion of the uterus. BREECH CASES. 155 In nearly every case, after a reasonable period of time, the woman will have another labor-pain and the placenta will appear at the vulva much like a miniature counterpart of the fetal head. It should be received in the palm of the hand and directed into a sterile bowl held for this purpose, and the string of membranes that trails behind is to be extracted with the utmost gentleness and deliberation, to prevent the detachment of any tags or frag- ments (Fig. 62). The method, formerly advised, of twisting the membranes into a firm cord by turning the placenta over and Fig. 62.—Delivery of placenta and membranes. (Bumm.) No traction should be used, but the membranes allowed to fall out of the vagina by their own weight. over on itself no longer meets with general approval and is not to be recommended. All that is necessary is to extract the mem- branes from the vagina slowly and carefully, taking plenty of time and using no force whatever. The placenta is to be preserved until the arrival of the physi- cian, in order that he may inspect it and make sure that it is intact. In precipitate breech cases, which occur when the infant is small or premature, there are two important points in the management which the nurse must not forget. Traction on the body, after it has passed through the vulva, 156 A NURSE'S HANDBOOK OF OBSTETRICS. must never be made, for it is essential to have the case progress as slowly as possible in order to secure complete dilatation of the parts and afford ample room for the passage of the head. Pressure must be made on the fundus as soon as the nature of the case is recognized, and maintained until the child is born, in order to prevent, if possible, the extension of the arms above the head. Fig. 63.—Delivery of the head in breech cases. The child's body is lifted up and back- ward over the mother's abdomen, and the head is pressed forward, so that the chin, mouth, nose, etc., will be successively delivered. The diagnosis of a breech presentation can often be made by the nurse, without vaginal examination and before the ap- pearance of the infant's buttocks at the vulva, by the escape of meconium in the vaginal discharge. As soon as the body is delivered to the level of the umbilicus the cord is to be secured and gently drawn down a few inches, to prevent traction on it when the head is born, and the extruded PRECIPITATE LABOR. 157 portion of the fcetus is to be wrapped in warm towels, which are to be renewed as often as they become cool. This is necessary, not only to prevent chilling the infant, but to avert the danger of respiratory movements while the head is still undelivered, due to the shock of cold air striking the abdomen and chest. The downward pressure on the fundus in the direction of the axis of the pelvic brim is to be kept up, and, when the shoulders have escaped from the vulva, the arm which is the more easily reached is drawn out of the vagina by passing a finger over the infant's shoulder, down the arm to the elbow, and sweeping the forearm and hand across the face and chest into the world. The other arm is delivered in the same way, and then the body of the infant is raised upward and backward until it almost lies on the abdomen of the mother (Fig. 63) to favor the birth of the head. Unless the head can be delivered within five minutes after it has passed into the cavity of the pelvis the life of the child will be in great danger from pressure on the cord, and if there is any delay the nurse may pass one or two fingers into the child's mouth, and with those of the other hand under the symphysis pressing on the occiput, attempt to tip the head forward on the chest while the body of the infant is raised upward and backward and firm downward pressure is made by an assistant through the abdominal wall. Fortunately the cases of breech delivery that will fall to the care of the nurse are seldom attended with any great difficulties, for the very fact of their precipitate character presupposes a small child or a very large pelvis. The chief danger is extension of the arms above the head (Fig. 64), and this can often be avoided by the maintenance of firm pressure on the abdomen throughout the entire course of the labor. After the child is delivered the further management of the case does not differ from that of vertex presentation. Twins are not infrequently delivered precipitately on account of the small size of each infant, and unless they are " locked" in such a way that neither can be expelled without artificial aid (Fig. 65), twin births seldom or never give any trouble to the 158 A NURSE'S HANDBOOK OF OBSTETRICS. medical attendant. As the babies are small, the first is delivered with very little difficulty, and the birth of the second is accom- plished with the utmost ease, because the passages are already dilated fully and there' is nothing to interfere with its descent. fig. 64.—Arms extended in breech delivery. The most serious complication that can arise in the extraction of the after-coming head. None of the other abnormalities of position and presentation possesses any special interest to the nurse, for, unless they are of such a precipitate character that delivery is accomplished within a very short time, there will be ample opportunity to secure the services of some physician, even if the regular medical attendant cannot be reached. When the nurse finds, on her arrival, that the baby and pos- sibly the- placenta are born and lying in the bed, her first duty is to grasp the fundus with as little delay as possible and see if its contraction is satisfactory, and then make sure that the child is not lying face downward in the blood and discharges and in danger of strangling. As soon as the fundus is firm and solid PRECIPITATE LABOR. 159 the cord may be tied and cut and the infant turned over to some one who will wash its eyes and mouth and wrap it in a warm blanket. Fig. 65.—Locked twins. (R. Barnes.) First child partly born in breech presentation, the second lodged with the face under the chin of the first. In all cases of labor occurring in the absence of the physician the nurse must keep a cool head, for the patient and those about her are usually in a state of great excitement and turmoil, and this may be enough to cause relaxation of the uterus and trouble- some hemorrhage. A level-headed nurse, who shows no trace of nervousness or fear, can often change the entire picture in an instant and bring order and quiet out of chaos with a word and an air of authority and self-confidence. i6o A NURSE'S HANDBOOK OF OBSTETRICS. Analgesia.—An obstetrician discovered chloroform and it was hoped that freedom from suffering at delivery had been found. Ether also offered relief. It has been seen that, in- telligently administered, they produce relief when suffering is at its keenest and may do no damage to mother or child; but the search for a drug that would diminish pain without narcosis has gone steadily on. Whiskey, chloral, and morphine have been used for this purpose. A mixture of scopolamine and morphine had been used in psychiatry and surgery for years and was first used in obstetrics in 1903. This treatment was developed in some clinics abroad, and an elaborate technic devised by which it is claimed there is a disturbance of thought without loss of consciousness, secured by a combination of drugs adminis- tered in progressive doses as indicated by the patient's psychical perceptions. This was determined by tests, four in number, and has gained widespread publicity among the laity in America. Only the extreme popularity of this subject calls for its mention here. It is essential that a pupil nurse caring for such cases in a hospital obey instructions concerning discussions. From the graduate nurse on private duty intelligent replies are demanded. She is frequently asked, by patients who ap- parently have secured full information about the intricate de- tails, concerning her views and experiences, where such treat- ment may be secured, and its relative safety. If she is interested, and she should be, she will ask her doctor to inform her and refer her to some scientific literature. There is much con- troversy among obstetricians concerning its value, and a nurse displays ignorance who hastens to discuss an obstetrical ques- tion upon the basis of popular information. Her interest lies purely in the nursing of such cases. It may be said that any method that is safe for child and mother must surely come into general use, if at the same time pain and suffering are lessened to a greater degree than is possible with our present means. Dammerschlaf or " twilight sleep " requires conditions of pre- natal care, environment, psychical and physical conditions, and constant medical attendance, that make its widespread use a large question aside from all possible phases of danger (physical ANALGESIA. 161 and mental) to mother and child. Not enough is known of its relative value as yet, for a nurse to assume the responsibility of an argument in its favor or otherwise. Patients are to be met by no expression of opinion whatever from the nurse, and in this, as in every similar instance, they should be referred to their physician. The nursing is done under the constant supervision of a medical attendant. Every preparation must have been made according to routine technic. In addition there is a special en- vironment demanded which must be arranged. As the patient may not be intelligent, no adequate usual warning may be given of the stage of labor and especially close watchfulness is essential. The nurse may have the drugs to administer, scopolamine or one of its derivatives, morphine, codeine, pituitrin, chloroform or thyroid extract. She will prepare for probable forceps delivery and for the resuscitation of the infant from varying degrees of asphyxia. So far these cases have been nursed almost entirely under hospital conditions. XV The Management of the Puerperium The fundus uteri is to be held through the abdominal wall for one full hour after the birth of the child, if the uterus shows the slightest tendency to relax. This duty may be performed by the physician or he may delegate it to the nurse, but it must never be forgotten that it is of far greater importance than anything else that can be done at this time, and the nurse should never begin to put the room in order, bathe the patient, or wash the baby unless some one has a hand on the fundus. If this procedure were conscientiously and systematically followed out in every case, post-partum hemorrhage due to uterine inertia would be practically unknown. The nurse should sit or stand by the side of the patient, facing her feet, and the ulnar edge (the edge on the side of the little finger) of the hand nearest the patient is to be pressed down firmly on the abdominal wall in the median line and at a point at about the level of the umbilicus (Fig. 66). In the relaxed and flabby condition of the abdominal wall after the birth of the child it is quite possible to force it back until the backbone can be felt, and the nurse never should make the mistake of not using suffi- cient pressure. The uterus should now be felt below, and prac- tically in the palm of the hand, as a firm rounded mass about the size and shape of a large cocoanut. If the nurse does not find it at once she should feel around for it, for it may be displaced to one side or it may have relaxed until it has lost its firmness. If this rapid search fails to locate the fundus, she should call at once for the assistance of the physician, or, if she is alone, redouble her efforts, watch for hemorrhage as indicated either by the flow or by the patient's pulse and expression of counte- nance (pallor, etc.), and have some one give the woman one teaspoonful of fluid extract of ergot if it is to be had. The nurse herself should not remove her hand from the abdomen, and the vigorous kneading of the belly caused by her efforts 162 Fig. 66.—Holding the fundus after delivery. MANAGEMENT OF THE FUNDUS. 163 to find the fundus, especially if assisted by the ergot, will usually be enough to make the uterus again contract firmly so that it can be distinctly felt under the hand. As long as it remains firm and hard it should be let alone, the hand resting against it with sufficient pressure to permit the immediate recognition of any tendency towards relaxation. From time to time this relaxation will occur and the uterus grow soft and slightly flabby, but still perfectly distinct to the touch. On these occasions the fundus should be grasped in the hand and " kneaded " with a rotary motion gently but with in- creasing force until firm contraction occurs and the uterus is again hard and solid. This manoeuvre is not at all unlike that often practised by patronizing adults when they grasp a small boy by the top of his head and while rumpling his hair in a most uncomfortable manner, and digging their finger-tips into his scalp, ask him, solicitously, what he is going to " be " when he is a man. As has been said, this attention to the fundus is to be kept up for one full hour after the birth of the child, by the end of which time the uterus will, in normal cases, have contracted firmly and permanently, and any further danger from hemor- rhage will be very remote. If, however, at the end of the hour the uterus is still relaxed and soft, and cannot be made to stay firmly contracted, the holding and kneading must be kept up until permanent contrac- tion takes place. If the delay is longer than two hours, it would be safer to notify the physician, even though the woman's gen- eral condition seemed to be good. As a rule, the physician prefers to attend to the fundus him- self for at least the first fifteen or twenty minutes, and this gives the nurse an opportunity to attend to the next most im- portant duty of the moment, which consists in " cleaning up " the bed and patient and making things as comfortable as possible. The worst of the blood and discharges should first be washed off with a towel dipped in warm bichloride solution (1 to 1000). Next, the Kelly pad and everything under the patient are to be slipped out and into the pail at the side of the bed. 164 A NURSE'S HANDBOOK OF OBSTETRICS. A clean towel is now placed under the patient, a vulva pad applied temporarily, and she is covered with a clean sheet. The pail containing the Kelly pad and all soiled towels and other articles that may have been thrown in it or dropped on the floor are removed from the room, and already the most unpleasant fea- tures of the labor are out of sight. If the patient's night-gown has become soiled, it should be removed by cutting it down the middle in front and taking it off like a coat, for an attempt to bring it over the head will usually result most unpleasantly. If the patient objects par- ticularly to having it torn, it may be slipped off the shoulders, rolled down under the buttocks, and taken off over the feet, but the best and simplest plan is to tear it. As soon as it is removed a fresh warm one should be slipped over the head, on to the arms, and drawn down in front to cover the chest, but the back part of the garment is best left in a roll or soft pile under the shoulders or neck to avoid the possibility of its being soiled before the patient's back has been bathed, or if pajamas have been worn they are easily and quickly removed, and as two suits have been provided and both may not have been used during confinement, a fresh suit may be worn at this time. In like manner, if there are any stains of blood or other matter on the stockings, they should be removed, and fresh, warm ones put on. The nurse should now prepare a warm solution of tincture of green soap and, with fresh pieces of absorbent cotton care- fully wash off any blood or other matter that may be on the ab- domen or thighs, drying the parts immediately with a clean, soft towel. When this is done, the patient is carefully turned on one side and the process is repeated on the back, buttocks, and back of the legs. It may be necessary to turn the patient first to one side and then to the other for this purpose, and as the towel under her will by this time be soaked with blood, it is to be removed and a clean one put in its place, as well as a clean pad over the vulva. A woman after delivery is in great danger from an air- embolus. A patient wearing a proper binder and a snugly ap- THE PATIENT'S TOILET. 165 plied perineal pad will be in less danger, particularly if, in ad- dition, the uterus is firmly held while she is moved. This pos- sibility exists only for a few hours and is possible through the introduction of a douche nozzle, from which air was not ex- pelled, and it is well for the nurse to exercise great care con- cerning the possible inrush of air into the uterus and its circula- tion. The doctor usually helps the nurse in the necessary mov- ing of the patient, as it is not possible for the nurse to do this alone. The patient is now returned to her back and preparations are made for cleansing the external genitals. This should be done according to the technic outlined under " Technic." From this time on it is by error in the nursing technic that infection may occur and it is a good plan to always adhere to one method. A sterile basin is to be placed against the vulva to receive the blood, and when everything is ready the person holding the fundus will draw the covering sheet out of the way, and the pa- tient is told to draw up her knees and separate them as far as possible. The hair covering the mons Veneris and vulva will be found matted together with clotted blood, and if it is at all abundant the greater part should be carefully cut away with scissors. The parts are then to be bathed with the utmost gentle- ness with the warm solution until every vestige of blood is removed and the parts are perfectly clean. The basin is now removed and a fresh vulva pad applied to take up the little stream of fresh blood that constantly trickles down over the perineum. This should be very quickly and efficiently done with no jarring of the patient. If the patient has been confined on a cot, the next step is to remove her to her bed. The bed should be warmed, except, of course, in summer, and on the draw-sheet is to be laid one of the " obstetrical pads " from the maternity outfit. If the patient is a large woman, and those who are to lift her are not very strong, it is better to move the cot up close to the side of the bed on which she is to lie; she may then be lifted up by two persons (usually the physician and nurse) standing side by side. As soon as she is raised from the cot, a third person draws it quickly 166 A NURSE'S HANDBOOK OF OBSTETRICS. out of the way and with one step forward her bearers place her gently in the bed and cover her with the bed-clothes. Unless a full hour after the birth of the child has elapsed she should not be moved except when the uterus is firmly contracted, and the fundus must be grasped again the moment she is laid down. During the brief interval required to change her from one bed to the other the unavoidable exertion to which she will be subjected will act as a sufficient stimulus to the uterine muscle to obviate the necessity of holding the fundus for a few seconds. If she is to remain in the bed in which she was confined, the next step after cleansing the vulva is to unpin and remove the white sheet and rubber sheet on which she is lying, leaving the bedding underneath fresh and clean. At the instant this is done an obstetrical pad is to be slipped under her buttocks to protect the draw-sheet and avoid the necessity of changing it for as long a time as possible. If the full hour for holding the fundus has not yet elapsed, and the nurse is not occupied with this matter herself, she is to put the room in order, as quietly, thoroughly, and expedi- tiously as possible. All soiled articles, basins, pitchers, and the like, are to be removed; towels, sheets, and other articles that are blood-stained are to be thrown into cold water, usually in the bath-tub with the water flowing in and out over them, until all stains are removed; the physician's instruments are to be scrubbed with nail-brush, soap, and hot water, rinsed in fresh hot water, and dried thoroughly; and the furniture arranged prop- erly and with as little confusion as possible. The irrigator, if it belongs to the physician, is to be emptied, flushed out with hot water, and dried thoroughly, and the Kelly pad must be washed carefully with soap and hot water until it is absolutely clean, then rinsed quickly with scalding water and dried. The air-ring must not be emptied nor the pad folded up until it is absolutely dry, or its opposed surfaces will stick together and ruin it. By this time there will usually be no further need of hold- THE ABDOMINAL BINDER. 167 ing the fundus, and the binder may be applied, so that the pa- tient may be left to herself and allowed to go to sleep. The function of the binder is often misunderstood by the laity, who are apt to suppose that it is used for the purpose of preserving the symmetry of the figure by preventing the lax abdominal walls from bulging outward. This is far from the truth, and in France, where women are supposed to be particu- larly solicitous as to their physical appearance, the obstetrical binder is not used at all. The objects of the binder are two: first, to prevent any tendency to hemorrhage by keeping up a firm and constant press- ure over the uterus; second, to make the woman comfortable by preventing cerebral anaemia, with its accompanying dizziness, headache, and, in some cases, even syncope. The causation of anaemia of the brain after labor will readily be understood when it is remembered that the walls, not only of the abdomen but of the abdominal blood-vessels, are lax and flabby after the comparatively sudden emptying of the cavity and the accompanying loss of from one to two pints of blood. To fill these empty vessels blood comes rushing in from other parts of the body, and unless they are subjected to the firm pressure of the binder, so much blood will be abstracted from other organs and tissues that the result, while not necessarily serious, is bound to be more or less uncomfortable to the patient. After about three days, when the balance of blood-pressure has again become established and the possibility of hemorrhage is past, the binder is no longer necessary, although the patient usually finds it very comfortable to wear it for a week or so more, and then to substitute an abdominal supporter, which she con- tinues to wear for another month, or until involution is complete. Acting on these principles, the author always insists on the use of the binder for the first three days. The perineal pad can be more snugly applied to an abdominal binder than a T, owing to the fact that it can be fitted closer around the groin and spread over a wider area in the back. This prevents an escape of the blood outside the pad. After this he allows the patient to de- cide for herself whether she wishes it used or not. 168 A NURSE'S HANDBOOK OF OBSTETRICS. The binder should be made of unbleached muslin, one and three-quarters yards long and three-quarters yard wide. The selvage may be torn off and the binder washed and ironed to make it soft and comfortable. Not less than six should be pro- vided, so that soiled ones may be changed as often as necessary. Binders should not be hemmed, as the hem is apt to cause un- pleasant pressure, but the edges may be " overcast" if desired. Binders of any other dimensions than those given are not desir- able, and those made of two thicknesses of cloth or in any way " fitted " to the body are very impracticable. In an emergency an excellent binder can be made of a piece of " roller " towelling cut the proper length. In applying the binder its purpose must be kept in mind and never overshadowed by efforts to gain an artistic effect in the arrangement of the pins. This is a common fault in the training that nurses receive in the wards, for not only is the strength and good nature of the private patient often exhauste'd by delay and fussiness in pinning up a binder, but the binder itself is seldom as snug at every point as it should be. In addition, the patient frequently succumbs to the enthu- siasm of the nurse and rather than disturb the work of art will spend considerable time in real discomfort, waiting to urinate, for instance, until the vulvar dressing is due, or for some other similar reason. Abdominal binders as ordinarily applied make beautiful photographs, but often are only a means of grace to the patient. The binder should be folded about half its length and slipped under the patient in the same way that a draw-sheet is changed. The ends are then held up in the air over the middle of the ab- domen and the binder drawn in one direction or the other until its middle is exactly under the middle of the patient's back, its lower edge well below the hips, and its upper edge at about the free border of the ribs. Beginning now at the lower edge, the two ends, held tightly together, are rolled up as firmly and as snugly as possible until the material at that point is as taut as it can be made. The pin is passed first through the roll and then through the single thickness of cloth on the side opposite the nurse and clasped. Beginning again a little above the first THE ABDOMINAL BINDER 169 *y Fig. 67.—Abdominal binder. A NURSE'S HANDBOOK OF OBSTETRICS, pin the rolling is repeated in the same way and another pin inserted, and so on till all is done (Fig. 67). When at a point about the level of the umbilicus, a towel, rolled or folded to about the size of a large banana, may be laid crosswise of the abdomen under the binder, to cause extra press- ure on the fundus. A pin should be passed through the binder into the towel on either side to keep it from slipping. There is much danger that the towel may become displaced and harm ensue. This procedure must be done in the right way or not at all. The binder must be changed with sufficient frequency to keep it clean and comfortable at all times, and during the first two days this should be done as often as every four or five hours. Blood trickles down over the perineum and soaks into the binder behind, soon drying and becoming stiff and irritating, so that, no matter how clean and soft the front of the binder may be, frequent changes are none the less necessary. When the soiled binder has been removed the patient should be turned on her side and the buttocks bathed gently with soap and warm water and rubbed with dilute alcohol. The amount of comfort that this affords the patient well repays the slight trouble that it entails. Soiled binders are to be washed immediately after they are removed, and boiled and ironed before used again. The vulva pads must be changed at intervals of not less than every four hours, and, for the first day or two, fresh ones may be required as often as every one or two hours. If, for any reason, an apparently clean pad is taken off, it is never to be replaced, but a new one used in its stead. The reason for this absolute rule is because of the possibility of placing over the vulva that part of the pad which formerly was in direct con- tact with the anus. Soiled pads must be removed at once from the room and destroyed by burning. Under no circumstances should a pad be washed or otherwise cleaned (?) and used a second time. Every time a pad is removed the external genitals are to be bathed carefully and gently with warm green soap solution made up with boiled water. The nurse is to disinfect her hands REMOVAL OF VULVA PADS. 171 and wear rubber gloves for this purpose, bestowing on them as much care as though she were going to make a vaginal examina- tion. Before the hands are disinfected the pad is to be unpinned and left loosely in position and a piece of paper laid on the floor to receive it. The dish containing the solutions and cotton sponges are to be placed on a chair or on the bed within easy reach, and the parcel of clean pads is opened and laid in a convenient spot; the forceps in a bottle of lysol, 2 per cent., in reach. After the hands are clean the soiled pad is removed with a thumb-forceps and laid quickly on the paper, out of sight of the patient, to whom its appearance is usually very unpleasant. The cleansing of the parts should begin with the separation of the labia majora with the thumb and forefinger of the left hand and the careful removal of any lochial discharge that may have accumulated in the creases of the vulva. This blood is always more or less irritating and tends to become dry in spots, which adds to the discomfort that it causes. In spite of this, the pa- tient often refrains from speaking of it, on account of her natural disinclination to require of the nurse duties which she knows must be of a somewhat repellant character. The nurse who will attend carefully to this little detail will find her efforts more highly appreciated than would seem to be warranted by the circumstance. This can all be done without variation from the sponge technic given under " Technic." After this has been done the external surfaces of the labia are carefully bathed from above downward, care being taken to remove every vestige of blood from the hair. If stitches have been inserted in the perineum the nurse must take pains not to let the cotton catch and pull on the free ends of the sutures, or she will cause the patient great pain. Sutures must always be carefully dried, and occasionally the doctor may order a dusting with aristol powder. But the nurse is never to apply boric acid or similar powder unless instructed to that effect. If any blood has collected on the buttocks and soaked into the back of the binder these parts must be made perfectly clean and the binder changed, as has already been said. 172 A NURSE'S HANDBOOK OF OBSTETRICS. The pads and draw-sheet under the patient must be removed as often as they become soiled, but if the nurse is particular to change the pads frequently or to keep folded sterile towels over them, the draw-sheet will last for an entire day or possibly a little longer. As a rule, the draw-sheet is to be changed every twenty-four hours, and clean vulva pads must be provided at least as often as every four hours, and oftener if they are much stained, for even when they do not appear to be par- ticularly soiled they always contain, after a few hours, enough of the lochia to serve as an excellent breeding-place for bacteria. If the patient does not void her urine naturally within twelve hours after labor the bladder should be emptied with the cath- eter, and after this she is to be catheterized every six hours until the normal function of urination is re-established. Twelve hours is allowed in the first instance, because the relaxed condition of the bladder and abdomen after the removal of the pressure from the gravid uterus often permits consider- able distention of the bladder with urine before any desire to urinate manifests itself. Every effort should be made to avoid the use of the catheter, because of the danger of infecting the parts at the time of its introduction, and also on account of the fact that its use always tends to delay the time when natural uri- nation can be accomplished. Moreover, if the patient can once be induced to empty her bladder in the normal way, the subse- quent use of the catheter is almost never required. Conse- quently, at the end of the first twelve hours, and thereafter at intervals of six hours, efforts should be made to excite normal urination by the familiar methods of allowing water to run from a faucet, pouring water from one pitcher to another, directing a gentle stream of warm sterile water down over the vulva, or placing under the patient a bed-pan containing hot water and letting the steam from it surround the genitals, occasionally a warm saline enema will relax the urethra or some pungent smell- ing salts may provide the necessary stimulation. With some patients the mere presence of a second person in the room is enough to prevent urination, and, in such cases, the nurse should THE USE OF THE CATHETER. 173 always leave the room on some pretext or other as soon as she has arranged the bed-pan, taking pains to tell the patient that she will not be back for a few minutes. Not infrequently, on her return she will find the bed-pan ready for removal. Per- haps the physician may order the patient to be helped to a sitting posture as there exists a strong prejudice against the catheteriz- ing, except as a last resource, and he may prefer this to be tried if the patient is in good condition. If, however, all these efforts fail after a reasonable trial, the catheter must be used. This is an operation requiring great dexterity in the case of a woman recently delivered, for the parts are swollen and congested to such a degree that all the usual landmarks are distorted or temporarily destroyed. On several occasions the writer has been called upon to pass the catheter in the first day of the puerperium after nurses of long obstetric experience have failed utterly to find the meatus. The Fig. 68.—Glass catheter. best catheter for the purpose in hand is the ordinary glass one (Fig. 68) about six inches long and slightly bent at the tip. The soft rubber catheter, so often used in the belief that it is less liable to injure the delicate tissues of the parts, is not worth considering, for it possesses no advantages over the glass in- strument and is inserted with much greater difficulty. It is the only one, however, to be used during delivery, as the smooth glass catheter may break or injure the bladder. The preparations for using the catheter in private practice, where there is usually only one nurse on the case, are important, and must be carried out in detail to avoid the danger of infecting the patient. The catheter is to be boiled and the urine should be received in the basin used for boiling the instrument, or in a douche-pan, but never in a urinal which has to be placed in position after the nurse's hands are sterilized. The simplest, and therefore, the best, method is as follows: A NURSE'S HANDBOOK OF OBSTETRICS. Boil the catheter in an agate basin of sufficient size to hold all the urine to be drawn off and with only enough water to cover the instrument. Prepare tincture of green soap solution and cotton sponges, and have a clean vulva pad within reach. Place a piece of paper on the floor to receive the soiled pad. As a lubricant for the catheter use white vaseline (in a tube) or, what is still better, any one of the preparations of Iceland moss lubricants which may be had of almost any druggist. Remove the screw-top and wrap the tube in sterile or bichloride gauze. Disinfect the hands, as before, with soap and hot water and bichloride solution, and after the patient has raised her knees and separated them as far as possible, take up the basin con- taining the catheter with a wet bichloride towel, pour off as much water as possible without spilling out the catheter and set the basin in the bed as close up to the vulva as possible. Remove the vulva pad with thumb-forceps and cleanse the parts thoroughly according to given technic. Then take up the cathe- ter, which by this time is sufficiently cool, squeeze on it some of the vaseline or other lubricant, and lay it back in the basin out of the water. (The basin can be tilted somewhat so that part of its bottom will be dry.) Now separate the labia as far as possible with the thumb and fingers of the left hand, until the opening of the meatus can be seen. Wipe off the tissues sur- rounding the urethral orifice with a clean cotton sponge dipped in the solution and, with the left hand still keeping the labia widely apart, pick up the catheter with the other and pass it, by the sense of sight, directly through the meatus into the bladder, taking every precaution not to let it touch any of the surround- ing parts (Fig. 69). The basin, if properly placed, will be near enough to the vulva to receive the stream of urine without any difficulty. When the bladder is empty, grasp the catheter between the thumb and second finger and press the forefinger firmly over the tip before withdrawing it (Fig. 70). When it is entirely out and over the basin the forefinger may be raised, and the urine within the tube will escape. This is a small matter of detail, but will often save soiling the bedding or the patient's clothing. THE USE OF THE CATHETER. 175 As has been said, every effort should be made to avoid the use of the catheter, and after the third day the patient may be allowed to sit up in bed to empty the bladder if the case is pro- Fig. 69.—Proper method of inserting catheter. The labia separated and the meatus exposed to view. gressing favorably. This, of course, should only be done with the consent of the physician, and the nurse should make sure that no ill effects follow the exertion. The patient's bowels should have been emptied by enema Fig. 70.—Method of withdrawing catheter. at the beginning of labor, and will not, as a rule, require any attention until the end of the second day. At this time the physi- cian usually orders a mild saline laxative, such as one-half of a bottle of the effervescent solution of the citrate of magnesia, at 176 A NURSE'S HANDBOOK OF OBSTETRICS. night, followed by the other half in the morning, or castor oil ad- ministered in the least objectionable way, either with sarsaparilla, lemon or grape juice, whiskey or sherry wine, in bottom and on top of dose in glass. Lay ice upon tongue first and it is usually easily taken. If this is not successful, a soapsuds enema may be given in the middle of the forenoon, after waiting a reasonable time for the magnesia to act. If the progress of the case up to this time has been perfectly normal, there is usually no objection to letting the patient sit up on the bed-pan to empty the bowels, and if this can be allowed the enema is seldom required. The patient must be well supported by the nurse with the assistance of an abundance of pillows. After this the bowels are to be moved every second day by enema or otherwise, as the physician may direct, unless the natural efforts are effectual. The nurse must exercise care and skill when inserting the rubber rectal tube. Usually there are hemorrhoids and when perineal sutures are present, these must receive special care to prevent tearing. When the patient is on the bed-pan she is to be directed to hold the vulva pad closely against the vulva with her hand to prevent the entrance of fecal matter into the genital canal, and the nurse, in cleansing the parts, must be careful to follow the technic of sponging toward the rectum and discarding the sponges. It is needless to say that no vaginal douche should ever be given by the nurse except in compliance with the express direc- tions of the physician. If the lochial discharge emits a foul odor the physician may order a douche, but the matter must be left entirely with him. The irrigator and nozzle must be boiled before use, and the solution used for douching is to be made of boiled water always. The irrigator should hang about four feet above the level of the patient's bed, and the woman is to lie on a bed-pan covered with a sterile towel. A pillow should be arranged under the back and between the shoulders for support. TEMPERATURE AND PULSE. 177 The nurse should cleanse the genitals as for catheterization and thoroughly irrigate the entrance to the vagina first. Then, changing the soiled tip for a clean one, she makes all necessary preparations of material and patient and then sterilizes her hands in the usual careful way. The greatest care must be taken, in inserting the nozzle, that it does not come in contact with the external surface of the body or with the hair covering the genital organs. She should hold the douche-tube in herrighthand, and with the fingers of the left separate the labia as far as possible so that the entrance to the vagina is clearly in sight. The tube can now be introduced into the genital canal without touching any of the external tissues, and the danger of carrying infection into the vagina is effectually eliminated. The physician will, of course, instruct the nurse as to the solution to be used for the douche and its temperature, but in the absence of any definite directions, as, for example, when he merely leaves word to the nurse while she is out, that the patient is to be douched, she may safely use two quarts of normal salt solution (two drachms to the quart) at a temperature of no° F. If a nurse makes a practice of doing all vaginal work about her patient wearing gloves and using a forceps in contact with sterile sponges and pads, she can be sure, if these articles are freshly boiled and sterile, that she will not infect her patient in that particular way. If she follows sponging technic outlined, she may be equally sure that she carries no infection into the uterus in that way. The temperature and pulse of both mother and child are to be taken every four hours during the first week and after- wards every night and morning unless the case is not doing well, when the four-hour record is to be continued. The tem- peratures of both patients are to be recorded on separate charts, to facilitate a clear understanding of the entire record at one glance. The public is so well educated in the matter of clinical ther- mometry that these charts must be kept out of sight of the mother from the very first, so that in the event of any unex- pected complication she will be ignorant of the amount of her 12 178 A NURSE'S HANDBOOK OF OBSTETRICS. fever and unsuspicious at the withdrawal of the chart from her daily inspection. A pulse of 100 or a temperature of 100.5° P- ls to De re~ ported to the physician without delay, as either may indicate the onset of some serious disorder. Every attention must be paid to the comfort of the patient, for the more nearly normal her case, the more tedious is her confinement in bed while awaiting the involution of the uterus Fig. 71.—Proper method of introducing douche-tube. and other generative organs. She should be moved from one side of the bed to the other several times a day, and required to turn frequently from side to side after the first twenty-four hours. Her personal toilet must never be neglected to the slight- est degree, and her face and hands should be washed and her teeth brushed several times daily. Her hair is to be well brushed and combed night and morning, and this is most easily managed by doing it up in two braids, so that there will be no mass of hair directly at the back of the head. A warm general sponge bath with a little soap is to be given once daily, and this is of especial importance on account of the excessive perspiration that DIET IN THE PUERPERIUM. 179 occurs during the puerperium. This bath is best given at night, just before the patient is ready to go to sleep, and but one part of the body should be exposed at a time. After the bath the entire body is to be rubbed with alcohol and water (equal parts), or, on account of the peculiar odor of the lochia, which is often quite distasteful to the patient, cologne or some favorite toilet- water may be used in place of the alcohol. It need not be said that the use of cologne or toilet-water must never be allowed to cover any laxity in the attention paid to the patient's toilet. The nurse must be quick to anticipate any and every need of the patient in the matter of her personal comfort, and never, under any circumstances, make it necessary for her to ask for attentions of this nature that should have been performed as a matter of course. The diet during the puerperium must be of a simple char- acter, but nourishing and sufficiently varied to please the appe- tite of the patient. In ordinary cases the following dietary will be all that is needed. First forty-eight hours: Milk (one and one-half to two pints a day), gruel, soup, one cup of tea a day, toast and butter. Second forty-eight hours : Milk-toast, poached eggs, por- ridge, soup, corn-starch, tapioca, wine-jelly, small raw or stewed oysters, one cup of tea or coffee a day. Third forty-eight hours: Soup, white meat of fowl, mashed potatoes, beets in addition to the above. After the sixth day return cautiously to ordinary light diet; that is, three meals a day, meat of an easily digested charac- ter at one of them, such as white meat of fowl, tenderloin of beef, etc. Also a glass of milk three times a day, between meals and before going to sleep at night, and a glass in the middle of the night. Since the nurse will have had a more or less thorough course in dietetics, she will be able to give a rational reply to the objections that may be offered when upon the fifth day she gives her patient white meat of fowl or a broiled lamb chop. Eating meat of course will not cause fever, infection alone can do that; but indigestion will result from over-feeding, as the patient has no great waste of heat and no energy is expended while she is quietly lying in a warm bed. 180 A NURSE'S HANDBOOK OF OBSTETRICS. Rich, heavy foods throw too much waste upon the body. The old belief that foods, acid fruits particularly, will insure colic in the infant is now much discredited, though the mother's milk may excrete drugs and a few foods. The diet should consist as before stated of an easily digested and eliminated mixed diet, properly balanced to replace the waste and secretions as well as bodily heat. Under-feeding will decrease the amount of milk secreted in a marked way. Nourishing food with suffi- cient water, on the other hand, is efficacious occasionally in in- creasing the amount. Visitors should be excluded as far as possible during the first two weeks of the puerperium, and, as a rule, none but members of the immediate family should be admitted, and these for not more than five or ten minutes at a time. Friends and distant relatives are usually more interested in the baby than in the mother, and the infant prodigy may be exhibited for a brief interval to such callers in another room. The practice, common even among the better classes, of turning the lying-in chamber into a general meeting-place for conversation and gossip must be distinctly forbidden by the nurse. Flowers, so often sent in great profusion to the puerperal wo- man, may be shown to her as an evidence of the interest of her friends, but should be banished at once to the parlor or dining- room. A few flowers of faint and delicate odor may be placed at the side of the bed or on a table within her sight, but large bouquets of much fragrance are too overpowering for the good of the patient. The room is to be aired freely and with sufficient frequency each day to keep it fresh and sweet, for the lochia, the milk, the discharges of the infant, and the perspiration of the mother all tend to vitiate the atmosphere to a marked degree. In cold weather the patient is to be entirely covered with a sheet and blanket reaching above her head while the windows are opened for the purpose of ventilation. If the arrangement of the house permits, the nurse should always sleep in an adjoining room, to which she can take the baby for the night, and in which, in fact, the infant should spend TIME TO GET OUT OF BED. 181 the greater part of its time. Under no circumstances should the nurse ever sleep with the patient, and if another room is not available she should be provided with a separate bed or cot. Unless the nurse is a very light sleeper, the patient should be given a small bell with which to call her when she is needed. The directions for the care of the infant and the management of its feeding are discussed elsewhere, and must be followed implicitly, and the nurse must keep a sharp watch for soreness or erosions of the nipples and report their occurrence at once to the physician. The time when the patient can get out of bed, or sit up in bed, is a question that always causes her great concern, and the nurse will do best to make no positive statement in this con- nection even in the most favorable cases. Physicians no longer observe any arbitrary rule in keeping a puerperal woman in bed, and each case must be decided on its own merits. As a rule, permission to sit up is granted when involution has progressed to such a point that the fundus uteri can no longer be felt above the symphysis pubis. Even this cannot al- ways be depended upon, and many factors may have to be con- sidered before a definite conclusion is reached. Generally speaking, women of the class likely to come under the care of the graduate nurse are required to spend two weeks in bed, one week on a couch or on the bed, gradually accustoming themselves to the use of an arm-chair, and one week up and about but confined to the same floor. After the fourth week the patient may begin to go up and down stairs slowly once or twice daily, but six weeks in all should elapse after the birth of her child before she can regard herself as entirely freed from all restraint. The fact should be impressed upon her that this pro- tracted period of non-exertion is not required because she is, in any sense, an invalid, but in order to permit involution to go on uninterruptedly. The idea is much the same as that which would hold in the case of a broken leg, where rest would be ab- solutely essential to perfect recovery, although the patient's gen- eral condition would be in no way affected. 182 A NURSE'S HANDBOOK OF OBSTETRICS. A doctor may order massage given in combination with pas- sive movements after the fifth day, to relieve the muscular in- activity, or he may prescribe exercises in bed for the patient. Some physicians lay great stress upon the manner in which these are carried out and give directions in detail. Nurses are more frequently called upon than is a masseuse and the application of this particular form of massage should be made familiar through practice. Whether massage is given or exercises practised, it is generally much enjoyed by the pa- tient, and the great prostration following the quiet of the pre- ceding ten or more days' confinement in bed is largely overcome. XVI Pathology of Pregnancy The disorders of pregnancy are, in many instances, merely exaggerated states of those conditions already described as being, in their milder forms, purely physiological and unavoidable. On the other hand, symptoms appear at times which must be regarded from the very moment of their onset as unnatural and pathological. The properly trained nurse should be able to dis- tinguish accurately between conditions which are mere exag- gerations of true physiological phenomena and those which are entirely pathological and inherently dangerous to the life or health of the patient. Nausea and vomiting, if occurring only in the morning and subsiding by about noon, so that during the latter part of the day the patient is able to enjoy and retain her food, are to be considered as physiological conditions, of importance only as they cause discomfort to the woman. However, about one- third of all pregnant women escape this, and it is believed much further relief could be afforded by the exercise of proper hy- gienic routine. A mental attitude that is absolutely healthy, fresh air and wide interest divert any morbid anticipations of trouble. This is the usual type of the " morning sickness " of pregnancy, and the patient is always able to assimilate enough nourishment each afternoon and evening to suffice for the entire day. In normal cases these symptoms should disappear en- tirely by about the middle of the fourth month, and they call for no medicinal treatment beyond the occasional administration of laxatives to keep the bowels in good condition. The nurse can, however, do much to make the patient comfortable and lessen the annoyance of morning sickness by giving a glass of hot milk or a cup of tea or coffee with toast or biscuits half an hour before the patient arises. This should be taken in the recum- bent position, and the woman should lie still on her back for a 183 184 - A NURSE'S HANDBOOK OF OBSTETRICS. full half hour afterwards. When she attempts to arise she should do so slowly and gradually, avoiding any sudden change, to the upright posture. The morning vomiting almost never be- gins until the patient gets out of bed on her feet, and if the stomach can be induced to retain even a small quantity of food in the early morning it will usually continue to do so for the rest of the day. This simple procedure, coupled with careful atten- tion to the condition of the bowels, often affords great relief, and should always be given a fair trial. This vomiting or nausea, if once established, is difficult to overcome, and so it is specially de- sirable to prevent the first attack. In cases which prove more troublesome, without actually becoming serious, the writer frequently prescribes ten grains of sodium bromide dissolved in one tablespoonful of camphor water and given every three or four hours. This remedy is perfectly harmless in the proportions named, and while, as a rule, it is not wise for the nurse to order drugs on her own responsibility, there can be no objection to her availing herself of it in certain cases, as, for example, when she is travelling with a patient and no physician is obtainable. When, however, the vomiting persists throughout the entire day and into the night, so that the patient is not only unable to retain any nourishment whatever, but loses her sleep as well, the condition is wholly different and becomes distinctly patho- logical. Such women lose flesh and strength and quickly be- come emaciated to a startling degree. As the condition ad- vances they develop fever, the so-called " starvation tempera- ture," and unless relief is afforded promptly they lapse into the typhoid state and die of exhaustion. This is, of course, an extreme type, and one that will rarely be encountered, but the passage from the harmless form of vomiting to the variety that may properly be termed pernicious is very insidious, and the nurse must constantly be on the alert lest her patient retain too little nourishment and so begin to lose flesh and strength. As a safe rule of guidance, the nurse should regard with suspicion any vomiting that persists beyond the noon hour, and report the fact to the physician. NAUSEA AND VOMITING. 185 The treatment of the more severe forms of morning sickness lies, of course, with the medical attendant, but the nurse must never forget that the whole affair is of nervous origin and that it is extremely detrimental for her to express before the patient the slightest evidence of apprehension as to the prospect of its ultimate control. So strongly does this psychical factor enter into the causation of the vomiting of pregnancy of whatever type, that it is not unusual for the mere entrance into the pa- tient's room of an eminent consulting physician to bring about an immediate cessation of the symptoms. The vomiting centre in the brain along with the brain tissue is hypersensitive and suffers from the general poor circulation. This has been likened by some obstetricians to a condition re- sembling chronic shock. All the factors entering into the causa- tion of vomiting in pregnancy are still matters for research, but a poor circulation and its effect upon the brain is one generally accepted. It follows logically that proper clothing and elimina- tion may combat the condition. In severe cases all feeding by mouth is usually stopped and rectal medication and alimentation substituted. For drugs, nerve sedatives of the bromide class are usually ordered, and nutrient enemata should consist of peptonized milk, egg-nog, liquid pep- tonoids, panopepton; or matzoon. These patients are usually sent to a hospital for treatment, as the definite routine necessary for their control can be best carried out and the psychical neurotic condition be best met. The family are rarely of much assistance in carrying out the doctor's treatment and unless this is strictly adhered to, the ner- vous condition may not be successfully combated. Before the administration of a nutrient enema, the rectum should be thoroughly washed out with a hot normal salt solution. This not only cleanses the canal and favors absorption, but the salt solution itself is taken up in considerable quantity, supplying fluid to the tissues and relieving the distressing thirst from which the patient always suffers. Not more than eight ounces of nourishment should be used at each feeding, and it should be at the body temperature and injected very slowly and as lS6 A NURSE'S HANDBOOK OF OBSTETRICS. high up in the canal as possible, preferably in the colon itself. As a rule, the rectal feeding should not be given oftener than twice daily, and once in every six hours is the extreme limit. Exclusive rectal alimentation can never be continued with safety for more than two weeks, and if by that time the vomit- ing has not been controlled to such a degree that the stomach will retain at least part of the required nourishment, the physi- cian is justified in adopting more radical measures, which usually consist in the prompt termination of the pregnancy. There is, unfortunately, a class of women who understand full well that the last resort in the treatment of the pernicious vomiting of pregnancy is the induction of abortion, and who, in their anxiety to avoid having children, deliberately keep up and aggravate their symptoms by the surreptitious self-ad- ministration of emetics. Happily, such women are not often en- countered, but the nurse as well as the physician must always be on guard against the successful practice of such criminal im- position. Many other methods of treatment have, of course, been ap- plied from time to time for the control of the vomiting of preg- nancy, and even such a simple procedure as elevating the pa- tient's buttocks to a level above that of her head has been known to succeed, but in general any marked vomiting should be re- ported promptly to the physician and the treatment left in his hands. Occasionally the doctor will relieve the stomach of the accu- mulation due to vomiting and retching, by lavage. The reversed peristalsis results in a condition making this often a great re- lief to the patient. Occasionally it has an excellent tonic effect upon her nervous system. This hyperemesis gravidarum rarely lasts more than three weeks and, if controlled, recovery is gen- erally rapid. Almost every drug in the Pharmacopoeia has been suggested at one time or another as a specific in this condition, but the fact remains that no definite plan of action can be outlined to fit all cases, and treatment that proves almost miraculously success- ful in one instance will, and often does, fail utterly in another. CONSTIPATION. 187 With the general health, and especially the bowels, in good con- dition, the next most important factor in treatment is to gain the entire confidence of the patient and imbue her mind with the idea that the condition is only temporary, and that it will surely be controlled in due course of time. Above all else, the subject of vomiting must never be discussed, or even mentioned in the presence of the patient, for the mildest and most well-inten- tioned inquiries of relatives at the breakfast table will not in- frequently precipitate a severe attack of vomiting that might otherwise have been avoided altogether. In like manner the patient should never be asked what she would like to eat, or if she feels inclined to partake of food, and the nurse must use her wits and ingenuity to learn the caprices of her patient's appetite, so that she can, without comment of any sort, place before her at proper intervals daintily prepared and tempting dishes. It is to be distinctly understood that any vomiting persisting after the fifth month may be of serious import, and that this statement applies especially to that which makes its initial ap- pearance in the latter half of pregnancy after the ordinary " morning sickness " of the early months has ceased. Any such late return of vomiting, however slight, should be reported at once to the medical attendant, for it is usually due to some form of general constitutional poisoning, known as " toxaemia " and is often the forerunner of eclampsia. Constipation is the usual condition of the bowels during pregnancy, and is due largely to impaired peristaltic motion of the intestine caused by pressure from the gravid uterus. The nurse should see that at least one satisfactory movement occurs daily, and, as a routine, it is well to have the patient drink a glass of hot water for this purpose each morning before break- fast. The water should be as hot as can be borne, and a pinch of salt may be added to give it a taste. In the chapter on the Management of Pregnancy, a number of routine suggestions are made, which, if followed, will materially aid in preventing con- stipation from becoming uncontrollable. Proper elimination can- not be too clearly insisted upon, and here daily, normal hygienic habits prove their priceless value. 188 A NURSE'S HANDBOOK OF OBSTETRICS. This simple treatment, combined with a largely farinaceous diet, is occasionally all that is necessary, but usually some simple laxative is required in addition. The best preparation in such cases is the fluid extract of cascara sagrada, given at bed time in doses of one-half to one teaspoonful. If the bitter taste of the plain fluid extract is objectionable to the patient, the aromatic extract may be given instead, but it will be necessary to adminis- ter the later preparation in about double the dosage. Starting with half a teaspoonful of the fluid extract (or one teaspoonful of the aromatic extract), either pure or in water as the patient prefers, the dose may be increased or diminished from night to night until the amount necessary to secure one daily evacuation is ascer- tained. In addition to this nightly medication, an occasional glass of Hunyadi water may be given before breakfast, and at times a soapsuds enema will be indicated. Preparations containing aloes in any form should be avoided lest they tend to aggravate the existing tendency toward hemorrhoids. Under no circumstances should the patient be overdosed with cathartics, and the physician should be consulted if the constipa- tion does not yield readily to some such simple plan of treat- ment as the one outlined above. Diarrhcea occasionally occurs during pregnancy, and its onset should be reported at once to the medical attendant. If it is allowed to persist it may result in a miscarriage, either be- cause of severe straining efforts at stool or on account of an ex- tension of the existing intestinal inflammation. Castor oil, so commonly given at the onset of a simple diar- rhcea, cannot be allowed during pregnancy except by direct order of the physician, for it is to be remembered that the abortifacient properties of the drug are so well marked that they have earned for it the unenviable name of " the poor woman's ergot." Dyspncea (difficult breathing) occasionally results from pressure on the diaphragm of the pregnant uterus, and may be sufficient, in the last weeks, to interfere considerably with the patient's sleep and general comfort. It is not a serious condition, but, unfortunately, it cannot be wholly relieved until VARICOSE VEINS. 189 after the birth of the child, when it will disappear spontaneously. It is most troublesome when the patient attempts to lie down, and her comfort may be greatly enhanced by propping her well up in bed with pillows and cushions. In this semi-sitting pos- Fig. 72.—Varicosities of the lower extremities. (Bumm.) ture she will at least sleep better and longer than with her head low. Varicose veins may occur in the lower extremities (Fig. 72), and at times extend up as high as the external genitals or even into the pelvis itself. A varicosity is an enlargement in the calibre of a vein due to a thinning and stretching of its walls, and may be compared roughly to the bulb in the middle of a David- A NURSE'S HANDBOOK OF OBSTETRICS. son syringe. These distended areas occur at short intervals along the course of the vessel, and give it a knotted appearance. They are caused by pressure in the pelvis from the enlarged uterus, which presses on the great abdominal veins and inter- feres with the return of the blood from the lower limbs. Added to this primary cause, any debilitated condition of the patient favors the formation of varicosities in the veins because of the general flabbiness and lack of tone of the tissues. Naturally, the greater the pressure in the abdomen the greater will be the tendency to this complication, so that in twin pregnancies or in cases of contracted pelvis, where the gravid uterus is relatively much larger than normal, varices are very frequently seen. Also any occupation which keeps the woman constantly on her feet in the latter part of preg- nancy causes an increase in abdominal pressure and so acts as an exciting factor. The most marked case of varicosities ever seen by the writer was in the case of a woman who kept a small bakery and luncheon-room and attended to her duties in the shop up to the hour of her confinement. The first symptom of the development of varices is a dull, aching pain in the limbs due to distention of the deep vessels, and inspection will show a fine purple net-work of superficial veins covering the skin like lace. Later, the true varicosities appear, usually first under the bend of the knee, in a tangled mass of bluish or purplish veins often as large as a lead-pencil and suggesting a strong resemblance to a bunch of fish worms. As the condition advances the varicosities extend up and down the limb along the course of the vessels, and in severe cases affect the veins of the labia majora, the vagina, and the uterus. The treatment consists first and chiefly in the prompt abandonment, at the beginning of pregnancy, of garters, cor- sets, and all other articles of clothing that can cause pressure at any part of the body. If varicosities develop in spite of this precaution, the patient should spend a good part of the time in the recumbent position, and when she is on her feet the legs should be bandaged firmly from the ankles to the hips or fitted with elastic stockings. Where the general condition of the pa- CEDEMA. 191 tient is below par the physician will prescribe iron or some other suitable tonic. Constipation is, of course, to be avoided, as an overloaded state of the bowels adds to the existing abdominal pressure. Every effort should be made to prevent the develop- ment of varices, for if they are once formed they never disappear entirely. In slight varicosities covering small areas, strips of adhesive plaster applied over the distention will often relieve the condition; but care must be taken not to encircle the leg. Hemorrhoids (piles) are nothing more than varicosities of the veins about the lower end of the rectum and the anus, and the little lumps and nodules seen in a mass of hemorrhoids are merely the distended portions of the affected vessels. Like varicosities in other places, they are due to pressure interfering with return venous circulation, and are aggravated by consti- pation. They often cause great distress to the patient, and their prominent symptom is a constant and painful desire to empty the bowel, which is called " rectal tenesmus," and is not relieved, but more often increased, by straining efforts at stool. The treatment consists in relieving the constipation, in the use of hot compresses, and in the application of an ointment containing gallic acid, which can be obtained of any druggist, without a prescription, under the name of " nut-gall ointment." If these measures are not successful the case should be referred to the physician, who will doubtless prescribe suppositories con- taining opium or morphine. CEdema (swelling) of the lower extremities is not of im- portance unless it is associated with albuminuria. If it causes much discomfort it may be relieved by rest in bed, and the wearing of a proper abdominal binder. When the swelling ex- tends to the hands or face it is to be regarded with great sus- picion as a possible forerunner of eclampsia, and the appear- ance of oedema in any part of the body should serve as an in- dication for the immediate examination of the urine. Irritability of the bladder, characterized by frequent and 192 A NURSE'S HANDBOOK OF OBSTETRICS. often painful efforts at urination ("vesical tenesmus"), may occur at any time during pregnancy, but is usually most trouble- some in the later weeks. The knee and chest position or the Sims position will sometimes afford relief. If it cause great dis- comfort it should be reported to the physician, who may be able to relieve it by the correction of an abnormal position or presen- tation of the fcetus or by the administration of vaginal sup- positories containing opium or belladonna. Anaemia, of mild degree, is the normal condition of the blood during pregnancy, but at times it becomes sufficiently severe to call for the most active treatment. In such cases the onset is usually gradual, and unless the patient is carefully watched her condition will become truly alarming before treatment is begun. The symptoms of severe anaemia usually begin with head- ache, and the face becomes colorless and puffy. CEdema of the lower extremities begins and gradually ascends until it covers the entire body, and may even invade the serous cavities. The patient now loses flesh and strength rapidly, and suffers from sleeplessness, dizziness, headache, dyspnoea, and frequent attacks of fainting. The treatment, of course, rests entirely with the physician, although the nurse can do much to prevent the occurrence of this severe type of anaemia by keeping a careful watch over the patient's general condition and encouraging her to exercise freely in the open air throughout the entire period of gesta- tion. No woman who sleeps well, has a good appetite for nourish- ing food, assimilates properly what she eats, and spends a fair portion of the time out of doors is in any danger of becoming markedly anaemic. Diseases of the heart, and especially affections of the mitral valve, are greatly aggravated by pregnancy, and their fatal termination is often hastened from this cause. If the patient has placed herself under medical care at the beginning of gestation, and if the physician has made a proper and thorough examination of all her organs at this time, he will PTYALISM. 193 be in a position to administer such treatment as may be neces- sary. The only thing the nurse can do, when it seems to her probable that the heart is affected, is to report the matter at once to the medical attendant. Personally, the writer believes that these patients should not be allowed to go on in the preg- nant state, but that abortion should be induced at the earliest opportunity after a positive diagnosis has been made. Ascites (dropsy) may affect the extremities and even invade the pleural and peritoneal cavities. It is due to the altered condition of the blood, and the treatment, which should be wholly in the hands of the physician, consists mainly in the relief of the anaemia, the administration of diuretics, rest in bed, and milk diet. Ptyalism, or salivation, while one of the rarer complications of pregnancy, is most annoying to the patient and very stub- born in responding to treatment. It is due entirely to altered enervation, and is characterized by an enormously increased secretion of the saliva. Women have at times been known to discharge as much as two quarts of saliva daily from this cause. Associated with ptyalism is occasionally seen an excessive secretion of tears, and the face becomes swollen and eczematous from being constantly bathed in moisture. This complication, if it occurs at all, usually appears in the early months of pregnancy, and, fortunately, is inclined to cease spontaneously. It is seen in highly nervous women of low vitality and is apt to cause great mental depression and interfere with nutrition. The treatment should be relegated to the physician, and con- sists in building up the general health with iron and arsenic and in the use of astringent mouth-washes accompanied by atropine and bromides, or chloral internally. The treatment is very unsatisfactory and the condition is a most disagreable one, not only for the patient, but for the physician and nurse as well. Insomnia often proves troublesome, and is best relieved by strict hygienic methods, open-air exercise, and massage, sup- plemented by alcohol rubbing after the patient has retired for 13 194 A NURSE'S HANDBOOK OF OBSTETRICS. the night. The sleeping-room should, if possible, be large and well ventilated, and so situated that the patient will not be sub- jected to any disturbing influences. If these measures do not enable her to secure a proper amount of natural and refreshing sleep the physician should be consulted, and will doubtless order trional, sulfonal, or some similar drug. Under no circumstances should opium or mor- phine ever be administered in these cases. Palpitation of the heart and syncope (fainting) are of no consequence unless it can be shown that they are associated with, and due to, some organic disease. As a rule, they are purely neurotic manifestations, and usually occur in the early part of a first pregnancy, and when the patient is in a hot, crowded, and badly ventilated room. Neuralgia and headache occurring during pregnancy should be carefully investigated by the physician, and the nurse is to be cautioned against the indiscriminate use of the various popular remedies for these conditions. Neuralgia, if facial, may be due to affections of the teeth, which require the attention of the dentist, and headache, while possibly of purely nervous origin, may be a symptom of severe constitutional disease. In any event, it is safer for the nurse to refer these appar- ently trivial symptoms to the medical attendant than to attempt their treatment herself. Paralysis occurs in certain cases, and may appear either before or after delivery. It may be due to uraemia, to cerebral congestion, or even to purely neurotic causes. Fortunately its outcome is usually favorable, and the treatment, of course, rests entirely with the physician. Cough, unless due to a distinct bronchitis, is ordinarily of reflex origin and is unimportant. In the last months of preg- nancy it may be due to direct pressure of the gravid uterus. Leucorrhcea ("whites") occurs frequently in pregnancy, especially if the patient is debilitated and anaemic, and is char- acterized by a more or less profuse mucous discharge from the vagina. It is often relieved by hot vaginal douches of a solu- PRURITUS. 195 tion of borax (one tablespoonful to the quart), given twice daily,—night and morning. The patient should lie on her back while taking the douche, so that the solution will reach every part of the vaginal canal, and at least two quarts, as hot as can be borne comfortably, should be used. The nurse must keep in mind, however, the possibility of irritating the uterine muscle to contraction by the use of the douche and so causing a miscarriage. This is not likely to happen unless the douche is too hot or administered with too much force, but at the first appearance of pain, or even " bear- ing-down" sensations in the lower abdomen the irrigation should be discontinued at once, the patient kept quietly in bed, and the matter reported to the physician without delay. If this treat- ment is not successful, he may find, on examination, erosions of the cervix or other causes sufficient to keep up the discharge. Pruritus (itching), when confined to the neighborhood of the vulva, is usually due to a coexisting leucorrhcea, and dis- appears when the leucorrhcea is cured. It may be relieved by hot applications or by the use of some preparation containing naphthol, such as " resinol ointment." When the pruritus is general and covers the entire body it is almost always neurotic in character, though it may be due to a gouty diathesis or to diabetes. The treatment in such cases should be in the hands of the physician, and usually consists of rest in bed, regulated diet, the use of bromides in large doses, and the practice of thorough cleanliness, which applies to all degrees of pruritus, however slight. If the patient is gouty or is suffering from diabetes, these conditions will, of course, receive appropriate treatment. Chorea, popularly known as " St. Anthony's," " St. John's," or " St. Vitus's" dance, is, fortunately, one of the rarest com- plications of pregnancy, for it is one of the most serious. It usually occurs in the early months of first pregnancies in very young women, though it may develop at any time. As a rule, the history will show that the patient has suffered previously with the disease. It may begin suddenly or insidiously, and is characterized 196 A NURSE'S HANDBOOK OF OBSTETRICS. by involuntary movements, or twitchings, of the arms and legs, which gradually become more and more marked and extended to other groups of muscles. There are exacerbations and remis- sions of the disease, and the movements regularly cease during sleep, to reappear again when the patient awakes. When the disease develops early in pregnancy the patient usually aborts, and in many cases it is necessary to induce abortion in order to save her life. Any symptoms suggesting chorea should be reported to the physician without delay. Displacements of the uterus may be of old standing or may occur after pregnancy is established. The symptoms of all types of displacement are practically the same, so far as the nurse is concerned, and consist chiefly in marked irritability of the bladder, excessive constipation, pains in the back and loins, and a feeling of weight and " bearing down " in the pelvis. Any such combination of symptoms should be reported promptly to the medical attendant, in order that he may correct the mal- position before the pregnancy is too far advanced. Albuminuria, complicating pregnancy, may be one of several types, and may occur as early as the third month, al- though it usually makes its first appearance at about the sixth month. The diagnostic and only positive symptom is, of course, the presence of albumin in the urine, which should be discovered by the physician in the course of his regular urinary examina- tion. The analysis must be a careful one, including a micro- scopic examination for casts, etc. In properly conducted cases, where analyses of the urine are made systematically and at stated intervals, the discovery of albumin will be made before any other marked symptoms develop, and it often happens that suitable treatment can be instituted with sufficient promptness to ward off the impending attack. Hence it is of the utmost importance for the nurse to attend carefully to the collecting of specimens of urine at regular three-week periods, and forward- ing them to the physician for analysis. If unchecked, the wastes ECLAMPSIA. 197 increase in amount and a group of certain symptoms show- ing the general toxaemia develop with rapidity. In neglected cases the patient becomes anaemic, suffers from headache, which is chiefly frontal, and develops oedema, first of the ankles and legs, and later of the face and upper extremities. This oedema involves the internal organs as well, the cir- culation being directly affected by the accumulation of waste in the kidneys. The patient may suffer from this condition in the lung. Ringing in the ears and dizziness soon become annoying symptoms, and disturbances of sight, such as double vision and the appearance of spots floating before the eyes, occur and in- crease as the albuminuria becomes more marked. In severe cases actual blindness may occur. The urine becomes high-colored and scanty and the pulse is hard, small, and rapid. Vomiting persists throughout the entire day, and is especi- ally significant in women whose ordinary " morning sickness " has ceased. In this disturbed state of the digestive system a slight attack of acute indigestion or the occurrence of any other ordinarily trivial disorder is enough to precipitate an eclamptic seizure. A woman in such condition is on the very brink of disaster, and the nurse should send at once for the physician, and while awaiting his coming put the patient in bed, in a dark quiet room, keep her body warm and give her water to drink freely. Put her on an exclusive diet of skimmed milk and move the bowels freely with dessert-spoonful doses of a saturated solution of Rochelle salt, given every fifteen minutes until free catharsis is established. Eclampsia is a disease of pregnancy characterized by the oc- currence of convulsions resembling somewhat those of epilepsy, and appearing, usually, late in pregnancy just at the onset of labor. It may develop, however, at any time during the last three months of utero-gestation, during labor itself, or, rarely, after labor has taken place. The exact cause of eclampsia is not definitely understood, but it is safe to say that it is largely dependent upon deficient 198 A NURSE'S HANDBOOK OF OBSTETRICS. elimination of waste products from the maternal organism. Many theories are advanced. According to one theory the liver and kidney disease is caused by the toxaemia which is due to an auto-intoxication from wastes not eliminated; according to another these poisons are due to the metabolic changes going on in the fcetus in utero or due to poisons developed in the in- testinal tract. Its threatened onset is indicated by the presence of albumin in the urine, by insufficient excretion of urea, or by both of these symptoms together. The premonitory symptoms are those which have just been described as characteristic of albuminuria. Eclampsia is very dangerous to the mother and child, and these facts are all the more lamentable when it is remembered that, under proper management and with careful attention to diet and urinary examinations, the disease should be. a wholly preventable complication. Carelessness in the management of pregnancy and neglect of the necessary urinary analyses are, unfortunately, so much more often the rule than the exception that, although the writer has never lost a mother from eclampsia in his own practice, he knows of no less than eight deaths from this cause alone, and within the past six years, among his own circle of friends and acquaintances. Of these, one woman was a physician her- self, and another, the mother of several children, had suffered from marked premonitory symptoms of eclampsia in all of her previous pregnancies, in spite of which no urinary examinations whatever were made by her physician and no special diet or treatment was given her. Such lack of management is nothing less than criminal, and the writer hopes and believes that no reader of this book will allow any pregnant woman, no matter how well she may appear to be, to go through her pregnancy without proper urinary analyses, at least during the last three months. After the woman has suffered from albuminuria, and has shown its characteristic symptoms for a varying period, she may, if the case has not been treated, have a miscarriage. This seems to be an effort on the part of nature to relieve her con- ECLAMPSIA. 199 dition, for by the death of the child and its expulsion from her body the strain on her eliminative organs is lessened at least to the extent that she no longer has to excrete the waste prod- ucts of the foetus. More frequently, however, even if the child dies and an attempt at miscarriage occurs, she will pass into the eclamptic state and have the characteristic convulsions of the disease. One attack is practically like another. The patient first complains of dizziness, and then everything grows black before her eyes. Her hands are clinched, with the thumbs drawn in; her head is drawn backward or to one side; her face is deathly pale; the corners of her mouth are drawn down, and the eyes, open but rolled upward so that only the " whites " are visible, give to the countenance a particularly ghastly appearance. Now the large vessels in the neck begin to pulsate violently, the face grows gradually more and more cyanotic until it becomes almost black, and the glottis closes, causing respiration to stop. In this condition the woman remains for from ten to twenty seconds, in a state of complete rigidity, after which, if death does not occur, her muscles gradually relax. Respiration now becomes rapid; she froths at the mouth, and may expel some blood if she has bitten her tongue; her arms and legs begin to twitch, and soon her entire body is in a state of violent con- vulsion. After three or four minutes this gradually ceases and the woman passes into a condition of coma, from which she emerges in a few minutes with no distinct recollection of what has taken place. In severe cases the coma may grow deeper and deeper until death occurs, or she may pass directly from one convulsion to another without regaining consciousness be tween the attacks. These convulsions resemble the uraemic con- vulsions due to kidney disease and found independent of preg- nancy. If the nurse first sees a patient on the occasion of the occur- rence of an eclamptic convulsion it will be necessary for her to make a diagnosis of the cause of the spasm, in order that she may proceed intelligently. Practically the only conditions that might be confused with A NURSE'S HANDBOOK OF OBSTETRICS. eclampsia are epilepsy and hysteria, and if the following points are borne in mind the nurse will have little difficulty in arriving at a correct opinion. Eclampsia occurs in a woman who is pregnant at least six months. She has suffered during her pregnancy from the symp- toms of albuminuria. Her face is swollen and her entire body is cedematous and puffy. Her friends will tell of her headache, vomiting, visual disturbances, and the like, and often inquiry will reveal the sad fact that her physician (if she has one) has not made any urinary examinations or ordered any special diet for her. Her urine will be scanty and highly colored, and if a little is placed in a teaspoon and boiled over the flame of a match or gas-jet it will turn white and often solid from the coagula- tion of albumin. This test is simple, quick, and absolutely con- clusive, for, while there may have been little or no albumen in the specimen prior to the onset of the attack, it is sure to be present in large amount before many convulsions have occurred. The author can see no objection to the nurse's availing herself of this means of diagnosis unless the physician is close at hand and his presence can be secured without delay. If he has to be summoned from a distance, a positive report as to the highly albuminous state of the urine might be of value to him in making his preparations for the treatment of the case, while such knowl- edge would certainly aid the nurse in her management of the patient while awaiting the arrival of the medical attendant. As she comes out of one convulsion she may pass almost at once into another, and, even without a thermometer, it will be evi- dent that she has considerable fever. She may have only one or two attacks and die, or miscarry and recover, or she may have fifty or sixty at intervals of from a few minutes to a few hours, any one of which may prove fatal. Epilepsy occurs independently of utero-gestation, and if the woman chances to be pregnant it is merely a coincidence. The convulsion is generally ushered in with an outcry, and after it is over the patient passes into a sound sleep which may last for an hour or more. The attack will not be repeated for days, HYSTERIA. 201 at feast, and often it will be weeks or even months before another seizure occurs. There are none of the premonitory symptoms of albuminuria, and the history will show that the patient has long been subject to similar attacks. The nurse must, of course, be on her guard against those rare cases in which eclampsia occurs in a patient known to be an epileptic. The history of the albuminuria and the time of the attack (during the last three months of pregnancy), together with the recurrence of the con- vulsions at short intervals, the appearance of the patient, and the presence of fever, should be enough to settle the question. Hysteria, like epilepsy, occurs independently of pregnancy, and if it happens that the woman is pregnant the hysterical attack may occur at any period of gestation. The convulsion of hysteria is not as severe as that of epilepsy or eclampsia, the patient never loses consciousness completely, fever is not present, and the pulse and respiration are normal or nearly so, and the urine, instead of being scanty, concentrated, highly colored, and albuminous, is pale, of low specific gravity, and excreted in large quantity. It is, of course, to be understood that any convulsion occur- ring during pregnancy is a sufficiently important matter to war- rant the nurse in sending at once for the physician, and if the immediate services of the regular medical attendant cannot be secured she should lose no time in summoning the nearest avail- able practitioner. The treatment of eclampsia begins primarily with those pre- ventive measures which should be instituted by the physician as soon as the pregnant woman comes under his professional care. These consist largely in the adoption of a proper hygienic regime which provides for a nourishing diet with the reduction of meat to once daily, the careful regulation of the bowels, the practice of daily bathing to keep the skin in good working order, the indulgence in regular out-of-door exercise, and the daily ingestion of at least two quarts of pure water to act as a diuretic and otherwise " flush out " the system. When these measures are carefully followed, and the urine is examined at stated intervals for evidences of albuminuria, it should always A NURSE'S HANDBOOK OF OBSTETRICS. be possible to avert a threatened eclamptic attack. Unfortu- nately, this plan can be put in operation only when the patient comes under observation at a comparatively early period of pregnancy, and in many cases the nurse will not be called to a case until shortly before labor. Her first duty, under these circumstances, will be to ascertain if the patient's pregnancy has been properly managed and if the necessary urinary examinations have been made. This inquiry can always be conducted in a tactful way that will cast no reflec- tion on the behavior of the attending physician, and if the nurse finds that the proper precautions have not been taken she is perfectly justified in making such suggestions as may be indi- cated concerning diet, exercise, and the like, and in securing a specimen of urine and sending it to the physician for analysis. Moreover, during the last two months of pregnancy, she should send a specimen of urine once a week to the medical attendant, whether it is asked for or not. This should be done entirely as a matter of course, for, in the light of modern obstetrics, no physician would dare to find fault with such a procedure, even if he belonged to that happily small class of men who do not bother to make urinary analyses at these times. If the patient shows any general symptoms of threatened eclampsia, such as headache, visual disturbances, severe vomiting, and marked oedema, the physician should be sent for at once and his atten- tion explicitly directed to her condition. Occasionally the nurse will encounter the patient for the first time when she is in a convulsion, or the woman will have an eclamptic seizure shortly after the nurse's arrival or at some other time when there is no physician at hand. After sending at once for the nearest medical man and as- suring herself, from the character of the convulsion, the history of the case, the bloated appearance of the patient, and the al- buminous state of the urine, that the attack is really due to eclampsia, the nurse may proceed as follows until assistance arrives. Let the patient be lifted without jar into a warm bed; insist upon absolute quiet in the room and the avoidance of all excitement; no anaesthetic must be given by the nurse. No HYSTERIA. 203 matter what the first cause, the kidneys are almost without ex- ception involved and chloroform has been shown to produce very serious toxic effects upon the liver of mother and child. The liver has the work of breaking up poisons preparatory to their excretion by the kidneys. Ether, with as large an admixture of oxygen as possible, may be ordered to control the typical convul- sions. Remove all the patient's clothing, cutting the garments with scissors, and wrap her entire body (arms and legs separately) in a hot wet pack and cover her with warm blankets; empty the bladder with the catheter, disturbing the patient as little as possible; as soon as she can swallow give two drops of croton oil in one teaspoonful of sweet oil, if it can be obtained; whether the croton oil is given or not, make a saturated solution of Ro- chelle salt and give a dessert-spoonful every fifteen minutes until the bowels move freely. Prepare saline solution for intravenous injection or hypodermoclysis, as these are usually demanded. Oxygen is often given with excellent effect upon the cyanosis and respiration. When the convulsion ceases insist upon ab- solute quiet, and do not allow so much as a whisper in the room; disturb the patient as little as possible and only for the necessary purposes mentioned above. The time to treat this culmination of symptoms kno.wn as an eclamptic convulsion is before the toxaemia has developed to this alarming stage. The tongue must be protected from being bitten by placing a spoon or clothespin covered with a cloth or napkin to prevent damage to the teeth themselves. This must be within instant reach to be of use. The nurse will, of course, remove all false teeth. If convulsions con- tinue uncontrolled, the child is usually born. If alive, tie and cut the cord and remove it to another room; if it is dead, leave it alone, to avoid disturbing the patient, but in any case keep a hand on the fundus, under the hot pack, as a preventive against hemorrhage. If there is bound to be a considerable delay in securing the attendance of a physician, get thirty grains of chloral hydrate and forty grains of sodium bromide and give it by rectum. Beyond this: Darken the room. 204 A NURSE'S HANDBOOK OF OBSTETRICS. Maintain absolute quiet. Keep up the hot pack. Keep ice-bag to head and throat. Observe closely to prevent burns from external heat applied. Do not disturb the patient under any circumstances. Secure medical aid as soon as possible. Wait till the physician arrives before doing anything else. DO NOT LOSE YOUR HEAD. As the patient is unconscious or much dazed, the nurse must not leave the irresponsible woman alone and must be able to secure and maintain the absolute quiet prescribed. Upon the doctor's arrival he may hasten to empty the uterus if this has not already occurred and the nurse must make the necessary preparations, or he may adopt elimination and seda- tives as he sees fit. The effect of these sedatives, given usually by rectum must be very carefully observed. Morphine or veratrum viride may be ordered. Hemorrhage from the uterus may occur at any time during pregnancy, and while it may be due to high arterial tension or to erosions or ulcers of the cervix, and so be of no special con- sequence, it may, on the other hand, be of serious import; and all attacks of bleeding should be reported at once to the physi- cian. In the early months of pregnancy hemorrhage may be due to a beginning abortion or the case may be one of ectopic gesta- tion. In the later months the bleeding may indicate placenta praevia or be due to the separation of a normally situated pla- centa from the uterine wall. These four conditions will be described in detail later on, but so far as the nurse is concerned the general treatment of hemorrhage occurring during pregnancy is the same in every case: send at once for the physician ; put the patient in bed and make her lie still on her back; elevate her bed at the foot; reassure her in every way possible, and avoid all noise and every suspicion of excitement on the part of her friends and relatives ; if she is very nervous or if the hemorrhage ECTOPIC PREGNANCY. 205 seems at all severe, give one-sixth grain of morphine hypo- dermically. If the bleeding continues, a sharp watch must be kept for symptoms of acute anaemia, and it may be necessary to send for the nearest physician available instead of waiting for the arrival of the regular medical attendant. When the blood escapes into the bed, as in the case of placenta praevia, the amount of the flow should be enough to indicate the proper course to pursue, but it must be remembered that in certain instances, as, for example, when a normally situated placenta becomes detached from the uterus, the woman may bleed to death inside of her own body and little or no blood escape from the vagina. In such a case the symptoms indicative of danger would be those of severe hemorrhage from any other cause. The patient would be pale, and her pallor would increase as the bleeding continued; she would be extremely nervous and restless, and her face, bathed in a cold sweat, would have an anxious and " wild" expression; her pulse would grow more and more rapid and feeble, and finally would disappear entirely at the wrist; her thirst would be extreme, and she would soon complain of ringing in the ears, dizziness, spots before the eyes, and at last total blindness; towards the end would be seen that horrible condition known as " air hunger," in which the patient literally tries to bite the air as she would a solid substance, so great is her need of oxygen. Under these circumstances the nurse can do nothing beyond getting medical aid as soon as possible and preparing for the probability of a surgical operation, with plenty of hot water and hot, sterile, normal salt solution for infusion. Pain in the region of the uterus may be merely neuralgic in character and of no consequence beyond the discomfort that it causes, but its occurrence should always be reported to the medical attendant, as it is one of the symptoms of abortion, of ectopic gestation, of concealed hemorrhage, and of many of the diseases that may complicate pregnancy, such as appendicitis and various other disturbances of the abdominal organs. Ectopic gestation, occasionally and incorrectly termed 206 A NURSE'S HANDBOOK OF OBSTETRICS. " extra-uterine pregnancy," means, literally, a pregnancy that is " out of place." In the chapter on Fetal Development it was said that the ovum is usually impregnated by the male element while it is still in the Fallopian tube, after which it passes on into the uterus. If, now, anything occurs to prevent its passage into the uterine cavity, it will either develop where it is or else, in very rare instances, fall out of the open trumpet-shaped end of the tube and develop in the cavity of the abdomen. If its prog- ress towards the uterus were not interfered with until it reached that portion of the tube which lies within the uterine wall, it would be in the uterus, although decidedly ectopic or " out of place," which explains the incorrectness of the general term " extra-uterine pregnancy." This accident may be caused by a narrowing of the tube due to a constriction within itself; to folds or twists of the tube which may be the result of accident or disease; to pressure from pelvic organs or tumors; or it may occur with a very long tube or when the impregnation takes place close to the ovarian ex- tremity, so that before the ovum reaches the uterus it has developed to such a size that it is too large for the canal through which it is supposed to travel. In any event it becomes firmly lodged at some point and development proceeds, up to a certain stage, as though it were safe within the uterine cavity. The most common form of ectopic gestation is that which goes on in the tube itself, and is called " tubal pregnancy" (Fig. 73) ; the next most frequent type occurs in that portion of the tube which lies within the uterine wall, and is termed' " inter- stitial pregnancy;" and the rarest form of all is known as " ab- dominal pregnancy," in which the ovum develops in the abdomi- nal cavity. Neither tubal nor interstitial pregnancy ever goes on to the full development of a living child, but occasionally, when the ovum falls into the cavity of the abdomen, the placenta attaches itself to some viscus and the fcetus develops to full term and is removed by abdominal section. In all cases of ectopic gestation the woman exhibits, to a certain degree, the usual early symptoms of pregnancy, and, as ECTOPIC PREGNANCY. 207 a rule, regards herself as being normally pregnant. The uterus enlarges somewhat, the irritability of the bladder and the breast symptoms appear, and the patient suffers more or less from " morning sickness." Her menstruation may cease entirely, but there is usually a slight flow at each monthly period due to con- gestion of the lining membrane of the uterus. This may be only enough to stain the napkin for one day, and although such a " show" may occur in the early part of a normal pregnancy, it is entirely unnatural and sufficiently suspicious to warrant the Fig. 73.—Ectopic gestation. Tubal variety, ruptured at the end of the third month. A, uterus from behind with several small fibroid tumors in its wall; B, right ovary; C, ruptured tube ; D, left ovary; E, fcetus. nurse in sending for the physician or at least advising him of its appearance. As the ectopic gestation advances there will be considerable pain of a sharp, shooting character on the side of the affected tube and extending down the leg. This pain is due to the stretching of the tissues of the tube or uterine wall, and any such combination of pain and slight bleeding should be brought to the notice of the medical attendant without delay. In abdominal pregnancy the condition may not be recognized 208 A NURSE'S HANDBOOK OF OBSTETRICS. until the case has gone on to full term, when, as labor does not occur, a careful examination will disclose the true state of affairs. In unrecognized abdominal pregnancy the child will die, and may cause death of mother from peritonitis, or it may become mummified and remain in the belly indefinitely or else adhere to the abdominal wall and later slough out as an abscess. Cases of tubal and interstitial pregnancy, unless recognized and operated upon, will rupture into the abdomen sooner or later (usually between the first and third months), and the patient may bleed to death or die of peritonitis or shock. A ruptured ectopic sac would be diagnosed by the history of the early symptoms of pregnancy, the excruciating pain at the time of the rupture, the occurrence of collapse, and the rapid onset of signs of severe internal bleeding. The nurse can only send at once for surgical aid, lower the patient's head, elevate the foot of the bed, keep the patient surrounded with hot packs and perfectly quiet, and prepare for an abdominal section. While it is possible that the hemorrhage will stop and the products of conception be absorbed, bleeding is usually severe, and only the most energetic action saves the life of the patient. Placenta previa (Fig. 74) signifies an attachment of the placenta directly over, or in the immediate neighborhood of the cervix instead of at its usual site near the fundus of the uterus. When the placenta completely covers the internal os the condi- tion is known as " central placenta pra>via; " when merely the edge of the placenta extends over the opening it is termed "mar- ginal placenta prccvia; " and when the placenta is simply attached low down on the uterine wall, near the os but not overlapping it, it is called " lateral placenta prccvia." In any case the condition forms a distinct obstruction to de- livery, and the first symptom is a sudden discharge of bright red blood zvithout any pain and apparently for no particular reason. The first hemorrhage is rarely fatal, but any subsequent one may result in the death of the mother before any surgical assistance can be obtained. At the first appearance of bleeding of this character the nurse should send the patient to bed, give one- PLACENTA PREVIA. 2og sixth grain of morphine hypodermically, summon the physician, and prepare for an immediate operative delivery,—usually a ver- sion. It is needless to say that all preparations for labor should be made without the patient's knowledge, to avoid the possi- bility of causing her any alarm. Fig. 74.—Placental attachment. A, normal attachment at the fundus; B, lateral placenta praevia ; C, marginal placenta praevia; D, complete, or central, placenta praevia. Hemorrhage due to the detachment of a normally situated placenta may show itself externally or it may be entirely con- cealed, the blood remaining in the uterus and finding room for itself by collecting between the fetal sac and the uterine wall (see Fig. 74). In such a case the only symptoms would be those of severe internal hemorrhage already described, together with excruciating pain located at the point of placental separation. These cases of concealed hemorrhage are often very difficult to 14 210 A NURSE'S HANDBOOK OF OBSTETRICS. diagnose, but the nurse would at least know that something serious was the matter, and in putting the patient to bed, giving morphine for the pain, and sending at once for the physician she would relieve herself of further responsibility. The symptoms of concealed hemorrhage from placental separation are practi- cally the same as those caused by rupture of the uterus, but when it is remembered that the placental detachment always occurs before, and the rupture of the uterus during, labor, it will not be a difficult matter to distinguish between the two conditions. Nose-Bleed occasionally occurs late in pregnancy or early in labor, and is due to the existing hydremic condition of the blood, coupled with a congested state of the nasal mucosa. It is seldom troublesome, but, in certain rare cases, it proves very intractable, and may persist until the patient loses an alarming quantity of blood. Such cases are, of course, very unusual, but the possibility of their occurrence should be kept in mind, and any profuse hemorrhage from the nose should be reported to the physician. Slight hemorrhages from the stomach or lungs, also due to the existing hydremia and from areas of local congestion, are occasionally met with late in pregnancy, and, unless it can be shown that they are due to other causes, such as a gastric ulcer or pulmonary tuberculosis, they are seldom of any moment. They are, however, usually more alarming to the patient than would be a really serious nose-bleed, and, of course, they should be reported to the medical attendant at once. While awaiting his arrival or advice the patient should lie quietly on her back and take small bits of cracked ice at frequent intervals. The eruptive fevers, when affecting a pregnant woman, are always exceptionally severe, and if the temperature is at all high, abortion or miscarriage is almost certain to occur. Scarlet fever is particularly fatal during pregnancy, and very little hope can be offered to the woman who contracts the disease at this time. Pneumonia in pregnancy is usually very fatal to both mother and child, although, when abortion occurs, as it often does, the maternal chances are somewhat improved. SYPHILIS. 211 Tuberculosis shows apparent improvement during preg- nancy, but its fatal outcome is probably hastened, for the woman's decline is usually very rapid after the birth of the child. Malaria is very apt to cause abortion, either by reason of its high temperature or because of the large doses of quinine given for its control. It must be said, however, that physicians practising in malarial districts give quinine to pregnant women without any regard to its oxytocic properties, and claim that under these conditions—that is, when given to a pregnant woman who is actually suffering from malaria—it has no tendency to cause miscarriage. In any event, the physician is between two horns of a dilemma when he encounters severe malaria com- plicating pregnancy, for if quinine is not given, through fear of causing abortion, the high temperature of the disease will most probably do so. Svphilis is the most common cause of all abortions, and a syphilitic patient should be under active treatment from the very beginning of gestation is she wishes to be at all certain of going to term and giving birth to a living child. The nurse should remember that syphilis is often encountered where it is least expected, and that her professional acquaintance with the disease will by no means be limited to her hospital training. Syphilis is defined as a chronic, infectious disease (which may also be hereditary, inducing cutaneous and other lesions), due to a specific germ the Treponema pallidum. The primary or first stage is marked by chancre and indolent bubo. This may appear almost anywhere and need not be of venereal origin at all. The secondary or second stage is characterized by skin erup- tions, glandular swellings, and mucous patches. These two stages are highly infectious, and follow each other within two or three months. The tertiary or third stage is marked by gumma and severe skin lesions. The gumma attests the degree of damage suffered by all tissues of the body. It develops after a lapse of years. Syphilis is curable and Osier and Churchman state that syphilitics may marry with safety after they have undergone 212 A NURSE'S HANDBOOK OF OBSTETRICS. three years of thorough treatment and been free from symptoms for a year after the last treatment. Paternal transmission of the disease is usually during the first and second stages. A patient who has tertiary lesions may have healthy children; but more often pregnancy results in a dead and typically macerated fcetus or an infant afflicted with the disease. It is a disease transmitted from man to man and there is no intermediate host. The knowledge concerning it is widespread. It is a communicable, preventable disease, and stands unequalled in its destruction of human life. Being, as has been said, the most common cause of all abor- tions, it leads as a factor in causing infant mortality. Nowhere will pre-natal care secure more definite results. A positive diag- nosis and treatment will lessen the damage to the child. Mercury, in the form of baths, inunctions, subcutaneous injections and internal administration, is usually ordered to control the condi- tion during pregnancy. Potassium iodide is often administered in conjunction with mercury. Salvarsan treatment early in syphilis will prevent the further spread of infection. A nurse may use her knowledge wisely and report symptoms observed in a patient and so save the life of the infant. A new-born infected babe will show a typical snuffle, a gen- eral eruption, ulcers on the mucous surfaces, and marasmus. Beaumes' or Colics' law: " that a child born of a mother who is without obvious venereal symptoms, and which, without being exposed to any infection, subsequent to its birth, shows this disease when a few weeks old, this child will infect the most healthy nurse, whether she suckle it or merely handle and dress it, and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue." The nurse may recognize some of the symptoms and will im- mediately take steps to prevent the highly communicable infec- tion from spreading. She will report the matter to the doctor and use every precaution that will protect the household and herself. She will nurse the patient as she would any contagious disease. Wear a gown and rubber gloves. As fast as possible GONORRHOEA. 213 destroy all discharges, by burning. Strictly individual articles must be used and kept inside the patient's room. Plenty of running water and antiseptic solution will be needed. A nurse will do well in caring for what is called a venereal disease to remember that many are innocent victims and her patient is under no circumstances to be told she has such an affliction. Her condition and symptoms must not be discussed or mentioned. The nurse must hold close to her school version of the Hip- pocratic oath and hold inviolate her knowledge of the patient's life. If she fails in this trust imposed upon her, she has failed in her whole life work ; and she should never forget that a word, or even a look, may inaugurate a domestic cataclysm. Gonorrhoea is said to be even more prevalent than syphilis. The point of infection first shows the reaction to be gonococcus. It invades the genital tract, causes inflammation, produces nu- merous complications in male and female, and has a most serious consequence, sterility. It sometimes invades the blood and a general septicaemia and pyaemia result. It may produce an arthritis and acute endocarditis, and what chiefly concerns the obstetrical nurse is the possible infection of the baby's eyes either at birth or later through the lack of care by the nurse. The patient usually suffers intensely; and the nurse, always remembering the case to be of an infectious nature, will give all nursing care, such as douches, treatment, tampons, etc., with scrupulous regard for technic. The doctor concentrates or- dinarily upon controlling the acute manifestations of the disease before confinement, and should a puerperal peritonitis follow, the measures for relief of the pelvic pain are usually a peritonitis bed and ice-caps to pelvis, with liquid diet. These cases require the best of intelligent care and absolutely perfect technic to avoid infection of the infant's eyes, navel or genitalia. The doctor may use injections of serum to control the infection. All of the eruptive fevers, syphilis, tuberculosis, malaria, and lead and sewer-gas poisoning may directly affect the fcetus in utero; and although the last two conditions do not cause any very serious disturbances if the child lives, they are very apt to cause abortion at an early period. XVII Operative Delivery Operative delivery may be either instrumental or non- instrumental. Instrumental delivery may be further divided into three classes,—cutting operations, non-cutting operations, and muti- lation of the foetus. The non-instrumental form of delivery consists in turning the fcetus with the hands from an undesirable into a desirable position in the uterus. This operation is termed version, and may be performed in any one of three ways,—by external ma- nipulation through the abdominal wall alone, called " external Fig. 75.- Internal version. (Garrigues.) Entire hand in the uterus grasping a foot. As the foot is drawn down the protruding arm will be drawn up into the womb, and Hie child will be delivered by the breech. version;" by internal manipulation through the vagina alone, called "internal version" (Fig. 75); and by a combination of these two methods, in which one hand is placed on the abdo- men of the mother and the other in the vagina with the finger- 214 VERSION. 215 tips in the uterus, called "combined version" or the " Brax- ton-Hicks Method" (Fig. 76). Fig. 76.—Combined or bipolar version. (Garrigues.) The finger in the vagina is assisted by the other hand on the abdominal wall. External version can only be performed before labor has begun, or immediately after and before the membranes have ruptured. It is often employed to convert a breech or trans- verse presentation into that of the vertex when the abnormality is recognized at a sufficiently early date to admit of the neces- sary manipulation. The combined, bipolar, or Braxton-Hicks method has a not much wider field of usefulness than the external method, and must also be done before or very early in labor. The finger- tips in the uterus push the undesired presenting part to one side, while the other hand of the operator presses through the abdom- inal wall and forces the desired fetal pole into the pelvis. The operation requires considerable skill and great patience and perseverance, and really amounts to turning the foetus around in the uterus and passing it along in a gradual, jerky way over the finger-tips until it is in a proper position. Neither external nor combined version call for the admin- 216 A NURSE'S HANDBOOK OF OBSTETRICS. istration of an anaesthetic unless the patient is in an extremely nervous condition or her abdominal wall is rigid and unyielding. The operation is not at" all painful, but is often unsuccessful, either because it proves to be entirely impossible, or, as is more often the case, because the fcetus returns to its original position within a few hours. The patient is to lie on her back, with her knees drawn up enough to relax the abdomen, and as soon as the fetal position has been corrected a firm binder should be applied with long pads on each side of the belly to prevent any change of position. In these two forms of version the head of the fcetus is almost invariably the part that is brought into the pelvis, and frequently, as soon as this is accomplished, the physician will rupture the FORCEPS OPERATIONS. 217 membrane artificially and allow labor to proceed at once. When internal version is performed the entire hand is introduced into the uterus, and instead of the head, as in the external and combined methods, a foot is grasped and brought down into the vagina, or even out of the vulva, converting the case into one of breech delivery (see Fig. 75). The patient is to be placed on her back in the lithotomy position, with her legs elevated and held by assistants or sup- ported in a leg-holder. Anaesthesia is always necessary, and should be carried to the degree of complete unconsciousness. The os uteri must be dilated sufficiently to admit the closed fist of the operator before the operation is begun, or rupture of the uterus may result; the membranes must, of course, be ruptured, in order that the surgeon may grasp a foot, and the bladder must always be empty. While external and combined version carry no danger what- ever to either mother or child except, in the latter variety, through possible infection of the uterus by a surgically unclean operator, internal version is extremely dangerous to the infant, and to the mother is one of the most perilous operations of sur- gery, not excepting those which necessitate opening the abdomi- nal cavity. Of the non-cutting instrumental operations, the most com- mon is forceps delivery. Forceps are merely metal substitutes for hands, which can grasp the sides of the fetal head, or rarely the breech, and draw it down and out of the pelvis (Fig. 78). Forceps operations are divided into three classes,—high, medium, and low. The high operation is done when the head is at or above the pelvic brim. It is extremely dangerous to the mother on account of the possibility of rupture of the uterus, and may be even more serious than version. The medium operation is done when the head has passed through the brim but lies in the vagina and does not yet distend the perineum. The low operation is done when the head lies well down on the perineum and pushes forward the vulva so that it is, in many cases, in plain sight. 2i8 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 78.-Forceps applied to head of brim. (Garrigues.) pIG 79—Walcher posture. This position tilts the pelvis forward and increases the true conjugate diameter nearly half an inch. FORCEPS OPERATIONS. 219 Fig. 80.—Patient in sling sheet. Ready for vaginal operation. In all forms of forceps deliveries the os uteri must be fully dilated, the membranes ruptured, and the bladder empty before the instruments are applied. 220 A NURSE'S HANDBOOK OF OBSTETRICS. The patient lies in the lithotomy position on a bed or table, with her buttocks drawn well over the edge, and, except in the case of a low operation, complete anaesthesia is required. If an anaesthetic is not used the patient may struggle and injure herself severely with the instruments. In certain rare cases where difficulty is encountered in making the head enter or " engage in " the pelvic brim, the physician will wish the patient placed in the Walcher posture (Fig. 79). This consists in lowering the legs until they hang freely over the edge of the table, while the buttocks are raised by means Fig. 81.—Sterile pillow cases for covering the limbs. of a thick pillow or a folded blanket. This tilts the pelvis for- ward, so that there is an increase of nearly half an inch (one centimetre) in the true conjugate diameter of the inlet; but to be effective, the position of the woman must be such that she is just at the point of slipping off the table,—an accident to be avoided by support from assistants at her shoulders and hips. The most common types of forceps are the "Elliott" (Fig. 83) and " Simpson " (Fig. 85) patterns, with fenestrated blades, the " Tucker-McLane " instrument (Fig. 85), with solid blades, FORCEPS OPERATIONS. 221 Fig. 82.—Kitchen table utilized for operating table. Kelly pad of white rubber sheeting. Improvised. and the "axis-traction " forceps (Fig. 86), which is only used for performing the high operation. With the axis-traction instrument the handles are used merely for applying the blades, 222 A NURSE'S HANDBOOK OF OBSTETRICS. and all the traction force is exerted on a handle-bar, which is attached, after the instrument is in place, to rods fastened to lower part of blades. It is a very powerful instrument, and a dan- gerous one in the hands of an operator unaccustomed to its use. Forceps, like other instruments, should be boiled before use, and the nurse should have ready sterile vaseline, lysol solution i per cent., always warmed, or other suitable lubricant for anointing them and the hands of the operator. The indications for the performance of version or the use of forceps do not especially concern the nurse, but in general it may be said that external and combined version are performed as prophylactic measures to correct a malposition before or early in labor; internal version is done when, for any reason, Fig. 83.—Elliott's forceps. speedy delivery is necessary, as in cases of eclampsia or of hemorrhage; low and medium forceps are chiefly indicated in cases of uterine inertia, when the patient is exhausted after pro- longed expulsive efforts; and high forceps are used usually on account of pelvic contraction or overgrowth of the foetus. These statements are, of course, made in a very general way, and must not be regarded in any other light, for the subject is a very complex one and cannot be treated briefly. Often, before performing version or using forceps, the sur- geon finds it necessary to dilate the cervix artificially. He may do this with his fingers or hands, or he may use rubber bags distended with water. These bags are of two kinds,—the "Barnes" bag (Fig. 87), which is fiddle-shaped, and the " Champetier de Ribes " bag (Fig. 88), which is conical. Both varieties come in sets of different sizes, and the largest one that FORCEPS. 223 Fig. 84.—Simpson's forceps. Fig. 85.—Tucker-McLane forceps. Fig. 86.—Tarnier axis-traction forceps. 224 A NURSE'S HANDBOOK OF OBSTETRICS. can be inserted is passed into the cervix and slowly distended with water pumped in through a Davidson syringe (Fig. 89). The water should be warm (no° F.), and must invariably be sterilized by boiling, so that if a bag bursts the accident will cause no danger of infection. The bags themselves should, of course, be boiled to sterilize them inside and out, and before this is done the nurse should test each bag by pumping it full of water to make sure that it does not leak. This can be much more aseptically accomplished by the use of a large glass syringe. A Davidson syringe cannot be made sterile except by prolonged Fig. 87.—Barnes's bags. For rapid dilatation of the cervix. soaking in solution of bichloride of mercury 1 : 1000; the valves and irregular surfaces are also far from satisfactory. The bag, whether of the Barnes or Champetier de Ribes pattern, is passed into the cervix by means of a specially con- structed instrument or with an ordinary sponge-holder. In private practice the nurse will often be called upon to hand the bag, grasped in the forceps, to the surgeon for introduction, and it should be rolled or folded as compactly as possible and secured between the blades of the instrument. The most important of the cutting operations on the mother is that by which the child is extracted through an in- CESAREAN SECTION. 225 cision in the abdominal wall and uterus. This operation is called " Cesarean section," the name being supposed by some au- thorities to have reference to the alleged fact that Julius Caesar r Fig. 88.—Champetier de Ribes bag. Fig. 89.—Bulb and valve, or " Davidson " syringe. was born in this manner, while other maintain that the word is derived from the Latin ccrsus, from cccderc, to cut. Cesarean section' may be performed in one of two ways, —the entire uterus and its appendages may be removed, or the 15 226 A NURSE'S HANDBOOK OF OBSTETRICS. uterus may merely be incised, the infant and placenta extracted, and the wound closed with catgut sutures, after which the abdominal incision is closed in the ordinary way. Formerly, when the Caesarean operation was one of the most dangerous in surgery, it was customary to remove the uterus, ovaries, and tubes, if for no other reason than to prevent the Fig. 90.—Method of inserting bag. possibility of a subsequent pregnancy, but at the present time there is so little danger attached to this form of delivery that most operators prefer to leave the uterus, unless it is itself the seat of disease. Few accoucheurs will attempt this operation in a private house, the patient usually being hurried to the protec- tion of the nearest hospital operating-room. Caesarean section is not to be regarded as an emergency operation. That is to say, it should not be performed without CESAREAN SECTION. 227 due preparation, and never, if it can be avoided, when the pa- tient is exhausted after protracted labor and futile attempts at delivery by forceps or version. Under such circumstances it is very apt to result fatally to the mother either from shock or infection or both, while, if it is performed by a competent sur- geon either just before or immediately after the natural onset of Fig. 91.—Method of inflating bag. labor, with the patient in good condition and all necessary con- veniences and assistants at hand, it is almost universally success- ful. Consequently, it is easy to understand that the best results in Caesarean section will follow careful and thorough ante- partum examination, by which the surgeon may know in ample time that the patient cannot by any possibility be delivered of a living child through the natural passages at full term or at any period of pregnancy sufficiently advanced to permit of its A NURSE'S HANDBOOK OF OBSTETRICS. living. It is hardly necessary to say that the operation subjects the child to no danger whatever, and that if it is in good con- dition at the time when the abdomen is opened it will be de- livered successfully. The chief indication for Caesarean section is contraction or deformity of the pelvis which is so marked that it is impossible for a viable child to pass through it even with the assistance of forceps or version, and it may also be rendered necessary by the presence of abdominal tumors (Fig. 92), cancer of the Fig.92.—Pelvic tumor preventing delivery. (Garrigues.) Large ovarian cyst, in front of head, obstruciing the genital canal. cervix, overgrowth of the fcetus, monstrosity, certain cases of twins, and certain malpositions of the fcetus which cannot be corrected. In malignant disease (cancer) of the cervix the uterus and appendages are usually removed at the time of the operation, unless the mother is already in a hopeless condition and the section is performed solely in the interest of the child. As in any other abdominal operation, the patient lies on her back on a firm table, with a Kelly pad under her buttocks (Fig. 93). All the hair on the abdomen, mons Veneris, vulva, and peri- neum is to be carefully shaved off, and the belly, external genitals, CESAREAN SECTION. 229 and thighs scrubbed and disinfected with the utmost care. The vagina is also usually made as sterile as possible, but this is generally performed by the surgeon or his assistant, and need not be taken up by the nurse, except under definite instructions. The case calls for at least two nurses, and four assistants to the operator. The head nurse has direct charge of the solutions, irrigation, and dressings, and the second nurse makes herself generally useful. The operator stands at the right side of the patient, facing her head; opposite him is the first assistant, facing the patient's feet. Standing on the same side of the Fig. 93.—Kelly pad in position under patient, with apron draining into tub or pail. patient as the first assistant, and facing him, is the second assist- ant, whose duty is usually to grasp the blood-vessels at the cervix after the abdomen is opened and control hemorrhage as much as possible when the uterus is incised. The third assist- ant gives the anaesthetic, and the fourth stands behind the oper- ator, out of the way, ready to take charge of the baby the instant it is extracted. The head nurse stands between the first and second assistants, facing the operator, but at a sufficient distance from the patient to be out of the way, and at her side should be a table with flasks (Fig. 94) or pitchers of saline solution (six- tenths per cent.) at a temperature of 1180 F. and plenty of hot sterile water, cotton sponges (Fig. 95) in holders (Fig. 96), and intestinal pads. The pads, for holding back the intestines as the A NURSE'S HANDBOOK OF OBSTETRICS. uterus contracts, must be supplied with long tapes and carefully counted and recorded before the beginning of the operation. The second nurse must keep a close watch on her superior, so that she can obey a glance instantly. The anaesthetist is to be provided with a small table for his hypodermic syringe, which must be tested and seen to be in per- Fig. 94.—Sterile salt solution in flasks. Fig. 95.—Sponge made of cotton and gauze. feet working order, tongue-forceps, throat-swabs, and stimu- lants, and the surgeon's instruments are laid out (usually by himself in definite arrangement) on a table close by his side where he can reach them easily. Some surgeons prefer a fifth assistant to pass instruments, but as this plan increases the dan- Fig. 96.—Sponge holder. ger of infection by bringing another (and unnecessary) pair of hands into the case, it is gradually being abandoned. The essential things for the nurse to have ready in private practice are: A room, as clean as soap, water and a knowledge of proper aseptic conditions can make it. CESAREAN SECTION. 231 Protection for the carpet, unless it is removed altogether, for blood and solution readily escape to the floor. A firm table for operating, narrow and long. Usually two kitchen tables, placed end to end, answer perfectly. These should Fig. 97.—Intestinal pad of folded gauze. Usual size about eight by ten inches. The tape extends out of the wound during the operation to avoid the possibility of leaving a pad behind when the abdomen is closed. be covered with a clean blanket, rubber sheeting, and sterile white sheet, all pinned securely in place. A table for instruments at the right side of the patient, with space between it and the operating table for the surgeon to stand. This; of course, is to be covered with sterile towels or sheet. Fig. 98.—Gauze packing. A table for dressings, sterile rubber gloves, packing, solu- tions, etc., on the left side of the patient, about four feet away, also covered with sterile or bichloride towels. A small table at the patient's head for the anaesthetist. Two clean slop-jars or pails with covers, one on either side of 232 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 99—Saline infusion. the operating-table, for receiving soiled towels and sponges and as much of the blood and solutions as can be directed into them. Two dozen sterile towels. Five gallons of sterile salt solution, with enough boiling water to raise it instantly to any desired temperature. Three dozen large safety-pins. CESAREAN SECTION. 233 Sterile irrigator completely equipped for giving a hypodermo- clysis or infusion. Pitchers or flasks for pouring salt .solution. These must be sterilized and wrapped in sterile or bichloride towels. Hot and cold water in large pans, and ice, all in a distant part of the room, for resuscitating the baby. A warm bed for the baby. A warm bed for the mother, with plenty of hot-water bottles, and provisions for raising the foot of the bed in case of shock. In emergencies the best hot-water bottles are beer bottles with patent stoppers, which can be corked rapidly and securely. Bichloride tablets; iodine; 95 per cent, alcohol. Tincture of green soap, eight ounces. Four nail-brushes. Four wash-bowls of good size for hand cleaning. Two or three extra wash-bowls for solutions. Hot and cold sterile water for scrubbing the hands. A warm room (750 to 8o° F.). A good overhead light. The surgeon should bring all necessary instruments, pads, gauze packing, and dressings, and may be expected to do so unless he expressly instructs the nurse to provide them. Ob- stetrical nurses rarely have the opportunity to perfect themselves in operating technic, owing to the large percentage of normal deliveries or minor repair cases, the abnormal deliveries usually being sent to a hospital if such a thing is at all possible. For this reason she is strongly urged to embrace every possible oppor- tunity to witness or assist in obstetrical surgery. In a laparotomy or Caesarean section one of her greatest responsibilities during the operation is to keep track of the sponges. She should not use one single sponge, even before the abdomen is open, that is not attached in such a manner as to make its loss practically im- possible. The method outlined in the operative chapter is the best devised and is given in detail for particular use in Caesarean sec- tion, by nurses to whom such cases are only a rare occurrence. Surgeons are more and more rejecting the use of small free sponges on holders as dangerous, and are using only large sponges 234 A NURSE'S HANDBOOK OF OBSTETRICS. on tapes attached by some mechanical arrangement which ab- solutely prevents their being permanently enveloped by the ab- dominal viscera. A supplementary operation, the removal of the tubes, may be done. The nurse will watch the abdominal dressing and the va- ginal discharge for hemorrhage. The baby, if alive, will per- haps not be able to nurse as soon as usual; but aside from this the usual routine is observed. The different operations are variously styled: Conservative Caesarean Section; Porro-Caesarean Section, which may include the removal or amputation of the uterus ; Extraperitoneal Caesar- ean Section for unclean infected cases; Post-mortem Caesarean Section (to save a child alive after the mother's death) may Fig. 100.—Galbiati knife. For cutting through the symphysis pubis in symphyseotomy. be successful if done quickly; and Vaginal Caesarean Section, where a hurried delivery is indicated or the cervix does not dilate. Every means must be immediately available to meet any emer- gency ; particularly shock, hemorrhage, violent or persistent nau- sea, acute pain, hiccough, etc. Symphyseotomy is an operation once in high favor among certain operators, but now, in view of the almost uniform success of properly timed and skilfully performed Caesarean section, gradually passing into disuse. It consists in cutting through the cartilage lying between the ends of the two pubic bones at the symphysis pubis and allowing these bones to separate for a dis- tance of about one and one-half inches, so as to make greater space for the passage of the head. The chief objection to the operation is that after this separation has occurred it is not at all certain that enough room will have been gained to permit de- livery, and it may, after all, have to be completed with forceps or SYMPHYSEOTOMY. 235 Pig ioi-Nurse's proper operating gown, Fig. io2.-Doctor's proper operating gown, cap, mask, and gloves. cap, mask, and gloves. 236 A NURSE'S HANDBOOK OF OBSTETRICS. by version. Moreover, in some few cases the bones have failed to unite after the operation, and the patient has been unable to walk. The woman is placed in the lithotomy position, and the legs are not supported in leg-holders, but are held by two assistants whose duty is to regulate the amount of separation in the joint. After the bladder has been emptied and the urethra drawn out of the way by means of a male sound passed into the canal, an incision is made directly over the symphysis pubis and a curved knife, known as the " Galbiati knife " is hooked under the sym- physis and drawn up through the joint until the parts are separ- ated. A little gauze is then packed into the wound to prevent ooz- ing, and while the assistants holding the legs keep them in such a position that the separation will not exceed one and one-half inches, the labor is allowed to proceed if it will, or is terminated by forceps or version if necessary. One nurse is all that is needed, and the surgeon requires three assistants, one to give the anaesthetic and two to hold the legs. The dressings should be provided by the surgeon, and consist of iodoform gauze to pack the wound, cotton, plain gauze, adhesive plaster strips, and a special binder or a many-tailed bandage. Certain operators join the bones with silver wire, but this is seldom done now, as it is found that firm coaptation of the parts by pressure, with the adhesive plaster drawn tightly around the body, will give equally good results. The after-care of these cases is very important and very dif- ficult, for under no circumstances can the thighs be separated until union is complete in the joint, and, as this occupies a period of about six weeks, it is extremely trying to the patient and troublesome for the nurse. Dr. Edward A. Ay res, of New York, has devised a " symphyseotomy bed," which is a sort of canvas hammock swung from a high frame and so arranged that a strip can be removed from the bottom and the buttocks uncovered, when it is necessary to move the bowels or empty the bladder. In other cases the patient lies flat on a hard bed, with long sand bags at each side of the hips, and when the catheter is used the legs, tightly bound together, are raised straight up in the air until the thighs are at right angles to the body and the catheter is in- MUTILATING OPERATIONS. 237 serted from below. While but one nurse is actually needed for the operation of symphyseotomy, at least two and often three are required to give the patient the proper after -treatment. Hebsoteotomy or lateral pubiotomy has largely super- seded this operation. The bone near the joint is severed instead of the joint itself. This is done by means of the Gigli wire saw familiar in other forms of bone work. The carrier, a large needle generally, is passed through a puncture to behind the pubic bone and the lip of the vulva. When the bone is severed a ver- sion or the application of forceps delivers the child. The severed pelvis requires careful and skilful handling. Bone surgery and obstetric delivery exact most careful technic to prevent infection and the nursing care no less. Infection of the wound is especially likely to occur owing to its location. Episiotomy is an operation designed to substitute for an un- avoidable, ragged, central laceration of the perineum, a clean in- cision, made with a knife, at each side of the vaginal floor. The only instruments required are a scalpel and suture material, with needles and needle-holder for immediate repair after delivery has been effected. No assistants or special nurse are needed. The operation often causes troublesome hemorrhage, and is seldom if ever performed at the present time. The mutilating operations on the fcetus are termed " embryotomy," and are divided into craniotomy, which con- sists in crushing the fetal head; decapitation, or amputation of the head; and evisceration, or removal of the thoracic and abdominal contents, piece by piece. When evisceration is per- formed it is usually necessary to follow it by craniotomy, for any condition which will not permit the passage of the chest or abdomen will almost certainly interfere to an even greater de- gree with the delivery of the head. Embryotomy in any of its forms is a rare operation, and one that should seldom be necessary if the patient has been under careful supervision throughout the course of her preg- nancy. Its indications are, in general, the same as for Caesarean section, but it is not justifiable unless the child is dead or the mother too much exhausted to withstand the shock of 238 A NURSE'S HANDBOOK OF OBSTETRICS. the abdominal operation. This procedure is, of course, neces- sarily fatal to the child, but the dangers to the mother from the operation itself are very few indeed, the great difficulty in such cases being that it is usually delayed until the woman is in a critical condition, either from exhaustion or from attempts at other methods of instrumental delivery. Embryotomy is a most unpleasant operation to witness or perform, but it is not, as a rule, painful, and an anaesthetic is required only to spare the mother the distressing spectacle of the mutilation of her infant. In almost every case the child is dead when the operation is begun, but it must be remembered that it is sometimes justi- fiable, in the case of a living child, to save the mother or to save one twin (as in cases of locked heads), when otherwise both children and possibly the mother herself would be lost. The nurse may be consulted by the family in these extremely rare cases as to the propriety of performing the operation on the living child, and she must not permit sentimental feelings to close her eyes to the fact that the mother is of far more impor- tance than the unborn child, and that when it is necessary to sacrifice the child in order to save the mother the latter should always receive the first consideration. It does not take a great deal of moral courage to arrive at this conclusion when it is remembered that in these cases delay will usually result in the loss of both lives, while prompt operation and the sacrifice of one may, and probably will, be the means of saving the other. Craniotomy is performed by perforating the fetal skull to allow escape of brain tissue and then crushing the head into as compact a mass as possible for extraction. The usual instru- ments for this purpose are the perforator and cranioclast (Figs. 103 and 104), but the best and most modern appliance is the basio- tribe (Fig. 105), which resembles an obstetrical forceps, and combines in one instrument the perforator, crusher, and extractor. Decapitation is seldom necessary except in the case of locked twins (see Fig. 63), when the body of the first infant is removed after decapitation, the head pushed out of the way while the second child is extracted, and last of all the severed head DECAPITATION. 239 removed with forceps. The operation may also be necessary in impacted shoulder presentations (Fig. 106), where the body is firmly wedged in the pelvis and cannot be pushed up above the brim. Fig. 103.—Naegele's perforator. Fig. 105.—Tarnier's basiotribe. The only special instrument used for decapitation is the " Braun's hook " (Fig. 107), which may either be blunt or sharp- ened to a knife edge at the concavity of its crook. 240 A NURSE'S HANDBOOK OF OBSTETRICS. Either hook is to be passed over the neck of the fcetus (Fig. 108), and when the blunt one is used the neck is merelv broken Fig. 106.—Impacted shoulder presentation. Delivery in this position is impossible and, unless it can be corrected, decapitation will be necessary. with a twisting motion and the operation completed with long heavy scissors (Fig. 109). If the sharp hook is employed, all the tissues of the neck are severed with this instrument alone. It is also quite possible to perform the entire operation with the scissors, and many surgeons do not use either hook at all. Fig. 107.—Braun's key-hook. Evisceration is accomplished with the long stout scissors shown in Fig. 109. After any form of operative delivery the danger of post- partum hemorrhage is always to be especially feared, and the nurse should have ready an ample supply of hot and cold sterile water for douches or infusions, in case they are needed, and a EVISCERATION. 241 Fig. 108.—Braun's hook applied. (Garrigues.) Fig. 109.—Long, blunt scissors. For decapitation and evisceration. 16 A NURSE'S HANDBOOK OF OBSTETRICS. number of hot-water bottles with which to surround the patient in case she goes into shock. The induction of premature labor is often indicated in cases of slight pelvic deformity, and is usually performed at about the end of the eighth month of gestation. In these cases there is no need of special haste, and the surgeon merely adopts such measures as will excite contractions of the uterus, after which the labor proceeds as in any normal case at term. There are three methods in ordinary use for starting up labor- pains. These are: the introduction of an elastic bougie, about the size of a lead-pencil (Fig. no), into the uterus; packing the Fig. no.—-Bougie for the induction of labor. About the size of a lead-pencil (No. 12. American scale). cervix and vagina with gauze; and the use of an elastic bag of small size, which is passed into the cervix, distended with water, and allowed to remain until uterine contractions force it out. The first, or " Krause," method is the one most commonly employed, and is perfectly safe. Its objections are its uncertainty and the danger of rupturing the membranes and causing " dry labor." The bougie should be about the size of a lead-pencil (No. 12, American scale), with a wire stylet to facilitate its intro- duction, and it is prepared for use by soaking it for twenty-four hours in cold bichloride solution (i to iooo) after it has been thoroughly washed with soap and water. The patient is usually placed in the lithotomy position at the edge of the bed or table, but some physicians prefer Sims's position (Fig. in) in these cases. No anaesthetic is required, as the operation is absolutely painless and of but a moment's dura- tion. Labor-pains usually begin in from thirty minutes to twelve hours after the insertion of the bougie. If there are no develop- ments at the end of twenty-four hours, it may be removed by the surgeon and inserted in a new place, or a second bougie INDUCTION OF PREMATURE LABOR. 243 may be passed in alongside of the first. In some cases it is neces- sary to use three bougies before labor-pains begin. Gauze is Fig. hi.— Sims's position. The patient lies on her left hip, her chest nearly flat on the table, her left arm hanging over the edge and her right leg drawn well up above the left knee. required to pack the vagina after the introduction of the bougie, but the physician usually supplies everything'of this sort him- self. None of the methods named for the induction of labor is at all painful, and after the bougie, gauze, or bag has been in- serted the patient may be up and on her feet as in the first stage of normal labor. If the membranes rupture, the nurse should report the fact at once to the physician, and he should be notified, as in any other case, the moment true labor-pains are established. With the exception that these cases are artificially started, they do not differ in any respect from ordinary labor, nor do they subject either mother or child to any greater danger. When haste in delivery is an essential factor, as in eclampsia or hemorrhage, the surgeon dilates the cervix under complete anaesthesia, either manually or with bags, and delivers by for- ceps or version. As version offers the most rapid means of delivery at our command, it is usually the method chosen. XVIII Abortion and Miscarriage Abortion, miscarriage, and premature labor are all terms which indicate the premature discharge of the fcetus from the cavity of the uterus. When the embryo is expelled before the end of the third month of gestation, the word " abortion" is, technically, the correct term to employ; while from the end of the third month up to the earliest date at which the child can, by any possibility, live (about six and a half months) the term " miscarriage" is used. If the woman is delivered at any time after the middle of the sixth month and within about two weeks of the proper end of her pregnancy, the birth is described as " premature labor." While, as has been said, the expulsion of the uterine contents during the first three months of gestation is technically termed " abortion," this word is so intimately asso- ciated in the public mind with some form of criminal procedure that the nurse should never use the word under any circum- stances, but group all such accidents occurring before the period of viability of the child under the general term " miscarriage." The first symptom of either abortion or miscarriage is usually pain of an intermittent character, followed soon by bleeding due to the separation of the placenta from its uterine attachment. In some cases the bleeding appears first, and the pain, which is of a " bearing down" type resembling that of labor, comes later. Premature emptying of the uterus at any time may be caused by fright, grief, or other form of severe nervous shock; it may result from disease of the mother or of the foetus, or from external injury, such as a fall, or a blow or kick over the abdomen. In the latter class of cases the element of fright must also be considered. Whenever the mother is suffering from an acute febrile disease she will surely miscarry if the temperature reaches 105 ° F., and she may do so at a much lower 244 ABORTION AND MISCARRIAGE. 245 degree. Hence in such cases the nurse must be always on the lookout and fully prepared for this accident. When abortion or miscarriage threatens the patient she is to be put in bed on her back and kept perfectly still until the physician arrives. The nurse should elevate the foot of the bed, and place pillows under the patient's buttocks so as to increase the elevation of the pelvis. If the symptoms are severe, one-sixth grain of morphine may be given hypodermically to relieve the pain and allay the nervousness of the patient. In many cases this treatment will be all that is necessary, and the pain will cease, -"trie bleeding stop, and the case go on to full term without further interruption. In other cases the symptoms will increase, and eventually the fcetus and its envelopes will be expelled from the uterus, either wholly or in part. The bleeding in these cases is seldom if ever enough to cause any serious alarm before the physician arrives, but it is of the utmost importance for the nurse to save for his inspection every particle of blood or other matter that comes away from the uterus. In many cases the embryo is so small that it is easily lost in a blood-clot, and unless the physician is afforded an opportunity of examining the discharges himself he cannot know exactly how much, if any, of the ovum has been expelled. Lacking this positive knowledge of the actual condition of affairs, the surgeon is obliged, in the interest of his patient, to proceed as if part, at least, of the ovum remained in the uterus, and a little care and forethought on the part of the nurse might have been the means of saving the patient the discomfort, not to say the danger, of a curettage under ether. Abortion and miscarriage are by no means the trivial matters that they are so commonly supposed to be by women in general. The process is distinctly an abnormal and unnatural one, and as the uterus is not prepared to cast off the placenta as it would at the normal end of pregnancy, some part of it is almost certain to be retained in the cavity of the uterus. These retained frag- ments of placental tissue cause chronic inflammation of the membrane lining the uterus, even if they do not decompose and result in " blood poisoning," with the possible death of the 246 A NURSE'S HANDBOOK OF OBSTETRICS. patient. In any event the outcome is bound to be serious unless the case is most carefully and intelligently treated, and even in those cases in which the entire ovisac has apparently come away a thorough curettage under general anaesthesia is usually indicated as the safest procedure to follow. The nurse should use all her influence to impress upon patients the .-;erious nature of abortion and miscarriage when proper treatment is neglected or refused ; and it is safe to say that the dangers to the woman are consider- ably greater than are those which follow in the train 01 a normal labor at term. An abortion is spoken of as complete when the entire uterine contents are expelled. It is called an incomplete abortion when some part of the membranes or placenta is retained. Here there is often much hemorrhage and discharge. A threatened abortion indicates a possible loss of contents of uterus but with proper care pregnancy may not be terminated. If curettage is to be performed after abortion or miscar- riage, the preparations for the operation are the same as when it is indicated in any other condition. If there is sufficient time a soapsuds enema with one drachm of turpentine should be given to thoroughly empty the lower bowel. No solid food should be allowed within six hours of the operation, on account of the ether. The woman is to be etherized and prepared for operation in precisely the same manner as for forceps delivery except that, if possible, she should lie on a firm table instead of on the bed. She is to be placed in the lithotomy position, and the legs are to be supported in some form of leg-holder (Figs. 112 and 113), or with the metal leg supporters screwed to the sides of the table if the physician has them. A strong, narrow kitchen table is the best for use in private practice, and it is to be covered with a folded blanket, rubber sheeting, and a clean white sheet, all pinned securely under the corners. As the patient will be removed to her bed as soon as the operation is concluded, she may be anaesthetized in bed, and need not know that a table is to be used. Many women, who will submit to almost any surgical procedure so long as they are not re- CURETTAGE. 247 moved from their beds, are stricken with terror at the mere sug- gestion of performing the same operation on a table, and it is best to keep all preparations out of their sight as far as possible. The instruments used for curettage are— Fig. 112.—Author's leg-holder. Fig. 113.—Robb's leg-holder. Sims's speculum (Fig. 114), or a vaginal retractor (Fig. 115). Bullet forceps (Fig. 116). Goodell uterine dilator (Fig. 117) occasionally. Uterine sound (Fig. 118). Placenta forceps (Fig. 119). Curette (Fig. 120) according to the case or to the individual preference of the operator. Sponge-holders (Fig. 121) at least four. Uterine applicators, four or five, wrapped with cotton. Double current catheter( Fig. 122). A Kelly pad is to be placed under the patient's buttocks, to drain into a pail at the foot of the table, and there should be a small table at the head for the hypodermic syringe and other articles used by the anaesthetist. A chair should face the buttocks for the operator, and at his right-hand side should be a low table within easy reach for his instruments. In private practice a dress-maker's " cutting table," to be found in nearly every 248 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 114.—Sims's speculum. Fig. 115.—Schroeder's vaginal retractor. Fig. 116.—Bullet-forceps. Fig. 117.—Modified Goodell-Ellinger dilator. INSTRUMENTS. 249 -■*•■ *' ^ Fig. 118.—Uterine sound. Fig. 119.—Placenta-forceps with heart-shaped jaws. Recamier's dull curette. Thomas's large dull wire curette. Fig. 120.—Curettes. Fig. 121.—Sponge-holder. 250 A NURSE'S HANDBOOK OF OBSTETRICS. house, is best for this purpose. The carpet at the foot of the operating-table is to be protected with many layers of old news- papers, over which a sheet should be securely tacked. A suitable place should be provided for hanging the irrigat- ing can, and if the operation is done at night this can usually be attached to the chandelier, which will be directly above the pa- tient's buttocks. Abundance of sterile water must be available, as a douche may be given. This may be of lysol, i per cent., or bichloride of mercury i : 3000, or alcohol one ounce, with tinc- ture of iodine two drachms to one quart of sterile water. Some surgeons use a gauze sponge instead of the curette and swab the uterus with tincture of iodine instead of using the douche. Fig. 122.—Two-way catheter. (Kelly.) If daylight is to be used, the windows must be protected so that outsiders cannot see into the room, and yet the supply of light must be curtailed as little as possible. If there are lace curtains in the window they may be pinned securely together, or the windows may be covered with newspapers, white wrap- ping paper, or cheese-cloth. Another method is to cover the glass with whiting mixed with water to the consistency of a thick paste, as it would be used for cleaning silver. There is no danger that this covering will fall off, and it scarcely inter- feres at all with the passage of light. The operating-table is to be placed in such a position that the light will fall over the left shoulder of the surgeon. In the daytime the back of the operator's chair should be towards the window, and at night the CURETTAGE. 251 patient's buttocks should lie directly under the middle of the chandelier. A good nurse will never undertake to prepare for a delivery unless she has systematically planned all details, with relation to the outline and size of the room, the available light, the position of the bed and furniture, the proximity to fire and water, and the possible assistants. The best way is to put the plan on paper. This clarifies ideas and at once shows mistakes before they occur. The nurse should have ready one dozen clean towels wrapped in n&reels, sterilized or baked in the oven, plenty of boiled water, both hot and cold, and a long stout sheet, to be used as a leg- holder in case the physician does not bring one with him. The doctor will carefully scrub his hands according to his preferred technic, put on his cap and gown, and sterile rubber gloves. The patient should be attired in night-gown and stockings only, or a pair of obstetrical stockings or a pair of pajamas may be used. The external genitals must be carefully cleansed, and if the pudendal hair is at all long or thick, it should be clipped closely with scissors, unless the physician wishes the parts shaved. After the patient has been etherized, placed in proper posi- tion on the table, and covered with sterile or bichloride towels, the operator will seat himself in the chair directly facing the vulva, insert the Sims speculum or the vaginal retractor to depress the perineum, and grasp the anterior lip of the cervix with the bullet-forceps to draw it forward. The nurse should have everything so arranged that it will not be necessary for her to leave the patient's side, and is now to assist the operator by standing or sitting at his left hand and holding the retractor and bullet-forceps while the operation is in progress. The pa- tient's bed is to be made up with rubber sheet, white sheet, and draw-sheet, and the pillow should be removed and a large towel laid in its place for use as she comes out of ether. Hot-water bottles (improvised most readily from beer-bottles with patent stoppers) should be at hand at the end of the operation, and if the case is at all a serious one the patient should be laid between blankets instead of sheets until she comes out of ether and reacts from the shock. The doctor may 252 A NURSE'S HANDBOOK OF OBSTETRICS. not curette, but treat the condition by packing the uterus and vagina with gauze. Upon removing the packing the placental tags or membranes will be attached to the gauze. As a rule no anaesthetic is required. The after-treatment of abortion and miscarriage, whether or not curettage has been performed, consists in the practice of the most scrupulous cleanliness and in the frequent removal of all discharges from the folds and creases of the external genital organs. Douches should never be given except by the express order of the physician, and the patient is to remain in bed on a light but nourishing diet for at least ten days. Premature labor does not differ in its management to any marked degree from normal labor. There is, however, more of a tendency towards retained membranes or placenta, and the shock to the mother in her disappointment over the possible, if not actual, loss of her child, often has a serious and very depress- ing effect on her nervous system and so upon her convalescence. The care of the premature child is discussed in another chapter. An abortion is a legitimate abortion when a reputable physi- cian, in consultation with a colleague, decides it is necessary to save the life of the mother. This may be the case if the mother is suffering from a serious constitutional disease of the lungs, heart, or kidneys, for example. The physician will arrange in every instance possible that the operation be done in a reputable hospital. If the operation is not necessary, it is called a criminal abor- tion, as opposed to a legitimate or legal abortion, and is a penal offense. A nurse incurs a grave responsibility if she is guilty of expressing her individual opinion upon any case. She has enough responsibility in meeting the preparations for the opera- tion, if it is to be done in a private house. XIX Accidents and Emergencies The accidents and emergencies of obstetrics may affect either the mother or the child, and may occur during the pregnancy, the labor, or the puerperium. In pregnancy the conditions that may affect the mother and call for prompt action on the part of the nurse are eclampsia, syncope, hemorrhage, and miscarriage. Eclampsia is a most serious complication occurring during the last three months of gestation, and is characterized by gen- eral oedema, convulsions, and coma. It must be differentiated from epilepsy and hysteria, and its management by the nurse is fully discussed in Chapter XVI. Syncope is usually an unimportant matter, unless it is due to toxaemia, and is often associated with anaemia or hysteria. The patient should be placed on her back, with no pillow under her head; her clothing loosened, especially at the waist, until all constriction is removed; ammonia applied to her nose ; and, as soon as she has recovered sufficiently to be able to swallow, whiskey or some other stimulant (such as one drachm of aromatic spirit of ammonia) may be administered by the mouth. Patients who are subject to attacks of fainting during pregnancy should avoid hot, crowded rooms and every form of excitement, and be under the direct supervision of a physician at all times. Hemorrhage during pregnancy, if occurring only in the first three months and of the menstrual type, is not necessarily of any consequence, but it should be reported to the physician in view of the possibility that it may be one of the early symptoms of ectopic gestation. Hemorrhage occurring late in pregnancy may be due to pla- centa praevia, to the accidental detachment of a normally situated placenta, or to the rupture of an ectopic gestation sac. Bleed- ing due to placenta praevia is termed " unavoidable " hemorrhage, because, from the very nature of the case, it is bound to occur, 253 254 A NURSE'S HANDBOOK OF OBSTETRICS. sooner or later; while that caused by the accidental separation of a normally situated placenta is called " accidental" hemor- rhage, since it need not necessarily have occurred except for the accident that caused the detachment of the placenta from the uterine wall. Unavoidable hemorrhage (that due to placenta praevia) is always external, and the first symptom of this complication is the sudden gush of bright-red blood unaccompanied by pain and dependent upon no discoverable exciting cause. The mere posi- tion of the placenta at or near the internal os uteri is sure to cause bleeding either at or before the beginning of labor. Fig. 123.—Concealed hemorrhage. The blood has collected between the placenta and the uterine wall, and the patient may bleed to death inside her own body. Accidental hemorrhage may be either external or concealed, and is accompanied by severe tearing pain at the site of the placental separation. In the concealed type the uterus merely bleeds into itself (Fig. 123), and the condition can only be recog- nized by the severe pain in the uterus and the general symp- HEMORRHAGE. 255 toms of hemorrhage,—namely, collapse, extreme pallor, feeble, rapid pulse, disturbances of sight and hearing, excessive thirst, and " air hunger." Hemorrhage due to the rupture of the sac in ectopic gesta- tion is always concealed, the blood escaping into the abdominal cavity and the patient suffering from pain of an excruciating character on the affected side, accompanied by collapse and the general symptoms of hemorrhage mentioned in the preceding paragraph. The gestation sac in ectopic pregnancy usually rup- tures not later than the fourth month, a period too early for pla- cental separation to occur, and this fact is an important factor in the differential diagnosis between the two conditions. All that the nurse can do in any case of severe hemorrhage during pregnancy is to send at once for the nearest physician; put the patient in bed, flat on her back, with as little delay or excitement as possible; give a hypodermic injection of mor- phine (one-sixth grain), repeating it in fifteen minutes if the pain is severe and the hemorrhage not due to placenta praevia; make immediate preparations for an operative delivery, or, if the case is one of ectopic gestation, for an abdominal section; and provide sterile normal salt solution (six-tenths per cent.) in ample quantity for infusion. It is needless to say that everything must be done in as quiet and methodical a manner as possible, and that no knowledge of the serious nature of the case must be permitted to reach the patient. Preparations for operation must be made in an adjoining room, and all members of the family who, by their manner, would have a tendency to frighten the patient and arouse her suspicions must be excluded from her presence on some pretext or other. Miscarriage may occur at any time during pregnancy, either as a result of a blow, fall, or other injury, or from an unknown cause. Any of the acute febrile diseases may cause miscarriage, and this accident is certain to occur if the patient's temperature rises to 105 ° F. Any pregnant woman suffering from a febrile disease may be expected to miscarry if the tern- 256 A NURSE'S HANDBOOK OF OBSTETRICS. perature rises to the point mentioned, and whenever the nurse sees that the fever is steadily increasing she should make such preparations as will be necessary when the miscarriage occurs. Miscarriage is seldom if ever accompanied by any immediate danger to the patient, although its remote effects may be very serious, but the patient is often greatly alarmed at the accident, and the nurse must do all in her power to allay her fears and make her comfortable in mind as well as in body. The first symptoms of miscarriage is pain which greatly re- sembles that of labor and is often equally severe. This is soon followed by the escape of bloody discharge from the vagina, and the diagnosis is positive. The woman should at once be put to bed (the head of which must be lowered and the foot elevated).. She is then given a hypo- dermic injection of morphine (one-sixth grain), and in some cases this will be enough to check the contractions of the uterus and the case may go on to full term in spite of the threatened interruption. The physician should, of course, be summoned at the first appearance of symptoms, and if the miscarriage occurs in spite of every effort to prevent it, he will usually wish to perform a thorough curettage at once. The preparations for this operation are described in Chapter XVIII. Death of the foetus during pregnancy is usually followed by miscarriage, and it is only under these circumstances that it can be regarded in the sense of an emergency. Occasionally the dead infant is retained in the uterus for a considerable period, and when this occurs the diagnosis of the condition is often extremely difficult. The symptoms that point to the death of the fcetus are cessation of fetal heart sounds and active movements, general malaise of the mother, the occasional appearance of a foul-looking, though not necessarily offensive, discharge from the vagina, dull pain in the back and limbs, and shrinking and general flabbiness of the breasts and abdomen. The physician should be notified if these suggestive symp- toms develop, and if he finds, on examination, that the child is actually dead, he will usually proceed to empty the uterus at once. During labor the mother may suffer from eclampsia, hemor- RUPTURE OF THE UTERUS. 257 rhage either from placenta praevia or placental separation, rup- ture of the uterus, inversion of the uterus, and sudden death from heart failure or other cause due to intercurrent constitu- tional disease. Eclampsia and hemorrhage have already been sufficiently discussed, and as the physician will usually be in attendance at this time, the nurse will be relieved of all responsibility. Fig. 124.— Rupture of the uterus. The specimen is opened opposite the laceration in its wall (A), and the points (B B) indicate the ends of the severed cervical ring. The roughened area of placental attachment is plainly seen at the upper part of the uterine cavity. Rupture of the uterus (Fig. 124) often resembles greatly the concealed hemorrhage of placental separation, the general symptoms of shock and collapse being common to both condi- tions, but the essential difference is that placental detachment occurs before or early in labor, while rupture of the uterus can only happen after the woman has been in severe labor for a con- siderable time. If the foetus escapes through the tear into the 17 258 A NURSE'S HANDBOOK OF OBSTETRICS. abdominal cavity, Caesarean section will be necessary for its removal, while if it can be delivered through the natural pas- sages by forceps or version, the surgeon may either open the abdomen and sew up the rent, or pack the uterine cavity through the vagina with gauze and leave the healing of the wound to nature. As the treatment by packing gives, in the general run of cases, as satisfactory results as the more radical abdominal operation, it is the one most commonly employed. Fig. 125.—Complete inversion of the uterus. (Boivin and Duges.) b, right labium majus; c, right labium minus; rf, clitoris ; e, meatus; f, anterior vaginal wall; g, external os uteri; h, internal surface of inverted uterus. Inversion of the uterus is one of the rarest accidents of labor, but it may occur in any degree, from a mere sinking down of the fundus to an actual turning inside out of the entire organ (Fig. 125). It may follow operative delivery, or it may be due to shortness of the umbilical cord, either actual, or rela- PROLAPSE OF THE CORD. 259 tive by being wrapped about the infant's body, which drags down the placenta and with it the adherent uterine wall. After the child is born, inversion may be caused by pulling on the umbilical cord to extract the placenta, or, if the uterus is empty and relaxed, by improper pressure on the fundus or violent straining or coughing by the mother. These last-men- tioned cases might better be classed as accidents of the puer- perium, but the complication is of such extreme rarity at any time that it need only be mentioned in this place. The symptoms are severe pain at the point of inversion, hem- orrhage which is more severe as the inversion is greater, faintness or actual syncope, collapse, and pain in the rectum and bladder. The treatment consists in replacing the inverted portion of the womb, and is easier the more promptly it is performed. It cannot be attempted by the nurse. Heart failure and other conditions of a like nature which greatly endanger the patient can, in the absence of the physician, only be treated by the prompt and energetic administration of stimulants, such as whiskey, strychnine, nitroglycerin, and cam- phor in olive oil, by the hypodermic needle and oxygen. The child may be endangered during labor by malposition, prolapse of the umbilical cord, and asphyxia from protracted or instrumental delivery. The only malpositions which the nurse can be expected to recognize are those accompanied by pro- lapse of an arm or leg, but if she finds an extremity protruding from the vagina she will, of course, know at once that the case is a serious one and send immediately for the physician. It is impossible to lay too much emphasis upon the danger, to both mother and child, of pulling or tugging upon an ex- truded hand or foot. This may be permitted only to a skilful physician and then only after all preparations have been made for concluding the delivery without delay. The situation may be compared roughly to the disentangling of a skein of wool. Injudicious traction may, and usually does, only serve to tighten the knots and snarls and make a bad matter very much worse. The care of the protruding part to prevent infection is also an important and serious matter. 200 A NURSE'S HANDBOOK OF OBSTETRICS. The properly trained nurse will, after summoning the physician at once, devote her attention in such an emergency to reassuring the patient as much as possible and preparing quickly and unobtrusively for a probable operative delivery under complete anaesthesia. These preparations are best made in an adjoining room, if such an arrangement is available, and should be completed as unconcernedly and expeditiously as possible in order that everything may be in readiness upon the arrival of the physician. The exposed arm or leg of the fetus should be protected with warm, sterile towels which are to be renewed as often as necessary; but otherwise it must be left severely alone. If a second nurse is on duty, or if the mother or a sister or other woman who is sufficiently sensible and self-controlled to be relied upon, is present, she may be directed to sit by the pa- tient's side and make firm but gentle support (not pressure) on the abdomen over the fundus uteri. This duty, however, should never be entrusted to an excitable person whose nervous- ness or anxiety might serve to alarm the patient. In such a case it is far better to let her lie quietly and alone, encouraging her with tactful words from time to time and, although in- specting the prolapsed part and changing the towels at frequent intervals, affecting such an apparent unconcern that she will not imagine she has anything to dread. As soon as the preparations for delivery are completed the nurse should seat herself by the patient and take further charge of the case herself until the physician arrives. Should delivery take place before he comes there is no occasion what- ever for alarm and the management of the case is described under the heading " Precipitate Labor." If the cord prolapses and descends in front of the present- ing part (Fig. 126a), the accident is usually due to premature rupture of the membranes when the head or breech is not sufficiently down in the pelvis to prevent the cord from being washed past it in the sudden gush of amniotic fluid. Unless the cord is carried down to the vulvar orifice, the nurse is not likely to know that this complication has arisen, for in private practice she is not expected to make any vaginal examinations Fig. 126a.---Prolapse of the umbilical cord. (Bumm.) As the head comes down the com. pression of the cord between the fetal skull and the pelvic brim will shut off its circulation completely. Fig. 126b.—Knee-chest position. (Potter). The back must be straight or slightly concave and the thighs perpendicular. TRENDELENBURG POSITION. 261 whatever, except for special reasons of the utmost urgency. If, however, she knows that the cord has prolapsed, she should send at once for the physician and then put the patient in the " knee- chest " position, or in the Trendelenburg position, easily arranged by slipping a straight chair-back covered with a flat pillow under the buttocks and shoulders of the patient. The knees should fall downward over the chair round toward the bed. This will favor its return into the cavity of the uterus. If the pulsations in the cord cease or even grow feeble or irregular, there can be no ob- jection to an attempt at its reposition with the hand. With the patient in one or the other of the positions named, the nurse should pass her entire hand, thoroughly scrubbed and disinfected, and wearing sterile rubber gloves, well lubricated with sterile vaseline or lubrichondrin, into the vagina and try, with the utmost gentleness, to push the cord up into the uterus past the presenting part until it falls entirely out of reach. This is often a very difficult thing to do, on account of the tendency of the cord to prolapse as soon and as often as it is replaced, but if the nurse has been thorough in the disinfection of her hands and in her observance of all the rules of asepsis, no harm can result from the attempt, and it may be the means of saving the infant's life. The patient's hips must be kept raised above the level of her shoulders, or the cord will be almost certain to come down again into the vagina, and this can best be accom- plished by placing a thick pillow or cushion under her buttocks, for it will be found quite impossible for her to remain in either the " knee-chest " or the Trendelenburg position for any length of time. In changing to the dorsal posture the patient must ex- ercise the greatest caution, and the pillow or cushion must be ready to be placed under her the moment she is on her back. As soon as this change in position has been accomplished the nurse should, with every antiseptic precaution, again insert her hand into the vagina to make sure that the cord has remained above the pelvic brim. It is, of course, assumed that every effort has been made to secure the services of some physician, even other than the regular medical attendant, before any manual correction of this condi- 262 A NURSE'S HANDBOOK OF OBSTETRICS. tion has been attempted by the nurse. If a physician can be se- cured within a reasonable length of time nothing should be done by the nurse beyond putting the patient in the " knee-chest " or the Trendelenburg position and awaiting his arrival. During the puerperium the conditions affecting the mother which can be classed as accidents and emergencies are eclampsia, retained placenta, hemorrhage, and embolism, or " heart clot." Eclampsia has already been fully discussed. It must be re- membered that it may occur during pregnancy, during labor and during the puerperium, but when this complication originates after the birth of the child it is of a far less serious nature than when it occurs before or during labor. This is known as puer- peral convulsion. Under the latter circumstances it may usually be relieved by the prompt emptying of the uterus; but when the convulsions appear for the first time after the child is born there is nothing to do beyond controlling the convulsions with the measures of quiet, rest, diet, elimination, sedatives and oxygen and fighting the attack in the manner described. The nurse will, of course, summon the physician at once if eclamptic convulsions appear, and she must be on her guard that the spasms are not due to excessive hemorrhage. There should be no difficulty whatever in distinguishing between the two con- ditions, for the convulsions due to hemorrhage do not appear until the body is practically bloodless and just before death su- pervenes, while in eclampsia the patient's face is flushed or even cyanotic and the pulse is full and hard. Retained placenta is not a serious condition unless the presence of the after-birth in the uterus prevents firm contrac- tion of the womb and causes severe hemorrhage. Even in these cases there is usually time to await the arrival of the physician, for it is assumed that he was summoned at the onset of labor, and it is not to be supposed that he will leave before the placenta is delivered. Firm pressure is to be maintained on the fundus, which is to be kneaded vigorously whenever it shows signs of relaxation, and it is hardly probable that enough blood will be lost to affect the patient seriously. If the bleeding becomes alarming, as shown by the amount of the flow and the general RETAINED PLACENTA. 203 condition of the patient, and no physician can be secured, the nurse may express the placenta according to the Crede or Dublin method. Grasping the fundus, firmly contracted, in the hand, the uterus is squeezed and pushed toward the pelvic outlet for one or two minutes. The nurse will have seen this manoeuvre, and if the placenta does not appear, she will again contract the uterus by kneading, take both hands and endeavor again to ex- press the placenta. Only a grave hemorrhage can excuse her resorting to this method of control. If no physician is as yet available and her efforts have proved unsuccessful, she may, after the most careful disinfection of her hand and putting on Fig. 1^7— Manual extraction of the placenta. (Garrigues.) This must never be attempted by the nurse, except for urgent reasons and after most careful aseptic precautions. boiled rubber gloves, pass it gently into the vagina up to the cervix, grasp the placenta firmly in her fingers and remove it slowly and with a deliberate twisting motion (Fig. 127). If it is still adherent to part of the uterine wall, two or three fingers are to be carried into the uterus, between it and the placenta, and the tissues separated much as one would separate the sec- tions of an orange. When the entire organ has been detached in this way, it is to be grasped in the palm of the hand and with- drawn carefully. If all antiseptic precautions have been faith- fully observed this manoeuvre will do no harm but it must be distinctly understood tbat it is a dangerous thing to do, and one 264 A NURSE'S HANDBOOK OF OBSTETRICS. never to be attempted by the nurse except in the gravest emer- gency when no physician at all can be obtained. Only once in perhaps a thousand cases will this be necessary. and to a nurse, perhaps ten times as rarely. A manual removal of the placenta is demanded of her also very rarely and the oft- witnessed Crede method, if rightly done, usually succeeds and the hemorrhage can be again controlled by efficient kneading of the uterus. Care must be taken not to massage the abdominal wall, but the uterus itself through the wall. Hemorrhage other than the type just mentioned may be due to laceration of the cervix or to the uterine inertia. Hemorrhage due to cervical laceration is almost invariably caused by instrumental or manual delivery, and seldom if ever by spontaneous labor. The bleeding appears the instant the child is extracted from the vagina, and in rare instances may be of sufficient severity to greatly endanger the mother. If the fundus is firm and well contracted and the blood continues to flow freely, the diagnosis is very simple. Fortunately for the nurse, the physician is usually present when this accident occurs, and the management of the case rests entirely with him. Occasionally it is necessary to bring the torn edges of the cervix together with one or two chromicized catgut sutures in order to check the bleeding; but in many cases snug packing of the vagina with gauze will be found effectual. Whether the cervix is to be sutured or the vagina merely packed, the patient should be turned crosswise in the bed with her buttocks well over the edge and her legs supported in the lithotomy position, either in a leg holder or by assistants. If packing is the method of treatment employed, the nurse must watch the fundus with special care during the next few hours, lest hemorrhage continue into the cavity of the uterus. The packing should never be left in the vagina for more than twenty-four hours, and in many cases it is better to remove it at the end of twelve hours, as it almost invariably interferes with natural urination and makes catheterization extremely difficult. POST-PARTUM HEMORRHAGE. 265 If the hemorrhage has been at all severe the nurse should prepare hot sterile normal salt solution (one teaspoonful to the quart) for infusion, arrange for elevating the foot of the bed, and provide an ample number of hot-water bottles (beer-bottles with patent stoppers in an emergency) with which to surround the patient. Post-partum hemorrhage, in the ordinary acceptance of the term, is that which occurs from the cavity of the uterus after the birth of the child and either before or after the delivery of the placenta. It is due in almost every case to relaxation of the uterus (uterine inertia), and may usually be prevented if proper attention is paid to the management of the fundus during the hour that immediately follows the delivery of the infant. It is apt to occur in severe cases of albuminuria or other constitutional disturbance; it frequently follows operative de- livery or prolonged and exhausting natural labor; and it may occur in any case from no discoverable cause, unless it be care- lessness in holding the fundus. Consequently, the occurrence of post-partum hemorrhage is to be regarded as a possibility after every case of labor, no matter how simple and normal its course may have been, and, as Dr. Gooch has said, " No physi- cian should have the assurance or hardihood to cross the thresh- old of a lying-in chamber who is not thoroughly conversant with the remedies for flooding." Un fortunately, there are many physicians who, although they may be as " thoroughly conversant with the remedies for flooding " as Dr. Gooch in his most exacting mood could desire, neglect systematically to provide themselves with the necessary drugs and appliances to meet this condition effectively. Nearly every case of post-partum hemorrhage that passes beyond con- trol may be accounted for by the neglect of some one to have ready the necessary articles for checking it at its very outset, and it may safely be said that there is no variety of hemorrhage that should be so amenable to the surgeon's skill as the one under consideration. The physician who attends obstetric cases with no other equipment than a vial of ergot, a bichloride tablet, and a pair 266 A NURSE'S HANDBOOK OF OBSTETRICS. of forceps in a little black bag is rapidly being relegated to the obscurity which he deserves, and his disappearance from society will be of untold benefit to the mothers of the future. Post-partum hemorrhage is usually external, or largely so, but when it occurs before the delivery of the placenta it may, in good part, be concealed within the cavity of the uterus. The concealed type can never occur if the fundus is properly held, for the blood will necessarily be squeezed out of the uterus into the vagina and escape. When, however, the uterine tissue is so inert that, although it may be compressed and the walls of the uterus approximated by the pressure on the fundus, the muscular fibres refuse to con- tract and close the blood-vessels, the condition is a most alarm- ing one, and in severe cases may cause death within a few minutes. As a rule, if hemorrhage does not occur within an hour after the birth of the child, especially when the fundus has been properly managed, it will not occur at all, but it may develop twenty-four hours or even longer after delivery, and the nurse will be called upon to meet the emergency without a moment's delay ; for the greatest factor in its control lies in the promptness with which it is met. In cases which occur before the departure of the physician he will usually pack the uterus firmly with strips of sterile gauze, if the administration of ergot, vigorous kneading of the fundus, and a hot (1200 F.) sterile or saline douche do not check the flooding at once. Every physician should have gauze for tam- poning the uterus in his maternity outfit, and the nurse should have ready, at every labor, a sufficient quantity of hot sterile water or saline solution for use at a moment's notice. It is easily prepared and may be preserved sterile in Mason jars. The patient is to be brought to the edge of the bed, in the lithotomy position, and if the physician decides to pack the uterus he will grasp the anterior lip of the cervix with a volsellum or bullet-forceps, draw it down to the vulva, and have the nurse steady it in this position while he inserts the gauze. Hot salt solution for infusion or rectal irrigation must POST-PARTUM HEMORRHAGE. 267 be provided at once, the patient laid flat on her back, without a pillow, and surrounded with hot-water bottles, the foot of the bed elevated, and hot water with whiskey or brandy given by the mouth unless there is vomiting. If hemorrhage occurs when the nurse is alone, she should, of course, send at once for the first physician that can be reached. In many cases her attention will be directed to the condition by the patient herself, who will complain that she is " flooding," and inspection will show a pool of blood (possibly a pint or more) in the bed. At other times the suspicions of the nurse will be aroused by the pallor of the patient's face, and on raising the bedclothes the evidences of severe bleeding will be found as before. The first thing to do, after sending a messenger hastily for the nearest physician, is to grasp the fundus, if it can be found, and knead it energetically. If ergot is to be had, some one should be directed to give the patient a teaspoonful by the mouth. If the nurse has equipped herself according to the directions given, she will be prepared for any emergency. The vigorous rub- bing of the fundus is to be kept up while some one is despatched for hot water and salt, and, if a piece of ice can be secured promptly, it may be rubbed briskly over the belly to stimulate uterine contraction while awaiting the arrival of the hot water. As soon as the materials for the douche are at hand the water is to be brought to the temperature of 1200 F. (or as hot as the hand can bear) by the addition of cold water if necessary, a teaspoonful of salt added to each quart, and the solution in- jected freely into the uterus, while the hand on the abdomen still exerts pressure on the fundus. This saline douche will serve in emergency, but emphasis is again laid upon the aseptic preparations which should be made for just this emergency. If the hot douche, continued, and the vigorous manipulation of the fundus with the nurse's left hand, and stimulation of ice cloths upon the lower abdomen, still fail to control; if ergot, 30 to 60 minims, and repeated in fifteen minutes has failed; if it has proven impossible to secure the at- 268 A NURSE'S HANDBOOK OF OBSTETRICS. tendance of a physician, the only remaining hope is to pack the uterus. The nurse cannot be expected to do this as expeditiously or as effectively as the physician, but if she has in her the stuff that heroines are made off, and keeps cool and collected, she may, in a desperate case, be the means of saving a life that would other- wise inevitably be lost. She will not have proper materials for packing nor instruments for the introduction of the tampon, but there is no time to be lost and she will have to do the best she can. If she has plain gauze, well and good. She has been told to provide herself with a jar of gauze for just this emergency, to avoid the desperate chance taken where unsterile material must be used. She uses all aseptic precautions, has the jar held close to the vagina, cleanses the external genitals, puts on gloves and using her forceps while the uterus is held down from above, so that the cervix will appear at the vulva, she will pack quickly in loops of about six inches at a time, until the cavity is entirely filled, after which the vagina is to be packed with equal firmness. Care must be taken not to do injury with the forceps. She is guilty of criminal neglect if she is not provided with uterine packing for a post-partum hemorrhage. Doctors answer- ing calls do not always possess information as to the patient's condition, but nurses who are left in charge of patients of a character making a hemorrhage always a possibility are not free from blame if their bag does not provide for such an emergency. If she is not ready, as her patient has the right to expect her to be, and depends upon her being, she will have to take a clean sheet, tear it into strips three inches wide and as long as the ma- terial will allow. She can usually buy a sterile bandage three inches wide. She proceeds as described. It is, of course, as- sumed that the rules of surgical cleanliness will be followed as far as the circumstances will permit, but in those cases where the question of life or death must be decided within a very few minutes the hemorrhage must first be controlled at any cost and the septic infection, if it occurs, combated afterwards. As soon as the uterus and vagina are packed the patient is to be placed on her back with no pillow, surrounded with hot-water POST-PARTUM HEMORRHAGE. 269 bottles, and the foot of her bed elevated, a quart of hot salt solu- tion (1180 F.) is to be injected slowly into her rectum, as high up as possible, to be absorbed and take the place of the blood lost, and this may be repeated every half-hour if necessary or a Murphy seepage apparatus may be used. Stimulation, in the form of whiskey, one drachm, strychnine, Fig. 128.—Murphy saline drip apparatus. Observe hot-water bottle of metal. The solution runs through the rubber tube from the can, and is heated by the hot water in the metal bottle. The gas from the rectum is expelled through the tube into the can. one-sixtieth grain, or nitroglycerin, one one-hundredth grain, is to be given hypodermically as indicated, and it may be helpful to force the blood out of the extremities into the trunk by band- aging the legs. These bandages should never be allowed to re- main for more than two hours, and they are to be removed with great caution, one at a time, to avoid the danger of collapse. If the patient still fails to respond to treatment, subcutaneous infusion of normal salt solution should be performed as follows; A pint of the solution, at a temperature of ioo° F., is placed in an ordinary irrigator and hung about three feet above the level A NURSE'S HANDBOOK OF OBSTETRICS. of the patient's body. An ordinary hypodermic needle (the larger the better), or, best of all, an aspirating needle (Fig. 129) Fig. 129.—Aspirating needle. is attached to the end of the tubing, and as soon as the liquid begins to flow the needle is thrust for its entire length into the chest at the base of the breast, parallel-to the surface of the body or on the anterior aspect of the thigh. Gentle massage should be practised as the solution distends the tissues, and the needle should be moved about from time to time and occasionally with- drawn and inserted in a new place. The time required for the infusion of a pint of solution in this manner will be from ten to twenty minutes according to the size of the needle, and fresh hot solution should be added at occasional intervals to keep the temperature up to the required point (1000). It is needless to say that the apparatus and the solution must be sterile, and the skin at the site of the infusion is to be wiped off with alcohol, and painted with tincture of iodine, the punc- ture protected from infection by towels and sealed with cotton and collodion or sterile adhesive. The nurse must not fail for an instant to exercise firm pressure upon the perineal pad with one hand, and with the other hand to exert pressure upon the fundus. The method of treatment outlined here is carried to com- pletion to cover those cases in which no physician at all Can be secured, but the nurse must exert every effort to obtain the services of some medical man at the earliest possible moment zvho zvill take charge of the case and relieve her of any further responsibility. Although a condition that is preventable in almost every properly managed case, post-partum hemorrhage is one of the most terrible complications that can arise in any branch of sur- gery, and the nurse who can, by her own efforts, bring a patient out of this emergency is worthy of all honor and respect. EMBOLISM. 271 Embolism, or " heart clot," may be formed originally in the right ventricle, or may be due to a thrombus which is washed along in the blood-current until it is lodged in the heart. The Fig. 130.—-Hypodermoclysis. A rubber bag should not be used for this. An irrigating can or a regular infusion apparatus is necessary. The solution must be sterile. clot obstructs the passage of blood into the lungs, either wholly or in part, and the patient may die of asphyxia within a few minutes. 272 A NURSE'S HANDBOOK OF OBSTETRICS. The condition may follow severe hemorrhage, septic infec- tion, shock, or general exhaustion, and may occur at any time during the puerperium. The entrance of air into the circulation through the uterine vessels, either from the careless administration of a douche or from the decomposition of septic matter within the uterus, pre- sents practically the same symptoms and calls for the same treat- ment as heart clot. The symptoms are sudden, severe pain over the heart, great dyspnoea, syncope, feeble, irregular pulse, or none at all, pallor in some cases and cyanosis in others, and death at any time within a few minutes to a few hours, according to the amount of obstruction to the pulmonary circulation. Very few cases recover. The treatment consists, first in preventing the accident by careful attention to all details in the proper management of every obstetric case, and secondly, if the complication arises, in the free administration of whiskey and strychnine and the main- tenance of absolute quiet on the back, for the slightest move- ment may result fatally. If the patient survives the attack, the body temperature must be kept up by the use of hot-water bottles, absolute rest en- joined, and a light, nourishing diet given, in the hope that she can be kept alive until the clot is absorbed. The only obstetric emergency that can affect the child after its birth is secondary hemorrhage from the navel or cord. If the blood escapes through the vessels of the cord before it has separated from the body, a fresh ligature is to be applied and tied tightly and carefully. If the blood comes from the navel itself at the base of the cord, either before or after its separation, it can usually be controlled by firm pressure with hot compresses (no° F.) until the arrival of the physician. The treatment which he will prob- ably adopt if the hemorrhage is severe and continues for a long time is to transfix the base of the navel with two long needies inserted at right angles to each other and compress the vessels against them with a tight " figure-of-eight" ligature. EMBOLISM. 273 In rare cases, where no physician can be secured, the nurse may have to do this herself. Every antiseptic precaution is to be faithfully observed, and the needles (darning needles will answer) and silk or bobbin tape must be boiled. The navel is to be pinched up with the thumb and forefinger and a needle thrust through its base from side to side at a Fig. 131.—Figure-of-eight ligature. For controlling secondary hemorrhage from the umbilicus. depth of about one quarter of an inch. The second needle is then to be inserted in the same manner, at right angles to the first, and the ligature passed tightly over the ends in " figure-of- eight" loops and drawn up until every vestige of bleeding, or even oozing, has ceased (Fig. 131). The needles may be re- moved at the end of six or eight hours, but the ligature should be allowed to remain and come off when it will. The dressings should be changed daily and the most rigid antiseptic precautions must be observed until the parts are entirely well. While the nurse should, of course, make every possible effort, both by study and training, to so prepare herself that she may be always ready to cope with the unexpected in obstetric or other surgical practice, it must be constantly borne in mind that technical perfection alone will avail little or nothing in such crises unless it is coupled with absolute cool- ness of head and promptness of action together with the exhibition of no small amount of good, old-fashioned, common sense. 18 XX Pathology of the Puerperium The disorders of the puerperium are: puerperal fever, in its various forms; phlegmasia alba dolens, or "milk leg"; diseases of the nipples and breasts and insanity. Puerperal fever, also known as puerperal septicaiuia and " child-bed fever," is a condition always due to infection from without, and this infection may, and usually does, result from the introduction of bacteria into the genital tract at the time of the labor, either by the hands or instruments of the physician, or after labor, by surgical uncleanliness on the part of the nurse, whether in the use of the catheter or in her general care of the patient. In detail it may be said that infection may be introduced by anything not sterile. The preparations for labor, the technic during confinement, the lack of systematic methods of nursing during the puerperium, all tend to swell the total number of deaths, and invalids, from this nearly always preventable cause. In rare instances the infection may be due to a septic in- flammation of the vagina or other pelvic organs which exists at the time of the labor and extends to the interior of the uterus or to other tissues after the birth of the child. The usual point of entrance for the septic germs is at the denuded placental site in the uterus, where the tissue is damaged and bacteria can easily find a way into the system, but any other raw surface, such as a laceration of the cervix or perineum, may afford an equally good starting-point for the disease. There are several varieties of puerperal fever, each of which, in its typical form, presents a very characteristic set of symp- toms, but it not infrequently happens that one form of the disease will eventually develop into another and more severe kind. The distinctions between these different types are, of course, of in- terest and importance to the physician, for not only the treat 274 PUERPERAL FEVER. 275 ment but the prognosis depends upon the particular form of in- fection from which the patient suffers. It may be said that the nature of the bacteria, their number, and the patient's power of resistance are the factors determin- ing the virulence of the infection. As far as the nurse is concerned, however, it is only necessary to be able to recognize at once the onset of the disease in order that the physician may be notified immediately and proper treat- ment instituted without delay. Puerperal fever usually develops about the third or fourth day after delivery, but its onset may be postponed until the eighth, ninth, or even tenth day. As a rule, however, if there are no symptoms by the end of the first week none will appear at any time. The cases that develop after this period are rare, are often due to infection introduced by the catheter or other- wise several days after delivery, and are seldom of sufficient severity to endanger the patient's life, although they may seri- ously affect her general health for months or even years. The patient first complains of malaise, headache, backache, and general discomfort. This is soon followed by a distinct chill, or, occasionally, only by chilly sensations, and the ther- mometer shows a considerable rise of temperature, often as high as 105 ° or 1060 F. In the severe cases the pulse becomes rapid and feeble and may be irregular, and the patient's face is pale and anxious. The tongue is at first heavily coated, but later becomes brown and dry, and the lips are covered with sordes. The lochial discharge stops, or it may become dark and very offensive. The abdomen is soft and usually slightly tender over the uterus, but there is no actual pain or tympanites unless general peritonitis develops as a complication. Vomiting may or may not occur, and severe diarrhoea is very common. The urine is scanty, high colored, and may contain albumin, and if the secretion of milk has begun it ceases. The patient has alter- nating delirium and stupor, followed by coma, and death may occur within a few days. These symptoms belong to the most severe type of puerperal fever, in which the infection, beginning in the uterus, extends 276 A NURSES HANDBOOK OF OBSTETRICS. rapidly throughout the entire system. In the milder cases, where the infection is less virulent, or where it is confined to the uterus itself or to lacerated tissue in the cervix, vagina, or perineum, the symptoms are not so pronounced, and the patient usually recovers, although she may be transformed into a con- firmed invalid or, at least, remain sterile the rest of her life. The treatment, of course, rests entirely with the physician, and usually consists in the thorough exploration of the interior of the uterus and the removal of any placental tissue, clots, or other foreign matter that may be present and undergoing decom- position. This is, in many cases, all that is required, and the careful emptying and douching of the uterine cavity is followed by an immediate fall in temperature and improvement in every way. More often, however, it is thought necessary to perform a thorough curettage under ether in order to remove every par- ticle of infected tissue from the uterine wall, and not a few phy- sicians adopt this method at the outset rather than take any chance with less radical treatment. As the prompt institution of measures to check the disease is of the greatest importance, the nurse must always be on the alert to recognize any one of the initial symptoms of puerperal fever the moment it appears and report it at once to the phy- sician. Headache, backache, malaise, or any feeling of discom- fort must not be overlooked, and a rise of temperature over 100.5 ° F- or pulse over 100 should be brought to the physician's notice without delay. These premonitory symptoms may not indicate puerperal fever, as they occur at the onset of almost any acute disease, but they are sufficiently significant to warrant immediate attention, and the nurse must never lay herself open to the charge of hav- ing neglected to recognize, and report to the physician in charge, any change in the patient's condition which might be indicative of danger. After the genital tract has been thoroughly cleansed of all foreign matter the treatment consists solely in fighting the con- stitutional effects of the disease with tonics, stimulants, and nou- rishing diet. Creole's ointment (unguentum Crede), a prepar- PUERPERAL FEVER. 277 ation of metallic silver used by inunction, has been highly recom- mended as a specific by some authorities; the subcutaneous in- jection of hot normal salt solution often seems to give good results; and, in those cases due to infection by the streptococcus, the antistreptococcic serum (streptococcus antitoxin) has been ad- ministered hypodermically with alleged benefit; but none of these methods has the unqualified approval of all physicians, and suc- cess can only be expected to follow a judicious combination of several of the recognized means of fighting the disease. The story of the discovery of the cause of puerperal sepsis has been made familiar to the laity by popular magazine writers, and the average mother is aware that some one is probably grossly guilty if any such condition develops. Barely sixty years ago Semmelweiss in Austria and before him Oliver Wendell Holmes of Boston, endeavored to prove that it was a " private pestilence " and the Austrian proved in his own hospital prac- tice that the infection within came from the introduction of in- fection from without. Only forty years ago the whole field of bacteriology was opened and the world is now converted to a standard of cleanliness that has made a case of puerperal sepsis a crime upon the head of the person responsible for it. It is a disease of great antiquity and strangely enough is still prevalent. Being a preventable disease, the number of deaths annually is a sufficiently serious reminder to a nurse of the duty she owes to the world and herself in the care of an obstetrical case. Again it may be said that obstetrical nursing demands a nurse of a superior order. In the United States there were re- ported 6000 deaths in one year from this cause, and in New York City the unbelievable total of 407 cases. Nurses should, there- fore, be alert and emulate in private practice the records of hos- pitals, in which the development of a case of sepsis is practically unknown. Phlegmasia alba dolens ("milk leg") is a disease of the puerperium characterized by pain and swelling in the affected limb due to the formation of a clot in the veins of the leg itself or in those of the pelvis, interfering with the return circulation of blood. It is due to septic infection extending from the uterus 278 A NURSE'S HANDBOOK OF OBSTETRICS. to the veins of the pelvis, and thence down the leg, and usually appears about two weeks after labor, the most common time being on the eleventh or twelfth day. The disease is ushered in with malaise, chilliness, and fever, which are soon followed by stiffness in the affected leg and pain, usually in the groin. The leg now begins to swell, either from above downward or from below upward, and in a few hours is so tense and exquisitely painful that the slightest movement causes intense suffering. The acute symptoms last a few days or a week, after which the pain gradually subsides and the patient slowly recovers. The course of the disease covers a period of from four to six weeks, and the affected leg seldom returns to its normal size, but remains permanently enlarged. The prognosis is usually favorable, although in some of the very severe cases abscesses form and the disease may become very critical or even prove fatal, while in very rare instances the clot may be dislodged and carried to the heart, causing instant death. The treatment consists in absolute rest, the use of ice-bags along the course of the affected vessels, and morphine as in- dicated for the pain. Some physicians apply warm wet dressings covered with cotton and oil silk or rubber. The heat is main- tained by electric coils or hot-water bottles. These dressings are applied well inside the thigh. The pain is lessened by elevation of the limb by means of a pillow, and pressure from bed-clothing is prevented by use of a cradle. Under no circumstances should a nurse rub or massage such a swelling; and the limb must be handled with the utmost care when changing dressings, applying a bandage or giving a bath. The patient's own movements must be guarded, and assistance must be given by the nurse. Skilful care is required to preserve the tissues of the body in good con- dition, as recovery is usually tedious. As the acute stage sub- sides, general tonics, nourishing food, and the most carefully regulated hygienic conditions are needed to build up the patient's strength. As in all acute febrile diseases occurring after labor, the se- DISEASES OF THE NIPPLES AND BREASTS. 279 cretion of milk ceases when phlegmasia alba dolens is developed, and the physicians of many years ago gave to the disease the name of " milk leg," in the absurd belief that the condition was due to a secretion and collection of milk in the affected limb. So firmly was this impossible idea fixed in the minds of woman- kind that to this day the expression " milk leg " is in common use among the laity. Diseases of the xipples and breasts. Any slight erosion of the nipple may be aggravated by nursing until an actual fis- sure is formed. The fissure will cause great pain at each nursing period, and the pain may be enough to absolutely prevent suck- Fig. 132.—Tray with everything needed for the care of the breasts. ling at the affected breast. This may cause congestion of the gland, and, as the surface of the fissure offers an ideal entrance for bacteria, septic inflammation or abscess of the breast may result. Even when septic infection does not occur, the pain may seriously affect the secretion of milk and, in highly nervous or hysterical women, cause a slight rise of temperature and retard involution of the uterus and its adnexa. ,If nursing is impossible the child is deprived of its proper food, while if nursing is continued in spite of the pain the pro- teids of the milk are apt to be increased, and the discharge from the eroded surface is extremely bad for the baby. Hence it will be seen that this condition, trivial though it may appear at first 280 A NURSE'S HANDBOOK OF OBSTETRICS. thought, exerts a most harmful influence on both mother and child. The first symptom of erosion or fissure of the nipple is pain at the time of nursing, and careful inspection of the part will at once disclose the true nature of the trouble. The treatment includes the preventive measures to be adopted during the last two or three months of pregnancy. These already discussed, consist in bathing the breasts night and morn- ing with cold water, and softening the crusts of colostrum with albolene, and removing them every day, so that the delicate tissue of the nipple will not be injured by the presence of these hard deposits. If these precautions are carefully followed the nipples will be in good condition when the infant begins to nurse, and no trouble will be likely to ensue. The treatment after the condition has developed rests with the physician, and the nurse should report to him at once if the nursing is painful or if any eroded surfaces are noticed. The usual treatment consists in cleansing the parts thoroughly and applying a solution of nitrate of silver (forty grains to one ounce) with a fine camel's-hair brush to the diseased surfaces, after which the nipple is dusted with some simple antiseptic powder, such as aristol, and nursing stopped on the affected side for twenty-four hours. A considerable quantity of milk will collect in the breast during the time in which nursing is stopped, and this must be removed with the breast-pump or by massage. Massage of the breast when merely for the purpose of removing an exces- sive quantity of milk is done in the following manner. There are four distinct steps in the emptying of the breast, each of which must be practised carefully and intelligently in order to secure a good result with the least amount of pain. The breast is first cleansed gently with soap and warm water, and then anointed with warm camphorated oil or albolene. The hands of the nurse must also be disinfected with the utmost care and the fingers should be dipped in the oil or other lubricant to be used. The first step (Fig. 133, A) consists in grasping the breast at MASSAGE OF THE BREAST. 281 its periphery with the fingers separated as widely as possible, and then drawing them towards the nipple with a firm but gentle pressure. The entire breast is to be gone over in this manner and the fingers are to be brought together as the nipple is approached, and this manoeuvre is to be kept up for at least five minutes, by the end of which time the breast should be fairly soft and the milk flowing freely. The second step (Fig. 133, B) consists in placing one hand, palm upward, under any indurated or " caked " portion of the breast, and with the fingers of the other pressing downward towards the supporting hand and forward towards the nipple. Each indurated spot is to be treated in turn in the same man- ner until all are soft. The third step (Fig. 133, C) consists in pressing downward against the chest wall with the flat of the hand over any hard- ened areas that may remain. The pressure should be greatest on the side of the hand next to the periphery of the breast, and should gradually increase towards the nipple with a sort of rocking motion. This is followed by a rotary motion of the palm of the hand over the induration, continued until no further softening can be accomplished. The fourth step consists in grasping the entire breast in both hands and squeezing out whatever milk remains. Massage of the breast must always be practised with the ut- most gentleness, for fear of injuring the delicate structures of the gland, and, in the manner described, it should never be es- pecially painful if it is properly performed. Any roughness in the manipulation may cause damage to the tissues and result in the formation of an abscess. Breasts are never to be massaged or pumped except by order of the physician in charge. So much serious damage may be done by unintelligent failure to recognize conditions that it is of the utmost importance that the breast be let severely alone so far as expression of milk is concerned until definite orders are received. The utmost surgical cleanliness is essential, as hands soiled with lochia or the colon bacillus are sure to accomplish mischief. The nipple itself is never to be touched with the fingers. 282 A NURSE'S HANDBOOK OF OBSTETRICS. In applying the nitrate of silver solution to the fissure the nurse must separate the edges as widely as possible and touch only the denuded tissue of the fissure with the tip of the brush. Care- lessness in the use of the solution not only smears the breast with a black dirty looking stain, but also causes more or less irritation to the surrounding parts. When the fissure does not heal sufficiently by the end of twenty-four hours to permit of painless nursing, it may be ne- Fig. 134.—The nursing bottles and rubber nipples at the left are practical. The hor- izontal bottle is excellent. The English breast pump is good. The nipple shield, marked 1, is the best, 2 is poorly constructed. The lead nipple shield is known as Wansbrough's. The lactic acid is supposed in combination with the leaden shield to cure cracked nipples. cessary to use a nipple shield for a few days, and this will always be the case when both breasts are affected at the same time, unless the child is given artificial food while the process of repair is going on. The shield must be sterile, and after being used it should be scrubbed clean, boiled and kept in a dry sterile Mason jar as immersion in boric or saline solutions soon renders rubber nipples useless. The shield must be applied to the nipple with the utmost gentleness, and before the child is allowed to nurse, enough milk to fill the glass part of the shield must be expressed into it by INFLAMMATION OF THE BREAST. 283 massaging the breast for a few moments. If this is neglected the infant will get little or no milk at all, while, on the other hand, he will suck in a quantity of air which will distend his stomach and cause colic. The nipple shield must never be placed on the breast in such a position that when suction begins the edges of the fissure will be drawn apart, and in certain cases, such as fissure at the base of the nipple, it will do more harm than good. The shield is always to be used with the greatest caution, and must at all times be kept in a perfectly aseptic condition. As the majority of fissures will, under proper treatment, heal com- pletely in twenty-four hours, it seldom happens that the use of the shield is necessary, and when, for any reason, it must be employed, it should be laid aside the moment that it can be dis- pensed with. The treatment outlined here is varied by different physicians. The use of castor oil, bismuth and collodion in different com- binations, glycerine, compound tincture of benzoin and the appli- cation of a Wansbrough leaden shield, all find advocates. If the nipples are in a healthy condition the mother should never be allowed to use the shield merely to avoid the discomfort caused by the suckling of a vigorous child. Mastitis (inflammation of the breast) may be of any grade, from a simple congestion to a suppurative process that results in the formation of multiple abscesses in the glandular tissue. The cases of simple congestion may be due merely to over- secretion of milk and consequent distention and congestion of the mammary gland, but those accompanied by suppuration are always due to septic infection which enters usually through a de- nuded or diseased nipple. Distention of breast: About the third day the congestion or distention of the breast is apt to cause intense pain. It is not altogether due to the amount of pressure caused by increase in the milk supply, but is chiefly caused by glandular swelling and by engorgement of the blood-vessels and lymph-spaces around the glands. The tenderness to touch is extreme, and nursing is perhaps impossible. For the heavy enlarged breasts, the usual 284 A NURSE'S HANDBOOK OF OBSTETRICS. treatment is a tight, snug, padded binder. Physicians usually prescribe salines to lessen the venous and lymphatic engorgement and the application of ice-bags or a continuous wet hot dressing to the breasts. Nurses must excel in carefulness here. The breast pump and massage are not to be used unless ordered, as infection may be present. This condition of simple distention is not attended with fever (fever would indicate infection). The discomfort is great, but it subsides in a few hours. If the infant is weak the milk may have to be expressed, and the breast massaged gently for a few minutes. Stimulation other than nursing of the infant is to be avoided. There are four periods when mastitis is especially liable to occur, but it may make its appearance at any time during lacta- tion. The periods of greatest frequency are during the first month, and especially the first fortnight after birth, when the nipples are tender and not accustomed to nursing; whenever nursing is suddenly stopped (as, for example, on account of the death of the child) and the breast becomes engorged with milk; at the time when the infant cuts its teeth and the nipples are again exposed to injury; and at the end of lactation, either be- cause of hypersecretion of milk due to careless management when the infant is weaned, or because the child, being dissatisfied with the quality or quantity of the milk, shows its displeasure by biting or gnawing the nipple until it is injured and sore. This infection is rarely, if ever, caused by the amount or stagnation of milk, but, as has been said, by infection through a nipple, which may be diseased as well, or an infected suppurating Montgomery gland. The necessity for a continuous exercise of asepsis in the care and covering of the nipples is evident, Their condition, their care, the amount of mechanical injury inflicted by the infant, and the condition of the mother are all factors entering into the probable outcome of a septic infection. The first symptoms of mastitis are a feeling of discomfort and pain in the breast, followed by chilliness or a distinct chill and a sharp rise of temperature to 1050 or 1060 F. Inspection shows that the gland is tense, hard, nodular, red, and exquisitely painful. Fig. 135.—Author's breast-binder. INFLAMMATION OF THE BREAST. 285 If treatment is begun at once, it may be, and often is, pos- sible to check the disease at the outset, but to accomplish this result energetic measures must be resorted to without delay. The physician must be notified immediately, and if there promises to be a wait of several hours before his presence or his advice can be secured the nurse may properly proceed as follows: A snug breast-binder (Fig. 135) is applied and, after it is pinned, holes about the size of a half-dollar are cut over each nipple to allow the milk to escape. This can be done by picking up the material directly' over the nipple with a thumb forceps, drawing it well away from the body, and cutting through it with scissors, after which the opening is carefully enlarged to its proper size and shape. If a piece of cotton is laid over each nipple before the binder is applied, there will be no difficulty what- ever about grasping the muslin, and after the hole is cut the cotton may be left until it is soaked with milk, when it is to be removed and fresh pieces inserted. Ice-bags are now placed over the inflamed area and left until all inflammation has sub- sided or until the physician orders their removal. These ice- bags must be lightly filled with slush ice and applied to secure cold to the gland. They may be supported by small pillows at either side. If one breast only is infected a roller bandage or a Boston Lying-in-Hospital binder may be ordered. The patient frequently complains of chill under this treatment. She should be in bed and external heat applied. The bowels are best moved with a saline cathartic, such as magnesium sulphate (Epsom salt), one-half ounce in half a glass of water. Nursing must, of course, be stopped at the affected breast, and the ingestion of fluids is to be restricted as much as possible until all the symptoms have disappeared. This treatment, if begun at once, is usually successful in checking the disease, but, as has been said, it must be instituted without a moment's delay if it is to be effective. The inflamma- tion, under the treatment of rest, tight bandaging and ice-caps, with salines, usually subsides at the end of a day or two, and nursing is resumed. A doctor may attempt to avert the incision 280 A NURSE'S HANDBOOK OF OBSTETRICS. ,► a 3 f S € 7 8 3 tpll 12 /3 & If J 7 8 9 Jo tJ h ft M 2S hr h is jy Fig. 136.—Pattern of author's breast-binder. PUERPERAL INSANITY. 287 in deep-seated infections by the the use of the Bier congestion bell. This is applied as often as is ordered for short periods of time, but because of the pain involved in comparison with the treatment outlined, it is but little used in practice. If the treatment outlined above is unsuccessful and the case goes on to suppuration, the treatment is necessarily surgical, and the nurse can only follow the directions of the medical at- tendant. • Local anaesthesia is generally given and the incision made as small as possible. Evacuation of the pus is sometimes difficult to secure. The drain is perhaps a small wick or may be some form of suction cup, depending upon the area involved. This implies the necessity at times for an anaesthetic at dressings. It is not necessary to repeat the caution concerning the handling of such pus. Gloves and gown to protect nurse and both pa- tients ; cleanliness and good technic are demanded. It may be said that the cases of mastitis that develop during the first month after labor seldom go on to suppuration, but those appearing later in the puerperium are very likely to do so unless they can be checked in the manner described. Syphilitic lesions may be found on the nipple, either primary from the bite of a syphilitic child, or of the tertiary type in a wo- man who is suffering from the disease in its advanced stage. The matter would, of course, be brought at once to the attention of the physician, and the treatment is the same as it would be under any other condition. Eczema of the nipple and areola, and occasionally extending over the entire breast, is a rare complication that may arise during the puerperium. Its treatment is both local and general, and can only be carried out by the physician. Insanity may occur at any time after conception and disap- pear within a few days or even hours, or it may continue through- out the entire pregnancy, into the puerperium, and even through the whole period of lactation. The insanity of pregnancy is usually melancholia, and is often so slight that it is entirely unnoticed, but it may, on the other hand, be very pronounced, with a marked suicidal tendency. 288 A NURSE'S HANDBOOK OF OBSTETRICS. The insanity of the puerperium, called " puerperal insanity," is most often of the maniacal type, and is the most common of the three varieties. The mania usually appears within a month after delivery, either following the melancholia of pregnancy or without any warning whatever. The patient is at first restless and disagreeable, and soon evinces a marked dislike for her husband and others who are most nearly related to her, or else the mania develops suddenly with no premonitory symptoms. The woman becomes noisy, talkative, and incoherent, and her mind may dwell on religious subjects, or she may be profane, obscene, and vulgar, with an absolute loss of all sense of decency or modesty. The tendency to suicide or murder is always strongly marked, and the patient must be most carefully watched. The insanity of lactation is usually of the melancholic type, like that of pregnancy, and is most commonly seen in multipara who have borne many children in rapid succession and whose general condition is greatly impaired. The causes of insanity cannot be stated very definitely, but may be supposed to include all conditions that greatly under- mine the general health of the patient. This would comprise severe injuries, mental disturbances, albuminuria, eclampsia, chorea, hemorrhages, septic infection, pronounced anaemia, and painful or prolonged labors. Heredity seems to play an im- portant part in the causation of this condition, and illegitimacy often exerts a sufficient-effect on the mother to account for the insanity of pregnancy or of the puerperium among unmarried women. These cases are seldom fatal except through personal injury inflicted by the patient herself, but quite a number die eventually of exhaustion, and others become chronically and hopelessly in- sane. Unless the patient recovers entirely within a year it is almost certain that she will remain permanently demented, but the majority of cases do not last more than a few weeks or a month. There is a sudden transitory mania which sometimes occurs during labor, but it is probably an hysterical manifestation due to the severity of the pain, and disappears within a few minutes. PUERPERAL INSANITY. 289 The treatment of these cases lies entirely with the physician, and consists chiefly in building up the shattered constitution with nourishing and easily digested food, fresh air, good hygienic surroundings, and careful nursing and attendance. The maniacal cases should be placed in an asylum, unless the circumstances warrant the employment of a sufficient num- ber of nurses for both day and night duty to keep the patient under constant surveillance, and even in the melancholic cases the suicidal and homicidal tendencies must be kept in mind at all times. XXI The Care of the Normal Infant As soon as the mother has been given the attention neces- sary to secure cleanliness and comfort, the nurse may, after as- suring herself that she is in good condition, direct her attention to the infant. The infant was wrapped in a sterile towel, to protect the umbilicus from infection, and a warm flannel blanket, and laid in a safe place at the time of its birth, and has been examined occasionally by the nurse to see that its breathing is satisfactory and that there is no bleeding from the cord. If the room is cold or the child is not warm and rosy, it should be surrounded with hot-water bottles filled with water no hotter than 1200 F. and covered to prevent the possibility of burning its delicate skin. The physician will, when the opportunity offers, inspect the in- fant's body carefully for deformity, injury, or abnormality of any sort, and, if it is perfectly developed, inform the mother of its satisfactory condition. If deformity or injury is found, it is best to keep the knowledge from the mother for as long a period as possible by giving more or less non-committal replies to her interrogations, but as soon as she begins to suspect in the slightest degree that she is being deceived as to the child's con- dition the doctor must be notified. The obstetrician will direct the nurse as he sees fit. Usually the father will be told at once and the mother informed by him or the doctor. The nurse rarely has this painful duty to meet. The baby's eyes first receive attention. The doctor usually gives this by washing the eyes from the inner angle toward the outer with a boric acid solution. He will take every care to prevent any contamination of the eye from foreign matter and when they have been thoroughly cleansed he will open them and use Crede's treatment or some similar 290 OILING AND DRESSING THE NEW-BORN INFANT. 291 Fig. 137.—Oiling and dressing the new-born infant. All articles are within reach. The table is warmed with hot-water bottles. 292 A NURSE'S HANDBOOK OF OBSTETRICS. method. If nitrate of silver solution, 1 or 2 per cent, is used, one drop in each eye, he may neutralize this with normal salt solution or a 2 per cent, boric acid solution. He may prefer argyrol, 25 per cent., or protargol, 15 per cent. Occasionally he leaves this to the nurse. She must take especial precautions against allowing vernix or blood to get into the eyes, and against any silver solution dropping upon the face. The infant must have warmth and protection from strong light and draughts. The nurse will soon find time to anoint the baby carefully with warm sweet oil or albolene, and to remove the vernix caseosa which covers the body. The oil is poured into a glass or cup, which is placed in a vessel and allowed to stand until it is thoroughly warm. The nurse will have a small table prepared to receive the infant and will never be guilty of placing it upon her lap when this can pos- sibly be avoided. No lap can properly support an infant when the person is continuously reaching for required articles and altering the position of her knees. It is entirely unnecessary and nurses should begin to grasp the fact that this ancient custom leaves very much to be desired in the way of comfort and effi- ciency to both nurse and infant. The method has nothing to recommend it save custom. The infant should be handled as little as possible. This can best be done by always placing it upon a table. Care can be given more expeditiously and efficiently in this way. In a hospital the op- portunity for infection through bathing a number of infants upon the nurse's lap is obvious. Some hospitals have instituted a system of spraying the in- fant upon a slab to avoid this source of very real danger. The general objections to the lap method occur to the mind at once. Any table covered with a blanket and a towel will suffice for the first anointing of the baby. Secure warmth beneath by a hot-water bottle, and, turning the infant upon its face, apply albolene gently but rapidly with a cotton sponge, going care- fully in all creases at knee, buttocks, neck and back of the ears Whfe^e th'e veir.ix is most abu'r.'dint. DRESSING THE CORD. 293 Take care that nothing comes in contact with the cord and that no oil enters the eye. The head usually requires a thorough anointing. Dry with a warmed soft towel. The infant is then turned over, and the anterior portion of the body anointed in the same manner, particular attention being given to the armpits and creases in the elbows, groin, and under the chin. Dry thoroughly. Doctors rarely dress the cord, but a nurse will be wise if she asks for orders as to method before assuming responsibility. It should be done with especial care and especially clean hands to avoid infection. The cord and surrounding area may be washed thoroughly, particularly the point of insertion, with 95 per cent, alcohol, and a wet gauze dressing of 95 per cent, alcohol applied, or it may be cleansed thoroughly with 95 per cent, al- cohol and a dry sterile gauze dressing applied. Never use powder. It is not sufficiently antiseptic, and it forms crusts. This dressing can best be done by using forceps to handle the dressings. The dressing is the usual one in shape. A pad of gauze or cotton is cut with a hole in the centre through which the stump protrudes. The corners are folded over the stump, allowing it to take the direction of least resistance. Over this is placed a sterile gauze sponge and then the binder is applied. After the temperature is taken and diaper applied, the baby should be dressed rapidly and put in a warm crib. Children should not receive a tub bath until the cord has be- come detached. The cord dressing is not to be disturbed unless it becomes soiled, when the same surgical care is to be shown in its renewal. Unless the dressing becomes soiled with urine or otherwise, it may be allowed to come off with the cord some time between the fifth and eighth day. If it is necessary to remove it, only such of the cotton as can easily be freed from the cord need be taken away and the fresh dressing applied exactly as in the first instance. The little tags and fibres of cotton that adhere to the cord will be sufficiently sterilized by the application of the fresh alcohol. 294 A NURSE'S HANDBOOK OF OBSTETRICS. The Umbilical Cord.—This usually becomes detached from the body between the fifth and eighth day after birth, but its de- tachment may be delayed until the tenth, twelfth, or even the fourteenth day without causing any harm unless signs of inflam- mation appear. The nurse will usually find the cord in the um- bilical dressing when she removes the binder to bathe the infant, and there may be a slight stain of blood. If the bleeding con- tinues, as it may in very rare instances, the physician should be notified. In most cases the navel will be depressed somewhat and absolutely free from any evidence of inflammation. No further treatment is required except to keep the part clean and dry. Fig. 138.—Method of dressing the umbilical cord. The clinical record of a normal infant should show a varia- tion in pulse of from no to 150. Only experience can teach a nurse to accurately count an infant's pulse-rate. Touching its wrist will generally startle and noticeably accelerate its heart beat. It can always be felt at the temporal artery to best ad- vantage, particularly when sleeping. The temperature may vary a whole degree, from 980 to 990 F. A feeble infant will have a temperature below this, from 97 ° to 98°. Sleep.—The newly born infant requires a great deal of sleep and is to be kept in its crib except when it is removed for some special purpose, such as nursing or bathing. The infant will, during the first few weeks of its life, sleep practically all SLEEP. 295 the time, but it must be expected to cry vigorously for at least half an hour each day in order to expand its lungs and develop the muscles of its chest and abdomen. It should be laid down at once so that it may go to sleep and digest its food properly, and if it cries and examination shows that it is perfectly dry and comfortable, it should be left alone to stop of its own accord, and must never be patted, rocked, or walked about. If at all possible the child should be kept in a room away from the mother until after the puerperium, in order that this process of disciplining may not disturb her. Systematic training of this kind during the first few weeks of the puerperium, coupled with a regular hour for undressing the baby and putting it to bed in a dark room for the night, will teach any child to go to sleep the moment it is laid in bed and the habit will cling to it as long as the rule is enforced. If the plan is to be successful, it must be adhered, to ab- solutely, and friends and relatives must understand clearly that they cannot see the baby under any circumstances after five o'clock. There is not a healthy child living who has to be rocked or otherwise cajoled to sleep whose parents or nurses are not di- rectly responsible for the whole matter, and while it may be very entertaining to ignore the welfare of the infant entirely and make a toy of it at first, the constant care and attention become most trying as the years go by, and especially so if other children are born and a similar program is followed. A child can be made a comfort just as easily as a trial and a burden; and people whose children are up at all hours of the night, have to be rocked to sleep and stayed with for hours each evening, and protected from bogie men and other terrors of the nursery, have absolutely no one to blame but themselves. In these matters of discipline the nurse can only advise the parents as to the best course to pursue for their own personal comfort and the good of the child, but if they prefer to make themselves and every one about them miserable for a number of years rather than forego an ill-timed frolic with the baby, they cannot be denied the pleasure of doing so. 296 A NURSE'S HANDBOOK OF OBSTETRICS. Infant's Cries.—After the child is born and has cried lust- ily, it becomes quiet and at once sleeps. After the eyes, navel and skin have received the necessary care it is dressed and placed in a warm crib, and it will not cry unless it is wet, hungry, or ill. A nurse should learn to distinguish an infant's condition and needs from the character of its cry, which all nurse's text- books describe—a loud insistent cry with drawing up and kick- ing of the leg, denoting colic, either intestinal or due to the pass- age of red uric acid deposit from the bladder. Sometimes this point may be decided by finding this red stain upon the diaper. A fretful cry if due to indigestion will be accompanied by green stools and passing of gas. A child's whining cry is noticeable when the infant is ill, premature or very frail. A fretful, hungry cry, with fingers in mouth, is easily known. A peculiar sharp, sounding cry is emitted where there has been any injury suggesting a cerebral condition. A nurse should make every effort to recognize any deviation from the usual manner in which an infant announces his normal requirements. Adherent Foreskin.—In a male child adhesions between the prepuce and the glans penis are very common. The fore- skin may be extended beyond the glans. A very small opening is spoken of as a phimosis. A curdy secretion, called smegma, may form in considerable amount and collect under the prepuce behind the glans; small amounts of urine may also be retained and all of these conditions favor irritation. The doctor will perform the delicate operation of separating the adhesions. A nurse must never attempt it. It should be left alone and in no way manipulated by unskilled hands, or a serious condition known as paraphimosis may result. The doctor will sometimes expect the nurse to do the daily dressing, following a dilatation and retraction and will direct her. The manipulation will be difficult at first and must be done quickly. But the use of the probe is rarely expected of a nurse, a cotton sponge, the gentlest pressure with sterile vaseline for the lubricant generally serving the purpose. Soapy water should never be used to bathe this denuded tissue. Use sterile warm salt solution. Similar adhesions are often found about the WEIGHT. 297 clitoris in female infants, but then destruction is not so easily accomplished and should be left entirely to the physician. Oc- casionally a slight bloody discharge may come from the vagina. It may be due to injury or is apparently menstrual in character. It rarely reappears and needs only cleanliness for treatment. Chafing, Scalding or Eczema Intertrigo.—This is due to moisture and the irritation of adjacent surfaces. In the female infant there is not infrequently a vaginitis with the usual swell- ing and purulent discharge. Practically all genital infection is the result of neglect and careless handling. It may be brought to the area by the nurse in the same manner she may infect the mother. It may be due to contaminated lochia or pus; neglect for a few hours is enough to start up irritation. All irritation of the genitalia must be treated with absolute cleanliness and the parts must be kept dry. This applies to all conditions not due to specific constitutional infections. Soap and water are to be discontinued at once, and the infant should be patted clean with olive oil and dusted with stearate of zinc or talcum powder, as commercial toilet powders nearly all contain boric acid powder which burns and irritates. Removal of the cause by eliminating pressure, with rest, cleanliness, and preventing moisture of the tissues, will usually check the inflammation. No properly quali- fied nurse will permit such a condition to arise in a child under her care. Properly fashioned, washed and ironed diapers used only once will be a large factor in preventing its occurrence. Weight.—The normal weight of a male child at birth is seven pounds and eight ounces, while that of a female infant is six pounds and eight ounces, or one pound less. These are the usual, average weights of normal infants, and two-pound mites or twelve-pound boys are as rare as Siamese twins, despite the marvelous tales of proud parents and ignorant midwives. During the first few days of life the infant normally loses in weight, until about the sixth or seventh day, it has dropped ten ounces below its birth-weight. This is because its digestive ap- paratus is barely learning to functionate at this time and the child assimilates little if any of the very small quantities of material which enter its stomach. For nearly a week it lives almost en- 298 A NURSE'S HANDBOOK OF OBSTETRICS. tirely on its own subcutaneous fat and gives off in meconium, urine, perspiration, and otherwise far more matter than it takes in by mouth. About the time that the meconium begins to disap- pear from the stools the weight commences to increase and, in normal cases, does so regularly until, by the tenth day of life, it equals the birth-weight; after which, if all goes well, it continues to increase until, at six months, it is double the birth-weight. For example, a child which weighs seven pounds and eight ounces at birth should be expected to drop to six pounds and fourteen ounces by the fifth or sixth day, increase to its original weight of seven pounds and eight ounces by the tenth day, and weigh fifteen pounds when it is six months old. Any marked deviation from this course should be reported to the physician. Directions for nursing are given and it must not be for- gotten that the baby requires a drink of tepid boiled water several times daily. This amount should be increased if a red deposit is found upon the diaper, following an attack of crying. The nurse must know with certainty whether the infant has urinated. If no urination occurs during the first twenty-four hours (an unusual condition) a cause must be looked for and an obstruction will probably be found. A prompt report should be made of the condition. The sterile water should never be given with a medicine dropper. The danger of injury to the mouth through careless administration is great. A small boiled bottle and nipple are better for the purpose. The needs of the baby and the ideal nursery will be included in the next chapter. XXII The Ideal Nursery and Layette the ideal nursery As a guide to the nurse in answering the many questions an inexperienced mother will put concerning the infant's wardrobe, nursery and accessories, this chapter is added. The change from the old to the new order as applied to the hygiene of the baby is nowhere else shown to be so great. For the nursery, which is to be a home for a child, theoreti- cally the only logical reason for the maintenance of a home itself, a room flooded with sunshine and properly ventilated is the best. The proper sort of nursery should be secured if it is at all possible. Families might change a cramped dark apart- ment for a more desirable residence if the baby was considered as he deserves. Necessities for the child's health, comfort and freedom, as well as his protection from infections and accidents, can all be secured by the exercise of intelligent common sense, ordinary foresight, and economy as well. Quiet, sunshine, simplicity, warmth and ventilation are es- sentials for the baby. A neutral washable brown or green paint upon the walls and window shades of tan or dark green are suitable. Window hangings may be dispensed with. Eye hy- giene must be carefully observed and the infant never be ex- posed to a light shining into his eyes. The room should be kept quiet and freshly aired at all times. Usually the heating system must be accepted and will need watchful control. The nursery temperature should be about. 66° to 700 F. during the day and 60° by night, and if the child con- tinues strong a much lower temperature can be safely borne by night. The chief point to remember is to afford the necessary protection of the child's body from the cold air. This is ab- solutely essential and can be accomplished by the use of proper sleeping apparel and a proper method of crib making, using 299 A NURSE'S HANDBOOK OF OBSTETRICS. coverings (such as wool or down) that give warmth with the least weight. The blankets should immediately cover the infant. Gas and oil heaters exhaust air rapidly, and if it is necessary to use them, they must be carefully watched, and the moisture in the atmosphere supplied, in a measure, by a large vessel containing water, always on the stove. The floor should be bare, with washable rugs or covered Fig. 139.—Infant's crib with adjustable sides. with linoleum. The bed is sometimes a clothes-hamper set upon two chairs, but should be a child's metal crib. This should have a hair mattress. Where this is not possible, many substitutes can be found. Mattress padding, four thicknesses deep, table felt- ing or a straw or southern moss may be used and covered with a quilted pad. Care and cleanliness by frequent washings and airing are essential and a rubber sheet is always necessary for PREPARATIONS FOR THE BATH. 301 protection if the mattress is to continue in use. The infant must never lie directly upon a rubber sheet, but always upon a dry pad. Babies require no pillows, breathing more easily lying upon the abdomen. When the infant is older a flat hair pillow may be used. Down is too heating for use at any time. In addition, the furniture, which should all be plain and washable, consists of: 1. A table fenced on all sides and divided through the centre. Fig. 140.—Practical infant's crib. It may be raised and swung over bed of mother ii desired. This is to be covered with rubber sheeting or oil-cloth, then a pad, and finally a towel or soft blanket for one half, two thick- nesses of padding for the dressing half. The infant is to be bathed on one compartment and dried. Then laid upon the other compartment for its careful toilet. This nursery furniture is a stock article abroad, but the fashion persists very strongly here of bathing, dressing and handling the infant upon the mother's knees. This is very undesirable. It is awkward for the mother, however low her chair and table of supplies. It results in much 302 A NURSE'S HANDBOOK OF OBSTETRICS. unnecessary handling of the infant, much more time is consumed than need be, and unless every detail of the bath and toilet has Fig. 141.—Double wash-basin. been remembered, it means the placing of the infant in some convenient spot until the mother returns with the forgotten article, pins, hot water, etc. When the baby is to be tubbed, the process of undressing, washing the head, nose, and ears, soaping Ihe body, can all be Fig. 142—Paper bags pinned together. One for soiled clothing to be washed; the other for articles to be destroyed. very expeditiously accomplished upon such a table and, with the tub beside it, all stooping is avoided. The dressing proceeds rapidly on the dry end of the table. Any small table 28 inches high may be so divided and fenced for protection. PREPARATIONS FOR THE BATH. 303 2. An infant's dressing screen is now on the market which does away with the insanitary exposure of the most personal toilet articles of the infant. This screen, which closes upon itself, has shelves, drawers, towel rack, and may be exceedingly elaborate with glass shelves, covering tufted satin, or plain wood. It may be made with a wooden frame and backed with linoleum or any washable material or most daintily fashioned. Every article belonging to the baby should find its place inside this screen, instead of the discredited baby basket which is invariably dirty. The soap should always be in a shaker, as are some shaving soaps. Nothing that the baby uses is quite so dirty as the usual cake of castile soap. Sea sponges, long discarded Fig. 143 A.—Infant's dressing screen. Holds all required articles and protects table. Fig. 143 B.— Infant's dressing table. One half for bath and change; one half for use aft. infant has been bathed and dried. in surgery, are equally insanitary for the use of the baby. Clean rags boiled often are far better. Cotton sponges in one piece may be shaped to cleanse the ears and nose. Never use cotton upon a tooth pick to cleanse nostrils. The danger of detachment is a real one and ears may be seriously injured by the manipulation of such an applicator. A NURSE'S HANDBOOK OF OBSTETRICS. The shelves will hold the double basin, two pitchers, hot- water bottle and all toilet accessories. This screen opens, is light and on rollers, and is to be placed around the nursery table. This avoids a draught and places within immediate reach all the articles which are required. 3. A chair without arms for the mother or nurse. 4. A metal bed for the nurse. 5. An infant's wardrobe or chiffonniere. 6. A table to hold scales and any other article. 7. A low table or flat chair to hold the bath-tub. 8. An armless rocker for visitors. 9. Infant's bath-tub. These articles may be as exquisitely dainty or severely plain as the mother may wish. But the infant thrives best where it has quiet, sunshine, cleanliness, and an equable temperature. If the nursery has an adjoining bath-room as well as a screened porch many steps may be saved. A board over one end of the bath-tub may serve instead of the nursery table. It is low, however, and inconvenient because of the number of times in the day the infant requires attention and appropriates the bath-room. Much has been written to popularize the long-recognized scientific fact that clothing and environment produce definite effects upon the baby's physical and mental development. Pins, tight bands, rough seams, weighty clothing, scratchy laces, insuffi- cient diapers, noise, unnecessary handling, bootees and a host of other sufferings to which the infant has long been subjected have now a great light thrown upon them, and mothers are asked, on all sides, to consider these matters and to remedy the defects. The National Children's Bureau of the U. S. Department of Labor has published two monographs on Pre-natal Care and Care of the Infant which are very valuable. Mothers are ad- vised to secure them. The diaper L quickest made in the old way, twice as lon°- as broad, in two sizes 20 X 40 inches and 26 X S2 inches. The first used should be still smaller, 36 inches square and folded four deep. PREPARATIONS FOR THE BATH. 305 Pins are required to adjust these diapers. They reach too high up the back and should be replaced by the shaped dia- per now so strongly recom- mended. The pattern is shown and explains itself. It is time the diaper pin dis- appeared from use. It has nothing in its favor except undisputed sway. Tapes that do not twist and straps not easily torn consume no more time in adjusting than does the finding, opening and applying the pins. The diaper is more comfortable when shaped, it allows more freedom to the limb, and, if properly fitted, it af- fords equal protection. An inside absorbent pad must al- ways be used, for the econ- omy is obvious. An oblong or towel-shaped diaper is excellent for larger chil- dren. The diaper is folded down from the top to double the thickness under the seat and the long end drawn up between the legs and fastened in four places. The tapes are to supersede the safety-pins where these are used. The fairly com- mon accident of swallowing safety-pins would be rare if the infant's clothing could be fashioned to dispense with their use. Being " stuck " with the point of a pin is only one of the possible discomforts to which the infant is subjected. There is Fig. 144.- -Method to secure air for infant in a city apartment. 306 A NURSE'S HANDBOOK OF OBSTETRICS. at all times more or less pressure of the small body upon them. Again, the large ill-fitting diaper between the thighs may result in a slight deformity to the femurs, and the delicate genitalia may be injured by the same pressure. The infant's temperature should be taken by rectum, and with proper training the bowels may be evacuated before the morning bath is begun. It is to be given according to a schedule. All necessary articles are to be within reach. The temperature Fig. 145.—Another view of Fig. 144. of the room should be about 70°to 75° F. All draughts are to be excluded and entrance to or egress from the room is not to be permitted unless the same temperature is maintained outside. The tub may be enamel, which is expensive but indestruct- ible ; a rubber tub, which it is impossible to scrub quite clean; a papier mache or a tin tub. These last are usually painted and will serve very well for at least one year. The temperature of the bath may vary somewhat accord- INFANT'S CLOTHING. 307 / ✓^N -.jwms^p', * Fig. 146.—Diaper shaped according to pattern. No pins required. 308 A NURSE'S HANDBOOK OF OBSTETRICS. ing to the age and strength of the infant, but it must never be cold enough to cause shivering or blueness of the extremities, and must invariably be gauged by the thermometer and not "guessed at " by the nurse. In -a general way the following table, given by Rotch, will meet the requirements of most infants, but the effect on the child must be watched carefully and the temperature raised if necessary. TEMPERATURE OF THE BATH FOR DIFFERENT AGES Age Temperature At birth.......................................... 98° F. During the first three or four weeks.................. 95° F. One to six months................................. 93° F. From six to twelve months......................... 900 F. Twelve to twenty-four months...................... 86° F. Then gradually reduce in summer to................. 80° F. In third or fourth year, if possible, reduce to.......... 750 F. The infant is to be laid upon the bath end of the table, its clothing removed excepting its band and diaper. A cotton sponge should be saturated in a 2 per cent, solution of warm boric acid or boiled water, and used for washing the exterior of the eye. Care must be taken that no fluid escapes into the eye. Washing the healthy eye can do no possible good and may do much harm, the solution being often contaminated and old. The ears and nostrils are to be washed with small shaped pledgets of absorbent cotton. Toothpicks with cotton or sponge attached have no place in nursery. There is a great reaction against wash- ing the baby's mouth frequently; all pediatricians seem to agree that this has been overdone in the past, and so now the avoidance of this source of danger for the introduction of germs and in- jury to the very delicate structure of the surface is strongly advised. Once a day the tongue may be cleansed with a 2 per cent. solution of warm boric acid. A piece of cotton should be ap- plied, most gently, with a surgically clean little finger. This is better than the cotton on a toothpick, so often used as an ap- plicator. If food is vomited, curds may be removed in this way. Separate pledget; must always be used for the mouth, ear, and TEMPERATURE OF THE BATH. 309 eyes. Paper bags may receive the articles to be destroyed and another those for the laundry. The head and the face are to be washed, The child's body is now to be soaped thoroughly and quickly with the sponge and water from the proper side of the double basin, and as soon as this is done the infant is lifted carefully into the tub and allowed to kick and splash for a few seconds. If the cord has not yet separated, the infant is not put into the bath. Nearly every baby will thoroughly enjoy its daily bath if it is begun before the child is old enough to know the meaning of fear, but when the tub bath is not commenced until the infant is several weeks old, or if it is ever dropped or otherwise fright- ened or injured in the bath, it may require great patience and perseverance to overcome the little one's terror of the water. The nurse must make sure that the water is of the proper temperature, and the baby is to be held firmly and dipped in the water slowly and carefully so as to avoid any sudden shock. When the child is, for any reason, actually afraid of the water, a thin towel may be laid across the top of the tub, covering it entirely, and the baby held over the towel and then lowered very slowly and carefully into the water. A few baths given in this way may be successful in reassuring the infant and over- coming its fear. After a few seconds in the tub the child is returned to the table, covered at once with a warm towel, and " spatted " softly until it is dry. A small soft towel is then used for drying the creases of the body and the armpits, groin, and buttocks, and talcum powder is applied lightly to all folds of the skin and places where moisture might collect. Remember that the baby is to be soaped and washed on the table, and not in the tub until it is old enough to sit up; that separate sponges, wash-cloths, and water are to be used for the body, buttocks and face. The infant, wrapped in the towel, is now laid in the scales and the weight carefully noted and recorded on the weight chart after the bath. Before recording the weight the towel is to be A NURSE'S HANDBOOK OF OBSTETRICS. weighed and its weight deducted from that of the infant and towel together. If the cord dressing has been removed it is replaced in the manner already described and the binder sewed carefully over it or tied. The diaper, folded in triangular shape, is laid well up under the buttocks and on it is placed a square of folded gauze, lintine, or old soft pieces of napkins or table-cloths, which will absorb a good part of the urine and take up all the discharges from the bowels. These are to be changed and destroyed as soon as they become soiled, and their use will effect a great saving in washing. The diaper is now tied carefully and fastened to the binder in front, and the infant's socks are put on. The outer clothing consists of three pieces,—an undershirt of stockinet with sleeves, a flannel petticoat without sleeves, and a muslin slip. These garments are all made so that they can be fitted into each other before the infant is bathed and all slipped on at once. They should be drawn up over the feet and never put on over the head, for fear of frightening the baby, and after the sleeves are adjusted properly the child is turned on its face and the three layers of clothing closed in the back. It will be seen that this method of dressing the child causes no pressure on the chest or elsewhere, and allows perfect free- dom of movement to all its muscles. As the infant is turned over but once in the entire process of dressing, it is not tired or excited as when the old-fashioned style of clothing is used. On this account it is not at all fretful, but more or less drowsy, after its bath, and quite inclined to nurse and go to sleep at once, to the great comfort of every one concerned. A folded diaper may be laid loosely under its buttocks, be- tween its body and the undershirt, to protect its clothing, and its diapers must be changed the instant they are wet or soiled. The whole process of bathing, drying, powdering and dress- ing the infant must be carried on with the keenest realization of the care which the delicate body requires. Roughness insures abrasions, and abrasions insure infections. The skin becomes dry after the infant is about four days old, and about half of them show, during the first fifteen days, THE INFANT'S LAYETTE. 3H a jaundice known as icterus neonatorum. The exact cause is not clear. It is no doubt due to a number of causes, but generally it disappears and needs no treatment, but it may be due to an in- fected navel and it is best that the dressing be carefully inspected for the assurance that this source may be eliminated, always re- membering that the point of union of the cord with the body is the point of possible infection. The gall-duct may be affected or there may be a congenital stricture. This demands the immediate care of the doctor. Carelessness in cleansing the scalp will result in the condition known as seborrhcea capitis, which consists of an over-secretion of the sebaceous glands, mixed with dirt, forming a yellowish- brown, waxy-looking crust on the head. This will never occur if the child is properly cared for, and when the condition is en- countered the crusts should be gradually softened with warm sweet oil and removed as gently as possible, after which, if the head is kept clean there will be no return of the trouble. The time when the baby can go out of doors depends upon the time of year, the weather, and the climate of the place of its birth. Babies born in the summer or in a warm climate may usually go out on dry, pleasant days when they are four or five weeks old, provided they are kept in the sun with their faces shielded from the light. Infants born in the winter or in a severe climate are better off in the house, even up to the fourth and fifth month, but they should receive fresh air once or twice daily by being bundled up warmly and carried into a good-sized room with open windows, where they may remain for ten or fifteen minutes. THE INFANT'S LAYETTE Twelve plain slips of nainsook, crepe, dimity or long cloth (linen is objectionable) 27 inches from shoulder to hem. Six sack gowns, sleeveless, opening in back, folding over at bottom; for the first two weeks. Made of part wool flannel for winter, lighter weight for summer. Popular in hospitals and difficult to improve upon for first clothing. May be utilized later as sleeping robes. Six part wool flannel petticoats made Gertrude fashion. For A NURSE'S HANDBOOK OF OBSTETRICS. summer wear should have cotton waists. Always close with snaps at shoulders. Six shirts, loosely woven mesh silk and wool for winter, or Six shirts, loosely woven mesh cotton or silk and cotton for summer. Unless the infant is quite small, purchase the second size. Two dozen cheese-cloth diapers. .The softest and most ab- sorbent for use the first two months. Cut one yard square and stitch into one-quarter yard square diaper pads. Use later for inside pads. Four dozen diapers of cotton birdseye, domett flannel or terry cloth, size 20 X 40 inches and 26 X 52 inches. These are better when shaped according to pattern and made same size. Best of all are the soft absorbent knit diapers so widely ad- vertised, but they are expensive because of the number required. These are more absorbent than any woven goods. But whatever is used must first be boiled to become shrunken and absorbent and changed as soon as known to be damp. Six straight bands, 6 inches wide and 22 inches long. These will be used to keep the umbilical dressing in place. If the doctor advises the wearing of a band after the first month these will be needed: Six knit bands fastened with straps. These have shoulder- straps and tabs for attaching to the diaper, and in summer may replace the shirt. Six knit straight bands fastened with tapes, of silk and wool or cotton. Six night-dresses of light soft flannel or crepon. Tapes applied flat at neck and wrists. Snaps down front and across bottom which is closed by being folded forward. Pinning blankets imprisons the legs, interferes with activity; are unneces- sary and objectionable. Six pairs cotton and wool long stockings, for winter. Six pairs cotton socks for summer. Avoid all kid shoes or knitted bootees. They are a source of irritation. THE INFANT'S LAYETTE. 313 3H A NURSE'S HANDBOOK OF OBSTETRICS. THE INFANT'S LAYETTE. 315 If the child has cold feet apply external heat. When covered with clothing the feet should have nothing at all upon them unless a soft pair of stockings are worn. Six bibs of fine absorbent Turkish towelling. A number of jackets are essential. These may be of dif- ferent weights. The body is often not protected in proportion to the lower limbs. This must be met by a more or less warm jacket of flannel or a knitted sack. A number of blankets for baby's use. The best size is a yard or yard and a half square. This outfit is enough to start with and does not leave the mother swamped with hopelessness upon the nurse's departure. The amount could profitably be doubled. If laundering can be promptly done four of each article with ten slips and four dozen diapers may be made to serve. Out- door garments may be secured later. All clothing must be changed night and morning. All articles 316 A NURSE'S HANDBOOK OF OBSTETRICS. worn by the baby as well as its bed must be thoroughly aired every day. The care of the shirts and bands is a part of the nurse's duty, and it is essential that she know how to supervise their washing, as they are expensive and easily ruined. They should be washed in soft water with a wool soap, and are best dried on a stretcher Diapers must be promptly placed in cold water, rinsed, boiled and again rinsed. The soap used must have no free alkali and must be carefully rinsed out; chafing and serious irritation may result if this is neglected. No diaper may ever be used a second time. Less expensive outer apparel and an unlimited supply of diapers is the part of common-sense. The infant's toilet screen will be fitted with: Four soft bath towels. Two dozen soft wash-cloths of old linen. One-half pound of absorbent cotton. One soft hair-brush. One small nail-scissors. One box talcum powder. Use cotton sponge instead of puff One bath thermometer. One hot-water bottle. One box of castile soap in shaker. One tube plain vaseline. Six ounces 95 per cent, alcohol. Six ounces sterile boric acid solution. Six ounces olive oil or benzoinated lard. Four dozen paper bags for waste. One double basin. Two pitchers. One cake white castile soap for the shaker. XXIII The Accidents, Injuries, and Diseases of the New-Born The accidents that may occur at or shortly after birth in- clude asphyxia and hemorrhage from the cord. Asphyxia neonatorum (asphyxia of newly born infants) may result from injury during manual or instrumental de- livery ; from compression or torsion of the umbilical cord, shut- ting off the fetal blood-current; or from protracted labor alone. Any one of these conditions should be enough to suggest the probability that the child will be born in a state of suspended animation, and preparations for its resuscitation should be made, if possible, before the termination of the labor, so that there will be no delay whatever. It may be asphyxiated with or without mucus in its throat. The nurse should have ready one large foot tub containing hot water (1050 F.) and a basin of ice water and a good sized piece of ice. These should be placed side by side on chairs or on a low table at a distance from the mother's bed, or even in another room. In addition there should be a gum elastic catheter, No. 8, for withdrawing mucus from the infant's throat, and a number of pieces of gauze, about eight inches square, for wiping out the mouth or for placing over the face if it is deemed neces- sary to blow air directly into the baby's lungs. At least two warm soft pieces of flannel blanket are required, as well as hot-water bottles and a pitcher of hot water to maintain a temperature of io5°-iio° F. for the bath. There are two types of asphyxia neonatorum. In one the baby's face and even its entire body are of a livid hue, and the vessels of the umbilical cord are gorged with blood (asphyxia livida) ; in the other the child's face and body are of a death-like pallor and the vessels of the cord are empty (asphyxia pallida). The livid cases usually recover, for the lividity only indicates an early stage of asphyxiation; but while the pallid infants izix/ 317 318 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. ISO.—Slapping upon the back to induce respiration after removing mucus and blood from the nose and throat. ASPHYXIA NEONATORUM. 319 Fig. isi.—Snapping the finger upon the soles of the feet, to stimulate respiration after removal of blood and mucus from nose and throat. A NURSE'S HANDBOOK OF OBSTETRICS. occasionally be made to breathe after prolonged efforts, the majority of them die at once or after a few days. If a child is born in an asphyxiated condition the cord should be tied and cut at once, so that there will be no interference with the performance of artificial respiration and also to permit the adoption of immediate measures towards its resuscitation. No time is to be wasted in determining whether it is dead or alive. It is always to be assumed that the child is living, for often it is over an hour before breathing can be established, and cases are on record where success has followed efforts extend- ing over the enormous period of seven or eight hours. More- over, even if the child is dead, it is a satisfaction and comfort to its parents to know that every possible effort was made to save it. There are several methods of performing artificial respiration on the newly born infant, but a description of one, and its clear understanding by the nurse, is all that is necessary in this place. The first thing to do is to hold the infant up by its heels, slap it sharply on its back and chest, and insert a finger in its mouth to the back of its throat and remove any mucus or blood that may be there. If the child does not breathe it should be laid on its back, its tongue brought forward and the No. 8 catheter inserted and the mucus aspirated. The tube is blown clean and again inserted. Respiration may now be excited by a brisk rubbing up and down the infant's spine while suspended by the feet in the left hand. If this is unsuccessful the child should next be dipped up to its neck in the hot water, held there for a moment or two, and then transferred to the cold water for an instant, or generously sprinkled with ice water upon the chest and back (many doctors object to the immersion of the infant in ice water as unnecessary), and back to the hot. While it is still in the hot water artificial respiration should be practised in the following manner. The child is held with the right hand of the nurse under its shoulders and its neck lying in the cleft between the thumb and forefinger, with the head falling loosely backward. The left hand of the nurse supports its thighs, and its entire body, with the exception of its head, is submerged in the hot water. ASPHYXIA NEONATORUM. 321 Fig. IS*-—Byrd's method of resuscitation. First movement. Expiration. 21 322 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 153.—Byrd's method of resuscitation. Second movement. Inspiration. ASPHYXIA NEONATORUM. 323 This means, of course, that the nurse's hands are both under water. Expiration is now affected by doubling up the body of the infant until its knees almost, if not quite, touch its chest. It i$ held a moment in this position, and then inspiration is caused by separating the hands and bending the body backward as far as possible. This process is repeated about twelve times a minute, or once in every five seconds, and by placing her ear close to the baby's mouth when the movement of expiration is performed, the nurse can tell if the manipulation is effective and air is actually being forced in and out of the lungs. Every few minutes the child is to be plunged into the cold water and returned instantly to the hot, in the hope that the shock will stimulate natural respiratory movements of the chest, and from time to time a finger is to be passed into its mouth to free it from mucus or other obstructing substance. It is highly important that the child be kept warm as possible. Receive it from the warm bath into a warmed blanket and if the artificial respiratiqn practised be Marshall Hall or Sylvester method, the extreme need to preserve the body heat is apparent. Whiskey may be rubbed along its spine. This routine of hot bath, removal of mucus, ice water, tongue traction, artificial respiration is to be repeated. Asphyxia means really lack of pulse, apncea meaning lack of breathing. If the infant's heart action is very feeble or irregular, or if no beats at all can be heard by placing the ear in close con- tact with the chest wall, a hypodermic injection of whiskey (ten minims) should be given, and if no air can be made to enter and leave the lungs when the artificial respiration is performed the air passages may be expanded by laying a piece of gauze over the infant's face and, with the lips in close contact with its mouth, blowing a short, sharp blast down its throat. The air must be prevented from entering the stomach and bowels by placing pressure directly upon it with the hand. The air is expelled from the chest by compression and the manoeuvre repeated. Too much air must not be thrown into the lungs, as their delicate structure may be ruptured. The artificial respiration is to be resumed and continued for at least an hour in the manner already described. 324 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 154.—Artificial respiration, Sylvester's method, First movement. Expiration. ASPHYXIA NEONATORUM. 325 Fig. 155.—Artificial respiration. Sylvester's method. Second movement. Inspiration 326 A NURSE'S HANDBOOK OF OBSTETRICS. The combination of the Byrd and Sylvester methods of in- ducing artificial respiration combined with a hot bath and the Laborde method tongue traction, alternated by the insufflation of air into the lungs, may be followed by the Schultze swinging method; usually a last resort. This may be repeated a dozen times when warmth must again be applied. This is considered a most efficient method and it is said that when properly done this method will inflate the lungs even if the child be dead. If at the end of this time there are still no signs of life, it is hardly probable that anything further can be accomplished, but it is usually wiser to continue the efforts for a somewhat longer period, if for no other reason than to satisfy the family. A pulmotor, if available, is sometimes used with success. The physician will, of course, attend to this matter of resuscitating the infant if the condition of the mother is such that he can leave her with safety, but often the task will fall to the nurse, and, in some cases, even after the physician has officially pronounced the child dead, the family will be grati- fied at further efforts to save it, futile though they be. Hemorrhage from the cord may be primary, due to the slipping or loosening of the ligature, or secondary from the base of the cord when it separates from the body. In the first instance the bleeding is from the end of the cord and not from its base, and can be controlled by the proper application of a fresh liga- ture. The secondary hemorrhage, from the base of the cord, occurs at about the fifth to the eighth day when separation takes place. It is often preceded by a slight jaundice, and is not an actual flow of blood but a persistent oozing, which frequently resists every form of treatment until the infant dies in a con- dition of exsanguination. This variety of hemorrhage is of rare occurrence, and may be due to that peculiar condition known as the " hemorrhagic diathesis," in which the individual's blood shows no disposition to coagulate, and bleeding from any denuded surface is persistent and often profuse; or the child may be the subject of a syphilitic taint. The treatment by the nurse of secondary hemorrhage from the cord consists in the application to the bleeding surface of a ASPHYXIA NEONATORUM. 327 Fig. 156.—Sylvester's method combined with tongue traction. 328 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. IS7-—Schultze's swinging method. First movement. Expiration. ASPHYXIA NEONATORUM. 329 piece of cotton saturated with liquor ferri subsulphatis (solution of the subsulphate of iron, to be had of any druggist). The physician should be notified promptly, and if by the time he arrives the use of the styptic has not effectually controlled the oozing, he will doubtless pass two long needles at right angles to each other through the base of the umbilicus and apply a tight "figure-of-eight" ligature (see Fig. 131). The needles must be removed at the end of six or eight hours and an anti- septic dressing applied. If this form of bleeding is at all severe and persistent, recoveries seldom take place and even if the um- bilical hemorrhage is controlled, bleeding may appear in the nose, mouth, stomach, intestines, or abdominal cavity; or the infant's body may develop purpuric spots at various points. The injuries to the new-born infant are those which occur during labor, either from pressure or from manual or instru- mental assistance to delivery. Fracture of a long bone or dislocation of an extremity may be the result of a version, or may occur in a breech case with the arms extended above the head when they are brought down into the vagina. Fracture of the clavicle (" collar bone ") or of the jaw, or dislocation of either of these bones, may follow for- cible efforts to extract the after-coming head in cases of breech presentation. These cases, of course, can only occur when the physician is present, and their treatment rests with him entirely. Fractures in the new-born infant usually heal rapidly, but it is often difficult to keep the parts in good position during repair. Dislocation should be reduced at once, or there will be great danger of permanent deformity in the joint. Injuries to the head caused by the forceps usually disappear within a few days, even when they are quite marked at first. If there is actual laceration of tissue, which will only occur when the instrument slips, or if there is a destruction of tissue-vitality from very prolonged pressure, it is quite probable that perma- nent scars will remain. Neither of these injuries will happen when the instruments are judiciously used, and any scar that may result will be so small and faintly marked by the time the child is five or six years old that it will be scarcely noticeable. 330 A NURSE'S HANDBOOK OF OBSTETRICS. >■ Fig. 158.—Schultze's swinging method. Second movement. Inspiration. ASPHYXIA NEONATORUM. 331 332 A NURSE'S HANDBOOK OF OBSTETRICS. Pressure from forceps may seriously affect the brain-tissue, causing paralysis of certain groups of muscles (Fig. 161), or an acute traumatic meningitis may develop; and the same con- ditions may occur when no instruments are used. Prolonged pressure on the head during a protracted first Fig. 160.—Warm bath combined with tongue traction. stage, where the membranes rupture before the os is fully dilated, causes a swelling of the scalp at the point where it is encircled by the cervix. This is called "caput succedaneum " (Fig. 162), and in its milder forms is very common. It is due INJURIES TO THE NEW-BORN INFANT. 333 to an extravasation of serum into the tissues of the scalp at the portion surrounded, by the os and free from pressure, and Fig. 161.—Facial paralysis of new-born child. (Ahlfeld.) it is the more marked the longer the first stage is delayed. The portion of scalp rendered oedematous in this manner varies, of <%f£i Fig. 162.—Caput succedaneum. Male, two hours old. (Rotch.) course, with the position and presentation, and the condition always disappears in a day or two without treatment of any sort. 334 A NURSE'S HANDBOOK OF OBSTETRICS. Another swelling of the scalp which resembles caput succe- daneum in certain respects is caused by an effusion of blood between the parietal bone of one side and the overlying scalp. This is seldom present when the child is born, and may not be noticed for two or three days, when the existence of a swelling will be observed, and it will be seen to increase gradually in size until about the seventh day after labor, when it remains stationary for a time and then slowly disappears. This condi- tion is termed "cephalhematoma" (Fig. 163), and usually Fig. ^63.—-Double cephalhematoma. Infant four days old. (Rotch.) ends in recovery without treatment. It may be due to pres- sure in normal labor, or by forceps, but it is also occasionally seen in breech cases in which no instruments were used nor pro- longed pressure exerted on the after-coming head. These cases are not common, and require no further mention. The diseases of the new-born infant are ophthalmia, icterus, spina bifida, mastitis, vaginal hemorrhage in female infants, umbilical hernia, umbilical vegetations, congenital cyanosis, and tetanus. OPHTHALMIA NEONATORUM. 335 Ophthalmia neonatorum is a disease of the eyes char- acterized by a profuse, purulent discharge due to infection generally from the genital canal at the time of birth and usually of gonorrhoeal origin. This is not always the case, how- ever. The lack of proper hygiene by the doctor or nurse or mother may carry the germ to the eyes of the infant. From 25 to 30 per cent, of all children in schools for the blind are the result of a gonorrhoeal infection. Pus, syphilis, trachoma, acci- dents, etc., are the other causes of preventable blindness. The disease appears two or three days after birth, provided the infection occurred at this time, but as the septic matter may be introduced into the eye at a later period by dirty cloths and by neglect of the proper care of the child, the onset of the trouble may be much later. Both eyes are usually affected, and they are first suffused with a watery discharge and somewhat con- gested. Within twenty-four hours the lids are very much swollen, and a thick, creamy, greenish pus is found under them. Later the swelling becomes so marked that the eyes cannot be opened, opacities of the cornea occur, the conjunctiva is ulcer- ated and then perforated, and the eye collapses and atrophies. The treatment consists, first in Crede's method or in the use of a 5 per cent, solution of protargol dropped into the eyes im- mediately after the labor, and this should always be done as a preventive measure. If the disease develops in spite of this prophylactic treatment, the infant is to be kept in a dark room and the eyes bathed at intervals of from twenty to thirty minutes with sterile ice-cold saturated solution of boric acid. Iced cloths must be kept constantly on the eyes until the inflammation has subsided, and when the boric acid solution is used the lids must be separated so that it will flow freely into the eye and reach every part of the diseased tissues. Whenever the iced cloths are changed or the boric acid is used, fresh pieces of gauze must be employed and the old ones destroyed at once by burning. If opacities appear on the cornea in the form of small milky-white spots, the physician must be notified immediately, for, unless the most energetic measures are adopted without delay, the sight will be destroyed. On > a w > C DC C C c c DC IT. H fn H 2 n Fig. 164.—Technic of applying ice compresses to the eye of an infant with ophthalmia neonatorum. Observe that the child is never placed in the lap of the nurse. OPHTHALMIA NEONATORUM. 337 The nurse must remember that this is a distinctly infectious disease, and that there is extreme danger of conveying it to others and of setting up an acute infection in the maternal genital tract. Even the eyes of the nurse herself may become infected unless she is most painstaking in her methods. Gloves, cap, gown, and glasses must be worn by the nurse. The pa- tient is placed upon a table and the nurse seated at its head. She must handle all dressings with forceps. If one eye only is in- fected the sound one must be protected by a Buller shield fastened to the face by an adhesive strip, and must be inspected at least twice a day for possible infection. Every article used by doctor, nurse, and patient must be absolutely diverted from use to other purposes. The ice-pads should be of soft lintine, quaker flannel or some such material and cut into one-inch squares. These should be placed upon a cake of ice, and applied (three to the minute) upon the eye; irrigations are done with a medicine dropper or syringe from the inner angle of the eye outward. The pus must be entirely removed while the eyelids are separated. Pro- longed irrigation of large amounts of solution over a surface already freed from pus is not so much ordered as formerly. The prescribed douches may be of boric acid, or bichloride mercury solution I : 10,000, saline or permanganate of potas- sium solution; the temperature should be tested by a ther- mometer and must not exceed 75 ° F. Care must be taken not to direct the stream from an irrigator directly against the child's eye. The child's head must be lowered and the solution drain into a kidney basin. If such a solution is used a small Kelly pad or an improvised one of stork sheeting or rubber may be employed, care being taken not to infect the ear with the solution; but the infant must never be picked up or placed upon the lap of the nurse. The doctor in charge issues orders as to drops, method of irrigation, solution, schedule of ice applications, etc. He may vary this treatment with hot applications. These can be ap- plied in the same manner, an electric or alcohol stove supply- ing heat for the solution. 22 338 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 165.—Technic of irrigating eye with medicine dropper and permanganate solu- tion. The child must be drawn to the head of the table and its body elevated if large amounts of solution are used. A small Kelly pad or rubber must be placed under the lowered head and empty into a pail. OPHTHALMIA NEONATORUM. 339 These cases always require two nurses. The feeding, bath- ing, proper disinfection of discharges and linen, preparation of dressings, treatments, etc., demand the utmost care in technic, and the care of the mother becomes a grave matter to prevent further infection. They require strict isolation, if an epidemic is to be averted, in a home, institution, or hospital, and the responsibility for Fig. 166.—Thumb forceps. spreading infection rests most often with the nurse. The dis- ease may last for weeks or may be of a less virulent type. Ophthalmia neonatorum is a serious condition which may result in total blindness, but if suitable treatment is adopted at the very outset of the disease and intelligently carried out the sight can usually be saved. The entire treatment is, of course, under the direct supervision of the physician, and in severe cases he will often, deem it best to call an oculist in consultation. A NURSE'S HANDBOOK OF OBSTETRICS. Icterus neonatorum (jaundice of the new-born) is a fairly common condition of somewhat uncertain origin, but be- lieved by many to be due to infection of the umbilicus. It often appears in its milder forms among strong, healthy infants, the yellow color of the skin showing first on the second or third day and increasing in intensity until the ninth or tenth, when it begins to disappear. No treatment is required unless the in- fant shows symptoms of severe constitutional disturbance, and in the vast majority of cases a favorable outcome may be ex- pected. Winckel's Disease.—This is a very rare and fatal septic Fig. 167.—Spina bifida of dorsal lumbar region. Infant forty-eight hours old. Died when ten days old. (Rotch.) disease of new-born infants, marked by icterus, hemorrhage, bloody urine and cyanosis with malignant jaundice. The cause is not clearly known. The poisons which cause these symptoms are said to be connected with the rapid metabolism of labor. The symptoms resemble pernicious vomiting or acute atrophy of the liver. The intense jaundice is found with hemorrhage or fatty degeneration. Among other causes suggested are over- doses of chloroform to the mother, and asphyxia, which is usually associated with it. The nurse by close observation of symptoms may secure immediate orders, and prompt measures may possibly prevent the development of this condition. Spina bifida (Fig. 167) is due to the congenital absence of SPINA BIFIDA. 341 one or more vertebral arches, usually at the lower part of the spine. This allows the membranes covering the spinal cord to bulge outward, forming a soft fluctuating tumor filled with Fig. 168.—Spina bifida. Spontaneous cure. Male, four and one-half years old. (Rotch.) cerebrospinal fluid. The tumor is diminished by pressure and enlarges when the infant cries. The disease is usually fatal, al- though a certain few cases have been cured (Fig. 168). The most common outcome is ulceration of the sac followed by its 342 A NURSE'S HANDBOOK OF OBSTETRICS. rupture and the escape of its contents. Convulsions then occur, and death follows within a few hours. When the tumor is very small and shows no signs of increas- ing in size, it may merely be protected from injury and infec- tion by carefully applied dressings, but the more severe cases are treated surgically if at all. Mastitis (inflammation of the breast) is occasionally seen in very young infants of either sex. The affected breast be- comes swollen, tense, hot, red, and painful, and the disease usually appears during the first two or three weeks of life. The breast is to be anointed gently with camphorated oil and pro- tected from injury by a soft, loose, cotton dressing. In other respects it is to be left severely alone, and under no circum- stances should it be squeezed, rubbed, or massaged. Nearly all cases will recover without any trouble, but if, as may pos- sibly happen, an abscess should form, it is to be treated sur- gically. A vaginal discharge of blood is not an uncommon oc- currence among female infants, the flow appearing a few days after birth, and usually causing the parents considerable anxiety. It is of no consequence whatever, and will disappear of itself in a few days without any treatment. Umbilical hernia (rupture at the umbilicus) may appear during the first few weeks of life, but usually not until a later period. The tumor may be made to disappear entirely on pres- sure but reappears when the pressure is removed and the child cries. This is due to a weakness in the navel opening of the ab- dominal wall caused by non-union of the recti muscles. The condition usually disappears spontaneously, but should the pro- trusion of omentum persist a two-inch strip of adhesive plaster will close the opening. Hernia buttons act as a wedge and pre- vent the reduction of this hernia. A pasteboard circle, one inch in diameter, covered with gauze may be placed under the strip, over the protrusion. Other hernias occasionally are observed. They require pres- sure applied and are usually outgrown. CONGENITAL CYANOSIS. 343 Umbilical vegetations are sometimes seen after the cord has separated, in the form of little red friable tubercles varying in size from that of a pin-head to that of a large pea. The vege- tations bleed readily, and are merely redundant granulations and of no special consequence. The physician can usually cure them promptly by removal with scissors or cauterization with nitrate of silver ("lunar caustic"). Constipation should be early recognized. It is not often met with. If the bowels have not moved in two days a saline enema is usually ordered. The nurse will know if there is a malformation, or whether the rectum is impacted. If malforma- tion is the cause, the constipation is not relieved by enemata of saline two ounces at a time, or an injection of two ounces of olive oil. This condition is a very serious matter. Hirsch- sprung's disease, an idiopathic dilatation of the colon, may be the cause. This condition, as well as the absence of an anus, require surgical treatment if the infant's life is to be saved. Castor oil or a laxative is usually ordered to clear the intestinal tract of the meconium and mucus. This generally solves the question of the cause of constipation. Water in sufficient amount with proper nursing and an occasional saline enema will soon establish a habit movement. Massage must not be given until after the cord is lost. The physician gives ample instructions concerning the treatment, whatever the cause. Congenital cyanosis occurs in those cases known popularly as " blue babies," and manifests itself at any time from a few hours to a few weeks after birth. The infant's body and, es- pecially, its face and extremities acquire a dusky bluish or purplish hue, which may be almost imperceptible when the child is resting, but which is very marked after exertion of any kind. The condition is due to a congenital defect in the circulatory apparatus, usually in the heart itself, which interferes with the flow of blood through the lungs, and so deprives the infant of its proper amount of oxygen. Most of the cases die in early infancy, although some may live to be ten or twelve years old. The only treatment is that directed towards the comfort of A NURSE'S HANDBOOK OF OBSTETRICS. the little sufferer, and consists of inhalations of oxygen to re- lieve urgent symptoms, and rest, quiet, good hygienic surround- ings, and nourishing food of'a simple character. Brandy or other stimulant may be given when the dyspnoea is severe, but no treatment can have any curative effect, and the disease will al- ways prove fatal eventually. Atelectasis, often present in premature infants, is due to several causes, general feeble defective tissues, particularly those of the nerve centres and lungs. It is taught by some that the special causes are hepatization, injuries to the brain, and pleural effusion. Frequent altering of position, artificial respira- tion, shaking, alternate cold and hot baths, holding the nose and mouth closed, and oxygen are said to be beneficial. In short, the Fig. 169.—Opisthotonos. The characteristic convulsion of tetanus. methods used to combat asphyxia are indicated in the treatment of atelectasis. The development of its muscles must be a very gradual process and every effort made to save the child from all forms of strain. To survive, it will need to be under the con- stant direction of a physician. Tetanus is a very rare disease in this country. It is due to the action of a special germ, the Bacillus tetani, which in the newly born infant enters the system through the umbilicus. The disease begins between the third and tenth day after delivery, and the first symptom noticed is a stiffness of the muscles of the face and an inability to nurse or swallow. This is followed by a contraction of the muscles that control the jaw, causing trismus or " lockjaw," and within ten or twelve hours the spasm extends to the muscles of the neck and back, caus- ing opisthotonos, or a rigid arching backward of the body so that DIARRHCEA. 345 it can rest on the neck and heels with the trunk and limbs above the level of the bed (Fig. 169). As a rule, death occurs within twenty-four hours, but if the child can be made to live for a few days it may possibly recover. If an epidemic of tetanus is prevalent in any locality, it is best for a prospective mother to go to some other place which is free from the disease, for her confinement. The treatment rests wholly with the physician, and, as the patient is unable to swallow, all drugs must be given hypoder- mically. The child must be disturbed as little as possible, for any sound or movement aggravates the condition. Tetanus antitoxin, if it can be secured, combined with stimu- lants and opiates, and chloroform by inhalation when the spasms occur, are the only means we have for combating the disease. Suffocation.—Nurses will always endeavor to arrange for separate sleeping quarters of mother and child. The tempera- ture required by the infant is between 65° and 700 F. The mother requires a cooler atmosphere than this and separate rooms are most desirable for many reasons. Either by malice or accident a very considerable number of infants are overlain. In London alone, in 1900, there were 615 such cases. Mothers showing mental symptoms must be closely watched and the oc- currence is always preventable if the nurse removes the infant from the mother's bed after each feeding. Diarrhoea.—Normally the new-born infant has perhaps two or four stools per day. The colostrum acts as an agent to- ward emptying the bowel of meconium. Some physicians as a routine order castor oil to hasten this process. Occasionally the baby has a movement after each nursing and unless the yellow liquid stools become green and there is mucus and a strong odor with marked excoriation of the buttocks, it is usually quickly controlled when the cause has been found. The fault is most often with the feeding. If the infant is not nursed the oppor- tunity for infection is of course greater than in the breast-fed babies. The doctor usually orders nursing to be discontinued for twenty-four hours, and water or barley water is given; at the same time a dose of castor oil with saline enemas or some 346 A NURSE'S HANDBOOK OF OBSTETRICS. similar treatment is ordered. Nurses must strictly observe the character of the stools and note the same on the chart. The irritated genitalia must be carefully cleansed and kept perfectly dry. Colic—-Most infants suffer from colic at times. The par- oxysm may be more or less acute. If intestinal, an enema of warm salt solution, a warm bath, a hot drink, a hot-water bottle to the abdomen, a few drops of some carminative such as peppermint or wintergreen, or lying upon its abdomen, will generally afford relief to the infant. If the colic is recurrent it should be reported. The doctor may order treatment such as colon irrigation, massage or lavage with external heat, or medi- cines such as castor oil or broken doses of calomel, usually 1/20 or 1/40 grain doses. By this treatment the cause of the indigestion is usually removed unless there is an infection. If inflammation is present there will be tenderness of the abdo- men upon pressure and green stools with mucus, lumps, froth, and a foul odor. If the colic is urinary, hemorrhage and nephritis as well as colic may be present. It is to be relieved by removing the cause. The fever and general auto-intoxication often present may cause cerebral disturbance and convulsions. In this case prompt action is called for, and the doctor is to be notified at the first rise of the child's temperature. Nurses frequently overstep proper bounds in their efforts to relieve colic. No drugs or teas must be administered by the nurse. A colic is always a symptom either of digestive or renal disturbance, and whether simple or not, during the first two weeks of life, calls for an avoidance of drugs that may dis- guise the condition, and the faithful administration of as large a quantity of boiled water as the infant will take. If convulsions appear, the nurse will observe the first painful twitching of muscles of the eyes, face, and body following a general rigidity. The doctor must be promptly notified, and the infant should receive a warm bath, ice cloths to the head and quiet. The temperature of the bath should be ioo° F., and this is gradu- ally raised to iio° to secure relaxation. A thermometer should COLIC. 347 be used and extreme excitement avoided. The child should not be immersed for a longer period than twenty minutes; and the ice application to the face and head must be continued. Upon the doctor's arrival, sedatives or stimulation may be ordered ac- cording to his view of the causative agent. In a new-born baby this may be tetanus, already referred to, injuries received during labor, pneumonia of the new-born, or some other infection. XXIV The Premature and Feeble Infant There are three essential factors in the management of an infant that is puny and feeble whether its low vitality is due to prematurity or to other causes operating on a full-term child. These are: to maintain its body temperature; to provide nourish- ment which it can assimilate readily; and to insure its absolute rest and quiet at all times. The best indication of an infant's ability to fight its own battles after birth is its zueight. The mere fact that the child is born prematurely is of little consequence when compared with the number of pounds that it weighs, and a premature infant of five pounds will, in general, require no more care and attention than a full-term baby that weighs the same. The routine of encasing all feeble, small infants in a cotton jacket and the anointing with warm olive oil, seems to be losing favor with a large number of obstetricians; it is claimed that the body heat is not maintained but the infant on the contrary is refrigerated. The newer teaching anoints the infant, if this is done at all, with benzoinated lard. Aside from a soft diaper, its band, Warren slip and coverings are all wool. The infant lies in absorbent cotton or eiderdown, either in a bassinette or incubator, depending upon the degree of prematurity, and prac- tical possibilities. As a safe general rule for guidance it may be said that babies weighing between four and a half and five and a half pounds are to be kept warm by flannel garments and coverings, in- stead of being regularly dressed, while those weighing less than four and a half pounds should be placed in the incubator; and even larger children whose temperature is subnormal often do better if wool clothing and coverings are used. As soon as a small, feeble child is born it should be well 348 CARE OF PREMATURE INFANT. 349 anointed with warm albolene or benzoinated lard, wrapped in warm flannel and surrounded with hot-water bottles. The cord must be tied with special care, and is to be inspected for bleeding at frequent intervals, for there is a well-marked tendency to secondary hemorrhage in this class of cases. A very warm bed for the infant in the baby basket is pro- vided by using soft pillows, and an even, warm surface is secured by the use of a number of hot-water bottles. Pure wool cover- ings should be obtained if possible, and every effort must be made to prevent a drop in the body temperature. This means great care at birth and immediately afterward. The shock, lack of fat, lack of lung expansion, and radiation all tend to send the body heat rapidly to 930 F. or even less. This, unless arrested by a warm bath, incubator or substitute, will quickly cause death. Large maternity hospitals all receive premature infants and provide efficient care generally. The infant is transported in an incubator ambulance, a small portable contrivance devised by Dr. J. B. DeLee. If no incubator station is within one hundred miles, arrangements can be made and the child successfully in- cubated and nursed at home, especially if mother's milk can be procured. If the child weighs four and one half pounds, or more, it need only be clothed and kept warm in a basket or box as described. The temperature is to be maintained about 850 F., and ventila- tion, moisture and complete freedom from draughts must be secured. Gas or electricity heated incubators are generally installed in the large hospitals. Some stations, however, use no incubators, but a specially constructed incubating room where the tempera- ture, moisture and ventilation are under perfect control. A small room in a private house answering these demands is ideal. In its absence, if the baby weighs less than four and a half pounds an incubator may be rented or purchased and the child (dressed as mentioned above) placed in it at the earliest possible moment. The principle of all incubators is the same, the only differ- ence being in the construction of the various kinds. It has long been known that the air surrounding a premature infant must A NURSE'S HANDBOOK OF OBSTETRICS. - sr Fig. 170.—Electrically heated infant incubator. INCUBATOR. 351 be kept exceptionally warm, and formerly this was accomp- lished by heating the room occupied by the child to a stifling temperature, to the great discomfort of the nurse or other at- tendant. Fig. 172 shows an incubator designed in 1880. Warmth may be supplied by the use of hot-water bottles, water tank, hot air, steam, gas, or electricity. The incubator is nothing but a miniature room in which the infant can lie, and is so arranged that its temperature can be regulated to any desired degree, while the interior can always be inspected through a glass in the top. Beyond this ability to con- trol the temperature perfectly, the only other essential feature of a satisfactory incubator is the apparatus which provides for its thorough ventilation. The incubator is usually heated by means of hot water, and this either circulates through a system of pipes, one portion of which is exposed to a gas or alcohol flame, or the hot water is placed in tanks or bottles in the lower part of the incubator and renewed as often as it cools. In hospitals there may be found installed elaborate electrically or gas heated incubators with more or less perfect devices for securing a continually changing cir- culation with the proper proportions of moisture, heat and fresh air; but in private practice a movable incubator must neces- sarily be used, the principle being always the same. The child lies on a shelf or platform, padded thickly with eiderdown or absorbent cotton, about six inches from the floor of the box and directly over the coil of pipe or the cans containing the hot water, or a large tank. Fresh air enters at the bottom, circulates around the heating apparatus, where it is raised to the proper temperature, passes over the shelf on which the infant rests, and escapes through a ventilator at the top. This ventilator is provided with an ane- mometer, or small revolving fan, to show whether or not there is a free circulation of air. As the warm air escapes from the ventilator at the top of the incubator it will cause the anemometer to revolve, and this revolution will be continuous unless the cir- culation of air is interfered with or the anemometer is out of 352 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 171.—Gas heated infant incubator. INCUBATOR. 353 order. Consequently it must be most carefully watched, and if the motion of the little fan ceases or becomes irregular a prompt investigation must be made; the mechanical device must be kept clean and well oiled. Another method of keeping track of the circulation of air within the incubator depends upon the appearance of the glass which covers the top. This should be clean and dry at all times, and if it becomes moist and cloudy on the inside it is positive proof that the ventilation is not good. A wet sponge (which must be kept wet, and its use alter- nated with another sponge so that the first one may be steri- Fig. 172.—Tarnier's incubator, interior. E, wet sponge; P, partition between lower ana upper compartments; A, tube for escape pf air; T, M, V, b, b, as in Fig. 151. lized) is to be kept in the incubator to moisten the air, but there must be a sufficiently rapid circulation to prevent any of the moisture from collecting on the glass A thermometer, of sufficient size to be read easily, is to be placed by the side of the infant in such a position that it can be seen clearly through the glass, and the temperature of the in- terior must be kept between 88° and 920 F., and with as little variation as possible. It is best to start at 920, and then reduce the temperature very gradually and evenly to 88°, reaching this 23 A NURSE'S HANDBOOK OF OBSTETRICS. point by the end of about a week and holding to it for several weeks longer, as the physician may direct. The electric and gas heated incubators which are found in large hospitals require the same intelligent watchfulness and care to avoid chilling or, what is equally fatal, overheating the infant. Sudden changes in temperature must be avoided absolutely, and thermometer and anemometer be watched constantly, whether the heat control is automatic or not. As the cry of a premature infant is very feeble at best, it is often quite inaudible when the child is shut up in an incubator, and the closest attention must be paid to the condition of the baby at all times. Many persons are of the impression that once the child is placed in a good incubator no further special precautions need be taken, but this is a most mistaken idea. Premature or under- developed infants require the most solicitous care in every way, and to merely keep them at a proper temperature will avail noth- ing unless the other details of their management are carefully carried out. Rest is a most important factor in the rearing of such chil- dren, and they must be shielded from excitement and every dis- turbing influence. Visitors invariably flock to see an unusually small child, and an " incubator baby " will be sure to attract a crowd of curiosity-seekers as soon as its existence becomes known. The nurse must positively refuse to let any one see the child except the members of its immediate family, and these favored few can only be allowed occasional and very short glimpses. All manipulations of the baby must be avoided except for absolutely necessary purposes, such as changing its clothing, ad- ministering nourishment, altering its position, or cleansing its body. The child requires an application of albolene or ben- zoinated lard as the doctor may order, twice a day. The lard, infant, and blanket must be very warm, and all exposure is to be avoided. Occasionally a physician will order gentle passive movements to improve the circulation of the extremities. FOOD FOR THE PREMATURE INFANT. 355 Light is to be curtailed by placing a shawl or other piece of dark cloth over the glass top of the incubator, and loud or sud- den noises must be forbidden. The skin, in these cases, is extremely delicate and tender, and diapers must be changed the instant they become wet or soiled. The child is not to be bathed except as is necessary for cleanli- ness, and when the diapers are changed the buttocks must not be washed with soap and water, but wiped carefully with cotton dipped in warm oil or albolene and then dried with cotton alone. If the child flourishes the doctor may order it taken from the incubator by day and returned at night, also an immersion, for a moment, in water warmer than its body heat, about 1050 F. The cotton jacket is to be changed twice daily, care being taken that the fresh one is warm and ready for instant use the moment the old one is removed, if this treatment has been ordered. If the infant is wearing a Warren gown, and flannel coverlets are used, they must be changed every twelve hours to be properly sunned and aired. The weight and temperature of the child are both matters of the greatest importance, for, as in the case of any baby, if the child loses weight and its temperature goes up, it is an evidence that its food is either insufficient or of improper quality. The temperature is to be taken in the rectum and recorded on a chart every night and morning, and the weight is to be taken and carefully recorded once a day, at the time when the infant is changed. It is unnecessary to say that any rise in tempera- ture or loss of weight must be reported at once to the attend- ing physician. The best food for a premature baby is mother's milk, not only because it is especially adapted by nature to the needs of the child, but because it is very desirable to keep up the secretion of the mammary glands, so that, when the baby grows older and stronger, it can nurse directly from the breast. The milk may be expressed from the breast with the hands or with a breast-pump, and is to be received into a perfectly clean cup and fed at once, before it has had time to cool. 356 A NURSE'S HANDBOOK OF OBSTETRICS. The only breast-pump worth considering is that known as the "English breast-pump" (Fig. 173). This must be kept scrupulously clean and free from any curds or particles of sour milk, and should be boiled each time it is used. The nurse must be very gentle in applying the breast-pump to the nipple, or the delicate tissues may be injured and much trouble result. After the nipple has been thoroughly cleansed, as for a nursing baby, the air is to be forced out of the bulb of the breast-pump and the bell placed gently but firmly against the breast so that the nipple comes exactly in the centre of the opening. The bulb is now al- lowed to expand slowly and gradually, and in a moment or two the milk will be seen to spurt out in two or three very fine jets. Fig. 173.—English breast-pump. As soon as the bulb is fully expanded and full of air the pump is to be lifted from the breast, the bulb again compressed, and the bell again pressed firmly over the nipple as before. If for any reason it becomes necessary to remove the pump from the breast while it is still exerting suction on the gland, a little com- pression of the bulb will restore the pressure within the pump and it will come off of itself. Under no circumstances should it ever be pulled forcibly from the breast, and the use of the breast-pump should never at any time be painful to the mother. In some cases it will be found necessary to combine massage of the breast with the use of the pump, and if the milk does not flow freely when the pump is used the gland should be stroked gently and firmly with the finger-tips from the edges towards FOOD FOR THE PREMATURE INFANT. 357 the nipple. Both breasts should be emptied at each feeding-time and the milk poured into a cup which stands in a basin of hot water, until enough is collected for one meal. It seldom happens that a premature baby is strong enough to nurse from a bottle and the milk must be fed with a spoon, Fig. 174.—Feeder for premature infant. (Rotch.) a medicine dropper, or some other appliance that will do away with all effort on the part of the child. Dr. Breck has devised a " feeder " for premature infants (Fig. 174) consisting of a graduated glass tube with a small rub- ber nipple at the smaller end and a rubber finger-cot at the larger. The cot serves as an air reservoir, and, when the nipple 358 A NURSE'S HANDBOOK OF OBSTETRICS. is placed in the infant's mouth, slight intermittent pressure on the cot will enable the child to get the milk without any effort whatever beyond that of swallowing. To fill the " feeder " the nipple and cot are removed, a cork fitted snugly in the smaller end, and the proper quantity of milk poured in through the larger opening. The cot is then attached to the top, the " feeder " inverted, and after the cork is removed, the nipple is slipped over the smaller end. The care of the breast-pump and nursing-bottle, or " feeder," whichever is used, is of the utmost importance, for, if germs of any sort are allowed to collect in them, the milk will be contaminated and the life of the infant will be greatly endan- gered. The cot and nipple are to be cleansed with soap and water inside and out, rinsed thoroughly, and boiled for five minutes before each feeding. The bottle, or glass portion of the " feeder " or breast-pump, must also be cleansed with the greatest care by scrubbing, rinsing, and boiling. It is well to have a number of " feeders," bottles, nipples, and cots, so that several of each may be boiled at one time and kept in sterile jars until they are needed. When mother's milk cannot be secured, cow's milk, modi- fied in the manner described in Chapter XXV, must be given, but no effort must be spared to secure human milk from some other source. This is generally possible and only as a last resource is artificial food to be considered. The physician must always regulate the strength and quantity of the food, for the problem of feeding a premature child with artificial nourish- ment presents many difficulties, and is too serious a matter for the nurse to undertake on her own responsibility. In general it may be said that the premature baby is to re- ceive food of half the strength and in half the amount, but twice as often as would be given to a full-term child. The feeding by mouth does not require the infant to be taken from the incubator. The babe may not be able to suck or even swallow. It may require feeding by a catheter or by drop- ping from the nipple of the feeder. Medicine droppers are to be avoided. Elaborate tables have been devised to guide in the ~; -^ Mt&zKr §k '1 It ^^j^-^^B Ife • 11 4 11' ^WM^mmm*^^^m m ^ 1 M -Js* ^V jlPv * a. _________- Fig. 175.—Infant premature at thirty weeks. Birth-weight, four and one-quarter pounds. Treated in incubator sixty-four days. Age, nine months. Weight, seventeen and one-half pounds. (Rotch.) FOOD FOR THE PREMATURE INFANT. 359 amount and times the infant is to be fed. The physician will at all times give definite orders, as over-feeding a premature in- fant is easily done. On the other hand, starvation is often the cause of its death and is evidenced by a steady loss in weight and vitality along with increased stupor. The feeding in every case must be regulated to meet the needs of the particular baby under treatment, but if the manage- ment is at all successful at the outset it will not be long before milk of the usual strength for a normal infant of corresponding age can be given with safety. The beginning may be made with one-half to one drachm every hour, day and night, the time and amount gradually in- creasing. The first few days it may be ordered diluted with water. When nursing is begun, persistence is required to induce the tiny babe to take the breast. A shield with small nipple may be used or the use of a teterelle may be ordered. It must be fed boiled water at regular intervals. The infant may be overcome by exhaustion or regurgitation. It may require that oxygen be given to prevent asphyxiation. It requires ceaseless vigilance on the part of a nurse at all times and the history notes must be complete. The nurse will often be asked if a premature infant will ever develop as well and be as strong and sturdy as one born at term. If it escapes asphyxia, atelectasis, starvation, pneumonia and other infections, and can be made to live and thrive during the first few weeks, there is no reason why it should not ultimately be as robust and healthy as any other baby. Licetus, Helmholtz, Goethe and Kant are said to have been premature infants. XXV Infant Feeding The best food for a baby is that designed for it by nature,— breast milk. The best breast milk is that furnished by the infant's own mother, and the next best is that from another woman acting as a wet-nurse. If the child's mother is unable to supply milk of a proper quality and in sufficient amount for its needs, and if the services of a suitable wet-nurse cannot be secured, the next best food is cow's milk, properly modified to meet the requirements of the child. Whenever the mother is able to do so she should nurse her infant as far as she can, and then make up the deficiency with modified cow's milk; for even a limited quantity of breast milk is better for the child than none at all, and the effect of nursing not only stimulates the breasts to the production of better milk from day to day, but greatly aids the process of involution by which the uterus and other pelvic organs return to their normal condi- tion after labor. Breast milk is to be preferred to any modified milk, no matter how carefully prepared, for the reason that it is exactly what the child requires, while the other is at best only an imitation; it is absolutely free from germs, while cow's milk always contains a certain number of bacteria; it is delivered to the child in proper quantity and at a proper temperature, while bottle food may escape through the nipple either too rapidly or too slowly, and is often too hot at the beginning of a feeding and too cold at the end. Moreover, the bottles and nipples are apt to become sour even when the utmost attention is given to their care; the quality of the milk is always liable to vary; and errors not infrequently occur in the preparation of the food. Hence we have to consider four distinct methods of feeding, named below in the order of their respective values: 360 MOTHER'S MILK. 361 I. Mother's milk. 2. Wet-nurse. 3. Mixed feeding. (Partly breast milk and partly modified cow's milk.) 4. Artificial feeding. (Modified cow's milk exclusively.) Mother's Milk.—Before we can expect a mother to furnish good milk for her infant we must see to it that her breasts are in the best of condition for performing their functions (Fig. 176). This necessitates the adoption of measures early in preg- Fig. 176.—Soft, flabby breasts. Not well adapted to nursing. nancy that will prepare the mammary glands for the work that lies before them. These measures have already been discussed in the chapter on the Management of Pregnancy, but will be reviewed here briefly. The breasts should be bathed night and morning with soap and tepid water, to keep the skin in good condition, and rinsed after each morning bathing with cool or even cold water, accord- ing to its effect on the patient, to stimulate the activity of the glands. During the last two months of pregnancy the nipples are to be anointed with white vaseline or albolene every night, and this is to be washed off carefully in the morning to remove 362 A NURSE'S HANDBOOK OF OBSTETRICS. any crusts of dried colostrum that may have formed. This dry- ing of colostrum on the nipples is one of the most potent factors in the causation of soreness or tenderness of these organs, and the daily application of the vaseline or albolene effectually pre- vents the colostrum from " crusting" and so irritating the deli- cate tissues of the parts. If the nipples are short or flattened, they should be drawn out with the thumb and forefinger every night and morning and held in this position for at least five minutes. This simple procedure, practised regularly twice daily during the last eight or ten weeks of gestation, will often work wonders with nipples so small or flat that nursing is, at first, apparently out of the question. The condition of the woman's general health has much to do with her ability to furnish good milk, and it goes without saying that corsets or other garments that compress the chest will inter- fere seriously with the development of the breasts. Assuming that everything is favorable for nursing, the child is not to be put to the breast until the mother has had a good rest from the effect of her labor, and, if possible, not until after she has had a nap of a few hours. Usually the baby can begin its nursing about four or five hours after birth, after which it is to be put to the breast regularly, every four hours, day and night for the first two days. During this time the breast secretes nothing but colostrum, a laxative substance containing prac- tically no nourishment whatever. If the infant does not seem satisfied with this diet of colostrum, the nurse may give it a five per cent, solution of milk-sugar made up with boiled water. One teaspoonful of sugar to twenty of water makes the solution in the required proportion, and it is best given in an ordinary two-ounce vial fitted with a small rubber nipple (Fig. 177). If a small enough nipple cannot be obtained, one may be impro- vised by taking the rubber cap of a medicine dropper and piercing it with a good-sized needle. At or about the end of forty-eight hours the true milk begins to appear in the breast, and the infant should now be nursed every two hours from six a.m. to ten p.m., with one night feed- ing at two a.m. This plan gives the mother two uninterrupted HOURS FOR NURSING. 3^3 periods of four hours each for sleep, and it is to be adhered to until the child is six weeks old, after which the intervals Fig. 177— Two-ounce vial with nipple. For administering nourishment, water, or sugai solution to a very young infant. between the feedings can be increased gradually until the fourth month is reached, when the night feeding can often be omitted entirely. For convenience of reference the hours for nursing may be tabulated as below: First two days......................Every four hours. rr>- , , . • ., , f 2, 6, 8, IO, 12 A.M. Third day to sixth week..........< ' ' ' ' t- 2, 4, 6, 8, 10 p.m. Six weeks to ten weeks..........\ '■* ' '' "-3 » *- 2.30, 5, 7.30, 10 P.M. Ten weeks to four months.........< -3 > 7» 11, 4, 7, 10 P.M. Four months to nine months......\ '' 11, 4, 7, 10 P.M. Of course, different meal-times might be chosen with the same intervals between, but the hours given are those which are least likely to interfere with the meals and other affairs of the 364 A NURSE'S HANDBOOK OF OBSTETRICS. household. Nurses, and physicians as well, will find it a great convenience to adopt the same feeding hours for all normal infants coming under their professional care, for this plan will do away entirely with the possibility of any confusion or mis- understanding as they go from one family to another. The child can easily be " started " at six o'clock every morning for the first six weeks, and this will bring the other meal-times right for the entire day. Afterwards the mother may be allowed to sleep until seven o'clock before the regular daily programme is begun. Some physicians may vary this routine according to the special needs of the infant. The feeding period is lengthened to two and a half, three, or even four hours if the child is large and steadily gains in weight. At least four ounces per week or over is the normal gain. If this gain is not shown by an accurate weight chart the food is not sufficient. Immediately before and after each nursing the entire breast is to be bathed gently with tepid water and a little castile soap, and the nipple washed off with alcohol (95 per cent.). The utmost gentleness must be exercised in cleansing the infant's mouth, for the tissues are extremely delicate, and if any force is used abrasions may be caused which may afterwards serve as starting-points for infection. For this reason a sterile wipe of cotton or linen saturated in a borax solution or plain boiled water may be used to remove particles regurgitated upon the gums or tongue. The danger from injury is greater than that from food; and the mouth cleansed carefully in the morning needs no further swabbing out, except to remove particles of food. The effect of the warm water on the breast is to favor the flow of the milk in the first instance, and after the nursing is over it adds greatly to the comfort of the patient by removing any of the secretion that may have trickled down over the skin. The alcohol (itself an antiseptic) sterilizes and probably tough- ens the nipple, and as it evaporates almost instantly it cannot exert any harmful effect on the infant as might be the case with ordinary antiseptic solutions made up of more or less CARE OF THE BREASTS. 365 poisonous drugs. The breasts should have an application of sterile lanolin at night. Both the alcohol and lanolin are to be applied with sterile cotton sponges on applicators. The cleans- ing of the infant's mouth is for the purpose of removing any curds or other substances that might, by decomposition, infect the nipple or cause trouble to the child. When the true milk begins to appear in the breast (about the second or third day), the patient is apt to suffer somewhat from a feeling of fulness and tenderness in the distended organs. This can be relieved by the application of a well-fitted and fairly snug breast-binder, so adjusted that it will raise the breasts up on the front of the chest and prevent them from hanging down at the sides and " dragging." After the binder has been placed in position under the patient's back and is ready for pinning, the breast on one side is to be raised up as high as possible over the chest wall, a pad of absorbent cotton about the size of the hand placed at its outer side, and held in this position by the patient herself while the other breast is treated in the same way. This will bring the two breasts close together in the median line, with a deep furrow between them, and it is well to place a small strip of absorbent cotton in this depression be- tween the organs to absorb perspiration and any possible excess in the secretion of milk. The milk at this time and for the next few days is apt to flow very freely and in much greater amount than is needed by the child, and other little pads of absorbent cotton should be placed over the nipples to take up the overflow and keep the clothing sweet and clean. These pads must be changed at very frequent intervals, for if any sour milk is allowed to collect it will not only tend to make the nipples sore, but it may seriously affect the child as well. The binder is, of course, to be unpinned for each nursing and replaced again as soon as the child is through and the breasts have been thor- oughly cleansed. It can usually be discarded entirely after a few days, and it must be remembered that its only purpose is to support the breasts, and that if too snugly pinned it will compress the organs and interfere with their functions. If the child is to nurse properly it must be properly held by 366 A NURSE'S HANDBOOK OF OBSTETRICS. the mother, and while most women seem to know instinctively how to support an infant at the breast, many are so awkward about it that definite instructions must be given them. First of all, the baby must be comfortable, and so placed that it can reach the nipple without any effort. Its head and shoulders should rest on the arm corresponding to the breast to be nursed, and the mother's other arm should reach over the child's body so that the hand can support its back. This is much more easily managed when the woman is sitting up, but during the early days of the puerperium the patient is, of course, on her back in bed. At this time a small pillow placed under her elbow is of great assistance to her in supporting the weight of the child, and when she is able to be up she should use a chair with arms, on which she can rest her elbow or upon which a pillow or cushion can be placed when the infant is at its meal. Feeding too rapidly, too slowly, allowing the infant's position to interfere with his breathing are points to be guarded against by the mother. The child should be made to understand that it is to begin nursing as soon as it is put to the breast, and it should con- tinue to nurse vigorously, with occasional brief rests for breath- ing, until its meal is finished, when it is to be removed at once and laid in its bed. A baby that " dawdles " at the breast, or one that is fretful and peevish, either is not hungry or there is some fault with the milk, the nipples, or with its own ability to nurse. In any event, such a child should be taken from its mother's arms as soon as a fair trial shows that it is not going to nurse properly, for it is the worst possible policy to keep a crying child at the breast for a long period when it is obviously unwilling or unable to take its nourishment. It should be kept away for a full interval, or until another feeding time comes round, when it will probably have learned what is expected of it and proceed to its duty properly and without delay. If, however, it continues to refuse the breast after this has been done, the physician should be consulted. He may find that the quality or quantity of the milk is at fault, that there is trouble VOMITING AND REGURGITATION. 367 with the nipples, or that the infant itself is ailing in some way. Possibly the infant may be found to be suffering from tongue- tie, cleft-palate, thrush, or Bednar's aphtha. If everything is satisfactory the baby should nurse heartily at its regular meal-times, which, of course, grow farther and farther apart as the child's age increases. It should be hungry as each feeding time comes round, satisfy itself in at least twenty minutes, and at the end of the meal fall into a comfortable, drowsy condition or even drop off to sleep. The infant should be weighed every day and its weight ac- curately recorded in pounds and ounces. It will be found that during the first few days of its life it will lose weight in every case, because its food, being chiefly colostrum, contains very little nourishment and it is obliged to live on its own fat. This initial loss in weight is always to be expected, and usually amounts to about ten ounces, after which the child begins to gain, and should be back to its original birth-weight by the time it is ten days old. Thus there is a normal initial loss of ten ounces in weight, normally regained in ten days' time. From this time on the child should gain steadily from day to day, until at the age of six months it should weigh twice as much as it did at birth. Besides gaining regularly in weight and strength, a baby should be happy and good-natured when awake, but inclined to sleep a good part of the time between nursings. It should be hungry at its proper nursing times, but not before, and its diges- tion should be perfect, as evidenced by the absence of vomiting and the passage of smooth, bright yellow stools entirely free from curds or mucus. Vomiting must not be confused with " regurgitation," which is a purely normal process by which the stomach gets rid of an overload of food. Vomiting is always accompanied by the symp- toms of nausea. It may occur at any time, but usually long after nursing. The child cries, grows pale, and even blue, about the mouth, develops a cold sweat on the forehead, and, with more or less effort, expels a quantity of sour, bad-smelling, 368 A NURSE'S HANDBOOK OF OBSTETRICS. curdled milk from the stomach. This process may be repeated at frequent intervals, and the child is evidently sick. Regurgi- tation occurs immediately after nursing and at no other time. The baby is bright and happy, and merely opens his mouth and lets the excess of milk run out on his dress. It is, in other words, nothing more than an overflow, and, far from doing the baby any harm, does him good by relieving his distended stomach. The milk is not sour, and the baby is obviously perfectly well. Occasionally a child appears to be hungry between feeding- times, when in reality it is only thirsty, and it should be given small sips of tepid boiled water until it has satisfied its thirst. There is no danger of giving it too much water, and it should be allowed to drink until it stops of its own accord. In this way loss of weight may be controlled to a slight degree. In no case should the baby be put to the breast more fre- quently than at the regular feeding-hours already named, for a young infant requires nearly two hours in which to digest its food, and if it is nursed too often one meal will be taken into the stomach before the preceding one is digested, with the result that vomiting and indigestion will occur. As the child grows older it takes more milk at a nursing, and a longer period is required for the digestion of its food, so that the intervals between the nursings are necessarily lengthened. The point is to give its feedings far enough apart to allow the stomach a short period of rest before each nursing. Usually the milk from one breast will be enough for a very young infant, in which case alternate breasts should be used for each nursing, but as the child grows older it will be neces- sary to put it to both breasts at every -feeding. There is no harm in doing this at any time, provided the milk of one breast alone does not seem to be in sufficient quantity to satisfy the child. The baby should never be played with or disturbed soon after a nursing, for such excitement will almost surely inter- fere with digestion and cause vomiting and other disorders of a INSUFFICIENCY OF MILK. 3^9 serious nature. In fact, a child should never be played with at all until it is past six months old, but allowed to devote all its energies to eating, sleeping, and developing in every way. When, after every precaution has been taken to secure proper milk for the child, the food is still not digested, the trouble, if not with the child itself or with the condition of the nipples, can usually be traced to alterations in the quantity or the quality of the breast milk. If the quantity is at fault, and the baby is not receiving enough nourishment (a condition known as agalactia), the fol- lowing signs will serve to indicate the nature of the trouble. 1. The baby will wake before its regular nursing time and be obviously hungry. It will cry and fret, refuse water with apparent disgust, and, when nursing is permitted, seize the nipple ravenously and nurse with great vigor. 2. It will continue to nurse long after the breast is empty, in its effort to secure enough food, and will cling to its mother and cry in a fretful way when an attempt is made to remove it from her arms. As has been said, a normal child, receiving normal milk, should be perfectly satisfied within twenty minutes at the most, after which it should drop the nipple of its own accord. 3. The breast itself, when examined just before a nursing hour, will not be full of milk as it should be, and on prolonged palpation it may be impossible to express any milk at all from the nipple. When the meal-time arrives the breasts should, under normal conditions, be firm and tense but never painful, and very slight pressure should be enough to cause the milk to escape in fine jets. 4. The child's weight will go down and its temperature will go up. In the chapter on the Care of the Normal Infant stress was laid on the importance of keeping a careful daily record of its morning and evening temperature taken in the rectum, for the onset of fever, coupled with a loss of weight, is one of the most significant indications that the amount of nourishment is not sufficient. With these four points in mind, the nurse should have no 24 A NURSE'S HANDBOOK OF OBSTETRICS. difficulty in knowing when the amount of milk secreted is too small. To increase the milk flow the condition of the mother's health should be looked into carefully, and she is to be shielded as much as possible from worry, grief, overwork, or other causes of low vitality. If coffee is included in her diet, it should be stopped entirely, for this beverage has a decided ten- dency to diminish milk secretion. She should drink milk, or cocoa, in its place, and extra milk should be taken between meals and at night before retiring. It must be remembered, however, that too much milk is apt to upset the stomach, especially in certain individuals, and lime water or vichy should be added to each glassful as a preventive against this form of gastric dis- turbance. If symptoms of indigestion develop, the milk should be stopped at once, and dispensed with until the stomach is again in good working order. There is great uncertainty regarding the value of any special foods to stimulate the milk secretion. Many foods on the markets have strong advocates among physicians, but the final value to the mother is questionable. If the milk taken cannot be properly digested, a starchy diet with large amounts of fluid may be given. Beets and all kinds of shell fish, noticeably crabs, are said to increase the quantity of milk to a marked degree. The tendency at present is to place the strongest hope upon stimulations of the body and the gland itself. Massage with cool baths and dry rubs, electricity, and breast massage may affect the amount secreted. Great patience is often required before the mother is re- warded. The present-day teaching is so overwhelmingly in favor of a woman nursing her infant that the nurse is urged to carry out with every faithfulness all orders that will make this possible. The infant's chances for life are doubled. The doctor will decide if the gland cannot secrete, or is diseased, or if further stimulation is unadvisable. An excessive flow of milk (or galactorrncca) is of rare oc- currence after lactation is fully established, but when it does occur to such an extent that it soils the patient's clothing and CHEMISTRY OF MILK. 371 keeps her in a constantly uncomfortable condition, it may often be checked by the administration of one or two cups daily of strong black coffee. This may be varied with the usual with- drawal of fluid and elimination. If belladonna is applied ex- ternally the effect must be closely watched. If the quality of milk is at fault the case will probably have to be referred to the physician. Up to this time no mention has been made of the chemical constituents of milk, but unless a nurse has a fair knowledge of these matters she cannot understand the subject of infant feed- ing in an intelligent way. Milk is a natural emulsion, and consists, roughly speaking, of 13 per cent, of solids and 87 per cent, of water. The solid substances are fat, sugar, proteids, and salts, and of these it is only necessary to consider the first three, for the salts are unimportant in many ways and never vary much. The fat of milk is the cream, the sugar is the kind known as " lactose," or " milk-sugar," and the proteids make up the curd. In good specimens of mother's milk there is, approximately, four per cent, of fat, seven per cent, of sugar, and two per cent. of proteid. It will be seen that this makes up the entire thirteen per cent, of solid matter, but, as a matter of fact, the true proportions are slightly less than the round numbers given, leaving room for a small percentage of salts. Normal mother's milk, as it leaves the breast, is a sterile fluid, absolutely free from germs, blood-corpuscles, or pus-cells. It should have an alkaline, possibly neutral, but never an acid, reaction, and its specific gravity should be from 1027 to 1032. Colostrum cells should be absent after the twelfth day, and the fat cells should be small, numerous, and of uniform size. The proteids of milk vary directly with the specific gravity, —that is, the higher the specific gravity the higher the proteids, and vice versa. If we know the amount of cream in a given specimen of milk, it is possible to make a fair estimate of the proteids in a very simple way. Professor Holt, of the College of Physicians and Surgeons, has devised a little apparatus, con- sisting of an hydrometer and jar, for ascertaining the specific 372 A NURSE'S HANDBOOK OF OBSTETRICS. gravity of milk, a pipette, and two long graduated cylinders with glass stoppers, for estimating the percentage of fat. The milk to be examined is to be taken from the middle of a nursing, or, if it is removed from the breast artificially, after about half the entire amount has been extracted. This milk is put into one of the glass cylinders with the pipette and should fill it exactly to the graduation marked O. If specimens from both breasts are to be examined at the same time, both cylinders are used. The cylinders, properly filled and securely corked, are set away in a temperature of 700 F. and left undisturbed for twenty-four hours, after which time the cream line will be distinctly visible and the percentage may be read on the scale. But this is cream and not fat, which is to the cream as 3 is to 5. Thus, if a specimen of milk shows seven per cent, of cream, we have: Fat : 7 : : 3 : 5, or four and one- fifth per cent, of fat. The estimation of the proteids is not quite so simple, but it is by no means difficult. We can determine accurately the amount of fat in a given specimen, and fat, being the lightest part of the milk, tends to lower the specific gravity; so that the more fat in a specimen the lower the specific gravity would naturally be. Proteid, on the other hand, is the heaviest part of the milk, and the greater the percentage of proteid, the higher will be the specific gravity. Hence: (a) If both fat and specific gravity are high the proteids must also be high, or the amount of fat will bring down the specific gravity. (b) If the fat is low and specific gravity high, the proteids are probably about normal, the high specific gravity being due: to the small amount of fat in the specimen. (c) If the fat is high and the specific gravity low, the pro- teids are again probably about normal, the low specific gravity being due to the large amount of fat. (d) U both fat and specific gravity are low, the proteids must also be low, for otherwise the small amount of fat would make the specific gravity high. VARIATIONS IN QUALITY. 373 In collecting the milk for examination great care must be taken to handle it as little as possible, and the glass cylinders for making the cream tests must be scrupulously clean, or the milk may sour before the cream has had time to rise. If at the end of twenty-four hours the cream line is not sharply defined, the specimen may be allowed to stand six hours longer before the percentage is recorded. Any marked variations in the proportions of fat and proteids, and the presence of any foreign substances in the milk, such as blood or pus, will cause, in the infant, indigestion of a more or less serious degree. The most common form of disturbance is that due to an increased percentage of proteids, and is evi- denced by constipation and the presence of curds in the stools, If the condition is not corrected promptly, serious illness may result. When fat is present to an excessive degree the infant vomits and has diarrhoea. It is not difficult to keep these two sets of symptoms in mind when it is remembered that the pro- teids, being the curd of the milk, would, if in excess, naturally cause curds in the stools; and that the fat, being an oil, would, if in too great amount, tend to the production of diarrhoea. Both fat and proteids are increased by a diet that is largely of animal food and diminished by one consisting chiefly of vegetables. In cases where the proteids are in too great amount it might be possible to remedy the matter by putting the woman on a vegetable diet and then, if necessary, making up the de- ficiency in fat by giving her cream to drink. Fright, worry, pain, or any other nervous shock, increases the proteids in the milk, and the patient must be shielded from these disturbances as far as possible. Menstruation increases the proteids, but the increase depends largely upon the amount of pain that the woman suffers at this time. Not long ago it was thought best to stop nursing entirely if the menstrual function returned during lactation, but it has been found wiser to be governed by the amount of suffering that the woman undergoes, and not take the child from the breast unless the mother's pain is extreme and the infant plainly shows the effect of the change in the milk. Ordinarily it is better to A NURSE'S HANDBOOK OF OBSTETRICS. let the baby undertake the extra digestive strain for a few days each month than to risk an entire change in diet. The presence of blood or pus in the milk is an absolute indication for stopping all nursing at the affected breast. This condition is usually due to injury or inflammation of the breast, and if the milk remains after an apparent cure, the child must not be allowed to nurse until, by microscopic examination, it is known that all evidences of suppuration have entirely disappeared. Pregnancy, when occurring during lactation, causes a marked decrease in the percentage of fat. It is another, and the only other, positive indication to stop nursing entirely. The milk is not good for the child, and the mother cannot properly nourish herself, her baby, and the fcetus in utero, while the reflex connection between the breasts and the uterus would make nursing under such conditions a very probable cause of abortion. As has been said, the presence of blood or pus in the milk and the occurrence of pregnancy are positive contraindications to nursing; and of the other conditions may or may not be, according as they can or cannot be corrected by diet or other treatment; and lastly, there are some women whose milk is apparently perfect in every respect and yet who cannot nurse their children because, from some unknown reason, the milk does not and cannot be made to " agree." Wet-Nurse.—Theoretically the wet-nurse is the best substi- tute for mother's milk, but practically it is usually better to try " mixed feeding " or adopt artificial feeding entirely. The wet- nurse is not easily secured; she is expensive, and usually an ex- treme care, causing trouble with other servants and making her- self generally unpleasant in her assurance that the family will put up with anything rather than have the baby's food changed again. The majority of wet-nurses are unmarried women secured from some public maternity hospital, as women with homes and husbands are not apt to neglect their own children in this way, and the probable, if not actual, lack of morality in the nurse is an added reason for making her an undesirable member of the family. Aside from this, however, an unmarried woman usually makes the best wet-nurse, not only because she parts with her MIXED FEEDING. 375 own baby with little or no regret, but she has no husband to appear at frequent intervals and demand her wages or upset the entire household by threatening to take her away. In selecting a wet-nurse a woman should be chosen whose baby is as nearly as possible of the age of the baby for whom her services are required. She should be a woman of neat and cleanly habits, and, preferably, one of more or less phlegmatic disposition, and both she and her child should be examined by the physician for evidences of disease of any and every sort. As has been said, a single woman usually makes a better nurse than one who is married, and the fact that the married woman has lost her infant through death does not help matters any, for her grief will usually be enough to spoil her milk. If the unmarried woman is physically all that could be de- sired, she should be given the preference, for the essential thing is to secure a good food for the baby. The question is often asked if there is not danger that the baby will acquire the disposition and character of the wet-nurse, and the best answer is that the proba- bilities are exactly the same as that a bottle baby will take on the manners and morals of a cow. Milk is milk, and if it agrees with the baby its source is a matter of no consequence whatever. After the nurse has been selected and the baby given into her charge the general directions governing the feeding are the same as when the infant nurses at its mother's breast. Mixed Feeding.—This is the method to be adopted when the mother has some milk, of good quality, but not in sufficient quantity to fully satisfy the child. The hours for feeding, according to the age of the child, are the same whether the baby is at the breast or on the bottle, and if the mother has not milk enough to satisfy her infant at every feeding she can often skip one or two nursing hours and give modified milk in place of the omitted breast feedings. This plan should always be tried when the quantity of breast milk is below normal and its quality is good, for, as has been said, it is better for both mother and child to have the breast milk utilized as far as possible. 376 A NURSE'S HANDBOOK OF OBSTETRICS. The modified milk to be used in mixed feeding is prepared in the proportions suited to the age of the child and given in the same quantity that would be allowed if the baby were exclusively on the bottle. Artificial Feeding.—This is a most important subject and one that can only be considered here as it may be applied to a normal and perfectly healthy infant. The various patented baby foods will not be discussed in any way. Directions for their use go with every bottle, and while each one claims to be better than all the others, and proves its claims by the publication of pictures of fat and usually rhachitic babies, they are all more or less bad and of no real value except in certain cases where they may be used by the physician's direc- tion to tide over a period of travel or to increase the carbohy- drates in a food greatly diluted to remove its proteids. Condensed milk, like the patented foods, contains too much sugar and too little fat to give it any value except on occasions, and while it also makes fat babies, these children, like those fed exclusively on the advertised baby foods, have no real honest strength and are liable to break down in childhood at the first attack of any serious disease. Mothers often point with pride to healthy grown children, and state that they were brought up on this, that, or the other food, but the fact remains that if they had been attacked by any serious disease of infancy they would have died, when babies fed on modified cow's milk might have weathered the gale without difficulty. The explanation is that these children were fortunate enough to escape any severe disease until they had been on a general diet long enough to enable them to resist it. That the " baby-food babies " are fat is merely because sugar makes fat. and these foods are chiefly composed of sugar, which is necessary as a preservative, just as the housewife adds sugar to her " preserves " to keep them from spoiling. Goat's milk and ass's milk are not worthy of consideration, although it is true that their constituents approach more nearly the proportions of breast milk than do those of cow's milk. The objection to their use lies in the fact that they are not ARTIFICIAL FEEDING. 377 exactly the same as mother's milk and must be modified with as much care and attention as is paid to the preparation of cow's milk. The only milk worthy of serious consideration as a substi- tute for breast feeding is that obtained from a herd of healthy cows. The milk from one cow, so long regarded as best for bottle feeding, is no longer used. It was formerly supposed that " one cow's milk " was less liable to change than that from mixed milkings, but it is now known that while the milk from a herd preserves a very constant average of quality, that from one cow is always subject to marked change. Laboratories exist in all large cities, which fill prescriptions for modified milk. They are known to be reliable and the doctor is assured there will be no error in the product. For this reason, where available, the feedings are purchased as ordered. Some hospitals maintain a diet kitchen service for the benefit of physicians requiring such a convenience. Occasionally one will be maintained in connection with a Nurses' Directory. All milk stations give instruction in milk modification, and such instruction is an important feature in the work of a Public Health Nurse. It is, however, quite possible for mothers to do this properly in the home and if systematized this consumes but little time. Where bottled milk is unattainable, cream may be removed from a pan with care and fat free milk siphoned from the bottom. The milk sold in bottles in the cities is usually of fairly good quality, owing to existing laws regulating the management of dairies and the shipment and sale of milk. The best bottled milk to be had in New York is that known as " certified" or ''guaranteed," milk and sold by certain dealers only. This dif- fers from ordinary bottled milk only in that it is milked, shipped, and sold strictly in accordance with suggestions made by a committee appointed by the New York County Medical Society to investigate the milk supply of the city. Ordinary bottled milk may be up to all the requirements of a good food, or it may not, but certified milk can always be relied upon in every way. If the child is at all feeble, or, in any event, if the parents can 378 A NURSE'S HANDBOOK OF OBSTETRICS. afford the slightly additional expense, certified milk should be used instead of the ordinary kind. It has been said that mother's milk contains, approximately, four per cent, of fat, seven per cent, of sugar, and two per cent. of proteids. Mixed cow's milk—that is, milk which has been stirred up, so that any cream which may have risen is thoroughly mixed with the rest of the milk—contains, approximately, four per cent, of fat, four per cent, of sugar, and four per cent, of proteids. At first sight it would seem that the only necessary step in modifying cow's milk to meet the requirements of an infant would be to dilute it one-half with water, giving fat, two per cent.; sugar, two per cent.; and proteids, two per cent.; and then adding two per cent, of fat and five per cent, of sugar to make the formula read, fat, four per cent.; sugar, seven per cent.; proteids, two per cent. This formula, from a chemical stand-point, is exactly the same as that of mother's milk, and it would be a proper food for the baby were it not for the fact that the proteids of cow's milk differ materially in point of digesti- bility from those of breast milk and must be greatly diluted before a young infant can assimilate them. By the time the child is about three months old its system has become accus- tomed to the proteids of cow's milk, the proportions of which have been gradually increased from day to day until, by this time, the formula is the same as that of mother's milk. To prepare milk for an infant under three months of age we find that it is most convenient to use, as a basis, cow's milk containing twelve per cent, of fat, four per cent, of sugar, and four per cent, of proteids. This is called " twelve per cent. milk," or " 12-4-4 milk." To prepare food for a baby between the ages of three and nine months it is most convenient to use cow's milk containing eight per cent, of fat, four per cent, of sugar, and four per cent. of proteids. This is called " eight per cent, milk," or " 8-4-4 milk." Ordinary mixed cow's milk, containing, as has been said, ARTIFICIAL FEEDING. 379 four per cent, each of fat, sugar, and proteids, is called " four per cent, milk," or " 4-4-4 milk." To make " eight per cent." or " twelve per cent." milk it is only necessary to add to ordinary mixed (4-4-4) milk the re quired amount of fat in the form of cream. Cream is nothing more than milk containing an excess of fat, and is of two kinds,—" gravity" cream and " centrifugal" cream. " Gravity" cream is that which rises to the top of a milk- bottle, or which, in the country, may be skimmed from the milk- pans. It contains fat, sixteen per cent.; sugar, four per cent.; proteids, four per cent. " Centrifugal" cream is that made with a centrifugal machine, and is sold in the cities in small sealed bottles as " cream." It is about as thick as honey, and contains fat, twenty per cent.; sugar, four per cent.; proteids, four per cent. The problem now is to make either " eight per cent." or " twelve per cent." milk by the addition of the proper quantity of either " gravity" or " centrifugal" cream to ordinary mixed (4-4-4) milk. These various formulas may seem a trifle confusing until they are placed in order, thus: Fat. Sugar. Proteids. 4 per cent. 4 per cent. 4 per cent. 8 " 4 a 4 K 12 " 4 a 4 (< 16 " 4 i< 4 CI 20 4 ■ < 4 (1 It will now be seen that nothing varies but the fat, and that the fat varies only in the perfectly regular progression of 4, 8, 12, 16, 20. The first formula is that of ordinary mixed milk, and the next two are those of the desired products for use as the basis of the baby's food; while the last two are those of the perfectly familiar kinds of cream in every-day use. In addition to the method of making " eight per cent." or " twelve per cent." milk by mixing cream and ordinary milk in proper proportions, the same results can be obtained by removing a definite amount of milk from the top of an ordinary quart 380 A NURSE'S HANDBOOK OF OBSTETRICS. milk-bottle in which cream has had time to rise. The method of removing this " top milk" and the amount to be removed will be taken up later. Thus we have three methods at our disposal,—the use of " gravity" cream, of " centrifugal" cream, or of " top milk." If " twelve per cent." milk is desired, it is made as follows: From gravity cream, by adding one part of 4-4-4 milk to two parts of gravity cream, thus: Fat. Sugar. Proteids. 16 4 4 16 4 4 _4_______________4_________________4 3)36 12 12 12 4 4 From centrifugal cream, by mixing equal parts of 4-4-4 milk and centrifugal cream, thus: Fat. Sugar. Proteids. 20 4 4 J___________4____________4 2)24 8 8 12 4 4 From top milk, by taking nine ounces from the top of the bottle as it comes from the dairy. The best way to remove the top milk is with the little dipper, holding exactly one fluid ounce, devised by Dr. Henry Dwight Chapin and known as the " Chapin dipper." The first dipperful is to be taken off with a teaspoon, or the milk will be lost when the dipper is lowered into the bottle. It is, of course, distinctly understood that the milk is to be dipped out and not poured, for any tipping of the bottle will disturb the cream and alter the proportion of fat in the top milk. This " twelve per cent." milk is now to be modified for the infant's use, and it is most convenient to prepare twenty ounces of food each time in order to make the proportions come right. It has been said, in speaking of breast milk, that it should be ARTIFICIAL FEEDING. 38l alkaline Or neutral in reaction, but never acid. Cow's milk, as it reaches the consumer, is always acid, so that it must be made alkaline by the addition of lime water or sodium bicar- bonate before it is fit for the baby's use. The sugar in cow's milk (four per cent.) is normally much less than that in mother's milk (seven per cent.), and the addi- tion of water, necessary to bring the fat and proteids down to a proper amount, reduces the sugar to almost nothing, so that sugar must be added to give sufficient sweetness to the food. With " twelve per cent." milk as a basis, it is only necessary, in preparing food for an infant under three months of age, to add lime water, or sodium bicarbonate, milk-sugar, and water in proper proportions. The amounts of lime water or sodium bi- carbonate and sugar do not change at all, but the milk is in- creased and the water proportionately diminished from day to day as the child grows older and is able to take stronger food. Twenty ounces of food are made at each time, and for this amount one ounce each of lime water and milk-sugar are re- quired, or sodium bicarbonate, 10 grains (or one-half grain to one ounce). When the amount of " twelve per cent." milk suited to the age of the child has been added, enough boiled water is poured in to make the total amount of food exactly twenty ounces and the work is done, thus: E - "■5 3 0 S 2S ■O v.' Result. Age. j£ Fat. Sugar. Proteids. 3i 3i ^ii ^iv 3V Up to 5 xx .60% 1.20% I.8o% 2.40% 3- % 3-60% 5% 5% 6% 6% 6% 6% .20% .40% .60% .80% I. % I 20% Second day. Third to fourth day. Fourth to seventh day. Seventh to thirtieth day. Second month. Third month. * If milk-sugar cannot be obtained, granulated sugar may be used in its place. One fluidounce or one Chapin dipperful of granulated sugar equals one ounce in weight. Milk-sugar is lighter, and one and one- half fluidounces or one and one-half dipperfuls are required to make one ounce in weight. 382 A NURSE'S HANDBOOK OF OBSTETRICS. It will be seen that the last formula in the above table, con- taining fat, 3.60 per cent.; sugar, six per cent.; and proteids, 1.20 per cent., is nearly the same as that of mother's milk (fat, four per cent.; sugar, seven per cent.; proteids, two per cent.) ; and beginning at about the fourth month the infant is usually able to take milk of the latter strength. " Eight per cent." milk is used for making the 4-7-2 for- mula, merely because it is more easily managed than " twelve per cent." milk. Like " twelve per cent." milk, it may be made either from gravity cream, from centrifugal cream, or from top milk. From gravity cream, by adding two parts of 4-4-4 milk to one of gravity cream, thus: Fat. Sugar. Proteids. 16 4 4 4 4 4 J___________4____________4 3)24 12 12 "8~" ~~T~ 4 From centrifugal cream, by adding three parts of 4-4-4 milk to one of centrifugal cream, thus: Fat. Sugar. Proteids. 20 4 4 4 4 4 4 4 4 _4_____________4_______________4 4)32 16 16 84^ From top milk, by removing with the Chapin dipper sixteen ounces of top milk from the full bottle. To modify " eight per cent." milk for the infant it is only necessary to dilute it one-half with boiled water, which reduces the formula to fat, four per cent.; sugar, two per cent.; proteids, two per cent.; and then add five per cent, of sugar, which raises that ingredient to seven per cent. (54-2). AMOUNT AT EACH FEEDING. 383 In preparing twenty ounces of food the exact formula is as follows: 1 u ^ Si 3i 00 >§ 73 ^ ■- rt 3ix Result. Age:. 3! Fat. Sugar. Proteids. 3i 3* 4% 7% 2% Fourth to ninth mouth. One ounce of sugar to twenty of food is, of course, exactly five per cent, (one in twenty), and as one ounce of lime water is used, only nine of water are needed to bring the total quan- FlG. 178.—Articles required for the preparation of artificial food. tity up to twenty ounces. If sodium bicarbonate is ordered, it will be added to the twenty ounces (one-half grain to one ounce). Having prepared the food properly, according to the age of the child, the next point is to ascertain how much is to be given at each feeding and how frequently the child is to be given the food. The hours for feeding are to be exactly the same as those 384 A NURSE'S HANDBOOK OF OBSTETRICS. for nursing at the breast, given on page 363, and the amount to be fed at each meal-time is as follows: Second day........................One-half to one ounce. Third to thirtieth day..............One to three ounces. Second month.....................Three to four ounces. Third month.......................Four to five ounces. Fourth to ninth month.............Five to six ounces. It will be seen that, until the baby is about three weeks old, twenty ounces of food will last throughout the entire twenty- four hours, but after this time it will be necessary to prepare twice the quantity, some of which will, at first, have to be thrown away. This double amount may be prepared at one time, or, if fresh milk is served twice daily, half may be prepared in the morning and the other half at night. Usually it is best to prepare the entire amount of food for the twenty-four hours at one time and keep it on ice until it is wanted. Food should never be kept over from one day to another, but a fresh supply should be made up each morning. Here again the period between feed- ings will be ordered by the doctor, but there is a very strong tendency to lengthen this interval to three hours if the child is developing normally. A convenient method of preparing milk in accordance with the foregoing formulae will be found in the use of the Sloane Maternity Milk Set, arranged by Dr. Edwin B. Cragin, of New York, and consisting of a measuring-glass (Fig. 178) and a Chapin dipper. The apparatus is used as follows: 1. Pour into the glass granulated sugar or milk-sugar up to the proper mark as indicated on the side. 2. Add one dipperful (one ounce) of lime water and mix by shaking the glass, or ten grains of sodium bicarbonate after the dilution is completed. 3. Add the required number of dipperfuls (ounces) of " twelve per cent." or " eight per cent." milk according to the age of the child as already explained. 4. Fill the measuring-glass up to the top graduation (marked METHOD OF ADMINISTERING FOOD. 385 " 20 oz. of food ") with plain boiled water, barley-water, or oat- meal-water. During the first month plain water is best, but afterwards barley-water may be used or oatmeal-water if the infant is very constipated, or the cream may be modified with whey. Barley-water may be made of the whole barley or of bar- ley flour as follows. From whole barley: Add two teaspoonfuls 3— 2 — 1— V. Fig. 179-—Nursing-bottles. A, improper pattern, with long, slender neck; B, proper pattern, without neck. of washed pearl barley to a pint of water; boil down slowly to two-thirds of a pint and strain. From barley dour: Put two tablespoonfuls of barley flour into a quart saucepan with one and one-half pints of water; boil down slowly to one pint. Strain and allow the liquid to set to a jelly. When warmed for use it will return to a liquid. Oatmeal-water is made as follows: Add one tablespoon- ful of well-cooked oatmeal to a pint of water; allow it to sim- 25 386 A NURSE'S HANDBOOK OF OBSTETRICS. mer slowly for an hour or two until a smooth mixture is ob- tained. Strain. It is to be distinctly understood that the problem of feeding an infant on artificial nourishment is often a most difficult one, and that the nurse must never attempt any important modifica- tions of diet on her own responsibility, but report at once to the physician any unfavorable symptoms that may arise. The next question to be considered is the method of adminis- Fig. 180.—Testing size of opening in nipple. Milk should drop out as indicated, and not flow in a stream. tering the food. It is, of course, to be taken from a bottle through a rubber nipple, and the selection of a proper nursing- bottle and nipple are matters of no small importance. The shape of the bottle should be such that every part of the inner surface can be reached with a swab or brush (Fig. 179). Bottles with sharp angles or broad shoulders should never be used, for it is impossible to clean them properly, and milk is very apt to collect and sour in their many nooks and corners. The bottle should be graduated so that it need only be filled CARE OF NURSING BOTTLES. 387 to the amount proper for a given feeding, and so that it will be possible at all times to tell exactly how much food the infant has taken. The best nipples are the plain ones of black rubber, but the most important point in the selection of a nipple has to do with the size of the hole through which the milk is to come. The hole is usually too large, and it is often best to'buy nipples without any holes at all and make them of the required size with a needle. The test consists in holding the bottle, filled with milk and with the nipple attached, upside down (Fig. 180). The milk should escape drop by drop, and if it runs out in a stream the hole is too large. The objection to the large hole is that the child nurses too rapidly, and develops indigestion, colic, and other disorders. The care of the bottles and nipples is another matter of the greatest importance, for if any sour milk is allowed to collect it will promptly sour fresh milk whenever it is used. There should be as many bottles and nipples in commission as there are feedings in the twenty-four hours, so that no bottle will be used more than once in any day. As soon as a nipple has been used it is to be washed thor- oughly inside and out with castile soap and hot water, and a needle or bristle passed through the hole in the end to force out any little curd which may have lodged there. All the nipples, after being freshly cleaned and sterilized, are placed in a dry sterile Mason jar. Boric acid solution is not antiseptic and is rarely properly cared for. Moreover, the soaking in solution ruins the rubber. Afterwards, as the nipples are used, and after they have been washed, they are placed one by one in a cup until all are used, when they are again boiled and made ready for the next day. The bottles, as has been said, must be so modelled that every part of the interior can be reached with a brush or swab. After each feeding the bottle is to be washed with castile soap and hot water and wiped inside and out, so that no vestige of milk or milkiness remains. It is then rinsed thoroughly with fresh water and placed on end to drain. Once in every twenty-four 388 A NURSE'S HANDBOOK OF OBSTETRICS. hours all the bottles are to be boiled. To prevent breakage they should be filled with cold water and placed in a vessel containing cold water, which is then brought to a boil. After boiling vigor- ously for not less than fifteen minutes the vessel is taken from the fire and allowed to cool until the bottles can be removed without scalding the hand. To attempt to cool them by the addition of cold water would be sure to crack some, if not all. When the baby is fed, it must be supported in a comfortable position, and the bottle is always to be held by the mother or nurse in such a way that the nipple will be full of milk. The child should never be put to bed with the nipple in its mouth, and, as in breast feeding, it should never be allowed to dawdle over its meal. If a fair trial shows that it is not anxious for its food, the bottle should be taken away and not offered again until the next meal time. If the infant persistently refuses to take its food there is usually something wrong with the milk, and the physician should be consulted. Only the proper amount of modified milk for one feeding should be put in the bottle, and it should then be warmed to body temperature by placing the bottle in a vessel of hot water. In cold weather a piece of warm flannel may be wrapped around the bottle to keep the milk from growing cold towards the end of the feeding. Under ordinary circumstances, a normal child should take the entire quantity of food prepared for one feeding, and if any is left over at the end of the meal it should be thrown away and never returned to the main supply. As a rule, city milk of good quality is so carefully cared for from the time it is milked until it reaches the consumer that, if put on ice at once, it will keep sweet for the entire twenty-four hours, but in very hot weather, or when the food has to last for a journey of several days, the milk will turn sour, even on the ice. In such cases it becomes necessary to treat it in a way which will destroy the germs of fermentation and so keep the milk sweet. This is done by heating the milk to such a degree of temperature that the fermentative organisms will be destroyed. This, in its most primitive form, is accomplished by the familiar STERILIZATION AND PASTEURIZATION. 389 process of " scalding " the milk, so commonly done by poor people who buy cheap milk which is so old that it is just at the turning-point when they get it. Sterilization is a process which was once in great vogue for preserving milk for the use of infants. This consists in placing the milk in a "sterilizer" (Fig. 181) and surrounding it with live steam for a definite period of time, which raises the tem- perature to 212° F. It is true that sterilization destroys all the germs in the milk and keeps it sweet for a long period, but it has the disadvantage not only of altering the taste to a decided degree, but of making the product much more indigestible than " raw " milk. On this account milk is not sterilized as much as formerly, for under ordinary circumstances it is safer to take the slight risk of infection from the comparatively small number of bacteria to be found in good milk than to subject the child to the greatly increased difficulties of digesting sterilized milk. Another reason, however, has done more than anything else to do away with the use of sterilized milk, and this is the discovery that if the milk is subjected for a considerable period of time to a temperature of 1670 F. (instead of 2120 F.) it will be suffi- ciently '* sterilized " for all practical purposes, without under- going any alteration in taste or increase in indigestibility. This process is known as pasteurization, and is accom- plished as follows: The "pasteurizer" (Fig. 182) is a large tin or copper pail with a cover, containing a rack which holds the nursing bottles. The rack consists of a number of water-tight cylinders, each large enough to admit a bottle, and the pail is so constructed that the rack may rest on the bottom and the cover be tightly ad- justed, or, with the cover off, the rack may be raised up and secured in such a way that the tops of the bottles are about two inches above the top of the pail. The bottles are those to be used for the feedings, and are graduated in ounces and half-ounces. As many bottles as there are to be feedings in the twenty-four hours are filled with prop- erly prepared milk up to the proper graduation mark, so that 390 A NURSE'S HANDBOOK OF OBSTETRICS. each bottle will contain one feeding and no more. They are then stoppered with ordinary cotton wadding (not absorbent cot- Fig. 181.—Steam sterilizer. (Arnold.) Fig. 182.—Freeman pasteurizer. ton) and placed in the cylinders. Cold water is poured in each cylinder around the bottle, and any empty cylinders are filled STERILIZATION AND PASTEURIZATION. with water. Each cylinder is to be filled, and the water should not be colder than runs from the faucet. The pail, without the rack and bottles, is now filled with water up to the rim on the inside and set on the stove to boil. As soon as it is boiling furiously it is removed from the fire and set on the table or floor, but never on iron or stone, which would abstract the heat too rapidly. The rack and bottles are lowered at once to the bottom of the pail, the cover adjusted snugly, and the apparatus left undis- turbed for three-quarters of an hour exactly. At the end of this time the pail is placed in the kitchen sink or in some other convenient place, the rack raised up and secured so that the tops of the bottles will be above the top of the pail, and cold water allowed to run in and out, around the cylinders and overflowing the sides of the pail, until the milk is thoroughly cool. The bottles are now placed on ice, and as each feeding time comes around, one is taken, the cotton stopper removed, the nipple attached, and the contents warmed for the infant's use. This milk should be used the same day that it is prepared but it will keep sweet for three or four days. Many very simple modifications can be made on this principle of pasteurization and preservation of milk. Many Infant Wel- fare Societies have devised simple substitutes. The emphasis is, of course, laid first upon a proper pasteurization and second upon the preservation of the feedings at the proper temperature. Instead of modifying milk, many different forms of feed- ing have been devised, Finklestein's feeding being one most often used. In general, " raw " milk is better for the baby than milk that has been " cooked," and the nurse should never suggest sterili- zation or pasteurization on her own responsibility, but con- sult the physician if such a process seems to be indicated. When, for any reason, it is necessary to remove the child from the breast, and the glands are still secreting milk, it will be necessary to " dry up " the milk. As a rule, the physician 392 A NURSE'S HANDBOOK OF OBSTETRICS. will give directions for this, but it occasionally falls to the lot of the nurse to attend to the matter herself. The breasts should be emptied as completely as possible, either by massage or with the breast-pump, the ingestion of fluids restricted to the smallest amount consistent with ordinary comfort, and the snuggest kind of a breast-binder applied and left undisturbed for three or four days. There should never be any fever, or pain in the breasts, but when the binder is re- moved the glands will be found somewhat hard and lumpy. This should disappear in the course of two or three days more, and the breasts appear soft and free from any trace of milk. Drugs Excreted by the Milk.—The Journal of the Ameri- can Medical Association (November i, 1902) publishes the fol- lowing list of drugs which are excreted by the milk and which, consequently, affect the infant: sulphur, rhubarb, senna, jalap, indigo, arsenic, bismuth, iron, mercury, potassium iodide, zinc, iodine, antimony, opium, oil of anise, oil of dill, garlic, castor oil, lead, oil of turpentine, oil of copaiba, all the volatile oils. magnesium sulphate (Epsom salt) carbolic acid, quinine, strych- nine, and cascara sagrada. The article goes on to say: " The elimination of these drugs by the milk is more liable to take place when the mother is in a disturbed condition physically and when the mammary glands are not in a nor rial condition. Con- sequently care must be observed in prescribing some of these preparations for the mother. For example, copaiba and tur- pentine will so affect the taste of the milk as to cause the infant to refuse the breast. Diarrhoea may be produced in the infant by administering castor oil or other of the above purgatives to the mother, and the opium preparations will produce the op- posite effect on the child through the mother's milk. It is said that sufficient action may be produced on the child by administer- ing mercury, arsenic, and potassium iodide to the mother." XXVI Obstetrical Nursing The care of obstetric cases presents so many differences from ordinary surgical nursing that the nurse requires a few special articles for this work in addition to her usual outfit. In the first place she should provide herself with an abundant supply of dresses and aprons, for the nature of her duties are Fig. 183.—Operating gown and case. such that, even with the utmost care, she cannot always prevent frequent soiling of her aprons at least. In addition to her white aprons she should have one large rubber apron for use when she is bathing the baby. 393 394 A NURSE'S HANDBOOK OF OBSTETRICS. A gown (Fig. 183), pinned in a towel or tied up in a muslin case, and sterilized, should be taken for use at the time of the delivery. Nurses often come to a case several days before the labor occurs, and, while wearing their uniforms, they are up and down stairs and in all parts of the house. Also, as will be seen in another chapter, the patient receives an enema at the beginning of labor, and frequent trips to the bath-room have to be made by the nurse on this account. Keeping these various matters in mind, it is evident that the nurse's uniform is any- thing but aseptic when labor is in progress, and the gown should be worn from the time the patient takes to her bed until after the placenta is delivered. If complications arise and the nurse must act as a clean nurse, she will, of course, scrub up with care, and wear the same long sleeved gown, with long rubber gloves, a cap and face guard as is worn by the doctor. The nurse's arms should be bare to the elbows throughout the entire labor, and afterwards several times each day while she is attending to the toilet of the patient or bathing the baby. Fre- quent rolling up of the sleeves for this purpose soon rumples them to such an extent that they present a very disordered ap- pearance, highly at variance with the picture of immaculate neatness which is always expected of a nurse. Her uniform is best preserved by wearing special gowns, made for the purpose. The infant is not to be handled by a nurse wearing starched cuffs or stiff uniforms. After the morning work about her patients the usual nursing uniform may be again worn. Two thermometers should be taken to each case, one for the mother's temperature and the other, a rectal thermometer, for the infant. There should be temperature charts for both mother and child in addition to the usual blanks for bedside notes. Temperature should always be charted, for its entire course can then be understood at a glance, while if it is recorded in any other way its significance is not always readily grasped, and unless the notes are studied with great care a single, isolated rise of temperature may escape the notice of the physician. The infant is to be weighed at birth, and afterwards once 17 irr- HAMAOCK* AKD SCALED ROLLED HAMMOCK OPEN- ■U Fig. 184.—Scales and hammock for weighing infant. THE INFANT'S WEIGHT. 395 daily, and as scales are seldom to be had when they are wanted for this purpose, it is a good plan for the nurse to add to her obstetrics outfit a small scales and hammock, such as is shown in Fig. 184. The best scales are large ones with weights, or the old-fashioned " steelyards," for no spring balance is exactly accurate; but in the absence of the bulky apparatus, the little pocket affair shown in the illustration, and to be had of any dealer in surgical supplies, answers very well. The importance of weighing the infant daily cannot be over-estimated, and it is needless to add that, as the daily variation in weight is always a matter of ounces or fractions of an ounce, the same scales should be used each time and, unless the infant is placed in the scales quite naked, any towels, blankets or diaper should after- ward be weighed separately and their weight deducted from the total. The infant's weight should be. recorded daily on a chart, and blanks for this purpose, having space for the infant's tempera- ture and weight, the mother's temperature and pulse, and all the other required data of a maternity case, have been de- signed. A glass feeding-tube is needed for administering fluids to the patient immediately after labor and before she is allowed to raise her head. Tape for tying the umbilical cord is not mentioned in the list of supplies to be provided by the mother, because the physician usually includes it in his own outfit, but occasionally it is over- looked, and at times, as in cases of precipitate labor, the nurse will have to tie the cord before the arrival of the physician. For these reasons it is best for her to provide herself with suit- able cord ligatures, and the best material for this purpose is ordinary linen bobbin tape cut into 12-inch lengths, thoroughly washed with soap and water, boiled, and then placed in 95 per cent, alcohol in a small glass or agate jar. The hypodermic case should contain tablets of ergotin in ad- dition to the usual assortment of drugs. Fluidextract of ergot is usually used if no anaesthetic has been given. The ergotol is ordered for those patients who have been anaesthetized. 396 A NURSE'S HANDBOOK OF OBSTETRICS. To recapitulate, the obstetric nurse needs, in addition to the ordinary supplies that she would take to any case: Extra aprons. Extra uniforms. One rubber apron. Two operating-gowns, sterilized. Two thermometers; one for mouth, the other for rectum. Temperature charts. Scales for weighing the infant. Weight charts. Glass feeding-tube. Linen bobbin tape, for tying the umbilical cord. Hypodermic tablets of ergotin. One safety razor. One pair rubber gloves. One pair tongue forceps. One dressing set of scissors, forceps, clamps. One pair long rubber gloves. One rectal tube. One sterile irrigating can complete. One jar of sterile io-yard length uterine packing. One rubber catheter. One glass catheter. One English catheter, No. 8. One bottle bichloride tablets. Four ounces of lysol. One narrow strip of sterile adhesive. One bottle saline tablets. One ounce of aromatic spirit of ammonia. List of articles required by mother, in Chapter XII. List of articles required by infant, in Chapter XXII. XXVII Diets The trained nurse will have had a course in dietetics and cooking for the sick. No recipes are given here. She should have at all times a pocket edition of recipes to be used in the nursing of obstetrical cases. The diets are classified variously in different hospitals. It is essential for the nurse to know how to prepare the following: Proper Diet During Pregnancy Soups.—Any kind. Fish.—Boiled or broiled fresh fish of any kind. Raw oysters and raw clams. Meat.—Chicken, game, ham, or bacon (broiled), tender lean mutton and lamb. Meat is allowed only in perfectly normal cases, and then but once daily. Farinaceous.—Hominy, oatmeal, wheatcn grits, mush, rice, sago, tapioca, arrow-root, stale bread, Graham bread, rye bread, brown bread, corn bread, toast, milk toast, biscuits, macaroni. Vegetables.—Potatoes, cabbage, onions, spinach, cauliflower, Brussels sprouts, asparagus, green corn, green peas, string beans, mushrooms, water-cress, lettuce or other salads with oil. Desserts.—Plain puddings of rice, arrow-root, sago, or tap- ioca ; custards, stewed fruits, ripe raw fruits, and ice cream. Drinks.—Plenty of pure water (hot, cold or aerated), at least two quarts daily, milk, buttermilk, peptonized milk, kumyss, or zoolak. Very little tea or cocoa, practically no coffee, and ab- solutely no alcoholic liquors unless specially ordered by the physician. Such a list is susceptible to many additions and elaborations, but in the absence of specific instructions from the physician, it will answer perfectly well to give to such patients as insist upon positive dietetic directions. 397 398 A NURSE'S HANDBOOK OF OBSTETRICS. FARINACEOUS DIET Breakfast: Tea or coffee (milk and sugar), bread and butter, corn bread, rolls, toast, toast and hominy, farina or Indian meal. Dinner: Vegetable soups, bread, baked potatoes, tomatoes, beans, rice, macaroni, pudding—rice, bread, tapioca or cornstarch. Supper: Tea (milk or sugar), bread and milk, milk toast, hominy, boiled rice or farina. Fruit such as apples, stewed or baked, prunes, and pears. Diet During Puerperium First forty-eight hours: Milk (one and one-half to two pints a day), gruel, soup, one cup of tea a day, cocoa, toast and butter. Second forty-eight hours: Alilk toast, poached eggs, porridge, soup, cornstarch, tapioca, wine-jelly, small raw or stewed oysters, one cup of tea or cocoa per day. Third forty-eight hours: Soup, white meat of fowl, mashed potato, beets in addition to above. After the sixth day return cautiously to ordinary light diet, that is, three meals a day, meat of an easily digested character at one of them, such as white meat of fowl, tenderloin of beef, etc. Also a glass of milk three times a day, between meals and before going to sleep at night and a glass in the middle of the night. Milk Diet.—Eight ounces every two hours of milk with water and whey, making ninety-six ounces of fluid in twenty- four hours. Liquid Diet.—Coffee, tea, hot or cold, in small quantities, cocoa, milk, milk-shake, peptonized milk, malted milk, butter- milk, whey, plain or with wine, champagne, a fruit juice or cream, junket, matzoon, kumyss, albumin, rice, barley-water and aerated waters, beef tea, beef juice, bouillon, oyster and clam broth, mutton, beef and chicken broth, oatmeal, barley, rice, corn- meal, rye, bran, or a mixture of all these cereals may be made into gruels. Soft Diet.—All soft puddings, fruit whips, ice cream and NUTRIENT ENEMATA. 399 sherberts, custards, well-cooked cereals, thickened soups and purees, lentil, pea and barley soups, strained vegetable soups, poached and soft boiled eggs, milk toast, plain or peptonized, scraped raw beef, and egg-nog. Nutrient Enemata The amount should be six ounces; it should never exceed eight ounces for an adult, or one to two ounces for a child. Its administration should follow one hour after a cleansing saline enema has been expelled. The patient must be in the usual position on the left side; but occasionally it may be better re- tained if the patient can be placed and supported with pillows, in the knee-chest position. Enemata must be introduced above the rectum very slowly. The temperature of the solution must be that of the body heat. The tube must be slowly withdrawn and pressure placed upon the rectum to assist retention. Sugar and Milk Enema.—Grape-sugar, two ounces; milk, six ounces. Glucose Solution.—Glucose, one ounce; water, seven ounces. Ewald's Enema.—Take the whites of two eggs; beat in four drachms of cold water; cook one drachm of cornstarch in glucose solution, 20 per cent. Two ounces of claret. One ounce of peptone solution. To be mixed at a temperature below the coagulation point of albumin. Amount eight ounces. Many combinations of egg, brandy, glucose, dextrose, pep- tonized milk, etc., are used. The more usual are beef tea, beef peptonoids, digested beef, egg-nog, coffee, and prepared com- binations of special foods always with a pinch of salt. Of the proprietary substances, the recipe for using is always found in the packet containing the purchase. Occasionally neurotic patients are fed by means of the stom- ach tube. Also in injuries to the neck or cases of poisoning in which there has been destruction of the mucous surfaces, and with small children, nasal feedings may be given. The nurse will, after slowly filling the funnel attached to the stomach tube or catheter used, give the required amount, after lubricating the 400 A NURSE'S HANDBOOK OF OBSTETRICS. small tube. The children's size must be used for this purpose. It is slowly withdrawn and the patient turned on her face at the edge of the bed to control possible regurgitation. Hypodermoclysis.—To the ordinary saline solution, brandy is sometimes added as a food and stimulant. Olive oil and various animal fats are taken up by the skin and are sometimes ordered as inunctions. The only other special food which concerns the obstetrical nurse is one which has been largely discussed but has not re- ceived unqualified approval. It represents one of a number of similar theories all subscribing to the belief that the size of the child in utero can be controlled. Prochownik's Diet.—Breakfast: Coffee, four ounces; toast, one ounce. Dinner: Meat, fish or egg; one vegetable with a sauce or pre- pared with fat; lettuce; cheese, one-half ounce. Supper: Same repeated; add bread, butter and milk in small quantities, and water, one pint per day. To be used during the last three months of pregnancy only under the supervision of a doctor. In hyperemesis gravidarum, test meals are occasionally or- dered. Usually this is withdrawn after one hour by siphoning with the stomach tube. Reigel and Leube's test meal consists of beef soup, beef- steak, white bread and water. More often a test breakfast of one white bread roll and a cup of hot tea without milk or sugar is ordered. APPENDIX Technic The most scientific knowledge concerning obstetrics may be rendered useless by an inefficient technic in hand preparation. The nurse should know how to prepare the following:. Sterile Water.—Boil for twenty minutes. Normal Salt Solution.—Sodium chloride, one drachm, sterilized; water, sixteen ounces, boiled and filtered. Boil one hour for three successive days. Do not use distilled water. Lysol.—An antiseptic saponaceous preparation; it is used as a lubricant, a douche for cleansing; and disinfection of the hands, in a one and two per cent, solution. Bichloride of Mercury.—Reliable if used sufficiently strong. To be effective it must be used in strength of i: 500 for hand disinfection. Care must be taken to prevent its absorption by mucous surfaces. Occasionally douches are ordered in strength of 1: 2000 at intervals of a few hours; in these cases symptoms of absorption must be closely watched for. Idiosyn- crasy for this drug is not uncommon. It is decomposed by blood and by albuminoids. Carbolic Acid.—As a hand solution it should be used in a strength of 1 : 40 or 1 : 100; when used for antiseptic cleansing of articles and disinfection of exudates, in strength of 1: 20. Bin iodide of Mercury.—It does not blacken the nails, and is said to be a stronger antiseptic than the bichloride; it is used in a solution of 1 : 1000. Sublamin.—A mercury preparation used as are both of the mercury solutions named above. Cyllin.—A fairly dependable antiseptic; ordered most often as a douche, 1: 500. Permanganate of Potassium.—Used as a douche to in- fected surface in weak solution, and as a hot saturated solu- 26 401 402 A NURSE'S HANDBOOK OF OBSTETRICS. tion for hand disinfection. It stains all substances coming in contact with it, and this stain is removed by immersing the part in a solution of oxalic acid of the same strength. It destroys much operating room equipment by discoloration and the disin- tegrating effect of the oxalic acid. Formalin.—Used in twenty to fifty per cent, solution for hands, and twelve per cent, solution for douches. Alcohol.—Strength, ninety-five per cent. Vessels must have been boiled for ten minutes before re- ceiving a sterile solution. Solutions must be made with boiled water. Hands must be scrubbed thoroughly under running warm water, the fingers, between fingers, around the nails and up to the elbows with any good soap and boiled tampico fibre brush for five minutes. Clean the nails, and then scrub for ten minutes, using a fresh brush, and gauze sponge on the arms and back of the hands. Rinse in biniodide or bichloride of mercury for five minutes. Rubber gloves which have been carefully scrubbed, turned, tested and boiled for ten minutes are then put on and the hands are sterile until something unsterile is touched. If this occurs the gloves must be removed and the process repeated. The same routine of scrubbing may be followed by immer- sion of the forearm in hot saturated solutions of permanganate of potassium and oxalic acid; then by rinsing in solution of bin- iodide or bichloride. Alcohol in strength of ninety-five per cent. is applied carefully to the fingers and arms by a gauze sponge. There are many varied technics named after the surgeons who devised them. Most obstetricians have a solution which they prefer above all others, and the nurse must see that this is properly prepared. The chief points to observe in hand disin- fection are the preliminary cleansing of the fingers, hands, and arms themselves, and the keeping of them perfectly clean. All the substances used are more or less deadly poisons, and they must be kept out of the reach of all who are not trained in their use. Where pus is present, particularly thorough care must be exercised. TECHNIC FOR CLEANSING EXTERNAL GENITALS. 403 technic for cleansing external genitals Two basins, eight inches in diameter, sterile. Eight ounces solution of lysol, two per cent. Eight ounces bichloride solution, 1: 5000. One dozen small sterile cotton sponges placed in each bowl. The patient is placed in the dorsal position and draped. The pad is removed and a douche pan placed beneath her. Her body is supported by pillows placed beneath her back. The hands are scrubbed clean, soaked in an antiseptic solution, and discarding each sponge as used, the nurse takes a sponge from the bowl of lysol with her right hand. This hand she keeps clean by toss- ing the sponge to her left hand each time. In this way both her right hand and the solutions are kept clean. 1. Swab across pubes. 2. Swab down each groin. 3. Swab across pubes and down each labium majus. 4. Swab between the labia majora and minora. 5. Swab between the labia minora. 6. Repeat the procedure by using the sponges from the bi- chloride basin. 7. If an examination is to be made, place a pledget from the bichloride basin between the labia minora. The labia are sep- arated by the second and index finger of the left hand; and fingers of the sterile hand are used in making the examination. 8. If a catheterization is to be done, after the labia minora are separated, the meatus is carefully cleansed. A pledget is placed in the vagina, and a sponge between the labia minora; and the sterile right hand inserts the catheter. 9. If a douche is to be given a pledget is placed in the rectum. 10. If a sterile douche, the tip is to be changed after the vagina has been douched. It will be seen that this is thorough and reliable. It has been used with modifications for years in various hospitals. The sponging is always toward the rectum. The sponge is discarded after each separate step is carried out. It is a very expeditious method, and, if followed as routine, infection is not possible. 404 A NURSE'S HANDBOOK OF OBSTETRICS. gauze sponge technic. To prevent the in-bedding in the tissues of small or large gauze sponges is one of the gravest responsibilities the nurse has. The obstetrical nurse may not be equally keen about this as is a surgical nurse and will need the assistance of a special technic devised by Dr. C. W. Barrett of Chicago. The usual routine of checking up after operation, attaching artery clamps, using rolls of gauze, all fail to make the accident impossible. Dr. Barrett's Gauze Sponge Technic—To laparotomy pads of all sizes, a small, smooth, inexpensive snap is attached through the medium of an eight- or ten-inch tape. To the la- parotomy sheet a large horse blanket pin such as is now com- monly used to group instruments, is attached near the wound. When each sponge comes to the field of operation it is snapped to the safety-pin and is then introduced with safety, the number of snaps indicating at all times the number of pads in the wound, and the tapes furnish a ready means of reaching the pads. The snaps are fixed, are not needed for other purposes, and are not confused with other instruments used and so remain at their task. Any sponge may be detached at will. If the snaps have not in any case been attached to the pads and sterilized with them, the snaps may be boiled with the in- struments, and the tapes then tied to them when the sponges are opened. This has seemed to help in solving the problem of abdominal sponges. The nurse, in a properly organized and administered gen- eral hospital, will have an invaluable opportunity to see placed before her the most effective, efficient, and economic ideals of general and obstetrical nursing. The equipment at command em- braces, in some instances, the very best in existence. The in- struction she receives is the last word of command in the battle against invalidism and death. She carries out into the world this source of power for ser- vice, and will use it in an infinite variety of ways. GAUZE SPONGE TECHNIC. 405 She has found, under the most improbable conditions of dirt, squalor and poverty, that the principles of obstetric nurs- ing can secure equally safe results if followed explicitly. The poor prospective mother of large cities is cared for most Fig. 185.—Sponge attached to safety-pin with snaps. often by out-patient clinics and dispensaries ; by visiting nurse associations employed by various agencies, such as Infant Wei- 4o6 A NURSE'S HANDBOOK OF OBSTETRICS. fare Organizations, Committees for Reduction of Infant Mortal- ity, Public Health Boards, Milk Committees, etc. The nurse may or may not be present at the actual delivery, concentrating perhaps on a policy of education of mothers and saving of babies, with all the social service which this demands. This is not always the case, however. She prepares the pa- tient for delivery, secures the conditions outlined for private cases, as nearly as possible, by the exercise of originality and judgment. She assists the doctor in the usual routine way. For this work she will require a special bag of supplies. She sees to it that the patients will be cared for, and makes the best provi- sion possible for their safety and health in the home. The nurse usually visits these cases once a day until the pa- tient is discharged by the doctor, then as often as necessary. The larger part of her duty lies in the definite demonstration and teaching of personal and general hygiene and the care of the family. This is a large factor in the reduction of infant mortality. In rural communities where a nurse elects to work, she will find entirely different conditions—scattered, small communities, doctors few in number, and transportation inadequate. Public Health nurses engaged in rural nursing are meeting and solv- ing many obstetrical problems. The rural Red Cross nurse is filling a sphere that is taking her into still more difficult surroundings, so far as clean ob- stetrics is concerned. According to the Superintendent: " In sections of the country where there are but few acces- sible doctors or even none at all, the relation of the visiting nurse to the midwifery question would become a serious problem. Up to the present time, however, the forty visiting nurses appointed by the Red Cross for service in small towns or rural districts, even in the southern mountains, are in communities where there is at least one practising physician. Rural nursing, as it is being developed by the Red Cross, cannot be well carried on unless there is at least one physician in the community under whose direction the actual nursing services may be rendered. " The rules of nursing organizations affiliated with the Red Cross state that the nurse is not allowed to act as a midwife RED CROSS NURSING. 407 where medical attention is available, thus only in an emergency are the nurses called upon to act as such and up to date this has not been a common occurrence. In fact, it has occurred so seldom in the experience of our rural nurses that the need of special midwifery training in preparation for rural nursing has not yet become evident. " Three months thorough training in an obstetrical ward or lying-in hospital ought to equip nurses sufficiently to handle emergency deliveries as they occur in Red Cross rural nursing. It is most advisable that during their obstetrical training, how- ever, they be allowed to deliver several normal cases. As a re- quirement for appointment to the Service, Red Cross visiting nurses are expected to have had practical and theoretical instruc- tions in obstetrics." Dr. Abraham Jacobi stated in an address before the American Medical Association, in 1912, that 50 per cent, of all the births in the United States were attended by non-medical women. In New York, 42; Buffalo, 50; St. Louis, 75 ; Chicago, 86; later figures give the State of Wisconsin 50 per cent. Leaving aside utterly the advisability or not of stamping midwives out of existence, or educating and continuing this form of obstetrical attendance, there is the question of how this 50 per cent, is to be cared for, for care they must have. Different State laws meet the problem in different ways. Some recognize and register the midwife, but give her no super- vision. In others she is not even registered, but practises with- out official recognition. This question is being attacked in different ways by different communities—by a substitute agency such as the obstetrical hos- pital, the out-patient services of such hospitals, the obstetrical dispensary, and similar organizations. Pittsburgh has an ob- stetrical hospital with a dispensary service in each quarter of the city, and a well-organized out-patient service. Manchester, New Hampshire, has a scheme of voluntary service of the physi- cians, under a head obstetrician. There is an obstetrical clinic in connection with a milk station in Baltimore, and a compre- hensive organization in Boston. 408 A NURSE'S HANDBOOK OF OBSTETRICS. The patients are largely foreign, of foreign parentage, and negroes. This accounts for the report of the Joint Committee of the Chicago Medical Society and Hull House, which conducted Fig. 186.—Delivery bag. Bellevue Hospital School for Midwives, New York City. an investigation of " The Midwives of Chicago." This report stated a fact that nurses doing visiting nursing so often encounter, and against which argument they are so helpless: " That mid- wives now, and probably for years to come, are socially inevi- OUT-PATIENT DELIVERY BAG. 409 table." Such an alien's social instincts and training are all against a physician and hospital care. The patient consenting and the husband refusing to permit a doctor's attendance is a fairly common complication in a nurse's work. Nurses are urged to do their share in teaching and practically demonstrating the value- of the best obstetrical care available. An attitude of disdain toward obstetrical work is fatal for the newer ideals of obstetrics. Visiting nurses have endless op- portunities for contact and for instructing these women. This must be seized upon and a definite educational work can in this way be accomplished. Bellevue Hospital School for midwives in New York City provides its pupils with a bag containing the necessary articles for use in the out-patient cases. The outfit consists of a copper receptacle covered with denim, the copper receptacle being used as a boiler, when contents are removed. out-patient delivery bag, contents One white enamel douche can with tubing. One enema tip. One glass vaginal douche nozzle. One medicine dropper (for eyes). One medicine glass. Two haemostats. One pair scissors. One thumb forceps. One rubber catheter. One scale for weighing baby. Four ounces green soap. Four ounces of alcohol. Two ounces cresol comp. Two ounces castor oil. Two ounces olive oil. One ounce of fluidextract of ergot. One ounce solution of nitrate of silver, 1 per cent. Six sterile towels. Six gauze sponges. A NURSE'S HANDBOOK OF OBSTETRICS. Two cord dressings. One sterile gown. Two packages sterile cotton balls. One square rubber sheeting. One pair rubber gloves. One hand brush. One orange-wood stick. Nurses visiting patients at their homes require supplies em- bracing a somewhat different group. Every association and hospital has its individual bag of supplies which serves more or less acceptably the class of pa- tients visited. The illustration shows that of the Instructive Fig. 187.—Nurse's bag. Instructive Visiting Nurse Association of Baltimore, Md. Visiting Nurse Association of Baltimore, Md., and will be found very complete. The nurse is reminded, that though the physicians are in- structed to report all births, in many small, new settlements this is not done with unfailing regularity. It is quite proper that she should suggest to the parents that they ask for a copy of the certificate, as the child will require it to enter school, to get work- ing papers, to prove citizenship, and to inherit property. In addi- tion it makes more possible reliable vital statistics. She is again reminded that, as suggested in the paragraph on menstruation, if she is informed by a woman in whom menstru- ation has ceased of the presence of a vaginal discharge, that this NURSE'S BAG. Fig. 188.—Contents of bag. Height, 6 inches;length, 12 inches (scant); width, 6 inches; weight, empty, 2 lbs.; weight, stacked, 7 lb. 3 oz. 1, rubber lining; 2, safety-pins; 3, alcohol, 50 per cent., 3 oz.; 4, mouth wash, 2 oz.; 5, cresol, 2 oz.; 6, aromatic spirit am- monia, 1 oz.; 7, liquid green soap, 1 oz.; 8, alcohol, 95 per cent., 1 oz.; 9, boracic acid crystals, 2 oz.; 10, talcum powder, pasteboard, adjustable box; 11, thermometers, 3; 12 and 13, rubber gloves, 1 pair and envelope (made of twilling); 14, instrument case, 1 (made of twilling); is, cord-dressings, sterile linen; 16, glass syringe, small, 1; 17, cord- tie; 18, enema nozzle, 1 (black rubber); 19, glass nozzle, small, 1; 20, silver probe, 1; 21, spatula for ointment, 2 (wooden); 22, glass catheter, 2; 23, Halsted clamp, 1; 24, scissors, 1 pair; 25, rectal tube, 1; 26, rubber catheter, small, 1; 27, instrument pan, 1 (white granite); 28, boracic acid unguent, 2 oz.; 29, unguent oxide zinc, 2 oz.; 30, funnel, aluminum, 1; 31, towels, paper, 6; 32, nail-brush, 1; 33, dressing envelope, 1 (made of twilling); 34, cotton; 35, gauze; 36, sterile gauze, 2 packages; 37, bandages; 38, adhesive plaster; 39. envelope for literature, 1 (made of twilling); 40, literature: pediculosis slips, hospital admission slips, bedside charts and envelopes, district cards, directions for patients, Thos. Wilson Fuel Saving Society blanks, Thos. Wilson Savings Bank blanks, Babies Milk Fund Association slips, Social Service slips, list of hospitals, dispensaries, day nurseries, hours for same, forms for Metropolitan Policy Holders and Nursing Manual, rules for agents and nurses, tablet for day's work, street directory; 41, day book and pencil; 42, nurse's crepe apron. 412 A NURSE'S HANDBOOK OF OBSTETRICS. suggests a possible cancer of the uterus. She is to be keenly sensitive to the duty of advising immediate examination by a reputable doctor. Long before the patient suffers pain she may be beyond surgical relief, as the progress of uterine cancer is most insidious. Occasionally a patient will tell a nurse of this symptom before mentioning the matter to any one else. The nurse must see her duty clearly, recognize the possible signifi- cance, and secure medical attention promptly. Cancer is said to be fatal in one woman in every eight and one man in fourteen, over forty years of age. It is curable if recognized locally and removed. It is incurable, in its later progress. Cancer is not impossible in a young woman, but it occurs usually after forty years of age. KEY TO PRONUNCIATION Note that c and g have always their true historical sounds, the so-called " hard," as in cat and go. a as in ask, fast, chant. a as in far, arm, calm. g. as in sofa, America, particular. a as in hat, mat, man. a as in bare, hare, faz'r. a as in American, republican. e as in regime, prostrate, usage. e as in fete, fate, eight. e as in met, men, head. e as in there, where, bear. e as in fern, earth, bird. e as in billet, comet, added. i as in piano, medial, studio. i as in pique, machine, meet. i as in pit, pin, begin. J as in pier, peer, clear. I as in spirit, necessity. o as in obey, potato, biological. 6 as in no, node, sowl. o as in actor, adductor. ovas in not, odd, what. o as in form, broad, fall. o as in atom, gallop. 6 as in German Gothe, gotten u as in instrument, prudential. u as in rule, prudent, move. u as in pull, could, book. u as in burn, co/onel. U as in but, bud, come. ii as in German Mitller, grim, French jms. ai as in aisle, isle, bite. au as in Faust, how, now. iu as in neutrality, emulate. iu as in feud, few, stupid. oi as in oil, coin, boy. c (hard):=k as in cat, ^ing,chasm. ch as in loch, German kocA. cw — qu as in queen, quit. dh = th as in thine, this, smooth. g (hard) as in go, gallon. hw — wh as in where, when. j as in /aw, /udge, edge. ng as in sing, bank. n. (French) as in ton, bon. s as in .yon, .rit, city. sh as in shall, machine, motion. th as in thin, breath. tsh as in church, much, witch. z as in £one, music. zh as in azure, cohesion. 413 GLOSSARY Note.—The definitions and pronunciations in this Glossary are taken, in the main, from Lippincott's Medical Dictionary. The refer- ences to illustrations refer to cuts and other figures in the body of the book. Abdomen (ab-do'men). The belly. Abdominal (ab-dom'i-nal). Belonging to or relating to the abdomen. A. Delivery, delivery of the child by abdominal section. See Cesarean Section. A. Gestation, ectopic pregnancy occurring in the cavity of the abdomen. A. Pregnancy. See Abdominal Gestation. A. Section. See Cesarean Section, Cceliotomy, Laparatomy. Abnormal (ab-nor'mal). Contrary to the usual or natural structure; contrary to the natural condition. Abortifacient (a-bor-ti-fe'shient). i. Causing miscarriage. 2. A drug capable of causing a miscarriage. Abortion (a-bor'shon). The expulsion of the fcetus which is not viable; expulsion of the fcetus during the first three months of pregnancy. Abrasion (ab-re'zhon). 1. The fretting or rubbing off of a patch of skin or other covering. 2. A spot rubbed bare of the skin or nearly so. 3. Denudation by means of chemical action, or by a destructive disease-process. Abscess (ab'ses). A collection of pus contained in a cavity formed in any part of the body by the disintegration and stretching of the tissue. Acid (as'id). 1. Sour, sharp to the taste. 2. Having the chemical prop- erties of an acid. Acid (as'id). In chemistry, a compound having the property of com- bining with an alkali or a base and thus forming a new compound. A. Reaction, a reaction by which litmus paper or solution is turned red by the addition of an acid. Acme (ac'mi). The highest degree or height of a disease; crisis. Accouchement (a-cush-moh'). [French, accoucher, to put to bed, to deliver.] The act of being delivered; delivery. A. Force, rapid delivery, artificially performed; as in cases of eclampsia or placenta praevia. 415 416 GLOSSARY. Accoucheur (a-cu-sher'). [French.] A male midwife; an obstetrician. Accoucheuse (a-cu-shez'). [French.] A midwife. Acute (a-ciut'). Sharp-pointed; ending at a point or in an angle less than a right angle; severe, as acute pain. In medicine the term is applied to diseases having violent symptoms attended with danger and terminating within a few days. Adnexa (ad-nec'saj. Appendages. Uterine A., the Fallopian tubes and ovaries. (Fig. u.) After-birth (after-berth). The structures cast off after the expulsion of the fcetus, including the membranes and the placenta with the attached umbilical cord; the secundines. (Figs. 21 and 22.) After-pains (af'ter-penz). Those pains, more or less severe, after ex- pulsion of the after-birth, which result from the contractile efforts of the uterus to return to its normal condition. Albolene, Alboline (al'bo-lin). An oily substance resembling white vaseline. Albuminuria (al-biu-mi-niu'ri-aj. An albuminous state of the urine. Alimentation (al"i-men-te'shon). The act of taking or receiving nour- ishment. Alkaline (al'ca-lain or -lin). Having the properties of an alkali. A. Reaction, the reaction in which red litmus paper is turned blue by alkalies. Alvine (al'vin or al'vain). Belonging to the belly, stomach, or intestines. A. Dejections, the faeces. Amenorrhcea (a-men-o-ri'aj. Absence or stoppage of the menstrual discharge. Amnion (am'ni-on). The most internal of the fetal membranes, con- taining the waters which surround the fcetus in utero. Amniotic (am-ni-ot'ic). Pertaining to the amnion. A. Sac, the " bag of membranes" containing the fcetus before delivery. Anemia, Anemia (a-ni'mi-aA Deficiency of blood in quantity, either general or local; also, deficiency of the most important constituents of the blood, especially the red blood-corpuscles. Anemic, Anemic (a-nem'ic). In a state of anaemia. Anesthesia, Anesthesia (an-es-thi'zi-3). 1. Loss of feeling or per- ception, especially loss of tactile sensibility. 2. The production of anaesthesia. Anesthetic, Anesthetic (an-es-thet'ic). 1. Having no perception or sense of touch. 2. A medicine having the power of rendering the recipient insensible to pain. Anesthetist, Anesthetist (an-es'thi-tist). A person who administers an anaesthetic. Anchylosis (ang-ci-16'sis). See Ankylosis. GLOSSARY. 417 Ankylosis (ang-ci-16'sis). The consolidation of the articulating sur- faces of two or more bones that previously formed a natural joint; stiff joint. Ante-partum (an"ti-par'tum). Before delivery or childbirth. Anterior (an-ti'ri-or). Situated before or in front of. Antiseptic (an-ti-sep'tic). 1. Preventing sepsis or putrefaction. 2. A substance which prevents or retards putrefaction,—that is, the de- composition of animal or vegetable bodies with evolution of offensive odors. Among the principal antiseptics are: alcohol, creosote, car- bolic acid, common salt, corrosive sublimate (bichloride of mercury), vinegar, sugar, charcoal, chlorine, boric acid, tannic acid, and benzole. A. Dressing, a surgical dressing containing antiseptics. A. Surgery, surgery with proper antiseptic precautions. Anus (e'nus). The external opening of the rectum. Areola (a-ri'o-laj. The ring of pigment surrounding the nipple. (Fig. 41.) Secondary A., a circle of faint color sometimes seen just outside the original areola about the fifth month of pregnancy. Arterial (ar-ti'ri-al). Belonging to an artery. A. Blood, the bright red blood of the arteries which has been aerated (charged with oxygen) in the lungs. A. Hemorrhage, hemorrhage directly from an artery. Artery (ar'te-ri). Any one of the vessels by which the blood is con- veyed from the heart to the organs and members of the body. (So called because they were supposed by the ancients to contain air.) Articular (ar-tic'iu-laj). Relating to joints. Articulation (ar-tic-iu-le'shon). The fastening together of the various bones of the skeleton in their natural situation; a joint. The articu- lations of the bones of the body are divided into two principal groups, — synarthroses, immovable articulations, and diarthroses, movable articulations. Ascites (a-sai'tiz). An accumulation of serous fluid in the peritoneal cavity; dropsy of the peritoneum; dropsy of the belly. Asepsis (a-sep'sis). The absence of septic materials; exclusion of dis- ease germs and other causes of septic poisoning. Aseptic (a-sep'tic). Not septic; free from septic matter; not exposed to the injurious effects of septic materials. Asphyxia (as-fic'si-3). Suspended animation; that state in which there is total suspension of the powers of body and mind, usually caused by interrupted respiration and deficiency of oxygen in the blood, as by hanging or drowning. A. Neonatorum, A. Neophitorum, " asphyxia of the new-born," deficient respiration in new-born children. Aspirating Needle (as'pi-re-ting). A hollow needle attached to a suc- tion syringe for withdrawing fluid from the body. 27 4i8 GLOSSARY. Assimilate (a-sim'i-let). To convert food into nutriment. Astringent (as-trin'jent). I. Binding; contracting. 2. A medicine having the power to check discharges, whether of blood, of mucus, or of any other secretion. Atrophic (a-trof'ic). Relating to atrophy; characterized by atrophy or failure of nutrition. Atrophied (at'ro-fid). Affected with atrophy; wasted. Atrophy (at'ro-fi). Defect of nutrition; wasting or emaciation with loss of strength, unaccompanied by fever. Axilla (ac-sil'aj. The armpit. Bacteria (bac-ti'riaj. The plural of bacterium. A form of microbes or vegetable micro-organisms. Basiotribe (be'si-o-traib). An instrument for crushing the base of the fetal skull. (Fig. 105.) Basiotripsy (be'si-o-trip-si). The crushing of the base of the fetal skull with the basiotribe. Bimanual (bai-man'iu-al). Performed with or relating to both hands. B. Palpation, examination of the pelvic organs of a woman by placing one hand on the abdomen and the fingers of the other in the vagina. Birth (berth). 1. The act of coming into life; the delivery of a child. 2. That which is born. See Delivery. B. Mark, a " maternal mark" or " mother's mark," a mark on the skin from birth,—the effect, as some erroneously sup- pose, of the mother's longing for, or aversion to, particular objects, or of some accidental occurrence affecting her own person during pregnancy. Bladder (blad'er). The urinary bladder; a thin distensible sac with membranous and muscular walls, situated in the anterior part of the pelvic cavity and acting as a reservoir for the urine secreted by the kidneys. Bland (bland). [Latin, blan'dus, agreeable.] Mild, soothing. Bougie (bu'ji or bu-zhe'). A slender instrument primarily designed for introduction into the urethra. (Fig. no.) Breech (britsh). The nates or buttocks. B. Labor or B. Delivery, labor or delivery marked by breech presentation. (Fig. 51.) Cesarean Operation, Cesarean Section (si-ze'ri-an). [From Julius Caesar,—said to have been born this way; more probably from Latin cce'dere, to cut.] The operation of cutting into the womb through the walls of the abdomen and removing a child when natural delivery is impracticable or impossible. GLOSSARY. 419 Capillary (cap'i-le-ri or ca-pil'a-ri). 1. Resembling a hair in size. 2. Pertaining to a fine hair-like tube; pertaining to a capillary ves- sel. 3. One of the minute blood-vessels which form a net-work between the terminations of the arteries and the beginnings of the veins. Caput (ce'put, Latin, cd'put). 1. The head, consisting of the cranium, or skull, and the face. 2. Any prominent object, like the head. C. Incuneatum, impaction of the head of the fcetus in labor. C. Succeda'neum, a dropsical swelling which appears on the pre- senting head of the fcetus during labor, caused by lack of pressure on that part. (Fig. 162.) Carbohydrate (car-bo-hai'dret). Any one of a group of chemical com- pounds, most of which are the sugars and starches and important elements of food. Caries (ce'ri-iz). [Latin, "rottenness."] 1. Ulceration of bone. 2. Decay of the teeth resulting in the formation of cavities. Cartilage (car'ti-lej). 1. Gristle,—a pearly white, glistening substance adhering to the articular surfaces of bones and forming parts of the skeleton. 2. Any organ or part of an organ made up of this material. Ensiform C. See Ensiform. Casein (ce'si-in). The most important of the proteids of milk; con- stituting the basis of cheese in a state of purity. Cathartic (ca-thar'tic). 1. Purging or purgative. 2. A medicine which quickens or increases evacuations from the intestines, or produces purging. Catheter (cath'e-ter). A surgical instrument like a tube, closed, but with one or more perforations towards the closed extremity, for passing into canals or passages,—used especially by introduction into the bladder through the urethra for the purpose of drawing off the urine. (Fig. 68.) Caul (col). A portion of the amniotic sac which occasionally envelops the child's head at birth. Cell (sel). 1. Literally, a " cellar" or " cavity;" hence, any hollow space. 2. One of the minute masses of protoplasm of which organized tissue is composed. Cephalic (se-fal'ic). Belonging to the head. C. Pole, the cephalic extremity of a fcetus. C. Presentation, presentation of any part of the fetal head in labor. (Figs. 43, 46, and 50.) Cephalotomy (sef-a-lot'o-mi). Dissection of the head; also the cutting or breaking down of the fetal head. Cephalotribe (sef'a-lo-traib). An instrument for crushing and extract- ing the fetal head in cases of difficult labor. 420 GLOSSARY. Cephalotripsy (s^f'a-lo-trip'si). The operation of crushing the fetal head with the cephalotribe. Cerebrospinal (ser"i-bro-spai'nal). Relating to the cerebrum and the spinal cord. C. Fluid, the clear, limpid fluid contained in the ventricles of the brain, the subarachnoid spaces and the central canal of the spinal cord. Cervix (ser'vix). The neck, more particularly the back part; also applied to those parts of organs that are narrowed like a neck. C. Uteri, the neck of the uterus; the lower and narrower end of the uterus. (See Fig. 12.) Chloasma (clo-az'maj. PI. chloasmata. A cutaneous affection exhibit- ing spots and patches of a yellowish-brown color. The term chlo- asma is a vague one and is applied to various kinds of pigmentary discolorations of the skin. C. Gravidarum, C. Uterinum, chloasma occurring during preg- nancy. Chorea (co-ri'aj. St. Vitus's dance; a convulsive disease characterized by irregular and involuntary movements of the limbs. It usually occurs in early life and affects girls more frequently than boys. Chorion (co'ri-on). The second, or most external, of the fetal mem- branes. Chromicized Catgut (cro'mi-saizd). Catgut treated with chromic acid for use as ligatures or sutures. Chronic (cron'ic). Long continued; lasting a long time; opposed to acute. Cicatricial (sic-a-trish'oT). Of the nature of, or relating to, a cicatrix. Cicatrix (si-ce'trix). PI. cicatrices. A scar; an elevation or seam con- sisting of a new tissue formation replacing tissue lost by a wound, sore, or ulcer. Circulatory (ser'ciu-le-to-ri). Relating to, or affecting, the circulation. C System, the system of the animal body consisting of the heart, arteries, capillaries, and veins, through which the blood circulates. Climacteric (clai-mac-ter'ic or clai-mac'te-ric). A particular epoch of the ordinary term of life, marked by periods of seven years, at which the body is supposed to be peculiarly affected and to siuffer consid- erable change; especially, the menopause or grand climacteric. The menopause or " change of life." Clitoris (clit'o-ris). A small, elongated, erectile body at the anterior angle of the vulva. (See Fig. 8.) Clonic (clon'ic). Applied to spasms in which the contractions and relaxations are alternate. Coagulated (co-ag'iu-le-ted). Clotted. GLOSSARY. 421 Coaptation (co-ap-te'shon). The fitting together of the ends of a frac- tured bone or the edges of a wound. Cceliotomy (si-li-ot'o-mi). Abdominal section; surgical opening of the abdominal cavity. Collapse (co-laps'). 1. A falling or caving in. 2. A state of extreme depression or complete prostration of the vital powers, such as occurs after severe injury or excessive bleeding. Colostrum (co-los'trum). A substance in the first milk after delivery, giving to it a greenish or yellowish color. C. Corpuscles, large, granular cells found in colostrum. Colpeurynter (col-piu-rin'ter). A dilatable bag, used to stretch the vagina by introducing the bag in a flaccid condition and then dis- tending it by the forcible injection of air or water. Colpeurysis (col-piu'ri-sis). Dilatation of the vagina by means of a colpeurynter. Coma (co'mg). A state of lethargic drowsiness, produced by compres- sion of the brain and other causes. Comatose (co'ma-tos). 1. Having a constant propensity to sleep; full of sleep. 2. Relating to coma. Conception (con-sep'shon). The impregnation of the female ovum by the semen of the male, whence results a new being. Congenital (con-jen'i-tal). Born with a person; existing from or from before birth, as, for example, congenital disease, a disease originating in the fcetus before birth. Congestion (con-jes'tshon). An excessive accumulation of the contents of any of the blood-vessels or ducts. Conjunctiva (con-jungc-tai'vg). The delicate mucous membrane lining the eyelids and covering the external portion of the eyeball. Conjunctival (con-jungc-tai'val). Pertaining to the conjunctiva. Conjunctivitis (con-jungc-ti-vai'tw). Inflammation of the conjunctiva. Constriction (con-stric'shon). A contraction or stricture; that which constricts. Contraindication (con"tr^-in-di-ce'shon). That which forbids the use of a remedy which otherwise it would be proper to exhibit. Any condition of disease which renders some special line of treatment or some particular remedy undesirable or improper. Convalescence (con-va-les'ens). The state or period between the re- moval of actual disease and the full recovery of the strength. Convalescent (con-va-les'ent). Returning to full health after a disease is removed. C. Diet, a diet for convalescing patients consisting of any light, simple, and appetizing food. Convulsion (con-vul'shon). Violent agitation of the limbs or body, generally marked by clonic spasms. 422 GLOSSARY. Cornea (cor'ni-a.). The transparent structure forming the anterior part of the eyeball. Coronal (cor'o-nal). Belonging to, or relating to, the crown of the head. C. Suture, the suture formed by the union of the frontal bone with the two parietal bones. (See Fig. 27.) Couveuse (cu-vez'). An arrangement or apparatus designed for the preservation and development of infants prematurely born or other- wise feeble. An incubator, which term is in more common use in the United States. Cranioclasis, Cranioclasm (cre-ni-o-cle'sts, cre'ni-o-clazm). The crushing of the fetal skull. Cranioclast (cre'ni-o-clast). An instrument used in effecting cranio- clasis. (Fig. 104.) Craniotomy (cre-ni-ot'o-mi). The opening of the fetal skull when nec- essary to effect delivery. C. Scissors, strong S-shaped scissors for use in craniotomy. (Fig. 109.) Crotchet (crotsh'et). A curved instrument for extracting the fcetus after craniotomy. No longer used. Curd (curd). The coagulum which separates from milk upon the addi- tion of acid, rennet, or wine. It consists of casein with most of the fatty elements of the milk. Curettage (ciu-ret'ej). The act of using a curette. Curette (ciu-ret'). [French.] 1. A sort of scraper or spoon used in removing granulations, foreign bodies, incrustations, etc., from the walls of normal or other cavities in the body. Most commonly used for removing diseased tissue or foreign matter such as retained pla- cental tissue from the walls of the uterus. (Fig. 120.) 2. To use a curette. Curettement (ciu-ret'ment). Same as Curettage. Cutaneous (ciu-te'ni-us). Belonging to the skin. Cutis (ciu'tis). The skin, consisting of the cutis vera and the epi- dermis. Also, the cutis vera, or true skin. Cyanosis (sai-a-no'sis). A blue color of the skin resulting from con- genital malformation of the heart from some defect of the' pulmonary circulation by which the venous blood is not wholly oxygenated. Cyanotic (sai-a-not'ic). Relating to cyanosis; affected with cyanosis. Decapitation (di-cap-i-te'shon). The removal of the head of the fcetus in embryotomy. Decidua (di-sid'iu-3). The membranous structure produced during ges- tation and thrown off from the uterus after parturition. It consists GLOSSARY. 423 of the greatly changed uterine mucous membrane and the fetal envelopes. D. Reflexa, that portion of the decidua which is reflected over and surrounds the ovum. D. Serotina, " late decidua," that portion of the decidua vera which becomes the maternal part of the placenta. D. Vera, that portion of the decidua which lines the interior of the uterus. (Fig. 19.) Decomposition (di-com-po-zish'on). 1. The separation of compound bodies into their constituent parts or principles; analysis. 2. Putre- factive decay. Delirium (di-lir'i-um). A derangement of the functions of the brain characterized by incoherent and wandering talk, illusions, and un- steady gait. Delivery (di-liv'er-i). [French, delivrer, to free, to deliver.] 1. The expulsion of a child by the mother, or its extraction by the obstetric practitioner. 2. The removal of a part from the body; as delivery of the placenta. Denudation (den-iu-de'shon). The laying bare of any part of an animal or plant; the stripping off of the integument, whether by a surgical or by a pathological process. Denuded. Laid bare. Diagnosis (dai-ag-no'sis). The art or science of signs or symptoms by which cne disease is distinguished from another. Diagnostic (dai-ag-nos'tic). 1. Relating to diagnosis. 2. Distinctive; of sufficient value to enable one to make a diagnosis. Diaphoresis (dai"a-fo-ri'sis). A state of perspiration; profuse per- spiration ; sweat. Diaphoretic (dai"a-fo-ret'ic). 1. Causing perspiration. 2. A medicine having the power to produce diaphoresis. Diathesis (dai-ath'e-sis). A particular habit or disposition of the body which renders it peculiarly liable to certain diseases; constitutional predisposition. Diet (dai'et). The food proper for invalids. Also, the regulation of food to the requirements of health and the cure of disease. D.-Sheet, a written or printed dietary. Dietary (dai'e-te-ri). A system or course of diet; a regulated allowance of food given to each person daily. See Diet-Sheet. Dietetic (dai-e-tet'ic). Belonging to the taking of proper food, or to diet. D. Treatment, treatment of disease by careful and scientific regulation of the diet. Differential (dif-e-ren'shal). Making a difference; showing a differ- ence; distinguishing. 424 GLOSSARY. D. Diagnosis, the determining of the distinguishing featur.es of a malady when nearly the same symptoms belong to two different classes of disease, as in gout and rheumatism or epilepsy and eclampsia. Dilute, Diluted (dai-liut', dai-liu'ted). Mixed, weak; reduced in strength; rendered weaker by the addition of water. Disintegration (dis-in-ti-gre'shon). The separation of the integrant parts or particles of a body. Diuresis (dai-iu-ri'sis). Increased discharge of urine, from whatever cause. Diuretic (dai-iu-ret'ic). i. Belonging to diuresis; causing diuresis. 2. A medicine which increases the flow of urine. Dropsy (drop'si). The accumulation of serous fluid in the tissues or in the thorax or abdomen. Duct. A tube or canal by which a fluid is conveyed. Ductus (duc'tus). A duct. D. Arteriosus, " arterial duct," a blood-vessel peculiar to the fcetus, communicating directly between the pulmonary artery and the aorta. (See Figs. 28 and 29.) D. Venosus, " venous duct," a blood-vessel peculiar to the fcetus, establishing a direct communication between the umbilical vein and the descending vena cava. (See Figs. 28 and 29.) Dysmenorrhea (dis-men-o-ri'q.). Difficult and painful menstruation. Dyspncea (dis-pni'aj. Difficult or labored breathing. Dystocia (dis-to'si-3). Difficult, slow, or painful birth or delivery. It is distinguished as Maternal or Fetal according as the difficulty is due to some deformity on the part of the mother or on that of the child. Placental D., difficulty in delivering the placenta. Eclampsia (ec-lamp'si-3). Any epileptiform seizure, especially recurrent convulsions, not immediately due to disease of the brain. Puerperal E., a convulsive attack coming on in women during or after labor and due probably to uraemia. Ectopic (ec-top'ic). Out of place. E. Gestation, gestation in which the fcetus is out of its normal place in the cavity of the uterus. See Extra-uterine Preg- nancy. E. Pregnancy, same as Ectopic Gestation. E. Sac, the amniotic sac in ectopic gestation. Eczema (ec'ze-ma). A superficial affection of the skin characterized by a smarting eruption of small vesicles, generally crowded together, without fever, and not contagious. Eczematous (ec-zem'a-tus). Belonging to or affected with eczema. GLOSSARY. 425 Eliminate (i-lim'i-net). To put out or expel; to throw off or set free. Elimination (i-lim-i-ne'shon). The act of expelling from the body as waste products. Eliminative (i-lim'i-ne-tiv). 1. Tending to increase elimination or ex- cretion. 2. Any agent or remedy that promotes excretion. Emaciation (i-me-shi-e'shon). The state of being or becoming lean. Embolism (em'bo-lizm). The obstruction of an artery or a vein by a clot of coagulated blood, or by any body brought from some point away from the site of obstruction. See Embolus and Thrombus. Air E., embolism in which the obstruction consists of air-bubbles. Embolus (em'bo-lus). A piece of blood-clot which has been formed in the larger vessels in certain morbid conditions and has afterwards been forced into one of the smaller arteries so as to obstruct the circulation. Embryo (em'bri-6). The product of conception in utero before the end of the third month of pregnancy; after that it is called the fcetus. (Fig. 24.) Embryotomy (em-bri-ot'o-mi). The destruction or separation of any part or parts of the fcetus in utero when circumstances exist to prevent delivery in the natural way. Emetic (i-met'ic). 1. Having the power to excite vomiting. 2. A medicine which causes vomiting. Emmenagogue (e-men'a-gog). A medicine having the power to promote the menstrual discharge. Emulsion (i-mul'shon). An oily or resinous substance suspended in water through the agency of mucilaginous or adhesive substances. Milk is a natural and perfect emulsion. Emunctory (i-mungc'to-ri). 1. Excretory. 2. Any excretory duct of the body. Enema (erie-mq). A medicine to be thrown into the rectum; a clyster; a rectal injection. Enervation (en-er-ve'shon). Weakness; languor; lack of nerve stimulus. Ensiform (en'si-form). Like a sword; sword-shaped. E. Appendix, Cartilage, or Process, the extremity of the ster- num or breast-bone. Epidemic (ep-i-dem'ic). 1. A term applied to any disease which seems to be upon the entire population of a country at one time, as distin- guished, on the one hand, from sporadic disease (or that which occurs in isolated cases) and, on the other, from endemic disease (or that which is limited to a particular district). 2. An epidemic disease; the season of prevalence of any epidemic disease. Epilepsy (ep'i-lep-si). The falling sickness; a chronic non-febrile nervous affection, characterized by seizures of loss of consciousness, with tonic or clonic convulsions ("fits"). The ordinary duration of 426 GLOSSARY. a fit is from five to twenty minutes. The frequency of the attacks or fits varies immensely; in some cases they occur daily and in others at intervals of ten years or more. Epileptic (ep-i-lep'tic). i. Belonging to epilepsy. 2. A person affected with epilepsy. Epileptiform (ep-i-lep'ti-form). Like epilepsy. Episiotomy (ep"i-sai-ot'o-mi). Surgical or obstetrical incision of the vulvar orifice. Ergot (er'got). A drug having the remarkable property of exciting pow- erfully the contractile force of the uterus, and chiefly used for this purpose, but its long-continued use is highly dangerous. Usually given in the fluid extract. Dose, gss-ii. Ergotin (er'go-tin). The extract of ergot or active principle of ergot. Dose, Vu to V2 grain. Ergotole (er'go-tol). A proprietary preparation of ergot said to possess double the strength of the official fluid extract. Dose, gss-i. Erosion (i-ro'zhon). An eating or gnawing away: similar to ulceration. Evacuation (i-vac-iu-e'shon). i. The act of discharging the contents of the bowels, or defecation. 2. The discharge itself; a dejection or stool. Evisceration (i-vis-e-re'shon). Taking the bowels or viscera out of the body. Obstetric E., removal of the abdominal or thoracic viscera of the fcetus in embryotomy. Exacerbation (eg-zas-er-be'shon). 1. An increased force or severity of the symptoms of a disease. 2. The stage or time of periodical aggravation in certain fevers. Excoriation (ecs-co-ri-e-shon). Abrasion or removal, partial or com- plete, of the skin. Excrement (ecs'cri-ment). Originally, anything that is excreted: usually applied to the alvine faeces. Excrementitious (ecs"cri-men-tish'us). Belonging to excrement. Excrete (ecs-crit'). To separate from the bodily tissues useless matter which is to be cast out of the system. Excretion (ecs-cri'shon). 1. The separation of those fluids from the blood which are supposed to be useless, as urine, perspiration, etc. 2. Any such fluid itself. Exostosis (ec-sos-to'sis). An exuberant growth of bony matter on the surface of a bone. Expiration (ecs-pi-re'shon). The act of breathing out or expelling air from the lungs. Expiratory (ecs-pair'e-to-ri). Relating to or of the nature of expiration. Expire (ecs-pair'). 1. To expel the breath; to breathe out. 2. To die. Expulsive (ecs-pvl'siv). Tending towards, promoting, or causing ex~ pulsion. GLOSSARY. 427 E. Pains, labor-pains occurring during the expulsive stage and accomplishing the expulsion of the fcetus. E. Stage, that stage of labor which follows complete dilatation of the uterine cervix, during which the expulsion of the fcetus takes place; the second stage of labor. Exsanguination (ec-sang-gui-ne'shon). The state of beir.g without blood. Extension (ecs-ten'shon). The reverse of flexion. Extravasation (ecs-trav-a-se'shon). The escape of any fluid of the body, normal or abnormal, from the vessel, cavity, or canal that naturally contains it, and its diffusion into the surrounding tissues. Extra-uterine (ecs-tr^-iu'te-rin). Outside of the uterus. E. Life, life after birth. E. Pregnancy, pregnancy in which the fcetus is contained in some organ outside of the uterus. Feces (fi'siz). The alvine excretions or excrement. The matter ex- pelled from the bowels at stool. Fallopian (fa-16'pi-an). [Relating to G. Fallopius, a celebrated Italian anatomist of the sixteenth century.] F. Tubes, the oviducts,—two canals extending from the side of the fundus uteri to the ovaries. (Fig. 11.) F. Pregnancy, pregnancy occurring in the Fallopian tubes,— same as tubal pregnancy. Febrile (fi'bril, or feb'ril). Belonging to fever; feverish. Fecal (fi'cal). Relating to faeces: containing faeces. Fecundation (fec-un-de'shon). The act of impregnating or the state of being impregnated; the fertilization of the ovum by means of the male seminal element. Fenestrated (fen-es-tre'ted). Pierced with openings. Fetus (fi'tus). The same as Fcetus. The spelling fetus is preferable from a linguistic point of view; but the other is far more common in professional literature. Fillet (fil'et). A noose for making traction on the foetus in difficult labor. Never used now. Finger Cot. A thin rubber covering for the finger to protect it from the air or from septic discharges. Occasionally used as a dressing to cover a slight wound or abrasion of the finger. Fissure (fish'iur). A crack or narrow opening. Flex (flex). To bend, as a joint or a jointed limb. Flexion (flec'shon). The act of bending; the state of being bent. F. Stage, that stage of labor in which the head of the fcetus bends forward. Fcetus (fi'tus). The child in utero from the end of the third month of 428 GLOSSARY. pregnancy till birth. (See Fig. 25.) During the first three months the product of conception is known as the embryo. Fontanel, Fontanelle (fon-ta-nel'). The quadrangular space between the frontal and two parietal bones in very young children. This is called the anterior f. and is the familiar " soft spot" just above a baby's forehead. A smaller, triangular one (posterior f.) sometimes exists between the occipital and parietal bones. Foramen (fo-re'men). A hole, opening, aperture, or orifice,—especially one through a bone. F. Ovale, an opening situated in the partition which separates the right and left auricles of the heart in the fcetus. Forceps (for'seps). An instrument consisting of two arms which can be approximated and used for grasping a part. (Figs. 83, 84, 85, and 86.) Formula (for'miu-laj. 1. A short Torm of prescription in practice in place of the more full instruction in the Pharmacopoeia. 2. A concise mode of indicating by symbols the chemical constituents of a com- pound or the result of chemical changes. Fornix (for'nics). PI. fornices. An arch; any vaulted surface. F. of the Vagina, the angle of reflection of the vaginal mucous membrane onto the cervix uteri. Fourchette (fur-shet'). [French, "fork."] The posterior angle or commissure of the labia majora. Friable. Easily reduced into small pieces. Function (fungc'shon). A power or faculty by the exercise of which the vital phenomena are produced; the special office of an organ in the animal or vegetable economy. Fundus (fun'dus). The base or bottom of any organ which has an external opening considered as the top. F. Uteri, the base of the uterus, which is to be considered as upside down with the top (os) pointing downward. (See Fig. 12.) Funis (fiu'm's). A cord,—especially the umbilical cord. Galactagogue (ga-lac'ta-gog). 1. Causing the flow of milk. 2. Any drug which causes the flow of milk to increase. Gastric (gas'tric). Belonging to the stomach. Genital (jen'i-toT). 1. Belonging to generation.. 2. Relating to the genital organs. Genupectoral (jen-iu-pec'to-raT). [Latin, ge'nu, knee, + pec'tus, breast.] Relating to the knees and chest. G. Position, that posture in which the patient rests on the knees with the thighs upright, the head and upper part of the chest being on the table or bed. The knee-chest position. GLOSSARY. 429 Germicidal (jer'mi-sai-dal). Destroying germs. Germicide (jer'mi-said). A substance which has the power of destroy- ing micro-organisms. Gestation (jes-te'shon). The condition of a pregnant female; preg- nancy ; gravidity. G. Sac, the sac enclosing the embryo in ectopic pregnancy. Gland (gland). An organ consisting of blood-vessels, absorbents, and nerves, for secreting or separating some particular fluid from the blood. Glandular (glan'diu-lar). Pertaining to or like a gland in appearance, function, or structure; also, furnished with glands. Glans (glanz). An acorn-shaped organ. G Clito'ridis, the bulbous extremity of the clitoris. G. Pe'nis, the nut-like head or end of the penis. Graafian Follicles or Vesicles (graf'i-an). Small spherical bodies in the ovaries, each containing an ovum. (Fig. 15.) Granulation (gran-iu-le'shon). The process by which little grain-like, conical fleshy bodies form on ulcers and suppurating wounds, filling up the cavities, and bringing nearer together and uniting their edges. 2. One of the bodies thus formed. Gravid Uterus (grav'id). The uterus in the impregnated state or during gestation. Gravidity (gre-t/id't-ti). The condition of a woman who is pregnant; gestation; pregnancy. Gynecic, Gynecic (ji-ni'sic). Relating to the female sex or to women. Gynecologist, Gynecologist (jin-i-col'o-jist). One who is skilled in gynaecology. Gynecology, Gynecology (jin-i-col'o-ji). A treatise on woman and the peculiarities of her constitution as compared with man; the science which treats of the female constitution and particularly of the dis- eases and injuries of the female genital organs. Hemorrhage, Hemorrhage (hem'o-rej). Escape of the blood from its natural channels; bleeding. Hemorrhoid, Hemorrhoid (hem'o-roid). A pile; a vascular tumor im- mediately within (internal h.) or just outside of (external h.) the" anus. Hemorrhoids are termed blind when they do not cause hemor- rhage and bleeding when they do. Hernia (her'-ni-aj. the displacement, through an abnormal opening, of an organ or tissue, most commonly of a portion of the intestine from the cavity in which it is naturally contained; a " rupture." Hydrometer (hai-drom'e-ter). An instrument for ascertaining the spe- cific gravity of fluids. Hygiene (hai'ji-in). That department of medicine which has for its direct object the preservation of health or the prevention of disease. 43° GLOSSARY. Hygienic (hai-ji-en'ic). Belonging to hygiene. Hypersecretion (hai"per-si-cri'shon). Excessive secretion. Hypertrophy (hai-per'tro-fi). Enlargement of a part or an organ, espe- cially when due to over-nutrition. Hypodermatic, Hypodermic (hai"po-der-mat'ic, hai-po-der'mic). I. Con- nected with the application of medicine under the skin; subcuta- neous. 2. A medicine introduced under the skin. H. Injection, an injection beneath the skin of drugs or nutrient solutions. H. Needle, the hollow needle forming the nozzle of a hypo- dermic syringe. H. Syringe, a small syringe with a fine-pointed nozzle for in- jecting fluids under the skin. Hypogastric Arteries. Same as the umbilical arteries which accompany and form part of the umbilical cord. Hysteria (his-ti'ri-a.). A functional disease often observed in young unmarried women, in which there may be a simulation of almost any disease and a great lack of self-control. Iliac (il'i-ac). Belonging to the ilium or the flanks. I. Artery, either of two arteries, right and left, given off from the abdominal aorta and dividing to form the external and internal iliac arteries on each side of the body. I. Fossa, a broad and shallow cavity at the upper part of the inner surface of the ilium. Ilium (il'i-um). PI. il'ia. The haunch bone; the broad, flat, upper portion of the innominate bone. (Fig. i.) Impregnation (im-preg-ne'shon). The act of making, or state of being pregnant; fecundation. Incise (in-saiz'). To cut, as with a knife. Incised Wound (in-saizd' wund). A wound made by a sharp cutting instrument. Incision (in-sizh'on). A wound made by cutting,—especially an opera- tion-wound. Incubator (in'ciu-be-tor). See Couveuse. Indurate, Indurated (in'diu-ret, -re-ted). Made hard; hardened. Induration (in-diu-re'shon). The state or process of hardening of the tissues from any cause; the hardening of any part from the effect of disease; any part or tract of abnormally hardened tissue. Infection (in-fec'shon). i. The communication of a disease by personal contact with the sick or by means of effluvia arising from the body of the sick; contagion. 2. The agent by which a communicable disease is conveyed; a contagium. Septic I., infection caused by septic germs. See Septic. GLOSSARY. 431 Infectious (in-fec'shus). Capable of extension by infection; con- tagious ; easily communicated. Inflammation (in-fla-me'shon). A state of disease characterized by redness, pain, heat, and swelling, attended or not with fever. Infusion (in-fiu'zhon). To pour in or upon. In surgery the injection of hot normal salt solution C/w per cent.) into a blood-vessel. Venous I., when the injection is made into a vein. Arterial I., when the injection is made into an artery. Subcutaneous I., when the injection is made into the subcu- taneous connective tissue, usually under the breast, over the shoulder-blade, or in the outer side of the thigh. Ingest (in-jest'). To throw in, or put in, as food into the stomach. Ingesta (in-jes't^). Food taken into the body by the mouth. Ingestion (in-jes'tshon). The act of putting or taking food into the stomach. Inhalation (in-he-le'shon). A drawing of the air into the lungs; the inspiring of medicated or poisonous fumes with the breath. Insomnia (in-som'ni-aj. Want of sleep; wakefulness; chronic or habitual privation of sleep. Innominate (i-nom'i-net). Having no name; unnamed. I. Bone, the hip-bone, composed of the ilium, ischium, and os pubis. (Fig. 1.) Innominatum (i-nom-i-ne'tum). The innominate bone. (Fig. 1.) Inspiration (in-spi-re'shon). The act of drawing in the breath. Inspiratory (in-spai're-to-ri). A term applied to muscles which by their contractions increase the dimensions of the chest and thus produce inspiration. Intertrigo (in-ter-trai'go). An excoriation or galling of the skin about the anus, axilla, or other part of the body, with inflammation and moisture. Intestine (in-tes'tin). The long membranous tube, continuing from the stomach to the anus, in the cavity of the abdomen; the bowels or entrails. Inunction (in-ungc'shon). The act of rubbing in an ointment, or simply of anointing. This is a method of applying certain substances to the cutaneous surface, the object being to promote their absorption. In utero. Inside the uterus. Inversion (in-ver'shon). A turning upside down, inside out, or end for end. I. of the Uterus, the state of the womb being turned inside out, caused by violently drawing away the placenta before it is detached by the natural process of labor. (Fig. 125.) 432 GLOSSARY. Involution (in-vo-liu'shon). i. A rolling or pushing inward. 2. A retrograde process of change the reverse of evolution: particularly applied to the return of the uterus to its normal size and condition after parturition. Irrigation (ir-i-ge'shon). 1. The continual application of water or of a lotion on an affected part; the washing out of a cavity by a stream of water. 2. The liquid used in washing out a cavity or a wound. Ischium (is'ci-um). The posterior and inferior bone of the pelvis, dis- tinct and separate in the fcetus or the infant; or the corresponding part of the innominate bone in the adult. (Fig. 1.) Jaundice (jan'dis, or jondis). Yellowness of the skin, eyes, tissues, and secretions generally from impregnation with bile-pigment; icterus. Knee-chest Position. See Genupectoral Position. Labia (le'bi-aj. The nominative plural of labium. Lips or lip-like structures. L. Majora, the folds of skin containing fat and covered with hair which form each side of the vulva. L. Minora, the nymphae, or folds of delicate skin inside of the labia majora. (Fig. 8.) Labor (le'bor). Parturition; the process by which a foetus is separated and expelled from its mother. Dry L., when there is a lack of amniotic fluid. Induced L., when brought on by outside interference. Missed L., when the normal processes cease and the fcetus is retained. Precipitate L., when of abnormally short duration. Premature L., when occurring before the normal time. Spontaneous L., when without any assistance. Laceration (las-e-re'shon). The act of tearing; a rent or torn place in any tissue; a wound made by tearing. Lactation (lac-te'shon). The act or period of giving suck; the secretion of milk; the time or period of secreting milk. Lacteal (lac'ti-al). Resembling or relating to milk. L. Calculus, a concretion of thickened milk occurring in the breast. L. Swelling, swelling of the breast from accumulation of milk due to obstruction of the lacteal ducts. Lactiferous (lac-tif'e-rus). Practically the same as lacteal. GLOSSARY. 433 Lactometer (lac-tom'e-ter). An hydrometer for determining the specific gravity of milk. Lambdoid, Lambdoidal (lam'doid, lam-doi'dal). Having the shape of the Greek letter A L. Suture, the suture between the occipital and two parietal bones. (See Fig. 27.) Laparotomy (lap-a-rot'o-mi). Cutting into the abdominal cavity through the flank; less correctly, abdominal section at any point. Larynx (lar'ingcs). That portion of the air-passages between the base of the tongue and the windpipe. Laxative (lac'sa-tiv). 1. Slightly purgative or aperient; mildly cathar- tic. 2. A laxative medicine. Lesion (li'zhun). A hurt, wound, or injury of a part; a pathological alteration of a tissue. Lethargic (le-thar'jic). Belonging to lethargy; in a state of lethargy. Lethargy (leth'ar-ji). A state of marked drowsiness, stupor, or sleep which cannot easily be driven off. Leucorrhcea (liu-co-ri'aj. A whitish discharge from the female genital organs; the whites. Ligature (lig'a-tshur). A thread or cord used for tying around an artery, vein, or any growth. Linea (lin'i-aj. PI. tinea. A line or thread. L. Alba, the central tendinous line extending from the pubic bone to the ensiform cartilage. Linee Albicantes, shining whitish lines upon the abdomen caused by pregnancy or distention; striae gravidarum. (Fig. 30.) Liquor (lic'or, or lai'cwor). A liquid. L. Amnii, the fluid contained within the amnion in which the fcetus floats. Lithotomy Position (li-thot'o-mi). The position of a patient flat on the back with legs and thighs flexed and thighs separated widely; also called the dorso-sacral posture. Lochia (16'ci-aJ. The discharge from the genital canal during several days subsequent to delivery. Lochial (16'ci-al). Relating to the lochia. Lying-in (lai"ing-in'). The puerperal state. L. Fever, puerperal fever. L. Hospital, a hospital where pregnant women are cared for before, during, and after labor. Malaise (mal-ez'). [French, mal, ill, + aise, ease.] Discomfort or un- easiness; indisposition. Malposition (mal-po-zish'on). An abnormal position, as of the fcetus; a displacement. (See Fig. 52.) 28 434 GLOSSARY. Malpractice (mal-prac'tis). Practice contrary to good judgment, whether from ignorance, carelessness, or a wrong motive. Mamma (mam'aj. PI. mamma. ["Ma-ma," the instinctive cry of an infant.] The breast of the human female. (Fig. 14.) Mammary (mam'a-ri). Belonging to the mamma, or female breast. Mania (me'ni-3). A form of insanity marked by an exalted but per- verted mental activity. Maniacal (me-nai'a-cal). Affected with mania; resembling mania. Manual (man'iu-al). Relating to, or performed by, the hands. Massage (ma-sazh'). The systematic therapeutical use of rubbing, kneading, stroking, slapping, straining, pressure, and other passive exercises applied to the muscles and accessible parts. Maternal (me-ter'nal). Relating to or originating with the mother. Maternity (me-ter'ni-ti). 1. Motherhood; the condition of being a mother. 2. A lying-in hospital. M. Nurse, an obstetric nurse. Meatus (mi-e'tus). A passage; an opening leading to a canal, duct, or cavity. M. Urinarius, the external orifice of the urethra. (Fig. 8.) Meconium (mi-co'ni-um). The dark-green or black substance found in the large intestine of the foetus or newly born infant. Median (mi'di-an). In the middle; between others; medial or mesial. Melancholia (mel-an-co'li-3). A form of insanity (and a condition of mind bordering upon insanity) in which there is great depression of spirits, with gloomy forebodings. Melancholic (mel-an-col'ic). Belonging to melancholia. Membrane (mem'bren). A skin-like tissue used to cover some part of the body, and sometimes forming a secreting surface. Mucous mem- branes line cavities and canals which communicate with the external air, as the nose, mouth, etc. Serous membranes line cavities which have no external communication, such as the pleural and peritoneal cavities. They have a smooth, glossy surface from which exudes a transparent serous fluid that gives to them their name. When this fluid is secreted in excess dropsy of those parts is the result. The word " Membranes" is also used to indicate the amniotic sac which surrounds the fcetus. Menses (men'siz). [PI. of Latin mensis, month.] The periodical monthly discharge of blood from the uterus; the catamenia. Menstrual (men'stru-al). Relating to, or caused by, the menses. Menstruate (men'stru-et). To have the catamenial flow; to have the " monthly flow." Menstruation (men-stru-e'shon). The monthly period of the discharge of a red fluid from the uterus; the function of menstruating. It occurs from puberty to the menopause. GLOSSARY. 435 Menopause (men'o-poz). The period at which menstruation ceases; the " change of life." Microscopic (mai-cro-scop'ic). So minute that it can be seen only by means of a microscope. Midwife (mid'waif). A woman who delivers women with child; a female obstetrician. Miscarriage (mis-car'ej). The expulsion of the fcetus at any time between the third and sixth month of gestation. More generally used to indicate the expulsion of the foetus at any time up to the period of viability of the child. Mons Veneris (monz ve'neris). The eminence in the upper and anterior part of the pubes of women. (Fig. 8.) Monster (mon'ster). A fcetus born with a redundancy or deficiency, a confusion or transposition, of parts. For example, a child born with two heads or with but one eye. Monstrosity (mon-stros'i-ti). A monster. Monthlies (munth'liz). The menses. Morbid (mor'bid). Diseased or pertaining to disease. Morbid is used as a technical or scientific term in contradistinction to the term healthy. Morbidity, Morbility (mor-bid'i-ti, mor-bil'l-ti). i. The condition of being diseased. 2. The amount of disease or illness existing in a given community; the sick-rate. Mother's Mark. A naevus; a birthmark. Mucosa (miu-co's%). A mucous membrane. Mucous, Mucose (miii'cus, miu'cos). Belonging to or resembling mucus; covered with a slimy secretion or with a coat that is soluble in water and becomes slimy. M. Membrane. See Membrane. Mucus (miu'cus). The viscid liquid secretion of a mucous membrane. Multigravida (mul-ti-grav'i-daj. A woman who has been pregnanl several times, or many times. Multipara (mul-tip'a-rg.). A woman who has borne several, or many, children. Mummification (mum"i-fi-ce'shon). The shrivelling up and compres- sion of a dead fcetus. Nevus (ni'vus). A natural mark or blemish; a mole, a circumscribed deposit of pigmentary matter in the skin. Nates (ne'tiz). The buttocks. Nausea (nd'shaj. Originally, sea-sickness. Any sickness at the stomach similar to sea-sickness. Navel (ne'vel). The umbilicus. N. String, the umbilical cord. 436 GLOSSARY. Nephritis (ne-frai'tis). Inflammation of the kidney. Neurotic (niu-rot'ic). Of or belonging to the nerves; nervous, Neutral (niu'tral). Neither one nor the other; indifferent. N. Reaction, a reaction which is neither acid nor alkaline. Nitrogenous (nai-troj'e-nus). Containing nitrogen; nitrogenized. Nodular (nod'iu-laj). Belonging to a nodule; having the form of a nodule. Nodule (nod'iul). A little node; a small rounded mass. Normal (nor'mal). Regular; without any deviation from the ordinary structure or function; according to rule. Nutrient (niu'tri-ent). I. Nutritious; nourishing. 2. A nutritious sub- stance. N. Enema, an injection of nutrient fluid into the rectum for the purpose of maintaining the strength of the system when, for any reason, food cannot be taken into the stomach. Nutriment (niu'tri-ment). Nourishment. Nutrition (niu-trish'on). The assimilation or identification of nutritive matter to or with our organs. Nutritious (niu-trish'us). Nourishing; affording nourishment or nutrition. Nutritive (niu'tri-tiv). Pertaining to nutrition; capable of repairing the waste of the body; nutritious. N. Enema, same as Nutrient Enema. Obstetric, Obstetrical (ob-stet'ric, ob-stet'ri-caD. Belonging to mid- wifery or obstetrics. Obstetrician (ob-ste-trish'an). An accoucheur, or man-midwife; a practitioner of obstetrics; one who is skilled in obstetrics. Obstetrics (ob-stet'rics). [Latin, obstetrix, midwife.] The art of as- sisting women in child-birth and of treating their diseases during pregnancy and after delivery; midwifery. Occiput (oc'si-put). The back part of the head. OZdema (i-di'maj. A swelling from effusion of serous fluid into the cellular substance; a dropsical swelling. Oligohydramnios (ol"i-go-hai-dram'ni-os). Deficiency of the amniotic fluid. Opacity (o-pas't-ti). 1. Incapability of transmitting light; the reverse of transparency. 2. Any defect in the transparency of the cornea, from a slight film to an intense whiteness. Organ (or'gan). A part of an animal or vegetable capable of perform ing some act or office appropriate to itself, as, for example, the heart, the lungs, or the stomach. Os. Mouth. O. Externum (external os), the external opening of the canal of the cervix. GLOSSARY. 437 O. Internum (internal os), the internal opening of the canal of the cervix. O. Uteri, "mouth of the uterus." (See Fig. 12.) Os. [PI. ossa.] A bone. O. Innominatum, the innominate bone. (Fig. 1.) Osmosis (os-mo'sis). The power or action by which liquids are impelled through a moist membrane and other porous partitions. Osteomalacia (os"ti-o-ma-le'si-aJ. A disease marked by progressive softening of the bones from loss of their earthy constituents, so that they become flexible and fragile and unable to support the body. The disease affects adults, especially pregnant women, and is fre- quently fatal. Ova. Plural of ovum. Ovarian (o-ve'ri-an). Belonging to the ovary. Ovary (6'va-ri). The sexual gland of the female in which the ova are developed. (Fig. 13.) There are two ovaries, one at each side of the pelvis. Oviduct (6'vi-duct). The Fallopian tube which conveys the ovum from the ovary to the uterus. (See Fig. 13.) Ovisac (6'vi-sac). Same as Graafian Follicle. Ovulation (ov-iu-le'shon). The. growth and discharge of an unimpreg- nated ovum, usually coincident with the menstrual period. Ovule (ov'iul). A "little egg." The ovum before its discharge from the Graafian follicle. Ovum (6'vum). 1. An egg, particularly a hen's egg. 2. The female reproductive cell. The human ovum is a round cell about V120 of an inch in diameter, developed in the ovary. (Fig. 23.) Oxytocic (oc-si-to'sic). 1. Accelerating parturition. 2. A medicine which accelerates parturition. Pack the Uterus. To tampon the uterus. See Tampon. Pallor (pal'or). Paleness; loss of color. Palpation (pal-pe'shon). [Latin, palpa're, to handle gently, to feel.] Examination by the hand or by touch; manipulation of a part with the fingers for the purpose of determining the condition of the underlying organs. Obstetric P., palpation of the abdomen of the pregnant woman to determine the size, position, and presentation of the fcetus. Palpitation (pal-pi-te'shon). Convulsive motion of a part: applied especially to the rapid action of the heart, whether caused by disease or by excitement. Papilla (pa-pil'aj [PI. papilla:.] Originally, a " pimple." Any minute, nipple-like eminence. 438 GLOSSARY. Parietal (pe-rai'e-tal). Belonging to the parietes or walls of any cavity, organ, etc. P. Bones, the two quadrangular bones that form the transverse arch of the cranium. Paroxysm (par'oc-sizm). An evident increase of symptoms which after a certain time decline; a periodical fit or attack; the periodic fits or attacks which characterize certain diseases. Paroxysmal (par-oc-siz'mal). Relating to, or characterized by, par- oxysms ; occurring in paroxysms. Parturient (par-tiu'ri-ent). Bringing forth; child-bearing. P. Canal, the canal through which the fcetus passes in child- birth: it consists of the uterus and vagina regarded as one canal. P. Woman, a woman about to give birth to a child. Parturition (par-tiu-rish'on). Expulsion of the fcetus from the uterus; also the state of being in child-bed; labor. Paternal (pe-ter'nal). Relating to or originating with the father. Pathologic, Pathological (path-o-log'ic, -log'i-cal). Belonging to pathology; morbid. Pathology (pa-thol'o-ji). The doctrine or consideration of diseases; that branch of medical science which treats of diseases, their nature and effects. Pelvimeter (pel-vim'e-ter). An instrument for measuring the diameters and capacity of the pelvis. (Fig. 5.) Pelvimetry (pel-vim'e-tri). The obstetrical measurement of the pelvis. It may be performed with the hand (Digital p.) or with a pelvimeter (Instrumental p.). When the measurements are made on the outside of the body it is External p.; when within the vagina, Internal p.; and when both within the vagina and outside of the body, Com- bined p. (See Figs. 6 and 7.) Pelvis (pel'vis). [Latin, " basin."] The bony cavity forming the lowest part of the trunk. It is bounded behind by the sacrum and coccyx; at the sides and in front by the ossa innominata. (Fig. 1.) Penis (pi'nis). The male organ of copulation. Perforator (per'fo-re-tor). An instrument for boring into the cranium. (Fig. 103.) Perineorrhaphy (per"i-ni-or'a-/"i). Suture of the perineum; the oper- ation for the repair of lacerations of the perineum. Perineum (per-i-ni'um). The space between the genital organs and the anus. (See Fig. 9.) Periphery (pe-rif'e-ri). The circumference of a circle; the parts most remote from the centre. Peristalsis (per-i-stal'sis). The peculiar movement of the intestines and other tubular organs, like that of a worm in its progress, by GLOSSARY. 439 which they gradually propel their contents. Peristalsis is produced by the combined action of circular and longitudinal muscular fibres. Peristaltic (per-i-stal'tic). Relating to peristalsis. Peritoneal (per"i-to-ni'al). Relating to the peritoneum. Peritoneum (per"i-to-ni'um). A strong serous membrane investing the inner surface of the abdominal walls and the viscera of the abdomen. Peritonitis (per"i-to-nai'tis). Inflammation of the peritoneum; popu- larly, " inflammation of the bowels." Pernicious (per-nish'us). Baleful, deleterious; highly dangerous: as pernicious anaemia, or pernicious vomiting. Perspiration (per-spi-re'shon). [Latin, perspva'rc, to breathe every- where.] I. Sweat. 2. The process or function of sweating. Pessary (pes'a-ri). An instrument, usually in the form of a ring or a ball, for introduction into the vagina, to prevent or remedy the prolapse of the uterus. Phantom (fan'tom). The small effigy of a child used to illustrate the progress of labor. P. Pregnancy, feigned, hysterical, spurious, or false pregnancy; pseudocyesis. P. Tumor, a tumor of the abdomen due to flatus or contraction of the abdominal muscles. Pharmacopoeia (far"ma-co-pi'a.). An authoritative book containing a description of the medicines and drugs in use in a country. The United States Pharmacopoeia is published by authority once in ten years, after it has been revised by a national convention of physicians and pharmacists. Phenomenon (fi-nom'e-non). PI. phenomena. An appearance; any- thing remarkable. In pathology it is synonymous with symptom. Phlegmatic (fleg-mat'ic). Dull; sluggish; cold; morose; not easily excited. The oppositie of nervous when applied to one's disposition. Physical (fiz'i-cal). Belonging to nature. Physiological (fiz"i-o-loj'i-cal). Belonging to physiology. Physiology (fiz-i-ol'o-ji). The doctrine of vital phenomena, or the science of the functions of living bodies. Physique (fi-zic'). Natural constitution; corporeal form; personal endowments; the physical or exterior parts of a person. Pigment (pig'ment). i. Any dye or paint. 2. The normal coloring- matter of the organs and fluids of the body. Pigmentary (pig'men-te-ri). Relating to pigment. Pigmentation (pig-men-te'shon). The formation or deposition of pig- ment. Pipette (pi-pet'). A tube used in withdrawing or adding small quan- tities of fluid; used chiefly in chemical and pharmaceutical work. 440 GLOSSARY. Placenta (ple-sen'taj. The circular, flat, vascular structure in the impregnated uterus forming the principal medium of communication between the mother and the child. (Figs. 21 and 22.) P. Previa, that condition in which the placenta is situated inter- nally over the mouth of the womb, often proving a cause of excessive hemorrhage. Pledget. A little plug. A wad of lint, cotton, or the like, applied as to a wound or a sore to keep out the air, absorb discharges, or retain a dressing. Plethora (pleth'o-raj. A condition characterized by fulness of the blood-vessels, strong heart action and pulse, florid complexion, and general plumpness of the body. Plethoric (pli-tho'ric, or pleth'o-ric). Relating to plethora; full of blood. Pleura (plu'raj. A serous membrane, divided into two portions and lining the right and left cavities of the chest or thorax. Pleural (plu'ral). Relating to the pleura. Podalic (po-dal'ic). By means of or relating to the feet. P. Version, version by which the feet of the child are made to present. (See Fig. 75-) Pole (pol). The extremity of the axis of a sphere. Polyhydramnios (pol"i-hai-dram'ni-os). Hydramnion; excess in the amount of the amniotic fluid. Posterior (pos-ti'ri-or). Situated dorsally or to the rear. Postnatal (post-ne'tal). Occurring after birth. Post-partum (post-par'tum). After or subsequent to child-birth. P. Chill, a chill, lasting several minutes, often following expul- sion of the child. P. Hemorrhage, hemorrhage following delivery. P. Shock, the exhaustion immediately following labor. Postpuerperal (post-piu-er'pe-ral). Occurring after child-birth. Pregnancy (preg'nan-si). [Latin, prceg'nans, literally "previous to bringing forth."] The state of being with young or with child. The normal duration of pregnancy in the human female is two hundred and eighty days, or ten lunar months, or nine calendar months. Pregnant (preg'nant). With young or with child. Premature (pri-me-tiur'). Before it is ripe. P. Infant, an infant born after the period of viability but before the last two weeks of normal pregnancy. P. Labor, labor which takes place during the last three months of the natural term, but before its completion. P. Respiration, respiration on the part of a child before it is completely born. GLOSSARY. 441 Premonitory (pri-mon'i-to-ri). Advising beforehand; giving previous warning; precursory; applied to symptoms which give an indication or warning of the advent or onset of certain diseases,—for instance, chills, during the invasion of fever. P. Pains, painless uterine contractions before the beginning of true labor. Prepuce (pri'pius). The fold of skin which covers the glans penis in the male. P. of the Clitoris, the fold of mucous membrane which covers the glans clitoridis. Primigravida (prai-mi-grav'i-d^). PI. primigravida. A woman who is pregnant for the first time. Primipara (prai-mip'a-rq). PL primipara. A woman who has brought forth her first child. Prognosis (prog-no'sis). The foreknowledge of the course of a disease drawn from a consideration of its signs and symptoms; the art of forecasting the progress and termination of any given case of disease. Prognostic Symptom (prog-nos'tic). A symptom from a consideration of which a prognosis of any particular disease is formed. Prognosticate (prog-nos'ti-cet). To make a prognosis. Prolapse (pro-laps'). A falling down, partial or complete, of some viscus, in its latest stage accompanied by protrusion so as to be partly external or uncovered. P. of the Cord, descent of the umbilical cord on the. bursting of the bag of waters. (Fig. 126a.) P. of the Uterus, descent of the uterus, " falling of the womb." Promontory (prom'on-to-ri). A .small projection; a prominence. P. of the Sacrum, the superior or projecting portion of the sacrum when in situ in the pelvis, at the junction of the sacrum and the last lumbar vertebra. Prophylactic (prof-i-lac'tic). Belonging to prophylaxis; preventive. Prophylaxis (prof-i-lac'sis). The art of guarding against disease; the observation of the rules necessary to the preservation of health or the prevention of disease. Proteid (pro'ti-id). Any one of a class of organic compounds forming the important part of animal and vegetable tissue. The proteid in milk is the part that forms the curd. Pruritus (pru-rai'tus). An intense degree of itching. Psychic, Psychical (sai'cic, sai'ci-cal). Belonging to the mind or intellect. Ptyalism (tai'a-lizm). Increased and involuntary flow of saliva. Puberty (piu'ber-ti). The age at which the generative organs become functionally active. Pubic (piu'bic). Belonging to the pubis. 442 GLOSSARY. Pubis (piu'bis). The os pubis or pubic bone forming the front of the pelvis. (Fig. i.) sometimes, but incorrectly, written pubes. Pudenda (piu-den'daj. Plural of pudendum. Pudendal (piu-den'dal). Relating to the pudendum. Pudendum (piu-den'dum). [Latin, pude're, to have shame or modesty.] The external genital organs or parts of generation of either sex, but especially of the female: also used, perhaps more correctly, in the plural (pudenda). (See Fig. 8.) Puerpera (piu-er'pe-raj. A woman in child-bed, or one who has lately been delivered. Puerperal (piu-er'pe-ral). Belonging to, or consequent on, child- bearing. P. Convulsions, epileptiform convulsions occurring immediately before or after child-birth. P. Eclampsia, same as puerperal convulsions. See Eclampsia. P. Fever, a severe febrile disease which sometimes occurs in the puerperal state, usually about the third day after child-birth, accompanied by an inflamed condition of the peritoneum, due to septic infection. P. Insanity or Mania, insanity occurring in females towards the end of pregnancy or soon after delivery. P. State, the condition of a woman in, and immediately after, child-birth. Puerperium (piu-er-pi'ri-um). The state or period of a woman in confinement. Pulmonary (pul'mo-ne-ri). Of the lungs or belonging to the lungs. Pulsation (pul-se'shon). Any throbbing sensation resembling the beat- ing of the pulse; the heart's action extending to the arteries, felt in any part of the body. Purpura (pur'piu-raj. A disease in which there are small distinct purple specks and patches on the surface of the body, with general debility but not always fever. Purpuric (pur-piu'ric). Relating to purpura. Purulent (piu'ru-lent). Consisting of pus; of the nature of pus. Pus (pus). A bland, cream-like fluid found in abscesses or on the surface of sores; matter; " corruption." Rational (rash'on-al). Conformable to reason or to a well-reasoned plan; reasonable. Also applied to the mental state of a person. R. Symptoms, symptoms communicated by the patient to the physician; subjective symptoms. Reaction (ri-ac'shon). i. Increase of the vital functions succeeding their depression. 2. The phenomena resulting from the action of two or more substances upon each other. GLOSSARY. 443 Rectal (rec'tal). Connected with or pertaining to the rectum. R. Alimentation, the administration of nourishment by means of enemata containing nutritive matter. Rectum (rec'tum). The last portion of the large intestine, terminating at the anus; the lower bowel. Reflex (ri'flecs). Reflected; caused by the conveyance of an impression to the central nervous system and its transmission through a motor nerve to the periphery. Regurgitation (ri-ger-ji-te'shon). A flowing back; a flowing the wrong way: applied, for example, to the passive vomiting of infants and to the rising of food in the mouth of adults. Relaxation (ri-lac-se'shon). The reverse of contraction or tension; looseness; want of muscular tone or vigor. Remission (ri-mish'on). An abatement or diminution of symptoms. Renal (ri'nal). Belonging to the kidney. Respiration (res-pi-re'shon). The function of breathing, including both inspiration and expiration. Restitution (res-ti-tiu'shdn). The act of restoring or returning some- thing,—particularly, rotation of the fetal head after its expulsion from the vagina, so that it looks in the same direction as it did before it entered the pelvic brim; external rotation of the fetal head. (Fig. 46.) Resuscitation (ri-sus-i-te'shon). The act of restoring to life those who are apparently dead. Retained Placenta (ri-tend'). A placenta not expelled by the uterus after labor. Retention (ri-ten'shon). The keeping back or stoppage of any of the secretions, particularly the urine. R. of Urine, a condition in which the urine is retained in the bladder and cannot be discharged voluntarily. Rhachitic (re-cit'ic). Relating to or affected with rhachitis or rickets. R. Pelvis, a pelvis deformed by rickets. Rhachitis (re-cai'tis). Rickets. Rickets (ric'ets). A disease of childhood in which there is a lack of the earthy salts in the bones, with resultant curvatures and deformi- ties of them, affections of the liver and spleen, and a condition of general weakness. Nourishing food, fresh air, exercise, and tonics furnish the best mode of treatment. Rotation (ro-te'shon). The act of turning round; the motion of any solid body about an axis. R. Stage of Labor, that stage of labor at which the presenting portion of the fcetus rotates or turns round. Rupture (rup'tshur). 1. Bursting or breaking of a part. 2. Hernia. 444 GLOSSARY. Sacrum (se'crum). The triangular bone wedged between the ossa in- nominata, forming the posterior wall of the pelvis, articulating above with the vertebral column and below with the coccyx, and formed by the fusion of the five sacral vertebrae or segments. (Fig. i.) Sagittal (saj'i-tal). Relating to, or shaped like, an arrow. S. Suture, the suture which unites the parietal bones. (Fig. 27.) Saliva (se-lai'vaj. The colorless ropy fluid in the mouth secreted by certain glands and glandular structures in the mouth ; the spittle. Salivation (sal-i-ve'shon). An excessive flow of the saliva. The word is practically synonymous with ptyalism, but, strictly speaking, de- scribes the condition when produced by the exhibition of medicines. Saturated Solution (satsh'iu-re-ted). A solution which at a given temperature cannot contain more of the substance than it already contains. Scalpel (scal'pel). A small knife usually with a straight blade which is fixed firmly in the handle; used in dissection and in surgical operations. Scapula (scap'iu-laj. The shoulder-blade. Scrotum (scro'tum). [Latin, "bag."] A pouch at the base of the penis in the male, containing the testicles and other organs. Sebaceous (si-be'shius). Fatty; suety; applied to glands which secrete an oily matter resembling suet. Resembling or pertaining to sebum or fat. Sebum (si'bum). A thick, semi-liquid substance discharged upon the surface of the skin, composed of fat and broken-down epithelial cells. Secretion (si-cri'shon). 1. A function of the body by which various fluids or substances are separated from the blood, differing in differ- ent organs according to their peculiar functions: thus, the liver secretes the bile, the salivary glands the saliva, etc. 2. The substance secreted. Secundines (sec'un-dins). The after-birth; the placenta, etc., expelled after the birth of a child. (See Fig. 62.) Segmentation (seg-men-te'shon). The process of division by which the fertilized ovum multiplies before differentiation into layers occurs. (Fig. 18.) Semen (si'men). 1. A seed. 2. The fluid secreted by the male repro- ductive organs. Septic (sep'tic). Tending to putrefy; causing or due to putrefaction. Sepsis (sep'sis). 1. Putrefaction. 2. Infection and poisoning by putre- factive matter. Serous (si'rus). Of the nature of serum; secreting serum. S. Membrane. See under Membrane. Serum (si'rum). The clear, straw-colored liquid which separates, in the clotting of blood, from the clot and the corpuscles. GLOSSARY. 445 Shock (shoe). A condition of sudden depression of the whole of the functions of the body, due to powerful impressions upon the system by physical injury or mental emotion. The former is termed surgical and the latter mental shock. Show (sho). i. Popularly, the red-colored mucus discharged from the vagina shortly before child-birth; called also "Labor-show." 2. The vaginal discharge in menstruation. Sims's Position (sim'ziz). [J. Marion Sims, noted American gynaecolo- gist, deceased.] That position of the patient in which she lies upon the left side and front of the left chest, with the right leg strongly flexed, or "drawn up:" called also Semiprone position and Side position. (Fig. in.) S.'s Speculum, a vaginal speculum with duck-bill blades: by it the posterior wall of the vagina is held up, while the anterior is depressed, the patient being placed in Sims's position. (Fig. 114.) Skim Milk (scim). Milk from which the cream has been removed, leaving only one or two per cent, of fatty matter. Smegma (smeg'maj. [From a Greek word meaning soap.] Sebum, especially the offensive, soap-like substance produced from the seba- ceous follicles around the glans penis and prepuce and in the region of the clitoris and labia minora. S. Embryo'num. Same as Vernix Caseosa. Solution (so-liu'shon). 1. The act of dissolving a solid body. 2. A clear, homogeneous liquid having particles of a solid, another liquid, or a gas uniformly diffused through it, so that the particles are invisible and do not separate upon standing. Sordes (sor'diz). Literally, "filth:" applied to the foul matter which collects on the teeth, particularly in certain low fevers. Sound (saund). [French, sonder, to fathom, to try the depth of the sea; hence, to try or examine.] An instrument for introduction through the urethra into the bladder, or into any canal. (See Fig. 118.) Specific (spi-sif'ic). 1. Relating to a species; distinguishing one species from another. 2. Suited for a particular purpose: as, a specific remedy. 3. Produced by a special cause. 4. A specific remedy; a remedy supposed to have a peculiar efficiency in the cure of a par- ticular disease, or one which has a special action on some particular organ. S. Disease, any disease produced by a special cause; as syphilis and the eruptive fevers. (The term is frequently, but wrongly, restricted to syphilis.) S. Gravity, the weight of a body compared with that of another of equal volume taken as a standard: hydrogen is the standard for gases, and distilled water for liquids and solids. 446 GLOSSARY. Spermatozoon (sper"ma-to-zo'on). PI. spermatozoa. The motile micro- scopic sexual element of the male, resembling in shape an elongated tadpole. (Fig. 17.) The male element in fecundation. Sterile (ster'il). 1. Affected with sterility; barren. 2. Not containing micro-organisms; aseptic. Sterility (ste-ril'i-ti). Inability, whether natural or as the result of disease, to procreate offspring. Sterilization (ster"il-i-ze'shon). The process of rendering an object sterile or free from micro-organisms or their germs. Sterilizer (ster'il-ai-zer). An apparatus for sterilizing objects. (Fig. 181.1 Stillborn (stil'born). Born without life; born dead. Stimulant (stim'iu-lant). 1. Stimulating. 2. A medicine having power to excite organic action or to increase the vital activity of an organ. A stimulant differs from a tonic in that its action is more speedy, more transitory, and usually followed by a reaction. Stimulate (stim'iu-let). Tc excite the organic action of a part of the animal economy. Stimulus (stim'iu-lus). PI. stimuli. A Latin word signifying a " goad," " sting," or " whip." In physiology, that which rouses or excites the vital energies, whether of the whole system or of a part. Stool (stiil). The faeces discharged from the bowels; a dejection; an evacuation. Streptococcus (strep-to-coc'us). A variety of micro-organism. Stria (strai'aj. PI. stria. A Latin word signifying a "groove," "fur- row," or " crease." S. Gravidarum, shining, whitish lines upon the abdomen caused by pregnancy or distention by abdominal tumors. (Fig. 30.) Stupor (stiu'por). A suspension or diminished activity of the mental faculties; loss of sensibility. Styptic (stip'tic). Having the power of stopping bleeding through an astringent quality; haemostatic. Subcutaneous (sub-ciu-te'ni-us). Situated just under the skin. S. Injection. See Hypodermic Injection. Suppository (su-poz'i-to-ri). A preparation of some substance (usually cacao butter) fusible at the temperature of the body, and combined with some medicinal substance, for introduction into the rectum, vagina, urethra, or other cavity of the body. Suppuration (sup-iu-re'shon). The formation of pus or the processes giving rise to it. Suppurative (sup'iu-re-tiv). Producing or discharging pus. Suture (siu'tshur). 1. The junction of the bones of the cranium by a serrated line resembling the stitches of a seam. (Fig. 27.) 2. A stitch used to draw together the lips of a wound. 3. The thread or material used in making a stitch. GLOSSARY. 447 Syphilis (sif'i-lis). A contagious venereal disease, communicable by contact of any abraded surface with the virus in coition or otherwise, and also by heredity and from the mother to a fcetus. Symphyseotomy (sim"fiz-i-ot'o-mi). The operation of severing the ligaments and the fibro-cartilages of the pubic symphysis; done in difficult labor. Symphysis (sim'fi-sis). The union of bones by means of an intervening substance; a variety of synarthrosis. S. Pubis, " symphysis of the pubis," the pubic articulation or union of the pubic bones which are connected with each other by interarticular cartilage. (Fig. I.) Synchondrosis (sin-con-dro'sis). A union of bones by intervening car- tilage ; a variety of synarthrosis. See Articulation. Syncope (sin'co-pi). Literally a "cutting short" of one's strength; swooning or fainting; a suspension of respiration and the heart's action, complete or partial. T-Bandage. A bandage shaped like the letter T,—especially one in which the transverse limb passes around the body and the longitu- dinal one under the perineum. Used to hold dressings against the vulva. Tampon (tam'pon). i. A portion of gauze, sponge, etc., used in plugging a cavity or canal. 2. To apply a tampon to. Tamponade (tam-po-ned'). The use of the tampon or the act of using it. Tamponage (tam'pon-ej). See Tamponade. Tamponing (tam'pon-ing). The act of using a tampon. Tenaculum (ti-nac'iu-lum). A small hook-shaped instrument. T. Forceps, a volsella. Tenesmus (.ti-nez'mus). A constant desire to go to stool or to urinate, with painful straining without the expulsion of faeces or urine. Testicle (tes'ti-cl). One of the two glands in the male contained in the scrotum. Thoracic (tho-ras'ic). Belonging to the thorax. Thorax (tho'racs). The chest, or that part of the body between the neck and the diaphragm and in the cavity of which are contained the heart and lungs. Thrombosis (throm-bo'sis). The formation or progress of a thrombus. Thrombotic (throm-bot'ic). Relating to or of the nature of thrombosis. Thrombus (throm'bus). A clot formed in any part of the circulatory apparatus. It differs from an embolus in that it is developed at the point where it is found, while an embolus is brought from a distance through the blood-vessels. Tissue (tish'ii). A web-like structure; a collection of cells or elements, of a constant structure and function, which go to make up the body. Examples: muscular tissue; brain tissue; bone tissue, etc. 448 GLOSSARY. Torsion (tor'shon). A twisting. T. of the Umbilical Cord, the normal spontaneous twisting of the umbilical cord. Toxemia (toc-si'mi-aj. Blood-poisoning. Toxemic (toc-si'mic). Relating to, or caused by, toxaemia. Traction (trac'shon). The act of drawing or pulling. Trendelenburg's Position or Posture (tren'de-len-burgz). That posi- tion in which the patient is placed flat on the back with body and thighs elevated to an angle of about forty-five degrees, the legs hanging over the edge of the table. It is used in abdominal surgery so that the abdominal viscera may be kept out of the way by gravi- tation. Tubercle (tiu'ber-cl). A rounded eminence. Tuberculosis (tiu-ber-ciu-16'sis). A specific infectious disease due to the presence of the tubercle bacillus and affecting most often the respiratory and alimentary tracts, the peritoneum and parts of the brain. When the disease affects the lungs it is popularly known as " consumption." Tumor (tiu'mor). i. A swelling. 2. A morbid growth of new tissue in any part of the body, not due to inflammation, and differing in structure from the part in which it grows. Tumors may be solid or hollow (Cystic t.). When a tumor tends to recur after removal, and infect the system, it is called Malignant; when it does not, Benign, Innocent, or Non-malignant. Tympanites (tim-pa-nai'tiz). Distention of the abdomen by gas in the intestines or in the peritoneal cavity; drum belly. Uterine T., distention of the uterus with gas; physometra. Typhoid State (tai'foid). A condition sometimes occurring in de- pressing diseases, in which there are great muscular weakness, brown tongue, muttering delirium, feeble pulse, and involuntary passage of urine and faeces. Ulcer (ul'ser). A loss of substance on some internal or external surface from gradual disintegration and destruction of the tissue. Ulcerate (ul'se-ret). 1. To form an ulcer in. 2. To become affected with ulcers. Umbilical (um-bil'i-cal). Pertaining to the umbilicus. U. Arteries, the arteries which accompany and form part of the umbilical cord. U. Cord [Latin, funis umbilicalis], the cord connecting the pla- centa with the umbilicus of the child, and at the close of gestation principally made up of the two.umbilical arteries and the umbilical vein, encased in a mass of gelatinous tissue called " Wharton's jelly." U. Hernia, hernia at or near the umbilicus. GLOSSARY. 449 Umbilicus (um-bi-lai'cus). The navel; the pit in the centre of the abdomen left by the shrinking of the umbilical cord. Uremia (iu-ri'mi-3). The presence of urinary constituents in the blood, due to the suppression of the urine, and marked by headache, nausea, vertigo, eclampsia, and a peculiar odor of the skin. Uremic (iu-ri'mic). Relating to uraemia; affected with uraemia. Urea (iu'ri-aj. The principal solid constituent of the urine. It is pro- duced by the decomposition of proteids and carries off most of the nitrogenous products of the body. Urea is also found in the blood and lymph. Urethra (iu-ri'thraj. The membranous canal forming a communication between the neck of the bladder and the external surface of the body. The female urethra does not exceed two inches in length, and the passage is considerably larger and more dilatable than that of the male. Urethral (iu-ri'thral). Belonging to the urethra. Urinal (iu'ri-nal). A vessel to receive urine. Urinalysis (iu-ri-nal'i-sis). Chemical analysis of the urine. Urinary (iu'ri-ne-ri). Relating to the urine. Urinate (iu'ri-net). To pass urine from the bladder. Urination (iu-ri-ne'shon). The act of passing urine. Urine (iu'rin). The saline secretion of the kidneys which flows from them through the ureters into the urinary bladder. Incontinence of U., inability to retain the urine in the bladder, so that it escapes without the knowledge or control of the patient. Retention of U., inability to pass the urine which accumulates in the bladder. Suppression of U., arrested secretion of urine from the kidneys. Urinometer, Urometer (iu-ri-nom'e-ter). An hydrometer for ascertain- ing the specific gravity of urine. Uterine (iu'te-rin). Relating to the uterus. U. Appendages, the ovaries and Fallopian tubes. (Fig. 11.) U. Colic, paroxysms of pain in the uterus due to menstruation or to other causes, such as " false pains" or " after-pains." U. Gestation, normal pregnancy. U. Inertia, deficiency of contractile power of the uterus in labor. U. Involution, the process by which, after child-birth, the uterus reassumes its normal size and shape. U. Mole, a mass sometimes occurring in the uterus, consisting of a dead fcetus which has undergone degeneration. U. Phlebitis, a form of puerperal fever. U. Pregnancy, normal pregnancy occurring in the uterus, as opposed to ectopic pregnancy. 29 450 GLOSSARY. U. Probe, a long, flexible probe for exploring the cavity of the uterus. (See Fig. 118.) U. Sinuses, cavities formed by the uterine veins in the walls of the uterus; they are especially conspicuous in the preg- nant uterus. U. Sound, an instrument somewhat resembling a urethral sound, used in making examinations of the uterus; a uterine probe. (Fig. n8.) U. Tubes, the Fallopian tubes. (Fig. n.) U. Wound, the area of the uterus from which the placenta has been detached. Uterus (iu'te-rus). The womb, a hollow muscular organ designed for the lodgement and nourishment of the foetus during its development until birth. (Figs. 9, 10, and 11.) Vagina (ve-jai'naj. [Latin, a sheath.] The curved canal, five or six inches in length, extending from the vulva to the uterus. (Fig. 9.) Vaginal (vaj'i-nal). Belonging or relating to the vagina. V. Examination, examination of the vagina by introducing a finger. V. Speculum, an instrument for keeping open the vagina in order that its interior may be viewed. (Figs. 114 and 115.) Varicose (var'i-cos). Unnaturally dilated; relating to a varix. Varicosity (var-i-cos'i-ti). 1. A varicose condition of the veins; vari- cosis. 2. A varicose vein; a varix. Varix (ve'rics). A dilatation of a vein. Vascular (vas'ciu-lar). Having, or relating to, vessels; full of blood- vessels. Vascularity (vas-ciu-lar'i-ti). The state or property of being vascular. Vectis (vec'tis). The lever. In obstetrics, an instrument resembling one blade of an obstetrical forceps, for making traction upon the head of the fcetus in retarded labor. Seldom used and never seen now, as a single forceps blade answers the same purpose. Vein (ven). A tube conveying blood from the various tissues of tb' body to the heart. Venous (vi'nus). Relating to the veins; contained in the veins. V. Blood, a dark-colored liquid collected in the veins from every part of the system. It is subsequently exposed to the in- fluence of the air in the lungs and is converted into bright red arterial blood. It contains more carbonic acid gas and less oxygen than arterial blood. V. Circulation, the circulation of the blood through the veins. V. Congestion, the engorgement of an organ with venous blood caused by interference with its return to the heart. GLOSSARY. 45 t Vernix Caseosa. " Cheesy Varnish." The layer of fatty matter which covers the skin of the foetus. Version (ver'shon). The act of turning; specifically, a turning of the child in the uterus so as to change the presenting part and bring it into more favorable position for delivery. (Figs. 75 and 76.) Vertebra (ver'ti-braj. PI. vertebra. A peculiarly shaped bone, thirty- two of which compose the spine or vertebral column. Vertex (ver'tecs). The summit or top of anything. In anatomy, the top or crown of the head. V. Presentation, presentation of the vertex of the fcetus in labor. (Fig. 43.) Vertigo (ver'ti-go). Dizziness; swimming of the head; giddiness. Vesical (ves'i-coT). Pertaining to the bladder; having the appearance of a bladder. Viability (vai-a-bil'i-ti). Ability to live. Viable (vai'a-bl). A term in medical jurisprudence signifying "able or likely to live:" applied to the condition of the child at birth. Virgin (ver'jin). A woman who has never had sexual intercourse. Virulent (vir'iu-lent). Poisonous; malignant; caused by virus or having the nature of virus. Virus (vai'rus). Any poisonous matter produced by disease and capable of propagating that disease by inoculation; a deleterious agent sup- posed to be a parasitic organism or germ. Viscus (vis'cus). PI. vis'cera. Any organ contained in the cavities of the body, especially within the abdomen. Visual (vizh'iu-al). Pertaining to, or used in, vision or sight. Vital (vai'tal). Belonging or essential to life. Vitality (vai-tal'i-ti). The principle of life. Volsella (vol-sel'3). A forceps each blade of which has hooked ex- tremities ; a volsellum. Vulsella, Vulsellum (vul-sel'3, vul-sel'um). See Volsella. Vulva (vul'vaj. The external genitals of the female. (Fig. 8.) Walcher Position or Posture (val'cer or wal'tsher). That position of the patient in which she lies on her back with her buttocks raised and well over the edge of the table and her limbs hang- ing down as much as possible. (See Fi-g. 79.) In this position the true conjugate diameter of the pelvis is lengthened by nearly half an inch. Wet-Nurse. One who gives suck to the child of another. Wharton's Gelatin or Jelly (hwor'tonz). [Thomas Wharton, English anatomist, died 1673.] The jelly-like mucous tissue composing the bulk of the umbilical cord. Whites (hwaits). A popular name for Leucorrhcea, which see. 452 GLOSSARY. Winckel's Disease (vinc'elz). A very rare and extremely fatal disease of new-born infants, marked by icterus, hemorrhage, bloody urine, and cyanosis. Malignant jaundice. Witches' Milk (witsh'ez). A milky fluid secreted from the breast of the newly born. Womb (wum). The Uterus, which see. INDEX V IP- Abdomen, pigmentation of, 72 in pregnancy, changes in, 85, 88 size of, 88 rupture into, 208 Abdominal binder, 103, 121, 167, 191. See also Binder pregnane}-, 206, 207, 208 pressure, 103, igo section, 255 sponges, 233, 404 supporter, 167 Abnormity of child, 290 of position, 158 Abortion, 244, 245. See also Mis- carriage after-treatment of, 252 a cause of, 374 criminal, 252 due to eruptive fever, 210 due to syphilis, 212 at four weeks, 55 haemorrhage from, 204. induction of, 186, 193, 196 legal, 252 pain as symptom of, 205 threatened, 246 Abscess of breast, 279, 281 from ectopic pregnancy, 208 Accidental haemorrhage, 254 Accidents of obstetrics, 253, 262, 317 Acini of breasts, 41 Adhesive plaster, 191 Adolescence, physical changes in, 45 Advice on care of infant, 304 After-birth, 148, 152. See aiso Placenta After-care of mother, 163 in symphyseotomy, 236, 237 After-pains, 82 Agalactia, 369 Air-embolus, 164 Air in the circulation, 272 hunger, 205, 255 passages, expansion of, 323, 326 Albumin, test for, 200 Albuminuria, 7^, 191, 196, 198, 200 Alcohol disinfection, 364, 402 dressings, 293 effects of, upon germ plasm, no during pregnancy, no, 397 rub, 170, 179, 193 Alimentation, rectal, 185 Aloes, 188 Ammonia as antidote, 144 Amnion, 51, 52, 53 Amniotic sac, 52, 78, 151, 255 rupture of, 78, 151, 255 Amputation of uterus, 234 Anaemia, acute, 205 of pregnancy, 192 Anaesthesia in bed, 246 chloroform, 143 at dressings, 287 ether, 145, 146 surgical, 141 during version, 217 Analgesia, 160 453 454 INDEX. Analysis of urine, 113, 118, 196, 198, 200, 202 Anenometer, 351 Animal food, 373 Ankylosis, sacrococcygeal, 31 Anointing baby, 292, 348, 354 Anterior position of vertex, 95 Antisepsis, 22, 401 Antiseptic solutions, 138, 149, 401 Antitoxin, tetanus, 345 Anus, absence of, 343 tearing of, 40 Apncea, 322 Appetite after labor, 83 perverted, no during pregnancy, 71, 86 Applicator, care of, 23 Areola of breasts, 41, 69, 87 pigmented, 42, 88 Aristol powder, 171 Arm in breech delivery, 158 prolapse of, 99, 259, 260 Arterial tension, 204 Arteries, hypogastric, 64, 65 Articulation of pelvis, 30 Artificial food, 358, 376 outfit for, 383 respiration, Byrd's, 321, 326 Sylvester's, 324, 325 Ascites, 193 Asepsis in obstetrics, 20, 22 Asphyxia as cause of septic dis- ease, 340 fatal, 271 of infant, 161, 323 livida, 317 neonatorum, 317 pallida, 317 in protracted delivery, 259 treatment of, 344 Aspiration of mucus, 270, 320 Aspirating needle, 270 Ass's milk, 376 Atelectasis, 344 Atmosphere, moist, 300 Auto-intoxication, 198 Automobiling, 106 Axis of child, 101 Axis-traction forceps, 221, 223 Ayres, Dr., bed devised by, 236 Baby basket, 303 extraction of, 229 saving, 406 " Baby-food babies," 376 Baby's soap, 303 Bacteria as cause of disease, 22, 274, 277 in cow's milk, 360 in vagina, 21 Bacillus tetani, 3^4 Bag of membranes, 51, 52 Bags for dilation, 222 Ballottement, 85, 89 Baltimore, visiting nurses in, 410 Barley-water, 385 Barnes's bags, 222, 224 Barrett, Dr., sponge technic of, 404 Bassinette, 127 Bath before labor, 131 thermometer, 308 Bath-tub for baby, 306 Bathing baby, 302 of incubator baby, 355 for mother, 107 Bearing-down in labor, 78 sensation, 136, 195, 196, 244 Beaumes' law, 212 Bed, change of, 165, 178 coverings, 300 double, 128 for delivery, 128, 129 for infant, 127, 300 for symphyseotomy, 236 metal, 128 Bed-pan, use of, 83, 176 INDEX. 455 Beer-bottles for hot water, 233, 251, 265 Beets, influence of, 370 Belladonna to breasts, 371 Bellevue Hospital School for Midwives, 19, 408 Benzoinated lard, 348, 354 Bichloride of mercury, 401, 402 Bier congestion bell, 287 Binder, abdominal, how to make, 121 advantage of, 164, 167 applied after version, 216 application of, 168 for baby, 293 maternity, 103, 285 Binders and pads, soiled, 170 Biniodide of mercury, 401, 402 Bipolar version, 215 Birth-marks, 115 Birth-weight, 297, 298, 367 Births, registration of, 410 Bladder during labor, 77 irritable, 76, 85, 191, 196, 207 Blankets for baby, 315 Bleeding from cervix, 264 from cord, 349 from retained placenta, 262 in ectopic pregnancy, 208 in feeble child, 154 internal and fatal, 205, 254 Blindness from albuminuria, 197 from opthalmia, 339 preventable, 335 Bloating, 202 Blondes, pigmentation in, 42, 88 Blood in breast-milk, 374 oozing of, 326 state of, in pregnancy, 70 sudden discharge of, 208 Blood-clot after labor, 82 Blood-current, fetal, 61, 64 Blood-passages, fetal, 64 Blood-poisoning from retained placenta, 245 Blood-vessels, pulsation of, 139 Blue babies, 343 Body temperature, 71 Bone salt theory, 109 surgery, 237 Bones, wiring of, 236 Bootees, 312 Borax for mouth, 364 Boric acid for eyes, 335 Boston Lying-in-Hospital binder, 285 Bottle feeding, 360, 388 Bougie, insertion of, 242 Bowels after delivery, 175 during labor, 77, 78 regularity of, in, 306 Box mattress, 128 Brace for patient, 141 Brain, anaemia of, 167 vomiting centre in, 185 Brassiere, 103 Braun's hook, 239, 240, 241 Braxton-Hicks method, 215 Breast, abscess of, 279, 281 child's refusal of, 366, 388 congestion of, 283 dawdling at, 366 distention of, 283 massage of, 280, 281 milk, 360 affected by grief, 375 affected by worry, 373 cream in, 371 drugs excreted by, 392 drying up, 392 for infant, 113 not digested, 369 quality of, 369, 375 quantity of, 369, 375 Breast-binder, 285, 286 application of, 365 author's, 285 456 INDEX. Breast-binder, to dry up milk, 392 Breast-feeding, 345, 370 reflex action of, 81 Breast-pump, 280, 355, 356, 358 Breasts and uterus, sympathy be- tween, 40 care of, 113, 361 changes in, 69, 85, 87 development of, 102 diseases of, 274, 279 enlarged, 283 formation of, 41 incision of, 287 infection of, 23 lactating, 369 painful, 284 pendulous, 103 secretion of, 40 shrinking of, 256 soft, flabby, 361 suppuration of, 287, 374 Breech, delivery, 214, 217 dangers of, 157 presentation, 91, 96, 99, 155, 157 in twins, 159 Brim of pelvis, 29 measurement of, 33 Brow presentation, g6, g8 Brunettes, pigmentation in, 42, 73, 88 Brushes, tampica fibre, 134, 402 Bubo, venereal, 211 Buller shield, 337 Bullet-forceps, 266 Burning of discharges, 170, 213 pads, 170 Burns from external heat, 204, 290 Buttocks, elevation of, 186 Caesarean section, 225, 228 after rupture of uterus, 258 Caesarian section, different forms of, 234 indication for, 228 owing to deformity, 33 preparations for, 228 Caked breast, 281 Calomel, dosage of, 346 Cancer, curability of, 412 of cervix, 228 of uterus, 412 Caput succedaneum, 332, 333 Carbolic acid solution, 401 Carbonic acid gas, elimination of, 70 Carpet, protection of, 231, 250 Catharsis, saline, 285 Cartilage, thickening and soften- ing of, 31, 73 Cascara sagrada, 188 Castor oil, 176, 188 Casts in urine, 196 Catching cold, 86 Catheter, aspirating, 317, 320, 331 feeding by, 358 passage of, in symphyseotomy, 236 varieties of, 173, 250 Catheterization, 172, 174, 264 technic for, 403 Cavity of cervix, 39 of uterus, 38 Cells, embryonic, 48 Cephalhematoma, 334 Cerebral anaemia, 167 Certificate of birth, 410 Certified milk, 377 Cervix of uterus, 38, 39, 85 dilation of, 52, 222, 243 lacerations of, 81, 264 ulcers of, 204 Chafing, 297 Champetier de Ribes bag, 222, 22.4 Chancre, 211 Change of life, 46 INDEX. 457 Chapin dipper, 380, 382 Chart records, 369 temperature, 394 weight, 309 Cheese-cloth diapers, 312 Chest walls, pressure on, 102 Chicago Medical Society, 408 midwives of, 408 Child-birth, suffering of, 77 Child-bed fever, 274 Child forced to cry, 152 viability of, 228, 244 Children's Bureau, National, 304 Chill after labor, 80 Chilling the body, 104, 105, 106 Chloasmata, 72 Chlorine gas, 143 Chloroform as cause of Winckle's disease, 340 cough, 143 dangers of, 144 poisonous effects of, 144, 203 use of, 141, 142, 143, 160 Chorea in pregnancy, 195 Chorion, 52, 53 Circulation after birth, 61, 62, 65 air in, 272 defective, 343 fetal, 53, 61, 63, 64, 65 obstruction to, 104, 272, 277 Citrate of magnesia, 175 Cleaning up, 163 Climacteric, 46 Clitoris, 35 adhesions of, 297 Clot in heart, 262 in veins, 277 Clothing during pregnancy, 102 for operations, 251 of premature baby, 348 outer, 104 Coccyx, 28, 29 Coffee, effects of, in lactation, 370, 37i Coffee, for nausea, 183 Cold baths, 107 Colic in infant, 180, 346 cause of, 283 cry of, 296 Collapse in labor, 257, 269 Colles' law, 212 Cologne water, use of, 179 Colon bacillus, 281 irrigation, 346 Colostrum, 70, 87, 113, 345 crusts of, 280, 362 disappearance of, 371 Coma, eclamptic, 199 in puerperal fever, 275 Combined version, 215 Comfort of mother, 178. 179 Computation of date of labor, 90 Concealed haemorrhage, 209, 254 Conception, processes of, 48 Condensed milk, 376 Confinement in hospital, 120 Congenital cyanosis, 343 syphilis, 212 Conjugate diameter, 218, 220 Constipation after labor, 83 in infants, 343 in pregnancy, in, 187, 191, 196 treatment of, 112 Contagion, safeguards against, 119 Contraction of pelvis, 31, 33, 46 of uterus, 163 Control of sex, 115, 117 Convulsions, causes of, 347 eclamptic, no, 200 epileptic, 200 from haemorrhage, 262 in renal colic, 346 in spina bifida, 342 of pregnancy, 197, 199 of tetanus, 344 puerperal, 262 458 INDEX. Cord, bleeding from, 148, 153, 272- 326 dressing, 23, 124, 293, 310 ligatures, 395 prolapse of, 138 traction on, 152, 154, 156 tying of, 148, 149. 152, 349 Cornea, opacities of, 335 Coronal suture, 59, 60 Correspondence school graduate, 19 Corsets, 102, 190, 362 maternity, 102, 103 Cotton jacket, 355 Cough in pregnancy, 194 Coughing caused by chlorine gas, 143 Cow's milk, 358, 377, 391 chemical constituents of, 378 digestibility of, 378 mixed, 378 modified, 360 reaction of, 381 Crabs, 370 Craniotomy, 237, 238 intruments for, 239 Cranium, passage of, at birth, 58 Cream, centrifugal, 379, 380, 382 gravity, 379, 380, 382 tests, 373 Crede's treatment, 133. 263, 264 Crib for baby, 301 Croquet, 106 Crusts on nipples, 114 Cry, characteristics, of labor, 78 of child, first, 152 significance of, 296 Curettage after abortion, 246 after infection, 276 instruments for, 248, 249 Cutting operations, 214, 224 Cyanosis, 148, 199 congenital, 343 Cyanosis of eclampsia, 262 Cyllin, 401 Cyst, ovarian, 228 Dammerschlaf, 160 Dance, St. Virus's, 19S Dancing, 106 Dangers of internal version, 217 Death from chlorine gas, 143 instant, from clot, 278 of child, 284, 320 Decapitation of fcetus, 237, 238, 240 Decidua, basilis and capsularis, 50 of menstruation, 49 reflexa and vera, 50, 51, 52 serotina, 50, 53 Deformity of child, 115, 290 from diaper, 306 from dislocation, 329 pelvic, 32, 242 Delivery bag, 408, 409, 410, 411 bed for, 128 by nurse, 149 hasty, 243 instrumental, 31 217 natural, impossibility of, 2.7 operative, 209, 251 Dental operations, 108 Descent of head, 93 Development of breasts, 362 of nipple, 114 Diabetes, 195 Diagnosis, obstetrical, 100 of pregnancy, 84, 85 Diameter of pelvis, 30, 218, 220 Diaper pin, 305 red stain on, 296 Diapers, 297, 304, 3™, 312 shaped, 305, 307 used but once, 297 washing of, 316 Diarrhoea, 188, 345 as cause of miscarriage, 112 INDEX. 459 Diarrhoea of infants, 373 Diet, 397 during pregnancy, 109, 397 puerperium, 179, 398 farinaceous, 398 kitchen, 377 Prochownik's, 109, 400 regulation of, in soft, 398 starchy, for mother, 370 vegetable, 373 Digestion at birth, 297 Digestive organs, tax upon, 70 Dipper for top milk, 380 Discharges, burning of, 170, 213 during labor, 129 Discipline, nursery, 295, 306 Diseases, parasitic, 22 Disinfection of room, 126 Dislocations, 329 Dispensary service, 407 Displacement of uterus, 196 Disposition during pregnancy, 86 Distention of breasts, 284 Dizziness in pregnancy, 197, 199, 205 Doctor's operating gown, 235 table, 133 Douche after miscarriage, 252 for eye, 337 infection from, 21, 22 nozzle, danger in, 165 solution for, 401, 402 sterile, 131, 403 tube, insertion of, 177, 178 uterine, 267 vaginal, 35, 176 " Dragging " breasts, 365 Drain for abscess, 287 Dressing baby, 310 on lap, 301, 336, 337 forceps, use of, 140 screen, 303 table, infant's, 303 Dressings, making of, 124 Draw-sheet, 130, 166, 172 Driving, 106 Dropsy, 193 Drugs excreted by the milk, 392 Dry labor, 242 Ductus arteriosus, 64, 65 venosus, 64, 65 Duration of labor, 79 Dusting powder for baby, 297 Dyspnoea in infants, 344 Dyspnoea of pregnancy, 188 Ears, ringing in, 197, 205 washing of, 308 Eclampsia, 197, 222, 253, 256 convulsions of, 199 forerunner of, 187, 191 in puerperium, 262 Eclamptic toxaemia, no Economy in home accouchement 24, 124, 126 in washing, 310 Ectopic gestation, 204, 205, 206 rupture of sac in, 255 Eczema intertrigo, 297 of face, 193 of nipple, 287 Efficiency of nurse. 25 Eight-months baby, 75 Eight per cent, milk, 378, 382, 384 Electricity, 370 Elliott's forceps, 222 Embryo, growth of, 50, 55, 56 Embolism, 271 Embryotomy, 237 Emergencies, 153, 253 Emergency dressings, 23 Emerson, Dr. Haven, 20 Emetics, self-administered, 186 Emotional phenomena, 74, 85 Enamel cloth, 122 Enemata during labor, 151 nutrient, 185, 399 460 INDEX. Enemata soapsuds, 131, 176 English breast-pump, 356 Engorged blood-vessels, 283, 284 Epidemic tetanus, 345 Epilepsy, 200 Episiotomy, 237 Ergot, 162, 267, 395 " poor woman's," 188 Eruptive fevers, 210, 213 Esmarch apparatus, 142, 148 Ether anaesthesia, 141, 145- 160 danger signals in, 148 for convulsions, 203 irritating action of, 145 cone, 145 Evisceration, 237, 240 Excretory organs, testing of, 70 Exercise, 105, 106, 192 Exostoses, 29 Expiration, artificial, 323 Exposure of patient, 122, 140 Expulsive forces of labor, 91 Extension of arms, 157 process of, 94 External os, 39 rotation, 94 Extremity, prolapse of, 259 Ewald's enema, 399 Eyebrows and eyelashes, 58 Eyes of infant, care of, 140, 149, 290, 299, 308 infection of, 213, 334, 337 Face, cyanotic, 139 pigmentation of, 72 presentation, 95, 96, 98 guard, 394 Facial paralysis, 333 Fainting, 192, 194 Fallopian tubes, 35, 37, 39, 43 impregnation in, 206 False pains, 135 Fat babies, 376 in milk, 372, 378 Fat of baby, 298 Fear of operation table, 247 Feather bed, 127 Feeder for feeble baby, 357 Feeding hours, 364, 368, 375, 383 mixed, 374 rectal, 185 Feeding-tube, glass, 395 Feminist movement, 24 Fermentation of milk, 389 Fetal circulation, 53, 61 development, 48, 55, 58 in multiple conceptions, 66 ducts, shrivelling of, 65 heart sounds, 90 cessation of, 256 movements, 89 structures, 61 Fever, cause of, 179 eruptive, 210 high, a cause of miscarriage, 244, 255 milk, 83 puerperal, 275, 276 Fibro-cartilage, pelvic, 31 Figure, preservation of, 167 Figure-of-eight ligature, 273, 329 Finklestein's feeding, 391 First stage of labor, 76, 77, 131 Fissure of nipple, 114, 279, 282, 283 Flabby uterus, 162 Flattening of belly, 88 Flesh, increase in, 71 Flexion of head, 93 Flooding, treatment of, 265, 267 Flowers in room, 180 Flushing the system, 201 Foetus, death of, 84, go, 199, 256 diseases which affect, 213 formation of, 48 mummified, 208 INDEX. 461 Fcetus nourishment of, 51, 52, 61, 64, 70 oxygenation of blood of, 52, 61, 64 passage of, through pelvis, 31, 39 position of, in uterus, 60 removed by abdominal sec- tion, 206 retained in belly, 208 Fontanelles of cranium, 58, 59, 60 Food as preventive of nausea, 183 cravings, 86, 87, no during pregnancy, 109 for premature baby, 355 Foot presentation, 100 Foramen ovale, closure of, 64, 65 Forceps, care of, 23 cephalhaematoma from, 334 delivery, 31, 217, 332 for dressings, 337 types of, 220 Foreskin, adherent, 296 Formalin, 402 Formulas for milk, 379, 381, 383 Fornices, 38 Fourchette, 35 Four per cent, milk, 379 Fractures of the new-born, 329 France, legitimacy in, 75 Freeman pasteurizer, 390 Fresh air for infant, 127 Fright, 244, 373 Frontal bone, 58 Fruit diet, 109 Fruits as cause of colic, 180 Fundus, care of, 152, 156, 158, 162, 203, 265 Funis, 53 Gait in pregnancy, 73 Galactorrhcea, 370 Galbiati knife, 236 Gall-duct, affection of, 311 Garters, 104, 190 Gas and oil heaters, 300 Gauze packing, 231 expulsion of, 269 sponge technic, 404 Genital canal, blood-supply of, 69 organs, changes in, 69 of foetus, 55 tract, infection of, 274 Genitalia, scalding of, 297 Genitals, external, cleansing of, 137, 165, 170, 251, 403 swelling of, 70 Gestation, duration of, 75 multiple, 65 Gigli wire saw, 237 Glands of Montgomery, 69 Glans penis, care of, 296 Glass catheter, 173 Gloves, rubber, necessity of, 21 sterilization of, 23, 134, 139, 150 Glucose enema, 399 in urine, 73 Goat's milk, 376 Golf, 106 Gonorrhoea, as cause of sterility. 213 Gonorrhoeal infection of eyes, 335 Gooch, Dr., views on flooding, 265 Goodell uterine dilator, 247 Gossip, 25, 180 Gout, a cause of pruritis, 195 Gown, operating for nurse, 150 393, 394 protective, 139, 150, 213, 287 Graafian follicle, 43, 48 "Granny" knot, 153 Grape-sugar enema, 399 Green stools, 296, 345 Grief, 244 effect of, on milk, 375 Groin, pain in, 278 Guaranteed milk, 377 462 INDEX. Gumma, 211 Gynaecological cases, 25, 27 Habits, formation of, 295 Hair bed, 127 care of, 131, 137, 178 improved growth of, 71 pubic, clipping of, 45, 130, 137, 165, 177, 228 Hammock, canvas, 236 for infant, 395 Handling of infant, 301 Hands, disinfection of, 23, 134, 139, 170, 401 infection from, 21 Head, delivery of, 79, 94, 151 descent of, 138, 150 injuries, 329 of fcetus, 58 prolonged pressure on, 332 Headache in pregnancy, 194 Heart, blood-clot in, 262, 271, 278 diseases of, 192 failure, 259 foetal, 90 hypertrophy of, 102 palpitation of, 72 sounds, foetal, 85 Heating of incubator, 349, 351 Hebsoteotomy, 237 Heels, high, injurious effects of, 105 holding by, 320 Hegar's sign, 85 Haemorrhage, concealed, 81, 205 Haemorrhage, control of, 266 during labor, 256, 257 during pregnancy, 204, 253 during puerperium, 262 from cord, 148, 153, 326 from stomach, 210 from vagina, 208 pallor from, 205 Haemorrhage, post-partum, 152, 162, 167, 203, 240 secondary, 272 Haemorrhagic diathesis, 326 Haemorrhoids, 176, 191 Heredity as cause of insanity, 288 twins, 65 Hereditary traits, 116 Hernia, umbilical, 342 High operation, 221 Hippocratic oath, 213 Hirschsprung's disease, 343 Holt's apparatus, 371 Holmes, Oliver Wendell, 277 Home accouchement, 120 Horseback riding, 106 Hospital, delivery in, 120, 137, 233 equipment, 404 incubators, 349, 351 maternity, 126 treatment for vomiting, 185 Hot applications, 337 bath for convulsions, 346 pack, 203, 208 Hot-water bottles, 233, 251, 265, 349 for constipation, 187 immersion, 320 Hull House, 408 Hunger of baby, 368, 369 Hunyadi water, 188 Hygiene for nurse, 119 of baby, 299 of pregnancy, 102, 118 of the eye, 299 personal, 24, in, 187 preventive, 201 Hyperemesis gravidarum, 186, 400. See also Pernicious Vomit- ing Hypodermic case, 395 Hypodermoclysis, 203, 233, 271, 400 INDEX. 4^3 Hysteria, convulsions of, 201 during labor, 288 Ice-bag to breasts, 285 Ice compresses, 336, 340 pads, 337 rub, 267 to eyes, 335 water immersion, 320 Iceland moss, 174 Icterus neonatorum, 311 Ilium, 28, 29 Illegitimacy as cause of insanity, 288 Immunity, natural, 21 Impregnation of ovum, 39, 44 Inability to nurse, 367 to walk, 236 Incubator, 348, 351 ambulance, 349 baby, cry of, 354 weight of, 355 ventilation of, 351, 353 Indigestion, cause of, 179 in pregnancy, 197 of infants, 373 Induration of breast, 281 Infant, care of, 290, 304 clothing, ideal, 313, 314 early training of, 295, 306 feeding, 360 regulation of, 359 inspection of, 149 mortality, 405 pre-natal care of, 304 separate room for, 180 Welfare Societies, 391, 405 Infants' crib, 300 mouth, care of, 364 underwear, 311 Infants, vaginal discharge in, 342 Infection, genital, in baby, 297 modes of conveying, 21 of breast, 284 Infection of eye, 335 of syphilis, 211 precautions against, 119, 150, 177 puerperal, 20, 274 septic, 22 Infusion apparatus, 24, 271 subcutaneous, 269 Inhaler, ether, 145 Injection, intravenous, 203 Injury of child, 290, 329 Innominate bones, 28 Insane, care of, 289 Insanity, maniacal, 288 of pregnancy, 74, 287, 288 of unmarried mother, 288 puerperal, 274 Insomnia, 193 Inspection of placenta, 155 Inspiration, artificial, 323 Instrumental delivery, 214 for craniotomy, 238, 239 for curettage, 247, 248 infection from, 21, 22 use of, 135, 140 Internal os, 39 Intestinal colic, 346 Inunctious, olive oil, 400 Invalidism as result of infection 22, 274 pregnancy, 27 Inversion of uterus, 154, 257 Involution, process of, 81, 82, 181 Irrigator, 24, 131, 166, 176, 250 Irrigation of eye, 337, 338 Ischium, 28, 29 Isolation for eye disease, 339 Jacobi, Dr. Abraham, 407 Jaundice, cause of, 144 of new-born, 311, 340 Jenness-Miller corset, 102 Kelly pad, 132, 140, 166 improvised, 221, 337 INDEX. 464 Kicking of foetus, 90 Kidneys, action of, 107 care of, 112 disease of, 73, 198 Kneading of uterus, 163 Knee-chest position, 261 Knot, square, 153 " Krause " method, 242 Labia, majora and minora, 34, 35 Labor bed, 127, 128, 129 beginning of, 136 cause of, 76 date of, 90 duration of, 79 forces of, 91 induction of, 242 mechanism of, 91 pains, 77, 82, 131, 136 phenomena of, 75 premature, 76 premonitory symptoms of, 76 preparations for, 118 room, care of, 149, 150 furnishing of, 133 scientific supervision of, 26, 27 stages of, 76 sudden death in, 257 supplies needed for, 121 unassisted, 135 Laborde's tongue traction, 326 Laceration of tissues, 91, 150 in first labor, 67 Lacing during pregnancy, 103 Lactation as cause of fever, 83 affected by menstruation, 373 function of, 102 insanity of, 288 mastitis in, 284 Lactose in milk, 371 Lamboidal suture, 59, 60 Lap, bathing upon, 292 Lap, for dressing baby, 301, 33^, 337 Laparotomy sheet, 404 Larynx, irritation of, 143 Lavage for vomiting, 186 Laxatives, mild, 175, 188 Layette for baby, 299, 311 Lead poisoning, 213 Leg, bandaging of, 269 clot in, 277 enlargement of, 2/8 holder, 236, 246, 247, 251 prolapse of, 259, 260 stiffness of, 278 Legal abortion, 252 Legislation concerning pregnancy, 75 Leube's test meal, 400 Leucorrhcea, 194 Ligaments of uterus, 36 Ligature, figure-of-eight, 273 Light diet, 179 Light for operation, 250 in incubator, 355 Lime water, 381 Linea albicantes, 67, 68 Liquid diet, 398 Liquor amnii, 51, 52 Lists for obstetrical nurse, 23 Liver, effect of chloroform upon. 144 in newborn child, 64 toxaemia of, 203 Lividity of child, 317 Living child, sacrifice of, 238 Lithotomy position, 217, 219, 236 L. O. A. position, 93 Lobules of breasts, 41 Local anaesthesia, 287 Lochia cruenta, 82 infection from, 172, 2S1 in puerperal sepsis, 275 odor of, T76, 1/9 purulenta. 82 INDEX. 465 Lochia rubra and sanguinolenta, 82 "Locked" twins, 157, 159 Lockjaw, 344. See also Tetanus London, overlain babies in, 345 Longings, morbid, 85 Lubrication, 23, 69, 174, 280 Lubrichondrin, 139, 140, 261 Lungs, hemorrhage from, 210 inflation of, 323, 326 pressure upon, 70 Lying-in hospital, 407 room, choice of, 125 disinfection of, 126 state, 80 Lysol solution, 23, 132, 401 Malaria, a cause of abortion, 211 213 Male germ, impregnation by, 39, 44. 206 pelvis, 31 Malformation of rectum, 343 Malposition of fcetus, 222, 228 dangers of, 259 Mammae, 40. See also Mammary Glands and Breasts Mammary glands, 40 Minia during labor, 288 Manipulation of baby, 354 of fcetus, 214 Marriage of syphilitics, 212 "Marked" children, 115 Marshall Hall artificial respira- tion, 323 Mask for doctor and nurse, 235 " Masque des femmes enceintes, 72 Massage for insomnia, 193 in pregnancy, 106 in puerperium, 182 of breast, 280, 281, 356, 370, 392 Mastitis, 283, 284 chills in, 285 Mastitis, in infants, 342 » suppurative, 287 surgical treatment of, 287 Maternal impressions, 115 Maternity hospitals, 349 Mattress for infant, 300 for labor bed, 129 Meat in dietary, 179 Meatus urinarius, 35 Meconium, disappearance of, 298 passage of, from vagina, 97, 156 Melancholia in pregnancy, 74, 287, 288 Membranes, expulsion of, 79, 151 Membranes, retained, 252 rupture of, 138 Meningitis, traumatic, 332 Menopause, 46. See also Change of Life, Climacteric pregnancy preceding, 47 Menstruation, 45, 46 cessation of, 410 changes in uterus during, 49 in ectopic pregnancy, 207 in nursing mother, 373 its relation to ovulation, 45 suppression of, 85, 86 Mental balance during adolescence, 45 phenomena, 85, 86 state, 345 Metabolism of labor, 340 Midwife as nurse, 406 Midwifery in New York City, 2C in United States, 19 Midwives, attendance of, 407 registration of, 407 Milk, affected by fright, 373 . ass's and goat's, 376 chemical constituents of, 371 contamination of, 358 diet, 398 ducts, 42 466 INDEX. Milk, eight per cent., 378, 382, 384 expression of, 280, 284, 355 fever, 83 formulas, 379 four per cent., 379 leg, 274, 278 over-secretion of, 280, 283, 370 pasteurized, 389 secretion of, 40, 370 solids in, 371 stations, 377, 407 sterilized, 389 sugar, 362, 381 supply in cities, 377, 388 true, appearance of, 362, 365 twelve per cent., 378, 380, 384 Miscarriage, 106, 108, 112, 195, 244 after-treatment of, 252 causes of, 255 dangers of, 246 first symptom of, 256 from albuminuria, 198 from diarrhoea, 188 precautions during, 245 prompt action in, 253 Mitral valve, 192 Mixed feeding, 361, 375 Modified milk, 376 apparatus for, 384 how secured, 377 Moisture in air, 353 Monstrosity, 228 Mons Veneris, 34, 72 Montgomery gland, suppurating, 69, 87, 284 " Morning sickness," 75, 85, 86, 207 nervous origin of, 185 prevention of, 183 Morphine, effects of, 116 in obstetrics, 160 Mortality from concurrent dis- eases, 210, 211 from eclampsia, 198 from sepsis, 277 Mortality, puerperal, 20, 22 Mother's bed, 127 milk, composition of, 371 drugs excreted by, 392 quality of, 371 substitute for, 358 value of, 370 outfit, 121 Mothers, education of, 406 unmarried, insanity of, 288 Moulding of infant's head, 60 Mouth, care of, 149, 151, 308 Mucous patches, 211, 212 surfaces, destruction of, 399 Mucus in throat, 317, 318, 320, 331 Multigravida, 68 Multiparas, impaired health of, 288 Multiple conceptions, 65, 66 foetal development in, 66 Murder, tendency to, 288 Murmur, uterine, 85 Murphy saline drip, 269 Mutilation of foetus, 214 Nail-bursh, 121 Nasal feeding, 399 National Children's Bureau, 304 Nausea during labor, 77, 78 in pregnancy, 70, 86, 183 Navel, 53. See also Umbilicus bleeding from, 272 infected, 311 Neck injuries, 399 of fcetus, broken, 240 Nephritis, latent, 74 Nerve impulses, 117 Nervous shock, 244 effects of, 373 system, disturbance of, 74, 114 Neuralgia, 194 Neurotics, feeding of, 399 New-born infant, 290 asphyxia of, 317 injuries pf, 329 INDEX. 467 New-born infant, septic disease of, 340 New York City, milk supply in, 377 statistics of obstetrics in, 20 Night-gown, changing of, 164 Nipple, 42 for bottle, 386 injured by infant, 284 precautions concerning, 282 shield, 282, 359 Nipples, anointing of, 361 care of, 24, 113 cracked or fissured, 114, 279, 282 diseases of, 274, 279 pigmentation about, 72 soreness of, 181 syphilitic, 287 Nitrate of silver, 292 Normal infant, 290 labor, 135 Nose-bleed, 210 Nostrils, care of, 303, 308 Nourishment of infant, 102 Nurse as anaesthetist, 144, 148 delivery by, 149, 150 disinfection of, 119 disqualification of, 119 duty of, 84, 119 efficiency and personality of, 25, 118, 159 engagement of, 120 infected by infant, 212 neglect on part of, 268, 276 obstetrical diagnosis by, 100 opinions of, 161, 252 pay of, 119 visiting, 406 Nurse's aprons and dresses, 393 bag, 268 gown, 235 obstetrical outfit, 393 Nurses' Directories, 119 Nursery bath-room, 304 ideal, 299, 301, 304 Nursing bottles, care of, 358, 385, 387, 388 dawdling in, 388 in twilight sleep, 161 obstetrical, 22, 27 private, 24 regularity in, 362 Nut-gall ointment, 191 Nutrient enemata, 399 Oatmeal-water, 385, 386 " Obstetrical camp-follower," 25 cases, agencies for care of, 19 nursing, ideals of, 404, 409 outfit for, 393 service, voluntary, 407 suit, 122 surgery, 233 training, 407 Occipital bone, 58 Occiput, rotation of, 93 Oedema during pregnancy, 113 general, 197, 200, 202 of extremities, 70, 191, 192 Olive oil inunctions, 348, 400 Operating cap, 394 Operation, preparations for, 228 Operations at home, 24 non-cutting, 214 Operative delivery, 91, 95, 214, 260 Operculum, 21 Opisthotonos, 344 Ophthalmia neonatorum, 334, 336 in New York City, 20 Opinions of nurse, 161, 252 Organs of generation, 34, 35 Osmosis, 53, 70 Ossification of fontanelles, 60 Osteomalacia, 32 Os uteri, dilatation of, 78, 139 Outdoor life for baby, 311 468 INDEX. Outfit for infant and mother, 121 Ova, transplantation of, 117 Ovarian cyst, .228 Ovaries, 35, 37, 39 contents of, at birth, 43 Over-feeding, 179 Overgrowth of fcetus, 222, 228 Overlaying of infant, 345 Ovulation, process of, 39, 43, 44 Ovum, impregnation of, 39, 44, 48, 206 in abdomen, 206 segmentation of, 49 Oxalic acid, 402 Oxygen, foetal intake of, 116 in convulsions, 203 inhalations of, 344 supply of, 102 Oxygenation of blood, 52, 61, 64, 70 Packing of uterus, 258, 268 Pads, intestinal, 229, 231 laparotomy, 404 obstetrical, 121, 130, 165, 166 vulva, 23, 133, 137, 170 Pain accompanying hemorrhage, 254 as symptoms of abortion, 205 during suckling, 280 excruciating, 208, 209, 255 in ectopic pregnancy, 207 menstrual, 45, 46, 373 Pains of labor, 77, 138 relief of, 160 shooting, in breasts, 85 Pajamas, 122, 137 Pallor after delivery, 162 sudden, 142 Palpation of abdomen, 100 of the heart, 72 Paper bags, 302, 309 Paralysis in pregnancy, 194 of infant, facial, 333 Paraphimosis, 296 Parietal bones, 58 Parturition, 75 Passive movements, 106, 182 Pasteur, views of, 22 Pasteurization, 389 Patent baby foods, 376 Pathology of pregnancy, T83 Pawlik's grip, 101 Payment of nurse, 120 Pelvic disorders, cause of, 25, 26 palpation, 101 Pelvimeter, 32 Pelvis, anatomy of, 28 contracted, 75, 222 deformity of, 228, 242 female, compared with male, 31 inclined planes of, 93 inlet of, 30 measurement of, 32, 33 sensation of weight in, 46 tilting of, 218, 220 Pendulous breasts, 103 Perineal pad, 122, 165, 167 Perineum, care of, 150 torn, 40, 171 Peritonitis, puerperal, 208, 213 Permanganate of potassium, 401 Pernicious vomiting, 184, 186 Perspiration, 104, 197 excessive, 178 during labor, 80 Phimosis, 296 Phlegmasia alba dolens, 274, 277 See also Milk Leg treatment of, 278 Physical development, faulty, 33 retardation of, 27 Physiology of pregnancy, 67 of puerperium, 80 Pigmentation, general, 72 of abdomen, 68, 88 of breasts, 42, 85 INDEX. 469 Pillow for baby, 301 Pins, discarding of, 305, 307, 315 Pin-sticking, 305 Placenta, as part of mother, 116 delivery of, 21, 79, 148, 152, 154 detachment of, 204, 210, 254 examination of, 148, 155 formation of, 51, 53 manual extraction of, 263 maternal surface of, 54 praevia a cause of bleeding, 204, 253 forms of, 208 retained, 245, 252, 262 site of, 44 Playing with baby, 295, 368 Pneumonia in pregnancy, 210 Poisons, care of, 402 excretion of, 203 Pole of foetus, 101 Poor mother, care of, 405 Position of foetus, 91, 93 Post-mortem Caesarean section, 234 Post-partum haemorrhage, 162, 265 emergency treatment of, 270 Poverty, nursing amidst, 405 Powder for baby, 171, 293 Precipitate delivery, 157 labor, 139, 149, 154. 157, 260 Pregnancy, abdominal changes in, 88 before menstruation, 45 care of breasts in, 361 convulsions in, 197 decidua of, 49 diseases complicating, 205 disorders of, 183 duration of, 75 during lactation, 374 emotional changes in, 74 extra-uterine, 206 extreme limit of, 75 Pregnancy, interstitial, 206 management of, 102, 202 physiology of, 67 prevention of, 226 requirements of, 26 sign of, 42, 69, 84, 85, 88 supervision during, 26 symptoms of, 84, 85 systemic changes in, 70 tubal, 206 urinary analyses in, 118, 196, 198, 200, 202 urine of, 73, 118, 196, 198, 200, 202 walking during, 105 Premature baby, 348 breast-fed, 355 feeding of, 357 temperature for, 349 birth, 154, 155 infants afterward famous, 359 labor, 244 labor, causes of, 244 induction of, 75, 242 management of, 252 Prenatal care, 20, 25, 304 Presentation, abnormal, 100, 158 of fcetus, 91 Preservation of milk, 391 Pressure, injury from, 103 uterine, in Prevention of waste, 19 Preventive medicine, 27 Primigravidae, care of, 26 Prochownik's diet, 109, 400 Prolapse of cord, 259, 260 Promontory of sacrum, 29, 30, 33 Proteids in milk, 371, 372, 373, 378 Protracted labor, 78 Pruritis, 195 Psychical development, 45 Psychology, nurse's knowledge of, 25 Ptyalism, 193 470 INDEX. Puberty, 45 Pubiotomy, lateral, 237 Pubis, 28, 29, 30 Public Health Nurse, 377, 406 Puerperal fever, 274 insanity, 287 sepsis, 20, 21, 274 mortality from, 20, 22, 277 state, 80 Puerperium, diet during, 398 duration of, 181 emergencies in, 262 management of, 162 pathology of, 274 Pulmotor, 326 Pulse after labor, 80 irregularity of, 142 of infant, 294 record of, 177 Purpura, 329 Pus cases, nursing of, 119 in breast milk, 374 in eyes, 337 Pyogenic organisms, 22 Quadruplets, 65, 66 Quickening, 85 Quiet for baby, 299, 368 Quinine as cause of abortion, 211 Rabbits, impregnation of, 117 Records, keeping of, 133, 395 Rectal irrigation, 269 medication, 185 tenesmus, 191 tube, rubber, 176 Rectum, impacted, 343 Red Cross nurse, rural, 19, 406 visiting, 407 Registration of births, 410 of midwives, 407 Regurgitation of food, 367 Reigel's test meal, 400 Resistant forces of labor, 91 Respiration, artificial, 320, 326 before delivery, 157 establishment of, 61 failure of, 142 in convulsions, 199 interference with, 103 stimulation of, 318, 319, 320 under anaesthesia, 147 Responsibility of nurse, 24, 26 Rest during menstruation, 45 for feeble baby, 354 Restitution of position, 94 Resuscitation of child, 317, 320 Byrd's method, 321, 322 Sylvester's method, 327 Rickets, 109 Robb's leg-holder, 247 Rochelle salt catharsis, 197 Room, incubating, 349, 351 lying-in, 125, 126 separate, for baby, 295, 345 Rotation of head, 94 Rubber apron, 393 bag, objections to, 131 gloves, 23, 134, 139, 150, 171, 213, 394, 402 sterilization of, 23, 134, 139, 150 nipples, care of, 386, 387 sheeting, 122, 129, 300 Rupture at umbilicus, 342 of uterus, 257 symptoms of, 210 Rural nursing, 100, 148, 406, 407 Sac, amniotic, rupture of, 78, 151, 255 Sacro-coccygeal articulation, 30 Sacro-iliac synchondroses, 30, 31 Sacrum, 28, 29 Safety-pins, swallowing of, 305 Sagittal suture, 59, 60 St. Anthony's dance, 195 St. John's dance, 195 INDEX. .-j St. Vitus's dance, 195 Saline douche, 267 enema, 399 infusion, 232 Saliva, secretion of, 193 Salivation, 193 Salt solution, normal, 177, 401 water bathing, 107 Salvarsan treatment, 212 Scalding milk, 389 Scales for infant, 309, 395 Scalp, care of, 311 swelling of, 332, 333 Scarlet fever, 210 Scars, 329 Schroeder's retractor, 248 Schultze swinging method, 326, 328, 330 Scopolamine in obstetrics, 160 Screen for baby, 303 Scrub-up technic, 134, 402 Sea sponges, 303 Seborrhoea capitis, 311 Second stage of labor, 76, 78, 138, 141 pain in, 138 Secondary haemorrhage, 273, 326 Secretion of milk, cessation of, 2/9 Secretory organs, tax upon, 70 Sedatives, effect of, 204 Segmentation of ovum, 49 Self-control, 115 Semmelweiss, 277 Sensation of weight in pelvis, 46 Sepsis, 22 constitutional effects of, 276 in hospitals, 277 Septicaemia, puerperal, 20, 21, 274 Serum injections, 213 Seven-months baby, 75 Sewer-gas poisoning, 213 Sewing-machine, use of, 107 Sex, control of, 115, 117 Sex control of twins, 65 recognition of, in embryo, 55 Shaving of patient, 45, 130, 137, 165, 177, 228 Sheets, arrangement of, 139, 140 Shock of labor, 81, 257 reaction from, 251 Shoes for baby, 312 for pregnancy, 105 Shoulder presentation, 100, 240 impacted, 239, 240 Shower bath, 132 Sight, disturbance of, 202 Sims's position, 242, 243 Simpson's forceps, 223 Sitting up, 181 Size of child, control of, 109 of uterus, 36 Skeleton of infant, 57 Skin, increased activity of, 71 of premature infant, 355 streaking of, 67 Skull, foetal, 59 Slapping infant, 318, 320 Sleep during pregnancy, 108 for nursing mother, 363 of infant, 294 Sleeping with patient, 181 Sling sheet, 219 Sloane Maternity Milk Set, 384 stocking, 122 Smegma, 296 Snap fastenings, 312, 405 Snapping soles of feet, 319 Snuffles, 212 Soap for baby, 303 green, 134, 170 Social standing a factor in preg- nancy, 74 Socks, 310, 312 Sodium bromide, 184 " Soft spot" on forehead, 60 Solutions, antiseptic, 139, 140, 401 for eyes, 290 472 INDEX. Souring of milk, 388 Special nurse, 120 Spermatozoa, within vagina, 44 Spermatozoon, union of, with ovum, 48 Spina bifida, 340 Spinal cord, bulging of, 341 Spine, fraction to, 320, 323 Sponge baths, 137, 178 Sponges, abdominal, 404 cotton and gauze, 230 loss of, 233, 404 sterile, 177 technic for, 404 Spots before eyes, 197, 205 Spraying of infant, 292 Stages of labor, 76 Stagnation of milk, 284 Stanis from chemicals, 402 Stair climbing, 107 Starvation temperature, 184 State laws on midwifery, 407 Statistics concerning obstetrics, 20 Steam sterilizer, 390 Steelyards, 395 Sterile soap, 23 Sterility, 213, 276 Sterilization, 22, 401 for infusion, 270 of bed, 128 of catheter, 173 of clothing, 122, 137 of hands, 134, 402 of instruments, 222 of milk, 389 of nursing bottles, 387 of rubber bags, 224 of rubber nipples, 387 of supplies, 123, 124 technic of, 401 Stiffness from clot, 278 Stimulation of patient, 259, 267 Stocking, maternity, 122 Stomach-tube, feeding by, 399 Stools, curds in, 373 Straining during labor, 259 Strangling, danger of, 158 Streptococcus infection, 277 Striae, abdominal, cause of, 68 gravidarum, 67, 68 in skin of breasts, 69 Stricture, congenital, 311 Study, excessive, 45 Subinvolution, 81 Sublamin, 401 Suckling as cause of uterine con- tractions, 41, 113 discomfort from, 283 impossible, 344 interference with, 279, 283 position for, 366 prevention of, 114 Suffering, puerperal, 25 Suffocation of infant, 345 Sugar, fat-producing, 376 in milk, 378, 381 in urine, 73 Suicide, tendency to, 278, 288 Sunshine for baby, 299, 304 Supervision of pregnancy, 26 Supplies needed by nurse, 396 renting of, 124 Suppression of menstruation, 45 Suppuration of breast, 283, 287, 342 Surgery in ectopic pregnancy, 208 Surgical dressings, 124 Suspended animation, 317 Sutures of cranium, 58, 59, 60 perineal, 171, 176 Swabbing the mouth, 364 Swallowing pins, 305 Sylvester's method, 327 Symphyseotomy, 31, 234, 236 Symphysis pubis, 28, 30, 33 Syncope, 192, 194, 253 Syphilis as cause of abortion, 211 transmission of, 212 INDEX. 473 Syphilitic infection, 212, 213 nipples, 287 Table, dressmaker's, 247 for dressing baby, 303, 309 Tampico fibre brush, 134, 402 Tamponing, 266, 268 Tape for cord, 395 fastenings, 305 Tarnier basiotribe, 239 forceps, 223 Tarnier's incubator, 353 Tarry discharge from vagina, 97 T-binder, 132 Tears, excessive secretion of, 193 Technic, hand preparation, 401 Teeth, care of, 108 false, 141, 145, 203 Temperature after labor, 81 charts, 177, 394 in puerperal fever, 275 of incubator, 349, 351, 353 of infant, 294, 306 of nursery, 299 of operating room, 233 of premature baby, 355 subnormal, 348, 349 Tenesmus, rectal, 191 Tennis, 106 Terror of water, 309 Terrors of nursery, 295 Test meal, 400 Tetanus, 344 Teterelle, 359 Thermometry, clinical, 177, 394 Third stage of labor, 77, 79 Thirst from hemorrhage, 205, 255 of baby, 298, 359, 368 relief of, 185 Threatened miscarriage, 256 Throat, mucus in, 317, 318, 319 Thrombus, 271 Time for labor, 75 Tissue, injury of, 329 Toilet of mother, 178 screen, contents of, 316 Tongue, biting of, 203 bleeding from, 199 cleansing of, 308 traction, 320, 323, 326, 332 Toothache, 108 Top milk, 380, 382 Towels, clean, 121, 123 Toxaemia, eclamptic, no general, 187, 197, 198 indicated by vomiting, 86, 187 of liver, 203 Traction on body during delivery, 155 Training of infant, 295, 306 Transverse presentation, 99, 101, 215 Tray for care of breasts, 279 Trendelenburg position, 261 Treponema pallidum, 211 Triplets, 65, 66 Tub-bath for baby, 293, 302, 304 for baby, temperature of, 306, 308 in pregnancy, 108 Tubal pregnancy, 206, 208 Tuberculosis in pregnancy, 211, 213 Tubes, removal of, 234 Tucker-McLane forceps, 223 Tumor, abdominal, 228 of spina bifida, 341 Turpentine enema, 137 Twelve per cent, milk, 378, 380, 384 _ Twentieth century civilization, 27 Twilight sleep 160 Twin, decapitation of, 238 pregnancies, 76, 190 Twins, abdomen containing, 68 causation of, 65 delivery of, 157, 158 locked, 157, 159, 238 474 INDEX. Twins, precautions concerning, 154 umbilical cords of, 66 Typhoid state, 184 Tubercles of Montgomery, 69, 87 Ulcer, syphilitic, 211, 212 Ulceration of tumor, 341 Umbilical cord, 53, 116 compression of, 317 cutting of, 65 detachment of, 294 prolapse of, 259 shortness of, 258 tying of, 66 hemorrhage, 326, 329 hernia, 342 vegetations, 343 Umbilicus, 53. See also Navel infection of, 340 protrusion of, 68, 69 Unavoidable hemorrhage, 253, 254 Unconscious patient, 204 Under-feeding, 180 Uniforms for nurse, 394 Uraemia, 194 convulsions of, 199 Urea, excretion of, 198 Urethra, 35 Uric acid deposit, 296 Urinary colic, 346 Urination in new-born, 298 stimulation of, 172 Urine, examination of, 113, 118, 196, 198, 200, 202 in hysteria, 201 of eclampsia 200 of pregnancy, 73 retention of, 83 voiding of, 172 Uterine dilator, 247, 248 inertia, 222, 264 Uterus as a nest, 117 bleeding from, 154 bleeding into, 254 Uterus, cancer of, 412 contraction of, 41, 81, 83, 85, 242 enlargement of, 89 infection of, 21 inversion of, 154 mucous membrane of, 49 openings of, 39 packing of, 252 palpation of, 101 pregnant, 36, 67 pressure of, upon lungs, 70 relaxed, 81, 162 removal of, 226, 228, 234 rupture of, 217, 257 sinking of, 76 tilting of, 38, 86 virgin state of, 35, 81 Vagina, 34 aseptic state of, 35 irrigation of, 177 Vagina of infant, bloody discharge from, 297 packing of, 243, 252 secretion of, 21, 69, 137 violet hue of, 69, 85, 89 Vaginal discharge after meno- pause, 412 meconium in, 156 douche, 35, 176, 194 examination, 139, 403 mucous membrane, 89 operation, 219 secretion a lubricant, 69 walls, return of, to normal, 82 Vaginitis, 297 Varicose veins, 104, 189, 191 Vegetations, umbilical, 343 Veins, clot in, 277 Ventilation, 180 of incubator, 351, 353 Vernix caseosa, 58, 292 INDEX. 475 Version, external, 214, 215 indications for, 222, 243 operation of, 101, 209 internal, 214, 217 Vertex presentation, 91, 93 Vesical tenesmus, 191 Virgin state of uterus, 81 Vision, double, 197 Visiting nursing, 406, 408 Visitors, 80, 180 to incubator baby, 354 Vital resources, conservation of, 19 Vomiting due to ether, 146 during labor, 77, 78 morning, 85, 86, 183 of albuminuria, 197 of infants, 367 of pregnancy, 70, 86 pernicious, 186 relieved by bromide, 184 uncontrollable, 186 Vulva, 34 cleansing of, 132, 171, 251, 403 infection of, 138 pads, 23, 133, 137, 170 Waist, pressure about, 103 Waiting, time lost by, 119 Walcher posture, 218, 220 Walking during pregnancy, 105, 106 Wansbrough's shield, 282, 283 Wash-basin, double, 302, 309 Washing of baby's clothing, 316 Washrags, 303, 309 Water, boiled, for baby, 298, 359, 368 for colic, 346 intake of, 112 sterilization of, 401 Water-closet, non-use of, during labor, 132, 137 Weather and out-door exercise, 105 Weight chart, 309 of baby, 309, 348, 394 doubled, 367 loss of, 368 new-born, 297 normal increase in, 298, 364 Wet-nurse, milk of, 360 mortality of, 374 selection of, 374, 375 Wharton's jelly, 55 Whiskey by hypodermic, 323 " Whites," 194 Winckel's disease, 340 Windows, protection of, 250 Wipes, burning of, 170, 213, 335 "Wobbly" gait, 73 position of head, 96 Womb, 35. 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