OBSTETRICS FOR NURSES Fig-1 Fig 2 Fig. 3 Fig 4 Fig. 5 Fig. 6 Germs most frequently found in cases of puerperal fever. (Kelly’s Gynecology.) 1, streptococci (in chains); 2, gonococci; 3, tubercle bacilli (not a source of puerperal infection); 4, bacillus, coli communis; 5, staphylococcus pyogenes aureus; 6, bacillus aerogenes capsulatus. OBSTETRICS FOR NURSES BY CHARLES B. REED, M.D., Obstetrician to Wesley Memorial Hospital, Chicago. ONE HUNDRED FORTY-FOUR ILLUSTRATIONS INCLUDING TWO COLOR PLATES ST. LOUIS C. Y. MOSBY COMPANY 1923 Copyright, 1917, 1923, by C. V. Mosby Company Printed in IT. S. A. Press of C. V. Mosby Company St. Louis TO IIIS LOYAL FRIEND EUGENE S. GILMORE THIS BOOK IS AFFECTIONATELY DEDICATED BY THE AUTHOR PREFACE TO SECOND EDITION It is no small gratification to tlie author that the large first edition of his “Obstetrics for Nurses” should be so quickly exhausted, for it not only shows a real need and appreciation for the book, but it also affords an opportunity for revision. The text has been abbreviated in many places and enlarged and emphasized in others to conform to our constantly changing thought. Besides the new text ma- terial, a number of illustrations have been added which class use has suggested. Various inaccuracies and obscurities in the text have been detected and removed through the careful super- vision of Dr. C. D. Hauch, whose assistance it is pleasant to mention. Chicago, 1923. C. B. R. PREFACE TO FIRST EDITION It might seem that an apology was necessary for presenting a new textbook on obstetrics for nurses when so many are to be had for the asking. But when a teacher is rarely or never satisfied with his own work it is too much to expect that he will ever fully endorse the product of another. It may be therefore largely a personal matter that none of the existent books seem to exhibit the fullness of information, the conciseness of expression, and the emphasis due to cer- tain subjects that the present writer would hope to find. The necessities apparently demand such an arrange- ment of our obstetrical doctrine that the book may serve for class instruction and at the same time be complete enough for post-graduate reference. To secure this much discrimination is necessary. The confusion attendant upon overabundance must be avoided as well as the discouragement that is not in- frequently produced by a large book or a periphrastic style. Hitherto there has been a tendency to teach the nurse too little rather than too much but conditions have changed. Vocational instruction is not only more methodical and far reaching but it is developmental. The present day nurse expects not merely to assist the physician and earn a stipulated reward, but she is constantly alert to attain her own maturity as a pro- fessional woman. To be a capable and intelligent assistant it is not sufficient to have a clear comprehension of her particu- 7 8 PREFACE lar duties, but she must have a defined and critical con- ception of what the doctor is aiming to accomplish. This is especially true in obstetrics where the nurse lias the additional responsibility of giving support and counsel to her patient in the various emergencies that arise. Moreover, to attain her intellectual maturity the nurse must strive unremittingly to understand the complicated processes that take place under her obser- vation. She must cooperate with her doctor whose associate she is and secure the confidence of her patient who re- lies upon her for guidance in the perils she is facing. For childbirth is a peril. It is no longer the normal process it once was. Civilization has changed the shape of the pelvic bones, altered the muscles of parturition and weakened the nerve centers that control the event. The birth of a child is equal in severity and serious- ness to many of the major operations. It is not an affair to be entered upon lightly nor managed without the utmost foresight and care. The dangers that are recognized and prepared for in this book by what may seem to some to be an ex- travagant technic, are very real dangers, extremely subtle, and against them at times every precaution and every defense proves unavailing. Nevertheless, skill, thoughtfulness, and above all, cleanliness, will avert the worst, as well as probably the most common of these disasters. If our nurses could be convinced of this, the difficulties and appre- hensions of childbirth would be greatly diminished. The nurse should see to it that her patient is sur- rounded by all the precautions and safeguards against infection that she would demand for a member of her own family. This means of course that her work will PREFACE 9 be far more exacting and onerous but also it will save many nights of anxiety and not infrequently a life. This book represents the obstetric ideas and technic which the writer has endeavored for years to impress upon his students and nurses with such emendations and changes as experience and scientific progress have suggested. It is a selective essence distilled from the recurrent harvests that workers in this field have brought forth during centuries of consecrated effort. To all these forerunners the writer acknowledges a deep personal indebtedness. In the iweparation of the book thanks are due par- ticularly to Charlotte Gregory, Head Nurse of the Wesley Maternity, whose rare ability as teacher, tech- nician and executive and whose untiring vigilance has been a leading factor in securing and maintaining the high state of efficiency in this department. She has kindly contributed Chapters NXIII and XXIV, to- gether with valuable suggestions and criticisms in other portions of the text. The author also takes pleasure in acknowledging his obligations to Florence Olmstead, Head Nurse of the Dispensary of the Northwestern University Medical School, whose long experience in feeding babies gives to her words an unquestioned authority. Chapter XXII is almost entirely her work. To the various publishers who have courteously al- lowed the reproduction of valuable illustrations from the books of other writers thanks are also extended, and to his own publishers especially for their cordial and sympathetic cooperation the author wishes to ex- press his warmest gratitude. C. B. R. Chicago, 1917. CONTENTS CHAPTER I PAGE Anatomy 17 CHAPTER II Physiology 34 CHAPTER III Normal Pregnancy 54 CHAPTER IV Hygiene of Normal Pregnancy 69 CHAPTER V Abnormal Pregnancy 77 CHAPTER VI Abnormal Pregnancy (Continued) 99 CHAPTER VII Preparations for Labor and the Normal Course of Labor 114 CHAPTER VIII The Mechanism of Normal Labor 136 CHAPTER IX The Care of the Patient During Normal Labor . . . 145 CHAPTER X The Normal Puerpeiuum 167 CHAPTER XI Unusual Presentations and Positions 181 CHAPTER XII Operations 195 10 CONTENTS 11 CHAPTER XIII PAGE Minor Operations 216 CHAPTER XIV Complications in Labor 231 CHAPTER XV Complications in Labor (Continued) 245 CHAPTER XVI The Abnormal Puerperium 260 CHAPTER XVII Infection 273 CHAPTER XVIII The Care of the Child 283 CHAPTER XIX The Care of the Child (Continued) 298 CHAPTER XX The Care of the Child (Continued) 307 CHAPTER XXI The Care of the Child (Continued) 323 CHAPTER XXII Infant Feeding 335 CHAPTER XXIII Cleanliness and sterilization 348 CHAPTER XXIV Diets and Formulae 355 CHAPTER XXV Solutions and Therapeutic Index 365 ILLUSTRATIONS FIG. PAGE Frontispiece. Germs most frequently found in puerperal fever (Colored) frontispiece 1. The normal female pelvis 18 2. The planes of the brim, the cavity, and the outlet . . 19 .3. Visceral relations 20 4. Uterus and appendages 22 5. Normal position of pelvic organs 24 6. The external genitals 25 7A. Varieties of hymen 27 7B. Varieties of hymen 28 8A. The excreting ducts of the mammary gland ... 29 8B. Lobules and duct of the mammary gland 29 9. Female perineum 30 10. Nipple, areola, and the glands of Montgomery ... 31 11. Supernumerary milk glands in the axilla; 32 12. The three ages of the breast 32 13. Section of corpus luteum from adult ovary 35 14. Development of the ovary 36 15. Graafian follicles 37 16. Human spermatozoa 39 17. Embedding of the ovum 40 18. The chorionic villi about the third week of pregnancy . 41 19. Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy . 42 20. Maternal surface of the placenta and membranes . . 44 21. Foetal surface of human placenta 45 22. The egg at term with uterus removed 46 23. Normal attitude of foetus . 47 24. Foetal skulls showing sutures 48 25A and B. Child’s head at term, showing diameters . . 49 26. The foetal circulation 52 27. Gravid uterus at the end of the eighth week .... 55 28. Striae gravidarum 57 29. Bimanual examination 63 30. Abdominal enlargement at different months of pregnancy 66 12 ILLUSTRATIONS FIG. PAGE 31. Height of the uterus at various mouths of pregnancy . 67 32. Twins 92 33. Anomalies of the placenta 97 34. Diagram representing the sites for the various forms of tubal pregnancy 100 35. Treponema pallida and Spirochete refrigens .... 102 36. The McDonald measurement 109 37. The Ferret measurement of the occipitofrontal diameter of the head Ill 38. The Ahlfeld measurement 112 39. Abdominal binder with crosspiece to hold vulvar pads . 116 40. T-binder, used in all cases after the fifth day postpartum 116 41. Breast binder 117 42. Baby’s dress with winged sleeves 118 43. The bag of waters begins to act on the cervix . . . 127 44. The effect of the pains. The cervix before labor begins 128 45. The effect of the pains. The cervix begins to be (‘ effaced ’ ’ 128 46. The effect of the pains. The cervix is effaced, and the dilatation of the os begins 129 47. The effect of the pains. The cervix is effaced and the os continues to dilate 129 48. The cervix is effaced and the os dilated 131 49. Child in second stage of labor 132 50. The head passing over the perineum 133 51. Normal expulsion of the placenta according to Sehultze . 134 52. The child in left-occipito-anterior position .... 138 53. The child in right-occipito anterior position .... 139 54. The descent of the head in right-occipito-anterior position 140 55. Internal anterior rotation and extension of the head in a left-occipito-anterior position 140 56. Extension 141 57. Extension completed. Expulsion 141 58. A cephalhgematoma 143 59. Points of greatest intensity of foetal heart tones . . . 146 60. Handling forceps, kept sterile in a jar of alcohol . . 148 61. Palpation. What is in the pelvis? 150 62. Palpation. What is in the fundus? 151 63. Palpation. Where is the back? Where are the small parts? 152 64. Patient draped for internal examination 153 65. Patient draped for normal delivery . . . • . . . , 155 14 ILLUSTRATIONS FIG. PAGE 66. Patient prepared for delivery on side 156 67. Delivery in side position 157 68. Sheet twisted into a sling 163 69. Repair of perineum 165 70. The progress of involution 168 71. The breech. Left-sacro-anterior position 182 72. The breech. Left-sacro-postcrior position 183 73. Extraction of the breech 186 74. Breech delivery. Extraction of the trunk .... 187 75. Breech delivery. Delivering the shoulder 188 76. The delivery of the after coming head by the Smellie- Yeit maneuver 188 77. Shoulder presentation 189 78. Face presentation 191 79. Descent of the chin in face presentation 192 80. Delivery in face presentation 193 81. Patient draped for operative delivery 197 82. Dorsal position when assistants are available . . . . 198 83. Instruments for artificial delivery of the head . . . 199 84. Forceps operation. Introduction of the left blade . . 202 85. Forceps operation. The introduction of the right blade . 203 86. Forceps operation. Locking the handles 203 87. Forceps operation. The way the blades should grasp the foetal head 204 88. Forceps operation. Traction on the handles .... 205 89. Forceps operation. The delivery of the head . . . 205 90. Version. Seizing a foot 206 91. Version. The child rotates as pressure is made upon the head and traction upon the foot 207 92. Version is complete when the knee appears at the vulva . 208 93. The Walclier position 210 94. The Wiegand compression of the child’s head to force it into the pelvis 211 95. The Naegelc perforator 212 96. Apparatus for getting a sterile specimen of urine from an infant 217 97. Tampon of the uterus 219 98. Tampon oE vagina 220 99. Bean forceps 225 ILLUSTRATIONS 15 FIG. PAGE 100. Hand bulb syringe; and Vorhees bags; bag rolled and grasped by Pean forceps ready for introduction . . 226 101. Vorhees bag in place 227 102. Episiotomy 229 103. Various forms of pelvic deformity 232 104. The pelvimeter 233 105. The various diameters of the inlet 233 106. Measuring the distance between the anterior superior spines of the pelvis 234 107. Measuring the external conjugate 235 108. Measuring the diagonal conjugate with the finger . . 236 109. Various forms of placenta prmvfa 246 110. The knee-elbow posture 253 111. The knee-chest posture 253 112. The exaggerated lithotomy position obtained with a sheet sling 254 113. The improvised Trendelenburg position 254 114. The dorsal position with stirrups 255 115. Dorsal position across the bed 256 116. Flexed dorsal position with feet on the tab’e . . . .257 117. The Sims position 258 118. Examples of imperfect nipples 263 119. A standard nipple shield 264 120. A standard breast pump 269 121. Diagram to illustrate the position of the lesions in puer- peral infection 278 122. Rubber bath tub 284 123. The Pettit cord clamp 286 124. Standard breast pump; Standard nursing bottle; the breast tray; the Wansbrough lead nipple shield; the Brophy nipple for harelip and cleft palate . . . 289 125. Proper position of mother while nursing child . . . 292 126. Proper method of taking rectal temperature . . . 294 127. Chart in case of inanition fever 295 128. Chart in case of inanition fever 296 129. Method of passing the tracheal catheter 299 130. Byrd’s method of artificial respiration. Extension and inspiration 300 131. Byrd’s method of artificial respiration. Beginning flexion and expiration 300 16 ILLUSTRATIONS FIG. PAGE 132. Byrd’s method of artificial respiration. Flexion and compression 301 133. Method of giving gavage 304 134. Apparatus for gavage or lavage 306 135. Cleft palate nipple 308 136. The device for feeding the child with cleft palate . 308 137. Device for assisting the cleft palate child to nurse . . 309 138. Method of strapping an umbilical hernia .... 310 139. Ulcer pterygoidea. Epstein’s pseudodiphtheria . . . 315 140. Proper position for introduction of a suppository . . 324 141. Hydrocephalus 332 142. Anencephalus 333 143. Elements of human milk 337 OBSTETRICS FOR NURSES CHAPTER I ANATOMY The study of obstetrics is an investigation of the passage, the passenger, and the driving powers of labor, as well as of the various complications and anomalies that may attend the process of reproduction. The passage is composed of a bony canal, called the pelvis, and the soft tissues which line and almost close its outlet. The pelvis is made up of four bones; the sacrum, the coccyx, and two other large structures of irregular shape, called the hip, or innominate bones. Joined by cartilage and held in place by ligaments, they form a cavity or basin which, in the male is deep, narrow, small and funnel-shaped, while in the female, slighter bones, expanded openings and wider arches make a broad, shallow channel, through which the child is born. The bony pelvis is divided for description into two parts, the upper or false pelvis, and the lower or true pelvis. The upper pelvis is formed by the wings of the innominate bones and has but two functions of im- portance to child-bearing. It acts as a guide to direct the child into the true passage, and when measured by the pelvimeter, it gives information as to the shape and size of the inlet to the true pelvis. The true pelvis is of most concern to the obstetrician, because anomalies in its size or shape may impede the progress of labor or 17 18 OBSTETRICS FOR NURSES render it impossible. The pelvis is divided conveniently into three parts: the brim, the outlet, and the cavity. The brim, inlet, or upper pelvic strait, is the boundary line between the false and true pelvis. It is traced from the upper border of the symphysis along the iliopectineal line on both sides to the promontory of the sacrum. The shape and size of this opening varies much in dif- ferent races and individuals, both normally and through Fig. 1.—The normal female pelvis. (Eden.) The lines ab and cd divide the pelvis into the right and left anterior and the right and left posterior quadrants, ab indicates the anteroposterior diameter of the brim, cd shows the transverse diameter while gh and cf represent, respectively, the right and left oblique diameters. disease; and when pathologically altered, both shape and size may exercise a marked influence on the course of labor. In American women, the outline of the brim is roughly heart-shaped, like an ovoid with an indenta- tion where the promontory of the sacrum impinges upon the opening. ANATOMY 19 The brim or inlet lias four important diameters to be remembered; important because the hard, round head of the child must pass through them by accommodating its diameters as favorably as possible to those of this opening. These diameters are named respectively the anteroposterior or conjugate diameter, the transverse, and the right and left oblique diameters. The two oblique diameters attain their greatest importance when the pelvis is irregularly distorted, but the others are essential in every case where labor impends. It is to secure an estimate of these latter diameters that the Fig. 2.—The planes of (a) the brim, (&) the cavity and (c) the outlet (Eden.) bony prominences are measured. This upper opening lies not horizontally, but in oblique relation to the body in standing position, and the weight of the. abdominal viscera rests largely upon the bones and in consequence does not crowd into the inlet unless forced in by corsets or faulty habits. Passing through the brim, a cavity is found below it, midway between the inlet and outlet, which is nearly round in shape. This is the “ excavation, ” or the true pelvis. Then comes the outlet, bounded in front by the pubic arch and soft parts, and behind by the coccyx pushed back as far as it can go. It is ovoid in shape, but the long axis of this ovoid lies at right angles with the axis of the ovoid inlet. 20 OBSTETRICS FOR NURSES We find, therefore, a succession of three geometric figures or planes through which the head must pass by means of a spiral motion called rotation. These figures are inclined to one another so markedly in front that a line drawn through the center of each will curve forward at both ends, one end passing out near the um- Fig. 3.—Visceral relations. (Redrawn from Gray.) bilious, the other through the vulva. This is known as the axis of the pelvis or the curve of Carus. THE SOFT PARTS Inside the pelvis are the organs of generation with their accessory structures and supporting tissues. 21 ANATOMY Of first importance are the ovaries, tubes and uterus, together with the vagina. These special structures are the true genital organs. They are bounded in front by the bladder, behind by the rectum, above by the ab- dominal viscera, and surrounded everywhere by muscu- lar, mucous and fatty tissues, which support them and aid their function. The Vagina.—The vagina is a hollow organ, about four inches long, attached to the cervix above and the vulva below. It is an elastic sheath bounded in front by the bladder and behind by the rectum. Under nor- mal conditions, this tube easily admits one or two fin- gers, but during labor it dilates enormously to allow the head to pass. The vagina is lined with a thick mucous membrane, ridged and roughened by folds, which are called rugas. Thus a continuous channel connects the ovary with the outside and through it pass, at appropri- ate times, the ovule, the menstrual blood, the uterine secretions, the child, the placenta, and the lochia. The Uterus.—The uterus (womb) is a pear-shaped organ, flattened from before backward, and composed of unstriped or involuntary muscle cells and connective tissue. Normally the virgin uterus measures from two and one-lialf to three inches in length, and weighs about two ounces. It is suspended in the middle of the pelvis by strong ligaments, so that the fundus inclines gently forward against the bladder. When the bladder fills, the uterus is pushed backward. Most of the organ is internal, but a small part of the lower pole is grasped by the vagina, in which the lower end with its invalu- able aperture, the os, dips and swings. The part above the vagina is called the body or fundus, and is covered with the serous membrane (peritoneum) that lines the abdominal cavity. Below the fundus is the cervix or neck, which lies partly above and partly within the 22 OBSTETRICS FOR NURSES vagina. The cavity of the uterus is usually closed by the apposition of the walls. The inner surface is covered with a peculiar kind of membrane called the endo- metrium, which is highly vascular. The uterine cavity opens into the vagina through the os, which is small and round in the nulliparous woman, and slit-shaped or gaping in the woman who has borne a child. Fig. 4.—Uterus and appendages. On either side of the uterus will be seen the ovary, the fimbriated extremity of the tube, the tube, and the round ligament. The vagina lies open below. (Eenoir and Tarnier.) Fallopian Tubes.—On either side of the upper end of the uterus are the orifices of the Fallopian tubes, through which the egg, escaping from the ovary, finds access to the uterine cavity. These tubes extend outward from the uterus about four inches, and terminate in a bell- shaped opening with long, ragged fingers which hang loosely down toward the ovary. The tubes are lined by epithelial cells having hair-like projections, (cilias) which wave automatically toward the uterus. Thus im- ANATOMY 23 pelled by a gentle current, the egg moves definitely along the tube toward the uterus and against this cur- rent the spermatozoa force their way to meet and fertilize the egg. The Ovaries.—On each side of the pelvis, close to the fringed end of the Fallopian tube and attached to it, lies a small, hard, almond-shaped organ, called the ovary. This is the intrinsic sexual gland of the female. It contains the small cells which are to ripen and be- come eggs. Each ovary is said to contain about thirty- six thousand eggs, or ovules. The Bladder.—The bladder lies between the pubic bone and the uterus. It is a reservoir for urine, filled by means of two little tubes called ureters, that run down from the kidneys. It drains through the urethra which opens just below the pubic bone in front of, and just above, the vaginal opening. The bladder should be emptied frequently during labor. The Anus.— The large bowel (colon) terminates in an opening near the middle of the genital crease. This opening is called the anus. It is closed by a contract- ing muscle, the sphincter, which acts like a puckering string. Just inside of the opening is a group of large veins which may become enlarged, inflamed, and bleed during pregnancy. They are then called haemorrhoids. The Rectum.—Upward from the anus and to the left of the uterus extends the rectum. This is the end of the intestinal canal and is supplied with an abundance of nerves. When the head presses upon it, it gives the sensation of a bowel movement, and warns the observer of the low position of the head. The anus pouts as the head comes down and the anterior walls become vis- ible. In severe cases of labor, the sphincter is some- times torn. The bowels should be emptied by an enema as early as possible in the first stage of labor. 24 OBSTETRICS FOR NURSES The Peritoneum.—The peritoneum is a thin, glisten- ing, serous membrane, which lines the abdominal cavity and drops down from above over the uprising tops of the bladder and uterus. Folding together at the sides and extending to the walls of the pelvis, it encloses the tubes and round ligaments in deep, flat masses, called the broad ligaments. This is the structure that becomes so perilously inflamed (peritonitis) when infected by germs that find entrance through the genital passage. Fig. 5.—Normal position of pelvic organs, seen from above and in front. They are enveloped in peritoneum. (Bougery and Jacob, in American Text Book.) THE EXTERNAL GENITALS The external genitals form the vulva. Under this name are included the mons veneris, the labia majora, the labia minora, the clitoris, the vestibule, the hymen and the glands of Bartholin. ANATOMY 25 The entire groove from the mons veneris to a point well up on the sacrum forms a deep fold or crevice, which is known as the genital crease. That part of the genital crease lying between the anus and vulva is tech- nically known as the perineum (q.v.). Fig. 6.-—The external genitals. (Redrawn from Gray.) The Mons Veneris.—The mons veneris is a gently rounded pad of fat lying just above the junction of the pubic bones (the symphysis). The overlying integu- ment is filled with sebaceous glands and covered with hair at puberty. The Labia Majora.—The labia majora are the large 26 OBSTETRICS FOR NURSES lips of the vulva. They are loose, double folds of skin extending downward from the mons veneris to the an- terior boundary of the perineum and covered exter- nally with hair. Normally they lie in apposition and conceal the vaginal opening. They correspond to the male scrotum. The Labia Minora.—The labia minora, or nymphae, are two small folds of skin and mucous membrane, that extend from the clitoris obliquely downward and out- Avard for an inch and a half on each side of the entrance to the vagina. On the upper side, where they meet and invest the clitoris, the fold is called the prepuce, but on the under side they constitute the fraenum. The labia minora are sometimes enormously enlarged in the black races and are then called the Hottentot apron. The Clitoris.—The clitoris is an erectile structure an- alogous to the erectile tissue of the penis. The free extremity is a small, rounded, extremely sensitive tuber- cle, called the glans of the clitoris. About the clitoris there forms a whitish substance called smegma. This is a good culture medium for germs and must be care- fully sponged away ivhen the vulwa is prepared for de- livery. The Vestibule.—The vestibule is bounded by the cli- toris above, the labia minora on the sides, and the vaginal orifice beloAV. It contains the opening of the urethra, which is called the meatus urinarius. The Hymen.—The hymen is a thin fold of membrane Avhich closes the vaginal opening to a greater or less extent in virgins. It varies much in shape and con- sistency. It is sometimes absent, or it may persist after copulation, hence its presence or absence can not be considered a test of virginity. When torn, the edges ANATOMY 27 shrink up and form little irregularities called carun- culae myrtiformes. Bartholin Glands (or Vulvo-Vaginal Glands).—Bar- Fig. 7 A.—Varieties of hymen. (American Text Book.) tliolin glands are located on each side of the commence- ment of the vagina. Each gland discharges a yellowish tenacious mucus through a small duct just external to 28 OBSTETRICS FOR NURSES the hymen. They are often the seat of a chronic gonor- rhoeal inflammation and must be watched carefully, lest Fig. 7 B.—Varieties of hymen. (American Text Book.) infection extend to the mother after labor, or to the eyes of the child in passing. The Perineum.—The perineum is a body of muscle, fascia, connective tissue, and skin, situated between the vagina and the rectum. The vagina bends forward ANATOMY 29 Fig. 8/1.—The excreting ducts of the mammary gland (Lenoir and Tarnier.) l'‘ig. SB.—Lobules and duct of the mammary gland. (Lenoir and Tarnier.) and the rectum backward, so a triangular area is left between them which is filled by the perineal body. It is about two inches long from before backward, and be- comes progressively thinner the deeper it extends. The perineal body is flattened out and compressed 30 OBSTETRICS FOR NURSES by the passage of the head and in many cases torn. (Thirty per cent of primiparas and ten to fifteen per cent of multiparas.) It should be repaired immediately. Pelvic Floor.—By a fortunate arrangement of the bones, ligaments, muscles, and fascia of the pelvis the Fig. 9.—Female perineum after removal of skin and superficial fascia. Shows the various structures on the pelvic floor and the muscles to be overcome or lacerated in the passage of the child. (From Gray’s Anatomy.) contents of the abdomen and pelvis are prevented from escaping from the body when crowded down from above. Jnst under the skin and superficial fascia lies a variety of interlaced muscles and tissues which cover in the out- let and are commonly called the pelvic floor although ANATOMY 31 the true pelvic floor extends from the skin outside to the peritoneum inside. This structure is pierced by the openings of the rectum, vagina, and urethra. The most important tissue in the pelvic floor is the levator ani muscle and the strong fascia which overlies its upper and lower surfaces. This muscle hangs like a hammock from its attachments and surrounds and sup- Fig. 10.—Nipple, areola, and the glands of Montgomery. (Fden.) ports the pelvic organs. It closes the outlet so effec- tually that it is sometimes called the pelvic diaphragm. It is from 3 to 5 millimeters in thickness, but increases greatly during pregnancy. The contraction of the leva- tor ani draws the vagina and rectum upward and for- ward toward the symphysis. It is the chief constrictor of the vagina. In lacerations of the perineum the injury frequently extends through the transverse perineal mus- 32 OBSTETRICS FOR NURSES cles and a variable distance into the levator ani. When this happens the resulting weakness permits the pelvic contents to sag down or prolapse. One author states Fig. 11.—Supernumerary milk glands in the axillae. They may he found also below the breasts. (Witkowski.) Fig. 12.—The three ages of the breast—virginity, maturity, and senescence. (Witkowski.) that entire absence of lacerations occurs only in 15 per cent of primiparas. (Munro-Kerr.) The Mammary Glands.—Tlie mammary glands are secondary lmt highly important parts of the genital sys- ANATOMY 33 tem. They are formed by a dipping down of skin glands and they perform the special function of secreting milk. The breast is made up of fifteen or twenty lobes, each of which, like a bunch of grapes, clusters about and discharges into a single tube which, in turn, leads to the nipple. The area between the lobes is filled with fat and connective tissue. The nipple is pink or darkly pigmented. It is com- posed of erectile tissue and under stimulation, it rises from the surface of the gland so that it is easily taken into the mouth. Surrounding the nipple is a darkly pigmented area from one inch to four inches in diameter that is called the areola. It contains hard, shot-like nodules, the glands, or tubercles, of Montgomery. These often secrete milk and sometimes become infected. It occasionally hap- pens that more than two breasts may be found on the human female, and not infrequently pieces of mammary tissue may be discovered in the axilla or on the chest or back. The mammary gland is undeveloped at birth, but, nev- ertheless it may fill with milk (witches’ milk). At pu- berty, after marriage, and during pregnancy, the gland reaches maturity. It is only after delivery, however, that the functional climax is attained. CHAPTER II PHYSIOLOGY Ovulation.—Ovulation is the process whereby the eggs are discharged from the Graafian follicle which matures and protects them in the ovary. The egg is a true cell with one, and sometimes more than one, nucleus. The ripening of the eggs, as well as their discharge, is attended with much general disturbance and great physical changes. This phenomenon begins from the twelfth to the fifteenth year, depending on race, climate, occupation and temperament, and marks the transition of the individual from childhood into maturity. This period is called puberty. At this time the breasts enlarge, the hips round out, the vagina, uterus and ex- ternal genitals increase in size. Hair appears upon the vulva, the emotions become more evident, and modesty de- velops through a consciousness of sexual difference and attraction. The process of ovulation is not simple. In the ovary the Graafian follicle gradually increases in size and ac- quires a layer of cells known as the membrana granulosa. The ovum at the same time acquires a thick outer coat, called the zona radiata on account of the numerous fine lines which appear in it. Fluid accumulates in the cells of the membrana granulosa and finally collects in a large cavity and is known as the liquor folliculi. Other changes appear and the Graafian follicle seems to sink down into the ovarian substance. As ripening ap- proaches, however, the follicle swells until it looks al- 34 PHYSIOLOGY 35 most as large as the ovary. The follicle now ruptures and the ovum which is about 200 microns in diameter, is set free. The ovum is now in the peritoneal cavity and is swept along toward the Fallopian tubes by vari- ous currents which are produced in the peritoneal fluids by the waving cilia? of the fimbriated extremities of the tubes. Corpus Luteum.—After the rupture of the Graafian follicle a series of changes take place which convert it Fig. 13.-—Section of corpus luteum from an adult ovary. X 3 into the corpus luteum. First there is a hemorrhage into the follicular cavity which may be either slight or profuse and is accompanied not infrequently by pain. Coagulation occurs and the clot is organized. A thick layer of cells called lutein cells forms on the outside of the clot. They enlarge and become crinkled. Capillary blood vessels appear and to the eye the follicle has a red center and a yellow husk. Gradually the clot is OBSTETRICS FOR NURSES absorbed. The cavity shrinks and the surface of the ovary contracts into a small hard mass. The theory is now established that the corpus luteum in some way controls or influences the implantation of the fertilized ovum upon the uterine wall. With the occurrence of ovulation another function becomes mani- fest. This is called menstruation. Fig. 14.—Development of the ovary (after Wiedersheim). A, an in- growth of the germinal epithelium, forming a cell-cord, which breaks up into primitive Graafian follicles; B, a primitive Graafian follicle, with its contained primitive ovum; C, D, E, later stages in the development of the Graafian follicle. (Crossen.) Menstruation.—Menstruation may be defined as a process wherein a bloody fluid is discharged from the uterus at regularly recurring periods between puberty and the menopause, except during pregnancy and lac- tation. It is a hgemorrhage which in some way is PHYSIOLOGY 37 closely associated with ovulation, but it is not known positively which is the precedent of the other, or whether one causes the other. Menstruation is not essential to pregnancy, for preg- nancy may occur when the flow is normally absent, as be- fore puberty, after the menopause, or during lactation. Nevertheless, regularity of menstruation is the rule in fer- tile women and clinicians agree that while conception may occur at any part of the menstrual cycle, it is most likely to happen just before or just after the menstrual flow. Fig. 15.—Graafian follicles. One contains two ovules which, if fertilized, will produce twins. If all three ovules are fertilized, triplets will result. (Bumm.) The best authorities at present support the theory that ovulation usually occurs soon after the close of the menstrual period. This is confirmed by the similarity of the physical changes that take place in the endo- metrium during menstruation and after conception. As the period of the flow approaches, the lining mem- brane of the uterus becomes hyperamiic and swollen with blood, serum, and glandular secretions. The blood vessels are engorged, the glands become longer and more tortuous, little haemorrhages appear, and the su- 38 OBSTETRICS FOR NURSES perficial epithelium is thrown off. A large amount of mucus is produced by the increased activity of the glands, and all is discharged into the vagina as a bloody, incoagulable flow with an odor of marigolds. The process continues usually from three to seven days, when the discharge ceases and the endometrium slowly resumes its uncongested state. Meanwhile, the psychic and bodily conditions have not remained unaffected. The nervous system is dis- turbed, the disposition is irritable and capricious and the head may ache. The woman takes cold easily. She is indisposed to exertion from a sense of languor and malaise. Pain may develop in the back, or cramps in the pelvis, so severe as to keep the woman in bed. Fre- quently the approach of the period is signalized by skin changes, such as a marked odor or an eruption of acne pustules. The flow usually returns every twenty-eight days, but it may vary within normal limits from twenty-one to thirty days. The flow continues at such intervals regu- larly from puberty to the menopause (change of life), which occurs between the ages of forty-five and fifty. Conception, or Fertilization.—This is the process wherein the male element (spermatozoon) meets and unites with the female egg. From what is known through investigations of lower animals, this meeting usu- ally takes place in the Fallopian tube. The egg expelled from the ovary is carried into the open end of the tube by peritoneal currents and passed on toward the uterus by the waving action of the hair-like outgrowths of the cells (cilias) that line the tube, aided, possibly, by the tubal muscle. The spermatozoon makes its way upward from the vagina by means of its tail. This activity, like the. tail PHYSIOLOGY 39 of a fish, or snake, or as a boat is sculled, drives the cell forward through the thin layer of fluid that covers the mucous membranes. The arrow-shaped spermatozoon travels at a rate that completes the passage to the ovary in twenty-four hours, but spermatozoa may lie in wait for the egg a con- siderable time, as is shown by the fact that they have been found alive in Fallopian tubes removed three aud a half weeks after copulation. As soon as the male and female elements approach each other, they exercise a Fig. 16.—Human Spermatozoa. h, head; c, intermediate portion; t, tail. (Williams.) powerful magnetic attraction, which draws them to- gether, and as soon as they touch, the two cells unite and the spermatozoon almost immediately disappears. Only one spermatozoon is required for the fertiliza- tion of an egg, and hence enormous numbers must per- ish without achieving their destiny. The fertilized egg has become the ovum, and origi- nally 1/125 of an inch in diameter, it now begins to grow, and tilled with a new energy, it passes down the tube 40 OBSTETRICS FOR NURSES and enters the uterus. Here it comes into contact with the soft mucosa and digs a hole for itself—a nest, very much as a warm bullet might sink into ice or snow—and is soon completely surrounded by a proliferating tissue called the decidua. The woman is now pregnant. The menstrual flow does not appear, and local and system- atic changes are inaugurated. Fig. 17.—Diagrams to show the embedding of the ovum, and the formation of the decidua, and the differentiation of the decidua basalis and the decidua capsularis from the decidua vera. (From Berkeley’s Mid- wifery.) Proliferative changes now occur in the uterine mucous membrane. The whole endometrium is transformed into a highly vascular and spongy substance which is known as the decidua. Special portions of this structure receive special names. The part on which the egg rests is called the PHYSIOLOGY 41 decidua basalis (formerly the serotina), the part cover- ing- the pole of the egg opposite to the basalis is called the decidua capsularis, while all the rest of the uterus is covered by the decidua vera. The egg enlarges rapidly. Little glove-finger-like pro- jections (the villi) appear on its surface and dip Fig. 18.—The chorionic villi about the third week of pregnancy. (Pdgar.) down into the maternal tissues. Through these villi the egg gets nourishment until about the twelfth week, when the placenta forms. Externally the ovum resem- bles a chestnut burr. As the egg grows, the villi on the surface find it more and more difficult to secure nutriment, and except at one place, all gradually shrink and disappear. At this significant point, they increase 42 OBSTETRICS FOR NURSES greatly in size, number, and complexity to form the thick, cake-like placenta. The egg or ovum is simply a growing cyst, filled with a fluid, normally sterile, in which the developing em- byro lives and swims. This fluid is the liquor amnii and Fig. 19.—Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy. (American Text Book.) it is retained by a cystic wall made up of two layers— the chorion, which represents the original cell membrane, and the amnion, which develops out of the foetus. At maturity, the ovum will contain from one to two pints of liquor amnii. PHYSIOLOGY The Liquor Amnii.—The liquor amnii is of vast im- portance to the child. It allows free movement for the growing limbs and body, protects the child from sud- den changes of temperature, prevents injury both from without and within, saves the child from birthmarks and deformities by keeping it from contact with the surrounding walls, and in labor lubricates the passages for the advancing part. In a measure, too, it probably serves as a food and as a source of fluid for the foetal tissues. In labor it forms a pouch called the bag of waters, which aids in dilating the os. Gradually, as nutrition becomes more abundant at the site of the growing placenta, a stalk-like structure thrusts out from the foetal abdomen and forms an at- tachment with the formative placenta. This is called the ventral stalk and as soon as the communication with the placenta is established, it is combined with other parallel structures and becomes vascularized, to form the umbilical cord. The Umbilical Cord.—The umbilical cord at maturity measures from five to fifty inches in length and from one-half to one inch in thickness. The cord is composed of a gelatinous connective tissue, called Wharton’s jelly, in the midst of which lie the twisted vessels (two arteries and a vein) that supply the embryo with air and food and carry off the waste. The Placenta.—The placenta or “after-birth” is an oval or circular somewhat flattened disc, six to ten inches in diameter, and three-quarters to one and one-lialf inches thick. It weighs about a pound and a half. It is the organ of respiration and nutrition for the foetus. It is formed about the third month outside the mem- branes covering the child and is more or less loosely at- tached to the uterine wall. The umbilical cord is at- 44 OBSTETRICS FOR NURSES tached to its foetal surface, inside the ovum. Like a flat sponge it takes oxygen, blood, and the nourishing fluids from the blood vessels in the uterine wall, carries them to the child by means of the umbilical vein, and carries back the carbonized blood and waste products by the umbil- Fig. 20.—Maternal surface of the placenta and membranes. The cord pro- trudes from the cavity which held the fcetus. (Edgar.) ical arteries to the placenta, and there returns them to the maternal blood for disposal. The blood of the veins is bright red, and of the arteries, dark and turbid. There is no direct communication between the ma- ternal tissues and the placenta, hence all the changes PHYSIOLOGY 45 occur by osmosis, and by the activity of the cells which form the walls of the villi. The liver of the child is large and active. The stom- Fig. 21.—-Foetal surface of human placenta. (Kden.) ach and intestines functionate mildly. The kidneys act, and urine is discharged into the liquor amnii, which the child occasionally swallows. 46 OBSTETRICS FOR NURSES During development, the movements of the child be- come more and more pronounced. Arms, legs, and en- tire body participate in turn. Periods of rest are also Fig. 22.—The egg at term with uterus removed and child showing through the membranes. (Edgar.) observed. Gradually the child assumes a definite at- titude in the uterus. It becomes more and more folded and flexed to accommodate its size to the limitations of space. The head bends on the chest, the arms are PHYSIOLOGY 47 folded, the thighs flex against the abdomen, the legs on the thighs, and even the back ultimately becomes convex. It attains a complete flexion, the normal atti- Fig. 23.—Normal attitude of foetus (complete flexion). (Barbour.) tucle of the child. As maturity approaches, the head becomes more and more palpable and seeks its usual lo- cation in the lower pole of the uterus, resting on the pelvic brim. 48 OBSTETRICS FOR NURSES The foetal skull at maturity (at term) is still incom- pletely ossified. The bones are thin and pliable and separated at their edges by intervals of unossified mem- brane which form the sutures and fontanelles. Thus the skull is compressible to a slight degree and capable of much change in shape. It can be measurably moulded by the uterine contractions to suit the pelvis. In front, the two coronary sutures meet the frontal and sagittal sutures to produce a kite-shaped figure, called the large or anterior fontanelle, or the bregma. Fig. 24.—'Foetal skulls showing sutures. Note the differences between the anterior and posterior fontanelles. (Eden.) Behind, the lambdoidal suture meets the sagittal suture to form the small or posterior fontanel]e. The large fontanelle is made up of four bones and four angles; the small, of three bones and three angles, and are usually easy to differentiate. Furthermore, the difference between these fontanelles is of great im- portance in labor, since by it the observer is enabled to determine the position of the head. In America, the shape of the head is that of an ovoid with the long Fig. 25-A.—Child’s head at term (from side), showing diameters. (American Text Book.) I'ig. 25 B.—The child’s head at term (from above), showing and fontanelles. (American Text Book.) 50 OBSTETRICS FOR NURSES diameter anteroposterior (Doiico-ceplialic). Thus it happens that when the head is completely flexed, the smallest diameters are presented for delivery. The important diameters of the head, with their meas- urements and names, are as follows: Nape of neck to center of bregma, 9.5 cm.—Suboccip- ito-bregmatic diameter. Occipital protuberance to root of nose, 11.25 cm.—Occipito-frontal diameter. Between the eminences of parietal bones, 9.25 cm.—Biparietal diameter. Between anterior ends of coronal sutures, 8 cm.—Bitemporal diameter. The smallest circumference is that of the suboccip- ito-bregmatie plane, which comes into relation with the brim of the pelvis when the flexion of the head is complete. It measures 27.5 centimeters. The foetus grows at a definite rate throughout gesta- tion and so regularly that the increase is rarely simu- lated by any other condition. To find the probable length of the foetus at any given time, square the month of the pregnancy (up to five) and the result is the foetal length in centimeters. After the fifth month, multiply the number of the month by five. Thus: 7th month x5=35 cm., the approximate length of the foetus at the lunar month.—Haase’s rule.) The Mature Foetus.—Although subject to considerable variation, the foetus at term will weigh about seven and one-fourth pounds, and measure 50 cm. in length. The weight is far more uncertain than the length, and there- fore not so reliable as a sign of maturity. To obtain an estimate of the weight of the child at any given month of the pregnancy, the number of lunar months minus 2, is squared and divided by 2, and the PHYSIOLOGY 51 result is the average weight of the child at that time in hundreds of grams. Thus: 8th month -2=6. 6x6=36. 36=2=18, or in hundreds of grams, 1800, the wreight of the child.—(Tuttle’s rule.) Differences between the mature and immature foetus: Mature 1. Skin smooth, plump, pink covered with vernix caseosa. 2. Generous amount of subcu- taneous fat. 3. Hair abundant and from 1 to 2 inches long. 4. Lanugo mostly absent. 5. Nails project from linger tips. G. Skull bones in contact ex- cept at fontanelles. 7. Length 48 to 52 cm. 8. Weight live to eight pounds. 9. Cartilage in ear well de- veloped. 10. Navel in middle of body. 11. Testes have descended in the male, and the labia majora in the female usu- ally cover the labia minora. 12. Moves and cries vigorously when born. Immature 1. Skin lax, wrinkled, dull red in color; little vernix case- osa. 2. Subcutaneous fat scanty. 3. Hair on scalp short. 4. Lanugo present all over body. 5. Short nails on lingers and toes. 6. Skull sutures open. 7. Moves and cries feebly when born. 8. Weight less than live pounds. The Foetal Circulation.—The placenta is an organ of nutrition as well as respiration, and through the umbilical vessels the food materials are brought to the foetus and the waste products removed. Surrounded by the jelly of Wharton that fills out the cord, and running in and out between the two arteries, 52 OBSTETRICS FOR NURSES Fig. 26.—The foetal circulation. (Edgar.) the umbilical vein passes into the foetal abdomen and di- vides into two branches, one, the larger, short-circuits di- rectly into the inferior vena cava. This branch is called the ductus venosus. The other joins the portal vein and PHYSIOLOGY 53 passes through the liver, after which it also enters the vena cava. Thus the heart is fed with a mixed blood, part com- ing fresh from the placenta and part coming up from the lower half of the foetus. This blood is poured into the right auricle, where it becomes mixed again with the blood coming down from the upper pole of the foetus through the superior vena cava. Now a small part goes down into the right ventricle and is forced into the pulmonary arteries to supply the lungs. But the lungs are not functionating, hence the greater part is again short-circuited through the duc- tus arteriosus into the arch of the aorta, where it meets with the great volume of blood which passed over into the left auricle through the hole in the septum between the right and left auricles, called the foramen ovale, thence down into the left ventricle and out through the aorta to supply the rest of the foetal body. With the exception of the ductus venosus and the ductus arteriosus and the foramen ovale, the circula- tion is the same as in the adult. The blood in the descending aorta again divides and part goes on to supply the lower extremities while the greater part leaves the internal iliac arteries by means of the hypogastric vessels and returns through the um- bilical arteries to the placenta for oxygenation. As soon as the child is born, the foetal structures are altered. The child breathes, the pulmonary circulation is established and the ductus arteriosus is closed. The placental circulation is abolished, and the ductus veno- sus and the hypogastric arteries are converted into solid fibrous cords. Owing to the immediate change of pres- sure in the auricles, the foramen ovale closes and the circulation assumes the adult type. CHAPTER III NORMAL PREGNANCY The entire body participates in the changes brought about by pregnancy. The hips and breasts become fuller, the back broadens, and the woman puts on fat. She becomes mature in appearance, but, of course, the phenomena connected with alterations in the breasts and genitals are most important, and late in pregnancy, most conspicuous. The uterus exhibits the most marked alteration. From an organ that weighs two ounces, it becomes the largest in the body, and increases in size from two and one-half or three inches to fifteen inches. The typical pear-shape becomes spheroidal near the end of the third month, becomes pyriform again at the fifth month, and continues thus until term. Up to the fourth month the walls become thicker, heavier and more muscular, but as pregnancy advances, more and more tissue is demanded, until at the end, a muscle wall of only moderate thickness protects the ovum. Meanwhile the muscular functions of contrac- tibility and irritability are greatly increased. At the fourth month the womb, which lias occupied a position of anteversion against the bladder, rises out of the pelvis. It is now an abdominal organ and as it gets heavier and heavier, it rests a certain amount of its bulk on the brim of the pelvis. About the sixth month, the uppermost part of the uterus (fundus) is at the level of the umbilicus. At the eighth month, the fundus is found a little more than midway betiveen the 54 NORMAL PREGNANCY 55 umbilicus and the ensiform cartilage. About two weeks before term, it reaches its highest point, the ensiform cartilage, and then sometimes sinks a little lower in the abdomen. The ovum, or egg, does not completely fill the uterine cavity at first, but grows from its side like a fungus until Fig. 27.—Gravid uterus at the end of the eighth week. (Braune.) the third month. Then the uterine cavity is entirely oc- cupied and thereafter the egg and the uterus develop at an equal rate. As the uterus rises in the abdomen, it rotates to one side, usually the right, forward on its vertical axis. The blood vessels and lymphatics also increase in size, number, and tortuosity. Many of the veins become 56 OBSTETRICS FOR NURSES sinuses as large as the little finger. This increased amount of fluid both within and without the uterus has a marked effect upon its consistency. The walls of the uterus, vagina, and cervix become softened, infiltrated and more distensible. There is also an increase in size and in number of the muscle cells. During pregnancy the uterine muscle exhibits a def- inite functional activity. Intermittent contractions oc- cur, feeble at first, but growing markedly stronger as pregnancy advances. These are the contractions of Braxton Hicks. They are irregular and painless, but can be felt by the examining hand. At term they merge into, and are lost in, the regular, painful contractions of labor. The breasts can not be said to be fully developed until lactation has occurred, nevertheless, the glands show pronounced changes as a result of marriage and preg- nancy. The size of the gland, as well as the size and appear- ance of the nipple and areola, varies greatly in different women; but under the stimulation of pregnancy the whole gland enlarges, including the connective tissue stroma. About the fourth month a pale yellow secretion can be squeezed from the nipple. This is called colostrum. The pigmentation extends over a wider area and deep- ens in color, while the increased vascularity is shown by the appearance of the blue veins under the thin ten- der skin. Light pinkish lines sometimes radiate from the nipple. These are stride and are more evident in blondes. The milk comes into the breasts about the third day after labor, and normally continues to flow for six, to ten or twelve months. NORMAL PREGNANCY 57 Why the pregnancy and labor induce such marked mammary activity is not known, but the fact is patent. The skin reacts both mechanically and biologically to the stimulus of pregnancy. Fig. 28.—Stria; Gravidarum. (Fdgar.) Strice Gravidarum,.—Striae gravidarum appear on the abdomen similar to those observed on the breasts and are due to the' same causes—mechanical stretching. When fresh, they are pinkish in color and variable in length and breadth, but attain the greatest size below 58 OBSTETRICS FOR NURSES the umbilicus. Occasionally they extend to the thighs and buttocks. After labor, they become pale, silvery, and scar-like and are called linea albicantes. They are sometimes found in other conditions than pregnancy, such as tu- mors or ascites. Increased Pigmentation.—Pigmentation is not limited to the breasts. On the abdomen, a dark line will appear between the umbilicus and the pubes. This is the linea nigra, and it becomes most conspicuous in the latter half of pregnancy. In the groins, the axillas, and over the genitals, the deposit is common, and sometimes patches appear on the face, either discrete or in coales- cence, to form a continuous discoloration, called chlo- asma; or when extensive, the “mask of pregnancy.” The pigmentation is absorbed, or at least greatly dimin- ished, after labor. The sebaceous and sweat glands are more active. The hair may fall out and the teeth decay. “With every child a tooth,” is the cry of tradition. These changes are due to imperfect nutrition, or to the pres- ence of toxins in the circulation. (Vid. also p. 76.) Eruptions of an erythematous, eczematous, papular or pustular type are not uncommon; and itching, either local or general, may make life miserable. The blood undergoes certain modifications that are fairly constant. The total amount is increased, but the quality is poorer, especially by an increase in water and white cells and a diminution of red cells. The amount of calcium is slightly increased and the fibrin is dimin- ished up to the sixth month, when it rises to normal again at term. The heart is slightly hypertrophied on the left side and blood pressure somewhat raised. A marked in- crease in blood pressure is suggestive of eclampsia. NORMAL PREGNANCY 59 The thyroid gland enlarges frequently, both as a con- sequence of menstrual irritation and of pregnancy. Goiters may show an increase of development, which may remain after labor. The urine is diminished in amount, but increased in frequency of evacuation. The bladder is more irritable during the first and last months, and micturition may be painful and unsatisfactory. The kidneys must be watched carefully during gestation. The nervous system is disordered in most women, but especially in those of neurotic tendencies. Irritability, insomnia, neuralgia of face or teeth, or perversion of appetite in the so-called “longings” are the more common manifestations. Cramps occur in the muscles of the legs, owing to varicose veins, pressure upon the lumbar and sacral plexuses of nerves, or toxemia. The lungs are croivded by the growing uterus and the respiration interfered with. The liver is enlarged, but functionally it is less com- petent, and constipation is common. It is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of foetal activity, which is more or less toxic in character. The more pronounced effects of this toxin will be studied under the abnormal conditions of pregnancy. Generally, if the pregnancy is normal, the whole body responds to the stimulating influence. After the nau- sea and vomiting of the early months subside, the woman feels energetic and ambitious. She is eager to do something at all times and feels fatigue but slightly. Music, literature or housework engages her attention and is zealously and joyfully practiced. The world OBSTETRICS FOR NURSES seems bright and the thought of her labor does not bring solicitude, but pleasant anticipations. The body fills out in all directions and the woman takes on the appearance of maturity. DIAGNOSIS OF PREGNANCY The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces. During the second half of the period the foetus can be made out distinctly by palpation, or by its move- ments, and the heart tones observed by auscultation. During the first half this is impossible and the diag- nosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician. It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhoea, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless fhe circumstances are especially favor- able. Amenorrhoea.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of haemorrhage. Sudden cessation of the peri- NORMAL PREGNANCY 61 ods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of preg- nancy. Why a developing ovum causes an immediate arrest of menstruation is not understood. Amenorrhoea may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity. A change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. A woman may have her babies in such rapid successions that the menses do not appear but once or twice during her sexual life. In addition to its value as a presumptive symptom, the amenorrhoea affords a common and con- venient method of estimating the date of confinement. The method is fallacious but practical, and will be dis- cussed later. Morning’ Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on ris- ing or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of ex- treme severity (hyperemesis) and will be discussed elsewhere. The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accom- panied by morning sickness, but with it the tongue is furred. Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretch- 62 OBSTETRICS FOR NURSES ing of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irrita- bility may be much relieved by putting the patient in the knee-chest position night and morning. Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at men- strual periods in nervous women. Tingling, pricking and shooting sensations may also be noted. Enlargement of the abdomen is only noticeable to- ward the latter part of the first half, when the uterus rises out of the pelvis. Quickening means “coming to life,” and refers to the first movements of the foetus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand or the twitching of a muscle. It is some- times accompanied by nausea and faintness. Quicken- ing usually occurs about the seventeenth week of preg- nancy, and continues to the end. Gas in the intestines will sometimes simulate quickening. The movements are important in the second half as indicating that the child is alive. Physical Signs.—During the first weeks no conclu- sive changes occur that can be detected by examination, and unless conditions are especially favorable, the ear- liest time for the definite diagnosis of pregnancy is the eighth Week. Previous to this it is presumptive only. At the eighth week, the breasts may show enlarge- ment and tenderness, with some secretion. In the multi- para, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids). 63 NORMAL PREGNANCY Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness. Softening of the lips of the os (Goodell’s sign) may Fig. 29.—Bimanual examination. (Fdgar.) be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips. The increased size and globular shape must also be considered as confirmatory. 64 OBSTETRICS FOR NURSES Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value. At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhcea, morning sickness, irritability of bladder, slight breast changes in primi- paras, lips of os externum softened, uterine body en- larged, softened, and nearly globular in shape, and Hegar’s sign. Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the for- mation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhcea remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is dne to the congestion and is called Jaequemier’s sign. Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement. The contractions of Braxton Hicks now become more easily palpable. NORMAL PREGNANCY 65 Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the fcetus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the foetus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be re- garded as a positive sign. During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdom- inal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnoea, and palpitations. Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hyper- trophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the um- bilicus. Spontaneous foetal movements appear and may be felt by the palpating hand. Auscultation reveals the uterine souffle and the foetal heart sounds. The heart sounds and the foetal move- ments, when obtained by the observer, are positive signs. Uterine souffle is a soft, blowing murmur, synchro- nous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is 66 OBSTETRICS FOR NURSES due to the passage of blood through the greatly dilated uterine arteries. It may he heard also in cases of fibroid tumors of the uterus. The foetal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valu- Fig. 30.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.) able information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more dis- tinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at NORMAL PREGNANCY 67 term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The fcetal heart tones have no significance as an indication of sex. Fig. 31.—Height of the uterus at various months of pregnancy. (Bumm) Funic souffle is the sound made, by the passage of blood through the umbilical cord when a loop acciden- tally lies under the tip of the stethoscope. It is syn- 68 OBSTETRICS FOR NURSES chronous with the foetal heart tones, but of no great practical importance when the heart tones can be ob- tained. Determination of the period to which pregnancy has advanced is sometimes important. This can be approx- imated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but in the last eight weeks the most accurate results are obtained from the McDonald, the Ahlfeld and Perret measurements which are described later. A method of estimation in gross, that is approxi- mately correct in many cases, depends on the observa- tion of the steady growth of the womb. Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening. Height of Fundus Above Symphysis at Various Weeks of Pregnancy (Spiegelberg) 28th Week 26.7 cm. 30th “ 28.4 “ 32nd “ 20.5 “ 34th “ 31 “ 36th “ 32 “ 38th “ 33.1 “ 40th “ 33.7 “ CHAPTER IV HYGIENE OF NORMAL PREGNANCY The day of delivery can never he accurately de- termined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three weeks. Pregnancy in the human family normally lasts from 273 to 280 days, and the approximate date of confine- ment can be obtained by the following convenient rules: 1. Take the first day of the last menstruation, count back three months and add seven days. 2. Or, assuming that quickening occurs at the seven- teenth week, count ahead twenty-two weeks from the day on which quickening was observed. 3. Or, count two weeks from the day of lightening. 4. Or, with a pelvimeter, get the length of the foetus by Ahlfeld’s rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare with fifty centimeters, which is the average length of a mature child. After the seventh month, the child in utero grows at the rate of about 1 cm. a week (0.9 cm.). 5. Or, by the tape, according to Spiegelberg’s stand- ard of growth, as previously mentioned. The hygienic rules to be observed during pregnancy 69 70 OBSTETRICS FOR NURSES are founded on three basic principles: (1) To watch attentively the different organs and see that they func- tionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These fac- tors will be taken up in detail. The best results in obstetrics are obtained in those cases which have prenatal care. There should be both mental and physical preparation of the mother for labor and lactation. The mother should know that in breast-fed babies diseases and complications are less frequent and that proper food plays an important part in the future health of the child. The Diet.—The appetite is usually somewhat in- creased, but it is unnecessary to indulge the stomach on the ground that the mother ‘ ‘ must eat for two. ’ ’ Long- ings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are use- ful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the preg- nancy and danger to the child. In contracted pelves it is sometimes desired to fur- nish a special diet, with the idea of controlling the size of the child (see Prochownick’s Diet, p. 357) but this HYGIENE OF NORMAL PREGNANCY 71 is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child will be injuriously affected. If it does not succeed, the claim is false. Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, ten- nis, dancing, horseback or bicycle riding and fast driv- ing in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walk- ing and slow driving are best, and housework is excel- lent up to a mild degree of fatigue. Walking in modera- tion develops the abdominal muscles, causes deep breath- ing, and assists the elimination. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abor- tive influences. The Bowels.—Most women have a tendency to consti- pation during pregnancy. Many times this can be cor- rected by increasing the “roughening” in the food; more vegetables and fruits, bran bread and muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary. Violent cathartics should not be used at all, and enemas as little as possible; only when quick results are necessary. 72 OBSTETRICS FOR NURSES Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordi- nate secretion of acid in the stomach. Soda mint tab- lets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative. The kidneys require particular care during preg- nancy, and in every case, the urine should be examined monthly, up to the fifth month, and every two weeks thereafter, until the last six weeks, when a weekly test should be made. The. amount passed in twenty-four hours should be measured. Three pints is an average quantity. Al- bumin, sugar, and casts must be looked for and re- ported. Albumin may or may not be a serious symp- tom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must always be investigated,, with the possibil- ity in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are always alarming symptoms until their innocence is established. Through constant watchfulness of the urine, many cases of eclampsia may be averted. Bathing’ is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept warm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and bland- est applications can be used. The water must be neither hot nor cold, but just a comfortable temperature. Cold bathing, whether shower, plunge, or sitz, must be denied. Sea bathing is also unwise. The warm tub bath of plain water or with bran answers all conditions until the ex- HYGIENE OF NORMAL PREGNANCY 73 pected labor is near, then the warm shower or sponge bath should be substituted, lest germs from the bath water enter the vagina. If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin with a coarse towel should follow the bath. The dress must be warm, loose, simple and suspended from the shoulders. To prevent chilling, wool or silk, or a mixture of both, should be worn next to the skin,— light in summer and heavy in winter. The patient must be sensibly clad in broad, loose, low- heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be worn. If a corset is insisted upon, it must support the abdo- men from below and lift it up. No corset is admissible that pushes down on the abdomen. This is especially true if the woman has borne one or more children and has a pendulous abdomen. The breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter. Fainting' is an annoying symptom in some women. It may come when quickening is first perceived, or from the excitement of crowds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not af- fect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and bowels investigated. Smelling salts will usually suffice for the attack. The abdominal walls may be strengthened by appro- priate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nurs- ing the child will help greatly in the preservation of the waist line and figure, by aiding involution. About the seventh month in primiparas, the abdo- men gets very tense and in places the skin is stretched 74 OBSTETRICS FOR NURSES until it gives way and forms stria?. This tightness can be relieved to a considerable degree by inunctions of coeoanut oil or albolene. Pain in the abdomen at this time may be due to me- chanical distention, to strain on the muscles, to stretch- ing of operative adhesions, to gas, constipation, or ap- pendicitis. The physician should be informed of it. In every case, constipation, sAvelling of feet, hands or eye- lids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor. The Breasts.—There should be no pressure on the glands and they should be warmly covered. The nip- ples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed with albolene or coeoanut oil and rubbed and pulled for a few minutes every night. This removes the crusts and dried secretions that collect on the nipple and prepares it for the macerating action of the baby’s mouth. No alcohol or strongly astringent washes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a wooden shield with a hollow center, such as Williams recommends. Leucorrhcea.—This is one of the commonest discom- forts of pregnancy, and the sense of uncleanliness, if the discharge is excessive, as well as the resulting irri- tation, may demand attention. It must be kept in mind, however, that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications. Vaginal douches of warm boric acid solution will do for cleanliness, but the douche bag must not be higher than the waist. Stronger and more antiseptic solutions HYGIENE OF NORMAL PREGNANCY 75 are potassium permanganate 1 :5000, or lysol 1:100. A suppository may be used, consisting of extract bel- ladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss. Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified. Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least two weeks before labor. The uterus may be infected from germs beneath the foreskin and haemorrhage may follow the act if the placenta is low. In healthy persons, at the instance of the female, intercourse in moderation is permissible. The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amuse- ment is desirable and a congenial occupation, but neigh- bors who tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided. Many women of neurotic temperament dread the la- bor desperately. They are sure that death impends and they dwell with tragic interest on the stories of compli- cated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive away the patientls fears just as effectively as the assurances of the physician. Great allowances must be made for attacks of irrita- bility, for the changes going on in the woman’s pelvis keep her in a capricious and whimsical condition. A good book to read at this time is, the “Prospective Mother,” by Slemons. 76 OBSTETRICS FOR NURSES The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knowledge of intrauterine changes. Furthermore, the same deformi- ties occur in lower animals, to which it is difficult to as- cribe such high nervous organization. Many of the birthmarks, supposedly due to shock, occur too late in the pregnancy to affect the child, even if it were possible, for the child is completely formed be- fore the fourteenth week. The Determination of Sex.—It is not possible to know in advance of delivery whether the child will be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been wasted in trying to solve this problem. Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably de- cided the moment conception occurs. The responsibil- ity for the decisions seems to lie with the male cell. All we really know is that the sexes appear in the ra- tio of 100 girls to 106 boys. Teeth.—In pregnancy the teeth are especially liable to decay on account of the unusual acidity of mouth and stomach. They should be kept rigorously clean and occasionally inspected by the dentist. Fillings ordi- narily can be put in and even emergency extractions done without great danger. CHAPTER V ABNORMAL PREGNANCY After the diagnosis of pregnancy has been satisfac- torily established, no further internal examinations are necessary in the absence of special indications, until about the thirtieth week. At this time a series of complete physical examina- tions may be required to determine the presentation and position of the child, the presence and rate of foetal heart tones, the diameters of the head, the length and approximate maturity of the child, as well as the con- dition of the bony and soft passages of the mother. It is thus that an appreciation of the obstetrical prob- lem is secured and a course laid out for its successful solution. Pregnancy is a normal function; but the woman is exposed, nevertheless, to many grave risks that are peculiar to her condition and to many complications ac- cidental or otherwise which are more serious on account of her pregnancy. The Toxaemias.—The growing ovum brings about changes in the maternal metabolism that are manifested by characteristic symptoms which in other better known conditions are recognized as due to toxaemia. Therefore, while there is no positive proof as yet that these symptoms, arising during pregnancy, are toxaemic in origin, the evidence goes to show that they are; and, therefore, should be classified as toxic. Postmortem findings in eclampsia and pernicious vomiting such as extensive thromboses, cell necrosis, and interstitial haemorrhages are very suggestive. 77 78 OBSTETRICS FOR NURSES Clinical findings in regard to the excretion of nitro- gen (urea, ammonia, uric acid, etc.), the occurrence of acidosis, elevation of blood pressure, fever, diminished excretion, coma and convulsions, all point to toxaemia. It is the minor disturbances, however, that the nurse Avill come in contact with most. They are nearly all toxaemic in origin, and a brief description of them must be given, together with suggestions for their manage- ment. Salivation or Ptyalism.—In the majority of cases, sa- liva is not especially noticeable; but at times the secre- tion shows an enormous increase, and may even threaten life. Patients will have saliva running constantly from the mouth. The amount may reach a pint or a quart a day, and the skin of the lower lip becomes greatly inflamed. Abortion sometimes occurs. The only satisfactory treatment is a rigorous milk diet on the theory that the disturbance is an intoxica- tion. The annoyance can be greatly benefited by giving thyroid extract, Belladonna aa grs. %, twice daily. Gingivitis.—The gums may become inflamed, spongy and haemorrhagic during pregnancy, usually in patients of low vitality. If a generous diet and astringent mouth washes do not relieve the condition, the milk diet should be instituted. Toothache and Dental Decay.—The patient may be given hypophosphites, and the teeth should be put in good condition by a dentist, Constipation has already been referred to. Strong cathartics should be avoided lest abortion follow. Condylomata of pregnancy occur most frequently around the labia, perineum, and anus. They are wart- like growths that develop slowly or quickly and may remain discrete or cover the entire area with masses as ABNORMAL PREGNANCY 79 small as beans or as large as cauliflowers, which in ap- pearance they much resemble. The etiology is obscure, but they are generally associated with irritating vagi- nal discharges, such as an old gonorrhoea. Treatment consists in stopping the discharge or neu- tralizing it, and in keeping the growths dry with a sali- cylic acid dusting powder. (See Therapeutic Index.) Pruritus is often distressing. The itching may be limited to the genitals or appear on other parts of the body. It may be due to the irritation of local discharges or to a condition of the nervous system, arising from toxaemia. The urine must be examined for glucose. The presence of lactose is not so important. Astringent douches and protective ointments will re- lieve some cases. Bromides and milk diet, bran or alkaline baths give good results, and local applications of sedative lotions and ointments containing menthol, carbolic acid or cocaine (cautiously) will aid. The woman in some instances becomes almost frantic and tears at the vulva with her nails until it bleeds. The iodine treatment of Ilensler is simple and often effective. If no skin changes are visible and but little leucorrhoea, the vulva is thoroughly prepared as for a vaginal operation, dried and painted with a 10 per cent solution of tincture of iodine. Generally one applica- tion suffices, but when the leucorrhoea is bad, it may be necessary to repeat the treatment on the third and fifth days thereafter. Between treatments, the vulvar sur- faces and even the vaginal walls (by insufflation) are kept dry with zinc oxide powder. If all other meas- ures fail and exhaustion is imminent the patient should be removed to a hospital with laboratory advantages for isolation and special study. 80 OBSTETRICS FOR NURSES Herpes is ail inflammatory, superficial eruption, char- acterized by red patches, blisters, or pustules. It is accompanied by burning, itching, and nervous depres- sion. The origin is probably toxic and the termination may be fatal. Milk diet, soothing lotions, and, if neces- sary, narcotics, constitute the routine methods of treat- ment. Areas of pigmentation (the chloasmata) are not ame- nable to treatment. They usually disappear after labor. Toxemias.—We now come to a class of cases which is more definitely toxic in origin although the clinical mani- festations may vary greatly in nature and severity. In this category we find: The Pregnancy Kidney; Eclampsia; Hyperemesis Gravidarum, and Icterus Gravis Gravi- darum, or in English, Acute Yellow Atrophy of the liver. These conditions are not always distinctly separated from each other in life and the pathological changes after death are similar. The whole Toxemic Theory is based on the work of Bouchard who suggested in 1887 that certain diseases of pregnancy might be an auto- intoxication. This theory assumes that in health the body contains a variety of toxic substances which are taken in with the food or produced by digestion or by tissue metabolism. These waste products are usually excreted through intestines, kidneys, or skin or ren- dered harmless by the liver. If the woman becomes pregnant, the waste products increase greatly, for she must then eliminate, in addi- tion to her own, the poisons of the enlarging uterus and of the fetal metabolism. To meet this emergency the maternal organs must exceed their normal func- tional activity or the waste accumulates. That these poisons circulate in llie blood and mav cause disease ABNORMAL PREGNANCY 81 is evidenced first by analogy. Thus certain known poi- sons, when absorbed, will produce lesions similar to those recognized and grouped under the head of “tox- emias of pregnancy.” The lesions in the liver from acute yellow atrophy are very similar to those produced by phosphorus, chloro- form or snakebite poisoning. The kidneys in eclampsia show the same changes as in cantharides, phosphorus or snakebite poisoning. Stillborn infants of eclamptic mothers show the same changes that are found in the liver and kidneys- of the mother. These changes are not the ones that usually follow inflammation, but are usually accompanied by a degeneration and necrosis as from chemical toxins. It has also been found that the blood and urine of eclamp- tic wo#nen is highly poisonous to animals. These toxins must arise either from the mother or the child. On the mother’s side it is possible for them to form either from over-production or under-excretion or both. Do they form in the intestines from sluggishness of function or, is there a relation between their appear- ance and a lack of thyroid function? Enlargement of the thyroid is normal in pregnancy and the absence of this increased activity may predispose to toxemia. On the other hand there is limited support for the theory that the ovum is responsible; but if so, it would seem to come from the point of attachment of the egg to the uterus rather than from foetal metabolism. The basis for this lies in the fact that cases of eclampsia and pregnancy kidney occur after the delivery of the babe, after its death, and in cases of vesicular mole where no foetus is present. Pregnancy Kidney (albuminuria of pregnancy, pre- eclamptic toxemia) occurs most frequently in primip- 82 OBSTETRICS FOR NURSES aras. The average is about twenty to one. It is more common also in cases of hydramnion, twins and hyda- tidiform mole. The presence in the maternal circula- tion of toxins which have been derived from the foetal elements of the placenta may be mentioned as a cause. The condition develops usually during the second half of gestation so that there is a slight support for the theory that it is the result of compression of the ureter between the pelvic bones and the heavy uterus. Re- striction of kidney function by heightened intraabdom- inal pressure may also be a factor. The symptoms differ much in severity. Headache is frequent, usually frontal and often persistent. Dimness of vision, flashes of light before the eyes or sudden blind- ness may occur. Edema of feet, hands and eyelids is common. Nausea and vomiting may be present or epi- gastric pain. The urine may not be greatly diminished and there may be only a trace of albumin, or the urine may be scant and contain as much as 5 per cent of albumin. The condition must not be confused with old standing kidney troubles which the pregnancy has intensified. Prognosis.—Patients rarely die from this disorder al- though the degree of toxemia is important. With early diagnosis and treatment a rapid improvement usually takes place in a week or ten days though in exceptional cases the kidney may be permanently impaired. If the toxemia is profound and the response to treat- ment slow, eclampsia is likely to come on. An attack during one pregnancy does not predispose to a recur- rence in the next. The labor is often premature and many Italics are stillborn. Treatment.—The urine must be examined regularly in normal cases as often as once in two weeks. The patient ABNORMAL PREGNANCY 83 should be warned to report any ill feeling and especially any of the symptoms enumerated above. As soon as the condition is suspected or recognized by physical findings or urinalysis the woman is put to bed on a diet of milk and milk products. All the eliminating organs are put to work. Magnesia sulphate is given as a purge, with drinks and hot baths to stimulate the skin and activate the kidneys. Meat and nitrogenous foods should be forbidden although in mild cases such foods as fish, eggs, bread and butter, tea, cocoa, milk pudding, junket, cus- tard, etc., may be allowed. The urine must be measured and examined every twenty-four hours. If the condi- tion does not clear up within a week eclampsis must be looked for. Eclampsia is an acute toxemic disease of pregnancy, labor and puerperium which is characterized outwardly by convulsions and inwardly by certain changes in the liver and kidneys. The attack occurs about once in 500 labors and in the ratio approximately of 3 to 2 to 1 in the antepartum, in- trapartum and postpartum epochs. Seventy-five per cent of the victims are primiparas. The disease appears in one of two ways. There may be a brief warning or none at all of the onset or it may follow the pregnancy as described above. Warning Signs.— 1. Severe and persistent headaches, mostly frontal. 2. Swelling of feet, hands, eyelids or vulva. 3. Epigastric pain and persistent vomiting. 4. Puffiness of eyelids, flashes of light before the eyes, dimness of vision, double vision or sudden total blind- ness. 5. The urine is diminished or suppressed and loaded 84 OBSTETRICS FOR NURSES with albumin. As much as six or eight drams to the ounce may be found. Many hyalin and granular casts are seen and a few epithelial casts. Blood, acetone, and diacetic acid are generally present. The ratio between the nitrogen ex- creted as ammonia and that excreted as urea is high, i.e., the ammonia coefficient is high. Clinical course.—The disease frequently begins with a convulsion. The attack may appear at any time even during sleep. The number of convulsions may vary from one to a hundred or more. The stage premonitory to the convulsion lasts only from fifteen to twenty seconds and may not be ob- served. The patient rolls her eyes while the muscles of the face and hands twitch slightly. Next the woman be- comes rigid from a general muscular contraction. The face is cyanosed from fixation of the diaphragm and chest muscles and the tongue may be caught and in- jured between the clenched teeth. This stage lasts or- dinarily half a minute. The stage of convulsions is unmistakable. The mus- cles relax and contract spasmodically. The jaw muscles share in the movement and the tongue may be bitten. Blood-stained saliva appears as a froth. The face is congested, the breathing stertorous and the patient deeply unconscious. This stage lasts from half a min- ute to two minutes. It is followed by coma. Coma.—The woman sinks into a deep stupor which may last for hours. At other times the coma may be quickly broken by another fit. The attacks may follow in such rapid succession that the coma does not inter- vene. The temperature may rise to 104° or 105° F. The blood pressure rises, possibly to 250 mm. or more of mercury. The pulse is full and bounding. ABNORMAL PREGNANCY 85 Complications.—Injury to tongue, septic bronchopneu- monia from insufflation of saliva, or improper efforts to put food or medicine into the stomach. Memory is lost during the attack. Mental derangement follows in from five to seven per cent of the cases. Jaundice sometimes occurs and has a serious significance. Antepartum ec- lampsia is usually followed by the rapid onset of labor. Results.—The patient may die undelivered, recover without delivery and later expel a living, but more often a dead, child. In intrapartum eclampsia the uterine contractions tend to become stronger and more frequent and thus brings about delivery. Postpartum eclampsia ordinarily comes on within forty-eight hours but may be postponed for a week. Prognosis.—One out of four mothers die. The outlook is bad if any of the following conditions prevail: 1. If convulsions recur at short intervals. 2. If the coma is deep and prolonged so that the pa- tient has no conscious intervals. 3. Urine markedly diminished in quantity or sup- pressed. 4. Pulse frequent and blood pressure high. 5. Temperature remaining at 103° or more. 6. Delivery cannot be easily and quickly accomplished. The outlook is worst in the antepartum and postpar- tum varieties. It is worse when it occurs in a patient with kidneys previously diseased. The prognosis is favorably affected in antepartum cases by the death of the child. The cause of the maternal death may be asphyxia, edema of the lungs, cerebral hemorrhage, a gradually deepening coma or later from infection or bronchopneu- monia. The babe’s prognosis is worse than the mother’s. 86 OBSTETRICS FOR NURSES Fifty per cent of the hahes are stillborn or die soon after delivery. Treatment should be prophylactic if possible. The preliminary stages should be managed like the preg- nancy kidney (see above). On the principle of thyroid insufficiency as a causative factor one could give thyroid extract in 10 gr. doses thrice daily. It acts as a diuretic and as a vasodilator. During the attack the patient must be kept from hurting herself. The head should be kept on one side to aid drainage from the mouth. If the morphine and chloral method of controlling convulsions is not employed (see p. 258) veratrum viride may be given in the form of veratrone. One cubic centi- meter may be given hypodermically at half-hour inter- vals until the physiologic effect is produced. This phys- iologic effect is a reduction in pulse rate to 60 or 80 per minute, a profuse perspiration and a copious “bilious vomiting.” (Gillette.) If anything is given by mouth it should be done through an esophageal tube. Subcutaneous continuous saline injection will add to the bodily fluids and stimu- late the kidneys. To each pint of the saline solution may be added one dram of sodium bicarbonate to in- crease the alkalinity; while to combat the condition of acidosis, one can add 5 per cent of sterile glucose to the same solution. Hyperemesis Gravidarum.—The nausea and vomiting of pregnancy is so usual as to be regarded as normal. It usually ceases from the fourth to the fifth month spontaneously; has no ill effect upon tlie ovum, and may respond readily to treatment. Hyperemesis comes on quite as early and exhibits all stages of violence, from the mild form above de- scribed, to eases that end fatally. 87 ABNORMAL PREGNANCY Three classes of this serious disorder may he distin- guished as associated (Eden), neurotic, and toxamiic vomiting. Associated vomiting is the vomiting that comes with gastric ulcer or cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease. These conditions must be excluded in diagnosis. Neurotic vomiting—severe and persistent nausea and retching—is common in pregnant women of the nervous type. It does not lead to loss of flesh ordinarily; the urine is somewhat diminished in quantity from the lack of fluids, but the amount of nitrogen excreted re- mains normal. This is important. Toxamiic vomiting includes a small but very import- ant class of cases, for all are severe and intractable and some end in death. Ilyperemesis Gravidarum, therefore, is the term applied to those cases of vomiting in which the stomach is emptied so frequently and so completely that the woman gets no nourishment. It occurs in all degrees of seriousness. Fortunately the severe conditions are not often met with, possibly not oftener than once in a thousand preg- nancies. In the toxic cases no cause for the vomiting can be found aside from the pregnancy. No food is retained. The vomiting occurs at short intervals even at night; the patient wastes rapidly and becomes exhausted. Headache is often present as well as edema of the ex- tremities. The vomit is at first mere stomach contents, then it becomes stained with bile and later becomes brownish in color. The woman complains of epigastric pain. The pulse becomes rapid (140 or more). The tem- perature goes up to 103° or 104° F. There is albumin in the urine. The quantity varies, but the percentage of 88 OBSTETRICS FOR NURSES nitrogen which is excreted as ammonia is raised. This condition may also be present in starvation which clouds somewhat the value of this factor in the diagnosis. If no change occurs in ten days or two weeks and the emaciation and exhaustion become more marked the patient’s condition will become extremely grave. She will begin to vomit coffee-ground-like material, jaun- dice may appear, and the consciousness will gradually fail. A low leucocyte count is always ominous. The prognosis in the group of toxic cases is much more un- favorable than in the neurotic group. These latter nearly always recover under appropriate treatment. Treatment.—Organic disease must be excluded and a diagnosis of pregnancy strongly evident. For the neurotic type, the patient must be segregated from her friends, and a competent, cheerful nurse put in charge. A cool, darkened room is best. If the pa- tient can be transferred to a hospital, the results are more satisfactory. Here the isolation from external interests and irritations can be made complete. The pa- tient does not talk. Even the nurse comes with food, at- tends to the obvious necessities, and departs in silence. Once a day a sedative bath is given (see Baths, p. 350) and medication in kind and frequency as the conditions demand. In any case, the patient should be put to bed and fed carefully every two or three hours on milk, peptonized food or barley water. If this is not retained, albumin water may be given for twenty-four hours at regular intervals, or rectal alimentation may be tried after stop- ping all foods by mouth. Iced champagne, seltzer or vicliy, either alone or with milk, may be tried. A dry diet is sometimes effective, rusk, toast, toasted shredded wheat biscuit, crackers, etc., taken early in the morn- 89 ABNORMAL PREGNANCY ing, as one eats cheese. No exercise is permitted ex- cept such muscular and nervous excitation as may be derived from massage or the sedative bath. Drugs are sometimes of great value—the bromides, in full doses, or 1 m. doses of tincture of iodine, well diluted, every hour; or thyroid extract, grs. v; or cocaine or oxalate of cerium. Occasionally good results are reported from a capsule of pepsin, 2 gr. and 14 gr. silver nitrate given just before meals; and adrenalin (1 in 1000) in 2 drop doses may be considered. Extract of corpus lutea has been tried by Hirst with favorable results. Sinapisms to the epigastrium and ice bags to the spine have been found useful, and washing out the stomach is efficient at times. I11 washing out the stomach, be sure the stomach tube is iced before it is introduced. When the case gets worse in spite of treatment and acidosis supervenes, bicarbonate of soda may be given in sixty grain doses every four hours, by rectum, if necessary, until the urine gives an alkaline reaction. Glucose as a readily assimilable carbohydrate may be given in doses up to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum, 1000 c.c. in twen- ty-four hours by drop method. Normal saline may be given by rectum. By these methods the toxin is diluted and its injurious effects diminished. Starvation must be combated by rectal feeding, but to prevent the decomposition of retained food the bowel should be cleaned daily by a soap suds enema. Before resorting to obstetric methods of treatment, the patient should be given from 15 c.c. to 20 c.c. of serum subcutaneously. This serum may be normal horse serum or blood serum taken from a woman in the sixth 90 OBSTETRICS FOR NURSES to the eighth month of pregnancy whose Wassermann is negative. The injection may he repeated in forty- eight hours, hut anaphylaxis must he kept in mind. The obstetric treatment is the emptying of the uterus, hut this is rarely necessary in well observed cases. To he effective the operation must he done before the condition of the patient is desperate. It is most favor- able before the febrile stage. If the vomiting persists in spite of treatment and is accompanied by emaciation, a pulse of over 100, albumin in the urine, with an in- crease of the ammonia output, the termination of the pregnancy will probably be useless. If the interference is attempted and the patient cannot go to a hospital, the nurse should prepare the room as described for operations. After emptying the uterus, the vomiting sometimes ceases but much labor is thrown upon the nurse in sup- plying nourishment and caring for an exhausted whim- sical or moribund patient. The back must be inspected daily for decubitus (bed sores) and her position changed frequently. A daily rub with alcohol and water (50 per cent) folloived by an oil inunction will be valuable. The teeth and gums should be cleaned with gauze, wrapped around the finger and dipped in solution of boric acid. No brush should be used. The treatment of the eclamptic convulsion will be considered more fully under the complications of labor, with which the attack is often associated. Headache, scanty urine, disorders of vision and swelling of feet, hands or eyelids should be reported to the doctor. Pyelitis of pregnancy is an acute, and rarely, a chronic infection of the pelvis of the kidney, commonly due to the Bacillus coli. It usually appears after the fourth ABNORMAL PREGNANCY 91 month (fifth to eighth) and attacks by preference the right side. Extension to the kidney substance, ureters, and bladder is occasionally observed. Symptoms.—Sudden, acute abdominal pain, at first diffuse, but after a few hours, becoming localized in the right side, and on this account is often confused with appendicitis, especially as vomiting is not infrequent. A chill may mark the onset and the temperature rise to 103° F. or 104° F. The bowels are constipated, the tongue coated, and there is tenderness over the kid- ney. The urine is scanty, turbid, slightly albuminous and contains pus and often epithelial cells. A cul- ture reveals the bacillus which has obtained access to the kidney, either by extension through the ureter from the bladder, by direct invasion of the tissues from the adjacent colon, or through the circulation. Treatment.—The diet should be fluid and mostly milk, the bowels should be moved freely and frequently. The urine is alkalinized with sodium citrate, since the Bacil- lus coli lives only in an acid medium. As the symp- toms subside, urotropin may be administered. If the patient does not improve within two weeks, the pelvis of the kidney should he washed out by means of the cystoscope and the ureteral catheter. With appropriate treatment the cases usually recover and go to term. Autogenous vaccines are occasionally successful. Un- treated cases sometimes abort. Nephrotomy is not to be thought of. Multiple Pregnancy.—Twins occur about once in ninety labors, triplets, once in six thousand. Heredity and multiparity seem to be the only recog- nized predisposing factors. The more pregnancies a woman has, the more liable she is to have twins. 92 OBSTETRICS FOR NURSES Twins may occur by superfecundation through the fertilization of two ova from the same or different ovaries, or by fertilization of a single ovum having two nuclei. (See Fig. 15.) The former are called binovular twins, and may or may not he of the same sex. The latter are called uniovular twins and are always of the same sex. Twins are usually some- what smaller than a single child, and frequently asso- Fig. 32.—Twins. (Fenoir and Tarnier.) ciated with hydramnios. Binovular twins have separate placentas and uniovular twins have one placenta, with separate cords. Binovular twins are the healthier. Twin pregnancies usually go into labor earlier than the single child, possibly on account of the over-disten- tion of the uterus. The diagnosis is occasionally difficult and at other times easy. Two sets of heart tones must be distin- guished and differentiated by their variation in fre- ABNORMAL PREGNANCY 93 quency, heard at the same time by different observers. The presence of twins may be strongly suspected also when the external measurements of child and uterus greatly exceed the average. In such cases a systematic and persistent search must he made for the two fcetal heart tones. The x-ray is sometimes an aid. The delivery is generally uncomplicated, unless the chins become locked. Superfecundation is the fertilization of two ova from the same ovulation. The fertilization does not occur at the same coitus, but the interval cannot be long. Superfetaticn is the fertilization of separate ova of different ovulations. Its occurrence is very doubtful. Displacements of the Uterus.—In most cases displace- ments of the uterus are a consequence of conception in organs that are previously retroflected or retroverted. They rarely produce symptoms until the end of the third month, when the attention is directed to the bladder. There may he absolute retention or a constant drib- bling from a full bladder (ischuria paradoxa), possibly associated with pain. If recognized early, an attempt should be made to replace the uterus by posture (knee chest) and when replaced, to hold it by pessary or tam- pon. The prone position in bed will aid. After retention has occurred, the patient should he put to bed and the bladder catheterized regularly every eight or ten hours for three or four days. As a rule, the organ will rise spontaneously into the abdomen. If il does not, it is probably incarcerated under the promon- tory, and the physician must try to release the uterus by manipulation or by continuous pressure from below before abortion occurs or the condition of the patient becomes too serious. The release is sometimes done by laparotomy. 94 OBSTETRICS FOR NURSES Ill multiparas with weak abdominal walls, or women with spinal curvature or contracted pelves, the uterus may fall forward and, passing between the recti mus- cles, continue to drop until the fundus lies lower than the symphysis pubis. Management, until labor occurs, consists in the use of a strong, well-fitting abdominal bandage. Malformation of the uterus may possess an obstet- ric interest at times. The double uterus (uterus didel- phys) and the uterus with a rudimentary horn (uterus bicornis) are examples. These are congenital condi- tions, due to imperfect development, and pregnancy may take place in one or both sides. If in one side only, the other half will also exhibit the softening and other changes as in normal cases. Binovular twins may be the result of a pregnancy in each side. Pressure Symptoms.—Edema of legs and sometimes of the vulva occurs during the last trimester. It is due to increased intraabdominal pressure and to direct in- terference with the return circulation by the pressure of the heavy uterus on the iliac veins at the brim of the pelvis. The urine should be examined for albumin and the patient put in the horizontal position if the edema is troublesome. Varicose veins of legs and vulva may cause much dis- tress. The limbs should be bound with flannel spirals or with rubber bandages in the recumbent position, or elastic stockings may be obtained. Operation during pregnancy is not to be considered. The vulva can only be relieved by a double bandage, which is sewed at the point where it crosses the vulva, and buckled or tied to a waistband above the hips, both before and behind. This brings support to the vulva. If the veins rupture, ABNORMAL PREGNANCY 95 the part should be elevated and compressed with an asep- tic pad. Ilcemorrhoids may either appear or grow worse late in pregnancy. If they protrude, they should he replaced. Ointments and iced applications may be used and the bowels kept loose. Cramps may occur in the muscles of the legs, due sometimes to the varicose veins and sometimes to pres- sure on the lumbosacral plexus. They may also be a sign of toxemia. Moles.—Mole is the name given to an ovum which is destroyed by disease of its coverings during the early months of gestation. Two kinds are known, the blood mole (carneous mole, fleshy mole, or haematoma mole) and the hydatidiform mole (vesicular mole). The blood mole results from progressive or recur- rent slight haemorrhages into the ovum during the first three months of pregnancy, but haemorrhages insufficient in quantity to produce an abortion. The blood forms a clot, which may be retained for several months and be- come solidified. Hydatidiform mole is a disease of the young chori- onic villi, characterized by the growth of an immense number of irregular clusters and chains of grape-like cysts from the very minute to bodies four-fifths of an inch in diameter. The causation is unknown. Age (35 or more) and nephritis seem to be frequently associated factors. Both forms occur in the first half of the pregnancy and are characterized by undue enlargement of the uterus and haemorrhagic discharge. The ovum is already destroyed and the uterus should be emptied. Diseases of the Membranes.—Hydramnios, or polyhy- dramnios, is the name applied to the condition wherein an 96 OBSTETRICS FOR NURSES excess of liquor amnii is formed. The amount normally present varies, but anything in excess of four pints could be called hydramnios. Six gallons have been re- ported. Since the source of the liquor amnii is not positively known, the etiology of hydramnios must be equally obscure. It is occasionally associated with morbid conditions of the mother, such as hepatic or cardiac dropsy, but more frequently with developmental anomalies of the foetus. Since the mother is usually healthy and the foetus fre- quently deformed, the theory is advanced that the dis- ease is foetal in origin. It frequently occurs with twin pregnancies, and in the first months it is most plausible that the liquor amnii is in some way derived from the foetus, The foetus is a male in 75 per cent of the cases. The disease is more common in multiparas. It is generally slow in onset, but it may be acute, and an immense amount of fluid may be formed in a few weeks. The symptoms are those due to pressure from the ex- tremely large uterus. The treatment, if interference with heart or lungs becomes pronounced, is puncture of the membranes. The child need not be considered for it is usually dead, horribly deformed or incapable of living. Oligohydramnios is the condition wherein the liquor amnii is deficient in amount. It gives no maternal symptoms, but it is the cause of many birthmarks and foetal deformities (club-foot, spinal curvature, wry-neck, ankylosis of joints). Amniotic adhesions are usually associated with oli- gohydramnios and cause deformities by amputation of limbs, strangulation of cord, and production of six fingers. It is claimed that harelip, cleft palate and spina bifida may result from this condition. ABNORMAL PREGNANCY 97 Fig. 33.—Anomalies of the placenta. (From Borland’s Dictionary.) 98 OBSTETRICS FOR NURSES The placenta may show anomalies of size and shape. Thus, there may be two lobes, or three. There may be the main placenta and a small out-lying mass con- nected by membrane and vessels with the larger seg- ment. The cord may be inserted in the middle or at the edge and yellowish-white masses called infarcts may be found in its substance. Unusual size and weight of the placenta are sugges- tive of syphilis. Abnormal conditions of the foetus may arise from pri- mary or transmitted disease or from errors of develop- ment. The developmental errors may be monsters, hy- drocephalus spina bifida, etc., which may not influence the pregnancy. The most commonly transmitted dis- ease is syphilis, which may produce abortion, prema- ture labor, or a child born with syphilitic shin changes on palms and soles, as Avell as internally. CHAPTER VI ABNORMAL PREGNANCY (Cont’d) Extrauterine Pregnancy.—This is a pregnancy which occurs outside the uterus, and while the event usually happens in the tube, cases have been reported where the egg developed in the ovary or abdomen. The ovum, owing to some delay in passage to the uterus, is fertilized either in the ovary or in the tube, and by reason of a chronic inflammation of the tube or pelvis, or of an over-growth it does not succeed in reaching the uterus at all. As the ovum develops, the tube expands, but it does not possess the capability of growing into a large organ like the uterus, hence a sudden jar, a strain, or a blow may cause it to rupture and discharge the egg into the abdomen (ruptured tubal pregnancy) or force it out through the end of the tube (tubal abortion). This phenomenon may be accompanied by a severe or even fatal haemorrhage; or the prostration may pass off in a few days or weeks, and leave the patient well. In the early stages the ovum is absorbed, but after the pregnancy becomes more advanced, it may remain as a tumor, or require an operation for its removal. Infection may occur and the mass ulcerate its way into neighboring organs (rectum, vagina, or bladder) and discharge itself in a long, suppurative process. Most cases of ectopic (extrauterine) gestation present definite and even dangerous symptoms between the second and fourth month. The symptoms are those of pregnancy, together with irregular haemorrhages from the uterus, 99 100 OBSTETRICS FOR NURSES which may result in the expulsion of pieces of tissue or of membrane. Besides this, there is a vomiting and acute irregular pain on one side, associated with a sense of fullness. Such symptoms should be brought to the attention of the physician, who will learn the true con- dition of the pelvis by internal examination, conducted as gently as possible so as not to produce rupture. If rupture occurs, it will be ushered in by a sharp lancinating pain on one side, followed by faintness, nausea, vomiting, prostration, rapid pulse, sighing Fig. 34.—Diagram representing the sites for the various forms of tubal pregnancy. 1, interstitial pregnancy; 2, isthmial pregnancy; 3, ampullar pregnancy; 4, infundibular pregnancy; 5, tubo-ovarian pregnancy. (Gil- liam.) respiration, and collapse. The temperature is sub- normal and death may occur in a few hours, unless an operation is done. In cases of tubal abortion (where the ovum escapes through the end of the tube) the symptoms are very similar, but the patient soon rallies and gradual re- covery takes place. If the diagnosis is made before rupture or abortion the treatment is laparotomy. If rupture occurs, the ABNORMAL PREGNANCY 101 laparotomy must bo done immediately to check the ha3morrhage, which threatens the life of the patient. In tubal abortion, if the diagnosis is certain, some delay may be permitted under extreme watchfulness of the nurse and physician. In such case, the nurse will keep the patient absolutely quiet and forbid exertion of any kind. If operation is necessary, the utmost gentleness must be used in preparing the abdomen. The tincture of iodine application to the site of the incision is sufficient preparation, and, of course, an abundance of sterile gauze, cotton, and towels should be supplied, as in every case where laparotomy is done. If the rupture occurs while the nurse is present, the doctor should be notified at once, and if not at home, another doctor should be summoned. Meanwhile, the nurse prepares the room, solutions and utensils for an abdominal operation. Immediate incision to check the haemorrhage and remove the mass offers the greatest safety. The after-care is the same as for any laparotomy, with the additional duty of making up the lost blood as soon as possible by nourishing foods, normal saline solution by rectum, and, if necessary, by hypoder- moclysis. Acute fevers are a serious complication of pregnancy on account of the danger of abortion or premature labor, which may come on either from the associated high temperature or from the transmission of the dis- ease to the ovum. The following diseases are known to affect the foetus in utero: cholera, yellow fever, small pox, scarlet fever- typhoid, measles, erysipelas, meningitis and syphilis. 102 OBSTETRICS FOR NURSES CHRONIC INFECTIONS Tuberculosis does not affect fertility or the course of the pregnancy, but the progress of the disease is hastened, and the maternal death accelerated. If the case goes on to term, the child must not be nursed or cared for by the mother. Syphilis is the most frequent systemic cause of the interruption of pregnancy. It is a blood disease, due to Fig. 35.—Oil the left Treponema pallida (Spirochete pallidum). A smear from a chancre. On the right Spirochete refrigens. A smear from a chancroid. (From Emerson’s Clinical Diagnosis.) an organism called spiroclueta pallida, and it appears in three distinct stages. The first is the primary stage, wherein a hard, nodular ulcer appears on some part of the body, as the vulva, lips, gums, tonsils, or hand. It is not always venereal in origin. The second stage be- gins six or eight weeks after the sore, and is marked by a general eruption of red spots, chronic sore throat, fall- ing hair, and rheumatic pains in the joints. The third ABNORMAL PREGNANCY 103 stage is the name given to the later conditions of the disease which affect the bones, blood vessels, and ner- vous system. Infection of the ovum may usually be traced to the father, who may transmit syphilis at any stage of the disease. In the third stage, the child alone will be in- fected; the mother escapes. The mother may or may not transmit the disease, depending on the period of pregnancy wherein her in- fection occurs. If she gets the disease at, before, or just about, the time of conception, she will abort three times out of four, and the ovum will show definite lesions. If infected later, abortion occurs less fre- quently; and if the disease is contracted late in preg- nancy, the child may be born apparently free from in- fection. Symptoms.—A child with congenital syphilis will show the eruption of coppery spots, blisters on palms and soles, deep cracks on the feet, snuffles, cracks and ulcers around the mouth and rectum, an enlarged spleen, and a weakly, marasmic condition of the body. The diagnosis in suspected cases can be rendered more certain by the 'Wassermann reaction. This is a labora- tory test of the blood which should always be made be- fore a wet nurse is allowed to nurse a child, or before a suspected child is nursed by a clean woman. In all cases of transfusion of blood, it is an imperative pre- liminary. Treatment.—Antisyphilitic treatment of an infected mother or child by salvarsan, mercury, and potassium iodide must be carried out vigorously in all cases. The syphilitic patient must be prevented from spread- ing the infection by having dishes and utensils of her own, which are kept sterile. Discharges are collected and burned, and the nurse in charge of these cases must 104 OBSTETRICS FOR NURSES carefully cover her hands with rubber gloves, and see that all cracks and fissures are properly protected from contact with sources of infection. Gonorrhoea is an acute or chronic disease of the mu- cous membranes due to a germ called the gonococcus. Beginning with a sharp inflammatory disturbance of the urethra or vagina, it may pass slowly up through the genital passage and produce chronic and permanent disabilities, such as sterility, pus tubes, and pelvic peri- tonitis. The symptoms are painful urination, painful inflam- mation of the vagina, with a purulent discharge. Dur- ing pregnancy all these symptoms are intensified, and warty growths (condylomata) may appear on the vulva. If infection occurs after pregnancy has begun, the course of the gestation is rarely affected, as the uterus is closed to germ invasion. During delivery, however, there is a serious danger of infection of mouth or eyes of the child if they come in contact with the discharge. Prophylaxis.—The eyes at birth must be immediately instilled with a drop or two of 1 per cent solution of silver nitrate in water. This is not neutralized by normal saline. Great care must be used that the pus does not come in contact with the eyes of the mother or attendants, lest infection follow. Treatment.—Scrupulous cleanliness must he observed. Douches of potassium permanganate, 1:5000, or painting the vagina with iodine or solution of silver nitrate, or suppositories of argyrol or protargol furnish the best means of treatment before labor. Neither syphilis nor gonorrhea is necessarily caused by venereal infection. They may he spread by barbers, dentists, physicians, and nurses,—by anyone who is un- clean; and may be acquired innocently everywhere. ABNORMAL PREGNANCY 105 These diseases should not be discussed by the nurse or physician except with the patient, Certainly nothing from the sick room should be repeated elsewhere. The valves of the heart are not uncommonly found to be diseased in pregnancy, the mitral being the most often affected, either as an insufficiency or as a stenosis (a narrowing of the mitral opening). Mitral stenosis is the most serious of all heart complications of preg- nancy, and where this is present, a woman should be advised to avoid conception. In other mitral lesions, many pregnancies may be successfully passed, if compensation is maintained; but every one brings further damage to the already weak- ened heart, and reduces its reserve of force. If the heart breaks down early in pregnancy, and does not respond to medication, abortion may result. In the second half of pregnancy, the mother should be given the prior chance, but the child should be saved, if possible. Renal diseases, such as nephritis, may not only induce abortion by destroying the foetus, but the kidney lesion may be greatly aggravated by the pregnancy. The most careful observation of the patient’s condition, the regu- lar examination of the urine, and the scientific manage- ment of the diet is necessary to relieve the work on the kidneys and keep the patient in a moderate degree of health. It is the duty of the nurse to protect her patient against fatigue and chill, and to see that the proper diet is followed; but other symptoms, such as headache and disturbance of vision and developing edema, must be noted and reported to the physician at once. Diseases of Liver.—Acute yellow atrophy is a rare condition, which, for reasons unknown, is promoted by pregnancy. It is due to toxemia. (See p. 80.) 106 OBSTETRICS FOR NURSES The symptoms are intense headache and pain in the abdomen, possibly accompanied by vomiting and purg- ing, which are soon followed by coma. There is generally a certain amount of jaundice. The urine is diminished in amount and contains albumin, casts, and sometimes blood. There is no known treatment, and the end is death. Diabetes is seldom found associated with pregnancy. Its presence is unfavorable to conception and to gesta- tion. Mother and child are both less secure. Abortion or premature labor is the rule. The haemorrhages of pregnancy in the first half gen- erally mean abortion, and in the last half, either placenta praevia or premature detachment of the normally im- planted placenta (see p. 248). Abortion is the expulsion of the ovum before the foetus is viable, that is, before it is capable of maintain- ing life after birth. This means the twenty-eighth week, or the seventh month. Subsequent to the seventh month, the interruption is called premature labor. Abortion is a miniature labor, consisting of a stage of dilatation, a stage of expulsion, and a stage of involution. The interruption of the pregnancy may occur spon- taneously or be induced. In spontaneous cases the causes may be sought in diseases of the ovum, or in the mother, in injuries to the uterus or its contents, and such systemic affections as syphilis, Bright’s disease, alcoholism, lead poisoning, etc. Abortions happen about once in every five or six preg- nancies, and more frequently at the third month than at any other time. The symptoms are haemorrhage and pain. The dangers are haemorrhage and infection. Infection is most common and most serious in abor- tions that are brought about mechanically. ABNORMAL PREGNANCY 107 Haemorrhage, in some degree, is an invariable symp- tom, which lias its origin in the separation of the ovum from the uterine wall. Haemorrhage from the uterus is serious at whatever stage of pregnancy it appears. The duty of the nurse is to put the patient in a cool, dark room, on her back, elevate the foot of the bed, put ice bags on the lower abdomen, and summon the at- tending physician, with the hope that an abortion can be averted. Bromides and opium are the drugs most to be relied upon. Opium may be given in suppository, 1 grain night and morning. If the haemorrhage is alarmingly profuse and the nurse is skillful and clean, under exceptional circum- stances she may pack the vagina with sterile cotton while waiting for the doctor. Then the room should be set for operation. Dead Ovum.—The ovum may be discharged in pieces or in a single complete mass. The egg may die at any period of the pregnancy, and be discharged in a few hours, or it may not be expelled for weeks, if at all. Foetal death in the uterus may have its cause on the paternal side in a father too old or too young, or affected with such diseases as diabetes, nephritis, tuberculosis, syphilis, or chronic lead poison- ing; on the maternal side, the same diseases, plus cancer, anaemia, insufficient food, and inflammation of the uterus; on the part of the embryo, syphilis or any trans- mitted or primary disease of the ovum. The results of retention of the dead ovum vary with the case. Infection of the ovum is rare, except where the membranes have ruptured and an open channel ex- ists. No harm follows the death of the foetus, except in the presence of infections, all other changes are be- nign. The embryo in the first and second months may 108 OBSTETRICS FOR NURSES be absorbed, but at later periods, it becomes macerated petrified, or otherwise altered. Among the signs of foetal death are prolonged cessa- tion of foetal movements after being definitely observed, chilliness, languor and malaise of the mother, sense of weight in abdomen, and possibly a bad taste in the mouth. Furthermore, the uterus does not correspond to the period of pregnancy, and may have become smaller. Retrogressive changes take place in the breasts. The diagnosis is only certain when the heart tones are persistently absent, or the macerated head of the foetus is felt through the partly dilated os as a flabby bag of bones. Treatment in noninfective cases is expectant. Sponta- neous expulsion will occur sooner or later and there is no necessitous indication for interference. Haemorrhage from retained pieces may indicate a curettement. In- fected cases should not be interfered with surgically until they have been free from fever for five days. The Postmature Child.—All large babies, 9 lbs. or more, must be suspected of postmaturity. Seventy-four and eight-tenths per cent of these babies have passed the estimated date of their delivery. Parvin declared that as many as 6 to 8 per cent of all babies went over- time. Some, of course, grow faster than others and may be as large at eight months as others at ten. At all events the pregnancy is prolonged beyond the proper time either from a primary uterine inertia or on account of the absence of the normally exciting causes of activity. These large babies are a source of danger both to the mother and child. The labor is greatly protracted, the mother exhausted, the overdistended uterus gives but weak and shallow contractions, the membranes are lia- ABNORMAL PREGNANCY 109 ble to premature rupture with a resultant dry birth, the hard, well ossified head moulds slowly or not at all and when it is finally forced through in the ultimate deliv- ery, it overcomes the soft parts by means of extensive Fig. 36.—The McDonald measurement. From upper border of symphysis to highest point of fundus. Note method of holding upper end of tape. It does not follow down into the depression above fundus. Normal fundus is 35 cm. above the symphysis at term. lacerations. Usually the normal powers fail and an operative delivery is imperative. Fistulas from the pro- longed pressure are frequent and maternal mortalities 110 OBSTETRICS FOR NURSES must be expected either from the exhausting labor, from haemorrhage, infection or the necessary but brutal in- strumentation. The child is endangered by the shrinkage of the blood supply, by strangulation of the cord and by the long cerebral compression. Asphyxia, intracranial haemor- rhage, skull fractures and paralyses are a constant men- ace and 1he death of the child forever impends. The large size of the child on the other hand is no advantage, for the extra weight is merely an accumula- tion of fat and water which melts off and disappears within three days after birth. All babies are mature which measure from 48 to 53 cm. in length, which weigh from five to nine pounds, and exhibit skulls with occipito-frontal diameters of 10 to 12 cm. and 8.5 to 10 cm. in the biparietal. Babies of smaller dimensions are usually premature and larger ones are postmature. The size of the babe in utero is readily determined by the Ahlfeld, McDonald and Ferret measurements. The Ahlfeld gives the length of the child on the well founded theory that the child extended is twice the length of the child folded up in the uterus. The McDonald measurement assumes that a uterus holding a mature babe will extend 35 cm. above the symphysis. Spiegelberg says 34 cm. The McDonald method is shown in the illustration. Also the height of the fundus in centimeters when divided by 3.5 gives approximately the stage of the pregnancy in months and days. Since the child grows at the rate of .75 cm. per week during the last few weeks anything less than 35 cm. is easily calculated. By the Ferret maneuver the occipito-frontal diameter ABNORMAL FREGNANCY 111 of the head is measured directly and the biparietal de- duced therefrom by a sliding scale. These measure- ments are all easily learned and very reliable. They should be employed in every case. Errors are possible Fig 37.—The Ferret measurement of the occipitofrontal diameter of the head. The poles of the head are found by the fingers and the assistant applies the pelvimeter. From this result the biparietal is de- ducted. where the head is deeply engaged or obesity or hydrani- nion is present. No pregnancy should he allowed to pass very much 112 OBSTETRICS FOR NURSES beyond the proper date of confinement. An overtime child commonly means a dead child and a long-ailing mother. In general more babies are lost from post- maturity than from prematurity. Fig. 38.—The Ahlfeld measurement. One tip of pelvimeter on upper pole of child. The other inside the lahia majora above the clitoris is pushed up until it impinges on upper border of symphysis. Subtract 2 cm. and multiply by 2 to get length of child. As soon as the pregnancy oversteps its time it must he carefully watched. The babe in utero must be meas- ured at frequent intervals and as soon as maturity is ABNORMAL PREGNANCY 113 assured and before the babe becomes too large, the labor must be induced. Any safe and convenient method may be employed. It is immaterial whether castor oil and quinine be used or the Voorhees bag or a catheter or rectal tube be pased into the uterus between the membranes and the endometrium. The pituitrin method is also excellent. The writer usually prefers the castor oil and quinine or the Voorhees bag or both. The important thing is to save the child. CHAPTER VII PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR The Nurse.—Scientific obstetric nursing is a specialty that enlists the interest of exceptional women only. It demands a high sense of duty, a strong physique, broad training, unusual judgment, and rare tact. The nurse must be professionally aseptic and personally clean. She should keep herself free from odors, and bathe at least three times a week. The presence of pus anywhere on her body disqualifies her at once, and she should report off duty. The compensation should always be somewhat higher than for other work, because there are two patients to be cared for. An obstetric nurse should specialize in her work, and not take infectious cases. Unhappily the haphazard character of the onset of labor presents a difficulty. The patient frequently can not afford to have the nurse for a long time in advance of labor, and the nurse whose income is limited by the number of her cases can not afford to be idle. Hence, it is better for two nurses to work in alternation with one another, so that one is al- ways available in an emergency. Both doctor and nurse should visit the lying-in room before labor begins, and plan its rearrangement. At least a week before the expected confinement, the cham- ber selected should be thoroughly cleaned and the wood- work wiped off. Curtains, draperies and bric-a-brac and all useless furniture should be removed. Carpets must 114 PREPARATIONS FOR LABOR 115 be taken up, or at time of confinement, well protected. Rugs can be easily managed. A chair, a bed, and the various tables for instruments and solutions are all that are required. The nurse usually is called to the case first, and upon her falls the responsibility of the diagnosis and the burden of the preparation. As soon as she arrives and satisfies herself that the patient is really in labor, she puts the final touches to the room. In her own mind she goes over all possible emergencies and prepares to meet them. The following supplies should be in the house for the labor: 3 hand basins, 10 inches in diameter. 3 hand brushes. 1 two-quart douche bag. 15 yards nonsterile gauze. 2 lb. each of cotton batting and absorbent cotton for making bed pads. 2 pieces of rubber sheeting 1 by 2 yards. 5-yd. jar of borated gauze. 4 oz. lysol (or ziratol). 100 c.c. of Squibb’s chloroform. 2 oz. green soap. 2 oz. solid albolene. 8 oz. alcohol. % oz. ergotol. V-2 oz. bismuth subnitrate and % oz. boric acid powder mixed (or Dermatol). 1 nail tile. Nurse’s outfit consists of the following: Nail file, surgi- cal scissors, catheter (silver is best), hypodermic syringe with tablets of morphine, strychnine, and digitalis; two fever thermometers, one for mouth and one for rectum; a pair of tissue forceps and a razor. Some time before the labor, the nurse should call on the patient and establish a working acquaintance. It adds greatly to her authority and to the patient’s con- Fig. 39.—Abdominal binder with crosspiece to hold vulvar pads, Fig. 40.—T-binder, used in all cases after the fifth day post partum. PREPARATIONS FOR LABOR 117 fidence in her. Her advice will be sought on a multitude of subjects, partly real and partly to try her out. Sterilizing’ may be done in a hospital, or, if this is not feasible, the nurse should go to the house two or three weeks before the expected labor and sterilize in an Arnold or Eochester sterilizer the following articles: Fig. 41.—Breast binder. y Hegar dilators. 1 Goodell dilator. 2 uterine applicators. 1 uterine douche point. 1 long curved dressing forceps. 1 long straight dressing for- ceps. 2 placenta forceps. 2 pairs scissors. 4 curettes. 2 artery clamps (eight inch). 1 oz. sterile glycerine as a lubri- cant. MINOR OPERATIONS 225 Whether the uterus is or is not packed with gauze after being emptied is a matter of personal technic. Usually it is not packed since the drainage is better. At all events the nurse should have the gauze ready in convenient sterile strips 3 in. wide by 5 yds. long, since an emergency like haemorrhage might make its use im- perative. The after-care is really that of the disease for which the interference was undertaken. The induction of labor at or near term is done for pelvic contraction, maternal disease, for danger threat- ening mother or child, or to avoid the birth of a post- Fig. 99.—Pean forceps. mature child. Either castor oil and quinine, introduc- tion of a bougie or the Yoorhees bag may be used. The latter is preferred. Before induction is undertaken for postmaturity of the child, the physician must be as- sured by means of the McDonald, the Ahlfeld, and the Ferret measurements that the child is really mature. Technic.—Assemble, and sterilize by boiling twenty minutes, a Yoorhees bag No. 3 or 4, Simon speculum or vaginal retractor, 1 pair long Fean forceps, 2 pairs vulsellum forceps, 1 dressing forceps, 2 pairs compres- sion forceps, 1 Gooclell dilator, 1 tenaculum forceps, Davidson hand bulb syringe with glass tubes and rub- ber connections for the bag. Patient, prepared as for delivery, is placed upon the 226 OBSTETRICS FOR NURSES table in exaggerated lithotomy position. Stirrups will serve. The vagina is retracted, a smear made from cervix, and the mucous membrane wiped clean with pledgets of gauze on forceps. Anaesthesia is only occasionally necessary even in pri- miparas. Fig. 100.—A, Hand bulb syringe; B and C, Voorhees bags; D, Bag rolled and grasped by Pean forceps ready for introduction. Before using, the apparatus must be tested by forcibly filling the bag with sterile solution. One lip and sometimes both are seized by vulsellum forceps and brought down. Usually, even in primiparas, the os is sufficiently patulous to admit the bag—if not, it should be dilated. MINOR OPERATIONS 227 The bag, emptied of residual air and fluid, is rolled up into a compact mass like a cigarette, seized with Pean forceps so that the tips extend just to the largest diam- eter of the rolled bag. Turn the concavity of forceps toward patient’s left leg and introduce. As the bag en- ters turn the mass to the left—a quarter turn—so that when operation is completed the forceps curve faces up- Fig. 101.—Voorhees bag in place. ward. Release the lock on forceps. Connect the tube of the bag’ with syringe tube and force the solution slowly into bag. Pean forceps may be removed as bag fdls. Remove vulsellum. Tie tube of bag with tape when bag is full—disconnect syringe. Put sterile pad on either side of tube. If pains do not start within an hour, or if compres- sion is desired as in placenta praevia or a more rapid 228 OBSTETRICS FOR NURSES dilatation, then a weight of one or two pounds is at- tached by a tape to the protruding tube and passed over the foot of the bed. Digital dilatation of cervix may be indicated in cases of rigid os or where prolonged labor or some danger to mother or child requires the hastening of the delivery. No instruments are needed, but a complete anaesthetic is necessary. Thorough asepsis must be observed. The patient’s genitals and the doctor’s hands are prepared as de- scribed for labor, and rubber gloves are imperative. The gloved hands and the vagina and vulva are well rinsed with lysol solution 1 per cent. The operation must be done carefully, patiently and gently, lest the cervix be lacerated. The hand is introduced into the vagina, and first the thumb and index finger are introduced into the os and separated as widely as possible, then the second finger and so on, until the dilatation is complete. (Hirst’s method.) Another method is the introduction of the tips of both index fingers, back to back. Force exerted will dilate the canal so second fingers may also be inserted. Then patiently and gently the rigid ring of the os is overcome. (Edgar’s method.) Episiotomy.—This is a clean incision of the vulva, which is done to avoid an apparently inevitable and ragged tear of the perineum. The instruments required are either a blunt tipped knife or a pair of blunt scissors. The operation may be done on one or both sides de- pending on the amount of room required. The incision begins at a point just above the lower third of the vulvar outlet when distended by the head, and passes MTNOR OPERATIONS 229 obliquely downward and outward. This severs unim- portant tissues only, instead of allowing the valuable perineal body to suffer. It makes a clean wound that heals readily, instead of a ragged tear through bruised tissue. The cut is high enough to be free from the constant bath in infectious lochia, which troubles the healing of the usual perineal laceration. Fig. 102.—Episiotomy. (Ilammerschlag.) Rectal Infusion (Drop Method).—A douche bag con- taining normal saline solution is hung near the bed and kept warm with an electric pad, a hot flatiron, or by a hot water bag on either side. The tube ends in a cathe- ter which is inserted into the rectum. The tube is clamped so that only a drop of solution can escape each second. 230 OBSTETRICS FOR NURSES Wet packs are both sedative and antipyretic and may be employed for a local or a general effect. For bronchitis the pack may be applied to the chest only as follows: The child (or adult) is stripped in a warm room (75° F.) and the chest swathed front and back with a thick towel wrung out of hot water (tem- perature 105° to 110° F.) Over this a woolen shirt may be drawn or a blanket wrapped, and the patient put to bed. After six or eight hours, the dressing is removed in a warm room, a hot bath administered, and the body well rubbed with alcohol, and dried. The treatment may be repeated if necessary. Do not burn the patient by applications too hot. The general pack is most serviceable in reducing tem- perature and producing a diaphoresis to relieve the kid- ney and cleanse the system, as in eclampsia. For this purpose the entire body, naked, is rolled in a sheet wrung out of hot water and then put between heavy blankets in bed. The pulse should be taken frequently and the temperature recorded at intervals. A cool ap- plication to the head is very soothing. The patient sweats profusely and hot drinks may be given to promote a more abundant diaphoresis. Usually the patient drops off to sleep as the fever subsides. Twenty to forty minutes is the average duration of such a treatment. When the pack is removed, the patient is wrapped at once, without drying, in warm blankets, and left for an hour or so. CHAPTER XIV COMPLICATIONS IN LABOR Pelvic contraction is not infrequently the cause o£ difficult or prolonged labor." The deformity is most com- monly due to rickets in childhood. There are many forms of pelvic contraction, hut in this country only two are at all common; the generally contracted, and the flat pelvis. The generally contracted pelvis is, in the main, a well shaped pelvis, only its measurements are smaller than normal. The flat pelvis is marked by a shortening of the an- teroposterior diameter of the inlet. It looks as if it had been pressed together from before backward while in a soft condition. These and other deformities will be recognized in ad- vance of labor by the routine application of the pelvi- meter. • The value of this instrument is so great, that no com- petent man does obstetrical work at the present time without using the pelvimeter as a routine. The average diameters in normal pelves may be tab- ulated as follows: Interspinous—between the anterior superior iliac spines—25 cm. Intereristal—between the iliac crests—28 cm. External conjugate—taken from the upper border of the symphysis to the depression below the last lumbar vertebra—20.5 cm. Take 9.5 cm. from this to get the true conjugate. 231 232 OBSTETRICS FOR NURSES Fig. 103.—Various forms of pelvic deformity compared with the normal inlet. (Bumrn.) The circumference of the hips just below the iliac crests and above the trochanters—90 cm. It is taken with a tape line. These are the usual external measure- ments. The internal measurements are made with the fingers. The diagonal conjugate is the distance from the lower COMPLICATIONS IN LABOR 233 Fig. 104.—The pelvimeter. Fig. 105.—The various diameters of the inlet with the length given in centimeters. (Williams.) 234 OBSTETRICS FOR NURSES border of the symphysis to the promontory of the sa- crum. It should measure 12.5 cm. The first and second fingers are passed into the vagina and pushed up until the tip of the second finger touches the promontory of Fig. 106.—Measuring t.lie distance between the anterior superior spines of the pelvis. (Williams.) the sacrum. The finger of the other hand marks the depth of the examining fingers just below the sym- physis. The distance is measured when the finger is with- drawn, and 1.5 cm. is subtracted. The result is the true COMPLICATIONS IN LABOR 235 conjugate. These measurements carefully made and the deduction judicially estimated, give one a fairly ap- proximate idea of size and shape of the pelvic inlet. The aim of nearly all the pelvic measurements is to get Fig. 107.—Measuring the external conjugate. (Williams.) not only the size and shape of the inlet, but so far as possible, a working estimate of the anteroposterior diam- eter of the brim, which is the most important of all the diameters. In normal cases this should be 11 cm. 236 OBSTETRICS FOR NURSES Thus, taking 9.5 cm. from the external conjugate (20.5 cm.) gives 11 cm. Subtracting 1.5 cm. from the diagonal conjugate as obtained with the fingers as above described, (12.5 cm.) gives 11 cm. The subtraction is made to compensate for the thickness of the pubic bone and its inclination outwards. A circumference of 90 cm. corresponds to an inlet of Fig. 108.—Measuring the diagonal conjugate with the finger. (Eden.) 11 cm. in its anteroposterior diameter, and every varia- tion of 5 cm. in this circumference makes a difference of 1 cm. (either larger or smaller) in the anteroposterior diameter. Thus, 95 cm. in circumference=12 cm. in the diam- eter; and 85 cm. in circumference = 10 cm. Complications increase in proportion to the degree of contraction in the pelvis. The most frequent difficulties superinduced by the COMPLICATIONS IN LABOR 237 small pelvis are prolapse of the cord, malpresentation and malpositions of the head, prolonged labor, and a large increase in the number of assisted deliveries. All the possibilities and probabilities in a given case Avill be carefully worked out before labor by the con- scientious obstetrician, and Caesarean section, induction of premature labor, pubiotomy, forceps, or version and extraction, will be done with a sure foreknowledge. Prolapse of the cord complicates labor once in about two hundred cases. It is most likely to occur when the presenting part does not enter or does not entirely fill the opening, as in transverse or shoulder presentations, or vertex presentations with small inlets. The mother is not endangered by this mishap, but the babe is lost in from 35 to 60 per cent of the cases. The diagnosis is easily made when a loop of cord pro- trudes from cervix or vulva, and the pulsation will dif- ferentiate it from everything else. If the cord does not pulsate, the family should be in- formed that the child is dead and the case may be al- lowed to terminate normally. If it still pulsates, the woman should be placed in the knee-chest position for ten or fifteen minutes, then upon the side, opposite to that on which the cord has prolapsed, and back again as soon as possible to the knee-chest position. A chair may be used to produce a Trendelenburg position by placing it so that the edge of seat and top of back rest on the bed. Then the patient puts her legs over the lower rungs and lies with her back against the chair back and her head on the bed. If the cervix is effaced and the os partly dilated, re- position may be attempted either with the finger or a male catheter. 238 OBSTETRICS FOR NURSES The operation will, of course, succeed most easily if done in the knee-chest position, with gravity to aid. If the cord can be pushed back, a Voorhees bag may be inserted to keep it from coming down again. This holds back the cord, dilates the canal and stimulates the pains. When the bag comes out, version and extraction can and should be done at once. In genera], the following summary may be useful: Causes.— Contracted pelves. Breech and transverse presentations. Malposition of head, or face and forehead presentation. Hydramnios. Accident. Low insertion of placenta. Diagnosis.— Before rupture of membranes careful examination will show pulsating cord in advance of head. After rupture the cord may be felt in vagina. Dangers.—• To mother:—None but those due to causative condition. To child:—Compression of the cord and asphyxiation. Contraction of exposed vessels of cord. Patient may lie on cord. Twenty-five per cent die as a rule under best conditions. Fifty per cent when left to nature. Treatment of Cephalic Presentation.— Extraction of child or reposition of cord, depending upon the degree of dilatation. If cervix is small, replace and fill cervix with Vorhees bag. ben cervix admits hand, either replace or do version and extraction. With head engaged, reposition or version is not possible. Child living:—Rapid delivery with forceps. Child dead:—Craniotomy or leave to nature. Prolapse of one or both hands may take place. If the head is engaged, no interference should be attempted. If not, replacement or version may be done. Prolapse of Cord COMPLICATIONS IN LABOR 239 The soft parts may also complicate the labor process. No time need be spent here on the rarer forms of ob- struction due to uterine or ovarian tumors. Rigidity of the cervix, or os is not uncommon. This may be due to a dense, almost cartilaginous con- sistence of that tissue, to premature rupture of the bag of waters, to weak, inefficient contractions in the first stage, or to a steel-spring-like contraction of the mus- cular fibers of the os. In all cases the first stage of labor is greatly pro- longed, but so long as the membranes are intact, the child is in no danger. Two kinds of eases are met with, those in which the pains are violent, and those in which they are weak and shallow. In the first class, as soon as the condition is recognized, a dose of morphine sulphate, 1/6 gr. and scopolamine hydrobromide 1/150 gr. should be given hy- podermically. The rigid ring relaxes under the influence of the narcotic, and labor proceeds rapidly and almost painlessly. Chloroform may be substituted if the mor- phine and scopolamine are not at hand. If the cervix is effaced and only the rigid ring of the os prevents the completion of the labor, or if the above methods fail, then the patient may be anaesthetized and the rigidity overcome by the fingers. This is an emergency that should not be attempted until all else has failed and some danger arises that makes it necessary to hasten the delivery. (See Minor Operations, p. 228.) Where the constriction is due to unusual density of the cervix or to cicatricial tissue, it is sometimes neces- sary to make incisions under aseptic precautions so that the rigid ring may expand. Weak and inefficient contractions can sometimes be 240 OBSTETRICS FOR NURSES stimulated satisfactorily by the introduction of a Voor- liees bag. Rigidity of the pelvic floor may be due to inadequate elasticity of the tissues as in old primiparas or in young women who have ridden horseback for many years in the cross-saddle position. The head may come down to the pelvic floor but will not advance further. If the tissues of the vulva do not, or can not yield sufficiently after appropriate time has been allowed, episiotomy may be done. (See Minor Operations, p. 228.) The uterus itself may functionate abnormally. Precipitate labor is an over rapid advance of the child wherein the stages of labor are merged into one another and the child expelled in tAvo or three pains. It may be due to unusual capacity of the pelvis, or to strong contractions which the patient is not aAvare of, or both. These cases predispose to post partum haemorrhage and to serious lacerations of cervix and perineum. The child is usually delivered in an undesirable place, such as a toilet basin or a street car, and perishes from the fall, from cold, from umbilical haemorrhage, or lack of facilities for revival. The nurse who is Avatching a case is responsible for the prevention of a precipitate. If the event impends, the woman must be placed upon her side Avith legs straight, and she should be instructed to cry out Avith every pain. Chloroform may be given and the head forcibly held back. Uterine Inertia.—A sluggish state of the uterus may characterize the labor and the contractions Avill be sIoav, shalloAV and inefficient. The intervals may be pro- longed, although the patient complains bitterly of pain. COMPLICATIONS IN LABOR 241 The condition is seen most frequently in multiparas and is due to defective innervation of the uterus or to im- perfect reflexes, and in primiparas also it may be due to the newness of the function that is suddenly called into play, or to contracted pelvis. Many times the trouble results from overfatigue and want of sleep. If this is the case, the remedy may be found in the administra- tion of morphine sulphate 1/6 gr. and scopolamine 1/150 gr. The pains are diminished or abrogated while the contractions continue. The scopolamine may be re- peated if necessary. Under proper indications and con- ditions this treatment is harmless, both to mother and child, but requires supervision on the part of the nurse or physician. If the patient is not overly fatigued, the introduc- tion of a Voorliees bag, as described under the head of Induction of Labor (p. 225) will dynamically increase the strength and frequency of the contractions, mechan- ically aid the effacement of the cervix and the dilata- tion of the os, and shorten the first stage anywhere from six to twelve hours. As soon as the os is dilated, pituitrin may be given under due precautions, as hereafter indicated. Pitui- trin has but little influence on the nonfunctionating organ, but acts well on a uterus which is definitely con- tracting. It should not be given during the first stage, since when the uterus contracts, there must be an ade- quate opening for the advance of the child. Five to seven minims is the usual dose, injected into the deltoid muscle. The injection may be repeated in an hour, if required, since the effects, which begin about five min- utes after the injections, will pass off in fifty-five minutes. By the use of pituitrin many operative procedures are 242 OBSTETRICS FOR NURSES altered or avoided. A high, forceps case may be con- verted into a case for the low instruments, and the latter in many instances avoided altogether. The use of pituitin may be briefly summarized as fol- lows: Pituitrin (Use no alcohol to cleanse syringe or skin before injection.) Indications.—• 1. Inertia uteri or weak, shallow pains in second stage. 2. Multiparity. 3. Post partum haemorrhage. 4. To avoid use of forceps or to reduce a high forceps case to a low one. 5. Caesarean section. If the patient is a multipara, sterile linen should be on and attendants ready for the delivery before an injection is given. Conditions.— 1. Cervix effaced. 2. Os admits three fingers. (Better if membranes have rup- tured.) 3. Head should be engaged. 4. No mechanical obstacle to delivery such as tumors or markedly contracted pelvis, etc. Dangers of Long Labors.— Compression of cord. . . ( Vesicovaginal fistula?. Necrosis of maternal tissues, -j Eectovaginal fistulfe. Infection—peritonitis. Necrosis of skin over skull. Necrosis of cranium. Fracture of skull. Death of child. Maternal exhaustion and prolonged convalescence. Premature rupture of the membranes not infrequently occurs from over-distention, when twins or hydram- nios is present, or at any stage of the pregnancy when the membranes are weak. The liquor amnii flows off, COMPLICATIONS IN LABOR 243 not all at once, but after the first gush by intermittent discharges, depending on the painless uterine contrac- tions and the accuracy with which the head fits the pelvis. Labor usually comes on in from twelve to forty- eight hours, but it may be postponed for a month. The labor is sometimes more painful and prolonged on account of the absence of the fluid wedge and the generous lubrication of the channel which is supplied by the liquor amnii. This is called “dry birth.” The danger of infection of the amniotic cavity with con- sequent death of the child is always to be apprehended after the escape of the liquor amnii. Also the foetal parts may prolapse and complicate the labor; or if the cord comes down, the child may be imperiled by its com- pression. If near term, the rupture of the membranes is not of great importance though the case must be watched atten- tively. Daily observation must be made of the foetal heart tones, the amount of liquor amnii flowing away, and the presence or absence of infection. If labor does not determine in a few days or if the heart tones rise above 160 or go below 120, labor must be inaugurated. (See Induction of Labor, p. 225.) Rupture of the uterus is the most serious accident that occurs in labor. It happens about once in three thou- sand confinements. The tear is usually in the lower part of the uterus and follows a prolonged period of labor, where the child is in a tranverse presentation, and, therefore, impossible to deliver, or the pelvis is too small or the child too large. It may also follow ill- advised or unskillful efforts to change the presentation by the introduction of the hand into the uterus. Occa- sionally rupture is produced by external violence, such as blows or kicks upon the abdomen. 244 OBSTETRICS FOR NURSES It is imperative to be able to recognize the symptoms when rupture impends or actually occurs. Signs of Threatened Rupture of Uterus.— 1. High position of the contracting ring—especially its obliq- uity. The contracting ring is a ridge-like formation that may be found running across the anterior and lower por- tion of the uterus. 2. High position of fundus. 3. Tension of round ligaments. 4. Eotation of uterus about its long axis. 5. Tenderness to pressure of lower uterine segment. 6. Contractions persistent with no pain-free interval. Signs of Actual Rupture of Uterus.— 1. Hemorrhage is one of the earliest and most significant signs, and may be either external or internal. 2. Cessation of uterine contractions either abruptly or gradually. 3. Extreme pain felt by patient. 4. Eecession of presenting part. The patient gives a sharp cry and lias the feeling that something has given way. Signs of shock rapidly super- vene. A predisposition to rupture may be present from the scars of a Ciesarean section, uterine tumors, and de- generation of the muscle. The treatment depends upon the degree of the injury, and if investigation shows that the uterus has opened into the abdominal cavity, immediate laparotomy is done. In other cases, the morcellation and removal of the child by the natural passage may permit the use of a uterine pack and avert the necessity for an abdo- minal operation. The child is usually dead and need not be considered. CHAPTER XV COMPLICATIONS IN LABOR (Cont’d) Vomiting’ in labor frequently occurs near the end of the first stage. It is due to the sympathetic excitement of the nerves of the stomach as the last fibers of the os uteri give way. It requires no treatment. Ilyperemesis in labor is very rare, but when it does occur, the delivery should be expedited. Haemorrhages may occur either before, during, or after labor. Haemorrhage is always serious. Haemorrhage before labor arises either from a pre- mature detachment of a normally implanted placenta or from placenta praevia. The first is sometimes called “accidental haemorrhage” to distinguish it from the latter, or “unavoidable haemorrhage.” Accidental haemorrhage may be the result of an in- jury or a blow, but in many cases, there is no such his- tory. The haemorrhage is most frequent in the later months of pregnancy, and may be without any apparent cause. The haemorrhage may be entirely inside the uterus (concealed haemorrhage) or it may appear ex- ternally. The haemorrhage, when concealed, takes place back of the placenta or between the membranes and the uterine wall. If the haemorrhage is concealed, it is usually followed by an attempt to expel the child. If the haemorrhage is pronounced, systems of shock appear. The diagnosis is made by the symptoms which are summarized in differentiating this condition from placenta praevia (p. 246). 245 246 OBSTETRICS FOR NURSES From this affection, nearly all the children and half the mothers die. When the haemorrhage is external and slight, the treatment may possibly be expectant for twelve hours, if carefully watched, but usually the symptoms become so serious that immediate emptying of the uterus is required either by the Voorhees bag, digital dilatation, version and extraction, or Caesarean section, the method Fig. 109.—■'Various forms of placenta praevia compared with normal attach ment of the placenta. (American Text Book—Williams.) chosen being dependent upon the amount of the haemor- rhage, the vigor of the mother and the condition of the cervix, os, pelvis, and child. Placenta praevia is the name given to a placenta that is attached low down in the uterus so that its margin or a large part of its mass overlies the os. This hap- pens through the action of the egg which embeds itself COMPLICATIONS IN LABOR 247 too far down on the endometrium—too close to the cervix. Three different kinds are known and named from their manner of encroaching on the os, as marginal, partial, or central implantation of the placenta. The haemorrhage is from a loosening of the placental attachment owing to the stretching and growth of the uterus. There is only one symptom of placenta prcevia—sud- den, painless, causeless hcemorrliage. The bleeding seldom appears before the twenty-eighth week, and no suspicion of a placenta praevia may arise before the ap- pearance of haemorrhage, which, as a rule, is soon re- peated. Labor frequently comes on prematurely and malpre- sentations naturally result from the inability of the pre- senting part to fit itself into the pelvis. There is no bag of waters, hence the first stage is longer and bloodier and fraught with much danger. Interference is regularly indicated to save the life of the mother, while the child also has a high mortality. Puerperal infection is not uncommon. Placenta praevia is always an emergency. If the pa- tient can be kept under observation in a good hospital, one may temporize, but under other conditions the uterus must be emptied at once, even if only a single haemorrhage has developed. The indications are, (a) to control the bleeding, and (b) to empty the uterus. The life of the child must be disregarded and the mother alone considered. If the contractions have not begun, they should be stimulated by the introduction of a Voorhees bag, which, at the same time, dilates the canal and mechanically shuts off the bleeding vessels by compression. In in- 248 OBSTETRICS FOR NURSES trodueing the bag, the membranes may be ruptured so the bag will pass into the uterine cavity. When the implantation is central, the finger must tear a hole through the placenta, and through this opening pass the bag inside the uterus. If the os is partially dilated, version may be done, and a foot brought down. The leg may then be pulled upon until it compresses the bleeding area and the traction maintained with a slowly developing pressure sufficient to check the haemorrhage, until dilatation is advanced enough for delivery. Occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. 220.) Caesarean section may be done in the interests of the child, as well as the mother. The foetal mortality in placenta praevia is said to be 60 per cent and the maternal 10 per cent. Differential diagnosis between Accidental haemorrhage and Placenta prcevia Usually occurs in later months. May be concealed or open. Soon followed by labor pains. Uterus becomes larger if bleed- ing is concealed. Uterus hard and woodeny. In severe cases, signs of shock whether hemorrhage is ex- ternal or internal. No placenta can be felt. Haemorrhage continuous. No history of previous attack. No contractions after labor be- gins in serious cases. No bogginess of cervix. Any time after the twenty- eighth week. Always open and external. Labor need not occur. Uterus remains same size. Uterus, normal consistency. In severe cases, signs of shock follow the invariable external haemorrhage. Placenta can be felt through the os. Haemorrhage intermittent. Possibly history of previous at- tack. Contractions as usual. Cervix boggy. COMPLICATIONS IN LABOR 249 Haemorrhages may occur during labor from retention of the major part of the placenta while a portion is detached. This may he due to pre-existent disease, such as endometritis, or from uterine inertia. Normally the placenta will separate and he discharged within an hour after labor and in the absence of haemor- rhage it may go even longer than this with safety. The occurrence of severe haemorrhage, however, requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments. Post partum haemorrhage includes all haemorrhages that occur after the delivery of the placenta. The “flooding” as it is called by the laity, is most apt to come on either immediately or within an hour or so after labor. If it comes on after the first twenty- four hours, it is called secondary haemorrhage. Such predisposing causes as over-distention from twins may be present, but the haemorrhage may follow a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour. There are four causes for post partum haemorrhage: namely, (a) uterine exhaustion (atonia uteri) ; (b) mechanical obstacles to retraction, such as clots or re- tention of pieces of placenta or membrane; (c) and lacerations of some part of genital passage, such as the vulva, vagina, cervix, or lower uterine segment; and (d) the systemic condition known as haemophilia. “Bleeders” (haemophilias) are women whose blood lacks coagulability, owing to the absence of fibrin-pro- ducing elements. Post partum haemorrhage is usually an external haemorrhage, but the woman may bleed to death into her own uterus. Besides the external signs, the patient may show the 250 OBSTETRICS FOR NURSES symptoms of acute anaemia, such as the rapid pulse, hurried, shallow respiration, pallor, cold sweat, yawn- ing, dizziness, etc. Nearly all these cases can he saved by prompt recog- nition and efficient treatment. The first step is to grasp the uterus. If the haemor- rhage is due to a tear low down, the uterus may he hard, but generally it is relaxed and requires vigorous mas- sage with both hands before it shows any signs of con- traction. In the absence of the doctor, the nurse must know how to undertake this maneuver. The uterus, after labor and especially when relaxed, is sometimes difficult to identify and the nurse can only make deep massage in the pelvis until the organ responds and its hard globular mass can be appreciated. As soon as the uterus contracts, clots and contained blood are expelled, and in many cases its bleeding ceases at once. (See Conduct of Third Stage, p. 159.) It may be necessary to keep the uterus contracted by manual massage in this way for several hours. As soon as possible, the nurse, or someone whom she directs, prepares a hypodermic of pituitrin—10 to 15 n\. An injection of ergot may follow because its effect is more lasting than pituitrin. Next, a hot douche is made ready and the materials for packing the uterus are as- sembled. When the doctor arrives, he sterilizes his hands, puts on gloves and introduces two fingers or the whole hand into the uterus to remove clots or any retained frag- ments of placenta. The hot intrauterine douche may follow, and if the contraction is not firm and the haemorrhage checked, the uterus must be packed with gauze. If haemorrhage comes from cervix, it should be grasped with long for- COMPLICATIONS IN LABOR 251 ceps, pulled down, and sutured. It from perineum, pack first, and afterward sutures may be introduced. If the patient is exsanguinated, the foot of the bed is raised, coffee given by mouth, camphorated oil hypo- dermically, and normal saline transfused under the breasts. Fifteen per cent aq. sol. of glucose (250 c.c.) given intravenously is valuable in case of shock. Pituitrin may be continued in larger doses. 1 c.c. will raise the blood pressure very definitely. Adrenalin also may be employed for this purpose. The following summary may be found convenient: Post Partum Haemorrhage Etiology, Functional.— Atony of the uterus, especially after rapid artificial or nat- ural emptying of the organ. More common after uterus has previously been greatly dis- tended. Premature version and extraction. Hydramnios and twins. Imperfect development of uterine musculature. Precipitate labors. Haste or improper management of third stage. Etiology, Mechanical.— Retention of placenta—partial, total or solitary cotyledons. Inversion of the uterus. Placenta succenturiata. Inflammation of decidua serotina. Conduct of third stage, i.e., wait until placenta separates. Etiology, Systemic, Haemophilia.—- Kind of haemorrhage. Haemorrhage before expulsion of placenta due to laceration of the soft parts, or Partial release of placenta and failure of uterus to con- tract, or Placenta may be attached to periphery or to one side. Attempts to expel placenta without waiting for uterine con- traction are sometimes productive of haemorrhage. Haemorrhage after expulsion of placenta. Haemorrhage in interval between pains—comes from pla- cental site. 252 OBSTETRICS FOR NURSES Hemorrhage in stream not checked by uterine contraction is due to laceration of the canal. Hemorrhage in abnormal quantities at beginning of pains. Pure atony—comes early. Hemophilia again. Diagnosis.— Palpation of uterus through abdomen. Placental site excluded from contraction (paralysis). View of vulva. Injuries. Flow continuous, fluid and bright red, shows ar- terial origin, probably from cervix. Examine. Atony—bleeding at intervals, clotted and dark. Hemorrhage from a tear begins at once. Uterus contracted and hemorrhage continues. Look for tear. If hemorrhage does not begin within ten or fifteen minutes after labor it is not from a tear. Always have hemophilia in mind. M anag ement.— Third stage must be conducted properly. Before expulsion of placenta—early expression. Credo or manual removal—then secure contraction by mas- sage. Pituitrin, Ergot, or both. After Third Stage.— Eestore an inverted uterus. Eepair lacerations. See that cavity is clear and clean. Massage, intrauterine hot water douche, hand in uterus and hand outside and rub, ergot. Pituitrin hypodermically. Pack uterus with sterile gauze or weak iodoform gauze. Strict asepsis for all intra- uterine maneuvers. Treat anaemia with transfusion, elevation of foot of bed, coffee, external heat, hot rectal enemas, stimulation, bandaging of legs. 15% solution of glucose. Strychnine sulphate, adrenalin, or camphorated oil may be re- quired in usual dosage. Ilypodermoclysis. (See Minor Operations, p. 222.) Sodium cacodylate (2 gr. doses may be given intravenously every third day). After the bleeding stops, the food must be most nu- tritious—milk, eggnog, rich soups, chicken and mutton COMPLICATIONS IN LABOR 253 Fig. 110.—The knee-elbow posture. (Bumm.) Fig. 111.-—The knee chest posture. broths, oyster stew, and beef steak as soon as she can take it. A diet of fluids and stimulating foods that raise the blood pressure will most quickly relieve the symptoms. Eclampsia occurs in the last three months of preg- nancy as a rule, and most frequently just before or during labor. 254 OBSTETRICS EOR NURSES In about one sixth of the cases only, the attack may follow labor. The attack is characterized by violent convulsions, which come on with little or no warning unless the urine has been carefully watched. Fig. 112.—The exaggerated lithotomy position obtained with a sheet sling. (American Text Book.) Fig. 113.—The improvised Trendelenburg position. (American Text Book.) The prodromal symptoms have already been de- scribed under albuminuria in pregnancy (p. 83). The marked features may be repeated for emphasis: per- sistent headaches, disorders of vision, spots before the eyes, blindness, edema of cheeks, eyelids, feet and hands, COMPLICATIONS IN LABOR 255 pain at the pit of the stomach, dizziness, nausea and vomiting and ringing in the ears. Suddenly the con- vulsion occurs, the facial muscles twitch, then the limbs and body are shaken by violent muscular spasms. The body becomes rigid, the tongue protrudes and the face is livid and cyanotic. The spasm usually lasts from one to five minutes and is succeeded by coma that lasts an Fig. 114.—Tlie dorsal position with stirrups. (Dorland’s Dictionary.) hour or more. In some instances there is no return to consciousness before the next attack, which comes on every hour or half hour, though occasionally only one seizure is noted. The blood pressure is greatly increased and the urine is diminished, the temperature rises to 103° or 104° F. When death ensues, it is most frequently due to edema of the lungs or cerebral haemorrhage. The. greater the number of convulsions, the more se- 256 OBSTETRICS FOR NURSES rious the outlook as to life, and it is said that after twenty seizures fifty per cent of the mothers die. Un- der the best treatment approximately fifty per cent of the babies die. Fig. 115.—Dorsal position across the bed. (Bumm.) There is no routine treatment for eclampsia. The principles of management for the attack are (1) to empty the uterus, on the theory that the disease is a toxemia of gestational origin, (2) to eliminate the poison, and (3) to control the convulsions. COMPLICATIONS IN LABOR 257 The albumin in the urine and other eclamptic symp- toms demand urgent attention in prophylaxis. For the pre-eclamptic period (see Albuminuria of Pregnancy, p. 80) a rigid milk diet is indicated. The bowels, kidneys, skin and blood vessels must all be brought into service. In the full blooded patient, venesection may be done and after drawing off ten or twelve ounces of blood, an equal amount of normal saline may be poured into the same vein. Subcutaneous transfusion or the submammary intro- Fig1. 116.—Flexed dorsal position with feet on the table. (American Text Book.) duction of saline solution may be done. The skin is stimulated by hot wet packs and the bowels by saline cathartics and frequent irrigation of the colon. During the attack, the patient must be kept from injuring herself. A spoon wrapped in gauze or a small, long roller bandage should be slipped between the teeth to keep the tongue from injury. The clothing must be loosened or removed. No food, but only water is given by mouth, until the patient is conscious. The convulsions are controlled by morphine, chloral, or both. 258 OBSTETRICS FOR NURSES Morphine sulphate, *4 »r- is given hypodermically, followed in an hour by 30 gr. of chloral by mouth. Two hours later the morphine is repeated and six hours after the first dose of chloral, it is repeated. In this method (Stroganoff’s), four doses of chloral and six of mor- phine are given in twenty-four hours. That is all. When the stomach will not retain the chloral it may be given by rectum in milk. If a general anaesthetic is used, it should not be chloroform, but ether. The labor, if begun, should be expedited by forceps, Fig. 117.—The Sims position. (Kelly.) or version and extraction. Bleeding during delivery should be looked upon as desirable. If more rapid measures of delivery seem demanded and obstacles ex- ist, such as pelvic contraction, imperfect dilatation, or the prospect of a prolonged first stage, Caesarean sec- tion or forcible delivery (accouchment force) may be attempted. If the labor has not begun, when the convulsion oc- curs and a quick delivery by the normal passage does COMPLICATIONS IN LABOR 259 not seem feasible, then the Caesarean operation may be the best treatment. Eclampsia,—Among the latest treatments for eclamp- sia, that of Davidson is the most promising. This ob- server regards the whole process as a toxemia due to the blocking of the renal and hepatic systems. He treats his cases by increasing the fluid intake by mouth. In all varieties of the disease he gives by gavage, every four hours, one quart of water in which twenty grains of pot. acet. (or pot. cit.) have been dissolved. Every twelve hours he adds one or one and a half ounces of epsom salts to the mixture. The woman is delivered as soon as possible. Flatulence is met by pituitrin, eserine salicylate and enemata. CHAPTER XVI THE ABNORMAL PUERPERIUM The practice of obstetrics has many features that are very gratifying to the nurse and physician. Instead of a surgical operation, which has come un- expectedly and undesired; a disaster in which some part of the body is removed or altered by means of a proce- dure associated with extreme pain, mental tribulation and large expense, a much-wished for addition is brought to the family, with pain, to be sure, but a pain that is soon forgotten in the general joy. This is the normal condition that causes the nurse and the doc- tor to rejoice that such a delightful specialty has been chosen. Then comes a case in which the labor may be com- plicated by some dreadful anomaly, or the puerperium burdened or disordered by some unwelcome invasion that tortures the souls of the family and may cost the life of the mother, or child, or both. At such a time the nurse and the doctor feel the full weight of their responsibility, and after a series of anxious days and sleepless nights, they wonder why they did not choose gardening or a clerical position for their life work. The disorders of the puerperium are many and vari- ous, but naturally the breasts and the pelvic organs are most frequently affected. The breasts of the human female are not reservoirs of milk like the cow’s, but a pair of highly sensitive organs that functionate and produce only as the de- 260 THE ABNORMAL PUERPERIUM 261 mand is made. It follows that when the milk comes in, the breasts become engorged and all the neighboring structures are involved in the new process. However, it is not milk that is overfilling the breasts, but serum, lymph and venous blood, which congest the tissues surrounding the glands and produce a hard painful mass. The breasts become heavy, hot, and painful; super- numerary glands in the axillae enlarge, but there is no fever. There is but little more reason for a fever when the mammary gland begins to functionate than when the lungs fill for the first time except in the case of nervous patients who bear discomfort badly. If fever appears simultaneously with the milk, the cause must be sought in some atrium of infection, pos- sibly in the breasts, but usually elsewhere. There is no such thing as “milk fever.” The enlarged glands, the tense mottled skin on which blue veins run visibly here and there, the nipple, flattened and drawn into the swelling, so that the child can not grasp it with the mouth, all produce a sense of disorder that ought to be associated with fever—but is not. This is the “caked breast” of the laity, and if let alone, the hyper- asmia subsides and the function remains. The temper- ature in possibly two cases out of five may rise to 100° F. for twenty-four hours, but it promptly sub- sides. These temperatures generally occur in neurotic women. If the breasts are irritated by binders, breast pumps, or massage,—like the blacksmith’s arm, with exercise— the trouble, if not increased, is at least much slower in disappearing. It is reported that the young virgins of some African 262 OBSTETRICS FOR NURSES tribes nurse the babies in the family, the breasts being stimulated to produce milk largely by massage. If the condition of the breasts becomes too painful, the liquids by mouth are reduced to the last degree, saline cathartics are given until frequent watery stools result, one or more ice bags are applied to each breast and codeine sulphate may be given at night. The child nurses every four hours only. Williams was the first to show that no tight binder is necessary, but only a support- ing bandage. The tight binder is a cruel and useless bar- barism that has been abandoned by progressive physi- cians. No massage is allowed; no pumps; no irritation whatever, and in twenty-four hours the trouble has dis- appeared. Hot dressings to the breast are equally ar- chaic. They should never be applied to any breast unless it is desired to hasten suppuration. If the child dies, or for any reason can not nurse (inverted nipple, cleft palate, harelip) and it becomes necessary to dry up the milk, the treatment for “ caked breast” is continued. After twenty-four hours the breasts are comfortable and rarely give trouble again. Cracks, Fissures and Abrasions of the Nipple.—The care of the nipples should be inaugurated about six weeks before labor, as elsewhere described: The nipple must be inspected and its possibilities determined, early in pregnancy, if possible, for many varieties of badly shaped and ill-developed nipples ex- ist which may make nursing difficult or impossible. Imperfect nipples especially are predisposed to fissure and crack, and will require extreme care on the part of the nurse. She should inspect them before and after each nursing and sedulously use cleanliness and asepsis in her management. In normal and tranquil as well as in neurotic women, the nipple may become so sore THE ABNORMAL PUERPERIUM 263 as absolutely to preclude nursing, and this entails much additional work on the nurse and mother, as well as considerable peril for the child. The condition usually begins as a fissure or crack, and is accompanied by much pain. It is serious, furthermore, in another aspect since all breaks in the surface of the nipple are avenues of infection that may result in mastitis. The Fig. 118.—Examples of imperfect nipples. (American Text Book.) child may produce fissures or abrasions by rubbing the nipple with his mouth, by pulling too hard, or by the habit of holding it in his mouth and macerating it with his gums when he has finished nursing. The child must not be left at the breast after he has nursed, but the nipple should be gently removed from the child’s mouth by passing one finger in beside the nipple. Fissures and abrasions usually occur within ten days if at all. Abrasions or erosions are due to 264 OBSTETRICS FOR NURSES the wearing away of th,e epithelial covering of the nipple in patches more or less extensive. Thin-skinned blonde women suffer more than those with dark, dense oily skins. A fissure is a distinct separation of tissue that goes deeply into the underlying substance. A crack is a long abrasion which may deepen into a fissure. Both fissure and crack may affect the top, the side of the apex, or the base of the nipple. They may be either longitudinal or circular. The entire nipple must Fig. 119.—A standard nipple shield. (American Text Book.) be kept under observation and the instant a raw sur- face is detected, treatment must begin. Compound tincture of benzoin, liberally applied, is a favorite and successful remedy. Our routine is to ap- ply a paste made of equal parts of castor oil and sub- nitrate of bismuth. This is put on after the child nurses, and must be removed carefully before the next nursing. Sometimes the child’s stools become black and consti- pated and the trouble may be traced to imperfect re- moval of the bismuth preparation. THE ABNORMAL PUERPERIUM 265 Whatever medication is used, the nipple must be protected from injurious friction by the clothing. This is best done by the hat-shaped lead nipple shield, which is placed over the nipple and held in place by a light binder. The shield should he boiled before use. To protect the nipple during nursing, a glass shield may he used for a day or so, but not long enough for the babe to get accustomed to it, else he will form a habit hard to break. This shield must be taken apart after use, washed and kept in saturated solution of boric acid until the next nursing. If all these measures fail, the fissure must be touched with a nitrate of silver stick once, or have a 2 per cent solution of nitrate of silver applied night and morning. It may be necessary to take the child from the breast for a day or so, in which case he nurses the other breast and the side with the bad nipple is pumped. The care of the nipple is highly important since the apprehension and the actual pain of each nursing may prevent sleep, destroy the appetite, and diminish the milk. If begun early, most fissures will heal in twenty- four to forty-eight hours. Mastitis.—From three to five per cent of lying-in women have mastitis in the European clinics, but the records in America show a much smaller number. The disease occurs most frequently in blondes and in primiparas. It is most apt to appear during the first two weeks, when the congestion accompanying the new mammary function produces a stasis that favors the growth of germs, which may enter through the abrasion or fissures of the nipple produced by zealous activity of the child’s gums. But it may also occur when the child’s first teeth come and the nipple is again exposed to in- 266 OBSTETRICS FOR NURSES jury. At times it is impossible to find a plausible excuse for its occurrence. Mastitis is usually described in three forms: The (a) parenchymatous or glandular type, which affects the substance of the gland or the enveloping connective tissue; in (b) subcutaneous mastitis the connective tis- sue beneath the skin is attacked; and in (c) the sub- glandular variety, the infection finds a lodging between the gland and the chest wall. Mastitis is always due to the presence of micro- organisms which in many cases gain access to the gland through fissures or abrasions by means of the lym- phatics. In other instances the germs may be in the blood and a local stasis may encourage the infection. Still again, they seem to enter through the normal nipple openings. Symptoms.—The parenchymatous inflammation begins with a chill, and the temperature promptly rises to 102° to 105° F. The pulse is high. The patient complains of headache and thirst. Examination reveals hard, tender nodules in some part of the gland. The skin may or may not be reddened. If the trouble has begun in the connective tissue, the skin will be diffusely reddened, the nodule ill- defined, the temperature will rise gradually and the chill may be absent. Treatment.—The breast is put at rest. No tight binder is applied, no breast pump, no massage. No heat is allowable. Ice bags surround the gland night and day. The liquids by mouth are restricted and saline cathartics given. Codeine may be administered for pain. Usu- ally the symptoms subside without suppuration in from one to tAvo days. THE ABNORMAL PUERPERIUM 267 Should the inflammation persist for more than two or three days, in most eases the tissue will break down and form a mammary abscess. When it is evident that suppuration has begun, heat may be applied to the gland and the process accelerated. The abscess may be superficial or deep and will be diagnosed by a bog- giness in a circumscribed area or by fluctuation. The abscess must be opened as soon as possible. The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol solution and cotton sponges are made and sterile gauze for packing. The hands are surgically prepared and rubber gloves worn. If an anaesthetic is required, gas may be used, or chloroform. The incision is made radially from the nipple so as to minimize the injury to the milk ducts. A gauze drain may be required for a few days. In the after-care, the nurse must be scrupulously clean and not convey contagion from the breast to the woman’s genitals, to the child’s eyes, navel or vagina, nor to her own person. Excess of milk is rare, but may be observed for a short time after the glands fill. It seldom requires treatment, but saline cathartics, restriction of fluids, and putting the child on a four-hour schedule will reduce it. Pads may be worn if it runs away freely. Scarcity of milk is only too common. There may be enough at first and the quantity gradually diminish, or it may be deficient from the very beginning. The faulty secretion may be due to the age of the mother, to disease (anaemia), to bad nutrition, or to overwork. It may follow a premature child. Com- pression of the breasts by corsets or tight dresses may prevent development. The amount of gland tissue is very important. Many women have large, fat breasts, 268 OBSTETRICS FOR NURSES but a small glandular development. Mental conditions, such as fright, worry, and anxiety, will diminish the flow of milk or stop it altogether. Symptoms.—The child is fretful, goes to sleep after nursing but soon wakes up, or may nurse awhile, and then finding it useless, will cry and refuse the nipple, lie loses weight and when weighed before and after feeding, the scales scarcely vary. No secretion or very little can be squeezed from the breasts. The child may be given a bottle after which he goes to sleep. Treatment.—When the gland tissue is defective, no treatment can succeed. The appetite must be improved by bitter tonics and the mind relieved of its anxieties, if possible. Change of scenery may help. The fluids must be increased, milk, cocoa, chocolate and gruel must be pushed, and such vegetables added as corn and beets. Oyster stews, clams, lobsters, and crabs will help. The diet must be. full and nutritious Avith especial stress on those foods that raise the blood pressure. A mixed diet con- taining from 2500 to 3000 calories is about ideal. Malt drinks or champagne may aArail in some cases. Exercise in moderation is desirable. Artificial stimulation of the breast sometimes suc- ceeds. Massage Avill irritate the glands, increase the congestion, and promote functional activity; or a Bier vacuum apparatus may be put over the gland several times a day and the air pumped out. The breast should be kept distended for fifteen to twenty minutes. There is difficulty in this country in getting glass bells of sufficient size. Galactorrhcea is the name applied to an abundant se- cretion of milk poor in quality toward the end of a long lactation or after the child is Aveaned. The symp- THE ABNORMAL PUERPERIUM 269 toms are an almost constant flow of milk with resultant antemia. Treatment.—Elix. of iron, quinine and strychnine with compression of the gland. A dry diet and the avoidance of all irritation of the breasts will aid. To “dry up the milk,” follow the treatment for “caked breast.” Quality of the milk may be such that the child will not take it or, if taken, it fails to nourish. In some cases this is due to overlong, or to irregular, periods between feedings; for when the nursing interval is too Fig. 120.—A standard breast pump. (American Text Book.) short, the milk becomes too rich, when too long, it becomes thinner and less nutritious. Fright, anxiety or anger may change the character of the milk so that colic, vomiting, and diarrhoea and indigestion are produced in the child. A wet nurse be- comes homesick and the milk dries up. It may become extremely indigestible, as shown in cases where a wet nurse quarrels with her husband and her foster child develops green stools. If the mother’s milk does not agree, the child may be put on feedings for twenty- four or forty-eight hours, while the milk, pumped from the breast, is sent to a laboratory for analysis. If a 270 OBSTETRICS FOR NURSES return to the breast is unsatisfactory, artificial feedings or a wet nurse must be supplied. Removal of the child from the breast may be re- quired for a variety of reasons. Thus, the mother’s ad- diction to alcohol or opium is good ground for taking away the child. Arsenic, bromides and iodides of potas- sium, saline cathartics, salicylates, alcohol, opium and bel- ladonna must be given to the mother with great caution during lactation, for they pass over into the milk. Acute diseases, such as erysipelas, pneumonia, diph- theria, typhoid, malaria, pronounced puerperal sepsis or persistently high fever from any cause, usually dries up the milk; while cardiac lesions, unless well compen- sated, chronic anaemia and tuberculosis, obviously de- mand the removal of the child for the sake of both. Sometimes a new conception, especially when the milk becomes poor in the last half of gestation, compels the mother to wean her babe. A syphilitic woman may nurse her own child, pro- vided her condition is good and the child also is syph- ilitic. Theoretically, the return of menstruation in no way affects the nursing child, unless the blood is lost to the point of anaemia. Yet cases do occur in which the child has indigestion, colic and bad stools, as well as loses weight, when the mother is menstruating. The quality of the milk is sometimes altered, but only for a day or so, and the child should continue at the breast unless some definite indication for removal arises. Weaning ordinarily is completed by the ninth month, but the child should never be carried beyond the twelfth month on account of changes in the character of the milk. THE ABNORMAL PUERPERIUM 271 When a child is weaned, the substitution of an arti- ficial food may be made gradually,—a bottle a day, two bottles a day, etc., until, in a couple of weeks, the breasts are at rest. The excessive prolongation of lactation is shown upon the mother by impairment of the health. The patient is pale, weak, anaemic, fretful, and thin. Head- aches, dizziness, loss of appetite, and constant fatigue will be complained of. The treatment is to remove the child at once and put the mother on stimulating drugs and foods. A change of air and scenery, if possible, will be highly beneficial. The wet nurse is always a tribulation, which must be endured until the child can be put on artificial food. She should have a Wassermann test before entering upon her duties. Syphilis, tuberculosis, and gonorrhoea must be guarded against. She must be kept like the family cow, in a placid frame of mind, fed on nutri- tious food that is not too rich, and exercised enough to keep the blood circulating. Light housework and duties that take her out of doors part of the time are advisable. Her moral char- acter can only be assured through those who have known her. If she brings her own child with her, she will need watching to provide for an equable distribu- tion of the milk. The first few days is never a criterion of a wet nurse’s effectiveness. Change of food and surroundings may interfere with her usefulness. Gas may complicate the puerperium after Caesarean section, and even after normal labor. A rectal tube of soft rubber may be passed as high as possible into the bowel and left for some time, or enemas of S. S., tur- 272 OBSTETRICS FOR NURSES pentine, asafoetida, or milk and molasses may be given. By mouth calomel or mag. cit. is valuable. Headache in the puerperium should be watched care- fully, and the cause discovered. Pain in the head may be a habit with the patient, or it may be a symptom of some complication either present or developing, such as toxaemia, eclampsia, or acute yellow atrophy of the liver. In general, it is due to milder conditions like exhaustion, too many visitors, excitement, nerves, or insomnia. After-pains.—Sometimes patients are greatly annoyed by after-pains. The pain may be due to a clot retained in the uterus or possibly a stimulation of the uterus when the child goes to breast. Gentle massage of uterus, or ergot, quinine, or codeine may be required to bring about the expulsion of the clot or to control the pain. A reasonable degree of after-pain is of favorable sig- nificance. (See p. 170.) Breast Pump.—The breast pump should be used as little as possible and with great care lest it produce a mastitis. If the nipples are too sore to permit of nurs- ing or if the patient will not suffer the pain of nursing, she shonld be informed of the danger of the pump. The responsibility is then hers. It is better to put the babe on artificial food than to use the pump without judg- ment or for long periods. Manual Expression of Milk may be done by nurse or wet nurse. The nipples are washed with sterile water and the patient seats herself with breast convenient to a sterile receptacle. Nurse or patient with aseptic hands expresses the milk by compressing, not the whole breast, but only that part corresponding to the areola. As this is compressed, the whole breast is at the same moment drawn downward and forward. CHAPTER XVII INFECTION Puerperal fever is a wound infection, a filth disease. The conditions of the pelvic organs during labor and postpartum, are well adapted to receive and develop microorganisms, for the healthy antimicrobic power of the vaginal secretion is absent or diminished. A long and exhausting labor, possibly accompanied by haemorrhage, or terminated by an operation, has diminished the immunity and broken the resistance of the tissues to a dangerous degree. The mucous membrane of vulva and vagina are torn and bruised, the vitality lowered, and the surface cov- ered with bloody lochia, which is an excellent nutri- tive medium for microbic development. The uterus is a vast, open wound, filled with fibrin, blood clot, and decomposing tissue, while the whole pelvis is main- tained at exactly the proper temperature for germ propagation. Through these wounds, toxins are carried into the circulation, and germs, nourished upon the abundant and favorable culture media, pass through the uterine walls or by way of the lymph channels first into the adjacent tissues and thence to all parts of the body. Certain definite organisms reach the disintegrating tissues and produce a putrefaction. They do not, how- ever, once their work is done, pass into the body. But in producing putrefaction, they also produce injurious poisons, called toxins, which do enter the body and cause an absorbtive fever known as saprasmia. 273 274 OBSTETRICS FOR NURSES Other organisms are the pus microbes, which begin their growth in any favorable location and continue to spread and flourish onward and inward by blood vessel, tissue or lymphatic, until overpowered by the resistances of the body, or until by general sepsis, they have killed the patient. These are the streptococcus, staphylococcus, bacillus coli and bacillus pyocyaneus. (See Frontispiece.) These are the germs that the nurse or the doctor may bring to the patient on hands, cloth- ing, or hair. These are the organisms against which our scrupulous asepsis and antisepsis is directed. It is against them and their activities that the doctor and nurse prepare by the long and painful scrubbing of the hands and elbows, the rubber gloves, by the shaving and scrubbing of the patient, and by all the paraphernalia and equipment that go to furnish the modern lying-in chamber or delivery room. It is on account of these germs that the conscientious doctor or nurse lies awake nights and painfully reviews his technic when his patient has a temperature, and it is on their account that he shudders at the callous disregard of human life that is shown by those who do not observe the known laws of asepsis. It is true that many women escape when the attend- ant is unclean, but this is due to a splendid immunity, and in no way absolves the man or woman who neglects his asepsis and has patient after patient running tem- peratures, some of whom are bound to die or be crip- pled for life. It is for this reason that a surgeon should do surgery and not general practice; it is for this rea- son that an obstetrician should limit himself to the care of women in childbirth and not endanger them by taking cases of scarlet fever, erysipelas, and unclean surgery. INFECTION 275 In country practice, all kinds of work must be done since there are not enough men to specialize, but it is inexcusable in the city where a man can always be clean and keep clean, if he is willing to forego the in- come derived from attendance upon septic and infec- tious cases. Any article not surgically clean may contaminate the patient by contact; but ulcers, sup- purating wounds, abscesses, and hands improperly or insufficiently cleaned are the deadliest causes of post partum temperature. Infections are said to be either self-produced or brought to the patient from without. The only organism that is demonstrably self-infec- tious is the gonococcus, which may be present in the vagina before labor and may infect the puerperal woman; but it is wiser, safer, and more nearly accords with the facts, to regard all infections as alien borne, as brought to the patient and introduced by the unclean hands or instruments of her medical attendants. Prevention.—A conscientious and capable nurse or doctor will not go from an infected case to a confine- ment. Both will keep their bodies clean, the teeth filled, and pyorrhoeas scraped and treated. The occur- rence of pus anywhere on the body is sufficient reason for the doctor to give up his confinements for a time, and the nurse to report off duty. No raw, and but few mucous surfaces should be touched by the fingers of the attendants, where a ster- ile instrument can be used. The nurse should never make vaginal examinations unless an emergency exists, and then only when her instruction lias been thorough and her experience great. Every examination is a possible source of danger, no matter how carefully the hands and patient are pre- 276 OBSTETRICS FOR NURSES pared. The nurse is not to change the pads without washing her hands, and she must wash her hands al- ways after changing the pads, before dressing the navel of the child. The navel or eyes of the child may be infected easily by the hands of nurse, doctor, or patient. The breasts of the mother may be infected by the hands of nurse, doctor or patient. The vulva and vagina of the puer- peral woman is highly susceptible to infection from the hands of nurse, doctor or patient. Puerperal sepsis may be prevented almost certainly by observing the following rules: 1. Have environment as aseptic as possible. Take the same care for a labor as for any other surgical condition. This means by preference a clean hospital with sterile linen and instruments. If these conditions are unavail- able they should be imitated as closely as circumstances permit. 2. Initial sterility of hands and instruments. Then keep them so. This means sterile rubber gloves on clean hands and a rigorous technic in keeping them sterile. An aseptic ritual brings salvation to the patient. 3. Render vulva and adjacent surfaces free from all organisms. This means a warm shower bath, evacuation of lower bowel, shaving of genitalia and scrubbing of hips, thighs, genitalia and lower abdomen with green soap and warm sterile water. 4. Do not carry organisms from lower to upper part of genitalia. This means that since the introitus cannot be perfectly sterilized one must use great care to touch the introitus as little as possible and to make no introduc- tion of fingers or instruments, even if clean, which is not definitely indicated. INFECTION 277 5. Keep the uterus empty and retracted by good drain- age. Subinvolution and clots may be corrected and re- moved by the use of ergot, pituitrin and massage. 6. Minimize the bruising and devitalizing of tissue dur- ing labor. Prolonged and obstructed labors result in compression of the soft parts which is followed by de- vitalization and necrosis. Early recognition of the com- plication and its correction will obviate serious injury. Episiotomy is better than a ragged laceration. 7. No Infection from the outside should endanger the woman. This means that the attendants should be scru- pulous about contaminating themselves or of being car- riers of contagion. Asepsis is the law of safety. Rule.—All temperatures arising in the puerperium are due to infection, unless satisfactorily explained by find- ing the source. The possibility of a slightly elevated temperature from insignificant causes may be kept in mind, but such temperatures are transient and yield quickly to appropriate treatment or to none at all. Puerperal infection is most apt to appear during the first week of the lying-in period, and it generally de- velops about the third or fourth day postpartum. If the symptoms come on later than this, there is always a hope that the infection has taken its origin in some- thing else than the labor. Symptoms.—In mild cases, a rapid pulse, headache, and a temperature of 101° or 102° F. may be the only symptoms. Severe cases begin with a chill, followed by a marked rise of temperature. The temperature is al- ways irregular and generally remittent. The pulse rises to 120 or 130 beats a minute, headache and prostration appear, occasionally associated with vomiting. The flow of lochia may be either increased or dimin- 278 OBSTETRICS FOR NURSES ishecl and either offensive or free from odor. Foul- smelling lochia is a sign of putrefaction but not nec- essarily of sepsis. At the same time there is some tenderness in the lower part of the abdomen, usually most marked at the sides of the uterus. The uterus is larger than it should be, and not hard, but doughy and sensitive to touch. The involution is arrested, except in cases of pure septicaemia. This is an important reason for the daily observation and recording of the regular descent of I lie organ. Whatever the point of invasion, the germs will either be confined to local and possibly superficial re- gions by the bodily resistance of the patient or if this is overpowered, the infective agents will extend by lymph channels and blood vessels constantly farther until their course is checked or the patient dies. The disease runs a variable and more or less pro- longed course and the prognosis is always doubtful un- til the event. Signs of grave import are: repeated chills, insomnia, pulse above 120, persistent vomiting and meteorism, with dry, brown tongue. Treatment.—Mild cases without chill when the uterus is large and the lochia sometimes offensive, are usually sapraemic. Free catharsis, ergot in full doses, and a half sitting position to aid drainage will cause the symptoms to subside in two or three days. In the severe type, the treatment is mostly a case for careful nursing. The more energetically the doctor acts, the more liable he is to do harm. The patient needs all her strength to fight the disease, and should not be required to fight the consequences of injudicious interference. Pig. 121.—Diagram to illustrate the position of the lesions in puerperal infection. (Midwifery, by Comyns Berkeley and Fairbairn.) In Yellow.—Primary lesions—the placental site, the cervix or the perinaeum. In Blue.—Local secondary lesions.—Thrombo-phlebitis of the uterine and ovarian veins—pelvic cellulitis—salpingitis—oophoritis and peritonitis. In Red.—Remote secondary lesions—septic pneumonia—pleurisy—peri- carditis—endocarditis,—toxic or septicaemic hepatitis and pyelitis meningitis —cerebral abscess—septic arthritis—abscesses in the subcutaneous tissues. INFECTION 279 There is still some discussion about the advisability of assuring oneself that the uterus contains no remnants of the labor. Some feel that this should be determined by curetting the uterus with finger or instrument and following the operation with an intrauterine douche. If this is the view of the attending man, the nurse must aid, for the responsibility is his and not hers. On the other hand, the weight of authority at pres- ent seems inclined to the view that any remnant of the labor will drain out naturally or be expelled by ergot- driven contractions without the necessity of opening up new raw surfaces by interference and thus spread- ing the infection. The main idea is to promote drainage in every way possible. No curette, no douche, no uterine packing. Nevertheless, the vulva may be cleansed and the vagina carefully retracted and by appropriate means a culture obtained from the uterus. If this shows streptococci, all local treatment is to be abandoned at once. In general, the food must be fluid, and as nutritious as possible. This means milk, beef and mutton broths, oyster stew, etc. The nourishment must be pushed art- fully and ingeniously. Alcohol is not indicated. The bowels are kept open. Normal saline, drop method, by rectum, will pro- mote diuresis, skin action, and supply the body with the much needed fluid. Subinvolution is controlled by er- got in full doses. The room must be light and as many windows opened as the weather will permit. Frequent change of posture, from side to side, from dorsal to prone and especially to the half-sitting position, will give the patient comfort and prevent decubitus (bed sores). The daily bath with an alcohol rub, keeps the skin in good condition and eases the mind. 280 OBSTETRICS FOR NURSES The child should be taken from the breast, because the milk is poor in quality and quantity and it may be infectious. Besides, the mother needs all her strength. Nature usually solves the problem by dry- ing up the milk. All pads soiled by the patient should be collected in paper bags or rolled in newspapers and burned. Sheets, towels, and pillow slips must be boiled in the house and not sent to the laundry. They should be soaked for half a day in a 2 per cent solution of lysol before, being washed, and exposed to the hot sun for a day or so afterward, if possible. No comforts should be used on the bed, and the blankets must be left sus- pended in the room Avhen it is fumigated at the con- clusion of the case. All dishes and utensils can be 1)oiled. Plenty of air and sunshine are essential for the cure of the patient and to prevent the spread of the disease. The nurse must use every precaution to avoid carry ing the infection to herself or others. Rubber gloves should be worn while changing the dressing. It is bet- ter to have the child cared for by another nurse. The nurse must get her rest and some exercise out of doors every day. It rejuvenates her and reacts to inspire the patient. When she leaves the case the nurse should boil her linen and wash her hair with soapsuds and hot water, and bathe frequently. Milk Leg.—This is an infection characterized by swelling of one, or rarely, both, limbs, from the foot to the groin. The leg is white from the edema, and as the condition is associated with fever and since the milk diminishes or disappears about the same time, it was thought in former days that the milk went to the leg. INFECTION 281 The cause of the swelling is a phlebitis of the exter- nal iliac or femoral vein which becomes thrombosed or so filled with clots that the return circulation is impeded. Symptoms.—The attack is signalized by a rise of tem- perature to 102° to 104° F. There is headache, pain in the affected limb, and general prostration. It is a true sepsis. The disease appears usually in the latter part of the second week of puerperium, when the patient has be- gun to congratulate herself that all danger is over. In many cases the doctor has yielded to importunity and let the patient get up before involution was suf- ficiently advanced and the patient will report that she got up too early. The limb must be immobilized and kept warm. The immobility should be maintained for at least ten days after the fever has subsided and the pain gone. The convalescence may be protracted over weeks and months. Bed sores may complicate a long convalescence. Bath- ing with alcohol or alcohol and alum, and the frequent change of the patient’s position will usually prevent them. Rubber rings and sheeting should not be used if it can be avoided. Ointments containing zinc are of great value in the cure of this affection. Phlebitis, in minor degree or in localized sections, may occur in the veins of the leg and the site of the invasion will be outlined as red lines or as irregular nodules. Some fever may attend the condition. Rest of the affected member, with ice bags for the pain, con- stitute the treatment. Bed sores must be guarded against. Sudden death in the puerperium is a shocking dis- aster. Rapid death may follow the complications of 282 OBSTETRICS FOR NURSES labor accompanied by haemorrhage, such as placenta praevia, rupture of the uterus, etc.; but death may be sudden, without warning, from pulmonary embolism, acute myocarditis, fatty degeneration of the heart, or the entrance of air into the uterine veins. This may happen several days after labor in a woman who is passing through a convalescence apparently normal in every respect. Such an event is probably due to a thrombus which may form in any of the veins of the body, but more frequently in those of the pelvis and legs. In the latter it may be recognized by hard lumps that form somewhere along the course of the veins in consequence of a phlebitis. There is always the men- ace that some fragment of this mass, which is merely a hard clot of blood, may become detached and float off in the circulation to other parts of the body, such as heart, lungs, or brain (embolism), and by inter- ference with those structures, produce paralysis or in- stant death. When a thrombus is diagnosed, the af- fected part must be kept as quiet as possible. No massage is permissible. Tincture of iodine or 20 per cent ichthyol may be applied. The woman should re- main quiet for at least ten days after the apparent disappearance of the symptoms. CHAPTER XVIII THE CARE OF THE CHILD Hitherto the mother and the complications and changes peculiar to her condition have been selectively considered, to the neglect of the child; but the labor being over, and the nurse having assured herself that the uterus is hard, that there is no haemorrhage, and that the mother is resting, now turns to the child ly- ing in its blanket. A hot water bag, carefully tested, should lie at its feet wrapped in toweling or napkins. The eyes have already received the Crede treatment, 1 per cent solution of silver nitrate or possibly a 15 per cent solution of argyrol for prevention of ophthal- mia, and a thorough cleansing comes next. In a warm room, away from drafts, the nurse takes the child in her lap, or on a table, with a blanket under- neath. She first anoints the child all over, either with benzoated lard, sterile vaseline, or olive oil. This soft- ens the vernix caseosa that covers the child and aids its removal. The skin is wiped carefully with cotton or a soft cloth, paying particular attention to the folds of the groin, the arm pits, and the genitals. The nostrils are gently wiped out with applicators dipped in oil. The child must be covered as much as possible dur- ing the operation and the work finished quickly. The whole period should not exceed twenty minutes. During the cleansing process the nurse should look closely for anomalies or anatomical imperfections, like an imperforate anus or urethra, supernumerary digits, etc. 284 OBSTETRICS FOR NURSES The Bath.—Daily, until the cord comes off, the baby is sponged with oiled pledgets, followed by a spray bath, or a sponging with lukewarm water and castile soap. The child must not be put into a full bath tub on account of danger of infecting the umbilicus. The bath water in a tub or basin quickly becomes filled Fig. 122.—Rubber bath tub. with bacteria from the surface of the child’s body and may be conveyed quite easily to a raw wound. All discharges must be wiped away, and the buttocks cleansed with oil. If the skin becomes irritated by urine or otherwise, the child should be well covered with talcum powder, especially in the folds of the groin CARE OF THE CHILD 285 and in the genital crease. All infants are benefited by a little mild massage after the bath. If other babies are handled, a child with infected eyes, or skin eruptions, must be quarantined and cared for separately by a special nurse. The color of the skin should be pink, changing under manipulation to red. If there is mucus in the mouth, it may be wiped out with an applicator, if in the throat, the child may be held up by the feet and the head drawn back for a few minutes so that gravity will aid the discharge of the obstruction. After cleansing the skin, the nurse sterilizes her hands and dresses the cord. The gauze which was temporarily wrapped around the stump is removed, the cord and adjacent skin washed with alcohol and dried. The stump is powdered above and at the sides with a mixture of equal parts of boric acid and subnitrate of bismuth, and then Avrapped in gauze. The band is put on, the temperature taken, and the baby dressed. Some physicians prefer to have the cord dressed in 95 per cent alcohol, which is frequently renewed. The normal separation of the cord takes place through a kind of dry gangrene, AAdiich should be favored by dry rather than Avet dressings. The 95 per cent alcohol does not remain at 95 per cent after it is exposed to air, hence it does not absorb moisture from the cord as absolute alcohol Avould. HoAvever, the attending man is respon- sible, and his orders must be folloAved. The Umbilicus.—The cord may be severed as soon as the child has cried lustily or the cessation of pulsa- tion may be aAvaited, in either case the child secures a little more blood, Avhich gives him a better start in life. Tavo tapes are tied about the cord, one close to the 286 OBSTETRICS FOR NURSES skin margin of the child and the cord is cut between them. A kind of mummification or dry gangrene nor- mally develops and the stump falls off, as a rule, about the fifth day, leaving a moist, granulating area, which forms the umbilicus. A metal clamp may be used in place of a tape to com- press the cord. The advantage of the clamp is that on account of its greater width and rigidity it does not cut through the cord when applied. Furthermore, it can be made and kept more nearly aseptic. It does not soak up the juices from the cord and form a culture medium for germs. It can be removed on second day. Fig. 123.—The Pettit cord clamp. The cord usually comes off a clay or so sooner than when the tape is used. The care of the cord is extremely important, as many infections can be transmitted through it to the child. At each dressing the cord is inspected, and whether it is dry or moist, offensive or inodorous, should be noted. These facts, with the falling off of the cord, are put down on the history sheet as they are observed. The binder, after each removal, is not pinned, but sewed on. The sewing should begin below and go up in or- der to have the tightness low down. CARE OF THE CHILD 287 Eyes.—After the first instillation of silver nitrate so- lution, a reaction appears with redness, swelling, and discharge, which passes oft without treatment in two or three days. During the hath, care must be used not to get anything into the eyes nor anything from the eyes or nose upon the navel. At each dressing the nurse should irrigate the edges of the lids gently with boric acid solution. If the eyes become red, swollen, and have a purulent discharge after the second day, ophthalmia must he suspected and they must be watched with extreme vigilance. A smear should be taken for the microscope and prepa- rations made for energetic treatment. The following summary may be of service in memo- rizing the routine of nursery procedure. 1. Keep temperature of nursery 68° to 72° F. 2. During bath, keep temperature of nursery 75° to 80° F. 3. Temperature of bath water 98° to 99° F. 4. Never use a diaper that has not been laundered. 5. Tie case number on child’s arm before leaving delivery room. 6. Watch cord for haemorrhage. 7. Record temperature, stools and urine. 8. Give water freely between feedings. 9. Put to breast twelve hours after birth, and every three hours thereafter until the child begins to gain, then night feedings may be omitted. 10. Change binder daily. 11. Oil bath first, then shower bath on subsequent days. 12. Dress cord with alcohol 95 per cent, dry and apply bismuth subnitrate and boric acid powder, equal parts (or Dermatol) into crevices beneath clamp or tape and under edges of the crust. Change dressing daily. Cord should fall off fifth day. Report failure to do so. 13. Clamp may be removed on second day. Nursery Rules 288 OBSTETRICS FOR NURSES Routine for the Child.— 1. Temperature. 2. Undress. 3. Weight. 4. Shower bath. 5. Dress cord—record condition. 6. Binder daily until discharged. 7. Diaper and dress. 8. Sponge eyes with boric solution. 9. Cleanse nostrils with albolene. 10. Brush hair. 11. Drink of warm water. 12. Observe case number daily. Clothing1.—(See Infant’s Outfit, p. 116.) The cloth- ing must be light, loose, warm, and not irritating to the skin. The outside garment should have wing sleeves which permit free motion of the hands, but do not per- mit them to reach the eyes. The band of plain outing flannel should always be worn for the first few weeks. Birds-eye linen makes the best diapers on account of its superior absorbent qualities. The feet must be kept warm by stockings, and arti- ficial heat, if necessary. On hot days much of the clothing may be removed and the shirt, band and dia- per may be all that are needed. The care of the shirts and bands is part of the daily duty of the nurse. They must be washed daily, either by the nurse herself or under her supervision, as they are easily injured. After washing, in soft water, if possible, and with wool soap, they must be dried on a stretcher. Diapers must be put directly into cold water. Faces may be brushed off with a whisk broom, and the napkin rinsed, boiled and again rinsed. No diaper should be used a second time until this has been done. No bluing may be used on the diapers and the soap CARE OF THE CHILD 289 must be mild, otherwise chafing and intertrigo will follow. The infant’s toilet basket must contain: 4 soft bath towels. 1 pound of absorbent cotton. 1 dozen wash cloths of soft material. 1 small hair brush. 1 pair nail scissors. Talcum powder. Bath thermometer. Hot water bottle. Albolene. Castile soap. 8 oz. boric acid solution. 8 oz. benzoated lard. Paper bags for waste. Pitchers and basins. Fig. 124.-—A, standard breast pump; B, standard nursing bottle; C, the breast tray; D, the Wansbrough lead nipple shield; E, the Brophy nipple for harelip and cleft palate. Weight .—The weighing of the child should precede, for convenience, the first cleaning of tire skin and the daily bath. The child is either put on the scale naked or weighed in a blanket, and the weight of the blanket, 290 OBSTETRICS FOR NURSES ascertained before or after, is subtracted. The daily weight record is just as important as the temperature. A scale that registers ounces and fractions thereof must be used, and the child should be guarded from falling during the performance. Usually the child loses from eight ounces to a pound the first week, but it should gain back to its birth weight, by the end of the second week. If the child does not gain, it may be due to lack of milk from the breast, and the weight may be taken before and after feeding to verify or refute the suspicion. The mouth should be inspected each morning, but not cleansed with the boric acid solution unless def- initely indicated. Spots or any unusual appearance should be reported. The Genitals.—The vulva of the female infant usu- ally requires but little care besides cleanliness. There is sometimes a whitish discharge which disappears spon- taneously in a few days. It is a drainage of vernix, smegma and epithelium from the vagina and labia. With a male, the prepuce must be inspected when the child is about a week old. If it is long and the orifice small, circumcision may be suggested. Under any circumstances, the foreskin must be retracted, the adhesions broken up, and the smegma removed. This must be repeated daily until the adhesions do not re- cur. The maneuver should be done the first few times by the physician, for fear of a paraphimosis. Sleep in the newborn is normally quite deep and al- most continuous, probably twenty-two hours a day, for the first week. The rather fast respiration of the child, even when sleeping, is no cause for alarm. A healthy infant breathes about twenty-five times a minute. The CARE OF THE CHILD 291 child should not be rocked, carried about, exhibited, or handled more than necessary. It should not sleep with the mother, lest it become too hot or too cold, be over- whelmed by bedding, or overlaid by the mother. Bowels.—The first stools are black and tar-like,—this is meconium. It disappears by the end of the first week. The presence or absence and the character of an evacuation, as well as the number in twenty-four hours, must be daily recorded. For a breast-fed child, there should be three or four a day, for the first ten days and the number should gradually diminish until a routine of two a day is obtained. The diaper of bird’s-eye linen should be large and thick; two may be used if required. They should be carefully washed after soiling. Bluing must not be used, because where this substance comes in contact with the skin, irritation follows. Weaning should be brought about by the gradual substitution of other foods, somewhere between the sixth and twelfth months. Urination should be copious. The child is always wet, and frequent changes are necessary to keep the skin from getting raw and sore. Both bowels and bladder should be emptied within the first twenty-four hours. Failure to do so should be reported, as an imperforate anus or urethra may exist. Frequently a piece of ice whittled out like a lead pencil and passed into the rectum Avill stimulate urina- tion. Catheterization is practically never necessary. The child may go three days without injury, but the con- dition of the bladder above the pubes must be atten- 292 OBSTETRICS FOR NURSES tively watched and its degree of fullness appreciated by percussion. Nursing’.—The child should be put to the breast twelve hour’s after birth and every three hours there- after—no more and no less without definite reasons. If the child is strong and vigorous, only one feeding may be given at night, and even this may be omitted in some cases where the child gets an abundance of food. Fig. 125.—Proper position of mother while nursing child. (Witkowski.) Six or seven feedings a day are enough. The child should stay at the breast from fifteen to twenty min- utes, depending on its activity and the rapidity of the milk flow, and then be removed. It must not be per- mitted to sleep at the breast. Care must be used that the child gets the nipple over the tongue and not under it. Many infants have to be taught to nurse. This may be due to a lack of strong animal instinct in many cases. There may be an abun- dance of milk and a good nipple, but the child will not CARE OF THE CHILD 293 learn to nurse without a vast expenditure of time, pa- tience, and energy on the part of the nurse. Squeezing a little milk into the mouth or filling a nipple shield with milk will sometimes aid in educating the infant, or even starting the supply with a pump, as many nurses do, is advantageous. Certain drugs, like castor oil and turpentine, taken by the mother, may affect the taste of the milk, and he reason enough for the refusal of the child to take hold. Other drugs like mercury, arsenic, potassium iodide, and alcohol may go over in the milk to the nursing child. If the child is weak or premature, the milk must be pumped from the breast and fed to it until strength comes. The difficulty about this is the bad habit ac- quired, but there is no way to avoid it. A child should get at each feeding half an ounce of milk to each pound of weight. The capacity of the stomach at various months is given by Hirst as, first week, 1/2 oz.; second week, 2 1/2 oz.; third and fourth week, 3 oz.; third month, 5 oz.; fifth month, 9 oz.; ninth month, 12 1/2 oz. Holt says that the capacity at birth should be one ounce, and increase at the rate of an ounce a month up to the sixth month. As hunger stimulates the gastric and salivary glands, so the sight of the child arouses some emotional cen- ter in the mother, which starts the milk, and the mouth of the child provides an additional stimulus of great power. About fourteen ounces is secreted by the sev- enth day, and after the second month the daily average rises to three or four pints. Milk secretion is favored by drugs and foods that raise the blood pressure and di- minished by substances that lower the blood pressure. 294 OBSTETRICS FOR NURSES There may be too little milk in the breasts, and if so, the child will lose weight daily; also the child will waken before nursing time, fret, refuse water, but greedily seize the nipple if it is presented. It will con- tinue to nurse long after its time is up and cling and cry when removed. The breast itself may seem flabby and loose, and no milk, or very little, can be pressed from the nipple. Fig. 126.—Proper method of taking rectal temperature. Normally, the breasts feel full and tense, both to pa- tient, and nurse, just before feeding time. The real test, however, is in taking the weight of the child be- fore and after feeding. Where the milk is insufficient, the scales will not vary, and after a few repetitions the nurse can be certain. An infant should be handled as little as possible after feeding lest the milk be vomited. Temperature of the newborn child varies from 98° to 99° F. It should be taken morning and evening, or oftener, if complications are suspected. CARE OF THE CHILD 295 The temperature often goes up on the third or fourth day, and may stay up for several days. This phenom- enon is called by some a starvation or inanition fever. The temperature may go to 106° F. and the rise is gen- Fig. 127.—Chart in case of inanition fever. erally associated with a hot dry skin, dry lips, weak pulse, restlessness, and great prostration. The fon- tanelle may be sunken and the cry sinks to a fretful, feeble whine. Objective examination of the child is negative. It is a fever without signs, though the how- 296 OBSTETRICS FOR NURSES els sometimes give off “starvation stools” (thin, slimy, dark brown or green). Strong and weak babies are alike affected. It is important that the fever should be recognized Fig. 128.—Chart in case of inanition fever. and treated. The etiology is obscure. Iti is probably due to one or several of the numerous metabolic changes in the intestine. The fever should not be confounded with pyogenic infections, for these rarely begin before the fifth or sixth day. CARE OF THE CHILD 297 The treatment is simple. Give water regularly every two hours by mouth, and rectal flushings of normal sa- line twice daily. The symptoms rapidly subside if the child is properly nourished. Hence the breasts should be inspected and the child weighed before and after feed- ing. Usually the milk is poor and scanty. If the tem- perature does not soon fall the child should be put to an- other breast or artificial feedings instituted. CHAPTER XIX THE CAKE OE THE CHILD (Cont’d) Heart.—The heart tones while in the uterus may vary between 138 and 150 per minute, but when higher than 160 or lower than 120, danger is near. After delivery, the heart runs from 130 to 140, and during the first year gradually drops to 115, approximately. Asphyxia neonatorum is a condition, wherein, for some reason, the child fails to breathe after delivery. Out of every one hundred babies born, about six will die at birth or within the first ten days, and a large proportion of them from asphyxia in some form. Asphyxia is found in two degrees: asphyxia livida (blue) and asphyxia pallida (white), or shock. In the first, the child is deeply cyanosed. This may be due to patency of the foramen ovale, and yet it is a question whether this cyanosis is not really a normal process. The child does not undertake its first respira- tion because it needs oxygen, but because an excess of carbon dioxide (C02) in the blood acts as a stimulant to the respiratory center, which is thus set to work, with the result that oxygen is taken in. The blue asphyxias, therefore, may be only the first step in the physiological process of respiration. In these cases, the pulse is strong and full, and the muscular tone is preserved, as well as the sensibility of the skin. In the second degree, the condition is quite different. The face is pale though the lips may be blue. The heart is irregular and many times can not be felt. The cord is soft and flaccid, with its vessels nearly CARE OF THE CHILD 299 empty. The reflexes are abolished, the skin and ex- tremities cold. A feAv convulsive efforts at breathing may occur, but they soon cease. Treatment is directed first, to opening up the respira- tory passage. The child is held up by the feet so the mucus, blood, and fluids may escape from the mouth. Compression of the chest Avail Avill aid. The tracheal catheter is passed into the trachea and the mucus sucked out. Next, the skin reflexes are stimulated by slapping the back, or buttocks, and by blowing upon the face. Fig. 129.—Method of passing the tracheal catheter. (Ilammerschlag.) The child at this time may be dipped in a tub of very warm water, (112° F.) and the chest and face sprinkled with cold water. Meanwhile, Laborde’s method of traction on the tongue may be tried. The tongue is seized Avith tongue forceps (handkerchief, napkin, or piece of gauze Avill do) and rhythmically drawn out and released about ten times per minute. Further, the Byrd method of artificial respiration must be employed. 300 OBSTETRICS FOR NURSES The back of the child is held in the right hand, so that the thumb and forefinger grasp the neck loosely, Fig. 130.—Byrd’s method of artificial respiration. Extension and inspiration. (Edgar.) Fig. 131.—Byrd’s method of artificial respiration. Beginning flexion and expiration. (Fdgar.) the other hand holds the buttocks from behind and the body is slowly but firmly flexed between them until the thorax is compressed, then the grip is relaxed and CARE OF THE CHILD 301 the body widely extended to allow the air to rush into the lungs. This maneuver should be repeated about twelve times per minute. When the heart ceases to beat, the child is dead and respiration can not be established. The same treatment is employed for the apnoeic child born in Caesarean section and the oligopnceic child born under “Twilight Sleep.” The method called “Schultze Swinging” is not to be recommended generally, on ac- count of the chilling which is so necessarily associated Fig. 132.—Byrd’s method of artificial respiration. Flexion and com- pression. Note position of child which aids the escape of fluids from the mouth and nose. (Fdgar.) with the exposure. The nurse should learn to practice all these methods of resuscitation. After the child breathes it must be watched carefully for at least forty-eight hours, lest the symptoms recur, and the child die. Asphyxia Neonatorum— (a) Livida—body congested—blue. (b) Pallida—body limp and pale. Remember possibility of patent foramen ovale. 302 OBSTETRICS FOR NURSES Etiology.— Too long compression of cord. Diminished irritability of medulla. Compression of brain during extraction, Shock during version. Aspiration of mucus. Treatment.—• Hold child by heels with head pulled back to straighten the trachea, and wipe out mouth and pharynx gently with cotton wound about the finger. Stimulate skin reflexes by slapping and blowing. Tracheal catheter, artificial respiration (Byrd) 8 to 10 times per minute. Hot and cold bath alternately—rub the skin and knead the muscles. Laborde’s method of traction on tongue 10 to 12 times per minute. Continue efforts so long as heart beats. Convulsions occur not infrequently during the first few weeks. They may develop as a result of injuries to the head during labor, or as a symptom of toxasmia. They may arise from constipation, from intestinal indi- gestion with curds, from fever or from haemophila. Meningitis and other infections are associated with this symptom, and occasionally atelectasis. They may also he the manifestation of a spasmophilic diathesis. The attack may begin with such premonitory phenomena as restlessness, muscular twitching, and staring of the eyes, but more frequently the onset is without warning. The facial muscles are contracted, the neck thrown back, the hands clenched and the extremities spasmod- ically cramped and tightened. There may be frothing of the mouth and consciousness is lost. Respiration is feeble, shallow and irregular. The face is discolored and strange rattling noises come from the larynx. The bowels and bladder may move involuntarily. The at- tack lasts from a few minutes to half an hour. CARE OF THE CHILD 303 Convulsions are not serious in all cases but meningeal haemorrhage must always be suspected. The responsibility for the management of this com- plication usually falls upon the nurse. She calls the doctor, to be sure, but the attacks in many cases have ceased and the child may either be dead or out of danger of a recurrence before his arrival. The hot bath is a universal remedy and quite as effi- cient as anything. The temperature should be taken and the bowels washed out. If the fontanelles are tense when the doctor arrives, a spinal puncture may relieve the tension. A specimen of the blood is drawn through a needle and sent to the laboratory for examination. The cause must be found, if possible, and removed. A change of food may be all that is required. Cod-liver oil may be added to the diet in dram doses, three times a day, and milk curds, suspended in arrow-root water. For the acute condition, chloral hydrate is best. It is given by rectum, one or two grains in an ounce of water, and may be repeated in four hours. Atelectasis is the name given to a failure of the lungs wholly to expand during the efforts at respiration. The condition may arise from prematurity, general debility, oedema or haemorrhages. The child may live for weeks with this affection, but usually it expires within a few days. The child has a constant tendency to get blue, the color deepens, and death may occur in spite of every aid. The treatment may be permanently efficacious in some cases, but in most, the revival is only temporary. Again, the child may live, but in a weakly, declining state for days, until death comes. Aside from the physical signs of dullness elicited by percussion over the lungs and the atelectatic crackling, 304 OBSTETRICS FOR NURSES the most conspicuous symptoms are the cyanosis, the intermittent but persistent whining cry and the shallow respirations. Fig. 133.—Method of giving gavage. (Grulee.) Treatment is by daily or hourly spanking, and by al- ternating hot and cold baths, by sprinkling with cold water or by massage to stimulate the skin reflexes. The treatment may have to be repeated every twenty or CARE OF THE CHILD 305 thirty minutes, and the earlier it is instituted, the more persistently carried out, the more chance of success. The child must not be allowed to lie quietly on its back for any length of time. Exercise is just as important to the infant as to the adult. The kicking of the legs, moving of the arms and lusty cry are all means of stimulating the circulation, the muscular development, and the expansion of the lungs. The position should be changed occasionally in the crib from back to side and from side to back. Also the child’s legs and back should be rubbed and mas- saged until the skin is red every time the bath is given. Flushing’s.—The child is laid across the lap, or on a table. A rubber sheet is so arranged that the discharge will drain away. A soft rubber catheter, No. 18-20 French scale, is attached to a small funnel. The apparatus is boiled and fdled with normal saline, or sterile water, at a tempera- ture of 85° F. to 95° F. Half a pint to a pint may be required. The catheter is oiled and passed into the rectum just beyond the sphincter. It must not go farther. The funnel is then raised and the fluid flows into the bowel. This flushing must not be confused with the administra- tion of an enema for constipation, for which, however, it is often an excellent substitute. Gavage is forced feeding by means of a tube. A soft rubber catheter or tube, about No. 7, French scale, is lubricated with albolene, vaseline or sweet oil. The up- per end is connected with a small tube or glass funnel holding two or three ounces. The child is laid upon its back in the arms of mother or nurse, the baby’s arms are held and the head steadied. In case of diphtheria or scarlet fever, the tube may be passed through the nose and down the pharynx and into the oesophagus five or six inches, or even into the 306 OBSTETRICS FOR NURSES stomach. It is more convenient and easier when possible to pass it through the mouth directly into the stomach. The food is then poured into the funnel, which, by ele- vation, empties itself into the stomach. If regurgitated, more food must be given. When withdrawn, the tube should be pinched to prevent leakage into the trachea. The great danger in these cases is the ease of over- feeding. For comatose adults, as eclamptics, a double mouth gag is used. Then a regular stomach or duodenal Fig. 134.—Apparatus for gavage or lavage. (Tuley.) tube is introduced. Moistened in water or glycerine, the tube may be passed under guidance of the finger if necessary, beyond the tracheal opening into the oesoph- agus. When the end reaches the stomach the outside portion is raised to allow the gas and air to escape from the stomach and the fluid is poured in. Be sure to pinch the tube during its withdrawal. Lavage or washing of the stomach may be performed in the same way with the above apparatus, when neces- sary. As soon as the stomach is filled, the tube is lowered and the fluid siphoned out. CHAPTER XX THE CARE OP THE CHILD (Cont’d) Tongue-tie is not met with so frequently as in the old days. It may, however, occur. In such a case, the frienum is unusually broad and seems to extend clear to the tip of the tongue, which apparently is hound down to the gum and to the floor of the mouth. Tongue-tie cannot interfere with suckling. The child nurses with its cheeks and not with its tongue. The thin membrane may be snipped with the scissors close to the tongue and then torn back with the finger. Harelip and cleft palate interfere with nursing and require continual attention to keep mucus out of the throat. Brophy has a rubber flap placed over the nipple of the bottle in such a way as to occlude the split tissue and thus enables the child to get nourishment. These babies must be fed systematically by gavage, if necessary, until the deformity can be repaired. Hernia at the navel is a common complication of in- fancy. It is not due to crying, to improper tying of the cord, nor to neglect by the nurse, as frequently charged. It is a congenital fault, wherein the cord opening does not close, and in time, crying and straining will drive the intestines out of the aperture like a pouch. The defect is revealed by the bulging outward of the navel when the child cries. Ordinarily the breach will close of its own accord. Treatment consists in folding up the skin of the abdomen so that the groove will be over the umbilicus OBSTETRICS FOR NURSES Fig. 135.—Cleft palate nipple. (Bropliy.) Fig. 136.—The device for feeding the child with cleft palate at the breast. (Brophy.) CARE OF THE CHILD 309 and include it. Then adhesive tape is put on to hold it. The surfaces of skin thus coming in contact should be dusted with rice powder or stearate of zinc. Another method of treatment is to place a wooden button form, round side down, on cotton, over the opening, and bind it on with a zinc adhesive plaster. The dressing should be changed at least once a week. If the protrusion is large, an operation is indicated. Inguinal hernia usually heals spontaneously also, but a truss may be required. Fig. 137.—Device for assisting the cleft palate child to nurse. (Brophy.) Haemorrhage of the newborn is either accidental or spontaneous. Accidental haemorrhage may arise from an imperfectly tied cord, or it may be an effusion, through compression or rupture, into any of the internal organs, such as the brain, lungs, or abdominal viscera. These latter conditions rarely give rise to symptoms, and are seldom recognized during life. There is no treatment. The intracranial haemorrhages are open to diagnosis 310 OBSTETRICS FOR NURSES through the presence of pressure symptoms, and con- vulsions, but these, too, are impervious to treatment un- less a vessel can be tied, like the middle meningeal artery. Spontaneous haemorrhages may develop during the first few days of life from sepsis, syphilis, Buhl’s dis- ease, haemophilia, and true melaena neonatorum. The fragile condition of the blood vessels, the great changes in the blood and circulation after birth, as well as con- stitutional dyserasias, are etiological factors of impor- tance. All the causes are not as yet known. Fig. 138.—Method of strapping an umbilical hernia. The blood may come from the umbilicus, the mucous membranes of the eyes, nose, mouth, stomach and intes- tines. It may be effused into the tissues beneath the shin, 01 into any organ of the body. Marked nosebleed is generally syphilitic in origin. As a rule haemorrhages in the newborn are most com- mon in males, and strongly hereditary. The tendency to bleed lasts only a few weeks, and if recovery takes place, it is permanent, In some cases, however, where haemorrhage has developed in the brain' CARE OF THE CHILD 311 clots may form in important centers, and the child be permanently paralyzed in speech, sight, hearing, or in- telligence. Symptoms of hiemorrhage begin between the second and the fifth day and almost never after the tenth day. The appearance of blood is the earliest and the most definite sign. The bleeding may come first from the umbilicus, or from the stomach, or from the intestines (melaena neonatorum). The amount lost is small, but the oozing is continuous. The temperature may be high or subnormal, and may or may not be due to the haemor- rhage. The skin is pale, the pulse feeble, prostration marked, and weight is lost rapidly. Convulsions are not infrequent. The diagnosis of the condition is simple. It is only necessary to be certain that the blood is really effused, and not a temporary or accidental event such as the regurgitation of swallowed blood. Black tarry stools will show blood if placed in water. The prognosis is fair. About two-thirds of these babies get well. The treatment is to stop the haemorrhage by ligature, suture, or compression if possible and to alter the char- acter of the blood by adding to its fibrin content. This is brought about by the administration of coagulose, coagu- len ciba, or by transfusion from an adult—preferably the father. Injection of horse serum is often successful. Gelatin may be given by enema (200 c.c. 10 per cent solution) or hypodermically (10 per cent solution 20 c.c.). Cal- cium chlorate is also valuable. Paralysis of the face (Bell’s paralysis) may follow the use of forceps. The prognosis is favorable. Paralysis of the nerve in the neck (musculospiral) is sometimes 312 OBSTETRICS FOR NURSES known as Erb’s paralysis. It happens in consequence of difficult breech deliveries or of vertex labors when much force is required to extract the shoulders. The deltoid, biceps, and other muscles are affected so that the arm can not be raised. The failure to raise one arm will be the symptom that will attract the attention of the nurse. Some cases recover in two or three months, either spontaneously or by the aid of electricity. If not, the injured nerve must be cut down upon and its con- tinuity restored. Success is problematical. Ophthalmia neonatorum is an infection of the eyes of the newborn by the gonococcus. The infection occurs as the child passes through the vagina or vulva, or when an unclean finger is put into the eye. The symptoms appear on the third day. The con- junctiva is red and slightly swollen. The edges of the lids are covered with a dried yellowish secretion. When separated a yellowish watery fluid and later a thick pus exudes. The inflamed conjunctiva bleeds readily. The conditions grow worse. If untreated, the eyesight may be lost by ulceration of cornea. In the asylums twenty- five per cent of the inmates are blind from this infec- tion; and as late as 1896, seven per cent of the blindness in the state of New York could be traced to this avoid- able disease. The preventive treatment consists in the frequent douching of the vagina before labor with potassium permanganate solution 1:5000. After labor, a drop or so, of I per cent solution of nitrate of silver is dropped into each eye and not neutralized. After the infection has occurred, iced compresses are applied to the eye, night and day, and a solution of argyrol 15 to 20 per cent instilled into the outer corner, twice a day. Once a day the conjunctiva should be irri- gated with the 1 per cent solution of silver nitrate. CARE OF THE CHILD 313 In female infants with ophthalmia, the vagina must be watched for discharge which does not fail to appear in many cases. Argyrol (20 per cent) should be injected Avith a medicine dropper and left to drain out spon- taneously. All dressings used about the child should be destroyed, and the nurse should use the most scrupu- lous cleanliness and care of her own person. Separation of the cord may be delayed in puny babies and in cases Avhere the cord is large and thick. Some, of these cases are doubtless due to a patency or fistulous condition of the urachus. Usually the separa- tion may be hastened by touching the constricted part with silver nitrate. Or, if the cord does not separate be- fore the second Aveek, it may be desirable to cut off the hanging fragment and touch the base with silver nitrate or dust Avith alum poAvder. Granulations may protrude like a mulberry from the stump of the navel (“proud flesh”). These are touched with nitrate of silver stick. Menstruation may appear occasionally from the vulva of the neAvborn. It is really a haemorrhage AAdiicli has nothing to do with precocious menstruation. It is due to local increase of the physiological irritability. It is rarely significant. There is no treatment. It disappears spontaneously in tAvo or three days. The breasts of the newborn may fill with milk and become indurated and tender. Nothing should be done to them. Let them alone, and the SAvelling Avill subside in a feAV days and the milk (“witches’ milk”) dis- appear. The condition is produced by the absorption into the child’s blood of the same excitants (hormones) which cause the mother’s breasts to functionate. Icterus may deAmlop from the third to the sixth day. The child becomes yelloAV and stays yelloAV for a week, 314 OBSTETRICS FOR NURSES when the color gradually leaves. It is thought to be due to the liberation of some embryonic residue in the foetus, but nothing is known certainly. For the simple form no treatment is required. Kecovery is prompt and un- eventful. However, jaundice is associated with other conditions that prove fatal, hence every icterus should be watched carefully until it disappears. Child’s Nails.—The nails are frequently rough and ragged at ends and sides. They should be smoothly trimmed lest they become infected at the junction with the skin and give rise to paronychia. If infection does occur, the skin and flesh may be pushed back with a sterile applicator, and the point touched with peroxide of hydrogen. A syphilitic history may be traced in some of the babies. Thrush is a form of contagious soreness, characterized by white flakes or patches on the mucous membrane of mouth or anus which look like milk, but can not be wiped off. It is due to a vegetable fungus and occurs most fre- quently among amende or poorly nourished babies or those suffering from harelip. It is associated with symp- toms of indigestion. It may always be prevented by keeping the mouth and nipples clean, as directed on another page, and by keeping the bottles and rubber nipples in a solution of boric acid when not in use. When the disease appears, the mouth must be swabbed three or four times a day with an applicator soaked in saturated solution of boric acid. Two per cent solution silver nitrate is also effec- tive. Aphthae or stomatitis is the name given to whitish vesicles, followed by superficial ulcers that occur upon fhe inside of mouth and lips of the infant. It is rare in CARE OF THE CHILD 315 the newborn child. Boric acid solution is cleansing, and stick alum, frequently applied, will effect a cure. Wheals, urticaria or “stomach spots” appear as gen- erally distributed small spots about the size of a split pea, with a white center and a red periphery. They ap- pear about the third day and last twenty-four hours. They may be mistaken for insect bites and they may, or may not, be accompanied by temperature, which is probably only a coincidence. Ulcer pterygoidea. (Bednar’s aphthae.) Epstein’s pseudodiphtheria. Fig. 139.—(From Von Reuss.) The wheals disappear spontaneously without treat- ment. Bednar’s disease is characterized by the appearance of two ulcers on the hard palate, one on either side and just above the spot where the last tooth will erupt. It is most liable to occur in sickly infants and supposedly arises from the abrading of the mucous membrane by a rubber nipple or through the rough cleansing of the mouth. It is very resistant to treatment. The child 316 OBSTETRICS FOR NURSES must be put in good condition by attention to the nourishment and the spots touched with tincture of io- dine, 2 per cent sol. silver nitrate or hydrogen peroxide on an applicator. Exudative Diathesis.—This condition is indicated su- perficially by a definitely bounded red patch on the cheeks. From this beginning it extends to other parts of the body. Serum exudes from the red area. Otherwise the skin is pale. The mother says “the face is chapped” or that the “baby has milk eczema.” These children are frequently fat, but the tissue is flabby. The urine is sometimes ammoniacal. There is no marked disturbance of temperature. Fretfulness and constipation are the principal symptoms. The symptoms appear in consequence of a constitu- tional predisposition to eczema. Formerly too much fat in the food was regarded as a causative factor, but this is now questioned. The disease is often found in con- nection with nervous disorders. Occasionally the child must be taken off milk entirely and a soup or gruel diet substituted. Sometimes a skimmed milk diet may be tolerated very well. Then the fats may be added gradually. If chalky masses ap- pear in the stools, the fat must be reduced again. For local application, the following formula is some- times beneficial: (Grulee.) Naphthalene 3i Starch 3iv Zinc stearate 3iv M. Sig. Apply frequently. The “cradle cap” is a frequent sign of the exudative diathesis in its milder stages. The term is applied to a yellowish-gray patch over the CARE OF THE CHILD 317 large fontanelle. The mother calls it “dirt,” which she finds hard to remove and it always recurs. The mass is composed of dry scales, which gradually change into an eczema. Vaseline or sweet oil left on over night makes the removal of the scales quite easy the next day. If a raw surface is left, zinc ointment should be applied. The diet must be changed as previously described. Erythema, especially of the diaper region, is some- times a manifestation of congenital syphilis. It is usu- ally limited to the inner side of the thighs, the perineum, scrotum or vulva, and buttocks. It must be associated with other and more characteristic signs, however, such as snuffles, cachexia, etc., before it becomes diagnostic of syphilis. Most erythemas of this area are due to ir- ritation from moist or soiled diapers, but other factors may be important. Bluing in the diaper, gastrointes- tinal troubles, and circulatory disturbances are con- tributing causes. The local treatment is the same as for intertrigo. If the child is syphilitic, systemic meas- ures must be instituted. Erythema (Physiological).—Nearly every newborn child exhibits a more or less definite hyperemia of the skin as soon as the vernix caseosa is removed, the bath given, the circulation in the skin inaugurated, and the temperature returns from its normal depression. This hy- peremia occurs in every degree of intensity. It is caused by the reaction of the cutaneous vessels to the coolness of the air. It is especially pronounced in premature infants whose skins lack the power of quick adaptation. The erythema reaches its height at the end of the first or second day, and then gradually fades. A slight branny desquamation follow’s. Erythema (Toxic) is a transient eruption occurring during the first week. It appears anywhere and all over 318 OBSTETRICS FOR NURSES the body as efflorescences which vary in size from a pin’s head to a dime. The lesions are closely set, slightly hard to the finger and intensely red. They tend to coalesce. Papules are sometimes present like wheals. Pressure of the finger changes the red color to yellow. They dis- appear usually in forty-eight hours leaving no residues, no pigment spots, no desquamation. It is believed that these skin changes are in some measure due to intestinal irritation. Talcum powder is beneficial. Intertrigo, or chafing, is a form of eczema due to moisture, bluing in the diapers or uncleanliness. Rubber pants often retain moisture injuriously. The child should be cleaned with oil instead of Avater, and well powdered with stearate of zinc, or; zinc ointment may be used. Talcum powder which contains boric acid is contraindicated. Dermatol or Babcock’s Motiya powder is effective. Pemphigus neonatorum is an eruption of blisters or blebs which seem to follow infection from the maternal passages or to be communicated by other babies who have the disease. From three to fourteen days after birth, the blebs develop on the abdomen, neck or thighs, and show a tendency to spread to other parts of the body. The vesicles vary in size from one-fourth of an inch to two inches in diameter, and contain a serous, purulent, or bloody fluid. Other signs of general sepsis may appear. In diagnosis care must be used to exclude syphilis, which also exhibits blebs, but usually on the soles of the feet or the palms of the hands. Besides, a nonsypliilitic child is generally better nourished. The prognosis is unfavorable if the child is weakly, if the blebs spread rapidly over a large area, or if the infection attacks the umbilicus. CARE OF THE CHILD 319 Treatment.—A rigid quarantine must be enforced. In the hospital no new cases can be admitted. The alimentation must be increased, the blisters evacuated, and the surfaces cleaned and covered with a 25 per cent ointment of ichthyol, or an ointment of ammoniated mercury 2 per cent. Strophulus, red gum, or miliaria rubra are names ap- plied to an inflammation of the sweat glands when their secretion is retained. It is a “sweat rash” character- ized by an eruption of scattered red papules or small vesicles which commonly appear on the cheeks or neck of young infants, or where skin surfaces come in contact. It is due to excessive clothing or heat. It is really a prickly heat. The treatment consists in the removal of the cause, and a generous use of stearate of zinc powder or rice powder. “Stork Bites” is the popular name applied to the intense red spots which are sometimes found in the vicinity of the hair margin of the scalp, the forehead and eyebrows. The spots or streaks are possibly half an inch in width, straight or irregular, but always sharply defined. The redness disappears under pressure but quickly returns. Usually they vanish spontaneously in the course of weeks or months. They must not be con- fused with naevi or true “birth marks” which as a rule are much darker in color. Multiple Abscess of the Skin (Impetigo, pustular fol- liculitis, impetiginous eczema) is an affection peculiar to the newborn. The abscesses are limited in most cases to the super- ficial fascia and differ radically from boils by reason of their slight inflammatory manifestations. They usu- ally occur during the first week of life in any child, 320 OBSTETRICS FOR NURSES whether robust or weak, mature or immature. The pus- tules develop in any part of the body, either singly, in groups, or coalescent. There may be hundreds of them ranging in size from a pin’s head to a walnut. The skin over the abscess varies in color from yellow to purplish red. If very superficial the disease may appear as ves- icles of pus on a reddish and sometimes indurated base. The contents of these abscesses is a yellow or yellowish green pus of peculiar odor. After incision the wall sinks in, collapses, immediately. Fever is slight or altogether absent. The disease is cpiite generally confused with impetigo from which it differs in many respects. MULTIPLE ABSCESS 1. Lesions are single, double or confluent. 2. Area of redness at base of lesion. 3. No crusts. 4. Lesions do not disappear unless opened. 5. Occurs anywhere on body. 6. Eruption primarily pus. 7. Base indurated. 8. Lesions in superficial fascia or beneath it. 9. Lesions appear during first two weeks. IMPETIGO 1. Lesions discrete. 2. Lesions have no area of redness unless rubbed. 3. Always crusts. 4. Lesion absorbs. 5. Lesion most common on cheeks and extremities. 6. Eruption primarily watery. 7. Base not indurated. 8. Lesions apparently sit on top of skin. 9. Lesions most common in child whose age is from two to six months. CARE OF THE CHILD 321 The etiological factor in the disease is the staphylo- coccus pyogenes aureus in every case we have examined. Streptococci, however, have been demonstrated. Whether the organisms come from without (conta- gion) or from within by way of the blood from the in- testinal tract of the babe, or through contamination of the mother’s milk is unknown. It is possible also that certain proteins in the maternal milk may reduce the resistance of the skin, as in the exudative diathesis, and favor external infection. This disease gave us much trouble in the Wesley Maternity until it was decided to abandon the use of lard and other unguents in cleansing the baby’s skin. Sterile green soap took the place of the fats at the first bath and the infection ceased. The prognosis is good where the child is properly cared for. Isolation is imperative until the etiology is understood. Nutrition must be maintained, the skin kept clean and the linen changed frequently. After the cleansing bath the entire body should be dredged with Babcock’s Motiya Powder, (a talcum which contains .075 per cent of formalin) or, with Dermatol (subgallate of bismuth. The abscesses should be opened as early as possible. Birth Injuries are due to the various traumatic fac- tors which act during the birth of the child. There is always a certain amount of pulling and pressure as the child passes and a general venous congestion from local or central interruptions of the circulation. Injuries may arise in the genital passages of the mother or from ob- stetric maneuvers. In spontaneous delivery they are associated with disproportions between the pelvis and the child or to anomalous complications. In assisted 322 OBSTETRICS FOR NURSES deliveries like versions and extractions and forceps oper- ations they are a little more common. All portions of the child’s body are exposed to injury but the trunk possibly is less often affected. On the head we find the caput succedaneum, cephalhematoma, injuries to eyes or skidl as well as superficial and deep pressure marks. Paralyses of face and shoulder, wry neck and fractures of the clavicle are not uncommon. Dislocations and fractures of the limbs are observed while the brain and even less protected organs are subject to injurious pres- sure which is sometimes fatal. Birth injuries may be noted in any case apparently without reference to whether the labor was easy or difficult, quick or pro- longed, natural or assisted. CHAPTER XXI THE CAKE OF THE CHILD (Cont’d) Constipation in the newborn may come from many causes. The amount of food may be so inadequate that no residue is left, and the bowels move only once in forty-eight hours. Over-stimulation of the bowel by castor oil or colonic flushings in the early weeks of life to correct colic may diminish its sensitiveness and pro- duce atonic constipation. In the artificially fed infant too much fat in the food is a very common cause of the trouble*. Treatment.—Correct the amount of fat in the milk. If the child is breast-fed, the mother’s diet should be non-nitrogenous and vegetables should preponderate. Drugs should not be given until all else has been tried. Gluten suppositories will furnish a mild irritation to the rectum. Orange juice arid prune juice may be given, or Meliin’s food or oatmeal water added to the milk. Milk of magnesia % to 1 teaspoonful, or Hus- band’s magnesia, in same dosage, may be given daily. Senna is also efficacious. Diarrhoea is generally significant of an error in diet which is usually a plain indigestion, though there may be too much sugar in the food. The stools are more frequent and always softer than usual, possibly fluid. Diarrhoea means increased intestinal action due to ir- ritation from something. It may be due to indigestion, to the presence of hard curds, to acidosis, or it may ac- company almost any disease of infancy as a symptom 324 OBSTETRICS FOR NURSES merely. The odor is due to gases formed in the canal by bacterial action. There is but little odor in fermen- tation, but much in putrefaction. Mucus appears either as balls or strings. The balls come from the small in- testine, strings from colon. Blood indicates ulceration at some point in the bowel, or an erosion just above the sphincter. Fatty curds may be either white, granular, sancl-like Fig. 140.—Proper position for introduction of a suppository. (Grulee.) masses, or small, soft, and yellow. The protein curd is large and smooth, or white and bean-like. Both occur only when the artificially fed infant is given raw milk (Brenneman). If the milk is boiled for two minutes these masses will not form. The cause must be determined. The frequent stools, however, are exhausting, and may have to be checked with opiates or mechanical astringents. CARE OF THE CHILD 325 When due to indigestion, all food by month may be stopped for two or three days and only barley water administered. In a breast-fed child, diarrhoea is sometimes cheeked by diluting the milk with a little barley water, given just before nursing. With these infants, not much change in the sugar content can be made by alterations of the maternal diet, but where artificial food is used, the amount of sugar is easily reduced to a satisfactory degree. Colic is a cramp-like pain of the bowels. Previous to the attack the child is restless, expels some gas, and has the “colic smile,” which leads the mother to believe the child is quite well. When the attack comes on, the thighs are flexed on the abdomen, and the legs on the thighs. The child has a sharp cry, that is nearly con- tinuous, but in some Avay related to the nursing period, for the attack comes on a few minutes, and sometimes an hour, after taking the breast. The belly is rigid, the arms wave aimlessly. Diarrhoea may be present, and the movements are accompanied by much flatus. Dis- tention is nearly always present. When the belly is tapped it gives a drum-like note and the child belches gas, sometimes accompanied by milk, which seems to relieve. Treatment.—Colonic flushings to relieve the bowel of irritating curds. The child may be laid face down with a bag of hot water under the belly. Mixture of asafoetida gtts. xx to xl, or whiskey and hot water should be given for the attack, followed later by a full dose of castor oil. The diet should be rigorously in- vestigated. Vomiting’ may or may not be serious. The child may nurse too rapidly or too much, and the over-distended 326 OBSTETRICS FOR NURSES stomach simply empties itself. Many infants “spit up” their excess of milk, and thus relieve themselves. This is a simple regurgitation, usually of unchanged milk, though it may be acid from admixture with the gastric juice. Vomiting, in a breast-fed child, may come during an attack of colic when the eructations of gas appear. It may be a symptom of gastrointestinal intoxication, of too much fat in the food, too short intervals between feedings, or too much sugar in the food. Projectional vomiting awakens suspicion of a pyloric stenosis or meningitis, and must be reported to the physician at once. Vomiting which occurs within twenty minutes after feedings is not serious ordinarily, even though gas and large curds are expelled, but all vomiting later than this, is significant of a pathology. Treatment.—Regulation of the hours of feeding is most important, and next, the character of the food. If the child vomits an hour or so after nursing, it may be that the milk is too rich (fat). Try a longer inter- val, or give an ounce or so of cereal water before put- ting the child to the breast. Prematurity exposes the child to three distinct dan- gers, which arise, respectively, from atmosphere, food, and infection. Very few children born before the seventh month survive. A child born at the eighth month, or with a weight of three pounds, or more, can be saved almost always. The premature child up to the time of birth, has been protected very carefully against temperature variations by the liquor amnii, and when suddenly precipitated into a new environment, which its vitality barely tolerates, the consequences are serious. CARE OP THE CHILD 327 These infants have a poor heat production, and the natural warmth of the body must be preserved. This is best done by incubators, which supply air and mois- ture in stable and appropriate amounts. Chilling of the child for even a few moments may be fatal. A room may be fitted up to produce the necessary conditions of light, air, heat and moisture. The child, wrapped in sheets of cotton, except the face, is then covered with a blanket, and surrounded by a temperature vary- ing from 88° to 95° F., which is gradually lowered to 80° F. as the child gains strength. An occasional whiff of oxygen, as prescribed for an atelectatic child, is sometimes advantageous. Bathing.—Premature infants must not be bathed, but the skin should be cleansed with cotton and warm sweet oil or albolene. All unnecessary handling is to be avoided. Food.—Breast milk is the secret of success with these cases. Since most of the infants are too weak to take the nipple, the breasts must be pumped, and the child fed with spoon or pipette. The interval between the feedings depends a little on the amount taken, but it should not be less than one and one-half hours, nor more than two hours. As the child gains, the interval may be lengthened to three hours. Lack of sufficient nourishment is shown by cyanosis and loss of weight, and overfeeding, by vomit- ing and diarrhoea. The child must be fed by hand until strong enough to nurse the breast. In certain cases of prematurity, as well as in diseases like pneumonia, scarlet fever, and diphtheria, the child must be fed by gavage. Nutritive inunctions of benzoated lard or cod-liver oil are also valuable, not only for the passive exercise supplied, but 328 OBSTETRICS FOR NURSES for the absorption of a certain amount of the unguent. Marasmus means wasting, but the term is applied to infants that steadily lose weight. The bodies of infants are so largely composed of fluid, that loss of weight occurs quite easily and rapidly. Loss of weight may be sudden or gradual. It comes on rapidly after acute diarrhoea, either with or without vomiting, or it may follow persistent vomiting without diarrhoea. Malnutrition from defective feeding is the most com- mon cause of wasting in infants. This may be from lack of sufficient food or lack of proper ingredients, as well as irregularity of intervals, and disease. Rickets, con- genital stenosis of the pylorus, congenital syphilis, and tuberculosis are all possible factors in the etiology. In any case, no treatment can be instituted until these conditions have been confirmed or excluded. Pyloric stenosis (the account follows Grulee) may be a thickening of the muscular coat of the outlet of the stomach (pylorus) or a spasmodic contraction. The condition is most frequent in males and in the first born. Symptoms usually begin before the second week. There is constipation with small ribbon-like stools, and the urine is scanty. The most marked sign, however, when it is present, is the excessive, uncontrollable vom- iting, which ordinarily occurs fifteen to thirty minutes after eating, but may be delayed for several hours. The vomiting may be of the common type, but more fre- quently it is projectile in character, like that seen in meningitis. The contents of the stomach are violently expelled, sometimes several feet. Physical examination may reveal the stomach bulging under the arch of the ribs and peristaltic waves moving back and forth across its surface. The pylorus itself may sometimes be felt as a lump or tumor. CARE OF THE CHILD 329 Prognosis.—About fifty per cent die. Treatment.—Dietetic and surgical. Grulee recom- mends small amounts of food, poor in fat, be given at short intervals. Belladonna will relieve many cases of pyloric spasm. If this fails, operation is required. Pneumonia in the newborn most frequently results from the aspiration of mucus out of the maternal pas- sages as the child is born. This may happen when the cord is compressed, or at any time when a partial as- phyxiation impels the child to try to breathe. It may also come on when a feeble child has been chilled by a prolonged first bath. The disease develops about twenty-four hours after birth in a child apparently well. The temperature rises, respiration becomes rapid, and cough develops. The child is fretful, restless, refuses the nipple, and gasps for breath. It may become cyanotic. The prognosis in new- born infants is very serious. Treatment is stimulation. A mustard bath will bene- fit where the respiration is rapid and the child blue. Tincture of digitalis may be administered in drop doses every three or four hours. Carbonate of ammonia, 14 gr., in mucilage of acacia, half a dram, may be given for cough. Child must be fed on mother’s milk pumped from breast. Snuffles may be due to improper clothing, to drafts of air, or to syphilis. If due to cold, camphorated oil may be rubbed on the nose and the passages kept clean with an applicator soaked in albolene. If this fails, a small pellicle of ana?sthone, or 10 per cent argyrol, may be placed in each nostril, and the child laid upon its back until the ointment melts and runs back into the pharynx. 330 OBSTETRICS FOR NURSES Furuncles (boils) may be numerous. They come from irritation of the skin by atmosphere, soap, water, and clothing, whereby infection enters. This is especially liable to occur in the hair. Keep the boils washed with boric acid solution and open them as soon as the focus, or head, appears. Phimosis is such a close adjustment of the prepuce to the glans penis that it can not be retracted. In some cases there may be obstruction to the outflow of urine, but generally a tiny portion of the glans can be seen. The prepuce may or may not be redundant. This condition makes cleanliness impossible and balan- itis may result. On account of the straining required to urinate, pro- lapsus ani, hernia, and hydrocele of the cord sometimes develop. Symptoms may arise from preputial adhe- sions, as well as phimosis. Frequent or difficult mictu- rition, nocturnal incontinence, priapism, pruritus, and masturbation may develop out of the irritation, as well as nervous manifestations, such as insomnia and night terrors. The condition should be recognized and corrected in infancy. If the adhesions are dense, an incision can be made down the dorsum of the prepuce, the tissue forci- bly separated from the glans, and the flaps cut off. Stitches may be required. In other cases circumcision may be necessary. Paraphimosis.—When a prepuce with a small orifice is forcibly retracted over the glans, it occasionally hap- pens that it cannot be pulled forward again. If al- lowed to remain this way, the parts will swell, and the penis become, strangulated as if with a ligature. The danger arises from the stoppage of the circulation, which may be followed by ulceration and gangrene. CARE OF THE CHILD 331 Reduction must be brought about by manipulation, if possible, but where this fails, the constricting band must be cut through and sedative applications used. Balanitis is inflammation of the prepuce from the de- composition of smegma, which collects under a tight foreskin. The condition is quickly relieved by clean- liness and a few applications of vaseline or zinc oxide ointment. Circumcision should not be done until the inflammation has subsided. Circumcision, either as a physical necessity or as a religious rite, is frequently performed. The nurse prepares a table with sterile linen, a basin with antiseptic solution and sponges, sterile towel, and sterile vaseline, with a roll of gauze bandage an inch wide. The object of the operation is to remove the prepuce and leave the glans exposed. The instruments needed are a pair of sharp scissors, a pair of dissecting forceps, two pairs of artery for- ceps, small, full curved needles, and fine catgut. The nurse gives the child some gauze to suck, which has been soaked in brandy and sugar-water, brandy one dram to an ounce of water. Then taking her place at the child’s head, she flexes the thighs back upon the abdomen, and widely separates them. The field of op- eration is thoroughly washed with soap and warm wa- ter, the prepuce is then retracted and the smegma wiped away. Then the body and limbs should be cov- ered with clean linen, except the penis, or a sterile towel may be used with a hole in it through which the penis is drawn. The redundant tissue is removed and fine catgut sutures put in. The operation being completed, the wound is covered 332 OBSTETRICS FOR NURSES with sterile vaseline and wrapped with a sterile gauze bandage, leaving the end of the glans exposed. The gauze and vaseline are changed whenever sat- urated with urine. Healing ought to be complete by Fig. 141.—Hydrocephalus. (Bumm.) the seventh day. The nurse should examine the dress- ing at frequent intervals during the first twenty-four hours, since serious haemorrhages may occur from ves- sels that have not been included in the sutures. CARE OF THE CHILD 333 Priapism is a condition of functional fullness and firmness of the penis that is more than ordinarily con- stant. Its importance lies in the fact that it may be a symptom of spinal irritation, balanitis, worms, phimosis or hydrocele of the cord. Spina bifida is the most common congenital deform- ity. It is characterized by a fluid tumor, which pro- trudes from an opening in the vertebral column. It may appear anywhere along the spine, but is found most frequently in the lumbar or cervical region. The Fig. 142.—Anencephalus. (Williams.) deformity is supposedly due to au arrest of develop- ment. It is nearly always fatal inside of two weeks, though cases have been known to reach mature years. Operation saves some cases, otherwise there is no treatment except protection from injury. Hydrocephalus is sometimes, but not necessarily, as- sociated with spina bifida. The ventricles of the head are filled with cerebro- spinal fluid, and the fontanelles are widely separated. The cause of the anomaly is unknown. 334 OBSTETRICS FOR NURSES This condition may render labor difficult or impos- sible until the diagnosis is made and the skull perfor- ated. Rupture of the uterus may result from the futile efforts to expel the child. If born alive, the child nearly always dies, or if it grows up, the intelligence is imperfect in most cases. Anencephalus is a monster, having a body, but only a part of a head. The eyes protrude, the tongue may hang from the mouth, and the brain is under-developed. Sudden death of infants that are apparently healthy comes with a shock to the physician as well as the par- ents, and in some instances, no plausible reason can be assigned for it. Apoplexy, pnetfmonia and stoppage of the trachea by milk curds may explain some cases. Suffocation by lying on the face in wet bedding, or overlying by the mother will account for others. In- ternal haemorrhage into lungs, pleura, stomach, or brain is also known to be causative. Retention of Testicle.—Abnormalities in the position of the testicle are not obvious enough to be always rec- ognized in the newborn. In many babies the inguinal canal permits for a long time the return of the testicle which may occur under the influence of cold. In most cases the gland acquires its normal position through its gradual increase in weight. Operation may well be de- ferred until puberty. CHAPTER XXII INFANT FEEDING A well fed infant is a happy little animal, who sleeps approximately twenty-two hours a day, and gains from four to six ounces a week. If properly fed at the breast, this condition is easily obtained; but if artifi- cial food is necessary, the resources and skill of the at- tendants may be tried to the utmost before the wel- come result is brought about. The feeding of infants may be considered under three heads, (1) the breast; (2) breast and bottle combined (mixed feeding); and (3) artificial, which is really mod- ified cow’s milk. Breast feeding has been taken up elsewhere, but the same care should be taken in feeding from the bottle as in feeding from the breast, so far as concerns the intervals between the feedings and the duration of the same. Since it takes from one to two hours longer for cow’s milk to digest than it does for mother’s milk the longer interval of three or four hours between feedings is better for the artificially fed child. With such an interval there will be less vomiting, less colic, less ten- dency to overfeed, and a better natured baby. One feeding should be omitted at night, and if pos- sible, two. Length of time for taking the bottle depends some- what on the child, but it should not exceed fifteen min- utes, as a rule. Supplemental Feeding.—A mother who has too little 336 OBSTETRICS FOR NURSES milk may have it supplemented by a modified mixture in one of two ways. First, the quantity furnished by the breast must be determined by weighing the infant before and after feeding, and then the total amount for twenty-four hours can be deduced. With this information, it is not difficult for the doctor to know how much cow’s milk to prescribe. The supplemental feeding may be given by alternating the bottle and the breast, or by giving the breast and following it immediately with the bot- tle. In the meantime, the mother must be put on tonics with an abundance of fluids, and a generous diet that will raise the blood pressure, in the hope that the milk will increase sufficiently to enable her to feed the child entirely from the breast. When it becomes necessary to substitute some other food for the breast milk, it means that the milk of some other mammal must be modified for the purpose. The most convenient and abundant source of supply is the cow. While in many respects co'w’s milk is similar to moth- er’s milk, it is in reality quite a different product. Mother’s milk is taken, undiluted, directly from the breast, while cow’s milk is given from a bottle, hours after milking, and not only must it be diluted, but cer- tain ingredients must be added to aid its digestibility. When taken into the stomach in its natural state, mother’s milk is a liquid, while under the same con- ditions, cow’s milk forms a semisolid gelatinous mass. It is essential that the milk should be as fresh, clean, and free from bacteria as possible, and this can be ap- proximated only in certified milk. This milk is re- quired by law to have its constituents definitely stand- ardized. Thus, there must be 4 per cent of fat, 4 per cent of protein, and 4 per cent of sugar, and it must be so free INFANT FEEDING 337 from bacteria that not more than 10,000 per cubic cen- timeter can be found. The cattle also are tuberculin tested. The following comparison is from Holt: Mother’s Milk Sp. Gr. av. 1.031 Fat 4. % Protein 1.50% Sugars, v.. 7. % Salts 2 % Water 87.3 % Reaction Alkaline Bacteria Very few Cow’s Milk av. 1.031. Fat 4. % Protein 3.50% Sugars 4.50% Salts 75% Water 87.3 % Reaction Acid Bacteria Many Both range from 1.026 to 1.06. Fig. 143.—Elements of human milk. (Eden.) The fats are substantially the same, but the fat of cow’s milk is less easily digested than the fat of moth- er’s milk. The protein of mother’s milk is virtually half 1 act- albumin and half casein, which is only slightly coagu- lated into soft flocculent curds by the action of rennin and acids, while the casein of cow’s milk is nearly three 338 OBSTETRICS FOR NURSES times greater in amount than the lactalbumin and is coagulated into coarse, tough curds. The sugars in both cases are lactose in solution, but mother’s milk contains a much higher percentage. Cow’s milk contains three times the quantity of salts found in human milk, but the water is the same in both. So, while the two milks seem in comparison to be much alike, in reality they are quite different; hence it is necessary to modify cow’s milk in such a way as to make it not like mother’s milk chemically, but to make it act like mother’s milk. It is extremely difficult to bring up an infant on arti- ficial food, and inasmuch as half the infants that die during the first year, perish from intestinal disorders, it is imperative that every resource should be exhausted before the breast feedings are abandoned. It is fal- lacious to believe that anyone can feed a baby, or that feeding consists merely in trying one food after an- other until one is found to agree. Only a competent physician should prescribe the food, and he should study his problem and make his modifications just as he would alter his medicines for a particular disease. However, it is necessary for the nurse to know how to carry out the doctor’s orders intelligently and how to report to him the conditions present. In prescribing for the child, the doctor usually has some definite outline in his mind, such as Age and weight. Example: 3 months old; weight 10 pounds; 7 feedings; 1 every 3 hours. Interval, three hours. Amount in each bottle, four ounces. Formula: Milk, 12 oz. Diluent, 16 oz. (Cereal water or plain water.) Sugar, % oz. Flour ball, if any, % oz. Boil if ordered. INFANT FEEDING 339 The infant should not take more than two ounces of milk to a pound of weight in each twenty-four hours. Proprietaries.—Baby foods are not to be recom- mended nor condemned. They are placed on the mar- ket as substitutes for mother’s milk with definite in- structions as to preparation. They are also very ex- pensive. They are not to be condemned, because many of them are invaluable when used in connection with cow’s milk. Sometimes a child will not tolerate any- thing but malted or condensed milk, or Nestle’s food, for example. The malt sugars, such as Ilorlick’s and Mellin’s, are easily assimilated, fattening, and laxative. All foods in the modification of milk should lie of the best. The standard sugars are Merck’s milk sugar, Mead’s Dextri Maltose, Nahrzucker, cane sugar, and Mellin’s and Horlick’s foods. Robinson’s barley flour or Johnson’s are the best known. Imperial granum is a partially dextrinized flour and corresponds to the home-made “flour ball.” FOOD PREPARATION Buttermilk Made from a Culture.—Bring two quarts of milk to a boil, cool to the temperature required for inoculation (80° to 100° F., depending on the culture employed). Introduce the culture, and allow it to stand at the temperature of the room until a solid clabber forms. Place on ice, whip with an egg beater or break up with a churn before using. If a fat-free butter- milk is desired, use skimmed instead of whole milk. There are many kinds of buttermilk cultures on the market, but Hansen’s is considered one of the best, be- cause it is not too acid, besides which, it has a good flavor, and the culture can be utilized over and over for a week or ten days. 340 OBSTETRICS FOR NURSES In preparing a subsequent portion, it is only neces- sary to use two or three ounces of the first buttermilk, which may be reserved for the purpose. This amount is introduced into the freshly boiled milk, instead of the original powder, and the preparation is continued exactly as described for the mother culture. In every case the mixture must be placed on ice as soon as the clabber forms, as it becomes too sour other- wise. Eiweiss Milk.—Heat one quart of whole milk to 145° F. and coagulate with pepsin, rennin, or chy- mogen, which is 10 per cent rennin. Let it stand until clabbered, which takes about ten minutes. Four into a gauze bag and let it stand until all the whey is drained off. To the dry curd, add 1/2 ounce of flour ball, and one pint of skimmed buttermilk, the whole to be rubbed through a very fine wire mesh sieve (as fine as a tea-strainer, at least), three separate times; or, it may be ground twice through a special mill to break up the curd as minutely as possible. Add a pint of water and measure. There should be a quart and three or four ounces over. Place upon a slow fire and bring to a boil while stirring constantly. Boil two min- utes, then cool, strain, measure, and add water to make up for evaporation. Shake well before measuring, as the curd is heavy and settles to the bottom. Peptonized Milk.—(See p. 363.) Whey.—To a pint of fresh, warm coav’s milk, add rennin as pepsin, or chymogen, and stir until mixed. Let it stand until coagulation is complete. Then the curd should be broken up with a fork, and the Avhey drained off through coarse muslin. This removes the coagulable proteins from the milk. A ten per cent cream can be had at home by alloAving a quart of milk INFANT FEEDING 341 to stand for six lionrs and then using the upper one- fourth. Whey-Cream Mixture.—Make whey as described and mix with cream, in the proportion of whey 11/2 ounces to cream, 1 dram for each feeding. Barley Water. No. 1.—Use one ounce of barley pearls to a quart of water. Wash thoroughly, put on a slow fire and boil for six hours. Add water to make up for evaporation, and add a pinch of salt. Strain and cool rapidly. Barley Water. No. 2.—Use one heaping teaspoonful of Robinson’s patent barley flour to each pint of cold water. Boil twenty minutes and add water to make up for evaporation. Add a little salt, strain and cool rapidly. Other cereal waters, like rice and oatmeal, are made like barley water No. 1, and in the same proportion. Flour Ball.—Take four cups of ordinary wheat flour and wrap it in a piece of muslin, and tie it tightly. Drop the mass into boiling water and boil six hours. Then take it out, cool it and remove the outer peeling with a sharp knife. Break into small pieces, the size of an English walnut, and dry thoroughly in a slow oven. Pulverize in a mill or meat-grinder, sift and keep in a dry place. Milk may he sterilized, pasteurized, or boiled. Sterilization kills both germs and spores, but it is not nearly so necessary as it is to have the right pro- portion of sugar and fats. Place in an autoclave and keep at a temperature of 160° F. for an hour. Pasteurization is desirable when a good, clean milk is not attainable. It kills the germs, but not the spores. The process must be carefully attended to, or the milk will sour more easily. Heat a quart of milk to 160° F. for twenty minutes. Cool rapidly to 40° F. 342 OBSTETRICS FOR NURSES Boiling milk for two minutes kills all bacteria, and renders the casein more easy of digestion and prevents the formation of curds. PUTTING FOODS TOGETHER Whole milk contains 4 per cent fat, and must be thoroughly shaken before it is measured, for otherwise one child will get all the fat and another all the skimmed milk. Fat-free, or skimmed milk, contains about 0.1 per cent fat. The cream has been removed by a siphon or centrifuge. If unable to get a fat-free milk from a dairy, the cream can be removed from a quart of whole milk quite easily with a siphon. Sugars and flours should be weighed when used, for they vary greatly in volume. In using flour ball or imperial granum, the flour must be mixed with water or cereal water, to make a smooth paste and brought to a boil. If the milk is to be boiled also, add the milk to the paste and boil all together. Cool and strain. All baby feedings should be strained, as tiny lumps of food will clog the rubber nipple and the nurse may think the baby is not taking its feedings well. The fol- lowing is a typical formula: Whole milk 15 oz. Barley water 15 oz. Sugar % oz. - Flour ball % oz. Boil two minutes. 5x6x4 Weigh the sugar and flour ball and make a paste with the barley water. Shake the whole milk, meas- ure out 15 oz. in the graduate, and add the barley "wa- ter mixture. Boil two minutes. Cool in running water, INFANT FEEDING 343 strain bottle and put on ice. The figures at the side mean that five feedings of six ounces each are to be given at four hour intervals. It is necessary to cool all feedings as soon as mod- ified, and keep them on ice for preservation until used. The only accurate way is to make up the whole quan- tity for twenty-four hours, put into separate bottles the exact amount of each feeding and give at the time ordered, after the bottle has been properly warmed. In warming the food, care must be used to get it nei- ther too hot nor too cold; 100° F., or when it feels warm to the back of the hand, is about right. The child should be held in the arms while taking the bottle. A buttermilk feeding must not be heated to more than 100° F. because it curdles and can not be used. The rubber nipples should be washed thoroughly after use, boiled once a day, and kept in boric acid solution. The necessary articles for home modification of milk can be obtained anywhere. One set of utensils should be kept for this purpose exclusively and boiled each time before the food is prepared. A list is convenient: A 16 ounce glass graduate. One tablespoon and one teaspoon may be used for measur- ing purposes, if unable to get a satisfactory scale. 1 2-quart aluminum cooking dish. 1 long-handled aluminum spoon. 1 fine wire mesh strainer, thirty holes to the inch. 1 dozen bottles, 5 ounce size if the child is small, and 10 ounce if the child takes large feedings. The bottles should have wide mouths, straight sides, and round bottoms, which clean easily. Paper caps or corks that fit tightly should be used instead of cotton stoppers. Close rubber caps are best, for, as the milk cools, a vacuum is created, the rubber is drawn in and 344 OBSTETRICS FOR NURSES the milk remains air-tight until opened. If infants are kept on a milk diet alone for too long at a time, they do not thrive so well, hence as early as six months, other things may he given. At this stage, the most de- sirable additions to the food would be cereal, farina or cream of wheat, orange juice, vegetable broth, toast crumbs, etc. The administration of orange juice should be started when the child is only a few weeks old. The quantity of all these foods may be increased as the child gets older, and by the end of a year the diet is broadened still further. Beside a quart of whole milk, it may have thickened soups, vegetables, such as cauliflower, spinach, carrots, creamed celery and a lit- tle baked potato. Fruits, orange juice, grape fruit juice, prune sauce, apple sauce and scraped apple may be given, but no bread. In place of bread, use toast, Huntley and Palmer wafers and biscuits, and soda or oatmeal crackers. Sweet desserts should be avoided, but flavored junket or simple custard is unobjectionable. No meats are permitted until the child is eighteen months old, except, perhaps, a little crisp bacon, or a bone to suck. None of these supplemental foods should be given be- tween meals, but always at the feeding hour. The above list supplies a dietary so varied that no child will tire of it. In reporting the condition of the infant to the physi- cian, the following form may be used to advantage. It is a clear cut, concise summary of what he wishes to know. Infant’s Daily Report 1. Food: Does baby take it all? Is he satisfied? 2. Bowel movements: How many in last 24 hours? What is the color? Are they hard, soft, or watery? Any odor? INFANT FEEDING 345 Any curds? Any slime? Any blood? Any colic? Much gas? 3. Does baby vomit? When? How much? 4. Does baby sleep well? Is he good natured? 5. Any fever? What is the iveiglit? Significant Symptoms and Conditions.—In an artifi- cially fed baby, the normal condition of the bowels is constipation. The stools are formed, alkaline in reac- tion, rather hard, and usually only one a day. The stools should have a characteristic color, accord- ing to the food taken. Thus: Sugar or starch will color the movement a dark brown, like vaseline. Too much fat gives a pale yellow stool, almost white, like putty. Eiweiss feedings show as a pale yellow, somewhat like the fatty stools, but constipated. Barley water gives a brown liquid stool. Starvation stools are thin, slimy, dark brown or green. The consistency of the movements is also important. Too much sugar or starch means diarrhoea, with thin, green, acid stools, and much gas and regurgitation, or, sometimes foamy, mucous discharges. Diarrhoea may also be due to indigestion. Mucus in the stools usually signifies intestinal irritation. Constipation may exceed the normal limits of the arti- ficially fed child when the food contains too much fat. Bad oclors of the stools result from putrefaction. Colic means imperfect digestion with gas. There is less colic when the intervals between the feedings are lengthened. Curds are of two kinds. The soft friable ones due to fat, and the hard bean-like masses of protein. Curds occur with feedings of raw milk only, and though as- sociated with symptoms of indigestion, they signify 346 OBSTETRICS FOR NURSES overfeeding. If the sugar content of the food is low, the child will gain very slowly. Vomiting is an important phenomenon. It may be due to overfeeding, to excess of sugar or fat in the food, or to pyloric stenosis. Excess of fat is shown by vomiting and regurgitation of small quantities of food one or two hours after feeding. It may be associated with constipation. If vomiting occurs immediately after feeding, it is probably due to the taking of an excessive amount, or to the too rapid ingestion of the regular bottle. If the vomiting takes place later than twenty minutes after feeding, it is probably pathological. It may be the re- sult of indigestion, meningitis, or of pyloric stenosis (q. v.). For the first weeks of life, mother’s milk should be obtained at all hazards, if possible, but if this is not to be had, the artificial feedings may be started. A desirable milk modification for the first weeks of life should begin with a low food value. For example, a child one week old weighing seven pounds, should start on a formula like this: Whole milk 7 oz. Water 7 oz. Cane sugar % oz. Boil two minutes. This will make seven feedings of 2 oz. each, and one is given every three hours with one feeding omitted at night. Cane sugar is less liable to produce colic than sugar of milk. Lime water, or sodium citrate may be added, if the child vomits, or if other indications arise. Both are alkalies. INFANT FEEDING 347 The strength of the mixture, as well as the quantity, must be increased as the child gets older and it is seen that the formula will agree. The percentage of protein is kept down by dilution, with plain or cereal water, while fats (as cream) and sugars are added to make up the strength lost by the dilution. CHAPTER XXIII CLEANLINESS AND STERILIZATION The nurse is called to a case on account of her spe- cial qualifications, but also she should lead her patient in all things, even in gentility. It is her part to antici- pate the wants of the patient, and regard it as a re- proach if the patient has to remind her that it is time for food, medicine, bath, or for child to come to the breast. Regularity, promptness, and thoughtfulness must be supreme. Be on hand when the doctor calls and stay until he goes. Be as cheerful as Mark Tapley, however dreary the prospect, and do not make noises either by the swish of overstarched skirts, the squeak of shoes, or the moving of equipment. Above all things, the nurse must keep her patient’s room, her patient, and her own person rigorously clean. She should not allow her hands to touch infectious material without protection by rubber gloves. This is as necessary for her own safety as for the patient and family. Her hands should be manicured frequently, her hair sham- pooed at short intervals, and her teeth kept in order. If the hands get hard, take a teaspoonful of sodium car- bonate and one of chloride of lime, mix in the palm of the hand with enough water to make a cream, and rub well into palms and about the nails. Rinse in clean water. (Weir.) The nurse’s dress should be neat, always mended, and carefully adjusted. The nurse who is slovenly in appear- ance will be slovenly in her mind and slovenly in her CLEANLINESS AND STERILIZATION 349 work. She should not wear her uniform on the street. It is bad taste, unprofessional, and unsanitary. She should bathe at least three times a week. There is always some odor of perspiration about the body, and especially around the axillary spaces which are filled with hair. Nothing is more offensive and nause- ating than being leaned over and waited on by a person who has a strong body smell. The prodigal use of warm water and soap will aid, but there are large sebaceous glands in the armpits and their decomposing excretions are retained by the hair so lastingly that more radical measures are necessary. The axilke should be shaved at least once a month, and then the soap and water becomes more efficacious. After thorough cleansing, the armpits should be dredged with Babcock’s Motiya powder, and the an- noying and offensive odor will disappear. If the patient is a refined and dainty woman, who may happen to be afflicted with the same misfortune, she will be deeply grateful to the nurse who tells her how to get rid of it. That some doctors, unfortunately, have strong odors about the person—the mixed effluvia of tobacco, alco- hol, bad teeth, and uncleanliness—is no excuse for the nurse. The doctor should know better, but at all events, his offense rarely needs to be suffered more than a few minutes at a time, while the nurse is in constant attendance. The trained nnrse should be polite to, but not familiar with servants, as she is looked upon as the highest type of the professionally educated gentlewoman, and she must be constantly alert that her reputation in this respect is not diminished. 350 OBSTETRICS FOR NURSES BATHS Hot Baths.—Temperature from 98° F. to 120° F. Water should be tepid at first and the hot water gradually added until the required degree is obtained. Warm bath 92° F. to 98° F. Tepid 85° F. to 92° F. Cold 33° F. to 65° F. Sedative Bath.—The patient is stripped and stands for an hour in the hydrotherapy room, while a hot spray is played up and down the spine. The tempera- ture of the water is 104° F. to begin with, and gradu- ally increased to the point of toleration. An alkaline bath is prepared by adding an ounce of sodium carbonate to each gallon of water. Bran Bath.—Add two ounces of bran to each gallon of water. Mix the bran in a small amount of boiling water and add to the bath water. Mustard Bath.—To three gallons of water at a tem- perature of 105° F. add a tablespoonful of mustard. Leave the child in the water for five minutes, all the while rubbing and stroking the limbs and back. Then wrap naked in a warm blanket and leave for half an hour. STERILE DRESSINGS—ANTISEPTIC SOLUTIONS— STERILIZATION OF INSTRUMENTS The preparation of sterile dressings, antiseptic solu- tions and the sterilization of instruments, is particularly the work of the nurse, whether in the hospital or in a private home. The following directions are therefore desirable: CLEANLINESS AND STERILIZATION 351 As soon as the nurse is sure her patient is in labor, she boils a milk bottle, fills it two-thirds full of 95 per cent alcohol, puts a pledget of sterile cotton in the bot- tom and then boils a pair of dressing forceps, which are placed, handle up, in the alcohol. (See Fig. 60, page 148.) With this forceps, she handles all clean dressings, instruments, and rubber goods that may be contaminated by touch. Dressing’s and Supplies.—The necessary dressings and supplies may be prepared one or two weeks before labor according to the following instructions: Five Yard Packing.—Draw threads at either end of five yard lengths of gauze to its full width. Fold the cut edge across until it lies one-third the distance from the opposite side. Next, fold the double edge over, and bring it to the outside edge of the first fold. Keep it perfectly straight. When folded full length, roll from the end and wrap in strong muslin wrappers. Sterilize in the autoclave or Arnold sterilizer. Pads for the Vulva.—Unroll a whole bale of common cotton and cover it with a % inch thickness of absorbent cotton. Cut in lengths of 12 in. by 4 in. wide. Cover with gauze cut 12 by 14 inches, and fold the ends of gauze over absorbent cotton. Roll from the end, wrap in paper, seal, and sterilize. Pledgets.—Tear two yard strips, lengthwise of the roll of absorbent cotton, pull from these, three inch pieces, roll them in the hands until round, place in clean bags, and sterilize. Breast Covers.—Squares of old, soft muslin 4 by 4 inches, with all strings removed, make the best dressings for the nipple. Do not use gauze, because the papillae of the nipple may get caught in the mesh and when it is taken off, the tender nipple is irritated or abraded. 352 OBSTETRICS FOR NURSES Breast Binders.—These are made of single material, because they would be too warm otherwise. They are sleeveless and jacket-shaped and measure 16 inches from shoulder to waist, 40 inches long, and 10 inches for the arm scallop. A binder of this size, if properly ad- justed, will fit a patient of any size. Three will be sufficient for the case. Abdominal Binders— The abdominal and breast bind- ers are worn during the bed period only. The abdom- inal binder is made of unbleached muslin, double ma- terial, 14 by 40 inches, and hemmed. In the center of the back, on the lower edge, a curved space, six inches wide, is cut out to prevent the binder from getting soiled. To this curved edge, the pad holder is attached by two safety pins, one on either side. The abdominal binder is adjusted by pinning firmly above the fundus, and loosely below. Pad holders are made of unbleached muslin, and meas- use 6 by 16 inches. Cord Dressings.—Cut squares of surgical lint 4 by 4 inches, and cut through to the center on one side. Gauze may be used, but it is not ideal. Nursery Cotton.—Tear absorbent cotton into narrow lengths and pull out small one inch pieces. Roll them, place in a clean bag and sterilize. Applicators.—Use absorbent cotton and toothpicks. Tear off small pieces of cotton, moisten the toothpick point with Avater, place in the middle of the cotton, and roll firmly. Gauze Sponges.—Cut gauze into squares 6 by 6 inches, and fold from each side to the center. This brings all the ragged edges inside. Fold into squares, place in jars, and sterilize. Sterilization of Instruments.—Place scalpels in car- CLEANLINESS AND STERILIZATION 353 bolic acid 95 per cent for ten minutes. Lift with sterile forceps, and put in a basin of 95 per cent alcohol for ten minutes. In the absence of carbolic acid and alcohol, the scalpels may be dropped in a 2 per cent solution of lysol for twenty minutes. Cleanse with hot sterile water. (Do not boil scalpels; it dulls the sharp edges.) All other instruments may be placed in a sterilizer (dishpan or wash boiler) with enough water to com- pletely cover them; boil twenty minutes. Cool in sterile pan, which may be set in cold water. Do not use soda on the instruments during sterilization, as it makes a thick, gummy precipitate on the metal. The sterile handling forceps must be immersed at all times for two-thirds their length in 95 per cent alcohol. Brushes.—After using, all brushes should be thor- oughly washed, boiled, and dried, wrapped in waxed papers, and sterilized in the autoclave. In the absence of the autoclave, boil thirty minutes. Basins, pitchers, and douche pans are sterilized by wrapping in strong muslin bags and put to boil for forty-five minutes in the basin boiler or wash boiler. They will not remain sterile longer than one week, even when kept in a clean place and well wrapped. Bedpans should be washed in a strong solution of soap and water, rinsed every morning and boiled for thirty minutes. Sterilization of Rubber Goods.— Tracheal Catheters.—Drop in a solution of bichloride 1: 5000 and leave for twenty minutes. Lift with sterile forceps into a basin of warm sterile water and leave for ten minutes, or until used. Voorhees Bags.—Boil twenty minutes. The bags and catheters may be given a longer life by keeping them in a 25 per cent solution of glycerine and water when not in use. Kerosene vapor is also preservative. 354 OBSTETRICS FOR NURSES Rubber Catheter.—Boil twenty minutes. Hot Water Bags, Ice Caps, Rubber Bed Rings.—Soak in 10 per cent lysol solution for two hours, wash with warm water, and dry thoroughly. The inside of the ice caps can he dusted with powder. Never leave rubber gloves in a damp place or lying in a solution. It stretches them and weakens the rub- ber. To sterilize, they must be washed in a strong solu- tion of soap and water, dried, and paired. Then they are wrapped in a heavy cloth covering and put in the autoclave for twenty minutes. Wet Process for Rubber Gloves.—Wrap in gauze or cloth and boil for thirty minutes. Lift with sterile for- ceps and place in lysol solution 1 per cent until used. They are easily drawn on by filling them with the solu- tion as the hand goes in. The autoclave is not always available, but an Arnold or Rochester sterilizer is readily portable, and takes the place of the hospital machine. Fumigation of rooms is sometimes necessary. Re- move all curtains, bed linen, and other washable fabrics from the room. Open the drawers of dressers, doors of closets, and loosen up and separate everything left so the air can get to it. Close the windows and seal the crevices with cotton and make the room as air-tight as possible. Place a large pan containing six ounces of potassium permanganate crystals in the center of the room. Pour over this twelve ounces of formalin, close and seal the outside doors of the room and leave for twelve hours. If the case has been a very septic one, it is always a good plan to wash the walls of the room before using again. The insides of the drawers and the bed should be thoroughly washed with water and green soap. A formaldehyde lamp is also quite satisfactory if obtainable. CHAPTER XXIV DIETS AND FORMULAE The nurse should serve everything in the most cleanly and appetizing way if it is only a cup of tea; and all waste, soiled dishes, napkins, and excreta must be re- moved as delicately as possible. Diet for Pregnancy.—Fresh fish, boiled, broiled or baked; and shell-fish raw or cooked,—any way but fried. Meat, once or twice a day, except when contra- indicated by condition of the kidneys. Veal is best omitted. All farinaceous foods and vegetables may be eaten freely. Desserts should be plain, but tempting. No alcohol is taken without direct permission from the doctor, and coffee and tea should be limited. Diet for Puerperium.—First two days, milk, butter- milk, soup, gruel, cocoa, toast and tea, chicken, oyster and clam broth. In the next two days, under ordinary conditions, the diet is increased and made somewhat heavier. Semisolids are added like milk-toast, eggs, poached or boiled soft, oysters, clams and boiled fish. After the milk comes in, the woman is put on a general diet as fast as she can digest it. Farinaceous diet—melons and oranges.— Breakfast.—Cereal, coffee with milk and sugar, if de- sired, bread and butter, corn bread, rolls, toast, muffins, hominy, cereal with cream. 356 OBSTETRICS FOR NURSES Lunch.—Vegetable soups, bread, butter, potatoes, beaus, rice, macaroni and cereal, peas, buttermilk, pud- ding, such as rice, tapioca, bread cornstarch, jellies, fruit juices, pumpkin, squash, turnips, tomatoes, etc. Dinner.—Bread, butter, milk-toast, hominy, rice, celery, fruit salads, lettuce, apples, pears, prunes, stewed fruits or fresh melons, etc. The following diets are routine at many hospitals: General Diet.—Full tray of food in season as fur- nished by the hospital. Three meals daily. Light Diet.—Foods from the following list may be selected, and served three or five times daily, as de- sired : Soups of all kinds. When leguminous foods are em- ployed, their outer coverings must be removed by rub- bing them through a sieve or colander. Vegetables of all kinds, except green vegetables (pro- vided they have been reduced to a pasty consistency). Those with excess of fiber or cellulose, such as turnips, celery, asparagus, and cabbage, should be chopped after thorough boiling, then mashed, while those having tunics should be sieved or colandered. Grain foods of all kinds thoroughly cooked, excepting corn preparations containing much cover, as hulled corn. Prepared foods such as tapioca, macaroni, and vermi- celli, require prolonged cooking. Meats, scraped beef. Eggs, soft boiled, raw or soft poached. Bread of all kinds, stale, homemade. Puddings, ices. Beverages, all kinds unless otherwise ordered. Forced Diet.—This includes the general diet with the addition of one quart of whole milk and four eggs. The DIETS AND FORMULAE 357 milk may be given plain or as an eggnog at seven, ten, three, and eight o’clock. The eggs may be given raw or cooked soft in any form. Milk Diet.—Twelve ounces of whole milk (375 c.c.) may be given every two hours; i. e., at six, eight, ten, twelve, two, four, five, and eight o’clock, or the patient may sip it at her pleasure. The milk may be given raw, boiled, diluted with plain water, lime water, Vichy, seltzer, or Apollinaris to taste. The daily amount should include three quarts of whole milk. Koumiss, buttermilk and milk soups are sometimes allowed. Note the exact amount taken, and give reasons for failure. Watch the stools for undigested milk. Liquid Diet.-—Whole milk, buttermilk, koumiss, beef tea, or beef, chicken, mutton, oyster, or clam broth, in eight ounce portions, or two ounces of beef juice, every two hours. Lemonade, orangeade, ice cream, or fruit ices, at intervals and amounts as desired. Ulcer Diet.—Whole milk and cream, equal parts, three ounces every two hours. Sodium bicarbonate, thirty grains, in a small amount of water, to be given before and thirty minutes after feeding. Albumin water, soft boiled eggs, scraped beef, custard, and cream soups to be added later by direction of the physician. No seasoning except salt is allowed. Prochownik Diet.-—This diet is advised where some necessity exists for preventing a large child. It is ad- ministered in the last six weeks of pregnancy only. Breakfast.—Small cup of coffee, two slices of toast (1 ounce). Lunch.—Small piece of meat, fish or an egg, a little sauce. A vegetable prepared with fat, lettuce, a small piece of cheese. Dinner.—Same as lunch with three slices of bread and butter, and a little milk. 358 OBSTETRICS FOR NURSES A pint of water daily is allowed; taken in sips it lasts longer. Soup, water, beer (all fluids) and sugar, pastry, and potatoes are forbidden. Skimmed Milk Diet (Karell).—Skimmed milk, to which a pinch of salt is added, 3 to 6 ounces, three or four times daily, increasing the amount gradually, taken slowly to allow thorough mixture with saliva, warmed in winter, room temperature in summer. Acute Nephritis Diet.—Whole milk, 1000 c.c.; cream, 250 c.c.; water, 150 c.c.; stewed fruit, well sweetened, 50 c.c. Bread, well buttered, may be toasted, 150 gm. (equal to three slices) 150 gm. Green salad of lettuce, celery, apple, pear or grape fruit, and served either with olive oil, or with a mayon- naise dressing made from olive oil, egg and lemon juice, with salt (but no pepper or condiments) may be given in two small portions daily. Cooked cereals (cream of wheat, etc.) with cream and sugar, one portion equal to about two ounces, once daily. The above represents a daily fluid intake of about 1500 c.c. The diet is to be given in “three meals,” at eight, one, and six o’clock, with fluid nourishment at eleven, three, and nine o’clock. RECTAL FEEDING Nutrient enemas should be given every six hours, un- less otherwise ordered. It is necessary to cleanse the lower bowel with a saline or soapsuds enema at least once a day. The cleansing enema should be given one hour before the nutrient enema is to be given. The proper quantity for the nutrient enema is four to six DIETS AND FORMULAE 359 ounces for an adult, and one to three ounces for a child. Nutrient enemas should be given slowly at very low pressure, the level of the fluid in the can being not over eight to ten inches above the level of the rectum. If the injected material is thick, a piston syringe may be re- quired. The patient should be placed upon the left side with the hips well elevated and should be kept in that position for fifteen to twenty minutes after the enema has been given. The tube should be oiled and not be inserted more than three or four inches. The tempera- ture of the enema should be about 98 degrees. If there is a strong tendency to evacuate the enema, pressure should be made against the rectum with a pad. The following nutrient enemas may be ordered by name. Glucose Enema.—Glucose (dextrose, grape sugar) 1 ounce, normal salt solution 5 ounces. The glucose should first be dissolved in hot water. The amount of glucose may be increased, upon order, if no irritation is produced. Pancreatinized Milk Enema.—Add 1 tube of peptoniz- ing powder, or 1 to 2 drams of “Pancreatic solution” to 1 pint of skimmed milk. Stir well and place in a warm water bath for one-half hour. Add 1 dram of salt. Milk and Egg’ Enema.—Thoroughly beat the whites of 2 eggs, add 1/3 dram of salt, and 6 ounces of skim- med milk. Add one tube of peptonizing powder, or 1 to 2 drams of “pancreatic solution,” stir well, and place in a warm water bath for one-half hour. Milk, Egg, and Beef Juice Enema.—Mix the beaten whites of 2 eggs, 2 ounces of fresh beef juice, 6 ounces of skimmed milk, and 1/3 dram of salt. Add 1 tube of peptonizing powder, or 1 to 2 drams of “pancreatic solution,” stir well, place in a warm water bath for one-half hour. 360 OBSTETRICS FOR NURSES Milk and Glucose Enema.—Add 1 tube of peptonizing powder to 6 ounces of skimmed milk, stir well, place in a warm water bath for one-half hour. Add 3 drams of glucose and 1/3 dram of salt. ELIMINATIVE ENEMAS Impaction Enema.— Castor oil or olive oil, 1 ounce. Soapsuds (100° F.), 1 quart. Mix as thoroughly as possible, add one dram of spirits of turpentine beaten up with the yoke of one raw egg. Soap Suds Enema.—Use 1 ounce of dissolved hard soap to a quart of warm water. S. S. and G. Enema.— Soapsuds, 1 quart. Glycerine, 1 ounce. Asafcetida Enema.— Milk of asafcetida, 8 ounces. Water, 8 ounces. 1-2-3 Enema.— Magnesium sulphate, 1 ounce. Glycerine, 2 ounces. Water, 3 ounces. Milk and Molasses Enema.— Milk, ordinary cooking molasses in equal parts, possibly 8 ounces of each. Heat, bnt do not boil. Turpentine Enema.— Soapsuds, 1 pint. Turpentine, 1 dram. It acts quickly and effectively. DIETS AND FORMULAE 361 All enemas should be given through a colon tube. The patient should be on the left side and the tempera- ture of the injection should be about 100° F. DIET LIST (FLUIDS) Albumin Water.—Take white of 1 egg, stir until separated. Add a little lemon juice and 1 pint of water. Ice and serve. Sugar or salt may be used. Barley Water.—Wash 2 ounces of barley with cold water. Boil for 5 minutes in fresh water. Strain. Then cover with 2 quarts of water and cook slowly down to 1 quart. Flavor with thinly cut lemon rind and sugar. Do not strain unless patient requests. Beef Juice.—Cut into cubes V/2 inches each, 1 pound round steak. Place in a clean, ungreased pan, and fry one and one-half minutes on each side. Pour into hot meat press and apply pressure. In absence of a press, a potato ricer may be used. Season with salt and pep- per. May be served iced or heated by putting in double boiler and stirred all the time. Do not allow to curdle. Beef Tea.—Put 1 pound of finely chopped round steak into a quart glass jar, fill with cold water. Place jar in kettle of warm water. Leave over slow fire for four hours. Strain, season with salt and pepper. Champagne Whey.—Boil 8 ounces milk for fifteen minutes. Strain through cheesecloth. Add l]/2 ounces champagne. Chicken Broth.—Skin and chop in small pieces one small or one-half large fowl. Boil bones and all with one blade of mace, a sprig of parsley, and 1 table- spoonful of rice, 1 crust of bread and 1 quart of water, for one hour. Skim from time to time. Strain through coarse colander and season to taste. 362 OBSTETRICS FOR NURSES Cinnamon Water.—One-half ounce stick cinnamon, 2 cups boiling water. Break sticks in small pieces. Add water, boil twenty minutes. Strain and serve hot or cold. Clam Broth.—Wash thoroughly 6 large clams in shell. Put in kettle with 1 cup of cold water, bring slowly to boil, and keep temperature for one minute. Pour off broth and serve hot. Add salt and pepper. Eggnog’.—Beat an egg, white and yolk separately. Add to the yolk 1 dram of vanilla extract, a pinch of salt and 4 oz. fresh milk, and 1 dram of sugar. Add dram of sugar to white of egg, stir a portion into the glass and heap remainder upon top of glass. Egg Cordial.—One egg white, 1 teaspoon sugar, 1 tablespoon brandy, 2 grains salt, 2 tablespoons cream. Beat white until stiff. Add cream, continue beating, add other ingredients, and serve cold. Egg Lemonade.—Beat 1 egg and 1 teaspoonful of su- gar until very light, add i/4 cake of yeast dissolved in one-fourth cup of water, two tablespoonfuls of sugar, pour into bottles with patent stopper, fill bottles only two-thirds full, cork tightly. Shake well. Allow to stand on ice twenty-four hours. Flaxseed Tea.—One ounce of whole flaxseed, 1 ounce powdered sugar, ounce licorice root, 1 ounce lemon juice. Pour over these materials 1 quart of boiling water and allow to stand four hours. Strain off liquor. Gum Arabic Water.—Dissolve 1 ounce of gum arabic in 1 pint boiling water. Add ounce sugar, a wine- glassful of sherry, and juice of one lemon. Serve with ice. Junket.—Take pint of fresh milk in a saucepan. Add 1 teaspoonful of essence of pepsin, stir just enough to mix. Pour into custard cups. Let stand until DIETS AND FORMULAE 363 firmly curded. Serve plain or with grated nutmeg. Sherry may be added. Koumiss.-—Heat four cups of milk, then cool; when lukewarm, add 14 cake of yeast dissolved in one-fourth cup of water, two tablespoonfuls of sugar, pour into bottles with patent stopper, fill bottles only two-tliirds full, cork tightly. Shake well, allow to stand on ice twenty-four hours. Milk Shake.—White of 1 egg, 1 ounce sugar, 1 ounce chipped ice, 1 ounce cream. Shake in milk shaker two minutes. Add milk to fill glass. Flavor with vanilla and lemon. Mutton Broth.—Boil slowly l]/2 pounds of lean loin mutton, including the bone. Add a little salt and J4 onion. Pour broth into a basin. Skim off; fat when cool. Warm as used. Oatmeal Gruel.—One teacup oatmeal flakes, cover with 1 quart cold water. Place on slow fire and soak three hours. Strain, add 4 teaspoonfuls of sugar and 1 tea- spoonful of salt. Oatmeal Water.—Cover 1 teacupful oatmeal with 1 quart cold water. Let it stand two hours. Stir often. Strain. Serve with salt, sugar and ice. Peptonized Milk. Warm Process.—Dissolve the con- tents of Fairchild’s peptonizing tube in 4 tablespoonfuls cold water. Add to 1 pint of milk. Put in glass jar, and place jar in vessel of warm water. Ileat slowly to 115° F. Stir slowly and allow it to remain thirty minutes. Place on ice at once to check further digestion. Peptonized Milk. Cold Process.—In a clean quart bottle, put one peptonizing powder (Fairchild). Add 1 teacupful of cold water. Shake. Add 1 pint fresh cold 364 OBSTETRICS FOR NURSES milk. Shake well. Place on ice. Do not heat before using. Rice Water.—Pick over and wash 2 tablespoonfuls of rice. Put in a saucepan with 1 quart of boiling water; simmer two hours. When rice is dissolved, strain. Add teaspoonful salt. Serve warm or cold. Sherry may be added. Rum Punch.—Two teaspoonfuls powdered sugar, 1 egg well beaten, warm milk, 1 large wineglassful; 4 ounces Jamaica rum. Flavor with nutmeg. Scraped Beef.—Place on breadboard a round steak. Scrape with tableknife but do not take any shreds of muscle. Salt and pepper. Spread on thin slices of bread. Place in toaster until seared. Toast Water.—Three slices of stale bread well browned, but do not burn. Put in a pitcher, pour over them 1 quart boiling water. Cover closely, and allow to stand until very cold. Strain. Wine and sugar may be added, to stimulate. Wine Whey.—Put 1 quart new milk in a saucepan and place over fire. Stir until nearly boiling. Add 2 ounces of sherry wine. Boil slowly for fifteen minutes. Skim off curds as they arise. Add 1 tablespoonful sherry. Skim again, then strain through gauze. CHAPTER XXV solutions and therapeutic index Acid, Boric. 5 dr. in a pint of water makes a 4% solution, or 1:25. Acid, Carbolic. 15 TT\_ in a quart of water makes a 0.1% solu- tion, or 1:1000. 5 dr. to the quart makes a 2% solution; and 1% oz. to the quart, a 5% solution. Formalin. 1 dr. to the quart of wrater makes a solution of about 1:500. Mercury Bichloride. 15 gr. to quart of water makes a 0.1% solution, or 1:1000. 1% gr. to the quart makes a 0.01% solu- tion, or 1:10,000. Normal Salt Solution. 2 dr. of salt to the quart of water, or 0.9%. Physiological Salt Solution. Take normal salt solution as given above and to every 314 oz. add 15 gr. of carbonate of soda. Potassium Permanganate. 2% dr. to the quart makes a 1% solution. 3 gr. to the quart makes a 1:5000 solution. Silver Nitrate. 4% gr. to the ounce of water or 1 gr. to 1-7/10 dr. makes a 1% solution. For general reference the following valuable table is appended: 366 OBSTETRICS FOR NURSES Quantity GRAINS OF SALT OR DRUG REQUIRED TO MAKE SOLUTIONS OF PERCENTAGE STRENGTH INDICATED tion to be till made 0.5% 1% 2% 3% 4%. 5% 6% ' 8% ' 1 1 i 10% 15% 20% 25% 50% 1:500 1:1000 1:2000 1:3000 t :4000 1:5000 Vz fl. oz. . 1.15 2.3 4.6 6.9 9.3 11.7 14.1 19 24 36.8 50.2 65 151. 2 0.46 0.228 0.12 0.075 0.06 0.05 1 fl. oz. • ■ 2.3 4.6 9.2 13.9 18.6 23.4 28.2 37.9 47.9 73.5 100.3 130 302.5 0.91 0.456 0.23 0.15 0.12 0.09 2 fl. oz. • • 4.6 9.2 18.4 27.8 37.2 46.8 56.4 75.8 95.8 147 200.6 260 605 1.8 0.91 0.46 0.3 0.23 0.18 3 fl. oz. • • 6.9 13.8 27.6 41.7 55.8 70.2 . 84.6 113.7 143.7 220.5 301 390 907.5 2.7 1.37 0.68 0.46 0.34 0.27 4 fl. cz.. . 9.2 18.4 36.8 55.6 74.4 93.6 112.8 151.6 191.6 294 401.2 520 1210 3.64 1.82 0.91 0.61 0.46 0.36 5 fl. oz.. . 11.5 23 46 69.5 93 117 141 189.5 239.5 367.5 501.5 650 1512.5 4.55 2.28 1.14 0.76 0.57 0.46 The table shows the quantity of drug required to yield a given volume of solution of the percentage strength desired. Thus, to make one fluid ounce of a 5 per cent solution it is merely necessary to dissolve 23.4 grains of the salt in suf- ficient water to make one fluid ounce. PERCENTAGE SOLUTION TABLE By Alfked I. Cohn, Phar. D., in Merck’s Report THERAPEUTIC INDEX 367 THERAPEUTIC INDEX Young’s Rule for Dosage: The age of the child is di- vided by the age of the child plus 12, and the result is the appropriate dose for the child. The doses given below are for the adult unless otherwise specified. Absorbent. A medicine or dressing that promotes absorption, such as potassium iodide, Tr. iodine, glycerine, or hot vaginal douches. Adrenalin. The blood-raising principle of the suprarenal glands. It is hmmostatie and astringent. Acts somewhat like digitalis on the heart. Uses.—Vomiting of pregnancy, increased glandular activity, haemorrhage, inflammation of mucous membranes. Dose.—Internally, 5-10 m. of the 1:1000 solution. Extern- nally, the solution of 1:1000 or 1:10,000 may be applied. Albolene. An oily white substance obtained from petroleum. It is used on the nipples and skin of the mother and to remove the vernix caseosa from the skin of the child. Aloin, Strychnia, and Belladonna. A laxative pill which usually contains aloin 1/6 gr., strychnia sulph. 1/60 gr., and Bella- donna 1/12 gr. Ammonia Carbonate. Antispasmodic, stimulant, and expecto- rant. Uses.—Stimulant to heart. Stimulating expectorant in pneu- monia and bronchitis. Dose.—5-20 grains in mucilage or syrup. Ansesthone. A mixture of adrenalin chloride (0.1%) and chloro- tone (5%) in an ointment base of wool fat and petrolatum. Astringent, antiseptic, anesthetic and germicide. Useful ap- plication to swollen mucous membranes or in coryza. Argyrol (Silver Vitellin). Antiseptic and germicide. Uses.—Like Silver Nitrate, but less irritating to the tis- sues. 3-5% solution in water is an injection for gonorrhoea. 15% solution dropped in the eyes of the new-born may pre- vent ophthalmia, 25% solution may be used twice a day as a remedy for existing ophthalmia, but the strength should be reduced after three or four days. 10-15% solution is used as an injection in cystitis. An ounce or more of the solution may be left in the bladder until the next evacuation. Asafcetida. A fetid gum resin. Carminative, antispasmodic, mild stimulant, and expectorant. Uses.—Gas pains of adults and infants. Hysteria and in- digestion. Dose.-^5-10 gr. t.i.d. For infantile colic, an emulsion called the mistura of asafcetida may be used in 2-4 dram doses. For adults 1-2 tablespoonfuls. 368 OBSTETRICS FOR NURSES Babcock’s Motiya Powder. A talcum powder for the toilette which contains .001% formalin. It is a deodorant to the axilla and other folds of the body. Useful to dry up moist eczemas aud intertrigo. Belladonna. Nervine, mydriatic, sedative, narcotic, antispas- modie and anodyne. Makes the throat dry and dilates the pupils. Uses.—Night sweats, nervous cough, pain, incontinence of urine and to restrain glandular activity. Dose.—FI. ext. 1-3 H\,; dry ext. %-l gr. Tincture 8-20 Tl\. Solid ext. 1/2-1A gr. All for adults. For infants, proportion- ately less. See Buie for Dosage. Benzoin. Antiseptic and externally a styptic and protective for sores. Uses.—Sore nipples and urticaria. Lard is also benzoin- ated for use in removing vernix caseosa. Compound Tr. of benzoin contains, benzoin, purified aloes, storax, balsam of Peru, and alcohol. Benzoinal, Albolene mixed with benzoin. Bismuth Subnitrate. A white heavy powder. Antiseptic and astringent. Uses.—Subacute gastritis, pyrosis, diarrhoea and vomiting of pregnancy. Particularly desirable in infancy because it is free from arsenic, lead and silver. Dose.—5-60 gr. in the adult. Boric Acid (Boracic Acid). A white crystalline powder. Anti- septic. Uses.—As a dressing and lotion for eyes, navel, mouth, nip- ples, and all mucous surfaces. In solution to preserve the sterility of rubber nipples until they are needed. Dose.—Internally, 5-15 gr. Solutions are usually about 4% or 5%. A saturated solution in water is about 6%. In hot water 25%. Boroglyceride. An antiseptic paste of boric acid and glycerine. When an excess of glycerine is present the preparation is called boroglycerol. Uses.—An oxydizer in endometritis. It is applied to the cervix on cotton tampons. Calcium (Lime). Stomach sedative, soothes the irritated or burned skin, corrects hyperacidity, increases the clotting power of the blood (?). Lime water is a saturated solution of calcium hydrate and is used for nausea, to break up the curds of milk, and to increase its digestibility. It is mildly constipating. Calomel. See Mercury. Camphor. A solid volatile oil. Nerve sedative. Anaphrodisiac. Antispasmodic. Stimulant. Uses.—The monobromated camphor is given internally for hysteria, neuralgia, and as a hypnotic. Dose.—1-10 gr. THERAPEUTIC INDEX 369 Camphorated Oil. A solution of camphor in cottonseed oil. Rube- facient and stimulant. Uses.—Internally in collapse. Externally as an application to the child for colds of chest and nose. Dose.—5-20 Tlf hypodermically in collapse. The injection should be made deep into the muscle. Carbolic Acid (Phenol). Derived from coal tar. Antiseptic, deodorant and local anaesthetic. Uses.—Vomiting of pregnancy, pruritus, eczema, steriliza- tion of instruments. Usual solution is 2%% to 5%. For sterilization of knives, scissors and other sharp instruments the 95% is used. In pruritus, the following wash will aid: carbolic acid, 12 dr., glycerine 2 dr., alcohol, 4 3 water q.s. 1 pt. Apply. Cascara Sagrada. Stimulant laxative, and cathartic. Useful in pregnancy, but after labor there is evidence that it may go over in the milk to the child. Dose.—FI. ext. 10-20 HD The Hinkle pill contains cascara. Castor Oil. Oil expressed from the seeds of the castor plant. A cathartic. Acts in four or five hours. Dose.—For adults, % oz. to 1 oz. For infants 10 to 60 drops given with a dropper—not with a spoon. Castor oil cocktail.—Rinse out. the glass with lemon juice or whiskey. Pour in teaspoonful of lemon juice and a teaspoonful of whiskey, add castor oil in amount required, cover with whiskey and give. A paste is made from the mixture of castor oil and bismuth subnitrate in equal parts, which is an excellent prepara- tion for sore nipples. Cerium Oxalate (and Cerium Valerianate). Sedative and nerve tonic. The oxalate is a white crystalline powder, odorless and tasteless. Uses.—Vomiting of pregnancy, seasickness. Dose.—2-10 gr. several times daily. Charcoal. Administered in tablet form or as a powder between two slices of buttered bread. Uses.—Acid stomach. Vomiting of pregnancy. Chinosol. Nonpoisonous, nonirritating and odorless. Antiseptic deodorant, styptic and analgesic. Dissolves instead of coagu- lates secretions. Uses.—Antiseptic solutions for hands and sponges, deodoriz- ing wash for vagina post partum, intrauterine douche, wash for gonorrhoea and cystitis. Dose.—For douche or hand solution 1:1000 or 1:5000. For dusting powder, 1 part to 10 or 20 of starch, talcum, boric acid, or bismuth subnitrate. . : Chinosol will corrode unplated steel. It may be mixed with salt, but not with soap. 370 OBSTETRICS FOR NURSES Choral Hydrate. White crystal masses. Pungent in odor and taste. Hypnotic, antispasmodie, antiseptic and analgesic. Uses.—Insomnia, eclampsia, convulsions, and to restrain se- cretion of milk. Dose.—By mouth, 10-30 gr. By rectum, not to exceed 60 gr. In infants 1-2 gr. by rectum in an ounce of water. Chymogen. A preparation of rennin (10%) made by Armour & Company. Coagulen Ciba. A physiological nontoxie styptic, prepared from the natural coagulents of the blood. A 10% solution in water will hasten the beginning and end of coagulation. May be applied to bleeding surfaces directly, or given under the skin, into the muscle, or into a vein. 3y2% to 5% solu- tion in distilled water, should be sterilized by boiling 2-3 minutes. Do not filter. Inject. Cocaine Hydrochlorate. Ana3sthctic, sedative, anodyne, anti- pruritic. Uses.—Vomiting of pregnancy, with caution. Dose.—Internally %-ly2 gr. Externally a 4%-10% solution in water. Codeine. Alkaloid of opium. Less narcotic than morphine. Uses.—After-pains and pain of over-distended breasts. Dose.—%-l% gr. by mouth. %-% gr. hypodermically. Compound Licorice Powder. See Senna. Condylomata. Use—■ B Acid. Salicyl. gr. x Acid Boric. gr. xxx Calomel. 3 i M. Sig.: Apply twice daily. Dermatol. The subgallate of bismuth. A yellow astringent anti- septic powder. Uses.—Externally on wounds, umbilical stump and as a desic- cator in cases of multiple abscess. Internally for diarrhea in doses of 10-30 grs. Digitalis. Cardiac tonic. Diuretic. Stimulant. Uses.—Weak heart. Syncope. Collapse. Dose.—For adult: of the tincture, 5-15 Til, fl. ext. 1-3 TIL, ext. gr. y6-y2. Digipuratum. A preparation of digitalis from which the inac- tive substances have been removed. It is used in the same conditions as digitalis. Dose.—The tablets contain 1% gr. and one is given four times daily until ten are taken. Then stop. Hypodermic- ally. Each viol contains 1 c.c. of fluid and equals 1 y2 gr. of digipuratum. Each dose contains enough of the active principle of digitalis to kill a 30 gm. frog. THERAPEUTIC INDEX 371 Ergot (Fungus of Bye). Contracts unstriped muscle fiber. Uses.—To check haemorrhage after labor. To promote in- volution. Must not be given in labor until the uterus is empty. Dose.—By mouth 15-60 Tfi, of the fl. ext. Hypodermically, 10-20 Iff. Ergotole, Ergotine. Concentrated solutions of ergot, 2times as strong as the fluid extract. They are sterilized and preserved in glass ampoules. Uses.—See Ergot. Dose.—30-60 Iff. Green Soap. A soap made of linseed or other oil, potash, alco- hol and water. ‘ ‘ The adoption by the TJ. S. Pharmacopoeia of the term Sapo Yiridis (green soap) is unfortunate, since soft soap even if made from green hempseed oil will become brown-yellow unless artificially colored. ”—U. S. Dispensatory. Haemophilia. A condition of the blood wherein its clotting power is diminished or absent. Coagulen, horse serum, or diphtheria antitoxin may be given hypodermically. Direct transfusion of blood from another is best. Hyoscine, Morphine, and Cactin. (H. S. & C. Tablets). A pro- prietary combination of drugs. The action is said to be similar to that of morphine and scopolamine. Iodine, Tincture. Uses.—To sterilize the skin before operation. In vomiting of pregnancy it is sometimes effective. Drop doses may be given well diluted. Externally it is applied to ulcers, as in Bednar’s disease, and sometimes as a dressing for the cord. In pruritus vulvse it is a valuable application. Iron. Tonic emmenagogue. Uses.—To increase the number of red blood corpuscles. To raise blood pressure and to increase the secretion of milk. Dose.—3-5 gr. Blaud’s pill contains the carbonate in a form that is easily assimilated. Laxatives. Laxatives are unirritating and excite moderate peristalsis. Sulphur, magnesia, cassia, manna, cascara sagrada, the Hinkle pill, and the A, B & S pill are usually mild in action. Lysol. Disinfectant and antiseptic for hands and instruments. It is a brown syrupy fluid made from coal tar oil, which is distilled and mixed with fat, soap, etc. It has a creosote odor and contains 50% cresol. Readily soluble in water. Used in %-4% solutions. Magnesia, Calcined. Antacid and cathartic. Comes in white cakes. Uses.—Acid stomach, vomiting of pregnancy, * ‘ heartburn, ” and constipation. Dose.—30-120 gr. 372 OBSTETRICS FOR NURSES Magnesia, Milk of. A mixture of magnesia and water. Has the same properties as the above. Dose.—For adults, 2-3 teaspoonfuls. For infants, \i-2 tea- spoonfuls. Magnesia Sulphate (Epsom Salts). Saline cathartic. Uses.—The profuse watery stools produced by magnesia are valuable aids to elimination when the kidneys are over- worked or defective. In congestion of the breasts and threatened eclampsia, or in any case where it is desirable to drain off waste or dehydrate the system. Dose.—1 teaspoonful daily in hot water before breakfast. %-l oz. as a single dose or 1 oz. by rectum, as in the 1-2-3 enema. Menthol (Mint Camphor, Japanese Peppermint). Analgesic, anti- septic, anaesthetic, and vascular stimulant. Uses.—In pruritus vulva?, vomiting of pregnancy, and haemor- rhoids. Dose.—By mouth 3-5 gr. In tampons, one part to five of oil. In ointments one part to sixteen. To the vulva for pruritus, use the spirits in 5% solution. Mercury (Hydrargyrum). Cathartic, alterative, antisyphilitic, antiseptic and disinfectant.. Readily absorbed by the un- protected mucous surface and relatively inert when the membrane is covered by a discharge. Solutions of the bi- chloride when used as a lotion unite with the albumin of a mucous discharge and form an albuminate of mercury, which is inactive. Bichloride solutions have small place in obstetrics. They are hard on the hands and destructive to instruments. Other agents like lysol, ziratol and chinosol have satisfactory germicidal properties and in addition are nonpoisonous, lubricative and cleansing. Mercury should only be given to the infant in the form of calomel (the mild chloride). The dose is gr., repeated if necessary. Morphine. Alkaloid of opium. Antispasmodic, hypnotic, analgesic and narcotic. Uses.—'To relieve pain, produce sleep, check diarrhoea, and to control the pain, as well as the contractions of abortion. To relax a rigid os. Dose.—In “Twilight Sleep” and rigid os the first dose is Morph, sul. %-Yt gr. and scopolamine hydrobromid 1/200- 1/150. The scopolamine to be repeated if required, in one- half or three-quarters of an hour. The usual dose of mor- phine hypodermically is gr- Nitroglycerine (Glonoin). Vasomotor dilator, arterial stimulant. Uses.—For the prostration following haemorrhage. Dose.—1/200-1/50 gr. hypodermically. Novocaine. Local anaesthetic, similar to cocaine, but less toxic. For local anaesthesia in solutions of 0.25% to 2% usually in association with adrenalin (5-10 drops of the 1:1000 solu- tion to each 10 c.c. of novocaine solution). THERAPEUTIC INDEX 373 Nux Vomica. The plant from which strychnia is derived. Tonic, stomachic, and stimulant to muscle, nerve, and heart. Uses.—Bitter tonic and stimulant. Vomiting of pregnancy and agalactia. Dose.—Ten drops of the tincture in -water before meals. Opium. The concrete juice of the poppy. Believes pain. Con- stipates. Uses.—Haemorrhoids in adults, colic and diarrhoea in infants. Dose.—One grain in suppository night and morning for adult. For infant, as paregoric only. Two to five drops only, not repeated. Children bear opium, badly. Pepsin. A ferment in the gastric juice that digests proteins. In commerce it is obtained from the pig. Uses.—Imperfect digestion. Dose.—For adult, 10-15 grs. For infant, 2 gr. Phenolphthalein. A nonofficial coal tar derivative. Mild laxa- tive. Dose.—2-3 gr. Phenolax and chocolax are preparations of the drug. Pituitary Extract (Pituitrin). A substance derived from the infundibular portion or the posterior lobe of the hypophysis cerebri. Nontoxic, stimulant to unstriped muscle. Uses.—Uterine inertia, post partum haemorrhage, Caesarean section and tympany. Will not produce abortion nor pre- mature labor. May be tried in acute anaemia to raise the blood pressure. Dose.—5-15 UL. Repeated if necessary. Potassium (or Sodium) Bromide. White granular powder. Sol- uble, 1 to 5 in water. Sedative, hypnotic, antiepileptic. Uses.—Neurasthenia, convulsions, nymphomania, vomiting of pregnancy. Dose.—20-60 gr. In enema with chloral. Pot. bromide 40 gr. and chloral 20 gr. in several ounces of water or milk. Potassium Iodide. Alterative emmenagogue. Uric acid solvent. Uses.—Syphilis rheumatism, swellings, slow inflammations, excessive secretion of milk. Dose.—2-10 gr. increased as required. Potassium Permanganate. Dark purple opaque prisms. Soluble in water 1 to 16. Disinfectant, deodorant, antiseptic, astringent. Uses.—As an injection in leucorrhcea and gonorrhoea, 1:5000 solution. Purgatives. Simple purgatives produce free discharges from the bowels with some griping. Senna, aloes, rheubarb, castor oil, and calomel arc examples. Saline purgatives are fol- lowed by profuse watery evacuations. Magnesia sulphate, and citrate, potassium and sodium tartrate, and sodium phosphate belong to this class. Drastic purgatives bring about a violent action of the bowels with much griping and tenesmus. Such are jalap, eolocynth, 374 OBSTETRICS FOR NURSES elaterium, and croton oil. Hydrogogue purgatives combine the results of the salines and drastics. They have much griping with profuse watery stools. The hydrogogues are elaterium, gamboge, croton oil, and potassium bitartrate. Quinine Sulphate. (Derived from Cinchona bark.) Antipyretic, tonic, antiperiodic, antiseptic, emmenagogue and ecbolic. Uses.—Valuable stimulant in a slow first stage. It is com- bined with castor oil to bring on labor at term. Castor oil 1 oz. and quinine sulphate 10 gr. is given as the first dose, fol- lowed in an hour by another 10 gr. of quinine, and an hour later by another. Dose.—2-20 gr. Regulin. A mixture of agar-agar in dry form with extract of cascara sagrada. Uses.—A laxative in chronic constipation. Dose.—Teaspoonful to tablespoonful in stewed fruit or mashed potatoes, once daily. Russian Oil (Liquid Petrolatum). Laxative in pregnancy and puerperium. Acts mechanically and as a lubricant. Not unpleasant to take. Dose.—y2 oz. at bedtime, and, if necessary, before each meal. May be given to breast-fed babies in doses of gtts. xv three times daily. Senna. Laxative and purgative. Acts especially on the large intestine. Sometimes passes over in the milk to the child. Dose.—FI. ext. 1-4 teaspoonfuls. In compound licorice pow- der the dose is 30-80 gr. (about 10 gr. of senna to the dose). Silver Nitrate. Caustic, antiseptic, stimulant, irritant and anti- gonorrlioeic. Table salt neutralizes it. Uses.—2% solution in water for pruritus vulvse. 1% solu- tion dropped into the eyes of the new-born to prevent oph- thalmia neonatorum. Do not neutralize the 1% solution. % gr. silver nitrate with 2 gr. of pepsin in capsule for pernici- ous vomiting of pregnancy. Sodium Bicarbonate (Baking poivder). Antacid, antirheumatic. Uses.—Gout, dyspepsia, acid stomach, acidosis, vomiting of pregnancy. Soothes the skin when burned. Sodium Chloride. (Salt.) For normal saline use 10 gr. to 3% oz. of water. For phys- iological salt solution, add 15 gr. of Sod. Carb. to every 3 y2 oz. of normal saline as made above. Sodium Citrate. A white odorless, granular powder with cool- ing salty taste. Uses.—Diuretic, antipyretic and refrigerant. Retards the coagulation of albumin in milk and aids the digestibility of proteins. May be indicated in gout and cystitis. Dose.—Internally, 15 to 60 gr. In the modification of cow’s milk about two grains should be used for each ounce of the mixture. THERAPEUTIC INDEX 375 Spirits of Nitre, Sweet (Spirit Nitrous Ether). 4% solution of nitrous ether in alcohol. Diaphoretic, diuretic, antipyretic, stimulant, antispasmodie. Uses.—Fever, dropsy, vomiting of pregnancy, colic, anuria. Dose.—For adult, 20-60 gtts. For infants small doses often repeated. Stramonium (Jimson Weed). Hypnotic, narcotic, antispasmodie. Uses.—For haemorrhoids take Ung. Stramonii and Ung. Galli in equal amounts and apply. Urotropin. (Trade name for hexamethylenamina.) A white pow- der soluble in water. Urinary antiseptic, diuretic. Uses.—Cystitis, typhoid bacilli in urine, gout. It makes the urine irritatingly acid when given long. It does not act in alkaline media. Dose.—7%-10 gr. well diluted. Valerian. Anodyne, stimulant, antispasmodie and nervine. Uses.—Hysteria, hypochondriasis, headache. Dose.—30-60 Ttl of the fl. ext. by mouth, or by rectum 2 oz. of the following mixture may be used P.R.N. for hysteria: Pot. Brom. 1 oz. Ext. Valerian fl. dr. vi. Normal saline q.s. oz xii. Veratrum Viride (Hellebore). Sedative, emetic, diaphoretic, diuretic. Retards the heart’s action without weakening it. Uses.—Eclampsia. Dose.—1 to 4 TTL of the fl. ext. is given hourly until the pulse comes dow*n to 80. Veronal. (Barbitol) White crystalline powder. Safe, reliable hypnotic. Uses.—Insomnia from hysteria, neurasthenia, and mental disturbance. Dose.—5 to 15 gr. dissolved in hot tea, milk, or water. May repeat. Zinc. Tonic, astringent, antispasmodie. Uses.—Stearate of zinc is a valuable dressing in excoriations of buttocks and external genitals. Zinc Ointment. It is indicated for bedsores (decubitus) eczema, herpes, and intertrigo. Zinc ointment contains one part of zinc oxide to four parts of benzoinated lard. GLOSSARY [Adapted from Dorland and Standard Dictionaries] Ab-nor'mal. Not normal; con- trary to the usual structure or condition. A-bor'tion. 1. The expulsion of the foetus before it is viable. 2. Premature stoppage of a morbid or a natural process. Ab-ra'sion. 1. A rubbing or scraping off. 2. A spot rub- bed bare of skin or mucous membrane. Ab'scess. A localized collection of pus in a cavity formed by the disintegration of tis- sues. Ac-couch'e-ment. Delivery in childbed; confinement. Ac'e-tone. 1. A colorless liquid found in pyro-acetic acid and in naphtha. 2. Any member of the series to which the nor- mal or typical acetone be- longs. A'ci-do"sis. Acid intoxication of the system from the elab- oration or too much acid by faulty metabolism or the imperfect disposition of nor- mal amounts of acid. A-ci'nus, pi. acini. One (acini, more than one) of the small- est lobules of a compound gland. Al'bo-lene. An oily white sub- stance derived from petro- leum. Al'bu-mi-nu"ri-a. The presence of albumin in the urine. Al'ka-line. Having the reaction of an alkali. A'men-or-rhce"a. Absence or abnormal stoppage of the menses. Am-mo'ni-a. A colorless alka- line gas, NH3, of penetrating odor, and soluble in water, forming ammonia-water. Am- moniacal urine contains am- monia, winch is one form of nitrogen excretion. An-se'mi-a. A condition in which the blood is deficient in quantity or in quality. An'aes-the"si-a. Loss of feel- ing or sensation, especially loss of tactile sensibility, though the term is used for loss of any of the other senses. An'ses-thet"ic. 1. Without the sense of touch or of pain. 2. A drug that produces anass- thesia. An'al-ge"si-a. Absence of sen- sibility to pain. An-aph'ro-dis"i-ac. A drug that allays sexual desire. An'a-sar"ca. An accumulation of serum in the cellular tis- sues of the body. An'en-ceph"al-ous. Having no brain. An'ky-lo"sis. Abnormal rigid- ity or stiffness of a joint. An'o-dyne. A medicine that re- lieves pain. An'te par'tum. Latin for “be- fore delivery.” An-te'ri-or. Situated in front of, or in the forward part of. GLOSSARY 377 An'ti-pe'ri-od"ic. A drug that tends to prevent recurrent at- tacks of disease. An'ti-sep"tic. 1. Preventing de- cay or putrefaction. 2. A substance destructive to poi- sonous germs. A-pe'ri-ent. Mildly cathartic. Ap-nce'a. The absence of res- piration—especially that form which occurs in a child de- livered by the Caesarean oper- ation. A-re'o-la. The darkish ring around the nipple. As-ci'tes. Dropsy (an accumu- lation of fluid) in the ab- domen. A-sep'sis. Absence of septic matter, or freedom from in- fection. As-phyx'i-a. Suffocation. As-trin'gent. 1. Causing con- traction and arresting dis- charges. 2. An agent that arrests discharges. At'e-lec-ta"sis. Imperfect ex- pansion of the lungs at birth; partial collapse of the lung. At'on-y. Lack of normal tone or strength. A'tri-um. L., a hall.) The point of entrance of a bac- terial disease. At'ti-tude. A posture or posi- tion of the body. The rela- tion which the various parts of the child’s body bears to its own long axis. The atti- tude of the foetus normally is complete flexion. Aus'cul-ta"tion. The act of lis- tening for sounds within the body. Bac-te'ri-a. The vegetable mi- croorganisms (Schizomycetes) especially the short-rod forms. Bal'an-i"tis. Inflammation of the glans penis. It is usual- ly associated with phimosis. Bal-lotte'ment. The diagnosis of pregnancy by pushing up the uterus by a finger in- serted into the vagina so as to cause the embryo to rise and fall again like a heavy body in water. Bar'tho-lin glands. The vulvo- vaginal glands. Bleb. A skin vesicle filled with fluid. A blister. Breg'ma. The point on the sur- face of the skull at the junc- tion of the coronal and sagit- tal sutures. Cae-sa're-an sec'tion. (Named from Julius Caesar, who is said to have been thus born). Delivery of the foetus by an incision through the abdom- inal and uterine walls. Ca'put. Any head, or head-like structure. Ca'put suc'ce-da"ne-um. A swelling formed on the pre- senting part of the foetus during labor. It is due to the effusion of fluid into the subcutaneous tissues of the scalp and its retention there. Car-min'a-tive. Drugs that stimulate the circulation, the mental faculties, and intes- tinal peristalsis. Asafoetida, camphor, capsicum, cardamon, chloroform, ether, ginger, horseradish, mustard, and the oils of anise, cloves, spear- mint, nutmeg and valerian are carminatives. Car'ne-ous. Fleshy. Cath'e-ter, tra'che-al. A long slender tube designed for in- troduction into the babe’s trachea as a means of suck- ing out mucus. Cath"e-ter-ize'. To introduce a tube and draw off fluid, as urine or mucus. 378 OBSTETRICS FOR NURSES Caul. 1. The great omentum. 2. A piece of amnion which sometimes envelopes a child’s head at birth. Cell. 1. Any one of the minute protoplasmic masses which make up organized tissue. Ceph-al'ic. 1. Pertaining to the head. 2. A medicine for the head. Ceph'al-hse-ma-to"ma. 1. A tu- mor or swelling filled with blood beneath the pericrani- um. Cer'vix. The neck or any neck- like part. Chlo-as'ma. The yellowish brown spots or patches that appear on the skin of pregnant wom- en. Cic'a-tri"cial. Pertaining to, or of the nature of, a cicatrix. Ci-ca'trix. A scar; the mark left by a sore or wound. Cil'i-a. 1. The eyelashes. 2. Minute lash-like processes that characterize certain cells. Cli'mac-ter"ic. A particular epoch of the ordinary term of life at which the body is be- lieved to undergo a radical change—especially applied to the menopause. Cli-ni'cians. Men who teach and explain diseases by show- ing actual cases. Clit'o-ris. The sensitive organ of the female, homologous with the penis in the male. Coc'cyx. The small bone situ- ated at the end of the sacrum. The very last portion of the spine. Col-lapse'. A state of extreme prostration and depression with failure of circulation. Col'les’ mem'brane. A layer of tough sensitive fascia back of the perineum and on either side of the vagina. Co-los'trum. The first fluid se- creted by the mammary glands after functional ac- tivity begins. It contains casein and more albumen than milk, as well as numerous fatty globules. Col'peu-ryn"ter. A dilatable bag, used to distend the vagina. Co'ma. Profound stupor occur- ring in the course of a dis- ease or after severe injury. Co'ma-tose. Pertaining to, or affected with, coma. Com'pli-ca"tion. A disease or diseases concurrent with an- other disease. Con-cep'tion. The fecundation of the ovum. Con'dyl-o"ma. A wart-like ex- crescence near the anus or vulva. It may be as large as a cauliflower. Con-gen'i-tal. Born with a per- son; existing at or before, birth. Con'ju-gate. The anteroposte- rior diameter of the pelvic inlet. Cor'o-nal. Pertaining to the crown of the head, as the coronal suture. Cra'dle cap. The dirty looking patch of epithelial scales and sebaceous material that de- velops over the anterior fon- tanelle of babies who have the exudative diathesis. Cra'ni-ot"o-my. The cutting in pieces of the foetal head to facilitate delivery. Cre-de Expression. The maneu- ver in which the uterus is grasped in the hollow of the hand and squeezed and pressed down upon to aid in the expulsion of the placenta. GLOSSARY 379 Cre-de Treatment. The instil- lation of a 1% solution of nitrate of silver into the eyes of the new-born to prevent ophthalmia. Curd. The coagulum of milk, consisting mainly of casein. Cy'an-o"sis. Blueness of the skin, often due to cardiac malformation causing insuf- ficient oxygenation of the blood. Cys-ti'tis. Inflammation of the bladder. De-cid'u-a. The membranous structure produced in the uterus during gestation and thrown off after parturition. D. capsularis, the part of de- cidua which is reflected upon and surrounds the ovum. D. Basalis, the late decidua; the part of the decidua vera which becomes the maternal portion of the placenta. D. Vera, the true decidua; the portion of the decidua which lines the uterus. De-cu'bi-tus. 1. An act of ly- ing down. 2. A bed-sore. De-hy'drate. To remove the water. Di 'a-be"tes. A disease marked by an habitual discharge of an excessive quantity of urine and the presence of sugar therein. Di"aph-o-re'sis. Perspiration, and especially profuse per- spiration. Di"aph-o-ret'ic. 1. Stimulating the secretion of sweat. 2. A medicine that increases the perspiration. Di-ath'e-sis. Natural or con- genital predisposition to a special disease. Dif'fer-en"tial. Pertaining to a difference, or differences. Dis-crete'. Separate lesions which do not blend or coalesce. Di'u-re"sis. Increased secretion of urine. Dor'sum. The back or any part corresponding to the back as the dorsum of the penis or foot. Duc'tus ve-no'sus. A foetal blood vessel connecting the umbilical vein with the post- cava. Dys-cra'si-a. A depraved state of the system, and especially of the blood, due to constitu- tional disease. Dysp-nce'a. Difficult or labored breathing. Dys-to'ci-a. Painful or slow delivery or birth. Ec-bol'ic. An agent that accel- erates labor. E-clamp'si-a. A sudden attack of convulsions, especially one of a peripheral origin. Ec-top'ic. Out of the normal place. E-de'ma. Swelling due to ef- fusion of watery liquid into the connective tissue. Em'bo-lism. The plugging of an artery or vein by a clot or obstruction which has been brought to its place by the blood-current. Em'bry-o. The foetus in its earlier stages of development, especially before the end of the third month. Em-men'a-gogue. A drug that aids or stimulates menstrua- tion. E-muTsion. An oily or resinous substance divided and held in suspension through the agency of an adhesive, muci- laginous, or other substance. En'do-me"tri-um. The mucous membrane that lines the cav- ity of the uterus. 380 OBSTETRICS FOR NURSES En-gage'ment. The head is said to be engaged when the larg- est diameters have passed the inlet. En'si-form. Shaped like a sword. Ep'i-si-ot"o-my. Surgical inci- sion of the vulvar orifice lat- erally for obstetric purposes. E-ro'sion. An eating or gnaw- ing away. Er'y-the'Tna. A morbid redness of the skin due to congestion of the capillaries, of many varieties. E'ti-ol"o-gy. The study or theory of the causation of any disease. Ex-co"ri-a'tion. Any superficial loss of substance such as that produced on the skin by scratching. Ex'os-mo"sis (Ex-os-mose). Dif- fusion or osmosis from within outward. Ex-san'guin-a"tion. An exhaus- tion of the blood from a part or the whole of the body. Ex-trac'tion. The process or act of pulling or drawing out, particularly the removal of a child by pulling either with hands or forceps. Ex'tra-u"ter-ine. Situated or occurring outside of the uterus. Ex"u-da'tive di-ath'e-sis. A con- genital predisposition to ec- zema in various parts of the body, as well as to infections of the respiratory tract. Fae'ces (or fe'ces). The excre- ment or undigested residue of the food discharged from the bowels. Fen'es-tra-ted. (L.. fenestrum, a window.) Pierced with one or more openings, like win- dows. Fer'ment. Any substance that causes fermentation in other substances with which it comes in contact. Fi'brin. A substance which, becoming solid in shed blood, plasma and lymph, causes the coagulation of these fluids. Fil'let. 1. A loop-shaped struc- ture. 2. A loop, as of cord or tape, for making traction. Fis'sure. A cleft or groove, normal or other. Fis'tu-la. A deep, sinuous ul- cer, often leading to an in- ternal hollow organ. Flu'id ex'tract. A concentrated solution of the active prin- ciple of a drug in such strength that 1 c.c. of the product equals 1 gr. of the crude drug. The fluid is a mixture of alcohol, water and glycerine in varying propor- tions. One may be omitted. Foe'tus (or fe'tus). The unborn offspring of any animal that brings forth living progeny; the child in the womb after the third month. Fon'ta-nelle". Any one of the unossificd spots on the crani- um of a young infant. It is so named because it rises and falls like a fountain. Fo-ra'men. A hole or perfora- tion, especially a hole in a bone. Four-chette'. The fold of mu- cous membrane at the poste- rior junction of the labia ma- jora. Frse'num (or fre’num). A fold of the integument or of the mucous membrane that checks, curbs, or limits the move- ments of an organ in part— as the frasnum of the tongue. Func'tion. The normal or proper action of an organ or set of organs. GLOSSARY 381 Func'tion-al. Of or pertaining to a function. Fun'dus. The base or part of a hollow organ remotest from its mouth. Ga-lac'tor-rhce"a. Excessive se- cretion of milk. Ga-vage'. Feeding by the stom- ach tube; also the thera- peutic use of a very full diet. Gen'it-als. The reproductive or- gans. Ger"mi-cide'. An agent that de- stroys germs. Ges-ta'tion. Pregnancy. Gians cli-tor'i-dis. The distal or outside end of the clitoris. Gians pe'nis. The head, or terminal end, of the penis. Gon-or-rhce'a. A contagious catarrhal inflammation of the genital mucous membrane. Graaf'i-an fol'li-cle. Any one of the small spherical ovarian bodies, each of which con- tains an ovum. Hsem'o-phil"i-a. A condition of the system wherein bleeding occurs readily, and the blood clots slowly or not at all. Hsem'or-rhage. A copious es- cape of blood from the ves- sels; bleeding. Accidental h., ha3morrhage during pregnancy, due to premature detachment of the placenta. Post partum h., that which occurs soon af- ter labor, or childbirth. Unavoidable h., that which re- sults from the detachment of a placenta prajvia. Haem'or-rhoid. A pile, or vascu- lar tumor of the rectal mu- cous membrane. Hy-dat'id. An encysted vesicle containing an encysted fluid. From the Greelc “ Uydatis,” meaning a drop of water. Hy-dat'i-form. Kesembling a hydatid in form. Hy-dram'ni-os. Dropsy of the amnion. Hy'dro-ceph" a-lus. A fluid ef- fusion within the cranium. This disease is marked by enlargement of the head, with prominence of the forehead, atrophy of the brain, mental weakness, and convulsions. Hy’giene. The science of health and of its preservation. Hy'men. The membranous fold which partially or wholly oc- cludes the external orifice of the vagina, at least during virginity. Hy'per-em"e-sis. Excessive vom- iting. H. gra-vi-da'nun, ex- cessive vomiting of preg- nancy. Hy'per-ae"mi-a. Excess of bloQd in any part of the feody. Hy-per'tro-phy. The ipprbid en- largement or overgrowth of a part. Hyp-not'ic. A drug thRt ijT duces sleep. Hy'po-der-moc'Ty-sis. The in- troduction, into ithe sflben- taneous tissues, of fluid in large quantity. Hy'po-gas"tric. Of or pertain- ing to the lower anterior re- gion of the abdomen in the middle line of the body. The hypogastric arteries arise from the internal iliac in ad- dition to the branches given off from those vessels in the adult. Hy'po-phos"phite. Any salt of hypophosphorous acid. Ic'ter-us. Jaundice. Id'i-o-syn"cra-sy. An effect ab- normal to the one usually produced. An effect peculiar to the individual. 382 OBSTETRICS FOR NURSES Im-mu'ni-ty. The condition of being immune or exempt from disease, especially the condi- tion arising from inoculation, or from a peculiar resistance of the organism. Im'preg-na"tion. 1. The act of fecundation or of rendering pregnant. 2, The process or act of saturation, a saturated condition. In'farct. A mass of substance extravasated either into the substance of an organ or into a vessel due to the obstruc- tion to the circulation. In"fan-tile' pel'vis. A pelvis which has not responded to the developmental stimulation of the sexual glands at puberty, and therefore re- mains in its infantile shape. A masculine pelvis. In"fan-tile' u'ter-us. An unde- veloped uterus. In-fec'tion. The cummuniea- tion of disease from one per- son to another, whether by effluvia or by contact, medi- ate or immediate; also the im- plantation of disease from without. In'fil-tra"tion. To cause a liquid or gas to penetrate or enter by pores or interstices. In'flam-ma"tion. A morbid con- tion characterized by pain, heat, redness and swelling. In-nom'in-ate. Not having a name, as the innominate bone. In-som'ni-a. Inability to sleep; abnormal wakefulness. In'ter-sti'tial. Pertaining to, or situated in, the interstices or interspaces of a tissue. In'ter-tri"go. A chafe, or chafed patch of the skin; also the erythema or eczema that may result from a chafe of the skin. In-tro'i-tus. The entrance to any cavity or space. In-ver'sion. A turning inward, inside out, upside down, or other reversal of the normal relation of a part. In'vo-lu"tion. 1. A rolling or turning inward. 2. The re- turn of the uterus to its nor- mal size after parturition. 3. A retrograde change, the re- verse of evolution. Is-chu'ri-a par-a-dox'a. A con- dition in which the bladder is over-distended with urine, al- though the patient continues to urinate, generally in drib- bles. Jaun'dice. Yellowness of the skin, eyes, and secretions, due to the presence of bile pig- ments in the blood. La'bi-a. Lip-shaped organs. The external folds of the vulva, labia majora, and the internal folds of the vulva, labia minora. Lac'e-ra"tion. 1. The act of tearing. 2. A wound made by tearing. Lac-ta'tion. 1. The secretion of milk. 2. The period of the secretion of milk. 3. Suckling. Lan-u’go. The line hair on the body of the fetus. Lav-age'. The irrigation or washing out of an organ, such as the stomach or bowel. Le'sion. Any hurt, wound or local degeneration. Leu'cor-rhce"a. A whitish, vis- cid discharge from the vagina and uterine cavity. Light'en-ing. The sense of lightness and easier breath- ing that follows the descent of the head into the pelvis during the last three weeks of pregnancy. It is most likely to occur in primip- aras. GLOSSARY 383 Lo'chi-a. The vaginal discharge that takes place during the first week or two after child- birth. Lymph. A transparent slightly yellow liquid of alkaline re- action which fills the lym- phatic vessels. Mal-aise'. An uneasiness or in- disposition, discomfort or dis- tress. Mal'po-si"tion. Abnormal or anomalous position. Mam'ma. The mammary gland; the breast. Mam'ma-ry. Pertaining to the Mamma. Ma-ras'mus. Progressive wast- ing and emaciation, especial- ly such a wasting in young children when there is no obvious or ascertainable cause. Mas-sage'. The systematic, therapeutic friction, strok- ing and kneading of the body. Mas-ti'tis. Inflammation of the breast. Me-a'tus. A passage or open- ing, as the meatus urinarius. Me-lae'na ne-o-na-to'rum. The passage of dark pitchy stools containing blood pigments and blood that has been ex- travasated into the alimen- tary canal of the newborn babe. Meni'brane. A thin layer of tissue which covers a surface or divides a space or organ. Men'o-pause. The period when menstruation normally ceases; the change of life. Mis-car'riage. Abortion; pre- mature expulsion of the foetus; birth of the foetus be- fore the twenty-eighth week. Milk-leg (Phlegmasia Alba Do- lens). A condition developing ing in one, and rarely, in both, legs, after delivery. It is due to occlusion of the veins of the pelvis and leg by throm- bosis or to septic inflamma- tion of the pelvic connective tissue. Mole. 1. A fleshy mass or tu- mor formed in the uterus by the degeneration or abortive development of an ovum. 2. A nevus; also a brownish spot on the skin. Mons ven'er-is. A rounded prominence at the symphysis pubis of a woman. Mor-bid'i-ty. The condition of being diseased or morbid. Mor'cel-la"tion. Division and piecemeal removal. Mu'cus. The viscid watery se- cretion of the mucous glands. Mul-tip'ar-a. A woman who has borne more than one child. Mum'mi-fi-ca"tion. Dry gan- grene; also the drying up and shrivelling of the foetus. Myd'ri-at"ic. A drug that di- lates the pupil. Nau'se-a. Tendency to vomit; sickness at the stomach. Ne-cro'sis. Death of a tissue, especially of a bone. Ne-phri'tis. Inflammation of the kidney. Neu-rot'ic. 1. Pertaining to or affected with a neurosis. 2. Pertaining to the nerves. Neu'tra-lize. To render neutral or ineffective. Ni'tro-gen. A colorless gaseous element found free in air. Nod'u-lar. 1. Like a nodule or node. 2. Marked with nod- ules. 384 OBSTETRICS FOR NURSES Nu'cle-us. 1. a spheroid body within a cell, forming the es- sential and vital part. 2. A mass of gray matter in the central nervous system. 3. In chemistry, the central ele- ment in the molecule of a compound. Nu'tri-ent. Nourishing; afford- ing nutriment. Nym'phae. The labia minora. Ob-stet'rics. The art of man- aging childbirth cases; that branch of surgery which deals with the management of preg- nancy and labor. Ob-ste-tri'cian. One who prac- tices obstetrics. Oc'ci-put. The back part of the head. Ori-go-hy-dram"ni-os. Scanti- ness of the liquor amnii. Ol'i-gop-noe"a. A delay follow- ing the birth of a child be- fore the first respiration is established. Oph-thal'mi-a. Severe inflam- mation of the eye or of the conjunctiva. Or'gan. Any part of the body having a special function. Os. (L., a mouth.) The orifice in the uterus or vagina. Os-mo'sis. The passage of a fluid through a membrane. O'va. Latin plural of ovum, Orrcr. 0'vu-la"tion. The formation and discharge of an unimpreg- nated ovum from the ovary. O'vule. 1. The ovum within the Graafian vesicle. 2. Any small egg-like structure. O'vum. 1. An egg. 2. The female reproductive cell which, after fertilization, de- velops into a new member of the same species. Ox'y-di"zer. Anything that combines with oxygen. Pal-pa'tion. The act of feeling with the hand; the applica- tion of the fingers with light pressure to the surface of the body for the purpose of de- termining the consistence of the parts beneath in physical diagnosis. Par-al'y-sis, Erb’s. 1. Same as birth-palsy. 2. Partial paral- ysis of the brachial plexus af- fecting various muscles of the arm and chest-walls. It is revealed by an inability to lift the arm toward the head. Par-al'y-sis facial (Bell’s). Paralysis of the face, due to lesion of the facial nerve or of its nucleus. Par'a-me-tri"tis. Inflammation of the parametrium, or cellu- lar tissue about the uterus. Par'a-phi-mo"sis. Retraction of a narrow or inflamed fore- skin which can not be re- placed. Pa-ren'chy-ma. The essential or functional elements of an organ as distinguished from its stroma or framework. Pa-ri'e-tal. Of, or pertaining to, the walls of a cavity. Par'o-nych"i-a. Infection and suppuration about the junc- tion of nails and skin. Par'ox-ysm. A sudden recur- rence or sudden intensifica- tion of symptoms. Path-o-log'ic. Pertaining to pathology. Pa-thol'o-gy. That branch of medicine which treats of the essential nature of disease, especially of the structural and functional changes caused by disease. Pel-vim'e-ter. An instrument for measuring the various di- ameters of the pelvis. GLOSSARY 385 Pel-vim'e-try. The act of deter- mining the dimensions of the pelvis by means of a pelvim- eter. Per'i-ne-or"rha-phy. Suturation of the perineum, performed for the repair of a laceration. Per'i-ne"um. The space or area between the anus and the genital opening. Pe-riph'e-ry. The outward part or surface. Per'i-to-ne'Tim. The serous membrane which lines the ab- dominal walls. Per'i-to-ni"tis. Inflammation of the peritoneum. Per'i-stal"sis. A worm-like movement by which the ali- mentary canal propels its contents. Per-ni'cious. Tending to a fatal issue. Phe-nom'e-non. Any remark- able appearance; any sign or objective symptom. Phys'i-o-log"ic. Pertaining to physiology. Phys'i-ol"o-gy. The science which treats of the functions of the living organism and its parts. Phi-mo'sis. Tightness of the foreskin such that, it can not be drawn back over the glans. Phle-bi'tis. Inflammation of a vein. Pig'men-ta"tion. The deposition of coloring matter. Pla-cen'ta prae'vi-a. A placenta which intervenes between the intra-uterine cavity and the inner orifice of the cervical canal. Pla-cen'ta suc'cen-tur'i-a"ta. An accessory or subsidiary pla- centa. Pled'get. A small compress or tuft as of wool or lint. Pleth'o-ra. A condition marked by vascular turgeseence, ex- cess of blood and fullness of pulse. Po-dal'ic. Pertaining to, or ac- complished by means of, the feet. Poby-hy-drain"ni-os. Excess in the amount of the liquor amnii in pregnancy. Po-si'tion. 1. The attitude or posture of a patient. 2. The relation of the presenting part of the foetus to the quadrants of the maternal pelvis. Pos-te'ri-or. Situated behind or toward the rear. Post par'tum. After delivery. Pre'ma-ture. 1. Occurring be- fore the proper time. 2. An infant born before its proper term, but viable. Pre'ma-tu"ri-ty. The condition of a child that has been de- livered before term, and be- fore maturity or ripening has taken place. Pre-mon'i-tory. Serving as a warning. Pre'puce. The fold of skin covering the glans penis; the foreskin. Pres'en-ta"tion. 1. The appear- ance in labor of some particu- lar part of the foetal body at the os uteri. 2. That part of the foetal body which first shows itself at the os in labor. Pri-mip'a-ra. A woman who has given birth, or who is giv- ing birth, to her first child. Prod'ro-mal. Premonitory. In- dicating the approach of an event, phenomenon, or dis- ease. Prog-no'sis. A forecast as to the probable result of an at- tack of disease; the prospect as to recovery from a disease afforded by the nature and symptoms of the case. 386 OBSTETRICS FOR NURSES Pro-jec'tion-al vom'i-ting. Hud- den violent emesis. Pro-lapse'. The falling down, or sinking, of a part, or vis- cuS. Pro-lep'sis. The anticipation and nullification of complica- tions before they arise. Prom"on-to'ry. A projecting eminence or process. Pro'phy-lax"is. The prevention of disease. Pro'te-in. Any one of a group of nitrogenized, noncTystal- lizable compounds similar to each other, widely distrib- uted in the animal and vege- table kingdoms, and forming the characteristic constitu- ents of the tissues and fluids of the animal body. They are formed by plants, the an- imal organism receiving them as food and transforming and assimilating them. They all contain carbon, hydrogen, nitrogen, oxygen and sulphur. Some of the most important are albumin, casein, legumin, fibrin, myosin and glutin. Psy'chic. Pertaining to the mind. Pu'bes. That part of the low- er central hypogastric region wThich, in the adult., is cov- ered with hair. The pubic region. Pu'bic. Pertaining to the pubes, or os pubis. Pu'ber-ty. The age at which the reproductive organs be- come functionally operative. Pu'bi-ot"o-my. (Tie-bos'te-ot"o- my.) The operation of cutting through the pubic bone, lateral to the median line. Pu-er’pe-ral. Pertaining to childbirth. Pu'er-pe"ri-um. The period or state of confinement. The puerperium is the time suc- ceeding labor which is neces- sary for the restoration of the genitals to their condi- tion previous to pregnancy, or as near it as possible. It varies from 6 weeks to sev- eral months. . Pu'ru-lent. Consisting of or containing pus. Py-ae'mia. Blood-poison of mi- crobic origin. Py'e-li"tis. Inflammation of the pelvis of the kidney. Py'or-rhoe"a. A discharge of pus, especially from infection around the roots of the teeth. Py-ro'sis. Heartburn. Acidity of the stomach. Eructations of acid. Re'flex-es. Reflected actions or movements. Impulses re- ceived and transmitted by the nervous system without con- scious volition. Involuntary responses to irritation. Auto- matic movements. Re-frig'e-rant. Relieving fever and thirst. A cooling remedy. Acidulous drinks and evapo- rating lotions are refrigerant. Re-gur'gi-ta"tion. 1. The cast- ing up of undigested food. 2. A backward flowing of the blood through the left auri- culo-ventricular opening, on account of imperfect closure of the mitral value. Re'lax-a"tion. 1. A lessening of tension. 2. A mitigation of pain. Re'nal. Pertaining to the kid- ney. Res'ti-tu"tion. 1. An act dr process of restoration. 2. The rotation of the present- ing-part of the fcetus outside of the. vagina,. GLOSSARY 387 Re'tro-gres"sive. Going or moving backward. Passing from a better to a worse con- dition. Re'tro-ver"sion. The tipping of an entire organ backward. Rick'ets. (Ba-chi'tis.) A con- stitutional disease of childhood in which the bones become soft and flexible from retarded os- sification, due to deficiency of the earthy salts. Ro-ta'tion. The process of turn- ing around an axis. Rough'en-ing. Any rough, coarse food that gives bulk to the intestinal contents with- out much nutrition. Ru'be-fa"ci-ent. An agent that reddens the skin. Ru'gse. Wrinkles or folds. Rup'ture. 1. Forcible tearing or breaking of a part. 2. Hernia. Sa'cmm. The triangular bone situated at the end of the spine. It is formed of five vertebrae, amalgamated and wedged in between the two innominate bones. Sag'it-tal. Shaped like, or re- sembling, an arrow. SaTi-va"tion. An excessive dis- charge of saliva. Sal'pin-gi"tis. Inflammation of an oviduct or of the eustach- ian tube. Sal"var-san'. A compound in- vented by Ehrlich for the treatment of diseases caused by the Spirilla}, such as syphilis and recurrent fever. It is popularly called 606. Sa-prae'mi-a. Poisoning of the blood by the absorption of toxins from localized infec- tions as from the uterus. Scap'u-la. The shoulder blade. Scro'tum. The pouch wdiieh contains the testicles and their accessory organs. Se-ba'ceous. 1. Pertaining to sebum or suet. 2. Secreting a greasy lubricating substance. Se-cre'tion. 1. The process or function of separating vari- ous substances from the blood. 2. Any secreted substance. Sec'un-dines. All that remains in the uterus after the birth of the child is called seeun- dines—placenta, membrane and cord. Se'men. 1. A seed or seed-like fruit. 2. The thick whitish liquid fecundating secretion produced in coition. Shock. Sudden vital depres- sion, due to an injury or emo- tion which makes a sinister impression upon the nervous system. Show. The appearance of blood that foreruns a labor or men- struation. Sm'a-pism. A plaster or paste of ground mustard-seed; a mustard plaster. Sin'ci-put. The portion of the head lying in front of the an- terior or large fontanelle. Si'nus. 1. A recess, cavity or hollow space. 2. A dilated channel for venous blood, found chiefly within the cra- nium and uterus during gesta- tion. 3. An air-cavity, in one of the cranial bones, especial- ly one communicating with the nose, such are the eth- moidal frontal maxillary and sphenoidal sinuses. 4. A sup- purating channel or fistula. Smeg'ma. A thick, cheesy, ill- smelling secretion found un- der the prepuce and around the labia minora. So-lu'tion. 1. The process of dissolving. 2. A liquid con- taining dissolved matter. 388 OBSTETRICS FOR NURSES Sor'des. The dark brown mat- ter which collects on the lips and teeth in low fevers. Spas'mo-phil"ic di-ath'e-sis. Is a condition characterized by an increased elective irritabil- ity and a tendency to spasm, like contractions of one or more groups of muscles. (Grulee). Spe-cif'ic. 1. Pertaining to a species. 2. Produced by a single kind of microorganism. 3. A remedy specially indi- cated for any particular dis- ease. Sper'ma-to-zo"on. The motile generative element of the se- men which serves to impreg- nate the ovum. Spi'na bif'i-da. Congenital cleft of the vertebral column with meningeal protrusion. Spi'ro-chae"te. A genus or form of flexile spirobacteria. Sta'sis. A stoppage of the flow of fluid in any organ or any part of the body. Ste-no'sis. Narrowing or stric- ture of a duct or canal. Ster'ile. Nonfertile. Ster'il-i-za''tion. The act or process of rendering sterile. Still-birth. The birth of a dead foetus. Stim'u-lant. 1. Producing stim- ulation. 2. An agent or rem- edy that produces stimulation. Strep'to-coc"cus. A genus or form of bacterial organism, which grows in consecutive links, like a chain. Stri'a, pi. striae. Streaks or lines. Stro'ma. The tissue which forms the ground substance, framework, or matrix of an organ. Styp'tic. Astringent, an agent for arresting haemorrhage. Sub'in-vo-lu"tion. Incomplete involution; failure of a part to return to its normal size and condition after enlarge- ment from functional activity. Sup-pos'i-to-ry. An easily fus- ible medicated mass to be in- troduced into the vagina, rec- tum, or urethra. Su'ture. 1. Surgical stitch or seam. 2. The line of junc- tion of adjacent cranial or facial bones. Sym'phys-e-ot"o-my. The divi- sion of the fibrocartilage of the symphysis pubis in order to facilitate delivery by in- creasing the anteroposterior diameter of the pelvis. Sym'phy-sis. The line of junc- tion and fusion between bones originally distinct. The sym- physis pubis. Syn'chro-nous. Occurring at the same time. Syph'i-lis. A contagious ven- eral disease leading to many structural and cutaneous le- sions, due to a microorganism called the spirochaeta pallida. Tam'pon. A plug made of cot- ton, sponge, or oakum. Te-nac'u-lum. A liook-like in- strument for seizing and hold- ing tissues. Te-nes'mus. Straining, especi- ally ineffectual and painful straining. Throm'bus. A plug or clot in a vessel remaining at the point of its formation. Tinc'ture. The solution of me- dicinal substances in fluids other than water or glycer- ine. There is usually about one part of the..drug, to eight of alcohol. Tis'sue. An aggregation of cells, fibers and various cell- products forming a structural element. GLOSSARY 389 Tox-se'mi-a. Blood-poisoning. Tox'in. Any poisonous albumin produced by bacterial action. Trau'ma. A blow, wound, or other violent injury. Trau'ma-tism. A condition of the system due to injury. Tu'mor. 1. Swelling; morbid enlargement. 2. A neoplasm. A mass of new tissue which persists and grows independ- ently of its surrounding struc- tures, and which has no physi- ologic use. Tym'pa-ni"tis. Distention of the abdomen from gas. Um-bil'i-cal. Pertaining to the umbilicus. Um-bi-li'cus. The navel. U 'ra-chus. A cord that extends from the apex of the blad- der to the navel. It repre- sents the remains of the canal in the foetus which joins the bladder with the allantois. U-re'a. A white crystallizable substance from the urine, blood and lymph. U -re'ter. The fibro-muscular tube which conveys the urine from the kidney to the blad- der. U-rse'mi-a. The presence of urinary constituents in the blood and the toxic condition produced thereby. U -re'thra. A membranous canal conveying urine from the bladder to the surface and in the male conveying the sem- inal ejaculations. U'rin-al"y-sis. The chemical analysis of urine. U'ter-us. The hollow muscular organ which provides lodge- ment for the fcetus from con- ception to birth. The womb. U'ter-us bi-cor'nis. A womb wherein the two sides have been incompletely joined dur- ing development, and two horns, or protrusions, appear on the fundus. U'ter-us di-del'phys. A womb in which there has been sepa- rate development and incom- plete fusion of the two sides. U'ter-us du'plex. A double uterus. U'ter-us sep'tate. A uterus that is divided by a partition or septum. Var'i-cose veins. Of the nature of, or pertaining to, a varix. The permanent, dilatation of a vein. Ven'e-sec"tion. The opening of a vein for the purpose of let- ting blood. Ven'tral stalk. An embryonic process which is the rudimen- tal precusor of the umbilical cord. It is known as the ven- tral stalk because somewhat later in the course of develop- ment it becomes attached to the ventral (abdominal) sur- face of the embryo. Ver'nix cas'e-o"sa. A fatty sub- stance that covers the skin of the foetus. Ver'sion. The act. of turning, especially the manual turn- ing of the foetus in delivery. External v., that which is per- formed by outside manipula- tion. Internal v., version per- formed by the hand intro- duced into the uterus. Brax- ton Hicks’ Version, a version done with the whole hand in the vagina and two fingers entering the uterus through the partially dilated os. Ves'i-cal. Pertaining to the bladder. 390 OBSTETRICS FOR NURSES Vi'a-bil"i-ty. Able to live af- ter birth. Villi. 1. The finger-like projec- tions that develop on the out- side of the egg and connect it vascularly and otherwise with the uterus; a vascular chori- onic tuft. 2. A minute club- shaped projection from the . mucous membrane of the intestine. Vul-sel'lum. A forceps with teeth on the ends of the jaws. Walch'er’s position. The pa- tient on the back with the hips at the edge of the table and the legs hanging down. Whar'ton’s jelly. The soft pulpy connective tissue that constitutes the largest part of the umbilical cord. Womb. Same as uterus. INDEX A Abderhalden test for preg- nancy, 64 Abdomen: care of, 73 changes in pregnancy, 62 weakness of, 94 Abortion, 106, 223 etiology, 223 management, 224 tubal, 100 Abscess, 319 Accessory articles of diet, 343 Accidental haemorrhage, 245 After-birth, 43 After pains, 170, 272 relief of, 170 Albuminuria, 83 (see Eclamp- sia) Amenorrhoea, 60 during lactation, 172 in the nonpregnant, 61 Amnion, 43 adhesions, 96 Anaesthetics, 119 Anencephalus, 334 Anus, 23 Aphthae, 314 Areola, 33 Asepsis in delivery, 158 Aseptic care, 216 Asphyxia neonatorum, 297 methods of resuscitation, 298 Atelectasis, 303 Attitude of child, 46, 181 B Baby: anencephalus, 334 aphthae, 314 asphyxia, 298 balanitis, 331 bath, 284 Baby—Cont ’cl birth injuries, 321 bowels, 291 breasts, 313 care after delivery, 161 care at birth, 159 circumcision, 331 cleansing, 288 clothing, 288 colic, 325 constipation, 323 convulsions, 302 cradle cap, 316 diaper, 291 diarrhcea, 323 exercise, 305 eyes, 287 furuncles, 330 flushings, 305 gavage, 305 genitals, 290 haemorrhage, 309 harelip and cleft palate, 307 heart, 298 hernia, 307 hydrocephalus, 333 icterus, 313 lavage, 306 marasmus, 328 menstruation, 313 mouth, 290 nails, 314 nursing periods, 292, 172 outfit, 117 overtime, 108 paraphimosis, 330 phimosis, 330 pneumonia, 329 prematurity, 326 priapism, 333 removal from breast, 270 respiration, first, 158 routine for, 287 392 INDEX Baby—Cont’d significant symptoms and conditions, 345 sleej), 290 snuffles, 329 spina bifida, 333 starvation fever, 295 sudden death, 334 temperature, 294 thrush, 313 tongue-tie, 307 toilet basket, 288 umbilicus, 287 urination, 291 urticaria, 315 vomiting, 325, 345 weaning, 270 weight, 289 Bag of waters, 43, 126 Balanitis, 320 Ballottement, 64 Baptism, 215 Barley water, 340 Bartholin glands, 27 Baths, 72, 350 Bed, making, 149 Bed-linen, care of, 166 Bed-sores, 281 Bednar’s disease, 315 Bichloride solution, 150 Birth injuries, 321 Birthmarks and deformities, 76, 98 Binder, 116, 169 Bladder, 23 after delivery, 174 in pregnancy, 61 Bleeders, 251, 310 Blood, in pregnancy, 58 Bowels, in pregnancy, 71 in puerperium, 173 Breast milk, quantity, 293 Breast pump, 272 Breasts, 32 caked, 172, 260 care of, 74, 171 changes due to marriage and pregnancy, 56 inflow of milk, 56, 172 massage, 172 Breasts—Cont’d nursing periods, 172 of puberty, 32 preparation for lactation, 171 removal of child, 270 sensations in pregnancy, 62 supernumerary, 33 Breech presentation, 181 Brow presentation, 190 Bulging, 131 Buttermilk, 339 C Care of labor, 160 Caesarean section, 211 Caput suecedaneum, 143 Case record, nurse’s, 180 Catheterization, after delivery, 175 before operations, 195 Caul, 114 Cephalhaematoma, 144 Cervix, effacement, 126 digital dilatation, 228 repair, 162, 228 rigidity of, 239 Child (see Baby) Chill in puerperium, 167 Chloasma, 58 Chloroform in labor, 120 Chorion, 43 Circumcision, 331 Clamp for cord, 286 Clitoris, 26 Coitus, 75 Colic, 325 Colostrum, 56, 172 Conception, 38 Condylomata, 78 Confinement, estimating date, 69, 123 Constipation, 78, 323 Contraction of pelvis, 231 Contractions of Braxton Hicks, 56, 64, 125 Convulsions, of child, 302 of mother, 83, 253 Cord, umbilical, 43 attachment to placenta, 44 INDEX 393 Cord—Cont’d cutting, 159 granulations of, 313 prolapse of, 237, 152 separation, 313 Corpus luteum, 35 Corset, 73 Course of labor, 126 Cow’s milk vs. breast milk, 337 Cradle cap, 316 Cramps, 59, 95, 156 Cranioelasis, 210 Crede expression, 166 Curettage of uterus, 222 in abortion, 223 Curve of Carus, 20 D Decapitation, 210 Delivery, asepsis during, 158 care of mother after, 160 on side, 158 Diabetes and pregnancy, 106 Diapers, 291 bluing on, 270, 317 Diarrhoea of child, 323 Diet in pregnancy, 70 Diet in puerperium, 171 Diets, 355, 361 Displacement of uterus, 93 Doctor, 145 when to call, 146 what to report, 146 Douche, vaginal, 176, 218 aseptic, 216 in pregnancy, 74 intrauterine, 221 Dress in pregnancy, 73 Drugs affecting the milk, 293 Dry birth, 243 Ductus arteriosus, 52 venosus, 53 E Early expression, 166 Eclampsia, 83, 253 blood pressure in, 58 Eclampsia—Cont’d prophylaxis, 86 symptoms and management, 83 wet packs in, 230 Ectopie pregnancy, 99 Edema, 94 Enemas, eliminative, 360 nutrient, 358 Episiotomy, 228 Ergot, 160 after delivery, 165 in abortion, 225 in postpartum haemorrhage, 250 Eruptions on the skin, 58 Erythema, 317 Ether in labor, 119 Examination of patient, 149, 150 Exercise in pregnancy, 71 Excavation of pelvis, 19 Extrauterine pregnancy, 99 rupture of, 100 Exudative diathesis, 316 Eye symptoms in pregnancy, 72 F Face presentation, 190 Fallopian tubes, 22 Fainting, 73 Feeding supplemental, 335 Fevers and pregnancy, 101 Flour ball, 341 Flushings, 305 Foetus, abnormal conditions, 98 attitude, 47 circulation, 51 diameters of head, 48 fontanelles, 48 heart tones, 66 movements, 46 rate of growth, 50 rule for estimating length, 50 rule for estimating weight, 50 signs of danger to, 196 signs of death, 108 394 INDEX Foetus—Cont-’d signs of maturity, 50 sutures, 48 Food mixings, 342 preparation for infants, 339 Foramen ovale, 52 Forceps, application, 207 conditions for, 200 dangers of, 200 in breech cases, 189 in face presentations, 192 indications for, 200 preparations for, 200 Fumigation, 354 Furuncles, 305 G Galactorrhcea, 268 Gas analgesia, 122 Gas pains, 169, 271 Gavage, 305 Genital crease, 25 Genitalia, care after delivery, 175, 179 preparation for delivery, 114, 147 preparation for operation, 198 Getting up, 177 Gingivitis, 78 Glands, Bartholin, 27 mammary, 32 Montgomery, 33 thyroid, 59 Glossary, 351 Glycosuria, 72 Gonorrhcea and pregnancy, 104 Goodell’s sign, 63 Gossip, 177 Graafian follicle, 35 Gums in pregnancy, 78 H Haemorrhage, accidental, 245 in abortion, 222 in labor, 134, 160 m the newborn, 308 in pregnancy, 106 postpartum, 249 unavoidable, 245 Haemorrhage—Cont ?<1 uterine douche for, 220, 250 Haemorrhoids, 95 Hair, 515, 148 Hands, care of, 176, 348 sterilization of, 149 Harelip and cleft palate, 307 Head, descent, 139 expulsion of, 131 effect of labor on, 142 extension, 142 external restitution, 142 flexion, 138 internal rotation, 140 Headache, 82, 270 Heartburn, 72 Heart changes in pregnancy, 58 lesions in pregnancy, 105 Heart tones, foetal, where heard, 66, 146 significance, 67 when membranes rupture pre- maturely, 226 Hegar’s sign, 64 Hemophilia, 251 Hernia, 307 Herpes in pregnancy, 80 Hospital drums, packing, 154 Hottentot apron, 26 Hydramnios, 95 and malpresentations, 191 and twins, 96 Hydrocephalus, 308 Hymen, 26 Hypodermoclysis, 222 Hyperemesis gravidarum, 86 I Icterus, 313 Impetigo, 319 Induction of labor, 225 Infant feeding, 335 outfit, 117 Infection, 102, 273 Injections, eliminative, 360 intravenous, 221 nutrient, 358 Insomnia, 59 Intertrigo, 317 Involution, 168 INDEX 395 J Jacquemier’s sign, 63 Jaundice, of child, 313 of mother, 85, 105 Iv Kidneys of child, 45 of mother, 72, 81, 105 L Labia majora, 25 minora, 26 Labor, blood loss, 135 care during, 145 course of, 126 causes of, 123 general effects of, 134 induction of, 225 mechanism of, 136 normal, 123 precipitate, 147, 240 preparations for, 114, 147, 350 signs of, 145 vomiting in, 245 Laceration, 32 Lactation and menstruation, 172 Lavage, 306 Leucorrhcea, 74 Lightening, 68, 124 Linea albicantes, 58 nigra, 58 Liquor amnii, 43 in disease, 95 Liver, of child, 45 of mother in pregnancy, 59, 96, 105 Lochia, 170 and the hands, 176 Longings, 59 Lungs in pregnancy, 59 M Malsena neonatorum, 309 Malformation of uterus, 94 Marasmus, 328 Mammary glands, 32 Mask of pregnancy, 58 Mastitis, 265 Maternal impressions, 76 Mechanism of labor, 136 Membranes, 125 disease of, 95 premature rupture, 242 relation of rupture to labor, 129 rupture of, 129 Menstruation, definition of, 36 during lactation, 173 in infant, 313 physiology of, 37 relation to conception and pregnancy, 37 systemic effects, 38 Milk fever, 261 Milk, elements of human, 337 excess of, 267 fat-free, 342 inflow, 56 manual expression, 272 peptonizing, 363 pasteurizing, 341 quality, 269 scarcity, 267 sterilization, 341 to dry up, 178 whole, 342 Milk leg, 280 Mind in pregnancy, 76 Moles, 95 Monsters, 98, 334 Mons veneris, 25 Morning sickness, 61 Mother, care after labor, 161 Multiple pregnancy, 91 Multiple abscess, 319 N Nausea, 61 Nervous system, 59 Neuralgia, 59 Nipple, 33 care of, 74 in pregnancy, 56 cracks and fissures, 262 396 INDEX Nipple—Cont’d imperfect, 263 preparation for lactation, 17.1 rubber, 264, 348 Normal labor, 123 amount of blood lost, 135 causes of, 123 course of, 126 date of onset, 123 duration of first stage, 130 duration of second stage, 130 general effects, 134 mechanism, 136 subjective phenomena, 131 Nurse, 114 and cleanliness, 145, 348 and history sheet, 147, 180 in obstetrics, 114 in puerperal fever, 280 outfit, 115 qualifications, 348 sterilizing, 117 Nursery rules, 287 Nursing periods, 172, 292 Nursing the child, 292 O Odors of person, 348 Oligohydramnios, 95 Operations, preparations for, 195 why required, 195 Ophthalmia neonatorum, 103, 158, 312 Os, digital dilatation, 228 physiology of dilatation, 127 rigidity of, 239 Ovaries, 23 Ovulation, 34 Ovum, 34, 38, 39, 55 death of, 107 fertilization, 40 implantation, 40 mode of progress, 23 relation to uterine cavity, 55 P Packs, wet, 230 Pains, after, 170 cause of, 125 character of, 127, 131, 153 false, 124 from gas, 170 regularity of, 126, 145 Palpation, 151 Paralysis, facial, 311 of shoulder (Erb’s), 312 Paraphimosis, 330 Patient, care of, after deliv- ery, 167 during second stage, 153 examination of, 77, 150 in first stage, 150 loss of weight postpartum, 171 preparation of, 147 rest, 176 visitors, 177 Pelvic floor, 30, 240 rigidity, 240 Pelvis, 17 brim, 18 contracted, 231 diameters, 19 false, 17 measurements, 231 outlet, 19 quadrants of, 136 shape, 18 true, 17 upper strait, 18 Pemphigus neonatorum, 317 Perineorrhaphy, 160, 162 instruments, 162 after care, 164 Perineum, 25, 28 head on, 131 preservation, 161 repair, 160 torn in labor, 30 Peritoneum, 24 Peritonitis, (see Infection) Phimosis, 330 Phlebitis, 281 Physical signs of pregnancy, 62 Pigmentation, 58, 80 Pituitrin, 160, 242, 251 INDEX 397 Placenta prsevia, 29 Placenta, 43 anomalies, 98 early expression, 166 infarcts, 98 conditions for Crede expres- sion, 166 manual removal, 166 Pneumonia in child, 329 Point of direction, 137 Position, occipito-posterior, 194 of breech, 181 of face, 190 of head, 137 Walcher, 209 Postmature child, 108 Powers of labor, 136 Pregnancy, Abderhalden’s test for, 64 age of, 68 albuminuria in, 83 at fourth month, 64 bowels in, 71 Braxton Hicks sign, 64 cathartics in, 71 condylomata, 78 constipation in, 78 cramps, 95 diabetes in, 106 diagnosis, 60 duration of, 69 exercise in, 71 extrauterine, 99 fevers and, 101 general effects, 59 gingivitis, 78 gonorrhoea, 104 haemorrhages, 106 haemorrhoids in, 95 heart disease and, 105 heartburn, 72 Hegar’s sign, 64 herpes, 80 hydramnios in, 95 hygiene of, 69 hyperemesis in, 86 kidneys in, 81 local effects, 54 maternal changes, 60 mental conditions in, 75 Pregnancy—Cont ’cl physical signs, 62 multiple, 91 pressure symptoms, 94 probable signs, 63 pruritus, 79 pyelitis, 90 salivation, 78 sexual relations, 75 signs at 6th week, 64 signs at 26th week, 65 syphilis, 102 toothache, 78 toxaemias, 77 tuberculosis, 102 varicose veins, 94 vomiting in, 87 Prematurity, 326 Presentation, definition, 136 frequency of vertex, 137 of breech, 181 of face and brow, 190 transverse, 190 Pressure symptoms, 94 Priapism, 333 Proprietary foods, 339 Pruritus in pregnancy, 79 Ptyalism, 78 Puberty, 34 Pubiotomy, 214 after-care, 215 Puerperal fever, 273 disposal of excreta, 280 etiology, 273 nurse and, 275, 280 prevention, 275 symptoms, 277 treatment, 278 Puerperium, 167 abnormal, 260 diet in, 168 douche in, 176 laxatives, 174 standing orders for, 178 temperature, 167 Pulse in puerperium, 167 Pyelitis, 90 Pyloric stenosis, 328 Q Quickening, 62 398 INDEX R Record, 180 Rectal feeding, 358 Rectal infusions, 229 Rectum, 23 in labor, 23 Red gum, 318 Renal disease, 105 Rest, 176 Retention of testicle, 334 Room, setting up, 147, 196 Rubber gloves, 151 Rubber nipples, 343 S Salivation, 78 Second stage of labor, 153 Sex, determination of, 76 Sexual relations, 75 Sheet sling, 163, 197 Show, 125 Skin, changes, 57 care of, 72 eruptions, 58 pigmentation, 58, 80 striae gravidarum, 57 Snuffles, 329 Solutions, 365 percentage table of, 366 Souffle, funic, 67 uterine, 65 Spermatozoa, 38 Spina bifida, 333 Stages of labor, 126 Standing orders for nurse, 180 for puerperium, 178 Starvation fever, 297 Sterile linen, application, 154, 198 Sterilization, 117 dressings, 350 instruments, 352 rubber goods, 353 Stitches, care of, 176 removal, 218 Stomach capacity of child, 293 Stork bites, 318 Subinvolution, 171 Subjective signs of pregnancy, 61 Sudden death of infant, 334 of mother-, 281 Sugar in urine, 72 Sugars and flours, 342 Superfecundation, 93 Superfestation, 93 Supplemental feedings, 335 Supplies for house, 115 for sterilization, 117 preparation of, 350 Symphyseotomy, 214 Syphilis and foetus, 98 and pregnancy, 102 of placenta, 98 T Tampon of uterus, 218 of vagina, 220 Temperature in puerperium, 167 Testicle retention, 334 Teeth, 58, 76, 78 Third stage of labor, 126, 134, 159 conduct of, 166 Thrombus, 282 Thrush, 313 Thyroid gland, 59 Toilet basket, 288 Tongue-tie, 307 Toothache, 78 Toxaemia, 77-80 Transfusion, 221 in eclampsia, 257 Tubercles of Montgomery, 33 Tuberculosis and pregnancy, 102 Twilight sleep, 119 Twins, 91 U Umbilicus, 287 Unavoidable haemorrhage, 245 Urination, after delivery, 174 of child, 291 Urine, 59 in pregnancy, 72, 82 in puerperium, 167 sterile specimen, 216 sterile specimen from child, 216 INDEX Urticaria, 315 Utensils for milk modification, 343 Uterus, anatomy, 21 balloons up, 165 changes in pregnancy, 54 curettage, 222 displacements, 93 height at various months of pregnancy, 68 inertia, 240 involution, 168 malformations, 94 rupture, 243 Uterine souffle, 66 V Yagina, anatomy, 21 attachments, 21 distensibility, 21 Vaginal tampon, 220 in abortion, 224 Varicose veins, 94 Ventral stalk, 43 Version, 206 Vestibule, 26 Vessels of cord, 51 Villi, 40 Visitors, 177 Vomiting, 325-345 in pregnancy, 87 in labor, 245 uncontrollable, 86 Voorhees bag, 225 Vulva, anatomy, 24 Vulvo-vaginal glands, 27 care of, 147 preparation, 147 W Walcher position, 209 Weaning, 270, 290 Wet nurse, 271 Wharton’s jelly, 43 Whey, 340 Wiegand compression, 189-210 Witch’s milk, 33