,,obstetrics ,,for ,,nurses ,,by ,,charles ,b4 ,,reed1 ,m4,d41 ,obstetrician to ,wesley ,memorial ,hospital1 ,chicago4 ,,one ,,hundred ,,thirty ,,illustrations ,,st4 ,,louis ,c4 ,v4 ,,mosby ,,company #aiag ,,copyright1 #aiag1 ,,by ,c4 ,v4 ,,mosby ,,company ,press of ,c4 ,v4 ,mosby ,company ,st4 ,louis ,,to ,,his ,,loyal ,,friend ,,eugene ,s4 ,,gilmore ,,this ,,book ,,is ,,affectionately ,,dedicated ,,by ,,the ,,author ---------------------------------------- -------------------------------- ,,preface ,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 asking4 ,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 another4 ,it may be therefore largely a personal matter that none of the existent books seem to exhibit the fullness of information1 the conciseness of expression1 and the emphasis due to certain subjects that the present writer would hope to find4 ,the necessities apparently demand such an arrangement of our obstetrical doctrine that the book may serve for class instruction and at the same time be complete enough for post-graduate reference4 ,to secure this much discrimination is necessary4 ,the confusion attendant upon overabundance must be avoided as well as the discouragement that is not infrequently produced by a large book or a periphrastic style4 ,hitherto there has been a tendency to teach the nurse too little rather than too much but conditions have changed4 ,vocational instruction is not only more methodical and far reaching but it is developmental4 ,the present day nurse expects not merely to assist the physician and earn a stipulated reward1 but she is constantly alert to attain her own maturity as a professional woman4 ,to be a capable and intelligent assistant it is not sufficient to have a clear comprehension of her particular duties1 but she must have a defined and critical conception of what the doctor is aiming to accomplish4 ,this is especially true in obstetrics where the nurse has the additional responsibility of giving support and counsel to her patient in the various emergencies that arise4 ,moreover1 to attain her intellectual maturity the nurse must strive unremittingly to understand the complicated processes that take place under her observation4 ,she must cooperate with her doctor whose associate she is and secure the confidence of her patient who relies upon her for guidance in the perils she is facing4 ,for childbirth is a peril4 ,it is no longer the normal process it once was4 ,civilization has changed the shape of the pelvic bones1 altered the muscles of parturition and weakened the nerve centers that control the event4 ,the birth of a child is equal in severity and seriousness to many of the major operations4 ,it is not an affair to be entered upon lightly nor managed without the utmost foresight and care4 ,the dangers that are recognized and prepared for in this book by what may seem to some to be an extravagant technic1 are very real dangers1 extremely subtle1 and against them at times every precaution and every defense proves unavailing4 ,nevertheless1 skill1 thoughtfulness1 and above all1 cleanliness1 will avert the worst1 as well as unhappily the most common of these disasters4 ,if our nurses could be convinced of this1 the difficulties and apprehensions of childbirth would be greatly diminished4 ,the nurse should see to it that her patient is surrounded by all the precautions and safeguards against infection that she would demand for a member of her own family4 ,this means of course that her work will be far more exacting and onerous but also it will save many nights of anxiety and not infrequently a life4 ,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 suggested4 ,it is a selective essence distilled from the recurrent harvests that workers in this field have brought forth during centuries of consecrated effort4 ,to all these forerunners the writer acknowledges a deep personal indebtedness4 ,in the preparation of the book thanks are due particularly to ,charlotte ,gregory1 ,head ,nurse of the ,wesley ,maternity1 whose rare ability as teacher1 technician and executive and whose untiring vigilance has been a leading factor in securing and maintaining the high state of efficiency in this department4 ,she has kindly contributed ,chapters ,,xxiii and ,,xxiv1 together with valuable suggestions and criticisms in other portions of the text4 ,the author also takes pleasure in acknowledging his obligations to ,florence ,olmstead1 ,head ,nurse of the ,dispensary of the ,northwestern ,university ,medical ,school1 whose long experience in feeding babies gives to her words an unquestioned authority4 ,chapter ,,xxii is almost entirely her work4 ,to the various publishers who have courteously allowed the reproduction of valuable illustrations from the books of other writers thanks are also extended1 and to his own publishers especially for their cordial and sympathetic cooperation the author wishes to express his warmest gratitude4 ,c4 ,b4 ,r4 ,chicago1 #aiag4 ,,contents ,,chapter ,i ,,page ,,anatomy #ag ,,chapter ,,ii ,,physiology #cc ,,chapter ,,iii ,,normal ,,pregnancy #ea ,,chapter ,,iv ,,hygiene ,,of ,,normal ,,pregnancy #ff ,,chapter ,v ,,abnormal ,,pregnancy #gd ,,chapter ,,vi ,,abnormal ,,pregnancy 7,,continued7 #hi ,,chapter ,,vii ,,preparations ,,for ,,labor ,,and ,,the ,,normal ,,course ,,of ,,labor #ih ,,chapter ,,viii ,,the ,,mechanism ,,of ,,normal ,,labor #abj ,,chapter ,,ix ,,the ,,care ,,of ,,the ,,patient ,,during ,,normal ,,labor #abi ,,chapter ,x ,,the ,,normal ,,puerperium #aea ,,chapter ,,xi ,,unusual ,,presentations ,,and ,,positions #afe ,,chapter ,,xii ,,operations #agi ,,chapter ,,xiii ,,minor ,,operations #bjj ,,chapter ,,xiv ,,complications ,,in ,,labor #bad ,,chapter ,,xv ,,complications ,,in ,,labor 7,,continued7 #bbh ,,chapter ,,xvi ,,the ,,abnormal ,,puerperium #bdb ,,chapter ,,xvii ,,infection #bee ,,chapter ,,xviii ,,the ,,care ,,of ,,the ,,child #bfe ,,chapter ,,xix ,,the ,,care ,,of ,,the ,,child 7,,continued7 #bgh ,,chapter ,,xx ,,the ,,care ,,of ,,the ,,child 7,,continued7 #bhg ,,chapter ,,xxi ,,the ,,care ,,of ,,the ,,child 7,,continued7 #bih ,,chapter ,,xxii ,,infant ,,feeding #caj ,,chapter ,,xxiii ,,cleanliness ,,and ,,sterilization #cbc ,,chapter ,,xxiv ,,diets ,,and ,,formul #ccj ,,chapter ,,xxv ,,solutions ,,and ,,therapeutic ,,index #cdj ,,illustrations ,,fig4 ,,page #a4 ,the normal female pelvis #ah #b4 ,the planes of the brim1 the cavity1 and the outlet #ai #c4 ,visceral relations #bj #d4 ,uterus and appendages #bb #e4 ,normal position of pelvic organs #bd #f4 ,the external genitals #be #g;,a4 ,varieties of hymen #bg #g;,b4 ,varieties of hymen #bh #h;,a4 ,the excreting ducts of the mammary gland #bi #h;,b4 ,lobules and duct of the mammary gland #bi #i4 ,nipple1 areola1 and the glands of ,montgomery #cj #aj4 ,supernumerary milk glands in the axill #ca #aa4 ,the three ages of the breast #ca #ab4 ,development of the ovary #cd #ac4 ,graafian follicles #ce #ad4 ,human spermatozoa #cf #ae4 ,the chorionic villi about the third week of pregnancy #ch #af4 ,diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy #ci #ag4 ,maternal surface of the placenta and membranes #dj #ah4 ,ftal surface of human placenta #da #ai4 ,the egg at term with uterus removed #db #bj4 ,normal attitude of ftus #dc #ba4 ,ftal skulls showing sutures #dd #bb;,a4 and ,b4 ,child's head at term1 showing diameters #de #bc4 ,the ftal circulation #di #bd4 ,gravid uterus at the end of the eighth week #eb #be4 ,stri gravidarum #ed #bf4 ,bimanual examination #fj #bg4 ,abdominal enlargement at different months of pregnancy #fc #bh4 ,height of the uterus at various months of pregnancy #fd #bi4 ,twins #hc #cj4 ,diagram representing the sites for the various forms of tubal pregnancy #ij #ca4 ,abdominal binder with crosspiece to hold vulvar pads #ajj #cb4 ,t-binder1 used in all cases after the fifth day post partum #ajj #cc4 ,breast binder #aja #cd4 ,baby's dress with winged sleeves #ajb #ce4 ,the bag of waters begins to act on the cervix #aaa #cf4 ,the effect of the pains4 ,the cervix before labor begins #aab #cg4 ,the effect of the pains4 ,the cervix begins to be 8effaced0 #aab #ch4 ,the effect of the pains4 ,the cervix is effaced1 and the dilatation of the os begins #aac #ci4 ,the effect of the pains4 ,the cervix is effaced and the os continues to dilate #aac #dj4 ,the cervix is effaced and the os dilated #aae #da4 ,child in second stage of labor #aaf #db4 ,the head passing over the perineum #aag #dc4 ,normal expulsion of the placenta according to ,schultze #aah #dd4 ,the child in left-occipito-anterior position #abb #de4 ,the child in right-occipito-anterior position #abc #df4 ,the descent of the head in right-occipito-anterior position #abd #dg4 ,internal anterior rotation and extension of the head in a left-occipito-anterior position #abd #dh4 ,extension #abe #di4 ,extension completed4 ,expulsion #abe #ej4 ,a cephalhmatoma #abg #ea4 ,points of greatest intensity of ftal heart tones #acj #eb4 ,handling forceps1 kept sterile in a jar of alcohol #acb #ec4 ,palpation4 ,what is in the pelvis8 #acd #ed4 ,palpation4 ,what is in the fundus8 #ace #ee4 ,palpation4 ,where is the back8 ,where are the small parts8 #acf #ef4 ,patient draped for internal examination #acg #eg4 ,delivery in side position #ada #eh4 ,sheet twisted into a sling #adg #ei4 ,repair of perineum #adh #fj4 ,the progress of involution #aeb #fa4 ,the breech4 ,left-sacro-anterior position #aff #fb4 ,the breech4 ,left-sacro-posterior position #afg #fc4 ,extraction of the breech #agj #fd4 ,breech delivery4 ,extraction of the trunk #aga #fe4 ,breech delivery4 ,delivering the shoulder #agb #ff4 ,the delivery of the after-coming head by the ,smellie-,veit maneuver #agb #fg4 ,shoulder presentation #agc #fh4 ,face presentation #age #fi4 ,descent of the chin in face presentation #agf #gj4 ,delivery in face presentation #agg #ga4 ,exaggerated lithotomy position #aha #gb4 ,dorsal position when assistants are available #ahb #gc4 ,instruments for artificial delivery of the head #ahc #gd4 ,forceps operation4 ,introduction of the left blade #ahf #ge4 ,forceps operation4 ,the introduction of the right blade #ahg #gf4 ,forceps operation4 ,locking the handles #ahg #gg4 ,forceps operation4 ,the way the blades should grasp the ftal head #ahh #gh4 ,forceps operation4 ,traction on the handles #ahi #gi4 ,forceps operation4 ,the delivery of the head #ahi #hj4 ,version4 ,seizing a foot #aij #ha4 ,version4 ,the child rotates as pressure is made upon the head and traction upon the foot #aia #hb4 ,version is complete when the knee appears at the vulva #aib #hc4 ,the ,walcher position #aid #hd4 ,the ,wiegand compression of the child's head to force it into the pelvis #aie #he4 ,the ,naegele perforator #aif #hf4 ,apparatus for getting a sterile specimen of urine from an infant #bja #hg4 ,tampon of the uterus #bjc #hh4 ,tampon of vagina #bjd #hi4 ,pean forceps #bjh #ij4 ,hand bulb syringe2 and ,vorhees bags2 bag rolled and grasped by ,pean forceps ready for introduction #bji #ia4 ,vorhees bag in place #baj #ib4 ,episiotomy #bab #ic4 ,various forms of pelvic deformity #bae #id4 ,the pelvimeter #baf #ie4 ,the various diameters of the inlet #baf #if4 ,measuring the distance between the anterior superior spines of the pelvis #bag #ig4 ,measuring the external conjugate #bah #ih4 ,measuring the diagonal conjugate with the finger #bai #ii4 ,various forms of placenta prvia #bbi #ajj4 ,the knee-elbow posture #bcf #aja4 ,the knee-chest posture #bcf #ajb4 ,the exaggerated lithotomy position obtained with a sheet sling #bcg #ajc4 ,the improvised ,trendelenburg position #bcg #ajd4 ,the dorsal position with stirrups #bch #aje4 ,dorsal position across the bed #bci #ajf4 ,flexed dorsal position with feet on the table #bdj #ajg4 ,the ,sims position #bda #ajh4 ,examples of imperfect nipples #bde #aji4 ,a standard nipple shield #bdf #aaj4 ,a standard breast pump #bea #aaa4 ,germs most frequently found in cases of puerperal fever #bef #aab4 ,rubber bath tub #bff #aac4 ,the ,pettit cord clamp #bfh #aad4 ,standard breast pump2 ,standard nursing bottle2 the breast tray2 the ,wansbrough lead nipple shield2 the ,brophy nipple for harelip and cleft palate #bga #aae4 ,proper position of mother while nursing child #bgd #aaf4 ,proper method of taking rectal temperature #bgf #aag4 ,method of passing the tracheal catheter #bgi #aah4 ,byrd's method of artificial respiration4 ,extension and inspiration #bhj #aai4 ,byrd's method of artificial respiration4 ,beginning flexion and expiration #bhj #abj4 ,byrd's method of artificial respiration4 ,flexion and compression #bha #aba4 ,method of giving gavage #bhd #abb4 ,apparatus for gavage or lavage #bhf #abc4 ,cleft palate nipple #bhh #abd4 ,the device for feeding the child with cleft palate #bhh #abe4 ,device for assisting the cleft palate child to nurse #bhi #abf4 ,method of strapping an umbilical hernia #bij #abg4 ,proper position for introduction of a suppository #bii #abh4 ,hydrocephalus #cjg #abi4 ,anencephalus #cjh #acj4 ,elements of human milk #cab ,,obstetrics ,,for ,,nurses ,,chapter ,i ,,anatomy ,the study of obstetrics is an investigation of the passage1 the passenger1 and the driving powers of labor1 as well as of the various complications and anomalies that may attend the process of reproduction4 ,the passage is composed of a bony canal1 called the pelvis1 and the soft tissues which line and almost close its outlet4 ,the pelvis is made up of four bones2 the sacrum1 the coccyx1 and two other large structures of irregular shape1 called the hip1 or innominate bones4 ,joined by cartilage and held in place by ligaments1 they form a cavity or basin which1 in the male is deep1 narrow1 small and funnel-shaped1 while in the female1 slighter bones1 expanded openings and wider arches make a broad1 shallow channel1 through which the child is born4 ,the bony pelvis is divided for description into two parts1 the upper or false pelvis1 and the lower or true pelvis4 ,the upper pelvis is formed by the wings of the innominate bones and has but two functions of importance to child-bearing4 ,it acts as a guide to direct the child into the true passage1 and when measured by the pelvimeter1 it gives information as to the shape and size of the inlet to the true pelvis4 ,the true pelvis is of most concern to the obstetrician1 because anomalies in its size or shape may impede the progress of labor or render it impossible4 ,the pelvis is divided conveniently into three parts3 the brim1 the outlet1 and the cavity4 ,the brim1 inlet1 or upper pelvic strait1 is the boundary line between the false and true pelvis4 ,it is traced from the upper border of the symphysis along the iliopectineal line on both sides to the promontory of the sacrum4 ,the shape and size of this opening varies much in different races and individuals1 both normally and through disease2 and when pathologically altered1 both shape and size may exercise a marked influence on the course of labor4 ,in ,american women1 the outline of the brim is roughly heart-shaped1 like an ovoid with an indentation where the promontory of the sacrum impinges upon the opening4 ,illustration3 ,fig4 #a4--,the normal female pelvis4 7,eden47 ,the lines ab and cd divide the pelvis into the right and left anterior and the right and left posterior quadrants4 ab indicates the anteroposterior diameter of the brim1 cd shows the transverse diameter while gh and ef represent1 respectively1 the right and left oblique diameters4 ,the brim or inlet has four important diameters to be remembered2 important because the hard1 round head of the child must pass through them by accommodating its diameters as favorably as possible to those of this opening4 ,these diameters are named respectively the anteroposterior or conjugate diameter1 the transverse1 and the right and left oblique diameters4 ,the two oblique diameters attain their greatest importance when the pelvis is irregularly distorted1 but the others are essential in every case where labor impends4 ,it is to secure an estimate of these latter diameters that the bony prominences are measured4 ,this upper opening lies not horizontally1 but in oblique relation to the body in standing position1 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 habits4 ,illustration3 ,fig4 #b4--,the planes of 7a7 the brim1 7b7 the cavity and 7c7 the outlet4 7,eden47 ,passing through the brim1 a cavity is found below it1 midway between the inlet and outlet1 which is nearly round in shape4 ,this is the 8excavation10 or the true pelvis4 ,then comes the outlet1 bounded in front by the pubic arch and soft parts1 and behind by the coccyx pushed back as far as it can go4 ,it is ovoid in shape1 but the long axis of this ovoid lies at right angles with the axis of the ovoid inlet4 ,we find1 therefore1 a succession of three geometric figures or planes through which the head must pass by means of a spiral motion called rotation4 ,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 ends1 one end passing out near the umbilicus1 the other through the vulva4 ,this is known as the axis of the pelvis or the curve of ,carus4 ,illustration3 ,fig4 #c4--,visceral relations4 7,redrawn from ,gray47 ,,the ,,soft ,,parts ,inside the pelvis are the organs of generation with their accessory structures and supporting tissues4 ,of first importance are the ovaries1 tubes and uterus1 together with the vagina4 ,these special structures are the true genital organs4 ,they are bounded in front by the bladder1 behind by the rectum1 above by the abdominal viscera1 and surrounded everywhere by muscular1 mucous and fatty tissues1 which support them and aid their function4 ,the ,vagina4--,the vagina is a hollow organ1 about four inches long1 attached to the cervix above and the vulva below4 ,it is an elastic sheath bounded in front by the bladder and behind by the rectum4 ,under normal conditions1 this tube easily admits one or two fingers1 but during labor it dilates enormously to allow the head to pass4 ,the vagina is lined with a thick mucous membrane1 ridged and roughened by folds1 which are called rug4 ,thus a continuous channel connects the ovary with the outside and through it pass1 at appropriate times1 the ovule1 the menstrual blood1 the uterine secretions1 the child1 the placenta1 and the lochia4 ,the ,uterus4--,the uterus 7womb7 is a pear-shaped organ1 flattened from before backward1 and composed of unstriped or involuntary muscle cells and connective tissue4 ,normally the virgin uterus measures from two and one-half to three inches in length1 and weighs about two ounces4 ,it is suspended in the middle of the pelvis by strong ligaments1 so that the fundus inclines gently forward against the bladder4 ,when the bladder fills1 the uterus is pushed backward4 ,most of the organ is internal1 but a small part of the lower pole is grasped by the vagina1 in which the lower end with its invaluable aperture1 the os1 dips and swings4 ,the part above the vagina is called the body or fundus1 and is covered with the serous membrane 7peritoneum7 that lines the abdominal cavity4 ,below the fundus is the cervix or neck1 which lies partly above and partly within the vagina4 ,the cavity of the uterus is usually closed by the apposition of the walls4 ,the inner surface is covered with a peculiar kind of membrane called the endometrium1 which is highly vascular4 ,the uterine cavity opens into the vagina through the os1 which is small and round in the nulliparous woman1 and slit-shaped or gaping in the woman who has borne a child4 ,illustration3 ,fig4 #d4--,uterus and appendages4 ,on either side of the uterus will be seen the ovary1 the fimbriated extremity of the tube1 the tube1 and the round ligament4 ,the vagina lies open below4 7,lenoir and ,tarnier47 ,fallopian ,tubes4--,on either side of the upper end of the uterus are the orifices of the ,fallopian tubes1 through which the egg1 escaping from the ovary1 finds access to the uterine cavity4 ,these tubes extend outward from the uterus about four inches1 and terminate in a bell-shaped opening with long1 ragged fingers which hang loosely down toward the ovary4 ,the tubes are lined by epithelial cells having hair-like projections1 7cili7 which wave automatically toward the uterus4 ,thus impelled by a gentle current1 the egg moves definitely along the tube toward the uterus and against this current the spermatozoa force their way to meet and fertilize the egg4 ,the ,ovaries4--,on either side of the pelvis1 close to the fringed end of the ,fallopian tube and attached to it1 lies a small1 hard1 almond-shaped organ1 called the ovary4 ,this is the intrinsic sexual gland of the female4 ,it contains the small cells which are to ripen and become eggs4 ,each ovary is said to contain about thirty-six thousand eggs1 or ovules4 ,the ,bladder4--,the bladder lies between the pubic bone and the uterus4 ,it is a reservoir for urine1 filled by means of two little tubes called ureters1 that run down from the kidneys4 ,it drains through the urethra which opens just below the pubic bone in front of1 and just above1 the vaginal opening4 ,the bladder should be emptied frequently during labor4 ,the ,anus4--,the large bowel 7colon7 terminates in an opening near the middle of the genital crease4 ,this opening is called the anus4 ,it is closed by a contracting muscle1 the sphincter1 which acts like a puckering string4 ,just inside of the opening is a group of large veins which may become enlarged1 inflamed1 and bleed during pregnancy4 ,they are then called hmorrhoids4 ,the ,rectum4--,upward from the anus and to the left of the uterus extends the rectum4 ,this is the end of the intestinal canal and is supplied with an abundance of nerves4 ,when the head presses upon it1 it gives the sensation of a bowel movement1 and warns the observer of the low position of the head4 ,the anus pouts as the head comes down and the anterior walls become visible4 ,in severe cases of labor1 the sphincter is sometimes torn4 ,the bowels should be emptied by an enema as early as possible in the first stage of labor4 ,the ,peritoneum4--,the peritoneum is a thin1 glistening1 serous membrane1 which lines the abdominal cavity and drops down from above over the uprising tops of the bladder and uterus4 ,folding together at the sides and extending to the walls of the pelvis1 it encloses the tubes and round ligaments in deep1 flat masses1 called the broad ligaments4 ,this is the structure that becomes so perilously inflamed 7peritonitis7 when infected by germs that find entrance through the genital passage4 ,illustration3 ,fig4 #e4--,normal position of pelvic organs1 seen from above and in front4 ,they are enveloped in peritoneum4 7,bougery and ,jacob1 in ,american ,text ,book47 ,,the ,,external ,,genitals ,the external genitals form the vulva4 ,under this name are included the mons veneris1 the labia majora1 the labia minora1 the clitoris1 the vestibule1 the hymen and the glands of ,bartholin4 ,the entire groove from the mons veneris to a point well up on the sacrum forms a deep fold or crevice1 which is known as the genital crease4 ,that part of the genital crease lying between the anus and vulva is technically known as the perineum 7q4v47 ,illustration3 ,fig4 #f4--,the external genitals4 7,redrawn from ,gray47 ,the ,mons ,veneris4--,the mons veneris is a gently rounded pad of fat lying just above the junction of the pubic bones 7the symphysis74 ,the overlying integument is filled with sebaceous glands and covered with hair at puberty4 ,the ,labia ,majora4--,the labia majora are the large lips of the vulva4 ,they are loose1 double folds of skin extending downward from the mons veneris to the anterior boundary of the perineum and covered externally with hair4 ,normally they lie in apposition and conceal the vaginal opening4 ,they correspond to the male scrotum4 ,the ,labia ,minora4--,the labia minora1 or nymph1 are two small folds of skin and mucous membrane1 that extend from the clitoris obliquely downward and outward for an inch and a half on each side of the entrance to the vagina4 ,on the upper side1 where they meet and invest the clitoris1 the fold is called the prepuce1 but on the under side they constitute the frnum4 ,the labia minora are sometimes enormously enlarged in the black races and are then called the ,hottentot apron4 ,the ,clitoris4--,the clitoris is an erectile structure analogous to the erectile tissue of the penis4 ,the free extremity is a small1 rounded1 extremely sensitive tubercle1 called the glans of the clitoris4 ,about the clitoris there forms a whitish substance called smegma4 ,this is a good culture medium for germs and must be carefully sponged away when the vulva is prepared for delivery4 ,the ,vestibule4--,the vestibule is bounded by the clitoris above1 the labia minora on the sides1 and the vaginal orifice below4 ,it contains the opening of the urethra1 which is called the meatus urinarius4 ,the ,hymen4--,the hymen is a thin fold of membrane which closes the vaginal opening to a greater or lesser extent in virgins4 ,it varies much in shape and consistency4 ,it is sometimes absent1 or it may persist after copulation1 hence its presence or absence can not be considered a test of virginity4 ,when torn1 the edges shrink up and form little irregularities called caruncul myrtiformes4 ,illustration3 ,fig4 #g ,a4--,varieties of hymen4 7,american ,text ,book47 ,bartholin ,glands4--,bartholin glands are located on each side of the commencement of the vagina4 ,each gland discharges by a small duct just external to the hymen4 ,they are often the seat of a chronic gonorrhal inflammation and must be watched carefully1 lest infection extend to the mother after labor1 or to the eyes of the child in passing4 ,illustration3 ,fig4 #g ,b4--,varieties of hymen4 7,american ,text ,book47 ,the ,perineum4--,the perineum is a body of muscle1 fascia1 connective tissue1 and skin1 situated between the vagina and the rectum4 ,the vagina bends forward and the rectum backward1 so a triangular area is left between them which is filled by the perineal body4 ,it is about two inches long from before backward1 and becomes progressively thinner the deeper it extends4 ,illustration3 ,fig4 #h ,a4--,the excreting ducts of the mammary gland4 7,lenoir and ,tarnier47 ,illustration3 ,fig4 #h ,b4--,lobules and duct of the mammary gland4 7,lenoir and ,tarnier47 ,the perineal body is flattened out and compressed by the passage of the head and in many cases torn4 7,thirty per cent of primiparas and ten to fifteen per cent of multiparas47 ,it should be repaired immediately4 ,the ,mammary ,glands4--,the mammary glands are secondary but highly important parts of the genital system4 ,they are formed by a dipping down of skin glands and they perform the special function of secreting milk4 ,the breast is made up of fifteen or twenty lobes1 each of which1 like a bunch of grapes1 clusters about and discharges into a single tube which1 in turn1 leads to the nipple4 ,the area between the lobes is filled with fat and connective tissue4 ,illustration3 ,fig4 #i4--,nipple1 areola1 and the glands of ,montgomery4 7,eden47 ,the nipple is pink or darkly pigmented4 ,it is composed of erectile tissue and under stimulation1 it rises from the surface of the gland so that it is easily taken into the mouth4 ,illustration3 ,fig4 #aj4--,supernumerary milk glands in the axill4 ,they may be found also below the breasts4 7,witkowski47 ,illustration3 ,fig4 #aa4--,the three ages of the breast--virginity1 maturity1 and senescence4 7,witkowski47 ,surrounding the nipple is a darkly pigmented area from one inch to four inches in diameter that is called the areola4 ,it contains hard1 shot-like nodules1 the glands1 or tubercles1 of ,montgomery4 ,these often secrete milk and sometimes become infected4 ,it occasionally happens that more than two breasts may be found on the human female1 and not infrequently pieces of mammary tissue may be discovered in the axilla or on the chest or back4 ,the mammary gland is undeveloped at birth1 but1 nevertheless it may fill with milk 7witches' milk74 ,at puberty1 after marriage1 and during pregnancy1 the gland reaches maturity4 ,it is only after delivery1 however1 that the functional climax is attained4 ,,chapter ,,ii ,,physiology ,ovulation4--,ovulation is the process whereby the eggs are discharged from the ,graafian follicle which matures and protects them in the ovary4 ,the egg is a true cell with one1 and sometimes more than one1 nucleus4 ,the ripening of the eggs1 as well as their discharge1 is attended with much general disturbance and great physical changes4 ,this phenomenon begins from the twelfth to the fifteenth year1 depending on race1 climate1 occupation and temperament1 and marks the transition of the individual from childhood into maturity4 ,this period is called puberty4 ,at this time the breasts enlarge1 the hips round out1 the vagina1 uterus and external genitals increase in size4 ,hair appears upon the vulva1 the emotions become more evident1 and modesty develops through a consciousness of sexual difference and attraction4 ,simultaneously a new function appears-- ,menstruation4--,menstruation may be defined as a process wherein a bloody fluid is discharged from the uterus at regularly recurring periods between puberty and the menopause1 except during pregnancy and lactation4 ,it is a hmorrhage which in some way is closely associated with ovulation1 but it is not known positively which is the precedent of the other1 or whether one causes the other4 ,menstruation is not essential to pregnancy1 for pregnancy may occur when the flow is normally absent1 as before puberty1 after the menopause1 or during lactation4 ,nevertheless1 regularity of menstruation is the rule in fertile women and clinicians agree that while conception may occur at any part of the menstrual cycle1 it is most likely to happen just before or just after the menstrual flow4 ,the best authorities at present support the theory that ovulation usually occurs soon after the close of the menstrual period4 ,this is confirmed by the similarity of the physical changes that take place in the endometrium during menstruation and after conception4 ,illustration3 ,fig4 #ab4--;,development of the ovary 7after ,wiedersheim74 ,a1 an ingrowth of the germinal epithelium1 forming a cell-cord1 which breaks up into primitive ,graafian follicles2 ,b1 a primitive ,graafian follicle1 with its contained primitive ovum2 ,c1 ,d1 ,e1 later stages in the development of the ,graafian follicle4 7,crossen47 ,as the period of the flow approaches1 the lining membrane of the uterus becomes hypermic and swollen with blood1 serum1 and glandular secretions4 ,the blood vessels are engorged1 the glands become longer and more tortuous1 little hmorrhages appear1 and the superficial epithelium is thrown off4 ,a large amount of mucus is produced by the increased activity of the glands1 and all is discharged into the vagina as a bloody1 incoagulable flow with an odor of marigolds4 ,the process continues usually from three to seven days1 when the discharge ceases and the endometrium slowly resumes its uncongested state4 ,illustration3 ,fig4 #ac4--;,graafian follicles4 ,one contains two ovules which1 if fertilized1 will produce twins4 ,if all three ovules are fertilized1 triplets will result4 7,bumm47 ,meanwhile1 the psychic and bodily conditions have not remained unaffected4 ,the nervous system is disturbed1 the disposition is irritable and capricious and the head may ache4 ,the woman takes cold easily4 ,she is indisposed to exertion from a sense of languor and malaise4 ,pain may develop in the back1 or cramps in the pelvis1 so severe as to keep the woman in bed4 ,frequently the approach of the period is signalized by skin changes1 such as a marked odor or an eruption of acne pustules4 ,the flow usually returns every twenty-eight days1 but it may vary within normal limits from twenty-one to thirty days4 ,the flow continues at such intervals regularly from puberty to the menopause 7change of life71 which occurs between the ages of forty-five and fifty4 ,conception1 or ,fertilization4--,this is the process wherein the male element 7spermatozoon7 meets and unites with the female egg4 ,from what is known from investigations of lower animals1 this meeting usually takes place in the ,fallopian tube4 ,illustration3 ,fig4 #ad4--;,human spermatozoa4 h1 head2 c1 intermediate portion2 t1 tail4 7,williams47 ,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 7cili7 that line the tube1 aided1 possibly1 by the tubal muscle4 ,the spermatozoon makes its way upward from the vagina by means of its tail4 ,this activity1 like the tail of a fish1 or snake1 or as a boat is sculled1 drives the cell forward through the thin layer of fluid that covers the mucous membranes4 ,the arrow-shaped spermatozoon travels at a rate that completes the passage to the ovary in twenty-four hours1 but spermatozoa may lie in wait for the egg a considerable time1 as is shown by the fact that they have been found alive in ,fallopian tubes removed three and a half weeks after copulation4 ,as soon as the male and female elements approach each other1 they exercise a powerful magnetic attraction1 which draws them together1 and as soon as they touch1 the two cells unite and the spermatozoon almost immediately disappears4 ,only one spermatozoon is required for the fertilization of an egg1 and hence enormous numbers must perish without achieving their destiny4 ,the fertilized egg has become the ovum1 and originally #a_/abe of an inch in diameter1 it now begins to grow1 and filled with a new energy1 it passes down the tube and enters the uterus4 ,here it comes into contact with the soft mucosa and digs a hole for itself--a nest1 very much as a warm bullet might sink into ice or snow--and is soon completely surrounded by a proliferating tissue called the decidua4 ,the woman is now pregnant4 ,the menstrual flow does not appear1 and local and systematic changes are inaugurated4 ,the egg enlarges rapidly4 ,little glove-finger-like projections 7the villi7 appear on its surface and dip down into the maternal tissues4 ,through these villi the egg gets nourishment until about the twelfth week1 when the placenta forms4 ,externally the ovum resembles a chestnut burr4 ,as the egg grows1 the villi on the surface find it more and more difficult to secure nutriment1 and except at one place1 all gradually shrink and disappear4 ,at this significant point1 they increase greatly in size1 number1 and complexity to form the thick1 cake-like placenta4 ,the egg or ovum is simply a growing cyst1 filled with a fluid1 normally sterile1 in which the developing embryo lives and swims4 ,this fluid is the liquor amnii and it is retained by a cystic wall made up of two layers--the chorion1 which represents the original cell membrane1 and the amnion1 which develops out of the ftus4 ,at maturity1 the ovum will contain from one to two pints of liquor amnii4 ,illustration3 ,fig4 #ae4--,the chorionic villi about the third week of pregnancy4 7,edgar47 ,the ,liquor ,amnii4--,the liquor amnii is of vast importance to the child4 ,it allows free movement for the growing limbs and body1 protects the child from sudden changes of temperature1 prevents injury both from without and within1 saves the child from birthmarks and deformities by keeping it from contact with the surrounding walls1 and in labor lubricates the passages for the advancing part4 ,in a measure1 too1 it probably serves as a food4 ,in labor it forms a pouch called the bag of waters1 which aids in dilating the os4 ,illustration3 ,fig4 #af4--;,diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy4 7,american ,text ,book47 ,gradually1 as nutrition becomes more abundant at the site of the growing placenta1 a stalk-like structure thrusts out from the ftal abdomen and forms an attachment with the formative placenta4 ,this is called the ventral stalk and as soon as the communication with the placenta is established1 it is combined with other parallel structures and becomes vascularized1 to form the umbilical cord4 ,illustration3 ,fig4 #ag4--,maternal surface of the placenta and membranes4 ,the cord protrudes from the cavity which held the ftus4 7,edgar47 ,the ,umbilical ,cord4--,the umbilical cord at maturity measures from five to fifty inches in length and from one-half to one inch in thickness4 ,the cord is composed of a gelatinous connective tissue1 called ,wharton's jelly1 in the midst of which lie the twisted vessels 7two arteries and a vein7 that supply the embryo with air and food and carry off the waste4 ,the ,placenta4--,the placenta or 8after-birth0 is an oval or circular somewhat flattened disc1 six to ten inches in diameter1 and three-quarters to one and one-half inches thick4 ,it weighs about a pound and a half4 ,it is the organ of respiration and nutrition for the ftus4 ,illustration3 ,fig4 #ah4--;,ftal surface of human placenta4 7,eden47 ,illustration3 ,fig4 #ai4--,the egg at term with uterus removed and child showing through the membranes4 7,edgar47 ,it is formed about the third month outside the membranes covering the child and is more or less loosely attached to the uterine wall4 ,the umbilical cord is attached to its ftal surface1 inside the ovum4 ,like a flat sponge it takes oxygen1 blood1 and the nourishing fluids from the blood vessels in the uterine wall1 carries them to the child by means of the umbilical vein1 and carries back the carbonized blood and waste products by the umbilical arteries to the placenta1 and there returns them to the maternal blood for disposal4 ,the blood of the veins is bright red1 and of the arteries1 dark and turbid4 ,illustration3 ,fig4 #bj4--,normal attitude of ftus 7complete flexion74 7,barbour47 ,there is no direct communication between the maternal tissues and the placenta1 hence all the changes occur by osmosis1 and by the activity of the cells which form the walls of the villi4 ,the liver of the child is large and active4 ,the stomach and intestines functionate mildly4 ,the kidneys act1 and urine is discharged into the liquor amnii1 which the child occasionally swallows4 ,during development1 the movements of the child become more and more pronounced4 ,arms1 legs1 and entire body participate in turn4 ,periods of rest are also observed4 ,gradually the child assumes a definite attitude in the uterus4 ,it becomes more and more folded and flexed to accommodate its size to the limitations of space4 ,the head bends on the chest1 the arms are folded1 the thighs flex against the abdomen1 the legs on the thighs1 and even the back ultimately becomes convex4 ,it attains a complete flexion1 the normal attitude of the child4 ,as maturity approaches1 the head becomes more and more palpable and seeks its usual location in the lower pole of the uterus1 resting on the pelvic brim4 ,illustration3 ,fig4 #ba4--;,ftal skulls showing sutures4 ,note the differences between the anterior and posterior fontanelles4 7,eden47 ,illustration3 ,fig4 #bb ,a4--,child's head at term 7from side71 showing diameter4 7,american ,text ,book47 ,illustration3 ,fig4 #bb ,b4--,the child's head at term 7from above71 showing diameters and fontanelles4 7,american ,text ,book47 ,the ftal skull at maturity 7at term7 is still incompletely ossified4 ,the bones are thin and pliable and separated at their edges by intervals of unossified membrane which form the sutures and fontanelles4 ,thus the skull is compressible to a slight degree and capable of much change in shape4 ,it can be measurably moulded by the uterine contractions to suit the pelvis4 ,in front1 the two coronary sutures meet the frontal and sagittal sutures to produce a kite-shaped figure1 called the large or anterior fontanelle1 or the bregma4 ,behind1 the lambdoidal suture meets the sagittal suture to form the small or posterior fontanelle4 ,the large fontanelle is made up of four bones and four angles2 the small1 of three bones and three angles1 and are usually easy to differentiate4 ,furthermore1 the difference between these fontanelles is of great importance in labor1 since by it the observer is enabled to determine the position of the head4 ,in ,america1 the shape of the head is that of an ovoid with the long diameter anteroposterior 7,dolico-cephalic74 ,thus it happens that when the head is completely flexed1 the smallest diameters are presented for delivery4 ,the important diameters of the head1 with their measurements and names1 are as follows3 ,nape of neck to center of bregma1 #i4e cm4--,suboccipito-bregmatic diameter4 ,occipital protuberance to root of nose1 #aa4be cm4--,occipito-frontal diameter4 ,between the eminences of parietal bones1 #i4be cm4--,biparietal diameter4 ,between anterior ends of coronal sutures1 #h cm4--,bitemporal diameter4 ,the smallest circumference is that of the suboccipito-bregmatic plane1 which comes into relation with the brim of the pelvis when the flexion of the head is complete4 ,it measures #bg4e centimeters4 ,the ftus grows at a definite rate throughout gestation and so regularly that the increase is rarely simulated by any other condition4 ,to find the probable length of the ftus at any given time1 square the month of the pregnancy 7up to five7 and the result is the ftal length in centimeters4 ,after the fifth month1 multiply the number of the month by five4 ,thus3 #gth month #ece cm41 the approximate length of the ftus at the lunar month4--7,hasse's rule47 ,the ,mature ,ftus4--,although subject to considerable variation1 the ftus at term will weigh about seven and one-fourth pounds1 and measure #ej cm4 in length4 ,the weight is far more uncertain than the length1 and therefore not so reliable as a sign of maturity4 ,to obtain an estimate of the weight of the child at any given month of the pregnancy1 the number of lunar months minus #b1 is squared and divided by #b1 and the result is the average weight of the child at that time in hundreds of grams4 ,thus3 #hth month #bf4 #ffcf4 #cfbah1 or in hundreds of grams1 #ahjj1 the weight of the child4--7,tuttle's rule47 ,differences between the mature and immature ftus3 ,mature ,immature #a4 ,skin smooth1 plump1 pink #a4 ,skin lax1 wrinkled1 dull red in covered with vernix caseosa4 color2 little vernix caseosa4 #b4 ,generous amount of subcutaneous #b4 ,subcutaneous fat scanty4 fat4 #c4 ,hair abundant and from #a to #b #c4 ,hair on scalp short4 inches long4 #d4 ,lanugo mostly absent4 #d4 ,lanugo present all over body4 #e4 ,nails project from finger tips4 #e4 ,short nails on fingers and toes4 #f4 ,skull bones in contact except #f4 ,skull sutures open4 at fontanelles4 #g4 ,length #ej cm4 born4 #g4 ,moves and cries feebly when #h4 ,weight five to eight pounds4 #h4 ,weight less than five pounds4 #i4 ,cartilage in ear well developed4 #aj4 ,navel in middle of body4 #aa4 ,testes have descended in the male1 and the labia majora in the female usually cover the labia minora4 #ab4 ,moves and cries vigorously when born4 ,the ,ftal ,circulation4--,the placenta is an organ of nutrition as well as respiration1 and through the umbilical vessels the food materials are brought to the ftus and the waste products removed4 ,surrounded by the jelly of ,wharton that fills out the cord1 and running in and out between the two arteries1 the umbilical vein passes into the ftal abdomen and divides into two branches1 one1 the larger1 short-circuits directly into the inferior vena cava4 ,this branch is called the ductus venosus4 ,the other joins the portal vein and passes through the liver1 after which it also enters the vena cava4 ,thus the heart is fed with a mixed blood1 part coming fresh from the placenta and part coming up from the lower half of the ftus4 ,this blood is poured into the right auricle1 where it becomes mixed again with the blood coming down from the upper pole of the ftus through the superior vena cava4 ,illustration3 ,fig4 #bc4--,the ftal circulation4 7,edgar47 ,now a small part goes down into the right ventricle and is forced into the pulmonary arteries to supply the lungs4 ,but the lungs are not functionating1 hence the greater part is again short-circuited through the ductus arteriosus into the arch of the aorta1 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 auricles1 called the foramen ovale1 thence down into the left ventricle and out through the aorta to supply the rest of the ftal body4 ,with the exception of the ductus venosus and the ductus arteriosus and the foramen ovale1 the circulation is the same as in the adult4 ,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 umbilical arteries to the placenta for oxygenation4 ,as soon as the child is born1 the ftal structures are altered4 ,the child breathes1 the pulmonary circulation is established and the ductus arteriosus is closed4 ,the placental circulation is abolished1 and the ductus venosus and the hypogastric arteries are converted into solid fibrous cords4 ,owing to the immediate change of pressure in the auricles1 the foramen ovale closes and the circulation assumes the adult type4 ,,chapter ,,iii ,,normal ,,pregnancy ,the entire body participates in the changes brought about by pregnancy4 ,the hips and breasts become fuller1 the back broadens1 and the woman puts on fat4 ,she becomes mature in appearance1 but1 of course1 the phenomena connected with alterations in the breasts and genitals are most important1 and late in pregnancy1 most conspicuous4 ,the uterus exhibits the most marked alteration4 ,from an organ that weighs two ounces1 it becomes the largest in the body1 and increases in size from two and one-half or three inches to fifteen inches4 ,the typical pear-shape becomes spheroidal near the end of the third month1 becomes pyriform again at the fifth month1 and continues thus until term4 ,up to the fourth month the walls become thicker1 heavier and more muscular1 but as pregnancy advances1 more and more tissue is demanded1 until at the end1 a muscle wall of only moderate thickness protects the ovum4 ,meanwhile the muscular functions of contractibility and irritability are greatly increased4 ,at the fourth month the womb1 which has occupied a position of anteversion against the bladder1 rises out of the pelvis4 ,it is now an abdominal organ and as it gets heavier and heavier1 it rests a certain amount of its bulk on the brim of the pelvis4 ,about the sixth month1 the uppermost part of the uterus 7fundus7 is at the level of the umbilicus4 ,at the eighth month1 the fundus is found a little more than midway between the umbilicus and the ensiform cartilage4 ,about two weeks before term1 it reaches its highest point1 the ensiform cartilage1 and then sometimes sinks a little lower in the abdomen4 ,the ovum1 or egg1 does not completely fill the uterine cavity at first1 but grows from its side like a fungus until the third month4 ,then the uterine cavity is entirely occupied and thereafter the egg and the uterus develop at an equal rate4 ,as the uterus rises in the abdomen1 it rotates to one side1 usually the right1 forward on its vertical axis4 ,illustration3 ,fig4 #bd4--;,gravid uterus at the end of the eighth week4 7,braune47 ,the blood vessels and lymphatics also increase in size1 number1 and tortuosity4 ,many of the veins become sinuses as large as the little finger4 ,this increased amount of fluid both within and without the uterus has a marked effect upon its consistency4 ,the walls of the uterus1 vagina1 and cervix become softened1 infiltrated and more distensible4 ,there is also an increase in size and in number of the muscle cells4 ,during pregnancy the uterine muscle exhibits a definite functional activity4 ,intermittent contractions occur1 feeble at first1 but growing markedly stronger as pregnancy advances4 ,these are the contractions of ,braxton ,hicks4 ,they are irregular and painless1 but can be felt by the examining hand4 ,at term they merge into1 and are lost in1 the regular1 painful contractions of labor4 ,the breasts can not be said to be fully developed until lactation has occurred1 nevertheless1 the glands show pronounced changes as a result of marriage and pregnancy4 ,the size of the gland1 as well as the size and appearance of the nipple and areola1 varies greatly in different women2 but under the stimulation of pregnancy the whole gland enlarges1 including the connective tissue stroma4 ,about the fourth month a pale yellow secretion can be squeezed from the nipple4 ,this is called colostrum4 ,the pigmentation extends over a wider area and deepens in color1 while the increased vascularity is shown by the appearance of the blue veins under the thin tender skin4 ,light pinkish lines sometimes radiate from the nipple4 ,these are stri and are more evident in blondes4 ,the milk comes into the breasts about the third day after labor1 and normally continues to flow for six1 to ten or twelve months4 ,why the pregnancy and labor induce such marked mammary activity is not known1 but the fact is patent4 ,the skin reacts both mechanically and biologically to the stimulus of pregnancy4 ,illustration3 ,fig4 #be4--,stri ,gravidarum4 7,edgar47 ,stri ,gravidarum4--,stri gravidarum appear on the abdomen similar to those observed on the breasts and are due to the same cause--mechanical stretching4 ,when fresh1 they are pinkish in color and variable in length and breadth1 but attain the greatest size below the umbilicus4 ,occasionally they extend to the thighs and buttocks4 ,after labor1 they become pale1 silvery1 and scar-like and are called linea albicantes4 ,they are sometimes found in other conditions than pregnancy1 such as tumors or ascites4 ,increased ,pigmentation4--,pigmentation is not limited to the breasts4 ,on the abdomen1 a dark line will appear between the umbilicus and the pubes4 ,this is the linea nigra1 and it becomes most conspicuous in the latter half of pregnancy4 ,in the groins1 the axill1 and over the genitals1 the deposit is common1 and sometimes patches appear on the face1 either discrete or in coalescence1 to form a continuous discoloration1 called chloasma2 or when extensive1 the 8mask of pregnancy40 ,the pigmentation is absorbed1 or at least greatly diminished1 after labor4 ,the sebaceous and sweat glands are more active4 ,the hair may fall out and the teeth decay4 8,with every child a tooth10 is the cry of tradition4 ,these changes are due to imperfect nutrition1 or to the presence of toxins in the circulation4 ,eruptions of an erythematous1 eczematous1 papular or pustular type are not uncommon2 and itching1 either local or general1 may make life miserable4 ,the blood undergoes certain modifications that are fairly constant4 ,the total amount is increased1 but the quality is poorer1 especially by an increase in water and white cells and a diminution of red cells4 ,the amount of calcium is slightly increased and the fibrin is diminished up to the sixth month1 when it rises to normal again at term4 ,the heart is slightly hypertrophied on the right side and blood pressure somewhat raised4 ,a marked increase in blood pressure is suggestive of eclampsia4 ,the thyroid gland enlarges frequently1 both as a consequence of menstrual irritation and of pregnancy4 ,goiters may show an increase of development1 which remains after labor4 ,the urine is diminished in amount1 but increased in frequency of evacuation4 ,the bladder is more irritable during the first and last months1 and micturition may be painful and unsatisfactory4 ,the kidneys must be watched carefully during gestation4 ,the nervous system is disordered in most women1 but especially in those of neurotic tendencies4 ,irritability1 insomnia1 neuralgia of face or teeth1 or perversion of appetite in the so-called 8longings0 are the more common manifestations4 ,cramps occur in the muscles of the legs1 owing to varicose veins or pressure upon the lumbar and sacral plexus of nerves4 ,the lungs are crowded by the growing uterus and the respiration interfered with4 ,the liver is enlarged1 but functionally it is less competent1 and constipation is common4 ,it is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of ftal activity1 which is more or less toxic in character4 ,the more pronounced effects of this toxin will be studied under the abnormal conditions of pregnancy4 ,generally1 if the pregnancy is normal1 the whole body responds to the stimulating influence4 ,after the nausea and vomiting of the early months subside1 the woman feels energetic and ambitious4 ,she is eager to do something at all times and feels fatigue but slightly4 ,music1 literature or housework engages her attention and is zealously and joyfully practiced4 ,the world seems bright and the thought of her labor does not bring solicitude1 but pleasant anticipations4 ,the body fills out in all directions and the woman takes on the appearance of maturity4 ,,diagnosis ,,of ,,pregnancy ,the presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces4 ,during the second half of the period the ftus can be made out distinctly by palpation1 or by its movements1 and the heart tones observed by auscultation4 ,during the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician4 ,it is of extreme practical importance to be able to recognize a pregnancy at all periods4 ,the subjective symptoms of the first half are--amenorrha1 morning sickness1 irritability of the bladder1 discomfort and swelling of the breasts1 enlargement of the abdomen and quickening2 but the appearance of any or all of these phenomena is not to be regarded as conclusive1 but merely as a presumption that pregnancy exists4 ,either through ignorance1 intent to deceive1 or from pathological conditions1 any or all of these symptoms may be present1 but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable4 ,amenorrha4--,cessation of the menses is practically invariable in pregnancy4 ,one or two periods may occur after conception1 but care must be used to exclude other causes of hmorrhage4 ,sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause1 is strongly suggestive of pregnancy4 ,why a developing ovum causes an immediate arrest of menstruation is not understood4 ,amenorrha may occur in consequence of chlorosis1 heart disease1 hysteria1 tuberculosis1 fright1 grief1 and some forms of insanity2 a change from a low to a high altitude1 or an ocean voyage not infrequently causes the flow to remain absent for one or more months4 ,in addition to its value as a presumptive symptom1 the amenorrha affords a common and convenient method of estimating the date of confinement4 ,the method is fallacious but practical1 and will be discussed later4 ,morning ,sickness4--,this symptom is not invariable4 ,it is most frequent in primiparas1 but not so likely to occur in subsequent pregnancies4 ,it usually appears about the second month1 shortly after the first period missed4 ,it varies in intensity4 ,some women have a little nausea on arising and no further trouble during the day1 others are nauseated and vomit either on rising or after the first meal1 and yet others after each meal2 but the general health is not ordinarily affected and the tongue remains clean4 ,some cases are of extreme severity 7hyperemesis7 and will be discussed elsewhere4 ,the morning sickness is probably toxic in origin4 ,it must be remembered that chronic alcoholism is accompanied by morning sickness1 but with it the tongue is furred4 ,irritability of bladder is shown by a frequency of urination4 ,it is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another4 ,after the third month an accommodation is established and the symptom does not reappear until late in pregnancy1 when the pressure of the heavy uterus tends to keep the bladder empty4 ,if especially annoying1 this irritability may be much relieved by putting the patient in the knee-chest position night and morning4 ,enlargement of the breasts is common in primiparas1 but this1 with changes in the areola1 may occur at menstrual periods in nervous women4 ,tingling1 pricking and shooting sensations may also be noted4 ,enlargement of the abdomen is only noticeable toward the latter part of the first half1 when the uterus rises out of the abdomen4 ,quickening means 8coming to life10 and refers to the first movements of the ftus that are felt by the mother4 ,it is described as similar to the flutter of a bird in the closed hand4 ,it is sometimes accompanied by nausea and faintness4 ,quickening usually occurs about the seventeenth week of pregnancy1 and continues to the end4 ,gas in the intestines will sometimes simulate quickening4 ,the movements are important in the second half as indicating that the child is alive4 ,physical ,signs4--,during the first weeks no conclusive changes occur that can be detected by examination1 and unless conditions are especially favorable1 the earliest time for the definite diagnosis of pregnancy is the eighth week4 ,previous to this it is presumptive only4 ,at the eighth week1 the breasts may show enlargement and tenderness1 with some secretion4 ,in the multipara1 this sign has no significance4 ,secretion is present sometimes in the breast of nonpregnant women with uterine disease 7fibroids74 ,examination of the abdomen at this time is of little value1 but changes in the uterus can be detected by careful bimanual examination4 ,it is needless to say that all internal examinations should be made with the utmost care and gentleness4 ,softening of the lips of the os 7,goodell's sign7 may be found1 but it must not be confused with erosions of the os4 ,the os of a nonpregnant woman feels like the tip of the nose1 and that of the pregnant woman like the lips4 ,illustration3 ,fig4 #bf4--;,bimanual examination4 7,edgar47 ,the increased size and globular shape must also be considered as confirmatory4 ,hegar's ,sign4--,the upper part of the uterus is soft and distended by the ovum1 the lower part is soft and not filled out by the ovum4 ,between the two is an isthmus that is compressible between the fingers of one hand in the vagina1 and of the other upon the abdomen4 ,when found1 this sign is of great value4 ,at the eighth week1 pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs3 ,amenorrha1 morning sickness1 irritability of bladder1 slight breast changes in primiparas1 lips of os externum softened1 uterine body enlarged1 softened1 and nearly globular in shape1 and ,hegar's sign4 ,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 formation of a ferment to destroy it4 ,abderhalden's plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein4 ,it is a very complicated test1 and subject to many inaccuracies and numerous sources of error4 ,at the same time1 the main features of this reaction have been confirmed1 and when it is worked out1 it will be of immense value not alone in early uterine pregnancies1 but in extrauterine pregnancy4 ,this view very properly demands that pregnancy be regarded as a parasitic disease4 ,it is practicable as early as the sixth week to make a diagnosis1 and it only fails in possibly ten per cent of the cases4 ,the negative test is equally definite as eliminating pregnancy4 ,sixteenth ,week4--,morning sickness and urinary symptoms have disappeared but amenorrha remains4 ,enlargement of the breasts is noticeable1 as well as the increased pigmentation4 ,the uterus begins to rise above the symphysis as an elastic1 somewhat ill-defined1 boggy mass4 ,the cervix is softer4 ,the characteristic dull lavender coloration of the vulvar mucous membrane is now evident4 ,it is due to the congestion and is called ,jacquemins' sign4 ,two ,new ,signs4--,irregular1 painless contractions of the uterus 7,braxton ,hicks' sign71 and ballottement4 ,the contractions of ,braxton ,hicks now become more easily palpable4 ,ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid4 ,in a standing position1 the ftus rests in the lower part of the uterus1 just above the cervix4 ,the woman stands with one foot on a low stool1 and two fingers of one hand are pushed into the vagina until they touch the cervix1 the other hand is placed on the fundus4 ,a smart upward blow by the internal hand is transmitted to the ftus1 and it can be felt to leave the cervix1 strike lightly the tissues underneath the external hand1 and return to the cervix4 ,it is simulated by so few things1 and so rarely1 that in practice it must be regarded as a positive sign4 ,during the second half1 the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs4 ,the symptoms of this period are mostly discomforts4 ,increased intraabdominal pressure brings on edema of the feet1 cramps in the legs1 varicose veins of the legs and vulva1 dyspna1 and palpitations4 ,twenty-sixth ,week4--,about the twenty-sixth week1 or1 at the end of the sixth calendar month1 the hypertrophy of the breasts1 the presence of secretion1 and the marked pigmentation are unmistakable4 ,the abdominal protrusion is now clearly visible1 and the fundus will be found at the level of the upper border of the umbilicus4 ,spontaneous ftal movements appear and may be felt by the palpating hand4 ,auscultation reveals the uterine souffle and the ftal heart sounds4 ,the heart sounds and the ftal movements1 when obtained by the observer1 are positive signs4 ,uterine souffle is a soft1 blowing murmur1 synchronous with the mother's pulse4 ,it is best heard at the lower parts of the lateral borders of the uterus4 ,it is due to the passage of blood through the greatly dilated uterine arteries4 ,it may be heard also in cases of fibroid tumors of the uterus4 ,illustration3 ,fig4 #bg4--;,abdominal enlargement at third1 sixth1 ninth1 and tenth months of pregnancy4 7,williams47 ,illustration3 ,fig4 #bh4--;,height of the uterus at various months of pregnancy4 7,bumm47 ,the ftal heart sounds are the most anxiously sought for of all the signs of pregnancy4 ,they are conclusive4 ,they not only determine the diagnosis1 but afford valuable information during labor1 and nurse and student should lose no opportunity of becoming familiar with them4 ,the heart tones can be heard as early as the twenty-sixth week1 but they become more and more distinct as pregnancy advances4 ,they vary from #adj to #afj beats to the minute at the twenty-sixth week1 and at term1 from #abj to #adj4 ,when they rise above #afj or sink below #abj1 some danger threatens the child4 ,the ftal heart tones have no significance as an indication of sex4 ,funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope4 ,it is synchronous with the ftal heart tones1 but of no great practical importance when the heart tones can be obtained4 ,determination of the period to which pregnancy has advanced is sometimes important4 ,this can be approximated by a calculation of the time that has elapsed since the last period1 or from the date on which quickening has occurred4 ,measurement of the height of the fundus and comparison with such scales as ,spiegelberg's1 may be carried out1 but it is not often required4 ,a method of estimation in gross1 that is approximately correct1 in many cases depends on the observation of the steady growth of the womb4 ,thus1 the uterus rises out of the pelvis at the fourth month1 and may be found well above the symphysis pubis4 ,at the fifth month the fundus is midway between the symphysis and the umbilicus4 ,at the sixth month it reaches the umbilical level4 ,at the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage1 which it attains in another month1 the ninth4 ,then it usually sinks a little1 especially in primiparas during the last two or three weeks4 ,this is called lightening4 ,,chapter ,,iv ,,hygiene ,,of ,,normal ,,pregnancy ,the time of confinement can never be accurately determined1 because the onset of labor is purely an accident1 dependent on many factors4 ,furthermore1 conception does not take place necessarily at the time of intercourse1 and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed4 ,so there is always a possible error of three weeks4 ,pregnancy in the human family normally lasts from #bge to #bhj days1 and the approximate date of confinement can be obtained by the following convenient rules3 #a4 ,take the first day of the last menstruation1 count back three months and add seven days4 #b4 ,or1 assuming that quickening occurs at the seventeenth week1 count ahead twenty-two weeks from the day on which quickening was observed4 #c4 ,or1 count two weeks from the day of lightening4 #d4 ,or1 with a pelvimeter1 get the length of the ftus by ,ahlfeld's rule 7measure from symphysis to breech of child1 subtract two cm4 for thickness of abdominal wall and multiply by two4 ,the result is the length of the child in centimeters7 and compare with fifty centimeters1 which is the average length of a mature child4 ,after the seventh month1 the child in utero grows at the rate of about #a cm4 a week 7#j4i cm474 #e4 ,or1 by the tape1 according to ,spiegelberg's standard of growth1 as previously mentioned4 ,the hygienic rules to be observed during pregnancy are founded on three basic principles3 7#a7 ,to watch attentively the different organs and see that they functionate normally2 7#b7 ,to eliminate all those conditions that favor the premature expulsion of the egg2 and 7#c7 ,to provide1 so far as possible1 for the normal gestation and the physiological delivery of the child4 ,these factors will be taken up in detail4 ,the ,diet4--,the appetite is usually somewhat increased1 but it is unnecessary to indulge the stomach on the ground that the mother 8must eat for two40 ,longings1 however1 should be gratified so far as the demand is not for unwholesome things4 ,food should be simple and plainly cooked4 ,meat is permitted in moderation unless some organic change exists to contraindicate it4 ,rich pastries and gravies should be avoided1 but cereals1 fruits and vegetables should be used in abundance4 ,it may be better to eat four times a day instead of three4 ,fluids should be taken freely1 from one to two quarts daily4 ,milk is especially valuable1 and alkaline1 natural and charged waters1 such as ,vichy and seltzer1 are useful4 ,wine1 beer and other alcohols should not be taken1 or if the patient is habituated to their use1 the amount should be restricted on account of danger to the pregnancy and danger to the child4 ,in contracted pelves it is sometimes desired to furnish a special diet1 with the idea of controlling the size of the child 7see ,prochownick's ,diet1 p4 #ccb7 but this is an emergency4 ,certain books on maternity1 designed for popular reading1 advocate diets that are supposed1 by depriving the child of lime salts1 to keep its bones soft and make the labor easy4 ,if it succeeds1 the child will be injuriously affected4 ,if it does not succeed1 the claim is false4 ,exercise4--,exercise should be taken1 but it should not be violent1 nor attended by risk4 ,golf1 swimming1 tennis1 dancing1 horseback or bicycle riding and fast driving in automobiles should be forbidden1 lest abortion follow4 ,general exhaustion must be avoided and all conditions that even approximate traumatism4 ,walking and slow driving are best1 and housework is excellent up to a mild degree of fatigue4 ,travel should be restricted4 ,if exercise is not feasible1 massage will furnish the required stimulation to the circulation4 ,the menstrual epochs are peculiarly favorable to abortive influences4 ,the ,bowels4--,most women have a tendency to constipation during pregnancy4 ,many times this can be corrected by increasing the 8roughening0 in the food2 more vegetables and fruits1 bran bread and muffins1 whole wheat bread1 spinach1 beans1 carrots1 turnips1 peas and especially potatoes1 baked and eaten1 skin and all4 ,prunes1 figs1 and dates are valuable aids4 ,agar may be eaten three or four times daily4 ,russian oil 7liquid petrolatum71 taken in tablespoon doses three times daily1 is an adjuvant1 and finally1 some form of cascara or aperient pill may be taken1 if necessary4 ,violent cathartics should not be used at all1 and enemas as little as possible2 only when quick results are necessary4 ,heartburn4--,heartburn is a frequent complication1 especially in the later months4 ,it is due to an inordinate secretion of acid in the stomach4 ,soda mint tablets1 bicarbonate of soda1 and magnesia1 in cake or as milk of magnesia1 will relieve4 ,the magnesia is also a laxative4 ,the kidneys require particular care during pregnancy1 and in every case the urine should be examined monthly1 up to the fifth month1 and every two weeks thereafter1 until the last six weeks1 when a weekly test should be made4 ,the amount passed in twenty-four hours should be measured4 ,three pints is an average quantity4 ,albumin1 sugar1 and casts must be looked for and reported4 ,albumin may or may not be a serious symptom4 ,casts are significant of nephritis and indicate danger4 ,sugar may be lactose and be derived from the milk secreted in the breast4 ,edema of feet1 hands and eyelids must always be investigated1 with the possibility in mind1 of heart and kidney lesions4 ,blindness1 dizzy spells1 headaches and spots before the eyes are always alarming symptoms until their innocence is established4 ,through constant watchfulness of the urine1 many cases of eclampsia may be averted4 ,bathing is more important in pregnancy than at other times4 ,the more the skin secretes1 the less the burden on the kidneys4 ,the skin must be kept warm1 clean1 and active4 ,then again1 during pregnancy the skin is often unusually sensitive and only the mildest soaps and blandest applications can be used4 ,the water must be neither hot nor cold1 but just a comfortable temperature4 ,cold bathing1 whether shower1 plunge1 or sitz1 must be denied4 ,sea bathing is also unwise4 ,the warm tub bath of plain water or with bran answers all conditions until the expected labor is near1 then the warm shower or sponge bath should be substituted1 lest germs from the bath water enter the vagina4 ,if the kidneys need aid1 a hot pack may be used2 but in all cases1 frequent rubbing of the skin with a coarse towel should follow the bath4 ,the dress must be warm1 loose1 simple and suspended from the shoulders4 ,to prevent chilling1 wool or silk1 or a mixture of both1 should be worn next to the skin1--light in summer and heavy in winter4 ,the patient must be sensibly clad in broad1 loose1 low-heeled shoes4 ,there should be no constriction about chest or abdomen4 ,circular garters must not be worn4 ,if a corset is insisted upon1 it must support the abdomen from below and lift it up4 ,no corset is admissible that pushes down on the abdomen4 ,this is especially true if the woman has borne one or more children and has a pendulous abdomen4 ,the breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter4 ,fainting is an annoying symptom in some women4 ,it may come when quickening is first perceived1 or from the excitement of crowds1 or from hysteria4 ,it usually passes quickly4 ,the pallor is not deep1 the pulse is not affected1 and consciousness is not lost4 ,it does not affect the ovum4 ,heart trouble should be excluded1 and the daily habits of dress1 diet1 and bowels investigated4 ,smelling salts will usually suffice for the attack4 ,the abdominal walls may be strengthened by appropriate exercise before and after gestation1 so that the muscles will preserve their tone4 ,after delivery nursing the child will help greatly in the preservation of the waist line and figure1 by aiding involution4 ,about the seventh month in primiparas1 the abdomen gets very tense and in places the skin is stretched until it gives way and forms stri4 ,this tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene4 ,pain in the abdomen at this time may be due to mechanical distention1 to strain on the muscles1 to stretching of operative adhesions1 to gas1 constipation1 or appendicitis4 ,the physician should be informed of it4 ,in every case1 constipation1 swelling of feet1 hands or eyelids1 blurring of vision1 ringing in the ears1 vomiting1 persistent backache1 or the passage of blood1 no matter how slight1 should be reported to the doctor4 ,the ,breasts4--,there should be no pressure on the glands and they should be warmly covered4 ,the nipples must be kept clean and soft by soap and water1 and about a month before the labor is expected1 the nipple should be anointed with albolene or cocoanut oil and rubbed and pulled for a few minutes every night4 ,this removes the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby's mouth4 ,no alcohol or strongly astringent washes should be used4 ,injuries must be avoided4 ,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 center1 such as ,williams recommends4 ,leucorrha4--,this is one of the commonest discomforts of pregnancy1 and the sense of uncleanliness1 if the discharge is excessive1 as well as the resulting irritation1 may demand attention4 ,it must be kept in mind1 however1 that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications4 ,vaginal douches of warm boric acid solution will do for cleanliness1 but the douche bag must not be higher than the waist4 ,stronger and more antiseptic solutions are potassium permanganate #a3ejjj1 or chinosol #a3ajjj4 ,a suppository may be used1 consisting of extract belladonna1 gr4 ss2 tannic acid1 gr4 v1 and boroglyceride dr4 ss4 ,sexual intercourse is distasteful to most pregnant women1 but sometimes the inclination is intensified4 ,coitus often causes much pelvic discomfort and may be an influential factor in producing abortion4 ,it should be forbidden during the early months1 at all menstrual epochs1 and for at least two weeks before labor4 ,the uterus may be infected by germs beneath the foreskin and hmorrhage may follow the act if the placenta is low4 ,in healthy persons1 at the instance of the female1 intercourse in moderation is permissible4 ,the mental condition should be placid without either excitement or fatigue4 ,anxiety should be dissipated by cheerful company and surroundings4 ,judicious amusement is desirable and a congenial occupation1 but neighbors who tell frightful tales of disaster in labor1 or nurses who relate the details of their critical cases1 are equally to be avoided4 ,many women of neurotic temperament dread the labor desperately4 ,they are sure that death impends and they dwell with tragic interest on the stories of complicated cases related by thoughtless or malicious neighbors4 ,the nurse can do much to allay these apprehensions by cheerfulness1 optimism1 and gentleness4 ,her buoyant temperament will drive away the patient's fears just as effectively as the assurances of the physician4 ,great allowances must be made for attacks of irritability1 for the changes going on in the woman's pelvis keep her in a capricious and whimsical condition4 ,a good book to read at this time is1 the 8,prospective ,mother10 by ,slemons4 ,the subject of maternal impressions is the cause of much anxiety during pregnancy4 ,it is safe to assure the mother that it is nearly impossible to mark her child by emotional stress4 ,there is no demonstrable nervous communication between mother and child1 and most of the deformities that occur and are attributable to shock1 etc41 can be explained by our knowledge of intrauterine changes4 ,furthermore1 the same deformities occur in lower animals1 to which it is difficult to ascribe such high nervous organization4 ,many of the birthmarks1 supposedly due to shock1 occur too late in the pregnancy to affect the child1 even if it were possible1 for the child is completely formed before the fourteenth week4 ,the ,determination of ,sex4--,it is not possible to know in advance of delivery whether the child will be a male or a female4 ,it is equally impossible to determine or even to influence the sex of the coming child4 ,many theories have been advanced1 and much talent has been wasted in trying to solve this problem4 ,reasoning by analogy from the facts obtained from lower animals1 the sex of the child is unalterably decided the moment conception occurs4 ,the responsibility for the decisions seems to lie with the male cell4 ,all we really know is that the sexes appear in the ratio of #ajj girls to #ajf boys4 ,,chapter ,v ,,abnormal ,,pregnancy ,after the diagnosis of pregnancy has been satisfactorily established1 no further internal examinations are necessary in the absence of special indications1 until about the thirtieth week4 ,at this time a series of complete physical examinations may be required to determine the presentation and position of the child1 the presence and rate of ftal heart tones1 the diameters of the head1 the length and approximate maturity of the child1 as well as the condition of the bony and soft passages of the mother4 ,it is thus that an appreciation of the obstetrical problem is secured and a course laid out for its successful solution4 ,pregnancy is not a disease1 but a normal function2 but the woman is exposed1 nevertheless1 to many grave risks that are peculiar to her condition and to many complications accidental or otherwise which are more serious on account of her pregnancy4 ,the ,toxmias4--,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 toxmia4 ,therefore1 while there is no positive proof as yet that these symptoms1 arising during pregnancy1 are toxmic in origin1 the evidence goes to show that they are2 and1 therefore1 should be classified as toxic4 ,postmortem findings in eclampsia and pernicious vomiting such as extensive thromboses1 cell necrosis1 and interstitial hmorrhages are very suggestive4 ,clinical findings in regard to the excretion of nitrogen 7urea1 ammonia1 uric acid1 etc471 the occurrence of acidosis1 elevation of blood pressure1 fever1 diminished excretion1 coma and convulsions1 all point to toxmia4 ,it is the minor disturbances1 however1 that the nurse will come in contact with most4 ,they are nearly all toxmic in origin1 and a brief description of them must be given1 together with suggestions for their management4 ,salivation or ,ptyalism4--,in the majority of cases1 saliva is not especially noticeable2 but at times the secretion shows an enormous increase1 and may even demand abortion4 ,patients will have saliva running constantly from the mouth4 ,the amount may reach a pint or a quart a day1 and the skin of the lower lip becomes greatly inflamed4 ,the only satisfactory treatment is a rigorous milk diet on the theory that the disturbance is an intoxication4 ,in extreme cases abortion may be indicated4 ,gingivitis4--,the gums may become inflamed1 spongy and hmorrhagic during pregnancy1 usually in patients of low vitality4 ,if a generous diet and astringent mouth washes do not relieve the condition1 the milk diet should be considered4 ,toothache and ,dental ,decay4--,the patient may be given hypophosphites1 and the teeth should be put in good condition by a dentist4 ,constipation has already been referred to4 ,strong cathartics should be avoided lest abortion follow4 ,condylomata of pregnancy occur most frequently around the labia1 perineum1 and anus4 ,they are wart-like growths that develop slowly or quickly and may remain discrete or cover the entire area with masses as small as beans or as large as cauliflowers1 which in appearance they much resemble4 ,the etiology is obscure1 but they are generally associated with irritating vaginal discharges1 such as an old gonorrha4 ,treatment consists in stopping the discharge or neutralizing it1 and in keeping the growths dry with a salicylic acid dusting powder4 7,see ,therapeutic ,index47 ,pruritus is often distressing4 ,the itching may be limited to the genitals or appear on other parts of the body4 ,it may be due to the irritation of local discharges or to a condition of the nervous system1 arising from toxmia4 ,astringent douches and protective ointments will relieve some cases4 ,bromides and milk diet1 bran or alkaline baths give good results1 and local applications of sedative lotions and ointments containing menthol1 carbolic acid or cocaine 7cautiously7 will aid4 ,the woman in some instances becomes almost frantic1 and tears at the vulva with her nails until it bleeds4 ,the iodine treatment of ,hensler is simple and often effective4 ,if no skin changes are visible and but little leucorrha1 the vulva is thoroughly prepared as for a vaginal operation1 dried and painted with a #aj per cent solution of tincture of iodine4 ,generally one application suffices1 but when the leucorrha is bad1 it may be necessary to repeat the treatment on the third and fifth day thereafter4 ,between treatments1 the vulvar surfaces and even the vaginal walls 7by insufflation7 are kept dry with zinc oxide powder4 ,if all measures fail and exhaustion is imminent1 emptying the uterus may be advisable4 ,herpes is an inflammatory1 superficial eruption1 characterized by red patches1 blisters1 or pustules4 ,it is accompanied by burning1 itching1 and nervous depression4 ,the origin is probably toxic and the termination may be fatal4 ,milk diet1 soothing lotions1 and1 if necessary1 abortion1 constitute the means of treatment4 ,areas of pigmentation 7the chloasmata7 are not amenable to treatment4 ,they usually disappear after labor4 ,albuminuria of ,pregnancy4--,albuminuria is so common as to be almost physiological when the amount of albumin is small4 ,when the amount of albumin in the urine is large1 it may be due to pre-existing disease1 which is first discovered when the urinalysis is made during pregnancy4 7,chronic nephritis874 ,if it makes its debut during gestation and continues as a mere trace without casts1 it is spoken of as the albuminuria of pregnancy1 but the patient must be watched with great care1 since the albuminuria may be a premonitory sign of eclampsia4 ,albuminuria and eclampsia must be considered together1 because1 while the two conditions may exist separately1 they are most frequently associated1 and it is believed that they have a common causation4 ,it is true that most cases of albuminuria terminate favorably1 yet the higher the albumin content1 the greater the danger of eclampsia4 ,albumin appears in the urine in from three to five per cent of all pregnancies4 ,it is more common in the latter half of gestation and the attacks differ greatly in severity4 ,symptoms4--,in the early stages the urine shows an abundant1 pale fluid of low specific gravity4 ,the seriousness of the case is generally indicated by the amount of albumin1 although this is not a reliable guide as to the danger of eclampsia4 ,casts and red and white blood corpuscles are occasionally found4 ,the output of urea usually remains normal1 but diminution usually occurs in connection with eclampsia4 ,anmia and anasarca are common1 but it is a hopeful clinical sign that the cases of extensive edema rarely develop eclampsia4 ,in albuminuria of pregnancy there is a large ftal mortality which1 to a degree1 is independent of eclampsia4 ,the infant dies in utero or is born feeble1 or prematurely4 ,eclampsia is the sudden appearance of convulsions in the course of pregnancy4 ,it may precede1 follow1 or accompany albuminuria4 ,it occurs rarely in the absence of albuminuria in a woman who was apparently in good health4 ,the two phenomena are best explained as a consequence of toxmia due to poisons at present unidentified4 ,treatment of the albuminuria is treatment for impending eclampsia4 ,regular examination of the urine is indispensable4 ,the presence of albumin suggests toxmia4 ,the daily output of urine and the output of urea must be compared1 for a fall in urea is a premonitory sign of eclampsia4 ,the bowels and the skin should be stimulated1 respectively1 by saline cathartics1 hot baths and packs4 ,the digestive organs must be spared as much work as possible1 especially the liver4 ,water is given in abundance1 and milk is the staple diet4 ,koumiss1 butter milk and ice cream may be allowed4 ,as the patient improves1 vegetables are allowed4 ,the food should be salt-free2 and alcohol1 as well as rich1 indigestible things should be forbidden4 ,in the milder cases boiled fish and a little chicken may be permitted4 ,the course of the disease and the condition of the patient is determined by frequent examinations of the urine1 while in all serious cases an examination of the fundus of the eye must be made to detect a possible albuminuric retinitis4 ,the treatment of eclampsia will be considered under the complications of labor1 where the attack usually begins4 ,pyelitis of pregnancy is an acute1 and rarely1 a chronic infection of the pelvis of the kidney1 due to the ,bacillus coli4 ,it usually appears after the fourth month 7fifth to eighth7 and attacks by preference the right side4 ,extension to the kidney substance1 ureters1 and bladder is occasionally observed4 ,symptoms4--,sudden1 acute abdominal pain1 at first diffuse1 but after a few hours1 becoming localized in the right side1 and on this account is often confused with appendicitis1 especially as vomiting is not infrequent4 ,a chill may mark the onset and the temperature rise to #ajc ,f4 or #ajd ,f4 ,the bowels are constipated1 the tongue coated1 and there is tenderness over the kidney4 ,the urine is scanty1 turbid1 slightly albuminous and contains pus and epithelium in the urinary canal4 ,a culture reveals the bacillus which has obtained access to the kidney1 either by extension of the ureter from the bladder1 by direct invasion of the tissues from the adjacent colon1 or through the circulation4 ,treatment4--,the diet should be fluid and mostly milk1 the bowels should be moved freely and frequently4 ,the urine is alkalinized with sodium citrate1 since the ,bacillus coli lives only in an acid medium4 ,as the symptoms subside1 urotropin may be administered4 ,if the patient does not improve within two weeks1 abortion must be seriously considered4 ,nephrotomy is not to be thought of unless abortion has failed4 ,hyperemesis ,gravidarum4--,the nausea and vomiting of pregnancy is so usual as to be regarded as normal4 ,it usually ceases from the fourth to the fifth month spontaneously2 has no ill effect upon the ovum1 and may respond readily to treatment4 ,hyperemesis comes on at the same period and exhibits all stages of violence1 from the mild form above described1 to cases that end fatally4 ,three classes of this serious disorder may be distinguished as associated 7,eden71 neurotic1 and toxmic vomiting4 ,associated vomiting is the vomiting that comes with gastric ulcer or cancer1 chronic gastritis1 cirrhosis of the liver1 and cerebral disease4 ,these conditions must be excluded in diagnosis4 ,neurotic vomiting--severe and persistent nausea and retching--is common in pregnant women of the nervous type4 ,it does not lead to loss of flesh ordinarily2 the urine is somewhat diminished in quantity from the lack of fluids1 but the amount of nitrogen excreted remains normal4 ,this is important4 ,toxmic vomiting includes a small but very important class of cases1 for all are severe and intractable and some end in death4 ,clinical ,features4--,the normal nausea and vomiting may seem unusually severe4 ,it persists and gets worse4 ,then vomiting occurs when no food is taken and nothing is held on the stomach4 ,the vomit is stained with bile or blood4 ,the tongue remains clean1 and the general condition is good4 ,next1 weight is lost and the pulse quickens4 ,a persistent pulse of over #ajj is serious4 ,the tongue becomes coated1 sordes develops1 sleeplessness and muscular twitching appear1 and the patient complains of epigastric pain4 ,abortion may now occur and the condition clear up4 ,in its final stage1 the urine becomes scanty and albuminous1 icterus may appear and the temperature rise to #ajj ,f4 or more1 though sometimes it is subnormal4 ,the pulse may go to #abj4 ,delirium and coma supervene1 and emptying the uterus is of no value4 ,fifty per cent of these bad cases die4 ,the especially prominent points to be noted are the urine1 which shows acetone1 albumin and blood1 either one or all1 as well as an increased amount of ammonia4 ,a persistently rapid pulse1 marked loss of flesh1 coated tongue1 jaundice and delirium are regularly present4 ,treatment4--,organic disease must be excluded and a diagnosis of pregnancy strongly evident4 ,for the neurotic type1 the patient must be segregated from her friends1 and a competent1 cheerful nurse put in charge4 ,a cool1 darkened room is best4 ,if the patient can be transferred to a hospital1 the results are more satisfactory4 ,here the isolation from external interests and irritations can be made complete4 ,the patient does not talk1 even the nurse comes with food1 attends to the obvious necessities1 and departs in silence4 ,once a day a sedative bath is given 7see ,baths1 p4 #cbe7 and medication in kind and frequency as the conditions demand4 ,in any case1 the patient should be put to bed and fed carefully every two or three hours on milk1 peptonized food or barley water4 ,if this is not retained1 albumin water may be given for twenty-four hours at regular intervals1 or rectal alimentation may be tried after stopping all foods by mouth4 ,iced champagne1 seltzer or ,vichy1 either alone or with milk1 may be tried4 ,a dry diet is sometimes effective1 rusk1 toast1 toasted shredded wheat biscuit1 crackers1 etc41 taken early in the morning1 as one eats cheese4 ,no exercise is permitted except such muscular and nervous excitation as may be derived from massage or the sedative bath4 ,drugs are sometimes of great value--the bromides1 in full doses1 or #a m4 doses of tincture of iodine1 well diluted1 every hour2 or bismuth with hydrocyanic acid2 or cocaine or oxalate of cerium4 ,occasionally good results are reported from a capsule of pepsin1 #b gr4 and gr4 silver nitrate given just before meals2 and adrenalin in #aj drop doses may be considered4 ,extract of corpus lutea has been tried by ,hirst with favorable results4 ,sinapisms to the epigastrium and ice bags to the spine have been found useful1 and washing out the stomach is efficient at times4 ,in washing out the stomach1 be sure the stomach tube is iced before it is introduced4 ,when the case gets worse in spite of treatment and acidosis supervenes1 bicarbonate of soda may be given in sixty grain doses every four hours1 by rectum1 if necessary1 until the urine gives an alkaline reaction4 ,glucose as a readily assimilable carbohydrate may be given in doses up to #aj oz4 of a #f per cent solution 7,eden7 or sugar infusions by rectum1 #ajjj c4c4 in twenty-four hours by drop method4 ,the obstetric treatment is the emptying of the uterus4 ,to be effective the abortion must be done before the condition of the patient is desperate4 ,it is most favorable before the febrile stage4 ,if the vomiting persists in spite of treatment and is accompanied by emaciation1 a pulse of over #ajj1 albumin in the urine1 with an increase of the ammonia output1 the pregnancy should be terminated at once4 ,if the patient can not go to a hospital1 the nurse should prepare the room as described for operations4 ,after emptying the uterus1 the vomiting usually ceases but much labor is thrown upon the nurse in supplying nourishment and caring for an exhausted and whimsical patient4 ,the back must be inspected daily for decubitus 7bed sores7 and her position changed frequently4 ,a daily rub with alcohol and water 7#ej per cent7 followed by an oil inunction will be valuable4 ,the teeth and gums should be cleaned with gauze1 wrapped around the finger and dipped in solution of boric acid4 ,no brush should be used4 ,illustration3 ,fig4 #bi4--,twins4 7,lenoir and ,tarnier47 ,multiple ,pregnancy4--,twins occur about once in ninety labors1 triplets1 once in seven thousand4 ,heredity and multiparity seem to be the only recognized predisposing factors4 ,the more pregnancies a woman has1 the more liable she is to have twins4 ,twins may occur through a division of the primitive cell through the fertilization of two ova from the same or different ovaries1 or by fertilization of a single ovum having two nuclei4 7,see ,fig4 #ac74 ,the former are called binovular twins1 and may or may not be of the same sex4 ,the latter are called uniovular twins and are always of the same sex4 ,twins are usually somewhat smaller than a single child1 and frequently associated with hydramnios4 ,binovular twins have separate placent and uniovular twins have one placenta1 with separate cords4 ,twin pregnancies usually go into labor earlier than the single child1 possibly on account of the over-distention of the uterus4 ,the diagnosis is occasionally difficult and at other times easy4 ,two sets of heart tones must be distinguished and differentiated by their variation in frequency1 heard at the same time by different observers4 ,the presence of twins may be strongly suspected also when the external measurements of child and uterus greatly exceed the average4 ,in such cases a systematic and persistent search must be made for the two ftal heart tones4 ,the delivery is generally uncomplicated1 unless the chins become locked4 ,displacements of the ,uterus4--,in most cases displacements of the uterus are a consequence of conception in organs that are previously retroflected or retroverted4 ,they rarely produce symptoms until the end of the third month1 when the attention is directed to the bladder4 ,there may be absolute retention or a constant dribbling from a full bladder 7ischuria paradoxa71 possibly associated with pain4 ,if recognized early1 an attempt should be made to replace the uterus by posture 7knee chest7 and when replaced1 to hold it by pessary or tampon4 ,the prone position in bed will aid4 ,after retention has occurred1 the patient should be put to bed and the bladder catheterized regularly every eight or ten hours for three or four days4 ,as a rule1 the organ will rise spontaneously into the abdomen4 ,if it does not1 it is probably incarcerated under the promontory1 and the physician must try to replace the uterus by manipulation or by continuous pressure1 but in bad cases1 he will empty the uterus before the condition of the patient becomes too serious4 ,in multiparas with weak abdominal walls1 or women with spinal curvature or contracted pelves1 the uterus may fall forward and1 passing between the recti muscles1 continue to drop until the fundus lies lower than the symphysis pubis4 ,management1 until labor occurs1 may be made more effective by using a strong1 well-fitting abdominal bandage4 ,malformation of the uterus may possess an obstetric interest at times4 ,the double uterus 7uterus didelphys7 and the uterus with a rudimentary horn 7uterus bicornis7 are examples4 ,these are congenital conditions1 due to imperfect development1 and pregnancy may take place in one or both sides4 ,if in one side only1 the other half will also exhibit the softening and other changes as in normal cases4 ,binovular twins may be the result of a pregnancy in each side4 ,pressure ,symptoms4--,edema of legs and sometimes of the vulva occurs during the last trimester4 ,it is due to increased intraabdominal pressure and to direct interference with the return circulation by the pressure of the heavy uterus on the iliac veins at the brim of the pelvis4 ,the urine should be examined for albumin and the patient put in the horizontal position if the edema is troublesome4 ,varicose veins of legs and vulva may cause much distress4 ,the limbs should be bound with flannel spirals or with rubber bandages in the recumbent position1 or elastic stockings may be obtained4 ,operation during pregnancy is not to be considered4 ,the vulva can only be relieved by a double bandage1 which is sewed at the point where it crosses the vulva1 and buckled or tied to a waistband above the hips1 both before and behind4 ,this brings support to the vulva4 ,if the veins rupture1 the part should be elevated and compressed with an aseptic pad4 ,hmorrhoids may either appear or grow worse late in pregnancy4 ,if they protrude1 they should be replaced4 ,ointments and iced applications may be used and the bowels kept loose4 ,cramps may occur in the muscles of the legs1 due sometimes to the varicose veins and sometimes to pressure on the lumbosacral plexus4 ,moles4--,mole is the name given to an ovum which is destroyed by disease of its coverings during the early months of gestation4 ,two kinds are known1 the blood mole 7carneous mole1 fleshy mole1 or hmatoma mole7 and the hydatidiform mole 7vesicular mole74 ,the blood mole results from progressive or recurrent slight hmorrhages during the first three months of pregnancy1 but hmorrhages insufficient in quantity to produce an abortion4 ,the blood forms a clot1 which may be retained for several months and become solidified4 ,hydatidiform mole is a disease of the young chorionic villi1 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 diameter4 ,the causation is unknown4 ,both forms occur in the first half of the pregnancy and are characterized by undue enlargement of the uterus and hmorrhagic discharge4 ,diseases of the ,membranes4--,hydramnios1 or polyhydramnios1 is the name applied to the condition where an excess of liquor amnii is formed4 ,the amount normally present varies1 but anything in excess of four pints could be called hydramnios4 ,six gallons have been reported4 ,since the source of the liquor amnii is not positively known1 the etiology of hydramnios must be equally obscure4 ,it is occasionally associated with morbid conditions of the mother1 such as hepatic or cardiac dropsy1 but more frequently with developmental anomalies of the ftus4 ,since the mother is usually healthy and the ftus frequently deformed1 the theory is advanced that the disease is ftal in origin4 ,it frequently occurs with twin pregnancies1 and in the first months it is most plausible that the liquor amnii is in some way derived from the ftus4 ,the disease is more common in multiparas4 ,it is generally slow in onset1 but it may be acute1 and an immense amount of fluid may be formed in a few weeks4 ,the symptoms are those due to pressure from the extremely large uterus4 ,the treatment1 if interference with heart or lungs becomes pronounced1 is puncture of the membranes4 ,the child need not be considered for it is usually dead or deformed4 ,oligohydramnios is the condition where the liquor amnii is deficient in amount4 ,it gives no maternal symptoms1 but it is the cause of many birthmarks and ftal deformities 7club-foot1 spinal curvature1 wry-neck1 ankylosis of joints74 ,amniotic adhesions are usually associated with oligohydranmios and cause deformities by amputation of limbs1 strangulation of cord1 and production of six fingers4 ,the placenta may show anomalies of size and shape4 ,thus1 there may be two lobes1 or three4 ,there may be the main placenta and a small out-lying mass connected by membrane and vessels with the larger segment4 ,the cord may be inserted in the middle or at the edge and yellowish-white masses called infarcts may be found in its substance4 ,unusual size and weight of the placenta are suggestive of syphilis4 ,abnormal conditions of the ftus may arise from primary or transmitted disease or from errors of development4 ,the developmental errors may be monsters1 hydrocephalus spina bifida1 etc41 which may not influence the pregnancy4 ,the most commonly transmitted disease is syphilis1 which may produce abortion1 premature labor1 or a child born with syphilitic skin changes on palms and soles1 as well as internally4 ,,chapter ,,vi ,,abnormal ,,pregnancy 7,cont'd7 ,extrauterine ,pregnancy4--,this is a pregnancy which occurs outside the uterus1 and while the event usually happens in the tube1 cases have been reported where the egg developed in the ovary or abdomen4 ,the ovum1 owing to some delay in passage to the uterus1 is fertilized either in the ovary or in the tube1 and by reason of a chronic inflammation of the tube or pelvis1 or of overgrowth does not succeed in reaching the uterus at all4 ,as the ovum develops1 the tube expands1 but it does not possess the power of growing into a large organ like the uterus1 hence a sudden jar1 a strain1 or a blow may cause it to rupture and discharge the egg into the abdomen 7ruptured tubal pregnancy7 or force it out through the end of the tube 7tubal abortion74 ,this phenomenon may be accompanied by a severe or even fatal hmorrhage2 or the prostration may pass off in a few days or weeks1 and leave the patient well4 ,in the early stages the ovum is absorbed1 but after the pregnancy becomes more advanced1 it may remain as a tumor1 or require an operation for its removal4 ,infection may occur and the mass ulcerate its way into neighboring organs 7rectum1 vagina1 or bladder7 and discharge itself in a long1 suppurative process4 ,most cases of ectopic 7extrauterine7gestation present definite and even dangerous symptoms between the second and fourth month4 ,the symptoms are those of pregnancy1 together with irregular hmorrhages from the uterus1 which may result in the expulsion of pieces of tissue or of membrane4 ,besides this1 there is a vomiting and acute irregular pain on one side1 associated with a sense of fullness4 ,such symptoms should be brought to the attention of the physician1 who will learn the true condition of the pelvis by internal examination1 conducted as gently as possible so as not to produce rupture4 ,if rupture occurs1 it will be ushered in by a sharp lancinating pain on one side1 followed by faintness1 nausea1 vomiting1 prostration1 rapid pulse1 sighing respiration1 and collapse4 ,the temperature is subnormal and death may occur in a few hours1 unless an operation is done4 ,illustration3 ,fig4 #cj4--;,diagram representing the sites for the various forms of tubal pregnancy4 #a1 interstitial pregnancy2 #b1 isthmial pregnancy2 #c1 ampullar pregnancy2 #d1 infundibular pregnancy2 #e1 tubo-ovarian pregnancy4 7,gilliam47 ,in cases of tubal abortion 7where the ovum escapes through the end of the tube7 the symptoms are very similar1 but the patient soon rallies and gradual recovery takes place4 ,if the diagnosis is made before rupture or abortion the treatment is laparotomy4 ,if rupture occurs1 the laparotomy must be done immediately to check the hmorrhage1 which threatens the life of the patient4 ,in tubal abortion1 if the diagnosis is certain1 some delay may be permitted under extreme watchfulness of the nurse and physician4 ,in such case1 the nurse will keep the patient absolutely quiet and forbid exertion of any kind4 ,if operation is necessary1 the utmost gentleness must be used in preparing the abdomen4 ,the tincture of iodine application to the site of the incision is sufficient preparation1 and1 of course1 an abundance of sterile gauze1 cotton1 and towels should be supplied1 as in every case where laparotomy is done4 ,if the rupture occurs while the nurse is present1 the doctor should be notified at once1 and if not at home1 another doctor should be summoned4 ,meanwhile1 the nurse prepares the room1 solutions and utensils for an abdominal operation4 ,immediate incision to check the hmorrhage and remove the mass offers the greatest safety4 ,the after-care is the same as for any laparotomy1 with the additional duty of making up the lost blood as soon as possible by nourishing foods1 normal saline solution by rectum1 and1 if necessary1 by hypodermoclysis4 ,acute fevers are a serious complication of pregnancy on account of the danger of abortion or premature labor1 which may come on either from the associated high temperature or from the transmission of the disease to the ovum4 ,the following diseases are known to affect the ftus in utero3 cholera1 yellow fever1 small pox1 scarlet fever1 typhoid1 measles1 erysipelas1 meningitis and syphilis4 ,,chronic ,,infections ,tuberculosis does not affect fertility or the course of the pregnancy1 but the progress of the disease is hastened1 and the maternal death accelerated4 ,the question of artificial abortion in the early months must be seriously considered1 and if the case goes on to term1 the child must not be nursed or cared for by the mother4 ,syphilis is the most frequent systemic cause of the interruption of pregnancy4 ,it is a blood disease1 due to an organism1 called spirochta pallida1 and it appears in three distinct stages4 ,the first is the primary stage1 wherein a hard1 nodular ulcer appears on some part of the body1 as the vulva1 lips1 gums1 tonsils1 or hand4 ,it is not always venereal in origin4 ,the second stage begins six or eight weeks after the sore1 and is marked by a general eruption of red spots1 chronic sore throat1 falling hair1 and rheumatic pains in the joints4 ,the third stage is the name given to the later conditions of the disease which affect the bones1 blood vessels1 and nervous system4 ,infection of the ovum may usually be traced to the father1 who may transmit syphilis at any stage of the disease4 ,in the third stage1 the child alone will be infected2 the mother escapes4 ,the mother may or may not transmit the disease1 depending on the period of pregnancy wherein her infection occurs4 ,if she gets the disease at1 before1 or just about1 the time of conception1 she will abort three times out of four1 and the ovum will show definite lesions4 ,if infected later1 abortion occurs less frequently2 and if the disease is contracted late in pregnancy1 the child may be born apparently free from infection4 ,symptoms4--,a child with congenital syphilis will show the eruption of coppery spots1 blisters on palms and soles1 deep cracks on the feet1 snuffles1 cracks and ulcers around the mouth and rectum1 and the weakly1 marasmic condition of the body4 ,the diagnosis in suspected cases can be rendered more certain by the ,wassermann reaction4 ,this is a laboratory test of the blood which should always be made before a wet nurse is allowed to nurse a child1 or before a suspected child is nursed by a clean woman4 ,in all cases of transfusion of blood1 it is imperative4 ,treatment4--,antisyphilitic treatment of an infected mother or child by salvarsan1 mercury1 and potassium iodide must be carried out vigorously in all cases4 ,the syphilitic patient must be prevented from spreading the infection by having dishes and utensils of her own1 which are kept sterile4 ,discharges are collected and burned1 and the nurse in charge of these cases must carefully cover her hands with rubber gloves1 and see that all cracks and fissures are properly protected from contact with sources of infection4 ,gonorrha is an acute or chronic disease of the mucous membranes due to a germ called the gonococcus4 ,beginning with a sharp inflammatory disturbance of the urethra or vagina1 it may pass slowly up through the genital passage and produce chronic and permanent disabilities1 such as sterility1 pus tubes1 and pelvic peritonitis4 ,the symptoms are painful urination1 painful inflammation of the vagina1 with a purulent discharge4 ,during pregnancy all these symptoms are intensified1 and warty growths 7condylomata7 may appear on the vulva4 ,if infection occurs after pregnancy has begun1 the course of the gestation is rarely affected1 as the uterus is closed to germ invasion4 ,during delivery1 however1 there is a serious danger of infection of mouth or eyes of the child if they come in contact with the discharge4 ,prophylaxis4--,the eyes at birth must be immediately instilled with a drop or two of #a per cent solution of silver nitrate in water4 ,this is not neutralized by normal saline4 ,great care must be used that the discharge does not come in contact with the eyes of the mother or attendants1 lest infection follow4 ,treatment4--,scrupulous cleanliness must be observed4 ,douches of potassium permanganate1 #a3ejjj1 or painting the vagina with iodine or solution of silver nitrate1 or suppositories of argyrol or protargol furnish the best means of treatment before labor4 ,neither syphilis nor gonorrhea is necessarily caused by venereal infection4 ,they may be spread by barbers1 dentists1 physicians1 and nurses1--by anyone who is unclean2 and may be acquired innocently everywhere4 ,these diseases should not be discussed by the nurse or physician except with the patient4 ,certainly nothing from the sick room should be repeated elsewhere4 ,the valves of the heart are not uncommonly found to be diseased in pregnancy1 the mitral being the most often affected1 either as an insufficiency or as a stenosis 7a narrowing of the mitral opening74 ,mitral stenosis is the most serious of all heart complications of pregnancy1 and where this is present1 a woman should be advised to avoid conception4 ,in other mitral lesions1 many pregnancies may be successfully passed1 if compensation is maintained2 but every one brings further damage to the already weakened heart1 and reduces its reserve of force4 ,if the heart breaks down early in pregnancy1 and does not respond to medication1 abortion should be induced4 ,in the second half of pregnancy1 the mother should be given the prior chance1 but the child should be saved1 if possible4 ,renal diseases1 such as nephritis1 may not only induce abortion by destroying the ftus1 but the kidney lesion may be greatly aggravated by the pregnancy4 ,the most careful observation of the patient's condition1 the regular examination of the urine1 and the scientific management of the diet is necessary to relieve the work on the kidneys and keep the patient in a moderate degree of health4 ,it is the duty of the nurse to protect her patient against fatigue and chill1 and to see that the proper diet is followed2 but other symptoms1 such as headache and disturbance of vision and developing edema1 must be noted and reported to the physician at once4 ,diseases of ,liver4--,acute yellow atrophy is a rare condition1 which1 for reasons unknown1 is promoted by pregnancy4 ,the symptoms are intense headache and pain in the abdomen1 possibly accompanied by vomiting and purging1 which are soon followed by coma4 ,there is generally a certain amount of jaundice4 ,the urine is diminished in amount and contains albumin1 casts1 and sometimes blood4 ,there is no known treatment1 and the end is death4 ,diabetes is seldom found associated with pregnancy4 ,its presence is unfavorable to conception and to gestation4 ,mother and child are both less secure4 ,abortion or premature labor is the rule4 ,the hmorrhages of pregnancy in the first half generally mean abortion1 and in the last half1 either placenta prvia or premature detachment of the normally implanted placenta 7see p4 #bbh74 ,abortion is the expulsion of the ovum before the ftus is viable1 that is1 before it is capable of maintaining life after birth4 ,this means the twenty-eighth week1 or the seventh month4 ,subsequent to the seventh month1 the interruption is called premature labor4 ,abortion is a miniature labor1 consisting of a stage of dilatation1 a stage of expulsion1 and a stage of involution4 ,the interruption of the pregnancy may occur spontaneously or be induced4 ,in spontaneous cases the causes may be sought in diseases of the ovum1 or in the mother1 in injuries to the uterus or its contents1 and such systemic affections as syphilis1 ,bright's disease1 alcoholism1 lead poisoning1 etc4 ,abortions happen about once in every five or six pregnancies1 and more frequently at the third month than at any other time4 ,the symptoms are hmorrhage and pain4 ,the dangers are hmorrhage and infection4 ,infection is most common and most serious in abortions that are brought about mechanically4 ,hmorrhage1 in some degree1 is an invariable symptom1 which has its origin in the separation of the ovum from the uterine wall4 ,hmorrhage from the uterus is serious at whatever stage of pregnancy it appears4 ,the duty of the nurse is to put the patient in a cool1 dark room1 on her back1 elevate the foot of the bed1 put ice bags on the lower abdomen1 and summon the attending physician1 with the hope that an abortion can be averted4 ,bromides and opium are the drugs most to be relied upon4 ,opium may be given in suppository1 #a grain night and morning4 ,if the hmorrhage is alarmingly profuse and the nurse is skillful and clean1 under exceptional circumstances she may pack the vagina with sterile cotton while waiting for the doctor4 ,then the room should be set for operation4 ,dead ,ovum4--,the ovum may be discharged in pieces or in a single complete mass4 ,the egg may die at any period of the pregnancy1 and be discharged in a few hours1 or it may not be expelled for weeks1 if at all4 ,ftal death in the uterus may have its cause on the paternal side in a father too old or too young1 or affected with such diseases as diabetes1 nephritis1 tuberculosis1 syphilis1 or chronic lead poisoning2 on the maternal side1 the same diseases1 plus cancer1 anmia1 insufficient food1 and inflammation of the uterus2 on the part of the embryo1 syphilis or any transmitted or primary disease of the ovum4 ,the results of retention of the dead ovum vary with the case4 ,infection of the ovum is rare1 except where the membranes have ruptured and an open channel exists4 ,no harm follows the death of the ftus1 except in the presence of infections1 all other changes are benign4 ,the embryo in the first and second months may be absorbed1 but at later periods1 it becomes macerated petrified1 or otherwise altered4 ,among the signs of ftal death are prolonged cessation of ftal movements after being definitely observed1 chilliness1 languor and malaise of the mother1 sense of weight in abdomen1 and possibly a bad taste in the mouth4 ,furthermore1 the uterus does not correspond to the period of pregnancy1 and may have become smaller4 ,retrogressive changes take place in the breasts4 ,the diagnosis is only certain when the heart tones are persistently absent1 or the macerated head of the ftus is felt through the partly dilated os as a flabby bag of bones4 ,treatment in noninfective cases is expectant4 ,spontaneous expulsion will occur sooner or later and there is no necessitous indication for interference4 ,local signs of putrefaction1 however1 make the immediate emptying of the uterus necessary4 ,,chapter ,,vii ,,preparations ,,for ,,labor ,,and ,,the ,,normal ,,course ,,of ,,labor ,the ,nurse4--,scientific obstetric nursing is a specialty that enlists the interest of exceptional women only4 ,it demands a high sense of duty1 a strong physique1 broad training1 unusual judgment1 and rare tact4 ,the nurse must be professionally aseptic and personally clean4 ,she should keep herself free from odors1 and bathe at least three times a week4 ,the presence of pus anywhere on her body disqualifies her at once1 and she should report off duty4 ,the compensation should always be somewhat higher than for other work1 because there are two patients to be cared for4 ,an obstetric nurse should specialize in her work1 and not take infectious cases4 ,unhappily the haphazard character of the onset of labor presents a difficulty4 ,the patient frequently can not afford to have the nurse for a long time in advance of labor1 and the nurse whose income is limited by the number of her cases can not afford to be idle4 ,hence1 it is better for two nurses to work in alternation with one another1 so that one is always available in an emergency4 ,both doctor and nurse should visit the lying-in room before labor begins1 and plan its rearrangement4 ,at least a week before the expected confinement1 the chamber selected should be thoroughly cleaned and the woodwork wiped off4 ,curtains1 draperies and bric-a-brac and all useless furniture should be removed4 ,carpets must be taken up1 or at time of confinement1 well protected4 ,rugs can be easily managed4 ,a chair1 a bed1 and the various tables for instruments and solutions are all that are required4 ,the nurse usually is called to the case first1 and upon her falls the responsibility of the diagnosis and the burden of the preparation4 ,as soon as she arrives and satisfies herself that the patient is really in labor1 she puts the final touches to the room4 ,in her own mind she goes over all possible emergencies and prepares to meet them4 ,the following supplies should be in the house for the labor3 #c hand basins1 #aj inches in diameter4 #c hand brushes4 #a two-quart douche bag4 #ae yards nonsterile gauze4 #b lb4 each of cotton batting and absorbent cotton for making bed pads4 #b pieces of rubber sheeting #a by #b yards4 #e-yd4 jar of borated gauze4 #d oz4 lysol 7or ziratol74 #ajj c4c4 of ,squibb's chloroform4 #b oz4 green soap4 #b oz4 solid albolene4 #h oz4 alcohol4 oz4 ergotol4 oz4 bismuth subnitrate and oz4 boric acid powder mixed4 #a nail file4 ,nurse's outfit consists of the following3 ,nail file1 surgical scissors1 catheter 7silver is best71 hypodermic syringe with tablets of morphine1 strychnine1 and digitalis2 two fever thermometers1 one for mouth and one for rectum2 a pair of tissue forceps and a razor4 ,some time before the labor1 the nurse should call on the patient and establish a working acquaintance4 ,it adds greatly to her authority and to the patient's confidence in her4 ,her advice will be sought on a multitude of subjects1 partly real and partly to try her out4 ,illustration3 ,fig4 #ca4--;,abdominal binder with crosspiece to hold vulvar pads4 ,illustration3 ,fig4 #cb4--,t-binder1 used in all cases after the fifth day post partum4 ,sterilizing may be done in a hospital1 or1 if this is not feasible1 the nurse should go to the house two or three weeks before the expected labor and sterilize in an ,arnold or ,rochester sterilizer the following articles3 doz4 sheets4 #c doz4 towels4 #b pillow slips4 #c abdominal binders of unbleached cotton1 #af in4 wide and #cf in4 long1 folded and hemmed4 #d ,t bandages4 #c breast binders4 #b jacket parts of pajama suits4 #c pairs of long white stockings4 #c packages of vulvar dressings 7see ,preparation of ,supplies1 p4 #cbf74 #b obstetric pads #a by #cf by #cf inches4 #a pillow slip full of cotton pledgets for sponges4 #a jar applicators 7cotton twisted about toothpicks74 #a jar of gauze pledgets for perineorrhaphy and cord dressings4 ,everything must be neatly wrapped and labeled4 ,illustration3 ,fig4 #cc4--;,breast binder4 ,illustration3 ,fig4 #cd4--;,baby's dress with winged sleeves4 ,infant's ,outfit4-- #ab plain slips #bg inches long of dimity or nainsook 7with winged sleeves74 #c long sleeve shirts1 silk and wool 7size ,no4 #b74 #f pinning blankets1 made of outing flannel1 if it is a winter baby4 #c bands1 #f by #ah inches1 clip or notch edges1 do not hem4 #c petticoats1 flannel bottoms and muslin waists1 without sleeves and with small button on shoulders4 #c outing flannel wrappers4 #f plain1 soft muslin dresses4 #c 7,arnold7 knitted night gowns1 light weight4 #d doz4 light weight cotton diapers1 #bj x #dj inches4 ,bird's-eye linen is the best4 ,wash and dry these in the air before using4 #d soft towels 7linen preferred74 #b quilted pads4 #d soft wash cloths4 #d wool wrapping blankets4 #a pair scales that weigh ounces and fractions thereof4 #d oz4 of olive oil or benzoated lard4 #d oz4 of alcohol 7#ie per cent74 lb4 boric acid crystals4 lb4 absorbent cotton4 #a cake of castile soap4 #b oz4 solid albolene4 oz4 subnitrate of bismuth powder and oz4 of powdered boric acid mixed4 #a bed pan4 #b basins1 holding #b quarts each4 #a papier mache1 rubber1 or enamel ware bathtub4 ,ansthetics4--,excessive pain is destructive and disintegrating to the vital forces4 ,many a woman who has passed through a particularly severe labor remembers her experience with a horror that forever precludes its repetition4 ,this is the day of relative painlessness in labor1 and all the world is striving to make childbirth easier and less lethal4 ,no woman1 unless she herself requests it1 should be permitted to go through the agony of labor without an ansthetic1 judiciously selected and carefully administered4 ,pain-deadening agents are numerous and inexpensive1 and it is only a matter of experience and judgment to choose a method that will reduce the suffering of childbirth to a minimum4 ,the second and first stages of labor1 in the order named1 demand the most in the way of relief4 ,a prolonged first stage with nagging1 violent and apparently useless pains may devitalize the patient more than short1 but acute pains of the second stage4 ,in the first stage1 under proper selection of cases and experienced supervision1 8,twilight ,sleep0 will be successful in seventy to eighty per cent of the cases4 ,by success1 is meant that the patient is relatively free from pain4 ,when the drugs do not relieve pain1 the case is a failure 7fifteen per cent71 although in no case1 when properly given1 is the mother or child endangered4 ,morphine solution gr4 and scopolamine hydrobromid #a_/bjj gr4 to #a_/aej gr4 is the customary dosage for the first injection4 ,another injection of #a_/bjj gr4 is given in a half or three-quarters of an hour4 ,the room is darkened1 talking is forbidden1 and the family exiled4 ,the patient gets red in the face and very thirsty1 the pulse is rapid but full4 ,she answers questions very slowly and drowsily1 awakes for her contraction but goes right off to sleep again4 ,in this condition she is kept through bi-hourly repetitions of the scopolamine until the delivery4 ,it is this half waking and half sleeping condition that suggested the name of 8,twilight ,sleep40 ,morphine and scopolamine will relieve the pains of the first stage without greatly protracting the labor4 ,the same drugs may and probably will prolong the duration of the second stage4 ,the first dose should be given as soon as the patient is well started in labor4 8,twilight ,sleep0 is at present a hospital procedure1 and the technic so exacting as to weary the attendants greatly4 ,it can not be employed until the woman has definitely gone into labor and is at least three hours away from delivery4 ,it is not serviceable where the pains are weak and shallow2 and it must be used with wise circumspection1 if at all1 in the presence of complications4 ,for the second stage1 there is a choice of three drugs3 gas1 chloroform1 and ether4 ,like twilight sleep each is open to some objection1 but each may be of the greatest assistance if used under appropriate indications and conditions4 ,gas has one advantage1 in that it in no way interferes with the pain activities2 and ,lynch and ,davis have shown that with a proper admixture of oxygen1 it may be given with comparative safety for the two or three hours which may mark a normal second stage4 ,to administer it a competent machine for mixing the gas is necessary4 ,it should not be given to patients who have bad hearts1 high blood pressure1 or toxmia4 ,neither is it a satisfactory ansthetic when the head delivers1 for the mother being less relaxed and more rigid1 the legs and muscle action are harder to control and unnecessary perineal lacerations are liable to occur4 ,the patient is instructed to take several deep breaths just as the uterine contraction comes on and the gas bags supply about #ge per cent nitrous oxide and #be per cent oxygen4 ,as the pain passes off the oxygen is increased and the nitrous oxide diminished until the mind is again clear4 ,to save the perineum and better to control the patient1 when the head is about to pass the vulva1 it is wiser to abandon the gas for chloroform or ether4 ,obstetrical operations1 such as forceps and version1 require ether or chloroform1 and not gas4 ,the dangers vary with the ansthetic chosen1 as well as the amount and the method of administration4 ,ether affects the respiration1 chloroform attacks the heart4 ,ether must not be given near an open flame4 ,chloroform is not explosive but is decomposed by fire into an irritating gas4 ,chloroform must be diluted with #ij per cent of air1 hence the mask must be open1 or the napkin held free from the face1 so that plenty of air can enter4 ,ether and chloroform1 when given 8a la reine20 i4 e41 a few drops on the mask at the beginning of each pain and increased up to the acme1 is relatively free from danger4 ,they have the additional advantage that the sleep may be instantly deepened if operation is required4 ,chloroform1 it is now believed1 predisposes mildly to post partum hmorrhage4 ,davis has shown that neither ether1 gas1 nor chloroform affects the child injuriously if the administration is intermittent and not too greatly prolonged4 ,to summarize3 ,morphine and scopolamine combined is a first stage analgesic1 which has too much value to be neglected4 ,gas1 if an apparatus is to be had1 may work well for the greater part of the second stage1 while for operations1 or for the period of expulsion1 during which the head passes the perineum1 chloroform and ether give bests results4 ,moreover1 chloroform 8a la reine0 may be given safely and efficiently by a competent nurse and in many instances must be given by the nurse1 if at all4 ,when the perineum bulges1 or the head becomes visible at the vulva1 the nurse should anoint the lips1 cheeks and tip of the nose with cold cream or olive oil1 to avoid burning the skin1 and lay two or three thicknesses of handkerchief or gauze over the nose 7an inhaler is best74 ,an abundance of room must be left underneath and at the sides of the mask for air to enter4 ,at the beginning of the pain a few drops of chloroform are poured on the cloth and the patient instructed to breathe vigorously4 ,the cloth is removed as soon as the pain ceases and when the next contraction comes on1 the process is repeated4 ,as the head passes the perineum1 the chloroform should be pushed to complete ansthesia1 both to save suffering and to give the doctor full control of the perineum4 ,when the nurse gives the ansthetic1 she should watch the doctor for his signal to increase the vapor or remove the mask4 ,summary4--,cover the eyes with a wet towel and anoint the face with cream or oil before using chloroform4 ,remove false teeth1 if present4 ,obstetric degree--a few drops on mask at beginning of each pain4 ,surgical degree--complete ansthesia4 ,watch pulse and respiration4 ,a nurse should never leave a patient who has had an ansthetic until she is conscious4 ,vomiting is especially dangerous4 ,normal ,labor4--,labor is the process by which a ftus of viable age is expelled from the uterus4 ,by normal labor is meant a case where the ftus presents by the vertex and terminates naturally without artificial aid1 or complications4 ,it varies greatly in severity1 duration and danger to mother and child4 ,a first labor is more prolonged and difficult than later confinements4 ,a woman in her first delivery is called a primipara1 in subsequent cases1 a multipara4 ,the date at which labor comes on is difficult to determine accurately4 ,the average duration of pregnancy is from #bge to #bhj days1 forty weeks1 or ten lunar months1 but conception does not occur necessarily at the time of coitus1 nor is it possible to know with any certainty when it does occur4 ,labor may occur two weeks earlier than calculated1 with benefit to the mother1 and no harm to the child2 but if the woman goes over time1 the child becomes much larger and the labor harder and more dangerous to both4 ,causes of ,labor4--,why labor should occur at all is not known4 ,many theories have been advanced1 none of which is entirely satisfactory4 ,some of the best known are the growing irritability of the uterus accompanied by an increase in the frequency and strength of the intermittent uterine contractions or increasing distention of the uterus4 ,thus it is believed that when the uterus is distended up to a certain point1 it will try to relieve itself like the bladder1 or a baby's stomach4 ,it may be that any one of the following factors1 or all of them acting together1 are influential4 ,dilatation of the cervix by the presenting part4 ,increasing distention of the lower half of the uterus with pressure on neighboring nerve structures4 ,the circulation of ftal products of metabolism 7toxins7 acting on the nerve centers4 ,the menstrual periodicity4 ,heredity and habit4 ,physical and emotional causes4 ,the onset of labor probably is not purely accidental1 and yet it is so inconstant in appearance and so indifferently early or late1 that it has every appearance of being an affair of chance4 ,the time when labor will come on is highly speculative in general1 but the phenomenon is preceded by certain definite symptoms3 ,the lightening4 ,false pains4 ,show4 ,rupture of membranes4 ,the pains4 ,lightening4--,about two weeks before labor1 especially in a primipara1 the uterus and the head sometimes descend into the pelvis4 ,the body of the child falls forward and the abdomen protrudes1 the stomach is flatter1 the patient breathes easier and feels1 as she says1 8lighter40 ,but walking is more difficult1 the bladder is stimulated to frequent evacuations and the rectum is compressed4 ,this occurrence is a premonitory sign of labor1 and also favorable inasmuch as it demonstrates that this particular head is not too large to pass this particular pelvis4 ,false pains may appear1 especially in multiparas1 from two to four weeks before labor4 ,in some of these cases the pains may be due to gas or indigestion and respond to hot applications and enemas1 or there may be definite uterine contractions1 as shown by the hardness of that organ during a pain1 but the phenomena are irregular and therefore not typical of labor pains4 ,usually they pass off in a few hours1 but if the patient is nervous1 the doctor or nurse may be called needlessly4 ,the patient1 therefore1 should be instructed to have the pains timed by the watch for half an hour or an hour4 ,if they are regular during this period1 the physician should be notified4 ,upon his arrival1 an internal examination will reveal the true character of the disturbance by the condition of the cervix and os4 ,the show is a discharge of thick1 white mucus1 slightly stained with blood4 ,this is the mucus plug which occludes the cervix during pregnancy and when the os begins to dilate1 the mass is released and passes out4 ,labor usually comes on vigorously within twelve hours4 ,the membranes may rupture before labor begins and much fluid escape4 ,the advantage of the dilating bag of water and lubricating qualities of the liquor amnii are thus lost4 ,such a labor is called a 8dry birth0 and is frequently slow1 exhausting1 and extremely painful4 ,the pains are the subjective manifestations of the powers of labor4 ,the forces concerned are uterine and abdominal muscles1 principally assisted by those of the back1 legs1 and arms4 ,their constricting action on the nerve fibers in the walls of the uterus is the cause of the pains in the first stage4 ,the onset may be violent and go on to a quick delivery1 but generally the inception is more insidious4 ,the irregular1 painless contractions1 7of ,braxton ,hicks7 that were mentioned on an earlier page1 gradually at term change their character and become regular and painful4 ,at first they may be slight and vague1 lasting only half a minute and separated by intervals of ten or fifteen minutes and scarcely attract the patient's attention4 ,they are felt chiefly in the abdomen4 ,more or less rapidly they increase in frequency1 severity and duration4 ,they last from a minute to a minute and a half and come every three minutes4 ,the whole uterus hardens and its outline is clearly defined during the contraction2 it relaxes and becomes soft in the interval4 ,the woman is now in labor4 ,the pains become grinding and the patient feels that she is not accomplishing anything1 yet under the influence of these contractions the cervix is effaced and the os is dilated4 ,the ,course of ,labor4--,labor is divided for convenience into three stages as follows3 ,the first stage1 from the beginning of pains until the complete dilatation of the os4 ,the second stage1 from the complete dilatation of the os to the delivery of the child4 ,the third stage1 from the delivery of the child to the expulsion of the placenta4 ,the first stage is the stage of dilatation4 ,usually at term1 the cervix is columnar and unshortened1 the canal intact1 and closed at both ends1 as shown in ,fig4 #cf4 ,in multiparas the outer opening will usually admit the tip of the finger4 ,as labor proceeds1 the cervix is effaced1 the os slowly dilates1 and the bag of waters forms4 ,the ,bag of ,waters4--,when the cervix is effaced and only the os remains1 the lower end of the egg with its fluid restrained by the membranes1 bulges forward into the canal4 ,the ftal head1 or breech presses into the pelvis1 and the fluid in the membranes1 compressed between the presenting part above and the cervix below1 is called the bag of waters4 ,when the contraction comes on the longitudinal muscular fibers of the uterus are drawn upward and the bag of waters becomes tense and pushes farther and farther down into the opening2 and by its even and universal pressure1 mechanically and slowly increases the size of the opening which the muscular traction is pulling apart4 ,at the same time1 the fluid around the child prevents1 for a time1 direct and injurious compression on the body4 ,when no definite cervical projection can be felt1 and when the teat-like protrusion of the cervix has disappeared1 the cervix is said to be effaced4 ,illustration3 ,fig4 #ce4--,the bag of waters begins to act on the cervix4 7,eden47 ,the os now begins to stretch and widen1 the bag of waters becomes more and more evident1 vomiting occurs1 and at last1 when the os has expanded to a diameter of four inches 7ten centimeters71 the membrane can withstand the pressure no longer4 ,it ruptures1 a certain amount of fluid escapes1 the presenting part comes down against the opening1 and like a valve1 prevents the outflow of the waters from above4 ,illustration3 ,fig4 #cf4--,the effect of the pains4 ,the cervix before labor begins4 7,bumm47 ,illustration3 ,fig4 #cg4--,the effect of the pains4 ,the cervix begins to be 8effaced40 7,bumm47 ,illustration3 ,fig4 #ch4--,the effect of the pains4 ,the cervix is effaced1 and the dilatation of the os begins4 7,bumm47 ,illustration3 ,fig4 #ci4--,the effect of the pains4 ,the cervix is effaced1 and the os continues to dilate4 7,bumm47 ,sometimes the labor may be preceded by some hours 7two or three71 or days 7two or three71 even weeks 7two or three71 by the rupture of the membrane1 and sometimes when the structure is thick and tough1 the rupture may be delayed until well into the second stage1 or even until the child is born4 ,in the latter case1 the head comes out1 covered with membrane4 ,in the old days1 this was called being 8born with a caul40 ,it was supposed to be a lucky omen1 but it was lucky only that the babe escaped suffocation4 ,the membrane should be torn open quickly4 ,the duration of this stage is variable4 ,it is much longer in primiparas than multiparas4 ,it averages sixteen hours in the former1 and eight hours in the latter4 ,vomiting during this stage is quite common1 but the pulse and temperature remain normal4 ,the first stage of labor is usually under the entire control of the nurse4 ,it is her responsibility4 ,with complete dilatation of the os1 the second stage1 or stage of expulsion1 begins1 whether the membranes rupture or not4 ,the presenting part1 usually the head1 passes from the cervix into the vagina4 ,the vagina in turn gradually dilates from above downward until uterus1 cervix and vagina form a single1 wide channel of the same diameter4 ,the child is driven forward by the uterine contractions1 strongly reinforced by the abdominal muscles1 which the patient uses vigorously4 ,the onset of each pain is accompanied by a deep inspiration1 followed by straining or bearing down with the abdominal muscles as in a highly exaggerated bowel movement4 ,the patient holds her breath1 braces her feet1 fastens her hands on bed or attendant1 and uses all the trunk muscles in the effort4 ,the face becomes congested1 the pulse quickened1 she perspires some1 and groans deeply during the contraction4 ,the pain is extreme and is due partly to the stretching of the vagina and vulva and partly to the distention of deeper sensitive structures4 ,when the head reaches the pelvic floor1 the first change observed in the external genitals is the stretching 7bulging7 of the perineal body4 ,next1 the anus becomes turgid1 dilates slightly1 the anterior wall becomes visible1 and the hairy scalp of the child appears at the vulva4 ,the actual expulsion of the head in a primipara is accomplished by a series of prolonged and severe contractions1 accompanied by violent straining4 ,illustration3 ,fig4 #dj4--,the cervix is effaced1 and the os dilated4 ,the second stage begins4 7,eden47 ,illustration3 ,fig4 #da4--;,child in second stage of labor with bag of waters unruptured and presenting at the vulva4 7,braune1 from ,barbour47 ,a short pause ensues1 followed in two or three minutes by a return of the pains1 which expel first the shoulders and then the trunk4 ,as the body escapes it is followed by a rush of blood-stained liquor amnii4 ,this is the fluid that has been pent up in the uterus by the obstructing body of the child4 ,the second stage lasts about two hours in a primipara and from fifteen minutes to one hour in a multipara4 ,the third stage is the delivery of the after-birth4 ,the after-birth sometimes called the secundines1 consists of placenta1 umbilical cord1 and membranes4 ,illustration3 ,fig4 #db4--,the head passing over the perineum4 7,bumm47 ,after the expulsion of the ftus1 the uterus undergoes a sudden diminution in size4 ,it is about as large as the child's head1 and the fundus lies near the level of the umbilicus4 ,the contractions still persist feebly1 but they are practically painless1 and the patient is greatly relieved1 possibly sleeping4 ,in from ten to thirty minutes1 the uterus becomes smaller1 harder1 more globular in shape and more movable4 ,the patient brings the voluntary muscles of the abdomen strongly into action again4 ,the nurse presents a sterile basin and the physician sustains and slowly twists the membranes free from their final attachment and out of the uterus4 ,when the placenta passes the vulva1 a moderate sized blood clot follows it4 ,illustration3 ,fig4 #dc4--,normal expulsion of the placenta like an inverted umbrella according to ,schultze4 7,williams47 ,the uterus is now much smaller1 and hard and firm in consistency1 but for some hours the contractions are intermittent1 and while this continues1 there is risk of hmorrhage4 ,general ,effects4--,the mother's pulse is quickened during the contraction4 ,the ftal heart beats more slowly and feebly during a contraction1 but quickly recovers in the interval4 ,the amount of blood lost during labor averages from ten to sixteen ounces4 ,the temperature may be elevated one or two degrees in a woman of moderate physique1 while one with a fragile body may present the signs and symptoms of surgical shock4 ,the chill1 pallor1 cold limbs and body1 rapid and feeble pulse with subnormal temperature1 suggest to the nurse at once the proper treatment4 ,heat1 to all parts of the body1 warm covers and hot milk or coffee4 ,if hmorrhage is present and the uterus relaxed1 the nurse should immediately inject pituitrin 7#ae 7 into the deltoid muscle and notify her attending physician4 ,,chapter ,,viii ,,the ,,mechanism ,,of ,,normal ,,labor ,the powers of labor are primarily the uterine contractions strongly aided by the muscles of the abdomen and diaphragm4 ,some assistance is given by the fixation of the legs and arms and sometimes by gravity1 when a sitting or standing position is maintained4 ,the resistances are the bony pelvis and its relatively soft coverings of muscle and fascia4 ,the problem is to get the awkwardly shaped passenger through the curiously shaped passage4 ,in the first1 and a part of the second stage1 the uterine contractions do not act directly upon the body of the child1 for the latter is surrounded by a wall of liquor amnii4 ,pressure is transmitted by a fluid medium in all directions1 hence1 the weak part of the wall1 which is the cervix1 must give way4 ,while the membranes remain intact1 or when sufficient fluid is retained1 no amount of pressure can injure the ftus4 ,when the membranes rupture1 the force of the pains is exerted directly upon the child to drive it forward1 and prolonged pressure may produce injurious effects through compression of ftus1 placenta1 or cord4 ,the progress of labor is registered usually by watching the advance of the ftal head4 ,the relation of the head to the pelvic brim is of great importance1 as it travels much faster and easier in certain positions than in others4 ,the term 8presentation0 is used to designate that part of the child which enters or tends to enter the pelvic inlet4 ,the presentation is named from the part of the child which comes into apposition with the brim4 ,thus1 one speaks of a vertex presentation1 or a breech presentation1 or a shoulder presentation4 ,the presentation is determined externally by palpation4 ,the vertex presents in #if per cent of all labors4 ,with the vertex presenting1 the head may occupy any one of four positions4 ,the term 8position0 is used to explain the relation which the most distinctive feature of the presenting part bears to the quadrants of the pelvic inlet4 ,thus1 the most distinctive feature or landmark of the vertex is the occiput1 which is the point of direction1 and so again1 the position is the relation of the point of direction to the brim of the pelvis4 ,the point of direction is the part that takes precedence in the process of delivery4 ,thus1 in all cases where the occiput is in advance1 the occiput is the point of direction and the position is called occipital4 ,where the chin is in advance1 it is mental 7mentum is ,latin for chin47 ,in breech cases1 the sacrum is the point of direction4 ,the pelvis is divided by the transverse and anteroposterior diameters into four quadrants named respectively the left anterior1 the right anterior1 and the right and left posterior4 7,see ,fig4 #a47 ,thus1 in a vertex presentation the back of the child may be 7and in #ec per cent is7 to the front and to the left4 ,the occiput is the point of direction1 and lies in relation to the left anterior quadrant of the pelvis1 and is spoken of as a left-occipito-anterior position4 ,similarly a right-occipito-anterior position is named1 and right- and left-occipito-posterior positions4 ,these occur respectively in about #ba per cent1 #ad per cent and #aa per cent of the cases4 7,eden47 ,in passing the pelvis1 the ftus not only follows the curved line of the pelvic axis1 but it describes a certain series of movements which alter its relations to the pelvis4 ,illustration3 ,fig4 #dd4--,the child in left-occipito-anterior position4 7,lenoir and ,tarnier47 ,there are five of these movements3 flexion1 descent1 internal anterior rotation1 extension1 and external restitution4 ,flexion4--,flexion is usually present before labor begins4 ,that is1 the head is bent down until the chin touches the breast4 ,this may be modified by various conditions1 but so far as it becomes extended1 the mechanism is disturbed and the labor complicated1 since large and less favorable diameters are brought to delivery4 ,illustration3 ,fig4 #de4--,the child in right-occipito-anterior position4 ,shows the flexion of the head intensified at the beginning of labor4 7,eden47 ,flexion is increased by pressure against the pelvic brim as labor begins4 ,descent4--,as the driving force of the contractions becomes effective1 the head passes the inlet and descends to the pelvic floor4 ,when the large diameters of the head 7biparietal7 have passed the inlet1 the head is said to be engaged4 ,illustration3 ,fig4 #df ,a4--,the descent of the head in right-occipito-anterior position4 ,seen from below4 7,edgar47 ,fig4 #df ,b4--,side view4 ,illustration3 ,fig4 #dg4--;,internal anterior rotation and extension of the head in a left-occipito-anterior position4 7,american ,text ,book47 ,internal ,rotation4--,the head most frequently enters the brim with the occiput to the left and anterior 7obliquely7 because it finds more room and an easier passage2 but upon passing this strait and entering the roomy1 true pelvis1 the head must rotate so that the long diameter of the head will conform to the long diameter of the pelvic outlet1 which lies in a direction just opposite to the long diameter of the inlet or brim2 hence1 the occiput turns forward under the pubic arch4 ,this movement is due largely to the sloping pelvic floor and the necessity of accommodation between the head and pelvis as the child is driven forward4 ,illustration3 ,fig4 #dh4--;,extension4 ,a1 the chin leaves the chest2 ,b1 extension in progress4 7,eden47 ,illustration3 ,fig4 #di4--;,a1 extension completed2 ,b1 expulsion4 7,eden47 ,rotation is much retarded or entirely stopped when the head is extended instead of flexed or when it enters the inlet with the occiput posterior instead of anterior4 ,extension4--,after internal1 anterior rotation1 the head emerges at the vulva1 the occiput coming out first1 then in succession the vertex1 forehead and face and chin4 ,as the chin rolls out over the perineum1 it moves away from the chest wall--it becomes extended4 ,external ,restitution4--,while the head is passing through the outlet1 the shoulders are entering the pelvic inlet1 and so soon as the head is released from the restraint of the vagina1 it naturally falls into its normal relation to the ftal back2 hence in the position now discussed1 it turns toward the left4 ,therefore1 we may summarize the mechanism in a normal left-occipito-anterior position of the head by saying3 ,the head is flexed and forced into the pelvis4 ,it descends to the pelvic floor4 ,the occiput rotates to the front of the pelvis and impinges against the symphysis4 ,extension ensues in consequence of the necessity for an accommodation between the pelvis and the advancing head1 and during this extension1 the head delivers over the perineum4 ,external restitution follows4 ,the ,effect of ,labor on the ,ftal ,head4--,as the head passes through the canal1 it is moulded by contact with the resistances4 ,the degree of moulding is proportionate to the pressure required to drive it through4 ,thus1 in a large head1 or a relatively small pelvis1 the moulding may be extreme1 and changes in the scalp are common4 ,caput ,succedaneum4--,since all parts of the scalp are in contact with a resistant wall1 except in the center of the birth canal1 an effusion of serum takes place here1 which is due to the obstruction of the venous circulation4 ,illustration3 ,fig4 #ej4--;,a cephalhmatomata4 ,do not confuse with caput succedaneum4 7,bumm47 ,swelling occurs in the subcutaneous cellular tissue1 and a tumor forms--the caput succedaneum--which spontaneously disappears in twenty-four or forty-eight hours4 ,it is useful in confirming the diagnosis of the position4 ,cephalhmatoma4--,following labor a tumor is sometimes found upon the head1 which is often confused with a caput succedaneum4 ,this tumor is caused by an effusion of blood beneath the periosteum or the covering of the bone--usually a parietal bone4 ,it is sometimes single and sometimes double1 and it varies in size from a filbert to a peach4 ,the swelling never extends across a suture4 ,the effusion takes place gradually1 and may not appear for a day or so after birth4 ,the cause is unknown1 for it occurs after normal and easy1 as well as after difficult1 deliveries1 and after breech1 as well as vertex1 cases4 ,at first it fluctuates1 then becomes hard1 and in a few weeks or months is gradually absorbed4 ,if symptoms of cerebral pressure develop1 it must be remembered that hmatoma may occur inside as well as outside the cranium4 ,no treatment is necessary4 ,puncture is inadvisable4 ,in extremely rare instances the tumor may suppurate and require incision4 ,,chapter ,,ix ,,the ,,care ,,of ,,the ,,patient ,,during ,,normal ,,labor ,every case of labor must be conducted with the most scrupulous attention to surgical cleanliness on the part of the patient1 doctor and nurse4 ,puerperal infection in most cases is due to the introduction of disease-producing microbes into the wounded genital canal4 ,to be sure1 the successful enforcement of surgical cleanliness is attained only in good hospitals1 but it can be approximated in a private house if the patient insists upon delivery at home4 ,a nurse or doctor who is clean of person1 is most apt to have an 8aseptic conscience40 ,the possession of such a conscience may entail financial sacrifices1 but it has many compensations4 ,neither the nurse nor the doctor is doing justice to the patient1 nor to the profession1 who indiscriminately takes pus cases1 contagious diseases1 and confinements4 ,the public will soon learn that such a nurse and such a doctor are unsafe attendants4 ,how may the nurse know that the patient is in labor8 ,this is the final assumption that must be confirmed or refuted when the nurse is called to her case4 ,it is ascertained partly by the history and partly by the conditions found4 ,thus1 the patient may report the passage of a piece of blood-stained mucus1 and the nurse will observe that the contractions of the uterus are regular1 rhythmical and painful4 ,she will observe that when the patient complains of pain1 the uterus gets hard4 ,she will also observe the definite regularity of the contractions by timing them4 ,under such conditions1 the doctor should be called at once if the symptoms develop between #g ,a4 ,m4 and #aa ,p4 ,m4 ,if the pains begin in the night1 say from #aa ,p4 ,m4 to #g ,a4 ,m41 the doctor need not be called unless he has requested it1 or1 unless in the judgment of the nurse or the anxiety of the patient1 it is desirable for him to see her4 ,illustration3 ,fig4 #ea4--,points of greatest intensity of ftal heart tones4 ,v1 vertex presentations2 ,b1 breech presentations4 7,eden47 ,when the doctor is notified he will want to know1 and the well trained nurse will be able to inform him1 when the pains began1 their strength1 duration and frequency4 ,he will want to know whether or not the membranes have ruptured4 ,many doctors also require1 and a well trained nurse who specializes in obstetrics should be able to say by external examination1 whether the head seems high or low1 as well as the position and frequency of the ftal heart tones4 ,in the hospital the following rules for summoning the resident physician may be found useful3 #a4 ,for multipara1 when pains are regular and five minutes apart4 #b4 ,for primipara1 when pains are regular and two minutes apart1 or when head is visible if pains are less frequent4 #c4 ,if a precipitate is imminent1 delivery must be delayed until arrival of attending man by-- 7a7 ,turning patient on side with legs straight2 7b7 ,instructing patient to breathe deeply or to cry out with mouth wide open2 then 7c7 ,place sterile towel over vulva1 and at time of pain prevent expulsion by compressing the head by means of locking the hands over a towel on the vulva4 ,it is possible thus to delay delivery two hours1 or until the doctor arrives4 ,do not permit a precipitate4 ,after the nurse has completed her preliminary observation1 she starts her history1 notes the character of the pains1 the pulse1 temperature and respiration4 ,all unusual phenomena should be recorded2 and after the visit of her attending man1 his examination1 if any1 and the conditions found1 are put down4 ,then she prepares the patient and sets up the room for the delivery4 ,preparation4--,as soon as the patient is known to be in labor1 the bowels are thoroughly cleansed with a soapsuds enema4 ,a toilet jar should be used and not the water closet4 ,the bladder must be emptied at the time of preparation and at frequent intervals throughout the labor4 ,as soon as the bowels and bladder are emptied1 the patient is given a bath and thoroughly soaped4 ,the shower is preferred lest the water1 contaminated by bacteria from the skin and external genitals1 should enter and pollute the vagina4 ,illustration3 ,fig4 #eb4--;,handling forceps1 kept sterile in a jar of alcohol4 ,the hair should be braided in two braids4 ,the vulva and perineum are shaved4 ,no patient will object to this when its importance as a feature of protection against blood poisoning is explained to her4 ,scrub thighs1 hips1 and abdomen as far as the navel with soap and warm water1 then sterile water1 followed by a #b per cent solution of lysol4 ,care must be taken to remove the smegma and dried secretions from the folds of the vulva4 ,put on a fresh pad1 a clean gown1 and long stockings4 ,a loose wrapper over all permits the patient to move about4 7,see ,chapter ,,xxiii47 ,guests are forbidden1 and the immediate family is kept at a distance--if possible4 ,an air of buoyancy1 composure1 and competence should prevail in the sick room1 and the patient should be cheered and encouraged in every possible way4 ,during the first stage1 the patient may be up and about1 as this diverts the mind4 ,she may assist in the arrangement of the room which should always be the best room in the house4 ,it should be well warmed and close to the bathroom4 ,all unnecessary furniture and hangings should be removed1 as previously described4 ,after the room has been put in order1 the bed is made4 ,making the ,bed4--,put mattress pad over mattress and cover with rubber sheet or oil cloth1 and spread a sheet over all4 ,then a smaller rubber sheet is put on1 extending from under the pillows to a couple of feet from the foot4 ,a plain muslin sheet goes over the rubber1 then the delivery pad4 ,when the bed is ready1 a small table or stand should be placed near the head1 on which is put the ansthetic1 the mask and the oil or cold cream4 ,the patient may be lightly covered with a sheet or a sheet and blanket4 ,during the first stage1 light and easily digested food and drinks may be served1 either cold or hot1 as the patient prefers4 ,when the doctor arrives he may want to examine the patient either externally or internally1 or both4 ,so a sheet is thrown across the lower part of the body and the night-dress pulled up as far as the breasts4 ,for the external examination the doctor washes his hands in warm water and green soap and scrubs with the nail brush for five minutes4 ,this period should be prolonged to fifteen minutes1 if1 by any mischance1 the hands have been in contact with pus or infectious material4 ,it is extremely difficult to get them even approximately clean after such an experience4 ,illustration3 ,fig4 #ec4--,palpation4 ,what is in the pelvis8 7,eden47 ,he now palpates the abdomen1 notes the location of the head and back1 finds and counts the heart tones1 measures the pelvis and child1 estimates the descent of the head and the character of the pains4 ,illustration3 ,fig4 #ed4--,palpation4 ,what is in the fundus8 7,eden47 ,if he thinks an internal examination is necessary1 he will now return to the bathroom1 pare and clean his nails1 scrub hands and arms to elbows for ten minutes in running water with green soap and a sterile brush1 soak the hands in lysol solution #j4e per cent for five minutes4 ,bichloride of mercury solutions have no place in obstetrics4 ,they ruin instruments and hands1 and are valueless for asepsis since the mercury unites with the albumin of the mucoid discharges and forms an albuminate of mercury1 which is inert4 ,the bichloride solutions also are nonlubricating1 harsh and astringent1 as well as poisonous1 as soon as the mucoid protection has been removed4 ,when the doctor takes his hands from the lysol solution1 they should be wiped on a sterile towel4 ,a sterile gown is put on1 if possible4 ,if it is not available1 he should be careful not to touch anything that may destroy or contaminate his preparation4 ,the hands are powdered and sterile rubber gloves pulled on 7one will do474 ,illustration3 ,fig4 #ee4--,palpation4 ,where is the back8 ,where are the small parts8 7,eden47 ,the nurse1 meanwhile1 has wrapped the legs of the patient in the ends of a sterile sheet1 the bulk of which covers the abdomen4 ,the knees are spread apart4 ,the vulva cleansed with pledgets of cotton soaked in lysol solution4 ,one or two pledgets are used on either side of the vulva and the same number for cleansing the introitus4 ,the fingers are now introduced4 ,the internal examination may be conveniently postponed until the waters break1 or it may be omitted altogether if the heart tones of the child remain good1 the labor progressive1 and the head continually advances into the pelvis1 as determined by the external examination4 ,the great advantage of an internal examination at this time is the diagnosis of the degree of dilatation and the assurance that the cord has not been washed down into the vagina by the rush of fluid4 ,if the first stage is prolonged1 the nurse should try to get the patient to rest1 and she should herself snatch a few moments of repose if possible4 ,illustration3 ,fig4 #ef4--,patient draped for internal examination4 7,williams47 ,the condition of the os and the character of the pains may make the doctor feel safe in leaving the house1 but his whereabouts and telephone number should be ascertained and the exact time of his return4 ,second ,stage4--,during this stage1 the patient should go to bed and the doctor should remain nearby4 ,the nurse may observe the vulva at intervals and note bulging1 if present1 or she may press a finger against the soft parts outside the labia and see if the hard resistant head has come into the outlet4 ,the pains are severe and all accessory muscles are called into action4 ,partial ansthesia should be maintained in most cases1 which should merge into complete narcosis as the head passes the vulva4 ,the nurse may have to administer this4 ,when this stage begins1 or is well under way1 the patient should be prepared4 ,a sterile pad should be placed under her1 then a sterile bed pan4 ,the nurse having prepared her hands and arms as previously directed for the doctor1 scrubs abdomen1 legs1 and vulva with green soap and warm water1 followed by lysol solution #j4e per cent and a rinsing with sterile water4 ,the cleansing of the patient should take about ten minutes4 ,cover with a sterile towel and put on the sterile linen4 ,if in the hospital1 the drums have been packed for sterilization so that when they are opened each article will appear in the order of its need3 ,no4 #a4 7,beginning at the bottom47 ,a receiving blanket1 which has a ticket1 marked with the weight of the blanket1 attached to it4 #a abdominal binder with pad holder attached4 #a pillow slip folded half way back4 #a gown for patient4 #b surgeon's gowns4 #c sheets4 #a pair surgical stockings folded half way4 #a surgeon's gown for nurse4 ,no4 #b contains cotton pledgets4 ,no4 #c contains strips of gauze and combination pads4 ,application of ,sterile ,linen--,normal ,case4--,sterile linen is to be applied as follows1 by a clean nurse2 #a4 ,lay sheet across foot of bed and half way up4 #b4 ,put surgical stocking on one foot and draw sheet up for foot to rest upon4 #c4 ,second foot as above4 #d4 ,lay sterile sheet across bed under patient1 letting ends hang4 #e4 ,lay sterile sheet over abdomen of patient4 ,in many hospitals the sterile stockings and protective sheet are all made in one piece1 which greatly simplifies the application of the linen4 ,as soon as the second stage begins1 the packet containing the perineorrhaphy and cord set1 carefully sterilized1 is brought out and placed in convenient reach of the doctor4 ,this set contains-- #h in4 forceps4 #b scissors curved on the flat4 #a dissecting forceps4 #a duck bill speculum4 #a needle holder4 #a metal catheter4 #h gauze sponges4 #a medicine dropper4 #a cord clamp1 or #b cord tapes4 #b case numbers1 attached4 #ab needles1 #d round1 #d half-curved cervix needles1 and #d skin needles4 ,this is the stage of expulsion and the patient may want to pull or push on something to aid the straining effort4 ,unless the nurse needs time to set up the room or to get the doctor1 this tendency may be encouraged4 ,a sterile sheet may be attached to the foot of the bed and the ends 7corners7 given into the patient's hands as a knot or loop to pull on1 or she may push upward against the head of the bed4 ,under no circumstances must she be permitted to touch or contaminate the clean linen in her movements1 either consciously or unconsciously4 ,the hands should be restrained1 if necessary1 to avoid this4 ,the face may be sponged and a cold towel laid across the eyes4 ,rubbing of the back and legs will bring great comfort1 and cramps of the limbs may be removed by straightening the legs and rubbing the muscles underneath4 ,everything is now ready for the delivery4 ,if the husband insists upon being in the room1 he should take off his coat and vest and wear a gown1 or if the labor is in the home1 drop a clean night robe over his clothes4 ,the prepared room will show at close hand-reach1 the basins of solutions1 the pledgets of cotton1 tape or clamp for cord1 scissors1 nitrate of silver solution 7#a per cent7 for the eyes1 with dropper1 the sterile douche can in readiness for hmorrhage and a large reserve of supplies4 ,whatever ansthetic has been chosen for the second stage1 is now administered4 ,throughout this stage1 the heart tones of the child must be watched1 as well as those of the mother1 for intra-partum death may occur at any moment4 ,a second examination may be desirable now to confirm the diagnosis and to secure an estimate of the advance4 ,as a rule1 the examinations should be as few as possible on account of the danger of infection4 ,this is the period of greatest responsibility for the doctor whose duty it is to watch and1 if necessary1 to restrain the advance of the head in order to protect the perineum from rupture4 ,this may be done at times most successfully1 or in the case of too few assistants1 most desirably1 by delivery on the side4 ,to secure this1 as the head becomes more and more visible1 the woman is turned upon her left side2 a pillow rolled tightly and pinned in a sterile covering is placed between the knees1 and a sheet flung across the body4 ,illustration3 ,fig4 #eg4--;,delivery in side position4 ,the hands should be gloved and the upper leg raised on a hard cushion or pillow4 7,american ,text ,book47 ,the hips must be brought to the edge of the bed while the chest and head are pulled over to the other edge of the bed1 leaving the legs just enough space to double up along the side of the bed parallel with its long axis4 ,the doctor may now sit on the edge of the bed1 or on a high stool at the back of the patient and facing the buttocks4 ,this is a most convenient and easily managed position4 ,as the head is born1 the fcal matter1 blood and discharges must be sponged away1 and the field kept clean1 with the whole perineum visible4 ,always sponge from vagina toward rectum and throw away the sponge4 ,should the hand touch nonsterile things or septic material1 like fces1 the glove must be changed4 ,the hands must be kept surgically clean4 ,it is a part of the nurse's duty tactfully to warn the doctor when such a thing occurs1 as it may happen accidentally while his attention is concentrated elsewhere1 and a conscientious man will be grateful for the information4 ,as the head passes the perineum the ansthesia should be deepened4 ,as soon as the head is born and the first respiration established 7see ,asphyxia1 p4 #bgh71 the cord is cut and clamped4 ,there is rarely any necessity for haste in this maneuver4 ,the eyes are treated1 and if in a hospital1 a numbered tape is tied about the wrist and a tape with a corresponding number about the mother's wrist4 ,the baby is now placed in the receiving blanket on its right side1 with artificial warmth at its back and feet4 ,the head must be lower than the body so any retained mucus can drain out of nose and mouth4 ,meanwhile1 the doctor 7or nurse7 keeps a hand on the fundus of the uterus to watch its contraction1 see that it does not balloon up1 and massage it occasionally if necessary while he awaits the onset of the third stage4 ,third ,stage4--,the patient is turned upon her back as soon as the child is delivered4 ,the pulse and face must be watched for signs of hmorrhage4 ,while waiting for the placenta1 the perineum is examined to note the degree of laceration1 if any4 ,to do this1 the vulva must be spread apart with clean fingers so as to bring the posterior wall into view1 and the discharge is sponged away with cotton pledgets taken from the lysol solution and squeezed dry4 ,the patient may now have the saturated dressings removed and clean1 dry ones substituted4 ,the new pads catch the oozing blood and give an estimate of its amount4 ,at this time1 if desirable1 the perineum can be repaired4 ,the woman is partly unconscious1 the tissues numbed1 and the needle hurts much less than it will later4 ,nevertheless1 ansthesia may be required4 ,in a period varying from a few minutes to an hour1 the hand on the uterus will note a hardening1 the mass will become smaller1 more globular1 and rise slightly in the abdomen4 ,a gush of blood appears at the vulva and usually the placenta follows4 ,if it does not1 or if hmorrhage or the condition of the mother requires it earlier1 the uterus may be compressed 7see ,cred expression7 and the placenta constrained to deliver4 ,the nurse holds a sterile basin for its reception4 ,as the mass drops into the pan1 the membranes drag after and it should be gently twisted1 or the loose portions drawn upon until the end slips out4 ,the placenta is set aside for examination1 and ergot or pituitrin may be given to enforce the uterine contraction4 ,the process of expulsion is generally assisted by a strong voluntary contraction of the abdominal muscles4 ,after a short rest1 the blood is washed off the genitals1 clean linen and clean pads applied1 and the abdominal binder or girdle is put on to hold the pads4 ,warm blankets are thrown over the patient and within an hour1 a glass of hot milk is administered4 ,the legs should be kept together1 and in case of hmorrhage1 the feet crossed4 ,the placenta is now inspected and not only its completeness or incompleteness noted1 but anomalies of every kind should be looked for4 ,,immediately ,,after ,,labor ,perineorrhaphy must be done if required4 ,a lacerated cervix is not to be repaired at this time1 except in case of hmorrhage1 for the tissues are greatly swollen1 and if sutures are put in tight enough to allow for sufficient shrinkage1 they will cut through2 while if not tight1 they will be useless in twenty-four hours4 ,care of ,mother4-- #a4 ,cleanse genitals with lysol solution #j4e per cent from above downward4 #b4 ,put on sterile pad1 with pad holder and binder4 #c4 ,wash face and hands4 #d4 ,take temperature1 pulse1 and respiration4 #e4 ,glass of hot milk4 #f4 ,keep on back four hours4 ,watch uterus for hmorrhage and keep firm by occasional massage4 #g4 ,put tape with case number on arm4 ,care of ,child4-- #a4 ,clamp for the cord4 #b4 ,place on right side with head lower than breech4 #c4 ,keep warm and watch for cord hmorrhage4 #d4 ,treat eyes with silver nitrate solution #a per cent1 or argyrol solution1 #ae per cent4 ,do not neutralize the #a per cent silver nitrate solution4 #e4 ,put tape with case number corresponding to mother's on arm4 ,to preserve the perineum from rupture is an important duty1 and in a definite percentage of cases1 unsuccessful4 ,nevertheless1 it is a duty1 which1 in the absence of the doctor1 may fall upon the nurse4 ,how shall she meet it8 ,the greatest danger to the perineum comes from a too rapid advance of the head2 hence1 the nurse retards the delivery by putting the woman on her side where she can not bear down so successfully1 and instructs her to cry out with her pains4 ,she may also delay the labor by holding the head back with a clean pad until the vulva stretches to its fullest capacity4 ,the rules which the doctor follows in protecting the perineum as the head advances1 may be thus summarized4 #a4 ,deliver the patient on her side4 #b4 ,maintain flexion of head4 #c4 ,delay extension of the head4 #d4 ,give chloroform to retard delivery and to prevent precipitate delivery4 #e4 ,deliver between pains1 if possible1 by ,ritgen's maneuver 7modified74 #f4 ,do episiotomy1 if necessary4 ,perineorrhaphy4--,lacerations of the perineum occur in about #cj per cent of all primiparas and in from #aj to #ae per cent of multiparas4 ,they occur when the child is large or too rapidly delivered1 and when the orifice is small or the tissues inelastic4 ,for convenience1 the lacerations of the perineum are divided for description into three degrees4 ,the first degree involves only the fourchette and a small portion of the mucosa4 ,it is rarely more than one-half an inch in depth and requires no attention except cleanliness by the nurse4 ,the second degree may tear a variable distance into the perineal body1 sometimes so deeply as to expose the sphincter ani4 ,it is usually on one side1 but may appear on both sides1 and be accompanied by prolongations into the vagina4 ,the third degree passes through the sphincter and sometimes well up the rectal wall4 ,this is also called a complete tear4 ,the lacerations of the perineum which require sutures should be attended to at once unless the patient's condition is critical4 ,in such cases the repair may wait from twelve to twenty-four hours4 ,for this operation the nurse will assemble and boil for fifteen minutes3 #b pairs of scissors4 #b tissue forceps1 one with teeth and one without4 #a bull-dog forceps4 #c artery forceps4 #f needles1 #c full and #c half-curved4 #a dressing forceps4 #a needle holder4 ,suture material of catgut and silkworm gut should be ready in sterile containers4 ,the catgut should be the twenty-day chromicized1 ,no4 #c and #d4 ,even then the strands are quickly absorbed when the lochial secretions flow over them4 ,silkworm gut is better1 but hard to remove from the vagina2 hence it is customary to use catgut inside the vagina and silkworm gut for the sutures outside4 ,the nurse renews the supplies of gauze and cotton sponges4 ,hot solutions are prepared1 and the patient brought into a position on table or across the bed so that the best light may be had4 ,the legs may be held by the husband or nurse1 or both4 ,if help is inadequate1 a sheet sling can be utilized4 ,this is made by twisting the sheet from corner to corner and passing it rope-like over the shoulders1 and back of the neck4 ,then each end is tied above the patient's knee on either side as the legs are flexed in an exaggerated lithotomy position4 ,the sutures are now introduced and tied loosely from below upward and from within outward4 ,if tied too tightly1 they will cut through4 ,the success of the operation depends on two things3 the care with which the levator ani1 if torn1 is found and restored2 and the scrupulous cleanliness obtained by the nurse in her after-care4 ,if the stitches become sore1 a few drops of sterile glycerine should be applied with an applicator4 ,illustration3 ,fig4 #eh4--,sheet twisted into a sling4 ,the patient lies on the unrolled portion4 ,the rolled cords bearing against the shoulders are tied to the legs below the knees4 ,see ,fig4 #ajb4 7,american ,text ,book47 ,if catgut is used inside the vagina1 the counting of the stitches is gratuitous1 since they absorb without removal4 ,if silkworm gut is used1 the number of sutures must be recorded1 lest one be overlooked in removal4 ,binding the legs together after repair is not required1 but the sutures must be given aseptic care after each bowel movement1 each urination1 and when the pads are changed1 if they have become contaminated4 ,the sutures are removed on the tenth day4 ,illustration3 ,fig4 #ei4--,repair of perineum4 ,sutures in place4 7,hammerschlag47 ,after complete tears1 the bowels are kept constipated for two or three days1 and then moved with a high enema of sweet oil1 followed by castor oil by mouth4 ,after the bowel movement1 the nurse should wash out the rectum with normal saline solution4 ,the nurse must look carefully at the stitches every time the pad is changed and note if the swelling is increasing or diminishing1 if there is irritation or tenderness1 or if they are cutting out through the tissues4 ,the external sutures are usually left long and tied together in a knot1 to prevent the ends from sticking into the patient4 ,if she complains of this1 the ends may be wrapped in sterile gauze4 ,during the progress of the case the nurse must watch for and report any sign of fluid passing from bowel through the vagina4 ,the perineorrhaphy being completed1 the woman is permitted to rest though the nurse will make frequent examinations of pulse and respiration4 ,she will note the look of the face and the hardness of the uterus4 ,the pad should be watched and the amount of blood discharged1 duly estimated4 ,if the flow does not diminish or if the uterus should balloon up1 the doctor should be notified and the nurse meanwhile should give a dram of ergot 7fluid extract7 by mouth or an ampoule of aseptic ergot hypodermically4 ,the doctor should remain within call of the patient for at least an hour after delivery4 ,in the hospital the following rules may be used as a concise guide for the conduct of the third stage3 ,,conduct ,,of ,,third ,,stage4 ,keep patient on back and keep a hand on fundus4 ,note amount of blood lost1 its character1 its flow1 and whether steady or in gushes4 ,the placenta should detach itself normally in thirty minutes4 ,after thirty minutes1 expulsion may be assisted by-- 7#a7 ,early expression4 7a7 ,massage1 rub and knead the uterus1 until it hardens under the hand4 7b7 ,seize contracted uterus by fundus with full hand1 fingers behind and thumb in front4 7c7 ,push slowly but firmly toward the pelvic outlet4 7#b7 ,cred expression4 ,same maneuver as above1 except that the fundus is compressed between thumb and fingers while the downward movement is progressing4 ,conditions for ,cred expression3 7a7 ,uterus must be contracted4 7b7 ,uterus must be in median line4 7c7 ,bladder must be empty4 ,if not successful1 wait ten minutes and then repeat maneuver4 ,never make traction on the cord4 ,never use ergot until uterus is empty4 ,if placenta does not come away within an hour1 manual removal must be considered4 ,in case of hmorrhage1 it must be removed at once4 ,carefully inspect placenta and be sure it is complete4 7,see ,post ,partum ,hmorrhage1 p4 #bcb47 ,when the patient is put to bed1 the bloody sheets and towels are put to soak in cold water1 and after several rinsings1 may be sent to the laundry4 ,drapings stained with fcal matter must be cleansed separately4 ,,chapter ,x ,,the ,,normal ,,puerperium ,the puerperium is the name given to the period succeeding the birth of the child as far as the time of the complete restoration of the genitals4 ,it may last from six to ten weeks1 or even longer if complicated4 ,when the labor is completed1 the most urgent desire of the patient is for rest4 ,she is thoroughly exhausted in nerves and body4 ,a post partum chill may appear1--a slight shiver that may last a quarter of an hour4 ,since the pulse and temperature remain unaffected1 this phenomenon may be regarded merely as a sign of prostration or nervous revulsion4 ,in the course of the first three days1 the temperature may rise to #ajj ,f4 in a case entirely normal4 ,it has no pathological significance unless persistent or increasing4 ,the temperature should be taken night and morning1 and in complicated cases every four hours4 ,all temperatures over #ajj ,f41 after the initial rise and descent just described1 must be regarded as septic4 ,the pulse does not rise with the temperature of the first three days1 but remains firm or even falls a little4 ,when the pulse rises and the temperature sinks1 it means hmorrhage4 ,the urine is usually increased for the first few days and then returns to the normal for that patient4 ,the labor affects the patient like a surgical operation4 ,the digestion is disturbed4 ,the appetite is gone1 and the stomach must be treated gently until its tone is restored4 ,the body in repose is less urgent in its demands for food4 ,liquids in abundance form the staple diet for the first two days4 ,for the next three days1 semisolids may be added1 and after the milk is well established1 a general diet is desirable2 but so long as the mother nurses her child1 the liquids must preponderate in most cases4 ,illustration3 ,fig4 #fj4--,the progress of involution on the various days of the puerperium4 7von ,winchkel1 from ,knapp47 ,meanwhile1 certain changes are taking place in the pelvis that are highly important4 ,involution is the process undergone by the uterus in returning to its normal nonpregnant state4 ,this shrinkage can be followed abdominally and is registered by the nurse in the number of finger-breadths or centimeters above the symphysis pubis4 ,edgar gives the rate of shrinkage as follows3 ,after delivery1 #e4ib in4 long1 or #ae4h cm4 #bnd day1 #d4fc in4 long1 or #aa4cj cm4 #crd day1 #d4cg in4 long1 or #aa4aj cm4 #fth day1 #c4db in4 long1 or #h4dh cm4 #hth day1 #b4ee in4 long1 or #f4dj cm4 #ajth day1 #b4bb in4 long1 or #e4fj cm4 ,the rate of involution not only varies greatly with different women1 but varies much after the different labors of the same woman4 ,ordinarily at the end of the first week the fundus should lie midway between the navel and the pubes1 and should shrink rapidly thereafter4 ,the necessity for watching the rate of involution is imperative for a number of reasons4 ,if involution is slow1 or stops1 it may indicate fatigue of the muscle from multiparity or over-distention 7twins1 hydramnios1 etc47 or it may follow a post partum hmorrhage4 ,subinvolution may also indicate infection1 the retention of clots1 or pieces of placenta4 ,it happens also when the woman gets up too soon or does not nurse her child and thereby delays the restoration of her waistline1 as well as diminishes her resistance to disease4 ,the binder is objectionable to some doctors on the ground that it favors retroversion of the uterus during involution4 ,this would be a plausible theory when the uterus is high1 if it were not that the vertebr of the patient and the pelvic brim keeps the uterus from being pushed out of its place and after the uterus descends into the pelvis the gentle pressure of the binder evenly distributed over the abdomen can not affect it appreciably4 ,furthermore1 the uterus in involution shows a persistent tendency toward anteflexion and anteversion4 ,the binder is merely a girdle put on just tight enough to hold in place the bandage that supports the perineal pads and to allow the patient more easily to grow accustomed to the sudden change in intraabdominal pressure which the delivery of the child creates4 ,however1 if the doctor objects to a binder1 it may be left off with safety4 ,the ,lochia4--,when the placenta is delivered1 the uterus normally closes down and all gross hmorrhages cease2 but for the next two weeks or possibly longer1 a vaginal discharge continues4 ,for the first few days it is hmorrhagic in character and it is called lochia rubra1 and consists mostly of fluid blood with occasional small clots4 ,by the fourth day1 usually it has become brown and thinner4 ,it is now called lochia serosa4 ,by the tenth day1 it is yellowish-white1 and is called lochia alba4 ,the lochia is the wastage from the shrinking uterus1 and is made up of red blood corpuscles1 epithelial cells1 leucocytes1 and pieces of broken-down decidu4 ,the entire lining of the uterus is loosened1 discharged and a new one formed during the puerperium4 ,the lochia is regularly infected by bacteria in the vagina4 ,if involution is slow1 the lochial discharge may be prolonged4 ,the ,after-,pains4--,the puerperium is not infrequently accompanied by painful contractions of the uterus called after-pains4 ,these are more common in multiparas and serve a useful purpose in maintaining a definite contraction of the uterus4 ,if the pains are at all severe1 they are a suggestive symptom of the retention of blood clots1 a fragment of placenta1 or of membrane4 ,this1 of course1 will occur either in a primipara or multipara4 ,in all cases the after-pains must be differentiated from gas and from the pains of pelvic inflammation4 ,gas pains can be relieved by hot spiced drinks1 asaftida and the high rectal tube4 ,subinvolution is treated by the administration of fluid extract of ergot1 in twenty to twenty-five drop doses1 three or four times daily4 ,this will bring about the discharge of the irritating fragment or clot1 and the nurse can aid the process by gently massaging the uterus several times daily or by giving a hot vaginal douche4 ,codeine may be used for after-pains if absolutely necessary4 ,diet in ,normal ,cases4--,there is no restriction on the kind of food the patient may take1 so long as she can digest it cleanly and without gas4 ,acids or alkalies1 cold or hot1 rich or otherwise1 fruits1 meats or vegetables1 all go to the formation of good milk if properly digested4 ,the old idea that acids should not be eaten is fallacious4 ,there is more acid in the stomach normally1 than could be added in a meal made up entirely of citrus fruits4 ,at the same time1 the heavy foods should be avoided on account of the serious demand on the liver and kidneys in the absence of exercise4 ,on the other hand1 if the breasts are engorged1 the fluids must be reduced to a minimum1 and a relatively dry diet enforced4 ,the patient loses about one-ninth of her previous body weight in the course of labor and the puerperium4 ,the breasts are made ready for lactation twelve hours after delivery by cleansing with sterile green soap and warm water and bathing in #ej per cent alcohol4 ,next1 the nipple is attended to1 and the infant is put to the breast4 ,the nipple is prepared by cleansing it with an applicator soaked in fresh boric acid solution1 and after nursing1 the same process is repeated4 ,this is routine1 whether the mother is in bed or walking about4 ,in the latter case1 the mother must be taught to care for her own breasts4 ,the child is put to the breast every three hours and given six feedings a day4 ,this leaves a six hour interval at night1 which is very necessary for the mother's rest and for the child4 ,if the babe is feeble1 seven or eight feedings in the twenty-four hours may be required for the first two weeks4 ,at first the breast only secretes a thick1 yellowish secretion called colostrum1 of which the child gets from a drachm to an ounce4 ,it is a mild laxative4 ,the irritation of the nipple by the child's mouth is begun as early as possible in order to stimulate the breasts to secrete milk and the uterus to contract1 and thus aid involution and the preservation of the maternal figure4 ,the milk usually 8comes in0 on the third day and is accompanied by a sense of distention and moderate pains in the breasts4 ,the glands may be hot1 hard and swollen1 but normally there is no rise of temperature with the inflow of the milk1 except with nervous women who stand pain badly4 ,there is no such thing as milk fever4 ,if fever appears at this time1 an infection must be suspected4 ,the engorgement of the glands may become so great that the nipples are drawn in and nothing is left for the child to grasp4 ,if the engorgement becomes too painful1 fluids are removed from the diet list1 and saline cathartics administered1 while ice packs are applied to both breasts4 ,heat should never be used except for the purpose of hastening suppuration4 ,this engorgement1 or so-called 8caking0 of the breasts is not due to the milk1 but to the infiltration of the connective tissue around the glands with serum and blood which stimulate the glands to secrete4 ,the distention usually disappears in twenty-four or forty-eight hours1 especially if the child is sturdy4 ,massage of the breasts only increases their activity and tends to make the trouble worse4 ,the weight of the glands may be considerable and require the application of a light supporting breast binder4 ,pillows under them will also give relief at times4 ,in putting the child to breast1 the mother should lie on the side with the arm raised and the child is dropped into the hollow thus created1 facing the mother 7see ,fig4 #aac74 ,in this position the nipple will most easily and conveniently slip into the child's mouth4 ,the child should nurse fifteen or twenty minutes and then be removed4 ,the toilet of the nipple is made by cleansing with boric solution as previously described1 and then placing not gauze but a piece of aseptic cotton cloth over it1 after which the binder is readjusted4 7,see ,breast ,covers1 p4 #cbf47 ,the menstrual flow ceases during lactation as a rule1 but not invariably4 ,the flow returns in from four to six weeks after delivery1 if the child is not nursing1 and about the same time after lactation ceases4 ,there is a popular idea that conception can not occur during lactation1 and many women injuriously prolong lactation in the hope of avoiding another child4 ,the theory is fallacious and conception during lactation is not uncommon4 ,the ,bowels4--,a lying-in woman is regularly constipated4 ,lack of exercise1 a nutritious diet1 but one with a minimum of wastage1 together with relaxed abdominal walls1 contribute to a condition that is primarily due to changes in intraabdominal pressure1 which follow the delivery4 ,for weeks the intestines have been under pressure and irritation by the growing uterus1 and when this is suddenly removed the intestines become sluggish4 ,on the morning of the second day the patient should receive an ounce of castor oil4 ,this dose1 suspended in black coffee1 beer1 orange juice1 or sherry wine can be taken by nearly everyone4 ,in from four to six hours a normal saline1 or soapsuds enema is given4 ,the enema may be repeated daily1 or if this is objectionable to the patient1 the castor oil or ,russian oil1 may be given as a routine4 ,saline cathartics should not be used unless there is an oversupply of milk4 ,there is sometimes a good deal of gas following labor1 which can be removed by the #a-b-c enema 7see ,enema1 p4 #cce74 ,in giving enemas1 the nurse must use great care to avoid touching or infecting an injured perineum4 ,many women secrete less gas and are agreeably influenced mentally by a five grain pill of asaftida taken thrice daily4 ,urination4--,one of the commonest difficulties after labor concerns micturition4 ,owing to the swollen and bruised condition of the urethra and the nerves supplying the neck of the bladder1 the usual stimuli do not act and the woman1 conscious of a painful distention1 is unable to pass water4 ,the helplessness is increased by her position in bed4 ,the nurse must make every effort to have the bladder emptied naturally4 ,the process is aided by letting the water run from the faucet into the toilet basin1 by using hot applications to bladder or vulva1 by allowing warm1 sterile water to run down over the vulva and perineum1 by an enema1 by putting smelling salts to the nose1 by using slight pressure over the bladder1 or by having the patient sit up on the bedpan4 ,if these measures fail and moral suasion is fruitless1 the bladder must be catheterized at the end of twelve hours4 ,the two dangers of catheterization are injury to mucous membrane1 and infection4 ,many cases of cystitis have resulted from an unclean catheter or the improper use of a sterile instrument4 ,to catheterize a patient1 she is first given aseptic care during which particular attention is paid to the meatus4 ,this should be cleansed with an applicator dipped in a solution of boric acid4 ,next1 the nurse prepares her hands by scrubbing ten minutes in hot running water with sterile nail brush and green soap4 ,the catheter either of soft rubber or glass1 is boiled for fifteen minutes and passed1 not by touch1 but by sight1 and the flow is received in a clean basin and the amount recorded4 ,as soon as the urine ceases to flow freely1 the tip of the index finger is placed tightly over the end of the catheter and the instrument is gently withdrawn4 ,the finger is placed over the end of the catheter not only to avoid the dripping of urine as it is removed1 but especially to prevent the disagreeable sensations produced by the inrush of air4 ,usually one catheterization is sufficient1 and every time the bladder fills1 the nurse must take the time and trouble to make the patient urinate spontaneously1 if possible1 for some women form a catheter habit1 from which it is difficult to break them4 ,after natural urination and after catheterization1 the aseptic care should be repeated4 ,the ,genitals4--,the vulvar pads should be changed as often as they are soiled4 ,four a day is an average number1 and six or eight in the first three days is not unusual4 ,every time the pad is changed1 the nurse should give aseptic care1 and extra attention whenever the bowels and bladder are emptied4 ,the dried secretions should be washed off with sterile sponges1 wiping always toward the rectum and throwing away the sponge4 ,smegma collects in the folds of the labia and about the clitoris4 ,this should be carefully sponged away4 ,if it becomes dry and hard1 oil or albolene will soften it and facilitate its removal4 ,plenty of soap and warm water should be used1 then with a pitcher or douche point1 the whole area is irrigated with a solution of lysol #a per cent4 ,especial care is given to the stitches if any are present4 ,no traction must be made on the ends of the sutures1 and if unusual soreness is complained of1 the doctor should inspect them at his next visit4 ,the nurse should be careful not to get lochia on her hands as the discharge contains germs which she may carry to herself1 to the baby1 or to the patient's breasts or eyes4 ,painful swelling of the vulva1 or edema of the rectal protrusion may be relieved by hot boric dressings or by ice bags to the anus4 ,the vaginal douche is rarely employed at present except under specific indications4 ,if the involution is slow1 it is safer to use ergot by mouth1 rather than the hot vaginal douche1 as sometimes recommended4 ,the douche is a frequent source of infection1 as well as a useless procedure4 ,nevertheless1 a dainty woman gets much comfort mentally1 as well as physically1 if she is kept clean and free from odors2 hence if the lochial discharge becomes offensive on the fifth day or sixth day1 as sometimes happens1 a single hot vaginal douche may be permitted4 ,a #a3ejjj solution of potassium permanganate1 or a teaspoonful of formaldehyde to a quart of water1 or a chinosol solution #a3ajjj may be used4 ,rest4--,since the patient will be in bed from eight days to two weeks in normal cases1 she must be made as happy and comfortable as possible1 and nothing contributes so much to her satisfaction as a cheerful1 competent nurse4 ,her mind is at ease about herself and her child1 and the companionship of the nurse can be made one of the pleasantest recollections of her illness4 ,any patient who is at all reasonable can be managed by a tactful nurse without the consciousness of being opposed or directed4 ,gossip1 hospital stories1 criticism of other cases1 other nurses1 or of doctors should be avoided4 ,the patient is deeply interested in her own case1 and the private troubles of the nurse do not concern her nor enlist her attention for more than a few polite but unpleasant moments4 ,the nerves of the patient are highly sensitized1 and therefore she should sleep as much as possible at night1 and take an additional nap in the afternoon4 ,only the members of the family should be allowed to see the patient the first week1 and they but for a short time4 ,it takes the strength of the patient unnecessarily to see guests even though they be close friends4 ,importunate visitors may be pacified frequently by a view of the baby4 ,the patient must be spared all household responsibilities1 and if necessary1 the nurse must take charge4 ,tact must be used to avoid being dictatorial1 either to family or servants4 ,if anything unusual arises1 the nurse must show no surprise1 annoyance1 or bewilderment4 ,everything is attended to quietly1 firmly1 and without friction4 ,getting ,up4--,it is a tradition that the woman is lazy who does not get out of bed by the ninth day4 ,there are three factors to be considered1 the progressive involution of the uterus1 the strength of the patient1 and the presence of stitches4 ,involution may be complete on the fifth day1 but the prostration from the labor may make the woman indifferent to arising4 ,she may be strong enough to rise on the third day1 but the uterus is large and heavy1 and the erect position will put an unnecessary strain on the supports which may retard involution and cause displacement or disease later4 ,also1 it is not desirable for a woman to sit up until her perineum is well on the road to restoration4 ,in general1 the woman should not get up until the uterus has gone down into the pelvis and is nonpalpable4 ,if this is the case on the fifth day and she feels strong1 she may get up4 ,if she is not strong1 time will be saved by staying in bed until her vigor returns1 whether it is ten days or twenty4 ,getting up may be followed by a return of the bloody discharge4 ,this may come from subinvolution1 from a relaxed and flabby uterus1 from a cervical tear1 or from change in posture4 ,if there has been a retroversion before pregnancy1 lying prone with an occasional knee chest position for a few moments will aid4 ,massage and passive exercises while in bed will aid the patient to recover and to maintain her strength4 ,even after she is up and about1 she should lie down frequently during the day and always when nursing the babe1 until she feels quite normal again4 ,for the hospital the following standing orders may be followed3 ,standing ,orders--,puerperium ,breasts3 #a4 ,prepare for lactation #ab hours after delivery4 7a7 ,clean breasts and nipples with soapy water and green soap4 7b7 ,sponge with sterile water4 7c7 ,sponge with boric solution4 7d7 ,sterile compresses over nipples and adjust binder4 #b4 ,babe to breast immediately after breast preparation4 #c4 ,every morning apply fresh compresses over nipples and oftener1 if necessary4 #d4 ,cleanse nipples with boric solution 7use applicator7 before and after each nursing4 ,to dry up milk3 ,restrict fluids2 give saline cathartics2 apply ice bags to breasts1 as needed2 for pain give codeine solution to gr4 hypodermically1 if necessary4 ,do not massage1 do not bind1 do not pump4 ,let breasts alone4 ,when breast is inflamed3 ,apply ice bags constantly until pain subsides and temperature goes down4 ,watch for signs of suppuration4 ,genitals3 #a4 ,s4,s4 enema each morning1 followed by aseptic care4 ,cleanse from above downward--#a per cent solution of lysol and cotton pledgets4 #a pledget for each side4 #a pledget for center4 #a pledget for rectum 7last74 ,external douche of sterile water4 ,dry sterile pad4 #b4 ,aseptic care following all bowel movements and urination4 ,routine3 #a4 ,record pulse and temperature twice a day1 unless otherwise ordered4 #b4 ,bladder must be emptied in twelve hours4 ,if all persuasive means fail 7may sit up in bed71 catheterize4 #c4 ,make daily records of conditions of uterus 7firmness and height71 breasts and nipples4 #d4 ,no vaginal douche unless ordered4 #e4 ,diet3 liquid two days2 semisolid two days2 then general4 #f4 ,watch for hmorrhage4 #g4 ,keep uterus firm by occasional massage4 #h4 ,all cases to have castor oil1 #a ounce within thirty-six hours after delivery 7before noon74 #i4 ,woman may get up as soon as uterus can not be felt above pubes1 if there is no contraindication4 ,the history sheet should be kept accurately and should show every incident in the course of the lying-in period4 ,the condition of the bowels1 bladder1 and lochia1 the temperature1 pulse and respiration and the height of the fundus above the symphysis from day to day must be set down in finger-breadths or centimeters4 ,for the hospital1 the following system will be found useful in establishing a routine4 ,nurse's ,record ,first ,stage4 #a4 ,when pains began4 #b4 ,frequency and duration of pains4 #c4 ,character vaginal discharge4 #d4 ,time membranes ruptured4 7a7 ,artificial4 7b7 ,spontaneous4 ,second ,stage4 #a4 ,time second stage began and ended4 #b4 ,ansthetic4 #c4 ,mode of delivery4 #d4 ,who delivered4 #e4 ,sex of child4 7a7 ,living4 7b7 ,dead4 #f4 ,perineum4 7a7 ,condition4 7b7 ,repair4 ,third ,stage4 #a4 ,method4 7a7 ,spontaneous4 7b7 ,early expression4 7c7 ,cred expression4 7d7 ,manual removal4 #b4 ,placenta delivery4 7a7 ,time4 7b7 ,size4 7c7 ,complete or incomplete4 7d7 ,length of cord4 #c4 ,note4 7a7 ,hmorrhage4 7b7 ,quantity4 7c7 ,color4 7d7 ,clots4 ,general condition--was case number put on mother and child8 ,other treatments4 ,medications4 ,condition of uterus4 ,temperature1 pulse and respiration before leaving delivery room4 ,signed 44444444444444444444444444 7,nurse's ,name47 ,,chapter ,,xi ,,unusual ,,presentations ,,and ,,positions ,breech ,presentation4--,the pelvic pole enters the inlet first1 once in thirty cases and more commonly in primiparas than otherwise4 ,etiology4--,anything that interferes with or deranges the laws of normal gestation will predispose to1 or produce this anomaly4 ,thus1 if the head is too large1 as in hydrocephalous1 or if the ftus is too movable1 as in hydramnios1 or if an obstacle1 like placenta previa1 contracted pelvis or tumors prevent the proper approach of the head to the inlet1 the mechanism will be disturbed and a breech or possibly a shoulder presentation will result4 ,abnormal flaccidity of the uterine or abdominal walls1 prematurity or twins also contribute definitely to its occurrence4 ,the attitude of the child generally retains its normal aspect of complete flexion4 ,this pose1 however1 is not maintained invariably for on occasion the buttocks and genitals may rest upon the inlet while one or both feet may be extended on the thighs and lie beside the neck1 or the thighs may be extended while the knees remain flexed1 and what is known as a knee presentation1 or if the foot comes down1 a footling presentation results4 ,positions4--,the sacrum is the most prominent bony landmark of the breech1 hence the positions are named from the relation this bone bears to the four quadrants of the inlet4 ,illustration3 ,fig4 #fa4--,the breech4 ,left-sacro-anterior position4 7,lenoir and ,tarnier47 ,we have therefore in their order of frequency the following designations3 ,left-sacro-anterior1 where the sacrum lies to the left of the median line of the mother's body and in front2 right-sacro-anterior1 where the sacrum lies to the right and in front2 right-sacro-posterior1 where the bone lies near the mother's vertebral column1 and on the right side2 and the left-sacro-posterior position1 where the bone occupies a corresponding place on the left side4 ,diagnosis4--,the recognition of this presentation is most easily secured by external abdominal palpation in pregnancy1 which may be reinforced during labor by the internal examination4 ,illustration3 ,fig4 #fb4--,the breech4 ,left-sacro-posterior position4 7,lenoir and ,tarnier47 ,externally the palpating fingers at the pelvic brim will note the absence of the hard1 round head1 and feel a mass1 softer1 quite irregular in shape1 and less defined than customary4 ,movements also may be appreciated that would be too far down in the uterus if the head was presenting4 ,next the hard1 spherical tumor of the head can be outlined somewhere in the fundus1 and the heart tones1 instead of being below the umbilicus will be on the same level or even higher4 ,vaginally the cervix is not filled out1 the presenting part does not come down1 but after labor has begun the distinctive features of the breech gradually become more evident1 as they are driven into the pelvis4 ,one or both feet1 or the buttocks1 may be recognized4 ,the examining finger may possibly enter the anus and be stained with meconium or pinched by the sphincter1 which differentiates this orifice from the mouth4 ,one after another the characteristic landmarks appear until the diagnosis can not be doubtful4 ,as soon as the sacrum is found or the legs definitely placed1 the position can be named4 ,mechanism4--,the hips always enter the inlet in one of the oblique diameters and the back is turned to the same part of the uterine wall as in the corresponding vertex positions4 ,the acts described in the mechanism for vertex deliveries show a somewhat different order4 ,descent is first1 then comes internal anterior rotation1 which brings the anterior hip under the symphysis and its delivery is quickly followed by the posterior hip1 which rolls out over the perineum4 ,the body advances1 as a rule1 with the back toward the front of the mother4 ,the shoulders with arms folded move under the pubic arch and then the head delivers in a state of flexion4 ,the head1 of course1 has no caput and it is not moulded4 ,this mechanism may be greatly impeded or complicated at any stage of the movement4 ,the advance may be retarded to a pathological degree1 the belly may be large and as it passes along the canal one or both arms may be stripped up alongside the head or even into the back of the neck4 ,the head may be arrested at the inlet by the arms1 by its degree of deflexion1 or by pelvic contraction4 ,the rotation may not take place1 or it may be abnormal1 and the belly of the child look forward toward the mother's4 ,any of these variations adds further to the difficulty of the labor and to the danger of the partners in the event4 ,artificial aid may be required which brings with it the possibility of sepsis4 ,the ftal mortality which averages five per cent is due mostly to asphyxiation4 ,interference with the supply of oxygen begins as soon as the cord passes the vulva and the child must be delivered in eight minutes from that time1 or perish4 ,partial detachment of the placenta may also cut off the oxygen to a fatal degree1 and the child may be unable to breathe when born on account of mucus sucked into the trachea by premature efforts at respiration4 ,minor accidents also occur1 such as fractures1 dislocations1 and paralysis from injury to the nerve trunks4 ,management4--,in the interest of the child1 this presentation is occasionally converted into a vertex by external version during the last weeks of pregnancy or in labor before the membranes have ruptured4 ,it is difficult1 however1 to maintain the vertex over the inlet4 ,the woman must be kept quiet in a horizontal posture and long roller splints applied to the side of the child in utero and bound on4 ,in primiparas1 this is nearly impossible1 and it is wiser1 in the absence of some great necessity to warn the parents of the conditions and dangers and let them share in the responsibility4 ,illustration3 ,fig4 #fc4--;,extraction of the breech4 ,traction on one leg4 7,hammerschlag47 ,when the labor begins1 the bag of waters must be kept from rupture as long as possible and when it finally breaks1 an internal examination should be made to see if the cord has come down4 ,if this happens it may be necessary to expedite the delivery by external assistance4 ,illustration3 ,fig4 #fd4--;,breech delivery4 ,extraction of the trunk by pulling on the hips4 7,hammerschlag47 ,the doctor brings down a foot1 if it is not already down1 or pulls on the breech until the feet drop out4 ,compression of the cord must be always in mind4 ,it is always compressed after the umbilicus has passed the navel4 ,the shoulders are delivered by seizing the feet with the operating hand and swinging the body out of the way4 ,this brings the posterior shoulder1 which should be first1 into the hollow of the pelvis4 ,extraction is then completed by what is called the ,smellie-,veit maneuver4 ,the child is put astride one arm1 the first finger of which is hooked into the child's mouth to maintain flexion4 ,the fingers of the other hand then grasp the shoulders of the child astride the back of the neck and traction is made downward in the axis of the inlet until the head slips into the excavation4 ,illustration3 ,fig4 #fe4--;,breech delivery4 ,delivering the shoulder4 ,the body is swung strongly upward and outward to bring posterior shoulder into the pelvis4 7,hammerschlag47 ,illustration3 ,fig4 #ff4--,the delivery of the after-coming head by the ,smellie-,veit maneuver4 7,hammerschlag47 ,if the head is delayed at the inlet1 it may be necessary to put the woman in the ,walcher position 7q4 v47 and for the nurse to use the ,wiegand compression 7q4 v474 ,the feet must not be fastened in stirrups for breech cases4 ,illustration3 ,fig4 #fg4--,shoulder presentation4 ,left-scapulo-anterior position4 7,lenoir and ,tarnier47 ,forceps are not recommended for application to the breech as they do not fit and are liable to slip off and injure both child and mother4 ,the fingers are best4 ,forceps are not recommended for the after-coming head unless the child is dead4 ,if the child lives1 the ,smellie-,veit is more-successful2 and if the child dies1 the cranioclast1 if possible1 will save the mother much suffering and avoid some injury to the tissues4 ,transverse or ,shoulder ,presentations4--,these are cases in which the long axis of the child lies directly across or obliquely across the long axis of the uterus4 ,the shoulder 7scapula7 is the bony landmark1 and the part which most frequently impends over the inlet4 ,this presentation probably occurs once in two hundred labors4 ,it is due to the same conditions that were given for breech cases2 namely1 weak abdominal or uterine muscles1 pelvic contraction1 placenta previa1 hydramnios1 and twins4 ,it is easily recognized in pregnancy1 and must not be neglected1 for it is impossible of delivery without first changing it into a longitudinal presentation4 ,if this correction is not done1 rupture of the uterus is liable to occur1 with the consequent death of both mother and child4 ,the treatment is invariably version4 ,face and ,brow ,presentations4--,the face presents once in about three hundred labors4 ,in this case1 the head is completely extended so that the occiput rests against the back of the neck4 ,the trunk and spine are straightened out while the legs and arms remain in the normal attitude of flexion4 ,the causes of these anomalies must be sought in those conditions which bring about the deflexion of the chin4 ,the most common are pelvic contraction1 large child1 placenta previa1 hydramnios1 goiter1 anencephalus and multiparity4 ,illustration3 ,fig4 #fh4--;,face presentation4 7,bumm47 ,face positions take their names from the location of the chin 7mentum--,latin74 ,thus the most frequent face position is the right-mento-posterior4 ,the diagnosis is not easy and may not be conclusive until the bony prominences of the face1 such as the nose and orbital ridges can be distinguished by vaginal examination4 ,illustration3 ,fig4 #fi4--;,descent of the chin in face presentation4 7,bumm47 ,the delivery is protracted from three to five hours beyond the average by this complication1 and the mortality is higher both for mother and child4 ,the face is badly swollen and disfigured1 but the normal condition of the tissues will be restored by the end of a week4 ,most face cases terminate spontaneously1 but operative interference is not infrequent on account of danger to mother or child4 ,version or manual correction of the presentation may be done before engagement4 ,forceps is the operation of choice after the head is fixed in the pelvis1 but it may be necessary to precede the delivery by a preparatory pubiotomy1 or in case of failure1 to do a craniotomy on the dead child4 ,if the chin does not rotate forward under the symphysis1 the labor is impossible without pubiotomy or the destruction of the child4 ,in general1 the case should be left to nature unless some definite indication to interfere develops4 ,illustration3 ,fig4 #gj4--;,delivery in face presentation4 7,bumm47 ,the brow presents much more rarely than the face1 possibly once in a thousand labors4 ,it is due to the same conditions as bring about the presentation of the face4 ,the mortality for both mother and child is higher than in face cases4 ,the whole labor is harder and longer1 besides being more dangerous to life and to tissues4 ,this presentation1 if recognized before the head is fixed1 should be converted into a breech by version1 but after the head comes down1 it may be possible by hand or forceps to deliver either as a face or as an occipito-posterior1 but otherwise the cranioclast must be considered4 ,occipito-posterior position is the name given to vertex cases wherein the occiput lies in one or the other of the two posterior quadrants of the pelvic inlet4 ,these labors are necessarily prolonged1 both in the first and second stages1 because the mechanism of delivery is deranged by the larger diameters brought into relation with the bony canal and by the ineffectiveness of the contractions4 ,the pains in the second stage may become violent and extremely painful1 but the labor does not advance appreciably4 ,after a little experience1 mere observation of the course of the labor will cause the suspicion to arise in the mind of a competent nurse that the occiput is posterior4 ,the diagnosis will be cleared up by the doctor's internal examination1 which shows the large fontanelle anterior and the sagittal suture running backward4 ,the head is partially deflexed and it may not be possible at first to find the small fontanelle4 ,the position terminates by delivery uncorrected1 by spontaneous rotation into an anterior position1 or is corrected by the doctor4 ,correction should not be attempted until it is apparent that the anomaly will not right itself1 which it will do in four cases out of five4 ,,chapter ,,xii ,,operations ,complications during labor may arise from abnormal positions of the head1 such as face or brow2 from abnormal presentations of the child1 such as breech1 transverse or shoulder2 from twin labors2 or from prolapse of a part like the foot1 arm or cord4 ,the mother may be responsible for some of these abnormalities through having a contracted pelvis1 a rigid os1 or a rigid pelvic floor4 ,the uterus1 too1 may functionate abnormally by acting too vigorously1 as in precipitate labor1 or too slowly1 as in uterine inertia4 ,the membranes may rupture prematurely and produce a dry birth4 ,there may be hmorrhages before labor 7ante partum hmorrhage7 during labor 7intra partum71 and after labor 7post partum hmorrhage71 or the labor may be preceded1 accompanied1 or followed by that extreme example of toxmia known as eclampsia4 ,face and brow presentations are rare and come to the attention of the nurse only when an operation is required for their relief4 ,further conditions may arise1 such as danger to mother or child1 which demand an acceleration of the labor4 ,if the head is engaged1 forceps is the operation most commonly undertaken1 and if not engaged1 the problem may be solved either by an early version and extraction or by forceps later4 ,the dangers to the mother are not usually difficult to diagnose if the case has been followed carefully4 ,signs of danger to child must be looked for constantly4 ,such are3 7a7 ,alteration of the heart tones4 7b7 ,retardation of pulse in cord between pains4 7c7 ,escape of meconium is not significant unless occurring in the pain-free interval1 when it may signify hypercarbonization of blood and a threat of asphyxiation4 ,the preliminaries for the performance of these operations may now be described1 and the indications and conditions briefly tabulated4 ,the preparation should be standardized so that the same set-up of the room will do for all of the major obstetrical operations1 except ,csarean section4 ,the kitchen table is generally regarded as a satisfactory operating table4 ,its length is sufficient for delivery when the legs are doubled up4 ,the table should be covered with a blanket or comfort on which it laid a clean sheet4 ,a rubber blanket or piece of oil cloth is put on1 so folded above the place for the patient's hips1 and so pinned at the sides1 that all drainage will flow off into a bucket or jar at the foot4 ,in front of the table is placed a straight-backed chair with flat seat4 ,to the right of the operator1 as he faces the table1 stands a bench1 or two chairs1 side by side2 or1 if possible1 another table4 ,this is covered with a clean sheet for the reception of the instruments4 ,to the operator's left1 another table similarly prepared carries the solutions1 sponges1 etc4 ,every operation for delivery should have tape and cord scissors within easy reach1 as well as facilities for the resuscitation of the child4 ,the light should come from behind the operator and fall full upon the field of operation4 ,the room should be warm4 ,the patient is laid upon the table and her knees elevated in the exaggerated lithotomy position4 ,if there are assistants enough1 one can stand on either side and hold a knee1 if not1 a sheet sling can be made and slung round the patient's shoulders and tied to the knees as previously described4 ,illustration3 ,fig4 #ga4--;,exaggerated lithotomy position4 ,the legs are held by a sheet sling4 ,the vulva should be shaved4 7,williams47 ,an ansthetic will be required4 ,if a doctor can not be had1 this duty will fall to the nurse4 ,a sterile douche bag hangs near the table4 ,a bath tub of hot water must be provided and a tracheal catheter must be ready for the removal of mucus from the child's windpipe4 ,an abundance of hot and cold sterile water must not be overlooked4 ,in the hospital the following synopsis for the placing of the linen may be found useful3 ,sterile ,linen for ,operative ,case4-- ,bring patient to foot of bed4 ,put in the stirrups4 7,for breech deliveries do not use stirrups47 ,same order as for normal case except that feet are put in stirrups instead of on bed4 ,illustration3 ,fig4 #gb4--;,dorsal position when assistants are available4 7,hammerschlag47 ,sterile sheet under patient extends now from basin under bed to buttocks4 ,combination pad over field of operation4 ,sterile sheet over abdomen4 ,the genitals of the patient are now cleansed with all care and attention described for labor4 ,if this has been done within an hour1 she need only be sponged off thoroughly with lysol solution 7#a per cent74 ,the feet and legs are covered with stockings1 the body kept warm1 and protected by sheets and blankets1 if necessary4 ,every operative delivery is preceded by catheterization4 ,all instruments are boiled for thirty minutes and brought to the table in the same container in which they are sterilized4 ,the hot water has been poured off and a cool1 weak solution of lysol 7#j4e per cent7 added4 ,illustration3 ,fig4 #gc4--;,instruments for artificial delivery of the head4 ,a1 ,braun's blunt hook2 ,b1 ,cranioclast 7,auvard72 ,c1 ,axis traction forceps 7,webster72 ,d1 ,low forceps 7,simpson74 ,forceps4--,before using forceps it should be determined that the woman can not deliver the child unaided1 or can not be permitted to do so without too great expenditure of physical and nervous energy4 ,the exact conditions must be recognized as to the location and position of the head1 the condition of the ftal heart tones and the size of the pelvis4 ,when the head is high up1 the axis traction instrument is employed and patient put in ,walcher's position for the traction4 ,axis traction forceps are extremely dangerous to mother and child1 and should be avoided wherever possible4 ,the following instruments are required3 ,the obstetric forceps4 #b eight-inch forceps4 #f artery forceps4 #a vulsellum forceps4 #a tissue forceps4 #a needle forceps and #f needles4 #b vaginal retractors4 #a pair dressing forceps4 #a douche point4 #a silver catheter4 ,suture material--both catgut and silkworm gut4 ,besides these instruments1 the nurse will also have solution basins as described for normal labor4 ,for operations outside of hospitals1 the nurse need not be clean1 as her duties will consist for the most part in changing solutions1 refilling basins1 handing towels1 etc41 all of which can be done with sterile forceps4 ,the following summary may be serviceable for advanced study or reference3 ,,preparation4-- ,thorough asepsis1 both subjective and objective4 ,patient should be pulled down to the foot of the labor bed with feet in the stirrups1 or put upon the kitchen table or across the bed with the legs held in the lithotomy position4 7,for breech cases1 legs should not be fastened47 ,bladder and rectum must be empty4 ,ansthetic is necessary4 ,the position of the head must be accurately known4 ,facilities for the treatment of asphyxia neonatorum must be at hand4 ,,conditions4-- ,cervix effaced and os dilated1 except when maternal or ftal life is threatened4 ,bag of waters must be ruptured4 ,the head must be engaged4 ,the child should be living4 ,,indications4-- ,insufficiency of the powers of labor4 ,deep transverse arrest of the head4 ,complications in labor1 such as3 ,eclampsia4 ,fever4 ,acute or chronic disease4 ,hernia--especially if incarcerated4 ,placenta previa4 ,prolapse of the cord4 ,face and brow presentations4 ,contracted pelvis4 ,occipito-posterior positions4 ,,dangers ,,from ,,forceps4-- ,injuries to ,child4--,overcompression1 especially with axis traction forceps or in contracted pelvis4 ,crushing of soft parts1 or such lesions as abrasions1 pressure marks1 hmatomata1 swelling of face and eyelids4 ,bone injuries3 ,spoon-shaped depression where the head has been dragged through a narrow inlet2 fissures in the parietal or frontal bones2 fractures4 ,when axis traction forceps are applied antero-posteriorly1 the occipital bone may be sprung inwards until it cuts the medulla4 ,compression of the cord1 especially if it is around the neck4 ,hmorrhage from the middle meningeal artery4 ,injury to eye4 ,erb's paralysis4 ,laceration of ears when the forceps are removed4 ,facial paralysis from pressure of the blade4 ,injury to ,mothers4-- ,infection4 ,improper application of the blades outside the cervix uteri4 ,soft parts torn by too rapid extraction4 ,when os is not dilated1 it is first pulled down and then torn4 ,the tear may extend into the vaginal vault4 ,fistul may be produced4 ,prolapse of the uterus from prolonged traction4 ,vaginal tears from the blades or from malplaced head4 ,slipping of blades4 ,traction must be not against the symphysis1 but down4 ,the forceps commonly used in this country 7,simpson or ,elliott7 are so made that the left blade must be introduced first on account of the lock4 ,the mortality for the child in forceps cases is about six per cent4 ,illustration3 ,fig4 #gd4--;,forceps operation4 ,the left blade1 in the left hand1 is introduced first into the left side of the mother so that the curve of the blade fits the child's head 7inside the cervix74 7,hammerschlag47 ,the axis traction instrument is used but seldom by good obstetricians1 since the danger to mother and child in this operation is very serious and it should be reserved for emergencies of exceptional character4 ,pubiotomy may precede the operation with advantage in many cases4 ,asphyxia of the child and maternal hmorrhage must be prepared for4 ,illustration3 ,fig4 #ge4--;,forceps operation4 ,the introduction of the right blade4 7,hammerschlag47 ,illustration3 ,fig4 #gf4--;,forceps operation4 ,locking the handles4 7,hammerschlag47 ,illustration3 ,fig4 #gg4--;,forceps operation4 ,the way the blades should grasp the ftal head4 7,hammerschlag47 ,illustration3 ,fig4 #gh4--;,forceps operation4 ,traction on the handles4 7,hammerschlag47 ,illustration3 ,fig4 #gi4--;,forceps operation4 ,the delivery of the head4 7,hammerschlag47 ,illustration3 ,fig4 #hj4--,version4 ,seizing a foot4 7,hammerschlag47 ,version 7,turning74--,version is a maneuver for altering the presentation of the child while it is still in the uterus4 ,a vertex may be converted into a breech1 a breech into a vertex or a transverse into either a vertex or a breech4 ,illustration3 ,fig4 #ha4--,version4 ,the child rotates as pressure is made upon the head and traction upon the foot4 7,hammerschlag47 ,version usually means that a transverse or a vertex presentation is changed into a breech and is followed by the extraction of the child4 ,the operation is serious and not to be undertaken without definite indications4 ,there is always the risk of sepsis and rupture of the uterus as well as a high probability of a dead child4 ,perineorrhaphy is1 if anything1 more frequent after this operation than after forceps4 ,illustration3 ,fig4 #hb4--,version is complete when the knee appears at the vulva4 7,hammerschlag47 ,,preparations4--,the room and patient are arranged as for forceps1 except that the stirrups can not be put in4 ,the legs must be held by assistants1 for the delivery of the after-coming head may be complicated and require the ,walcher position1 which can not be quickly obtained if the legs are fast4 ,only eight minutes are allowed for the delivery of the child after the navel passes the vulva1 if it is expected to live4 ,the bladder and rectum must be empty4 ,asepsis must be rigid and both subjective and objective4 ,the dorsal position on a table is imperative4 ,the diagnosis must be accurate and the ansthesia carried to the surgical degree4 ,facilities for treating asphyxia neonatorum must be provided4 ,the following summary of the indications and conditions may be convenient for reference4 ,,indications4--,contracted pelvis4 7,consider pubiotomy47 ,abnormal position of the head4 7,face position with chin posterior47 ,prolapse of cord or an extremity with a presentation of the head4 ,placenta previa4 ,transverse position after the seventh month4 ,any condition requiring rapid delivery4 ,,conditions4--,cervix effaced and os dilated4 ,uterus not in tetanus nor contracted down over the child4 ,the ftus must be movable4 ,the head should not be engaged4 ,the ,walcher position is produced by bringing the patient down to the end of the table so that the sacrum rests upon the edge4 ,the thighs and legs are allowed to hang down of their own weight and the patient is restrained from falling off by traction upwards on the axill4 ,in the ,walcher position the diameter of the pelvic inlet is increased from to inch 7#a cm47 and thereby the delivery of heads that otherwise could not pass becomes possible4 ,in addition to the ,walcher position other measures may be required to help the head through4 ,thus1 traction from below may be carried to the limit of safety and in spite of the ,walcher position the head may not pass the inlet4 ,then pressure from above is added4 ,this maneuver will have to be executed in many cases by the nurse4 ,the fingers palpate the head above the pubes4 ,then one or both fists are placed upon the abdomen over the head and force is exerted to crowd the head down into the pelvis4 ,this is known as the ,wiegand compression4 ,for the operations destructive to the child1 craniotomy or decapitation1 the same arrangements are made4 ,illustration3 ,fig4 #hc4--,the ,walcher position4 7,american ,text ,book47 ,cranioclasis is the crushing of the ftal skull so that in its reduced condition the child can be delivered and the mother's life spared4 ,in addition to the solutions1 the only instruments required are the ,auvard cranioclast1 a ,naegele perforator1 and a douche bag with glass1 or any tip that can be sterilized4 ,in many of these cases1 both mother and child could be saved if seen early enough to have a ,csarean operation4 ,decapitation is done to save the maternal life in cases of transverse or shoulder presentation4 ,the preparations are the same as already described for forceps and version and the only instrument needed is a ,braun blunt hook4 7,fig4 #gc47 ,illustration3 ,fig4 #hd4--,the ,wiegand compression of the child's head to force it into the pelvis4 7,hammerschlag47 ,csarean section is the delivery of the child through an opening in the abdomen4 ,it is made necessary by contraction of the pelvic bones1 or by the presence of a fleshy or bony mass which diminishes the size of the inlet4 ,it may be required on account of the closure of the vagina or cervix by scars or on account of urgent conditions of the mother1 such as eclampsia1 heart disease1 and sometimes placenta previa4 ,the technic is simple1 but good judgment must be used in knowing when to do it4 ,many operators find it so easy that they prefer it to the harder but safer obstetrical operations4 ,illustration3 ,fig4 #he4--,the ,naegele perforator4 7,hammerschlag47 ,the time of election is when the woman is at term but not in labor4 ,this1 of course1 can be determined by the history1 but more certainly by careful measurements of the child4 ,when it becomes necessary to operate on a woman who has been in labor a long time and especially if she has been examined frequently1 the mortality is disproportionately high4 ,it is a hospital operation1 but may be done in the house4 ,if not an emergency1 the bowels are emptied by a laxative and enema the day before4 ,regular preparations for laparotomy are made1 plus the equipment necessary for tieing the cord and resuscitating the child4 ,a table must be found large enough to hold the patient in the horizontal position at full length4 ,solutions of lysol #a per cent and sterile water are placed on each side of the table4 ,the instrument table carries towels and suture material as well4 ,on a stand behind the operator is placed the hot bath and tracheal catheter4 ,this center is presided over by someone skilled in the treatment of respiratory difficulties in the new born4 ,altogether1 five assistants are required for the operation3 an ansthetizer1 a clean nurse1 and a nonsterile nurse to manage supplies1 an operating assistant and one to take charge of the child4 ,rubber gloves must be worn by the clean assistants4 ,instruments4-- #b scalpels4 #b scissors4 #h eight-inch forceps4 #aj six-inch artery forceps4 #d sponge carriers4 #d tenaculum forceps4 #b rat-toothed tissue forceps4 #d full curved round needles for uterine wall4 #d smaller needles for the fascia4 #b ,hagedorn needles for the skin4 #b needle holders4 #a dressing forceps4 ,plenty of suture material1 both catgut 7,no4 #c and #d7 and silkworm gut for the abdominal wall4 ,supplies4-- #a doz4 laparotomy sponges with metal rings sewed in or a long tape attached4 #f large laparotomy pads4 #a large pillow slip full of sterile cotton4 ,sponges4 #a laparotomy sheet4 #a dozen towels4 #a pair of leggins4 ,gowns and head dressings 7gauze will do7 for the operator and assistants2 rubber gloves1 basins and accessories4 ,all are sterilized4 ,if the woman has been examined1 the vagina should be sponged out with tincture of iodine4 ,the abdomen is shaved1 scrubbed with green soap1 nail brush1 and hot water for five minutes4 ,it is then rinsed with ether and painted with iodine4 ,the presentation of the child1 the presence and location of the heart tones must be determined before operation4 ,the patient is ansthetized with ether1 chloroform or gas4 ,the incisions are made2 the child delivered to the proper assistant2 the placenta and membranes removed2 the sponges counted2 and the uterus and abdominal wall sutured4 ,after-care4--,the nurse watches the patient for sighing respiration1 rapid pulse1 pallor1 and other symptoms of hmorrhage1 either external or internal4 ,artificial heat is supplied4 ,hmorrhage from vagina should be looked for4 ,it is normal4 ,salt solution by hypodermoclysis may be required4 ,hot water by mouth in small sips or tap water by rectum 7drop method7 will relieve the thirst4 ,morphine may be given if pain is extreme4 ,an enema may be given on the second day or calomel may be started in the morning of the second day4 ,distention from gas1 with or without nausea and vomiting1 hiccough and rise of temperature are all signs of danger4 ,no milk should ever be given on account of the gas it causes4 ,the child is put to breast as usual after twelve hours4 ,the stitches are to be taken out on the tenth or twelfth day4 ,symphyseotomy is a separation of the pelvis at the pubic joint and is done with a scalpel or a specially devised knife4 ,pubiotomy is the division of the pelvis1 three or four centimeters to the right or left of the pubic joint4 ,the division passes through the pubic bone and is usually done with a serrated wire called the ,gigli saw4 ,it is introduced subcutaneously by a special instrument called a pubiotomy needle4 ,both symphyseotomy and pubiotomy are preparatory to delivery4 ,pubiotomy is the more desirable and successful operation4 ,the ends of the severed bones separate from one and a half to two inches1 and the child delivers easily through the enclosed opening4 ,the after-care is usually simple4 ,instruments4-- #a scalpel4 #b ,gigli saws4 #a pubiotomy needle4 #f artery forceps4 #c eight-inch forceps4 #a needle holder4 #b retractors4 ,suture material and sponges as usual4 ,the hips are strapped in circumference with zinc adhesive plaster to support the bones4 ,the danger of infection of the wound from the lochia is always present4 ,the main difficulty is in moving the patient1 who is more than usually helpless4 ,the bony ring of the pelvis is broken and she can not raise her leg4 ,the repair is cartilaginous at first1 but solidifies in a few months so that locomotion is not impaired4 ,especial pains must be taken to avoid bed sores4 ,,chapter ,,xiii ,,minor ,,operations ,aseptic ,care4--,place patient on a clean bed pan4 ,it need not be sterile4 ,drape with a sheet and arrange it so the fold may be easily raised by nurse's elbow4 ,have sterile basin with cotton pledgets to be filled with solution of lysol #a per cent4 ,lysol must be put in basin first and the water added4 ,take to bedside4 ,nurse scrubs her hands ten minutes with a sterile brush1 hot water1 and green soap4 ,use no towel1 no gloves4 ,keep hands wet and clean4 ,cleanse vulva with wet pledgets from above downward4 ,apply sterile pad4 ,sterile ,specimen4--,to get a sterile specimen of urine without catheter1 give aseptic care1 tampon vagina with large pledget of sterile cotton4 ,have patient urinate in a sterile basin4 ,remove tampon4 ,sterile ,specimen from ,child4--,take a glass test tube and thrust its round end through a hole in a square piece of adhesive plaster4 ,push it down until the plaster is caught and stopped by the enlarged rim at the mouth of the tube1 with adhesive side of plaster on same side as opening of tube4 ,fasten the tube over the male penis or female vulva by applying the plaster to the surrounding skin4 ,leave until full4 ,aseptic ,douche4--,boil douche point and basin4 ,leave point in sterile basin4 ,fill douche can with sterile water1 temperature #ajd to #aaj ,f4 ,put clean bedpan under patient who is draped with a sheet4 ,have at hand a sterile basin containing solution of lysol #j4e per cent1 or boric acid #e per cent in which cotton pledgets are immersed4 ,scrub the hands as for aseptic care4 ,cleanse the vulva with cotton pledgets1 washing always toward the anus1 and use each pledget but once4 ,adjust the douche point and introduce it just inside the labia4 ,the douche can should be only a trifle higher than the pelvis4 ,when can is empty1 apply a sterile pad4 ,illustration3 ,fig4 #hf4--;,apparatus for getting a sterile specimen of urine from an infant4 ,if the douche is to be used as a deodorant after the fifth day of the puerperium1 either of the following solutions may be employed3 ,potassium permanganate1 #a3ejjj2 formaldehyde #a dram to quart1 or chinosol #a3ajjj4 ,the vaginal douche may be used in cases of gonorrhal infection in pregnancy during the last weeks1 in the hope of avoiding infection of the child's eyes4 ,it is given like the aseptic douche 7q4 v47 with potassium permanganate #a3ejjj1 or chinosol #a3ajjj4 ,it should be hot 7#aab to #abj ,f471 and be begun not long before term1 so that in case labor comes on1 the danger to the child will be minimized4 ,the reservoir must not be too high1 nor the douche point inserted much beyond the labia4 ,the woman should be on her back and the douche point should be rubber or glass4 ,removal of ,sutures4--,on1 or about1 the tenth day the removal of sutures is required4 ,the nurse will sterilize by boiling1 #a pair of long-handled1 sharp-pointed scissors1 #a pair of tissue forceps1 and if the sutures extend far into the vagina1 a vaginal retractor4 ,a basin of lysol solution 7#a per cent7 with cotton sponges1 a sterile towel to lay the instruments on1 a dish to receive the soiled dressings1 sutures and discarded sponges1 completes the arrangement4 ,the patient is now draped with sheets as for examination4 ,the doctor prepares his hands as for operation4 ,the nurse holds the limbs of the patient in lithotomy position and the operation is begun4 ,uterine ,tampon4--,packing the uterus is mostly employed for hmorrhage after labor4 ,the patient1 therefore1 has been prepared and only fresh sponging with lysol solution is required4 ,the instruments are1 #a vaginal retractor1 #a pair of dressing forceps1 #a vulsellum forceps and a jar of gauze1 four to six inches wide and ten or twelve feet long4 ,always use a single continuous strip4 ,a very large quantity is necessary to fill the uterine cavity4 ,any sterile gauze may be used1 but weak iodoform is satisfactory4 ,illustration3 ,fig4 #hg4--,tampon of the uterus4 7,hammerschlag47 ,the vagina is held open with retractors1 the cervix seized with a tenaculum and pulled down1 the end of the gauze strip is then carried into the uterus as far as the fundus1 the dressing forceps withdrawn and a new length carried in until the cavity is packed tightly from the fundus clear to the os4 ,care must be taken that the strip of gauze is not contaminated by vaginal contact during the introduction4 ,a pad and binder are now applied4 ,if no instruments are at hand1 or there is not time to sterilize1 then the nurse can grasp the fundus through the abdominal wall with her hand and push the cervix down to the vulva where the gauze can be pushed in by the doctor's fingers1 if necessary4 ,the tampon acts as a hmostatic through its direct mechanical pressure1 and dynamically by stimulating the uterus to contract4 ,it should be removed in from twelve to twenty-four hours4 ,illustration3 ,fig4 #hh4--,tampon of vagina4 7,american ,text ,book47 ,to tampon the vagina the woman lies on her back across the bed1 with her feet on the knees of the doctor1 who sits facing her4 ,a sterile retractor holds back the posterior wall of the vagina4 ,with a pair of dressing forceps the doctor seizes the pledgets of cotton or gauze out of the lysol solution and carries them one by one as far as they will go1 in various directions around the cervix4 ,one is pushed forwards toward the bladder1 the next back toward the rectum1 the next in the middle1 and so on until no more can be introduced4 ,a pad and binder are applied tightly4 ,the uterine douche is sometimes employed for hmorrhage4 ,the field of operation and the doctor's hands are prepared as usual4 ,the nurse cools the boiled douche water down to #abj ,f4 and if ordered1 adds #b drams of sterile salt to each quart4 ,the instruments are a vaginal retractor1 a long uterine douche point1 and one vulsellum forceps4 ,the cervix is seized and brought down1 the long douche point connected with the tube from the reservoir is carried to the fundus and the water started4 ,care must be used that the return flow is free and unobstructed4 ,this method is most satisfactory in uterine hmorrhage after the uterus has been entirely emptied4 ,it stimulates a prolonged and profound uterine contraction4 ,intravenous ,injections4--,the vein in the front of the elbow is usually chosen4 7,median basilic or median cephalic47 ,a rubber bandage or tourniquet is wound tightly about the middle of the upper arm to make the veins stand out prominently4 ,the surface of the skin should be sterilized for operation by scrubbing with green soap and hot water and rinsing with #ej per cent alcohol1 followed by #a3bjjj solution of bichloride1 or by the application of tincture of iodine4 ,the hypodermic needle is then introduced after expulsion of all the contained air and the piston is drawn up until the blood enters4 ,this assures the operator that the needle has entered the vein4 ,the bandage is now loosened and the solution of the drug is introduced very slowly4 ,intravenous infusion or transfusion is given in the same way4 ,the fluid 7normal saline87 must be running from the needle as it is introduced4 ,hypodermoclysis is the introduction of normal saline solution1 under the skin1 or under the breasts4 ,the solution may be transfused also into a vein4 ,by this operation1 the quantity of fluid in the vessels is greatly increased and a circulatory stimulant is provided4 ,normal saline also promotes diuresis and aids in the removal of wastage4 ,the principal dangers arise from too great rapidity or too large a quantity of the flow4 ,the skin should be sterilized at the point of attack by a coating of tincture of iodine4 ,the instruments required are1 a bath thermometer1 a douche can 7fountain syringe7 with long tubes and an aspirating needle4 ,a hypodermic needle will do1 but the reservoir must be well elevated since the caliber is so small4 ,ordinarily the reservoir need be held only two or three feet above the point of discharge4 ,the water should be flowing through the needle when it enters the tissues4 ,if the fluid is to be introduced under the skin1 the best place is in the loose region between the hips and the ribs in front4 ,if under the mammary gland1 the needle must go below and under the gland from the outside edge1 not into the gland4 ,if into a vein1 such additional instruments will be needed as a rat-toothed tissue forceps1 a pair of sharp-pointed scissors1 a knife and some fine catgut4 ,from four to sixteen ounces of fluid may be used at a temperature varying from #aje to #aaj ,f4 ,the openings where the needles entered are closed by cotton and collodion4 ,curettage of uterus is done for abortion or puerperal sepsis when foreign fragments are left in the uterus4 ,the room is prepared as for delivery4 ,the instruments are3 #a vaginal retractor4 #a vulsellum forceps4 #a long uterine douche point4 #b dull curettes4 #b sharp curettes of different sizes1 together with gauze for packing the uterus4 ,rubber gloves should be worn both by nurse and physician as much for personal protection as for the patient's safety4 ,in many cases of incomplete abortion or of puerperal sepsis the endometrium is more satisfactorily curetted with the gloved fingers4 ,abortion may be indicated in many of the early complications of pregnancy1 such as hyperemesis1 nephritis1 uncompensated heart lesions1 tuberculosis1 insanity1 hydramnios1 incarcerated retroversions of the uterus and the presence of hmorrhage4 ,these cases require the operation to be undertaken and finished by the doctor1 but other conditions develop wherein1 without volition on the part of the patient or doctor1 the abortion begins4 ,some may be saved1 but at times the attempt is futile4 ,if the emptying of the uterus seems inevitable1 the function of the physician is to see that the process is finished as quickly and cleanly as possible4 ,this may be done in the early stages by packing the cervix and vagina with iodoform gauze and administering ergot in twenty-five drop doses thrice daily4 ,in case of dangerous hmorrhage from spontaneous abortion1 the vagina can be tamponed with cotton pledgets or gauze by a clean nurse while awaiting the arrival of the doctor4 ,when the uterus has partially emptied itself and the retained fragments prevent the complete contraction and allow of serious bleeding1 or if the fragments are septic1 then their removal is required4 ,this is done by the finger or curette4 ,the preparation of rooms1 patient and doctor are the same whether the operation is for therapeutic or incomplete abortion4 ,these have been described4 ,the instruments are3 #a pair dressing forceps4 #b vaginal retractors4 artery forceps4 #b curettes of different sizes4 #b vulsellum forceps4 #a long uterine douche point4 #a pair ,goodell dilators4 #a douche can4 ,illustration3 ,fig4 #hi4--,pean forceps4 ,the induction of labor at or near term is done for pelvic contraction1 maternal disease1 for danger threatening mother or child1 or to avoid the birth of a post-mature child4 ,a variety of methods may be employed1 but the ,vorhees bag is best4 ,technic4--,assemble1 and sterilize by boiling twenty minutes1 a ,vorhees bag ,no4 #c or #d1 ,simon speculum or vaginal retractor1 #a pair long ,pean forceps1 #b pairs vulsellum forceps1 #a dressing forceps1 #b pairs compression forceps1 #a ,goodell dilator1 #a tenaculum forceps1 ,davidson hand bulb syringe with glass tubes and rubber connections for the bag4 ,patient1 prepared as for delivery1 is placed upon the table in exaggerated lithotomy position4 ,stirrups will serve4 ,the vagina is retracted1 a smear made from cervix1 and the mucous membrane wiped clean with pledgets of gauze on forceps4 ,ansthesia is only occasionally necessary even in primiparas4 ,illustration3 ,fig4 #ij4--;,a1 ,hand bulb syringe2 ,b and ,c1 ,vorhees bags2 ,d1 ,bag rolled and grasped by ,pean forceps ready for introduction4 ,before using1 the apparatus must be tested by forcibly filling the bag with sterile solution4 ,one lip and sometimes both are seized by vulsellum forceps and brought down4 ,usually1 even in primiparas1 the os is sufficiently patulous to admit the bag--if not1 dilate4 ,illustration3 ,fig4 #ia4--,vorhees bag in place4 ,the bag1 emptied of residual air and fluid1 is rolled up into a compact mass like a cigarette1 seized with ,pean forceps so that the tips extend just to the end of the bag4 ,turn the concavity of forceps toward patient's left leg and introduce4 ,as the bag enters turn the mass to the left--a quarter turn--so that when operation is completed the forceps curve faces upward4 ,release the lock on forceps4 ,connect the tube of the bag with syringe tube and force the solution slowly into bag4 ,pean forceps may be removed as bag fills4 ,remove vulsellum4 ,tie tube of bag with tape when bag is full--disconnect syringe4 ,put sterile pad on either side of tube4 ,if pains do not start within an hour1 or if compression is desired as in placenta prvia or a more rapid dilatation1 then a weight of one or two pounds is attached by a tape to the protruding tube and passed over the foot of the bed4 ,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 delivery4 ,no instruments are needed1 but a complete ansthetic is necessary4 ,thorough asepsis must be observed4 ,the patient's genitals and the doctor's hands are prepared as described for labor1 and rubber gloves are imperative4 ,the gloved hands and the vagina and vulva are well rinsed with lysol solution #a per cent4 ,the operation must be done carefully1 patiently and gently1 lest the cervix be lacerated4 ,the hand is introduced into the vagina1 and first the thumb and index finger are introduced into the os and separated as widely as possible1 then the second finger and so on1 until the dilatation is complete4 7,hirst's method47 ,another method is the introduction of the tips of both index fingers1 back to back4 ,force exerted will dilate the canal so second fingers may also be inserted4 ,then patiently and gently the rigid ring of the os is overcome4 7,edgar's method47 ,episiotomy4--,this is a clean incision of the vulva1 which is done to avoid an apparently inevitable and ragged tear of the perineum4 ,the instruments required are either a blunt tipped knife or a pair of blunt scissors4 ,the operation may be done on one or both sides depending on the amount of room required4 ,the incision begins at a point just above the lower third of the vulvar outlet when distended by the head1 and passes obliquely downward and outward4 ,this severs unimportant tissues only1 instead of allowing the valuable perineal body to suffer4 ,it makes a clean wound that heals readily1 instead of a ragged tear through bruised tissue4 ,the cut is high enough to be free from the constant bath in infectious lochia1 which troubles the healing of the usual perineal laceration4 ,illustration3 ,fig4 #ib4--;,episiotomy4 7,hammerschlag47 ,rectal ,infusion 7,drop ,method74--,a douche bag containing normal saline solution is hung near the bed and kept warm with an electric pad1 a hot flatiron1 or by a hot water bag on either side4 ,the tube ends in a catheter which is inserted into the rectum4 ,the tube is clamped so that only a drop of solution can escape each second4 ,wet packs are both sedative and antipyretic and may be employed for a local or a general effect4 ,for bronchitis the pack may be applied to the chest only as follows3 ,the child 7or adult7 is stripped in a warm room 7#ge ,f47 and the chest swathed front and back with a thick towel wrung out of hot water 7temperature #aje to #aaj ,f47 ,over this a woolen shirt may be drawn or a blanket wrapped1 and the patient put to bed4 ,after six or eight hours1 the dressing is removed in a warm room1 a hot bath administered1 and the body well rubbed with alcohol1 and dried4 ,the treatment may be repeated if necessary4 ,do not burn the patient by applications too hot4 ,the general pack is most serviceable in reducing temperature and producing a diaphoresis to relieve the kidney and cleanse the system1 as in eclampsia4 ,for this purpose the entire body1 naked1 is rolled in a sheet wrung out of hot water and then put between heavy blankets in bed4 ,the pulse should be taken frequently and the temperature recorded at intervals4 ,a cool application to the head is very soothing4 ,the patient sweats profusely and hot drinks may be given to promote a more abundant diaphoresis4 ,usually the patient drops off to sleep as the fever subsides4 ,twenty to forty minutes is the average duration of such a treatment4 ,when the pack is removed1 the patient is wrapped at once1 without drying1 in warm blankets1 and left for an hour or so4 ,,chapter ,,xiv ,,complications ,,in ,,labor ,pelvic contraction is not infrequently the cause of difficult or prolonged labor4 ,the deformity is most commonly due to rickets in childhood4 ,there are many forms of pelvic contraction1 but in this country only two are at all common2 the generally contracted1 and the flat pelvis4 ,the generally contracted pelvis is1 in the main1 a well shaped pelvis1 only its measurements are smaller than normal4 ,the flat pelvis is marked by a shortening of the anteroposterior diameter of the inlet4 ,it looks as if it had been pressed together from before backward while in a soft condition4 ,these and other deformities will be recognized in advance of labor by the routine application of the pelvimeter4 ,the value of this instrument is so great1 that no competent man does obstetrical work at the present time without using the pelvimeter as a routine4 ,the average diameters in normal pelves may be tabulated as follows3 ,interspinous--between the anterior superior iliac spines--#be cm4 ,intercristal--between the iliac crests--#bh cm4 ,external conjugate--taken from the upper border of the symphysis to the depression below the last lumbar vertebra--#bj4e cm4 ,take #i4e cm4 from this to get the true conjugate4 ,illustration3 ,fig4 #ic4--,various forms of pelvic deformity compared with the normal inlet4 7,bumm47 ,the circumference of the hips just below the iliac crests and above the trochanters--#ij cm4 ,it is taken with a tape line4 ,these are the usual external measurements4 ,the internal measurements are made with the fingers4 ,illustration3 ,fig4 #id4--,the pelvimeter4 ,illustration3 ,fig4 #ie4--,the various diameters of the inlet with the lengths given in cubic centimeters4 7,williams47 ,illustration3 ,fig4 #if4--,measuring the distance between the anterior superior spines of the pelvis4 7,williams47 ,the diagonal conjugate is the distance from the lower border of the symphysis to the promontory of the sacrum4 ,it should measure #ab4e cm4 ,the first and second fingers are passed into the vagina and pushed up until the tip of the second finger touches the promontory of the sacrum4 ,the finger of the other hand marks the depth of the examining fingers just below the symphysis4 ,the distance is measured when the finger is withdrawn1 and #a4e cm4 is subtracted4 ,the result is the true conjugate4 ,these measurements carefully made and the deduction judicially estimated1 give one a fairly approximate idea of size and shape of the pelvic inlet4 ,the aim of nearly all the pelvic measurements is to get not only the size and shape of the inlet1 but so far as possible1 a working estimate of the anteroposterior diameter of the brim1 which is the most important of all the diameters4 ,in normal cases this should be #aa cm4 ,illustration3 ,fig4 #ig4--,measuring the external conjugate4 7,williams47 ,thus1 taking #i4e cm4 from the external conjugate 7#bj4e cm47 gives #aa cm4 ,subtracting #a4e cm4 from the diagonal conjugate as obtained with the fingers as above described1 7#ab4e cm47 gives #aa cm4 ,the subtraction is made to compensate for the thickness of the pubic bone and its inclination outwards4 ,illustration3 ,fig4 #ih4--,measuring the diagonal conjugate with the finger4 7,eden47 ,a circumference of #ij cm4 corresponds to an inlet of #aa cm4 in its anteroposterior diameter1 and every variation of #e cm4 in this circumference makes a difference of #a cm4 7either larger or smaller7 in the anteroposterior diameter4 ,thus1 #ie cm4 in circumference#ab cm4 in the diameter2 and #he cm4 in circumference#aj cm4 ,complications increase in proportion to the degree of contraction in the pelvis4 ,the most frequent difficulties superinduced by the small pelvis are prolapse of the cord1 malpresentation and malpositions of the head1 prolonged labor1 and a large increase in the number of assisted deliveries4 ,all the possibilities and probabilities in a given case will be carefully worked out before labor by the conscientious obstetrician1 and ,csarean section1 induction of premature labor1 pubiotomy1 forceps1 or version and extraction1 will be done with a sure foreknowledge4 ,prolapse of the cord complicates labor once in about two hundred cases4 ,it is most likely to occur when the presenting part does not enter or does not entirely fill the opening1 as in transverse or shoulder presentations1 or vertex presentations with small inlets4 ,the mother is not endangered by this mishap1 but the babe is lost in from #ce to #fj per cent of the cases4 ,the diagnosis is easily made when a loop of cord protrudes from cervix or vulva1 and the pulsation will differentiate it from everything else4 ,if the cord does not pulsate1 the family should be informed that the child is dead and the case may be allowed to terminate normally4 ,if it still pulsates1 the woman should be placed in the knee-chest position for ten or fifteen minutes1 then upon the side1 opposite to that on which the cord has prolapsed1 and back again as soon as possible to the knee-chest position4 ,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 bed4 ,then the patient puts her legs over the lower rungs and lies with her back against the chair back and her head on the bed4 ,if the cervix is effaced and the os partly dilated1 reposition may be attempted either with the finger or a male catheter4 ,the operation will1 of course1 succeed most easily if done in the knee-chest position1 with gravity to aid4 ,if the cord can be pushed back1 a ,vorhees bag may be inserted to keep it from coming down again4 ,this holds back the cord1 dilates the canal and stimulates the pains4 ,when the bag comes out1 version and extraction can and should be done at once4 ,in general1 the following summary may be useful3 ,prolapse of ,cord ,causes4-- ,contracted pelves4 ,breech and transverse presentations4 ,malposition of head1 or face and forehead presentation4 ,hydramnios4 ,accident4 ,low insertion of placenta4 ,diagnosis4-- ,before rupture of membranes careful examination will show pulsating cord in advance of head4 ,after rupture the cord may be felt in vagina4 ,dangers4-- ,to mother3--,none but those due to causative condition4 ,to child3--,compression of the cord and asphyxiation4 ,contraction of exposed vessels of cord4 ,patient may lie on cord4 ,twenty-five per cent die as a rule under best conditions4 ,fifty per cent when left to nature4 ,treatment of ,cephalic ,presentation4-- ,extraction of child or reposition of cord1 depending upon the degree of dilatation4 ,if cervix is small1 replace and fill cervix with ,vorhees bag4 ,when cervix admits hand1 either replace or do version and extraction4 ,with head engaged1 reposition or version is not possible4 ,child living3--,rapid delivery with forceps4 ,child dead3--,craniotomy or leave to nature4 ,prolapse of one or both hands may take place4 ,if the head is engaged1 no interference should be attempted4 ,if not1 replacement or version may be done4 ,the soft parts may also complicate the labor process4 ,no time need be spent here on the rarer forms of obstruction due to uterine or ovarian tumors4 ,rigidity of the cervix1 or os is not uncommon4 ,this may be due to a dense1 almost cartilaginous consistence of that tissue1 to premature rupture of the bag of waters1 to weak1 inefficient contractions in the first stage1 or to a steel-spring-like contraction of the muscular fibers of the os4 ,in all cases the first stage of labor is greatly prolonged1 but so long as the membranes are intact1 the child is in no danger4 ,two kinds of cases are met with1 those in which the pains are violent1 and those in which they are weak and shallow4 ,in the first class1 as soon as the condition is recognized1 a dose of morphine sulphate1 gr4 and scopolamine hydrobromide #a_/aej gr4 should be given1 hypodermically4 ,the rigid ring relaxes under the influence of the narcotic1 and labor proceeds rapidly and almost painlessly4 ,chloroform may be substituted if the morphine and scopolamine are not at hand4 ,if the cervix is effaced and only the rigid ring of the os prevents the completion of the labor1 or if the above methods fail1 then the patient may be ansthetized and the rigidity overcome by the fingers4 ,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 delivery4 7,see ,minor ,operations1 p4 #baa74 ,where the constriction is due to unusual density of the cervix or to cicatricial tissue1 it is sometimes necessary to make incisions under aseptic precautions so that the rigid ring may expand4 ,weak and inefficient contractions can sometimes be stimulated satisfactorily by the introduction of a ,vorhees bag4 ,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 position4 ,the head may come down to the pelvic floor but will not advance further4 ,if the tissues of the vulva do not1 or can not yield sufficiently after appropriate time has been allowed1 episiotomy may be done4 7,see ,minor ,operations1 p4 #baa47 ,the uterus itself may functionate abnormally4 ,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 two or three pains4 ,it may be due to unusual capacity of the pelvis1 or to strong contractions which the patient is not aware of1 or both4 ,these cases predispose to post partum hmorrhage and to serious lacerations of cervix and perineum4 ,the child is usually delivered in an undesirable place1 such as a toilet basin or a street car1 and perishes from the fall1 from cold1 from umbilical hmorrhage1 or lack of facilities for revival4 ,the nurse who is watching a case is responsible for the prevention of a precipitate4 ,if the event impends1 the woman must be placed upon her side with legs straight1 and she should be instructed to cry out with every pain4 ,chloroform may be given and the head forcibly held back4 ,uterine ,inertia4--,a sluggish state of the uterus may characterize the labor and the contractions will be slow1 shallow and inefficient4 ,the intervals may be prolonged1 although the patient complains bitterly of pain4 ,the condition is seen most frequently in multiparas and is due to defective innervation of the uterus or to imperfect reflexes1 and in primiparas also it may be due to the newness of the function that is suddenly called into play1 or to contracted pelvis4 ,many times the trouble results from overfatigue and want of sleep4 ,if this is the case1 the remedy may be found in the administration of morphine sulphate gr4 and scopolamine #a_/aej gr4 ,the pains are diminished or abrogated while the contractions continue4 ,the scopolamine may be repeated if necessary4 ,under proper indications and conditions this treatment is harmless1 both to mother and child1 but requires supervision on the part of the nurse or physician4 ,if the patient is not overly fatigued1 the introduction of a ,vorhees bag1 as described under the head of ,induction of ,labor 7p4 #bjh7 will dynamically increase the strength and frequency of the contractions1 mechanically aid the effacement of the cervix and the dilatation of the os1 and shorten the first stage anywhere from six to twelve hours4 ,as soon as the os is dilated1 pituitrin may be given under due precautions1 as hereafter indicated4 ,pituitrin has but little influence on the nonfunctionating organ1 but acts well on a uterus which is definitely contracting4 ,it should not be given during the first stage1 since when the uterus contracts1 there must be an adequate opening for the advance of the child4 ,five to seven minims is the usual dose1 injected into the deltoid muscle4 ,the injection may be repeated in an hour1 if required1 since the effects1 which begin about five minutes after the injections1 will pass off in fifty-five minutes4 ,by the use of pituitin many operative procedures are altered or avoided4 ,a high forceps case may be converted into a case for the low instruments1 and the latter in many instances avoided altogether4 ,the use of pituitin may be briefly summarized as follows3 ,pituitrin 7,use no alcohol to cleanse syringe or skin before injection47 ,indications4-- #a4 ,inertia uteri or weak1 shallow pains in second stage4 #b4 ,multiparity4 #c4 ,post partum hmorrhage4 #d4 ,to avoid use of forceps or to reduce a high forceps case to a low one4 #e4 ,csarean section4 ,if the patient is a multipara1 sterile linen should be on and attendants ready for the delivery before an injection is given4 ,conditions4-- #a4 ,cervix effaced4 #b4 ,os admits three fingers4 7,better if membranes have ruptured47 #c4 ,head should be engaged4 #d4 ,no mechanical obstacle to delivery such as tumors or markedly contracted pelvis1 etc4 ,dangers of ,long ,labors4-- ,compression of cord4 ,vesicovaginal fistul4 ,necrosis of maternal tissues4 ,rectovaginal fistul4 ,infection--peritonitis4 ,necrosis of skin over skull4 ,necrosis of cranium4 ,fracture of skull4 ,death of child4 ,maternal exhaustion and prolonged convalescence4 ,premature rupture of the membranes not infrequently occurs from over-distention1 when twins or hydramnios is present1 or at any stage of the pregnancy when the membranes are weak4 ,the liquor amnii flows off1 not all at once1 but after the first gush by intermittent discharges1 depending on the painless uterine contractions and the accuracy with which the head fits the pelvis4 ,labor usually comes on in from twelve to forty-eight hours1 but it may be postponed for a month4 ,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 amnii4 ,the danger of infection of the amniotic cavity with consequent death of the child is always to be apprehended after the escape of the liquor amnii4 ,also the ftal parts may prolapse and complicate the labor2 or if the cord comes down1 the child may be imperiled by its compression4 ,if near term1 the rupture of the membranes is not of great importance though the case must be watched attentively4 ,daily observation must be made of the ftal heart tones1 the amount of liquor amnii flowing away1 and the presence or absence of infection4 ,if labor does not determine in a few days or if the heart tones rise above #afj or go below #abj1 labor must be inaugurated4 7,see ,induction of ,labor1 p4 #bjh47 ,rupture of the uterus is the most serious accident that occurs in labor4 ,it happens about once in three thousand confinements4 ,the tear is usually in the lower part of the uterus and follows a prolonged period of labor1 where the child is in a transverse presentation1 and1 therefore1 impossible to deliver1 or the pelvis is too small or the child too large4 ,it may also follow ill-advised or unskillful efforts to change the presentation by the introduction of the hand into the uterus4 ,occasionally rupture is produced by external violence1 such as blows or kicks upon the abdomen4 ,it is imperative to be able to recognize the symptoms when rupture impends or actually occurs4 ,signs of ,threatened ,rupture of ,uterus4-- #a4 ,high position of the contracting ring--especially its obliquity4 ,the contracting ring is a ridge-like formation that may be found running across the anterior and lower portion of the uterus4 #b4 ,high position of fundus4 #c4 ,tension of round ligaments4 #d4 ,rotation of uterus about its long axis4 #e4 ,tenderness to pressure of lower uterine segment4 #f4 ,contractions persistent with no pain-free interval4 ,signs of ,actual ,rupture of ,uterus4-- #a4 ,hmorrhage is one of the earliest and most significant signs1 and may be either external or internal4 #b4 ,cessation of uterine contractions either abruptly or gradually4 #c4 ,extreme pain felt by patient4 #d4 ,recession of presenting part4 ,the patient gives a sharp cry and has the feeling that something has given way4 ,signs of shock rapidly supervene4 ,a predisposition to rupture may be present from the scars of a ,csarean section1 uterine tumors1 and degeneration of the muscle4 ,the treatment depends upon the degree of the injury1 and if investigation shows that the uterus has opened into the abdominal cavity1 immediate laparotomy is done4 ,in other cases1 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 abdominal operation4 ,the child is usually dead and need not be considered4 ,,chapter ,,xv ,,complications ,,in ,,labor 7,cont'd7 ,vomiting in labor frequently occurs near the end of the first stage4 ,it is due to the sympathetic excitement of the nerves of the stomach as the last fibers of the os uteri give way4 ,it requires no treatment4 ,hyperemesis in labor is very rare1 but when it does occur1 the delivery should be expedited4 ,hmorrhages may occur either before1 during1 or after labor4 ,hmorrhage is always serious4 ,hmorrhage before labor arises either from a premature detachment of a normally implanted placenta or from placenta prvia4 ,the first is sometimes called 8accidental hmorrhage0 to distinguish it from the latter1 or 8unavoidable hmorrhage40 ,accidental hmorrhage may be the result of an injury or a blow1 but in many cases1 there is no such history4 ,the hmorrhage is most frequent in the later months of pregnancy1 and may be without any apparent cause4 ,the hmorrhage may be entirely inside the uterus 7concealed hmorrhage7 or it may appear externally4 ,the hmorrhage1 when concealed1 takes place back of the placenta or between the membranes and the uterine wall4 ,if the hmorrhage is concealed1 it is usually followed by an attempt to expel the child4 ,if the hmorrhage is pronounced1 systems of shock appear4 ,the diagnosis is made by the symptoms which are summarized in differentiating this condition from placenta prvia 7p4 #bca74 ,from this affection1 nearly all the children and half the mothers die4 ,illustration3 ,fig4 #ii4--,various forms of placenta prvia compared with normal attachment of the placenta4 7,american ,text ,book--,williams47 ,when the hmorrhage is external and slight1 the treatment may possibly be expectant for twelve hours1 if carefully watched1 but usually the symptoms become so serious that immediate emptying of the uterus is required either by the ,vorhees bag1 digital dilatation1 version and extraction1 or ,csarean section1 the method chosen being dependent upon the amount of the hmorrhage1 the vigor of the mother and the condition of the cervix1 os1 pelvis1 and child4 ,placenta prvia 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 os4 ,this happens through the action of the egg which embeds itself too far down on the endometrium--too close to the cervix4 ,three different kinds are known and named from their manner of encroaching on the os1 as marginal1 partial1 or central implantation of the placenta4 ,the hmorrhage is from a loosening of the placental attachment owing to the stretching and growth of the uterus4 ,there is only one symptom of placenta prvia--sudden1 painless1 causeless hmorrhage4 ,the bleeding seldom appears before the twenty-eighth week1 and no suspicion of a placenta prvia may arise before the appearance of hmorrhage1 which1 as a rule1 is soon repeated4 ,labor frequently comes on prematurely and malpresentations naturally result from the inability of the presenting part to fit itself into the pelvis4 ,there is no bag of waters1 hence the first stage is longer and bloodier and fraught with much danger4 ,interference is regularly indicated to save the life of the mother1 while the child also has a high mortality4 ,puerperal infection is not uncommon4 ,placenta prvia is always an emergency4 ,if the patient can be kept under observation in a good hospital1 one may temporize1 but under other conditions the uterus must be emptied at once1 even if only a single hmorrhage has developed4 ,the indications are1 7a7 to control the bleeding1 and 7b7 to empty the uterus4 ,the life of the child must be disregarded and the mother alone considered4 ,if the contractions have not begun1 they should be stimulated by the introduction of a ,vorhees bag1 which1 at the same time1 dilates the canal and mechanically shuts off the bleeding vessels by compression4 ,in introducing the bag1 the membranes may be ruptured so the bag will pass into the uterine cavity4 ,when the implantation is central1 the finger must tear a hole through the placenta1 and through this opening pass the bag inside the uterus4 ,if the os is partially dilated1 version may be done1 and a foot brought down4 ,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 hmorrhage1 until dilatation is advanced enough for delivery4 ,occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton4 7,see ,vaginal ,tampon1 p4 #bjd47 ,csarean section may be done in the interests of the child1 as well as the mother4 ,the ftal mortality in placenta prvia is said to be #fj per cent and the maternal #aj per cent4 ,differential diagnosis between ,accidental hmorrhage and ,placenta prvia ,usually occurs in later months4 ,any time after the twenty-eighth week4 ,may be concealed or open4 ,always open and external4 ,soon followed by labor pains4 ,labor need not occur4 ,uterus becomes larger if bleeding ,uterus remains same size4 is concealed4 ,uterus hard and woodeny4 ,uterus1 normal consistency4 ,in severe cases1 signs of shock ,in severe cases1 signs of shock whether hmorrhage is external or follow the invariable external internal4 hmorrhage4 ,no placenta can be felt4 ,placenta can be felt through the os4 ,hmorrhage continues4 ,hmorrhage intermittent4 ,no history of previous attack4 ,possibly history of previous attack4 ,no contractions after labor begins ,contractions as usual4 in serious cases4 ,no bogginess of cervix4 ,cervix boggy4 ,hmorrhages may occur during labor from retention of the major part of the placenta while a portion is detached4 ,this may be due to pre-existent disease1 such as endometritis1 or from uterine inertia4 ,normally the placenta will separate and be discharged within an hour after labor and in the absence of hmorrhage it may go even longer than this with safety4 ,the occurrence of severe hmorrhage1 however1 requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments4 ,post partum hmorrhage includes all hmorrhages that occur after the delivery of the placenta4 ,the 8flooding0 as it is called by the laity1 is most apt to come on either immediately or within an hour or so after labor4 ,if it comes on after the first twenty-four hours1 it is called secondary hmorrhage4 ,such predisposing causes as over-distention from twins may be present1 but the hmorrhage may follow a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour4 ,there are four causes for post partum hmorrhage3 namely1 7a7 uterine exhaustion 7atonia uteri72 7b7 mechanical obstacles to retraction1 such as clots or retention of pieces of placenta or membrane2 7c7 and lacerations of some part of genital passage1 such as the vulva1 vagina1 cervix1 or lower uterine segment2 and 7d7 the systemic condition known as hmophilia4 8,bleeders0 7hmophilias7 are women whose blood lacks coagulability1 owing to the absence of fibrin-producing elements4 ,post partum hmorrhage is usually an external hmorrhage1 but the woman may bleed to death into her own uterus4 ,besides the external signs1 the patient may show the symptoms of acute anmia1 such as the rapid pulse1 hurried1 shallow respiration1 pallor1 cold sweat1 yawning1 dizziness1 etc4 ,nearly all these cases can be saved by prompt recognition and efficient treatment4 ,the first step is to grasp the uterus4 ,if the hmorrhage is due to a tear low down1 the uterus may be hard1 but generally it is relaxed and requires vigorous massage with both hands before it shows any signs of contraction4 ,in the absence of the doctor1 the nurse must know how to undertake this maneuver4 ,the uterus1 after labor and especially when relaxed1 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 appreciated4 ,as soon as the uterus contracts1 clots and contained blood are expelled1 and in many cases its bleeding ceases at once4 7,see ,conduct of ,third ,stage1 p4 #adi47 ,it may be necessary to keep the uterus contracted by manual massage in this way for several hours4 ,as soon as possible1 the nurse1 or someone whom she directs1 prepares a hypodermic of pituitrin--#aj to #ae 4 ,an injection of ergot may follow because its effect is more lasting than pituitrin4 ,next1 a hot douche is made ready and the materials for packing the uterus are assembled4 ,when the doctor arrives1 he sterilizes his hands1 puts on gloves and introduces two fingers or the whole hand into the uterus to remove clots or any retained fragments of placenta4 ,the hot intrauterine douche may follow1 and if the contraction is not firm and the hmorrhage checked1 the uterus must be packed with gauze4 ,if hmorrhage comes from cervix1 it should be grasped with long forceps1 pulled down1 and sutured4 ,if from perineum1 pack first1 and afterward sutures may be introduced4 ,if the patient is exsanguinated1 the foot of the bed is raised1 coffee given by mouth1 camphorated oil hypodermically1 and normal saline transfused under the breasts4 ,pituitrin may be continued in larger doses4 #a c4c4 will raise the blood pressure very definitely4 ,adrenalin also may be employed for this purpose4 ,the following summary may be found convenient3 ,post ,partum ,hmorrhage ,etiology1 ,functional4-- ,atony of the uterus1 especially after rapid artificial or natural emptying of the organ4 ,more common after uterus has previously been greatly distended4 ,premature version and extraction4 ,hydramnios and twins4 ,imperfect development of uterine musculature4 ,precipitate labors4 ,haste or improper management of third stage4 ,etiology1 ,mechanical4-- ,retention of placenta--partial1 total or solitary cotyledons4 ,inversion of the uterus4 ,placenta succenturiata4 ,inflammation of decidua serotina4 ,conduct of third stage1 i4e41 wait until placenta separates4 ,etiology1 ,systemic1 ,hmophilia4-- ,kind of hmorrhage4 ,hmorrhage before expulsion of placenta due to laceration of the soft parts1 or ,partial release of placenta and failure of uterus to contract1 or ,placenta may be attached to periphery or to one side4 ,attempts to expel placenta without waiting for uterine contraction are sometimes productive of hmorrhage4 ,hmorrhage after expulsion of placenta4 ,hmorrhage in interval between pains--comes from placental site4 ,hmorrhage in stream not checked by uterine contraction is due to laceration of the canal4 ,hmorrhage in abnormal quantities at beginning of pains4 ,pure atony--comes early4 ,hmophilia again4 ,diagnosis4-- ,palpation of uterus through abdomen4 ,placental site excluded from contraction 7paralysis74 ,view of vulva4 ,injuries4 ,flow continuous1 fluid and bright red1 shows arterial origin1 probably from cervix4 ,examine4 ,atony--bleeding at intervals1 clotted and dark4 ,hmorrhage from a tear begins at once4 ,uterus contracted and hmorrhage continues4 ,look for tear4 ,if hmorrhage does not begin within ten or fifteen minutes after labor it is not from a tear4 ,always have hmophilia in mind4 ,management4-- ,third stage must be conducted properly4 ,before expulsion of placenta--early expression4 ,cred or manual removal--then secure contraction by massage4 ,pituitrin1 ,ergot1 or both4 ,after ,third ,stage4-- ,restore an inverted uterus4 ,repair lacerations4 ,see that cavity is clear and clean4 ,massage1 intrauterine hot water douche1 hand in uterus and hand outside and rub1 ergot4 ,pituitrin hypodermically4 ,pack uterus with sterile gauze or weak iodoform gauze4 ,strict asepsis for all intrauterine maneuvers4 ,treat anmia with transfusion1 elevation of foot of bed1 coffee1 external heat1 hot rectal enemas1 stimulation1 bandaging of legs4 ,strychnine sulphate1 adrenalin1 or camphorated oil may be required in usual dosage4 ,hypodermoclysis4 7,see ,minor ,operations1 p4 #bjf47 ,after the bleeding stops1 the food must be most nutritious--milk1 eggnog1 rich soups1 chicken and mutton broths1 oyster stew1 and beef steak as soon as she can take it4 ,a diet of fluids and stimulating foods that raise the blood pressure will most quickly relieve the symptoms4 ,illustration3 ,fig4 #ajj4--,the knee-elbow posture4 7,bumm47 ,illustration3 ,fig4 #aja4--,the knee-chest posture4 ,eclampsia occurs in the last three months of pregnancy as a rule1 and most frequently just before or during labor4 ,in about one sixth of the cases only1 the attack may follow labor4 ,the attack is characterized by violent convulsions1 which come on with little or no warning unless the urine has been carefully watched4 ,illustration3 ,fig4 #ajb4--,the exaggerated lithotomy position obtained with a sheet sling4 7,american ,text ,book47 ,illustration3 ,fig4 #ajc4--,the improvised ,trendelenburg position4 7,american ,text ,book47 ,the prodromal symptoms have already been described under albuminuria in pregnancy 7p4 #gg74 ,the marked features may be repeated for emphasis3 persistent headaches1 disorders of vision1 spots before the eyes1 blindness1 edema of cheeks1 eyelids1 feet and hands1 pain at the pit of the stomach1 dizziness1 nausea and vomiting and ringing in the ears4 ,suddenly the convulsion occurs1 the facial muscles twitch1 then the limbs and body are shaken by violent muscular spasms4 ,the body becomes rigid1 the tongue protrudes and the face is livid and cyanotic4 ,the spasm usually lasts from one to five minutes and is succeeded by coma that lasts an hour or more4 ,in some instances there is no return to consciousness before the next attack1 which comes on every hour or half hour1 though occasionally only one seizure is noted4 ,illustration3 ,fig4 #ajd4--,the dorsal position with stirrups4 7,dorland's ,dictionary47 ,the blood pressure is greatly increased and the urine is diminished1 the temperature rises to #aja or #ajb ,f4 ,when death ensues1 it is most frequently due to edema of the lungs or cerebral hmorrhage4 ,the greater the number of convulsions1 the more serious the outlook as to life1 and it is said that after twenty seizures fifty per cent of the mothers die4 ,under the best treatment approximately fifty per cent of the babies die4 ,illustration3 ,fig4 #aje4--;,dorsal position across the bed4 7,bumm47 ,there is no routine treatment for eclampsia4 ,the principles of management for the attack are 7#a7 to empty the uterus1 on the theory that the disease is a toxmia of gestational origin1 7#b7 to eliminate the poison1 and 7#c7 to control the convulsions4 ,the albumin in the urine and other eclamptic symptoms demand urgent attention in prophylaxis4 ,for the pre-eclamptic period 7see ,albuminuria of ,pregnancy1 p4 #gg7 a rigid milk diet is indicated4 ,the bowels1 kidneys1 skin and blood vessels must all be brought into service4 ,in the full blooded patient1 venesection may be done and after drawing off ten or twelve ounces of blood1 an equal amount of normal saline may be poured into the same vein4 ,illustration3 ,fig4 #ajf4--;,flexed dorsal position with feet on the table4 7,american ,text ,book47 ,subcutaneous transfusion or the submammary introduction of saline solution may be done4 ,the skin is stimulated by hot wet packs and the bowels by saline cathartics and frequent irrigation of the colon4 ,during the attack1 the patient must be kept from injuring herself4 ,a spoon wrapped in gauze or a small1 long roller bandage should be slipped between the teeth to keep the tongue from injury4 ,the clothing must be loosened or removed4 ,no food1 but only water is given by mouth1 until the patient is conscious4 ,the convulsions are controlled by morphine1 chloral1 or both4 ,morphine sulphate1 gr4 is given hypodermically1 followed in an hour by #cj gr4 of chloral by mouth4 ,two hours later the morphine is repeated and six hours after the first dose of chloral1 it is repeated4 ,in this method 7,stroganoff's71 four doses of chloral and six of morphine are given in twenty-four hours4 ,that is all4 ,when the stomach will not retain the chloral it may be given by rectum in milk4 ,if a general ansthetic is used1 it should not be chloroform1 but ether4 ,illustration3 ,fig4 #ajg4--,the ,sims position4 7,kelly47 ,the labor1 if begun1 should be expedited by forceps1 or version and extraction4 ,bleeding during delivery should be looked upon as desirable4 ,if more rapid measures of delivery seem demanded and obstacles exist1 such as pelvic contraction1 imperfect dilatation1 or the prospect of a prolonged first stage1 ,csarean section or forcible delivery 7accouchment forc7 may be attempted4 ,if the labor has not begun1 when the convulsion occurs and a quick delivery by the normal passage does not seem feasible1 then the ,csarean operation may be the best treatment4 ,,chapter ,,xvi ,,the ,,abnormal ,,puerperium ,the practice of obstetrics has many features that are very gratifying to the nurse and physician4 ,instead of a surgical operation1 which has come unexpectedly and undesired2 a disaster in which some part of the body is removed or altered by means of a procedure associated with extreme pain1 mental tribulation and large expense1 a much-wished for addition is brought to the family1 with pain1 to be sure1 but a pain that is soon forgotten in the general joy4 ,this is the normal condition that causes the nurse and the doctor to rejoice that such a delightful specialty has been chosen4 ,then comes a case in which the labor may be complicated by some dreadful anomaly1 or the puerperium burdened or disordered by some unwelcome invasion that tortures the souls of the family and may cost the life of the mother1 or child1 or both4 ,at such a time the nurse and the doctor feel the full weight of their responsibility1 and after a series of anxious days and sleepless nights1 they wonder why they did not choose gardening or a clerical position for their life work4 ,the disorders of the puerperium are many and various1 but naturally the breasts and the pelvic organs are most frequently affected4 ,the breasts of the human female are not reservoirs of milk like the cow's1 but a pair of highly sensitive organs that functionate and produce only as the demand is made4 ,it follows that when the milk comes in1 the breasts become engorged and all the neighboring structures are involved in the new process4 ,however1 it is not milk that is overfilling the breasts1 but serum1 lymph and venous blood1 which congest the tissues surrounding the glands and produce a hard painful mass4 ,the breasts become heavy1 hot1 and painful2 supernumerary glands in the axill enlarge1 but there is no fever4 ,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 badly4 ,if fever appears simultaneously with the milk1 the cause must be sought in some atrium of infection1 possibly in the breasts1 but usually elsewhere4 ,there is no such thing as 8milk fever40 ,the enlarged glands1 the tense mottled skin on which blue veins run visibly here and there1 the nipple1 flattened and drawn into the swelling1 so that the child can not grasp it with the mouth1 all produce a sense of disorder that ought to be associated with fever--but is not4 ,this is the 8caked breast0 of the laity1 and if let alone1 the hypermia subsides and the function remains4 ,the temperature in possibly two cases out of five may rise to #ajj ,f4 for twenty-four hours1 but it promptly subsides4 ,these temperatures generally occur in neurotic women4 ,if the breasts are irritated by binders1 breast pumps1 or massage1--like the blacksmith's arm1 with exercise--the trouble1 if not increased1 is at least much slower in disappearing4 ,it is reported that the young virgins of some ,african tribes nurse the babies in the family1 the breasts being stimulated to produce milk largely by massage4 ,if the condition of the breasts becomes too painful1 the liquids by mouth are reduced to the last degree1 saline cathartics are given until frequent watery stools result1 one or more ice bags are applied to each breast and codeine sulphate may be given at night4 ,the child nurses every four hours only4 ,williams was the first to show that no tight binder is necessary1 but only a supporting bandage4 ,the tight binder is a cruel and useless barbarism that has been abandoned by progressive physicians4 ,no massage is allowed2 no pumps2 no irritation whatever1 and in twenty-four hours the trouble has disappeared4 ,hot dressings to the breast are equally archaic4 ,they should never be applied to any breast unless it is desired to hasten suppuration4 ,if the child dies1 or for any reason can not nurse 7inverted nipple1 cleft palate1 harelip7 and it becomes necessary to dry up the milk1 the treatment for 8caked breast0 is continued4 ,after twenty-four hours the breasts are comfortable and rarely give trouble again4 ,cracks1 ,fissures and ,abrasions of the ,nipple4--,the care of the nipples should be inaugurated about six weeks before labor1 as elsewhere described3 ,the nipple must be inspected and its possibilities determined1 early in pregnancy1 if possible1 for many varieties of badly shaped and ill-developed nipples exist which may make nursing difficult or impossible4 ,imperfect nipples especially are predisposed to fissure and crack1 and will require extreme care on the part of the nurse4 ,she should inspect them before and after each nursing and sedulously use cleanliness and asepsis in her management4 ,in normal and tranquil as well as in neurotic women1 the nipple may become so sore as absolutely to preclude nursing1 and this entails much additional work on the nurse and mother1 as well as considerable peril for the child4 ,the condition usually begins as a fissure or crack1 and is accompanied by much pain4 ,it is serious1 furthermore1 in another aspect since all breaks in the surface of the nipple are avenues of infection that may result in mastitis4 ,the child may produce fissures or abrasions by rubbing the nipple with his mouth1 by pulling too hard1 or by the habit of holding it in his mouth and macerating it with his gums when he has finished nursing4 ,illustration3 ,fig4 #ajh4--;,examples of imperfect nipples4 7,american ,text ,book47 ,the child must not be left at the breast after he has nursed1 but the nipple should be gently removed from the child's mouth by passing one finger in beside the nipple4 ,fissures and abrasions usually occur within ten days if at all4 ,abrasions or erosions are due to the wearing away of the epithelial covering of the nipple in patches more or less extensive4 ,thin-skinned blonde women suffer more than those with dark1 dense oily skins4 ,a fissure is a distinct separation of tissue that goes deeply into the underlying substance4 ,a crack is a long abrasion which may deepen into a fissure4 ,both fissure and crack may affect the top1 the side of the apex1 or the base of the nipple4 ,they may be either longitudinal or circular4 ,the entire nipple must be kept under observation and the instant a raw surface is detected1 treatment must begin4 ,illustration3 ,fig4 #aji4--;,a standard nipple shield4 7,american ,text ,book47 ,compound tincture of benzoin1 liberally applied1 is a favorite and successful remedy4 ,our routine is to apply a paste made of equal parts of castor oil and subnitrate of bismuth4 ,this is put on after the child nurses1 and must be removed carefully before the next nursing4 ,sometimes the child's stools become black and constipated and the trouble may be traced to imperfect removal of the bismuth preparation4 ,whatever medication is used1 the nipple must be protected from injurious friction by the clothing4 ,this is best done by the hat-shaped lead nipple shield1 which is placed over the nipple and held in place by a light binder4 ,the shield should be boiled before use4 ,to protect the nipple during nursing1 a glass shield may be used for a day or so1 but not long enough for the babe to get accustomed to it1 else he will form a habit hard to break4 ,this shield must be taken apart after use1 washed and kept in saturated solution of boric acid until the next nursing4 ,if all these measures fail1 the fissure must be touched with a nitrate of silver stick once1 or have a #b per cent solution of nitrate of silver applied night and morning4 ,it may be necessary to take the child from the breast for a day or so1 in which case he nurses the other breast and the side with the bad nipple is pumped4 ,the care of the nipple is highly important since the apprehension and the actual pain of each nursing may prevent sleep1 destroy the appetite1 and diminish the milk4 ,if begun early1 most fissures will heal in twenty-four to forty-eight hours4 ,mastitis4--,from three to five per cent of lying-in women have mastitis in the ,european clinics1 but the records in ,america show a much smaller number4 ,the disease occurs most frequently in blondes and in primiparas4 ,it is most apt to appear during the first two weeks1 when the congestion accompanying the new mammary function produces a stasis that favors the growth of germs1 which may enter through the abrasion or fissures of the nipple produced by zealous activity of the child's gums4 ,but it may also occur when the child's first teeth come and the nipple is again exposed to injury4 ,at times it is impossible to find a plausible excuse for its occurrence4 ,mastitis is usually described in three forms3 ,the 7a7 parenchymatous or glandular type1 which affects the substance of the gland or the enveloping connective tissue2 in 7b7 subcutaneous mastitis the connective tissue beneath the skin is attacked2 and in 7c7 the sub-glandular variety1 the infection finds a lodging between the gland and the chest wall4 ,mastitis is always due to the presence of microorganisms which in many cases gain access to the gland through fissures or abrasions by means of the lymphatics4 ,in other instances the germs may be in the blood and a local stasis may encourage the infection4 ,still again1 they seem to enter through the normal nipple openings4 ,symptoms4--,the parenchymatous inflammation begins with a chill1 and the temperature promptly rises to #ajb to #aje ,f4 ,the pulse is high4 ,the patient complains of headache and thirst4 ,examination reveals hard1 tender nodules in some part of the gland4 ,the skin may or may not be reddened4 ,if the trouble has begun in the connective tissue1 the skin will be diffusely reddened1 the nodule ill-defined1 the temperature will rise gradually and the chill may be absent4 ,treatment4--,the breast is put at rest4 ,no tight binder is applied1 no breast pump1 no massage4 ,no heat is allowable4 ,ice bags surround the gland night and day4 ,the liquids by mouth are restricted and saline cathartics given4 ,codeine may be administered for pain4 ,usually the symptoms subside without suppuration in from one to two days4 ,should the inflammation persist for more than two or three days1 in most cases the tissue will break down and form a mammary abscess4 ,when it is evident that suppuration has begun1 heat may be applied to the gland and the process accelerated4 ,the abscess may be superficial or deep and will be diagnosed by a bogginess in a circumscribed area or by fluctuation4 ,the abscess must be opened as soon as possible4 ,the nurse sterilizes a bistoury and a pair of long artery forceps4 ,lysol solution and cotton sponges are made and sterile gauze for packing4 ,the hands are surgically prepared and rubber gloves worn4 ,if an ansthetic is required1 gas may be used1 or chloroform4 ,the incision is made radially from the nipple so as to minimize the injury to the milk ducts4 ,a gauze drain may be required for a few days4 ,in the after-care1 the nurse must be scrupulously clean and not convey contagion from the breast to the woman's genitals1 to the child's eyes1 navel or vagina1 nor to her own person4 ,excess of milk is rare1 but may be observed for a short time after the glands fill4 ,it seldom requires treatment1 but saline cathartics1 restriction of fluids1 and putting the child on a four-hour schedule will reduce it4 ,pads may be worn if it runs away freely4 ,scarcity of milk is only too common4 ,there may be enough at first and the quantity gradually diminish1 or it may be deficient from the very beginning4 ,the faulty secretion may be due to the age of the mother1 to disease 7anmia71 to bad nutrition1 or to overwork4 ,it may follow a premature child4 ,compression of the breasts by corsets or tight dresses may prevent development4 ,the amount of gland tissue is very important4 ,many women have large1 fat breasts1 but a small glandular development4 ,mental conditions1 such as fright1 worry1 and anxiety1 will diminish the flow of milk or stop it altogether4 ,symptoms4--,the child is fretful1 goes to sleep after nursing but soon wakes up1 or may nurse awhile1 and then finding it useless1 will cry and refuse the nipple4 ,he loses weight and when weighed before and after feeding1 the scales scarcely vary4 ,no secretion or very little can be squeezed from the breasts4 ,the child may be given a bottle after which he goes to sleep4 ,treatment4--,when the gland tissue is defective1 no treatment can succeed4 ,the appetite must be improved by bitter tonics and the mind relieved of its anxieties1 if possible4 ,change of scenery may help4 ,the fluids must be increased1 milk1 cocoa1 chocolate and gruel must be pushed1 and such vegetables added as corn and beets4 ,oyster stews1 clams1 lobsters1 and crabs will help4 ,the diet must be full and nutritious with especial stress on those foods that raise the blood pressure4 ,malt drinks or champagne may avail in some cases4 ,exercise in moderation is desirable4 ,artificial stimulation of the breast sometimes succeeds4 ,massage will irritate the glands1 increase the congestion1 and promote functional activity2 or a ,bier vacuum apparatus may be put over the gland several times a day and the air pumped out4 ,the breast should be kept distended for fifteen to twenty minutes4 ,there is difficulty in this country in getting glass bells of sufficient size4 ,galactorrha is the name applied to an abundant secretion of milk poor in quality toward the end of a long lactation or after the child is weaned4 ,the symptoms are an almost constant flow of milk with resultant anmia4 ,treatment4--,elix4 of iron1 quinine and strychnine with compression of the gland4 ,a dry diet and the avoidance of all irritation of the breasts will aid4 ,to 8dry up the milk10 follow the treatment for 8caked breast40 ,illustration3 ,fig4 #aaj4--;,a standard breast pump4 7,american ,text ,book47 ,quality of the milk may be such that the child will not take it or1 if taken1 it fails to nourish4 ,in some cases this is due to overlong1 or to irregular1 periods between feedings2 for when the nursing interval is too short1 the milk becomes too rich1 when too long1 it becomes thinner and less nutritious4 ,fright1 anxiety or anger may change the character of the milk so that colic1 vomiting1 and diarrha and indigestion are produced in the child4 ,a wet nurse becomes homesick and the milk dries up4 ,it may become extremely indigestible1 as shown in cases where a wet nurse quarrels with her husband and her foster child develops green stools4 ,if the mother's milk does not agree1 the child may be put on feedings for twenty-four or forty-eight hours1 while the milk1 pumped from the breast1 is sent to a laboratory for analysis4 ,if a return to the breast is unsatisfactory1 artificial feedings or a wet nurse must be supplied4 ,removal of the child from the breast may be required for a variety of reasons4 ,thus1 the mother's addiction to alcohol or opium is good ground for taking away the child4 ,arsenic1 bromides and iodides of potassium1 saline cathartics1 salicylates1 alcohol1 opium and belladonna must be given to the mother with great caution during lactation1 for they pass over into the milk4 ,acute diseases1 such as erysipelas1 pneumonia1 diphtheria1 typhoid1 malaria1 pronounced puerperal sepsis or persistently high fever from any cause1 usually dries up the milk2 while cardiac lesions1 unless well compensated1 chronic anmia and tuberculosis1 obviously demand the removal of the child for the sake of both4 ,sometimes a new conception1 especially when the milk becomes poor in the last half of gestation1 compels the mother to wean her babe4 ,a syphilitic woman may nurse her own child1 provided her condition is good and the child also is syphilitic4 ,theoretically1 the return of menstruation in no way affects the nursing child1 unless the blood is lost to the point of anmia4 ,yet cases do occur in which the child has indigestion1 colic and bad stools1 as well as loses weight1 when the mother is menstruating4 ,the quality of the milk is sometimes altered1 but only for a day or so1 and the child should continue at the breast unless some definite indication for removal arises4 ,weaning ordinarily is completed by the ninth month1 but the child should never be carried beyond the twelfth month on account of changes in the character of the milk4 ,when a child is weaned1 the substitution of an artificial food may be made gradually1--a bottle a day1 two bottles a day1 etc41 until1 in a couple of weeks1 the breasts are at rest4 ,the excessive prolongation of lactation is shown upon the mother by impairment of the health4 ,the patient is pale1 weak1 anmic1 fretful1 and thin4 ,headaches1 dizziness1 loss of appetite1 and constant fatigue will be complained of4 ,the treatment is to remove the child at once and put the mother on stimulating drugs and foods4 ,a change of air and scenery1 if possible1 will be highly beneficial4 ,the wet nurse is always a tribulation1 which must be endured until the child can be put on artificial food4 ,she should have a ,wassermann test before entering upon her duties4 ,syphilis1 tuberculosis1 and gonorrha must be guarded against4 ,she must be kept like the family cow1 in a placid frame of mind1 fed on nutritious food that is not too rich1 and exercised enough to keep the blood circulating4 ,light housework and duties that take her out of doors part of the time are advisable4 ,her moral character can only be assured through those who have known her4 ,if she brings her own child with her1 she will need watching to provide for an equable distribution of the milk4 ,the first few days is never a criterion of a wet nurse's effectiveness4 ,change of food and surroundings may interfere with her usefulness4 ,gas may complicate the puerperium after ,csarean section1 and even after normal labor4 ,a rectal tube of soft rubber may be passed as high as possible into the bowel and left for some time1 or enemas of ,s4 ,s41 turpentine1 asaftida1 or milk and molasses may be given4 ,by mouth calomel or mag4 cit4 is valuable4 ,headache in the puerperium should be watched carefully1 and the cause discovered4 ,pain in the head may be a habit with the patient1 or it may be a symptom of some complication either present or developing1 such as toxmia1 eclampsia1 or acute yellow atrophy of the liver4 ,in general1 it is due to milder conditions like exhaustion1 too many visitors1 excitement1 nerves1 or insomnia4 ,after-pains4--,sometimes patients are greatly annoyed by after-pains4 ,the pain may be due to a clot retained in the uterus or possibly a stimulation of the uterus when the child goes to breast4 ,gentle massage of uterus1 or ergot1 quinine1 or codeine may be required to bring about the expulsion of the clot or to control the pain4 ,a reasonable degree of after-pain is of favorable significance4 7,see p4 #aed47 ,,chapter ,,xvii ,,infection ,puerperal fever is a wound infection4 ,the conditions of the pelvic organs during labor and post partum1 are well adapted to receive and develop microorganisms1 for the healthy antimicrobic power of the vaginal secretion is absent or diminished4 ,a long and exhausting labor1 possibly accompanied by hmorrhage1 or terminated by an operation1 has diminished the immunity and broken the resistance of the tissues to a dangerous degree4 ,the mucous membrane of vulva and vagina are torn and bruised1 the vitality lowered1 and the surface covered with bloody lochia1 which is an excellent nutritive medium for microbic development4 ,the uterus is a vast1 open wound1 filled with fibrin1 blood clot1 and decomposing tissue1 while the whole pelvis is maintained at exactly the proper temperature for germ propagation4 ,through these wounds1 toxins are carried into the circulation1 and germs1 nourished upon the abundant and favorable culture media1 pass through the uterine walls or by way of the lymph channels first into the adjacent tissues and thence to all parts of the body4 ,certain definite organisms reach the disintegrating tissues and produce a putrefaction4 ,they do not1 however1 once their work is done1 pass into the body4 ,but in producing putrefaction1 they also produce injurious poisons1 called toxins1 which do enter the body and cause an absorptive fever known as saprmia4 ,illustration3 ,fig4 #aaa4--;,germs most frequently found in cases of puerperal fever4 7,kelly's ,gynecology47 #a1 streptococci 7in chains72 #b1 gonococci2 #c1 tubercle bacilli 7not a source of puerperal infection72 #d1 bacillus coli communis2 #e1 staphylococcus pyogenes aureus2 #f1 bacillus aerogenes capsulatus4 ,other organisms are the pus microbes1 which begin their growth in any favorable location and continue to spread and flourish onward and inward by blood vessel1 tissue or lymphatic1 until overpowered by the resistances of the body1 or until by general sepsis1 they have killed the patient4 ,these are the streptococcus1 staphylococcus1 bacillus coli and bacillus pyocyaneus4 ,these are the germs that the nurse or the doctor may bring to the patient on hands1 clothing1 or hair4 ,these are the organisms against which our scrupulous asepsis and antisepsis is directed4 ,it is against them and their activities that the doctor and nurse prepare by the long and painful scrubbing of the hands and elbows1 the rubber gloves1 by the shaving and scrubbing of the patient1 and by all the paraphernalia and equipment that go to furnish the modern lying-in-chamber or delivery room4 ,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 temperature1 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 asepsis4 ,it is true that many women escape when the attendant is unclean1 but this is due to a splendid immunity1 and in no way absolves the man or woman who neglects his asepsis and has patient after patient running temperatures1 some of whom are bound to die or be crippled for life4 ,it is for this reason that a surgeon should do surgery and not general practice2 it is for this reason that an obstetrician should limit himself to the care of women in childbirth and not endanger them by taking cases of scarlet fever1 erysipelas1 and unclean surgery4 ,in country practice1 all kinds of work must be done since there are not enough men to specialize1 but it is inexcusable in the city where a man can always be clean and keep clean1 if he is willing to forego the income derived from attendance upon septic and infectious cases4 ,any article not surgically clean may contaminate the patient by contact2 but ulcers1 suppurating wounds1 abscesses1 and hands improperly or insufficiently cleaned are the deadliest causes of post partum temperature4 ,infections are said to be either self-produced or brought to the patient from without4 ,the only organism that is demonstrably self-infectious is the gonococcus1 which may be present in the vagina before labor and may infect the puerperal woman2 but it is wiser1 safer1 and more nearly accords with the facts1 to regard all infections as alien borne1 as brought to the patient and introduced by the unclean hands or instruments of her medical attendants4 ,prevention4--,a conscientious and capable nurse or doctor will not go from an infected case to a confinement4 ,both will keep their bodies clean1 the teeth filled1 and pyorrhas scraped and treated4 ,the occurrence of pus anywhere on the body is sufficient reason for the doctor to give up his confinements for a time1 and the nurse to report off duty4 ,no raw1 and but few mucous surfaces should be touched by the fingers of the attendants1 where a sterile instrument can be used4 ,the nurse should never make vaginal examinations unless an emergency exists1 and then only when her instruction has been thorough and her experience great4 ,every examination is a possible source of danger1 no matter how carefully the hands and patient are prepared4 ,the nurse is not to change the pads without washing her hands1 and she must wash her hands always after changing the pads1 before dressing the navel of the child4 ,the navel or eyes of the child may be infected easily by the hands of nurse1 doctor1 or patient4 ,the breasts of the mother may be infected by the hands of nurse1 doctor or patient4 ,the vulva and vagina of the puerperal woman is highly susceptible to infection from the hands of nurse1 doctor or patient4 ,rule4--,all temperatures arising in the puerperium are due to infection1 unless satisfactorily explained by finding the source4 ,the possibility of a slightly elevated temperature from insignificant causes may be kept in mind1 but such temperatures are transient and yield quickly to appropriate treatment or to none at all4 ,puerperal infection is most apt to appear during the first week of the lying-in period1 and it generally develops about the third or fourth day post partum4 ,if the symptoms come on later than this1 there is always a hope that the infection has taken its origin in something else than the labor4 ,symptoms4--,in mild cases1 a rapid pulse1 headache1 and a temperature of #aja or #ajb ,f4 may be the only symptoms4 ,severe cases begin with a chill1 followed by a marked rise of temperature4 ,the temperature is always irregular and generally remittent4 ,the pulse rises to #abj or #acj beats a minute1 headache and prostration appear1 occasionally associated with vomiting4 ,the flow of lochia may be either increased or diminished and either offensive or free from odor4 ,foul-smelling lochia is a sign of putrefaction but not necessarily of sepsis4 ,at the same time there is some tenderness in the lower part of the abdomen1 usually most marked at the sides of the uterus4 ,the uterus is larger than it should be1 and not hard1 but doughy and sensitive to touch4 ,the involution is arrested1 except in cases of pure septicmia4 ,this is an important reason for the daily observation and recording of the regular descent of the organ4 ,the disease runs a variable and more or less prolonged course and the prognosis is always doubtful until the event4 ,signs of grave import are3 repeated chills1 insomnia1 pulse above #abj1 persistent vomiting and meteorism1 with dry1 brown tongue4 ,treatment4--,mild cases without chill when the uterus is large and the lochia sometimes offensive1 are usually saprmic4 ,free catharsis1 ergot in full doses1 and a half-sitting position to aid drainage will cause the symptoms to subside in two or three days4 ,in the severe type1 the treatment is mostly a case for careful nursing4 ,the more energetically the doctor acts1 the more liable he is to do harm4 ,the patient needs all her strength to fight the disease1 and should not be required to fight the consequences of injudicious interference4 ,there is still some discussion about the advisability of assuring oneself that the uterus contains no remnants of the labor4 ,some feel that this should be determined by curetting the uterus with finger or instrument and following the operation with an intrauterine douche4 ,if this is the view of the attending man1 the nurse must aid1 for the responsibility is his and not hers4 ,on the other hand1 the weight of authority at present seems inclined to the view that any remnant of the labor will drain out naturally or be expelled by ergotdriven contractions without the necessity of opening up new raw surfaces by interference and thus spreading the infection4 ,the main idea is to promote drainage in every way possible4 ,no curette1 no douche1 no uterine packing4 ,nevertheless1 the vulva may be cleansed and the vagina carefully retracted and by appropriate means a culture obtained from the uterus4 ,if this shows streptococci1 all local treatment is to be abandoned at once4 ,in general1 the food must be fluid1 and as nutritious as possible4 ,this means milk1 beef and mutton broths1 oyster stew1 etc4 ,the nourishment must be pushed artfully and ingeniously4 ,alcohol is not indicated4 ,the bowels are kept open4 ,normal saline1 drop method1 by rectum1 will promote diuresis1 skin action1 and supply the body with the much needed fluid4 ,subinvolution is controlled by ergot in full doses4 ,the room must be light and as many windows opened as the weather will permit4 ,frequent change of posture1 from side to side1 from dorsal to prone and especially to the half-sitting position1 will give the patient comfort and prevent decubitus 7bed sores74 ,the daily bath with an alcohol rub1 keeps the skin in good condition and eases the mind4 ,the child should be taken from the breast1 because the milk is poor in quality and quantity and it may be infectious4 ,besides1 the mother needs all her strength4 ,nature usually solves the problem by drying up the milk4 ,all pads soiled by the patient should be collected in paper bags or rolled in newspapers and burned4 ,sheets1 towels1 and pillow slips must be boiled in the house and not sent to the laundry4 ,they should be soaked for half a day in a #b per cent solution of lysol before being washed1 and exposed to the hot sun for a day or so afterward1 if possible4 ,no comforts should be used on the bed1 and the blankets must be left suspended in the room when it is fumigated at the conclusion of the case4 ,all dishes and utensils can be boiled4 ,plenty of air and sunshine are essential for the cure of the patient and to prevent the spread of the disease4 ,the nurse must use every precaution to avoid carrying the infection to herself or others4 ,rubber gloves should be worn while changing the dressing4 ,it is better to have the child cared for by another nurse4 ,the nurse must get her rest and some exercise out of doors every day4 ,it rejuvenates her and reacts to inspire the patient4 ,when she leaves the case the nurse should boil her linen and wash her hair with soapsuds and hot water1 and bathe frequently4 ,milk ,leg4--,this is an infection characterized by swelling of one1 or rarely1 both1 limbs1 from the foot to the groin4 ,the leg is white from the edema1 and as the condition is associated with fever and since the milk diminishes or disappears about the same time1 it was thought in former days that the milk went to the leg4 ,the cause of the swelling is a phlebitis of the external iliac or femoral vein which becomes thrombosed or so filled with clots that the return circulation is impeded4 ,symptoms4--,the attack is signalized by a rise of temperature to #ajb to #ajd ,f4 ,there is headache1 pain in the affected limb1 and general prostration4 ,it is a true sepsis4 ,the disease appears usually in the latter part of the second week of puerperium1 when the patient has begun to congratulate herself that all danger is over4 ,in many cases the doctor has yielded to importunity and let the patient get up before involution was sufficiently advanced and the patient will report that she got up too early4 ,the limb must be immobilized and kept warm4 ,the immobility should be maintained for at least ten days after the fever has subsided and the pain gone4 ,the convalescence may be protracted over weeks and months4 ,bed sores may complicate a long convalescence4 ,bathing with alcohol or alcohol and alum1 and the frequent change of the patient's position will usually prevent them4 ,rubber rings and sheeting should not be used if it can be avoided4 ,ointments containing zinc are of great value in the cure of this affection4 ,phlebitis1 in minor degree or in localized sections1 may occur in the veins of the leg and the site of the invasion will be outlined as red lines or as irregular nodules4 ,some fever may attend the condition4 ,rest of the affected member1 with ice bags for the pain1 constitute the treatment4 ,bed sores must be guarded against4 ,sudden death in the puerperium is a shocking disaster4 ,rapid death may follow the complications of labor accompanied by hmorrhage1 such as placenta prvia1 rupture of the uterus1 etc42 but death may be sudden1 without warning1 from pulmonary embolism1 acute myocarditis1 fatty degeneration of the heart1 or the entrance of air into the uterine veins4 ,this may happen several days after labor in a woman who is passing through a convalescence apparently normal in every respect4 ,such an event is probably due to a thrombus which may form in any of the veins of the body1 but more frequently in those of the pelvis and legs4 ,in the latter it may be recognized by hard lumps that form somewhere along the course of the veins in consequence of a phlebitis4 ,there is always the menace that some fragment of this mass1 which is merely a hard clot of blood1 may become detached and float off in the circulation to other parts of the body1 such as heart1 lungs1 or brain 7embolism71 and by interference with those structures1 produce paralysis or instant death4 ,when a thrombus is diagnosed1 the affected part must be kept as quiet as possible4 ,no massage is permissible4 ,tincture of iodine or #bj per cent ichthyol may be applied4 ,the woman should remain quiet for at least ten days after the apparent disappearance of the symptoms4 ,,chapter ,,xviii ,,the ,,care ,,of ,,the ,,child ,hitherto the mother and the complications and changes peculiar to her condition have been selectively considered1 to the neglect of the child2 but the labor being over1 and the nurse having assured herself that the uterus is hard1 that there is no hmorrhage1 and that the mother is resting1 now turns to the child lying in its blanket4 ,a hot water bag1 carefully tested1 should lie at its feet wrapped in toweling or napkins4 ,the eyes have already received the ,cred treatment1 #a per cent solution of silver nitrate or possibly a #ae per cent solution of argyrol for prevention of ophthalmia1 and a thorough cleansing comes next4 ,in a warm room1 away from drafts1 the nurse takes the child in her lap1 or on a table1 with a blanket underneath4 ,she first anoints the child all over1 either with benzoated lard1 liquid albolene1 sterile vaseline1 or olive oil4 ,this softens the vernix caseosa that covers the child and aids its removal4 ,the skin is wiped carefully with cotton or a soft cloth1 paying particular attention to the folds of the groin1 the arm pits1 and the genitals4 ,the nostrils are gently wiped out with applicators dipped in oil4 ,the child must be covered as much as possible during the operation and the work finished quickly4 ,the whole period should not exceed twenty minutes4 ,during the cleansing process the nurse should look closely for anomalies or anatomical imperfections1 like an imperforate anus or urethra1 supernumerary digits1 etc4 ,the ,bath4--,daily1 until the cord comes off1 the baby is sponged with oiled pledgets1 followed by a spray bath1 or a sponging with lukewarm water and castile soap4 ,the child must not be put into a full bath tub on account of danger of infecting the umbilicus4 ,the bath water in a tub or basin quickly becomes filled with bacteria from the surface of the child's body and may be conveyed quite easily to a raw wound4 ,illustration3 ,fig4 #aab4--,rubber bath tub4 ,all discharges must be wiped away1 and the buttocks cleansed with oil4 ,if the skin becomes irritated by urine or otherwise1 the child should be well covered with talcum powder1 especially in the folds of the groin and in the genital crease4 ,all infants are benefited by a little mild massage after the bath4 ,if other babies are handled1 a child with infected eyes1 or skin eruptions1 must be quarantined and cared for separately by a special nurse4 ,the color of the skin should be pink1 changing under manipulation to red4 ,if there is mucus in the mouth1 it may be wiped out with an applicator1 if in the throat1 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 obstruction4 ,after cleansing the skin1 the nurse sterilizes her hands and dresses the cord4 ,the gauze which was temporarily wrapped around the stump is removed1 the cord and adjacent skin washed with alcohol and dried4 ,the stump is powdered above and at the sides with a mixture of equal parts of boric acid and subnitrate of bismuth1 and then wrapped in gauze4 ,the band is put on1 the temperature taken1 and the baby dressed4 ,some physicians prefer to have the cord dressed in #ie per cent alcohol1 which is frequently renewed4 ,the normal separation of the cord takes place through a kind of dry gangrene1 which should be favored by dry rather than wet dressings4 ,the #ie per cent alcohol does not remain at #ie per cent after it is exposed to air1 hence it does not absorb moisture from the cord as absolute alcohol would4 ,however1 the attending man is responsible1 and his orders must be followed4 ,the ,umbilicus4--,the cord may be severed as soon as the child has cried lustily or the cessation of pulsation may be awaited1 in either case the child secures a little more blood1 which gives him a better start in life4 ,two tapes are tied about the cord1 one close to the skin margin of the child and the cord is cut between them4 ,a kind of mummification or dry gangrene normally develops and the stump falls off1 as a rule1 about the fifth day1 leaving a moist1 granulating area1 which forms the umbilicus4 ,a metal clamp may be used in place of a tape to compress the cord4 ,the advantage of the clamp is that on account of its greater width and rigidity it does not cut through the cord when applied4 ,furthermore1 it can be made and kept more nearly aseptic4 ,it does not soak up the juices from the cord and form a culture medium for germs4 ,it can be removed on second day4 ,the cord usually comes off a day or so sooner than when the tape is used4 ,illustration3 ,fig4 #aac4--,the ,pettit cord clamp4 ,the care of the cord is extremely important1 as many infections can be transmitted through it to the child4 ,at each dressing the cord is inspected1 and whether it is dry or moist1 offensive or inodorous1 should be noted4 ,these facts1 with the falling off of the cord1 are put down on the history sheet as they are observed4 ,the binder1 after each removal1 is not pinned1 but sewed on4 ,the sewing should begin below and go up in order to have the tightness low down4 ,eyes4--,after the first instillation of silver nitrate solution1 a reaction appears with redness1 swelling1 and discharge1 which passes off without treatment in two or three days4 ,during the bath1 care must be used not to get anything into the eyes nor anything from the eyes or nose upon the navel4 ,at each dressing the nurse should irrigate the edges of the lids gently with boric acid solution4 ,if the eyes become red1 swollen1 and have a purulent discharge after the second day1 the case is possibly ophthalmia and they must be watched with extreme vigilance4 ,a smear should be taken for the microscope and preparations made for energetic treatment4 ,the following summary may be of service in memorizing the routine of nursery procedure4 ,nursery ,rules #a4 ,keep temperature of nursery #fh to #gb ,f4 #b4 ,during bath1 keep temperature of nursery #ge to #hj ,f4 #c4 ,temperature of bath water #ih to #ii ,f4 #d4 ,never use a diaper that has not been laundered4 #e4 ,tie case number on child's arm before leaving delivery room4 #f4 ,watch cord for hmorrhage4 #g4 ,record temperature1 stools and urine4 #h4 ,give water freely between feedings4 #i4 ,put to breast twelve hours after birth1 and every three hours thereafter until the child begins to gain1 then one and possibly 787 two night feedings may be omitted4 #aj4 ,change binder daily4 #aa4 ,oil bath first1 then shower bath on subsequent days4 #ab4 ,dress cord with alcohol #ie per cent1 dry and apply bismuth subnitrate and boric acid powder 7equal parts7 into crevices beneath clamp or tape and under edges of the crust4 ,change dressing daily4 ,cord should fall off fifth day4 ,report failure to do so4 #ac4 ,clamp may be removed on second day4 ,routine for the ,child4-- #a4 ,temperature4 #b4 ,undress4 #c4 ,weight4 #d4 ,shower bath4 #e4 ,dress cord--record condition4 #f4 ,binder daily until discharged4 #g4 ,diaper and dress4 #h4 ,sponge eyes with boric solution4 #i4 ,cleanse nostrils with albolene4 #aj4 ,brush hair4 #aa4 ,drink of warm water4 #ab4 ,observe case number daily4 ,clothing4--7,see ,infant's ,outfit1 p4 #aja47 ,the clothing must be light1 loose1 warm1 and not irritating to the skin4 ,the outside garment should have wing sleeves which permit free motion of the hands1 but do not permit them to reach the eyes4 ,the band of plain outing flannel should always be worn for the first few weeks4 ,birds-eye linen makes the best diapers on account of its superior absorbent qualities4 ,the feet must be kept warm by stockings1 and artificial heat1 if necessary4 ,on hot days much of the clothing may be removed and the shirt1 band and diaper may be all that are needed4 ,the care of the shirts and bands is part of the daily duty of the nurse4 ,they must be washed daily1 either by the nurse herself or under her supervision1 as they are easily injured4 ,after washing1 in soft water1 if possible1 and with wool soap1 they must be dried on a stretcher4 ,diapers must be put directly into cold water4 ,fces may be brushed off with a whisk broom1 and the napkin rinsed1 boiled and again rinsed4 ,no diaper should be used a second time until this has been done4 ,no bluing may be used on the diapers and the soap must be mild1 otherwise chafing and intertrigo will follow4 ,the infant's toilet basket must contain3 #d soft bath towels4 #a pound of absorbent cotton4 #a dozen wash cloths of soft material4 #a small hair brush4 #a pair nail scissors4 ,talcum powder4 ,bath thermometer4 ,hot water bottle4 ,albolene4 ,castile soap4 #h oz4 boric acid solution4 #h oz4 benzoated lard4 ,paper bags for waste4 ,pitchers and basins4 ,illustration3 ,fig4 #aad4--;,a1 standard breast pump2 ,b1 standard nursing bottle2 ,c1 the breast tray2 ,d1 the ,wansbrough lead nipple shield2 ,e1 the ,brophy nipple for harelip and cleft palate4 ,weight4--,the weighing of the child should precede1 for convenience1 the first cleaning of the skin and the daily bath4 ,the child is either put on the scale naked or weighed in a blanket1 and the weight of the blanket1 ascertained before or after1 is subtracted4 ,the daily weight record is just as important as the temperature4 ,a scale that registers ounces and fractions thereof must be used1 and the child should be guarded from falling during the performance4 ,usually the child loses from eight ounces to a pound the first week1 but it should gain back to its birth weight1 by the end of the second week4 ,if the child does not gain1 it may be due to lack of milk from the breast1 and the weight may be taken before and after feeding to verify or refute the suspicion4 ,the mouth should be inspected each morning1 but not cleansed with the boric acid solution unless definitely indicated4 ,spots or any unusual appearance should be reported4 ,the ,genitals4--,the vulva of the female infant usually requires but little care besides cleanliness4 ,there is sometimes a whitish discharge which disappears spontaneously in a few days4 ,it is a drainage of vernix1 smegma and epithelium from the vagina and labia4 ,with a male1 the prepuce must be inspected when the child is about a week old4 ,if it is long and the orifice small1 circumcision may be suggested4 ,under any circumstances1 the foreskin must be retracted1 the adhesions broken up1 and the smegma removed4 ,this must be repeated daily until the adhesions do not recur4 ,the maneuver should be done the first few times by the physician1 for fear of a paraphimosis4 ,sleep in the newborn is normally quite deep and almost continuous1 probably twenty-two hours a day1 for the first week4 ,the rather fast respiration of the child1 even when sleeping1 is no cause for alarm4 ,a healthy infant breathes about twenty-five times a minute4 ,the child should not be rocked1 carried about1 exhibited1 or handled more than necessary4 ,it should not sleep with the mother1 lest it become too hot or too cold1 be overwhelmed by bedding1 or overlaid by the mother4 ,bowels4--,the first stools are black and tar-like1--this is meconium4 ,it disappears by the end of the first week4 ,the presence or absence and the character of an evacuation1 as well as the number in twenty-four hours1 must be daily recorded4 ,for a breast-fed child1 there should be three or four a day1 for the first ten days and the number should gradually diminish until a routine of two a day is obtained4 ,the diaper of bird's-eye linen should be large and thick2 two may be used if required4 ,they should be carefully washed after soiling4 ,bluing must not be used1 because where this substance comes in contact with the skin1 irritation follows4 ,weaning should be brought about by the gradual substitution of other foods1 somewhere between the sixth and twelfth months4 ,urination should be copious4 ,the child is always wet1 and frequent changes are necessary to keep the skin from getting raw and sore4 ,both bowels and bladder should be emptied within the first twenty-four hours4 ,failure to do so should be reported1 as an imperforate anus or urethra may exist4 ,frequently a piece of ice whittled out like a lead pencil and passed into the rectum will stimulate urination4 ,catheterization is practically never necessary4 ,the child may go three days without injury1 but the condition of the bladder above the pubes must be attentively watched and its degree of fullness appreciated by percussion4 ,nursing4--,the child should be put to the breast twelve hours after birth and every three hours thereafter--no more and no less without definite reasons4 ,if the child is strong and vigorous1 only one feeding may be given at night1 and even this may be omitted in some cases where the child gets an abundance of food4 ,six or seven feedings a day are enough4 ,the child should stay at the breast from fifteen to twenty minutes1 depending on its activity and the rapidity of the milk flow1 and then be removed4 ,it must not be permitted to sleep at the breast4 ,illustration3 ,fig4 #aae4--,proper position of mother while nursing child4 7,witkowski47 ,care must be used that the child gets the nipple over the tongue and not under it4 ,many infants have to be taught to nurse4 ,this may be due to a lack of strong animal instinct in many cases4 ,there may be an abundance of milk and a good nipple1 but the child will not learn to nurse without a vast expenditure of time1 patience1 and energy on the part of the nurse4 ,squeezing a little milk into the mouth or filling a nipple shield with milk will sometimes aid in educating the infant1 or even starting the supply with a pump1 as many nurses do1 is advantageous4 ,certain drugs1 like castor oil and turpentine1 taken by the mother1 may affect the taste of the milk1 and be reason enough for the refusal of the child to take hold4 ,other drugs like mercury1 arsenic1 potassium iodide1 and alcohol may go over in the milk to the nursing child4 ,if the child is weak or premature1 the milk must be pumped from the breast and fed to it until strength comes4 ,the difficulty about this is the bad habit acquired1 but there is no way to avoid it4 ,a child should get at each feeding half an ounce of milk to each pound of weight4 ,the capacity of the stomach at various months is given by ,hirst as1 first week1 oz42 second week1 #b oz42 third and fourth week1 #c oz42 third month1 #e oz42 fifth month1 #i oz42 ninth month1 #ab oz4 ,holt says that the capacity at birth should be one ounce1 and increase at the rate of an ounce a month up to the sixth month4 ,as hunger stimulates the gastric and salivary glands1 so the sight of the child arouses some emotional center in the mother1 which starts the milk1 and the mouth of the child provides an additional stimulus of great power4 ,about fourteen ounces is secreted by the seventh day1 and after the second month the daily average rises to three or four pints4 ,milk secretion is favored by drugs and foods that raise the blood pressure and diminished by substances that lower the blood pressure4 ,there may be too little milk in the breasts1 and if so1 the child will lose weight daily2 also the child will waken before nursing time1 fret1 refuse water1 but greedily seize the nipple if it is presented4 ,it will continue to nurse long after its time is up and cling and cry when removed4 ,the breast itself may seem flabby and loose1 and no milk1 or very little1 can be pressed from the nipple4 ,normally1 the breasts feel full and tense1 both to patient and nurse1 just before feeding time4 ,the real test1 however1 is in taking the weight of the child before and after feeding4 ,where the milk is insufficient1 the scales will not vary1 and after a few repetitions the nurse can be certain4 ,an infant should be handled as little as possible after feeding lest the milk be vomited4 ,illustration3 ,fig4 #aaf4--,proper method of taking rectal temperature4 ,temperature of the newborn child varies from #ih to #ii ,f4 ,it should be taken morning and evening1 or oftener1 if complications are suspected4 ,the temperature often goes up on the third or fourth day1 and may stay up for several days4 ,this phenomenon is called by some a starvation or inanition fever4 ,the temperature may go to #ajf ,f4 and the rise is generally associated with a hot dry skin1 dry lips1 weak pulse1 restlessness1 and great prostration4 ,the fontanelle may be sunken and the cry sinks to a fretful1 feeble whine4 ,it is important that the fever should be recognized and treated1 since the condition may terminate fatally4 ,the etiology is obscure4 ,the fever should not be confounded with pyogenic infections1 for these rarely begin before the fifth or sixth day4 ,the treatment is simple4 ,give water regularly every two hours by mouth1 and rectal flushings of normal saline twice daily4 ,the symptoms rapidly subside if the child is properly nourished4 ,hence the breasts should be inspected and the child weighed before and after feeding4 ,usually the milk is poor and scanty4 ,if the temperature does not soon fall the child should be put to another breast or artificial feedings should be instituted4 ,,chapter ,,xix ,,the ,,care ,,of ,,the ,,child 7,cont'd7 ,heart4--,the heart tones while in the uterus may vary between #ach and #aej per minute1 but when higher than #afj or lower than #abj1 danger is near4 ,after delivery1 the heart runs from #acj to #adj1 and during the first year gradually drops to #aae1 approximately4 ,asphyxia neonatorum is a condition1 wherein1 for some reason1 the child fails to breathe after delivery4 ,out of every one hundred babies born1 about six will die at birth or within the first ten days1 and a large proportion of them from asphyxia in some form4 ,asphyxia is found in two degrees3 asphyxia livida 7blue7 and asphyxia pallida 7white74 ,in the first1 the child is deeply cyanosed4 ,this may be due to patency of the foramen ovale1 and yet it is a question whether this cyanosis is not really a normal process4 ,the child does not undertake its first respiration because it needs oxygen1 but because an excess of carbon dioxide 7,,co#b7 in the blood acts as a stimulant to the respiratory center1 which is thus set to work1 with the result that oxygen is taken in4 ,the blue asphyxias1 therefore1 may be only the first step in the physiological process of respiration4 ,in these cases1 the pulse is strong and full1 and the muscular tone is preserved1 as well as the sensibility of the skin4 ,in the second degree1 the condition is quite different4 ,the face is pale though the lips may be blue4 ,the heart is irregular and many times can not be felt4 ,the cord is soft and flaccid1 with its vessels nearly empty4 ,the reflexes are abolished1 the skin and extremities cold4 ,a few convulsive efforts at breathing may occur1 but they soon cease4 ,treatment is directed first1 to opening up the respiratory passage4 ,the child is held up by the feet so the mucus1 blood1 and fluids may escape from the mouth4 ,compression of the chest wall will aid4 ,the tracheal catheter is passed into the trachea and the mucus sucked out4 ,next1 the skin reflexes are stimulated by slapping the back1 or buttocks1 and by blowing upon the face4 ,illustration3 ,fig4 #aag4--,method of passing the tracheal catheter4 7,hammerschlag47 ,the child at this time may be dipped in a tub of very warm water1 7#aab ,f47 and the chest and face sprinkled with cold water4 ,meanwhile1 ,laborde's method of traction on the tongue may be tried4 ,the tongue is seized with tongue forceps 7handkerchief1 napkin1 or piece of gauze will do7 and rhythmically drawn out and released about ten times per minute4 ,further1 the ,byrd method of artificial respiration must be employed4 ,illustration3 ,fig4 #aah4--;,byrd's method of artificial respiration4 ,extension and inspiration4 7,edgar47 ,illustration3 ,fig4 #aai4--;,byrd's method of artificial respiration4 ,beginning flexion and expiration4 7,edgar47 ,the back of the child is held in the right hand1 so that the thumb and forefinger grasp the neck loosely1 the other hand holds the buttocks from behind and the body is slowly but firmly flexed between them until the thorax is compressed1 then the grip is relaxed and the body widely extended to allow the air to rush into the lungs4 ,this maneuver should be repeated about twelve times per minute4 ,when the heart ceases to beat1 the child is dead and respiration can not be established4 ,illustration3 ,fig4 #abj4--;,byrd's method of artificial respiration4 ,flexion and compression4 ,note position of child which aids the escape of fluids from the mouth and nose4 7,edgar47 ,the same treatment is employed for the apnic child born in ,csarean section and the oligopnic child born under 8,twilight ,sleep40 ,the method called 8,schultze ,swinging0 is not to be recommended generally1 on account of the chilling which is so necessarily associated with the exposure4 ,the nurse should learn to practice all these methods of resuscitation4 ,after the child breathes it must be watched carefully for at least forty-eight hours1 lest the symptoms recur1 and the child die4 ,asphyxia ,neonatorum-- 7a7 ,livida--body congested--blue4 7b7 ,pallida--body limp and pale4 ,remember possibility of patent foramen ovale4 ,etiology4-- ,too long compression of cord4 ,diminished irritability of medulla4 ,compression of brain during extraction4 ,shock during version4 ,aspiration of mucus4 ,treatment4-- ,hold child by heels with head pulled back to straighten the trachea1 and wipe out mouth and pharynx gently with cotton wound about the finger4 ,stimulate skin reflexes by slapping and blowing4 ,tracheal catheter1 artificial respiration 7,byrd7 #h to #aj times per minute4 ,hot and cold bath alternately--rub the skin and knead the muscles4 ,laborde's method of traction on tongue #aj to #ab times per minute4 ,continue efforts so long as heart beats4 ,convulsions occur not infrequently during the first few weeks4 ,they may develop as a result of injuries to the head during labor1 or as a symptom of toxmia4 ,they may arise from constipation1 from intestinal indigestion with curds1 from fever or from hmophila4 ,meningitis and other infections are associated with this symptom1 and occasionally atelectasis4 ,they may also be the manifestation of a spasmophilic diathesis4 ,the attack may begin with such premonitory phenomena as restlessness1 muscular twitching1 and staring of the eyes1 but more frequently the onset is without warning4 ,the facial muscles are contracted1 the neck thrown back1 the hands clenched and the extremities spasmodically cramped and tightened4 ,there may be frothing of the mouth and consciousness is lost4 ,respiration is feeble1 shallow and irregular4 ,the face is discolored and strange rattling noises come from the larynx4 ,the bowels and bladder may move involuntarily4 ,the attack lasts from a few minutes to half an hour4 ,convulsions are not serious in all cases4 ,the responsibility for the management of this complication usually falls upon the nurse4 ,she calls the doctor1 to be sure1 but the attacks in many cases have ceased and the child may either be dead or out of danger of a recurrence before his arrival4 ,the hot bath is a universal remedy and quite as efficient as anything4 ,the temperature should be taken and the bowels washed out4 ,if the fontanelles are tense when the doctor arrives1 a spinal puncture may relieve the tension4 ,a specimen of the blood is drawn through a needle and sent to the laboratory for examination4 ,the cause must be found1 if possible1 and removed4 ,a change of food may be all that is required4 ,cod-liver oil may be added to the diet in dram doses1 three times a day1 and milk curds1 suspended in arrow-root water4 ,for the acute condition1 chloral hydrate is best4 ,it is given by rectum1 one or two grains in an ounce of water1 and may be repeated in four hours4 ,atelectasis is the name given to a failure of the lungs wholly to expand during the efforts at respiration4 ,the child may live for weeks with this affection1 but usually it expires within a few days4 ,in this condition1 the child has a constant tendency to get blue1 the color deepens1 and death may occur in spite of every aid4 ,the treatment may be permanently efficacious in some cases1 but in most1 the revival is only temporary4 ,again1 the child may live1 but in a weakly1 declining state for days1 until death comes4 ,aside from the physical signs of dullness elicited by percussion over the lungs1 the most conspicuous symptoms are the cyanosis and the intermittent but persistent whining cry4 ,illustration3 ,fig4 #aba4--,method of giving gavage4 7,grulee47 ,treatment is by daily or hourly spanking1 and by alternating hot and cold baths1 by sprinkling with cold water or by massage to stimulate the skin reflexes4 ,the treatment may have to be repeated every twenty or thirty minutes1 and the earlier it is instituted1 the more persistently carried out1 the more chance of success4 ,exercise is just as important to the infant as to the adult4 ,the kicking of the legs1 moving of the arms and lusty cry are all means of stimulating the circulation1 the muscular development1 and the expansion of the lungs4 ,the position should be changed occasionally in the crib from back to side and from side to back4 ,also the child's legs and back should be rubbed and massaged until the skin is red every time the bath is given4 ,flushings4--,the child is laid across the lap1 or on a table4 ,a rubber sheet is so arranged that the discharge will drain away4 ,a soft rubber catheter1 ,no4 #ah-bj ,french scale1 is attached to a small funnel4 ,the apparatus is boiled and filled with normal saline1 or sterile water1 at a temperature of #he ,f4 to #ie ,f4 ,half a pint to a pint may be required4 ,the catheter is oiled and passed into the rectum just beyond the sphincter4 ,it must not go farther4 ,the funnel is then raised and the fluid flows into the bowel4 ,this flushing must not be confused with the administration of an enema for constipation1 for which1 however1 it is often an excellent substitute4 ,gavage is forced feeding by means of a tube4 ,a soft rubber catheter or tube1 about ,no4 #g1 ,french scale1 is lubricated with albolene1 vaseline or sweet oil4 ,the upper end is connected with a small tube or glass funnel holding two or three ounces4 ,the child is laid upon its back in the arms of mother or nurse1 the baby's arms are held and the head steadied4 ,in case of diphtheria or scarlet fever1 the tube may be passed through the nose and down the pharynx and into the sophagus five or six inches1 or even into the stomach4 ,it is more convenient and easier when possible to pass it through the mouth directly into the stomach4 ,the food is then poured into the funnel1 which1 by elevation1 empties itself into the stomach4 ,if regurgitated1 more food must be given4 ,when withdrawn1 the tube should be pinched to prevent leakage into the trachea4 ,illustration3 ,fig4 #abb4--;,apparatus for gavage or lavage4 7,tuley47 ,the great danger in these cases is the ease of overfeeding4 ,lavage or washing of the stomach may be performed in the same way with the above apparatus1 when necessary4 ,as soon as the stomach is filled1 the tube is lowered and the fluid siphoned out4 ,,chapter ,,xx ,,the ,,care ,,of ,,the ,,child 7,cont'd7 ,tongue-tie is not met with so frequently as in the old days4 ,if the child can suck and nurses energetically1 this complication can be excluded4 ,it may1 however1 occur4 ,in such a case1 the frnum is unusually broad and seems to extend clear to the tip of the tongue1 which apparently is bound down to the gum and to the floor of the mouth4 ,the thin membrane may be snipped with the scissors close to the tongue and then torn back with the finger4 ,harelip and cleft palate interfere with nursing and require continual attention to keep mucus out of the throat4 ,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 nourishment4 ,these babies must be fed systematically by gavage1 if necessary1 until the deformity can be repaired4 ,hernia at the navel is a common complication of infancy4 ,it is not due to crying1 to improper tying of the cord1 nor to neglect by the nurse1 as frequently charged4 ,it is a congenital fault1 wherein the cord opening does not close1 and in time1 crying and straining will drive the intestines out of the aperture like a pouch4 ,the defect is revealed by the bulging outward of the navel when the child cries4 ,ordinarily the breach will close of its own accord4 ,illustration3 ,fig4 #abc4--;,cleft palate nipple4 7,brophy47 ,illustration3 ,fig4 #abd4--,the device for feeding the child with cleft palate at the breast4 7,brophy47 ,treatment consists in folding up the skin of the abdomen so that the groove will be over the umbilicus and include it4 ,then adhesive tape is put on to hold it4 ,the surfaces of skin thus coming in contact should be dusted with rice powder or stearate of zinc4 ,another method of treatment is to place a wooden button form1 round side down1 on cotton1 over the opening1 and bind it on with a zinc adhesive plaster4 ,the dressing should be changed at least once a week4 ,inguinal hernia usually heals spontaneously also1 but a truss may be required4 ,illustration3 ,fig4 #abe4--;,device for assisting the cleft palate child to nurse4 7,brophy47 ,hmorrhage of the newborn is either accidental or spontaneous4 ,accidental hmorrhage may arise from an imperfectly tied cord1 or it may be an effusion1 through compression or rupture1 into any of the internal organs1 such as the brain1 lungs1 or abdominal viscera4 ,these latter conditions rarely give rise to symptoms1 and are seldom recognized during life4 ,there is no treatment4 ,the intracranial hmorrhages are open to diagnosis through the presence of pressure symptoms1 but these1 too1 are impervious to treatment unless a vessel can be tied1 like the middle meningeal artery4 ,spontaneous hmorrhages may develop during the first few days of life from sepsis1 syphilis1 ,buhl's disease1 hmophilia1 and true melna neonatorum4 ,the fragile condition of the blood vessels1 the great changes in the blood and circulation after birth1 as well as constitutional dyscrasias1 are etiological factors of importance4 ,all the causes are not as yet known4 ,illustration3 ,fig4 #abf4--,method of strapping an umbilical hernia4 ,the blood may come from the umbilicus1 the mucous membranes of the eyes1 nose1 mouth1 stomach and intestines4 ,it may be effused into the tissues beneath the skin1 or into any organ of the body4 ,marked nosebleed is generally syphilitic in origin4 ,as a rule hmorrhages in the newborn are most common in males1 and strongly hereditary4 ,the tendency to bleed lasts only a few weeks1 and if recovery takes place1 it is permanent4 ,in some cases1 however1 where hmorrhage has developed in the brain1 clots may form in important centers1 and the child be permanently paralyzed in speech1 sight1 hearing1 or intelligence4 ,symptoms of hmorrhage begin during the first week and almost never after the twelfth day4 ,the appearance of blood is the earliest and the most definite sign4 ,the bleeding may come first from the umbilicus1 or from the stomach1 or from the intestines 7melna neonatorum74 ,the amount lost is small1 but the oozing is continuous4 ,the temperature may be high or subnormal1 and may or may not be due to the hmorrhage4 ,the skin is pale1 the pulse feeble1 prostration marked1 and weight is lost rapidly4 ,convulsions are not infrequent4 ,the diagnosis of the condition is simple4 ,it is only necessary to be certain that the blood is really effused1 and not a temporary or accidental event such as the regurgitation of swallowed blood4 ,black tarry stools will show blood if placed in water4 ,the prognosis is not good4 ,about two-thirds of these babies die4 ,the treatment is to stop the hmorrhage by ligature1 suture1 or compression if possible and to alter the character of the blood by adding to its fibrin content4 ,this is brought about1 if at all1 by the administration of coagulose1 coagulen ciba1 or by transfusion from an adult--preferably the father4 ,paralysis of the face 7,bell's paralysis7 may follow the use of forceps4 ,the prognosis is favorable4 ,paralysis of the nerve in the neck 7musculospiral7 is sometimes known as ,erb's paralysis4 ,it happens in consequence of difficult breech deliveries or of vertex labors when much force is required to extract the shoulders4 ,the deltoid1 biceps1 and other muscles are affected so that the arm can not be raised4 ,the failure to raise one arm will be the symptom that will attract the attention of the nurse4 ,some cases recover in a month or so1 either spontaneously or by the aid of electricity4 ,if not1 the injured nerve must be cut down upon and its continuity restored4 ,ophthalmia neonatorum is an infection of the eyes of the newborn by the gonococcus4 ,the infection occurs as the child passes through the vagina or vulva1 or when an unclean finger is put into the eye4 ,the reaction is violent4 ,the discharge at first is thin1 then thick1 pus4 ,if untreated1 the eyesight may be lost by ulceration4 ,in the asylums twenty-five per cent of the inmates are blind from this infection2 and as late as #ahif1 seven per cent of the blindness in the state of ,new ,york could be traced to this avoidable disease4 ,the preventive treatment consists in the frequent douching of the vagina before labor with potassium permanganate solution #a3ejjj1 or chinosol #a3ajjj4 ,after labor1 a drop or so1 of #a per cent solution of nitrate of silver is dropped into each eye and not neutralized4 ,after the infection has occurred1 iced compresses are applied to the eye1 night and day1 and a solution of argyrol #ae to #bj per cent instilled into the outer corner1 twice a day4 ,in female infants with ophthalmia1 the vagina must be watched for discharge which does not fail to appear in most cases4 ,argyrol 7#bj per cent7 should be injected with a medicine dropper and left to drain out spontaneously4 ,all dressings used about the child should be destroyed1 and the nurse should use the most scrupulous cleanliness and care of her own person4 ,separation of the cord may be delayed in puny babies and in cases where the cord is large and thick4 ,some of these cases are doubtless due to a patency or fistulous condition of the urachus4 ,usually the separation may be hastened by touching the constrictured part with silver nitrate4 ,or1 if the cord does not separate before the second week1 it may be desirable to cut off the hanging fragment and touch the base with silver nitrate or dust with alum powder4 ,granulations may protrude like a mulberry from the stump of the navel 78proud flesh074 ,these are touched with nitrate of silver stick4 ,menstruation may appear occasionally from the vulva of the newborn4 ,it is really a hmorrhage1 a menstrual flow1 which is associated with uterine activity1 but rarely significant4 ,there is no treatment4 ,it disappears spontaneously4 ,the breasts of the newborn may fill with milk and become indurated and tender4 ,nothing should be done to them4 ,let them alone and the swelling will subside in a few days and the milk 78witches' milk07 disappear4 ,icterus may develop from the third to the sixth day4 ,the child becomes yellow and stays yellow for a week1 when the color gradually leaves4 ,it is thought to be due to the liberation of some embryonic residue in the ftus1 but nothing is known certainly4 ,for the simple form no treatment is required4 ,recovery is prompt and uneventful4 ,however1 jaundice is associated with other conditions that prove fatal1 hence every icterus should be watched carefully until it disappears4 ,child's ,nails4--,the nails are frequently rough and ragged at ends and sides4 ,they should be smoothly trimmed lest they become infected at the junction with the skin and give rise to paronychia4 ,if infection does occur1 the skin and flesh may be pushed back with a sterile applicator1 and the point touched with peroxide of hydrogen4 ,a syphilitic history may be traced in some of the babies4 ,thrush is a form of contagious soreness1 characterized by white flakes or patches on the mucous membrane of mouth or anus which look like milk1 but can not be wiped off4 ,it is due to a vegetable fungus and occurs most frequently among anmic or poorly nourished babies or those suffering from harelip4 ,it is associated with symptoms of indigestion4 ,it may always be prevented by keeping the mouth and nipples clean1 as directed on another page1 and by keeping the bottles and rubber nipples in a solution of boric acid when not in use4 ,when the disease appears1 the mouth must be swabbed three or four times a day with an applicator soaked in saturated solution of boric acid4 ,this is curative4 ,aphth or stomatitis is the name given to whitish vesicles1 followed by superficial ulcers that occur upon the inside of mouth and lips of the infant4 ,it is rare in the newborn child4 ,boric acid solution is cleansing1 and stick alum1 frequently applied1 will effect a cure4 ,wheals1 urticaria or 8stomach spots0 appear as generally distributed small spots about the size of a split pea1 with a white center and a red periphery4 ,they appear about the third day and last twenty-four hours4 ,they may be mistaken for insect bites and they may1 or may not1 be accompanied by temperature1 which is probably only a coincidence4 ,the wheals disappear spontaneously without treatment4 ,bednar's disease is characterized by the appearance of two ulcers on the hard palate1 one on either side and just above the spot where the last tooth will erupt4 ,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 mouth4 ,it is very resistant to treatment4 ,the child must be put in good condition by attention to the nourishment and the spots touched with tincture of iodine on an applicator4 ,the exudative diathesis is indicated superficially by a definitely bounded red patch on either cheek1 which is not relieved1 or only temporarily1 by the common ointments and powders4 ,the mother says the 8face is chapped10 or that the baby has a 8milk eczema40 ,otherwise the skin is pale4 ,these children are frequently fat1 but the tissue is flabby4 ,the urine is sometimes ammoniacal4 ,there is no marked disturbance of temperature4 ,fretfulness and constipation are the principal symptoms4 ,the condition is due to too much fat in the food4 ,a skimmed-milk diet is best for a time4 ,the fat can be added gradually until the limit of tolerance is found4 ,if chalky masses appear in the stools1 the fat must be reduced again4 ,occasionally the child must be taken off the milk entirely1 and a soup or gruel diet substituted4 ,for local application1 the following formula is sometimes beneficial3 7,grulee47 ,naphthalene i ,starch iv ,zinc stearate iv ,m4 ,sig4 ,apply frequently4 ,the 8cradle cap0 is a frequent sign of the exudative diathesis in its milder stages4 ,the term is applied to a yellowish-gray patch over the large fontanelle4 ,the mother calls it 8dirt10 which she finds hard to remove and it always recurs4 ,the mass is composed of dry scales1 which gradually change into an eczema4 ,vaseline or sweet oil left on over night makes the removal of the scales quite easy the next day4 ,if a raw surface is left1 zinc ointment should be applied4 ,the diet must be changed as previously described4 ,erythema1 especially of the diaper region1 is sometimes a manifestation of congenital syphilis4 ,it is usually limited to the inner side of the thighs1 the perineum1 scrotum or vulva1 and buttocks4 ,it must be associated with other and more characteristic signs1 however1 such as snuffles1 cachexia1 etc41 before it becomes diagnostic of syphilis4 ,most erythemas of this area are due to irritation from moist or soiled diapers1 but other factors may be important4 ,bluing in the diaper1 gastrointestinal troubles1 and circulatory disturbances are contributing causes4 ,the local treatment is the same as for intertrigo4 ,if the child is syphilitic1 systemic measures must be instituted4 ,intertrigo1 or chafing1 is a form of eczema due to moisture1 bluing in the diapers or uncleanliness4 ,the child should be cleaned with oil instead of water1 and well powdered with stearate of zinc or zinc ointment may be used4 ,talcum powder which contains boric acid is contraindicated4 ,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 disease4 ,from three to fourteen days after birth1 the blebs develop on the abdomen1 neck or thighs1 and show a tendency to spread to other parts of the body4 ,the vesicles vary in size from one-fourth of an inch to two inches in diameter1 and contain a serous1 purulent1 or bloody fluid4 ,other signs of general sepsis may appear4 ,in diagnosis care must be used to exclude syphilis1 which also exhibits blebs1 but usually on the soles of the feet or the palms of the hands4 ,besides1 a nonsyphilitic child is generally better nourished4 ,the prognosis is unfavorable if the child is weakly1 if the blebs spread rapidly over a large area1 or if the infection attacks the umbilicus4 ,treatment4--,a rigid quarantine must be enforced4 ,in the hospital no new cases can be admitted4 ,the alimentation must be increased1 the blisters evacuated1 and the surfaces cleaned and covered with a #be per cent ointment of ichthyol1 or an ointment of ammoniated mercury #b per cent4 ,strophulus1 red gum1 or miliaria rubra are names applied to an inflammation of the sweat glands when their secretion is retained4 ,it is a 8sweat rash0 characterized by an eruption of scattered red papules or small vesicles which commonly appear on the cheeks or neck of young infants1 or where skin surfaces come in contact4 ,it is due to excessive clothing or heat4 ,it is really a prickly heat4 ,the treatment consists in the removal of the cause1 and a generous use of stearate of zinc powder or rice powder4 ,,chapter ,,xxi ,,the ,,care ,,of ,,the ,,child 7,cont'd7 ,constipation in the newborn may come from many causes4 ,the amount of food may be so inadequate that no residue is left1 and the bowels move only once in forty-eight hours4 ,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 produce atonic constipation4 ,in the artificially fed infant too much fat in the food is a very common cause of the trouble4 ,treatment4--,correct the amount of fat in the milk4 ,if the child is breast-fed1 the mother's diet should be non-nitrogenous and vegetables should preponderate4 ,drugs should not be given until all else has been tried4 ,gluten suppositories will furnish a mild irritation to the rectum4 ,orange juice and prune juice may be given1 or ,mellin's food or oatmeal water added to the milk4 ,milk of magnesia to #a teaspoonful1 or ,husband's magnesia1 in same dosage1 may be given daily4 ,senna is also efficacious4 ,diarrha is generally significant of an error in diet which is usually a plain indigestion1 though there may be too much sugar in the food4 ,the stools are more frequent and always softer than usual1 possibly fluid4 ,diarrha means increased intestinal action due to irritation from something4 ,it may be due to indigestion1 to the presence of hard curds1 to acidosis1 or it may accompany almost any disease of infancy as a symptom merely4 ,the odor is due to gases formed in the canal by bacterial action4 ,there is but little odor in fermentation1 but much in putrefaction4 ,mucus appears either as balls or strings4 ,the balls come from the small intestine1 strings from colon4 ,blood indicates ulceration at some point in the bowel1 or an erosion just above the sphincter4 ,illustration3 ,fig4 #abg4--,proper position for introduction of a suppository4 7,grulee47 ,fatty curds may be either white1 granular1 sand-like masses1 or small1 soft1 and yellow4 ,the protein curd is large and smooth1 or white and bean-like4 ,both occur only when the artificially fed infant is given raw milk 7,brenneman74 ,if the milk is boiled for two minutes these masses will not form4 ,the cause must be determined4 ,the frequent stools1 however1 are exhausting1 and may have to be checked with opiates or mechanical astringents4 ,when due to indigestion1 all food by mouth may be stopped for two or three days and only barley water administered4 ,in a breast-fed child1 diarrha is sometimes checked by diluting the milk with a little barley water1 given just before nursing4 ,with these infants1 not much change in the sugar content can be made by alterations of the maternal diet1 but where artificial food is used1 the amount of sugar is easily reduced to a satisfactory degree4 ,colic is a cramp-like pain of the bowels4 ,previous to the attack the child is restless1 expels some gas1 and has the 8colic smile10 which leads the mother to believe the child is quite well4 ,when the attack comes on1 the thighs are flexed on the abdomen1 and the legs on the thighs4 ,the child has a sharp cry1 that is nearly continuous1 but in some way related to the nursing period1 for the attack comes on a few minutes1 and sometimes an hour1 after taking the breast4 ,the belly is rigid1 the arms wave aimlessly4 ,diarrha may be present1 and the movements are accompanied by much flatus4 ,distention is nearly always present4 ,when the belly is tapped it gives a drum-like note and the child belches gas1 sometimes accompanied by milk1 which seems to relieve4 ,treatment4--,colonic flushings to relieve the bowel of irritating curds4 ,the child may be laid face down with a bag of hot water under the belly4 ,mixture of asaftida gtts4 xx to xl1 or whiskey and hot water should be given for the attack1 followed later by a full dose of castor oil4 ,the diet should be rigorously investigated4 ,vomiting may or may not be serious4 ,the child may nurse too rapidly or too much1 and the over-distended stomach simply empties itself4 ,many infants 8spit up0 their excess of milk1 and thus relieve themselves4 ,this is a simple regurgitation1 usually of unchanged milk1 though it may be acid from admixture with the gastric juice4 ,vomiting1 in a breast-fed child1 may come during an attack of colic when the eructations of gas appear4 ,it may be a symptom of gastrointestinal intoxication1 of too much fat in the food1 too short intervals between feedings1 or too much sugar in the food4 ,projectional vomiting awakens suspicion of a pyloric stenosis or meningitis1 and must be reported to the physician at once4 ,vomiting which occurs within twenty minutes after feedings is not serious ordinarily1 even though gas and large curds are expelled1 but all vomiting later than this1 is significant of a pathology4 ,treatment4--,regulation of the hours of feeding is most important1 and next1 the character of the food4 ,if the child vomits an hour or so after nursing1 it may be that the milk is too rich 7fat74 ,try a longer interval1 or give an ounce or so of cereal water before putting the child to the breast4 ,prematurity exposes the child to three distinct dangers1 which arise1 respectively1 from atmosphere1 food1 and infection4 ,very few children born before the seventh month survive4 ,a child born at the eighth month1 or with a weight of three pounds1 or more1 can be saved almost always4 ,the premature child up to the time of birth1 has been protected very carefully against temperature variations by the liquor amnii1 and when suddenly precipitated into a new environment1 which its vitality barely tolerates1 the consequences are serious4 ,these infants have a poor heat production1 and the natural warmth of the body must be preserved4 ,this is best done by incubators1 which supply air and moisture in stable and appropriate amounts4 ,chilling of the child for even a few moments may be fatal4 ,a room may be fitted up to produce the necessary conditions of light1 air1 heat and moisture4 ,the child1 wrapped in sheets of cotton1 except the face1 is then covered with a blanket1 and surrounded by a temperature varying from #hh to #ie ,f41 which is gradually lowered to #hj ,f4 as the child gains strength4 ,an occasional whiff of oxygen1 as prescribed for an atelectatic child1 is sometimes advantageous4 ,bathing4--,premature infants must not be bathed1 but the skin should be cleansed with cotton and warm sweet oil or albolene4 ,all unnecessary handling is to be avoided4 ,food4--,breast milk is the secret of success with these cases4 ,since most of the infants are too weak to take the nipple1 the breasts must be pumped1 and the child fed with spoon or pipette4 ,the interval between the feedings depends a little on the amount taken1 but it should not be less than one and one-half hours1 nor more than two hours4 ,as the child gains1 the interval may be lengthened to three hours4 ,lack of sufficient nourishment is shown by cyanosis and loss of weight1 and overfeeding1 by vomiting and diarrha4 ,the child must be fed by hand until strong enough to nurse the breast4 ,in certain cases of prematurity1 as well as in diseases like pneumonia1 scarlet fever1 and diphtheria1 the child must be fed by gavage4 ,nutritive inunctions of benzoated lard or cod-liver oil are also valuable1 not only for the passive exercise supplied1 but for the absorption of a certain amount of the unguent4 ,marasmus means wasting1 but the term is applied to infants that steadily lose weight4 ,the bodies of infants are so largely composed of fluid1 that loss of weight occurs quite easily and rapidly4 ,loss of weight may be sudden or gradual4 ,it comes on rapidly after acute diarrha1 either with or without vomiting1 or it may follow persistent vomiting without diarrha4 ,malnutrition from defective feeding is the most common cause of wasting in infants4 ,this may be from lack of sufficient food or lack of proper ingredients1 as well as irregularity of intervals1 and disease4 ,rickets1 congenital stenosis of the pylorus1 congenital syphilis1 and tuberculosis are all possible factors in the etiology4 ,in any case1 no treatment can be instituted until these conditions have been confirmed or excluded4 ,pyloric stenosis 7the account follows ,grulee7 may be a thickening of the muscular coat of the outlet of the stomach 7pylorus7 or a spasmodic contraction4 ,the condition is most frequent in males and in the first born4 ,symptoms usually begin before the second week4 ,there is constipation with small ribbon-like stools1 and the urine is scanty4 ,the most marked sign1 however1 when it is present1 is the excessive1 uncontrollable vomiting1 which ordinarily occurs fifteen to thirty minutes after eating1 but may be delayed for several hours4 ,the vomiting may be of the common type1 but more frequently it is projectile in character1 like that seen in meningitis4 ,the contents of the stomach are violently expelled1 sometimes several feet4 ,physical examination may reveal the stomach bulging under the arch of the ribs and peristaltic waves moving back and forth across its surface4 ,the pylorus itself may sometimes be felt as a lump or tumor4 ,prognosis4--,about fifty per cent die4 ,treatment4--,dietetic and surgical4 ,grulee recommends small amounts of food1 poor in fat1 be given at short intervals4 ,if this fails1 operation is required4 ,pneumonia in the newborn most frequently results from the aspiration of mucus out of the maternal passages as the child is born4 ,this may happen when the cord is compressed1 or at any time when a partial asphyxiation impels the child to try to breathe4 ,it may also come on when a feeble child has been chilled by a prolonged first bath4 ,the disease develops about twenty-four hours after birth in a child apparently well4 ,the temperature rises1 respiration becomes rapid1 and cough develops4 ,the child is fretful1 restless1 refuses the nipple1 and gasps for breath4 ,it may become cyanotic4 ,the prognosis in newborn infants is very serious4 ,treatment is stimulation4 ,a mustard bath will benefit where the respiration is rapid and the child blue4 ,tincture of digitalis may be administered in drop doses every three or four hours4 ,carbonate of ammonia1 gr41 in mucilage of acacia1 half a dram1 may be given for cough4 ,child must be fed on mother's milk pumped from breast4 ,snuffles may be due to improper clothing1 to drafts of air1 or to syphilis4 ,if due to cold1 camphorated oil may be rubbed on the nose and the passages kept clean with an applicator soaked in albolene4 ,if this fails1 a small pellicle of ansthone may be placed in each nostril1 and the child laid upon its back until the ointment melts and runs back into the pharynx4 ,furuncles 7boils7 may be numerous4 ,they come from irritation of the skin by atmosphere1 soap1 water1 and clothing1 whereby infection enters4 ,this is especially liable to occur in the hair4 ,keep the boils washed with boric acid solution and open them as soon as the focus1 or head1 appears4 ,phimosis is such a close adjustment of the prepuce to the glans penis that it can not be retracted4 ,in some cases there may be obstruction to the outflow of urine1 but generally a tiny portion of the glans can be seen4 ,the prepuce may or may not be redundant4 ,this condition makes cleanliness impossible and balanitis may result4 ,on account of the straining required to urinate1 prolapsus ani1 hernia1 and hydrocele of the cord sometimes develop4 ,symptoms may arise from preputial adhesions1 as well as phimosis4 ,frequent or difficult micturition1 nocturnal incontinence1 priapism1 pruritus1 and masturbation may develop out of the irritation1 as well as nervous manifestations1 such as insomnia and night terrors4 ,the condition should be recognized and corrected in infancy4 ,if the adhesions are dense1 an incision can be made down the dorsum of the prepuce1 the tissue forcibly separated from the glans1 and the flaps cut off4 ,stitches may be required4 ,in other cases circumcision may be necessary4 ,paraphimosis4--,when a prepuce with a small orifice is forcibly retracted over the glans1 it occasionally happens that it cannot be pulled forward again4 ,if allowed to remain this way1 the parts will swell1 and the penis become strangulated as if with a ligature4 ,the danger arises from the stoppage of the circulation1 which may be followed by ulceration and gangrene4 ,reduction must be brought about by manipulation1 if possible1 but where this fails1 the constricting band must be cut through and sedative applications used4 ,balanitis is inflammation of the prepuce from the decomposition of smegma1 which collects under a tight foreskin4 ,the condition is quickly relieved by cleanliness and a few applications of vaseline or zinc oxide ointment4 ,circumcision should not be done until the inflammation has subsided4 ,circumcision1 either as a physical necessity or as a religious rite1 is frequently performed4 ,the nurse prepares a table with sterile linen1 a basin with antiseptic solution and sponges1 sterile towel1 and sterile vaseline1 with a roll of gauze bandage an inch wide4 ,the object of the operation is to remove the prepuce and leave the glans exposed4 ,the instruments needed are a pair of sharp scissors1 a pair of dissecting forceps1 two pairs of artery forceps1 small1 full curved needles1 and fine catgut4 ,the nurse gives the child some gauze to suck1 which has been soaked in brandy and sugar-water1 brandy one dram to an ounce of water4 ,then taking her place at the child's head1 she flexes the thighs back upon the abdomen1 and widely separates them4 ,the field of operation is thoroughly washed with soap and warm water1 the prepuce is then retracted and the smegma wiped away4 ,then the body and limbs should be covered with clean linen1 except the penis1 or a sterile towel may be used with a hole in it through which the penis is drawn4 ,the redundant tissue is removed and fine catgut sutures put in4 ,the operation being completed1 the wound is covered with sterile vaseline and wrapped with a sterile gauze bandage1 leaving the end of the glans exposed4 ,illustration3 ,fig4 #abh4--;,hydrocephalus4 7,bumm47 ,the gauze and vaseline are changed whenever saturated with urine4 ,healing ought to be complete by the seventh day4 ,the nurse should examine the dressing at frequent intervals during the first twenty-four hours1 since serious hmorrhages may occur from vessels that have not been included in the sutures4 ,priapism is a condition of functional fullness and firmness of the penis that is more than ordinarily constant4 ,its importance lies in the fact that it may be a symptom of spinal irritation1 balanitis1 worms1 or phimosis4 ,spina bifida is the most common congenital deformity4 ,it is characterized by a fluid tumor1 which protrudes from an opening in the vertebral column4 ,it may appear anywhere along the spine1 but is found most frequently in the lumbar or cervical region4 ,the deformity is supposedly due to an arrest of development4 ,it is nearly always fatal inside of two weeks1 though cases have been known to reach mature years4 ,illustration3 ,fig4 #abi4--;,anencephalus4 7,williams47 ,there is no treatment except protection from injury4 ,hydrocephalus is sometimes1 but not necessarily1 associated with spina bifida4 ,the ventricles of the head are filled with cerebrospinal fluid1 and the fontanelles are widely separated4 ,the cause of the anomaly is unknown4 ,this condition may render labor difficult or impossible until the diagnosis is made and the skull perforated4 ,rupture of the uterus may result from the futile efforts to expel the child4 ,if born alive1 the child nearly always dies1 or if it grows up1 the intelligence is imperfect in most cases4 ,anencephalus is a monster1 having a body1 but only a part of a head4 ,the eyes protrude1 the tongue may hang from the mouth1 and the brain is under-developed4 ,sudden death of infants that are apparently healthy comes with a shock to the physician as well as the parents1 and in some instances1 no plausible reason can be assigned for it4 ,apoplexy1 pneumonia and stoppage of the trachea by milk curds may explain some cases4 ,suffocation by lying on the face in wet bedding1 or overlying by the mother will account for others4 ,internal hmorrhage into lungs1 pleura1 stomach1 or brain is also known to be causative4 ,,chapter ,,xxii ,,infant ,,feeding ,a well fed infant is a happy little animal1 who sleeps approximately twenty-two hours a day1 and gains from four to six ounces a week4 ,if properly fed at the breast1 this condition is easily obtained2 but if artificial food is necessary1 the resources and skill of the attendants may be tried to the utmost before the welcome result is brought about4 ,the feeding of infants may be considered under three heads1 7#a7 the breast2 7#b7 breast and bottle combined 7mixed feeding72 and 7#c7 artificial1 which is really modified cow's milk4 ,breast feeding has been taken up elsewhere1 but the same care should be taken in feeding from the bottle as in feeding from the breast1 so far as concerns the intervals between the feedings and the duration of the same4 ,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 child4 ,with such an interval there will be less vomiting1 less colic1 less tendency to overfeed1 and a better natured baby4 ,one feeding should be omitted at night1 and if possible1 two4 ,length of time for taking the bottle depends somewhat on the child1 but it should not exceed fifteen minutes1 as a rule4 ,supplemental ,feeding4--,a mother who has too little milk may have it supplemented by a modified mixture in one of two ways4 ,first1 the quantity furnished by the breast must be determined by weighing the infant before and after feeding1 and then the total amount for twenty-four hours can be deduced4 ,with this information1 it is not difficult for the doctor to know how much cow's milk to prescribe4 ,the supplemental feeding may be given by alternating the bottle and the breast1 or by giving the breast and following it immediately with the bottle4 ,in the meantime1 the mother must be put on tonics with an abundance of fluids1 and a generous diet that will raise the blood pressure1 in the hope that the milk will increase sufficiently to enable her to feed the child entirely from the breast4 ,when it becomes necessary to substitute some other food for the breast milk1 it means that the milk of some other mammal must be modified for the purpose4 ,the most convenient and abundant source of supply is the cow4 ,while in many respects cow's milk is similar to mother's milk1 it is in reality quite a different product4 ,mother's milk is taken1 undiluted1 directly from the breast1 while cow's milk is given from a bottle1 hours after milking1 and not only must it be diluted1 but certain ingredients must be added to aid its digestibility4 ,when taken into the stomach in its natural state1 mother's milk is a liquid1 while under the same conditions1 cow's milk forms a semisolid gelatinous mass4 ,it is essential that the milk should be as fresh1 clean1 and free from bacteria as possible1 and this can be approximated only in certified milk4 ,this milk is required by law to have its constituents definitely standardized4 ,thus1 there must be #d per cent of fat1 #d per cent of protein1 and #d per cent of sugar1 and it must be so free from bacteria that not more than #aj1jjj per cubic centimeter can be found4 ,the cattle also are tuberculin tested4 ,the following comparison is from ,holt3 ,mother's ,milk ,cow's ,milk ,sp4 ,gr4 av4 #a4jca av4 #a4jca4 ,fat #d4 ,fat #d4 ,protein #a4ej ,protein #c4ej ,sugars #g4 ,sugars #d4ej ,salts 4#b ,salts 4#ge ,water #hg4c ,water #hg4c ,reaction ,alkaline ,reaction ,acid ,bacteria ,very few ,bacteria ,many ,both range from #a4jbf to #a4jf4 ,illustration3 ,fig4 #acj4--;,elements of human milk4 7,eden47 ,the fats are substantially the same1 but the fat of cow's milk is less easily digested than the fat of mother's milk4 ,the protein of mother's milk is virtually half lactalbumin and half casein1 which is only slightly coagulated into soft flocculent curds by the action of rennin and acids1 while the casein of cow's milk is nearly three times greater in amount than the lactalbumin and is coagulated into coarse1 tough curds4 ,the sugars in both cases are lactose in solution1 but mother's milk contains a much higher percentage4 ,cow's milk contains three times the quantity of salts found in human milk1 but the water is the same in both4 ,so1 while the two milks seem in comparison to be much alike1 in reality they are quite different2 hence it is necessary to modify cow's milk in such a way as to make it not like mother's milk chemically1 but to make it act like mother's milk4 ,it is extremely difficult to bring up an infant on artificial food1 and inasmuch as half the infants that die during the first year1 perish from intestinal disorders1 it is imperative that every resource should be exhausted before the breast feedings are abandoned4 ,it is fallacious to believe that anyone can feed a baby1 or that feeding consists merely in trying one food after another until one is found to agree4 ,only a competent physician should prescribe the food1 and he should study his problem and make his modifications just as he would alter his medicines for a particular disease4 ,however1 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 present4 ,in prescribing for the child1 the doctor usually has some definite outline in his mind1 such as ,age and weight4 ,example3 #c months old2 weight #aj pounds2 #g feedings2 #a every #c hours4 ,interval1 three hours4 ,amount in each bottle1 four ounces4 ,formula3 ,milk1 #ab oz4 ,diluent1 #af oz4 7,cereal water or plain water47 ,sugar1 oz4 ,flour ball1 if any1 oz4 ,boil if ordered4 ,the infant should not take more than two ounces of milk to a pound of weight in each twenty-four hours4 ,proprietaries4--,baby foods are not to be recommended nor condemned4 ,they are placed on the market as substitutes for mother's milk with definite instructions as to preparation4 ,they are also very expensive4 ,they are not to be condemned1 because many of them are invaluable when used in connection with cow's milk4 ,sometimes a child will not tolerate anything but malted or condensed milk1 or ,nestle's food1 for example4 ,the malt sugars1 such as ,horlick's and ,mellin's1 are easily assimilated1 fattening1 and laxative4 ,all foods in the modification of milk should be of the best4 ,the standard sugars are ,merck's milk sugar1 ,mead's ,dextri ,maltose1 ,nhrzucker1 cane sugar1 and ,mellin's and ,horlick's foods4 ,robinson's barley flour or ,johnson's are the best known4 ,imperial granum is a partially dextrinized flour and corresponds to the home-made 8flour ball40 ,,food ,,preparation ,buttermilk ,made from a ,culture4--,bring two quarts of milk to a boil1 cool to the temperature required for inoculation 7#hj to #ajj ,f41 depending on the culture employed74 ,introduce the culture1 and allow it to stand at the temperature of the room until a solid clabber forms4 ,place on ice1 whip with an egg beater or break up with a churn before using4 ,if a fat-free buttermilk is desired1 use skimmed instead of whole milk4 ,there are many kinds of buttermilk cultures on the market1 but ,hansen's is considered one of the best1 because it is not too acid1 besides which1 it has a good flavor1 and the culture can be utilized over and over for a week or ten days4 ,in preparing a subsequent portion1 it is only necessary to use two or three ounces of the first buttermilk1 which may be reserved for the purpose4 ,this amount is introduced into the freshly boiled milk1 instead of the original powder1 and the preparation is continued exactly as described for the mother culture4 ,in every case the mixture must be placed on ice as soon as the clabber forms1 as it becomes too sour otherwise4 ,eiweiss ,milk4--,heat one quart of whole milk to #ade ,f4 and coagulate with pepsin1 rennin1 or chymogen1 which is #aj per cent rennin4 ,let it stand until clabbered1 which takes about ten minutes4 ,pour into a gauze bag and let it stand until all the whey is drained off4 ,to the dry curd1 add ounce of flour ball1 and one pint of skimmed buttermilk1 the whole to be rubbed through a very fine wire mesh sieve 7as fine as a tea-strainer1 at least71 three separate times2 or1 it may be ground twice through a special mill to break up the curd as minutely as possible4 ,add a pint of water and measure4 ,there should be a quart and three or four ounces over4 ,place upon a slow fire and bring to a boil while stirring constantly4 ,boil two minutes1 then cool1 strain1 measure1 and add water to make up for evaporation4 ,shake well before measuring1 as the curd is heavy and settles to the bottom4 ,peptonized ,milk4--7,see p4 #cch47 ,whey4--,to a pint of fresh1 warm cow's milk1 add rennin as pepsin1 or chymogen1 and stir until mixed4 ,let it stand until coagulation is complete4 ,then the curd should be broken up with a fork1 and the whey drained off through coarse muslin4 ,this removes the coagulable proteins from the milk4 ,a ten per cent cream can be had at home by allowing a quart of milk to stand for six hours and then using the upper one-fourth4 ,whey-,cream ,mixture4--,make whey as described and mix with cream1 in the proportion of whey #a ounces to cream1 #a dram for each feeding4 ,barley ,water4 ,no4 #a4--,use one ounce of barley pearls to a quart of water4 ,wash thoroughly1 put on a slow fire and boil for six hours4 ,add water to make up for evaporation1 and add a pinch of salt4 ,strain and cool rapidly4 ,barley ,water4 ,no4 #b4--,use one heaping teaspoonful of ,robinson's patent barley flour to each pint of cold water4 ,boil twenty minutes and add water to make up for evaporation4 ,add a little salt1 strain and cool rapidly4 ,other cereal waters1 like rice and oatmeal1 are made like barley water ,no4 #a1 and in the same proportion4 ,flour ,ball4--,take four cups of ordinary wheat flour and wrap it in a piece of muslin1 and tie it tightly4 ,drop the mass into boiling water and boil six hours4 ,then take it out1 cool it and remove the outer peeling with a sharp knife4 ,break into small pieces1 the size of an ,english walnut1 and dry thoroughly in a slow oven4 ,pulverize in a mill or meat-grinder1 sift and keep in a dry place4 ,milk may be sterilized1 pasteurized1 or boiled4 ,sterilization kills both germs and spores1 but it is not nearly so necessary as it is to have the right proportion of sugar and fats4 ,place in an autoclave and keep at a temperature of #afj ,f4 for an hour4 ,pasteurization is desirable when a good1 clean milk is not attainable4 ,it kills the germs1 but not the spores4 ,the process must be carefully attended to1 or the milk will sour more easily4 ,heat a quart of milk to #afj ,f4 for twenty minutes4 ,cool rapidly to #dj ,f4 ,boiling milk for two minutes kills all bacteria1 and renders the casein more easy of digestion and prevents the formation of curds4 ,,putting ,,foods ,,together ,whole milk contains #d per cent fat1 and must be thoroughly shaken before it is measured1 for otherwise one child will get all the fat and another all the skimmed milk4 ,fat-free1 or skimmed milk1 contains about #j4a per cent fat4 ,the cream has been removed by a siphon or centrifuge4 ,if unable to get a fat-free milk from a dairy1 the cream can be removed from a quart of whole milk quite easily with a siphon4 ,sugars and flours should be weighed when used1 for they vary greatly in volume4 ,in using flour ball or imperial granum1 the flour must be mixed with water or cereal water1 to make a smooth paste and brought to a boil4 ,if the milk is to be boiled also1 add the milk to the paste and boil all together4 ,cool and strain4 ,all baby feedings should be strained1 as tiny lumps of food will clog the rubber nipple and the nurse may think the baby is not taking its feedings well4 ,the following is a typical formula3 ,whole milk #ae oz4 ,barley water #ae oz4 ,sugar oz4 #efd ,flour ball oz4 ,boil two minutes4 ,weigh the sugar and flour ball and make a paste with the barley water4 ,shake the whole milk1 measure out #ae oz4 in the graduate1 and add the barley water mixture4 ,boil two minutes4 ,cool in running water1 strain bottle and put on ice4 ,the figures at the side mean that five feedings of six ounces each are to be given at four-hour intervals4 ,it is necessary to cool all feedings as soon as modified1 and keep them on ice for preservation until used4 ,the only accurate way is to make up the whole quantity for twenty-four hours1 put into separate bottles the exact amount of each feeding and give at the time ordered1 after the bottle has been properly warmed4 ,in warming the food1 care must be used to get it neither too hot nor too cold2 #ajj ,f41 or when it feels warm to the back of the hand1 is about right4 ,the child should be held in the arms while taking the bottle4 ,a buttermilk feeding must not be heated to more than #ajj ,f4 because it curdles and can not be used4 ,the rubber nipples should be washed thoroughly after use1 boiled once a day1 and kept in boric acid solution4 ,the necessary articles for home modification of milk can be obtained anywhere4 ,one set of utensils should be kept for this purpose exclusively and boiled each time before the food is prepared4 ,a list is convenient3 ,a #af ounce glass graduate4 ,one tablespoon and one teaspoon may be used for measuring purposes1 if unable to get a satisfactory scale4 #a #b-quart aluminum cooking dish4 #a long-handled aluminum spoon4 #a fine wire mesh strainer1 thirty holes to the inch4 #a dozen bottles1 #e ounce size if the child is small1 and #aj ounce if the child takes large feedings4 ,the bottles should have wide mouths1 straight sides1 and round bottoms1 which clean easily4 ,paper caps or corks that fit tightly should be used instead of cotton stoppers4 ,close rubber caps are best1 for1 as the milk cools1 a vacuum is created1 the rubber is drawn in and the milk remains air-tight until opened4 ,if infants are kept on a milk diet alone for too long at a time1 they do not thrive so well1 hence as early as six months1 other things may be given4 ,at this stage1 the most desirable additions to the food would be cereal1 farina or cream of wheat1 orange juice1 vegetable broth1 toast crumbs1 etc4 ,the administration of orange juice should be started when the child is only a few weeks old4 ,the quantity of all these foods may be increased as the child gets older1 and by the end of a year the diet is broadened still further4 ,beside a quart of whole milk1 it may have thickened soups1 vegetables1 such as cauliflower1 spinach1 carrots1 creamed celery and a little baked potato4 ,fruits1 orange juice1 grape fruit juice1 prune sauce1 apple sauce and scraped apple may be given1 but no bread4 ,in place of bread1 use toast1 ,huntley and ,palmer wafers and biscuits1 and soda or oatmeal crackers4 ,sweet desserts should be avoided1 but flavored junket or simple custard is unobjectionable4 ,no meats are permitted until the child is eighteen months old1 except1 perhaps1 a little crisp bacon1 or a bone to suck4 ,none of these supplemental foods should be given between meals1 but always at the feeding hour4 ,the above list supplies a dietary so varied that no child will tire of it4 ,in reporting the condition of the infant to the physician1 the following form may be used to advantage4 ,it is a clear cut1 concise summary of what he wishes to know4 ,infant's ,daily ,report #a4 ,food3 ,does baby take it all8 ,is he satisfied8 #b4 ,bowel movements3 ,how many in last #bd hours8 ,what is the color8 ,are they hard1 soft1 or watery8 ,any odor8 ,any curds8 ,any slime8 ,any blood8 ,any colic8 ,much gas8 #c4 ,does baby vomit8 ,when8 ,how much8 #d4 ,does baby sleep well8 ,is he good natured8 #e4 ,any fever8 ,what is the weight8 ,significant ,symptoms and ,conditions4--,in an artificially fed baby1 the normal condition of the bowels is constipation4 ,the stools are formed1 alkaline in reaction1 rather hard1 and usually only one a day4 ,the stools should have a characteristic color1 according to the food taken4 ,thus3 ,sugar or starch will color the movement a dark brown1 like vaseline4 ,too much fat gives a pale yellow stool1 almost white1 like putty4 ,eiweiss feedings show as a pale yellow1 somewhat like the fatty stools1 but constipated4 ,barley water gives a brown liquid stool4 ,starvation stools are thin1 slimy1 dark brown or green4 ,the consistency of the movements is also important4 ,too much sugar or starch means diarrha1 with thin1 green1 acid stools1 and much gas and regurgitation1 or1 sometimes foamy1 mucous discharges4 ,diarrha may also be due to indigestion4 ,mucus in the stools usually signifies intestinal irritation4 ,constipation may exceed the normal limits of the artificially fed child when the food contains too much fat4 ,bad odors of the stools result from putrefaction4 ,colic means imperfect digestion with gas4 ,there is less colic when the intervals between the feedings are lengthened4 ,curds are of two kinds4 ,the soft friable ones due to fat1 and the hard bean-like masses of protein4 ,curds occur with feedings of raw milk only1 and though associated with symptoms of indigestion1 they signify overfeeding4 ,if the sugar content of the food is low1 the child will gain very slowly4 ,vomiting is an important phenomenon4 ,it may be due to overfeeding1 to excess of sugar or fat in the food1 or to pyloric stenosis4 ,excess of fat is shown by vomiting and regurgitation of small quantities of food one or two hours after feeding4 ,it may be associated with constipation4 ,if vomiting occurs immediately after feeding1 it is probably due to the taking of an excessive amount1 or to the too rapid ingestion of the regular bottle4 ,if the vomiting takes place later than twenty minutes after feeding1 it is probably pathological4 ,it may be the result of indigestion1 meningitis1 or of pyloric stenosis 7q4 v474 ,for the first weeks of life1 mother's milk should be obtained at all hazards1 if possible1 but if this is not to be had1 the artificial feedings may be started4 ,a desirable milk modification for the first weeks of life should begin with a low food value4 ,for example1 a child one week old weighing seven pounds1 should start on a formula like this3 ,whole milk #g oz4 ,water #g oz4 ,cane sugar oz4 ,boil two minutes4 ,this will make seven feedings of #b oz4 each1 and one is given every three hours with one feeding omitted at night4 ,cane sugar is less liable to produce colic than sugar of milk4 ,lime water1 or sodium citrate may be added1 if the child vomits1 or if other indications arise4 ,both are alkalies4 ,the strength of the mixture1 as well as the quantity1 must be increased as the child gets older and it is seen that the formula will agree4 ,the percentage of protein is kept down by dilution1 with plain or cereal water1 while fats 7as cream7 and sugars are added to make up the strength lost by the dilution4 ,,chapter ,,xxiii ,,cleanliness ,,and ,,sterilization ,the nurse is called to a case on account of her special qualifications1 but also she should lead her patient in all things1 even in gentility4 ,it is her part to anticipate the wants of the patient1 and regard it as a reproach if the patient has to remind her that it is time for food1 medicine1 bath1 or for child to come to the breast4 ,regularity1 promptness1 and thoughtfulness must be supreme4 ,be on hand when the doctor calls and stay until he goes4 ,be as cheerful as ,mark ,tapley1 however dreary the prospect1 and do not make noises either by the swish of overstarched skirts1 the squeak of shoes1 or the moving of equipment4 ,above all things1 the nurse must keep her patient's room1 her patient1 and her own person rigorously clean4 ,she should not allow her hands to touch infectious material without protection by rubber gloves4 ,this is as necessary for her own safety as for the patient and family4 ,her hands should be manicured frequently1 her hair shampooed at short intervals1 and her teeth kept in order4 ,if the hands get hard1 take a teaspoonful of sodium carbonate and one of chloride of lime1 mix in the palm of the hand with enough water to make a cream1 and rub well into palms and about the nails4 ,rinse in clean water4 7,weir47 ,the nurse's dress should be neat1 always mended1 and carefully adjusted4 ,the nurse who is slovenly in appearance will be slovenly in her mind and slovenly in her work4 ,she should not wear her uniform on the street4 ,it is bad taste1 unprofessional1 and unsanitary4 ,she should bathe at least three times a week4 ,there is always some odor of perspiration about the body1 and especially around the axillary spaces which are filled with hair4 ,nothing is more offensive and nauseating than being leaned over and waited on by a person who has a strong body smell4 ,the prodigal use of warm water and soap will aid1 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 necessary4 ,the axill should be shaved at least once a month1 and then the soap and water becomes more efficacious4 ,after thorough cleansing1 the armpits should be dredged with ,babcock's ,motiya powder1 and the annoying and offensive odor will disappear4 ,if the patient is a refined and dainty woman1 who may happen to be afflicted with the same misfortune1 she will be deeply grateful to the nurse who tells her how to get rid of it4 ,that some doctors1 unfortunately1 have strong odors about the person--the mixed effluvia of tobacco1 alcohol1 bad teeth1 and uncleanliness--is no excuse for the nurse4 ,the doctor should know better1 but at all events1 his offense rarely needs to be suffered more than a few minutes at a time1 while the nurse is in constant attendance4 ,the trained nurse should be polite to1 but not familiar with servants1 as she is looked upon as the highest type of the professionally educated gentlewoman1 and she must be constantly alert that her reputation in this respect is not diminished4 ,,baths ,hot ,baths4--,temperature from #ih ,f4 to #abj ,f4 ,water should be tepid at first and the hot water gradually added until the required degree is obtained4 ,warm bath #ib ,f4 to #ih ,f4 ,tepid #he ,f4 to #ib ,f4 ,cold #cc ,f4 to #fe ,f4 ,sedative ,bath4--,the patient is stripped and stands for an hour in the hydrotherapy room1 while a hot spray is played up and down the spine4 ,the temperature of the water is #ajd ,f4 to begin with1 and gradually increased to the point of toleration4 ,an alkaline bath is prepared by adding an ounce of sodium carbonate to each gallon of water4 ,bran ,bath4--,add two ounces of bran to each gallon of water4 ,mix the bran in a small amount of boiling water and add to the bath water4 ,mustard ,bath4--,to three gallons of water at a temperature of #aje ,f4 add a tablespoonful of mustard4 ,leave the child in the water for five minutes1 all the while rubbing and stroking the limbs and back4 ,then wrap naked in a warm blanket and leave for half an hour4 ,,sterile ,,dressings--,,antiseptic ,,solutions--,,sterilization ,,of ,,instruments ,the preparation of sterile dressings1 antiseptic solutions and the sterilization of instruments1 is particularly the work of the nurse1 whether in the hospital or in a private home4 ,the following directions are therefore desirable3 ,as soon as the nurse is sure her patient is in labor1 she boils a milk bottle1 fills it two-thirds full of #ie per cent alcohol1 puts a pledget of sterile cotton in the bottom and then boils a pair of dressing forceps1 which are placed1 handle up1 in the alcohol4 7,see ,fig4 #eb1 page #acb47 ,with this forceps1 she handles all clean dressings1 instruments1 and rubber goods that may be contaminated by touch4 ,dressings and ,supplies4--,the necessary dressings and supplies may be prepared one or two weeks before labor according to the following instructions3 ,five ,yard ,packing4--,draw threads at either end of five yard lengths of gauze to its full width4 ,fold the cut edge across until it lies one-third the distance from the opposite side4 ,next1 fold the double edge over1 and bring it to the outside edge of the first fold4 ,keep it perfectly straight4 ,when folded full length1 roll from the end and wrap in strong muslin wrappers4 ,sterilize in the autoclave or ,arnold sterilizer4 ,pads for the ,vulva4--,unroll a whole bale of common cotton and cover it with a inch thickness of absorbent cotton4 ,cut in lengths of #ab in4 by #d in4 wide4 ,cover with gauze cut #ab by #ad inches1 and fold the ends of gauze over absorbent cotton4 ,roll from the end1 wrap in paper1 seal1 and sterilize4 ,pledgets4--,tear two yard strips1 lengthwise of the roll of absorbent cotton1 pull from these1 three inch pieces1 roll them in the hands until round1 place in clean bags1 and sterilize4 ,breast ,covers4--,squares of old1 soft muslin #d by #d inches1 with all strings removed1 make the best dressings for the nipple4 ,do not use gauze1 because the papill of the nipple may get caught in the mesh and when it is taken off1 the tender nipple is irritated or abraded4 ,breast ,binders4--,these are made of single material1 because they would be too warm otherwise4 ,they are sleeveless and jacket-shaped and measure #af inches from shoulder to waist1 #dj inches long1 and #aj inches for the arm scallop4 ,a binder of this size1 if properly adjusted1 will fit a patient of any size4 ,three will be sufficient for the case4 ,abdominal ,binders4--,the abdominal and breast binders are worn during the bed period only4 ,the abdominal binder is made of unbleached muslin1 double material1 #ad by #dj inches1 and hemmed4 ,in the center of the back1 on the lower edge1 a curved space1 six inches wide1 is cut out to prevent the binder from getting soiled4 ,to this curved edge1 the pad holder is attached by two safety pins1 one on either side4 ,the abdominal binder is adjusted by pinning firmly above the fundus1 and loosely below4 ,pad holders are made of unbleached muslin1 and measure #f by #af inches4 ,cord ,dressings4--,cut squares of surgical lint #d by #d inches1 and cut through to the center on one side4 ,gauze may be used1 but it is not ideal4 ,nursery ,cotton4--,tear absorbent cotton into narrow lengths and pull out small one inch pieces4 ,roll them1 place in a clean bag and sterilize4 ,applicators4--,use absorbent cotton and toothpicks4 ,tear off small pieces of cotton1 moisten the toothpick point with water1 place in the middle of the cotton1 and roll firmly4 ,gauze ,sponges4--,cut gauze into squares #f by #f inches1 and fold from each side to the center4 ,this brings all the ragged edges inside4 ,fold into squares1 place in jars1 and sterilize4 ,sterilization of ,instruments4--,place scalpels in carbolic acid #ie per cent for ten minutes4 ,lift with sterile forceps1 and put in a basin of #ie per cent alcohol for ten minutes4 ,in the absence of carbolic acid and alcohol1 the scalpels may be dropped in a #b per cent solution of lysol for twenty minutes4 ,cleanse with hot sterile water4 7,do not boil scalpels2 it dulls the sharp edges47 ,all other instruments may be placed in a sterilizer 7dishpan or wash boiler7 with enough water to completely cover them2 boil twenty minutes4 ,cool in sterile pan1 which may be set in cold water4 ,do not use soda on the instruments during sterilization1 as it makes a thick1 gummy precipitate on the metal4 ,the sterile handling forceps must be immersed at all times for two-thirds their length in #ie per cent alcohol4 ,brushes4--,after using1 all brushes should be thoroughly washed1 boiled1 and dried1 wrapped in waxed papers1 and sterilized in the autoclave4 ,in the absence of the autoclave1 boil thirty minutes4 ,basins1 pitchers1 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 boiler4 ,they will not remain sterile longer than one week1 even when kept in a clean place and well wrapped4 ,bedpans should be washed in a strong solution of soap and water1 rinsed every morning and boiled for thirty minutes4 ,sterilization of ,rubber ,goods4-- ,tracheal ,catheters4--,drop in a solution of bichloride #a3ejjj and leave for twenty minutes4 ,lift with sterile forceps into a basin of warm sterile water and leave for ten minutes1 or until used4 ,vorhees ,bags4--,boil twenty minutes4 ,the bags and catheters may be given a longer life by keeping them in a #be per cent solution of glycerine and water when not in use4 ,kerosene vapor is also preservative4 ,rubber ,catheter4--,boil twenty minutes4 ,hot ,water ,bags1 ,ice ,caps1 ,rubber ,bed ,rings4--,soak in #aj per cent lysol solution for two hours1 wash with warm water1 and dry thoroughly4 ,the inside of the ice caps can be dusted with powder4 ,never leave rubber gloves in a damp place or lying in a solution4 ,it stretches them and weakens the rubber4 ,to sterilize1 they must be washed in a strong solution of soap and water1 dried1 and paired4 ,then they are wrapped in a heavy cloth covering and put in the autoclave for twenty minutes4 ,wet ,process for ,rubber ,gloves4--,wrap in gauze or cloth and boil for thirty minutes4 ,lift with sterile forceps and place in lysol solution #a per cent until used4 ,they are easily drawn on by filling them with the solution as the hand goes in4 ,the autoclave is not always available1 but an ,arnold or ,rochester sterilizer is readily portable1 and takes the place of the hospital machine4 ,fumigation of rooms is sometimes necessary4 ,remove all curtains1 bed linen1 and other washable fabrics from the room4 ,open the drawers of dressers1 doors of closets1 and loosen up and separate everything left so the air can get to it4 ,close the windows and seal the crevices with cotton and make the room as air-tight as possible4 ,place a large pan containing six ounces of potassium permanganate crystals in the center of the room4 ,pour over this twelve ounces of formalin1 close and seal the outside doors of the room and leave for twelve hours4 ,if the case has been a very septic one1 it is always a good plan to wash the walls of the room before using again4 ,the insides of the drawers and the bed should be thoroughly washed with water and green soap4 ,a formaldehyde lamp is also quite satisfactory if obtainable4 ,,chapter ,,xxiv ,,diets ,,and ,,formul ,the nurse should serve everything in the most cleanly and appetizing way if it is only a cup of tea2 and all waste1 soiled dishes1 napkins1 and excreta must be removed as delicately as possible4 ,diet for ,pregnancy4--,fresh fish1 boiled1 broiled or baked2 and shell-fish raw or cooked1--any way but fried4 ,meat1 once or twice a day1 except when contraindicated by condition of the kidneys4 ,veal is best omitted4 ,all farinaceous foods and vegetables may be eaten freely4 ,desserts should be plain1 but tempting4 ,no alcohol is taken without direct permission from the doctor1 and coffee and tea should be limited4 ,diet for ,puerperium4--,first two days1 milk1 buttermilk1 soup1 gruel1 cocoa1 toast and tea1 chicken1 oyster and clam broth4 ,in the next two days1 under ordinary conditions1 the diet is increased and made somewhat heavier4 ,semisolids are added like milk-toast1 eggs1 poached or boiled soft1 oysters1 clams and boiled fish4 ,after the milk comes in1 the woman is put on a general diet as fast as she can digest it4 ,farinaceous diet--melons and oranges4-- ,breakfast4--,cereal1 coffee with milk and sugar1 if desired1 bread and butter1 corn bread1 rolls1 toast1 muffins1 hominy1 cereal with cream4 ,lunch4--,vegetable soups1 bread1 butter1 potatoes1 beans1 rice1 macaroni and cereal1 peas1 buttermilk1 pudding1 such as rice1 tapioca1 bread cornstarch1 jellies1 fruit juices1 pumpkin1 squash1 turnips1 tomatoes1 etc4 ,dinner4--,bread1 butter1 milk-toast1 hominy1 rice1 celery1 fruit salads1 lettuce1 apples1 pears1 prunes1 stewed fruits or fresh melons1 etc4 ,the following diets are routine at many hospitals3 ,general ,diet4--,full tray of food in season as furnished by the hospital4 ,three meals daily4 ,light ,diet4--,foods from the following list may be selected1 and served three or five times daily1 as desired3 ,soups of all kinds4 ,when leguminous foods are employed1 their outer coverings must be removed by rubbing them through a sieve or colander4 ,vegetables of all kinds1 except green vegetables 7provided they have been reduced to a pasty consistency74 ,those with excess of fiber or cellulose1 such as turnips1 celery1 asparagus1 and cabbage1 should be chopped after thorough boiling1 then mashed1 while those having tunics should be sieved or colandered4 ,grain foods of all kinds thoroughly cooked1 excepting corn preparations containing much cover1 as hulled corn4 ,prepared foods such as tapioca1 macaroni1 and vermicelli1 require prolonged cooking4 ,meats1 scraped beef4 ,eggs1 soft boiled1 raw or soft poached4 ,bread of all kinds1 stale1 home-made4 ,puddings1 ices4 ,beverages1 all kinds unless otherwise ordered4 ,forced ,diet4--,this includes the general diet with the addition of one quart of whole milk and four eggs4 ,the milk may be given plain or as an eggnog at seven1 ten1 three1 and eight o'clock4 ,the eggs may be given raw or cooked soft in any form4 ,milk ,diet4--,twelve ounces of whole milk 7#cge c4c47 may be given every two hours2 i4 e41 at six1 eight1 ten1 twelve1 two1 four1 five1 and eight o'clock1 or the patient may sip it at her pleasure4 ,the milk may be given raw1 boiled1 diluted with plain water1 lime water1 ,vichy1 seltzer1 or ,apollinaris to taste4 ,the daily amount should include three quarts of whole milk4 ,koumiss1 buttermilk and milk soups are sometimes allowed4 ,note the exact amount taken1 and give reasons for failure4 ,watch the stools for undigested milk4 ,liquid ,diet4--,whole milk1 buttermilk1 koumiss1 beef tea1 or beef1 chicken1 mutton1 oyster1 or clam broth1 in eight ounce portions1 or two ounces of beef juice1 every two hours4 ,lemonade1 orangeade1 ice cream1 or fruit ices1 at intervals and amounts as desired4 ,ulcer ,diet4--,whole milk and cream1 equal parts1 three ounces every two hours4 ,sodium bicarbonate1 thirty grains1 in a small amount of water1 to be given before and thirty minutes after feeding4 ,albumin water1 soft boiled eggs1 scraped beef1 custard1 and cream soups to be added later by direction of the physician4 ,no seasoning except salt is allowed4 ,prochownik ,diet4--,this diet is advised where some necessity exists for preventing a large child4 ,it is administered in the last six weeks of pregnancy only4 ,breakfast4--,small cup of coffee1 two slices of toast 7#a ounce74 ,lunch4--,small piece of meat1 fish or an egg1 a little sauce4 ,a vegetable prepared with fat1 lettuce1 a small piece of cheese4 ,dinner4--,same as lunch with three slices of bread and butter1 and a little milk4 ,a pint of water daily is allowed2 taken in sips it lasts longer4 ,soup1 water1 beer 7all fluids7 and sugar1 pastry1 and potatoes are forbidden4 ,skimmed ,milk ,diet 7,karell74--,skimmed milk1 to which a pinch of salt is added1 #c to #f ounces1 three or four times daily1 increasing the amount gradually1 taken slowly to allow thorough mixture with saliva1 warmed in winter1 room temperature in summer4 ,acute ,nephritis ,diet4--,whole milk1 #ajjj c4c42 cream1 #bej c4c42 water1 #aej c4c42 stewed fruit1 well sweetened1 #ej c4c4 ,bread1 well buttered1 may be toasted1 #aej gm4 7equal to three slices74 ,green salad of lettuce1 celery1 apple1 pear or grape fruit1 and served either with olive oil1 or with a mayonnaise dressing made from olive oil1 egg and lemon juice1 with salt 7but no pepper or condiments7 may be given in two small portions daily4 ,cooked cereals 7cream of wheat1 etc47 with cream and sugar1 one portion equal to about two ounces1 once daily4 ,the above represents a daily fluid intake of about #aejj c4c4 ,the diet is to be given in 8three meals10 at eight1 one1 and six o'clock1 with fluid nourishment at eleven1 three1 and nine o'clock4 ,,rectal ,,feeding ,nutrient enemas should be given every six hours1 unless otherwise ordered4 ,it is necessary to cleanse the lower bowel with a saline or soapsuds enema at least once a day4 ,the cleansing enema should be given one hour before the nutrient enema is to be given4 ,the proper quantity for the nutrient enema is four to six ounces for an adult1 and one to three ounces for a child4 ,nutrient enemas should be given slowly at very low pressure1 the level of the fluid in the can being not over eight to ten inches above the level of the rectum4 ,if the injected material is thick1 a piston syringe may be required4 ,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 given4 ,the tube should be oiled and not be inserted more than three or four inches4 ,the temperature of the enema should be about #ih degrees4 ,if there is a strong tendency to evacuate the enema1 pressure should be made against the rectum with a pad4 ,the following nutrient enemas may be ordered by name4 ,glucose ,enema4--,glucose 7dextrose1 grape sugar7 #a ounce1 normal salt solution #e ounces4 ,the glucose should first be dissolved in hot water4 ,the amount of glucose may be increased1 upon order1 if no irritation is produced4 ,pancreatinized ,milk ,enema4--,add #a tube of peptonizing powder1 or #a to #b drams of 8,pancreatic solution0 to #a pint of skimmed milk4 ,stir well and place in a warm water bath for one-half hour4 ,add #a dram of salt4 ,milk and ,egg ,enema4--,thoroughly beat the whites of #b eggs1 add dram of salt1 and #f ounces of skimmed milk4 ,add one tube of peptonizing powder1 or #a to #b drams of 8pancreatic solution10 stir well1 and place in a warm water bath for one-half hour4 ,milk1 ,egg1 and ,beef ,juice ,enema4--,mix the beaten whites of #b eggs1 #b ounces of fresh beef juice1 #f ounces of skimmed milk1 and dram of salt4 ,add #a tube of peptonizing powder1 or #a to #b drams of 8pancreatic solution10 stir well1 place in a warm water bath for one-half hour4 ,milk and ,glucose ,enema4--,add #a tube of peptonizing powder to #f ounces of skimmed milk1 stir well1 place in a warm water bath for one-half hour4 ,add #c drams of glucose and dram of salt4 ,,eliminative ,,enemas ,impaction ,enema4-- ,castor oil or olive oil1 #a ounce4 ,soapsuds 7#ajj ,f471 #a quart4 ,mix as thoroughly as possible1 add one dram of spirits of turpentine beaten up with the yoke of one raw egg4 ,s4 ,s4 and ,g4 ,enema4-- ,soapsuds1 #a quart4 ,glycerine1 #a ounce4 ,asaftida ,enema4-- ,milk of asaftida1 #h ounces4 ,water1 #h ounces4 #a-b-c ,enema4-- ,magnesium sulphate1 #a ounce4 ,glycerine1 #b ounces4 ,water1 #c ounces4 ,milk and ,molasses ,enema4-- ,milk1 ordinary cooking molasses in equal parts1 possibly #h ounces of each4 ,heat1 but do not boil4 ,turpentine ,enema4-- ,soapsuds1 #a pint4 ,turpentine1 #a dram4 ,it acts quickly and effectively4 ,all enemas should be given through a colon tube4 ,the patient should be on the left side and the temperature of the injection should be about #ajj ,f4 ,,diet ,,list ,albumin ,water4--,take white of #a egg1 stir until separated4 ,add a little lemon juice and #a pint of water4 ,ice and serve4 ,sugar or salt may be used4 ,barley ,water4--,wash #b ounces of barley with cold water4 ,boil for #e minutes in fresh water4 ,strain4 ,then cover with #b quarts of water and cook slowly down to #a quart4 ,flavor with thinly cut lemon rind and sugar4 ,do not strain unless patient requests4 ,beef ,juice4--,cut into cubes #a inches each1 #a pound round steak4 ,place in a clean1 ungreased pan1 and fry one and one-half minutes on each side4 ,pour into hot meat press and apply pressure4 ,in absence of a press1 a potato ricer may be used4 ,season with salt and pepper4 ,may be served iced or heated by putting in double boiler and stirred all the time4 ,do not allow to curdle4 ,beef ,tea4--,put #a pound of finely chopped round steak into a quart glass jar1 fill with cold water4 ,place jar in kettle of warm water4 ,leave over slow fire for four hours4 ,strain1 season with salt and pepper4 ,champagne ,whey4--,boil #h ounces milk for fifteen minutes4 ,strain through cheesecloth4 ,add #a ounces champagne4 ,chicken ,broth4--,skin and chop in small pieces one small or one-half large fowl4 ,boil bones and all with one blade of mace1 a sprig of parsley1 and #a tablespoonful of rice1 #a crust of bread and #a quart of water1 for one hour4 ,skim from time to time4 ,strain through coarse colander and season to taste4 ,cinnamon ,water4--,one-half ounce stick cinnamon1 #b cups boiling water4 ,break sticks in small pieces4 ,add water1 boil twenty minutes4 ,strain and serve hot or cold4 ,clam ,broth4--,wash thoroughly #f large clams in shell4 ,put in kettle with #a cup of cold water1 bring slowly to boil1 and keep temperature for one minute4 ,pour off broth and serve hot4 ,add salt and pepper4 ,eggnog4--,beat an egg1 white and yolk separately4 ,add to the yolk #a dram of vanilla extract1 a pinch of salt and #d oz4 fresh milk1 and #a dram of sugar4 ,add dram of sugar to white of egg1 stir a portion into the glass and heap remainder upon top of glass4 ,egg ,cordial4--,one egg white1 #a teaspoon sugar1 #a tablespoon brandy1 #b grains salt1 #b tablespoons cream4 ,beat white until stiff4 ,add cream1 continue beating1 add other ingredients1 and serve cold4 ,egg ,lemonade4--,beat #a egg and #a teaspoonful of sugar until very light1 add cake of yeast dissolved in one-fourth cup of water1 two tablespoonfuls of sugar1 pour into bottles with patent stopper1 fill bottles only two-thirds full1 cork tightly4 ,shake well4 ,allow to stand on ice twenty-four hours4 ,flaxseed ,tea4--,one ounce of whole flaxseed1 #a ounce powdered sugar1 ounce licorice root1 #a ounce lemon juice4 ,pour over these materials #a quart of boiling water and allow to stand four hours4 ,strain off liquor4 ,gum ,arabic ,water4--,dissolve #a ounce of gum arabic in #a pint boiling water4 ,add ounce sugar1 a wineglassful of sherry1 and juice of one lemon4 ,serve with ice4 ,junket4--,take pint of fresh milk in a saucepan4 ,add #a teaspoonful of essence of pepsin1 stir just enough to mix4 ,pour into custard cups4 ,let stand until firmly curded4 ,serve plain or with grated nutmeg4 ,sherry may be added4 ,koumiss4--,heat four cups of milk1 then cool2 when lukewarm1 add cake of yeast dissolved in one-fourth cup of water1 two tablespoonfuls of sugar1 pour into bottles with patent stopper1 fill bottles only two-thirds full1 cork tightly4 ,shake well1 allow to stand on ice twenty-four hours4 ,milk ,shake4--,white of #a egg1 #a ounce sugar1 #a ounce chipped ice1 #a ounce cream4 ,shake in milk shaker two minutes4 ,add milk to fill glass4 ,flavor with vanilla and lemon4 ,mutton ,broth4--,boil slowly #a pounds of lean loin mutton1 including the bone4 ,add a little salt and onion4 ,pour broth into a basin4 ,skim off fat when cool4 ,warm as used4 ,oatmeal ,gruel4--,one teacup oatmeal flakes1 cover with #a quart cold water4 ,place on slow fire and soak three hours4 ,strain1 add #d teaspoonfuls of sugar and #a teaspoonful of salt4 ,oatmeal ,water4--,cover #a teacupful oatmeal with #a quart cold water4 ,let it stand two hours4 ,stir often4 ,strain4 ,serve with salt1 sugar and ice4 ,peptonized ,milk4 ,warm ,process4--,dissolve the contents of ,fairchild's peptonizing tube in #d tablespoonfuls cold water4 ,add to #a pint of milk4 ,put in glass jar1 and place jar in vessel of warm water4 ,heat slowly to #aae ,f4 ,stir slowly and allow it to remain thirty minutes4 ,place on ice at once to check further digestion4 ,peptonized ,milk4 ,cold ,process4--,in a clean quart bottle1 put one peptonizing powder 7,fairchild74 ,add #a teacupful of cold water4 ,shake4 ,add #a pint fresh cold milk4 ,shake well4 ,place on ice4 ,do not heat before using4 ,rice ,water4--,pick over and wash #b tablespoonfuls of rice4 ,put in a saucepan with #a quart of boiling water2 simmer two hours4 ,when rice is dissolved1 strain4 ,add teaspoonful salt4 ,serve warm or cold4 ,sherry may be added4 ,rum ,punch4--,two teaspoonfuls powdered sugar1 #a egg well beaten1 warm milk1 #a large wineglassful2 #d ounces ,jamaica rum4 ,flavor with nutmeg4 ,scraped ,beef4--,place on breadboard a round steak4 ,scrape with table-knife but do not take any shreds of muscle4 ,salt and pepper4 ,spread on thin slices of bread4 ,place in toaster until seared4 ,toast ,water4--,three slices of stale bread well browned1 but do not burn4 ,put in a pitcher1 pour over them #a quart boiling water4 ,cover closely1 and allow to stand until very cold4 ,strain4 ,wine and sugar may be added1 to stimulate4 ,wine ,whey4--,put #a quart new milk in a saucepan and place over fire4 ,stir until nearly boiling4 ,add #b ounces of sherry wine4 ,boil slowly for fifteen minutes4 ,skim off curds as they arise4 ,add #a tablespoonful sherry4 ,skim again1 then strain through gauze4 ,,chapter ,,xxv ,,solutions ,,and ,,therapeutic ,,index ,acid1 ,boric4 #e dr4 in a pint of water makes a #d solution1 or #a3be4 ,acid1 ,carbolic4 #ae in a quart of water makes a #j4a solution1 or #a3ajjj4 #e dr4 to the quart makes a #b solution2 and #a oz4 to the quart1 a #e solution4 ,chinosol4 #ae gr4 to the quart of water makes a solution of #a3ajjj4 ,formalin4 #a dr4 to the quart of water makes a solution of about #a3ejj4 ,mercury ,bichloride4 #ae gr4 to the quart of water makes a #j4a solution1 or #a3ajjj4 #a gr4 to the quart makes a #j4ja solution1 or #a3aj1jjj4 ,normal ,salt ,solution4 #b dr4 of salt to the quart of water1 or #j4i4 ,physiological ,salt ,solution4 ,take normal salt solution as given above and to every #c oz4 add #ae gr4 of carbonate of soda4 ,potassium ,permanganate4 #b dr4 to the quart makes a #a solution4 #c gr4 to the quart makes a #a3ejjj solution4 ,silver ,nitrate4 #d gr4 to the ounce of water or #a gr4 to #a-g_/aj dr4 makes a #a solution4 ,ziratol4 #b teaspoonfuls to a quart of water makes a #a solution4 ,for general reference the following valuable table is appended3 ,,percentage ,,solution ,,table ,,by ,,alfred ,i4 ,,cohn1 ,,phar4 ,d41 in ,merck's ,report ,quantity of solution ,,grains ,,of ,,salt ,,or ,,drug ,,required ,,to ,,make ,,solutions ,,of to be ,,percentage ,,strength ,,indicated made #j4e #a #b #c #d #e #f #h #aj fl4 oz #a4ae #b4c #d4f #f4i #i4c #aa4g #ad4a #ai4 #bd4 #a fl4 oz #b4c #d4f #i4b #ac4i #ah4f #bc4d #bh4b #cg4i #dg4i #b fl4 oz #d4f #i4b #ah4d #bg4h #cg4b #df4h #ef4d #ge4h #ie4h #c fl4 oz #f4i #ac4h #bg4f #da4g #ee4h #gj4b #hd4f #aac4g #adc4g #d fl4 oz #i4b #ah4d #cf4h #ee4f #gd4d #ic4f #aab4h #aea4f #aia4f #e fl4 oz #aa4e #bc4 #df4 #fi4e #ic4 #aag4 #ada4 #ahi4e #bci4e ,quantity of solution ,,grains ,,of ,,salt ,,or ,,drug ,,required ,,to ,,make ,,solutions ,,of ,,percentage to be ,,strength ,,indicated made #ae #bj #be #ej #a3ejj #a3ajjja3bjjja3cjjja3djjja3ejjj fl4 oz #cf4h #ej4b #fe4 #aea4b #j4df #j4bbh #j4ab #j4jge #j4jf #j4je #a fl4 oz #gc4e #ajj4c #acj4 #cjb4e #j4ia #j4def #j4bc #j4ae #j4ab #j4ji #b fl4 oz #adg4 #bjj4f #bfj4 #fje4 #a4h #j4ia #j4df #j4c #j4bc #j4ah #c fl4 oz #bbj4e #cja4 #cij4 #ijg4e #b4g #a4cg #j4fh #j4df #j4cd #j4bg #d fl4 oz #bid4 #dja4b #ebj4abaj4 #c4fd #a4hb #j4ia #j4fa #j4df #j4cf #e fl4 oz #cfg4e #eja4e #fej4aeab4e #d4ee #b4bh #a4ad #j4gf #j4eg #j4df ,the table shows the quantity of drug required to yield a given volume of solution of the percentage strength desired4 ,thus1 to make one fluid ounce of a #e per cent solution it is merely necessary to dissolve #bc4d grains of the salt in sufficient water to make one fluid ounce4 ,,therapeutic ,,index ,young's ,rule for ,dosage3 ,the age of the child is divided by the age of the child plus #ab1 and the result is the appropriate dose for the child4 ,the doses given below are for the adult unless otherwise specified4 ,absorbent4 ,a medicine or dressing that promotes absorption1 such as potassium iodide1 ,tr4 iodine1 glycerine1 or hot vaginal douches4 ,adrenalin4 ,the blood-raising principle of the suprarenal glands4 ,it is hmostatic and astringent4 ,acts somewhat like digitalis on the heart4 ,uses4--,vomiting of pregnancy1 increased glandular activity1 hmorrhage1 inflammation of mucous membranes4 ,dose4--,internally1 #e-aj m4 of the #a3ajjj solution4 ,externally1 the solution of #a3ajjj or #a3aj1jjj may be applied4 ,albolene4 ,an oily white substance obtained from petroleum4 ,it is used on the nipples and skin of the mother and to remove the vernix caseosa from the skin of the child4 ,aloin1 ,strychnia1 and ,belladonna4 ,a laxative pill which usually contains aloin gr41 strychnia sulph4 #a_/fj gr41 and ,belladonna #a_/ab gr4 ,ammonia ,carbonate4 ,antispasmodic1 stimulant1 and expectorant4 ,uses4--,stimulant to heart4 ,stimulating expectorant in pneumonia and bronchitis4 ,dose4--#e-bj grains in mucilage or syrup4 ,ansthone4 ,a mixture of adrenalin chloride 7#j4a7 and chlorotone 7#e7 in an ointment base of wool fat and petrolatum4 ,astringent1 antiseptic1 anesthetic and germicide4 ,useful application to swollen mucous membranes or in coryza4 ,argyrol 7,silver ,vitellin74 ,antiseptic and germicide4 ,uses4--,like ,silver ,nitrate1 but less irritating to the tissues4 #c-e solution in water is an injection for gonorrha4 #ae solution dropped in the eyes of the newborn may prevent ophthalmia4 #be solution may be used twice a day as a remedy for existing ophthalmia1 but the strength should be reduced after three or four days4 #aj-ae solution is used as an injection in cystitis4 ,an ounce or more of the solution may be left in the bladder until the next evacuation4 ,asaftida4 ,a fetid gum resin4 ,carminative1 antispasmodic1 mild stimulant1 and expectorant4 ,uses4--,gas pains of adults and infants4 ,hysteria and indigestion4 ,dose4--#e-aj gr4 t4i4d4 ,for infantile colic1 an emulsion called the mistura of asaftida may be used in #b-d dram doses4 ,for adults #a-b tablespoonfuls4 ,belladonna4 ,nervine1 mydriatic1 sedative1 narcotic1 antispasmodic and anodyne4 ,makes the throat dry and dilates the pupils4 ,uses4--,night sweats1 nervous cough1 pain1 incontinence of urine and to restrain glandular activity4 ,dose4--,fl4 ext4 #a-c 2 dry ext4 -#a gr4 ,tincture #h-bj 4 ,solid ext4 gr4 ,all for adults4 ,for infants1 proportionately less4 ,see ,rule for ,dosage4 ,benzoin4 ,antiseptic and externally a styptic and protective for sores4 ,uses4--,sore nipples and urticaria4 ,lard is also benzoinated for use in removing vernix caseosa4 ,compound ,tr4 of benzoin contains1 benzoin1 purified aloes1 storax1 balsam of ,peru1 and alcohol4 ,benzoinal4 ,albolene mixed with benzoin4 ,bismuth ,subnitrate4 ,a white heavy powder4 ,antiseptic and astringent4 ,uses4--,subacute gastritis1 pyrosis1 diarrha and vomiting of pregnancy4 ,particularly desirable in infancy because it is free from arsenic1 lead and silver4 ,dose4--#e-fj gr4 in the adult4 ,boric ,acid 7,boracic ,acid74 ,a white crystalline powder4 ,antiseptic4 ,uses4--,as a dressing and lotion for eyes1 navel1 mouth1 nipples1 and all mucous surfaces4 ,in solution to preserve the sterility of rubber nipples until they are needed4 ,dose4--,internally1 #e-ae gr4 ,solutions are usually about #d or #e4 ,a saturated solution in water is about #f4 ,in hot water #be4 ,boroglyceride4 ,an antiseptic paste of boric acid and glycerine4 ,when an excess of glycerine is present the preparation is called boroglycerol4 ,uses4--,an oxydizer in endometritis4 ,it is applied to the cervix on cotton tampons4 ,calcium 7,lime74 ,stomach sedative1 soothes the irritated or burned skin1 corrects hyperacidity1 increases the clotting power of the blood 7874 ,lime water is a saturated solution of calcium hydrate and is used for nausea1 to break up the curds of milk1 and to increase its digestibility4 ,it is mildly constipating4 ,calomel4 ,see ,mercury4 ,camphor4 ,a solid volatile oil4 ,nerve sedative4 ,anaphrodisiac4 ,antispasmodic4 ,stimulant4 ,uses4--,the monobromated camphor is given internally for hysteria1 neuralgia1 and as a hypnotic4 ,dose4--#a-aj gr4 ,camphorated ,oil4 ,a solution of camphor in cottonseed oil4 ,rubefacient and stimulant4 ,uses4--,internally in collapse4 ,externally as an application to the child for colds of chest and nose4 ,dose4--#e-bj hypodermically in collapse4 ,the injection should be made deep into the muscle4 ,carbolic ,acid 7,phenol74 ,derived from coal tar4 ,antiseptic1 deodorant and local ansthetic4 ,uses4--,vomiting of pregnancy1 pruritus1 eczema1 sterilization of instruments4 ,usual solution is #b to #e4 ,for sterilization of knives1 scissors and other sharp instruments the #ie is used4 ,in pruritus1 the following wash will aid3 carbolic acid1 #ab dr41 glycerine #b dr41 alcohol1 #d water q4s4 #a pt4 ,apply4 ,cascara ,sagrada4 ,stimulant laxative1 and cathartic4 ,useful in pregnancy1 but after labor there is evidence that it may go over in the milk to the child4 ,dose4--,fl4 ext4 #aj-bj 4 ,the ,hinkle pill contains cascara4 ,castor ,oil4 ,oil expressed from the seeds of the castor plant4 ,a cathartic4 ,acts in four or five hours4 ,dose4--,for adults1 oz4 to #a oz4 ,for infants #aj to #fj drops given with a dropper--not with a spoon4 ,castor oil cocktail4--,rinse out the glass with lemon juice or whiskey4 ,pour in teaspoonful of lemon juice and a teaspoonful of whiskey1 add castor oil in amount required1 cover with whiskey and give4 ,a paste is made from the mixture of castor oil and bismuth subnitrate in equal parts1 which is an excellent preparation for sore nipples4 ,cerium ,oxalate 7and ,cerium ,valerianate74 ,sedative and nerve tonic4 ,the oxalate is a white crystalline powder1 odorless and tasteless4 ,uses4--,vomiting of pregnancy1 seasickness4 ,dose4--#b-aj gr4 several times daily4 ,charcoal4 ,administered in tablet form or as a powder between two slices of buttered bread4 ,uses4--,acid stomach4 ,vomiting of pregnancy4 ,chinosol4 ,nonpoisonous1 nonirritating and odorless4 ,antiseptic deodorant1 styptic and analgesic4 ,dissolves instead of coagulates secretions4 ,uses4--,antiseptic solutions for hands and sponges1 deodorizing wash for vagina post partum1 intrauterine douche1 wash for gonorrha and cystitis4 ,dose4--,for douche or hand solution #a3ajjj or #a3ejjj4 ,for dusting powder1 #a part to #aj or #bj of starch1 talcum1 boric acid1 or bismuth subnitrate4 ,chinosol will corrode unplated steel4 ,it may be mixed with salt1 but not with soap4 ,choral ,hydrate4 ,white crystal masses4 ,pungent in odor and taste4 ,hypnotic1 antispasmodic1 antiseptic and analgesic4 ,uses4--,insomnia1 eclampsia1 convulsions1 and to restrain secretion of milk4 ,dose4--,by mouth1 #aj-cj gr4 ,by rectum1 not to exceed #fj gr4 ,in infants #a-b gr4 by rectum in an ounce of water4 ,chymogen4 ,a preparation of rennin 7#aj7 made by ,armour ,company4 ,coagulen ,ciba4 ,a physiological nontoxic styptic1 prepared from the natural coagulants of the blood4 ,a #aj solution in water will hasten the beginning and end of coagulation4 ,may be applied to bleeding surfaces directly1 or given under the skin1 into the muscle1 or into a vein4 #c to #e solution in distilled water1 should be sterilized by boiling #b-c minutes4 ,do not filter4 ,inject4 ,cocaine ,hydrochlorate4 ,ansthetic1 sedative1 anodyne1 anti-pruritic4 ,uses4--,vomiting of pregnancy1 with caution4 ,dose4--,internally -#a gr4 ,externally a #d-aj solution in water4 ,codeine4 ,alkaloid of opium4 ,less narcotic than morphine4 ,uses4--,after-pains and pain of over-distended breasts4 ,dose4--#a gr4 by mouth4 - gr4 hypodermically4 ,compound ,licorice ,powder4 ,see ,senna4 ,condylomata4 ,use-- ,acid4 ,salicyl4 gr4 x ,acid ,boric4 gr4 xxx ,calomel4 i ,m4 ,sig43 ,apply twice daily4 ,digitalis4 ,cardiac tonic4 ,diuretic4 ,stimulant4 ,uses4--,weak heart4 ,syncope4 ,collapse4 ,dose4--,for adult3 of the tincture1 #e-ae 1 fl4 ext4 #a-c 1 ext4 gr4 #a_/f4 ,digipuratum4 ,a preparation of digitalis from which the inactive substances have been removed4 ,it is used in the same conditions as digitalis4 ,dose4--,the tablets contain #a gr4 and one is given four times daily until ten are taken4 ,then stop4 ,hypodermically4 ,each viol contains #a c4c4 of fluid and equals #a gr4 of digipuratum4 ,each dose contains enough of the active principle of digitalis to kill a #cj gm4 frog4 ,ergot 7,fungus of ,rye74 ,contracts unstriped muscle fiber4 ,uses4--,to check hmorrhage after labor4 ,to promote involution4 ,must not be given in labor until the uterus is empty4 ,dose4--,by mouth #ae-fj of the fl4 ext4 ,hypodermically1 #aj-bj 4 ,ergotole1 ,ergotine4 ,concentrated solutions of ergot1 #b times as strong as the fluid extract4 ,they are sterilized and preserved in glass ampoules4 ,uses4--,see ,ergot4 ,dose4--#cj-fj 4 ,green ,soap4 ,a soap made of linseed or other oil1 potash1 alcohol and water4 8,the adoption by the ,u4 ,s4 ,pharmacopoeia of the term ,sapo ,viridis 7green soap7 is unfortunate1 since soft soap even if made from green hempseed oil will become brown-yellow unless artificially colored40--,u4 ,s4 ,dispensatory4 ,hmophilia4 ,a condition of the blood wherein its clotting power is diminished or absent4 ,coagulen1 horse serum1 or diphtheria antitoxin may be given hypodermically4 ,direct transfusion of blood from another is best4 ,hyoscine1 ,morphine1 and ,cactin4 7,h4 ,s4 ,c4 ,tablets74 ,a proprietary combination of drugs4 ,the action is said to be similar to that of morphine and scopolamine4 ,iodine1 ,tincture4 ,uses4--,to sterilize the skin before operation4 ,in vomiting of pregnancy it is sometimes effective4 ,drop doses may be given well diluted4 ,externally it is applied to ulcers1 as in ,bednar's disease1 and sometimes as a dressing for the cord4 ,in pruritus vulv it is a valuable application4 ,iron4 ,tonic emmenagogue4 ,uses4--,to increase the number of red blood corpuscles4 ,to raise blood pressure and to increase the secretion of milk4 ,dose4--#c-e gr4 ,blaud's pill contains the carbonate in a form that is easily assimilated4 ,laxatives4 ,laxatives are unirritating and excite moderate peristalsis4 ,sulphur1 magnesia1 cassia1 manna1 cascara sagrada1 the ,hinkle pill1 and the ,a1 ,b1 ,s pill are usually mild in action4 ,lysol4 ,disinfectant and antiseptic for hands and instruments4 ,it is a brown syrupy fluid made from coal tar oil1 which is distilled and mixed with fat1 soap1 etc4 ,it has a creosote odor and contains #ej cresol4 ,readily soluble in water4 ,prepared in -#d solutions4 ,magnesia1 ,calcined4 ,antacid and cathartic4 ,comes in white cakes4 ,uses4--,acid stomach1 vomiting of pregnancy1 8heartburn10 and constipation4 ,dose4--#cj-abj gr4 ,magnesia1 ,milk of4 ,a mixture of magnesia and water4 ,has the same properties as the above4 ,dose4--,for adults1 #b-c teaspoonfuls4 ,for infants1 -#b teaspoonfuls4 ,magnesia ,sulphate 7,epsom ,salts474 ,saline cathartic4 ,uses4--,the profuse watery stools produced by magnesia are valuable aids to elimination when the kidneys are overworked or defective4 ,in congestion of the breasts and threatened eclampsia1 or in any case where it is desirable to drain off waste or dehydrate the system4 ,dose4--#a teaspoonful daily in hot water before breakfast4 -#a oz4 as a single dose or #a oz4 by rectum1 as in the #a-b-c enema4 ,menthol 7,mint ,camphor1 ,japanese ,peppermint74 ,analgesic1 antiseptic1 ansthetic1 and vascular stimulant4 ,uses4--,in pruritus vulv1 vomiting of pregnancy1 and hmorrhoids4 ,dose4--,by mouth #c-e gr4 ,in tampons1 one part to five of oil4 ,in ointments one part to sixteen4 ,to the vulva for pruritus1 use the spirits in #e solution4 ,mercury 7,hydrargyrum74 ,cathartic1 alterative1 antisyphilitic1 antiseptic and disinfectant4 ,readily absorbed by the unprotected mucous surface and relatively inert when the membrane is covered by a discharge4 ,solutions of the bichloride when used as a lotion unite with the albumin of a mucous discharge and form an albuminate of mercury1 which is inactive4 ,bichloride solutions have small place in obstetrics4 ,they are hard on the hands and destructive to instruments4 ,other agents like lysol1 ziratol and chinosol have satisfactory germicidal properties and in addition are nonpoisonous1 lubricative and cleansing4 ,mercury should only be given to the infant in the form of calomel 7the mild chloride74 ,the dose is #a_/ab- gr41 repeated if necessary4 ,morphine4 ,alkaloid of opium4 ,antispasmodic1 hypnotic1 analgesic and narcotic4 ,uses4--,to relieve pain1 produce sleep1 check diarrha1 and to control the pain1 as well as the contractions of abortion4 ,to relax a rigid os4 ,dose4--,in 8,twilight ,sleep0 and rigid os the first dose is ,morph4 sul4 #a_/f gr4 and scopolamine ,hydrobromid #a_/bjj-a_/aej4 ,the scopolamine to be repeated if required1 in one-half or three-quarters of an hour4 ,the usual dose of morphine hypodermically is #a_/ab gr4 ,nitroglycerine 7,glonoin74 ,vasomotor dilator1 arterial stimulant4 ,uses4--,for the prostration following hmorrhage4 ,dose4-#jj-a_/ej gr4 hypodermically4 ,novocaine4 ,local ansthetic1 similar to cocaine1 but less toxic4 ,for local ansthesia in solutions of #j4be to #b usually in association with adrenalin 7#e-aj drops of the #a3ajjj solution to each #aj c4c4 of novocaine solution74 ,nux ,vomica4 ,the plant from which strychnia is derived4 ,tonic1 stomachic1 and stimulant to muscle1 nerve1 and heart4 ,uses4--,bitter tonic and stimulant4 ,vomiting of pregnancy and agalactia4 ,dose4--,ten drops of the tincture in water before meals4 ,opium4 ,the concrete juice of the poppy4 ,relieves pain4 ,constipates4 ,uses4--,hmorrhoids in adults1 colic and diarrha in infants4 ,dose4--,one grain in suppository night and morning for adult4 ,for infant1 as paragoric only4 ,two to five drops only1 not repeated4 ,children bear opium badly4 ,pepsin4 ,a ferment in the gastric juice that digests proteins4 ,in commerce it is obtained from the pig4 ,uses4--,imperfect digestion4 ,dose4--,for adult1 #aj-ae grs4 ,for infant1 #b gr4 ,phenolphthalein4 ,a nonofficial coal tar derivative4 ,mild laxative4 ,dose4--#b-c gr4 ,phenolax and chocolax are preparations of the drug4 ,pituitary ,extract 7,pituitrin74 ,a substance derived from the infundibular portion or the posterior lobe of the hypophysis cerebri4 ,nontoxic1 stimulant to unstriped muscle4 ,uses4--,uterine inertia1 post partum hmorrhage1 ,csarean section and tympany4 ,will not produce abortion nor premature labor4 ,may be tried in acute anmia to raise the blood pressure4 ,dose4--#e-ae 4 ,repeated if necessary4 ,potassium 7or ,sodium7 ,bromide4 ,white granular powder4 ,soluble1 #a to #e in water4 ,sedative1 hypnotic1 antiepileptic4 ,uses4--,neurasthenia1 convulsions1 nymphomania1 vomiting of pregnancy4 ,dose4--#bj-fj gr4 ,in enema with chloral4 ,pot4 bromide #dj gr4 and chloral #bj gr4 in several ounces of water or milk4 ,potassium ,iodide4 ,alterative emmenagogue4 ,uric acid solvent4 ,uses4--,syphilis rheumatism1 swellings1 slow inflammations1 excessive secretion of milk4 ,dose4--#b-aj gr4 increased as required4 ,potassium ,permanganate4 ,dark purple opaque prisms4 ,soluble in water #a to #af4 ,disinfectant1 deodorant1 antiseptic1 astringent4 ,uses4--,as an injection in leucorrha and gonorrha1 #a3ejjj solution4 ,purgatives4 ,simple purgatives produce free discharges from the bowels with some griping4 ,senna1 aloes1 rheubarb1 castor oil1 and calomel are examples4 ,saline purgatives are followed by profuse watery evacuations4 ,magnesia sulphate1 and citrate1 potassium and sodium tartrate1 and sodium phosphate belong to this class4 ,drastic purgatives bring about a violent action of the bowels with much griping and tenesmus4 ,such are jalap1 colocynth1 elaterium1 and croton oil4 ,hydrogogue purgatives combine the results of the salines and drastics4 ,they have much griping with profuse watery stools4 ,the hydrogogues are elaterium1 gamboge1 croton oil1 and potassium bitartrate4 ,quinine ,sulphate4 7,derived from ,cinchona bark47 ,antipyretic1 tonic1 antiperiodic1 antiseptic1 emmenagogue and ecbolic4 ,uses4--,valuable stimulant in a slow first stage4 ,it is combined with castor oil to bring on labor at term4 ,castor oil #a oz4 and quinine sulphate #aj gr4 is given as the first dose1 followed in an hour by another #aj gr4 of quinine1 and an hour later by another4 ,dose4--#b-bj gr4 ,regulin4 ,a mixture of agar-agar in dry form with extract of cascara sagrada4 ,uses4--,a laxative in chronic constipation4 ,dose4--,teaspoonful to tablespoonful in stewed fruit or mashed potatoes1 once daily4 ,russian ,oil 7,liquid ,petrolatum74 ,laxative in pregnancy and puerperium4 ,acts mechanically and as a lubricant4 ,not unpleasant to take4 ,dose4- oz4 at bedtime1 and1 if necessary1 before each meal4 ,may be given to breast-fed babies in doses of gtts4 xv three times daily4 ,senna4 ,laxative and purgative4 ,acts especially on the large intestine4 ,sometimes passes over in the milk to the child4 ,dose4--,fl4 ext4 #a-d teaspoonfuls4 ,in compound licorice powder the dose is #cj-hj gr4 7about #aj gr4 of senna to the dose74 ,silver ,nitrate4 ,caustic1 antiseptic1 stimulant1 irritant and antigonorrhic4 ,table salt neutralizes it4 ,uses4--#b solution in water for pruritus vulv4 #a solution dropped into the eyes of the newborn to prevent ophthalmia neonatorum4 ,do not neutralize the #a solution4 gr4 silver nitrate with #b gr4 of pepsin in capsule for pernicious vomiting of pregnancy4 ,sodium ,bicarbonate 7,baking powder74 ,antacid1 antirheumatic4 ,uses4--,gout1 dyspepsia1 acid stomach1 acidosis1 vomiting of pregnancy4 ,soothes the skin when burned4 ,sodium ,chloride4 7,salt47 ,for normal saline use #aj gr4 to #c oz4 of water4 ,for physiological salt solution1 add #ae gr4 of ,sod4 ,carb4 to every #c oz4 of normal saline as made above4 ,sodium ,citrate4 ,a white odorless1 granular powder with cooling salty taste4 ,uses4--,diuretic1 antipyretic and refrigerant4 ,retards the coagulation of albumin in milk and aids the digestibility of proteins4 ,may be indicated in gout and cystitis4 ,dose4--,internally1 #ae to #fj gr4 ,in the modification of cow's milk about two grains should be used for each ounce of the mixture4 ,spirits of ,nitre1 ,sweet 7,spirit ,nitrous ,ether74 #d solution of nitrous ether in alcohol4 ,diaphoretic1 diuretic1 antipyretic1 stimulant1 antispasmodic4 ,uses4--,fever1 dropsy1 vomiting of pregnancy1 colic1 anuria4 ,dose4--,for adult1 #bj-fj gtts4 ,for infants small doses often repeated4 ,stramonium 7,jimson ,weed74 ,hypnotic1 narcotic1 antispasmodic4 ,uses4--,for hmorrhoids take ,ung4 ,stramonii and ,ung4 ,galli in equal amounts and apply4 ,urotropin4 ,a white powder soluble in water4 ,urinary antiseptic1 diuretic4 ,uses4--,cystitis1 typhoid bacilli in urine1 gout4 ,it makes the urine irritatingly acid when given long4 ,it does not act in alkaline media4 ,dose4--#g-aj gr4 well diluted4 ,valerian4 ,anodyne1 stimulant1 antispasmodic and nervine4 ,uses4--,hysteria1 hypochondriasis1 headache4 ,dose4--#cj-fj of the fl4 ext4 by mouth1 or by rectum #b oz4 of the following mixture may be used ,p4,r4,n4 for hysteria3 ,pot4 ,brom4 #a oz4 ,ext4 ,valerian fl4 dr4 vi4 ,normal saline q4s4 oz xii4 ,veratrum ,viride 7,hellebore74 ,sedative1 emetic1 diaphoretic1 diuretic4 ,retards the heart's action without weakening it4 ,uses4--,eclampsia4 ,dose4--#a to #d of the fl4 ext4 is given hourly until the pulse comes down to #hj4 ,veronal4 ,safe1 reliable hypnotic4 ,uses4--,insomnia from hysteria1 neurasthenia1 and mental disturbance4 ,dose4--#e to #ae gr4 dissolved in hot tea1 milk1 or water4 ,may repeat4 ,zinc4 ,tonic1 astringent1 antispasmodic4 ,uses4--,stearate of zinc is a valuable dressing in excoriations of buttocks and external genitals4 ,zinc ,ointment4 ,it is indicated for bedsores 7decubitus7 eczema1 herpes1 and intertrigo4 ,zinc ointment contains one part of zine oxide to four parts of benzoinated lard4 ,ziratol4 ,a mixture of phenols in soap1 water1 and glycerine4 ,antiseptic1 deodorant and germicide4 ,relatively odorless1 easily soluble and does not injure hands1 instruments1 or rubber4 ,it is said to be only as toxic as carbolic acid4 ,used in solutions of #j4e up to #e4 ,,glossary ,adapted from ,dorland and ,standard ,dictionaries ,ab-normal4 ,not normal2 contrary to the usual structure or condition4 ,a-bortion4 #a4 ,the expulsion of the ftus before it is viable4 #b4 ,premature stoppage of a morbid or a natural process4 ,ab-rasion4 #a4 ,a rubbing or scraping off4 #b4 ,a spot rubbed bare of skin or mucous membrane4 ,abscess4 ,a localized collection of pus in a cavity formed by the disintegration of tissues4 ,ac-couche-ment4 ,delivery in childbed2 confinement4 ,ace-tone4 #a4 ,a colorless liquid found in pyro-acetic acid and in naphtha4 #b4 ,any member of the series to which the normal or typical acetone belongs4 ,aci-dosis4 ,acid intoxication of the system from the elaboration or too much acid by faulty metabolism or the imperfect disposition of normal amounts of acid4 ,a-cinus1 pl4 acini4 ,one 7acini1 more than one7 of the smallest lobules of a compound gland4 ,albo-lene4 ,an oily white substance derived from petroleum4 ,albu-mi-nuri-a4 ,the presence of albumin in the urine4 ,alka-line4 ,having the reaction of an alkali4 ,amen-or-rha4 ,absence or abnormal stoppage of the menses4 ,am-moni-a4 ,a colorless alkaline gas1 ,,nh#c1 of penetrating odor1 and soluble in water1 forming ammonia-water4 ,ammoniacal urine contains ammonia1 which is one form of nitrogen excretion4 ,an-mi-a4 ,a condition in which the blood is deficient in quantity or in quality4 ,ans-thesi-a4 ,loss of feeling or sensation1 especially loss of tactile sensibility1 though the term is used for loss of any of the other senses4 ,ans-thetic4 #a4 ,without the sense of touch or of pain4 #b4 ,a drug that produces ansthesia4 ,anal-gesi-a4 ,absence of sensibility to pain4 ,an-aphro-disi-ac4 ,a drug that allays sexual desire4 ,ana-sarca4 ,an accumulation of serum in the cellular tissues of the body4 ,anen-cephal-ous4 ,having no brain4 ,anky-losis4 ,abnormal rigidity or stiffness of a joint4 ,ano-dyne4 ,a medicine that relieves pain4 ,ante partum4 ,latin for 8before delivery40 ,an-teri-or4 ,situated in front of1 or in the forward part of4 ,anti-peri-odic4 ,a drug that tends to prevent recurrent attacks of disease4 ,anti-septic4 #a4 ,preventing decay or putrefaction4 #b4 ,a substance destructive to poisonous germs4 ,a-peri-ent4 ,mildly cathartic4 ,ap-na4 ,the absence of respiration--especially that form which occurs in a child delivered by the ,csarean operation4 ,a-reo-la4 ,the darkish ring around the nipple4 ,as-cites4 ,dropsy 7an accumulation of fluid7 in the abdomen4 ,a-sepsis4 ,absence of septic matter1 or freedom from infection4 ,as-phyxi-a4 ,suffocation4 ,as-tringent4 #a4 ,causing contraction and arresting discharges4 #b4 ,an agent that arrests discharges4 ,ate-lec-tasis4 ,imperfect expansion of the lungs at birth2 partial collapse of the lung4 ,aton-y4 ,lack of normal tone or strength4 ,atri-um4 7,l41 a hall47 ,the point of entrance of a bacterial disease4 ,atti-tude4 ,a posture or position of the body4 ,the relation which the various parts of the child's body bears to its own long axis4 ,the attitude of the ftus normally is complete flexion4 ,auscul-tation4 ,the act of listening for sounds within the body4 ,bac-teri-a4 ,the vegetable microorganisms 7,schizomycetes7 especially the short-rod forms4 ,balan-itis4 ,inflammation of the glans penis4 ,it is usually associated with phimosis4 ,bal-lottement4 ,the diagnosis of pregnancy by pushing up the uterus by a finger inserted into the vagina so as to cause the embryo to rise and fall again like a heavy body in water4 ,bartho-lin glands4 ,the vulvo-vaginal glands4 ,bleb4 ,a skin vesicle filled with fluid4 ,a blister4 ,bregma4 ,the point on the surface of the skull at the junction of the coronal and sagittal sutures4 ,c-sare-an section4 7,named from ,julius ,csar1 who is said to have been thus born74 ,delivery of the ftus by an incision through the abdominal and uterine walls4 ,caput4 ,any head1 or head-like structure4 ,caput succe-dane-um4 ,a swelling formed on the presenting part of the ftus during labor4 ,it is due to the effusion of fluid into the subcutaneous tissues of the scalp and its retention there4 ,car-mina-tive4 ,drugs that stimulate the circulation1 the mental faculties1 and intestinal peristalsis4 ,asaftida1 camphor1 capsicum1 cardamon1 chloroform1 ether1 ginger1 horseradish1 mustard1 and the oils of anise1 cloves1 spearmint1 nutmeg and valerian are carminatives4 ,carne-ous4 ,fleshy4 ,cathe-ter1 trache-al4 ,a long slender tube designed for introduction into the babe's trachea as a means of sucking out mucus4 ,cathe-ter-ize4 ,to introduce a tube and draw off fluid1 as urine or mucus4 ,caul4 #a4 ,the great omentum4 #b4 ,a piece of amnion which sometimes envelopes a child's head at birth4 ,cell4 #a4 ,any one of the minute protoplasmic masses which make up organized tissue4 ,ceph-alic4 #a4 ,pertaining to the head4 #b4 ,a medicine for the head4 ,cephal-h-ma-toma4 #a4 ,a tumor or swelling filled with blood beneath the pericranium4 ,cervix4 ,the neck or any neck-like part4 ,chlo-asma4 ,the yellowish brown spots or patches that appear on the skin of pregnant women4 ,cica-tricial4 ,pertaining to1 or of the nature of1 a cicatrix4 ,ci-catrix4 ,a scar2 the mark left by a sore or wound4 ,cili-a4 #a4 ,the eyelashes4 #b4 ,minute lash-like processes that characterize certain cells4 ,climac-teric4 ,a particular epoch of the ordinary term of life at which the body is believed to undergo a radical change--especially applied to the menopause4 ,cli-nicians4 ,men who teach and explain diseases by showing actual cases4 ,clito-ris4 ,the sensitive organ of the female1 homologous with the penis in the male4 ,coccyx4 ,the small bone situated at the end of the sacrum4 ,the very last portion of the spine4 ,col-lapse4 ,a state of extreme prostration and depression with failure of circulation4 ,colles' membrane4 ,a layer of tough sensitive fascia back of the perineum and on either side of the vagina4 ,co-lostrum4 ,the first fluid secreted by the mammary glands after functional activity begins4 ,it contains casein and more albumen than milk1 as well as numerous fatty globules4 ,colpeu-rynter4 ,a dilatable bag1 used to distend the vagina4 ,coma4 ,profound stupor occurring in the course of a disease or after severe injury4 ,coma-tose4 ,pertaining to1 or affected with1 coma4 ,compli-cation4 ,a disease or diseases concurrent with another disease4 ,con-ception4 ,the fecundation of the ovum4 ,condyl-oma4 ,a wart-like excrescence near the anus or vulva4 ,it may be as large as a cauliflower4 ,con-geni-tal4 ,born with a person2 existing at or before1 birth4 ,conju-gate4 ,the anteroposterior diameter of the pelvic inlet4 ,coro-nal4 ,pertaining to the crown of the head1 as the coronal suture4 ,cradle cap4 ,the dirty looking patch of epithelial scales and sebaceous material that develops over the anterior fontanelle of babies who have the exudative diathesis4 ,crani-oto-my4 ,the cutting in pieces of the ftal head to facilitate delivery4 ,cre-d ,expression4 ,the maneuver 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 placenta4 ,cre-d ,treatment4 ,the instillation of a #a solution of nitrate of silver into the eyes of the newborn to prevent ophthalmia4 ,curd4 ,the coagulum of milk1 consisting mainly of casein4 ,cyan-osis4 ,blueness of the skin1 often due to cardiac malformation causing insufficient oxygenation of the blood4 ,cys-titis4 ,inflammation of the bladder4 ,de-cidu-a4 ,the membranous structure produced in the uterus during gestation and thrown off after parturition4 ,d4 reflexa1 the part of decidua which is reflected upon and surrounds the ovum4 ,d4 serotina1 the late decidua2 the part of the decidua vera which becomes the maternal portion of the placenta4 ,d4 ,vera1 the true decidua2 the portion of the decidua which lines the uterus4 ,de-cubi-tus4 #a4 ,an act of lying down4 #b4 ,a bed-sore4 ,de-hydrate4 ,to remove the water4 ,dia-betes4 ,a disease marked by an habitual discharge of an excessive quantity of urine and the presence of sugar therein4 ,diaph-o-resis4 ,perspiration1 and especially profuse perspiration4 ,diaph-o-retic4 #a4 ,stimulating the secretion of sweat4 #b4 ,a medicine that increases the perspiration4 ,di-athe-sis4 ,natural or congenital predisposition to a special disease4 ,differ-ential4 ,pertaining to a difference1 or differences4 ,dis-crete4 ,separate lesions which do not blend or coalesce4 ,diu-resis4 ,increased secretion of urine4 ,dorsum4 ,the back or any part corresponding to the back as the dorsum of the penis or foot4 ,ductus ve-nosus4 ,a ftal blood vessel connecting the umbilical vein with the post-cava4 ,dys-crasi-a4 ,a depraved state of the system1 and especially of the blood1 due to constitutional disease4 ,dysp-na4 ,difficult or labored breathing4 ,dys-toci-a4 ,painful or slow delivery or birth4 ,ec-bolic4 ,an agent that accelerates labor4 ,e-clampsi-a4 ,a sudden attack of convulsions1 especially one of a peripheral origin4 ,ec-topic4 ,out of the normal place4 ,e-dema4 ,swelling due to effusion of watery liquid into the connective tissue4 ,embo-lism4 ,the plugging of an artery or vein by a clot or obstruction which has been brought to its place by the blood-current4 ,embry-o4 ,the ftus in its earlier stages of development1 especially before the end of the third month4 ,em-mena-gogue4 ,a drug that aids or stimulates menstruation4 ,e-mulsion4 ,an oily or resinous substance divided and held in suspension through the agency of an adhesive1 mucilaginous1 or other substance4 ,endo-metri-um4 ,the mucous membrane that lines the cavity of the uterus4 ,en-gagement4 ,the head is said to be engaged when the largest diameters have passed the inlet4 ,ensi-form4 ,shaped like a sword4 ,epi-si-oto-my4 ,surgical incision of the vulvar orifice laterally for obstetric purposes4 ,e-rosion4 ,an eating or gnawing away4 ,ery-thema4 ,a morbid redness of the skin due to congestion of the capillaries1 of many varieties4 ,eti-olo-gy4 ,the study or theory of the causation of any disease4 ,ex-cori-ation4 ,any superficial loss of substance such as that produced on the skin by scratching4 ,exos-mosis 7,ex-os-mose74 ,diffusion or osmosis from within outward4 ,ex-sanguin-ation4 ,an exhaustion of the blood from a part or the whole of the body4 ,ex-traction4 ,the process or act of pulling or drawing out1 particularly the removal of a child by pulling either with hands or forceps4 ,extra-uter-ine4 ,situated or occurring outside of the uterus4 ,exu-dative di-athe-sis4 ,a congenital predisposition to eczema in various parts of the body1 as well as to infections of the respiratory tract4 ,fces 7or feces74 ,the excrement or undigested residue of the food discharged from the bowels4 ,fenes-tra-ted4 7,l41 fenestrum1 a window47 ,pierced with one or more openings1 like windows4 ,ferment4 ,any substance that causes fermentation in other substances with which it comes in contact4 ,fibrin4 ,a substance which1 becoming solid in shed blood1 plasma and lymph1 causes the coagulation of these fluids4 ,fillet4 #a4 ,a loop-shaped structure4 #b4 ,a loop1 as of cord or tape1 for making traction4 ,fissure4 ,a cleft or groove1 normal or other4 ,fistu-la4 ,a deep1 sinuous ulcer1 often leading to an internal hollow organ4 ,fluid extract4 ,a concentrated solution of the active principle of a drug in such strength that #a c4c4 of the product equals #a gr4 of the crude drug4 ,the fluid is a mixture of alcohol1 water and glycerine in varying proportions4 ,one may be omitted4 ,ftus 7or fetus74 ,the unborn offspring of any animal that brings forth living progeny2 the child in the womb after the third month4 ,fonta-nelle4 ,any one of the unossified spots on the cranium of a young infant4 ,it is so named because it rises and falls like a fountain4 ,fo-ramen4 ,a hole or perforation1 especially a hole in a bone4 ,four-chette4 ,the fold of mucous membrane at the posterior junction of the labia majora4 ,frnum 7or frenum74 ,a fold of the integument or of the mucous membrane that checks1 curbs1 or limits the movements of an organ in part--as the frnum of the tongue4 ,function4 ,the normal or proper action of an organ or set of organs4 ,function-al4 ,of or pertaining to a function4 ,fundus4 ,the base or part of a hollow organ remotest from its mouth4 ,ga-lactor-rha4 ,excessive secretion of milk4 ,ga-vage4 ,feeding by the stomach tube2 also the therapeutic use of a very full diet4 ,genit-als4 ,the reproductive organs4 ,germi-cide4 ,an agent that destroys germs4 ,ges-tation4 ,pregnancy4 ,glans cli-tori-dis4 ,the distal or outside end of the clitoris4 ,glans penis4 ,the head1 or terminal end1 of the penis4 ,gon-or-rha4 ,a contagious catarrhal inflammation of the genital mucous membrane4 ,graafi-an folli-cle4 ,any one of the small spherical ovarian bodies1 each of which contains an ovum4 ,hmo-phili-a4 ,a condition of the system wherein bleeding occurs readily1 and the blood clots slowly or not at all4 ,hmor-rhage4 ,a copious escape of blood from the vessels2 bleeding4 ,accidental h41 hmorrhage during pregnancy1 due to premature detachment of the placenta4 ,post partum h41 that which occurs soon after labor1 or childbirth4 ,unavoidable h41 that which results from the detachment of a placenta prvia4 ,hmor-rhoid4 ,a pile1 or vascular tumor of the rectal mucous membrane4 ,hy-datid4 ,an encysted vesicle containing an encysted fluid4 ,from the ,greek 8,hydatis10 meaning a drop of water4 ,hy-dati-form4 ,resembling a hydatid in form4 ,hy-dramni-os4 ,dropsy of the amnion4 ,hydro-cepha-lous4 ,a fluid effusion within the cranium4 ,this disease is marked by enlargement of the head1 with prominence of the forehead1 atrophy of the brain1 mental weakness1 and convulsions4 ,hygiene4 ,the science of health and of its preservation4 ,hymen4 ,the membranous fold which partially or wholly occludes the external orifice of the vagina1 at least during virginity4 ,hyper-eme-sis4 ,excessive vomiting4 ,h4 gra-vi-darum1 excessive vomiting of pregnancy4 ,hyper-mi-a4 ,excess of blood in any part of the body4 ,hy-pertro-phy4 ,the morbid enlargement or overgrowth of a part4 ,hyp-notic4 ,a drug that induces sleep4 ,hypo-der-mocly-sis4 ,the introduction1 into the subcutaneous tissues1 of fluid in large quantity4 ,hypo-gastric4 ,of or pertaining to the lower anterior region of the abdomen in the middle line of the body4 ,the hypogastric arteries arise from the internal iliac in addition to the branches given off from those vessels in the adult4 ,hypo-phosphite4 ,any salt of hypophosphorous acid4 ,icter-us4 ,jaundice4 ,idi-o-syncra-sy4 ,an effect abnormal to the one usually produced4 ,an effect peculiar to the individual4 ,im-muni-ty4 ,the condition of being immune or exempt from disease1 especially the condition arising from inoculation1 or from a peculiar resistance of the organism4 ,impreg-nation4 #a4 ,the act of fecundation or of rendering pregnant4 #b4 ,the process or act of saturation1 a saturated condition4 ,infarct4 ,a mass of substance extravasated either into the substance of an organ or into a vessel due to the obstruction to the circulation4 ,infan-tile pelvis4 ,a pelvis which has not responded to the developmental stimulation of the sexual glands at puberty1 and therefore remains in its infantile shape4 ,a masculine pelvis4 ,infan-tile uter-us4 ,an undeveloped uterus4 ,in-fection4 ,the communication of disease from one person to another1 whether by effluvia or by contact1 mediate or immediate2 also the implantation of disease from without4 ,infil-tration4 ,to cause a liquid or gas to penetrate or enter by pores or interstices4 ,inflam-mation4 ,a morbid condition characterized by pain1 heat1 redness and swelling4 ,in-nomin-ate4 ,not having a name1 as the innominate bone4 ,in-somni-a4 ,inability to sleep2 abnormal wakefulness4 ,inter-stitial4 ,pertaining to1 or situated in1 the interstices or interspaces of a tissue4 ,inter-trigo4 ,a chafe1 or chafed patch of the skin2 also the erythema or eczema that may result from a chafe of the skin4 ,in-troi-tus4 ,the entrance to any cavity or space4 ,in-version4 ,a turning inward1 inside out1 upside down1 or other reversal of the normal relation of a part4 ,invo-lution4 #a4 ,a rolling or turning inward4 #b4 ,the return of the uterus to its normal size after parturition4 #c4 ,a retrograde change1 the reverse of evolution4 ,is-churi-a par-a-doxa4 ,a condition in which the bladder is over-distended with urine1 although the patient continues to urinate1 generally in dribbles4 ,jaundice4 ,yellowness of the skin1 eyes1 and secretions1 due to the presence of bile pigments in the blood4 ,labi-a4 ,lip-shaped organs4 ,the external folds of the vulva1 labia majora1 and the internal folds of the vulva1 labia minora4 ,lace-ration4 #a4 ,the act of tearing4 #b4 ,a wound made by tearing4 ,lac-tation4 #a4 ,the secretion of milk4 #b4 ,the period of the secretion of milk4 #c4 ,suckling4 ,lan-ugo4 ,the fine hair on the body of the fetus4 ,lav-age4 ,the irrigation or washing out of an organ1 such as the stomach or bowel4 ,lesion4 ,any hurt1 wound or local degeneration4 ,leucor-rha4 ,a whitish1 viscid discharge from the vagina and uterine cavity4 ,lighten-ing4 ,the sense of lightness and easier breathing that follows the descent of the head into the pelvis during the last three weeks of pregnancy4 ,it is most likely to occur in primiparas4 ,lochi-a4 ,the vaginal discharge that takes place during the first week or two after childbirth4 ,lymph4 ,a transparent slightly yellow liquid of alkaline reaction which fills the lymphatic vessels4 ,mal-aise4 ,an uneasiness or indisposition1 discomfort or distress4 ,malpo-sition4 ,abnormal or anomalous position4 ,mamma4 ,the mammary gland2 the breast4 ,mamma-ry4 ,pertaining to the ,mamma4 ,ma-rasmus4 ,progressive wasting and emaciation1 especially such a wasting in young children when there is no obvious or ascertainable cause4 ,mas-sage4 ,the systematic1 therapeutic friction1 stroking and kneading of the body4 ,mas-titis4 ,inflammation of the breast4 ,me-atus4 ,a passage or opening1 as the meatus urinarius4 ,me-lna ne-o-na-torum4 ,the passage of dark pitchy stools containing blood pigments and blood that has been extravasated into the alimentary canal of the newborn babe4 ,membrane4 ,a thin layer of tissue which covers a surface or divides a space or organ4 ,meno-pause4 ,the period when menstruation normally ceases2 the change of life4 ,mis-carriage4 ,abortion2 premature expulsion of the ftus2 birth of the ftus before the twenty-eighth week4 ,milk leg 7,phlegmasia ,alba ,dolens74 ,a condition developing in one1 and rarely1 in both1 legs1 after delivery4 ,it is due to occlusion of the veins of the pelvis and leg by thrombosis or to septic inflammation of the pelvic connective tissue4 ,mole4 #a4 ,a fleshy mass or tumor formed in the uterus by the degeneration or abortive development of an ovum4 #b4 ,a nevus2 also a brownish spot on the skin4 ,mons vener-is4 ,a rounded prominence at the symphysis pubis of a woman4 ,mor-bidi-ty4 ,the condition of being diseased or morbid4 ,morcel-lation4 ,division and piecemeal removal4 ,mucus4 ,the viscid watery secretion of the mucous glands4 ,mul-tipar-a4 ,a woman who has borne more than one child4 ,mummi-fi-cation4 ,dry gangrene2 also the drying up and shrivelling of the ftus4 ,mydri-atic4 ,a drug that dilates the pupil4 ,nause-a4 ,tendency to vomit2 sickness at the stomach4 ,ne-crosis4 ,death of a tissue1 especially of a bone4 ,ne-phritis4 ,inflammation of the kidney4 ,neu-rotic4 #a4 ,pertaining to or affected with a neurosis4 #b4 ,pertaining to the nerves4 ,neutra-lize4 ,to render neutral or ineffective4 ,nitro-gen4 ,a colorless gaseous element found free in air4 ,nodu-lar4 #a4 ,like a nodule or node4 #b4 ,marked with nodules4 ,nucle-us4 #a4 a spheroid body within a cell1 forming the essential and vital part4 #b4 ,a mass of gray matter in the central nervous system4 #c4 ,in chemistry1 the central element in the molecule of a compound4 ,nutri-ent4 ,nourishing2 affording nutriment4 ,nymph4 ,the labia minora4 ,ob-stetrics4 ,the art of managing childbirth cases2 that branch of surgery which deals with the management of pregnancy and labor4 ,ob-ste-trician4 ,one who practices obstetrics4 ,occi-put4 ,the back part of the head4 ,oli-go-hy-dramni-os4 ,scantiness of the liquor amnii4 ,oli-gop-na4 ,a delay following the birth of a child before the first respiration is established4 ,oph-thalmi-a4 ,severe inflammation of the eye or of the conjunctiva4 ,organ4 ,any part of the body having a special function4 ,os4 7,l41 a mouth47 ,the orifice in the uterus or vagina4 ,os-mosis4 ,the passage of a fluid through a membrane4 ,ova4 ,latin plural of ovum1 egg4 ,ovu-lation4 ,the formation and discharge of an unimpregnated ovum from the ovary4 ,ovule4 #a4 ,the ovum within the ,graafian vesicle4 #b4 ,any small egg-like structure4 ,ovum4 #a4 ,an egg4 #b4 ,the female reproductive cell which1 after fertilization1 develops into a new member of the same species4 ,oxy-dizer4 ,anything that combines with oxygen4 ,pal-pation4 ,the act of feeling with the hand2 the application of the fingers with light pressure to the surface of the body for the purpose of determining the consistence of the parts beneath in physical diagnosis4 ,par-aly-sis1 ,erb's4 #a4 ,same as birth-palsy4 #b4 ,partial paralysis of the brachial plexus affecting various muscles of the arm and chest-walls4 ,it is revealed by an inability to lift the arm toward the head4 ,par-aly-sis facial 7,bell's74 ,paralysis of the face1 due to lesion of the facial nerve or of its nucleus4 ,para-me-tritis4 ,inflammation of the parametrium1 or cellular tissue about the uterus4 ,para-phi-mosis4 ,retraction of a narrow or inflamed foreskin which can not be replaced4 ,pa-renchy-ma4 ,the essential or functional elements of an organ as distinguished from its stroma or framework4 ,pa-rie-tal4 ,of1 or pertaining to1 the walls of a cavity4 ,paro-nychi-a4 ,infection and suppuration about the junction of nails and skin4 ,parox-ysm4 ,a sudden recurrence or sudden intensification of symptoms4 ,path-o-logic4 ,pertaining to pathology4 ,pa-tholo-gy4 ,that branch of medicine which treats of the essential nature of disease1 especially of the structural and functional changes caused by disease4 ,pel-vime-ter4 ,an instrument for measuring the various diameters of the pelvis4 ,pel-vime-try4 ,the act of determining the dimensions of the pelvis by means of a pelvimeter4 ,peri-ne-orrha-phy4 ,suturation of the perineum1 performed for the repair of a laceration4 ,peri-neum4 ,the space or area between the anus and the genital opening4 ,pe-riphe-ry4 ,the outward part or surface4 ,peri-to-neum4 ,the serous membrane which lines the abdominal walls4 ,peri-to-nitis4 ,inflammation of the peritoneum4 ,peri-stalsis4 ,a worm-like movement by which the alimentary canal propels its contents4 ,per-nicious4 ,tending to a fatal issue4 ,phe-nome-non4 ,any remarkable appearance2 any sign or objective symptom4 ,physi-o-logic4 ,pertaining to physiology4 ,physi-olo-gy4 ,the science which treats of the functions of the living organism and its parts4 ,phi-mosis4 ,tightness of the foreskin such that it can not be drawn back over the glans4 ,phle-bitis4 ,inflammation of a vein4 ,pigmen-tation4 ,the deposition of coloring matter4 ,pla-centa prvi-a4 ,a placenta which intervenes between the intrauterine cavity and the inner orifice of the cervical canal4 ,pla-centa succen-turi-ata4 ,an accessory or subsidiary placenta4 ,pledget4 ,a small compress or tuft as of wool or lint4 ,pletho-ra4 ,a condition marked by vascular turgescence1 excess of blood and fullness of pulse4 ,po-dalic4 ,pertaining to1 or accomplished by means of1 the feet4 ,poly-hy-dramni-os4 ,excess in the amount of the liquor amnii in pregnancy4 ,po-sition4 #a4 ,the attitude or posture of a patient4 #b4 ,the relation of the presenting part of the ftus to the quadrants of the maternal pelvis4 ,pos-teri-or4 ,situated behind or toward the rear4 ,post partum4 ,after delivery4 ,prema-ture4 #a4 ,occurring before the proper time4 #b4 ,an infant born before its proper term1 but viable4 ,prema-turi-ty4 ,the condition of a child that has been delivered before term1 and before maturity or ripening has taken place4 ,pre-moni-tory4 ,serving as a warning4 ,prepuce4 ,the fold of skin covering the glans penis2 the foreskin4 ,presen-tation4 #a4 ,the appearance in labor of some particular part of the ftal body at the os uteri4 #b4 ,that part of the ftal body which first shows itself at the os in labor4 ,pri-mipa-ra4 ,a woman who has given birth1 or who is giving birth1 to her first child4 ,prodro-mal4 ,premonitory4 ,indicating the approach of an event1 phenomenon1 or disease4 ,prog-nosis4 ,a forecast as to the probable result of an attack of disease2 the prospect as to recovery from a disease afforded by the nature and symptoms of the case4 ,pro-jection-al vomi-ting4 ,sudden violent emesis4 ,pro-lapse4 ,the falling down1 or sinking1 of a part or viscus4 ,pro-lepsis4 ,the anticipation and nullification of complications before they arise4 ,promon-tory4 ,a projecting eminence or process4 ,prophy-laxis4 ,the prevention of disease4 ,prote-in4 ,any one of a group of nitrogenized1 noncrystallizable compounds similar to each other1 widely distributed in the animal and vegetable kingdoms1 and forming the characteristic constituents of the tissues and fluids of the animal body4 ,they are formed by plants1 the animal organism receiving them as food and transforming and assimilating them4 ,they all contain carbon1 hydrogen1 nitrogen1 oxygen and sulphur4 ,some of the most important are albumin1 casein1 legumin1 fibrin1 myosin and glutin4 ,psychic4 ,pertaining to the mind4 ,pubes4 ,that part of the lower central hypogastric region which1 in the adult1 is covered with hair4 ,the pubic region4 ,pubic4 ,pertaining to the pubes1 or os pubis4 ,puber-ty4 ,the age at which the reproductive organs become functionally operative4 ,pubi-oto-my4 7,he-boste-otomy47 ,the operation of cutting through the pubic bone1 lateral to the median line4 ,pu-erpe-ral4 ,pertaining to childbirth4 ,puer-peri-um4 ,the period or state of confinement4 ,the puerperium is the time succeeding labor which is necessary for the restoration of the genitals to their condition previous to pregnancy1 or as near it as possible4 ,it varies from #f weeks to several months4 ,puru-lent4 ,consisting of or containing pus4 ,py-mia4 ,blood-poison of microbic origin4 ,pye-litis4 ,inflammation of the pelvis or the kidney4 ,pyor-rha4 ,a discharge of pus1 especially from infection around the roots of the teeth4 ,py-rosis4 ,heartburn4 ,acidity of the stomach4 ,eructations of acid4 ,reflex-es4 ,reflected actions or movements4 ,impulses received and transmitted by the nervous system without conscious volition4 ,involuntary responses to irritation4 ,automatic movements4 ,re-frige-rant4 ,relieving fever and thirst4 ,a cooling remedy4 ,acidulous drinks and evaporating lotions are refrigerant4 ,re-gurgi-tation4 #a4 ,the casting up of undigested food4 #b4 ,a backward flowing of the blood through the left auriculo-ventricular opening1 on account of imperfect closure of the mitral valve4 ,relax-ation4 #a4 ,a lessening of tension4 #b4 ,a mitigation of pain4 ,renal4 ,pertaining to the kidney4 ,resti-tution4 #a4 ,an act or process of restoration4 #b4 ,the rotation of the presenting part of the ftus outside of the vagina4 ,retro-gressive4 ,going or moving backward4 ,passing from a better to a worse condition4 ,retro-version4 ,the tipping of an entire organ backward4 ,rickets4 7,ra-chitis47 ,a constitutional disease of childhood in which the bones become soft and flexible from retarded ossification1 due to deficiency of the earthy salts4 ,ro-tation4 ,the process of turning around an axis4 ,roughen-ing4 ,any rough1 coarse food that gives bulk to the intestinal contents without much nutrition4 ,rube-faci-ent4 ,an agent that reddens the skin4 ,rug4 ,wrinkles or folds4 ,rupture4 #a4 ,forcible tearing or breaking of a part4 #b4 ,hernia4 ,sacrum4 ,the triangular bone situated at the end of the spine4 ,it is formed of five vertebr1 amalgamated and wedged in between the two innominate bones4 ,sagit-tal4 ,shaped like1 or resembling1 an arrow4 ,sali-vation4 ,an excessive discharge of saliva4 ,salpin-gitis4 ,inflammation of an oviduct or of the eustachian tube4 ,salvar-san4 ,a compound invented by ,ehrlich for the treatment of diseases caused by the ,spirill1 such as syphilis and recurrent fever4 ,it is popularly called #fjf4 ,sa-prmi-a4 ,poisoning of the blood by the absorption of toxins from localized infections as from the uterus4 ,scapu-la4 ,the shoulder blade4 ,scrotum4 ,the pouch which contains the testicles and their accessory organs4 ,se-baceous4 #a4 ,pertaining to sebum or suet4 #b4 ,secreting a greasy lubricating substance4 ,se-cretion4 #a4 ,the process or function of separating various substances from the blood4 #b4 ,any secreted substance4 ,secun-dines4 ,all that remains in the uterus after the birth of the child is called secundines--placenta1 membrane and cord4 ,semen4 #a4 ,a seed or seed-like fruit4 #b4 ,the thick whitish liquid fecundating secretion produced in coition4 ,shock4 ,sudden vital depression1 due to an injury or emotion which makes a sinister impression upon the nervous system4 ,show4 ,the appearance of blood that foreruns a labor or menstruation4 ,sina-pism4 ,a plaster or paste of ground mustard-seed2 a mustard plaster4 ,sinci-put4 ,the portion of the head lying in front of the anterior or large fontanelle4 ,sinus4 #a4 ,a recess1 cavity or hollow space4 #b4 ,a dilated channel for venous blood1 found chiefly within the cranium and uterus during gestation4 #c4 ,an air-cavity1 in one of the cranial bones1 especially one communicating with the nose1 such are the ethmoidal frontal maxillary and sphenoidal sinuses4 #d4 ,a suppurating channel or fistula4 ,smegma4 ,a thick1 cheesy1 ill-smelling secretion found under the prepuce and around the labia minora4 ,so-lution4 #a4 ,the process of dissolving4 #b4 ,a liquid containing dissolved matter4 ,sordes4 ,the dark brown matter which collects on the lips and teeth in low fevers4 ,spasmo-philic di-athe-sis4 ,is a condition characterized by an increased elective irritability and a tendency to spasm1 like contractions of one or more groups of muscles4 7,grulee74 ,spe-cific4 #a4 ,pertaining to a species4 #b4 ,produced by a single kind of microorganism4 #c4 ,a remedy specially indicated for any particular disease4 ,sperma-to-zoon4 ,the motile generative element of the semen which serves to impregnate the ovum4 ,spina bifi-da4 ,congenital cleft of the vertebral column with meningeal protrusion4 ,spiro-chte4 ,a genus or form of flexile spirobacteria4 ,stasis4 ,a stoppage of the flow of fluid in any organ or any part of the body4 ,ste-nosis4 ,narrowing or stricture of a duct or canal4 ,sterile4 ,nonfertile4 ,steril-i-zation4 ,the act or process of rendering sterile4 ,still-birth4 ,the birth of a dead ftus4 ,stimu-lant4 #a4 ,producing stimulation4 #b4 ,an agent or remedy that produces stimulation4 ,strepto-coccus4 ,a genus or form of bacterial organism1 which grows in consecutive links1 like a chain4 ,stria1 pl4 stri4 ,streaks or lines4 ,stroma4 ,the tissue which forms the ground substance1 framework1 or matrix of an organ4 ,styptic4 ,astringent1 an agent for arresting hmorrhage4 ,subin-vo-lution4 ,incomplete involution2 failure of a part to return to its normal size and condition after enlargement from functional activity4 ,sup-posi-to-ry4 ,an easily fusible medicated mass to be introduced into the vagina1 rectum1 or urethra4 ,suture4 #a4 ,surgical stitch or seam4 #b4 ,the line of junction of adjacent cranial or facial bones4 ,symphys-e-oto-my4 ,the division of the fibrocartilage of the symphysis pubis in order to facilitate delivery by increasing the anteroposterior diameter of the pelvis4 ,symphy-sis4 ,the line of junction and fusion between bones originally distinct4 ,the symphysis pubis4 ,synchro-nous4 ,occurring at the same time4 ,syphi-lis4 ,a contagious venereal disease leading to many structural and cutaneous lesions1 due to a microorganism called the spirochta pallida4 ,tampon4 ,a plug made of cotton1 sponge1 or oakum4 ,te-nacu-lum4 ,a hook-like instrument for seizing and holding tissues4 ,te-nesmus4 ,straining1 especially ineffectual and painful straining4 ,thrombus4 ,a plug or clot in a vessel remaining at the point of its formation4 ,tincture4 ,the solution of medicinal substances in fluids other than water or glycerine4 ,there is usually about one part of the drug to eight of alcohol4 ,tissue4 ,an aggregation of cells1 fibers and various cell-products forming a structural element4 ,tox-mi-a4 ,blood poisoning4 ,toxin4 ,any poisonous albumin produced by bacterial action4 ,trauma4 ,a blow1 wound1 or other violent injury4 ,trauma-tism4 ,a condition of the system due to injury4 ,tumor4 #a4 ,swelling2 morbid enlargement4 #b4 ,a neoplasm4 ,a mass of new tissue which persists and grows independently of its surrounding structures1 and which has no physiologic use4 ,tympa-nitis4 ,distention of the abdomen from gas4 ,um-bili-cal4 ,pertaining to the umbilicus4 ,um-bi-licus4 ,the navel4 ,ura-chus4 ,a cord that extends from the apex of the bladder to the navel4 ,it represents the remains of the canal in the ftus which joins the bladder with the allantois4 ,u-rea4 ,a white crystallizable substance from the urine1 blood and lymph4 ,u-reter4 ,the fibro-muscular tube which conveys the urine from the kidney to the bladder4 ,u-rmi-a4 ,the presence of urinary constituents in the blood and the toxic condition produced thereby4 ,u-rethra4 ,a membranous canal conveying urine from the bladder to the surface and in the male conveying the seminal ejaculations4 ,urin-aly-sis4 ,the chemical analysis of urine4 ,uter-us4 ,the hollow muscular organ which provides lodgement for the ftus from conception to birth4 ,the womb4 ,uter-us bi-cornis4 ,a womb wherein the two sides have been incompletely joined during development1 and two horns1 or protrusions1 appear on the fundus4 ,uter-us di-delphys4 ,a womb in which there has been separate development and incomplete fusion of the two sides4 ,uter-us duplex4 ,a double uterus4 ,uter-us septate4 ,a uterus that is divided by a partition or septum4 ,vari-cose veins4 ,of the nature of1 or pertaining to1 a varix4 ,the permanent dilatation of a vein4 ,vene-section4 ,the opening of a vein for the purpose of letting blood4 ,ventral stalk4 ,an embryonic process which is the rudimental precursor of the umbilical cord4 ,it is known as the ventral stalk because somewhat later in the course of development it becomes attached to the ventral 7abdominal7 surface of the embryo4 ,vernix case-osa4 ,a fatty substance that covers the skin of the ftus4 ,version4 ,the act of turning1 especially the manual turning of the ftus in delivery4 ,external v41 that which is performed by outside manipulation4 ,internal v41 version performed by the hand introduced into the uterus4 ,braxton ,hicks' ,version1 a version done with the whole hand in the vagina and two fingers entering the uterus through the partially dilated os4 ,vesi-cal4 ,pertaining to the bladder4 ,via-bili-ty4 ,able to live after birth4 ,villi4 #a4 ,the finger-like projections that develop on the outside of the egg and connect it vascularly and otherwise with the uterus2 a vascular chorionic tuft4 #b4 ,a minute club-shaped projection from the mucous membrane of the intestine4 ,vul-sellum4 ,a forceps with teeth on the ends of the jaws4 ,walcher's position4 ,the patient on the back with the hips at the edge of the table and the legs hanging down4 ,wharton's jelly4 ,the soft pulpy connective tissue that constitutes the largest part of the umbilical cord4 ,womb4 ,same as uterus4 ,,index ,a ,abderhalden test for pregnancy1 #fa ,abdomen3 care of1 #gj changes in pregnancy1 #ei weakness of1 #he ,abortion1 #ie etiology1 #bjg management1 #bjg ,accessory articles of diet1 #cai ,accidental hmorrhage1 #bbh ,after-birth1 #da1 #aag ,after-pains1 #aed1 #bed relief of1 #aed ,albuminuria1 #gg 7see ,eclampsia7 ,amenorrha1 #eg during lactation1 #aeh in the nonpregnant1 #eh ,amnion1 #ch adhesions1 #hg ,ansthetics1 #ajc1 #ach1 #adb ,anencephalus1 #cji ,anus1 #bc ,aphth1 #bid ,areola1 #ca ,asepsis in delivery1 #adb ,aseptic care1 #bjj ,asphyxia neonatorum1 #bgh methods of resuscitation1 #bgi ,atelectasis1 #bhc ,attitude of child1 #afe ,b ,baby3 anencephalus1 #cji aphth1 #bid asphyxia1 #adb1 #bgh balanitis1 #cjf bath1 #bff bowels1 #bgc breasts1 #bic care after delivery1 #add care at birth1 #adb circumcision1 #cjf cleansing1 #bfe clothing1 #bgj colic1 #bii constipation1 #bih convulsions1 #bhb cradle cap1 #bie diarrha1 #bih exercise1 #bhd eyes1 #bfh furuncles1 #cje flushings1 #bhe gavage1 #bhe genitals1 #bgb hmorrhage1 #bhi harelip and cleft palate1 #bhg heart1 #bgh hernia1 #bhg hydrocephalus1 #cjh icterus1 #bic lavage1 #bhf marasmus1 #cjc menstruation1 #bic mouth1 #bgb nails1 #bhi nursing periods1 #bgc1 #aef paraphimosis1 #cje phimosis1 #cje pneumonia1 #cjd prematurity1 #cja priapism1 #cjh respiration1 first1 #adb routine for1 #bgj significant symptoms and conditions1 #cbj sleep1 #bgb snuffles1 #cjd spina bifida1 #cjh temperature1 #bgf thrush1 #bid tongue-tie1 #bhg toilet basket1 #bga umbilicus1 #bfg urticaria1 #bid vomiting1 #cjj weight1 #bga ,bag of waters1 #ci1 #aaj ,balanitis1 #cjf ,ballottement1 #fb ,barley water1 #caf ,baths1 #fi1 #cbe ,bed1 making1 #acc ,bed-linen1 care of1 #aej ,bed sores1 #bfc ,bednar's disease1 #bid ,bichloride solution1 #ace ,birthmarks and deformities1 #gb1 #hg ,binder1 #aec ,bladder1 #bc after delivery1 #aei in pregnancy1 #ef1 #eh ,bleeders1 #bcb1 #bij ,blood1 in pregnancy1 #ee ,bowels1 in pregnancy1 #fh in puerperium1 #aeg ,breast milk1 quantity1 #bge ,breasts1 #cj caked1 #aef1 #bdc care of1 #ga changes due to marriage and pregnancy1 #ec1 #ei inflow of milk1 #ec massage1 #aef nursing periods1 #aef of puberty1 #cc preparation for lactation1 #aee removal of child1 #beb1 #bfa sensations in pregnancy1 #ei supernumerary1 #ca ,breech presentation1 #afh ,brow presentation1 #agg1 #agi ,buttermilk1 #cad ,c ,csarean section1 #aie ,caput succedaneum1 #abg ,case record1 nurse's1 #aca ,catheterization1 after delivery1 #aei before operations1 #ahc ,caul1 #aad ,cephalhmatoma1 #abh ,cervix1 effacement1 #aaj repair1 #add1 #baa ,child 7see ,baby7 ,chill in puerperium1 #aea ,chloasma1 #ee ,chloroform in labor1 #ajc ,chorion1 #ch ,circumcision1 #cjf ,clamp for cord1 #bfh ,clitoris1 #bf ,coitus1 #ga ,colic1 #cjj ,colostrum1 #ec ,conception1 #cf ,condylomata1 #ge ,confinement1 estimating date1 #eh1 #ff ,constipation1 #fh1 #bih ,contraction of pelvis1 #bad ,contractions of ,braxton ,hicks1 #ec1 #fb1 #aji ,convulsions1 of child1 #bhb of mother1 #bcf ,cord1 umbilical1 #dj attachment to placenta1 #db cutting1 #adb granulations of1 #bic prolapse of1 #bbj1 #acg separation1 #bib ,cow's milk vs4 breast milk1 #caa ,cradle cap1 #bie ,cramps1 #ef1 #hf ,cranioclasis1 #aid ,curettage of uterus1 #bjf in abortion1 #bjg ,curve of ,carus1 #bj ,d ,decapitation1 #aid ,delivery1 asepsis during1 #adb care of mother after1 #add on side1 #adj ,diabetes and pregnancy1 #ie ,diapers1 #bgj1 #bgc bluing on1 #bgj1 #bif ,diarrha of child1 #bih ,diet in puerperium1 #aeb1 #aee ,diets1 #ccf ,doctor1 #acj when to call1 #aca what to report1 #aca1 #cai ,douche1 vaginal1 #bjb aseptic1 #bjj in pregnancy1 #ga1 #afj intrauterine1 #bje1 #bcc ,dress in pregnancy1 #fi ,drugs affecting the milk1 #bge ,dry birth1 #bbe ,ductus arteriosus1 #di venosus1 #dh ,e ,eclampsia1 #gh blood pressure in1 #ee symptoms and management1 #bcg wet packs in1 #bca ,ectopic pregnancy1 #hi ,edema1 #fi ,enemas1 eliminative1 #cee nutrient1 #ccd ,episiotomy1 #baa ,ergot1 #adc after delivery1 #aej in abortion1 #bjg in post partum hmorrhage1 #bcc ,eruptions on the skin1 #ee ,erythema1 #bif ,ether in labor1 #ajc ,examination of patient1 #acd1 #adj ,excavation of pelvis1 #ai ,extrauterine pregnancy1 #hi ,exudative diathesis1 #bie ,eye symptoms in pregnancy1 #fi ,f ,face presentation1 #agd1 #agi ,fallopian tubes1 #bb ,fainting1 #gj ,fevers and pregnancy1 #ia ,flour ball1 #caf ,flushings1 #bhe ,ftus1 attitude1 #dd circulation1 #dh diameters of head1 #df fontanelles1 #df heart tones1 #fc1 #ahj movements1 #dd1 #fb rate of growth1 #df rule for estimating length1 #dg rule for estimating weight1 #dg signs of danger to1 #ahj signs of death1 #ig signs of maturity1 #dg ,food mixings1 #cag preparation for infants1 #cad ,foramen ovale1 #ej ,forceps1 application1 #ahf conditions for1 #ahe dangers of1 #ahe in breech cases1 #agc in face presentations1 #agf indications for1 #ahe preparations for1 #ahc ,fumigation1 #cbi ,furuncles1 #cje ,g ,galactorrha1 #bej ,gas analgesia1 #ajd ,gas pains1 #aed1 #aeh1 #bec ,gavage1 #bhe ,genital crease1 #be ,genitalia1 care after delivery1 #adb1 #adh preparation for delivery1 #aca preparation for operation1 #ahb ,getting up1 #afa ,gingivitis1 #ge ,glands1 ,bartholin1 #bg mammary1 #cj ,montgomery1 #ca thyroid1 #ef ,glossary1 #cea ,glycosuria1 #fi ,gonorrha and pregnancy1 #ic ,goodell's sign1 #fj ,gossip1 #afa ,graafian follicle1 #cc ,gums in pregnancy1 #ge ,h ,hmorrhage1 accidental1 #bbh in abortion1 #bjg in labor1 #add1 #aai1 #adc in the newborn1 #bhi in pregnancy1 #ie post partum1 #bcb1 #bcd unavoidable1 #bbh uterine douche for1 #bje ,hmorrhoids1 #hf ,hair1 #ee1 #acb ,hands1 care of1 #afj1 #cbc sterilization of1 #acd ,harelip and cleft palate1 #bhg ,head1 descent1 #abc expulsion of1 #aae effect of labor on1 #abf extension1 #abf external restitution1 #abf flexion1 #abc internal rotation1 #abd ,headache1 #bcg1 #bed ,heart changes in pregnancy1 #ee lesions in pregnancy1 #id ,heart tones1 ftal1 where heard1 #acj significance1 #acg when membranes rupture prematurely1 #bbf ,hegar's sign1 #fj ,hernia1 #bhg ,herpes in pregnancy1 #gf ,hospital drums1 packing1 #ach ,hottentot apron1 #bf ,hydramnios1 #hg and malpresentations1 #age and twins1 #hd ,hydrocephalus1 #cjh ,hymen1 #bf ,hypodermoclysis1 #bjf ,hyperemesis gravidarum1 #gi ,i ,icterus1 #bic ,induction of labor1 #bjh ,infant feeding1 #caj outfit1 #aja ,infection1 #bbf1 #bee ,injections1 eliminative1 #cce intravenous1 #bje nutrient1 #ccd ,insomnia1 #ef ,intertrigo1 #bif ,involution1 #aeb1 #afj1 #afa ,j ,jacquemins' sign1 #fb ,jaundice1 of child1 #bic of mother1 #ie ,k ,kidneys of child1 #dd of mother1 #ef1 #fh1 #ie ,l ,labia majora1 #be minora1 #bf ,labor1 care during1 #adj induction of1 #bjh precipitate1 #bbc preparations for1 #acj1 #ach1 #cbf signs of1 #abi vomiting in1 #bbh ,lactation and menstruation1 #aeg ,lavage1 #bhf ,leucorrha1 #ga ,lightening1 #fe1 #ajh ,linea albicantes1 #ee nigra1 #ee ,liquor amnii1 #ch in disease1 #hg ,liver1 of child1 #dd of mother in pregnancy1 #ef1 #ie ,lochia1 #aed and the hands1 #afj ,longings1 #ef ,lungs in pregnancy1 #ef ,m ,malna neonatorum1 #bij ,marasmus1 #cjc ,mask of pregnancy1 #ee ,mastitis1 #bdg ,maternal impressions1 #gb ,membranes1 #aaj premature rupture1 #bbe relation of rupture to labor1 #aad rupture of1 #aji1 #aad ,menstruation1 definition of1 #cc during lactation1 #aeg in infant1 #bih physiology of1 #cd relation to conception and pregnancy1 #cc systemic effects1 #ce ,milk fever1 #bdc ,milk1 elements of human1 #cab excess of1 #bdi fat-free1 #cag inflow1 #aef peptonizing1 #cch pasteurizing1 #caf quality1 #bea scarcity1 #bdi sterilization1 #caf to dry up1 #afc whole milk1 #cag ,milk leg1 #bfb ,mind in pregnancy1 #gb ,moles1 #hj ,monsters1 #hh1 #cjh ,mons veneris1 #be ,morning sickness1 #eh ,multiple pregnancy1 #hc ,n ,nausea1 #eh ,nervous system1 #ef ,neuralgia1 #ef ,nipple1 #cj care of1 #ga cracks and fissures1 #bdd imperfect1 #bde preparation for lactation1 #aee rubber1 #cah ,normal labor1 #ajg amount of blood lost1 #aai causes of1 #ajg course of1 #aaj date of onset1 #ajg duration of first stage1 #aad duration of second stage1 #aad general effects1 #aah mechanism1 #abj subjective phenomena1 #aae ,nurse1 #ih and cleanliness1 #abi1 #cbc and history sheet1 #aca in obstetrics1 #ih in puerperal fever1 #bfb outfit1 #ii qualifications1 #cbc sterilizing1 #aja ,nursery rules1 #bfi ,nursing periods1 #aef ,nursing the child1 #bic ,o ,odors of person1 #cbd ,oligohydramnios1 #hg ,operations1 preparations for1 #ahj why required1 #agi ,ophthalmia neonatorum1 #ic1 #adb1 #aib ,os1 digital dilatation1 #baa physiology of dilatation1 #aaa rigidity of1 #bbb ,ovaries1 #bc ,ovulation1 #cc ,ovum1 #cc death of1 #if fertilization1 #cf implantation1 #cg mode of progress1 #bc relation to uterine cavity1 #eb ,p ,packs1 wet1 #bac ,pains1 after1 #aed cause of1 #aji character of1 #aae1 #aca1 #ach false1 #ajh from gas1 #aed regularity of1 #aaj1 #acj ,palpation1 #acd ,paralysis1 facial1 #bia of shoulder 7,erb's71 #bia ,paraphimosis1 #cje ,patient1 care of1 after delivery1 #add during second stage1 #acg examination of1 #gd1 #acc in first stage1 #acc loss of weight post partum1 #aee preparation of1 #aca1 #ach rest1 #afj visitors1 #acc1 #afa ,pelvic floor rigidity1 #bbc ,pelvis1 #ag brim1 #ah contracted1 #bad diameters1 #bad false1 #ag measurements1 #bad quadrants of1 #aba shape1 #ah true1 #ag upper strait1 #ah ,pemphigus neonatorum1 #bif ,perineorrhaphy1 #add instruments1 #aci1 #ade1 #adf after-care1 #adg ,perineum1 #bh1 #be head on1 #aae preservation1 #ade repair1 #adc1 #add torn in labor1 #cj ,peritoneum1 #bd ,peritonitis1 7see ,infection7 ,phimosis1 #cje ,phlebitis1 #bfc ,physical signs of pregnancy1 #ei ,pigmentation1 #ee1 #gg ,pituitrin1 #adc1 #bbd ,placenta prvia1 #bi ,placenta1 #da anomalies1 #hh early expression1 #adi infarcts1 #hh conditions for ,crede expression1 #aej manual removal1 #aej ,pneumonia in child1 #cjd ,point of direction1 #aba ,position1 occipito-posterior1 #agh of breech1 #afe of face1 #age of head1 #aba ,walcher1 #aic ,pregnancy1 ,abderhalden's test for1 #fa age of1 #fe albuminuria in1 #gg at fourth month1 #fa bowels in1 #fh cathartics in1 #fh condylomata1 #ge constipation in1 #ge cramps1 #hf diabetes in1 #ie diagnosis1 #eg duration of1 #ff1 #ajg extra uterine1 #hi fevers and1 #ia general effects1 #ef gingivitis1 #ge gonorrha1 #ic hmorrhages1 #ie hmorrhoids in1 #hf heart disease and1 #id heartburn1 #fh herpes1 #gf hydramnios in1 #hg hygiene of1 #ff hyperemesis in1 #gi kidneys in1 #fh local effects1 #ea maternal changes1 #ea mental conditions in1 #gb pressure symptoms1 #he probable signs1 #fa pruritus1 #gf pyelitis1 #gi salivation1 #ge signs at #bfth week1 #fb syphilis1 #ib toothache1 #ge toxmias1 #gd tuberculosis1 #ib varicose veins1 #he vomiting in1 #gi ,prematurity1 #cja ,presentation1 definition1 #abj frequency of vertex1 #aba of breech1 #afe of face and brow1 #agd transverse1 #agd ,pressure symptoms1 #he ,priapism1 #cjh ,proprietary foods1 #cad ,pruritus in pregnancy1 #gf ,ptyalism1 #ge ,puberty1 #cc ,pubiotomy1 #aih after-care1 #aii ,puerperal fever1 #bee disposal of excreta1 #bfa etiology1 #bee nurse and1 #bfb prevention1 #beh symptoms1 #bei treatment1 #bfj ,puerperium1 #aea diet in1 #aeb laxatives1 #aeh standing orders for1 #afb ,pulse in puerperium1 #aea ,pyelitis1 #gi ,pyloric stenosis1 #cjc ,q ,quickening1 #ei ,r ,rectal feeding1 #ccc ,rectal infusions1 #bab ,rectum1 #bc in labor1 #bc1 #adb ,red gum1 #big ,renal disease1 #ie ,rest1 #afj ,room1 setting up1 #acj1 #ahj ,rubber gloves1 #acf ,rubber nipples1 #cah ,s ,salivation1 #ge ,second stage of labor1 #aad ,sex1 determination of1 #fe1 #gb ,sexual relations1 #ga ,sheet sling1 #adf1 #aha ,show1 #aji1 #abi ,skin1 changes1 #ed care of1 #fi eruptions1 #ee pigmentation1 #ee1 #gg stri gravidarum1 #ed ,snuffles1 #cjd ,solutions1 #cdj percentage table of1 #cda ,souffle1 funic1 #fe uterine1 #fc ,spermatozoa1 #cf ,spina bifida1 #cjh ,standing orders for nurse1 #afd for puerperium1 #afc ,starvation fever1 #bgf ,sterile linen1 application1 #ach1 #ahb ,sterilization1 #aja1 #cbc dressings1 #cbe instruments1 #cbg rubber goods1 #cbh ,stitches1 care of1 #afj removal1 #bjb ,stomach capacity of child1 #bge ,subinvolution1 #aee1 #bfj1 #bfa ,subjective signs of pregnancy1 #eg1 #ei ,sudden death of infant1 #cji of mother1 #bfc ,sugar in urine1 #fi ,sugars and flours1 #cag ,supplemental feedings1 #caj ,supplies for house1 #ii for sterilization1 #aja preparation of1 #cbf ,symphyseotomy1 #aih ,syphilis and ftus1 #hh and pregnancy1 #ib of placenta1 #hh ,t ,tampon of uterus1 #bjb of vagina1 #bjd ,temperature in puerperium1 #aea ,third stage of labor1 #aag1 #adb1 #adc conduct of1 #adi ,thrombus1 #bfc ,thrush1 #bid ,thyroid gland1 #ef ,toilet basket1 #bga ,tongue-tie1 #bhg ,toothache1 #ge ,toxmia1 #gd ,transfusion1 #bje in eclampsia1 #bdj ,tubercles of ,montgomery1 #ca ,tuberculosis and pregnancy1 #ib ,twilight sleep1 #ajc ,twins1 #hc ,u ,umbilicus1 #bfg ,unavoidable hmorrhage1 #bbh ,urination1 after delivery1 #aeh of child1 #bgc ,urine1 #ef in pregnancy1 #gg in puerperium1 #aea sterile specimen1 #bjj sterile specimen from child1 #bjj ,urticaria1 #bid ,utensils for milk modification1 #cah ,uterus1 anatomy1 #ba changes in pregnancy1 #ea1 #ei curettage1 #bjf displacements1 #hd height at various months of pregnancy1 #fd inertia1 #bbc malformations1 #he rupture1 #bbf ,uterine souffle1 #fc ,v ,vagina1 anatomy1 #ba attachments1 #ba distensibility1 #ba ,vaginal tampon1 #bjd in abortion1 #bjg ,varicose veins1 #he ,ventral stalk1 #dj ,version1 #aij1 #aib1 #aic ,vestibule1 #bf ,vessels of cord1 #dh ,villi1 #cg ,visitors1 #acc1 #afa ,vomiting1 #cjj1 #cba in pregnancy1 #gi in labor1 #bbh uncontrollable1 #gi ,vorhees bag1 #bbd1 #bcj ,vulva1 anatomy1 #bd care of1 #adc preparation1 #acb ,w ,walcher position1 #agc1 #aic ,weaning1 #beb1 #bgc ,wet nurse1 #bec ,wharton's jelly1 #dj ,whey1 #cae ,wiegand compression1 #agc1 #aid ,witch's milk1 #cb ---------------------------------------- -------------------------------- ,,transcriber',s ,,notes #a4 ,silently corrected typographical errors and variations in spelling4 #b4 ,anachronistic1 non-standard1 and uncertain spellings retained as printed4 #c4 ,enclosed italics font in underscores4 #d4 ,enclosed bold font in equals4