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Mother, Nurse and Infant:
A MANUAL
ESPECIALLY ADAPTED FOR THE GUIDANCE OF MOTHERS AND MONTHLY NURSES,
COMPRISING FULL INSTRUCTION IN REGARD TO
Pregnancy, Preparation for Child-Birth,
AND
The Care of Mother and Child,
AND DESIGNED TO IMPART SO MUCH KNOWLEDGE OF ANATOMY, PHYSIOLOGY, MIDWIFERY, AND THE PROPER USE OF MEDICINES AS WILL SERVE INTELLIGENTLY TO DIRECT THE WIFE, MOTHER AND NURSE IN ALL EMERGENCIES.

By S. P. SACKETT, M. D.

NEW YORK:

H. CAMPBELL CO., Publishers

140–142 Nassau St.

1889.

Copyrighted, 1889,

—BY—

S. P. SACKETT.

All rights reserved.

PRESS OF E. D. NORTON,

ITHACA, N. Y.

PREFACE.

The object of the author in writing this volume is to offer to nurses, and especially to those women who desire to make “monthly nursing” a vocation, the instruction which they need for that purpose, sufficiently illustrated and at a moderate price.

The book is written under a firm conviction in the mind of the author that a work of this character is needed at the present time—a work that combines some information to the monthly nurse in regard to her peculiar duties with considerable instruction in midwifery. He has many times heard inquiries made for a book of this kind and has not been able to point to one of the character desired. He has learned during the forty-five years that he has practiced medicine in a small city and its vicinity, that mother and nurse are often combined in the same person. The important duty of nursing the sick is so generally performed by mothers, that they also, as a class, require some scientific knowledge to be acquired by means of plain, practical instruction. And, in fact, throughout our country, every mother is liable, in an emergency, to be called upon to fill the office of an accoucheur.

For the professional nurse, such technical and accurate knowledge should be considered indispensable. The training schools for nurses in some of our largest cities are doing a noble work, and are elevating the standard of requirements for those who seek this field of true womanly labor. But comparatively few of the many thousands who follow this vocation are able to attend such schools; yet they are willing and desirous to learn. Women seem instinctively to desire such knowledge. A proper effort to place within their reach the means of obtaining the necessary technical knowledge for their work, and especially for the work of the nurse who attends upon the mother in childbirth, will not, the author trusts, be deemed presumptuous. There are many excellent nurses, who have become so without the aid of training school or such a book as this, but it is hoped that this volume may make the acquirement of the necessary knowledge more easy and furnish ready information of value to those nurses who are most thoroughly perfected in their work. Physicians, they will find, stand ready to aid them. The attending physician, as a rule, may be depended upon to give such help as may be necessary to the understanding of the instructions here presented, and through their cooperation the number of earnest students in this department of womanly labor may be multiplied.

The author, during the preparation of it, consulted many writers upon obstetrics, medicine and nursing; and it is only because it would not be compatible with the size of this volume, that he has not made frequent references to these excellent works. But all that he has written has been founded on his own knowledge, experience, and observation, while it coincides with the expressed opinions of others who may be considered good authority. In only two or three things has the author ventured to advance beyond others.

S. P. S.

Ithaca, March, 1889.

CONTENTS.

INTRODUCTION.

From the nature of the subjects treated in this work, the information given becomes of interest to every woman, and is not intended for the nurse of lying-in women only. It is believed that many young women will study it carefully, that they may be prepared for all the duties and responsibilities of life; some, perhaps, that they may be fitted for a vocation under certain contingencies. But many of the instructions are addressed particularly to mothers, because they especially will be able to make a practical application of the knowledge received. Hence considerable matter is inserted which is designed to be used by mothers in their daily life, and having only a slight bearing on monthly nursing. Necessarily, as the two objects are combined to suit the wants both of the mother and nurse, there is not as much order and system in the topics presented as would otherwise be desirable. I seek only to have my instructions in the form that will be most useful, and I believe that if mothers at the present time are sufficiently taught there will be no lack, a few years hence, of nurses who are fully competent to care for the sick, under the direction of competent physician. Hence I address myself, first,

TO THE MOTHER.

To those who are mothers, every part of this small book is especially commended. Upon the knowledge and skill and right action of those who have the care of children and of the household, it will depend that the right thing shall be done in such emergencies as are liable to occur. You must necessarily care for your children, both to guard them from sickness and to relieve their ailments. You must know the symptoms, at least, how to observe the symptoms of diseases; and you may be called upon, in the absence of the physician, to act as midwife. Be especially careful to learn the instructions in regard to emergencies, because upon your knowledge and prompt action the lives of your dear ones may depend.

TO THE PROFESSIONAL NURSE.

This work is written for you, and to you is especially commended the modicum of medical knowledge herein contained. It is better for you to learn well what you read than it is to read very extensively. You will find sufficient in this small volume to demand your time and study for months, and even for years, in connection with your nursing. It is not expected that you will learn all the formulæ and prescriptions given. These are inserted partly that you may learn to read prescriptions in the various forms in which they are written, and partly that you may occasionally use one, after consulting with your physician. Sometimes you may copy one of them accurately and use it at the drug store, consulting only with the apothecary.

But it will be of importance to you to obtain as much medical knowledge as is herein contained, though it is not designed to make you physicians. Do not act the part of a doctor until you understand every thing pertaining to Anatomy and Physiology, and the nature and properties of every medicine employed in the cure of disease. Of all sciences the medical should embrace the widest domain of knowledge, because ignorance here is fatal. But ignorance and thoughtlessness, and want of skill and adaptation, may be fatal in your particular province. The physician will generally tell you that the recovery of his patient depends as much upon faithfulness and skill and care on your part as upon his own medicines. Seek always to aid him, never to supercede him. If you learn midwifery, it should be with the design of co-operating with the doctor, and assisting him. You should be so educated that the physician will feel willing to leave a case of tedious labor in your care, instead of waiting at the bedside of the patient one or two days, and neglecting his other patients. Your educated service will be appreciated at such times by the doctor, as well as by the patient and her friends. You will do the duties of nursing well, and take upon yourself that part of the practice of a physician which he does not desire, and which you can do equally well. Your part will be an important one, and second only to that of the physician.

I expect, as the result of the study of this book, not that you will assume to be physicians to any greater extent than you otherwise would, but that you will act wisely and intelligently instead of confusedly, or blindly, in the emergencies in which you will be called upon to act,—that you will be, not merely attendants at the bedside of the sick, but, that best aid to the physician, the true nurse.

Do not claim to be doctor or midwife, or anything whatever that you are not. If a smattering of knowledge causes any affectation, it will only degrade you. Study physiology in the books commonly used; store your minds with the facts and instructions in this book; obtain additional knowledge in every way that is practicable. As you have opportunity, make practical application of the knowledge received, and you will commend yourself more and more to your sick or suffering friends.

PART I.
PREGNANCY AND CONFINEMENT.

CHAPTER I.
CONDUCT OF THE MOTHER BEFORE AND AFTER MARRIAGE.

The physical treatment of children should begin, as far as may be practicable, with the earliest formation of the embryo. It will involve the conduct of the female even before her marriage, as well as during her pregnancy—the various contingencies which effect her in health as well as in disease. Very much depends on her to insure for her child a vigorous constitution, or to prevent a feeble frame in the child. She should not enter into the holy state of marriage with heedless haste; if she does, she will discharge its duties with inexcusable neglect. To constitute a mother, in the best sense of the term, requires a patient endurance of fatigue, and anxious solicitude, which will sorely tax the mother’s strength. I would, if possible, diminish the toil and danger of childbirth, and relieve the fatigue and anxiety of nursing.

And let me, in one paragraph, give a hint to the husband: that the responsibility and care of the children is too much laid on the mother; she is overburdened. Let the father partake in the arduous and responsible duty of their education. And let me hint, also, that the health and strength of the child depends upon the father as well as the mother.

Marriage should not be at too Early a Period of Life.—I am not disposed to discourage early marriage, but I am decidedly opposed to a premature one. Marriage should not take place until the body is healthily and completely developed; to bear offspring prematurely endangers not only the mother’s health, but it materially influences the health and well-being of the child.

We cannot fix rigorously the age at which the body becomes fully expanded. I am inclined to say it is at 20 in the female, and at 24 in the male; but original stamina, education, climate, mode of life, etc., have their influence, and may make an earlier or a later marriage proper.

The evil consequences resulting from precocious unions in this country are: diminished vigor and shortened life in the husband; faded beauty, blasted health, and premature old age in the mother, and a diminutive stature, debility of body and imbecility of mind, perhaps a strong predisposition to consumption, rickets, scrofula, etc., in the children.

Marriage should be when the Parties are in Health.—I do not say that every ailment should be a bar to marriage or child-bearing. It is possible that prolapsis uteri may be benefited by a pregnancy and parturition. But if a woman has prolapsis uteri, or other ailment, it is a poor preparation for the burdens of gestation, and good health is an important qualification for the responsibilities of married life. No learning can be of more importance to a young lady than to know how to preserve health, and how to restore it when lost, for we cannot reasonably expect healthy children from unhealthy parents. There are numerous other complaints besides scrofula and insanity, inherited by children. If a wife is to be healthy and strong, she must use means; health will not come by wishing for it merely, and whether pleasant at first or not, habit will make early rising, temperate living, taking exercise, thorough ablution of the whole body, etc., easy. That state of vigorous health and strength which prepares a woman to bear strong and vigorous children, is attained not by idleness and luxury, and neglect of personal cleanliness, nor by tight lacing, the use of stimulants, nor by irregular modes of sleeping, etc., but by rising early, and taking early walks in the open air, and engaging in household labor, or other exercise during the day, going to bed betimes, living on an abundance of good, wholesome food, by daily ablutions, followed by rubbing the skin thoroughly, and in general by observing the laws of health. If a woman who has thus preserved her health, marry a man who has been equally careful to observe the laws of continence and hygiene, she may hope to be the mother of a healthy child, and a blessing to all.

The Constitution of both the Male and Female should be good and strong. It is not enough that the body be well developed, if there is at the same time a very feeble constitution. Even if the children of such parents seem to be hale looking and robust, they do not attain old age—are very liable to die young. If there is only a predisposition to disease, such as is often inherited, it may be very doubtful whether the parties ought to marry. If there is only a disposition to habits of intoxication or dissipation, or to gout, madness, scrofula, consumption, etc., in the man, we may advise the woman not to unite herself to him, for these diseases do not show themselves until called into action by some exciting cause.

But we advise the woman, if there is any physical disability which renders her ineligible to the married state, that she should not pass it over lightly, or conceal it, and we would recommend to a woman who may have deformed pelvis, that she abstain from marriage, as she “may purchase the title of wife at too dear a price.”

Temperament is a matter of less importance in choosing a husband. It is said to be the case that in choosing a mate, a person inclines strongly to one unlike themselves. If it be true that a person of a nervous temperament has a preference for the sympathetic, the sanguine for the bilious, etc., it is probably nature imparts the liking that the offspring may combine the excellence of both, the defects of neither.

Blood relationship is not necessarily a bar to union. Cousins may marry when the family has traits of mental and physical excellence as a means of perpetuating them, but it is not best to develop, by repeated unions, a lurking disposition to disease, which may exist in any family.

Moral and mental character is of the greatest importance. It is not true that “the reformed rake makes the best husband.” If he is not the prey of loathsome diseases, the results of a vicious life, his constitution is probably impaired, so that he cannot be the father of good, strong children. The only way that women can guard their own health, and preserve from degeneracy their offspring, is by having husbands of a different character from that of the debauched rake.

CONDUCT OF THE MOTHER AFTER MARRIAGE.

The mother is accountable for the health and intelligence of her first child; she must be careful of her own health before marriage and at the time of marriage, as well as for the succeeding time.

I will here state a few things which seem unimportant, and yet are of some little consequence. I consider that the great object of conjugal union is the transmission of life, and I cannot believe that anything is unnecessary or unimportant that has a tendency towards the perfect health or well-being of the child that is yet to be born.

During the first few months after marriage the wife should seek to have bodily quiet, and mental calmness and serenity. The custom of hurrying the bride from place to place may properly be condemned. So we would have her avoid going into a whirl of excitement and pleasure—into a round of visiting and late hours—into close, heated rooms—into fashionable amusements—rich living and a want of rest—sitting in ill-ventilated apartments—quickly bolting unquiet meals—drinking wine, beer, or brandy, or other alcoholic stimulants—late rising in the morning—sleeping in close, badly-ventilated rooms—living in rooms that are kept dark—tight lacing—wearing thin clothing—worrying, and indulging in ill-temper.

She should avoid these at all times, but her future health and happiness depend so much upon her prudence and care during the first year of married life, that we may properly give these hints and cautions in regard to this particular time.

CHAPTER II.
CONDUCT OF THE MOTHER DURING PREGNANCY.

There are no signs of a fruitful conjugation, which in all cases indicate to the woman that she is pregnant. Some few seem to know the exact time; in some instances there is faintness, or vertigo, that in these particular cases impress the fact upon the mind of the woman. But usually, within a month, the point is tolerably certain, she being assured by such signs as will be here pointed out. It now becomes her duty to be especially careful, not only for herself, but also for her offspring. Abortions frequently occur, especially in the first and last pregnancies, and in the first months of pregnancy, these should be avoided if possible.

The train of evils which follow when the habit of abortion is established, as well as the moral obligation she is under to preserve the life committed to her, should make her willing to endure the few privations and conformities which her situation imposes on her. She must avoid undue exercise of the muscles, such as long walks, dancing in hot weather, hastily running up stairs, lifting heavy weights; she must avoid things that inordinately hurry the circulation, such as heated rooms, stimulating liquors, etc.; she must not overload the stomach, or eat late suppers; she must not take drastic purgatives; must not constipate her bowels by taking laudanum, etc.; must not compress the chest by tight lacing; must not use strong tea or narcotics; must not lie long in warm feather beds, and must not engage in severe study, night watching, etc.

The pregnant woman need not indulge in a wayward or voracious appetite, and, although there is a tendency to fullness and fever, she need not necessarily be bled.

The pregnant woman needs fully as much food as usual, but she must avoid excess in eating and drinking. Ripe fruits, lamb, veal, fresh fish, milk, coffee, and, in general, every thing which agrees with the stomach may be eaten; the taste, as a rule, is a safe guide, and may be reasonably indulged. After the sixth month, she may properly eat four or five meals a day.

The best plan of treatment for one to adopt who has longings is not to give way to them, unless the longings be of a harmless, simple nature.

The CLOTHING of the pregnant woman should be suited to the season; but as the vicissitudes of the weather affect her more than they previously did, she should be dressed rather warm. In general, she should wear flannel drawers, especially during advanced pregnancy.

Many women have done themselves an injury by lacing tight to conceal their pregnancy. The dress should be loose and comfortable, nowhere pressing tightly or unequally.

Stays or corsets may be used, in a proper manner, during the first five or six months; they should be moulded to the shape of the changing figure, and must not depress the nipple or the enlarging breasts. The garters ought to be worn slack; tight garters are very injurious, and if the veins are enlarged or varicose, it will be necessary for her to wear an elastic silk stocking.

Moderate exercise in the open air is proper during the period of pregnancy, and walking is a good kind of exercise; but very long walks, and dancing, ought not to be indulged in. Riding in a wagon over rough roads, and railway traveling, are objectionable.

Bathing should be practiced with great care. A warm bath is too relaxing; a tepid bath once a week is beneficial. Sponging the body every morning with lukewarm water may be practiced, and the skin should be quickly dried with a coarse towel. The temperature of the water may be reduced gradually until it is quite cold. A sitz bath may be used every morning, although it is best to sit in it but a few seconds. If it gives a slight shock, it will be immediately followed by an agreeable glow. Put a little warm water with the cold at first.

Ventilation is of the utmost importance. During the day time, the windows in every unoccupied room in the house ought to be thrown open.

Attention should be directed to keeping the atmosphere in the sitting and sleeping rooms of the house fresh. Many poor people sleep in a very small, close bedroom, and breathe an air that is really poisonous. The lady should see also that the house is kept light, that the drains are in good and perfect order; that the privies are frequently emptied of their contents, and that the drinking water supply be not contaminated.

Sleep, by its sedative influence, and by the calmness of all the functions that attend it, has a favorable influence upon the disturbed nervous system of the mother, and upon the growth of the fœtus. Her bedroom ought to be large and airy, and she should not have curtains closely drawn about her bed. The windows of the room should be opened during the day; the bedclothes should be thrown back, and everything ventilated; the bed must not be loaded with clothes, and the bedroom at night should be dark, and as far as possible from noise. These things will tend to secure sleep; but if the pregnant woman should still be restless, and feeling oppressed and hot, she should perhaps admit more air into the room. Let her also attend every day to her bowels, that they be not allowed to become costive; perhaps eat cooling fruits, live on an abstemious diet, and if there is a feeling of faintness when she attempts to lie down, she should have a bed so arranged that her shoulders and head are elevated.

The pregnant woman ought to retire early to rest, and I would advise her to lie abed in the morning as long as she can sleep well. If she cannot sleep well, let her get up in good time in the morning, take a bath, or thorough ablution, a stroll in the garden, an early breakfast, and then perhaps a short walk, while the air is cool and exhilarating. A nap of an hour or two after that, upon a sofa or lounge, will prove very refreshing.

A TRANQUIL MIND is of the greatest importance. Forebodings of a gloomy nature should not be encouraged, as they often are, by relating dismal stories, etc. Unnecessary fear upon the part of the mother may have a bad effect upon the child, as may also the indulgence in unbridled anger, or yielding to temper,—perhaps may cause convulsions or hemorrhage, or even abortion. There is reason to believe that the imagination of the mother has an influence on the beauty of the child; and it is quite certain that cheerfulness and equanimity of mind contributes to the future good health of the child, and may even affect its disposition and mental traits.

CHAPTER III.
DISEASES OF PREGNANCY.

Pregnancy is not a disease. Many women enjoy better health during its continuance than any other time, and in general the pregnant woman is not quite as much exposed to contagious and other diseases. But there are certain disorders incident to pregnancy, of which it is necessary to speak.

Morning sickness, when it is only troublesome during the early part of the day, is generally borne without much complaint, or much medical care. Before taking any medicine for it, I advise that the lady try such simple means as the following: Let her take a cup of coffee or milk, and eat a few crackers or a biscuit, after washing her hands and face, and before rising in the morning; then let her remain in bed for about fifteen minutes, then dress quickly and take a short walk. If the sickness continues, let her eat freely of pop corn, and she may eat of this occasionally during the day, or whenever she is suffering from sickness, and let her partake of other food also during the day. Persistent sickness and vomiting indicates a disordered condition of the digestive apparatus, and requires appropriate remedies. Use successively the following: Formula 85, 104, 81, 107.

Vomiting is sometimes so persistent and severe that the stomach can retain nothing, or but very little food. Of course, such cases demand the aid of a physician, and his efforts to give relief may be effectual, when the medicine here directed fails.

Costiveness is another complaint to which pregnant women are liable. This is hurtful in its consequences, being not uncommonly the cause of fever, tenesmus, pain in the bowels, and abortion. Care must be taken to obviate costiveness by the use of such food as will have a laxative effect. The use of graham bread, oatmeal gruel, raisins, figs, grapes, roasted apples, baked pears, brown bread, cracked wheat, stewed prunes, and other varieties of farinaceous food and fruit, may obviate the necessity of taking opening medicines (F. 108, or milk of magnesia.) An enema is an excellent remedy, and every lady should have a good enema apparatus, by which she can administer an injection to herself, and if she suffer from constipation, she should take an enema twice or three times a week, and the early morning is the best time. The clyster may be warm water, or castile soap and water, of the temperature of new milk. It may be well to give occasionally an aperient to insure a thorough clearance of the whole bowels, and castor oil, salad oil, citrate of magnesia, seidlitz powder, stewed rhubarb, or an electuary of figs may be given. I sometimes direct that the woman should take every day a small dose of oil, in a cup of water gruel or oatmeal gruel.

Severe pain in the bowels and rectum is sometimes caused by a column of hard and indurated feces, which remain for a number of days in the rectum and colon. Not only pain but inflammation, and other serious ills, may result if such a condition is neglected. If taking injections does not suffice to give relief, manual assistance is necessary. The nurse should learn the art of removing them if necessary; she should use a convenient instrument, carefully conducting it into the anus, or she may thrust her finger into the vagina to break the hard mass, and assist in its expulsion, then she should wash it out with repeated clysters.

For abdominal pains that are caused by its distention, and by the weight of the enlarged uterus, the woman should wear a bandage, or an abdominal supporter, adjusted to fit the abdomen, and made with proper straps and buckles to accommodate the increasing size of the abdomen. To relieve the pain, the abdominal walls may be rubbed with equal parts of sweet oil and laudanum.

Troublesome HEMORRHOIDS may be caused by constipation, and also by the congestion in the parts, and by the pressure made on the vessels of the part by the enlarged uterus. It is proper sometimes to use emollient fomentations and cataplasms. Relief may often be given by making firm and gentle pressure between the finger and thumb of each distinct tumor, till they are all compressed and returned within the anus.

In cases of BLEEDING PILES, blood comes away each time the patient has a stool. The patient ought to be as quick as possible in relieving the bowels, and should not at such times sit one moment longer than is absolutely necessary. If the piles are inflamed and painful, foment them three times a day, and for half an hour each time, with hot water containing a little carbolic acid—a one per cent. solution. Apply it by means of a sponge. Extract witch hazel may be used also, and relief may often be obtained by sitting over the steam of hot water for fifteen or twenty minutes. Simply put hot water in a close vessel, and sit over it. Sometimes the woman cannot sit in an ordinary chair, and she should sit either on an air cushion, or a water cushion half filled with water, placed on the chair. (F. 107.)

Diarrhœa is a less frequent attendant of pregnancy than constipation, and the latter is sometimes the cause of the former; in such cases an aperient is required. (F. 109.) Should the complaint remain after the operation of the laxative, opiates are proper, mixed with some mild astringent medicine, aromatics, antacids, etc. (F. 69, 74, 79, 80, 95.)

Tenesmus, and also diarrhœa, are common attendants on abortion, of which they are, indeed, sometimes the cause. Ipecac in half grain doses, with powdered opium, and given every six hours; or frequently repeated doses of opium may be needed. (F. 91, 92.) A flannel bag filled with hot table salt, and applied near the part affected, may give great relief to pain.

Heartburn is a common and often a distressing symptom of pregnancy. I would prescribe in such cases an abstemious diet, pepsin, ingluvin, and other medicine to help digestion; antacids and laxatives. (F. 71, 72, 74.) Calcined magnesia is good; prepared chalk is harmful.

It is not necessary for me to dwell upon the few ailments that occasionally afflict pregnant women that I have not yet referred to,—a few words must suffice. If a woman who is pregnant is apt to be FAINT, or to FAINT AWAY, I advise that she be laid down—that she lie flat on her back, with a pillow under her head—that tight articles of dress be loosened—windows raised—water should be sprinkled on her face, a few drops of aromatic ammonia may be administered, and perhaps smelling salts or hartshorn held to the nose. If it is simply fainting, it is not dangerous.

A nervous pregnant woman is sometimes subject to PALPITATION OF THE HEART, especially when lying down. A small dose of aromatic ammonia will generally give relief.

If CRAMPS of the legs or thighs are troublesome, take F. 92, and tie a handkerchief around the limb, above the part affected, and let it remain a few minutes, and use friction. If cramp attacks the bowels or back, a hot bag of salt, or a stone bottle filled with hot water and wrapped in flannel, may be pressed against the part, and something similar should be placed to the sole of the feet.

If PRURITIS PUDENDI—irritation and itching of the external parts—are troublesome, use F. 195, 217, 220, and take frequently a tepid salt and water sitz bath, remaining but a short time in the bath. If the parts are hot and inflamed, and covered with an eruption, use either of the following lotions: F. 217, 195.

CHAPTER IV.
INSTRUCTIONS TO A WOMAN DURING THE LAST MONTH OF PREGNANCY.

1. Do not take too much exercise.—You may get relief from some of your ailments by lying down considerably during the day. If there is leucorrhœa (whites), strangury (a frequent inclination to void the urine), incontinence (an inability to hold the water), pain in the hips with numbness of the inferior (lower) extremities—if the veins of the leg become varicose—if there are anasarcous swellings of the inferior extremities—if there is a pendulous belly, the woman ought not to so exercise as to produce fatigue. She may get some relief by sitting or reclining in the way that is most agreeable.

2. Use means to harden the nipples.—Those women who have never had children ought to observe, before labor, whether there is a depressed condition of the nipples; whether they contract as the breasts increase in size. If they do, the condition can be corrected by wearing nipple shields on them. And to harden the nipples: For at least a month before labor, two or three times a day, rub them between the thumb and finger, and bathe them in tincture of myrrh or cologne water, in which a little alum has been dissolved. This will render the skin less sensitive, and avert the distress occasioned by the tenderness of the nipples. If there is especial reason to apprehend excoriated nipples, as there is when they are rough and nodulated like a strawberry or raspberry, make a solution of sulphate of zinc, one grain to the ounce of rosewater, in a wide-mouth bottle, and tilt the bottle upon the nipple, and allow it to remain there for a few minutes, several times every day (F. 198, 217.) It is necessary also to protect the part from the pressure of stays and the friction of the flannel vest. The stays may be removed entirely, or the nipple may be protected by laying a soft linen rag, wet with water and cologne, around it so that the pressure will not be directly on the nipple. If the breasts are swollen or painful, the soreness will subside of itself before the commencement of labor. It may be well, however, to foment them with flannel wrung out of hot water, and support them as in a sling by a broad handkerchief, passing over the opposite shoulder.

3. Pay no attention to the chilling and “horrifying tales of gossiping beldames.”—A cheerful flow of spirits which arises from the hope of a happy event, inspires a woman with activity and resolution, and is the best preparation for the pains of labor. Do not give way to gloomy and melancholy forebodings or indulge in idle reveries. Any person is your enemy who would exaggerate to you the dangers of labor; and let me here say to you, that if you read in this book of certain unfavorable contingencies, do not let your mind dwell upon them; they occur very rarely indeed, and I hope I have given such advice and instruction, and that you have been so cautious and careful that your chance is unusually favorable.

4. Do not expose yourself at this time to wet and cold.—Do not go out in bad weather, and do not go to theatres and other crowded places at all. You are especially liable at this time to renal difficulties, and if you take cold, it will cause congestion of the kidneys, and more or less urinary difficulty. It is easier to prevent such complaints than to cure them.

5. Take but little medicine.—In general you may rest in the hope that all your troubles will vanish after your confinement, and you can hardly hope to cure them sooner. But keep your bowels loose. If you cannot have daily passages by eating fruits, bread made from unbolted flour, or other laxative diet, take saline waters, compound licorice powder, etc., (F. 108.) If your bowels are constipated at the time that labor commences, take at that time an active cathartic (F. 109).

6. Seek and engage the best possible physician.—I do not know but the educated monthly nurse of the future may be well qualified to do all that is necessary in an ordinary natural parturition. But heretofore very few nurses trained in this country are thus prepared; perhaps the popular sentiment is against such an education. But you must always select a physician that you can confide in and trust if an operation is necessary, or there is unusual difficulty.

7. It is generally well to have your physician see you a month before the time that you expect to be confined.—Indeed, I would have you consult with your physician during the whole period of your pregnancy. You may get very full directions from this book, but still, where it is practicable, I advise that you consult with some skilled medical friend, who knows your idiosyncracies, and can suggest modifications of the directions as your own case demands. Specimens of your water should be analyzed each week during the last month, if there are any signs of albuminaria, etc., (especially if the face and ankles are bloated.) If there is inability to pass the water, it may be necessary to draw it with a catheter.

8. Submit yourself entirely to the direction of your physician.—Do not indulge in any opinion that may clash with his, even if that opinion is founded upon what is here written; you cannot expect to know more than he. It may be that he will wish to examine you by palpation, etc., to know if the fœtus lies as it should do, as something may be done to correct a malposition by external manipulation if the effort is made early. No good physician will permit that your sensibilities should be shocked by an unreasonable demand. If you have studied this book diligently you will be prepared to converse intelligently with your physician, and you will understand and appreciate any directions that he may give. If you have taken any medicine prepared from formula herein inserted, you know, and can inform him what the medicine is; this is better than it would be if you had taken patent medicine, of the ingredients of which you are ignorant. Consult with your physician in regard to the choice of a nurse, as he will be likely to know those that understand their business, and that are in the habit of following the doctor’s directions, or he may know whether the one you selected is now attending a woman that has contagious disease.

9. Choose a good nurse.—You should have the best possible aid that the nature of circumstances will permit. Do not get a fine lady nurse that requires to be constantly waited on by a servant, and do not get a croaker that discourses of the sad and dreadful cases that have occurred in her experience. Do not get any one that is addicted to intemperance, or a potterer that is devoid of method and efficiency; that does the wrong thing in the wrong way, and that is always out of her proper place. Get a nurse that will not dose and medicate either the mother or child when they are under the care of a physician, or assume any duty or responsibility that belongs to him; that admits that the doctor is the one to give orders. Get one that never reveals the private concerns of her former employers; one that is not a mischief-maker, causing dissention and disagreement in the household. Do not get one that is young, if she is giddy and thoughtless and inexperienced, nor one that is old, if she is deaf and stupid. Get, preferably, a married woman or a widow; one that has at some time had the care of infants; one that has a pleasant countenance, and is naturally cheerful; one that has calmness and self possession, and firmness, and at the same time is gentle, kind, good-tempered and obliging; she should have a light step, a pleasant voice, a cheering smile, a dextrous hand, a gentle touch, and be gifted in cooking for the sick. By preference, engage a monthly nurse; she will not be so likely to come to you from a case of scarlet fever or erysipelas, or other contagious disease.

If you can find a nurse of the kind described above, and if she be properly instructed and educated, she will be invaluable to you, and if she devotes her talents and her best energies to you and your infant, she should be liberally paid. But there are many such women all over the country, or will be when we can induce them to qualify themselves by study and special effort. But, as really good nurses are full of engagements, it may be necessary for you to engage her in the early months of your pregnancy; only stipulate in the start that you will be obliged to dispense with her services, if it happens that immediately preceding your confinement she had been attending a woman that had puerperal fever.

I do not say that you should necessarily engage a nurse that is educated as a midwife. But such a one is to be preferred even if you have a physician, and then the latter need not be detained from his patients for so long a period of time; and if the last stage of the labor is so rapid that the child is born before the doctor arrives, there need be no trepidation; she will know well what to do. Thousands are born in this country without the slightest assistance from a doctor, he not being at hand nor not being in time, and yet both the mother and babe do well almost invariably. As a rule the nurse that has studied and learned the most is the best prepared to discharge the duties resting upon her.

A NURSE MAY PROPERLY BE IN ATTENDANCE A WEEK OR MORE BEFORE THE TERMINATION OF PREGNANCY, if circumstances permit or require it. If present she will attend to the following things: Choose a good airy room for the lying-in chamber—one that can be well ventilated, where the temperature can be kept at from 60° to 65°; one that is removed as much as possible from noise and disturbance, and where the patient need not be exposed to draughts. Provide needed articles of clothing for mother and child, and dressings for the bed; short gowns to wear over the chemise or ordinary night gown; a proper bandage of heavy muslin, as much as one and a quarter yards in length and fourteen inches in width. I prefer to have it of several thicknesses, and if it is quite long so that the ends meet to be folded it keeps in place better, and if it is gored it should be in such a manner that it is narrower at the lower edge than it is two inches above, so as to prevent it when adjusted from sliding upwards; the child’s binder, preferably some woolen material about five inches in width and fourteen inches in length; the child’s shirt (woolen or cotton, not starched); both a long and a short petticoat; a frock or slip; a shawl or flannel blanket; napkins and muslin diapers; also pieces of old muslin to be used to absorb blood and water. Provide also for dressing the bed, a piece of impervious oiled cloth, oiled silk, or rubber cloth; old sheets and comfortables; a piece of carpet; have in readiness a pair of shears or scissors, a small box of prepared lard or vaseline or a flask of salad oil, a package of pins one and a half inches in length, besides ordinary pins; tape, bobbin or wrapping twine; fine toilet soap; fine sponge for washing the child; soft linen or carbolated cotton for dressing the naval; a box of unirritating powder; a pile of towels, and a little aromatic ammonia or brandy to be used in an emergency. Let every thing be placed in such order that either may be found without hurry or bustle at a moment’s notice. Hot and cold water should always be in readiness.

CHAPTER V.
DIRECTIONS TO THE MONTHLY NURSE.

If you attend a woman to whom the physician has already been called, you will thereafter be subject entirely to his orders. Whatever your opinion is, notwithstanding you have this book or any good authority for your opinion, if it seems to conflict with his directions, obey him; on him rests the responsibility and he is presumed to know what is best. But it is best that you should confide in each other—be on such relations that you can communicate to him anything you have learned about the case; be free to ask of him explicit directions and instructions. But your duties may precede his as well as accompany them, and I wish now to give special directions in regard to things that first demand your attention.

1. A nurse may properly provide a soft rubber catheter and also a syringe; this should be constructed so that it acts as an enema apparatus when one pipe is used, and as a vaginal syringe when the other pipe is applied. The holes in this pipe should be made so that the fluid injected is thrown backward.

It is important that this last direction be observed. I know of one instance where the vaginal pipe of a Davidson syringe was used, yet the fluid injected passed through the cavity of the uterus and through the Fallopian tube and entered the cavity of the peritoneum, causing severe pain and inflammation.

Besides the things already mentioned, I advise that there be furnished for use if needed a small blanket to receive the baby, a little bath tub, two chamber vessels, a bed pan, carbolic acid, fluid extract of ergot, and chloroform.

2. Being employed as a monthly nurse, do not (except very rarely indeed in an emergency) give any medicine at all or any stimulant that has not been ordered by the attending physician. Many women do not consider that labor is a natural process; it is painful indeed, and often lingering and tedious, but will go to a safe termination ordinarily without interference; any medicine given, unless very wisely administered, is much more likely to do harm than good.

3. Be still and noiseless as possible in doing necessary duties when your patient is trying to sleep, or when she is in special need of sleep. Sleep may be of great importance to her, and it may be put to flight by a little carelessness in renewing the fire, or in walking if you wear heavy and creaking shoes. Nurses at these times should wear slippers and not shoes.

4. If you attend the lady for a week or more before the doctor is called, there may be different ailments which you ought to note, at least enough to know their true significance. Perhaps she has false pains, and suffers so much that she believes that labor has commenced. You will decide partly from the character of the pains. False pains are colicky, though they may shift occasionally from the bowels to the back and loins and may extend to the hips and thighs. They come at irregular intervals, are sometimes violent and sometimes feeble, and they are particularly troublesome at night.

Spurious pains are often caused by disordered stomach and may be somewhat relieved by attention to the diet and by mild aperients (F. 108, 109), or by applying a flannel bag of hot salt. If quite severe send for the doctor; do not give stimulants.

5. You may benefit the patient at this particular time when labor is approaching, perhaps without giving her medicine. Possibly she may feel very well for a day or two, and you will need to direct her exercise so that she does not do too much. You may keep from her unpleasant sights and seeming dangers; keep her room from being overheated; see that she does not have late suppers, too great a quantity of food, or anything that will produce a costive state of the bowels. See that her clothing is not too light, that she does not have strong tea or coffee, and that she does not lie too much in the bed. Secure as much as possible tranquility and equanimity, by guarding against gusts of passion, by keeping from her tales of horror and disaster which have happened to the pregnant, by teaching her that she has nothing to fear in regard to her child from the simple fact that some longing has been ungratified or that she was appalled at some frightful object, as such fears are seldom if ever realized; relieve her if possible of gloomy forebodings by informing her how rarely death happens after a well conducted labor.

6. If you give any medicine at this time give only that which is unirritating and mild.

7. Notice all the indications of approaching labor, the sinking down of the uterus in the pelvis, the contractions of the womb that come on without pain, or with slight pain, the change in the mind and temper of the lady, the augmented mucous secretion, &c.

8. Although there is usually a sensation of buoyancy and lightness accompanying or preceding the setting in of labor, there may be on the other hand a feeling of anxiety and depression of spirits. Be very careful that you are not betrayed into any manifestations of impatience; no words but those of gentleness and encouragement and hope should fall upon her ear.

CHAPTER VI.
CARE OF THE MOTHER DURING LABOR AND CONFINEMENT.

True labor pains are distinguished from the false by the fact that they are felt considerably in the back, passing down to the thighs, and by their coming on at regular intervals. At first they recur nearly every two hours, and they steadily increase in number and frequency, and are grinding in their character. There are other signs which denote the actual commencement of labor; there is usually a frequent desire to empty the bowels and bladder, perhaps shiverings or rigors unattended with a sensation of cold, sometimes a severe rigor, and these signs are preceded or accompanied or followed by a discharge of mucus and blood, called the show.

It is well now to send for the medical man, though if he lives near by it is only necessary to let him know that his services may shortly be required. If the patient suffers from nausea, vomiting, or chills and shiverings, let her know that they are only incidents of her labor and not unfavorable. Do not let her increase the pains or attempt to increase them in any way; it is much better that the labor should progress in a natural manner, even if it is very slow.

The preparation of the bed for the occupancy of the mother is now to be attended to. Cover the right side of the bed (as the patient will probably lie on her left side) with a piece of water-proof cloth or oil cloth; upon the top of this a sheet is to be placed and fastened with safety pins. Over this permanent dressing (on the top of the bed sheet) a neatly folded draw sheet is adjusted (and a second rubber and draw sheet is desirable), which, after the labor, can be removed, leaving the first clean and dry. This second draw sheet and rubber, and also a folded comfortable can be placed a little nearer the foot of the bed than the other, and after the lady’s confinement she can be drawn up on the permanent dressing, and the temporary dressing can be easily removed. The other bedclothes may be adjusted in the usual manner.

A piece of carpet can be thrown on the floor by the side of the bed, and it is well to have a hassock to put between the patient’s feet and the foot-board or bed-post.

To dress for the occasion, a folded sheet should be adjusted around the waist (or, instead of this, or above this, a petticoat), to extend from the waist to the feet. (These will be removed after the delivery.) Then a chemise should be put on in the usual manner, and drawn up and folded high under the arms. She should then have on a clean nightgown, and over it a warm wrapper; this can easily be slipped off when she is about to go to bed, and the night-dress, if it is a long one, can be folded up under her arms, so that it will not be soiled.

The STAYS must not be worn, as that prevents the free action of the muscles of the chest and abdomen. The patient, during the first stage of labor, may walk about or sit down, and need not confine herself to the bed. She may be allowed such food as she can eat, but should not be urged to take food.

The best beverage for her is either a cup of warm tea, or of gruel or arrowroot. Cold water will not hurt her if she desires it. A patient ought, during labor, frequently to pass water. Some women, from false delicacy, do not attend to it, and suffer severely for it.

The doctor ought to have some room to retire to that the patient may be left very much to herself, and that she may have opportunity whenever she desires to of thoroughly emptying either the bladder or bowels. It is better that not more than two women be present with her, and even one of these can be dispensed with if necessary.

The room should be kept quiet.—Let the attendants be quiet and self-possessed, and let there be no noise, or excitement, or whispering. There may be ordinary cheerful conversation, but when the pains become very frequent and severe, it is best that this should be hushed enough to have the patient feel that the attendants are not neglectful of her, or careless about her. Cheerful words spoken to the patient of the blessed relief that will come after enduring so much pain will do good.

When the membranes are ruptured and the waters discharged, the doctor should be called in immediately. When he is present you will be subject entirely to his direction.

If the medical man cannot be present pretty soon, I advise any nurse who has diligently studied this book to make a digital examination, and ascertain if there is a head presentation; if there is, there need not be any anxiety about getting a doctor.

If the child is born before the doctor has time to reach the house, let the patient be made to understand that there is not the slightest danger; and, for yourself, observe the following directions:

Ascertain if a coil of naval string be about the neck of the infant; if there is, remove it immediately. See that it has room to breathe; that there is not a membrane over its mouth, and that its face is not buried in the clothes or the discharges. If the child cries, give a minute’s attention to the mother, to see that she is in an easy position, and for a few minutes make pressure with one hand over her abdomen. If the child does not cry the moment it is born, give it a smart blow on the back, sprinkle a little cold water upon it, and put your finger in its mouth to remove any mucus that may interfere with respiration.

After the child cries, and when no pulsation can be felt in the cord, tie and cut it. Tie with a strong and not too fine a string, about one and a half inches from the child’s body, and cut so as to leave that portion of the cord attached to the child’s body about two and a half inches long. Cut far enough from the ligature so that it will not be liable to slip off. The ligature should be drawn tight when applied, and it ought to be examined afterwards to know that it does not continue to bleed.

I shall here summarize, in a very brief way, what you are to do in the absence of the doctor: After the child is breathing properly and the cord is cut, the mother may receive your attention. If the placenta is not expelled spontaneously, place one or both your hands over the uterus, and by friction, squeezing and pressure there, you will probably cause enough contraction of the womb to start the placenta from its attachments. You may then make slight traction on the cord, pulling only gently, and it will probably come down; as it emerges from the vagina gently twist or turn over the afterbirth, and you will secure the removal of the membranes.

The soiled articles are now to be removed, a binder applied, the patient placed nicely in bed and kept quiet; no talking, no visiting, no excitement allowed.

The baby may now be attended to—be washed and dressed. Have at hand a bowl of warm water, a small quantity of lard or oil, soap, fine sponge, and the articles of clothing, including a binder, and by preference a piece of flannel for washing. It is well also to have a small tub large enough to dip the child in. If the child is much covered with the “vernix caseosa,” rub it over with some unctuous substance, and then wipe it off with the flannel or some soft cloth, being careful at the same time that nothing gets into the eyes of the child, and being careful to remove all the cheesy matter from the angles of the joints, and from behind the ears. Have the water for the bath warm, but not hot; take hold of the feet of the child with your right hand and putting the left under its back and shoulders, lower it into the water, supporting its head by your arm. While supporting its head with your left hand, wash it all over, using toilet soap and (if you have it) a fine, clean sponge; then lift it out into a warm towel and dry it thoroughly. Dust with fine starch powder, made of wheaten flour, under the arms and between the legs, and dress the naval by using a soft piece of linen dipped in vaseline and having a hole in the center. It is well to put another piece of linen around the cord, which may then be turned upward or to the left side, and the binder applied. Some prefer to put absorbant cotton around the cord. The binder or belly-band should be made of flannel, and should be cut bias. Care should be taken to apply it tight enough not to slip, but too tight an application should be particularly avoided. All the garments of the child should be made subservient to comfort and not to show; should be warm and not too small; should consist in part of flannel during cool weather. When dressing the child put one garment inside the other, and put the whole on over the feet. But few pins need to be used if the clothes be properly arranged; three pins are sufficient for the binder. The washing or dressing of the child should be done quickly; a little cold water should be given it; it should be all the time in a warm room, and may be laid where it is quite warm.

The mother may demand a little more attention before the child is applied to the breast. A folded napkin should at first have been applied to the vulva. Look to it and see if it is much soiled with blood. When it is, apply a clean one, and observe particularly that one is placed so that it is partly under her; observe if her bandage is well retained in its place, and if it presses well on the lower portion of the bowels. If the binder is kept well adjusted it does good; it is of no use if it is allowed to slip up from its place. A towel folded and laid over the lower portion of the bowels, under the bandage, is useful as a compress, and helps to keep the binder in place.

Everything should be arranged so that the patient can have rest and quietness; but before she goes to sleep put the child to the breast. If the nipple is retracted, an ordinary tobacco pipe may be used to draw it out so that the child can get hold of it. If the child draws on the breast, the milk which it obtains will serve to physic it, and it should be applied to the breast every four or five hours; nothing else need be given it, except perhaps a little sugar and water.

If necessary to induce the child to take the breast, a little sweetened water or sweetened milk may be applied to the nipple. While the child is nursing the mother may lay upon her side, and receive the child upon the arm of that side upon which she is lying. Perhaps, in order to draw out the nipple so that the child can grasp it in its mouth, it may be necessary to use some bottle with a flat, smooth mouth; fill the bottle with hot water; after a minute, empty it and place the mouth of the bottle immediately over the nipple; as the bottle cools there will be sufficient suction to elevate the sunken nipple.

Soon after the termination of the labor the woman may partake of some light food—tea and toast, panada, or anything of a light, unirritating character. From the very first, under ordinary circumstances, the woman may be permitted to change her position as she may desire, from side to side, or to be propped up in bed. Before going to sleep she ought to urinate—in a lying position, if so inclined, or she can be raised up and supported in a sitting position for a few minutes, if she desires to be. The patient must not be allowed to exert herself, or remain too long in a sitting posture. But I have never known a woman to be harmed by being raised up and sitting for a minute at this particular time.

Unless there is unusual suffering from afterpains or hemorrhage, or something that requires the attention of the physician, the patient will now be desiring and seeking sleep, and everything should be arranged for this object.

CHAPTER VII.
DIRECTIONS TO THE NURSE DURING THE MONTH.

The nurse will receive from the medical man such directions as the peculiarities of the case seem to demand, but I deem it proper here to give some general instructions. First, in regard to

CARE OF THE MOTHER.

Rest is essential to the mother during the month. She should remain in bed nearly all the time for at least two weeks, and should not return to her household duties under a month. Perfect tranquility is essential, that the womb may resume its former size and situation, and that inflammation, ulceration, prolonged debility, pain and excessive discharges be avoided, and that a good form be preserved. As a means of preventing a flabby, pendulous belly, she may also, when she does walk around, wear a utero-abdominal supporter or a well-fitting bandage. If a bandage is worn it should be made of strong linen, cut bias, setting snugly to the form, but not exerting unpleasant pressure. Its breadth should be from twelve to eighteen inches.

The diet of a nursing woman should be both light and nourishing. I would suggest for the first day well-boiled gruel, bread and milk, panada, tea, dry toast and butter, or bread and butter. For the second day, beef tea may be added (F. 58), and she should be served with food four times; the third day she may eat a little chicken or game, and mashed potatoes or rice pudding, and on the fourth day she can partake once of mutton or beef. Arrow root (F. 44), with these articles mentioned, may form part of her diet thereafter, but she may partake of such articles of her former diet as are wholesome and nourishing. The woman must not be starved; she demands food that will allow her to recuperate her strength. Give her as nutritious food as she has appetite for, and can easily digest and assimilate. (F. 58.)

For a BEVERAGE give toast water, barley water, and milk with the chill taken off and a little salt added, tea, cocoa, or chocolate made with one-half milk, new milk and water, cacao and broma, made with a large proportion of milk. Either of these may be freely used as a drink. I have always allowed my patients to drink freely of water from the first, and an occasional cup of coffee is not harmful. When the mother experiences any inconvenience from any articles of diet or drink, she should not hesitate to abandon them, for if they disagree with her they will also disagree with the child. (F. 10, 16, 18, 19, 20, 23, 25, 28.)

The LOCHIAL DISCHARGE, which occurs directly after a lying-in, is at first of a reddish color, and gradually changes to a brownish hue, and afterwards to a greenish shade. It is necessary that there should be some discharge to continue for a week, and it often continues for three weeks more. In some cases it has a disagreeable odor.

Ablutions and cleansings are very necessary at this time. The parts should be carefully cleansed every day, and it is never amiss to use for this purpose a weak solution of chlorinated soda, or carbolic acid, or permangenate of potassa, etc., (F. 153.) They may be used quite weak at first, and afterwards of greater strength, if they do not cause smarting. Tar water is excellent for an injection. The woman should daily assume a position that will facilitate the discharge of the lochia; sometimes get on her knees, or she may occasionally lie on her face and stomach. There should be no bandages applied so as to confine the secretions. A soft sponge and warm water may be used for ablutions at first, or the parts may be bathed with warm water and oat meal gruel; after bathing they should be dried with warm, dry towels; they may then, by means of a piece of linen rag, be anointed with salad oil or vaseline, or other bland oil. Once or twice a day the vagina should be syringed out with some injection. (F. 153, 155.)

To wash or cleanse the patient so that the pores of the skin in every part are free and unobstructed, a soft napkin wet with warm soap and water, should be passed underneath the bedclothing, and she should be rubbed all over without any exposure to a draught of air. In some way she should take a sponge bath every day.

The CLOTHING which a patient will wear immediately after a labor has been already, indicated. As some garments worn during labor are not necessarily soiled, they may be worn until the third or fourth day, when the dress should be changed. This may be done without tiring or exposing the patient. Without raising her up you can pull the bedgown down from over each arm, and after removing it from under the body, you can draw down the chemise and remove it from below. You can place her arms in the sleeves of the clean chemise, throw it over her head and pull it down; and put on a clean bedgown in a similar manner, or both may be put on at once.

The BED CLOTHING as well as the body linen should be changed frequently. In changing the upper sheet it should be pulled off from below, and the clean one can be carried down in its place without removing the other bedclothes, by plaiting the lower half of it. To put on a clean under-sheet, plait one side of it, and place that under the patient while she lies on her side, then let her turn on her back or other side onto it, and draw out the plaited part. Care of this kind is necessary until she is able to sit. Have the sheets well aired, and have a proper temperature in the room.

The lying-in room should always be kept well ventilated and rather cool; it is injurious to the patient to have the room kept at a high temperature. Perhaps the ventilation can be secured by having a little fire in the room, and by occasionally leaving the door of the apartment ajar, at the same time being careful to guard against draughts. But visitors remaining in the room, or any additional number of persons, serve to vitiate the air, as well as to prevent the necessary repose of the patient. A sensation of chilliness may be felt by the woman after delivery, and her feet may be cold; if they are, something warm should be applied to them, and sufficient clothing should be on the bed; but afterwards be careful not to overload her with clothes, as well as to avoid having the room overheated.

Too much light in the room may be injurious to the eyes of the mother or child, and it is often necessary to darken the room somewhat for a few days.

The lying-in woman will usually be confined to her room for two weeks. After the first fifteen days she may very properly remove to another room adjoining, or near at hand, and during her absence her room and bed may be ventilated by throwing the windows wide open and throwing the bedclothes back. Ordinarily she may, at the end of three weeks, take her meals with the family, but she ought still to lie down occasionally to rest her back. At about this time she may take an airing in a carriage, if the weather be fine.

All lying-in women ought not to be treated alike in regard to DIET, etc. While a light, unstimulating diet is best at first in ordinary cases, the weak and delicate require good, nourishing food from the commencement, such as beef tea, chicken broth, mutton chops, eggs, etc., (F. 57, 58, 59.) Oatmeal gruel increases the secretion of milk, is nourishing and easily digested, at the same time it is simple and bland, and proper for those that are corpulent, or strong and robust, and the same may be said of good cow’s milk. But, as the healthy mother furnishes daily from a quart to a quart and a half, she needs some meat to keep up her strength. Never give stimulants to increase the woman’s strength, or to increase the quantity of milk.

In some cases, after a severe and lingering labor, there is RETENTION OF URINE. If the bladder cannot otherwise be emptied, the catheter must be used every six or eight hours.

The bowels are usually costive after a confinement, and I prefer to give a dose of castor oil the third day. If this or some other aperient is not given, enemas should be administered sufficient to cause evacuations.

The care of the MOTHER’S BREASTS is important. Before the milk is abundantly secreted, she should not be fretted by very frequent ineffectual attempts at nursing, though it may be necessary to draw out the nipple by means of a breast pump. The milk should be drawn out when the breasts become full and distended, and they should not be allowed to remain hard and sore. Apply fomentations; cabbage leaves, wilted in hot vinegar and water, or warm solution of carbolic acid, one part to eighty. If they continue to be swelled and painful use F. 221, 223. It may be necessary to make gentle pressure upon them by means of strips of adhesive plaster, or by a sort of jacket or bandage, that should be prepared especially for the purpose. When the breasts are closely bandaged they should be supported on each side by pads of cotton, so that the pressure will be made equally upon them.

Delay in applying the child to the breasts is often a cause of swelled breasts. After it has been fed for a few days it may refuse to nurse, and if it does nurse the nipple may be quite tender. But, unless for some cause the secretion is to be checked, the effort should be made every two hours to induce the child to draw. You will be more successful in these efforts if you can reduce the heat and swelling. Rub the breasts every four hours with good, warm olive oil, vaseline, or camphorated oil, and keep the excoriated nipple thickly coated with sub-nitrate of bismuth.

The breast should be rubbed, and the child should be nursed regularly, although I do not advise that the child or the mother should be roused from their slumbers; it is better to delay for awhile the usual effort. But, even at first, a child can be nursed with considerable regularity every hour and a half during the day, and twice during the night; and it should be applied alternately to either breast, even if it seems to prefer one to the other.

It is often necessary to wash the breast and nipple with warm water, and dry it with a soft napkin, before applying the babe.

During all the time that the mother nurses the child, the MIND OF THE MOTHER exerts an influence on the latter through her milk. If the mother’s mind is very much disturbed by any apprehensions, fears or anxieties, these perturbations will not only be likely to check the flow of milk, but will alter its quality, and perhaps render it hurtful and dangerous to the infant. The nurse should guard the patient as much as possible from anything causing nervous agitation, fretting, anger, grief, fear, sudden terror, or great anxiety, as these are injurious to the mother, and may be harmful and fatal to the child. Equanimity and cheerfulness of mind on the part of the mother are important at any period of her pregnancy or nursing. I will now give more particular directions in regard to

THE CARE OF THE CHILD.

The food of the child, if it is necessary to feed it at first, may be one-third of new milk and two-thirds of warm water, slightly sweetened. It is not necessary that it should be fed for at least eight hours after birth, and at first the quantity fed it must be small. Except in rare cases the milk furnished by the mother will come soon enough, and in sufficient quantity to supply the wants of the child, and it is best for both that the child should draw it when secreted. For the instruction of the mother, as well as the nurse, I here quote a paragraph upon the nourishment and feeding of the child, not only of the new-born, but also of the subsequent months:

“No form of artificial nourishment can compare with that furnished by the mother. Women should know and consider the probability of disease and death occurring from any other mode, and the difficulties and annoyances to be encountered in the use of artificial food. As a further inducement to her to nurse her own child, she should know that her offspring is sure to imbibe with its milk, deep, earnest affection. The mother who can nurse her own offspring should commence within eight hours after delivery, and in the mean time no trash should be put in its mouth to still its cries, or for any other reason; if it has not been surfeited, it will be disposed to take the breast. It should be placed to the breast before they are gorged with milk, for at that later time the flow is less easy, the parts are more irritable, and the child sucking with greater power, we are more likely to have, as the result, irritated nipples. Nature prompts all animals to suck their mother soon after they are born; we are less liable to have sore, irritated, cracked nipples, and there is less liability to infantile colics, etc., if we follow the guidance of nature and instinct.”

As soon as possible accustom the child to the habit of nursing every two hours. If there is a proper interval between the times of nursing, the child draws with more avidity, actually empties the breast, and obtains that part that contains the most cream. Endeavor also to have the intervals longer at night, so that, from 10 P. M. to 6 A. M., it nurses but once or twice. Still, if it wakes every two or three hours, demands its supply of nourishment, and you cannot otherwise quiet the child, you must indulge it. Do not accustom the child to sleeping on the mother’s breast. If it sleep in its own crib or bed, properly clothed and protected, it is less liable to have its rest disturbed. Avoid the custom of having a young child sleep with old and sickly persons, and also of having them sleep in ill-ventilated rooms, and of covering the child’s face as it sleeps. There is danger that a child may die from want of pure fresh air, from having its face pressed tightly in the embrace of the person with whom it sleeps, from the multiplicity of its clothes, and from the mass of bedclothing used by the mother, as well as from improper food. A child should never be covered to sweat by reason of the warmth of its clothing, or of that of the apartment.

If the mother does not enjoy good health, it may be better for her not to nurse the child at night, but to have it fed once or twice with a little diluted cow’s milk at night, and to nurse it during the day.

The following have been named as CAUSES WHY THE MOTHER CANNOT PROPERLY NURSE THE CHILD:

1. When she cannot have a sufficient quantity of milk.

2. When the supply falls off from some defect which is not remediable.

3. When there is a strong venereal or scrofulous taint in the constitution.

4. When suckling produces an active or painful disease in the mother, as colic, etc.

5. When the mother is subject to great nervous debility; possesses an irascible temperament, and cannot avoid grief and sorrow; and also when she is suffering from certain hereditary chronic diseases.

When a mother cannot suckle her child, if circumstances will allow, a healthy wet-nurse should be procured. Choose one that is of a healthy family; ascertain that there are no eruptions on her skin, or if there be other disease; if she have a plentiful breast of milk, and if it be of a good quality; if she has good nipples, and if her child is born near the time that the one was that she is to nurse. Do not get a nurse that menstruates during suckling, nor one that has a child which is unhealthy, or has a sore mouth or blotches upon the skin.

Very feeble new-born babes cannot take the breast sometimes. In such cases cow’s milk, water and sugar (F. 1) may be given in small quantities at a time, but frequently repeated. If it takes only a teaspoonful at a time it should be repeated every half hour.

Many mothers are unable to obtain the services of a wet-nurse. The milk of a cow is the best substitute, and when this is of ordinary richness, it may be diluted with an equal quantity of water, or thin barley water.

The following are leading principles to guide in giving infant food:

1. Aliment should always be presented to the infant stomach in a fluid form.

2. Bread and other farinaceous substances are generally indigestible in the infant stomach, and may better be excluded from infant feeding.

3. Cow’s or goat’s milk, when pure and modified so as to resemble as much as possible human milk, will generally be found sufficient without any other help to nourish the new-born infant.

4. If cow’s milk is used at first, diluted with twice as much water and slightly sweetened, the proportion of water must be gradually lessened, until after six months the milk may be given undiluted.

5. When good milk from one cow cannot be obtained, and the child does not thrive upon the milk used, condensed milk may properly be substituted.

6. There are various forms of infant food referred to in F. 1, 2, 3, 4, 11, 28, 45, 49, and if one of these is tried and proves satisfactory, it will not be advisable to try new kinds of infant food which are at the present time offered for sale. Milk should be the basis of all infantile food; neither starch, dextrine or glucose sufficiently nourishes without it; but we may use one of these foods without milk for one or two days, in unsettled state of the stomach, with good results. (F. 61.)

Thoroughly wash the babe every morning from head to foot, using a large wash bowl or nursing basin, half filled with water. First wet the head, then immediately put the body in the bath, and with a sponge or piece of flannel, cleanse the whole body, particularly the armpits, groins, and between the thighs. The skin, after being thus cleansed, must be quickly and thoroughly dried with soft towels, and the parts liable to become sore, powdered; then all parts of the body and limbs should be gently rubbed. During all the time, when the child is but a few days old, it should not be exposed at all to the cold. The water for its bath should be slightly warmer than new milk, and the time occupied in the bathing should be short. Each time, after a passage from the bowels, the parts should be washed with warm water, and if there is any chafing the calamine powder should be applied.

The naval string should receive the attention of the nurse; within an hour of the time it is at first tied, she should examine the dressing to see if there has been any bleeding. If it bleeds, and the doctor is not at hand, retie with a stout cord, drawing it quite tight. Each morning, when the child is bathed, lift up the naval string with the rag dressing and insert a little nice fresh tallow under it. When it is loose remove it, but use no means to cause the separation. The naval is sometimes a little sore, but seldom needs any dressing more than simply vaseline or tallow.

At night a child should be entirely undressed, and its clothing replaced by other garments, those that are loose, light, and sufficiently warm for it while it is under the bedclothes. For a very young child the proper night-dress is a loose slip; when older, a pair of drawers, fitting up well around the neck and covering the body and limbs, is a good article. The clothing worn during the day should not be worn at night, and the clothing when soiled should be immediately changed. Whenever the child seems disposed to sleep, this should be encouraged. Never arouse a child suddenly from its sleep. Be careful that there is no unnecessary noises to disturb its sleeping. Time the bathing and dressing so that the little one may not be unnecessarily disturbed. But never give soothing syrups, anodynes for infants, or other nostrums to induce them to sleep. If the child is restless, endeavor to ascertain if there is not some cause that can be removed, such as tight clothing, etc.

Premature infants may, under favorable circumstances and assiduous care, live and thrive. Immediately after birth the child should be placed in a warm bath, and then wrapped in cotton. The baths should be warmer than usual, and must be frequently repeated. Awaken the child every one or two hours to feed it. Milk (woman’s milk is the best) must be given it by a teaspoon. With a view to the better development of the lungs, it may be excited to cry by a slight irritation. Do not bring such children into the open air for several months after the birth, as their passages are readily affected.

PART II.
ANATOMY AND PHYSIOLOGY OF THE FEMALE ORGANS AND FŒTAL DEVELOPMENT.

CHAPTER I.
OF THE PELVIS.

The formative organs of generation are situated within a large cavity, called the cavity of the pelvis, the walls of which are composed of bones and soft parts. This basin (in Latin, pelvis) is an irregular, long cavity, situated at the base of the spinal column, and above the inferior extremities. In the adult the bony pelvis may be divided into four parts or bones, viz: the os sacrum, two ossa innominata, and the os coccygis, but in early life they are more minutely divisible.

THE SACRUM.

The sacrum (Fig. [1]) terminates the vertebral column, and is perhaps the most important bone in the pelvis, obstetrically considered, as it enters largely into the various deformities of the pelvis. In the adult it is of a triangular shape, the base of the triangle being above and inclining forwards, the apex below and somewhat backwards; its length is from four to four and a half inches; its breadth about four inches, and the greatest thickness, two and a half inches. The internal surface is concave to the amount of half an inch, crossed by four transverse lines, marking the former division by cartilage; here are four pair of holes, through which pass numerous nervous filaments, which afterwards form part of the great sciatic nerve.

It is placed at the posterior part of the pelvis, where it appears like a wedge forced in between the ossa innominata, immediately below the vertebral column and directly above the coccyx.

THE OSSA INNOMINATA.

The os innominata (nameless bone, Fig. [2]) is of a very irregular figure, and the pair occupy the lateral and anterior parts of the pelvis. The external or femoral surface is turned backwards and downwards, as well as outward; at its superior part, inferiorly it looks downwards. Towards the front, the external face presents the cotyloid cavity, or the acetabulum; a little more in advance and below is the subpubic or obturator foramen, which is nearly closed by the obturator ligament.

Fig. 2. Right os innominatum, external surface.
Fig. 2—Represents the external surface of the right os innominatum. A. The external iliac fossa; B, crest of the ilium; C, anterior superior spine of the ilium; D, anterior inferior spine of the ilium; E, horizontal branch of the pubis; F, posterior superior spine of the ilium; G, posterior inferior spine of the ilium; H, acetabulum; I, ischium; K, obturator foramen. At birth the haunch bone, or os innominata, is composed of three bones connected by cartilage. Fig. [3].

The superior portion of the bone is characterized on its abdominal or internal face by a large excavation called the internal iliac fossa (Fig. [4].) This portion is terminated below by a large rounded and concave line. The inferior (lower) portion presents behind a nearly triangular plane surface; near the middle of this is the obturator foramen, and in front is the internal face of the os pubis.

Fig. 3. Left os innominatum, external surface, etc.
Fig. 3—Left os innominatum, partly ossified. The haunch bone as it exists in the child. A, pubis; B, ilium; C, ischium.

Fig. 4. Right os innominatum, internal surface.
Fig. 4—Right os innominatum, internal surface. A, internal iliac fossa; B, anterior superior spinous process of the ilium; C, crest of the ilium; D, posterior superior spinous process of the ilium; E, posterior inferior spinous process of the ilium; F, articular surface; G, spine of the ischium; H, tuberosity of the ischium; I, obturator foramen; K, ischia pubic ramus; L, crest of the pubis; M, the pectineal eminence.

THE OS COCCYGIS.

Fig. 5.
The os coccygis.

The OS COCCYGIS (Fig. [5]) is three or four little bones united together on the median line of the body, and attached to the os sacrum. Each little bone is tipped with cartilage, and they are so united as to be movable. The entire bones form a pyramid, the apex of which is below. The internal surface is smooth, like that of the sacrum, terminating the plane of the sacrum and bounding it anteriorly.

Fig. 6. Vertical section of the pelvis.
Fig. 6—Inlet, outlet, and axis of the pelvis. a, b, plan of inlet—superior strait; c, d, plan of outlet, or inferior strait; e, f, axis of cavity; g, the coccyx extended as it is in labor.

Of the JOINTS OF THE PELVIS it is only necessary here to say that there is no motion in them to facilitate labor, except that the sacro-coccygeal joint is of the kind called ginglymoid, admitting of extensive motion, especially backward, so as to permit the enlargement of the lower outlet an inch or more. (Fig. [6].)

OF THE PELVIS IN GENERAL.

We will now consider the pelvis collectively or as a whole; its relation to the rest of the body; its magnitude, axis, etc. It is connected with the trunk by the articulation of the sacrum with the last lumber vertebra, effected in the same manner as the junction of the vertebra with each other; with the lower extremities it is connected by means of the hip joints. When the pelvis is in situ, the brim is neither horizontal nor perpendicular. It represents a cone, slightly flattened from before backwards, the base of which being above, while the apex is directed downwards.

When the body is erect the upper part of the sacrum and the acetabula are nearly on the same descending line, the point of the os coccygis being a little above the arch of the pubis, and the sacro-vertebral angle three inches and nine lines higher than the pubis. Were it not for the obliquity owing to the upright position of the human female, the womb would gravitate low in the pelvis, and produce most injurious pressure on the contained viscera. The lower or true pelvis is the part involved in parturition, and its size and shape demands our attention.

THE BRIM OF THE PELVIS.

This is defined by the LINEO ILIO PECTINEA, which marks the boundary of the true and false pelvis, and this superior strait is the entrance of the lesser pelvis. Its form has been variously described as being oval, heart-shaped, and triangular. If we call it “triangular with angles rounded off,” the base of the triangle is behind and the apex in front. It would be nearly oval were not the oval form broken by the promontory of the sacrum. This brim is the first solid resistance the head of the fœtus meets in its descent through the pelvis.

DIAMETER OF THE PELVIS.

Different estimates are made by different anatomists of the measurements of the brim of the pelvis. The following is nearly the correct size of the ordinary female pelvis:

Fig. 7. The bony pelvis.
Fig. 7—The pelvis seen from above. a a, The antero-posterior or sacro-pubic diameter; b b, the transverse diameter; c c, the two oblique diameters.

The circumference varies from thirteen to fifteen inches; the antero-posterior diameter, i. e., from the prominence of the sacrum to the upper edge of the symphasis pubis, (Fig. [6]), is about four and a quarter inches; the transverse across the widest part of the brim, at right angles to the antero-posterior, is five and a quarter inches, and the oblique from the sacro-iliac synchondrosis of one side to the opposite of the brim, just above the acetabulum, is five inches. (Fig. [7]).

The cavity of the pelvis, of which the fixed boundaries are the sacrum and the pubis, is of unequal depth. The height in front is one and a half inches; upon the sides, three and three-quarter inches, and it is four and a quarter inches if a straight line be drawn from the sacro-vertebral angle to the point of the coccyx, five and a quarter inches following the curve of the sacrum, and six inches if the coccyx be extended. (Fig. [6]).

The antero-posterior diameter of the outlet from the arch of the pubis to the point of the coccyx is usually four and a quarter inches, but may increase to five inches during labor by the retrocession of the coccyx (Fig. [8]); the transverse from one tuber ischii to another is four and a quarter inches, and the oblique about four and three-quarter inches.

Fig. 8—Position of the pelvis and the axis at the termination of labor.
Fig. 8—a b, Total axis of the excavation; c, the axis of the superior strait; d e, perineum as distended at the moment of the passage of the head.

It is important to notice that the diameters are entirely changed between the rim and the outlet, and that the change is effected gradually. The axes of the inlet and outlet form an obtuse angle with each other (this is illustrated in Figs. 6 and 8.) The three diameters taken at the center of the pelvis are very nearly equal—about four and three-quarter inches.

DIFFERENCES OF THE PELVES.

There is considerable difference between the male and female pelvis, in shape and size. The pelvis in the male is smaller but deeper; the bones are thicker and the brim is more circular, the depth of the symphasis pubis is greater, the sacrum is more perpendicular, the arch of the pubis is narrower, the tuber ischii are nearer each other, and the coccyx less movable. In the female the iliac fossæ are larger, the interval separating the angle of the pubis from the acetabulum is greater, causing the prominence of the hips and wider separation of the thighs, the superior straight is larger and more elliptical, the curve of the sacrum deeper and more regular, the tuberosities of the ischii are further apart, and the arch of the pubis broader. From the greater width of the female pelvis, and from the upper end of the thigh bones being farther apart than in the male, the thigh bones approach each other in their descent, giving a peculiarity to the movements of the female in walking.

The soft parts lining the pelvis and covering it externally modify the diameters of the pelvis, but the effect of these additions in diminishing the internal diameter is not very great. The diameter of the cavity is lessened thereby from one-fourth to one-half an inch.

USES OF THE PELVIS.

One function of the pelvis is to inclose and protect the bladder, rectum and seminal vesicles of the male, the uterus, Fallopian tubes and ovaries, as well as the bladder and rectum in the female. During labor it affords a passage for the child.

TERMINAL OUTLET OF THE PELVIC CANAL.

This is not at the coccyx, but rather at the anterior commissure of the perineum. This is so greatly distended at the last moment of labor as to much prolong the posterior wall of the pelvic excavation and the canal to be traversed by the fœtus. (Fig. [8]).

Fig. 9—Section of sacrum and pubis.
Measuring superior strait.

Fig. 10.
Measuring inferior strait.

CHAPTER II.
PARTS CONTAINED IN THE PELVIS.

The internal organs of generation are the vagina and uterus with its appendages; but I will first describe the urethra and the perineum.

The URETHRA is a membranous dilatable canal about an inch and a half in length, and directed obliquely from before backwards, and from below upwards, running under and behind the symphasis pubis, from which it is separated by loose celular tissue. Its inferior portion is intimately united to the vaginal walls. Its meatus, the outlet for the urine, is situated about an inch from the clitoris, and immediately above the prominent enlargement of the anterior part of the vagina.

Internally the urethra opens into the bladder. Its direction is subject to variation during pregnancy, the bladder being carried upwards with the uterus, the urethra curves under the pubic arch, and then ascends perpendicularly. The same change occurs when the uterus is enlarged from other causes. In prolapse of the pelvic viscera the course is reversed.

The PERINEUM is the portion between the rectum and the vagina.

THE UTERUS.

The uterus is the organ provided for the reception, growth, and ultimately for the expulsion of the fœtus. In the virgin normal state it is pear-shaped, flattened from before backwards; is situated in the cavity of the pelvis, between the bladder and the rectum, and projects into the upper end of the vagina below. Its upper end or base is directed upwards and forwards, so that its axis corresponds very nearly with that of the superior strait, and forms an angle with the vagina.

The uterus measures about three inches in length, at its upper part two in breadth, an inch in thickness, and it weighs from one ounce to an ounce and a half. The fundus is the upper broad extremity of the organ; it is convex, covered by peritoneum, and placed in a line below the level of the brim of the pelvis. The body gradually narrows from the fundus to the neck. Its anterior surface is flattened, covered by peritoneum in the upper three-fourths of its extent, and separated from the bladder by some convolutions of the small intestines; the lower fourth is connected with the bladder. Its posterior surface is convex, covered by peritoneum throughout, and separated from the rectum by some convolutions of the intestines. The lateral margins are concave, and give attachment to the Fallopian tubes above or superiorly, and the round ligaments below; and behind these, and also below the ligament of the ovary. The cervix is the lower and constricted portion of the uterus; around its circumference is attached the upper end of the vagina, and this extends upwards a greater distance behind than in front. At the vaginal extremity of the uterus is a transverse aperture, the OS UTERI, bounded by two lips, an anterior one which is thick, and a posterior one, narrow and long. The os uteri, or os tincæ, is generally about the size of a small goose-quill. The canal of the cervix is from half to three-quarters of an inch long; leading from the os uteri it first widens and then contracts again where it enters the body of the uterus. The surface of the canal exhibits a variable number of follicles or vesicles called the glandula nabothi, which secrete a thick mucus; this blocks the canal after impregnation. The cavity of the body and neck has a longitudinal extent of about two and a half inches; in virgins it is much less. (Fig. [12]).

Fig. 11 Uterus, bladder, etc., showing relative position.
Fig. 11—Section of pelvis. a, section of pubis; b, bladder distended; c, the uterus in normal position; e, sacrum; f, urethra; g, vagina; h, hymen; i, the os uteri; j, meatus of urethra; k, vagina.

STRUCTURE OF THE UTERUS.

The proper tissue of the womb is composed of fibres, and is proved to be muscular. In the unimpregnated state it is dense, firm, and of a grayish color. The neck appears less firm than the body.

The internal or mucous membrane is thin, smooth, and closely adherent to the subjacent tissue. It is a quarter of an inch thick at the middle of the body of the uterus; in the neck it does not exceed one-twenty-fourth part of an inch in thickness. It is continuous through the fimbriated extremity of the Fallopian tubes with the peritoneum, and through the os uteri with the mucous membrane of the vagina.

THE FALLOPIAN TUBES.

The uterine or Fallopian tubes are two canals, about four inches long, placed in the superior border of the broad ligaments of the uterus. They extend for about three inches and a half, when they expand and terminate with a fringed process called the fimbria, which is applied to the ovary after impregnation. The Fallopian tubes serve the double purpose of a canal for transmitting the fecundating principle of the male and for carrying the germ furnished by the female to the uterus—in fact they are excretory ducts of the ovary.

Injections into the uterus may pass into the peritoneal cavity, through the Fallopian tubes, and cause peritonitis.

At each menstrual period an ovula passes along with the serum current in the Fallopian tubes to the uterus.

THE OVARIES.

The ovaries in the female are said to be the analogues of the testicles in the male; they both secrete a fluid that is essential to impregnation. They are situated on either side of the uterus, and are attached to either side of it by the posterior duplicature of the broad ligament called the ligament of the ovary. (Fig. [12]).

They are oval flattened bodies about an inch and a half long, three-quarters of an inch wide at their greatest breadth, and a quarter of a inch thick. They are situated on the sides of the uterus in that portion of the broad ligament called the posterior wing, just behind the Fallopian tubes. The ovary consists of a peculiar structure enclosed by two envelopes, one of which is serous and the other fibrous. Within the fibrous coat is a special tissue called the stroma; imbedded in this are numerous small round transparent vesicles in various stages of development, varying in size from that of a millet seed to that of a hemp seed. They are the ovisacs, containing the ova, and are called the Graafian vesicles. These have thin transparent walls and contain a clear fluid, and within that the ovula. Fifteen or twenty may readily be distinguished in the adult female without the aid of magnifying glasses.

THE VAGINA.

The vagina is a membranous canal, extending from the vulva to the uterus obliquely through the pelvic cavity, between the bladder and rectum, having about the same direction as the axis of the pelvis. It is described as being five or six inches in length and about two inches in diameter, but it would be more correct to say that it is capable of being distended to these or greater dimensions, for in its common state the os uteri is seldom found to be more than three inches from the external orifice, and the vagina is contracted as well as shortened. In great part the walls of the vagina are composed of spongy erectile tissue, and their vascularity is a cause of considerable hemorrhage consequent on their rupture. Three layers combine to form the walls; one external or cellulo-fibrous, a middle or muscular one, and the internal or mucous one. The latter is of a pale red hue, which becomes violet during menstruation and especially during pregnancy. The mucous coat is disposed in the form of rugæ or folds anteriorly and posteriorly, which are better developed in young virgins and aged females; during advanced pregnancy, and for a short time after delivery, they are entirely effaced.

Fig. 12—Section of the Uterus, &c.
Fig. 12—Uterus, ovaries and Fallopian tubes. Section of the uterus, etc. a, Fundus of the uterus; b, cavity of the womb; c, cavity of the neck of the uterus; d, d, the cavity of the Fallopian tubes; e, fimbriated extremity; f, f, the ovaries; g, the vagina; h, h, the round ligaments; i, i, the ligaments of the ovaries.

The upper part of the vagina is connected to the circumference of the os uteri but not in a straight line, for the former stretches beyond the latter, and being joined to the cervix, its mucous membrane is reflected over the os uteri, which by this mode of union is suspended with protuberant lips in the vagina, and permitted to change its position in various ways and directions.

THE EXTERNAL ORGANS.

The situation of the external organs of generation are indicated in the accompanying diagram (Fig. [11].) It is not deemed necessary here to describe these, but in regard to the hymen (the membrane that in infancy nearly closes the orifice of the vagina), we may remark that it is not a perfect test of virginity. There are, however, examples recorded in works on midwifery where a slight surgical operation was necessary after marriage, because this membrane was uncommonly strong.

CHAPTER III.
PHYSIOLOGY OF THE UTERUS AND OVARIES.

Menstruation is a periodical flow of blood having its source in the walls of the uterus. But menstruation is excited by and dependent upon ovulation, and the effective cooperation of both the uterus and ovaries is necessary to both menstruation and conception. We shall consider these functions separately.

MENSTRUATION.

In healthy women at the period of puberty, a certain amount of sanguineous fluid is secreted by the lining membrane of the uterus, and is excreted through the vagina every month; this is termed the catamenia, or menses, and the function itself menstruation. A female in whom the discharge recurs at the usual periods, in the usual quantity, and of the usual quality, is said to be regular, The occurrence of menstruation defines the period of puberty at which a girl becomes a woman capable of conception, and its cessation terminates the prolific period of female life.

Dr. Robinson, of Manchester, England, in a paper on the natural history of menstruation, has stated the age at which it occurred in 450 cases.

According to his table, 10 menstruated for the first time at 11 years of age, 19 at 12, 53 at 13, 85 at 14, 97 at 15, 76 at 16, 57 at 17, 26 at 18, 23 at 19, and 4 at 20.

The time at which the first menstruation occurs varies exceedingly from the influence of climate, habits of life and constitution. There have been occasional instances of very precocious menstruation, in which the first appearance of the discharge was attended with all the attributes of puberty. I myself knew one case where a girl of nine years, not only menstruated, but presented the external signs of puberty, such as prominent breasts, wide pelvis, rounded contour of body, &c.

The first appearance of the menses very rarely occurs without being preceded by premonitory symptoms. There is usually a degree of languor and lassitude, fatigue after exertion, inequality of spirits, dark shade under the eyes, headache, sometimes pain in the thyroid gland, pain in the back, a sensation of tension and swelling in the lower part of the abdomen, and occasionally considerably fever. Not unfrequently strange nervous disturbances occur; but all of these symptoms may pass off, the first and second time, without the appearance of the menses, or with a white discharge only. Usually the phenomena may last from one to eight days, then there is an abundant flow of mucus, which after one or two days is mixed with blood, and soon gives place to almost pure blood. When this discharge takes place most of the unpleasant symptoms disappear, and the female only complains of weakness and is somewhat pale. The hemorrhage continues for several days, then the amount of blood mingled with the vaginal mucosities diminishes, soon there is mucus alone, then the discharge ceases.

I should remark now that the propriety of applying the terms, blood or hemorrhage, to the menstrual secretion is properly questioned.

Sometimes the first menstruation takes place without being preceded by any discomfort, but pretty generally there is a change in the girl at the time, both in her body and mind, a change that fits her for the important duties that devolve upon her.

Most young girls have a return of the discharge after a month, the menses afterwards recurring regularly; some do not become regular until after several months. Sometimes the function is imperfectly performed; such cases are accompanied with considerable distress.

In some young girls the precursory symptoms of the first appearance of the menses may not be followed by a flow of blood, and there is an apparent effort of nature recurring monthly for several months before the courses become established.

There are occasional examples of retarded menstruation. I am acquainted with one woman who at the age of twenty-five years has not menstruated. The absence of the menses does not render conception impossible, in every case.

After the menses are established, until the time of their cessation, they generally return every month, unless interrupted by pregnancy or nursing. The average of the catamenial period is about twenty-eight days; in a large number it is thirty days; in some instances they recur every fifteen days.

The duration of the flow varies from one to eight days; three or four days is the most usual duration. The quantity of blood lost is variable; from three to five ounces is said to be the average.

When the ovaries are congenitally absent, or have been removed, or have become disorganized, menstruation is absent, or ceases. The cause of the menses is the successive evolution of the Graafian vesicles; but the regular process may go on in the ovary without the regular sanguineous discharge.

The menses continue in the majority of cases until about the age of 46 years, or perhaps in this country 48 years.

According to Dr. Robertson, of England, the periods at which it closed in 77 individuals was, in 1 at the age of 35 years, 4 at 40, 1 at 42, 1 at 43, 3 at 44, 4 at 45, 3 at 47, 10 at 48, 7 at 49, 26 at 50, 2 at 51, 2 at 52, 2 at 53, 2 at 54, 1 at 57, 2 at 60, and 1 at 70.

The average duration of the menstrual function is about 30 years. The cessation of the ovarian function is generally announced several years in advance by irregularities of the menses. Besides the intermissions and irregularities, there are other symptoms; a general and indefinite feeling of uneasiness, pelvic pains, itching at the genital parts, flashes of heat in the face, alterations of chilliness and perspiration, leucorrhœa, etc. These troubles are usually slight, and disappear promptly. The time of life has been called the CRITICAL PERIOD, because there has been an opinion prevalent that peculiar dangers attend it. However, the mortality is not greater between the ages of 45 and 50 years than at any other period of life. Yet it is true that in some instances diseases that had been latent previously, declare themselves at this period.

THE FUNCTION OF THE OVARIES.

We will now consider the physiological action of the ovaries and its intimate connection with the action of the uterus in menstruation, etc.

Preceding the first menstruation an ovary is considerably enlarged, becomes of a red color, and its vascular apparatus is considerably congested; the Fallopian tube also becomes congested; its fimbriated extremity is of a violet red color, and has a velvety appearance. The Graafian vesicles increase in size; fifteen or twenty of them, more advanced than the others, project from the surface of the ovary; one of these grows so that after a few days it forms a tumor of the size of a cherry; the walls of the vesicle, being distended by an increased secretion of fluid, becomes quite thin, and at last are ruptured. When the thinned walls give way, the ovule is expelled, with a part of the granular contents of the vesicle; these are grasped by the fimbriated extremity of the Fallopian tube which is prepared to receive it and convey it through its canal into the cavity of the uterus.

This evolution of an ovule excites numerous sympathies throughout the organism of the female, and especially the generative organs. The vascular apparatus of the womb becomes developed in an unusual manner; a network of fine blood vessels surround the orifices of the numerous glandular tubes, of which the membrane is almost entirely composed; this gives a violet hue to the internal surface of the womb; the utricular glands increase in size, the muscular structure of the uterus acquires greater extension, becomes redder and more spongy and supple, the volume of the organ is increased, the neck is tumefied and its orifice narrower, the lips of the os tincæ are warmer and their color deeper.

The vascular congestion which the uterus undergoes is accompanied with the exudation of sanguineous fluid, which is at first but a few drops; this communicates to the increased vaginal mucus a reddish hue. After a day or two there is a bloody flow from the vascular network of the mucous membrane. This flow, which constitutes the menses, is diminished after three or four days, and the discharge again contains a large proportion of mucus and serum. It is probable that the rupture of a Graafian vesicle occurs during the last days of the flow, ordinarily, and it is also believed that venereal excitement is capable of exerting so much influence upon it that it may determine the rupture of an enlarged vesicle, which, without sexual intercourse, would have remained whole several days longer.

After the discharge of the ovule consequent on the rupture of the Graafian vesicle, the walls of the vesicle contract on the matter that is effused within it, and form a compact mass, which after a time has an orange yellow color—this is called the corpus luteum.

Ordinarily, in the human female in the normal condition, a new Graafian vesicle increases in size every month, becomes excessively developed, and finally bursts and discharges its ovule, to become, through successive transformations, the corpus luteum. What is called the “monthly sickness,” “monthlies,” “courses,” etc., never occurs without having been preceded and accompanied by the development of a Graafian vesicle.

CHAPTER IV.
OF DISPLACEMENTS OF THE UTERUS.

In order to compress as much as possible what I say upon these topics, I shall consider here displacements of the uterus, both of those which occur in the pregnant and non-pregnant women.

By the inflection of the peritoneum the uterus is permitted to expand freely during pregnancy, and to rise without inconvenience into the cavity of the abdomen; this it could not do if it was confined to its place by short ligaments, or by adhesions. But from the same cause, women become liable to various diseases; to the retroversion of the uterus, and other displacements; to dropsy of the peritoneum, and to that species of hernia which is occasioned by the descent of the intestines between the vagina and rectum.

By PROLAPSIS is meant that condition in which the uterus falls below its natural level in the pelvic cavity. Procidentia is a term used to signify the protrusion of the uterus beyond the vulva. Women are liable, even when young, to a falling of the womb, but it occurs most commonly after the age of thirty-five, in such as lead a laborious life. Amongst other causes may be enumerated violent bearing down efforts, such as are made in straining to pass hardened feces, or in urging an evacuation through a stricture in the rectum, in coughing, lifting heavy weights, etc.

The immediate causes of the displacements are the pressure on the uterus by the viscera above it, and a diminution in tone of the uterine supports.

Displacements of the womb are more common among women who have hollow and capacious pelves; in sufferers from dropsy, and in delicate, flabby subjects, where the broad and round ligaments are affected and elongated.

There may be prolapsis during the early months of pregnancy, and in cases where the pelvis is large and the ligaments are relaxed, the womb may rest on the perineum; or the neck, and even the body may become visible externally; but it subsequently rises out of the pelvic cavity, assuming a normal position.

When a woman has prolapsis uteri she often complains of a sense of weight about the pelvis, of dragging pains, of a wearisome backache, and of a leucorrhocal discharge. Menstruation is seldom interfered with, and as the uterus goes back of itself, or is easily pushed up when the patient is in bed, conception may take place, and the general health may not be directly affected.

In some few instances there is complete inability to pass water until the patient lies down and replaces the uterus with her finger; in other cases micturition may be annoyingly frequent. Constipation is often complained of, and, if the woman be careless, a large accumulation of feces may take place in the rectum.

By a vaginal examination the os uteri is found low down, and if the cervix is of the natural length, we know that it is prolapsis.

If a round tumor is seen projecting beyond the vulva, and if at the lowest part of it there is what seems to be the mouth of the uterine cavity, it may be advisable to introduce a sound or catheter, to make sure that the opening is not a mere cleft in a uterine polypus. (Of course, you would not use a sound if you suspected pregnancy.) If there are ulcers, cracks, etc., they may be detected, the ulcers looking as if portions of the mucous lining had been punched out.

In pregnancy, displacements may occur either slowly or suddenly, though the woman may have had nothing of the kind previously, or they may be the continuation of a previous prolapse. The progressive development of the uterus generally removes the prolapsis about the fourth or fifth month, but if the pelvis is very large, it may possibly continue.

As in other cases of prolapsis, the pregnant woman may suffer very much from it. She may suffer from a feeling of weight at the anus; painful tractions in the groins, lumber regions and umbilicus; a fetid discharge may come on; there may be complete retention of urine, very obstinate constipation, etc.; and the pressure on the uterus may cause abortion.

For complete retention of the urine the catheter may be used, or the womb may be pressed up by one or two fingers introduced into the vagina; or the woman may be able to urinate if she lies down and elevates her hips considerably.

THE OPERATION OF INTRODUCING THE CATHETER may be performed by the educated nurse. The patient being placed upon her back and the labia separated, the point of the forefinger of the left hand should be placed just within the orifice of the vagina so as to press slightly the upper edge; the catheter should then be passed along the inner surface of the finger until it is arrested by the anterior part of the vagina; when there, a very slight movement so as to elevate the point of the instrument a little, enables the operator in the majority of cases to enter the catheter into the canal. The operation is more difficult when the parts are swollen or distended, as happens occasionally from disease, during pregnancy or labor, or after delivery. If we cannot detect the orifice by the touch, we may use a light, and the patient may be placed on her side. We may adopt another way to proceed. The point of the forefinger finds the clitoris, and passes from above downwards to the middle of the vestibule; the first inequality met with is the orifice of the urethra, into which the instrument can then be passed. It will easily slide in if the instrument is not passed either to the right or the left of the median line.

When a woman who has previously suffered from prolapsis becomes pregnant, it is sometimes necessary for her to keep the horizontal position during the first three or four months of pregnancy, and after her confinement she should keep her bed a considerable time—perhaps for two months.

For the treatment of prolapsis in non-pregnant women, the general principles are to be applied: To afford artificial support to the superincumbent abdominal viscera; give tone to the broad and round ligaments of the uterus, to the vaginal walls and the perineum; and to remove any complications that induce the falling, such as uterine congestion, hypertrophy, cough, constipation, etc.

The uterus may usually be easily pushed back to its place when the patient is lying down, or, what is better, her head much lower than her pelvis. (Fig. [13]). The knee-chest position is the best one.