THE MOTHER

AND HER CHILD

BY

WILLIAM S. SADLER, M. D.

PROFESSOR OF THERAPEUTICS, THE POST-GRADUATE MEDICAL

SCHOOL OF CHICAGO; DIRECTOR OF THE CHICAGO INSTITUTE

OF PHYSIOLOGIC THERAPEUTICS; FELLOW OF THE

AMERICAN MEDICAL ASSOCIATION; MEMBER OF

THE CHICAGO MEDICAL SOCIETY; THE ILLINOIS

STATE MEDICAL SOCIETY; THE AMERICAN

ASSOCIATION FOR THE ADVANCEMENT

OF SCIENCE, ETC.

AND

LENA K. SADLER, M. D.

ASSOCIATE DIRECTOR OF THE CHICAGO INSTITUTE OF PHYSIOLOGIC

THERAPEUTICS; FELLOW OF THE AMERICAN MEDICAL

ASSOCIATION; MEMBER OF THE CHICAGO MEDICAL

SOCIETY; THE MEDICAL WOMEN'S CLUB OF CHICAGO;

NATIONAL CONGRESS OF MOTHERS AND

PARENT-TEACHER ASSOCIATION; THE

CHICAGO WOMAN'S CLUB, ETC.

ILLUSTRATED

TORONTO

McCLELLAND, GOODCHILD & STEWART

CHICAGO: A. C. McCLURG & CO.

1916

Copyright

A. C. McClurg & Co.

1916

Published August, 1916

Copyrighted in Great Britain

W. F. HALL PRINTING COMPANY, CHICAGO

TO

"BILLY"

WHO, BECAUSE OF HIS UNCONSCIOUS CONTRIBUTIONS TO ITS

PRACTICAL FEATURES, SHOULD BE REGARDED AS A

CO-AUTHOR, THIS VOLUME IS AFFECTIONATELY

DEDICATED BY HIS PARENTS

THE AUTHORS

For many years the call for a book on the mother and her child has come to us from patients, from the public, and now from our publishers—and this volume represents our efforts to supply this demand.

The larger part of the work was originally written by Dr. Lena K. Sadler, with certain chapters by Dr. William S. Sadler, but in the revision and re-arrangement of the manuscript so much work was done by each on the contributions of the other, that it was deemed best to bring the book out under joint authorship.

The book is divided into three principal parts: Part I, dealing with the experience of pregnancy from the beginning of expectancy to the convalescence of labor: Part II, dealing with the infant from its first day of life up to the weaning time; Part III, taking up the problems of the nursery from the weaning to the important period of adolescence.

The advice given in this work is that which we have tried out by experience—both as parents and physicians—and we pass it on to mothers, fathers, and nurses with the belief that it will be of help in their efforts at practical and scientific "child culture." We believe, also, that the expectant mother will be aided and encouraged in bearing the burdens which are common to motherhood by the advice and instruction offered.

While we have drawn from our own professional and personal experience in the preparation of this book, we have also drawn freely from the present-day literature dealing with the subjects treated, and desire to acknowledge our indebtedness to the various writers and authorities.[Pg viii]

We now jointly send forth the volume on its mission, as a contribution toward lightening the task and inspiring the efforts of those mothers, nurses, and others who honor us by a perusal of its pages.

William S. Sadler.
Lena K. Sadler.

Chicago, 1916.

There can be no grander, more noble, or higher calling for a healthy, sound-minded woman than to become the mother of children. She may be the colaborer of the business man, the overworked housewife of the tiller of the soil, the colleague of the professional man, or the wife of the leisure man of wealth; nevertheless, in every normal woman in every station of life there lurks the conscious or sub-conscious maternal instinct. Sooner or later the mother-soul yearns and cries out for the touch of baby fingers, and for that maternal joy that comes to a woman when she clasps to her breast the precious form of her own babe.

Motherhood is by far woman's highest and noblest profession. Science, art, and careers dwindle into insignificance when we attempt to compare them with motherhood. And to attain this high profession, to reach this manifest "goal of destiny," women are seeking everywhere to obtain the best information, and the highest instruction regarding "mothercraft," "babyhood," and "child culture."2

In an Indiana town not long ago, at the close of a lecture, a small, intellectual-appearing mother came forward, and, tenderly placing her tiny and emaciated infant in my arms, said: "O Doctor! can you help me feed my helpless babe? I'm sure it is going to die. Nothing seems to help it. My father is the banker in this town. I graduated from high school and he sent me to Ann Arbor, and there I toiled untiringly for four years and obtained my degree of B. A. I have gone as far as I could—spent thousands of dollars of my unselfish father's money—but I find myself totally ignorant of my own child's necessities. I cannot even provide her food. O Doctor! can't something be done for young women to preparé them for motherhood?"

The time will come when our high and normal schools will provide adequate courses for the preparation of the young woman for her highest profession, motherhood. This young mother, who had reached the goal of Bachelor of Arts, found to her sorrow that she was entirely deficient in her education and training regarding the duties and responsibilities of a mother. In every school of the higher branches of education that train young women in their late teens there should be a chair of mothercraft, providing practical lectures on baby hygiene, dress, bathing, and the general care of infants, and giving instruction in the rudiments of simple bottle-feeding, together with the caloric values of milk, gruels, and other ingredients which enter into the preparation of a baby's food.

Young women would most enthusiastically enroll for such classes, and as years passed and marriage came and children to the home, imagine the gratitude that would flood the souls of the young mothers who were fortunate enough to have attended schools where the chairs of motherhood prepared them for these new duties and responsibilities.

Just as soon as it is known that a baby is coming into the home, the expectant mother should engage the best doctor3 she can afford. She should make frequent calls at his office and intelligently carry out the instruction concerning water drinking, exercise, diet, etc. Twenty-four hour specimens of urine should be frequently saved and taken to the physician for examination. In these days the blood-pressure is closely observed, together with approaching headaches and other evidences of possible kidney complications. The early recognition of these dangers is accompanied by the immediate employment of appropriate sweating procedures and other measures designed to promote the elimination of body poisons. Thus science is able effectively to stay the progress of the high blood-pressure of former days, and which was so often followed by eclampsia—uremic poisoning.

In these days of careful urine analysis, expertly administered anaesthetics, and up-to-date hospital confinements, the average intelligent woman may enter into pregnancy quite free from the oldtime fears, whose only rewards were grief and cankering care. All fear of childbirth and all dread of maternal duties and sacrifices do not in the least lessen the necessary unpleasantness associated with normal labor. It lies in the choice of every expectant mother to journey through the months of pregnancy with dissatisfaction and resentment or with joy and serenity. "The child will be born and laid in your arms to be fed, cared for, and reared, whether you weep or smile through the months of waiting."

A little woman came into our office the day of this writing, saying: "Doctor, I'm just as mad as I can be; I don't want to be pregnant, I just hate the idea." As I smiled upon this girl-wife of nineteen, I drew from my desk a sheet of paper and slowly wrote down these words for the head of a column: "Got a mad on," and for the head of another, "Got a glad on;" and then we quickly set to work carefully to tabulate all the results that having a "mad on" would bring. We found to her dismay that its harvest would be sadness of the heart, husband unhappy, work unbearable, while all church duties as well as social functions would be sadly marred. Then, just4 as carefully, we tabulated the benefits that would follow having a "glad on." Her face broke into a smile; she laughed, and as she left the office she assured me that she would accept Nature's decree, make the best of her lot, and thus wisely align herself with the normal life demands of old Mother Nature. This view of her experience, she came to see, would bring the greatest amount of happiness to both herself and husband. She left me, declaring that she was just "wild for a baby;" and there is still echoing in my ears her parting words: "I'm leaving you, Oh, such a happy girl! and I'm going home to Harold a happy and contented expectant mother."

There often enters on the exit of a discontented and resentful expectant mother, a woman, very much alone in the world—perhaps a bachelor maid or a barren wife, who, as she sits in the office, bitterly weeps and wails over her state of loneliness or sterility; and so we are led to realize that discontentment is the lot of many women; and we are sometimes led to regret that ours is not the power to take from her that hath and give to her that hath not.

Among the first questions an expectant mother asks is: "What are early signs of pregnancy?" The answer briefly is:

Menstruation may be interrupted by other causes than pregnancy, but the missing of the second or third periods usually indicates pregnancy. Accompanying the cessation of menstruation, changes in the breast occur. Sensation in the breasts akin to those which usually accompany menstruation are manifested at this time in connection with the unusual sensations of stinging, prickling, etc. Fully one-half of our patients do not suffer with "morning sickness;" however, it is the general consensus of opinion that "morning sickness" is one of the5 early signs of pregnancy, and these attacks consist of all gradations—from slight dizziness to the most severe vomiting. It is an unpleasant experience, but in passing through it we may be glad in the thought that "it too, will pass."

Because of the pressure exerted by the growing uterus upon the bladder, disturbances in urination often appear, but as the uterus continues to grow and lifts itself up and away from the bladder these symptoms disappear.

Chief of the later signs of pregnancy are "quickening" or fetal movements. The movements are very much like the "fluttering of a young birdling." They usually are felt by the expectant mother between the seventeenth and eighteenth weeks. This sign, together with the noting of the fetal heartbeat at the seventh month, constitute the positive signs of pregnancy.

And now our expectant mother desires to know when to expect the little stranger. From countless observations of childbirth under all conditions and in many countries, the pregnant period is found to cover about thirty-nine weeks, or two hundred and seventy-three days. There are a number of ways or methods of computing this time. Many physicians count back three months and add seven days to the first day of the last menstruation. For instance, if the last menstruation were December 2 to 6, then, to find the probable day of delivery, we count back three months to September 2, and then add seven days. This gives us September 9, as the probable date of delivery. The real date of delivery may come any time within the week of which this calculated date is the center.

As a rule, ten days to two weeks preceding the day of delivery, the uterus "settles" down into the pelvis, the waist line becomes more comfortable, and the breathing is much easier.

On the accompanying page, may be found a table for computing the probable day of labor, prepared in accordance with the plan just described.6

TABLE FOR CALCULATING THE DATE OF CONFINEMENT

Supposing the upper figure in each pair of horizontal lines to represent the first day of the last menstrual period, the figure beneath it, with the month designated in the margin, will show the probable date of confinement.

To every physician in every community, sooner or later in his experience there come thoughtless women making requests that we even hesitate to write about. Their excuses for the crime which they seek to have the physician join them in committing, range all the way from "I don't want to go to the trouble," to "Doctor, I've got seven children now, and I can't even educate and dress them properly;" or, maybe, "I nearly lost my life with the last one."

One little woman came to us the other day from the suburbs, and honestly, frankly, related this story:

"We've been married just six months, I have continued my stenographic work to add the sixty-five dollars to our monthly income. Doctor, we must meet our monthly payments on the home, I must continue to work, or we shall utterly fail. I am perfectly willing a baby shall come to us two years from now, but, doctor, I just can't allow this one to go on, you must help me just this once. Why doctor, there can't be much form or life there, it's only three months now, or will be next week, and you know it's nothing but a mass of jelly."

She had talked with a "confidential friend" in her neighborhood, had been told that she "could do it herself," but fearing trouble or infection, had come to the conclusion she had better go to a "clean, reputable physician," to have the abortion performed.

This is not the place to narrate the experiences of the unfortunate victims of habitual criminal abortion, but we would like to impress upon the reader some realization of the untimely8 deaths, the awful suffering, and the life-long remorse and sorrow of the poor, misguided women who listen to the criminal advice of neighborhood "busybodies." The infections, the invalidism, the sterility that so often follow in the wake of these practices, are well known to all medical people.

And so after the patient's last statement, "It's nothing but a mass of jelly," we began the simple but wonderfully beautiful story of the development of the "child enmothered." Just as all vegetables, fruits, nuts, flowers, and grains come from seeds sown into fertile soil, and just as these seeds receive nourishment from the soil, rain, and sunshine, so all our world of brothers and sisters, of fathers and mothers, came from tiny human seeds, and in their turn received nourishment from the peculiarly adapted stream of life, which flows in the maternal veins for the nourishment and upbuilding of the unborn embryo.

Every little girl and boy baby that comes into the world, has stored within its body, in a wonderfully organized capsule, a part of the ancestral stream of life that unceasingly has flowed down through the centuries from father to son and from mother to daughter. This "germ plasm" is a divine gift to be held in trust and carefully guarded from the odium of taint, to be handed down to the sons and daughters of the next generation. Any young man who grasps the thought that he possesses a portion of the stream of life, that he holds it in sacred trust for posterity, cannot fail to be impressed with a sense of solemn responsibility so to order his life as to be able to transmit this biologic trust to succeeding generations free from taint and disease.

Just as within the body of "Mother Morning Glory" (See Fig. 18) may be found the ovary or seed bed, so there are two wonderfully organized bodies about the size of large almonds found in the lower part of the female abdomen on either side of the uterus, and connected to it by two sensitive tubes. There ripens in one of these bodies each month a human baby-seed,9 which finds its way to the uterus through the little fallopian tube and is apparently lost in the debris of cells and mucus which, with the accompanying hemorrhage go to make up the menstrual flow. This continues from puberty to menopause, each gland alternatingly ripening its ovum, only to lose it in the periodical phenomenon of menstruation, which is seldom interrupted save by that still more wonderful phenomenon of conception.

At the time of conception, countless numbers of male germ-cells (sperms) are lost—only one out of the multitude of these perfectly formed sperms made up of the mosaics of hereditary depressors, determiners, and suppressors that so subtly dictate and determine the characteristics and qualifications of the on-coming individual—I repeat, only one of these wonderful sperms finds the waiting ovum (Fig. 1). In this search for the ovum, the sperm propels itself forward by means of its tail—for the male sperm in general appearance very much resembles the little pollywog of the rain barrel (Fig. 1).

The fateful meeting of the sperm and the ovum takes place usually in the upper end of one of the fallopian tubes. It is a wonderful occasion. The wide-awake, vibrating lifelike sperm plunges head first and bodily into the ovum. The tail, which has propelled this bundle of life through the many wanderings of its long and perilous journey, now no longer needed, drops off and is lost and forgotten. This union of the male and female sex cells is called "fertilization." There immediately follows the most complete blending of the two germ cells—one from the father and one from the mother—each with its peculiar individual, family, racial, and national characteristics. Here the combined determiners determine the color of the eyes, the characteristics of the hair, the texture of the skin, its color, the size of the body, the stability of the nervous system, the size of the brain, etc., while the suppressors do a similar work in the modification of this or that family or racial characteristic.

The fertilized ovum remains in the tube for about one week, when it slowly makes its way down into the uterus, all the 11while rapidly undergoing segmentation or division. It does not grow much in size during this first week, but divides and subdivides first, into two parts, then four, then eight, then sixteen and so on, until we have a peculiar little body made up of many equally divided parts, and known as the "Mulberry Mass" (Fig. 1). The blending of the sperm and ovum has been perfect, the division of the original body multitudinous.

While this division of the united sex cells is progressing, a wonderful change is also taking place in the inside lining of the uterus. Instead of the usual thin lining, it has greatly thickened and has become highly sensitized, and as the ovum enters the uterus from the fallopian tube, this sensitized lining catches it and holds it in its folds—actually covers it with itself—holding the precious mass much as the cocoon, you have so often seen fastened to the side of a plant or leaf, holds its treasure of life.

Just as soon as the new uterine home is found the baby heart begins to make its appearance, as also do many other rudimentary parts. By the end of the third week, our round mass has flattened and curved and elongated, and the nervous system and brain begin to develop, while the primitive ears begin to appear. At this time, the alimentary canal presents itself as one straight tube which is a trifle larger at the head end. And it is interesting to note that at this early date, even the arms and legs are beginning to bud and push out from the body.

In the fourth and fifth weeks, the lungs and the pancreas may be found, the heart develops, the nervous system has taken on more definite form, and several of the larger blood-vessels are appearing.

By the eighth week, by the most wonderful and complicated processes of overlapping, pushing out, indentation, enfolding, budding, pressing, and curving, the majority of the important structures are formed—the eyes, ears, nose, hands, feet, abdominal organs, and numerous glands. Thus, at the end of12 two months, almost every structure and organ necessary to life is present in a rudimentary state.

By the close of the third month, witness the work of creation! From the blending of the two germ cells there has come forth a beautifully formed body (Fig. 1). True, it is but three and one half inches in length, but it is nevertheless a perfect body. About this time, the sex may be determined. The eyes, nose, ears, chin, arms and legs and even the fingers and toes may all be clearly distinguished.

A "jelly mass" at three months? No, by no means! No! Life and form and features are all there. It really has a face, whose features may easily be delineated.

In all my experience, I have yet to find the woman who wished to continue in her wicked and criminal intent after she had listened to this story of the creative development of the first three months of her "child enmothered."

During the next four months, which take us to the close of the seventh, rapid growth and farther development take place to the extent, that, should birth occur at that time, life may continue under proper conditions.

Everything is now nearing completion—only awaiting further growth, development, and strength—except some of the bone development, which takes place during the remaining two months. Growth is rapid, strength is doubled, and as the two hundred and seventy-three days draw to a close, everything has been completed. It has all taken place according to the laws of creation in an infinite way and with clock-like precision.

With the developmental growth of the product of conception, the uterus or room that had been particularly prepared for the "big reception" of the second week, has also grown to great dimensions. It fills almost the entire abdomen and as a result of the pressure against the diaphragm the breathing is somewhat embarrassed.

The door of this "room" has been closed by a special13 mechanism, while, in the fullness of time, Mother Nature begins the delicate work of opening the door, through whose portals passes out into the world the completed babe.

The authors feel that this discussion of, and protest against, abortions, should be accompanied by an appropriate consideration of the control of pregnancy. We are never going to eliminate the abortion curse of present-day civilization by merely preaching against it—warnings and denouncements alone will not suffice to remove the stain. Notwithstanding our feelings and convictions in this respect, we are also well aware of the fact that public sentiment is not now sufficiently ripe to welcome such a full and frank discussion of the subject of the prevention of conception as the authors would feel called upon to present; we are equally cognizant of the fact that existing postal regulations and other Federal laws are of such a character (at least capable of such interpretation) as possibly to render even the scientific and dignified consideration of such subjects entirely out of question.

In the preceding chapter we learned that when the two germ cells came together, there occurred a complete blending of two separate and distinct hereditary lines, reaching from the present away back into the dim and distant past. By the union of these two ancestral strains a new personality is formed, a new individual is created, with its own peculiar characteristics.

Probably none of the laboriously acquired accomplishments of the present generation can be directly—and as such—handed down to our children. What we are to be and what we will do in this world was largely determined by the laws of heredity by the time we were well started on our development experience en-utero during the third or fourth week of our prenatal existence, as outlined in a former chapter.

It is now generally accepted in scientific circles that acquired characteristics are not transmissible. Someone has aptly stated this truth by saying that "wooden heads are inherited, but wooden legs are not." This does not by any means imply that we do not have power and ability to fashion our careers and carve out our own destiny, within the possible bounds of our hereditary endowment and environmental surroundings. Heredity does determine our "capital stock," but our own efforts and acts determine the interest and increase which we may derive from our natural endowment. From the moment conception takes place—the very instant when the two sex cells meet and blend—then and there "the gates of heredity are forever closed." From that time on we are dealing with the problems15 of nutrition, development, education, and environment; therefore, so-called prenatal influence can have nothing whatever to do with heredity.

A father may have acquired great talent as a physician or a surgeon, in fact he may hold the chair of surgery in a medical college, but each of his children come into the world without the slightest knowledge of the subject, and, as far as direct and immediate heredity is concerned, will have to work just about as hard to master the subject as will the same average class of children whose parents were not surgeons. This must not be taken to mean that certain abilities and tendencies are not inheritable—for they are; but they are inherited through the parents—and not from them—directly. These transmitted characteristics are largely "stock" traits, and usually have long been present in the "ancestral strain."

A mother may sing and pray all through the nine months of expectancy, or she may weep and scold, or even curse. In neither case can she influence the spiritual or moral tendencies of her child and cause it, through supposed prenatal influence, to be born with criminal tendencies or to grow up a pious lad or become a devout minister. These tendencies and characteristics are all largely determined by the "depressors," "suppressors," and "determiners" which were present in the two microscopic and mosaic germ cells which united to start the embryo at the time of conception.

The child is destined to be born, endowed, and equipped with the mental, nervous, and physical powers which his line has fallen heir to all through the past ages. Down through the ages education, religion, environment, and other special influences have no doubt played a small part in influencing and determining hereditary characteristics; just as environment in the ages past changed the foot of the evolving horse from a flat, "cushiony" foot with many toes (much needed in the soft bog of his earlier existence) into the "hoof foot" of later days, when harder soil and necessity for greater fleetness, assisted by some sort of "selection" and "survival," con16spired to give us the foot of our modern horse, and this story is all plainly and serially told in the fossil and other remains found in our own hemisphere. It would appear that many, many generations of education and environment are required to influence markedly the established and settled train of heredity regarding any particular element or characteristic in any particular line or lines of hereditary tendencies.

There is probably more misinformation in the minds of the people on the subject of "maternal impressions" and "birthmarks" than any other scientific or medical subject. The popular belief that, if a pregnant woman should see an ugly sight or pass through some terrifying experience, in some mysterious way her unborn child would be "marked," deformed, or in some way show some blemish at birth, is a time-honored and ancient belief.

Such unscientific and unwarranted teaching has been handed down from mother to daughter through the ages, while the poor, misguided souls of expectant women have suffered untold remorse, heaped blame upon themselves, lived lives literally cursed with fear and dread—veritable slaves to superstition and bondage—all because of the simple fact that a certain percentage of all children born in this world have sustained some sort of an injury or "embryological accident" during the first days of fetal existence. For instance, take the common birthmark of a patch of reddened skin on the face, brow, or neck. As soon as the baby is born, the worried mother asks in anxious tones: "Doctor, is it all right, is it perfect, has it got any birthmarks?" On being told that the baby has a round, red patch on its left brow, the ever-ready statement of the mother comes forth: "Yes, I knew I'd mark it, I was picking berries one day about three months ago, and I ate and ate, until I suddenly remembered I might mark my baby, and before I knew what I was doing, I touched my brow and I just knew I had marked my baby." Do you know, reader, that that birthmark was present fully four months before she passed through that experience in the berry patch? And yet so worried17 and apprehensive has been the pregnant mother, that, although she can never successfully predict the "birthmarks" and blemishes of her child, nevertheless when these defects are disclosed at birth she is unfailingly able immediately to recall some extraordinary experience which she has carefully stored away in her memory and which, to her mind, most fully explains and accounts for the defect.

Is it much wonder that in the very early days of embryonic existence, during the hours of delicate cell division, indentation, outpushing, elongation, and sliding of young cells—is it much wonder, I repeat—that there occur a few malformations, blemishes, or other accidents which persist as "birthmarks?"

There are many factors which may enter into the production of birth-blemishes, deformities, monstrosities, etc. These influences are all governed by certain definite laws of cause and effect. A pre-existent systemic disease in the father, or a coexistent disorder in the mother, may be a leading factor. A mechanical injury, such as a sudden fall, a blow, or a kick, or certain kinds of prolonged pressure, not to mention restrictions and contractions of the maternal bony structures, may all possibly contribute something to these prenatal miscarriages of growth and development. Maternal or prenatal embryonic infections could bring about many sorts of birthmarks and malformations. These defects might also be caused by certain types of severe inflammatory disorders in the uterus during the early days of pregnancy.

The same factors that produce the accidents of embryology resulting in malformations or monstrosities in the human family, are also operative in the case of our lesser brethren of the animal kingdom, for monstrosities and birth-defects are very common among the lower animals, notwithstanding the fact that the animal mother probably does not "believe in birthmarks."

"It is a striking fact that during the nineteenth century, the teratologists, those who have scientifically investigated the causes of monstrosities and fetal morbid states, have almost18 without exception, rejected the theory of maternal impressions." Scientists and physicians are coming to recognize the fact that fears and frights do not in any way act as causes in the production of monstrosities and deformities. Let us seek forever to liberate all womankind from the common and harassing fear and the definite dread and worry that, because they failed to control themselves at the instant of some terrifying sight or experience, they were directly responsible for the misfortune of their abnormal offspring.

It should be remembered that there exists no direct connection whatsoever between the nervous system of the unborn child and the nervous system of the mother. The only physiological or embryological relationship is of a nutritional order, and even that is indirect and remote.

By the end of the third month, the "cocoon" attachment described in chapter two has disappeared; the fetus is slowly pushed away from the uterus which has so snugly held it for more than eleven weeks; while upon the exact site of its previous attachment the thickened uterine membrane undergoes a very interesting and important change—definite blood vessels begin to form—which begin indirectly to form contact with the maternal vessels, and thus it is that the placenta, or "after birth" is formed; and then, by means of the umbilical cord, nourishment from the mother's blood-stream is carried to the growing and rapidly developing child. In exchange for the nourishing stream of life-giving fluid by which growth and development take place, the embryo gives off its poisonous excretions which are carried back to the placenta, from which they are absorbed into the veinous circulation of the mother; so, while the mother does, through the process of nutrition, influence growth and development in the embryo, she is wholly unable to produce specific changes and such definite developmental errors as birthmarks and other deformities.

Just as truly as it would be impossible so to frighten a setting hen as to "mark" or otherwise influence the form or character of the chicks which would ultimately come forth from19 the eggs in her nest, it is just as truly impossible to frighten the pregnant mother and thereby influence the final developmental product of the human egg which is so securely tucked away in its uterine nest; for, when conception has occurred, the human embryo is just as truly an egg—fashioned and formed—as is the larger and shell-contained embryo of the chick which lies in the nest of the setting hen.

And so we are compelled to recognize the fact that there is little more danger to the unborn child when the mother is frightened than when the father is scared. The one contributes as much as the other to the general character of the child, while neither is to blame for development errors and defects.

Certain fears are suggested to children. For twenty years I lived under the delusion that I was terribly afraid of snakes—more so than any other human being; for I was told when a mere child that I had been "marked with the fear of snakes," that just two months before I saw the peep of day, my esteemed mother had been terrified by a snake. Everywhere I went, I announced to sympathizing and ofttimes mischievous friends, that "I was marked with the fear of snakes and must never be frightened with them." It is needless to add in passing, that I was teased and frightened all through my girlhood days. I was a veritable slave to the bondage of snake-fear. Everywhere I went I looked for my dreaded foe, expecting to sit on one, step on one, or to have one drop into my lap from the roof.

The day of deliverance came after marriage, when in a supreme effort to deliver me from the shackles of fear, the goodman of the house tenderly, but firmly, maneuvered a morning walk so that it halted in front of a large plate-glass window of the Snake Drug Store in San Francisco. Just back of this plate glass, and within eighteen inches of my very nose, were fifty-seven varieties of the reptiles, big and small, streaked and checkered, quiet and active. After much remonstrance and waiting, I came-to—gazed at the markings, beautiful in their20 exactness—while slowly the change of mind took place. Faith took the place of fear, calmness subdued panic, and I was wondrously delivered from the veritable bondage of a score of years. And so it is that the mother suffers and then the child suffers, ofttimes a living death, because of the superstition "I'm marked," while there is ever present the fear or dread that "something is going to happen, because I'm different from all other individuals—because 'I'm marked!'"

As soon as a woman discovers that she is pregnant, she should sit down and quietly think out the plan for the nine months of expectancy.

The cessation of the menses may come as a surprise to her, and for a while she is more or less confused; she must go over the whole situation and adjust future plans to fit in with this new and all important fact. From a large experience with maternity cases, I have reached the conclusion that the larger percentage of pregnancies do come as a surprise, and in many instances a complete change of program must be painstakingly thought out. This is especially true of the business woman, the professional woman, the busy club woman, or the active society woman.

Let me say to the woman who is pregnant for the first time, the experiences of the pregnant state should cause you no fear, worry, or anxiety. Giving birth to a baby is a perfectly natural, normal procedure, and if you are in reasonable health—if your physician tells you you are a fairly normal woman—then you can dismiss further thought of danger and go on your way rejoicing. For thousands of years maternity has been women's exclusive profession and no doubt will continue to be many ages hence.

By far the most important and the first thing to do is carefully to select the best physician your means will allow, and place yourself under his or her care. Your doctor will help you to plan wisely and intelligently during the waiting time, for physicians have learned from experience that the better22 care the pregnant woman receives, the easier will be her labor, and the more speedy and uneventful the recovery.

And now, we proceed to take up one by one the particular phases of the hygiene of pregnancy which touch the comfort, convenience, and health of both the mother and her unborn child.

At all times and under all circumstances the pregnant woman's clothing should be comfortable, suitable for the occasion, artistic, and practical. And to be thus beautifully clothed is to be as inconspicuous as is possible. Of all times, occasions, and conditions, that of pregnancy demands modesty in color, simplicity in style, together with long straight lines (Fig. 2). For the "going out" dress, select soft shades of brown, blue, wine, or dark green. Let the house dresses be simple, easy to launder, without constricting waist bands, of the one-piece type, in every way suitable for the work at hand. Under this outer dress, a princess petticoat should cover a specially designed maternity corset (if any corset at all be worn), to which is attached side hose-supporters. A support for the breasts may be worn if desired, it should be loose enough to allow perfect freedom in breathing.

The union suit may be of linen, silk, or cotton, with the weight suitable for the season. Stockings and shoes should be of a comfortable type, straight last, low or medium heel and at least as wide as the foot. There are two or three shoes on the market that are particularly good, whose arches are flexible, heels comfortable, straight last, and whose soles look very much like the lines of the foot unclothed. This style is particularly good during the maternity days. Painful feet are a great strain upon the general nervous system. Who of us has not seen women with strained, tense faces hobbling about in high-heeled, narrow-toed shoes? And if we followed them we would not only see tenseness and strain in the features of the face, but could hear outbursts of temper on the least provocation. Aching feet produce general irritability. If ease of body and calmness of spirit is desired, wear shoes that are comfortable, and the surprising part of it is that many of them are very good looking.

Toward the end of pregnancy ofttimes the feet swell, in which instance larger shoes should be worn in connection with the bandaging of the ankles and legs.

During the latter days of expectancy an abdominal supporter may be worn advantageously. Much of the backache and heaviness in the pelvis is entirely relieved by the supporting of the pendulous abdomen with a well-fitted binder. An ordinary piece of linen crash may be fitted properly by the taking in of darts at the lower front edge; or elastic linen, or silk binder may be secured; in fact, any binder that properly supports the abdomen will answer the purpose.

It should be within the means of every pregnant woman to have a neat, artistic out-door costume, for social, club and church occasions (Fig. 2). For no reason but illness should an expectant mother shut herself up in doors.

True men and true women hold the very highest esteem for the maternal state, and the opinion of all others matters not; so joyfully go forth to the club, social event, concert, or church; and to do this, you must have a well-designed, artistic dress. The material does not matter much, but the shade and style are important.

There are certain laws which govern the diet at all times; for instance, the man who digs ditches requires more of a certain element of food and more food in general, than does the man who digs thoughts out of his brain. The growing child requires somewhat different elements of food than does an adult. In other words, "The diet should suit the times, occasions, occupations, etc."

In the case of the expectant mother it should be remembered that the child gains nine-tenths of its weight after the fifth month of pregnancy, and it is, therefore, not necessary that a woman shall begin "eating for two" until after the fifth month. And since it is also true that the baby doubles its weight during the last eight weeks of pregnancy, it follows that25 then is the time when special attention must be given to the quantity as well as the quality of "mothers' food."

During the first five months, if the urine and blood-pressure are normal, the "lady in waiting" should follow her usual dietetic tastes and fancies so long as they do not distress or cause indigestion. Because of the additional work of the elimination of the fetal wastes, much water, seven or eight glasses a day, should be taken; while one of the meals—should there be three—may well consist largely of fruit. All of the vegetables may be enjoyed; salads with simple dressings and fruits may be eaten liberally. Of the breads, bran, whole wheat, or graham are far better for the bowels than the finer grain breads, or the hot breads.

Something fresh—raw—should be taken every day, such as lettuce, radishes, cabbage salad, and fresh fruits.

If the prospective mother is accustomed to the liberal use of meat, providing the blood-pressure and urine are normal, she may be able to indulge in meat once a day. Many physicians believe that the maternal woman should eat meat rather sparingly—from once a day to once or twice or three times a week.

Of the desserts, gelatine, junket, ice cream, sponge cake, and fruit are far better than the rich pastries, which never fail even in health to encourage indigestion and heart burn. The fruitades are all good. Candies and other sweets may be eaten in moderation. Alcohol should be avoided. Tea and coffee should be restricted, and in many cases abandoned. For many, two meals and a lunch of fruit or broth are better than three full meals. There is a continual and increased accumulation of waste matter which must be thrown off by the lungs, kidneys bowels, and skin; so that clogging of one channel of elimination makes more work for one or more of the other eliminative organs.

Sometimes the craving for food is excessive, and the desire to nibble between meals is quite troublesome. These unusual feelings should be controlled or ignored. A glass of orangeade will sometimes satisfy this unnatural craving. Save your appetite for meal time—for a good appetite means good digestion26 —all things equal. The woman who habitually eats between meals is the sluggish, constipated individual who needs to acquire self-control and learn self-mastery.

Water is the circulating medium of the body, from which the digestive secretions are formed, and by which the food is assimilated and distributed to individual cells. And, finally, water is the agent for dissolving and removing waste products from the body through the various eliminating organs. We literally live, think, and have our being, as it were, under water. The tiny cell creatures of our bodies, from the humble bile workers of the liver to the exalted thinking cells of the brain, all carry on their work submerged. Accordingly, the amount of water we drink each day, determines whether the liquids circulating through our tissues shall be pure, fresh, and life-giving, or stagnant, stale, and death-dealing.

Thirst is the expression of the nervous system, constituting a call for water, the same as hunger represents a call for food. Pure water, free from all foreign substances, is the best liquid with which to quench this thirst.

It is just as important to supply abundance of water for the proper bathing and cleansing of the internal parts of the body, as it is to wash and bathe the external skin frequently. The living tissues are just as literally soiled and dirtied by their life action and their poisonous excretions, as is the skin soiled by its excretions of sweat and poisonous solids. Thus the regular drinking of water is absolutely necessary to enable the body to enjoy its internal bath, and this internal cleansing is just as grateful and refreshing to the cells and tissues, as is the external bath to the nerves which exist in the skin.

The total amount of water necessary varies according to the nature of one's work, the amount of sweating from the skin, the moisture of the atmosphere, the amount of water in the food, etc. We believe the average person requires about eight glasses of liquid a day; that is, about two quarts. By the word "glass" we refer to the ordinary glass or goblet, two of which equal one pint. This amount of water should be27 increased, if anything, throughout pregnancy; while, during the later months, the amount of water taken each day should be at least doubled.

In the condemnation of so-called artificial beverages, an exception should be made of the fruit juices. The fresh, unfermented juices of various fruits come very near being pure, distilled water, as they consist of only a little fruit sugar and acid, together with small amounts of flavoring and coloring substances, dissolved in pure water. None of these substances contained in pure fruit juice needs to be digested.

Lemonade not too sweet, and taken in moderate quantities, is certainly a beverage free from objection when used by the average pregnant woman. Unripe or overripe fruits frequently cause bowel disturbances; as also do the millions of germs which lurk upon the outside of fruits, and which find their way into the stomach and bowels when these fruits are eaten raw without washing or paring. Otherwise, the juices of fruits and melons are wholesome food beverages when consumed in moderation.

It should be the regular practice of every expectant mother to spend a portion of each day in agreeable, suitable exercise or physical work of some description. This exercise will be far more beneficial if it can be taken in the open air. The weather and the strength of the patient must be taken into consideration and the necessary modifications of the daily exercise should be made.

An expectant mother living in the city and enjoying the average health and strength, should engage in such agreeable exercise as the raising of flowers, the training of vines, with brisk walks in the fresh air. As much time as possible should be spent in the parks.

The rural "mother in waiting," may do light gardening, raising of chickens, or pigeons, training of vines, or other outdoor work she may enjoy.

No matter what kind of weather prevails, a daily brisk walk should be taken, out of doors, on the porch or in a room with28 open windows. A daily sweat, as well as the daily prayer, is good for the well-being of the expectant mother. All forms of light housework are commendable. Keep out of crowds. Spend more time in the parks than in the department stores. An occasional evening at the concert or theater is diversion and harmless provided the ventilation is good. Such exercises as horseback riding, bicycling, dancing, driving over rough roads, lifting and straining of any kind, and all other forms of fatiguing exercise should be avoided.

Rest and relaxation are quite necessary for men and women even in the best of health. A kind providence has arranged that we spend a large portion of our time resting, and sleeping. In addition to unbroken rest at night it is well for the prospective mother quietly to withdraw from the family circle, when the first signs of fatigue begin to appear, and indulge in a little rest, before she gets into a state of nervousness—where nerves twitch and she becomes irritable.

I have told many women whose household duties press hard: "Your husband would rather see a cold lunch on the table, or 'go out' for dinner, while his wife rested, smiling and happy, than to have a most sumptuous meal spread before him and the wife tired, and fretful." Every woman should make it the rule of her life to stop just this side of the outburst of words, and lie down long enough, breathing deeply, to calm the spirit.29

"With all persons plenty of fresh air, night and day, is indispensable to health, and to none more than the pregnant woman. She should sleep with the windows open, or out of doors, at all seasons of the year; of course, making due allowance for the severity of the winters in the North. It is not only necessary to provide for the adequate ventilation of sleeping-rooms, but also for that of the living-rooms of the house.

Many persons, who are quite particular to open wide the windows of the bedrooms, forget that the other rooms need it quite as much. All the rooms of the house which are occupied should be thoroughly ventilated by throwing doors and windows open every morning; at night when the family is assembled the air must be changed now and then or it will become unfit for human lungs."

Men and women are outdoor animals. They were made to live in a garden, not a house. Remember that each person requires one cubic foot of fresh air every second. Don't allow the temperature of living-rooms, during the winter season, to go above sixty-eight degrees. If your home has no system of ventilation, open wide the windows and doors several times a day and enjoy the blessings of a thorough-going flushing with fresh air.

Oxygen is the vital fire of life. Our food, however well digested and assimilated, is just as useless to the body without oxygen, as coal is to the furnace without air. It is equally important to keep up the proper degree of moisture in the air of the living-rooms.

Bathing is made necessary by the clothes we wear and by our indoor life. If the skin were daily exposed to sunshine and fresh air, it would seldom be necessary to bathe. The neglect of regular bathing results in overworking the liver and kidneys, and debilitates the skin. Regular bathing—ofttimes sweating baths—is very essential to the hygiene of pregnancy.30

The neutral bath (97 F.) is excellent to quiet the nerves and induce sleep. Morning bathing is an exceedingly valuable practice. If properly taken before breakfast or midway between breakfast and lunch, it is found to be refreshing and tonic in nature. The feet should be in warm water, the application of cold should be short and vigorous. A rough mit dipped in cold water, rubbed over the body until the skin is pink, is a splendid tonic.

Warm cleansing baths should be taken twice a week at night. There is no good reason for the use of the vaginal douche during pregnancy.

Because the mother's system is drained of the lime salts which aid in building up the bones of the child, along with other metabolic changes which cause the retention of certain acids which ofttimes affect the teeth, they should be frequently examined and carefully guarded. Severe dental work should be avoided, but all cavities should receive temporary fillings while the teeth are kept free from deposits.

As a preventive to this tendency of the teeth to decay, a simple mouth wash of one of the following may be used after meals:

Any one to be dissolved in a glass of water.

Beginning with the second voiding of urine after rising on the morning of the day you are to save the specimen, save all that is passed during the following twenty-four hours, including the first voiding on the second morning. Measure carefully the total quantity passed in the twenty-four hours. Shake thoroughly so that all the sediment will be mixed, and immediately after shaking take out eight ounces or thereabouts for delivery to the physician the same forenoon. The following items31 should be noted, and this memoranda should accompany the specimen:

1. Patient's name.

2. Address.

3. This specimen was taken from a twenty-four hour voiding of urine, which began at .... a. m. ...., and ended at .... a. m. ....

4. The total quantity voided during this twenty-four hours was .... pints.

This specimen should reach the laboratory by ten o'clock the same morning.

It is of utmost importance the specimen should be taken to your physician every two weeks, and oftener if conditions indicate it. Take it yourself at the appointed time.

Owing to the increasing pressure exerted upon the intestines, most expectant mothers experience a tendency to sluggish bowels and constipation. This unpleasant symptom is usually increased during the later months.

In the first place, a definite time must be selected for bowel action. It may ofttimes be necessary, and it is far less harmful, to insert a glycerine suppository into the rectum, than to get into the enema habit. The injection of a large quantity of water into the lower bowel will mechanically empty it; but the effects are atonic and depressing as regards future action.

Before we take up the advisability of taking laxatives let us consider what foods will aid in combating constipation. The following list of foods are laxative in their action and will be found helpful in overcoming the constipation so often associated with pregnancy:

1. All forms of sugar, especially fruit sugar, honey, syrup, and malt. All the concentrated fruit juices. Sweet fruits, such as figs, raisins, prunes, fruit jellies, etc.

2. All sour fruits, and fruit acids: Apples, grapes, gooseberries, grape fruit, currants, plums, and tomatoes.

3. Fruit juices, especially from sour fruits: Grape juice, lemonade, fruit soup, etc.32

4. All foods high in fat: Butter, cream, eggs, eggnog, ripe olives, olive oil, nuts—especially pecans, brazil nuts, and pine nuts.

5. Buttermilk and koumiss.

6. All foods rich in cellulose: Wheat flakes, asparagus, cauliflower, spinach, sweet potatoes, green corn and popcorn, graham flour, oatmeal foods, whole-wheat preparations, bran bread, apples, blackberries, cherries, cranberries, melons, oranges, peaches, pineapples, plums, whortleberries, raw cabbage, celery, greens, lettuce, onions, parsnips, turnips, lima beans, and peanuts.

White bread should be tabooed, and in its place a well-made bran bread should be used. Two recipes for bran bread follow, one sweetened and containing fruit, the other unsweetened:

1. Two eggs, beaten separately; three-fourths cup of molasses, plus one round teaspoon of soda; one cup of sour cream; one cup of sultana seedless raisins; one cup of wheat flour, plus one heaping teaspoon baking powder; two cups of bran; stir well and bake one hour.

2. One cup of cooking molasses; one teaspoon of soda; one small teaspoon of salt, one pint of sour milk or buttermilk, one quart of bran, one pint of flour. Stir well, and bake for one hour in a very slow oven. It may be baked in loaf, or in gem pans, as preferred. The bread should be moist and tender, and may be eaten freely, day after day, and is quite sure to have a salutary effect if used persistently.

The drinking of one-half glass of cold water on rising in the morning often aids in keeping the bowels active. Of the laxative drugs which may be used at such a time, cascara sagrada and senna are among the least harmful. Two recipes of senna preparation follow, and may be tried in obstinate cases:

1. Senna Prunes. Place an ounce of senna leaves in a jar and pour over them a quart of boiling water. After allowing them to stand for two hours strain, and to the clear liquid add a pound of well-washed prunes. Let them soak over night. In the morning cook until tender in the same water, sweetening33 with two tablespoons of brown sugar. Both the fruit and the sirup are laxative. Begin by eating a half-dozen of the prunes with sirup at night, and increase or decrease the amount as may be needed.

2. Senna with prunes and figs. This recipe does not call for cooking. Take a pound of dried figs and a pound of dried prunes, wash well. Remove the stones from the prunes and if very dry soak for an hour. Then put both fruits through the meat chopper, adding two ounces of finely powdered senna leaves. Stir into this mixture two tablespoons of molasses to bind it together, the result being a thick paste. Begin by eating at bedtime an amount equal to the size of an egg, and increase or decrease as may be necessary. Keep the paste tightly covered in a glass jar in a cool place. If the senna is distasteful a smaller quantity may be used at first.

The breasts are usually neglected during the months of pregnancy, and as a result complications occur after the baby comes which cause no end of discomfort to the mother. If, during the pregnancy, the breasts are washed daily with liquid soap and cold water, and rubbed increasingly until all sensitiveness has disappeared, they may be toughened to the extent that no pain whatsoever is experienced by the mother when the babe begins to nurse. During the last month of pregnancy a solution of tannin upon a piece of cotton may be applied after the usual vigorous bathing. If the nipples are retracted they should be massaged until visible results are attained.

Keep the mind occupied with normal, useful, and healthy thoughts. Listen to no tales of woe. Stay away from the neighborhood auntie dolefuls. Keep yourself happy and free from all worry, care, and anxiety.

"Put no faith in fables of cravings, markings, signs, or superstitions. They are all unfounded vagaries of ignorant old women and will not bear investigation."

Don't take drugs for worry and sleeplessness. Take a bath.34

The secret of deliverance from worrying is self-control. Minimize your difficulties. Cultivate faith and trust.

The conditions which favor sound sleep are: Quiet, mental peace, pure blood, good digestion, fresh air (the colder the better), physical weariness (but not fatigue), mental weariness (but not worry).

When tempted to borrow trouble, when harassed by fictitious worries, remember the old man who had passed through many troubles, most of which never happened. Train the mind to think positive thoughts. Replace worry-thought with an opposite thought which will occupy the mind and enthuse the soul. Drive out fear-thought by exercising faith-thought. Cultivate the art of living with yourself as you are, and with the world as it is. Learn the art of living easily. Associate with children and learn how to forget the vexing trifles of everyday life.

There is something decidedly wrong with one's nerves when everybody is constantly "getting on them." They are either highly diseased or abnormally sensitive. Every woman is a slave to every other that annoys her.

Fear is capable of so disarranging the circulation as to contribute to the elevation of blood-pressure—which will be more fully considered in a later chapter.

It is the purpose of this chapter to take up the various complications which may appear in the course of an otherwise normal pregnancy, and offer advice appropriate for their management.

About one-half of the expectant mothers that come under our care and observation, experience varying degrees of nausea or "morning sickness." This troublesome symptom makes its appearance usually about the fourth week of pregnancy and lasts from six to eight weeks.

On attempting to rise from the bed, there is an uncomfortably warm feeling in the stomach followed by a welling up into the throat of a warmish, brackish tasting liquid which causes the patient to hasten to rid herself of it; or, as she rides on the train, on the street cars, in a carriage or automobile, she frequently senses the same unpleasant and nauseating symptoms during the second and third months of pregnancy. Normally, this uncomfortable symptom quite disappears by the end of the third month. A number of remedies have been suggested for it, but that which seems to help one, gives little or no relief to another; we therefore mention a variety of remedies which may be tried.

First and most important of all remedies—is to keep the bowels open. Sluggishness of the intestinal tract greatly increases the tendency to dizziness and nausea. During the attack, it is advisable not to attempt to brush the teeth, gargle, or even drink cold water. While you are yet lying down, the maid or the goodman of the house should bring to you a piece36 of dry, buttered toast, a lettuce sandwich with a bit of lemon juice, or perhaps a cup of hot milk or hot malted milk. Coffee helps to raise the blood-pressure, and all articles of diet that tend to raise the blood-pressure are best avoided during pregnancy. A cup of cocoa may be tried, but, as a rule, women at this time do not relish anything sweet. Oftentimes a salted pretzel is just the thing, or a salted wafer will greatly help. Remain in bed from one-half to one hour and then rise very slowly. There should be plenty of fresh air in the room, as remaining in overheated places is quite likely to produce a feeling of sickness at the stomach.

When the attack comes on during a train ride, open the window and breathe deeply, this, with the aid of a clove or the tasting of a bit of lemon, will usually give relief. In extreme instances the patient should lie down flatly on the back, with the eyelids closed. Go to the rear of the street car, so that you can get off quickly if necessity demands; breathe deeply of the air; resort to the use of cloves or lemons; and thus by many and varied methods will the expectant mother be enabled to continue her journey or finish her shopping errand. We would suggest that, as far as possible, walking should be substituted for riding. I have never heard of a woman being troubled with nausea while walking in the parks, on shady streets, along the country road, or on the beach.

Of the medicines prescribed for "morning sickness" and the nausea of pregnancy, cerium oxalate taken three times a day in doses of five grains each, is probably one of the best.

The persistent or pernicious vomiting which continues on through pregnancy will be spoken of later.

Acid eructations are spoken of as "heartburn," and are occasioned by the increased activity of the acid making glands of the stomach. Under certain conditions this acid content of the stomach is regurgitated back into the throat and even belched up into the mouth. In this condition it is well to avoid most acid fruits. Ice cream and other frozen desserts are beneficial. The lowered temperature of cold foods depresses37 the activity of the acid glands, as also does the fats of the cream, while protein food substances such as white of egg, cheese, and lean meat, help by combining with the excess of acid present in the stomach. Buttermilk or the prepared lactic acid milk, if taken very cold, is often helpful, notwithstanding it is an acid substance, in connection with the dietetic management of heartburn. If the acid eructations be troublesome between the meals, the taking of calcined magnesia (one round teaspoon in a glass of cold water), or, one-half teaspoon of common baking soda in a glass of water, will afford immediate and temporary relief. Simply nibbling a little from a block of magnesia will often give instant relief. These alkalines effectively neutralize the mischievous acids which cause the so-called "heartburn."

The flexing or bending forward of the gravid uterus, by making pressure on the bladder, sets up more or less irritation and consequent disturbance of the urinary function. The capacity of the bladder is actually diminished, and this produces frequent urination. There is usually no pain connected with this annoying symptom—the chief discomfort is the frequent getting up at night. This inconvenience may be lessened by drinking less water after six p. m. These bladder disturbances are most marked in the earlier months, and gradually disappear as the uterus raises higher up into the abdomen; although this symptom may reappear in the last two weeks, as the head descends downward on its outward journey.

Should the urine at any time become highly colored, take a specimen to your physician at once. Twenty-four hour specimens of urine should be taken by the patient to her physician every two weeks. Do not send it—take it.

While leucorrhea is an unusual complication of pregnancy, it is often very troublesome and sometimes irritating. Do not take a vaginal douche unless it has been ordered by your physician, and even then make sure that the force of the flow of38 water is very gentle. The bag of the fountain syringe should be hung only about one foot above the hips. Soap and water used externally, followed by vaseline or zinc ointment, will usually relieve the accompanying irritation.

In the third chapter attention was called to the formation of the placenta or "after birth," on the site of the attachment of the cocoon embryo. At this particular time of the pushing away of the embryo from the uterine wall, one of the accidents of pregnancy occurs, in which the embryo becomes completely detached and starts to escape from the uterus, accompanied by varying degrees of pain and hemorrhage. The symptoms of this threatened abortion are:

The approach of the calendar date of the third month of pregnancy should be watched for, and all work of a strenuous nature studiously avoided; while at the first signs of the backache or any unusual symptom, the expectant mother should immediately go to bed and send for the physician. One patient who had aborted on four different occasions was able to pass this danger period by adhering to a rigid program of prevention during her fifth pregnancy. Two weeks before the third month arrived she discontinued her teaching and went to bed. She remained there four weeks, thus running over into the middle of the following month. Gradually, she resumed her duties of teaching, carried her precious bundle of life to full term, and is now the proud and happy mother of a splendid baby girl.

Should abortion seem imminent, from one-eighth to one-fourth of a grain of morphine sulphate will greatly reduce all uterine contractions, and this, with the general quieting effect on the whole system, will usually suffice to prevent an abortion. The patient should quietly remain in bed from three days to one week.39

If the abortion takes place—if a clot accompanied by hemorrhage is passed—save everything, lie in bed very quietly and send for your physician at once; and when he does arrive, be content if he does not make an internal examination at once, for if he should there is more or less danger of infection. And I repeat—throw nothing away—burn nothing up, save everything that passes until your physician has carefully examined it.

Sudden or severe pains in the abdomen should be reported at once to your physician, while you should immediately go to bed and quietly remain there until you receive further instruction from your doctor when he calls.

In the later stages of pregnancy any appearance of blood should likewise be noted and reported without delay. These symptoms may not always be serious, but they are also associated with grave complications, and should, therefore, be given prompt attention.

Abortion is a term used to designate the loss of the embryo prior to or at the third month. Miscarriage applies to the expulsion of the fetus or emptying of the uterus after the third month. It is possible for a miscarriage to occur anytime during the interim between the fourth and ninth months. After the uneventful passing of the third month, if an accident threatens, we instruct the mother to remain quietly in bed three to five days at the calendar date comparable with each menstrual period; and as she approaches the seventh month, we adjure her to be unusually careful and prudent.

The causes of miscarriages are many: Disease of the embryo, imperfect fetal development, some constitutional disease of the mother, a faulty position of the uterus, or it may result from something unusual about the lining of the uterus such as an endometritis—an inflammation of the mucus membrane.

Expectant mothers who manifest symptoms of a threatened miscarriage should studiously avoid such exercises as climbing, riding, skating, tennis, golf, dancing, rough carriage or auto40mobile riding, and such taxing labor as sweeping, lifting, washing, running the sewing machine, window cleaning, the hanging of pictures, draperies, etc.

Within reason, a pregnant mother should follow her natural appetite and satisfy her dietetic longings. Should she desire unusual articles of food, as far as possible she should have them. The idea has long prevailed that if the mother does not get what her longing soul supremely desires, that the on-coming baby is going to cry and cry until it is given what the mother wanted with all her heart and did not get. Such an idea is the very quintessence of folly and the personification of foolishness and superstition.

Many a precious babe has suffered as a victim of this notion of "craving" and "marking." One mother gave her baby a huge mouthful of under-ripe banana because "she knew that was just what he wanted, because, when pregnant, she had craved and craved bananas and for some reason or another she did not get them." The soft, smooth piece of banana slipped down the baby's throat—on into the stomach and intestines—caused intestinal obstruction and finally the end came; and we registered one more victim to the fallacies of fear and the superstitious belief in "cravings" and "markings." Occasionally some cravings are unusual and freakish, for instance, egg shells, leather, candles, chalk, and other abnormal tastes are developed. Of these we have only to say, "Rise above them, become mistress of the situation and change your longings." If such abnormal cravings come to you in the kitchen, don your bonnet and go at once out of doors and take a walk. Don't be foolish just because somebody told you foolish stories about these things.

Bowel hygiene is an important part of the management of pregnancy. Constipation often proves to be very troublesome. In another chapter this subject is treated at some length. Here, we pause only long enough to say that habit has much to do41 with this difficulty. A regular time should be set apart each day for attending to this important matter.

Of all the maladies that the human family falls heir to, hemorrhoids are among the commonest and, we may add, the most neglected. Any woman who enters pregnancy, suffering from hemorrhoids, is going to have her full share of suffering and pain before she has finished with her labors. Taken early, they may be greatly helped, if not entirely relieved, by the daily use of the medicated suppository (See Appendix). The bowel movements should never be allowed to become hard, the dietetic advice of another chapter should be carefully followed and the oil enema, as described in the appendix, should be used if necessary. For immediate relief, hot witch-hazel compresses may be applied; or, in the case of badly protruding piles, the patient should immerse the body in a warm bath and by the liberal use of vaseline they can usually be replaced. The physician should be called and he will advise any further treatment the case may require.

Varicose veins or the distension of the surface veins of the legs are very common among women in general and pregnant women in particular. The legs should be elevated whenever the patient sits, while in bad cases they should be bandaged while standing. There are many elastic surgical stockings on the market today that, if put on before rising in the morning, will give much relief and comfort all during the day. Any large medical house or physician's supply house can furnish them according to your measurements—which should be taken before getting out of bed in the morning. These measurements are taken according to instructions and usually are of the instep, ankle, calf of leg, length of ankle to knee, etc.

Cramps are sharp, exceedingly painful muscular spasms occurring in the muscles of the calf of the leg, the toes, etc. The42 expectant mother in the later months of pregnancy awkwardly turns in bed, is suddenly awakened and without a moment's warning, is seized with a most excruciating pain in her leg or toe. The most effectual treatment for these cramps is quickly to apply a very cold object to the cramping muscle. Extremes of either heat or cold usually relieve as well as the vigorous grasping or kneading of the muscle. A hot foot bath on going to bed will often prevent an attack. A long walk in the latter months of pregnancy should invariably be followed by a short hot bath or a foot bath. Many attacks may be avoided by this procedure.

All swellings should be taken seriously by the pregnant mother to this extent, that she save a twenty-four hour specimen of urine and that she personally take it to her physician, with a report of her "swellings." This symptom may or may not indicate kidney complications. The blood-pressure together with chemical and microscopical analysis of the urine will determine the cause.

Slight swelling of the feet is often physiological and is due to pressure of the heavily weighted uterus upon the returning veins of the legs. The progress of the veinous blood is somewhat impeded, hence the accumulation of lymph in the tissues of the legs, ankles, and feet.

Never allow yourself to guess as to the cause of swellings, always take urine to the physician and allow him definitely to ascertain the true cause. All tight bands of the waist and knee garters must be discarded at this time. The same general treatment suggested for varicose veins holds here.

The enlargement of the thyroid gland—goitre—is physiological during pregnancy, and is believed to be caused by the throwing into the maternal blood stream of special protein substances derived from the fetus. As just stated, this is more or less physiological, will usually pass away after the babe is born, and, therefore, need give the mother no particular con43cern. Tight neck bands should be replaced by low, comfortable ones. The bowels should move freely every day, and water drinking be increased as well as sweating of the skin encouraged by a short, hot bath, followed by the dry blanket pack, while the head is kept cool by compresses wrung from cold water. In this manner the elimination of these poisons is increased through both the skin and the kidneys.

The backache of the later months of expectancy is very annoying and often spoils an otherwise restful night's sleep. This is probably also a pressure symptom, if the physician's analysis of the urine proves that the kidneys are not at fault. If you have electric lights in the home, a very useful contrivance can be made which will give you great relief. The light end of an extension cord, five to seven feet in length, is soldered into the center of the bottom of a bright, pressed tin pail about twelve inches in diameter at the top and nine or ten inches deep. With the bail removed, screw in a sixteen or thirty-two candle power bulb and attach the extension cord to a nearby44 wall or ceiling socket. This arrangement supplies radiant heat and is called a photophore (See Fig. 3). Apply this twofold remedial agent—light and heat combined—to the painful back (underneath the bed clothing) and our restless mother will go to sleep very quickly. This may safely be used as often and as long as desired.

Persistent, prolonged, and very much aggravated cases of morning sickness are termed pernicious vomiting. The patient emaciates because of the lack of ability to keep food long enough to receive any benefits therefrom.

In treating these cases the sufferer should be put to bed in a room with many open windows, or, if the weather permit, should be out of doors on a comfortable cot. She should remain in bed one hour before the meal is served and from one to three hours afterward. The mind should be diverted from her condition by good reading, friends, or other amusements. The utmost care and tact should be used in the preparation of her food, and art should be manifested in the daintiness of the tray, etc. We found one mother was nauseated even at the sight of her tray and so we planned a call that should bring us to her home at the meal hour. The tray came in with the attendant in unkempt attire, who said, as she placed it carelessly down on a much-loved book our patient had been reading: "I heard you say you liked vegetable soup so I brought you a big bowl full." As I gazed at the tray, I saw a large, thick, gravy bowl running over with the soup. I usually like vegetable soup, but at the sight of that sloppy looking bowl—well, I thought I should never care for it again.

After installing a new maid who had a sense of service and daintiness, and who took real pleasure in the selection of the dishes for the tray, as well as the quality and quantity of food served in them, our patient made speedy recovery, went on to full term and became a happy mother.

There is no doubt that the mind has very much to do with this vexing complication of pregnancy. One mother immediately stopped vomiting everything she ate when told by her45 husband that "the doctor said he was coming in the morning to take you away from me to the hospital if you didn't stop vomiting." Everything known should be tried for the relief of these patients and in extreme cases, when the mother's life is endangered, pregnancy should be terminated.

The neutral full bath, temperature 97 F., maintained for twenty minutes to one-half hour, should be taken just on going to bed. The patient must not talk—must rest in the bath—absolutely quiet. The causes of insomnia should be determined if possible, and proper measures employed to remove them. They may consist of backache, cramps, frequent urination, pressure of the uterus on the diaphragm or pressure against the sides of the abdomen. The bed should be large, thus giving the patient ample room to roll about.

The following procedures may be tried in an effort to relieve the sleeplessness:

Rubbing of the spine, alcohol or witch-hazel rubbing of the entire body, the neutral bath, or the application of the electric photophore—described a few pages back—may be made to the painful part. Do not resort to drugs, unless you are directed to do so by your physician.

Headaches should not be allowed to continue unobserved by the attending physician. Measure the daily output of urine, which should be at least three pints or two quarts. In case of daily or frequent headaches, notify your physician at once and take a twenty-four hour specimen of urine to him. Headache is an early symptom of retained poisons and if early reported to the physician quick relief can be given the patient and often severe kidney complications be avoided by the proper administration of early sweating procedures. Water drinking should be increased to two quarts (about ten glasses) a day. Less food and more water are the usual indications in the headaches of pregnancy.46

Blood-pressure is called high when the systolic pressure registers above 150 to 160 millimeters of mercury. Pressure above 165 should be taken seriously and the patient should keep in close touch with her physician. Tri-weekly examinations of the urine should be made, while eliminating baths should be promptly instituted. The subject of blood-pressure in relation to pregnancy will be fully dealt with in the next chapter—in connection with toxemia, eclampsia, etc.

At the close of the preceding chapter on the complications of pregnancy, brief mention was made of blood-pressure as a possible source of anxiety. This chapter will be devoted to a further discussion of the subjects of toxemia, eclampsia, convulsions, and especially blood-pressure—in connection with other leading symptoms of these serious complications of pregnancy.

In a former chapter we learned that the developing child nearly doubled its weight in the last two months of pregnancy. As the child grows, its metabolic waste matter is greatly increased, while all these poisonous substances must finally be eliminated by the mother. Now, the mother's waste matter is of itself considerably increased; and so, if the kidneys, the liver, and the skin are already over-taxed in their work of normal elimination—if they are already doing their full quota of work—we can readily see that the additional waste matter of the unborn child will throw much extra work on the already overworked eliminative organs, and this results in a condition of toxemia. Certain symptoms accompany this state of constitutional poisoning or auto-intoxication—the chief of which are:

Any one of these symptoms may or may not indicate toxemia; but it should be reported at once to the attending physician. In the presence of one or more of these symptoms an expectant mother is always safe, while awaiting the physician's advice, in carrying out the following program:

This serious complication of the last weeks of pregnancy demands immediate attention. They may almost invariably be avoided if the blood-pressure and the urine are studiously watched during the latter part of the expectant period.

If you are unable to get your physician at once, the following treatment should be administered immediately.

1. A hot colonic flushing (See Appendix).

2. A hot bath followed by the hot blanket pack (See Appendix).

3. One drop of croton oil on a bit of sugar may be placed on the back of the tongue.

4. Chloroform may be administered, provided a competent nurse or other medical person is present.

The appearance of convulsions which have been preceded by one or more of the symptoms noted under the head of "toxemia," indicates that the patient has become so profoundly intoxicated and poisoned by the accumulating toxins, that the lives of both mother and child are jeopardized by threatened eclampsia. At such a time, the attending physician will immediately set about to bring on labor, and thus seek to empty the uterus at the earliest possible moment.

Since toxemia (eclampsia) is one of the complications of pregnancy most to be dreaded, it is fortunate that it almost invariably exhibits early danger signals which, if recognized and heeded, would enable the patient and physician to initiate 49proper measures to avert danger and escape the threatened disaster. The presence of this toxic danger is indicated by the persistent presence of the following three symptoms:

Of course, albumin will probably appear in the urine along with the casts, but it is the continued appearance of the casts that is of more importance as a danger signal. Albumin is quite common in the urine of the expectant mother, but casts—long continued—suggest trouble. Headache as an indicator of toxemia is of special significance when coupled with the other two cardinal symptoms of eclampsia—urinary casts and increasing high blood-pressure. Therefore, the necessity for frequent urinary tests and blood-pressure examinations during the last weeks of pregnancy—especially, if the patient has suffered from headaches and has been running albumin in the urine.

Blood-pressure is a term used to indicate the actual pressure of the blood stream against the walls of the blood vessels. The blood-pressure machine tells us the same story about our circulatory mechanism, that a steam gauge does about a high-pressure boiler (See Fig. 4). The normal blood-pressure varies according to the age of the patient. For instance, the normal pressure of a young person, say up to twenty years of age, runs from 100 to 120 millimeters of mercury; and then, as the age advances, the blood-pressure increases in direct ratio; for every two years additional age the blood-pressure increases about one point—one millimeter.

The average pregnant woman starts in her pregnancy with a blood-pressure of say, 125 millimeters, but as pressure symptoms increase, and as constipation manifests itself, and as the circulating fluids are further burdened with the toxins which are eliminated from the child, the blood-pressure normally increases to about 140 mm., and later, possibly to 150 mm.50 If the pressure goes no higher, we are not alarmed, for we have come to recognize a blood-pressure of 140 as about the normal pressure of the pregnant woman.

There are a number of factors which enter into the raising of the blood-pressure. For instance, at any time during the pregnancy, if the eliminative organs of the mother are doing inefficient work, if she falls a victim to a torpid liver, diseased kidneys, decreased skin elimination, or sluggish bowels, then, with the added and extra excretions from the child, there is superimposed upon the mother far more than the normal amount of eliminative work—and then, because of improper and incomplete elimination, the blood-pressure is increasingly raised.

This whole subject can best be illustrated by relating a story, the actual experience of Mrs. A. This patient came to the office with a history of Bright's disease (albumin and casts in the urine), and chronic appendicitis. While treating her for the kidney condition, preparatory to an operation for the removal of the troublesome appendix—in the very midst of this treatment—she became pregnant, and great indeed was our dismay. We entertained little hope of getting both the mother and child safely through. Frequent examination of urine was instituted, the albumin did not increase and the blood-pressure remained at normal—about 124 mm. She paid weekly or bi-weekly visits to the office and carefully followed the regime outlined. She drank abundantly of water and strictly followed the dietary prescribed. Weeks and months passed uneventful, until we approached the last six weeks of pregnancy, and then we found to our surprise one day that the blood-pressure had made a sudden jump up to 175 mm., while the urine revealed the presence of numerous casts and albumin—in the meantime the albumin had entirely disappeared. There were also other urinary findings which showed that the liver was not doing its share in the work of burning up certain poisons.

In her home we began the following program: Every day51 we had her placed in a bathtub of hot water, keeping cold cloths upon her brow, face and neck, and then, by increasing the temperature of the bath, we produced a very profuse perspiration. She was taken out of this bath and wrapped in blankets, thus continuing the sweat. All meat, baked beans, and such foods as macaroni and other articles containing a high per cent of protein were largely eliminated from her diet. At times she did not even eat bread. Her chief diet was fruit, vegetables, and simple salads, and yet the albumin and casts continued to increase in the urine and the blood-pressure climbed up to 190 mm.

As we approached the last two weeks of pregnancy, this little woman was taken to the hospital and systematic daily treatment with sweating procedures was begun. Among other things, she had a daily electric light bath. After each of these baths she was wrapped in blankets and the sweating continued for some time. Careful estimations of albumin were made daily and the blood-pressure findings noted three times a day. During the last week of pregnancy she lived on oranges and grapes. Day by day she was watched until the eventful hour arrived. She went into the delivery room and gave birth to a perfectly normal child. The albumin and casts quickly cleared up, the blood-pressure lowered, and today the little woman is a fond mother of a beautiful baby boy.

It is hard to estimate what might have taken place had not her elimination been stimulated. The blood-pressure was our guide. Had the albumin (without casts) appeared in the latter weeks of pregnancy with a blood-pressure of 140 or 150 mm., we would not have become excited, for the reason that in every normal pregnancy there is often present a trace of albumin in the latter weeks; but when the blood-pressure jumped to 170 or 190, then we knew that toxemia—eclampsia—convulsions—were imminent. So we have in recent years, come to look upon the blood-pressure as an exceedingly important factor—as an infallible indicator of approaching trouble—as a red signal light at the precipice or the point of danger; and it not only warns us of the danger, but it tells us about how near the boilers are to the bursting point. The glassy eye, the head52ache, the full bounding pulse and the blurring of vision, are all symptoms accompanying this high blood-pressure, so that in these enlightened days no practitioner can count himself worthy the name, or in any way fit to carry a pregnant woman through the months of waiting, unless he sees, appreciates, and understands the value of blood-pressure findings in pregnancy.

Two months before baby is to arrive, the expectant mother should pay particular attention to the conservation of her strength. The woman who is compelled to leave her home for the factory, the laundry, the office, or other place of employment, should stop work during these last two or three months. The active club woman should pass the burdens on to others, and the woman of leisure should withdraw from active social life with its varied obligations. During the final weeks of pregnancy, the prospective mother needs the same hygienic care regarding fresh air, exercise, diet, and water drinking, as outlined in a former chapter.

As the gravid uterus rises higher in the abdomen, increased pressure is exerted on the stomach, the lungs, and upon the nerve centers of the back; and it is because of this situation, that the duties and obligations of the prospective mother should be reduced to a minimum, that she may feel at liberty to lie down several times during the day on the porch or in a well-ventilated room, in the midst of the best possible surroundings. Sexual intercourse should be largely discontinued during the last months of pregnancy.

I sometimes wish the prospective mothers in our dispensary districts might have some of the care and the kind treatment which is bestowed upon an ordinary prospective mother horse, which at least enjoys a vacation from heavy labor, and whose food is eaten with calm nerves and in the quietness of a clean stall. While the state of the mother's mind does not materially influence the child; nevertheless, the state of the mother's body,54 the weary over-worked muscles and nerves of hot, tired women, bending over cook stoves, laundry tubs, or scrubbing floors, does materially derange the mother's health and digestion, which in turn, reflexly interferes with the growth and physical development of her child. Extra strength is required for the day of labor, and since the baby doubles its weight during the last two months, the mother is living for two, and should, therefore, avoid extreme fatigue, over tiring, and irksome labor during these final weeks of watchful waiting.

It may or may not be within the province of prospective parents to rearrange, rebuild, or otherwise change the home. Usually the size of the pocketbook, the bank account, or the weekly pay envelope decide such things for us. The home may be in the country or suburbs, with its wide expanse of lawns, its hedges of shrubbery, and with its spacious rooms and porches; or it may be a beautifully equipped, modern apartment on the boulevard of a city, with its sun parlors, large back porches, conveniently located near some well-kept city park, or it may be one of those smaller but "snug as a bug in a rug" apartments, in another part of the city, where usually there is a sunny back porch; or again some of my readers may themselves be, or their friends may be, in a darkened basement with broken windows, illy ventilated rooms, with no porches, no yards, no bright rays to be seen coming in through windows—and yet into all of these varied homes there come little babies—sweet, charming little babies, to be cared for, dressed, fed, and reared. And we must now proceed to the subject of making the most of what we have—to create out of what we have, as best we can, that which ought to be.

In both the country and city place, yards and alleys should be cleaned up. Garbage—the great breeding place of flies—should be removed or burned. The manure pile of the stable or alley should also be properly covered and cared for. In this way breeding places for flies are minimized and millions55 and billions of unhatched eggs are destroyed. In the large cities, provision is made for the prompt disposal of garbage, and laws are beginning to be enforced regarding the covering and the weekly removal of manure, and thus in many of our large cities flies are diminishing in numbers each year. Fly campaigns and garbage campaigns are teaching us all to realize the dangers of infection, contagion, and disease as a result of filth; while through the schools, the children of even our foreign tongued neighbors take home the spirit of "cleaning up week." Even in the rural districts we hope for the dawning of the day when filth, stagnant pools, open manure piles, and open privies, will be as much feared as scorpions or smallpox.

As suggested elsewhere, as soon as the expectant mother is aware that she is pregnant, she should engage her physician. And since these are days of specialists, he may or may not be the regular family doctor. The husband and friends may be consulted, but the final choice should be made by the prospective mother herself. "The faith which casts out fear, the indefinable sense of security which she feels in her chosen physician, supports her through the hours of confinement." Twenty-four hour specimens of urine should be saved and taken to the physician twice each month and oftener during later months of pregnancy. The chosen physician's instructions and suggestions should be carried out and counsel should be sought of him as to the place of confinement.

There are a number of factors that enter into the selection of the place of confinement. In the first place, if the home be roomy, bathroom convenient, if the required preparation of all necessities for the day of labor can be effected, and it is further possible to prepare a suitable delivery-room at home with ample facilities for emergencies and complications, and you can persuade your physician to do it—then the best place in the world for the mother to be confined is within the walls of her own home. But such is the case in but one home out56 of hundreds, and I regret that time and space will not allow me to describe and portray the many untimely deaths that might have been avoided if this or that supply had only been ready at the moment of the unexpected complication of delivery. Why should we needlessly risk the lives of prospective mothers, when, in every up-to-date hospital delivery-room, all these life-saving facilities are freely provided? Here in the modern hospital, the mothers from small homes and apartments, the mothers who live in stuffy basements, as well as those from the average home in the average neighborhood, can come with the assurance of receiving the best possible care and attention. Every woman who can arrange or afford it, should plan to avail herself of the benefits, comforts, quietness, and calm of a well-equipped hospital and the surgical cleanliness and safety of its aseptic delivery-room.

Fortunately, the mother of the basement home may have the same clean, sterile dressings used upon her as does the mother of the boulevard mansion. The maternity ward bed at $8.00 to $10.00 a week can be just as clean as the bed of the $40.00 a week room. The methods and procedures of the delivery-room can be just as good in the case of the very poor woman as in the case of the magnate's wife. In no way and for no reason fear the hospital. It is the cleanest, safest, and by far the cheapest way. The weekly amount paid includes the board of the patient, the routine care, and all appliances and supplies of every sort that will be used. Under no circumstances should a midwife be engaged. Any reputable physician or any intellectual minister will advise that. Let your choice be either the hospital or the home; but always engage a physician, never a midwife.

After selecting the place of confinement, the question of the nurse may next be considered. If it is to be the hospital, you need give little further thought to the nurse, for your physician will arrange for the nurse at the time you enter the hospital. She will be a part of the complete service you may enjoy. You will find her on duty as you, quietly resting in your room, awaken57 in the sweet satisfaction that at last it is all over—at last your baby is here.

A competent nurse is a necessity, if the confinement takes place in the home. She may be a visiting nurse, who, for a small fee, will not only come on the day of labor, but will make what is known as "post-partum calls" each day for ten or twelve days. These are short calls, but are long enough to clean up the mother and wash and dress the babe. She is not supposed to prepare any meals or care for the home. Then there is the practical nurse—women who have prepared themselves along these lines of nursing, whose fees range from $12.00 to $18.00 a week. If your physician recommends one to you, you may know she is clean and dependable. The trained nurse, who has graduated from a three years' course of training, is prepared for every emergency, and will intelligently work with the physician for the patient's welfare and comfort. Her fees range from $25.00 to $35.00 a week.

Both the practical and the trained nurses are human beings, and require rest and sleep the same as all other women do. One nurse, after having faithfully remained at her post of duty some sixty hours reminded the husband and sister of the patient that she must now have five hours of unbroken rest and they replied in a most surprised manner, "Why we are paying you $30.00 a week, and besides, we understood you were a trained nurse."

The physician usually makes arrangement with the family for competent relief for the nurse. She should have at least one to two hours of each day for an airing, and six hours out of the twenty-four for sleep.

The supplies should all be in the home and ready, as the seventh month of pregnancy draws near. In the first place, select the drawer or closet shelf where the supplies are to remain, untouched, until your physician orders them brought out. The supplies requiring special preparation and sterilization are:58

Other articles needed by physician, nurse, and patient are:

Just before confinement send for one ounce of fluid extract of ergot and an original pint bottle of Squibb's Chloroform.

1. The sanitary pad is used to absorb the lochia after confinement, and needs to be changed many times during the day and night; fully five or six dozen will be required. They are usually made from cotton batting and a generous layer of absorbent cotton. If made entirely from absorbent cotton they mat down into a rope-like condition. They are four and one-half to five inches wide and ten inches long. The sterile cheesecloth is cut large enough to wrap around the cotton filling and extends at both ends three inches, by which it is fastened59 to the abdominal binder. With a dozen or fifteen in each package these vulva pads are wrapped loosely in pieces of old sheets and pinned securely and marked plainly on the outside.

2. Delivery pads. These pads should be thirty-six inches square and about five inches thick, three or four inches of which may be the cotton batting and the remainder absorbent cotton. Three of these are needed. Each should be folded, wrapped in a piece of cloth and likewise marked.

3. Gauze squares. Five dozen gauze squares about four inches in size may be cut, wrapped and marked. These are needed for the nipples, baby's eyes, etc.

4. Cotton pledgets. These are cotton balls, made as you would a light biscuit with the twist of the cotton to hold it in shape. They should be about the size of the bottom of a teacup. These are thrown in a couple of pillow slips and wrapped and marked.

5. The Bobbin. Cut the bobbin or tape into four nine-inch lengths and wrap and mark.

6. The tooth picks are left in the original package and do not require sterilization.

7. Sterilization. Before steaming and baking, wrap each bundle in another wrapping of cloth and pin again securely. Mark each package plainly in large letters or initials. These packages may be sent to the hospital for sterilization in the autoclave60 or they may be steamed for one hour in the large wash boiler, by placing them loosely into a hammock-like arrangement made by suspending a firm piece of muslin from one handle of the boiler to the other. The center of the hammock should come to within five inches of the bottom of the boiler which contains three inches of boiling water. The cover of the boiler is now securely weighed down and the water boils hard for one hour, at the end of which time they are removed and placed in a warm oven to dry out. The outer wrapping may be slightly tinged with brown by this baking. After a thorough drying they are allowed to remain in the same wrappings into which they were first placed and put away in a clean drawer awaiting the "Natal Day."

Each hospital has its own methods and regulations for caring for obstetrical patients and it is well for the expectant mother to visit the obstetrical section, the delivery-room and the baby's room, that she may personally know more about the place where she is to spend from ten days to two weeks. Here she may ascertain from the superintendent just what she will need to bring for the baby. Many of the hospitals furnish all the clothes needed for the baby while in the hospital; in such instances, the hospital also launders them. Other hospitals require the baby's clothes to be brought in, in which case the mother looks after the laundry. The mother always takes her toilet articles, a warm bed jacket with long sleeves, several night dresses and a large loose kimono or wrapper to wear to the roof garden or porch in the wheel chair. Warm bedroom slippers and a scarf for the head completes the outfit.

Baby's basket on the day of confinement should contain:

By special preparation, the ordinary bedroom may be fashioned into a delivery-room. Carpets, hangings and upholstered furniture must be removed. Clean walls, clean floors, and a scrupulously clean bed must be maintained throughout the puerperium. Bathroom, and if possible, a porch should be near by. In the wealthy home, a bedroom, bathroom and the nursery adjoining is ideal; but I find that real life is always filled with anything but the ideal.

The dispensary doctor is compelled to depend upon clean newspapers to cover everything in the room he finds his patient in. The only sterile things he uses he brings with him, and should he have to spend the night, the floor is his only bed. A student who was in my service told me that there was not one article in the entire home, which consisted of but one room, that could be used for the baby. He wrapped his own coat about it and laid it carefully in a market basket and placed it on the floor at the side of the pallet on which the mother lay and by the aid of a nearby telephone secured clothes from the dispensary for the babe.

Always select the best room in the house for a home confinement. If the parlor is the one sunny room, take it; remove all draperies, carpet, etc., and make it as near surgically clean as possible. While sunshine is desirable, ample shades must be supplied, as the eyes of both mother and babe must be protected.

A three-quarter bed is more desirable than a double bed. If it is low, four-inch blocks should be placed under each leg,62 the casters having been removed to prevent slipping. The bed should be so placed that it can be reached from either side by the nurse and physician. The mattress may be reenforced by the placing of a board under it if there is a tendency to sag in the middle. Over this mattress is securely pinned the strip of rubber sheeting or table oilcloth. A clean sheet covers mattress and rubber cloth and at the spot where the hips are to lie may be placed the large sterile pad to absorb the escaping fluids. The floor about the bed is protected by newspapers or oilcloth. Good lighting should always be provided. Much trouble and possible infection may be avoided by clean bedding, plenty of clean dressings, boiled water, rubber gloves, and clean hands.

As the two hundred and seventy-three days come to a close, our expectant mother approaches the day of labor with joy and gladness. The long, long waiting days so full of varied experiences, so full of the consciousness that she, the waiting mother, is to bring into the world a being which may have so many possibilities—well, even the anticipated pangs of approaching labor are welcomed as marking the close of the long vigil. These days have brought many unpleasant symptoms, they have been days of tears and smiles, of clouds and sunshine.

The prospective mother has thought many times, "Will my baby ever come?" But nature is very faithful, prompt, and resourceful. She ushers in this harvest time under great stress and strain, for actual labor is before us—downright, hard labor—just about the hardest work that womankind ever experiences—and, as a rule, she needs but little help—good direction as to the proper method of work and the economical expenditure of energy. In the case of the average mother this is about all that is needed, and if these suggestions come from a wise and sympathetic physician—one who understands and appreciates asepsis—she may count herself as fortunately situated for the oncoming ordeal.

In the days of our grandmothers it was almost the exception rather than the rule to escape "child-bed fever," "milk leg," etc.; but in these enlightened days of asepsis, rubber gloves, and the various antiseptics, puerperal infection is the exception, while a normal puerperium is the rule; and this work of pre64vention lies in the scrupulous care taken by anyone and everyone concerned in any way with the events of the day of labor.

On this day of labor, the mother, who has gone through the long tedious days of waiting, should see to it that nothing unclean—hands, sponges, forcep, water, cloth—is allowed to touch her. Above all things do not employ a physician who has earned the reputation of being a "dirty doctor." Puerperal infection is almost wholly a preventable disease and every patient has a right to insist upon protection against it.

In a former chapter will be found a detailed description of the "delivery bed." Beside this bed, or near by, are to be found the rack on which are airing the necessary garments for the baby's reception—the receiving blanket and other requisites for the first bath—together with numerous other articles essential to safety and comfort.

There should be an easy chair in the room for the mother to rest in between her walking excursions during the first stages of labor. The sterilized pads and necessary articles mentioned in an earlier chapter are, of course, close at hand.

Regular, cramp-like pains in the lower portion of the abdomen which are frequently mistaken for intestinal colic, often beginning in the lower part of the back, and extending to the front and down the thigh, are often the first symptoms of the approaching event. With each cramp or pain the abdomen gets very hard and as the pain passes away the abdomen again assumes its normal condition. These regular cramp-like pains are the result of the early dilation of the cervix—the first opening of the door to the uterine room which has housed our little citizen through the developmental stages of embryonic life—and as a result of this stretching and dilating there soon appears that special blood-tinged mucus flow commonly known as "the show."

At this time a very thorough-going colonic flushing should be administered. The patient takes the "knee-chest" position,65 or the "lying-down" position, and there should flow into the lower bowel three pints of soapy water; this should be retained for a few moments; and after its expulsion, a short, plain water injection should be given. Now follows the preliminary general bath.

Just prior to the bath, the pubic hair should be clipped closely, or better shaved. Then should follow a thorough soap wash, with patient standing up in the tub, using plenty of soap, applied with a shampoo brush or rough turkish mit. The rinsing now takes place by either a shower or pail pour. Do not sit down in the tub. This is a rule that must not be broken, because of the danger of infection in those cases where the bag of waters may have broken early in the labor.

A weak antiseptic solution, prepared by putting two small antiseptic tablets into one pint and a half of warm water, is now applied to the body from the breasts to the knee. Put on a freshly laundered gown, clean stockings and wrapper. The head should be cleansed and hair braided in two braids.

If all the mothers who read this volume could bear children with the comfort Mrs. C. does, I should be happy, indeed.

At four o'clock one morning a very much excited father telephoned me, "Hurry, quick, Doctor, it's almost here." It was well that we did hurry, for the first sign the little mother had was the deluge of the waters—at this point the husband ran to telephone for the doctor—no more pains for thirty-eight minutes (just as we entered the door) and the baby was there. But such is not usually the case, nor will it be, as labor usually progresses along the lines of conscious dilating pains, occurring at intervals twenty minutes apart at first, later drawing nearer together until they are three to five minutes apart. This "first stage of labor" lasts from one to fifteen hours—during which time the tiny door to the uterine room which was originally about one-eighth of an inch open—dilates sufficiently to allow the passage of the head, shoulders and body of the fully developed child.

About this time the bag of waters usually bursts, and, as a66 rule, this marks the beginning of the "second stage of labor." The amount of water passed varies in amount. Should the rupture take place before the door is fully open, then labor proceeds with difficulty and the condition is known as "dry labor."

The head after proper rotation now begins the descent; and here the pains begin to change from the sharp, lancinating, cramp-like pains which begin in the back and move around to the front, to those of the "bearing down" variety, while at the same time there begins to appear the bulging at the perineum, which means that the head is about to be born. At this time great stress is brought to bear upon the perineum and often, in spite of anything that can be done to prevent it, the perineum is more or less lacerated.

As soon as the baby is born the "second stage of labor" has passed and within thirty to fifty minutes the close of the third stage of labor is marked by the passage of the placenta or "afterbirth."

Sometimes, as long as two weeks before the birth of the child, certain irregular, heavy, cramp-like pains occur in the abdomen and back. For a half-dozen pains they may show some signs of regularity; but they usually die down only to start up again at irregular intervals. These are known as "false pains."

When the pains begin to take on regularity and gradually grow heavier and it is near the appointed time for the labor, the patient should prepare to start for the hospital; or, if it is to be a home delivery, the physician should be called. As noted above, the first subjective symptom may be the rupture of the bag of waters, and it is imperative to prepare at once for the labor. It is far better to spend the day at the hospital, or even two days waiting, rather than to run the risk of giving birth to the child in a taxicab or street car; or, in the event of a home labor, to have the child born before the doctor arrives.67

It is often the case that when we need our physician the most, he is busy with another patient and cannot come, or perhaps an automobile accident detains the man of the hour. The hospital delivery always possesses this advantage over the home—physicians are always on hand. We deem it wise to relate in detail the method of procedure during the rapid birth of a child; that the husband or nurse may give intelligent and clean service.

After the patient has been given the enema and has been shaved and the bath has been administered as previously directed, the helper most vigorously "scrubs up." There are three distinct phases to the "scrubbing up": First, the three-minute scrubbing of the hands and forearms with a clean brush and green soap; to be followed by, second, the trimming and cleaning of the finger nails, for it is here, under the nails, that the micro-organism lives and thrives that causes child-bed fever or septicemia; and, third, the final five-minute scrubbing of the fingers, hands, and forearms. An ordinary towel is not used to dry the well-cleansed hands, but they are now dipped in alcohol and allowed to dry in the air.

And now if the pains are returning every three to five minutes or if the bag of waters has broken, the patient should go to bed. She will lie down on her back with the knees drawn up and spread apart. The patient, having had the cleansing bath, is now washed with the disinfectant bath (2 antiseptic tablets to 1½ pints of water), from the breasts to the knees. Another member of the family takes the outer wrappings off the sterilized delivery pad and the "clean" helper places the sterile delivery pad under the expectant mother, who is directed to "bear down" when her pains come. She may be supported during these pains by pulling on a sheet that has been fastened to the foot of the bed.

The clean, helper then sits by her constantly until the baby is born but under no circumstances should touch her until after the head appears. Immediately after the birth of the head, the shoulders usually follow with the next pain, which ought to68 occur within two or three minutes. Occasionally the face turns blue, in such an instance, the mother is directed to strain vigorously and presses down heavily on the abdomen with both her hands, this usually hurries matters materially, and the body of the child follows quickly. The baby should cry at once. If the child does not show signs of life, quick, brisk slapping on the back usually brings relief. During the birth of the head it is imperative that, in the event of liquid passing at the same time, no water or blood be sucked into the mouth by the baby. Great care must be exercised in this matter. Should the baby remain blue, lay it quickly upon its right side near the mother, and after the pulse of the cord has stopped beating the clean helper ties the cord twice, two inches from the child and again two inches from this tying toward the mother, and then the cord is cut between the two tyings with scissors that have been boiled twenty minutes.

Should there be more difficulty with the breathing of the new born child, if slapping it on the back brings no relief, its back (with face well protected) may be dipped first in good warm water, then cold, again in the warm, again in the cold—this seldom fails. The child should then be kept very warm, lying on its right side.

All this time, a member of the family has been firmly grasping the mother's abdomen, and within an hour the afterbirth passes out through the birth canal. If the physician has not yet arrived, all dressings, the pad, the afterbirth, must all be saved for his inspection.

The inside of the thighs and the region about the vagina is now washed with bichloride solution, the soiled delivery pad removed, a clean delivery pad is placed under her; an abdominal binder is applied and two sterile vulva pads are placed between the legs, and hot water bottles are put to her feet, as usually at this stage there is a slight tendency toward chilliness. She should now settle down for rest. Fresh air should be admitted into the room. There may be some hemorrhage, and if it is excessive, grasp the lower abdomen and begin to knead69 it until you distinctly feel a change in the uterus from the soft mass to a hard ball about the size of a large grape fruit; thus contraction has been brought about which causes the hemorrhage to decrease. If the doctor has not yet arrived put the baby to the breast, and place an ice bag for ten or fifteen minutes on the abdomen just over the uterus. Should there be lacerations, the doctor will attend to their repair when he comes. One teaspoonful of the fluid extract of ergot is usually given at this time, if possible get in touch with the physician before it is administered.

After the mother is comfortable, your attention is directed to the baby; the condition of the cord is noted; should it be bleeding, do not disturb the tying, but tie again, more tightly just below the former tying, and with the long ends of the tape, tie on a sterile gauze sponge or a piece of clean untouched medicated cotton, thus efficiently protecting the severed end of the cord. No further dressing is needed until the doctor arrives.

Grave disorders have arisen from infection through the freshly cut umbilical cord.

Should the doctor be longer delayed, one drop of twenty per cent argyrol should be dropped in each of the infant's eyes and separate pieces of cotton should be used for each eye to wipe the surplus medicine away.

This application must not be long neglected, for a very large per cent of all the blindness in this world might have been avoided had this medicine been placed in each eye soon after birth.

The warmed albolene is now swabbed over the entire body of the infant (this is done with a piece of cotton), the arm pits, the groins, behind the ears, between the thighs, the bend of the elbow, etc, must all receive the albolene swabbing. In a few minutes, this is gently rubbed off with a piece of gauze or an old soft towel, and the baby comes forth as clean and as smooth as a lily and as sweet as a rose.

The garments are now placed on the child—first the band,70 then shirt, diaper, stockings, flannel skirt, and outing flannel gown—and it is put to rest after the administration of one teaspoonful of cooled, boiled water. In six to eight hours it will be put to the breast.

In recent years much has appeared in both the popular magazines and the medical press concerning the so-called "twilight sleep" and other methods of producing "painless childbirth." Many of these popular articles in the lay press cannot be regarded in any other light than as being in bad taste and wholly unfortunate in their method and manner of presenting the subject; nevertheless, these writings have served to arouse such a general public interest in the subject of obstetric anesthetics, that we deem it advisable to devote two chapters to the brief and concise consideration of the subjects of pain and anesthetics in relation to the day of labor.

First, let us briefly consider the question of pain in connection with childbirth. Many women—normal, natural, and healthy women—suffer but comparatively little in giving birth to an average-sized baby during an average and uncomplicated labor. Like the Indian squaw, they suffer a minimum of pain at childbirth—at least this is largely true after the birth of the first baby; and so there is little need of discussing any sort of anesthesia for this group of fortunate women; for at most, all that would ever be employed in the nature of an anesthetic in such cases, would be a trifle of chloroform to take the edge off the suffering at the height or conclusion of labor.

But the vast majority of American mothers do not belong to this fortunate and normal class of women who suffer so little during childbirth; they rather belong to that large and growing class of women who have dressed wrong; who have lived unhealthful and sometimes indolent lives; who are more or less72 physically and temperamentally unfitted to pass through the experiences of pregnancy and the trials of labor.

The average American woman shrinks from the thought and prospect of suffering pain; she is quite intolerant with the idea of undergoing even the few brief moments of physical suffering attendant upon childbirth. She refuses to contemplate the day of labor in any other light than that which insures her against all possible pain and other physical suffering.

And it is just this unnatural and abnormal fear of labor-pains—this unwomanly dread of the slightest degree of physical suffering—that has indirectly led up to so much discussion regarding the employment of "twilight sleep" and other forms of obstetric anesthesia.

While the authors recognize the great blessing of anesthesia to the woman in labor—and almost unfailingly make use of it in some form—nevertheless, we also recognize that it would be a fine form of mental discipline and mighty good moral gymnastics, if a great many self-centered and pampered women would "spunk right up" and face the ordeal of labor with natural courage and normal fortitude. It would be "the making of them," it would make new women out of them, it would start them out on the road to real living. At the same time we do not mean to advocate that women should suffer unnecessary pain in childbirth any more than we allow them to suffer in connection with surgery.

While so much is being written about "twilight sleep" and "painless labor," it might be well to remind the American mother that much can be done to lessen the sufferings of the day of labor by one's method of living prior to the confinement.

We believe that child-bearing is a perfectly normal physical function for a healthy and normal woman—that it is even essential to her complete physical health, mental happiness, and moral well-being. Theoretically, child-bearing ought to be but little more painful than the functionating of numerous other vital organs—stomach, heart, bladder, bowels, etc.—and, in73deed, it is not in the case of certain savage tribes and other aboriginal people, such as our own North American Indian.

But we must face the facts. The average American woman does suffer at childbirth; and she suffers more than we are disposed to allow her, or more than she, as a general rule, is willing to suffer. So, while we discuss appropriate methods of lessening the pain of labor and the pangs of childbirth by the scientific use of anesthetics, let us also call attention to certain things which may aid in decreasing the amount of pain which may reasonably be expected to attend child bearing.

To assist in bringing about this preparation for decreased pain at childbirth, mothers should teach their daughters how to develop, strengthen, and preserve their physical, mental, and moral resistance. The young mother should be taught by both her mother and her physician how to dress, how to work, and how to eat. Every care should be given to the hygiene of pregnancy and labor.

The expectant mother should have plenty of fruits and fruit juices, and if not physically well endowed to give birth to a large babe, she should have her diet restricted in meat, bread and milk, as well as the cereals. Overeating during pregnancy should be carefully guarded against, as emphasized in an earlier chapter. Deformities of the pelvis, etc., should rule out a consideration of pregnancy.

While artificial painless childbirth by means of "twilight sleep" and other similar methods all have their place; nevertheless, these procedures should not lead to the neglect of those natural methods and preventive practices which aid in preparing the normal expectant mother for nature's relatively painless labor. When so much anesthesia has to be used in a normal labor, it cannot but strongly suggest that both patient and physician have neglected those common but efficient methods which contribute indirectly to lessening the pangs of child bearing.

"Twilight sleep" is a recent term which has become associated in the public mind with "painless labor." The reader74 should understand that "twilight sleep" is not a new method of obstetric anesthesia. While this method of inducing "painless labor" has been brought prominently before the public mind in recent years by much discussion and by numerous magazine articles—being often presented in such a way as sometimes to lead the uninstructed layman to infer that a new method of obstetric anesthesia had just been discovered—it has, nevertheless, been known and more or less used since 1903. Later known as the "Freiburg Method," and as the "Dammerschlaf" of Gauss, and still later popularized as "twilight sleep," this "scopolamin-morphin" method of obstetric anesthesia, has gained wide attention and acquired many zealous advocates.

"Twilight sleep" is, therefore, nothing new—it is simply a revival of the old combination of scopolamin and morphin anesthesia. While many different methods of administering "twilight sleep" have been devised, the following general plan will serve to inform the reader sufficiently regarding the technic of this much-talked-of procedure.

The scopolamin must always be fresh, although different forms of the drug are used. It tends quickly to decompose—forming a toxic by-product—and, according to some authorities, this decomposed scopolamin is responsible for many undesirable results which have attended some cases of "twilight sleep." Various forms of morphin are also used, as also is narcophin.

The "twilight-sleep" injections are not started until the patient is in the stage of active labor. The initial injection consists of the proper dose of scopolamin and morphin (or some of their derivatives), while the patient's pupils, pulse, and respiration are carefully noted, as also are the character of the uterine contractions and the character of the fetal heart action.

Usually within an hour, a second dose of scopolamin is given, while the application of so-called "memory tests" serves to indicate whether it is advisable to administer additional injec75tions. Some leading advocates of this method claim that the majority of the unfavorable results attendant upon "twilight sleep" are the direct result of failure to control the dosage of the drug by these "memory tests;" and they call attention to the large percentage of "painlessness" as proof of probable overdosing. If the patient's memory is clear and she is not yet under the influence of the drug, a third dose is soon given. If, however, the patient is in a state of amnesia (lack of memory), this third injection is not commonly given until about one hour after the second injection. The amount of amnesia present is used as a guide for repeated injections at intervals of one to one and a half hours. As a rule, the morphin is not repeated.

It must be evident that the success of such a method of anesthesia must depend entirely upon thoroughgoing personal supervision of the individual patient by a properly trained and experienced physician; and it is for just these reasons that "twilight sleep" is destined to remain largely a hospital procedure for a long time to come.

Experience has shown that those cases of "twilight sleep" that are not under the influence of scopolamin over five or six hours do vastly better than those under a longer time. When employed too long before labor this method seems to favor inertia and thus tends to increase the number of forceps deliveries.

The number of injections may run from one to a dozen or more, and patients have come through without accident with fifteen or more doses, running over a period of twenty-four hours.

While "twilight sleep" as a method of anesthesia is not altogether new, many of the claims made for it by recent advocates are more or less new; and, to enable the reader clearly to comprehend both the advantages and disadvantages of this method, both the favorable and unfavorable facts and contentions will be summarized in this connection. The favorable claims made for "twilight sleep" are:76

1. That eighty to ninety per cent of all women who use this method can be carried through a practically painless labor.

2. That there is practically no danger to the mother (some degree of danger to the child is admitted by most of its champions) other than those commonly attendant on the older and better known methods in general use.

3. That "twilight sleep," being almost exclusively a hospital procedure, would result in more women going to the hospital for their confinement—if it were used more; and would, therefore, tend to bring about more careful supervision and individual care on the part of the attending obstetrician.

4. That by lessening the dread of labor and the fear of painful childbirth, there will probably occur an increase in the birth rate of the so-called "higher classes of society"—the social circles which now show the lowest birth rates.

5. That it is of special value in the cases of certain neurotic women and those of low vital resistance; especially those patients suffering from certain forms of heart, respiratory, kidney, and other organic diseases.

6. Some authorities maintain that "twilight sleep" is of value even in threatened eclampsia, although they admit it tends to produce a rise in blood-pressure.

7. It is supposed to shorten the first stage of labor—by facilitating the dilation of the cervix—owing to the painless stretching; although the majority of its special advocates admit that it lengthens the second stage of labor, during which the patient must be very closely watched.

8. That even in those cases where the sense of pain is not entirely destroyed, the patient seems to possess little or no subsequent memory of any physical suffering or other disagreeable sensations.

9. That the method is of special value in sensitive, high-strung, nervous women of the "higher classes," who so habitually shun the rigors of child bearing—especially in the instance of their first child.

10. That the action of scopolamin is chiefly upon the central nervous system—the cerebrum—that it diminishes the perception of pain without apparently decreasing the contractile77 power of the uterus; labor may, therefore, proceed with little or no interruption, while the patient is quite oblivious to the accompanying pains.

11. That the physical and nervous exhaustion is quite entirely eliminated—especially in the case of the first labor—that patients who have had this method of anesthesia appear refreshed and quite themselves even the first day after labor.

12. That there is decidedly less "trauma" (appreciable injury) to the nervous system and therefore less "shock;" and that all this saving of nervous strain tends greatly to hasten convalescence.

13. And, finally, that "twilight sleep" does not interfere with the carrying out of any other therapeutic measures which may be deemed necessary for a successful termination of the labor.

While we are recounting the real and supposed advantages of "twilight sleep"—especially in certain selected cases—it will be wise to pause long enough to give the same careful consideration to the known and reputed dangers and drawbacks which are thought to attend this method of anesthesia in connection with labor cases.

We desire to state that these expressions, both for and against "twilight sleep," are not merely representative of our own experience and attitude; but that they also represent, as far as we are able to judge at the time of this writing, the consensus of opinion on the part of the most reliable and experienced observers and practitioners who have used and studied this method in both this country and Europe. The dangers and difficulties of "twilight sleep" may be summarized as follows:

1. That this method tends to weaken the mental resistance of many women; to lessen their natural courage and to decrease that commendable fortitude which is such a valuable feature of the character endowment of the normal woman.

2. That "twilight sleep" is essentially a hospital method and is, therefore, inaccessible to the vast majority of women belong78ing to the middle and lower classes of society, as well as to those women who live in rural communities.

3. That in fifteen or twenty per cent, the method fails to produce the desired results—at least, when administered in amounts which are deemed safe.

4. That this method does decrease the baby's chances of living; that the second stage of labor is definitely prolonged; that from ten to fifteen per cent of the babies are sufficiently under the influence of the anesthesia when born as to be unable to breathe or cry without artificial stimulus.

5. That it is a method requiring special training and experience; that it will be many years before the average practitioner will become proficient in its use; and that the older methods are probably far safer for the average physician.

6. That the method requires more care in its administration than can be expected outside of the hospital in order to avoid the dangers of fetal asphyxiation—which danger has led not a few obstetricians to abandon it.

7. That a satisfactory technic is almost impossible of development; that every patient must be individualized; that the chief dangers are connected with the over dosage of morphin; that the method is not adaptable to the general practice of the average doctor.

8. That by prolonging the second stage of labor and by sometimes giving too much morphin, the number of forceps deliveries is greatly increased, with their attendant and increased dangers to both mother and child.

9. That the prospects of passing through labor which may be rendered painless by artificial methods, tends to produce an attitude of carelessness and indifference towards those natural methods of living and other hygienic practices which so greatly contribute to naturally painless confinements.

10. That this method as sometimes practiced greatly increases the dangers of a general anesthetic, if such should be found necessary later on during the labor.

11. That "twilight sleep" is contra-indicated (should not be used) in the following conditions: primary inertia (abnormally delayed and slow labor); expected short labor—especially79 in women who have already borne children; when the fetal head is known to be large and the mother's pelvis small; placenta praevia (abnormal placental attachment); accidental hemorrhage; absent or doubtful fetal heart beat; when labor is already far advanced; and in threatened convulsions and eclampsia.

Having presented the evidence both for and against "twilight sleep," it may be of assistance to the lay reader to have placed before her the personal conclusions and working opinions of the authors. We, therefore, undertake to summarize our present attitude and outline our practice as follows:

1. "Twilight sleep" as a method of obstetric anesthesia in certain selected cases and in well-equipped hospitals, and in the hands of careful and experienced practitioners, has demonstrated that it is a scientific reality—and has probably come to stay—at least until better and safer methods of affecting a relatively painless confinement are discovered; although we are compelled to state that it is not the panacea the lay press has led many of our patients to believe. (That we believe a much better and safer method has been devised, the next chapter will fully disclose.)

2. We do not expect this method ever to become general in its use; we do not look for a chain of special "twilight hospitals" to stretch across the continent and then to overrun the country. We expect much of the recent forced enthusiasm to die down, while scopolamin-morphin anesthesia takes it proper place among other scientific methods of alleviating the pangs of labor.

3. We know that standard and fresh solutions—as already noted—are absolutely essential for the success of this method.

4. We are certain that no routine method or technic can be developed. Each patient must be individualized. The method does not consist in injecting scopolamin every so often. The patient's mental and physical condition—as also that of the unborn child—must control the administration of "twilight sleep."80

5. The patient must be in a quiet and partially darkened room. She must not be disturbed; while the physician, or a competent trained nurse, must be in constant attendance. well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.

6. While this method of treatment is best carried out in the well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.

7. Even when the treatment is not instituted early in labor, it can, in certain selected and appropriate cases, be utilized even in the second stage of labor—thus saving these special cases much unnecessary pain; in fact, some authorities regard it as a valuable adjunct in the management of "borderland contractions" as it allows the patient a full test of labor.

8. In our opinion, this method has little effect on the first stage of labor if properly administered; but it does undoubtedly prolong and tend to complicate the second stage; in fact, we are coming to look upon "twilight sleep" as being more distinctly a first stage procedure; that it bears the same relation to the first stage of labor that chloroform bears to the second stage—relieving the pain but not stopping the progress of labor.

9. That when safe amounts of the drug are used the pain is greatly lessened in all cases—the subsequent memory of pain is absent in the majority of the patients—but the labor is not always entirely painless as is popularly supposed.

10. We do not believe that this method when properly administered increases the number of forceps deliveries—at least not in the case of high forceps operations. It undoubtedly does cover up the symptoms of a threatened rupture of the uterus, and thus increases danger from that source; nevertheless it may be safely stated that this method does not in any way greatly interfere with any other measures which might be found necessary to institute in order to bring about a successful termination of the labor.

11. The baby's heart beat must be carefully and constantly watched; sudden slowing means that the treatment must be discontinued81 and the child delivered as soon as possible; even then, difficulty may be experienced in getting the baby's breathing started after it is born. In the vast majority of cases where the baby does not cry or breathe at birth, the usual methods employed in such cases serve quickly to establish normal respiration, and the baby seems to be but little the worse for the experience.

12. While altogether too much has been claimed for "twilight sleep" at the same time many false fears have also been suggested, among which may be mentioned the fear of the mother losing her mind after the treatment; the undue fear of asphyxiation on the part of the baby; the fear of post-partum hemorrhage; and the fear that it will lessen the milk supply. We cannot deny that the child's dangers are often increased; but in other respects, this method (in properly selected cases) presents little more to worry us than the older methods of anesthesia.

13. We are inclined to the belief that this method has but little influence on the course of convalescence following labor. Certain nervous and highly excitable women certainly seem to do better, as a result of experiencing less pain and nervous shock; while other cases do not turn out so well. It certainly does not retard repair and recovery during the puerperium.

14. This method seems to have its greatest field of usefulness in those cases of highly intelligent but excessively neurotic women who have an abnormal dread of pain and child bearing; or women who have suffered unusually at the time of a previous confinement—perhaps in the case of the first baby—or from other complications; women such as these, and other special cases, are the ones to benefit most from the employment of "twilight sleep."

15. This method as has already been intimated, is most useful in the case of the first baby, or in the case of women who have established a record of tedious and painful labors. It has no place in normal and short labors; although it may be used to great advantage in certain cases during the first stage of labor—being carefully and lightly administered—while chloroform or gas is utilized at the end of the second stage just as has been our custom for a generation.82

16. As noted under the special claims made for this method, it is (as also is nitrous oxid) the ideal procedure in cases of heart, respiratory, kidney, and other organic difficulties, the details of which have already been noted, and their repetition here is not necessary.

17. It must be remembered that scopolamin and morphin are more or less uncertain in their action; scopolamin is variable in its results, often producing such marked nervous excitement in the patient as greatly to interfere with the carrying out of an aseptic technic; while morphin has been shunned by obstetricians for a whole generation, because of its well-known bad effects on the unborn child as well as its interference with muscular activity on the part of the mother.

In Germany, it is said, that a great many damage suits against prominent physicians have resulted because of the alleged ill effects which have followed the use of "twilight sleep."

18. In presenting these facts and opinions regarding "twilight sleep," the reader should bear in mind that we are not only endeavoring to state our own views and experience, but also to give the reader just as clear and fair an idea of what other and experienced physicians think of the method, both favorably and unfavorably; and we will draw these conclusions to a close by citing the opinion of one or two who have had considerable experience with the method and who, in summing up their observations, say:

This chapter has been devoted to "twilight sleep;" the following chapter will consider "nitrous oxid" and other methods of anesthesia in connection with labor, and should be read along with the foregoing discussion in order to obtain an intelligent view of the whole subject of "painless labor."

Since the public has already been told so much about obstetric anesthesia, we deem it best to go into the whole subject thoroughly, so that the expectant mothers who read this book will be able to form an intelligent opinion regarding the question, and thus be in a position to give hearty cooperation to the decision of their physician to employ, or not to employ, any special form of anesthesia or analgesia in their particular case. In order to give the reader a complete understanding of "painless labor," it will be necessary to give attention to that newer and more safe method of obstetric anesthesia called "sunrise slumber." This method of anesthesia consists in the employment of nitrous oxid or "laughing gas," and will be fully considered in this chapter.

In this connection we desire to reiterate and further emphasize some statements made in the preceding chapter concerning the unnatural fear and abnormal dread of childbirth.

We feel that it is very important in connection with this new movement in obstetrics to reduce the woman's pain and suffering to the lowest possible minimum, that the trials of labor should not be overdrawn and the pangs of confinement overestimated. We must not educate the normal woman to look upon labor as a terrible ordeal—something like a major surgical operation—which, since it cannot be escaped, must be endured with the aid of a deep anesthesia.

The facts are that a very small per cent of healthy women suffer any considerable degree of severe pain—at least not after the first child. We often observe that judicious mental85 suggestion on the part of the physician or nurse in the form of encouraging words and supporting assurances tends to exert a marked influence in controlling nervousness and subduing the sufferings of the earlier labor pains.

We must not allow the efforts of medical science to lessen the sufferings of child-bearing, to rob womankind of their natural and commendable courage, endurance, and self-reliance.

We do not mean to perpetuate the old superstition that pain and suffering are the necessary and inevitable accompaniments of child-bearing—that the pangs of labor are a divine sentence pronounced upon womankind—and that, therefore, nothing should be done to lessen the sufferings of confinement. Severe and unnatural pain is not at all necessary to childbirth, and there exists no reason under the sun why women should suffer and endure it, any more than they should suffer the horrors of a very painful surgical operation without an anesthetic. In this connection, it should be recalled that analgesic drugs have been introduced into obstetric practice only during the last fifty years, while such methods of relieving pain have been used in general surgery for a much longer period. It is now only sixty-nine years since Simpson first employed anesthetic in obstetrics, while six years afterwards Queen Victoria gave her seal of approval to the use of chloroform in labor cases.

Thirty years ago, in speaking of the expectant mothers, Lusk warned us:

Nitrous oxid, or "laughing gas," was first used in labor cases in 1880 by a Russian physician. During the last twenty-five years it has been used off and on by numerous practitioners in connection with confinement, but not until the last few years has this method of relieving labor pain come into prominent notice.

While the "laughing gas" method of obstetric anesthesia did86 not gain notoriety and publicity from being exploited in magazines and other lay publications, it did get its initial boost in a very unique and unusual manner. A gentleman who manufactured and sold a "laughing gas" and oxygen mixing machine for the use of dentists, insisted that this method of anesthesia should be used in the case of his daughter, who was about to be confined. This patient was kept under this nitrous oxid anesthetic for six hours—came out fine—no accidents or other undesirable complications affecting either mother or child, and thus another and safe method of reducing the sufferings of childbirth has been fully demonstrated and confirmed, although it had previously been known and used in labor cases to some extent.

Starting from this particular case in 1913, many obstetricians began experimental work with "gas" in labor cases; and, at the time of this writing, it has come to occupy a permanent place in the management of labor, alongside of chloroform, ether, and "twilight sleep."

The reader should understand the difference between analgesia and anesthesia. Anesthesia refers to the condition in which the patient is more or less unconscious—wholly or partially oblivious to what is going on, and, of course, entirely insensible to all pain. Analgesia is a term applied to the loss of pain sensation. The patient may not be wholly or even partially unconscious—merely under the influence of some agent which dulls, deadens, or otherwise destroys the realization of pain. This is the condition aimed at by the proper administration of any form of "twilight sleep," whether by the scopolamin-morphin method, or by the nitrous oxid ("sunrise slumber") method.

Any method of treatment which can more or less destroy the pain of labor without in any way interfering with its progress, and which in no way complicates its course or leaves behind any bad effects on either mother or child, must certainly be hailed with joy by both the patient and the physician. While chloroform has served these purposes fairly well, there have87 been numerous drawbacks and certain dangers; and it was the knowledge of these limitations in the use of both chloroform and ether, that has led to further experimentation and the development of these newer methods of producing satisfactory analgesia—freedom from pain—without bringing about such a state of profound anesthesia as accompanies the administration of the older methods.

It should be borne in mind that in using "sunrise slumber" (nitrous oxid) for labor pains, the gas is so administered that the patient is just kept on the "borderline"—in a typical "twilight" state—and not in the condition of deep anesthesia which is developed when nitrous oxid is employed by physicians and dentists as an anesthetic for major and minor surgical operations.

Analgesia is the first stage of anesthesia—the "twilight zone" of approaching unconsciousness—in which the sense of pain is greatly dulled or entirely lost, while even that which is experienced is not remembered. It seems to the authors that "gas" is the ideal drug for producing this condition whenever it is necessary, as nitrous oxid is the most volatile of anaesthetics, acts most quickly, and its effects pass away most rapidly, while its administration is under the most perfect control—it may be administered with any desired proportion of oxygen—and may be discontinued on a moment's notice. It is practically free from danger even when continued as an analgesic for several hours. Nitrous oxid never causes any serious disturbance in the unborn child, as chloroform sometimes does when used too liberally.

It will not be necessary to compare the favorable and unfavorable claims for nitrous oxid as we did the contentions for and against "twilight sleep." Whatever service "laughing gas" or "sunrise slumber" can render the cause of obstetrics we can accept, knowing full well that, in competent hands, it can do little or no harm; and this we know from the facts herewith recited and from the further fact that we have gained a wide experience with this agent in the practice of both dentistry88 and surgery. In a general way, the influence of "sunrise slumber" on mother and child may be summarized as follows:

1. It can accomplish its purpose—can quite satisfactorily relieve the mother of severe pain—when employed as an analgesic. It is not necessary to administer the gas to the point of anesthesia except at the height of suffering at the end of the second stage of labor, when the head of the child is passing through the birth canal.

2. This method can be stopped at any moment—the patient ran be brought out from under its influence entirely and almost instantaneously. It is not like a hypodermic injection of a drug which may exert a varying and unknown influence upon the patient, and which, when once given, cannot be recalled.

3. It is a method which may be used in the patient's home just as safely as in a hospital; the only drawback being the inconvenience of transporting the gas-containing cylinders back and forth. This is even now partially overcome by the improved combination gas and oxygen form of apparatus which has been devised.

4. The administration of nitrous oxid analgesia or anesthesia does not interfere with or lessen the uterine contractions or expulsive efforts on the part of the mother—at least not to any appreciable extent.

5. Just as soon as a severe uterine contraction—attended by its severe pain—begins to subside, the gas inhaler is immediately removed, and in a few seconds the patient is again conscious. It is not necessary to keep the patient continuously under the influence of the drug, as in the case of the scopolamin-morphin method of "twilight sleep."

6. This method ("sunrise slumber") is certainly far more safe in ordinary and unskilled hands than the "twilight sleep" procedure. The patient is more safe with this method in the hands of the average doctor or trained nurse.

7. It has been our experience that nitrous oxid in the smaller, interrupted and analgesic doses, actually tends to stimulate the uterine pains and contractions, while at the same time rendering the patient quite oblivious to their presence. When properly administered, the freedom from pain is perfect.89

8. Under the influence of "gas," patients often appear to "bear down" with increased energy. It certainly does not lessen their cooperation in this respect.

9. We have not observed, nor have we learned of, any cases of inertia (weak and delayed contractions), post partum hemorrhage, or shock, as a result of "laughing gas" or "sunrise slumber" analgesia.

10. This method lends itself to perfect control—it may be decreased, increased, or discontinued, at will; it may be given light now and heavy at another time; while, at the height of labor, it may be pushed to the point of complete anesthesia, if desired.

11. We have found "sunrise slumber" (nitrous oxid) analgesia to be the ideal obstetric anaesthetic, and have adopted it quite to the exclusion of both chloroform and "twilight sleep." We find that this form of analgesia has all the advantages of "twilight sleep" without any of its dangers or disadvantages.

12. A possible objection to the nitrous-oxid method is the cost, especially in the private home. The average cost in the hospitals where we are using this method runs about $2.00 for the first hour and $1.50 for each hour thereafter. This is the cost when using large tanks of gas, and is, of course, somewhat increased when the smaller tanks are used in the patient's home.

Since it was thought best to give the reader some idea of the technic for the administration of "twilight sleep," it may not be amiss to explain how "sunrise slumber" is usually employed in labor cases. The technic is very simple. The administration of the gas is generally begun about the time the patient begins seriously to complain of the severity of the second stage pains; although, of course, the gas can be given during the first stage pains if desired. In the vast majority of cases, however, we think it is best to encourage the patient to endure these earlier and lighter pains without resorting to analgesic procedures.

The form of apparatus used is the same as that employed by dentists and contains both nitrous oxid and oxygen cylinders.90 A small nasal inhaler is best, although the ordinary mouthpiece will do very well. The gasbag attached to the tank should be kept under low pressure and, as a pain begins, the patient is told to breathe quietly, keeping the mouth closed. As a rule this sort of light inhalation serves to produce the desired analgesic effect. It is not necessary to put the patient deeply under in order to relieve the pain.

It is our custom to begin "sunrise slumber" as soon as the uterine contractions become painful. The earlier the gas is started, the more oxygen should be used. Two or three inhalations will suffice to take the "edge" off the earlier and lighter pains. When the pains grow heavier we use less oxygen and permit three or four deep inhalations just before a bearing-down pain. At the first suggestion of a contraction, the patient must begin to inhale the gas; while after the patient has pulled hard on the traction strops—just as the contraction pain is passing—she is given an inhalation containing a larger percentage of oxygen.

At the beginning of a pain, pure nitrous oxid is administered, and the patient is instructed to breathe deeply and rapidly through the nose. The gasbags should be about half filled. The mixture of gas and oxygen must be determined by the severity of the pains and individual behavior of the patient.

Four to six inhalations of the gas are sufficient to produce the required analgesia in the average case. Following the first few deep inspirations through the nose, the patient can be instructed to breathe through the mouth, while the gas is well diluted with oxygen and continued until the end of the pain. In this way a satisfactory analgesia is maintained throughout the "pain" with a minimum of "gas." The proportion of oxygen used will run from nothing up to ten per cent. This procedure is repeated with the occurrence of each pain.

The use of the "mask" is just as effective as a nasal inhaler, but wastes more gas and so is more costly.

When the head is passing the perineum the gas should be pushed to the point of anesthesia, while the patient's color will suggest the amount of oxygen to be used as well as serve to control the administration of the nitrous oxid.91

For many years chloroform and ether have been used to alleviate the pains of women in labor. Valuable as these agents are when deep anesthesia is required for the carrying out of operative procedures, they have not proved satisfactory as analgesic agents. If administered in small quantities at the commencement of a strong uterine contraction, the patient does not usually inhale sufficient to abolish pain. She is then apt to be irritated and is certain to insist on being given a larger quantity. If a sufficient amount be administered to satisfy the woman, the continued repetition gradually inhibits the power both of the uterus and of the accessory muscles, so that labor is unnecessarily prolonged, and, possibly, the life of the fetus endangered. Physicians have, therefore, been accustomed to employ these drugs very sparingly, restricting their use to the very end of the second stage, during the painful passage of the head through the vulva. The results of the administration at this time are also uncertain. If delivery be rapid the woman may not be able to inhale sufficient to abolish her consciousness of pain. If it be slow she may take too much and weaken the muscular powers, thereby prolonging labor and, often, necessitating forceps delivery. It is not surprising, therefore, that the medical profession has long been hoping that a more satisfactory method of relieving the pain of labor would be found.

In summing up our conclusions regarding analgesia and anesthesia in labor cases, the authors would state their present position as follows:

1. That anesthetics or analgesics are a necessary accompaniment of confinement in this day and age; that the average labor case demands some sort of pain-relieving agent at some time during its progress; but that intelligent efforts should be put forth to limit and otherwise control their use. While we recognize the necessity for avoiding needless suffering, at the same time we must also avoid turning our women into spineless weaklings and timid babies.92

2. That we should seek to develop, strengthen, and train our girls for a normal and natural maternity; that we should study to attain something of the naturalness and the painlessness of the labors of Indian tribes; and, even if we partially fail in this effort, we shall at least leave our women with ennobled characters and strengthened wills.

3. That the scopolamin-morphin method of inducing "twilight sleep" has its place—in the hands of experts—and in the hospital; and that in many cases it probably represents the best method of obstetric anesthesia which can be employed.

4. That as a general rule and in general practice, the safest and best method of inducing the "twilight" state of freedom from severe pain, is by the use of nitrous oxid or "laughing gas"—the "sunrise slumber" method. It has been our practice to start all general ether anesthetics with "gas" for a number of years, while we have been doing an increasing number of both minor and major operations with "gas" alone.

5. That we still employ general ether or chloroform anesthesia in Cesarean sections and other major obstetric operations, although several operators are beginning to use "gas" in even these heavy cases.

6. That the intelligent and careful use of pituitary extract in certain cases of labor serves greatly to shorten the second stage; that it is of great value in certain "slow cases," and serves greatly to reduce the use of low forceps.

We have treated the subject of obstetric anesthesia in this full manner, because of the fact that so much has appeared in the public press on these subjects, and, further, because we desired that our readers should have placed before them the facts on all sides of the question just as fully as a work of this scope would permit.

Popularly spoken of as the "lying-in period," and medically known as the puerperium, this time of convalescence immediately following childbirth is usually occupied by two important things: the restoration of the pelvic organs to their normal condition before pregnancy, and the starting of that wonderfully adaptative mechanism concerned with the production of the varying and daily changing food supply of the offspring.

The uterus, now more than fifteen times its normal size and weight, begins gradually to contract and assume its normal weight of about two ounces; and it requires anywhere from four to eight weeks to accomplish this involution. In view of all this it is obvious that there can be no fixed time to "get up." It may be at the end of two weeks, or it may not be until the close of four or five weeks, in the case of the mother who cannot nurse her child; for the nursing of the breast greatly facilitates the shrinking of the uterus. Extensive lacerations may hinder the involution as well as other accidents of childbirth, so it must be left with the physician to decide in each individual case when the mother may enter into the activities of life and assume the responsibilities of the care of the baby and the management of her home.

During this period of the puerperium a member of the family, a neighbor, a visiting nurse, a practical nurse, or a trained nurse, looks after the mother and gives to the babe its first care; whoever it may be, certain laws of cleanliness must be carried out if infection is to be guarded against. If there are94 daily or semi-daily calls made by the physician, a member of the family may be trained to care for the mother with proper cleanliness and asepsis; but it is far better for the mother, if possible, to secure the services of a trained nurse, or the visiting nurse, in which instance she will call each day, wash and dress the baby, clean up the mother and care for the breasts. She is not supposed to clean the room, make the bed or prepare the food. If a trained nurse can be in charge, the convalescing time is usually shortened as the responsibilities are taken from the mother, her mind freed from care and it is her's to improve, rest, and wait for the restoration of the pelvic organs, when she may again go forth among her family.

The nurse may have to sleep in the same room; but, if it be possible, she should occupy an adjoining room, she should have a regular time each day for an hour's walk in the fresh air, she should be served regular meals, and be allowed some time out of the twenty-four hours for unbroken slumber. In return she will intelligently cooperate with the physician in bringing about the restoration of body and upbuilding of the mother's nerves.

From a monetary standpoint there can be nothing so wasteful or extravagantly expensive in the home as to allow the mother to drag about from day to day and week to week with chronic weakness or invalidism because she did not have proper care during her already too short puerperium, or because she got up too soon.

Having a baby is a perfectly normal, physiological procedure. It is also, usually, downright hard work; and, beside the hard laborious work, there is not only a wearied and severely shocked nervous system to be restored, but there is also a certain amount of uterine shrinkage which must take place—and this requires from four to eight weeks; and so our mother must be allowed weeks or even a month or two to rest, to enjoy a certain amount of well-directed exercise, to have an abundance of fresh air, to be wheeled or lifted out of doors if possible into the sunshine, that she may be the better prepared for the additional duties and responsibilities the little new comer entails. Sunshine and95 fresh air are wonderful health restorers as is also a well-directed cold water friction bath administered near the close of the second week of a normal puerperium. During the second week a few carefully selected exercises such as the following are not only beneficial, but tend to increase circulation and thus to promote the secretion of milk and the shrinking of the uterus.

A splendid tonic circulatory bath may be administered at the close of the second week (in normal puerperium), known as the "cold mitten friction," which is administered as follows: The patient is wrapped in a warm blanket, hot water bottle at feet, and each part of the body—first one arm then the other; the chest, the legs, one at a time—is briskly rubbed with a coarse mit dipped in ice water. As one part is dried it is warmly covered, while the next part is taken, and so on until the entire body has been treated. The body is now all aglow, the blood tingling through the veins, and the patient refreshed by this wide-a-wake bath. Properly given, the cold-mitten friction bath is one of the most enjoyable treatments known and under ordinary conditions, if intelligently administered, may be given as early as the eighth day.

After the birth of the first baby the uterus usually is in a state of constant contraction, hence there are no "after pains;" but after the birth of the second or third child, the uterine muscle has lost some of the tone of earlier days—there is a tendency toward relaxation—so that when the uterine muscle does make renewed efforts at contraction, these "after pains" are produced. They usually disappear by the third day. Nothing should be done for them, indeed they should be welcomed, for their presence means good involution (contraction) of the uterus.96

Careful notations of the temperature should be made during the first week. A temperature chart should be accurately kept and if the temperature should rise above 100° the physician should be notified at once. The third day temperature is watched with expectancy, for if an accidental infection occurred at the time of labor, it is usually announced by a chill and sudden rise of temperature on the third day. This may be as good a place as any to mention the commonly met night sweating. This is due to a marked accentuation of the function of the skin. It is not at all unusual for a sleeping mother in the early puerperium to wake up in a sweat with night gown very nearly drenched. The gown should be changed underneath the bedding, while alcohol is rubbed over the moistened skin surface.

These sweats will disappear as soon as the mother begins to regain her strength. A vinegar rub administered on going to bed may often prevent these sweats.

Immediately after the birth of the baby and the expulsion of the afterbirth, the thighs and vulva are cleansed as follows: Into a basin of warm, boiled water are dropped four small antiseptic tablets of bichlorid of mercury; this gives a proper antiseptic wash. Into this solution are placed four pieces of sterile cotton Two of these are used, one at a time, without being returned to the solution to wash each inside of the thigh, the remaining two to cleanse the vulva. Without drying the vulva, two sterile pads are applied and pinned to the binder. These pads are changed every hour during the first day or two because of the profuse lochial flow.

After each urination and bowel movement, a lysol solution (prepared by putting one teaspoonful of lysol in a quart of sterile water) is poured from a clean pitcher over the vulva into the bed pan, and fresh pads applied. This toilet continues until the close of the second week or longer, if there is a lochial flow.97

These sterile pads not only absorb the lochia but also, among ignorant or thoughtless mothers, prevent contamination by the patient's hands.

The patient should be encouraged to urinate during the first few hours after labor; catheterization should not take place until every effort has been made to bring about normal urination; or, until there is a well marked tumor above the bony arch of the pelvis in the lower part of the abdomen. It is far less harmful to the patient for her to sit up on the jar placed on the edge of the bed, than to undergo the risk of inflammation of the bladder which so often follows catheterization.

The first few days the lochia is very red because of the large amount of blood which it contains. After the third or fourth day it is paler and after the tenth it assumes a whitish or yellowish color. During the three changes it should always smell like fresh blood. Any foul, putrifying odor should be promptly reported to the physician.

If on getting up at the close of the second week the lochia should resume its red color, the patient should return to bed and notify her physician.

After the tenth day, the abdominal binder may be pinned as tightly as the patient desires, but prior to the tenth day many physicians believe the exceedingly tight binder causes misplacements of the enlarged, softened, and boggy uterus. It should be pinned snugly; but not drawn as tight as possible with the idea of keeping the uterus from relaxing, for at best, it does not do it; while tight constriction may produce a serious turning or flexion of the uterus. The breast binder is applied during the first twenty-four hours to support the filling breasts, loosely at first, and as they increase in size, as the glands become engorged, the binder is drawn more tightly. A sterile piece of gauze is placed over the nipples.98

On the morning of the second day a cathartic is usually given—say one ounce of castor oil or one-half bottle of citrate of magnesia. The bowels should move at least once during each twenty-four hours; if they are obstinate, a simple laxative may be nightly administered. Certain constipation biscuits, sterilized dry bran, or agar-agar may be eaten with the breakfast cereal. Prunes and figs should be used abundantly. Bran bread should be substituted for white bread. The enema habit is a bad one and should not be encouraged; however, the enema is probably less harmful than the laxative-drug habit. Mineral oil is useful as a mild laxative, and does not produce any bad after results.

Fissures of the nipples should be reported to the physician at once. There are many good remedies which the physician may suggest; in his absence, Balsam Peru may be advantageously applied. Boracic acid solution should be applied before and after each nursing from the very first day; in this way much nipple trouble may be prevented through cleanliness and care. The nipples should be kept thoroughly dry between nursings Nipple shields should be used where fissures persist.

For the first three days a liquid and soft diet is followed such as hot or cold milk, gruels, soups, thin cereals, eggnog (without whiskey), eggs, cocoa, dry toast, dipped toast, or cream toast. There should be three meals with a glass of hot milk at five in the morning (if awake) and late at night; nothing between meals except plenty of good cold water. After the third day, if temperature is normal, a semi-solid diet may be taken, such as baked, mashed, or creamed potatoes, soups thickened with rice, barley or flour, vegetables (peas, corn, asparagus, celery, spinach, etc.); eggs, light meats, stale breads, toast, bland or subacid fruits (sweet apples, prunes, figs, dates, pears, etc.); macaroni, browned rice (parched before steaming), etc.; ice cream, custards, and rice puddings for desserts after99 the seventh day. Three good meals a day, at eight and one and six, with a couple of glasses of hot milk or cocoa or an eggnog at five a. m., to be repeated at 9 or 10 p. m., with plenty of cold water between the meals, will abundantly supply the necessary milk for the growing babe. Tea and coffee are not of any special value in encouraging a flow of milk.

The constant coaxing of the mother with "Do drink this," and "You must drink this, or you won't have any milk," not only saddens her but seriously upsets digestion and thus indirectly interferes with normal lactation.

Everybody should stay at home and away from the mother and her new born child until after the seventh day, and then, if our patient is normal, visitors may call, but should not stay longer than five minutes. The convalescing mother will improve faster without the neighborhood gossip, or the tales of woe so often carried by well-meaning, but woefully ignorant acquaintances.

When the hard ball-like mass can no longer be felt in the lower abdomen, when the lochia has passed through the three changes already mentioned, and the flow is whitish or yellowish, scanty and odorless, the patient may sit up in a chair increasingly each day. Such conditions are usually found anywhere from the tenth to the fifteenth day. The patient first sits up a little in a chair—she has already been exercising some in bed—and this enables her to sit up with ease for a half-hour the first day, increasing one-half hour each day during the week following. At the end of three weeks, she may be taken down stairs providing there is ample help to carry her back up stairs. After another week (at the close of the fourth), if the lochia is entirely white or yellow, with no blood, she may begin carefully to go about the house. There should be no lifting, shoving, pulling, wringing, sweeping, washing, ironing, or other heavy exercise for at least another two weeks, better four weeks. Any variance from this program usually means backache, lassitude, diminished milk supply, and frequently a general invalidism for weeks or months—sometimes years.100

Cystitis, or painful urination, is avoided by tardy "getting up;" quietly, slowly moving about; abundant water drinking; and the avoidance of catheterization.

Hemorrhage. Notify the physician if it occurs at any time. The treatment is heavy kneading of the abdomen until the uterus again becomes like a hard ball. Cold compresses over the lower abdomen may sometimes help.

Infection is manifested by chilly sensations or a distinct chill followed by fever, usually on the third day. Take a cathartic; notify the physician at once and follow his directions.

Mastitis, inflammation or caking of the breasts. Very hot fomentations wrung out of boiling water, alternating with ice-cold compress, should be applied to the breast for an hour or more, three or four times a day. Cathartics should be administered, and eliminative measures instituted such as the hot-blanket pack.

Pneumonia. Keeping the arms and chest well protected by a long-sleeved coat of warm texture, should help in preventing this serious complication. Pneumonia complicating labor is usually the result of carelessness and exposure.101

Happy is the mother and fortunate is the home that possesses the intelligent services of a trained attendant during the early days of the baby's career. A century or more ago skilled nurses were unheard of, and both mothers and babies seemed to thrive on the unskilled but faithful and sympathetic care given by the willing neighbor who "thought I'd just run over and help out." Who of us cannot remember the days when mother was "gone to a neighbor's" to give this same willing but unskilled care at the time of "confinement."

And why are we so concerned today about asepsis, sterilization, etc., when a generation ago they were not? We used to live more slowly than we do now. Then it took the entire day to do the marketing for the week, now we take a receiver from the hook and a telephone wire transmits the verbal message. Our days are literally congested with events that were almost impossibilities a century ago. The ease and leisure of former days are unknown and unheard of today. The artificial way in which we live exerts more or less of a strain upon the present generation; the average woman's nervous system is keyed up to a high pitch; her general vital resistance is running at a low ebb; while child-bearing brings a certain added stress and strain that requires much planning to avoid and overcome.

For many days and ofttimes weeks the mother is unfit—physically unable—properly to care for her child, and so104 whether it be the trained assistant in constant attendance or the visiting nurse in her daily calls, or the kind, willing, but unskilled neighbor—each helper must acquaint herself, in varying degrees, with the physical, nervous, and mental needs of the child, as well as take into account and anticipate the numerous habits and wants of the new born babe, such as urination, bowel movement, pulse, respiration, temperature, etc.

At birth, the head is remarkably large as compared to the rest of the body, for, surprising as it may seem, the distance from the crown to the chin is equal to the length of the baby's trunk; and, too, if birth has been prolonged this large head has also been pressed or squeezed somewhat out of shape. This state of affairs, however, need give no cause for either alarm or anxiety, for the head will shape itself to the beautiful rotundity of the normal baby's head within a few days.

The general shape of the baby's head, as seen from above is oval. Just back of the forehead is formed a diamond-shaped soft spot known as the anterior fontanelle which should measure a little more than one inch from side to side. On a line just posterior to this soft spot and to the back of the head, is found another soft spot somewhat smaller than the one in front. Gradual closure of these openings in the bones occurs, until at the end of six or eight months, the posterior fontanelle is entirely closed; while eighteen months are required for the closure of the anterior fontanelle.

These "soft spots" should not be depressed neither should they bulge. The head is usually covered with a growth of soft, silky hair which will soon drop out, to be replaced, however, by a crop of coarser hair in due season. The scalp should always be perfectly smooth. Any rash or crusts or accumulation of any kind on the scalp is due to uncleanliness and neglect, and should be carefully removed by the thorough application of vaseline followed by a soap wash. The vaseline should be applied daily until all signs of the accumulation are entirely removed. The eyes of all babies are generally varying tints of blue, but usually change to a lighter or darker hue by the105 seventh or eighth week. The whitish fur which often is seen on the baby's tongue is the result of a dry condition of the mouth which disappears as soon as the saliva becomes more abundant.

The baby's chest, as compared to the size of the head and abdomen, appears at a disadvantage, while the arms are comparatively short and the legs particularly so, since they measure about the same as the length of the trunk. They naturally "bow in" at birth so that the soles of the feet turn decidedly toward each other. All these apparent deformities, as a rule, right themselves without any help or attention whatsoever.

The pulse may be watched at the anterior fontanelle or soft spot on top of the head while the child quietly sleeps and should record, at varying ages, as follows:

The above table is correct for the inactive normal child. Muscular activity, such as crying and sucking, increases the pulse rate from 10 to 20 beats per minute.

The respiration of the baby often gives us no small amount of real concern at the first. The baby may be limp and breathless for some few moments at birth, and this condition calls for quick action on the part of the nurse and doctor.

The utmost care to avoid the "sucking in" of any liquid or blood during its birth must be exercised, for this often seriously interferes with the breathing. Sometimes this condition is not relieved until a soft rubber catheter is placed in the throat and the mucus is removed by quick suction. When you are reasonably sure that there is no more mucus in the throat,106 then sudden blowing into the baby's lungs (its lips closely in touch with the lips of the nurse or physician) often starts respiration. Slapping it on the back also helps, while the quick dip into first hot then cold water seldom fails to give relief.

A quiet-sleeping infant breathes as shown below at varying ages. An increase of six to ten breaths per minute may be allowed for the time it is awake or otherwise active.

The normal weight of the average baby is seven to seven and one-half pounds. Its length may range anywhere from sixteen to twenty-two inches.

There is an initial loss of weight during the first few days; however, after the milk has been established the child should make a weekly gain of four to eight ounces until it is six months old, after which time the usual gain is from two to four ounces per week.

If the weight has been doubled at six months and the weight at one year is three times the birth weight, the child is said to have gained evenly and normally.

At birth the skin of the baby is red and very soft owing to the presence of a coating of fine down. A blue-tinged skin may be occasioned by unnecessary exposure or it may be due to an opening in the middle partition of the heart which should close at birth. As soon as the baby is born, it should be placed on its right side while the cord is being tied, as this position facilitates closure of this embryonic heart opening. With the provision for a little additional heat the blue color should disappear, if it is not due to this heart condition. At the close of the first week the red color of the skin changes to a yellow tint due to the presence of a small amount of bile in the blood. This sort of jaundice is very common and is in no wise evidence107 of disease. The "down" falls off with the peeling of the skin which takes place during the second week; by the end of which time, the skin is smooth and assumes that delightful "baby" character so much admired.

The cut end of the tied umbilical cord is swabbed and squeezed with a sterile sponge saturated with pure alcohol. It is then wrapped in a sterile dressing made as follows: Four or five thicknesses of sterile cheese cloth are cut into a four-inch square with a small hole cut in the center and one side cut to this center. This is slipped about the stump of the cord and wrapped around and about in such a manner as entirely to cover the stump of the cord. The wool binder is then applied and sewed on, thus avoiding both pressure and the prick of pins. If it remains dry this dressing is not disturbed until the seventh or eighth day, when the cord ordinarily drops off. Should it become moistened the dressing is removed and the second dressing is applied exactly like the first.

The closed eyes of the newly born child are generally covered with mucus which should be carefully wiped off with a piece of sterile cotton dipped in boracic acid solution, in a manner not to disturb the closed lid. A separate piece of cotton is used for each eye and the swabbing is done from the nose outward. The physician or nurse drops into each opened eye two drops of twenty per cent argyrol, the surplus medicine being carefully wiped off with a separate piece of cotton for each eye. The baby should now be placed in a darkened corner of the room, protected from the cold.

The eyes are washed daily by dropping saturated solution of boracic acid into each eye with a medicine dropper. Separate pieces of gauze or cotton are used for each eye.

As soon as the cord and the eyes have received the proper attention and the mother has been made comfortable, the baby108 is given its initial bath of oil. This oil may be lard, olive oil, sweet oil, or liquid vaseline. The oil should be warmed and the baby should be well covered with a warm blanket and placed on a table which is covered with a thick pad or pillow. The temperature of the room should be at least eighty degrees Fahrenheit. Quickly, thoroughly, and carefully the entire body is swabbed with the warmed oil—the head, neck, behind the ears, under the arms, the groin, the folds of the elbow and knee—no part of the body is left untouched, save the cord with its dressing. This oil is then all gently rubbed off with an old soft linen towel.

After the oil bath, the silk and wool shirt (size No. 2), the diaper and stockings are quickly put on to avoid the least danger of chilling. The band having been applied at the time of the dressing of the cord, our baby is now ready for the flannel skirt. This should hang from the shoulders by a yoke of material adapted to the season, cotton yoke without sleeves if a summer baby, and a woolen yoke with woolen sleeves if a winter baby. The outing-flannel night dress completes the outfit and should be the only style of dress worn for the first two weeks. Loosely wrapped in a warm shawl, the baby is about ready for its first nap, save for a drink of cooled, boiled water.

This cooled, boiled, unsweetened water should be given in increasing amounts every two hours until the child is two or three years of age. It is usually given the child in a nursing bottle. In this way it is taken comfortably, slowly, can be kept clean and warm, and should the babe be robbed of its natural food and transferred to the bottle as a substitute for mother's milk, it will already be acquainted with the bottle and thus one-half of a hard battle has already been fought and won.

The baby's bed should be separate and apart from the mother's. It may be a well-padded box, a dresser drawer, a clothes basket, or a large market basket. A folded comfortable109 slipped in a pillow slip makes a good mattress. A most ideal bed may be made out of a clothes basket; the mattress or pad should come up to within two or three inches of the top, so the baby may breathe good fresh air and not the stale air that is always found in a deeply made bed. Into this individual bed the baby is placed as soon as it is dressed; and a good sleep of four to six hours usually follows.

Frequent observations of the cord dressing should be made as occasionally hemorrhage does take place, much to the detriment of the babe. If bleeding is at any time discovered the cord is retied just below the original tying. By the time baby has finished a six- or eight-hour nap the mother is wondrously refreshed and is ready to receive it to her breast.

During the first two days the baby draws from the breasts little more than a sweetened watery fluid known as the colostrum; but its intake is essential to the child in that it acts as a good laxative which causes the emptying of the alimentary tract of the dark, tarry appearing stools known as the meconium. On the third day this form of stool disappears and there follows a soft, yellow stool two or three times a day.

The child should be put to the breast regularly every four hours; two things being thus encouraged: an abundant supply of milk on the third day and the early shrinking of the uterus. More than once a mother has missed the blessed privilege of suckling her child because some thoughtless person told her "why trouble yourself with nursing the baby every four hours, there's nothing there, wait until the third day;" and so when the third day came, there was little more than a mere suggestion of a scanty flow of milk, which steadily grew less and less.

The urine of the very young child should be clear, free from odor and should not stain the diaper, nor should it irritate the skin of the babe. Often urination does not take place for several hours, sometimes not at all during the first twenty-four hours. If the infant does not show signs of distress, there is110 no cause for alarm; the urine should pass, however, within thirty hours. As a rule there are usually between ten and twenty wet diapers during each twenty-four hours. The following table shows about the amounts of urine at different ages:

The foreskin of the male child is often long, tight, and adherent, and is often the direct cause of irritability, nervousness, crying, and too frequent urination. It should be closely examined by both physician and nurse and when the foreskin does not readily slip back over the acorn-like head of the organ, circumcision is advised early in the second week. This simple operation will start the child out on his career with at least one moral handicap removed and one desirable possibility established—that of being able to keep himself clean.

The dressings that are loosely applied at the time of the operation should remain untouched (especially those next to the skin), unless otherwise directed by the physician, until the seventh or eighth day when the babe is placed in a warm soap bath, at which time the dressings all come off together. Clean sterile gauze is so placed as entirely to protect the inflamed skin from the diaper at all times before this bath, and these same dressings should be continued for at least another week. Sterile vaseline (from a tube) should be applied twice a day after the original dressings are removed in the bath at the end of the first week. There should be little or no bleeding following the operation, neither should the penis swell markedly; if either complication should occur, the physician should be promptly notified.

The girl baby is often neglected in respect to the proper care of the genitals. The lips of the vulva should be separated and 111thorough but careful cleaning should be the daily routine. The foreskin or covering of the clitoris should not be adherent; while the presence of mucus, pus, or blood in the vulva should be at once reported to the physician; in his absence, the application of twenty per cent argyrol should be made daily.

Let us thoroughly come to understand the very first day the little one's life, that it was not sent to us because the family needed something to play with; it is not a ball to toss up, neither is it a variety show. It is a tiny individual, and your responsibilities as parents and caretakers are very great. The child was sent to be fed, clothed, kept warm, dry, and otherwise cared for by you, until such a time as it will become able to care for itself. Remember, what we sow, that shall we also reap. If we sow indulgence we shall reap anger, selfishness, irritability, "unbecomingness"—the spoiled child. At two or three days the baby learns that when it opens its mouth and emits a holler, someone immediately comes. If we do it on the second and third day, why should we object to run, bow, and indulge on the one hundredth and second day?

Handle the baby as little as possible. Turn occasionally from side to side, feed it, change it, keep it warm, and let it alone; crying is absolutely essential to the development of good strong lungs. A baby should cry vigorously several times each day. If the baby is to be handled, support the back carefully (Fig. 6).

During the first week the baby is oiled daily over his entire body, with the exception that the cord dressing remains untouched. The face, hands, and buttocks are washed in warm water. After the third week the bathroom is thoroughly warmed and the small tub is filled with water at temperature of 100 F. The baby having been stripped and wrapped in a warm turkish towel, is placed on a table protected by a pillow, while the caretaker stands by and vaselines the creases of the neck, armpits, folds of the elbows, knees, thighs, wrists, and genitals; and then, with her own hands, she applies soap suds all over112 the body—every portion of which is more quickly and readily reached—than by the use of a wash cloth. And now, with the bath at 100 F., with a folded towel on the bottom of the small tub, the soapy child is placed into the water and after a thorough rinsing is lifted out again to a warm fresh towel on the table and the careful drying is quickly begun. After the bath all the folds and creases are given a light dusting with a good talcum.

During hot weather the bath should be given daily, soap being used twice a week. On the other days there should be the simple dipping of the child into the tub. During the cold weather the full bath is given but twice a week, while on the other days a sponge bath or an oil rub may be administered.

A weak, delicate child should not be exposed to the daily full bath, but rather the semi-weekly sponge bath and the daily oil rub should be administered. We have found the late afternoon hour to be better than the early morning hour for baby's bath. It requires too much vital resistance to react to an early morning bath, especially when the house is cool.

The use of soap is very much abused with young babies. I recall one mother who came into the office with her poor little baby which was constantly crying and fretting because of a greatly inflamed body—all a result of the too frequent use of soap. I said, "I am afraid you do not keep your baby clean." "O Doctor!" she replied, "I wash him with soap every time I change him; I am sure he is clean." And come to find out, the poor little fellow's tender skin had been subjected to soap several times a day. We ordered the use of all soap discontinued, vaseline and talcum powder to be used instead, and the child's skin got well in a very short time.

Tight bands should not be placed about the babe. If the umbilicus protrudes, do not endeavor to hold it in by a tight band, but consult your physician about the use of a bit of folded cotton and adhesive plaster, and then allow the child the free113dom of the knitted bands, with skirts suspended from yokes. The day of tight bands and pinning blankets with their additional and traditional windings is over. After the complete healing of the cord, the need for a snug binder to hold the dressings in place is over. Should the baby cry violently, the umbilicus should be protected in the manner described above—the fold of cotton and the adhesive plaster.

The diaper, stockings, shirt, skirt, and dress with an additional wrapper for cold days completes the outfit at this age.

"One of the most important services to render the newborn baby is to have his birth promptly and properly registered."

In most states the attending physician or midwife is required by law to report the birth to the proper authority, who will see that the child's name, the date of his birth, and other particulars are made a matter of public record. Birth registration may be of the greatest importance when the child is older, and parents should make sure this duty is not neglected.

A public health official some time ago epitomized some of the uses of birth registration as follows:

We wish it were possible for every mother who reads this book to have a special baby's room or nursery. Some of our readers have a separate nursery-room for the little folks, and so we will devote a portion of this chapter to the description of what seems to us a model arrangement for such a room; but, realizing that ninety-five per cent of our readers can only devote a corner of their own bedroom to the oncoming citizen, we have also carefully sought to meet their needs and help them to take what they have and make it just as near like the ideal nursery as possible.

The nursery should be a quiet room with a south or southwesterly exposure. The bathroom should adjoin or at least be near. A screened-in porch is very desirable.

Draperies that cannot be washed, and upholstered furniture, do not belong in the baby's room. A hardwood floor is better than a carpet or matting; while a few light-weight rugs, easily cleaned, are advisable. Enameled walls are easily washed and are, therefore, preferable to wall paper or other dressings.

The windows should be well screened, for by far the greatest dangers to which the baby is exposed, are flies and mosquitoes—carriers of filth and disease. Flies, mosquitoes, cockroaches, bed bugs, cats, dogs, lice, and mice are all disease carriers and must therefore be kept out of baby's room.

At each window should be found dark shades, and if curtains are desired they should be of an easily washable material, such115 as mull, swiss, lawn, voile, or scrim. The hardwood floor may be covered where necessary with easily handled rugs which should be aired daily. The other necessary articles of furniture are a crib of enameled iron whose bedding will be described elsewhere in this chapter, a chest for baby's clothes and other necessary supplies, a screen or two, a low table and a low rocker, a small clothes rack on which to air the clothes at night, a pair of scales, and a medicine chest placed high on the wall.

If the room will conveniently admit it, a couch will add greatly to the mother's comfort; and, if possible, it should be of leather upholstery; otherwise, it should possess a washable cover, for all articles that promote the accumulation of dust are not to be allowed in the nursery. In these early weeks and months baby will not benefit from pictures or other wall decorations, and so let him have clean walls that are easily washed and quickly dusted.

The necessities for baby's personal care are:

Since the days of Solomon, accidents have occurred where mother and babe have occupied the same bed. Not only is there the ever-present danger of smothering the babe, but there are also many other reasons why a baby should have its own bed. The constant tendency to nurse it too often and the possibility of the bed clothing shutting off the fresh air supply, are in and of themselves sufficient reasons for having a separate bed for baby.

The first bed is usually a basinet—a wicker basket with high sides—with or without a hood. A suitable washable lining116 and outside drape present a neat as well as sanitary appearance. The mattress of the basinet is usually a folded clean comfort slipped into a pillow slip; this is to be preferred to a feather pillow, as it is cooler and in every way better for the babe.

Drapes about the head of the basinet are not only often in the way, shutting out air, etc., but they also gather dust and are unsanitary. Screens are movable—they may be used or put away at will—and are, therefore, very convenient about the nursery.

The basinet may be dispensed with entirely if the sides of the enameled crib are lined to cut off draughts and the babe is properly supported by pillows. After the baby is four to six months of age it is transferred to the crib. The basinet has an advantage over the crib during those early weeks in that its high sides protect the babe from draughts, and the comforts and blankets can be more easily tucked about the little fellow to keep him warm. The sides should not extend more than four inches above the lying position of the child.

The enameled iron crib should be provided with a woven-wire mattress, over which is placed a mattress; hair is best as a filling for the mattress, wool next, and cotton last. Over the mattress should be placed a rubber sheet, and over all a folded sheet.

A pillow of hair or down is not to be discarded; for recent investigation has shown that the pillow favors nasal drainage, while lying flat encourages the retaining of mucus in the nose and nasal chambers—the sinuses. The pillow slip should be of linen texture.

During the winter a folded soft blanket over the rubber sheet increases both softness and warmth. No top sheet is used during the first months, particularly if the first months are the winter months. The baby is wrapped loosely in a light weight clean blanket or shawl, and other blankets—as many as the season demands are tucked about the child. These blankets should be aired daily, and the one next to the baby changed, aired, or washed very often.117

To prevent baby from becoming uncovered the sleeping blanket has been devised. The blanket is folded and stitched in such a way as completely to envelop the sleeping babe, and at the same time afford the utmost freedom (Fig. 7). The babe may turn as often as he desires, but cannot possibly uncover himself. Bed clothes fasteners are also used—an elastic tape being securely fastened to the head posts and then by means of clamps or safety pins attachment is made to the blankets on either side. The elasticity allows considerable freedom to the child in turning (See Fig. 8).

The subject of ventilation has been so fully discussed by the authors in another work that we refer the reader to The Science of Living, or the Art of Keeping Well.

For the first two or three weeks the nursery temperature should be maintained at seventy degrees Fahrenheit by day and from sixty degrees to sixty-five degrees by night. In the third week the day temperature should be sixty-eight degrees Fahrenheit measured by a thermometer hanging three feet from the floor. After three months the night temperature may go as low as fifty-five degrees Fahrenheit, and after the first year it may go as low as forty-five degrees.

The heating of the nursery is usually controlled by the general heating plant, and no matter what system of heating is maintained, humidifiers must be used, the necessity for which is doubled when the system is that of the hot-air furnace.

These shallow pans of water with large wick evaporating surfaces will evaporate from three to four quarts during the twenty-four hours. The humidity should be fifty throughout the seasons of artificial heating.

Many colds may be entirely avoided by the use of humidifiers or evaporators. The open grate is one of the very best means of nursery heating. Gas and oil heaters should not be depended upon for nursery heat. Only in an emergency should they be used at all, and the electric heater is by far the best device for such occasions.

It is probably a conservative estimate to say that ninety-five per cent of all the babies occupy a corner of mother's and father's bedroom for the first two or three years. And believing this estimate to be correct, it is advisable to give the matter some consideration. To begin with, a lot of the non-essentials, ruffles and fluffles of the average bedroom, must go. The good father's chiffonier may have to be put in the bath room; heavy floor coverings must be discarded, to be replaced by one or two small, light-weight rugs; wall decorations and the usual bric-a-brac of dressers, tables, etc., should be carefully packed away. In fact, there should be nothing in the room save the parents' bed, dresser (several drawers of which must be devoted to baby's necessities), table, low rocker, a stool, baby's bed and a good big generous screen, made out of a large clothes horse enameled white and filled with washable swiss.

Window draperies must be taken down and packed away, while they are replaced with simple muslin which can go to the laundry twice a month. If it be within the means of the family purse, it is well to renovate the walls just prior to the advent of the little stranger.

And now the baby's bed is placed in the corner most protected from draughts and the glare of the sunlight. If it can be so arranged that baby looks away from the light, and not at it, we are guarding it from defective vision in the future.

Many a beautiful artistic creation so much admired in this world is found to be, on closer inspection, a very ordinary thing which has received an artistic touch; and so, many convenient, sanitary, and beautiful cribs are fashioned from market baskets fastened to tops of small tables whose legs are sawed off a bit; from soap boxes fastened to a frame, and from clothes baskets. A can of white enamel, a paint brush and the deft hand of a merry, cheery-hearted expectant mother can work almost miracles. Remember, please, that all draperies must be washable and attached with thumb tacks so as to admit of easy and frequent visits to the laundry.120

A medium-sized clothes basket will take care of our baby for four or five months. The same general plan for the mattress and bedding is followed as before described.

If necessary—and it usually is, especially during the winter months—a hot-water bottle may be placed underneath the bedding on top of the mattress. This insures a steady, mild, uniform warmth and it not only saves the baby from the danger of being burned, but it also obviates the temporary overheating of the child which usually occurs when the bottle is placed inside the bed, next to the baby. If the bed is properly made—the blankets coming from under the babe up and over—there is little or no need for extra heat for well babies after the first month.

If electric lighting is not an equipment of the home neither gas or oil lamps should be allowed to burn in the room for long periods. For emergency night lighting a well-protected wax candle should be used. However, don't go to sleep and allow a candle to burn unprotected as did one tired, exhausted mother. The father, suddenly aroused from his sleep, saw a large flame caused by the overturning of a wax candle into a box of candles, while the lace drapery of the basinet was within a few inches of the flame and the baby just beyond. Grabbing a pillow he smothered the flames and saved baby and all.

Plenty of fresh air and lots of sunshine should enter baby's room. The large screen amply shields from draughts, and when thus protected there need be no unnecessary concern about cool fresh air, especially after two or three months, as it is invigorating and prevents "catching cold." Warm, stuffy air is devitalizing and even during the early weeks when the fresh air must be warm, an electric fan should be advantageously placed so that many times each day the warm fresh air may be put in motion without creating a harmful draught.121

Warm stuffy air makes babies liable to catch cold when taken out into the open.

Throw open the windows several times each day and completely change the air of baby's room. In the absence of the large screen, a wooden board five or six inches high is fitted into the opening made by raising the lower window sash. Then as the upper sash is lowered the impure air readily escapes while fresh air is admitted.

Make early preparations for bathing the baby in the easiest possible manner; in fact, the young mother should seek to attend to all her duties—the family, the home, and the baby—in the easiest way. For the administration of a bath during the early months, a table is needed, protected by oilcloth on which is placed a roomy bathtub with a folded turkish towel on the bottom for baby to sit on. In addition to the tub, have:

See that the bathtub is clean and enamel unbroken, and if it has been used by another babe, freshen it with a coat of special enamel sold for that purpose.

A bath at ninety-eight degrees is a neutral bath, and after the baby is six months and over, the bath may be given at this temperature, and at the close quickly cooled to ninety degrees.122

All bedding and rugs should receive their daily shaking and airing out of doors, remembering that particles of dust are veritable airships for the transportation of germs. In every way possible avoid raising a dust. So much of the lint which commonly comes from blankets may be avoided with the daily shaking out of doors.

Soiled diapers should not accumulate in a corner or on the radiator; their removal should be immediate, and if they must await a more opportune time, soak them in a receptacle filled with cold water. Even those diapers slightly wetted should never be merely dried and used again, but should be properly washed and dried. No washing soda should be used in the cleansing of diapers—just an ordinary white soap, a good boil, and plenty of rinse water, with drying in the sun if possible. They require no ironing. Hands that come in contact with soiled or wet diapers must be thoroughly cleansed before caring for the baby or preparing his food.

As before mentioned, and it will bear repetition often, all windows and doors must be well screened, for flies and mosquitoes are dreaded foes in any community and in babyland in particular. All used bottles and nipples as well as used cups, pitchers, bits of used cotton, should be removed at once. The washcloth is a splendid harbinger of germs. There should be one for the face, and one for the body and bath, and both should receive tri-weekly boiling. Bath towels should not be used more than twice, better only once.

The technic of bathing, together with the location, furnishings, and cleanliness of the baby's sick room, will be taken up in later chapters.

It is surprising how soon even a young and inexperienced mother will learn to distinguish between the pain cry and the plain cry of her baby; for most crying can easily be traced to some physical discomfort which can be relieved, or to some phase of spoiling and indulgence which can be stopped.

The young baby can neither walk, talk nor engage in gymnastics, except to indulge in those splendid physical exercises connected with a good hearty cry. To be good and healthy, an aggregate of an hour a day should be spent in loud and lusty crying. He should be allowed to kick, throw his arms in the air and get red in the face; for such gymnastics expand the lungs, increase general circulation and promote the general well-being of the normal child. As the child grows older and is able to engage in muscular efforts of various sorts, these "crying exercises" should naturally decrease in frequency and severity. When baby cries, see that the abdominal band is properly applied, that rupture need not be feared.

The sound most welcomed by both doctor and nurse is the cry of the newly born child, for it shows that the inactive lungs have opened up and the baby has begun to use them, for all the time baby was living in the uterine room he did not breathe once, the lungs having been in a constant state of collapse; and not until now, the very moment the air comes in contact with his skin, do the lungs begin to functionate as he emits his first lusty holler.124

The cry is said to be abnormal when it continues too long or occurs too often. It may be strong and continuous, quieting down when he is approached or taken up; or it may be a worrying, fretful cry, a low moan or a feeble whine. And now as we take up the several cries, their description, cause, and treatment, we desire to say to the young mother: Do not yourself begin to fret and worry about deciding just which class your baby's cry belongs to; for help, knowledge, and wisdom come to every anxious mother who desires to learn and who is willing to be taught by observation and experience.

The continuous, fretful cry, accompanied by vigorous sucking of the fists, both of which stop when hunger has been satisfied, is without question the hunger cry.

If this cry is constant with regular feedings, then the quantity of the food must be increased, or the quality improved. The tired, fretful hunger cry must not be neglected; the cause must be removed, for it points to malnutrition.

One day when lecturing at an Iowa chautauqua, I remained in the beautiful park for the noonday meal. It was a warm day and the tables in the well-screened dining tent were filled with mothers who, like myself, preferred the cool shade of the park to the hot ride through the city to the home or hotel dinner. At my table a baby was pitifully crying. The mother had offered the little child seated in a small uncomfortable go-cart, milk, bread, and a piece of cake—all of which were ruthlessly pushed aside. My little son, then only four and a half, said "Mamma, maybe the baby's thirsty," and up he jumped, hurried to the mother's side with his glass of water, saying, "I haven't touched it, maybe the baby's thirsty." The mother brushed the boy aside, saying, "No, I never give the baby water." In spite of the mother's remonstrance, the baby cried on and on, and finally on "trying" the water, the child drank fully one-half the glass and the crying was hushed.125

Babies should be given water regularly—many times every day—from birth, in varying amounts from two teaspoons to one-half cup, according to the age of the child. The water should be boiled for the first few months, and longer if there is any suspicion of impurities.

Milk to the nursing infant is like beefsteak and potatoes to the adult; and many times the milk bottle or the breast is just as nauseating to the thirsty babe, as meat would be to the very thirsty adult whose hunger has previously been fully satisfied.

The babe who is wet, soiled, too hot, or is wrapped too tightly, or who has on a tight, uncomfortable belly band, or whose clothing is full of wrinkles, has only one way to tell us of his discomfort, and that is to cry. It is a fretful cry and should command an immediate investigation as to the possible cause. It takes but a moment to discover a wet diaper; to run the hand up the back under the clothes; to sprinkle with talcum if perspiring; to straighten out the wrinkled clothing; to find the unfastened pin that pricks; or to loosen the tight band. Acquire the art of learning to perform these simple tasks easily, and any or all of these services should be rendered without taking the child from its bed.

Let the child early learn to rest happily and quietly in his own bed. The pillow or mattress may be turned or perhaps the mattress be raised nearer the edge of the basinet. One poor youngster instantly stopped his fretful cry when his mattress was raised four or five inches so he could get the air, at the same time taking him out of his hot room to a cooler room with raised windows. Babies like cold air. They cry when the air is hot, or even warm and close. Every day—rain or shine, wind or sleet—babies should nap out of doors on the porch, in a well-sheltered corner. A screen or a blanket protects from the wind, sleet, or rain; and if the baby's finger tips are warm, you can rest assured the feet and body are warm. Scores of babies will sleep out on the porch, on the protected fire escape, or in a room with opened windows, from one bottle or feeding to another; being aroused at the end of the three or four hour126 interval just enough to nurse, when back they go to their delightful, warm nest in the cool, fresh air to sleep for another period. Babies should never sleep in a room with closed windows.

One of the incidents that surprised me most in my early work with dispensary babies was the utter misconception of the purpose of the belly band. Invariably it was put on so tightly that I could not slip a finger between it and the babe. It is not a surgical instrument, neither is it a truss. These tight belly bands are a source of much fretting and crying.

The little pinched look about the face, the drawing up of the legs, the jerking of the head, arms, or legs, associated with a strong, sharp, unceasing or intermittent cry, demands immediate attention Our first work should be to go about quietly, painstakingly, and systematically to locate the cause of this "cry of pain."

There are often some accompanying symptoms to the cry of pain which demand skilled medical advice and attention, such as the arching of the body backward, the drawing of the head strongly to one side, the inability to use one side of the body, or the presence of fever. There may be an earache, an abdominal complication, or a sore throat, any one of which will be detected by the skilled doctor.

Earache frequently occurs in young babies who have been taken out of doors without proper protection to the ears; or, it may be associated with a cold in the head, which is not detected until the mischief has already been done, while the resulting running ear tells the tale of woeful suffering. Earache must always be thought of as a possible cause when the cry of pain accompanies a cold in the head, and if medical aid is secured early, the abscess may be aborted and the deafness of later years entirely avoided. There is only one home remedy for earache, and that is the application of external heat, either by a hot-water bottle or hot-salt bag. Medical advice should be sought before anything whatsoever is dropped into the baby's ear.127

In this connection should be mentioned the wild cry at night which so often accompanies tuberculosis of the bone. A careful X-Ray examination will reveal the disease, and proper medical measures should be instituted at once. Other fretful night crying will be mentioned further on.

By the frequent repetition of actions, habits are formed. When the baby is two or three days old, he is so new to us and we have waited for him so long, and it is such a great big world that he has come into, that we jump, dance, and scramble to attend to his every need and adequately to provide for his every want. At this very early, tender age whenever he opens his mouth to cry or even murmur—some fond auntie or some overly indulgent caretaker flies to his side as if she had been shot out of a gun, grabs him up and ootsey tootsey's him about as she endeavors to entertain and quiet him. The next time and the next time and the succeeding time he whimpers—like a flash someone dashes to the side of the basket, and baby soon learns that when he opens his mouth and yells, somebody comes. In less than a week the mischief has been done and baby is badly spoiled. No other factor enters so largely into the sure "spoiled" harvest as picking a new baby up every time he cries. Often in the early days some indulgent parent will say, "Oh, don't turn out the light, something might happen to the dear little thing"—and old Mother Nature sees to it that a constant repetition of "leaving the light on" brings its sure harvest of "he just won't go to sleep without the light." And then, "just once" he had the pacifier—perhaps to prevent his crying disturbing some sick member of the family—and so we go on and on. If a thing is bad, it is bad, and a supposedly good excuse will not lessen the evil when the habit has been thus started and acquired.

The rocking of babies to sleep may be a beautiful portrayal of mother love, but we all pity the child who has to be rocked to sleep as much as we do the mother who sits and rocks, wanting, Oh, so much! to do some work or go for a walk—but she must wait till baby goes to sleep.128

And so now we come to the temper cry—that lusty, strong outburst of the cry of disappointment when he finds that all of a sudden people have stopped jumping and dancing for his every whim. The baby is not to blame. We began something we could not keep up, and he—the innocent recipient of all our indulgences—is in no sense at fault. It is most cruel to encourage these habits of petty indulgence, which must cause so much future disappointment and suffering on the part of the little fellow as he begins to grow up.

Nobody is particularly attracted to the spoiled baby. After the over-indulgent parent and caretaker have completed their thoughtless work, they themselves are ashamed of it and not infrequently begin to criticise the product of their own making—the formation of these unpleasant bad habits. More than anything else, the spoiled child needs a new environment, new parents, and a new life.

Seek to find out if possible—and it usually is possible—just what he is crying for. It may be for the pacifier, for the light, or to be rocked, jolted, carried, taken up and rocked at night, or a host of other trifles; and if he is immediately hushed on getting his soul's desire—then we know he is "spoiled."

The unfortunate thing about it all is that the one who has indulged and spoiled the baby usually does not possess the requisite nerve, grit, and will power to carry out the necessary program for baby's cure. And the pity of it all is that overindulgence in babyhood so often means wrecked nerves and shattered happiness in later life. So, fond, indulgent parents, do your offspring the very great kindness to fight it out with them while they are young, even if it takes all summer, and thus spare them neurasthenia, hysteria, and a host of other evils in later life.

This sort of "spoiled baby crying" can be stopped only through stern discipline—simply let the baby "cry it out." The first lesson may require anywhere from thirty minutes to an hour and thirty minutes. The second lesson requires a much129 shorter time, and, in normal babies with a balanced nervous system, a third or fourth lesson is not usually required.

The cry of the severely sick child is the saddest cry of all. The low wail or moan strikes terror to the saddened mother-heart. It is often moaned out when the child is ill with "summer complaint" or other intestinal disturbances. Instant help must be secured, and, if medical help is not obtainable, remember, with but one or two exceptions, you are safe in carefully washing out the bowels, in applying external heat and giving warmed, boiled water to drink.

Another cry which demands immediate attention, and the faithful carrying out of the doctor's orders, is the hoarse, "throaty" cry indicative of croup or bronchitis.

Perhaps the greatest cause of the most crying during infancy, next to that of over-indulgence, is ordinary colic which—

A colicky baby completely upsets the household and greatly disturbs the mother, who requires both quiet and rest that she may the better produce the life-sustaining stream so much needed for the upbuilding and development of the growing child.

While colic is so often seen in the bottle-fed babe, it often occurs in the breast-fed child, and is usually traceable to some error in the mother's diet or to some other maternal nutritional disturbance. One mother who was sure she had eaten nothing outside the diet suggestions she had received, was requested to130 bring to the office a fresh voiding of her own urine which was found to be highly acid. The administration of an alkaline such as simple baking soda or calcined magnesia to the mother, corrected this acidity, and the colic in the baby entirely disappeared. I recall the case of one mother who ate her dinner in the middle of the day, with a light meal in the evening and thereby stopped the colic in her babe.

Another source of colic in the breast-fed baby is the unclean nipple. The nipples should be washed with soap and water and rinsed in boracic acid solution before each nursing. If the mother worries greatly, or thoughtlessly "gets very angry" just before the nursing hour, there is a substance known as "epinephrin" secreted by the glands located just above the kidneys which is thrown into the blood stream and which raises the blood pressure of the mother and often produces not only colic in the babe, but many times throws him into severe convulsions.

There are many opportunities for colic in the bottle-fed baby; for instance, dirty bottles, dirty nipples, careless cleansing of utensils used in the preparation of baby's food, improper mixtures, too much flour, the wrong kind of sugar, too much cream or too little water—all these things help to produce wind under pressure in the intestine, which is commonly known as colic. Underfeeding or overfeeding, too rapid feeding or too frequent feeding also contribute their mite in producing colic.

As a rule, the bottle-fed child is fed too often. In the new born, the interval between feeds should be three hours from the start; after six months the interval may be lengthened to four hours.

Hiccough—a spasm of the diaphragm—often accompanies colic, and, in the case of infants, is usually due to the swallowing of air or over-filling the stomach; gentle massage, external heat, and a few sips of very warm water usually corrects the condition.131

The chilling of the skin very often produces a temporary intestinal congestion with colic as the result. Cold feet, wet diapers, and loitering at bath are all very likely to produce colic; and when it is thus caused by chilling, quickly prepare a bath at 100 F., and after immersing the child for five minutes, wrap up well in warm blankets.

Those of my mother readers who have electric lights in their home, will find the photophore to be a source of great comfort and convenience; for this simple contrivance is usually able to banish colic in a few moments. The photophore is simply radiant heat—heat plus light (See Fig. 3)—and as this heat is applied to legs and buttocks of the crying child the diaper is warmed, the abdomen relaxes, gas is expelled, intestinal contractions relieved, and the baby is soon fast asleep.

Occasionally with the aid of the photophore, and even without it, the warm two-ounce enema containing a level teaspoon of baking soda and a level teaspoon of salt to a pint of water when allowed to flow into the bowel, will soon bring down both gas and feces to the great relief of the baby. Warm water to drink is also very helpful. Putting the feet in very warm water is also quieting to the crying colicky babe.

It is often necessary in cases of repeated and persistent colic, Do not jolt or bounce the baby, do not carry him about, and don't walk the floor with him.

Heat him up inside and outside, warm his clothing and his bedding, and thus bring about relief without sowing seeds for future trouble—the sorrow of a spoiled child.

One very quiet little baby was one day brought to the dispensary whose mother said: "Doctor, I didn't bring him 'cause he's sick, but 'cause he looks so pale; he's as quiet as a mouse; he never cries any more since I got to giving him medicine." On examination of the baby and on inquiring about the medicine, we found that the baby was dead drunk all the time. Some "neighbor friend" had told the tired out mother, "Give him a teaspoon of whiskey at each feeding and that'll fix him all132 right." If a few more states go dry maybe it will not be so easy for the ignorant mother to dope and drug her helpless baby.

And neither is paregoric to be administered wholesale for colic. It contains an opiate, and should not be given without definite orders from a physician. And so as a parting word on "Why Babies Cry," we ask each mother to run over the following summary of the chapter, and thus seek to find out why her baby cries.

Happy is the mother, and thrice blessed is the babe when he is able to enjoy the supreme benefits of maternal nursing. The benefits to the child are far reaching; he stands a better chance of escaping many infantile diseases; the whole outlook for health—and even life itself—is greatly improved in the case of the nursing babe, as compared with the prospect of the bottle-fed child. Maternal nursing lays the foundation for sturdy manhood and womanhood.

Out of every one hundred bottle-fed babies, an average of thirty die during the first year, while of the breast-fed babies, only about seven out of every one hundred die the first year. At the same time, nursing the babe delivers the mother from all the work and anxiety connected with the preparation of the artificial food, the dangers and risks of unclean milk, and the ever-present fear of disease attendant upon this unnatural feeding. The mother who nurses her child can look forward to a year of joy and happiness; whereas, if the babe is weaned, she is compelled to view this first year with many fears and forebodings. Mother's milk contains every element necessary for the growth and development of the child, and contains them in just the proportions required to adapt it as the ideal food for that particular child.

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Outings and Exercise. It is most highly important that the nursing mother should be able thoroughly to digest her food; otherwise the flow of milk is likely to contain irritants that will disturb the baby's digestion, even to the point of making him really sick. In order to avoid these complications, exercise and outings are absolutely essential for the mother. A vigorous walk, gardening, light housework or other light athletics, greatly facilitate digestion and increase the bodily circulation, as well as promote deep breathing, all of which are of paramount importance to a good appetite and good digestion.

The Bowels. The bowels should move regularly and normally once or twice during the twenty-four hours. Unfortunately, this is not usually the case: and in this connection we would refer our reader to the chapter on "The Hygiene of Pregnancy," particularly those sections relative to the care of the bowels, recipes for bran bread, lists of laxative foods and other suggestions pertaining to the hygiene of the nursing mother.

Sleep. Nothing less than eight hours sleep will suffice for the nursing mother, and during the day she should take at least one nap with the baby.

Care of the Skin. Salt-rub baths are very beneficial taken once a week. The daily cold-friction rub described elsewhere, will tone up the system and increase digestion and improve the general well being. The soap wash may be taken once a week. The thorough cleansing of the breasts, and the frequent changing of the undergarments, will help to keep the baby happy; for oftentimes it is the odor of perspiration as well as the smell of soiled clothing that spoils the appetite of the baby, causing it to refuse food.

Recreation. Pleasant diversion is very essential for the mother, and should be indulged in at least once a week. The bedtime hours, however, should not be interfered with and the recreation should be selected with a view to amuse, refresh and create a harmless diversion for the mother's mind. Under no circumstances should the mother settle down to the thought: "No, I can't go out any more. I can't leave my baby." You135 should get away from the baby a short time each day, and go out among your former friends and acquaintances. Many a wrecked home—a shattered domestic heaven—dates its beginnings back to the days when the over-anxious young mother turned her back on her husband and looked only into the face of her (their) child. Nothing should come in between the filial friendship of husband and wife, not even their child. So, dear mother, if you can, go out occasionally, away from the baby, and enjoy the association of your husband and keep in touch not only with his interests, but with the outside world. You will come back refreshed and wonderfully repaid, and the face of the adored infant will appear more beautiful than ever.

The general suggestions on diet which we made to the expectant mother are also valuable for the nursing mother. The food should be appetizing, nutritious, and of a laxative nature. Three meals should be eaten: one at seven a. m., one at one p. m. and one about six-thirty at night, with the heaviest meal usually at one p. m. As the mother usually wakens at five o'clock, or possibly earlier, she should be given a glass of milk, cocoa, or eggnog. If she awakens at six, nothing should be taken until the breakfast, which should consist of a good nourishing meal, such as baked potatoes with white sauce, poached eggs, cereal, milk or cocoa, prunes, figs, or a baked sweet apple, with bread and butter, etc.

From that hour until one p. m. only water is taken, and several glasses are urged during this interval. With nothing between meals but water and a little outdoor exercise, a good appetite is created for the one p. m. meal which should abundantly supply and satisfy the hungry mother; and then again, nothing is to be taken between dinner and supper but water. And after the supper hour, a walk out into the cool night air should be enjoyed with the husband and on going to bed about ten p. m., an eggnog or glass of milk may be taken. At the close of the other meals a cup of oatmeal gruel or milk or any other nourishing liquid may be enjoyed.

The eating of food or the drinking of nourishing drinks136 between the meals not only interferes with digestion and disturbs the mother, but it also upsets the baby; and it is often the reason why the appetite of the mother is so deranged at the meal time, her spirits depressed, and her milk diminished. Plenty of good nourishing food, taken three times a day with an abundance of water drinking between the meals, together with a free happy frame of mind occasioned by the recreation before mentioned, usually produces good milk and plenty of it. A nap between meals will probably produce more milk than eating between meals.

All foods that cause indigestion in the mother or babe should be avoided.

Some mothers continue to eat tomatoes, peaches, sour salads, acid fruits, and it appears in no way to interfere with baby's comfort; but they are the exception rather than the rule. Usually tomatoes, acid salad dressings, and mixed desserts must be avoided. Each mother is a law unto herself. Certainly none of our readers will selfishly continue any food she feels will make her baby cry. All acid fruits, rich desserts, certain coarse vegetables, concoctions of all descriptions such as rarebit, condiments, highly seasoned sauce, etc., should be avoided.

Acid fruitades, such as lemonade, limeade and orangeade, can be taken by a small per cent of nursing mothers; and, since fruit acids are neutralized and alkalized in the process of digestion and assimilation, and since they are the very fruit-drinks we prescribe for patients suffering with an increased acidity, it would appear that they were in every way wholesome for the mother—if they in no way interfere with the baby. Practically, they do as a rule disturb the baby's digestion and should be avoided by those mothers who have found this to be the case.

During the first week of lactation the milk tubes of the breasts very often become blocked and the breasts become engored with milk, this condition being known as "caked137 breasts." At this particular time of the baby's life, he takes little more than an ounce of milk at a feed; so, beside the incoming engorgement of milk, an additional burden is thrown upon the milk tubes of the breasts in that they are not entirely emptied each nursing time by the young infant. When the breasts threaten to "cake," immediate steps must be taken to relieve the condition—to empty the breasts—and this is usually accomplished in the following manner: with hands well lubricated with sweet oil or olive oil the nurse begins gentle manipulation of the breasts toward the nipple in circular strokes, with the result that the milk soon begins to ooze out. This massage should be continued until relief is obtained; or the breast pump may be applied. Hard nodules should not be allowed to form or to remain in the breasts. Hot compresses (wrung from boiling water by means of a "potato ricer") may be applied to the caked breast which is protected from the immediate heat by one thickness of a dry blanket flannel. These hot compresses should be removed every three minutes until three have been applied, then an ice water compress is quickly applied, to be followed by more hot ones and then a cold; and so on, until as many as four sets each have been administered.

Gentle massage may again be administered and it will be found that they empty now with greater ease because of the preceding heat. After the breasts have been emptied, and thoroughly washed with soap suds and carefully dried, they should be thickly covered with cotton batting and firmly compressed against the chest wall by a snug-fitted breast binder, which serves the double purpose of relieving pain by not allowing the breasts to sag downward, at the same time preventing an over-abundant secretion of milk by diminishing the blood supply to the glands of the breast. In case the persistent manipulation of the breast and the use of the breast pump do not relieve the condition, and if the repeated effort day after day seems to avail nothing; then, as a rule, we must look for a breast abscess to follow if the breasts are not immediately "dried up." In all such cases of engorgement, the attending physician should be notified at once.138

The nipple must be kept dry between nursings, which should be limited to twenty minutes. Regularity should be maintained. The nipples should never be touched or handled by hands that have not been scrubbed with soap and a nail brush. During the early nursing days they are wet much of the time and are subject to much stress and strain in the "pulling effort" of the baby, as a result of which they become very tender, chapped, cracked, and often bleed. Allowing the baby to go to sleep with the nipple in his mouth also exposes the nipple to unnecessary moisture which increases the possibility of painful cracking. The pain occasioned by nursing at this time is truly indescribable, and is most often the cause of absolute refusal on the part of the mother to nurse her babe—with the result that it is put on the bottle. Again, the fear and dread of being hurt so often tends to diminish the flow of milk. It is entirely possible so to prepare the nipple for this exposure, during the last months of pregnancy, that all this discomfort and pain may be entirely avoided (See chapter, "The Hygiene of Pregnancy").

Before the mother is put to rest after the birth of the baby the breasts are prepared as follows: A thorough cleansing with soap and water is followed by a careful disinfection with alcohol which leaves the nipple perfectly dry. A soft sterile pad is then applied and held in place by a breast binder. Before and after each nursing the nipple and surrounding area is swabbed with boracic acid (saturated solution) and carefully dried by applying a clean, dry, sterile pad.

Painful cracks and fissures are nearly always due to lack of the care described above, and are almost wholly preventable. When the first crack appears and nursing becomes painful, the baby's mouth should not touch the nipple again until healing has taken place. A thorough cleansing with boiled water should be made and then the sterile nipple shield should be applied through which baby will get abundant satisfaction, while the mother is spared the pain, and the nipple has an opportunity to get well.139

In the case of sore and cracked nipples, thorough cleansing with boiled water and boracic acid solution follows each nursing seance; and, after careful drying, balsam peru—equal parts with glycerine—may be applied with a tiny piece of sterile gauze or cotton; a sterile cotton pad is then applied to each breast which is held in place by a breast binder.

The nipple shield, when employed, is boiled after each nursing and washed in boracic acid solution just before each nursing. The strictest cleanliness must be observed, and then we hope to bring relief and comfort to the mother, and effect the saving of nature's best food for the baby.

Mother's milk—that wonderfully adaptable, ever-changing food, so accurately and scientifically suited to the hourly and daily needs of the growing child—is composed of five different parts, totally unlike in every particular, and each part exactly suited to the needs which it supplies. The cream of the milk, as well as the lactose or sugar, builds up the fatty tissues of the body as well as helps provide the energy for crying, nursing, kicking, etc. The proteins (the curd of the milk) are exceedingly important; they are especially devoted to building up the cells and tissues of the body of the growing child. The salts form a very small part of the baby's food, but an important one, for they are needed chiefly for the bones and the blood. The fats, sugars, proteins, and salts, taken together, form the solids of mother's milk, and are held in solution in the proportion of thirteen parts of solids to eighty-seven parts of water; which so holds these solids in solution that the baby can digest and assimilate these necessary food elements. The mother's milk increases in strength day by day and month by month as the baby grows, and is the only perfect infant food on earth.

Soon after the birth of the baby the wearied mother seeks rest—she usually falls into a quiet, restful slumber; the baby likewise goes to sleep and usually does not awaken for several hours. After six or eight hours the child is put to the breast140 and he begins to nurse at once, without any special help. This first nursing should be discontinued after four or five minutes, while he is put to the other breast for the same length of time.

If there is difficulty in sucking, a bit of milk may be made to ooze out on the clean nipple, while the baby's lips are pressed to it, after which the nurse gently presses and rubs the breasts toward the nipple. After the nursing, the nipples should be elongated, if necessary, by rubbing, shaping, or breast pump.

The baby gets but little nourishment during the first two days, but that which he does get is essential; for the colostrum—the first milk—is highly laxative in nature and serves the important purpose of cleaning out the intestinal tract of that first tarry, fecal residue, the meconium. This early sucking of the child accomplishes another purpose besides the obtaining of this important laxative—it also reflexly increases the contractibility of the muscles of the womb, which is an exceedingly important service just at this time.

Should the mother or caretaker feel that baby will starve before the milk comes, or that it is necessary to provide "sweetened water;" let us assure them that nothing is needed except what nature provides. Nature makes the babe intensely hungry during these first two days, so that he will suck well, and if he is fed sweetened water, gruel, or anything else, he will not suck forcefully; and so nature's plan for securing extra or increased uterine contractions and the stimulation of the breast glands will be seriously interfered with.

As soon as the new born babe is washed and dressed he is given two teaspoons of warmed, boiled water; and this practice is continued every two hours during the day, until as much as two to four ounces of unsweetened water is taken by the tiny babe during the twenty-four hours. Inanition fever—the fever that sometimes follows a failure to give water to the new born infant—is thus avoided. The bottle from which the water is given should be scalded out each time, the nipple boiled, and just before the "water nursing" the nipple should be swabbed with boracic acid solution.141

From earliest infancy the baby should be nursed by the "clock," and not by the "squawk." Until he reaches his sixth-month birthday, he is fed with unerring regularity every three hours during the day. Asleep or awake he is put to the breast, while during the night he is allowed to sleep as long over the three-hour period as he will. Babies are usually nursed at night: during the early weeks, at nine o'clock in the evening, at midnight, and at six o'clock in the morning. After four months all nursing after ten p. m. may be omitted.

The baby is ordinarily allowed to remain at the breast for about twenty minutes. He may often be satisfied with one breast if the milk is plentiful; if not, he is given both breasts; and may we add the following injunction? insist that nothing shall go into your baby's mouth but your own breast milk and warm or cool-boiled water; no sugar, whiskey, paregoric, or soothing syrup should be given, no matter how he cries. Never give a baby food merely to pacify him or to stop his crying; it will damage him in the end. More than likely he is thirsty, and milk to him is what bread and meat are to you, neither of which you want when you are thirsty.

A perfectly comfortable position during nursing for both mother and babe is necessary for satisfactory results. During the lying-in period the mother should rest well over on her side with her arm up and her hand under her head, the other hand supports the breast and assists in keeping the nipple in the baby's mouth, as well as preventing the breast from in any way interfering with baby's breathing. A rolled pillow is placed at the mother's back for support.

After the mother leaves the bed, she will find a low chair most convenient when nursing the baby, and if an ordinary chair be used, she will find that a footstool adds greatly to her comfort. Once during the forenoon and once during the afternoon the nursing mother will find it a wonderful source of rest and relaxation if she removes all tight clothing, dons a comfortable wrapper, and lies down on the bed to nurse her babe;142 and as the babe naps after the feed, she likewise should doze and allow mother nature to restore, refresh, and fit her for restful and happy motherhood.

Worry, grief, fatigue, household cares, loss of sleep, social debauches, emotional sprawls—all debilitate the mother, and usually decrease the flow of milk.

Overheating, irritability, and sudden anger, almost invariably tend to raise the blood-pressure, which means the entry into the blood stream of an increased amount of epinephrin, which disturbs the baby greatly, often throwing him into convulsions or other sudden, acute illness.

Menstruation often interferes with the nursing mother, the milk becoming weaker at this time; however, if the infant continues to gain and the mother feels comparatively well, no attention need be paid to this fact.

Another pregnancy demands a drying up of the breast at once, as the tax is too great on the mother.

The stools of the breast-fed baby do not require as much attention as those of the bottle-fed child. In cases of constipation, after four months, from one teaspoon up to one-half cup of unsweetened prune juice may be given one hour before the afternoon feed.

In instances of colic with signs of fermentation in the stool, the mother may take several doses (under her physician's orders) of common baking soda; or, if she is constipated, calcined magnesia will usually right the condition. Nature's mother milk is so beautifully adapted to the baby's needs that it is the rule for baby to have perfectly normal stools.

A happy baby is a satisfied baby. He lies quietly in a sleepy, relaxed condition if he has enough to eat, provided he is otherwise comfortable and dry. He awakens at the end of two hours and perhaps cries; but plain, unsweetened, warm, boiled water143 quenches his thirst, and he lies content for another hour, when he is regularly nursed. He gains on an average of about one ounce a day.

Constant discomfort, vomiting, fretful crying, passing and belching of gas, colicky pain, disturbed sleep, greenish stools with mucus, are among the more prominent earmarks of unsuccessful nursing. These symptoms appearing in a pale, flabby, listless, indifferent or cross baby, with steady loss of weight continued over a period of three or four weeks, point to "nursing trouble;" which, if not corrected, will lead to that much dreaded infantile condition—malnutrition.

Bolting of food or overeating results in vomiting and gas, and thus interferes with normal nursing, as also may tongue-tie. A condition in the mouth, medically known as "stomatitis," and commonly known as "thrush," often gives rise to a fretful cry when nursing is attempted. In the first place, the baby cannot "hold on" to the nipple; while, in the second place, it hurts his inflamed mouth when he makes an effort to nurse.

Long continued nursing covering three-fourths of an hour or more, seizing of the nipple for a moment and then discarding it, apparently in utter disgust, are the earmarks of very scanty milk supply and should receive immediate attention.

Believing that many more mothers than do so should nurse their babies, we have carefully tabulated a number of aids to the milk supply, which we hope will be most earnestly tried before the baby is taken from the breast—for so many, many more bottle-fed babies die during the first year than the breast fed. The dangers of infection, the worry of the food preparation, the uncertainty of results, all call for a most untiring effort on the part of every doctor, nurse, and mother, in their endeavors to secure maternal nursing. The following is a summary of "aids to the milk supply:"

1. Regular periodical sucking of the breasts from the day of baby's birth.144

2. Systematic applications of alternate hot and cold compresses, followed by massage to the breasts.

3. Three good nourishing meals each day, eaten with merriment and gladness of heart.

4. A glass of "cream gruel," milk, cocoa, or eggnog at the close of each meal, with a glass just before retiring.

5. Three outings each day in the open air.

6. Nurse the baby regularly and then turn its care over to another, you seek the out of doors and engage in walking, rowing, riding and other pleasurable exercise.

7. Take a daily nap.

8. You can bank on fretting and stewing over the hot cook stove to decrease your milk. It seldom fails to spoil it.

9. Regular body bathing, with cold friction rubs to the skin.

10. A happy, carefree mental state. Nothing dries up milk so rapidly as worry, grief, or nagging.

11. The administration, preferably in the early days, of desiccated bovine placenta; although it may be given at any time during the period of nursing.

As much as we desire maternal nursing for the babe, there do occur instances and conditions which demand a change to artificial feeding, such as the following:

When a maternal anesthetic is to be administered, or in case of inflammation of the breast or during a very short illness not covering more than two or three days, then the breast pump may be used regularly every three hours to both breasts; the145 baby may be artificially fed and then returned to the breast after the effects of the anesthetic has worn off or the temperature has been normal for twenty-four hours.

There may also appear definite indications in certain children which make it imperative that the nursing child should early be weaned. These manifestations of disordered nutrition and failing health admonish us to put the baby on properly modified milk, or to transfer it to a wet nurse.

These conditions are:

1. Progressive loss in weight.

2. A bad diarrhea of long standing; one which does not yield to the usual remedies, at least not as long as the baby continues to feed from the breast. These diarrheas are especially serious when accompanied by a steady loss in weight.

3. Excessive vomiting accompanied by progressive loss in weight.

Because of the rarity of good, healthy wet nurses, it is always better to attempt to feed the baby with scientifically modified milk (not proprietary foods), good, clean, cow's milk properly modified to suit the weight and age of the child. We put weight first, for we prepare food for so many pounds of baby rather than for the number of months old he is.

If modified food has failed and the best specialist within your reach orders a wet nurse; she must have the following qualifications:

If an unmarried mother of her first child is engaged as a wet nurse, she should not be "stuffed" or allowed to overeat, which is commonly the result of moving her from her lower life into more comfortable surroundings, or given ale or beer to increase her milk. She should continue her normal eating, take light exercise, which does not mean the scrubbing of146 floors or doing the family washing, and live under the same hygienic regime outlined for the nursing mother. Should she be the mother of the second or third illegitimate child, then she is quite likely to be mentally deficient and she should not be engaged. Her own babe will have to be fed artificially as very few mothers can endure the strain of two suckling children.

The baby's own mother should keep general supervision and not turn her babe entirely over to the care of the wet nurse. Remember always that no one in the wide world will ever take the same mother interest in your offspring that can spring from your own mother heart.

In taking up the subject of the bottle-fed baby, we must repeat that the only perfect baby food on earth is the milk that comes from the breast of a healthy mother.

But sudden illness, accident, chronic maladies, or possibly the death of the mother, often throw the helpless babes out into a world of many sorts and kinds of artificial foods—foods that are prepared by modifying cow's, ass', or goat's milk; foods arranged by the addition to the milk of various specially prepared cereals, albumens or malted preparations, otherwise known as "proprietary foods." We shall endeavor, then, in this chapter and in that on "the feeding problem," to lay down certain general suggestions to both the nurse and the mother, which may assist them in their effort to select the food which will more nearly simulate nature's wondrous mother-food, and which will, at the same time, be best suited to some one particular baby.

The normal baby, from birth to six months, should receive properly prepared nourishment every three hours, beginning the day usually at six a. m., the last feeding being at nine p. m. During the early weeks an additional bottle is given at midnight, but this is usually discarded at four months, at which time the last feeding should be given at about ten instead of at nine at night.

Should the baby continue to awaken during the night before six in the morning, unless he is under weight, a bottle of warm, boiled, unsweetened water should be given.148

The quantity of food to be given is always determined by the size of the baby's stomach, which, of course, depends somewhat upon the age of the child; for instance, the stomach of the average baby one week old holds about one ounce, while at the age of three months the stomach holds five ounces; so it would not only be folly to give two ounces at one week and seven ounces at three months, but it would also be very detrimental to the babe, causing severe symptoms due to the overloading of the stomach.

Careful study of the size of the stomach at different ages in infancy, together with the quantity of milk drawn from the breast by a nursing baby, has led to the following conclusions regarding the capacity of the baby's stomach:

It is highly important that the day's feedings be kept in a cold place, free from the odors of other foods as well as free from dust, flies, and filth. In order that this may be accomplished, the well-protected bottles, each containing its baby-meal, are placed in a covered pail containing ice and water. This covered receptacle is now put in an ice box; and, in order that our most economical reader—one who may feel that she cannot afford to keep up the daily expense of the family refrigerator—may herself prepare a simple home refrigerator, the following directions are given (Fig. 9).

Procure a wooden box about eighteen inches square and sixteen or eighteen inches deep and put four inches of sawdust into the bottom; now fill in the space between a ten-quart pail, which is set in the middle of the box with more sawdust. A cover for the box is now lined with two or three inches of newspaper, well tacked on, and is fastened to the box by hinges. We are now ready for the inside pail of ice, into which is carefully placed the well-protected bottles of milk, all of which is then set into the ten-quart pail in the box. Five cents worth of ice each day will keep baby's food cool, clean, and provide protection against the undue growth of germs.149

At each feeding hour, one of baby's bottled meals is taken from the ice box and carefully dipped in and out of a deep cup of hot water. A very convenient receptacle is a deep, quart aluminum cup, which may be readily carried about. The hot water in the cup should amply cover the milk in the bottle (Fig. 10).

To test the warmth allow a few drops to fall on the inner side of the arm, where it should feel quite warm, never hot. A baby's clean woolen stocking is now drawn over the bottle, which keeps it warm during the feeding. No matter how great the danger of offending a fond grandparent or a much adored friend never allow anyone to put the nipple in her mouth to make the test for warmth of baby's food.

There are many contrivances, both electrical and alcoholic, for heating baby's bottle, many of which are both convenient and inexpensive.

And now we realize that we are about to advise against the time-honored injunction which has been handed down from "Grandma This" and "Mother That" to all young mothers who have lived in their neighborhoods: "My dear young mother, if you can't nurse your precious infant, you can at least 'mother it' at the nursing time by holding it in your arms and gently rocking it to and fro as you hold the bottle to its lips." This so-called "mothering" has resulted in regurgitation, belching, and numerous other troubles, as well as the formation of the "rocking habit."

A young mother came running into my office one day saying: "Doctor, it won't work, the food's all wrong; my baby is not151 going to live, for he throws up his food nearly all the time." We arranged to be present when the next feeding time came and watched the proceedings. A dear old friend had told her "she must 'mother' her baby at the nursing time," and so she had held the child in a semi-upright position as she endeavored to hold the bottle as near her own breast as was possible. The hole in the nipple was a bit large, which occasioned the subsequent bolting of the food, and then to continue the "mothering" she swayed him to and fro, all of which was interrupted suddenly by the vomiting of a deluge of milk.

I drew the shade in an adjoining room, opened the windows, and into a comfortable carriage-bed I placed the baby on his side. Seating myself beside him I held the warm, bottled meal as he nursed. Several times I took it from his mouth, or so tipped it that "bolting" was impossible. Gradually, carefully, and slowly, I took the empty bottle away from the sleepy babe, and as I closed the door the mother said in anxious amazement: "He won't forget I'm his mother if I don't hold152 him while he nurses?" You smile as I smiled at this girl-mother's thought; but, nevertheless there are many like her—anxious, well-meaning, but ignorant.

The infant stomach is little more than a tube, easily emptied if the baby's position is not carefully guarded after nursing. No bouncing, jolting, patting, rocking, or throwing should take place either just before, during, or immediately after meals.

From twelve to twenty minutes is long enough time to spend at a bottle meal. The nipple hole may have to be made larger, or a new nipple with a smaller hole may have to be purchased. When new, you should be able to just see a glimmer of light through the hole, and if the infant is too weak to nurse hard, or the hole too small, it may be made larger by a heated hatpin run from the inside of the nipple out; great care must be taken, else you will do it too well. If the nipple hole is too large, bolting is the sure result; while too small a hole results in crying and anger on the part of the hungry child, because he has to work too hard to get his meal.

We have seen some mothers, in their anxiety to prevent the sucking in of air from the emptied bottle, rush in and jerk the nipple from the going-to-sleep babe so forcibly that all thoughts of sleep vanished and a crying spell was initiated. The tactful mother is the quiet one who slowly, quietly, draws the empty bottle with its "much loved nipple" from the lips. If you observe that the babe is going to sleep, with an occasional superficial draw at the nipple, wait a moment; he will drop it himself, and you can pick it up as you quietly leave the room. In all instances, whether it be indoors or out of doors, arrange the babe in a comfortable sleeping position, remembering that nursing is warm exercise and the babe gets uncomfortably sweaty if overbundled, especially about the head and neck. No one should unnecessarily touch the babe immediately after feeding; even his diaper may be changed without awakening him while he is thus lying quietly in his bed.153

The three-hour interval is reckoned from the beginning of the meal, and not from its close. More than two hours is spent in the stomach digestion, and any food or sweetened water which may enter between meals only tends to cause indigestion and other disturbances. And that this important organ may have a bit of rest, we fix the interval at three hours, which in our experience and that of many other physicians, has yielded good results. As a rule we have no regurgitation and no sour babies on the three-hour schedule. Sick babies, very weak babies, and their feeding time, will be discussed in a later chapter.

At six months, and often as early as four, in cases of constipation, unsweetened, well-strained prune juice may be given, beginning with one-half teaspoon one hour before the afternoon feed and increasing it daily until two tablespoons are taken. At six months, both orange juice and vegetable broths are given, whose vegetable salts add a very important food element to the baby's diet—an element which our grandmothers thought could only be obtained through the time-honored "bacon rind" of by-gone days.

Orange juice is also unsweetened and well strained, and is administered in increasing amounts, beginning with one-half teaspoon one hour before the afternoon feeding, until the juice of a whole orange is greedily enjoyed by the time of the first birthday. The vegetable juices are obtained from cut-up spinach, carrots, tomatoes, and potatoes, strained, with a flavor of salt and onion—really a bouillon—and is given just before the bottle at the six p. m. feeding. They are also begun in teaspoon amounts.

Baby travel should be reduced to a sheer necessity; never should the babe be subjected to the exposure of disease germs, the change of food, the possibilities of draughts and chilling, for154 merely a pleasure trip—the risks are too great and the possibilities of future trouble too far reaching.

If you are in touch with the milk laboratory of a large city, you will find that they make a specialty of preparing feedings which are good for a number of days for the traveling baby, and we strongly advise that their preparations be accepted; but in the event of not being in touch with such a laboratory we suggest the making of a carrying ice-box covered with wicker, which must be kept replenished with ice. Food kept in such a device may be kept fresh for twenty-four to forty-eight hours. Plans other than the laboratory preparations or the ice-box are risky, and should not be depended upon.

Many of our railway dining cars now pick up fresh, certified milk at stations along the line for use on their tables, and where such is the case fresh preparations of milk may be made on a trans-continental trip by the aid of an alcohol stove. Malted milk may also be used, provided you have accustomed the baby to its use a week before leaving home, by the gradual substitution of a fourth to a half ounce each day in the daily food; all of which, of course, should be done under your physician's direction.

If possible, leave baby at home in his familiar, comfortable environment in the care of a trained nurse and a trusted relative, and under the supervision of the baby's own physician. He is much better off, much more contented, and we are all aware of the fact that contentment and familiarity of sights and people promote good appetite, good digestion, and happiness—the very essentials of success in baby feeding. We speak touchingly and sympathetically to the mother who must leave her babe; and likewise we wish to cheer her as we remind her that by wireless messages and night letters it is possible to keep in touch with loved ones though a thousand miles away.

The sanitation and modification of cow's milk, as well as stools, etc., are taken up in later chapters.

1. Never play with a baby during or right after a meal.

2. Lay the baby on his side when nursing the bottle.155

3. Three full hours should intervene between feedings.

4. Don't give the food too hot—it should just be warm.

5. Make the test for warmth on the inner side of your arm.

6. Give a drink of water between each meal if awake.

7. Never save the left-overs for baby.

8. If possible, give three feedings each day in the cool air, with baby comfortably warm.

9. Do not jump, bounce, pat, or rock baby during or after meals.

10. Never coax baby to take more than he wants, or needs.

11. No solid foods are given the first year.

12. Orange juice may be given at six months; while, after four months, unsweetened prune juice is better than medicine for the bowels.

Cow's milk, like mother's milk, is made up of solids and water. In a previous chapter we learned that in one-hundred parts of mother's milk, eighty-seven parts were water and thirteen parts were solid. These thirteen parts of solids consist of sugar, proteins, and salts; this is likewise the case with cow's milk, except that in the case of the cow's milk, the sugar is decreased while the proteins are increased as will be noted by the accompanying comparative analysis:

Mother's milk is absolutely sterile, that is, free from the presence of germs; on the other hand, cow's milk is anything but sterile—the moment it leaves the udder it begins to accumulate numerous bacteria, all of which multiply very rapidly.157 Cow's milk is generally twenty-four to forty-eight hours old before it can possibly reach the baby. It is just as important to keep in mind these facts of milk contamination—dirt, filth, flies, and bacteria—as it is to plan for the modification of cow's milk for the purpose of making it more nearly resemble mother's milk. While mother's milk has about the same percentage of fat as cow's milk, it is almost twice as rich in sugar, and has only one-fourth to one-third as much protein. This protein is vastly different from that found in cow's milk, which you recall has a tough curd, as seen in cottage cheese. While mother's milk contains a small amount of casein similar to that found in the cheese of the cow's milk, the principal protein constituent is of another kind (lactalbumin), and is much more easy of digestion than the casein of cow's milk.

This is a most important point to remember, because the baby's stomach is not at first adapted to the digestion of the heavier and tougher protein curds of cow's milk. It requires time to accustom the infant stomach to perform this heavier work of digestion. There are a number of factors which must be borne in mind in the modification of milk, whether it be cow's milk, or goat's milk (for many European physicians use goat's milk entirely in the artificial feeding of infants): namely, the cleanliness of the milk, the acidity of milk, the difference in the curd, the percentage of sugar, and the presence of bacteria.

In the modification of cow's milk, sugar must be added to make up for the sugar which is decreased when the water was added to reduce the protein. There are several sorts of sugar used in the modification of milk. These sugars are not added to sweeten the milk alone, but to furnish a very important element needed for the growth of the baby. Sugar is the one element which the infant requires in the largest amount.

Milk sugar is probably most universally used in the modification of milk, but a good grade of milk sugar is somewhat expensive, costing from thirty to sixty cents a pound, and this places it beyond the reach of many mothers. It is added to158 the food mixtures in the proportion of one ounce to every twenty ounces of food. Cane sugar (table sugar) may also be used, but it must be clean and of good quality. It is used in rather less quantity than that of milk sugar, usually from one-half to one-third of an ounce by measure to each twenty ounces of food. Dextri-maltose (malt sugar) is very easy of digestion and may be used in the modification of milk. Maltose seems to help the children to gain more rapidly in weight than when only milk or cane sugar is used. It is also exceedingly useful in constipation, as its action is more laxative than any of the other sugars; but it should not be given to children who vomit habitually or have loose stools.

Like mother's milk, the cow's milk is neutral as it comes from the udder; but, on standing, it quickly changes, soon becoming slightly acid, as shown by testing with blue litmus paper. In fact, what is known as ordinarily fresh milk, if subjected to the litmus paper test, always gives an acid reaction. This acidity is neutralized by adding lime water to the formula in the proportion of one ounce to each twenty-ounce mixture. Ordinary baking soda is sometimes prescribed by physicians in place of the lime water. In the event of obstinate constipation, milk of magnesia is sometimes added to the day's feedings.

There may be procured in any large city an instrument called the cream gauge, which registers approximately (not accurately) the richness of milk. Some milk, even though rich, parts with its cream very slowly; while some poor milk allows nearly all the cream quickly to rise to the surface. We know of no way for the mother to determine the amount of cream (without the cream gauge) except by the color and richness of the milk. In cities it is very convenient to send a specimen of the milk to the laboratories to be examined by experts, who will gladly render a report to both physician and mother.

The lactometer is a little instrument used to estimate the specific gravity of milk. An ordinary urinometer such as used 159by physicians in estimating the specific gravity of urine may also be used. The specific gravity of cow's milk should not register below 1028 or above 1033.

Milk from a single cow is not to be desired for baby's food because of its liability to vary from day to day, not to mention the danger of the cow's becoming sick. Authorities have agreed that herd milk of Holstein or ordinary grade cows is best for infant feeding. This mixed-herd milk contains just about the proper percentage of fat; whereas, if Jersey milk must be used, some of the cream should be taken away. Our milk should come from healthy cows which have been tested for tuberculosis at least every three months.

Annatto is sometimes added to milk to increase its richness of color. To test for annatto proceed as follows: To a couple of tablespoons of milk add a pinch of ordinary baking soda. Insert one-half of a strip of filter paper in the milk and allow it to remain over night. Annatto will give a distinct orange tint to the paper. The commonly used milk preservatives are boracic acid, salicylic acid, and formaldehyde, any of which may be readily detected by your health officials.

In close proximity to most large cities there is usually to be found one or more sanitary dairies. It is a joy indeed to visit a farm of this kind with its airy stables and concrete floors, which are washed with water coming from a hose. The drainage is perfect—all filth is immediately carried off (Fig. 11). The cows are known to be free from tuberculosis, actinomycosis (lumpy jaw), and foot and mouth disease. The milkmen on this farm wear washable clothes at the milking time, and their hands are painstakingly cleansed just before the milking hour. Previous to the milking the cattle have been curried outside the milking room and their udders have received a careful washing. The milkman grasps the teat with clean hands, while the milk is allowed to flow through several thicknesses of sterilized gauze into the sanitary milking pail. This milk is160 at once poured into sterile bottles, is quickly cooled and shipped in ice to the substations where the delivery wagon is waiting. In the ideal delivery wagon there are shallow vats of ice in which the bottles are placed, thus permitting the milk to reach the baby's home having all the while been kept at a temperature just above the freezing point.

And why all this trouble? Why all this worry over temperature and cleanliness? Babies were not so cared for in the days of our grandmothers. The old-fashioned way of milking the cows with dirty clothes and soiled hands, while cattle were more or less covered with manure, with their tails switching millions of manure germs into the milking pail, produced a milk laden not only with manure germs—the one great cause of infantile diarrhea—but also swarming with numerous other mischief making microbes. Even tuberculosis, that much dreaded disease germ of early infancy, may come from the dairy hands as well as from infected cows.

There used to be many dairymen like the old farmer who, when interrogated by the health commissioner concerning the cleanliness of his milk, laughed as he reached down into the bottom of a pail of yellow milk and grabbing up a handful of manure and straw, said: "That's what makes the youngsters grow." But it does not make them grow; it often causes them to die, and even if they do live, they live in spite of such contaminated food, for the germ which is always found in the colon of the cow (coli communis), probably kills more babies every year than any other single thing.

It is possible to reduce the growth of these germs by keeping the milk at a very low temperature from the time it leaves the cow until the moment it gets to the home refrigerator. Those which survive this process of refrigeration may be quickly rendered harmless by pasteurizing or sterilizing at the time of preparing baby's food.

In the absence of the modern sanitary dairy, we would suggest that the milk supply be improved by giving attention to the following:

The cattle should be tested for tuberculosis every three months. The walls of the cowhouse should be whitewashed161 three times a year. The manure should be stored outside the barn. The floor of the cowhouse should be sprinkled and swept each day. The cattle should be kept clean—curried each day, and rubbed off with a damp cloth before milking. The udders should be washed before each milking. The milker can wear a clean white gown or linen duster which should be washed every two days, while his hands should be washed just before the milking. The milking pail should be of the covered sanitary order. The barn should be screened.

Immediately after leaving the cow, the milk should be cooled to at least 45 F. It should at once be put into bottles that have been previously sterilized and then be tightly covered, and should be kept in ice water until ready for consumption. No matter how carefully the milk is handled, it is infected with many bacteria, but if it is quickly cooled, the increase of the bacteria is greatly retarded. Under no circumstances buy milk from a grocery store out of a large can. Go to your health officer and encourage him in his campaign for sanitary dairies and certified milk.

Such milk as we have described under the head of sanitary dairies, when it has been tested by the board of health and has received the approval of the medical profession, is known as "certified milk;" and, although the price is usually fifteen to twenty cents a quart, when compared with the cost of baby's illness it will prove to be cheaper than the dirty milk which sickens and kills the little folks.

There is no doubt that the increased use of "certified milk" has been a great factor in the reduction of deaths from infant diarrhea in recent years.

When certified milk cannot be had, it is absolutely dangerous to give raw, unboiled, or unpasteurized milk to the baby, particularly in warm weather; for the countless millions of manure germs found in each teaspoon of ordinary milk not only disturbs the baby's digestion, but actually makes him sick, causing162 colic, diarrhea, and cholera infantum. The only way this milk can be rendered safe is by cooking it—actually killing the bacteria. This process of boiling, however, does not make good milk out of bad milk nor clean milk out of that which is dirty, it simply renders the milk less dangerous.

There are two methods of killing bacteria—sterilization and pasteurization. By sterilization is meant the process of rendering the milk germ free by heating, by boiling. Many of the germs found in milk are comparatively harmless, merely causing the souring of milk; but other microbes are occasionally present which cause serious diseases, such as measles, typhoid and scarlet fever, diphtheria, tuberculosis, and diarrhea. It is always necessary to heat the milk before using in warm weather, and during the winter it is also important when infectious or contagious diseases are prevalent.

Milk should be sterilized when intended for use on a long journey, and may be eaten as late as two or three days afterward.

To sterilize milk, place it in a well-protected kettle and allow to boil for one hour and then rapidly cool. This process renders it more constipating, and for some children many of its nutritive properties seem to be destroyed, as scurvy is often the result of its prolonged use. When a child must subsist upon boiled milk for a long period, he should be given the juice of an orange each day. Children are not usually strong and normal when fed upon milk of this character for indefinite periods. All living bacteria (except the spores or eggs) may be destroyed by boiling milk for one or two minutes.

When baby is to use the milk within twenty-four hours, "pasteurization" is better than boiling as a method of destroying microbes.

There are many pasteurizers on the market which may be depended upon, among which are the Walker-Gordon Pasteurizer, and Freeman's Pasteurizer; but in the absence of either of these pasteurization may be successfully accomplished by the following method:163

On the bottom of a large kettle filled with cold water, place an ordinary flatiron stand upon which is put a folded towel. On this place the bottle of milk as it comes from the dairyman, with the cap of the bottle loosened. The cold water in the kettle should come up to within an inch of the top of the bottle of milk. Heat this water quickly up to just the boiling point—until you see the bubbles beginning to rise to the top. The gas is then turned down or the kettle is placed on the back of the range and held at this near-boiling point for thirty minutes, after which it is taken to the sink and cold water is turned into the water in the kettle, until the bottle of milk is thoroughly cooled. It is now ready to be made up into the modified food for baby.

Never let pasteurized milk stand in the room, nor put it near the ice when warm. It must be cooled rapidly, as described above; that is, within fifteen or twenty minutes.

The "spores" of the milk are not killed by pasteurization and they hatch out rapidly unless the milk is kept very cold, and, as already stated, it should be used within twenty-four hours after pasteurization.

The certified milk or the ordinary milk that has been delivered to your home and is to be used without pasteurization or sterilization, should receive the following care:

1. It should be placed at once in a portion of the ice box that is not used to store such foods as radishes, cabbage, meats or any other open dishes of food whose odors would quickly be absorbed by the milk. The milk should never be left standing on the doorsteps in the sun, for many reasons: the sun heats the milk, encourages the growth of bacteria, and a passing cat or dog, whose mouth often contains the germs of scarlet fever, tonsilitis, and diphtheria, should it be hungry, laps the tops of the bottles, particularly in the winter when the cream has frozen and is bulging over the edge.

2. It should never be kept in the warm kitchen, as when visiting her sick baby we discovered one young mother doing. In answer to my question, she explained; "Doctor, we do not164 take ice in the winter time, everything is ice outdoors, so I just set the bottle outside the window bringing it in whenever I need to give the baby some food. I forget to put it out sometimes, but really now, does it matter?" It really matters much, for you see, reader, the milk is first freezing then thawing and it is rendered entirely unfit for the baby.

3. Milk should be kept covered and protected from dust and flies; it should be kept in glass jars which have been sterilized by boiling before being filled, and then placed in the refrigerator. If the milk is sour, or if there is any sediment in the bottle, it is unfit for baby's use.

In a previous chapter it was found from comparing the analysis of mother's milk with that of cow's milk, that they widely differed in the proteins and sugar. The art of so changing cow's milk that it conforms as nearly as is possible to mother's milk is known as "modification." Where protein, sugar, and fat are given in proper amounts, healthy infants get along well; but when either the fats or proteins are given in excess, or when the digestion of the child is deranged, there is often no end of mischief.

There are two groups of milk formulas that are useful. First, those in which the fats and proteins are about the same, known as "whole milk," or "straight" milk mixtures; second, those in which the fats are used in larger proportions than proteins, and known as "top milk"—milk taken from the upper part of the bottle after the cream has risen. And since the larger proportion of babies take the lower fats or "whole milk" formulas, and seem to get along better than the babies who have the "top milk" formulas, we will first take up the consideration of the modification of whole milk.

To begin with, everything that comes in contact with the preparation of baby's food must be absolutely clean. The table on which the articles are placed, and any towel that comes in contact with the articles or the mother's hands, or those of the nurse, must be thoroughly scrubbed.

There is only one way to prepare the utensils that are to be used in making the baby's food, and that is to put them in a large kettle and allow them to boil hard for fifteen minutes166 just before they are to be used. The articles needed are (Fig. 12):

There is but one bottle which can be thoroughly washed and cleaned, and that is the wide-mouthed bottle. It should hold eight ounces and should have the scale in ounces blown in the side (Fig. 10). The nipple for this bottle is a large, round breast from which projects a short, conical nipple, which more nearly resembles the normal breast than do the old-fashioned nipples so frequently seen on the small-necked nursing bottles. There is a great advantage in this, in that the baby cannot grasp the nipple full length and thus cause gagging. These bottles and nipples are known as the "Hygeia," and have proven to be a great source of comfort to the baby as well as to the mother or nurse whose duty it is to keep them clean. There are a number of other nursing bottles on the market, which, if they are used, must be thoroughly cleansed with a special bottle brush each day. The neck is small and the nipple is small and great care must be taken in the cleansing of both of them.167

When there is a bottle for each individual feeding in the day, immediately after each nursing both bottle and nipple should 168be rinsed in cold water and left standing, filled with water, until the bottles for one day's feeding have all been used. The nipples should be scrubbed, rinsed, and wiped dry and kept by themselves until their boiling preparation for the following day's feeding.

If the same bottle is to be used for the successive feedings during the day, it should be rinsed, washed with soap and water, and both bottle and nipple placed in cold water and brought quickly to the boiling point and allowed to boil for fifteen minutes. No bottles or nipples must ever be used after a mere rinsing; boiling, preceded by a thorough washing in soap and water, must take place before they are used a second time.

New nipples are often hard and need to be softened, which is readily done by either prolonged boiling or rubbing them in the hands.

All new bottles should be annealed by placing them on the stove in a dishpan of cold water and allowing them to boil for twenty minutes, and then allowing them to remain in the water until they are cold. When bottles are treated in this manner they do not break so readily when being filled with boiling water or hot food.

In a large preserving kettle place all the utensils needed in the preparation of the food—pitcher, spoon, fork, measuring glass, bottles, nipples, cheesecloth for straining, agate cup, wire strainer, in fact everything that is to be used in the preparation of the food. Now fill the kettle with cold water and place over the gas and allow to boil for fifteen minutes. On a well-scrubbed worktable place a clean dish towel, and on this put the utensils and the bottles right side up. The nipples on being taken out of the boiling water will dry of themselves; they should be placed in a glass-covered jar until they are needed for each individual feeding, the nipples not being placed on the bottles as they go to the ice box.

Having been given your formula by your physician, proceed in the following way. Suppose we were preparing the food169 for a normal two-months old baby that weighed ten pounds, with the prescription as follows:

Two level tablespoons of cane sugar are placed in the agate cup and dissolved in a small amount of boiling water. The solution should be perfectly clear, and if it does not clear up put it over the heat for a few moments.

This is now turned into the eight-ounce measuring glass which is then filled with boiling water and emptied into the two-quart pitcher. We need four and one-half more ounces of boiling water to complete the prescription requirement of twelve and one-half ounces.

The bottle of milk, if properly certified, need not be pasteurized; but if it is not, it should have been previously pasteurized while the utensils were boiling according to the suggestions found in the chapter on "milk sanitation." The top of the milk bottle should be thoroughly rinsed and wiped dry, and after a thorough shaking of the milk, the cover is removed with the sterile fork and eleven ounces are measured out by measuring glass and poured into the pitcher. All is now stirred together with an ounce of lime water, which should never look murky, but should be as clear as the clearest water and should always be kept in the ice box when not in use.

The sterile cheesecloth which has been boiled for fifteen minutes is now put over the nose of the pitcher, the contents of which is accurately measured into the seven clean, empty bottles, each containing three and one-half ounces. Over the top of each of the nursing bottles is placed a generous piece of170 waxed paper which is held down by a rubber band. Each meal for the day is now contained in a separate bottle, and all are placed in a covered pail of water containing ice, and put in the ice box.

If the prescription for the baby's food contains gruel, it is prepared in the following manner:

Suppose the baby is eight months old and the prescription called for two level tablespoons of flour and eight ounces of boiled water. The two level tablespoons of flour, whether it be wheat (ordinary bread flour), or barley flour, are put into a cup and stirred up with cold water, just as you would stir up a thickening for gravy; now measure out eight ounces of water and allow it to come to a boil in the inner pan of the double boiler, into which the thin paste is stirred until it comes to a boil. After boiling for twenty minutes, remeasure in the measuring glass and what water has been lost by evaporation must be added to complete accurately the prescription requirement of eight ounces; this is now added to the other ingredients of the prescription.

We now offer a monthly schedule—a table which is the result of our experience in feeding hundreds of babies in various sections of Chicago. It is not a schedule for the sick baby, but it is a carefully tabulated outline for the normal, healthy, average child ranging from one week to one year in age. In offering this table we remind the mother, if the baby is six months old and not doing well on the food it is getting and a change is desired by both mother and physician, that it is far better to begin with the second or third month's prescription and quickly work up to the sixth month's. This change may often be accomplished in two or three days.

In all large cities there are to be found milk laboratories which make it their business to fill prescriptions for the modification of milk under the direction of baby specialists. This milk can be absolutely relied upon. In specialized diet kitchens in many large hospitals, these feeding prescriptions also may be filled.171

ARTIFICIAL FEEDING SCHEDULE

(This table is calculated on the basis of about 45 calories for each pound of baby weight)

Top milk is the upper layer of milk which has been removed after standing a certain number of hours in a milk bottle or any other tall vessel with straight sides. It contains most of the cream and varying amounts of milk. It may be removed by a small cream dipper which holds one ounce, or it may be taken off with a siphon, but it should never be poured off. To obtain seven per cent top milk which is the one most ordinarily used in the preparation of top milk formulas, we take off varying amounts—according to the quality of the milk—which Doctor Holt describes as follows:

Cream is often spoken of as if it were the fat in milk. It is really the part of the milk which contains most of the fat and is obtained by skimming, after the milk has stood usually for twenty-four hours; this is known as "gravity cream." It is also obtained by an apparatus called a separator; this is known as "centrifugal cream," most of the cream now sold in cities being of this kind. The richness of any cream is indicated by the amount of fat it contains.

The usual gravity cream sold has from sixteen to twenty per cent fat. The cream removed from the upper part (one-fifth) of a bottle of milk has about sixteen per cent fat. The usual centrifugal cream has eighteen to twenty per cent fat. The heavy centrifugal cream has thirty-five to forty per cent fat.

The digestibility of cream depends much upon circumstances. Many serious disturbances of digestion are caused by cream.

It is convenient in calculation to make up twenty ounces of food at a time. The first step is to obtain the seven per cent milk, then to take the number of ounces that are called for in the formula desired.173

One should not make the mistake of taking from the top of the bottle only the number of ounces needed in the formula, as this may be quite a different per cent of cream and give quite a different result.

There will be required in addition, one ounce of milk sugar and one ounce of lime water in each twenty ounces. The rest of the food will be made up of boiled water.

These formulas written out would be as follows:

The approximate composition of these formulas expressed in percentages are as follows:

Usually we begin with number one on the second day; number two on the fourth day; number three at seven to ten days; but after that make the increase more slowly. A large infant with a strong digestion will bear a rather rapid increase and may be able to take number five by the time it is three or four weeks old. A child with a feeble digestion must go much174 slower and may not reach number five before it is three or four months old.

Another modification which at times may be ordered by your physician is peptonized milk. Since it is infrequent for the proteins of milk to be the cause of indigestion, peptonized milk has only a limited use, chiefly in cases of acute illness. The milk is peptonized in the following manner:

Place the peptonizing powder (it is procurable in tubes or tablets from the drug store) in a small amount of milk, and after being well dissolved, put into the bottle or pitcher with the plain or modified milk, after which the whole is shaken up together. The bottle is then put into a large pitcher containing water heated to about 110° F. or as warm as would bear the hand comfortably, and left for ten or twenty minutes (if the milk is to be partially peptonized). To completely peptonize the milk, two hours are required. Either of these formulas is only used on the advice of a physician.

In many cases of chronic intestinal indigestion, buttermilk is used in place of the milk. It is prepared as follows: After the cream has been taken from the milk and it has been allowed to come to a boil, it is cooled to just blood heat. A buttermilk tablet, having first been dissolved in a teaspoonful of sterile water, is now stirred into the quart of warmed, skimmed milk and allowed to stand at room temperature for twenty-four hours at which time it should look like a smooth custard. With a sterile whip this is now beaten and is ready for the sugar and175 the boiled water which is added according to the written prescription from the doctor.

Under no circumstances should condensed milk be used as the sole food of the baby for more than one month. Children often gain upon it, but as a rule they have little resistance, and they are very prone to develop rickets and oftentimes scurvy; and, as noted elsewhere, orange juice should always be administered at least once during the twenty-four hours as long as condensed milk is used.

Of all the brands of condensed milk, those only should be selected which contain little or no cane sugar. Perhaps the "Peerless Brand" of evaporated milk is the most reliable and in the preparation of food from this evaporated milk the same amount of sugar, etc., should be added as we do in the preparation of "whole milk" or "top milk."

We do not in any way advise the use of condensed milk. Fresh milk should always be used where it is obtainable, but in traveling it sometimes has to be used. Holt says, "It should be diluted twelve times for an infant under one month and six to ten times for those who are older."

Malted milk is a preparation suitable in some cases where fresh cow's milk is not obtainable. Even better than condensed milk, this food will be found serviceable in traveling, or in instances where only very bad cow's milk is within reach.

Most patent foods are made up of starches and various kinds of sugars, and some of them have dried milk or dried egg albumin added. Many flours under fanciful names are sold on the market today. For instance, one flour with a very fanciful name is simply the old fashioned "flour ball" that our great, great grandmothers made; and, by the way, perhaps there is no flour for which we are more grateful in the preparation of infant food than the flour ball which is prepared as follows: A pound of flour is tied tightly in a cheesecloth and is put into a kettle of boiling water which continues to boil for five or six176 hours, at the end of which time the cheesecloth is removed and the hard ball, possibly the size of an orange, is placed on a pie pan and allowed slowly to dry out in a low temperatured oven. At the end of two or three hours, the ball, having sufficiently dried, has formed itself into a thick outer peel which is removed, while the heart which is very hard and thoroughly dry, is now grated on a clean grater, and this flour has perhaps helped more specialists to serve more sick babies than any other form of starch known. It is used just as any other flour is used—wet up into a paste, made into a gruel, which is boiled for twenty minutes before it is added to the milk.

Whey is sometimes used in the preparation of sick babies' food and is prepared as follows:

The heavy proteins remain in the curd, and the protein that goes through with the whey is chiefly the lactalbumin.

A friend of ours who presides over a court of domestic relations in a large city, recently told us that he believed much trouble was caused in families—many divorces, occasioned, and many desertions provoked—because improperly fed babies were cross and irritable and so completely occupied the time of the mother, who, herself, knew nothing about mothercraft or the art of infant feeding. Consequently, the home was neglected and unhappy, quarreling abounded and failure, utter failure, resulted. The children were constantly cross, and so much of the mother's time was consumed in caring for these irritable, half-fed babies, that the home was disheveled, the meals never ready, the husband's home-coming was a dreaded occurrence, and he, endeavoring to seek rest and relaxation, usually sought for it in the poolroom or the saloon, with the usual climax which never fails to bring the time-honored results of debauch—despair and desertion.

In the beginning of this book we paid our respects to the present-day educational system which does not provide an adequate compulsory course in which all women could be given at least a working knowledge of home making and the care and feeding of the babies; so that statement need not be repeated in this chapter. But we wish to add, in passing, that ignorance is the basis and the foundation of more unhappy homes, broken promises, panicky divorces, and shattered hopes, as well as of more deaths during the first year of infancy, than any other cause. And in speaking of its relationship to babycraft, we believe that ignorance concerning normal stools, how many times a day the bowels should move; how much a baby's stomach holds; how often he should be fed, etc.—I say it is178 ignorance of these essential details that lies at the bottom of many problems which come up during the first year, particularly the "feeding problem."

In the city of Chicago at the time of this writing, the Infant Welfare Association maintains over twenty separate stations where meetings are held for mothers, where lectures are delivered on the care and feeding of babies. Babies are brought to these stations week in and week out; they are weighed and measured and, if bottle-fed, nurses are sent to the homes to teach the mother how properly to modify the milk in accordance with the physician's orders. The health authorities of our city also maintain several such stations where mothers and babies may have this efficient help. A corps of nurses are employed to carry out the instructions and to follow up the mothers and the babies in their homes, and thus the death rate has been greatly reduced, not only in our city but in all such cities where baby stations have been instituted. In a certain ward in Philadelphia the death rate was reduced forty-four per cent in one year after the baby stations were established.

There are three classes of infants who require weak-milk mixtures to begin with: namely, the baby who has been previously nursed and whose mother's milk has utterly failed; the baby just weaned; and the infant whose power to digest is low. If these children were six months old, and the formula best suited to them is unknown, we must begin with a formula suited to a two- or three-month-old child and quickly work up to the six-month formula, which may often be accomplished within two or three days.

When a baby is getting on well with his food, he should show the following characteristics: He should have a good appetite; should have no vomiting or gas; he should cry but little; and he should sleep quietly and restfully. His bowels179 should move once or twice in twenty-four hours. His stool should be a pasty homogeneous mass. He should possess a clear skin and good color. He should show some gain each week—from four to eight ounces—and he should also show mental development.

As long as a baby appears happy and gains from four to eight ounces a week and seems comfortable and well satisfied, the feeding mixture should not be changed or increased.

In our experience with the artificial feeding of infants, we have come to look upon the practice of gradually changing the food formula as the most important element in successful baby feeding.

We recall one mother in the suburbs who came to us with her baby who had been feeding on a certain proprietary food. She declared that it "just couldn't take cow's milk." She admitted "it was not doing well," and so she would like to have help. The baby was old enough, had it been normal, to have been taking whole milk for some time. We recall our having the mother prepare the proprietary food just as she had been used to preparing it, and each day we had her throw away one-half ounce and put in one-half ounce of whole milk, this mixture she fed the baby for two days.

The next time, we had her take out one ounce of the mixture and put in one ounce of whole milk, which we fed the baby for three successive days; and then one and one-half ounces were substituted which was fed to the baby for four days; and thus we carefully, slowly, and gradually withdrew the proprietary food and substituted fresh, certified cow's milk. It took us a month to complete the change, but we are glad to add that it was done without in the least disturbing the child.

Now, had the change been made abruptly—in a day or two, or three days—the baby would probably have been completely upset, while both the mother and the doctor would have been greatly discouraged. Many mothers and even some physicians have jumped from one baby food to another baby food; they have tried this and they have tried that, until the poor child,180 having been the victim of a number of such dietetic experiments, finally succumbed.

We cannot urge too strongly the fact that, as a rule, whenever a change is made from one food to another, it should be done gradually, unless it be the change of a single element such as that of a very high per cent of cream found in top milk mixtures, when it seems to be a troublesome element in the milk. No bad effects will follow the quick change to skimmed milk with added sugar, starches, etc; but in changing from a proprietary food to a milk mixture, the change should always be made gradually, the quantity of the new food being increased gradually. Milk should be increased by quarter (1/4) ounce additions, and it should not be increased more than one ounce in one week; while the mixture should not be increased as long as the baby is gaining satisfactorily. A wise mother and an experienced physician can usually see at a glance when a child is doing well—by the color and consistency of the stools, the child's appetite, his sleep, and his general disposition.

First and foremost, we believe a great mistake is often made in using too heavy cream mixtures; babies as a rule do not stand the use of too high a percentage of cream. Formulas that call for whole milk should contain four per cent fat or cream; and while babies often gain rapidly on the higher percentage of cream found in a rich Jersey milk, nevertheless, sooner or later serious disturbances of digestion usually occur. Herd milk is, therefore, better for the babies because in the "whole milk" of the herd of Holsteins we have only about four per cent fat.

Another common mistake is too heavy feeding at the time of an attack of indigestion; even the usual feeding may be too heavy during this time of indisposition. It is not at all uncommon for us to dilute baby's food to one-third its strength at the time of an acute illness.

Still another trouble maker is dirt—dirt on the dish-towel, dirt on the nipple, dirt in the milk, dirt on the mother's hands. Dirt is an ever present evil and an endless trouble maker, as181 evidenced by stool disturbances, indigestion, fretful days, and sleepless nights. A dirty refrigerator is another factor which has been responsible for much illness and distress.

Indigestion is often brought on because a nurse, caretaker, or possibly the mother, not wishing to go down to the refrigerator in the middle of the night, brings up the food early in the evening and allows it to become warm—to remain in a thermos bottle—and we are sure that had they been able to see the enormous multiplication of germs because of this warm temperature, they would never have given occasion for such an increase in bacteria just to save themselves a trifle of inconvenience.

Still another common mistake is to use one formula too long; a feeding mixture which was good for four or possibly six weeks, must be changed as the child grows older and his requirements become greater. Let the weight, stools, general disposition and sleep of the child be your guides, and with these in mind errors in feeding can be quickly detected and minor mistakes speedily rectified.

Some of the pointed questions which are put to a young mother who brings her child into the office of the baby specialist, are the following:

Does the baby seem satisfied after his feeding?
Does he suck his fist?
How much does he gain each week in weight?
Does he sleep well?
Does the baby vomit?
What do his bowel movements look like?
Will you please send a stool to the office?

With the intelligent answers to these questions—after knowing the birth weight and the age of the child and its general nervous disposition—the physician can formulate some conclusion as to the babe's general condition and can usually find a feeding formula that will make him grow.

Vomiting, restlessness, sleeplessness and the condition of the182 bowels, are the telltales which indicate whether or not the food is being assimilated; and the stools may vary all the way from hard bullet-like lumps to a green diarrhea.

Babies do not thrive well in large institutions where the food is so often made up in a wholesale manner, for the simple reason that the food elements are not suited to the need of each individual baby. Some infants are unable to digest raw milk, and for them sterilized or boiled milk should be tried; others require a fat-free mixture such as skimmed milk, while still others may need buttermilk for a short time. Babies require individual care, particularly in their food, and the good or bad results are plainly shown in the stools, weight, sleep, etc.

Flatulence is an excessive formation of gas in the stomach and bowels leading to distension of the abdomen and the belching of gas, and often the bringing up of a sour, pungent, watery fluid.

Flatulence is seen in infants suffering from intestinal indigestion and the food is nearly always at fault. This condition is the result of the faulty digestion of the sugar and starches—particularly the starch—which should be immediately reduced. In such conditions the addition of a slight amount of some alkaline (such as soda, magnesia or lime water) to the food often produces good results. Great patience must be exercised with a child that suffers from flatulence, for immediate improvement can hardly be expected; time is required for the restoration of good digestion.

Vomiting is perhaps more often the result of over feeding or too frequent feeding than anything else. A healthy, breast-fed baby may now and then regurgitate a bit, but it simply spills over because it is too full. We do not refer to this as vomiting, we refer to the belching up or vomiting of very sour or acrid milk which leaves a sour odor on the clothing. This can all usually be rectified by lengthening the intervals from two to three hours and preventing bolting of food by getting a nipple183 whose hole is not so large. Too much cream in the food will also sometimes cause vomiting.

Too frequent feeding at night is another cause of vomiting. When the stomach is full, the failure to lay the baby down quietly, as is so often seen in those homes where bouncing and jolting are practiced, may also result in vomiting.

Vomiting may be the first sign of many acute illnesses such as scarlet fever, measles, pneumonia, whooping cough, etc.

The treatment for acute vomiting is simple. All foods should be withheld—nothing but plain, sweetened water should be administered, while it is often advisable to give a dose of castor oil. A physician should be called at once if the vomiting continues, and not until the vomiting has entirely ceased for a number of hours and water is easily retained, should food be given, and even then it should be begun on very weak mixtures.

The size of the child's stomach should be the guide to the quantity of food given, and attention is called to the table given in a previous chapter. All food taken in excess of his needs lies in his stomach and intestines only to ferment and cause wind and colic. The symptoms of over-feeding are restlessness, sleeplessness, stationary weight (or loss in weight), and oftentimes these very symptoms are interpreted by the mother as sufficient evidence that the baby needs more food; and so the reader can see the terrible havoc which is soon wrought where such ignorance reigns.

The weighing time should immediately follow a bowel movement and just before a feeding time; then, and only then, we have the real weight of baby, as a retained bowel movement may often add from four to five ounces to the child's weight. There should be a careful record of each weighing, for there may develop a great difference if different members of the family endeavor to keep the weight in their minds. The normal baby should gain four to eight ounces a week up to six months,184 and from then on the weekly gain is from two to four ounces; in other words, by six months the baby should double his birth weight and at the end of a year his weight should be three times the birth weight. A stationary or diminishing weight demands careful attention; a good doctor should be called at once. Likewise, a very rapid increase in weight is not to be desired, as we do not want a fat baby, but we do desire a well-proportioned and alert baby, and, as someone has said, it is better to have little or no gain during the excessive heat than to upset the digestion by over-feeding, designed to keep the baby gaining.

In weighing, usually the outside garments are removed, leaving on a shirt, band, diaper, and stockings with the necessary pins; the little fellow thus protected is placed into the weighing basket and at each successive weighing, these same clothes or others just like them are always included in the weight, and it should be so reported to the physician.

In the chapter "Baby's Early Care," the first stools were described in detail, and there we learned that the dark, tarry, meconium stools are quickly changed within a week to the normal canary-yellow stool, having the odor of sour milk.

The bottle-fed babies' stools differ somewhat in appearance; they are thicker and a lighter color, but should always be homogeneous if the food is well digested. They do not have nearly the number of bowel movements each day that the breast-fed baby does. If a bottle-fed baby's bowels move once a day and he seems perfectly well otherwise, we are satisfied. And curds (white lumps), or mucus (sedimentary, slimy phlegm), indicate that the food is not well digested.

A bottle baby may be constipated because the proteins are too high, the fat too high, the food of an insufficient quantity or quality, or the milk have been boiled, while weak babies really may lack the muscular power to produce a bowel movement. With the help of your physician endeavor to arrive185 at the cause of the constipation, and, if the baby is two or three months old, from one to two teaspoons of unsweetened prune juice may be administered. Milk of magnesia may be added to the food (leaving out the lime water), or a gluten suppository may be used.

The change from milk sugar to malt sugar has helped many infants; while the giving of orange juice (after six months) is very beneficial in many cases. A small amount of sweet oil may be injected into the rectum which will lubricate the hard lumps and thus favor comfortable evacuation. The periodicity of the bowel movement (at definite times each day) is a matter of great importance. Immediately after a meal, if the child is old enough, he should be placed on the toilet chair. A bit of cotton, well anointed with vaseline and inserted into the rectum just before meals, will often aid in producing a bowel movement shortly after the meal has been taken.

Abdominal massage should be administered in all instances of constipation, beginning with light movements and gradually increasing, with well-oiled hands.

Diarrhoea usually accompanies acute intestinal indigestion and is so often associated with the common disorders of infancy that we refer the reader to the chapter "Common Disorders of Infancy." Dark stools should always be saved for the physician to observe, as they frequently contain blood. Stools full of air bubbles with pungent sour odor show fermentation; in which cases the starches should be reduced, if not entirely taken away from the food mixtures. Green stools mean putrefaction from filth-germs; a thorough cleansing of the bowel should be immediately followed by a reduction in the strength of the food and the boiling of the milk.

At a certain time each day the napkin should be removed and the child should be held out over a small jar. It is surprising to note how quickly and readily the little fellow cooperates. Diaper experiences may be limited to much less than186 a year if the mother has patience enough and the baby has the normal intelligence to enter into this regulation regime. We recall one caretaker who complained bitterly because the child under her care constantly wet his diaper; so the caretaker was instructed to keep a daily schedule of the baby's actions for five days; and, to her surprise, she discovered that the baby urinated about the same time each day. A regularity was also noted concerning the bowel movements.

The variations in the time of the urinations were only fifteen or twenty minutes, so nearly did the kidneys act at the same time each day. The caretaker was instructed to remove the diaper and hold the baby out at the earliest occurrence on the daily schedule, and, to the astonishment of the entire family, no further accidents occurred, and the child soon acquired the habit of letting them understand when he was about to wet his diaper. Bowel movements may be regulated more easily than the urination. After the child is about a year old, very few accidents should occur.

In many instances, and particularly if the infant is under six months of age, and where he has had to have additional feeding from the bottle—under such circumstances the breast milk may be continued as "partial feeding," at least until the baby has reached his ninth or tenth month, at which time it may be wholly discontinued.

At each nursing time the baby empties both breasts, and the amount he draws may readily be estimated by carefully weighing him before and after each nursing. By referring to the directions in a previous chapter, the quantity of food needed for his size and age may be determined; while the deficit is made up from a bottle of milk containing properly modified cow's milk.

If the mother's health admits, or if the breasts continue to secrete a partial meal for the babe, mixed feeding should be continued until after the ninth or tenth month, when it can gradually be reduced from four or five times each day to once or twice a day, until it is finally omitted altogether. In the187 meantime, the baby is gradually getting stronger food and at eleven or twelve months the little fellow is able to subsist and thrive upon whole milk.

It is very difficult to explain how some babies thrive on some certain food while others grow thin and speedily go into a decline on the same régime. The hereditary tendencies and predispositions undoubtedly have a great deal to do with such puzzling cases.

Again, sometimes a slight variation in technic or some other trifling error in connection with the preparation of the baby's food, may be more or less responsible for the variation in the results obtained. No two mothers will prepare food exactly alike even when both are following the same printed directions and these slight discrepancies are enough to upset some delicately balanced baby.

On the other hand, some babies are born with such strong digestive powers and such a powerful constitution that they are easily able to survive almost any and all blunders as regards artificial feeding, while at the same time they also manifest the ability to surmount a score of other obstacles which the combined ignorance and carelessness of their parents or caretakers unknowingly place in the pathway of early life which these little folks must tread.

The fact that so many babies do so well on such unscientific feeding only serves to demonstrate the old law of "the survival of the fittest"—they are born in the world with an enormous endowment of "survival qualities"—and in many cases the little fellows thrive and grow no matter how atrociously they are fed.

There may be other factors in the explanation of why some babies do so well on such poor care, but heredity is the chief explanation, while adaptation is the other. If the little fellows can survive for a few weeks or a few months, the human machine possesses marvelous powers of adaptation, and we find here the explanation why many a neglected baby pulls through.188

Rickets and scurvy have so often followed the prolonged use of the so-called "infant foods" which have flooded the market for the past decade, that intelligent physicians unanimously agree that they are injurious and quite unfit for continued use in the feeding of infants. If they are prescribed to replace milk during an acute illness, or at other times when the fats and proteins should be withheld for a short period, both the physician and the mother should be in the possession of definite and exact knowledge as to just what they do and do not contain. To provide such knowledge, we present the analysis (Holt) of some of the more commonly used infant foods.

1. The Milk Foods. Nestle's Food is perhaps the most widely known. The others closely resembling it in composition are the Anglo-Swiss, the Franco-Swiss, the American-Swiss, and Gerber's Food. These foods are essentially sweetened, condensed milk evaporated to dryness, with the addition of some form of flour which has been dextrinized; they all contain a large proportion of unchanged starch.

2. The Liebig or Malted Foods. Mellin's Food may be taken as a type of the class. Others which resemble it more or less closely are Liebig's, Horlick's Food, Hawley's Food, malted milk, and cereal milk. Mellin's food is composed principally (eighty per cent) of soluble carbohydrates. They are derived from malted wheat and barley flour, and are composed chiefly of a mixture of dextrins, dextrose, and maltose.

3. The Farinaceous Foods. These are Imperial Granum, Ridge's Food, Hubbell's Prepared Wheat, and Robinson's Patent Barley. The first consists of wheat flour previously prepared by baking, by which a small proportion of the starch—from one to six per cent—has been converted into sugar.

In chemical composition these four foods are very similar to each other, consisting mainly of unchanged starch which forms from seventy-five to eighty per cent of their solid constituents.

4. Miscellaneous Foods. Under this head may be mentioned Carnrick's Soluble Food and Eskay's Food.

The composition of the foods mentioned is given in the accompanying table.189

¹ Chiefly Lactose.     ² Largely Maltose.

From earliest girlhood, women have loved their dolls, and one of the greatest joys connected with the adored experience was the make-believe bath and the dressing of the make-believe baby; so now, when we are the happy possessors of real live dolls, we should go about the task with the same lightheartedness of a score of years ago when we hugged, kissed, bathed, and dressed our dolls. There is one big advantage now, the doll won't break; but, we sigh as we stop to think, we can't stick pins into it as we all did into the sawdust bodies of our dolls those years and years ago.

In the chapter on "Baby's Early Care," this subject was fully discussed and we only wish to repeat, in passing, that before baby's bath or toilet is undertaken the hands of the mother, nurse, or caretaker must be scrupulously clean. And while the first day's bath usually consists of sweet oil, albolene, or benzoated lard, if the new baby happens to come during the very warm days of July or August and the oil seems to irritate the soft downy skin, as it often does during those hot days, a simple sponge bath may be substituted. The cord dressing remains as the doctor left it, and if there be any interference, let it be subject to his orders.

The cord usually drops off, and the abdomen is entirely healed by the seventh to the tenth day, after which time baby is daily sponged for another week. And now we will describe in detail the simplest, easiest manner of administering an oil bath or a sponge bath.191

A large pillow or a folded soft comfort is placed on a table in a warm room—temperature not below 75 F. On baby's tray near by, and within reaching distance, are the boracic acid solution in a small cup, a medicine dropper, the warm saucer of oil, the toothpick applicators (made by twisting cotton about one end, making sure the sharp end of the pick is well protected), a glass jar of small cotton balls made from sterile absorbent cotton, the castile soap, talcum powder, needle and thread. A vessel of warm water, several old, soft, warmed towels and the clean garments required, complete the layout.

Into the warm, soft blanket on the pillow or comfort we place the partially undressed baby, for the binder, diaper, and socks are not removed until the head-and-face toilet is completed.

The top of the head, behind the ears, the folds of the neck, and the armpits are now gently but thoroughly rubbed with oil, which is then all rubbed off with a soft linen towel. The eyes next receive two or three drops of the boracic acid solution, put in by the aid of the medicine dropper, while, with a separate piece of cotton, the surplus solution is wiped off each eye, rubbing from the nose outward.

Then with the applicator made by wrapping cotton about the end of a toothpick, oil is put into each nostril, all the time exercising the utmost care not to harm the tender mucous membrane. The ears are also carefully cleansed with a squeezed-out dip of boracic acid on the applicator.

Unless there is an inflammation present in the mouth, and the physician in attendance has ordered mouth swabbing, do not touch it; for much harm is done the mucous membrane of the baby's mouth by the forceful manner in which much of the swabbing is done. The face and head are then washed with warm water; very little soap is needed and, when used, must be most thoroughly rinsed off.

And now during the second week, we proceed to sponge the baby's body; the hands are washed with soap and rinsed, and,192 only those who have performed this feat know just how tightly they hold shut their little fists. These hands must be relaxed, and all the lint, dirt, and perspiration be thoroughly washed away. The arms, shoulders, chest, and back are then sponged. All the time the nurse or caretaker is standing while carrying out this most pleasant task. At any time she may quickly cover the babe and stop for this or that with no inconvenience to herself or the child.

After the thorough drying of baby's upper body, a bit of talcum is put under the arms, in the folds of neck, etc., and the shirt is slipped on. Next the band, diaper, and stockings are removed and after first oiling the groin and the folds of the thighs and the buttocks, the same sponging, drying, and powdering is done here as on the upper body.

The band is now applied, and sewed on. The diaper, stockings, booties, and—if a winter baby—the skirt and outing flannel gown (for babies should wear only night dresses for the first two or three weeks) are now slipped over the feet and drawn upward, and baby is ready for nursing or for his nap.

First few weeks, 100 F.; early infancy, 98 F.; after six months, 97 F., cooling down to 90 F.

A wooden bath thermometer may be purchased for twenty-five cents and it should be in every home where babies are bathed. In the absence of a thermometer do not depend upon the hand to determine temperature. Thrust the bared elbow into the water and if it is just comfortable—neither hot or cool—it is probably about the correct temperature for baby. Do not shock the baby by dashes of cold water, for, while it may amuse an onlooker, it unnecessarily frightens your child, and, subconsciously, he learns to dread his bath.

If the bathroom is warm—temperature 75 F.—that is the most logical place for the bath, provided baby has his own tub. Place a couple of strong slats several inches wide across the big tub, six inches apart, and on this place the baby's tub. Of193 course, care must be exercised to prevent slipping by means of properly fitted cleats on the under surface of the slats. The mother should always stand to bathe her baby and the small tub should be placed at such a height that she neither has to stoop nor bend. Thus the bathing of the baby becomes a pleasure instead of a "job" or an "irksome task."

If the bathroom is not warm then the kitchen table or a small table pulled up near the stove is a place par excellence for the dip.

Many boils seen on young baby's tender skin have been traced to the careless use of the family tub to bathe the baby in. Not until the child is two or three years of age, when his skin has become more toughened, should he be allowed to use the family tub.

To begin with, we never bathe either a baby or an adult immediately after a full meal. From one hour to one and one half hours should intervene.

The frequency of baths depends somewhat upon the season of the year, the vitality of the child, and the warmth of the home.

We have seen many infants who were bathed too often. The vitality expended upon the necessary reaction following a tub bath was too much for the little fellow; the daily bath was stopped and a semi-weekly bath substituted, much to the gain of the child. Of course in this instance the hands, face, and buttocks received a daily sponging.

The oil bath may be administered daily. In robust children the tub bath may be a daily affair; while in pale, anemic little folks, the tub bath is perhaps better given twice a week. In hot summer days a sponge bath may be given many times a day.

Again this depends upon several factors; the warmth of the house or apartment, the vitality of the child, and the kind of bath to be administered.194

An oil bath may be given any time—often it may be administered entirely under the bed clothes, only care must be taken to keep oil from the blankets.

Many of our mothers prefer to give the tub bath at five o'clock in the afternoon, when the house is thoroughly warm, and the child is thereby prepared for the long night's sleep. Before dressing in the morning an oil bath or rub may be given in such cases.

If the forenoon is selected as the time for bathing the child, then an hour just before the mid forenoon meal is the best. In either event, be regular about it—do it at the same time every day. Let the caretaker attend to her many duties, and, as far as possible, mothers, bathe your baby yourself. The folds of the skin, the creases in the neck, the clenched fists, must all receive particular care, and no one in all the world will ever care as you—the mother—cares.

Select a soap free from irritants and excess of alkalis. There are few kinds that equal the old-fashioned, white castile soap our grandmothers used.

Very hard water which makes the skin rough and sore may be improved by boiling, but if possible substitute rain water for it. A flannel bag tied over the faucet and changed each day will help to clarify muddy water, provided the stream flows gently through it.

Just as we directed the nurse or caretaker to stand while the oil rub or sponge bath was given, so we admonish the mother to stand while the tub bath is given. First, get everything in readiness for the bath as directed for the oil bath, and then the baby's tub setting on the securely cleated slats placed across the top of the family tub may be filled with water by means of a hose attached to the faucet. The temperature should be 100 F. when baby is dipped in to be rinsed.

The head and face toilet are identical with that described before, and with the baby undressed and wrapped in a warm 195towel placed inside the warm blanket on the pillow or comfort as before mentioned, we proceed with a good lather of castile soap and water to lather the baby's body all over—under the arms, the neck, chest, groins, thighs, buttocks, legs, feet, and between the toes, while the genitals also receive their share of attention. The foreskin of the boy baby is gently pushed back and cleansed thoroughly; while the vulva of the little girl baby, having first been swabbed with boracic acid, is now gently lathered and cleansed. Now grasp the ankles and legs with the right hand and support the upper back and neck and shoulders with the left and gently lower the baby into the water in a semi-reclining position (See Fig. 13). The water should cover the shoulders. Keep a good firm supporting left hand under the head, neck, and shoulders, and with the right, rinse all soap from the body.

After this is thoroughly done, lift the baby out onto a fresh warm towel inside the warm blanket on the pillow, and remain standing, while you gently pat (never rub) the baby dry. All the little folds, creases, and places between fingers and toes, are carefully patted dry, and where any two skin surfaces rub together put on a bit of talcum.

The dressing takes place in the manner already described—first the shirt, then the band (sewed on), the diaper, stockings, skirt, and gown.

Please note that the soap bath is contra-indicated (should not be given) in case of eczema.

This soap bath should be administered for cleanliness only, and should be given twice a week. If a tub bath is to be given on other days, after the routine head and face toilet, the baby is simply dipped into the water and the soft skin gently rubbed.

If the sponge or tub bath is given in the afternoon just before the long sleep at night, then the oil rub should take place before the mid-forenoon meal; and likewise, if the sponge or tub bath is given during the mid forenoon, then the oil rub or dry hand rub is given before the going-to-bed time. The rub should be a daily procedure for the first two years. Nothing196 rougher than the soft palm of the hand should be rubbed on baby's soft skin.

Babies have come to my clinic with cakes of talcum under their arms, and particularly between their thighs and in the crease of the buttocks. Here the well-meaning but thoughtless mother had reasoned, "a little is good; more is better" which is not always the case.

Talcum is not used to replace careful drying, and it should never be found in quantities on the baby's skin any more than you would expect to find quantities of face powder caked in the creases of the neck or behind the ears of an adult. The skin is first cleaned, then patted entirely dry, and, as a finishing touch, a bit of talcum is put on by means of a puff.

Tonic baths are usually given to older children when they are able to enter into the sport and frolic of a cool bath. Baths are called tonic because they call forth from the body a reaction—a sort of circulatory rebound. This rebound or reaction brings the blood to the skin, increases the circulation, and tones up the nerves. The room should be properly warmed and, if necessary, some form of exercise be continued after the bath to prevent the chill that sometimes follows a poorly administered bath.

In the case of the anemic child, after six months of age, the mother's hand dipped in cold water may briskly rub the chest and back until it glows or becomes red. The child should enjoy this bath. Never frighten a child by throwing cold water on it or by giving it a too sudden cold plunge; great harm may be permanently done by these efforts to "toughen the baby."

The simple medicated baths may be administered according to the following directions:

Salt. Use half a teacup of common salt or sea salt to each gallon of water. The salt should first be dissolved in a cup of warm water to prevent the sharp particles from pricking the skin. The doctor sometimes orders a salt bath.197

Starch. Add a cup of ordinary, cooked laundry starch for every gallon of water in the bath.

Soda. A soda bath requires two tablespoons of ordinary baking soda to a gallon of water, dissolving it in a little water before adding it to the bath.

Bran. Make a cotton bag of cheesecloth or other thin material, six inches square. Fill loosely with bran. Soak the bag in the bath water, squeezing it frequently until the water becomes milky.

Starch, soda, and bran baths are often used in place of the ordinary soap and water bath when the skin is inflamed, as in cases of chafing or prickly heat.

Force and harshness are not likely to cause baby to overcome very much of the fear of a tub bath. Patience, perseverance, and purposeful diversion of mind will bring sure results.

In the case of a very young baby, have a helper stretch a towel across the filled baby tub, lay the baby in it, with its head well supported, and then gently lower the towel into the water, keeping the head out. (Most anyone would fear an all-over ducking, if he had ever been completely ducked into water by a careless or mischievous friend).

In the case of older children, celluloid ducks, fish, or boats may float about on the water, and the entire bath be forgotten by the little fellow's enjoyment of "his boats."

Although a baby under two years should never be given a sea bath, a word of caution about sea bathing for young children may not be amiss. The cruelty with which well-meaning parents treat young, tender children by forcibly dragging them into the surf, a practice which may be seen at any seaside resort in the summer, can have no justification. The fright and shock that a sensitive child is thus subjected to is more than sufficient to undo any conceivable good resulting from the plunge. On the other hand, a child who is allowed to play on the warm sand and becomes accustomed to the water slowly and naturally will soon learn to take delight in the buffeting of the smaller waves, but he should198 not be permitted to remain more than a minute or two in the water, and should be thoroughly dried, dressed immediately, and not left to run about the beach in wet clothing.

Any roughness on the scalp must receive immediate attention. This roughness, or milk crust, is entirely avoidable; it is the result of accumulated oil and dirt. When it has formed a complete crust or cake, it may quickly become eczematous and require a physician's advice; however, in the beginning, at the first sight of brown patches or roughness, oil the scalp thoroughly at night with vaseline or cold cream, which should be gently rubbed off in the morning.

This vaseline or cold cream should be applied repeatedly, several nights in succession, followed by the morning's gentle rubbing and daily washing of the head. Often the washing with water must be entirely avoided; only sweet oil or vaseline being used in those cases where the crusting seems to be persistent.

At birth the eyes are particularly cared for. First, the mucus is gently swabbed off the closed lids from the nose side outward, and then follows the application of one drop of twenty per cent argyrol or two per cent silver nitrate, either of which thoroughly disinfects the eye and prevents the growth or development of any bacteria that may have gotten into the child's eye during the descent of the head through the birth canal. The neglect of this procedure may sometimes result in lifelong blindness.

Under no circumstances should "a mere cold in the eyes" be neglected; it may result in blindness. Call your physician at once, and if he is not at hand, wash out the eye thoroughly every hour with warmed ten per cent boracic acid solution, by means of a medicine dropper, using a separate piece of cotton for each eye, for if the slightest bit of discharge be carried from one eye to the other an inflammation will quickly appear.

From birth, especially during the first week, baby's eyes are199 very sensitive to light; hence they must be carefully protected. Babies should be so placed during their outings, sleep, or naps, that they do not directly gaze at either the sunlight or sky. The lining of the hood of the carriage should be green, instead of white, as much eye strain is thus prevented.

The daily care of the normal, well eye has been already described, and while it need not be reiterated, we may say, in passing, that if the eyelid be at all inclined to be sticky or adherent, never use force, but instead, gently swab with boracic acid. As a preventive of this condition, a little vaseline from the tube may be rubbed on the edges of the lids at night.

In the toilet of the ears, never attempt to introduce anything beyond the external ear, which may be carefully cleansed with a soft cloth. It is often found necessary to apply oil to the creases behind the ears before the daily bath. There should be no irritation, redness, or roughness present, all such conditions being readily prevented by the use of oil or vaseline before the bath.

With the sharp point removed, make a cotton applicator out of a toothpick, and gently (with no force, whatever) introduce vaseline or oil into the nose. This should be a part of baby's daily toilet. Any stoppage of mucus or snuffiness in the nose should be reported at once to baby's physician. Young babies often have adenoids.

Leave the well mouth alone until the teeth appear, and then keep the teeth very clean (allowing no particles of milk to accumulate at their bases) with a soft bit of cotton and gentle rubbing. When a child attains the age of two, he should have his own toothbrush; previous to this time all food particles should be removed from between the teeth with waxed silk floss. All decay should be promptly attended to by a competent dentist.

Thrush and ulcers are often caused, not prevented, by the frequent wiping out of baby's tender mouth. The treatment of thrush and other mouth infections will be considered in a later chapter, "The Common Disorders of Infancy."200

Before the bath, the baby girl's genitals are carefully swabbed between all the folds with boracic acid solution. The foreskin of the boy baby should be pushed well back and washed gently with water. If the foreskin of the male child be long, tight, or adherent, circumcision is advised. See our chapter, "Teaching Truth."

The genitals of both the boy and girl should be kept scrupulously clean every day, with as little handling as possible, and, upon the appearance of the least swelling, discharge, or even redness, the physician's attention should be at once called to it. In a later chapter, the subject of irregularities of sex habits will be taken up.

Often, because of irritating bowel movements, the buttocks become reddened, chafed, and sometimes raw in places. Some poor little babies are sometimes roughly rubbed—scoured on the buttocks—much like the kitchen sink, many times a day, and it is not surprising that they become reddened, chafed, and very much inflamed.

The buttocks require a gentle swabbing and thoroughgoing "patting dry" after each soiling or wetting of the diaper, but no soap is required in this region but once a day, and even then it should be used sparingly.

When the buttocks are inflamed, after a good cleansing with water and a thorough drying, vaseline or zinc ointment should be applied on a piece of sterile cotton, and this application should be repeated after each changing of the diaper. Wet diapers should be removed at once, for the acidity of the urine causes more chafing. A dusting powder composed of starch two parts, and boracic acid one part, may be dusted on after a cleansing with oil.

Great care should be exercised in the thorough daily rinsing of the diapers as well as in the tri-weekly boil in the laundry. White soap only should be used in their cleansings; no washing sodas or other powders should be used.201

Under the arms and in the creases of the neck the skin sometimes becomes irritated because of neglect. To prevent such chafing the following program should be carefully carried out:

With a fine camel's hair brush the hair should receive its brushing after the cleansing of the scalp. Combs are for just one purpose and that is to part the hair. The brush should be used to do all the smoothing.

While the frequent trimming of the hair has no marked effect upon its growth, yet the comfort the little girls enjoy, especially during the warm-weather months, should not be denied them.

And certainly the boy should become a boy when he puts on trousers and not be made the laughing stock of his mirthful companions just because his "beautiful long curls are much admired by the mother and his aunts."

The finger nails should be trimmed round with the scissors, while all hangnails are properly cared for every day. Toe nails should be cut straight across and the corners never rounded off. Many ingrowing nails may be thus avoided.

The Eden story suggests that in the beginning of our racial experience artificial clothing was unnecessary; but after a time, in that selfsame garden, proper clothing became an important problem and has remained so ever since. Everybody seems to agree, however, that baby's clothing in particular should at least be comfortable. It may give the child great discomfort because it may be too warm, or it may not be warm enough, or it may be too tight, and so, in the discussion of baby's clothing in this chapter, we are going to keep in mind these two things—comfort and heat.

The choice of material demands some thought and attention. As a rule, baby's clothing materials should be light in weight, good moisture absorbers, and at the same time able to retain the body heat. Most layettes have the common fault of being prematurely outgrown; and so it is well to allow for ample growth in making baby's first clothes. Since the principal object of clothing is to insure a uniform body temperature, it is important that the mother be constantly on her guard to keep the baby cool enough in the summer and warm enough in the winter.

The mothers of various races and nations have their own ideas concerning the clothing of their babies. One mother will wrap her baby in cotton, which is held in place by means of a roller bandage, and as you visit this home during the first week of baby's life, you will be handed a little mummy-shaped creature—straight as a little poker—all wrapped up in cotton and a roller bandage. The surprising feature is that the baby does not seem to complain.203

In another district of the city we find the baby dressed in starched clothes, ribbon sashes, bright ribbon bows on its arms and around its neck. At first glance you wonder if the little child is not many years older and is about to make a visit to a county fair, but on inquiry we find that he has only been prepared for the event of circumcision on the eighth day.

And if you go into the forest of primeval days you will find another mother bandaging her baby to a board, head and all, and he seems to live and thrive in his little woven nest strapped on the back of his Indian mother.

Other babies in the warmer portions of the earth have almost less than nothing on, and are left to be swung by the breezes in little baskets tied to the boughs of trees; being taken up only when it is time to feed.

In preparing an outfit for the newcomer it is wise to provide for the necessities only, because of the fact that since the baby grows very fast the layette will soon have to be discarded; it is always possible to get more clothing after the baby is here and started on his little career. We offer the following list of essentials for the new born baby: